Every finding on record at Careview Health and Rehab of Minocqua

Based on staff interview and record review, the facility did not ensure 1 of 3 residents (R) out of a sample size of 6 residents reviewed for conveyance of resident funds, had funds returned to the Power of Attorney (POA), family, or estate within 30 days of resident death. The facility did not refund R6's funds to POA within 30 days of discharge from facility.Findings include:R6 was admitted to the facility on [DATE] under Hospice Private Pay and the facility was provided with a check for $8500.00. On 04/08/26, R6 discharged from facility to home under care of an outside Hospice entity.On 06/22/26, the state agency received a complaint from Spouse F of delay in receiving reimbursement on this date for the 1-day admission in early April 2026 after providing facility with a deposit of $8500.00.On 07/09/26, Surveyor interviewed R4 and R5 who had no concerns regarding billing from facility.On 07/09/26 at 12:30 PM, Surveyor interviewed NHA A regarding the process for issuing reimbursement check to family and residents. NHA A stated that a request for reimbursement is sent to the corporate accounts payable department, and the 10th of the month is end or prior month's billing cycle and can take anywhere from 30 to 60 days. NHA A looked into the facility's computer system and stated that a check was cut on 06/12/26 and could see that the check was cashed on 06/22/26. Surveyor interviewed NHA A why the long delay between R6 discharge and receival of check. NHA A was not aware of the reason but stated there were changes in accounts payable personnel and the facility's business office manager during this time period.

Based on record review and interview, the facility did not ensure that residents are free of significant medication errors for 4 of 5 residents (R) [R2, R3, R5, and R9] reviewed for medication administration. R5 is being cited at severity level 3 (actual harm). R2, R3, R9 are being cited at severity level 2 (potential for more than minimal harm). -R5 has a history of pancreatic and kidney transplant and receives antirejection medications. R5 did not receive his antirejection medications Mycophenolate Mofetil (medications that prevents the body from rejecting a transplanted organ) for 37 days and Tacrolimus (medication that prevents body from rejecting a transplant) for several days. This caused R5 psychosocial harm evidenced by R5 stating he had ongoing feelings of anxiety, fear, and depression surrounding the potential rejection of his transplanted organs due to the lack of medication availability. -The facility missed 3 days of R3's anticonvulsant medications (Lacosamide) (a medication that aids in prevention of seizure activity in the brain) which cannot be abruptly stopped. -The facility did not follow R2's hospital discharge orders for warfarin 2.5 mg daily. R2 received warfarin 5 mg on Monday and Friday and warfarin 2.5 mg the rest of the days. -R9 received double warfarin dosage when the facility failed to discontinue previous warfarin order. -R5 is being cited at severity level 3 (actual harm). R3, R2, R9 are being cited at severity level 2 (potential for more than minimal harm). Findings include: The facility policy, titled Medication orders and receipt record dated April 2007, states: .2. The medication order/receipt record shall contain: The prescription number; Resident's name; Name, quantity ordered, and strength of the drug; Order date; Name and title of person placing the order; Name of the dispensing pharmacy; The date and quantity received; and Name and title of the person receiving order. 4. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time. 7. Noted discrepancies shall be reported to the dispensing pharmacy. National Kidney Foundation. (2024, September 16). Immunosuppressants (Antirejection Medicines), state in part, .Your immune system's job is to fight anything that is foreign to your body. It looks for things that do not belong, like bacteria and viruses (germs). For people who have received a kidney transplant, your immune system will also try to fight, or reject, your new kidney since it isn't like the rest of your body. So, anti–rejection (immunosuppressant) medications are needed to increase your chances of keeping your new kidney healthy. Anti-rejection medicines are for life. Stopping, missing, or skipping these medicines will very likely cause rejection, either right away or overtime. Example 1 R5 was re-admitted on [DATE], with diagnoses including kidney transplant status, pancreatic transplant status, immunodeficiency due to drugs, diabetes mellitus with diabetic retinopathy, type 1 diabetes with polyneuropathy, dementia without behavioral disturbance, Charcot's joint of multiple sites acquired absence of right great toe, hypertension, foot drop of left foot, and osteoporosis. R5's care plan includes: R5 has impaired immunity related to chronic steroid use and antirejection medications status post kidney and pancreas transplants (2004), 03/20/26 order received to place on hold until available due to pharmacy delay related to prior authorization requirement, unable to obtain emergency supply, resident is already on prednisone. Initiated on 05/28/25 and revised on 04/21/26. Interventions: -Administer medications as ordered initiated on 09/02/25. -Encourage fluid intake and adequate rest to bolster the immune system initiated on 05/28/25. -Monitor/document/report as needed abnormal laboratory values (e.g., white blood cell counts and differential, serum protein, serum albumin, and cultures) initiated on 05/28/25. -Monitor/document/report as needed signs and symptoms of infection: fever, redness, drainage or swelling around wounds or catheter sites, cough, respiratory symptoms, dysuria, hematuria, flank pain and foul-smelling urine, initiated on 05/28/25. -Monitor/document/report to the provider, signs and symptoms of delirium, changes in behavior, altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, periods of lethargy, restlessness, agitation, and altered sleep cycle initiated on 05/28/25. -R5 is at risk for contracting infections due to impaired immune status. Keep the environment clean and people with infections away, initiated on 05/28/25. -Use universal precautions as appropriate, initiated on 05/28/25. Surveyor reviewed R5's care plan initiated on 05/27/25: R5 uses antidepressant medication. Interventions: -Educate the residents/family/caregivers about risks, benefits, the side effects and/or toxic symptoms, revised on 03/16/26. -Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness revised on 03/16/26. -Monitor/document/report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in ADL ability, continence, no voiding, falls, dizziness, weight loss, dry mouth, and dry eyes revised on 03/16/26. -Refer to psych and/or counseling services as needed revised on 03/16/26. Surveyor reviewed R5's physician orders: -Mycophenolate Mofetil Oral Capsule 250 MG (Mycophenolate Mofetil), Give 3 capsules by mouth one time a day for transplant related to Pancreas transplant status 1 hour before meals or 2 hours after in the am. Ordered on 02/07/26. -Mycophenolate Mofetil Oral Capsule 250 MG (Mycophenolate Mofetil), Give 3 capsules by mouth one time a day for transplant related to Pancreas transplant status 1 hour before meals or 2 hours after in the pm. Ordered on 02/07/26. -Refer to nephrology for renal transplant history ordered on 02/10/26. Of note, missing 37 days of mycophenolate mofetil (MMF) is a significant interruption in antirejection therapy. This medication is essential for preventing your immune system from attacking your transplant and increases the risk of acute, and potentially irreversible, graft rejection. Surveyor reviewed R5's Medication Administration Record (MAR): -On 02/20/26-03/28/26, Mycophenolate Mofetil was signed out as not given and/or held. Surveyor reviewed R5's progress notes, which state, -On 02/20/26 at 3:18 PM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MGGive 3 capsule by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. Not in facility, reordered 2/20/26 -On 02/21/26 at 6:50 AM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MGGive 3 capsule by mouth one time a day for transplant related to Note Text: Mycophenolate Mofetil Oral Capsule 250 MG, give 3 capsules by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. Ok to hold per nurse practitioner, nurse practitioner aware. -On 02/21/26 at 4:41 PM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MGGive 3 capsule by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. On order. Ok to hold per nurse practitioner. -On 02/22/26 at 8:24 AM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MG. Give 3 capsules by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. Prior auth needed. Nurse practitioner aware ok to hold. -On 02/22/26 at 4:54 PM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MGGive 3 capsule by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after, Hold until received per nurse practitioner. -On 02/23/26 at 7:15 AM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MG give 3 capsules by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. Medication ordered but not available. -On 02/23/26 at 3:25 PM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MG give 3 capsule by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. Ordered but not available yet. -On 02/24/26 at 11:31 AM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MG. Give 3 capsule by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. -On 02/25/26 at 3:21 PM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MG. Give 3 capsules by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. Ordered but not in facility. -On 02/26/26 at 9:40 AM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MG. Give 3 capsules by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. Awaiting prior authorization. -On 02/26/26 at 3:46 PM, Note Text: Mycophenolate Mofetil Oral Capsule 250 MG. Give 3 capsules by mouth one time a day for transplant related to pancreas transplant status 1 hour before meals or 2 hours after. On order nurse aware. -On 02/27/26 at 2:43 PM, Provider progress note: Late Entry:Note Text: CC: Prior authorization The patient requires paperwork to be filled out for prior authorization for his mycophenolate. He clearly needs this since he had 2 solid organs transplanted in the year 2004. Assessment and plan: Remote pancreas and renal transplant: The patient requires mycophenolate for his very survival in prior authorization was filled out today and we will be sent on to pharmacy and insurance for coverage. -On 04/22/26 at 7:42 AM, Progress note pertaining to 03/20/26 at 7:35 AM, Updated resident [R5] and spouse that we should be receiving antirejection medications today. Thanked writer for update. -On 04/22/26 at 7:44 AM, Progress note pertaining to 03/25/26 at 7:44 AM, Updated resident [R5] and spouse that we should be receiving antirejection medications today. Thanked writer for update. -On 04/21/26 at 6:50 PM, Progress note pertaining to 03/25/26 at 6:24 PM, Resident [R5] with history of renal transplant (2004) on maintenance immunosuppressive therapy. Missing evening dose of medication for several days regarding delay in pharmacy delivery related to prior authorization, R5 stable, nurse practitioner notified and aware about pharmacy delay, order to resume medication as soon as delivered, resident is already on prednisone, no new orders. Surveyor reviewed R5's physician orders: - Tacrolimus 1mg capsule by mouth in the morning for transplant related to kidney transplant status. Ordered on 02/07/26. -Tacrolimus 0.5mg capsule by mouth at bedtime for transplant related to pancreas transplant status. Ordered on 02/07/26. Surveyor reviewed R5's Medication Administration Record (MAR): -On 03/19/26-03/26/26, Tacrolimus was signed out as not given and/or held. Surveyor was also unable to locate a medication error report regarding R5 being out of Tacrolimus and never given between 03/19/26-03/26/26. Surveyor reviewed R5's progress notes, which state, -On 03/19/26 at 6:47 AM, Note Text: Tacrolimus Oral Capsule 1 MGGive 1 capsule by mouth in the morning for transplant related to kidney transplant status. Ordered. -On 03/20/26 at 9:32 PM, Note Text: Tacrolimus Oral Capsule 0.5 MG.Give 1 capsule by mouth at bedtime for transplant related to pancreas transplant status. Received order to hold from nurse practitioner. -On 03/21/26 at 7:03 AM, Note Text: Tacrolimus Oral Capsule 1 MGGive 1 capsule by mouth in the morning for transplant related to transplant related to kidney transplant. Ordered but not in yet. -On 03/22/26 at 8:03 AM, Note Text: Tacrolimus Oral Capsule 1 MGGive 1 capsule by mouth in the morning for transplant related to kidney transplant status. Held. -On 03/23/26 at 8:45 AM, Note Text: Tacrolimus Oral Capsule 1 MGGive 1 capsule by mouth in the morning for transplant related to kidney transplant status. Ordered but not available in facility. -On 03/24/26 at 7:32 AM, Note Text: Tacrolimus Oral Capsule 1 MGGive 1 capsule by mouth in the morning for transplant related to kidney transplant status. Not delivered. -On 03/25/26 at 6:24 PM, Note Text: Tacrolimus Oral Capsule 0.5 MGGive 1 capsule by mouth at bedtime for transplant related to pancreas transplant status.Coming from pharmacy. Order to hold until it arrives. -On 03/26/26 at 12:01 PM, Note Text: Tacrolimus Oral Capsule 1 MGGive 1 capsule by mouth in the morning for transplant related to kidney transplant status. Stat delivery. According to Novartis Pharmaceuticals, . (hydralazine hydrochloride) is an antihypertensive medication originally developed to treat essential hypertension, often as a second-line agent or in combination with other medications. It acts as a direct-acting vasodilator that relaxes blood vessels, increasing blood flow to the heart while reducing its workload . Surveyor reviewed R5's progress notes, which state, -On 02/03/26 at 3:12 PM, Change in Condition note: Depression (e.g., crying, hopelessness, not eating, multiple somatic complaints). -On 02/03/26 at 3:24 PM, Health status note: concern for depression. Resident [R5] expressed he did not want to be on this earth anymore. Resident [R5] was previously taken off Duloxetine 20 mg per nurse practitioner, CMP and CBC labs. Restart duloxetine 20 mg every other day. Resident [R5] and wife agreeable to plan. -On 02/19/26 9:40 PM, Physiatrist progress note: Patient [R5] is not doing well today. Reports frustration with many things today and lack of interest in participating in therapy or any activities. Therapy reports that in the last several sessions as scheduled, R5 has declined. They have concerns regarding mental health. Social work has reached out to R5's active power of attorney regarding initiation of psych services, they are awaiting a response. Psych: Alert and oriented x2 with argumentative ornery mood and affect. -On 03/24/26 at 5:46 PM, Physiatry progress note: Patient [R5] is non-participatory in our visit today, placing his blanket over his head. Psych: Alert and oriented x2 with ornery mood and non-participatory affect, with blanket pulled over his head. Depression: Patient [R5] to continue Zoloft per primary care. Recommend initiation of psychiatric services, awaiting power of attorney approval. On 04/21/26 at 11:21 AM, Surveyor interviewed R5 and asked R5 how R5 is doing in the facility and if R5 had any concerns. R5 reported that R5 is tired and wants to give up. Surveyor asked R5 to elaborate on R5's feelings. R5 reported to Surveyor that the facility has dropped the ball and missed giving R5 his antirejection medication. R5 reported back in February of 2026 R5 tried asking facility to please re-fill antirejection medications as R5 is getting anxious and worried. R5 stated, I remember when I received the transplant years ago, my doctor told me I would need to be on the antirejection medications for life and to not miss a single dose. I went so long without I don't know what the long-term results are going to be and the facility acted like they did not care or try to fix the issue until a month later. R5 stated not receiving his medication made him feel anxious, afraid and depressed daily. On 04/21/26 at 1:15 PM, Surveyor interviewed Family Member (FM) N and asked FM N if FM N had any concerns with R5's cares at the facility. FM N reported FM N is concerned with R5 not receiving antirejection medications for over a month and FM N was not contacted until weeks later with no plan in place on when facility would receive antirejection medications. FM N reported R5 has declined and become increasingly anxious, depressed, and withdrawn, and wants to stay in room all the time now due to R5 feeling like R5 is a nuisance to facility staff. FM N stated, I am concerned with [R5's] depression and all the hiccups that have happened since [R5] was readmitted to facility. On 04/21/26 at 3:08 PM, Surveyor interviewed Registered Nurse (RN) D and asked how RN D determines when to order medication for when a resident runs out or is getting low. RN D reported staff should look ahead of time to see if residents are getting low on certain medications. RN D reported staff will place a reorder with the pharmacy before residents run out of medications. RN D reported if resident runs out of medication and pharmacy has not filled medication yet, then RN D would hold medication and notify physician of the medication needing to be refilled and waiting on pharmacy to re-fill. On 04/21/26 at 3:40 PM, Surveyor interviewed Pharmacist O and asked when facility had notified pharmacy R5 needed antirejection medications re-filled. Surveyor asked what Pharmacist O's process is for pharmacy refilling medications requested by facilities. Pharmacist O reported that Pharmacist O would transfer Surveyor to the billing department as [NAME] Assistant has detailed documented communication between facility and pharmacy pertaining to R5's antirejection medications. Pharmacist O reported to Surveyor the process for facilities to refill medications are to call in or fax a refill request. Pharmacy receives the request and turnaround time is within one day. Pharmacy reports if [NAME] Assistant needs any other information, then [NAME] Assistant will reach out to the facility and request the documentation needed and await facility's request. Pharmacist O reported it is common with this facility to not respond back to pharmacy in a timely fashion, so they have had to profile medications before. Surveyor asked Pharmacist O what profile means. Pharmacist O reported profile means after several attempts to communicate or gather pertinent information for prior authorizations and other insurance related concern, if facility has not gotten back to pharmacy within 3 attempts pharmacy puts the medication on standstill and discontinues the request to be re-filled, so pharmacy does not dispense until further notice is received. Surveyor asked Pharmacist O how important it is that R5 receive R5's antirejection medications for R5's status post kidney and pancreas transplant. Pharmacist O stated to Surveyor, It is critically important that [R5] receive his antirejection medications and to not stop abruptly without physician oversight due to [R5's] body rejecting the transplants. On 04/21/26 at 4:03 PM, Surveyor interviewed Pharmacist Business Assistant P and asked Pharmacist Business Assistant P to explain the timeline when facility requested R5's antirejection medications and when facility received the medications. Pharmacist Business Assistant P reported that facility sent a request to pharmacy on 02/20/26 at 3:20 PM. Pharmacist Business Assistant P reported since this was pharmacy's first interaction with the facility and R5's antirejection medication, Pharmacist Business Assistant P just needed a quick form filled out asking about the date R5 had a transplant, so that Pharmacist Business Assistant P could decipher between Medicare part B eligibility or if facility was going to be covering the medication costs until approved by insurance. This was sent on 2/20/26. Pharmacist Business Assistant P reported to Surveyor it is not uncommon to not hear from facility, so pharmacy tries to contact facility often but with minimal response back from facility. Pharmacist Business Assistant P reached out again on 02/21/26 for clarification if facility would cover the cost of the medication or to answer the questions on form, Documentation for Medicare Part B vs D. Pharmacist Business Assistant P reported there was no response from the facility, so Pharmacist Business Assistant P sent out requested documentation again on 02/23/26, 02/24/26, 02/25/26, and 02/26/26. Pharmacist Business Assistant P then profiled the request until facility reached out again. Pharmacist Business Assistant P reported to Surveyor it wasn't until 03/21/26, when facility reached out again for a refill request for antirejection medication for R5 to be refilled. Pharmacist Business Assistant P reported that Mycophenolate Mofetil was filled and dispensed to facility on 03/26/26 and Tacrolimus was filled and dispensed to facility on 03/26/26 after communication came back from Director of Nursing (DON) B the facility would cover the antirejection medication until facility can give the information requested to pharmacy. Surveyor asked Pharmacist Business Assistant P how the facility knows when they are receiving medications and what the medications are and for whom. Pharmacist Business Assistant P reported once pharmacy dispenses medications to facility, pharmacy courier drives to facility, and facility is given medications with a manifestation form stating when facility receives medications and how much is dispensed. On 04/22/26 at 11:17 AM, Surveyor interviewed Certified Nurse Assistant (CNA) F and asked about R5's mood and if R5 seems more depressed. CNA F reported that R5 usually is an unhappy guy since coming back from the hospital 02/06/26. CNA F is unsure why though. On 04/22/26 at 11:30 AM, Surveyor interviewed Assistant Director of Nursing (ADON) H and asked ADON H why R5 did not receive antirejection medications. ADON H reported R5 did not get antirejection medications due to insurance issues, but Surveyor would need to speak with DON B about the exact reason. Surveyor asked ADON H if ADON H is aware of R5's depression related to antirejection medications. ADON H reported to Surveyor, ADON H knows R5's wife and R5 were upset R5 was not receiving antirejection medications and concerned with R5's transplant being rejected. ADON H reported R5 has been secluding himself in R5's room due to transfer status and not being up to coming out and thinks the lack of antirejection medications could be a cause of the seclusion as well. On 04/22/26 at 12:34 PM, Surveyor interviewed DON B and asked for expectation for staff notifying provider on call for the unexpected discontinue use of antirejection medications for 37 days. DON B reported to Surveyor DON B started on 03/01/26 so DON B knows nothing prior to DON B starting with the facility, but staff should have let the provider on call know right away R5 was not receiving antirejection medications as those medications are critical to R5's health and making sure R5's body does not reject the transplant. Surveyor asked DON B what the reason was for pharmacy not refilling R5's antirejection medications. DON B reported the pharmacy has been notorious for not sending medications which are requested to be refilled. DON B reported pharmacy and the facility have a big meeting together this Thursday, 4/23/26, to address the concerns. Surveyor asked DON B's expectations on monitoring R5 for unexpected discontinuation of antirejection medications. DON B reported DON B's expectation would have been to monitor labs often and vitals on regular basis, which were not completed. Surveyor asked if DON B was aware R5 was becoming increasingly anxious, depressed and afraid of rejection issues due to not receiving antirejection medications from 02/20/26-03/28/26. DON B reported DON B was aware of the concern R5 had of not receiving antirejection medications but what was DON B supposed to do, when it was the pharmacy who was not sending the medication. Surveyor asked if DON B filled out the requested form from pharmacy asking for more documentation about R5's transplant from 2004 for pharmacy to refill the antirejection medications. DON B reported to Surveyor, DON B did fill out the form and sent it back to pharmacy but would need to look for the information on DON B's computer. Surveyor requested the email chain of communication between pharmacy and DON B and the form of documentation request filled out. On 04/22/26 at 1:05 PM, DON B reported to Surveyor that DON B could not find the form for documentation the pharmacy requested when facility asked for refill on R5's antirejection medication. DON B reported DON B did not start emailing communication to the account manager and pharmacy until 03/26/26 pertaining to R5's antirejection medications. On 04/22/26 at 4:31 PM, Surveyor interviewed Nurse Practitioner (NP) L and asked NP L if NP L was aware R5 did not receive antirejection medications for 37 days. NP L reported the facility only contacted NP L one time around 02/20/26 or so stating R5 was out of antirejection medication, and the facility requested a refill. NP L had no further orders as NP L was under the impression R5 would only be out short term. Surveyor asked NP L what short term meant. NP L reported that short-term means, maybe 24 hours. NP L reported NP L would have placed some parameters in place to assess R5 for the sudden discontinued use of antirejection medications. NP L stated, I would have expected vitals being done daily or at least weekly with labs being drawn as well periodically assessing kidney function levels. NP L reported to Surveyor it is very critical R5 not abruptly discontinue antirejection medications. NP L reported after R5 had hospitalization 02/04/26-02/06/26 he was readmitted back to facility with infection in the urine and a small Acute Kidney Injury (AKI), but NP L has been watching creatine levels and ALT, AST levels. R5 is doing ok with no changes on levels. NP L reported the expectation would be that staff would notify NP L immediately with changes in medications as crucial as antirejection medications and crucial steps could be taken to try to retrieve the antirejection medications STAT. NP L stated, I was not aware it was greater than 30 days [R5] went without antirejection medications. Example 2 R3 was re-admitted to facility on 01/16/26 with diagnoses of end stage renal, acute posthemorrhagic anemia, type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, portal hypertension, unspecified cirrhosis of liver, kidney transplant, unspecified hydronephrosis, hypotension, diastolic heart failure, acute respiratory failure with hypoxia, arteriovenous fistula, traumatic brain injury, dependence on renal dialysis, kidney transplant infection, and history of sepsis. Surveyor reviewed R3's care plan: R3 is on an anticonvulsant medication related to nontraumatic intracranial hemorrhage, prophylactic initiated on 06/28/24, revised on 01/28/25. Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Date revised on 06/28/2024. -Lab monitoring by MD orders revised on 06/28/24. -Monitor side effects every shift and as needed revised on 06/28/24. -Targeted behavior: Seizure activity revised on 06/28/24. Surveyor reviewed R3's physician orders: -Lacosamide oral tablet 100mg, give 1 tablet by mouth two times a day for seizures. Ordered on 01/17/26. -Monitor VS (vital signs) Monday, Wednesday, and Friday. Notify MD of abnormalities. Ordered on 06/28/24. Surveyor reviewed R3's Medication Administration Record (MAR): -On 03/28/26-03/31/26, Lacosamide was signed out as not given and/or held. Surveyor reviewed R3's progress notes, which states, -On 03/28/26 at 8:39 AM, Note Text: Lacosamide Oral Tablet 100 MGGive 1 tablet by mouth two times a day for seizures. Not available, ordered. -On 03/29/26 at 1:32 AM, Note Text: Lacosamide Oral Tablet 100 MGGive 1 tablet by mouth two times a day for seizures. Not available. -On 03/29/26 at 7:17 AM, Note Text: Lacosamide Oral Tablet 100 MGGive 1 tablet by mouth two times a day for seizures. Ordered but not received. -On 03/30/26 at 4:33 AM, Note Text: Pharmacy called for refill of Lacosamide 100mg. E-script request sent via pharmacy staff to provider. Awaiting arrival. -On 03/30/26 at 6:40 AM, Note Text: Lacosamide Oral Tablet 100 MGGive 1 tablet by mouth two times a day for seizures. Pending delivery. -On 03/30/26 at 5:54 PM, Note Text: Lacosamide Oral Tablet 100 MGGive 1 tablet by mouth two times a day for seizures. Order to hold until arrival from pharmacy. On 04/22/26 at 12:34 PM, Surveyor interviewed DON B and asked if DON B knew that R3 did not receive R3's lacosamide anticonvulsant medication as ordered between 03/28/26-03/31/26 before R3 was transferred to the hospital. DON B reported to Surveyor DON B did not even know R3 was on an anticonvulsant as R3 does not have a seizure diagnosis. Surveyor asked DON B's expectations regarding medications being filled as soon as possible to prevent negative outcomes. DON B reported R3's seizure medication should not have been missed but doesn't think it contributed to R3's hospitalization on 04/01/26. Surveyor asked DON B what parameters DON B has put into place to prevent medication errors from happening in the future. DON B reported DON B will be educating staff right away on medication errors and reporting the errors right away. DON B reported DON B has gone over medication error policy back on 04/09/26 to all staff but can see with the recent medication errors that Surveyors are finding there needs to be more education given to staff. DON B reported R3 should have received R3's anticonvulsant medication. On 04/22/26 at 4:31 PM, Surveyor interviewed Nurse Practitioner (NP) L and asked NP L if NP L was aware R3 did not receive anticonvulsant medication for 4 days straight prior to hospitalization on 04/01/26. NP L reported NP L was unaware R3 did not receive her anticonvulsant medication. NP L reported to Surveyor anticonvulsant medication is imperative to not stop abruptly as it is used to prevent seizure activity from happening. NP L reported there should have been parameters put into place to try and get the medication right away. Example 3 R2 was admitted to the facility on [DATE] with diagnoses that include enterocolitis due to clostridium difficile, chronic atrial fibrillation, congestive heart failure, and abdominal aortic aneurysm. R2 was re-admitted to the hospital on [DATE] and did not return to the facility. Minimum Data Set (MDS) dated [DATE] documented R2's Brief Interview for Mental Status (BIMS) score of 3, meaning severe cognitive impairment. R2's hospital Discharge summary dated [DATE] documented Follow-up Issues to Address: She will need a repeat INR drawn on 3/27/26 for ongoing monitoring of her warfarin anticoagulation. She will follow-up with the anticoagulation service on Monday, 3/30/26 for continued monitoring of her anticoagulation.Her INR was also supratherapeutic on admission at 5.6 and her warfarin was held. Her INR was down to 3.2 prior to discharge. She has been monitored as an outpatient by the anticoagulation service. Repeat INR on 3/28/26 was recommended for ongoing monitoring and she will follow-up with the anticoagulation service on 3/30/26.Discharge Medication Reconciliation.warfarin (warfarin 2.5 mg oral tablet) Special Instructions: Take one tablet by mouth once daily as a blood thinner. Review of facility's medication orders for R2 documented Warfarin Sodium Oral tablet 2.5 MG (Warfarin Sodium), (anticoagulation medication) Give 2 tablet by mouth at bedtime every Mon, Fri for anticoagulation factor and give 1 tablet by mouth at bedtime every Tue, Wed, Thu, Sat, Sun for anticoagul

Based on interview and record review, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 1 or 7 residents (R2). R2 has a history of an elevated international normalized ratio (INR) blood test for blood clotting time while taking an anticoagulant (blood thinner) medication. R2 did not receive adequate monitoring while receiving the anticoagulant medication in conjunction with an antibiotic. Registered Nurse (RN) C assessed R2 and found a large amount of blood in R2's stool, on an incontinent pad, and when R2 was rolled a large amount of blood expelled from R2's rectum. R2 was transferred to the emergency room and found to have a critical INR level of 9.3. R2 was given vitamin K and Kcentra to reverse the anticoagulation and prevent further bleeding. This is evidenced by:Facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol with revised date of April 2007, documented 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.The National Library of Medicine documented on 02/14/25 International Normalized Ratio: Assessment, Monitoring and Clinical Implications.Normal and Critical Findings.the therapeutic INR value ranges between 2.0 and 3.0 for patients on anticoagulant therapy. INR values exceeding 4.9 are considered critical and significantly increase the risk of bleeding.<According to https://www.ncbi.nlm.nih.gov/books/NBK441964/> Signs and symptoms of bleeding require vigilant monitoring upon initiation of warfarin since this is the most common adverse effect. There are multiple medications and herbal products that can potentiate or inhibit the effects of warfarin.However, drug-drug interactions usually lead to an increased INR.Antimicrobial (antibiotics) agents are one of the most common medication classes that can interact with warfarin. Some antimicrobials directly interfere with the metabolism of warfarin. including metronidazole, trimethoprim-sulfamethoxazole, and ciprofloxacin. These are usually considered major interactions .R2 was admitted to the facility on [DATE] with diagnoses that include enterocolitis due to clostridium difficile, chronic atrial fibrillation, congestive heart failure and abdominal aortic aneurysm. R2 was re-admitted to the hospital on [DATE] and did not return to the facility.Minimum Data Set (MDS) dated [DATE] documented R2's Brief Interview for Mental Status (BIMS) score of 3/15, meaning severe cognitive impairment. Anticoagulant medication is being taken. R2's hospital Discharge summary dated [DATE] documented Follow-up Issues to Address: She will need a repeat INR drawn on 3/27/26 for ongoing monitoring of her warfarin anticoagulation. She will follow-up with the anticoagulation service on Monday, 3/30/26 for continued monitoring of her anticoagulation.Her INR was also supratherapeutic (elevated level) on admission at 5.6 and her warfarin was held. Her INR was down to 3.2 prior to discharge. She has been monitored as an outpatient by the anticoagulation service. Repeat INR on 3/28/26 was recommended for ongoing monitoring and she will follow-up with the anticoagulation service on 3/30/26.Discharge Medication Reconciliation.warfarin (warfarin 2.5 mg oral tablet) Special Instructions: Take one tablet by mouth once daily as a blood thinner. Vancomycin 125 mg (antibiotic) oral capsule four times a day for clostridioides difficile infection duration 11 days.Review of facility's medication orders for R2 documented Warfarin Sodium Oral tablet 2.5 MG (Warfarin Sodium), (anticoagulation medication) Give 2 tablet by mouth at bedtime every Mon, Fri for anticoagulation factor and give 1 tablet by mouth at bedtime every Tue, Wed, Thu, Sat, Sun for anticoagulation factor starting 03/27/26.Of note, this warfarin order is not consistent with R2's discharge order. R2's discharge order indicated 2.5 mg daily. The facility transcribed 2.5 mg (two tablets) on Mondays and Fridays and 2.5 mg (one tablet) Tue, Wed, Thu, Sat, Sun. As written in R2's MAR (Medication Administration Record) R2 received an extra dose of 2.5 mgs of warfarin on Mondays and Fridays.Vancomycin HCL oral capsule 125 mg by mouth four times a day for clostridioides difficile infection until 04/08/26. Start date of 03/28/26. Prednisone oral tablet 20 mg, give 2 tablets by mouth two times a day for cough for 5 days. Start date of 03/30/26.On 04/08/26 at 3:06 PM, by Regional Clinical Specialist M created an order for PT/INR every Monday and Thursday with a start date of 3/27/26. R2's progress notes documented on 03/30/26 at 9:57 PM, Physician Assistant wrote: Assessment & Plan: .8) Atrial fibrillation: - On warfarin anticoagulation per primary care. Follow-up with anticoagulation clinic today for repeat INR.On 03/31/26 at 12:04 AM, Nurse Practitioner (NP) L documented Nursing to reach out to [Name] Clinic ACC (Anticoagulation Clinic) for warfarin dose.On 04/03/26 at 10:50 AM Late entry note from NP L documented Spoke with DON (Director of Nursing) and was assured Nursing reached out to [Name] Clinic ACC for warfarin dosing/INR monitoring.There is no documentation in R2's progress notes indicating staff updated the ACC of prednisone medication being started. On 04/23/26 at 3:45 PM, Surveyor interviewed NP L about R2's INR and warfarin dosing. NP L stated that when a resident is admitted to the facility NP L would request for the anticoagulation clinic (ACC) to follow the resident and to prescribe an INR therapeutic level, warfarin dose and when to recheck INR. NP L asked the Director of Nursing (DON) to follow up with the ACC for R2's dosing and this was noted in NP L's progress note. NP L had not seen changes of the warfarin and DON assured NP L the nurses were in contact with ACC. Surveyor asked when R2 was started on prednisone would R2 need additional monitoring of INR since prednisone and vancomycin have the potential to increase INR levels. NP L stated that when a new medication is added or changed the ACC should automatically be updated with the change and the ACC would adjust medication and INR testing accordingly. On 04/23/26 at 4:09 PM, Surveyor interviewed Registered Nurse (RN) D and RN C about process of obtaining a resident's INR and results. RN D stated they would obtain INR with point of care testing and call the ACC with the results. The ACC would give a verbal order for next steps, and the ACC would fax over the order. This would be documented in the resident's progress notes and the order for the next time to draw would be entered into the resident's orders in the electronic medication administration record. Surveyor asked if a paper INR/Warfarin log is used to document results and orders. RN D and RN C stated no, never seen a paper log. Orders would be scanned in and documented in the computer. RN C stated RN C worked with R2 twice and did not obtain any INRs. RN C stated there were no orders to obtain INRs for R2.Of note, despite R2's discharge summary indicating the facility should obtain an INR this was not transcribed in R2's medical record and INRs were not completed. Surveyor reviewed R2's medical record and confirmed there were no orders transcribed to complete an INR and no INR results obtained for R2.RN C reviewed R2's orders on the computer and confirmed no documented INRs, ACC orders and the order to obtain INRs on Monday and Thursday were entered on 04/08/26 this was two days after R2 was sent to the hospital. RN C stated RN C found R2 in bed with the incontinent pad soaked with blood. When R2 was rolled on to their side more blood expelled from R2's rectum. R2 had more bleeding when R2 was transferred with EMS to the stretcher. RN C stated there was more than a liter of blood. RN C stated RN C followed up with the ER about R2's status the ER stated R2 was admitted with an INR of 9.3.On 04/24/26 at 3:30 PM, Surveyor interviewed DON B asking for ACC documentation of INR results and warfarin orders. DON B stated there are no records from ACC only verbal orders. Surveyor asked where the order came from to check R2's INR on Monday and Thursday. DON B stated it was a facility's corporate order. Surveyor asked when the INR/Warfarin patient logs began. DON B stated the logs started on 04/09/26. Surveyor asked where did R2's information for the INR/Warfarin patient log come from. DON B stated Regional Clinical Specialist M gave DON B the information to write on the log from the computer. Surveyor asked if DON B was able to locate the same information in the computer. DON B stated no.R2 received physician orders upon hospital discharge to receive warfarin 2.5 mg oral tablet daily and to monitor R2's INR. The facility did not transcribe these orders and R2 received warfarin 2.5 (2) every Mon, Fri and 1 tablet by mouth at bedtime every Tue, Wed, Thu, Sat, Sun, R2 previous warfarin dose, and no INRs were completed. R2 was receiving medications that can increase bleeding risk when taken in conjunction with warfarin; however, the facility did not increase monitoring or notify to anticoagulation clinic as ordered. R2 was hospitalized with a supratherapeutic INR requiring vitamin k.

Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less for 1 error out of 10 medication opportunities, resulting in an error rate of 10%. This had the potential to affect 1 of 1 resident (R) observed for medication administration. (R10) ~ R10 received topical medication without prior measurement for correct dosing. This is evidenced by: The facility policy titled, Administering Medications, dated December 2009, states: Medications shall be administered in a safe and timely manner, and as prescribed. The facility policy titled Administering Topical Medication, undated, states: Purpose: To ensure the safe, accurate, and compliant administration of topical medications in accordance with Wisconsin nursing home regulations, promoting resident safety and preventing medication errors. Administration of Topical MedicationsPerform hand hygiene . Apply medication a. Use thin, even layer unless otherwise ordered. b. Use applicator or glove hand.The packaging insert titled, Voltaren Gel, updated Jun 16, 2025, states: The dosing card can be found attached to the inside of the carton. The proper amount of VOLTAREN GEL should be measured using the dosing card supplied in the drug product carton. The dosing card should be used for each application of drug product. The gel should be applied within the rectangular area of the dosing card up to the 2-gram or 4-gram line.R10 was admitted to the facility on [DATE] with the following related diagnoses of low back pain, difficulty walking, spondylopathy: lumbosacral region, pain in left shoulder, and pain in left knee. R10 has moderate cognitive impairment and is forgetful at times, has clear speech and is easily understood and understands others' conversations. R10 can make R10's needs known. R10 needs assistance for mobility and activities of daily living such as toileting, showering, and dressing.R10's orders state:Voltaren external gel 1% (Diclofenac Sodium (Topical) Apply to left knee topically two times a day for left knee pain not to exceed 4g/application, 16gm/joint/day, or 32gm total/day.On 4/21/26 at 12:11 PM, Surveyor observed Certified Medication Aide (CMA) E prepare Voltaren topical gel for R10. Surveyor observed CMA E squirt two lines of gel into a plastic medication cup. CMA E then took the medication to R10's room and administered the medication. CMA E donned gloves and took his fingers and scooped out gel and rubbed it into R10's left knee and then scooped out the remaining gel and rubbed it into R10's back. On 4/22/26 at 3:07 PM, Surveyor interviewed CMA E and asked how do you know how many grams you are administering. CMA E stated it doesn't say how much you are supposed to put on. CMA E stated I was taught to put one squirt in the cup for each area. CMA E stated you do not need a lot; they are not huge squirts; you put on a thin layer. CMA E picked up the medication cup and stated I don't think you can use these things to measure. CMA E stated again that he learned through school, and no one here has ever showed me or said different. Surveyor asked CMA E if he had ever seen the dosing card that comes with Voltaren gel. CMA E said he had not.On 4/22/26 at 4:15 PM, Surveyor interviewed Director of Nursing (DON) B and asked what the facility policy is regarding administering topical medications. DON B stated the nurses should verify the correct medication with the order in the MAR (medication administration order) prior to administration. Surveyor asked how they ensure the residents are receiving the correct dosage of a topical medication. DON B stated I'm not sure, it is usually just a thin layer. Surveyor asked DON B if Voltaren gel requires measuring dosage beyond a thin layer. DON B stated I don't think there is anything different. Surveyor inquired if DON B was aware of the dosing card and printing on the Voltaren box. DON B stated she did not think so. Surveyor followed DON B to the medication cart. CMA E stated he found the dosing card in the other cart. CMA E could not find it in the cart he was working with. Surveyor followed DON B to the medication room and looked at the stock supply of Voltaren gel. DON B opened the box and located the plastic dosing card. DON B stated she had never seen that and would complete training for nursing staff.

Based on staff interview and record review, the facility did not ensure 1 resident (R3) of 1 resident reviewed for intravenous therapy received intravenous care consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. R3 was re-admitted to the facility on [DATE] with a PICC (Peripherally Inserted Central Catheter) which is a soft, thin, flexible tube in a vein used to administer IV (Intravenous) medications. The facility did not administer IV medications or complete PICC line care as physician orders state. Findings include:R3 was re-admitted to facility on 01/16/26 with diagnoses of end stage renal disease, acute posthemorrhagic anemia, type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, portal hypertension, unspecified cirrhosis of liver, kidney transplant, unspecified hydronephrosis, hypotension, diastolic heart failure, acute respiratory failure with hypoxia, arteriovenous fistula, traumatic brain injury, dependence on renal dialysis, kidney transplant infection, and history of sepsis.Surveyor reviewed R3's care plan:R3 is on antibiotic therapy IV (intravenous) daptomycin related to infection, abdominal pelvic abscess, initiated on 12/07/25, revised on 01/27/26.Interventions:-Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness, initiated on 12/07/25, revised on 02/12/26.-Observe/document/report as needed adverse reactions to antibiotic therapy, initiated on 01/27/26, revised on 02/12/26.-Report pertinent lab results to provider, initiated on 01/27/26, and revised on 02/12/26.Surveyor reviewed R3's physician orders:-Flush IV every 8 hours. Sodium Chloride flush 9% three times a day, every shift for patency, ordered on 01/16/26, discontinued 04/02/26.-Flush PICC line every 8 hours, ordered on 01/16/26, discontinued 04/02/26.-Central venous catheter (PICC)- measure arm circumference (3 inches or specify length) above insertion site on admission, with each dressing change, and prn (as needed): one time only on admission for 1 Day and every day shift every Friday and as needed, ordered on 01/19/26 and discontinued on 04/02/26.-PICC: Central venous catheter (PICC)- measure external catheter length, on admission, with each dressing change, and as needed every Friday and Sunday day shift, ordered on 01/19/26, and discontinued on 04/02/26. -IV - central venous catheter - change catheter site dressing: 24 hours post PICC insertion, every week and as needed with transparent dressing, change catheter securement device every week and as needed, and every day shift every Friday, ordered on 01/19/26 and discontinued 04/02/26.-PICC (all types)-change needless connector on admission, weekly, and as needed thereafter unless TPN (then change every 24 hours) and change every blood draw as needed and every day shift every Friday, ordered on 01/19/26, and discontinued on 04/02/26.-PICC (valved) when being used intermittently flush with 10ml of normal saline, infuse medication and then flush with 10ml of normal saline every shift, ordered on 01/19/26, and discontinued on 04/02/26.-PICC line dressing change due every 7 days, every night shift on Friday for dressing change, ordered on 03/13/26, and discontinued 04/02/26.-PICC site monitor every shift for signs/symptoms of infection and/or infiltration every shift for monitoring, ordered on 01/19/26, and discounted on 04/02/26.-Daptomycin intravenous solution reconstituted, use 501.6 mg intravenously in the afternoon every Monday and Wednesday after dialysis for abscess until 04/17/26. And use 752.4 mg, intravenously in the afternoon every Friday after dialysis for abscess at least until next ID (infectious disease) appointment on 04/17/26, ordered on 02/16/26, discontinued on 04/02/26. -Daptomycin intravenous solution reconstituted, use 752.4 mg intravenously in the afternoon every Friday after dialysis for abscess at least until next ID appointment on 04/17/26, ordered on 02/20/26, discontinued on 04/02/26. Surveyor reviewed R3's Medication Administration Record (MAR) between 02/01/26-04/01/26:-On 02/01/26-04/01/26, Normal Saline flushes were not administered consistently and were signed out as not given and/or held or blank indicating not administered every 8 hours.-On 03/13/26 and 03/27/26, PICC line measuring arm circumference above insertion site was not documented, completed or performed.-On 03/13/26, measuring external catheter length was not documented, completed or performed.-On 03/09/26 and 03/23/26, Daptomycin intravenous solution 501.6 mg in the afternoon every Monday and Wednesday, intravenously was not administered on both days.-On 03/13/26 and 03/27/26, Daptomycin intravenous solution 752.4 mg in the afternoon every Friday, intravenously was not administered on both days.-On 03/13/26 and 03/27/26, PICC line needless connector change was not documented, completed or performed.Surveyor reviewed R3's hospital notes, dated 04/01/26, which state, .Resident [R3] known for non-operable chronic pelvic abscess on chronic antibiotics as well as dialysis with frequent admissions for sepsis was brought into the ER after being found minimally responsive at nursing home. According to nursing home R3 has had increased shortness of breath as well as confusion. R3's PICC line was accidentally removed in the nursing home sometime in the last 24 hours.Surveyor reviewed Emergency Medical Transport (EMT) report, dated 04/01/26, that does not indicate R3 has a PICC in place during transport from nursing home to the ER.Surveyor reviewed documentation in R3's medical record at facility noting R3's PICC line dressing in R3's MAR was changed on 03/13/26, 03/20/26, and 03/27/26. However, Surveyor reviewed a photo date stamped on 03/30/26. The photo on 3/30/26 shows R3's PICC line dressing with staff initials dated 03/13/26. The data written on PICC line dressing indicated R3's PICC line dressing had not been changed every 7 days as ordered. On 04/21/26 at 9:10 AM, Surveyor interviewed Licensed Practical Nurse (LPN) U and asked if LPN U remembers R3 and the PICC line care for R3. LPN U reported that LPN U did not do anything with R3's PICC line and that dialysis usually completes all the PICC line care. Surveyor asked LPN U if she was the nurse on duty on 4/1/26 when R3 had a change of condition. LPN U stated yes. Surveyor asked LPN U if she remembers if R3 had a PICC line in place. LPN U stated, If I recall correctly [R3] had a PICC line in [R3's] right arm and it was patent. Surveyor asked LPN U how LPN U knows the PICC line was patent for R3. LPN U reported that Registered Nurse (RN) D performed PICC line care for R3. Surveyor asked LPN U to explain why LPN U has signed initials on R3's MAR that R3's external catheter length was measured as completed, every 8-hour PICC line flushes were completed by LPN U, but the dressing change for R3's PICC line was signed initials by LPN U but noted 9 as not administered. LPN U reported that LPN U is unsure why LPN U's initials are on R3's MAR but that LPN U does not do anything with R3's PICC and could have been RN D or someone else. On 04/21/26 at 9:27 AM, Surveyor interviewed RN D and asked RN D if RN D had any concerns with R3's PICC line and was the PICC line in place upon transfer to the ER on [DATE]. RN D reported that R3's PICC line functioned well throughout R3's stay. RN D reported that RN D thinks R3 had a PICC line in before being transferred out to the ER on [DATE], but not 100% certain. RN D reported that RN D never heard any PICC line concerns prior to R3 being transferred to ER.On 04/21/26 at 10:41 AM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B knew of any concerns with R3's PICC line prior to R3 being transferred to the ER. DON B reported that DON B did not hear there were concerns. Surveyor asked if DON B knew if R3's PICC line was in place prior to being transferred to ER. DON B reported that DON B is unsure and would need to review R3's medical record. DON B reviewed R3's medical record and reported no progress notes stating that R3's PICC line had been taken out by accident or not functioning properly. Surveyor asked DON B for the expectations of nursing staff assessing PICC lines, administering IV medications, PICC line dressing changes, along with measuring PICC line length and arm circumference. DON B reported that all nursing staff are to complete physician orders as ordered. Surveyor asked if DON B was aware that the management of R3's PICC line care was a concern and that staff missed administering normal saline flushes every 8 hours as ordered consistently from 02/01/26 - 04/01/26, on 03/13/26 and 03/27/26, measuring arm circumference above insertion site was not documented, completed or performed. On 03/13/26 measuring external catheter length was not documented, completed or performed. On 03/09/26 and 03/23/26, Daptomycin intravenous solution 501.6 mg given intravenously was not administered on both days. On 03/13/26 and 03/27/26, Daptomycin intravenous solution 752.4 mg given intravenously was not administered on both days. On 03/13/26 and 03/27/26, PICC line needless connector change was not documented, completed or performed. On R3's MAR documentation staff signed out that R3 received PICC line dressing changes on 03/13/26, 03/20/26, and 03/27/26 but a photo shows the PICC line dressing change in place to PICC line dated 03/13/26 with staff initials. Surveyor asked if DON B knew that the dressing change had a date of 03/13/26. DON B reported that DON B was not aware of that concern. DON B reported expectations would be staff administer IV antibiotics on time and as ordered. DON B reported to Surveyor that all nursing staff should follow all provider orders on time. If staff cannot complete the orders such as the dressing change or measurements of the length of PICC line catheter, then staff are to notify DON B and provider on call to receive new orders or directions on how to move forward and why the orders cannot be followed.

Based on interview and record review, the facility did not ensure the resident (R) maintained acceptable parameters of nutritional status for 1 out of 3 residents reviewed. (R1)~ Facility did not implement daily weights per admission orders for R1. R1 experienced a 11-pound weight loss, 9.55% in the first 17 days. ~ Facility did not ensure a registered dietician assessment of the nutrition status and diet orders for resident with tube feeding with admission.Findings include:The facility policy titled, Enteral Nutrition, dated November 2011, states:1. A dietician will assess residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings.2. If a dietician is not available prior to the first feeding, the Dietician on call will be contacted. The Dietician will review admission information with the nursing staff and physician to determine the initial orders.R1 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, acute kidney failure, dysphagia oropharyngeal phase, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R1 was moderately impaired cognitively and forgetful but staff state R1 could make his needs known. R1 received nutrition via tube feeding.R1's care plan states: Focus: The resident has nutritional risk r/t (related to) CHF, CAD (coronary artery disease), .dysphagia (difficulty swallowing); need for tube feed; underweight BMI (body mass index). ~ Monitor/record/report to MD PRN (as needed) s/sx (signs and symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. in 1 week, >5% in 1 months, >7.5% in 3 months, >10% in 6 months Date initiated 2/26/26.~ Monitor: intake, weight, skin, labs, medication, diet tolerance and hydration status. Dated initiated 2/26/26.~Resident will maintain weight w/o (without) significant weight changes. Dated Initiated 2/26/26.~3/10/26 Resident triggered wight loss 10% in 30 days. RD (Registered Dietician) consult, MD aware. Date initiated 2/26/26. Revision on 3/27/26.~ Daily weights. Date initiated 3/27/26. Revision 3/27/26~Nursing will inform MD/family/POA (Power of Attorney) of significant weight changes. Date initiated 3/27/26.R1 has a swallowing problem related to dysphagia.~The resident will maintain weight and nutritional balance through the review date. Date initiated: 4/9/26 Target Date. 6/7/26.Resident disconnects tube feeding, dated 2/16/26.R1's admission orders from PAM (Post-Acute Medical) clinic discharge packet orders state Weigh patient daily at 5am.R1's weights were:~2/16/26 - 115.2 lbs. ~ 2/17/26 through 3/5/26 there are no weights documented.~3/6/26- 104.2 lbs., this is an 11 lb. weight loss/9.55%.~3/7/26- no weightR1's order from the Heart Failure Clinic dated 3/8/26 states, Daily weights in the morning.Weights completed daily from 3/8/26 to 3/22/26, 3/24/26 through 3/27/26, and 3/29/26 through 4/4/26. R1 did not have weights documented and there were no refusals of weights on 3/23/26 and 3/28/26. Review of R1's Medical Administration Record (MAR), R1 was receiving nutrition orders as prescribed by physicianR1 did not receive a registered dietician assessment until 3/13/26; 7 days after weight loss was identified.Surveyor asked Assistant Director of Nursing (ADON) H to print all notes from nutrition services and the dietician. The only note for dietary and nutrition services is dated 3/13/26. Note states: Saw resident today r/t (related to) recent weight loss. CBW (current body weight) (3/13): 105.6, BMI: 16.5 (underweight). WT (weight hx (history): 3/12 105.6, 3/6 104.2, 2/16 115.6# (30D:-8.3% significant weight loss since admission.). On 3/16/26, R1's weight was 92.0 lbs. Indicating a 23.2 lb. weight loss or 20.14% loss.Nursing Progress notes dated 3/20/26 state R1 turned off tube feeding. On 4/21/26 at 3:43 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F who stated we know who needs weights from our Point of Care (electronic medical record) access. Some residents are weighed daily, and everyone is weighed at least once a month. We weigh all residents on admission. If a resident refused to be weighed, we should document refused. We would have weighed R1 on admission. I don't recall if he received daily weights right away or after he started losing weight and was changed to a daily weight.On 4/22/26 at 8:59 AM, Surveyor interviewed Registered Nurse (RN) C who stated admission orders are put in the medical record by the nursing staff. We enter the orders in and add interventions to the resident's care plan. RN C stated I think Director of Nursing (DON) B checks all the orders. On 4/22/26 at 9:20 AM, Surveyor interviewed DON B who stated, the document she provided Surveyor from Post Acute Clinic (PAM) were the admission orders. DON B stated the RN on duty enters the orders into the computer. Surveyor reviewed orders with DON B. DON B read out loud the order daily weights at 5am. DON B stated we did not start daily weights with admission. On 4/22/26 at 9:22 AM, Surveyor interviewed DON B who stated the registered dietician is part of the care of residents with tube feedings and special diets. Surveyor asked if the dietician reviews and assesses resident special diets when the resident is admitted . DON B stated the dietician does assess everyone's diets and weights, but we initially follow the admission orders. DON B stated that the dietician was involved when R1 started losing weight. Surveyor asked DON B about the facility policy which states residents with an enteral feeding receive a dietician assessment at admission. DON B stated again, we follow the physician's order with admission. Surveyor asked DON B about R1. DON B stated that R1 is no longer here. DON B stated he was here post-acute care for nursing care related to his tube feeding. DON B stated that he was difficult because R1 was always stopping his tube feeding, and this resulted in R1 losing weight. DON B stated R1 also had diarrhea and didn't want staff to flush his tube with water because he felt the water flushes caused the diarrhea. Surveyor reviewed R1's Certified Nursing Assistant (CNA) charting in tasks with ADON H. ADON H pulled up the Kardex charting and printed a report for Surveyor. R1's bowel movements were monitored and tracked. There was no documentation in CNA charting regarding R1 having diarrhea. R1 received bolus feedings from 2/16/26 through 3/7/26. R1's order changed to, One time a day enteral nutrition via continuous NOC (night): Nepro 1.5 cal; 1,320 ml over 8 hrs. start 3/7/26.R1 had weight loss, and the facility did not complete daily weights as ordered by physician. Facility dietician did not assess R1 until after R1 had weight loss.

Based on interview and record review, the facility did not ensure a thorough investigation of an allegation of abuse for 1 of 1 abuse investigations reviewed involving (R11 and R12). On 3/29/26, the facility was made aware that R12 yelled at R11 to shut up and if R12 did not shut up R11 would help R12 to shut up.~ There was no formal investigation of the incident.~ There was no care plan intervention to protect R11 from R12 from further verbal abuse. \Findings include:The facility policy titled, Abuse Prevention Program, dated August 2006, states: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility policy titled, Reporting Abuse to Facility Management, dated April 2010, states: It is the responsibility of our employees, facility of our employees, . To promptly report any incident or suspected incident of neglect or resident abuse.2. To help with recognition of incidents of abuse, the following definitions of abuse are provided:b. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability.13. A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator within ___ hours of the occurrence of an incident of suspected abuse. An immediate investigation will be made a copy of the findings of such investigation will be provided to the Administrator within ___ working days of the occurrence of such incident. The facility policy titled Abuse Investigations, dated April 2010, states: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management.6. The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted.12. The result of the investigation will be recorded on approved documentation forms.15. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. Per State Operations Manual Appendix PP, revised 8/8/24, it states, A resident-to-resident altercation should be reviewed as a potential situation of abuse. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Nursing homes are mandated to protect residents from abuse, including resident-to resident altercations. Facilities must investigate all incidents, assess residents for injures, develop care plans to prevent recurrence, and report incidents. On 4/22/26 at 6:12 PM, Surveyor interviewed Certified Nursing Assistant (CNA) G regarding potential abuse in the facility and procedures for staff. CNA G stated there was an altercation between two residents, R11 and R12. CNA G stated R11 was heard yelling at R12, telling R12 to shut up or R11 would help shut R12 up. On 4/23/26 at 10:08 AM, Surveyor interviewed R11 who stated that R12 just lives down the hall. R11 says we visit sometimes. R11 stated that R12 gets loud sometimes and irritates R11. R12 states I just yell at R11 to shut up. R11 stated I don't think I'd hurt him but wanted to shut him up. On 4/23/26 at 10:30 AM, Surveyor reviewed R11 and R12's progress notes, medical records and care plans. There is no documentation in R11 or R12's medical record regarding an altercation between R11 and R12.On 4/23/26 at 12:37 PM, Surveyor interviewed Social Services Director (SSD) I who stated SSD I was not there when R11 was yelling at R12. SSD I stated she heard about it. SSD I stated R12 can be loud, loves to sing, and is repetitive verbally and in his actions, although he hasn't been doing that this week. SSD I stated that R11 gets irritated by R12 and has been heard yelling at R12 to shut up. Surveyor told SSD I that one CNA told Surveyor that R11 was heard telling R12 he would help shut him up. SSD I said I wouldn't be surprised. Surveyor asked SSD I what procedure the facility follows when there is an allegation of verbal abuse. SSD I stated the usual procedures is the CNA would let the nurse know, the nurse would report it to the Director of Nursing (DON) or Nursing Home Administrator (NHA), who would start the investigation. On 4/23/26 at 1:22 PM, Surveyor interviewed Licensed Practical Nurse (LPN) J. LPN J was the nurse working the evening of incident between R11 and R12. LPN J stated I did not witness the situation, she heard R11 yelling at R12, everyone did. LPN J stated she doesn't recall what was said but could hear they were yelling in the dining room. LPN J stated R11 and R12 were in the dining room and it happened before LPN J got into the dining room. LPN J stated she reported the fall and we all talked about hearing them yell at each other.On 4/23/26 at 12:49 PM, Surveyor interviewed DON B regarding resident to resident abuse. DON B stated that when there is a resident-to-resident altercation we try to separate them. We would have moved R11 and R12 apart. DON B stated she remembers when it was reported that they were yelling in the dining room. DON B is not certain the date. They were hollering at each other. DON B stated whenever there is an incident her staff let her know. DON B stated that she then lets NHA A know and gets direction from NHA A. Usually NHA A does the investigation and interviews. DON B stated Surveyor should ask NHA A about the investigation. On 4/23/26 at 12:59 PM, Surveyor interviewed NHA A regarding abuse, investigations, and reporting. NHA A stated you report to State when there is abuse, neglect, falls with injury, elopements and misappropriation. NHA A stated yes, you would report resident to resident physical altercations. Surveyor asked what about verbal. NHA A stated only if emotional or mental distress is noted. NHA A expects staff to communicate with NHA A, and he will assess the situation and complete an investigation. Surveyor asked if there was an investigation regarding the incident between R11 and R12 in the dining room on 3/29/26. NHA A stated there is no formal investigation, they were just yelling at each other. I only do paper documentation if it is reportable. NHA A stated if I am told about things I look into them but do not always document it, everyone was fine. NHA stated he was not here when the altercation occurred. Surveyor asked NHA A what constitutes verbal abuse. NHA states when someone is yelling threatening things. Surveyor asked what they were yelling about, do you have documentation that says what was said. NHA A stated no, they were just yelling. If I investigated every time someone yelled at someone that is all I would do. I can't do that. Surveyor asked clarifying question to which NHA A stated yes it was in the dining room and unwitnessed. Staff heard the altercation. On 4/23/26 at 2:32 PM, DON B brought Surveyor a 1 page document that was created on 4/23/26. It was unclear what the document was referencing, and it was not signed by the creator either. Surveyor took it back to DON B who stated she just did it. DON B wrote on the form the date of the incident between R11 and R12. DON B stated she just found out the details of the incident and completed an interview because the Surveyor brought it to her attention. Surveyor stated to DON B it is my understanding you were aware R11 and R12 were yelling at each other in the dining room on 3/29/26. The facility was aware of the verbal altercation between R11 and R12. R12 stated R11 needed to shut up or R12 would shut R11 up. This was not investigated as an allegation of abuse nor were interventions put in place to protect R11.

Based on interview, and record review, the facility did not ensure a resident is free from verbal abuse perpetrated by a resident for 1 (R12) of 5 residents reviewed for abuse. On 3/29/26, R11 was heard verbally yelling and threatening R12 to shut up and if R12 did not shut up R11 would help R12 to shut up. Findings include:The facility policy titled, Abuse Prevention Program, dated August 2006, states: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility policy titled, Reporting Abuse to Facility Management, dated April 2010, states:2. To help with recognition of incidents of abuse, the following definitions of abuse are provided:b. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability.13. A completed copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator within ___ hours of the occurrence of an incident of suspected abuse. An immediate investigation will be made a copy of the findings of such investigation will be provided to the Administrator within ___ working days of the occurrence of such incident. (Policy has these blanks, they are not completed in copy provided to surveyor.)Per State Operations Manual Appendix PP, revised 8/8/24, it states, A resident-to-resident altercation should be reviewed as a potential situation of abuse. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Nursing homes are mandated to protect residents from abuse, including resident-to resident altercations. Facilities must investigate all incidents, assess residents for injuries, develop care plans to prevent recurrence, and report incidents.R11 was admitted to the facility on [DATE] and has diagnoses that include alcohol abuse with intoxication, atrial fibrillation, chronic obstructive pulmonary disorder and sepsis. R11's Minimum Data Set (MDS) assessment, dated 2/23/26, indicated that R11 has clear speech, is easily understood and understands others. R11's Brief Interview for Mental Status (BIMS) scored a 12/15, meaning he is moderately cognitively impaired. R11 has no hallucinations, delusions or reported behaviors per the MDS. R11 requires partial to substantial assistance for personal care and activities of daily living. R11 can ambulate independently with a walker.R11's care plan dated initiated 2/18/26 and last revised on 3/16/26 has no care plan related to behaviors or interventions related to resident-to-resident altercations or incidents.R12 was admitted to the facility 2/6/23, and has diagnoses that include age related cognitive decline, malignant neoplasm of bladder, type 2 diabetes, prosthetic heart valve, and chronic kidney disease. R12's MDS, dated [DATE], indicated that R12 has clear speech, is easily understood and understand others. R12's BIMS was an 8/15, indicating that R12 is moderately cognitively impaired. R12 has no hallucinations, delusions or reported behaviors per the MDS. R12 needs partial to substantial assistance for hygiene and activities of daily living and touching supervision to dependent for assistance related to mobility.R12's care plan initiated 4/20/24 and revised on 5/20/24, states: [R12] has the potential to be physically aggressive r/t (related to) poor impulse control.Analyze times of day, places, circumstances, triggers, and what de-escalates behaviors and document. Date initiated 5/20/24.When the resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Date initiated 5/20/24.On 4/22/26 at 6:12 PM, Surveyor interviewed Certified Nursing Assistant (CNA) G regarding potential abuse in the facility and procedures for staff. CNA G stated there was an altercation between two residents, R11 and R12. CNA G stated R11 was heard yelling at R12, telling R12 to shut up or R11 would help R12 shut up. CNA G stated that R12 had fallen while R11 was yelling at him. CNA G stated no one witnessed the fall, but we all heard them yelling and the RN on duty knew about it. CNA G is not aware of any care planned interventions to monitor R11 and R12 when together or to keep them apart.On 4/23/26 at 10:08 AM, Surveyor interviewed R11 who stated that R12 just lives down the hall. R11 says we visit sometimes. R11 stated that R12 gets loud sometimes and irritates R11. R11 states I just yell at R12 to shut up. R11 stated I don't think I'd hurt him but wanted R12 to shut up. R11 states he doesn't know if R12 has ever fallen in the dining room.On 4/23/26 at 10:16 AM, Surveyor interviewed R12 who was unable to answer Surveyor's questions. R12 could not state if R12 had fallen in the dining room or ever argued with anyone in the dining room. R12 was able to state he feels safe and is not afraid of any staff or residents. R12 stated yes when asked if he knew who R11 was. R12 did not make any other response and walked away from Surveyor.On 4/23/26 at 10:30 AM, Surveyor reviewed R11 and R12's progress notes, medical records and care plans. There is no documentation in R11 or R12's medical record regarding an altercation between R11 and R12.On 4/23/26 at 12:37 PM, Surveyor interviewed Social Services Director (SSD) I who stated SSD I was not here when R11 was yelling at R12. SSD I started hearing about it. SSD I stated R12 can be loud, loves to sing, is repetitive, although he hasn't been doing that this week. SSD I stated that R11 gets irritated by R12 and has been heard yelling at R11 to shut up. SSD I stated she would not be surprised if the yelling was loud or that R11 told R12 to shut up. Surveyor told SSD I that one CNA told Surveyor that R11 was heard telling R12 he would help shut him up. SSD I said I wouldn't be surprised. SSD I doesn't know exactly what was said and believes that R11 was on other side of the dining room from R12 when R12 fell. SSD I stated that R12 is unsteady on his feet and not compliant with using his wheelchair. SSD I looked in computer and identified that the fall in dining room was documented 3/29/26. SSD I stated the usual procedure is the CNA lets the nurse know, the nurse would report it to the Director of Nursing (DON) or Nursing Home Administrator (NHA), and the NHA would start the investigation. On 4/23/26 at 1:22 PM, Surveyor interviewed Licensed Practical Nurse (LPN) J who was reported to be the nurse working the evening of incident between R11 and R12. LPN J stated I did not witness the situation, she heard R11 yelling at R12, everyone did. LPN J stated she doesn't recall what was said but could hear they were yelling in the dining room and LPN J was on the unit. LPN J stated R11 and R12 were in the dining room and it happened before LPN J got into the dining room. LPN J stated she was told by staff that R11 had fallen. LPN J stated she went into the dining room for that reason, R11 was not standing by R12. LPN J stated I'm not sure R11 was still in the dining room anymore. LPN J stated she reported the fall, and we all talked about hearing them yell at each other. LPN J is not aware of any care planned interventions to monitor R11 and R12 when together or to keep them apart.On 4/23/26 at 12:49 PM, Surveyor interviewed Director of Nursing (DON) B regarding resident-to-resident abuse. DON B stated in response, I just did an all staff regarding that and on what abuse is. DON B stated that when there is a resident-to-resident altercation we try to separate them. We would have moved R11 and R12 apart. DON B stated she remembers when it was reported that they were yelling in the dining room. DON B is not certain of the date but stated R12 fell that day too. They were hollering at each other. DON B stated I don't think they are related. DON B states whenever there is an incident her staff let her know they are very good about that. DON B states that she then lets NHA A know and gets direction from NHA A. Usually NHA A does the investigation and interviews. DON B stated Surveyor should ask NHA A about the investigation. DON B stated the care plan would be adjusted if there was a need. DON B stated we would have investigated the fall. Surveyor asked DON B for the fall investigation report and the schedule from 3/29/26. The schedule for 3/29/26 was not provided with schedules for this week.On 4/23/26 at 12:59 PM, Surveyor interviewed NHA A regarding abuse, investigations, and reporting. NHA A stated you report to State when there is abuse, neglect, falls with injury, elopements and misappropriation. NHA A stated yes, you would report resident to resident physical altercations. Surveyor asked what about verbal. NHA A stated only if emotional or mental distress is noted. NHA A expects staff to communicate with NHA A, and he will assess the situation and complete investigation. Surveyor asked if there was an investigation regarding the incident between R11 and R12 in the dining room on 3/29/26. NHA A stated there was no formal investigation, they were just yelling at each other. I only do paper documentation if it is reportable. NHA A stated if I am told about things I investigate them but do not always document it, everyone is fine. Surveyor asked NHA A what constitutes verbal abuse. NHA states when someone is yelling threatening things. Surveyor asked what they were yelling about, do you have documentation that says what was said. NHA A stated no, they were just yelling. If I investigated every time someone yelled at someone that is all I would do. I can't do that. Surveyor asked clarifying question to which NHA A stated yes it was in the dining room and unwitnessed. Staff heard the altercation. On 4/23/26 at 1:12 PM Surveyor reviewed the fall report NHA A provided. The fall report did not mention anything about R11 and R12 yelling in the dining room. On 4/23/26 at 2:32 PM, DON B brought Surveyor a 1 page document that was created on 4/23/26. It was unclear what the document was referencing, and it was not signed by the creator either. Surveyor took it back to DON B who stated she just did it. DON B wrote on the form the date of the incident between R11 and R12. DON B stated she just found out the details of the incident and completed an interview because Surveyor brought it to her attention. Surveyor stated to DON B it is my understanding you were aware R11 and R12 were yelling at each other in the dining room on 3/29/26.

Based on interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards before and after dialysis treatments the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 dialysis residents (R3) sampled out of a total of 9 sampled residents.The facility did not provide monitoring of R3's fistula access dialysis site, monitoring of R3 post dialysis treatments, and R3's vitals as ordered.This is evidenced by:The facility policy, titled Care of a Resident with End-Stage Renal Disease dated October 2009, states: .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.Education and training staff includes, specifically:the nature and clinical management of ESRD.The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis.Signs and symptoms of worsening condition and/or complications of ESRD.How to recognize and intervene in medical emergencies such as hemorrhages and septic infections.g. The care of shunts and fistulas.5. The residents comprehensive care plan will reflect the residents needs related to ESRD/dialysis care.R3 was re-admitted to facility on 01/16/26 with diagnoses of end stage renal, acute posthemorrhagic anemia, type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting unspecified side, portal hypertension, unspecified cirrhosis of liver, kidney transplant, unspecified hydronephrosis, hypotension, diastolic heart failure, acute respiratory failure with hypoxia, arteriovenous fistula, traumatic brain injury, dependence on renal dialysis, kidney transplant infection, and history of sepsis.Surveyor reviewed R3's care plan:R3 needs dialysis related to renal failure-fistula to left forearm -two failed kidney transplants and infected kidney transplant, initiated on 06/13/2024.Interventions:-On 9/30/24, Fistula construction rescheduled initiated on 09/30/24.-Administer medications as ordered, initiated on 10/12/2025, revised on 02/12/26.-Daily weights. Dialysis days pre and post weights initiated on 06/24/24, revised on 02/16/26.-Dialysis Monday-Wednesday-Friday. Time for Pick up:1230 by transportation. Transport to: Dialysis. It was initiated on 06/24/2024 and revised on 02/12/2026.-Do not draw blood or take blood pressure in arm with graft. Left forearm, initiated on 09/30/2024, revised on 02/12/2026.-Monitor fistula for thrill and bruit, update MD/NP immediately if not noted to left forearm, initiated on 06/24/2024, and revised on 02/12/2026.-Monitor left fistula and site for any concerns, if dressing falls off or is removed do not replace, if excessive bleeding noted hold pressure call 911, update MD/NP, initiated on 06/24/2024, revised on 02/12/206.-Monitor vital signs (VS), Monday, Wednesday, and Friday. Notify MD of abnormalities initiated on 06/24/2026.Surveyor reviewed R3's physician orders:-Monitor VS (vital signs) Monday, Wednesday, and Friday. Notify MD of abnormalities. Ordered on 06/28/24. -Dialysis Monday, Wednesday, and Friday, Left forearm graft fistula. Monitor fistula for thrill and bruit immediately, notify MD if not noted. Ordered on 06/28/24.-Daily weights on dialysis days pre and post weights. Ordered on 02/12/26.Surveyor reviewed R3's Medication Administration Record (MAR) and Treatment Administration Record (TAR) and Surveyor could not find documentation assessments of R3's fistula in left forearm. Surveyor could not find weights performed every Monday, Wednesday, and Friday pre and post dialysis.Surveyor reviewed all other of R3's progress notes dated 01/16/26-04/01/26.Surveyor could not find documentation that assessments of R3's fistula in left forearm were performed.Surveyor reviewed weight progress notes:-On 02/10/26 at 7:39 AM, 128.0 lbs.-On 03/10/26 at 3:53 PM, 120.0 lbs.-On 03/10/26 at 4:00 PM, 120.0 lbs.-On 03/11/26 at 2:21 PM, 120.0 lbs.-On 03/23/26 at 6:59 AM, 123.4 lbs.Surveyor could not find documentation that weights were completed every Monday, Wednesday, and Friday pre and post dialysis treatments.Surveyor reviewed R3's vital signs and found that vital signs were not assessed and documented as ordered every Monday, Wednesday, and Friday pre and post dialysis for the management of dialysis treatments and hypertension medications or reported to the provider of an abnormal B/P (blood pressure) result.R3's vital signs, states, .On 03/24/26 at 8:36 AM, B/P 186/105 mmHg, and on 03/30/26 at 6:41 AM, B/P 197/96 mmHg.Surveyor could not find that R3's provider on call was notified of abnormal B/P or any interventions put into place managing while R3 is on dialysis.Interviews:On 04/22/26 at 9:10 AM, Surveyor interviewed Licensed Practical Nurse (LPN) U and asked about the process of managing R3's care pre and post dialysis treatments. LPN U reported to Surveyor that R3 was to receive head-to-toe assessments, along with vitals, and report any abnormalities to provider on call and dialysis facility. Surveyor asked LPN U if that included R3's fistula site. LPN U reported to Surveyor that LPN U does not do anything to R3's fistula as that is out of LPN U's scope of practice.On 04/23/26 at 9:47 AM, Surveyor interviewed Registered Nurse (RN) D and asked for the process for assessing R3 pre and post dialysis. RN D reported that staff were to assess fistula in left forearm, assess vitals as ordered, and complete a head-to-to-toe assessment to monitor for any concerns. RN D reported that staff then document in R3's medical record on Dialysis Communication Form, that is sent back and forth to dialysis appointments every Monday, Wednesday, and Friday. RN D reported to Surveyor that the forms should be in R3's medical record.On 04/23/26 at 10:01 AM, Surveyor requested Director of Nursing (DON) B to provide Surveyor with Dialysis Communication Form for R3's dialysis treatments from 01/16/26 to present 04/23/26.Surveyor reviewed the facility form titled, Dialysis Communication Form for 01/02/26, 01/19/26, 02/02/26, 02/06/26, 02/11/26, and 03/02/26On 04/23/26 at 10:26 AM, Surveyor interviewed DON B regarding expectations for staff to assess R3 pre and post dialysis treatments. DON B reported to Surveyor that staff were to assess R3 from head-to-toe, gather vitals and weights every day. Surveyor asked DON B how staff should care for R3's fistula. DON B reported to Surveyor that staff should be monitoring for bruit or thrill and notify physician on call if there are any concerns. Surveyor asked DON B about the dressing to R3's fistula. DON B reported that staff were to assess it on every shift and if any abnormalities or concerns immediately notify DON B, dialysis unit, nephrologist, and provider for further direction. Surveyor asked DON B if R3 was being assessed pre and post dialysis treatments as ordered. DON B reported that staff were not accurately monitoring R3's care during dialysis treatments pre and post.

Based on observation, interview and record review, 1 of 3 residents (R5) at risk of falls did not receive adequate supervision and assistance devices to prevent potential accidents from occurring. R5 required the assistance of 2 staff for transfers with mechanical Hoyer lift. Staff continued to transfer R5 with a mechanical sit-to-stand lift, then to assist of 2 stand-pivot transfer.Findings include:R5 was re-admitted on [DATE], with diagnoses including in part, kidney transplant status, pancreatic transplant status, immunodeficiency due to drugs, diabetes mellitus with diabetic retinopathy, type 1 diabetes with polyneuropathy, dementia without behavioral disturbance, Charcot's joint of multiple sites acquired absence of right great toe, hypertension, foot drop of left foot, and osteoporosis. Minimum Data Set (MDS) dated [DATE] indicates R5 has Brief Interview for Mental Status (BIMS) scored 14/15, indicating R5 had intact cognition. MDS indicates R5's Activities of Daily Living (ADL) with transfers, dressing, and toileting requires substantial maximal assistance. Surveyor reviewed R5's ADL care plan initiated on 05/27/25, revised on 09/02/25.Interventions:-Toileting hygiene assist: total dependence revised on 05/27/25.-Therapy to eval and treat as indicated, revised on 05/27/25.-Toileting hygiene transfer assist: Weight bearing assistance revised on 09/02/25.-Transfer assist: Weight bearing assistance revised on 09/02/25.Surveyor reviewed R5's Fall care plan initiated on 05/27/25, Actual fall on 08/17/25, and revised on 03/18/26.Interventions:-Dycem added to wheelchair to prevent slipping/sliding, initiated on 08/18/25.-Transfer in bed for naps initiated on 02/20/26.-PT evaluate and treat as ordered and as needed, initiated on 05/27/25.Surveyor reviewed R5's Physical Therapy (PT) notes from 01/01/26-04/15/26 states, .Resident [R5] transfers with Hoyer with two assist.Surveyor reviewed R5's PT communication sheet dated 02/03/26 to staff indicating R5 was dependent on 2 staff assistance with Hoyer mechanical lift.Surveyor reviewed R5's progress notes, which state,On 03/19/26 at 12:32 PM, Interdisciplinary Description of Incident: 2/21/26-unwitnessed fallRoot Cause of Incident: deconditioning, psychoactive medication, unsteady gaitInterventions in place at time of incident: Dycem added to wheelchair, commonly used items within reach. New Interventions: transfer to bed for naps. On 04/21/26 at 11:21 AM, Surveyor interviewed R5. R5 reported to Surveyor that R5 has not been able to get out of bed because R5 does not trust staff to transfer R5 the correct way. Surveyor asked R5 to explain more. R5 stated to Surveyor, I have been stuck using this mechanical lift that pulls me into the air, and I hover. This has been recently because I was being transferred by a sit-to-stand lift. Then suddenly, they took the sit-to-stand away and had two staff assist where they stood me up and pivoted me to the wheelchair. This scares me and so most of the time I refuse to get up. I don't trust the staff to transfer me safely. Surveyor asked if the lift R5 used that hovered R5 in the air was a Hoyer lift. R5 stated yes, it is called a Hoyer lift. R5 reported that R5 just wants to get up and walk again and hates the Hoyer lift. Surveyor asked if R5 has gotten out of bed yet today. R5 reported that R5 has not and does not want to.On 04/22/26 at 11:10 AM, Surveyor observed R5 lying in bed. Surveyor observed 2 slings in R5's room lying on a chair across R5's room.On 04/22/26 at 11:17 AM, Surveyor interviewed Certified Nurse Assistant (CNA) F and asked about R5's transfer and when it had changed. CNA F reported that CNA F is usually not down this hall but R5 transfers heavy assist of 2 sometimes stand pivot but R5 used to be sit-to-stand mechanical lift. CNA F reported that CNA F is unsure when if it was changed though. CNA F entered R5's room and observed two slings with Surveyor. CNA F reported that one sling was for sit-to-stand that is no longer being used, and another sling is a Hoyer sling which R5 is no longer a Hoyer lift.On 04/22/26 at 11:30 AM, Surveyor interviewed Assistant Director of Nursing (ADON) H and asked when R5 changed from sit-to-stand to assist of 2 staff stand-pivot. ADON H reported that ADON H is unsure when PT assessed R5 and when the sit-to-stand was discontinued. ADON H reported that ADON H would check when R5 was changed. ADON H reported the facility recognized that transfer status changes were not being placed on the care plan or the CNA Kardex to show staff how residents' transfer status changed when PT made recommendations. Facility recognized that the new changes from Physical Therapy (PT) need to be placed in the care plan right away and on CNA task list. ADON H reported to Surveyor that ADON H is going to make changes now. ADON H reported that R5 is supposed to be a Hoyer mechanical lift transfer. On 04/22/26 at 11:49 AM, Surveyor interviewed PT Director R and PT S and asked what the transfer status of R5 is. PT Director R reported to Surveyor that R5 has always been Hoyer lift as transfers. PT S reported that R5 was evaluated as sit-to-stand in the PT room but under strict supervision and was deemed not appropriate for sit-to-stand. Surveyor asked PT Director R and PT S if they were aware that R5 is being transferred with two-assist stand pivot. PT S reported to Surveyor that R5 is always a mechanical Hoyer lift and cannot safely bear weight on lower extremities.On 04/22/26 at 12:15 PM, Surveyor interviewed Physical Therapy Assistant (PTA) T and asked what R5's transfer status was on re-admission to facility. PTA T reported that R5 has always been a Hoyer lift and never anything else.On 04/22/26 at 12:34 PM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B was aware that R5 is being transferred as a stand-pivot with two-person assistance. DON B reported to Surveyor that R5 is only supposed to be Hoyer lift transfer. DON B reported that DON B will educate staff on the current transfer status for R5. Surveyor asked DON B how staff would follow R5's care plan if the care plan does not reflect R5's transfer status requirement of a Hoyer lift. DON B reviewed R5's care plan and observed R5's transfer status indicates transfer assistance: Weight bearing assistance. DON B reported the facility has been working on correcting care plans and completing audits since 04/09/26. Surveyor asked DON B for a copy of the audits that facility started.On 04/22/26 at 2:07 PM, DON B entered conference room and handed a comprehensive audit completion to Surveyor. Surveyor reviewed audit sheet and pointed out on document that R5 was not triggered as being an affected resident with improper transfer status. DON B reported that this is what the Regional Clinical Specialist M gave DON B regarding the facility's comprehensive transfer audit. DON B acknowledged that R5's care plan and transfer status was not found as part of the facility's audit process but that it would be corrected shortly.

Based on observations, interview, and record review, the facility did not treat each resident with respect and dignity and care for each resident in a manner that promotes their quality of life. This occurred for 2 of 2 residents (R3 and R29).R3 and R3's representative were not informed of audio and visual surveillance that had been placed in his room for his roommate, R29.R3 and R29, or their resident representatives, did not consent to the audio and visual surveillance.R3 was admitted to the facility on [DATE], after a hospitalization for altered mental status and falls at home.R3's Brief Interview for Mental Status (BIMS) confirmed R3 scored 08/15, indicating moderate cognitive impairment. R3 was appointed a guardian to assist with decision making.R3 was admitted to a room with R29. Prior to R3's admission, R29's activated power of attorney (POA) had placed a video monitoring camera in R29's room. R29's POA has access to observe both video and audio surveillance. The facility does not have access to the surveillance.On 03/17/26 at 1:18 PM, Surveyor observed placement of camera, on the right side of the room, atop R29's closet and pointed to the corner of R29's room. The camera was not in line of sight of the doorway, hallway, or R3's side of the room.On 03/17/26 at 1:30 PM, Surveyor interviewed R3. R3 stated he was aware there was a camera in the room and pointed above the doorway. Surveyor told R3 there was not a camera in the area where R3 was pointing. During conversation with R3 it was noted R3 was not answering questions appropriately.Surveyor reviewed R3's record and could not find evidence R3 or his guardian consented to the camera in R3's room. Surveyor could not find documentation R3 was made aware there was a camera in the room.Surveyor reviewed R29's record and noted there was no consent for the camera in R29's room.Surveyor reviewed R3 and R29's care plans and noted there was no care plan for the video surveillance in R3 and R29's room.On 03/17/26 at 3:04 PM, Surveyor interviewed R3's guardian. R3's guardian reported she was not aware there was a camera in the room R3 was residing in. R3's guardian reported she was not comfortable with a camera being in the room.On 03/17/26 at 3:52 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported the camera in R29's room does have volume, so R29's family would be able to hear conversations in R3 and R29's room. This would include any conversations R3 may have in his room.NHA A reported Social Services Director (SSD) C discussed this with R3's guardian at a care conference and stated this was not documented in R3's record. Surveyor was unable to find documentation this was discussed at a care conference in R3's record.NHA A provided Surveyor with an email chain from January 2026, including SSD C and R29's POA, indicating the need to sign a consent for the camera. R29's record did not include a consent for the camera. Surveyor understands this was discussed with R29's POA; however, the facility did not obtain the consent.

Based on interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 1 of 4 resident (R2) care plans reviewed.The facility did not revise R2's care plan after each fall. R2 was admitted to the facility on [DATE] after a hospitalization for increased confusion and falls at home. An elopement assessment was conducted on 02/05/26 and indicated no elopement risk. A fall assessment was conducted on 02/05/26 and indicated low fall risk.R2 scored 08/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R2's power of attorney (POA) was activated to assist with decision making.Surveyor reviewed R2's record and noted the following falls:-02/14/26, fall with major injury. Sent to ER and hospitalized for fractured pelvis.-02/18/26, fall in room. New intervention on eINTERACT form, Call for Help sign.-02/21/26, fall in room. New intervention on eINTERACT form, remove walker when in bed and place wheelchair at bedside.R2's care plan included:-Increased risk for falls related to deconditioning due to ataxia, recent fall, muscle weakness unwitnessed fall 02/18/2026, noncompliant with transfer assistance. Date Initiated: 02/05/2026 Revision on: 03/16/2026.-Interventions: Call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 02/05/2026.-Interventions: Therapy evaluate and treat as ordered or PRN. Date Initiated: 02/05/2026.On 03/18/26 at 9:20 AM, Surveyor observed R2's room. Surveyor observed a call for help sign placed on the wall next to R2's bed, and R2's walker was placed near her closet. R2 was not in her room at the time of the observation.On 03/18/26 at 9:30 AM, Surveyor interviewed Certified Medication Assistant (CMA) E. CMA E reported R2's fall interventions were to toilet her after each meal and a floor mat next to her bed. CMA E reported staff can find interventions in the resident's care plan or it is communicated during shift-to-shift report.On 03/18/26 at 9:35 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F. CNA F reported R2 uses her wheelchair for mobility and has recently been approved by physical therapy to ambulate with staff with walker and gait belt. CNA F stated she was aware R2 was a fall risk, and the interventions were to put R2's bed in the lowest position. CNA F reported fall interventions could be found in the resident's care plan.On 03/18/26 at 9:40 AM, Surveyor interviewed Physical Therapy Assistant (PTA) G. PTA G confirmed R2 has been in therapy since her admission on [DATE]. R2 was reevaluated for continuing therapy due to her fall with injury. PTA G confirmed R2 was doing well in therapy and was able to ambulate with walker and assistance. PTA G was aware R2 was a fall risk and stated R2 self-transfers frequently. PTA G stated the facility does not use alarms and was unsure if therapy had made any recommendations related to R2's fall risk, as R2 was currently still in therapy.On 03/18/26 at 10:00 AM, Surveyor interviewed Director of Nursing (DON) B. DON B confirmed she was present the day R2 eloped. DON B confirmed she assessed R2 outside, stating R2 complained of knee pain and R2's ROM was within normal limits. DON B stated her and three staff assisted R2 into a wheelchair as it was not safe to use the Hoyer lift outside where there was snow and ice. DON B reported that R2 did not complain of pain until she was brought into the building. DON B stated she called the on-call provider and obtained order to send R2 the ER.DON B reviewed R2's care plan and noted fall interventions were not added to R2's care plan after her falls. DON B provided Surveyor with eINTERACT forms, which are also in R2's progress notes, indicating the fall interventions that were added after each fall. DON B confirmed it is the nurses' responsibility to add the interventions to the care plan after completing the eINTERACT form. DON B stated she had begun immediate education with licensed nursing staff, as the nurses were not aware they were to update the care plan.Surveyor determined the facility did not revise R2's care plan to reflect the current interventions in place to reduce her fall risk.

Based on interview and record review, the facility failed to ensure 1 of 5 residents (R43) received care, consistent with professional standards of practice, to prevent pressure injuries and received necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries (PI) from developing.R43 was at risk for pressure injury development. The facility failed to implement aggressive interventions to prevent PI development, ensure treatment orders were completed as ordered, and failed to complete a comprehensive assessment upon discovery of a new PI on R43's left heel. R43 developed an avoidable pressure injury (PI) that deteriorated to stage IV with osteomyelitis requiring hospitalization and intravenous antibiotic therapy. This created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A of the immediate jeopardy on [DATE] at 2:10 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of E (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan.This is evidenced by:The facility's policy titled, Pressure Ulcer/Skin Breakdown- Clinical Protocol, revised [DATE], states in part, Assessment and Recognition . 3. The physician and staff will examine the skin of new admission for ulcerations or indications of Stage 1 pressure area that has not yet ulcerated at the surface. Treatment and Management . 1. The physician will authorize pertinent orders related to wound treatments . Monitoring . 2. The physician will help staff review and modify the care plan as appropriate, especially when . new wounds develop despite existing interventions.According to the National Pressure Injury Advisory Panel (NPIAP), a stage 3 pressure injury is defined as full-thickness loss of skin in which adipose (fat) is visible in the ulcer, and granulation tissue and rolled wound edges (epibole) are often present. Slough and/or eschar may be visible, but it does not obscure the depth of tissue loss.A stage 4 pressure injury is defined as full-thickness skin and tissue loss with directly palpable or exposed fascia, muscle, tendon, ligament, cartilage, or bone. These deep, often crater-like wounds may include slough, eschar, undermining, and tunneling.<According to https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-causes/syc-20375913> Osteomyelitis is an infection in a bone. Infections can reach a bone through the bloodstream or from nearby infected tissue. Infections also can begin in the bone if an injury opens the bone to germs. People who smoke and people with chronic health conditions, such as diabetes or kidney failure, are at higher risk of getting osteomyelitis. People who have diabetes with foot ulcers may get osteomyelitis in the bones of their feet. Most people with osteomyelitis need surgery to remove areas of the affected bone. After surgery, most often people need strong antibiotics given through a vein. Risk factors: Healthy bones resist infection. But bones are less able to resist infection as you get older. Besides wounds and surgery, other factors that can increase your risk of osteomyelitis may include Conditions that weaken the immune system. This includes diabetes that isn't well-controlled. Peripheral artery disease. This is a condition in which narrowed arteries cut blood flow to the arms or legs. Pressure injuries. People who can't feel pressure or who stay in one position for too long can get sores on their skin where the pressure is. These sores are called pressure injuries. If a sore is there for a time, the bone under it can become infected. Complications: Osteomyelitis complications may include bone death, also called osteonecrosis. An infection in your bone can block blood flow within the bone, leading to bone death. If you have areas where bone has died, you need surgery to remove the dead tissue for antibiotics to work.R43 was admitted on [DATE] after hospitalization for sepsis with multi-organ failure, type 2 diabetes mellitus without chronic complications, chronic kidney disease stage 3 unspecified, unspecified dementia, type 2 diabetes mellitus with diabetic chronic kidney disease, essential (primary) hypertension, and heart failure unspecified.R43's initial care plan, dated [DATE], contains the goal of having intact skin, free of redness, blisters, or discoloration ongoing and through review date. The care plan identified R43 at increased risk for pressure ulcer development with an intervention of a pressure reducing mattress. Interventions for initial care plan included, administer treatments as ordered, the resident requires pressure reducing mattress to bed, utilize barrier creams with each incontinent episode.A Comprehensive Minimum Data Set (MDS) dated [DATE] indicated no pressure ulcer/injuries and no surgical wounds. The MDS identified R43 was at risk for pressure ulcer development. Of note, the surveyor could not obtain documentation of the tool used to assess this or the score indicating R43's risk for pressure ulcers.The quarterly MDS assessment dated [DATE] indicated R43 had no pressure ulcers/injuries and 1 surgical wound.On [DATE] at 3:30 PM, a wound care progress note written by Medical Doctor (MD) Z stated, R43 had a Stage 3 pressure wound of the right medial buttock, measuring 3.1 cm long x 0.9 cm wide x 0.1 cm deep. This wound on the right medial buttock was resolved on [DATE].On [DATE] at 2:30 PM, R43's medical record had a Situation-Background-Assessment-Recommendation (SBAR) form completed, which indicated resident [R43] has a new wound to the right heel 8cm x 5cm open. Resident [R43] is not voicing any complaints of (c/o) pain at this moment. A bandage is put on wound and wrapped in gauze. Pressure boots were put on the resident while in bed. There was no comprehensive assessment completed which would include characteristics of the wound.Note: documentation of right heel is incorrect. The new wound is on the left heel.On [DATE], R43's TAR indicated, Location of wound left (L) heel. Treatment, at bedtime, cleanse with Normal Saline, pat dry, apply foam dressing, secure in place with Kerlix, change daily. Daily assessment of wound drainage, general appearance, and surrounding skin noted. Surveyor could not find evidence of a comprehensive wound assessment completed on left heel wound until [DATE].On [DATE] at 3:55 PM, wound care progress notes by MD Z, documented R43 had a blister on left heel has ruptured, open wound today. Wound size 4cm long x 6.2 cm wide, depth is not measurable due to presence of nonviable tissue and necrosis. MD Z performed debridement to remove necrotic tissue and establish margins of viable tissue. Post surgical wound of the left heel. MD Z's new wound care treatment plan was to add Betadine to the dressing change and perform dressing change twice a day and as needed: if saturated, soiled or dislodged for 30 days.R43's TAR indicates order was not changed and treatment to R43's left heel remained once a day at bedtime, cleanse with Normal Saline, pat dry, apply foam dressing, secure in place with Kerlix until [DATE]. The new order stating the addition of Betadine to the dressing change and to change the dressing twice daily and as needed; if saturated, soiled or dislodged for 30 days was not transcribed onto TAR nor performed by nursing for R43's wound.On [DATE] at 3:12 PM, a progress note indicates R43 was seen by MD Z. R43's left heel wound measured 3.2 cm long x 2.1 cm wide x 0.1 cm deep. MD Z did debridement of R43's wound. R43's order was changed back to performing wound care once a day. New order written stated, primary dressing, Betadine, apply once daily and as needed: if saturated, soiled, or dislodged for 23 days. Secondary dressing, gauze roll (kerlix) 3.4 apply daily and as needed: if saturated, soiled, or dislodged for 30 days.On [DATE], R43's TAR indicated to start every shift and as needed, left heel, treatment to cleanse with NS, pat dry, paint with betadine, ABD secured and kerlix applied. TAR indicated this was started on [DATE] as ordered and performed until [DATE].R43's care plan was not updated until [DATE] to include R43's actual impairment to skin integrity of the left heel related to surgical wound. An intervention of weekly treatment documentation to include measurement of skin breakdown and to monitor/document location, size, and treatment of skin injury.On [DATE] at 3:14 PM, wound care progress notes by MD Z stated R43's wound measured 3.1 cm long x 5.4 cm wide. Depth was unmeasurable due to presence of dried fibrinous exudate. MD Z ordered to discontinue betadine and start Hydrofera blue applied once daily and as needed: if saturated, soiled or dislodged for 30 days. And a secondary gauze kerlix for 16 days and gauze island with border applied daily for 30 days.On [DATE] at 12:02 PM, MD Z's progress note stated R43 was hospitalized due to a non-wound matter.On [DATE] at 11: 11 PM, R43's progress note states: R43 arrived to the facility via [transport company name]. Surveyor found no documentation of a comprehensive assessment upon admission.On [DATE] at 11:05 AM, wound care progress notes by MD Z stated R43 returned from hospital with a Stage 4 pressure wound of the left heel. Left heel measures 3.5 cm long x 7 cm wide x 1.3 cm deep. MD Z's treatment orders are primary dressing Hydrofera blue apply once daily and as needed. For 8 days, Collagen powder apply once daily and as needed. For 30 days, Hypochlorous acid solution (vashe) apply once daily and as needed.On [DATE], R43 had an additional wound care order from the hospital, which stated Tobramycin Sulfate Injection solution [antibiotic used to treat serious bacterial infections], apply to left heel topically two times a day for wound care.Progress notes from MD Z dated [DATE], [DATE], and [DATE] indicated no change in treatment orders and R43's left heel wound continued to improve and decrease in size.On [DATE] at 12:30 PM, an SBAR was completed on R43 related to change in condition. SBAR documents Blood Pressure 145/65, Pulse 111, Respirations 22 per minute, oxygen saturation 98%, Blood Sugar 162 mg/dl/ States R43 weak, has a bloody nose. R43 seen by Nurse Practitioner (NP).On [DATE] at 7:04 PM, R43's progress note from MD Z stated, this (wound) has been gently packed, and the patient is going to be sent to the ER for chills and rigors possibly due to sepsis. The note states the patient [R43] appears to be septic with tachypnea and tachycardia. The source is unknown at this time, but it was felt that a rapid workup could not be done at the facility so he [R43] can be sent to the emergency room for treatment and workup.On [DATE] at 2:50 PM, Surveyor called hospital SW BB, who reported R43 has since been admitted to the hospital with sepsis and needed to be transferred to a higher level of care for treatment of sepsis. On [DATE] at 1:10 PM, Surveyor interviewed MD Z, who reported he felt R43's wounds were improving and that R43 was hospitalized due to urosepsis.On [DATE] at 1:00 PM, Surveyor reviewed R43's hospital discharge record, which indicated R43 was hospitalized for sepsis secondary to streptococcus dysgalactiae bacteremia-left calcaneal osteomyelitis (a left heel infection). Hospital noted as diagnosis this was an open wound of the left heel, and pressure injury of the left heel, stage 4. Hospital records state the podiatry clinic was consulted and due to R43's comorbidities, R43 would be discharged to facility with IV (intravenous) antibiotics first. Records indicate that a biopsy followed by cutting half of R43's heel may result in loss of mobility for a long time and R43 will also need extensive wound care including wound VAC etc. R43 may not heal well after the procedure; it may interfere with quality of R43's life given multiple comorbidities. Podiatry recommended against procedure and try IV antibiotics with goals of care discussion.On [DATE] at 2:37 PM, R43 was readmitted to the facility following hospitalization.On [DATE] at 9:20 AM, Surveyor interviewed DON J, who agreed wound care orders from MD Z were not followed and R43's care plan was not updated. DON J also agreed that the expectation of the facility staff would be R43's wound care treatment orders be followed, completed, and documented by facility nurses, and R43's care plan been updated to address changes and new interventions. DON J stated the comprehensive wound assessments were performed by MD Z and that is why there is not documentation of comprehensive wound care assessment by facility nurses.On [DATE] at 11:04 AM, Surveyor interviewed NHA A via telephone and asked why the facility did not complete comprehensive assessments on R43 with development of the new PI on the heel, changes in treatments for the PI, and for ensuring wound is observed for changes between the weekly wound MD visits. NHA A stated the facility doesn't do comprehensive assessments. NHA A stated they fill out the SBAR if there is a change in the residents. Surveyor stated to NHA A that there was only one SBAR that was completed on R43 dated [DATE] at 2:30 PM, documenting a new PI on the left heel with only measurements and that PI was wrapped and pressure boots applied to feet when R43 is in bed. NHA A did not have any further information.On [DATE] at 12:41 PM, Surveyor received a summary of R43's treatment progress from MD Z. The email concludes its review of R43's care by noting: On [DATE], MD Z's progress note states: Pt. [R43] brought to ER for acute abdominal pain, diagnosed with acute cholecystitis; hospital record denotes history of (h/o) peripheral artery disease (PAD), diabetes mellitus (DM),chronic kidney disease (CKD), describes L heel ulcer status post (s/p) recent debridement; heel ulcer treated with antibiotic (Abx), noted that hospital discharge summary recommends out-patient follow-up with no indication of urgent wound debridement requiring transfer, as patient has remained vitally stable.On [DATE], MD Z's progress note states: Pt. [R43] seen at facility by [name of physician] reports feeling well, L heel wound much improved. MD Z's treatment progress goes on to say that comprehensive clinical diagnosis and intraoperative wound debridement were performed during his hospitalization of [DATE] to [DATE], and specialty out-patient recommendations continued thereafter, the clinical impression is that these unfortunate complications appear to have developed despite appropriate and consistent out-patient care at [name of facility], on the basis of chronicity of this gentleman's [R43's] wound and co-morbidities; (documentation supporting the above has been submitted, i.e. Unavoidable Pressure Injury criteria). Surveyor, however, notes the facility did not conduct comprehensive assessments of R43 with the development of the left heel PI, nor conduct comprehensive assessments of R43 to note any changes in the PI in between the weekly MD visits for wound care, did not implement new interventions for R43 to prevent further development of PIs, and failed to ensure treatment orders were transcribed and followed as per physician orders. This PI deteriorated to a stage IV with osteomyelitis, which required hospitalization and IV antibiotics.The facility's failure to implement aggressive interventions to prevent PI development, ensure treatment orders were completed as ordered and complete a comprehensive assessment upon discovery of a new left heel PI created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. R43 developed an avoidable PI which deteriorated to a stage IV with osteomyelitis requiring IV antibiotics. The facility removed the immediate jeopardy on [DATE], when it completed the following:Facility initiated education for all licensed nursing staff (RNs and LPNs) immediately upon IJ notification and completed prior to the next scheduled shift including:Prompt identification and reporting of new pressure injuries.Completion of comprehensive assessments upon discovery of a new PI.Completion of daily diabetic foot checks.Accurate transcription, initiation, and completion of physician ordered treatments.Implementation of aggressive PI prevention and treatment interventions per standards of practice.Education on notification of physician/np of all new PI as well as any significant changes to PI.Licensed nursing staff completed competency validation related to PI staging and documentation, treatment application per physician orders, and heel offloading, repositioning, skin protection, and preventive interventions.Facility conducted skin assessments and Braden scale assessments of all residents in the facility.Facility conducted TAR audits of residents to ensure wound treatments were completed as ordered.Facility reviewed resident wound treatment orders to ensure they were accurate and appropriate.Facility conducted wound round audits on all residents with wounds/PIs.The deficient practice continues at a scope/severity level E (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan.

Based on interview and record review, the facility failed to ensure abuse training was provided at hire and annually for 9 of 9 staff reviewed. This deficient practice had the potential to affect all 47 residents in the facility who are cared for by staff who did not receive ongoing training on recognizing and reporting abuse, neglect, exploitation, and misappropriation. Certified Nursing Assistant (CNA) W was hired 10/1/20 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for CNA W upon hire or annually.CNA GG was hired 10/20/25 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for CNA GG upon hire.CNA HH was hired 1/5/26 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for CNA HH upon hire.CNA G was hired 7/2/24 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for CNA G upon hire or annually.CNA II was hired 1/9/26 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for CNA II upon hire.Dietary Aide (DA) JJ was hired 11/10/25 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for DA JJ upon hire.Business Office (BO) KK was hired 6/4/25 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for BO KK upon hire.Registered Nurse (RN) LL was hired 1/5/26 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for RN LL upon hire.Licensed Practical Nurse (LPN) K was hired 7/7/25 and no abuse, neglect, exploitation, and misappropriation training was provided to the Surveyor for LPN K upon hire.This is evidenced by:The facility policy titled, Abuse prevention, read in part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 6. Identify and assess all possible incidents of abuse. Facility Assessment, dated 6-1-25, states in part for training topics: Abuse, neglect, and exploitation educates staff on 1. Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, 2. Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, and 3. Care/management for persons with dementia and resident abuse prevention.On 02/27/26 at 11:30 AM, Surveyor requested proof of abuse, neglect, exploitation, and misappropriation training from Nursing Home Administrator (NHA) A on CNA W, CNA GG, CNA HH, CNA G, CNA II, DA JJ, BO KK, RN LL, and LPN K. NHA A provided 2 large binders of in-services but could not readily provide evidence of the abuse training for staff requested. Surveyor asked if the training was tracked for staff to ensure trainings are documented and hours accounted for. NHA A stated the facility does not have a system to track education for staff, but NHA A is working on getting some type of system for that. NHA A could not provide the training for staff requested for upon hire or annually. NHA A stated staff do get abuse, neglect, exploitation, and misappropriation of resident property training upon hire in orientation and annually but could not provide evidence of such.

Based on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which had the potential to affect all 47 residents.-Staff did not sanitize mechanical lift after transferring a resident on enhanced barrier precautions.-Hand hygiene not offered to residents prior to meals.-Lack of Personal Protective Equipment (PPE) worn in isolation rooms.-No Enhanced Barrier Precautions (EBP) for resident with indwelling catheter.-No droplet precautions for resident COVID positive.-Improper hand hygiene with cares-Dirty linens placed on the floor-Urinary catheter lying on the floorFindings include: Facility policy titled, Policies and Practices-Infection Control, last revised July 2014, reads in part: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and general public alike.The objectives of our infection control policies and practices are to.prevent, detect, investigate, and control infections in the facility.Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions (TBP). Facility Policy titled, Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others.Resident-Care Equipment: When possible dedicate the use of non-critical resident-care equipment items.to a single resident.if use of common items is unavoidable, then adequately clean and disinfect them before use for another resident.Implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets. A Memorandum Summary from The Centers for Medicare and Medicaid Services (CMS), dated 03/20/24, reads in part: EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. No facility policy on EBP was available upon request. Example 1 R55 was admitted to the facility on [DATE]. R55 was admitted with an indwelling urinary catheter. On 01/11/26 at 10:14 AM, Surveyor interviewed R55. Surveyor observed R55 had an indwelling urinary catheter. Surveyor observed there was no sign for EBP on or near R55's door, and no PPE outside/just inside R55's room. Example 2 R10 was admitted to the facility on [DATE]. R10's diagnosis included paraplegic, post laminectomy syndrome, fusion of the spine, uninhibited neuromuscular dysfunction of bladder. R10 was on Enhanced Barrier Precautions (EBP) due to indwelling urinary catheter and had signage posted upon entrance of room. On 1/11/2026 at 12:09 PM, Surveyor observed R10's uncovered urinary catheter bag touching the floor while hanging from bottom of wheelchair. R10 stated it is usually hooked up higher, but she had new staff help her this morning. R10 put her light on and requested staff reposition catheter bag. On 1/12/26 at approximately 9 AM, Surveyor observed R10's uncovered urinary catheter bag lying directly on the floor under R10's bed, not hooked to anything. CNA DD entered R10's room and asked R10 if she wanted to get out of bed. R10 stated she did and CNA DD brought in Hoyer lift and put on gloves. CNA DD did not put on a gown. CNA DD picked up R10's catheter bag off the floor and placed it on top of R10's bed. CNA DD rolled R10 from side to side laying across R10's torso, touching R10 with CNA's exposed clothing, and placing mesh sling under R10. After transferring R10 into wheelchair, CNA DD hooked urinary catheter bag under R10's wheelchair. Surveyor interviewed CNA DD, who stated she is unaware of who put R10's urinary catheter bag on the floor. CNA DD is aware the catheter should never touch the floor. Surveyor interviewed CNA DD about R10's EBP. CNA DD reported R10 is on EBP because R10 has a catheter. Surveyor asked CNA about use of gowns with direct patient care and transfers. CNA DD reviewed sign on R10's door on EBP and stated she was unaware that she should have worn a gown providing direct patient contact and transferring R10. On 1/13/2026 at 8:35 AM, Surveyor interviewed DON J, who stated the resident catheter bags should not touch the ground and agreed the expectation would be to wear gowns when providing direct patient care, such as transfers, with resident on EBP. Example 3 On 01/11/26 at 10:42 AM, Surveyor observed LPN V come out of an enhanced barrier precautions room. LPN V came out of the room with a Hoyer lift. Surveyor observed LPN V place lift in corner of hall near shower room and did not clean lift. Surveyor observed there were no cleaning supplies on lift. Facility currently has COVID 19 in building. On 01/11/26 at 10:48 AM, Surveyor interviewed CNA W. CNA W stated the facility's policy is to sanitize lifts using sani-wipes. CNA W states sani-wipes are on medication carts or in PPE bins. CNA W confirmed sani-wipes are not kept in resident rooms. On 01/11/26 at 11:04 AM, Surveyor interviewed LPN V. LPN V was aware she did not sanitize the lift, and stated she was just trying the help the CNA with a transfer. Example 4 On 01/12/26 at 10:49 AM, Surveyor observed Maintenance Director (MD) H entering rooms [ROOM NUMBERS] with only a facemask on. Both rooms have droplet precautions in place in relation to positive COVID infections. On 01/12/26 at 11:03 AM, Surveyor interviewed MD H. MD H stated staff should wear gowns, gloves, and masks in EBP rooms. MD H stated in droplet rooms, staff should wear a mask to protect from droplets. MD H asked Surveyor if that was right. Surveyor informed MD H that MD H would have to answer independently. MD H stated that MD H was previously provided education in relation to all the isolation precautions. Surveyor reviewed MD H's onboarding education checklist. The checklist indicated MD H was educated on bloodborne pathogens, EBP, and donning and doffing PPE, but did not include specific training related to TBP. Example 5 On 01/14/26 at 6:45 AM, Surveyor interviewed R58. R58 reported being upset as R58 was just informed R58 was COVID positive. Surveyor observed no isolation precautions signs related to COVID were present on or near R58's room/door. On 01/14/26 at 6:49 AM, Surveyor interviewed Hospitality Aide (HA) CC. HA CC confirmed R58 was positive for COVID and was in the process of making copies of droplet precautions signs. Surveyor reviewed R58's progress notes. Progress notes indicated R58 was confirmed positive for COVID the evening of 01/13/26. On 01/14/26 at 11:14 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L. LPN L stated 5 new cases of COVID popped up on 01/13/26 in the evening. LPN L reported the infection control nurse was responsible for the signage and PPE for new cases or changes. If the infection control nurse is not in the building, such as after hours, the charge nurse is then responsible. LPN L stated Certified Nursing Assistants (CNAs) are able to retrieve the PPE and place the signage, but the charge nurse on duty is responsible for making sure it is done. On 01/14/26 at 1:27 PM, Surveyor interviewed Director of Nursing (DON) J. DON J stated staff are educated on TBP upon hire and as needed. DON J stated the charge nurse is responsible for signage and PPE for any changes and new cases and then notifies the DON who makes sure it is in place. Staff then notifies the provider and power of attorney if appropriate. Example 6 R60 was admitted to the facility on [DATE] with diagnoses including malnutrition, syncope and collapse, age related osteoporosis, and atrial fibrillation. On 1/12/26 at 10:15 AM, Surveyor observed CNA G provide incontinence cares to R60. After CNA G wiped stool from R60's buttocks and continued to provide incontinent cares, CNA G did not change gloves. CNA G continued to reposition R60 with same gloves on, moved linens from bed to chair and touched items on the bed table before removing gloves and washing her hands. On 1/12/26 at 10:35 AM, Surveyor interviewed CNA G about when to remove gloves and practice hand hygiene, prior to repositioning and touching linens etc. CNA G stated she should have changed her gloves and performed hand hygiene after wiping stool from R60 and before touching items. On 1/13/2026 at 8:35 AM, Surveyor interviewed DON J, who stated staff should change gloves and perform hand hygiene immediately after performing incontinence cares. Example 7 On 01/12/2026 at 8:48 AM, Surveyor observed CNA G cue R50 to reach for grab bar and stand from toilet after voiding. CNA G conducted hand hygiene and donned a clean pair of gloves, conducted peri care with a wet washcloth and proceeded to throw contaminated washcloth on floor. CNA G removed gloves and without conducting hand hygiene, pulled up R50's pants, adjusted R50's shirt and removed gait belt. On 01/12/2026 at 2:08 PM, Surveyor interviewed CNA G regarding observation of no hand hygiene after glove change following peri care on R50, and observation of discarding used washcloth on the floor. CNA G stated she should have conducted hand hygiene after removing gloves before proceeding with cares. Surveyor asked CNA G the expectation of what to do with soiled linens. CNA G stated linens should go in a plastic bag and taken to soiled utility room. Surveyor asked CNA G what she did with washcloth after conducting peri care on R50. CNA G stated she believed she held onto it. When Surveyor told CNA G of observation of discarding washcloth on the floor, CNA G laughed and said, Did I really do that? I don't remember. On 01/13/26 at 4:12 PM, Surveyor interviewed DON J regarding expectation of discarding soiled linens and hand hygiene and glove change after incontinence care. DON J stated the expectation is to remove soiled gloves, sanitize hands, apply clean gloves when going from dirty to clean area and place soiled linen in a plastic bag. Example 8 The facility's policy, titled Policies and Practices - Infection Control, revised 07/2014, states in part: The objectives of our infection control policies and practices are to: .maintain a safe, sanitary, and comfortable environment for personnel, residents . On 01/11/2026, at 12:50 PM, residents were observed being brought to their tables and meals delivered without hand hygiene offered by staff, or sanitizer wipes made available at tables for residents to use. On 01/14/2026, at 9:05 AM, residents were observed being brought to tables for breakfast and meals delivered to them without hand hygiene being offered by staff, or sanitizer wipes made available for resident to use at tables. On 01/14/2026, at 8:35 AM, Surveyor interviewed R10 about the availability of hand hygiene prior to meals being served. R10 stated staff never offer hand hygiene at meals to the residents. R10 stated it would be nice if prepackaged hand wipes were available on the meal trays. R10 has inquired staff about having hand wipes available and was told that hand sanitizer units are available on the walls in the dining room for everyone to use. R10 stated, I cannot reach them in a wheelchair. And what about the residents who cannot ask? On 01/14/2026, at 1:00 PM, Surveyor interviewed Dietary Manager (DM) E and asked if hand hygiene is offered to residents prior to meals being served. DM E stated no hand hygiene is routinely offered, and DM E would like to see sanitizer wipes be made available on resident trays or the tables for residents to use.

Based on interview and record review, the facility did not ensure a registered nurse (RN) worked at the facility for at least eight (8) consecutive hours a day, seven days a week, on 3 of 92 days reviewed. This deficient practice had the potential to affect all 47 residents.The facility was unable to provide documentation to support that an RN was working in the facility for at least 8 consecutive hours on 08/15/25, 09/08/25, and 09/09/25.This is evidenced by:Surveyor reviewed the PBJ Staffing Data Report for fiscal year Quarter 4 2025 (July 1 - September 30) which triggered for 4 or more days within the quarter with no RN hours on 08/15/2025, 09/08/25, 09/09/25 and 09/14/25.Surveyor reviewed the facility staff scheduled and nurse posting for the last 92 days of Quarter 4 2025 (July 1- September 30). Surveyor noted on 08/15/2025 (Friday), 09/08/25 (Monday), and 09/09/25 (Tuesday) there was not an RN scheduled for 8 consecutive hours. On 01/14/26 at 10:05 AM, Surveyor interviewed Nursing Home Administrator (NHA A) and the Assistant Nursing Home Administrator (ANHA B) regarding the facility PBJ Staffing report for fiscal year quarter 4 (July 1 - September 30).On 01/14/26 at 10:40 AM, Surveyor interviewed NHA A and ANHA B regarding the facility's daily staff posting process who indicated the receptionist will post the staff posting in the mornings after updating the census and that the facility not manually update the posting but reflect changes on schedule which is not posted for the public.On 01/14/2026 at 1:24 PM, Surveyor received documentation to support RN coverage on 09/14/25 from ANHA B who stated that during the time period of on 8/15/25 - 0/9 /14/25, corporate RNs were doing a rotating schedule for the 8 hours required coverage but was unable to provide further documentation to support RN coverage for 08/15/2025, 09/08/25, and 09/09/25.

Based on observation and interview, the facility did not ensure safe storage and labeling of foods in accordance with professional standards for food service safety for 47 of 47 residents which could result in residents consuming unsafe foods with biological, chemical, or physical contamination. Facility's dry storage area contained packages of food opened, not in labeled containers and without a use by date identified on packaging.Refrigerator in resident common area contained opened dishes of food without resident identification, date opened or use by dates. This is evidenced by: The facility policy, titled Food Receiving and Storage, revised 12/2008, states in part: Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date) .All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). On 01/11/2026 at 9:08 AM, Surveyor observed an opened package of yellow cake mix sitting on top of a box on shelf in kitchen dry food storage area. The cake mix's packaging was not labeled with date opened, or a use by date. Surveyor also observed three opened and partially used bags of dry cereal sitting on shelf in dry food storage area not labeled with a date opened or use by date. On 01/11/2026 at 11:04 AM, Surveyor observed half a sandwich on plate covered with clear film wrap in resident refrigerator in resident day room area. The sandwich did not have a use by date. Surveyor observed in same refrigerator a large plastic red container containing a pasta meal with no identification of ownership, date opened or use by date on container. Surveyor observed in same refrigerator an opened bottle of Miracle Whip salad dressing and plastic tub of Land O' Lakes butter with no use by date. Surveyor observed in same refrigerator a solidified yellow substance in a storage drawer and along bottom of refrigerator that spilled from an unknown source. On 01/11/2026 at 11:05 AM, Surveyor observed a temperature reading of 50 degrees on thermostat inside of resident refrigerator in day room area. Refrigerator door was slightly ajar at time of observation caused by a large box of pudding stored inside of refrigerator. On 01/12/2026 at 7:00 AM, Surveyor observed a partially eaten pizza in a cardboard box in resident refrigerator in day room area without identification of ownership or use by date. Surveyor also observed an unmarked Kwik Trip disposable cup of unknown liquid substance with no identification of ownership or use by date in resident refrigerator in day room. On 01/12/2026, at 8:49 AM, Surveyor observed an opened and partially used bag of elbow pasta on shelf in dry food storage area not labeled with opened date or use by date. Opened and unlabeled bags of yellow cake mix and dry cereals observed on 01/11/2026 remained in same condition on shelves. On 01/13/2026 at 7:00 AM, Surveyor interviewed Dietary Manager (DM) E and asked what facility expectations are for dry food storage in kitchen and food storage in resident refrigerators in designated common areas. DM E stated all opened foods in dry food storage should be transferred from original packaging once opened into a container and labeled with name of food and a use by date. DM E stated for resident refrigerators, all foods should be labeled with a resident's name and date opened or delivered. DM E stated no staff foods are to be stored in resident refrigerators and could not confirm if any foods observed in resident refrigerators belonged to residents or staff. DM E stated nursing staff oversee resident refrigerators and maintain temperature logs and cleaning. DM E stated dietary will make up sandwiches to be provided as bedtime snacks for residents and they should always be labeled with a use by date.

Based on interview and record review, the facility did not develop and implement policies that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property and includes the screening of prospective employees and residents. 16 out of 17 sampled staff (Certified Nursing Assistant (CNA) O, CNA P, CNA Q, Social Worker (SW) F, Dietary Manager (DM) E, Activities Director (AD) I, and Licensed Practical Nurse (LPN) R), CNA W, CNA GG, CNA HH, CNA G, CNA II, Dietary Aide (DA) JJ, Business Office (BO) KK, Registered Nurse (RN) LL, and LPN K did not receive a full background check, which includes the Background Information Disclosure (BID), Department of Justice (DOJ) criminal background response and State of Wisconsin Caregiver Background Check - Government Findings Reports (previously IBIS) reviewed. 1 out of 17 staff reviewed (CNA G) previously lived in another state and the background check was not completed for that state. Incomplete background checks could impact all 47 residents residing at facility. With incomplete background checks the facility would not know an employee's history of possible abuse, neglect, exploitation, or mistreatment or misappropriation of property by a court of law.CNA O was hired on 07/13/25 and did not have a DOJ criminal background record or Government Findings Report within 60 days of hire.CNA P was hired on 10/02/25 and did not have a DOJ criminal background record or Government Findings Report within 60 days of hireCNA Q was hired on 12/09/24 and did not have a DOJ criminal background record or Government Findings Report within 60 days of hire.LPN R was hired on 04/08/25 and did not have a DOJ criminal background record or Government Findings Report within 60 days of hire. DM E was hired on 04/15/25 and did not have a DOJ criminal background record or Government Findings Report included in required background checks. SW F was hired on 02/20/25 and did not have a DOJ criminal background record or Government Findings Report included in required background checks. AD I was hired on 09/08/25 and did not have a DOJ criminal background record or a Government Findings Report included in required background checks. CNA W was hired on 10/1/20 and last background check was completed on 03/9/21. CNA W did not have a current BID, DOJ criminal background record, or a Government Findings Report within the last 4 years.CNA GG was hired on 10/20/25 and did not have a DOJ criminal background record or a Government Findings Report included in required background checks within 60 days of hire.CNA HH was hired on 1/5/26, did not have a BID, and DOJ criminal background and the Government Findings Report were completed on 01/27/26 after Surveyor entered the facility.CNA G was hired on 07/02/24 and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 after Surveyor entered the facility. CNA G had previously lived in Florida from 2017 to 2023, and no background check was completed for the state of Florida.CNA II was hired on 01/09/26, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 after Surveyor entered the facility.DA JJ was hired on 11/10/25, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 after Surveyor entered the facility.BO KK was hired on 06/04/25, did not have BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 after Surveyor entered the facility.RN LL was hired on 01/05/26, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 after Surveyor entered the facility.LPN K was hired on 07/07/25, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 after Surveyor entered the facility.This is evidenced by: Facility policy titled Abuse Investigation and Reporting, revised 12/2016, states in part: As part of the resident abuse prevention, the administration will.2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: (a) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law: (b) Have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (c) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Facility policy titled Background Screening Investigations, no revision date states in part: Our facility conducts employment background screening checks, reference checks, and criminal conviction investigation checks on individuals making application for employment with our facility. Policy Interpretation and Implementation:The Personnel/Human Resources Director or other designee will conduct employment background checks, reference checks, and criminal conviction checks (including fingerprinting as may be required by state lawa0 on persons making application for employment with this facility. Such investigations will be initiated within two days of employment or offer of employment.For any individual applying for a position of Certified Nursing Assistant, the state nurse aide registry will be contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file.On 01/11/2026, Surveyor requested caregiver background check and misconduct reporting on a sample of 8 staff members from Assistant Nursing Home Administrator (ANHA) B. Reports were provided by ANHA B on 01/12/2026.On 01/12/2026, Surveyor noted background checks were incomplete for CNA O, CNA P, CNA Q, CNA R, SW F, DM E, AD I, and LPN R. A second request was made to ANHA B for missing reports on 01/12/2026.On 01/13/2026 at 10:53 AM, Surveyor made a third request to Director of Nursing (DON) J for complete background checks for CNA O, CNA P, CNA Q, CNA R, SW F, DM E, AD I and LPN R. On 01/13/2026 after 4:00 PM, ANHA B provided requested DOJ and Government Findings Reports for DM E, SW F, CNA O. Surveyor notes all reports are dated as 01/13/2026 after 3:00 PM, the request date and time made by the facility, which is after Surveyor entered the facility. CNA O was hired on 07/13/25 and did not have a DOJ criminal background record or Government Findings Report within 60 days of hire.CNA P was hired on 10/02/25 and did not have a DOJ criminal background record or Government Findings Report within 60 days of hireCNA Q was hired on 12/09/24 and did not have a DOJ criminal background record or Government Findings Report within 60 days of hire.LPN R was hired on 04/08/25 and did not have a DOJ criminal background record or Government Findings Report within 60 days of hire. SW F was hired on 02/20/25 and did not have a DOJ criminal background record or Government Findings Report included in required background checks within 60 days of hire.AD I was hired on 09/08/25 and did not have a DOJ criminal background record or a Government Findings Report included in required background checks within 60 days of hire.On 01/13/2026, ANHA B provided Surveyor with the DOJ criminal background record and Government Findings report for DM E. DM E was hired on 04/15/25 and did not have a DOJ criminal background record or Government Findings Report included in required background checks within 60 days of hire. Both the DOJ and the Government Findings reports were dated 01/13/2026 at 3:42 PM, which was after Surveyor entered building for survey. On 01/13/2026, Surveyor reviewed the DOJ report, which was not completed until 07/13/25, by a third-party vendor, Checkr, which is greater than 60 days of hire date. On 01/14/2026 at 4:00 PM, time of survey exit from facility, no DOJ or Government Findings reports were made available to Surveyor by facility for LPN R and CNA P. On 01/14/2026 at 12:44 PM, Surveyor interviewed DON J and Nursing Home Administrator (NHA) A and asked what the facility expectations are for completing background checks on new employee hires. NHA A stated they use third party vendors for all new employee hire background checks. NHA A and DON J stated they were not aware Department of Justice criminal background checks, as well as State of Wisconsin caregiver background checks, were required upon hire. NHA A informed Surveyor both NHA A and DON J resided in the state of Texas and were not aware of Wisconsin criminal background and caregiver check laws. NHA A confirmed all requested DOJ and Government Findings Reports provided to Surveyor on 01/13/2026, were also dated for 01/13/26, which was after the Surveyor entered the facility. On 01/27/26 at 11:30 AM, Surveyor requested background checks from Nursing Home Administrator (NHA) A on CNA W, CNA GG, CNA HH, CNA II, CNA G, CNA II, DA JJ, BO KK, RN LL, and LPN K.CNA W was hired on 10/1/20 and last background check was completed on 03/9/21. CNA W did not have a current BID, DOJ criminal background record, or a Government Findings Report within the last 4 years.CNA GG was hired on 10/20/25 and did not have a DOJ criminal background record or a Government Findings Report within 60 days of hire. Reports Surveyor received were completed on 01/17/26 at 12:06 PM, after Surveyor entered facility for survey.CNA HH was hired on 1/5/26, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 at 12:17 PM, after Surveyor entered the facility.CNA G was hired on 07/02/24 and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 at 12:52 PM, after Surveyor entered the facility, which was greater than 60 days of hire. CNA G had previously lived in Florida from 2017 to 2023, and no background check was completed for the state of Florida.CNA II was hired on 01/09/26, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 at 12:15 PM, after Surveyor entered the facility.DA JJ was hired on 11/10/25, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 at 12:26 PM, after Surveyor entered the facility, which is greater than 60 days of hire.BO KK was hired on 06/04/25, did not have BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 at 12:27 PM, after Surveyor entered the facility, which is greater than 60 days of hire.RN LL was hired on 01/05/26, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 at 12:29 PM, after Surveyor entered the facility, which is greater than 60 days of hire.LPN K was hired on 07/07/25, did not have a BID, and the DOJ criminal background and the Government Findings Report were completed on 01/27/26 at 12:31 PM, after Surveyor entered the facility which is greater than 60 days of hire.On 01/27/26 at 3:30 PM, Surveyor interviewed NHA A and asked why the sampled employees did not have the BID completed. NHA A stated that was something the facility is working on to implement in their hiring process. NHA A gave Surveyor a newly completed policy titled Training: Completing the Wisconsin BID Form at Time of Hire. NHA A stated this will be started for new hires. Surveyor informed NHA A that the DOJ criminal backgrounds and the Government Findings Reports on the sampled staff were completed on today's date of 01/27/26, which was after the Surveyor entered the facility. NHA A stated he realizes these were not completed timely. Surveyor informed NHA A that CNA W's last background check was completed on 03/09/21 and it should be completed every 4 years. Surveyor informed NHA A that CNA G also lived in Florida and there was no background check completed for Florida. NHA A stated this entire part of hiring is something the facility is working on.

Based on observation and interview, the facility did not ensure all garbage and refuse was properly contained inside dumpsters to prevent the harborage and feeding of pests. This has the potential to affect all 47 residents residing at facility.This is evidenced by: On 01/11/2026 at 9:27 AM, Surveyor observed several bags of garbage on the ground next to dumpsters located outside and near kitchen back door. On 01/11/2026 at 9:27 AM, Surveyor asked Dietary Manager (DM) E what facility policy was for disposal of garbage. DM E stated none of the bags observed on the ground was disposal from the kitchen. DM E stated the bags observed were left there by other staff, namely nursing, and it happened every day. DM E stated administration has been made aware on several occasions this was happening.

Based on record review and interview, the facility did not ensure residents/representatives received notice of bed-hold policy indicating reserve payment and did not receive notice before indicating specific reason for the transfer/discharge for 5 of 5 residents (R2, R7, R8, R14, and R43).Example 1 R43 was admitted to the facility on [DATE]. On 10/10/25, R43 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R43 was transferred to the hospital on 1/5/26. Surveyor noted a summary that was sent with R43 upon transfer. On 1/12/25 at 12:11 PM, Social Worker F reported she does not have bed-hold notice for R43's hospital transfer. Example 2 R8 was admitted to the facility on [DATE]. On 01/05/26, Brief Interview for Mental status score was 9/15, indicating moderate cognitive impairment. On 01/07/26, R8 was admitted to the hospital for hip pain in relation to injury of unknown origin. There was no bed hold notice provided to R8 or representative related to transfer to hospital on [DATE]. Example 3 R7 was transferred to hospital for change in condition on 11/23/2025 and 01/10/2026 and was not provided a notice of bed hold indicating reserve paymentand did not receive notice before transfer/discharge indicating specific reason for the transfer/discharge. Surveyor attempted to interview Social Worker F regarding resident transfer/discharge process who was out ill last part of survey. Assistant Nursing Home Administrator (ANHA) B was not aware of process and would have to ask Nursing Home Administrator (NHA) A. At time of survey exit, there was no follow up from ANHA B or NHA A. Example 4 R2 was admitted to the facility on [DATE]. On 12/11/25, R2 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R2 was transferred to the hospital on [DATE]. R2's bed-hold notice was signed on 11/13/25 noting, I wish to reserve my room. R2's bed-hold notice was signed by a care manager from a Managed Care Organization (MCO). R2's bed-hold notice did not include the daily rate for reservation. Example 5 R14 was admitted to the facility on [DATE]. On 12/17/25, R14 scored 15/15 during BIMS assessment indicating intact cognition. R14 was transferred to the hospital on [DATE]. R14's bed-hold notice was signed on 12/30/25 noting, I wish to reserve my room. R14's bed-hold notice was signed by a care manager from a MCO. R14 was transferred to the hospital on [DATE]. There was no bed-hold notice provided to R14 for this transfer.

Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 3 of 3 residents (R4) reviewed.-R4's suprapubic catheter output was not monitored per physician's order and assessments not completed per professional standards of practice. R4 was transferred to the hospital on [DATE] after 2 days of increased incontinence, and hospitalized for four days with a Urinary Tract Infection. This example is cited at actual harm.-R2's Foley catheter output was not monitored per physician orders.-R5's suprapubic catheter output was not monitored per physician orders.This is evidenced by:Facility policy titled, Catheter Care, Urinary, with a revised date of 04/2010, states in part: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Input/Output: 1. Observe the resident's urine level for noticeable increases or decrease. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Maintain an accurate record of the resident's daily output, per facility policy and procedure. Complications: 1. Observe the resident for complications associated with urinary catheters.Facility policy titled, Output, Measuring and Recording, with a revised date of 09/2005, states in part: The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period. 1. Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy. 2. Review the resident's care plan and provide for any special needs of the resident. Reporting: 2. Report other information in accordance with facility policy and professional standards of practice.According to Lippincott Nursing 2025, professional standards of nursing care for suprapubic catheter include: inspecting catheter for patency, measure urine output at least every 8 hours, and to notify the health care provider immediately if the catheter stops draining or leaking of urine is noticed.Example 1R4 was admitted to the facility on [DATE] with pertinent diagnoses of multiple sclerosis and neurogenic bladder.R4's most recent Minimum Data Set (MDS) assessment, dated 05/07/25, noted a Brief Interview for Mental Status (BIMS) score of 13, indicating cognition is intact. R4 has an indwelling catheter and is always incontinent.R4's care plan, dated 02/08/24, with a target date of 08/21/25, states: Monitor and report output to nurse every shift. CATHETER: Catheter cares, Output every shift and prn. Notify the nurse if no urine output in eight hours.R4's physician orders:5/17/25 SP: Document SP catheter output every shift EVERY SHIFT5/16/25 SP: Change SP catheter PRN dislodgement or occlusion. PRN5/17/25 SP: Document Urine color q shift: N-no color PY-pale straw yellow [NAME]-translucent yellow [NAME]-dark yellow A-amber BO-burnt orange R-red BG-blue/green. EVERY SHIFT6/12/25 SP: Suprapubic catheter size 16 Fr with 10 cc balloon related to Diagnosis of Neuromuscular dysfunction of bladder5/20/25 IC: Enhanced Barrier Precautions related to: SP catheter every shift5/16/25 SP: Cleanse SP catheter site with NS, pat dry, leave open to air/cover with gauze dressing and secure with tape every day shift AND as neededSurveyor reviewed R4's nurse administration record for July 2025:-Of note: the facility documents dayshift as 12-hours and night shift as 12-hours.07/01/25: Urine output for night shift was documented as zero. No documentation of notifying provider. No additional assessments were noted.07/02/25: No documentation was noted for urine output. No additional assessments were noted.07/03/25: No documentation of urine output was noted for the day shift. No additional assessments were noted.07/05/25: Urine output for night shift was documented as zero. No documentation of notifying provider. No additional assessments were noted.07/06/25: Urine output for night shift was documented as zero. No documentation of notifying provider. No additional assessments were noted.07/10/25: Urine output for night shift was documented as zero. No documentation of notifying provider. No additional assessments were noted.07/11/25: Urine output for night shift was documented as zero. No documentation of notifying provider. No additional assessments were noted.07/14/25: Urine output for day shift was documented as zero. No documentation of notifying provider. No additional assessments were noted.07/16/25: Urine output for both day and night shift was documented as zero. No documentation of notifying provider. No additional assessments were noted.07/19/25: Urine output for night shift was documented as zero. No documentation of notifying provider. No additional assessments were noted.Surveyor reviewed R4's nursing notes:07/20/25 Certified Nursing Assistant (CNA) reported resident's supra pubic catheter had not been draining, writer assessed resident noting moderate build up in cath. Resident stated it had not been draining well for 2 days and she had large amounts of urine in her briefs coming from her bladder. Writer updated provider to sending resident out to ED. Resident sent to hospital, hospital called and will be admitting resident.-Of note: No documentation of amount or frequency of urinary incontinence noted prior to this. No other documentation noted of assessing catheter site for patency, occlusion, or signs/symptoms of infection. No additional vital signs were noted. No abdominal assessment was completed for distention or pain.R4 was admitted to the hospital on [DATE] with a severe urinary tract infection.On 09/03/25 at 6:30 AM, Surveyor interviewed Registered Nurse (RN) G regarding catheter output monitoring. RN G stated that CNAs record output and inform nurse of amounts. Surveyor asked RN G how nurses assess for abnormalities with urinary output. RN G stated that the aides are familiar with the residents and inform the nurse if there are concerns. Surveyor asked RN G if there were any guidelines or parameters to use to monitor for changes in urinary output. RN G stated not being aware of any. On 09/03/25 at 6:40 AM, Surveyor interviewed CNA E regarding urinary output monitoring and reporting. CNA E stated that amounts are tallied each 12-hour shift on paper and reported to the nurse at the end of the shift. The nurse then enters this information into the resident's electronic chart.On 09/03/25 at 9:22 AM, Surveyor interviewed RN F regarding catheter assessment, monitoring, and provider notification. RN F stated CNAs are expected to round on residents with catheters every 2 hours. If a resident has no urine output or less than 200 ml in 8 hours, an assessment should be completed and the results reported to the provider. Surveyor RN F asked if provider notification would be documented. RN F stated that it should be. Surveyor asked RN F what assessments a nurse is expected to complete if abnormal urine output is noted. RN F stated that the catheter site and tubing should be assessed for kinks, patency, and placement. A set of vitals and abdominal assessment should also be completed.On 09/03/25 at 9:49 AM, Surveyor interviewed Director of Nursing (DON) B regarding findings. DON B stated that no set parameters are in place for notifying the provider with urinary outputs unless the provider specifies this in the order. Surveyor asked DON B if nurses would be expected to report no output in urine during a 12-hour shift. DON B stated yes. Surveyor asked DON B if any additional assessments should be completed with residents who have a catheter and have no output. DON B stated no, unless the provider orders it. Example 2R2 was admitted to the facility on [DATE] with pertinent diagnoses of obstructive and reflux uropathy and neurocognitive disorder with lewy bodies.R2's MDS assessment dated [DATE] noted indwelling catheter present.R2's care plan, dated 08/09/24, with a target date of 11/20/25, states: Monitor and document output Q-SHIFTR2's physician orders:08/06/25 Please call to get appointment with urology due to recent urethra injury and ER visitNote: A urology consult order from July 8, 2025 was mistakenly entered, referencing a past incident; it was properly discontinued on August 5, 2025, indicating a corrective oversight. Since readmission nearly a year ago, R2 has had no ER visits related to urinary issues and no evidence of catheter-associated UTI.08/08/25 FC: Document foley catheter output every shiftSurveyor reviewed R2's medical record and noted:07/25/25 Changed patient's catheter due to displacement. Facility did not have 16 fr catheters so received verbal from [provider name] to place an 18 fr. Patient tolerated well. Catheter secured to R leg. Patient's wife updated.Surveyor reviewed R2's nurse administration record for July 2025:07/02/25: Urinary output for nightshift is noted as zero. No provider notification noted.07/05/25: Urinary output for nightshift is noted as zero. No provider notification noted.07/06/25: Urinary output for nightshift is documented as 'xx.' No amount noted.07/14/25: Urinary output for dayshift is documented as 'n.' No amount noted. Urinary output for nightshift is noted as zero. No provider notification noted.07/15/25: Urinary output for nightshift is noted as zero. No provider notification noted.07/16/25: Urinary output for dayshift is documented as 'x.' No amount noted.07/20/25: Urinary output for nightshift is documented as 'cna.' No amount noted.07/24/25: Urinary output for nightshift is noted as zero. No provider notification noted.07/25/25: Urinary output for nightshift is documented as 'cna.' No amount noted.07/30/25: Urinary output for nightshift is documented as 'cna.' No amount noted.Surveyor reviewed R2's nurse administration record for August 2025:08/01/25: Urinary output for nightshift is documented as zero. No provider notification noted.08/03/25: Urinary output for nightshift is documented as 'xx'. No amount noted.08/05/25: Urinary output for nightshift is documented as zero. No provider notification noted.08/07/25: Urinary output for nightshift is documented as 'yello'. No amount noted.08/08/25: Urinary output on nightshift has nothing documented.08/13/25: Urinary output for nightshift is documented as 'A'. No amount noted.08/17/25: Urinary output on nightshift has nothing documented.08/27/25: Urinary output for nightshift is documented as 'N'. No amount noted.08/28/25: Urinary output on nightshift has nothing documented.08/30/25: Urinary output on nightshift has nothing documented.Facility did not provide any additional documentation.Example 3R5 was admitted to the facility on [DATE] with pertinent diagnoses of osteomyelitis of vertebra and neuromuscular dysfunction of bladder.R5's most recent MDS, dated [DATE], noted the presence of an indwelling catheter.R5's care plan, dated 01/08/25, with a target date of 12/25/25, states: Monitor and document intake and output as per facility policy. Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output.R5's physician orders:12/28/24 SP: Document SP catheter output every shiftSurveyor reviewed R5's nurse administration record for July 2025:07/02/25: No urinary output documented.07/04/25: No urinary output documented for dayshift.07/05/25: Urinary output for nightshift is documented as 'clear.' No amount noted.07/08/25: Urinary output for dayshift is documented as zero. No provider notification noted.07/10/25: Urinary output for nightshift is documented as 'yello.' No amount noted.07/14/25: Urinary output for dayshift and nightshift is documented as zero. No provider notification noted.07/16/25: Urinary output for dayshift is documented as zero. No provider notification noted.07/19/25: Urinary output for nightshift is documented as zero. No provider notification noted.Surveyor reviewed R5's nurse administration record for August 2025:08/05/25: Urinary output for nightshift is documented as zero. No provider notification noted.08/11/25: No urinary output documented for nightshift.08/16/25: No urinary output documented for nightshift.08/17/25: No urinary output documented for nightshift.08/18/25: No urinary output documented for dayshift.08/19/25: No urinary output documented for dayshift.08/26/25: Urinary output for nightshift is documented as 'CLR.' No amount noted.08/27/25: Urinary output for nightshift is documented as zero. No provider notification noted.

Based on record review and interview, the facility did not ensure the physician was notified of laboratory results for 1 of 2 residents (R), R7, reviewed for lab results. -A urinalysis (U/A) determined R7 had a urinary tract infection (UTI). The facility did not update R7's primary provider or urologist with the results; four days later R7 was hospitalized due to sepsis. Findings: R7 admitted to the facility on [DATE] with past medical history notable for cerebral palsy, urinary retention with chronic suprapubic catheter, and urinary tract infections. Minimum Data Set (MDS) assessment completed on 02/14/25 confirmed R7 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R7 is dependent on staff for activities of daily living (ADLs). R7's care plan included the following: -Renal insufficiency related to hydronephrosis (fluid in kidneys), history of calculus (stone) of ureter (a tube that carries urine from the kidney to the bladder) with obstruction, nephritis (kidney inflammation), and UTI, 10/31/24. In August 2024, R7 had ureter stents placed due to obstruction caused from kidney stones. On 03/06/25, R7 was scheduled to have stents removed at urology clinic. R7's stents were unable to be removed due to a small bladder, inflammatory debris, patient discomfort, and possible encrustation. Urologist E recommended removal in the operating room with date to be determined. On 03/17/25, Urologist E ordered a urine sample with culture and sensitivity, one time only for pre-surgical orders. R7's stent removal was scheduled for 04/02/25. On 03/19/25, R7 complained of abdominal pain and bladder spasms rating pain 8/10. Facility staff changed R7's suprapubic catheter. R7 stated she felt relieved and had no other complaints at that time. Urine specimen was collected and taken to lab per orders. On 03/23/25, R7's U/A results confirmed growth of pathogens, >100,000 klebsiella variicola and >100,000 proteus mirabilis. On 03/27/25 at approximately 5:46 AM, R7 reported to facility staff she felt dizzy and unwell. Vital signs were stable, rapid covid was negative, blood glucose was 196. R7's provider, Nurse Practitioner (NP) C was updated and ordered to obtain the following blood tests, Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP). On 03/27/25 at approximately 1:05 PM, facility staff updated NP C of R7's change in condition related to lethargy and fever. NP C ordered R7 be sent to the emergency room (ER) for evaluation. R7 was admitted to the hospital due to septicemia (a body's response to an infection, causing inflammation which can lead to organ failure and death). Surveyor reviewed the discharge summary from R7's hospitalization from [DATE]-[DATE]. The discharge summary read in part, Brought to ER d/t mental status changes and fever, found to be septic. Two possible causes of sepsis, CAUTI from enterococcus. Blood cultures grew klebsiella pneumonia and imaging suggests possible pneumonia. UTI was treated with vancomycin, and pneumonia was treated with cefepime. There were no other concerns indicated during R7's hospitalization . On 04/02/25, R7 was discharged from the hospital and readmitted to the facility. On 04/21/25 at 2:11 PM, Surveyor interviewed R7. R7 stated she went to the urology clinic to have her ureter stents removed, however, they were unable to remove them due to pain, and she will be receiving anesthesia to have the stents removed on 04/30/25. R7 confirmed she was hospitalized about a month ago related to a UTI and states she has had UTIs in the past. R7 stated on the day she was sent to the ER, she had told staff she was not feeling well. After telling staff she was not feeling she was sent to the ER. R7 denied feeling ill prior to the day she was sent to the ER and hospitalized . On 04/22/25, Surveyor reviewed R7's record and noted NP C or Urologist E were not updated after the facility received R7's U/A results on 03/23/25. Surveyor noted the facility placed the order for R7's U/A under Medical Director (MD) D, and not under Urologist E, who ordered the U/A. On 04/22/25 at 9:17 AM, Surveyor interviewed NP C. Surveyor asked NP C if he was aware of R7's U/A results from 03/23/25. NP C stated he was not aware of R7's U/A results, as he did not order it. NP C stated because R7's U/A was ordered by Urologist E and not ordered by NP C, NP C would not have been sent R7's U/A lab report on 03/23/25, and he would have to go into R7's record to see the results. NP C stated he would not have looked in R7's record for the results, as he was not aware a U/A was ordered. NP C stated the results would have been sent to MD D, as her name was entered on the order. NP C stated MD D may not have reviewed the results as she would not have been aware a U/A was ordered. NP C stated facility should have put Urologist E's name on the order to ensure follow up. On 04/22/25 at 10:22 AM, Surveyor interviewed Infection Preventionist (IP) F. IP F reviewed R7's U/A results from 03/23/25, and stated she would expect staff to update a provider with the results. IP F stated a provider should be updated with both negative and positive results. IP F was unable to report why a provider was not updated on R7's U/A results. On 04/22/25 at 11:01 AM, Surveyor interviewed NP C. NP C stated residents with catheters will usually grow bacteria in urine due to colonization (bacteria is present without causing signs or symptoms) and may not require treatment. NP C confirmed R7 was asymptomatic until 03/27/25, when she was sent to ER. NP C stated R7's U/A results on 3/23/25 were not critical results. R7's U/A on 03/23/25 grew klebsiella variicola and proteus mirabilis and the U/A in theER on [DATE] grew enterococcus, and the blood culture grew klebsiella pneumoniae. Klebsiella variicola comprises seven klebsiella pneumoniae species. Klebsiella variicola causes a wide range of health-care-associated infections and community-acquired infections. Klebsiella variicola is an opportunistic pathogen that can infect in the bloodstream, the respiratory tract, and the urinary tract. ([NAME] E, [NAME] SA. A case of Klebsiella variicola infection. Consultant. 2021;61(2):e33-e34. doi:10.25270/con.2020.07.00006) On 04/22/25 at 11:24 AM, Surveyor interviewed Medication Tech (MT) G. MT G stated she also works as Certified Nursing Assistant (CNA.) MT G reported she has cared for R7 and is familiar with R7. MT G reported R7 was at her normal baseline prior to her hospitalization on [DATE]. On 04/22/25 at 11:26 AM, Surveyor interviewed Registered Nurse (RN) H. RN H stated R7 absolutely had no symptoms until 3/27/25, when she spiked a fever and had tremors. RN H stated R7 has a history of elevated temperature being related to UTI. On 04/22/25 at 11:51 AM, Surveyor interviewed Urologist E's staff. Urologist E's staff confirmed Urologist E did not receive R7's U/A results on 03/23/25, and they would discuss this with Urologist E and call Surveyor back. On 04/22/25 at 4:07 PM, Surveyor interviewed Urologist E about R7's U/A and treatment. Urologist E reported R7's U/A was ordered as part of her pre-operative plan and not due to symptoms. She would have treated R7's UTI approximately 3-4 days prior to R7's procedure, which was scheduled for 04/02/25. Facility staff did not update R7's primary provider or urologist related to the results of R7's U/A, to determine if R7 required treatment at the time of her UTI. Four days later R7 was hospitalized with sepsis.

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act,) the comprehensive person-centered care plan, and the resident's choice for 2 of 12 sampled residents (R6 and R21.) R21 did not have comprehensive Congestive Heart Failure (CHF) assessments completed or labs completed to determine worsening CHF. R21 was hospitalized with exacerbation of CHF and Non-ST segment elevation myocardial infarction. This example is cited at actual harm. R6 has multiple non pressure wounds that were not assessed weekly and had missed wound care appointments. Findings include: Example 1: According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. R21 was admitted to the facility on [DATE] with diagnoses including in part, congestive heart failure, atherosclerotic heart disease, essential hypertension, edema, non-ST elevation myocardial infarction, dilated cardiomyopathy, diabetes mellitus type 2 with underlying condition with foot ulcer, and cellulitis of right and left lower limb. R21's Minimum Data Set (MDS) assessment, dated 05/15/24, identified R21 required substantial maximal assistance for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. On 09/30/24 at 10:17 AM, Surveyor observed Certified Nurse Assistant (CNA) G enter R21's room. CNA G stated to R21, Oh you look better today. I know you have not been feeling well the last few days. R21 stated to CNA G, I feel a little bit better this morning but still having shortness of breath, maybe it's just anxiety. CNA G then indicated to R21 that CNA G was just checking to see if R21 needed anything. R21 declined needing any services at the time. On 09/30/24 at 10:25 AM, Surveyor interviewed R21 who indicated that R21 had been feeling cruddy last few days with some shortness of breath and nausea but seemed to not be nauseated this morning. On 10/01/24 at 6:45 AM, Surveyor noticed R21 not in R21's room. Surveyor interviewed Registered Nurse (RN) F and asked where R21 was as Surveyor did not observe R21 in R21's room. RN F indicated that R21 had been having some shortness of breath and difficulty breathing the last few days and was finally sent out in the middle of the night on 09/30/24 into early morning 10/01/24 via EMS. Review of R21's medical record identified the following note, which stated in part: -On 09/19/24 at 12:47 PM, [Nurse Practitioner (NP) H] had provider visit with [R21]. Facility staff had concerns with [R21] complaining of shortness of breath. [NP H] recommended to continue monitoring for signs of fluid overload or decompensated heart failure. [NP H] ordered Basic Metabolic Panel (BMP) and B-type Natriuretic Peptide (BNP) today. -On 09/19/24 at 2:45 PM, nurse note indicates monitor for fluid overload, increased edema, shortness of breath, abnormal lung sounds, update provider if changes noted every shift for Congestive Heart Failure (CHF), [NP H] ordered Metolazone 2.5mg started today and continues for 3 days. Recheck BMP and BNP on 09/23. -On 09/19/24 at 3:19 PM, nurse note indicates new order for metolazone, and follow up labs due to edema. Resident updated and aware. -On 09/23/24 at 10:51 AM, nurse note indicates one attempt of left hand unsuccessful. Resident tolerated well. Will attempt later. -On 09/23/24 at 5:16 PM, nurse note indicates BMP and BNP one time only for monitoring for 2 days. Unable to collect. -On 09/30/24 at 6:35 AM, Ipratropium-Albuterol solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally every 6 hours as needed for wheezing, shortness of breath given for complaint of dyspnea. -On 09/30/24 at 7:36 AM, Ipratropium-Albuterol solution 0.5-2.5 (3) MG/3ML, 1 vial inhale orally every 6 hours as needed for wheezing, shortness of breath effective, sp02 99-100% pre and post nebulizer, lungs with no adventitious sounds, respirations 18 even and relaxed. - On 10/01/24 at 1:39 AM, Resident sent to Hospital ED for difficulty breathing. Hospital returned update with resident being sent out related to myocardial infarction . Surveyor reviewed hospital note that stated in part: On 09/30/24 9:39 PM, [R21] stated [R21] has had increasing shortness of breath at rest over the last few days with some intermittent episodes of substernal chest pain. [R21] is found to have an Non-ST segment elevation myocardial infarction (N-STEMI) and CHF exacerbation. [R21] was then transferred to a higher level hospital for cardiac care. Surveyor reviewed all progress notes and assessments in R21's medical record and found no CHF assessments completed. Interviews: On 10/02/24 at 8:59 AM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B knew why R21 had not had labs drawn for monitoring CHF as ordered from NP H on 09/23/24. DON B indicated the day nurse on 09/23/24 could not draw the lab and the nurse had reported this to the night shift nurse. DON B indicated that then the night nurse attempted and could not draw lab. DON B indicated it was not relayed in report to the next day shift, and the lab was cancelled. DON B indicated that R21's labs were not completed. On 10/02/24 at 2:15 PM, Surveyor interviewed Registered Nurse (RN) F and asked what events led up to R21 being hospitalized on [DATE] in the early hours. RN F indicated that RN F did not know much about the transfer other than R21 had to request to the night nurse that was on that R21 needed to go to the hospital as R21 was having a hard time breathing. Surveyor asked RN F to explain what a CHF assessment is and does RN F complete the CHF assessments regularly. RN F indicated that RN F listens to lungs, heart, and takes vitals. RN F monitors for edema and monitors weights daily. Surveyor asked RN F if the CHF assessments have been being completed and where they are documented. RN F indicated they should be getting done and would need to review R21's medical record to see if RN F documented this. RN F reviewed documentation and indicated that when R21 is having shortness of breath and RN F does not to a CHF assessment, RN F documents when a nebulizer treatment is given that there is shortness of breath noted and if it is effective or not. RN F indicated there is no comprehensive CHF assessment documented. On 10/02/24 at 3:14 PM, Surveyor interviewed DON B and asked what DON B's expectation is for monitoring CHF for residents. DON B indicated that residents should be weighed daily, and a full head to toe assessment should be completed which entails heart sounds, lung sounds, edema, and vitals. Surveyor asked DON B to review R21's medical record and show Surveyor the CHF assessments. DON B reviewed R21's medical record and stated, [R21] does not have any completed at all. Not even a change in condition related to breathing issues or notification to physician of the change in [R21's] status. No further documentation was given. 44863 The facility's policy titled Skin Integrity, Pressure Injuries Nursing Protocol, read in part .The resident will receive care, consistent with professional standards of practice, to prevent pressure injuries and will not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and the resident with pressure injuries will receive necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers from developing. A. Identify if the resident is at risk for developing pressure injury on admission and thereafter. D. If a pressure injury is present, provide treatment to heal it and prevent development of additional pressure injuries. R6 was admitted to the facility on [DATE], with deep tissue injury (DTI) to left heel. R6's diagnoses included type 2 diabetes mellitus, polyneuropathy, peripheral vascular disease, dependence on renal dialysis, and amputation of right lower leg. R6's physician orders included, To left heel and foot: If dressing becomes dislodged/soiled: Cleanse with soap and warm water, Cleanse with wound cleanser. Apply aquacel ag and adhesive foam, and secure with gauze roll and elastic bandage wrapped lightly. Keep heel suspension boots on at all times. R6's record did not contain a comprehensive skin assessment upon admission. On 09/26/23, a comprehensive skin assessment was completed on R6. The next comprehensive skin assessment was completed 14 days later, on 10/10/23. On 10/17/23, a comprehensive skin assessment was completed. The next comprehensive skin assessment was completed 14 days later, on 10/31/23. R6's comprehensive skin assessments were completed timely through 12/08/23, when R6 was referred to wound care clinic. The facility did not provide comprehensive skin assessments for R6 after 12/08/23. On 12/15/23, the wound care clinic ordered a podiatry referral and an arterial blood flow study to determine healing ability of R6's wound. R6's record did not contain evidence R6 was referred to podiatry or arterial blood flow study. On 01/05/24, R6 attended wound care clinic for treatment of left heel DTI; no measurements of this wound were completed at the appointment. Wound care clinic documentation indicated R6 developed two additional wounds to his left anterior foot and left lateral foot. The documentation is not specific to indicate if these wounds are pressure, vascular, or diabetic related. The facility did not complete a comprehensive assessment of R6's wounds. On 01/19/24, R6 attended wound care clinic for treatment; no measurements of wounds were completed at this appointment. The facility did not complete a comprehensive assessment of R6's wounds. On 01/30/24, R6 attended wound care clinic, with a note to return on 02/02/24. R6 did not attend wound care clinic until 02/06/24, four days after he was scheduled to attend. R6's treatment administration record confirmed the facility did not provide dressing change or treatment between 01/30/24 and 02/06/24. On 02/09/24, R6 was hospitalized for abscess on left foot. R6 was readmitted to the facility on [DATE]. On 02/12/24, R6 was hospitalized for multiple necrotic wounds of left foot. On 02/22/24, R6 required a left below the knee amputation. R6 was readmitted to the facility on [DATE]. On 09/30/24 at 10:26 AM, Surveyor interviewed R6. During the interview, R6 rolled his eyes and sighed when asked questions, but he denied any concerns related to his care. R6 confirmed he had wounds to both bilateral legs resulting in amputations, stating the wounds were from his diabetes. R6 confirmed he attended wound care clinic for treatment of his wounds, and denied any concerns related to transportation to appointments. R6 confirmed he had a wound on his buttocks, but it has healed. R6 reported his only skin concern was he had eczema and confirmed staff provide a topical treatment. On 10/02/24, Surveyor interviewed wound care clinic nurse. Nurse reported R6's wounds and amputation were unavoidable due to R6's co-morbidities, including poor wound healing related to diabetes and vascular disease. 10/02/24 at 1:35 PM, Surveyor interviewed DON B. DON B confirmed R6's wounds and amputation were unavoidable related to his co-morbidities and his non-compliance of interventions. DON B confirmed comprehensive skin assessments should be completed within 24 hours of admission, and residents with wounds should be assessed weekly. The facility expectation is assessments be comprehensive and include measurements, description, and location. DON B confirmed there was not a comprehensive skin assessment completed upon R6's admission, and not until 09/26/24, four days after admission. DON B reported if a wound care appointment is missed, the expectation is staff call the wound care clinic for direction; if the resident has a PRN (as needed) order, staff can complete the treatment if directed to do so by wound care clinic. DON B confirmed the facility did not complete PRN treatment orders for R6. On 10/02/24, Surveyor requested documentation to support R6's provider was updated with wound changes, concerns, or missed appointments; the facility did not provide further documentation. DON B confirmed she could not find evidence of this in R6's record. On 10/02/24, Surveyor requested additional documentation related to podiatry and blood flow studies; the facility did not provide further documentation to support R6 attended these appointments.

Based on observations, interviews, and record reviews, the facility did not provide sufficient staffing to meet the needs of 26 of 26 residents living in the facility. On 08/04/22 and 08/05/22, during a complaint survey, the state survey agency noted the facility did not have a DON (Director of Nursing). The facility was not providing supervision to an RN (registered nurse) who has license restrictions that included direct supervision. The NHA (Nursing Home Administrator), who is also a nurse, was working as a floor nurse as many as 84 hours in a row without leaving the facility. The NHA was also noted to be sleeping in the therapy room at night during the 84 hours without relief. While the NHA slept, there was only one or two certified nursing assistants caring for resident needs. The failure to provide adequate staffing created a finding of immediate jeopardy that began on 08/05/22. The NHA (Nursing Home Administrator) A and VP (Vice President) C were notified of the immediate jeopardy on 08/05/22 at 2:25 PM. The immediate jeopardy was removed on 08/15/22, however the deficient practice continues at a scope/severity of an F (potential for more than minimal harm/widespread). This is evidenced by: A review of the facility assessment dated [DATE] indicates that the number of hours of licensed nurses and CNAs needed to ensure there is sufficient staff to meet resident needs is 72 hours per day. On 08/04/22 at 5:40 AM, Surveyor completed entrance with NHA/RN A. NHA/RN A stated, We currently do not have a DON. She quit on the spot on 07/28/22 without giving any notice. We are working on getting a replacement. The DON's last working day was 07/27/22. Corporate has been working on a contract with someone, but I am not sure where that is at. If I need anything I can call NC D (Nurse Consultant). Surveyor asked NHA/RN A if they had appointed anyone to be the interim DON. NHA/RN A stated, We have not appointed anyone at this time, no one wants to do it. RN F would do it but is unable to do so as she has restrictions on her license. On 08/04/22, at 5:19 AM, Surveyors were told the census was 26. Surveyors toured the building to determine the nurse and CNA (Certified Nursing Assistant) staffing levels. There was 1 RN who is also the NHA, and 2 CNAs. Surveyors requested the Daily Assignment Sheets and schedules beginning on 07/01/22. A review of the actual hours worked revealed the following: 07/28/22: 74 hours worked that day by direct care staff (licensed nurses and CNAs). This included 18 hours worked by the NHA/RN A (6AM to midnight). 07/29/22: 52 hours worked that day by direct care staff. This included 24 hours worked by the NHA/RN A. This is 20 hours (30%) below the minimum number of hours the facility determined was necessary to meet resident needs. (Note: from 6:00 AM to 2:00 PM and from 10:00 PM to 6:00 AM, there was only 1 CNA to care for 26 residents. The facility notes they have 7 residents that need assistance of a full body lift that requires 2 staff to safely operate.) 07/30/22: 64 hours worked that day by direct care staff. This included 24 hours worked by the NHA/RN A. This is 8 hours below the minimum number of hours the facility determined was necessary to meet resident needs. NHA/RN A worked the following hours and was the only nurse on duty from 07/28/22 at 6:00 AM until 07/31/22 at 6:00 PM. (Note: NHA/RN A worked a total of 84 hours straight between 07/28/22 and 07/31/22.) NHA/RN A worked on 08/01/22 from 6:00 AM to 6:00 PM and 08/03/22 from 6:00 PM to 6:00 AM on 08/04/22. Note: NHA/RN A did not leave on 08/04/22 at 6:00 AM due to Surveyors being in the facility. NHA/RN A worked 08/04/22 from 6:00 PM to 11:30 AM on 08/05/22 Note: NHA/RN A did not leave on 08/05/22 at 6:00 AM due to Surveyors being in the facility. RN F did not show up for her shift until 11:30 AM on 08/05/22. NHA/RN A worked a total of 17.5 hours without leaving the building between 08/03/22 and 08/05/22. At the time of this complaint survey, the facility employed a total of 3 Nurses, one which has restrictions on her license that requires her to have direct supervision, second is the NHA who is also an RN, and the third is the staff development coordinator. On 08/05/22 at 7:10 AM, Surveyor spoke with NHA/RN A. Surveyor asked NHA/RN A if she had left on 08/04/22 after Surveyors left the building. NHA/RN A stated, No, I ended up staying through the night shift as there was no one to relieve me. I only got about an hour of sleep. On 08/04/22 at 5:30 AM, Surveyor interviewed CNA G (Certified Nursing Assistant). Surveyor asked CNA G if she had worked with NHA/RN A between 07/29/22 and 07/31/22. CNA G stated, Yes, the nurse was available. I was to wake her up if I needed her. I did wake her once. She was not asleep the whole night. None of the residents had to wait for medications and there were no falls. One of the three nurses who work at the facility is RN F. RN F requires direct supervision (another nurse present in the building) while working in accordance with her license restrictions. It was determined that this RN worked as the only nurse in the building on the following dates without the supervision her license requires: 07/02/22, 07/03/22, 07/04/22, 07/09/22, 07/10/22, 07/23/22, 07/24/22, 08/06/22, and 08/07/22. On 08/04/22 at 7:50 AM, Surveyor interviewed RN F. RN F stated, There is always someone here acting as the charge nurse, NHA, DON, for RN K. If no one else is here, like on the weekend, I am the charge nurse. On 08/05/22 at 9:00 AM, Surveyor interviewed NHA/RN A. Surveyor asked NHA/RN A if she was aware RN F had restrictions on her RN license: NHA/RN A stated, The previous DON stated she needed to send in quarterly reports. That was all I knew. I have not read her restrictions. On 08/05/22 at 9:14 AM, Surveyor interviewed CHR L (Corporate Human Resources). Surveyor asked CHR L about RN F's license restrictions. CHR L stated, Our clinical team, including the DON and Corporate Team, reviewed RN F's restrictions. I knew she needed some type of supervision. VP C (Vice President) and NC D (Nurse Consultant) would have reviewed those restrictions. On 08/05/22 at 9:25 AM, Surveyor interviewed NC D. Surveyor asked NC D if he had reviewed RN F's RN license restrictions. NC D stated, I read the limitations on her license. I understood them as she had no limitations to practice but needed to be observed. She would then be reviewed by licensing in March of 2023. She had no more issues with narcotics, and I believed her oversight would be by the Board of Nursing. Surveyor asked NC D if he had asked DSPS (Department of Safety and Professional Services) to explain RN F's restrictions. NC D stated, I never contacted them to clarify her restrictions. I thought everyone would have reviewed her restrictions. RN F should have been supervised. Surveyor asked if VP C knew about RN F's restrictions. NC D stated, I am unsure if VP C knew about RN F's restrictions. I am not involved in the hiring process unless they have questions. Surveyor asked NC D when he was made aware of RN F's restrictions. NC D stated, I was made aware one week ago due to a discussion of making RN F the DON. During that discussion NHA/RN A indicated that RN F had a limited license. No one ever said she needed direct supervision. On 08/05/22 at 9:49 AM, Surveyor interviewed VP C. Surveyor asked VP C when he was made aware of RN F's license restrictions. VP C stated, I was made aware in March 2022 that she needed a licensed individual in the facility when she was working the medication cart. They wanted her to be the DON at one time and we discussed her restrictions then. Surveyor asked VP C if NHA/RN A was aware of RN F's license restrictions. VP C stated, I told the NHA that RN F needed to be supervised. NHA/RN A and I spoke and discussed it could be the NHA or someone in a supervisory capacity. We have had no issues with RN F. The DON walked out and the NHA and I discussed again the possibility of RN F taking over the DON role. Surveyor asked VP C about RN F's restrictions and if he was aware of the duration of those restrictions. RN F stated, The incident occurred in 2019 and signed in 2021. Surveyor asked VP C if he was aware RN F was working without supervision. VP C stated, I was aware she was working as the only nurse at times. We have had zero issues with her performance. We also felt that resident care was more important than supervision. I realize she should have been supervised. On 08/05/22 at 11:46 AM, Surveyor spoke with NHA A. Surveyor explained to NHA A the concern of working several days in a row without leaving the facility, along with sleeping during part of those shifts in the therapy room while being the only licensed nurse in the facility. The concern of RN F working without the supervision her license required, and having only 1 CNA on a shift when several residents required two staff assist with a full body lift. The failure to ensure adequate staffing to meet resident needs created a reasonable likelihood that serious harm could occur, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 08/15/22, when it had completed the following: 1. NHA/RN A was inserviced on ensuring the appropriate qualified nursing staff on 08/04/2022 by the VPO (Vice President of Operations). 2. An interim Director of Nursing on 08/05/2022 and began on 08/11/2022. 3. RN F will no longer serve as a nurse at the facility as of 08/10/2022. The facility will be covered by a licensed nurse to ensure the well being of the residents is monitored and maintained. 4. The staffing patterns will be based upon the in-house census and the desire is to meet the minimum staffing hours necessary to meet the needs of the residents illustrated in the facility assessment. Therefore 1 nurse to 30 residents per shift regardless of 8 hours or 12 hours shifts. 1 Certified Nursing Assistant to 15 residents on days, evenings. The midnight shift is dependent upon the acuity level of the residents and the maximum is 1:30 residents. 5. Facility has increased the nurse wages, offered retention bonuses, and increased the radius of the help wanted ads. 6. An RN MDS Coordinator, Interim Director of Nursing, and other RNs have been hired but they do not begin til after their required 2 week or 30 day notices. After 08/27/22 the facility will be fully staffed (if no changes to the current hires) with licensed nurses. 7. The schedule after 08/12/22 is currently under review by the VPO, Nurse Consultant, NHA A and the DON. NHA A and Interim DON were inserviced on ensuring the nurses do not work excessive hours during the day. 8. The facility assessment will be revised to illustrate the staffing patterns to meet the physical and psychosocial well being of the residents 08/08/22. 9. The staffing contingency plan was updated. 10. The RN Consultant will be at the facility on 08/09/22 to ensure the facility staffing is appropriate for the physical and psychosocial well being to be maintained. The corporate office will ensure a corporate nurse representative is at the facility weekly to support the facility. 11. The VPO will be at the facility on 08/10/22 to further assist with ensuring the physical and psychosocial well being of the residents is maintained.

Based on interview and record review, the facility did not have a system to ensure there was someone working each shift who was certified in CPR (cardiopulmonary resuscitation), which had the potential to affect 8 of 26 residents (R1, R2, R4, R6, R8, R9, R13, and R15) who are full code and wished to be resuscitated. On admission, R6's Advanced Directives indicates he wanted to be a full code. The facility's electronic charting system indicated R6 elected to be a DNR (do not resuscitate). R2, R4, R6, R8, R9, R13, and R15 all have Advanced Directives indicating their choice was to be a full code and they desired to have CPR (cardiopulmonary resuscitation) should they become unresponsive. There was no one in the building from 6:00 AM on [DATE] to 6:00 PM on [DATE] and from 6:00 PM to 6:00 AM on [DATE] and [DATE] who was CPR certified. Until survey, the facility could not readily determine if nurses who worked other shifts were CPR certified. CNA/Main/Transp I (Certified Nursing Assistant/Maintenance/Transportation) was transporting residents to appointments without current and up-to-date CPR certification. The facility's failure to ensure a CPR certified staff was working in the facility at all times and it's failure to ensure R6's record accurately identified R6's wishes/advance directives created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A on [DATE] at 2:16 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: The facility policy titled, Do Not Resuscitate Order, undated, states in part, .Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record . 6. The Interdisciplinary Care Planning Team will review advanced directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. The facility policy titled, Emergency Procedure - Cardiopulmonary Resuscitation, undated, states in part . Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [CONDITION(S)]. Preparation for Cardiopulmonary Resuscitation: 1. Obtain and/or maintain a state approved BLS-CPR certification with skills check off in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. Example 1: R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 was a full code on admission. On [DATE] at 10:40 AM, Surveyor reviewed code status for R6. R6's Advanced Directives indicate he wished to be a full code. The facility's electronic charting system identified R6 as a DNR (Do Not Resuscitate). This contradicts R6's Advanced Directive. Hospital PPOC (Physician's Plan of Care) dated [DATE] indicates in part . No CPR. Hospital PPOC dated [DATE] indicates in part . No CPR. The facility did not verify with R6 his wishes of having CPR or being a DNR despite the differences in documentation. If R6 really wished to be DNR, his order would have been invalid because Wisconsin statute 154.19(1)(d) requires the signature of the patient, the guardian, or the health care agent. On [DATE] at 12:03 PM, Surveyor interviewed RN F. Surveyor asked RN F where she would look to find a resident's code status. RN F stated, I would look in computer charting. The computer charting would have indicated R6 did not want CPR even though he had elected to be a full code. On [DATE] at 9:36 AM, Surveyor asked NHA A for R6's signed DNR. NHA A stated, If it isn't in the chart, we don't have it. RN F was looking at this yesterday. She was going to take something down to R6 to have him sign. We should not be going off something that comes from the hospital for the code status. We would need to get something signed by the resident and physician. Example 2: Based on record review, R2, R4, R6, R8, R9, R13, and R15 all have Advanced Directives indicating their choice was to be a full code and they desired to have CPR should they become pulseless and non-breathing. On [DATE] at 9:18 AM, Surveyor requested copies of CPR certifications for the licensed nursing staff. On [DATE] at 11:50 AM, NHA A stated to Surveyor, I have been unable to find the CPR certifications, but they are here somewhere. Surveyor asked NHA A if all staff are required to be CPR certified. NHA A stated, All nurses but not CNAs (Certified Nursing Assistants). I just have been unable to locate the documentation. On [DATE] at 10:48 AM, Surveyor reviewed personnel files for NHA A, RN F, and RN K (these are the only licensed nursing staff for the facility). There is no evidence in any of the files indicating that the nurses are CPR certified. Following the survey, the facility was able to provide current and up-to-date CPR certifications for RN F and RN K but not for NHA A. Starting on [DATE] at 6:00 AM, NHA A, who is also an RN (Registered Nurse), worked as a floor nurse in the facility without leaving the building until [DATE] at 6:00 AM; NHA A was the only nurse in the building during these 84 hours. NHA A also worked on [DATE] and [DATE] from 6:00 PM to 6:00 AM during the night shift and was the only nurse in the building. NHA A did not have current CPR certification. On [DATE] at 10:30 AM, Surveyor spoke with CNA/Main/Transp I who indicates he does a little bit of everything including taking residents out to appointments. Surveyors requested evidence that CNA/Main/Transp I was CPR certified. The facility was unable to provide that documentation. On [DATE] at 11:46 AM, Surveyor spoke with NHA A. Surveyor explained to NHA A the concern of R6's Advanced Directives indicating he wanted CPR, but the electronic charting system indicates R6 was a DNR. Furthermore, Surveyor explained that RN F indicated that the electronic charting system is where she would look to find a resident's code status. Surveyor also explained the concern that the facility has no record of their nursing staff's CPR certification and no system in place to keep track of CPR certification. The failure to ensure R6's wishes were accurately and consistently identified in the medical record and the failure to ensure CPR-certified staff worked each shift created a reasonable likelihood that serious harm could occur, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: 1. NHA A completed an audit of the 26 residents and found 2 residents to not have the EMR (electronic medical record) updated. On [DATE] the EMR was updated and reflected the correct Advanced Directive by the NHA A. 2. NHA A and all other licensed nurses will have their CPR recertification completed by [DATE]. 3. NHA A was reeducated by Nurse Consultant on [DATE] on ensuring the CPR certifications are maintained and that 1 person per shift must be certified to provide CPR in the event a resident would code on [DATE]. 4. All licensed nurses will be reeducated by [DATE] on ensuring they maintain their CPR status by NH A. 5. The Social Worker was reeducated by the NHA A on [DATE] on ensuring the advanced directives are addressed upon admission and readmission and the EMR reflects the status of the resident's wishes. 6. The Human Resource Department was reeducated on [DATE] by the Vice President of Operations on ensuring all licensed nurses have their CPR certification upon hire and renewed every 2 years thereafter. 7. The Human Resource (HR) Department will ensure the licensed nurses upon hire have the required CPR certification. The HR department will notify the employee 30 days prior to the expiration of the certification for renewal. Any employee that is not able to complete the re-certification will be removed from the schedule until the CPR certification is received by the facility. 8. The Social Worker will bring to the daily stand-up meeting the completed advanced directive audit for review by NHA A for further follow up as identified. 9. HR Director will bring the completed licensed nurse CPR audit to the stand-up meeting to ensure all nurses have or have recertified in CPR. 10. The completed HR audit of CPR certification and recertification along with the Advanced Directive audit will be reviewed with the monthly QAPI committee monthly for 6 months for further follow up and recommendations as indicated.

Based on observation, interview, and record review, the facility did not put measures in place to prevent pressure injuries from developing, did not comprehensively assess pressure injuries, did not consult physician timely, and did not put measures in place to promote healing when 1 of 1 residents (R4) developed pressure injuries. R4 was admitted at risk for the development of pressure injury. The facility did not develop a care plan to address his risk factors. R4 developed pressure injuries that progressed to Stage IV. The facility did not comprehensively assess the pressure injuries, did not consult the physician timely, and did not put appropriate measures in place to promote healing of the pressure injuries. R4's pressure injuries got infected, requiring R4 to be hospitalized with a Stage IV pressure injury that required antibiotics and debridement. The facility's failure to put measures in place to prevent the development of a pressure injury and to promote the healing of pressure injuries created a finding of immediate jeopardy that began 05/22/22. Surveyor informed Nursing Home Administrator (NHA) A of the immediate jeopardy on 08/09/22 at 3:01 PM. The immediate jeopardy was removed on 08/16/22. However, the deficient practice continues at a scope and severity level D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Findings Include: R4 was admitted [DATE] after a lengthy stay in the hospital (01/16/22 through 04/22/22) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's hospital discharge record notes resident at risk for skin integrity due to decreased sensory perception because of limited sensation and [CONDITION(S)], exposure to moisture because of urinary or fecal incontinence, and altered activity/mobility because of inability to reposition independently. Skin is intact. Pressure injuries were noted in the hospital on R4's right great toe and 4th great toe that were unstageable and healed during his hospital stay. R4's admission skin assessment dated [DATE] notes skin integrity is normal with no pressure injuries noted. R4's Braden Scales for Predicting Pressure Score Risk noted: ~ 04/22/22: (on admission) resident at risk for pressure injury (15). Risk factors of bedfast, limited mobility, and requires moderate to maximum assistance in moving were noted. Surveyor reviewed R4's care plan and noted R4's care plan did not address strategies to prevent recurrence of pressure injuries that were noted in the hospital or address the identified risk. ~04/29/22 notes - resident now considered high risk for pressure injury (12). With risks of very limited sensory perception and moisture changed to very moist skin vs. rarely moist added. ~05/06/22, 05/13/22 and 05/20 notes resident remains high risk (10). Surveyor reviewed R4's Admission MDS dated [DATE] which notes R4 understands, is understood, and is cognitively intact. R4 does not reject care and has no mood or behavioral concerns. R4 required extensive assist of 2 for bed mobility and transfer. R4 was dependent on staff for bathing and toilet use. R4's range of motion is impaired in 1 upper extremity and both lower extremities. R4 was frequently incontinent of bladder and always incontinent of bowel. R4 had no pain and is on scheduled pain medications. R4 weighs 201 with no weight loss. R4 is at risk for pressure injury and had no pressure injury. R4's Nutritional Risk assessment dated [DATE] notes adding 1 oz of additional dietary protein at meals and 4 oz Ensure Plus at breakfast and supper due to recent skin impairment and variable intakes. Per nursing notes, skin is good with history of pressure injuries noted. R4's interim plan of care dated 04/22/22 simply states Skin integrity: Preventive Care. It instructs staff to check and change R4 every 2 hours and transfer with a Hoyer (mechanical lift). Nurses notes from admission to 05/22/22 show no issues with R4's skin. 05/22/22 Skin evaluation notes left heel with unstageable pressure injury with Length (L)=4 x Width (W)=4.5, necrotic wound bed with heavy dressing saturation (75%), no odor, no tunneling, no undermining. Care plan shows no updates related to skin integrity. 05/22/22 Nurses Note: Resident educated related to new order: no. Resident education provided related to new Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . 05/25/22 Nurses note: Request order change to left heel DTI (deep tissue injury), ischemic area top of left toe .MD with new orders. 05/25/22 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~Cleanse left heel ulcer with wound cleanser, pat dry, skin prep surrounding area, apply medi-honey to wound bed, cover [MEDICATION(S)], cover with adhesive foam, secure with kerlix and tape. Change Monday, Wednesday and Friday and prn (as needed) ~skin prep right and left outer ankles Monday, Wednesday and Friday and PRN ~skin prep right heel DTI, cover with duoderm, change Monday, Wednesday and Friday and prn, if opens update MD ~skin prep right heel DTI, cover with duoderm, change Monday, Wednesdays and Fridays and prn, if opens/changes update MD. Care plan shows no changes related to skin integrity. 05/27/22 Skin evaluation: blister left top of foot L=2x W=1, no odor, no tunneling, no undermining. Tissue painful. Provider Contacted: blank Care plan unchanged. 06/01/22 (5 days after blister on left top foot noted and 7 days after left great toe noted with ischemic area) Physician order: skin prep left great toe distal ischemic area Monday, Wednesday and Fridays and prn, apply [MEDICATION(S)] to blister area every Monday, Wednesday, and Friday. 06/03/22: Skin evaluation: Pressure injury left heel, unstageable: L, W, D: see notes (there are no notes from 05/29/22-06/09/22). Wound bed: slough, wound exudate: none, peri wound: [CONDITION(S)], dressing saturation: moderate, mushy. Pressure injury left big toe where nail meets skin, unstageable 0.1 x 0.1 x none, no odor, no tunneling, no undermining, no dressing saturation. 06/10/22 Skin evaluation: Pressure ulcer left heel unstageable, wound bed necrotic, wound exudate: serosanguineous, peri wound: WNL (within normal limits), dressing saturation: none, no odor, no tunneling, no undermining. Right heel suspected DTI depth unknown, no wound exudate, peri wound normal, no dressing saturation, no odor, no tunneling, no undermining. Anterior Left foot with no staging, no measurements or wound description (first mention of left anterior foot) concern. Provider contacted: blank. Record shows no evidence of MD consult until 06/14/22. 06/14/22: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No mention of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 06/17/22 Skin evaluation: No documentation related to wounds or wound descriptions. All blank. 06/17/22 Nurses note: changed dressing to left heel and top of foot per wound orders. Resident has a scab on heel and around scab is purulent draining. 06/21/22: Nurses Note: New order: Can be seen at wound clinic. Appointment at MCLC Thursday 06/23/22 at 11:20 06/23/22 Wound Clinic Note (Initial visit): Medical History: [CONDITION(S)], wheelchair bound due to hip [CONDITION(S)], long term hospitalization (3 months) ICU related to Covid. Examination: Wound #1: pressure, left heel Measurements: 3.3 x 2.7 x depth 0.6 No undermining, no tunneling Wound bed: adherent eschar with softened edges, was removed to reveal slough tissue with granulation on the periphery. Edges: irregular Peri wound skin: intact without [CONDITION(S)] or maceration Exudate: moderate serosanguineous drainage Odor: none [CONDITION(S)]: none Pain: none Wound #2: Pressure, left dorsum foot Measurements: L=1.7 x W=1.8 x D=0 No undermining, no tunneling Wound bed: Granulation tissue with some adherent slough Edges: irregular Peri wound skin: intact without [CONDITION(S)] or maceration Exudate: moderate serous drainage [CONDITION(S)]: none Pain: none Procedure: Wound and surrounding area cleansed with wound cleanser and normal saline and patted dry. Slough and necrotic eschar were debrided using Adson's and iris scissors. Primary dressing: medi-honey Secondary dressing: foam adhesive dressing Assessment: pressure injury left heel stage 3, friction injury to skin Plan: debridement of bilateral wounds was recommended and performed in office today. Medi-honey will be placed to continue to promote autolytic debridement of the wound beds .follow up in 1 week. If he has not made significant progress, we will consider culturing the wounds to determine if infection is the cause for delayed wound healing. 06/23/22 Wound Clinic Orders: Lower extremity wounds 1. Removal dressing, discard 2. Cleanse wounds and surrounding skin with normal saline or wound cleanser, pat dry 3. Apply Medi honey to wound beds 4. Apply foam adhesive dressing Change dressing every 2 to 3 days or more frequently for saturation or dislodgement. Scheduled for follow up 06/30/22. 06/24/22 Skin evaluation: Left heel unstageable pressure injury, necrotic wound bed, Serosanguineous wound exudate, normal peri wound, moderate dressing saturation, mushy, boggy. No measurements. Anterior Left foot, no measurements, no staging, moderate dressing saturation, normal peri wound, wound exudate: serosanguineous Right heel DTI with no tunneling, odor or undermining. 06/27/22: New order per RD (Registered Dietician) notes: recommendation for [MEDICATION(S)] BID to promote wound healing. Care plan Date Initiated: 06/27/22: Focus: Resident has pressure injury to left heel and anterior left foot, right heel: Goal: resident pressure ulcer will show no signs of healing and remain free of infection. Interventions: ~Heels up device while in bed ~Monitor dressing to ensure it is intact and adhering, report loose dressing to treatment nurse ~Monitor nutritional status, serve diet as ordered, monitor intake and record ~Monitor/document/report prn any changes in skin: appearance, color, wound healing, s/s of infection, wound size (LxWxD) stage ~Obtain and monitor lab and diagnostics work as ordered. Report results to MD and follow up as indicated ~Administer treatments as ordered and monitor effectiveness. ~Assess/record/monitor wound healing, measure; length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress, report improvements/decline to MD 06/30/22 Wound clinic notes: Examination: Wound #1: pressure, left heel Measurements: 3.0 x 2.7 x depth 0.4 No undermining, no tunneling Wound bed: adherent slough with adipose tissue Edges: irregular Peri wound skin: intact without [CONDITION(S)] or maceration Exudate: moderate serosanguineous drainage Odor: none [CONDITION(S)]: none Pain: none Wound #2: Pressure, left dorsum foot Measurements: L=1.2 x W=1.4 x D=0 No undermining, no tunneling Wound bed: Granulation tissue with exposed tendon Edges: irregular Peri wound skin: intact without [CONDITION(S)] or maceration Exudate: moderate serous drainage [CONDITION(S)]: none Pain: none Procedure: Wound and surrounding area cleansed with wound cleanser and normal saline and patted dry. Aerobic cultures of left heel obtained Slough and eschar were debrided Primary dressing: Xeroform Secondary dressing: foam adhesive dressing Assessment: pressure injury left heel stage 3, friction injury to skin 06/30/22 Wound Care Orders: Left anterior ankle: 1. Remove old dressing and discard 2. Cleanse wound and surrounding skin with saline or wound cleanser and pat dry 3. Apply collagen dressing such as [MEDICATION(S)] to wound bed 4. Apply foam adhesive dressing Change dressing every 3 days or more frequently for saturation of dislodgement Left heel: 1. Remove old dressing and discard 2. Cleanse wound and surrounding skin with saline or wound cleanser and pat dry. 3. Apply Xeroform to wound bed 4. Apply foam adhesive dressing. 5. Ensure no pressure is applied to heels at any point. The heel should remain floating off of any surface. Change dressing every 2-3 days of more frequently for saturation of dislodgement. Next appointment 07/06/22 07/01/22 Skin evaluation: Left heel: Noted as Unstageable with no measurements, slough, normal peri-wound, moderate dressing saturation, no tunneling, no undermining and no odor Anterior left foot, unstageable with slough and serosanguineous wound exudate serosanguineous, peri wound normal, moderate dressing saturation, no odor, no tunneling and no undermining. Right heel DTI, no tunneling, no odor, no undermining. 07/06/22 Skin evaluation: Left heel: Unstageable, Measurement's state: 2.9 x 2.9 with depth unmeasurable d/t (due to)slough, normal peri-wound, moderate dressing saturation, no odor, no undermining or tunneling Anterior left foot Now noted as a stage IV measuring 0.9 x 1.3 x 0 with granulation and serosanguineous wound exudate. Right heel now noted as pressure ulcer and DTI measuring 0.5 x 0.5, no description of wound bed, normal peri wound, no odor, no tunneling or undermining. Skin note: left heel depth unmeasurable r/t bed wound slough-100%, wound edges irregular, left anterior foot ulcer 50% granulation and 50% tendon exposed, wound edges irregular, Right heel-DTI scattered dark purple, New orders obtained from wound clinic, seen today. 07/06/22 Wound clinic notes: Extremities: patient's right foot is slightly cooler than his left foot. He has 2 wounds present on his left foot. There is one wound on the dorsum of his foot and one wound on the posterior heel. His ankle is in a fixed plantar flexion position. He has trace [CONDITION(S)]. Bilateral ankles are extremely plantar flexed with curling of his toes. Wound #1: pressure, left heel, Stage IV Measurements: 2.9 x 2.1 x depth 0.9 No undermining, no tunneling Wound bed: soft yellow slough tissue Edges: irregular Peri wound skin: intact without [CONDITION(S)] or maceration Exudate: moderate serosanguineous drainage Odor: none [CONDITION(S)]: none Pain: none Primary dressing: gauze slightly moistened with normal saline Secondary dressing: 4 x 4 gauze secured with gauze roll Wound #2: Pressure stage IV left dorsum foot Measurements: L=0.9 x W=1.3 x D=0 No undermining, no tunneling Wound bed: 50% [CONDITION(S)] granulation tissue, 50% exposed tendon Edges: irregular Peri wound skin: intact without [CONDITION(S)] or maceration Exudate: moderate serous drainage [CONDITION(S)]: none Pain: none Primary dressing: Xeroform gauze Secondary dressing: gauze roll 07/11/22 Wound Clinic note: Peripheral pulse regular of left foot but not palpable on right foot Extremities: The right lower extremity is very warm to touch from the foot to below the knee. He has 2 wounds present on left foot. There is one wound on the dorsum of foot and one wound on his posterior heel. His ankles are in a fixed plantar flexion position. He has trace [CONDITION(S)]. Bilateral ankles are extremely plantar flexed with curling of his toes. Wound #1: pressure, left heel, Stage IV Measurements: 2.9 x 2.0 x depth 0.5 No undermining, no tunneling Wound bed: mostly granular tissue, boggy. Edges: irregular Peri wound skin: intact without [CONDITION(S)] or maceration Exudate: moderate serosanguineous drainage Odor: none [CONDITION(S)]: none Pain: none Primary dressing: gauze slightly moistened with normal saline Secondary dressing: 4 x 4 gauze secured with gauze roll Wound #2: Pressure stage IV left dorsum foot Measurements: L=2.0 x W=2.1 x D=0 No undermining, no tunneling Wound bed: 50% [CONDITION(S)] granulation tissue, 50% exposed tendon Edges: well, defined, attached Peri wound skin: deep tissue pressure injury superiorly Exudate: moderate serous drainage, active bleeding [CONDITION(S)]: none Pain: none Primary dressing: [MEDICATION(S)] Secondary dressing: dressing with adhesive border Plan: patient is chilled and has an elevated temperature (100.1F), low blood pressure (106/65) and elevated heart rate, pulse (90). His left lower extremity is very warm to touch. There is [CONDITION(S)] and warmth around his wounds. This is concerning for [CONDITION(S)]. Laboratory studies recommended. Patient has leukocytosis and elevated CRP. Procalcitonin is pending. Patient's case discussed with MD from MMC Minocqua inpatient floor. Agreed to admit patient for [CONDITION(S)] due to pressure injuries of left leg. Recommend blood cultures, [MEDICATION(S)] level and COVID swab. General surgery service will follow patient while hospitalized . Hospital notes and discharge summary notes: admitted : 07/11/22 Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Infected pressure ulcer 07/11/22 2. [CONDITION(S)] 07/11/22 3. Immobility 4. Anticoagulated 5. [CONDITION(S)] HPI: Patient admitted via the wound care clinic .hospitalized January-April of this year for pneumonia, complicated by [CONDITION(S)] .Today when he came into the wound clinic, he was noted to have a low-grade fever of 100.1. Heart rate 90, blood pressure 106/65. CBC showed leukocytosis with WBC 17.6 CRP was elevated 8.3. Procalcitonin was not elevated as it was less than 0.05. Source of leukocytosis and possible [CONDITION(S)] was felt to be infected pressure ulcers on left heel and dorsum of the left foot. admitted for further evaluation and treatment. It is felt he would need IV antibiotics and wound debridement. Exam: patient is alert and oriented x3 .Right lower extremity is very warm to touch from the foot to below knee, 2 wounds present on left foot. One on dorsum of foot and one on heel. Ankles in fixed plantar flexion. Skin: 2 pressure ulcers: 1 stage IV pressure to left heel with some serosanguineous drainage and second Stage IV to dorsum of left foot with tendon exposed and serous drainage. Assessment/Plan: Infected pressure injury, [CONDITION(S)]. Placed on [MEDICATION(S)] and [MEDICATION(S)] while we await cultures. Surgery is planning to do possible debridement. 07/11/22: Start [MEDICATION(S)], 2 GM (gram)=20ml (milliliter) total volume=100, IV piggyback Q (every) 8 hour, infuse over 4 hours, first dose stat. [MEDICATION(S)]=1GM=200ml total volume (ml) 200, IV piggyback Q 12 hours, infuse over 60 minutes: start 07/13/22 07/14/22 progress notes: Wound 1: Stage IV left heel, measurement 2.9x 2.7x0.57 mostly granular tissue, less slough, irregular wound beds. Peri wound intact without [CONDITION(S)] or maceration, exudate moderate serosanguineous draining, dressing: primary: [MEDICATION(S)], secondary: transparent tape. Wound 2: Pressure stage IV left dorsum of foot measuring 3.4x 3.0x0.4 exposed tendon and hemorrhagic tissue, peri wound: deep tissue injury, exudate: serous drainage and active bleeding. Primary dressing: [MEDICATION(S)], secondary: dressing with adhesive foam. Negative pressure wound therapy: non-disposable KCI wound VAC system applied .Negative pressure therapy continued at 125 mmHg. Assessment plan: [CONDITION(S)] of left foot with associated left ankle and left heel wounds complicated by [CONDITION(S)]. Wound vac .[MEDICATION(S)] and Vanco for antibiotics .Plan to discharge tomorrow with wound VAC. Wound culture: gram stain with moderate GCP in pairs with moderate GNR. Gram plus cocci in pairs and gram-rods. Operative report: 07/12/22 Procedure: Debridement of left foot pressure ulcer down to the tendon (3.4x3x0.4). Debridement of left heel pressure ulcer down to deep fat (2.8x2.9x0.7). On admission was on [MEDICATION(S)] thus debridement was deferred to today. He tells me his legs are profoundly weak, but he is able to move them. No radiographic evidence of [CONDITION(S)] .Following debridement wound vac placed. 07/15/22: discharged back to facility with orders: Left heel: remove old dressing cleanse wound and surrounding skin with saline or wound cleanser, apply skin barrier prep to skin surrounding the wound, apply transparent drape to skin surrounding wound to the dorsum of the foot, displace the [NAME] pad to the dorsum of the foot, change dressing M, W, F or more frequently for dislodgement. Left ankle: remove old dressing and discard, cleanse wound and surrounding skin with saline or wound cleanser, apply [MEDICATION(S)] to wound bed, cover with foam adhesive dressing, change dressing every 2-3 days of more for saturation or dislodgement. [MEDICATION(S)] Clavulanate 875/125mg every 12 hours for 5 days [MEDICATION(S)] 100 mg bid for 5 days Follow up in one week. Care plan with date initiated 07/15/22 (readmission from hospital) ~Air mattress setting #3 ~W/C (wheel chair) cushion Care plan with date initiated: 07/16/22: Doesn't like to reposition in bed. Risks and benefits explained, and he states understanding. Needs encouragement. Care plan with date initiated: 07/19/22: ~follow wound vac orders and follow up with wound clinic as needed On 08/05/22 at 8:14 AM, Surveyor spoke with R4. Resident indicated he believes the pressure injuries are from [CONDITION(S)], foot drop, and staff not elevating his feet at first. Further stating he did not have an air mattress or heels up pad. Surveyor observed R4's heels sitting on heels up pad. R4's heels were not floating over the device. R4 was lying flat on back on air mattress. On 08/05/22 at 9:04 am, Surveyor spoke with NHA A who verified resident has an air mattress set at 3. She was unsure when it was initiated/just went and made sure on care plan. On 08/08/22 at 9:28 am, Surveyor spoke with R4 who indicated he had a lengthy stay in the hospital, over 3 months, before coming to the nursing home. R4 indicated he was quite sick and depended on staff assistance for all bed mobility/transfers. R4 expressed having [CONDITION(S)] in feet with the inability to feel his feet well. R4 expressed he moves his feet around in bed but is not sure why. R4 expressed his wounds are now improving since his hospital stay and the addition of the wound vac, air mattress, and device to float his heels. R4 expressed the air mattress was not placed until after his hospital stay and the heel floating device was not added until he started going to the wound clinic. R4 expressed his heels were flat on the bed prior to the device. R4 further expressed his pressure injuries are from his feet laying flat on the bed. Surveyor observed the air mattress with proper setting, heels up device with resident's feet floating and wound vac in place with clean dressing dated 08/06/22. Surveyor asked R4 about his toileting schedule. R4 expressed he can tell when he has been incontinent of bladder and bowel. He turns on his call light for staff to come in and change him. R4 expressed this is usually twice per shift. (Staff coming in when R4 turns on his call light twice a shift to be changed is not consistent with his care plan to check and change every 2 hours). On 08/08/22 at 2:02 pm, Surveyor spoke with Certified Nursing Assistant (CNA) M who has been on staff [AGE] years and is familiar with R4. CNA M indicated resident is reliable in his reporting. CNA M confirmed R4 did not have an air mattress until his return from the hospital on 07/15/22. CNA M further indicated she believes resident did not have a heels up device until he started seeing the wound clinic. Staff attempted to elevate/float resident heels using a pillow until he went to wound clinic. The pillows did not properly elevate resident's legs enough to float his heals from bed, which is how he got the pressure injuries to his heels. CNA M expressed R4's pressure injury on the top of his foot may be due to deformity of his feet with his other foot and resting it on top of his foot with the pressure injury. Expressing if his foot was left laying on top of his left ankle/foot for long periods of time it would cause a pressure injury. On 08/09/22 at 11:41 AM, Surveyor again spoke with NHA A. NHA A expressed the facility conducted a chart review of R4's pressure injuries. No additional information was found, no risk management was completed, nothing was documented, and appropriate follow up for R4's pressure injuries was not located. Further stating the staff involved are all gone. The failure to put measures in place to prevent the development of a pressure injury and to promote the healing of pressure injuries created a finding of immediate jeopardy that began 05/22/22. The facility removed the immediate jeopardy on 08/16/22 when it had completed the following: 1. Work closely, on a weekly basis, with the Wound Care Center to ensure proper measurement, staging, and treatment is conveyed related to R4. 2. To ensure wound care is documented correctly and that the wound care orders are followed under the direction of the wound care provider and attending physician. 3. The administrator/RN will provide coordination of care between the resident's Wound Care provider and attending provider. 4. The resident plan care was updated with the correct problem, goal, and interventions by the wound care nurse on 08/09/22. 5. All residents will have a head-to-toe skin assessment completed by the Certified Wound Care Nurse. Any identified skin care issues will be reviewed with the resident's attending physician and orders received and processed to the TAR if warranted. All resident weekly skin assessment will be completed within 7 days each week and scheduled for the Wound Care Nurse to complete daily going forward. 6. The residents' plan care was updated with the correct problem, goal, and interventions by the wound care nurse. 7. The Director of Nursing will review the weekly skin assessments during the weekly risk assessment meeting to determine the status of each wound and interventions to promote healing. Any identified area not healing as planned will have a referral made to the wound care clinic for further follow up treatment as warranted. 8. The wound care nurse was reeducated on ensuring the residents receive a head-to-toe assessment at a minimum of 7 days. Any identified area of concern will be reported to the physician and orders implemented for the treatment or preventative to deter skin break down. 9. The Wound Care Physician was notified of the head-to-toe assessment on all residents and the physician will assess each and provide physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10. The Director of Nursing will review the head-to-toe skin assessment daily; wounded resident weekly; and during the weekly at-risk meeting to ensure the proper treatment was followed as prescribed by the physician and treatments are being followed on the TAR. 11. The wound care nurse will be educated on obtaining the wound care physician documentation to ensure continuity of care and treatment by the Wound Care Physician ensuring that these orders are reviewed, implemented, and followed through on the TAR.

Based on record review and interview, the facility did not ensure 1 out of 3 sampled residents (R2) was free of significant medication errors. *R2 was taking [MEDICATION(S)] for underactive [CONDITION(S)] due to [CONDITION(S)]. R2's Nurse Practitioner (NP) ordered a medication increase from 75mcg by mouth daily to 125mcg by mouth daily on 04/28/22 due to an elevated TSH level of 111.18. Normal TSH levels are 0.25-5.0. R2 did not receive [MEDICATION(S)] dose increase from 04/29/22 through 05/18/22 when R2 was hospitalized for unresponsiveness and diagnosed with myxedema coma. Increased dose of [MEDICATION(S)] was not received for 20 days before R2 was hospitalized . *Upon readmission to facility from hospital on 05/26/22, R2 did not receive [MEDICATION(S)] 125mcg by mouth daily ordered on discharge from hospital from 05/27/22 through 06/01/22 when omission identified. R2 did not receive the [MEDICATION(S)] for 6 days until error identified upon readmission. Findings include: R2's original admitted to the facility was on 08/31/18. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed R2's [MEDICATION(S)] dose from 12/01/21 through 06/01/22. R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/28/22 the order was changed to 125mcg by mouth daily. The facility never transcribed this order into R2's medical record. R2 continued to receive 75mcg by mouth daily until 05/18/22. On 05/18/22, R2 was hospitalized . On 05/26/22 R2 was discharged from the hospital and returned to facility with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order from the hospital on discharge was never transcribed into R2's medical record. R2 did not receive [MEDICATION(S)] dose of 125mcg by mouth from 05/27/22 through 06/01/22 when error identified. Surveyor reviewed R2's MAR (Medication Administration Record) from 12/01/21 through 06/01/22. Monthly MARs documentation shows all [MEDICATION(S)] 75 mcg were administered correctly 12/1/21 - 3/31/2022. April 2022: [MEDICATION(S)] 75mcg tablet orally in the morning. All doses from 04/01/22 through 04/30/22 documented as given. No order change documented for 04/28/22 changing the dose to 125mcg tablet orally in the morning as per physician order, so R2 received 75mcg daily and not 125mcg from 04/29/22 through 04/30/22. May 2022: [MEDICATION(S)] 75mcg tablet orally in the morning (MAR does not have dose transcribed as 125mcg tablet as per order 04/28/22). R2 received 75mcg tablet orally 05/01/22 through 05/04/22. [MEDICATION(S)] dose of 75mcg received except on 05/04/22 through 05/06/22 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/07/22 through 05/12/22 [MEDICATION(S)] 75 mcg documented as given (not 125 mcg that was ordered). On 05/13/22 no documentation for dose. On 05/14/22 through 05/18/22 [MEDICATION(S)] 75 mcg documented as given. On 05/19/22 through 05/22/22 R2 documentation stated R2 in hospital. On 05/23/22 through 05/27/22 documentation for [MEDICATION(S)] is blank. On 05/28/22, 05/29/22, 5/31/22 [MEDICATION(S)] documented as refused. On 05/30/22 dose documented as given. Surveyor spoke with LPN (Licensed Practical Nurse) C on 06/01/22 at 9:30 a,m., and asked to see [MEDICATION(S)] medication and LPN C stated R2 was not on [MEDICATION(S)] medication and there was no medication card. June 2022: MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's medical record reviewed for TSH levels and physician/NP documentation from 12/01/21 to 06/01/22. -Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation of TSH for 12/2021. No documentation in R2's medical record for labs drawn nor results for TSH levels. Surveyor received documentation for labs for TSH level and physician and NP documentation. -Physician nursing home visit on 02/17/22 stated R2 was due for a TSH level. -R2 had clinic visit on 04/26/22. Documentation per clinic stated on 04/28/22 clinic RN spoke to DON B at the facility and DON B stated she had not seen a recent TSH level. Clinic informed DON B of lab result of 111.18 and need to increase medication and repeat lab in 10 weeks. Documentation stated order sent to facility as well. (Normal TSH is 0.4 to 4; levels above 4-5 indicate an underactive [CONDITION(S)].) Surveyor reviewed fax cover sheet and documentation sent to facility from clinic. Fax cover sheet dated 04/29/22 at 12:16 p.m. Documentation included: Order from NP for 1. [MEDICATION(S)] 125 mcg p.o. (by mouth) daily and 2. Repeat [CONDITION(S)] (TSH) lab in 10 weeks. Order signed by NP. Surveyor reviewed R2's medical record for hospital discharge information from hospitalization from [DATE] through 05/26/22. Discharge summary by NP from the medical facility stated when R2 was sent to the emergency department for evaluation, R2's blood pressure was 72/40. Documentation stated initially R2 was not able to respond to questions or any verbal commands nor would she make her needs known. Incidental findings also included COVID but asymptomatic. Subsequently, due to her [CONDITION(S)] R2's TSH level was checked and came back at 190. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation states R2 clinically did not show signs of improvement and after 4 days a second TSH was checked and came back at 120. Documentation stated clinically R2 improved to baseline, which included simple responses to questions, but not able to use the call light nor make needs known. While at the hospital, a palliative care meeting was held with R2's daughter, who is also R2's Power of Attorney (POA). It was decided that R2 be admitted to hospice and return to the nursing home facility. Included with the hospital discharge summary were copies of signed prescriptions, which included [MEDICATION(S)] 125mcg Tablet by mouth once daily. This order was never transcribed into R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Included with the hospital discharge summary was a discharge patient sheet, which listed R2's medication on it. [MEDICATION(S)] 125mcg 1 tablet by mouth daily was listed and it was documented to start taking on 05/27/22. The medication list was electronically signed by the NP from the medical facility. On 05/31/22 at 12:05 p.m., and 06/02/22 at 09:30 a.m., Surveyor attempted to contact NP L who had prescribed the [MEDICATION(S)] 125 mcg from the admitting medical facility. No return call received from NP L. On 05/31/22 at 11:25 p.m., Surveyor interviewed Social Worker (SW) F. Surveyor asked SW F about [MEDICATION(S)] medication and orders per clinic. SW F stated R2 had an appointment at the clinic on 04/26/22 and R2's TSH level was high at 111.18. SW F stated the clinic sent a fax on 04/28/22 with an order to increase the [CONDITION(S)] medication to 125mcg daily and to repeat the TSH in 10 weeks. SW F stated the facility did not increase the medication and R2 wound up in the hospital. 05/31/22 at 1:00 p.m., Surveyor interviewed DON B. Surveyor asked why [MEDICATION(S)] was not changed from 75mcg by mouth daily to 125mcg by mouth daily, when NP changed the order on 04/28/22. DON B stated the facility never received the fax from the clinic. Surveyor asked DON B why no follow-up on the TSH level since DON B wrote in the nursing progress notes on 04/26/22 that R2 went to clinic and part of labs drawn were a TSH level. DON B stated there is not enough staff and she is only one person to do it all. Surveyor asked why the discharge orders, which included a signed script for [MEDICATION(S)] 125mcg by mouth daily, were not transcribed into R2's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B unaware of omission.

Based on interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. This occurred for 3 of 3 residents who were reviewed for falls, Residents (R) R1, R5, and R6. R1 sustained a fall and facility staff did not provide supervision and R1 immediately fell again resulting in facial fractures. The facility did not provide immediate supervision, investigate to identify a root cause, implement new interventions, or evaluate the effectiveness or modify interventions. After R5 and R6 fell , the facility did not investigate to identify a root cause, implement new interventions, or evaluate the effectiveness or modify interventions. This is evidenced by: Review of facility's policy titled, Falls and Fall Risk, Managing, with the revised date of March 2018, read in part: .Resident-Centered Approaches to Managing Falls and Fall Risk .5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable .Monitoring Subsequent Falls and Fall Risk .1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Review of R1's medical record documents current diagnoses of traumatic subarachnoid hemorrhage without loss of consciousness, dementia with behavioral disturbance, repeated falls, anxiety disorder, [CONDITION(S)], [CONDITION(S)] stage 2, and dysphagia. Review of the Minimum Data Set (MDS) dated [DATE], a quarterly assessment, documented R1 as having severely impaired cognitive skills for daily decision making. The MDS documents R1 as having two or more falls without injury and one fall with injury that was not a major injury. Review of fall risk assessments completed on 05/21/22 and 05/04/22 documented R1 having a score of 18, identifying as being at high risk for falling. Review of comprehensive care plans identified on 05/27/22, the fall care plan focus had added, Resident has chair alarm on w/c, kept at nurse's station for observation to avoid falls. No new fall interventions were added. The last revision to the high risk for falls care plan was completed on 03/19/22. Review of progress notes documented, in part: 05/21/22 7:16 p.m., Writer heard CNA [certified nursing assistant]yell for the nurse, Resident stood up by the nurses station and fell over. Resident did not hit head but does have a cut on right index finger. Left resident to call POA to notify about fall. Resident then stood up and fell face first into the floor by the nurses station. POA was on the phone when this happened was notified. Resident was bleeding from nose and started swelling in his face. EMS was notified immediately and was sent out to . Hospital . 05/21/22 7:18 p.m., 'Injuries to resident post fall are bruise to bottom left lip, right black eye, swelling to nose and face. Resident passed a quarter size clot from his right nostril but was continuing to have epistaxis. Has a laceration to right index and ring finger. Resident is alert and oriented x1. Resident first fall was at 1615 (4:15 p.m.) and second fall was at 1620 (4:20 p.m.) while writer was on the phone with POA (Power of Attorney). Both falls happened next to nurses station. Resident's mouth was intact and dentures not broken. Resident did call out with pain but writer help (sic) a towel with ice pack to resident's face. Police officer .arrived on scene to assist until medics arrived. Medics (Names) transported resident to (Name) Hospital .DON (Director of Nursing) was notified of incident. 05/21/22 7:23 p.m., .RN from ER called resident has a periorbital fracture and maxilla fracture. They are awaiting for surgical consults and will notify when resident is to return. 05/21/22 8:59 p.m., Resident returned from (Name) ER via son and was helped into facility by staff at 2030 (8:30 p.m.) Resident diagnosed with [NAME] II fracture, frontal sinus fracture, facial swelling and [CONDITION(S)]. [MEDICATION(S)] PO 100mg capsule BID for 10 days ordered. Resident is to have puree diet and to leave dentures out for 5 days. 05/22/22 7:16 a.m., Resident has lots of swelling and bruising to face. Resident is unable to (sic) medications this morning due to swelling of face and mouth. Applied ice pack to face and checked oxygen saturation which was 94 on room air. Resident has a gurgle noise when breathing and nose is still bleeding. Will continue to monitor. Will update MD. 05/22/22 9:54 a.m., Talked with POA about seeing if he would be ok with getting resident evaluated for hospice. POA confirmed he was ok with his father being evaluated for hospice due to recent events. Upon review of R1's medical record, Surveyor did not find a fall investigation report determining the root cause, identification of hazards and risks and implementation of interventions or supervision to prevent future falls. The medical record did not document reviews of the effectiveness of interventions or modifications of interventions. The medical record did not document neurological assessments upon return to the facility and only had a neurological assessment documented once daily as being within normal limits. On 05/31/22 at 11:19 a.m., Surveyor interviewed Registered Nurse (RN) D about R1's fall interventions. RN D indicated a Hospitality Aide was just hired and will sit with R1 and assist staff passing water and meal trays. RN D indicated the Hospitality Aide just started this past weekend. RN D indicated R1 is not able to tell if he is having pain and has had no signs or symptoms of pain over the weekend. RN D reviewed what interventions are in place to prevent falls and indicated there were no new interventions since the last fall. They have a put together a book about meters as this was R1's previous job of reading meters. On 05/31/22 at 1:29 p.m., DON B indicated not having a completed fall investigation for R1. Surveyor requested R1's ER notes and orders. DON B indicated not being able to locate the documents and that it would take days to receive from the hospital. On 05/31/22 at 2:10 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) C asking about R1's fall. LPN C indicated R1 fell and had no injuries noted and no reports of pain. R1 was sitting by the nurse's station and LPN C went to chart and call POA. When on the phone with POA, LPN C heard a thud and the chair alarm sounding and found R1 on the floor bleeding from his face. Called 911 and sent R1 to the hospital. A nurse from the ER called and stated R1 had multiple fractures to face. LPN C indicated when a resident has a fall with head injuries, neurological checks are to be done and would be in the 24-hour binder. 05/31/22 at 4:00 p.m., Surveyor reviewed with Nursing Home Administrator (NHA) A the concerns of R1's fall and that no immediate supervision was provided to prevent further falls. Within minutes, R1 then fell again causing major injuries of fractures to R1's face. The facility did not complete an investigation to determine the root cause of the fall, and did not put any interventions into place to prevent further falls. Reviewed with NHA A R5 and R6 also having falls and no investigations were completed. On 06/01/22 at 7:15 a.m., Surveyor interviewed DON B about the fall investigations. DON B indicated the staff should be filling out the fall investigation paper report and this has not been completed. DON B indicated not being able to catch up on job duties since having to work the night shift as the floor nurse. DON B indicated there has been no interdisciplinary team since being in between Nursing Home Administrators. DON B stated, Things have fell by the wayside. On 06/01/22 at 10:14 a.m., Surveyor interviewed MD G asking about R1's fall, pain, and hospice. MD G indicated R1 has a history of falls related to dementia. R1 is always in the wheelchair and trying to get out of chair and R1 needs distraction to prevent from getting up. R1 is very impulsive and very high fall risk. Example 2: Review of R5's medical record documents current diagnoses of Alzheimer's, dementia, [CONDITION(S)], and depression. Review of fall risk assessments dated 05/24/22 having a score of 15, 04/21/22 having a score of 11, and on 04/08/22 a score of 14. The fall risk assessment score of 10 or greater identifies as being at high risk for falls. Review of the progress notes document on 05/26/22, R5 had a fall to the floor and was found between the bed and wheelchair. Review of R5's medical record; Surveyor did not find a fall investigation report determining the root cause, identification of hazards and risks and implementation of interventions or supervision to prevent future falls. The medical record did not document reviews of the effectiveness of interventions or modifications of interventions. Review of the care plan did not document new fall interventions. On 05/31/22 at 1:29 p.m., DON B indicated not having a completed fall investigation for R5. Example 3: Review of R6's medical record; documents current diagnoses of dementia without behavioral disturbance, dysphagia, cognitive communication deficit, and depression disorder. Review of the progress notes document on 05/15/22; R6 had a fall to the floor, found sitting next to bed. R6 states had slid out of bed because didn't have bar to grab onto. Review of R6's medical record; Surveyor did not find a fall investigation report determining the root cause, identification of hazards and risks and implementation of interventions or supervision to prevent future falls. The medical record did not document reviews of the effectiveness of interventions or modifications of interventions. Review of the care plan did not document new fall interventions. On 05/31/22 at 1:29 p.m., DON B indicated not having a completed fall investigation for R6.

Based on observation, interview and record review the facility failed to ensure 6 of 20 sample residents (R8, R11, R12, R14, R3, and R15) were provided appropriate supervision and interventions to prevent elopement/unsafe wandering from occurring. The facility did not have a system in place to activate or monitor the door alarm system to prevent residents from exiting the building unsupervised. R8 eloped from the facility on 04/26/22. R8 was found outside at approximately 9:00 p.m. R8 was found down a ravine with his wheelchair tipped over and R8 laying on the ground. R8 had been wandering throughout the building earlier, exhibiting exit seeking behavior and staff did not increase supervision. Facility staff lacked knowledge on how to operate the door alarm system and did not know one of the exit doors was not alarmed. The facility's failure to provide supervision on for a resident at risk for elopement, the failure to have a working knowledge of the door alarm system, and the failure to ensure the alarm system was operational created a finding of Immediate Jeopardy (IJ) that began on 4/26/22. Surveyor notified the Nursing Home Administrator (NHA) A of the IJ finding on 04/28/22 at 3:30 PM. The IJ was removed on 05/02/22, however the deficient practice continues at a scope/severity level E (potential for more than minimal harm/pattern) as the facility continues to implement its removal plan and as evidenced by the following. The facility did not provide appropriate supervision and put interventions in place to prevent elopement/unsafe wandering from occurring for R11, R12, R3, R14, and R15, who are also at risk for elopement from the facility. This practice places R11, R12, R3, R14, and R15 at risk for elopement as demonstrated by R8. Findings Include: The facility policy entitled, Prevention of Elopement dated 11/01/2016 with a review date of 11/2017 states: Purpose: To prevent a safe environment by assessing residents' risk factors and implementing a plan of care to prevent accidents related to wandering behavior or elopement. Elopement is defined as leaving the facility or supervised environment without accompaniment or knowledge of the staff prior to their scheduled discharge. To prevent elopements, appropriately assess resident risk factors, observe resident patterns, communicate with family/responsible party, identify the significance of risk factors and implement prevention interventions. Residents identified as risk for wandering/elopement: ~A wandering/elopement risk book will be kept at the nurses' station and contain a photograph and identifying information about each resident for each resident identified at risk for wandering/elopement. ~Signs such as Stop or Do not enter may be posted at each exit door as a possible deterrent to cognitively impaired residents. Door Alarm Drills: ~Staff will be educated on proper identification, risk factors and interventions for residents at risk for wandering/elopement behavior. ~The facility shall develop a schedule of conducting unannounced elopement drills at least quarterly and more frequently based on resident population at risk. ~Additional training and education will be provided in response to the door alarm drill as necessary. Example #1: Surveyor reviewed R8's record and noted the following: R8 was admitted [DATE] with diagnoses that include, traumatic subarachnoid hemorrhage, dementia with behavioral disturbance, repeated falls, anxiety, and difficulty walking. R8's Elopement risk assessment dated [DATE] notes R8 is at risk for elopement. Risk factors include resident has verbally expressed desire to go home, packed belongings to go home or stayed near an exit door, resident wanders, wanders aimlessly, and is confused. R8's physician orders included: 1/15/22: Order: check wander guard each shift for proper function. R8's Treatment Administration Record (TAR) was reviewed from 1/15/22 through 4/27/22. The TAR for monitoring Wander guard function each shift shows no check was completed on 26 occasions. R8's Admission MDS dated [DATE] notes: ~ Sometimes understands, is sometimes understood and has moderately impaired cognition. ~ Displays: other behavioral symptoms, does not wander. (Of note: this information is not consistent with R8's Elopement Risk assessment dated [DATE]). ~ Requires extensive asst of 2 staff for transfer and bed mobility, does not walk. ~ Has a fall history and balance is not steady. R8's record contained no care plan to prevent accidents from unsafe wandering or elopement, identifying risk factors and directing staff of R8's prevention interventions. R8's care card, which is used by staff to direct his care, does not identify R8 is at risk for elopement. The care card did not contain prevention interventions for R8's unsafe wandering/elopement. R8's picture is in the elopement risk book at nurses' station, however there is no identifying information for R8 as outlined in the facility policy. R8's care plan indicates resident at high risk for falls with a clip alarm, room close to nurses' station, appropriate footwear, and bedside alarm identified as interventions. Surveyor reviewed R8's progress notes with the following noted: 3/25/22: 11:25 am (Social Services) Continuing to exit seek all morning, stating he needs to go outside and read meters. Resident leaving activities, 1:1's and writers office, all attempts of redirection unsuccessful. 3/30/22: (Social Services) 2:23 pm Continues to exit seek all morning/afternoon. Setting off door alarms at ends of hallways. 4/04/22: 4:04 pm (Social Services) Resident exit seeking all day setting off door alarms in each hallway, interventions of 1:1, ice cream and activities not effective 4/26/22: Incident: which was noted 4/27/22 at 2:00 a.m. Resident was outside of facility, resident got outside of facility and fell outside of building by green hall door at approximately 9:00 p.m. Found lying on his back, in the ravine, wheelchair was upside down. Resident assessed with noted abrasions to face and bruising to left upper cheek by his eye. PCP (Personal Care Provider) notified and sent to ER for evaluation. EMS arrived at approx. 9:15 pm. Transferred via [NAME] to local hospital. POA (Power of Attorney) and DON (Director of Nursing) notified. CT and other tests negative. Returned at 12:15 am. Transferred to bed. No pain voiced at this time. *The note does not indicate the door alarm was not armed, all doors were checked to ensure the alarm was armed, or immediate education was provided to staff regarding the door alarm system. On 4/27/22 at 4:57 p.m., Surveyor spoke with RN O via phone about R8's elopement/fall incident. RN O indicated she had given R8 medications somewhere between 8-8:30 p.m. on 4/26/22. At approximately 9:00 p.m. Certified Nursing Assistant (CNA) Q went looking for R8 to put him to bed. R8 was not at nurse's station. CNA Q and CNA E started an internal search going room to room on each hall and checking other areas in the building such as therapy and the dining room. R8 was not located. RN O went out the front door that was not locked and heard both R8's clip alarm and him yelling. RN O located R8 down a grassy sloped area off the end of the 400 wing. R8's wheelchair was tipped over and he was flat on his back. R8 was assessed and found to have facial abrasions and a goose egg that was bruised with abrasion below his eye on his cheek. 911 was called and R8 was transferred to the ER. Report from hospital were all tests and CT scan were negative. R8 was returned to the facility and again assessed before lying down. R8 reported no pain. RN O indicated the root cause of R8's elopement and fall was the door alarm at the end of 400 wing was not set. RN O also reported lack of sufficient staffing to properly supervise residents at risk for elopement. RN O indicated there were 2 certified nursing assistants in the building, along with RN O at the time of the incident. RN O reported it is not possible for staff to care for all the residents and try to keep residents from leaving the building with current staffing levels. RN O further reported it is not uncommon for the facility to have 1 nurse and 1 CNA in the building from 6:00 p.m. to 10:00 p.m., which she reports is not sufficient to care for the residents and supervise residents. RN O expressed she informed DON B of incident and was not directed to check all alarmed doors or to start immediate staff education. RN O indicated she was not aware the door alarm needs to be first turned off then the alarm button pushed again to reset the alarm. RN O reported she is still not clear on the functions of the door alarms and how to properly work the alarm system. RN O reports a daily check of resident wander guard should be done each shift to ensure they are functioning. RN O indicated there is a device on the medication cart to check the wander guard systems on the doors armed with the wander guard system to ensure they are functioning properly. RN O reported the front door is not checked at night to ensure it is locked. The alarm doors are not checked to ensure proper function. Alarms cannot be heard in resident rooms or up the hall until at the nurse's station. Surveyor checked the outside temperature via Weather.com and noted the outside temperature at 9:00 p.m. on 4/26/22 as 26 degrees Fahrenheit. On 4/27/22 at 5:30 p.m., Surveyor visualized area outside 400 wing's exit door. Surveyor noted a cement pad just outside the door with an adjacent sidewalk. A grassy sloped area was just past the sidewalk. Surveyor noted the grassy sloped area to be 10 steps from the sidewalk. A ravine area was at the bottom of the grass slope, just before some wetlands. A highway is just past the wetland area. R8 was noted to be found at bottom of slope in ravine area. The location is 84 paced steps from front entrance which RN O exited when she heard R8's alarm and him yelling. Surveyor observed R8 throughout 4/27/22 wandering about facility, at times down hallways near exit doors. The doors at the end of the hallways did not have signs to deter residents that are cognitively impaired from going outside as outlined in the facility policy. On 4/27/22 at 1:53 p.m., Surveyor and Maintenance Director (MD) M spoke regarding the facility's door alarm system, conducting checks of doors on alarm or any facility drills that have occurred in the facility as outlined in the facility policy. MD M has been on staff approximately one month. MD M does not conduct formal audits or drills of the door alarm system and is not aware of any auditing system. MD M indicated he does an informal walk through maybe one time a week and checks the doors to ensure the alarms are armed. On 4/27/22 at 1:55 p.m., Surveyor and MD M conducted a walk through and observed the facility exits. The facility has doors at the end of each of the 4 hallways that are on an alarm system, which alerts at the panel across from the nurse's station. The doors at the end of the hallways do not have a wander guard monitoring system in place. The facility front door is not alarmed and not locked. It has a set of double doors that are on the wander guard system just prior to the lobby at the front door entrance. The facility is checking the doors daily with a device that is maintained in the medication cart. There are two exits to the left side of the building. One is employee entrance and one is for deliveries. Both have a set of double doors on wander guard system prior to the exits. Both are not locked. The delivery door is on the alarm system but is not armed. MD M indicated the delivery door should not be armed due to the frequency of the noise it creates. The staff entrance door is not locked or tied to the alarm system. The door previously had a keypad for staff to open the door without alarm. The keypad at the door had wiring issues and the pad was not replaced. The door is not locked or on alarm system. There is a door off the dining room that leads to a resident fenced area. The door does not have wander guard system. The door is on the alarm system. The doors on the alarm system were checked as follows: Doors at the end of the hallway were checked for alarm system. All alerted at panel at nurse's station. The alarm was heard by peer Surveyor at nurse's station. Surveyor with MD M could not hear the alarm sounding when at end of hall or coming up the hallway until approaching the nurse's station. The doorway from the dining room was opened and no sound was heard at the alarm system by peer Surveyor. MD M and Surveyor repeated opening of the door and holding it open for a short period. Again, the alarm was not heard at the alarm panel. Surveyor and MD M reported to the alarm panel and noted the door was not armed. MD M armed the door, indicating it should be armed to alert staff of the door being opened and resident going to patio. Residents could have exited this door on 4/27/22 and an alarm would not have sounded. On 4/27/22 at 2:20 pm, NHA-A indicated he learned of R8's elopement incident at approximately 9:30 am 4/27/22. He was not called when the incident occurred thus, he did not direct staff to check all alarmed doors or to start immediate staff education. On 4/27/22 at 2:25 pm, Surveyor spoke with DON B who was called by Registered Nurse (RN) O on 4/26/22 at 9:26 p.m. RN O reported R8's elopement incident and assessment as well as R8's transfer to ER. DON B indicated she asked RN O how R8 got out of the building. RN O told DON B the root cause of the elopement/fall was the door at the end of the 400 hall alarm was not set. DON B indicated she did not direct RN O to check all doors on the alarm system or to start immediate staff education related to the alarm system. DON B expressed she is not familiar with the system and was not aware staff need to turn off the alarm by pushing the corresponding button to the door and push the button again to rearm the alarm. Surveyor requested investigation information the facility has completed thus far. Surveyor requested staff education that had been completed. On 4/27/22 at 2:40 p.m., NHA A informed Surveyor all doors on alarm system are now set, just learning now about the door alarm system and the need to first disarm the alarm by pushing button and push button again to rearm the alarm system. On 4/27/22 at 2:57 pm, Surveyor reviewed a staff education note left at nurses' desk by DON B. It read: No One is to turn off the door alarms for any reason. If there is a problem with them, please alert maintenance, administrator or DON. It contains DON B's signature and 2 other staff. **Education does not address the alarm process for rearming alarms. On 4/27/22 at 3:11 pm, Surveyor spoke with CNA P about door alarm system. CNA P indicated the doors at the end of the halls are on alarm system. Staff can tell which door has been opened by sound and corresponding light at alarm panel. CNA P indicated the button should be turned off when it is safe. CNA P was not aware she needed to push the button again to rearm the alarm. CNA P worked since 10:00 am today. On 4/27/22 at 5:29 p.m., Surveyor attempted to call CNA Q who first noted R8 was missing. CNA Q was not working on 4/27 and her phone was not working. On 4/27/22 at 6:10 p.m., Surveyor spoke with CNA E. CNA E has worked at facility over one year with previous employment for over [AGE] years. CNA E expressed he also works as a medication technician at the facility. CNA E reported R8 could not be found, and an internal search of building areas was initiated. R8 could not be located. RN O went out front door and heard R8 and his alarm. R8 was found down a grass sloped area off 400 wing. R8 was damp from wet grass, shivering, and had abrasions to nose/face. R8 was provided blankets. R8 was assessed and 911 was called, R8 was transferred to ER. CNA E found the front door unlocked and the button on the alarm system was not pushed in or armed for the 400 wing door. CNA E reported he needed to help answer resident call lights, put people to bed, and help the nurse with medications when he returned inside. Further expressing he did not recheck other doors and reported he did not believe anyone checked the doors. CNA E also expressed he was not provided education on the door alarm system. On 4/27/22 at 6:28 p.m., NHA A provided Surveyor with a form titled, Minocqua Health and Rehab Elopement Response it noted: Root cause analysis completed regarding 4/26/22 elopement. Root cause was the control panel button for alarm was in a position/silencing alarm. A lack of education was the reason the button being pushed in due to the button needing to be pressed twice to return to active status. Door alarm control panel education has been initiated. New elopement assessment was completed for resident that eloped; care plan updated. DON verified all residents identified as elopement risk have elopement interventions in their care plans. Education regarding elopement book and elopement prevention. Maintenance Director verified all wander guard's door alarm sensors are functioning properly. Maintenance Director verified all wander guard pendants are functioning properly. Maintenance Director verified all door alarms are functioning properly. Surveyor requested and reviewed Staff Education completed to this point and noted pm staff working 4/27/22 had not yet been educated. Requested pm education be provided and a plan for night staff before survey team would exit. On 4/27/22 at 7:44 p.m., Surveyor received and reviewed education provided to pm staff with context discussed. Context now includes process for rearming alarm. The facility's failure to provide supervision of a resident at risk for elopement, the failure to have a working knowledge of the door alarm system, and the failure to ensure the alarm system was operational created a reasonable likelihood for serious harm to occur, thus creating a finding of Immediate Jeopardy (IJ) that began on 4/26/22 The IJ was removed on 05/02/2 when the facility completed the following: Wandering and elopement assessments completed; Door alarm panels audited each shift to ensure activated; Visual cues in form of stop signs posted at all exit doors; Care plans updated for all residents assessed to be at risk; Education and training provided to all staff on activating and alarming all doors; Education on wandering and elopement policies and procedures for all staff. The deficient practice continues at a scope/severity level E based on the following examples: Example #2: Surveyor requested and received a list of residents at risk for elopement from DON B. The list contained R3, R11, R12, R14, and R15, in addition to R8. Surveyor reviewed records for residents at risk for elopement and noted the following: R3 was admitted [DATE] with diagnoses that include, dementia with behavioral disturbance, and [CONDITION(S)] and [CONDITION(S)] following a cerebral infarction. R3's Admission MDS dated [DATE] is not complete and is in progress. The MDS notes R3 is cognitively impaired. Although the facility identified R3 as an elopement risk, the facility did not complete a care plan to direct staff in his elopement risk factors or elopement prevention interventions. R3's care card did not inform staff of R3's risk of elopement. R3's picture was on the facility resident elopement risk book at the nurse's station; however, the book contained no identifying information for R3 as directed in the facility policy. Example #3: R11 was admitted [DATE] with diagnoses that include, dementia with behavioral disturbance, repeated falls, history of traumatic [CONDITION(S)], and muscle weakness. R11's most recent quarterly MDS dated [DATE] notes: ~Severe cognitive impairment with inattention and disorganized thinking ~Does not wander ~Requires extensive assistance of one staff for bed mobility and transfer ~Has balance concerns and is not steady and has experienced falls with no injury R11's Elopement Risk assessment dated [DATE] notes: ~History of elopement ~History of attempting to leave facility without informing staff ~Wanders aimlessly or non-goal directed ~Wandering likely to affect safety and well-being of self and others ~Wandering likely to affect privacy of others R11's care plan notes: Focus: Elopement: potential for injury attempts to leave the facility without supervision related to behavioral and psychological symptoms of dementia, impaired judgement, Alzheimer's disease. Goal: Will not leave the facility without supervision throughout review date: Date Initiated: 1/14/21, revised on 5/20/21. Target date: 7/27/21. Interventions: Alarm mat at end of 300 hall, check wander guard bracelet per facility protocol, elopement assessment on admission, quarterly, readmission, significant change in status, and as needed . There is no evidence an elopement risk assessment was completed from 8/27/21 to time of R8's elopement as directed in R11's plan of care. R11's picture was in the wander risk book at the nurse's station. The picture did not resemble R11. The picture did not show R11 with a beard as he currently has grown out. There was no identifying information in the book for R11. Example #4: R12 admitted [DATE] with diagnoses that include, dementia without behavioral disturbance, cognitive communication deficit, muscle weakness, difficulty walking, and repeated falls. R12's most recent significant change in status MDS dated [DATE] notes: ~Usually understands, usually understood and is severely cognitively impaired ~Requires extensive assistance of two staff for bed mobility and transfer and does not walk R12's Elopement Risk evaluation dated 4/13/22 notes: ~History of elopement ~History of attempting to leave facility without informing staff ~Verbally expressed the desire to go home, packed belongings to go home or stayed near and exit door ~Resident wanders ~Wanders aimlessly or non-goal directed ~Wandering likely to affect privacy of others R12's care plan indicated: Focus: Resident is an elopement risk/wanderer related to dementia and cognitive impairment, poor safety awareness, wandering . Goal: Resident safety will be maintained through review date. Date initiated: 3/14/21, Revised on: 4/27/21, target date: 7/27/21. Interventions: Check function of wand guard daily, replace every 3 months and as needed, document wandering behavior and attempted diversional interventions, elopement assessment quarterly and as needed with safety and behavioral concerns . R12's care card indicates she has a wander guard. R12's picture is in the book at the nurses station. It does not contain identifying information. Example #5: R14 was admitted [DATE] with diagnoses that included, mild cognitive impairment, repeated falls, difficulty walking, cognitive communication deficit, and muscle weakness. R14's most recent annual MDS dated [DATE] notes: ~Understood, understands and has moderately impaired cognition ~Does not wander ~Requires extensive staff assistance of one for bed mobility and transfer R14's Elopement Risk Evaluation dated 2/11/22 notes: ~Resident wanders ~Wanders aimlessly or non-goal directed ~Wandering likely to affect privacy of others R14's Care plan notes: Focus: Resident is an elopement risk related to impaired safety awareness, tried leaving the facility unattended, confusion Goal: Resident will not leave the facility unattended, Resident safety will be maintained. Date Initiated: 4/19/21, Revised on: 11/19/21, target date: 2/24/22 Interventions: Check function of wander guard daily and replace every 3 months and as needed. Document wandering behavior, elopement assessment quarterly and as needed .like to go on patio, sign in and out and do frequent checks . R14's Care card indicates he has a wander guard. R14's picture was in the book at the nurse's station but contained no identifying information Example #6: R15 was admitted [DATE] with diagnoses that include dementia, altered mental status, and weakness. R15's most recent quarterly MDS dated [DATE] notes: ~Understood, usually understands and has moderately impaired cognition ~Does not wander ~Independent in bed mobility, transfer and walking R15's Elopement Risk Evaluation dated 4/06/22 notes: ~History of attempting to leave facility without informing staff ~Verbally expressed the desire to go home, packed belongings to go home or stayed near and exit door ~Resident wanders ~Wanders aimlessly or non-goal directed ~Wandering behavior likely to affect the safety and well-being of self/others ~Wandering likely to affect privacy of others R15's care plan indicates: Focus: Potential for elopement related to attempts to leave the facility without supervision and verbalizing the need/want to leave Goal: Resident will not leave the facility without supervision through next review date. Date Initiated: 1/15/21, Revised on: 1/10/22, target date: 1/20/22 Interventions: Check wand guard per facility protocol, elopement assessment on admission/readmission, quarterly and as needed . R15's care card indicates she has a wander guard. R15's picture was in the book at the nurse's station but did not contain any identifying information. R3, R11, R12, R14, and R15 were at risk for elopement out the 400 wing door due to no alarm being set as demonstrated by R8 on 04/26/22.

Based on observations, staff and resident interviews, and record reviews, the facility did not provide care consistent with professional standards to prevent Pressure Injuries (PI) for 6 of 7 residents reviewed for PIs (R7, R1, R16, R17, R6, and R4). 1. R7 did not have his skin assessed for the risk for the development of PIs upon admission and the facility did not implement a Care Plan (CP) to direct staff in the care and interventions to assist in the prevention and healing of PIs. As a result, R7 developed 6 unstageable PIs. 2. R1 was admitted with 8 wounds of various stages to his legs, feet, and back. Upon hospital discharge, he had two Stage IV PIs to his back (shoulder and spine). The facility did not complete an initial comprehensive assessment of these wounds, nor were there weekly wound assessments. 3. R16 was admitted on [DATE]. R16 required two+ persons physical assistance with bed mobility and transfers. The facility did not complete a skin assessment upon admission and did not coordinate care with the wound clinic to monitor pressure injuries for promotion of healing. R16's wounds were not assessed and reassessed weekly. The facility's failure to comprehensively assess wounds, it's failure to develop a care plan to direct staff on care and treatment to promote healing and prevent new PIs from developing, and it's failure to perform treatments to the wounds as ordered by the Physician created a finding of immediate jeopardy that began on 3/29/2022. Surveyor notified Nursing Home Administrator (NHA) and Director of Nursing (DON) of the immediate jeopardy on 5/2/22 at 2:36 PM. The immediate jeopardy was removed on 5/4/2022. However, the deficient practice continues at a scope/severity of G (harm/isolated) as the facility continues to implement its action plan and as evidenced by the following. 4. R17's skin integrity was not comprehensively assessed upon admission and weekly skin assessments were not conducted. Also, the facility did not develop a CP for R17 to direct staff in the care and interventions to assist in prevention and healing of PIs for each resident. As a result, R17 developed 3 new Stage II PIs. 5. R6 developed an unstageable pressure injury on right heel. No routine skin assessments of heel were performed by facility as per current professional standards of practice. 6. R4 had areas of skin breakdown on ankle and toes; areas were not routinely assessed in a manner consistent with current professional standards of practice. This is evidenced by: According to Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] - Assess the pressure injury initially and reassess it at least weekly; - With each dressing change .assess and accurately document physical characteristics such as correct anatomical location, category/stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and epithelialization. According to the NPIAP/EPUAP, Weekly assessments (of a pressure injury) provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. Without critical aspects of a comprehensive wound assessment, the professionals involved with a resident's treatment and care plans, cannot accurately determine if the wound is healing or worsening. Without this important information, the professional cannot order a more appropriate treatment plan in order to assist the wound to progress to the healing phase. The facility's policy and procedure for Pressure Ulcers, which was a canned policy written by Med-Pass 2001 with their revision date of 2009, directs staff to initially complete a comprehensive skin assessment then to proceed to complete an MDS (Minimum Data Set) Assessment to determine risk factors, medications, comorbidities, or potential behaviors, such as refusing certain care or treatments. Staff are then directed to develop an individualized care plan. Additional directives instruct nursing to complete comprehensive skin assessments on a weekly basis or more frequently if indicated. Example 1: R7 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) documents R7 has no pressure injuries but is at risk to develop pressure injuries. The MDS documents R7 has a pressure relieving device for his bed and chair. R7 has a Brief Interview for Mental Status score of 13, meaning he is alert and oriented and able to answer most questions accurately. R7 needs extensive assistance with assist of two persons for transfers, bed mobility, and personal hygiene. R7 is always incontinent of urine and frequently incontinent of bowel. The medical record contains no admission skin assessment or skin care plan. The nurses' notes contain in part: 3/29/22 Resident admitted to facility on 3/29/22. admitted to hospital on 3/22 for Acute kidney injure, acute [CONDITION(S)], aspiration pneumonia and [CONDITION(S)]. Episodes of confusion .Incontinent wears brief. Does have a pressure ulcer to buttocks, dressing on for protection . The admission note does not identify a location for a pressure injury, size or stage. Dietary Note 3/31/2022 19:46 Nutrition/Dietary Note Text: Initial RD Nutrition Risk Assessment: Calorie Goal: 2400/d Fluid Goal: 2300 ml/d minimum Protein Goal: 140 g/d (1.5 g/kg due to skin impairment). Skin: Open areas on buttocks- spots of blistering. Resident has history of pressure areas to buttocks. Care plans Potential for nutritional problems .Interventions: Provide and serve supplements as ordered: 1 oz additional dietary protein at meals and 1 scoop protein powder tid 3/31/22. Activities of Daily Living Care Plan: Repositioning: Assist of one Transfers: ext assist of 2 sit to stand. The skin assessments that were completed since R7's admission contain the following information. 4/21/22 Skin Only Evaluation: Does resident have skin issues? Yes, IAD ( Incontinence associated [CONDITION(S)], admitted with). No other information is on this assessment related to wound bed, size, wound exudate, peri wound condition, wound color, or tissue condition. 4/22/22 Skin Only Evaluation: Does resident have current skin issues? No Education provided: Resident aware of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Treatment Administration Record (TAR) Moisture Barrier Ointment BID (Twice daily) as indicated to keep irritants or moisture from skin surface. This is signed out by licensed nursing staff twice a day, except for 8 entries that are left blank. On 04/27/22 at 9:40 a.m., Surveyor interviewed R7 to ask if he had any skin issues. R7 stated he had a problem on his bottom, and it hurt really bad lately. Surveyor observed his bed and noted a regular mattress on the bed. Surveyor examined the wheelchair cushion that had an approximate 1.5 inch cushion in it. Surveyor asked if R7 gets care done to this area. R7 said, Sometimes they do. I can't say how often, but not every day. Surveyor asked if R7 had been educated about staying off of his bottom to make it feel better. R7 said, No. On 4/27/22 at 3:15 p.m., Surveyor asked Director of Nursing (DON) B what treatments R7 had to his pressure injury, as DON B had identified R7 on the pressure injury list. DON B said, I don't know. Surveyor reviewed the TAR with the DON B and noted that barrier cream was the only skin treatment identified. DON B said, Maybe it's healed. Surveyor asked if staff could assist R7 with lying down so Surveyor could see the status of the skin. On 4/27/22 at 3:35 p.m., RN C assisted R7 with turning onto his side and pulled down his brief for Surveyor to observe the area. Surveyor noted 5 open areas. Each of these areas contained slough, had regular borders with observable depth on the approximate 2 cm x 1 cm area on the left lower buttock. This wound is located in an area that would get direct pressure when R7 is seated in his wheelchair. R7 had yellow slough apparent on the coccyx. Surveyor asked RN C to separate the buttocks for better visibility. RN C separated the buttock cheeks. Surveyor observed a large amount of yellow slough, with the base of the pressure injury partially visible. Surveyor asked RN C what these areas were. RN C stated that the areas didn't look like this before. The area on the coccyx was not present before. Surveyor asked RN C how she would stage these areas. RN C stated they are unstageable. On 4/27/22 at 3:45 p.m., Surveyor went to DON B and shared concerns with the findings of R7's skin integrity. Surveyor asked if R7 had a pressure reducing mattress or special cushion. DON B stated, No, I will get a roho cushion and a better mattress on the bed right now. Surveyor asked to review the CNA care card for R7. DON B pulled up the information on the computer and noted that it was blank other than R7's transfer status. Surveyor asked how R7 had no wound care treatments or assessments. DON B indicated that because she has no MDS nurse the care plans don't get done. DON B went on to say, I can honestly tell you I haven't seen his pressure injuries. I have no idea what is there. On 4/27/22 at 5:15 p.m., Surveyor interviewed CNA D, asking if R7 has had skin issues. CNA D indicated that R7 was admitted with a pink dressing on his bottom. One day when transferring R7, it came off. The CNA said she told the nurses and they told CNA D to apply barrier cream. Surveyor asked if any other dressings had been applied. CNA D stated, No, nothing else. Surveyor asked if R7 would ever refuse to lie down or lay on his side. CNA D indicated that R7 is very pleasant and does not refuse to do things. On 4/27/22 at 6:30 p.m., Surveyor interviewed CNA E and asked if R7 refused to lie down or reposition. CNA E stated that R7 is always agreeable. Surveyor asked if R7 had any special instructions for offloading his bottom. CNA E was not aware of anything. On 4/27/22 at 7:45 p.m., Surveyor asked for the assessment of R7's pressure injuries during the observation at 3:45 p.m DON B brought Surveyor the nurse's note that contained the following: 4/27/2022 17:43 Skin/Wound Note Note Text: Resident has unstageable pressure ulcer to left buttock X 4. Inner: 0.8 cm X 2.4 cm. Bed wound mixed slough-50% and granulated with epithelial islands-50%. Scant serous drainage. No odor. Wound edges raised. Surrounding area blanchable. No s/s of pain with palpation. Outer: 0.3 cm X 1.0 cm. Bed wound mixed slough-50% and granulated with epithelial islands-50%. Scant serous drainage. No odor. Wound edges raised. Surrounding area blanchable. No s/s of pain with palpation. Mid: 0.2 cm X 0.2 cm. Bed wound mixed slough-50% and granulated with epithelial islands-50%. Scant serous drainage. No odor. Wound edges raised. Surrounding area blanchable. No s/s of pain with palpation. Inferior: 1.3 cm X 2.1 cm. Bed wound mixed slough-50% and granulated with epithelial islands-50%. Scant serous drainage. No odor. Wound edges raised. Surrounding area blanchable. No s/s of pain with palpation. Resident has unstageable pressure ulcer to coccyx. 3.0 cm X 1.8 cm. Bed wound mixed slough in center of wound-50% and granulated with epithelial islands-50% to surrounding. Scant serous drainage. No odor. Wound edges raised. Surrounding area blanchable. No s/s of pain with palpation. Right buttock has unstageable pressure ulcer. 0.2 cm X 3.0 cm. Bed wound mixed slough-50% and granulated with epithelial islands-50%. Scant serous drainage. No odor. Wound edges raised. Surrounding area blanchable. No s/s of pain with palpation. Resident c/o pain to left areas when in room assessing. Writer went into room to dress wounds and resident stated that wound felt much better now that writer put stuff on them. Writer did not put anything on wounds at this time. Resident rate pain 0 on 0-10 scale at that time. Updated NP [name] of areas, gave new orders per writer recommendations. Updated RD of areas. SP mattress. Resident encouraged to lay in bed throughout day. SP cushion will be applied to w/c when charged. Resident aware of new orders. Will continue to monitor. Example 2: On 4/4/22, R1 was admitted to the facility with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further documentation revealed that R1 also has conditions such as Diabetes Mellitus Type II, Failure to Thrive, and Congestive Heart Failure. Initial medical record review revealed that as of 4/28/22, the facility did not initiate a Minimum Data Set Assessment (MDSA) or a CP for R1. This is 10 days overdue. There was a CNA (Certified Nursing Assistant) Care Card available for review. Bathing needs, oral hygiene needs, and personal hygiene needs were blank. The CNA Care Card did indicate that R1 is transferred with the Hoyer lift and requires assistance of one staff for bed mobility and dressing. The Care Card directs CNA staff to float R1's heels and to wear a blue boot on the right foot. DON B completed initial wound care on R1's admitted [DATE]. The documentation indicated the size and location of the wounds and the treatment performed. This included: 1. Underside of right shin: 9.0 centimeters (cm) Length (L) x 4.5 (cm) Width (W) reddened area 2. Middle back: 4.5 cm L x 2 cm W with an open area measuring 0.5 cm x 0.5 cm. 3. Lower back: 2 cm L x 3.0 cm W- Stage II 4. Right Shoulder: 7 cm L x 3 cm W- stage IV 5. Left Shoulder: 1.0 cm L x 1.0 cm W- currently superficial 6. Right Heel: 4.0 cm L x 3.0 cm W, oblong in shape- stage IV 7. Right Buttock: 0.5 cm L 1.0 cm W- Stage IV 8. Right Buttock: 4.0 cm L x 3.0 cm W with an open area that measured 0.5 cm L x 1.0 cm W Per documentation, Allevyn was applied to all the wounds. Surveyor observations indicated that R1 requires staff assistance to meet his most basic daily tasks of bathing, personal hygiene, dressing, and toileting. He is on bed rest as he is unable to sit upright in a chair. He is nonambulatory and requires transfers with the use of a Hoyer mechanical lift. He has a Suprapubic catheter and is continent of bowel function, but because of functional disabilities, will notify staff of need, in which they place a pad under his buttocks and he will move his bowels while in bed. He is unable to sit on a bedpan or on a toilet. He is able to feed himself finger foods, but if utensils are required for the meal he requires staff assistance. R1 was noted to be alert and oriented and remains his own decision-maker. On 4/27/22 at 10:21 AM, Surveyor interviewed R1. During the interview, R1 expressed concerns regarding his wounds stating, .I have 6 major wounds, on my butt, my back, my shoulders and my heel. I do not get the treatments sometimes for 4 or 5 days. God, they smell so bad . My right shoulder smells of rotting flesh .the nurses are charting that I've been getting the treatments every day, but I'm actually lucky if they are done twice a week. Or they will chart that I refused. I've never refused a treatment . Surveyor reviewed the documentation of treatments performed for R1 and noted a treatment was signed out on admission day (4/4/22) but no treatments were documented on 4/5, 4/6 or 4/7/22. There was then an entry on the Treatment Administration Record (TAR) on 4/8/22 of details for wound care for each wound to be completed each morning. These were then signed out 4/8/22 - 4/11/22. On 4/12/22, the treatment time was changed to Hour of Sleep, and they were signed out daily with the exception of 4/17 in which the nurse documented that resident was asleep and wound dressings were not conducted. Surveyor was unable to obtain affirmation from nursing staff of missing any scheduled treatments. The treatment orders as written on 4/8/22 were: 1. Left Shoulder: Cleanse with wound cleanser and pat dry. Cover each wound bed with [MEDICATION(S)] AG (silver), then cover all with an island dressing. Change daily and as needed. 2. Right Shoulder: Cleanse with wound cleanser and pat dry. Cover wound bed with damp/moist 4 x 4 gauze in Dakins Solution then cover with and ABD pad and secure with tape. Change daily and as needed. Note: an ABD pad is an abdominal pad that is used for large wounds or for wounds requiring high absorbency because of large amounts of drainage. 3. Midline Lower Back: Cleanse with Dakins Solution, Cover with [MEDICATION(S)] AG then adhesive foam. Change daily and as needed 4. Right Buttock: Cleanse with soap and water and pat dry. Apply Calazinc twice daily and as needed 5. Left Buttock: Cleanse with soap and water and pat dry. Apply Calazinc twice daily and as needed 6. Left Gluteal Fold: Cleanse with soap and water and pat dry. Apply Calazinc twice daily and as needed 7. Right Ankle: Cleanse wound with Dakins Solution and cover with [MEDICATION(S)] AG. Cover with an ABD pad and wrap lightly with Kerlix. Secure with tape. Change daily and as needed. 8. Right Heel: There is no treatment listed for this area even though it was present according to the initial wound care DON B completed on admission. During the interview with DON B on 4/27/22 at 12:45 PM, DON B indicated that R1's wounds were assessed on admission, as she herself completed it. Also, DON B stated the lower back wound was very deep, and she admitted she should have staged it as a Stage IV as it was deep and covered with slough. She also indicated the right shoulder wound had visible bone. She could not recall if she started a CP for R1's wounds, and upon checking in the Electronic Medical Record (EMR), noted that there was no CP for R1. Upon further interview, DON B stated, To be honest, I do not know who does the CPs. We currently do not have anyone doing MDSAs (Minimum Data Set Assessments) and are behind on those as well. R1's wounds have not been evaluated since he was admitted by either a trained wound nurse or a physician. Surveyor then reviewed the documentation DON B entered into the NPNs for R1's admitted [DATE]. According to the documentation, there were 8 wounds identified. Of concern is the documentation was not a comprehensive assessment as it did not include a full description of each wound's characteristics, such as the presence of eschar or slough, infection, drainage amount and type, the presence or absence of granulation, tunneling/undermining, staging of each wound, or the appearance of the surrounding tissue of each wound as well as wound bed. Wound Care Observation: On 4/27/22 at 6:25 PM, Surveyor observed LPN F (Licensed Practical Nurse) complete wound care for R1. After preparing her supplies, LPN F washed her hands and donned gloves. She then proceeded with wound care, as follows: a. Right Heel: LPN F removed an eggcrate foam pad that was fastened with Velcro over the top of the right foot. The old dressing contained a bloody to yellowish drainage and the wound measured approximately 6.0 Centimeters (cm) length x 7.0 cm width. This wound appeared to be a Stage II as depth could not be measured related to the nearness to the surface the wound bed was. LPN F cleansed the wound with Sterile Saline by pouring the liquid over the wound. There was no wiping or patting the wound dry afterwards. She then proceeded to cover the wound bed with Derma/Col AG and a foam dressing, covered with Kerlix. This technique of not wiping the wound with a solution prevents the removal of potential bacteria, which can create a burden on the wound healing process as bacteria compete for the oxygen and nutrients in a wound. The foam pad that was being used on R1's foot was not a pressure floating or redistribution boot. The pad did not allow for floating of the heel and there was no floating Heels-Up device on the bed, allowing the heel to rest directly on the bed mattress, creating additional pressure to the heel. Note: There were no treatment orders written for the right heel to compare accuracy of observation. The wound has increased in size from 4/4/22 and also was originally staged as a Stage IV. b. Right Shoulder: The old dressing contained large amounts of a light lime green drainage. The wound measured approximately 6.5 cm length x 3.0 cm width. There was no odor from the wound. The wound was filled with what can only be described as a pale pink pigmented cluster of grapes indicating hypergranulation to the wound. There was a presence of slough from 7 O'clock to 10 O'clock inside the wound bed and approximately 0.5 centimeters (cm) from the edge into the wound. This wound was an Unstageable wound as one could not visualize the depth of the wound with the cluster of tissue on the surface. LPN F poured Sterile Saline over the wound and did not wipe or pat the wound dry. LPN F applied a Derma/Col Ag dressing over this as well. Note: The treatment order for this wound was to cleanse with wound cleanser and pat dry. Cover wound bed with damp/moist 4 x 4 gauze in Dakins Solution then cover with and ABD pad and secure with tape. This was not completed as ordered. The wound did decrease in size, however DON B noted that she could see bone on 4/4/22 and there is an addition of hypergranulation currently, which was not present on 4/4. Hypergranulation prevents epithelialization (new, healthy cell growth) and the healing process may be halted. The wound generally will not heal when there is hypergranulation tissue because it will be difficult for epithelial tissue to migrate across the surface of the wound. c. Left Shoulder: The old dressing contained a moderate amount of bloody drainage and the wound measured approximately 1.0 cm in diameter. This was a Stage II wound. LPN F poured Sterile Saline over the wound and did not wipe or pat it dry prior to applying a Derma/Col Ag dressing covered with a foam dressing. Note: The treatment orders for this wound were to cleanse with wound cleanser and pat dry. Cover each wound bed with [MEDICATION(S)] AG (silver), then cover all with an island dressing. This was not completed as ordered. Also, this wound remained the same with no changes from 4/4/22. d. Lower Middle Back (spine): This was a 5.0 cm long linear wound with an open area approximately 1 cm length x 0.5 cm width at the lowest section of the wound. This was a Stage II wound. LPN F repeated the same procedure of pouring the Sterile Saline over the wound and without wiping or patting the wound dry, covered it with a Derma/Col Ag dressing. Note: The treatment orders for this wound were to cleanse with Dakins Solution, Cover with [MEDICATION(S)] AG then adhesive foam. This was not completed as ordered. The wound has worsened in size from 4/4/22. e, Left Buttocks: The old dressing contained a small amount of bloody drainage. The wound was a Stage II that was an area of four tiny excoriated open areas. The procedure completed by LPN F was the same as the others listed above. Note: The treatment orders for this wound were to cleanse with soap and water and pat dry. Apply Calazinc twice daily and as needed. This was not completed as ordered. Also, it is unclear if this wound was incorrectly documented as another on the right buttock as the entry made on 4/4/22 does not make mention of a wound on the left buttock, but does note two right buttock areas. f. Right Buttock: The old dressing contained a moderate amount of bloody drainage. This wound had two separate open areas. The first measured approximately 2.0 cm length x 1.0 cm width. Below this was a second area that approximately 3.0 cm length that broke off into three separate open areas: 1) 1.0 cm length x 0.5 cm width 2) next to this was another area that measured approximately 1.0 cm length x 0.5 cm width and 3) below the two was another area that measured 0.5 cm length x 0.5 cm width. All Stage II. This wound appears to have decreased in size. Note: The treatment orders for this wound were to cleanse with soap and water and pat dry. Apply Calazinc twice daily and as needed. This was not completed as ordered There were no open wounds located on the right ankle or the calf. There was no comprehensive skin assessment to identify the severity and number of wounds R1 was admitted to the facility with. In addition, key concerns include the following: - There is no MDS completed (29 days after admission). - There was no Braden Risk Assessment completed. - There is no Care Plan for wound care. - There are no weekly wound assessments to indicate to the staff if the wounds are healing or worsening. This in turn prevents a critical nursing analysis of the wounds to determine if a treatment needs to be changed or a Physician needs to be more involved to assist with the healing. - Treatment orders were not entered into the record until 4/8/22. - The foam boot used for the heel was a simple eggcrate bootie fastened with Velcro over the top of the foot. It was not a heel-floating boot. - There was no Heel floating observed during the length of the survey (4/26 - 4/28). - Treatment observed was not completed as ordered On 4/27/22 at 12:45 PM, Surveyor interviewed DON B (Director of Nursing) regarding the expectations of wound assessments. DON B stated the expectation of all residents is that upon admission, the admitting nurse completes a full body assessment, including an assessment of all wounds and documents the assessment in the Nursing Progress Notes (NPNs). All other residents, the expectation is that nursing complete weekly assessments of all wounds. DON B also stated a CP should be developed to assist staff in following interventions to promote healing of the wounds and to prevent additional wounds from developing. On 4/28/22 at 10:01 AM, DON B was interviewed regarding wound assessment and documentation. DON B stated, I really don't have much experience with wound care and we do not have a wound nurse since (Registered Nurse C) transitioned into a floor nurse on 4/8/22. There is no one else on staff trained to do wound care. When asked if there were issues related to not having properly trained individuals for wound care, DON B stated, Well yes, there really isn't the knowledge to correctly assess wounds. This is a problem because there would be, but isn't any consistency. I really need to work on this . Example #3: R16 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge summary from hospital dated 4/6/2022 indicated R16 needs ongoing wound care. Summary indicated resident has multiple chronic wounds, dating back to 2017. Multiple skilled nursing facility and hospital admissions. Most recent hospital stay approximately 88 days. The admission Minimum Data Set (MDS) dated [DATE] indicated R16 had a Brief Interview for Mental Status (BIMS) score of 15. Skin Condition indicated R16 had one or more unhealed pressure ulcers/injuries. Current number of unhealed pressure injuries at each stage is not completed. The medical record contains no skin assessments. Nursing note dated 4/8/2022: -Wounds to bilateral lower extremities. Change daily. Cleanse with wound cleanser. Apply collage dressing, silver foam wrap, and Unna boot compression with cast padding and compression wrap in the morning. Bilateral lower extremities cannot be measured entire lower legs are open areas scattered throughout. Skin not intact to wound beds, peri areas have skin sloughing off due to maceration, moderate mixture of discharges present (purulent, serosanguineous). -Right knee laceration measuring 3.5cm in length. scab intact and no drainage or signs of infection. -Left thigh cluster of four open areas 2cm X 2cm, 1.5cm x 1cm, 4cm x 1.5cm, 2cm x 1.5cm all wound beds present with epithelial tissue, bloody drainage present. -Left low back closed area tissue is red measures 4cm X 0.50cm, protective bandage applied. -Right shoulder wound measures 3cm x 1.5cm bloody drainage present, wound bed present with epithelial tissue, no signs of infection. -Mid back two open wounds close in proximity measure 0.75 x 0.50, 0.25 x 0.25 both with epithelial tissue present, no drainage, no signs of infection. -Right buttock area measures 17cm x 9cm x 6cm. Wound bed red with scant blood drainage. No signs of infection, resident stated area was painful to touch. Dietary note dated 4/9/2022: Ht: 67 Weight: 253# No noted significant changes in weight in past 180 days. BMI: 39.6 and within obese class II category. Calculation weight: 174# (adjusted due to obesity). Calorie Goal: 2580/d Fluid Goal: 2000 mL/d Protein Goal: 120 g/d minimum (1.5 g/kg- increased needs to support healing progress of wounds). Skin: 5 pressure ulcers to back and upper thighs. Bilateral wounds on shins. Diet: Regular/Regular Texture/Thin Consistency Meal intakes are excellent: 76-100%. Recommend 2 oz additional protein at meals, 1 scoop protein powder tid added to food or drink, and [MEDICATION(S)] bid to support healing progress of wounds. Cook confirmed that resident is receiving this. Care Plan dated 4/6/2022 with revision date of 4/9/2022 and target date of 7/5/2022: Baseline care plan: Interventions: skin monitoring, pressure relief mattress, cushion in wheelchair, float heels on wedge pillow, repositioning assist of two, transfers with hoyer lift assist of two. Dietary interventions include 2 ounces additional protein at meals, [MEDICATION(S)] twice daily, 1 scoop protein powder three times daily. A care plan for skin integrity or pressure injuries was not located. Treatment Record April 2022: All treatment orders contained start date of 4/12/2022 and discontinued date of 4/29/2022: -Cleanse bilateral lower extremity wounds with cleanser, pat dry, cover with petroleum gauze, cover with meplix superabsorbent or non-adhesive foam. Wrap with Kerlix, wrap with ACE wrap. Change daily and PRN. -Cleanse intergluteal cleft with soap and water, pat dry. Paint open area no-string skin prep. Let dry. Every day shifts. -Cleanse left hip wound with wound cleanser. Pat dry. Cover with non-adherent pad/[MEDICATION(S)]. Secure with tape. Change daily and PRN. -Cleanse left knee with abrasion with wound cleanser. Pat dry. Cover with non-adherent pad/[MEDICATION(S)]. Secure with tape. Change daily and PRN. -Cleanse left lower back and right side of mid back abrasion with wound cleanser. Pat dry. Apply skin protectant ointment daily and PRN. -Cleanse right buttock denuded area and left buttock excoriation with soap and water. Pat dry. Paint open area with no-string skin prep. Let dry. -Cleanse right hip wounds with wound cleanser. Pat dry. Cover with ABD pad. Secure with tape. Change daily and PRN. -Cleanse right upper shoulder area with wound cleanser. Pat dry. Cover with [MEDICATION(S)]. Change daily and PRN. Orders: -[MEDICATION(S)]-1 packet BID -Braden scale on admission and weekly for 4 weeks. Documented on 4/13/2022 and 4/27/2022. No documentation on 4/20/2022. -Nurse to do full skin inspection on shower day, every Tuesday for shower. Documented 4/12/2022, 4/19/22. Not documented on 4/26/2022. 5/2/2022 at 6:52 AM, Surveyor requested face sheet, care plan, MDS assessment, skin assessment, and treatment record for R16. DON B stated that she knows R16 does not have a completed MDS. Surveyor requested to observe R16's wounds. DON B reported that Surveyor would not be able to observe R16 wounds as he went to wou [TRUNCATED]

Based on interview, observation, and record review, the facility failed to assess the safety risks of using an air mattress in combination with the enabler bars attached to each side of the bed, and failed to assess whether the bed rail was still needed for 3 of 3 residents (R) utilizing bed rails with an air mattress (R2, R7, R10). Failure to assess the residents for the risk of entrapment with the use of the assist bars and the air mattress resulted in R2 becoming entrapped between the mattress, enabler bar, and the wall. This created a finding of immediate jeopardy that began on 05/01/22. Surveyor notified the facility of the finding of immediate jeopardy on 05/05/22 at 4:40 p.m. The immediate jeopardy was removed on 05/05/22. This is evidenced by: Manufacturer's instructions for the Air Advance Bariatric Mattress include, but are not limited to, the following information under the heading of Warning: -Failure to comply with all directions and warning may result in injury or death; use only as directed. -This product is not suitable for all individuals. Other devices may be required. -This product is designed to assist in the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This may include, but is not limited to: *Bedrails for repositioning and fall prevention *Resident monitoring devices for elopement prevention *Other devices as specified by the caregiver -This device is only a tool to assist with pressure reduction as part of an overall care plan. Failure to comply with all instructions, warning, and precautions or using the product for a purpose other than the recommended use could result in bodily injury or death. -This product is not designed to replace good caregiving practices including, but not limited to: *Direct patient and resident supervision *Adequate care plans and training for staff personnel for entrapment and fall prevention *Inspection and testing before use Manufacturer's instruction also NOTE: Selection of an appropriate bed system to use with the product and proper maintenance and use of the product. Manufacturer's instructions state under Preventative Maintenance: It is important to periodically test the Panacea Air Advance control unit to verify the proper functionality. Lack of regular maintenance can result in poor or reduced resident support. Manufacturer's instructions state the mattress is also available with optional 3 inch raised side perimeters to further help minimize resident falls. (R2 had the lipped edges on the mattress.) Manufacturer's instructions state the mattress has a low-pressure alarm, which sounds indicating loss of air pressure. Manufacturer's instructions did not specify compatible side rails or bed frames to be used with the mattress. Example 1: R2 was admitted to the facility on [DATE]. Power of Attorney (POA) is activated. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS) assessment dated [DATE] indicates Brief Interview for Mental Status (BIMS) is 8 (moderate cognitive impairment). MDS functional status with bed mobility states resident requires extensive assist with 2+ physical assist and uses a wheelchair for mobility. R2 receives [MEDICATION(S)] 20 mg by mouth every evening, and [MEDICATION(S)] 50 mg by mouth at bedtime. Care Plan: Date initiated: 02/26/21 ADL: Baseline Care Plan Self Care deficit related to [CONDITION(S)], Dementia, Type II Diabetes Mellitus, [CONDITION(S)], Depression, and Chronic Kidney Disease. Goal: Date initiated 02/26/21, Revision: 11/29/21, Target Date: 05/17/22 In the next 3 months will actively participate in ADLs (activities of daily living) through next review. Interventions: Date initiated: 02/26/21 Bari-Bed, lip mattress Repositioning: Assist of 1. Reposition approximately every 2 hours and prn (as needed). Right/Left enabler bars for bed mobility and transferring. Ensure proper positioning to promote comfort R2 has no order for the Air Advance Bariatric Mattress. Care Plan states the date initiated was 02/26/21. R2's enabler bars were ordered 12/14/21. Facility did not perform a side rail assessment. Only Physical Therapy (PT) order is dated 11/25/20 for PT evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Facility did not assess the risk of entrapment for the use of the air mattress with the enabler bars when the enabler bars were placed on the bed. No individualized assessment for the risk of entrapment, including evaluating possible areas of entrapment, or measuring and testing by an assessment team, could be located within R2's medical record. On 05/01/22, Surveyor observed R2's bed/mattress but could not assess. R2's mattress was deflated and turned in the off position due to hospitalization of R2. R2's medical record progress note documented an entry on 05/01/22 at 10:08 p.m. by Licensed Practical Nurse (LPN) F stated: When the shift started LPN F and CNA P observed R2 rolled towards wall in bed. and CNA P repositioned R2 and noticed R2's face was extremely puffy. The note states they did a set of vital signs that were within normal limits and R2 was very restless. LPN F observed bruising to R2's right top of hand with a skin tear or laceration. R2's arms were swollen. R2's head was elevated and was monitored. R2's head of bed was elevated and R2 received fluids with medications. Towards the afternoon, R2's swelling in the face decreased and Director of Nursing (DON) B was notified. Note states all vital signs were within normal limits, but R2 had increasing pain. LPN F then noticed two different bumps on each side of R2's forehead by the temple region. R2 also had a hematoma on the right shoulder blade posterior to the spinal cord. DON B was notified of all R2 injuries and injuries were reported to POA (Power of Attorney. Note states R2 was seen at the ER (emergency room ) and diagnosed with a [CONDITION(S)] (urinary tract infection) and was being kept overnight for observation. The note states this communication was through an RN at Marshfield Minocqua emergency department. Further documentation states the facility will continue to monitor R2's status. R2 was very scared and timid when cares were performed. R2 was difficult to console. Documentation states at the ER, R2 notified POA that R2 had been struck but didn't say by what or who. LPN F documented that the information would be reported to primary physician and LPN F would follow up with POA, DON B and NHA (Nursing Home Administrator) A. On 05/03/22, Surveyor reviewed the emergency room /Hospital Documentation 05/01/22 H & P time stamp 6:42 PM Marshfield Medical Center-Minocqua. Document stated R2 was brought in for pain control. R2 was unable to provide any history due to neurocognitive dementia with [CONDITION(S)]. Physician documented he spoke with R2's daughter and the nursing home staff who stated R2 was found wedged between the bed and the wall at the nursing home. Documentation stated trauma work-up was unremarkable with a head CT and CT of the spine and x-ray of the chest. CK was slightly elevated at 200. UA was done that showed pyuria. Physician documented he asked if anything was wrong or if R2 was in pain and R2 stated she felt weird. Physician documented that R2 was able to, interact with him despite the observation in the ER. Documentation stated R2 was intelligible in the ER. Documentation in the H & P stated R2 had a [CONDITION(S)], which was uncomplicated due to no fever and no leukocytosis. R2 was started empirically on [MEDICATION(S)] (antibiotic). Documentation stated R2 would be on observation overnight and discharged back to nursing home tomorrow (05/02/22). On 05/03/22, Surveyor reviewed R2's pending discharge information from Marshfield Medical Center-Minocqua. Documentation stated R2 was kept for observation because of concern about worsening mental status having been discovered stuck between the bed and the wall. Was found to have a [CONDITION(S)]. Observed overnight. No evidence of rhabdomyolysis. R2 did have bruising on both arms. On 05/02/22 at 1:12 p.m., Surveyor interviewed Certified Nursing Assistant CNA Q. CNA Q was asked the incident that occurred with R2. CNA Q stated on the night shift of 04/30/22 into 05/01/22, R2 slept well. CNA Q stated she last checked R2 at 3:30 AM and R2 was sleeping well. CNA Q stated she burped (let the gas out of) R2's [CONDITION(S)] and let R2 sleep. No problems at that time were noticed. On 05/02/22 2:30 p.m., Surveyor interviewed LPN F. LPN F was asked about the incident that occurred with R2. LPN F stated that on 05/01/22 between 6-6:30AM, R2 was found face down on the bed wedged between the bed and the wall. LPN F was asked if R2's body was involved with the bed rail. LPN F stated R2's forehead was leaning on the bed rail. LPN F stated the side rail probably prevented the resident from falling further as she was pressed up against the rail. LPN F stated she and a CNA P repositioned R2 and R2's face was swollen, vital signs were normal, bed was locked, call light was within reach. LPN P stated that the air mattress on the bed was not working properly. Box at end of bed was beeping. LPN P stated she did call MD M and MD M came to the facility, but she wound up changing out the pump on the mattress. LPN P stated R2 was monitored throughout the day. LPN P stated the swelling did start to go down on R2's face and it was noticed she had two lumps on her head. LPN P was asked where the lumps were. LPN P stated on the top of R2's forehead as LPN P is pointing to the top of her own forehead. LPN P stated R2 also had a laceration on her right hand and a bruise on her right shoulder. LPN P was asked if physician, family, or administration were called regarding incident. LPN P stated the nurse practitioner was faxed an SBAR (Situation, Background, Assessment, Recommendation) form, the POA, DON B, and NHA A were notified by phone. LPN F couldn't state what time notifications were made. LPN P stated R2 started to have pain and so she thought she should be evaluated, and R2 was sent to the ER shortly after the PM shift started at 3:00 p.m. On 05/02/22 at 1:20 p.m., Surveyor interviewed CNA P. CNA P was asked about the incident that occurred with R2. CNA P stated she came on shift at 6:00 AM on 05/01/22. At 6:30 AM, LPN F called her down to R2's room. R2's bed was against the wall and R2 was wedged between the bed and the wall. R2 was laying on her stomach/face. R2's face was swollen, and R2 had red spots on her head. CNA P stated the LPN F and herself repositioned R2 and elevated the head of the bed. CNA P stated R2 did not make any sound or move much at all during the day. CNA P stated she was in the room multiple times throughout the day. CNA P stated when the PM (afternoon) shift started, she and CNA D went into R2's room to change R2 (perform incontinence cares). The swelling did start to go down on the R2's face and when that happened, it was noticed the red spots on the head (sides of head) were raised. CNA P stated LPN F was notified to come down to R2's room. CNA P stated R2 had her arms clenched across her chest and was in pain. LPN F decided to send R2 to the ER due to the pain. CNA P was asked what time that was? CNA P stated she was not sure exactly, but it was between 3-3:30 p.m. CNA P added that R2's hand was very red and puffy but could not state which hand. CNA P was asked if R2's bed rail was involved with how R2 was positioned when found. CNA P stated she thought R2 was positioned below from where the bed rail was. On 05/02/22 at 1:10 p.m., Surveyor interviewed RN O. RN O was asked about the incident that occurred with R2. RN O stated she came on shift on 05/01/22 at 6:00 PM and received report from previous shift nurse, LPN F. The report included that R2 was found face down in bed and R2's face was swollen at 6 AM. R2 was monitored during the day. RN O stated she was told it was possible [MEDICATION(S)]. Report given stated swelling went down throughout the day, but it was decided to send R2 out to the ER because of increased pain. RN O stated this was not until 3:00 p.m. RN O stated the aides told her that R2 had bruising and wasn't acting like herself. RN O stated the LPN F did not mention any bruising/hematoma. RN O stated R2's daughter, who is R2's POA, came to the facility at 5:00 PM and was asking questions. RN O stated she did not have much information to give her because she herself wasn't given very much information. On 05/02/22 at 10:20 a.m., Surveyor interviewed Registered Nurse (RN) C. RN C was asked about the incident that occurred with R2. RN C stated this morning, 05/02/22, RN C received report from the night nurse (RN R) that R2 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN C stated the only thing reported was R2 had swelling of the face and mouth and RN R stated something about bruising. RN C stated there was no report of a fall. RN C stated she asked if there was a fall because R2 is known to tip out of chair when she hallucinates. On 05/02/22 at 1:53 p.m., Surveyor interviewed Maintenance Director (MD) M. MD M was asked if any issues were noted with R2's mattress or if MD M received any notification of any issues. MD M stated, No. MD M was asked what process is in place to ensure the mattresses are working properly. MD M stated if the alarm sounds on the mattress, then there is an issue. MD M was asked about the facility process for side rail checks/placement. MD M stated he just made an inventory list of all the beds with air mattresses and side rails. There is no current process for side rail safety inspections. No specific system for checking mattresses or side rails provided by MD M. On 05/02/22 at 2:03 p.m., Surveyor interviewed DON B. DON B was asked what the facility plan is for prevention of any further incidents with R2 upon return to facility. DON B stated the mattress was fixed, there will be a body pillow put between the bed and the wall, R2 will be placed on more frequent monitoring, and R2 already has a mat on the floor at the bedside. DON B stated that all residents are to be assessed for bed rails and mattresses prior to placement. DON B was asked what time she was notified of the incident with R2. DON B stated she was notified at approximately 11:00 a.m. on 05/01/22. Mattress not working properly with air pressure not accurate, which led to cause of entrapment of R2 between mattress and the wall. It is unknown how long the mattress alarm was had been beeping or how much earlier that staff should have been aware that the mattress had malfunctioned. The failure to have a system in place to ensure bed rails, air mattress and bed frames are compatible, and the failure to have a process to ensure that bed rails are installed correctly and inspected regularly created a reasonable likelihood for serious harm, which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 5/5/22 when it had completed the following: All residents were assessed for use of side rails. Provided education and training to Maintenance Director and Director of Nursing and all direct care staff on entrapment guidelines. Maintenance Director measured the 7 zones identified by the Food and Drug Administration Entrapment Guidelines to ensure all zones were within the standard parameters for all residents with bed rails. Entrapment and bed rail assessments completed for residents with bed rails. Implemented inspection schedule for bed rails. The deficient practice continues at a scope/severity level of D based on the following examples for R7 and R10: -The facility does not have a process to ensure bed rails, mattress, and bed frames are compatible. The facility does not have a process to ensure that bed rails are installed correctly and inspected regularly. Example #2: R7 was admitted to the facility on [DATE]. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] documented the following: -Brief Interview for Mental Status score of 15, indicting cognitively intact response. -Pressure injuries Stage 2 and Stage 4. Pressure relieving device for bed and chair. -Bed rails are not used. -Extensive assistance with assist of two persons for bed mobility. Total dependence with two persons for transfers. Extensive assist of two persons for ADLs. -Indwelling catheter and always incontinent of bowel. Physician Orders, dated 4/4/22: -Enabler bars to aid in mobility and repositioning. -Physical, Occupation and Speech therapy evaluation and treatment as indicated. Care Plan dated 4/6/22: -Did not include any information regarding the use of bed rails. -Did not include therapy services. -Did not include adaptive equipment. 5/3/22 at 8:14 AM, Surveyor observed R1 sleeping in his bed, lying on his back. R1 was sleeping on an air mattress and had bilateral enabler bars attached to his bed. Surveyor reviewed R1's record and was unable to locate a bed rail assessment or consent to the use of bed rails. 5/3/22 at 11:35 AM, Surveyor observed R1 sleeping in his bed, rolled partially to his left side. 5/3/22 at 12:10 PM, Surveyor conducted an interview with R1. R1 reported that he was told at admission that he would be getting an air mattress for his bed. R1 stated that it took a week or two to get his mattress. R1 confirmed that he requires assistance with bed mobility but uses the bilateral enabler bars to independently reposition himself as much as he can. Surveyor asked R1 if facility staff provided him any education on the risks of entrapment related to the air mattress and the enabler bars, R1 reported that he did not think so. Surveyor asked if R1 signed a consent indicating that he was aware of the risks, and R1 reported that he did not think so. Surveyor asked R1 if he or the facility had tried any other methods to assist with repositioning besides the enabler bars, and R1 reported no other methods. R1 stated, I'm not worried about getting stuck, it would be hard to do. Surveyor observed that R1's air mattress was working properly. The air mattress fit tightly against the enabler bars. Enabler bars were secured to the bed. 5/3/22 at 12:14 PM, interview with Certified Nursing Assistants (CNAs) G and L. CNAs G and L reported that any resident that may need an air mattress or bed rails is referred to the Director of Nursing (DON B). If an air mattress or bed rails are not working properly a referral is made to the facility maintenance department. 5/3/22 at 12:22 PM, DON B reported that facility procedure for bed rails is that all new admissions are assessed by therapy department to determine a resident's transfer status. Nursing is then responsible to enter a progress note indicating the use of bed rails. DON B confirmed that consents for bed rails have not been completed. Therapy department did not have documentation of assessments indicating a resident's need for bed rails. 5/3/22 at 1:05 PM, Surveyor requested manufacturer's instructions for R1's bed, mattress, and enabler bars. Interview with Maintenance Director M. Maintenance Director M confirmed that he was not aware of the resource identified by the Food and Drug Administration, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. Reviewed manufacturer's instructions regarding R1's mattress, which reads in part, .This product may require other equipment. This includes bed rails for repositioning. Instructions did not reference compatible bed frames and bed rails. Reviewed manufacturer's instructions for bed frame model number SC900DLX, Invacare Continuing Care, Inc., regarding the use of bed rails, which indicated the model number for assist rails, IHRAILAE-DLX. 5/3/22 at 2:59 PM, Maintenance Director M showed Surveyor the enabler bar the facility uses. Enabler bar is tall and narrow and widens at the bottom. Maintenance Director M had referenced the Invacare website to determine if this was the correct model bed rail to be used with bed frame model. He confirmed that he was unable to match the model number of the bed rail the facility is currently using to the Invacare online catalog and is unable to determine if current bed rail is compatible with bed frame. Example #3: R10 was admitted to the facility on [DATE]. Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] documented the following: -Brief Interview for Mental Status score of 14, indicting cognitively intact response. -No pressure injuries, at risk for developing pressure injuries. -Bed rails are not used. -Extensive assistance with assist of two persons for bed mobility and transfers. Extensive assist of two persons for ADLs. -Frequently incontinent of urine and always incontinent of bowel. Physician Orders, dated 1/27/22: -Enabler bars to aid in mobility and repositioning. -Physical, Occupation and Speech therapy evaluation and treatment as indicated. Care Plan dated 1/28/22: -Bilateral enabler bars for bed mobility and repositioning. 5/3/22 at 8:14 AM, Surveyor observed R10 sleeping in her bed, lying on her back. R10 has air mattress and left side enabler bar. Surveyor reviewed R10's record and noted enabler bar assessment completed on 1/27/22. Indicated for transfers and bed mobility related to weakness. Assessment does not indicate if R10 was assessed for safety using enabler bar. Surveyor observed that R10's air mattress was working properly. The air mattress fit tightly against the enabler bar. Enabler bar was secured to the bed. Right side of bed against wall. 5/3/22 at 12:14 PM, interview with Certified Nursing Assistants (CNAs) G and L. CNAs G and L reported that any resident that may need an air mattress or bed rails is referred to the Director of Nursing (DON B). If an air mattress or bed rails are not working properly a referral is made to the facility maintenance department. 5/3/22 at 12:22 PM, DON B reported that facility procedure for bed rails is that all new admissions are assessed by therapy department to determine a resident's transfer status. Nursing is then responsible to enter a progress note indicating the use of bed rails. DON B confirmed that consents for bed rails have not been completed. Therapy department did not have documentation of assessments indicating a resident's need for bed rails. 5/3/22 at 1:05 PM, Surveyor requested manufacturer's instructions for R10's bed, mattress, and enabler bars. Interview with Maintenance Director M. Maintenance Director M confirmed that he was not aware of the resource identified by the Food and Drug Administration, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment. Reviewed manufacturer's instructions regarding R10's mattress, which reads in part, .This product may require other equipment. This includes bed rails for repositioning. Instructions did not reference compatible bed frames and bed rails. Reviewed manufacturer's instructions for bed frame model number SC900DLX, Invacare Continuing Care, Inc., regarding the use of bed rails, which indicated the model number for assist rails, IHRAILAE-DLX. 5/3/22 at 2:59 PM, Maintenance Director M showed Surveyor the enabler bar the facility uses. Enabler bar is tall and narrow and widens at the bottom. Maintenance Director M had referenced the Invacare website to determine if this was the correct model bed rail to be used with bed frame model. He confirmed that he was unable to match the model number of the bed rail the facility is currently using to the Invacare online catalog and is unable to determine if current bed rail is compatible with bed frame.

Based on observation, interview, and record review, the facility did not ensure that a resident (R) identified as at risk for impaired skin integrity received necessary care and treatment in accordance with professional standards of practice for 1 of 7 residents reviewed for skin integrity (R19). The facility did not promptly identify R19's skin impairment, resulting in non-pressure related wounds. This is evidenced by: R19 admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set (MDS) completed 1/12/2022: Brief Interview for Mental Status (BIMS) 15, indicated R19 had intact cognitive response. Braden score for assessing pressure injury risk, 10, indicated high risk. MDS showed R19 as having no pressure injuries. Care Plan: dated 1/31/2021 and revised 2/6/2022. Included area for potential to develop pressure injury. No current focus area, or interventions for actual pressure injury or skin integrity. Skin assessment dated [DATE] indicated no skin issues. Orders: Shower day every Monday, complete skin assessment. No documentation on treatment record or progress notes for 4/18/2022 and 4/25/2022. Reviewed the following progress notes: 3/6/2022 Late Entry: Note Text: Resident had Incontinence Associated [CONDITION(S)] (IAD) to right buttock. 3 area: superior 0.5 cm X 0.3 cm mid: 0.3 cm X 0.3 cm and inferior 0.4 cm X 0.4 cm. Area excoriated. No drainage. Surrounding area pink. No signs and symptoms (s/s) of infection. Denies pain to area. Resident has IAD area to left gluteal fold. 0.3 cm X 0.3 cm. Area excoriated. No drainage. Surrounding area pink. No s/s of infection. Denies pain to area. Updated on call Nurse Practitioner (NP), new orders obtained for cream every shift and as needed. Power of Attorney (POA) updated. Will continue to monitor. 3/17/2022 Note in paper chart: NP received note from Skilled Nursing Facility (SNF) staff that resident's excoriation to right and left buttock are healed. 4/9/2022 Note Text: Quarterly nutrition note: Height: 68 Weight: 227.5# Weight is stable within 3.7# range when compared to 30, 90, and approximately 180 days ago. No significant changes in weight. BMI: 34.6 and within obese class I category. Skin: Per 3/6/22 skin note: IAD to right buttock and left gluteal fold. No noted pressure areas. Diet: Diabetic/Regular Texture/Thin Consistency Meal intakes are excellent: 76-100%. Nutritional intake is adequate for needs and to support healing progress of skin. R19 eats independently and is tolerating diet without chewing or swallowing problems. Nutritional status is stable currently. Current diabetic diet is appropriate secondary to diabetes diagnosis. Will continue to monitor weight, nutritional intake, tolerance of diet, and will provide medical nutrition therapy as necessary. 5/2/2022 at 8:20 AM, interview with R19, reported that R19's butt is sore, and does not have a dressing. R19 stated that R19 has had skin concerns before; R19 had some difficulty recalling details of skin concerns. R19 was able to state that R19 had an amputation of her right lower extremity. R19 has bilateral enabler bars and uses these to help reposition self. 10:24 AM, observed peri-care of R19, provided by Registered Nurse (RN C) and Certified Nursing Assistant (CNA L). Observed 3 excoriated areas to R19's buttocks. RN C described areas as excoriated, scabbed, dry. RN C reported that she was not aware of these areas and R19 has no treatment orders. Observed RN C measure areas and reported: superior area: 1.5 cm X 2.0 cm, area dry and excoriated, no drainage. Inferior area: 0.8 cm X 0.6 cm. Area dry scabbed, no drainage. Inner area: 1.9 cm X 0.4 cm, area dry and excoriated, no drainage. 5/2/2022 at 2:36 PM, record review of progress note: Note Text: resident has excoriated area to right buttock. Superior area: 1.5 cm X 2.0 cm. Area dry and excoriated. No drainage. Surrounding area pink and blanchable. No s/s of pain. Inferior area: 0.8 cm X 0.6 cm. Area dry scabbed. No drainage. Surrounding area pink and blanchable. No signs of pain. Inner area: 1.8 cm X 0.4 cm. Area dry and excoriated. No drainage noted. Surrounding area pink and blanchable. No s/s of pain. Updated NP on areas, new orders obtained per wound nurse recommendations. Resident and POA update on new orders. Will continue to monitor. New orders reviewed: -Cleanse excoriated area to right inner buttock with soap and water, pat dry. Apply Calazinc every shift and as needed. Discontinue when healed. -Cleanse inferior excoriated area to right buttock with soap and water, pat dry. Apply Calazinc every shift and as needed. Discontinue when healed. -Cleanse superior excoriated area to right buttock with soap and water, pat dry. Apply Calazinc every shift and as needed. Discontinue when healed. 5/2/2022 at 3:42 PM, Surveyor requested comprehensive care plan, Activities of Daily Living (ADL) care plan, and shower log for April from DON B. DON B provided documentation for 4/25 of shower completed by CNA D; shower sheet indicates no skin issues on this date. DON B reported that if a resident refuses a shower the protocol is that CNA will update DON B, DON B to reapproach resident, if resident continues to refuse, CNA to chart in resident record. Surveyor asked if CNAs could document in progress notes and DON B stated that the policy should be changed that nurses will document resident refusal in progress notes. Reviewed care plan interventions for potential for pressure injury: -Follow facility policies and protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Monitor/document/report any changes in skin status. -Repositioning: See ADL care plan. -Toileting: See ADL care plan. Reviewed ADL care plan: -Reposition every 2 hours. -Toileting: Hoyer lift. Offer bed pan. 5/2/2022 at 3:47 PM, Surveyor conducted an interview with Social Services Director (SSD K). She reports that she works as a CNA sometimes. SSD K reported that if staff find skin concerns during cares or showers, they are to update the RN working. 5/2/2022 at 4:16 PM, Surveyor conducted an interview with CNA D who reported that the facility protocol regarding observation of resident skin concerns, is to update the nurse working. The nurse should observe the resident's skin at time of update. CNA D stated that if the nurse is busy and unable to observe, the nurse will often instruct staff to apply barrier cream. CNA D confirmed that she observed a skin concern to R19's bottom last week but could not determine the date. Last week's dates would have included dates 4/24/2022-4/30/2022. CNA D stated that she reported R19's skin concerns to Licensed Practical Nurse (LPN F). LPN F did not observe R19's skin and directed CNA D to apply barrier cream. Surveyor was unable to obtain interview with LPN F. There is no documentation in R19's record to confirm that a skin assessment was completed after CNA D reported R19's skin concerns. R19's incontinence associated [CONDITION(S)] skin breakdown had increased in size due to the lack of assessment and interventions to promote skin integrity for R19.

Based on observation, record review, and interview, the facility did not consistently provide care and services for 3 (R10, R8, R12) out of 29 incontinent residents to manage incontinence and prevent IAD (incontinent associated disorders) or promote the healing of non pressure skin ulcers for 1 (R7) out of 1 resident reviewed for non pressure skin ulcers R10 developed an IAD due to frequent bowel incontinence, lack of supplies to manage incontinence, and lack of timely incontinence care R8 developed an IAD due to frequent bladder incontinence, lack of supplies to manage incontinence, and lack of timely incontinent care The first two examples were cited at Scope/Severity Level 3-actual harm/isolated; the remaining examples are at a Scope/Severity Level 2. R12 developed an IAD due to frequent bladder incontinence, lack of supplies to manage incontinence, and lack of timely incontinence care R7 was prescribed [MEDICATION(S)], a nutritional drink to support wound healing. R7 did not receive [MEDICATION(S)] as prescribed. The facility was unable to obtain [MEDICATION(S)] (a powder supplement used for wound healing) to aide in healing R7's ulcer. This is evidenced by: Example #1: R10 was admitted to the facility for short term care on 01/27/2022 with the following, but not all inclusive, Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed an admission MDS (minimum data set) assessment for R10 on 02/09/2022 with the following data: ~able to make self understood and understand others. ~BIMS (brief interview for mental status) score of 14 out of 15, cognitively intact. ~required extensive staff assistance for bed mobility, toilet use, and hygiene. ~frequently incontinent of bladder. ~always incontinent of bowel. Review of the admission nursing assessment noted R10 had no skin problems upon admission. On 02/27/2022, R10 was noted to have an IAD on buttocks. The medical provider was consulted and ordered barrier cream with every brief change and leave open to air when able. On 03/05/2022, R10 had a new order which was Triad Wound Care to right and left buttock every shift for IAD. On 03/08/2022, RN (Registered Nurse) F assessed R10's IAD and documented 2.4 cm (centimeters) by 0.6 cm on left buttock and 2.5 cm by 0.8 cm on right buttock. Review of the care plan titled, The resident has IAD to right and left buttock . dated 02/28/2022 noted R10 was to notify staff when soiled and staff to change immediately. On 03/07/2022 at 11:45 a.m., Surveyor observed CNA (Certified Nursing Assistant) D and PTA (Physical Therapy Assistant) S assist R10 to transfer from the wheelchair into bed. R10 was able to reposition self in bed onto right side. CNA D removed R10's poorly fitted brief and Surveyor observed R10's excoriated buttock with actual open areas. On the right buttock the wound was approximately 2 cm (centimeters) by 0.3 cm. The wound bed was filled with yellow slough and the wound edges were irregular and fragile. There was another open area on the left buttock that was approximately 1 cm by 0.3 cm. The wound bed was also filled with yellow slough and had irregular fragile edges. R10 stated staff used Triad Wound Care ointment 2-3 times per day on the excoriated buttock. On 03/08/2022 at 10:30 a.m., Surveyor interviewed R10 regarding staffing, care, and supplies. R10 stated the excoriated buttocks was caused from involuntary diarrhea and being soiled frequently throughout the day and night. R10 stated the buttocks, [CONDITION(S)] and sometimes feels on fire, when there is fecal matter in her brief. R10 stated she will call for staff assistance to change her brief and has waited for more than an hour before staff arrive to help. R10 stated she called for staff assistance during the night and a staff member answered her call light and told her she could not help her until morning. R10 stated call light response time was 15 minutes to never. R10 stated there just aren't enough staff to care for all of us. Example #2: R8 was admitted to the facility for short term rehabilitation on 01/27/2022 with the following, but not all inclusive, Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed an admission MDS assessment for R8 on 02/08/2022 with the following data: ~able to make self understood and understand others. ~BIMS score 14 out of 15, cognitively intact. ~required extensive staff assist for bed mobility, toilet use, and hygiene. ~frequently incontinent of bladder. Review of the admission nursing assessment noted R8 had no skin problems upon admission. On 02/28/2022, the facility developed a care plan titled, The resident has actual impairment to skin integrity . for R8. The interventions included a specialty mattress, wheelchair cushion, and weekly skin assessments. On 03/05/2022 the medical provider was notified of R8's bilateral buttock excoriations and ordered Triad Wound Care every shift for IAD. On 03/07/2022 at 11:56 a.m., Surveyor observed DON B and COTA (Certified Occupational Therapy Assistant) T assist R8 from a seated position to a standing position. DON B removed R8's poorly fitted brief and Surveyor observed a large area of excoriation that covered R8's bilateral buttocks. The area was dark purple in color and evidence of a thick white barrier cream present. DON B stated the current treatment was the Triad Wound Care ointment every shift. R8 stated the buttock area was painful at times when he lays on his back for long periods of time. On 03/08/2022 at 10:05 a.m., Surveyor interviewed R8 regarding care received, staffing, and supplies. R8 stated the staff work hard but are very understaffed and cannot care for people when needed. R8 stated call light response may take as long as an hour and sometimes staff, never answer the call light. R8 stated he has poor control of his bladder and was often incontinent. R8 stated staff help him change his brief about one to two times per shift, otherwise R8 stated his brief was usually wet. R8 stated sometimes staff will use 2 briefs when there are no 2XLarge briefs available. R8 also stated staff do not reposition him as often as needed. R8 stated he goes up to seven hours lying on his back without being repositioned. R8 stated he does have buttock pain and will call for staff assistance and hope staff comes. Example #3: R12 was admitted to the facility for long term care on 03/12/2020 with the following, but not all inclusive, Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed a quarterly MDS assessment for R12 on 01/25/2022 with the following data noted: ~able to make self understood and understand others. ~BIMS score of 15 out of 15, cognitively intact. ~required extensive staff assistance with bed mobility, toilet use, and hygiene. ~always incontinent of bladder and bowel. On 03/06/2022, RN F identified IAD of R12's right buttock and left gluteal fold. RN F consulted with the medical provider and requested R12's excoriated right buttock and left gluteal fold be treated with barrier cream every shift. Review of the nurses notes dated 03/08/2022 noted RN F requested to change treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility developed a care plan titled, The resident has actual impairment to skin integrity . dated 03/06/2022. The interventions included treatment per physician orders, weekly wound assessments, and use draw sheet to move resident. On 03/07/2022 at 3:35 p.m., Surveyor observed CNA I and CNA J assist R12 from the wheelchair into bed using the full mechanical lift. R12 was observed to be wearing a poorly fitted brief and the brief was wet with urine. CNA I and CNA J assisted R12 to roll onto her left side and Surveyor observed R12's excoriated buttock (both sides) with an actual open area on the right buttock that was approximately 1 cm by 0.3 cm. The wound bed was pink and the wound edges were irregular and fragile. Surveyor interviewed R12 who reported staff are kind but staff shortages are present. R12 stated she preferred to stay in bed and staff change her two times per shift. Interviews: On 03/07/2022 at 8:00 a.m., Surveyor interviewed CNA D regarding staffing and available supplies. CNA D stated most supplies are available but getting 2XLarge briefs was difficult. CNA D stated the facility has many residents who wear a 2XLarge brief and the facility often runs out of this size. CNA D stated facility staff go to Wal Mart or Walgreens and purchase briefs and barrier cream when supplies are gone. On 03/07/2022 at 8:31 a.m., Surveyor interviewed CNA C who reported facility staff often need to purchase briefs and barrier cream at Wal Mart or Walgreens because the stock has been depleted. CNA C stated she was assigned to the blue hall which had 2 residents, the orange hall which had 3 residents, and the purple hall which had 11 residents. CNA C stated the usual staffing pattern for 40 plus residents was 2 CNAs. CNA C stated she does the best job possible to care for her residents. On 03/07/2022 at 11:20 a.m., Surveyor interviewed NP (Nurse Practitioner) R regarding skin problems and supply shortages. NP R stated she had recently been notified of an increase in IAD skin problems by RN F and was alerted to the facility not having any barrier cream or incontinent briefs. NP R stated RN F will notify her of skin problems via facsimile and request treatment orders. NP R stated she was told by RN F that RN F purchased barrier cream out of her own money because the facility could not obtain supplies. On 03/07/2022 at 11:34 a.m., Surveyor interviewed DON (Director of Nurses) B regarding supplies and shortages. DON B stated the facility does have problems obtaining supplies like barrier cream and briefs at times. DON B stated she has alerted the VPO (Vice President of Operations) Q of the problem. DON B stated on 03/04/2022, a large medical supply order was placed but was declined due to insufficient funds. DON B stated according to VPO there was a misunderstanding and the order was being processed as of today. DON B stated staff are very creative with supplies and believes the necessary supplies will be arriving soon. DON B stated staff has gone to Wal Mart and Walgreens to purchase barrier cream and briefs and will continue to do so as needed. On 03/07/2022 at 4:00 p.m., Surveyor interviewed CNA I who reported usual staffing patterns for the second shift were two CNAs. CNA I stated there have been occasions where there was only one CNA on the second shift and she was unable to get her work done. CNA I stated there have been shortages of 2XLarge briefs and barrier cream. CNA I stated staff must use the wrong size brief and this results in residents with soiled clothes and skin problems. CNA I stated when there are no 2XLarge briefs, she doubles up on the XLarge briefs. CNA I stated she can provide repositioning and incontinence care about two times per shift for residents. On 03/08/2022 at 11:25 a.m., Surveyor interviewed RN (Registered Nurse) F who stated she was the Certified Wound Treatment Associate and completed weekly wound rounds. RN F stated there had been an increase in the number of residents with IAD beginning in early February. RN F stated the facility used calazinc as the house stock barrier cream but had been out of this product. RN F stated on 03/04/2022, she spent between $50 and $60 to purchase barrier cream at Wal Mart because the facility did not have any barrier cream. RN F stated she witnessed former DON P attempt to order supplies like briefs, [MEDICATION(S)], and barrier cream, but the orders were declined due to insufficient funds. RN F stated former NHA (Nursing Home Administrator) M was aware of supply shortages and staffing patterns. On 03/09/2022 at 11:20 a.m., Surveyor interviewed VPO (Vice President of Operations) Q regarding RN F's statement about declined payment for medical supplies. VPO Q stated the orders were declined because former DON P and former NHA (Nursing Home Administrator) M did not follow procedure to complete the order process. VPO Q stated when the facility placed an order, the facility then would contact VPO Q to transfer money into the facility debit card to cover the cost of the medical supplies. VPO Q stated former NHA M and former DON P would randomly place orders and not request for the money to be transferred into the facility debit card. VPO Q stated the order would be canceled due to insufficient funds. R7 was admitted to the facility on [DATE]; POA (Power of Attorney) is activated. R7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review noted the following: · 12/4/2021, R7 sustained second and third degree [CONDITION(S)] to bilateral feet, after placing them on the room heater. · 1/6/2022, RD (Registered Dietician) recommended [MEDICATION(S)] twice daily to support healing progress of skin. · 1/12/2022, R7 had been prescribed [MEDICATION(S)] two times daily as a supplement for wound healing to bilateral feet. · 2/21/2022, R7's MAR (Medication Administration Record) showed that R7 had not been administered [MEDICATION(S)] from 2/21/2022-3/8/2022. · 3/3/2022, facility staff faxed NP (Nurse Practitioner) to request [MEDICATION(S)] be held until available. · 3/4/2022, nurse progress notes indicated that [MEDICATION(S)] was on hold. On 3/9/2022 at 11:02 AM, Surveyor reviewed weekly wound documentation for R7, beginning 12/29/2021 through 3/8/2022; notes indicated improvement in wound healing. On 3/9/2022 at 1:19 PM, Surveyor observed DON B and RN F change dressing to R7's left foot. Wound was dry, area was pink and defined, and there were no signs of infection. R7 tolerated dressing change well and denied any pain. On 03/08/2022 at 11:25 a.m., Surveyor interviewed RN (Registered Nurse) F who stated the facility had not been able to purchase [MEDICATION(S)] due to declined payment. RN F stated she witnessed the previous DON (Director of Nurses) P place orders for [MEDICATION(S)] and other medical products and the orders were canceled due to denial of payment. RN F stated the facility has been out of [MEDICATION(S)] since early February. RN F stated the medical provider was contacted and placed the [MEDICATION(S)] order on hold until it could be obtained.

Based on observation, interview, and record review, the facility did not ensure adequate supervision to prevent accidents and identify environmental hazards for 1 of 1 resident (R7), resulting in physical harm. R7's diagnosis of [CONDITION(S)], hallucinations, need for assistance with bed mobility, and history of being found on the floor, puts her at higher risk of harm and increased need for supervision. R7's bed was placed with right side of bed against the wall with a room heater. Care plan intervention of placing pillows under draw sheet on the left side of resident prevented her from exiting her bed on the left side. This resulted in R7 attempting to exit her bed on the right side, experiencing second or third degree [CONDITION(S)] to her feet. Findings include: R7 was admitted to the facility on [DATE]. Her POA (Power of Attorney) is activated. Her diagnoses include, Dementia with Lewy Body, [CONDITION(S)], Type 2 Diabetes Mellitus, history of falling, cognitive communication deficit, and hallucinations. R7 is non-ambulatory and uses a wheelchair for mobility. HHS (U.S. Department of Health and Human Services) website provides information on [CONDITION(S)], and includes the following common symptoms: problems judging distance or depth, visual hallucinations, sensitivity to heat or cold, and movement changes (https://www.alzheimers.gov/alzheimers-dementias/lewy-body-dementia). R7's MDS (Minimum Data Set) assessment dated [DATE], reported her BIMS (Brief Interview for Mental Status) was scored at an 8, indicating moderate impairment. Facility documentation indicated that R7 was found on the floor on 09/29/2021, 11/02/2021, and 11/11/2021. R7's care plan dated 11/30/2021, reads: · Cognition: alert and oriented to person and place, often forgetful, varies with time of day and level of fatigue. · The resident has had actual falls related to hallucinations, cognitive impairment, weakness, and repeated falls. Interventions include place pillows on left side under draw sheet to prevent resident from sliding/crawling out of bed. · Bed mobility: Extensive assist of 1. Reposition every two hours. Right and left enabler bars. On 3/7/2022 at 12:55 PM, Surveyor conducted record review for R7, and noted the following: · 12/4/2021, Resident calling out from bedroom. Resident's legs hanging on right side of bed with feet resting on in room heater. Resident was stating, It's burning. It's burning. Legs moved back into bed and this nurse assessed resident's feet. Right foot lateral side has 3 areas of redness. No blistering present at this time. Left foot clear of redness. POA voicemail left to call facility for update. Nurse Practitioner made aware. · 12/5/2021, Resident right foot has three red markings on the lateral side. All are red in color fading to purple at the bottom of the foot. The most distal mark has a blister measuring 2.5cm x 0.5cm. The left foot has two red markings on the interior side that are red in color fading to purple at the bottom of the foot. Skin prep applied. · 12/28/2021, a physician order was entered, paint left plantar superior and inferior foot areas with iodine. Paint right anterior foot area and right lateral foot area, proximal to the right ankle with iodine. · 1/25/2022, a physician order was entered, cleanse left plantar area with wound cleanser, pat dry, cover with island dressing. Every Monday, Tuesday, Thursday, and Saturday. On 3/3/2022, R7's MDS Skin Condition was updated and indicated [CONDITION(S)] (second or third degree). On 3/8/2022 at 3:10 PM, Surveyor interviewed RN-F (Registered Nurse) and WTA-C (Certified, Wound Treatment Associate). RN-F reported that she was not told when R7's incident happened. She was not able to report date that she was informed but stated that it may have been 12/28/2021 when the first treatment orders were obtained, and wound assessment was completed. Surveyor requested facility investigation from NHA-A (Nursing Home Administrator). NHA-A reported that he was not the NHA when this incident occurred and that he was unable to find a facility investigation. RN-F reported that NHA-M did complete a facility investigation and staff also assessed other residents in the facility at potential risk for injury related to room heaters. Surveyors observed 21 other sampled residents during the survey and did not observe any concerns with beds near the heaters. On 3/9/2022 at approximately 9:00 AM, NHA-A and RN-F confirmed that documentation related to a facility investigation could not be found. No facility investigative documentation was provided to Surveyor. On 3/9/2022 at 1:00 PM, Surveyor interviewed CNA-C (Certified Nursing Assistant). CNA-C reported that R7 has a history of crawling out of her bed on the left hand side. The care plan was updated in November after R7 crawled out of bed on the left hand side to include pillows under draw sheet on left side. CNA-C reported that R7's bed was positioned with the right side of the bed against the wall and room heater. CNA-C had not observed R7 trying to get out on the right side of her bed prior to the incident on 12/4/21. CNA-C confirmed that she was working on 12/4/2021 when R7 was yelling from her room, and staff responded immediately. CNA-C stated that she thought R7 would have the physical ability to remove her feet from the heater but thought that R7's attempt to transfer on the right side of the bed caused increased disorientation and R7 was not able to remove her feet from the room heater. CNA-C reported that RN working that shift was immediately updated, however this RN no longer works at the facility. On 3/9/2022 at 1:19 PM, Surveyor interviewed DON-B (Director of Nursing). DON-B confirmed that R7 is not able to reposition herself in bed without staff assistance. On 3/9/2022, at approximately 1:30 PM, Surveyor observed R7's room during observation of R7's dressing change. R7's bed had been moved to a different wall, not near the heater. Right side of bed was against the wall, right and left enabler bars, mat on the floor, lipped mattress, and long wedge pillow to place under left side of R7 when in bed.

Based on observations, interviews, and record review, the facility did not provide needed care to prevent a physical decline for 1 of 3 residents (R1) reviewed for skin concerns. Facility did not follow up on orders from wound clinic for referral to dermatologist. R1's skin condition deteriorated and spread from back to other parts of R1's body. Surveyor observed R1's back on 12/20/21, which was red with excoriated areas and drainage. Findings include: R1 was admitted to facility on 11/07/19 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has chronic Foley catheter in place. On 12/20/21 at 8:55 AM, Surveyor entered R1's room and observed her to be scratching her left shoulder and left upper back. R1 stated, My back is itchy today, my back is always itchy until they put something on it. R1 confirmed an appointment at the wound clinic a few weeks ago and stated, They are supposed to do it three times a day, but I'm lucky if they do it once. R1 denies back pain. R1 is noted to have Foley catheter with bedside drainage bag. R1 reported that staff assist her with repositioning in bed, but she is able to help by using the bilateral enabler bars on her bed. R1 agreed to roll to her right side and let Surveyor observe her upper left shoulder and back. When R1 rolled to her side, Surveyor noted R1's back was red and her sheets were soiled with red and brown drainage. On 12/20/21 at 9:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E. CNA-E reported that R1 prefers to stay in her bed most days, but that R1 is cooperative with cares and does not decline assistance to be repositioned. On 12/20/21 at 11:05 AM, Surveyor interviewed CNA-D. CNA-D reported that R1 does refuse to get out of bed and will refuse showers. CNA-D reported that R1 is scheduled to receive a shower every Tuesday; if R1 refuses a shower she is offered a bed bath. CNA-D stated that R1 is to wear a gown with opening to back and have brief open to allow for air flow. CNA-D reported that aides are to let a nurse know of any changes to R1's back or any refusals of showers or cares. Record review indicated: On 11/02/21, MASD had worsened, involving R1's whole back. Area documented as bright red, raised, rash appearance, and excoriation in some areas, drainage, no odor. R1 did have complaints of pain. Shower was offered to R1, where she had emesis related to pain, Tylenol offered and effective. Nurse Practitioner (NP) was updated at this time. On 11/03/21, NP recommended that R1 be transferred to emergency room , R1 refused. Documentation reported that back has improved after shower, no odor, nor painful. NP to see R1 on 11/04/2021. NP made referral to wound clinic. On 11/05/21, Electronic Health Record (EHR), documentation by Registered Nurse (RN)-C, R1 went out to wound clinic this afternoon shift, no new orders. R1's paper chart contained an order from the wound clinic dated, 11/05/21. Order for topical medication to back twice daily, and states, Seek dermatology referral for possible oral anti-fungal if not resolved in two weeks. Treatment Administration Record (TAR) indicates that R1 received topical medication to back from 11/08/21-11/21/21. TAR indicates there were no treatments for R1's skin from 11/22/21-12/07/21. RN-C confirms that there were no treatment orders for those dates. There is no documentation to support follow up after completion of topical medication on 11/21/21, or a referral to dermatology when the area was not resolved after 2 weeks. On 11/23/21, skin assessment indicated MASD present to back and groin, no odor, tissue painful. On 11/30/21, skin assessment indicated, MASD present to back, groin, buttocks, inner thighs, and back of right leg. No odor present. On 11/30/21 the area has worsened and is now present in several more areas of R1's skin. On 12/08/21, an order is obtained from NP to apply topical medication to R1's back every shift. Review of TAR confirmed that staff have been applying medication every shift beginning 12/08/21. On 12/20/21 at 11:50 AM, Surveyor interviewed RN-C and asked about referral to dermatology, RN-C reported that she was not aware of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/20/21 at 12:05 PM, RN-C and Surveyor observed R1's MASD, noting that R1's back was red, with excoriated areas and small amount of drainage. RN-C stated that area has deteriorated from the previous week. On 12/20/21 at 12:30 PM, during interview with Director of Nursing (DON)-B, Surveyor asked DON-B who is responsible for entering orders when a resident returns from an appointment. DON B reported that the floor nurse receiving the member back to the facility is responsible for entering new orders, including referrals. Based on Surveyor's investigation, the facility did not follow orders, resulting in a worsening of R1's skin condition.

Based on observations, interviews, and record reviews, the facility failed to ensure that 51 of 51 residents were free from neglect. The facility was aware of the needs of each of the 51 residents living in the facility. The facility did not provide sufficient staffing to provide cares to all residents beginning on 6/25/21. Because there were inadequate staff, residents were left in their rooms, left in bed with no way of getting up independently, and did not receive needed cares such as personal hygiene cares, toileting assistance, and/or repositioning. Staff had to choose which residents received care while others went without. As a result, there were resident falls, worsening of pressure injuries, and the development of pressure injuries, and medication errors. The facility failure to ensure residents were free from neglect, created a finding of immediate jeopardy that began on 6/25/21. ANHA-A (Acting Nursing Home Administrator), ADON-B (Acting Director of Nursing), and the COO-GG (Chief Operating Officer) were notified of the immediate jeopardy on 7/1/21 at 12:00 p.m. The immediate jeopardy was removed 7/1/21, however the deficient practice continues at a scope/severity of F (potential for more than minimal harm that is not immediate jeopardy/Widespread). This is evidenced by: On 6/25/21, Surveyor spoke with FNHA-DD (Former Nursing Home Administrator) regarding staffing. FNHA-DD stated that after the recertification survey on 6/14/21, the survey team had recommended a sufficient staffing deficiency. FNHA-DD indicated she had told the corporation that she would not accept any new admissions until staffing increased. FNHA-DD stated that she was told until she started admitting residents to the building, her pay would be cut $1,000 a month. FNHA-DD stated that there were phone conversations with corporate representatives who directed her to make cutbacks and to begin working on a plan. Ultimately, as determined in a follow up interview with FNHA-DD on 7/1/21 at 8:08 a.m., FNHA-DD stated she was directed to [NAME] 4 staff. These staff included the Medical Coder-N the Activities Director, a Laundry Assistant, and an Activities Assistant. FNHA-DD stated that she was asking CEO-FF and COO-GG to allow her to move the Medical Coder/Purchaser into a vacancy in laundry, and then have the Activities Assistant in laundry 3 days and activities 2 days. When she did not get a reply, she indicated she had to [NAME] those staff. FNHA-DD stated in light of the furloughs and the staffing shortage that was not addressed by the corporation, she and the Director of Nursing (DON) resigned from their positions effective immediately on 6/27/21, leaving the facility without two key administrative staff. FNHA and the former Director of Nurses contributed to resident neglect by abandoning their positions and the oversight of resident care. On 6/28/21, at 11:30 a.m., Surveyors entered the building and were told the census was 51. Surveyors toured the building to determine the nurse and CNA (Certified Nursing Assistant) staffing levels. There was 1 Medication Technician/Graduate Nurse, and 1 CNA. Therapy staff were observed to be assisting with some resident cares. Surveyors requested the Daily Assignment Sheets and schedules beginning on 6/25/21. Both documents reveal the following: A review of the facility assessment, dated 2017, indicates that the number of licensed nurses and CNAs needed to ensure there is sufficient staff to meet resident needs is 160 hours to 216 hours per day. A review of the actual hours worked revealed the following: 6/25/21: 88.98 hours worked that day by direct care staff (licensed nurses and CNAs) This included 8 hours worked by a light duty CNA who is unable to perform all CNA duties. On 6/28/21, Surveyor interviewed CNA Y who is on light duty. She indicated she is a CNA, but due to restrictions, she is not able to perform all CNA duties. This is more than 71 hours below the minimum number of hours the facility determined was necessary to meet resident needs. 6/26/21: 112.11 hours worked that day by direct care staff. *From 6:00 a.m. until 2:00 p.m., there were only 2 CNAs to care for 50 residents as the nurses had their own work to complete. *From 2:00 p.m. to 6:00 p.m. there was only 1 CNA to care for 50 residents. This is more than 47 hours below the minimum number of hours the facility determined was necessary to meet resident needs. 6/27/21: 100.89 hours worked that day by direct care staff. This included 4 hours worked by a light duty CNA who is unable to perform all CNA duties. This is more than 59 hours below the minimum number of hours the facility determined was necessary to meet resident needs. 6/28/21: 64 hours worked that day by direct care staff. There were no licensed nurses working on the day shift, only a Graduate Nurse. Therapy staff were observed to assist, however, are not CNAs and not able to perform all duties of a CNA. This is 96 hours below the minimum number of hours the facility determined was necessary to meet resident needs. On 6/28/21 at 1:36 p.m., Surveyor spoke with the AC-C (Admissions Coordinator). AC-C confirmed that there was no licensed nurse in the building on 6/28/21, only a graduate nurse. Surveyor asked if medications were passed. AC-C indicated a Nurse Practitioner was completing regular resident rounds and medications were passed while she was in the building. AC-C stated the NP had to leave at 10:40 a.m. so med pass stopped at that time. AC-C stated that a licensed nurse was coming on soon to assist. When asked if anyone from the corporation had been notified, AC-C indicated that the RNC (Regional Nurse Consultant) had been notified of the staffing situation on 6/27/21. AC-C indicated the response from the RNC was, what do you want me to do about it? On 6/29/21 at 5:20 a.m., Surveyor interviewed RN Z. RN Z stated she had just been hired on 6/28/21. Surveyor asked if she had received any orientation prior to beginning her shift, such as emergency policies and procures. RN Z indicated she had not. On 6/29/21 at 5:25 a.m., Surveyor interviewed RN X. Surveyor asked RN X what a typical staffing pattern is for the facility. RN X stated most often, it is 2 licensed nurses and 1 CNA. RN X stated on those days, residents may receive the minimum care, as long as nothing unforeseen happens. On 6/29/21 at 9:30 a.m., Surveyor interviewed CNA I. CNA I stated that all residents stay in their rooms over the weekend because there aren't enough staff to get everyone up or to assist them to bed in the evening. CNA I stated that today (6/29/21) was the first time she had ever seen therapy assist with residents. CNA I stated that when she came in this morning, she found R 25 had taken off his incontinent pad because it was saturated with urine, had a full urinal, and had urinated in cups that were in his room. CNA I was visibly shaken and stated she knows no one checked on him through the night. CNA I stated without enough staff, residents are not being repositioned or toileted like they should. CNA I also stated that showers are not being given because they do not have the time to do them. CNA I stated that this past weekend, there were a number of falls, 1 of which resulted in the resident going to the hospital. On 6/29/21 at 10:00 a.m., Surveyor interviewed R5. R5 stated that her concern is there is not enough staff in the building. R5 stated that often there is only 1 nurse and 1 CNA in the entire building. R5 stated, How are they supposed to do that? R5 stated this past weekend all of the meals were served in resident rooms. When asked why, R5 stated because there was not enough staff to get everyone up. R5 stated that she can transfer herself to the toilet when she needs to, cannot get off the toilet alone as she needs assistance to pull up her pants afterwards. R5 stated that more than once this weekend, she had to wait for over 45 minutes to get off the toilet. Surveyor asked about the call light timer that is at the nurses station. R5 stated that staff will come in to answer the light, turn it off and then turn it back on. This way they timer won't show the actual time the resident waited. Surveyor asked if this has happened to her. R5 stated it has. R5 also stated that she had a concerns with her medications on 6/28/21. She said she counts her pills to make sure she is getting all of them. She stated that she did not have enough pills in her cup and had to tell the nurse to go look for the rest of them. R5 stated that she is the Resident Council President so she hears concerns from several other residents. R5 stated, It is getting to the point where I am scared to be here. On 6/29/21 at 10:20 a.m., Surveyor interviewed R4. R4 stated there is not enough staff in the building. He stated the ones that are working are working very hard to try to care for everyone, there just aren't enough people. R4 stated that over the weekend, everyone had to stay in their rooms for meals. R4 stated he normally goes to the dining room for meals. R4 stated that those meals that were served in the room were cold. R4 stated his daughter brought in food for him so he could have a decent meal. He stated that his bed had not been made for quite some time. R4 stated that this bothered him as his bed was made daily. R4 stated I am a type A personality, and that he wants things neat. Surveyor asked R4 if he received the cares and assistance he needs. R4 stated he is not. Surveyor asked for examples. R4 stated he is supposed to walk with staff assistance every day and this has not been happening. Review of R4's medical record found this to be accurate. Since 6/14/21 (exit date of the last survey) R4 was ambulated in his room and the hall only 2 times, once on 6/28/21 and again on 6/29/21. All other dates are marked as activity did not occur. R4 stated that he used to use the bathroom independently, but had an occasion where his knees buckled and staff wanted him to wait for assistance. R4 stated last Thursday (6/24/21) he was following the recommendations and waiting for assistance. He was incontinent 5 times because staff did not respond to his call light. He stated it was embarrassing and he is no longer waiting for staff and is taking himself to the bathroom. On 6/30/21 at 1:50 p.m., Surveyor spoke with CNA AA. CNA AA stated that she is the last full time CNA for the evening shift. CNA AA stated that she had worked this past weekend on the evening shift and that she was the only CNA working. CNA AA stated that nearly all residents had to stay in bed as there weren't enough staff to get them up or to put them back to bed later. CNA AA stated that only the ones that absolutely had to get up for safety reasons were gotten up. Those residents were then brought to the nurses station so staff could somewhat observe them. Surveyor asked CNA AA how she was able to care for the residents if she was the only CNA in the building. CNA AA stated she couldn't. Surveyor asked what cares she could provide. CNA AA stated she fed residents who needed assistance, and provided toileting, incontinence care, and reposition to as many people as she could. Surveyor asked CNA AA if she was able to provide those care at appropriate intervals. CNA AA stated, she didn't get to everyone once a shift let alone every two hours. The lucky ones received cares once during the shift. CNA AA stated she feels like she is breaking down physically and mentally with the stress of being the only caregiver. Surveyor asked if the nurses or therapy provide any assistance. CNA AA stated the nurses are just as busy as they are trying to care for resident with only 1 or 2 of them. CNA AA indicated therapy will help if you specifically ask them to help. On 06/28/21 at 12:05 p.m., Surveyor interviewed R18 to ask how things were going with her cares. R18 stated, I am very disappointed with what is going on here, firing staff when we have no help. We wait for over an hour for help and they fired staff. On 06/28/21 at 12:10 p.m., Surveyor interviewed R5 asking how staffing has been. R5 stated, It is terrible there are no workers here. We have 1 aide and 1 nurse on duty for days. I have to wait at least 45 minutes for any help. On the weekend there was no help to get me out of bed. I ended up dressing myself and after waiting for hours I got some help because I can tell them I need it. I feel so bad for those who can't ask for help. On 06/28/21 at 12:15 p.m., Surveyor interviewed R6 about staffing and getting help with cares. R6 stated she has been waiting about 1 1/2 hours for help with toileting. Surveyor asked what has happened to R6 as a result of waiting so long. R6 said she has pooped her pants and has to sit in it until they get there. Surveyor asked if this is bothering R6 feeling humiliated. R6 stated, I feel bad but not that upset. I'm getting used to it. On 06/28/21 at 12:17 p.m., Surveyor interviewed R13 about staffing. R13 stated she has to wait at least 45 minutes for help to get to the bathroom and was left on the toilet over 45 minutes on the weekend before she was helped. On 06/28/21 at 12:20 p.m., Surveyor interviewed R23. R23 stated, I wait at least 45 minutes for anyone to answer my call light. They have no time to walk me, there is no staff. Please get us help! On 06/28/21 at 12:50 p.m., Surveyor interviewed CNA G about staffing. CNA G stated on the weekend there was only 1 CNA working. Residents could not be repositioned or toileted. Today they have the Physical Therapy Assistant (PTA) M, Speech Therapy (P), Occupational Therapist (OT) Q helping with cares. On 06/28/21 at 1:05 p.m., Surveyor interviewed R1 asking about staffing and getting assistance with cares. R1 stated, I stay in bed a lot. I need help with my incontinence care. I put my light on they come in turn it off and leave. Surveyor asked when was the last time R1 had been assisted with cares. R1 stated, I want to use the bedpan for my bowel movements but they don't get here. I put my light on they come in turn it off and leave. R1 stated, They were in here about 8:00 a.m. or so, I have laid on my back like this since then, it has been really bad the last few days. Surveyor asked R1 to put on her call light to get help. After about 5 minutes Speech Therapy came and answered the call light, turned it off and said she would get a CNA to help R1. Surveyor continued to observe for staff to come back and assist R1. Surveyor continued to observe for staff to come back and assist R1. At 1:37 p.m. Surveyor observed CNA enter the room to assist R1. On 06/28/21 at 1:30 p.m., Surveyor interviewed Medication Technician (MT) H. MT H stated she worked from 6 a.m. - 10 a.m. on the weekend as a CNA. MT H indicated they got up a few residents that had to get up, but there was not enough staff to get all residents out of bed. Surveyor asked which residents did not get out of bed. MT H was not sure of all the residents but named R26, R10, R28 and R8. On 06/28/21 at 1:40 p.m., Surveyor interviewed PTA M. PTA M stated he came to work this morning and was informed at the morning meeting about the staffing situation. He called his supervisor and was told to help on the floor with transfers. PTA M stated, It is impossible for 1 CNA to keep up and help the residents. PTA M stated that all therapy services were canceled for Monday and Tuesday as all the therapy staff are working on the floor. PTA M stated his last day of work here is Thursday. As a result of the lack of appropriate staffing levels as defined by the Facility Assessment, the following deficient practices were identified in which the facility and their staff failed to provided services to residents: ~13 residents did not receive activities of daily living cares, including repositioning, incontinence cares, personal hygiene, and mobility. (Refer to F677.) ~2 residents were not provided with appropriate care to prevent and/or improve non-pressure related skin ulcerations resulting in actual harm. (Refer to F684.) ~5 residents did not receive appropriate care to prevent the development or redevelopment of pressure injuries. (Refer to F686.) ~6 residents did not receive treatment and services to improve, prevent further decline, and/or maintain range of motion resulting in actual harm. (Refer to F688.) ~4 residents were not provided with care and supervision to prevent accidents. (Refer to F689.) ~4 residents were not provided with care to maintain and/or prevent decline of bowel and bladder incontinence resulting in actual harm. (Refer to F690.) ~8 residents received medications from an unauthorized personnel without supervision of a licensed nurse. (Refer to F755.) ~6 residents received insulin outside of the prescribed time frames when no licensed nurse was on duty. (Refer to F760.) The facility removed the immediate jeopardy on 7/1/21 when the following were implemented: 1. The facility signed contracts with staffing agencies. 2. Plan to implement Emergency CNA Training Program. 3. Implemented twice weekly town hall meetings with staff to review schedules, get feedback, and provide updates. 4. Incentive program expanded to include sign on, retention, and shift pick up bonuses. 5. All staff, not only nursing staff, are to interact/check in with residents and respond to resident needs as appropriate. 6. Daily staffing to be reviewed and signed off by 2 management team members as being adequate using 2.75 hours per patient day as a threshold. 7. Implemented a Manager of Duty during the weekends. 8. Management will interview residents with a BIMS (Brief Interview for Mental Status) of 8 or above to ensure they are receiving appropriate care and to follow up on any concerns. 9. For residents with a BIMS of 8 or lower, or who cannot communicate, nursing staff will be assigned to sign off on cares received. 10. All staff will be educated on neglect prior to the beginning of their next shift.

Based on observations, interviews, and record reviews, the facility did not provide necessary cares and services to promote quality of life and help 51 of 51 residents maintain their highest practicable level of of physical, mental, and psychosocial well-being. Residents stated they felt scared, felt embarrassed from wetting themselves, were getting used to wetting themselves, felt neglected, and felt as if no one would help them. The facility and governing body did not provide an adequate level of staff to provide cares and services to residents of the facility for an extended period of time. In addition, the governing body did not ensure payments were made to facility vendors in a timely manner, which put the facility at risk of not receiving necessary food, supplies, and utilities. This resulted in noncompliance at 14 federal regulations during the survey. This pervasive disregard of residents' quality of life created a finding of immediate jeopardy that began on 6/25/21. ANHA-A (Acting Nursing Home Administrator), ADON-B (Acting Director of Nursing) and COO-GG (Chief Operating Officer) were notified of the immediate jeopardy on 7/1/21 at 12:00 p.m. The immediate jeopardy was removed on 7/1/21, however the deficient practice continues at a scope/severity of F (potential for more than minimal harm that is not immediate jeopardy/widespread). This is evidenced by: During the complaint investigation, the following deficiencies were identified: ~6 residents' physicians were not notified that insulin had been administered outside of the prescribed time parameters. (Refer to F580.) ~51 residents were not free from neglect when the facility and governing body did not ensure that sufficient staff were deployed to care for residents. This resulted in a finding of immediate jeopardy and substandard quality of care. (Refer to F600.) ~13 residents did not receive activities of daily living cares, including repositioning, incontinence cares, personal hygiene, and mobility. (Refer to F677.) ~2 residents were not provided with appropriate care to prevent and/or improve non-pressure related skin ulcerations resulting in actual harm. (Refer to F684.) ~5 residents did not receive appropriate care to prevent the development or redevelopment of pressure injuries. (Refer to F686.) ~6 residents did not receive treatment and services to improve, prevent further decline, and/or maintain range of motion resulting in actual harm. (Refer to F688.) ~4 residents were not provided with care and supervision to prevent accidents. (Refer to F689.) ~4 residents were not provided with care to maintain and/or prevent decline of bowel and bladder incontinence resulting in actual harm. (Refer to F690.) ~The facility and governing body did not ensure there were sufficient staff to care for 51 residents. This resulted in a finding of immediate jeopardy. (Refer to F725.) ~8 residents received medications from an unauthorized personnel without supervision of a licensed nurse. (Refer to F755.) ~6 residents received insulin outside of the prescribed time frames when no licensed nurse was on duty. (Refer to F760.) ~The governing body did not ensure there was sufficient resources, including staff and accounts payable, were available to the facility. This resulted in a finding of immediate jeopardy. (Refer to F837.) ~The facility did not ensure that staff and visitors were actively screened prior to entrance to the facility and also did not ensure staff wore all appropriate PPE (personal protective equipment) was worn for resident interactions. (Refer to F880.) Resident interviews during survey revealed that residents were scared, felt embarrassed from wetting themselves, were getting used to wetting themselves, felt neglected, and felt as if no one would help them, as evidenced by: On 6/29/21 at 10:00 a.m., Surveyor interviewed R5. R5 stated that her concern is there is not enough staff in the building. R5 stated that often there is only 1 nurse and 1 CNA in the entire building. R5 stated, How are they supposed to do that? R5 stated this past weekend all of the meals were served in resident rooms. When asked why, R5 stated because there was not enough staff to get everyone up. R5 stated that she can transfer herself to the toilet when she needs to, cannot get off the toilet alone as she needs assistance to pull up her pants afterwards. R5 stated that more than once this weekend, she had to wait for over 45 minutes to get off the toilet. Surveyor asked about the call light timer that is at the nurses station. R5 stated that staff will come in to answer the light, turn it off and then turn it back on. This way they timer won't show the actual time the resident waited. Surveyor asked if this has happened to her. R5 stated it has. R5 also stated that she had a concerns with her medications on 6/28/21. She said she counts her pills to make sure she is getting all of them. She stated that she did not have enough pills in her cup and had to tell the nurse to go look for the rest of them. R5 stated that she is the Resident Council President so she hears concerns from several other residents. R5 stated, It is getting to the point where I am scared to be here. On 6/29/21 at 10:20 a.m., Surveyor interviewed R4. R4 stated there is not enough staff in the building. He stated the ones that are working are working very hard to try to care for everyone, there just aren't enough people. R4 stated that over the weekend, everyone had to stay in their rooms for meals. R4 stated he normally goes to the dining room for meals. R4 stated that those meals that were served in the room were cold. R4 stated his daughter brought in food for him so he could have a decent meal. He stated that his bed had not been made for quite some time (R4's bed was observed to be unmade during the interview). R4 stated that this bothered him as his bed was made daily. R4 stated I am a type A personality, and that he wants things neat. Surveyor asked R4 if he received the cares and assistance he needs. R4 state he is not. Surveyor asked for examples. R4 stated he is supposed to walk with staff assistance every day and this has not been happening. Review of R4's medical record found this to be accurate. Since 6/14/21 (exit date of the last survey) R4 was ambulated in his room and the hall only 2 times, once on 6/28/21 and again on 6/29/21. All other dates are marked as activity did not occur. R4 stated that he used to use the bathroom independently, but had an occasion where his knees buckled and staff wanted him to wait for assistance. R4 stated last Thursday (6/24/21) he was following the recommendations and waiting for assistance. He was incontinent 5 times because staff did not respond to his call light. He stated it was embarrassing and he is no longer waiting for staff and is taking himself to the bathroom. On 06/28/21 at 12:15 p.m., Surveyor interviewed R6 about staffing and getting help with cares. R6 stated she has been waiting about 1 1/2 hours for help with toileting. Surveyor asked what has happened to R6 as a result of waiting so long. R6 said she has pooped and peed her pants and has to sit in it until they get there. Surveyor asked if this is bothering R6 feeling humiliated. R6 stated, I feel bad but not that upset. I'm getting used to it. On 06/28/21 at 12:20 p.m., Surveyor interviewed R23. R23 stated, I wait at least 45 minutes for anyone to answer my call light. They have no time to walk me, there is no staff. Please get us help! On 06/29/21 at 9:25 a.m., R1 was observed in bed with her breakfast tray on the side table. R1 was in a green colored gown that appeared to be her pajamas. Surveyor asked R1 if she was done with breakfast and if she was ready to get up for the day. R1 stated, What's the use, there isn't anyone to come and help me anyway. Surveyor asked R1 how she asks for help and R1 said she uses her call light but no one comes. Surveyor asked R1 if she had been helped yet this mornng with any cares and R1 said she had not. She said, They tilted my bed up so I could eat my breakfast, that is it. R1 stated she was still in her pajamas and had not been changed before breakfast. R1 stated she does have a catheter, but doesn't know why. Surveyor asked R1 if she would like someone to come in and help her and R1 stated, If I want to get help I ring, if they have anyone here to help. The other day there was only one person in the whole place. They come in and then they say they will be back and they leave and I don't get any help. R1 stated on the weekends there is never anyone around and she doesn't hear anyone out in the hallway. R1 said if you put your light on no one comes. When Surveyor asked R1 how that made her feel, R1 stated, Neglected. Surveyor asked R1 if she was afraid she wouldn't get any help and R1 stated she felt neglected, I am not getting the care I should be. On 06/30/21 at 9:25 AM, Surveyor interviewed R7. Surveyor asked about staffing and getting assistance with cares. R7 lifted his call light and stated, See this. This is for emergencies. When you need help. The other day I put this on and waited an hour and a half for someone to answer it. I had to go to the bathroom. Another time, I waited 2 and a half hours for my light to be answered. It wasn't for the bathroom; but still---it isn't right. On 06/29/21 at 10:50 a.m. Surveyor asked R7 if he had recently experienced any falls. R7 said he had fallen on 06/27/21. When Surveyor asked what had happened, R7 said he was tired of waiting for more than an hour and tried to get himself into bed and fell on his knee. R7 stated, I need help getting from my chair to my bed. Surveyor asked R7 if he had to wait any other times. R7 said he always has to wait for assistance. R7 stated it always takes at least an hour or more after putting on his call light to get anyone to help him. R7 stated, It is really bad when a grown man has to go in your pants because you have to wait to get help to go to the bathroom. On 06/28/21 at 1:00 p.m., Surveyor interviewed R4 about cares and staffing. R4 stated he was so happy to be in this facility near his family but things have gotten so bad. R4 went on to describe the events of the past weekend. R4 indicated there was only 1 nurse and 1 CNA to care for over 50 people. R4 stated he observed several residents did not get out of bed for 2 days. R4 indicated he is to have assistance to walk to the bathroom but no one comes to help. R4 stated on the weekend he waited for one hour after the call light was put on, so I just took myself to the bathroom. R4 stated he has continued to transfer, dress himself and ambulate without assistance so that he can get to the bathroom and get dressed. R4 indicated he is to be getting therapy but as of today therapy is canceled because all of the therapy workers have to work on the floor. R4 stated, I don't want to fall again, my knee gives out at times and down I go. No one will help me. On 06/29/21 at 10:20 a.m., Surveyor observed R2 lying in her bed fully clothed with the wheelchair by the side of the bed. When Surveyor asked R2 how she had gotten into bed, R2 stated she had transferred self to bed because no one had answered her call light to assist her. Surveyor asked R2 what she does if she wants assistance. R2 stated she will put on the call light but has to wait over an hour. R2 stated, I put myself to bed. Who is going to do it? If I put on my call light no one comes. There are so few people here to help that there isn't anyone to do it. Surveyor asked R2 if she requires assistance for toileting. R2 stated, I can't walk, so I can't go to the bathroom myself. It is humiliating to have to go in my pants when I have to wait for over an hour for someone to answer my light. That's why I have to wear this pad. Surveyor asked R2 if anyone had assisted her this morning. R2 said she had gotten up for breakfast which is served between 7:30 and 8:00 a.m. and was changed and ready to go to therapy. When asked if she had any assistance since breakfast, R2 stated no one had come in to assist her or to change her incontinence product. R2 stated she had waited, but no one came to assist her out of her wheelchair into her bed so she did it herself. She also stated no one had helped her to go to the bathroom or change her incontinent product since getting up this morning. Surveyor asked R2 if she had ever fallen. R2 stated she had fallen just recently. When Surveyor asked R2 what had happened, R2 stated, I had to go to the bathroom. I put my call light on but no one came to help me so I went in my pants. It is so humiliating when that happens. I was so wet, so I tried to change myself because I knew I wouldn't get help. I slid off the bed. When asked if she had been changed or toileted the day she fell , R2 indicted she had not since she had gotten up for breakfast. R2 fell at approximately 11:26 a.m., which is over 3 hours after breakfast is served. On 6/29/21 at 9:30 a.m., Surveyor interviewed CNA-I. CNA-I stated that all residents stay in their rooms over the weekend because there aren't enough staff to get everyone up or to assist them to bed in the evening. CNA-I stated that today (6/29/21) was the first time she had ever seen therapy assist with residents. CNA-I stated that when she came in this morning, she found R25 had taken off his incontinent pad because it was saturated with urine, had a full urinal, and had urinated in cups that were in his room. CNA-I was visibly shaken and stated she knows no one checked on him through the night. CNA-I stated without enough staff, residents are not being repositioned or toileted like they should. CNA-I also stated that showers are not being given because they do not have the time to do them. CNA-I stated that this past weekend, there were a number of falls, 1 of which resulted in the resident going to the hospital. Failure to provide residents with the care and services necessary to promote quality of life and promote each resident's highest practicable physical, mental, and psychosocial well-being created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 7/1/21 when the following were implemented: 1. The facility signed contracts with staffing agencies. 2. Plan to implement Emergency CNA Training Program. 3. Implemented twice weekly town hall meetings with staff to review schedules, get feedback, and provide updates. 4. Incentive program expanded to include sign on, retention, and shift pick up bonuses. 5. All staff, not only nursing staff, are to interact/check in with residents and respond to resident needs as appropriate. 6. Daily staffing to be reviewed and signed off by 2 management team members as being adequate using 2.75 hours per patient day as a threshold. 7. Implemented a Manager of Duty during the weekends. 8. Management will interview residents with a BIMS (Brief Interview for Mental Status) of 8 or above to ensure they are receiving appropriate care and to follow up on any concerns. 9. For residents with a BIMS of 8 or lower, or who cannot communicate, nursing staff will be assigned to sign off on cares received.

Based on observations, interviews, and record reviews, the governing body failed to implement policies and procedures related to the management and operation of the facility by cutting staffing and failing to ensure there were adequate numbers of direct care staff to meet the needs of 51 of 51 resident as outlined in the Facility Assessment. In addition, it was found that payments to multiple vendors were in arrears, some being sent to collection agencies. In one instance, CEO-FF (Cheif Executive Officer) directed facility staff to issue a check for a past due utilities bill from the resident funds account. This account contains resident money and is not to be used for any other purposes than resident use. This places the facility at risk of not having supplies to maintain operations for 51 of 51 residents. The governing body's failure to ensure adequate staffing and financial accountability created a finding of immediate jeopardy that began on 6/25/21. ANHA-A (Acting Nursing Home Administrator), ADON-B (Acting Director of Nursing), and COO-GG (Chief Operating Officer) were notified of the immediate jeopardy on 6/30/21 at 12:20 p.m The immediate jeopardy was removed on 6/29/21, however the deficient practice continues at a scope/severity of an F (potential for more than minimal harm/widespread). This is evidenced by: STAFFING On 6/14/21, following a recertification survey, the state survey agency notified the facility that there was insufficient staff to meet the needs of the residents. Facility administration communicated the deficiency to the Corporate staff and informed them she would not accept new residents. Corporate staff responded by informing FNHA (former Nursing Home Administrator) that her pay would be cut $1000 a month and directing her to begin furloughing staff. In an interview with FNHA (former Nursing Home Administrator) on 7/1/21 at 8:08 a.m., FNHA stated that she was directed to [NAME] four staff. These staff included the Medical Coder/Purchaser, the Activities Director, a Laundry Assistant, and an Activities Assistant. FNHA stated that she asked the CEO and COO to allow her to move the Medical Coder/Purchaser into a vacancy in laundry, and then have the Activities Assistant in laundry 3 days and activities 2 days. When she did not get a reply, she indicated she had to [NAME] those staff. FNHA-DD stated in light of the furloughs and the staffing shortage that was not addressed by the coporation, she and the DON resigned from their positions effective immediately on 6/27/21, leaving the facility without two key administrative staff. From 6/25/21 through 6/28/21, the facility only provided 40% to 70% of the staffing hours identified in their facility assessment as the amount needed to meet the needs of the residents. On 6/28/21, at 11:30 a.m. Surveyors entered the building and were told the census was 51. Surveyors toured the building to determine the nurse and CNA (Certified Nursing Assistant) staffing levels. There was 1 Medication Technician/Graduate Nurse, and 1 CNA. Therapy staff were observed to be assisting with some resident cares. Surveyors requested the Daily Assignment Sheets and schedules beginning on 6/25/21. Both documents reveal the following: A review of the facility assessment, dated 2017 indicates that the number of licensed nurses and CNAs needed to ensure there is sufficient staff to meet resident needs is 160 hours to 216 hours per day. A review of the actual hours worked, provided by he Human Resources Coordinator, revealed the following: 6/14/21: 110 hours worked that day by direct care staff (licensed nurses and CNAs). 50 hours below the minimum number of hours the facility determined was necessary. 6/15/21: 124 hours worked that day by direct care staff. 36 hours below the minimum number of hours the facility determined was necessary. 6/16/21: 90.25 hours worked that day by direct care staff. 69.75 hours below the minimum number of hours the facility determined was necessary. 6/17/21: 110.25 hours worked that day by direct care staff. 49.75 hours below the minimum number of hours the facility determined was necessary. 6/18/21: 111 hours worked that day by direct care staff. 49 hours below the minimum number of hours the facility determined was necessary. 6/19/21: 87.5 hours worked that day by direct care staff 72.5 hours below the minimum number of hours the facility determined was necessary. 6/20/21: 91.75 hours worked that day by direct care staff. 68.25 hours below the minimum number of hours the facility determined was necessary. 6/21/21: 82.25 hours worked that day by direct care staff. 77.75 hours below the minimum number of hours the facility determined was necessary. 6/22/21: 125 hours worked that day by direct care staff. 35 hours below the minimum number of hours the facility determined was necessary. 6/23/21: 94.5 hours worked that day by direct care staff. 65.5 hours below the minimum number of hours the facility determined was necessary. 6/24/21: 115 hours worked that day by direct care staff. 45 hours below the minimum number of hours the facility determined was necessary. 6/25/21: 88.98 hours worked that day by direct care staff (licensed nurses and CNAs) This included 8 hours worked by a light duty CNA who is unable to perform all CNA duties. This is more than 71 hours below the minimum number of hours the facility determined was necessary to meet resident needs. On 6/29/21, Surveyor interviewed CNA-Y who is on light duty. She indicated she is a CNA, but due to restrictions, she is not able to perform all CNA duties. 6/26/21: 112.11 hours worked that day by direct care staff. This is more than 47 hours below the minimum number of hours the facility determined was necessary to meet resident needs. *From 6:00 a.m. until 2:00 p.m., there were only 2 CNAs to care for 50 residents as the nurses had their own work to complete. *From 2:00 p.m. to 6:00 p.m. there was only 1 CNA to care for 50 residents. 6/27/21: 100.89 hours worked that day by direct care staff. This included 4 hours worked by a light duty CNA who is unable to perform all CNA duties. This is more than 59 hours below the minimum number of hours the facility determined was necessary to meet resident needs. 6/28/21: 64 hours worked that day by direct care staff. There were no licensed nurses working on the day shift, only a Graduate Nurse. Therapy staff were observed to assist, however, are not CNAs and not able to perform all duties of a CNA. This is 96 hours below the minimum number of hours the facility determined was necessary to meet resident needs. Because there were inadequate staff, particularly over the weekend of 6/25 to 6/27/21, residents were left in their rooms, left in bed with no way of getting up independently, and did not receive needed cares such as personal hygiene cares, toileting assistance, and/or repositioning. Staff had to choose which residents received care while others went without. As a result, there were resident falls, worsening of pressure injuries, and the development of pressure injuries, and medication errors. Cross reference the other federal citations issued during this survey for details concerning unmet resident needs, including F725 (staffing, cited at immediate jeopardy), F600 (neglect, cited at immediate jeopardy), F675 (quality of life, cited at immediate jeopardy), F677 (services to maintain good nutrition and grooming), F684 (quality of care, cited at the level of harm), F686 (prevention of pressure injuries), F688 (maintain ability to perform activities of daily living, cited at the level of harm), F689 (superision to prevent accidents), F690 (maintain continence, cited at the level of harm), F757 (pharmacy services), and F760 (free of significant medication errors). FINANCIAL During the course of the survey (6/28/21 through 7/14/21) Surveyors reviewed financial information from the facility and noted the following past due bills 1. Windsor Capital Management. On 5/12/21, Windsor Capital Management requested a payment update as the account was 4 months past due for a total of $3,253.12. On 5/21/21, Accounts Payable issued a check for $1,091.52 leaving an unpaid balance of $2,161.60. As of 6/28/21, Windsor Capital Management acknowledged receipt of the payment, but indicated in an email that the account is still 4 months past due and requested a payment timeline as well as an explanation as to why the account was so far in arrears. On 6/29/21, Surveyor spoke with a Windsor Capital Representative who confirmed the facility is in arrears, but could not confirm the amount. 2. eSolutions. Invoice dated 3/1/21 in the amount of $250.00. On 6/29/21, eSolutions Collections notified the facility that the account is, seriously overdue and requires immediate attention. 3. SimpleLTC. An email dated 6/23/21 indicated an invoice dated 5/8/21 was overdue. The Accounts Payable manager directed staff to select payment for 7/2/21. 4. EcoLab (cleaning supplies) . Final Past Due Notice dated 6/22/21 states, Your account remains seriously delinquent and on credit hold due to lack of response . The past due balance is $4,849.06. The longest unpaid invoice shows 489 days in arrears. On 6/29/21, Surveyor spoke with an EcoLab Representative via telephone and was told that the current balance was $5,314.23 and that all orders have been put on hold until the bill is paid in full. 5. Dalco Enterprises (janitorial supplies). Statement dated 6/1/21 showing a past due balance of $5,543.01. On 6/29/21, Surveyor spoke with a Dalco Representative who indicated they had received a partial payment, but the facility still had 3 open invoices and was still $971.21 in arrears. 6. [NAME] Healthcare. Statement date 6/16/21 showing a past due amount of $449.44 that was due on 4/2/21. This was communicated with the Accounts Payable Director who scheduled payment for 7/2/21. On 6/29/21, Surveyor spoke with a [NAME] Healthcare Representative who confirmed the facility has settled their account. 7. Frontier Communications (telephone and internet provider). Statement showing $979.06 past due with a final due date of 5/28/21. On 6/29/21, Surveyor contacted Frontier Communications automated account line. A payment of $1,964.26 was received on 5/28/21 with $963.10 due on 7/12/21. 8. Lakeland Sanitary District. Invoice for sewer and water marked past due in the amount of $2,398.55. Payment due 5/31/21. A second statement for private fire, also marked past due in the amount of $111.00. 9. United Laboratories. Statement dated 6/1/21 has a past due balance of $974.85. A note on the statement reads, Please remit immediately to avoid collection proceedings. On 6/29/21, [NAME] Credit Services (collection agency) notified the facility that the United Labs account had been transferred to them for collections. The Business Office Manager contacted CEO-FF and COO-GG of this. In response, CEO-FF indicated when things get referred to a collection agency, the go to the bottom of the list of importance. 10. [NAME] Foods (food vendor). A number of statements of past due amounts were received. The most current, dated 6/24/21 indicates an amount due or $11,785.76. On 6/21/21, [NAME] Foods Area Manager notified the facility tht their orders are on Stop Ship until payment is made. This was communicated to the Accounts Payable Director of the Corporation. A payment was released and a food shipment was observed to be delivered on 6/29/21. On 7/1/21, Surveyor spoke with a [NAME] Foods Representative who indicated the facility is not in arrears. They are currently on a 30 day term with a 7 day grace period. At the time of the call, the facility was at 29 days. 11. [NAME] Bakeries (bread supplier). Statement dated 6/12/21 with a total amount due of $294.88. 12. Plunkett's Pest Control. Letter dated 5/20/21 indicates a past due balance of $300.00 13. [NAME] (foodservice eqipment maintenance). Undetermined amount due was communicated to Accounts Payable Director on 5/25/21. Payment was first scheduled for 7/2/21. 14. [NAME] Services Collections representing Regions Bank. Delinquent balance of $951.30. Regions Bank attempted to pull the monthly auto payment and found there is a corporate block preventing payments. 15. [NAME] Medical (medical/personal care supplies). Message sent on 5/24/21 indicating the facility is $42,454.54 in arrears. The last payment made was received on 4/23/21. The provided invoice includes dates as far back as December 2020. 16. Wisconsin Public Service (gas and electric utilities). Facility received a disconnection notice on 2/17/21 due to a past due amount of $4,707.51. A billing statement dated 6/15/21 indicated the facility had a past due balance of $5,293.7 and a current amount due of $6,325.71 for a total balance of $11,619.28. The facility received another disconnection notice dated 6/16/21 for the past due amount of $5,243.71 (total amount past due minus the late fee). The Accounts Payable Director indicated payment was made on 6/24/21. On 6/29/21, Surveyor contacted the automated account billing system. The facility made a payment of $5243.71 on 6/24/21 (amount identified on the disconnection notice). Current amount due of $6,375.57. On 6/16/21, the facility received a disconnection notice from Wisconsin Public Service (provider of gas and electric). The amount past due was $5,243.71. Surveyor was provided with an email string between the facility and the governing body. The emails contained the following information: On 6/21/21, facility accounts payable forwarded the disconnection notice to the APD HH of the corporation. On 6/22/21, facility accounts payable forwarded the same message to CEO-FF and COO-GG as there had been no response from APD HH. On that same date, CEO-FF directed the facility accounts payable to issue a check from petty cash with the assistance of the BOM (Business Office Manager). The BOM replied that the facility is only able to issue checks from the RFMS (resident funds) account. Corporate II stated the BOM was correct, they are only to be used for resident trust accounts. We are using this as an emergency resort. CEO FF and COO GG were both included on Corporate II's response and did not disagree with the approval to use the resident trust account to pay an over due bill. OTHER Surveyor received a copy of the contract between the facility and the RD (Registered Dietitian). The contract was signed by the RD on 2/9/21 and FNHA DD (Former Nursing Home Administrator) on 2/10/21. Section 4 of the contract indicates it was to commence on 2/8/21. During the recertification survey, completed on 6/14/21, surveyors reviewed this contract as part of an investigation related to lack of RD response. At the time the surveyor reviewed the contract, only the FNHA had signed; the RD had yet to sign and return it to the facility. In email correspondences regarding the unsigned contract between CEO FF, RD and FNHA DD, the CEO stated, Since it hasn't been signed yet, is there any reason not to date it for January? Surveyor received and reviewed a copy of the signed contract on file at the facility. Section 4 of this contract has a commencement date of 1/1/21. During an interview with FNHA DD on 6/25/21, FNHA DD indicated that she identified the date change when the signed contract was returned to her. FNHA DD indicated that she did not agree to the date change and was not told it was going to occur. Failure to ensure the governing body implemented policies and procedures related to the management and operation of the facility contributed to multiple care issues identified during this survey (and created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 6/29/21 when they implemented the following: 1. Governing Body met with the Chief Compliance Officer to expand the scope of the policy to include the entire chain of command. The policy will be posted in a conspicuous area and all staff will be educated on who they are to communicate with. 2. The lead staff will be responsible for notifying the governing body of any deficient staffing issues. 3. The governing body established a revolving line of credit. 4. Establish monitoring of all accounts payable on a monthly basis. 5. DON and NHA to monitor staffing sheets to assure appropriate staffing levels and notify the chain of command if minimums are not met.

Based on observations, interviews, and record reviews, the facility did not provide sufficient staffing to meet the needs of 51 of 51 residents living in the facility. On 6/14/21, following a recertification survey, the state survey agency notified the facility that there was insufficient staff to meet the needs of the residents. Facility administration communicated the deficiency to the governing body. The governing body did not take adequate action to ensure there was enough staff to care for residents. On 6/25/21 through 6/28/21, the facility only provided 70% to 40% of the staffing hours identified in their facility assessment as the amount needed to meet the needs of the residents. Because there were inadequate staff, residents were left in their rooms, left in bed with no way of getting up independently, and did not receive needed cares such as personal hygiene cares, toileting assistance, and/or repositioning. Staff had to choose which residents received care while others went without. As a result, there were resident falls, worsening of pressure injuries, and the development of pressure injuries, and medication errors. The failure to provide adequate staffing created a finding of immediate jeopardy that began on 6/25/21. The Acting NHA (nursing home administrator), Acting DON (Director of Nurses), and Chief Operating Officer were notified of the immediate jeopardy on 6/30/21 at 12:20 p.m The immediate jeopardy was removed on 6/30/21, however the deficient practice continues at a scope/severity of an F (potential for more than minimal harm/widespread). This is evidenced by: On 6/28/21, at 11:30 a.m. Surveyors entered the building and were told the census was 51. Surveyors toured the building to determine the nurse and CNA (Certified Nursing Assistant) staffing levels. There was 1 Medication Technician/Graduate Nurse, and 1 CNA. Therapy staff were observed to be assisting with some resident cares. Surveyors requested the Daily Assignment Sheets and schedules beginning on 6/25/21. Both documents reveal the following: A review of the facility assessment, dated 2017. indicates that the number of licensed nurses and CNAs needed to ensure there is sufficient staff to meet resident needs is 160 hours to 216 hours per day. A review of the actual hours worked revealed the following: 6/25/21: 88.98 hours worked that day by direct care staff (licensed nurses and CNAs) This included 8 hours worked by a light duty CNA who is unable to perform all CNA duties. On 6/28/21, Surveyor interviewed CNA-Y who is on light duty. She indicated she is a CNA, but due to restrictions, she is not able to perform all CNA duties. This is more than 71 hours below the minimum number of hours the facility determined was necessary to meet resident needs. 6/26/21: 112.11 hours worked that day by direct care staff. *From 6:00 a.m. until 2:00 p.m., there were only 2 CNAs to care for 50 residents as the nurses had their own work to complete. *From 2:00 p.m. to 6:00 p.m. there was only 1 CNA to care for 50 residents. This is more than 47 hours below the minimum number of hours the facility determined was necessary to meet resident needs. 6/27/21: 100.89 hours worked that day by direct care staff. This included 4 hours worked by a light duty CNA who is unable to perform all CNA duties. This is more than 59 hours below the minimum number of hours the facility determined was necessary to meet resident needs. 6/28/21: 64 hours worked that day by direct care staff. There were no licensed nurses working on the day shift, only a Graduate Nurse. Therapy staff were observed to assist, however, are not CNAs and not able to perform all duties of a CNA. This is 96 hours below the minimum number of hours the facility determined was necessary to meet resident needs. On 6/28/21 at 1:36 p.m., Surveyor spoke with the Admissions Coordinator (AC)-C. AC-C confirmed that there was no licensed nurse in the building on 6/28/21, only a graduate nurse. Surveyor asked if medications were passed. AC-C indicated a Nurse Practitioner (NP) was completing regular resident rounds and medications were passed while she was in the building. AC-C stated the NP had to leave at 10:40 a.m. so med pass stopped at that time. AC stated that a licensed nurse was coming on soon to assist. When asked if anyone from the corporation had been notified, AC-C indicated that the RNC (Regional Nurse Consultant) had been notified of the staffing situation on 6/27/21. AC-C indicated the response from the RNC was, what do you want me to do about it. The facility failed to provide sufficient staff to provide ADL (Activities of Daily Living) to R1, R4, R23, R2, R3, R8, R11, R12, R13, R14, R34, R9 and R10. ADL care not provided includes, but is not limited to personal hygiene, repositioning, toileting, incontinence cares, and ambulation. (Refer to F677.) The facility failed to provide sufficient staff to provide care and treatment to heal existing pressure injuries and to prevent the development and/or redevelopment of pressure injuries. ~R9 was observed to not be repositioned for over 4 hours. Previously healed areas were found to have redeveloped after the observations of lack of repositioning. ~R1 has an open area to the right inner elbow. Treatment was not completed over the weekend. Observation by the wound nurse and the surveyor found it had doubled in size. R1 was observed to not be repositioned and did not have his heals floated for over 3 hours. ~R10 was observed to have heels resting directly on the mattress. The heels were observed to be dark pink. ~R2 is high risk for development of Pressure Injuries (PI) and/or impaired skin integrity. R2 is to be repositioned every 2 hours, use of heelz up device, and wedge pillow/pillows to offload. R2 is incontinent and requires checking and changing every 2 hours and PRN. An observation was made on 06/30/21, in which this was not completed by staff for a time period of 3 hours and 31 minutes. ~R7 has a pressure injury to right heel. R7 is to have pressure relieving device: PRAFO to right foot: heelz up device, egg crate mattress, ROHO, and heels to be floated on pillow when up in wheelchair, repositioning every 2 hours and PRN. Pressure injuries worsened. R7 observed in bed with no offloading of heels. (Refer to F686.) The facility failed to provide sufficient staff to ensure residents were provided care to maintain or improve range of motion. ~R27 needs extensive assist of 1 with transfers and ambulation. R27 has not received the scheduled ambulation and restorative services resulting in decreased ability to ambulate and decreased range of motion in R27's knee joints. ~R3 needs extensive assist of one for ambulation and restorative dressing and grooming care. R3 has not received these services as instructed. ~R11 needs extensive assist of on person for the restorative walking program and restorative dressing and grooming. R11 has not received these services. ~R6 needs extensive assistance of one for ambulation. R6 did not receive her restorative ambulation program or restorative dressing and grooming services. ~R29 needs extensive assistance of one person for ambulation. R29 did not receive the restorative ambulation services or restorable dressing and grooming services as scheduled. ~R30 needs extensive assistance of one for ambulation and personal hygiene. R30 did not receive restorative dressing/grooming program or the restorative walking program services as scheduled. (Refer to F688.) The facility failed to provide sufficient staff to provide supervision to timley respond to call lights and to prevent accidents/falls for R7, R2, R3, and R4. R7, R2, and R4 tranfered themselves in order to use the bathroom when no staff responded to their call lights. R3 was left unsupervised in the bathroom and fell off the toilet. (Refer to F689.) The facility failed to provide sufficient staff to maintain 4 residents' bladder and/or bowel continence because staff couldn't respond timely to requests for assistance with toileting. R6, R12, R15, and R1 all had declines in their bowel and/or bladder continence with no evidence the declines were unavoidable. In addition, there were no actions taken to improve the diminished status. (Refer to F690.) On 6/28/21, the facility failed to have adequate staffing to ensure authorized personnel were administering medications consistent with state requirements. A medication aide, which requires supervision from a licensed nurse, was administering medications without having a licensed nurse in the building. There was no charge nurse on duty or any other facility employed nurse in the building at the time of the medication administration. The medication aide did not meet the state requirements of being a charge nurse under her temporary Registered Nurse (RN) license on 06/28/21 and was working in the capacity of a medication aide on that date. (Refer to F755.) On 6/28/21, 6 residents, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] ~R31 is prescribed [MEDICATION(S)] 100 UNIT/ML Vial, 17 units subcutaneously with meals. Scheduled 11:30a.m R31 received 17 units on 06/28/2021 at 1:56p.m ~R5 is prescribed NovoLOG [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML, inject as per sliding scale subcutaneously with meals. On 06/28/21 R5 received 2 units at 1:59p.m ~R27 is prescribed [MEDICATION(S)] Solution 100 UNIT/ML. Inject 16 units subcutaneously with meals. R27 received 16 units on 06/28/21 at 1:58p.m ~R32 is prescribed Insulin [MEDICATION(S)] Solution, sliding scale, subcutaneously before meals and at bedtime. Scheduled 11:00a.m. On 06/28/21 R32 received 4 units at 2:13 p.m ~R33 is prescribed [MEDICATION(S)] KwikPen Solution Pen-injector 100 UNIT/ML, sliding scale, scheduled 11:00a.m On 06/28/21 R33 did not receive any units at 2:24p.m ~R34 is prescribed [MEDICATION(S)] R Solution 100 UNIT.ML, sliding scale, scheduled 11:00 a.m. On 06/28/21 R34 received 4 units at 2:45 p.m. (Refer to F760.) On 6/29/21 at 5:20 a.m., Surveyor interviewed RN-Z. RN-Z stated she had just been hired on 6/28/21. Surveyor asked if she had received any orientation prior to beginning her shift, such as emergency policies and procedures. RN-Z indicated she had not. On 6/29/21 at 5:25 a.m., Surveyor interviewed RN-X. Surveyor asked RN-X what a typical staffing pattern is for the facility. RN stated most often, it is 2 licensed nurses and 1 CNA. RN-X stated on those days, residents may receive the minimum care, as long as nothing unforeseen happens. On 6/29/21 at 9:30 a.m., Surveyor interviewed CNA-I. CNA-I stated that all residents stay in their rooms over the weekend because there aren't enough staff to get everyone up or to assist them to bed in the evening. CNA-I stated that today (6/29/21) was the first time she had ever seen therapy assist with residents. CNA-I stated that when she came in this morning, she found R25 had taken off his incontinent pad because it was saturated with urine, had a full urinal, and had urinated in cups that were in his room. CNA-I was visibly shaken and stated she knows no one checked on him through the night. CNA-I stated without enough staff, residents are not being repositioned or toileted like they should. CNA-I also stated that showers are not being given because they do not have the time to do them. CNA-I stated that this past weekend, there were a number of falls, 1 of which resulted in the resident going to the hospital. On 6/29/21 at 10:00 a.m., Surveyor interviewed R5. R5 stated that her concern is there is not enough staff in the building. R5 stated that often there is only 1 nurse and 1 CNA in the entire building. R5 stated, How are they supposed to do that? R5 stated this past weekend all of the meals were served in resident rooms. When asked why, R5 stated because there was not enough staff to get everyone up. R5 stated that she can transfer herself to the toilet when she needs to, cannot get off the toilet alone as she needs assistance to pull up her pants afterwards. R5 stated that more than once this weekend, she had to wait for over 45 minutes to get off the toilet. Surveyor asked about the call light timer that is at the nurses station. R5 stated that staff will come in to answer the light, turn it off and then turn it back on. This way they timer won't show the actual time the resident waited. Surveyor asked if this has happened to her. R5 stated it has. R5 also stated that she had a concerns with her medications on 6/28/21. She said she counts her pills to make sure she is getting all of them. She stated that she did not have enough pills in her cup and had to tell the nurse to go look for the rest of them. R5 stated that she is the Resident Council President so she hears concerns from several other residents. R5 stated, It is getting to the point where I am scared to be here. On 6/29/21 at 10:20 a.m., Surveyor interviewed R4. R4 stated there is not enough staff in the building. He stated the ones that are working are working very hard to try to care for everyone, there just aren't enough people. R4 stated that over the weekend, everyone had to stay in their rooms for meals. R4 stated he normally goes to the dining room for meals. R4 stated that those meals that were served in the room were cold. R4 stated his daughter brought in food for him so he could have a decent meal. He stated that his bed had not been made for quite some time (R4's bed was observed to be unmade during the interview). R4 stated that this bothered him as his bed was made daily. R4 stated I am a type A personality, and that he wants things neat. Surveyor asked R4 if he received the cares and assistance he needs. R4 state he is not. Surveyor asked for examples. R4 stated he is supposed to walk with staff assistance every day and this has not been happening. Review of R4's medical record found this to be accurate. Since 6/14/21 (exit date of the last survey) R4 was ambulated in his room and the hall only 2 times, once on 6/28/21 and again on 6/29/21. All other dates are marked as activity did not occur. R4 stated that he used to use the bathroom independently, but had an occasion where his knees buckled and staff wanted him to wait for assistance. R4 stated last Thursday (6/24/21) he was following the recommendations and waiting for assistance. He was incontinent 5 times because staff did not respond to his call light. He stated it was embarrassing and he is no longer waiting for staff and is taking himself to the bathroom. On 6/30/21 at 1:50 p.m., Surveyor spoke with CNA-AA. CNA-AA stated that she is the last full time CNA for the evening shift. CNA-AA stated she had worked this past weekend on the evening shift and that she was the only CNA working. CNA-AA stated that nearly all residents had to stay in bed as there weren't enough staff to get them up or to put them back to bed later. CNA-AA stated that only the ones that absolutely had to get up for safety reasons were gotten up. Those residents were then brought to the nurses station so staff could somewhat observe them. Surveyor asked CNA-AA how she was able to care for the residents if she was the only CNA in the building. CNA-AA stated she couldn't. Surveyor asked what cares she could provide. CNA-AA stated she fed residents who needed assistance, and provided toileting, incontinence care, and reposition to as many people as she could. Surveyor asked CNA-AA if she was able to provide those care at appropriate intervals. CNA-AA stated, she didn't even get to everyone once a shift let alone every two hours. The lucky ones received cares once during the shift. CNA-AA stated she feels like she is breaking down physically and mentally with the stress of being the only caregiver. Surveyor asked if the nurses or therapy provide any assistance. CNA-AA stated the nurses are just as busy as the CNAs are trying to care for resident with only 1 or 2 of them. CNA-AA indicated therapy will help if you specifically ask them to help. On 06/28/21 at 11:30 a.m., Surveyor entered the building and noted there was no one in the Director of Nursing office, Nursing Home Administrator office, Minimum Data Set (MDS) office or the reception/business offices. Admissions Coordinator (AC) C greeted the surveyors. AC C informed Surveyor that the NHA and DON walked out on Friday. Several nurses have called in and do not plan to come back due to the staffing situation and working conditions. AC C stated she was here all weekend and most residents did not get out of bed. There was not enough staff to help the residents. All residents stayed in their rooms and were served their meals. On 06/28/21 at 12:05 p.m., Surveyor interviewed R18 to ask how things were going with her cares. R18 stated, I am very disappointed with what is going on here, firing staff when we have no help. We wait for over an hour for help and they fired staff. On 06/28/21 at 12:10 p.m., Surveyor interviewed R5 asking how staffing has been. R5 stated, It is terrible there are no workers here. We have 1 aide and 1 nurse on duty for days. I have to wait at least 45 minutes for any help. On the weekend there was no help to get me out of bed. I ended up dressing myself and after waiting for hours I got some help because I can tell them I need it. I feel so bad for those who can't ask for help. On 06/28/21 at 12:15 p.m., Surveyor interviewed R6 about staffing and getting help with cares. R6 stated she has been waiting about 1 1/2 hours for help with toileting. Surveyor asked what has happened to R6 as a result of waiting so long. R6 said she has pooped and peed her pants and has to sit in it until they get there. Surveyor asked if this is bothering R6 feeling humiliated. R6 stated, I feel bad but not that upset. I'm getting used to it. On 06/28/21 at 12:17 p.m., Surveyor interviewed R13 about staffing. R13 stated she has to wait at least 45 minutes for help to get to the bathroom and was left on the toilet over 45 minutes on the weekend before she was helped. On 06/28/21 at 12:20 p.m., Surveyor interviewed R23. R23 stated, I wait at least 45 minutes for anyone to answer my call light. They have no time to walk me, there is no staff. Please get us help! On 06/28/21 at 12:50 p.m., Surveyor interviewed CNA G about staffing. CNA G stated on the weekend there was only 1 CNA working. Residents could not be repositioned or toileted. Today they have the Physical Therapy Assistant (PTA) M, Speech Therapy (ST) P, Occupational Therapist (OT) Q helping with cares. On 06/28/21 at 1:00 p.m., Surveyor interviewed R4 about cares and staffing. R4 stated he was so happy to be in this facility near his family but things have gotten so bad. R4 went on to describe the events of the past weekend. R4 indicated there was only 1 nurse and 1 CNA to care for over 50 people. R4 stated he observed several residents did not get out of bed for 2 days. R4 indicated he is to have assistance to walk to the bathroom but no one comes to help. R4 stated on the weekend he waited for one hour after the call light was put on, so I just took myself to the bathroom. R4 stated he has continued to transfer, dress himself and ambulate without assistance so that he can get to the bathroom and get dressed. R4 indicated he is to be getting therapy but as of today therapy is canceled because all of the therapy workers have to work on the floor. R4 stated, I don't want to fall again, my knee gives out at times and down I go. No one will help me. On 06/28/21 at 1:05 p.m., Surveyor interviewed R1 asking about staffing and getting assistance with cares. R1 stated, I stay in bed a lot. I need help with my incontinence care. I put my light on they come in turn it off and leave. Surveyor asked when was the last time R1 had been assisted with cares. R1 stated, About 8:00 a.m. or so, I have laid on my back like this since then, it has been really bad the last few days. Surveyor asked R1 to put on her call light to get help. After about 5 minutes, Speech Therapy came and answered the call light, turned it off and said she would get a CNA to help R1. Surveyor continued to observe for staff to come back and assist R1. Surveyor continued to observe for staff to come back and assist R1. At 1:37 p.m. Surveyor observed CNA enter the room to assist R1. On 06/29/21 at 9:25 a.m., R1 was observed in bed with her breakfast tray on the side table. R1 was in a green colored gown that appeared to be her pajamas. Surveyor asked R1 if she was done with breakfast and if she was ready to get up for the day. R1 stated, What's the use, there isn't anyone to come and help me anyway. Surveyor asked R1 how she asks for help and R1 said she uses her call light but no one comes. Surveyor asked R1 if she had been helped yet this mornng with any cares and R1 said she had not. She said, They tilted my bed up so I could eat my breakfast, that is it. R1 stated she was still in her pajamas and had not been changed before breakfast. R1 stated she does have a catheter, but doesn't know why. Surveyor asked R1 if she would like someone to come in and help her and R1 stated, If I want to get help I ring, if they have anyone here to help. The other day there was only one person in the whole place. They come in and then they say they will be back and they leave and I don't get any help. R1 stated on the weekends there is never anyone around and she doesn't hear anyone out in the hallway. R1 said if you put your light on no one comes. When Surveyor asked R1 how that made her feel, R1 stated, Neglected. Surveyor asked R1 if she was afraid she wouldn't get any help and R1 stated she felt neglected, I am not getting the care I should be. At 9:45 a.m., CNA F came into the room, lowered R1's bed and straightened R1's upper body, raised the upper half of the bed, and then left the room. CNA did not offer or ask R1 if she wanted to wash up, brush her teeth, get dressed or if she needed continence cares. On 06/28/21 at 1:30 p.m., Surveyor interviewed Medication Technician (MT) H. MT H stated she worked from 6 a.m. - 10 a.m. on the weekend as a CNA. MT H indicated they got up a few residents that had to get up, but there was not enough staff to get all residents out of bed. Surveyor asked which residents did not get out of bed. MT H was not sure of all the residents but named R26, R10, R28 and R8. On 06/28/21 at 1:40 p.m., Surveyor interviewed PTA M. PTA M stated he came to work this morning and was informed at the morning meeting about the staffing situation. He called his supervisor and was told to help on the floor with transfers. PTA M stated, It is impossible for 1 CNA to keep up and help the residents. PTA M stated that all therapy services were canceled for Monday and Tuesday as all the therapy staff are working on the floor. PTA M stated his last day of work here is Thursday. On 06/30/21 at 8:14 AM, Surveyor interviewed R2. Surveyor asked R2 about staffing and getting assistance with cares. R2 stated, The staff that are here are caring, but there is not enough. We spend a lot of time waiting. Surveyor noticed water pitcher on bedside table and asked if R2 had received any fresh water. R2 stated, No, not yet. Hopefully they will come. On 06/30/21 at 9:25 AM, Surveyor interviewed R7. Surveyor asked about staffing and getting assistance with cares. R7 lifted his call light and stated, See this. This is for emergencies. When you need help. The other day I put this on and waited an hour and a half for someone to answer it. I had to go to the bathroom. Another time, I waited 2 and a half hours for my light to be answered. It wasn't for the bathroom; but still---it isn't right. Failure to ensure the facility had sufficient numbers of staff to meet the care needs of residents and to promote their highest practicable level of physical, social, and psychosocial well-being created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 7/1/21 when the following were implemented: 1. The facility signed contracts with staffing agencies. 2. Plan to implement Emergency CNA Training Program. 3. Implemented twice weekly town hall meetings with staff to review schedules, get feedback, and provide updates. 4. Incentive program expanded to include sign on, retention, and shift pick up bonuses. 5. All staff, not only nursing staff, are to interact/check in with residents and respond to resident needs as appropriate. 6. Daily staffing to be reviewed and signed off by 2 management team members as being adequate using 2.75 hours per patient day as a threshold. 7. Implemented a Manager of Duty during the weekends. 8. Management will interview residents with a BIMS (Brief Interview for Mental Status) of 8 or above to ensure they are receiving appropriate care and to follow up on any concerns. 9. For residents with a BIMS of 8 or lower, or who cannot communicate, nursing staff will be assigned to sign off on cares received. 10. All staff will be educated on neglect prior to the beginning of their next shift.

Based on observations, interviews and record reviews, the facility failed to ensure 2 of 2 residents reviewed for skin ulceration (R9 and R1) received treatment and care per professional standards of practice to prevent reoccurrence and worsening skin ulcerations. R9 had a denuded area to the right inner elbow as a result of skin to skin contact. The facility failed to complete weekly wound assessments or measurements regarding the wound, resulting in the wound increasing in size and becoming wet, red and weepy. The facility failed to provide necessary interventions, monitoring, and care, for a resident who was identified to be at risk due to the presence of contractures. Care plan interventions were not followed resulting in the wound becoming larger, increasing the potential for infection. R1 has macerated area to her left lower back that was documented by the wound nurse as being healed on 6/22/21. On 06/30/21 a new area was noted on R1's right lower back and the left lower back maceration was reoccurring. The facility failed to identify, evaluate, and respond to a change in a resident's skin integrity of the lower back maceration or follow care plan interventions to ensure repositioning to prevent reoccurrence or new areas developing. This is evidenced by: 1. R9 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's most recently completed Minimum Data Set Assessment (MDSA) was a Quarterly assessment dated [DATE]. According to this assessment, R9 requires extensive assistance of one staff to meet his most basic daily tasks of bed mobility, transfers, personal hygiene, dressing and toilet use. He is non-ambulatory and has limited range of motion to his right side upper and lower extremities as a result of a stroke. Surveyor reviewed wound records (Wound Tracking, Interdisciplinary Progress Notes and Skin Only Assessments) from 12/1/20 to present completed for R9 in order to determine onset and progression or healing of wounds and noted the following: Right Elbow crease (Antecubital space) denudation was noted on 3/21/21. The area was measured as being 4.0 cm length x 3.0 cm width. It was described as moisture-associated skin damage (MASD) related to the right arm contracture and was reoccurring. On this date, the entry indicates Area is improving and more pink now. This was first entry located regarding this wound. It is unknown what its appearance was prior to this or when it first appeared, as that documentation was not located. Note: MASD is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture. Intertriginous [CONDITION(S)] (ITD) results from sweat being trapped in skin folds with minimal air circulation. When the sweat is not able to evaporate, the skin becomes overly hydrated and macerated, facilitating friction damage that is often mirrored on both sides of the fold. This in turn leads to inflammation and denudation of the skin, making the area more prone to infection. Wound documentation is as follows: -3/21/21 4.0cm length x 3.0 width. Area improving and more pink now. -3/28/21 no weekly entries located. -4/4/21 no weekly entries located. Documentation entries for 4/11/21 mirrored the 03/21/21 documentation -4/18/21 no weekly entries located. Documentation entries for 4/25/21 mirrored the 03/21/21 documentation -4/27/21 the area was documented as being 3.0 cm length x 7.0 cm width and was documented as being caused by skin-to-skin contact. A soft cloth was placed to keep the area dry and to prevent intertriginous contact. - 5/4/21 no weekly entries located. - 5/9/21 mirrored the 03/21/21 documentation - 5/11/21 no weekly entries located. - 5/18/21 no weekly entries located. - For 5/23/21, mirrored the 03/21/21 documentation - 5/25/21 no weekly entries located. - 6/1/21 no weekly entries located. - 6/6/21 mirrored the 03/21/21 documentation - 6/8/21 no weekly entries located - 6/15/21 no weekly entries located. - 6/20/21 mirrored the 03/21/21 documentation - 6/22/21 no weekly entries located. On 06/30/21 at 8:30 AM Surveyor observed R9 in his room. R9 did not have a soft cloth in his right elbow crease. Two staff entered R9's to provide cares. - 9:21 AM, CNA-I entered R9's room to remove the meal tray. There were no offers to place a cloth in the right elbow space. - 9:49 AM SW-D entered R9's room and placed a fresh pitcher of ice water on his table. There were no offers or attempts to place a cloth in R9's inner right elbow. He remained on his back with the head of bed up at 90 degrees. R9's right elbow remained flexed with skin-to-skin contact occurring with the wound. - 10:16 AM, Medication Technician (MT) - H entered R9's room to inform him that she was preparing his medications. She returned to his room at 10:19 M to administer medications. There was no repositioning, or a cloth placed to the right inner elbow at this time. On 06/30/21, 11:54 AM the Surveyor approached RN-J, who is also the facility wound nurse, to ask about R9's elbow wound. RN-J stated, He is supposed to have a cloth in that space to prevent the skin to skin contact. In examining R9's arms, it was noted severe contracture at the elbow of his right arm. RN J attempted to open R9's right elbow. Upon opening the area slightly, a wet and weepy area was noted in the crevice. RN-X stated, It comes and goes, but this is the worst I have seen it. He is supposed to have a cloth in there to prevent the skin-to-skin contact. On 06/30/21 at 11:56 AM, RN-J measured the right inner elbow wound of R9. It was noted to be 5.5 cm length x 10.0 cm width, which is more than double the area compared to 04/27/21 when it was 3.0 x 7.0 cm.) It was wet, weepy and red. After examining the area, RN-X did not apply a cloth to the area. At 12:25 PM, the Surveyor interviewed CNA-I regarding care of R9. CNA-I stated as a result of a stroke, R9 is unable to use his right side, and his right arm was severely contracted. She stated R9 was to have a cloth in his right elbow to keep it dry or it will breakdown. There was no evidence that the right elbow area was assessed. There was no weekly wound documentation with measurements or documentation other than the 3/21/21 and 4/27/21 entries. Surveyor did not observe a soft cloth in the elbow area on 06/30/21. There was no evidence a soft cloth to keep the area dry and prevent skin to skin contact was used after being placed on 4/2721. RN X did not apply a soft dry cloth to the area after examining on 6/30/21 after stating there should be a cloth between the layers of skin to protect them. Skin to skin contact increases the progression of the wound from the accumulation of sweat and heat to the area. Lack of weekly assessments and measurements and lack of using a soft dry cloth to the area meant the wound continued to worsen. 2. R1 was admitted to the facility on [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set Assessment was an Annual assessment dated [DATE]. According to this assessment: - R1 requires extensive assistance of two staff to meet her most basic tasks of bed mobility, transfers and toileting. - R1 also requires extensive assistance of one staff for personal hygiene and dressing and is dependent on staff for bathing. She is non-ambulatory and uses an indwelling Foley catheter for her urinary function and is always incontinent of bowel function. - R1 has a BIMs (Brief Interview of Mental Status) score of 11/15, indicating a slight cognitive deficit. According to the Care Plan (CP) implemented for R1, dated 1/28/21 and last revised on 5/28/21, R1 had the following area of concern: 1. ADL: BASELINE CARE PLAN: Self-care deficit related to dementia, anxiety, reduced mobility. Interventions for this plan included: - Specialty mattress, ROHO cushion in wheelchair, Float heels - Repositioning: extensive assist of one staff, approximately every two hours and as needed, use a wedge cushion to keep resident on sides, and Heels up while in bed. Surveyor reviewed the wound documentation (Wound Tracking, Interdisciplinary Progress Notes and Skin Only Assessments) for R1 and the following was noted: - 1/24/21 R1 had Moisture Associated Skin Damage to the buttocks and coccyx regions. - 3/8/21 blisters appeared to R1's mid to lower back that measured 10.0 centimeters (cm) in length x 7.0 cm width. - 6/21/21, documentation stated skin normal pink in color no redness and no open areas. The most recent Braden assessment was dated 4/21/21 and scored R1 as 11. A score of 10-12 indicates a high risk for the development of a pressure injury (PI). On 06/28/21 at 1:05 p.m. Surveyor interviewed R1 asking about staffing and getting assistance with cares. R1 stated, I stay in bed a lot. I need help with my incontinence care. Surveyor asked if R1 uses the toilet. R1 stated, I want to use the bedpan for my bowel movements but they don't get here. I put my light on they come in turn it off and leave. Surveyor asked when the last time was R1 had been assisted with cares. R1 stated, About 8:00 a.m. or so, I have laid on my back like this since then, it has been really bad the last few days. Surveyor asked R1 to put on her call light to get help. After about 5 minutes Speech Therapy Pathologist P came and answered the call light, turned it off and said she would get a CNA to help R1. Surveyor continued to observe for staff to come back and assist R1. At 1:37 p.m. Surveyor observed CNA enter the room to assist R1. On 06/29/21 at 9:25 a.m., R1 was observed in bed with her breakfast tray on the side table. R1 was in a green colored gown that appeared to be her pajamas. R1 was on back with head of bed elevated about 90 degrees. There was no wedge cushion noted in the bed and R1's heels were not floated. Surveyor asked R1 if she was done with breakfast and if she was ready to get up for the day. R1 stated, What's the use, there isn't anyone to come and help me anyway. Surveyor asked R1 how she asks for help and R1 said she uses her call light but no one comes. Surveyor asked R1 if she had been helped yet this morning with any cares and R1 said she had not. She said, They tilted my bed up so I could eat my breakfast, that is it. R1 stated she was still in her pajamas and had not been changed since before breakfast. R1 stated she does have a catheter, but doesn't know why. Surveyor asked R1 if she would like someone to come in and help her and R1 stated, If I want to get help I ring, if they have anyone here to help. The other day there was only one person in the whole place. They come in and then they say they will be back and they leave and I don't get any help. R1 stated on the weekends there is never anyone around and she doesn't hear anyone out in the hallway. R1 said if you put your light on no one comes. When surveyor asked R1 how that made her feel, R1 stated, Neglected. Surveyor asked R1 if she was afraid she wouldn't get any help and R1 stated she felt neglected, I am not getting the care I should be. At 9:45 a.m., CNA F came into the room, lowered R1's bed and straightened R1's upper body, raised the upper half of the bed, and then left the room. On 6/30/21, the following observation was made by Surveyor: - 8:10 AM: R1 was positioned in bed on her back with the head of the bed elevated to 90 degrees. There was an over-the-bed table in front of her with her morning meal. Her legs were resting on a pillow or pad of a sort under the sheet. - 9:16 AM, C.N.A- I (Certified Nursing Assistant) entered R1's room and removed the meal tray from her table. There was no repositioning done at this time. The head of the bed remained at 90 degrees and the over-the-bed table remained in front of R1. - 12:15 PM: R1 remained as noted above with no staff entering her room to attempt or offer repositioning. At this time, the Surveyor approached RN- J (Registered Nurse), who is also the Wound Nurse, and informed her of the observation above. RN-J and the Surveyor entered R1's room for repositioning. Upon uncovering R1's legs it was noted that her heels were resting on top of the Heels-up device and not floating and her legs were edematous. The Surveyor then asked RN-J what the expectation is. RN-J stated Her heels should be floating to relieve pressure so that she doesn't develop a wound. She should be repositioned off of her back and side to side as she can tolerate because of the rash and her high risk for developing a PI. She used to have one on her bottom RN-J then rolled R1 onto her right side to observe her skin. R1's back was very red with a dark red to purple raised, shiny and wet rash on both sides of her lower back. There was a greenish drainage on the white linens underneath the resident that measured approximately 3 inches in length x 4 inches wide. The wounds were weepy and inflamed. There was scar tissue also noted on R1's buttocks, but no open areas. RN-J stated that R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She also stated the area to R1's back had been nearly healed and now, it appeared severe again with new development to the right side. When asked if laying on the area may have worsened the back wounds, RN-J stated, I am not sure but I would say the potential is there because of the heat and moisture. She should be on her side as much as she will allow or tolerate. RN-J then measured the existing maceration to R1's back and noted the following: Left middle to lower back: 10.5 cm length x 8.0 cm width Right middle to lower back: 3.0 cm length x 5.0 cm width Lack of repositioning observed 06/28, 06/29 and for over 4 hours on 06/30/21 increased the potential for R1 to develop skin breakdown and created the potential for the wounds on her back to resurface. At 12:25 PM, the Surveyor approached CNA-I and asked what the care needs of R1 were. CNA-I stated that R1 was to be repositioned off her back every two hours. There is only me down there and one floating and I'm going crazy. We need more CNAs. 400 Hall is a difficult hall with the high level of cares and number of mechanical lifts. I always need to go and find people when I need to transfer a resident with a lift. It's so hard. It opens residents up for dignity issues, declines in function and increased incontinence. I won't skimp on resident cares because of no help. Unfortunately, with only me down there, cares are delayed and I can't get to residents in the required time frames they need.

Based on observation, interview and record review, the facility did not ensure residents received appropriate treatments and services to increase or maintain range of motion and/or prevent further decline or that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility. This occurred for 6 of 8 (R27, R3, R11, R6, R29, And R30) residents reviewed for range of motion R27 needs extensive assist of 1 with transfers and ambulation. R27 has not received the scheduled ambulation and restorative services resulting in decreased ability to ambulate and decreased range of motion in R27's knee joints. R3 needs extensive assist of one for ambulation and restorative dressing and grooming care. R3 has not received these services as instructed. R11 needs extensive assist of one person for the restorative walking program and restorative dressing and grooming. R11 has not received these services. R6 needs extensive assistance of one for ambulation. R6 did not receive her restorative ambulation program or restorative dressing and grooming services. R29 needs extensive assistance of one person for ambulation. R29 did not receive the restorative ambulation services or restorative dressing and grooming services as scheduled. R30 needs extensive assistance of one for ambulation and personal hygiene. R30 did not receive restorative dressing/grooming program or the restorative walking program services as scheduled. R27 is being cited at severity level 3 (actual harm). This is evidenced by: R27 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's most recent quarterly MDS dated [DATE] documents R27 has a Brief Interview for Mental Status score of 15. This means R27 is alert and oriented and able to answer questions accurately. The MDS indicates R27 needs 1 person physical assistance to walk in the room or corridor. The frequency with which walking occurred in the look back period was 1 - 2 times. The MDS documents no functional limitations in range of motion. R27's care plan in part, The resident has potential for decreased ROM to upper extremities and lower extremities The resident will participate in theraband home exercise program at least 15 minutes, 6-7 days per week. The resident will participate in ambulation program at least 15 minutes, 6-7 days per week. Review program quarterly, annually, with sig changes, and prn Update RN with any concerns with program NURSING REHAB/RESTORATIVE: ACTIVE ROM Program #1 Green theraband with both right arm and left arm #1-6 exercises, 2 sets of 10 each one (sheet in room) NURSING REHAB/RESTORATIVE: Walking Program #1 amb 100-120 feet 2-3x daily using 2ww [wheeled walker] with limited assist, w/c to follow. Walking: only with therapy 06/30/2021 (This entry was made after Surveyor interviewed about restorative/ambulation programs.) Walking: limited assist of 1 with FWW [front wheeled walker], to and from bathroom, ambulate with CNA in hall 100-120 ft 1/25/2021 [RN J] Walking: limited assist of 1 with FWW, ambulate with CNA in hall 100 ft 1/21/2021 Surveyor interviewed R27 on 06/30/21 at 10:35 a.m. to ask how cares were going for him. R27 expressed concerns with not walking anymore. Surveyor asked how long since R27 had walked. R27 said, It's been months, there is no one to walk with me, they won't let me walk alone. Surveyor asked if R27 has noticed any changes since not walking. R27 stated, My legs are getting weak, it's harder to stand up. If they walked me every day I'd be strong so I could go home. Surveyor reviewed the restorative documentation for the past 3 months. Each month has several blanks for the assigned tasks above. For the month of June the walking progrm of 100-120 feet 2-3x daily did not occur at any time. On 07/01/21 at 8:00 a.m., Surveyor interviewed Physical Therapy Assistant (PTA) M to ask if physical therapy had worked with R27. PTA M said in the past R27 was in therapy and then put on an ambulation and restorative program. Surveyor asked if R27 is currently getting those services PTA M stated, That has not been happening; there is not staff here to have the time. Surveyor interviewed Licensed Practical Nurse (LPN) R at 8:05 a.m. to ask about R27's walking and restorative programs. LPN R indicated R27 has not been walking or getting exercises because of the short staffing situation. Surveyor asked if LPN R has noticed a change in R27's mobility. LPN R stated, He is so stiff now, his ability to move and transfer has decreased. On 07/01/21 at 8:30 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) I to ask about the restorative programs. CNA I stated, The programs have not been done in approximately 6 months since this staffing shortage started. I was the restorative aide and I have not been able to do it. Surveyor asked if CNA I had noticed any changes in R27's mobility or transfers in the past few months. CNA I stated, Yes, he is weaker, it is harder for him to stand and even do a pivot transfer. He is unable to stand up straight. On 07/01/21, at 8:45 a.m., Surveyor observed Physical Therapy Assistant (PTA) M and CNA I assist R27 to ambulate. PTA M used a gait belt and walker. PTA M encouraged and cued R27 to stand up. R27 was unable to do so without assist from PTA M. R27 stood up but remained in a hunched position, with his knees bent. PTA M asked R27 if he could stand up straight. R27 said that was as straight as he could get. Surveyor asked PTA M if that was a change in R27's range of motion. PTA M said, Yes this is a change. He can no longer straighten his knee joints. PTA M had R27 start to walk down the hall. After 25 feet R27 said, I have to sit down. Surveyor asked PTA M if this has changed since PTA M had walked R27 before. PTA M pointed to the fire doors and down the hall indicating that is how far R27 would ambulate in the past. Surveyor asked how many feet that would be. PTA M stated, He would walk 125-150 feet. This is a notable decline in his ambulation ability. 2. R3's most recent quarterly MDS documents R3 needs extensive assistance with walking and personal hygiene. R3's care plan states in part, ADL: BASELINE CARE PLAN: Self care deficit related to dementia, [CONDITION(S)], depressive disorder, type 2 diabetes In the next 3 months [R3] will continue to participate in ADLs and mobility through next review. 6. WALKING: limited assist of 1 with FWW, ambulate in hallway 60 feet, ambulate to/from bathroom as tolerates. The Certified Nursing Assistant task lists: Restorative dressing/grooming to be done twice daily and walking to be done twice daily. Surveyor reviewed the past month of R3's restorative services that were provided. R3 did not receive the dressing and grooming 28 times. R3 received the restorative walking program one time in the past month. On 23 of these occasions the code 97 is used. This code means not applicable per the documentation instructions. R3 has had a current care plan and assignment to be completing these tasks. 3. R11's annual MDS dated [DATE] indicates R11 needs assistance of 1 person for ambulation and grooming. R11's care plan in part, ADL: BASELINE CARE PLAN: Self care deficit related to [CONDITION(S)], dementia, type 2 diabetes, [CONDITION(S)], depression, CKD [[CONDITION(S)]]. In the next 3 months will actively participate in ADLs through next review. + 6. WALKING: CGA [contact guard assist] of 1 with 4WW with CNA in hallway approx 100 feet The CNA task list in part: Restorative dressing/grooming assigned twice a day. Restorative walking assigned twice a day. Surveyor reviewed the past month restorative services that were provided. R11 did not receive the dressing/grooming 17 times. R11 received the ambulation program 9 times in the month of June. On 23 of these occasions the 97 is used. This code means not applicable. R11 has a current care plan and assignment for the restorative services during the month of June. 4. R6's most recent MDS dated [DATE] indicates R6 needs extensive assistance of one for ambulation and personal hygiene. The MDS documents ambulation in the room or corridor did not occur in the look back period. R6's care plan states in part, ADL: BASELINE CARE PLAN: Self care deficit related to pancreatitis, dementia, type 2 diabetes, OA [[CONDITION(S)]], weakness. In the next 3 months [R6] will have all ADLs met with staff assistance through next review. 6. WALKING: min assist of 1 with FWW, w/c to follow. Encourage to ambulate in hallway as tolerated. The CNA task list states in part, Restorative dressing/grooming assigned twice a day, and restorative walking assigned twice a day. Surveyor reviewed the month of June restorative documentation. R6 did not receive the restorative grooming/dressing 26 times. R6 did not receive the restorative ambulation 33 times. On 9 of these occasions the code 97 is used. This code means not applicable. R6 has a current care plan and assignment for the restorative services to be completed during the month of June. Surveyor interviewed R6 on 06/28/21 at 12:15 p.m. asking about cares and her ability to move independently. R6 indicated that she does not get help with walking because there are no staff in the building to help her. 5. R29's most recent MDS dated [DATE] indicates R29 needs extensive assistance for ambulation and personal hygiene. The MDS documents the activity of walking in the room or hallway did not occur in the look back period. R29's BIMS score is 10, meaning R29 has moderate cognitive impairment. R29's care plan in part, 6. WALKING: min assist of 1 with FWW, w/c to follow. Encourage to ambulate in hallway as tolerated. Walking program: Ambulate limited/CGA assist of 1 with FWW and gait belt, to and from bathroom twice a day. 3/4/2021 The CNA task list states in part, Restorative grooming/dressing assigned twice a day and Restorative walking assigned twice a day. Surveyor reviewed the month of June restorative documentation. R29 did not receive the restorative grooming/dressing 23 times. R29's restorative ambulation did not occur one time in the month of June. On 25 of these occasions the code 97 is used. This code means not applicable. R29 has a current care plan and assignment for the restorative services to be completed during the month of June. 6. R23's most recent MDS dated [DATE] documents R23 has a BIMS score of 15, meaning R23 can recall information and answer questions accurately. R23 needs supervision and oversight of one person for personal hygiene and ambulation. R23's care plan states in part, ADL: BASELINE CARE PLAN: Self care deficit related to hypertensive heart disease with heart failure, pulmonary fibrosis, [CONDITION(S)], PVD [peripheral vascular disease], OA, stress incontinence. In the next 3 months [R23] will maintain current level of functioning through next review. 6. WALKING: Ambulate length of hallway (up to 175 ft) with 4ww and gait belt, limited assist. Requests w/c to follow at times. Ambulate to/from bathroom with FWW-supervision The CNA task list states in part, Walk in corridor or walk in room has not occurred one time in June. The assignment is coded as 8 on most days or there are blanks for the month of June. The code 8 means the Activity did not occur. On 07/01/21 at 9:30 a.m., Surveyor interviewed R23 about assistance with ambulation. R23 indicated there have been no staff to help get people out of bed and no one has time to help her walk. 7. R30's quarterly MDS dated [DATE] indicates R30 has BIMS of 10 and needs extensive assistance of 1 person for bed mobility and transfers. The MDS documents ambulation in the corridor or room did not occur in the look back period. R30's care plan states in part, The resident at risk for limited physical mobility r/t arthropathy, Intervertebral disc degeneration, spinal stenosis, back pain, weakness. The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review. The resident will maintain current level of mobility of CGA with FWW, w/c to follow through review date. Re-evaluate per policy and prn. Provide supportive care, assistance with mobility as needed. Document assistance as needed. PT, OT referrals as ordered, PRN. NURSING REHAB/RESTORATIVE: Walking Program: walk from room to nurses station daily with FWW and CGA with w/c following. The CNA tasks list in part, Restorative grooming/dressing assigned twice a day and Restorative walking program assigned twice a day. Surveyor reviewed the month of June restorative documentation. R30 did not receive the restorative grooming/dressing 33 times. R30's restorative ambulation occurred 3 times in the month of June. On 20 of these occasions the code 97 is used. This code means not applicable. R30 has a current care plan and assignment for the restorative services to be completed during the month of June. Surveyors were in the facility for 4 days. No observations of residents ambulating or restorative services were observed other than when Surveyor requested to observe R27 ambulate. Cross Reference F725 Staffing On 7/13/21, the facility Policy and Procedure for Restorative Nursing Programs was reviewed and noted that the facility utilizes a policy from a policy book titled The Compliance Store, LLC (C) 2020. Although it is acceptable to use these manuals for facility policies, the facility needs to make it their own by individualizing the policy to meet the needs of the facility. The policy as presented to the Surveyor, did not include an implementation date, a review date, the signature of the individual that completed the review or revision dates, if warranted. The Surveyor then requested evidence that the facility Medical Director had completed a review of this policy. There was no evidence presented. The acting Director of Nursing (DON) stated that he would submit these documents to the Medical Director for her review. On 7/14/21 at 7:40 AM, the acting DON approached the Surveyor and presented a form for the facility's use of the Med-Pass Policy and Procedure Manual approval by the Medical Director through the date of 12/31/2021. This was signed by the Medical Director, the Nursing Home Administrator and the acting DON, however it does not indicate the date these signatures were obtained. The acting DON then presented a revised Restorative Nursing Program policy to the Surveyor with an implementation date and review date of 7/13/21. This policy was reviewed by the DON. There was no form presented indicating that the Medical Director reviewed and accepted this policy.

Based on record review and interview, the facility did not ensure assessments for bowel and bladder decline were completed to determine the needs of residents (R) to maintain or restore bowel and bladder function for 4 of 6 (R6, R12, R15, and R1) residents reviewed with a bowel and bladder decline. R6 had a decline in her urine and bowel continence from continent of bowel and bladder 11/25/20 to frequently incontinet of bowel and bladder 05/26/21. Revisions to the care plan or a toileting program were not established to restore R6's bladder and bowel function. R12 had a decline in bowel continence from February 2021 to present. R12 was occasionally incontinent of bowel in February and currently is always incontinent of bowel. An assessment, care planning, or a toilet program revision were not established to attempt to restore R12's bowel continence. R15 was always continent of bowel on 03/24/21. On 05/25/21, R15 is occasionally incontinent of bowel. R15 did not have updates to the care plan or a toileting program put in place to restore R15's bowel continence. R1 has bowel incontinence and wishes to use the bedpan. The care plan was updated to a check and change only on 02/02/21 when the most recent bowel and bladder assessment indicates R1 is a candidate for a scheduled bowel training program. R6 is being cited at severity level 3 (actual harm). This is evidenced by: 1. R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Brief Interview for mental status score is 15 on the most recent MDS dated [DATE], meaning R6 is cognitively intact. The MDS documents R6 was continent of bowel and bladder on the quarterly MDS dated [DATE]. The quarterly MDS dated [DATE] documents R6 is occasionally incontinent of of bladder and frequently incontinent of bowel. The quarterly MDS dated [DATE] documents R6 is frequently incontinent of bowel and bladder. The ADL baseline care plan states in part, 7. TOILETING: ext x 1. Uses FWW [front wheeled walker] to transfer to toilet and off toilet. Able to make all toileting needs known. May be left alone in the bathroom but stay in the room. Occasional incontinence of urine and bowel. 3/15/2021 Original Care Plan Item Description Created Date Created By 7. TOILETING: assist before morning cares, at bedtime and every 2-3 hours while awake and upon request NIGHTS to check every 2-3 hours and assist Good pericare and barrier cream with incontinence 3/4/2021 The last update to the toileting program was on 03/04/21. On 06/28/21 at 12:15 p.m., Surveyor interviewed R6 about staffing and getting help with cares. R6 stated she has been waiting about 1 1/2 hours for help with toileting. Surveyor asked what has happened to R6 as a result of waiting so long. R6 said she has pooped and peed her pants and has to sit in it until they get there. Surveyor asked if this is bothering R6 causing her to feel humiliated. R6 stated, I feel bad but not that upset. I'm getting used to it. The bowel/bladder screener was completed on 02/20/21 and indicates R6 is never incontinent of stool. This contradicts the 02/24/21 MDS. The screener states R6 needs assistance of 1 person and is always aware of the need to toilet. R6 has a total score of 16 on the bowel/bladder screening tool. A score of 16 means R6 is a good candidate for retraining. The bowel/bladder screener is completed on 05/20/21 indicating R6 is not always continent of urine, and is incontinent of stool 1-3 x per week. The screener states R6 is always aware of the need to toilet and needs assistance of 1 person. R6 has a score of 15, meaning R6 is a good candidate for retraining. Surveyor reviewed R6's bowel and bladder tracker. R6 has been frequently incontinent of bowel and bladder since 05/20/21. The care plan was not revised with individualized interventions for R6 to restore her bowel and bladder function when a decline was noted. 2. R12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] documents R12 is continent of bowel and bladder. The significant change in status MDS dated [DATE] documents R12 is always incontinent of urine and occasionally incontinent of bowel. The quarterly MDS dated [DATE] documents R12 is always incontinent of bowel and bladder. All of the above MDS assessments document there is no bowel or bladder program in place. R12's BIMS score is 8, meaning R12 has moderate cognitive impairment. R12's care plan states in part, 7. TOILETING: Ext assist of 1. Incontinent of bowel and bladder. Wears brief. Staff to assist/prompt toileting at routine intervals- upon rising, before and after meals, before going to bed, offer during rounds on noc. Check and change approx q2hr and prn. Good pericare and barrier cream with incontinence *cannot be left alone in bathroom. 2/15/2021 7. TOILETING: Ext assist of 1. Incontinent of bowel and bladder. Wears brief. Staff to assist/prompt toileting at routine intervals- upon rising, before and after meals, before going to bed, offer during rounds on noc. Check and change approx q2hr and prn. Good pericare and barrier cream with incontinence. 2/15/2021 R12's bladder and bowel screener has been done one time on 02/03/21. The screener documents R12 is never incontinent of stool, and voids appropriately without incontinence at least daily. R12's score is 14, meaning she is a candidate for scheduled toileting.The screener identifes R12 is confused, needs prompting and is usually aware of the need to toilet. A bowel and bladder screener was not completed after the MDS of 5/03/21 that indicates a decline from occasionally incontinent to always incontinent of bowel. The care plan has had no changes; a toileting program has not been established for R12. Surveyor reviewed the bowel tracker that shows R12 has not had a continent BM since 5/13/21. 3. R15 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R15's quarterly MDS assessment dated [DATE] documents R15 is occasionally incontinent of bladder and always continent of bowel. The Significant Change in Status MDS dated [DATE] documents R15 is now occasionally incontinent of bowel. R15 has a BIMS score of 4, meaning R15 has severe cognitive impairment. R15's care plan states in part, The resident has occ bowel and bladder incontinence r/t Alzheimer's disease, depression, anxiety, h/o UTI's, decreased mobility The resident will remain free from skin breakdown and experience no complications due to incontinence and brief use through the review Clean peri-area with each incontinence episode. .Ensure the resident has has unobstructed path to the bathroom. Monitor and document intake and output as per facility policy. Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. .Monitor/document/report PRN any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Toileting: resident toilets self, assist prn. Offer assistance. Toilet riser.6/8/2021 Toileting: ext assist x 1, resident will frequently toilet herself as she does not remember to use call light, re approach to provide cares, incontinent at times, offer to take to bathroom upon rising, before and after meals, each period in bed at hs and PRN. She is able to make her toileting needs known and she will take herself to the bathroom. Toilet riser. 1/18/2021 The bowel/bladder screener was completed on 05/30/21 and documents R15 is never incontinent of stool. This contradicts the 5/25/21 MDS. The screener has a score of 20, meaning R15 is a good candidate for retraining. The screener indicates R15 is forgetful but follows commands and is always aware of the need to toilet. New interventions to restore R15's bowel continence have not been put into place with a retraining program with individualized approaches or care plan updates since the decline in bowel function on 05/25/21. Surveyor reviewed R15's bowel tracker. R15 has been occasionally incontinent of bowel consistently since 04/09/21. 4. R1 was admitted to the facility 11/7/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/28/21 documents R1 is always incontinent of bowel. R1 has a BIMS score of 11, meaning R11 can understand and answer questions accurately. The most recent Bowel and Bladder Screener was completed on 04/21/21. The screener identifies R1 as being incontinent of bowel 4- 6 times per week. R1's score for incontinence is 12, meaning she is a candidate for scheduled toileting. The screener indicates R1 is forgetful but follows commands and is sometimes aware of the need to toilet. The care plans were reviewed and include in part, 7. TOILETING: Foley. Incontinent of bowel. Requests bedpan prn. Check and change approx q2hr and prn. Good pericare and cream with incontinence. 2/2/2021 7. TOILETING: assist before morning cares, at bedtime and every 2-3 hours while awake and upon request NIGHTS to check every 2-3 hours and assist Good pericare and barrier cream with incontinence 1/28/2021 On 06/28/21 at 1:05 p.m., Surveyor interviewed R1 asking about getting assistance with cares. R1 stated, I stay in bed a lot. I need help with my incontinence care. Surveyor asked if R1 uses the toilet. R1 stated, I want to use the bedpan for my bowel movements but they don't get here. I put my light on they come in turn it off and leave. Surveyor asked when was the last time R1 had been assisted with cares. R1 stated, About 8:00 a.m. or so, I have laid on my back like this since then, it has been really bad the last few days. Surveyor asked R1 to put on her call light to get help. After about 5 minutes, Speech Therapy Pathologist P came and answered the call light, turned it off and said she would get a CNA to help R1. Surveyor continued to observe for staff to come back and assist R1. Surveyor continued to observe for staff to come back and assist R1. At 1:37 p.m. Surveyor observed CNA enter the room to assist R1. R1 has had only one bowel and bladder screening since her admission that indicated she is a candidate for scheduled toileting. A plan was not established for R1 to maintain or improve R1's bowel continence. R1 has not been offered the opportunity to use the bedpan for bowel movements as she requests. Surveyor reviewed the past months of bowel records for R1 from 6/1/21 - 6/30/21. R1 has not had one continent bowel movement during this time. F

Based on observations, interviews, and record reviews, the facility failed to implement new approaches with changes in the care plans (CP) in attempts to prevent additional falls from occurring for 2 out of 5 residents (R) reviewed for falls (R11 and R33). The facility failed to do a root cause analysis of the falls, conduct a complete investigation of the falls, or do a risk assessment to identify potential for additional falls. - R33 had a fall in January 2021 after she attempted to transfer self onto the toilet. There was no investigation into the root cause of the fall and no care plan interventions implemented following this fall. R33 made another similar self transfer attempt onto the toilet in April 2021. R33 sustained a left [CONDITION(S)] and T11-T12 vertebral (spine) fractures. R33 was hospitalized to treat the [CONDITION(S)] and manage the pain associated with multiple fractures. R33 returned to the facility under Hospice services. R33's ADLs (activities of daily living) have declined and R33 experienced pain as a result of the fall. - R11 had a fall during evening hours. The facility did not determine a root cause analysis nor implement a new intervention after this fall. A few hours later R11 fell again and sent to the hospital where it was determined R11 had sustained multiple fractures. After returning to the facility R11 continued to experience falls during evening hours. The facility did not complete a root cause analysis of the falls, did not increase monitoring of R11 during the evening hours, nor implement new interventions. This is evidenced by: Example #1: R33 was admitted to the facility for long term care on 10/26/18 with the following, but not all inclusive, diagnoses: dementia, [CONDITION(S)], stroke, depression, and kidney disease. R33 had an AHCPOA (activated health care power of attorney) effective April 2018. R33's AHCPOA was son and FM (Family Member)-F. The facility completed a quarterly MDS (Minimum Data Set) assessment for R33 on 02/02/21 with the following data noted: ~always able to make self understood and usually able to understand others. ~BIMS (brief interview for mental status) was an 8 out of 15 indicative of moderate cognitive deficits. ~able to locomote in room and outside of room with supervision. ~frequently incontinent of bladder and bowel. ~had no pain. ~weight was 141#. The facility completed a significant change in status MDS assessment for R33 on 05/03/21 and noted the following declines: ~decline in ability to make self understood. ~decline in BIMS or cognitive function to 5 out of 15. ~change in bladder function. R33 had an indwelling catheter placed. ~decline in transfers. R33 was bedrest and did not transfer. ~decline in ability to locomote in room and outside of room. R33 was bedrest and did not locomote. ~decline in weight to 130#. ~reported frequent moderate pain that affected sleep and day to day activities. Review of the care plan titled .ADL self care . initiated 01/14/21 and last revised on 04/27/21 included fall interventions that read Fall Risk: bed in low position, anti rollback device on w/c (wheelchair), bilateral grab bars ., dycem under w/c seat, floor matt on side of bed, left side of bed against wall, call light in reach, pressure alarm to bed . Review of the care plan titled .risk for falls r/t (related to) confusion, incontinence, unaware of safety needs, decreased vision, Alzheimer's, diuretic (water pill) use, hx (history of) falls . initiated on 01/14/21 and last revised on 05/10/21 included interventions such as anticipate and meet needs, check on resident every 1-2 hours and provide repositioning, and review information on past falls and attempt to determine cause of falls, record root cause of falls, and remove potential causes. Review of R33's progress notes indicated on 01/04/21 at approximately 11:45 a.m., R33 was found on the bathroom floor. According to the nurses notes, R33 needed to go to the bathroom and had not put on call light. R33 did not sustain any injuries. The fall incident report noted R33 was confused, had impaired gait/balance, and memory. The incident report and progress notes did not indicate any changes to the care plan. Surveyor was unable to locate any change to the care plan or the identified root cause. On 01/04/21 at 3:32 p.m., the previous DON (Director of Nurses) documented in R33's progress notes that R33 was reaching for something on the floor which caused the fall to the floor. The facility gave R33 a reacher. The fall investigation did not include the last time a staff member provided care to R33 or did not include any investigation into the root cause of R33's fall. There was no information to support the previous DON's action to provide R33 with a reacher as that was not included in the investigation or identified as the root cause of the fall. The facility did not update the care plan to include the reacher. Review of R33's progress notes indicated on 04/11/21 at approximately 7:30 to 8:00 p.m. R33 was heard yelling for help by an adjacent resident (R16). R16 put on her call light to summon staff to help R33. RN-E, CNA-D, CNA-L, and RN-BB responded to R33's calls for help and found R33 laying on her left side with her head against the wall in the bathroom. R33 complained of pain in her left leg, left shoulder, and back with movement. R33 had a fall and sustained a left [CONDITION(S)], T11-T12 vertebral (spine) fractures, and was hospitalized to repair the left [CONDITION(S)] and manage the pain associated with the multiple fractures. R33 was readmitted to the facility on [DATE] under Hospice services due to poor prognosis following the fall. Review of the fall incident report noted R33's fall factors were incontinence, impaired memory, and weakness. There was no investigation into the root cause of the fall. There were no staff interviews when R33 had last received staff assistance with cares. The facility completed an admission pain assessment on 04/20/21 and noted R33 had moderate pain as evidenced by her statements, moaning, and crying out in pain with movement. In addition, R33 was placed on bedrest and an indwelling foley catheter was placed due to pain with movement. On 06/09/21 and 06/10/21, Surveyor requested any information regarding R33's falls that would identify a thorough investigation into the root cause of the fall and any changes to the care plan. On 06/14/21 at 10:50 a.m., DON-B stated there was no additional information on R33's falls in January or April of 2021. DON-B stated the root causes of R33's falls were not identified and there were no changes to the care plan made following R33's falls in January and April 2021. DON-B stated there were no investigations of R33's falls documented. On 06/14/21 at 11:05 a.m., ADON (Assistant Director of Nurses)-CC approached Surveyor and stated there was no additional information to provide regarding R33's falls in January and April, 2021. ADON-CC stated there was no investigation, no root cause analysis, and no changes to the care plan following R33's falls. Surveyor requested a list of all staff working on 04/11/21 on the second shift and noted there was two RNs (Registered Nurses) and two CNAs (Certified Nursing Assistants) for a census of 51 residents. During the survey, all four staff working on 04/11/21 were interviewed regarding the events surrounding R33's fall. All four staff reported inability to meet R33's needs due to short staffing as the cause of R33's fall and injuries. CNA-L, RN-BB, RN-E, and CNA-D reported R33 had been sitting in wheelchair since prior to supper and was likely tired and wanted to use the toilet then go to bed. RN-BB, CNA-L, RN-E, and CNA-D stated R33 was inconsistent when asking staff for assistance with toilet use. RN-BB, CNA-L, RN-E, and CNA-D also stated R33 was usually in bed between 7:00 and 7:30 p.m. On 06/09/21 at 3:00 p.m., Surveyor interviewed RN-E regarding R33's care needs and fall. RN-E confirmed she was on duty on 04/11/21 and assisted R33 following the fall. RN-E stated R33 had been sitting in the wheelchair for several hours and likely attempted to toilet self and fell . RN-E stated R33 was usually in bed around 7:00 p.m. RN-E stated usual staffing pattern for the second shift was 2 nurses and 2 CNAs (Certified Nursing Assistant) for an average census of 50 or more. RN-E stated all staff try to provide good care, but residents have to wait for call light response, help with toileting, and help getting ready for bed. RN-E stated all staff are frustrated because there isn't enough help and the facility continues to take new admissions. RN-E stated staff try hard to get the work done, but just can't when there are only 2 CNAs. RN-E stated showers, oral hygiene, toileting, and repositioning are not getting done because of not enough staff. On 06/9/21 at 7:15 p.m., Surveyor interviewed CNA-D who confirmed she worked on 04/11/21. CNA-D stated she had not provided any care for R33 since she arrived at the facility around 6:00 p.m. CNA-D stated there were only 2 CNAs on for the second shift on 04/11/21. CNA-D stated insufficient staffing was a factor in R33's fall because staff could not help her to the toilet after supper and R33 likely attempted to toilet self and fell . On 06/14/21 at 11:15 a.m., Surveyor interviewed CNA-L who confirmed he worked on 04/11/21. CNA-L stated R33 needed help with all ADL (activities of daily living) and was unsafe to transfer independently. CNA-L stated R33 had been up in the wheelchair since before supper and had likely wheeled self into the bathroom and attempted to toilet self and fell . CNA-L stated R33's usual bedtime routine was to use the toilet, wash up, brush her teeth, and settle into bed around 7:00 p.m. CNA-L stated the insufficient staffing was absolutely a factor in R33's fall. On 06/14/21 at 10:50 a.m. Surveyor interviewed DON (Director of Nurses)-B regarding the facility expectation following resident falls. DON-B stated the nurse at the time of the fall should conduct a thorough investigation of the cause of the fall. The investigation would include asking the resident what happened as well as interviewing the staff on duty. DON-B stated the nurse should attempt to determine the root cause of the fall and then implement appropriate care plan interventions based on the root cause. DON-B stated the IDT (interdisciplinary team) does meet to review the falls on the next business day and also to review the investigations completed at the time of the fall. The IDT looks for the root cause analysis identified. The IDT documents in the resident's progress notes that the fall was reviewed and reiterates the root cause as well as any changes to the care plan that were implemented. The IDT reviews the care plan and ensures that all changes were added and carried forward to be shared during the shift to shift report. On 6/14/21 at 4:00 p.m., Surveyor interviewed RN-BB via telephone regarding R33. RN-BB stated she was familiar with R33's care needs. RN-BB stated R33 required extensive to total staff assist for all ADL (Activities of Daily Living) needs. RN-BB stated R33 was able to make basic needs known and would sometimes use call light to ask for staff assistance, but was not consistent in the use of a call light. RN-BB stated R33 preferred to be assisted into bed before or near 7:00 p.m. RN-BB stated R33 had a fall on 04/11/21 when she attempted to toilet self. R33 was found in the bathroom on the floor. RN-BB stated she was called to assist RN-E, CNA-D, and CNA-L assess R33 following the fall. RN-BB stated R33 was unable to move without significant pain in her leg, back, and shoulder. RN-BB stated the contributing factors for R33's fall with injury and pain were R33's dementia and the lack of sufficient staffing in the building. RN-BB stated R33's fall was likely avoidable had staff assisted R33 with toileting and then into bed prior to 7:00 p.m. RN-BB stated R33 had likely been sitting in the wheelchair since before supper and was incontinent of urine and needing to be repositioned. RN-BB stated staff are unable to assist resident with repositioning and toileting needs timely. RN-BB stated the second shift was usually staffed with two nurses and one or two CNAs for an approximate census of 50 or more. RN-BB stated residents were not receiving adequate care with toileting, call light response, oral hygiene, skin care, and falls prevention because of the short staffing situation. On 06/09/21 at 8:30 p.m., Surveyor interviewed FM (Family Member)-F regarding the care of R33. FM-F stated R33 received marginal care at best and stated R33 has had several falls likely related to insufficient staffing. FM-F stated there was not enough staff to help R33 to the bathroom and due to R33's dementia, she does not know her transfer limits. Example #2: R11 has multiple medical diagnoses that include, but are not limited to Peripheral Vascular Disease (PVD), Spinal Stenosis of the Lumbar region, Major Depressive Disorder, Anxiety Disorder, [CONDITION(S)], [CONDITION(S)] of the Knee and Right Wrist, Migraine Headaches, Cognitive Communication Deficit, History of Falls and Dementia. On 6/8/21 at 10:36 AM, the Surveyor conducted the screening process of R11 and noted a low bed with a concave mattress and a floor mat placed on the floor beside the right side of the bed with the left side of the bed against the window. R11 also had an alternating air mattress set at 15 with the firmness setting 5/8. The Surveyor completed a review of R11's Minimum Data Set Assessments (MDS's) and noted the following: 1. Quarterly MDS dated [DATE]: - Independent with bed mobility, transfers, ambulation both in her room and in the hall, locomotion on and off the unit, eating, toileting, personal hygiene and continent of bowel and bladder. - Supervision with no assistance from staff for dressing 2. Significant Change in Status MDS dated [DATE]: - Dependent on two staff for transfers - Dependent on one staff for bathing and locomotion on and off unit - Extensive assistance of two staff for bed mobility and toileting - Extensive assistance of one staff for dressing and personal hygiene - Indwelling urinary Foley catheter in place and always incontinent of bowel function - Non-ambulatory - Supervision of one staff for eating The following care plans (CP) were noted in R11's record: 1. CP plan: 1/16/20 start date: Last revised/reviewed 10/10/20: Problem: Resident is at risk for falls due to: [CONDITION(S)] and opioid medications use, pain, spinal stenosis, [CONDITION(S)], low back pain, [CONDITION(S)] (OA), anxiety disorder Approaches: all dated 1/16/20 - 1:1 visit prn, assure comfort and dignity are maintained, invite family to care conferences. - Assure well light clutter free environment - Call light in reach in own room and bathroom, answer promptly, orient to to use and remind-especially at night - Comprehensive medication review by pharmacist, assess for polypharmacy and medications that increase the fall risk per policy and prn. - Increased staff supervision with intensity based on resident need. - Proper footwear with transfers and ambulation - Shoe rack in place. (R11) chooses to not declutter room. 2. CP dated 12/19/20: Initiated 3/1/21, revised on 5/25/21 (R11) is at risk for future falls r/t (related to) anxiety, depression, spinal stenosis, OA ([CONDITION(S)]), complaints of pain-migraines, antidepressant medication use, opioid medication use, antianxiety medication use, history of falls. History of a fractured humerus, right fibular, right foot, and dislocation of right shoulder joint, PVD On 6/9/21 at 8:32 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) DD regarding R11's decline in functional status. LPN DD stated R11 had two falls during the night shift hours. LPN DD did not know the details of R11's falls, indicating that she wasn't on duty at the time, but did state that R11 sustained several fractures with the falls and now requires a lot of care. On 6/10/21 at 2:37 PM, the Surveyor interviewed RN-K (Registered Nurse) regarding fall investigations. RN-K is also the facility Minimum Data Set (MDS) Coordinator. RN-K stated a complete fall investigation process is to always have a root cause analysis to determine what the resident was trying to do at the time of the fall and implement new interventions in hopes of preventing another fall from occurring. FALLS: Surveyor conducted interviews and record review with LPN CC on 6/14/21 at 1:54 PM. The following records were reviewed and discussed: Record Review: 3/1/21: 12:13 AM Incident Note . Resident was found sitting in the hallway at the doorway of the orange utility room. The nurse at the nurses' station did not hear any noises from the fall. She was sitting on her buttocks with her legs folded to the right. She denied hitting her head, she denied injuries although it was noted she had a red area on the top of her right knee. She was assisted back to her room. She was able to walk normal for self with her wheelchair . Doctor on call was notified and had no new orders. Power Of Attorney (POA) was notified . The fall occurred on 2/28/21 at 11:00 PM, as learned through review of Interdisciplinary Team Progress Notes; There was no root cause analysis. There were no new interventions put into place in attempts to prevent another fall and a fall risk assessment was not completed at the time of the fall. LPN CC stated (R11) sustained a bruise to her right knee. The next shift started and the nurse coming on duty completed a neurological assessment following the fall. The risk assessment report was dated 3/6/21, 5 days after the fall. LPN CC was asked what the process was following a resident fall. LPN-CC stated The nurse should have determined a root cause analysis and implemented a new intervention based on that root cause, in order to attempt to prevent another fall occurring. That is the standard. On 3/1/21 at 12:35 AM, it was noted R11 had worsening pain in the right arm. The doctor ordered R11 to be seen in the ER (emergency room .) However, there was no note corresponding to this order and no evidence that R11 was seen in the ER. 3/1/2021 5:32 AM: Incident Note . Resident was found on the floor near the doorway of her room. She was screaming in pain that her arm hurt. She denied pain elsewhere. She was on her left side on the floor with her right arm draped over her right hip/thigh. She said she couldn't move it. She had no shoes or socks on. Her skirt was in the bathroom. The wheel chair and walker were underneath where the TV hangs. Her POA was called and informed of injury . Report was called to the ER staff. Resident left with the EMTs (Emergency Medical Technicians) at 3:50 AM. Of concern with this fall is that the incident report indicates the fall occurred at 5:32 AM, R11 left in the ambulance to be evaluated after this fall at 3:50 AM. There was no root cause analysis for this fall. At 7:05 AM, the facility received a report from the hospital nurse stating that R11 sustained several fractures as a result of this fall, including a dislocated right shoulder, a fracture of the right proximal humerus and spinal [MEDICATION(S)] #2 compression fracture. R11 was transferred from the local hospital to Medical Center 1 hour and 48 minutes away. At 3:52 PM the facility did implement changes and updated R11's care plan to include:, - For no apparent acute injury, determine and address causative factors of the fall. (Initiated 3/1/21) - Keep the orange utility door closed- (Initiated 3/1/21) - Make frequent checks on her at NOC (night) due to her history of pacing at night or seeking out a nurse for a snack or due to complaints of a headache. (Initiated 3/1/21) - Offer/provide assist with toileting as needed or as resident allows to reduce risk of falls. Initiated (3/1/21) - Replenish supply of briefs every shift to decrease anxiety related to not having them available. (Initiated 3/1/21) R11 returned to facility on 3/4/21 at 1:00 PM. R11's POA decided on no surgical interventions. The following Medical Diagnoses were added to R11's diagnosis listing following this fall: - Nondisplaced Fracture of Lateral Malleolus of the Right Fibula (outer right ankle) - Displaced (moved out of its normal position) Fracture of the Greater Tuberosity of the Right Humerus (right shoulder) - Displaced Fracture of the Upper End of the Right Humerus (right shoulder) - Dislocation of the Tarsometatarsal Joint of the Right Foot (junction between the midfoot and the forefoot) - Wedge Compression Fracture of the Second [MEDICATION(S)] Vertebra On 3/5/21 the facility completed a Fall Risk Evaluation and scored R11 as 27, indicating At Risk. 3/5/2021 8:50 PM: Incident Note . Unwitnessed fall. Resident was noticed by writer as resident was sitting on the floor in the hall outside of her room. She said she got out of bed on the floor and scooted herself into the hall. CNA had just recently left resident room to let nurse know (R11) wanted to talk with the nurse. (R11) did not wait for nurse to go to her room . Resident had pulled out her catheter during incident. No blood noted. No injuries noted. Catheter reinserted after discussion with POA . PCP (Primary Care Provider) via fax and DON (Director of Nursing) also updated . Care plan updated with the following: - Resident has a bed alarm to alert staff to attempts to get up without assistance. (Initiated 3/6/21, Discontinued 3/29/21) - Encourage/remind to use call light to call for assistance, resident often refuses to use call light- (Initiated 3/8/21) When asked by Surveyor, LPN CC stated there was no fall investigation or Risk assessment completed at the time of the incident. On 3/9/21, the facility rearranged R11's room to place the bedside table closer to her as she could not reach her water with the alarming floor mat next to her bed. This note entered at 11:39 PM states that R11 . does not generally sleep through the whole night and that is her normal routine even when she was up and about. There was no record of increased monitoring of R11 during night hours. 3/11/2021 at 12:30 AM: Incident Note . Resident was found at approximately 12:30 AM laying supine on the floor in front of her bed. Resident was laying on her floor alarm that was not alarming. Batteries were switched out, floor mat was changed twice due to faulty alarms not sounding. When asked what resident was doing, stated that one (leg) is heavy and I am trying to make it lighter Resident was last checked on at 2345 (11:45 PM), resident was laying in bed. Resident denied having any new pain or discomfort. DON, POA, and MD was notified. Immediate intervention was finding a floor mat that works. The Surveyor asked LPN-CC what the alarm checking system is to ensure alarms are functioning properly. LPN-CC stated The staff are supposed to check that alarms are functioning properly each time they visit the room. There is no place to document that staff have checked the alarms with all cares, that I am aware of. There is no place on the MARs (Medication Administration Records) or TARs (Treatment Administration Records) for nursing to sign off, and no place for CNAs (Certified Nursing Assistants) to document that they checked the alarms with cares. 4/18/2021 at 3:34 AM: Incident Note . Resident found on floor of hallway in front of her doorway. Resident said she had spilled some water on the floor and was trying to get some help to clean it up. She said she scooted on her buttocks to the hallway where she was found by staff. Resident had pulled her catheter out when she crawled out of bed. Catheter was replaced once resident was assessed for injuries and placed back into bed. Resident was assisted off of floor with a hoyer. On call notified, primary updated via fax, POA notified. Vitals and neuros within normal limits. Will continue to monitor. Note: There was no new intervention with this fall. 5/31/2021 at 11:50 PM: Incident Note . Resident heard calling out for help. She was found sitting on the floor in the hallway outside of her room. She was upright with her legs curled underneath her. She stated she had fallen out of bed. She was unable to explain what she needed. She had pulled out her Foley and it was laying on the floor next to her bed with balloon inflated . She had a slipper on one foot and a gripper sock on the other foot . Denies any pain other than a headache . No injuries noted . There was no new intervention following this fall. The 'Immediate action taken' according to the Risk Assessment was Resident assisted off the floor with the hoyer lift and placed back into bed. Care plan update on 6/1/21 include: - Bed to be in low position during HS (Hour of Sleep) and NOC (night) shift. (Initiated 6/1/21) The facility did not conduct thorough fall investigations to include root cause analysis, falls risk assessments or implement new interventions. The facility did not increase monitoring of resident during evening hours despite knowing resident did not sleep all night and a majority of her falls occurred during that time, as indicated on the CP intervention dated 3/1/21

Based on observation, record review, and staff and resident interviews, the facility did not ensure they had sufficient nursing staff to provide nursing care and services to all the residents and assure resident safety as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This has the potential to affect all 54 residents residing in the facility. Example#1: The facility did not ensure 8 of 14 residents (R2, R18, R21, R34, R15, R10, R3, R48) received prompt response to their needs and call lights due to insufficient staffing as voiced during individual resident interviews and resident group meeting. Example #2: The facility did not ensure residents reviewed for falls (R33) received adequate supervision and assistive devices to prevent accidents due to lack of sufficient direct care staff. Example #3: The facility did not ensure 1 of 3 residents reviewed for Pressure Injuries (PI) (R21), received adequate repositioning due to lack of sufficient staffing. Example #4: The facility did not provide adequate Activities of Daily Living (ADLs) cares for 1 of 12 residents (R2) dependent on staff cares due to insufficient staffing. Example #5: The facility did not ensure dignified care due to insufficient staffing for 3 residents (R2, R18, and R21). Example #6: The facility did not provide the nurse staffing considering the number, acuity and needs of the facility's resident population in accordance with the required facility assessment. This is evidenced by: The Surveyor reviewed the facility completed Resident Census and Conditions of Residents (CMS-672) for the entrance date of the survey of 6/8/21 and noted the current resident information: Census: 54 Bathing: 0 independent, 49 assist with one or two staff, 5 dependent Dressing: 1 independent, 51 assist of one or two staff, 2 dependent Transferring: 4 independent, 42 assist of one to two staff, 8 dependent Toilet Use: 1 independent, 52 assist of one to two staff, 1 dependent Eating: 24 independent, 29 assist of one or two, 1 dependent Catheters: 5 Occasionally or frequently incontinent of bladder: 42 Occasionally or frequently incontinent of bowel: 27 Urinary toileting program: 6 Bowel toileting program: 5 Ambulation with assistance or assistive device: 16 Dementia: 19 Behavioral healthcare needs:18 Pressure Injury, excluding Stage I: 4 IV: 1 Staff Posting for this date was reviewed on Tuesday 6/8/21 at 8:17 AM: Dayshift: 6AM - 2 PM: RNs- 2 (16 hours), CNAs- 3 (24 hours), other (Nurse grad) 1 (8 hours) Evening Shift: 2 PM -10 PM: RN- 1 (8 hours), LPN-1 (4 hours), CNAs- 4 (22 hours), other (nurse grad)- 1 (4 hours) Night Shift: 10 PM - 6 AM: RNs -1 (4 hours), LPNs- 2 (16 hours), CNAs- 2 (16 hours) Example #1 Interviews On 06/08/21 at 2:03 pm the surveyor spoke with CNA AA. CNA AA explained she is the only full time nurse aide on the pm shift. The facility attempts to schedule 3 nurse aides on pm shift. Often it is a.m. staff staying over and night shift coming in early. CNA AA expressed residents are not toileted and repositioned as they should be. Resident showers are not given as scheduled. A weekly shower list is used. Each week a new one is put out for staff to highlight and initial when shower is done for the week. If the shower is not given on the scheduled night, staff try to make it up another day but often are not able to. Residents are going greater than a week without a shower. Office staff help out by passing meal trays and nurses try to help out as able. The facility is trying to hire staff but nurse staffing has gotten progressively worse since hired last December. On 06/09/21 at 9:52 a.m. the surveyor spoke with Certified Nursing Assistant (CNA) M. CNA M expressed the facility is currently scheduling 3 nurse aides on am and pm shift for 4 floors and 50+ residents. CNA M further expressed it is impossible to respond to call lights timely when the CNA is pulled off one floor to assist on another floor. Often the CNA is absent from the floor for long period of time which causes long wait times for residents to have their needs met. The surveyor asked CNA M if residents are having to wait one hour or greater. CNA M responded she has heard residents complain that they have had to wait over an hour. On 6/14/21 at 11:10 am the surveyor spoke with Graduate Nurse (GN) Y regarding nurse staffing. GN Y expressed she tries to help the nurse aides as much as she can. The facility needs more help. The residents wait a long time to get their call lights answered and have their needs met. On 6/10/21 at 8:23 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) O regarding the expectation of cares to residents. CNA-O stated that she makes attempts to get to residents in a timely manner, but with the staffing shortage, cannot respond to call lights timely. She indicated that sometimes the call light will be on for a while before she can respond to them, and very often more residents have an increase in incontinence as a result, causing the resident to lay in a soiled brief for a while. I feel bad for them, but I can only do so much, it's sad. On 6/10/21 at 1:18 PM, the Surveyor interviewed CNA P regarding general staffing and services provided to residents. CNA P stated she felt concerned because she is unable to provide residents with care they are deserving of. It takes a long time sometimes to answer their call lights because we are short staffed and if we are in a room taking care of someone, we cannot leave to answer call lights. So sometimes it can be one-half to one hour, sometimes longer if there are several call lights going off at one time. I feel terrible for them (residents), they deserve better care. Some nurses will help out, but others won't. We don't have all people that work here help with call lights, which is frustrating when you see people just walk past them. CNA P was asked if she had noticed some decline in residents as a result of not being able to assist them timely. CNA P stated, Oh yes, there is an increase with incontinence because we can't get them to the bathroom in time, so they have to wait for us and end up going in their pants or in bed. I apologize to them, but I know it is embarrassing for some of the residents . I just wish we could give them better care but we are so strapped and can only do so much . Resident Group Meeting On 10/09/2021 at 10:30AM, the resident group meeting was held with the Surveyor, as part of the survey process. Those with concerns who attended the group meeting included R15, R10, R48, R3, R34. All residents present with the exception of R3, attend facility Resident Council meetings regularly. Prior to the resident group meeting the Surveyor reviewed the past six months of meeting minutes from the facility Resident Council meetings. The minutes spoke to grievances during the meetings being given to Social Services to be followed up on. Surveyor asked to review these grievances prior to the meeting. These were reviewed and it was found that there were several grievances related to staff shortages and answering of call lights. The following questions were asked. Do you get the help and care you need without waiting a long time? Do staff respond to your call light timely? R34 stated they get help but not on time. As an example R34 stated that when they are put in the bathroom on the toilet that it takes 45 minutes for staff to answer the call light to get them off the toilet. R34 stated that this happened frequently. The average call light response time is 30 to 45 minutes. R34 stated there were way too few staff to cover the needs of the residents. R15 said that they did get showers but they were sometimes not as scheduled due to staffing issues. They added that the diet they were supposed to get was gluten and sodium free and sometimes is not. R10 commented on not getting a shower. Wait time when a call light is pulled can be very long. It can be over 45 minutes during night time cares and in requesting medications. R10 stated the average wait time for call lights was 45 minutes. R3 stated that sometimes they got what they needed, and sometimes they did not. R48 stated that they felt the staffing numbers were low because the company was trying to make money. There is only 1 nurse and 1 CNA (certified nursing assistant) on during the night shift for the entire building. This fact makes call light response even longer during those nights. The group consensus was that there was a lack of staffing due to missing showers, and the long call light response time. Example #2 - Falls R33 had a fall with multiple fractures, pain, and decline in status. R33 was hospitalized to treat the [CONDITION(S)] and manage the pain associated with multiple fractures. R33 returned to the facility under Hospice services. According to the staff interviews and family interviews, this fall was a result of insufficient staffing and unmet care needs of R33. On 04/11/21, R33 had a fall and sustained a left [CONDITION(S)], T11-T12 vertebral (spine) fractures, and was hospitalized to repair the left [CONDITION(S)] and manage the pain associated with the multiple fractures. R33 was readmitted to the facility on [DATE] under Hospice services due to poor prognosis following the fall. Review of the care plan titled .risk for falls r/t (related to) confusion, incontinence, unaware of safety needs, decreased vision, Alzheimer's, diuretic (water pill) use, hx (history of) falls . initiated on 01/14/21 and last revised on 05/10/21 included interventions such as anticipate and meet needs, check on resident every 1-2 hours and provide repositioning, and review information on past falls and attempt to determine cause of falls, record root cause of falls, and remove potential causes. Review of R33's progress notes indicated another fall on 04/11/21 at approximately 7:30 to 8:00 p.m. R33 was heard yelling for help by an adjacent resident (R16). R16 put on her call light to summon staff to help R33. RN-E, CNA-D, CNA-L, and RN-BB responded to R33's calls for help and found R33 laying on her left side with her head against the wall in the bathroom. R33 complained of pain in her left leg, left shoulder, and back with movement. RN-E stayed with R33 while RN-BB telephoned emergency services to transport R33 to the hospital for evaluation. Review of the fall incident reported noted R33's fall factors were incontinence, impaired memory, and weakness. There was no investigation into the root cause of the fall. There were no staff interviews when R33 last received staff assistance with cares. Surveyor requested a list of all staff working on 04/11/21 on the second shift and noted there was two RN (Registered Nurses) and two CNAs (Certified Nursing Assistants) for a census of 51 residents. During the survey, all four staff working on 04/11/21 were interviewed regarding the events surrounding R33's fall. All four staff reported inability to meet R33's needs due to short staffing as the cause of R33's fall and injuries. CNA-L, RN-BB, RN-E, and CNA-D reported R33 had been sitting in wheelchair since prior to supper and was likely tired and wanted to use the toilet then go to bed. RN-BB, CNA-L, RN-E, and CNA-D stated R33 was inconsistent when asking staff for assistance with toilet use. RN-BB, CNA-L, RN-E, and CNA-D also stated R33 was usually in bed between 7:00 and 7:30 p.m. On 06/09/21 at 3:00 p.m., Surveyor interviewed RN E regarding R33's care needs and fall. RN E stated she had cared for R33 since January of 2021 and primarily worked full time on the second shift. RN E stated prior to R33's fall, R33 was up in the wheelchair and would propel self throughout the facility. R33 would enjoy small group socialization and would at times eat her evening meal in the dining room. RN E stated R33 was able to make needs known, was dependent on staff for transfers, toilet use, and hygiene. RN E confirmed she was on duty on 04/11/21 and assisted R33 following the fall. RN E stated R33's fall was a result of insufficient staffing. RN E stated R33 had been sitting in the wheelchair for several hours and likely attempted to toilet self and fell . RN E stated R33 was usually in bed around 7:00 p.m. RN E stated usual staffing pattern for the second shift was 2 nurses and 2 CNAs (Certified Nursing Assistant) for an average census of 50 or more. RN E stated all staff try to provide good care, but residents have to wait for call light response, help with toileting, and help getting ready for bed. RN E stated all staff are frustrated because there isn't enough help and the facility continues to take new admissions. RN E stated staff try hard to get the work done, but just can't when there are only 2 CNAs. RN E stated showers, oral hygiene, toileting, and repositioning are not getting done because of not enough staff. On 06/9/21 at 7:15 p.m., Surveyor interviewed CNA D who confirmed she worked on 04/11/21. CNA D stated she had not provided any care for R33 since she arrived at the facility around 6:00 p.m. CNA D stated there were only 2 CNAs on for the second shift on 04/11/21. CNA D stated insufficient staffing was a factor in R33's fall because staff could not help her to the toilet after supper and R33 likely attempted to toilet self and fell . On 06/14/21 at 11:15 a.m., Surveyor interviewed CNA L who confirmed he worked on 04/11/21. CNA L stated R33 was a quiet, private, and reserved resident who would propel herself in the wheelchair throughout the facility. CNA L stated R33 needed help with all ADL (activities of daily living) and was unsafe to transfer independently. CNA L stated R33 had been up in the wheelchair since before supper and had likely wheeled self into the bathroom and attempted to toilet self and fell . CNA L stated R33's usual bedtime routine was to use the toilet, wash up, brush her teeth, and settle into bed around 7:00 p.m. CNA L stated the insufficient staffing was absolutely a factor in R33's fall. CNA L stated the short staffing problem was a factor in other resident falls as well. 6/14/21 at 4:00 p.m., Surveyor interviewed RN BB via telephone regarding R33. RN BB stated she has worked at the facility for approximately 6 months full time on the second shift. RN BB stated she was familiar with R33's care needs. RN BB stated R33 required extensive to total staff assist for all ADL (Activities of Daily Living) needs. RN BB stated R33 was able to make basic needs known and would sometimes use call light to ask for staff assistance, but was not consistent in the use of a call light. RN BB stated R33 preferred to be assisted into bed before or near 7:00 p.m. RN BB stated R33 had a fall on 04/11/21 when she attempted to toilet self. R33 was found in the bathroom on the floor. RN BB stated she was called to assist RN E, CNA D, and CNA L assess R33 following the fall. RN BB stated R33 was unable to move without significant pain in her leg, back, and shoulder. RN BB stated R33 remained on the floor with staff present until emergency services arrived and transported R33 to the hospital. RN BB stated the contributing factors for R33's fall with injury and pain were R33's dementia and the lack of sufficient staffing in the building. RN BB stated R33's fall was likely avoidable had staff assisted R33 with toileting and then into bed prior to 7:00 p.m. RN BB stated R33 had likely been sitting in the wheelchair since before supper and was incontinent of urine and needing to be repositioned. RN BB stated staff are unable to assist resident with repositioning and toileting needs timely which was a significant factor in R33's fall along with other residents' falls. Example #3- Pressure Injuries R21 is a high risk for the development of PI's (Pressure Injuries) with a former history of one to her buttocks. She is to be a check and change and repositioned every two hours. An observation was made on 6/9/21 in which this was not completed by staff for a time period of 3 hours 42 minutes. According to the most recent Minimum Data Set Assessment (MDSA) completed for R21, which was a Significant Change in Status assessment dated [DATE] related to R21 enrolling in Hospice Services, R21 requires extensive assistance of two staff to meet her most basic daily tasks of bed mobility, dressing and toilet use. She requires extensive assistance of one staff to meet tasks such as transfers and personal hygiene. She is non-ambulatory and frequently incontinent of bowel and bladder function. The Surveyor conducted a brief record review of R21 and noted Care Plans (CP) in place direct staff to reposition R21 every two hours and resident is toileted by a check and change process. 6/8/21 at 10:27 AM, R21 stated that she needs to wait upwards of two hours for assistance when she activates her call light. R21 also stated that often she wets her incontinent brief several times before she receives assistance. Surveyor conducted a continuous observation of R21 on 6/9/21 from 9:45 AM - 1:27 PM (3 hours, 42 minutes) in which no staff entered her room to offer or assist R21 with toileting or repositioning, even though R21 is a high risk for the development of PI's. At 1:27 PM CNA W entered R21's room and then offered to assist her to the bed. At that time CNA W provided perineal cleansing for R21 after removing a heavily urine saturated brief. R21's buttocks and front perineum were dark red. CNA W verified that R21 was to be checked and repositioned every two hours but . because I am watching two wings, . things are a little behind. Example #4 - ADL's On 06/08/21 at 1:34 pm the surveyor spoke with R2. R2 indicated she is supposed to get a full bed bath every Friday am but does not. R2 further expressed she gets a bed bath every couple of weeks. R2 further expressed she is unable to get supplies and complete the bed bath on her own. She is blind and bedridden for the most part. R2 further expressed staff change her diaper in the morning and evening but most often do not wash her up. The bed bath is needed each week to feel clean. R2 told the surveyor her teeth are not brushed by staff each day. R2 expressed she depends on staff to provide her with toothbrush with paste for her to brush teeth. Staff need to help her brush her teeth as she is blind and not sure she is doing a good job. Need staff to provide cup of water to rinse mouth and basin to spit. She can not get up on own to get supplies, cannot fill a glass with water and cannot do a thorough job brushing teeth. Further expressing she needs staff to help and has lost teeth in the past due to poor hygiene. R2 further expressed she is provided supplies and assisted with brushing her teeth about one time a month for the past year. R2 expressed her teeth feel grimy and she has resorted to cleaning her teeth by picking at them with her fingernails and wiping her teeth with a Kleenex. R2 further expressed she has had 4 teeth removed since living at the facility about a year ago due to poor oral hygiene. R2 indicated her cares are not being done adequately due to lack of sufficient staff. On 06/09/21 at 10:07 am the surveyor spoke with Certified Nursing Assistant (CNA)-M regarding R2's cares. CNA-M indicated she is familiar with R2. CNA-M expressed she completes R2's bed bath on Friday a.m. when she is assigned the 100 unit. CNA-M further expressed CNAs are often unable to complete thorough cares; including bed baths, due to being rushed to complete cares for too many residents. The facility is currently staffing 3 CNAs for 4 units of 50+ residents. Staff try their best but can not get everything done as thorough as it should be for the residents. CNA-M also indicated resident toothbrushing is often one of the things the aides do not have time to do because of rushing with cares and lack of staffing. 6/09/21 at 2:45 p.m. the surveyor requested and received R2's data for bed baths since 1/01/21. The data verifies R2 has not received a weekly bed bath as indicated in her plan of care. Example #5 - Dignified Care On 06/08/21 at 1:50 p.m. the surveyor spoke with R2. R2 indicated she is blind and bedridden for the most part. R2 is unable to care for her own needs. R2 voiced feelings of humiliation due to having to lay in bowel movement as staff are unable to respond to her call light and needs promptly due to insufficient staffing. R2 indicated staff tell her they are to busy to respond to call light because there is not enough help causing R2 to lay in BM for periods sometimes greater than one hour. R2 expressed there are a lot of nurses but the facility need aides. Some nurses help, but not all. Some will not help out when you ask. Waiting over an hour full of (*X*X-expletive) bowel movement and you can't help yourself is humiliating. The surveyor reviewed R2's most recent Minimum data set completed 5/19/21 and noted the following: R2 understands, is understood and is cognitively intact. R2 is always incontinent of bowel movement and is dependent on staff for personal hygiene. R2's care plan notes: incontinent of bowel, approximately change every 2 hours and prn (as needed). On 06/09/21 at 9:52 a.m. the surveyor spoke with Certified Nursing Assistant (CNA) M. CNA M expressed the facility is currently scheduling 3 nurse aides on am and pm shift for 4 floors and 50+ residents. CNA M further expressed it is impossible to respond to call lights timely when the CNA is pulled off one floor to assist on another floor. Often the CNA is absent from the floor for long period of time which causes long wait times for residents to have their needs met. The surveyor asked CNA M if residents are having to wait one hour or greater. CNA-M responded she has heard residents complain that they have had to wait over an hour. R18 has a Brief Interview of Mental Status (BIMS) score of 13/15, indicating slight areas of confusion but overall, cognitively intact. Minimum Data Set Assessment (MDS) completed for R18, which was an admission assessment dated [DATE], include: - R18 requires extensive assistance of two staff to meet his most basic daily tasks of bed mobility, transfers and toilet use. He is non-ambulatory related to a recent [CONDITION(S)] and the inability to apply direct pressure on his right leg, as well as a Stage III PI to his left heel that was recently skin grafted, thus is transferred with the use of a mechanical lift. He requires extensive assistance of one staff to meet his most basic needs of dressing and personal hygiene, and is dependent on staff for bathing. This MDSA also assessed R18 as being occasionally incontinent of bladder function and always incontinent of bowel function. 06/08/21 at 11:03 AM, the Surveyor asked R18 if he receives care and his needs are met in a timely manner. R18 frowned and stated, There is a terrible, terrible staffing problem here. I am supposed to get the dressing on my foot (sticks out his left leg) every morning. Yesterday, they didn't come and they didn't come. Finally at 7:00 last night I asked 'when is my dressing going to get replaced?' The nurse on the evening shift finally did it. I have to direct all my own care or I wouldn't get taken care of the way I am supposed to. They don't either follow the orders the doctor has written, or they have no time to read them. Last night, I put on my call light a little after 7:00, after the nurse did my treatment. I had to go diarrhea. When I need to go, I need to go NOW. I tried to hold it, but finally it flowed like the Niagara falls out of me. That was after 1 hour and 10 minutes of waiting for someone to answer my call light. If you don't think that was embarrassing. Just terrible to s--- (expletive) your pants and have to lay in it until some young chickie comes and has to clean you up. Horrible! I am a grown man, and let me tell you, taking a dump in your pants is a most horrific feeling . right now, I am paying for the full load. I just wrote them out a check .the other day. I don't mind paying for it, but the expectation is that with that amount of money, I damn well better get better care than I am at this point. I will pay whatever is needed, but I expect better service than laying in s--- (expletive) for over an hour! Minimum Data Set Assessment (MDSA) completed for R21, which was a Significant Change in Status assessment dated [DATE] related to R21 enrolling in Hospice Services, R21 requires extensive assistance of two staff to meet her most basic daily tasks of bed mobility, dressing and toilet use. She requires extensive assistance of one staff to meet tasks such as transfers and personal hygiene. She is non-ambulatory and frequently incontinent of bowel and bladder function. The facility conducted a Brief Interview of Mental Status (BIMS), which scores the individual's cognitive function, and scored R21 as 9/15, indicating moderate impairment. The facility also conducted a PHQ-9 (Patient Health Questionnaire) which assesses each of the 9 DSM-IV (Diagnostic and Statistical Manual of Mental Disorder) criteria. R21 scored 8/27, which indicates mild depression. During the screening process on 6/8/21 at 10:27 AM, the Surveyor asked R21 if she receives care and her needs are met in a timely manner. R21 shook her head and stated, I feel they really need help badly. There are times I do have to wait upwards of two hours for help. Once I laid in my soiled diaper in bed for over two hours with my call light on. I soiled several times in that same incontinent product before someone came to help me. I think I would have been able to go on the toilet had someone come in when I put on my call light. Sometimes it is frustrating. That was very embarrassing for me, having to have young girls clean up a soiled diaper of an old lady. They are short staffed like everyone else in this country right now, people don't want to work . Sometimes the girls get short with us and say they can't help that they can't provide better service because they are short staffed, and will get grumpy. I just tell them, 'Well, I am not receiving the services I would want either, we're all in the same boat. I have to wait until they help me. They don't let me get out of my wheelchair by myself, but yet, they don't walk me in the hall either, so that I can get stronger. They don't have enough staff to do that, so I sit here, all day, just waiting. I guess I could put on my call light and ask for help, but I feel so bad for them. They just don't have the time . On 6/10/21 at 1:18 PM, the Surveyor interviewed Certified Nursing Assistant (CNA) P regarding general staffing and services provided to residents. CNA P stated she felt concerned because she is unable to provide residents with care they are deserving of. CNA P stated, It takes a long time sometimes to answer their call lights because we are short staffed and if we are in a room taking care of someone, we cannot leave to answer call lights. So sometimes it can be one-half to one hour, sometimes longer if there are several call lights going off at one time. I feel terrible for them (residents), they deserve better care. Some nurses will help out, but others won't. We don't have all people that work here help with call lights, which is frustrating when you see people just walk past them. Example #6 - Nurse Staffing per Facility Assessment The surveyor requested and reviewed the Facility Assessment Tool which notes the following: Requirement: Nursing facilities will conduct, document and annually review a facility-wide assessment, which includes both their resident population and resources the facility needs to care for their residents. Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during day to operations. Use the assessment to make decisions about your direct care staff needs as well as your capabilities to provide services to the residents of your facility. Date of assessment update: most recently on 4/21 Date reviewed by QAA/QAPI committee: 5/21 Indicate average daily census: 49-53 Consider if it would be helpful to describe the number of persona admitted and discharged , as these processes impact staffing needs: Weekly: Number (average or range of persons admitted ) : 2-3, Number (average or range of persona discharged : 2-3 Evaluation of overall number of facility staff to ensure a sufficient number of qualified staff are available to meet each residents needs. Census: 42 RN: AM: 2, PM: 2 and Nights: 1 CNA: AM: 3.5, PM: 3.5 and Nights: 3 Total Nursing Staff: AM: 5.5, PM: 5.5 and Nights: 4 Total Nursing staff in a 24 hour period=15 *Of note 1 staff is equal to a 8 hour shift Census of 50=addition of 3 nursing staff, for a total of 18 nursing staff in a 24 hour period Census of 53=addition of 4 nursing staff, for a total of 19 nursing staff in a 24 hour period Census of 56=addition of 5 nursing staff, for a total of 20 nursing staff in a 24 hour period Census of 59=addition of 6 nursing staff, for a total of 21 nursing staff in a 24 hour period The surveyor requested and reviewed the facility resident census reports since 4/21/21. The surveyor noted a range of 50 to 57 residents. The average daily census was 53.69 residents from 4/21/21 through 6/14/21. The surveyor requested and reviewed the nurse staff postings form 4/21/21 to 6/14/21 and noted the information did not include staff actual hours worked and the information did not match the nursing staff schedules and nursing assignment sheets used by the facility. See F732 citation. The surveyor requested and reviewed the nursing staff schedules from 4/21/21 to 6/14/21 and noted the schedules did not include actual nursing staff hours worked or changes that occurred during the scheduled pay period. The surveyor requested the nursing staff assignment sheets used by the facility to note actual staff working during each shift from 4/21/21 through 6/14/21 (55 days). The surveyor reviewed the following days and noted the following nurse staffing: Friday April 23, 2021: Census was 56 residents: AM nursing staff included: 3.5 CNAs and 2.5 nurses PM nursing staff included: 3 and 3 nurses Night staffing included: 2 CNAs and 1 nurse Total staffing in a 24 hour period: 8.5 CNAs and 6.5 nurses=15 nursing staff Based on the facility assessment the facility determined 20 nursing staff are needed to adequately care for 56 residents in a 24 hour period. The facility was 5 nursing staff short to meet their residents needs. Saturday April 24, 2021: Census was 53 residents: AM nursing staff included: 2.5 CNAs and 2 nurses PM nursing staff included: 2.75 CNAs and 2 nurses Night staffing included: 2 CNAs and 1 nurse Total staffing in a 24 hour period: 7.25 CNAs and 5 nurses=12.25 nursing staff Based on the facility assessment the facility determined 19 nursing staff are needed to adequately care for 53 residents in a 24 hour period. The facility was 6.75 nursing staff short to meet their residents needs. Sunday April 25, 2021: Census was 55 residents: AM nursing staff included: 2.5 CNAs and 2 nurses PM nursing staff included: 2 CNAs and 2 nurses Night staffing included: 1.5 CNAs and 1 nurse Total staffing in a 24 hour period: 6.0 CNAs and 5 nurses=11.0 nursing staff Based on the facility assessment the facility determined 19 nursing staff are needed to adequately care for 53 residents in a 24 hour period. The facility was greater than 8 nursing staff short to meet their residents needs as the census was greater than 53. Friday May 28, 2021: Census was 56 residents: AM nursing staff included: 2 CNAs and 2 nurses PM nursing staff included: 3 CNAs and 2 nurses Night staffing included: 2 CNAs and 2 nurse Total staffing in a 24 hour period: 7.0 CNAs and 6.0 nurses=13.0 nursing staff Based on the facility assessment the faci [TRUNCATED]

Based on record review and interview the facility did not ensure 2 (R1 and R2) out of 14 female residents who reside on the 100 wing were free from sexual abuse by a CNA (Certified Nursing Assistant). R1 was sexually assaulted by CNA-A sometime between [DATE] and [DATE]. CNA-A inserted his fingers into R1's vagina and also placed R1's hand on his penis and masturbated to ejaculation. R1 had advanced dementia and was unable to consent to any sexual acts. R2 was sexually assaulted by CNA-A on [DATE]. While R2 was seated on the shower chair and naked, CNA-A used his hand without a washcloth to wash R2's perineal area for ,[DATE] seconds. R2 told CNA-A to stop touching her perineal area. R2 stated CNA-A was attempting to insert his fingers into her vagina when CNA-A was told to stop. The sexual abuse created serious psychosocial harm for both R1 and R2. Even though R1 had advanced dementia and unable to report the affects of sexual assault, the reasonable person would be at risk for serious psychosocial harm including but not limited to debilitating anxiety, tearfulness, anger, and feelings of fear. The immediate jeopardy began on [DATE] and was removed on [DATE]. The interim nursing home administrator was notified of the immediate jeopardy on [DATE] at 10:45 AM. The deficient practice was corrected [DATE]. This is evidenced by: Surveyor requested and reviewed the facility policy on abuse prohibition. The policy contained all seven components of abuse prohibition. The facility policy defined sexual abuse as willful non-consensual sexual contact of any type. This definition is consistent with the federal definition. On [DATE] at approximately 10:00 a.m., Surveyor interviewed the DON (Director of Nurses) and the ADON (Assistant Director of Nurses) regarding the 2 abuse allegations. According to the DON and ADON the following data was confirmed via the facility investigation. On [DATE], CNA-A began employment after the facility had completed a background check and a check of references. From [DATE] through [DATE], CNA-A worked as a hospitality aide and did not provide any direct care. On [DATE], CNA-A passed the CNA exam and was added to the state CNA Registry. On [DATE], [DATE], [DATE], [DATE], and [DATE], CNA-A worked second shift on the 100 wing. On [DATE] CNA-A confided to a friend he had done something bad to a resident. CNA-A did not divulge all details to the friend on [DATE]. According to the friend, it was over several days and several face time conversations before CNA-A shared details of what he had done to a resident. On [DATE] the confidential friend reported to the high school police liaison what CNA-A had done to R1. On [DATE] the high school police liaison notified MPD (Minocqua Police Department). On [DATE] the Minocqua Police Department (MPD) notified the DON (Director of Nurses) and ADON (Assistant Director of Nurses) of the allegations of sexual abuse that occurred to R1, but the date of the event was unclear. The MPD determined the abuse occurred sometime between [DATE] and [DATE]. On [DATE], the MPD interviewed CNA-A at his home and then arrested and charged CNA-A with 2 class C felonies for sexual assault of R1. On [DATE], R2 saw CNA-A on the local 10:00 p.m. news and learned he was charged with sexual assault of a resident at the nursing home. R2 then reported to the ADON that she had been sexually abused by CNA-A on [DATE]. The ADON immediately reported the allegation to the MPD on [DATE] shortly after 10:00 p.m. On [DATE] around 11:30 p.m., the MPD conducted an interview and investigation of the sexual assault allegation of R2. The investigation included an interview with R2. R2 stated it felt as if CNA-A was fondling her genitals. On [DATE], CNA-A was again interviewed, arrested, and charged with a class C felony for sexual assault. CNA-A would not speak with the MPD officer; he requested an attorney and to remain silent. Resident 1: R1 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. R1 was to receive rehabilitation and be discharged to an assisted living center once able. R1 was determined to be incapacitated due to dementia prior to admission to the nursing home. R1 had a spouse who made health care decisions. The facility completed an MDS (Minimum Data Set) assessment for R1 on [DATE]. During that assessment, the BIMS (brief interview for mental status) scored 3 out of 15 indicative of severe dementia. Review of the nurses progress notes revealed R1 required extensive staff assist for all dressing, hygiene, bathing, toilet use, transfers, and mobility. R1 was both continent and incontinent of bladder and bowel. Review of the MPD report noted CNA-A acknowledged R1 was afflicted with really bad Alzheimer's dementia and was unlikely to remember any events. CNA-A stated he was assisting R1 with a bed bath when R1 took his hand and used it on herself. CNA-A admitted to inserting his fingers into R1's vagina while R1's hand was on his penis. CNA-A stated he masturbated and ejaculated into a washcloth. CNA-A stated the interaction with R1 had gone too far and he should have stopped. The MPD officer attempted to interview R1, but determined R1 was not capable of making any decisions, giving consent, or providing any information due to advanced dementia. On [DATE] the facility developed a temporary care plan for R1 titled Resident is at risk for exhibiting post traumatic symptoms due to sexual assault. The interventions included staff to provide 1:1 interaction as needed, report any unusual behavior to nurse, provide family with information about post traumatic stress response, and to watch for signs of distress such as crying, yelling, nightmares etc. Resident 2: R2 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS assessment for R2 on [DATE]. The MDS assessment noted R2 was able to make self understood, understand others, was nonambulatory, required extensive staff assist for bathing, dressing, hygiene, and toilet use, and was occasionally incontinent of bladder. R2 scored a 15 out of 15 on the BIMS indicative of intact memory and orientation, Review of the MPD reported revealed CNA-A had offered to assist R2 with a shower on [DATE]. R2 accepted the offer. R2 was placed into a shower chair and was naked. R2 felt CNA-A's hand rubbing the perineal area without a washcloth. R2 described CNA-A's actions as fondling her genitals and playing around down there. R2 also stated CNA-A was attempting to insert his fingers into her vagina, but R2 demanded CNA-A stop touching her genitals. R2 stated she felt uncomfortable about what had happened, she was in disbelief, and ashamed. R2 stated it was hard to believe that an almost [AGE] year old woman would have to deal with being raped. On [DATE] at 1:50 p.m., Surveyor interviewed R2 regarding the sexual assault. R2 was alert and oriented and able to recall details of the event. R2 reported consistent details of the sexual assault as compared to the MPD report. R2 stated she would continue to pray for CNA-A and forgiveness of the assault. R2 stated after [AGE] years, the only male who had ever touched her perineum was her deceased husband and her physician. R2 was in disbelief that a young man would do such a terrible thing. During the interview, R2 was tearful but composed. The facility developed a temporary care plan on [DATE] for R2 titled Resident is at risk for developing post traumatic symptoms due to sexual assault. The goal was for R2 to be able to express feelings openly. The interventions included offer support, report any unusual behaviors or signs of distress such as crying, yelling, nightmares, etc to the nurse, offer counseling, and allow R2 to express feelings. The failure to keep residents free from sexual abuse created a finding of immediate jeopardy. The jeopardy was removed on [DATE] and the deficient practice corrected on [DATE]: CNA-A's last day worked was [DATE] and he was terminated on [DATE]. On [DATE] the facility interviewed all staff and residents to determine if other abuse had occurred and to determine if residents felt safe. The facility had corrected the deficient practice by [DATE], prior to survey exit on [DATE]. The facility had completed staff education, crisis counseling for staff and residents, record review looking for signs of post traumatic stress symptoms, daily resident interviews, held an emergency resident council meeting to inform all residents, informed all resident representatives of the abuse, and completed daily audits/interviews with staff.

Based on observation, interview, and record review the facility did not ensure 1 of 3 sampled residents (R11) received the necessary services to promote the healing of a pressure injury and to prevent the development of infection. R11 was admitted with a stage 4 pressure injury on the coccyx (tailbone). Since 1/1/18 R11's pressure injury has improved and deteriorated multiple times. The facility did not: ~Develop modalities to off-load (relieve pressure) to R11's coccyx pressure injury based on R11's needs; ~Manage R11's incontinence; ~Ensure R11's dressings were in place; ~Ensure the correct treatment was applied; ~Re-evaluate R11's pressure redistribution mattress and wheel chair cushion to ensure they met R11's needs; ~Reposition R11 according to R11's care plan and wound clinic recommendations. R11 was subsequently observed over a period of 5 hours in which R11 was not repositioned in her wheel chair. On 7/18/18 R11 was admitted to the hospital and diagnosed with [REDACTED]. Hospital records indicated R11 had progressive loss of bone in the sacrum and coccyx related to infection. R11 had also developed a fistula (opening) from the coccyx to the rectum resulting in stool matter entering R11's pressure injury. Due to the aggressive surgical and post treatment requirements, R11 was placed on Hospice and returned to the facility. Failure to provide the necessary treatment and services to promote healing and prevent infection of R11's pressure injury lead to the findings of immediate jeopardy that began on 7/18/18. The facility was informed of the immediate jeopardy on 8/23/18 at 11:05 AM. The immediate jeopardy was removed on 8/23/18 The deficient practice continued at a scope/severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. This is evidenced by: R11's current [DIAGNOSES REDACTED]. R11 also had [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus Aureus) infection in the wound. A stage 4 pressure injury is a full thickness injury with loss of skin and tissue and exposed or palpable bone, muscle, or tendons. All wounds need to heal from the bottom up. In order to ensure proper healing, all dead space within a wound cavity needs to be filled with some form of packing. R11's most current MDS (Minimum Data Set) dated 8/1/18 indicates R11: ~Has a BIMS (Brief Interview for Mental Status) score of 7 indicating a severe cognitive impairment; ~Requires extensive assistance of 1 to 2 staff persons for all aspects of care; ~Did not walk; ~Was always incontinent of both bowel and bladder; and ~Has 1 stage 4 pressure injury. R11's MDS dated [DATE] indicated R11 required extensive assistance of 2 staff for all mobility and was always incontinent of bowel and bladder. R11's MDS dated [DATE] indicated R11 required extensive assistance of 2 staff persons for all mobility and was frequently incontinent of both bowel and bladder. R11's skin care plan was dated 9/17/16 includes the following approaches all dated 9/17/16: ~Speciality mattress set at 4. ~A roho cushion in the seat of R11's wheel chair. ~Directions to follow the wound clinic recommendations for treatment. ~To discourage from lying on back and only position and reposition from right to left. ~A toileting program. All of R11's wound clinic notes included, .need for pressure relief measure to this area .limit seating to no more than 1 hour at a time, 3 times a day, with shifts in weight every 15 minutes while sitting .reposition in bed every 2 hours from right to left, avoiding the back side .Sitting should be avoided as much as possible .when up in a chair .should have a pressure reducing cushion under her at all times . The treatment modalities as noted in the wound clinic notes were not all noted on R11's plan of care. Surveyor completed a review of a Discharge Summary dated 6/15/16. The Discharge Summary indicated, .Stage 4 infected sacral decubitus .Hospital Course .admitted for infected sacral decubitus ulcer stage 4 with coccygeal osteomylitis and coccygeal abscess . During the hospitalization R11's sacrum was incised, drained, and debrided. R11 was admitted to the facility on IV (intravenous) antibiotics for 6 weeks for [MEDICAL CONDITION] infection in the wound. On 11/29/16 R11's coccyx wound measured 1.4 cm x 0.4 cm x 2.7 cm (1.4 centimeters by 0.4 centimeters by 2.7 centimeters). Measurements are noted by length, width, and depth. Surveyor completed a review of R11's wound clinic notes and facility wound notes since 1/1/18 and noted the following. ~Wound clinic on 1/4/18, .chronic coccyx stage 4 pressure ulcer .has had debridment of the wound and treatment for [REDACTED].Her dressings continue to be undermined due to urinary incontinence. Dressing today is saturated with urine, adhesive dressing in not over the wound .Measurement .1.5 x 1.4 x 4 (1.5 cm x 1.4 cm x 4.0 cm) .Undermining .circumferential, deepest at 11 o'clock of 2 cm (2.0 cm) .Primary Dressing: [MEDICATION NAME] AG .written instructions, sent with the patient, of the need for pressure relief measures to this area .instructed to limit sitting to no more than 1 hour at a time, 3 times a day, with shifts in weight every 15 minutes while sitting .instructed to reposition in bed every 2 hours from right to left avoiding the back side .Sitting should be avoided as much as possible .increased measurements of the opening .no s/s of infection . The wound clinic note indicated R11's incontinence continued to not be managed by the facility as noted by R11's dressing being saturated with urine. Urine and or stool which comes into contact with R11's wound significantly increased the chance for R11 developing a wound infection. The wound note also indicated the secondary dressing covering R11's wound was not in place also placing R11 at greater risk for infection. On 1/2/18 a facility wound note indicated, .Wound Status .improved .Measurements .Length - 1.00 cm (1.0 cm) .Width - 0.50 cm .Depth - 1.50 cm . ~2/8/18 wound clinic, .has had the stage 4 pressure ulcer at least since (YEAR) when she had surgical debridment for osteomylitis .Examination .dressing has yellow drainage, the [MEDICATION NAME] AG ribbon (the dressing the wound cavity was packed with) cannot be visualized and has to be 'fished' out. No odor .Measurement .1.8 x 1.6 x 4 .(1.8 cm x 1.6 cm x 4.0 cm) .Undermining .circumferential 12 o'clock - 1.8 (1.8 cm) 3 o'clock 4.2 (4.2 cm) 6 o'clock - 4 (4.0 cm) 7 o'clock 5.8 (5.8 cm) .Odor faint .change in wound care .need for pressure relief measures to this area .limit sitting to no more than 1 hour at a time .Sitting should be avoided as much as possible .pressure reducing cushion under her at all times .Chronic stage 4 pressure ulcer to the coccyx with significantly increased measurement of the undermining . A facility wound note dated 2/6/18 indicated, .Wound Status deteriorated .Measurements Length - 2.00 cm .Width - 1.00 cm .Depth - 2.0 cm . The wound clinic note indicated the cavity of R11's wound had not been packed appropriately as the packing itself needed to be 'fished' out. Both the wound clinic note and facility wound note indicated R11's wound had deteriorated including increased measurements and yellow drainage. While the wound clinic changed the treatment to R11's wound there were no other changes made to R11's care plan to promote healing. ~ On 3/8/18 a wound clinic note indicated, .Her dressing is saturated with urine. Her pants are wet as well .Measurement .1.6 (cm) x 0.8 (cm) x 2.5 cm) .Undermining .circumferential .12 o'clock - 1 (1.0 cm) .6 o'clock - 2.2 (2.2 cm) . The wound clinic sent the same instructions to the facility for off-loading and repositioning as noted in previous wound notes. R11's dressing was again noted with problematic incontinence with both R11's wound dressing and clothing noted as saturated with urine. A facility wound note dated 3/6/18 indicated, .Wound Status .Improved .Measurements .Length - 1.00 cm .Width - 0.50 cm .Depth - 2.00 cm . ~ On 4/5/18 a wound clinic note indicated, .When patient is transferred to the bed .very weak and required a 2 person assist .Measurement .1.1 x 0.8 x 3.2 .(1.1 cm x 0.8 cm x 3.2 cm) .Undermining .circumferential .12 o'clock - 1 (1.0 cm .3 o'clock - 3.1 (3.1 cm) . The wound clinic sent the facility the same instructions for off-loading and repositioning as noted in previous wound notes. Weakness was a change in R11's condition. Weakness can be a sign of illness including infection. A facility wound note dated 4/3/18 indicated, .Wound Status .Improved .Measurements .Length - 0.9 cm .Width - 0.50 cm .Depth - 1.50 cm . ~ On 5/3/18 a wound clinic note indicated, .Nursing staff had called with concern of an infection 2 days ago. Culture was obtained and packing was switched to [MEDICATION NAME] AG .Examination .very weak .Upon assessment 4 small .gauze were removed from the wound. They were very malodorous. The [MEDICATION NAME] AG packing which was started 2 days prior was on top of the gauze .Measurement .1.3 x 0.6 x 3.8 .(1.3 cm x 0.6 cm x 3.8 cm) .Undermining .circumferential .12 o'clock - 1 (1.0 cm) .3 0' clock - 3.2 (3.2 cm) 6 o'clock - 1 (1.0 cm) .9 o'clock - 1 (1.0 cm) .ensure all packing is removed from the wound by using one continuous piece .Culture 5/1/18 was positive [MEDICAL CONDITION] . The wound clinic sent the same instructions to the facility for off loading and repositioning as noted in previous wound clinic notes. The 4 small gauze found in the cavity of R11's wound had been there for an undetermined amount of time but greater than 2 days. Inappropriate wound care and lack of proper cleansing and removal of all old dressing materials created an environment in R11's wound for growth of bacteria and infection. R11's wound culture from 5/1/18 was positive [MEDICAL CONDITION]. A facility wound note dated 5/1/18 indicated, .Wound Status .Deteriorated .Measurements .Length - 0.90 cm .Width - 0.5 cm .Depth - 1.5 cm .Symptoms of Infection .Malodorous or purulent drainage . By 5/3/18 it had been identified R11's continence status had not been managed, the dressings ordered by the wound clinic were not always in place or placed appropriately, R11's wound had not been cleansed properly, the wound measurements of R11's pressure injury indicated deterioration of the wound, R11 had a decline in status including weakness, and R11 had a wound culture positive [MEDICAL CONDITION]. Despite that, there were no changes made to R11's plan of care. ~ On 5/18/18 a wound clinic note indicated, Examination .has a hoyer lift sling under her, so the ceiling lift is used to transfer .with assist of 2 .Measurement .0.9 x 0.6 x 3.8 .( 0.9 cm x 0.6 cm x 3.8 cm) .Undermining .circumferential .12 o'clock - 3.5 (3.5 cm) .3 o'clock - 1 (1.0 cm) .6 o'clock - 1 (1.0 cm) .9 o'clock - 4 (4.0 cm) .Drainage Amount .unable to assess, pad is saturated with urine from patient being incontinent . The wound clinic sent the same instructions to the facility for off-loading and repositioning as noted in previous wound notes. R11's condition had declined. R11 had previously transferred with assistance. R11 was now requiring a lift for transfers. A facility wound note dated 5/15/18 indicated, .Wound Status .Deteriorated .Measurements .Length - 1.60 cm .Width - 1.70 cm .Depth - 3.90 cm .Difficult to assess wound bed .? (question) bone visible between 2-3:00 (2 o'clock to 3 o'clock) .Requested new orders from the wound clinic . ~ On 5/31/18 a wound clinic note indicated, .Measurement .0.9 x 0.6 x 3.8 .( 0.9 cm x 0.6 cm x 3.8 cm) .Undermining .circumferential, but is reduced .the edges have [MEDICATION NAME] down into the cavity . The wound clinic sent the same instructions for off-loading and repositioning as previously noted. A facility wound note dated 5/29/18 indicated, Wound Status .Improved .Measurements .Length - 1.40 cm .Width - 1.00 cm .Depth - 3.60 cm .Wound Edges .rolled . Assessments of R11's wound having rolled edges or [MEDICATION NAME] edges is an indication R11's wound is not healing properly from the bottom up. ~ On 6/21/18 a wound note indicated, .Measurement .0.6 x 0.6 x 4.2 .(0.6 cm x 0.6 cm x 4.2 cm) .Undermining .circumferential .12 o'clock - 3.8 (3.8 cm) .9 o'clock - 3.8 (3.8 cm) .Instruction .Please do not use gauze fluffs to pack wound! . The wound clinic sent the same instructions for off-loading and repositioning as previously noted. The wound note indicated the appropriate packing material of [MEDICATION NAME] AG had not been used to pack R11's wound. A Physicians progress note dated 6/21/18 and starred indicated, .Please do not use gauze fluffs for packing. Small strings or particles can remain in the wound causing infection . A facility wound note dated 6/19/18 indicated, .Wound Status .Improved .Measurements .Length - 1.00 cm .Width - 0.5 cm .Depth .3.00 cm . On 7/12/18 a wound clinic note indicated, .Measurement .0.5 x 0.6 x 4.2 (0.5 cm x 0.6 cm x 4.2 cm) .Undermining .circumferential. Tunneling .7 cm at 7 o'clock .edges have [MEDICATION NAME] down into the cavity .Instruction .Please do not use gauze fluffs to pack wound! . The wound clinic sent the same instructions for off-loading and repositioning as previously noted. This was the first notation of tunneling. This was indicative the wound had deteriorated. The facility again used an inappropriate packing material. According to R11's nursing notes on 7/16/18 R11 began complaining of not feeling well and was febrile. On 7/18/18 R11 was examined by a physician. The physician directed the facility to send R11 to the emergency room . R11 was subsequently admitted to the hospital. Surveyor completed a review of R11's Discharge Summary dated 7/25/18. The Discharge Summary indicated, .sepsis from stage 4 pressure ulcer. Osteomylitis involving the sacrum and coccyx .Compared to 6/13/16, there has been progressive loss of bone in the sacrum and coccyx with soft tissue thickening and gas, suggesting osteomylitis with possible fistula to the anorectum .Hospital Course was brought to the emergency room because of respiratory distress .CT (cat scan) was done that showed pretty significant osteomylitis involving the coccyx and the sacrum .There was a fistula connection between the bone and the anorectum .would require aggressive surgical intervention with a diverting [MEDICAL CONDITION] and then hyperbaric oxygen and long-term antibiotics .is not considered a surgical candidate .family elected for her to be enrolled in hospice .Patient is felt to be terminal . According to the Discharge Summary, there was a fistula between the coccyx bone, where R11's wound was, and the rectum. Due to the opening, it was highly likely for stool or stool particles to pass through the opening and into R11's wound. On 7/19/18 R11 was seen by the wound clinic while hospitalized . The wound clinic notes indicated, .Measurement .0.4 x 0.4 x 2.8 (0.4 cm x 0.4 cm x 2.8 cm) .Undermining .circumferential with largest at 9 o'clock at 4.8 (4.8 cm) and 12 0' clock at 2.4 (2.4 cm) .Edges macerated .mild amount of surrounding [DIAGNOSES REDACTED] .edges were macerated and no packing was removed from wound .mild amount of surrounding [DIAGNOSES REDACTED] noted . On 8/23/18 at 9:20 AM Surveyor spoke with MD-Q (Medical Doctor). MD-Q was the physician who followed R11 during the hospitalization of 7/18/18. MD-Q indicated R11 had a long standing chronic wound on the coccyx. MD-Q stated during the hospitalization , it was discovered R11 had a fistula which MD-Q felt was new and not related to a previously noted sinus tract. MD-Q indicated the only way to treat the fistula and prevent stool from entering R11's stage 4 pressure injury was to surgically divert R11's colon and place a [MEDICAL CONDITION]. MD-Q indicated R11 would have then required further treatment of [REDACTED]. MD-Q indicated due to R11's co-morbidities it was determined R11 was not a surgical candidate. MD-Q stated R11 returned to the facility under hospice with orders to keep R11 comfortable. On 8/2/18, Hospice placed a Foley catheter. According to FM-O (Family Member), the Foley was placed at their request. On 08/21/18 at 7:59 AM Surveyor observed LPN-I (Licensed Practical Nurse) and the ADON (Assistant Director of Nursing) complete a dressing change on R11's coccyx wound. LPN-I gathered her supplies. Surveyor noted the wound had no dressing and no packing within the cavity of the wound. LPN-I indicated she had been notified by a CNA (Certified Nursing Assistant) R11's dressing was off. LPN-I cleansed the wound, measured the wound at 1.5 cm x 1.0 cm x 3.5 cm, packed and redressed the wound. Surveyor noted a very slight odor during the cleansing of the wound. The wound edges were rolled inward into the wound. There was no [DIAGNOSES REDACTED] noted. On 08/22/18 at 9:25 AM Surveyor spoke with CNA-C. CNA-C indicated she worked full time on the unit where R11 resides. Surveyor asked CNA-C about R11's dressing as noted during the observation on 8/21/18. CNA-C indicated she cared for R11 on 8/21/18 and when she completed morning cares there was no dressing on R11's wound. CNA-C indicated she looked and did not find the dressing in any of R11's bedding or in R11's brief. CNA-C indicated R11 dressing did not adhere well to R11's skin and many times was found loose or off. On 08/22/18 at 8:45 AM Surveyor observed R11 in bed and positioned on her back. On 08/22/18 at 9:11 AM Surveyor observed R11 on her back with knees bent up. On 08/22/18 at 9:57 AM Surveyor observed R11 was still in bed, on her back, with her knees bent. R11's legs were tilted to the left however not far enough to off-load buttock area. On 08/22/18 at 10:10 AM Surveyor observed R11 was in bed in the same position. According to R11's care plan, R11 is not to lay on her back but be positioned on the right or left side. On 08/22/18 at 11:16 AM Surveyor noted an Air Therapy mattress on R11's bed. The mattress was set at 4. According to the manufacturers specifications the mattress can be set on a 1 to 5 scale with 1 being soft and 5 being firm. This had been the same mattress at the same setting since 9/17/16. On 8/22/18 beginning at 11:30 AM Surveyors made the following continuous observation. ~11:30 AM, R11 was in her wheel chair seated in dining room. ~12:07 PM, R11 was still in the dining room. ~12:15 PM, R11 propelled herself out of the dining room and back to her room. R11 remained in her room until 1:40 PM. ~1:40 PM, CNA-J escorted R11 to an activity in the activity room. R11 remained in the activity room until 2:52 PM. ~2:52 PM, CNA-K escorted R11 to her room. CNA-K assisted R11 to put on a sweater. ~3:23 PM, R11 was greeted by CNA-L. ~3:39 PM, R11 was escorted to the nurses station by CNA-K. R11 remained at the nursing station until 4:02 PM. ~4:02 PM, R11 was escorted to the dining room by CNA-P for trivia. ~4:15 PM, R11 propelled herself to a dining room table. ~4:30 PM, R11 continued to be seated at a dining room table and waiting for supper. From 11:30 AM until 4:30 PM, a period of 5 hours, no staff offered or encouraged R11 to lay down. No staff repositioned R11 in her wheel chair. The facility was informed of the observation. 08/22/18 at 9:25 AM, Surveyor spoke with CNA-C. Surveyor asked CNA-C about R11. CNA-C indicated R11 did not like to lay down and would refuse as she liked to attend all the activities. Surveyor asked CNA-C how they reposition R11 in the wheelchair knowing she doesn't like to lay down. CNA-C indicated she shifted her weight while seated in the chair. On 08/27/18 at 11:58 AM, Surveyor spoke with CNA-G. CNA-G indicated she worked full time on the unit where R11 resides. Surveyor asked CNA-G about R11's wound. CNA-G indicated she wasn't sure why R11's wound did not heal. CNA-G indicated R11 refused a lot to lay down. CNA-G indicated they repositioned R11 in her wheel chair by shifting her weight. On 08/22/18 at 1:04 PM, Surveyor spoke with LPN-I. LPN-I indicated she worked full time on the unit where R11 resides. LPN-I indicated there had been times when she has come on duty and R11's dressing was not on. Surveyor asked LPN-I about the facility's wound management program. LPN-I indicated it was a collaborative approach with the NHA (Nursing Home Administrator) and the DON (Director of Nursing). LPN-I indicated therapy staff were not involved in their program. LPN-I indicated they would change pressure reduction modalities when needed. On 8/21/18 at 4:26 PM Surveyor spoke with FM-O. FM-O indicated they had a lot of concerns over the facility's lack of managing R11's incontinence. FM-O indicated they visited R11 approximately 2 times a week. FM-O stated R11 was found on many occasions saturated and sitting in urine. FM-O stated R11's pressure injury kept getting worse and worse which FM-O attributed to R11's sitting in urine. FM-O stated they spoke with the facility on more than one occasion regarding R11's incontinence however nothing changed and they kept finding R11 soaking wet. FM-O stated they had hopes of R11 returning home when the pressure injury healed. FM-O stated R11 had gotten so bad it ate into R11's lower spine due to infection. FM-O indicated R11 was now on Hospice care because of the wound and wound infection. On 08/22/18 at 2:56 PM Surveyor spoke with the WCC (Wound Care Coordinator) and WTA (Wound Treatment Associate) at the wound clinic R11 was seen at. Both the WCC and WTA indicated they were familiar with R11. Both the WCC and WTA indicated R11 had a chronic wound. Both the WCC and WTA indicated prolonged pressure and incontinence were the two greatest factors of why R11's wound did not heal. The WCC questioned how long R11 sat in her wheel chair without off-loading the coccyx area where the wound was. The WCC also questioned if R11's dressing changes were completed timely and correctly. The WCC indicated the biggest factors in healing R11's wound was off-loading the wound and management of R11's incontinence. The WCC indicated some time ago she was doing rounds at the facility and noted R11's dressing was sometimes not in place or rolled. Both the WCC and WTA indicated there were times R11 was seen in the wound clinic and R11 was found saturated with urine, ordered dressing had not been applied, and on one recent occasion when gauze packing had been left inside the cavity of R11's wound. The WCC indicated they were not sure how long the gauze had been there, but felt the gauze had been there for quite some time. Surveyor asked the WCC and WTA if the facility had ever contacted them for assistance in the management of R11's wound. Both the WCC and WTA indicated they had not. Surveyor asked if there were any off-loading modalities that could be used while R11 was seated in her wheel chair. The WCC indicated a foam wedge alternately placed under the hip and upper thigh tilted the body far enough to take pressure directly off the coccyx bone. On 8/23/18 at 8:20 AM Surveyor spoke with the DON (Director of Nursing). Surveyor asked the DON if the facility received the wound clinic's progress notes. The DON indicated the wound notes were faxed to the facility and placed into resident charts. The DON indicated while the wound clinic notes for R11 were in her chart she never read them. The DON indicate she only looked at the measurements. On 8/23/18 at 11:05 AM Surveyor spoke with the NHA (Nursing Home Administrator) and DON. Surveyor asked why they had never assessed or changed R11's mattress or wheel chair cushion. The NHA indicated the felt the current air loss mattress R11 had was appropriate. The DON indicated she felt a roho cushion was a top of the line cushion and appropriate. The DON did not indicate if any other cushions had been tried. On 8/27/18 at 12:36 PM Surveyor spoke with the DON. Surveyor asked the DON why she felt R11's wound did not heal. The DON indicated R11 had multiple co-morbidities. The DON also indicated R11 drove her care and did not like to lay down. The DON indicated however she would expect staff to follow current treatment modalities. On 8/27/18 at 1:45 PM Surveyor spoke with CNA-C and CNA-G. Both indicated R11 was now up in the wheel chair for only 1 hour. CNA-C and CNA-G stated they are asking R11 if she wants to lay down or go into a recliner to rest. Both CNA-C and CNA-G stated R11 is choosing to lay down in bed. Surveyor asked both CNA's why R11 was now willing to lay down. Both CNA's indicated they were not sure. The immediate jeopardy that began on 7/18/18 was removed on 8/23/18 when the facility: 1. Reassessed R11 to include therapy evaluation for seating surfaces and repositioning devices; 2. Updated R11's care plan; 3. Reviewed all residents who currently have a pressure injury to validate appropriateness of interventions; 4. Reviewed facility policies and procedures as the related to pressure injuries; 5. Education of all nursing staff before the start of their next scheduled shift on assessment, dressing changes, and interpretation of physician orders; and, 6. Education of all CNA staff before the start of their next shift on reporting changes in skin condition and missing or compromised dressings.

Based on observation, interview and record review, the facility did not ensure that 2 of 6 sampled residents with pain, received the necessary care and treatment for [REDACTED]. Resident #14 had significant daily pain and would cry, whimper and moan with any movement including positioning, daily cares, transferring or when sitting. While the facility was aware of this, there were no changes made in Resident #14's plan of care to promote comfort and improve Resident #14's quality of life. Additionally, observations of care revealed Resident #14 called out, moaned, whimpered and cried with any type of movement of any part of her body. While staff were aware, there was no PRN (as needed) pain medication given to ease Resident #14's pain during these times. Resident #7's pain was not assessed by the nursing staff when she continued to complain of pain for one to two hours after receiving an as needed dose of [MEDICATION NAME] sulfate. In addition, periodic/quarterly pain assessments were not completed to include location, intensity, frequency, how the pain affects her quality of life, what makes the pain better or worse, and no non-pharmacological relief measures identified and evaluated. This is evidenced by: Example #1: Resident #14 has current [DIAGNOSES REDACTED]. Resident #14's most current MDS (Minimum Data Set), dated 5/22/15, indicated Resident #14: ~Had unclear speech; ~Had a BIMS score (Brief Interview for Mental Status) of 2 indicating a severe cognitive impairment; ~Required extensive to total assistance of one to two staff persons for all aspects of care; ~Did not walk; ~Was on a scheduled pain regimen; ~Had received no PRN pain medications; and ~Had no pain. Resident #14's pain care plan was dated 12/1/11. The care plan directed staff to administer pain medications as needed during care, for staff to inform a nurse with symptoms of pain, to observe Resident #14 for non-verbal symptoms of pain, to offer rest periods, and to ensure proper body alignment. Resident #14's most current comprehensive pain assessment was dated 5/28/15. The pain assessment indicated Resident #14 had non-verbal indicators of pain including .Crying.Moaning.Wrinkled brow.Facial Grimacing.Wincing. The pain assessment indicated Resident #14's pain was affecting her quality of life. However, no changes were made to Resident #14's pain management regimen. Surveyor # completed a review of Resident #14's physician orders [REDACTED]. The dates as noted are the start dates of each medication. ~1/11/13, Tylenol suppository 650 mg (milligrams) every four hours as needed. ~1/5/15, [MEDICATION NAME] 600 mg (milligrams) twice a day. ~2/3/15, [MEDICATION NAME] sulfate 5 mg to 20 mg every hour as needed. ~3/31/15, [MEDICATION NAME] two tablets in the morning and evening and one tablet in the afternoon. Surveyor # completed a review of Resident #14's MARs (Medication Administration Records) and noted the following: ~April 2015 - Resident #14's regularly scheduled pain medications were administered as ordered. Resident #14 received no PRN Tylenol and one PRN dose of [MEDICATION NAME] sulfate. ~May 2015 - Resident #14's regularly scheduled pain medications were administered as ordered. Resident #14 received no PRN Tylenol and one PRN dose of [MEDICATION NAME] sulfate. ~June 2015 - Resident #14's regularly scheduled pain medications were administered as ordered. Resident #14 received no PRN Tylenol and six doses of PRN [MEDICATION NAME] sulfate. ~July 1 to July 28, 2015 - Resident #14 received her regularly scheduled pain medications. Resident #14 received no PRN doses of Tylenol or [MEDICATION NAME] sulfate. Surveyor # completed a review of Resident #14's nursing notes from 3/2/15 through 7/29/15. There were no nursing notes describing nor critically analyzing Resident #14's pain. On 7/28/15 at 9:50 a.m., Surveyor # observed Resident #14 sitting in her room in a geri chair facing the window. Surveyor # could hear Resident #14 moaning and whimpering from the hallway just outside the entrance to Resident #14's room. Surveyor # entered Resident #14's room. Resident #14 had facial grimacing and was moaning. Surveyor # asked Resident #14 if she was okay. Resident #14 stated, Not good today. Surveyor # asked Resident #14 in several different ways if she was having pain. Resident #14 did not respond but continued to grimace and moan. On 7/28/15 at 10:50 a.m., Surveyor # again observed Resident #14 seated in her room in a geri chair facing the window. Surveyor # again could hear Resident #14 moaning and whimpering. On 7/28/15 at 1:25 p.m., Surveyor # observed CNA-N (Certified Nursing Assistant) and CNA-M assist Resident #14 with care. CNA-M indicated she had just completed a shower for Resident #14. CNA-N and CNA-M began to dry Resident #14 with a towel. Resident #14 was noted to moan and grimace when her right arm was dried. CNA-M and CNA-N assisted Resident #14 to turn from side-to-side. Resident #14 was noted to call out, moan, and grimace. CNA-M and CNA-N placed an adult brief. During this time Resident #14 again cries out, moans and grimaces. CNA-M and CNA-N placed Resident #14's pants by rolling Resident #14 from side-to-side. Resident #14 again moaned, cried out, grimaced, whimpered and then began to cry. CNA-M and CNA-N again turned Resident #14 from side-to-side to place a Hoyer lift sling. Resident #14 again moaned, grimaced and cried out. CNA-M and CNA-N assisted Resident #14 into a wheelchair, removed the Hoyer lift sling, escorted Resident #14 to her room, placed the Hoyer sling again, assisted Resident #14 into bed, and positioned Resident #14 onto her right side. Surveyor # noted with all movements Resident #14 would call out, grimace, moan, whimper and sometimes begin to cry. Neither CNA-M nor CNA-N stopped cares to report Resident #14's pain. Surveyor # spoke with CNA-M about Resident #14. CNA-M indicated Resident #14 was having pain and stated she was going to inform the nurse. CNA-M stated Resident #14 didn't cry out all the time during cares, just when her legs were bothering her. On 7/29/15 at 9:50 a.m., Surveyor # spoke with CNA-GG. CNA-GG stated is was pretty common for Resident #14 to have pain during cares. CNA-GG indicated Resident #14 moaned a lot during care which she considered normal behavior for Resident #14. On 7/29/15 at 12:05 p.m., Surveyor # spoke with CNA-P. CNA-P indicated she worked full time on the unit where Resident #14 resided. CNA-P stated Resident #14 had pain anytime cares were completed. CNA-P stated Resident #14 also sometimes had pain when sitting in the geri chair. CNA-P stated Resident #14's pain was mostly in her legs. CNA-P stated she wasn't sure what made Resident #14's pain better as even positioning doesn't ease Resident #14's pain. On 7/29/15 at 9:55 a.m., Surveyor # spoke with CNA-M. Surveyor # asked CNA-M if she had reported Resident #14's pain as observed the day prior. CNA-M indicated she had told the nurse who in turn told CNA-M she would report it to the evening shift. Surveyor # completed a review of Resident #14's MAR for 7/28/15 to 7/29/15. According to the MAR, Resident #14 never received any additional pain medication to promote comfort and improve Resident #14's quality of life. Surveyor # also completed a review of Resident #14's nursing notes. There was no documentation identifying, describing, or how the facility was going to manage Resident #14's pain. On 7/29/15 at 10:25 a.m., Surveyor # spoke with RN-HH. RN-HH stated Resident #14 had pain daily due to contractures and immobility. RN-HH indicated Resident #14 received scheduled pain medications. RN-HH also indicated she felt Resident #14's pain had not changed over the recent past. On 7/29/15 at 10:00 a.m., Surveyor # spoke with RN-Z (Registered Nurse). RN-Z indicated it was the facility's practice to complete pain assessments quarterly. RN-Z also indicated if any resident was having increased pain she would also complete a pain assessment. RN-Z stated she would enter her findings into the nursing notes. RN-Z indicated the facility utilized the faces pain scale. RN-Z stated their Medical Director just recently suggested the use of a pain scale for those residents with dementia which she had started to use. Surveyor # asked RN-Z about Resident #14's pain. RN-Z indicated Resident #14 had chronic pain due to arm and leg contractures. RN-Z indicated Resident #14 did have orders for PRN pain medications, however Resident #14 had not received them for some time. RN-Z viewed Resident #14's MARs and indicated the last time Resident #14 received additional pain medication was on 6/26/15. Example #2: Resident #7 has been a resident of the facility for over 15 months. Her [DIAGNOSES REDACTED]. Resident #7 is completely dependent on the physical assistance of one to two staff members for all of her activities of daily living, transfers and bed mobility. The current plan of care for pain management, developed 2/10/14, states Resident #7 has pain related to her [MEDICAL CONDITION] joint disease, [MEDICAL CONDITION], and surgical repair of her right ankle. Approaches include: alerting the nurse of pain immediately; administer pain medications as ordered; do pain assessments per policy; encourage her to report pain before it becomes too intense; monitor for non-verbal signs of pain; encourage a balance between rest and activity; reposition frequently for comfort; and, assure proper body alignment. On 7/28/15 from 12:40 p.m. to 1:01 p.m., Resident #7 was observed by this surveyor to be intermittently calling out that she needed help. At 1:01 p.m., CNA-KK (Certified Nursing Assistant) entered Resident #7's room to help. Resident #7 had half undressed herself and positioned herself on her backside while she had called out. CNA-KK asked Resident #7 if she had pain and was told she had pain in her left leg and butt. CNA-KK was observed to approach RN-Y (Registered Nurse) at the nurses' station and have a conversation. Surveyor # continued to observe and hear Resident #7 calling out for staff to Help! Help! Help! Come here! Come here! and Oh, I hurt so bad! Help me! The yelling continued and was repeated every 10 to 15 seconds for the next 40 minutes until CNA-KK and RN-Y came to her room at 1:44 p.m. to put a dressing on her pressure ulcer. While RN-Y was in the room washing her hands, CNA-KK asked Resident #7 if she was still hurting and the resident replied, Oh god! and nodded. RN-Y changed the dressing but at no time did she ask or assess Resident #7's pain. At 1:55 p.m., Surveyor # interviewed CNA-KK and asked if she had made RN-Y aware of Resident #7's pain. CNA-KK said she had told RN-Y about 45 minutes ago and was told that Resident #7 already had a medication for pain. On 7/29/15, Surveyor # reviewed the MAR (Medication Administration Record) and found that RN-Y had given Resident #7 [MEDICATION NAME] sulfate at 11:35 a.m. and RN-Y had charted that the medication was effective at 12:18 p.m. RN-Y did not reassess the resident when told that Resident #7 had breakthrough pain approximately 45 minutes after she charted the medication was effective. Surveyor # reviewed the quarterly pain assessment for Resident #7. The assessments were dated 2/10/14, 11/20/14, 4/9/15, and 6/30/15. These assessments were not completed to include location, intensity, frequency, how the pain affects her quality of life, what makes the pain better or worse, and no non-pharmacological relief measures identified and evaluated. An assessment is not comprehensive without this basic information. The tool the facility uses only prompts the user to complete this information if the resident is actively having pain during the assessment. There is no evidence that staff completed an assessment when Resident #7 was complaining of pain. On 7/29/15 at 9:50 a.m., RN-Z told Surveyor # that Resident #7 can readily express that she is in pain and where it is located. Resident #7 has recurrent pain for which she receives a narcotic patch and the [MEDICATION NAME] sulfate. RN-Z stated Resident #7 cannot rate her pain but there was a tool that was used to do so. RN-Z shared with Surveyor # a photocopy of the current standard of practice for pain assessment scales for those residents with advanced dementia that have pain. The memo from the facility's medical director is dated 7/22/15. RN-Z stated all of the nurses were given this new assessment tool and should be using it for Resident #7.

Based on observation, interview and record review, the facility did not ensure that 5 of 7 sampled residents with pressure ulcers, received the necessary care and treatment to prevent pressure ulcers from developing, promote healing of an existing pressure ulcer, and/or prevent new pressure ulcers from redeveloping. On 6/9/14, Resident #1 developed an unstageable pressure ulcer on the left buttock. Since that time Resident #1 has developed recurrent unstageable pressure ulcers including both buttocks. The facility did not: ~Complete timely assessments and place interventions into place when there was evidence Resident #1 was developing a pressure ulcer. ~Re-evaluate and make changes to Resident #1's plan of care when Resident #1's pressure ulcers deteriorated. ~Complete timely documentation of Resident #1's pressure ulcers. ~Follow Resident #1's care plan for positioning. ~Follow Resident #1's care plan for off-loading devices. ~Utilize off-loading devices appropriate to the stage of Resident #1's pressure ulcers. Resident #3 was admitted to the facility with a stage III pressure ulcer. Since admission, the pressure ulcer has deteriorated and Resident #3 has been treated with an antibiotic for a wound infection. While the facility placed pressure reduction modalities in place on admission, there were no changes to Resident #3's plan of care when the pressure ulcer deteriorated and became infected. Additional observations revealed staff were not repositioning Resident #3 according to Resident #3's plan of care. Resident #2 was admitted to the facility without a pressure ulcer. On 5/14/15, the facility identified skin concerns. Despite that, there were no new interventions added to Resident #2's plan of care to prevent the development of a pressure ulcer. On 5/25/15, 11 days later, Resident #2 developed two stage II pressure ulcers. Additionally, Resident #2 was to have a pressure redistribution cushion on the seat of his recliner. This was noted not to be in place. Resident #8 developed a stage II pressure ulcer to the left medial buttock in the facility. Once healed, the facility did not revise the care plan with approaches to prevent redevelopment of another pressure ulcer. Resident #8 redeveloped a stage II pressure ulcer in the same location. Resident #8 also developed a second stage II pressure ulcer to the coccyx. The pressure ulcer to the coccyx was also documented as healed, and later redeveloped and progressed to a stage III. Although some pressure relieving modalities were changed, they were not appropriate for treatment of [REDACTED]. Residents #1, #3, #2, and #8 examples are being cited at severity level 3 (actual harm/pattern) while the remaining example (Resident #9) is being cited at severity level 2 (no actual harm with potential for more than minimal harm). On 4/7/15, Resident #9 fell and fractured left lower leg (tibia and fibula) which is treated by immobilization. There is no evidence that nursing removed the splint and assessed the leg daily for any skin issues per physician order. On 6/3/15, Surveyor # requested that the nurse remove the splint to observe the skin. Observed was a stage I nonblanchable pressure ulcer on the left aspect 5th metatarsal of left foot measuring 0.5 cm x 0.4 cm. and five areas of bruising on the plantar surface with two large areas deep purple in color. This is evidenced by: Example #1: Resident #1 has current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) was dated 4/5/15 and indicated Resident #1: ~Had BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment; ~Did not reject care; ~Required extensive to total assistance of 1 to 2 staff persons for all aspects of care; ~Did not walk; ~Was frequently incontinent of both bowel and bladder; ~Weighed 230 pounds and was 5 feet 5 inches tall; ~Was at risk for developing pressure ulcers; ~Had no pressure ulcers. Resident #1's most current CAA (Care Area Assessment) for pressure ulcers was dated 4/7/15. The CAA indicated Resident #1 was at risk for the development of a pressure ulcer due to immobility and incontinence. The goal was to ensure appropriate interventions were in place in order for Resident #1 to maintain skin integrity. Resident #1's skin care plan was dated 4/12/14 and had approaches of: ~"...Roho cushion in w/c (wheel chair)...Encourage to reposition Q1 hour (every hour) while in chair...use lift sheet & (and) assist of 2 to turn/Repo (reposition) or boost in bed...Reposition Q (every) 1-2 hours in chair and Q 2-3 hours in bed. Encourage resident to shift weight when up in chair...Encourage to change position every two hours in bed, assist as needed..." None of these approaches were dated. ~ 5/16/15, "...Special pressure reducing mattress on bed...Barrier cream q (every) shift and prn (as needed)..." Resident #1's most current skin risk assessment was dated 5/16/15. The risk assessment had a cumulative score of 11. According to the facility's scoring system, a score of 11 represented a high risk for the development of a pressure ulcer. Surveyor # completed a review of Resident #1's nursing notes and noted the following: ~ 5/22/14, "...Resident presented with back and buttock pain...continues on q 2 hours repositioning schedule..." Pain in the buttock is indicative that a pressure ulcer could be developing. There was no indication an assessment was completed to visualize Resident #1's buttock area. There were no changes made to Resident #1's plan of care. Nursing notes continue. ~ 6/9/14, "...Impaired skin to left buttock, unstageable pressure ulcer, dark purple in color measures 0.3 cm x 0.3 cm (0.3 centimeters by 0.3 centimeters) with nonblanchable redness extending 1 cm around dark purple area...Roho cushion ordered...air mattress placed on bed, q 2 hours turn scheduled and barrier cream BID (twice a day) and PRN (as needed)..." A Roho cushion was supposed to have been implemented already per the 4/12/14 care plan. According to the documentation, Resident #1 presented with a DTI (Deep Tissue Injury). A DTI presents as dark purple localized area. It is a result of pressure and represents damage to the underlying soft tissue. While the facility implemented new approaches, this was done after the development of the DTI. There were no further nursing notes describing the left buttock DTI until 6/17/14, eight days after the development of the pressure ulcer. Nursing notes continue. ~ 6/17/14, "...Unstageable pressure ulcer to left buttock...previous assessment, area was dark purple in color, appeared as a bruise. Area assessed and measured today and has opened...Area measure 1.4 cm x 1.7 cm with a depth of 0.2 cm. Wound bed is 100% yellow, slough... Area was cleansed with warm water and soap and covered with a thick layer of barrier cream...MD (Medical Doctor) updated again with decline in wound, requested order for ...Wound Clinic...Roho cushion in in W/C. Resident has air mattress on bed and due to repositioning schedule, larger bed was requested..." On 6/18/14, Resident #1 was seen by the wound clinic. A wound clinic note dated 6/18/14 indicated, "...has a sore on his buttock that has been getting worse...The patient reports use of the bedpan at night and believes the sore is related to the bedpan use stating that he experiences a lot of pain to his buttock with bed pan use...Examination...2 pressure ulcers: Medial stage 2; lateral Unstageable full thickness...left buttock...Stage 2 1.3 x 0.8 (1.3 cm x 0.8 cm); Unstageable 1.4 x 1.3...Limit time...to no longer than one hour sitting or 2 hours laying down with reposition changes every 2 hours. Limit use of bed pan..." According to the wound clinic note, Resident #1 now had two pressure ulcers. Nursing notes continue. ~ 6/24/14, "...Unstageable pressure ulcer to the left buttock...measure 1.5 cm x 1.5 cm. The edges of the wound are dark red in color, this measures 0.1 cm...and surround the entire wound. The center of the wound measures 1.4 cm x 1.4 cm is yellow slough around the edges and in the middle is an area of dark brown eschar which measure 0.2 cm x 0.3 cm. Surrounding skin is indurated approximately 3 cm (3.0 cm) around the wound, very firm to palpation...Now has a larger bed...air mattress on bed and roho cushion in w/c..." Eschar is devitalized (dead tissue). On 9/2/14, the pressure ulcer was noted as healed. It took almost three months for the pressure ulcers to heal. Nursing notes continue. ~ 3/28/15, "...Buttocks red..." ~ 4/2/15, "...[DIAGNOSES REDACTED] (redness) to perineal area/buttocks..." ~ 4/7/15, "...blanchable redness to the bilateral buttocks but skin is intact..." Resident #1's buttock was again showing signs of pressure ulcer development. There were no changes made to Resident #1's plan of care. Nursing notes continue. ~ 4/13/15, "...Seen...on rounds, orders received...Monitor sacral decub (pressure ulcer); frequent positioning. Notify MD if worsens..." Surveyor # could not determine when the pressure ulcer as noted on 4/13/15 developed. Surveyor # completed a review of Resident #1's TAR (Treatment Administration Record) from 4/1/15 through 6/1/15. The TAR beginning 4/13/15 directed staff three times a day to "...Monitor Sacral Decub (pressure ulcer) - Frequent repositioning. Notify MD if worsens..." This order was discontinued on 5/25/15. From 4/1/15 through 5/14/15, there were no nursing notes describing the sacral pressure ulcer. This was 32 days since the physician identified the pressure ulcer. Nursing notes continue. ~ 5/14/15, "...reported to have pressure ulcer...noted to have two open area, one on each medial buttock. Right buttock measure 0.5 cm x 0.5 cm with no depth, left buttock measure 0.5 cm x 0.5 cm with no depth. Wounds beds are pink...has bariatric bed, will request pressure reduction mattress of overlay to prevent pressure when in bed..." While the pressure reduction overlay was implemented, it was done after the development of the pressure ulcer. There were no further nursing notes identifying Resident #1's pressure ulcer characteristics until 5/24/15. This was ten days after the previous assessment. Nursing notes continue. ~ 5/24/15, "...Ulceration to the right buttock is now unstageable, 100% black eschar, measures 1 cm long x 0.6 cm wide...left buttock is also unstageable, 100% black, eschar measure 1 cm long x 0.6 cm wide...decline in wound status..." In ten days, Resident #1's pressure ulcers deteriorated from superficial wounds to unstageable wounds with black eschar. There were no changes made to Resident #1's care plan. ~ 5/28/15, "...right buttock, 100% of the eschar was debrided, leaving a pink, moist wound bed...small superficial open area remaining which measures 0.5 cm x 0.3 cm...Duoderm was removed from left buttock...found to be healed. Skin is healthy, pink with no open area..." According to the nursing notes, on 5/28/15 the pressure ulcer on Resident #1's left buttock was noted as healed. Nursing notes continue. ~ 6/1/15, "...Returned from appointment @ (at) Wound Clinic...Bolateral (sic) stage 2 pressure ulcers buttocks...can only be in wheelchair 1 hours @ at time for meals..." The pressure ulcer noted as healed on 5/28/15 was again open. Nursing notes continue. ~ 6/4/15, "...Pressure ulcer to the left buttock is superficial with pink tissues in the wound bed....measures 3 cm x 1 cm (3.0 cm x 1.0 cm) with no depth...Pressure ulcer to the right buttock is also superficial with pink tissue in the wound bed which measures 1 cm x 1 cm (1.0 cm x 1.0 cm)..." On 6/2/15 at 10:00 a.m., Surveyor # spoke with Resident #1. Surveyor # asked Resident #1 how he developed a pressure ulcer. Resident #1 stated, "They tell me it's from sitting too long in my wheelchair." Resident #1 also indicated the CNAs were putting cream on his buttock and CNA-M had applied the cream this morning. (Refer to F281.) Surveyor # noted a Roho cushion on the seat of Resident #1's wheelchair. Surveyor # also noted Resident #1 had a standard mattress on the bed with no air overlay or pressure reducing modality. On 6/2/15 at 10:50 a.m. Surveyor # observed CNA-C and CNA-O assist Resident #1 with care. Both CNA-C and CNA-O assisted Resident #1 to roll from side to side removing Resident #1's pants and adult brief. Surveyor # noted Resident #1's bilateral buttocks was heavily caked with a barrier cream and the pressure ulcers on Resident #1's bilateral buttocks were not clearly visible. CNA-O cleansed Resident #1's bilateral buttocks in attempt to remove the barrier cream, however was unable to. At 10:58 a.m., both CNA-C and CNA-O assisted Resident #1 via a Hoyer lift into Resident #1's wheelchair. Surveyor # noted Resident #1 had a standard bariatric foam mattress on the bed with no air overlay. On 6/2/15 beginning at 10:58 a.m., Surveyor # made the following observations: ~ At 10:58 a.m., Resident #1 was assisted to the wheelchair. Resident #1 remained in his room. ~ At 11:55 a.m., Resident #1 was assisted to the main dining room. ~ At 12:03 p.m., Resident #1 received lunch. ~ At 1:00 p.m., Resident #1 was escorted out of the dining room to Resident #1's room by AS-Q (Activity Staff). ~ At 1:02 p.m., Resident #1 put on his call light and requested to lay down. CNA-M answered Resident #1's call light, retrieved the Hoyer lift, and placed Resident #1 in bed. Resident #1 sat in his wheelchair for 2 hours prior to being assisted into bed. At no time during the observation did staff approach Resident #1 and assist Resident #1 with repositioning. Resident #1 was laid down at his request. On 6/3/15 at 11:50 a.m., Surveyor # spoke with CNA-P. Surveyor # asked CNA-P why Resident #1 developed the pressure ulcers. CNA-P indicated she didn't think it was from sitting in urine but stated Resident #1 "didn't like to lay down before he got them." CNA-P stated, "They had cleared them up but then he got them again." CNA-P indicated she did put barrier cream on every time she changed Resident #1's brief. On 6/4/15 at 12:15 p.m., Surveyor # spoke with RN-T (Registered Nurse). RN-T indicated she and RN-U were the facility's wound nurses. RN-T indicated herself or RN-U completed wound rounds every week. RN-T stated this included documentation of wound characteristics. RN-T stated if she didn't see a wound during the week RN-U would. RN-T indicated if wounds changed or if a new wound developed, the nurses on the the floor were to document wound characteristics excluding staging the wound. Surveyor # asked RN-T about repositioning of residents with a pressure ulcer. RN-T indicated residents with a pressure ulcer should be turned or repositioned every one to two hours. RN-T indicated some residents require every hour positioning. Surveyor # asked RN-T about Resident #1's positioning schedule. RN-T stated she would expect staff to follow residents' care plans for positioning including Resident #1. RN-T stated Resident #1 should also have an air overlay mattress on his bed. Surveyor # indicated to RN-T that no air overlay had been observed on Resident #1's bed. Surveyor # requested both RN-T and Surveyor # view Resident #1's bed. On 6/4/15 at 12:30 p.m., Surveyor # and RN-T visualized Resident #1's bed. There was no air overlay. RN-T stated the mattress on Resident #1's bed was the original Panacea bariatric mattress. Surveyor # completed a review of the manufacturer's specifications for the "Panacea Original Bariatric Mattresses." The specifications indicated, "...May be appropriate through Stage II wounds..." Resident #1's pressure ulcers have been unstageable. On 6/4/15 at 2:20 p.m., Surveyor # spoke with the DON (Director of Nursing). The DON indicated she expected staff to document in the nursing notes wound characteristics anytime a dressing was changed. Example #2: Surveyor # completed a review of Resident #3's clinical record and noted the following. Resident #3's current [DIAGNOSES REDACTED]. Resident #3's most current MDS was noted as an admission assessment dated [DATE]. The MDS indicated Resident #3: ~ Had a BIMS (Brief Interview for Mental Status) score of 2 indicating a severe cognitive impairment; ~ Did not reject care; ~ Required extensive to total assistance of 2 to 3 staff persons for all aspects of care; ~ Did not walk; ~ Was always incontinent of both bowel and bladder; ~ Was at risk for developing a pressure ulcer; and ~ Had one stage III pressure ulcer which was present on admission. Resident #3's CAA (Care Area Assessment) for pressure ulcers was dated 5/21/15. The CAA indicated, "...on reposition program...has a air mattress on her bed and a Roho in her chair...extensive/total assist with bed mobility and repositioning...totally incontinent..." The CAA indicated a care plan would be developed. Resident #3's care plan for pressure ulcers was dated 5/11/15. The care plan had the following approaches. ~ "...Air mattress in bed...Roho in w/c (wheel chair)...head of bed less than 30 degrees...weekly evaluation of wound healing...daily observation of skin...supplemental nutritional support...Repo (reposition) QH (every hour) in bed...keep off left sacrum...up in w/c no more than 1H (one hour)..." None of the approaches were dated. Resident #3's most current skin risk assessment was dated 5/28/15. The risk assessment had a cumulative score of nine. According to the facility's scoring system, a score of nine indicated Resident #3 was at high risk for the development of a pressure ulcer. Surveyor # completed a review of Resident #3's nursing notes and wound notes since admission on 5/11/15 and noted the following. On 5/11/15, Resident #3's left sacral pressure ulcer measured 1.0 cm x 1.5 cm (1.0 centimeters by 1.5 centimeters) and had a depth of 1.6 cm. There was also tunneling (a passageway of skin destruction under the surface of the skin) to 2.3 cm at 5 o'clock and undermining (the destruction of tissue which extends under the wound margins) at 0.7 cm. The wound note indicated there was a moderate amount of serosanguineous exudate, no odor, and the wound bed had granulation tissue. On 5/14/15, Resident #3's left sacral pressure ulcer measured 1.6 cm x 1.4 cm and had a depth of 1.5 cm. There was tunneling to 1.8 cm at 5 o'clock and undermining to 1.1 cm. The wound note indicated there was a large amount of purulent serosanguineous drainage and the wound bed had slough. The wound note indicated Resident #3's wound was not unstageable. Resident #3's wound had deteriorated and was showing signs of an infection. There were no changes made to Resident #3's plan of care aside from a change in treatment. The facility obtained a culture of the wound. The culture indicated the wound was infected and on 5/15/15, Resident #3 was started on an antibiotic. On 5/22/15, a nursing note indicated Resident #3's left sacral wound measured 2 cm x 2 cm x 2.5 cm depth (2.0 cm x 2.0 cm x 2.5 cm). The note indicated the old dressing was saturated with brown green drainage. The above nursing note did not include a comprehensive assessment of Resident #3's wound including tunneling, undermining, and the appearance of the wound bed. On 5/25/15, 11 days since the last comprehensive assessment, Resident #3's wound measured 2.0 cm x 1.7 cm x 1.8 cm deep. The nursing note indicated, "...Dressing was completely saturated with purulent drng (drainage)...very foul smelling...copious amounts of purulent drng inside the wound...There is no longer tunneling present, wound now has complete circumferential undermining which measures 1 cm (1.0 cm)...Wound bed is a mix of yellow, necrotic tissue which is approximately 75% of the wound bed...Wound edges are indurated and rolled...decline in wound status...awaiting response from MD (Medical Doctor)..." The facility again identified Resident #3's wound had deteriorated. While the facility obtained an order for [REDACTED]. On 5/27/15, a nursing note indicated, "...dressing was removed and was saturated with very foul smelling, purulent drainage...copious amounts of purulent drainage inside the wound...measure 2 cm wide x 1.6 cm long with a depth of 1.8 cm...complete circumferential undermining which measure 1 cm up to 4 cm in the deepest part. Wound bed is a mixture of yellow, necrotic tissue which is approximately 75% of the wound bed...Wound edges are indurated and rolled...does have approximately 1.2 cm of pinkened tissue surrounding the opening of the wound...Resident does have a referral to the wound clinic..." Resident #3's wound continued to deteriorate. On 6/1/15, a nursing note indicated, "...dressing was removed and was saturated with foul smelling, serosanguineous/purulent drainage...measures 1.4 cm wide x 1.5 cm long with a depth of 1.7 cm...There is complete circumferential undermining which measure from 1 cm up to 4.8 cm...Wound edges are indurated and rolled...does have approximately 1.5 cm of pinkened tissue surround the opening of the wound..." On 6/1/15 at 2:30 p.m., Surveyor # observed RN-T (Registered Nurse), RN-V and CNA-W (Certified Nursing Assistant) complete a dressing change on Resident #3's left sacral pressure ulcer. Surveyor # noted apparent drainage coming through the dressing. RN-T removed the old dressing which was noted to be saturated with brownish colored foul smelling drainage. The measurements were noted as in the nursing notes of 6/1/15. Surveyor # noted Resident #3 had an alternating air overlay on the surface of the bed as well as a Roho cushion in the seat of the wheelchair. Surveyor # requested and received the manufacturer's specifications for Resident #3's alternating air overlay. It was noted as an "Alternating Pressure Pump and Pad System." Under the heading "Intended Use," the specifications indicated, "...The Med Aire series is intended to reduce the incidence of pressure ulcers while optimizing patient comfort..." On 6/10/15 at 12:44 p.m., Surveyor # spoke with HMR-X (Home Medical Representative). HMR-X indicated the air overlay mattress currently being used by Resident #3 was a "group I mattress" and was an appropriate mattress for any stage pressure ulcer on the trunk or pelvis. HMR-X stated this type of mattress would not be appropriate given a decline in the condition of a stage III pressure ulcer. HMR-X stated a group II mattress would be more appropriate. On 6/2/15 at 7:05 a.m., Surveyor # observed Resident #3 seated in her wheelchair in the hallway just outside of her room. Surveyor # made the following continuous observations: ~At 7:48 a.m., Resident #3 was escorted from the hallway to the assisted dining room by CNA-O. ~At 8:03 a.m., Resident #3 received breakfast. ~At 8:34 a.m., CNA-L escorted Resident #3 from the dining room to the hallway by the nursing station. ~At 8:36 a.m., CNA-C escorted Resident #3 to the hallway just outside of Resident #3's room. ~At 8:45 a.m., CNA-C obtained a Hoyer lift and entered Resident #3's room. CNA-C indicated she was going to lay Resident #3 down. During the observation, Resident #3 was not offered or assisted with repositioning. Resident #3 sat uninterrupted for 1 hour and 40 minutes. On 6/4/15 at 12:15 p.m., Surveyor # spoke with RN-T (Registered Nurse). RN-T indicated she and RN-U were the facility's wound nurses. RN-T indicated either she or RN-U completed wound rounds every week which included documentation of wound characteristics. RN-T stated if she didn't see a wound during the week RN-U would. RN-T indicated if wounds changed or if a new wound developed, the nurses on the the floor were to document wound characteristics excluding staging the wound. Surveyor # asked RN-T about repositioning of residents with a pressure ulcer. RN-T indicated residents with a pressure ulcer should be turned or repositioned every one to two hours. RN-T indicated some residents require every hour positioning. Surveyor # asked RN-T about Resident #3's positioning schedule. RN-T stated she would expect staff to follow residents' care plans for positioning including Resident #3. Example #3: Surveyor # completed a review of Resident #2's clinical record and noted the following. Resident #2 had current [DIAGNOSES REDACTED]. Resident #2's most current MDS (Minimum Data Set) was dated 3/24/15 and noted as an admission MDS. The MDS indicated Resident #2: ~ Had a BIMS (Brief Interview for Mental Status) of 13 indicating Resident #2 was cognitively intact; ~ Required the assistance of 1 staff person for all aspects of care; ~ Walked in his room; ~ Was frequently incontinent of bladder and occasionally incontinent of bowel; ~ Was at risk for the development of pressure ulcers; and ~ Had no pressure ulcers. Resident #2's skin care plan was dated 3/17/15. The care plan had the following approaches: ~ "...Position every two hours in recliner...Check for incontinence every 2 hours...Cushion on wheelchair seat..." None of the approaches were dated. ~ 4/2/15, "...Roho cushion in w/c (wheelchair)..." ~ 5/14/15, "...Barrier cream to coccyx QD (every day) and prn (as needed)..." Resident #2's most current skin risk assessment was dated 4/7/15. The risk assessment cumulative score was noted as 15. According to the facility's scoring system, Resident #2 was at mild risk for the development of a pressure ulcer. Surveyor # completed a review of Resident #2's nursing notes and noted the following. ~ 5/16/15, "...Later Entry for 5/14/15...is reported to have skin breakdown on his coccyx/buttocks. Resident was assessed this AM (morning) by writer and skin to coccyx/sacrum and buttocks is WNL (within normal limits)...does have Roho cushion in W/C and is encouraged to turn/reposition frequently when in bed or in recliner..." ~ 5/25/15, "...reported to have pressure sore to bilateral medial/inner buttocks...Left ulceration measure 1 cm long x 0.7 cm wide (1.0 centimeters long by 0.7 cm wide)...shallow with depth of approx (approximately) 0.1 cm. Right ulceration...measuring 0.5 cm long x 0.4 cm wide...with a depth of approx 0.1 cm. Wound beds are red/pink...Surrounding tissue is macerated...currently has roho cushion in w/c, will request to have one added to his recliner, which is where he chooses to sleep...Will encourage resident to reposition q 1 (every hour) during the day when up, and q 2 (every 2) hours at Noc (night). Will assure resident is wearing extra absorbent...briefs...Duoderm to be applied bilaterally..." According to the facility's wound notes, dated 5/25/15, the facility identified both pressure ulcers at stage II. On 5/14/15, the facility identified skin concerns for Resident #2. Despite that, there were no changes made to Resident #2's plan of care. Resident #2 subsequently developed two stage II pressure ulcers 11 days later. On 6/1/15 at 2:15 p.m., Surveyor # observed Resident #2's room. Surveyor # noted two beds on one side of the room and two recliners on the other. Neither recliner had a pressure redistribution cushion on the seat. On 6/3/15 at 1:30 p.m., Surveyor # spoke with Resident #2. Resident #2 was seated in his room in a wheelchair. Surveyor # asked Resident #2 how he developed a pressure ulcer. Resident #2 indicated he was not sure. During the conversation with Resident #2 Surveyor # noted there was no pressure redistribution cushion on the seat of Resident #2's recliner. Resident #2 indicated he slept in the recliner each night. Resident #2 indicated he had "slept in a recliner for [AGE] years." According to the nursing note of 5/25/15, Resident #2 was to have a pressure redistribution cushion placed on the seat of his recliner. This was not observed on 6/1/15 and 6/3/15. It was also not noted on Resident #2's plan of care. Nursing notes continue. ~ 5/28/15, "...Right buttock is healed...Left buttock...measure 0.5 cm x 0.6 cm x 0.1 cm...continues with roho cushion in his w/c..." On 6/4/15 at 12:15 p.m., Surveyor # spoke with RN-T (Registered Nurse). RN-T indicated she and RN-U were the facility's wound nurses. RN-T indicated herself or RN-U completed wound rounds every week. RN-T stated this included documentation of wound characteristics. RN-T stated if she didn't see a wound during the week RN-U would. RN-T indicated if wounds changed or if a new wound developed, the nurses on the the floor were to document wound characteristics excluding staging the wound. Surveyor # asked RN-T why Resident #2 developed a pressure ulcer. RN-T stated she was not sure. Surveyor # asked RN-T why Resident #2 did not have a pressure redistribution cushion on the seat of the recliner. RN-T indicated Resident #2 should have one. On 6/4/15 at 12:30 p.m., Surveyor # and RN-T observed Resident #2's recliner and noted a Roho cushion on the seat of the recliner. On 6/4/15 at 1:15 p.m., RN-T approached Surveyor # . RN-T stated Resident #2's care plan had not included the use of a redistribution cushion on the recliner. RN-T stated she changed Resident #2's care plan to include a cushion in both Resident #2's wheelchair and recliner. Example #4: Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 12/26/14 was diagnosed with [REDACTED]. Review of Resident #8's latest MDS (Minimum Data Set) assessment, dated 4/3/15, indicates cognitive status is moderately impaired and makes her own decisions; power of attorney was recently activated; requires extensive assistance of two staff for bed mobility, transfers, dressing, eating and toilet use; is frequently incontinent of bowel and bladder; has one stage II pressure ulcer and one healed stage II pressure ulcer; and, is on hospice care. Review of wound care notes (measured in centimeters, length x width x depth), interdisciplinary notes, temporary care plans and care plan updates indicate the following: ~On 10/2/14, nursing note: Left Medial buttock open area, measuring 0.5 cm x 0.5 cm x 0.1, red, granulation tissue. Barrier cream applied. Resident complained of pain to the area. ~10/2/14, RN-U documented a stage II pressure ulcer left medial buttock. Interventions: Resident has air mattress on bed, will add every two hour repositioning scheduled and dietary referral. ~10/26/14, comprehensive care note, buttocks resolved. There were no changes made to Resident #8's care to prevent redevelopment of the pressure ulcers. ~12/17/14, nurse's note, open area left buttock. Wound bed red in color with sloughing noted. Pain and applied barrier cream. No measurements completed. ~12/18/14, RN-U documented on the left medial buttock/ishial area. Tender with cleaning and applying of barrier cream. Measures 0.6 cm x 0.5 cm x 0.1 cm. Temporary care plan started. Intervention: Roho cushion or similar placed on wheelchair. ~12/26/14 (eight days later) RN-U documented, left medial measures: 0.6 cm x 0.5 cm x 0.1. New area: Superior to the 1st pressure ulcer 0.2 cm x 0.2 cm x 0.2 cm. Intervention: Will put Roho cushion in recliner chair. ~1/1/15, Left med

Based on observation, interview and record review, the facility did not ensure that 7 of 12 sampled residents either incontinent of urine or with a Foley catheter, received the necessary care and services based on current standards of practice to promote or improve normal bladder function. Resident #1 had a decline in bladder continence even though Resident #1 was able to determine when he needed to void. There was no thorough comprehensive bladder assessment completed in order to determine an appropriate toileting schedule. Observations revealed that staff were not assisting Resident #1 with toileting according to his plan of care. Resident #1 subsequently just voided into his adult brief. According to an interview with Resident #1 and record review, this bothered Resident #1 and made him feel uncomfortable. Resident #1 example is being cited at severity level 3 (actual harm); the remaining examples (Residents #3, #10, #11, #9, #6, and #5) are being cited at severity level 2 (no actual harm with potential for more than minimal harm). Resident #3 was noted by the facility to be always incontinent of bladder due to functional incontinence. While the facility completed a bladder assessment, the assessment was not thorough making it impossible to determine a toileting schedule. Additionally, functional incontinence occurs when a person's bladder is working normally, however, the person cannot get to the bathroom timely. Functional incontinence can be reversible. Resident #10 was noted by the facility to be frequently incontinent of bladder due to functional incontinence. While the facility completed a bladder assessment, the assessment was not thorough making it impossible to determine a toileting schedule. Additionally, observations revealed that staff were not assisting Resident #10 with toileting according to his plan of care. Resident #11 was noted by the facility to have functional and urge incontinence. While the facility completed a bladder assessment, the assessment was not thorough making it impossible to determine a toileting schedule. Resident #9 is coded as always incontinent. A 3-day voiding diary completed is incomplete. The complete bladder assessment indicates Resident #9 has functional incontinence; which occurs when the bladder is working normally, but the person has difficulty getting to the bathroom in time. This can be due to anything that makes walking to or finding a bathroom difficult, such as impaired mobility or memory loss. Resident #6 is coded as frequently being incontinent. A 3-day voiding diary completed in April 2015 is incomplete. In addition, staff did not offer Resident #6 the opportunity to use the bathroom. Resident #5 has a Foley catheter for [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #5 also has a physician's orders [REDACTED]. The physician has not indicated a clear rationale of the need for the monthly changes. In addition, Resident #5 has indicated the catheter changes are "torturous." This is evidenced by: Example #1: Resident #1 had current diagnoses, including but not limited to, historical stroke with left sided weakness, flexion contracture of the left upper extremity, [MEDICAL CONDITION], and depression. The most current MDS (Minimum Data Set), dated 4/5/15, indicated Resident #1: ~Had BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment; ~Required extensive to total assistance of 1 to 2 staff persons for all aspects of care; ~Did not walk; and ~Was frequently incontinent of bladder. Resident #1's MDS, dated [DATE], indicated Resident #1 was continent of urine. Resident #1's most current CAA (Care Area Assessment) for urinary incontinence was dated 4/7/15. The CAA indicated, "...Potential for incontinence due to requiring assist of staff with ADLS (Activity of Daily Living) and use of diuretic...Will...assure toileting needs are met and to improve continence..." Resident #1 did not have a care plan specific to urinary incontinence. Approaches for toileting were noted in multiple areas within the care plan and included: ~"...Toileting: Offer & (and) prompt to void upon rising, AC (before meals), PC (after meals), outings, and naps, HS (hour of sleep) & prn (as needed). Toilet with shower chair over toilet as he chooses..." This approach was undated. ~5/16/15, "...Wears green brief D/T (due to) heavy urinary incontinence..." Heavy urinary incontinence is indicative that Resident #1 was able to hold his urine for periods of time prior to being incontinent. Resident #1's most current risk assessment for bladder training was dated 4/8/15. The risk assessment had a cumulative score of seven. According to the facility's scoring system, a score of seven indicated Resident #1 was a candidate for timed toileting. Resident #1's most current comprehensive bladder assessment was dated 3/30/15. The assessment indicated Resident #1 was frequently incontinent of bladder and had both functional and urge incontinence. The toileting plan included for staff to toilet Resident #1 in the bathroom in the morning, before and after meals, outings, and naps, when Resident #1 went to bed and to use a urinal when Resident #1 was in bed. Surveyor # completed a review of Resident #1's bladder diary, which corresponded to the bladder assessment dated [DATE]. The bladder diary was dated 3/27/15 through 3/29/15. On every day the bladder diary was incomplete. This would make it impossible to determine an appropriate toileting schedule. The "Toilet Motivation And Preference Assessment" for Resident #1 was dated 3/30/15. The form indicated it bothered Resident #1 to "...wet in your diaper..." On 6/2/15 at 10:00 a.m., Surveyor # spoke with Resident #1. Surveyor # asked Resident #1 how often he was assisted into the bathroom to void. Resident #1 stated he didn't use the bathroom and just "go in my diaper." Surveyor # asked Resident #1 why he didn't use the bathroom. Resident #1 indicated he was not sure but thought it was because staff could not use the lift required to transfer him into the bathroom. Resident #1 indicated it made him "uncomfortable" to have to void in his adult brief. During the course of the conversation with Resident #1, Resident #1 indicated to Surveyor # he needed to urinate. Resident #1 put on his call light at 10:20 a.m. The call light was answered by CNA-M at 10:30 a.m. Resident #1 indicated to CNA-M he wanted to get up. CNA-M stated she would be back with another CNA shortly. At 10:37 a.m. CNA-M and CNA-C entered Resident #1's room. Resident #1 indicated to both CNAs he needed to urinate. CNA-M asked Resident #1 if he was sure he needed to void. Resident #1 responded, "Yes." Both CNA-M and CNA-C rolled Resident #1 from side-to-side removing Resident #1's pants then adult brief. At 10:40 a.m., CNA-M placed a urinal for Resident #1 to void into. At 10:45 a.m., Resident #1 indicated he was done. CNA-C removed the urinal. CNA-C indicated Resident #1 had voided 300cc's (cubic centimeters) of urine. Surveyor # asked CNA-C if Resident #1's brief was soiled. CNA-C indicated Resident #1's adult brief was slightly wet but indicated she felt this was due to the urinal spilling. Resident #1 indicated at 10:20 a.m. he needed to void. At 10:40 a.m., Resident #1 was given the urinal and voided. Resident #1 was able to hold his urine for 20 minutes without being incontinent. On 6/3/15 at 7:55 a.m., Resident #1 was escorted to the dining room for breakfast. At 9:02 a.m., Resident #1 was escorted back to his room by Activity-R. At 9:25 a.m., Resident #1 put on his call light which Activity-R answered. Resident #1 indicated to Activity-R he needed to use the bathroom. Activity-R indicated she would need to get the assistance of another staff person. On 6/3/15 at 9:30 a.m., Activity-R and CNA-P assisted Resident #1 into bed. Resident #1 was not offered toileting even though he had stated that he needed to use the bathroom. Resident #1's adult brief was not checked to ensure it was not soiled. On 6/3/15 at 11:50 a.m., Surveyor # observed CNA-P and CNA-G assist Resident #1 into the wheelchair. Surveyor # asked CNA-P when she had assisted Resident #1 with toileting. CNA-P indicated after she laid Resident #1 down after breakfast, Resident #1 put on his call light and indicated he had voided into his brief. CNA-P stated Resident #1 was aware of when he needed to void but didn't ask or he "tells us after the fact." CNA-P also indicated Resident #1 was a "heavy wetter." CNA-P also stated she had checked Resident #1's pad when she laid him down after breakfast. Per Surveyor # 's observation, Resident #1 had indicated he needed to use the bathroom. Resident #1 was not assisted to use the bathroom and the adult brief was not checked. CNA-P indicated to Surveyor # she had checked Resident #1's adult brief approximately 30 minutes prior to getting Resident #1 up for lunch. CNA-P indicated Resident #1's brief was not soiled. Neither CNA-P nor CNA-G offered to assist Resident #1 with toileting when they assisted him into the wheelchair for lunch. On 6/2/15 at 11:07 a.m., Surveyor # spoke with CNA-N. CNA-N indicated Resident #1 waited too long to use the bathroom and then didn't let them know he needed to use the bathroom until it was too late. CNA-N indicated Resident #1 was aware when his adult brief was soiled. On 6/4/15 at 12:45 p.m., Surveyor # spoke with RN-B (Registered Nurse). RN-B indicated it was the facility's practice to complete a bladder assessment on admission, annually, and with a significant change in condition. RN-B indicated a toileting schedule was based on patterning noted on the bladder diary. RN-B indicated if there was an incomplete bladder diary, they would put another one out for staff to complete. RN-B also indicated she would expect staff to follow existing toileting plans for all residents. Example #2: Resident #3's current [DIAGNOSES REDACTED]. Resident #3's most current MDS was noted as an admission assessment dated [DATE]. The MDS indicated Resident #3: ~ Had a BIMS (Brief Interview for Mental Status) score of 2 indicating a severe cognitive impairment; ~ Did not reject care; ~ Required extensive to total assistance of 2 to 3 staff persons for all aspects of care; ~ Did not walk; and ~ Was always incontinent of both bowel and bladder. Resident #3 did not have a specific care plan for urinary incontinence. The care plan problem identified as "Self Care Deficit," dated 5/11/15, had the following approaches. None of the approaches were dated. ~ "...Completely incontinent...Staff to check and change frequently each shift..." Surveyor # completed a review of Resident #3's most current bladder assessment dated [DATE]. The assessment indicated Resident #3 had..."frequent incontinence related to cognitive status/mobility...suggest that resident be on check and change program..." Surveyor # completed a review of Resident #3's bladder diary dated 5/12/15 through 5/14/15. The bladder diary was incomplete. This would make it impossible to determine an individualized toileting schedule. On 6/4/15 at 12:45 p.m., Surveyor # spoke with RN-B (Registered Nurse). RN-B indicated it was the facility's practice to complete a bladder assessment on admission, annually, and with a significant change in condition. RN-B indicated a toileting schedule was based on patterning noted on the bladder diary. RN-B indicated if there was an incomplete bladder diary, they would put another one out for staff to complete. RN-B also indicated she would expect staff to follow existing toileting plans for all residents. Example #3: Resident #10 had current [DIAGNOSES REDACTED]. Resident #10's most current MDS (Minimum Data Set) was dated 3/27/15. The MDS indicated Resident #10: ~ Had a BIMS (Brief Interview for Mental Status) score of 4 indicating a severe cognitive impairment; ~ Required the assistance of 1 to 2 staff persons for all aspects of care; ~ Was frequently incontinent of bladder; and ~ Was always continent of bowel. Resident #10 did not have a specific care plan for bladder incontinence. Under the problem titled, "...self care deficit..." dated 12/28/12, the care plan directed staff to check and change Resident #10 every two to three hours. Surveyor # completed a review of Resident #10's most current comprehensive bladder assessment dated [DATE]. The assessment indicated, "...Resident noted to be consistently incontinent of...bladder. Does not appear to be aware of toileting needs...suggest that resident has functional incontinence related to general debility. Further suggest that resident be on check and change program..." Surveyor # completed a review of Resident #10's bladder diary which corresponded with the assessment of 3/6/15. The bladder diary was dated 2/12/15 through 2/14/15. The bladder diary was incomplete. This would make it impossible to determine an individualized toileting schedule. The facility utilizes a form titled "Assessment for Bowel and Bladder Training." Surveyor # completed a review of Resident #10's "Assessment for Bowel and Bladder Training" dated 3/13/15. The assessment had a cumulative score of 11. According to the facility's scoring system, a score of 11 indicated Resident #10 was a candidate for timed toileting. On 6/2/15 at 10:00 a.m., Surveyor # noted Resident #10 was resting in bed. At 11:45 a.m., CNA-M (Certified Nursing Assistant) and CNA-N entered Resident #10's room and assisted Resident #10 into the wheelchair. At no point did either CNA-M or CNA-N offer to assist Resident #10 with toileting. Neither CNA checked Resident #10's brief to ensure it was not soiled. CNA-M indicated to Surveyor # she hadn't checked Resident #10's adult brief because she checked him when she laid him down after breakfast. On 6/4/15 at 12:45 p.m., Surveyor # spoke with RN-B (Registered Nurse). RN-B indicated it was the facility's practice to complete a bladder assessment on admission, annually, and with a significant change in condition. RN-B indicated a toileting schedule was based on patterning noted on the bladder diary. RN-B indicated if there was an incomplete bladder diary, they would put another one out for staff to complete. RN-B also indicated she would expect staff to follow existing toileting plans for all residents. Example #4: Resident #11 had current [DIAGNOSES REDACTED]. Resident #11's most current MDS was noted as an admission MDS dated [DATE]. The MDS indicated Resident #11: ~ Had a BIMS (Brief Interview for Mental Status) score of 11 indicating a moderate cognitive impairment; ~ Required the assistance of 1 to 2 staff persons for all aspects of care; ~ Did not walk; and ~ Was frequently incontinent of bladder. Surveyor # completed a review of Resident #11's most current bladder assessment dated [DATE]. The assessment indicated Resident #11 had both urge and functional incontinence. The assessment indicated, "...Based on findings, suggest that resident has functional and urge incontinence. Further suggest that resident be offered toileting on rising, before and after meals, outings, naps,and HS (hour of sleep) and as she desires..." Surveyor # completed a review of a bladder diary completed which corresponded to the bladder assessment. The bladder diary was dated 3/24/15 through 3/26/15. The dairy was incomplete. This would make it impossible to develop an individualized toileting schedule. On 6/4/15 at 12:45 p.m., Surveyor # spoke with RN-B (Registered Nurse). RN-B indicated it was the facility's practice to complete a bladder assessment on admission, annually, and with a significant change in condition. RN-B indicated a toileting schedule was based on patterning noted on the bladder diary. RN-B indicated if there was an incomplete bladder diary, they would put another one out for staff to complete. RN-B also indicated she would expect staff to follow existing toileting plans for all residents. Example #5: Resident #9 has [DIAGNOSES REDACTED]. Review of Resident #9's last quarterly Minimum Data Set (MDS) Assessment, dated 3/13/15, and significant change in condition MDS dated [DATE], indicate Resident #9 is always incontinent and is totally dependent on two staff for transfers and toilet use. Review of Resident #9's quarterly bladder assessment dated [DATE], indicates a score of 9. A score of 7-14 indicates a scheduled toileting program will be trialed/ implemented. Review of the 3-day urinary status record, dated 2/12/15 - 2/14/15, revealed that the data collection was incomplete with several blanks in the hourly documentation. Due to the incomplete form a person would not be able to make an accurate toileting plan. Review of the completed incontinence assessment dated [DATE] states: "...Resident noted to have a recent decline in condition. Based on above findings, suggest that resident has functional incontinence related to general decline. Further suggest that resident be offered toileting in bathroom for bowel movement as she indicates need, check and change q 2-3 hrs. through day and noc for bladder incontinence." A second assessment dated [DATE], indicates the facility completed two days of bladder data collection. Again, the data collection was incomplete with several blanks in the hourly documentation. Review of completed Incontinence Assessment, dated 4/17/15, states: "...Based on above findings, suggest that resident has frequent functional incontinence related to cognition/mobility. Further suggest that resident be on check and change program q 2-3 hours day and noc." On 6/1/15 at 1:08 p.m., Surveyor # observed CNA-N and CNA-P asking Resident #9 if they could check her underwear. Resident #9 stated, "No! You heard me....You're not gonna come back." CNA-P stated sometimes she will let us know if she has to be changed, it all depends on the day. CNA-P stated, "We used to toilet her in the bathroom when she was using the sit-to-stand but for a while now we are using the Hoyer lift to transfer her so she can't be toileted. Also, she would probably refuse." Example #6: Review of Resident #6's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicates Resident #6 is frequently incontinent of bladder. Review of Resident #6's most recent assessment for bowel and bladder training completed on 04/21/15 indicates a score of 15. A score of 15-24 indicates she is a poor candidate for a scheduled toileting program or retraining. Review of the 3-day voiding diary, completed on 04/14/15 - 04/16/15, reveals incomplete data. The afternoon shift data for 04/14/15 was not completed. Review of the summary, dated 04/21/15, indicates Resident #6 should be offered toileting in the bathroom every one hour when awake. On 06/02/15 at 11:30 a.m., Surveyor # observed CNA-I and CNA-J (Certified Nursing Assistant) assist Resident #6 get up out of bed for lunch. CNA-I and CNA-J changed Resident #6's soiled brief. The staff did not offer Resident #6 the opportunity to use the bathroom. Example #7: Surveyor # 's review of Resident #5's medical record includes the following Diagnoses: [REDACTED]. Review of Resident #5's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicates a BIMS score of 15 (Brief Interview of Mental Status) and the use of an indwelling catheter. Review of Resident #5's most recent physician orders [REDACTED]." Review of Resident #5's treatment records reveals Resident #5's catheter was changed monthly: 05/17/15, 04/17/15, 03/18/15, 02/16/15 and 01/16/15. On 06/01/15 at 1:00 p.m., Surveyor # spoke with Resident #5. Resident #5 indicated he has had the catheter because of prostate problems. Resident #5 indicated they change the catheter monthly and it is "torturous" for him. On 06/02/15 at 10:35 a.m., Surveyor # spoke with RN-B. (Registered Nurse). RN-B indicated Resident #5 has a catheter due to [MEDICAL CONDITION] with [MEDICAL CONDITION]. RN-B indicated Resident #5 is followed by a urologist in addition to his primary physician. RN-B indicated the standard of practice is change catheters as needed not on a monthly basis. Surveyor # asked RN-B why Resident #5's catheter is changed monthly. RN-B indicated she would have to check on this. On 06/02/15 at 11:00 a.m., Surveyor # spoke with RN-A. RN-A indicated they typically change the catheters only as needed and they are not asking for scheduled catheter changes. There was no medical justification for the monthly catheter changes as noted in January 2015 through May 2015 treatment records. On 06/03/15 Surveyor # received a copy of a progress note written by Resident #5's primary physician on 06/03/15. The physician indicated Resident #5 was hospitalized with urosepsis in July 2014 and that was when it was discovered that Resident #5 had incomplete emptying of the bladder. The physician indicated the catheter was inserted during that hospitalization because of this. The physician indicated the rationale for changing the catheter monthly to be as follows: "Waiting for sign of infection before changing the catheter may lead to life threatening urosepsis...An obstructed Foley catheter could have the same result." This rationale for monthly catheter changes came after Surveyor's questioning on 06/02/15.

Based on observation, staff interviews, and record review, staff did not provide the necessary supervision to prevent falls for 1 of 2 sampled residents reviewed for falls. Resident #4 has a history of falls both prior to and while in the facility. Resident #4's care plan indicated she was not to be left alone in the bathroom. On 11/29/14, staff left Resident #4 unattended in her bathroom at which time she fell . The fall resulted in a 7 inch laceration to her left forehead requiring sutures, subdural hematoma and subarachnoid hemorrhage. Resident #4 was hospitalized from [DATE] until 12/01/14 because of that fall. This is evidenced by: Resident #4 was admitted to the nursing home on 10/17/14 with a history of falls. The record reveals Resident #4 is under guardianship/protective placement at the nursing home. Resident #4's [DIAGNOSES REDACTED]. Resident #4's most recent Minimum Data Set assessment (MDS), dated [DATE], indicates the following: ~BIMS (Brief Interview of Mental Status) score of 4/15. ~Signs of inattention and disorganized thinking. ~Extensive assist of 1 person for transfers. ~Did not walk in room or corridor. ~Extensive assist of 1 person for toilet use. ~Balance not steady moving on off toilet, only able to stabilized with staff assistance. ~Anxiety Disorder. ~Falls since admission. The CAAs (Care Area Assessments) dated 10/24/14, states, "Notes: Resident denies hx (history) of falls but it is clearly noted that she has had at least 3 in the past month. Analysis of Findings: Potential for falls due to altered gait and balance. Risk factors include Dementia with inability to recognize limitations or safety hazards...Resident working with PT (physical therapy) to attain increased balance and to improve gait...will proceed with plan of care." Review of the Physical Therapist Progress and Discharge Summary with an end of care date of 11/25/14, includes the following "...Unable to transition to walking program due to high fall risk... Precautions: Fall Risk, poor safety awareness..." Resident #4's care plan includes a problem of "Potential for falls" dated 10/17/14. Interventions include, but are not limited to, "...Do not leave unattended in bathroom..." The care plan of "eCare Routine Tasks" includes an approach dated 12/1/14 that states, "Not to be left unattended when up in W/C (wheel chair) H/W, B/R, D/R, (hallway, bedroom, dining room), toilet, common areas." The eCare plan also indicates Resident #4 uses alarms. Resident #4's CNA care plan reflects the same approach. Resident #4's Departmental notes reveals Resident #4 had falls on 10/18/14 (2), 10/21/14, 10/24/14, 11/11/14, 11/16/14, and 11/21/14. Following the 11/21/14 fall, the facility added the approach, "Not to be left unattended in any room..." to the care plan. Resident #4's Departmental notes include the following: ~"11/29/14 11:04 a.m. 0600 (6:00 a.m.) CNA called out for this writer from resident's room. This writer entered room and found resident on floor in bathroom next to toilet. CNA stated that resident was on the toilet when CNA stepped away to get resident's clothes and slipped off the toilet and fell to the floor. She was bleeding from the left side of forehead. Upon assessment she presented with a 7 inch laceration. This writer applied pressure to head wound and covered with ABD pads and kerlix....She did have slurred speech upon assessment. This writer called 911 for transport via ambulance to HYMC ER (Howard Young Medical Center emergency room )..." A follow-up note on 11/29/14 indicates the nursing home nurse spoke with the nurse at the hospital. Had transferred from the local hospital to another hospital with admission [DIAGNOSES REDACTED]. Review Resident #4's hospital discharge summary, dated 12/01/14, indicates the following final Diagnoses: [REDACTED]. Same level fall at nursing home. 2. Closed head injury with unknown loss of consciousness. 3. Subdural Hematoma right frontal region. 4. Associated scattered subarachnoid hemorrhage. 5. Scalp hematoma left frontal region. 6. Scalp laceration left frontal region, 10 cm, repaired at HYMC (Howard Young Medical Center). 7. Diffuse volume loss on CT head. 8. Dementia at baseline." On 12/02/14 and 12/03/14, Surveyor # observed Resident #4 numerous times seated in her wheelchair. Resident #4 was observed to have a large laceration on her left forehead into scalp. Sutures and bruising was also noted in this area. On 12/02/14 at 10:35 a.m., Surveyor # spoke with RN-I (Registered Nurse). RN-I indicated she was called to Resident #4's room by CNA-A (Certified Nursing Assistant) on 11/29/14 around 6:05 a.m. RN-I indicated CNA-A said she had assisted Resident #4 into her bathroom and left her sitting on the toilet and left the bathroom to go into Resident #4's room to get her clothes. RN-I said CNA-A had stated when she turned around to go back into the bathroom, Resident #4 had fallen onto the floor on her left side and was bleeding. RN-I said when she went into Resident #4's room, Resident #4 was observed lying on the floor on her left side bleeding from her head. RN-I indicated Resident #4 was conscious. RN-I said she called the ambulance and stayed with Resident #4 until the arrival of the ambulance. RN-I said Resident #4 was not supposed to be left alone in the bathroom due to high fall risk. On 12/02/14 at 1:05 p.m., Surveyor # spoke with CNA-A. CNA-A said when a resident uses personal alarms due to a fall risk, they are to stay with the resident when they are in the bathroom. CNA-A said she was working with Resident #4 on the morning of 11/29/14. CNA-A said she assisted Resident #4 from her wheelchair onto the toilet in the bathroom. CNA-A said she left Resident #4 sitting on the toilet in the bathroom and went into Resident #4's room to get her clothes. CNA-A said she was out of the bathroom maybe 1.5 to 2 minutes and when she turned to go back into the bathroom, Resident #4 was lying on the bathroom floor bleeding from her head. CNA-A said Resident #4 was an alarmed resident and knew that she was not to be left alone anywhere because of her fall risk. CNA-A said she knew that she shouldn't have left Resident #4 alone in the bathroom, but she had only worked with her for 2 days. On 12/02/14 at 2:50 p.m., Surveyor # spoke with the Director of Nursing (DON). The DON said CNA-A was working with Resident #4 on the morning of 11/29/14. The DON said CNA-A had assisted Resident #4 to the bathroom and left her sitting on the toilet and went into her room for Resident #4's clothes, had her back turned to Resident #4, and when she turned to come back into the bathroom, Resident #4 was on the floor. The DON said when a resident has personal alarms and the alarms are removed, staff should stay with the resident in the bathroom. The DON said Resident #4 had been falling at home prior to her admission to the nursing home. The DON said Resident #4 cannot be anywhere unattended due to her high fall risk and now has to be in line-of-sight when up.