Every finding on record at Colonial Health Services

Based on observation and interview, the facility did not store and follow proper sanitation and food handling practices to prevent foodborne illnesses for 50 residents who consume food out of 51 residents who reside at facility. -The facility's resident refrigerator had food items brought in by family/visitors that were not labeled with resident names, content, or dated which could affect 50 of 51 residents at facility who consume food and this could lead to foodborne illnesses.-The facility's resident refrigerator had food items brought in by residents' families that were not dated for 3 residents (R16, R31, R38) of a possible 50 residents who may use refrigerator to store food. A plastic container of what appeared to be a pasta with meat soup or hotdish with R31's name, was not labeled with content or brought in date. -A plastic container labeled as stir fry with R38's name on it, was not labeled with a brought in or opened date. -A plastic container labeled as chicken soup with R16's name on it, was not labeled with a brought in or opened date. This could lead to foodborne illnesses.-Dietary staff transferred foods to the steam table using hand towels instead of oven mitts, dragging the towels through uncovered pans of food already in steam table which could affect 50 of 51 residents at facility who consume food. This food contamination could lead to a foodborne illness.-Dietary staff did not use proper sanitization techniques when temping foods in steam table prior to serving foods which could affect 50 of 51 residents at facility who consume food and lead to a foodborne illness.Findings include: The facility policy, titled Use and Storage of Food Brought in by Family or Visitors, dated 12/14/2022, states, All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.The prepared food should be consumed by the resident within 3 days.If not consumed within 3 days, food should be disposed of by facility staff.The facility policy, titled General Food Preparation and Handling, last revised 08/16/2022, states, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.On 07/06/2026 at 9:40 AM, Surveyor observed resident refrigerator located in a common area had the following:-An opened package of prosciutto without a resident name and not dated when opened. -An opened package of sourdough bread without a resident name and not dated when it was opened. -An opened bottle of V-8 juice without a resident name. Bottle of V-8 had a opened date of 06/30/2026. -An opened package of hard-boiled eggs without a resident name and not dated when opened. The manufacturer expiration date on the package was 07/04/2026. -A plastic container of what appeared to be a pasta with meat soup or hotdish with R31's name, was not labeled with content or brought in date. -A plastic container labeled as stir fry with R38's name on it, without a brought in or opened date. -A plastic container labeled as chicken soup with R16's name on it, without a brought in or opened date. -Signage on door of refrigerator informing staff/family/visitors that all foods brought in should be labeled with resident names, content, and dated when opened. After 3 days from date of food, those foods will be disposed of by facility staff. On 07/06/2026 at 10:10 AM, Surveyor observed Dietary Manager (DM) D going through the resident refrigerator attempting to label and date foods listed above. DM D was observed by Surveyor going to specific resident rooms asking them when foods were brought in by their family members.On 07/06/2026 at 10:10 AM, Surveyor interviewed DM D and asked what facility protocol was for foods brought in by family/visitors for residents and stored in resident refrigerator. DM D stated all foods needed to be labeled with resident's names and dated when opened. DM D stated after 3 days of opened date, a food item was disposed of. DM D stated they check the refrigerator every Monday morning when they come and make sure foods brought in over the weekend are labeled and dated. DM D stated if foods with resident names are not dated, they ask the residents when the food was brought in for them, then dates the food according to what residents state. Surveyor asked DM D if the refrigerator was all staff's responsibility to monitor and DM D confirmed it was. Surveyor asked DM D who checks the food items in refrigerator when they are not there, and DM D stated they were not aware anyone did. On 07/06/2026 at 11:23 AM, Surveyor observed dietary cook (DC) G check temperatures on food for the lunch meal: -DC G did not sanitize the thermometer with alcohol wipe prior to inserting thermometer into a pan of gravy. -DC G did not remove the foil or plastic wrap coverings on the gravy, chicken fried steaks, baked spaghetti, carrots, puree steak, puree carrots and mashed potatoes prior to inserting the thermometer. DC G inserted the thermometer through the food coverings and wiggled thermometer around one spot to check food temps.-DC G did not stir foods prior to checking food temperatures.On 07/06/2026 at 11:30 AM, Surveyor observed DC G remove foil covering on gravy, pick up hand towels lying on a countertop surface nearby, and using a hand towel on each side of the pan, transfer the pan of gravy to the steam table. The hand towels touched inside surface of gravy pan. In the process of placing the gravy pan into the steam table, both hand towels drug over the top of the uncovered pans containing chicken fried steaks and potatoes. The towels came into direct contact with the chicken fried steaks and potatoes. DC G informed Surveyor she could not locate oven mitts. On 07/07/2026 at 9:50 AM, Surveyor interviewed DM D about what the proper technique was for staff to measure temperatures of foods prior to serving. DM D stated the thermometer should be wiped with alcohol before, in between, and after temping foods. Foods should be stirred first, then the thermometer should rest in the food for a minimum of 15 seconds for accurate temperatures. DM D confirmed to Surveyor all foods should have the foil and plastic wrap coverings removed prior to temping and the thermometer should not pass through these as this could cause food contamination. Surveyor asked DM D if using hand towels to handle hot pans of food was appropriate, and DM D stated there were oven mitts available for dietary to use. However, at times the oven mitts are dirty in laundry and there may not be any clean ones available for staff to use by claiming it takes laundry forever sometimes to get them back to us.

Based on interview and record review, the facility did not ensure residents (R) were notified of the specific reason for transfer/discharge, in writing to the resident or their representative. This occurred for 4 of 5 residents (R2, R3, R28, and R52) reviewed for hospitalization, out of a sample of 13 residents. -R2 was transferred to the hospital on 3/22/26. A written notice of transfer was not completed.-R3 was transferred to the hospital on [DATE], 11/8/25, and 7/5/26. A written notice of transfer with specific reason for transfer was not completed for all 3 days. -R28 was transferred to the hospital on 1/17/26, 2/3/26, and 3/19/26. A written notice of transfer with specific reason for transfer was not completed for all 3 dates. -R52 was transferred to the hospital on 3/11/26. A written notice of transfer with specific reason for transfer was not completed. This is evidenced by: The facility policy titled, Transfer and Discharge, dated 7/15/22, states in part: 7. Emergency Transfers/Discharges. g. Provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand. i. Provide a notice of the resident's bed hold policy to the resident and representative at time of transfer, as possible, but no later than 24 hours of the transfer. The State Operations Manual (SOM), section 42 CFR 483.15(c)(5) Contents of the Notice states in part: The facility's notice must include all of the following at the time notice is provided: The specific reason for the transfer or discharge, the basis under 483.15(c)(1)(i)(A)-(F) Example 1 R2 was admitted to the facility on [DATE], with diagnoses including vascular dementia, depression, arthritis, history of right hip fracture, and a hip replacement. R2's Minimum Data Set (MDS) assessment, dated 4/10/26, documents the facility's inability to complete a Brief Interview for Mental Status (BIMS). This indicates R2 is severely impaired cognitively. On 03/22/26, R2 was transferred to the hospital due to pain after a fall. R2's 3/22/26 notice of transfer to the hospital had a general statement of, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, including hospital transfer. The form did not indicate the specific reason the resident required the transfer. Example 2 R3 was admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia and gastroesophageal reflux. R3's Minimum Data Set (MDS) assessment, dated 4/28/26, had a BIMS score of 3 out of 15. This indicates R3 is severely impaired cognitively. On 11/3/25, R3 was transferred to the hospital after choking. R3 was sent for evaluation because they felt like something was still lodged in R3's throat. R3's 11/3/26 notice of transfer to the hospital had a general statement of, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, including hospital transfer. The form did not indicate the specific reason the resident required the transfer. On 11/8/25, R3 was transferred to the hospital due to change in mental status. R3's 11/8/26 notice of transfer to the hospital had a general statement of, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, including hospital transfer. The form did not indicate the specific reason the resident required the transfer. On 7/5/26, R2 was transferred to the hospital due to abdominal pain and suspected gastrointestinal bleed. R3's 7/5/26 notice of transfer to the hospital had a general statement of, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, including hospital transfer. The form did not indicate the specific reason the resident required the transfer. Example 3 R28 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, history of diseases of the digestive system, a ventral hernia, and constipation. R28's MDS, dated [DATE], had a BIMS score of 15 out of 15. This indicates R28 is cognitively intact and R28 is their own person. R28 was transferred to the hospital on 1/23/2026 for nausea and vomiting. R28's 1/23/26 notice of transfer to the hospital had a general statement of, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, including hospital transfer. The form did not indicate the specific reason the resident required the transfer. R28 was transferred to the hospital on 2/3/26 for nausea, vomiting, and concern with bowel obstruction. R28's 2/3/26 notice of transfer to the hospital had a general statement of, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, including hospital transfer. The form did not indicate the specific reason the resident required the transfer. R28 was transferred to the hospital on 3/19/26 for nausea, vomiting, and concern with bowel obstruction. R28's 3/19/26 notice of transfer to the hospital had a general statement of, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, including hospital transfer. The form did not indicate the specific reason the resident required the transfer. On 7/7/26 at 7:45 AM, Surveyor interviewed Registered Nurse (RN) I regarding transferring a resident to the hospital. RN I stated the aides and staff let the nurses know if something is going on with a resident. This prompts the nurses to assess the resident. RN I stated we then contact the provider for direction. If an order is received to send the resident to the hospital, nurses are to complete the e-interact note that goes to the hospital, talk to the resident, and call the family if the resident wants us to. Nurses then print the order summary, face sheet, and paperwork for the hospital which is sent with the ambulance. Surveyor asked if there was any paperwork that pertains to the resident acknowledging why they were being transferred out. RN I stated we complete the bed hold and transfer notice. Surveyor asked what is documented on the transfer notice. RN I stated the reason that the resident is going to the hospital, which usually is the first option. Surveyor asked what happens to that form. RN I stated that it goes to the business office. On 7/7/26 at 1:10 PM, Surveyor interviewed R28 regarding her recent hospitalizations. R28 stated that she has been doing ok and hasn't had a problem since March. R28 stated they have a hernia, and it causes their bowel to get blocked once in a while. R28 stated they are on a daily stool softener. R28 stated they had to go to the hospital in January, February, and in March because they couldn't stop throwing up and their stomach really hurt. R28 said they knew why they had to go, no one had to tell them. R28 does not remember signing anything to keep their bed, but I had no worries about coming back. On 7/8/26 at 8:23 AM, Surveyor interviewed Director of Nursing (DON) B who stated their expectation is that nursing staff make sure the resident or resident representative know why they are being transferred out. DON B stated the notification can be verbal or in writing but needs to be documented in the record. Surveyor asked what pieces are supposed to be completed for a transfer. DON B stated nurses complete the e-interact change of condition that goes to the provider, e-interact transfer form that goes to the receiving hospital and gets a signed bed hold or verbal over the phone. DON B indicated staff should complete a transfer notice letting the resident representative know why the resident is being transferred out. The reason should be on the form. DON B stated an example would be shortness of breath. On 7/8/26 at 8:58 AM, Surveyor interviewed Licensed Practice Nurse (LPN) N about transferring a resident to the hospital. LPN N stated that when they send a resident out to the hospital, they have to complete the bed hold/transfer notice. LPN N said we are supposed to write the reason as to why they are transferring out. LPN N indicated that sometimes we get verbal consent over the phone with the family. If it is verbal, then LPN N signs the form themselves. LPN N stated that the facility's transfer notice and bed hold form does not go with the resident but stays here. LPN N indicated the form is given to records, and she is not sure what they do with it. On 7/8/26 at 9:14 AM, Surveyor interviewed Business Office (BO) R regarding their role with hospital transfers. BO R stated they make sure everything is filled out properly. BO R indicated that if staff forget to document the reason for transfer, they find out what it is and add it to the form. Surveyor asked BO R if the resident or their representative is given a copy of the bed hold and transfer notice. BO R stated they ask them if they want a copy and if they do they give them one. Example 4 On 07/07/26, Surveyor reviewed R52's medical record. R52 was admitted to the facility on [DATE], On 03/11/26, R52 was sent to the hospital for evaluation of a bloody nose that would not stop. On 07/07/26, Surveyor reviewed R52's notice of transfer to the hospital on [DATE] which listed a general statement of, The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, including hospital transfer. The form did not indicate the specific reason the resident required the transfer.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has potential to affect 51 of 51 residents reviewed. -R35 is on Enhanced Barrier Precautions (EBP) and Certified Nursing Assistant (CNA) P did not perform proper hand hygiene practices during personal care or utilize Personal Protective Equipment (PPE).-Medication Aide (MA) F directly touched R47's medications with their fingers for 1 of 3 residents (R) observed during medication administration (R47). Findings include: Example 1 Surveyor reviewed facility policy titled, Enhanced Barrier Precautions, dated last revised 03/25/24, which states: .3. Implementation of Enhanced Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities (described below) and may not need to be donned prior to entering the resident's room. 4. High contact resident care activities include: c. Transferring. d. Providing hygiene. F. Changing briefs or assisting with toileting. R35 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of the right femur, nonrheumatic aortic valve stenosis, anemia, hypertension, and arthritis. R35's Minimum Data Set (MDS) assessment, dated 03/10/26, indicated R35 had Brief Interview for Mental Status (BIMS) score of 13/15, indicating R35 had intact cognition. R35 was at risk for PIs and 3 unstageable DTIs were present on admission. Surveyor reviewed R35's medical record. R35's physician orders: -On 03/02/26, Wound care physician to eval and treat. -On 03/06/26, Enhanced barrier precautions due to wounds. On 07/06/26 at 11:55 AM, Surveyor observed Personal Protective Equipment (PPE) cart outside R35's room near door. Surveyor observed a sign labeled, EBP. On 07/06/26 at 11:55 AM, Surveyor observed CNA P enter R35's room. Surveyor observed that CNA P did not sanitize hands upon entering R35's room. CNA P did not don PPE before entering R35's room. Surveyor observed CNA P don gloves once in room and then transfer R35 to bed to check and change R35's brief. Surveyor observed CNA P lean over R35's bed with scrub top touching R35's blankets on bed. Surveyor observed CNA P place R35 in a wheelchair. CNA P did not utilize correct PPE in R35's EBP room. On 07/06/26 at 1:35 PM, Surveyor interviewed CNA P and asked why CNA P did not utilize PPE while providing peri cares to R35 when transferring R35 from wheelchair to bed. CNA P reported to Surveyor CNA P should have applied gown and gloves prior to entering R35's room because of R35's open wound on foot. On 07/07/26 at 3:48 PM, Surveyor interviewed Director of Nursing (DON) B and asked for expectation for utilizing PPE in an EBP room as for R35. Surveyor informed DON B of Surveyor's observations of CNA P not donning PPE when entering R35's room and providing personal cares. DON B reported to Surveyor expectation is CNA P should have applied gown and gloves prior to transferring R35 to bed to provide peri cares as R35 is on precautions for R35's open wound on heel. Example 2 R47 was admitted to the facility on [DATE]. On 07/07/2026 at 7:45 AM, Surveyor observed medication aide (MA) F administer medications to R47. While MA F was preparing R47's medications, Surveyor observed MA F pop out each medication from its original prepackaged bubble pack provided by pharmacy into their fingers, then place each medication using their fingers into one medication cup containing applesauce. MA F was not wearing gloves and did not perform hand hygiene between each medication. Surveyor observed MA F administer these medications to R47, and R47 took the medications. On 07/07/2026 at 7:59 AM, Surveyor asked MA F what the proper technique was for removing prepackaged medications. MA F stated the medications are individually removed from the packaging and placed into medication cups. Surveyor asked MA F if it was recommended to touch medications directly with fingers or ungloved hands and MA F stated it was not the correct way to remove the medications from packaging. MA F stated, I was taught to pop the pills from the packs into the medication cups.

Based on observation, interview and record review, the facility did not ensure residents are free of any significant medication errors for 1 of 3 residents (R) observed during medication administration in a sample of 13 residents (R5). The facility staff did not ensure R5's crushed Phenytoin was completely dissolved in water, and all medication particles were administered via R5's gastric tube resulting in R5 not receiving accurate dose of medication.Findings include:The facility policy, titled Medication Administration Enteral Tubes, dated 01/2026, states, The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose.The facility policy, titled Medication Administration General Guidelines, dated 02/2026, states, Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices.Prior to administration, review and confirm for each individual client on the Medication Administration Record (MAR).R5 was admitted to the facility on [DATE] with diagnoses including dysphagia, spastic quadriplegic cerebral palsy, epilepsy and history of venous thrombosis and embolism. R5 receives all medications via a Percutaneous Endoscopic Gastrostomy (PEG) tube. R5 is nonverbal and has a Brief Interview for Mental Status (BIMS) score of 0/15, which is severe cognitive impairment. R5's physician orders: Phenytoin oral tablet chewable 50mg - Give 3 tablets via G-tube three times a day. Dissolve in water before administration for epilepsy.Note: Phenytoin (also known as Dilantin) is an anticonvulsant medication primarily used to prevent and control seizures in epilepsy patients. Phenytoin requires periodic blood level monitoring to determine safe serum drug levels and determine correct dosing and need for drug dose titrations. On 07/07/2026 at 7:15 AM, Surveyor observed Licensed Practical Nurse (LPN) E administer medications to R5 via a PEG tube. LPN E crushed the Phenytoin chewable tablet and placed it into a cup of water. LPN E mixed the phenytoin particles with a spoon attempting to dissolve medication. LPN E stated to Surveyor the phenytoin medication was difficult to completely dissolve and get out of the cup. LPN E proceeded to administer the phenytoin via R5's PEG tube. Surveyor observed several particles of undissolved phenytoin medication attached to the sides and bottom of cup. LPN E rinsed the cup with a small amount of water and administered via R5's PEG tube, then disposed of the cup into garbage. Surveyor observed the cup in the garbage with several particles of the phenytoin medication remaining in cup. On 07/07/2026 at 8:13 AM, Surveyor interviewed director of nursing (DON) B and asked what the facility's protocol is for nursing staff to administer crushed medications via a PEG tube. DON B stated crushed medications are dissolved in water, and the medication must be completely dissolved without particles remaining before administering into a PEG tube. Surveyor asked DON B if phenytoin was available in a liquid form and DON B stated she was not definite on that. DON B confirmed with surveyor the facility should check with R5's physician and pharmacy provider if an available liquid form of phenytoin is appropriate for R5 to ensure correct dosing of phenytoin is administered.

Based on observation, interview and record review, the facility did not ensure that its medication error rate was not 5 percent or greater for 2 residents (R5, R47) of 3 residents observed for medication administration in a sample of 13 residents. The facility:-Did not ensure R5's crushed Phenytoin was completely dissolved in water, and all medication particles were administered via R5's gastric tube resulting in R5 not receiving accurate dose of medication.-Did not correctly administer R5's subcutaneous injection of Lovenox possibly resulting in incorrect absorption/dosing of R5's Lovenox. -Gave R47 2 tablets of aspirin when physician order indicated 1 tablet to be given resulting in overdosing of R47's aspirin. -Had a medication error rate of 11.11%.Findings:The facility policy, titled Medication Administration Enteral Tubes, dated 01/2026, states, The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose.The facility policy, titled Medication Administration General Guidelines, dated 02/2026, states, Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices.Prior to administration, review and confirm for each individual client on the Medication Administration Record (MAR).The Federal Drug Administration Prescribing information for Lovenox (an anticoagulant medication used to prevent clots) states, Administered via deep subcutaneous (fatty tissue layer located between the skin and the muscle) injection only.grasp and pinch a fold of skin between the thumb and forefinger.and hold the skin fold throughout the entire injection.Example 1R5 was admitted to the facility on [DATE] with diagnoses that include dysphagia, spastic quadriplegic cerebral palsy, epilepsy and history of venous thrombosis and embolism. R5 receives all medications via a PEG (a soft, flexible tube placed directly through abdominal wall into the stomach allowing delivery of liquid nutrition and medications). R5 is nonverbal and has a Brief Interview for Mental Status (BIMS) score of 0 which is severe cognitive impairment. On 07/07/2026, record review of R5's physician orders:-Enoxaparin Sodium (Lovenox) injection solution prefilled syringe 30mg/0.3ml - inject 30 mg subcutaneously in the morning for DVT (Deep Vein Thrombosis) prophylactics. -Phenytoin oral tablet chewable 50mg - Give 3 tablets via G-tube three times a day. Dissolve in water before administration for epilepsy.On 07/07/2026 at 7:15 AM, Surveyor observed licensed practical nurse (LPN) E administer medications to R5 via a PEG tube. LPN E crushed the Phenytoin chewable tablet and placed it into a cup of water. LPN E mixed the phenytoin particles with a spoon attempting to dissolve medication. LPN E stated to Surveyor the phenytoin medication was difficult to completely dissolve and get out of the cup. LPN E proceeded to administer the phenytoin via R5's PEG tube. Surveyor observed several particles of undissolved phenytoin medication attached to the sides and bottom of cup. LPN E rinsed the cup with a small amount of water and administered via R5's PEG tube, then disposed of the cup into garbage. Surveyor observed the cup in the garbage with several particles of the phenytoin medication remaining in cup. On 07/07/2026 at 8:13 AM, Surveyor interviewed director of nursing (DON) B and asked what the facility's protocol is for nursing staff to administer crushed medications via a PEG tube. DON B stated crushed medications are dissolved in water, and the medication must be completely dissolved without particles remaining before administering into a PEG tube. Surveyor asked DON B if phenytoin was available in a liquid form, and DON B stated she was not definite on that. DON B confirmed with Surveyor the facility should check with R5's physician and pharmacy provider if an available liquid form of phenytoin is appropriate for R5 to ensure correct dosing of phenytoin is administeredOn 07/07/2026 at 7:18 AM, Surveyor observed LPN E administer R5's Lovenox injection. LPN E injected the Lovenox into R5's right upper abdomen at a 90-degree angle. LPN E did not grasp and pinch a fold of R5's abdominal skin prior to inserting Lovenox into R5's abdomen. LPN E did not hold a pinch of R5's abdominal skin fold throughout the entire Lovenox injection. On 07/07/2026 at 8:14 AM, Surveyor interviewed DON B and asked what the facility's protocol is for nursing staff administering subcutaneous injections. DON B stated nursing is to pinch a fold of skin at injection site and hold while injecting medication. DON B confirmed absorption of medication can be affected if medication is not injected correctly. Example 2R47 was admitted to the facility on [DATE] with diagnoses that include intellectual disabilities and morbid obesity. R47 has a BIMS score of 9/15, which means moderate cognitive impairment.R47's physician orders: Aspirin Chew tab 81mg - Give 81mg orally one time a day for antiplatelet therapy related to morbid obesity due to excess calories. On 07/07/2026 at 7:45 AM, Surveyor observed medication aide (MA) F administer medications to R47. MA F stated to Surveyor 2 tablets of aspirin were to be administered according to the MAR. MA F administered 2 tablets of Aspirin 81mg whole in applesauce to R47. Surveyor observed R47 take all of the medication.

Based on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 of 1 resident (R5) reviewed of a sample of 13 residents.R5's bilevel positive airway pressure (BiPAP) machine was not applied per provider's orders.This is evidenced by:R5 was admitted to the facility on [DATE] with obstructive sleep apnea and asthma.R5's most recent significant change Minimum Data Set (MDS) assessment, dated 06/17/26, noted a Brief Interview for Mental Status (BIMS) score of 0/15, indicating severe cognitive impairment. R5 was noted to be dependent for all activities of daily living (ADL).R5's care plan, dated 11/05/25, with a target date of 09/18/26, states: Obstructive sleep apnea used bipap with a goal to adhere to CPAP/BiPAP regimen. Interventions include: encourage resident's use of CPAP/BiPAP.R5's physician orders:06/11/26 BI-PAP SETTING 14/8, PATIENT HAS TO HAVE BIPAP MACHINE ON WHEN SHE IS SLEEPING INCREASING PRESSUE TO 14/8, EVEN IF IT IS NOT NIGHT. DO THIS DILIGENTLY. ADD O2 bleed at 1 liter to Bipap three times a day related to Sleep apnea.On 07/06/26 at 9:19 AM, Surveyor observed R5 sitting upright in recliner with eyes closed. BiPAP machine was observed on nightstand and not in use on R5. Surveyor attempted to talk with R5 but R5 did not open eyes or interact.On 07/06/26 at 10:38 AM, Surveyor entered R5's room and observed R5 sitting upright in recliner with eyes closed. No BiPAP observed in use on R5. Surveyor again attempted to speak with R5. R5 did not open eyes or respond. Surveyor heard R5 making quiet snoring sounds.On 07/06/26 at 11:45 AM, Surveyor entered R5's room and observed Certified Nursing Assistant (CNA) L and CNA M providing assistance to R5's roommate. Surveyor observed R5 sitting in recliner in upright position with eyes closed and snoring softly. No BiPAP was in use. Surveyor asked CNA L if R5 was sleeping. CNA L stated yes. Surveyor asked CNA L if R5 was supposed to have a BiPAP on. CNA L stated only at night.On 07/06/26 at 11:49 AM, Surveyor interviewed Registered Nurse (RN) H regarding R5's BiPAP. Surveyor asked RN H when R5 was supposed to use the BiPAP. RN H stated when in bed sleeping. Surveyor asked RN H about R5's order to have BiPAP used anytime R5 was sleeping. RN H the provider said it could be left off if R5 was sleeping in the chair. Surveyor asked RN H if this communication with the provider was documented. RN H stated not being sure and would look. No additional documentation was provided.On 07/06/26 at 11:53 AM, Surveyor interviewed Director of Nursing (DON) B regarding R5's BiPAP. Surveyor asked DON B if R5's BiPAP was supposed to be in use while sleeping. DON B stated yes. Surveyor explained to DON B of the multiple observations of R5 sleeping without the BiPAP in place. DON B stated that R5 was likely not sleeping and just had their eyes closed. Surveyor informed DON B of observing snoring sounds. DON B stated if R5 was sleeping, then BiPAP should be on.

Based on observation, interview and record review, the facility did not ensure resident was free from complications of a feeding tube for 1 of 1 resident reviewed for tube feedings in a sample of 13 residents (R5).The facility did not verify proper Percutaneous Endoscopic Gastrostomy (PEG) tube placement on R5 prior to administering medication through it which could result in physical harm to resident.Findings include: The facility policy, titled Verifying Placement of Tube Feeding, last revised 08/10/2022, states, Before beginning a feeding, flushing a tube, or administering medication via a feeding tube, proper placement and functioning will be verified.for gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube.R5 was admitted to the facility on [DATE] with diagnoses inclduing dysphagia, spastic quadriplegic cerebral palsy, epilepsy and history of venous thrombosis and embolism. R5 receives all medications via a PEG tube. R5 is nonverbal and has a Brief Interview for Mental Status (BIMS) score of 0 which is severe cognitive impairment. On 07/07/2026 at 7:15 AM, Surveyor observed Licensed Practical Nurse (LPN) E administer medication via a PEG tube to R5. LPN E verified R5's PEG tube placement by auscultation above the epigastrium while injecting air into a syringe. LPN E aspirated less than 5ml of gastric contents using same syringe. LPN E did not verify R5's PEG placement by gently pulling on the tube for retention or confirming tube marking/measurement on feeding tube at insertion site prior to administering R5's medications via the PEG tube. On 07/07/2026 at 7:30 AM, Surveyor asked LPN E how R5's PEG tube placement is monitored for possible migration outward. LPN E stated daily PEG tube measurements from insertion are done by nursing and documented on the medication administration record (MAR). LPN E demonstrated measurement of R5's PEG tube of 19cm from insertion site to surveyor and compared it prior documentations in R5's MAR. LPN E stated to Surveyor she was not aware that auscultation is no longer recommended for checking placement of feeding tubes. LPN E stated they were not aware of recent standards of practice for correct verification of feeding tube placement was observation for changes in external length of tubing from insertion site. On 07/07/2026, record review of R5's physician orders: Measure G-tube daily and record in centimeters in the morning for G-tube placement - measure from ABD (abdomen) to end of tube. R5's medication administration record (MAR) indicated daily AM documentation of feeding tube measurements. R5's MAR did not include documentation of feeding tube measurements with each medication or enteral feeding administrations throughout the day.On 07/07/2026 at 8:13 AM, Surveyor interviewed director of nursing (DON) B and asked how facility nursing staff should verify correct feeding tube placement prior to enteral feedings and medications administrations. DON B stated feeding tubes should be measured from insertion site prior to every administration of medications or feedings to ensure safe administration of medications/feedings and monitor for accidental misplacement of feeding tube.

Based on observation, interview and record review, the facility failed to ensure a resident who receives nutrition and hydration maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates otherwise for 1 of 13 residents (R6) reviewed for nutrition and hydration.R6 had a daily fluid restriction of 1500cc. On 03/12/26, 03/13/26, 03/17/26, 03/22/26, 03/29/26, 04/19/26, 04/20/26, 05/10/26, 05/23/26, 05/29/26, 06/22/26, and 06/30/26, R6 went over the fluid restriction. The facility did not complete additional lung assessments or notify the provider.This is evidenced by:R6 was admitted to the facility on [DATE] with stage 5 chronic kidney disease with heart failure and dependence on renal dialysis.R6's physician orders include:01/03/26 24-hour fluid intake one time a day for monitoring.03/21/26 1500 cc Fluid intake - record q shift. Dietary - Breakfast: 360cc, Lunch 240cc, Dinner 240cc Nursing - AM: 280cc, PM: 280cc, NOC 100cc three times a day for heart failure, dialysis.Surveyor reviewed R6's medication administration record (MAR) and noted R6 exceeded the 1500 cc fluid restriction:03/12/26: 1640 cc03/13/26: 1720 cc03/17/26: 1680 cc03/22/26: 1660 cc03/29/26: 1720 cc04/19/26: 1800 cc04/20/26: 1740 cc05/10/26: 1960 cc05/23/26: 2080 cc05/29/26: 1800 cc06/22/26: 1600 cc06/30/26: 1760 ccOf note: no documentation of additional lung assessments or provider notification were documented.On 07/07/26 at 2:49 PM, Surveyor interviewed Registered Nurse (RN) I regarding fluid restrictions. Surveyor asked RN I to explain the process for nursing if a resident exceeds a fluid restriction. RN I stated that if a resident goes over their fluid restriction, the nurse should complete a thorough lung assessment, notify the provider and document all of this in the resident's chart.On 07/08/26 at 9:36 AM, Surveyor interviewed Director of Nursing (DON) B regarding R6's fluid restriction. Surveyor asked DON B how R6's fluid restriction is monitored. DON B stated the overnight nurse tallies the daily total in R6's MAR and the Assistant DON (ADON) reviews this daily. Any overages are discussed with the provider. Surveyor asked DON B if this is documented. DON B stated the ADON is currently on vacation, but that it should be documented. Surveyor asked DON B if the expectation was for nursing to complete additional assessments and notify the provider when the fluid restriction was exceeded. DON B stated yes. No additional documentation was provided demonstrating the provider was notified of R6 exceeding the fluid restriction or additional lung assessments were completed.

Based on observation, interview and record review, the facility did not ensure 1 of 13 residents at risk for falls received adequate supervision and assistance devices to prevent accidents.Facility staff left R11 on commode alone without the ability to use call light for assistance.Findings include: R11 was admitted to the facility on [DATE] with diagnoses including in part, obstructive hydrocephalus, and unspecified dementia.R11's Minimum Data Set (MDS) assessment, dated 05/20/26, identified R11 had Brief Interview for Mental Status (BIMS) score of 10/15 indicating R11 had impaired cognition. MDS identified R11 as being dependent with assistance sitting to lying, chair to bed, toileting, and for transfers. R11's care plan:Focus:Actual/at risk for falls due to weakness, pain, cardiac diagnosis, impaired mobility, and obesity. Date Initiated: 08/05/25 with revision on: 02/16/26:Interventions:-On 06/13/25, staff education including footwear (gripper socks/soled shoes), gait belt for all transfers, 2 person assist for all transfers, go slow and explain what you are doing.-On 08/05/25, Reinforce need to call for assistance.-On 08/06/25, Soft touch call light. R11's ADL self-care deficit care plan. Date initiated: 08/05/25 with revision on 05/19/26: Interventions:-On 08/05/25, Toileting assist of 2 with walker.-On 10/07/25, Transfer: EZ stand with assist x2. Invacare sling - X-Large. -On 10/07/25, Transfer: sit to stand lift. R11's care plan:Difficulty communicating as evidenced by losing track of conversations, memory issues, related to decline in cognitive status, cognitive communication deficit, obstructive hydrocephalus care plan. Date initiated 08/05/25 with revision on 01/27/26: Interventions:-On 08/05/25, Demonstrate understanding by completing task when requested.-On 08/05/25, Speak in a manner that can be understood.-On 08/05/25, Gain individual's attention before beginning to converse.-On 08/05/25, Provide reassurance and patience when communicating with resident.-On 08/05/25, Repeat information as needed. R11's fall risk assessment, dated 05/09/26, identified R11 at risk for falls. On 07/07/26 at 9:21 AM, Surveyor observed Certified Nurse Assistant (CNA) P and CNA T enter R11's room and close R11's door.On 07/07/26 at 9:26 AM, Surveyor observed CNA P and CNA T exit R11's room and close the door to room.On 07/07/26 at 9:30 AM, Surveyor entered R11's room and observed R11 on commode using the bathroom. Surveyor exited R11's room and closed R11's door.On 07/07/26 at 9:40 AM, Surveyor entered R11's room and observed R11 still sitting on commode using bathroom in the middle of the room. Surveyor peeked around curtain and asked R11 if R11 was ok. Surveyor observed R11 trying to scoot commode back with R11's feet on floor scooting and leaning backwards. R11 stated to Surveyor, I am but I am not sure what I am doing on this and why I can't back up, but I am done. My chair must be broken. Surveyor informed R11, R11 was on the commode to use the bathroom. Surveyor asked R11 if R11's call light was in reach. R11 stated, My what? Surveyor explained that R11 had a call light attached to R11's shirt on left shoulder. R11 stated, I cannot see what you are talking about. Surveyor exited R11's room to find assistance. Surveyor could not find assistance at this time.On 07/07/26 at 9:47 AM, Surveyor observed Nurse Practitioner (NP) Q walk up to R11's door and asked Surveyor if staff are completing cares. Surveyor informed NP Q that R11 was still on commode but stated that R11 was done. NP Q stated, I will come back.On 07/07/26 at 10:01 AM, Surveyor observed NP Q approach R11's room and asked Surveyor if R11 is still on commode. Surveyor let NP Q know that R11 was still on the commode. NP Q stated, R11 is still on the commode! NP Q went into R11's room to check on R11 and asked, [R11] are you done using the commode? R11 responded, I sure hope so. NP Q entered and had to push the call light for R11 so that staff could come assist R11 off the commode. Surveyor observed R11's call light go on.On 07/07/26 at 10:02 AM, Surveyor observed NP Q exit R11's room and told R11, Make sure to tell staff you are done using the commode. Surveyor interviewed NP Q and asked if NP Q had to push R11's call light for R11's call light to go on. NP Q reported to Surveyor NP Q had to push R11's call light, and sitting on the commode for that long is not appropriate for [R11's] skin nor should [R11] be left alone that long on commode. Surveyor asked NP Q if R11 is appropriate to be left alone to use call light as R11 seemed confused about the use of the call light. NP Q reported to Surveyor R11 has been declining in memory and should not be left alone to use the call light.On 07/07/26 at 10:07 AM, Surveyor observed CNA P and CNA T enter R11's room to assist R11 off the commode. Surveyor observed CNA T lift R11 up with EZ-stand. Surveyor asked CNA P why R11 was left on commode for about 45 minutes. CNA P stated to Surveyor, R11 likes to sit on commode for a while and so CNA P usually goes in and checks on R11 to see when R11 is done every so often. Surveyor asked CNA P did CNA P ever go in and check on R11 at any time after placing R11 on commode at 9:26 AM. CNA P reported to Surveyor CNA P did not get a chance to check on R11.On 07/07/26 at 10:14 AM, Surveyor interviewed CNA P and asked if R11 uses call light appropriately. CNA P reported R11 uses call light about 50/50. CNA P reported to Surveyor R11 sometimes refuses to use call light. Surveyor asked CNA P if refusals to use call light are documented or care planned. CNA P reported to Surveyor CNA P does not document refusals in medical record.On 07/07/26 at 10:47 AM, Surveyor interviewed R11's Family Member (FM) U and asked FM U if R11 uses the call light when FM U is around. FM UM reported that R11 forgets easily what the call light is for so the only time it is used is when FM U is in building and reminds R11 or pushes call light for R11.-On 07/07/26 at 3:33 PM, NP Q (Nurse Practitioner) dictation note: R11 seen today psychiatric follow-up evaluation the patient [R11] reports that R11 would just want to go home. R11 reports sleeping and eating well. There is noted progression of dementia, as the patient is unsure of how to use the call light appropriately. These changes in cognition should be communicated to staff to implement in the plan of care with the decline in cognition. Follow up in 4 weeks or sooner if changes in mood or behaviors. Cognition: alert, oriented x2; decline noted as patient is unsure of how to use the call light appropriately, consistent with progression of dementia- Judgement: poor/impaired; further decline given inability to use call light appropriately- Insight: poor/impaired; further decline given inability to use call light appropriately.-On 07/07/26 at 4:00 PM, Summary for Provider (SBAR) change in condition: Outcomes of physical assessment: Positive findings reported on the resident/patient evaluation for this change in condition were:- Mental Status Evaluation: Increased confusion (e.g. disorientation)Resident [R11] also was seen by psych provider [NP Q] today and provider had stated that resident was noted to have more confusion and seemed that she was not able to comprehend how to use call light today.Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:A. Recommendations: Per psych provider [NP Q] please check on resident more frequently to make sure resident care needs are met due to inability to comprehend how to use call light.On 07/07/26 at 3:48 PM, Surveyor interviewed DON B and asked how long R11 can sit on commode. DON B reported R11 likes to sit on commode for a long time and often refuses to get off commode until finished. Surveyor asked DON B's expectation of CNA P to check in on R11 and see if R11 was completed using the commode. DON B reported R11 sometimes wants to stay on for a long time, but staff are to check on R11 periodically and document the attempts. Surveyor reported to DON B that Surveyor could not find documentation of R11's commode uses for long periods of time, nor could Surveyor find interventions in R11's care plan.

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice to prevent further deterioration and promote healing of an existing PI for 2 of 3 residents (R) reviewed for pressure injuries (PI) (R35 and R8) out of 13 sample residents. R35 is being cited at a scope and severity level of actual harm/isolated. R8 is being cited at a scope and severity of potential for harm/isolated. R35 was at risk for development of PIs and had 3 Deep Tissue Injuries upon admission to the facility. DTIS were on R35's sacrum, right buttocks, and the right heel. The facility failed to complete a comprehensive skin assessment upon admission, failed to complete weekly wound assessments, and implement offloading interventions. The facility failed to apply an ace wrap correctly to R8's right foot and did not ensure replacement of foam for a post-op shoe was completed. Findings include: Facility policy titled, Pressure Injuries and Non-pressure Injuries, last revised 07/20/22, states: .1. Upon admission: a. A head-to-toe body evaluation will be completed on every resident upon admission/readmission and will be documented on the Admission/readmission Evaluation UDA. If skin is compromised: i. If pressure injury: Initiate the Pressure Injury Weekly Tracker UDA- one per wound. iii. Ensure primary care physicians are aware of wounds/location of wounds and current treatment orders. iv. Ensure appropriate treatment orders for each wound area, as needed. C. Initiate the baseline plan of care related to current skin status and skin risk level. 2. Weekly: a. Complete a head-to-toe skin check and document findings on the Skin Review weekly NSHC UDA. If new areas are present: i. Notify MD. iii. Initiate treatment per order. v. Update Plan of Care. vi. Discuss during shift-to-shift report process. vii. Review with IDT. b. Assess current wounds at least every seven days, or more frequently as needed (e.g., decline in wound, presence of infection, wound healed). 4. As needed or upon a significant change of condition: a. A complete Braden Scale and update care plan as needed if changing/new risk factors. Example 1 R35 was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of the right femur, nonrheumatic aortic valve stenosis, anemia, hypertension, arthritis, DTI on sacrum, DTI right buttocks, and DTI right heel R35's Minimum Data Set (MDS) assessment, dated 03/10/26, identified R35 had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. R35 required substantial maximal assistance for bed mobility, taking on and off footwear, rolling left to right, sitting to lying, chair to bed, toileting, and transferring. R35 was at risk for PIs and was admitted with 3 unstageable DTIs, which were present on admission. R35's admission skin assessment dated [DATE], identified R35's Braden scale was scored at 15, indicting moderate risk for skin breakdown. Of note: the facility did not create a skin integrity care plan for R35 until 03/02/26. R35's care plan: Focus: actual/at risk for skin impairment (bruising, blister, and surgical incision at right hip related to impaired mobility, recent right hip surgery, fragile skin related to age, open area to heel). Date Initiated: 03/02/26. Goal: Will heal without complication. Date initiated 03/02/26. Interventions: On 03/02/26, Administer treatment per MD orders. On 03/02/26, Podiatric care as needed. On 03/02/26, Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify MD PRN. On 03/02/26, Therapy eval and treat as ordered. On 03/02/26, Toileting program as indicated. R35's physician orders: On 03/02/26, Wound care physician to eval and treat. R35's facility Pressure Injury Weekly Tracker, identified, On 03/05/26, R35 sacrum pressure injury suspected DTI measuring 3.5 x 1.0 x 0.1cm. On 03/01/26-Interventions: specialty mattress. Of note: sacrum DTI present on admission. No assessment/measurements until 03/05/26. On 03/05/26, R35 right buttock pressure injury suspected DTI measuring 5.0 x 4.0 x 0.1cm. On 03/01/26-Interventions: specialty mattress. Of note: right buttocks DTI present on admission. No assessment/measurements until 03/05/26. On 03/05/26, R35 right heal pressure injury suspected DTI measuring 4.0 x 6.0 x 0.1cm closed with moderate serous drainage. On 03/04/26- Interventions: Float heels off bed. Additional interventions/plans are to skin prep three times per week and cover with composite dressing with boarder(waterproof) as needed. Of note: right heel DTI present on admission. No assessment/measurement until 03/05/26. Facility did not have complete documentation on wound characteristics or peri wound tissue. R35's specialty wound care documentation dated 03/05/26, states initial wound evaluation and management indicate R35 presents with wounds on right hip [surgical wound], right heel, right buttock, and sacrum. R35 had a right heal unstageable DTI measuring 4.0 x 6.0 x 0.1cm with moderate serous drainage. Interventions: skin prep three times per week and cover with composite dressing with boarder (waterproof) as needed, reposition per facility protocol every 2 hours, upgrade off-loading chair cushion, and low air loss mattress. Evaluation by specialty wound care provider weekly, or sooner as needed, with further intervention as indicated based upon treatment plan. R35's Braden scale assessment dated [DATE] indicates moderate risk score of 15. R35's care plan: Focus: actual/at risk for skin impairment, bruising, blister, and surgical incision at right hip related to impaired mobility, recent right hip surgery, fragile skin related to age, open area to heel. Date Initiated: 03/02/26. On 03/06/26, the resident needs pressure reducing mattress to protect the skin while in bed. Facility did not implement a pressure injury care plan with specific interventions to address R35's right heel suspected DTI. R35's physician orders: -On 03/06/26, Enhanced barrier precautions due to wounds. R35's Braden scale assessment: On 03/13/26, R35 scored a 15 which indicates R35 is at moderate risk for skin breakdown. On 03/20/26, R35 scored a 15 which indicates R35 is at moderate risk for skin breakdown. R35's specialty wound care documentation: On 03/12/26, Unstageable DTI of right heel: 3.1 x 5.5 x 0.1cm. Surface are 17.05 cm2 Exudate-moderate serous, no signs of infection. Calcium Alginate apply 3 times per week as needed: if saturated, soiled, or dislodged. Apply foam silicone border and faced apply 3 times per week and as needed: if saturated, soiled, or dislodged. Skin prep apply 3 times per week and as needed if saturated, soiled, or dislodged. The wound was cleansed with normal saline and anesthesia, though not required, was achieved using topical benzocaine. Then with clean surgical technique, curette was used to selectively remove biofilm, remove devitalized epidermis and/or dermis over the wound surface area of 17.05 cm². The wound was cleansed again, and a clean dressing was applied. On 03/12/26, R35's right buttocks stage 3. 2.9 x 3.1 x 0.1cm. Surface area 8.99 cm2 Exudate Light serous, no signs of infection. House barrier cream apply every shift (3x day) and as needed. R35's facility Pressure Injury Weekly Tracker documentation: On 03/20/26, Rt heel: suspected DTI 3.5 x 5.5 x 0.1 cm. Area closed. Exudate: serosanguinous. Peri-wound dark red or purple and/or non-blanchable. Wound edges distinct, outline clearly visible, attached, even with wound base. No signs of infection. DTI unchanged. Heel protectors, specialty mattress. Skin prep peri wound, apply calcium alginate, 3x week and cover with composite dressing with boarder (waterproof) and as needed. R35's specialty wound care documentation: On 03/26/26, Unstageable (due to necrosis) of the right heel full thickness. 2.2 x 2.5cm Depth unmeasurable due to presence of nonviable tissue and necrosis. Surface area 5.50cm2 Exudate-moderate serous. Thick adherent devitalized necrotic tissue-90%. Granulation tissue 10%. Alginate calcium apply three times per week and as needed: if saturated, soiled, or dislodged. For 16 days; Leptospermum honey apply three times per week and as needed: if saturated, soiled, or dislodged. Foam silicone bdr & faced apply three times per week and as needed: if saturated, soiled, or dislodged. For 16 days Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 1.10cm² of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 90 percent to 70 percent. Hemostasis was achieved and a clean dressing was applied. R35's stage 3 PI right buttocks-resolved. R35's facility Pressure Injury Weekly Tracker, identified, -On 04/02/26, R35 had the right heal suspected DTI measuring 2.0x2.0x0cm closed with moderate serous drainage, 10% granulation, 90% slough, and 90% necrotic tissue, peri wound tissue dark red or purple and/or non-blanchable, acquired in house on 03/04/26. Interventions: Float heels off bed. Skin prep peri wound, Medihoney, apply calcium alginate, three times a week and cover with composite dressing with boarder and as needed. R35's specialty wound care documentation: On 04/09/26, unstageable (due to necrosis) of the right heel-full thickness. 1.5 x 2.2cm. Depth is unmeasurable due to presence of nonviable tissue and necrosis. Surface area 3.30cm2 Exudate-moderate serous Alginate calcium apply three times per week and as needed: if saturated, soiled, or dislodged. Leptospermum honey apply three times per week and as needed: if saturated, soiled, or dislodged. Foam silicone bdr & faced apply three times per week and as needed: if saturated, soiled, or dislodged. Peri Wound Treatment-Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 1.32cm² of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 100 percent to 60 percent. Hemostasis was achieved and a clean dressing was applied. On 04/09/26, stage 3 PI sacrum full thickness. 0.9 x 0.3 x 0.2cm. Surface area 0.27cm2 Exudate-moderate serous. Slough 100%. Alginate calcium apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days; Leptospermum honey apply three times per week and as needed: if saturated, soiled, or dislodged. Foam silicone bdr & faced apply three times per week and as needed: if saturated, soiled, or dislodged. Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. Selective debridement of slough only. R35's physician orders: On 04/13/26, Liquid Protein, two times a day for wound care 30cc twice a day (may mix with 4oz of beverage of choice). R35's specialty wound care documentation: On 04/16/26, unstageable (due to necrosis) of the right heel full thickness. 1.6 x 2.2 x 0.4cm. Surface area 3.52cm2 Exudate-moderate serous. Thick adherent devitalized necrotic tissue 50%. Slough 10%. Granulation 40%. Alginate calcium apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days; Leptospermum honey apply three times per week and as needed: if saturated, soiled, or dislodged. Foam silicone bdr & faced apply three times per week and as needed: if saturated, soiled, or dislodged. Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.41 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 60 percent to 40 percent. Hemostasis was achieved and a clean dressing was applied. On 04/16/26, stage 3 PI sacrum full thickness. 0.7 x 0.32 x 0.2cm. Surface area 0.21cm2 Exudate-moderate serous. Slough 90%. Granulation tissue 10%. Alginate calcium apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days; Leptospermum honey apply three times per week and as needed: if saturated, soiled, or dislodged. Foam silicone bdr & faced apply three times per week and as needed: if saturated, soiled, or dislodged. Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. Selective debridement of slough only. R35's specialty wound care documentation: On 04/23/26, wound evaluation and management indicate, R35 presents with a right heel wound now identified as stage 3 pressure wound to the right heal with full thickness measuring 1.7 x 2.0 x 0.2cm with moderate serous drainage, 40% granulation, 50% slough, and 10% necrotic tissue. Interventions: Reposition every 2 hours to offload. R35's facility Pressure Injury Weekly Tracker, identified, On 05/07/26, facility identified the right heel pressure suspected DTI is now identified as a stage 3 PI, measuring 1.7 x 1.7 x 0.2cm with moderate serous drainage, 50% granulation, 50% slough, acquired in house on 03/04/26. Interventions: Interventions: Lie down after meals. Maintain correct wheelchair in position. Turning and repositioning program, heel protectors, and specialty mattress. R35's physician orders: On 06/23/26, wound care to be managed by Specialty wound provider. On 07/02/26, right heel, skin prep peri wound, Medihoney, calcium alginate, abdominal pad, kerlix and secure with tape once daily and as needed. Facility did not implement a pressure injury care plan with specific interventions to address R35's right heel suspected DTI that deteriorated to a stage 3 PI. On 07/06/26 at 9:40 AM, Surveyor observed R35 sitting in wheelchair watching TV. Surveyor observed R35 sitting in front of bedside table resting right heel on bedside table leg underneath the bedside table. Surveyor did not observe an off-loaded boot in R35's room or on R35. On 07/06/26 at 11:55 AM, Surveyor observed R35 sitting in wheelchair working on a crossword puzzle prior to lunch. Surveyor observed R35 sitting in front of bedside table resting right heel on bedside table leg underneath the bedside table. Surveyor observed Certified Nurse Assistant (CNA) P transfer R35 and place them back in the wheelchair to get ready for lunch. Surveyor observed R35 placing right heel on top of bedside table. Surveyor did not observe an off-loaded boot on R35's right foot nor in their room. On 07/06/26 at 12:20 PM, Surveyor observed R35 sitting in wheelchair eating lunch. Surveyor observed R35 sitting in front of bedside table resting right heel on bedside table leg underneath the bedside table. Surveyor did not observe R35 wearing an offloading boot nor observe a boot in R35's room. On 07/07/26 at 12:58 PM, Surveyor observed R35 sitting at bedside table resting right heel on bedside table. Surveyor observed brown gripper sock on R35's right foot. Surveyor observed R35 did not have an off-loading boot in R35's room and R35 was not wearing an off-loading boot. On 07/07/26 at 1:02 PM, Surveyor interviewed CNA P and asked if R35 had a Pressure Injury (PI) on right heel. CNA P reported to Surveyor R35 had a PI on their right foot near the heel. Surveyor asked CNA P if R35 was supposed to have an offloading boot or heel protector on right foot. CNA P reported to Surveyor CNA P did not know if R35 is supposed to have a heel protector on right foot and CNA P has never seen a boot in R35's room. Surveyor asked CNA P about R35's care plan for lying down after every meal to offload R35's heel. CNA P reported to Surveyor, R35 refuses to lay in bed. CNA P asked R35 earlier if they wanted to get into bed. CNA P reported to Surveyor, R35 refused to lay down after lunch. Surveyor asked CNA P if they documented R35's refusals of not wanting to lay down in R35's medical record. CNA P stated, I reported the refusal to nursing staff, I don't document refusals in the medical record. On 07/07/26 at 1:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E and asked them if R35 is supposed to have off-loading boots on to prevent further deterioration of R35's PI to the right heel. LPN E reported to Surveyor that R35 should have off-loading boots on. Surveyor asked LPN E if they knew where the boots were as Surveyor did not observe R35 to have off-loading boots in their room. LPN E entered R35's room and started looking around R35's room. LPN E walked over to R35's closest and found their off-loading boots on the top shelf in the closet sitting behind a stack of clothes. LPN E grabbed R35's off-loading boots and placed the boots on bedside table. LPN E exited R35's room. LPN E did not place offloading boots on R35. On 07/07/26 at 1:51 PM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation is if R35 refuses to lay down after meals to offload R35's heels. DON B reported to Surveyor R35 refuses a lot, but CNAs are to report right away to nursing staff and then it can be documented in the resident's medical record as a refusal. Surveyor asked DON B if staff had been documenting refusals in R35's medical record. DON B reported they would have to review R35's medical record. Surveyor requested documentation of R35's refusals to lay down after meals. Surveyor asked DON B if R35 is to have heel protector boots on to offload R35's PI to the right heel. DON B reported to Surveyor that R35 is supposed to have an offloading boot on the right foot. On 07/07/26 at 2:21 PM, Surveyor observed LPN E and Assisted Director of Nursing (ADON) C enter R35's room to complete wound dressing change. Surveyor observed R35 did not have offloading boots on while lying in bed. Surveyor interviewed ADON C and asked the expectation of R35 to use the offloading boots. ADON C reported to Surveyor that the offloading boots should be placed on R35 to offload their feet. ADON C reported to Surveyor ADON C will get a physician order placed into the medical record. Surveyor asked ADON C if the offloading boot should be in the physician's orders and care planned. ADON C reported to Surveyor once a wound care specialist orders an intervention, staff are to place the order in the medical record and update the care plan. ADON C reported to Surveyor that ADON C works very closely with the wound care provider and ADON C should have entered the order for the offloading boots for R35 and updated R35's care plan. On 07/07/26 at 2:45 PM, Surveyor and ADON C walked by R35's room and looked at R35's foot placement. ADON C stated, Oh I see her foot is sitting directly on top of the bedside table leg underneath the bedside table. Surveyor asked ADON C if they thought the bedside table leg could cause pressure on R35's right heel. ADON C stated they never thought about that. ADON C reported they would get an order for the offloading boots to be placed right away. Surveyor informed ADON C of the wound care provider ordered R35 offloading boots to decrease pressure to the right heel. On 07/08/26 at 9:11 AM, Surveyor interviewed DON B and ADON C. Surveyor asked if R35's stage 3 PI to the right heel could have been avoided if staff had completed a comprehensive skin assessment, continued to offload R35's heels with offloading boots, updated care plan, and placed correct recommendations in medical record for proper interventions to avoid or decrease further PI deterioration. ADON C stated yes it could have probably been avoided. On 07/08/26 at 9:56 AM, DON B [NAME] a document to Surveyor explaining the facility had completed a Past Non-Compliance (PNC) plan for PIs back in June 2026 when they recognized R35 was not properly assessed for skin concerns upon admission on [DATE]. DON B reported the PNC plan was put into place in June when the facility identified PI concerns and then educated staff on facility's PI policy pertaining to R35's right heel injury, and all staff are to assess skin upon admission head to toe thoroughly. Surveyor reviewed PNC plan and noted only nurses were educated about assessing new admissions thoroughly. Surveyor asked DON B why staff are still not following PI interventions for R35 such as lying down after meals and documenting refusals, as well as not applying offloading boots. DON B stated, I guess the facility is not PNC then and more education needs to be had. Example 2 R8 was admitted to the facility on [DATE] with polyneuropathy, chronic venous hypertension (idiopathic) with ulcer of right lower extremity, and pressure ulcer of unspecified site stage 3, and history of frostbite. R8's comprehensive Minimum Data Set (MDS) assessment, dated 04/15/26, noted a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. is intact. R8's physician orders: On 04/16/26 Apply ace wrap in the morning and remove at bedtime. Wrap from toes to below the knee for edema, as resident allows. On 05/23/26 Right plantar foot: wash with normal saline, skin prep peri wound, calcium alginate, cover with boarder gauze, change once daily as needed. On 07/06/26 at 10:54 AM, Surveyor interviewed R8. Surveyor asked R8 if they had any concerns with cares or services at the facility. R8 stated having trouble with their shoe and pointed to their right foot. Surveyor observed R8's right foot in a post-op shoe. R8 stated the shoe was falling apart. Surveyor asked R8 if they told anyone about this. R8 stated yes, multiple times but was told that they couldn't find one and it had to be ordered. Surveyor asked when R8 was told this. R8 stated for at least a couple months. Surveyor asked R8 how long they had been wearing that shoe. R8 said a long time but couldn't remember exactly. Surveyor asked R8 who was ordering a new shoe. R8 said they couldn't remember. R8's chart does not contain documentation of ordering a new shoe or foam inserts. R8's wound care provider notes indicate: On 06/18/26: stage 3 pressure ulcer (PU) right plantar foot; wound measures 1.5 x 1 x0.2cm/. Exudate-moderate serous. Granulation tissue-100%. Wound progress-improved evidenced by decreased surface area. Surface area-1.50cm2. Surface area decreased by 6.2%. Infection assessment-no signs of infection. On 06/25/26: stage 3 pressure ulcer (PU) right plantar foot; wound measures 1.7 x 1 x 0.2cm. Exudate-moderate serous. Granulation tissue-100%. Infection assessment-no signs of infection. Surface area 1.70cm2. Wound present for >435 days and has failed to respond appropriately for over >28 days despite standard management. This includes mitigation of contributing factors and appropriate preventative strategies for pressure reduction. Offloading, pressure reduction cushion, compliance to treatment regimen have been observed. The wound has no signs of infection or osteomyelitis. The wound bed does not contain exposed muscle, tendon, bones, hardware, joint space, or sinus tract. The patient is not diabetic. The patient is not a smoker, is not receiving medications that significantly impact wound healing and is without uncontrolled autoimmune disease. On 07/02/25: stage 3 pressure ulcer (PU) right plantar foot; wound measures 1.1 x 1.6 x 0.2cm. Peri wound radius-maceration. Exudate-moderate serous. Granulation tissue 100%. Wound progress improved and evidenced by increased epithelialization. No signs of infection. Revisit to care goals: Difficulty with footwear. Recommend changing foam in footwear to prevent moistening. Care goals this month: decrease undermining and decrease ulcer area. Of note: footwear with sole cutout for wound was not entered into R8's care plan or orders. On 07/07/26 at 8:12 AM, Surveyor observed R8 ambulating in hallway wearing the post-op shoe on right foot. Surveyor observed an ACE wrap loosely wrapped on right foot over gripper sock. Surveyor asked R8 if they would show Surveyor the post-op shoe and explain a little more about their wound care. R8 removed their shoe on the right foot. Surveyor observed the shoe to have an area cutout of the foam in the mid-arch area. The cutout area was very worn, discolored, and had old remnants of pieces of padding that were placed on top of the shoe's built-in foam. Surveyor asked R8 what the pieces were in the cutout of the shoe. R8 stated that they believed it was pieces of foam that the wound provider had put in there a while ago. Surveyor asked R8 about the compression wrap on the right foot. R8 raised their pant leg and Surveyor observed the ACE wrap loosely wrapped on right foot up to approximately mid-calf height. Underneath the ACE wrap, Surveyor observed a black gripper sock sticking out on the toes. Surveyor asked R8 when the ACE wrap had been applied. R8 stated yesterday. Surveyor asked R8 if the ACE wrap was normally applied this way, being loose and over the gripper sock. R8 stated sometimes. On 07/07/26 at 12:54 PM, Surveyor observed R8's wound care completed by Licensed Practical Nurse (LPN) E. LPN E removed R8's ACE wrap and sock; Surveyor observed R8's right foot and calf to be edematous. Surveyor asked LPN E if R8's compression wrap was applied by LPN E this morning. LPN E stated no that the ACE wrap was applied the previous evening. Surveyor asked LPN E if it was normal practice for the ACE wrap to be applied loosely over the gripper sock. LPN E stated no, it shouldn't. Surveyor asked LPN E if they were aware of the type of shoe R8 was wearing and any assessments related to it. LPN E stated not knowing what kind of shoe it is or who is supposed to be monitoring or assessing it. On 07/07/26 at 1:24 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C regarding R8's wound care interventions. ADON C stated they complete wound care assessments weekly with wound care provider. ADON C stated they complete weekly assessments of R8's shoe. Surveyor asked ADON C if this is documented. ADON C stated no. Surveyor asked ADON C how they would know if the wound had worsened if they did not have any previous documentation of wound measurements. ADON C could not answer. Surveyor asked ADON C if they were aware of any concerns reported by R8. ADON C stated yes it was addressed last week to order a new shoe, but that the wound care provider wanted podiatry to handle this. Surveyor asked ADON C if podiatry had done this. ADON C stated no because R8 was refusing to see podiatry. Surveyor asked ADON C how long R8 had this post-op shoe. ADON C didn't answer question. R8's medical record noted no documentation of refusing podiatry visits or a consultation with podiatry requested within the last week. On 07/07/26 at 1:51 PM, Surveyor interviewed DON B regarding wound care interventions. Surveyor informed DON B of observation of the ACE wrap on R8's right foot being on loosely and over the gripper sock. Surveyor asked DON B if this was an appropriate application for the ACE wrap. DON B stated no. Facility did not provide any documentation as to whether the boot or new insoles were ordered for R8.

Based on record review and interview, the facility did not conduct a Preadmission Screening Resident Review (PASRR) - Level II screening to ensure resident with mental illness received the care and services needed. This occurred for 1 of 1 resident (R) reviewed for PASSR, out of the sample size of 13. (R7) R7 has been admitted to the facility for greater than 30 days, has a serious mental disorder, is taking psychotropic medication, and does not have a PASSR Level II completed. This is evidenced by: The facility policy titled, Resident Assessment-Coordination with [PASSAR] (preadmission screening and resident review) Program, dated 11/20/25, states in part:5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days:a. The facility should screen the individual using the State's Level 1 screening process and refer any resident who has or may have MD [mental disorder], ID [intellectual disability] or a related condition to the appropriate state designated authority for Level II [PASSAR] evaluation and determination.b. The Level II resident review must be completed within 40 calendar days of admission. R7 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder (PTSD) and mood affective disorder. On R7's day of admission, the facility completed a Brief Interview for Mental Status (BIMS) assessment, which determined a score of 10 out of 15. This means R7's cognition is moderately impaired. On 7/9/25, a Level 1 preadmission screening and resident review (PASRR) was completed on admission and reads in part: Resident is suspected of having a serious mental illness, and includes the documentation that Provider agreed and resident is taking a psychotropic medication. Review of admission paperwork indicates a hospital discharge exemption 30-day maximum was noted and stated R7 was not planned to stay at the facility longer than the permitted exemption period. R7's physician orders include: 12/9/25 07:00 PARoxetine HCl Oral Tablet 10 MG (Paroxetine HCl) Give 10 mg by mouth one time a day for mood disorder. Surveyor completed record review and noted R7 is still a resident at the facility, almost a year after the exemption period. No additional PASRR screenings were completed. On 7/7/26, Surveyor observed behaviors with R7. At 7:18 AM, R7 yelled at Certified Nursing Assistant (CNA) V, R7 did not want to get up. At 7:26 AM, R7 refused to change clothes and brush their teeth. At 7:55 AM, R7 yelled at CNA V, I don't want that breakfast tray. CNA V asked if they were hungry. R7 stated they were not hungry for that rubbish, and they pushed away from the table. CNA V asked R7 if they wanted something else. R7 yelled, get out of here. CNA V quickly grabbed tray and exited room. Surveyor interviewed CNA V regarding R7's demeanor and behavior. CNA V stated R7 has a lot of days like that. On 7/7/26 at 11:50 AM, Surveyor interviewed Director of Nursing (DON) B regarding R7's PASRR completion. DON B stated R7 was not expected to stay greater than 30 days. DON B stated when R7 became a long-term care resident, we did not go back and address the PASSR Level II. Surveyor clarified with DON B that R7 was admitted on [DATE], meaning the PASRR Level 2 was due in 30 days or approximately 8/8/2025. DON B stated unfortunately yes. On 7/8/26 at 8:24 AM, Surveyor attempted to interview the new social service staff member. They were not available. On 7/8/26 at 8:25 AM, Surveyor interviewed License Practical Nurse (LPN) O regarding their role with the PASSR. LPN O stated recently the PASSR became their responsibility. LPN O stated it has been about a month since the previous social services staff member left, and I was asked to help. Surveyor asked what LPN O knew about PASRR requirements. LPN O stated that Level 1 is required during admission for everyone. If the resident has major mental health issues or intellectual disability, the assessment triggers the need for a Level 2 screening. LPN O stated that if the resident is not planned to stay past 30 days, then Level 2 is not completed. If the resident ends up staying past 30 days, then Level 2 is needed. Surveyor asks what triggers indicate a Level 2 is needed or how is it tracked to know if it is past 30 days admission. LPN O stated they did not have any idea.

Based on record review and interview, the facility did not ensure that professional standards of practice were met to maintain quality of care for 1 of 1 resident (R) reviewed for diabetic management and 1 of 1 resident reviewed for toileting out of 13 sampled residents.-Facility did not implement immediate hypoglycemic interventions and follow established protocols when R4's blood sugar was 60mg/dl.-Certified Nursing Assistant (CNA) P left R11 sitting unattended on a commode for 37 minutes and failed to monitor, identify, or report an open area between R11's buttocks to licensed nursing staff placing resident at risk for further skin breakdown, and pain.Example 1 Facility policy titled, 'Hypoglycemia Management,' with a revised date of 08/05/22, states: Compliance Guidelines: 3. Residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner. 5. If the blood glucose reading is 70 mg/dL or below, the nurse will utilize the hypoglycemic protocol as per the practitioner's order, with follow up blood glucose as indicated, and notify the practitioner of the results as ordered. 6. Nursing will continue to follow up and observe for any further hypoglycemic episodes post treatment and notify the practitioner of any changes.Facility Standing Orders, with a date of 06/15/26, states: .Diabetic order set: if glucose 60 or less or 300 and higher, recheck for accuracy. if glucose 51 to 60 give juice or 15 grams glucose gel if able to take PO.call MD if glucose less than 60 or greater than 400 unless otherwise specified.Hypoglycemia: if blood glucose 70 or less give orange juice with sugar packet or glucose gel.R4 was admitted to the facility on [DATE] with type 2 diabetes mellitus.R4's physician orders:Check blood sugars QID (four times a day) for diabetes monitoring.Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units 401 and greater give 12 units, notify provider, subcutaneously four times a day for diabetes.Note: R4's orders did not include hypoglycemic interventions or parameters to notify provider.R4's medical record:On 06/28/26 at 7:25 AM, R4's blood glucose was documented as 60.0 mg/dL. No additional assessment, hypoglycemic intervention, or provider notification were documented.On 07/08/26 at 9:30 AM, Surveyor interviewed Registered Nurse (RN) J regarding diabetic monitoring. Surveyor asked RN J if diabetic residents have hypoglycemic interventions entered as an order. RN J stated yes, they should, because if an event were to happen the nurse shouldn't be looking up standing orders to implement. Surveyor asked RN J to explain the facility's hypoglycemic protocol. RN J stated that if a resident's blood sugar is below 70, then the nurse should give orange juice with a sugar packet, recheck blood sugar every 15 minutes until over 70-80, and monitor for hypoglycemic symptoms. Surveyor asked RN J if the provider would be notified. RN J stated yes and that it would be documented in the resident's chart.On 07/08/26 at 9:38 AM, Surveyor interviewed Director of Nursing (DON) B regarding diabetic management. Surveyor asked DON B if the facility's standing orders for diabetic and hypoglycemic management are expected to be entered as an order for diabetic residents. DON B stated yes, unless the provider has a different order set or parameters to monitor. Surveyor asked DON B if residents with insulin interventions should have ordered and care planned to address hypoglycemic events. DON B stated yes. Surveyor informed DON B of R4's blood sugar of 60 with no documented interventions, provider notification, or additional documentation of monitoring for hypoglycemic symptoms. DON B stated being unaware of this. Surveyor asked DON B if R4's provider should have been notified and hypoglycemic interventions in place. DON B stated yes. Example 2 R11 was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, atrial fibrillation, unspecified dementia, and history of transient ischemic attack. R11's Minimum Data Set (MDS) assessment, dated 05/20/26, indicates R11 had Brief Interview of Mental Status (BIMS) score of 10/15 indicating R11 had moderately impaired cognition. R11 required substantial maximal assistance for bed mobility, taking on and off footwear, and rolling left to right. R11 dependent with assistance sitting to lying, chair to bed, toileting, and for transfers. R11 was at risk for PI's but had no PIs on admission. R11's care plan:Focus:Actual/at risk for alteration in skin integrity related to diabetes, edema, impaired mobility, incontinence, and morbidity obesity. Date Initiated: 08/05/25 with revision on: 07/08/26.Interventions:-On 08/05/25, Barrier cream to peri area/buttocks, groin as needed -On 08/05/25, Encourage to reposition as needed, use assistive devices as needed. -On 08/05/25, Observe skin condition with ADL care daily, report abnormalities -On 08/05/25, Pressure redistributing device on bed/chair R11's ADL self-care deficit care plan. Date initiated: 08/05/25 with revision on 05/19/26: Interventions:-On 08/05/25, Toileting assist of 2 with walker. -On 10/07/25, Transfer: EZ stand with assist x2. Invacare sling - X-Large. -On 10/07/25, Transfer: sit to stand lift. On 07/07/26 at 9:21 AM, Surveyor observed CNA P and CNA T enter R11's room and closed R11's door. On 07/07/26 at 9:26 AM, Surveyor observed CNA P and CNA T exit R11's room and closed the door to room. On 07/07/26 at 9:30 AM, Surveyor entered R11's room and observed R11 on commode using the bathroom. Surveyor exited R11's room and closed R11's door. On 07/07/26 at 9:40 AM, Surveyor entered R11's room and observed R11 still sitting on commode using bathroom. R11 stated to Surveyor, I am not sure what I am doing on this, but I am done. Surveyor exited R11 to find a staff member to assist R11. Surveyor could not find assistance at this time. On 07/07/26 at 9:47 AM, Surveyor observed Nurse Practitioner Q walk up to R11's door and asked Surveyor if staff are completing cares. Surveyor informed NP Q that R11 was still on the commode but stated R11 was done. NP Q stated, I will come back. On 07/07/26 at 10:01 AM, Surveyor observed NP Q approach R11's room and asked Surveyor if R11 is still on commode. Surveyor let NP Q know that R11 was on the commode still. NP Q stated, [R11] is still on the commode! NP Q went into R11's room to check on R11 and asked, [R11] are you done using the commode? R11 responded, I sure hope so. NP Q entered and had to push the call light for R11 so staff could come assist R11 off the commode. Surveyor observed R11's call light was activated. On 07/07/26 at 10:02 AM, Surveyor observed NP Q exit R11's room and told R11, Make sure to tell staff you are done using the commode. Surveyor interviewed NP Q and asked if NP Q had to push R11's call light for R11's call light to go on. NP Q reported to Surveyor NP Q had to push R11's call light, and sitting on the commode for that long is not appropriate for [R11's] skin nor should [R11] be left alone that long on commode. On 07/07/26 at 10:07 AM, Surveyor observed CNA P and CNA T enter R11's room to assist R11 off the commode. Surveyor observed CNA T lift R11 up with EZ-stand. Surveyor observed R11 stand to an upright position on EZ-stand. Surveyor observed CNA P wipe R11's buttock area. R11 quickly moaned in pain and stated, That hurts. Surveyor asked CNA P if there was an open sore on R11's bottom. CNA P reported to Surveyor CNA P saw R11 had an open slit between R11's buttocks at the crease last week. Surveyor asked CNA P who knew about the open area on R11's bottom area, since CNA P observed the slit last week. CNA P stated, All staff should know about the open area as we are to apply barrier cream over every time [R11] goes to the bathroom. Surveyor asked CNA P why R11 was left on commode for almost an hour. CNA P stated to Surveyor, R11 likes to sit on commode for a while and so CNA P usually goes in and checks on R11 to see when R11 is done every so often. Surveyor asked did CNA P go in and check on R11 at any time after placing R11 on commode. CNA P reported to Surveyor CNA P did not get a chance to check on R11. On 07/07/26 at 10:47 AM, Surveyor interviewed R11's Family Member (FM) U and asked FM U if R11 uses the call light when FM U is around. FM UM reported R11 forgets easily what the call light is for, so only time it is used is when FM U is in building and reminds R11 or pushes call light for R11. Surveyor asked if FM U is aware of an open sore on R11's bottom. FM U reported no one has told FM U that R11 has an open spot on R11's bottom. On 07/07/26 at 3:41 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E and asked about R11's skin integrity and if CNA P reported any open skin areas for R11. LPN E reported to Surveyor R11 does not have any open skin areas they know about, and CNA P did not report any skin issues before leaving their shift today on 07/07/26. Surveyor informed LPN E that R11 has an open slit between their buttocks in the crease. LPN E reported to Surveyor they were not aware R11 had an open area. LPN E reported they would take care of the concern right away. On 07/07/26 at 3:48 PM, Surveyor interviewed DON B and asked if DON B knew about an open area in between R11's buttocks in the crease. DON B reported to Surveyor they did not know about any open skin areas on R11 and that staff complete weekly skin checks. Surveyor asked DON B what the expectation is for reporting a skin concern for R11. DON B reported CNA P should have reported the skin issue right away so nursing staff can address. Surveyor asked DON B's expectations for how long R11 can sit on commode. DON B reported R11 likes to sit on commode for a long time and often refuses to get off commode until finished. Surveyor asked DON B's expectation of CNA P to check in on R11 and see if they were finished using the commode. DON B reported R11 sometimes wants to stay on for a long time, but staff are to check on R11 periodically and document the attempts. Surveyor reported to DON B that Surveyor could not find documentation of R11's commode uses for long periods of time, nor could Surveyor find interventions in R11's care plan. On 07/08/2026 at 9:11 AM, Surveyor interviewed DON B and ADON C and asked if R11's slit in R11's buttocks could be pressure related due to sitting on commode for a long period of time. ADON C reported to Surveyor R11 does sit on the commode for a long time, so the slit in the crease of R11's buttocks could be pressure related but ADON C would have to go look at the skin injury but has not had a chance yet.

Based on interview and record review, the facility did not immediately report to the physician a significant decline in condition for 1 of 3 residents (R) reviewed for change of condition (R2).The facility did not immediately consult with the resident's physician regarding R2's significant change of condition on 07/13/25 at 3:00 PM until 07/14/25 at 1:52 PM, when R2 had a decline in cognition, developed an inability to communicate, had noted thick phlegm coming out of mouth, developed an inability to pivot transfer with assist of 2, and required use of a Hoyer lift for transfers, which ultimately required R2 to be transferred the emergency room (ER) and then to critical care for unresponsiveness, diaphoresis (excessive sweating), and bilateral crackle sounds noted in lungs. R2 was diagnosed with a Cerebrovascular Accident (CVA) (stroke) and pneumonia.The facility's failure to promptly consult with the physician about R2's change of condition, created a finding of immediate jeopardy that began on 7/13/25. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 08/06/25 at 10:01 AM. The immediate jeopardy was removed on 08/06/25; however, the deficient practice continues at a scope/severity level of D (isolated/potential for more than minimal harm) as the facility continues to implement its action plan. Findings include:Surveyor reviewed the facility protocol titled Change in Condition of the Resident, last revised on 09/20/22, which states in part, .References: Change in condition; When to report to the MD. Interact Version 4.5 tool states,Immediate notification with any symptom, sign, or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed.Vital signs:Report immediately: -if Systolic BP >200mmHg or <90mmHg, Diastolic >115mmHg -Abrupt significant change in cognitive function from usual, with or without altered level of consciousness. -Sudden change in level of consciousness or responsiveness. -Gait disturbances-Abrupt onset of slurred speech, or other new focal neurological findings. -Lung sounds-Abrupt onset of wheezing, rales, or rhonchi (new)-Dyspnea - Abrupt onset of SOB (shortness of breath) with pain, fever, or respiratory distress or with progressive leg edema.-Abrupt change in speech, with or without other focal neurological findings. -Walking difficulty-Acute onset accompanied by other neurological signs. Non-immediate reporting: -Diastolic BP >90mmHg -Persistent change from usual cognitive function with no criteria met for immediate notification. -Gradual change in level of consciousness not associated with other criteria for immediate notification.-Significant recent changes in gait without other symptoms or findings. -Recently progressive or persistent minor SOB without other symptoms. -Recent onset not resolving spontaneously.R2 was admitted to the facility on [DATE] with diagnoses including, in part, Parkinson's disease, muscle weakness, unsteady on feet, pyothorax without a fistula, pneumonitis, schizophrenia, and hypotension.R2's Minimum Data Set (MDS) assessment, dated 07/15/25, identified R2 required assistance from 1-2 people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and transfers. Surveyor reviewed R2's physician orders, which included:.-Monitor VS (vital signs) daily with special attention to blood pressure.-Continue IV antibiotics.-Reassess respiratory status and infection regularly.-Neurology consult.-Full Code. Surveyor reviewed R2's admission assessment, which states in part:-On 07/10/25, R2 did not have any swallowing issues presently. Alert and oriented to time, place, and person. Breath sounds were clear bilaterally. Vital signs are stable. R2's vital signs:On 07/10/25 at 3:47 PM, blood pressure (BP) 126/80, heart rate (HR) 85, and respirations 20. Surveyor reviewed R2's progress notes from 07/10/25-07/18/25:-Nurse daily skilled observation note:On 07/10/25 at 9:00 PM, a daily nurse assessment was conducted, indicating R2's respiratory status was even and regular, unlabored. R2's neuromuscular system had no issues. Progress notes from the Nurse Practitioner (NP): On 07/11/25 at 3:00 PM, NP visit today, the patient [R2] is seen lying in bed, appearing comfortable at rest. She is pleasant during the visit, providing only brief statements and yes or no responses. She tells me that she misses eating food, although she seems to understand the need for tube feeding due to dysphagia. She did experience nausea yesterday, and staff report that this seems to be relieved with as-needed Zofran. She is currently requiring supplemental O2 to maintain SpO2 greater than 90%. Vital signs have been stable, afebrile. There are no indications of increased shortness of breath, chest pain, fever, chills, diarrhea, constipation, dysuria or other urinary concerns. NP's physical examination: general- no acute distress, comfortable at rest. Respiratory- clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Neurological- cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness.On 07/11/25 at 4:39 PM, Occupational Therapy (OT) worked with R2 on sit-to-stand (transfers). R2 completed sit to stand with moderate assist, limited standing tolerance, c/o (complaints of) dizziness and wanting to lie down, pivot transferred to bed. R2 is educated on the use of the call light for all transfers and needs. R2's response to session interventions is that R2 is fatigued and wants to return to bed to rest.On 07/12/25 at 12:21 PM, OT performed Passive Range of Motion (PROM) on R2's upper extremities. 100% physical assistance is required due to compromised strength, technique, and muscle tone to facilitate muscle recruitment to enable increased participation in self-care tasks. Skilled interventions focused on building rapport and attempts at establishing communication techniques were unsuccessful. OT used visual tools to help improve patient communication with the writer, although R2 was not able to consistently demonstrate the ability to respond. R2's eyes were open and able to focus on the writer, but minimal to no verbal attempts were made by R2 to communicate. 0 attempts by R2 to point to yes/or no cards. R2 found with thick phlegm on the right side of her mouth. R2 was attempting to cough throughout the session but was never able to clear what was in her throat. OT discussed concerns with the RN; stated she would perform oral care with R2. Also confirmed that today, she was unable to successfully communicate with R2, and R2 appears more lethargic today than yesterday. On 07/13/25 at 12:42 AM, late entry: On 07/12/25 at 11:30 PM, R2 was not able to pivot transfer assist of 2. Hoyer lift used. R2 had a large amount of foamy secretions.-12:45 AM, R2 had another small amount of foamy secretions, R2 coughing, lung sounds upon both assessments were clear in the left lobes and coarse in the right lobes (wet sounding). R2 opens eyes when spoken to. R2 is resting comfortably. NP notified via email and gave orders to continue to monitor.Surveyor did not find documentation that the nurse notified the physician of R2's mobility and cognition changes that were documented on 7/12 and 7/13/25.Vital signs: On 07/13/25 at 10:01 AM, BP 91/64, and HR 90. Nurse daily skilled observation note: On 07/13/25 at 3:00 PM, R2's respiratory status, with abnormal lung sounds (rales, rhonchi, wheezing). The neuromuscular system decreased movement/mobility, and R2 has paralysis/weakness. Summary: R2 has been resting quietly in bed most of the shift. No s/s (signs/symptoms) of pain or discomfort. Opens eyes and looks at the writer when speaking but does not answer questions. Surveyor did not find documentation that the nurse notified the physician about abnormal lung sounds, paralysis and weakness, and R2's nonverbal status. Daily skilled observation:On 07/13/25 at 5:00 PM, R2's neuromuscular system is paralysis/weakness. Surveyor did not find documentation that the nurse notified the physician about paralysis and weakness, and R2's nonverbal status. On 07/14/25 at an unknown time in the morning, Physical Therapy (PT) was seeing R2 for therapy. R2 not able to respond verbally, not able to gesture, or make eye movement. PT deferred.Surveyor did not find documentation that the nurse notified the physician about paralysis and weakness, and R2's nonverbal status. Vital signs:On 07/14/25: 1:41 PM, BP 100/57, HR 70, and respirations 16. On 07/14/25 at 1:52 PM, R2 has been unresponsive all morning. Mouth care is provided frequently. Drooling at times. R2 diaphoretic. Lung sounds diminished with crackles bilaterally. Sounds as though R2 has fluid in the throat. NP came to assess the resident. Orders to send to Emergency Department (ED) for unresponsiveness, diaphoresis, and crackles bilaterally.Surveyor did not find documentation that the nurse notified the physician all morning about paralysis, weakness, and unresponsiveness. On 07/14/25 at 2:50 PM, the hospital report from the Emergency Department (ED) states, R2 arrived by Emergency Medical Services (EMS) with fever and was non-communicative. R2 had a head Computerized Tomography (CT) scan that revealed diffuse middle cerebral artery Cerebral Vascular Accident (CVA).Telephone call received from radiologist with final report on CT. The patient has a diffuse MCA cerebrovascular accident. Nursing staff contacted the skilled nursing facility, and the last reported normal was this past Friday, 07/11/25, post-discharge from the hospital. The patient is normally speaking and doing some swallowing independently. Currently obtunded, making gurgling noises, respirations. The head of the bed is up at 45 degrees. Chest x-ray pending, maintaining airway at present.On 07/21/25, while R2 was in the hospital, R2 suffered cardiac arrest and is now intubated and on a ventilator. R2 changed code status in hospital to Do Not Resuscitate (DNR) and palliative care. On 08/05/25 at 12:52 PM, Surveyor interviewed Registered Nurse (RN) H and asked RN H how R2 presented to RN H the times RN H cared for R2 in the facility. RN H reported that RN H was not familiar with R2 as RN H took care of R2 for the first time on RN H's shift 07/12/25. RN H reported to Surveyor that RN H thought the nonverbal communication and not moving in bed was R2's baseline. RN H did not notify the provider of the nonverbal communication. RN H reported that the day before, the provider was notified and to continue to monitor was the order.On 08/05/25 at 1:08 PM, Surveyor interviewed RN C and asked how R2 was during R2's care when RN C worked with R2. RN C reported that on 07/12/25, R2 could nod yes or no, but couldn't transfer with staff. RN C stated RN C spoke with a Certified Nursing Assistant (CNA) about R2 and CNA stated this was not R2's baseline. RN C acknowledged she did not notify the MD.Surveyor could not find any documentation RN C notified physician of R2's inability to transfer with 2 staff assist.On 08/05/25 at 1:52 PM, Surveyor interviewed hospital RN E and asked RN E how R2 presented to the ED. RN E reported that R2 was very unkempt looking and was non-verbal. RN E reported RN E did not know what R2's baseline was, but through further assessment, found that R2 could not lift or move the right side of the body. RN E immediately activated the stroke protocol, and a CT scan was performed, showing a large stroke affecting the right side of R2's body. RN E reported when RN E called the facility to try and grasp when the last well-known date and time was, a staff member from the facility stated, [R2] has not been well since Friday the 11th and could not use the right side. RN E then reported this to the hospital physician right away. Surveyor asked RN E if RN E remembered the staff member who gave the report, and RN E stated, I do not. RN E reported R2 also presented to the ER with a fever and hypotension. On 08/05/25 at 2:01 PM, Surveyor interviewed RN I and asked RN I how R2 presented on 07/11/25. RN I reported to Surveyor that tube feedings went well and R2 seemed to be quiet but ok. RN I just thought that R2 was at R2's baseline, but RN I did not review what R2's baseline was, so unsure if R2's state was normal for R2. On 08/06/25 at 9:03 AM, Surveyor interviewed Rehab Director (RD) F and asked if R2 was provided PT services or an evaluation of care during R2's stay. RD F reported to Surveyor that R2 was evaluated on Friday, 07/11/25, and RD F worked with R2 personally by assisting R2 with sitting on the edge of the bed and sitting and standing. RD F reported that R2 could answer simple questions with short answers and yes or no answers. RD F reported that come Monday, 07/14/25 in the AM, unsure of time frame, R2 could not move her body or speak at all. R2 would not answer Certified Occupational Therapy Assistant (COTA)'s questions, and the RD F deferred R2 for PT/OT services at this time. Surveyor asked RD F if RD F or COTA reported to any other staff what COTA assessed while working with R2 during the PT session or reported this to anyone. RD F reported to Surveyor that RD F is unsure if COTA reported this to any staff members besides RD F unfortunately. On 08/06/25 at 9:30 AM, Surveyor interviewed MD D, who reported not knowing who R2 was as MD D has been out on medical leave and the NP was following. Surveyor asked MD D if any nurses report to the provider or NP of a decline in cognition, mobility, and communication, what would be the expectation from the provider on call for nursing staff to do. MD D stated that nursing staff should already have a neurological assessment complete and be calling the provider with this information. MD D would immediately order that the resident be sent to the ED with a decline in cognition, mobility, and communication. MD D stated, I would have ordered [R2] to immediately be sent out to the ED. On 08/06/25 at 10:01 AM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B could explain R2's disposition at the facility on admission and then through the 4-day stay in the facility. DON B reported to Surveyor that DON B was in R2's room on Friday, 07/11/25, in the morning. DON B spoke with R2, and R2 answered questions, yes and no, but was a little slower in answering questions. R2 had trouble with word finding with yes and no, but R2 was comfortably lying in bed. DON B reported that RN C was providing care for R2 on Friday, 07/11/25, Saturday, 07/12/25, and Monday, 07/14/25. DON B reviewed RN C's progress notes and RN C noted lung sound changes in R2, called the provider got an order for chest x-ray. Licensed Practical Nurse (LPN) G had R2 on Sunday, 07/13/25. DON B reported that LPN G was able to give tube feedings to R2 with no issues, and R2 was able to track with eyes. DON B stated that RN C spoke with NP Monday, 07/14/25, as soon as R2 had more secretions, and during tube feeding at around 11 AM, NP assessed R2 while onsite, and determination was made for R2 to be sent out right away to the ED. Surveyor asked DON B if DON B expects that staff should have notified the provider on call on 07/12/25 at 10:46 AM, 12:21 PM, 1:43 PM,11:30 PM, on 07/13/25 at 3 PM and 5 PM, as well as when a nurse assessment of unresponsiveness was documented on 07/14/25 at 1:52 PM. DON B reported to Surveyor that DON B's expectation is for staff to follow the facility's policy on change of condition and notify the provider of any changes right away.The facility failed to notify R2's physician on 07/12/25 at 10:46 AM, 12:21 PM, 1:43 PM, 11:30 PM, on 7/13/25 at 3:00 PM and 5:00 PM, and 7/14/25 at 1:52 PM of R2's changes in condition.The facility's failure to promptly notify the physician of a resident's significant change of condition led to a reasonable likelihood for serious harm on 07/13/25 which created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 08/06/25; however, the deficient practice continues at a scope/severity level of D (isolated/potential for more than minimal harm) as the facility continues to implement the following action plan:1. In house residents were assessed by Registered Nurse or designee including head to toe assessment using E-interact head to toe and review of skin assessment in last week to ensure residents experiencing a change in condition have complete assessment. Any changes from baseline will be reported to Primary care physician. This assessment will be completed by 8/6/25. 2. The DON initiated re-education with Licensed Nurses on change of condition policy including interact change of condition Sbar documentation to ensure thorough assessment of resident & primary care physician notification as appropriate. Licensed nurses will utilize interact 5.1 tool as guidance to determine change of condition and document in resident's medical record.3. On 8/6/2025, the DON VP of success and Executive Director reviewed facility established policies and guideline including Change in condition Primary Care Provider notification E-interact 4.5 guidelines (MD notification)*Policies and guidelines remain appropriate4. DON/designee to complete audits of nursing documentation and provider notification daily x 2 weeks. This audit will include ensuring accurate and thorough assessment of resident. After the initial audit period, audits will continue 5x week for 6 weeks. Ad Hoc QAPI held on 08/06/25, with Director of Nursing, Executive Director, VP of Success to review recovery plan. 5. Results of audits to be brought to monthly QAPI meeting for further review and recommendations.

Based on observations, interviews, and record reviews, the facility did not ensure 2 out of 3 residents (R) reviewed, (R2, R1), who had changes in condition were provided immediate care and treatment consistent with professional standards of practice (N6, Wisconsin Nurse Practice Act) for neurological/comprehensive assessments. The facility did not perform neurological assessments from 07/12/25 at 10:46 AM until 07/14/25 at 1:52 PM, when R2 had a decline in cognition, developed an inability to communicate, had noted thick phlegm coming out of mouth, developed an inability to pivot transfer with assist of 2 and required use of Hoyer lift for transfers, which ultimately required R2 to be transferred to the emergency room (ER) and then to critical care for unresponsiveness, diaphoresis, and bilateral crackle sounds noted in lungs. R2 was diagnosed with a Cerebrovascular Accident (CVA) (stroke) and pneumonia. While at the hospital, R2 suffered cardiac arrest and is now intubated and on a ventilator.The facility's failure to provide immediate care and treatment for a resident who displayed changes in condition from 07/12/25 until 07/14/25, created serious harm for R2, which created a finding of immediate jeopardy that began on 07/12/25. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on 08/06/25 at 10:01 AM. The immediate jeopardy was removed on 08/06/25; however, the deficient practice continues at a scope/severity level of G as the facility continues to implement its removal plan and as evidenced by the following example: The facility did not assess R1 for a decline in cognition and noted reddened penis with purulent drainage from the tip of R1's penis. R1 became unresponsive on 7/14/25 and was transferred to critical care, diagnosed with a urinary tract infection, hypotension (low blood pressure) and decreased oxygen levels. Findings include:Surveyor reviewed the facility protocol titled Change in Condition of the Resident, last revised on 09/20/22, which states in part, When a resident presents with a possible change of condition, such as fall or noted changes in mental or physical functioning:1. Assess the resident's need for immediate care/medical attention. Provide emergency care as needed. 2. Assess/evaluate the resident: This assessment could include, but is not limited to the following: A. Vital signs, oxygen saturation, blood glucose level C. Swelling, edema, discoloration. E. Personality, behavioral, and/or cognitive changes F. Alteration in level of consciousness, ability to respond.H. Sensory weakness or change I. Generalized or localized weakness J. Speech disorder K. Gait, posture, or balance changeM. Reflexes, response to stimuli, neurological signs Q. Dyspnea, or irregular breathing 3. Notify the resident's physician of any use-interaction change in condition. a. Immediate notification: for any symptom, sign of apparent discomfort that is: i. Acute or sudden in onset, and ii. A marked change in relation to usual symptoms and signs, or iii. unrelieved by measures already prescribed requires a phone call to the provider.5. Monitor the resident's condition frequently until stable or transported to a higher level of care if needed. 6. Ensure the resident's condition is included on the 24-hour report to be reviewed later by the IDT. According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) 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 (Licensed Practical Nurse) 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.A nurse conducting a neurological assessment should systematically evaluate the patient's mental status, cranial nerves, motor function, sensory function, coordination, and reflexes. Key actions include assessing the level of consciousness, orientation, pupil reaction, muscle strength, gait, sensation, balance, and performing specific tests for coordination and reflexes.Example 1:R2 was admitted to the facility on [DATE] with diagnoses including, in part, Parkinson's disease, muscle weakness, unsteady on feet, pyothorax without a fistula, pneumonitis, schizophrenia, and hypotension. R2's Minimum Data Set (MDS) assessment, dated 07/15/25, identified R2 required assistance from 1-2 people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and transfers. Surveyor reviewed R2's physician orders, which include:.-Monitor VS (vital signs) daily with special attention to blood pressure. -Continue IV antibiotics.-Reassess respiratory status and infection regularly.-Neurology consult.-Full Code. Surveyor reviewed R2's admission assessment, which states in part: On 07/10/25, R2 did not have any swallowing issues presently. Alert and oriented to time, place, and person. Breath sounds were clear bilaterally. Vital signs are stable. R2's vital signs: On 07/10/25 at 3:47 PM, blood pressure (BP) 126/80, heart rate (HR) 85, and respirations 20. Surveyor reviewed R2's progress notes from 07/10/25-07/18/25: -Nurse daily skilled observation note: On 07/10/25 at 9:00 PM, a daily nurse assessment was conducted, indicating that R2's respiratory status was even and regular, unlabored. R2's neuromuscular system had no issues. Progress notes from the Nurse Practitioner (NP): On 07/11/25 at 3:00 PM, NP visit today, the patient [R2] is seen lying in bed, appearing comfortable at rest. She is pleasant during the visit, providing only brief statements and yes or no responses. She tells me that she misses eating food, although she seems to understand the need for tube feeding due to dysphagia. She did experience nausea yesterday, and staff report that this seems to be relieved with as-needed Zofran. She is currently requiring supplemental O2 to maintain SpO2 greater than 90%. Vital signs have been stable, afebrile. There are no indications of increased shortness of breath, chest pain, fever, chills, diarrhea, constipation, dysuria or other urinary concerns. NP's physical examination: general- no acute distress, comfortable at rest. Respiratory- clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Neurological- cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness. On 07/11/25 at 4:39 PM, Occupational Therapy (OT) worked with R2 on sit-to-stand. R2 completed sit to stand with moderate assist, limited standing tolerance, c/o (complaints of) dizziness and wanting to lie down, pivot transferred to bed. R2 is educated on the use of the call light for all transfers and needs. R2's response to session interventions is that R2 is fatigued and wants to return to bed to rest. Nurse daily skilled observation note: On 07/11/25 at 9:00 PM, Shortness of breath on exertion, Neuromuscular system none. R2's vital signs: On 07/12/25 at 10:11 AM, BP 119/55, HR 89, respirations 18. On 07/12/25 at 10:46 AM, the nurse contacted the provider on call and reported R2 on tube feeds/nothing by mouth (NPO). On Intravenous (IV) antibiotics. Currently, R2 is very congested. Sounds like R2 has fluid in her throat. Lungs, sounds diminished bilaterally with rales. BP 119/55; HR 91, and respirations 16. R2 is lethargic and weak. Portable x-ray is here in the building and is willing to get a chest x-ray. Would you be okay with this? Provider ordered yes to Chest x-ray. On 07/12/25 at 12:21 PM, OT performed Passive Range of Motion (PROM) on R2's upper extremities. 100% physical assistance is required due to compromised strength, technique, and muscle tone to facilitate muscle recruitment to enable increased participation in self-care tasks. Skilled interventions focused on building rapport and attempts at establishing communication techniques were unsuccessful. OT used visual tools to help improve patient communication with the writer, although R2 was not able to consistently demonstrate the ability to respond. R2's eyes were open and able to focus on the writer, but minimal to no verbal attempts were made by R2 to communicate. 0 attempts by R2 to point to yes/or no cards. R2 found with thick phlegm on the right side of her mouth. R2 was attempting to cough throughout the session but was never able to clear what was in her throat. OT discussed concerns with the Registered Nurse (RN); stated she would perform oral care with R2. Also confirmed that today, she was unable to successfully communicate with R2, and R2 appears more lethargic today than yesterday. Surveyor did not find a neurological assessment completed for R2. On 07/12/25 at 1:33 PM, the nurse contacted the provider on call and reported R2 has a history of Dysphagia/catatonia/drooling/cognitive disorder/psychosis/empyema of the right pleural space, and atrial fibrillation. Chest X-Ray results Anterior Anterior-posterior view right basilar opacity by 1 view. R2 is being treated for pneumonia on the right side. Vital Signs stable and afebrile, she appears to be at baseline with more fatigue today, yet she has been awake this past afternoon. Would you like to just monitor? Provider ordered to continue to monitor. Surveyor did not find a neurological assessment completed for R2. On 07/12/25 at 1:43 PM, RN C documents R2 had been fatigued today and at times appears she has difficulty swallowing her saliva. Mouth care has been provided frequently due to intermittent drooling and dry lips. Chest x-ray obtained per provider, notified history of fatigue and drooling, which was not reported yesterday on 07/11/25. No new orders, the provider would like staff to continue to monitor. Surveyor did not find a neurological assessment completed for R2. On 07/13/25 at 12:42 AM, late entry: On 07/12/25 at 11:30 PM, R2 was not able to pivot transfer assist of 2. Hoyer lift used. R2 had a large amount of foamy secretions. -12:45 AM, R2 had another small amount of foamy secretions, R2 coughing, lung sounds upon both assessments were clear in the left lobes and coarse in the right lobes (wet sounding). R2 opens eyes when spoken to. R2 is resting comfortably. NP notified via email and gave orders to continue to monitor. Vital signs: On 07/13/25 at 10:01 AM, BP 91/64, and HR 90. Nurse daily skilled observation note: On 07/13/25 at 3:00 PM, R2's respiratory status, with abnormal lung sounds (rales, rhonchi, wheezing). The neuromuscular system decreased movement/mobility, and R2 has paralysis/weakness. Summary: R2 has been resting quietly in bed most of the shift. No s/s (signs/symptoms) of pain or discomfort. Opens eyes and looks at the writer when speaking but does not answer questions.Surveyor did not find a comprehensive neurological assessment completed for R2 when R2 was exhibiting decreased movement/mobility and had paralysis and weakness. Daily skilled observation:On 07/13/25 at 5:00 PM, R2's neuromuscular system is paralysis/weakness.Surveyor did not find a neurological assessment completed for R2 when continuing to exhibit paralysis and weakness. On 07/14/25 at an unknown time in the morning, Physical Therapy (PT) was seeing R2 for therapy. R2 not able to respond verbally, not able to gesture, or make eye movement. PT deferred. Surveyor did not find a neurological assessment completed for R2. Vital signs: On 07/14/25 at 1:41 PM, BP 100/57, HR 70, and respirations 16. On 07/14/25 at 1:52 PM, R2 has been unresponsive all morning. Mouth care is provided frequently. Drooling at times. R2 diaphoretic. Lung sounds diminished with crackles bilaterally. Sounds as though R2 has fluid in the throat. NP came to assess the resident. Orders to send to Emergency Department (ED) for unresponsiveness, diaphoresis, and crackles bilaterally. Surveyor did not find a neurological assessment completed for R2. On 07/14/25 at 2:50 PM, the hospital report from ED states R2 arrived by Emergency Medical Services (EMS) with fever and was non-communicative. R2 had a head Computerized Tomography (CT) scan that revealed diffuse middle cerebral artery Cerebral Vascular Accident (CVA).Telephone call received from Radiologist with final report on CT. The patient has a diffuse MCA cerebrovascular accident. Nursing staff contacted the skilled nursing facility, and the last reported normal was this past Friday, 07/11/25, post-discharge from the hospital. The patient is normally speaking and doing some swallowing independently. Currently obtunded, making gurgling noises, respirations. The head of the bed is up at 45 degrees. Chest x-ray pending, maintaining airway at present. On 07/21/25, while R2 was in the hospital, R2 suffered cardiac arrest and is now intubated and on a ventilator. R2 changed code status in hospital to Do Not Resuscitate (DNR) and palliative care. On 08/05/25 at 12:21 PM, Surveyor tried calling NP that was covering R2's care at the time and ordered Continue to monitor when nurses reported R2's symptoms. Surveyor was informed that the NP resigned and went to a different job a couple of weeks ago. On 08/05/25 at 12:32 PM, Surveyor called MD D and had to leave a message for a return call. On 08/05/25 at 12:52 PM, Surveyor interviewed RN H and asked RN H how R2 presented to RN H the times RN H cared for R2 in the facility. RN H reported that RN H was not familiar with R2 as RN H took care of R2 for the first time on RN H's shift 07/12/25. RN H reported to Surveyor that RN H thought the nonverbal communication and not moving in bed was R2's baseline. RN H reported that the day before, the provider was notified and advised to continue to monitor. Surveyor asked RN H what continuing to monitor means. RN H stated to Surveyor, I am not entirely sure, but it just means monitor [R2] further for further decline from [R2's] baseline. Surveyor asked RN H how RN H knew what R2's baseline was. RN H stated, I thought what I was seeing was [R2's] baseline, so I just continued to monitor. On 08/05/25 at 1:08 PM, Surveyor interviewed RN C and asked how R2 was during R2's care when RN C worked with R2. RN C reported that on 07/12/25, R2 could nod yes and no, and RN C thought it was R2's baseline not to talk but R2 could not transfer with staff as well. RN C called a Certified Nurse Assistant (CNA) in who had worked with R2 the previous night before and the CNA reported that it was not R2's baseline and that R2 was transferring with the assistance of 2 with a stand pivot. RN C had to grab the Hoyer lift and assist aides with transferring R2. Surveyor asked RN C how RN C would know what R2's baseline is. RN C reported to Surveyor that RN C usually comes on shift and looks at the admission assessment and then knows what is normal or not for residents. Surveyor asked if RN C reviewed R2's admission assessment to depict if this was R2's baseline. RN C reported to Surveyor that RN C did not review the admission baseline for R2. RN C stated, I just assumed it was her baseline being non-communicative and barely moving. I should have done a thorough exam of [R2] for possible concerns. On 08/05/25 at 1:52 PM, Surveyor interviewed hospital RN E and asked RN E how R2 presented to the ED. RN E reported that R2 was very unkempt looking and was non-verbal. RN E reported that RN E did not know what R2's baseline was, but through further assessment, found that R2 could not lift or move the right side of the body. RN E immediately activated the stroke protocol, and a CT scan was performed, showing a large stroke affecting the right side of R2's body. RN E reported that when RN E called the facility to try and grasp when the last well-known date and time was, a staff member from the facility stated, [R2] has not been well since Friday the 11th and could not use the right side. RN E then reported this to the hospital physician right away. Surveyor asked RN E if RN E remembered the staff member who gave the report, and RN E stated, I do not. RN E reported that R2 also presented to the ED with a fever and hypotension. On 08/05/25 at 2:01 PM, Surveyor interviewed RN I and asked RN I how R2 presented on 07/11/25. RN I reported to Surveyor that tube feedings went well and R2 seemed to be quiet but ok. RN I just thought that R2 was at R2's baseline, but RN I did not review what R2's baseline was, so unsure if R2's state was normal for R2. On 08/06/25 at 9:03 AM, Surveyor interviewed Rehab Director (RD) F and asked if R2 was provided PT services or an evaluation of care during R2's stay. RD F reported to Surveyor that R2 was evaluated on Friday, 07/11/25, and RD F worked with R2 personally by assisting R2 with sitting on the edge of the bed and sitting and standing. RD F reported that R2 could answer simple questions with short answers and yes or no answers. RD F reported that come Monday, 07/14/25 in the AM, unsure of time frame, R2 could not move her body or speak at all. R2 would not answer Certified Occupational Therapy Assistant (COTA)'s questions, and RD F deferred R2 for PT/OT services at this time. Surveyor asked RD F if PT Rehab Director F or COTA reported to any other staff of what COTA assessed while working with R2 during the PT session or reported this to anyone. RD F reported to Surveyor that RD F is unsure if COTA reported this to any staff members besides RD F unfortunately. On 08/06/25 at 9:30 AM, Surveyor interviewed MD D, who reported not knowing who R2 was as MD D has been out on medical leave and the NP was following. Surveyor asked MD D if any nurses report to the provider or NP a decline in cognition, mobility, and communication, what would be the expectation from the provider on call for nursing staff to do. MD D stated that nursing staff should already have a neurological assessment completed and be calling the provider with this information. MD D would immediately order that the resident be sent to the ED with a decline in cognition, mobility, and communication. MD D stated that a neurological assessment is going to show Glasgow Coma Scale (GCS)s, Range of Motion (ROM) for all extremities, vitals, and much more to see what is going on. MD D stated, I would have ordered [R2] to immediately be sent out to the ED. On 08/06/25 at 10:01 AM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B could explain R2's disposition at the facility on admission and then through the 4-day stay in the facility. DON B reported to Surveyor that DON B was in R2's room on Friday, 07/11/25, in the morning, sometimes to fix R2's television. DON B spoke with R2, and R2 answered questions, yes and no, but was a little slower in answering questions. R2 had trouble with word finding with yes and no, but R2 was comfortably lying in bed when DON B saw R2 at that time. DON B reported that RN C was providing care for R2 on Friday, 07/11/25, Saturday, 07/12/25, and Monday, 07/14/25. DON B reviewed RN C's progress notes and RN C noted lung sound changes in R2, called the provider got an order for chest x-ray. DON B reported that RN C didn't notice a change other than lung sounds in R2. Licensed Practical Nurse (LPN) G had R2 on Sunday, 07/13/25, and DON B spoke with LPN G about R2, and it was LPN G's first time working with R2. DON B reported that LPN G was able to give tube feedings to R2 with no issues, and R2 was able to track with eyes. LPN G reported to DON B that LPN G did not notice anything out of the ordinary for R2 at that time. LPN G reported to DON B that LPN G stated that LPN G thought R2 was at her baseline. DON B stated that RN C spoke with NP Monday, 07/14/25, as soon as R2 had more secretions, and during tube feeding at around 11 AM, RN C assessed residual was greater than 100ml before starting the tube feeding. NP assessed R2 while onsite, and determination was made for R2 to be sent out right away to the ED. Surveyor reported to DON B the findings of lack of nurse neurological assessments on 07/12/25 at 10:46 AM, 12:21 PM, 1:43 PM, and 11:30 PM. Also, on 07/13/25 at 3 PM and 5 PM. Then on 07/14/25 in the morning, OT was working with R2 and could not due to a decline, as well as a nurse assessment of unresponsiveness on 07/14/25 at 1:52 PM. DON B reported that staff should have assessed R2 more when R2's cognition, mobility, and verbal communication diminished, and staff did not. The failure to conduct neurological/comprehensive assessments and provide immediate care and treatment prevented staff from timely recognizing a significant condition change and from timely contacting the physician, thus delaying treatment. This created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy which began on 07/12/25. The facility removed the immediate jeopardy on 08/06/25; however, the deficient practice continues at a scope/severity level of G (actual harm/isolated) as the facility continues to implement the following removal plan and as evidenced by example 2 for R1:1. In house residents were assessed by Registered Nurse or designee including head to toe assessment using E-interact head to toe and review of skin assessment in last week to ensure residents experiencing a change in condition have complete assessment. Any changes from baseline will be reported to Primary care physician. This assessment will be completed by 8/6/25. 2. The DON initiated re-education with Licensed Nurses on change of condition policy including interact change of condition Sbar documentation to ensure thorough assessment of resident & primary care physician notification as appropriate. Licensed nurses will utilize interact 5.1 tool as guidance to determine change of condition and document in resident's medical record.3. On 8/6/2025, the DON VP of success and Executive Director reviewed facility established policies and guideline including Change in condition Primary Care Provider notification E-interact 4.5 guidelines (MD notification)*Policies and guidelines remain appropriate4. DON/designee to complete audits of nursing documentation and provider notification daily x 2 weeks. This audit will include ensuring accurate and thorough assessment of resident. After the initial audit period, audits will continue 5x week for 6 weeks. Ad Hoc QAPI held on 08/06/25, with Director of Nursing, Executive Director, VP of Success to review recovery plan. 5. Results of audits to be brought to monthly QAPI meeting for further review and recommendations.The deficient practice continues at a scope/severity of G (harm/isolated), based on the following example:Example 2:R1 was admitted to the facility on [DATE] with diagnoses including, in part, type 2 diabetes mellitus, urinary tract infection, poor hygiene, hypoxia, and hypotension. R1's Minimum Data Set (MDS) assessment, dated 07/13/25, identified R1 required substantial assistance for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, hygiene, and transfers. Surveyor reviewed R1's physician orders, which include: .-On 07/08/25, indicate level of pain using pain scale two times a day.-Catheter care every morning and at bedtime. -Cath care as needed. -Change catheter as needed for infection, obstruction, or leakage.- Urology follow-up appointment recommended - serial ureteral stent monitoring.-Monitor urine output. R1's pain documentation:On 07/08/25, R1 rated pain of 0/10. Surveyor found no other pain rating until 07/15/25 when R1 was back from the hospital. Surveyor reviewed R1's progress notes dated 07/08/25-07/16/25, which state in part:On 07/08/25, R1 was admitted to facility with no skin issues or respiratory issues. On 07/09/25 at 2:51 AM, nurse documented no musculoskeletal issues. On 07/09/25 at 2:30 PM, NP visit today, Patient [R1] seen seated in wheelchair, appears comfortable at rest. He is very hard of hearing and demonstrates poor memory recall, and he tells me more than once, I have no idea what in the hell is going on. Staff report that he has been requiring EZ stand for transfers due to significant weakness and unpredictability during transfers. He continues to experience hematuria, although he denies pain or discomfort in the bladder or urethra. Appetite has been fair, and staff assist him with meals as needed. Patient [R1] denies increased shortness of breath, chest pain, fever, chills, nausea, diarrhea, constipation, flank or suprapubic pain. Physical Examination: General frail appearing, no acute distress, comfortable at rest. Respiratory-clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Skin- warm and dry, no apparent rash or suspicious lesions on exposed skin. Neurological-cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness. Psychiatric alert, oriented to person, poor memory, impaired insight and judgement, underlying dementia. On 07/11/25 at 2:30 PM, NP progress note states R1 is seen lying in bed, appears comfortable. He continues to experience hematuria, although he denies pain or discomfort in the bladder or urethra, and urine is now pink-tinged. Appetite has been fair, and staff assist him with meals as needed. Staff report that the patient has been combative with cares, sometimes swinging at nursing staff. Will place referral to psych NP. Physical Examination: General frail appearing, no acute distress, comfortable at rest. Respiratory-clear, no wheeze, no accessory muscle use. Musculoskeletal- no erythema, no increased warmth, no significant joint deformity. Skin- warm and dry, no apparent rash or suspicious lesions on exposed skin. Neurological-cranial nerves grossly intact, able to move all four extremities, sensation intact, generalized weakness. Psychiatric alert, oriented to person, poor memory, impaired insight and judgement, underlying dementia. R1combative with cares, sometimes swinging at nursing staff. On 07/12/25 at 3:31 AM, the nurse documented skin turgor: normal, neuromuscular: none of the above. musculoskeletal: none of the above. On 07/13/25 at 12:10 PM, the nurse documented R1 had refused to get up for lunch. Staff stated they tried multiple times to see if R1 wanted to have some lunch and the resident refused. Nurse checked on R1and R1 got angry and stated that he did not want to eat lunch either. Will reapproach R1 later and see if he would like a snack later. On 07/13/25 at 4:43 PM, the nurse notified provider of R1's blood sugar of 270 and R1 having behaviors and refusing to eat lunch, stating he was not hungry. No assessment completed.On 07/13/25 at 5:54 PM, the nurse documented R1's penis reddened, discharge noted from tip of penis. |Surveyor could not find treatment for the assessment of R1's tip of penis being reddened and having discharge. Surveyor could not find a pain assessment completed for R1. Nurse did not complete a comprehensive assessment to include vital signs, to assess for signs of infection.On 07/13/25 at 10:14 PM, the nurse documented R1's penis reddened, and discharge noted from tip of penis. On 07/13/25 at 11:00 PM, the nurse notified provider of R1's redness around the base of the glans penis. R1's foreskin is retractable and resident yells it hurts when area is cleansed. Purulent drainage noted from ureteral meatus and urine is dark. No assessment completed. On 07/13/25 at 11:01 PM, R1 is noted to have redness around the base of the glans penis. R1's foreskin is non-retractable, and the resident yells out and states it hurts when the area is cleansed. Purulent drainage is noted from the urethral meatus. Area gently cleansed. Foley patent and draining. Urine is dark in color. No assessment completed. On 07/14/25 at 7:24 AM, provider reported to nurse that NP will see R1 today. There is concern for compartmental syndrome. On 07/14/25 at 8:00 AM, a change in condition form was completed for altered mental status, behavioral symptoms, decrease in food intake, and functional decline. Unresponsiveness. And hypoxia. Surveyor found that no comprehensive assessment was completed by nurses before R1 was transferred to the hospital on 7/14/25. On 07/14/25 at 9:35 AM, R1 left the facility via ambulance to ED for further evaluation. On 07/16/25 at 12:00 PM, NP progress note: History of Present IllnessR1 is an [AGE] year-old male, is being seen today for initial SNF evaluation following a recent hospitalization and emergency department visit on 07/14/2025. R1 was sent to the ED two days ago due to altered level of consciousness, genital swelling with nonretractable foreskin, and poor oral intake. At that time, he was unresponsive to questions and sternal rub, which represented a marked decrease in his level of consciousness from previous visits. Examination had revealed paraphimosis with erythema, crusting, edema, and purulent drainage from the urethra.Following the ED visit, R1 was admitted to the hospital on [DATE] for UTI, transient hypotension, and decreased oxygen level. R1 returned to facility and on 8/6/25 was back to baseline.On 08/06/25 at 11:25 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor reported a timeline through record review of R1's care before R1 was transferred to the hospital on [DATE]. Surveyor asked DON B what DON B's expectation is when the nurse found redness and drainage on R1's penis on 07/13/25 at 5:54 PM. DON B reported that staff should have followed the facility's change in condition policy and felt the nurse should have reported the finding immediately to the provider on call so that R1 could receive treatment instead of waiting hours later.

Based on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 2 of 15 residents (R) reviewed for quality of care (R34, R29). R34 did not receive adequate assessment and monitoring of edema associated with congestive heart failure (CHF) per current professional standards of practice. R29 did not receive adequate assessment and monitoring of cellulitis per current professional standards of practice. This is evidenced by: Example 1 According to the National Institutes of Health (NIH) Congestive Heart Failure (CHF): Nursing Diagnosis, 2023, indicates nurse assessment of CHF is to assess current symptoms such as dyspnea, fatigue, orthopnea, peripheral edema, vital signs, cardiovascular examination such as abnormal heart sounds, jugular venous distention. Respiratory examination such as auscultate lung sounds for crackles or wheezing and assess respiratory effort, daily weights, edema assessments, dietary habits, weight changes, medication adherence and any side effects related to diuretics or blood pressure medications, and assess emotional well-being related to potential anxiety or depression related to the chronic nature of CHF. According to National Institutes of Health, 2020, edema assessments should include visual inspection, palpation, and circumference and length measurement of the edema present on a routine basis to monitor for worsening. Circumference measurements of the lower extremity edema should be measured at two points, the maximum circumference of calf and ankle, and mark above the measurement line to ensure repeat measurements are accurate. The height of the edema should be marked to note if edema increases beyond initial measurement. According to the American Heart Association and the Heart Failure Society of America, 2015, Heart Failure Management in Skilled Nursing Facilities Recommendation Guidelines include identifying residents at low or high risk for exacerbation and implement standing order/assessment guidelines to document weight goals, vital signs (including orthostatic blood pressures), heart failure (HF) medications, medications to avoid (eg, nonsteroidal anti-inflammatory drugs), and patient/family education. Nursing staff should have advanced training in fluid volume assessments, HF medications, assessment of exacerbations, and when to notify the provider regarding changes in condition or weight. Patients at risk for exacerbation should have daily weights, with a gain of 3-5 lbs over 3 to 5 days reported to provider, advanced assessment of volume status, vital signs and oxygen saturation completed daily. R34 was admitted to the facility on [DATE] with pertinent diagnoses of right knee effusion, diastolic congestive heart failure, atrial fibrillation, and farmer's lung. R34's admission Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15/15 indicating cognition intact, had shortness of breath with exertion and lying flat, and had impaired range of motion on one lower extremity. R34's care plan, dated 04/30/25, states: Will be free of complications related to edema/excess fluid volume with interventions of reporting signs and symptoms of edema/fluid overload, such as change in mental status, weight gain, neck vein distention, abnormal lung sound, extremity swelling . Will maintain adequate hydration with interventions of monitoring for poor skin turgor and decreased urine output . Will exhibit no acute cardiac distress with interventions to obtain weights as ordered. Of note: Lung sound assessments were not completed on a routine basis or with changes, urine output was not monitored, and weights were not completed per order. R34's physician orders: 04/30/25 Weight - on admit, daily x2, weekly x3, monthly. Obtain reweight if change of 5 lbs. since last weight. 05/14/25 Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for CHF AND Give 1 tablet by mouth one time a day for CHF for 1 Day 05/15/25 Daily weight one time a day for CHF 05/16/25 Apply Tubi grips to BLE - on every morning; remove at bedtime for edema 05/17/25 Spironolactone Oral Tablet 25 MG Give 1 tablet by mouth one time a day for CHF R34's weights: 04/30/25 165.1 lbs. 05/02/25 163.1 lbs. 05/03/25 164.1 lbs. 05/14/25 177.2 lbs. 05/15/25 177.8 lbs. 05/16/25 180.4 lbs. 05/17/25 178.1 lbs. 05/18/25 179.2 lbs. 05/19/25 178.4 lbs. 05/20/25 179.6 lbs. Of note: No weight was documented for 10 consecutive days between 05/04/25 - 05/13/25. Provider was notified on 05/14/25 of the 13.1 lb increase in weight. Surveyor reviewed R34's daily assessments and noted the following: 04/30/25: Lungs clear, heart regular; +2 edema to RLE and +1 edema to LLE. Pedal pulses equal and normal. 05/01/25 - 05/13/25: Respiratory: Regular/unlabored. No edema noted. No lung sound assessment noted. No pedal pulses assessment noted. 05/14/25: +2 BLE edema. Respiratory: Regular/unlabored. No lung sound assessment noted. No pedal pulses assessment noted. 05/15/25: +2 BLE edema. Respiratory: Regular/unlabored. No lung sound assessment noted. No pedal pulses assessment noted. 05/16/25: BLE edema. Respiratory: Regular/unlabored. No lung sound assessment noted. No pedal pulses assessment noted. 05/17/25: +2 BLE edema. Respiratory: Regular/unlabored. No lung sound assessment noted. No pedal pulses assessment noted. 05/18/25: +2 BLE edema. Respiratory: Regular/unlabored. No lung sound assessment noted. No pedal pulses assessment noted. 05/19/25: +1-2 BLE edema. Respiratory: Regular/unlabored. No lung sound assessment noted. No pedal pulses assessment noted. 05/20/25: No edema noted. Respiratory: Regular/unlabored. Lung sounds clear. No pedal pulses assessment noted. Of note: Edema assessments reviewed did not include circumference and length measurements or skin temperature. Surveyor reviewed R34's provider notes and noted the following: 05/01/25: Respiratory assessment - clear, no wheeze, no accessory muscle use. Cardiovascular assessment - irregular rate and rhythm, no murmur, lower extremities without edema. Denies increased shortness of breath while at rest 05/07/25: Respiratory assessment - clear, no wheeze, no accessory muscle use. Cardiovascular assessment - irregular rate and rhythm, no murmur, lower extremities without edema. Vital signs have been stable. Denies increased shortness of breath while at rest. 05/14/25: Of concern, patient has 2+ edema noted to BLEs today. Weight is up over 10 pounds over the past several days as well. He reports symptoms of paroxysmal nocturnal dyspnea and increased nocturia, as well as cough with whitish sputum production. Denies shortness of breath at rest. Discussed with nursing staff. Cardiovascular assessment - irregular rate and rhythm, no murmur, lower extremities with 2+ edema. Respiratory assessment - clear, no wheeze, no accessory muscle use. New orders: - order CBC, BMP, and BMP around 05/21/25. - daily weights to monitor fluid status, response to furosemide and spironolactone. - referral to Heart Failure clinic. Of note: Daily weights completed per order starting 05/14/25. Heart Failure clinic appointment scheduled for 05/22/23 at 1:30 PM. 05/16/25: Patient continues to have 2-3+ edema to BLEs. Lung sounds are clear and denies increased respiratory distress. Assessment and Plan - Adding furosemide 20 mg at 12:00 PM x5 days. Increase spironolactone from 12.5 mg to 25 mg daily. Continuing furosemide 40 mg daily. Monitor for worsening edema, weight gain, increased dyspnea, orthopnea, decreased exercise tolerance, and signs of fluid overload. Daily weights essential to track response to diuretic therapy. Of note: Medication orders were implemented 05/16/25. No additional edema monitoring was noted in assessments. No orders were implemented to monitor fluid intake or output. On 05/19/25 at 9:42 AM, Surveyor observed R34 sitting in recliner in room. R34 was observed wearing gripper socks and Tubi grips in place with 3+ BLE, pitting edema. R34's socks and Tubi grip were rippled in various areas demonstrating pitting areas on top of both feet and ankles. R34's feet were flat on the floor. R34's raised pant leg was just below knee and Surveyor observed the top of Tubi grip rolled down creating a deep indentation in upper calf. R34's edema extended to just below knee on both legs. On 05/20/25 at 6:51 AM, Surveyor observed R34 ambulating independently with feet in wheelchair in hallway. R34 had gripper socks and Tubi grips on with 3+ BLE, pitting edema just behind toes, on top of feet, and extending into calf. On 05/20/25 at 10:46 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G regarding Tubi grips. CNA G stated that CNAs typically apply and remove Tubi grips and sizing is determined by the nurse. CNA G was unable to state what size Tubi grip R34 was wearing. On 05/20/25 at 2:43 PM, Surveyor interviewed Registered Nurse (RN) E regarding Tubi grip assessment and sizing. RN E stated there are a couple different options available for sizes in Tubi grips and the nurse determines which size to pick based on visual inspection. Surveyor asked RN E if measurements of any kind were used to assess for Tubi grip size. RN E stated no. Surveyor asked which size Tubi grip R34 was wearing. RN E stated not knowing for sure, but that most of the nurses typically use the same size for everyone. On 05/21/25 at 10:15 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H regarding edema assessments and Tubi grips. LPN H stated no standard of practice being in place for HF and edema related to assessments. LPN H stated that weights, vital signs, intake/output monitoring frequency are determined by the provider. LPN H stated lung sounds are only typically assessed if there is a change observed in fluid or respiratory status. Surveyor asked how edema is monitored for worsening. LPN H stated by weight gain or increase in size. Surveyor asked how size is determined. LPN H stated using the pitting scale of 0-4. Surveyor asked if nursing staff do any kind of circumference measurement to assess and monitor edema. LPN H stated no. On 05/21/25 at 10:30 AM, Surveyor interviewed RN F regarding edema assessments and Tubi grips. Surveyor asked RN F how fluid volume is assessed and monitored in residents with CHF and edema. RN F stated they would typically do daily weights and monitor intake and output. Surveyor asked RN F if this was being completed for R34. RN F stated daily weights were started on 05/14/24, but no intake and output monitoring has been completed. Surveyor asked why this was not being monitored. RN F stated because the provider did not order it. Surveyor asked RN F how Tubi grips are assessed for fit and efficacy. RN F stated that it should be flat on the skin with no ripples, lay just behind the toes and reach just below the knee. RN F stated that once Tubi grips are cut from the box and placed on a resident, no assessment of the Tubi grip is completed to assess for compression. Surveyor asked RN F how long a Tubi grip can be used. RN F was not sure. Surveyor asked RN F what size Tubi grip was being used for R34. RN F stated not knowing. On 05/21/25 at 10:40 AM, Surveyor interviewed LPN H and RN F regarding manufacturer's recommendation for Tubi grip size and length of use. RN F provided Surveyor with the Mediline Tubi grip packages of sizes E and G. Surveyor noted the manufacturer's instructions: 1) Measure the area with the largest circumference. Use the sizing chart to determine the appropriate sized bandage to deliver the desired compression and cut to desired length. Further instructions state, Change Frequency: up to 7 days. Surveyor asked LPN H and RN F if they were aware of these instructions. Both LPN H and RN F stated no, they had never read these instructions before. On 05/21/25 at 2:01 PM, Surveyor interviewed Director of Nursing (DON) B regarding edema assessments. DON B stated that no current standard of practice is in place for assessing and monitoring edema and all assessments completed are per provider order. Surveyor asked DON B if she was aware of the current standard of practice to assess edema using circumference measurements, assessing lung sounds, monitoring daily weights, and intake and output. DON B stated that she was not aware of the circumference measurements, but the other assessments are only completed if the provider orders to do so. Surveyor asked DON B if she was aware that the Tubi grip manufacturer's recommendation is to complete a circumference measurement and choose a size based on the measurement. DON B stated not being aware of this. DON B stated acknowledgment the facility's current practice in assessing and monitoring did not follow current professional standards of practice and had the potential of negatively affecting resident's outcomes. Example 2 According to National Institutes of Health, 2023, Cellulitis management includes thoroughly inspecting the affected area for any signs of skin breakdown. The area should be demarcated with a marker to monitor for continuous spread. The area should be palpated to note any presence of warmth, tenderness, or purulent drainage. R29 was admitted to the facility on [DATE] with pertinent diagnoses of dementia, anemia, and hypertensive chronic kidney disease stage 3. R29's most recent quarterly MDS assessment dated [DATE] noted a BIMS score of 08 indicating moderate cognitive impairment and infection of the foot is present. R29's care plan states: ADL self-care performance deficit with interventions of skin inspection completed weekly and daily with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. Check nail length, trim, and clean on bath day and as necessary. Of note: Facility was unable to provide documentation of nail care and inspection on bath day. R29's provider orders: 05/14/25 Doxycycline Hyclate Oral Tablet 100 MG (Doxycycline Hyclate). Give 1 tablet by mouth two times a day for left great toe infection for 7 Days. 05/14/25 Warm soapy water soak 15 minutes 2 times daily. Surveyor reviewed R29's progress notes and noted the following: 05/12/25 Note: RN trimmed R29's toenails. R29 stated that his left great toe nail was hurting. Nails are thick. After pressing down on the nail, a small amount of purulent drainage was noted and toe is warm and red. NP notified. No new orders. R29 is on the list to see podiatry in 1 week for nail evaluation and trim. Of note: Podiatry assessed R29 on 05/19/25. No new orders received. Surveyor found no documentation of redness, tenderness, drainage, wounds, or signs of infection by nursing prior to 05/14/25 or after. Surveyor reviewed R29's provider notes and noted the following: 05/14/25 - R29 is being seen today due to staff reports of left great toenail pain. Reports continued pain to left great toenail, and (particularly when comparing to other foot) there is erythema noted to left toes and distal portion of foot. He experiences pain with slight manipulation of toenail, which has significant onychomycosis. Vital signs have been stable, afebrile. Denies chest pain, fever, chills, nausea, vomiting, diarrhea, constipation, dysuria or other urinary concerns. Extremities - no lower extremity edema bilaterally, no clubbing or cyanosis, erythema noted to left toes and distal portion of foot, pain with slight manipulation of left great toenail, significant onychomycosis of left great toenail and other toenails. Assessment and Plan - Cellulitis of left toe - Started doxycycline 100 mg twice daily for 7 days. Recommended warm soapy water soaks for 15 minutes twice daily and Band-Aid application to toenail per patient's request. Monitor for spreading erythema, increased pain, fever, or purulent drainage that would indicate worsening infection requiring IV antibiotics. Of note: No documentation of erythema monitoring noted in nursing documentation following this note on 05/14/25. On 05/21/25 at 9:32 AM, Surveyor observed R29's left foot. The left great toe was edematous. Redness seen on top of foot approximately 1 inch below toes spreading to great toe, 2nd, 3rd, and 4th toes. All toenails were yellow in color, thickened and raised. Great toenail was approximately 1/4 inch thick. No purulent drainage noted. Patchy areas noted on top of foot between great toe and second toe. R29 denied pain at this time, but stated it comes and goes. No markings on foot were observed noting where erythema was being monitored. On 05/21/25 at 10:37 AM, Surveyor interviewed RN F regarding cellulitis assessments. RN F stated a progress note should be completed assessing skin condition (color, temp, etc.) in by nurse each shift. Surveyor asked RN F how to assess for improvement/worsening of cellulitis. RN F stated that a line is sometimes drawn and then monitored, but the NP would usually be the one to start this. Surveyor asked RN F if marking the red area would be expected to monitor for worsening. RN F stated that it is not expected as part of assessment but recognizes why that would be important. On 05/21/25 at 12:41 PM, Surveyor interviewed DON B regarding cellulitis assessments. DON B stated not having a standard of practice in place and assessment and monitoring is ordered by the provider. DON B stated that staff are expected to assess residents daily and document findings that are abnormal. Surveyor asked DON B if it would be expected to see documentation of R29's skin assessment in relation to recent diagnosis of cellulitis. DON B stated yes, staff should be documenting redness, swelling, discharge/drainage, tenderness/pain, vital signs, fever, edema, and whatever the provider orders to monitor. Surveyor asked DON B if staff would be expected to mark the area of redness to monitor if it was worsening. DON B stated no, unless the provider orders it. Surveyor asked DON B if she was aware that current standards of practice recommend marking the area to monitor the spread of infection as this also helps evaluate antibiotic efficacy. DON B stated no, that they rely on the provider's judgement to determine what assessments and monitoring should be completed per current standards.

Based on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 2 of 5 residents (R32 and R50) observed for medication administration. The facility had 37 opportunities and 2 medication errors resulting in a 5.41% error rate. Licensed Practical Nurse (LPN) D administered two different inhalers in the wrong sequence for R32. LPN D administered Carafate after breakfast for R50. This is evidenced by: Facility policy titled, Oral inhalations dated January 2023, stated in part, .Inhaler Sequencing: 1. Bronchodilators/Beta Agonists-administer first if more than one inhaler to be administered at the same med pass time. a. These agents work by promoting bronchodilation which relaxes bronchial smooth muscle. 2. Anticholinergic Agents a. Antagonizes the action of acetylcholine with resulting bronchodilation 4. Corticosteroids-administer last if more than one inhaler to be administered at the same med pass time . Example 1 On 05/20/25 at 7:53 AM, Surveyor observed LPN D administer R32's Fluticasone Propionate inhaler as the second inhaler, which is a Corticosteroid based inhaler, out of 3 inhalers administered during R32's medication pass. LPN D then waited 5 minutes and administered R32's Anor Ellipta inhaler which is an Anticholinergic based inhaler. On 05/20/25 at 12:31 PM, Surveyor interviewed LPN D and asked LPN D what the facility process is for sequencing inhalers when using multiple inhalers. LPN D stated LPN D tried to sequence the right way but was unsure which inhaler went second and third. Surveyor informed LPN D beta agonists such as Albuterol was administered correctly as the first inhaler but the second inhaler for R32 should have been the Anticholinergic inhaler (Anor Ellipta) and then the Corticosteroid inhaler (Fluticasone propionate). LPN D stated LPN D should have double checked this before administering inhalers. On 05/20/25 at 12:40 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A what the expectation is for sequencing inhalers when using multiple inhalers. NHA A stated LPN D should be following the facility policy which indicates beta agonists such as Albuterol was administered correctly but the second inhaler for R32 should have been the Anticholinergic inhaler (Anor Ellipta) and then the Corticosteroid inhaler (Fluticasone propionate) last. Example 2 Surveyor reviewed R50's physician orders that state in part, .-On 03/25/25, Carafate Oral Suspension 1 GM/10ML (Sucralfate)-Give 10 ml orally two times a day for small intestines Arteriovenous malformations (AVMs). Give before meals . On 05/20/25 at 8:01 AM, Surveyor observed LPN D administer Carafate 10mls to R50 during medication pass. Surveyor observed R50's breakfast tray was empty, and a Certified Nurse Assistant (CNA) came into R50's room and took R50's breakfast tray while LPN D was administering Carafate. On 05/20/25 at 8:06 AM, Surveyor interviewed LPN D and asked LPN D if R50's Carafate was to be given before breakfast or after breakfast. LPN D stated physician orders for R50 do say give before breakfast. LPN D stated LPN D should have gotten into R50's room before now but LPN D did not. On 05/20/25 at 12:40 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A what the expectation is for administering Carafate to R50 before meals to help coat the stomach as intended use is for. NHA A stated LPN D should follow the physician orders for Carafate use with R50.

Based on observation, interview and record review, the facility did not provide pharmaceutical services including procedures that ensure the accurate acquiring/accounting for, receiving, dispensing, administering and reconciliation of all drugs and biologicals to meet the needs of each resident for residents (R) R49, R113 and R262. Findings include: Example 1 Surveyor reviewed facility policy titled, Disposal of Medications, dated as revised in January 2024, stated in part, .1. Discontinued medications and/or medications left in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner according to state and federal regulations for disposition . On 05/19/25 at 10:07 AM, Surveyor toured medication storage room on 400 hall with Registered Nurse (RN) E. Surveyor observed a locked narcotic box located on the wall. Surveyor asked RN E if RN E could unlock box and Surveyor assess what is in the locked narcotic box. Surveyor observed R49's Butalbital bottle with 24 capsules noted in the bottle. Surveyor observed R113's Oxycodone 5mg tabs pack with quantity of 30 tabs located in pack sitting in the locked narcotic box on wall in medication storage room. On 05/19/25 at 10:17 AM, Surveyor interviewed RN E and asked RN E if R49 and R113 are still residents in the building. RN E indicated R49 and R113 are no longer residents in the building. R113 was discharged over a week ago from the facility. Surveyor asked RN E what the process is for narcotics left in the locked box after residents are discharged from the facility or passed away. RN E indicated RN E knows two licensed staff members are supposed to destruct the narcotics after resident is discharged and RN E stated RN E is unsure why these medications have not been destroyed. RN E stated RN E will complete this now. On 05/19/25 at 1:27 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked what the process is for narcotic storage after a resident has been discharged from facility. NHA A stated NHA A understands there were two residents, R49 and R113, who were discharged over a week ago. NHA A stated nursing staff should have destroyed these medications right after residents were discharged . NHA A stated two nurses are destroying the narcotics right now, and NHA A is placing education out to staff about not storing narcotics past the time the residents have been discharged from the facility. 49353 Example 2 According to the Wisconsin Nurse Practice Act, a licensed nurse must administer medications according to the licensed prescriber's order of dosage, route, frequency, and duration. Administering medications without an order is a violation of the nursing scope of practice and prohibited by law. R262 was admitted to the facility on [DATE] with pertinent diagnoses of Alzheimer's disease and dementia with behavioral disturbance. R262's physician orders: 04/25/25 alprazolam oral tab 0.25mg (Alprazolam) Give 1 tab orally every 8 hours as needed (PRN) for anxiety. Surveyor reviewed R262's progress notes and noted: 05/09/25 8:40PM, Clinical follow-up note - R262 was exit seeking and trying to self-transfer. 1/2 tablet of PRN Alprazolam given per family request. Surveyor reviewed R262's medication administration record (MAR) and noted: On 05/09/25 at 6:42 PM, physician ordered dose of Alprazolam 0.25 mg was documented as administered with attached note stating resident exit seeking and trying to self-transfer. 1/2 tablet of PRN Alprazolam given per family request. Result: Effective. On 05/21/25 at 2:01 PM, Surveyor interviewed Director of Nursing (DON) B regarding this medication administration. DON B stated yes, that a half dose was administered. Surveyor asked DON B if there was a provider order to give this dose. DON B was unable to locate an order. Surveyor asked DON B if this would be an acceptable practice for nursing staff to administer a medication in a dosage different than prescribed. DON B stated yes, residents have the right to determine what medication dosage they want to take. Surveyor asked DON B if DON B was aware this is not an acceptable practice as it is outside a nurse's scope of practice. DON B acknowledged that a nurse should not administer medications outside of a prescriber's order, and the provider should be contacted for an order to administer medications in a different dosage.

Based on observation, interview and record review, the facility staff did not implement infection control practices when warranted. Facility staff did not perform hand hygiene when warranted during care affecting 1 of 7 residents (R) observed for care (R19). Insulin pens were not disinfected for 2 of 2 observations for R6. This is evidenced by: Example 1 Surveyor requested and received the facility policy titled Hand Hygiene dated 11/02/2022. The policy in part read: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards practice. 2. Hand hygiene is indicated and will be performed under conditions listed in, but not limited to. the attached hand hygiene table. Additional Considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves; perform hand hygiene prior to donning gloves, and after immediately after removing gloves. Hand Hygiene Table: ~Before applying and after removing personal protective equipment (PPE), including gloves. ~After assistance with personal body functions . Facility policy titled Subcutaneous Insulin, dated revised in January 2023, stated in part, .Procedures: #9. Prepare Injection: c. Swab rubber cap with antimicrobial agent . On 5/20/25 at 7:03 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide morning care for R19. CNA C entered R19's room, proceeded to R19's closet to obtain clothes, obtain a clean brief, and gather care supplies that were brought to R19's bed. CNA C did not perform hand hygiene prior to handling R19's clean clothing and clean brief. CNA C went to R19's sink and performed hand hygiene, donned gloves to wet a washcloth and apply soap to a cloth. CNA C washed and dried R19's upper body, applied deodorant and donned a clean shirt. CNA C returned to the sink and wet a cloth and applied soap to wash R19's peri area. CNA C removed her gloves and proceeded to dress R19 with a clean brief, clean pants, and clean socks. CNA C did not perform hand hygiene after she removed her contaminated gloves and proceeded to dress R19 with clean brief and clothing. On 5/20/25 at 7:17 AM, Surveyor interviewed CNA C about the observation. CNA C expressed she should have washed her hands when gloves were removed after peri care and before proceeding to touch clean items. CNA C further expressed hand hygiene is important for infection control. On 5/21/25 at 9:43 AM, Surveyor interviewed Director of Nursing (DON) B regarding the expectation of staff hand hygiene when entering resident rooms for care and when removing gloves after performing peri care. DON B expressed she would expect staff to perform hand hygiene when entering resident rooms to assist with care. DON B further expressed she would expect staff to perform hand hygiene when removing gloves after peri care and before proceeding with dressing resident with clean clothing. 48793 Example 2 On 05/20/25 at 7:45 AM, Surveyor observed Registered Nurse (RN) E prep R6's Humalog pen 13 units and Lantus pen 42 units. Surveyor did not observe RN E cleanse tip of rubber on insulin pens to sanitize the tip before applying the needle and administering insulin in R6's lower left quadrant of abdomen. On 05/20/25 at 12:26 PM, Surveyor interviewed RN E and asked what the process is for sanitizing insulin pens. Surveyor stated to LPN E that Surveyor did not observe RN E sanitize the rubber cap on insulin pen with a microbial agent before applying the insulin needle and administering insulin to R6. RN E stated RN E did forget to sanitize the rubber tips of insulin pens with an alcohol pad. RN E stated RN E should have sanitized before administering to R6. On 05/20/25 at 12:40 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A what the expectation is for sanitizing insulin pens. NHA A stated facility policy indicates the rubber caps be sanitized before applying insulin needle to insulin pens for administration.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the Comprehensive Person-Centered Care Plan, and the residents' choices for 1 of 3 sampled residents (R2). R2 had 4 tarry red stools between 11:00 AM and 1:00 PM on 8/31/24. R2's vitals were not monitored. There is no documentation of red tarry stools or physician notification until R2 was sent to the emergency roiagnom on [DATE] at 1:58 AM. This is evidenced by: Facility policy titled, Acute Condition Changes - Clinical Protocol, last revised, 3/2018, states in part . 2. In addition, the nurse shall assess and document/report the following baseline information: a. vital signs. g. onset, duration, severity. 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician. 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 10. The nurse and physician will discuss and evaluate the situation. a. The physician should request information to clarify the situation; for example, vital signs, physical findings, and detailed sequence of events and descriptions of symptoms. Facility policy titled, Change of a Resident's Condition or Status, last revised 5/2017, states in part . Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call where there has been a(an): d. significant change in the resident's physical/emotional/mental condition; i. specific instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-harming); 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Interact Version 4.5 Tool for Change in Condition: When to report to the MD/NP/PA, states in part . Immediate Notification: Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A Marked Change (i.e., more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. Blood Pressure: Systolic BP (blood pressure) > (greater) 200 mmHg or < (less than) 90 mmHg. Diastolic BP >115 mmHg. Facility document titled, [Oak Medical] Onsite Physician Services, states in part . What should be placed in the binder: 1. non-urgent paperwork. 2. DNR (do not resuscitate) consents. 3. Discharge paperwork. 4. Therapy certs. 5. Pharmacy Recommendations. 6. Papers that need signed by MD (medical doctor) only. What should NOT be placed in the binder: 1. Anything urgent/stat. 2. Lab/Diagnostic results-these should be communicated through Hucu.ai (Hucu.ai provides facilities with HIPAA compliant instant messaging for internal facility use, but also allows facilities to securely communicate with network partners, patients, and approved patient's family members in one universal system. It also can be integrated into your EHR to further improve your staff's efficiencies. It comes with built-in capabilities that streamlines communication across different staff/collaborators working in different organizations but caring for the same patients.) 3. Controlled substance refills-these should be communicated through Hucu.ai. Send HUCU Message URGENTLY IF . Vitals: SBP (systolic blood pressure) >200 or <90; DBP (diastolic blood pressure) >120 or <50. Change of Condition: Symptoms that need immediate addressing. According to AMDA (American Medical Directors Association) Guidelines, acute change of condition, protocols for Physician Notification, states in part . Bleeding, rectal ((melena) - dark stools with or without blood)). Immediate Notification: Persistent, or accompanied by diaphoresis, tachycardia, significant orthostatic BP drop. Non-Immediate: Recent self-limited bleeding, tarry stool, or melena without change in vital signs. R2 was admitted to the facility on [DATE], with diagnoses, including, but not limited to, ankylosing spondylitis of thoracic region, dementia, polyp of stomach and duodenum, gastrointestinal hemorrhage, low back pain, and malaise. R2's most recent quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 9/10/24 indicates R2 has moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. R2's care plan states in part . Focus: Risk for Impaired Circulatory-orthostatic hypotension, CAD (coronary artery disease), hyperlipidemia, HTN (hypertension). Revision on: 8/12/24 Interventions: Encourage oral fluid intake, maintain hydration. Date Initiated: 8/08/24. Evaluate heart rate. Date Initiated: 8/08/24. Focus: The resident has anemia r/t (related to) GI (gastrointestinal) bleed, gastric polyps, duodenal polyn, HX (history) GI bleed. Date Initiated: 8/28/24. Revision on: 9/30/24. Interventions: Monitor/document/report PRN (as needed) following s (signs)/sx (symptoms) of anemia: Pallor, Fatigue, Dizziness, Syncope, Headache, Palpitations, Weakness, fell ing of cold, Low Hgb (hemaglobin)/hct (hematocrit), SOB (shortness of breath) on exertion, Sore tongue, Chest pain, Tinnitus, Headache, changes in condition. Date Initiated: 8/28/24. Note: Care plan does not include monitoring for bleeding. R2's eMAR (electronic medical record), states in part . ASA (Aspirin) 81 mg (milligrams). Give 1 tablet by mouth one time a day related to Atherosclerotic heart disease of native coronary artery w/o (without) angina pectoris. Start Date: 8/02/24. Facility document titled, Weights and Vitals Summary, Blood Pressure Summary states in part . 8/31/24 at 8:22 AM, Blood Pressure: 116/52 (sitting l (left)/arm) 8/31/24 at 2:23 PM, Blood Pressure: 116/57 (sitting r (right)/arm) 8/31/24 at 3:26 PM, Blood Pressure: 110/38 (sitting l/arm) 8/31/24 at 2:23 PM, O2 sats (saturation): 95% (percent) 8/31/24 at 2:23 PM, Pulse: 70 (regular) 8/31/24 at 2:23 PM, Respirations: 20 Breaths/min (minute) 8/31/24 at 2:23 PM, Temperature: 97.2 (Temporal Artery) Note: Blood pressure on 8/31/24 at 3:26 PM was outside of parameters and not reported to the physician. Nurses Note, dated 9/01/24 at 1:58 AM, states, Hello, resident with 4 tarry red stools earlier between 1100 (11:00 AM) - 1300 (1:00 PM) today. BP reading this morning 112/38. On assessment, writer took residents BP manually, getting readings of 118/>20, because the gauge stopped reading. She is very pale. Denies pain. Above information related to PA, who requests a stat H&H (hemoglobin and hematocrit). When informed we would be unable to do this in our facility, and this was discussed with [name], who does want evaluated in ED (emergency department). [Name] okay with this plan. 911 called; resident left facility via ambulance to [hospital name] at 2100 (9:00 PM). Report called to RN (registered nurse). Hospital Discharge Summary, dated 9/03/24, states in part . Discharge Diagnosis: Dark stools. Hospital Course/Treatment Rendered: [AGE] year-old female past medical history significant for upper GI bleed 2/2 gastric polyps, CAD (coronary artery disease), with pacemaker, HTN, dementia, orthostatic hypotension, HF (heart failure), gout, E.coli sepsis, liver cirrhosis, stomach and duodenal polyp, previous GI bleed history evaluated in the ED due to black stools. She was recently discharged on ,d+[DATE] after being evaluated for possible GI bleed. On 10/7/24 at 3:05 PM, Surveyor interviewed ADON C and NHA A. Surveyor asked ADON C what SOP (standard of practice) the facility for physician notification. ADON C stated, we use [Name] Onsite Physician Services. On 10/7/24 at 3:30 PM, Surveyor asked ADON C and UM (unit manager)/RN D (registered nurse) when notification would be appropriate for rectal bleeding or dark tarry stools. ADON C stated, I would update after a second episode, would look at the patient history. UM/RN D stated, I would have updated after the first red tarry stool. Surveyor asked UM/RN D about R2's blood pressure reading from 8/31/25 at 2:35 PM. UM/RN D stated, someone should have contacted the physician with that blood pressure reading. On 10/7/24 at 4:15 PM, Surveyor interviewed RN F. Surveyor asked RN F what the protocol was for a change of condition. RN F stated, we have a system called Hucu to talk with physician or NP (nurse practitioner) via message board on the computer. We would complete an assessment and send the information. Within 10 minutes we get an answer. If an emergency can call [doctor's name], he is everyone's physician. We have his cell number. We also have a binder and guidelines for Hucu and there is always a nurse manager on call. On 10/7/24 at 4:30 PM, Surveyor interviewed LPN E (licensed practical nurse). Surveyor asked LPN E what the protocol was notification for a change of condition. LPN E stated, notify the physician via Hucu message board. If a severe change of condition would call immediately. The facility failed to update the physician when R2 had 4 red tarry stools and blood pressure reading was outside parameters. The facility did not monitor R2's vital signs regular following her red tarry stools.

Based on record review and staff interview, the facility failed to ensure screening of all employees was completed to prevent abuse, by failing to conduct timely background checks for 1 of 8 facility staff (LPN (Licensed Practical Nurse) G). This had the potential to affect all residents. LPN G was hired by the facility on [DATE]. Facility was not able to provide proof that LPN's BID (Background Information Disclosure) form, DOJ (Department of Justice) letter or IBIS (Integrated Background Information System) letter were completed within the past four years as required to screen. Findings include: The Wisconsin Caregiver Program Manual for Entities Regulated by the Division of Quality Assurance (P-00038 updated ,d+[DATE]) stated, After the initial background check at the time of employment or contracting, entities must conduct new caregiver background checks at least every four years or at any time within that period that an entity has reason to believe new checks should be obtained. Facility provided policy titled Background Investigations, which stated, .The facility has developed a background investigation program that is conducted on all new or rehired employees within the guideline of applicable federal, state and local law. This program does not suggest a general distrust of our employees or job applicants; rather it serves the purpose of meeting the safety, legal and ethical expectation of our residents, their families and all of our employees. On [DATE], a sample of employees was selected to review for background check compliance by Surveyor, including LPN G. On [DATE], facility provided Surveyor with requested background check documents. Surveyor reviewed the facility's caregiver background check records provided. LPN G was listed as hired by the facility on [DATE] and continued to work at the facility at the time of survey. LPN G's BID, DOJ and IBIS were dated [DATE]. On [DATE] at 10:15 AM, Surveyor asked Human Resources Manager (HR) F if LPN G had an updated background check completed as the one on file had expired [DATE]. HR F called the agency contact person to ask for this, as LPN G was a contracted staff member. The agency was looking into this and would call HR F back. HR F said she keeps a file for her direct staff members indicating each month when an updated background check was due in four years. HR F said she does not have contracted staff background checks on file. On [DATE] at 12:14 PM, Surveyor spoke with HR F who said the agency did not have LPN G's updated BID/DOJ/IBIS completed since it was due in 2023. The agency said they will do it now. HR F said she will work on having all contracted staff background checks and license verification on file here at the facility.

Based on interviews and record review the facility did not provide care and services to 1 (R1) out of 4 sampled residents related to wound care and medical management. R1 did not receive wound care to a skin graft according to physician orders. In addition, the skin graft was lost (no longer present) at some point between 9/26/19 and 10/10/19. R1 was scheduled to have a second skin graft completed. R1 began to report weakness and dizziness on 10/08/19. The NP (Nurse Practitioner) ordered for twice daily orthostatic blood pressures for 5 days with follow up report to be provided. There were only 2 orthostatic blood pressures taken and there was no follow up. At a pre-operative appointment on 10/15/19 R1 was hospitalized with severe [MEDICAL CONDITION] and [MEDICAL CONDITION]. This is evidenced by: R1 was admitted to the facility on [DATE]. R1 required wound care and therapy with plans to return home when able. R1 had the following Diagnoses: [REDACTED]. R1 had sustained a large hematoma (blood tumor) on the left lower shin prior to admission. The hematoma required surgical debridement (cleaning out the blood). Upon admission, the physician ordered a nonadherent dressing over the debrided wound on the left shin followed by a saline soaked gauze and wrapped with a kerlix (gauze wrap). This dressing change was ordered twice daily until 09/11/19. On 09/11/19, R1 underwent a skin graft procedure and returned to the facility with a [DEVICE] dressing in place for 7 days. On 09/19/19, R1 saw the wound clinic PA (Physician Assistant) who noted The skin graft is viable. The PA ordered wet to dry using Dakin's (diluted bleach) solution gauze wrapped with kerlix dressing change twice daily. The PA noted R1's left shin wound had drainage and odor present and suspected pseudomonas infection. On 09/26/19 the wound clinic PA changed R1's skin graft treatment to a TAB (triple antibiotic) solution wet to dry three times daily dressing. The wound clinic progress notes read Unfortunately the skin graft is no longer present to the lower leg wound .To prevent drying out and pulling of the wound, we will change wet-to-dry dressing changes to 3 times daily . On 10/10/19 R1 saw the wound clinic physician who noted the graft was lost due to infection and difficulty with dressing changes. The physician also noted R1 wound need another skin graft attempt. R1 was scheduled to have another skin graft surgery on 10/21/19. Review of the facility NP progress notes revealed on 10/08/19, R1 complained of dizziness. The NP ordered to check R1's orthostatic blood pressures twice daily for 5 days and review results on 10/11/19. The facility only checked R1's orthostatic blood pressures once on 10/08/19 and once on 10/10/19. There was a significant drop in R1's standing blood pressure indicative of orthostatic [MEDICAL CONDITION]. R1's standing blood pressure was 77/58. There was no further follow up or documentation regarding R1's low blood pressure or complaints of dizziness. Review of the nurses notes indicated on 10/12/19 R1 refused orthostatic blood pressure checks. On 10/15/19, R1 again saw the facility NP and reported weakness and dizziness. The NP ordered orthostatic blood pressures daily for 3 days. Also on 10/15/19, R1 had a pre-operative appointment at the Marshfield Clinic. Upon arrival, R1 reported weakness and dizziness. R1 was severely hypotensive and very somnolent according to the clinic progress notes. R1 was hosptalized on [DATE], diagnosed and treated for [REDACTED]. R1 remained in the hospitalized until 10/29/19 when she was transferred to another nursing facility. Review of the TAR (Treatment Administration Record) for (MONTH) and October, 2019 noted R1 did not receive dressing changes on 4 separate dates according to the physician orders. The physician ordered TAB solution wet to dry dressing three times per day. The TAR noted the times to be at 4:00 a.m., 12:00 noon, and 8:00 p.m. daily. R1 did not receive the ordered dressing change on 09/27/19 at 4:00 a.m., 10/03/19 at 4:00 a.m., 10/04/19 at noon, and 10/10/19 at 4:00 a.m. R1's family had filed 2 grievances regarding wound care being missed on 09/27/19 and again on 10/04/19. This information correlates with R1's TAR. The facility completed an investigation for these grievances. On 10/29/19 at 11:55 a.m., Surveyor interviewed RN-C (Registered Nurse) regarding R1's care needs. RN-C stated R1's daughter had told her that the nursing staff at the facility had ripped the skin graft off according to the wound clinic P[NAME] RN-C stated the dressing to R1's left shin would dry out between changes. RN-C stated she was instructed to use saline to rewet the dressing and to remove dressing slowly. On 10/29/19 at 4:00 p.m., Surveyor interviewed LPN-D (Licensed Practical Nurse) regarding R1's dressing change. LPN-D confirmed the left leg dressing was often adhered to R1's leg and painful to remove. LPN-D stated pain was treated with [MEDICATION NAME] and Tylenol with some relief. LPN-D stated [MEDICATION NAME] solution was used to rewet the dressing and treat pain prior to removing the old dressing. LPN-D stated when removing R1's left leg dressing, she would soak the old dressing with saline and [MEDICATION NAME] but it was often still partially adhered to the wound bed. LPN-D stated staff needed to remove the old dressing very slowly. LPN-D stated once the dressing change was completed, staff would go to the electronic medical record and sign the TAR as completed. LPN-D stated if the TAR was not signed, it meant the dressing was not changed. LPN-D stated all staff are aware of if not documented, it wasn't done. On 10/29/19 at 4:10 p.m., Surveyor interviewed the DON (Director of Nurses) regarding documentation. The DON confirmed the 4 times R1's left leg dressing change was not documented. The DON stated all staff are aware if you don't document, it was not done. On 10/29/19 at 4:55 p.m., Surveyor requested from the DON or NHA (Nursing Home Administrator) any evidence of orthostatic blood pressures, follow up from the NP regarding R1's complaints of dizziness, or additional evidence the dressing changes were completed as ordered. The facility provided additional information via email on 10/30/19 and 11/05/19. Surveyor reviewed the information and noted 3 additional orthostatic blood pressures recorded but still no follow up of these values with the NP on or before 10/11/19.