Every finding on record at Complete Care at Hales Corners

Based on record review, interviews, and policy review, the facility failed to document a thorough investigation into the allegation of neglect for one resident (Resident (R) 4) and did not evaluate a Certified Nursing Assistant's (CNA's) history of concerning interactions with residents during an investigation of neglect reported by R2 for two of three facility reported incidents reviewed for abuse or neglect. This failure created the potential for similar incidents to recur.Findings include: 1. Review of R4's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R4 was admitted to the facility on [DATE] and had diagnoses including myocardial infarction, congestive heart failure, and cellulitis. Review of the facility's Misconduct Incident Report, provided by the facility and dated 01/21/26, revealed that on 01/19/26, R4's family member (FM) 5 expressed concern about swelling in R4's feet. Nursing staff assessed her condition, noted swelling in both legs and feet, and recommended evaluation in the emergency room. The resident was subsequently admitted to the hospital for treatment of acute exacerbation of chronic heart failure. Social Worker (SW) 1 assisted with filing a grievance on FM5's behalf during a follow-up call on 01/21/26 when FM5 alleged the facility had neglected R4. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/26, located in the EMR under the MDS tab, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R4 was cognitively intact. Review of the facility's investigation, provided by the facility, revealed no documentation that the facility had interviewed any other residents about neglect concerns or educated staff on the abuse and neglect policies as part of a comprehensive investigation of the allegation. During an interview with the Administrator on 02/19/26 at 5:55 PM, she stated she did not deem it necessary to conduct interviews with other residents as part of the facility's investigation because R4's case was unique and there were no other residents with similar concerns. Also, she did not deem it necessary to conduct staff training related to the incident because the matter was reported out of the abundance of caution, and there was no actual neglect or abuse in R4's case. The administrator stated R4's leg swelling was resolved, and the wound had progressed to being scabbed over. 2. Review of R2's admission Record, located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with diagnoses that included vaginal cancer. R2 was discharged on 11/11/25. Review of a Misconduct Incident Report, provided by the facility and dated 08/26/25, revealed that R2 reported an allegation of abuse by CNA3 to her daughter and Registered Nurse Supervisor (RN) 4. R2 stated that CNA3 entered her room, got close to her, and said, Be sure you know who you accuse. R2 reported feeling intimidated by the interaction with CNA3. Review of the facility's investigation, provided by the facility, revealed the facility found the allegation to be unsubstantiated. The investigation did not provide education on abuse training for CNA3 or any other staff and did not provide any other education or training for CNA3. Review of CNA3's personnel file, provided by the facility, revealed her employment ended 10/06/25. Multiple areas of concern with CNA's conduct were documented to include: On 05/25/25, former resident, R6, reported that CNA3 told him he should be more independent, including propelling himself to the dining room and completing his own personal care tasks. CNA3 provided supplies but did not ensure that R6 was properly set up or that his needs were met before leaving. R6 noted this had occurred on prior Sundays and stated that CNA3's tone was authoritative. The resident was subsequently reassigned to a different caregiver. On 06/01/25, former resident R5 reported that CNA3 yelled at her for being wet and made comments that caused embarrassment regarding her incontinence. R5 also stated CNA3 insisted R5 sleep in a gown instead of a T shirt, selected clothing for her without her preference, and repeated care tasks R5 had already completed. She further reported being left on the toilet long enough to play two games on her phone. CNA3 was removed from her care. Further review of CNA3's personnel file revealed CNA3 was placed on a Growth and Development Plan on 09/16/25 which stated, The purpose of this Performance Improvement Plan [PIP] is to define serious areas of concern, gaps in your work performance, reiterate expectations, and allow you the opportunity to demonstrate improvement and commitment.Areas of concern: Customer service, speaking to residents/staff respectfully and in a professional manner. Observations, previous discussion, or additional training provided:1. Discussions about proper communication with residents;2. Resident Rights - not following resident preferences;3. Performance improvement plan on 06/13/25 [referring to previous PIP];4. Discussion on previous grievances with residents. During an interview with the Administrator on 02/19/26 at 5:55 PM, she explained that a new entity assumed control of the facility on or about September 2025, resulting in a clean slate for personnel files and prior staff-related incidents. When asked why additional corrective actions had not been taken regarding CNA3, despite multiple past documented resident concerns, the Administrator stated the incidents occurred before her tenure and that the facility was following the disciplinary process already in place, including a performance improvement plan for CNA3. She stated she was unaware of all the concerns related to CNA3's work documented in the personnel file. She further noted she was not permitted to disclose or utilize CNA3's prior personnel records after the new ownership assumed control. The Administrator stated that all nursing staff received annual abuse prevention training. Review of Review of facility's policy titled Abuse, Neglect and Exploitation dated 3/2005 and revised 6/2005 revealed, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. A. Written procedures for investigations include: . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation.

Based on record review, observation, interviews, and facility document review, the facility failed to maintain a resident's dignity by failing to close the door and curtains while providing care for one resident (Resident (R) 3) out of total sample of six residents. This failure had the potential to compromise the resident's dignity. Findings include: Review of R3's comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/25, located in the MDS tab of the EMR, revealed R3 was admitted to the facility on [DATE] with diagnoses that included dementia and age-related osteoporosis. R3 had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated R3 had severe cognitive impairment. On 02/19/26 at 5:30 AM, observation from the hallway revealed Certified Nursing Assistant (CNA) 1 at R3's bedside performing cares. R3 was undressed with curtains open and door open, visible to the hallway. During an interview on 02/19/26 at 5:37 AM, CNA1 admitted she had failed to provide privacy and dignity for R3 by failing to draw the curtains and close the room door during cares. During an interview on 02/19/26 at 5:40 AM, the nursing supervisor, Registered Nurse (RN) 3 stated it was her expectation that CNA1 should have provided privacy and dignity to R1 regardless of the time of the day. During an interview with the Director of Nursing (DON) on 02/19/26 at 6:00 PM, she stated it was her expectation that CNA1 should have covered R1 during care. Review of a copy of the facility's undated admission Agreement revealed, the facility shall ensure that all residents are afforded their right to dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy in treatment and care for personal needs and communication with and access to persons and services inside and outside the facility. The facility shall protect and promote the rights of each resident and shall encourage and assist each resident in the fullest possible exercise of these rights.

Based on interview and record review the facility did not maintain an effective pest control for 1 (R2) of 1 resident.On 7/21/25 R2 was identified with having maggot looking like organisms moving all over R2's left facial mass. The facility did not increase their pest control services to treat R2's room for flies. Findings include:The facility's policy titled, Pest Control Program and dated 5/25 under policy documents It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Under policy explanation and compliance guidelines documents 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated.R2 was originally admitted to the facility on [DATE] with diagnoses which includes dementia (loss of cognitive function that interferes with a person's daily life & activities), hypertension (high blood pressure), depression, and squamous cell carcinoma of skin. R2's change in condition note dated 7/21/25, at 14:17 (2:17 p.m.), written by RN-L includes documentation of Nursing observations, evaluations, and recommendations are: Left facial mass presenting with purulent, continuous drainage and organisms magot looking like moving all over its surface. Resident denies pain and is alert and oriented within his baseline VSS.R2's nurses note dated 8/31/25, at 11:36 a.m., written by LPN-D documents Resident had irrigation and suction to facial growth completed x2 this AM shift d/t maggots crawling on face. Resident continues to have lg (large) amount of bloody drainage from mass. Area has several flies hovering around and worms continue to come out of holes and then burrow back in. Acetic acid irrigation completed f/b suctioning, resident very resistive to treatment and procedure. Eyes washed with warm wash cloths, remain red and crusty. Resident denies any pain at this time, monitoring continues for any new changes.R2's nurses note dated 9/26/25, at 22:02 (10:02 p.m.), written by LPN-O documents F/U acute charting: Left facial mass and MASD to Neck and chest. Left facial mass treatment continues as ordered, pat and dry as tolerated as resident verbalizing Leave them alone, educated resident the importance of the tx during treatment, small amount of serosanguinous noted, observed fly flying around the room, this writer was able to get rid of the fly, no signs of maggots noted as of this time. MASD to neck and chest treatment applied as ordered, c/o pain during care to neck area, refused the removal of thick crusty drainage, also refuse the top clothing to be change, placed new towels neck area at all times.On 10/13/25, at 1:55 p.m., Surveyor asked Maintenance Director (MD)-E if he is responsible for exterminating services at the facility. MD-E explained they have a company that comes in and the exterminator will be here tomorrow. MD-E explained they spray for general pests once a month, the 2nd Tuesday of the month. Surveyor asked if there have been any problems with flies. MD-E replied no and explained the exterminator sprays the sewer drains. Surveyor asked for the monthly exterminating reports from June to September 2025.Surveyor reviewed [Name] Pest Management inspection report dated 6/10/25. Surveyor noted the kitchen, utility room, boiler room, dining room, restrooms, basement, break room, exterior, baseboards, & storage room were treated for general crawling insects.Surveyor reviewed [Name] Pest Management inspection report dated 7/8/25. Surveyor noted the utility room, laundry room, boiler room, basement, break room, exterior, baseboards, & storage room were treated for general crawling insects.Surveyor noted there is not a pest management inspection report after 7/8/25 for flies in R2's room until the monthly pest management inspection report dated 8/12/25.Surveyor reviewed [Name] Pest Management inspection report dated 8/12/25. Surveyor noted the kitchen, laundry room, boiler room, dining room, restrooms, basement, break room, baseboards, & storage room were treated for general crawling insects. Surveyor noted R2's room was not treated for flies.Surveyor reviewed [Name] Pest Management inspection report dated 9/9/25. Surveyor noted the kitchen, laundry room, boiler room, basement, break room, baseboards, & storage room were treated for general crawling insects. Surveyor noted R2's room was not treated for flies.On 10/14/25, at approximately 7:30 a.m., Surveyor spoke with Licensed Practical Nurse (LPN)-V regarding R2's maggots on R2's facial mass. Surveyor asked LPN-V if she saw flies in R2's room & around R2. LPN-V replied I saw a couple and killed a couple. Surveyor asked LPN-V if an exterminator came in and sprayed R2's room for flies. LPN-V replied not that I know of. LPN-V informed Surveyor after R2 went to the hospital she went in and wiped everything down with a wipe.On 10/14/25, at 11:06 a.m., Surveyor asked Exterminator-J if he was asked to spray any resident's rooms for flies. Exterminator-J replied, no not for flies. No information was provided to Surveyor as to why the facility did not increase their pest control services to address flies in R2's room.

Based on observation, interview and record review the facility did not allow residents and/or residents representative to obtain a copy of personal and medical records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request for 1 of 1 (R1) resident reviewed.R1's daughter/POA (power of attorney) requested copies of his medical record were not provided.Findings include:R1 admitted to the facility on [DATE] and had diagnoses that included right femur fracture, right radius fracture, right ulnar fracture, acute posthemorrhagic anemia, chronic diastolic congestive heart failure, hypertensive heart disease, dementia, obstructive sleep apnea, hypokalemia, gastroesophageal reflux disease, insomnia, benign prostatic hyperplasia, presence of prosthetic heart valve, history of malignant neoplasm of prostate, cardiac pacemaker, pyelonephritis, metabolic encephalopathy, intervertebral disc degeneration lumbar region, polyneuropathy, spinal stenosis, cystitis.The facility policy titled Release of Medical Records dated 5/25 documents (in part) . Medical records will be released with a valid request and in accordance with state and federal laws.6. Upon receipt of a request for medical record copies, the facility should notify the requesting party, in writing, of the cost for obtaining records and that records are available 2 days after receipt of payment for the copies. Copies should not be released prior to the receipt of payment for copying charges.8. Once a request for records is received, all records for that resident should be gathered and secured in a place inaccessible to anyone except the Administrator, Director or Nursing or designee. If the resident is a current resident, the minimum required information should be maintained at the nurse's station. As the active medical record is thinned, those documents should be filed with the secured record.On 10/14/25 at 10:47 AM, Surveyor spoke with Medical Records-F who reported she received a call from R1's daughter requesting medical records. Medical Records-F reported she called R1's daughter back to have her fill out the form for medical record request, but she never came to fill it out. Medical Records-F advised Surveyor she had the envelope with the date and would bring to Surveyor.On 10/14/25 at 10:50 AM, Medical Records-F stated, See, it's right here, she never filled it out and handed Surveyor an envelope with a sticky note dated 8/8/25, which read: Please give this to (R1's daughter) to fill out and return it back to me please in my mailbox. Surveyor opened the envelope noting the form was completed and signed by R1's daughter. Surveyor showed it to Medical Records-F, noting it was filled out and signed by R1's daughter on 8/24/25. Medical Records-F stated, I'll have to look to see if that's her signature. After reviewing the form, Medical Records-F stated, I guess it was filled out. All I know is the last NHA (Nursing Home Administrator) handed the envelope to me and said she never filled it out, so I just kept it. I should have looked inside. Surveyor verified medical records were not provided to R1's daughter/POA as requested. No additional information was provided.

Based on interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R2) of 3 Residents.On 7/21/25 R2's left facial mass was observed with organism maggot looking like moving all over its surface. R2 was transferred to the hospital and hospitalized until 7/25/25. Hospital course includes documentation of chronic left facial mass for the past 2 years which apparently the patient has refused treatment which has grown bigger in size fungating with maggots' infestation. The facility did not investigate R2's maggot infestation, did not monitor the maggots and did not develop a plan of care for maggots and R2's refusals.Findings include:R2 was originally admitted to the facility on [DATE] with diagnoses which includes dementia (loss of cognitive function that interferes with a person's daily life & activities), hypertension (high blood pressure), depression, and squamous cell carcinoma of skin. R2 has an activated power of attorney for healthcare.On 10/13/25 Surveyor reviewed R2's care plans and noted the following care plans:*ADL (activities daily living) functional/potential/rehabilitation and/or limited mobility. Initiated 1/27/25 & revised 10/7/25.*Resident is independent in leisure initiation and pursuit RT (recreation therapy) personal preference and customary routine. Initiated & revised 2/3/25.*Resident at risk for infection. Initiated & revised 2/8/25.*Resident is a potential for alteration in cardiac output. Initiated 2/8/25 & revised 10/7/25.*Resident is at risk for falls. Initiated 2/8/25 and revised 10/7/25.*Resident has bowel incontinence. Initiated 2/8/25 & revised 10/7/25.*Resident is at risk for pain. Initiated 2/8/25 & revised 8/9/25.*Impaired skin integrity. Initiated & revised 2/8/25.*Altered urine pattern. Initiated & revised 2/9/25.*Resident has potential for adverse medication side effects. Initiated & revised 2/9/25.*Resident has a mood problem. Initiated & revised 2/25/25.*Resident has depression. Initiated 2/25/25 & revised & resolved 8/7/25.*Resident has impaired cognitive function/impaired thought process. Initiated 2/25/25 & revised 10/7/25.*Patient has an advanced directive. Initiated 2/25/25 & revised 8/18/25.*Discharge not anticipated at this time, as long-term care placement has been determined due to resident's level of care needed. Initiated 2/25/25.*Resident requires enhanced barrier precautions. Initiated 6/13/25.*Resident occasionally makes unwanted verbal sexual advances toward female staff members when peri cares and catheter cares are being tended to. Initiated 6/17/25 & revised 8/18/25.*Resident has actual impairment to skin integrity of left side of face r/t (related to) facial mass and MASD (moisture-associated skin damage) to buttocks. Initiated 7/25/25 & revised 8/11/25.*Resident is on a general diet. Initiated 7/25/25 & revised 8/5/25.*Resident has infection of the left cheek cellulitis. Initiated 8/6/25 & revised & resolved 10/13/25.Surveyor noted R2's actual impairment to skin integrity care plan has an intervention dated 9/28/25 & revised 10/13/25 of Ivermectin cream 1x (times)/week as needed for left facial mass maggots. There are no other interventions regarding maggots and there is not a maggot care plan.The facility developed acute care plan alteration in skin integrity dated 9/2/25 & 9/4/25. Neither of these acute care plans address R2's maggots.R2's nurses note dated 7/20/25, at 17:05 (5:05 p.m.), written by Nursing-K for What is the resident exhibiting documents Informed by team nurse that mass to resident's face has a large portion that separated from the main mass that is presently hanging off his face, with active bleeding and large amount of foul-smelling drainage present. Resident denies any pain or discomfort and appears to be oblivious to the present situation. When told about the mass to his face and what has happened, he responds Where? Where is it, what is it I don't know what you're talking about. When asked if he has seen it on his face he replied No, where is it? He then stated I need more Kleenex as he was touching it and wiping it. Explained that the rea is bleeding and that he will need to go to the hospital to have it evaluated. He said, oh ok. VSS (vital signs stable). For describe current condition and your assessment documents Very large mass present to entire outer area (above the skin) on the L side of his face protruding outwards of at least approximately 5cm (centimeters) x 15cm or more. Irregularly shaped, open, draining and bleeding. A portion of the mass has separated questionably caused by the weight of the mass and gravity causing it to bleed more and drain more. For new orders or interventions put into place documents Send to ER (emergency room) for evaluation. Pt (patient) sent via [Name] Ambulance.R2's nurses note dated 7/20/25, at 19:56 (7:56 p.m.), written by Nursing-K documents Resident returned to facility from [Hospital initials] ER. Dx (diagnosis) facial mass and NOR (new order received) for Dermatology consult. Received report from [Name] RN (Registered Nurse), who stated that areas of bleeding to mass have been cauterized and pt is discharged back to facility with order to be seen by dermatology. Family is aware.R2's nurses note dated 7/21/25, at 12:09 p.m., written by Registered Nurse (RN)-L documents Resident is leaving this facility at this time to the ER. By [Name] Ambulance and accompanied by 2 EMTs (emergency medical technicians) and POA (power of attorney)/daughter. R2's change in condition note dated 7/21/25, at 14:17 (2:17 p.m.), written by RN-L includes documentation of Nursing observations, evaluations, and recommendations are: Left facial mass presenting with purulent, continuous drainage and organisms magot looking like moving all over its surface. Resident denies pain and is alert and oriented within his baseline VSS.R2's nurses note dated 7/21/25, at 23:31 (11:31 p.m.), written by Nursing-K documents Received call from [Hospital initials] requesting pts MARs (medication administration record) be faxed over. Pt has been admitted to [Hospital initials] for facial mass. MARs and TARs (treatment administration record) have been faxed over.R2's hospital radiation oncology consultation dated 7/22/25 under chief complaint documents I am seeing the patient for consideration of radiation therapy as primary treatment for a left facial mass which is concerning for a malignant process. Under History of Present Illness documents [R2's name] is a [AGE] year-old former smoking (quit 1975 after smoking 45 years) male who is completed bedbound requiring a Hoyer life to move out of bed with past medical history significant for but not limited to hypertension, dementia and current findings of a large left fungating facial mass concerning for malignancy. He denies history of smokeless tobacco use. He resides at [Facility's name] who called in 8/20/25 to make a dermatology appointment for him for evaluation of a facial growth that was partially falling off. A virtual visit was requested but no appointment scheduled as they type of visit needed to be in person. His daughter has been trying to get him to see a physician for evaluation for some time now. But he refuses. He ultimately presented to the ED (emergency department) 7/20/25 for evaluation. He was noted to have a large LEFT cheek mass present and progressive over at least 2 years which was now draining and bleeding. On exam, the tissue was noted to be soft and to come apart with friable (easily crumbed or reduced to powder) areas that were cauterized with silver nitrate stick. He was apparently discharged back to the facility but again present to ED 7/21/25 due to a foul or odor emanating from the wound with maggots crawling in and out of the wound.R2's hospital discharge summary for date of discharge date d 7/25/25 under Hospital course documents Left facial mass. History of present illness documents Patient is a very pleasant [AGE] year-old gentleman with past medical history significant for advanced dementia chronic left facial mass for the past 2 years which apparently the patient has refused treatment which has grown bigger in size fungating with maggots' infestation was brought in from nursing facility for evaluation of left facial mass he was admitted for further workup and management. Hospital instructions include Recommended BID (twice daily) Acetic acid soaks to area. Continue to wash the area to help remove maggots. Recommend setting up suction and Yankauer (rigid, curved suction catheter) to remove the maggots from the wound after washing and soaking with acetic. Can apply lidocaine to wound to help with discomfort with dressing changes.R2' nurses noted dated 7/25/25, at 13:45 (1:45 p.m.), written by RN Supervisor-N documents Resident readmitted from [Hospital name] at 1340 (1:40 p.m.) via [Name] ambulance, C/O (complained of) pain in buttocks presently, skin check to be completed. Blood noted on face under left cheek tumor. Nurse to assess.R2's nurses note dated 7/26/25, at 15:27 (3:27 p.m.), documents 24h (hour) board F/U (follow up) s/p (status post) hospitalization d/t (due to) left facial mass infestation left facial mass has small amount of serous sanguineous drainage with no live organisms observed on its surface on this shift. Area was irrigated with Acetic acid as ordered and once dried, powered Flagyl was sprinkled on mass. Resident denied pain to the area and no odor was noted from mass. Resident was cooperative with Tx (treatment) and assessment.R2's nurses note dated 7/26/25, at 22:38 (10:38 p.m.), written by LPN-O documents 24-hour Board monitoring continues: S/P hospitalization d/t left facial growth infestation, small amount of purulent drainage with signs of live organism noted. Irrigated with Acetic acid 2x this shift and as ordered and tolerated well and resident for once is very cooperative with care and treatment, denies pain and discomfort. Continues on ABT (antibiotic) po (by mouth) therapy for Left cheek growth infection no ill effect noted, po fluids encouraged by nursing staff and taken well by resident. Treatment to buttocks applied as ordered, slight pink noted, keep clean and dry, monitoring in progress. R2's nurses note dated 7/31/25, at 23:33 (11:33 p.m.), written by LPN-O documents F/U acute charting: Left cheek growth/mass infection, continues on ABT po therapy with no adverse reactions noted, treatment to affected area continues as ordered and tolerated well, small amount of blood noted, c/o pain during treatment but tolerable, no living organism noted this shift, keep clean and dry and place new towel in between neck and face, monitoring in progress.R2's nurses note dated 8/2/25, at 11:29 a.m., written by LPN-D documents Resident tolerated all meds and treatments this shift. Treatment to facial growth completed with concern to how close growth is to the L eye. Resident denies pain or discomfort and denies any loss of sight. Area irrigated as ordered, bloody drainage noted, no movement noted or reported. Foley remains patent and flowing clear, yellow urine. Monitoring continues for any changes.R2's nurses note dated 8/5/25, at 22:15 (10:15 p.m.), written by LPN-O documents F/U Acute Charting: Left facial grown/mass monitoring continues, Irrigated affected area with Acetic Acid Solution 2x this shift, attempted to refuse both treatment but with education resident verbalized understanding, c/o not pleasant during treatment but tolerable, place eye patch to left eye during treatment to protect the eye. Slightly pat and dry the mass after tx (treatment), small amount of serosanguinous drainage noted, clean neck area with wet towel as tolerated. Place new towel in between neck and should every tx, keep clean and dry. No living observed and will continue to monitor.Surveyor noted there is no monitoring or progress notes regarding maggots until 8/30/25.R2's quarterly MDS (minimum data set) with an assessment reference date of 8/6/25 has a BIMS (brief interview mental status) score of 0 which indicates severe cognitive impairment. R2 is assessed as not having any behavior including refusal of care. R2 is assessed as requiting set up or clean up assistance for eating and dependent for toileting hygiene, roll left & right, and chair/bed to chair transfer. R2 has an indwelling urinary catheter and is always incontinent of bowel.R2's nurses note dated 8/30/25, at 09:41 (9:41 a.m.), written by RN-P includes documentation of Nursing observations, evaluation, and recommendations are: Writer recommended hospitalization for extraction/irrigation, daughter declines. Writer educated the daughter on the risks of not going to the hospital as the larvae could eat healthy tissue and spread to the vital tissues in the eyes, sinus cavity, or the brain. If resident will be staying the facility writer recommends topical medication like ivermectin to kill the maggots and antibiotics to prevent infection.R2's nurses note dated 8/30/25, at 14:32 (2:32 p.m.), written by LPN-D documents Resident had irrigation treatment completed this AM when writer noticed maggots crawling out of hole on resident's face. Area was irrigated with acetic acid without incident from resident. Supervisor informed of situation, family called and [Physician name] aware. Resident tolerated meds and ate fair for meals, had all other cares completed and was repositioned in bed only to find more maggots in resident's bed. Sheets changed, area cleaned, and bedding put in separate bin from other laundry. Family refused to have resident sent to hospital to have face treated. Daughter came in, talked to supervisor and CNA (Certified Nursing Assistant), walked into resident's room and walked out and left within 5 mins (minutes). Monitoring resident continues. R2's nurses note dated 8/30/25, at 20:10 (8:10 p.m.), written by RN-Q documents resident continues to have maggots and bloody drainage from face- daughter does not want resident sent out- [Names] aware. [Name] hospice updated- recommended sending to ER (emergency room) for removal of maggots. Pharmacy called to stat out Ivermectin External Cream 1%. Resident took Tylenol for pain, has increased cough- tolerating food and liquids [Hospital initials] ER called for recommendations: per AVS (after visit summary) acetic acid soaks BID (twice daily) and PRN (as needed) with yankauer suctioning after- can use topical lidocaine for pain control.R2's nurses note dated 8/31/25, at 05:12 (5:12 a.m.), written by RN-Q documents writer irrigated facial growth, suctioned drainage- multiple maggots removed from site- bilateral eyes have yellow crust in medial aspect-left eye worse than right-warm washcloth to remove crust. Resident denied pain.R2's nurses note dated 8/31/25, at 11:36 a.m., written by LPN-D documents Resident had irrigation and suction to facial growth completed x2 this AM shift d/t maggots crawling on face. Resident continues to have lg (large) amount of bloody drainage from mass. Area has several flies hovering around and worms continue to come out of holes and then burrow back in. Acetic acid irrigation completed f/b suctioning, resident very resistive to treatment and procedure. Eyes washed with warm wash cloths, remain red and crusty. Resident denies any pain at this time, monitoring continues for any new changes.R2's physician progress note written by Physician-M and dated 9/2/25 documents Patient is laying in bed. Asked to evaluate L (left) side mass; necrotic with bleeding related to squamous cell cancer. It measures 2.5 x (times) 1.5 x 0.5 inches covering left side of face. It has holes where maggot larvae are free swimming and burrowing. It has been treated with NS (normal saline) and acetic acid 0.25% and suctioned. However due to the size and safety concerns, he will be sent to the ED for further evaluation and assist with care. Will discuss with ER physician and request ENT (ear nose throat), wound care and possible oncology referrals.R2's hospital ED provider notes dated 9/2/25 under history of present illness documents the patient is a [AGE] year-old male who has a large growth on the left side of his cheek, which has been confirmed by a biopsy to be squamous cell carcinoma. This growth had previously been infested with maggots and is now being managed with acetic acid washes at his care facility. But the facility is concerned that it is still housing maggots. Under Physical Exam for HEENT (head, eyes, ears, nose and throat) documents Large exophytic lesion on the left cheek. Maggots visible.R2's nurses note dated 9/2/25, at 19:17 (7:17 p.m.), written by RN-R documents Resident returned from [Hospital initials]. Alert per usual. Hungry and wanted to eat supper. Received verbal from Hospital nurse that he would be returning and will continue to have maggots in Cancerous facial growth. To DC (discontinue) acetic acid and apply 2% topical lidocaine to face and leave on for 10 min (minutes) prior to rinsing with Dakin's solution TID (three times daily). He will continue to have the maggots unless he went to OR (operating room) for I & D which would then involve grafting. She reports POA was not on board with that option. Writer questioned if he were a hospice candidate and was told yes, he was a hospice candidate. Writer questioned if MD could address that in discharge notes. Writer and staff nurse attempted to remove some of the visible maggots and cleanse dL face with the Dakin's as ordered. Face appeared very moist/raw/and very tender. He was agreeable to something stronger than Tylenol for pain prior to the rinses Lungs clear. Foley patent draining clear yellow urine. Buttocks raw, excoriated and painful which is not new. No edema. Heels elevated up on pillows. BS (bowel sounds) present x 4. Abdomen soft, nontender. L eye with pink sclera and partially past shut. Writer cleaned and it is open a little bit more. Still needs more cleansing, but he wanted to stop.R2's nurses note dated 9/3/25, at 14:15 2:15 p.m., written by RN-L documents 24H (hour) board f/u D/t facial mass with maggot infestation/MASD (moisture associated skin damage) to neck and chest caused facial mass drainage: resident facial mass continues to be infested with maggots. Area irrigated as ordered. Suction x2 by the start of the shift and later after lunch. Very large number of maggots removed. Resident tolerated procedure well and denied pain. MASD to chest and neck areas remain. Tx as ordered. Resident refused breakfast and lunch. Refused scheduled meds, despite re approaching. Foley cath (catheter) patent and draining yellow, clear and non-malodorous urine. Resident drank sips of water and output = (equal) 450. T (temperature) 97.3.R2's nurses note dated 9/26/25, at 22:02 (10:02 p.m.), written by LPN-O documents F/U acute charting: Left facial mass and MASD to Neck and chest. Left facial mass treatment continues as ordered, pat and dry as tolerated as resident verbalizing Leave them alone, educated resident the importance of the tx during treatment, small amount of serosanguinous noted, observed fly flying around the room, this writer was able to get rid of the fly, no signs of maggots noted as of this time. MASD to neck and chest treatment applied as ordered, c/o pain during care to neck area, refused the removal of thick crusty drainage, also refuse the top clothing to be change, placed new towels neck area at all times.R2's nurses note dated 10/13/25, at 22:38 (10:38 p.m.) written by LPN-O documents F/U acute charting: Left facial mass and MASD to neck and chest. Treatment continues to left facial mass as ordered, pat and dry as tolerated as resident tend to c/o discomfort during drying the area, trying to clear and trim facial hair with thick dried drainage, resident refused and stated leave them alone educated and explained to resident that it needed to be cleansed and dry the area, continue to refuse, no signs of maggots noted this shift. Clean the affected area as tolerated. MASD to neck and chest is responding well to skin prep place clean towel in between neck and chest, change clean gown, bed sheets and encouraged resident to keep towel, as resident frequently throw towel in the floor, will continue to monitor.On 10/13/25, from 11:30 a.m. to 11:50 a.m., Surveyor observed R2's treatments with LPN-T. During this observation, Surveyor did not observe any maggots. At 11:51 a.m., Surveyor asked LPN-T if she has ever seen maggots. LPN-T replied no, not me that's why I used a flashlight.On 10/13/25, at 12:49 p.m., Surveyor asked CNA-S if she has ever seen maggots on R2's face. CNA-S replied to no. CNA-S informed Surveyor he has something on his face, a fly landed and laid eggs that's why they keep the door closed. Surveyor asked CNA-S how she knew a fly landed on R2's face. CNA-S informed Surveyor that's what she was told happened before she got here.On 10/13/25, at 12:53 p.m., Surveyor asked CNA-U if he has seen maggots on R2's face. CNA-U replied I personally did not. Surveyor asked CNA-U if he has heard about the maggots. CNA-U informed Surveyor he heard the maggots were falling off R2's face onto the sheets.On 10/13/25, at 3:42 p.m., Surveyor asked CNA-I if she has seen maggots on R2's face. CNA-I replied I personally have not other people have. On 10/14/25, at approximately 7:30 a.m., Surveyor asked LPN-V if she has seen maggots on R2's face. LPN-V replied yes. LPN-V informed Surveyor she observed maggots a couple times and wasn't sure if it was before or after R2 went to the hospital. LPN-V informed Surveyor at one point they were taking tweezers and pulling the maggots out.On 10/14/25, at 12:32 p.m., Surveyor met with RN Supervisor-C to discuss R2. Surveyor asked RN Supervisor-C who is responsible for implementing new care plans or revising current care plans. RN Supervisor-C informed Surveyor she is working on care plans for the 200 & 300 units and another nurse has the 100 unit. RN Supervisor-C informed Surveyor the care plans are a team effort. Surveyor informed RN Supervisor-C Surveyor was unable to locate a care plan for R2's maggots and only noted sporadic nurses notes regarding maggots. Surveyor was not able to locate consistent monitoring of R2's maggots. Surveyor asked RN Supervisor-C if there was any investigation regarding R2's maggots. RN Supervisor-C informed Surveyor they treated the maggots. Surveyor asked if she was aware of any investigation. RN Supervisor-C replied to no. RN Supervisor-C informed Surveyor they cleaned the area for maggots.On 10/14/25, at 12:59 p.m., Surveyor asked Director of Nursing (DON)-B if there is any investigation regarding how R2's facial growth became infested with maggots. DON-B informed Surveyor she thinks they sent R2 out, was thinking at that the time the ER could see him and maybe they could explain better. Surveyor asked DON-B again if there was any investigation. DON-B informed Surveyor she couldn't recall. DON-B informed Surveyor she knows when they were identified, Physician-M was called and R2 was sent out. Surveyor informed DON-B there were sporadic nurses notes regarding whether maggots were observed but Surveyor was unable to locate consistent monitoring of R2's maggots including how many maggots were observed. Surveyor informed DON-B Surveyor was unable to locate a care plan for R2's maggots.On 10/14/25, at 2:17 p.m., DON-B informed Surveyor there is a risk management for R2's maggots. Surveyor asked DON-B for a copy of R2's risk management which DON-B provided. Surveyor noted R2's 3-page incident report dated 7/21/25 at 12:00 pm was prepared by Corporate RN-W. Under nursing description documents Nursing staff found maggot like insect. Large mass area to face. Under resident description documents Resident continues to refuse any type of invasive treatment. Mass open to air. Under the section immediate action taken under description documents Area cleansed- Called POA Daughter- agreed to send to ER. Potential cause fly/infection/dead tissue. Resident was outside the day prior. Hospital to assist with plan of care. Surveyor noted there are no staff interviews, there isn't an interview with R2, and no additional information was provided to Surveyor regarding an investigation.On 10/14/25 the facility obtained a physician order which documents monitor for maggots every shift for skin protection. Every shift for skin protection.

Based on interview and record review, the facility did not ensure 1 (R20) of 2 residents reviewed for investigations regarding allegations of abuse, that lawn enforcement was notified of potential allegations of abuse. On 4/20/25, R20 told RN (registered nurse) Supervisor-D that CNA (certified nursing assistant)-C pushed R20. The facility immediately placed CNA-C on suspension pending the investigation. The investigation was conducted immediately. The facility failed to notify the police of this allegation of abuse. Findings include: The facility's Abuse, Neglect and Exploitation policy dated 5/28/25 documents: . VII.Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1.) R20 was admitted to the facility on [DATE] with diagnoses of dementia, chronic kidney disease stage 3 and spinal stenosis. R20's Quarterly MDS (minimum data set) dated 4/2/25 indicates R20 has severe cognitive impairment. The MDS also documents that R20 needs maximum assistance with personal hygiene. On 6/16/25 at 9:31 a.m., Surveyor interviewed R20. R20 stated she is happy at the facility and has no concerns with any staff. Surveyor reviewed the facility self report investigation dated 4/20/25. The self report investigation indicates that on 4/20/25, R20 reported to RN Supervisor-D that CNA-C pushed her. The investigation indicates CNA-C was sent home pending the results of the investigation. NHA (nursing home administrator)-A was notified immediately and the investigation into the potential abuse was initiated immediately. A body check was conducted on R20 and no injuries or discoloration noted. The investigation interviewed staff working with R20 on 4/20/25. Interviewable residents were interviewed regarding CNA-C. R20 was reinterviewed on 4/21/25 and R20 did not remember any incident involving CNA-C. The facility's investigation does not indicate that law enforcement were notified of R20's allegation of abuse. The conclusion of the investigation documents that during cares, CNA-C repositioned R20 onto her side and the action of positioning R20 on her side could have felt like R20 was being pushed. On 6/18/25 at 9:42 a.m. Surveyor interviewed NHA-A. Surveyor asked NHA-A if the facility called the law enforcmenet regarding R20's allegation of abuse. NHA-A stated NHA-A would have to look to see if law enforcement was called. On 6/18/25 at 10:20 a.m. NHA-A informed Surveyor that the facility did not call law enformcent regarding R20 allegation of abuse. NHA-A stated they did not observe any injuries on R20 so the police were not notified. No additional information was provided as to why the facility did not ensure that R20's allegations of abuse involving a staff member pushing R20 were reported to law enforcement.

Based on observation, interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R1) of 12 sampled residents reviewed for a change of condition. *R1 was diagnosed with a wound on 03/09/2025. The facility did not ensure that at the time of R1's initial assessment and diagnosis of a skin wound, a clinician assessed the wound to determine the wound type. The facility did not document the evaluation, assessment, treatment and treatment outcomes for R1's wound. The facility did not have a skin care plan or risk for pressure injuries care plan for R1 until the discovery of R1's wound. R1's Orthopedic specialist was not consulted in the change of condition regarding the orthopedic hardware protruding from R1's skin. The facility did not specify the location of R1's wound on the facility's wound evaluation assessments until 03/26/2025. Findings include: 1.) R1 was admitted to the facility on [DATE] following a hospital stay from an ankle fracture resulting in an Open Reduction and Internal Fixation (ORIF) (a surgical procedure used to treat ankle fractures) of the right ankle, with diagnoses which include Dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life). R1's Annual Minimum Data Set (MDS), dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 is cognitively intact and is at risk for pressure ulcers. R1's Quarterly MDS, dated [DATE], documents R1 has a BIMS score of 3, indicating R1 is severely cognitively impaired, is at risk for pressure ulcers, and has 1 stage 4, unhealed pressure ulcer. Surveyor reviewed R1's care plan, with revision history, and noted the Facility did not have a care plan for R1's risk for pressure injuries prior to R1 developing R1's wound. Surveyor reviewed the Facility provided document titled, WEEKLY PRESSURE ULCER QA&A LOG, dated 06/15/2025 and noted R1 on the list. Surveyor noted R1 is documented on the Facility's list as having a stable, right lateral shin wound. Surveyor reviewed the Facility's documents titled, CAOB- WOUND TEAM: PRESSURE INJURY EVALUATION. Surveyor noted that on 03/09/2025 R1 had a new pressure wound of an unspecified site that was listed as an unstageable pressure injury. The summary on 03/09/2025 documents R1 had a previous scab that has now opened but does not provide the exact location of the open area. The treatment is documented as, cleanse with normal saline followed by skin prep, apply Santyl (Wound debridement: It is used to remove dead tissue (necrotic tissue) from wounds, which helps them heal.) to wound bed and pack with packing gauze followed by foam dressing daily. On 03/12/2025, documents R1's wound has 100 percent slough (a layer of dead tissue, usually yellow or white, that accumulates in the wound bed) on wound bed and edges, with possible bone exposure at base of slough. On 03/26/2025, documents R1 that R1 has an unstageable, pressure wound of the right outer calf. On 04/02/2025, documents R1 has a stage 4 pressure wound from medical device and documents Area now stage 4 pressure injury r/t (related to) medical device. Now able to see screw from ankle ORIF in 11/2020. Silver screw seen and in center bone noted. On 04/07/2025, documents R1's wound is a stage 4 pressure wound to right, lateral (the side of something, particularly in relation to the body) shin related to a medical device, and documents screw intact. Surveyor noted R1's wound is documented as a stage 4 pressure wound to R1's right, lateral shin through current assessments. Surveyor reviewed R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated March 2025. Surveyor noted that on the day R1's wound was identified, R1 experienced a pain 6 of 10. Surveyor reviewed the Medical Director (MD)-J 's assessments of R1 from 01/31/2025 through current. Surveyor noted that all assessments document R1's skin is intact and warm to touch. Surveyor noted that the assessments did not include a comprehensive evaluation of R1's wound to determine if the wound was caused by pressure or surgical equipment. The assessments also did not document the treatment for R1's wound or the progress of R1's wound treatment. On, 06/17/2025, at 03:14 PM, Surveyor requested documentation from the facility regarding a doctor's evaluation and/or assessment of R1's wound and notification to the doctor when the foreign body was observed coming from R1's wound on 04/02/2025. On, 06/18/2025, at 08:00 AM, Nursing Home Administrator (NHA)-A provided Surveyor with a progress note on 04/02/2025, documenting R1's Power of Attorney (POA) was updated on R1's right lower extremity (RLE), educated that a screw was showing. Discussion with POA regarding consulting an Orthopedic Surgeon to remove the screw or keeping wound clean and treating pain in the Facility. After risk and benefits explained to POA of both options, POA's main goal was to keep R1 comfortable and pain free and to continue wound care and pain management within the facility. Plan of care discussed with R1's Power of Attorney (POA) and MD-J in agreement. Surveyor was also provided a SBAR (Situation, Background, Appearance Review and notify) communication form, dated 03/09/2025 regarding the physician notification of R1's new wound. Surveyor reviewed the document titled PODIATRY GROUP, dated 04/28/2025, which documents that R1 has a painful wound with a dressing in place to R1's lateral right instep/ankle. On, 06/18/2025, at 08:06 AM, Surveyor requested any physician's documentation regarding the evaluation and determination of R1's wound and the evaluation and assessment of the foreign body for R1's wound. On, 06/18/2025, at 08:30 AM, NHA-A provided Surveyor with documents from R1's hospital stay in 11/2020 showing the operation and hardware installed into R1's ankle during that time. Surveyor noted R1 had an Open Reduction and Internal Fixation (ORIF) (a surgical procedure used to treat ankle fractures) of the right ankle on 11/03/2020 by Aurora Orthopedics. On, 06/18/2025, at 08:38 AM, Surveyor requested MD-J evaluation of R1's wound and asked NHA-A to reach out to MD-J to see if MD-J could speak with Surveyor regarding R1's wound. Surveyor informed NHA-A of concerns regarding no Doctor evaluation or assessment for R1's wound. NHA-A indicated that NHA-A has provided all documentation that NHA-A that Surveyor has requested. Surveyor asked NHA-A if Surveyor could speak with MD-J. On, 06/18/2025, at 09:00 AM, Surveyor received a call from MD-J. MD-J indicated that MD-J is aware of the screw coming from R1's ankle and no further interventions were taken cased on R1 and family wishes. MD-J indicated that MD-J is not the wound doctor, but over sees the wound nurse. MD-J indicated that MD-J has assessed R1's wound and there should be notes in the old system. Surveyor noted the Facility's old system changed to the new system prior to the development of R1's wound. MD-J indicated that MD-J would have to go into the system to look at the last time MD-J assessed R1's wound. MD-J indicated that MD-J will only assess wounds if the Wound Nurse needs a second opinion or if there is a concern. Surveyor asked if MD-J assessed R1's wound once the screw became visible. MD-J indicated that MD-J would have to look into that information. Surveyor asked MD-J if MD-J reviews the Wound Nurse's documentation of wounds, MD-J indicated yes, the wound notes are reviewed every 1 to 2 weeks. MD-J indicated MD-J agrees with the Wound Nurse's assessment of R1's wound. Surveyor encouraged MD-J to provide any assessment MD-J documented regarding R1's, MD-J indicated that if MD-J finds MD-J 's assessment documentation of R1's wound, MD-J would send the information to NHA-A to provide to Surveyor. Surveyor noted the Wound Nurse was currently out of the country and could not be interviewed. On, 06/18/2025, at 09:32 AM, Surveyor interviewed Registered Nurse (RN)-K in the presence of Director of Nursing (DON)-B. RN-K indicated that RN-K is currently covering for the Wound Nurse and was training with the Wound Nurse for about 2 weeks. RN-K indicated that RN-K is not currently wound certified and just needs to take the test. RN-K informed Surveyor that all wound rounds are done weekly on Mondays. RN-K indicated that she would go around with the Wound RN, the supervisor and DON-B. Surveyor asked RN-K how often MD-J comes to wound rounds, RN-K paused to think, and before RN-K could answer, DON-B interjected saying that MD-J will comes a couple times a week to do rounds. On 06/18/2025, at 09:38 AM, Surveyor observed R1's wound with DON-B and RN-L. Surveyor noted R1 to have a small, silver, circular foreign body resembling the head of a small screw, protruding from R1's right, posterior ankle region located laterally from R1's Achilles tendon. Surveyor was only able to observe R1's wound by staff assisting R1 in raising R1's right leg and using a mirror to observe the underside of R1's ankle region. Surveyor observed R1's lower leg circumferentially and no open wounds noted to R1's calf or shin. On, 06/18/2025, at 10:20 AM, Surveyor interviewed NHA-A. Surveyor asked NHA-A who over sees the Wound Care Program to ensure wounds are being assessed, treated and documented properly. NHA-A indicated that the Certified Wound Nurse is the one to see the residents with wounds and update the physician and families. NHA-A indicated that the Facility has recently hired a Nurse Practitioner (NP) that was supposed to start this week or next from Oak Medical. Surveyor asked if NHA-A would expect the physician to be updated regarding R1's screw coming through R1's skin, NHA-A indicated she would have to clarify with the wound team on what they would do. NHA-A indicated that DON-B is in charge of overseeing the wound care program as a whole. Surveyor asked if there was any further information NHA-A has for Surveyor, NHA-A indicated that NHA-A has provided Surveyor with everything. NHA-A informed Surveyor that usually residents will go out to the wound clinic, which is why the Facility is having the NP coming in and the NP would be the dedicated wound care provider. On 06/20/2025, at 03:07 PM, NHA-A sent an email to Surveyor with the recently hired Wound NP's assessment of R1's wound, dated 06/20/2025. Surveyor noted the NP's diagnosis of R1's wound is documented as, unspecified open wound, right lower leg, initial encounter and other specified complication of internal orthopedic prosthetic devices, implants and grafts, initial encounter. Surveyor noted the NP's wound care assessment included evaluation of R1's wound and the treatment plan. Based on the additional information that was provided, Surveyor conclude that R1's wound was due to R1's internal prosthetic devices protruding from R1's skin and not pressure related as previously documented in R1's medical record. No additional information was provided as to why the facility did not ensure that R1 received treatment and care in accordance with professional standards of practice for R1's wound.

Based on observation, interview, and record review the facility did not ensure 2 (R19 and R35) of 2 residents received the necessary services for acceptable nutrition. * R19 had a 7.65% weight loss in one month. The weight loss was not communicated to the physician and dietician. A comprehensive assessment was not completed regarding the weight loss. The care plan was not reviewed and updated regarding the weight loss. Interventions were not implemented for R19's weight loss. * R35 required supervision during meals and was observed on two occasions not to receive assistance with meals as per care plan. Findings include: The facility's Weight Monitoring policy dated 5/28/25 documents: 4. Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in 1 month (30 days) b. 7.5% change in weight in 3 months (90 days) c. 10% change in weight in 6 months (180 days) The following formula may be used to calculate the percentage of weight change: % of body weight loss= (previous weight-current weight/previous weight) x 100 Though a significant weight change may not occur, the resident may be identified as below ideal body weight by the Registered Dietician or designee. 5. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the diagnosis or clinical conditions that may contributing to the weight loss. c. Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed. d. If the interdisciplinary care team desires to explore specific meal consumption information for a resident, the Registered Dietician, Dietary Manager, or the nursing department may initiate this process. e. The Registered Dietician or Dietary Manager should be consulted to assist with interventions; actions are recorded in nutrition progress notes. f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. g. The interdisciplinary plan of care communicates care instructions to staff. 1) R19 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, atrial fibrillation and dementia. The significant MDS (minimum data set) dated 3/18/25 indicates R19 has severe cognitive impairments and needs moderate assistance with eating. R19's Nutrition CAA (Care Area Assessment) dated 3/18/25 documents: R19 is underweight. R19's weight at the time of the assessment was 88 lbs and R19 averages 26%-50% meal intake. (R19) also triggered for a mechanical soft diet. (R19) dementia is causing the low intakes and ability to eat without help. R19's most recent comprehensive nutritional assessment dated [DATE] documents: R19 weight at this assessment was 87 lbs. The assessment documents underweight related to dementia as evidence by BMI (body mass index) <18.5. Weight loss gradual; resident has not experienced significant weight change in the past 6 months. The nutritional intervention includes continue current diet/supplements; monitor weight, po (oral) intake, nutrition related lab values, and skin integrity. R19's physician orders dated 2/15/25 indicate R19 is given Boost nutritional supplement twice a day. R19's nutritional problem care plan dated 2/16/25 documents: Monitor/record/report to MD PRN (as needed) s/sx (signs/symptoms) of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. RD to evaluate and make changes PRN. Surveyor reviewed the last 30 days of meal intakes. From 5/29/25 though 6/11/25, R19 ate between 25% to 50% for each meal. From 6/13/25 through 6/17/25 R19 was eating between 25% to 100% of her meals. Surveyor reviewed R19 weights and it documents: 6/12/2025 80.9 Lbs 6/5/2025 83.0 Lbs 5/29/2025 86.0 Lbs 5/22/2025 86.1 Lbs 5/15/2025 87.9 Lbs 5/8/2025 87.6 Lbs 5/1/2025 90.4 Lbs From 5/29/25 to 6/5/25, R19 lost 3 lbs and from 6/5/25 to 6/12/25, R19 lost 3 lbs. From 5/8/25 to 6/12/25, R19 has weight loss of 7.65%. There is no documentation R19's physician was made aware of the recent weight loss. On 6/17/25 at 12:33 p.m., Surveyor observed R19 being assisted with her lunch meal. LPN (licensed practical nurse)-Q assisted R19 with eating. R19 had mechanical soft ham sandwich, a tomato salad, coffee and a package of [NAME] cookies (hard shortbread cookies). R19 ate all of her sandwich and refused the salad because she didn't like it. On 6/17/25 at 12:40 p.m., Surveyor observed R19 meal tray ticket and the dessert listed was pudding not [NAME] cookies. LPN-Q stated to Surveyor she noticed that R19 was served [NAME] cookies and knew the cookies were not for a mechanical soft diet. LPN-Q stated R19 wanted jello and not pudding. LPN-Q stated she was going to get jello for R19. On 6/17/25 at 3:00 p.m., during the daily exit meeting with NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B, Surveyor asked to speak with the dietician. NHA-A stated their dietician just started last week and the previous dietician no longer works for the facility. NHA-A stated the dietary manager is responsible for monitoring of weights and dietary manager would report any concerns to the dietician. Surveyor asked to speak with the dietary manager. On 6/18/25 at 9:26 a.m. Surveyor interviewed Dietary Manager (DM)-I, with NHA-A present. Surveyor asked DM-I, what is DM-I's role regarding residents weights. DM-I stated she manages a monthly meeting on weights. DM-I states she gets a print out of all residents weights once a month and the program will trigger residents who have had weight loss. DM-I stated the staff involved in the monthly weight meetings are dietician, nursing, therapy and social service. DM-I states the team comes up with strategies to prevent further weight loss. Surveyor asked DM-I when does she notify the RD (registered dietician). DM-I stated the RD is notified if something pops up out of the blue and is notified of the weight loss data prior to the monthly meeting. Surveyor asked DM-I, if she was aware R19 in last month had more than 7% weight loss. DM-I stated R19 has been sick with Covid recently and wasn't eating as well. DM-I stated they were scheduled to have the monthly meeting on 6/20/25 and it would have been addressed at that time. Surveyor explained R19 has slowly been losing weight and there is no documentation this was addressed with the physician and interventions put into place based on a comprehensive nutritional assessment. NHA-A stated R19 weight loss should have been addressed and not waited until the 6/20/25 meeting. Surveyor also asked DM-I regarding the observation of [NAME] cookies on R19 meal tray and if it was appropriate for a mechanical soft diet. DM-I stated she spoke with her cook. DM-I stated the cook indicated the facility was out of vanilla wafers, which are appropriate for mechanical soft diets, and thought [NAME] cookies were appropriate. Surveyor explained R19 meal ticket did not indicate any cookies but pudding and that was not on her tray. DM-I stated she understood the concern and will address it with her staff. No additional information was provided as to why the facility did not ensure that R19 received the necessary services for acceptable nutrition. 2.) R35 was admitted to the facility on [DATE], with diagnoses including dementia (the loss of cognitive function, including memory, thinking, and reasoning, that interferes with daily life). R35's Significant Minimum Data Set (MDS), dated [DATE], documents Brief Interview for Mental Status (BIMS) score of 2, indicating R35 has severe cognitive impairment and requires supervision or touching assistance with eating. Surveyor reviewed the facility provided list of residents who need assistance at meals, and noted R35 was on the list indicating that R35 required supervision while eating. R35's Activities of Daily Living (ADL) Functional Potential/Rehabilitation and/or Limited mobility care plans documents under the intervention section: EATING: The resident needs supervision / touching assistance by staff to eat. Date Initiated: 01/20/2025. On 06/17/2025, at 09:45 AM, Surveyor observed R35 sitting in a chair in R35's room alone. Surveyor observed R35's meal tray brought to R35's room, and Surveyor noted the Dietary aide delivered R35's tray and placed it on R35's bedside table in front of R35, with the Dietary aide then leaving R35's room. On 06/17/2025, at 09:48 AM, Surveyor observed R35 eating in R35's room unsupervised. At 09:51 AM, Surveyor noted Certified Nursing Assistant (CNA)-P came into R35's room and helped R35 remove lids from R35's cups. At 10:03 AM, CNA-P left R35's room, leaving R35 to eat unsupervised. On 06/17/2025, at 03:14 PM, Surveyor informed the facility of the concern regarding R35 being observed eating with out supervision. Nursing Home Administrator ( NHA)-A indicated that under normal circumstances, all residents requiring supervision at meals would sit at the same table in the dining room and someone is supervising the whole time during the meal and if eating in the room they will have an assigned CNA or feeding assistant in the room. On 06/18/2025, at 10:37 AM, Surveyor observed R35 in R35's room having breakfast. Surveyor noted, no staff in R35's room providing supervision while R35 is eating. R35 began crying and expressed being upset that there was no one there to assist R35 to go to the bathroom. At 10:42 AM, CNA-O came into R35's room to assist R35 to the bathroom. No additional information was provided as to why R35 did not receive supervision to ensure that R35 received the necessary services for acceptable nutrition.

Based on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 3 (R5, R9 and R250) of 3 residents residing at the facility whom receive a puree diet. *Cook-C was observed not following a recipe for preparing texture and modified consistency food for puree diets. Findings include: The facility's policy titled, Pureed Food Preparation dated 5/28/25 documents: Each resident must receive and the facility must provide food that is prepared by methods that conserve nutritive value, flavor and appearance. The policy does not document that the facility must follow a recipe to prepare pureed food. On 06/16/25 at 9:43 AM, Cook-C was observed preparing grilled cheese for residents receiving pureed food. Cook-C was observed putting 8 pieces of untoasted white bread, and 3.5 cups of liquid cheese prepared from a powder mix into the blender. The blended mix was put in a metal cooking container and placed in the oven to keep warm. [NAME] -C was asked for the recipe used for the pureed grilled cheese and Cook-C informed Surveyor that Cook-C does not use a recipe for preparing puree foods. On 6/16/25 at 9:50 AM, Surveyor interviewed Food Service Manager (FSM)-D regarding puree recipes. FSM-D informed Surveyor that recipes for pureed food are available on the computer, but they are not used and the cook just eyeballs puree preparation to make sure it's the right consistency. FSM-D indicated that the cook just purees the food that residents with a regular diet receive. The Surveyor asked if the residents on a regular diet get untoasted white bread with liquid cheese in it. FSM-D said no. On 6/16/25, the facility provided the recipe for pureed grilled cheese that was supposed to be used to prepare puree grilled cheese sandwiches. The recipe documented: Remove portions of grilled cheese sandwich from the regular recipe. Process until fine in consistency. Gradually add hot milk to sandwich mixture while processing. Surveyor noted that the recipe did not indicate how many grilled cheese are used in the recipe but indicated to add 3 and ½ cups of milk. On 6/17/25, at 3:00 PM, at the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above findings. Additional information was requested if available. None was provided as to why Cook-C did not follow recipes to prepare pureed food for residents.

Based on observation, interview, and record review the facility did not provide special assistive eating equipment for 1 (R250) of 1 sampled resident reviewed for assistive eating devices. R250's emergency contact and family member (FM)-E, informed Surveyor that R250 does not always get the adaptive equipment placed on R250's meal tray so that R250 can eat independently. Surveyor observed R250's meal tray ticket and noted that the adaptive equipment listed on the meal tray ticket did not match what was provided on R250's meal tray. Findings include: The facility policy dated 5/28/25 titled, Meal Supervision and Assistance, documents, in part: Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. Ensure that the necessary non-food items (i.e., silverware, napkin, special devices, straw, etc.) are on the tray; especially assistive and adaptive devices. Report or replace missing items. 1.) R250 was admitted to the facility on [DATE] with diagnosis that include Parkinson's disease, Osteoarthritis, Osteoporosis and Unspecified lack of coordination. R250's admission MDS (Minimum Data Set) dated 6/12/25 documents a BIMS (Brief Interview for Mental Status) score that indicates that R250 has a moderate cognitive impairment. R250's Activities of Daily Living Care plan dated 6/7/25 documents, in part: [R250] needs set up or clean up assistance to eat. On 6/16/25 at 9:50 AM, Surveyor interviewed FM-E. FM-E informed Surveyor that R250 needs built up silverware, a split plate and a nosey cup to eat and drink independently. FM-E indicated that the facility does not always supply these utensils on R250's tray. R250 Occupational Therapy Treatment Encounter note dated 6/10/25 documents, in part: [R250] assessed . during meal. Trailed built up handled fork and divided plate for increase ease of loading fork. [R250] reports increase ease and shows success with each forkful. [R250] had increase difficulty drinking out of regular cup/lifting up cup. [R250] provided with small nosey cup. [R250] reports it is better as it is lighter. [R250] is able to drink 4 sips then needs assist due to fatigue. On 6/16/25 at 9:50 AM, Surveyor observed R250's breakfast meal tray on R250's bedside table. R250 was finishing eating breakfast. Surveyor observed a meal tray ticket on R250's tray that documented, in part: Adaptive Equip-Built up utensils, small nosey cup, divided plate. Surveyor observed a nosey cup filled with juice and built-up silverware. Surveyor observed a regular glass plate and noted R250 was not supplied with a divided plate. On 6/16/25 at 1:23 PM, Surveyor observed R250's lunch meal tray on R250's bedside table. R250 was eating lunch. Surveyor observed a meal tray ticket on R250's tray that documented, in part: Adaptive Equip-Built up utensils, small nosey cup, divided plate. Surveyor observed built up silverware. Surveyor observed a regular cup of water and a regular cup of coffee and noted R250 was not supplied with a nosey cup for R250's liquids. Surveyor observed a regular glass plate and noted R250 was not supplied with a divided plate. On 6/17/25 at 10:39 AM, Surveyor observed R250's breakfast meal tray on R250's bedside table. R250 was eating breakfast while being evaluated by Speech therapist (ST)-F. Surveyor observed a meal tray ticket on R250's tray that documented, in part: Adaptive Equip-Built up utensils, small nosey cup, divided plate. Surveyor observed juice in a regular cup and noted R250 was not supplied with a nosey cup for R250's liquid. Surveyor observed a regular glass plate and noted R250 was not supplied with a divided plate. Surveyor observed regular silverware and noted R250 was not supplied with built-up silverware. On 6/17/25 at 10:42 AM, Surveyor interviewed ST-F. Surveyor asked who evaluates a resident for adaptive equipment and makes sure the meal tray ticket is correct. ST-F stated that Occupational therapy communicates the need for adaptive equipment, but it is collaborative. ST-F stated that ST-F spoke to the Occupational therapist about the nosey cup. ST-F stated that R250 does not need a nosey cup because [R250] was refusing. ST-F then asked R250 if R250 wanted the nosey cup and R250 indicated that [R250] was fine with a regular cup. ST-F did not address the need for built up silverware or a divided plate with R250 while Surveyor was observing. On 6/17/25 at 1:19 PM, Surveyor observed R250's lunch meal tray on R250's bedside table. Surveyor observed a meal tray ticket on R250's tray that documented, in part: Adaptive Equip-Built up utensils, small nosey cup, divided plate . Surveyor observed built up silverware. Surveyor observed water, juice and coffee in a regular cup. Surveyor noted R250 was not supplied with a nosey cup for R250's liquids. Surveyor observed a regular glass plate and noted R250 was not supplied with a divided plate. Surveyor noted that over 4 observations, R250's meal tray ticket did not match what R250 received on R250's tray. On 6/17/25 at 10:58 AM, Surveyor interviewed Dietary Aid (DA)-G. Surveyor asked who is responsible for making sure adaptive equipment is listed on the resident's meal tray tickets. DA-G stated that the therapy department communicates the need for any adaptive equipment and that is how it makes it to the meal tray ticket. The cook puts the tray together and makes sure the equipment is correct. DA-G indicated the cook would make sure the plate and silverware are correct and other staff would take care of the liquids on the tray. On 6/17/25 at 1:55 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H. Surveyor asked if CNA-H delivers meal trays to resident's room. CNA-H indicated that CNA-H does help to deliver trays. Surveyor asked who is responsible for making sure that the meal tray ticket matches what the resident receives. CNA-H stated that when CNA-H delivers a tray, CNA-H will always check to make sure that the ticket and the tray match. Surveyor asked if that includes any adaptive equipment needed. CNA-H stated that CNA-H will make sure that the resident has the adaptive equipment they need. On 6/18/25 at 9:34 AM, Surveyor interviewed Food Service Director (FSD)-I and Nursing Home Administrator (NHA)-A. Surveyor asked who is responsible for determining what adaptive equipment is needed for each resident. FSD-I indicated that the Occupational Therapist would let FSD-I know what the resident needs and FSD-I will make sure it is placed on the meal tray ticket. Surveyor asked who is responsible for assuring the meal ticket and the resident's tray match and are correct. FSD-I stated that the Dietary aid or whoever delivers the tray should review the tray for accuracy, and that would include any adaptive equipment needed. FSD-I stated that adaptive silverware is typically on the table when a resident eats in the dining room. FSD-I stated that the Dietary aid is responsible for making sure the liquid is served in the correct cup. FSD-I stated that the cook would be responsible for making sure a resident's plate is correct. Surveyor informed FSD-I and NHA-A that Surveyor observed 4 of R250's meal trays and noted that R250 did not always receive the adaptive equipment that is listed on R250's meal tray ticket. FSD-I stated that the facility only has one 4-ounce nosey cup, which is the cup that [R250] needs. FSD-I indicated that the 8-ounce nosey cup is too heavy for [R250]. FSD-I indicated that FSD-I has ordered more 4-ounce nosey cups to accommodate [R250]. On 6/18/25 at 9:41 AM, Surveyor informed NHA-A of the concern that R250's meal tray ticket that listed R250 needed adaptive equipment was not always observed being followed. No additional information was provided.

2.) R19 was hospitalized on [DATE] with a change in condition and returned to the facility on 3/11/25. After R19 was readmitted to the facility, on 3/11/25, R19 was sent back to the hospital for increased pain in her knee. R19 was readmitted to the facility on [DATE]. On 6/17/25 Surveyor requested the transfer and bed hold notice for R19 hospitalization from 3/5/25 to 3/11/25 and from 3/11/25 to 3/12/25. On 6/17/25 at 1:52 p.m. NHA (Nursing Home Administrator)-A explained to Surveyor that the facility has not been doing the transfer and bed hold notices since they switch over to a new EMR (electronic medical record) in January 2025. NHA-A stated the nurses had been doing the notices when the facility had the old EMR system. No additional information was provided. Based on interview and record review, the facility did not ensure 3 (R49, R19, and R43) of 3 resident's reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman. * R49 was transferred to the hospital on 5/20/25 and a transfer notice was not given to R49 and/or R49's representative. * R19 was transferred to the hospital on 3/5/25 and 3/11/25 and a transfer notice was not given to R19 and/or R19's representative. * R43 was transferred to the hospital on 5/12/25 and 6/2/25 and a transfer notice was not given to R43 and/or R43's representative. Findings include: On 6/17/25 at 1:52 PM, Nursing Home Administrator (NHA)- A was interviewed and indicated the facility has not been completing transfer notices for any residents since 1/1/25, when the facility changed medical records systems. NHA-A indicated no transfer notices were issued for transfers to the hospital for the following residents: R19, R43, and R49. The facility's policy titled Transfer and Discharge dated 5/28/25 documents: The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manor in which they can understand. 1.) On 6/17/25, the Surveyor reviewed R49's medical record and it indicated R49 was transferred to the hospital on 5/20/25. R49's medical record did not include documentation that a transfer notice had been given to the resident and/or their representative for the hospitalization. On 6/17/25 at 3:00 PM, the above findings were shared with NHA-A and Director of Nursing (DON)-B. Additional information was requested if available. None was provided as to why a transfer and bed hold notice were not given to R49 and/or their representative for R49's transfer to the hospital on 5/20/25. 3.) R43 was admitted to the facility on [DATE] with diagnosis that include Right leg fracture and Chronic Kidney disease. R43's late entry progress note dated 5/12/25 documents, in part: [R43] was admitted to . hospital . on 5/12/25. Writer contacted resident's daughter to explain bed hold options. Family does not wish to pay for bed hold but does want resident to return to the facility . R43 was hospitalized on [DATE] and returned to the facility on 5/16/25. Surveyor reviewed R43's electronic medical record for documentation that a transfer notice was given to R43. No transfer notice was found. R43's late entry progress note dated 6/2/25 documents, in part: . [R43] was admitted to . hospital . Writer spoke to resident's daughter . regarding bed hold status. Family wants [R250] to return to the facility if needed following this hospitalization but does not wish to pay for the bed hold . R43 was hospitalized on [DATE] and returned to the facility on 6/10/25. Surveyor reviewed R43's electronic medical record for documentation that a transfer notice was given to R43. No transfer notice was found. On 6/17/25 at 12:48 PM, Surveyor interviewed Director of Social Services (SSD)-M. Surveyor asked who is responsible for providing the transfer notice to the resident or resident's family. SSD-M stated that SSD-M takes care of the bed hold notice. SSD-M stated that the Assistant Director of Nursing (ADON)- and nursing staff are typically in charge of presenting the transfer notice to residents and/or families. SSD-M stated that the facility recently changed Electronic Medical Record Systems and before the change, the transfer notice would automatically print with a transfer to the hospital. The new system no longer does that. On 6/17/25 at 12:55 PM, Surveyor interviewed Director of Nursing (DON)-B and ADON-N. Surveyor asked who is responsible for assuring that transfer notices are given to residents or resident representatives when a resident is transferred to the hospital. ADON-N stated that the facility started to do transfer forms again last week. ADON-N stated prior to the new medical record system, which started at the beginning of the year, the old system would automatically print out a packet that would go along with the resident and it included the transfer notice. On 6/17/25 at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concern that R43 and/or their representative was not provided a transfer notice when R43 was transferred to the hospital on 5/12/25 and 6/2/25. No additional information was provided.

Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice to prevent pressure ulcers from developing for 2 (R43 and R19) of 3 residents reviewed for pressure injuries. *R43 was admitted to the facility with an Unstageable pressure injury to the right elbow that required antibiotics for a wound infection and developed pressure injuries to the left heel and right Achilles. Wound documentation was not an accurate description of staging, measurements, and characteristics of the wound. *R19 was admitted to the facility with a Stage 3 pressure injury to the right outer ankle. Wound documentation was not an accurate description of staging, measurements, and characteristics of the wound. Findings include: The facility policy and procedure entitled Pressure Ulcer Management dated 11/29/6 states: Procedure: . 2. The licensed nurse further assesses all wounds, including location, type of wound, stage, measurement, exudate, pain, wound bed, periwound, and any other comments. This assessment is recorded on the 'Guide for Wound Assessment and Documentation' form by the nurse performing the assessment, on the date that the wound was identified. Physician's orders for treatment are obtained as appropriate.8. During a skin assessment, if a new wound is identified, the licensed nurse further assesses the wound, including location, type of wound, stage, measurement, exudate, pain, wound bed, periwound, and any other comments. This assessment is recorded on the 'Guide for Wound Assessment and Documentation' form by the nurse performing the assessment, on the date that the wound was identified. Physician's orders for treatment are obtained as appropriate. 11. Current ulcers are assessed by a licensed nurse weekly. Assessment includes type of wound, stage, measurement, exudate, pain, wound bed, periwound, and any other comments. This assessment is scheduled on the TAR and documented on the 'Wound Evaluation Flow Sheet'. 1.) R43 was admitted to the facility on [DATE] with diagnoses of right femoral neck fracture, dementia, history of bladder cancer, coronary artery disease, atrial fibrillation, congestive heart failure, and macular degeneration with legal blindness. R43's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R43 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5 and needed substantial assistance with bed mobility. On 1/23/2024, on admission, R43 had a Stage 2 pressure injury to the sacrum, a wound to the upper right elbow, a Stage 3 pressure injury to the right scapula, and an Unstageable pressure injury to the left elbow that healed by 2/18/2024. In addition, R43 was admitted with an Unstageable pressure injury to the right elbow. The hospital discharge paperwork dated 1/23/2024 documented R43 had a history of osteomyelitis due to Staphylococcus aureus to the right arm in 2003. On 1/23/2024 on the Treatment Administration Record (TAR), nursing was instructed to suspend heels with pillows while in bed and was to have a turn schedule while in bed and sign off on the intervention every shift. RIGHT ELBOW On 1/24/2024 on the Wound Evaluation Flow Sheet, Registered Nurse Supervisor (RN Sup)-D charted the right elbow Unstageable pressure injury measured 1.8 cm x 1.4 cm with no depth measurement with 90% scab and 10% slough. The surrounding tissue was red and swollen. A treatment was initiated on 1/24/2024 to cleanse with soap and water, pat dry, apply Santyl to the wound bed followed by foam dressing daily. R43 had an order for Keflex 500 mg three times daily for seven days for cellulitis of right elbow. R43's Alteration in Skin Integrity Care Plan for the right elbow wound was initiated on 1/24/2024 with the following interventions: -Refer to interdisciplinary wound care team, if appropriate. -Monitor color, drainage, odor, pain daily or with dressing change and document. -If dressing not due to be changed, monitor surrounding skin, condition of dressing, presence of odor, drainage, and pain. Document findings. -Measure size weekly and record. -Move in bed using breezy pad. -Turn and reposition every two hours using assist of two. -Dietary referral for nutrition assessment. -Therapy referral for positioning, appropriate cushion. -Labs per physician order. -Treatment per physician order. -Culture open area per physician order if indicated. -Wheelchair cushion. -Analgesic for discomfort prior to treatment and as needed. -Assess for pain at least daily and as needed; document and treat as appropriate. On 1/28/2024 on the Wound Evaluation Flow Sheet, RN Sup-D charted the right elbow Unstageable pressure injury measured 1.2 cm x 1 cm with no depth measurement with 90% yellow slough and 10% black. RN Sup-D charted the dark scab was almost gone and the wound continued with yellow slough. R43 continued with antibiotics for cellulitis with the area less red/swollen. On the Wound Charting progress notes, RN Sup-D charted the wound was 100% slough with two small black areas at 9 o'clock and 3 o'clock. Surveyor did not find any documentation the physician was notified of the change in presentation of the pressure injury. On 2/5/24 the impaired skin integrity care plan was updated to include: treat as ordered, cleanse right elbow with soap and water, pat dry, skin prep to periwound, apply Santyl, f/b (followed by) adhesive dressing qd (each day) and prn (as needed). Revise care plan approaches if wound worsens. Minimize pressure on bony prominences. Instruct on the importance of good skin care and frequent repositioning .there is no indication the facility specifically addressed offloading or decreasing pressure to R43's elbow as the wound continued to worsen. On 2/6/2024 on the Wound Evaluation Flow Sheet, RN Sup-D charted the right elbow Unstageable pressure injury measured 0.5 cm x 0.6 cm with no depth measurement with 100% dark slough. RN Sup-D charted the surrounding tissue was erythematous and swollen. On 2/12/2024 the right elbow Unstageable pressure injury was measured by a Licensed Practical Nurse (LPN) and reviewed by RN Sup-D. The pressure injury measured 0.5 cm x 0.7 cm x 0 cm with yellow thick exudate with 10% slough and 90% eschar. On 2/18/2024 the right elbow pressure injury was measured by an LPN and reviewed by RN Sup-D. The LPN charted in the Wound Charting progress notes the wound was a worsening Stage 3 pressure injury that measured 0.7 cm x 0.6 cm x 0 cm with 100% slough and purulent yellow thick exudate. Surveyor noted the pressure injury was staged as a Stage 3 even though the wound base was covered with slough and not visible. On 2/25/2024 on the Wound Evaluation Flow Sheet, RN Sup-D charted the right elbow Unstageable pressure injury measured 0.7 cm x 0.5 cm x 0.4 cm with 100% thick yellow slough. A wound culture was done and came back positive for Staphylococcus and Doxycycline 100 mg twice daily for seven days was started. A consult for the wound clinic to assess R43's elbow was completed. On 2/28/2024, R43 went to the wound clinic for a consultation for the non-healing right elbow wound. The consult note contained the following information: Findings: Right elbow shallow ulcer with deep circumferential undermining with serous drainage. R43 was on doxycycline for staph infection. Recommendations: ortho consult to debride and close elbow joint ulcer, daily packing with vashe moistened gauze. Treatment: wash with soap and water, pat dry. Vashe moistened quarter inch Nugauze packing daily. Offload and avoid direct pressure on elbow. Complete prescribed antibiotic. Return to clinic in one month or as needed. Review of R43's care plan indicates the recommendation to avoid direct pressure to R43's elbow was not added to R43's plan of care. On return from the wound clinic appointment on 2/28/2024, an order was obtained for a consult to the ortho clinic for debridement and closure of the right elbow joint ulcer. An appointment was made for 3/6/2024. On 3/3/2024 on the Wound Charting progress notes, RN Sup-D charted the Unstageable pressure injury measured 0.7 cm x 0.6 cm x 0.4 cm with 100% granulation tissue with less than 2 cm undermining in any area. The wound had non-pitting edema that extended less than 4 cm around the wound and had thick yellow purulent drainage. R43 completed the antibiotic for the wound infection and the area was less red and swollen. R43 was taking multivitamins, high calorie boost, magic cup and milk with protein powder. RN Sup-D charted the area had a punched out look with undermining around entire circular area of wound and continued with yellow purulent drainage. The wound bed was 100% pink, the margins slightly macerated and was being followed by the wound clinic. Surveyor noted the pressure injury was not staged when the base of the wound was visible and not covered with slough. On 3/4/2024, R43 had an order for doxycycline 100 mg twice daily for seven days for the wound infection. On 3/5/2024, R43 had an order to start Megestrol Acetate 40 mg/ml (10 ml or 400 mg) daily for cachexia, or muscle and adipose tissue wasting. On 3/6/2024, R43 went to the ortho clinic for the right elbow wound. Recommendations were to continue packing the wound and must correct protein deficiency for wound healing. On 3/10/2024 on the Wound Evaluation Flow Sheet and the Wound Charting progress notes, RN Sup-D charted the right elbow Unstageable pressure injury measured 0.5 cm x 0.5 cm x 0.4 cm with 100% granulation and undermining 2 cm circumference with purulent drainage and was receiving doxycycline for the wound infection. Surveyor noted the pressure injury was not staged with 100% granulation tissue. The treatment was changed to include irrigating the wound with vashe. On 3/18/2024 on the Wound Charting progress notes, RN Sup-D charted the right elbow Unstageable pressure injury measured 0.5 cm x 0.5 cm x 0 cm and noted the wound was covered by a scab with the surrounding area red and soft. RN Sup-D called and spoke with the wound clinic and an appointment was made for 3/20/2024. A treatment of betadine swab to the wound bed and cover with dry dressing was ordered daily. On 3/20/2024, R43 went to the wound clinic and the wound clinic evaluated the wound stating the right elbow wound had undermining approximately 1.7 cm circumferentially. The wound clinic ordered the same treatment with the packing of the wound daily with quarter inch vashe soaked Nugauze. On 3/20/2024 on the Wound Charting progress notes, RN Sup-D charted the right elbow Unstageable pressure injury measured 0.5 cm x 0.5 cm x 0.4 cm with 90% granulation and 10% slough with undermining at 9 o'clock 2 cm, 12 o'clock 1 cm, 3 o'clock 1 cm, and 6 o'clock 1 cm. The surrounding tissue was non-pitting edema that extended less than 4 cm around the wound with purulent yellow thick exudate. RN Sup-D noted the depth of the wound was unchanged, but the undermining was deeper since R43 was at the wound clinic on 3/20/2024. Surveyor noted the pressure injury was not staged. LEFT HEEL On 1/23/2024 on the Treatment Administration Record (TAR), nursing was instructed to suspend heels with pillows while in bed and was to have a turn schedule while in bed and sign off on the intervention every shift. On 2/8/2024 on the Wound Evaluation Flow Sheet, R43 developed a Stage 2 pressure injury that measured 1.5 cm x 0.8 cm. On 2/10/2024 on the TAR, wound care was ordered to apply skin prep to bilateral heels twice daily. On 2/14/2024 on the Wound Evaluation Flow Sheet, RN Sup-D charted the Stage 2 pressure injury measured 2.0 cm x 2.5 cm that was 50% red non-blanchable and 50% dark red in the center. RN Sup-D charted the area was previously a blister. On 2/18/2024 the left heel pressure injury was measured by an LPN and reviewed by RN Sup-D. The LPN charted in the Wound Charting progress notes the Deep Tissue Injury (DTI) measured 0.3 cm x 1.0 cm x 0 cm with 100% yellow scab. Surveyor noted a DTI does not have the characteristic of a scab and would be considered an Unstageable pressure injury and the wound had previously been staged as a Stage 2 pressure injury. The left heel was assessed weekly with the following measurements and characteristics: 2/25/2024 - DTI that measured 0.3 cm x 1.0 cm with 100% yellow scab. 3/3/2024 - Unstageable pressure injury that measured 0.4 cm x 1.0 cm with 80% yellow and 20% dark purple tissue. 3/10/2024 - Unstageable pressure injury that measured 1.0 cm x 0.5 cm with yellow and purple scab. 3/18/2024 - DTI that measured 1.0 cm x 0 cm with a yellow scab on the Wound Charting progress notes and measured 0.8 cm x 0.6 cm on the Wound Evaluation Form. No tissue type was written on the Wound Evaluation Form. Surveyor noted the inconsistencies of the documentation of the measurements and the tissue type. 3/25/2024 - DTI that measured 1 cm x 0.5 cm with deep purple tissue on the Wound Charting progress notes and measured 0.5 cm x 0.5 cm with a yellow scab on the Wound Evaluation Flow Sheet. Surveyor noted the inconsistencies of the documentation of the measurements and the tissue type. On 3/19/2024 on the TAR, R43 had an order of no shoes, only grippy socks for the bilateral DTIs to the heels. RIGHT ACHILLES On 1/23/2024 on the Treatment Administration Record (TAR), nursing was instructed to suspend heels with pillows while in bed and was to have a turn schedule while in bed and sign off on the intervention every shift. On 2/10/2024 on the TAR, wound care was ordered to apply skin prep to bilateral heels twice daily. On 2/14/2024 on the Wound Evaluation Flow Sheet, RN Sup-D charted R43 developed a DTI to the right Achilles that measured 0.2 cm x 0.3 cm that was deep maroon in color. The right Achilles was assessed weekly with the following measurements and characteristics: 2/18/2024 - DTI that measured 2.5 cm x 2.0 cm that was deep maroon and not blanchable. 2/25/2024 - DTI that measured 2.5 cm x 2.0 cm that was deep maroon and not blanchable. 3/3/2024 - DTI that measured 1.0 cm x 0.8 cm that was deep maroon and not blanchable. 3/10/2024 - DTI that measured 0.5 cm x 0.5 cm that was 100% purple. 3/18/2024 - DTI that measured 0.8 cm x 0.6 cm with no characteristics of the wound. 3/25/2024 - DTI that measured 0.5 cm x 0.5 cm with a yellow scab. Surveyor noted the yellow scab was not consistent with a DTI. On 3/25/2024 at 11:06 AM, Surveyor observed R43 in the doorway of R43's room. R43 stated R43 had a sore on the elbow and indicated by pointing it was on the right elbow. R43 denied any other wounds. R43 was difficult to direct in conversation and verbalized confusion as to where R43 should be at that time. R43 was observed to be wearing gripper socks and no shoes. RN Sup-D came to assist R43 to the bathroom. RN Sup-D stated R43 had fallen at home and was on the ground for about seven hours before help came and R43 sustained the pressure injury to the right elbow at that time. RN Sup-D stated they are packing the wound as a treatment. In the evening of 3/25/2024, R43 was transferred to the hospital for cardiac concerns and did not return to the facility during the remainder of the survey. In an interview on 3/27/2024 at 10:00 AM, Surveyor asked Director of Nursing (DON)-B to discuss R43's pressure injuries. DON-B stated R43 had been living at home alone and had not been taking showers and the home was not clean. DON-B stated R43 had a lot of wounds when first admitted , which most have healed since admission. DON-B stated they were concerned about R43's right elbow wound because it looked infected, and they had the physician look at the wound and got a consult for the wound clinic. Surveyor asked why the right elbow wound did not have depth measurements from admission until 2/12/2024. DON-B stated they thought R43 had cellulitis and was not making progress and now has undermining because the wound clinic removed a lot of junk from the wound so now, they are irrigating and packing the wound. DON-B did not answer why there were no depth measurements for the right elbow wound. DON-B stated the wound did not look good, so they called the wound clinic. DON-B stated they call the wound clinic if a wound is not improving. DON-B stated they measure all the wounds every Sunday or Monday, depending on staffing, and then they have a wound meeting every Monday with the dietician, therapists, and Nursing Home Administrator (NHA)-A. Surveyor asked DON-B again why the right elbow wound did not have any depth measurements from admission until 2/12/2024. DON-B stated there was not depth in the beginning because of the cellulitis. DON-B stated RN Sup-D is aggressive with wounds and a lot of progress has made with wounds; the residents with wounds were admitted with them from the community. Surveyor asked DON-B who does the weekly measurements and assessments. DON-B stated DON-B and RN Sup-D will do the measurements; the LPNs will measure the wounds and then RN Sup-D will follow up. Surveyor shared with DON-B the concern depths were not documented and then the wound measured 0.4 cm depth on 2/25/2024 and needed antibiotics for a staphylococcus infection. Surveyor asked DON-B what prompted them to do a wound culture. DON-B stated there must have been something that would have made them do a culture or no progress was being made. DON-B stated they would have to look at R43's notes. Surveyor shared there was not documentation prior to the wound culture and the start of the antibiotic that showed an infective process. RN Sup-D joined the interview. RN Sup-D stated measurements are done every week. RN Sup-D stated the wound was opened to begin with. Surveyor asked RN Sup-D why there were no depth measurements of the right elbow wound for the first few weeks. RN Sup-D did not have an answer. Surveyor asked RN Sup-D what caused them to culture the right elbow wound. RN Sup-D stated there was greenish drainage and an odor, so they cultured it, and it was positive for staphylococcus and then the ortho clinic extended the antibiotic for an additional week. Surveyor asked RN Sup-D why the right elbow wound was not staged when it had 100% granulation tissue. RN Sup-D stated the staging cannot be changed. Surveyor shared with RN Sup-D that an Unstageable wound can be staged once the necrotic tissue is no longer covering the wound bed and the underlying tissue can be observed. RN Sup-D stated RN Sup-D did not know that. Surveyor asked RN Sup-D how R43 developed the DTIs to the left heel and right Achilles. RN Sup-D stated R43 kicks off the boots and constantly moves the legs. Surveyor asked RN Sup-D why the left heel was determined to be a DTI when it started as a Stage 2 blister. RN Sup-D stated it should have been documented as a healing DTI. On 3/27/2024 at 10:33 AM, Surveyor shared with NHA-A the concern R43's pressure injuries did not have accurate documentation of staging or measurements. No further information was provided at that time. 2.) R19 was admitted to the facility on [DATE] with diagnoses of prostate cancer with metastases to the bone, Stage 3 pressure injury to the right lateral ankle, and cardiomyopathy. R19's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated R19 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 11 and required substantial assistance with bed mobility. R19 was admitted to hospice services on 12/1/2023, shortly after admission to the facility. R19's hospital discharge summary dated 11/16/2023 indicated R19 had a chronic right ankle ulcer that was stable. On 11/20/2023 on the Wound Evaluation Flow Sheet, nursing charted R19 had a Stage 3 pressure injury that measured 1.0 cm x 0.7 cm x 0.3 cm with 50% granulation and 50% slough and a dark dot in the center with thick tan exudate. The narrative on the Wound Charting progress notes stated R19 goes to the wound clinic every three weeks. Surveyor noted R19 did not go to the wound clinic at any time since admission. On 11/20/2023 on the Treatment Administration Record (TAR), R19 had a treatment order for the right outer ankle: cleanse with soap and water, iodosorb paste to the wound bed and cover three times a week. R19's right outer ankle Stage 3 pressure injury was comprehensively assessed weekly: 11/28/2023 - Stage 3 that measured 1.0 cm x 1.2 cm x 0.4 cm with 50% granulation and 50% slough. 12/4/2023 - Stage 3 that measured 1.0 cm x 0.7 cm x 0.2 cm with 100% granulation. 12/12/2023 - Stage 3 that measured 1.1 cm x 0.6 cm x 0.2 cm with 100% granulation. 12/17/2023 - Stage 3 that measured 1.3 cm x 1.3 cm x 0.2 cm with 100% granulation. A notation was made that the wound was larger, the margins indurated, and a small circular area at 9 o'clock measured 0.1 cm x 0.1 cm x 0.2 cm. Surveyor noted the smaller area did not have any characteristics other than a measurement. 12/25/2023 - Stage 3 that measured 1.6 cm x 1.5 cm x 0.3 cm with bone visible in the center and white tissue possibly cartilage. Surveyor noted a Stage 3 pressure injury does not have bone visible; a Stage 4 pressure injury involves bone. No documentation was found the physician was notified with the deterioration of the wound. 1/2/2024 - Stage 3 that measured 1.7 cm x 1.6 cm x 0.2 cm with 50% granulation and 50% slough. 1/7/2024 - Stage 3 that measured 1.5 cm x 2.0 cm x 0.2 cm with 10% granulation and 90% slough. 1/14/2024 - Stage 3 that measured 1.9 cm x 2.0 cm x 0.2 cm with 10% granulation and 90% slough. 1/22/2024 - Stage 3 that measured 1.6 cm x 1.6 cm x 0.2 cm with 100% necrotic white tissue and macerated wound edges rolled in and purulent cream opaque exudate. 1/28/2024 - Stage 3 that measured 1.2 cm x 1.4 cm x 0.2 cm with 100% cream colored slough and cream colored purulent drainage. 2/6/2024 - Stage 3 that measured 1.5 cm x 1.1 cm x 0.1 cm with 40% granulation and 60% slough with cream colored purulent drainage. 2/11/2024 - Stage 3 that measured 1.5 cm x 1.1 cm x 0.1 cm with 40% granulation and 60% slough. 2/18/2024 - Stage 3 that measured 2.0 cm x 1.2 cm x 0.1 cm with 100% granulation. 2/25/2024 - Stage 3 that measured 2.0 cm x 1.3 cm x 0.1 cm with 10% granulation and 90% slough with purulent thick yellow exudate. 3/3/2024 - Stage 3 that measured 2.0 cm x 1.5 cm x 0.2 cm with 60% granulation and 40% slough with purulent thick yellow exudate. 3/10/2024 - Stage 3 that measured 1.5 cm x 1.0 cm x 0.4 cm with 90% granulation and 10% slough. 3/18/2024 - Stage 3 that measured 1.5 cm x 1.0 cm x 0.4 cm with 100% granulation. 3/25/2024 - Stage 3 that measured 1.5 cm x 1.0 cm x 0.4 cm with 80% granulation and 20% slough. Surveyor reviewed the treatment orders for R19's right outer ankle Stage 3 pressure injury. -On 11/20/2023, cleanse with soap and water, iodosorb paste to the wound bed and cover three times a week. -On 12/3/2023, metronidazole 250 mg tablet crushed and place in wound bed, cover with calcium alginate and a dry dressing. This treatment was applied one time and then the original order was reinstated. -1/5/2024, apply lidocaine ointment 5% for 10 minutes prior to completing right lateral ankle treatment of cleanse with soap and water, iodosorb paste to the wound bed and cover three times a week. The lidocaine ointment prior to the treatment was initiated by the hospice Nurse Practitioner on 12/21/2023 and after clarification with physicians, hospice, and pharmacy, the final 5% ointment was implemented. Surveyor noted the treatment to the wound had not changed since admission on 11/20/2023 even with a change in the appearance of the wound. On 3/27/2024 at 8:24 AM, Surveyor observed Registered Nurse Supervisor (RN Sup)-D complete the treatment to R19's Stage 3 right outer ankle pressure injury. R19 was in bed with heel boots on, grippy socks on, and a pillow under the calves. RN Sup-D stated R19 had gotten the scheduled morphine about 15 minutes prior so that would help with pain control during the treatment. R19 had pain to touch during the treatment. The wound measured approximately 1.0 cm x 1.0 cm x 0.3 cm with 100% granulation. On 3/27/2024 at 10:00 AM, Surveyor interviewed Director of Nursing (DON)-B and RN Sup-D about R19's Stage 3 pressure injury to the right outer ankle. DON-B stated R19 has prostate cancer with bone metastases so is compromised. RN Sup-D stated R19 has not had any change in measurements to the wound and sometimes the slough comes and goes. RN Sup-D stated R19 is always premedicated and then lidocaine is applied to control pain. Surveyor asked RN Sup-D if R19 goes to the wound clinic because it was stated in the first assessment of the wound that R19 goes to the wound clinic every three weeks. RN Sup-D stated that may have been the case when R19 was at home, but now R19 is on hospice and with the overall decline and prognoses, we are just keeping R19 comfortable. RN Sup-D stated the iodosorb is keeping the wound clean and dry. Surveyor shared with RN Sup-D the documentation that R19 had purulent drainage and asked if the wound had ever been infected. RN Sup-D stated the wound has never been infected and purulent was the wrong adjective; the slough was thick and stringy but has never had an infection. Surveyor asked RN Sup-D why the treatment has never changed since the wound has not progressed at all. RN Sup-D stated the wound has never been infected so they do not feel like a different treatment wound help it or close it. DON-B stated R19's spouse does not want any aggressive treatments. RN Sup-D stated R19 had morphine as needed and now it is scheduled as well as needed. Surveyor asked RN Sup-D why the wound was not staged at a Stage 4 when bone was exposed. RN Sup-D stated it was not bone, it could have been white slough. DON-B showed RN Sup-D the charting where RN Sup-D documented bone or cartilage. RN Sup-D stated that RN Sup-D did not know why RN Sup-D charted that, but did not think at this time it was bone. Surveyor shared with DON-B and RN Sup-D the concern there was no documentation showing the physician was notified when there was a change in the presentation of the pressure injury. RN Sup-D stated RN Sup-D calls the physician's office every day about something and is updated when they are on the phone and the physician comes in every week and sees R19 and R19's wound. Surveyor reviewed R19's physician visit notes. R19 was seen by the physician on 11/23/2023, 12/18/2023, 1/21/2024, 3/3/2024, and 3/24/2024. Each visit note had the same documentation of PHYSICAL EXAM: . EXTREMITIES: no deformity, no ulceration. There was no documentation that was found indicating the physician was monitoring R19's Stage 3 pressure injury. In an interview on 3/27/2024 at 11:08 AM, Surveyor asked RN Sup-D if hospice was involved in the management of R19's pressure injury. RN Sup-D stated no, hospice was not involved. RN Sup-D stated the RN from hospice gets wound measurements from RN Sup-D. In a phone interview on 3/27/2024 at 11:46 AM, Surveyor asked hospice RN-E what involvement hospice had in the care of R19's pressure injury. RN-E stated the wound is monitored and RN-E will peel back the dressing to visualize the area but does not take measurements since the facility is already doing that. RN-E stated RN-E is the one that suggested the use of lidocaine with the wound treatments because R19 was in a lot of pain during the procedure. RN-E stated pharmacy did not have the dosage prescribed so between hospice, the facility, and the pharmacy, an appropriate lidocaine was obtained. Surveyor asked RN-E what the expectation was regarding the wound. RN-E stated they are palliative and do not expect the wound to heal because R19 has had it for a long time. On 3/27/2024 at 10:33 AM, Surveyor shared with NHA-A the concern R19's pressure injury documentation was difficult to follow and, after the interview with RN Sup-D, inaccurate. Surveyor shared RN Sup-D stated when bone and purulent drainage was documented, those were not accurate in describing the wound. No further information was provided at that time.

Based on record review and interview, the facility did not thoroughly investigate an allegation of misappropriation affecting 1 (R147) of 1 residents in a Facility Reported Incident that was reviewed. R147 reported a missing wallet. The facility administration did not interview residents in the facility at the time of the report to determine if any other residents were affected by potential theft. Findings include: On 11/15/2023, R147 reported to Social Worker (SW)-C their wallet was missing. The wallet contained money, credit cards, insurance cards and driver's license. SW-C initiated an investigation by interviewing R147's family members who were aware of the missing wallet to determine when the wallet was last seen and to verify no family member had taken the wallet out of the facility. It was determined through those interviews that the wallet was last seen on Friday evening, 11/10/2023. SW-C interviewed all staff members that had worked at the facility 11/10/2023-11/15/2023 with no staff aware of R147's wallet. Surveyor noted no residents were interviewed to determine if there were any other items missing at that time. In an interview on 3/26/2024 at 3:28 PM, Surveyor asked SW-C what position SW-C held at the facility. SW-C stated SW-C was a Social Worker, the Grievance Officer, and the Admissions Officer. Surveyor asked SW-C if SW-C could recall the events surrounding R147 reporting a missing wallet on 11/15/2023. SW-C stated R147's family came in to visit R147 on 11/15/2023 and SW-C was in R147's room when the family realized R147's wallet was missing. SW-C stated SW-C knew R147 had their wallet on the day of admission on 11/7/2023 because R147 provided insurance cards at that time. SW-C was not aware of what happened to R147's wallet after getting the insurance cards; SW-C did not know if a family member took the wallet home or if R147 kept the wallet with them in the facility. SW-C stated SW-C interviewed all of R147's family members to determine if any of them had the wallet or knew where the wallet may be and none of the family members had any information. SW-C stated SW-C interviewed all the staff members that worked over the weekend from Friday when the wallet had last been seen until 11/15/2023 when the wallet was reported missing. SW-C stated no staff members had any knowledge of R147's missing wallet. Surveyor asked SW-C if any residents had been interviewed to see if they had any knowledge of the missing wallet regarding seeing anyone with the wallet or if they had any personal items missing at the same time to broaden the scope of the investigation. SW-C stated no, none of the residents were interviewed. SW-C stated no other missing items had been reported so that did not prompt SW-C to ask anyone if they had anything missing. SW-C stated SW-C had overheard R147 telling other residents about the missing wallet, so SW-C knew some residents were aware and no one brought anything forward to SW-C of missing money or items. On 3/27/2024 at 10:33 AM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern when R147's wallet went missing on 11/15/2023, no other residents were interviewed to determine if that was an isolated incident or if any residents had seen activity that would help discover what happened to the wallet. NHA-A did not provide any further information at that time.

Based on observations and record review, the facility failed to ensure the facility developed and followed the menus and that the menus met the nutritional needs of the residents. This failure placed all 38 facility residents at risk of nutritional problems and dissatisfaction with their meals. Findings include: Review of the facility's 01/09/23 to 01/13/23 weekly menu, provided on paper by Dietary Manager (DM) E, revealed it did not include extensions for therapeutic diets or portion sizes. The weekly menu documented the 01/11/23 lunch menu for the following for Wednesday: -Chicken noodle soup or yogurt and fruit plate -Corndog -Potato chips -Peppermint cake There were no alternatives listed for therapeutic diets, such as Mechanical Soft, and there were no portion sizes listed. Observation in the kitchen during lunch tray line on 01/11/23 at 12:01 PM revealed, Cook L served: -Four ounces chicken noodle soup or a pre-prepared fruit salad -One corn dog -One small bag of potato chips -One approximately 4 inches (in) by 4 in piece of cake. Additionally, Cook L served the following for the residents receiving a Mechanical Soft diet portion: -A #10 scoop (2.75 ounces) of ground corn dog -One small bag of crunchy Cheetos -Four ounces chicken noodle soup or pre-prepared fruit salad (which consisted of large, 1-inch. cubes of honeydew and cantaloupe melon, and blueberries, and strawberries) -One approximately 4 in by 4 in piece of cake. Cook L served the following for a resident with an order for a low fat, low cholesterol diet: -Pre-prepared fruit salad -One corn dog -One small bag of potato chips -One approximately 4 inches (in) by 4 in piece of cake. On 01/11/23 at 12:45, Cook L stated that the Meal Ticket should indicate if it is for small portions and if not then she will assume that it is large portions. She stated since there was only one scoop size available to use that she used what she had. She stated that the portion for grilled cheese is half sandwiches and that they will give half a piece of cake instead of full slice if a resident is diabetic. Cook L stated that when it comes to knowing what to serve for specific therapeutic diets that nothing is different except for cake. She stated that they would still give diabetics half piece of cake unless they asked for fruits or something special. She stated that the CNAs communicated with them if the resident had an issue with the food after the cook serves them. If the resident is not okay with it, then they adjust it. Cook L stated that if the resident is on a mechanical soft diet that they cannot give them chips or grapes. She states that, We were told we can have fruits just no grapes. She also stated that they do not have a form or somewhere to reference sizes and scoops, they just used what they had. During an interview on 01/12/23 at 10:39 AM, Registered Dietician (RD) D stated that they use the recipe to determine the serving/portion sizes. She also stated that there were certain serving size expectations for certain foods like veggies which are about 1/2 cup of cooked veggies. RD D stated that usually the residents would ask for 1/2 portion if they wanted them and that a lot of it was up to the resident. RD D stated that the tray cards indicated what food to serve for each diet and has the specifications. RD D stated that the staff used the tray card to indicate serving size preference and likes. RD D stated that the tray card would also indicate if the resident needed to receive mechanical soft/therapeutic diet. RD D stated that they know the right texture specification for diets like mechanical soft by talking to the resident before each meal. RD D also stated that she was new, so she did not receive formal training on some of this. RD D also stated that there was no existing database for the missing diet extensions for the menus and that they were in the process of doing that. When asked if it was okay to serve raw cantaloupe and honeydew in 1-inch cubes to someone who is on mechanical soft diet, RD D stated, depends on the ripeness and if too firm then no. When asked how the staff would know/assess for the right ripeness, RD D stated, Maybe we need a specific plan or better system to teach staff to chop food more finely. During an interview on 01/11/23 at 11:58 AM, Dietary Manager (DM) E stated that she did not have the extension menu of therapeutic diets for the current weekly menu. DM E stated that she did not know that she was supposed to do it. DM E stated that she was new and that she wasn't trained on that, and she only had one general extension menu she provided.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to implement staff COVID-19 testing in the presence of a COVID-19 outbreak in the facility. This failure affected all 134 who worked in the facility and all 38 residents. This failure had the potential to contribute to spread of COVID-19 within the facility. Findings include: Review of the facility's policy titled, Testing for COVID-19 in Residents and Employees dated 09/28/22, documented All employees will be tested for CO\/ID-19 if there is an outbreak, defined as one case. Review of the CDC's COVID-19 Data Tracker website, accessed on 01/10/23 at https://covid.cdc.gov/covid-data-tracker/#datatracker-home, the facility's community transmission level was high. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html on 01/11/23, revealed, A single new case of SARS-CoV-2 [COVID-19] infection in any HCP [health care professional] or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . Close contact [is defined as] being within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with SARS-CoV-2 infection. During an interview on 01/10/23 at 1:47 PM, Infection Preventionist Nurse (IP) C stated the COVID-19 outbreak started 01/01/23. IP C stated, We only test staff with COVID-19 symptoms during an outbreak, if an employee wants to test themselves, they can. IP C provided a line listing of four employees tested for COVID-19 due to being symptomatic which revealed the test results for all four employees were positive for COVID-19. IP C confirmed that no other employees have been tested for COVID-19. During an interview on 01/10/23 at 02:18 PM IP C stated, We think if our caregivers were wearing masks they were not exposed and we do ask if they had their masks off. Employee contact tracing was requested but not provided. During an interview on 01/12/23 at 10:39 AM Director of Nursing (DON) B stated, We screen all employees when they come and if they show symptoms we test. Employee contact tracing and testing was requested but not provided. During an interview on 01/12/23 at 1:00 PM, Administrator A stated that employees do not need to be tested unless they were unmasked during an outbreak. Administrator A did not provide contact tracing to show they were asking employees if they had their masks off.

Based on interview, record review, and facility policy review, the facility failed to ensure that one resident (Resident (R) 28) of three residents reviewed for accidents received adequate interventions to prevent the resident from sustaining continued falls. Findings include: Review of the facility's undated policy titled, Falls Prevention, provided by facility revealed, Each resident shall be assessed for risk of falls upon admission, quarterly, annually and as a change of condition warrants .Upon determination, per assessment and observation, that a risk for falls is present, facility staff will initiate any and/or all, but not limited to, the following interventions as appropriate: A. An individualized care plan will be developed to meet any resident's safety needs. B. A speech, Physical and Occupational Therapy Screen will be performed to determine limitations and needs. C. Adaptive equipment will be provided as appropriate to meet safety needs. D. Interventions specific to the resident's need will be initiated including but not inclusive to low beds, bed sensors, floor mats, cradle mattresses, anti-Dycem, bathroom door alarm and seat sensors. Review of R28's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/06/22 revealed the facility assessed R28 to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. R28 required excessive assistance for bed mobility, transfers, walking in a room, toilet use, and personal hygiene. R28 used a wheelchair and walker for mobility. Review of R28's Fall Risk assessment dated [DATE], revealed the resident was at high risk for falls with a total score of 11 out of 11. The resident had five falls in the previous six months. Review of R28's Quality of Life Charting in the EMR revealed falls on the following dates: 11/14/21, 11/18/21, 11/23/21, 12/05/21, 03/16/22, 05/05/22, 05/29/22, 06/14/22, 07/03/22, 10/01/22, 10/09/22, 10/30/22, and 12/04/22. Review of R28's Falls Management Team Review revealed the resident was observed on the floor on 11/14/21 and sustained a reddened area on her chin. The Falls management team determined that current safety interventions: resident reminded to ask for help were appropriate. Review of R28's Falls Management Team Review revealed on 11/18/21 and 11/23/21 the resident was observed on the floor. Falls management team determined that current interventions of self-locking w/c (wheel chair) brakes, Dycem in wheelchair/Broda seat and referring to PT for evaluation were appropriate. Review of R28's Falls Management Team Review revealed the resident was observed on the floor on 12/05/21. Resident sustained laceration to right forehead and two hematomas. Falls management team determined current interventions of self-locking w/c brakes, Dycem in wheelchair/Broda seat, immediate measure hip protectors and wheelchair adjusted by in-house PT were appropriate. It revealed no additional interventions were recommended. Review of R28's Falls Management Team Review revealed the resident was observed sitting upright between her wheelchair and bed on 03/16/22. The Falls management team determined current safety interventions of wearing daily hip protectors, self-locking w/c brakes and Dycem in wheelchair/Broda seat to be appropriate. No additional interventions were recommended. Review of R28's Falls Management Team Review revealed on 05/29/22 the resident was observed on the floor. The Falls management team determined current safety interventions of wearing daily hip protectors, self-locking w/c brakes and Dycem in wheelchair/Broda seat to be appropriate. No additional interventions were recommended. Review of R28's Falls Management Team Review revealed on 06/15/22 the resident was observed on the floor. The Falls management team determined current safety interventions of wearing daily hip protectors, self locking w/c brakes and Dycem in wheelchair/Broda seat to be appropriate. No additional interventions were recommended. Review of R28's Falls Management Team Review revealed on 07/03/22 the resident was observed sitting upright on the floor, leaning her back against the bed. It was noted that she had a skin tear to right forearm and 2 scratches to the mid back. The Falls management team determined current safety interventions of wearing daily hip protectors, self-locking w/c brakes and Dycem in wheelchair/Broda seat to be appropriate. No additional interventions were recommended. Review of R28's Falls Management Team Review revealed on 10/01/22 the resident was observed on the floor next to bed. The Falls management team determined current safety interventions of wearing daily hip protectors, self-locking w/c brakes and Dycem in wheelchair/Broda seat to be appropriate. No additional interventions were recommended. Review of R28's Falls Management Team Review revealed on 10/09/22 the resident was observed on the floor. It was noted that she had sustained laceration on forehead with hematoma and on left cheek. The Falls management team determined current safety interventions of wearing daily hip protectors, self-locking w/c brakes and Dycem in wheelchair/Broda seat to be appropriate. No additional interventions were recommended. Review of R28's Falls Management Team Review revealed on 12/04/22 the resident was observed on the floor. The Falls management team determined current safety interventions of wearing daily hip protectors, self-locking w/c brakes and Dycem in wheelchair/Broda seat to be appropriate. No additional interventions were recommended. During an interview on 01/12/23 at 1:01 PM, Director of Nursing (DON) B stated, The resident likes to be in her room, so we have her room closest to the nursing station. If she needs help she'll call. She also stated, We will work with [R28's Name]. She has a tendency to transfer herself. The family knows. We work with the family; they know about it. Sometimes the daughter will tell us, 'You have to respect what my mom wants.' Our staff is always involved with [R28's Name] and her daughter. During an interview on 01/12/23 at 1:01 PM, Administrator A stated, We have weekly meetings with the falls committee about what happened and fall interventions. The Patient, Social Worker, Administrator, and POA (Power of Attorney) also attend. When Administrator A was asked if they have tried any new interventions since 2022. Administrator A stated, We can't do that (referencing maybe moving R28's bed in the room against the wall) because we have to be able to get around the bed and we have been coded for that, so it is no longer an intervention. When asked why she did not do anything new, the Administrator stated, We still thought that (repeated interventions) was the most appropriate for her. She has all the interventions. The administrator stated, We will not eliminate falls, she is her own person. This is where interventions come in like self-locking breaks. We have talked to her, and her daughter and they also input things for our team. I'm not sure of any other interventions available that we haven't tried. She has a restorative program . We have a strong restorative program here and she has been on it since she came. She is walked by staff a couple times a week. ROM (range of motion) on lower extremities and AROM (active range of motion) on arms.

Based on interviews, record review, and review of the facility's policy, the facility failed to develop and implement their policy for additional infection control precautions for unvaccinated staff. These failures had the potential to reduce efforts to mitigate COVID-19 transmission, consequently placing all staff and all current clients receiving care at this facility at risk of exposure to COVID-19. Findings include: Review of the CDC's COVID-19 Data Tracker website, accessed on 01/10/23 at https://covid.cdc.gov/covid-data-tracker/#datatracker-home, the facility's community transmission level was high. Review of the facility's policy titled COVID-19 Mandatory Vaccination Program, updated 06/2021 documented Employees that have been granted an exemption will adhere to additional precautions, such as source control, testing, NIOSH-approved N-95 masks, which are intended to mitigate the spread of COVID-19. These precautions may be modified in response to state and local COVID-19 positivity and transmission rates. During an interview and observation on 01/11/23 at 2:26 PM, Licensed Practical Nurse (LPN) F was observed wearing a surgical mask, not an N-95. LPN F stated, I have not been vaccinated. When the risk level is high, I'm supposed to wear an N-95. I don't know what the current risk level is. During an interview on 01/11/23 at 2:41 PM Medical Records (MR) G said she was not vaccinated and wore the N-95 because she was pregnant. MR G stated, I wear the N-95, I don't know what everyone else does. During an interview and observation on 01/11/23 at 3:26 PM, Registered Nurse (RN) I was observed wearing a surgical mask, not an N-95 mask. RN I said I am not vaccinated. For a while we were wearing N-95 but have been told its ok to wear the surgical masks. I think it's based on the number of cases. During an interview and observation on 01/12/23 at 9:30 AM, the Social Worker (SW) J was observed wearing surgical mask and not an N-95. SW J stated, I am not vaccinated. I wear a N-95 when I go to see some residents but for the majority of the day I wear this regular mask [surgical mask]. During an interview and observation on 01/12/23 9:30 AM, the Physical Therapy Aide (PTA) H was observed wearing a surgical mask, not an N-95. PTA H stated he was not vaccinated and stopped wearing N-95s a few months ago at the direction of the facility. During an interview on 01/12/23 at 10:39 AM Director of Nursing (DON) B stated, Unvaccinated employees were being tested and we were really strict, we were testing all the time and now because of changes we don't test. In the past unvaccinated employees were fit tested and all unvaccinated used to wear the N-95. The exempted people are now wearing a regular mask.

Based on observation, staff interviews, and record review the facility did not ensure food was stored in a safe and sanitary manner which had the potential to affect all 38 residents at the facility. Foods in refrigerators and coolers were not labeled and dated per food safe practices and/or were expired or beyond use-by dates. Findings include: On [DATE] at 9:45 AM, Surveyor began initial kitchen tour with DM (Dietary Manager)-C. During the tour, Surveyor and DM-C entered the cooler located in the kitchen. Surveyor observed food items within the cooler including: -6 bottles of [NAME] Choice yellow mustard, 2# 8oz size. Received date marked as [DATE] and best by date of [DATE]. -1 4# 4oz container of Fruit Blendz pear puree with a received dated of [DATE]. This container was approximately ,d+[DATE] full. The container had no opened date and a best by date of [DATE]. - 1 48 oz opened bag of matchstick carrots with an opened date of [DATE], and a best by date of [DATE]. -1 unsealed, opened bag in a cardboard container of Markon green onions. Received date was marked [DATE] with a best by date of [DATE]. The onion packaging contained no opened date. During the cooler review, DM-C indicated the food items, Should be dated when received and when opened, and indicated expired items and items past the best by date should have been thrown away. On [DATE] at 2:11 PM, Surveyor reviewed the refrigerator located in the main nursing station. DM-C indicated this refrigerator contained resident supplements, med pass items and nourishments. Surveyor observed the following items in the refrigerator: - 1 24 oz bottle of Dutch Chocolate flavored syrup dated [DATE]. -1 cream puff in a Styrofoam container with no dating. -A gallon size bag with 15 1 oz containers of sweet & sour sauce with no dating. -1 1.9 oz sealed container of Culver's raspberry vinaigrette dressing with a use by date of [DATE]. On [DATE] at 2:16 PM, Surveyor interviewed RN (Registered Nurse)-E. RN -E. indicated the chocolate syrup was used periodically for residents who liked chocolate. RN-E indicated the number of residents who received the chocolate syrup would vary every day. On [DATE] at 2:19 PM, Surveyor interviewed DM-C. DM-C indicated the date of [DATE] on the bottle of chocolate syrup was the date the facility received the syrup from the distributor. The printing on the bottle of syrup stated the syrup was good for 12 months however, the bottle contained no opened date and DM-C was unsure what the use by or discard date would be. The bottle contained no reference date to base the 12 months on. On [DATE] at 2:35 PM, Surveyor conducted a review of the activity refrigerator in the main dining room with AD (Activity Director)-D. The activity refrigerator was secured with locks. The activity refrigerator contained: -1 Opened container of [NAME] brand maraschino cherries with a best by date of [DATE] with no opened date. - 1 Bottle of red liquid with label removed that was ,d+[DATE] full. AD-D found the label in the refrigerator and stated the label had come off. The bottle had no dating. -5 cans of [NAME] beer with a best by date of [DATE]. -1 Dead bug in a refrigerator drawer. AD-D removed the bug. AD-D indicated that the items in the activity refrigerator were currently not used by residents. The Wisconsin State Food Code at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Commercially processed food open and hold cold .refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as Day 1 . On [DATE] at 3:15 PM, DM-C indicated the facility used the Wisconsin Food Code. Surveyor review of the infection control log revealed no recent GI (gastrointestinal) outbreaks. On [DATE] at 9:00 AM, Surveyor interviewed DM-C: DM-C indicated that food items were supposed to be dated when they were received from the distributor. Left-over food items were to be placed in a sealed container and dated with the date the item goes in the container. DM-C indicated that items including the sweet and sour sauce and Culvers dressing belonged to staff and were not supposed to be in the refrigerators with resident items.

Based on observation and staff interview, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 1 Resident (R) (R38) of 4 sampled residents during observations of cares. CNA (Certified Nursing Assistant)-C provided peri care for R38 and did not change gloves or sanitize hands according to standards of practice. Findings include: Facility's Handwashing/Hand hygiene Policy dated 8/2020 indicates: To prevent the spread of infections by performing hand washing/hand hygiene. 1. All personnel shall be trained and regularly in-services on the important of hand hygiene in preventing the transmission of healthcare- associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. 6. Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap and water for the following situations. h. Before moving from a contaminated body site to a clean body site during resident care. i, After contact with resident's intact skin j. After contact with blood or bodily fluids. R38 was admitted to facility on 1/23/20 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R38's MDS (Minimum Data Set) dated 4/8/20 indicates R38 requires extensive assist with bed mobility, transfers, hygiene and dressing. On 11/2/21 at 8:47 AM Surveyor observed CNA-F perform peri care to R38. Surveyor entered room, CNA-F had gloves on already and had basins set up on night side table. CNA-F raised bed with remote. CNA-F then began to remove hip abductors down to knees, then removed soiled brief partially. CNA-F then began cleansing scrotum area with clean wash cloth front to back. CNA-F then rinsed scrotum front to back then dried area. CNA-F assisted R38 to one side, then with same gloved hands cleansed buttocks area with clean cloth front to back. CNA-F then rinsed front to back then dried. CNA-F then removed soiled brief with same gloved hands and placed brief into garbage. With the same gloved hands CNA-F put on clean brief. CNA-F assisted R38 to back, pulled up hip abductors, and assisted R38 with putting on a clean pair of pants wearing same soiled gloves. CNA-F then removed socks and applied clean socks for R38 with the same gloved hands. CNA-F then picked up floor mat, set it aside, and put R38's shoes on with the same gloved hands. CNA-F assisted R38 up to edge of bed before transferring to chair without changing gloves. CNA-F applied gait belt around R38 and with the assistance of OT (Occupational Therapist)-G, transferred R38 to Broda Chair. CNA-F then removed R38's soiled T shirt and assisted with applying a clean shirt with the same gloved hands. CNA-F then assisted R38 to the bathroom. Without changing gloves or performing hand hygiene, CNA-F took R38's toothbrush, ran it under the water, and began touching toothbrush bristles with the same gloved hands. Surveyor stopped CNA-F from contining with cares. CNA-F removed gloves and washed hands. On 11/2/21 at 9:05 AM Surveyor interviewed CNA-F. CNA-F verified that CNA-F had not changed gloves one time throughout the entire morning care process of R38. When asked if CNA-F had been trained in hand hygiene during peri care, CNA-F said, Not here, but I guess I have. CNA-F also indicated that they had been a CNA for 2 years.

Based on interview and record review the facility did not ensure the physician was immediately consulted with and provided all relevant information for one 1 (R1) of 4 residents reviewed when R1 experienced a significant change in the resident's physical, mental or psychosocial status. * R1 had a fall with a head injury on 1/17/21. The facility contacted R1's physician via text message and waited 4 hours for a response. The facility did not inform the physician R1 experienced a change in mentation at the time of the fall. Three and a half hours after the fall R1 experienced increased head pain rating the pain as 9 out of 10 on a pain scale. R1's physician was not notified of the increased head pain following a head injury. R1 was receiving an anticoagulant medication at the time of the fall. R1's physician provided the facility with a text order to transfer R1 to the hospital 4 hours after the fall but the facility did not see the text until an hour later and R1 did not transfer to the hospital until 6 ½ hours after the fall. The fall resulted in a cerebral hematoma and admission to the hospital with subsequent transfer to a different long term care facility. R1 passed away on 2/3/21 with the death certificate indicating it was due to complications of a head injury with cerebral hematoma. The facility's failure to ensure nursing staff immediately consulted with a physician when a resident on a blood thinner sustained a fall with a head injury and ensuring nursing staff conveyed all relevant information regarding the resident to the physician in a timely manner prevented timely medical intervention, which could have allowed underlying conditions to worsen. This created a situation of immediate jeopardy. The Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on 5/19/21 at 3:46 pm. The immediate jeopardy began on 1/17/21 and was removed on 1/25/21. The deficient practice continues at scope/severity of an E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: The facility policy, entitled Change of Condition, undated, states: [The Facility] will promptly inform the resident, consult with the resident's physician and resident's legal representative when there is a change in condition. A change of condition includes the following definitions: An accident involving the resident that resulted in injury and has the potential for requiring physician intervention. Any change in the resident's baseline physical, mental, or psychosocial status. A need to alter treatment significantly such as to discontinue and existing forms of treatment or to commence a new form of treatment. A decision to transfer or discharge the resident from the facility. Process: 1. Recognition: Identify individuals at risk for change in condition. All residents are at risk for a change in condition. Residents who are newly admitted , have had previous complications, have started new medications or have had any recent changes are at a greater risk for a change in condition. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Initial Minimum Data Set Assessment (MDS), with an Assessment Reference Date (ARD) of 1/12/21, documents: highly impaired vision-object identification in question, but eyes appear to follow objects; Brief Interview of Mental Status (BIMS) assessment score of 15, indicating cognitively intact for daily decision making; Patient Health Questionnaire (PHQ-9) score of 3, indicating minimal depressive symptoms; extensive assistance of 2 staff for transfers, toilet use, extensive assist of 1 staff for bed mobility, locomotion off unit, dressing, personal hygiene, not steady and only able to stabilize with staff assist for moving from seated to standing position, moving on and off toilet, surface to surface transfer; functional limitations in range of motion on one side of lower extremities, frequently has pain. R1's Care Plan, dated 1/6/21, documents: Potential for falls. Interventions include: Nursing: Therapy assessment, transfers with assistance, review medications, instruct to call for help, keep personal items in reach, non-skid footwear, instruct to rise slowly, monitor for drug side effects, assure adequate pain management; Nursing Aide: Encourage to ask for assistance, call light in reach; assist with ambulating, transferring, toileting, toilet every 2 hours and as needed; keep personal items in reach, non-skid footwear, instruct to rise slowly; All staff: observe for/report all unsafe situation/conditions. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)], 5mg AM (morning) and HS, start: 1/16/21. Both [MEDICATION(S)] and [MEDICATION(S)] are anticoagulants (blood-thinning) medications that can reduce blood-clotting ability. R1's baseline care plan does not address R1's need for anticoagulant medication or the risks associated with it. (Cross-reference F655.) R1's Admission Assessment, dated 1/6/21, documents: Resident is always aware of need to use toilet; no behavior issues; vision is highly impaired-object identification in question, but eyes appear to follow; Resident is legally blind but when assessed was able to see writer but unable to say what color shirt writer was wearing; resident's decisions are consistent and reasonable.; transfer assistance-requires 2 aides assist to transfer and to provide weight bearing support during transfers, safety measures: call light kept in reach, non-skid shoes used; hearing is adequate; speech is clear with distinct and intelligible words, is understood by other, understands other, communicates with speech; resident's decisions are consistent and reasonable. R1's Fall Risk Assessment, dated 1/6/21, documents: Resident did not have a fall in the last month, did not have a fall in the last 2-6 months, did not have any fractures related to a fall in the last 6 months; no confusion, no depression, no altered elimination, no dizziness/[CONDITION(S)], no anticonvulsants, no benzodiazepines, total score of 3, indicating a low risk for falls. 1/10/21, at 9:24 AM, R1's medical record documents: Spoke with niece, this am and stated [R1] has not slept in a bed for a 'long time, sleeps in a recliner chair and would like to bring her chair from home in, instructed to call social services to arrange for same. On 5/18/21, at 3:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, who stated R1's family did want to bring in a recliner for R1 to sleep in but due to COVID quarantine the facility did not want any such items brought in from home. NHA-A stated the facility rooms are not furnished with recliners. However, the facility had donated recliners available and were able to provided R1 with a donated recliner. NHA-A stated she isn't certain where the donated recliner is currently but there are recliners in the lounge area. Surveyor toured the lounge area and located two electric lift recliners in the lounge area, one brown and one mauve. NHA-A stated it is possible one of those recliners were used by R1. On 1/16/21, at 8:00 AM, R1's medical record documents: [MEDICATION(S)], 60 mg.0.6ml solution, all 7 doses given. On 1/17/21, at 12:52 PM, R1's medical record documents: Alert and oriented to time, oriented to person, oriented to place, oriented to situation, forgetful. On 1/18/21, at 00:36 AM (12:36 AM), R1's medical record documents: Incident type: Fall, observed on the floor. Date of incident: 1/17/21. Time of incident: 23:40 (11:40 PM). Day of week: Sunday. Possible cause: found down. Observation at the time of incident: RN [RN-D] was notified by CNA (Certified Nursing Assistant) [CNA-E] that resident was on the floor. [RN-D] immediately responded and found resident laying on right side in front of her recliner, her back towards the heater. [R1] had a pillow under her head. Her call light was not engaged and the foot rest of her recliner was up. When asked what happened, [R1] replied I fell out of my bed. When asked if she needed to go to the bathroom [R1] replied no. [R1] was immediately assessed for injury and found a contusion to her Rt (right) forehead the size of a golf ball, and abrasion to her Rt knee and Rt arm was bruised as well as the left. [R1] was complaining of headache. Vitals were obtained. [R1] was hoyered from the floor into the wheelchair then transported to the bathroom for toileting. [R1] was bare feet. [R1] overhead light was on. After toileting, [R1] asked to go back to her recliner, vitals were obtained again, ice pack applied to her contusion and Tylenol given for 5/10 headache. Immediate interventions: gripper socks applied. Mental status: confused, alert, afraid. Neuro (neurological) checks: immediately after (legally blind, alert, pupils equal 2 mm (millimeter). First aid: immediately applied, ice pack and Tylenol. Vitals: BP (Blood Pressure): 153/66; P (Pulse): 75; R (Respirations): 20; T (Temperature): 96.2; Pulse Ox (Oxygen): 94. Injury: Bruising to Rt forehead, Rt knee small abrasion OTA (Open To Air), BUE (Bilateral Upper Extremity) bruises. Witnesses: none. Staff involved: nurse, CNA. Actions: place on 24-hour report, body check completed, continue to observe. Teaching Done: instruct resident to use call light. Family notification: Family notified, niece [nieces name] at midnight 1/18/21, Physician notified [Medical Director/Physician-F] at 23:58, 1/17/21. Administrator notification: Administrator/designee notified: 1/18/21 [former staff name] via VM (Voice Mail) 00:34 (12:34 AM) 1/18. On 1/18/21, at 00:17 (12:17 AM), R1's medical record documents: Acetaminophen 325 mg tablet given for pain/discomfort. 5 in headache. On 1/18/21, at 1:18 AM, R1's medical record documents: medication is effective pain level: 0. R1's Neurological Flow Sheet, following the fall on 1/17/21, documents: Vitals but does not document pupil reaction for the left and right pupil. The Neurological Flow Sheet documents: R1 is blind or the pupil reaction assessment area is left blank. It is important to assess vision or eye disturbance, such as unequal pupils, when a resident experiences a head injury. Eye disturbances can be an indication of a concussion or other brain injuries. The facility does not have a policy or procedure to complete neurological assessments on a resident that is legally blind or has significant visual limitations. On 1/18/21, RN-D's Statement of Witness, documents: At 2340 (11:40 PM) [RN-D] just walked into the nurse's station from the back hallway when CNA notified of resident on the floor. [RN-D] immediately responded and found resident laying on her Rt side, pillow under her head, feet towards her recliner, back against the heater, facing the door. [R1] was immediately assessed for injury when [RN-D] found a golf ball sized contusion to Rt forehead, Rt knee small abrasion, Rt elbow and upper arm bruised, bruising to Lt (left) arm noted as well. [R1] appeared confused, bare feet when I asked [R1] what happened [R1] stated I fell from my bed. [R1] was previously sitting on her recliner, when asked if she needed to urinate. [R1] replied no. [R1] had her room light on. [RN-D] obtained vitals and asked if [R1] was in pain, she replied yes, she has the beginning of a headache, speech was clear but she was confused per baseline. We hoyered her off the floor into a wheelchair then toileted her. Per [R1]'s request was placed back in her recliner. Ice pack given for forehead and Tylenol for headache. Vitals obtained per neuro sheet. Notified next of kin [next of kin name], notified doctor [MD-F] via text, left VM for DON (Director of Nursing). [R1] was assessed frequently, neuro exams and vitals, remained stable thus far. Pain meds effective, placed call light in reach, night light turned on, gripper socks applied. Educated to use call light for needs. On 1/18/21, at 4:22 AM, R1's medical record documents: RN-D completed Medicare Charting from an assessment completed at 0325 (3:25 AM). RN-D documents: R1 is on a scheduled pain medication regimen, receives PRN (as needed) pain medications and non-medication pain interventions of ice and elevate. Current pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 can make herself understood. R1 has occasionally had pain in the last 5 days. The pain has not made it hard to sleep at night or limited day to day activities in the last 5 days. Worst pain over last 5 days: 9 (on a scale of 0-10. Zero is no pain and 10 is the worst pain you can imagine). Rate the intensity of your worst pain over the last 5 days: Moderate Severe. Manner of expression of pain: verbal. Location of pain: forehead, Lt knee. Onset/duration of pain: recent fall. Description of pain: throbbing. Alleviating factors: Rest, [MEDICATION(S)] position changes. Exacerbating factors: Therapy, Ambulation. Plan: continue POC (Plan of Care). Surveyor unable to locate documentation R1's physician was notified of R1's increased head and knee pain documented after the fall. On 5/19/21, at 10:12 AM, Surveyor interviewed Medical Director/Physician (MD)-F, who stated he does prefer communication with the facility staff to occur via text message. MD-F stated he did receive a text from the facility in regards to R1 and a fall on 1/17/21 and he did respond several hours later. MD-F stated he instructed the facility to have R1 sent to the hospital. MD-F stated if facility staff do not receive a text response from him in a reasonable amount of time, MD-F would expect facility staff to call the answering service to get a hold of him. MD-F stated he would expect facility staff to wait only 10 minutes for a text response before they attempt to call him. MD-F stated he did receive a text message from the facility at 5:28 am stating R1's vitals were stable and neurological assessments were with in normal limits. Surveyor asked MD-F when R1 was assessed at 3:25 AM to have an increased headache and knee pain at a 9/10 level would he expect to be updated. MD-F stated he would expect to be informed of increased pain experienced by a resident following a fall with head injury and receiving anticoagulant mediation and would view that as a change of condition. MD-F stated he was not informed of this change in condition by the facility. MD-F stated when the facility texted him at 5:28 AM stating the R1 was stable and another text message at 5:59 AM stating the facility would be sending R1 out, MD-F believes the facility staff did not see MD-E's earlier text response sent at 3:38 AM requesting R1 be transferred out to the hospital until the facility responded via text to MD-F at 5:59 AM that they would be sending R1 to the hospital. MD-F stated he does not know why the facility staff did not attempt to reach him by phone when a text response was not received timely as these are his instructions to the facility staff. On 1/18/21, at 6:11 AM, R1's medical record documents: Transferred to: [Hospital Name] by ambulance s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/18/21, at 16:19 AM, R1's medical record documents: Call placed to [Hospital Name]. Report called to [staff name] ER (emergency room ) nurse at 0610 (6:10 AM). Family [family member's name] notified at 0615 (6:15 AM). Informed [family member's name] that resident will be sent to [hospital name] per MD advice. On 1/18/21, at 6:43 PM, R1's medical record documents: [Ambulance company name] arrived around 0635 (6:35 AM) to transport resident to [hospital name]. Left at 0643 (6:43 AM) via ambulance. On 1/18/21, at 11:46 AM, R1's medical record documents: Family notified [family member's name] notified of admit to [hospital name]. On 2/11/21, at 8: 11 AM, R1's medical record documents: Late Entry for 1/18/21 @ (at) 10:15 AM, Nurse at [hospital name] ER, status of [R1's name] following fall. Nurse stated she (R1) will be admitted with ? (questionable) cerebral hemorrhage. [Doctor's Name] @ 10:30 am and updated on admission dx. (Diagnoses). On 5/19/21, at 2:35 PM, Surveyor interviewed RN-D, who stated she was the night shift nurse on duty the night R1 fell from the recliner. RN-D stated she assessed R1 and texted MD-F to inform MD-F of R1's fall. RN-D stated she could not recall the time she texted MD-F to inform him of R1's fall or how long it took for MD-F to respond to the text. RN-D stated she usually just sends residents out to the hospital if there is a fall with injury and will text the doctor to notify them of the fall and that the resident being sent to the hospital. Surveyor reviewed with RN-D the timeframe of text messages between RN-D and MD-F with initial contact of RN-D to MD-F on 1/17/21 at 11:58 PM, MD-F responded on 1/18/21 at 3:58 AM with request to send R1 to the hospital. RN-D responded via text at 5:28 AM with information of R1 being stable and neuro checks within normal limits, no response from MD-F. RN-D texted MD-F again at 5:59 AM with information R1 was being sent out. RN-D stated she could not recall the events or timeline surrounding R1's fall but does recall R1 was sent to the hospital. RN-D stated if MD-F does not return a text in a short amount of time she knows to call MD-F with update on resident. RN-D stated she could not recall a reason she did not call MD-F when she did not receive a return text timely. RN-D stated she usually just sends residents to the hospital if they have a fall with injury and RN-D stated she must have been distracted by another emergency at the facility since there was a 4-hour delay in notification of MD-F of R1's fall and a 6 1/2-hour delay in sending R1 to the hospital for evaluation. RN-D stated she is responsible for many things on the night shift such a rounds, the updating of the 24 hour boards and all emergencies. Surveyor asked RN-D if she is responsible for Medicare Charting on the night shift. RN-D stated she was responsible for the Medicare Charting and she likes to see each resident before she does the Medicare charting. RN-D stated if the progress notes state she did Medicare Charting for R1 on 1/18/21 then she must have done it, RN-D stated she did not recall. RN-D stated she did not recall R1's orientation at the time of the fall. RN-D stated she knows she sent R1 to the hospital but she does not recall the timeframe and usually sends residents to the hospital after a fall with an injury so she cannot speak to the delay other than she must have been side tracked by another emergency. RN-D stated she does believe a resident with a fall, head injury, on an anticoagulant medication and had complaints of increased pain and change in orientation would be experiencing a change of condition and the physician should be notified. RN-D stated she does not know why she did not provide that information to MD-F other than she must have been side tracked. Surveyor asked why R1 did not go to the hospital until 6:43 AM on 1/18/21 when the fall occurred at 11:40 PM on 1/17/21. RN-D stated she does not know why there was a delay in sending R1 to the hospital, typically she sends residents out to the hospital after a fall with an injury but it does take time to get paperwork together and call the ambulance but cannot recall what caused the delay. RN-D stated all she could recall was that R1 was sent to the hospital. On 5/19/21, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-C of the concern for the delay in physician notification/consultation, and accurate assessment information not being provided to the physician related to R1's fall on 1/17/21. Surveyor informed NHA-A, DON-B and ADON-C of the concern RN-D did not attempt to contact MD-F via phone when a timely text response was not received from MD-F related to R1's fall with head injury and RN-D did not notify MD-F of R1's change of condition noted at 2:23 AM with increased head pain at a 9/10. As a result of the fall, R1 sustained a cerebral hematoma and was admitted to the hospital with subsequent transfer to a different long term care facility. R1 passed away on 2/3/21 with the death certificate indicating it was due to complications of a head injury with cerebral hematoma. According to Brain Bleed, Hemorrhage (Intracranial Hemorrhage), Any type of bleeding inside the skull or brain is a medical emergency. If you or a loved one have experienced a blow to the head or have symptoms that may indicate a brain bleed, call 911. It is important to get to a hospital emergency room immediately to determine the cause of the bleeding and to begin medical treatment .Prompt medical treatment can help limit damage to the brain, which will improve your chance of recovery .Bleeding (hemorrhage) may require immediate decompression of the brain to release pooled blood and relieve pressure. https://my.clevelandclinic.org/health/diseases/ -brain-bleed-hemorrhage-intracranial-hemorrhage Failure to immediately consult with the physician and to provide the physician with all pertinent information prevented timely emergency medical intervention. This created a finding of immediate jeopardy. The facility removed the jeopardy on 1/25/21 when it began implementing the following: 1. Starting on 1/18/21 the facility began to train all nursing supervisors responsible for notifying physicians in regards to resident change in condition. 2. The training was completed prior to any nursing supervisors next tour of duty and included notifying physician immediately if a resident had a fall with head trauma, even when there is no significant/obvious trauma and if the resident is on a blood thinner. 3. The nursing supervisors were instructed to contact the physician and send the resident to the emergency room for immediate evaluation. 4. The facility also trained the nursing supervisors if the physician does not respond to communication via text after 10 minutes then staff should contact the physician paging service to reach the physician or the covering physician but the resident should be sent to the emergency room immediately for evaluation.

Based on observation, record review and interview, the facility did not ensure that 1 (R1) of 4 residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents. Facility staff did not follow the facility's standard of practice and ensure that R1's Broda chair was locked prior to transferring R1, resulting in a fall with fracture for R1. Findings include: On [DATE], a complaint was called into the Southeastern Regional Office alleging that R1 had a fall that resulted in a fracture. The complaint also alleged that R1 expired as a result of the fall. R1 expired while at the facility under hospice care on [DATE]. R1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's Significant Change in Status MDS (Minimum Data Set) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 5, indicating that R1 is severely cognitively impaired. Section G (Functional Status) documents that R1 requires extensive assistance and two person physical assist for her bed mobility needs. Section G also documents that R1 has total dependence and requires a two person physical assist for her transfer needs. R1's Falls CAA (Care Area Assessment) dated [DATE] documents under the Falls Management Team Review Section, Resident remains alert with confusion and impaired memory, has recent fall-staff assisted. Remains total care with transfers, mobility, uses Broda chair with staff assistance. Under the Care Plan section it documents, Will develop care plan, continue current plan. R1's Falls care plan dated as initiated on [DATE] documents under the Problem section, Problem: Potential for falls. Under the Approach section it documents, Nurses- transfer with EZ lift. R1's Guidelines for Daily Care dated [DATE] documents, Transfers: To transfer I need- Total assist of 2; Special Instructions: EZ lift/HOYER; Sling- Lg (large). R1's nursing note dated [DATE] at 5:03 p.m. documents, DATE OF INCIDENT: [DATE]; TIME OF INCIDENT: 13:30; DAY OF WEEK: Monday; POSSIBLE CAUSE: Resident slid from Broda chair; L[NAME]ATION: Residents room [ROOM NUMBER]; OBSERVATIONS AT TIME OF INCIDENT: Called to room by CNA that resident was on the floor. Upon entering room, found resident sitting in L position on footrest of Broda chair. Resident resting back on leg rest of Broda chair. Informed by witnesses that resident had sling on but when raised up to transfer noted sling not on properly. Lowered resident back in Broda chair but chair not locked. CNA (Certified Nursing Assistant) assisted resident forward to reposition the sling and she slid down chair onto footrest of Broda chair. Sling still under her and buttocks on foot rest of Broda chair; INJURY: Resident able to move both upper extremities but limited d/t (due to) severe arthritis able to move elbows and wrist without pain. LLE (Left Lower Extremity), knee bends, contracted but no c/o (complaints of) pain in right hip and right knee. Obtained order to check x-ray; WITNESSES: Staff; STAFF INVOLVED: Staff; ACTIONS: Continue to observe X-ray ordered, placed on 24 hour report, body check completed; TEACHING DONE: To both staff members involved to check proper placement of sling, to make sure of Broda chair is properly locked when place and repositioning sling. R1's nursing note dated [DATE] at 7:34 p.m. documents, MENTAL STATE: Alerted, oriented, person, speech is normal. Very HOH (hard of hearing). Writer had to repeat the same question 5 times before she was able to answer. C/o (complains of) R (right) leg pain after sliding down from WC (wheelchair). Was not specific as to where R (right) leg it hurt her. Declined any pain medications when writer offered. Symphony Mobilex here at this time to obtain X-rays of R (right) knee and R(right)-hip. R1's nursing note dated [DATE] at 10:07 p.m. documents, SPOKE WITH: POA (power of attorney) who writer updated on residents tibia fx (fracture) and NOR (new order) to send her out to hospital for eval (evaluation) and tx (treatment) of tibia fx. R1's Radiology Report from MobilexUSA dated [DATE] documents, KNEE AP (anterioposterior) OR LAT(Lateral) ,[DATE]V, RIGHT: Results: No dislocation or destructive bony process. Severe vascular calcifications. Moderate [MEDICAL CONDITION] changes. Acute [MEDICATION NAME] fracture through the proximal tibia. Mild diffuse anterior knee and soft tissue swelling on the lateral view; Conclusion: Acute [MEDICATION NAME] fracture through the proximal tibia. R1's Emergency Department Discharge Summary dated [DATE] documents under the ED (Emergency Department) notes section, Pt (patient) arrives from hales corners care center with CC (chief complaint) of right tibial fracture following a fall out of her wheel chair around 1400 (2 PM) today. Under the ED [DIAGNOSES REDACTED]. R1's Incident Report dated [DATE] documents, Date: [DATE] Time:13:30; Description of Events: L[NAME]ATION: Residents room [ROOM NUMBER]; IMMEDIATE INTERVENTIONS: Check for any injuries, transfer off floor with hoyer lift. ACTIVITY AT THE TIME: Transferring; EQUIPMENT INVOLVED: Hoyer lift, Broda chair, sling POSSIBLE CAUSE: Resident slid form Broda chair; NEED FOR RE-EDUCATION OF RESIDENT: Yes therapy to reeducate both staff members involved with sling placement and transfer with hoyer lift. R1's Incident Report dated [DATE] includes a statement from PTA (Physical Therapy Assistant)-C which documents, Approximately 1:45 PM, I was walking down the hall towards another patient's room and was asked to assist with a mechanical lift transfer for (name of R1). After assisting previous pt., I went to (R1's) room to assist the CNA (Certified Nursing Assistant) with the transfer. Sling was in place, but upon initial lifting (with me positioned behind the pt. (patient)) it was determined that the sling needed to be repositioned before the transfer should occur. Once the pt. was back in the chair, the CNA moved the lift forward and got in front of the pt to reposition the sling. With the brake nearest he locked and the opposite brake unlocked, the chair slid back as the pt. was lowered to the floor. I asked the CNA to bring a nurse in at this time, which was one for further evaluation. R1's Incident Report dated [DATE] includes a statement from CNA-D which documents, I was lifting her (R1) up and under her good due to the fact that once you remove it from under her it's very hard to put back under her cause she is on the heavy side so I was lowering back down and she slid to the floor another staff member was with me (PTA-C). On [DATE] at 1:09 p.m., Surveyor interviewed R1's family member regarding R1's fall. Surveyor asked Family Member-H if R1 had experienced a decline due to R1's fall on [DATE]. Family Member-H informed Surveyor that when R1 was in the emergency roiagnom on ,[DATE], he was told that due to R1's age, R1 would not have surgery to repair the fracture and that subsequently R1 was referred to hospice care. Family Member-H informed Surveyor that he was also informed by Milwaukee County Coroner-F that the reason for R1's death as documented on R1's death certificate, was complications of a tibia fracture which R1 obtained when she fell on [DATE]. On [DATE] at 2:54 p.m., Surveyor interviewed PTA-C regarding R1's fall on [DATE]. Surveyor asked PTA-C to confirm his above statement and asked if R1's Broda chair was locked when he transferred R1 with CNA-D on [DATE]. PTA-C confirmed his above statement and informed Surveyor that R1's Broda chair was not locked on one side which caused R1 to slide forward and fall onto the Broda chair leg platform. Surveyor asked PTA-C if he had formal training in the use of an EZ lift prior to transferring R1 on [DATE]. PTA-C informed Surveyor that he did have formal training in the use of an EZ lift prior to transferring R1 on [DATE]. According to the Broda Seating Operation Instruction: 1.7 Total Lock Wheel Brakes Danger of Falling The special casters found on the BRODA chair have total lock brakes which prevent the wheels from turning and swiveling. The brakes must always be applied when: 1) the chair is not in use; 2) a resident is being transferred (moved) into or out of the chair; and, 3) the chair is not being moved by a caregiver. It is important to note that if the wheel locks are applied while the patient is in the chair, that the caregiver does not leave the patient unattended, especially those patients who have the capability or tendency to move the chair and/or those who may be agitated. This could cause harm to the patient if they attempt to move the chair while the wheel locks are applied. Note that removing and attaching the footrest may be easier for the caregiver with the brakes applied Failure to follow these instructions will unnecessarily increase the risk of serious falls by residents, caregivers, or third parties caused by the chair unintentionally moving. On [DATE] at 3:19 p.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if facility staff should ensure that bed/wheelchair/Broda chair legs are locked when residents are transferred to and from one surface to another. DON-B informed Surveyor that it is the facility's standard of practice that staff should ensure that bed/wheelchair/Broda chair legs are locked when residents are transferred to and from one surface to another. On [DATE] at 9:55 a.m., Surveyor interviewed Rehabilitation Director-E regarding EZ lift transfer training for PTA-C. Surveyor asked Rehabilitation Director-E if PTA-C had received EZ lift transfer training prior to R1's fall on [DATE]. Rehabilitation Director-E confirmed to Surveyor that PTA-C had received EZ lift transfer training prior to R1's fall on [DATE]. On [DATE] at 11:48 a.m., Surveyor interviewed Milwaukee County Coroner-F regarding R1's listed cause of death as listed on R1's death certificate. Surveyor asked Milwaukee County Coroner-F what was R1's documented cause of death as listed on R1's death certificate. Milwaukee County Coroner-F informed Surveyor that R1's cause of death was documented as complications of fracture of R1's tibia and [MEDICAL CONDITION]. Milwaukee County Coroner-F informed Surveyor that this was listed as a cause of R1's death because R1 had experienced a fall with fracture on [DATE] that ultimately caused R1 to become hospice care. Milwaukee County Coroner-F informed Surveyor that he came to this conclusion after performing a medical record review that included hospital records and after the Milwaukee County Coroner's office had spoken with Hospice RN (Registered Nurse)-G. No additional information was provided by Milwaukee Coroner-F. On [DATE] at 12:39 p.m., Surveyor spoke with Family Member-H and asked why R1 was initiated into hospice care on [DATE]. Family Member-H informed Surveyor that R1 was initiated into hospice care on [DATE] because of a decline in her condition due to R1's fall with fracture on [DATE]. Family Member-H informed Surveyor that after being told at the hospital that R1 could not have surgery due to her age and condition, there was no choice for R1's family but to put R1 into hospice care. On [DATE] at 1:02 p.m., Surveyor asked Rehabilitation Director-E if the facility had trained all therapy staff regarding the use of an EZ lift and ensuring that wheelchair/bed/Broda chair legs are locked when residents are transferred to and from one surface to another after R1's fall on [DATE]. Rehabilitation Director-E informed Surveyor that the facility had not. Rehabilitation Director-E informed Surveyor that only PTA-E received education and training regarding the use of an EZ lift and ensuring that wheelchair/bed/Broda chair legs were locked when residents are transferred to and from one surface to another. On [DATE] at 1:09 p.m., Surveyor asked DON-B if the facility had trained all nursing staff regarding the use of an EZ lift and ensuring that wheelchair/bed/Broda chair legs are locked when residents are transferred to and from one surface to another after R1's fall on [DATE]. DON-B informed Surveyor that the facility had trained all nursing staff after R1's fall on [DATE]. On [DATE] at 1:20 p.m., Surveyor interviewed Hospice RN (Registered Nurse)-G regarding R1's cause of death. Surveyor asked Hospice RN-G if the Milwaukee County Coroner's office had spoken with her (Hospice RN-G) regarding the cause of R1's death. Hospice RN-G informed Surveyor that the Milwaukee County Coroner's office had spoken with her regarding R1's death and that she (Hospice RN-G) had informed the Milwaukee County Coroner's office that R1 had experienced a fall with fracture that immediately precipitated her admission into hospice care. Hospice RN-G informed Surveyor that while R1 had an admission [DIAGNOSES REDACTED]. No additional information was provided as to why facility staff did not follow the facility's standard of practice and ensure that R1's Broda chair was locked prior to transferring R1, resulting in a fall with fracture for R1.

Based on observation, interview and record review the facility failed to follow proper food handling/serving practices in accordance with professional standards of practice to prevent the outbreak of foodborne illness for 5 (R211, R312, R220, R318, and R215) of 5 residents who were observed eating over-easy eggs; these residents received non-pasteurized eggs with runny yolks that were not set and completely firm. The facility's practice of cooking and serving non-pasteurized eggs that were not fully cooked and set created a finding of Immediate Jeopardy beginning 9/17/18. Administrator-A was informed of the Immediate Jeopardy on 9/17/18 at 2:25 pm. The Immediate Jeopardy was removed on 9/17/18, however the deficient practice continues at a scope/severity of F (potential for harm/widespread) as evidenced by facility staff observed washing dishes without proper sanitation and staff observed filling up water pitchers with water from the handwashing sink. This deficient practice has the potential to affect all 58 residents who reside at the facility who receive their meals from the main kitchen. Findings include: According to the (YEAR) FDA Food Code: 3-302.13 Pasteurized Eggs, Substitute for Raw Shell Eggs for Certain Recipes. Raw or undercooked eggs that are used in certain dressings or sauces are particularly hazardous because the virulent organism Salmonella Enteritidis may be present in raw shell eggs. Pasteurized eggs provide an egg product that is free of pathogens and is a ready-to-eat food. The pasteurized product should be substituted in a recipe that requires raw or undercooked eggs. Highly susceptible population means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining FOOD at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center. 3-801.11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION: (B) Pasteurized EGGS or EGG PRODUCTS shall be substituted for raw EGGS in the preparation of . (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from EGGS, and meringue; On 9/17/18 at 8:49 AM during the initial tour of the kitchen with Food Service Director-B the surveyor observed shelled eggs in an ice bath on the counter in the food preparation area of the kitchen. The surveyor observed that there was no P mark on the eggs, which would indicate the eggs were pasteurized. Food Service Director-B informed the surveyor the facility only buys pasteurized eggs and sometimes the P comes off in the water of the ice bath. Food Service Director-B confirmed the shelled eggs were raw. The surveyor observed the cooler with Food Service Director-B. The surveyor observed shelled eggs in the cooler on grey crates. The surveyor observed no P's marked on the shelled eggs to indicate they were pasteurized. The surveyor observed no indication on the grey crates the eggs were on indicating they were pasteurized. The surveyor observed the date 9/3 written in black marker on the grey crates. The surveyor asked Food Service Director-B if the facility uses pasteurized eggs. Food Service Director-B stated yes. The surveyor informed Food Service Director-B she was unable to find a P marking indicating the eggs were pasteurized. Food Service Director-B checked the eggs and was also unable to find an indication that the eggs were pasteurized. Food Service Director-B stated the facility always uses pasteurized eggs and that she was unsure what happened but she would look into it. Food Service Director-B stated unless they subbed them out on me and didn't tell me. Food Service Director-B confirmed the eggs observed are the only eggs that the facility was currently using. The surveyor proceeded back to the food preparation area and observed at least 10 egg shells cracked open with no P mark visible. On 9/17/18 at 9:08 AM the surveyor observed R211 and R215 eating over easy eggs with a runny yolk. On 9/17/18 at 9:14 AM the surveyor observed R318 and R220 eating over easy eggs with runny yolks. On 9/17/18 at 9:19 AM the surveyor observed R312 eating over easy eggs with runny yolks. On 9/17/18 at 9:32 AM the surveyor interviewed Dietary Aide-C. Dietary Aide-C confirmed she usually makes breakfast for residents and was making breakfast today. The surveyor asked Dietary Aide-C if she was ever trained to do anything special related to egg safety. Dietary Aide-C states she was not shown how to properly, but knows the eggs needed to be on ice. The surveyor asked if she was ever trained to check to see if eggs are pasteurized. Dietary Aide-C states she was never told to see if they are pasteurized. On 9/17/18 at 09:36 AM the surveyor informed Administrator-A of the concern that eggs were being used to provide over easy eggs to residents that did not have indications that they were pasteurized. Administrator-A informed the kitchen to stop using the eggs at that time. On 9/17/18 at 9:44 AM the surveyor interviewed Food Service Director-B. The surveyor asked if somebody checks egg orders when they come in to ensure they are pasteurized. Food Service Director-B stated they should be. On 9/17/18 at 10:56 AM Food Service Director-B provided the surveyor with the order details for Gordon Food Service with a submission date of 8/30/18 and a delivery date of 9/3/18. The surveyor noted an order for [REDACTED]. On 9/17/18 at 12:28 PM the surveyor interviewed Cook-D. Cook-D confirmed that she checks food orders in when they arrive. Cook-D stated she checks the orders to make sure they get the right thing. The surveyor asked Cook-D if she checks the eggs to make sure they are pasteurized. Cook-D stated I will be honest with you, no I do not. On 9/17/18 at 12:46 PM the surveyor interview GFS (Gordon Food Service) Employee-E. GFS Employee-E confirmed that the pasteurized eggs should have a mark on them indicating they are pasteurized. GFS Employee-E stated it should also state it on the box. GFS Employee-E confirmed the facility did order pasteurized eggs, but informed the surveyor it was possible that the driver may have delivered the wrong box. On 9/17/18 at 1:15 PM the surveyor interviewed Administrator-A. The surveyor asked if the facility has a policy and procedure related to undercooked eggs/use of pasteurized eggs. Administrator-A informed the surveyor it is the facility's practice to always use pasteurized eggs. Administrator-A stated she was not sure if it was written in policy, but that it is the procedure the facility follows. The serving of unpasteurized eggs that were not fully cooked created the potential that residents could contact Salmonella. This created a finding of Immediate Jeopardy. Administrator-A was made aware of the finding of Immediate Jeopardy on 9/17/18 at 2:25 PM. The Immediate Jeopardy was removed on 9/17/18 when the facility began implementing the following: * When the use of unpasteurized eggs for breakfast orders was brought to the attention of the Administrator, kitchen staff were directed to stop using the eggs for made-to-order breakfast. *Dietary Manager confirmed that the order had been placed with GFS for pasteurized eggs. She contacted GFS to make them aware of the error *Education was provided to the kitchen staff regarding the proper use of pasteurized and unpasteurized eggs, how to identify the difference, and direction to only use pasteurized eggs (marked with a P) when making breakfast eggs to the residents choice. *Dietary Manager reviewed the procedure for checking in stock with the cook, assuring that what gets delivered is actually what was ordered. *Education will provided to additional kitchen staff depending on their schedule. In addition, all kitchen staff will be provided with written instruction on the use of pasteurized eggs. The scope and severity of the deficient practice continues at a scope and severity of an F (potential for harm/widespread) related to the following examples. DISHWASHING SANITATION The facility's DISHWASHING PR[NAME]EDURES FOR DISHMACHINE policy and procedure, updated 3/23/11, with a purpose of To ensure that all utensils, pots and pans, dishes, and eating utensils are properly washed and sanitized states 8. Hales Corners Care Center utilizes a low temp, chemically sanitized dishmachine .10. PPM (Parts per Million) of the sanitizer, using the Precision Chlorine Test Paper Strips, must be recorded in the morning, afternoon, and evening on the Dishwasher Temperature and Sanitizer Log. Test strips are located in the smoke box in dishwashing area. A. After first rack of dishes are completed, open door of dishmachine, holding test strip, immediately put strip to side of test strip vial and record the PPM. Testing must be done after the first rack, midway through dishwashing, and after last rack of dishes to insure proper sanitization of the dishes. B. Proper sanitization is 50-100 PPM. If PPM is higher alert the Food Service Director, Maintenance, or Cook in charge .C. If PPM is under 50 PPM, dishwashing process must be stopped until a dishmachine repair Person has fixed the problem. On 9/19/18 at 9:19 AM the surveyor observed Dietary Aide-F running dishes through the dishwasher machine. On 9/19/18 at 9:27 AM the surveyor observed Dietary Aide-F was continuing to wash dishes. The surveyor observed dishes, including pitchers and pans, on a rack drying on the clean side of the dishwasher. The surveyor interviewed Dietary Aide-F. Dietary Aide-F stated she usually washes dishes in the evening. Dietary Aide-F was unable to describe the process for checking dishwasher sanitation functioning to the surveyor. Dietary Aide-F stated the machine was already started before her coming on shift. The surveyor then asked Food Service Director-B to show her the process for ensuring dishes are being sanitized. Food Service Director-B ran a load of dishes including pans and a plate through the machine. Food Service Director-B tested the water on the dishes after the machine had cycled through. The surveyor observed the indicator strip Food Service Director-B used remained white, indicating the chemical concentration level was below 50 pm. Food Service Director-B ran the dishes through a second time, and rechecked the water on the dishes after going through the machine. The surveyor noted the indicator strip Food Service Director-B used remained white. Food Service Director-B informed Dietary Aide-F to stop doing dishes, and the dishes that had already been done would have to be redone. Food Service Director-B stated she would have to call maintenance to check the machine. On 9/19/18 at 9:52 AM Food Service Director-B informed the surveyor that the dishwasher was now working. The surveyor observed Food Service Director-B take the indicator strip and dip it into the water inside the dishwasher. The surveyor observed the strip turn purple. The surveyor asked Food Service Director-B if she could run a strip through the cycle. Food Service Director-B ran an indicator strip through a dishwashing cycle. The surveyor observed the indicator strip remained white after going through a dishwashing cycle. The surveyor reviewed the DISHWASHER TEMPERATURE and SANITIZING LOG and noted that 9/19/18 was blank with no temperatures or chemical ppm documented. The surveyor asked Food Service Director-B who checked the dishwasher machine this morning. Food Service Director-B stated Dietary Aide-F is not the usual dishwasher and did not know that she was supposed to be checking (that the dishwasher is sanitizing properly) in the morning. Food Service Director-B stated Dietary Aide-F usually washes dishes in the evening and knows that she is supposed to check then. On 9/20/18 at 8:41 AM the surveyor interviewed Maintenance Director-G. Maintenance Director-G informed the surveyor the rinse arm on the dishwasher machine was in disrepair. Maintenance Director-G informed the surveyor a pug was missing on the rinse arm, causing it to not build pressure. Maintenance Director-G stated sanitizer was still going through the machine, it just wasn't going to the upper arm, only the lower arm. HANDWASHING SINK According to the (YEAR) FDA Food Code: 5-205.11 Using a Handwashing Sink. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. (B) A HANDWASHING SINK may not be used for purposes other than handwashing. On 9/17/18 at 12:25 PM the surveyor observed Dietary Aide-H and another staff filling up pitchers with ice in them with water from the sink designated for handwashing. The surveyor noted the sink also had an eye rinse function. The surveyor observed the pitchers were placed on the cart with other liquids for lunch service. On 9/20/18 at 10:12 AM the surveyor interviewed Food Service Director-B. The surveyor asked Food Service Director-B if staff should use the handwashing sink for filling water pitchers. Food Service Director-B stated it is clean water coming out, and that they have never had a problem with it. Food Service Director-B informed the surveyor the facility utilized the FDA food code for their standards of practice. The surveyor informed Food Service Director-B of the FDA Food Code stating the handwashing sink may not be used for purposes other than handwashing.

Based on record review, observations and staff interviews, the facility did not always ensure that based on a resident's comprehensive assessment that 1 out of 5 residents ( #5), who were at nutritional risk, maintained acceptable nutritional parameters, including body weight. Resident #5 experienced a significant weight loss of 13.9 % over 5 months, and the facility did not comprehensively re-assess Resident #5's weight loss, update the plan of care, and evaluate additional interventions to aid in weight gain, monitor weight weekly as directed in facility policies and procedures, or maintain appropriate nutritional parameters. Findings include; On 3/15/11, Surveyor # initiated a medical record review of Resident #5. It was noted that Resident #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility completed the " Nutrition Risk Assessment" on 1/11/11, indicating that Resident #5 is at high risk. The Dietary assessment note stated that Resident #5 has had a 7.9 % weight loss in the past 3 months due to his overall decline, dementia and inadequate oral intake. Present weight is 187 pounds, on admission he weighed 208 pounds. Resident #5 is at high risk due to an increased BMI ( body mass index), weight loss, decreased food/fluid intake, medication, diagnosis, total assist at meals and labs. Resident # 5 is currently receiving 4 ounces of Kemps three times a day and consuming 75- 100 % and other times refuses. Will recommend protein powder three times a day with meals, will continue to provide nutrient dense foods for increased calories, will monitor weekly weights. The most recent updated plan of care, dated 1/12/11 states that Resident #5 has an alteration in nutrition, related to [DIAGNOSES REDACTED]. Listed approaches included to monitor food intake, give 4 ounces of Kemps plus three times a day with meds for increased calories and protein and vitamin D3 as a supplement, record food intake, provide ordered diet and provide 1 scoop of protein powder in foods at all meals for increased protein. A review of the weights in the medical record for Resident # 5 were the following: 10/29/10 - 204 #'s 11/10/10 - 196#'s 12/8/10 - 195 #'s 1/7/10 ( re-admission weight) 187#'s 2/10/10 179 #'s Dietary progress note, dated 2/8/11 states that Resident #5 is receiving increased protein with Kemp's Plus 4 ounces threes times a day and 1 scoop of protein powder 3 times a day with meals. He is declining overall and at times refusing the 4 ounces of Kemp's. Would recommend increasing the supplement, but discussed with nursing and was not recommenced due to the frequent refusals. He continues to lose weight and has had a severe weight loss of 13.9 % in the past five months. Will monitor skin assessments. Quality of life progress note dates 2/16/11 states that that Resident #5 was discussed in the Dining CQI meeting on 2/11/11. Resident #5's February weight is 179 pounds. He has had a weight loss of 4.3 % over the past month. This is due to decreased intake at meals and overall decline in condition. He continues on a mechanical soft diet and is tolerating this well. He is eating an average of 62 % at meals which is a slight increase over the past month. He is receiving 1 scoop of protein powder for increased protein with all 3 meals . Resident # 5 is also receiving 4 ounces of Kemps plus three times a day with meds for increased calories. Will continue to monitor. On 3/16/11, Surveyor # conducted a review of the facility's " Weight Policy",no date noted. The policy states that resident's weight will remain stable within 3% of usual weight to be reviewed/ adjusted at least annually. Procedures included: * Residents showing a significant weight loss will be referred to nursing supervisor who will update the physician. * Residents with a significant weight loss will be weighed weekly for one month and will be recorded in the clinical record. * A weight loss or gain of 5% in a 30 day period or 7.5 % in a 3 month period or 10% in a 6 month period is to be documented in the Quality of Life Notes and on resident's care plan. * The nursing supervisor will be notified of significant weight change and update the resident's physician. Based upon further review of the medical record, there was not evidence that Resident #5's primary physician was notified, after dietary had assessed Resident #5, noticing the significant weight loss of 7.9 % in 3 months on 1/11/11 and then also that there was a 13.9 % weight loss over 5 months according to the notes on 2/8/11. It was also noted that the plan of care was not updated to reflect the significant weight loss that Resident #5 was was experiencing and what interventions had been put in place to help maintain or gain the weight to bring him back to his usual body weight. Further record review, did not provide evidence that Resident #5 was being weighed weekly, per policy and dietary recommendation. It was noted that the only weights within the clinical record were on 10/29/10, 11/10/11, 12/8/10, 1/7/11 and 2/10/11. There were no weekly weights on 2/17/11, 2/24/11, 3/1/11, 3/8/11, or 3/15/11. Surveyor # conducted a review of the supplement intake totals, which was documented on the Medication Administration record for Resident #5. It was noted that from 2/8/11 to 2/28/11, Resident #5 had either refused or drank 50 % or less of the Kemps supplement 22 times. It was noted that from 3/1/11 to 3/14/11, that Resident #5 had refused or drank 50 % or less of the Kemps supplement 15 times. On 3/15/11 at 8:00 a.m., Surveyor # made observations of Resident #5 in the dining room for the breakfast meal. At this time,Resident #5 was being assisted to eat by a staff member and the nurse came over and administered Resident #5's medications, and provided Resident #5 with the 4 ounces of Kemps plus, which he drank 100%. On 3/15/11 at 2:30 p.m., Surveyor # interviewed Registered Dietician ( RD) - N in regards to Resident #5 losing weight. RD- N was asked by surveyor #1 if she had notified the physician that Resident #5 had lost a significant amount of weight. RD- N stated that she is not aware of the physician being notified of the weight loss, and that she personally did not contact the physician. RD- N stated that it would be nursing's responsibility to notify the physician after she gives them the information in their weekly meeting. RD- N stated that if someone's weight loss was in question, they would be put on the weekly weight list, which is nursing's responsibility to conduct the weights. RD- N also stated Resident #5 had lost a significant amount of weight and the goal would be to not have him lose anymore weight. RD- N stated that when she reviewed Resident #5's lab work, it was noted his protein levels were low, so they added to protein powder. RD- N was able to verify that the last laboratory values were from January, 2011. RD- N was asked about the updating of the care plan for Resident #5. RD- N stated that she in not involved in the care plan and that would be the Dietary Manager and Nursing's responsibility to update the plan of care. RD- N stated that she had been giving Resident #5 the Kemps plus- 4 ounces three times a day. RD- N stated this is not to be given with meals, it is a supplement with med pass, not with any meals to ensure better intake of the supplement. RD- N stated that she is aware that Resident #5 had refused the supplement on several occasions, and that it was a behavioral issued with him, that Resident #5 would sometimes accept it or not, and this is why she did not increase the amount. RD- N was able to verify that no additional interventions were put into place for Resident #5's weight loss. On 3/15/11 at 3:30 p.m., Surveyor # interviewed the Director of Nursing regarding the physician not being notified of Resident #5's significant weight loss. At this time, The DON, was unable to provide any additional evidence that the physician had been notified. On 3/16/11 at 8:58 a.m., Surveyor # interviewed RD- N via the telephone. A this time, RD-N was able to verify that she could not provide Surveyor # with the weekly weights for Resident #5 because they had not been done. On 3/17/11 at 10:45 a.m., Surveyor # interviewed the Director of Nursing in regards to Resident #'5's significant weight loss. The DON stated that she had no additional information as to why the plan of care was not updated to reflect the significant weight loss and why new interventions had not been added to the plan of care, even after it was noted that Resident #5 was not always accepting of the supplement. The DON, at this time was not able to provide any additional information as to why the nursing staff did not conduct the weekly weights, as per the weight policy and recommendation from the Dietician.

Based on observation, interviews and record reviews facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well being for 1 (Resident #1) of 13 sampled residents. Resident #1 was observed 3/14-3/16/11 exhibiting pain during cares, repositioning, transfers and treatments. Facility staff did not adequately assess Resident #1's pain, consult with Hospice and the physician and update the plan of care to help alleviate pain. Findings include; On 3/14/11 at 8:30 PM Surveyor # observed Resident #1 in bed. Resident #1 told Surveyor # that she was not comfortable. CNA (Certified Nursing Assistant) G and MT (Med Tech) J assisted in repositioning Resident #1. Resident #1 told CNA G and MT J that her bottom hurt. When Resident #1 was boosted up in bed she indicated that it wasn't too bad and when right leg was positioned she called out in pain. CNA G told Surveyor # that since Resident #1 had an open area they were complaining of pain and being uncomfortable so Resident #1 is repositioned more often. On 3/14/11 at 9:25 PM Surveyor # observed Resident #1's pressure ulcer treatment being completed by MT J and RN (Registered Nurse) I. RN I asked Resident #1 if she was having any pain. Resident #1 answered no. MT J did not inform RN I of Resident #1's indicators of pain she observed at 8:30 PM. Surveyor # observed Resident #1 doing facial grimacing during any movement throughout the treatment. When MT J and RN I boosted and placed a pillow behind Resident #1's head she asked them to wait a minute and stated "oh, oh ", "no more", "I can't stand this" and my "hinder hurts." Resident #1 stated she was comfortable when asked by RN I after the treatment was completed. At 9:38 PM RN I told Surveyor # that Resident #1 will sometimes complain of pain and can rate pain using the number scale ( 1-10 with 10 being the worst pain) at times but not always. RN I stated Resident #1 was lethargic in the past with routine pain medication and is not sure what Resident #1 is taking now. At 9:45 PM Resident #1 was saying "oh, oh," sounding as if in pain. When Surveyor # asked Resident #1 if she had pain during the dressing change and repositioning they indicated "I don't think so." At 10:10 PM MT J administered 1/2 tablet of [MEDICATION NAME] 5/500 mg to Resident #1. MT J told Surveyor # that she does not think that Resident #1 gets anything routinely for pain. On 3/15/11 at 7:25 AM Surveyor # observed CNA C and CNA D assist Resident #1 with toileting and placing in bed to lay down. CNA C assisted Resident #1 with the use of a EZ stand lift by placing right foot on the platform and placing strap across calf and sling around back and chest and placing loops on lift. CNA D entered room and assisted CNA C with the transfer. When Resident #1 was starting to be moved to a standing position with the lift when she asked CNA C and D to wait and indicated "no", "Oh", and "it hurts." When Resident #1 was in a full standing position the back/chest sling was tight and pulling under the arms and Resident #1 appeared to be hanging from the straps. Resident #1 was holding onto the bars appropriately. During the transfer to the toilet Resident #1 was grimacing and stating "help me" and "come on" and "oh my." Resident #1 complained of the toilet seat being cold and then stated she couldn't go to the bathroom and requested to be placed in bed. At 8:15 AM the EZ stand was moved to the bed and Resident #1 was lowered to a seated position on the bed. When CNA C and D pivoted her to lay down in bed Resident #1 stated that it hurt. When CNA C and D positioned Resident #1 on left side and placed a pillow behind her back and straightened her right leg Resident #1 asked them not to do that and stated "its killing me" and groaned. Resident #1 responded "a little bit" when CNA C asked if she was comfortable. At 8:22 AM Resident #1 started to have a bowel movement and CNA C and CNA D assisted Resident #1 on the bedpan. When placed on bed pan Resident #1 said "ouch" and "please, I can't." When taken off bed pan and boosted in bed Resident #1 stated "come on", back and forth, back and forth. Surveyor # observed Resident #1 grimacing during the entire time of the repositioning. CNA C told Surveyor # that Resident #1 usually complains when repositioned and that today is calmer than usual. CNA C did not inform the nurse of Resident #1's pain. On 3/15/11 at 8:30 AM LPN (Licensed Practical Nurse) Q told Surveyor # that Resident #1 received Tylenol Arthritis every morning for pain and that prn (as needed) [MEDICATION NAME] works. LPN Q states that Resident #1 has pain at times and it is helpful if she is put to bed off her bottom. LPN Q states that she feels Resident #1's pain is controlled from what she sees and that CNA's are good at telling her when Resident #1 has pain. LPN Q is not able to recall how often Resident #1 has been given as needed pain medication. On 3/15/11 at 9:00 AM Surveyor # reviewed Resident #1's medical record and noted the following: Resident #1 has [DIAGNOSES REDACTED]. Resident #1 has a recurring Stage 3 pressure ulcer to the coccyx that opened again on 2/26/10. Allergy list entry dated 10/28/05 indicates not to give Non-steroidal anti-[MEDICAL CONDITION] drugs because Resident #1 has a history of Gastro-Intestinal Bleeding. An entry dated 8/31/09 indicates to avoid narcotic pain medications. physician's orders [REDACTED]. An order dated 11/18/10 for [MEDICATION NAME] 50 mg every morning for wound pain. An order dated 2/28/11 for [MEDICATION NAME] 5/500 mg 1/2 tablet every 4 hours as needed for pain. Quarterly MDS (Minimum Data Set) dated 5/6/10 indicates Resident #1 has short term memory problems with some difficulty making decisions in new situations only and does not have pain. Change in condition MDS dated [DATE] indicates that Resident #1 has short and long term memory loss, with poor decision making skills and does not have pain. Quality of Life Progress Notes specific to Resident #1's pressure ulcer management dated 7/14/10 does not discuss the pain related to the pressure ulcer. Social Service Staffing note dated 7/27/10 indicates that Resident #1 had a change of condition staffing held on 7/23/10. The note indicates that Resident #1 requires more assistance with daily cares and is alert with increased confusion and forgetfulness. Memory is poor, is easily distracted and has loose train of thought with level of communication deteriorated. Resident #1's Health Care Power of Attorney was activated-due to Resident #1 being unable to make health care decisions. Pain was not addressed during this staffing note. The note does indicates that Resident #1 has an open area. Social Service note dated 8/6/10 indicates that Resident #1 was admitted to Hospice Care on 8/5/10. A Care plan dated 10/08/04 indicates a problem of potential for comfort, alteration: [MEDICAL CONDITION] and history of Carpal Tunnel Syndrome. Approaches dated 4/11/01 indicates to assess physical symptoms, monitor/record medications, document pain level, notify the MD as needed. Approaches for the CNA's include to encourage rest periods, position for comfort, offer diversion and report pain to the nurse. The goal was updated 8/14/09 and indicates that Resident #1 continues to have expressed feelings of comfort or of pain relief, with current [MEDICATION NAME] regiment. On 10/05/10 the care plan indicates that the problem of potential for comfort alteration was related to left above the knee amputation, non healing stage 3 pressure ulcer and to coccyx and neuropathic pain. No additional approaches were added to the plan of care. Quarterly MDS dated [DATE] indicates that Resident #1 has poor short and long term memory and says no when asked if had pain On 12/28/10 an approach was added to the potential for comfort alteration care plan that indicates to administer pain med's, Tylenol arthritis, [MEDICATION NAME], Tylenol Extra Strength and prn Tylenol 1000 mg. The care pan does not contain additional non-medication interventions or how Resident #1 exhibits pain and when to use the prn medications. A Staffing note dated 12/30/10 indicates that Resident #1 remains alert and oriented with periods of forgetfulness. It indicates that Resident #1 continues to have an open wound on buttocks and takes [MEDICATION NAME] for pain. No further assessment of pain is noted. On 3/15/11 at 3:30 PM Surveyor # reviewed The wound evaluation flow sheets used for weekly measurements and treatments. The wound bed section under pain indicates the following: 8/11/10-12/15/10-indicates pain as "yes" with weekly measurements 12/22/10 indicates: tender 12/29/10-3/9/11-indicates pain as "yes" with weekly measurements The weekly wound evaluation flow sheets also indicates that 11/17/10 the treatment was changed and included [MEDICATION NAME] to be applied around the wound area 5 minutes prior to wound care to help alleviate pain during the treatment. [MEDICATION NAME] was not applied to the surrounding area of the wound on 3/14/11 when Surveyor # observed wound care for Resident #1. On 3/15/11 at 4:35 PM Surveyor # interviewed MT J regarding not using the [MEDICATION NAME] prior to the dressing change observed on 3/14/11. MT J stated that it was not on but should have come up with the treatment order. On 3/4/11 when the treatment order was changed the [MEDICATION NAME] was put on the MAR (medication administration records) as a prn treatment instead of with each treatment. It is now included with the treatment order. MT J showed Surveyor # the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The January MAR indicated [REDACTED]. No indication of type of pain or if pain medication was effective. The February MAR indicated [REDACTED]. The March MAR indicated [REDACTED]. Review of the Nurse's Notes indicate: 11/18/10 at 2:04 PM the physician was notified of complaints of wound pain and Resident #1's sensitivity to narcotics. an order for [REDACTED]. 11/21/10 at 11:49 AM indicates that Resident denies pain and [MEDICATION NAME] appears to be effective for pain management from the coccyx wound. 12/1/10 at 12:35 PM indicates that Resident #1 received [MEDICATION NAME] lotion in coccyx wound prior to cleansing wound that is effective. 12/17/10 at 1:56 PM indicates that when asked if Resident #1 has had pain in last 5 days, if pain has made it hard to sleep or limited day to day activities because of pain Resident #1 answered No. This method of pain assessment is not appropriate for a Resident with short and long term memory loss as Resident can't remember events clearly from 5 days ago. -The evidence based protocol for acute pain management in the elderly by the University of Iowa Research Dissemination Core written 6/2000 and Revised 9/2000 under baseline pain assessment page 6 #5 indicates that cognitively impaired elders tend to underreport pain, but many can report pain reliably. Mildly to moderately cognitively impaired individuals are often able to rate pain using instruments (such as verbal descriptor scale, faces pain scale, numeric rating scale etc) the individuals ability to do so should be assessed. It may be necessary to try several tools to evaluate which one is most easily used by the cognitively impaired individual. Scales that are the simplest and most usable for cognitively impaired elders include verbal descriptor scales, pain thermometers and faces pain scales. 1/5/11 at 2:29 PM the pain assessment indicates that Resident #1 has not received PRN pain medications even though Tylenol was administered on 1/2/11. The pain assessment used was the same as 12/17/10. 1/12/11 at 12:38 PM pain assessment indicates that Resident #1 has not received PRN pain medications for pain even though Resident #1 received a pain prn on 1/7/11. The assessment indicates that Resident #1 complains of moderate pain occasionally over the past 5 days that is sharp and that [MEDICATION NAME] and position changes alleviate the pain and that these interventions are effective. The question related to should the staff assessment for pain be conducted was answered no. No further evaluation of the pain was conducted nor was the Physician or Hospice service notified of the complaints of sharp pain. 1/15/11 at 7:50 AM documentation indicates that Resident #1 rates coccyx pain 10/10 (10 being the worst pain) and is calling out in severe pain from coccyx wound. Writer offered to lay resident back down or lay in recliner off coccyx until [MEDICATION NAME] was working. Resident accepted recliner but continued to call out in pain. Discussed changing [MEDICATION NAME] time to 6:00 AM with Resident who agreed so it would give time to work prior to getting out of bed. Resident #1 agreed. There is no indication that the physician was notified or Hospice consulted regarding this level of pain. No PRN pain medication was administered or follow up pain assessment was noted. 1/27/11 at 1:39 PM indicates that Resident #1's manner of expressing pain is Verbal/facial expressions. No specific indicators of type of verbalization or facial expression indicated. 2/16/11 at 2:48 PM indicates that Resident #1 has a pain level of 5/10 and that pain level is not acceptable, is on scheduled pain medications and able to make self understood. Resident #1 complains of occasional aching pain on coccyx that has not affected ability to sleep or limit day to day activities over the past 5 days. Should the staff assessment for pain be conducted? No. No prn pain medication was administered nor was Resident #1's physician or Hospice service notified of ineffective pain management regime. 2/27/11 at 6:03 AM notes indicate that Resident #1 was crying out during the night. Tylenol was given prn and (Resident #1) is on the call board for something stronger than Tylenol. At 2:19 PM The Resident is complaining of pain 10/10, constant on the coccyx. It indicates that the response to [MEDICATION NAME] is ineffective. The on call physician was notified and an order was received for [MEDICATION NAME] 5/500 mg. 2/28/11 at 12:15 PM Hospice note indicates that they received a call regarding increased pain over the weekend and [MEDICATION NAME] was ordered. Resident is not able to tolerate narcotics but did take 1/2 tablet with no adverse effects. MD called and an order was received to continue prn [MEDICATION NAME]. No additional pain assessment or update to the care plan was noted. No additional consultation between Hospice and Facility staff to further assess Resident #1's pain, evaluate the effectiveness of current pain interventions and update the plan of care were noted. 3/9/11 at 1:55 PM Resident #1 complained of pain level at 10/10, frequently over coccyx area. The note indicates that [MEDICATION NAME], position changes, rest and distraction alleviate the pain. The effects of pain are crying and a decrease in appetite. Should the staff assessment for pain be conducted? No. There is no indication that the Physician or Hospice service were called regarding the continuing complaints of pain. No changes to the care plan were noted. On 3/16/11 at 9:45 AM Surveyor # interviewed DON (Director of Nursing) B and Assistant DON Q regarding Resident #1's significant change MDS, and pain. ADON Q indicated that she completes the MDS. ADON Q indicated that Resident #1's change in condition MDS completed 7/10/10 was due to a functional and cognitive decline and weight loss. ADON Q was asked about completion of the pain interview for MDS 3.0 which she indicated is completed unless a resident can't verbalize or is rarely or never understood. Resident #1 does not fall into this category so the interview was conducted and Resident #1 answered no to pain so no further assessment was completed. ADON Q indicated that the nurses do the pain assessments weekly and that Hospice nurses assess pain with each visit. ADON Q would assess quarterly with the MDS. DON B and ADON Q both indicated that pain is assessed daily. On 3/16/11 at 10:10 AM Surveyor # observed Resident #1 in the hallway in her wheelchair. Resident #1 was displaying facial grimacing and when asked what was wrong she responded that her buttocks hurt and wanted help to get to her room. Facility staff pushed Resident #1 to room. On 3/16/11 at 12:45 PM RN Y told Surveyor # that Hospice assesses pain during each visit and gets a report from the facility nurses related to pain. RN Y indicated that Resident #1 would have pain at times when in bed or up in chair related to the wound/coccyx area. RN Y indicated that she was informed of increased pain in late February and that [MEDICATION NAME] 1/2 tablet was ordered. RN Y told Surveyor # that she felt pain was managed and that Neuropathic pain was not an issue. On 3/16/11 at 4:25 PM DON B and NHA ( Nursing Home Administrator) A told Surveyor # that Resident #1 had a decline in overall status starting 12/09 and was being monitored closely. DON B indicated that she was not aware of Resident #1's increased pain and pain during transfers. DON B indicated that staff can treat pain as a behavior symptom at times but should be recognizing facial grimacing, non verbal and verbal indicators of pain. DON B stated that she would expect data to be collected on pain and that her expectation is that Resident #1's pain is controlled. DON B told Surveyor # that she did feel that Resident #1's pain was controlled in the past but not at this time. NHA A and DON B were informed of the pain and how Resident #1 was positioned during the observation of a transfer using an EZ stand on 3/14/11. NHA A indicated that CNA's are expected to monitor any Residents change in transfer ability and contact the nurse who would contact the therapy staff to screen the Resident. NHA A indicated that therapy would evaluate in the morning. On 3/17/11 at 9:25 AM PT (Physical Therapist) Z told Surveyor # that staff had not told her that Resident #1 was having difficulty using the EZ stand and was exhibiting pain during transfers. PT Z indicated that a change in condition screen was done in July due to Resident #1's change in condition and that abilities go up and down. Resident #1 was unhappy with the use of the Hoyer and wants to continue to use the EZ stand so can continue to use the toilet. PT Z told Surveyor # that all residents are screened for transfers when they are admitted , with a change in condition, if staff notify the department of a change and on an annual basis. PT Z also indicated that all new staff are inserviced during orientation and all staff are inserviced annually on appropriate transfer techniques and reporting changes to the nurses. PT Z told Surveyor # that Resident #1 would be evaluated and assessed for the use of a thigh strap with the EZ stand. On 3/17/11 at 10:35 AM PT Z told Surveyor # that Resident #1 would now use a thigh strap and a 3/4 stand so there won't be so much strain on shoulders. Care plan and care card were updated. Following the time of exit from the facility, no additional information regarding lack of appropriate assessment, updating physician, consultation with Hospice services or updating the care plan regarding Resident #1's pain was provided.