Every finding on record at Delavan Health Services

Based on record review and staff interviews, the facility did not ensure 9 out of 12 sampled residents (R9, R10, R11, R3, R13, R8, R2, R4, and R31) medical records contained Physician progress notes. R9, R10, R11, R3, R13, R8, R2, R4, and R31 have Physician-C designated as their Primary Care Physician while residing at the facility. The facility did not maintain Physician-C's progress notes in the residents' medical record. This is evidenced by: Facility policy entitled, Designated Record Set, effective May 2018.Purpose: To describe the documents that comprise the Designated Record Set.The Company maintains the following as the Designated Record Set:The resident Medical Record;The resident Business Office File;The resident Personal Health Records. The Medical Record includes, at a minimum, the following: Physician and professional consultant progress notes. R9, R10, R11, R3, R13, R8, R2, R4 and R31 have designated Physician- C as their primary care provider. Physician- C is responsible for supervising the medical care of R9, R10, R11, R3, R13, R8, R2, R4 and R31 at least every 60 days. Physician-C is then to write, date and sign a progress note after each visit. Surveyor conducted medical record reviews for R9, R10, R11, R3, R13, R8, R2, R4 and R31 and noted the medical record did not include an electronic or scanned copy of the Physician-C's progress note after each visit for a period of time from January 1st, 2026, until August 5, 2026. On 8/5/26 at 10:30 AM, Surveyor conducted an interview with Nursing Home Administrator A regarding R9, R10, R11, R3, R13, R8, R2, R4 and R31's medical record not containing progress notes from Physician-C. Nursing Home Administrator- A stated it is possible copies of the progress notes were sent to the facility and not scanned into the electronic medical record. Nursing Home Administrator- A stated she would need to contact Physician-C to determine what happened to their progress notes. On 08/05/2026 at 10:44 AM, Surveyor spoke to Nursing Home Administrator-A who stated they did obtain faxed copies of R4's progress notes from January 15, 2026, through June 17th,2026. Nursing Home Administrator- A stated Physician-C had been behind in getting the progress notes completed and to the facility over the last 6 to 7 months. Nursing Home Administrator- A verified R9, R10, R11, R3, R13, R8, R2, R4 and R31 did not have the progress notes as part of their medical record, although the visits had been completed. Nursing Home Administrator- A stated Physician- C would give verbal report to the nursing staff after each visit regarding any changes in care. Nursing Home Administrator- A verified Physician- C is the primary care Physician for 37 residents currently at the facility. As of the time of exit on 8/5/26, the facility did not provide evidence that each residents' medical record contained Physician progress notes.

Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 36 residents. * The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Reflect changes in program members - Include the Infection Preventionist (IP) - Identify control measures based on where Legionella could grow and spread and identify how to monitor the control measures and risks - Identify acceptable ranges of control limits and corrective actions to take when control limits are not met * The facility did not implement Enhanced Barrier Precautions (EBP) for 1 resident (R13) when R13 required EBP as recommended by the Center for Disease Control (CDC) and per the facility's policy. Findings include: Water Management Plan (WMP) The facility's policy titled Infection Prevention and Control Program with a last review date of 07/23/2024, documents in part, .16. Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program. The 06/24/2021 CDC Toolkit, titled: Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings identifies the key elements of a water management program for healthcare facilities to include: 1. Establish a water management program team 2. Describe the building water systems using text and flow diagrams 3. Identify areas where Legionella could grow and spread 4. Decide where control measures should be applied and how to monitor them 5. Establish ways to intervene when control limits are not met 6. Make sure the program is running as designed and is effective 7. Document and communicate all the activities The CDC toolkit identifies locations in a building's water system where Legionella can grow and spread to include but not limited to: ~Hot and cold water storage tanks ~Water heaters ~Water Filters ~Electronic and manual faucets ~Aerators ~Shower heads and hoses ~Pipes, valves and fittings ~Infrequently used equipment including eye wash stations ~Ice machines ~Hot tubs The CDC toolkit identifies factors internal to buildings that can lead to Legionella growth to include: ~Biofilm (microorganisms that are adhered to surface and form a protective slime layer, like the inside of plumbing system) ~Scale and sediment ~Water temperature fluctuations: Provides conditions where Legionella grows best (77 -108 F) ~Water pressure changes ~PH (measurement of acidity or alkalinity of a solution on a scale 0 to 14) ~Inadequate disinfectant: Does not kill or inactivate Legionella ~Water stagnation: Encourages biofilm growth and reduces temperature and levels of disinfectant The Wisconsin State Plumbing Code, Chapter SPS 382.50(3)(b)6, requires a nursing home's hot water system to be installed and maintained to provide bacterial control by one of the following methods: ~Water stored and circulation initiated at a minimum of 140 F and with a return of a minimum of 124 F. This standard is best practice even considering the facility was built prior to May 2003 and grandfathered to meet requirement. ~Water chlorinated at 2mg/L residual ~Another disinfection system approved by the department 1.) Surveyor reviewed the facility's document titled, LEGIONELLA WATER MANAGEMENT PLAN, date of plan review 02/28/2024, which documents that the WMP team consists of Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Director of Maintenance (DM)-D, and Business Office Manager. Surveyor noted the facility's WMP team did not include the Infection Preventionist (IP) and that in the Describe Your Building Water Systems section it simply documents, Using Text. Surveyor reviewed the facility's document titled, LEGIONELLA WATER MANAGEMENT PLAN, date of plan review is 02/09/2023, which documents the WMP team consists of NHA-A, DON-B, former Director of Maintenance, and former Business Office Manager. Surveyor again noted that this previous version of the plan also did not include the IP. Surveyor noted the facility's document states the following, II. Describe Your Building Water System Water from the city enters the building in two areas, the director of nursing closet and the therapy office closet. The water in the DON office goes through a water softener. Cold water is sent throughout the building overhead and drops down to showers, sinks and bathrooms. One pipe of cold water runs overhead to the boiler room to two hot water heaters. They are set to 148 degrees that go directly to the laundry area and the kitchen. Hot water is sent to mixer that keeps water to showers, resident bathrooms and bathrooms and employee bathrooms at 110 degrees. The therapy addition water that enters in the therapy office closet is sent to the water softener in the maintenance closet. Cold water is sent overhead to resident bathrooms, two employee bathrooms and two sinks in therapy area. Hot and cold water is also sent to the washer in therapy. Water heater is in the maintenance closet goes to a mixer that keeps the water at 110 degrees. III. Areas Where Legionella Could Grow and Spread The areas identified with the best conditions for the growth of Legionella are the dead-end branches. The document indicates the facility's fish tank has scheduled cleanings from an outside vendor, but then indicates the fish tank has a minimal or no risk of contracting Legionnaires. IV. Control Measures and Monitoring documents, Daily water temperatures and hot water heater checks will be made by the maintenance department to ensure everything is working as it should. These are done Monday-Friday. Water will be flushed through pipes in area that are not used very often on a schedule. Water management plan will be reviewed after any additions, or changes to the building. All residents with symptoms will be evaluated. V. Ways to Intervene When Control Limits Are Not Met In the event water management gets out of control, [NAME] Health Services will look to the experts for advice and come into the building to perform repairs or if something should need replacing. Surveyor noted the facility included a document in the WMP titled, [FACILITY NAME] EVACUATION PLAN layout. Surveyor notes on the facility layout, the facility marked water source incoming, dead end water, water heater, water softeners, and hot/cold water mixer. Surveyor noted the facility's description of water systems did not include ice machines, eye wash stations, or areas that have changed, such as the Social Service office is now the Maintenance office, and if those locations still have dead legs. On 12/18/2024 at 08:32 AM, Surveyor interviewed DM-D. Surveyor asked DM-D to explain the facility's WMP to Surveyor by walking through the facility's WMP documents. DM-D informed Surveyor the IP was not part of the WMP team. Surveyor asked DM-D if the facility has any dead legs in the facility. DM-D indicated to Surveyor that the facility no longer has dead legs. Surveyor showed DM-D the facility's document titled [FACILITY NAME] EVACUATION PLAN. DM-D informed Surveyor the document is the diagram of the facility's water systems. DM-D indicated the dead ends identified in the WMP need to be updated and the remaining dead legs are flushed every other month. DM-D indicated to Surveyor that a communication room located on the map was previously a shower room, and DM-D believes may have been capped. DM-D indicated to Surveyor that the Social Services office on the map needs to be updated to what is now the Maintenance office, which has two pipes with open and close valves that are capped. Surveyor asked DM-D to identify the WMP risk areas in the facility. DM-D indicated to Surveyor that the only identified risk for the WMP is in the kitchen, where the water is set to 148 degrees Fahrenheit (F). DM-D indicated the water temperature is hot there and there is a risk for burns. Surveyor noted there was no documentation of the water heater maintaining the set temperature, and Surveyor was not provided with the ranges in which the water heater is maintained. Surveyor asked DM-D to indicate where the risk areas for Legionella are located. DM-D indicated to Surveyor that the drains from the coffee machine and ice machine drain into the floor drain, so nothing can crawl or wash back up into those machines. DM-D indicated to Surveyor that daily water temperatures are obtained and documented for all resident rooms and areas where residents use the water. DM-D indicated all faucets and shower heads are flushed weekly, but no logs are kept. DM-D indicated the WMP flow map needs to be updated, and a few updated areas are missing on the map. Surveyor noted DM-D began adding to the map with a pen while speaking to Surveyor. Surveyor requested DM-D provide Surveyor with all logs associated with the WMP control measures. Surveyor was provided with the log for water temperature checks in resident rooms and therapy areas. Surveyor reviewed the temperature logs and noted water temperatures were documented for all resident rooms, therapy north sink, and therapy kitchen. DM-D indicated to Surveyor that the water heaters and dead legs are flushed monthly, but logs are not kept of the specific areas being flushed. On 12/18/2024 at 09:30 AM, Surveyor interviewed IP-C. IP-C informed Surveyor that IP-C is not part of the WMP and stated the WMP has members that include the NHA-A and DM-D. On 12/18/2024 at 03:10 PM, Surveyor interviewed NHA-A regarding concerns with the WMP. NHA-A informed Surveyor the flow chart for the WMP plan was currently being redone. NHA-A indicated that the WMP plan was not updated to reflect changes in WMP team members and did not include the current IP. Surveyor noted the facility's WMP did not have an identified risk assessment to indicate all areas where Legionellas could grow and spread. Surveyor noted the facility did not have identified control measures or acceptable ranges for control measures for all areas where Legionellas or other water borne pathogens could grow and spread. Enhanced Barrier Precautions (EBP) The facility's policy titled Enhanced Barrier Precautions with a last review date of 08/08/2024, documents in part, .2. Initiation of Enhanced Barrier Precautions: a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently defined as a CDC-targeted or novel MDRO. B. An order for enhanced barrier precautions (in accordance with physician-approved standing orders) will be initiated for residents with any of the following: i. Wounds (eg., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (eg., central lines, peripherally inserted central catheters (PICCs), hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. 2.) R13 was originally admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of right ankle, type 2 diabetes mellitus with foot ulcer, and non-pressure chronic ulcer of right ankle with an onset date of 11/05/2024. Surveyor reviewed the facility's document titled Order Summary report and noted R13 has treatment orders documenting, left great toe diabetic: cleanse with wound wash and pat dry f/b betadine daily . with an order date of 12/17/2024. Surveyor noted a treatment order documenting, umbilical OA (open area): wash with wound cleanser, pat dry, apply calcium alginate,cover with ABD (abdominal gauze pad) and tape daily and PRN (as needed) . with an order date of 12/13/2024. Surveyor reviewed [NAME] wound notes titled WOUND EVALUATION & MANAGEMENT SUMMARY dated 12/17/2024, which documents in part: R13's diabetic wound of the left posterior ankle resolved on 12/17/2024, diabetic wound of the left first toe full thickness, measuring 0.5 x 0.5 x 0.1 cm with 100% thick adherent black necrotic tissue, and abdominal wound. R13's abdomen wound is documented as etiology-fungal infection, measuring 0.4 x 0.5 x 0.1 cm with moderate serous exudate, 10% slough and 90% granulation.B. Plan/Treatment . 6. Additional interventions/plans: Seen by [doctor name] at bedside. Continue current treatment with calcium alginate and ABD daily and PRN. This area is scar tissue from surgical wound s/p (status post) hysterectomy a couple years ago. It opens at times. Large abdomen causing some MASD at times. On 12/17/2024 at 09:51 AM, Surveyor interviewed R13. R13 informed Surveyor that R13 has a pressure wound and a chronic wound and receives wound care treatments. Surveyor noted no EBP (enhanced barrier precautions) sign on R13's door and no Personal Protective Equipment (PPE) in or outside of R13's room for staff to wear when treating R13. On 12/18/2024 at 09:15 AM, Surveyor interviewed IP-C. IP-C informed Surveyor that EBP are used with residents if the resident has a catheter, invasive device, or chronic wound. IP-C informed Surveyor that standard precautions plus gown and gloves are expected with EBP. On 12/18/2024 at 10:56 AM, Surveyor observed wound care with Wound Nurse-E. Surveyor noted no EBP sign and no EBP PPE in room or outside of room. Surveyor observed Wound Nurse-E did not put on gown before performing wound care on R13. On 12/18/2024 at 02:50 PM, Wound Nurse-E informed Surveyor that R13 is not on EBP due to wound not being chronic. On 12/18/2024 at 03:10 PM, Surveyor interviewed NHA-A and DON-B. Surveyor notified NHA-A and DON-B of concerns regarding R13 not being on EBP. Surveyor inquired why R13 was not on EBP. DON-B indicated to Surveyor that DON-B was not sure if the facility was considering R13's wound to be chronic or not. On 12/19/2024 at 08:07 AM, Surveyor observed EBP now in place for R13 and R13's care plan was updated to include EBP. On 12/19/2024 at 09:16 AM, Surveyor interviewed Registered Nurse (RN)-F. RN-F indicated to Surveyor that R13 has had the wound on R13's belly on and off for four years which started as a surgical site and has grown tremendously since being at the facility. RN-F indicated to Surveyor that R13's abdomen wound was healed then reopened.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment, alleged violations are thoroughly investigated for 2 of 6 (R1 and R3, R4) reviewed for abuse. A review of the facility self-report involving R1, showed an allegation of neglect and the investigation into this allegation is not complete. R1 reported that her legs were wet, she was in pain, and had asked for her dressing to be changed and none of those needs were met. A review of the facility self-report involving R3 and R4, showed an allegation of abuse. R3 reported R4 touched R3 above the breast and 1-2 inches below the collar bone. Findings include: The facility's policy Abuse, Neglect and Exploitation last revised on 715/22 includes, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: b. Establish written policies and procedures to investigate any such allegations. V. Investigation of Alleged Abuse, Neglect and Exploitation. A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 3. Investigating different types of alleged violations; 4. Identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. 1.) R1 was admitted to the facility on [DATE] with diagnosis that include metabolic encephalopathy, diabetes mellitus type 2, end stage renal disease, renal dialysis, pulmonary hypertension, chronic pain, and disorders of calcium metabolism. On 12/22/23, the facility filed a Misconduct Incident Report to the State indicating that a staff member felt that two nurses failed to properly care for a resident. The CNA (Certified Nursing Assistant) reported that R1 needed something for pain and that she requested to have her dressings changed. LPN (Licensed Practical Nurse) indicates that she did not change R1's dressing as R1 stated they were too painful and that she did not want her bandages changed until tomorrow morning. R1 was provided with Norco. Dressing were reinforced but not changed by the nurse on the following shift. On 8/19/24 at 8:50 AM, Surveyor interviewed R1. R1 had no concerns and indicated that her legs have since healed. R1 indicated she got wound care when she needed it and pain has been controlled. On 8/19/24 at 2:30 PM, Surveyor interviewed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B. Surveyor asked NHA-A and DON-B if other residents were interviewed to see if they had any concerns with wound care, care in general or pain. NHA-A stated, I didn't look at it like that, I need to widen the investigation. Surveyor asked if any other residents had concerns. NHA-A stated, I see what you are saying. Surveyor noted that the facility failed to complete a thorough investigation. The facility failed to interview other residents to ensure that they had no concerns with wound care or pain and the facility also failed to provide any education to staff on wound care and pain. 29360 2.) R3 was admitted to the facility on [DATE] with diagnosis that include Parkinson's, diabetes, dementia and anxiety. R4 was admitted to the facility on [DATE] with diagnosis that include prostate cancer, dementia, hypertension and congested heart failure. On 5/28/24 the facility filed a Misconduct Incident Report to the State Agency indicating that R3 alleged R4 touched her breast. On 8/19/24 at 2:17 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing). Surveyor asked for documentation of other resident's interviews and staff interviews that were completed as stated in the Investigation Summary. NHA A stated we are unable to find the documentation. Surveyor asked NHA A if the interview documentation should be in the investigation. NHA A stated yes, the documentation should be available. Surveyor noted that the facility failed to complete a thorough investigation and that the facility failed to have evidence other residents and staff were interviewed regarding the accusation of abuse. No additional information was provided as to why the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment, alleged violations were thoroughly investigated for R1, R3 & R4.

Based on observation, interview and record review the facility did not ensure the medication error rate was below 5%. During medication pass, surveyors observed 3 errors out of 36 opportunities with a medication error rate of 8.33%. * 2 (R35 and R31) of 4 residents observed during medication administration did not receive their medication as ordered. R35 received one spray of Futicasone nasal spray in each nostril instead of two sprays as per physician order. R35 received 2 puffs of the Fluticasone inhaler instead of the physician order of one puff. On 9/26/23 at 7:47am, R31 was administered Metoprolol Succinate ER 25 mg when it should have been held if R31's heart rate was below 60. R31's heart rate was 59. Findings include: 1. On 9/26/23 at 8:03 a.m. Surveyor observed RN-F administer medications to R35. R35 was administered Fluticasone Proprionate nasal suspension 50 mcg/act one spray in each nostril. R35 was also administered Fluticasone Propionate HFA Inhalation Aerosol 110 mcg/act two quick puffs inhalation. After medication administration pass, Surveyor reviewed R35 physician orders and MAR (medication administration record). R35 orders for Fluticasone Propionate Nasal Suspension 50 mcg/act indicate two sprays in each nostril. The orders for Fluticasone Propionate HFA Inhalation Aerosol 110 mcg/act indicate one puff inhalation. On 9/26/23 at 3:00 p.m., during the daily exit meeting, Surveyor explained to DON (director of nursing)-B and NHA(nursing home administrator)-A the concern R35 received the one spray each nostril of Fluticasone nasal spray and the physician order indicates two sprays each nostril. Surveyor also explained R35 received 2 puffs of the Fluticasone inhaler and the order indicates one puff. On 9/27/23 at 9:30 a.m. DON-B acknowledged the medication errors and stated she had no additional information. 2. On 09/26/2023 at 7:47 am, Surveyor observed Licensed Practical Nurse (LPN)-C prepare and administer R31's morning medications. On 09/26/2023 at 7:47 am, LPN-C administered Metoprolol Succinate ER 25 mg to R31. After completion of the medication pass, Surveyor reviewed R31's physician orders and September 2023 MAR (medication administration record). R31 was admitted to the facility on [DATE] with diagnoses of paroxysmal atrial fibrillation, hypertensive heart, chronic kidney disease and chronic diastolic heart failure. The September 2023 MAR for R31 indicates to hold Metoprolol Succinate ER 25 mg if heart rate is less than 60. On 09/26/2023 at 9:30 am, Surveyor interviewed LPN-C. LPN-C confirmed heart rate of 59 at the time of morning medication pass. Surveyor explained medication error observed during medication pass. LPN-C indicated she made a mistake and should not have given Metoprolol Succinate with a heart rate of 59. The above finding was shared with the Nursing Home Administrator (NHA)-A on 9/26/2023 at 2:59 pm at end of day meeting.

Based on record review and interviews, the facility did not ensure a fall was thoroughly investigated, along with a corrective intervention, in a transport van. This was discovered with 1 (R11) of 5 residents reviewed with accidents. * R11 had a fall in a transport van on 4/1/23 and there was not an investigation completed at the time of the event. There was no documented corrective action/intervention from this fall. Findings include: Surveyor reviewed the policy and procedure for Fall Prevention and Management Guidelines dated 11/8/2022. - Section 7. When any resident experiences a fall, the facility will: 5) Environmental review for possible factors; 6) Contributing factors to the fall; 9.b) Complete an incident report in Risk Management; 9.e.) Document all assessments and actions. On 09/25/23 at 09:11 AM Surveyor spoke with R11. R11 goes out to dialysis three times a week. R11 indicated they fell in the van twice because of no seatbelt. R11 thought it was a couple months ago. R11 did not have any injury. R11 indicated they have a new chair now and has no concerns. R11's medical record was reviewed by Surveyor. R11 was admitted on [DATE] and has an activated Power of Attorney for Healthcare. R11 has a leg amputation, hemiparesis/hemiplegia from a stroke, and end stage renal disease with hemodialysis. On 4/1/23 R11 had an After Visit Summery from the emergency department. The diagnosis was a closed head injury, abrasion of the left hand and strain of neck muscles. The Progress Note on 4/1/23 at 10:27 PM by RN(Registered Nurse)-D indicated R11 fell at dialysis with a head injury. There is a documented assessment. The Admission MDS(minimum data set) assessment completed 3/9/23 indicates total staff assist for activity for daily living. R11 was assessed as having moderate cognitive impairment. RN-D was not available for interview. R11 has had no falls since 4/1/23. R11 has a plan of care for Fall risk started 3/4/23 does not include the fall on 4/1/23. There was no revisions to the plan of care from the fall on 4/1/23. The Interventions are a low bed from 3/4/23. On 9/25/23 at 3:00 PM at the facility daily end of the day meeting Surveyor requested any information regarding the fall with seatbelt. DON(Director of Nurses)-B indicated they will get more information. On 09/26/23 at 07:54 AM DON-B spoke with Surveyor. DON-B did not have any documented investigation from the fall on 4/1/23. There was a progress note in R11 medical record. They performed neuro assessments. DON-B did not have any further information. There has been no fall events since 4/1/23. There is no investigation into the circumstances of the fall in the transport van. On 09/26/23 at 12:58 PM DON-B spoke with Surveyor. DON-B indicated they spoke today to the van Driver-E. The Driver-E is also the owner of this community transport service. Driver-E felt the pillow under R11 wheelchair could have been the issue. Driver-E indicated R11 was seat belted in. The transportation is arranged through Community Care and R11 is the only resident that used this service. There has been no issues since 4/1/23. On 09/26/23 at 01:39 PM Surveyor called Driver-E. Driver-E indicated they did not talk about what happened with the facility until today. Driver-E indicated [R11] wears a blanket over their lap and felt [R11] was not in an appropriate wheelchair, was a wrong wheelchair, the leg was just amputated and the wheelchair was secured. Driver-E indicated [R11] was sitting on pillows and slid off the wheelchair seat when they turned a corner. They did call 911 and R11 was taken to the hospital. There has been no concerns since then. They have not transported R11 since May or June of 2023. On 9/26/23 at 3:00 PM at the facility end of day meeting, Surveyor shared the concerns with R11's fall investigation. No further information was provided.

Based on record review and interview, the facility did not always ensure that 1 (R8) out of 4 residents reviewed, were given psychotropic medications for valid reasons, with appropriate behavioral interventions and adequate monitoring. * R8 was administered scheduled Quetiapine Fumarate (Seroquel- antipsychotic) and Venlafaxine (Effexor-antidepressant) with no identified targeted behaviors for staff to be monitoring in order to determine the effectiveness of each medication. Findings include: On 9/27/23 the facility's policy and procedure titled Psychotropic Medications dated 10/24/22 was reviewed and read: the facility will identify an indication for use. The indications for use of any psychotropic drug will be documented in the medical record. The resident's response to medication, including progress toward goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. R8 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia and Bipolar Disorder. On 9/27/23 R8's current physician's orders for Quetiapine Fumarate and Venlafaxine were reviewed and indicated R8 started Quetiapine Fumarate 400 milligrams (MG) once a day on 7/14/23 for schizoaffective disorder. R8's Venlafaxine 37.5 MG was started on 7/15/23 for schizoaffective disorder. On 9/26/23 R8's care plan for use of psychotropic medication dated 8/2/23 was reviewed and read: Monitor and document all behaviors and targeted behaviors. Report behavior changes to physician. No where in R8's care plan does it indicate any adverse behaviors R8 has exhibited due to his mental health conditions. On 9/27/23 R8's medical record was reviewed and the only behavior monitoring found was charted by the Certified Nursing Assistant and only identified if R8 had a behavior. No identified targeted behavior was identified for Quetiapine Fumarate and Venlafaxine administration. On 9/27/23 R8's Medication Administration Record (MAR) for August and September 2023 was reviewed and indicated R8 received Quetiapine Fumarate and Venlafaxine daily as ordered as it was signed off each nurse who administered it. No targeted behaviors for the medications use was identified. On 09/27/23 at 10:09 AM Administrator-A indicated the new social worker did not identify targeted behaviors for R8. Administrator-A indicated targeted behaviors for R8 should have been identified and put on R8's MAR for the nurse to document on and this was not done for R8's administration of Quetiapine Fumarate and Venlafaxine. The above findings were shared with the Administrator and Director of Nurses on 9/27/23 at 10:09 AM. Additional information was requested if available, none was provided.

Based on observation, record review and staff interviews, the facility did not always ensure that 2 out of 4 (R27, R9) residents reviewed with pressure injuries received the necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing. R27 was admitted to the facility with areas of skin impairment to the right lateral ankle- noted to be a stage 3 open area. An area to the right great toe which was noted to be a stage 3 open area and dark blue/purple areas on bottom of feet, possible DT (Deep Tissue). The facility failed to comprehensively assess these areas upon first observation and also failed to obtain a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not update the individual plan of care with interventions that would assist in healing these areas. R9 developed a suspected deep tissue injury to the right heel and the facility did not compressively assess the area from the initial observation on 12/2/21 until 12/9/22 when the area is noted to be necrotic by Wound MD- M. The facility had interventions in place at the time to avoid pressure injury development such as a speciality air- mattress but they did not updated the plan of care with further interventions to assist in the healing of the wound to R9's right heel. Findings include: 1.) R27 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility conducted an admission Braden assessment on 5/4/22 and noted R27 was at risk for developing a pressure ulcer. A review of the admission assessment, dated 5/4/22, identified the following skin integrity concerns: Right anecdotal- bruising IV site Left anecdotal- bruising IV site Right lateral ankle- open area 1.5 x 1.9 x 0.7 Stage 3 Right great toe open area 0.3 x 0.6 x 0.1 stage 3 Heel inspection- mushy and discolored Comments: Dark blue/purple areas on bottom of feet, possible DT (Deep Tissue). Applied skin prep, made nurse aware, put-on blue boots to float heels. Applied dressing to ankle OA and great toe, d/t (due to) drainage. Will update wound team to wounds. This assessment was created by LPN (Licensed Practical Nurse) - E. Surveyor noted the wounds were not comprehensively assessed as there was no description of the wound beds and no treatment obtained until 5/15/22. R27's Individual Plan of Care, initiated on 5/4/22, states that R27 is at risk for skin integrity condition, or pressure sores due to impaired mobility, thin/ fragile skin. Interventions included apply alternating pressure mattress to bed if indicated. Assure proper inflation- check frequently. Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. Frequent repositioning in bed and chair. Conduct pressure injury assessments (i.e.- Braden Scale) as indicated. Assess skin for redness or pressure related changes with each care encounter- report any changes immediately. The admission MDS (Minimum Data Set), dated 5/11/22, stated that R27 had a BIMS (brief interview for mental status) of 4 (severely impaired). R27 needs extensive 1 person physical assistance for all ADL's (activities of daily living). R27 did not experience any pain in the last 5 days prior to this assessment reference date. R27 is at risk for pressure injuries and yes- unhealed areas are noted. R27 had 1 unstageable- deep tissue injury that was present upon admission. 0- venous and arterial ulcers and no other wounds. The skin CAA (Care Area Assessment) dated 5/11/22 stated that R27 was admitted with DTI (Deep Tissue Injury) and [CONDITION(S)] to right great toe. Currently has DTI to ankle and r great toe [CONDITION(S)]. Is able to make needs known. Is frequently incontinent of bowel and bladder. Requires assist with transfers and mobility. No concerns with nutritional status, appetite poor on therapeutic diet, is diabetic. RISKS: skin breakdown, infection, pain. Surveyor continued to review R27's medical record which did not show any further documented, comprehensive assessment of R27's wounds to her right foot/ ankle and heel that were first observed upon admission on 5/4/22. Surveyor conducted a review of the Treatment Administration Record (TAR) for May 2022. The TAR did not show evidence that any type of treatment had been administered to R27's right foot, heel or ankle from 5/4/22 until a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The first comprehensive assessment of R27's wounds to her right foot/ ankle/ heel was completed on 5/17/22. The following note was documented in the electronic medical record: 5/17/2022 at 11:03 a.m.; Skin/Wound Note- [R27] with wounds to right foot since admission. Right great toe has an abrasion measuring 0.6 x 0.9 x 0.1 with 100% granulation, right lateral ankle with scab measuring 1 x 0.4 x 0 dry without drainage, right heel with S (suspected) DTI measuring 3 x 1.5 x 0 purple and closed. Treatments in place for all three of these wounds. Coccyx with pinkness that is blanchable and closed. Groin and peri-anus pink with cream ordered for MASD (moisture-associated [CONDITION(S)]) r/t (related to) incontinence. Air mattress in place, blue boots on when resident is in bed, continue to turn and repo q 2 hours (reposition every 2 hours) and PRN. MD and daughter aware of wounds and in agreement with the plan. Resident denies pain to these areas. 5/19/2022 at 5:36 p.m. Skin/Wound Note MD- M was in to see R27 last night. R27 seen for right great toe, right lateral ankle, right heel wounds and MASD to perineal and peri-anal area. NOR (new order). Added additional supplement and vit (Vitamin) C BID (two times a day). Review of (name of clinic) Wound Physician Assessment: dated 5/18/22: CHIEF COMPLAINT: This patient has multiple wounds. HISTORY OF PRESENT ILLNESS At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. R27 has an unstageable DTI of the right, lateral heel for at least 4 days duration. There is no exudate. The patient verbalizes pain with score of 0 out of 10. Arterial Wound of the right, dorsal, first toe full thickness wound size: 0.6 x 0.9 x 0.1 cm 90% granulation, 5% bone, 5% necrotic tissue. Surveyor noted the Wound Physician is now referring to the right great as an Arterial wound versus previous reference to the area being a pressure injury. *ADDITIONAL WOUND DETAIL Pt w/ Hx [CONDITION(S)] of R great toe, as seen on X-ray 3/29/22. Pt treated with 2 courses oral abx as outpatient. IV abx during recent hospitalization d/c'd due to new C diff infection. Pt evaluated 4/26/22 as inpatient by podiatry to discuss possible amputation--surgery deferred out of concern for advanced peripheral arterial disease *DRESSING TREATMENT PLAN Primary Dressing(s) [MEDICATION(S)] apply once daily for 30 days *Arterial Wound of the right, lateral ankle partial thickness 1.0 x 0.4 x not measurable, dried scab Surveyor noted the Wound Physician is now referring to the right lateral ankle as an Arterial wound versus previous reference to the area being a pressure injury. DRESSING TREATMENT PLAN for the first dorsal toe, right foot and Lateral ankle: Primary Dressing(s) [MEDICATION(S)] apply once daily for 30 days *Unstageable DTI of the right, lateral heel partial thickness pressure Wound size: 3.0 x 1.5 x not measurable surface area 4.5 cm DRESSING TREATMENT PLAN for the Unstageable DTI of the right lateral heel. Primary Dressing(s): Skin prep apply once daily for 30 days PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Off-load wound; Reposition per facility protocol; Sponge boot; Vitamin C 500mg twice daily PO; Multivitamin once daily PO; Protein supplements 3x daily with meals PLAN OF CARE REVIEWED AND ADDRESSED: My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. Wound Care Note from, dated 5/31/22: NOTE: Signing off on patient (R27) who remains in the facility. Pt now enrolled in hospice services, who requested to take over primary management of pt's wounds. Skin / Wound note dated 5/31/2022 at 09:55 a.m.; Right heel sDTI remains intact and light purple in color measuring 3 x 1.5 x 0. [MEDICATION(S)] paint BID per hospice orders. Right great toe abrasion measures 0.6 x 0.5 x 0.2 with pinkness and slight swelling noted, minimal drainage noted with twice a week honey and foam dressing in place per hospice. Right lateral ankle scab measures 1.4 x 0.3 x 0. adding BID [MEDICATION(S)] treatment at this time. No s/s of infection noted. Hospice following wounds. Resident and family in agreement with hospice plan of care for wounds. Skin / Wound note dated 6/9/2022 at 2:31 p.m.; Right heel sDTI remains intact and light purple in color measuring 3.2 x 1.4 x 0. [MEDICATION(S)] paint BID per hospice orders. Right great toe abrasion measures 0.9 x 0.9 x 0.4 with pinkness and slight swelling noted, minimal drainage noted with twice a week honey and foam dressing in place per hospice. Right lateral ankle scab measures 1.1 x 0.3 x 0. adding BID [MEDICATION(S)] treatment at this time. No s/s of infection noted. Hospice following wounds. Resident and family in agreement with hospice plan of care for wounds. Skin/ Wound note dated 6/14/2022 at 08:19 a.m.; Right heel sDTI remains intact and dark brown in color measuring 3.5 x 1.5 x 0, it is 90% necrotic tissue and 10% granulation to the border. [MEDICATION(S)] paint BID per hospice orders. Right great toe abrasion measures 0.9 x 1 x 0.4 with pinkness and slight swelling noted, minimal drainage noted with twice a week honey and foam dressing in place per hospice. It is 20% bone, 70% granulation and 10% slough with minimal s/s drainage. Right lateral ankle scab measures 1 x 0.3 x 0. adding BID [MEDICATION(S)] treatment at this time. Right lateral bunion area 1 x 0.5 x 0 discoloration and intact. No s/s of infection noted. Hospice following wounds. Resident and family in agreement with hospice plan of care for wounds. Will add gauze wrap to foot/heel for protection. MD in agreement with the plan. Surveyor conducted a review of the current treatment orders for R27. The following was noted: Assist resident to turn and reposition q (every) 2 hours and PRN. No directions specified for order. Surveyor noted review of the plan of care showed that this intervention was not added for R27. Right great toe, clean with wound wash, apply thin layer of medi honey to slough, cover with foam dressing. Change 2 x a week and PRN until healed, at bedtime every Tues, Fri Right heel, right lateral bunion and right lateral ankle-paint with [MEDICATION(S)] BID and wrap foot/ankle with rolled gauze for protection, keep heel boots on al all times, may remove when doing treatment. Every morning and at bedtime AND as needed for may change if soiled or dislodged. Place pillows or blue heels off device in a comfortable position to float residents' heels when in bed and chair as tolerated. No directions specified for order. Surveyor noted this intervention was not added to R27's individual plan of care. On 6/15/22 at 11:21 a.m., Surveyor observed LPN- D provide treatment to R27's wounds to her right foot/ ankle/ heel. The following was observed: R27 gives permission for Surveyor to observe treatment along side of LPN- D. LPN- D proceeds to the bathroom to wash her hands. LPN- D has placed the treatment supplies on R27's bedside table without any type of barrier for infection control. R27's table had candy wrappers, papers and miscellaneous belongings on the table along side the gauze, tape, scissors and treatment medication. It was observed that R27 did have boots on both her right and left feet and LPN- D removed the boots and socks. There was a bandage dated 6/14 to R27's right great toe that LPN- D removed. LPN- D then started to cut the tape that was applied to R27's right foot/ ankle holding the gauze in place. At this time R27 begins to show facial grimacing and winches in pain. LPN- D continues to remove gauze. LPN- D then lifts R27's right leg up to inspect the areas and R27 begins to state ouch, ouch, ouch. LPN- D does not address R27's pain level and begins to cleanse the right great toe with gauze that has been sprayed with wound cleanser. LPN- D then dries the area with gauze. LPN- D then removes her gloves, does not wash her hands and leaves the room to obtain additional supplies from the cart that is located in hallway. LPN- D then returns into the room and applies new gloves without washing her hands. LPN- D applies the medi-honey to the bandage and adheres it to R27's right great toe. LPN- D then removes her gloves and goes into bathroom to wash her hands. Surveyor asks R27 if she has pain from the areas on her right foot, R27 responds yes, my foot hurts all of the time. LPN- D applies new gloves and opens the [MEDICATION(S)]/Iodine treatment and begins to paint the wound located on the side of R27's right foot. It was noted that LPN- D did not cleanse the right heel or lateral foot before applying the iodine. (Directions for use of [MEDICATION(S)] state 1. Clean. Gently clean the affected area. 2. Treat. Apply a small amount of solution to affect area. 3. Protect. Let dry and cover with sterile bandage if needed.) LPN- D lifts R27's right leg to apply the Iodine treatment and R27 winces out in pain again. LPN- D continues to swab the heel and then places R27's heel back down on the bedsheet. The bedsheet appeared with some stains prior to treatment and noted that the Iodine has also now left a stain to the bed sheet. LPN- D applies the Iodine to the lateral foot and then proceeds to wrap the right foot/ heel with gauze. LPN- D places the extra gauze, tape and scissors on the bed sheet next to R27. The gauze taped and dated and LPN- D applies the boots back to R27's feet. LPN- D then walks over to the garbage can and removes the trash bag with her gloved hands. LPN- D then removes additional garbage from the garbage can that was not in the trash bag and places into trash bag. LPN- D then removes hers gloves, grabs the tape and scissors and leaves the room without washing her hands. LPN- D then returns the tape and scissors back in the drawer of the treatment cart and then uses hand sanitizer. Surveyor conducted further review of R27's plan of care after observing R27's pain during the above treatment observations. The plan of care stated the following: Resident has pain or the potential for pain r/t or evidenced by: Decreased mobility . Interventions included: o Administer analgesics per MD orders. Give prior to treatments, therapy or cares. o Anticipate Resident's need for pain relief and respond as soon as possible to any complaint of pain. o Observe Resident during cares for signs of pain i.e. facial grimacing, hesitancy with movement, furrowed brows, saying Ouch, refusing to move or transfer. Always ask Resident about their pain with each encounter. On 6/15/22 at 7: 55 a.m., Surveyor interviewed DON- B and Director of Clinical Operations- N in regard to R27' skin impairments to the right foot and heel. DON- B stated that upon admission, R27 was wearing heel boots for protection and was receiving a multi vitamin. On 5/13/22 a protein supplement was added. Surveyor asked if there had been a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DON- B confirmed that if a wound is identified, it should be comprehensively assessed, and a treatment should be ordered. DON- B stated she is not aware why a treatment was not initiated upon discovery of the areas. On 06/15/22 01:41 p.m. Surveyor interviewed DON- B in regard to R27's area of skin impairment to the right foot/ ankle and heel. Surveyor verified with DON- B that a treatment was not obtained for R27 upon admission when the areas to the right lateral ankle and right great toe and dark blue/purple areas on bottom of feet, possible deep tissue. Surveyor shared the above observation of the treatment provided to R27 on 6/15/22 by LPN- D. Surveyor spoke of the pain R27 experienced during the treatment that went unaddressed by LPN- D and the infection control concerns during the treatment. DON- B was asked what areas remain for R27. DON- B stated that the bunion listed on her assessment is a new area and developed sometime between 6/9/22 and 6/14/22. DON- B obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . As of the time of exit, the facility was not able to provide additional evidence that they had Comprehensively assessed R27's wounds to her right foot, upon admission on 5/4/22. The facility did not obtain a treatment order until 5/15/27 and did not update the plan of care with further interventions to assist with the healing of these areas. The facility originally identified the areas to R27's right foot as pressure injuries, they were then documented as a suspected deep tissue injury to the heel and possible arterial ulcers to the lateral foot and top of great right toe. The areas were then described as abrasions, suspected deep tissue area and the development of a new bunion. The facility staff did not practice safe infection control practices during the treatment observation and did not address the pain R27 was experiencing during the treatment administration. 2. Resident 9 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon admission, R9 was noted to have an unstageable (due to Necrosis ) area on her sacrum. R9 has been seen by a wound MD prior to admission to the facility to treat the area. Surveyor conducted a review of the weekly skin assessments and on 12/2/21 it was noted that R9 had a New skin impairment- see note DTI ( Deep Tissue Injury) right heel- assessment 12/2/21 Surveyor noted that there was not a comprehensive assessment, completed by a Registered Nurse (RN) of the DTI to R9's right heel following the initial observation on 12/2/21. Nursing note dated 12/2/2021 at 9:22 p.m. stated R9 returned from shower, writer informed of darkened area to right heel, assessment of site, area dark purple in color, no open areas, measures approximately 5.5 cm x 5.5 cm, DON (Director of Nursing), NP (Nurse Practitioner) for MD, and family made aware, treatment order per DON of [MEDICATION(S)], pad with ABD and wrap with Kerlix daily, fax to MD to update, orders for blue boots and elevator to keep heels off bed, wrier explained to resident how injury occurs and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . It was noted that this entry was written by LPN- E A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Clinical Follow-up note dated 12/3/2021 at 12:45 a.m., late Entry: Note Text: R9 is on follow up for: late entry for 12/3/21. f/u IR on 12/2/21 right heel deep tissue bruise. The current status is Resident does not c/o heel pain. Wound is dressed per Dr orders. Clinical Follow- up note dated 12/3/2021 at 5:38 a.m., R9 is on follow up for: R heel (possible DTI). The current status is R heel bandaged. remains dry and intact. no complaints of pain or other concerns Health Status Note dated 12/3/2021 at 9:25 a.m., Late Entry: Note : IDT met to review the sDTI noted to this R9's right heel on PM shift last night. R9 was given a shower and the CNA told LPN- E about the findings. R9 was not aware of the injury as she does not have much feeling in her legs related to her multiple [CONDITION(S)]. She also has [CONDITION(S)]. R9 prefers to lay on her back with a pillow under her legs. She does state that often times the pillow doesn't keep her heels off the bed but that's how she likes it. Offloading was discussed and foam boots were added to her careplan. She is in agreement with the plan to wear blue boots and off load when she is in bed. (name of clinic) wound MD will be into see this resident 12/09/2021. Treatment was obtained from the MD and R9's brother was notified. Health status note dated 12/3/2021 at 11:16 p.m Resident is on follow up for: R heel (possible DTI). The current status is R heel bandaged. remains dry and intact. See TAR for Tx for healing pressure ulcer Clinical Follow- up note dated 12/4/2021 at 8:45 p.m , R9 is on follow up for: IR - right heel - DTI. The current status is f/u IR - DTI to right heel, no new skin issues noted, no c/o pain r/t wound, blue boots in place for protection, treatment to site per orders, no other c/o. Clinical follow-up note dated 12/5/2021 at 12:45 a.m., R9 is on follow up for: DTI to right heel, dressing/treatment per orders. Resident denies pain. Skin intact The current status is DTI has intact skin, resident denies pain, following treatment orders; blue boots on. It was noted that there still was not a comprehensive assessment of the Suspected deep tissue injury from 12/2/21 to 12/9/21. There was no description of the area, measurement or investigation as to how the deep tissue injury may have been caused. On 12/9/21, R9 is seen by (name of clinic) Wound Physician. Chief complaint- multiple wounds. Site #2 Unstageable (due to Necrosis) of the right heel. Pressure, Duration- greater than 12 days. Wound size (LxWxD) 6.5 X 3 X no measurable cm. Surface area 19.50 cm. Exudate- moderate Serous. Thick adherent black necrotic tissue (eschar)- 100%. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Site #2- surgical excisional debridement procedure . Remove necrotic tissue and establish the margins of viable tissue. Plan of care recommendations: reposition per facility protocol; off-load wound. EZ boot to be worn in bed and chair to off-load wound. Surveyor noted that in the nursing notes from 12/2/21 until 12/9/21, the SDTI to R9's right heel was never described as having necrosis present on the wound bed. The next skin wound note was dated: 12/16/2021 at 4:25 p.m which stated, Wound team saw patient (R9) this morning. coccyx/right buttock unstageable pressure injury worsening. Odor present. Dr. updated via phone and she will be in tomorrow to assess and treat the wound. measurements 6 x 6 with undermining at 0000 2.5cm, 0300 2cm, 0600 1.2cm, wound is all necrotic inside and we will continue Santyl treatment daily. Right heel unstageable pressure injury improving. Measurements 4.5 x 5 x 0 and it appears to be a fading purple color. Will continue same treatment and have Dr assess tomorrow as well. Resident denies pain and discomfort. She is on an air mattress with blue boots and pillows under her legs, she is encouraged to lay side to side and chooses to lay in her back often. She verbalizes understanding of need to side lay. A review of the Individual Plan of Care for R9 stated that R9 has 2 pressure injuries (sacrum and right heel) r/t Immobility. This plan of care was initiated on 4/1/22. Interventions included: *The residents will Pressure ulcer will show signs of healing and remain free from infection by/through review date. ·Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The plan of care was not updated with the interventions for the use of the blue boots and to elevate the heels off the bed. R9 continued to receive treatment to the deep tissue injury located on the right heel daily and continued to be seen by Wound MD- M weekly for assessment of the areas. Skin Wound note dated 4/14/2022 at 4:33 p.m., per most recent hospitalization D/C orders IV ABX's [MEDICATION(S)] and [MEDICATION(S)] were only to be given for 32 days ending this weekend, however, per wound MD -M assessment on res's (sic) wounds on Wed. 4/13/2022 there are worsening S/S of wound and healing process, wound culture to Right heel was picked up by lab and results pending at this time, Infectious Disease (ID) MD was called and notified of wound MD - M concerns regarding worsening wounds and concern for IV ABX's ending this weekend, writer and wound RN/DON - B present during call with ID MD, ID MD gives orders at this time to D/C end date for IV ABX Vanco and [MEDICATION(S)] and to continue both IV ABX's until further notice from ID MD, continue with weekly labs and fax results to ID on Mondays, when wound culture results from Right heel are final please send to ID for orders, and to update ID in 1 week with appearance and assessment of wounds from Wound MD- M. Skin Wound Note dated 4/15/2022 at 3:26p.m. stated Wound MD- M was provided a copy of R9's preliminary right heel culture results. It showed gram negative rods. Wound MD- M stated that this could be why her right heel is worsening. He would like to see the final culture when available and no new orders are needed at this time based on the preliminary culture. Skin/ Wound note dated 6/9/2022 at 2:46 p.m. stated Wound MD- M off this week. Nursing wound rounds done by DON- B. Right heel wound improving and measures 0.2 x 1 x 0.3 50% gran and 50% slough, skin tear to right heel 0.9 x 0.4 x 0 almost healed. On 6/15/21 at 8:40 a.m., Surveyor interviewed DON-B who stated that she is pretty sure she was made aware of the SDTI to R9's right heel on 12/2/21 when it was first observed. DON- B stated that the expectation is that any wound is comprehensively assessed by a Registered Nurse. DON- B stated that she recalls the area to R9's heel being purple and that she did call the physician to get a treatment order. DON- B stated that R9 had MS and really doesn't have feeling in her legs/ feet and that she will have her heels lifted by a pillow in bed or wear the blue boots. R9 was also on an air-mattress at the time the area developed. R9 does get up in her wheelchair twice daily for 1-hour periods of time and is to wear the blue boots when up. As of the time of exit, the facility was not able to provide evidence that R9's SDTI was comprehensively assessed upon the initial observation of the wound. The first comprehensive assessment was completed on 12/9/21 when Wound MD- M assessed the area to the right heel and documents there is an area of necrosis present. The facility did obtain a treatment on 12/2/21 and R9 was using a specialty air mattress at the time of discovery. The facility also did not provide evidence that they had updated the plan of care with all of the interventions that were to be in place to promote the healing of the wound to R9's right heel.

Based on observation, interview, and record review the facility did not follow an effective infection control program to help prevent the transmission of infections for 1 (R34) of 5 residents observed for medication administration and for 14 ( R17, R2, R4, R29, R246, R10, R43, R42, R26, R18, R21, R38, R37, and R41) of 40 residents observed during meal tray pass. During medication administration on 6/14/22, Licensed Practical Nurse (LPN)-D touched 2 pills with her bare hands and placed them in the med cup for R34. LPN-D dropped a pill onto the medication cart and then picked it up with her bare hands and placed it in the med cup for R34. LPN-D administered the potentially cross contaminated pills to R34. During 2 meals, staff did not perform hand hygiene inbetween delivering meal trays to 16 residents potentially cross contaminating food trays. Findings include: Surveyor reviewed the facility's Administering Medications policy with a revision date of April 2019. Documented was: Policy Statement Medications are administered in a safe and timely manner, and as prescribed . 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable . On 6/14/22 Surveyor observed LPN-D prepare and pass medications for R34. R34's medications were in blisters packs. LPN-D popped a pill out of the blister pack into her bare hands and placed it in a medication cup. LPN-D took a second blister pack and popped a pill out into her bare hands and placed it in the medication cup. LPN-D took a third blister pack and popped a pill out and it fell on to the medication cart. LPN-D picked up the pill with her bare hands and placed it in the medication cup. LPN-D continued to pop 4 more pills directly into the medication cup. LPN-D mixed pudding with the pills and administered them to R34. LPN-D potentially contaminated 3 of the pills for R34 by not following infection control guidelines. On 6/14/22 at 2:52 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked how staff should handle medications from blister packs they will administer. DON-B stated they should pop the medications directly into the cup. Surveyor asked if staff should touch them with bare hands. DON-B stated no. Surveyor asked if a pill falls onto the medication cart what should be done. DON-B stated the pill should be destroyed and a new clean medication should be administered. Surveyor noted the observations of LPN-D touching 2 pills, dropping 1 pill and picking it up and administering those medications to R34. DON-B stated they should have been destroyed and replaced. Surveyor reviewed the undated facility Handwashing/Hand Hygiene policy and procedure and notes the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance 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. 3. Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap(antimicrobial or non-antimicrobial) and water for the following situations: p. Before and after assisting a Resident with meals Surveyor notes that at time of survey, there were 16 Residents residing on the 200 unit. Surveyor notes that all Residents eat their meals in their rooms at this time due to a COVID-19 outbreak. Surveyor observed two (2) meal tray passes. Surveyor observed CNAs obtaining a tray from the cart, going into the room and set up the tray for each Resident. Surveyor's observation for tray set-up includes the following: placing the tray on the overbed table, taking lids off of the food and drink items, cutting up food items, and/or opening condiment packets. On 6/13/22 at 12:31 PM, Surveyor observed lunch tray pass on unit 200. Surveyor observed Certified Nursing Assistant (CNA-I) pass and set up a tray for R17. CNA-I performed no hand hygiene. CNA-I obtained R10's tray from the cart and passed and set up the tray for R10. CNA-I performed no hand hygiene. CNA-I then passed and set up a tray for R43. Surveyor observed CNA-I perform no hand hygiene. CNA-I passed and set up R18's lunch tray. CNA-I observed CNA-I perform no hand hygiene. CNA-I obtained a tray for R41 and set up and performed no hand hygiene. CNA-J passed and set up R37's tray and performed no hand hygiene. CNA-J then passed and set up R246's tray and Surveyor observed CNA-J perform no hand hygiene. CNA-J then passed and set up R21's tray and performed no hand hygiene. CNA-J then obtained R38's tray, set up the tray, and CNA-J performed no hand hygiene. CNA-J then passed and set up tray for R42. Surveyor observed CNA-J not to perform hand hygiene. CNA-J obtained R29's tray and set up, and CNA-J performed no hand hygiene. CNA-J then served tray to R41, set up the tray and perform no hand hygiene. On 6/14/22 at 8:38 AM, Surveyor observed breakfast tray pass on unit 200. CNA-I passed and set up tray for R38 and performed no hand hygiene after exiting the room. CNA-G passed and set up a tray for R10 and performed no hand hygiene. CNA-G then passed and set up a tray for R17 and performed no hand hygiene. CNA-G obtained R21's tray and passed and set up R21's tray and performed no hand hygiene. CNA-H obtained, passed, and set up R37's tray and performed no hand hygiene. CNA-H then passed and set up R26's tray and performed no hand hygiene. CNA-H then passed and set up R41's tray and performed no hand hygiene before exiting the room. CNA-F obtained, passed, and set up R4's tray and performed no hand hygiene. CNA-F then obtained R19's tray, and passed and set up R19's tray and performed no hand hygiene before exiting the room. CNA-J obtained R29's tray passed and set up and performed no hand hygiene before exiting the room. On 6/14/22 at 2:42 PM, Surveyor asked Director of Nursing(DON-B) what is the expectation for hand hygiene between tray pass. DON-B stated to wash hands or use hand sanitizer after/before every new tray pass. Surveyor shared the concern with DON-B and Administrator (NHA-A) of no hand hygiene between tray passes with breakfast and lunch observations. Surveyor requested documentation of the date and content of the most recent hand washing inservice. DON-B stated DON-B would need to look for it. Surveyor notes the facility did not provide any documentation of a hand washing inservice for facility staff.

Based on observation, interview, and record review, the facility did not ensure that 1 (R21) of 12 sampled Residents were reasonably accommodated by providing Residents access to a call light. Findings include: Surveyor reviewed the facility's Call Light, Use of policy and procedure effective June 2017 and notes the following: Purpose * To respond promptly to Resident's call for assistance. * To ensure call system is in proper working order. Procedure 8. When providing care to Resident, be sure to position the call light conveniently for the Resident to use. Tell the Resident where the call light is and show him/her how to use the call light. 9. Orient all new Residents to the call light at the bedside as well as the call light in the bathroom, shower, or tub rooms. Have the Resident demonstrate the use of the call light to be sure he/she understands your instructions. 11. Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. R21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21 has a legal guardian. Surveyor reviewed R21's Quarterly Minimum Data Set (MDS) dated [DATE]. R21's documented Brief Interview for Mental Status (BIMS) score is 4, meaning R21 demonstrates severely impaired skills for daily decision making. R21's MDS documents that R21 requires limited assistance for bed mobility and transfers. R21 requires extensive assistance for toileting. Surveyor notes that R21's Certified Nursing Assistant (CNA) care card dated 6/15/22 documents under Safety the following: * Place call light or communication device within reach, answer call light promptly-always. Surveyor reviewed R21's comprehensive care plan and notes the following: R21 is at risk for falls due to deconditioning/weakness, gait balance problems, absence of right toes, joint/range of motion reduction, cognition with no safety awareness, behaviors, and pain. Initiated 12/5/18, Revised 2/1/22 Intervention: Place call light or communication device within reach. Answer call light promptly-always Initiated 12/5/18, Revised 5/24/20 On 6/13/22 at 9:37 AM, Surveyor observed R21 in bed sleeping. R21's call light was clipped on the backside of the privacy curtain which was at the end of R21's bed, not within reach of R21. On 6/13/22 at 2:35 PM, Surveyor observed R21 in bed sleeping. R21's call light was clipped on the backside of the privacy curtain which was at the end of R21's bed, not within reach of R21. On 6/15/22 at 9:17 AM, Surveyor observed R21's call on the floor, under R21's bed on the right side. R21 is sitting in R21's wheelchair in front of overbed table eating breakfast by the doorway, to the left of the bed. R21's bed is pushed against the wall. On 6/15/22 at 9:18 AM, Surveyor interviewed CNA-J in regards to R21 and use of the call light. CNA-J confirmed that R21 can physically turn the call light on, knows what to do with the call light, and that the call light is for requesting the need for help. CNA-J states R21 does not use the call light frequently. CNA-J states that R21 uses the call light more in the bathroom. CNA-J confirmed that R21 should be using the call light to transfer from bed to wheelchair. On 6/15/22 at 9:32 AM, Surveyor showed R21 the call light that was draped across the empty bed on the other side of the room. Surveyor asked R21 if R21 knew what it was. R21 stated, its the thing to call for help, I push the red button and the nurses will come. I know how to use and have used it when I need to. Surveyor asked R21 if R21 knew where his call light was right now, and R21 said, I don't see it. Surveyor notes R21's call light is still located under R21's bed. On 6/15/22 at 1:50 PM, Surveyor spoke to Director of Nursing (DON-B) in regards to call lights. DON-B stated that call lights should be within reach at all times. Surveyor shared concern of R21's call light not being within reach. No further information was provided at this time. On 6/15/22 at 2:00 PM, CNA-F confirmed the facility policy and procedure is that all Resident call lights should be clipped to either the shirt or blanket so the Resident can reach the call light.

Based on observations, record review and staff interviews the facility did not always ensure that 1 out of 1 residents reviewed (R9) who entered the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterized was necessary. R9 was admitted with a stage #4 pressure ulcer to the sacral wound. R9 was also noted to be incontinent of urine. On 11/1/21, the Wound MD ordered for R9 to have an indwelling catheter put in place to aide in healing of the sacral wound. The facility did not develop a plan of care with interventions to prevent urinary tract infections while the catheter was in use as well as did not have a goal for the removal of the catheter when R9's clinical condition no longer demonstrated that the catheterization was necessary. This is evidenced by: R9 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor conducted a review of R9's medical record and noted that R9 was being seen by [NAME] (wound management) and there was a progress note dated 11/9/21. The note stated that following: Focused Wound Exam (Site 1) UNSTAGEABLE (DUE TO NECROSIS) SACRUM FULL THICKNESS Etiology (quality) Pressure MDS 3.0 Stage Unstageable Necrosis Duration > 53 days Objective Healing Wound Size (L x W x D): 4 x 5.5 x 0.3 cm Surface Area: 22.00 cm² Cluster Wound Periwound radius: Callus Exudate: Moderate Sero - sanguineous Slough: 40 % Granulation tissue: 20 % Skin: 40 % This wound is in an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of a biofilm. Wound progress: No Change ADDITIONAL WOUND DETAIL Was seen by [NAME] physician in past, and wound has changed since last evaluation. hospitalized , finished therapy in [name of state], and now transferred to [NAME] SNF for long term care. Although it has some non-blanching areas, slough, and is slightly larger, it does have sections of intact skin. Clinically, these even out and is not changed from prior (all granulated 4 x 5 x 0.1) wound debrided, tolerated well. Issues with urine getting under the foam dressing - will try waterproof gauze island to see if it helps. If adhesive is too harsh despite skin prep, consider using gauze and covering with transparent film. Encouraged offloading, changing position for short periods using upper body, keeping head of bed less than 30 degree to offload wound, etc Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility's skin / wound note dated 11/22/2021 at 08:22 a.m., R9 was admitted with unstageable pressure ulcer to her right buttock measuring. Today it measures 2.7 x 6.5 x 0.2 with 25 necrotic tissue, 25% slough and 50% granulation tissue. Moderate drainage noted. Resident on an air mattress. She is incontinent of B and B. Product in place. Encouraged resident to try to position self-off this right buttock when able. She denies pain and discomfort to the area. Last debrided 11/16/2021. Vorah wound MD scheduled to see resident 11/23/2021. Resident now with foley catheter in place for wound healing. Resident very incontinent of urine and dressing needed to be replaced multiple times a day r/t urinary incontinence. Foley draining clear yellow to amber colored urine without complication. Skin/ Wound note dated 11/29/2021 at 07:05 a.m., Late Entry; R9 was admitted with an unstageable pressure injury to her right buttock. Today it measures 5.7 x 5 x 0.2. There is a circular area inside these measurements with necrotic tissue which measures 2.7 x 2.2 x 0. Resident denies pain and states that she has been lying on her back more this week. She was educated that it would be best if she could lay on her side. She verbalized understanding and agrees to try to stay off her back. No odor is present, moderate s/s drainage is noted. MD scheduled to visit resident tomorrow and this wound will more than likely need manual debridement. She denies pain to the area. Skin/ wound note dated 12/23/2021 at 2:37 p.m., Wound MD into see resident today and gave orders to start a wound vac when available to right buttock/sacral ulcer. Continue [MEDICATION(S)] to right heel eschar. Surveyor conducted a review of the Significant Change MDS (Minimum Data Set), dated 3/23/22. The MDS indicates that R9 has a indwelling catheter in place. It also indicates that R9 had 2- stage #4 pressure injuries, present upon admission. The Care Area Assessment (CAA) for Catheter stated: Nature of the problem/condition: RES IS INCONTINENT OF BOWEL AND HAS FOLEY CATHETER FOR BLADDER AND HAS DEFICIT IN MOBILITY REQUIRES STAFF OF 2 WITH TRANSFERS. RES HAS DX OF DEPRESSION AND AT TIMES HAS DIFFICULTY MAKING NEEDS KNOWN *Will Urinary Incontinence and Indwelling Catheter be addressed in the care plan? Yes, Objective: improvement, avoid complications and minimize risks *Describe impact of this problem/need on the resident and your rationale for care plan decision. (Include complications and risk factors and the need for referral to other health professionals) RES HAS BEEN IDENTIFIED AS HAVING INCONTINENCE DUE TO WEAKNESS AND MOBILITY, DEPRESSION. RES CONT ON FOLEY CATHETER DUE TO WOUNDS AND DX OF [CONDITION(S)] AND MS TO DECREASE OR MAINTAIN CURRENT FUNCTION SEE RES CURRENT MEDS. STAFF TO ASSIST WITH 2 FOR TRANSFERS HOYER LIFT AND 1 WITH PERICARE AND CLOTHING MANAGEMENT. RISK INCLUDE SKIN BREAKDOWN, [CONDITION(S)], CONFUSION. Surveyor conducted a review of the Individual Plan of Care for R9. It was noted that the plan of care did not include anything regarding the use of the indwelling Foley catheter to assist in wound healing. R9 has a history of urinary tract infections and the plan of care did not address this along with continuing to assess the use of the Foley catheter as wound healing progressed. Nursing noted dated 3/19/2022 at 03:24 a.m., R9 is afebrile. Interim. Alert and oriented per baseline. HOB elevated to ease respirations. No pedal [CONDITION(S)] noted. Abdomen soft, nontender to touch. Bowel sounds active all 4 quadrants. Foley catheter patent draining clear yellow urine. Wound vac intact and patent to sacral wound. Continues on IV [MEDICATION(S)] for tx of [CONDITION(S)] and IV [MEDICATION(S)] for tx of sacral wound infection. No adverse reaction to abx's noted. No s/sx of inflammation noted at PICC site. No c/o discomfort at this time. Skin/ Wound Note dated 5/19/2022 at 7:49 a.m., Wound MD was into see resident last night for sacral ulcer and right heel ulcer. NOR. Wound vac dc. See details in misc tab vorah note. Skin/ Wound note dated 6/9/2022 at 2:46 p.m., Wound MD off this week. Nursing wound rounds done by DON- B. Right heel wound improving and measures 0.2 x 1 x 0.3 50% gran and 50% slough, skin tear to right heel 0.9 x 0.4 x 0 almost healed. Sacral pressure injury measures 7.0 x 4.5 x 2.7 with undermining 4 cm at 11 o'clock. moderate drainage noted to dressing. Peri-wound pale and without complication. No odor noted to wound. Resident denies pain to both areas. Air mattress in place. Continues on PO ABT x 2 for [CONDITION(S)] in the sacral wound. Nursing note dated 5/26/2022 at 9:58 a.m., Medicare meeting was held on 5-25. R9's heel wound is improving. She requires daily dressing changes. Catheter possibly being discontinued next week. Patient meets with Wound MD. Patient will remain in facility for LTC. Nursing note dated 6/3 stated that lab results faxed to MD. Order for [MEDICATION(S)] 100 mg po q daily x 7 days. Nursing note dated 6/13/2022 at 02:10 a.m., R9 started on po [MEDICATION(S)] 100mg qd x 7 days per the ua results, this order was faxed over by MD earlier this shift. med to start in the am. resident continues with Foley and clear yellow urine. Surveyor made observation of R9 on 06/13/22 02:43 PM awake lying in bed. TV on. Air mattress in place. Cath beg in place with privacy cover. Nursing note dated 6/14/2022 at 2:07 a.m. R9 is afebrile. Continues the [MEDICATION(S)] and [MEDICATION(S)] for tx of [CONDITION(S)] in sacral wound. Resident is on the [MEDICATION(S)] for tx of [CONDITION(S)]. Foley catheter patent draining clear yellow urine. Dressing intact to sacral wound. No adverse reaction to abx's noted. On 6/14/22, Surveyor interviewed DON- B in regard to R9's continued use of the indwelling catheter for wound healing. Surveyor asked about the nursing noted dated 5/26/22 where there was mention that R9's catheter might be discounted in the next week. DON- B stated that the Wound MD was going to follow-up on the next visit and then he was on vacation, so it didn't get addressed yet. DON- B stated she would follow up on the issue. DON- B was asked why there was not a plan of care and continued assessment for the need of the indwelling catheter for R9. DON- B stated that she would have to review the medical record before answering. Skin wound note dated 6/14/2022 at 11:46 a.m., Discussed catheter with Wound MD on 05/26/2022. He stated that we would leave it in for wound healing at this time. He will re-evaluate on his next visit. Discussed resident again at this time with Wound MD and he wishes for the catheter to stay in until he is able to assess the wound tomorrow afternoon. At that time, he will make a decision. Nursing note dated 6/15/2022 at 3:47 a.m., R9 is afebrile. Continues on the [MEDICATION(S)] and [MEDICATION(S)] to tx [CONDITION(S)] in sacral wound. Resident is on the [MEDICATION(S)] to treat yeast in her urine. No adverse reaction to abx's noted. As of the time of exit, the facility was not able to provide additional information as to why R9's use of the indwelling catheter for wound healing was not assessed for the need for continued use. The facility did not develop a plan of care with interventions to avoid the possibility of R9 being diagnosed with an urinary tract infection while the indwelling catheter was in place and also recently developed a yeast infection in the urine. There was no goal for the removal if the indwelling catheter.

Based on observation, record review, and interview, the facility did not ensure each Resident received adequate supervision or assistance devices to prevent accidents for 1 (R38) of 4 Residents reviewed for falls. * R38 had a fall on 6/11/22. R38 has an intervention documented on R38's care plan to not place R38 in a nightgown until ready for bed and to encourage R38 to stay in common area after supper to detour R38 from attempting to self transfer to bed. R38's fall incident report documented R38 was placed in night gown and left in R38's wheelchair. Findings Include: Surveyor reviewed the facility's Fall Prevention and Management Guidelines policy and procedure revised 3/10/21 and noted the following: Policy The facility will maintain a fall prevention and management program. Fall Prevention and Management Guidelines Objectives: *Limit or prevent the occurrence of falls with the parameters that can be controlled through structured program interventions. Details of Key Elements B. Plan of Care 1. Specific interventions should be developed based on results of the fall assessment and individual Resident's preferences. 2. As information is updated, it needs to be communicated to the staff, Resident and family. C. Evaluation 1. Complete a post fall evaluation and completed required notification after every fall. 2. Activate reporting mechanism/tracking of falls within the facility 3. Facility protocol should include falls management review and analysis by the QAPI committee. R38 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Type 2 Diabetes mellitus, [CONDITION(S)], Major Depressive Disorder, and Adjustment Disorder with Mixed Anxiety and Depressed Mood. R38 has an activated Health Care Power of Attorney (HCPOA). R38's Quarterly Minimum Data Set (MDS) documents R38's Brief Interview for Mental Status(BIMS) score to be a 2, indicating R38 demonstrates severely impaired skills for daily decision making. R38's MDS also documents that R38 requires extensive assistance for bed mobility, transfers, and toileting. R38's Certified Nursing Assistant (CNA) care card dated 6/15/22 documents the following for Safety: *2/15/22 Do not put R38's nightgown on until he is ready to go to bed *4/8/22 Encourage R38 to stay in common areas after supper to detour R38 from attempting to self transfer to bed R38's comprehensive care plan documents that R38 is at risk for falls due to deconditioning/weakness Initiated 4/21/21 Interventions documented for R38 2/15/22 Do not put R38's nightgown on until R38 is ready to go to bed 4/8/22 Encourage R38 to stay in common areas after supper to detour R38 from attempting to self transfer to bed Surveyor reviewed the fall incident report dated 6/11/22. The incident report indicates R38 is at risk for falls. R38 was found on the mat next to the bed. R38 was interviewed and indicated he was trying to lay down. R38 was assessed for injuries and none were indicated. Surveyor notes that the physician and HCPOA was notified. Surveyor also notes that neurochecks were completed per policy and procedure. The following statement was obtained from CNA-L: R38 was in R38's room in R38's wheelchair. R38 had dinner and I took out R38's tray and got R38 in R38's gown and changed R38's brief in the bathroom around 7:30 PM. At 9:00 PM, I found R38 in R38's room laying on the floor mat by R38's bed. Surveyor notes that R38 should have been in the common area and gown should not have been put on R38 until R38 was ready for bed per care card and care plan. Surveyor also notes that R38's care plan has not been updated with any new interventions from the 6/11/22 fall. On 6/15/22 at 10:37 AM, Surveyor interviewed Director of Nursing (DON-B) in regards to R38's 6/11/22 fall. DON-B stated: I have been talking to the staff about after dinner, to get R38 ready for bed and not leave R38 in a gown in R38's wheelchair. R38 gets tired and antsy so R38 needs to be laid down very soon after meals. DON-B stated that it is DON-B's responsibility to update the care plan. On 6/15/22 at 1:55 PM, Surveyor spoke to DON-B and shared the concern that R38's care plan interventions of leaving in common area until ready for bed and R38's gown should not be placed on until ready for bed was not implemented at time of fall. DON-B is in agreement that the interventions were not followed and understands the concern and agree that both interventions should have been in place. No further information was provided at this time.

Based on record review and staff interviews, the facility did not always ensure that 2 out of 5 (R7 and R9) residents reviewed for unnecessary medications and the daily use of a Anti-psychotic medication were comprehensively assessed for possible adverse consequences such as Tardive dyskinesia (abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected.) Monthly medication reviews, completed by the licensed Pharmacist, recommenced over a period of several months that both R7 and R9 have an AIMS (Abnormal Involuntary Movement Scale) assessment conducted to determine if there may be any adverse consequences to the continued use of a [CONDITION(S)] medications. The facility did not respond to these recommendations in a timely manner. This is evidenced by: 1. R7 was admitted on [DATE] with diagnosis that include [CONDITION(S)] with behavioral disturbance, hypertension, [CONDITION(S)], kidney failure, depressive disorder, [CONDITION(S)]. A review of R7's physician orders showed that R7 was receiving the following medication: [MEDICATION(S)] Tablet 25 MG ([MEDICATION(S)]) Give 1 tablet by mouth in the evening every Tue, Wed, Thu, Fri, Sat, Sun for delusions/hallucinations related to [CONDITION(S)] WITH BEHAVIORAL DISTURBANCE (F01.51) Give early per NP as res sundowns and ref after 1600 most meds AND Give 0.5 tablet by mouth every evening shift every Mon for delusions/hallucinations According to the annual MDS (Minimum Data Set), dated 3/31/22, R 7 has a BIMS (Brief interview for mental status) score of 1- severely impaired. R7 displays behaviors such as inattention- behavior present, fluctuates (comes and goes, changes in severity) Disorganized thinking- behavior present, fluctuates. R7 also received both antipsychotic meds and anti-depressant medications over the past 7 days. Yes- antipsychotics were received on a routine basis only. No GDR (gradual dose reduction) attempted. Yes- Physician documented GDR as clinically contraindicated- 3/22/22 R7's individual plan of care stated that R7 was at risk for adverse effects r/t use of antidepressant medication ([MEDICATION(S)]) prescribed for depression. Interventions included o AIMS (Abnormal Involuntary Movement Scale used to measure tardive dyskinesia, possible side effect for medication use) testing per facility guidelines (upon admission, initiation of, change of, every 6 months, and PRN). Surveyor conducted a review of the required monthly pharmacy review. On 11/15/21, the Pharmacist conducted a monthly review of medications. The pharmacist recommend that the facility check the AIMS for R7. This was again recommended on 12/15/21, 1/19/22 and 2/16/22. There was no evidence that the facility had followed up on the Pharmacist recommendations. Further review of the medical record showed that the facility had conducted an AIMS assessment on 5/21/21 and then not again until 2/25/22. R7's score was a zero. A review of the instructions for the AIMS assessment stated the following: *This exam is used for assessing side effects of antipsychotic drugs only; it should not be used for antianxiety, antidepressant or sedative drugs. Complete examination procedure before making rating. For all MOVEMENT ratings (section A, B, and C) rate highest severity observed. Check one code for each evaluation. Complete upon admission, initiation of antipsychotic med; change of antipsychotic med, and every 6 months. On 6/15/22 at 1:30 p.m., Surveyor interviewed DON (Director of Nursing)- B in regard to the monthly pharmacy reviews. DON- B stated that she reviewed the monthly recommendations from the Pharmacist and will forward any recommendations onto the physician for review and any changes. Surveyor asked DON- B why the facility did not respond to the Pharmacist's recommendations for R7 to have an AIMS assessment done from November, 2021 through February, 2022. DON- B responded that she was not aware of those recommendations. 2. R9 was admitted on [DATE] with diagnosis that included [CONDITION(S)], abnormal posture, muscle weakness generalized, [CONDITION(S)], mood disorder, visual hallucinations, major depressive disorder, hypertension. Surveyor conducted a review of the Significant Change MDS (Minimum Data Set) dated 3/23/22. R9 had a BIMS (Brief Interview for mental status) of 13- cognitively intact. R9 did not have any behaviors noted. R9 used antipsychotic medications for the last 7 days prior to this assessment. A review of the Individual Plan of Care for R9 stated; at risk for adverse effects r/t use of antidepressant medication ([MEDICATION(S)]) prescribed for depression and use of antipsychotic medication ([MEDICATION(S)]) for mood disorder due to unknown physiological condition (F06.30). 11-23-21 GDR of psych meds clinically contraindicated. 02-24-22 GDR of psych meds clinically contraindicated. Interventions included: AIMS testing per facility guidelines (upon admission, initiation of, change of, every 6 months, and PRN) Surveyor conducted a review of the required monthly pharmacy review. On 11/15/21, the Pharmacist conducted a monthly review of medications. The pharmacist recommend that the facility check the AIMS for R9. This was again recommended on 12/15/21, 1/19/22 and 2/16/22. There was no evidence that the facility had followed up on the AIMs recommendations from the Pharmacist dated 11/15/21, 12/15/21, 1/19/22, and 2/16/22 until 2/25/22. Further review of the medical record showed that the facility had conducted an AIMS assessment, upon admission on 11/4/21 to establish a baseline. The facility conducted an Initial AIMS assessment on 2/25/22 with a score of 7. The assessment suggests that a referral for a neurological assessment be made based on the AIMS results. It was noted that the facility did not follow-up on a neurological referral for R 9. On 6/15/22 at 1:30 p.m., Surveyor interviewed DON (Director of Nursing)- B in regard to the monthly pharmacy reviews. DON- B stated that she reviewed the monthly recommendations from the Pharmacist and will forward any recommendations onto the physician for review and any changes. Surveyor asked DON- B why the facility did not respond to the Pharmacist's recommendations for R9 to have an AIMS assessment done from November, 2021 through February, 2022. DON- B responded that she was not aware of those recommendations.

Based on staff interview and record review, the facility did not ensure the facility-wide assessment was reviewed and updated at least annually. This had the potential to effect all 40 Residents. The facility did not review and update the facility assessment since 11/1/2017. The facility assessment was last reviewed with QAA (Quality Assessment and Assurance)/QAPI (Quality Assurance and Performance Improvment) committee on 11/28/17. Findings Include: Surveyor reviewed the facility's Facility Assessment Tool policy dated 10/2017 and notes the following: Requirement Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their Resident population and the resources the facility needs to care for their Residents. Guidelines for Conducting the Assessment 3. The facility must review and update this assessment annually or whenever there is/the facility plans for any change that would require a modification to any part of this assessment. On 6/14/22 at 1:32 PM, Surveyor reviewed the facility assessment and noted the date of 11/1/2017, meaning the facility assessment has not been updated on annual basis. On 6/15/22 at 2:36 PM, Nursing Home Administrator (NHA)-A verified the facility assessment, dated 11/1/2017, was the most recent facility assessment available. NHA-A revealed no facility assessment review or revision was completed since that date. NHA-A stated, I may or may not know it is part of the regulation to update the assessment on a annual basis. Surveyor asked NHA-A if the facility assessment had been reviewed at QAPI committee meetings. NHA-A states that maybe parts of the facility assessment have been updated through QAPI, but is not able to specify what parts of the facility assessment may have been updated. NHA-A stated NHA-A has no documentation that the facility assessment was reviewed and updated through the QAPI process. NHA-A stated, I will need to get it updated.

Based on record review and interviews, the facility did not ensure a resident's advanced directives for code status were implemented. This was observed with 1 (R1) of 5 sampled residents. R1 was admitted to the facility on [DATE]. At the time of admission, the facility presented a CPR/DNR (cardiopulmonary resuscitation/do not resuscitate) to R1's spouse who indicated R1 wanted to have a DNR for their code status. R1 was their own person and should have made their own decisions. On [DATE] the facility presented the CPR/DNR form to R1 who continued to indicate they wanted DNR as their code status. This form was signed by R1 and witnessed by facility staff. The facility did not process the form beyond this point and did not obtain physician orders to confirm the DNR status; without the signed physician order, R1 remained having a full code status. This meant R1 would receive CPR in a code situation despite R1 designating their specific wishes regarding code status. On [DATE] R1 again signed a facility CPR/DNR form indicating they wanted to have DNR as their code status. Again, the facility did not process the advanced directive form and obtain physician orders to reflect R1's wishes. On [DATE] R1 experienced a change in condition that led to R1 becoming unresponsive and pulseless requiring invoking R1's code status. Facility staff did not demonstrate a timely response to the code situation and began calling R1's spouse for input on what to do regarding the code status. Despite R1 indicating consistently the intent to not receive CPR, R1 was provided CPR on [DATE]. R1 did not survive the code status and was pronounced deceased following the event. The facility's failure to ensure the advanced directives signed by R1 designating their code status was processed correctly and to ensure physician orders to legally designate R1 as having a DNR code status led to a situation of immediate jeopardy that began on [DATE] when R1 received CPR despite indicating DNR status. Surveyor notified Administrator-A and DON-B (Director of Nurses) of the immediate jeopardy on [DATE] at 11:03 AM. The immediate jeopardy was removed on [DATE] when the facility initiated an audit process to verify code status and the deficient practice corrected on [DATE]. This is being cited as past noncompliance. Findings include: The facility's Do Not Resuscitate (DNR) - No Extraordinary Life-Saving Measures policy and procedure, dated [DATE], was reviewed by Surveyor. The procedure indicates under section 3: This wish will be shared with the resident's family, responsible person, and physician. Under section 5, it indicates a copy of these documents will be maintained in the resident's record, sent to the family/responsible person and the physician. Under section 9, if the resident is uncomfortable, struggling, or in pain, emergency services will be called for palliative measures. Surveyor reviewed R1's medical record due to a concern with R1's death at the facility. R1 was admitted to the facility on [DATE] for respite care and was their own person regarding decision making. R1 used a wheelchair for mobility and was on continuous oxygen for [CONDITION(S)]. R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record included a form that asked/explained if you want to be resuscitated or did not want to be resuscitated. On [DATE] R1's spouse signed this form and indicated no resuscitation was to be completed for R1. This indicates on the form no CPR (cardiopulmonary resuscitation), or external defibrillation is to be completed, and to refer to State approved DNR (do not resuscitate) form if required. Surveyor noted there was not a State form located in the medical record. Surveyor also noted there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon further review, it was noted, R1 did not have an activated POAHC (power of Attorney for Healthcare) meaning R1's spouse could not sign for R1's advanced directives. On [DATE] R1 signed the No Resuscitation with 2 facility staff witnesses. Review of the record continues to indicate there was not a State form completed per policy and procedure in the medical record to indicate R1's DNR status. Surveyor also noted there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor noted there continued to be no State form located in the medical record and a physician order still was not obtained to designate R1 to have a DNR code status. On [DATE] at 2:50 PM Surveyor spoke with DON-B about the advance directive process. DON-B indicated the facility has their own form for a resident to sign to indicate their wish for CPR or DNR. DON-B indicated this is reviewed in the admission process. R1's admission DNR wishes were signed by the spouse. DON-B indicated they thought R1's spouse was the activated POA (Power of Attorney) so R1's spouse signed the DNR facility form on [DATE]. Then it was discovered that R1 does not have an activated POA, and the form was signed by R1 on [DATE]. R1's spouse could not provide paperwork that they were the activated POA. R1 wanted to be a DNR and signed the forms. DON-B indicated they typically then get a physician order and a State Form and place it in the medical record. DON-B indicated the nurse doing the admission or the unit manager does the physician order. R1 did not have physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON-B indicated the paramedics use the State Form for DNR status and R1 did not have one. On [DATE] at 3:03 PM Surveyor spoke with SW-L (Social Worker) who indicated prior to the event involving R1 on [DATE], the facility did not have DNR bracelets or the State form in the facility to indicate code status. The facility self-report investigation statement from RN-D was reviewed. RN-D indicated that on [DATE] a CNA came into the breakroom and told them (R1) was not breathing . (R1) was taken out of the dining room and brought to the nurse's station. RN-D checked (R1's) code status and it was a DNR. (R1) was wheeled to R1's room and placed into bed. RN-D indicated that since (R1) had a change in condition they couldn't make decisions for themselves and called (R1's) spouse. (R1's) spouse indicated to call 911. RN-D indicated they took (R1's) vital signs and the temperature was 97.3 degrees Fahrenheit, pulse 103. blood pressure ,d+[DATE] and oxygen saturation at 100% with erratic breathing. RN-D indicated 911 came and wanted them to clarify (R1's) code status. RN-D called (R1's) spouse back and they wanted CPR done. RN-D indicated they left the room to get information the paramedics were requesting. RN-D indicated CNA-I and CNA-H started CPR with the paramedics and they stayed out of the way and at one point was holding an IV pole. On [DATE] at 9:46 AM Surveyor spoke to CNA-G who was working in the facility during this event. CNA-G indicated R1 was gasping for air in the dining room. CNA-H and RN-C were with R1. CNAs wheeled R1 to R1's room and laid R1 in bed. R1 was transferred to an oxygen concentrator. RN-D then called R1's spouse to get direction. R1's spouse wanted 911 to be called. RN-D then called 911 and indicated R1 is a DNR. CNA-G indicated everyone seemed confused and saw CNA-I start CPR on R1 because RN-D would not. CNA-G then went to tell RN-C that CPR was started. When we returned to R1's room the paramedics were doing CPR with CNA-I and CNA-H. RN-D did not call 911 right away because they kept saying R1 is a DNR. RN-D was yelling back and forth with CNA-I and CNA-H over doing CPR on R1. On [DATE] at 8:35 AM Surveyor left a message for CNA-I who participated in completing CPR with the Paramedics. There was not a return call for interview. The facility self-report investigation statement for CNA-I was reviewed. CNA-I indicated they were near RN-C in the hallway when CNA-H yelled out for help from the dining room. (R1) was not breathing. CNA-I and RN-C wheeled R1 out of the dining room. RN-D then appeared and RN-C asked about R1's code status. RN-D didn't know and had to look for it. RN-D returned and said (R1) is a DNR. RN-D called R1's spouse and they wanted 911 called. RN-C questioned why since (R1) is a DNR. Then CNA-I, CNA-H and RN-C put R1 in bed. Then RN-C left, and RN-D was in the room. CNA-I indicated RN-D started CPR on (R1). Then the paramedics came into the room and RN-D did not know if (R1) was a CPR or not. The paramedic asked who could do CPR, and CNA-I and CNA-H started CPR on (R1) and then RN-D returned and indicated (R1's) spouse wanted CPR done. The paramedics placed an IV (intravenous) line into (R1's) leg and set-up machine as CNA-I and CNA-H did CPR on (R1). On [DATE] at 9:20 AM Surveyor spoke with RN-D. RN-D indicated there was no DNR order for the paramedics. They started CPR with CNA-I and CNA-H in the room. The facility submitted a self-report investigation to the State Agency on [DATE]. R1 had breathing difficulties in the dining room and was eventually wheeled to their room and placed in bed (Cross-reference F684). The staff took time to determine R1's code status and RN-D (Registered Nurse) did not call the physician right away due to the conflicting designated code status. RN-D called the family for direction. Then 911 was called. The physician. nor emergency response, was contacted or consulted when R1 was experiencing breathing difficulties and decreased responsiveness. When 911 personnel arrived at the facility R1's code status was not available on the required forms. RN-D called the family again for direction. The family directed CPR to be performed. R1's wishes were DNR and were not processed correctly to honor this directive. The 911 personnel, along with Agency CNA (Certified Nursing Assistant) staff performed CPR on R1. R1 did not respond to CPR measures and passed. The Paramedic Report indicates they were called at 12:49 PM on [DATE]. They arrived to R1 at 12:52 PM and R1 was unresponsive and had no pulse. The summary of events indicate code status for (R1) was requested by emergency personnel upon entering the facility. The RN indicated (R1) was a DNR and the spouse wanted 911 to be called. The RN was not able to provide paperwork for DNR status. The Agency CNAs assisted the paramedics with CPR measures. The RN kept leaving the room before questions could be asked of them. The CNAs in the room were upset that the RN kept leaving the room. (R1) did experience a heart rhythm change for a short time with CPR then ceased. (R1) was pronounced dead at 1:22 PM by paramedic staff. On [DATE] at 1:05 PM Surveyor called the Paramedic Station to talk with EMT-K (Emergency Medical Tech) that completed the report. There was not a return call for interview. The facility self-report investigation did not contain an interview with the paramedics involved in R1's code event. As evidenced above, facility staff initially did not know what R1's advance directives were. Staff, at some point, either before or at the direction of the paramedics, began CPR. Paramedics were required to begin CPR because there was no legal document indicating R1 did not want to be resuscitated. According to Five Possible Side Effects of CPR, You Should Know, The methods used in Cardiopulmonary Resuscitation can have adverse effects such as the following: 1. Aspiration & Vomiting: The most frequent occurrence during CPR, vomiting can present a danger to the [CONDITION(S)] victim. Since the [CONDITION(S)] victim is unconscious, he cannot clear the vomit from his mouth. If not cleared, the victim is likely to aspirate (inhale) it into his lungs, blocking the airway and leading to possible infection. 2. Broken Ribs Bone: A rib fracture is the most common complication of CPR because the force of chest compressions is likely to break ribs. Other chest injury related to chest compressions are sternal fracture and other uncommon complication like lung contusion, pneumothorax, and haemothorax. In the elderly, this is significantly more common due to the brittleness and weakness of their bones. Broken ribs present danger because a broken rib could puncture or lacerate (cut) a lung, the spleen, or the liver. They are also very painful. The frequency of rib fractures associated with out of hospital cardiopulmonary resuscitation is underestimated by conventional chest x-ray. 3. Internal Brain Injuries: Since CPR leaves the brain receiving 5% less oxygen than normal, brain damage is possible. Brain damage occurs within 4 to 6 minutes from the time the brain is deprived of oxygen, and after 10 minutes, it definitely occurs. This can lead to long-term health complications. 4. Abdominal Distension: As a result of air being forced into the lungs, the abdomen of the [CONDITION(S)] patient usually becomes distended (bloated) and full of air during CPR, leading to compression of the lungs (making ventilation more difficult) and an increased chance of vomiting. 5. Aspiration Pneumonia: The result of vomit and foreign objects (like a person's own teeth) being inhaled into the lungs can lead to aspiration pneumonia. This can be very dangerous to a victim's health and could complicate recovery, or even be fatal, even if the [CONDITION(S)] victim does survive CPR. Overall, all of these side effects mean that if a person survives CPR, their long-term health could suffer and be alive. But their overall health and quality of life may be significantly affected. Additionally, the psychological ramifications of a near-death experience can substantially affect a survivor, leading to anxiety, stress, and depression, among other psychological conditions. https://www.mycprcertificationonline.com/blog/five-possible-cpr-side-effects-you-should-know/ The facility's failure to ensure R1's advanced directive decision to not receive CPR and to have a DNR code status properly designated and ordered by a physician created a situation of immediate jeopardy that started on [DATE] and was removed on [DATE]. On [DATE] the facility completed staff training regarding the facility policies and procedures regarding code status and established a system to ensure the residents code status is correctly designated and ordered. Additionally, the facility established a process to utilize the State of Wisconsin bracelet form including use of the DNR bracelets. Facility audit on [DATE] verified that the code status of all residents was correct and that residents with DNR orders had DNR bracelets. On [DATE] at 10:45 AM Surveyor spoke with Administrator (NHA)-A. NHA-A indicated they did start education for code status requirements, including obtaining DNR bracelets. They started mock codes. They educated on how to determine if someone is their own person.

Based upon interview and record review, the facility failed to ensure 1 (R1) of 5 sampled residents reviewed for a change in condition received care and treatment to reach their highest practicable well-being based upon assessment and current standards of practice, in particular, N6 Wisconsin Nurse Practice Act. On [DATE] R1 was observed in the facility dining room to experience a change in condition that included difficulty breathing including grasping for air and panic while grabbing R1's throat as R1 struggled to breathe. Nursing staff did not complete a thorough assessment that was shared with the physician for consultation on what care and treatment should be provided to R1. As R1's condition progressed, nursing staff attempted to have R1 moved from the dining room to the resident's room and transferred to bed instead of assessing R1 and calling 911 or consulting with the physician. Following transfer to his room, R1 became unresponsive and pulseless and 911 was called only after facility nursing staff called R1's spouse to ask what the spouse wanted done for R1. 911 was indicated as being called for supportive measures. Statements from staff provide conflicting details on the care provided to R1 however, no staff indicated R1's physician was consulted with. There also is no documented indication an assessment was completed by the RNs on duty. In RN-C's statement dated [DATE] it is stated both RN-C and RN-D stood there observing R1 as R1 became apneic and grey in the face with RN-D allegedly stating R1 is gone, R1 is going. The failure of nursing staff to assess R1 and consult with R1's physician regarding R1's change in condition or immediately calling 911 to address the difficulty in breathing created a delay in care for R1. This delay led to R1 becoming unresponsive and pulseless. This created a situation of immediate jeopardy that started on [DATE]. Surveyor notified Administrator (NHA)-A and DON-B (Director of Nurses) of the immediate jeopardy on [DATE] at 11:03 AM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's Change in Condition of the Resident (Observing, Recording, and Reporting) policy revised on [DATE] was reviewed by Surveyor. The procedures include under section 3 the following: a. Immediate notification for any symptom, sign or apparent discomfort that is acute/sudden onset; a marked change in relation to usual symptoms; unrelieved by measures already prescribed requires a phone call to the provider. Wisconsin's Nurse Practice Act N6 indicates: An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R1 was admitted to the facility on [DATE] for respite care and was their own person regarding decision making. R1 used a wheelchair for mobility and was on continuous oxygen for [CONDITION(S)]. R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record included a form that asked/explained if you want to be resuscitated or did not want to be resuscitated. On [DATE] R1 signed the No Resuscitation facility form with 2 facility staff witnesses. There was not a State form located in the medical record to indicate R1's DNR status nor was there a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no State form located in the medical record and there continued to be no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:16 PM Surveyor spoke with DON-B (Director of Nurses) regarding R1 events on [DATE]. DON-B indicated RN-D was on break. R1 was having breathing difficulties in the dining room. CNA-H got RN-C. CNA-H indicated RN-C did not assess R1 and they could not find RN-D. RN-D thought R1 had an activated POA (Power of Attorney) for Healthcare. RN-D then called 911 after talking with spouse. The paramedics wanted RN-D to call the family to determine what measures they wanted done for R1. The paramedics started CPR. The CNAs wanted RN-D to start CPR and were yelling at each other. RN-C was not involved in the code itself. The CNAs were yelling at RN-D and the paramedics were asking RN-D to get information from R1's chart. On [DATE] at 8:25 AM Surveyor left a message for CNA-H. There was not a return call for interview. The facility self-report investigation statements by CNA-H were reviewed. CNA-H's statements indicate R1 was wheeled into the dining room for lunch around 12:10 PM. At this time, R1 was having trouble breathing and pointing to their throat so they got RN-C right away. RN-C told CNA-H to check the oxygen tank and tubing while R1 told CNA-H that R1's chest was burning. RN-C just adjusted the oxygen tubing, and RN-C indicated this was normal for R1 to have breathing concerns after using the bathroom. RN-C told R1 to breathe out of the nose instead of the mouth but R1 was not following directions and was just staring into space. RN-C put their hand over R1's mouth to try to force R1 to breathe through the nose. RN-C then said this is not RN-C's resident and RN-C then left the dining room telling the CNA to go find R1's nurse. All the staff were searching for RN-D and CNA-H indicates that it took ,d+[DATE] minutes to locate RN-D. By that time, R1 had been wheeled to R1's room and put in bed. CNA-H indicated RN-D was not around to answer questions for the paramedics and could not locate R1's code status and called the spouse. CNA-H, in her statement, does not indicate that a nurse assessed R1 or consulted with a physician. On [DATE] at 8:35 AM Surveyor left a message for CNA-I. There was not a return call for interview. The facility self-report investigation statement for CNA-I was reviewed. CNA-I indicated they were near RN-C in the hallway when CNA-H yelled out for help from the dining room. R1 was not breathing, and RN-C went into the dining room and was asking where RN-D was. RN-C then left the dining room. CNA-H then came back out of the dining room and said R1 is scaring the other residents and struggling to breathe. CNA-I indicated R1's oxygen piece was not in R1's nose and when put back R1 still could not breathe. CNA-I indicated R1 was hyperventilating and had a blank stare. CNA-I and RN-C wheeled R1 out of the dining room to the hallway. RN-D then appeared and RN-C asked about R1's code status indicating R1 was a DNR. RN-D didn't know and had to look for it. RN-D returned and said R1 is a DNR. RN-D called R1's spouse and they wanted staff to call 911. RN-C questioned why since R1 is a DNR. Then CNA-I, CNA-H and RN-C put R1 in bed. Then RN-C left, and RN-D was in the room. CNA-I indicated RN-D started CPR on R1 (this was later clarified by RN-D that RN-D did not do CPR on R1). Then the paramedics came into the room and RN-D did not know if R1 was a CPR or not. The paramedic asked who could do CPR, and CNA-I and CNA-H started CPR on R1 and then RN-D returned and indicated R1 spouse wanted CPR done. RN-D kept leaving the room and the paramedic were asking questions. The paramedics placed an IV (intravenous) line into R1's leg and set-up machine as CNA-I and CNA-H did CPR on R1. RN-C was not around, and RN-D kept leaving. CNA-I, in her statement, does not indicate that a nurse assessed R1 or consulted with a physician. On [DATE] at 9:10 AM Surveyor spoke with CNA-F who was in the facility at the time of the events. CNA-F indicated R1 was in the dining room and lunch was not served yet. CNA-I yelled out for the nurse due to R1 struggling to breathe. RN-C came into the dining room and took R1 out of the dining room and was trying to get R1 to respond. RN-C and CNA-H and CNA-I took R1 to R1's room and put R1 in bed. Then RN-D showed up. The CNAs were yelling at RN-D to do CPR and RN-D indicated R1 was a DNR. CNA-F saw RN-D do CPR then stopped before the paramedics arrived. Then CNA-I and CNA-H started CPR with the paramedics. CNA-F thought RN-C was also in the room to get paramedic's support. RN-D was at the Nurses station trying to find information about R1 code status and the CNAs were yelling they were calling the police because RN-D wasn't doing their job. CNA-F was taking care of the other residents during this event, however heard and saw some things. CNA-F, in her statement, does not indicate that a nurse assessed R1 or consulted with a physician. On [DATE] at 9:20 AM Surveyor spoke with RN-D. RN-D indicated they were taking their lunch break and the CNA (doesn't recall who) got me for an emergency. RN-C was at the nurse's station taking care of R1. RN-D checked R1's code status and it was DNR. R1 was still breathing at the nurse's station and unresponsive. R1 was a no code so they called R1's spouse for direction. RN-D did not indicate why they did not call the physician or 911 at this point. RN-D indicated R1 was a DNR and did not elaborate. RN-D indicated CNA-I and CNA-H were yelling at them to do CPR. These CNAs would not leave R1's room when the paramedics arrived. RN-D indicated they were yelling with CNA-I and CNA-H that R1 was a DNR and to leave the room. RN-D indicated they were in R1's room with the paramedics holding the IV bag for them. RN-D also indicated they were asked for medical information from R1's medical record and left the room. The paramedics wanted R1's spouse called for clarification of code status. RN-D called R1's spouse and they wanted CPR done. RN-D did not have a response for the DNR paperwork or R1's wishes to be a DNR. RN-D indicated CNA-I and CNA-H were yelling and threatening them. RN-D indicated they did not do CPR on R1. RN-D indicated they assessed R1 in their room and had vital signs and was awake before paramedics arrived. RN-D indicated there was no DNR order for the paramedics. They started CPR with CNA-I and CNA-H in the room. RN-D indicated if R1 was unresponsive in the dining room they would have called 911 and indicated RN-C was taking care of R1 in the dining room The facility self-report investigation statement from RN-D was reviewed. RN-D indicated a CNA came into the breakroom and told RN-D there was an emergency in the dining room. RN-D went to R1 and R1 looked white as a ghost, and R1 was still breathing. RN-D indicated R1 was a DNR, and had a 99% carotid artery blockage. RN-D indicated they called R1's spouse and asked if they wanted RN-D to call 911 for support and R1's spouse indicated yes. RN-D indicated they called 911 thinking R1 had an activated POA. RN-D indicated RN-C and the CNAs got R1 in bed and RN-D assessed R1. Surveyor noted there is no documentation to indicate the details of an assessment. RN-D indicated R1's pupils were dilated and R1 was breathing erratically and was gasping. RN-D indicated 911 arrived and began working on R1 and the CNAs were telling RN-D to do CPR but R1 was a DNR. RN-D indicated the CNAs were going to call the spouse and were yelling at RN-D. RN-D indicated multiple calls were made to R1's spouse indicating on first call the spouse did not change R1's code status, 911 called for supportive measures because R1 was still breathing. RN-D indicated R1 must have stopped breathing while 911 was working on him because RN-D was asked if they should do CPR, so RN-D called the spouse to ask and the spouse said to do CPR. RN-D returned to the room and told them yes. On [DATE] at 9:46 AM Surveyor spoke to CNA-G who was working in the facility during this event. CNA-G indicated R1 was gasping for air in the dining room. CNA-H and RN-C were with R1. They were trying to get R1 to respond to them and grabbed R1 legs to straighten them up in the wheelchair. RN-C indicated to find R1's nurse (RN-D). RN-D came to the dining room and R1 was wheeled out to the nurse's station. CNA-G indicated it took a while find RN-D. They thought it took up to 5 minutes to find RN-D. The RN-C and some CNAs wheeled R1 to R1's room and laid R1 in bed. R1 was transferred to an oxygen concentrator. RN-D then called R1's spouse to get direction. R1's spouse wanted 911 to be called. RN-D then called 911 and indicated R1 is a DNR. CNA-G indicated everyone seemed confused and saw CNA-I start CPR on R1 because RN-D would not. CNA-G then went to tell RN-C that CPR was started. When we returned to R1's room the paramedics were doing CPR with CNA-I and CNA-H. RN-D did not call 911 right away because they kept saying R1 is a DNR. RN-D was yelling back and forth with CNA-I and CNA-H over doing CPR on R1. On [DATE] at 11:10 AM Surveyor spoke with RN-C. RN-C indicated their medication cart was by the dining room and they heard CNA-H come out and say R1 is having a hard time breathing. RN-C went to R1 and fixed their oxygen tubing and took an oxygen saturation, which was 100%. R1 was not eating yet, their color was good, and their vital signs were good. RN-C then left the dining room. CNA-H came back out of the dining room and said R1 is not breathing. RN-C indicated R1 was talking, however was having a hard time breathing. RN-C indicated R1 was tensing up their body and felt they were getting anxious over breathing. RN-C tried to move R1 out of the dining room, however R1 was tall, and their feet were blocking the wheelchair wheels. Other residents in the dining room were getting scared. R1's oxygen saturations were dropping. RN-C indicated CNA-H was panicking. R1's lips were turning blue, and the oxygen saturation continued to drop. RN-C had CNA-H tilt R1's wheelchair back and wheeled R1 out of the dining room. R1's pulse became erratic. Another CNA was in the hallway, and they told them to get RN-D. They could not locate RN-D right away and RN-D was not in the breakroom. RN-C indicated R1 has spells of not breathing at times. RN-C still did not know R1's code status and R1 was not responding. RN-C wanted to get R1 in their bed in case they need to do CPR. RN-C assumed someone had already called 911. RN-C did not call 911 or R1's physician. After R1 was in bed they had a low pulse and RN-D indicated R1 is a DNR. RN-D left the room to call 911. CNA-I and CNA-H wanted CPR done and were getting worked up and wanted 911 and the physician called. RN-D was indicating R1 was a DNR, and we don't do anything. RN-C tried to calm the CNA's down then left R1's room because RN-D was now there. RN-C indicated CNA-H and CNA-I were yelling and crying and arguing with RN-D. There were police in the facility calming people down. RN-C's statement dated [DATE] indicated they were by a resident room when a CNA got them. RN-D was at lunch. R1 had complaints of shortness of breath to the CNAs so she went to assess. RN-C checked the oxygen tank, and it was ½ full and R1 was breathing deeply. RN-C indicated the CNA said R1 had just been toileted and was brought to the dining room. RN-C tried to check R1's O2 sats but R1's fingers were cold. RN-C traced the oxygen line from R1's face to the tank and it was behind R1's back but it was not pinched or kinked. RN-C tried to tell R1 to breathe through the nose and out through the mouth. RN-C indicated it looked like R1 recovered and said that was getting scary and R1 indicated feeling better. RN-C left the dining room to go get the vitals machine. At this time, CNA was calling into the hallway R1 was hyperventilating. RN-C went back & reapplied the O2 sensor and coached R1 to breathe through the nose and out through the mouth. RN-C indicated a CNA helped sit R1 up in a more upright position and the breaths were getting shallower. RN-C saw R1's lips turn blue and they still could not get an O2 reading. RN-C snapped fingers but could not get a response and RN-C moved R1 out of the dining room and wheeled R1 back to R1's room. RN-C asked a CNA to get the chart to check code status and to get RN-D. RN-D came out to the nurse's station and was asked if R1 was a DNR or full code. RN-D indicated they did not know and went to the chart and said No DNR No CPR. The CNA brought the chart to RN-C and it said DNR. RN-C then assisted R1 into bed while RN-D was possibly calling the spouse. RN-C indicated R1 was apneic breathing every few seconds, they could not get a pulse and R1 was grey in the face. RN-D stated R1 is gone, R1 is going. RN-C indicated the CNAs were saying you have to do CPR and RN-C told them no R1 is a DNR, his spouse said no CPR. RN-C indicated RN-D was getting vitals and RN-C left to allow RN-D to assess R1. RN-C went to the breakroom and heard people crying and screaming. The Paramedic Report indicates they were called on [DATE] at 12:49 PM. They arrived at the bedside at 12:52 PM and R1 was unresponsive and had no pulse. The summary of events indicates the code status for R1 was requested by emergency personnel upon entering the facility. The RN indicated (R1) was a DNR and the spouse wanted 911 to be called. The RN was not able to provide paperwork for DNR status. The Agency CNAs assisted the paramedics with CPR measures. The RN kept leaving the room before questions could be asked of them. The CNAs in the room were upset that the RN kept leaving the room. (R1) did experience a heart rhythm change for a short time with CPR then ceased. (R1) was pronounced dead at 1:22 PM by paramedic staff. R1's Nurses Note on [DATE] at 3:28 PM indicates the spouse was at the bedside and the physician was called to pronounce death. The Coroner was contacted due to a recent fall, also aware of history of asymptomatic severe right carotid artery stenosis. (R1's) body was released to the funeral home and end of investigation. Surveyor noted this was the only nurse's note regarding the events on [DATE]. Surveyor noted there is no documentation in R1's record of any vitals or assessments being completed on R1 on [DATE]. Surveyor noted during the change in condition, there is no indication R1's physician was consulted with or that RN-C stayed to assist in providing medical care to R1 during the change in condition. On [DATE] at 3:15 PM Surveyor spoke with MD-J (Medical Doctor). MD-J indicated with any change of condition with breathing or unresponsiveness they would expect to be called and emergency 911 should be called as well. MD-J indicated they were not called about R1's change in condition. R1 experienced breathing difficulties, with changes in responsiveness. Contrary to N6, there was, no immediate head-to-toe assessment, no immediate intervention, such as an immediate call to R1's physician or to 911. R1 started with a change in status before lunchtime (approximately 12:,d+[DATE]:15 PM) and the paramedics were not called until 12:49 PM. During this time there is no documented nursing assessment of R1's condition and no indication that nursing called the physician. This created a reasonable likelihood for serious harm, and thus created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when the facility implemented the following: ~ Education was initiated regarding change in condition and expectations to consult with the physician to be completed prior to staff assuming their next shift. ~ Licensed nursing staff were educated on the responsibility of being a lead nurse for assigned care and delegation of lead responsibilities when staff are on break. ~ Licensed staff were educated on the State of Wisconsin N6 regulations. ~ The facility established a policy and procedure regarding a charge nurse position that will be designated on the daily schedules. ~ The facility established a system to use the INTERACT regarding change in condition. ~ The facility established a process for auditing and addressing the facility's plan through QAPI.

Based on observation, record review, and interview, the facility did not comprehensively assess and document pressure injuries consistent with professional standards of practice to prevent development or worsening of pressure injuries for 1 (R3) of 3 residents reviewed for pressure injuries. Findings include: The facility policy and procedure entitled Pressure and Non-pressure Injuries dated 8/2/2021 states: Procedure: 1. Upon Admission: a. A head-to-toe body evaluation will be completed on every resident upon admission/readmission and will be documented on the Admission/Readmission Evaluation UDA. (User Defined Assessments). 2. Weekly: . b. Assess current wounds at least every seven days, or more frequently as needed (e.g., decline in wound, presence of infection, wound healed). R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated R3 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and coded R3 as needing extensive assistance with bed mobility, toilet use, and hygiene. A Risk for Skin Integrity Care Plan was initiated on 3/26/2019. On 5/22/2021, R3 was admitted to the hospital with a [CONDITION(S)]. R3 returned to the facility on [DATE]. On 5/27/2021 on the Admission/Readmission Evaluation form, the Braden scale score was 14 indicating moderate risk for pressure injury. Nursing documented in the Skin Integrity Section the right heel had a Stage 1 pressure injury measuring 1.5 cm x 1.5 cm and the left heel had a Suspected Deep Tissue Injury with a blister that measured 2.0 cm x 2.5 cm x 0.25 cm. In the Comments Section, nursing charted: Injuries noted above to heels and toes were not there when resident left to be admitted to the hospital a week ago. Heel [sic] were just at soft stage, skin prep and cushion used under heels. (R3) does not want to wear blue boots - kicks them off. Writer cleansed feet, applied skin prep to blister and area around pressure areas and tops of toes with DTP (deep tissue pressure) areas. The writer applied foam heel protectors f/b (followed by) Kerlix wrapped around to secure in place, for protection of heels and prevent worsening of blister and pressure areas. Note left for DON (Director of Nursing)/wound team with areas in question and measurements for them to further inspect and update treatment as needed. Res states pain to both heels and tops of 1st 3 toes on rt (right) foot (purple w/pressure area noted) and 1st 2 toes of lt (left) foot (red but blanchable, pain). No documentation was found on the right heel or the toes on the right and left foot after the initial assessment on 5/27/2021. A Bilateral Heel Pressure Ulcer Care Plan upon return from the hospital was initiated on 5/29/2021 with interventions to float heels when in bed, determine why (R3) refuses treatment and try alternative methods to gain compliance, and monitor/document/report as needed any changes in skin status such as appearance, color, wound healing, infection, wound size and stage. On 6/1/2021 on the Wound Evaluation Tracker form, DON-B documented the left heel pressure injury was a Stage 2 clear fluid filled blister that was noted on readmission. The blister measured 2.2 cm x 2.0 cm. The treatment was changed to skin prep to area and foam heel with rolled gauze every Tuesday, Thursday, and Saturday and as needed with offloading of heels. The left heel pressure injury was not comprehensively assessed from 6/1/2021 to 6/16/2021. On 6/16/2021 on the Wound Evaluation Tracker form, DON-B documented the left heel Stage 2 pressure injury measured 2.0 cm x 2.0 cm x 0.4 cm with 100% skin. On 6/23/2021 on the Wound Evaluation Tracker form, DON-B documented the left heel Stage 2 pressure injury measured 1.0 cm x 1.1 cm with 50% granulation and 50% skin. DON-B charted a small area was superficially open. No change in treatment was obtained. On 6/29/2021 on the Wound Evaluation Tracker form, DON-B documented the left heel Stage 2 pressure injury measured 0.5 cm x 0.5 cm x 0 with 100% skin. DON-B charted a small scab remained to the left heel. The left heel pressure injury was not comprehensively assessed from 6/29/2021 to 7/13/2021. On 7/13/2021 in the progress notes, DON-B charted the left heel Stage 2 pressure injury measured 1.4 cm x 1.1 cm x 0 cm and was painful to touch. A new order to add xeroform to the wound base was obtained. The treatments continued to be Tuesday, Thursday, and Saturday. No description of the wound base was documented. The left heel pressure injury was not comprehensively assessed after 7/13/2021. On 7/28/2021 in the progress notes, DON-B charted the left heel pressure injury was much improved and was not open to air per R3's request. On 8/3/2021 in the progress notes, DON-B charted the left heel Stage 2 pressure injury was closed and will keep a dressing in place for protection per R3's choice. On 8/31/2021 in the progress notes, DON-B charted R3 did not want the wound team to assess the pressure injury or have a dressing in place. R3 agreed to let DON-B look at the area. DON-B charted there was a small superficial area measuring 0.5 cm x 0.5 cm x 0.1 cm with epithelial tissue and the wound was not fully closed. DON-B charted the wound will continue to be assessed as allowed and treated as allowed. The pressure injury was not staged. R3 was admitted to the hospital from 9/4/2021-9/8/2021 for an upper [CONDITION(S)]. On 9/8/2021 on the Admission/Readmission Evaluation form, nursing charted the Braden scale score was 16 indicating at risk for pressure injury. Nursing documented in the Skin Comments Section a healing scab on the left heel. No measurements were documented. In an interview on 9/15/2021 at 11:10 AM, DON-B stated wound rounds are completed every Tuesday with DON-B, Assistant Director of Nursing (ADON), and Licensed Practical Nurse (LPN)-C. On 9/15/2021 at 11:15 AM, Surveyor observed the wound treatment to R3's left heel. R3 was lying in bed with heels floated on a heels up positioning device. R3 stated the device is used whenever R3 is in bed. LPN-C was assisted by ADON-D to complete the wound treatment to R3. R3 had a small brown area measuring approximately 0.5 cm x 1.0 cm. Skin prep spray was applied to the area and a foam dressing was put on the heel. In an interview on 9/15/2021 at 2:30 PM with DON-B and LPN-C, Surveyor asked what the process was for new admissions and readmissions. DON-B stated two nurses do the skin assessment as soon as possible once admitted or readmitted . DON-B stated if the nurse notices any wounds, they let DON-B know what they found and get a treatment in place right away by calling the attending physician. DON-B stated some residents come from the hospital with a treatment order in place already, but not always. DON-B stated the wound team follows through on the new wounds on Tuesdays or sooner if the nurse lets them know about a concern. DON-B stated the nurses use the Admission/Readmission Evaluation form and there is a comment box underneath the assessment to describe the wound more fully. Surveyor asked DON-B if there was no additional documentation in the comment box, where would the nurse chart a wound more comprehensively. DON-B stated they probably would not write it anywhere else. Surveyor reviewed the left heel pressure injury documentation with DON-B and LPN-C. Surveyor shared the concern R3's left heel pressure injury was not comprehensively assessed on readmission or weekly. DON-B stated DON-B saw R3 on 6/1/2021 and assessed both heels at that time. DON-B stated the right heel did not have any discoloration at that time. Surveyor asked if DON-B documented that observation anywhere. DON-B stated no. Surveyor showed DON-B the left heel was documented on 5/27/2021 on readmission to be both a Suspected Deep Tissue Injury and have a blister. DON-B stated that was not correctly documented by the admitting nurse and when DON-B assessed the left heel on 6/1/2021, the staging was corrected by DON-B. Surveyor shared the concern the left heel pressure injury was not assessed from 6/1/2021-6/16/2021, 6/29/2021-7/13/2021, and then no comprehensive assessment was completed after 7/13/2021, even with a readmission on 9/8/2021. Surveyor shared the observation of the wound treatment and R3 currently has a wound to the left heel. LPN-C stated R3 does not always cooperate for measurements, but will say if the left heel is hurting. DON-B stated R3 likes to be outside and wants to have the wound looked at later; they try to reapproach, but that is not always successful. Surveyor asked if the refusals are documented. DON-B stated no. No further information was provided at that time.

Based on interview and record review the facility did not ensure 2 (R1 and R3) of 4 sampled residents medications were administered with adequate monitoring to determine if the drug was necessary. -R1 received [MEDICATION NAME] without receiving labs to determine the effectiveness of the [MEDICATION NAME]. R1's Carvedilol was frequently held due to low blood pressure. R1 did not have parameters in place to indicate when staff should hold the medication. -R3 was readmitted to the facility after hospitalization with orders for Blood Glucose Monitoring 3 times daily which was not transcribed to orders and was not completed. R3 had parameters for holding Hypertension medication for low blood pressure, the medication was held outside of parameters without MD order. Findings include: 1.) R1 has [DIAGNOSES REDACTED]. [MEDICATION NAME] Monitoring- The facility's [MEDICATION NAME] PROTOCOL policy and procedure, not dated, states Residents who are prescribed [MEDICATION NAME] will have appropriate monitoring for PT/INR ([MEDICATION NAME] time/international normalized ratio, labs used to monitor the effectiveness of [MEDICATION NAME]) levels as ordered by the physician. Residents receiving [MEDICATION NAME] should have routinely scheduled PT/INR levels. Usually weekly, every 2 weeks, every 4 weeks or monthly. R1's plan of care includes a focus area for At risk for nutritional status change r/t (related to) [MEDICAL CONDITION] (chronic heart failure). Interventions initiated on [DATE] include Administer medications as ordered and Obtain labs as ordered and notify MD of results. R1 was admitted to the hospital on [DATE]-[DATE] for a surgical repair of a hernia. Hospital discharge instructions include to start taking [MEDICATION NAME] 2mg daily. Discharge orders in the hospital discharge documentation included anticoagulation monitoring with date of the first INR ordered to be [DATE] and expected length of treatment for 6 months. A pharmacy review on [DATE] includes recommendations for INR monitoring. Review of R1's Medication Administration Record documents R1 received [MEDICATION NAME] 2mg once a day from [DATE]-[DATE]. R1 expired on [DATE]. R1's primary physician progress notes [REDACTED]. Under treatment the note documents [MEDICAL CONDITION] Flutter .The patient's heart rate is controlled and he's not anticoagulated. The surveyor reviewed R1's medical record and was unable to find documentation of INR monitoring. The surveyor asked the facility to view any INR documentation for R1. On [DATE] at 12:49 pm DON (Director of Nursing)-B informed the surveyor R1 did not have an INR completed from [DATE]-[DATE]. DON-B stated she had called the lab and they did not have any. DON-B stated R1 somehow did not make it into the PT/INR log, and was supposed to have an INR completed on [DATE]. DON-B stated it would have been the admitting nurse who would be responsible for starting that process. On [DATE] at 1:59 pm the surveyor interviewed RN (registered nurse)-F. RN-F confirmed she had assisted in admitting R1. RN-F informed the surveyor she recalled discussing admission orders [REDACTED]. RN-F stated she did not recall if she discussed getting an INR with NP-E. RN-F stated she did not recall if she saw the order for an INR on [DATE]. On [DATE] at 3:32 pm the surveyor interviewed NP-E. The surveyor asked NP-E what her expectations were for INR's for R1. NP-E stated her understanding was that the INR was being followed by the [MEDICATION NAME] clinic who would handle the labs and the dosing. Review of R1's medical record did not document any signs or symptoms of R1 bleeding. Blood Pressure Monitoring- R1 was readmitted to the facility following a hospitalization on [DATE]. Upon readmission to the facility R1 was ordered to receive Carvedilol 6.25mg for heart failure and [MEDICAL CONDITION] and [MEDICATION NAME] 40mg daily for water retention. The surveyor noted that prior to R1's hospitalization R1's Carvedilol had parameters in place to hold if R1's systolic blood pressure was less than 100. The surveyor noted upon return to the hospital R1 had no parameters in place to hold medications related to blood pressure. An administration note on [DATE] documents R1's Carvedilol was held for BP (blood pressure) ,[DATE]. On [DATE] R1's MAR (Medication Administration Record) documents R1's Carvedilol was held due to vitals outside of parameters for administration. The surveyor noted R1 had no documented ordered parameters. An administration note documents SBP (systolic blood pressure) ,[DATE] asymptomatic, encouraged to take in oral fluids and cooperative, BP meds held at this time HR (heart rate) 90. On [DATE] R1's MAR documents R1's Carvedilol was held due to vitals outside of parameters for administration. An administration note documents writer held for BP ,[DATE]. On [DATE] an administration note documents R1's [MEDICATION NAME] was held for medication held for low bp of ,[DATE] and their Carvedilol was held for vitals being outside of parameters with a note documenting bp ,[DATE]. At 7:22 pm R1's second dose of Carvedilol was held with an administration note documenting res (resident) has been hypotensive most part of day BP WNL (within normal limits) at ,[DATE] now although HR (heart rate) at 54 med held at this time for low HR. On [DATE] R1's MAR documents both doses of his Carvedilol were held due to vitals outside of parameters for administration. An administration note at 7:29 am documents BP ,[DATE] and at 7:58 pm BP ,[DATE] hr 52. On [DATE] R1's MAR documents R1 did not receive his pm dose of Carvedilol due to vitals outside of parameters for Administration. On [DATE] R1's MAR documents R1 did not receive his am or pm dose of Carvedilol due to vitals outside of parameters for administration. On [DATE] an administration note documents R1's pm dose of Carvedilol was held for BP ,[DATE]. On [DATE] R1's MAR documents R1 did not receive his am dose of Carvedilol due to vitals outside of parameters for administration. On [DATE] R1's MAR documents R1 did not receive his am dose of Carvedilol with a note documenting (blood pressure) ,[DATE]. On [DATE] R1's MAR documents R1 did not receive his am dose of Carvedilol due to vitals outside of parameters for administration. On [DATE] R1's administration notes document R1 did not receive his am dose of Carvedilol with a note stating (blood pressure) ,[DATE]. On [DATE] and [DATE] R1's MAR documents R1 did not receive his am or pm dose of Carvedilol due to vitals outside of parameters for Administration. On [DATE] and [DATE] R1's MAR documents R1 did not receive his am dose of Carvedilol due to vitals outside of parameters for Administration. On [DATE] at 1:30 pm the surveyor interviewed RN (registered nurse)-G. The surveyor asked what RN-G would do if a resident has a low blood pressure and has medications that could affect blood pressure. RN-G stated usually residents have parameters, if not would use the parameters she learned in school and if the systolic blood pressure is less than 100 she would hold. On [DATE] at 1:59 pm the surveyor interviewed RN-H. RN-H had processed admission orders [REDACTED]. RN-H informed the surveyor R1 had had parameters to hold some of his medications on his 1st admission. The surveyor asked how parameters are determined. RN-H stated by the physician if they would like to give out parameters will put in and that sometimes the physician wants the medication given regardless so parameters may not be put in. The surveyor asked RN-H if she had discussed parameters for R1 when was admitted . RN-H stated she did not recall. On [DATE] at 2:04 pm the surveyor interviewed RN-I. The surveyor asked RN-I about the process for holding medications that can affect blood pressure. RN-I stated for blood pressure medication and diuretics would get any set of vitals, would look for parameters, if does not have parameters RN-I stated she would hold if low. On [DATE] at 3:32 pm the surveyor interviewed NP (Nurse Practitioner)-E. NP-E had informed the surveyor she had been aware of R1 having lowing blood pressure and did not want to adjust his medications at that time related to R1 having other health issues that she wanted to resolve. NP-E stated she had instructed for staff to continue what they were doing and to hold the medication if low. The surveyor asked if NP-E had given parameters. NP-E stated if his systolic blood pressure was less than 110. On [DATE] at 4:00 pm the surveyor interviewed DON (Director of Nursing)-B. the surveyor asked if a resident has blood pressure parameters to a hold medication where would they be. DON-B stated in the order. The surveyor asked if a resident does not have orders for parameters what the expectation was. DON-B stated usually if less than 100 would hold. The surveyor asked DON-B if there was a policy related to that. DON-B stated she did not believed so. The surveyor informed DON-B of the concern of R1 not having documented parameters. 2.) R3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor reviewed R3's MD orders from Hospital Discharge Summary dated [DATE]. Documented was [MEDICATION NAME] 25 mg tab, commonly known as [MEDICATION NAME], Take 0.5 tablets by mouth 2 (two) times daily. Documented was Call Physician if heart rate is greater than 140 or less than 50. If systolic blood pressure is less than 90 mmHg or greater than 160 mmHg. Surveyor reviewed R3's MD orders from Telemedicine visit on [DATE]. Documented under Outpatient Encounter Medications as of [DATE] was [MEDICATION NAME] 25 mg tab, commonly known as [MEDICATION NAME], Take 0.5 tablets by mouth 2 (two) times daily. Surveyor reviewed R3's Individual Resident Care Plan with an initial date of [DATE]. Documented was Focus: [MEDICAL CONDITION] (related to (r/t)) presence of aortocoronary bypass graft, [MEDICAL CONDITION], [DIAGNOSES REDACTED], [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris, [MEDICAL CONDITION], essential primary hypertension, ([MEDICAL CONDITION].) Goal: Blood pressure will remain within resident's normal limits . Interventions: Administer medications as ordered . Obtain vital signs as indicated; report changes to physician. Surveyor reviewed R3's Medical Administration Record (MAR) and Treatment Administration Record for November and [DATE]. Per DON-B interview Hypertension medication should be given if systolic BP is over 100. [MEDICATION NAME] was not given to R3 on [DATE] PM with the note of Medication not Given, see Progress Notes. [MEDICATION NAME] was not given to R3 on the following dates with a note of Vitals Outside of Parameters for Administration: [DATE] with a BP of ,[DATE]; [DATE] AM with a BP of ,[DATE]; [DATE] PM with a BP of ,[DATE]; and [DATE] PM with a BP of ,[DATE]. Surveyor reviewed R3's Progress Notes. On [DATE] at 3:56 PM, Licensed Practical Nurse (LPN)-D documented BP ,[DATE] ([MEDICATION NAME]) held due to resident BP can drop dramatically after med. On [DATE] at 3:25 PM, Surveyor interviewed LPN-D. Surveyor asked what the process was for administering a Hypertension medication. LPN-D stated take BP and make sure it is within the parameters. LPN-D stated R3's parameters were to hold the medication if systolic BP is less than 100. Surveyor asked about holding R3's BP medication on [DATE]. LPN-D stated R3 was not drinking that much that day and she had seen his BP drop with lower BP's so she held the medication. On [DATE] at 3:56 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if staff were able to hold BP medications not out of parameters such as LPN-D did on [DATE]. DON-B stated she should have given the medication. Surveyor reviewed R3's MD orders from Hospital Discharge Summary with a date of [DATE]. Documented under Medication List: continue these medications was Contour Next Test Strips, Generic Drug, glucose blood test strips, Test three times daily on insulin #300 . for type 2 diabetes mellitus. Lancets Misc, Commonly known as Microcet lancet, Use as directed, for type 2 diabetes mellitus. Surveyor reviewed R3's Individual Resident Care Plan with an initial date of [DATE]. Documented was Focus: Endocrine system r/t type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. Goal: To minimize/be free of complications r/t disease process. Interventions: Administer medications per MD orders . Obtain glucometer readings and report abnormalities as ordered . Report symptoms of [MEDICAL CONDITION]: excessive thirst/urination, hunger, weakness, (nausea/vomiting,) [MEDICATION NAME] breath. Report symptoms of [DIAGNOSES REDACTED]: weakness, pallor, diaphoresis, vision changes, changes in consciousness. Surveyor reviewed signed MD orders from facility with a start date of [DATE]. There were no orders for Blood glucose testing. Surveyor reviewed R3's MAR and TAR for November and [DATE]. There were no documented Blood Glucose readings. On [DATE] at 2:48 PM, Surveyor interviewed Registered Nurse Unit Manager (RN)-C. Surveyor asked if R3 was on Insulin. RN-C said no. Surveyor asked if R3 had Blood Glucose readings per orders. RN-C stated yes, once a week. Surveyor asked why discharge orders read three times daily and they were currently not being done at all. RN-C was unsure. On [DATE] at 3:25 PM, Surveyor interviewed LPN-D. Surveyor asked if R3 had Blood Glucose readings daily. LPN-D stated only if he is symptomatic for hyper or [DIAGNOSES REDACTED]. On [DATE] at 3:56 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked why R3's Blood Glucose readings were not completed per orders. DON-B stated she was unsure because he did not have them done prior to hospitalization . DON-B stated she will follow up with MD to clarify.

Based on observation interview, and record review the facility did not ensure that food was stored, prepared, and served under sanitary conditions in 1 out of 1 kitchens. This deficient practice has a potential to effect 43 out of 45 residents who receive food from the kitchen and the steam table. * The dry storage area that had sliced apple (box full), along with thickened dairy drink, 8 cans of V8 juice, and 3 boxes of coffee were on the floor. * The main freezer food stored on the floor including: a box of margarine on the floor and full box of cooked breaded chicken. * Cook-E and Cook-F were touching ready to eat food and contaminating the food by not changing gloves nor washing their hands between contaminated surfaces and other food. Findings include: On 05/22/19 The facility's policy entitled Food storage dated on 05/2014 and revised on 09/2017, was reviewed and read: All items will be stored on shelves at least 6 inches above the floor. All packaged and canned food items will be kept clean, dry, and properly sealed. On 05/22/2019 The facility's policy entitled Food: Preparation dated on 05/2014 and revised on 09/2017, was reviwed and read: All staff will practice proper hand washing techniques and glove use. Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Separate cutting boards for meat, poultry, and produce will be maintained. On 05/22/19 The facility's policy entitled Meal Distribution dated on 05/2019 and revised on 09/2017, was reviewed and read: Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point of service dining. On 05/19/19 at 8:42 AM, The Surveyor conducted an initial tour of the kitchen. The surveyor observed, in the main freezer, a box of margarine on the floor, along with a full box of cooked breaded chicken. A garbage can next to the cooking area did not have a cover. The juice machine had what appeared to be dust on the front of it. Several coffee lids and plastic cups were noted underneath the small steam table inside of the kitchen, and they had a brown substance on them. An ice scooper was placed on the top of the ice machine without anything underneath it. The dry storage area had sliced apple (box full) cans on the floor, along with thickened dairy drink, 8 cans of V8 juice, and 3 boxes of coffee on the floor. On 05/19/19 at 12:01 PM, The surveyor observed Cook-E serving lunch to residents. Cook-E was touching meatballs with gloved hands, and then Cook-E was touching her shirt. After Cook-E touched her shirt, she then touched meatballs again, touched bread, and then touched moving food cart with the same gloves. Cook-E then left the dining area with a food cart. Cook-E came back and then continued to touch food again with gloved hands that was touching the food cart she brought back. Without changing her gloves, cook-E started to touch plates, and continued with serving and touching the food with her same gloved hands. Cook-E then was touching plates underneath the steam table, and then continued to touch meatballs. Cook-E was also touching meal tickets and the top of the steam table, then continued to touch food with her same gloved hands. Cook-E was patting and arranging meatballs with her contaminated gloved hands. Cook-E continued to implement this process until no more food tickets were left. Cook-E also picked up a bag of Lays chips, placed her hand inside and took some chips out with her contaminated gloved hands, and then continued to touch meatballs, without glove change, and without hand washing at any time. Cook-E then took meatballs and started to cut them with a scooper, touching a scooper too. Cook-E then went back into the kitchen and brought a box, placing it next to the steam table, and then continued with the same gloves to serve, and touch meatballs. On 05/20/19 at 12:05 PM The Surveyor observed lunch being prepared in the main dining room with Cook-F preparing the food. Cook-F had gloved hands. Cook-F was observed placing her palm of the hand on top of an empty plate, and then cook-F placed food inside of the same plate. Cook-F touched meal ticket, and then placed her fingers inside of each plate she picked up without changing gloves or washing her hands. Cook-F then sliced up turkey meat into smaller pieces and then picked up the meat with same contaminated gloves that she was touching scooper handles, covers, plates. Cook-F then picked up a baked potato, held it with the same contaminated gloves, cut the potato in the middle, and then placed the potato onto the plate to be served. Cook-F then was observed placing her fingers inside of the turkey meat at the steam table and then pulled it out and placed it onto the plate. Cook-F then touched grilled cheese with the same gloves. Cook-F was also observed touching inside of the small bowls. During serving meals, the Cook-F did not change her gloves, nor washed her hands. On 05/20/19 at 12:35 PM The Surveyor interviewed District Manager-G that was observing lunch meal preparation. District Manager-G indicated that Cook-F needed few more utensils to properly handle food preparation. Disctrict Manager-G also indicated that procedure to follow was to have gloves on for just one kind of food, and then Cook-F should of change her gloves, and washed her hands, between different foods. Facility has Food comittee meetings. On 05/21/19 Surveyor informed Administrator-A and Director of Nursing (DON)-B of above findings.

Based on interview and record review the facility did not conduct an investigation into the cause or corrective infection prevention action plan based on the investigation when there was an increase in the urinary tract infections (UTI's). In (MONTH) (YEAR) the urinary tract infection rate was 2.27% and in (MONTH) (YEAR) UTI's increased to 11.63%. This deficient practice had a potential to affect a pattern of residents at risk for development for UTI's as demonstrated in Residents R23, R202, R203, R204 and R205. Findings include: On 05/22/19 The Surveyor initiated a review of the facility's Infection prevention and control program manual surveillance policy dated (YEAR). The policy read: Based on analysis of data, develop and implement an action plan that includes correction action, staff education, and measurable goals. Assess the effectiveness of the corrective actions on the outcome measures identified in the action plan. The Infection Preventionist and the infection prevention and control committee will utilize the information collected from both process and outcome surveillance activities in order to analyze the data to identify opportunities for improved care and process and identify an action plan for follow up and corrective action and reporting. Action plan: determine if the increase is associated with a particular nursing unit or type of organism. On 05/22/2019 the surveyor reviewed last 6 months of the monthly baseline infection rates for the facility. From (MONTH) 2019 to (MONTH) 2019 UTI's increased from 2.27% to 11.63%. The facility did not conduct an analysis of the increase in UTI's, and did not implement corrective plan of action. The infection control log for (MONTH) (YEAR) was reviewed and indicated R23, R202, R203, R204, and R205 had in house acquired UTI's accounting for 11.63%. Despite the fact no investigation into the cause of the increase in UTI's or corrective action based on that investigation the rate of UTI's for (MONTH) 2019 was down to 4.76%. On 05/22/19 at 9:19 am The surveyor conducted an interview with the Director of Nursing (DON)-B. DON-B indicated for urinary tract infections urinalysis were performed, the facility takes urine cultures, and signs and symptoms of the residents. If residents qualify with the McGeer's surveillance monitoring, then residents are tested for urinary tract infections, and the primary physician is aware. If residents are not qualified, based on McGeer's criteria, then urinalysis order will be discontinued. Proper antibiotic for the urinary tract infection is provided from the primary care physician of each resident On 05/22/19 The surveyor reviewed the infection control and prevention facility analysis that showed no investigation for the cause of the increase in the rate of UTI's or corrective action based on the results of the investigation was performed. The facility did not determine the need for additional education and staff competencies. There were no evidence of investigation into the increased rate of the UTI infections, and no plan of action implemented In (MONTH) 2019. On 05/22/19 at 11:10 am Administrator-A and DON-B were made aware of the findings above.

Based on interview and record review, the facility did not complete a Preadmission Screen and Resident Review (PASARR) Level 2 screen with a change in [DIAGNOSES REDACTED]. R16 was admitted to the facility on [DATE] with orders for [MEDICATION NAME] for a [DIAGNOSES REDACTED]. At that time a PASARR Level 2 screen was not completed as Dementia was not a mental illness diagnosis. On 3/22/19 R [DIAGNOSES REDACTED]. Findings include:: R16 was admitted on [DATE]. A PASARR Level 1 was completed on admission and referred for a level 2 screening. On 11/1/17 Social Worker (SW)-D wrote the following progress note for R16: SW-D spoke with Behavioral Consulting Services (BCS) in regards to Level 1 PASARR that was referred to BCS and BCS informed the writer that the screen did not need to be referred as R16 is prescribed [MEDICATION NAME] for Dementia and not a mental illness diagnosis. On 3/22/19 R16's [DIAGNOSES REDACTED]. On 5/20/19 R16's medical record was reviewed and a Level 2 PASARR could not be found. On 05/20/19 at 1:22 PM SW-D was interviewed and indicated R16's [DIAGNOSES REDACTED]. On 5/20/19 the Level 1 PASARR form instructions were reviewed for R16's PASARR dated 10/24/17 and read: for persons presently residing in a nursing home, this form should be filled out only if there is a change of status in Section A. Section A includes a section of current [DIAGNOSES REDACTED]. The above findings were shared with the Administrator and Director of Nurses on 5/21/19 at 3:00 PM. The Administrator indicated that a new screening was being completed for R16.