Every finding on record at Door County Memorial Hospital SNF

Based on observation, staff and resident interview, and record review, the facility did not ensure appropriate fall interventions were implemented for 2 residents (R) (R5 and R2) of 2 sampled residents.R5 had multiple falls from January to April 2026. Interventions to prevent falls or reduce injury from falls were not consistently implemented or care planned. R2 fell out of bed after a bolstered air mattress (a specialized mattress with raised, air-filled side chambers that create a protective barrier to prevent roll-outs and falls) was broken and replaced with a mattress without bolstered edges. Findings include: The facility's Resident Fall Policy, revised 12/16/25, indicates: It is the policy of Door County Center Skilled Nursing Facility (SNF) to perform a fall risk assessment for each resident and to develop a plan of care that provides interventions to reduce and/or prevent resident falls .C) A care plan will be developed, and resident-centered interventions will be implemented based on identified risks .5. Document objective facts related to a resident's fall by completing SNF Fall Safety documentation .8. Review and update the resident's plan of care. A post-fall process algorithm was included with the facility's policy which indicates: Implement additional fall prevention interventions. Document facts related to the fall in the medical record. Modify/update the plan of care. 1. On 4/27/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including cerebrovascular accident (CVA), Alzheimer's dementia, and rheumatoid arthritis. R5's Minimum Data Set (MDS) assessment, dated 1/20/26, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R5 had severely impaired cognition. R5's medical record indicated R5 sustained a femur (leg bone) fracture from a fall on 1/8/26 while ambulating without a walker and carrying a Dycem (a non-slip material). An intervention was added to R5's care plan on 1/8/26 for a Dycem to recliner to prevent falls. R5 required hospitalization with surgical repair on 1/9/26 and returned to the facility on 1/12/26. After returning from the hospital, R5 had the following falls: ~ 1/13/26 at 12:05 AM - R5 fell in R5's room while attempting to self-transfer. A fall assessment contained the following interventions: apply a bed alarm; walker on one side of the bed and wheelchair on the other side. A bed alarm and wheelchair next to the bed when in bed were added to R5's care plan on 1/13/26. ~1/13/26 at 9:10 AM - R5 fell from an unlocked wheelchair. When asked if R5 had pain, R5 pointed to the upper right leg and said yes. There were no new interventions noted on the assessment or added to R5's care plan. ~ 1/20/26 - R5 was found on the floor with an unlocked wheelchair. R5 was attempting to use the walker. There were no new interventions noted on the assessment. I have an anti-rollback device on wheelchair to prevent falls was added to R5's care plan on 1/20/26. ~ 1/23/26 - R5 was found on the floor beside an unlocked wheelchair. R5 was attempting to self-transfer. There were no new interventions noted on the assessment or added to R5's care plan. ~ 2/16/26 - R5 was found after attempting to self-transfer. The assessment indicated to continue with current care plan. There were no new interventions added to R5's care plan. ~ 2/19/26 - R5 was found on the floor outside the bathroom. R5 was attempting self-transfer and did not use a walker. The assessment indicated to continue with current care plan. There were no new interventions added to R5's care plan. ~ 2/20/26 - R5 fell to the floor from an unlocked wheelchair. Dycem came out of the chair with R5. There were no new interventions noted on the assessment or added to R5's care plan. ~ 3/1/26 at 11:28 AM - R5 fell to the floor from a wheelchair. There were no new interventions noted on the assessment or added to R5's care plan. ~ 3/1/26 at 7:30 PM - R5 fell to the floor from a wheelchair. R5 was observed leaning forward with R5's head resting on the baseboard of the bed. An intervention was added for a Broda Scoot wheelchair. R5's care plan contained a handwritten note (dated 3/8/26) for a Broda Scoot wheelchair. ~ 3/4/26 - R5 was found on the floor next to a wheelchair. R5 was attempting self-transfer. The assessment indicated to continue the plan of care. There were no new interventions added to R5's care plan at that time. An intervention for a wheelchair alarm was added via a handwritten note on 3/12/26 and again on 3/24/26. ~ 4/7/26 - R5 rolled/slid out of bed and was found on the floor. There were no new interventions noted on the assessment or added to R5's care plan. On 4/28/26 at 9:54 AM, Surveyor interviewed MDS Registered Nurse (RN)-C who confirmed R5's care plan (dated 1/23/26) was the most current type-written care plan. RN-C indicated nurses hand-write interventions on the side of the typed care plan and RN-C periodically adds the interventions to the resident's typed care plan. RN-C confirmed RN-C does not enter the date of the interventions when adding them to the electronic care plan but stated one can refer to prior hand-written notes on previous care plans to determine the date an intervention was initiated or discontinued. Surveyor reviewed R5's fall on 1/20/26 with RN-C in which the intervention was an anti-rollback device to R5's wheelchair. Surveyor and RN-C also reviewed subsequent fall assessments that indicated R5's wheelchair brakes were unlocked. RN-C provided Surveyor with a work ticket that indicated maintenance staff installed an anti-roll back device on R5's wheelchair on 1/20/26. On 4/28/26 at 10:12 AM, Surveyor interviewed Director of Nursing (DON)-B about R5's most recent fall on 4/7/26 where R5 was found on the floor by Hospice staff. R5 had a small laceration on the forehead. R5's medical record indicated the bed alarm was not sounding. DON-B stated the bed alarm was unplugged when R5 was found and may have become unplugged when moving R5's bed up and down. DON-B indicated R5's Kardex (an abbreviated care plan used by nursing staff) was being updated with entries for each shift to check the bed alarm and sign off that it is plugged in and in place. DON-B provided Surveyor with a document used as a quality-assurance tool (dated 4/7/26) that indicated fall precautions implemented included activation of bed and chair alarms, a new mattress, and initiation of safety checks every 15 minutes. R5's mattress was exchanged for a bolster mattress provided by Hospice. The document indicated R5's bed alarm did not alarm during the fall because one of the cords was unplugged. It was discussed during a huddle that staff should check all alarms every shift for proper functioning. On 4/28/26 at 10:26 AM, Surveyor reviewed R5's Kardex which did not contain an intervention to check the bed alarm. DON-B was at the nurses' station and verified the intervention was not on R5's Kardex. DON-B indicated it may have been discussed during a huddle to check R5's bed alarm to ensure it is plugged in. DON-B provided Surveyor with a staffing schedule from 4/7/26 which included staff who may have participated in the huddle. On 4/28/26 at 10:31 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who did not recall instructions provided during a huddle to check bed alarms at the start of the shift. CNA-D indicated CNA-D ensures alarms are working. On 4/28/26 at 10:59 AM, Surveyor interviewed DON-B regarding why some fall assessments contain interventions and some do not. DON-B indicated if the initial assessment does not have an intervention, the fall is discussed during a huddle and an intervention is determined. DON-B confirmed interventions determined during huddles should be added to a resident's care plan. On 4/28/26 at 2:10 PM, Surveyor interviewed CNA-F who recently started on the PM shift and provided care for R5. When asked if CNA-F does anything at the start of the shift for bed alarms, CNA-F did not indicate staff should check bed alarms for function or ensure they are plugged in. When asked about interventions for R5, CNA-F could not provide any interventions. On 4/28/26 at 2:18 PM, Surveyor provided NHA-A with a list of falls for which Surveyor could not locate an intervention on R5's care plan that correlated with the fall date. On 4/28/26 at 2:42 PM, Surveyor interviewed Hospice RN-E who confirmed RN-E asked staff where R5 was on the morning of 4/7/26 when RN-E noted R5 was not in bed and the lights were out. RN-E verified an alarm was not sounding. Upon returning to R5's room, RN-E observed R5 on the floor next to the bed with a laceration on the forehead that measured 0.2 centimeters (cm) x 1.2 cm. On 4/28/26 at 3:00 PM, DON-B provided information for R5's falls without interventions in the fall assessments or care plan. For R5's second fall on 1/13/26, DON-B indicated 1:1 staffing was implemented because R5 was restless and anxious. A therapy evaluation was also attempted. For R5's fall on 1/23/26, DON-B stated R5 was in R5's spouse's room on the couch which was not alarmed. A new intervention was not implemented. For R5's fall on 2/16/26, DON-B indicated a medication review was completed. DON-B provided a Hospice note that indicated R5's Seroquel was increased and a progress note (dated 2/16/26) that indicated staff from the adjoining hospital sat with R5. DON-B indicated no new interventions were implemented following R5's fall on 2/19/26. Following R5's fall on 2/20/26, DON-B indicated Exelon (a medication in patch form to treat dementia) was started on 2/21/26 due to R5 refusing other medications. For R5's fall on 3/4/26, DON-B indicated R5 was sleeping and interventions were in place. No new interventions were added. DON-B confirmed there were no interventions added to R5's care plan or Kardex following the fall on 4/7/26 as previously indicated. DON-B confirmed DON-B looked in areas other than R5's care plan to locate the interventions provided to Surveyor. 2. On 4/27/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including below knee amputation of right lower extremity, diabetic neuropathy, type 2 diabetes, and anxiety. R2's MDS assessment, dated 2/10/26, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. R2's care plan included a bolster bed implemented on 10/5/23. (Of note: At some point, the bolster bed was removed from R2's care plan.) (Of note: Resident care plans are generated through electronic medical records, then printed on paper and maintained by hand-writing updates and changes. Reviews, updates, and changes are indicated by a signature and a date hand-written on the printed care plan.) R2's medical record contained documentation, dated 5/16/25 at 5:46 AM, titled SNF Fall Safety Assessment that indicated R2 had an unwitnessed fall at 4:45 AM and was found kneeling at the bedside between the window and the bed. R2's back was to the window and head was resting on the bed. R2 indicated R2 must have rolled too far. During a huddle, it was reported that R2 was restless due to itching and a recent diagnosis of urinary tract infection (UTI). The documentation indicated R2 rolled too far and slid onto R2's knees. A lipped air mattress was added to prevent future falls. R2's medical record indicated R2 fell again on 12/11/25. Documentation indicated the root cause was restlessness due to itching. R2 rolled too far and slipped out of bed onto R2's knees. R2's mattress was exchanged earlier that day from one with bolsters to one without. R2 stated R2 was laying on R2's side and rolled out out of bed. The documentation indicated the bolster mattress would be replaced. The facility informed R2's physician who provided orders via fax at 5:00 PM for a cold compress three times daily, check for bleeding, provide ibuprofen if persistent pain or tramadol if severe pain, and report if pain persists. The facility contacted the physician again at 7:02 PM and received an order to send R2 to the emergency room (ER) for evaluation due to pain. X-ray results, dated 12/11/25, indicated R2 had a below-the-knee amputation with no visible fracture or dislocation. There was a small knee joint effusion (excess buildup of fluid within or around the knee joint caused by injury, overuse, infection, or underlying arthritis). R2 felt better after receiving Norco (a prescription medication that combines hydrocodone and acetaminophen to treat moderate-to-severe pain) and was discharged back to the facility. On 12/11/25, a hand-written note was added to R2's paper care plan that indicated R2 will have a bolster bed to help recognize the boundary of the bed. On 4/27/26 at 1:14 PM, Surveyor interviewed R2 who stated R2 fell out of bed because R2's air mattress with bolster edges had deflated and the facility replaced it with a mattress without raised edges. R2 stated the same day the facility provided the replacement mattress without bolstered edges, R2 took a nap and fell out of bed. R2 stated staff rolled blankets to prevent R2 from falling out of bed, but the rolled blankets did not work. R2 stated R2's right below-the-knee amputation site was hurt in the fall and R2 went to the ER due to pain. R2 stated R2's right stump was likely bruised internally which is what caused the pain. R2 stated the facility provided R2 with a different air mattress with bolstered edges that evening. Surveyor viewed R2's mattress and noted the mattress had bolstered edges at the head and foot of the bed with a lower spot in the middle. On 4/28/26 at 9:06 AM and 11:01 AM, Surveyor interviewed DON-B who stated R2 had issues with the bolstered mattress on the morning of the fall so the facility provided a regular air mattress without bolsters while R2's mattress was being fixed. DON-B who did not know why R2 had a bolstered air mattress and did not know when R2 originally received the mattress. DON-B verified the facility should have provided R2 with a bolstered air mattress to replace the broken mattress and confirmed R2 rolled out of bed hours after receiving the non-bolstered mattress. DON-B stated bolstered air mattresses are used as a soft-barrier at times to prevent a resident from falling out of bed. DON-B stated R2 had an air mattress upon admission for wounds that had since healed but did not recall if it was bolstered.

Based on staff and resident interview and record review, the facility did not ensure allegations of abuse and an injury of unknown origin were thoroughly investigated for 4 residents (R) (R1, R2, R10, and R7) of 8 sampled residents. R1 reported an allegation of abuse by Certified Nursing Assistant (CNA)-G on 4/10/25. The facility did not remove CNA-G from resident care pending an investigation or provide staff education regarding appropriate behavior with residents and professional boundaries. In addition, a skin assessment was not completed until two days after the allegation was reported.R2's family reported an allegation of abuse that involved CNA-L. The facility did not provide staff education on the facility's abuse policy or education on appropriate behavior during resident care. In addition, during the abuse investigation for R2, R10's Resident Representative ((RR)-E) reported an allegation of abuse involving R10 and CNA-F. The facility did not investigate the allegation of abuse.R7 had a skin tear that was discovered on 6/7/25. The facility did not provide thorough staff education regarding wearing jewelry, appropriate fingernail length, and selecting the correct sling size following the injury of unknown origin. Findings include:The facility's Prevention, Investigating, and Reporting Violations of Resident Rights Including Allegations of Abuse, Neglect, Misappropriation of Property, and Injuries of Unknown Origin policy, revised 4/23/25, indicates: The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis .to identify the plan of investigation should such allegations or injuries occur and to protect the resident during the investigation .It is the policy of this facility to train employees, through orientation and ongoing sessions, on issues related to abuse and prohibition practices .Staff and volunteers will receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source .upon first employment and annually after that. Staff will be trained to immediately report to the appropriate person all allegations of misconduct including abuse, neglect, misappropriation of client property, and injuries of unknown origin .Occurrences, patterns, and trends that may constitute abuse will be investigated .The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. The investigation form will include comments, insights from staff who worked the previous two and current shift, other residents, family, and visitors as determined reasonable .The charge person will immediately assess the resident's personal safety and potential of harm to other residents. If the alleged perpetrator is named, that individual should leave resident care areas immediately. A complete body assessment will be completed. An assessment of the victim for psychosocial changes will be completed and medical/psychosocial treatment and support will be provided as necessary .The Nursing Home Administrator (NHA) or designee with be notified and an investigation will be initiated immediately .The charge person and NHA will determine whether an accused caregiver or another alleged perpetrator may continue to have contact with residents when the investigation is complete .a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: .i. The alleged perpetrator will immediately be removed and the resident protected. Employees accused of alleged abuse will be immediately removed from the facility and will remain removed pending the results of a thorough investigation .Education will be provided as needed to all parties involved .1.On 7/2/25, Surveyor reviewed a facility-reported incident (FRI) that indicated R1 reported that CNA-G pulled R1's hair in the dining room during lunch. The 24-hour report indicated the discovery date was 4/15/25 and the report was submitted on 4/16/25. The five-day report was submitted on 4/18/25. The five-day report indicated Registered Nurse (RN)-J was notified by CNA-K on 4/10/25 at approximately 5:30 PM that another resident pulled R1's hair. RN-J spoke with R1 who indicated CNA-G pulled R1's hair. The FRI indicated education was provided to CNA-G by Social Worker (SW)-C on appropriate ways to interact with residents and professional boundaries. The FRI also indicated CNA-G was able to return to work after the education was provided. Surveyor noted the FRI did not include education for other staff and a skin assessment to check for injuries was not completed until after R1's weekly scheduled shower on 4/12/25. On 7/2/25, Surveyor reviewed R1's medical record. R1 had diagnoses including bilateral leg weakness, cellulitis, lymphoma, and multiple sclerosis. R1's Minimum Data Set (MDS) assessment, dated 6/24/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.On 7/2/25 at 11:35 AM, Surveyor interviewed R1 who indicated CNA-G pulled R1s hair. R1 indicated the incident upset R1 which is why R1 told another CNA and RN-J talked to R1 about the incident. R1 indicated CNA-G was kidding, however, CNA-G did not know CNA-G was kidding at first and thought CNA-G pulled R1's hair to make R1 upset. R1 swore at CNA-G when CNA-G pulled R1's hair twice. R1 indicated CNA-G should have told R1 it was a joke and said, Who pulls someone's hair? Kids do that.On 7/2/25, Surveyor reviewed time care punches for CNA-G. Surveyor noted CNA-G was accused of alleged abuse on 4/10/25 but provided resident care (including to R1) on the following dates and times until the investigation was completed on 4/18/25:~ 4/11/25: 6:00 AM - 3:00 PM~ 4/14/25: 5:54 AM - 2:44 PM~ 4/15/25: 6:00 AM - 2:40 PM~ 4/16/25: 6:00 AM - 11:00 [NAME] 7/2/25 at 1:40 PM and 2:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the potential allegation of abuse was reported and documented on 4/10/25. NHA-A indicated NHA-A did not follow-up with R1 and thought R1 was fine with the incident. NHA-A indicated there was no indication of an issue until R1 spoke with SW-C on 4/15/25 and indicated R1 was upset during the incident. NHA-A also indicated CNA-G should not have worked during the investigation and should have been immediately removed from resident care. NHA-A confirmed an assessment was not completed for R1 following the allegation of abuse and confirmed the only documented skin assessment was completed on R1's scheduled shower day which was two days after the allegation was reported. 2. On 7/2/25, Surveyor reviewed a FRI that contained a 24-hour report, dated 3/10/25, regarding an allegation of abuse involving CNA-L and R2. The FRI indicated CNA-L firmly put a soaker pad on R2 and potentially slapped R2. The investigation included resident and family interviews, including an interview with R10's Resident Representative ((RR)-E) who was interviewed on 3/10/25. RR-E indicated to SW-C that RR-E was not concerned about the safety of residents, however, sometimes CNA-F talked roughly and it appeared R10 tensed up around CNA-F. On 7/2/25, Surveyor reviewed R10's medical record. R10 had diagnoses including dementia, Alzheimer's disease, and anxiety disorder. R10's MDS assessment, dated 6/10/25, had a BIMS score of 1 out of 15 which indicated R10 had severely impaired cognition. R10 had an activated Power of Attorney for Healthcare (POAHC).On 7/2/25 at 2:10 PM, Surveyor interviewed RR-E who indicated no one followed-up with RR-E regarding care provided to R10 by CNA-F. RR-E indicated CNA-F's demeanor and the rough cares provided to R10 and other residents were also reported to administration, including SW-C, during one of R10's care conferences. RR-E indicated CNA-F is rough with cares at times and grabs R10's arms or legs and puts them in bed or grabs R10's arms and roughly states we need to do this or we need to do that. RR-E indicated RR-E reported the concerns because it was concerning that CNA-F was rough and RR-E had heard other residents say the same thing. RR-E did not know if administrative staff spoke to CNA-F about the rough cares and language with residents.On 7/2/25 at 2:57 PM, Surveyor interviewed SW-C who indicated SW-C reports all concerns brought to SW-C's attention during an investigation of abuse to NHA-A or Director of Nursing (DON)-B and indicated SW-C informed NHA-A or DON-B most likely in an email. SW-C indicated RR-E stated CNA-F was short with R10 and verified SW-C did not investigate any further. On 7/2/25 at 3:01 PM, Surveyor interviewed NHA-A who was not aware of the concerns RR-E reported to SW-C regarding care provided by CNA-F. NHA-A indicated if NHA-A was aware of the concerns, an investigation would have been initiated. On 7/2/25 at 12:31 PM while reviewing employee training files with Human Resources (HR)-D, Surveyor noted accused staff in abuse allegations did not have documented in-service training. Surveyor noted CNA-F, CNA-G and CNA-L's employee training files did not contain training regarding behaviors, appropriate interactions, boundaries, resident care, and/or customer service. Surveyor interviewed HR-D who indicated all completed in-service trainings are documented in employees' training logs. On 7/2/25 at 2:57 PM, Surveyor interviewed SW-C who could not provide documentation of education to staff during the time frames of the allegations of abuse involving R1 and R2. SW-C indicated education may have been provided by the Ombudsman or during a stand-up or CNA meeting. On 7/2/25 at 1:40 PM, Surveyor interviewed NHA-A who indicated NHA-A would check in DON-B's office for education documentation and employee sign-off sheets. NHA-A indicated the Ombudsman provided some education and NHA-A would provide the documentation to Surveyor. On 7/2/25 at 2:16 PM and 2:47 PM, NHA-A approached Surveyor and indicated abuse training is done annually for employees. NHA-A indicated NHA-A could not locate documented education for the abuse allegations involving R1 and R2. NHA-A provided Surveyor with Ombudsman education that was provided to staff on 5/19/25. Surveyor noted the education was on guardianships, powers of attorney and their rights, and general resident rights training. The employee sign-off sheet did not indicate all employees received the education. 3. On 7/2/25, Surveyor reviewed a FRI that indicated R7 had a skin tear on the right upper arm that was discovered on 6/7/25 between 7:00 PM and 7:45 PM. The summary indicated SW-C indicated the skin tear could have occurred when R7's arm rubbed against a lift sling since R7 had fragile skin. A larger size sling was requested from the Hospice agency that provided the sling. The summary indicated SW-C provided education to CNA-H regarding wearing jewelry and fingernail length. The FRI contained interviews from RN-Q who was not sure how the skin tear occurred and CNA-H who provided care to R7 when the skin tear was discovered and also was not sure how the skin tear occurred. The investigation did not determine how the skin tear occurred. On 7/2/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including myasthenia gravis, hypertension, heart failure, and depression. R7's most recent MDS assessment, dated 6/24/25, had a BIMS score of 3 out of 15 which indicated R7 had severely impaired cognition. R7 had an activated POAHC.On 7/2/25 at 12:11 PM, Surveyor interviewed RN-N who assisted with the investigation and indicated the skin tear could have been from a sling or staffs' jewelry or long fingernails. RN-N indicated the skin tear was not identified when R7 was transferred to bed but was identified during cares. On 7/2/25 at 12:31 PM, Surveyor interviewed CNA-R who did not recall the last time CNA-R was educated on lift sling sizes. CNA-R indicated CNA-R received education on nail length, jewelry, and working with fragile skin approximately a month and a half prior when CNA-R was given a policy to read. CNA-R indicated no one followed up to ensure CNA-R read the policy. On 7/2/25 at 12:37 PM, Surveyor interviewed CNA-H who did not recall receiving education on lift sling sizes. CNA-H indicated CNA-H was educated on R7's fragile skin after an injury occurred prior to the skin tear that was identified on 6/7/25. CNA-H indicated a policy about jewelry and fingernail length was distributed approximately 2 months prior and an email was sent with the policy after R7's skin tear was discovered on 6/7/25. CNA-H stated CNA-H was not asked to verify or sign that CNA-H read the policy. CNA-H indicated SW-C talked to CNA-H after the incident on 6/7/25.On 7/2/25 at 12:49 PM, Surveyor interviewed CNA-I who stated CNA-I received an email approximately 2 weeks prior that indicated staff should not wear dangly jewelry or fake nails and nails should be short. CNA-I was not sure what was considered short for nail length.On 7/2/25 at 2:16 PM, Surveyor interviewed NHA-A who indicated staff are educated on abuse, neglect, and misappropriation during onboarding and on an annual basis. On 7/2/25 at 3:10 PM, Surveyor interviewed SW-C who indicated NHA-A and/or DON-B send education emails to staff. On 7/2/25 at 3:48 PM, NHA-A indicated NHA-A was not sure if staff opened or understood educational emails with attached policies. NHA-A indicated administration does huddles with AM and PM staff and provide education at monthly staff meetings, however, they are not as consistent with night (NOC) staff.On 7/2/25 at approximately 4:00 PM, Surveyor reviewed a staff meeting folder provided by NHA-A that contained staff meeting information for a 2/5/25 education on Body and Lifts (a sheet with 14 staff signatures with training information) that did not include how to select the correct sling size.

Based on staff interview and record review, the facility did not ensure medical records contained accurate and complete documentation for 2 residents (R) (R3 and R4) of 12 sampled residents.R4 hit R3 in the legs on 5/9/25. Neither R3 or R4's medical records contained documentation of the altercation. Findings include: On 7/2/25, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the State Agency (SA) on 5/9/25 and indicated Certified Nursing Assistant (CNA)-I observed R4 hit R3 in the legs when CNA-I walked by R3's room. CNA-I indicated R3 was in bed and R4 was in a wheelchair in R3's room. CNA-I brought R4 out of R3's room and reminded R4 not to hit R3. R4 responded, I can. The nurse assessed R3's skin and found no injuries. R3 and R4's representatives were notified and had no concerns. Local law enforcement was notified and indicated no further action was necessary. The physician was informed of R4's increasing behaviors and prescribed sertraline (an antidepressant medication). R3 denied that anyone had hurt R3 and did not report any pain. Neither R3 or R4 could recall the incident. On 7/2/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia, diabetes, and cerebrovascular accident (CVA) (stroke). R3's Minimum Data Set (MDS) assessment, dated 4/22/5, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R3 had severely impaired cognition. R3 had an activated Power of Attorney for Healthcare (POAHC). On 7/2/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including memory impairment gradual onset and osteoarthritis. R4's MDS assessment, dated 6/17/25, had a BIMS score of 3 out of 15 which indicated R4 had severely impaired cognition. R4 had an activated POAHC. Surveyor noted the altercation was not documented in R3 or R4's medical records, including where and what occurred, interventions implemented to deescalate of the situation, physical and psychosocial assessments of R3 and R4, whether R3 and R4's representatives were notified, and whether R3 and R4's care plans were reviewed or revised. Surveyor noted it was difficult to ascertain whether R3 and R4's care plans were reviewed or revised after the altercation because dates were not included with interventions that were handwritten on the care plans. R3's care plan indicated R3 had a diagnosis of Alzheimer's dementia (created 2/13/25). A handwritten intervention indicated: Staff will help redirect me when I'm unaware of going into other residents' personal space to help avoid others from being upset with me (the intervention was not dated and did not contain the initials of who made the addition). R4's care plan indicated R4 became more confused during the evening hours (created 1/30/25) and contained and intervention that indicated: During the evening hours, I become more confused. Historically, I have been concerned about safety and intruders coming into my home. With my confusion, I may feel threatened by others (in the evening was crossed out in pen and did not contain a date or initials to signify who made the change) due to this. Staff will ensure my safety and help me with distancing from others when I feel this way.On 7/2/25 at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was unsure if R3 and R4's care plans were reviewed or revised since revision dates were not clearly documented. NHA-A also verified R3 and R4's medical records did not contain documentation of the altercation.

Based on staff interview and record review, the facility did not ensure an activated Power of Attorney for Healthcare (POAHC) and physician were notified timely of a change in condition for 1 resident (R) (R7) of 12 sampled residents.R7 sustained a skin tear of unknown origin on 6/7/25. R7's physician and POAHC were not notified of the injury until 6/10/25. Findings include:The facility's Notification of Changes in Condition or Status of Resident policy, revised 7/31/24, indicates: To assure that each resident receives prompt, high quality nursing service and medical care .Changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and reported to the attending physician .1. Appropriate notification of the resident's physician .Resident and/or resident representative if any, and any other responsible person designated in writing .occurs in the event of the following: A. An unexpected or substantive change in the resident's physical, communicative, psychosocial, or functional status; B. An accident or injury that may involve physician intervention .1. Requirements for the notification of resident, their representative, and their physician: A. An accident involving the resident which results in injury and has the potential for requiring physician intervention .2. The nurse will immediately notify the resident, resident representative, physician, and as appropriate, the resident's Healthcare Power of Attorney (HCPOA) .An accident involving the resident which results in injury and has the potential for requiring physician intervention .4. If the attending physician or designated alternate is not available or does not respond appropriately, he/she must take further steps to obtain service for the resident. a. Notify the on- call physician. B. Notify Director of Nursing (DON) or designee .c. If the DON or designee is not immediately available, call the Medical Director .On 7/2/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including myasthenia gravis, hypertension, heart failure, and depression. R7's most recent Minimum Data Set (MDS) assessment, dated 6/24/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R7 had severely impaired cognition. On 7/2/25, Surveyor reviewed a facility-reported incident (FRI) that indicated R7 sustained a skin tear on the right upper arm which was identified on 6/7/25 between 7:00 and 7:45 PM. Registered Nurse (RN)-Q identified the skin tear during a skin assessment and prepared a physician update statement on 6/8/25 at 2:46 AM with instructions to send the fax to the physician with the update. On 7/2/25 at 12:11 PM, Surveyor interviewed RN-N who indicated RN-N sent a fax to the physician on 6/10/25 regarding R7's skin tear that was identified on 6/7/25. RN-N indicated the skin tear was small and if it had been larger, the on-call physician would have been notified. RN-N indicated the facility does not have a policy that indicates when a skin tear should be reported to the physician. RN-N indicated R7's POAHC was also notified of the skin tear on 6/10/25. On 7/2/25 at 1:00 PM, Surveyor interviewed RN-O who indicated it is up to the nurse's discretion when to notify the physician of a skin tear. RN-O indicated RN-O would only notify the on-call physician if the skin tear required medical attention such as stitches. RN-O indicated RN-O would update the physician on Monday if the skin tear occurred over the weekend if that was okay with the resident's POAHC. On 7/2/25 at 1:49 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility does not have a policy for reporting skin tears. NHA-A indicated a resident's POAHC should be notified immediately of a skin tear, usually within 24 hours. NHA-A indicated the on-call physician should be notified if a resident falls or hits their head, then clarified the physician should also be notified right away for skin tears. NHA-A indicated there are on-call physicians for weekends and nursing staff should follow-up with a fax to the resident's primary physician.

Based on staff interview and record review, the facility did not report allegations of abuse and an injury of unknown origin to the State Agency (SA) for 3 residents (R) (R1, R10, and R7) of 4 sampled residents.R1 reported an allegation of abuse on 4/10/25. The facility did not report the allegation of abuse to the SA until 4/15/25. During an abuse investigation for R2, R10's Resident Representative ((RR)-E) reported an allegation of abuse involving Certified Nursing Assistant (CNA)-G and R10. The facility did not report the allegation of abuse to the SA. R7 had an injury of unknown origin that was discovered on 6/8/25. The facility did not report the injury of unknown origin to the SA until 6/11/25.Findings include: The facility's Prevention, Investigating, and Reporting Violations of Resident Rights Including Allegations of Abuse, Neglect, Misappropriation of Property and Injuries of Unknown Origin policy, revised 4/23/25, indicates: Any employee or contractor who witnesses or becomes aware of alleged misconduct, as defined in this policy, by another employee or contractor is to report such incident to the Nursing Home Administrator (NHA) and Director of Nursing (DON), Social Worker (SW), or Human Resources (HR) Department within 24 hours .Local law enforcement will also be notified of any situation where there is potential criminal offense .Notification of law enforcement and/or State Agency (SA) .as indicated .If the injury is unexplainable and if abuse is substantiated and if there is caregiver negligence or a therapeutic error that resulted in injury, a report must be made to Wisconsin Department of Health Services/Division of Quality Assurance within 24 hours of the findings. A. Within five business days of the original report, the NHA, DON, or SW will make a final decision regarding the outcome of the investigation .It is the policy of the facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property) are reported per federal and state law. The facility will ensure all alleged violations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the NHA or designee in accordance with state law. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility . 1. On 7/2/25, Surveyor reviewed a facility-reported incident (FRI) that alleged CNA-G pulled R1's hair in the dining room during lunch. The 24-hour report indicated the date discovered was 4/15/25 and the report was submitted on 4/16/25. The five-day investigation was submitted on 4/18/25. The investigation indicated CNA-K notified Registered Nurse (RN)-J on 4/10/25 at 5:30 PM that another resident had pulled R1's hair. RN-J interviewed R1 who indicated CNA-G had pulled R1s hair. Surveyor noted the incident occurred on 4/10/25 but was not reported to the SA until 4/15/25.On 7/2/25, Surveyor reviewed R1's medical record. R1 had diagnoses including bilateral leg weakness, cellulitis, lymphoma, and multiple sclerosis. R1's Minimum Data Set (MDS) assessment, dated 6/24/25, had a Brief Interview for Mental (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker.On 7/2/25 at 11:35 AM, Surveyor interviewed R1 who indicated CNA-G pulled R1's hair. R1 indicated it upset R1 at the time which is why R1 told another CNA and RN-J talked to R1 about the incident. R1 indicated CNA-G was kidding, however, R1 did not know CNA-G was kidding at first. R1 thought CNA-G pulled R1's hair to make R1 upset and swore at CNA-G when CNA-G pulled R1's hair twice. R1 indicated CNA-G should have told R1 that it was a joke and said, Who pulls someone's hair? Kids do that. On 7/2/25 at 2:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who reviewed the FRI and indicated the allegation of abuse was reported and documented on 4/10/25 and interviews were done on 4/10/25. NHA-A indicated NHA-A thought the incident was a joke and that R1 was not upset and knew CNA-G was joking. NHA-A thought R1 was fine with the incident and stated there was no indication of an issue until R1 spoke with Social Worker (SW)-C on 4/15/25 and indicated the incident had upset R1. NHA-A verified NHA-A did not follow-up with R1 about the incident on 4/11/25 and indicated the allegation of abuse should have been reported within 24 hours. 2. On 7/2/25, Surveyor reviewed a FRI, dated 3/10/25, regarding an allegation of abuse between R2 and CNA-L. The investigation included resident and family interviews. RR-E was interviewed on 3/10/25 and indicated RR-E was not concerned for the safety of residents, however, sometimes CNA-F talked roughly and R10 appeared tense around CNA-F. On 7/2/25 at 2:10 PM, Surveyor interviewed RR-E who indicated no one followed-up with RR-E regarding the allegation of abuse and the care provided to R10 by CNA-F. RR-E indicated CNA-F's demeanor and the rough cares provided to R10 and other residents were reported to administration, including SW-C, during one of R10's care conferences as well. RR-E stated CNA-F is rough with cares at times and grabs R10's arms or legs and puts them in bed or grabs R10's arms and roughly states we need to do this or we need to do that. RR-E indicated it concerned RR-E because RR-E heard other residents mention the same thing.On 7/2/25 at 2:57 PM, Surveyor interviewed SW-C who indicated SW-C reported concerns that were brought to SW-C's attention to NHA-A or Director of Nursing (DON)-B most likely in an email. SW-C indicated RR-E indicated CNA-F was short with R10. On 7/2/25 at 3:01 PM, Surveyor interviewed NHA-A who was not aware of RR-E's concerns regarding the care R10 received from CNA-F. NHA-A indicated if NHA-A had known about the concerns, NHA-A would have reported the potential allegation of abuse to the SA.3. On 7/2/25, Surveyor reviewed a FRI that indicated R7 had a skin tear of unknown origin on the right upper arm that was identified on 6/7/25 between 7:00 and 7:45 PM. The Alleged Nursing Home Mistreatment, Neglect and Abuse Report indicated the injury was identified on 6/8/25 but was not reported to the SA until 6/11/25 at 12:08 PM. On 7/2/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including myasthenia gravis, hypertension, heart failure, and depression. R7's MDS assessment, dated 6/24/25, had a BIMS score of 3 out of 15 which indicated R7 had severely impaired cognition. R7 had an activated Power of Attorney for Healthcare (POAHC) for medical decision making. On 7/2/25 at 2:25 PM, Surveyor interviewed NHA-A who indicated staff should report injuries of unknown origin to NHA-A or DON-B whenever they are discovered. NHA-A indicated NHA-A was aware R7's injury of unknown origin was identified on 6/8/25 and was not reported to the SA timely.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R28 and R17) of 2 residents. This practice had the potential to affect more than 4 of the the 31 residents who resided in the facility. Staff did not ensure the facility's infection surveillance line list was current and up-to-date for R28 and R17. Staff did not ensure a laundry cart was covered to prevent contamination of clean linens and did not ensure clean and dirty areas were not subject to cross-contamination in the laundry room. Findings include: The facility's Infection Prevention Surveillance policy, revised 11/6/24, indicates: .Surveillance will include observing the environment for cleanliness and other evidence of compliance to policies and procedures .Responsibility for collection of data and compiling reports will be that of the Infection Prevention Practitioner. Immediate problems will be brought to the attention of the physician, the hospital staff, or the Public Health Department .Special investigation of unusual epidemics, clusters of infections, or single cases of unusual infections or pathogens will be performed. Reports will be reviewed by the Infection Prevention Physician Advisor on a regular basis. The facility's Infection Prevention Plan, revised 3/14/24, indicates: It is the policy of the facility to have a comprehensive infection control plan and an active infection control program. An Infection Control Practitioner, along with a Physician Advisor, shall be responsible for the program of identification, prevention, and control of infections acquired in the facility or brought from the community .C. Surveillance: The skilled nursing facility (SNF) surveillance system uses two approaches: process surveillance which reviews compliance with established recognized guidelines for the prevention of infections and outcome surveillance which uses standard definitions/criteria (McGeers criteria) to determine infections by reviewing date and outcomes .The Director of Nursing (DON) makes daily rounds and uses a line listing log for staff to document symptoms of potential infections. The facility's Antibiotic Stewardship policy, revised 9/20/24, indicates: The Infection Preventionist or DON will track antibiotic use and monitor adherence to evidence-based criteria .1. Documentation related to antibiotic selection and use. 2. Tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions. 3. Monitoring for clinical outcomes such as rates of C. difficile infections, antibiotic-resistant organisms, or adverse drug events. On 2/18/25, Surveyor reviewed the facility's line list and noted R28 was not on the list for a urinary tract infection (UTI) or an antibiotic that was prescribed on 2/10/25. R28's medical record indicated a urinalysis was ordered on 2/7/25 and R28's physician ordered cipro (an antibiotic medication) for the UTI. An Infection Control Checklist in R28's medical record was completed on 2/11/24 instead of 2/10/24 for the 72 hour physician follow-up. On 2/18/25, Surveyor reviewed a January 2025 antibiotic usage sheet that was provided by the facility's contracted pharmacy and had a print date of 2/10/25. The sheet indicated R17 received doxycycline (an antibiotic medication) and cefepime (an antibiotic medication). Surveyor reviewed the facility's January 2025 line list which did not indicate R17 was treated with an antibiotic for a UTI. On 2/19/25 at 11:30 AM, Surveyor interviewed DON-B who confirmed residents on antibiotics should be placed on the line list for surveillance. DON-B indicated there are individual sheets for infection control monitoring in residents' medical records and the Infection Preventionist pulls that information from the record and puts it on the line list. DON-B confirmed neither R28 or R17 were on the line list. 2. On 2/18/25 at 8:21 AM, Surveyor observed an uncovered linen cart in the 100 wing hallway that contained Chux pads, blankets, sheets, top sheets, towels, wash clothes, and gowns. On 2/18/25 at 8:25 AM, Surveyor interviewed CNA-E who confirmed the linen cart should be covered and immediately covered the cart. On 2/18/25 at 11:30 AM, Surveyor interviewed DON-B who confirmed linen carts should be covered and put away after the majority of cares are completed in the morning. 3. On 2/18/25 at 8:31 AM, Surveyor observed the 200 wing laundry room and noted a bag of dirty linens on the clean side of the room next to folded clothes. On 2/18/25 at 8:33 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who confirmed the bag of linens was dirty and should not be on the clean side of the room next to clean folded clothes. On 2/19/25 at 11:30 AM, Surveyor interviewed DON-B who indicated the clean and dirty sides of the laundry room should be kept separate. DON-B indicated clean clothes should be kept on the clean side and dirty items should be kept on the dirty side.

Based on staff interview and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R17) of 5 sampled residents. On 2/2/25, R17 was not administered an extra 1 milligram (mg) dose of bumetanide (a diuretic medication) in accordance with the physician's order. Findings include: From 2/17/25 to 2/19/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including edema, diabetes mellitus, hypertensive heart with chronic kidney disease with heart failure and end stage renal disease, and chronic obstructive pulmonary disease (COPD). R17's Minimum Data Set (MDS) assessment, dated 7/1/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 had intact cognition. R17's nutritional status care plan, dated 10/5/23, indicated R17 took diuretics as prescribed by the physician. R17's treatment administration record (TAR) contained an order for daily weights and to notify the physician if R17 had a weight change of more or less than 5 pounds. R17 had the following physician orders: ~Bumetanide 1 mg (2 tabs) daily for congestive heart failure (CHF) with an instruction to give an additional 1 mg of bumetanide if R17's weight increased 4 pounds in 1 day. ~Bumetanide 1 mg tablet as needed (PRN) with an instruction to give an additional 1 mg of bumetanide if R17's weight increased 4 pounds in 1 day. Surveyor reviewed R17's weights and noted R17 weighed 241.12 pounds. On 2/2/25, R17 weighed 245.6 pounds which was an increase of 4.48 pounds. R17's medication administration record (MAR) did not indicate staff administered an additional 1 mg of bumetanide as ordered for the increased weight gain. On 2/19/25 at 10:27 AM, Surveyor interviewed RN-C who confirmed R17 should receive an extra 1 mg dose of bumetanide for a 4 pound or greater weight increase. RN-C indicated R17 was weighed daily and confirmed bumetanide was not administered on 2/2/25 in accordance with the physician's order. On 2/19/25 at 11:36 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R17 had a 4.48 pound weight increase on 2/2/25. DON-B verified an extra 1 mg of bumetanide was not administered to R17 as ordered.

Based on staff interview and record review, the facility did not ensure notification was provided in accordance with a physician's order for 1 resident (R) (R17) of 1 sampled resident. R17 had an order for daily weights and to notify the physician if R17 gained or lost more than 5 pounds. Staff did not consistently follow the order. Findings include: From 2/17/25 to 2/19/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including edema, diabetes mellitus, hypertensive heart with chronic kidney disease with heart failure and end stage renal disease, and chronic obstructive pulmonary disease (COPD). R17's Minimum Data Set (MDS) assessment, dated 7/1/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 had intact cognition. R17's care plan, dated 10/5/23, indicated R17 had fluctuations in weight from retaining excess fluid and due to fluid shifts with dialysis. The care plan indicated R17 received diuretic medication as ordered and contained an intervention for daily weights and to closely follow changes. R17's treatment administration record (TAR) contained an order for daily weights and to notify the physician if R17's weight fluctuated more or less then 5 pounds. Surveyor reviewed R17's weights and noted R17 weighed 245.6 pounds on 2/2/25. R17's morning weight on 2/3/25 was 251 pounds which was an increase of over 5 pounds from the previous day. R17's medical record did not indicate R17's physician was notified of the weight increase. On 2/19/25 at 10:27 AM, Surveyor interviewed Registered Nurse (RN)-C who confirmed R17 had a more than 5 pound weight gain from 2/2/25 to 2/3/25. RN-C verified R17's TAR indicated the physician should be notified if R17 had a more than 5 pound weight gain. RN-C indicated there was no documentation or fax slip to indicate the physician was notified of R17's weight increase on 2/3/25. On 2/19/25 at 11:36 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should follow the physician order and notify the physician if there is a loss or gain of more than 5 pound from R17's last weight. DON-B confirmed physician notification was not documented in R17's medical record.

Based on staff interview and record review, the facility did not thoroughly investigate an allegation of abuse for 1 Resident (R) (R18) of 1 resident prior to allowing the accused staff member to continue providing resident care. This had the potential to affect 14 residents. On 12/28/23 at 6:30 PM, an allegation of verbal abuse involving Certified Nursing Assistant (CNA)-C and R18 was reported to Nursing Home Administrator (NHA)-A. CNA-C was not removed from resident care areas per the facility's policy pending the results of the investigation. Findings include: The facility's abuse policy titled Prevention, Investigating and Reporting Violations of Resident Rights ., with a revision date of 8/29/23, indicates any staff member named in an allegation of abuse will be removed from resident care areas pending the outcome of the investigation. On 1/4/24, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE], recently began dialysis treatment, and had diagnoses including recent amputation of the right knee, depression, and type 2 diabetes. R18's Minimum Data Set (MDS) assessment, dated 12/19/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R18 had intact cognition. On 1/4/24, Surveyor reviewed a facility-reported incident investigation that indicated NHA-A received a phone call on 12/28/23 at 6:30 PM from CNA-C who stated R18 said CNA-C called R18 fat during a transfer. R18 was upset and angry about the incident. As a preventative measure, CNA-C was moved to another unit which contained 14 residents, but was not removed from resident care areas or supervised during resident care. On 1/4/24 at 3:22 PM, Surveyor interviewed NHA-A who confirmed CNA-C continued to provide care and interact with residents while the investigation was in process. NHA-A acknowledged NHA-A should have removed CNA-C from resident care areas pending the outcome of the investigation per the facility's policy.

Based on observation, staff interview, and record review, the facility did not ensure food was prepared and stored under sanitary conditions. These practices had the potential to affect multiple residents at the facility. ice maker - brown/rust color on ice curtain; fruit punch on door interior mixer bowl - not covered or inverted with visible crumbs inside bowl freezer drawer - visible crumbs in gaskets and along top door edge dishwasher - visible dust hanging from equipment coils located at top back of machine oven - handle and knobs sticky/tacky to touch Findings include: On 4/29/19 during initial kitchen tour beginning at 8:34 AM, Dietary Manager (DM)-B indicated to the Surveyor the kitchen utilized ServSafe (which is based on the Food and Drug Administration (FDA) Food Code (YEAR)) as the standard of practice. Food Contact Surface Cleaning Ice Maker FDA Food Code (YEAR) documents at cleaning expectations at 4-602.11 Equipment Food-Contact Surfaces and Utensils . (E)(4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (b) .at a frequency necessary to preclude accumulation of soil or mold. On 4/29/19 during initial kitchen tour beginning at 8:34 AM, the Surveyor observed and DM-B verified the facility ice maker had some brown colored residue which DM-B described as rust colored on the interior water curtain. The discoloration extended horizontally along the ice curtain and DM-B was able to remove residue by wiping it with a cloth. The ice machine door had dried red residue on the top left edge. DM-B indicated the red residue was fruit punch and verified staff should have cleaned the splash at the time it occurred. DM-B explained the interior of the machine is deep cleaned and sanitized every six months. Mixer Bowl FDA Food Code (YEAR) documents cleaning expectations at 4-601.11 (B) The Food contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. On 4/29/19 during initial kitchen tour beginning at 8:34 AM, the Surveyor observed and DM-B verified a mixing bowl located adjacent to a food preparation table had visible crumbs in the bottle of the bowl. DM-B indicated it was not the practice of the facility to invert or cover the mixer's bowl when not in use. Non-Food Contact Surfaces FDA Food Code (YEAR) documents cleaning expectations at 4-601.11 (C) Non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Freezer Drawers On 4/29/19 during initial kitchen tour beginning at 8:34 AM, the Surveyor observed and DM-B verified the eight drawer style freezers and refrigerators located under the food preparation table had visible debris on the top of the drawer edges and in the door gaskets. Oven On 4/29/19 during initial kitchen tour beginning at 8:34 AM, the Surveyor observed the facility oven door handle and stovetop knobs were visibly soiled. DM-B indicated the interior of the oven was on a monthly cleaning schedule and verified the exterior handle and knobs were sticky to the touch. Dishwasher On 4/30/19 at 9:26 AM, the Surveyor was observing dishwashing and noted a green coil located at the top rear of the dishwasher had visible dust buildup when was hanging down in bunches. At that time, the Surveyor interviewed DM-B who verified the coil was dusty and not on a cleaning schedule.

Based on staff interview and record review, the facility did not ensure the minimum required members of the Quality Assurance (QA) committee met at least quarterly. This practice has the potential to impact all residents that reside at the facility. Three of four QA meetings over the past year did not have Nursing Home Administrator (NHA)-C, the owner, a board member, or similar individual in a leadership role and/or the Medical Director (MD)-D in attendance. Findings include: On 5/1/19, the Surveyor reviewed the facility's quarterly QA meetings attendance for the last year and noted NHA-C did not attend the 4/22/19 meeting and MD-D did not attend the 7/2018 and 1/21/19 meetings. On 5/1/19 at 9:33 AM, during an interview with the Surveyor, NHA-C verified she had missed the (MONTH) 2019 meeting as she was on vacation. NHA-C also verified MD-D did not attend the (MONTH) (YEAR) and (MONTH) 2019 meetings. NHA-C indicated they have tried to get MD-D to attend the QA meetings by changing the date and time, however, conflicts still arise with MD-D's daily schedule.

Based on observation, staff interview and record review, the facility did not ensure food was stored, prepared, distributed and served under sanitary conditions. Multiple storage racks containing dishes had an accumulation of dust on them. Staff did not test the sanitizer solution according to manufacturer instructions. This practice had the potential to affect 24 out of 25 residents in the building. One resident receives nutrition via a tube feeding. Findings include: On 3/27/18 at 8:28 AM, the Surveyor conducted the initial tour of the kitchen with Dietary Cook (DC)-B. DC-B indicated the facility follows the Federal Food Code, State of Wisconsin Food Code and ServSafe. 1. WI Food Code 4-601.11(C) indicates nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. WI Food Code 4-602.13 indicates nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During the initial tour, the Surveyor observed multiple storage racks containing clean dishes that had an accumulation of dust on them. On 3/28/18 at 1:30 PM, the Surveyor interviewed DC-B regarding the storage racks. DC-B verified the racks were dusty. DC-B indicated the cleaning of the racks was not on the daily cleaning schedule and the facility cleans them in the Summer when they can take them outside and use a pressure washer on them. 2. On 3/27/18, the facility provided instructions entitled, Array Comprehensive Clean Sanitizer Test Procedures for Three Compartment Sink. The instructions state: 1. Remove a 1.5 strip of clean, dry test paper from container below. Make sure you select test paper for sanitizer being used. 2. Dip strip of test paper in clean, fresh, room temperature (75 degrees Fahrenheit(F)) sanitizer solution. Hold test paper strip in sanitizer solution for time required on test paper container, or as shown below. 3. Immediately compare test paper strip to chart on test paper container. Test results must be within the range shown below. Requirements for Quaternary solution: Test paper reading: 150-400 ppm Test paper immersion time: 10 seconds Sanitizer Solution Temperature for Testing: 75 degrees F room temperature Utensil, Pot and Pan Immersion Time: At least 1 minute **Caution: Testing sanitizer solutions above or below recommended temperatures may result in inaccurate readings. On 3/27/18 at 8:45 AM, the Surveyor reviewed the Sanitizer Concentration Log. The log indicates dietary staff are testing the sanitizer multiple times during the day, however, there is no record of the dietary staff taking the temperature of the sanitizer solution before testing. During the initial tour, DC-B tested the sanitizer solution in the three compartment sink. DC-B removed a test strip from container. DC-B dipped his finger into the solution and indicated to the surveyor that the water was room temperature. DC-B then dipped the test strip into the water and held it for 10 seconds. DC-B then removed the test strip and compared the test strip to the container and indicated the paper read around 200 parts per million (ppm). At the time of testing, DC-B indicated they do not use a thermometer to take the temperature of the sanitizer solution water and confirmed they do not record the temperature of the water when testing. On 3/28/18 at 1:30 PM, the Surveyor interviewed Nutrition Technician (NT)-C regarding the sanitizer testing procedures for the three compartment sink. NT-C stated she does not check the sanitizer solution water temperature when testing and verified she does not record the sanitizer solution water temperature on the log.

Based on observation, record review, and staff interview, the facility did not ensure that 1 (R (Resident) 13) of 2 sampled residents observed received appropriate treatment and services to prevent urinary tract infections. R13 was not provided complete perineal cleansing following an episode of incontinence. Findings include: According to Lippincott's Textbook for Nursing Assistants 3rd edition published in 2012, proper perineal care helps to prevent skin breakdown, pressure ulcers, infection and odor. The standard also directs staff to provide thorough incontinent cares by cleansing all potentially contaminated areas including the rectum and buttocks. R13's quarterly MDS (Minimum Data Set) assessment dated [DATE], documented R13 was frequently incontinent of bladder and bowel. R13 required extensive assistance from staff for transfer, personal hygiene and toileting. On 03/28/18 at 09:43 AM, the Surveyor observed CNA (Certified Nursing Assistant)-E and CNA-F provide incontinence and toileting cares for R13. With cleansed and gloved hands CNA-E and CNA-F transferred R13 to the commode. CNA-E verified R13 was incontinent of urine and while on the commode had a bowel movement. With cleansed and gloved hands CNA-E provided posterior perineal care for R13 without concern. CNA-E and CNA-F assisted R13 with a new incontinence pad, pulled up mesh undergarment/pants then transferred R13 back to the wheelchair. During the provision of perineal care, R13's anterior perineal area was not cleansed. Immediately following the above observation, the Surveyor interviewed CNA-E regarding the above observation of incontinence/perineal care for R13. CNA-E verified R13 was incontinent of urine and no anterior perineal care had been provided. CNA-E further indicated it is the facility's policy to provide thorough perineal care for all residents. On 03/29/18 at 09:32 AM, the Surveyor interviewed DON (Director of Nursing)-D regarding the observation of care for R13. DON-D indicated it is the facility's policy to cleanse the perineal area thoroughly after each incontinence episode. DON-D further indicated anterior perineal care should have been completed for R13.

Based on staff interview and record review, the facility did not ensure 1 (R (Resident) 8) of 12 sampled residents were provided services following State statute Chapter 55.03(4). The law requires a court ordered protective placement for any resident admitted to a nursing home, who has a legal guardian and whose nursing home stay exceeds ninety days. R8 was admitted to the facility with the consent of a legal guardian; however, the facility did not pursue protective placement when the resident's stay exceeded ninety days. The facility extended the rights of the guardian, for nursing home admission, beyond those rights allowed in State law. Findings include: R8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Surveyor was unable to locate any additional guardianship documentation or a protective placement order in R8's medical record. On 3/27/18 at 1:10 PM, the Surveyor interviewed SW (Social Worker)-A regarding R8. SW-A stated the guardianship papers in the chart were from long ago and was not aware of any additional forms. SW-A stated R8 was admitted from another Nursing Home. SW-A stated she will look to see if she can locate current guardianship and protective placement documentation. On 3/27/18 at 2:37 PM, SW-A verified to the Surveyor R8 did not have any additional protective placement documentation or current guardianship forms. On 3/27/18 at 3:10 PM, during an interview with the Surveyor, SW-A stated the facility has initiated the protective placement process with the court.

Based on observations, record review and staff interviews, the facility did not distribute and serve food in accordance with professional standards for food service safety as it relates to sanitary warewashing. The high temperature dishwasher, which is used to clean and sanitize dishes in the facility, was observed to have sanitization rinse temperatures above accepted parameters for the proper sanitization of dishes. Three observations were made whereby the rinse temperature exceeded 194 degrees F (Fahrenheit). Additionally, review of temperature logs revealed several entries for which rinse temperatures exceeded 194 degrees F. The (DSM) Dietary Services Manager was unaware of the maximum machine temperature recommendations and there was no written policy or manual to guide staff for what to do if dishwashing temperatures did not fall within safe and recommended parameters. Findings include: The 2013 Federal Food Code 4-501.112(A)(2) indicates mechanical warewashing equipment, hot water sanitization temperatures in mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more that 194 degrees F, or less than 180 degrees F. According to the 2013 Federal Food Code Annex-3 Public Health Reasons/Administration Guidelines the surface temperature must reach at least 71 degrees C (Celsius) (160 F) as measured by an irreversible temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. On 3/6/17 at approximately 8:30 a.m., during initial tour of the kitchen, DSM (Dietary Services Manager)-A verified to Surveyor the facility followed the Federal Food Code as its standard of practice. On 3/7/17 at 9:20 a.m., Surveyor observed dishwashing in the kitchen which served the facility. A manufacturer's placard attached to the machine, posted above the temperature gauges, indicated the wash temperature should be 165 degrees F and the rinse (sanitization) temperature, 185 degrees F. The first wash temperature observed reached 165F, followed by rinse temperature of 202F. At 9:26 a.m., the wash temperature reached 165F, followed by rinse temperature of 208F. At 9:30 a.m., the wash temperature reached 166F, followed by rinse temperature of 200F. At 9:31 a.m., the wash temperature reached 172F, followed by rinse temperature of 200F. At 9:32 a.m., Surveyor interviewed DSM-A who stated the maximum temperature for this high temperature dishwasher was 220F. DSM-A added that at temps above 220F, the water turned to steam and was ineffective for sanitization of dishware surfaces. At that time, Surveyor requested the manufacturer's manual or written recommendations for use. On 3/7/17 at 10:00 a.m., DSM-A approached Surveyor indicating he called the manufacturer of the dishmachine and the Business Office Manager at the office stated, The maximum temperature should be between 195F and 212F, but in Wisconsin, the maximum temperature should be 198F. It was verified DSM-A did not have written guidance or a manufacturer's manual for the dishwashing machine. On the same day at 11:55 a.m., DSM-A verified to Surveyor that upon research and review of available Internet resources, DSM-A agreed the maximum dishwashing temperature should be 195F. DSM-A indicated the plant operations manager had been contacted and the water temperatures would be corrected. When asked for policies and procedures related to staff monitoring dishwashing temperatures, DSM-A indicated there were none, but presented a job aid which consisted of a list of duties for dietary aides. This document entitled, AM DISHES, updated 9/30/16, indicated, 9:00 am., Record sanitizer levels and dish machine temps .10:00-12:30 .Record dish temperatures .6:45 - 7:00 .Record dish machine temps. Upon review of dish machine temperature logs recorded 3 times a day for the previous 6 months, Surveyor noted the following: During 8/16, the sanitization temperatures recorded exceeded 194F 14 times ranging from 195 to 198 degrees F. During 9/16, the sanitization temperatures recorded exceeded 194F 25 times ranging from 195 to 200 degrees F. During 10/16, the sanitization temperatures recorded exceeded 194F 19 times ranging from 195 to 220 degrees F. During 11/16, the sanitization temperatures recorded exceeded 194F 27 times ranging from 195 to 220 degrees F . During 12/16, the sanitization temperatures recorded exceeded 194F 5 times ranging from 195 to 200 degrees F. Additionally 17 expected opportunities for recording the dishwashing temps were missed during this month. During 1/17, the sanitization temperatures recorded exceeded 194F 17 times ranging from 195 to 204 degrees F. The above record was reviewed and confirmed with DSM-A on 3/7/17 at 12:00 p.m.

Based on observation, staff interview and record review, the facility did not maintain an infection control program designed to prevent the development and transmission of disease and infection during 2 of 7 observations of hand hygiene for R (Resident) 4 and R8. Staff did not appropriately cleanse hands during the provision of perineal cares for R4. Staff did not appropriately cleanse hands during the provision of perineal cares for R8. Findings include: The facility policy entitled Hand Hygiene with a revision date of 9/15/16, indicated hands should be washed before and after direct contact with a resident, after contact with blood, body fluids, excretions, mucous membranes, non-intact skin, or wound dressings. Hands should be washed after removing gloves and when moving from a contaminated body site to a clean site during patient care. 1. On 3/7/17 at 9:47 a.m., Surveyor observed CNA (Certified Nursing Assistant)-H apply gloves to assist R4 with toileting. CNA-H cleansed R4's urethral and anal area from front to back with a wet wipe. CNA-H removed gloves and without washing/sanitizing hands, CNA-H applied a clean glove to the right hand, placed barrier cream on R4's anal area with the right hand and placed the left hand on R4's back over the gait belt. CNA-H removed the right glove and sanitized hands prior to pulling up R4's pants and removing the gait belt. After cares were completed at 10:02 a.m., Surveyor interviewed CNA-H regarding hand hygiene. CNA-H verified hands were not sanitized/washed after cleansing R4's perineal area and prior to placing barrier cream on R4. 2. On 3/7/17 at 4:40 p.m., Surveyor observed CNA-E and CNA-F apply gloves to assist R8 with incontinence cares. CNA-E verified R8 was incontinent of a large amount of urine. After CNA-E and CNA-F transferred R8 from the commode to the bed, CNA-E cleansed R8's anal area with a wet wipe and removed gloves. Without washing/sanitizing hands, CNA-E picked up the tube of thick barrier cream and placed barrier cream on the gloved right hand of CNA-F. CNA-E then sanitized hands. On 3/7/17 at 5:44 p.m., Surveyor interviewed CNA-E regarding the above observations related to hand hygiene. CNA-E verified gloves were removed after providing incontinence cares and hands were not washed/sanitized prior to picking up the tube of thick barrier cream to place cream on the right hand of CNA-F.

Based on observation, staff interview and record review, the facility did not ensure residents were free of a medication error rate of 5 percent or greater for 1 (Resident (R) 4) of 5 sampled and supplemental sampled residents observed during medication administration. Two of twenty-seven opportunities observed during medication administration resulted in errors to equal an error rate of 7.4 percent. Errors included crushing an [MEDICATION NAME]-coated aspirin and a multivitamin with iron that had a coating on the tablet. Findings include: 1. On 3/6/17 at 8:47 a.m., Surveyor observed RN (Registered Nurse)-G crush 1 [MEDICATION NAME]-coated aspirin and 1 Tab-A-Vite (multivitamin) with iron that had a coating on the tablet for R4 along with additional medications. RN-G placed the crushed medications in a cup with applesauce and administered the medications to R4. RN-G verified the medications were crushed for R4. R4's current physician order, dated 2/21/17, indicated R4 had an order for [REDACTED]. According to the 2015 ISMP (Institute for Safe Medication Practices), EC aspirin should not be crushed. According to the manufacturer guidelines, Tab-A-Vite capsules or tablets should be swallowed whole, unless the directions say you can break, crush, or chew the vitamin with iron. Some tablets have a special coating and should not be chewed. On 3/6/17 at 4:33 p.m., Surveyor interviewed RN-G regarding crushing the EC aspirin and the multivitamin with iron that had a coating on the tablet. RN-G verified EC aspirin and multivitamins with iron shouldn't be crushed. On 3/6/17 at 4:47 p.m., Surveyor interviewed DON (Director of Nursing)-D regarding crushing an EC aspirin and a multivitamin with iron that had a coating on the tablet. DON-D stated no, should not crush either medication.

Based on record review and staff interview, the facility did not immediately inform/consult with the resident's physician for 1 (R (Resident) 8) of 10 sampled residents when a deterioration of health required a need for the physician to prescribe treatment. R8 developed a Stage 3 pressure injury to the coccyx area on a Friday (3/3/17). A fax message was sent to the physician later in the day on that Friday. On Monday (3/6/17), the facility had not received a response from the physician and did not follow-up with the physician. Four days after the original fax was sent to the physician, on Tuesday (3/7/17) evening, the physician sent an order via fax for the treatment of [REDACTED]. Findings include: The facility policy with a revision date of 5/6/16 and entitled Notification of Changes in Condition or Status of Resident SNF Policy, indicated nurses have the responsibility to obtain medical care for residents under their care . When an assessment completed by a nurse indicates that the resident requires intervention that is beyond his/her scope of practice he/she must obtain that service for the resident. Appropriate notification of the resident's physician will occur in the event of a significant change in treatment. If the attending physician or designated alternate is not available, or does not respond appropriately, he/she must take further steps to obtain service for the resident. Steps to be taken include notifying the DON (Director of Nursing) or her designee of the problem. She will make a decision regarding immediate transfer and/or involvement of the medical director. If the DON or her designee is not immediately available, call the medical director. If the nurse is not able to contact any of the above persons immediately, contact the hospitals emergency physician on duty. On 3/7/17, Surveyor reviewed R8's electronic medical record and it indicated R8 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. An undated fax without a time, indicated was sent to the physician by RN (Registered Nurse)-C, which indicated R8 had a weekly skin assessment completed with a shower. Previously was staged/documented by wound APNP (Advanced Practice Nurse Prescriber) as incontinence [MEDICAL CONDITION]. Area is open and deeper than before measuring 1.6 cm (centimeter) L (length), 1.2 cm W (width) and 0.4 cm D (depth). Applying thick barrier cream directly to open area & thin around the open area. Will continue to monitor. Wound has zero odor. Serosanguineous drainage. Staging it a Stage 3 pressure ulcer. The nursing note dated 3/3/17 at 4:36 p.m. (created 3/7/17 at 4:36 p.m.), by RN-C, indicated the focus of the note was a fax to the physician. The note stated R8 had weekly shower and skin assessment. Coccyx wound previously incontinent [MEDICAL CONDITION] now is a Stage 3 pressure ulcer. Wound is open and deeper than previously noted and assessed. Wrote fax to update MD (medical doctor), waiting for response. Applied thick protective cream to area. The physician orders [REDACTED]. PT (physical therapy) eval and treat. On 3/7/17 at 4:55 p.m., Surveyor interviewed RN-C, who verified R8 had a Stage 3 pressure injury to the coccyx area that started as contact [MEDICAL CONDITION]. Last week Friday (3/3/17) paste (thick barrier cream) was removed from the wound to find the wound was open more. RN-C then stated there is not a dressing (on the Stage 3 pressure injury) because there is not an order from the doctor. Sent it (fax) Friday evening, unknown time. Haven't heard yet. Can send another fax to the doctor. The doctor is aware there is not a dressing on the Stage 3 pressure injury to the coccyx and that R8 is incontinent. On 3/7/17 at 5:35 p.m., Surveyor interviewed RN-C, who did not know the time the fax was sent because there is not a time on the fax. RN-C stated it was sent in the evening and verified the physician returned the fax earlier today (Tuesday 3/7/17) at 5:08 p.m., with an order to put a dressing on the Stage 3 pressure injury to the coccyx area. RN-C indicated the order was found on the fax machine. RN-C confirmed the facility staff did not attempt to contact the physician or another physician via fax or telephone when the facility did not receive an order from the physician as requested on 3/3/17.

Based on observation, record review and staff interview, the facility did not ensure residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure injuries from developing in 1 of 7 sampled residents (R8). R8 was readmitted to the facility on [DATE] with chronic incontinence associated [MEDICAL CONDITION] and an unstageable pressure injury on the coccyx. On 3/1/17, the unstageable pressure injury was changed to a Stage 3 pressure injury. A fax was sent to the physician and the facility did not follow-up with the physician when the physician did not respond. The facility followed a treatment ordered by a physician prior to the development of the Stage 3 pressure injury. R8's Stage 3 pressure injury was not covered as indicated by current clinical practice. The care plan indicated R8 was to have a pressure redistribution cushion while seated in the recliner, but R8 did not have a cushion on the seated surface of the recliner because of positioning/safety. The facility was waiting for an order from the physician to have physical therapy evaluate R8 for a positioning device/pressure redistribution cushion. Additionally, R8's anal area was cleansed with a wet wipe and then the same wet wipe was used to cleanse the Stage 3 pressure injury on the coccyx area. Findings include: The Clinical Guideline, published by the NPUAP (National Pressure Ulcer Advisory Panel) in 2009, entitled Pressure Ulcer Prevention encourages healthcare personnel to consider individuals who are bedfast and/or chair fast to be at risk of pressure ulcer development and to develop and implement a prevention plan when individuals have been identified at risk of developing pressure ulcers. The use of repositioning should be considered in all at-risk individuals. Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas. Pressure redistribution seat cushions should be used for individuals sitting in a chair when mobility is reduced and who are thus at risk of pressure ulcer development .Without pressure relief, a pressure ulcer may occur very quickly. The second edition published in 2014, entitled Prevention and treatment of [REDACTED]. Pressure redistributing support surfaces are designed to either increase the body surface area that comes in contact with the support surface (to reduce interface pressure) or to sequentially alter the parts of the body that bear load, thus reducing the duration of loading at any given anatomical site. Even a tight, non stretch cover will adversely affect cushion performance. Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced. Ensure that selection of a pressure redistributing seat cushion is appropriate to the individual. Provide complete and accurate training on use and maintenance of a seating support surface and cushion devices delivered to the individual. If sitting in a chair is necessary for individuals with pressure injury consult a seating specialist to prescribe appropriate seating surface. According to the NPUAP 2014 Quick Reference Guide, Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown is classified as full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. The NPUAP also indicated research has found that chronic wounds such as pressure ulcers heal differently from acute wounds, primarily because of differing biochemical and cellular characteristics. Current clinical practice indicates that Stage 3 and Stage 4 ulcers should be covered. 1. R8's electronic medical record included an admission MDS (Minimum Data Set) assessment dated [DATE], that documented R8 was re-admitted to the facility on [DATE] with diabetes mellitus, diabetic [MEDICAL CONDITION] and moisture associated skin damage. In addition, this MDS assessment documented R8 scored 13 out of 15 on the cognitive screen (the higher the score, the more cognizant), required extensive assistance for bed mobility, was dependent on staff for transfers, did not ambulate, was at risk for the development of pressure injury and had a pressure reducing device for bed and chair. R8's Braden skin risk score assessment (scale for predicting pressure injury risk), dated 3/7/17, documented the following regarding R8: ~ moderate risk with a score of 14 for the development of a pressure injury ~ has very limited mobility ~ chairfast with the ability to walk severely limited/none ~ skin is very moist requiring linen to be changed at least every eight hours ~ friction/shear is a problem as frequently sliding down in bed or chair ~ requires frequent repositioning with maximum assistance R8's pressure ulcer CAA (Care Area Assessment) dated 1/31/17, indicated R8 had an open/fragile area on buttocks. Cream is applied to help heal and reduce further breakdown. This will be care planned. R8's current plan of care, dated 2/9/17, indicated the following: ~ readmitted with incontinence [MEDICAL CONDITION] on buttocks ~ has very sensitive skin ~ mobility is limited and assistance is required with repositioning during rounds and as needed ~ has a specialty mattress as well as a cushion for wheelchair and recliner to help reduce pressure ~ notify physician as appropriate The current undated Resident Care Givers Worksheet indicated R8 was to have a specialty cushion in wheelchair and recliner. R8's wound care notes dated 1/24/17, and documented by wound APNP (Advanced Practice Nurse Prescriber), indicated R8 had incontinence associated [MEDICAL CONDITION] to bilateral buttocks and an unstageable pressure injury of skin and tissue on the coccyx. Additionally, the physician wrote an order on 1/24/17 at 9:00 a.m., to apply thick barrier cream to affected area on sacrum daily and as needed and to place protective barrier on surrounding skin. R8's wound care notes dated 2/14/17 at 7:18 p.m., documented the location of the wound was the buttocks below coccyx. Wound type was partial thickness and incontinence [MEDICAL CONDITION]. Drainage was serosanguineous with pink macerated surrounding tissue. Dressing type was thick cream. R8's wound care notes dated 3/1/17 at 4:40 p.m., documented the location of the wound was the buttocks below coccyx and the wound type was a Stage 3 pressure injury with serosanguineous drainage and pink macerated surrounding tissue. The wound measured 1.6 cm (centimeter) length, 1.2 cm wide and 0.4 cm depth. The wound was cleansed with soap and water. Thick protective cream was placed on the wound. R8's wound care notes dated 3/3/17 at 3:39 p.m., documented the same as the note of 3/1/17. R8's nursing note dated 3/3/17 at 4:36 p.m. (created 3/7/17 at 4:36 p.m.) by RN (Registered Nurse)-C indicated the focus of the note was a fax to the physician. The note stated R8 had weekly shower and skin assessment. Coccyx wound previously incontinent [MEDICAL CONDITION] now is a Stage 3 pressure ulcer. Wound is open and deeper than previously noted and assessed. Wrote fax to update MD (medical doctor), waiting for response. Applied thick protective cream to area. An undated fax without a time, indicated was sent to the physician by RN-C, which indicated R8 had a weekly skin assessment completed with a shower. Previously was staged/documented by wound APNP as incontinence [MEDICAL CONDITION]. Area is open and deeper than before measuring 1.6 cm (centimeter) L (length), 1.2 cm W (width) and 0.4 cm D (depth). Applying thick barrier cream directly to open area & thin around the open area. Will continue to monitor. Wound has zero odor. Serosanguineous drainage. Staging it a Stage 3 pressure ulcer. The care conference nursing notes dated 3/7/17 at 11:14 a.m., documented R8's wound measurements have been stable for the past week. Incontinent [MEDICAL CONDITION] has improved, however the shearing is impacting wound. PT will assess R8's sitting posture to evaluate possible need for specialty seat. On 3/7/17 at 3:06 p.m., Surveyor observed R8 sitting in the recliner without a pressure redistribution cushion on the seated surface of the recliner. CNA (Certified Nursing Assistant)-E verified R8 did not ambulate and was sitting in the recliner without a pressure redistribution cushion on the seated surface. CNA-E confirmed R8 had a pressure redistribution cushion on the seated surface of the resident's wheelchair. R8 continued sitting in the recliner without a pressure redistribution cushion on the seated surface of the recliner when observed by Surveyor at 4:03 p.m., 4:11 p.m., 4:25 p.m., and 4:39 p.m. On 3/7/17 at 4:40 p.m., Surveyor observed CNA-E and CNA-F transfer R8 using a full mechanical lift from the recliner to the bed. CNA-E verified R8 had not been sitting on a pressure redistribution cushion while seated in the recliner. After transferring R8 to bed, CNA-E verified R8 was incontinent of urine and had an open area (Stage 3 pressure injury) to the coccyx area that did not have a dressing on it. At 4:57 p.m., CNA-E cleansed R8's anal area with a disposable wet wipe and using the same soiled wet wipe, CNA-E wiped thick paste from the Stage 3 pressure injury in the coccyx area. CNA-F then applied thick barrier cream on the Stage 3 pressure injury after the wound had been cleansed with a soiled wet wipe that had cleansed the anal area. On 3/7/17 at 4:55 p.m., Surveyor interviewed RN-C, who verified R8 had a Stage 3 pressure injury to the coccyx area that started as contact [MEDICAL CONDITION]. RN-c indicated last week Friday (3/3/17), paste (thick barrier cream) was removed from the wound to find the wound was open more. RN-C then stated there is not a dressing (on the Stage 3 pressure injury) because there is not an order from the doctor. RN-C stated Sent it (fax) Friday evening (3/3/17), unknown time. Haven't heard yet. Can send another .The doctor is aware (there is not a dressing on the Stage 3 pressure injury to the coccyx and that R8 is incontinent). R8's physician orders [REDACTED]. PT (physical therapy) eval and treat. On 3/7/17 at 5:25 p.m., Surveyor interviewed DON (Director of Nursing)-D, who verified the facility had an order for [REDACTED]. On 3/7/17 at 5:35 p.m., Surveyor interviewed RN-C regarding the time the fax was sent to the physician on 3/3/17 because there is not a time on the fax. RN-C indicated the fax was sent in the evening of 3/3/17. RN-C verified the physician returned the fax on Tuesday 3/7/17 at 5:08 p.m., with an order to put a dressing on the Stage 3 pressure injury to the coccyx area, as the order was on the fax machine. The physican's order included a Moist [MEDICATION NAME] to be placed on wound with [MEDICATION NAME] adhesive. Change every third day. PT (physical therapy) to eval and treat. Additionally, RN-C confirmed staff did not attempt to contact the physician or another physician via fax or telephone when the facility did not receive an order from the physician, as requested on 3/3/17. On 3/7/17 at 5:44 p.m., Surveyor interviewed CNA-E regarding cleansing the anal area and using the same soiled wet wipe to cleanse R8's Stage 3 pressure injury. CNA-E confirmed the anal area was wiped with the disposable wet wipe and then the Stage 3 pressure injury was wiped with the same wet wipe to remove thick barrier cream from the wound. CNA-E stated should not have wiped the Stage 3 pressure injury with the same wet wipe used to cleanse the anal area. On 3/8/17 at 10:10 a.m., Surveyor interviewed DON-D, who verified the facility recognized shearing was a problem last week because R8 was sliding down in the recliner. The facility was waiting for an order from the physician for PT to evaluate the resident sliding down while seated in the recliner.

Based on record review and staff interview, the facility did not ensure 3 (Resident (R) 9, R4, and R7) of 10 sampled residents reviewed met the PASRR (Pre-Admission Screen and Resident Review) requirements. Resident 9's medical record did not include an updated PASRR after the resident was diagnosed with [REDACTED]. R4's medical record did not include an updated PASRR after R4 was diagnosed with [REDACTED]. R7 was admitted to the facility taking the prescribed antipsychotic [MEDICATION NAME], A level II PASRR was not initiated. Additionally, R7's medical record did not include an updated PASRR after the resident was diagnosed with [REDACTED]. Findings include: 1. R9 was admitted to the facility on [DATE] and a Level I PASRR screen was completed on 12/30/15 for the resident. In Section A, the No box was checked for Does the person have a major mental disorder under the Diagnostic and Statistical Manual or Mental Disorders, 3rd edition, revised (DSM III-R) or DSM IV?; the No box was checked for Within the past six months, has this person received [MEDICAL CONDITION] medication(s) to treat symptoms or behaviors of a major mental disorder under DSM III-R or DSM IV?; the No box was checked for Has the person displayed any of the following symptoms that may suggest the presence of a major mental illness?; the No box was checked for Is there a [DIAGNOSES REDACTED].? and also for Is there a [DIAGNOSES REDACTED].? Per PASRR requirements, If you have answered No to all the above questions in Section A, the person does not require further PASRR evaluation . Based on the requirements, the facility did not pursue a Level II screen. On 1/18/16, R9 was diagnosed with [REDACTED]. Based on PASRR requirements, For those persons presently residing in a nursing home, this form (PASRR Level I) should be filled out only if there is a change in status in Section A. On 3/8/17 at 9:50 a.m., Surveyor interviewed SW-B regarding the PASRR screen. SW-B confirmed a new Level I screen should have been completed at the time the depression [DIAGNOSES REDACTED]. 2. R4 had a Level I PASRR screen completed on 5/9/08. R4 was not suspected of having a serious mental illness or developmental disability at the time of the screen. All questions in Section A regarding mental illness were answered no, which indicated R4 did not require further PASRR evaluation. R4 was diagnosed with [REDACTED]. An additional 25 mg of [MEDICATION NAME] was ordered on [DATE] to treat R4's ongoing depression. Although the resident had a significant change in status ([DIAGNOSES REDACTED]. On 3/7/17 at 10:40 a.m., Surveyor interviewed SW-B regarding R4's PASRR screen. SW-B verified R4 should have had a new Level I screen completed when diagnosed with [REDACTED]. SW-B then completed a new Level I screen for R4. 3. On 3/7/17 Surveyor reviewed the medical record of R7, who was admitted to the facility on [DATE]. The level I PASRR completed on 7/8/16 documented the use of [MEDICATION NAME] by R7, and in section A, Questions Regarding Mental Illness, #2, labeled Medications was marked with a Yes. In section B, Short Term Exemptions, nothing was checked. A level II PASRR was not found. A Medical [DIAGNOSES REDACTED]. On 3/8/17 at 9:50 a.m., Surveyor interviewed SW-B regarding the PASRR screen. SW-B confirmed a new Level I screen should have been completed at the time the depression [DIAGNOSES REDACTED]. R7 was not exempted as the Section B questions were unanswered.