Every finding on record at Edenbrook Sheboygan

Based on observation, interview and record review, the facility did not ensure food was served and stored in a safe and sanitary manner. This practice had the potential to affect 59 of 60 residents residing in the facility. (One resident received all nutrition through a feeding tube.) Staff did not properly label, date, or store food in a manner to ensure food safety. Testing and documentation of parts per million (PPM) of the sanitizing solution were not accurately completed. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not follow safe food cooling protocol. Staff did not reheat food served to a resident in accordance with their policy. Findings include: On 7/6/26 at 9:02 AM, Surveyor and Dietary Manager (DM)-C began an initial tour of the kitchen. DM-C stated the facility follows the Federal Food and Drug Administration (FDA) Food Code. Food Labeling/Dating/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (Celsius) (41 F) (Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. The 2022 FDA Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Disposition: (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). The facility's Food Safety Requirement policy, revised 12/23/25, indicates: It is the policy of this company that all facilities provide safe and sanitary storage, handling, and consumption of all foods .This includes the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety .The Centers for Medicare and Medicaid Services (CMS) recognizes the U.S. Food and Drug Administration (FDA) Food Code and the Centers for Disease Control and Prevention's (CDC's) Food Safety Guidance as national standards to procure, store, prepare, distribute, and serve food in long term care facilities in a safe and sanitary manner . The Facility's Sanitation and Cleaning Schedule policy, revised 8/15/23, indicates: .Storage (refrigerated) .All refrigerated and prepared food must be covered, labeled, and dated with a use-by date that is a maximum of 7 days from the date of preparation. The label must include the name of the food and the date by which it should be used . During the initial kitchen tour with DM-C on 7/6/26, Surveyor observed the following food storage concerns: Coolers:~ An unsealed 5 pound bag of shredded parmesan cheese that was open to air with an open date of 6/25 (per DM-C) and no use-by date.~ A bag of shredded mozzarella cheese with an open date of 6/25 (per DM-C) and no use-by date.~ An opened bag of sliced Swiss cheese without an open or use-by date. ~ An open container of cream cheese with an open date of 6/7 (per DM-C) and no use-by date.~ An open container of cottage cheese with an open date of 6/7 (per DM-C) and no use-by date. ~ A container labeled blushing pears with an open/made date of 6/4 (per DM-C) and no use-by date. Survyor interviewed DM-C who stated all open or made food should contain open/made and use-by dates. When asked the use-by dates for the above items, DM-C stated the use-by/discard date is 7 days from the open/made date. Freezers:~ An unlabeled pan of macaroni and cheese (per DM-C) without an open/made or use-by date.~ An open bag of blueberries without an open or use-by date. ~ In the walk-in freezer, Surveyor and DM-C observed ice drips from the ceiling fans in the back of the freezer. Food was stored on shelves under the left side of the dual fan ceiling unit. Ice was observed on a bag of tater tots, an open box of pancakes, and a container of English muffins. Piles of ice were also observed on the freezer floor. Surveyor interviewed DM-C who stated food should not be stored under the fans which were dripping liquid. DM-C stated the food would be discarded and a maintenance request would be completed. DM-C was not sure of the use-by dates for the above items observed in the freezers. Sanitizing Solution: The 2022 FDA Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions. The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. A posted TMA Quaternary Sanitizer data sheet indicated the sanitizing solution should be tested for effectiveness between 65 and 75 degrees Fahrenheit (F) to accurately measure the parts per million (PPM). Hydrion Quat test strips used to test the sanitizing solution indicate the solution temperature should be tested and be within 65-75 degrees F. The effective PPM range is 150-400. The Facility's Sanitation and Cleaning Schedule policy, revised 8/15/23, indicates: .5. The sink sanitizer log must be completed per policy for both three and four-compartment manual warewashing sinks and buckets or spray bottles filled with Quat sanitizer and reviewed daily. 6. Any temperatures that are out of compliance must be addressed immediately . During the initial kitchen tour with DM-C on 7/6/26, Surveyor noted temperatures on the sanitizing solution testing log were out of range for the solution and testing strips used by the facility. Surveyor and DM-C reviewed the log and Hydrion test strip and TMA Quat sanitizer information. The log indicated the sanitizing solution should be between 75 and 110 degrees F. The Hydrion test strip and TMA Quat sanitizer information indicated the sanitizing solution should be between 65 and 75 degrees F when testing PPM effectiveness. DM-C stated the facility's log was incorrect and would be corrected. On 7/7/26 at 9:32 AM, Surveyor reviewed the July 2026 sanitizing solution testing log which was posted in the kitchen. The log indicated the solution in the 3-compartment sink and sanitizing buckets used to clean/sanitize the kitchen was tested twice daily. The top of the sheet indicated the temperature of the sanitizing solution should be between 75 and 110 degrees F. All the documented temperatures were between 104 and 112 degrees F. On 7/8/26 at 9:39 AM, Surveyor asked [NAME] (CK)-I to test the sanitizing solution. CK-I tested the temperature of the solution in the 3-compartment sink which was 104 degrees F. CK-I dipped a test strip in the solution for approximately 10 seconds and compared the strip to the color legend on the back of the test strips container. CK-I stated the PPM were 400. When Surveyor asked if CK-I was aware of the temperature testing requirement to ensure effective PPM of the sanitizing solution, CK-I stated the temperature should be between 75 and 110 degrees F. Surveyor and CK-I reviewed the Hydrion test strip and TMA Quat sanitizer information which indicated the sanitizing solution should be between 65 and 75 degrees F for effective testing. Cleanliness: The 2022 FDA Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. The 2022 FDA Food Code documents at 4-602.12 Cooking and Baking Equipment: (A) Food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. The 2022 FDA Food Code documents at 4-602.13 Nonfood-Contact Surfaces: Non-food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. The Facility's Sanitation and Cleaning Schedule policy, revised 8/15/23, indicates: The facility has set forth the following standard for sanitary conditions in the Dietary Department based on compliance with the regulations in the State Operations Manual and the Standards of Practice in the 2022 FDA Food Code .Equipment: 1. All equipment must be cleaned and sanitized with approved sanitizer after each use. 2. The daily cleaning schedule is to be completed as assigned and monitored by the Dietary Manager. 3. A sanitation checklist must be completed weekly by the Dietary Manager to monitor and address areas of concern. Identified areas should be documented on the sanitation checklist follow-up form and assigned to staff members for completion. 4. Staff members should date when their cleaning assignments are completed. 5. Dietary staff will be regularly educated on cleaning and sanitizing of equipment . During the initial kitchen tour on 7/6/26, Surveyor and DM-C observed the following: ~ The walk-in cooler floor was littered with dirt, debris, and food particles, including a piece of browning produce.~ Stovetop burners were caked with food and debris that coated the surfaces of the burners and the sides of the stove top.~ The floor in the cook/prep area contained dirt, debris, and food build-up.~ The bottom of the cooler contained spilled juice that appeared to be congealed. On 7/6/26 at 9:02 AM, Surveyor interviewed DM-C who verified the kitchen should be kept clean and is supposed to be cleaned daily. DM-C confirmed the walk-in cooler and kitchen floor did not appear to have been recently cleaned. Surveyor and DM-C observed the daily cleaning logs which contained 17 detailed daily cleaning assignments, none of which were marked as completed on 7/2/26, 7/3/26, 7/4/26, 7/5/26, or 7/6/26. Examples of cleaning tasks not documented as completed include: Sweep and mop the kitchen floor-PM; Check coolers and clean as needed; Wipe up all spills; Clean equipment after each use; Check dates on leftovers. DM-C stated staff are aware they should complete and document cleaning tasks daily. DM-C stated they were responsible for auditing cleaning and cleaning log documentation. Food Cooling Temperatures: The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celcius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The 2022 FDA Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. The facility's Cooling Food Temperature Log policy, dated 6/19/23, indicates: .Monitor cooling temperatures of time/temprature control for safety (TCS) foods in order to ensure that all food is cooled within specified guidelines for the prevention of foodborne illness. Procedure: 1. Cooked TCS foods shall be cooled under refrigeration within 2 hours from 135 F or greater to 70 F and within a total of 6 hours from 135 F or greater to 41 F or less. 2. Temperatures of TCS foods placed in cooler shall be recorded by the cook on the Cooling Food Temperature Log . During the initial kitchen tour with DM-C on 7/6/26, Surveyor observed the July 2026 food cooling log that was posted in the kitchen. The log did not contain any items for cooling. Surveyor interviewed DM-C who stated the log was not correct. Surveyor and DM-C noted the following foods were cooked and stored in July 2026 and should have been on the log: ~ Chicken Kiev, 7/5/26~ Broccoli, 7/1/26~ Cheese omelettes, 7/5/26~ Pork, 7/5/26 Reheating Procedure: The 2022 FDA Food Code documents at 3-401.12 Microwave Cooking: The rapid increase in food temperature resulting from microwave heating does not provide the same cumulative time and temperature relationship necessary for the destruction of microorganisms as do conventional cooking methods. In order to achieve comparable lethality, the food must attain a temperature of 74 degrees C (165 degrees F) in all parts of the food. Since cold spots may exist in food cooked in a microwave oven, it is critical to measure the food temperature at multiple sites when the food is removed from the oven and then allow the food to stand covered for two minutes post microwave heating to allow thermal equalization and exposure. Although some microwave ovens are designed and engineered to deliver energy more evenly to the food than others, the important factor is to measure and ensure the final temperature reaches 74 degrees C (165 degrees F) throughout the food. The 2022 FDA Food Code documents at 3-403.11 Reheating for Hot Holding (B): .Time/Temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees F and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating.The facility's Reheating Food policy, dated 2/25/25, indicates: .Per ServSafe, all food heated in a microwave must be heated to 165 F for a minimum of 15 seconds, but no higher than 180 F .Food must be stirred to distribute heat and allowed to sit for at least 2 minutes before retesting the temperature . On 7/7/26 at 8:55 AM, Surveyor observed Licensed Practical Nurse (LPN)-F heat a plate of food in the microwave. The food was immediately delivered to a resident. The temperature was not obtained prior to delivery. In addition, the food was not stirred and did not sit for the required 2 minutes before the temperature was tested and the food was served. On 7/7/26 at 8:56 AM, Surveyor interviewed LPN-F who verified they reheated food for a resident. LPN-F stated the plate was nice and hot so they knew the food was nice and hot for the resident also. On 7/8/26 at 2:04 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated kitchen staff should be aware of and follow all policies related to food preparation, storage, safety, cleanliness, and serving.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 60 residents residing in the facility. Staff did not offer residents hand hygiene before a meal. R8 was on enhanced barrier precautions (EBP) due to a feeding tube. Staff flushed R8's feeding tube without donning the appropriate personal protective equipment (PPE). Findings include: The Centers for Disease Control and Prevention (CDC) About Handwashing information from CDC.gov dated 2/16/24 indicates: Many diseases and conditions are spread by not washing hands with soap and clean, running water. Hand washing with soap is one of the best ways to stay healthy. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Washing hands can keep you healthy and prevent the spread of respiratory and diarrheal infections. Germs can spread from person to person or from surface to person when you: Touch your eyes, nose, and mouth with unwashed hands; Prepare or eat food and drinks with unwashed hands; Touch surfaces or objects that contain germs; Blow your nose, cough, or sneeze into your hands and then touch other peoples' hands or common objects. You can keep yourself and your loved ones healthy by washing your hands often, especially during these key times when you are likely to get and spread germs: Before, during, after preparing food; Before and after eating food . The facility's Enhanced Barrier Precautions (EBP) Policy & Procedure, dated 3/26/24, indicates: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident care activities .3. EBP is used in conjunction with standard precautions and expands the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staffs' hands and clothing .5. For residents for whom EBP is indicated, EBP is employed when performing the following high-contact resident care activities: Device care or use: central line, urinary catheter, feeding tube . On 7/7/26, Surveyor requested a policy for hand hygiene at meals. The policy that was provided did not contain hand hygiene information. 1. On 7/7/26 at 8:00 AM, Surveyor observed the second floor main dining room where 20 residents were eating/being served breakfast. Surveyor observed Certified Nursing Assistant (CNA)-D and CNA-E assist 8 residents into the dining room and help them prepare for breakfast. The residents were offered clothing protectors and drinks prior to the meal. The residents were not offered hand hygiene prior to or after the meal. On 7/7/26 at 8:40 AM, Surveyor interviewed R37 who stated they were not offered hand hygiene before meals but would like to be offered. On 7/7/26 at 9:00 AM, Surveyor interviewed R31 who stated they were not offered hand hygiene at breakfast. On 7/7/26 at 9:13 AM, Surveyor interviewed R19 who stated they were not offered hand hygiene before or after breakfast. R19 stated they can get an extra napkin if they want but staff don't wash their hands and sometimes the food is sticky. R19 stated staff could at least provide a wipe or something to clean their hands with but they would prefer staff wash their hands. On 7/7/26 at 9:15 AM, Surveyor interviewed Family Member (FM)-G who was assisting R33 with breakfast. FM-G stated R33 was not offered hand hygiene prior to breakfast. FM-G stated they assist R33 with meals daily and hand hygiene is not offered. FM-G stated they wash R33's hands because staff do not do so. On 7/7/26 at 10:45 AM, Surveyor interviewed FM-H who stated they visit R33 often. FM-H stated staff do not offer to wash R33's hands before or after meals. FM-H stated they have to wash R33's hands. On 7/7/26 at 1:00 PM, a Resident Council meeting was conducted with Surveyors in attendance. During the meeting, R3, R13, R19, R35, R38, R51, and R56 stated they are not offered hand hygiene before meals but would like to be offered. On 7/7/26 at 1:23 PM, Surveyor interviewed CNA-D who verified they did not offer hand hygiene to residents in the dining room prior to or after breakfast. CNA-D was unsure why hand hygiene was not offered. On 7/8/26 at 8:19 AM, Surveyor interviewed R3 who stated they are not offered hand hygiene before meals but would like to be offered. On 7/8/26 at 2:04 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated staff should offer hand hygiene to residents prior to and after meals. 2. R8 was admitted to the facility on [DATE], had a diagnosis of dysphagia oropharyngeal, and required a feeding tube. A care plan, dated 7/6/26, indicated R8 was on EBP due to a feeding tube. On 7/7/26 at 2:16 PM, Surveyor observed Licensed Practical Nurse (LPN)-O flush R8's feeding tube with a syringe. LPN-O did not wear a gown as required by the facility's EBP policy. On 7/7/26 at 2:22 PM, Surveyor interviewed LPN-O who indicated they did not have to wear a gown to flush R8's feeding tube. On 7/7/26 at 3:02 PM, Surveyor interviewed NHA-A who confirmed after reviewing the facility's EBP policy that LPN-O should have worn a gown when flushing R8's feeding tube.

Based on observation, interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R38) of 18 sampled residents.R38 used an insulin pump to administer insulin at the bedside 3 times daily. R38 did not have a self-administration of medication assessment, an order to self-administer medication, or an order to administer insulin via pump. In addition, staff did not document the insulin administration in R38's Medication Administration Record (MAR). Findings include: The facility's Medication Self-Administration policy, dated 3/1/24, indicates: 1. The resident shall have a screen completed by a licensed nurse to determine factors that may impact the safe administration of medication. 2. The ability to self-administer medication will indicate: a. Able to self-administer medication independently; b. Able self-administer medication with supervision, cueing, and/or set-up; c. Not able to self-administer medication safely; 3. Residents who have been deemed appropriate to self-administer medication independently or with supervision/cuing or after set-up shall have a physician order to do so. 4. The resident's service plan will be updated with their ability to self-administer medication. 5. The Self-Administration Screen will be re-evaluated annually and more frequently as clinically indicated.The facility's Medication Administration policy, dated 5/20/23, indicates: When administration of medication or treatment/therapy is delegated or assigned to unlicensed personnel (ULP), the facility will ensure the Registered Nurse has: 1. Instructed the ULP in the proper methods with respect to each resident to administer the medication or perform treatment, and the ULP has demonstrated the ability to competently follow the procedures. 2. Specified, in writing, specific instructions for each resident and documented the instructions in the resident's record .Prior to a ULP providing delegated medication administration and/or treatment, the following must occur: 1. An RN must conduct a face-to-face assessment to determine what medication management or treatment services will be provided and how .2. The facility will prepare and include in the service plan a written statement of the medication management or treatment services to be provided .3. The medications have current prescriber's orders on file. 4. An RN must specify in writing specific instructions for each resident and document the instructions in the resident's record. 5. An RN must instruct the ULP on the following medication administration tasks before delegating the task to them: a) The complete procedure of checking a resident's medication administration record (MAR); b) The preparation of medication for administration; c) The administration of the medication to the resident; d) The reminder to self-administer medication; e) The documentation after assistance with medication reminder or medication administration, of the date, time, dosage, and method of administration of all medications, or the reason for not assisting with medication administration as ordered .6. The ULP must demonstrate their ability to competently follow the delegated medication administration or treatment to an RN. 7. Written records signed by an RN shall be maintained regarding ULP training and competency testing of delegated medication administration and treatment. The facility's Insulin Administration with Pump policy, dated 6/30/25, indicates: .2. Insulin will be administered via provider orders. 3. The resident will be assessed for awareness of hypoglycemia and hyperglycemia symptoms; the ability to calculate and deliver bolus doses; suspend insulin delivery; and ability to refill the pump. R38 was admitted to the facility on [DATE] and had diagnoses including type 1 diabetes mellitus and presence of insulin pump. A Minimum Data Set (MDS) assessment, dated 6/6/26, stated R38 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. A care plan, revised 6/11/26, indicated R38 had type 1 diabetes mellitus and an insulin pump per physician order (dated 6/16/26). The care plan did not contain interventions related to the insulin pump. R38's medical record did not contain an order for the insulin pump or orders for insulin dosing via the pump. R38's medical record also did not contain an order for self-administration of medication or a self-administration of medication assessment. R38's MAR did not indicate insulin was administered. On 7/6/26 at 11:38 AM, Surveyor interviewed R38 who stated they had a continuous glucose meter that monitored their blood glucose level. R38 stated staff ask about their blood glucose level when necessary and R38 verbally communicates the information. R38 stated they independently dose short-acting Novolog insulin via the pump. R38 stated they dose insulin with meals by counting carbs and entering the number of carbs in the pump. R38 stated staff do not ask about the insulin dose and they do not communicate the dose to staff. Surveyor observed staff enter R38's room and ask about their blood glucose level which R38 provided. Surveyor observed R38 dose insulin via the pump. On 7/6/26 at 1:30 PM, Surveyor interviewed Director of Nursing (DON)-B about R38's insulin orders. DON-B stated they would provide the information to Surveyor.On 7/7/26, Surveyor reviewed an insulin pump order in R38's medical record (dated 7/7/26) that indicated: Insulin pump orders: Carb ratio: 2.6 g/u (grams per unit). Sensitivity: 30 milligrams/deciliter (mg/dL) per U blood glucose target: 110-120 mg/dL Bolus Increment: 0.1 U Max Basal: 5.0 U/Hr Max Bolus: 25 U Bolus Speed: Quick Current High Limit: 250 mg/dL Rise Alert: 4.0 mg/dL/min Current Low Limit: 80 mg/dL.On 7/7/26 at 1:45 PM, Surveyor interviewed R38 and Family Member (FM)-P who stated they order insulin pump supplies and change insulin infusion sites as directed by R38's endocrinologist. FM-P stated staff have called them to come to the facility, including in the middle of the night, to assist with the pump, trouble shoot, and/or change the infusion site when it gets pulled out. R38 stated they are comfortable using the insulin pump and prefer to dose insulin that way. On 7/8/26 at 9:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who verified the new order in R38's medical record for the insulin pump. LPN-L verified there had not been an order for the insulin pump since LPN-L started in 5/2026. LPN-L stated R38 manages the pump and staff contact FM-P to come to the facility if the pump requires trouble shooting. LPN-L stated staff ask R38 for their blood glucose level and document it in their medical record. LPN-L verified staff do not document the insulin R38 doses via the pump. LPN-L stated staff give verbal report to the next shift to ask R38 for their blood glucose level and communicate the presence of the continuous glucose monitor and insulin pump.On 7/8/26 at 1:27 PM, Surveyor interviewed DON-B who verified R38 had an insulin pump and managed it independently. DON-B confirmed FM-P assists with the pump as needed. DON-B indicated the Assistant Director of Nursing (ADON) obtained an order for the insulin pump on 7/7/26 because the facility did not have a prior order. DON-B verified R38 had the insulin pump since they were admitted to the facility on [DATE].

Based on interview and record review, the facility did not ensure adequate supervision and assistive devices to prevent accidents were provided for 1 resident (R) (R11) of 5 sampled residents. R11 fell on 3/3/26 and 5/15/26. Post-fall assessments for the 3/3/26 fall did not start until 3/4/26. Two post-fall assessments were not completed. In addition, two post-fall assessments for the 5/15/26 fall were not completed. Findings include:The facility's Fall Prevention, Post Fall, and Communication policy, dated 1/21/26, indicates: Fall prevention interventions will be individualized by the Interdisciplinary Team (IDT) and must be implemented consistently. For monitoring and re-evaluation post-fall, staff should document on a resident's condition at a minimum of every shift for 72 hours. Staff should document relevant post-fall clinical findings such as vital signs, pain, swelling, bruising, and changes in function or cognitive status. R11 was admitted to the facility on [DATE] and had diagnoses including cognitive impairment, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia and supplemental oxygen. A Minimum Data Set (MDS) assessment, dated 5/9/26, stated R11 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition.A care plan, dated 5/9/26, indicated R11 was at high risk for falls related to cognitive issues, weakness, and respiratory failure with equipment management needs and often got up alone without assistance. Risk versus benefits education related to self-transferring was completed. A nursing note, dated 3/3/26 at 10:51 PM, indicated staff observed R11 sitting on the floor in their room with their back facing the nightstand and feet facing the wheelchair. R11 stated they tripped over their oxygen tubing.Surveyor reviewed R11's post-fall assessments which did not start until 3/4/26 at approximately 7:00 AM (8 hours post-fall.) In addition, R11's medical record did not contain post-fall assessments for the 3/5/26 or 3/6/26 night (NOC) shifts. A nursing note, dated 5/15/26 at 7:14 AM, indicated staff observed R11 sitting on their buttocks leaning against their bed at 4:55 AM. R11 stated they lost their balance on the way to the bathroom, fell onto their right side, and grabbed the curtain on the way down. R11 denied hitting their head.R11's medical record did not contain post-fall assessments for the 5/16/26 NOC shift or on 5/18/26.On 7/8/26 at 1:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated residents are monitored via post-fall assessments. NHA-A stated neuro checks are not completed unless ordered by the provider. NHA-A verified R11 had multiple missing post-fall assessments. NHA-A stated staff should document post-fall assessments every shift for at least 72 hours post-fall.On 7/8/26 at 1:28 PM, Surveyor interviewed Director of Nursing (DON)-B who stated nurses should document post-fall assessments every shift for the next 72 hours.

Based on interview and record review, the facility did not ensure feeding assistance was provided for 2 residents (R) (R24 and R23) of 3 sampled residents.Staff did not provide feeding assistance for R24 and R23 in accordance with their plans of care. In addition, R24 and R23's Minimum Data Set (MDS) assessments and plans of care contained inconsistent information regarding their feeding requirements. Findings include: The facility's Activities of Daily Living policy, revised 2/25/25, indicates: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure a resident's abilities in activities of daily living (ADLs), do not diminish unless circumstances of the resident's clinical condition demonstrate that such diminution was avoidable .2. The facility will provide services for the following activities of daily living: .Eating: Assistance with feeding or preparation of meals .3. Based on the assessment, a personalized care plan is created. It outlines the level of assistance needed .The care plan is adjusted over time as a resident's condition changes. 4. Residents' abilities to perform ADLs will be monitored for evidence of any decline and appropriate interventions put in place as applicable. 5. ADLs will be individualized considering factors like physical abilities, cognitive function, and mental health. ADL cares will be provided based on resident preferences. 6. Resident ADL care needs will be communicated to staff via the care plan and Kardex.1. R24 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, vascular dementia, abnormal weight loss, dysphagia, and delirium. An MDS assessment, dated 5/8/26, stated R24's Brief Interview for Mental Status (BIMS) score was not assessed. The assessment indicated R24 required partial/moderate feeding assistance. R24 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. R24's care plan indicated they had the potential for altered nutritional status related to frontal neurological disorder, altered mental status, dysphagia, and Parkinson's disease and required extensive assistance and a sectioned plate to assist with loading utensil to eat. R24 required assistance to self-feed to prevent food from falling off the utensil. The goal indicated R24 would accept assistance with meals as needed.R24's Kardex (an abbreviated care plan used by nursing staff) indicated they required extensive assistance with eating. A weight change note on 7/6/26 at 11:01 AM by the Registered Dietitian indicated R24 was down 6.4 lbs or 4.3% in the past month.On 7/7/26 at 12:25 PM, Surveyor observed R24 feeding themself with their left fingers. R24's meal was on a divided plate, however, they could not reach the food on the left side of the plate and ate the food closet to them. R24 pulled a paper placemat to the edge of the table. At 12:53 PM, Certified Nursing Assistant (CNA)-D asked another staff to turn R24's plate around so it was within reach. R24 attempted to eat mashed potatoes by tipping the plate forward and used their right pointer finger to eat the potatoes until the plate slid from the table and leaned into R24's lap. R24 also attempted to eat pieces of meat with their left hand while the plate was on their lap. At 1:09 PM, CNA-D sat down to assist R24 with eating mashed potatoes and apple pie and drinking a beverage.On 7/7/26 at 9:12 AM, Surveyor interviewed POAHC-N who stated they come to the facility every day for breakfast and supper to feed their spouse (R20) who would not be fed adequately if they were not present. POAHC-N stated they observed many residents sit at the dining table and wait to be fed for up to an hour. POAHC-N stated they observed staff give residents a spoonful of food as they walked past while completing other tasks. POAHC-N also stated they observed residents not being fed meals. POAHC-N stated there is not enough staff for the number of residents who require feeding assistance.On 7/8/26 at 2:38 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R24 is not assessed as needing feeding assistance. On 7/8/26 at 3:30, Surveyor interviewed Nursing Home Administrator (NHA)-A who acknowledged the inconsistency in R24's feeding assistance care plan, Kardex, and MDS assessment.2. R23 was admitted to the facility on [DATE] and had diagnoses including dementia and white matter disease. An MDS assessment, dated 5/7/26, stated R23's BIMS score was not assessed. The assessment indicated R23 required substantial/max feeding assistance. R23 had an activated POAHC to assist with healthcare decisions. A care plan, revised 6/12/26, indicated R23 had the potential for altered nutritional status related to dementia, white matter disease, and alcohol abuse and required supervision, placement of utensil in the right hand, encouragement for intake, plate set-up, food cut in bite-sized pieces, and open containers. The goal indicated R23 would maintain stable nutrition and hydration with no significan weight fluctuations.R23's Kardex indicated they required supervision with eating. On 7/7/26 at 12:03 PM, Surveyor observed R23 at a dining room table. At 12:39 PM, Surveyor observed R23 at the table with a covered plate. Licensed Practical Nurse (LPN)-F asked if R23 was going to eat their meal. CNA-D was feeding another resident and stated R23's plate was covered because they needed assistance. At 12:41 PM, Surveyor observed R23 at the table with a covered plate and observed 7 other residents eating lunch around them. At 12:45 PM, R23 attempted to uncover their plate. At 12:47 PM, CNA-D moved R23's dishes to the other side of the table, moved R23's chair, uncovered their food, and began to feed them. At 1:07 PM, R23 was finished eating.On 7/8/26 at 8:22 AM, Surveyor observed LPN-M feed R23 in a wheelchair. LPN-M stated R23 required verbal prompts to eat. LPN-M stated R23 was physically able to eat finger foods but was not able to eat foods that required utensils.On 7/8/26 at 11:30 AM, Surveyor interviewed DON-B who stated R23 did not need to be fed and could independently eat finger foods. On 7/8/26 at 3:30 PM, Surveyor interviewed NHA-A who acknowledged the inconsistency in R23's feeding assistance care plan, Kardex, and MDS assessment.

Based on interview and record review, facility staff failed to provide basic life support to a resident in accordance with physician orders and an advance directive for 1 resident (R) (R2) of 6 sampled residents.R2 was enrolled in Hospice services and was discovered pulseless and nonbreathing on [DATE]. At the time of the incident, R2 was a full code. Staff failed to check R2's code status, provide cardiopulmonary resuscitation (CPR) and basic life support, or call 911. The facility's failure to provide CPR/basic life support and call 911 for a full code status resident created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 10:30 AM. The immediate jeopardy was removed and corrected on [DATE] and is being cited at past non-compliance. Findings include: The facility's Code Status policy, revised [DATE], indicates the purpose of the policy is to ensure advance directives for residents are individualized by/for the resident, documented, and effectively implemented at the facility .The facility will: verify the presence of advance directives or the resident's wishes regarding CPR upon admission. If the resident's wishes are different than the admission orders .will be documented in the resident's medical record following obtaining a physician order for code status .If a resident becomes unresponsive (either witnessed or unwitnessed), the resident's advance directive will be followed . R2 had diagnoses including peritoneal abscess, type 2 diabetes, and severe-protein calorie malnutrition. A Quarterly Minimum Data Set (MDS) assessment, dated [DATE], stated R2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. R2 was their own decision maker. R2's medical record indicated they were full code status (signed and dated [DATE]). R2 enrolled in Hospice services on [DATE]. A facility-reported incident (FRI) and Deficient Practice document submitted to the State Agency (SA) indicated Certified Nursing Assistant (CNA)-G and CNA-H provided a bed bath for R2 on [DATE] at approximately 9:00 PM. Registered Nurse (RN)-E entered the room to complete a skin check and replace the dressing on R2's buttocks. Immediately following the dressing change, R2 began having loose stools. RN-E left the room to retrieve additional wound supplies while CNA-G and CNA-H completed cares. During cares, CNA-H thought R2 passed away and left the room to alert RN-E who returned to the room to assess R2. RN-E indicated R2 was unresponsive without observable respirations or signs of life. RN-E thought R2's code status changed from full code to do not resuscitate (DNR) when R2 started Hospice services. RN-E did not initiate CPR or call a code blue. RN-E asked Licensed Practical Nurse (LPN)-F to inform Hospice of R2's passing. The Deficient Practice document indicated R2's code status was accurately documented in their medical record, physician orders, and care plan. The investigation indicated RN-E responded to the event and was aware R2 was a full code status but failed to initiate CPR as required by the facility's policy, professional standards of practice, and R2's documented wishes. The facility determined that the deficient practice was not related to inaccurate code status documentation, the availability of code status information, or Hospice enrollment but rather the failure of RN-E to follow established emergency response procedures. RN-E was immediately removed from resident care and suspended pending completion of the investigation. The FRI and Deficient Practice document included staff education and signature sheets, code status audits, emergency response competencies for licensed staff, competency drills, mock emergency code drills, and CPR certification documentation for nursing staff. In addition, the facility reviewed records of recent residents' deaths to ensure advance directives were followed. The facility was in compliance as of [DATE]. On [DATE] at 3:06 PM, Surveyor interviewed RN-I who indicated if a resident is found unresponsive, staff should complete an assessment and check the resident's electronic health record (EHR) for their code status. On [DATE] at 3:10 PM, Surveyor interviewed Licensed Practical Nurse Extern (LPNE)-J who indicated they were a CNA but were in training to become an LPN. LPNE-J indicated a nurse should be informed if a resident is found unresponsive and stated they would inform the charge nurse immediately if they discovered an unresponsive resident. LPNE-J indicated the nurse should confirm the resident's code status, assess the resident, and provide the necessary care. On [DATE] at 3:13 PM, Surveyor interviewed LPN-K who indicated nurses are responsible for checking code status and following the order if a resident is found unresponsive. LPN-K verified nursing staff received training on code status and indicated code status is found in a resident's EHR. On [DATE] at 2:30 PM, Surveyor interviewed NHA-A who indicated at approximately 6:30 AM on [DATE], they received a call from the AM nurse who informed them of R2's passing and that RN-E did not follow R2's code status. NHA-A stated an investigation was started and an inital report was submitted to the SA. NHA-A indicated the investigation revealed RN-E did not follow the facility's policy to verify a resident's code status and did not provide CPR as indicated per R2's advance directive. RN-E indicated they thought R2's code status had changed due to enrollment in Hospice services. NHA-A also stated LPN-F was employed through a staffing agency and was asked not to return to the facility. NHA-A indicated immediate education was provided, competency drills, audits, and monitoring were initiated, and the facility's systematic process would be reviewed in upcoming QAPI meetings. The failure to provide CPR/basic life support and call 911 for a full code status resident who was discovered pulseless and non-breathing created a reasonable likelihood for serious harm for R2 thus leading to a finding of immediate jeopardy. The facility removed and corrected the jeopardy on [DATE] when it completed the following:Re-educated facility, agency, and contracted nursing staff on CPR requirements, resident rights regarding code status, emergency response procedures, and requirements to initiate CPR for residents designated as full code, including residents receiving Hospice services.Completed an audit of resident code status documentation to verify code status was accurately reflected throughout the medical record and physician orders.Completed mock code drills on all shifts to validate staff competency in emergency response procedures.Reinforced expectations regarding immediate response to cardiopulmonary arrest and adherence to advance directives.Reviewed CPR certification for nursing staff.

Based on observation, staff and resident interview, and record review, the facility did not ensure adequate supervision and assistive devices to prevent accidents were provided for 4 residents (R) (R1, R2, R3, and R5) of 4 sampled residents. R1 fell on 1/10/26. R1's post-fall assessments did not start until 1/12/26. In addition, three of 8 post-fall assessments did not include an updated set of vital signs (VS). In addition, an intervention for gripper socks was not added to R1's care plan.R2 fell on [DATE], 12/2/25, and 12/10/25. Ten of 31 documented post-fall assessments did not include an updated set of VS. R3 fell twice on 11/27/25 while reaching for items. Three of 10 documented post-fall assessments did not include an updated set of VS. In addition, R3 did not have grabbers within reach on 2/4/26 in accordance with R3's care plan.R5 fell on [DATE]. Three of 10 documented post-fall assessments for R5 did not include an updated set of VS. In addition, a call for assisstance reminder sign was not posted in R5's room on 2/4/26 in accordance with R5's care plan. Findings include:The facility's Fall Prevention, Post Fall, and Communication policy, dated 1/21/26, indicates fall prevention interventions will be individualized by the Interdisciplinary Team (IDT) and must be implemented consistently. For monitoring and re-evaluation post-fall, staff should document on a resident's condition at a minimum of every shift for 72 hours. Staff should document relevant post-fall clinical findings such as vital signs, pain, swelling, bruising, and changes in function or cognitive status. Care plans will be updated to include new or revised interventions.1. From 2/3/26 to 2/4/26, Surveyor reviewed R1's medical reocrd. R1 was admitted to the facility on [DATE] and had diagnoses including dementia, hypertension, anxiety, and hemiplegia (loss of motor function) of the right side. R1's most recent Minimum Data Set (MDS) assessment, dated 1/7/26, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R1 had severe cognitive impairment. R1 had an activated Power of Attorney for Healthcare (POAHC) and discharged from the facility on 1/22/26.R1's most recent comprehensive care plan, initiated on 1/7/26, indicated R1 was at high risk for falls related to cognitive impairment with behaviors and weakness. The care plan also indicated R1 was at risk for bleeding and excessive bruising related to anticoagulant (blood thinner) therapy. A nursing note, dated 1/10/26 at 3:58 AM, indicated staff observed R1 on R1's back on the floor with the bottom of R1's bare feet facing the side of the bed. R1 was incontinent of urine and unable to tell staff what happened.A fax to the physician, dated 1/10/26, did not indicate that R1 was on anticoagulant medication. Surveyor reviewed R1's fall investigation, dated 1/10/26, which indicated R1 had an unwitnessed fall in R1's room. The root cause was due to R1's impulsive behavior, decreased safety awareness, and cognitive impairment. An immediate intervention was added to ensure gripper socks were on both feet. (Of note: R1's care plan, revised 1/28/26, did not contain the intervention.)Surveyor reviewed R1's post-fall assessments (which did not start until 1/12/26 at approximately 5:00 AM which was 48 hours post-fall). R1's medical record did not contain any post-fall assessments between 1/10/26 and 1/12/26. Surveyor noted the following post-fall assessments did not include an updated set of VS:~ On 1/13/26 at 1:50 AM, R1's VS were taken from 1/12/26 at 10:07 PM (3 hours and 43 minutes prior to the assessment).~ On 1/14/26 at 6:57 PM, R1's VS were taken from 1/14/26 at 12:04 AM (18 hours and 53 minutes prior to the assessment).~ On 1/15/26 at 6:32 PM, R1's VS were from 1/15/26 at 2:48 AM (15 hours and 44 minutes prior to the assessment).(See interviews under example 4.)2. From 2/3/26 to 2/4/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, anxiety, depression, and chronic pain. R2's most recent MDS assessment, dated 12/18/25, had a BIMS score of 11 out of 15 which indicated R2 had moderate cognitive impairment.R2's most recent comprehensive care plan, initiated on 1/7/26, indicated R2 was at high risk for falls related to Parkinson's disease, neuropathy, and dementia with impaired safety awareness. Surveyor reviewed R2's fall investigation, dated 11/28/25, which indicated R2 had an unwitnessed fall in R2's room at approximately 12:00 PM. The root cause was due to R1's impaired safety awareness and attempt to self-transfer. A Certified Nursing Assistant (CNA) Fall Investigation form, which included the last interaction with R2, items within reach, toileting plan, care plan, and areas for improvement was not completed during the investigation. Surveyor reviewed R2's post-fall assessments and noted the following assessments did not include an updated set of VS:~ On 11/30/25 at 9:19 AM, R2's VS were taken from 11/30/25 at 1:30 AM (7 hours and 49 minutes prior to the assessment).~ On 12/2/25 at 10:16 AM, R2's VS were taken from 12/2/25 at 1:01 AM (9 hours and 15 minutes prior to the assessment).Surveyor reviewed R2's fall investigation, dated 12/2/25, which indicated R2 had an unwitnessed fall in R2's room at approximately 1:40 PM. The root cause of the fall was due to R2's attempt to self-transfer into bed. Surveyor reviewed R2's post-fall assessments and noted the following assessments did not include an updated set of VS:~ On 12/2/25 at 5:27 PM, R2's VS were taken from 12/2/25 at 1:01 AM (16 hours and 26 minutes prior to the assessment).~ On 12/3/25 at 1:03 PM, R2's VS were taken from 12/3/25 at 4:20 AM (8 hours and 43 minutes prior to the assessment). ~ On 12/4/25 at 11:41 AM, R2's VS were taken from 12/3/25 at 4:20 am (1 day, 7 hours, and 21 minutes prior to the assessment).~ On 12/4/25 at 1:40 PM, R2's VS were taken from 12/3/25 at 4:20 AM (1 day, 9 hours, and 20 minutes prior to the assessment).~ On 12/5/25 at 9:24 PM, R2's VS were from 12/5/25 at 1:00 PM (8 hours and 24 minutes prior to the assessment).Surveyor reviewed R2's fall investigation, dated 12/10/25, which indicated R2 had an unwitnessed fall in R2's room at approximately 3:15 PM. The root cause of the fall was due to R2 reaching for something on the floor. On 2/3/26, Surveyor reviewed R2's post-fall assessments and noted the following assessments did not include an updated set of VS:~ On 12/11/25 at 3:17 PM, R2's VS were taken from 12/11/25 at 9:57 AM (5 hours and 20 minutes prior to the assessment).~ On 12/12/25 at 8:41 AM, R2's VS were taken from 12/11/25 at 11:17 PM (9 hours and 24 minutes prior to the assessment).~ On 12/12/25 at 12:42 PM, R2's VS were taken from 12/11/25 at 11:17 PM (13 hours and 25 minutes prior to the assessment).(See interviews under example 4.)3. From 2/3/26 to 2/4/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including hemiplegia of the left side, dementia, diabetes, and mood disorder. R3's most recent MDS assessment, dated 1/23/26, had a BIMS score of 10 out of 15 which indicated R3 had moderate cognitive impairment. R3's most recent comprehensive care plan, revised on 11/5/25, indicated R3 was at moderate risk for falls related to left-sided weakness and dementia with impaired safety awareness. Surveyor reviewed R3's fall investigations for two separate falls on 11/27/25. The investigations, dated 11/27/25, indicated R3 had unwitnessed falls in R3's room at approximately 10:20 AM and 5:30 PM. Both falls occurred when R3 reached for an item. An intervention was added on 12/1/25 to have two reachers within reach in R3's room. Surveyor reviewed R3's post-fall assessments and noted the following assessments did not include an updated set of VS:~ On 11/29/25 at 1:46 PM, R3's VS were taken from 11/29/25 at 2:07 AM (11 hours and 39 minutes prior to the assessment).~ On 11/30/25 at 1:39 PM, R3's VS were taken from 11/30/25 at 4:17 AM (9 hours and 22 minutes prior to the assessment).~ On 12/1/25 at 12:13 AM, R3's VS were taken from 11/30/25 at 4:17 AM (19 hours and 56 minutes prior to the assessment).On 2/4/26 at 12:01 PM, Surveyor observed R3 in a wheelchair in the middle of R3's room. R3's reachers were on opposite sides of R3 against the wall (one was next to R3's bed and one was on top of supplies next to the TV). When Surveyor asked about the reachers, R3 demonstrated that R3 could not reach either one.On 2/4/26 at 12:25 PM, Surveyor and Director of Nursing (DON)-B verified both reachers were not within R3's reach. DON-B stated the reachers should be within R3's reach at all times.(See interviews under example 4.)4. From 2/3/26 to 2/4/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, diabetes, and stroke. R5's most recent MDS assessment, dated 12/13/25, had a BIMS score of 10 out of 15 which indicated R5 had moderate cognitive impairment.R5's most recent comprehensive care plan, revised on 5/22/25, indicated R5 was at moderate risk for falls related to weakness and dementia. Surveyor reviewed R5's fall investigation, dated 12/27/25, which indicated R5 had an unwitnessed fall in R5's room at approximately 3:35 AM and could not recall what happened. An intervention for a reminder to call for assistance before getting up sign in R5's room was added to R5's care plan on 12/30/25.Surveyor reviewed R5's post-fall assessments and noted the following assessments did not include an updated set of VS:~ On 12/27/25 at 12:46 PM, R5's VS were taken from 12/27/25 at 3:47 AM (8 hours and 59 minutes prior to the assessment). ~ On 12/29/25 at 1:32 AM, R5's VS were taekn from 12/28/25 at 6:25 PM (7 hours and 7 minutes prior to the assessment).~ On 12/30/25 at 9:07 AM, R5's VS were from 12/30/25 at 1:07 AM (8 hours prior to the assessment).On 2/4/26 at 10:54 AM, Surveyor observed R5 in a chair in R5's room. Surveyor did not observe a reminder to call for assistance sign in the room.On 2/4/26 at 12:25 PM, Surveyor and DON-B observed R5's room. DON-B stated the reminder sign was hung near R5's calendar but must have been taken down or misplaced. DON-B was not sure how long the sign had been missing.On 2/3/26 at 2:11 PM, Surveyor interviewed Registered Nurse (RN)-E who stated the facility's policy was to check on the resident once or twice per shift and not do neurological checks. RN-E stated RN-E would document VS and any changes in a progress note.On 2/3/26 at 2:14 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated the facility still does the standard post-fall neurological checks (every 15 minutes x 4, every 30 minutes x 4, every 60 minutes x 2, and then once per shift). LPN-F stated LPN-F would also obtain a set of VS for each assessment.On 2/4/26 at 12:43 PM, Surveyor interviewed DON-B who verified the facility's policy indicates staff should do an assessment once per shift unless otherwise ordered by the provider. DON-B stated if a resident is on anticoagulant medication, staff should let the provider know because the provider will likely send the resident to the emergency room (ER) for evaluation or order close monitoring due to an increased risk of bleeding.

Based on staff and resident representative interview and record review, the facility did not ensure the right to participate or designate others to participate in the care planning process for 3 residents (R) (R2, R3, and R5) of 5 sampled residents.Quarterly care conferences were not offered for R2, R3, and R5 in the last year.Findings include:The facility's Care Conference policy, revised 6/20/23, indicates the purpose is to provide interdisciplinary communication with the resident and/or legal representative for purposes of the development of an individualized plan of care. It also indicates the resident and/or their responsible party will receive communication in advance of the scheduled care conference .The Interdisciplinary Team (IDT) shall consist of, but is not limited to: Minimum Data Set (MDS) coordinator, nursing representative, therapy representative, activity representative, social services representative, and dietary representative. The IDT will review some of the following in preparation for the care conference: falls, restraints, psychotropic medications, wounds, labs, advanced directives, immunizations, care plan/Certified Nursing Assistant (CNA) Kardex (an abbreviated care plan used by nursing staff), weight loss/gain, and physician orders. The Care Conference User Defined Assessment (UDA) will be completed in the electronic health record for attendance tracking and record of discussion.1.From 2/3/26 to 2/4/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, dementia, obsessive compulsive disorder (OCD), anxiety, depression, osteoarthritis, and chronic pain. R2's most recent Minimum Data Set (MDS) assessment, dated 12/18/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R2 had moderate cognitive impairment. R2 had a Guardian.On 2/4/26, Surveyor reviewed care conference documentation for R2 and noted that in the last year, R2 had care conferences on 2/25/25 and 11/12/25. R2's medical record did not indicate any other care conferences were offered or declined in the last year.On 2/4/26 at 10:43 AM, Surveyor left a voicemail for R2's Guardian regarding care conferences. As of this writing, a return call was not received. R2's medical record did not indicate R2's Guardian was invited to quarterly care conferences.(See interviews under example 3.)2. From 2/3/26 to 2/4/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including dementia, hemiplegia of the left side, type 2 diabetes, mood disorder, and chronic kidney disease. R3's most recent MDS assessment, dated 1/23/26, had a BIMS score of 10 out of 15 which indicated R3 had moderate cognitive impairment. R3 had an activated Power of Attorney for Healthcare (POAHC).On 2/4/26, Surveyor reviewed care conference documentation for R3 and noted that in the last year, R3 had a care conference on 1/29/26. R3's medical record did not indicate any other care conferences were offered or declined in the last year.On 2/4/26 at 11:01 AM, Surveyor left a voicemail for R3's POAHC regarding care conferences. As of this writing, a return call was not received. R3's medical record did not indicate R3's POAHC was invited to quarterly care conferences. (See interviews under example 3.)3. From 2/3/26 to 2/4/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, history of stroke, and type 2 diabetes. R5's most recent MDS assessment, dated 12/13/25, had a BIMS score of 10 out of 15 which indicated R5 had moderate cognitive impairment. R5 had an activated POAHC.On 2/4/26, Surveyor reviewed care conference documentation for R5 and noted that in the last year, R5 had a care conference on 4/21/25. R5's medical record did not indicate any other care conferences were offered or declined in the last year.On 2/4/26 at 10:15 AM, Surveyor interviewed POAHC-C regarding R5's care at the facility. POAHC-C stated POAHC-C had not been invited to a care conference for R5 in almost a year. POAHC-C had never refused a care conference and wanted to have a care conference to discuss R5's care.On 2/4/26 at 12:38 PM, Surveyor interviewed Social Worker (SW)-D who stated the timing of care conferences is personalized for each resident and dependent on their needs. SW-D verified care conferences should include the resident or their representative and the Interdisciplinary Team (IDT). SW-D stated SW-D documents assessments/notes that review the resident's plan of care but does not consistently use the Care Conference UDA per the facility's policy. On 2/4/26 at 2:14 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified care conferences should be attempted at least quarterly and upon request. NHA-A stated SW-D should use the Care Conference UDA per the facility's policy.

Based on staff and resident interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 3 residents reviewed for elopement.R1's care plan upon admission on [DATE] indicated R1 was at risk for wandering/elopement. A WanderGuard (a security device that triggers an alarm if the wearer exits the facility) was placed on R1's right ankle. On 11/27/25, R1 attempted to exit the unit multiple times and was redirected by staff. The facility did not implement increased supervision for R1. On 11/27/25 at 5:15 PM, the police department notified the facility that R1 was found 0.6 miles from the facility in a hospital parking lot. Staff were unaware R1 had left the facility. An investigation indicated R1 exited through a second-floor stairwell door with a functioning alarm. Another resident's family member silenced the alarm and informed staff, who were busy with other residents. Staff did not follow the facility's procedure to conduct a head count when notified of the alarm.The facility's failure to provide adequate supervision for a resident at risk for elopement and with a history of exit seeking and staffs' failure to follow the facility's elopement procedure created a finding of immediate jeopardy that began on 11/27/25. Nursing Home Administrator (NHA)-A was notified of the the immediate jeopardy on 12/9/25 at 4:40 PM. The immediate jeopardy was removed on 12/9/25; however, the deficient practice continues at a scope/severity level E (potential for more than minimal harm/pattern) as the facility continues to implement it's action plan.Findings include: The facility's Elopement Risk and Prevention policy, dated 6/2/22, indicates: .3. The Administrator and Director of Nursing will be notified immediately of any concerns with secured doors or keypads .5. At no time shall a door alarm be turned off without the continual supervision of the exit .Procedure for Missing Residents and/or Elopements: .3. Contact the resident's family or responsible party .Procedure on How to Respond When an Armed Door Alarms: 1. All stuff must respond immediately to any door alarm. 2. Staff must identify which door was triggered. 3. Notify the Administrator and Director of Nursing that an exit door alarm was triggered. Staff responding to a door alarm must open the alarming door and check the outside of the building and immediate surrounding area to make sure no resident exited the building through that door. 4. Unit nurse must immediately conduct a head count of all residents on the unit to make sure everyone is accounted for. Report the final count to the Director of Nursing/designee. 5. If a resident is identified as missing (a resident who has left the facility without signing themselves out of the facility or has wandered away from the facility), initiate the following steps: a. Notify the Administrator and Director of Nursing immediately b. Notify the Charge Nurse c. Call a Code Yellow (missing resident).On 12/8/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, post-traumatic stress disorder (PTSD), delirium, and anxiety. R1's Minimum Data Set (MDS) assessment, dated 11/2/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1 had severe cognitive impairment. R1 had a court-appointed Guardian.A care plan, revised 10/27/25, indicated R1 was at risk for elopement/wandering/leaving the facility without notice. R1 had a WanderGuard. The care plan indicated it was unsafe for R1 to leave the unit on R1's own due to Alzheimer's dementia and an inability to recognize safety risks.R1's medical record indicated R1 was found on 11/27/25 at approximately 4:45 PM in a hospital parking lot. R1 told hospital staff R1 was going to the dentist and walked from across town. R1 then stated R1 drove but locked the keys in R1's car at the dentist's office. R1 did not remember the name of the dentist or where the office was located. R1 did not have a coat. (According to weatherunderground.com, the temperature at the time R1 left the facility was approximately 25 degrees with wind gusts around 22 miles per hour.) R1 was seen in the waiting room and initially declined Emergency Department (ED) evaluation; however, R1 appeared confused and required an evaluation under the Emergency Medical Treatment and Active Labor Act (EMTALA) (a federal law that requires Medicare-participating hospitals to provide emergency medical screening and stabilizing treatment to anyone with an emergency medical condition regardless of their insurance, etc.) R1 was assessed and had no injuries. R1 provided R1's name and date of birth . R1's spouse was contacted and indicated R1 must have eloped from the nursing home's dementia unit. The hospital attempted to call the facility but there was no answer. Hospital staff then called the police.Surveyor reviewed a map of the city and noted the hospital was 0.6 miles from the facility. Surveyor noted R1 would have walked down a busy street with numerous stop lights and under an overpass with limited sidewalk areas before reaching the hospital parking lot. A police report, dated 11/27/25, indicated the police went to the facility and informed staff that R1 was found wandering in a hospital parking lot. R1 was identified as a resident who resided on a dementia unit at the facility. The hospital attempted to call the facility but no one answered. An officer went to the facility to verify if R1 was a resident. The officer spoke with Registered Nurse (RN)-I who verified R1 was a resident and had eloped at approximately 4:00 PM. RN-I indicated R1 walked around the elevator to the stairwell exit door and activated the alarm on the door. Staff stopped R1 from exiting the facility and silenced the alarm. RN-I indicated staff were busy with a resident who had fallen and a new admission and did not notice that R1 had left the facility. RN-I indicated if the door handle is held down for 15 seconds, the door will open due to fire restrictions. When the officer asked if someone from the facility could pick up R1 at the hospital, RN-I indicated RN-I had called NHA-A and the police should bring R1 back. Neither the hospital or the facility were willing to bring R1 back. The police convinced R1 go back to the facility in a squad car. On 12/8/25, Surveyor reviewed the facility's investigation which indicated R1 was last seen by staff between 3:30 and 3:40 PM on 11/27/25. The facility was unable to determine how R1 eloped from the building without staffs' knowledge. The investigation indicated staff were unaware that R1 was missing until the police arrived at the facility at approximately 5:15 PM. A progress note, dated 11/27/25 at 11:29 PM and written by RN-I, indicated R1 was standing near the elevator talking with a resident at the beginning of the shift. R1 was redirected away from the area because R1's WanderGuard set off the alarm. There were many visitors coming and going due to it being Thanksgiving Day which also caused the alarm to go off more frequently than usual. Between 3:00 and 3:30 PM, R1 was observed pressing on the fire door to the stairwell on the East hallway. RN-I walked R1 back to the common area and informed R1 that R1 could only leave the floor with staff or family. An admission arrived shortly afterward and RN-I was detained in another resident's room. At approximately 4:45 PM, R1's spouse called the unit's cell phone and stated the hospital called and said R1 was in the ED. R1's spouse asked if the facility could transport R1 back to the facility without calling an ambulance.On 12/9/25 at 12:09 PM, Surveyor interviewed RN-I who indicated staff were extremely busy on the 11/27/25 PM shift because many family members were coming and going and asking staff to bring the phone to their loved ones. RN-I saw R1 talking to another resident near the elevator. R1 was redirected away from the elevator. R1 was later seen trying to exit the infirmary stairwell. The alarm sounded and R1 was redirected away from the exit. RN-I then received an admission. RN-I was in the admission resident's room and stated alarms were going off due to the amount of people coming and going. RN-I stated a Certified Nursing Assistant (CNA) told RN-I that a family member turned off the alarm because it was going off so much and they were irritated. RN-I stated R1's spouse called the unit and informed them that the hospital stated R1 was in the ED. That was the first time RN-I was aware that R1 was missing. RN-I indicated R1's spouse asked the facility to transport R1 back without using an ambulance because it was costly. Police then arrived and RN-I asked if the police could transport R1 back to the facility. When RN-I informed R1's spouse of the police transport, R1's spouse was concerned that R1 would become combative due to PTSD. RN-I did not know how to arrange another form of transportation. R1 arrived at the facility approximately 15 minutes later with police. R1's WanderGuard alarmed when R1 entered the building.On 12/8/25 at 3:02 PM, Surveyor interviewed CNA-C who indicated CNA-C worked for an agency and was assigned to the facility for four weeks. CNA-C worked CNA-C's second shift at the facility on 11/27/25. CNA-C was provided a list of residents that CNA-C was assigned to but was not provided orientation to the unit or training on the facility's WanderGuard system. CNA-C worked the 11/27/25 PM shift on the second floor. CNA-C stated there were two CNAs on the second floor at the beginning of the shift and a third arrived at 4:00 PM; however, the floor was usually staffed with 3 to 4 CNAs. CNA-C indicated R1 attempted to leave the unit by getting on the elevator or exiting the infirmary stairwell at approximately 3:00 PM. CNA-C walked R1 back toward the elevators and made sure R1 did not follow CNA-C when CNA-C silenced the infirmary stairwell alarm which sounds until a code is entered into the keypad. CNA-C indicated it was the first time CNA-C cleared an alarm. A short time later, CNA-C heard the alarm again while assisting a resident with cares. Family Member (FM)-F was in the room and asked if FM-F should look in the hallway. FM-F left the room, returned a short time later, and stated FM-F did not see any residents and the alarm was no longer sounding. CNA-C thought FM-F cleared the alarm despite FM-F's denial. CNA-C stated CNA-C did not clear the alarm a second time. On 12/9/25 at 10:10 AM, Surveyor interviewed FM-F who indicated FM-F observed a resident attempt to exit the infirmary stairwell on 11/27/25. FM-F found a staff who redirected the resident. FM-F indicated the infirmary exit door alarm sounded again later. FM-F looked around the corner, saw a resident, and silenced the alarm with the key code. FM-F indicated two residents try to elope when staff/visitors get off the elevator. FM-F stated FM-F did not usually enter the key code to silence the alarm but did so that day because staff were in rooms providing care and there was no one around. FM-F assumed the key code for the stairwell was the same as the code for the elevator. FM-F indicated residents get worked up when the alarms sound. FM-F let staff know that FM-F had silenced the alarm.On 12/8/25 at 3:30 PM, Surveyor interviewed CNA-D who worked the 11/27/25 PM shift on the second floor. CNA-D indicated CNA-D saw R1 attempt to exit the unit near the elevators at approximately 3:00 PM and 3:30 PM. CNA-D walked R1 back to the common area and asked if R1 wanted a bath. R1 refused and began talking to another resident. CNA-D then assisted another resident with cares. CNA-D was informed at some point during the shift that R1's spouse called and stated R1 was at the hospital. CNA-D did not see any other staff turn off the alarm. CNA-D indicated staff were very busy providing cares because there were 2 CNAs at the beginning of the shift and then another started at 4:00 PM. On 12/8/25 at 3:16 PM, Surveyor interviewed RN-J who indicated WanderGuards are checked every shift by a nurse or Med Tech. Staff ensure alarms are working properly, residents' WanderGuards are in place, and safety checks are documented in residents' medical records. RN-J indicated if an alarm sounds, staff have to clear it. RN-J indicated the elevators stop until the alarm is cleared and (egress) doors are usually locked unless they are pushed hard. RN-J had not witnessed a resident exit the door and had never witnessed R1 attempt to elope from the unit; however, RN-J had heard numerous reports of R1 attempting to elope. RN-J showed Surveyor the facility's resident WanderGuard book which contained seven residents. On 12/9/25 at 9:31 AM, Surveyor tested the alarms with CNA-E. A key code was needed to get the elevators doors to open. If the alarm was sounding, the elevator doors did not close if a WanderGuard sensor was near the elevator. Surveyor tested all five exit doors which alarmed when a WanderGuard was nearby. Surveyor held down the door handle of each exit door for 15 seconds while the alarm sounded, and the door eventually opened (due to fire code requirements). CNA-E indicated R1 frequently packed personal items, stored the items in the common area, and stated R1 was leaving. CNA-E indicated staff put the items back in R1's room. On 12/9/25 at 2:15 PM, Surveyor interviewed NHA-A who indicated the facility's investigation was inconclusive. NHA-A verified the alarmed doors were tested and functioned properly. NHA-A was unaware that staff were aware that FM-F had silenced an alarm. NHA-A confirmed family members have access to alarm codes which are the same between the doors and elevators. NHA-A stated if staff knew that FM-F had silenced an alarm, a head count should have been conducted. NHA-A verified exit doors have a delayed egress for fire codes.The facility's investigation indicated staff did not know R1 left the facility until the officer arrived. When R1 returned to the facility, door function tests were completed to ensure alarms were working properly. R1's care plan was updated with an intervention for staff to redirect R1 by talking about model cars, the news, and other interests. R1 also enjoyed visits from family and friends but had difficulty when the visits ended. R1's care plan indicated to redirect R1 back to R1's room for activities of choice after friends and family left. R1 continued to exit seek in the days following the elopement. On 11/29/25, R1's primary care physician increased R1's Zyprexa (an antipsychotic medication) dose. A 3-day sleep evaluation was also initiated on 11/29/25 as R1 was noted to have increased pacing and decreased sleep throughout the night. On 11/29/25, the facility initiated 15-minute checks until 12/3/25 when behavioral health assessed R1. Risk management and staff statements indicated there was a potential failure of the alarm system or a delayed staff response to the alarm. The facility's failure to follow their elopement procedure when a resident eloped, a visitor silenced the alarm, and staff did not check the perimeter of the facility or complete a head count created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed and corrected the jeopardy on 12/9/25 when it had completed the following: 1. Initiated fifteen-minute checks for R1 and updated R1's care plan.2. Changed alarm keypad codes to ensure family members/visitors do not have access to codes or a means to clear alarms.3. Instructed maintenance staff to change the codes at certain intervals.4. Educated staff on the facility's elopement policy, door alarm system, and new procedure for elevator/door codes.5. Completed elopement drills and tested both systems weekly.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe manner. This practice had the potential to affect all 65 residents residing in the facility. Food temperatures logs were incomplete for items served to residents.Beverage temperatures were greater than 41 degrees Fahrenheit (F) prior to serving residents on the third floor.Findings include:The Wisconsin Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) .Time/temperature control for safety food shall be maintained: (1) 135 degrees F or above, except that roasts cooked to a temperature and for a time specified in paragraph 3-401.11 (B) or reheated as specified in paragraph 3-403.11 (E) may be held at a temperature of 130 degrees F or above; or (2) At 41 degrees F or less.On 12/8/25 and 12/9/25, Surveyor observed the second and third floor November and December 2025 food temperature logs in the second and third floor dining rooms. The logs were undated and contained missing documentation. Surveyor noted the following on the third floor dining room food temperature log:~ Week of 11/1/25 to 11/7/25: No meal temperatures were recorded on 11/4/25; No breakfast or lunch temperatures were recorded on 11/5/25; No lunch or dinner temperatures were recorded on 11/6/25; No dinner temperatures were recorded on 11/2/25 and 11/3/25; No beverage temperatures were recorded from 11/1/25 to 11/7/25.~ Week of 11/16/25 to 11/22/25: No lunch temperatures were recorded on 11/18/25; No dinner or beverage temperatures were recorded from 11/16/25 to 11/22/25.~ Week of 11/23/25 to 11/29/25: No meal temperatures were recorded from 11/25/25 to 11/26/25; No breakfast or lunch temperatures were recorded on 11/23/25; No dinner temperatures were recorded from 11/24/25 to 11/29/25; No beverage temperatures were recorded from 11/23/25 to 11/29/25.~ Three undated food temperature documents contained multiple missing food temperatures and no beverage temperatures.Surveyor noted the following on the second floor dining room food temperature log:~ Week of 11/2/25 to 11/8/25: No meal temperatures were recorded on 11/3/25 and 11/8/25; No lunch temperatures were recorded on 11/7/25; No dinner or beverage temperatures were recorded from 11/2/25 to 11/8/25.~ Week of 11/9/25 to 11/15/25: No meal temperatures were recorded from 11/10/25 to 11/15/25; No dinner temperatures were recorded on 11/9/25; No beverage temperatures were recorded from 11/9/25 to 11/15/25.~ Week of 11/16/25 to 11/22/25: No breakfast or lunch temperatures were recorded from 11/18/25 to 11/22/25; No dinner temperatures were recorded on 11/20/25; No beverage temperatures were recorded from 11/16/25 to 11/22/25.~ Week of 11/23/25 to 11/30/25: No breakfast or lunch temperatures recorded from 11/28/25 to 11/30/25; No dinner temperatures were recorded on 11/23/25 or from 11/25/25 to 11/29/25; No beverage temperatures were recorded from 11/23/25 to 11/30/25.~ Week of 12/8/25: No dinner temperatures were recorded on 12/8/25; No beverage temperatures were recorded on 12/8/25.~ One undated food temperature document contained multiple missing food temperatures and no beverage temperatures.On 12/9/25 at 11:52 AM, Surveyor interviewed Dietary Aide (DA)-K who indicated DA-K is present to temp food prior to serving breakfast and lunch. DA-K indicated food temperature logs should be filled out for breakfast, lunch, and dinner for starch, meat, vegetables, and beverages. Surveyor reviewed the incomplete food temperature logs with DA-K who indicated DA-K worked at the facility part-time and was not present for dinner. DA-K indicated it is the responsibility of the aides who serve the food at dinner to temp the food prior to serving. On 12/9/25 at 11:52 AM, Surveyor observed lunch in the third floor dining room and observed DA-K obtain beverage temperatures prior to lunch service. DA-K indicated hot food from the steam table should have a temperature greater than 135 degrees F prior service and beverage temperatures should be above 40 degrees F per the Wisconsin Food Code and the facility's policy. Surveyor observed DA-K temp apple juice in a pitcher on the serving cart and verified the apple juice was 48 degrees F. Surveyor observed DA-K temp a glass of freshly poured chocolate milk and verified the milk was 48.4 degrees F. Surveyor also observed DA-K temp white milk on the serving cart and verified the milk was 49 degrees F. On 12/9/25 at 2:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated it is the responsibility of the cooks and aides to temp food and beverages prior to meal service. Surveyor reviewed the incomplete food logs with NHA-A who indicated staff education was provided related to food temperature logs in October due to a grievance. Surveyor reviewed the signed education that was provided on 10/13/25 NHA-A indicated the Dietary Manager was at the facility 2 to 3 days per week. NHA-A stated the facility did not have a policy regarding food temperatures and staff should follow the Wisconsin Food Code for temping food and beverages.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents was assessed following a fall with injury prior to being transferred from the floor into bed.R1 sustained a fall with injury on 12/1/25 at 11:20 AM. An X-ray was ordered and pending review. R1 sustained a second fall with reported pain on 12/1/25 at 7:28 PM. R1 was transferred from the floor into bed with the use of Hoyer slings without a physical assessment to ensure R1 was medically safe to be transferred. Findings include:The facility's Post Fall policy, dated 10/13/23, indicates: .Evaluation: Before moving the resident, ask the resident what they believe caused the fall and assess any associated symptoms. Then conduct a comprehensive evaluation .Be aware of the following warning signs: numbness or tingling in the extremities, back pain, rib pain, or an externally rotated or shortened leg. These symptoms suggest spinal cord injury, leg or pelvic fracture, or head injury. If symptoms are noted, resident should not be moved from current position. Update provider immediately or call 911 .On 12/8/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, post-traumatic stress disorder (PTSD), delirium, and anxiety. R1's Minimum Data Set (MDS) assessment, dated 11/2/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1 had severe cognitive impairment. R1 had a court-appointed Guardian.A nursing progress note, dated 12/1/25 at 7:28 PM, indicated Licensed Practical Nurse (LPN)-H heard R1 yell from down the hallway and observed R1 sitting on the floor next to the foot of R1's bed. R1's right shoe was off. R1 grimaced and stated, I was sitting on my bed playing Solitaire. I got excited during the game and slid off my bed. LPN-H assisted R1 to a supine position on the floor and assessed R1 for pain or injury. R1 stated the top of R1's right thigh/hip was painful and throbbing. LPN-H ensured R1 was safely positioned and had staff help transfer R1 to bed with Hoyer slings. LPN-H then obtained R1's vital signs, completed neuro and accuchecks, and assessed R1's right upper thigh/hip. LPN-H noted an existing yellow/pink bruise on R1's upper right thigh, relieved R1's hip pain with a pillow, and contacted a Nurse Practitioner (NP) for pain medication. On 12/9/25 at 3:36 PM, Surveyor interviewed LPN-H who stated R1 complained of hip pain and wanted to lay down when LPN-H found R1 sitting on the floor on 12/1/25 at 7:28 PM. LPN-H was worried that R1 would lay down or move on R1's own so LPN-H assisted R1 to a supine position and called for assistance. LPN-H indicated three staff put the same color Hoyer slings underneath R1 and lifted R1 into bed. LPN-H then completed a physical assessment of R1. On 12/9/25 at 4:01 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility's policy indicates not to move a resident who had a fall with injury until staff complete vital signs and skin and pain assessments. Staff can then transfer the resident unless there is visible blood, bone, or dislocation. NHA-A stated R1 was not in severe pain and had no signs of a fracture. Range of motion was completed and R1 was able to move all extremities without pain or discomfort. R1 did not hit R1's head. NHA-A stated R1's family told the nurse that R1 had right hip pain and the facility obtained an order for an X-ray. NHA-A was not aware that the injury information was for R1's first fall and that R1 sustained a second fall at 7:28 PM. While waiting for the results of the pending X-ray, staff transferred R1 (who complained of pain) from the floor to the bed.

Based on staff and resident representative interview and record review, the facility did not notify a Guardian of a change in condition or a need to alter treatment for 1 resident (R) (R1) of 1 sampled resident.R1 eloped from the facility on 11/27/25. R1's Guardian was not notified of the elopement until 12/1/25.R1 fell on [DATE] at 11:20 AM and 7:28 PM. R1's Guardian was not notified of the second fall.Findings include:The facility's Elopement Risk and Prevention policy, dated 6/2/22, indicates: .Procedure for Missing Residents and/or Elopements: .3. Contact the resident's family or responsible party .The facility's Acute Care Transfer policy, dated 9/15/21, indicates: .4. Notification shall be made to the durable power of attorney/responsible party for any change in condition, including those requiring transfer to an acute care facility .On 12/8/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, post-traumatic stress disorder (PTSD), delirium, and anxiety. R1's Minimum Data Set (MDS) assessment, dated 11/2/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1 had severe cognitive impairment. R1 had a court-appointed Guardian.On 12/8/25, Surveyor reviewed an elopement investigation that indicated the facility could not determine how R1 eloped from the facility on 11/27/25 without staffs' knowledge. Staff last saw R1 between 3:30 and 3:40 PM. Staff were not aware that R1 had eloped until police arrived at the facility at approximately 5:15 PM and stated R1 was discovered in the parking lot of a nearby hospital. R1's Guardian was not notified of the elopement until 12/1/25. On 12/9/25 at 10:00 AM, Surveyor interviewed Guardian (GD)-G who stated R1's family notified GD-G on the morning of 12/1/25 that R1 had eloped from the facility on 11/27/25. GD-G also received an email from Adult Protective Services (APS) with a copy of the police report and left a message for the facility's Social Worker on 12/1/25. Nursing Home Administrator (NHA)-A returned the call shortly afterward. When GD-G indicated GD-G heard about the elopement from R1's family, NHA-A apologized for the late notification and stated staff were busy with an admission and did not notice R1 leave. NHA-A indicated the facility would notify the State Agency (SA) and ensure R1 did not elope again.On 12/9/25, Surveyor reviewed two fall reports for R1 that were dated 12/1/25. The first report indicated R1 was in a recliner in the common area on 12/1/25 at 11:15 AM when R1 woke up and started walking down the west infirmary hall toward R1's room. At ll:20 AM, a Certified Nursing Assistant (CNA) witnessed R1 lose balance and fall on R1's right side. R1 did not hit R1's head and was able to move all extremities without pain or discomfort. R1's vital signs were stable. Staff brought R1 to R1's room, provided care, and took R1 to the dining room for lunch. R1's family sat with R1 during lunch and notified staff that R1 complained of right hip pain. A Nurse Practitioner (NP) ordered a stat (immediate) X-ray. GD-G was notified. A second fall report indicated R1 fell again at 7:28 PM. The report indicated GD-G was called at 8:40 PM when R1's X-ray showed a right hip fracture and the NP requested that R1 be sent to the hospital. GD-G gave verbal consent for a bed hold.A nursing progress note, dated 12/1/25 at 7:28 PM, indicated Licensed Practical Nurse (LPN)-H heard R1 yell from down the hallway and observed R1 sitting on the floor next to the foot of R1's bed. R1's right shoe was off. R1 grimaced and stated, I was sitting on my bed playing Solitaire. I got excited during the game and slid off my bed. LPN-H assisted R1 to a supine position on the floor and assessed R1 for pain or injury. R1 stated the top of R1's right thigh/hip was painful and throbbing. LPN-H ensured R1 was positioned safely and had staff help transfer R1 to bed. LPN-H then obtained R1's vital signs, completed neuro and accuchecks, and assessed R1's right upper thigh/hip. LPN-H noted an existing yellow/pink bruise on R1's upper right thigh, relieved R1's hip pain with a pillow, and contacted the NP for pain medication. On 12/9/25 at 11:54 AM, Surveyor interviewed GD-G who stated GD-G was notified on 12/1/25 at 1:37 PM that R1 fell that morning and complained of right hip pain and an X-ray was ordered. GD-G received a second call at 8:40 PM and was told R1's X-ray showed a fractured hip. GD-G gave permission to transfer R1 to the hospital. GD-G stated the facility did not inform GD-G that R1 sustained a second fall on 12/1/25 at 7:28 PM. On 12/9/25 at 2:15 PM, Surveyor interviewed NHA-A who stated NHA-A called GD-G about the elopement on 11/27/25 but received a voice message that did not include GD-G's name and did not feel comfortable leaving a message. NHA-A called GD-G again on 12/1/25 regarding the elopement; however, R1's family had already notified GD-G. NHA-A was aware staff notified GD-G about the first fall and contacted GD-G again that evening regarding the need to send R1 to the hospital. NHA-A was not aware that GD-G was not informed of R1's second fall and indicated staff should notify responsible parties of all falls.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents was free from a chemical restraint not required to treat the resident's medical symptoms. The facility did not implement non-pharmacological interventions prior to administering antipsychotic medication to decrease R2's behaviors. Findings Include:The facility's Policy & Procedure Psychotropic Medication, dated 5/1/25, indicates: Purpose: To provide guidance for the psychopharmacologic drug treatment for a resident with a specific condition, including but not limited to dementia and other cognitive disorders, and/or behaviors as documented in the resident's clinical record .1. An assessment must be conducted to identify specific behaviors/symptoms, potential causative factors, and recommendations for managing identified behavior. 2. The medical record documentation must reflect the specific behaviors/symptoms and the resident's response to non-pharmacological interventions to manage the behaviors/symptoms .7. After implementation of psychotropic medication, behavior/symptom and medication side-effects will be monitored and documented. 8. Residents receiving antipsychotic medication will be assessed using the Abnormal Involuntary Movement Scale (AIMS) upon admission or initiation of antipsychotic medication therapy and every six months and upon significant change while remaining on antipsychotic medication therapy. 9. Residents will receive ongoing evaluation to identify possible causes that may be reduced or eliminated through care plan modification. 10. For those residents requiring as needed (PRN) psychotropic medication administration, non-pharmacological interventions need to be attempted and documented prior to medication administration. Residents receive PRN medication only if necessary to treat a diagnosed specific condition that is documented in the clinical record .14. A plan of care will be developed to include precipitating factors, non-pharmacologic interventions, and potential side effects. On 9/3/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of overlapping sites of rectum, anus and anal canal, anxiety disorder, and depression. R2's Minimum Data Set (MDS) assessment, dated 5/31/24, had a Brief Interview for Mental Status (BIMS) score of 00 (not appropriate to assess) out of 15 which indicated R2 had severely impaired cognition. R2 had an activated Power of Attorney of Healthcare (POAHC).R2's medical record contained the following orders:~ Lorazepam oral tablet 1 milligram (mg) - Give 1 tablet by mouth every 2 hours as needed for anxiety, agitation, restlessness (start date 8/26/25).~ Haloperidol oral tablet 1 mg - Give 1 tablet by mouth every 6 hours for restlessness and agitation (start date 8/26/25). ~ Haloperidol oral tablet 2 mg - Give 1 tablet by mouth every 6 hours for restlessness and agitation (start date 9/3/25).R2's Kardex (an abbreviated care plan used by nursing staff) contained the following: ~ Frequent monitoring for increased anxiety or restlessness.~ Monitor for Target Behaviors - 1. Social isolation interventions for behaviors: Encourage (R2) to participate in social activities of choice.A care plan, dated 6/12/25, indicated R2 was at high risk for falls related to weakness, cancer, and heart disease. The care plan contained the following interventions:~ Check on (R2) every 2 hours while in bed for safety (initiated 5/20/25)~ Bed controller out of reach related to cognition (initiated 4/29/25)~ Bolster mattress (initiated 4/14/25)~ Encourage (R2) to use call light for assistance (initiated 3/13/25); Sign in room to use call light when assistance is needed (initiated 3/13/25)~ Frequent monitoring for increased anxiety or restlessness (initiated 6/1/25)~ (R2) moves (R2's) self from lowest bed position to floor mattress, sometimes to floor (initiated 8/1/25)~ Staff to ensure (R2) is lying in the center of the bed (initiated 3/13/25)~ Toileting schedule implemented (initiated 3/13/25)~ While (R2) is up and out of bed, place in common area for supervision (initiated 4/16/25)~ Implement sensory strategies to meet sensory needs. (Stimulation of the 5 senses, beware of over-stimulating. Agitation may be a sign that sensory stimulation should be changed. Sensory activities: walking, conversation, music, [NAME] lamp/light show, tasting/eating/snacking, aromatherapy, nail care/hand massage, bath, weighted blanket, fidget pads, sensory boards) (initiated 4/8/24)~ Provide/offer snacks in between meals and/or with signs of restlessness (initiated 4/8/24)~ Encourage to wear gripper socks when up (initiated 3/13/25); Fall mat at bedside (initiated 5/7/24); Ensure the environment is free of clutter (initiated 4/1/24).R2 was assessed for anxiety disorder. Interventions included:~ Monitor for Target Behaviors - 1. Social isolation interventions for behaviors: Encourage (R2) to participate in social activities of choice (initiated 4/8/25).~ Monitor/document/report PRN any adverse reactions to anti-anxiety medications: drowsiness, lack of energy, clumsiness, slow refluxes, slurred speech, confusion, disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, and blurred or double vision (initiated 4/1/25).~ Offer anti-anxiety medication as ordered by physician. Monitor for side effects and effectiveness (initiated 4/1/24). (R2 did not have an antipsychotic medication care plan.) R2's medical record did not contain any progress notes regarding behaviors in July of 2025.A progress note, dated 8/26/25 at 12:19 PM, indicated Registered Nurse (RN)-C notified R2's Hospice Nurse Practitioner (NP) that lorazepam was ineffective. RN-C received an order to discontinue scheduled and PRN lorazepam and start haloperidol 1 mg four times daily (QID) and every 4 hours PRN.A progress note, dated 8/26/25 at 8:15 PM, indicated R2 was agitated and crying out. Lorazepam was administered. R2's Medication Administration Record (MAR) indicated the following: ~ Anxiety - Monitor/document/report adverse effects: drowsiness, lack of energy, clumsiness, slow refluxes, slurred speech, confusion, disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, and blurred or double vision. Every shift document why - if side effects noted, and document side effects in progress note. Document N - checked and no side effects noted (start date 7/18/24).R2's MAR indicated R2 experienced anxiety on the 8/4/25, 8/6/25, and 8/31/25 PM shifts. R2's August and September 2025 MARs indicated R2 received 1 mg of haloperidol on the following dates:~ 8/26/25 at 6:00 PM~ 8/27/25, 8/28/25, 8/29/25, 8/30/25, 8/31/25, 9/1/25, and 9/2/25 at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM~ 9/3/25 at 12:00 AM and 6:00 AMR2's MAR indicated R2 received 2 mg of haloperidol on 9/3/25 at 12:00 PM.R2's MAR indicated R2 was administered lorazepam on the following dates:~ 8/26/25 at 4:56 PM~ 8/29/25 at 4:11 AM and 3:25 PM~ 8/30/25 at 6:40 AM and 8:14 PMSurveyor reviewed R2's Treatment Administration Record (TAR) which contained an identification (ID) key that indicated:~ 2 = Pinching~ 3 = Scratching~ 4 = Hitting/Punching~ 12 = Cursing at Others~ 19 = Throwing/Smearing Food~ 21 = Screaming/Yelling out~ 27 = No Behaviors ObservedR2's TAR indicated the following:~ From 8/1/25 to 8/8/25, R2's behavior was documented as 27 on all shifts.~ On 8/9/25, R2's behavior was documented as 21, 3, and 19 on the AM shift, not applicable (NA) on the PM shift, and 27 on the night (NOC) shift.~ On 8/10/25, R2's behavior was documented as 27 on the AM shift, 21 on the PM shift, and 27 on the NOC shift.~ From 8/11/25 to 8/20/25, R2's behavior was documented as 27 on all shifts.~ On 8/21/25, R2's behavior was documented as 27 on the AM shift, 21 on the PM shift, and NA on the NOC shift.~ On 8/22/25, R2's behavior was documented as 27 on all shifts.~ On 8/23/25, R2's behavior was documented as 21, 2, and 3 on the AM shift, 21 and 3 on the PM shift, and 27 on the NOC shift.~ On 8/24/25, R2's behavior was documented as 27 on all shifts.~ On 8/25/25, R2's behavior was documented as 21, 3, 4, and 12 on the AM shift.~ From 8/26/25 to 8/31/25, R2's behavior was documented as 27 on all shifts.~ On 9/1/25 and 9/2/25, R2's behavior was documented as 27 on all shifts.On 9/3/25 at 9:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who indicated R2 receives Hospice services and is bedbound. CNA-G indicated CNA-G was instructed by nurses not to get R2 out of bed. CNA-G indicated CNA-G asked about bringing R2 out of R2's room but nursing staff does not listen to CNA-G. CNA-G indicated CNA-G follows R2's Kardex and offers R2 a snack and water, change R2's brief, and/or repositions R2 when R2 is restless. CNA-G indicated R2 does not use the soft touch call light in R2's room and is not on frequent checks. CNA-G indicated R2 is anxious at times, is not alert and oriented, and cries out for R2's kids. CNA-G indicated R2 has a Mepilex dressing on the coccyx due to skin breakdown and is propped with pillows in bed but scoots out of bed onto a fall mat that is even with the bed. On 9/3/25 at 11:00 AM, Surveyor interviewed Hospice CNA (HCNA)-E who indicated HCNA-E sees R2 twice weekly for a full bed bath and cares. HCNA-E worked with R2 since May of 2025 and had not seen R2 out of bed at the facility. HCNA-E indicated R2 has not had any falls since a fall mat was implemented. On 9/3/25 at 12:12 PM, Surveyor interviewed Hospice Secretary (HS)-F who indicated Hospice provided R2 with 2 floor mats and an alternating air mattress with a side bolster. HS-F indicated a Broda chair was not provided for R2. On 9/3/25 at 12:15 PM, Surveyor interviewed Hospice RN (HRN)-D who indicated HRN-D worked with R2 for 1 month. HRN-D indicated HRN-D visits twice weekly and as needed and has not observed R2 out of bed. HRN-D indicated the facility called recently and requested R2's lorazepam order be changed to Haldol.On 9/3/25 at 2:10 PM, Surveyor interviewed RN-C who indicated R2 is restless at times and rolls all over the bed and onto a fall mat next to the bed. RN-C indicated R2 yells out daily and is often found on the fall mat when staff check on R2 as they walk past R2's room. RN-C indicated staff do not follow a schedule to check on R2 who is not on frequent checks and does not use a call light to call for assistance. RN-C indicated R2's behaviors of calling out and attempting to get out of bed had increased. RN-C felt R2's restlessness increased because R2 was not able to get out of bed. RN-C indicated R2 is appropriate for a Broda chair but stated staff have not tried to get R2 into a Broda chair. RN-C asked Hospice about a Broda chair but was told R2's family does not want R2 out of bed. RN-C indicated RN-C contacted the Hospice NP and requested an order for Haldol in place of lorazepam since lorazepam was ineffective and R2 continued to be restless in bed. RN-C received a verbal order to administer haloperidol 1 mg every 6 hours. RN-C indicated staff attempt to decrease restlessness for R2 by making sure R2's brief is dry, offering food and water, and changing R2's bedding. RN-C indicated assessing R2 for pain was tricky and stated RN-C administered as needed morphine when R2 was restless, grimacing, or bracing R2's self.On 9/3/25 at 2:42 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-H who indicated R2's behavior interventions include providing companionship, talking with R2, and music. When Surveyor indicated R2 was observed throughout the day in bed without music, ADON-H indicated staff play music on the TV at times, however, R2 does not like the light of the TV. ADON-H indicated ADON-H would request a radio from R2's family or Hospice. ADON-H indicated R2's dietary intake was better when staff fed R2 in a wheelchair in the dining room. ADON-H indicated R2 loves interaction and enjoys being in a wheelchair. ADON-H indicated R2 requires 1:1 supervision while in the wheelchair because R2 attempts to get out of the wheelchair. ADON-H indicated R2 was in a Broda chair supplied by the facility during R2's last fall. ADON-H indicated R2's POAHC does not want R2 in a wheelchair since R2 has fallen out of a wheelchair. ADON-H indicated the facility does not have a signed risks versus benefits statement regarding getting R2 up in a wheelchair and indicated ADON-H had R2 in a wheelchair for dinner last night which was not documented. ADON-H stated RN-C contacted the Hospice NP for a Haldol order and indicated R2's behavior has not changed since Haldol was started. ADON-H indicated R1 refused to take medication on 9/2/25 and R2's Haldol order was increased to 2 mg every 6 hours for restlessness and agitation. When Surveyor asked about documentation that indicated R2 ambulates, ADON-H indicated R2 has not ambulated in the 5 months ADON-H has been employed. ADON-H indicated R2 is up in a wheelchair 3 to 4 times a week but it is not documented. On 9/3/25 at 4:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R2's POAHC does not want R2 out of bed. NHA-A indicated the facility should have obtained a risks versus benefits statement for R2. NHA-A also indicated non-pharmacological interventions should be reviewed, updated, and added to R2's care plan.

Based on observation, staff, resident, and resident representative interview, and record review, the facility did not ensure 4 residents (R) (R1, R2, R7, and R10) of 5 sampled residents who required assistance for activities of daily living (ADLs) were provided care in a timely manner.R1 expressed concerns about long call light response times. On 7/9/25, R1 indicated R1 was incontinent and requested to be changed but was told R1 would have to wait until after lunch.R2 and R2's Guardian expressed concerns about call light response times and that R2 was not changed timely. R7 expressed concerns about long call light response times. R7 filed a grievance related to the concerns but continued to experience long call light response times.R10 expressed concerns about long call light response times which resulted in R10 having to wait for R10's needs to be met.Findings include:The facility's Activities of Daily Living policy, revised 2/25/25, indicates: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices .8. Residents have the right to be involved in decisions about their care, including ADLs. Care should be provided in a way that respects the resident's dignity, preferences, and privacy.The facility's Call Light Use and Response policy, revised 7/18/23, indicates: To respond to a resident's call for assistance .2. Answer call lights promptly whether or not the staff person is assigned to the resident or not.On 7/9/25, Surveyor reviewed resident council minutes, dated 6/24/25, which indicated call light response times were still long on the second shift on the third floor and Certified Nursing Assistants (CNAs) sat in the nurses' station while call lights were on. The Overview of Action section indicated the issue was resolved and the facility would continue to run audits and work with the Assistant Director of Nursing (ADON) and Director of Nursing (DON). (Surveyor noted staff education was not provided regarding call light response times and there were no completed call light audits attached.) On 7/9/25, Surveyor reviewed the facility's grievances and noted a grievance, dated 5/28/25, that indicated call light response times were long over the weekend. In response, the facility ran call light audits on both floors, including an audit for R1 between 5/31/25 and 6/2/25. The audit contained the following highlighted dates/times/call light response times:~ On 6/1/25 at 4:13 PM: A response time of 42 minutes.~ On 6/1/25 at 5:57 PM: 1 hour and 16 minutes.In addition, Surveyor noted the following call light response times that were in excess of 30 minutes:~ On 5/31/25 at 2:57 PM: 36 minutes.~ On 5/31/25 at 5:53 PM: 55 minutes.The resolution of the grievance indicated random call light audits were completed to determine patterns or long wait times, most results were in normal limits, and the facility would continue to monitor. Surveyor noted the facility had also highlighted call light response times for other residents on the audit, including one response time on 6/2/25 at 2:19 PM for 1 hour and one on 6/1/25 at 6:36 AM for 1 hour and 20 minutes. The audits included in the grievance contained an average call light response time of less than 30 minutes. The grievance did not contain staff education regarding the long call light response times that were discovered during the audits.1. On 7/9/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including mild neurocognitive disorder, adult neglect or abandonment, post traumatic stress disorder (PTSD), and major depressive disorder. R1's Minimum Data Set (MDS) assessment, dated 5/6/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 did not have an activated Power of Attorney for Healthcare (POAHC).A care plan, initiated on 5/21/25, indicated R1 had a hyper-fixation on being changed/going to the bathroom. The care plan contained a goal that indicated R1 will decrease the repetitive need to be checked for bowel movements less than 3 times per day. Caregivers will support R1's need to be checked repeatedly for bowel movements by encouraging R1 to discuss with caregivers prior the need to have a bowel movement. Staff will discuss R1's current needs prior to going in the lift.A care plan, initiated on 5/1/25, indicated R1 had bowel incontinence related to weakness, limited mobility, and required staff assistance for toileting needs. The care plan contained an intervention, dated 5/1/25, to check R1 every 2 hours and assist with toileting as needed. An ADL care plan, initiated on 5/1/25, indicated R1 required extensive assistance of 1 staff for toileting and toileting hygiene. R1's plan of care also indicated R1 required a full body lift with the assistance of 2 staff.On 7/9/25 at 11:40 AM, Surveyor observed staff wheel R1 back to R1's room after an activity. On 7/9/25 at 11:57 AM, Surveyor interviewed R1 who indicated it sometimes took staff 1 to 2 hours to respond to R1's call light. R1 indicated R1 was sitting in R1's own shit during the interview and had asked to be changed but staff stated R1 had to wait until after lunch. During an interview at 12:16 PM, R1 indicated R1's call light was on but Certified Nursing Assistant (CNA)-C turned the light off and said R1 would be changed after lunch. At 12:21 PM, Surveyor could smell stool and asked R1 to activate the call light. At 12:23 PM, a staff member responded. R1 stated R1 needed to be changed and indicated R1's bottom hurt. The staff member indicated they would get help. At 12:27 PM, CNA-C and a nurse entered the room to provide care. On 7/9/25, Surveyor reviewed R1's call light log and noted on 7/9/25 at 11:40 AM, R1's call light was on for 2 minutes. Surveyor interviewed CNA-C who indicated CNA-C did not answer R1's call light prior to assisting with changing R1. On 7/9/25, Surveyor reviewed R1's call light log for the previous 30 days which indicated R1 used the call light 501 times. Surveyor noted 98 call light response times were over 30 minutes which meant approximately 19% of R1's call light response times were greater than 30 minutes. The following call light response times were also noted:~ Number of call light response times between 30 minutes and 45 minutes: 41~ Number of call light response times between 45 minutes and 1 hour: 34~ Number of call light response times between 1 hour and 1.5 hours: 18~ Number of call light response times between 1.5 hours and 2 hours: 3 (6/3/25 at 6:19 PM: 1 hour and 40 minutes; 6/18/25 at 7:49 AM: 1 hour and 37 minutes; 7/6/25 at 6:56 AM: 1 hour and 41 minutes)~ Number of call light response times greater than 2 hours: 1 (7/6/25 at 4:58 PM: 2 hours and 46 minutes)On 7/9/25 at 2:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R1 was hyper-fixated on thinking R1 had a bowel movement and activated the call light for a courtesy wipe which was on R1's care plan. NH-A indicated staff check and change R1 every 2 hours, however, staff can be in R1's room many times per day. NHA-A indicated R1 activates the call light thinking R1 had a bowel movement. Surveyor informed NHA-A that R1 was told by staff that R1 had to wait until after lunch to be changed and was changed at approximately 12:30 PM. Surveyor observed the change and noted R1 was incontinent of stool. NHA-A indicated NHA-A would look into it and confirmed a resident should not be left sitting in a bowel movement. 2. On 7/9/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, major depressive disorder, aphasia and dysarthria following cerebral infarction, type 2 diabetes mellitus with diabetic chronic kidney disease, anxiety disorder, and hemiplegia/hemiparesis following cerebral infarction affecting the right non-dominant side. R2's MDS assessment, dated 5/3/25, had a BIMS score of 7 out of 15 which indicated R2 had severely impaired cognition. R2 had a Guardian for decision making.A care plan, initiated on 6/16/22, indicated R2 had ADL self-care performance deficits and required the assistance of 1 staff for bed mobility. R2 required the assistance of 2 staff and a full body lift (revised 11/18/24) for transfers. For toileting, R2 required assistance to be checked and changed with AM and HS (evening) cares and per R2's request. The care plan contained interventions to provide peri-care twice daily (BID) and with each incontinent episode and apply barrier cream to protect skin.A care plan, initiated on 6/16/22 and revised on 2/21/24, indicated R2 exhibited behavior symptoms (psychosocial adaptation and/or psychotropic medication use) and used inappropriate language toward staff and others. The care plan also indicated R2 yelled from R2's room and disrupted other residents on the unit. Surveyor noted an intervention was added during the survey on 7/9/25 that indicated R2 no longer used a bell and preferred the call light on at all times and always within reach.A care plan, initiated on 6/16/22 and revised on 10/31/24, indicated R2 had alteration in elimination and functional bladder and bowel incontinence secondary to cerebrovascular accident (CVA) (stroke). The care plan contained interventions, dated 6/16/22, to encourage/assist with check and change, provide peri-care with AM and HS cares and with each incontinent episode, apply barrier cream, and monitor skin integrity with cares. An additional intervention, dated 2/21/24, indicated R2 called out to staff when R2 was incontinent and needed to be changed and staff should answer promptly. A care plan, initiated on 6/21/22, indicated R2 had a seizure disorder.On 7/9/25 at 11:22 AM, Surveyor interviewed R2 who indicated R2's call light did not work. When Surveyor asked R2 to activate the call light, Surveyor heard an audible beeping sound and noted the call light worked. R2 then yelled to staff in the hallway that R2 needed to be changed. R2 also indicated call light response can take a while.On 7/10/25 at 11:51 AM, Surveyor interviewed R2's Guardian ((GD)-F) via phone. GD-F indicated R2's biggest concern was call light response time and indicated R2 leaves the light on because no one comes when it is on. GD-F indicated R2 called GD-F on R2's cell phone in the past 90 days and indicated R2 was sitting in shit and no one was coming. GD-F indicated GD-F tries to contact the facility when R2 calls but has a difficult time getting ahold of anyone, especially in the evening. GD-F indicated when staff do answer, they tell GD-F they are very busy. GD-F also indicated staff walk by R2's room when the call light is on and do not check to see what R2 needs which makes R2 upset and yell as people walk by. GD-F does not think R2 is checked or changed timely due to R1's calls to GD-F when R2 needs to be changed but no one responds. On 7/9/25, Surveyor reviewed R2's call light log for 6/9/25 through 7/9/25 which indicated R2 activated the call light 605 times. Surveyor noted approximately 183 call light response times were greater than 30 minutes which meant approximately 30% of R2's call light response times were greater than 30 minutes. The following call light response times were also noted:~ Call light response times between 30 minutes and 1 hour: 89 ~ Call light response times between 1 and 2 hours: 74 ~ Call light response times between 2 and 3 hours: 14 ~ Call light response times greater than 3 hours: 3 ~ Call light response times greater than 4 hours: 3On 7/9/25 at 2:28 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R2's call light is always on and when staff enter the room they state R2 has no concerns, however, sometimes R2 has a need. DON-B indicated staff gave R2 a bell but R2 was not receptive to using the bell. DON-B indicated after staff respond to the call light, R2 turns the call light back on and gets anxious when staff take the call light out of R2's hands when doing cares. When asked how staff know if R2 has a need if R2's call light is on at all times, DON-B indicated staff check on R2 frequently. On 7/9/25 at 3:02 PM, Surveyor interviewed CNA-D who indicated R2 activates the call light all the time. CNA-D indicated when staff turn off the light and exit the room, R2 activates the call light again. CNA-D indicated R2 does not seem to understand that R2 activates the call light all the time. 3. On 7/9/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, acquired absence of right foot, acquired absence of other left toe(s), and peripheral vascular disease (PVD). R7's MDS assessment, dated 7/1/25, had a BIMS score of 15 out of 15 which indicated R7 had intact cognition. The MDS assessment also indicated R1 required partial to moderate assistance of staff (helper does less than half) for toilet transfers. A care plan, initiated on 6/25/25, indicated R7 was at risk for alteration in skin integrity related to diabetes mellitus type 2 and had foot ulcers to bilateral plantar feet, right with infection, stage 2 pressure injuries to bilateral post/proximal thighs, and a deep tissue injury on the right plantar. A care plan. initiated on 6/26/25, indicated R7 was prescribed intravenous (IV) medication. On 7/9/25 at 11:43 AM, Surveyor interviewed R7 who indicated call light response times can be approximately 30-60 minutes depending on the time of day. R7 indicated R7's IV was beeping that morning and R7 had to wait 30 minutes. R7 spoke with CNA and nursing staff about the long call light response times and was once told staff could not change R7 when R7 was incontinent because R7's IV was running.Surveyor reviewed a grievance, dated 6/27/25, that indicated on the 6/26/25 PM shift, R7 reported that R7 was incontinent of urine and had diarrhea and loose stools numerous times in one brief due to R7's antibiotics. R7 activated the call light, however, 3 CNAs turned the light off. R7 stated it occurred between 6:45 PM and 9:45 PM when 2 nurses entered the room to hang an IV and called a CNA to help clean up R7. The grievance indicated staff were told by a nurse that a resident can not be changed while an IV is running. Staff education was completed.On 7/9/25, Surveyor reviewed R7's call light response log for 6/25/25 through 7/9/25 which indicated R7 used the call light 107 times. Surveyor noted 9 response times were greater than 30 minutes which meant approximately 5% of R7's call light response times were greater than 30 minutes. The following call light response times were also noted:~ On 6/26/25 at 6:48 PM: 1 hour and 4 minutes (related to grievance)~ On 6/26/25 at 8:31 PM: 1 hour and 5 minutes (related to grievance)~ On 6/27/25 at 6:25 AM: 1 hour and 34 minutes~ On 6/27/25 at 10:45 AM: 1 hour and 14 minutes~ 7/1/25 at 7:15 AM: 35 minutes~ 7/6/25 at 10:56 AM: 35 minutes~ 7/6/25 at 8:58 PM: 56 minutes~ 7/8/25 at 8:42 AM: 43 minutes~ 7/9/25 at 7:46 AM: 44 minutes4. On 7/9/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dementia without behavioral disturbance, Parkinson's disease, generalized anxiety disorder, obsessive compulsive disorder (OCD), and weakness. R10's MDS assessment, dated 7/1/25, had a BIMS score of 11 out of 15 which indicated R10 had moderately impaired cognition. A care plan, initiated on 5/24/22 and revised on 1/7/25, indicated R10 had an ADL self-care performance deficit and altered mobility related to dementia, weakness, chronic pain and Parkinson's disease. The care plan contained an intervention, revised on 9/23/24, that indicated R10 required limited assistance of 1 staff for bed mobility and supervision for toileting hygiene. R10 required contact guard assistance (CGA) of 1 staff and a four-wheeled walker in and out of the bathroom. The care plan also contained an intervention to stay in room or close by when R10 is on the commode/toilet. On 5/20/25, a risk versus benefit statement was implemented for self-transfers and indicated R10 transferred with limited assistance of 1 staff with a wheeled walker and gait belt (revised on 2/19/25).A care plan, initiated on 10/31/24 and revised on 5/28/25, indicated R10 had functional bladder and bowel incontinence and a diagnosis of benign prostatic hypertrophy (BPH). The care plan contained interventions, dated 10/31/24, that indicated R10 used disposable briefs, staff should clean R10's peri-area after each incontinence episode, and staff should check R10 when toileting. A care plan, initiated on 5/24/22 and revised on 1/7/25, indicated R10 was at high risk for falls related to Parkinson's disease, neuropathy, and dementia with impaired safety awareness. The care plan contained an intervention, dated 11/5/24, to revise R10's toileting schedule to ensure R10's needs are addressed and to prevent self-transferring. An intervention, dated 6/25/24, indicated staff should check on R10 every 2 hours when in room to help prevent self-transfers.On 7/9/25 at 11:34 AM, Surveyor interviewed R10 who indicated R10 had to wait a long time for staff to answer R10's call light. R10 indicated R10 did not use the call light much because there was no point. R10 stated in two instances R10 waited 1 hour and 1 hour and 20 minutes. R10 indicated one of the times R10 had to use the bathroom and needed assistance. On 7/9/25, Surveyor reviewed R10's call light log for 6/26/25 through 7/9/25 and noted R10 used the call light 52 times. Surveyor noted 14 call light response times were more than 30 minutes which meant approximately 27% of R10's call light response times were greater than 30 minutes. The following call light response times were also noted: ~ On 6/26/25 at 5:49 PM: 58 minutes~ On 6/27/25 at 6:15 PM: 40 minutes~ On 6/28/25 at 5:52 PM: 32 minutes~ On 6/29/25 at 2:56 PM: 54 minutes~ On 6/29/25 at 5:30 PM: 54 minutes~ On 6/30/25 at 6:06 PM: 34 minutes~ On 7/1/25 at 6:10 PM: 37 minutes~ On 7/1/25 at 7:08 PM: 35 minutes~ On 7/2/25 at 6:02 PM: 1 hour and 55 minutes~ On 7/4/25 at 3:23 AM: 31 minutes~ On 7/4/25 at 1:12 PM: 41 minutes~ On 7/4/25 at 7:05 PM: 41 minutes~ On 7/5/25 at 6:32 PM: 2 hours and 20 minutes~ On 7/6/25 at 6:25 PM: 33 minutesOn 7/9/25 at 3:02 PM, Surveyor interviewed CNA-D who indicated staff should answer call lights within 15 minutes, however, it can be difficult to answer lights timely around meal time.On 7/9/25 at 3:15 PM, Surveyor interviewed CNA-E who indicated there are issues answering call lights timely, especially after meals. On 7/9/25 at 2:58 PM, Surveyor interviewed NHA-A who was not aware of a standard call light response time and did not provide an expectation for a reasonable number of minutes it should take to answer a resident's call light. NHA-A verified NHA-A was at the resident council meeting in May when call light response times were discussed. NHA-A stated follow-up was completed but not documented. NHA-A stated NHA-A reminds residents at resident council meetings that if they use their call light during high need times (after meals, getting up, going to bed, shift change), they might have to wait a bit longer. When asked about the grievance investigation related to call light response times, NHA-A indicated the average call light response time was okay, however, some of the audits showed one-offs or that call lights were activated during busy times (after meals, before bed, when nurses were passing medications). NHA-A indicated there was not an investigation or staff education after the audits were completed despite the discovery that call light response times were lengthy. NHA-A indicated call light audits are not run or checked regularly but are completed when a concern is reported. When Surveyor showed NHA-A the call light audits for R1, R2, R7, and R10, NHA-A confirmed there were multiple extensive call light response times that should have been followed-up on.

Based on observation, staff interview, and record review, the facility did not ensure food was prepared and served in a safe and sanitary manner. This practice had the potential to affect 58 of 59 residents residing in the facility. One resident received nutrition via tube feeding. The facility's dishwasher did not reach the minimum wash temperature to prevent the spread of foodborne illness. Staff did not complete appropriate hand hygiene during two meal service observations. Findings include: On 4/28/25 at 8:58 AM, Surveyor interviewed Dietary Manager (DM)-J who stated the facility follows the Wisconsin Food Code. Dishwasher Temperatures: The Wisconsin Food Code documents at 4-204.113 Warewashing Machine, Data Plate Operating Specifications: A warewashing machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine(s) design and operating specifications including the: (A) Temperatures required for washing, rinsing, and sanitizing. The Wisconsin Food Code documents at 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (1) For a stationary rack, single temperature machine, 74 degrees C (165 degrees F); (2) For a stationary rack, dual temperature machine, 66 degrees C (150 degrees F); (3) For a single tank, conveyor, dual temperature machine, 71 degrees C (160 degrees F); or (4) For a multi-tank, conveyor, multi-temperature machine, 66 degrees C (150 degrees F). The facility's undated Dishwashing Procedure states the policy is to ensure consistency in dishwashing methods as well as compliance with temperatures and concentrations of all chemicals used for mechanical warewashing equipment, including hot water sanitizing and chemical sanitizing machines. On 4/29/25 at 1:30 PM, Surveyor observed the dishwashing process with DM-J. Surveyor noted the facility has an American Dish Service model ADC-44 multi-tank conveyor dish machine. Surveyor noted a data plate on the front of the machine listed the following operational requirements for hot water sanitizing temperatures: ~ Final sanitizing rinse minimum temperature: 180 degrees F ~ Pump rinse tank minimum temperature: 160 degrees F ~ Wash tank minimum temperature: 159 degrees F During the observation, Surveyor noted the wash temperatures did not meet the minimum posted temperature. During Surveyor's first observation, the dish machine displayed a temperature of 156 degrees F. During Surveyor's second observation, the dish machine displayed a temperature of 158 degrees F. The temperatures were confirmed by DM-J who sent another rack through the conveyor and included an internal thermometer. The thermometer indicated the internal temperature of the machine reached 156.5 degrees F for that cycle. Surveyor did not observe staff rewash the dishes to ensure the wash temperature reached the minimum requirement. On 4/29/25, Surveyor reviewed the facility's dishwashing temperature log for March 2025 and noted the following wash temperatures: ~ 3/21/25: 154 degrees F ~ 3/24/25: 157 degrees F ~ 3/25/25: The original temperature was crossed out and 150 degrees F was written on the side. ~ 3/26/25: 157 degrees F ~ 3/27/25: 156 degrees F On 4/29/25 at 1:30 PM, Surveyor interviewed DM-J who stated the company that does maintenance on the dish machine indicated if the wash temperature is above 150 degrees F, it is good. DM-J indicated the wash temperature should be at least 160 degrees F. On 4/29/25 at 1:58 PM, Surveyor interviewed Corporate Dietitian (CD)-O who confirmed the data plate on the dish machine indicates a minimum wash temperature of 159 degrees F. Hand Hygiene: The Wisconsin Food Code documents at 3-304.15 Gloves, Use Limitation: If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness 2-301.14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. The facility's Sanitation and Cleaning Schedule policy, dated 8/15/23, indicates: .2. All food service employees must use one of two acceptable sanitary procedures when handling foods: a) Hands are washed using appropriate procedure and food is handled with tongs, deli paper, or other utensils. b) Disposable gloves are used and changed when soiled, torn, or switching tasks. 3. Barehand contact with ready-to-eat food is not permitted by dietary staff preparing or serving food. On 4/28/25 at 11:54 AM, Surveyor observed Dietary Aide (DA)-M don a pair of gloves prior to lunch service. DA-M did not wash hands prior to donning gloves. DA-M plated food with gloved hands and touched scoop handles, drawer handles, and cabinet door handles with gloved hands. Without changing gloves or cleansing hands, DA-M scooped mash potatoes onto a plate and touched the potatoes with a gloved hand. DA-M used the opposite gloved hand to wipe off the potatoes. DA-M then continued serving with visibly soiled gloves. Surveyor also observed DA-M touch ready-to-eat food in bowls with gloved hands and put the food on plates. DA-M continued to touch scoop handles, drawers handles, and cabinet door handles. Surveyor did not observe DA-M change gloves or cleanse hands throughout lunch service. On 4/29/25 at 11:56 AM, Surveyor observed DA-N use hand sanitizer and don gloves prior to lunch service. DA-N completed food holding temperatures and touched the thermometer, sanitizing wipes, and cabinet door handles with gloved hands. During a temperature check, DA-N touched a piece of chicken baked in tomato sauce with a gloved hand when removing the thermometer. Without changing gloves or cleansing hands, DA-N touched cabinet door handles, residents' meal slips, and scratched DA-N's head with visibly soiled gloves. DA-N then removed a chopped grilled cheese sandwich from a bowl and put it on a resident's plate. DA-N did not change gloves or cleanse hands throughout lunch service. On 4/29/25 at 1:46 PM, Surveyor interviewed DM-J who stated staff complete annual hand hygiene training. DM-J confirmed DA-M and DA-N should have changed gloves and completed hand hygiene after touching contaminated surfaces and when their gloves were visibly soiled. DM-J confirmed the facility's policy indicates staff should not touch ready-to-eat food unless using a utensil.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R43 and R107) of 7 sampled residents. R43 was on droplet precautions. On 4/29/25, Maintenance/Transport Employee (MTE)-L was observed programming a remote control in R43's room without a mask, gloves, or eye protection. R107 was on enhanced barrier precautions (EBP) (an infection control strategy that uses gloves and gowns during high-contact resident cares to reduce the spread of multidrug-resistant organisms). On 4/28/25, Assistant Director of Nursing (ADON)-C administered R107's intravenous medication without wearing a gown. Findings include: The facility's Isolation Precautions policy, dated 5/8/24, indicates: Purpose: To establish transmission-based precautions for residents who are suspected or confirmed to have a communicable disease/infection that can be transmitted to others. Procedure: 1. Transmission-based precautions will be used when transmission cannot be reasonably prevented by standard precautions alone. 2. Post clear signage on the door or wall outside the resident's room indicating the type of precautions and required personal protective equipment (PPE) (e.g., gown and gloves). 3. For enhanced barrier precautions (EBP), signage should also clearly indicate the high-contact resident care activities that require the use of gowns and gloves. Droplet Precautions: 1. Implement droplet precautions for residents with suspected or confirmed to be infected with a communicable disease/infection transmitted via droplets generated by sneezing. talking, or during procedures such as suctioning .3. Prior to entering the isolation room, the following steps are required: a. Perform hand-hygiene and apply gloves, gown, and mask .b. While providing direct resident care, remove gloves and wash hands after coming in contact with infectious material. c. Remove gown and gloves and perform hand-hygiene before leaving room (do not use alcohol-based hand gels for isolation due to suspected or confirmed Clostridium difficile). The facility's Enhanced Barrier Precautions (EBP) policy and procedure, dated 3/26/25, indicates: EBP is used in conjunction with standard precautions and expands to donning of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROS) to staffs' hands and clothes. 1. On 4/29/25, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, hemiplegia, diabetes, and chronic kidney disease. R43's Minimum Data Set (MDS) assessment, dated 3/28/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R43 was severely cognitively impaired. The MDS assessment also indicated R43 was dependent on staff for toileting and required substantial maximal assistance with dressing and hygiene. R43 was placed on droplet precautions due to upper respiratory symptoms of congestion and cough as well as malaise and general aches. On 4/22/25, R43 tested positive for rhinovirus. A chest X-ray noted nothing acute. R43 was prescribed Levaquin (an antibiotic medication) 750 milligrams (mg) daily for pneumonia prophylactic. On 4/29/25 at 10:09 AM, Surveyor knocked on R43's door to speak with R43 from the doorway. Surveyor noted Maintenance/Transport Employee (MTE)-L sitting in a chair next to R43. MTE-L was not wearing a mask, gloves, or eye protection and indicated MTE-L was programming R43's remote control. Surveyor proceeded down the hallway and spoke with Registered Nurse (RN)-K who indicated R43 was on droplet precautions and staff should don a mask, gloves, and eye protection before entering R43's room. When Surveyor indicated MTE-L was in R43's room without a mask, gloves, or eye protection, RN-K indicated RN-K would speak with MTE-L right away. On 4/29/25 at 1:50 PM Surveyor interviewed RN-K who verified MTE-L was in R43's room without a mask, gloves, or eye protection. RN-K reminded MTE-L that MTE-L needs to wear a mask, gloves and eye protection if a resident is on droplet precautions. RN-K verified the sign outside R43's room indicated R43 was on droplet precautions and stated what PPE was required before entering R43's room. 2. From 4/28/25 to 4/30/25, Surveyor reviewed R107's medical record. R107 was admitted to the facility on [DATE] and had diagnoses including acute osteomyelitis and sepsis. R107's MDS assessment, dated 4/25/25, had a BIMS score of 15 out of 15 which indicated R107 was not cognitively impaired. R107 had an order to infuse 1 mg of cefepime (an antibiotic medication) intravenously (IV) over 30 minutes via peripherally inserted central catheter (PICC) line (a thin flexible tube that is inserted into a vein in the arm and threaded up into a larger vein in the chest near the heart). On 4/28/25 at 9:18 AM, Surveyor observed an EBP sign outside R107's room and observed ADON-C administer R107's IV antibiotic. Surveyor observed ADON-C wash hands and apply gloves prior to administering the antibiotic. ADON-C did not don a gown in accordance with the facility's EBP policy for high-contact-resident care. On 4/28/25 at 9:35 AM, Surveyor interviewed ADON-C who acknowledged ADON-C should have worn a gown when administering R107's IV antibiotic. ADON-C verified R107 was on EBP and had an EBP sign posted outside R107's room. On 4/30/25 at 1:26 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should wear gowns during high-contact cares for a resident on EBP. DON-B confirmed administering IV medication is considered high-contact resident care.

Based on observation, staff and resident interview, and record review, the facility did not ensure adequate supervision and assistance devices were provided for 1 resident (R) (R33) of 3 sampled residents. R33 had 7 falls in the past 6 months. R33's plan of care indicated R33 required assistance with ambulation and transfers to the bathroom and bed, however, staff allowed R33 to ambulate and transfer independently in R33's room. Findings include: The facility's Care Plan - Baseline and Comprehensive policy, revised 6/20/23, indicates: To ensure each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative .Procedures: .10. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan .13. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met . On 4/28/25, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including dementia, psychotic disturbance, anxiety, frontal lobe and executive function deficit, Parkinson's disease, and spondylosis. R33's Minimum Data Set (MDS) assessment, dated 4/6/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R33 was not cognitively impaired. R33 had a corporate Guardianship for healthcare decisions. R33's plan of care indicated R33 had a self-care performance deficit and altered mobility related to dementia, weakness, chronic pain, and Parkinson's disease. The care plan contained the following interventions: Bed mobility: Limited assist 1 (revised 9/23/24); Toilet use: Supervision with toilet hygiene - caregiver assist of 1 and 4 wheeled walker in/out of bathroom. Stay in room or close by when on commode/toilet (revised 10/8/24); Transfer: Limited assist 1 with wheeled walker and gait belt (revised 2/19/25); and Keep bed in low position (revised 10/8/24). R33's [NAME] (an abbreviated care plan used by nursing staff) contained the same assistance levels as R33's care plan. Surveyor reviewed R33's fall history and noted R33 had 7 unwitnessed falls in the past 6 months. R33 had 3 separate falls on 11/1/24 and also fell on 1/29/25, 2/5/25, 3/13/25, and 4/17/25. On 4/28/25 at 1:02 PM, Surveyor observed R33 ambulate from the bathroom to a chair to a wheelchair in R33's room. Surveyor noted R33's bed was not in a low position. Surveyor interviewed R33 who indicated R33 was independent with transfers, ambulation, and toileting. On 4/29/25 at 10:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who indicated R33 transfers from bed to wheelchair and from wheelchair to wheeled walker to the bathroom, and self-propels a wheelchair to the dining room. LPN-G indicated R33's bed is set at a normal height and R33 calls for assistance when needed. On 4/30/25 at 9:13 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who indicated R33 is independent with toileting and transfers in R33's room, however, staff like to assist R33 because R33 does not clean R33's self properly after toileting. CNA-H indicated R33 should call for assistance but does not. On 4/30/25 at 9:17 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects staff to follow residents' plans of care.

2. On 4/28/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, depression, and psychotic disorder. R13's MDS assessment, dated 2/27/25, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R13 had severely impaired cognition. R13's PASRR Level I Screen was completed on 11/19/24 by the facility. The Level I Screen indicated R13 did not have a major mental disorder and did not receive psychotropic medication to treat symptoms or behaviors of a major mental disorder. As a result of the Level I Screen, a Level II Screen was not completed. R13's physician orders indicated R13 was prescribed the following medications with contributing diagnoses: ~ Lorazepam (an antianxiety medication) 1 mg as needed every two hours for anxiety (beginning 3/14/25) ~ Seroquel (an antipsychotic medication) 25 mg for delusional disorder (from 1/23/25 to 4/4/25) ~ Sertraline (an antidepressant medication) 75 mg daily for depression (beginning 4/17/25) R13's medical record did not contain an updated PASRR Level I or Level II Screen for the initiation of new psychotropic medication or changes in R13's diagnoses. On 4/28/25 at 12:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R13 should have had an updated PASRR Level I Screen and a Level II Screen a due to the changes in R13's medication and diagnoses. Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated to initiate a PASRR Level II Screen when a newly evident mental disorder and/or change in medication was identified for 2 residents (R) (R46 and R13) of 8 sampled residents. R46 and R13 received new diagnoses and orders for psychotropic medication, including an antipsychotic medication. The facility did not update R46 and R13's PASRR Level I Screen and submit for PASRR Level II reevaluation. Findings include: 1. From 4/28/25 to 4/30/25, Surveyor reviewed R46's medical record. R46 was admitted to the facility on [DATE] and had diagnoses including frontotemporal neurocognitive disorder, vascular dementia, delirium, Parkinson's disease, anxiety disorder, and major depressive disorder. R46's Minimum Data Set (MDS) assessment, dated 3/26/25, indicated R46 was rarely to never understood and had severely impaired cognition. R46's PASRR Level I Screen was completed on 1/16/25 by R46's previous skilled nursing facility. The Level I Screen indicated R46 had a diagnosis of a major mental disorder and received Celexa (an antidepressant medication) and Wellbutrin (an antidepressant medication). The Level I Screen also indicated R46 did not have cognitive deficits due to dementia. Based on the information provided on the Level I Screen, R46's previous facility submitted for a PASRR Level II Screen which was completed on 1/17/25. R46's physician orders indicated R46 was prescribed the following medications with contributing diagnoses which were not included on R46's PASRR Level I or Level II Screens: ~ Buspirone (an antianxiety medication) 7.5 milligrams (mg) three times daily for anxiety disorder ~ Divalproex sodium extended release (ER) (an anticonvulsant medication) 250 mg in the AM for mood stabilization ~ Divalproex sodium ER 500 mg at bedtime for mood stabilization ~ Mirtazapine (an antidepressant medication) 7.5 mg at bedtime for appetite stimulant. (The original order date of 3/18/25 had a corresponding diagnosis of mood.) ~ Olanzapine (an antipsychotic medication) 7.5 mg for behaviors R46's medical record did not contain an updated PASRR Level I or Level II Screen for the initiation of new psychotropic medication and changes in R46's diagnoses. On 4/30/25 at 12:18 PM, Surveyor interviewed Social Service Director (SSD)-D who confirmed SSD-D was responsible for completing the PASRR process. SSD-D verified R46 had several medication changes and additions since R46 was admitted to the facility. SSD-D acknowledged R46's PASRR Level I Screen should have been updated and resubmitted for another Level II evaluation.

Based on staff interview and record review, the facility did not notify the State Long-Term Care Ombudsman when 2 residents (R) (R17 and R46) of 6 sampled residents were transferred to the hospital. R17 was transferred to the hospital on [DATE]. The facility did not notify the Ombudsman of R17's hospital transfer. R46 was transferred to the Emergency Department (ED) on 3/19/25 and 3/28/25. The facility did not notify the Ombudsman of R46's ED transfers. Findings include The facility's Admission, Readmission, Bed Hold and Transfer/Discharge Policy, dated 10/12/21, indicates a copy of the transfer/discharge notice must be sent to a representative of the Office of the State Long-Term Care Ombudsman .The facility must update the Office of the State Long-Term Care Ombudsman of any unplanned or emergency transfers or discharges. 1. From 4/28/25 to 4/30/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE]. On 12/24/24, R17 had a change in condition and was transferred to the hospital. R17 returned from the hospital on [DATE]. Surveyor reviewed the facility's list of December 2024 transfers and discharges which was sent to the Ombudsman on 1/16/25 via email. Surveyor noted R17's 12/24/24 hospital transfer was not included on the list. On 4/30/25 at 12:11 PM, Surveyor interviewed Medical Records (MR)-I who confirmed MR-I was responsible for sending monthly reports to the Ombudsman. MR-I confirmed R17's 12/24/24 hospital transfer was not included on the list that MR-I sent to the Ombudsman. MR-I verified R17's 12/24/24 transfer should have been on the list. 2. From 4/28/25 to 4/30/25, Surveyor reviewed R46's medical record. R46 was admitted to the facility on [DATE]. On 3/19/25 and 3/28/25, R46 had a change in condition and was transferred to the ED. R46 returned to the facility on the same days R46 was transferred. Surveyor reviewed the facility's list of March 2025 transfers and discharges which was sent to the Ombudsman on 4/1/25 via email. Surveyor noted R46's 3/19/25 and 3/28/25 transfers were not included on the list. On 4/30/25 at 12:11 PM, Surveyor interviewed MR-I who confirmed R46's 3/19/25 and 3/28/25 ED transfers were not included on the list MR-I sent to the Ombudsman. MR-I indicated MR-I was not aware the Ombudsman needed to be notified of ED transfers.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R47) of 2 sampled residents with a Guardian had protective placement in the facility. R47 had a legal Guardian at the time of admission on [DATE]. The facility did not have evidence of court-ordered protective placement (required when nursing home residency exceeds 90 days). Findings include: State Statute Chapter 55.03(4) indicates court-ordered protective placement is required for any resident admitted to a nursing home who has a legal Guardian and whose nursing home stay exceeds 90 days. Protective placement is reviewed annually (State Statute Chapter 55.18) to determine if placement continues to be the least restrictive and in the best interest of the resident. On 4/28/25, Surveyor reviewed R47's medical record. R47 was admitted to the facility on [DATE] and had diagnoses including traumatic brain injury, restlessness and agitation, anxiety, and mood disorder. R47's Minimum Data Set (MDS) assessment, dated 3/12/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R47 had intact cognition. R47 had court-ordered Michigan Guardian paperwork, dated 6/14/24, for healthcare decisions. R47's medical record did not contain protective placement documentation. On 4/29/25 at 8:28 AM, Surveyor interviewed Social Services Director (SSD)-D who indicated SSD-D notified Aging and Disability Resource Center Staff (ADRCS)-E on 11/18/24 of R47's admission to the facility on [DATE] and the need for protective placement. SSD-D provided Surveyor a copy of the communication. A response from ADRCS-E, dated 11/18/24, indicated ADRCS-E contacted R47's son twice and needed copies of R47's Michigan Guardianship papers (petitions, doctors report, orders, letters of Guardianship) before ADRCS-E could move forward. On 4/29/25 at 8:37 AM, Surveyor interviewed ADRCS-E who indicated an email was sent to the facility on [DATE] requesting assistance in obtaining petitions for Guardianship, an order for Guardianship, a physician's report, and a letter of Guardianship to move forward. The email indicated if the facility did not have the documents the should contact the Register in Probate in Michigan. ADRCS-E indicated ADRCS-E had not received any of the requested documents. ADRCS-E indicated ADRCS-E identified last week that R47 was at a facility in another city in WI prior to admission which would require the protective placement paperwork to be filed in that county. ADRCS-E notified R47's Guardian of the update. On 4/30/25 at 9:50 AM, Surveyor interviewed SSD-D who indicated SSD-D left a message on 4/30/25 with the county in which R47 previously resided to forward R47's protective placement paperwork. SSD-D also left a message for ADRCS-E regarding SSD-D's request. SSD-D indicated R47's Guardian frequently visited the facility and had developed a good rapport with SSD-D. On 4/30/25 at 1:42 PM, Surveyor interviewed Regional Director of Clinical Services (RDCS)-F who indicated an effort was made to obtain protective placement, however, the facility could have pursued it further.

Based on observation, staff interview, and record review, the facility did not provide the appropriate care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R1) of 5 sampled residents. On 12/19/24, R1 developed what was initially classified as an arterial wound on the left foot (hallux) by former Assistant Director of Nursing (ADON)-C, who is not wound care certified. Pressure relieving interventions for R1's feet were not implemented, and the wound was not formally assessed until 1/2/25. R1 was hospitalized from 1/11/25 to 1/13/25 for pneumonia and a urinary tract infection (UTI). On 1/13/25 at the hospital, R1's left foot wound was classified as an unstageable deep tissue injury. Pressure-relieving interventions (heel boots) for R1's feet were not implemented or added to R1's plan of care until 1/23/25. On 1/29/25, R1's wound was classified as a stage 4 pressure injury and the treatment order was changed. Staff did not transcribe the new treatment order correctly and did not complete wound care as ordered by R1's physician. In addition, during multiple observations on 2/10/25, R1 was observed in a recliner without heel boots. The failure to properly assess and monitor a new wound, implement pressure-relieving interventions, and transcribe a treatment order correctly led to a finding of immediate jeopardy that began on 1/29/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 2/24/25 at 1:45 PM. The immediate jeopardy was removed on 2/24/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Pressure Injury Prevention and Wound Care Management Policy, revised 3/4/24, indicates: The facility will ensure that a resident who is admitted without a pressure injury does not develop a pressure injury unless clinically unavoidable and that a resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers .Skin injuries (pressure and non-pressure) should be assessed weekly by the wound nurse or designee. Weekly documentation will include pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissue, and a description of any drainage, eschar, necrosis, odor, tunneling or undermining. Documentation of wound characteristics will be completed using the Skin and Wound Assessment form. Wound and skin care interventions will be monitored and evaluated for effectiveness. On 2/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including peripheral vascular disease, type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, and congestive heart failure. R1's most recent Minimum Data Set (MDS) assessment, dated 1/27/25, noted a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had intact cognition. R1 made R1's own healthcare decisions. R1's comprehensive care plan, developed on 11/5/24, indicated R1 was at risk for alteration in skin integrity related to weakness, low body mass index (BMI)/weight loss, peripheral vascular disease, diabetes, anemia, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and declining health status. Interventions for a pressure-relieving air mattress on bed and a pressure-relieving cushion for wheelchair were initiated on 11/5/24. Surveyor reviewed R1's progress notes, weekly skin assessments, and wound assessments for December 2024 to February 2025 and noted the following: ~ A nursing progress note, dated 12/19/24, indicated ADON-C identified a skin concern for R1 and noted a small black dot with surrounding redness on R1's left medial foot. R1 was prescribed antibiotics for cellulitis. ADON-C (who was not wound care certified) classified the wound as arterial. There were no documented wound assessments until two weeks later. ~ A Skin and Wound Evaluation, dated 1/2/25, indicated R1 had an in-house acquired left medial (arterial) foot wound that measured 2.8 centimeters (cm) x 2.3 cm x 1.6 cm that was present for two weeks and was healable. Nurse Practitioner (NP)-D determined the wound was arterial in nature. Nursing updated R1's care plan, and interventions to turn and reposition every two hours and monitor weights per facility policy were initiated on 1/2/25. ~ A Skin and Wound Evaluation, dated 1/7/25, indicated R1 had a left medial (arterial) foot wound that measured 3.3 cm x 2.4 cm x 1.8 cm and was healable. The wound was noted to be stable despite its increase in size. ~ From 1/11/25 to 1/13/25, R1 was hospitalized for pneumonia and a UTI. R1's left medial foot wound was assessed at the hospital on 1/13/25 and classified as an unstageable deep tissue injury (DTI). ~ A Skin and Wound Evaluation, dated 1/14/25, indicated R1 had a left medial (arterial) foot wound that measured 3.2 cm x 2.6 cm x 1.6 cm. The wound bed was pink/red and R1 experienced intermittent pain with wound cleansing. Medical Doctor (MD)-E was notified and ordered a new treatment. ~ A Skin and Wound Evaluation, dated 1/23/25, indicated R1 had an unstageable left medial (pressure) foot wound that measured 2.9 cm x 2.4 cm x 1.6 cm. The treatment was adjusted R1's care plan was revised on 1/23/25 and indicated R1 had a pressure injury on the left medial foot related to impaired mobility and functional ability. An intervention to have heel boots on at all times (may come off for transfers) was added on 1/23/25. ~ A Skin and Wound Evaluation dated 1/29/25, indicated R1 had an unstageable left medial (pressure) foot wound that measured 1.9 cm x 2.1 cm x 1.1 cm and contained 20% slough and 80% eschar (dead tissue). ~ A Wound Clinic Visit note, dated 1/29/25, indicated R1 had a stage 4 pressure injury on the left foot that measured 2.1 cm x 1.1 cm x 0.1 cm. Surgical excisional debridement removed 2.31 cm of devitalized tissue and necrotic muscle tissue. (The post-debridement assessment of the previously unstageable necrotic wound revealed underlying deep tissue at the muscle/fascia level which had been obscured by necrosis prior to that point.) The note indicated the wound was then classified as a stage 4 pressure injury. R1's dressing order was changed to apply Leptospermum honey and a gauze island dressing to be changed daily. ~ A Skin and Wound Evaluation, dated 2/5/25, indicated R1 had a stage 4 left medial (pressure) foot wound that measured 1.6 cm x 2.1 cm x 1 cm and had light serosanguineous (blood-tinged) drainage ~ A Wound Clinic Visit note, dated 2/5/25, indicated R1 had a stage 4 pressure injury on the left foot that measured 2.1 cm x 1.0 cm x 0.1 cm and contained light serosanguineous drainage. Surgical excisional debridement removed additional necrotic muscle tissue. R1's treatment was continued from the previous wound clinic visit. Surveyor reviewed R1's treatment administration records (TARs) for November 2024 to February 2025 and noted the following: ~ From 11/1/24 to 1/12/25, R1 had an order for diabetic foot checks daily and to notify the provider of any concerns. Diabetic foot checks were documented as completed with no concerns identified. ~ From 1/14/25 to 1/23/25, R1 had an order to apply Iodoflex to the left foot to aide in demarcation of eschar tissue followed by a foam dressing every 3 days and as needed. Every day shift every 3 day(s) for wound care and as needed. ~ From 1/23/25 to 1/29/25, R1 had an order to apply Medihoney to the left medial foot wound, apply skin prep to the peri-wound, and cover with a foam border. Every day shift every other day for wound care and as needed. ~ From 1/30/25 to the present, R1's TAR indicated to apply Medihoney to the left medial foot wound, apply skin prep to the peri-wound, and cover with a gauze island. Daily. Every day shift every other day for wound care. (Note: R1's TAR indicated the treatment was being completed every other day rather than daily as ordered by the wound clinic on 1/29/25.) On 2/10/25 at 9:43 AM, Surveyor observed R1 in a recliner without heel boots. Surveyor observed heel boots in the corner of R1's room. Surveyor interviewed R1 who stated R1 wore the heel boots at times and had no problem wearing them when offered. On 2/10/25 at 10:45 AM and 1:12 PM, Surveyor observed R1 in a recliner without heel boots. On 2/10/25 at 1:24 PM, Surveyor interviewed NHA-A regarding the assessment and treatment of R1's pressure injury. NHA-A stated ADON-C classified R1's left medial foot wound as arterial on 12/19/24. NHA-A verified ADON-C was not wound care certified. NHA-A also verified there were no documented wound assessments until 1/2/25 and no pressure-relieving interventions for R1's feet until 1/23/25. NHA-A stated when R1 came back from the hospital on 1/13/25, R1's left medial foot wound was re-classified as a pressure injury. NHA-A stated the facility identified deficiencies and initiated a past non-compliance plan on 1/20/25. NHA-A stated the facility completed skin sweeps for all residents and was in the process of completing audits to ensure wounds were identified and assessed and treatments were being completed as ordered. Director of Nursing (DON)-B verified R1's wound treatment was currently not being completed as ordered due to a transcription error. DON-B also indicated R1 was compliant with wearing heel boots. The failure to correctly identify, assess, monitor, and implement appropriate interventions for a resident at risk for pressure injuries led to serious harm for R1 which created a finding of immediate jeopardy. The facility removed the jeopardy on 2/24/25 when it completed the following: 1. Educated staff on the Pressure Injury Prevention and Wound Care Management policy, specifically related to physician orders, documentation, treatment completion, implementation of care plan interventions, and how to access the Kardex (an abbreviated care plan used by nursing staff). 2. Conducted a skin sweep of all residents to ensure there were no new areas of skin alteration. 3. Conducted a chart audit of all residents with pressure injuries to ensure accuracy of physician orders, treatments were being completed, and care plan interventions were appropriate and effective. 4. Implemented a system where a second licensed staff is needed to confirm physician orders for accuracy. 5. Implemented skin and wound audits.

Based on staff interview and record review, the facility did not ensure adequate supervision was provided for 1 Resident (R) (R1) of 3 residents reviewed for suicidal ideation. On 6/12/24, R1 went to the Emergency Department (ED) for suicidal ideation. An ED note instructed the facility to continue 1:1 supervision for R1, however, R1 returned to the facility without adequate supervision in place and no documented 1:1 supervision. On 6/13/24 at approximately 6:30 AM, R1 ran into the dining room and sat down near Certified Nursing Assistant (CNA)-G who left the dining room a short time later to assist other residents. R1 crawled out an open second story window without a screen, walked along a narrow ledge that was approximately 18 inches wide to a roof landing, and stood on the far ledge of the landing with R1's arms outstretched. R1 stated that R1 wanted to die. Registered Nurse (RN)-I went out the window, pulled R1 away from the ledge of the landing, walked R1 back along the same narrow ledge, and assisted R1 back through the window and into the facility. The facility's failure to supervise a resident who expressed suicidal ideation, experienced hallucinations, and recently returned from the hospital with a recommendation for 1:1 supervision created a reasonable likelihood for serious harm which lead to a finding of immediate jeopardy that began on 6/13/24. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 7/2/24 at 12:00 PM. The immediate jeopardy was removed on 7/2/24, however, the deficient practice continues at a scope/severity level D (potential for more than minmal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Responding to Intent of Self-Harm or Suicide Threat policy, revised 3/17/23, states that any staff member who becomes aware of a resident's intent to self harm, including but not limited to suicidal ideation, suicidal attempt and/or parasuicidal behaviors/self-directed violence, is required to report the behavior immediately or as soon as possible given the situation. Staff may be requested to provide routine checks as directed by the Nursing Home Administrator (NHA) and/or Director of Nursing (DON) or as otherwise ordered by the physician. The checks are to be documented in the medical record. The routine checks are to continue until the designated staff or psychiatrist deems the checks no longer necessary. Continued documentation must be kept ongoing. Said documentation should include all plans, goals, interventions, and care plan updates when applicable. Always document efforts, situation, observations, dates and times, location, witnesses, staff members present, outcomes, who was contacted and who made the contact, as well as future plans for safety. On 7/1/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, vascular dementia with mood disturbance, schizoaffective disorder, anxiety, schizophrenia, insomnia, depression, and chronic pain. R1's most recent Minimum Data Set (MDS) assessment, dated 5/20/24, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R1 had severe cognitive impairment. R1 was not interviewed for the Patient Health Questionnaire (PHQ-9) (an assessment tool used to assess the severity of depression) and the staff assessment was also not completed. The MDS also indicated R1 was independent with ambulation. R1's care plan, revised 2/26/24, indicated R1 received specialized psychiatric services for schizoaffective disorder and schizophrenia and exhibited behaviors such as disrobing, verbal aggression, refusing cares/medication, and wandering. R1's medical record contained the following information: ~ A nursing note, dated 2/6/24 at 9:49 AM, indicated R1 repeatedly stated, I'm a bad person. I made a lot of mistakes. I don't like myself. I don't want to live. ~ A nursing note, dated 6/3/24 at 10:59 PM, indicated R1 experienced a mental decline over the last 2 weeks, was unwilling to take medication, was more melancholy, talked less, was more apprehensive, and had a sadder look on R1's face. ~ A nursing note, dated 6/8/24 at 10:10 AM, indicated R1 sobbed loudly in R1's room and stated R1's dead baby was in Heaven and everyone else was going straight to Hell. R1 spoke about R1's self in the third person and preferred not to be called R1's name. The name R1 chose to call R1's self changed frequently. R1 also spoke and looked to R1's left with nobody there. The writer crushed medication in pudding and convinced R1 to take the medication. R1 thought writer was trying to poison R1. ~ A Psych Services Visit note, dated 6/10/24, indicated R1 reported suffering every day but no suicidal ideation. ~ A nursing note, dated 6/11/24 at 11:30 AM, indicated R1 sang Oh God please send me to Hell at breakfast. R1 then screamed, walked swiftly to R1's bedroom without R1's walker, and slammed the door. R1 also tried to elope out the west exit door. R1 cried and told staff R1 wanted to leave the city so God could take R1 to Heaven and end R1's suffering. ~ A nursing note, dated 6/11/24 at 10:19 PM, indicated R1 was calm at the beginning of the shift but refused medication and then showed signs of agitation. Staff attempted to meet R1's needs and redirect and calm R1. At approximately 8:30 PM, R1 deteriorated to the point where R1 was yelling and screaming. R1 resisted redirection and attempts to calm, made statements that R1 wished R1 was dead, and put R1's finger in a socket. R1 was immediately placed on direct 1:1 observation to monitor and provide for R1's safety. Director of Nursing (DON)-B and Psych Services were notified. Staff attempted to contact Crisis Services with no response. The on-call physician ordered to R1 be sent to the ED for evaluation and treatment. ~ An ED note, dated 6/11/24, indicated R1 presented to the ED for psychiatric evaluation. Per Emergency Medical Services (EMS), R1 experienced suicidal ideation and stated I want to die several times. R1 stated R1 had a lot of physical and emotional pain which is why R1 wanted to die. R1 was not admitted to the hospital due to an activated guardianship and was discharged back to the facility. The note indicated facility staff should call Psych in the morning and continue 1:1 nursing. ~ A nursing note, dated 6/12/24 at 2:29 AM, indicated R1 returned to the facility at 2:00 AM. R1 was stable and calm but started crying and had hallucinations. R1 rested in bed with direct observation of staff at all times. ~ A nursing note, dated 6/12/24 at 6:46 AM, indicated R1 was tearful during the night and stated R1 did not want to live anymore. The writer and a CNA took turns sitting, talking, and praying with R1. ~ A Psych Services Visit note, dated 6/12/24, indicated R1 was acutely worsening/declining. Staff reported during the night (NOC) shift (10:00 PM - 6:00 AM) that R1 threw R1's self against a wall, acted out, was violent, and yelled. R1's Seroquel was restarted at 25 mg (milligrams) BID (twice daily.) ~ A nursing note, dated 6/13/24 at 7:15 AM, indicated at approximately 6:30 AM, R1 was sitting in the dining room with a CNA. R1 became agitated and displayed self-harming behavior. The writer went to the dining room toward R1 and instructed the CNA to get the charge nurse. The charge nurse immediately assisted R1 to safety and the writer notified management. The writer spoke to the Assistant Director of Nursing (ADON) and was advised to call 911. EMS and a police officer arrived at 7:00 AM. At 7:15 AM, R1 left with EMS to the hospital. The writer updated R1's guardian on R1's suicidal ideation and hospital transfer. ~ An ED note, dated 6/13/24, indicated R1 presented to the ED with altered mental status and suicidal ideation. R1 discharged from the ED at approximately 10:19 AM. ~ A Threats to Harm Self Summary, dated 6/13/24 at 5:17 PM, indicated Behavioral Consulting Services (BCS) followed R1 who recently had a gradual dose reduction (GDR) of Seroquel (an antipsychotic medication) which was decreased and ultimately discontinued. R1 did not tolerate the GDR and Seroquel was restarted last evening. R1 stated R1 wanted to die and end R1's suffering. R1 sang to God asked God to take R1 to Heaven. R1 had a clear plan to jump off a ledge/out the window. The following interventions were placed: 1:1 scheduled; Cords/call light removed from R1's room; Lock on bathroom door removed; Plastic utensils to be used with all meals; Window affixed not to open greater than 4-6 inches; Outlet covers on outlets; Shoelaces removed. ~ A nursing note, dated 6/14/24 at 3:22 AM indicated R1 slept for a short time at the beginning of shift but was awake, agitated, and spoke about wanting to die. Staff were at R1's side to reassure R1 and keep R1 safe. ~ A nursing note, dated 6/14/24 at 12:38 PM, indicated R1 stated to a Med Tech, I don't want to be alive anymore. The Med Tech alerted a nurse right away. ~ A nursing note, dated 6/15/24 at 1:42 AM, indicated R1 continued on 1:1 supervision. R1 was agitated at the start of the shift and made frequent comments that R1 wanted to die. R1 refused medication. ~ A nursing note, dated 6/15/24 at 10:21 PM, indicated R1 was occasionally calm, generally anxious, often agitated, and sometimes stated R1 wished R1 could leave R1's body and go to Heaven. Approximately every 2 hours, R1 emitted a maximum volume scream that lasted 1-2 minutes. R1 was angry, grabbed at staff, and was hard to redirect. ~ A Psych Services Visit note, dated 6/17/24, indicated R1 climbed out a second story window last week with the intent to jump to R1's death. R1 continued to express a desire to end R1's life. R1 reported feeling possessed and experienced several delusions/hallucinations during the visit. Suicidal ideation was noted with 1:1 status as an intervention. ~ A nursing note, dated 6/20/24 at 10:20 PM, indicated R1 refused medication and was verbally and physically aggressive toward staff. ~ A nursing note, dated 6/24/24 at 1:19 PM, indicated R1 wept and screamed from R1's room to the lounge. R1 sat in a recliner in the lounge, was visibly upset, and spoke non-sensibly. R1 stated R1 wanted R1's hair short and begged the writer to cut R1's hair off. When the writer tried to explain to R1 that a professional should cut R1's hair, R1 screamed, hit R1's self in the head, and asked, Why can't I cut my hair off? R1 got out of a recliner, screamed, and walked at a fast pace down the hallway. ~ A Psych Services Visit note, dated 6/24/24, indicated R1 experienced hallucinations, was on 1:1 status, and continued to state that R1 wanted to die. The note also indicated R1 ran through the hallway and went in empty resident rooms. ~ A nursing note, dated 6/24/24 at 6:07 PM, indicated R1 pulled out a small chunk of hair. The writer called the Crisis line. Since R1 had no injury, staff were told to continue 1:1 supervision and call 911 if R1 injured R1's self. ~ A nursing note, dated 6/30/24 at 10:13 AM, indicated R1 continued on 1:1 supervision with increased confusion, agitation, psychosis, and increased aggression. On the previous shift, R1 bit a caregiver and attempted to go after 2 residents. On 7/1/24 at 10:56 A.M., Surveyor interviewed CNA-G regarding R1's incident on 6/13/24. CNA-G stated CNA-G was not told anything in morning report and did not see anything in R1's care plan that indicated R1 was on 1:1 direct supervision. CNA-G stated CNA-G had been in the dining room on the morning of 6/13/24 when R1 ran into the dining room and sat down. CNA-G verified there were no other staff or residents in the dining room at the time. CNA-G stated CNA-G left the dining room to assist other residents and saw Licensed Practical Nurse (LPN)-H and LPN-K prepare medications at the carts just outside the dining room and within eyesight of R1. CNA-G stated CNA-G was approximately 1 or 2 resident rooms away when CNA-G head staff yell for assistance. CNA-G also reported that during a recent 1:1 assignment on the morning of 6/30/24, CNA-G observed R1 enter an empty resident room with no safety precautions in place (i.e., removal of phone cords/call lights, etc.) CNA-G stated CNA-G waited outside the room and heard R1 rummage around/move something. CNA-G looked in the room and observed R1 attempt to slide a chair into the hallway. CNA-G stated CNA-D did not follow R1 into the empty room so R1 would not get agitated. On 7/1/24 at 1:01 PM, Surveyor interviewed LPN-H regarding R1's incident on 6/13/24. LPN-H stated LPN-H was told that R1 went to the ED during the NOC shift but was not told that R1 was on 1:1 supervision. LPN-H stated LPN-H was only told to keep an eye on R1. When asked what keep an eye on R1 meant, LPN-H stated R1 should be kept within eyesight but verified that did not happen due to lack of staff and no direct assignments. LPN-H stated LPN-H was preparing medication at the medication cart outside the dining room and saw R1 go into the dining room and sit down. LPN-H then saw CNA-G leave the dining room to assist other residents. While LPN-H looked at a computer and in the medication cart, R1 got up and started climbing out the second story window in the dining room. LPN-H verified that LPN-H looked away from R1 to prepare medication for a resident. LPN-H stated by the time LPN-H got across the dining room to the open window, R1 had climbed out onto the ledge and was moving toward the rooftop. LPN-H got RN-I and other staff to assist and called out the window for R1 to come back inside. LPN-H stated RN-I climbed out the window and walked along the ledge to the roof to get R1 to safety. LPN-H verified LPN-H had been assigned to R1's 1:1 supervision several times since the incident and had not been provided education regarding R1's supervision/suicidal ideation. On 7/2/24, Surveyor reviewed staff schedules from 6/11/24 through 7/2/24 and noted there were no staff assigned to be 1:1 with R1 until 6/13/24 at 11:30 AM. On 7/1/24 at 2:58 PM, Surveyor interviewed NHA-A and Regional Operations Manager (ROM)-L regarding R1's supervision. NHA-A and ROM-L verified R1 was not on documented/scheduled 1:1 supervision until R1 returned from the ED on 6/13/24 at approximately 10:30 AM. NHA-A stated staff were assigned to R1's 1:1 supervision and were to keep R1 in eyesight at all times, remain side-by-side with R1 when out of R1's room, and document in R1's medical record on an observation flow sheet. On 7/1/24, Surveyor observed the second floor dining room. Per staff interview, R1 climbed out the second window from the right. Surveyor noted the second window from the right did not have a screen and was bolted shut and unable to be opened. The window was approximately 18 inches high and opened downward at an approximate 45 degree angle. The ledge outside the window was approximately 18 inches wide and covered with aluminum siding. The ledge extended approximately 25 feet to the right onto a rooftop landing covered with gravel. There was a cement sidewalk below. Per staff interview, R1 went to the far ledge which was approximately 1.5 stories high with grass below and stood on the ledge with intent to jump. On 7/1/24 at 3:01 PM, Surveyor requested the facility's investigation for the incident on 6/13/24. The facility's incident report indicated staff observed R1 climb out the second floor dining room window and walk on a ledge toward a second landing while stating R1 wanted to die and end R1's suffering. The report indicated R1 had a recent failed GDR of Seroquel and the medication had been resumed on 6/12/24. The investigation included staff statements from RN-I, LPN-K, and CNA-J. NHA-A verified there were no written statements from LPN-H or CNA-G in the investigation file. ~ RN-I's statement indicated RN-I had come to work at approximately 6:30 AM and was working on the third floor. CNA-G came to the nurses' station and stated R1 had gone onto the roof. RN-I climbed out the open dining room window and walked along the ledge to the rooftop landing. RN-I hugged R1 from behind and pulled R1 back from the ledge of the landing. RN-I walked back along the ledge and went back through the open window with R1. RN-I assured that staff were with R1 before RN-I left to notify administration. ~ LPN-K's statement indicated LPN-K and LPN-H were preparing AM medication at medication carts just outside the dining room. LPN-K verified that after CNA-G walked away from R1, LPN-H observed R1 dart to an open window without a screen and climb out. LPN-K then heard LPN-H scream and ran to see what happened. LPN-K observed R1 outside the second floor window and observed RN-I go out the window and guide R1 back inside. LPN-K conducted a head-to-toe assessment of R1 with no injuries noted. LPN-K stated R1 returned to the facility from the ED at approximately 10:30 AM and LPN-K provided 1:1 supervision. ~ CNA-J's statement indicated shortly after CNA-J arrived at 6:00 AM, CNA-J observed R1 walk around the hallways/common areas while crying. CNA-J's statement indicated CNA-J was giving another resident a bath when R1 climbed out the window. On 7/1/24, Surveyor reviewed the facility's staff education: ~ On 6/13/24, the facility initiated education regarding notification of changes to [NAME] of Attorney (POAs)/administration/police/Medical Doctors (MDs)/etc., care plan revisions, and accidents/supervision. Administrative staff conducted a walk-through to ensure all windows were adjusted to not open more than 6 inches, including all common areas and resident rooms. All residents were reviewed for psychosocial behavior and suicidal ideation and their care plans were updated as needed. An audit tool was initiated to monitor compliance with notifications and revision of care plans related to threats of self harm and incident reporting. Audits were scheduled weekly x 4, bi-weekly x 2, and monthly x 1 to ensure compliance. ~ On 6/21/24, the facility initiated education regarding R1's care plan updates and 1:1 supervision expectations such as filling out the log and walking with R1 when out of R1's room. At the time of the survey, the facility had educated 34 of their 74 regular staff (~46% of staff). A comparison of the facility's schedules (including 1:1 supervision assignments) with the staff training revealed that at least 13 staff members who were assigned to R1's 1:1 supervision between 6/21/24 and 7/1/24 had not been educated. On 7/1/24, Surveyor reviewed the facility's Observation Flow Sheets for R1 and noted the log did not begin until 6/13/24 at 3:00 PM which was approximately four and a half hours after R1 returned from the ED. On 6/17/24 from 6:15 PM to 10:15 PM, the observation log indicated R1's location, but did not include initials for the staff member responsible for R1's 1:1 supervision. The failure to supervise a resident who had suicidal ideation, experienced hallucinations, and recently returned from the hospital, created a reasonable likelihood for serious harm which led to a finding of Immediate Jeopardy. The facility removed the jeopardy on 7/1/24 when it had completed the following: 1. Maintained 1:1 supervision for R1. 2. Educated staff immediately or before their next scheduled shift on the requirements of 1:1 supervision, checking the schedule to determine who is assigned to 1:1 supervision, and referencing residents' care plans to see which residents require 1:1 supervision. 3. Conducted ongoing 1:1 shift audits to ensure adequate and safe supervision was provided. 4. Conducted ongoing staff interviews to ensure 1:1 supervision competency.

Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent and/or promote healing for 2 Residents (R) (R32 and R18) of 4 residents reviewed for pressure injuries. R32 had an area of moisture-associated skin damage (MASD) that was identified on 12/18/23. R32 did not have a documented treatment for the area until 1/13/24 and did not see a wound doctor until 1/24/24. The area deteriorated to an unstageable pressure injury that became infected. The facility did not contact R32's physician when the wound deteriorated and R32's care plan was not updated until 1/24/24. In addition, on 2/28/24, Surveyor observed R32 sitting on a sling in R32's wheelchair. R18 was admitted to the facility with pressure injuries on the left buttock and left heel. R18's Treatment Administration Record (TAR) indicated R18's treatments were not consistently completed. In addition, R18's skin integrity care plan contained an intervention that was not implemented. Findings include: The facility's Pressure Injury Prevention and Wound Care Management policy, with a review date of 2/24/23, indicates: It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers .Risk Identification and Assessment: 7. Skin impairments, including pressure injuries, non-pressure wounds .should be assessed and documented weekly by the Wound Nurse, or designee, using PCC (Point Click Care) Weekly Wound Assessment. 9. Daily, the clinicians responsible for caring for the resident will assess the status of the dressing if present, (intact, soiled, leaking) and evaluate for complications such as infection and/or uncontrolled pain. 12. Wound and skin care interventions will be monitored for effectiveness. Care plans will include specific measurable goals and interventions. The care plan will be reviewed and revised at least quarterly, or with significant change in condition Prevention and Treatment Guidelines: The skin care program will be utilized following the guidelines of the Agency for Healthcare Research and Quality (AHRQ), the National Pressure Ulcer/Injuries Advisory Panel (NPIAP) and current standards of clinical practice .3. Wounds will be treated based on the etiology of the wound .9. Nursing staff should update the attending physician immediately of wounds that have developed complications and/or not healing as anticipated. The attending physician will also be updated upon assessment if a wound has not improved in 2 weeks. 1. R32 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the right buttock, unstageable, neuromuscular dysfunction of the bladder, aphasia following cerebral infarction, obesity, paraplegia (paralysis on one side of the body), and lumbar spina bifida (a birth defect in which the spinal cord fails to develop properly) with hydrocephalus (a build-up of fluid in the cavities of the brain). R32's Minimum Data Set (MDS) assessment, dated 1/30/24, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R32 had intact cognition. Between 2/26/24 and 2/28/24, Surveyor reviewed R32's medical record and noted the following care plans: ~Alteration in skin integrity related to decreased mobility, incontinence, and history of skin breakdown (initiated 5/17/23). Interventions included: Reposition every 2 hours or as needed; Heel suspension boots while in bed; Manage clinical conditions and contributing factors to decrease risk of skin breakdown; Use a pressure relieving cushion for wheelchair; Use A&D ointment, BAZA, or other skin barrier cream on skin as needed; Keep skin clean and dry. ~Alteration in elimination related to indwelling Foley and bowel incontinence (initiated 5/17/23). Interventions included: Apply barrier cream to peri area after each incontinent episode; Check and change as needed due to incontinence, incontinent of bowel. ~Infection: (R32) is on an antibiotic for wound infection multiple bacteria (initiated 2/11/24). Interventions included: Antibiotics per Medical Doctor (MD) order; Isolation precautions: Contact precautions; Communicate (R32's) status and precautions to all care providers; Monitor infected site daily and report changes to provider as applicable; Notify MD/Nurse Practitioner (NP) with any change in condition; Observe color and consistency of urine and report changes to nurse. ~Nutritional status related to spina bifida, paraplegia, neurogenic bowel, constipation, pressure ulcer of sacrum, obesity, hypertension, aphasia, dysphasia, and history of UTI (urinary tract infection) (initiated 5/17/23). Interventions included: Double protein portions; Provide supplements with med pass as ordered; Document and monitor acceptance. ~A resolved care plan in R32's medical record indicated R32 was admitted with a stage 4 pressure injury on the sacrum (initiated 6/7/23). The care plan was resolved on 10/23/23 when R32's pressure injury healed. ~Pressure Ulcer (unstageable) on the right buttocks related to decreased sensory perception, impaired mobility and functional ability, and paraplegia or quadriplegia (initiated 1/24/24). Interventions included: Monitor air mattress and ensure mattress settings are at manufacturer recommendations; Turn and reposition at least every 2 hours and on a schedule that is specific to routine and tolerance; Position body with pillows/support devices, and protect bony prominences; Foley catheter to prevent contamination of wound. Between 2/26/24 and 2/28/24, Surveyor reviewed R32's orders prior to 12/18/23 (when the area of MASD was discovered) and noted the following: ~An intervention for an air mattress due to pressure sore and limited mobility every shift for wound was in place per R32's TAR prior to the discovery of the area of MASD on R32's gluteal fold on 12/18/23. ~An order for Pro-Stat AWC 30 cc (cubic centimeters) 2 times daily for wound healing was in place per R32's TAR prior to the discovery of the area of MASD on R32's gluteal fold on 12/18/23. Between 2/26/24 and 2/28/24, Surveyor reviewed R32's medical record and noted the following: ~A progress note, dated 12/18/23 at 3:35 PM, indicated: New open area to right buttock. Appears to be a result of shearing. Calling (MD-K) to update. Left voicemail to call back. ~A progress note, dated 12/18/23 at 3:40 PM, indicated: Cleansed and applied Mepilex to right buttock until MD-K calls back. ~A fax in R32's chart, dated 12/18/23, indicated: New areas of concern: .2. Right buttock: new open area looks like shearing. Did attempt to call related to both alterations since we could not contact you. Area cleansed and Mepilex in place. Please review and advise .Physician Response: 3rd floor call me to discuss tonight (MD-K). A note at the bottom indicated: Spoke with MD-K. MD-L updated. ~A progress note, dated 12/18/23 at 10:08 PM, indicated: Spoke with (MD-K). Writer was under the impression (MD-K) was on call, but MD-K sent email to MD-L regarding faxed updates. ~A weekly wound assessment, dated 12/25/23, indicated R32 had MASD related to incontinence-associated dermatitis (IAD) to the right gluteal fold that measured 1.9 cm (centimeters) x 3.4 cm. The treatment section was not filled out. ~A progress note, dated 12/29/23 at 1:57 PM, indicated: Advance Practice Nurse Practitioner (APNP)-J saw (R32). Refer to wound care for open area to right buttocks. ~On 12/29/23, APNP-J responded to the fax sent on 12/18/23 related to R32's open area and indicated APNP-J would refer R32 to wound care. ~A fax sent to MD-L, dated 12/31/23, indicated: Also note wound to right buttock .applying Mepilex at this time. Wound care to assess .Please advise at next facility visit. Physician response on 1/2/4: Can (R32) be seen by wound MD? A note on the fax indicated: Copy wound MD. ~A progress note, dated 1/2/24 at 3:03 PM, indicated R32 would be seen by the wound MD. ~A weekly wound assessment, dated 1/8/24, indicated R32 had MASD on the right gluteal fold related to IAD that measured 4 cm x 2.8 cm. The assessment indicated the wound contained moderate serous exudate (a type of drainage that appears as clear or pale yellow, thin, and watery plasma. During the inflammatory stage, serous is a regular part of healing, and small amounts are considered normal.) and no evidence of infection. The edges of the wound were attached and the surrounding tissue was fragile. The treatment section indicated the dressing was intact. No other treatment sections were filled out. A note indicated: New wound. Will be assessed by wound MD on next round. The wound was marked as deteriorating. ~A fax to MD-L, dated 1/13/24, indicated: Deep tissue wound right sacral buttocks. Can we cleanse with normal saline (NS) or soap water? Apply foam dressing daily and PRN (as needed). On 1/13/24, MD-L indicated Yes. R32's medical record indicated the first treatment for the area was initiated on 1/13/24. The treatment order indicated: Right buttocks, cleanse with soap and water or NS, apply form dressing daily and PRN in the evening. The order was discontinued on 1/23/24. ~A weekly wound assessment, dated 1/18/24, indicated R32 had MASD on the right gluteal fold related to IAD that measured 4.5 cm x 3.85 cm. The wound contained moderate serosanguineous exudate (drainage that contains blood and a clear yellow liquid known as blood serum and can be a sign of healing in small amounts) and there was no evidence of infection. The periwound tissue was attached and the surrounding skin was fragile. The treatment section indicated the dressing was intact, but no other treatments were marked. A note indicated: Wound care MD to assess area. Unstageable. Will continue to monitor. The wound was marked as deteriorating. ~On 1/23/24, a change in treatment indicated: Right buttocks cleanse with NS, apply Santyl to wound bed, cover with foam dressing daily and PRN for soiling every evening shift. The order was discontinued on 1/26/24. ~A weekly wound assessment, dated 1/24/24, indicated R32 was seen by the wound MD for an unstageable pressure injury that measured 7.6 cm x 6.6 cm. The wound bed contained eschar (necrotic tissue that is typically dry, black, firm, and usually adhered to the wound bed and edges) and there was no evidence of infection. The wound contained moderate serosanguineous drainage with a faint odor after cleansing and the edges were attached. The dressing was intact and the treatment indicated: Cleansing solution: Sodium hypochlorite; Debridement: Enzymatic; dry dressing. A note that indicated: Call placed to Power of Attorney (POA) for verbal permission for debridement. Bedrest order until improvement in wound. The wound was marked as deteriorating. ~On 1/24/24, an unstageable pressure injury care plan was initiated. ~On 1/24/24, an order was initiated for bedrest (no wheelchair time) while wound to buttocks heals. Every shift for wound rounds. ~On 1/26/24, R32's treatment was changed to: Right buttocks wound, cleanse with Dakins, apply Santyl to wound bed, cover with ABD pad, and tape daily and PRN for soiling every evening shift. The order was discontinued on 2/6/24. ~A weekly wound assessment, dated 1/31/24, indicated R32 had an unstageable pressure injury due to slough and/or eschar on the right gluteal fold that measured 6.3 cm x 3.9 cm. The wound bed contained granulation(granulation tissue formation is required for the healing of deep pressure ulcers), eschar, and moderate exudate. The treatment section was not filled out. The wound was marked as improving. ~A weekly wound assessment, dated 2/7/24, indicated R32 had an unstageable pressure injury due to slough and/or eschar that measured 7 cm x 4.6 cm with no evidence of infection. The wound contained light serous exudate with a faint odor after cleansing. The periwound edges were attached with fragile surrounding tissue and the dressing was intact. The treatment was NS and enzymatic debridement; primary dressing: Calcium Alginate, secondary dressing: dry. The wound was marked as improving. ~On 2/7/24, R32's treatment was changed to: Cleanse with Dakins, apply Santyl to area of eschar and Calcium Alginate to granulation wound bed, cover with moist gauze daily and PRN every evening shift. The order was discontinued on 2/24/23. ~A progress note, dated 2/10/24 at 9:21 PM, indicated: Per on-call MD, new order for culture swab of coccyx wound and UA (urinalysis) with culture and sensitivity due to fever of 102.7 degrees Fahrenheit (F). Keflex 500 mg (milligrams) TID (three times daily) for 2 days. ~On 2/11/24, MD-K ordered to stop Keflex and start ciprofloxacin 500 mg BID (twice daily). ~On 2/12/24, R32 started ciprofloxacin for a UTI and completed the course of antibiotics on 2/17/24. ~A weekly wound assessment, dated 2/14/24, indicated R32 had an unstageable pressure injury due to slough and/or eschar that measured 6.5 cm x 3.3 cm. The wound bed contained granulation with eschar and moderate serosanguineous exudate with a faint odor after cleansing. The dressing was intact. The remainder of the treatment section was not completed. The wound was marked as improving and the section for MD/Provider indicated an infection. A note indicated: Slow improvement. (R32) to see outpatient wound care on 2/15/24 for further management. On 2/15/24, R32 saw the wound clinic. The wound clinic note indicated: .for evaluation of sacral pressure ulcer. Reports it has been there for approximately 3 weeks. Was treated by a wound provider who came to the facility; however, the contract recently ended recently with no new provider stepping in so (R32) is here for ongoing care. Culture was obtained on 2/10/24 without antibiotics prescribed. (R32) grew out proteus mirabilis, strep agalactiae group B, and Escherichia (E) coli. Large amount of boggy eschar to wound base was debrided, however, unable to get to a viable wound bed in this area because there's more slough underneath. Very heavily draining. No foul odor. Some surrounding erythema (redness), but no increased warmth, fluctuance, or induration. No bone probed. Measured 10.4 cm x 8 cm x 1.9 cm. Plan: Due to the amount of necrotic tissue and drainage, .prescribed Augmentin based on culture results. Will also order an X-ray to rule out osteomyelitis (infection of the bone). Would like to start a referral to general surgery as was not able to get to the base of the wound. Still quite a bit of dead tissue that could cause more infection if not removed. For now, will have facility start BID Dakins moist dressing changes. ~On 2/15/24, R32's treatment was changed to: Sacrum: Remove dressing, irrigate with saline then apply .5% Dakins, moist gauze to wound, and cover with .dressing. Change BID and as needed two times daily. The order was discontinued on 2/27/24. ~A weekly wound assessment, dated 2/21/14, indicated R32 had an unstageable pressure injury due to slough and/or eschar that measured 8.6 cm x 4.1 cm. The wound bed contained granulation, slough, and no eschar and had heavy serosanguineous drainage. The periwound was attached with surrounding fragile tissue and the dressing was intact. The treatment indicated: NS cleansing solution; sodium hypochlorite. The primary dressing was antimicrobial, the secondary dressing was foam. The wound was marked as improving and the MD/Provider indicated an infection. A note indicated: Continue bedrest and outpatient wound clinic. ~On 2/22/24, R32 saw the wound clinic. The wound clinic note indicated: Unstageable pressure ulcer of sacrum, quality improving. Plan: There is less necrotic tissue present today, but still unable to get to base of wound. Surgery office contacted. (R32) can be seen on (2/26/24). Will continue with Dakin's .25% moist gauze for now. Wound measures 10.5 cm x 10 cm x 2.3 cm. The wound was noted to be improving. ~On 2/28/24, R32 saw the wound clinic. The would clinic note indicated: The wound measured 8.6 cm x 11.2 cm x 1.9 cm. Sacral/coccyx X-ray: Impression: Decreased bone stock of the distal coccyx which is of uncertain age. This could reflect sequelae from prior or active osteomyelitis. Assessment: After debridement, the wound is nearly all granular. Will plan to start NPWT (negative pressure wound therapy) (wound vac) at next appointment .Reviewed X-ray results, will plan to proceed with MRI (magnetic resonance imaging) (a diagnostic test that can create detailed images of nearly every structure and organ inside the body) versus CT (computed tomography) (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body). Discussed advanced imaging options with Radiology. Due to prior shunt and underlying hardware, CT without contrast was recommended. Order placed. ~On 2/28/24 at 10:31 AM, Surveyor observed R32 in the lobby in R32's wheelchair. Per Registered Nurse (RN)-D, R32 just returned from a wound care appointment. Surveyor observed a blue sling underneath R32 in the wheelchair. On 2/28/24 at 11:34 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-I who was also the wound care nurse. When asked about the missing orders between 12/18/23 and 1/13/24, ADON-I indicated on 12/18/23, a fax was sent to MD-L and the nurse indicated staff were going to apply foam to the wound. ADON-I said MD-L said okay and to have R32 see the wound MD (who was off over the holidays). ADON-I indicated ADON-I saw R32 on wound rounds and placed a call to the wound MD who agreed to see R32 on 1/24/24. There was an order to cover the wound with Mepilex which ADON-I continued on wound rounds, however, ADON-I confirmed the order was not entered in R32's medical record and there was no documentation the treatment was completed. ADON-I indicated the treatment was provided in report so staff knew to complete it. ADON-I verified ADON-I did not check R32's medical record to see if the order was transcribed, but should have. ADON-I indicated staff noticed the order was not in R32's medial record on 1/13/24. The MD was notified and the order was entered. ADON-I verified orders should to be transcribed in the medical record and documented as completed. Surveyor asked if there was documentation that the MD was notified when R32's wound deteriorated as noted on the 12/25/23, 1/8/24, and 1/18/24 weekly wound assessments. ADON-I did not provide notification that the MD was notified of the deterioration or that there was a delay in having R32 seen by the wound doctor. When Surveyor asked about weekly wound assessments and noted more than one week between in-house wound assessments, dated 12/25/23 to 1/8/24 (2 weeks) and 1/8/24 and 1/18/24, ADON-I verified wound assessments should be completed weekly. ADON-I indicated ADON-I had issues with the camera during the 12/31/23 assessment and thought the assessment uploaded. When Surveyor informed ADON-I that Surveyor observed R32 sitting on a sling in R32's wheelchair which was not on R32's care plan, ADON-I confirmed residents should have a care plan intervention to leave a sling underneath them when in a wheelchair. When Surveyor asked ADON-I about the delay in R32 seeing a wound doctor, ADON-I verified APNP-J responded to the 12/18/23 fax on 12/29/23 and indicated R32 should see the wound doctor, but R32 did not see a wound doctor until 1/24/23 (26 days later). ADON-I indicated the facility's wound doctor was out of the office over the holidays and when ADON-I contacted the wound doctor, ADON-I was under the impression the wound doctor would see R32 the following week. The facility realized the contracted wound doctor was inconsistent with facility visits and worked on getting a new contract. In the meantime, ADON-I stated R32 was scheduled to see wound care at the local hospital. ADON-I confirmed a resident should be seen by a wound doctor as soon as possible if ordered by a physician. When asked if the facility had a backup wound doctor if the regular wound doctor was on vacation or couldn't see a resident, ADON-I indicated that's when the facility should refer a resident to the outpatient clinic. ADON-I reviewed ADON-I's cell phone history and stated ADON-I contacted the wound MD around 12/31/23 to inform the wound MD the facility had a new resident ADON-I contacted the wound MD again on 1/8/24 and expected a 1/10/24 visit that did not happen. ADON-I confirmed contact with the wound MD was not documented in R32's medical record. ADON-I acknowledged that was a long period of time and indicated the backup for the wound doctor should get the resident seen at an outpatient clinic. When Surveyor asked why R32's care plan not was not updated after the MASD area was discovered on 12/18/24 or until after R32 saw the wound doctor on 1/24/24, ADON-I indicated residents' care plans should be reviewed if there is a new issue to ensure all new approaches are added and discontinued approaches are removed. On 2/27/24 at 4:35 PM, Surveyor interviewed APNP-J via phone who confirmed APNP-J was initially notified of R32's wound. APNP-J indicated generally APNP-J does not write wound orders and refers residents to a wound doctor. APNP-J indicated R32 had loose stools for awhile and the biggest problem was getting R32's bowels regulated. APNP-J reviewed R32's medical record, but could not locate an order or treatment request until 1/13/24. APNP-J indicated R32 was not seen by a wound specialist until 2/15/24 (the outpatient wound clinic). APNP-J confirmed there was a delay and would have wanted R32 seen sooner. APNP-J also indicated APNP-J wanted to be notified when R32's wound deteriorated. APNP-J checked APNP-J's documentation and confirmed the facility notified APNP-J of the wound, but did not request APNP-J care for the wound if the wound doctor was unavailable. APNP-J could not find documentation that indicated R32's physician was notified when a wound doctor was not available. APNP-J indicated communication was difficult because sometimes there were verbal discussions, sometimes there were faxes, and sometimes there were phone calls. APNP-J stated APNP-J is not sure what happens to a fax on the facility's end after APNP-J responds. The above example was cited at a severity/scope level G (Actual Harm/Isolated). 2. R18 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, pressure ulcer of left buttock, and pressure ulcer of left heel. R18's MDS assessment, dated 2/23/24, contained a BIMS score of 11 out of which indicated R18 had moderate cognitive impairment. R18 had a skin integrity care plan (initiated 4/13/22) related to R18's current pressure ulcers and bilateral leg edema (swelling). Interventions included: Use wedge under right shoulder and along right side to keep straight in bed. On 2/26/24 at 10:52 AM, Surveyor observed R18 in bed without a wedge underneath R18's right side. On 2/27/24 at 10:20 AM, Surveyor observed R18 asleep in bed without a wedge underneath R18's right side and noted R18's head leaned to the right. On 2/27/24 at 10:58 AM, Surveyor interviewed R18 and asked if the green wedge cushion on R18's chair should be under R18's right shoulder. R18 was unsure what Surveyor was referring to. On 2/28/24 at 12:56 PM, ADON-I indicated ADON-I placed the wedge underneath R18's right shoulder. ADON-I verified the wedge should have been in place per R18's skin integrity care plan. Between 2/26/24 and 2/28/24, Surveyor reviewed R18's medical record and noted the following: ~An order, dated 10/2/23, indicated: Left buttock: Cleanse with soap and water, cover with skin prep, allow to dry and apply Allevyn Life foam dressing in the evening until healed. The order was discontinued on 12/4/23. Surveyor noted in October 2023, documentation indicated the treatment was not completed on 4 out of 31 opportunities. In November 2023, documentation indicated the treatment was not completed on 5 out of 30 opportunities. ~An order, dated 10/17/23, indicated: Left heel: Cleanse with NS, apply Santyl to wound bed followed by border gauze daily. Apply tubigrip and heel protector boots (to be worn at all times) every evening shift. The order was discontinued on 10/30/23. In October 2023, documentation indicated the treatment was not completed on 4 out of 14 opportunities. ~An order, dated 11/15/23, indicated: Left foot (bottom): Cleanse with NS and apply foam dressing daily. Apply tubigrip and heel protector boots (to be worn at all times.) every evening shift. The order was discontinued on 2/21/24. In December 2023, documentation indicated the treatment was not completed on 3 out of 31 opportunities. In January 2024, documentation indicated the treatment was not completed on 2 out of 31 opportunities. ~An order, dated 12/12/23, indicated: Wound to ischium, left buttocks: Cleanse with saline, apply Dakins 0.25%, soak for 5 minutes, apply Aquacel AG to wound, cover with Mepilex border, and seal with Tegaderm 3 times per week and PRN every evening shift. The order was discontinued on 2/15/24. In December 2023, documentation indicated the treatment was not completed on 3 out of 19 opportunities. In January 2024, documentation indicated the treatment was not completed on 2 out of 31 opportunities. On 2/28/24 at 1:59 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expected staff to document all treatments. DON-B indicated if the treatment was not completed, there should be a note.

Based on observations, interviews, and record review, the facility did not ensure a resident was given appropriate treatment and services to maintain or improve methods of communication for 1 Resident (R) (R50) of 1 Resident reviewed for communication needs. R50's preferred language was Spanish. R50's communication needs were not appropriately assessed, documented, and implemented resulting in ineffective communication between R50 and non-Spanish speaking staff. As a result of isolation and unassessed pain due to impaired communciation, R50 expressed suicidal ideation. Findings: R50 was admitted [DATE] with pertinent diagnoses of Alzheimer's Disease with late onset, chronic kidney disease, major depressive disorder, anxiety, dementia, Type 2 diabetes, AAA ([CONDITION(S)]) without rupture, limitations of activities due to disability, unilateral inguinal hernia without obstruction or gangrene, dysphagia oropharyngeal phase (small pouch that forms and collects food particles in your throat that leads to difficulty swallowing, gurgling sounds, bad breath, and repeated throat clearing or coughing), chronic pain syndrome, hearing loss, cervalgia (neck pain), [CONDITION(S)], pain in right knee, and cataract extractions. Surveyor reviewed R50's medical record which included the following; R50's most recent Minimum Data Set (MDS), annual, dated [DATE] stated: Section A: Does the resident need or want an interpreter to communicate with a doctor or health care staff? NO. Preferred language? BLANK Section C: Brief Interview for Mental Status (BIMS) indicated 5 (severe impairment.) Section E: Rejection of care: behavior of this type occurred ,d+[DATE] days. Section L: No to mouth or facial pain, discomfort or difficulty with chewing. R50's admission MDS dated [DATE] stated: Section A: Does the resident need or want an interpreter to communicate with a doctor or health care staff? NO Preferred language? BLANK Section C: BIMS not assessed. Section E: Rejection of care: Did not occur. Section L: . Mouth or facial pain, discomfort or difficulty with chewing? No MDS Section D, Mood, Total Severity Score: According to CMS's RAI Version 3.0 Manual, The Total Severity Score is a summary of the frequency scores on the PHQ-9© that indicates the extent of potential depression symptoms and can be useful for knowing when to request additional assessment by providers or mental health specialists. The PHQ-9© Total Severity Score also provides a way for health care providers and clinicians to easily identify and track symptoms and how they are changing over time. In addition, PHQ-9© Total Severity Score can be used to track changes in severity over time. Total Severity Score can be interpreted as follows: ,d+[DATE]: minimal depression ,d+[DATE]: mild depression ,d+[DATE]: moderate depression ,d+[DATE]: moderately severe depression ,d+[DATE]: severe depression. R50's MDS Total Severity Scores: [DATE] - 8 [DATE] - 2 [DATE] - 5 [DATE] - 2 [DATE] - 2 [DATE] - 2 [DATE] - 0 R50's MDSs between [DATE] and [DATE] did not indicate mouth or facial pain, rejection of cares, or the need for an interpreter or that Spanish was R50's preferred language. R50's Care Plan stated: I have an alteration in my communication-language barrier. I mainly speak and understand my native language of Spanish,and I have decreased hearing and use bilateral hearing aids. I will be accepting of group activities of interest daily where language/communication is not needed for enjoyment / visual aides help with understanding, i.e. sports/games, exercise, music, church, outdoors, outings. I will have adequate communication AEB (as evidenced by): ability to communicate basic needs. My needs will be anticipated and met by staff. I will have adequate communication AEB: Appropriate response. I do not speak English, but am good at letting you know my needs with hand signals such as eating and drink. A communication board may be helpful. Provide CD player and Hispanic Music for listening in my room. Repeat/rephrase statements as needed to promote effective communication. Provide an activity schedule in Spanish; invite and escort to groups of potential interest: guitar music, Catholic Mass/Communion, Wednesday worship, special programs, pets. Monitor independent pursuits and level of satisfaction. I am accepting of daily history sheets and puzzles in Spanish. Identify words and staff that know Spanish to provide invites/socialize with me. Repeat conversation as needed Provide adequate time for resident to communicate needs. Assist to clean bilateral hearing aids and change batteries PRN (as needed.) Assist with placement and removal of hearing aids as needed Speak to me in simple to understand terms. Repeat as needed. Speak clearly and distinctly to resident or use resident preferred communication method. Alternate communication method- gestures, pictures, translation line. Assist resident with communication devices. A Social Services Note created by Social Worker (SW)-F on [DATE] at 10:38 AM included; The resident had [R50's] quarterly care conference on [DATE] .The resident is not [R50's] own person and has an activated POA (power of attorney.) The resident currently has a hernia to [R50's] left side and complains of pain at bedtime. The residents weights and appetite have deceased this quarter and is on supplements for diet to receive a magic cup at lunch daily . There is some communication barriers. The resident does speak Spanish and needs translation services to properly communicate . A Social Services Note created by SW-F on [DATE] at 9:36 AM included; The resident had [R50's] quarterly care conference on [DATE] .The resident is not [R50's] own person and has an activated POA (power of attorney.) The resident currently has a hernia to [R50's] left side and complains of pain at bedtime. The residents weights and appetite have deceased this quarter and is on supplements for diet to receive a magic cup at lunch daily . There is some communication barriers. The resident does speak Spanish and needs translation services to properly communicate . A Social Services Note created by SW-F on [DATE] at 10:38 AM included; The resident had [R50's] quarterly care conference on [DATE] .The resident is not [R50's] own person and has an activated POA (power of attorney.) The resident currently has a hernia to [R50's] left side and complains of pain at bedtime. The residents weights and appetite have deceased this quarter and is on supplements for diet to receive a magic cup at lunch daily . There is some communication barriers. The resident does speak Spanish and needs translation services to properly communicate . A Social Services Note created by SW-F on [DATE] at 10:04 AM included; The resident had [R50's] quarterly care conference on [DATE] .The resident is not [R50's] own person and has an activated POA (power of attorney.) The resident currently has a hernia to [R50's] left side and complains of pain at bedtime. The residents weights and appetite have deceased this quarter and is on supplements for diet to receive a magic cup at lunch daily . There is some communication barriers. The resident does speak Spanish and needs translation services to properly communicate . A Nursing Note created by Registered Nurse (RN)-FF on [DATE] at 3:54 PM included; Resident's hearing aid was missing from date [DATE], when writer was there in resident's room to take out hearing aid it was not in [R50's] ear and searched in [R50's] room, unable to find on that night, so the writer was again there in the resident's room today to find the hearing aids, writer tried to convince resident in symbolic language that writer want to look your [sic] hearing aids in the room, could not understand [R50] due to the language barrier and writer tried looking at [R50's] drawer, clothes and every corner, suddenly resident got extremely angry and hit writer with [R50's] cane in the right lower back, hardly escaped from the resident's room. DON (Director of Nursing) updated. On [DATE] at 1:22 PM, Surveyor interviewed RN-R. RN-R stated R50 spoke Spanish as primary language, very minimal English, and had a speech impediment. RN-R stated RN-R speaks Spanish, but it is even difficult for RN-R to understand R50. RN-R stated there is one other Spanish speaking nurse which is helpful when that nurse is staffing, Licensed Practical Nurse (LPN)-M. RN-R stated R50 can read body language and hand gestures. RN-R stated RN-R tried to have R50 write, but R50 refused. RN-R stated R50's pain is assessed using a Pain Assessment in Advanced Dementia (PAINAD) Scale (resident's pain determined by nurse through observation.) RN-R stated RN-R will ask R50 in Spanish, but R50 does not answer about pain. RN-R stated it is hard to meet R50's needs and that R50 is frustrated as well. R50 does not have family available to interpret for R50. R50's HC-POA (Healthcare Power of Attorney) is very hard to get a hold of and HC-POA will not return messages. RN-R stated the facility does not have an interpretation service that RN-R is aware of. RN-R had been employed less than one year. RN-R stated RN-R had observed staff members using hand gestures and talking louder to attempt to communicate with R50. RN-R stated R50 does not eat well due to not having dentures as R50 was not a candidate for dentures. RN-R stated R50's gums are too painful to chew. RN-R stated R50 will eat bananas and mushy things. RN-R stated R50 refused pureed diet. RN-R stated R50's mood and behavior was very up and down. RN-R stated at a recent outside medical appointment, R50 told the staff R50 wanted to kill self by hanging. The medical office called facility and informed nursing home that they (outside medical office) called an interpreter service who verified R50 stated R50 wanted to kill self by hanging. R50 was sent to hospital, but determined not to be a candidate for inpatient hospitalization and sent back to long term care facility. RN-R stated R50 was placed on precautions for safety and R50 became combative, striking out with R50's cane. RN-R stated R50 had since slowly improved. On [DATE] at 5:50 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-O. LPN-O stated R50 speaks Spanish. LPN-O stated LPN-O knows some words in Spanish. LPN-O stated a few words in Spanish is what LPN-O used for communicating with R50 other than hand gestures. LPN-O stated R50 always refuses bio freeze and LPN-O does not know why, but maybe due to the lack of communication. LPN-O stated LPN-O is not aware of translation services for R50 at the facility. On [DATE] at 6:14 PM, Surveyor observed R50 talking to LPN-O in Spanish. R50 then self-propelled towards R50's room. LPN-O turned towards Surveyor and stated, The only thing I got from that was milk and something blue. On [DATE] at 6:37 PM, Surveyor went into interview R50 with Certified Nursing Assistant (CNA)-P. CNA-P attempted to read questions Surveyor translated in writing format from English to Spanish on Surveyor's electronic tablet. CNA-P attempted to read in Spanish as CNA-P stated CNA-P had taken some Spanish classes in the past. CNA-P was unable to effectively communicate in Spanish with R50. R50 ended up reading from Surveyor's electronic tablet after enlarging the font. R50 read the questions and answered with si (yes), no, or body language. Do you feel the staff know how to communicate with you? No with head shaking no side to side. Are you in pain? R50 pointed to left hip. CNA-P stated that is the hip that was broken. Are your needs met? No with head slightly shaking no side to side, but difficult to confirm as R50 was saying more in Spanish. Are you depressed? Si (yes) with head slightly shaking yes up and down. Are you sad? Si (yes) with head slightly shaking yes up and down. Do you want a translator? Si! Surveyor heard Tres and verified with CNA-P R50 stated 3 years. R50 had been in facility nearly three years. R50's body language appeared to brighten and show excitement that a translator would be used for Surveyor to interview R50. On [DATE] at 6:48 PM, Surveyor interviewed NHA-A and Infection Preventionist (IP)-E. Surveyor asked if there is a translation service provided for residents who may need one. NHA-A stated there was not a service like that, then IP-E stated there should be a number to call at the nurses station. IP-E stated there was not currently a resident who used an interpreter, but there was an interpreter that used to come see R50 once a month to check in. IP-E stated either SW-F or DON-B set up the translator but did not recall. IP-E and Surveyor went to the unit where R50 lives. IP-E asked LPN-O where a translation number would be. LPN-O stated LPN-O had never known of a translation number or saw one posted. IP-E did not find a translator number in the nurses station. Surveyor asked how a staff would communicate with R50 without translation number and IP-E stated staff would call DON-B or the charge nurse on duty. On [DATE] at 9:06 AM, Surveyor interviewed DON-B. Surveyor asked DON-B with assistance setting up a translator to assist with interviewing with R50. DON-B stated Surveyor could call the translator number, but stated the translators have a difficult time understanding R50. DON-B stated there are two nurses who speak Spanish; LPN-M worked PM shift and understood R50 best. RN-R is the other nurse who spoke Spanish. DON-B stated the staff rely on LPN-M and RN-R to communicate with R50. On [DATE] at 12:38 PM, Surveyor observed R50 in the dining room. Surveyor observed R50's meal card which stated mechanical soft diet and preference of banana. R50 was served lunch of mechanical soft ribs, potatoes, and cake. Staff did not offer R50 an alternate meal. R50 took a bite of the ribs and coughed and placed bite in napkin. R50 ate cake and drank beverages provided. On [DATE] at 12:57 PM, Surveyor asked R50 questions utilizing electronic tablet. R50 does not get to choose R50's meals. R50 did not like lunch. R50 confirmed no one has asked R50 what R50 likes to eat. R50 indicated R50's gums hurt. R50 answered questions with nods indicating yes or no and would begin speaking more in Spanish. On [DATE] at 2:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-M who stated it is very difficult to understand R50 at times. Surveyor and LPN-M entered R50's room. Surveyor and LPN-M could not find any signs in Spanish in R50's room. R50 was not aware of any signs or cards in Spanish. The activity calendar was in English. R50 did not have activities in Spanish in room in accordance with R50's care plan. With LPN-M translating for R50 and Surveyor, R50 stated staff have used their phones for translation but does not recall who. R50 stated R50 does not feel R50 has enough menu choices. R50 stated R50 would ask LPN-M or RN-R when they are working if R50 had to talk to a staff member. Surveyor asked R50 if R50 likes the food R50 is given. R50 stated it is difficult at the time of eating to say what R50 wants. R50 stated staff do not ask what R50 wants or if R50 likes the food and that R50 is given what they give R50. R50 stated R50's gums and insides of cheeks hurt when R50 eats. R50 showed Surveyor and LPN-M a black pant belt around R50's waste on skin that R50 stated R50 used for hernia pain. LPN-M took off black belt and explained that is not used for hernia pain, the white belt is. R50 pointed to a thick white strap for inguinal hernia pain and pointed to a missing strap which is why R50 does not have the white belt on. R50 stated around midnight R50 starts to feel pain in inguinal hernia area. R50 continued talking about the pain from inguinal hernia. R50 stated R50 tries to tell people around midnight or 3:00 am. R50 stated staff do not come too often, but do bother him at times about pain, but translation was unclear what R50 was attempting to say. R50 stated at night R50 said R50 tries sleep to get though the pain. LPN-M stated LPN-M will assess R50's pain by asking R50 pain level from ,d+[DATE] and R50 will say yes or no. LPN-M stated R50 will point to pain. LPN-M asked R50 how R50 would rate pain ,d+[DATE]. R50 stated pain is when he tries to go to sleep and at night time R50 experiences the most excruciating pain. R50 stated pills help so so. R50 stated R50 was on suicide watch last month some time and staff took everything out of R50's room. R50 made motion like hanging self. LPN-M stated staff took hair brushes, tied up call light cord to leave enough to use, radio, cords, combs, and shoe laces. R50 stated nobody asked R50 if R50 was having suicidal thoughts. R50 stated R50 still does feel that way because R50 is restricted from using the phone to call family. LPN-M stated R50's family member's phone lines are disconnected or nobody calls R50 back. R50 stated before coming here, at home R50 was being tying up so R50 would not leave. R50 stated R50 does not know whey R50 is even here. R50 feels R50's HC-POA brought R50 here and sold him to the facility and was accused of stealing from R50's HC-POA. LPN-M stated R50's HC-POA does not answer the phone. HC-POA did not show up for eye surgery three times. When LPN-M called to update HC-POA, HC-POA does not answer or call back. LPN-M verified R50's room did not contain a Spanish activity calendar, only three months of English activity calendars, and no other Spanish communication aides. LPN-M did not recall seeing Spanish communication aides. LPN-M state it would, Do a world of wonders for R50 if there were other ways to communicate with R50 and not rely on two nurses. LPN-M works on the east end of hall and is not always assigned by R50. LPN-M stated when LPN-M started in [DATE], R50 informed LPN-M R50's gums's hurt when R50 eats. LPN-M stated that is when the dentist came to see R50. R50's gum pain was documented in a dental visit dated [DATE] from named dental group who visits residents in the facility. R50's dental document stated, .Reviewed Medical History; Used staff member who speaks Spanish. Patient does not speak English. C/O (complaints of) pain while eating. Diet is ground texture Nursing station had no order sheets so left note for MD (Medical Doctor) to consider pureed diet and prescribe [MEDICATION(S)]/[MEDICATION(S)] (pain reliever) based mouth rinse. R50's medical record did not contain additional information regarding gum pain or an order for [MEDICATION(S)]/[MEDICATION(S)] mouth rinse. On [DATE] at 4:08 PM, Surveyor interviewed SW-F. SW-F stated Dietary Supervisor (DS)-I does not say much when DS-I attends R50's care conferences. SW-F stated SW-F offered DS-I to use a translator application on the phone that SW-F used to communicate with R50 during care conferences. SW-F stated DS-I stated, I don't think that is necessary. SW-F stated during the care conferences DS-I attended with R50 and SW-F, DS-I did not ask R50 food preferences or how meals were going. On [DATE] at 11:11 AM, Surveyor interviewed DS-I who stated DS-I does initial assessment of likes and dislikes for residents and the dietician assesses residents for, Weight loss and that stuff. DS-I stated if there are no complaints about what a resident liked or did not like, DS-I will not talk to the Resident. DS-I will update the resident's meal ticket only when something is brought to DS-I's attention. DS-I stated R50's preferences included bananas which was on R50's meal ticket prior to DS-I starting in [DATE]. DS-I stated DS-I added bread products to R50's meal ticket due to R50 liking bread based on when DS-I and CNA's observe R50 scraping meat off of bread and R50 eating only the bread. DS-I stated softer bread works better R50 has, Teeth issues. DS-I stated DS-I does not recall if DS-I attended R50's care conferences ,d+[DATE], ,d+[DATE], or ,d+[DATE]. DS-I stated DS-I had shown R50 a plate of food and will ask R50, Is this ok? DS-I stated R50 will shake head yes or no. DS-I stated DS-I did not ask R50's preferences because R50 was already a resident when DS-I started working in the facility. DS-I stated DS-I had not used an interpreter application and was not offered to use an interpreter application to communicate with R50. DS-I stated there are a couple staff who speak Spanish. DS-I stated DS-I does feel DS-I should have assessed R50 further by asking R50 preferences and adding onto R50's meal ticket. DS-I stated DS-I would talk with R50 through RN-R as R50's interpreter. If RN-R was not working, DS-I stated DS-I would schedule when RN-R was working. On [DATE] at 11:41 AM, Surveyor interviewed Dietician-J. Dietician-J stated R50 was Spanish speaking so Dietician-J, Usually will ask one of the aides who is able to communicate with [R50.] Dietician-J was unsure who the CNA was and does not know if the CNA speaks fluent Spanish, but Dietician-J will ask un-named CNA if R50 is complaining about pain and if that was why R50 was not eating. Dietician-J stated R50 had weight loss at one point due to a hernia issue. Dietician-J recalled R50's family refused surgery. Dietician-J stated R50 was wearing a binder (belt type strap for hernia pain) and eating magic cup and R50 began to gain weight and had been stable for six months. Dietician-J stated Dietician-J was not aware R50 had mouth pain. Dietician-J stated Dietician-J did not assess R50's likes or dislikes in June of 2021 when R50 had weight loss, but stated Dietician-J was pretty sure pain was the cause of R50's loss of appetite. Dietician-J stated when a resident is first admitted Dietician-J will do the assessment and ask resident's preferences. Dietician-J started working at facility [DATE]. Dietician-J had asked staff if there are any preferences. If a resident is not eating well, Dietician-J will go and assess and ask them their preferences. Dietician-J stated last week Friday, [DATE], Dietician-J talked with DS-I and added more of R50's food preferences. R50 stated R50 preferred sweeter foods, favorite meal is breakfast, waffles, chocolate milk and apple juice, sausages, and bananas, and to offer softer foods. Dietician-J stated R50's care plan was updated with preferences [DATE]. On [DATE] at 11:29 AM, Surveyor interviewed MDS Nurse, RN-Q via telephone. RN-Q stated RN-Q is familiar with R50 and will communicate with R50 with pictographs and hand gestures. RN-Q stated RN-Q uses a Spanish form that R50 can point to pictures, and a pain scale with pictures. RN-Q stated RN-Q does fill out the Minimum Data Set (MDS) pertaining to mouth or facial pain, discomfort or difficulty with chewing. Surveyor asked RN-Q how RN-Q assesses R50 for mouth or facial pain, discomfort or difficulty with chewing and RN-Q stated, I don't know, I just go through the documents and see if I could find something. RN-Q stated RN-Q does not know how to do that (assess for mouth pain) with R50. When RN-Q asks R50 about pain R50 can point to groin. RN-Q stated R50 had not voiced concern with pain in gums. RN-Q stated when RN-Q asked R50 about pain R50 only points to mouth. RN-Q stated MDS section L which identifies a resident's preferred language and if an interpreter is needed, is done by the social worker or whoever enters admission data. RN-Q stated RN-Q believes R50's preferred language is Spanish. RN-Q stated R50 would need an interpreter for detailed conversations, bur not for RN-Q's brief interactions with R50. On [DATE], Surveyor reviewed R50's medical record which contained an order dated [DATE]: Charting every shift regarding suicidal ideations, behavior, etc. Surveyor observed R50's medical did not contain suicidal ideation and behavior monitoring recorded every shift as ordered. On [DATE] at 12:27 PM, Surveyor interviewed DON-B who stated suicidal ideation and behavior monitoring should be documented by nursing staff in a progress note every shift and verified documentation order was not charted as ordered. On [DATE] at 2:34 PM, Surveyor interviewed DON-B who stated the sign DON-B provided Surveyor that contained pictures labeled with words used to communicate with R50 was in English, not Spanish and that R50 would be unable to read the English word attached to the picture. DON-B stated DON-B did have laminated signs with pictures and the English and Spanish names on it and posted in R50's room. DON-B verified signs are no longer in R50's room and not sure where they went. DON-B stated the MDS section A should reflect that resident's needs including the need for an interpreter and Spanish as R50's preferred language. On [DATE] at 2:43 PM, Surveyor did not observe Spanish activity calendar, Spanish signs, or any form of Spanish communication aides in R50's room to assist staff in effective communication with R50.

Based on observation, record review and staff interview, the facility did not closely supervise Resident 1 (R1) and ensure that 25 of 25 female residents on the unit and one male resident - Residents (R) (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26 and R27) - were free from potential sexually aggressive behavior. R1 had a history of sexually aggressive behavior. R1 was placed on fifteen minute checks following multiple incidents in which R1 was observed in a female resident's room or with a female resident in R1's room. A Tile Tracker (a small, flat plastic GPS (global positioning system)-like monitoring device commonly used to find lost keys, wallets and purses that measured 3.4 inches long by 2.1 inches wide and 0.1 inches thick) was placed on R1's ankle after R1 and R4 were observed in bed fully clothed with R1's hands between R4's legs. Staff used a Tile App on the charge nurse's phone to track R1 if R1 could not be located during a fifteen minute check. Despite the monitoring interventions, staff observed R1 and R2 in R1's room on 9/07/21. Staff stated R1 attempted to guide R2's hand toward R1's genitals while R1's pants and brief were around R1's ankles. The facility's failure to ensure residents on R1's unit were safe from a resident with sexual behaviors created a finding of immediate jeopardy that began on 9/07/21. RFOD (Regional Field Office Director)-J notified NHA (Nursing Home Administrator)-A of the immediate jeopardy on 9/10/21 at 1:45 PM. The immediate jeopardy was removed on 9/10/21; however, the deficient practice continues at a scope/severity level E (Potential for Harm/Pattern) as the facility continues to implement its action plan. Findings include: The Surveyor reviewed R1's medical record. R1 had diagnoses to include Wernicke's [CONDITION(S)] (neurological symptoms caused by [CONDITION(S)] of the central nervous system after exhaustion of B-vitamin reserves), dementia with behavioral disturbance and amnestic disorder (memory loss). R1's most recent Quarterly MDS, dated [DATE], indicated R1 was cognitively impaired and required limited assistance of staff for bed mobility and transfers. R1's plan of care indicated R1 had a history of physical aggression with staff and others and was prescribed 75 mg (milligrams) of [MEDICATION(S)] (an antipsychotic medication used to rebalance [MEDICATION(S)] and serotonin (neurotransmitters) to improve thinking, mood and behavior) twice daily for dementia with sexual aggression. R1's plan of care indicated R1 had an activated power of attorney, was cognitively impaired and had impaired decision making skills, poor judgement and impaired safety awareness. R1's plan of care contained interventions to keep R1 separated from R4 during activities and meals and to have R1 sit by males when in common areas. The care plan also contained interventions to keep R1 at arms length from females, to notify nursing staff if R1's Tile Tracker was removed and to reinforce/redirect R1 not to touch peers or check peers' rooms. R1's medical record indicated R1 had a history of sexual encounters with female residents. R1 had an order, dated 9/07/21, to ensure fifteen minute checks were completed every shift. R1 also had an order, dated 4/17/20, to utilize the Tile Tracker if R1 could not be found during a fifteen minute check. Staff were instructed to document R1's behaviors twice daily every Tuesday, Thursday and Friday and document non-pharmacological interventions for aggressive behavior three times daily and PRN (as needed). R1 also saw MD (Medical Doctor)-C for psychiatric services. On 3/12/19, a facility self report indicated R14 was observed in R1's room. R1 was observed sitting on the bed fully clothed. R14 was observed sitting on R1's lap with R14's pants and brief down. Following the incident, R1 was placed on fifteen minute checks and moved to a unit with increased activities. On 6/24/20, a facility self report indicated R4 was found in R1's room. R1 and R4 were fully clothed and laying on R1's bed facing the same direction. Staff observed R1's hand between R4's legs on top of R4's clothing. Following the incident, R1 was placed on fifteen minute checks and the Tile Tracker was initiated. A nursing note on 7/02/20 stated R1's Tile Tracker was not working well. The note stated staff needed to be closer to R1 to fully pick up the signal. A nursing note on 7/15/20 stated R1 was found in bed with a female resident. R1's hands were observed on the resident's stomach. A care conference note on 10/08/20 indicated R1 had an increase in physical and verbal behavior over the past three months. [MEDICATION(S)] was restarted on 9/30/20. A facility self report on 10/14/20 indicated R1 entered R8's room and grabbed R8's breast. R1 remained on fifteen minute checks and the Tile Tracker following the incident. A nursing note on 10/16/20 stated R1's [MEDICATION(S)] was increased and R1 continued to enter other residents' rooms. A nursing note on 10/17/20 stated R1 attempted to enter female residents' rooms all shift and was constantly' redirected. A nursing note on 10/18/20 stated R1 removed mesh stop signs from doorways, wandered into female residents' rooms and required supervision all shift. A nursing note on 10/31/20 stated R1 would not leave a female resident alone and had to be supervised at all times. A nursing note on 12/19/20 stated a CNA did a thirty minute check on R4 and found R4 standing at R1's bedside. R1 was in bed and naked from the waist down. A care conference note on 1/08/21 stated R1 had an increase in verbal and sexual behavior over the past three months. A nursing note on 4/28/21 stated R1 wandered on the west wing of the hallway and bothered those that lived toward the end of the hallway. A nursing note on 6/06/21 stated R1 was yelled at by R5 who didn't want R1 on the west end of the hallway. A nursing note on 8/01/21 stated R1 was seen in the hallway ten minutes earlier and then found in a female resident's room. On 9/07/21 the facility submitted a self-report, which stated CNA (Certified Nursing Assistant)-D observed R1 and R2 in R1's room. CNA-D stated R1's pants and brief were down to R1's ankles. CNA-D observed R1 guide R2's hand toward R1's genitals. The Surveyor reviewed R2's medical record. R2 had diagnoses to include Alzheimer's disease and vascular dementia with behavioral disturbance. R2's most recent Quarterly MDS (Minimum Data Set), dated 7/06/21, indicated R2 was severely cognitively impaired and exhibited physical and verbal behavior. R2 was independently ambulatory, but required extensive assistance of staff for most ADLs (activities of daily living). R2's medical record indicated R2 frequently wandered the hallways and had no recollection of the incident on 9/07/21. On 9/09/21 at 9:10 AM, the Surveyor interviewed DON (Director of Nursing)-B regarding the self report. DON-B stated R1 received psychiatric services on a routine basis; however, following the incident, the facility initiated a weekly program with Behavioral Health Services as well. DON-B stated the facility hoped to have a psychiatrist prescribe medication to suppress R1's sexual urges. R1 was on fifteen minute checks and had a Tile Tracker attached to R1's ankle. DON-B stated staff used a Tile App on the charge nurse's phone to track R1 if R1 could not be found during a fifteen minute check. DON-B stated R1 was very sexual and GDR (gradual dose reduction) attempts of [MEDICATION(S)] were not effective for R1's sexual urges and anger. DON-B stated R1 was sneaky, but the CNAs on the floor always knew R1's whereabouts. DON-B also stated when R1 was questioned, R1 stated R1 did not do anything and nothing happened. DON-B verified CNA-D saw R1 guide R2's hand toward R1's genitals; however, DON-B was not sure if contact was made. DON-B stated R2 had no recollection of the encounter. On 9/09/21 at 10:30 AM, the Surveyor observed R1 sitting on the edge of R1's bed. The Surveyor located LPN (Licensed Practical Nurse)-G in the hallway and interviewed LPN-G about R1's fifteen minute checks. LPN-G showed the Surveyor a clipboard that contained documentation of the checks. When interviewed about the Tile Tracker on R1's ankle, LPN-G showed the Surveyor the Tile Tracker, but stated LPN-G was new to the floor and was not aware the Tile was monitored via an App on the charge phone. On 9/09/21 at 10:45 AM, the Surveyor interviewed RN (Registered Nurse)-I regarding R1. RN-I stated RN-I was aware of the incident between R1 and R2 was told R2 assisted R1 with sexual gratification. RN-I stated RN-I did not witness sexually inappropriate behavior by R1, but heard R1 had prior incidents. RN-I stated R1 was pleasant and compliant during the AM shift; however, R1's behavior increased on the PM shift. On 9/09/21 at 11:15 AM, the Surveyor interviewed CNA-H regarding R1. CNA-H stated R1 wandered into R8's room a couple nights ago and liked to wander into R6 and R10's rooms also. CNA-H stated R1's behaviors decreased for awhile; however, the behaviors started again in the past two weeks. CNA-H stated CNA-H was not aware of any triggers for R1's behavior. CNA-H stated R1 had a history of entering female residents' rooms and attempting to get female residents to enter R1's room. On 9/09/21 at 11:32 AM, the Surveyor again interviewed DON-B regarding R1's history and the incident on 10/14/20 between R1 and R8. DON-B stated DON-B was unaware of the incident between R1 and R8. DON-B also stated many of the stop signs across doorways on the west hallway were due to R1 and other residents who wandered. DON-B verified R1 was placed on and taken off of fifteen minute checks multiple times as a result of wandering and resident-to-resident altercations. Following the incident on 9/07/21, DON-B stated no new interventions were implemented aside from the facility's consultation with Behavioral Health Services. DON-B also verified staff education was not completed for use and monitoring of R1's Tile Tracker. On 9/09/21 at 11:40 AM, the Surveyor attempted to interview R2 regarding the incident. R2 reported no safety concerns and no recollection of the incident. On 9/09/21 at 1:04 PM, the Surveyor interviewed CNA-D via telephone. CNA-D stated CNA-D saw R2 in R1's room when CNA-D passed R1's room while on the way to assist another resident. CNA-D stated CNA-D was not in the process of conducting R1's fifteen minute check. CNA-D stated when CNA-D passed R1's room, CNA-D noted R1's pants and brief were around R1's ankles. CNA-D stated R1 was trying to guide R2's hand toward R1's genitals. CNA-D stated CNA-D was pretty sure no contact was made. CNA-D stated CNA-D asked what was going on and took R2 out of the room. CNA-D stated R2 was confused and didn't say anything. CNA-D stated, I suggested (R1) be moved to the third floor because all those residents are with it . CNA-D stated CNA-D thought R1's fifteen minute checks were effective; however, CNA-D verified R2 was in R1's room prior to the completion of the next fifteen minute check and with approximately four minutes to spare before the check was due. CNA-D verified CNA-D happened to pass by R1's room at the right time. CNA-D also stated R1 had a history of guiding female residents by the hand toward R1's room. CNA-D stated, I saw (R2) in the middle of the west hallway at 6:30 (PM). (R1) was in the common area at 6:55 PM when I did my check. CNA-D stated CNA-D observed R1 and R2 in R1's room at approximately 7:06 PM. On 9/09/21 at 2:03 PM, the Surveyor interviewed LPN-E via telephone. LPN-E stated, I was coming out of a different resident's room when (CNA-D) said (CNA-D) found (R2) in (R1's) room LPN-E stated LPN-E was told R1's pants were around R1's ankles and R1 was guiding R2's hand toward R1's genitals. LPN-E stated R1 dropped R2's hand when CNA-D approached. LPN-E stated when R1 was questioned about the incident, R1 stated R1 didn't do anything. LPN-E stated LPN-E checked on R2 after the incident and notified R2's nurse. LPN-E stated, (R1) is very sexual. (R1) tries to go in others' rooms and tries to get them to come into (R1's) room It's hard to answer if (R1) knows what (R1) is doing. LPN-E stated LPN-E felt R1's fifteen minute checks were an effective intervention when the facility had enough staff which was not always the case. On 9/09/21 at 3:55 PM, the Surveyor again interviewed DON-B regarding R1. DON-B stated DON-B believed the incident between R1 and R14 on 3/12/19 was the first time R1 was placed on fifteen minute checks. DON-B stated nurses could implement fifteen minute checks at their discretion. DON-B stated DON-B believed R1's fifteen minute checks were effective; however, DON-B verified, due to staffing issues, there was the potential for R1 to be out of staffs' sight for longer than fifteen minutes. The failure to ensure female residents were free from sexual advances by R1 created a finding of immediate jeopardy. The facility removed the jeopardy on 9/10/21 when it began implementing the following: 1. R1 was relocated to a room on a floor with alert and oriented female residents. 2. The faclity implemented 1:1 monitoring for R1. 3. The facility contacted the Dementia Crisis Network for guidance on dementia behaviors and staff training. 4. The facility made a referral to Behavioral Care Solutions for R1.

Based on record review and interviews, the facility did not ensure that 1 Resident (R) (R1) of 4 sampled residents remained as free of accident hazards as possible and received the supevision necessary to prevent accidents. R1 was admitted to the facility on [DATE] after a fall in which R1 sustained injuries that resulted in R1 being unable to use left arm. R1 utilized a wheelchair for mobility. R1's smoking assessment documented R1's decision-making skills were not reasonable and consistent and that R1 had poor safety awareness. On 7/2/21, R1 was taken outside by staff to smoke unsupervised. When R1 re-entered the building unsupervised after smoking, R1 self-propelled backward in wheelchair and fell backwards in wheelchair down 12 steps in an unsecured stairwell located in lobby of facility. R1 was thrown from wheelchair as a result of fall and sustained multiple fracture ribs, closed head injury, and cephalhematoma (an accumulation of blood under the scalp.) Facility failure to properly assess and supervise a resident with documented poor decision-making skills and poor safety awareness created a finding of Immediate Jeopardy (IJ) that began on 7/2/21. Surveyor notified Nursing Home Administrator (NHA)-A of the IJ on 7/8/21 at 4:30 PM. The IJ was removed on 7/9/21. However, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan. Findings include: The facility titled Smoking Policy - Residents with a revision date of 5/4/21 states: It is the policy of this facility to meet the needs and provide a sage environment for residents to smoke . 6. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. R1 was admitted to the facility on [DATE] following a hospitalization from a fall. R1's facility diagnoses list on admission documented history of falling, unsteadiness of feet, repeated falls, displaced fracture of distal phalanx (a bone in finger) of left ring finger, laceration to right forearm, left forearm, right knee, left knee, right lower leg. R1's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/25/21 documented R1 to be dependent on staff for bed mobility, dressing and toilet use. R1's MDS documented R1's locomotion on and off the unit required supervision (oversight, encouragement or cueing) of one staff person physical assistance required. R1's MDS, BIMS (Brief Interview of Mental Status) score documented 14/15, which indicated R1 was cognitively intact. R1's care plan dated 6/18/21, titled Safe Smoking documented the following interventions: ~ Educate to interventions and facility smoking policy and procedures. ~ Offer/encourage smoking cessation. ~ Secure smoking materials. R1's Safe Smoking care plan did not include interventions as to how staff were to transport R1 to and from the smoking area or if R1 required supervision when smoking R1's care plan dated 6/18/21, titled At risk for falls related to history of multiple falls, recent hospitalization s for fall with multiple lacerations and blood loss, muscle weakness documented the following interventions: ~ Cue resident to call for assist as needed ~ Ensure resident has on non-slip footwear when up ~ Keep call light and frequent used items within resident's reach ~ Maintain bed in low position ~ Provide assistance to transfer and ambulate as needed On 6/24/21, LPN (Licensed Practical Nurse)-C completed a safe smoking evaluation for R1 which documented the following: ~ Decision-making skill are reasonable and consistent - No ~ Alert and orientated and can consistently perform safe smoking techniques - No ~ Has total or limited range of motion of both arms and legs - No ~ Resident is able to light cigarette safely with a lighter - No Despite the above, the 6/24/21 safe smoking evaluation concluded that R1 may smoke independently. The other section of R1's safe smoking evaluation documented, help with setup. R1's medical record did not include documentation regarding R1 having limited mobility due to R1 having an injury to left arm which prevented R1 from using left arm to propel wheelchair. On 6/24/21 at 10:07 AM, the Surveyor interviewed LPN-C who confirmed on 6/24/21 LPN-C completed R1's safe smoking assessment. LPN-C stated that on 6/24/21 LPN-C escorted R1 to the facility smoking area which is located on the first floor. LPN-C stated R1 needed physical assistance pushing R1's wheelchair the entire way to the smoking area and the entire way back which included going up and down a ramp because R1 could not propel self due to R1's injured left arm. LPN-C stated LPN-C had not been trained on how to complete smoking assessments to determine what qualifies a resident to be unsupervised or supervised when smoking. LPN-C stated the smoking assessment is a staff determination based on observation if the resident can safely smoke. LPN-C confirmed to the Surveyor R1's safe smoking assessment documented no to R1 having decision making skills which were reasonable and consistent because R1 has poor safety awareness. LPN-C stated R1 is impatient when waiting for staff to assist, R1 self-transfers, and R1 needs constant reminders to wait for staff assistance and not self-transferring. LPN-C informed the Surveyor no was answered when the safe smoking assessment asked if R1 was alert and orientated and can consistently perform safe smoking techniques because R1 could only use one hand to smoke and could not light R1's own cigarettes. LPN-C stated R1 required help with set up because R1 could not use R1's left arm due to a previous injury from a fall. R1 needed staff assistance to get to and from the smoking area because R1 was unable to move wheelchair independently. LPN-C confirmed to the Surveyor R1's smoking assessment documented no to R1 being able to light cigarette safely with a lighter. LPN-C stated R1 could not light the cigarette safely because R1 could not use left arm, and was not able to hold R1's cigarette and light R1's cigarette with only one hand. LPN-C informed the Surveyor the questions that were answered no during R1's safe smoking assessment were not taken into consideration when determining if R1 should smoke with staff supervision or unsupervised. LPN-C informed the Surveyor the other section of R1's safe smoking assessment documented, help with set up which meant R1 required staff assistance to and from smoking area, and R1 required staff assistance with lighting cigarette because R1 was unable to use left arm. LPN-C stated LPN-C did not document in R1's plan of care the assistance R1 required when R1 went out to smoke so all staff would be aware how to care for R1. LPN-C stated LPN-C should have been more specific so staff were aware of how to assist R1 when smoking. LPN-C stated staff would not be aware of R1's smoking status because it was not documented any place in R1's plan of care. LPN-C informed the Surveyor R1's poor safety awareness, R1's inability to light a cigarette, R1's lack of consistency performing safe smoking techniques, and R1's decision making skills not being reasonable or consistent were not factored into R1's safe smoking assessment determination. On 7/2/21, R1 was taken outside to smoke by CNA (Certified Nursing Assistant)-D at approximately 6:50 PM. R1 was transported by CNA-D down the facility ramp, which leads to the outside doors. CNA-D made an agreement with R1 in which CNA-D would come back in 30 minutes and assist R1 up ramp and upstairs to the unit where R1 resides. R1 was left unsupervised by staff in the facility's smoking area where additional residents were present. On 7/2/21, approximately ten minutes after CNA-D left R1 outside, R1 decided R1 wanted to go back into the building. One of the other residents who was also outside smoking punched a code in the locked facility door, which allowed R1 to enter the building. R1 wheeled self backwards down the lobby towards the ramp to access upstairs unit. R1 continued wheeling backwards across the lobby approximately 20 feet and went down an unsecured set of 12 stairs which were directly across from the main door. R1's and R1's wheelchair fell down the basement stairs. The residents in the facility's smoking area heard R1 fall down the basement stairs and came inside the building. One resident called 911 and one resident went to the nursing unit to get a staff to assist R1. When facility staff found R1, R1 was lying on back with both feet resting upon the last stair and R1's wheelchair upright next to R1's legs. R1 was immediately transferred to the emergency department by the paramedics. R1's hospital discharge summary, dated 7/3/21, documented discharge diagnoses as: fall downstairs, multiple closed fracture of ribs left side, closed head injury, cephalhematoma. R1's discharge summary documented R1's indication for admission to be; R1 with multiple recent falls presented to the emergency room as a trauma activation following a fall down stairs while in wheelchair. On survey date of 7/8/21, R1 had not yet returned to the facility from the hospital. On 7/8/21 at 11:39 AM., the Surveyor interviewed CNA (Certified Nursing Assistant)-D. CNA-D informed the Surveyor CNA-D had worked with R1 on multiple occasions and stated R1 had poor safety awareness and would frequently self-transfer even if staff would remind R1 not to self-transfer. CNA-D would have to assist and redirect R1 multiple times during a shift when R1 was attempting to self-transfer. On 7/8/21 at 9:47 AM., the Surveyor interviewed DON (Director of Nursing)-B regarding R1's fall. DON-B stated R1's smoking assessment on admission determined R1 was able to smoke unsupervised. DON-B stated R1 needed assistance up and down the ramp to get outside the building because R1 could not propel self in wheelchair because R1 had an injured left arm. DON-B stated the staff member that took R1 outside to smoke would agree on a time with R1 to see how long R1 wanted to stay outside, and the staff member would set a timer and return at the agreed on time. DON-B confirmed to the Surveyor R1's required assistance with lighting cigarettes and required staff transport to and from the smoking area were not in R1's plan of care. DON-B informed the Surveyor when staff assess a resident's smoking ability the determination is based on the observation staff observe to determine if a resident can smoke unsupervised or supervised. DON-B informed Surveyor there are questions which are asked related to cognition and communication but the biggest factor is the observation. DON-B informed the Surveyor R1's poor safety awareness, R1's inability to light a cigarette, R1's lack of consistency performing safe smoking techniques, and R1's decision making skills not being reasonable or consistent were not factored into R1's safe smoking assessment determination. Facility failure to properly assess and supervise a resident with documented poor decision-making skills and poor safety awareness created a finding of Immediate Jeopardy (IJ) that began on 7/2/21. The facility removed the IJ on 7/9/21, when it had completed the following: Mandatory Training being held 7/9/2021, no staff will be allowed to work until training has been completed. Director of Nursing and Administrator are responsible to ensure training has been completed. All staff to be educated on the categories of a smoker which is determined by the Smoking Assessment and the new Safe Smoking Assessment questionnaire. Training on 7/9/2021 and any remaining by the next shift. All Nurses will be individually educated on properly completing a Smoking Assessment and the Safe Smoking Assessment Questionnaire. All nurses will be individually educated by the Director of Nursing on 7/9/2021, any remaining nurses by the next shift. All Nurses will be individually trained on the Ring Doorbell utilizing the Charge Nurse Phone by the Director of Nursing on 7/9/2021, any remaining by the next shift. All staff at the 7/9/2021 Mandatory Training will be toured through the front entrance to allow them a visual guide of the smoking area, the Ring Doorbell and the newly secured stairway. Management will provide demonstrations and videotape them for any absent staff and also to educate any new hires. Training on 7/9/2021, any remaining staff will be educated by the next shift. In addition to the Smoking Assessment, we have created a Safe Smoking Assessment Questionnaire that have been completed for all current resident smokers on 7/8/2021. This assessment determines if they can safely exit and enter the facility independently or if they require staff assistance. All 10 residents who smoke have been reassessed to determine if they are Independent, need assistance with entering & exiting the facility or if they need to be completely chaperoned by staff while smoking on 7/8/2021. Walkie Talkie Program was put into effect to aide in communication with an Independent Smoker that needs physical assistance getting in and out of the facility. Put into effect on 7/8/2021. Ring Doorbell was purchased and will be mounted outside the front entrance for residents & visitors to utilize if the doors are locked (after hours) or if there is a malfunction with the front door. Put into place 7/9/2021. The open stairway leading to the basement level has been blocked using three 700 lb capacity ratchet straps that are Caution Yellow in color. Straps are securely mounted and staff tested several times to ensure proper placement and effectiveness. Straps are able to be released incase of an emergency. Put into place on 7/8/2021. Smoking Assessments & Safe Smoking Assessment Questionnaire will be updated quarterly & annually, and reviewed every quarter at QAPI. DON & Nurse Managers are responsible for the completion. The Walkie-Talkies used for resident to staff communication will be kept with the smoking cart and will be charged daily by the receptionist Monday-Friday and charge nurse on Saturday and Sunday. The Receptionist will check the Ring Doorbell Monday-Friday. The receptionist will go outside, ring the doorbell and ensure that the Charge Nurse answers appropriately. On Saturday & Sunday, the Weekend Manager will check the Ring Doorbell and ensure staff are answering it appropriately. This will be documented and kept in a binder at the front desk and reviewed every month at QAPI. If the equipment is not working or if there is any issue, staff will call the Administrator, DON or the Maintenance Director for assistance. The front entrance and stairwell will be checked at least weekly by maintenance and documented on a safety log which will be reviewed monthly at the Safety Committee Meeting.

Based on record review and staff interview, the facility did not ensure all violations of abuse for 1 Resident (R) (R1) of 4 residents were reported to the appropriate personnel in a timely manner. R1 was physically and verbally abused by an agency LPN (Licensed Practical Nurse) on two separate occasions during a N[NAME] (night) shift. A total of three staff witnessed one or both incidents. The incidents were not reported to the appropriate personnel until one staff finished the shift, exited the building and called the charge nurse. The failure to immediately report resident abuse prevented prompt investigation and prevented management from taking steps to prevent further potential abuse. The LPN continued working and abused R1 again approximately four hours later. This created a finding of Immediate Jeopardy that began on 7/7/19. Surveyor notified administrator of Immediate Jeopardy on 7/10/19 at 3:30 PM. The Immediate Jeopardy was removed on 7/9/19 after all staff involved in the abuse or who had not reported the abuse were removed from the facility and facility-wide training was completed for all staff related to abuse recognition and reporting. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Abuse Prevention/Vulnerable Adult Plan, dated 10/2017, states: The philosophy of Monarch Healthcare Management is to provide quality long-term care in a loving and caring atmosphere. Purpose: 2. To ensure that all incidents of alleged or suspected abuse/neglect are promptly investigated and reported. Response/Reporting: 1. All staff are responsible for reporting any situation that is considered abuse or neglect. 2. The Unit Nurse will be notified immediately, assess the situation to determine if any emergency treatment or action is required, and complete an initial investigation. Immediately upon learning of the incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the incident is being investigated .The Nurse will also ensure that any potential for further abuse is eliminated by taking one of the following actions: a. If this is staff to resident abuse, the staff person will be excused from position until the investigation is completed. 4. Notify the facility Administrator (or the designee) immediately if there are any incidents of mistreatment, resident abuse, exploitation or neglect of a resident, misappropriation of residents' property, or injuries to a resident of unknown source. In case of absence of the Administrator, staff will follow the chain of command for notification. On 7/10/19, the Surveyor reviewed R1's medical record. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent Quarterly MDS (Minimum Data Set), dated 6/27/19, indicated R1 was cognitively impaired, experienced [MEDICAL CONDITION], hallucinations and delusions and exhibited verbally and physically aggressive behavior. On 7/10/19, the Surveyor reviewed the facility's twenty-four report involving an instance of staff to resident abuse. The initial report was submitted to the State Agency on 7/07/19. The report stated, It was reported to (DON (Director of Nursing)-B) at 0600 by (RN (Registered Nurse)-G) that (CNA (Certified Nursing Assistant)-D) reported to (RN-G) that allegedly (LPN-C) slammed (R1) on the ground, punched (R1) in the chest, stepped on (R1's) chest, slammed (R1) in the chair, grabbed (R1's) shirt (which tightened around (R1's) chest) and wheeled (R1) into (R1's) room and closed the door. During an interview with the Surveyor, DON-B and HRD (Human Resources Director)-I on 7/10/19 at 11:50 AM, CNA-F indicated R1 was combative in the early morning hours of 7/07/19 and LPN-C came to the unit to provide assistance. CNA-F stated LPN-C placed LPN-C's leg across R1's chest and was containing and roughing (R1) up. CNA-F indicated when the first incident was over, LPN-C wheeled R1 to R1's room, pushed the wheelchair into the room and let the chair go. CNA-F and CNA-D entered R1's room and found R1 on the floor with the wheelchair tipped over. CNA-F stated CNA-F didn't witness the second incident; however, CNA-F heard a commotion on the unit and heard R1 yell, Help, he's beating me. CNA-F stated CNA-D indicated LPN-C was always really rough like that and always beats residents. CNA-F stated CNA-F didn't report the abuse to RN-G because CNA-D left the unit multiple times during the shift and stated the situation was taken care of. CNA-F also stated CNA-D indicated when CNA-E left the unit following the second incident of abuse, CNA-E was going to get (RN-G). CNA-F stated CNA-F was unable to leave the unit because CNA-F and CNA-D were the only staff on the unit and CNA-F needed to hold the memory care doors closed so R1 couldn't exit the unit. During an interview with the Surveyor on 7/10/19 at 2:32 PM, CNA-E stated when CNA-E entered the second floor with LPN-C to provide assistance to another resident at approximately 4:30 AM, R1 was agitated and yelling for R1's wife. CNA-E stated, (LPN-C) tried to move R1 down the hall toward R1's room, but R1 entered another resident's room. And then (LPN-C) went crazy. CNA-E stated LPN-C tried to get R1 in a wheelchair by initially pushing the wheelchair into the back of R1's legs. CNA-E stated, (LPN-C) went after (R1), grabbed (R1) by the back of the shirt, pulled (R1) down and sat (R1) on (R1's) butt (LPN-C) pulled (R1's) shirt and it came off. I'm not sure what (LPN-C) was trying to do. I blocked out some of it (LPN-C) had me help (LPN-C) pick (R1) up off the floor and put (R1) in the wheelchair. (LPN-C) pushed (R1) down the hallway and pushed (R1) in (R1's) room not very professionally and closed the door. CNA-E stated CNA-E returned to the third floor following the incident to continue (CNA-E's) assignments. During the interview, CNA-E stated, Things weren't registering in my head that things were wrong .I should have stopped (LPN-C). I was in disbelief. I should've done more. I'm sitting here kicking myself .I should've gone to (RN-G), but I didn't .I was doing morning cares with an orientee (on the third floor). I went back upstairs and finished my cares on my people . A written statement by CNA-E stated, At approximately 4:45 (AM) or so, (LPN-C) attempted to redirect (R1) back from the hallway on 2 West. (R1) was yelling profanities and was attempting to gain access to other patients' rooms. Upon entering a resident's room, (LPN-C) grabbed (R1) by the back of the shirt and (R1) was pulled down on the floor. (LPN-C) pulled on (R1's) t-shirt and it came up over (R1's) shoulders . A progress note, dated 7/07/19 and written by RN-G, stated, At approximately 0540 (5:40 AM) writer received a call from a CNA with a report of an altercation between resident and an agency LPN. I immediately went to this resident and assessed for injuries. Phone calls made to Manager on Call, DON, Administrator. Police contacted. A written statement by RN-G stated, My phone rang at approximately 0540 (5:40 AM) and it was (CNA-D) asking if (CNA-D) could tell me something privately and not to tell anyone. RN-G's statement included a description of the 2 incidents of abuse referenced in the criminal complaint. In the statement, RN-G stated, I immediately told the reporting CNA I have to go look and report this. I hung up the phone and ran up the stairs to the 2nd floor. (R1) was standing with (R1's) hands on the glass doors begging for help .I did see marks on (R1). (R1) was afraid, asked me to help .telling me (R1) was being beaten up . During interviews with the Surveyor on 7/10/19 at 8:30 AM and 11:30 AM, DON-B indicated the facility was made aware of the first abuse incident at 5:11 AM on 7/7/19 when CNA-D left work and telephoned RN-G. After receiving the call, RN-G placed R1 under staff supervision, made the appropriate notifications and called the police. DON-B stated, Sometime during the N[NAME] shift, (LPN-C) put (R1) in (R1's) room, but before that (LPN-C) shoved (R1) in a wheelchair, shoved (R1) in (R1's) room and the wheelchair tipped over. (LPN-C) closed the door and left (R1). CNA-D got (R1) up, got (R1) situated and didn't report the incident until (CNA-D) left the building. (CNA-D) is no longer employed here. (CNA-E) witnessed the second incident at approximately 4:45 AM where R1 was wandering on the West wing went into another resident's room and (LPN-C) grabbed (R1) by the t-shirt, pulled (R1) backwards and down onto the ground .(CNA-E) didn't report the incident right away because (CNA-E) got busy. (CNA-E) told (RN-G) about it when (RN-G) went to the floor after getting the call from (CNA-D). DON-B stated DON-B was not able to interview CNA-D following the incident. DON-B stated, I'm just sickened that neither CNA reported the incidents right away. DON-B stated LPN-C worked the entire shift because the incidents weren't reported in a timely manner. On 7/10/19, the Surveyor reviewed the Criminal Complaint. The complaint indicated CNA-D witnessed LPN-C physically and verbally abuse R1 on 7/07/19 at 12:30 AM and physically abuse R1 again at approximately 4:15 AM. The assaults left R1 with bruises, scratches, abrasions and mental anguish. (For additional information regarding the criminal complaint, see citation F600.) The failure to report immediately upon witnessing resident abuse prevented prompt investigation and prevented management from taking steps to prevent further potential abuse. This created a finding of Immediate Jeopardy that began on 7/7/19. The facility removed the Immediate Jeopardy on 7/9/19 when it completed the following: 1. All staff involved in the abuse or who had not reported the abuse were removed from the facility 2. All facility abuse policies were reviewed and facility-wide training was completed for all staff related to abuse recognition and reporting.

Based on record review and staff interview, the facility did not ensure 1 Resident (R) (R1) of 4 residents was free from physical and verbal abuse. On or about [DATE], R1 was physically and verbally abused by an agency LPN (Licensed Practical Nurse) on two separate occasions during a N[NAME] (night) shift. A total of three additional staff witnessed one or both incidents.The LPN punched R1, stepped on R1 and, later, dragged R1 across the floor. R1's injuries included bruises, scratches and abrasions to R1's torso, arms, hands and neck. R1 expressed pyschosocial harm to include fear; stated (R1) was beaten up and asked staff not to leave (R1) alone. The failure to prevent resident abuse and failure of staff to intervene immediately upon witnessing resident abuse created a finding of Immediate Jeopardy that began on [DATE]. Surveyor notified administrator of Immediate Jeopardy on [DATE] at 3:30 PM. The Immediate Jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Abuse Prevention/Vulnerable Adult Plan, dated ,[DATE], states: The philosophy of Monarch Healthcare Management is to provide quality long-term care in a loving and caring atmosphere. Purpose: 1. To ensure that residents are not subjected to abuse by anyone including but not limited to, facility staff, other residents, volunteers, staff of other agencies serving the individual, family members or legal guardians, friends or other individuals . c. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Willful as used in this definition of abuse means the individual must have acted deliberately, intended to inflict injury, psychosocial harm, harassment, humiliate, threaten or frighten a resident. On [DATE], the Surveyor reviewed R1's medical record. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent Quarterly MDS (Minimum Data Set), dated [DATE], indicated R1 was cognitively impaired, experienced [MEDICAL CONDITION], hallucinations and delusions and exhibited physically and verbally aggressive behavior. R1 required extensive assistance of staff for transfers and ADLs (activities of daily living), but was noted to be independently ambulatory with an unsteady gait. R1 received antipsychotic medication and resided on the facility's memory care unit. The unit was accessible through a set of glass and wooden doors that were secured but able to be disengaged after 15 seconds of pressure. R1's Increased Restlessness During N[NAME] Hours care plan, dated [DATE], directed staff to divert and redirect R1's energy, validate R1's feelings and provide repetitive tasks such as folding towels and sorting playing cards. Additional interventions directed staff to check for possible needs related to hunger, thirst, fatigue, pain or bathroom usage and to provide an escort at all times when off the unit. On [DATE], the Surveyor reviewed the Criminal Complaint. The complaint indicated LPN-C was charged with two Class G Felonies for Intentionally Subjecting An Individual At Risk to Abuse-Likely to Cause Great Bodily Harm and two Class H Felonies for Aggravated Battery-Elderly Person. The complaint stated, (PO (Police Officer)-H) made contact with (CNA-D) who had witnessed the assault to (R1) by (LPN-C), herinafter referred to as the defendant. (CNA-D) stated that (CNA-D) worked at the nursing home and stated (CNA-D) was assigned to the second floor which primarily is for patients with dementia and Alzheimer's. (CNA-D) stated the first incident occurred around 12:30 AM on ([DATE]). (CNA-D) stated that (R1) broke out of (R1's) room and was walking in the hallway. (CNA-D) stated that (CNA-D) went to assist (R1) back into (R1's) room and (R1) slid down onto the floor. (CNA-D) stated that (CNA-D) and another CNA attempted to get (R1) off the floor. The defendant then approached the situation where both (CNA-D) and the other CNA were attempting to get (R1) to stand but were having a difficult time due to (R1's) size. The defendant also came to help get (R1) back into (R1's) room. (R1) began yelling and screaming while still on the floor. The defendant then punched (R1) in the chest. (CNA-D) stated that the defendant then took (the defendant's) foot and put it on (R1's) waist area with force in order to hold (R1) down. (CNA-D) indicated that while this was going on the defendant called (R1) (an expletive). All three parties again attempted to get (R1) into a standing position. Both CNAs were on each arm and the defendant took (R1's) shirt and twisted it around (R1's) neck. The defendant with the use of the twisted shirt dragged (R1) to (R1's) wheelchair. Once (R1) was placed in the wheelchair, the defendant continued applying pressure to (R1's) neck, including dragging the shirt behind the wheelchair and extending (R1's) (sic) backwards. With (R1) in the wheelchair the defendant started pushing the wheelchair back into (R1's) room. (CNA-D) indicated that while the defendant started pushing the wheelchair the defendant entered (R1's) room and pushed it with great force. (CNA-D) stated that (CNA-D) entered the room and saw (R1) on the floor and the wheelchair flipped over. (CNA-D) stated that the defendant closed the door to (R1's) room and said, 'If the (expletive) gives you any more problems call me.' (CNA-D) also described the second incident that occurred between 4:15 and 4:20 AM on ([DATE]). (CNA-D) stated that (R1) was again outside of (R1's) room and (CNA-D) attempted to re-direct (R1) to (R1's) sleeping quarters. (R1) was not complying with (CNA-D's) directions but was not acting aggressively towards (CNA-D). The defendant entered the floor and saw what was going on and again came down to assist (CNA-D) with (R1). (R1) having seen the defendant coming down the hallway made a statement to (CNA-D) that that's the (person) that tried to kill (R1) earlier in the night. The defendant had a wheelchair approaching (R1) from behind and started ramming the wheelchair into (R1's) legs. (R1) stated that the defendant was hurting (R1). (R1) attempted to enter another resident's room. The defendant again grabbed (R1's) shirt in a twisting motion and dragged (R1) down to the ground. The defendant continued to drag (R1) out of the room. When the defendant grabbed onto (R1's) t-shirt and yanked (R1) backwards to the ground the defendant then pulled (R1) backwards across the hall by (R1's) t-shirt and in doing so pulled (R1's) shirt off of (R1). (CNA-D) stated that the defendant had made several statements upon completion of the second assault. The defendant first stated, 'If (R1) gives you a problem I'll (expletive) (R1) up.' (CNA-D) stated that (CNA-D) had worked with the defendant approximately 20 times in the past and (CNA-D) has reported (the defendant) to administration for previous situations of negligence including one time when the defendant refused to provide needed medications to dying patients (*Note: CNA-D's statement of reporting the defendant to administration refers to incidents that occurred at a different facility than Sunny Ridge.) (CNA-D) also reported that the defendant said to (CNA-D), 'Whatever happened here you did not see it.' It should be noted that there were several visible injuries to (R1) including (R1's) neck. There was redness around (R1's) neck. There was also redness and abrasions around (R1's) armpits. There was also a scratch mark to (R1's) left shoulder area. It should be noted that (R1) has dementia. A written statement by RN-G stated, . My phone rang at approximately 0540 (5:40 AM) and it was (CNA-D) asking if (CNA-D) could tell me something privately and not to tell anyone. (CNA-D) said (LPN-C) abused (R1) and described it as: slammed (R1) to the ground, punched (R1's) chest, stepped on (R1's) chest and stomach, slammed (R1) into (R1's) wheelchair, grabbed (R1) by (R1's) shirt and the shirt tightened around (R1's) neck. (CNA-D) states (LPN-C) slammed resident into (R1's) wheelchair and the wheelchair flipped over. Told me (LPN-C) 'rammed' the wheelchair into (R1) and brought (R1) to (R1's) room and closed the door. Sometime shortly thereafter, (R1) came out of (R1's) room and wandered through the locked doors to the West side. When (R1) saw (LPN-C), (R1) turned and went in a different resident's room. (CNA-D) said as if (R1) were afraid when (R1) saw (LPN-C). (R1) was in a different resident's room and (LPN-C) went in, grabbed (R1) by the back of (R1's) shirt and pulled (R1) backward, pulling (R1) and dragging (R1) down, (R1's) shirt being pulled across (R1's) neck. (LPN-C) reportedly instructed a CNA to help (LPN-C) get (R1) in (R1's) wheelchair, which (the CNA) did. At that point, (LPN-C) pushed the wheelchair back to the East side with (R1) seated in the chair back to (R1's) room and closed the door. I immediately told the reporting CNA I have to go look and report this. I hung up the phone and ran up the stairs to the 2nd floor. (R1) was standing with (R1's) hands on the glass doors begging for help, standing in (R1's) gripper socks and boxer shorts, shirtless .In dim light, I did see marks on (R1). (R1) was afraid, asked me to help (R1), telling me (R1) was being beaten up .I saw 2 pink areas the size of a hand on (R1's) abdomen, (R1's) left knee was bloodied , pink/red abrasions on each side of (R1's) neck, abrasion along left shoulder/scapula, abrasion on right side of chest below/next to right arm, appears to have bruised forearms . During an interview with the Surveyor, DON-B and HRD (Human Resources Director)-I on [DATE] at 11:50 AM, CNA-F indicated R1 was combative in the early morning hours of [DATE] and LPN-C came to the unit to provide assistance. CNA-F stated LPN-C placed LPN-C's leg across R1's chest and was containing and roughing (R1) up. CNA-F stated LPN-C stated, I was detaining (R1). That's how you detain someone. You throw your leg over them. CNA-F indicated when the first incident was over, LPN-C wheeled R1 to R1's room, pushed the wheelchair into the room and let the chair go. CNA-F and CNA-D entered R1's room and found R1 on the floor with the wheelchair tipped over. During the second incident, CNA-F stated CNA-F was in the linen room, but ran out of the room when (CNA-F) heard a commotion on the unit and R1 yelled, Help, he's beating me. CNA-F stated R1 wasn't wearing a shirt and was real red. CNA-F stated CNA-D indicated LPN-C was always really rough like that and always beats residents. A written statement by CNA-E stated, At approximately 4:45 (AM) or so, (LPN-C) attempted to redirect (R1) back from the hallway on 2 West. (R1) was yelling profanities and was attempting to gain access to other patients' rooms. Upon entering a resident's room, (LPN-C) grabbed (R1) by the back of the shirt and (R1) was pulled down on the floor. (LPN-C) pulled on (R1's) t-shirt and it came up over (R1's) shoulders. (LPN-C) had me help (R1) up and we put (R1) in a wheelchair and (LPN-C) pushed (R1) back to (R1's) room and closed the door. During an interview with the Surveyor via telephone on [DATE] at 2:32 PM, CNA-E stated CNA-E entered the second floor with LPN-C to provide assistance to another resident at approximately 4:,[DATE]:45 AM on [DATE]. CNA-E indicated R1 was agitated and yelling for R1's wife. CNA-E stated, I didn't make any contact with (R1), I hung back. (LPN-C) tried to move (R1) down the hall toward (R1's) room, but (R1) entered another resident's room. And then (LPN-C) went crazy. CNA-E stated LPN-C tried to get R1 in the wheelchair by initially pushing the wheelchair into the back of R1's legs. CNA-E stated, (LPN-C) went after (R1), grabbed (R1) by the back of the shirt, pulled (R1) down and sat (R1) on (R1's) butt (LPN-C) pulled (R1's) shirt and it came off. I'm not sure what (LPN-C) was trying to do. I blocked out some of it (LPN-C) had me help (LPN-C) pick (R1) up off the floor and put (R1) in a wheelchair. (LPN-C) pushed (R1) down the hallway and pushed (R1) in (R1's) room not very professionally and closed the door. CNA-E stated CNA-E returned to the third floor following the incident to continue (CNA-E's) assignments. CNA-E did not come in contact with LPN-C for the remainder of the shift. CNA-E stated CNA-E worked with LPN-C in the past and never witnessed LPN-C be abusive toward residents. The Surveyor reviewed R1's body audit completed immediately following the assault and noted the following injuries: an abrasion on the right torso beneath R1's armpit, an abrasion on R1's right shoulder, abrasions to the front and back of R1's neck, 2 pink areas on R1's abdomen, a bruise on the back of R1's left lower arm, scratches on the back of R1's left upper back, a scratch on the back of R1's left lower arm and a scratch on the back of R1's left hand. A body audit completed later in the day on [DATE] contained the above mentioned injuries including 4 bruises on the back of R1's right arm. A progress note, dated [DATE] at 8:42 PM, stated, (FM (Family Member-J) left at (6:30 PM). Resident has been calling out help me since (FM-J) left. Unable to verbalize what type of help (resident) needs .wandering and yelling .has been on 1:1 since (7:00 PM) .Continues to refuse to sit for any length of time. Resident yells they are trying to kill me, where are the cops, we need to get the cops, (someone) is trying to kill me .Resident is visibly upset. Resident has been knocking on the windows in (resident's) room, the day room and the dining room and yelling help me, come on help me . During an interview with the Surveyor on [DATE] at 2:36 PM, FM-J indicated FM-J was notified immediately following the incident and arrived at the facility at 8:00 AM. FM-J indicated R1 was restless on [DATE] and stated, (R1) wasn't sleeping like (R1) usually does. (R1) kept looking at (R1's) arms and didn't want me to touch (R1's) right shoulder. (R1) had marks and bruises .fresh bruises .It looked like (R1) had a hand print with scratches and red marks on the back of (R1's) neck. (R1's) neck was red all around in the front I'm here every day. I know when things are different. FM-J also stated, (R1's) shirt was ripped at the neck. During an interview with the Surveyor on [DATE] at 2:15 PM, LPN-N stated LPN-N worked with LPN-C as both a CNA and an LPN. LPN-N stated LPN-N didn't witness or hear that LPN-C was abusive toward residents. LPN-N also stated LPN-N cared for R1 on the [DATE] AM shift. LPN-N stated when LPN-N assisted R1 to the bathroom, R1 asked LPN-N not to leave and stated, He'll come back. The failure to prevent resident abuse and failure of staff to intervene immediately upon witnessing resident abuse, created a finding of Immediate Jeopardy that began on [DATE]. The facility removed the Immediate Jeopardy on [DATE] when it completed the following: 1. All staff involved in the abuse or who had not reported the abuse were removed from the facility 2. All facility abuse policies were reviewed and facility-wide training was completed for all staff related to abuse recognition and reporting. The deficient practice continues at a scope/severity of D as the facility continues to implement its action plan.

Based on record review and staff interview, the facility did not ensure all violations of abuse for 1 Resident (R) (R1) of 4 residents were reported to the appropriate personnel in a timely manner. R1 was physically and verbally abused by an agency LPN (Licensed Practical Nurse) at approximately 12:30 AM on 7/7/19. This was witnessed by two certified nursing assistants (CNAs). Neither CNA reported the abuse; consequently no steps were taken to prevent further potential abuse and the LPN continued to work. Approximately four hours later, the LPN physically and verbally abused R1 again, this time dragging R1 across the floor by pulling on R1's shirt. The failure to take steps to prevent further potential abuse created a finding of Immediate Jeopardy that began on 7/7/19. Surveyor notified administrator of Immediate Jeopardy on 7/10/19 at 3:30 PM. The Immediate Jeopardy was removed on 7/9/19. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Abuse Prevention/Vulnerable Adult Plan, dated 10/2017, states: The philosophy of Monarch Healthcare Management is to provide quality long-term care in a loving and caring atmosphere. Purpose: 2. To ensure that all incidents of alleged or suspected abuse/neglect are promptly investigated and reported. Response/Reporting: 1. All staff are responsible for reporting any situation that is considered abuse or neglect. 2. The Unit Nurse will be notified immediately, assess the situation to determine if any emergency treatment or action is required, and complete an initial investigation. Immediately upon learning of the incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the incident is being investigated .The Nurse will also ensure that any potential for further abuse is eliminated by taking one of the following actions: a. If this is staff to resident abuse, the staff person will be excused from position until the investigation is completed. 4. Notify the facility Administrator (or the designee) immediately if there are any incidents of mistreatment, resident abuse, exploitation or neglect of a resident, misappropriation of residents' property, or injuries to a resident of unknown source. In case of absence of the Administrator, staff will follow the chain of command for notification. On 7/10/19, the Surveyor reviewed R1's medical record. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent Quarterly MDS (Minimum Data Set), dated 6/27/19, indicated R1 was cognitively impaired, experienced [MEDICAL CONDITION], hallucinations and delusions and exhibited verbally and physically aggressive behavior. On 7/10/19, the Surveyor reviewed the facility's twenty-four report involving an instance of staff to resident abuse. The initial report was submitted to the State Agency on 7/07/19. The report stated, It was reported to (DON (Director of Nursing)-B) at 0600 by (RN (Registered Nurse)-G) that (CNA (Certified Nursing Assistant)-D) reported to (RN-G) that allegedly (LPN-C) slammed (R1) on the ground, punched (R1) in the chest, stepped on (R1's) chest, slammed (R1) in the chair, grabbed (R1's) shirt (which tightened around (R1's) chest) and wheeled (R1) into (R1's) room and closed the door. During an interview with the Surveyor, DON-B and HRD (Human Resources Director)-I on 7/10/19 at 11:50 AM, CNA-F indicated R1 was combative in the early morning hours of 7/07/19 and LPN-C came to the unit to provide assistance. CNA-F stated LPN-C placed LPN-C's leg across R1's chest and was containing and roughing (R1) up. CNA-F indicated when the first incident was over, LPN-C wheeled R1 to R1's room, pushed the wheelchair into the room and let the chair go. CNA-F and CNA-D entered R1's room and found R1 on the floor with the wheelchair tipped over. CNA-F stated CNA-F didn't witness the second incident; however, CNA-F heard a commotion on the unit and heard R1 yell, Help, he's beating me. CNA-F stated CNA-D indicated LPN-C was always really rough like that and always beats residents. CNA-F stated CNA-F didn't report the abuse to RN-G because CNA-D left the unit multiple times during the shift and stated the situation was taken care of. CNA-F also stated CNA-D indicated when CNA-E left the unit following the second incident of abuse, CNA-E was going to get (RN-G). CNA-F stated CNA-F was unable to leave the unit because CNA-F and CNA-D were the only staff on the unit and CNA-F needed to hold the memory care doors closed so R1 couldn't exit the unit. Neither CNA-D nor CNA-F reported the abuse witnessed at approximately 12:30 AM on 7/7/19 and LPN-C continued working the remainder of the shift. During an interview with the Surveyor on 7/10/19 at 2:32 PM, CNA-E stated when CNA-E entered the second floor with LPN-C to provide assistance to another resident at approximately 4:30 AM, R1 was agitated and yelling for R1's wife. CNA-E stated, (LPN-C) tried to move R1 down the hall toward R1's room, but R1 entered another resident's room. And then (LPN-C) went crazy. CNA-E stated LPN-C tried to get R1 in a wheelchair by initially pushing the wheelchair into the back of R1's legs. CNA-E stated, (LPN-C) went after (R1), grabbed (R1) by the back of the shirt, pulled (R1) down and sat (R1) on (R1's) butt (LPN-C) pulled (R1's) shirt and it came off. I'm not sure what (LPN-C) was trying to do. I blocked out some of it (LPN-C) had me help (LPN-C) pick (R1) up off the floor and put (R1) in the wheelchair. (LPN-C) pushed (R1) down the hallway and pushed (R1) in (R1's) room not very professionally and closed the door. CNA-E stated CNA-E returned to the third floor following the incident to continue (CNA-E's) assignments. During the interview, CNA-E stated, Things weren't registering in my head that things were wrong .I should have stopped (LPN-C). I was in disbelief. I should've done more. I'm sitting here kicking myself .I should've gone to (RN-G), but I didn't .I was doing morning cares with an orientee (on the third floor). I went back upstairs and finished my cares on my people . A written statement by CNA-E stated, At approximately 4:45 (AM) or so, (LPN-C) attempted to redirect (R1) back from the hallway on 2 West. (R1) was yelling profanities and was attempting to gain access to other patients' rooms. Upon entering a resident's room, (LPN-C) grabbed (R1) by the back of the shirt and (R1) was pulled down on the floor. (LPN-C) pulled on (R1's) t-shirt and it came up over (R1's) shoulders . A progress note, dated 7/07/19 and written by RN-G, stated, At approximately 0540 (5:40 AM) writer received a call from a CNA with a report of an altercation between resident and an agency LPN. I immediately went to this resident and assessed for injuries. Phone calls made to Manager on Call, DON, Administrator. Police contacted. A written statement by RN-G stated, My phone rang at approximately 0540 (5:40 AM) and it was (CNA-D) asking if (CNA-D) could tell me something privately and not to tell anyone. RN-G's statement included a description of the 2 incidents of abuse referenced in the criminal complaint. In the statement, RN-G stated, I immediately told the reporting CNA I have to go look and report this. I hung up the phone and ran up the stairs to the 2nd floor. (R1) was standing with (R1's) hands on the glass doors begging for help .I did see marks on (R1). (R1) was afraid, asked me to help .telling me (R1) was being beaten up . During interviews with the Surveyor on 7/10/19 at 8:30 AM and 11:30 AM, DON-B indicated the facility was made aware of the first abuse incident at 5:11 AM on 7/7/19 when CNA-D left work and telephoned RN-G. After receiving the call, RN-G placed R1 under staff supervision, made the appropriate notifications and called the police. DON-B stated, Sometime during the N[NAME] shift, (LPN-C) put (R1) in (R1's) room, but before that (LPN-C) shoved (R1) in a wheelchair, shoved (R1) in (R1's) room and the wheelchair tipped over. (LPN-C) closed the door and left (R1). CNA-D got (R1) up, got (R1) situated and didn't report the incident until (CNA-D) left the building. (CNA-D) is no longer employed here. (CNA-E) witnessed the second incident at approximately 4:45 AM where R1 was wandering on the West wing went into another resident's room and (LPN-C) grabbed (R1) by the t-shirt, pulled (R1) backwards and down onto the ground .(CNA-E) didn't report the incident right away because (CNA-E) got busy. (CNA-E) told (RN-G) about it when (RN-G) went to the floor after getting the call from (CNA-D). DON-B stated DON-B was not able to interview CNA-D following the incident. DON-B stated, I'm just sickened that neither CNA reported the incidents right away. DON-B stated LPN-C worked the entire shift because the incidents weren't reported in a timely manner. On 7/10/19, the Surveyor reviewed the Criminal Complaint. The complaint indicated CNA-D witnessed LPN-C physically and verbally abuse R1 on 7/07/19 at 12:30 AM and physically abuse R1 again at approximately 4:15 AM. The assaults left R1 with bruises, scratches, abrasions and mental anguish. (For additional information regarding the criminal complaint, see citation F600.) The failure to report immediately report witnessed resident abuse prevented prompt investigation and prevented management from taking steps to prevent further potential abuse. This created a finding of Immediate Jeopardy that began on 7/7/19. The facility removed the Immediate Jeopardy on 7/9/19 when it completed the following: 1. All staff involved in the abuse or who had not reported the abuse were removed from the facility 2. All facility abuse policies were reviewed and facility-wide training was completed for all staff related to abuse recognition and reporting.

Based on record review and staff interview, the facility failed to ensure abuse and dementia care training were completed for one CNA (Certified Nursing Assistant) prior to the CNA's ability to work without a preceptor. In addition, the facility failed to ensure agency staff were educated on the facility's abuse policy and dementia care training. This practice directly affected 1 Resident (R) (R1) and had the potential to affect all residents on the memory care unit. R1 had a [DIAGNOSES REDACTED]. The facility did not provide abuse and dementia training for agency staff. In addition, a newly hired employee of the facility (CNA-F) was scheduled on the memory care unit without a preceptor prior to completing abuse and dementia training. CNA-F did not know that the technique the LPN used to detain R1 was abuse and did not know what to do afterwards in terms of reporting abuse. CNA-F did not know how to manage R1's behaviors to prevent these behaviors from escalating, which contributed to a second episode of abuse approximately four hours after the first incident. The failure to prevent resident abuse and failure to train staff to intervene/report immediately upon witnessing resident abuse, created a finding of Immediate Jeopardy that began on 7/7/19. Surveyor notified administrator of Immediate Jeopardy on 7/10/19 at 3;30 PM. The Immediate Jeopardy was removed on 7/9/19. The deficient practice continues at a scope/severity of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's Abuse Prevention/Vulnerable Adult Plan, dated (MONTH) (YEAR), states: Training 1. Monarch Healthcare Management provides corporate orientation to all new employees. At this time Residents' Rights and Vulnerable Adult Law Policies and Procedures are reviewed and staff receives an employee policy book which outlines these policies/procedures. All new employees receive training on how to report alleged abuse/neglect at this time. All employees of Monarch Healthcare Management receive annual in-service training on Residents' Rights and Vulnerable Adult Policies and Procedures. In addition to this, employees receive additional training on interventions to deal with aggressive residents and residents exhibiting catastrophic reactions. The facility's Health Care Academy Requirements (used for abuse and dementia training) states: New Hires: Complete the following courses in HCA (Health Care Academy) within the first week of hire Elder Justice Act Vulnerable Adult: Freedom from Abuse, Neglect & Exploitation . The following courses are to be completed before (MONTH) 15th . Understanding Dementia Abuse Prevention in Persons with Dementia The facility's Employee Policy Manual, dated 6/17/19, states: Orientation: An orientation program shall be conducted for all newly hired employees. Our orientation program includes, but it not limited to: A series of online orientation courses, including but not limited to abuse prohibition policies, to be completed within the first 7 days of hire. In addition to our general and online orientation, each department will orientate the newly hired employee to his or her department's policies and procedures, as well as other information that will aide him/her in understanding the team concept, attitudes and approaches to resident care. Required Reporting: In order to ensure the highest level of services to our clients, every employee is assigned the responsibility to report the his/her Department Director or person in charge of the facility when any of the following occurs: Any knowledge of, or a reasonable cause to believe: A client is being mistreated or neglected. During an interview with the Surveyor on 7/10/19 at 8:30 AM, NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B indicated R1 had dementia with behaviors. R1 was verbally and physically aggressive and was known to wander, hit, kick and slam doors. NHA-A stated R1's behaviors caused the facility to evacuate the memory care unit on at least one occasion. NHA-A and DON-B stated facility staff received Vulnerable Adult/Freedom from Abuse, Neglect and Exploitation and Elder Justice Act training within the first week of hire and at least annually thereafter; however, agency staff received abuse training from their agencies. NHA-A and DON-B stated agency staff received a one hour orientation session prior to the start of their first shift; however, the training was geared toward a tour of the facility, the unit upon which they were scheduled and what was expected of them task-wise. NHA-A and DON-B stated agency staffs' training at the facility did not cover the facility's Abuse Prevention/Vulnerable Adult Plan. On 7/10/19, the Surveyor reviewed a facility Self Report, Criminal Complaint and investigation regarding two instances of abuse incurred by R1 and inflicted by LPN (Licensed Practical Nurse)-C. The abuse occurred during the N[NAME] (night) shift on 707/19 and was witnessed by two facility CNAs and one agency CN[NAME] The Criminal Complaint indicated Agency CNA-D witnessed Agency LPN-C physically and verbally abuse R1 at 12:30 AM and physically abuse R1 again at approximately 4:15 AM. The facility's investigation concluded facility CNA-F witnessed the first assault and facility CNA-E witnessed the second assault. The assaults left R1 with bruises, scratches, abrasions and mental anguish. (For additional information regarding the Criminal Complaint and the subsequent investigation, see citation F600.) During an interview with the Surveyor, DON-B and HRD (Human Resources Director)-I on 7/10/19 at 11:50 AM, CNA-F indicated R1 was combative in the early morning hours of 7/07/19. CNA-F stated LPN-C placed LPN-C's leg across R1's chest and indicated R1 was being detained. CNA-F stated CNA-F was unfamiliar with R1, the facility's policy regarding detainment and the memory care unit in general as that was the first shift CNA-F worked on that unit. CNA-F stated CNA-F was hired on 6/25/19 and worked approximately 3 shifts prior to the 7/07/19 N[NAME] shift. DON-B and HRD-I indicated CNA-F was scheduled for orientation on the N[NAME] shift; however, CNA-F was counted in the staffing when the facility received a call-in on that shift. HRD-I stated the schedule was changed by RN (Registered Nurse)-G and CNA-F was mistakenly removed from orientation. HRD-I stated new employees were required to complete twelve training modules, including modules related to abuse and dementia care, within the first week of orientation. HRD-I stated staff worked with a mentor until the training was completed. HRD-I and DON-B verified CNA-F didn't complete any of the modules prior to the 7/07/19 N[NAME] shift. In addition, CNA-F was left alone on the unit for periods of time. CNA-F was unfamiliar with R1's plan of care and the interventions it contained to redirect R1 and provide alternative activities. CNA-F stated CNA-F felt it was appropriate to hold the memory care unit doors closed so R1 couldn't exit the unit and wake up residents in the East wing. CNA-F indicated R1 was agitated most of the shift and stated, I was holding the door trying to detain (R1). CNA-F stated R1 became increasingly agitated when CNA-F held the door and R1 was unable to exit the unit. During an interview with the Surveyor on 7/10/19 at 8:30 AM, NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B NHA-A and DON-B stated they were unsure of the nature of the abuse and dementia training LPN-C and CNA-D's agencies provided prior to the incidents on 7/07/19. DON-B provided the Surveyor with a copy of LPN-C's agency training. The training included a section entitled Abuse and Neglect, but didn't specify what was included in the training. DON-B stated the facility did not have a copy of CNA-D's training. During an interview with the Surveyor on 7/10/19 at 11:20 AM, DON-B stated agency staff were not required to read and sign the facility's Abuse Prevention/Vulnerable Adult Plan prior to working in the facility and before the incidents on 7/07/19. Because of a lack of training, CNA-F did not recognize that the detainment method used by LPN-C was abuse and did not know that abuse needed to be immediately reported so that appropriate follow-up and prevention could be implemented. The failure to prevent resident abuse and failure to train staff to intervene/report immediately upon witnessing resident abuse, created a finding of Immediate Jeopardy that began on 7/7/19. The facility removed the Immediate Jeopardy on 7/9/19 when it completed the following: 1. All staff involved in the abuse or who had not reported the abuse were removed from the facility 2. All facility abuse policies were reviewed and facility-wide training was completed for all staff related to abuse recognition and reporting.

Based on observation, interview, and record review, the facility did not ensure 5 of 23 sampled and supplemental sampled residents reviewed for advance directives (residents #5, #22, #23, #10, and #15) had the necessary advance directive documentation to ensure their life sustaining wishes would be honored. Additionally, the facility did not have a system in place whereby all nurses knew how to accurately identify each resident's life sustaining wishes. Resident #5 was to be full code status and, as of [DATE], had requested to receive CPR (Cardiopulmonary Resuscitation), a medical intervention used to restore circulatory and/or respiratory function if he became pulseless and non-breathing. However, the facility's documentation was inaccurate and the facility had not implemented the appropriate measures that would identify resident #5 as being a Full Code. If resident #5 were to become pulseless and non-breathing, staff may not have provided CPR as the resident had requested, which would have denied Resident #5 the only chance he had for living. Resident #22 had requested a code status of DNR (Do Not Resuscitate)upon admission to the facility. However, the facility had not obtained a physician's order for the resident's DNR status. Under Wisconsin law, there must be a signed physician's order before an individual can be considered "no-code." Additionally, the facility did not obtain a DNR bracelet to identify the resident's wishes for first responders if the resident became pulseless and non-breathing while out of the facility. The facility's failure to obtain a DNR order had the potential to result in this resident receiving CPR when it was against the resident's wishes. Resident #10 had requested a code status of DNR upon admission to the facility. However, the current physician's orders indicated that the resident was a "FULL CODE." The facility failed to obtain a physician's order for the resident's DNR and DNR bracelet to identify the resident's wishes. The facility's failure to obtain a DNR order had the potential to result in this resident receiving CPR when it was against the resident's wishes. Resident #15 had requested a code status of DNR upon admission to the facility. The physician's orders indicated that the resident was a "DNR." However, the facility had not obtained the required State DNR form signed by the physician indicating the DNR status and had not obtained a DNR bracelet to identify the resident's wishes for first responders when the resident was out of the building. The facility's failure to obtain a DNR order had the potential to result in this resident receiving CPR when it was against the resident's wishes. Resident #23 was identified as a Full Code status and when surveyor # observed the resident's room door on [DATE], the room door did not have a blue sticker, as defined in the facility's CPR policy. This could have created a situation where staff may not have initiated CPR in a timely manner in accordance with the resident's wishes. The facility's CPR policy and procedure provided no system or direction to staff on what code status identification system was to be implemented and staff gave different responses as to how they would identify a resident's code status. This created the potential for residents to not receive CPR when indicated, or to receive CPR when not indicated. The failure of the facility to implement appropriate measures to ensure that staff could accurately identify and implement the measures that residents had requested in relation to life-sustaining measures created a finding of immediate jeopardy. The jeopardy began on [DATE] when Resident #5's life-sustaining wishes changed and these were not accurately reflected in the record. NHA (Nursing Home Administrator)-W was formally notified on [DATE] that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on [DATE], however the deficient practice continued at a scope and severity of F (potential for harm/wide spread) while the facility works to fully implement its action plan. Findings include: The facility's CPR (cardiopulmonary resuscitation) policy and procedure dated ,[DATE] and revised ,[DATE], indicates that this facility will provide CPR in accordance with each resident's advance directives or in the absence of a DNR order. The procedure indicated each resident or their decision maker would be informed upon admission about their rights to make decisions, including formulating advance directives and their CPR wishes should a [MEDICAL CONDITION] occur. The facility was to indicate each resident's CPR preferences in Advance Directive documents or on the facility's CPR preference form. Although the facility's policy indicated each resident's CPR preference would be readily available for quick identification, the procedures implementing this policy did not outline a system by which this would be done. The facility provides CPR certified staff on every shift. First responders, per chapter 154 Wisconsin Statutes, must see a state-recognized DNR bracelet on an individual who is in the community before they will not perform CPR. Residents who leave the facility on an outing must be wearing a DNR bracelet if they want their do-not-resuscitate wishes to be honored. 1. Resident #5's face sheet dated [DATE], indicated that resident #5 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's CPR preferences have changed more than once during his stay at the facility. On [DATE], the resident completed the "Power of Attorney for Health Care" documents and designated FM (Family Member)-V as his POAHC (Power of Attorney for Health Care). The "Statement to Activate Durable Power of Attorney for Healthcare/ Living Will" document was signed by two physicians on [DATE] and [DATE], indicating resident #5 was "incapacitated" and "lacks the capacity to mange his/her healthcare decisions." On [DATE], a "CPR Preference" document was filled out by a facility RN (Registered Nurse) indicating resident #5's code status was changing and the resident should now receive CPR if needed. The "CPR Preference" form documented that this preference had been verified by FM-V via a telephone interview on [DATE]. FM-V signed the "CPR Preference" form dated [DATE] on [DATE], indicating that resident #5 was now to receive CPR if needed. On [DATE], surveyor # reviewed resident #5's medical record. The face sheet dated [DATE], indicated resident #5's code status was "DNR no CPR." Resident #5's [DATE] monthly "Physician's Orders" form was signed and dated [DATE], by the resident's PCP (Primary Care Provider) and included documentation that the resident's code status was a "Full Code" (to receive CPR if needed). Resident #5's current plan of care did not address the resident's code status. Resident #5's medical record included documentation that on [DATE], the nurse practitioner noted the resident's code status had changed to a Full Code (yes CPR) per FM-V. On [DATE] at 10:30 a.m., surveyor # interviewed DON (Director Of Nursing)-D regarding resident's code status identification. DON-D indicated residents who want to be a "Full Code" have a blue dot near their name plate on their room door and a blue dot on the outside of their medical record. When DON-D was asked if there was a backup system or another place staff could identify or double check a resident's code status, DON-D replied, "No, it's pretty much just those two things." On [DATE] at 3:55 p.m., surveyor # interviewed DON-E regarding resident's code status. DON-E stated the SW (Social Worker), RN, or LPN (Licensed Practical Nurse) that is admitting the resident is responsible for obtaining the appropriate advance directive information and CPR information from the resident or family, and implementing the blue dot system if a resident is a Full Code. DON-E indicated the nurse working with the resident was responsible to update the resident's code status and the resident's physician via a phone call or fax if the resident's code status changed. On [DATE] at 10:35 a.m., surveyor # observed resident #5's medical record and name plate on the door outside of resident #5's room. Resident #5's medical record and room door did not include any indication that the resident was a Full Code (i.e., a blue dot). In addition, resident #5 was not wearing any type of identifying or code status bracelet. On [DATE] at 9:00 a.m., surveyor # interviewed RN-K regarding resident's code status. RN-K indicated the "face sheet" in the medical record would be used to determine the resident's code status. In addition, RN-K indicated she was not aware of a blue dot system or any another method to double check the code status of a resident. On [DATE] at 9:10 a.m., surveyor # interviewed LPN-M regarding resident's code status. LPN-M stated if a resident was found needing CPR, she would verify their code status by checking the resident's "face sheet or the front page sheet" in the medical record. In addition, LPN-M indicated she was unaware of a blue dot system or any another backup system that could be used to verify a resident's code status. On [DATE] at 9:05 a.m., surveyor # interviewed RN-L regarding resident's code status. RN-L indicated staff would know a resident's code status by checking their wrist bands, stating not all residents wear wrist bands. In addition, RN-L indicated the CPR preference form in the resident's medical record could be used to determine a resident's code status if staff thought the wrist bracelet was incorrect. On [DATE] at 9:15 a.m., surveyor # interviewed RN-D regarding resident's code status. RN-D stated if a resident was found needing CPR, she would verify their code status by looking for a blue dot on their medical record. In addition, RN-D stated she would check the CPR preference form to double check if the blue dot or lack of blue dot was accurate. On [DATE] at 3:20 p.m., surveyor # interviewed RN-H regarding resident's code status. RN-H stated the RN, LPN, or SW that is working when the resident is admitted to the facility is responsible for completing the code status paperwork and implementing the blue dot system. On [DATE] at 3:40 p.m., surveyor # interviewed MT (Medication Tech)-I regarding resident's code status. MT-I stated she floats to all units in the facility and indicated if a resident was a Full Code, he or she would wear a bracelet and have a blue dot near their door. MT-I verified she was not aware of resident #5's code status. On [DATE] at 4:30 p.m., surveyor # interviewed NC (Nurse Consultant)-C regarding resident's code status. NC-C stated the facility did not provide CPR to residents prior to ,[DATE]. NC-C acknowledged the concerns and stated it was "unfortunate," but the facility would be correcting the flawed system immediately. On [DATE] at 8:45 a.m., surveyor # interviewed NC-C. NC-C indicated that staff performed an audit of resident's code status the evening of [DATE] and found the results to be "eye-opening." NC-C verified the facility's code status system was "a problem" and felt that it is corrected now. NC-C indicated that staff were trained on their CPR policy and procedure in ,[DATE], but is not sure what information was included in the training. NC-C indicated the CPR policy that staff were trained on, had not included the procedure regarding the blue dot system and did not include information where staff were to look to obtain verification of a resident's code status. NC-C indicated that all staff are being trained on current resident code status system immediately, and the training was going to be added to regularly scheduled staff inservices. In addition, NC-C verified that resident #5's care plan did not address the resident's code status, and indicated that all the residents will have their code status added to their care plans. 2. On [DATE] at 8:25 a.m., surveyor # and RN-D reviewed resident #22's medical record. According to the face sheet dated [DATE], resident #22 was admitted to the facility on [DATE]. The face sheet indicated resident #22's code status requested was DNR. The blue "CPR Preference" form dated [DATE], indicated the resident had requested DNR status and did not want to receive CPR if indicated. Resident #22's medical record did not include documentation that the PCP's orders included the code status of DNR. According to chapter 154.19(1), Wisconsin Statutes: "No person except an attending physician may issue a DNR (do?not?resuscitate order)." Resident #22's medical record did not include the required State of Wisconsin "Do Not Resuscitate" form or a DNR bracelet, which would notify first responders when a resident was outside of the facility that the resident did not want to be resuscitated. RN-D verified resident #22's medical record did not include the required physician's order for DNR status. On [DATE] at 8:45 a.m., surveyor # interviewed NC-C regarding resident #22's wishes for a code status of DNR and that the resident's medical record did not have a physician's order for a DNR, as requested by the resident. On [DATE] at 9:45 a.m., NHA-W informed surveyor # that resident #22's medical record now has a physician's order for the resident's requested code status of DNR. Resident #22's physician's order was on facility letterhead and dated [DATE]. In addition, NHA-W indicated that the facility was in the process of obtaining the required DNR documentation, physician's orders and bracelets for residents requesting the code status of DNR. 3. On [DATE], surveyor # reviewed resident #10's medical record. The record indicated resident #10 had been admitted on [DATE] and contained a "CPR Preference" form dated [DATE], and signed by resident #10 indicating NO CPR. The required state DNR form with the physician's signature was not located in resident #10's record. Resident #10's record contained current monthly "Physician's Orders" printed [DATE] for ,[DATE] which documented "Code Status: Full Code" dated [DATE]. Resident #10's monthly Physician's orders did not reflect the resident's current code status of DNR. On [DATE] at 4:05 p.m., surveyor # interviewed DON-E regarding the conflicting information of resident #10's code status. DON-E stated the expectation is for the nurse who reviews and signs the "reviewed by" line of the monthly physician's orders should verify all the orders. Documentation indicated that resident #10's orders were signed as reviewed on [DATE]. On [DATE] at 9:18 a.m., surveyor # interviewed RN-D regarding resident #10's DNR bracelet. RN-D searched the floor's DNR bracelet box, resident #10's medical record, and called the staff working on the unit that resident #10 previously lived on, in an attempt to locate the resident's DNR bracelet. RN-D was unable to locate resident #10's DNR bracelet. RN-D referred surveyor # to meet with HIS (Health Information Services)-U when resident #10's required State DNR form with their physician's signature was not located in the resident's medical record. On [DATE] at 9:24 a.m., surveyor # interviewed HIS-U regarding resident #10's DNR bracelet and the required State DNR form. HIS-U stated she mailed resident #10's DNR form and DNR bracelets for signatures on [DATE] or [DATE], via courier to the physician's office. HIS-U stated PCP-F was on out of the office from [DATE] until [DATE]. HIS-U indicated PCP-F was in the building today. In addition, HIS-U stated it was very unusual for PCP-F not to return the DNR forms and DNR bracelets to the facility in a timely manner. HIS-U indicated that PCP-F had been in the building on three different days since resident #10's admission. HIS-U stated resident #10 had been out of the building for one medical appointment without the DNR bracelet, but the nurse should have sent a copy of the resident's "CPR preferences" form with the resident when they went out. On [DATE] at 10:41 a.m., surveyor # conducted a phone interview with resident #10's FM (Family Member)-T. FM-T stated they observed that resident #10 didn't have a DNR bracelet. FM-T stated FM-S has taken resident #10 out into the community to get a haircut and stated FM-S and another family member frequently took resident #10 out of the facility building and walked resident #10 around the facility grounds. 4. On [DATE], surveyor # reviewed resident #15's medical record. Resident #15 was admitted on [DATE], went out to the hospital for 4 days and was readmitted on [DATE]. Resident #15's "CPR Preference" form, signed [DATE], indicated the resident did not want to be resuscitated, (DNR). Resident #15's medical record did not include the required State DNR form with the physician's signature. Resident #15's current monthly "Physician's Orders" dated ,[DATE] indicated the resident's code status was DNR. On [DATE] at 11:33 a.m., surveyor # interviewed RN-H regarding resident #15's DNR bracelet. RN-H said "I don't believe it's back yet from the physician's office for a signature." On [DATE] at 11:48 a.m., surveyor # interviewed HIS-U regarding resident #15's required State DNR form and DNR bracelet. HIS-U stated resident #15's State DNR form and DNR bracelets were received today with the physician's signature dated [DATE]. Surveyor # then interviewed HIS-U regarding what process is used by the staff to track and obtain DNR forms and DNR bracelets. HIS-U stated that HIS-U keeps a list of residents that have their DNR forms and DNR bracelets out for physician signatures and the list is reviewed weekly. HIS-U indicated that the courier is asked to stop at the physician's offices when the resident's DNR forms and bracelets have not been returned with the physician's signatures timely. HIS-U indicated the current monitoring of the DNR forms and bracelets sent out for physician signatures does not include staff calling/contacting the physician's office to inquire about returning them to the facility signed. HIS-U said, "I should call the doctor's office." 5. On [DATE] at 8:22 p.m., surveyor # made observations on the hallway of resident #23's room and noted that the resident's room door did not have a blue dot. On [DATE] at 8:25 p.m., surveyor # observed RN-D reviewing the medical records of the residents that reside on the third floor. At that time, the surveyor interviewed RN-D. RN-D indicated she was reviewing the resident's medical records to make sure the resident's blue dots matched their code status, as directed by NC-C. Surveyor # observed resident #23's medical record and noted that the resident's medical record had a blue dot. At 8:31 p.m., surveyor # interviewed RN-D regarding resident #23's room door, and that a blue dot had not been observed. RN-D indicated that she had just placed a blue dot on the resident's room door. RN-D then observed resident #23's room door and commented to the surveyor that it must have fallen off and that she had replaced it with another blue dot. The facility's failure to have system so that residents' wishes concerning advance directives accurately reflected their wishes and could be readily identified by staff in an emergency created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], by which time it had completed the following: ~ Resident #5's plan of care was updated. Blue dots were applied to the outside of the resident's chart and door, and the resident's face sheet was updated to indicate that resident #5 was a full code. ~ All residents charts and rooms were audited to ensure that their CPR preference form was in place and signed. ~ All Physician's orders were reviewed to ensure resident's preference/choice for CPR were included in the MD's orders. ~ Residents' plan of care were reviewed to ensure that their code status was reflected. ~ Residents that are a full code have a Blue sticker in place outside of the resident's chart and door. ~ The advance direction section of the resident's face sheet indicated their code status. ~ The facility's CPR policy and Procedure was reviewed and updated. ~ All nursing staff starting [DATE] prior to their start of their shift were educated on the updated policy and procedure to include taking a CPR quiz to ensure comprehension/understanding. ~ All other staff educated prior to working their shift were educated on the updated policy and procedure to include taking a CPR quiz to ensure comprehension/understanding. ~ CPR policy and procedure added to mandatory annual in-services. ~ Resident admission check off sheet updated to include CPR preference form, use of Blue dots if yes for CPR, MD order for code status, face sheet and plan of care updated of CPR preference. ~ CNA, LPN and RN orientation check-off lists were updated to include CPR preference form, use of Blue dots if yes for CPR, MD order for code status, face sheet updated of preference and plan of care updated of CPR preference. ~ Identified an RN to oversee the CPR compliance and to conduct 1 audit per week. ~ Medical Director updated on all removal plan interventions.

Based on record review and staff and resident interview, the facility did not ensure that each resident receives adequate supervision to prevent accidents for 1 of 7 sampled residents. The effects had the potential for harm for 46 residents that resided on the 2nd floor of the facility. Resident #1 displayed explosive and unpredictable behaviors, towards staff and residents. Resident #1 had caused an arm fracture for staff. Staff indicated they were unable to keep other residents safe from resident #1's violent/explosive behaviors. Although the facility implemented 1:1 supervision for resident #1 and multiple medication changes were conducted, and diagnostic medical testing in attempt to determine the causal factors for the behavior, resident #1 continued to have physical contact with other residents. A plan of care was developed, which was not accurate. Staff indicated inconsistencies in care for providing 1:1 monitoring to keep other residents safe. Formal and specific training was not provided for staff who completed 1:1 monitoring. As a result of the facility's action, this posed an Immediate Jeopardy situation beginning 6/29/12. The facility was notified on 7/18/12 (State Agency QA call conducted 7/17/12 and continued 7/18/12). The Immediate Jeopardy was removed on 7/16/12 (State Agency made provider aware of potential of citation; facility took immediate actions that day, ultimately accepted as the abatement/removal plan). Removal included the actions of a facility QA meeting with the Interdisplinary Team on the evening of 7/16/12 with modifications to the care plan including 2:1 staff monitoring with specific direction and education given to staff conducting the monitoring with appropriate interventions; alternative placement sought and guardianship placement updates as well as medical director continued involvement with appropriate medical professionals. Residents of the unit where assessed, interviewed and given options by facility if they felt unsafe. The facility was aware of resident #1's volatile behavior shortly after admission and failed to provide adequate supervision to keep the residents safe. Findings include: The facility has a policy and procedure on "Abuse, Prevention/Resident Treatment", revised November 2011. The policy indicated it is directed for abuse that is willful. There was no directions for staff to follow if resident to resident altercations occurred when the perpetrator did not have willful intent to harm another resident but was a result of a behavior. No other policy and procedure was provided to address non willful intent of resident to resident altercations. On 7/12/12, surveyor # reviewed resident #1's medical record. According to the facesheet, dated 6/26/12, resident #1 was admitted to the facility on [DATE]. The updated MD (medical doctor) office visit notes, dated 6/15/12, indicated resident #1 had a [DIAGNOSES REDACTED]. The facility completed a MDS (minimum data set) with an ARD (assessment reference date) of 6/22/12, which indicated resident #1 had severe cognitive impairment, had hallucinations and delusions, and was physically and verbally abusive. The MDS indicated resident #1 ambulated with staff supervision. The MDS indicated resident #1 was 65 inches tall and weighed 179 pounds. The facility nurses' notes indicated the following: * 6/17/12- 0130 (1:30 AM) resident entered room..., grabbed the residents right great toe and elevated leg off of the bed to a near perpendicular position. He then stated, "I'm going to throw you into the fire!" He then proceeded to to shove the bedside table across the room. The resident who resided in the room called out for help. Two staff responded and were able to remove resident #1 from the room. (Resident who's toe was grabbed was resident #6) * 6/17/12 -0320 (3:20 AM)- awake again, wandering halls and agitated. Going into other peoples rooms and slamming doors shut, up and down the hall. Requiring 1:1 supervision. * 6/17/12- 0345 (3:34 AM)- in dining room with CNA (Certified Nursing Assistant), he was removing things from the window sill. Wanting to jump out, then took the water pitcher and hit the CNA on the right side of her jaw with it. Then proceeded to throw vases off the table and attempted to knock the table over. * 6/17/12- 0350 (3:30 AM)- 911 called. Officers arrived to help calm resident. They were able to get him into his room... * 6/17/12 0400 (4:00 AM)- Able to administer Clonazepam with assist of police, but after leaving room, patient became agitated towards police officers and he was placed in handcuffs. * 6/17/12- 0420 (4:20 AM)- MD updated on patients aggression and orders received to send patient to the ER (emergency room ). Police to transport. * 6/17/120 0540 (5:40 AM)- returned from ER with police escort...1:1 observation initiated. Facility initiated a plan of care for "Is at risk for wandering/elopement related to his dementia. History of wandering into peers rooms. Plan of care indicated it was created on 6/22/12. The plan of care had a written intervention, dated 6/17/12, indicated 1:1 staff to try to deter him from going into peers rooms as able. The facility initiated a behavior log documentation, for the staff doing 1:1 observation, upon return from the hospital on [DATE]. The nurses' notes indicated the following: *6/19/12- indicated resident #1 was seen by the psychiatrist and new orders received. * 6/20/12 at 0700 (7:00 AM)- currently smiling, greeting peers and shaking hands with peers. Through his comments, it becomes clear that he perceives that he is the president. * 6/19/12 at 1330 (1:30 PM)- POC (plan of care) reviewed. Agitation tracking reviewed. Resident with improved night sleep. Will continue 1:1 while awake with motion sensors when asleep to notify staff of rising. The facility developed a POC for "Potential for alteration in behavior, dated 6/22/12. Needs invites, encouragement, assists to possible activity interests. Needs redirection, reminders, guidance regarding appropriate behaviors, help maintain the most beneficial activity environment. A goal for this problem indicated resident will not injure himself or others during the next 90 days. Interventions included: 1- re-orientate as needed 2- provide safe wandering space off of the unit, as able, during times of altered perception for his safety and the safety of others. 3- provide bed, fluids, snacks in wandering space. PRN (as needed) 4- monitor for sedation, and provide wheelchair as needed. 5- is noted to have delusional episodes and hallucinations at times. Re-orientate as able. 6- provide with activity bag of history and geography books. Provide verbal prompts to encourage resident to make known his past knowledge regarding these topics. Discuss his teaching experiences. 7- Behavior tracking each shift by 1:1 staff. 8- 1:1 when awake. Motion sensors placed when asleep to alert staff of rising. 9- assist to collect info related to past interest and occupation. Provide with binder for collected sheets. 10- provide invites. encouragement, assists to target interest programming, special programs- anything with the Green Bay Packers, history, geography, facts, catholic communion, catholic mass, worship programs, etc. 11-per family. resident always enjoys rearranging items within his basement. Items have been placed in resident's room-encourage resident to organize his room as he wishes. The nurses' notes indicated the following: * 6/24/12 at 1330 (1:30 PM)- resident pacing and yelling, "you will lose your jobs". Very argumentative. 1:1 not working. Yelling at residents and staff. Was answering white call light phone at the nurses station. Stating he "needed to jump to sidewalk (were on the second floor)". He disconnected receiver from phone, walked to center dining room. opened window and was about to throw the phone out when the CNA asked him not to. He took the phone and banged it very forcefully on the window ledge 3 or 4 times, separating the plastic mouthpiece from the phone. 1:1 throughout. Ordeal with several CNA's and 2 nurses at close hand to prevent harm to himself and others. * 6/24/12 at 1340 (1:40 PM)- resident attempting to open double doors that are shut to contain. Resident hit CNA with fist after grabbing her at 1300 that was watching him 1:1. Resident pacing and telling everyone that are fired and to leave. Resident entering rooms and trying to pull residents out. * 6/25/12 at 1700 (5:00 PM)- resident hallucinating at beginning of the shift. Shaking hands with people who were not in area and conversing with unseen people. Enters peers rooms, Urinated on the floor of another resident's bathroom. Restless wandering in the hall. Resident is yelling in the hallway and attempting to evacuate the building re: a fire. Attempted to push another resident's w/c (wheelchair). Was redirected. Became agitation with redirections. Resident turned a chair over that was in the hallway. Wandered into the center dining room. Attempts to redirect were made and not successful. Resident attempted to turn a table upside down. Dumped salt onto another resident. Supervisor was called. Supervisor able to redirect. *6/25/12 at 1730- (5:30 PM)- heard "someone help me". Entered room ... and noted resident to have staff member pressed against the wall. Resident had tight grip on staff's bilateral forearms, able to have resident release staff's forearms. *6/25/12 at 1800 (6:00 PM)- staff reports resident was attempting to move his television, upon redirecting him, resident became aggressive and punched staff in the abdomen twice and grabbed her forearms again. The Social Services notes dated 6/26/12, indicated the Social Worker was informed that resident #1 had outbursts over the weekend injuring two co-workers. One of which went to the emergency room of the hospital and had a wrist fracture. The nurses' notes indicated the following: * 6/26/12 at 1715 (5:15 PM)- hitting CNA and supervisor-grabbing floor signs attempting to throw, grabbing objects and attempting to throw. Holding CNA and supervisors hands and fingers-bending them. * 6/26/12 at 1730 (5:30 PM)- crisis center called... * 6/26/12 at 1740 (5:40 PM)- 911 called- resident struck supervisor in the face. * 6/26/12 at 1745 (5:45 PM)- police here at this time. * 6/26/12 at 1800 (6:00 PM)- tipped dresser over in room. Police standing in doorway of room. * 6/26/12 at 1900 (7:00 PM)- sent to ER with family present. * 6/26/12 at 2030 (8:30 PM)- returned from ER accompanied by police...per ER nurse, resident received Haldol (an antipsychotic medication) at the hospital. * 6/26/12 at 2300 (11:00 PM)- up in hall looking for the bathroom, followed by staff and attempted to redirect to room. Went into room .... and sat in the recliner and when trying to get him out of the room, he grabbed the back of staff's neck and sweater and was pulling on the neck. Got him out of the room and back to his bed. *6/27/12 at 1500 (3:00 PM)- IDT (Interdisciplinary Team) met with family to discuss current status, med changes and options for alternate placement. Per Social Worker several options explored and ombudsman contacted for recommendations...Per MD, cannot admit resident to hospital due to dementia. On 6/28/12, the facility added to the 1:1 behavioral clipboard, information on dealing with dementia residents and also "Tips on Working with " resident #1. The informational sheet indicated resident #1 had delusions and hallucinations, past history of his life, and things the facility had found that have sometimes worked when escalated. One intervention listed was if resident .... is pacing the halls, try to position yourself AS SAFELY AS YOU CAN between him and other residents. If he's pacing and agitated, your co-workers should jump in to assist in moving other residents to their rooms or common areas...where ever they will be out of harm's way. Suggestions on how to converse with resident #1 was provided. The nurses' notes indicated the following: * 6/28/12 at 1500 (3:00 PM)- 911 called for police. Resident tried to climb window sill in other residents room. Took fan and threw across the room, almost hitting the other resident. * 6/28/12 at 1530 (3:30 PM)- police officers talking with family...resident safe and other residents are also safe. The facility sent a self report to the state agency indicating on 6/29/12 at 3:30 PM, resident #1 grabbed resident #2, breast. Resident #1 was removed from the room and instructions given to the 1:1 staff member for closer 1:1 status. (There was no documentation of this incident in the medical record). On 7/16/12 at 12:45 PM, surveyor # interviewed RN/UM-A (Registered Nurse/Unit Manager) regarding missing documentation. RN/UM-A verified the medical record had not contained documentation of the incident that occurred on 6/29/12. RN/UM-A stated the facility management staff became aware of the incident from verbal reporting. On 7/12/12 at 1:41 PM, surveyor # completed a telephone interview with CNA-B regarding the events that occurred on 6/29/12. CNA-B stated she could not recall if she was the 1:1 at the time the incident had occurred, but indicated she was walking down the hall and resident #1 entered resident #2's room. CNA-B stated CNA-C entered the resident #2's room at the same time with herself and resident #1. CNA-B stated she recalled resident #2 saying hello to resident #1 and staff allowed resident #1 to interact with resident #2. CNA-B indicated resident #2 was sitting in her w/c (wheelchair) in her room. CNA-B stated resident #1 appeared to have been fixing resident #2's clothing by pulling down her shirt, that pulling on the sleeves of her shirt. CNA-B indicated approximately 30 seconds later, resident #1 was moving his hand toward resident #2's breast and had touched the left breast over resident #2's shirt. CNA-B stated as soon as she saw resident #1's hand reaching for resident #2's breast she placed her arm around resident #1 and stated "let's go", in which he followed staff out of the door. CNA-B stated resident #1 was allowed to pull on resident #2's clothing without redirection because resident #2 was telling resident #1 that he was pulling on her clothing, and we didn't want to agitate resident #1. CNA-B stated 1:1 means that if resident #1 isn't agitated he was allowed to walk into other resident rooms, and if he was agitated staff were to remove resident #1 from other resident rooms. CNA-B indicated resident #1 stated resident #1 has thrown items in the facility when agitated, to include other resident's bedside table and was told by another staff that he threw a fan at another resident. CNA-B stated she had read some written information on resident #1's mental status, but has never been formally trained on how to work with resident #1. On 7/16/12 at 1:20 PM, surveyor # completed a telephone interview with CNA-C regarding the incident which occurred on 6/29/12. CNA-C verified she was present during the incident which occurred on 6/29/12. CNA-C stated resident #1 had dementia and was confused, ambulated independently on the unit with 1:1 observation from staff. CNA-C indicated resident #1 was placed on 1:1 monitoring due to violent outbursts and behaviors towards staff and residents. CNA-C stated on 6/29/12 she thought she was doing the 1:1 observation and stated resident #1 was ambulation up and down the hall and went into resident #2's room. Resident #2 was sitting up in her w/c. CNA-C stated initially resident #1 was pulling on resident #2's shorts and she was telling him no that wasn't his wife, and then resident #1 proceeded to touch her hand and then was going up her arm. CNA-C stated resident #1 reached over and touched resident #2's left breast with his left hand. CNA-C stated she was trying verbal redirection and tried taking his hand to be redirected, but he kept going back towards resident #2. CNA-C stated after resident #1 touched resident #2's breast, she immediately took his hand and walked him out of the room. CNA-C stated that she was trying to redirect resident out of the room, but he wouldn't and then she called out for help and that was when CNA-B arrived in the room. CNA-C stated resident #1 can be around other residents if he is not agitated and the 1:1 is present. CNA-C stated if resident #1 is agitated he is to be kept further than arms reach apart from other residents. CNA-C indicated when she is 1:1 and ambulating in the hall she keeps herself between resident #1 and other residents. The nurses' notes indicated the following: * 6/29/12 at 2100 (9:00 PM)- pacing up and down hallways. In other resident rooms. Encouraged resident out of rooms as needed. * 6/29/12 at 2115 (9:15 PM)- pulling drawers out in room. Moving furniture around . Unable to redirect. * 7/2/12 at 1205 (12:05 PM)- suddenly with a sense of urgency in gait-- walks rapidly toward dining room full of residents. Four staff members assist to provide "wall" of protection for residents. Resident perceives that he needs to escape because "the bomb will detonate in three minutes." * 7/2/12 at 1420 (4:20 PM)- resident went in social service office, grabbing coffee pot to throw. CNA stopped resident and redirected out of office... The facility completed changes to resident #1's "Tips for Working" with resident #1, that was located on the 1:1 clipboard. Changes written were of resident's perception which places him at increase risk for falling. Also indicated resident #1 had made repeated comments about windows, jumping out of them to escape and comments of death. "It is crucial for staff to monitor for these low moods and report them", since resident #1 is sometimes aware of his memory deficit, he is at increased risk for depression and self harm. The "Tips" worksheet continued to direct staff to try and position self as safely as you can between him and other residents if he was pacing. If he's pacing and agitated, your co-workers should jump in to assist in moving other residents to their rooms or common areas...wherever they will be out of harms way. The nurses' notes indicated the following: * 7/3/12 at 1330 (1:30)- to clinic (was scheduled to have MRI completed) * 7/3/12 at 2030 (8:30 PM)- continued up and down hallways and into other residents rooms.... * 7/3/12 at 1050 (10:50 AM)- resident ambulating in hall with 2 staff for safety. * 7/5/12 at 1325 (1:25 PM)- call received from MD- stated MRI revealed small tumor but due to significant loss of brain mass secondary to dementia, is not likely a surgical candidate...but likely will not benefit as behavioral changes likely more due to dementia than tumor per MD. * 7/11/12 at 0600 (6:00 AM)- resident was ambulating and restless all night. Attempted to give lorazepam and he spit it on the floor and threw cup of water also on the floor...he would hit and kick at staff saying where is his gun. People need to be shot... * 7/11/12 at 1600 (4:00 PM)- resident flipped lounge chair. CNA redirected. Resident with fist to CNA's face. Put clipboard up for protection....Five minutes later punched CNA in her chest.... * 7/11/12 at 1930 (7:30 PM)-...continues to paces up and down hallway and in/out of residents rooms. Redirecting 1:1 constantly... * 7/13/12 at 1820 (6:20 PM)- resident #1 was in the hallway and hit resident #3 in the back with hand while holding a nourishment. Staff intervened and was able to separate. No injuries noted. * 7/13/12 at 1830 (6:30 PM)- resident was at the nurses station and grabbed resident #4 on the forearm and shook it. Staff intervened and was able to separate. No injuries. On 7/16/12 at 10:50 AM, surveyor # completed a telephone interview with CNA-D regarding the incidents that occurred on 7/13/12. CNA-D verified she was the staff person that was doing the 1:1 monitoring with resident #1 on 7/13/12. CNA-D stated on 7/13/12 at approximately 5:45 PM resident #1 was ambulating in the east dining room at meal time and suddenly grabbed resident #7's left leg. CNA-D stated she had to pry resident #1's hand from resident #7's leg (could not recall if resident #1 grabbed the leg with one or two hands). CNA-D indicated she then redirected resident #1 out of the dining room and into the hall. CNA-D stated resident #1 ambulation to the nurses' station and picked up an empty milk carton and they proceeded to ambulate. CNA-D stated she could not recall if she saw resident #3 approaching them, but suddenly the residents were next to each other and resident #1 suddenly struck resident #3 in the back, while holding the milk carton, with enough force that resident #3's upper body went forward. CNA-D redirected resident #1 and within five minutes had grabbed resident #4's right forearm. CNA-D indicated resident #4 was trying to get away from resident #1 and CNA-D needed to physically remove resident #1's hands from resident #3's forearm. CNA-D stated it had only been approximately 10 to 15 minutes between the altercation with resident #7 and #3. CNA-D indicated she reported the altercation of resident #1 and resident #7 to the nurse after the altercation had occurred. CNA-D stated she could not recall which nurse she had reported the altercation to. CNA-D indicated she thought she was reporting the initial altercation to the nurse and was looking away from resident #1 and when she turned resident #1 was right next to resident #3. CNA-D stated resident #1 is not suppose to have contact with other residents in the common areas. Surveyor # questioned CNA-D how the altercations had occurred if resident #1 was not to have interactions with other residents in the common areas? CNA-D then indicated resident #1 could have interactions with other residents if not agitated, but was not allowed to enter other resident rooms. Surveyor # questioned CNA-D how other residents were kept safe. CNA-D replied, "accidents happen and you can't prevent all accidents".CNA-D stated resident #1 was confused and ambulated independently with 1:1 supervision. CNA-D indicated resident #1 was on 1:1 supervision due to striking at staff and of the incident which at occurred on 6/17/12. CNA-D stated she was unaware of any altercations or attempted altercations with other residents since the incident of 6/17/12. CNA-D stated resident #1 is very sexually inappropriate and physical with staff. CNA-D indicated resident #1's behaviors were unpredictable and violent and thought he would "go after anyone". CNA-D stated resident #1 had the potential to harm other residents. CNA-D indicated she has never received any formal/specific training on working with resident #1. CNA-D stated "there's a bunch of papers on the 1:1 clipboard, but she didn't read them". On 7/16/12 at 2:00 PM, surveyor # interviewed the PM shift RN (Registered Nurse) Supervisor- E regarding the altercations which occurred on 7/13/12. RN Supervisor-E verified she was the supervisor in charge on the PM shift of 7/13/12. RN Supervisor-E stated she was called to the floor in which resident #1 resided either from LPN (Licensed Practical Nurse)-F or CNA-D, but could not recall who, because resident #1 had struck resident #3 in the back and then grabbed resident #4's arm. RN Supervisor-E stated she told a nurse to assess the residents. RN Supervisor-E stated she notified the NHA (Nursing Home Administrator) and was told to call the police. RN Supervisor-E said the police came and said they can't do anything and left the facility. RN Supervisor-E stated there was information on the 1:1 clipboard which says to keep staff between resident #1 and other residents. RN Supervisor-E stated she had only read the information once when it was first initiated and hasn't read it since. RN Supervisor-E stated she asked CNA-D what happened, told her to right a statement, in which she didn't, and I went to another floor because I was extremely busy that night. RN Supervisor-E verified she had not initiated an investigation into how the altercations had occurred, nor had she changed the plan of care to protect residents from harm from resident #1. On 7/16/12 at 2:25 PM, surveyor # interviewed LPN-F regarding her awareness of the altercations of resident #1 with other residents on the unit on 7/13/12. LPN-F stated she was on break when the altercations had occurred. LPN-F indicated when she returned from break RN Supervisor-E was already on the unit. On 7/16/12 at 2:30 PM, surveyor # interviewed LPN-G regarding her awareness of the altercations of resident #1 with other residents on the unit on 7/13/12. LPN-G verified CNA-D had told her of the altercations between resident #3 and #4, but had not informed her about an altercation with resident #1 and resident #7. LPN-G stated she called RN Supervisor-E and updated her on the altercations that were occurring with resident #1, and she came to the unit. The nurses' notes indicated the following: * 7/14/12 at 1300 (1:00 PM)- behavior episodes past 24 hours, striking out at staff/residents, able to redirect as needed.... * 7/15/12 at 1305 (1:05 PM)- resident was walking in hallway with 1:1 when resident #5 reached out her hand for a shake. Resident #1 grabbed resident #5's wrist and started shaking it, raising hand up and attempted to pull her out of the w/c. 1:1 intervened and removed hand and attempted to explain to resident #1 that resident #5 couldn't walk and removed from area for safety. Resident #1 starting hitting 1:1... On 7/16/12 at 10:25 AM, surveyor # conducted a telephone interview with LPN-K regarding resident #1's violent behaviors and the altercation which had occurred on 7/15/12. LPN-K verified she was the unit nurse in charge of resident #1 on 7/15/12. LPN-K stated she never observed the altercation, but heard the "commotion" and responded to the area, but the residents were already separated. LPN-K stated she was told of what had happened. LPN-K stated resident #1 was totally disoriented except was able to recognize family. LPN-K indicated since admission resident #1 continuously "beats up staff" and has already fractured a CNA's wrist. LPN-K indicated at times resident #1 enters other residents rooms and it takes 2 staff to remove him from the room. LPN-K stated she was not aware of any other residents that have been inappropriately touched or struck by resident #1. LPN-K indicated she wasn't aware of resident #1 throwing objects at residents or in the common areas. LPN-K stated the behavior towards residents have been new, and the last altercation resident #1 had with another resident was on 6/17/12. LPN-K indicated the objective of the 1:1 for resident #1 was to keep other residents safe from him. LPN-K stated resident #1 was not be allowed to enter other residents room, and if had entered a room, additional staff would be called to assist resident #1 out of the room. LPN-K there were not restrictions regarding resident #1 allowing to interact with other residents in the common areas of the unit, as long as the 1:1 staff was present. LPN-K stated "we don't want him to touch other residents". Surveyor # questioned LPN-K as how staff were to ensure other residents safety, LPN-K stated, "but that's the problem is his behaviors are so unpredictable". LPN-K indicated staff were concerned on how to keep other residents safe from resident #1. LPN-K indicated RN/UM-A developed a clipboard which contains information on how to work with resident #1. LPN-K stated she had initially read the information, but has not read the information since the initiation. LPN-K stated she wasn't sure if there had been any specific directions regarding distance to keep resident #1 away from other residents, how body to be positioned if becomes aggressive etc. LPN-K indicated resident #1 was very strong, explosive, violent and could easily hurt anyone at anytime. LPN-K stated resident #1 already fractured a CNA's wrist. LPN-K indicated most other residents on the unit had dementia and memory deficits, but some residents will say to "keep him away". when they see him. LPN-K stated she could not be specific as to which residents would make comments. On 7/16/12 at 1:20 PM, surveyor # completed a telephone interview with CNA-C regarding the incident which occurred on 7/15/12. CNA-C verified she was completing the 1:1 monitoring when the incident occurred. CNA-C stated she and resident #1 were ambulating in the hall and was walking past resident #5. CNA-C indicated resident #5 was seated in her w/c and reaching her hand out to resident #1 as if she wanted to shake his hand. CNA-C stated she was in between both residents, but the residents were within arms reach of each other. CNA-C she thought resident #1 was going to shake resident #5's hand when he extended his hand out to hers. CNA-C indicated he grabbed her hand tightly and shook her hand and seemed to have been trying to pull her from her w/c. CNA-C stated resident #5 cried out as if she was in pain during the altercation. CNA-C stated resident #1 had shown no previous agitation prior to grabbing resident #5's hand. CNA-C indicated she had to physically remove his hand from resident #5's hand and then resident #1 started to hit her and when she backed up, resident #1 struck her in the stomach. CNA-C indicated three staff came and assisted with removing resident #5 and redirecting resident #1. CNA-C stated resident #1 could easily harm other residents as he becomes dangerous when his mood changes. CNA-C indicated resident #1 needs to be removed from the facility to keep other residents from the facility safe. CNA-C stated she had never received formal or specific training on how to work with resident #1, and was only told to read the information on the 1:1 clipboard. CNA-C indicated other residents stay in their rooms and are" afraid of" resident #1, "and hears it everyday". (CNA-C could not be specific as to which residents she was speaking of). On 7/12/12 at 9:55 AM, surveyor # interviewed LPN-H regarding what was the responsibility for the person completing 1:1 observations with resident #1. LPN-H verified she was the 1:1 staff person assigned for the day shift on 7/13/12. LPN-H indicated 1:1 observation is for protection for resident #1 and other residents. LPN-H stated the direction is if resident #1 approached other residents on the unit, the 1:1 was to watch closely. LPN-H indicated resident #1 was not allowed to go into other resident rooms and she would place her body between the room and resident #1 and redirect. LPN-H stated resident #1 was allowed to ambulate in common areas on the unit and if would touch another resident and was not inappropriate, resident #1 was allowed to touch other residents. LPN-H indicated if resident #1 would start to talk threatening, she would physically take his hand and redirect. LPN-H stated she was a float staff in the facility and not very familiar with resident #1. LPN-H stated she hadn't any knowledge if resident #1 had very inappropriately touched a resident or had become violent with any residents. LPN-H indicated there was printed instructions on what to do with resident #1. On 7/12/12 at 2:25 PM, surveyor # interviewed LPN-G regarding resident #1. LPN-G stated the 1:1 staff was to ensure the safety of resident #1 and other residents. LPN-G indicated resident #1 can be calm and suddenly become agitated and violent. LPN-G indicated she was aware there was one time when resident #1 touched a resident's breast, but was unaware of any altercations with other residents. LPN-G stated the 1:1 staff were to place their body between resident #1 and other residents at all times, if resident #1 would become to close to another resident because staff are unable to predict when the agitations will start and would never know what resident #1 might do. Surveyor # questioned how resident #1 touched a resident's breast if staff were to stay between resident #1 and other residents. LPN-G stated she wasn't sure how that would have happened. LPN-G stated resident #8 was afraid of resident #1. On 7/12/12 at 2:40 PM, surveyor # interviewed CNA-I regarding resident #1. CNA-I verified she was the staff that was completing 1:1 monitoring for resident #1 on the PM shift of 7/12/12. CNA-I stated this was the first time she was doing the 1:1 monitoring. CNA-I indicated she didn't know much ab

Based on observations, record reviews and staff interviews and on the comprehensive assessment of a resident, the facility must ensure that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing in 2 of 13 residents reviewed for pressure ulcer risk. Resident #20 had a history of [REDACTED]. When the facility was aware that the area on her buttocks had deteriorated, no revision to her treatment order to the area had been initiated. Additionally, on the day of discovery and in the days following the change in skin integrity, no documented assessment of the pressure ulcer had been completed. The resident's fragile area on the buttocks developed into a stage II pressure ulcer. Additionally, the resident was assessed to be at high risk for the development of pressure related ulcers due to multiple comorbidities and mobility deficits. No care plan intervention had been established relating to prevention of pressure to the heels. Resident #1 was assessed to be at risk for pressure ulcer development. The resident had care plan interventions to include use of a pressure reducing cushion on seated surfaces and the use of a wedge abductor between her knees. Those care plan interventions had not been consistently implemented. Findings include: The facility's Clinical Practice Guideline entitled "Pressure Ulcers in the Long-Term Care Setting" published by The American Medical Directors Association in 2008 indicated seventy percent of pressure ulcers occur in patients over the age of 70. Almost 95 percent of pressure ulcers develop on the lower body. Common sites include the coccyx, heel, ishium, iliac crest, lateral foot, lateral malleolus, sacrum, and trochanter. Mortality risk is two to six times as high in a patient with a pressure ulcer as in a patient with intact skin, primarily because pressure ulcers occur in sicker patients. Early recognition of pressure ulcers and of any risk factors associated with the development of pressure ulcers is critical to their successful prevention and management. A history of pressure ulcers is a primary risk factor for the development of new pressure ulcers. Patients with a history of pressure ulcers are more than five times as likely to develop another pressure ulcers as are patients with no such history. The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcers, and identify related causes and complications. Documentation should cover all pertinent characteristics of existing pressure ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining. Identify priorities in managing the ulcer and the patient. Effective management of a pressure ulcer requires but is not limited to determination of the best topical care to facilitate ulcer healing. The scope of a treatment plan and the urgency with which it is implemented will depend on conclusion about the patient's condition and prognosis and on the likelihood of ulcer healing. The same factors that increase a resident's susceptibility to developing pressure ulcers may also impair the healing of an existing pressure ulcer. Pressure ulcer prevention measures include positioning the patient to minimize pressure over bony prominence's. For patients who have pressure ulcers, treatment choices are generally not stage specific, that is, the stage of the ulcer should not determine the choice of treatment. Establish a realistic, individualized interdisciplinary care plan. Use appropriate positioning devices such as pillows or foam padding between the knees and ankles. Patients who have or are at risk of developing heel ulcers, will require offloading or pressure redistribution devices that "floats" the hell to relieve pressure on the heels and prevent skin breakdown. Cover and protect the ulcer and surrounding skin. The goals of dressing an ulcer are to keep the ulcer bed moist and the surrounding skin dry; to protect the ulcer from contamination, and to promote healing. 1. Resident #20's admission face sheet dated 3/20/08 indicated the resident had [DIAGNOSES REDACTED]. The resident's most recent MDS (minimum data set) dated 3/11/12 indicated the resident was extensively cognitively impaired; required total assistance from staff to perform all activities of daily living including transfers, eating, bed mobility and personal hygiene; was non ambulatory; was totally incontinent of bowel and bladder; had one healed stage II pressure ulcer, and had range of motion deficits in both upper and lower extremities. The resident's skin integrity progress report dated 2/16/12 indicated the resident had developed a stage II pressure ulcer to the left buttock which was documented as healed by 2/24/12. An additional skin integrity progress report dated 4/13/12 indicated the resident had developed a stage II pressure ulcer to the left buttocks which was documented as healed by 5/2/12. The resident's two most recent Braden Scale for Predicting Pressure Sore Risk dated 3/7/12 and 6/11/12 indicated the resident had scored an 11 on the scale indicative of high risk for pressure ulcer development. The assessment for 3/12 indicated the resident had an actual open area assessed to be a stage II pressure ulcer to left buttock and interventions included keep skin clean and dry, pericare after each incontinent episode, barrier cream to areas exposed to moister, turn and reposition, pressure reduction support surface in bed and on seated surfaces, lift don't slide, inspect skin daily, weekly skin assessment by licensed staff, moisturize dry skin, and monitor pain. The assessment for 6/12 indicated the resident was unable to reposition herself and current skin prevention interventions included removable Hoyer sling only at all times, air mattress, special wheelchair cushion, barrier cream and repositioning every hour. There was no interventions listed to protect the resident's heels from pressure. A physician's progress note, located in the resident's medical record dated 5/26/12 indicated, "...gradual decline in function noted". The resident's current skin plan of care revised on 6/29/11 indicated interventions of needs assistance with repositioning every hour while in bed and chair, special cushion on chair, air mattress, two person mechanical lift for all transfer with a removable Hoyer sling, do not get up from afternoon nap before 4:00 p.m., provide incontinence care after each incontinent episode, use barrier cream to perineal area, monitor skin integrity daily with cares and weekly with bath. Report any red, sore or open areas to the nurse, and offer nutritional supplements as suggested. There was no care plan intervention relating to protecting the resident's heels from pressure. The Nursing Assistant Care Card for resident #20 dated 6/1/12 included interventions of removable Hoyer sling only, barrier cream, reposition every hour, up for meals only and no longer than 30 minutes after eating to be laid down, and do not get up before 4:00 p.m. after p.m. nap. There was no care plan intervention listed relating to protecting the resident's heels from pressure. Review of the resident's TAR (treatment administration record) dated 6/12 indicated a directive to check buttock weekly alternating shifts and chart in nurses notes. The directive listed on the resident's TAR was last initialed as completed on 6/13/12. A corresponding nurses notes dated 6/13/12 at 2:15 p.m. indicated, "...no red or open areas noted at this time to left buttock". After 6/13/12, no assessments of the resident's skin was documented in the resident's medical record, TAR or 24 hour report. A therapy screen report located in the resident's medical record dated 6/09/12 indicated, "...dark red area on right great toe and proximal ball of right foot from foot rest on wheel chair. Foot rest is very hard. Please check positioning of lower extremities". The corresponding nursing entry dated 6/9/12 indicated the same information but did not have a thorough assessment of the dark areas of the resident's foot to include size or blachability. The therapy response dated 6/13/12 indicated "...resident has custom chair. Note sent to R.N. (Registered Nurse) for proper alignment. RN will correct foot rest". On 6/18/12 at 8:30 a.m., NP (Nurse Practitioner)-M verified to surveyor # that resident #20 had been issued a specialized tilt recliner approximately 4-5 months prior due to persistent scar tissue to buttocks, skin integrity issues, and pain in the lumbar spine. On 6/18/12 at 1:25 p.m., surveyor # observed CNA (Certified Nursing Assistant)-H and CNA-R assist resident #20 into bed with use of a total body lift. The surveyor asked to inspect the resident's buttocks. CNA-H removed the resident's brief and the surveyor noted a crusted over area the size of a nickel on the resident's left buttocks. CNA-H verified the surveyors findings. Surveyor # also observed resident #20's right great toe and proximal ball of her foot. Both areas were purple/red in color. The resident was positioned slightly onto her right side, a flat pillow was placed under her knees and the staff exited the room. Both of the resident's heels were in full contact with the mattress. The resident remained in the same position until 2:15 p.m. On 6/18/12 at 2:00 p.m., DON (Director of Nursing)-O verified to surveyor # that if a resident was immobile, spent most of the day in bed and was assessed to be at high risk for pressure ulcer development, a care plan intervention for that resident should include free floating of heels. On 6/18/12 at 2:15 p.m., surveyor # interviewed CNA-G. CNA-G verified to the surveyor that resident #20 did not have an intervention on the CNA care card for free floating of the heels. CNA-G also verified to the surveyor that both the resident's heels were in full contact with the mattress. CNA-G then attempted to free float the resident's heels with the pillows available in the resident's room but was unable to do so with the supplies at hand. CNA-G positioned two pillows under the resident's calves and stated, "...that's not working". On 6/18/12 at 2:20 p.m., surveyor # interviewed RN-L. RN-L stated that resident #20 "...should have a plan of care intervention to protect her heels from pressure". RN-L then retrieved and placed a device under the resident's calves to promote free floating of her heels. On 6/19/12 at 9:00 a.m., RN-L verified to surveyor # that she had not been aware of the changes in resident #20's skin integrity on the buttocks. RN-L stated, "...staff didn't mention it to me and it wasn't on the 24 hour report". On 6/19/12 at 9:30 a.m., surveyor # interviewed RN-C. RN-C functions as the facility's wound nurse. RN-C stated, "...I haven't heard of any skin issue with her (resident #20) buttocks since April. She had a stage II pressure ulcer on her buttocks that healed on 5/2/12. She has never had any open areas on her heels that I know of". On 6/19/12 at 9:40 a.m., NP-M evaluated resident #20's left buttock. NP-M indicated the resident now had a stage II pressure ulcer on the left buttock measuring 1.3 cm (centimeters) by 1.3 cm with a firm pale pink base and added a treatment of [REDACTED]. NP-M also inspected the dark areas on the resident's right great toe and ball of foot and indicated both the areas blanched to digital pressure. On 6/19/12 at 10:00 p.m., surveyor # interviewed CNA-G. CNA-G stated, "...around a week ago I noticed a change in the area on her (resident #20's) left buttocks. It looked red and abraised but wasn't open. I thought it was iffy to just use the barrier cream so I told I think it was LPN (Licensed Practical Nurse)-S and she looked at the wound and told me just to put barrier cream on it. I can't remember what day it was last week". On 6/19/12 at 10:05 a.m., surveyor # interviewed RN-L. RN-L stated, "...the open area on her buttocks (resident #20) would be reported on the 24 hour report but never was". RN-L further verified that assessments of the skin integrity of resident #20's buttocks had not been documented in the nurses notes or the TAR since 6/13/12". On 6/19/12 at 1:00 p.m., surveyor # again interviewed CNA-G. CNA-G stated, "...I saw the open area on her (resident #20) butt last night. It looked like a scabbed over area. I didn't say anything last night because I thought they knew all about it because I reported it last week and were doing to it what they needed to". On 6/19/12 at 1:10 p.m. SC (Scheduling Coordinator)-N verified to surveyor # that LPN-S had worked the afternoon shifts on both 6/13/12 and again on 6/16/12 on resident #20's unit. On 6/19/12 at 1:12 p.m. surveyor # interviewed LPN-S via the telephone. LPN-S stated, "...I did look at her (resident #20's) butt. It was superficial and red but not open. I told CNA-G to put barrier cream on it. I probably forgot to chart it. I can't say if it was the 13th or the 16th of June. I know she (resident #20) has a chronic area on her butt that opens easily. It is protocol to let a unit manager and/or wound nurse know about the area when it changed. It was my fault because I didn't do that". 2. Resident #1's admission face sheet dated 2/6/10 indicated the resident had [DIAGNOSES REDACTED]. The resident's most recent MDS dated [DATE] indicated the resident had significant cognitive deficits; required total assistance from staff to perform all activities of daily living including bed mobility, transfers, hygiene and eating; was non ambulatory; was frequently incontinent of bowel and bladder, and was at risk for pressure ulcer development. The resident's most recent Braden Scale for Predicting Pressure Sore Risk dated 5/1/12 indicated the resident was assessed to be at risk for the development of pressure ulcers. The assessment also indicated interventions to position body with pillow/support devices, protect bony prominence's, keep skin clean and dry, pericare after each incontinent episode, turn and reposition every two hours, pressure reduction support surface in bed and seated surfaces, elevate heels off bed, keep linen free of wrinkles, lift don't slide, moisturize dry skin, inspect skin daily and weekly skin assessments by licensed staff and no more than 30 degree side lying position and/or head elevation in bed. The resident's current skin plan of care revised on 7/10/11 indicated to reposition every two hours while in bed and chair, small abductor wedge cushion that is used when up in wheel chair, bilateral theraboots/sage to feet in bed. A therapy screen dated 5/24/12 located in resident #1's medical record indicated "...right knee tips inward. Would abduction wedge when up in wheel chair be appropriate"? The therapy response on 5/25/12 indicated, "...trial abduction wedge". Resident #1's CNA care card dated 5/29/12 indicated interventions to include sage boot right foot and theraboot on left foot in bed, abductor wedge when up, and assist to reposition every 2 hours. The CNA care card had not indicated use of a pressure reducing surface in all seated surfaces. On 6/11/12 during period observations of resident #1 seated in her wheel chair by surveyor # from 12:00 p.m. until 1:45 p.m., it was noted that resident #1 had shorts on. Her right knee was in direct contact with her left knee and no abductor pillow was in place. On 6/13/12 at 7:45 a.m., surveyor # again observed the resident seated in her wheel chair with shorts on and her legs in the same exact position as above without an abductor wedge placed. On 6/11/12 at 1:45 p.m., surveyor # observed CNA-J and CNA-K transfer resident #1 into a reclining lounge chair in her room without a pressure reducing cushion on the seat of the recliner. The resident remained seated in the recliner until 3:15 p.m. On 6/12/12 at 8:45 a.m., surveyor # interviewed RN-T. RN-T stated "...staff are to use an abductor pillow wedge between her (resident #20) knees to prevent contractures and pressure. We were seeing positioning issues with her so initiated a therapy screen. She received a lower wheel chair and we noticed her one knee was turning in and we didn't want issues with increased contractures or pressure so we initiated the wedge. She is to have it on when she is up in the wheel chair. She will occasionally remove it herself but that was more so when it was first initiated. She is doing better with keeping it in. I did note during my audits today that the wedge wasn't in place this morning. It went down to the wash, but I'm not sure when. I just asked therapy to get her a new one. She doesn't use her recliner much, but if she does, staff are to move the cushion from her wheel chair into the seat of the recliner".

Based on observation, staff and resident interview and record review, the facility did not implement procedures that prohibited 1 (resident #2) of 14 sampled residents from potentially abusing other residents. Resident #3 alleged resident #2 touched her inappropriately on the breasts on 1/1/11. The facility implemented 15 minute check monitoring for resident #2 on 1/2/11. Resident #2 was assessed by a psychiatrist on 1/3/11, and the psychiatrist discontinued [MEDICATION NAME] (antidepressant) for the resident. Staff indicated the psychiatrist thought it was possible the antidepressant could have caused [MEDICAL CONDITION] for resident #2. The facility discontinued the 15 minute checks for resident #2 on 1/3/11. The facility did not implement a supervision plan to ensure other female residents were safe from resident #2's inappropriate sexual touching after the 15 minute checks were discontinued on 1/3/11. On 1/6/11 resident #4 stated resident #2 touched her inappropriately on the breasts. Findings include: On 1/7/11 surveyor # reviewed resident #2's medical record. According to the face sheet dated 10/26/10, resident #2 was admitted to the facility on [DATE]. The facility completed an MDS (Minimum Data Set), dated 10/24/10, which indicated some cognitive impairment for resident #2. The MDS indicated resident #2 had no previous behaviors and was independent with locomotion on and off the unit. A Nurse Practitioner's progress note dated 1/6/11 indicated resident #2 had [DIAGNOSES REDACTED]. Resident #2's nurses' notes dated 1/1/11 indicated the resident was using inappropriate verbalization and touching towards staff and a peer. An incident report dated 1/1/11 at 7:00 a.m. indicated resident #2 was inappropriately using verbal words and touching staff and resident #3. The incident report indicated resident #2 was placed on 15 minute checks on 1/2/11 for his behaviors. On 1/7/11 at 9:50 a.m. surveyor # interviewed RN (Registered Nurse)-H regarding resident #2 and the incident on 1/1/11. RN-H stated she was unaware of any triggers that may have occurred prior to the allegation on 1/1/11. RN-H stated resident #3 was able to recall the incident and said resident #2 came up to her in the dining room and touched her breasts. Resident #2 was seen by the psychiatrist on 1/3/11. The psychiatry note dated 1/3/11 indicated resident #2 was admitted to the facility due to frequent falls at home and was started on [MEDICATION NAME] for depression following admission. The psychiatrist saw the resident on 1/3/11 because the resident was referred for sexually inappropriate behaviors and agitation. The note indicated Nursing observed resident #2 to exhibit more confusion the past couple of months and also increasing episodes of agitation. [MEDICATION NAME] titration was started on 12/7/10. The psychiatry note indicated facility staff observed increasing sexually inappropriate behavior on the part of resident #2, with grabbing at staff during the weekend of 1/1/11 and 1/2/11. The psychiatrist's assessment of resident #2 indicated dementia with mood lability may have elevated mood secondary to antidepressant. The psychiatrist's plan was to continue [MEDICATION NAME] and discontinue [MEDICATION NAME]. Surveyor # reviewed resident #2's 15 minute check flow sheet. The flow sheet indicated resident #2 was started on 15 minute checks on 1/2/11 at 1:00 p.m. The flow sheet indicated the 15 minute checks were discontinued on 1/3/11 at 5:45 a.m. The flow sheet did not contain any documentation the 15 minute checks were completed on 1/2/11 from 2:15 p.m. through 10:45 p.m. Surveyor # reviewed resident #2's plan of care dated 1/3/11 for, "I sometimes act sexually inappropriately. I have been known to touch my peers and staff inappropriately and refuse redirection at times." The plan of care had the following interventions: - Avoid type of conversation that could encourage or initiate inappropriate behavior. - Document a summary of each episode. - Protect other peers if unable to protect themselves. - Remove from public area when behavior is disruptive/unacceptable... - Set limits for acceptable behavior. - I require 2 person assist with all my cares and toileting needs due to my behaviors. - Added 1/5/11-Continuous monitoring by staff for triggers that may lead to sexual behavior...... - Added 1/6/11-Make sure resident keeps distance from female residents. On 1/7/11 at 11:20 a.m. surveyor # interviewed RN-H regarding the plan of care for resident #2. RN-H verified she updated resident #2's plan of care on 1/5/11. Surveyor # asked what "continuous monitoring" meant; and RN-H replied it wasn't continuous monitoring, but staff were to observe for triggers for resident #2's behaviors. RN-H verified resident #2 self-propelled his wheel chair on the unit, and staff were not always present. On 1/7/11 at 11:50 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-K regarding resident #2. CNA-K verified she was responsible for resident #2's cares on the PM shift of 1/5/11. CNA-K stated she was told in shift report resident #2 had touched a female resident inappropriately. CNA-K indicated there had been no change in resident #2's supervision plan, and the resident was not on 1:1 supervision or 15 minute checks. CNA-K stated resident #2 was allowed to self-propel his wheel chair about the unit. CNA-K indicated resident #2's routine was to self-propel his wheel chair, usually around the nursing station or into the dining room and on rare occasions down on the halls. CNA-K stated occasionally resident #2 would use the elevator independently and leave the unit. On 1/7/11 at 12:00 p.m. surveyor # interviewed CNA-L regarding resident #2. CNA-L indicated resident #2 had recent cognitive changes. CNA-L stated resident #2 usually self-propelled his wheel chair near the nurses' station or into the dining room and occasionally would leave the unit. CNA-L verified she worked the PM shift on 1/5/11. CNA-L indicated she was told in shift report resident #2 was to have two staff present for cares. CNA-L stated she was unaware resident #2 had inappropriately touched female residents in a sexual manner. CNA-L stated there had been no change in resident #2's supervision plan as of 1/5/11 on the PM shift. Nurses' notes and the facility's incident report, dated 1/6/11 at 8:30 a.m., indicated resident #2 leaned over resident #4 and grabbed resident #4's breasts. Resident #4 stated, "...cut it out" and hit resident #2 on the right arm. The incident report indicated staff intervened and removed resident #4 from the area. The report indicated staff were monitoring resident #2 closely in his room. On 1/7/11 at 12:15 p.m. surveyor # interviewed resident #4. Resident #4 verified she recalled the incident with resident #2, which occurred on 1/6/11. Resident #4 stated she was sitting at a table waiting for breakfast, when resident #2 came up to her and grabbed both of her breasts and squeezed. Resident #4 stated resident #2 had not caused her any pain, but she was very upset over the incident. Resident #4 stated no one had ever treated her that way. Resident #4 indicated staff came running into the dining room from some where when she yelled. On 1/7/11 at 8:50 a.m. surveyor # interviewed SW (Social Worker)-B regarding the 1/6/11 incident involving residents #2 and #4. Although direct care staff working with resident #2 on the PM shift on 1/5/11 indicated resident #2's plan of care had not changed to include the need for 1:1 supervision, SW-B stated 1:1 supervision was implemented on 1/5/11 on the PM shift for the resident. SW-B indicated resident #2 was in his room on the morning of 1/6/11 with the assigned 1:1 staff and self-propelled his wheel chair into the dining room at approximately 8:30 a.m. SW-B indicated the 1:1 staff stayed with resident #2 and was standing about three feet away from the resident. SW-B indicated two other female residents and a visitor were already seated in the dining room. SW-B stated she thought RN-H was standing near the nurses station, followed resident #2 when he came out of his room and was doing 1:1 supervision with resident #2. SW-B indicated RN-H turned her head away from resident #2; and when she turned back, resident #4 was yelling out. SW-B stated RN-H did not witness the incident on 1/6/11. SW-B indicated resident #4 was alert and oriented and would be able to repeat the incident. SW-B verified to surveyor # resident #4 was very upset regarding the 1/6/11 incident with resident #2. SW-B indicated the police were called, and resident #2 verified he had touched resident #4's breasts. SW-B indicated resident #2's plan of care changed on 1/6/11 from 1:1 supervision to 1:1 supervision and to keep resident #2 away from other female residents. On 1/7/11 at 9:15 a.m. surveyor # interviewed LPN (Licensed Practical Nurse)-F regarding resident #2. LPN-F stated resident #2 was alert, but orientation was questionable. LPN-F indicated resident #2 had a history of [REDACTED]. LPN-F indicated on 1/6/11 at approximately 8:30 a.m. she was outside of the dining room passing medications. LPN-F stated resident #2 was not on 1:1 supervision at that time. LPN-F indicated resident #2 was in his room and self-propelled his wheel chair out of his room. RN-H was near the nurses' station, and she pushed resident #2's wheel chair just inside the dining room. Resident #2 then self-propelled in the dining room. LPN-F stated RN-H left the dining room after she pushed resident #2 into the dining room. LPN-F stated a loud yell was heard from the dining room, and she observed RN-H run into the dining room and push resident #2 out of the area. LPN-F stated she asked RN-H what had happened, and RN-H stated resident #4 said resident #2, "...tried to grab my breasts, and I slapped him in the face." LPN-F stated she was not sure if resident #2 actually had touched resident #4 inappropriately. LPN-F indicated 1:1 supervision was then initiated for resident #2. LPN-F stated resident #2 had been allowed to self-propel his wheel chair independently on/off the unit until after the incident on 1/6/11. Surveyor # asked LPN-F how staff would have known if resident #2 touched female residents who were confused and could not communicate the inappropriate touching from resident #2. LPN-F stated facility staff would probably not have known if there had been other incidents. LPN-F indicated resident #2 was not allowed out of his room following the 1/6/11 incident, and staff were to remain with him in his room. Surveyor # asked what happened if resident #2 wanted to come out of his room. LPN-F stated resident #2 would be forced to stay in his room with his 1:1, and the situation would have to be discussed with the supervisor. On 1/7/11 at 11:10 a.m. surveyor # interviewed SW-J regarding the 1/6/11 incident involving residents #2 and #4. SW-J verified on 1/6/11 at 8:30 a.m. she happened to be near the nurses' station, when she observed resident #2 self-propel his wheel chair out of his room. Resident #2 patted an LPN's buttocks as he self-propelled by her. SW-J stated she and RN-H told resident #2 his behavior was inappropriate, and resident #2 self-propelled his wheel chair into the dining room. SW-J stated she and RN-H remained at the nurses' station, and they heard a loud yell coming from the dining room. SW-J stated she asked RN-H to come into the dining room with her. SW-J stated both she and RN-H responded. RN-H removed resident #2 from the area, and she spoke with resident #4. SW-J stated there was one other confused resident and her spouse, who was visiting, in the dining room at the time of the incident. SW-J indicated she spoke with the spouse, who stated he witnessed resident #2 go up to resident #4 and grab her breasts. SW-J stated resident #4 told her resident #2 stopped by her and grabbed both of her breasts. SW-J verified 1:1 supervision for resident #2 was initiated after the incident with resident #4. SW-J indicated resident #2 was only allowed to leave his room in the presence of 1:1 if he was attending a Men's group activity. SW-J stated she was unsure if resident #2 could leave his room for any other reason and would need to defer to the supervisor if the situation occurred. During the 1/7/11, 9:50 a.m. interview with surveyor # , RN-H verified resident #2 did not have a supervision plan and self-propelled his wheel chair about the unit and into the dining room. RN-H confirmed staff would not always have been present with resident #2, so staff would not have known if any triggers for sexual behaviors were present. RN-H indicated staff would not know if resident #2 touched other female residents who were confused and could not communicate with staff. RN-H stated thirty-six female residents resided on the unit where resident #2 resided, and ten of the thirty-six female residents were confused. RN-H indicated she told the PM shift on 1/5/11 to monitor for any triggers for resident #2's sexual behavior. RN-H indicated on 1/6/11 she observed resident #2 come out of his room and touch a nurse's buttocks. RN-H indicated she told resident #2 his behavior was inappropriate, and the resident self-propelled himself into the dining room. RN-H indicated she was in the dining room and turned her head to answer a question posed from a staff person outside of the dining room, when she heard resident #4 yelling. RN-H stated she was about ten feet away from resident #4. RN-H stated she removed resident #2 from the area, and SW-J spoke with resident #4. RN-H indicated she had spoken with SW-J regarding what resident #4 reported. RN-H stated resident #4 reported resident #2 had touched her breasts. RN-H stated resident #2 was placed on 1:1 supervision after the incident with resident #4. RN-H indicated resident #2 must remain in his room with 1:1 supervision, even if the resident did not want to be in his room. RN-H stated if resident #2 wanted to leave his room, staff could close the door and stand in front of the door to keep him from leaving. Staff were directed to attempt diversional activities with resident #2 in his room. RN-H indicated, "I have to keep other residents safe." RN-H stated CNA-E was in morning report on 1/7/11 and knew resident #2 was to remain in his room. On 1/7/11 at 9:00 a.m. surveyor # observed CNA-E in resident #2's room and interviewed the CNA regarding resident #2's supervision plan. CNA-E verified she was completing 1:1 supervision for resident #1. CNA-E indicated she received care information regarding residents from the verbal report staff received at the start of the shift and also from the CNA care card located in resident rooms. CNA-E indicated when she came into work that morning, she was told she was to do 1:1 with resident #2, so she was unable to receive verbal report. CNA-E stated the nurse had not come to her and given her a verbal report regarding resident #2's plan of care. CNA-E stated she had spoken with other CNAs, who indicated she was to keep resident #2 in his room and occupied with activities. Surveyor # asked if resident #2 was allowed to leave his room. CNA-E indicated she thought he could leave his room, but she needed to stay with him. CNA-E stated resident #2 was not to be allowed in the dining room and was not to be near resident #5, because of a disturbance the day prior. CNA-E indicated she didn't know what the disturbance was. CNA-E stated she thought resident #2 could have been around other female residents in her presence. CNA-E indicated she was not aware if resident #2 had ever been sexually inappropriate with female residents. On 1/7/11 at 10:20 a.m. surveyor # interviewed CNA-I. CNA-I stated CNA-E was in morning report for a short time. CNA-I indicated CNA-E had to leave report early that morning, as CNA-E was told night shift had to leave the facility; and she needed to do 1:1's with resident #2. CNA-I indicated she was told in morning report by RN-H resident #2 needed to remain in his room. CNA-I stated she was unsure what to do if resident #2 wanted to leave his room. CNA-I did indicate RN-H told staff resident #2 could leave his room if he wanted to, but staff would need to stay with him, he would be unable to go to the dining room, and resident #2 was to be kept away from residents #3 and #4. Surveyor # asked CNA-I if resident #2 could interact with other female residents. CNA-I responded that was never discussed, indicating, "I would have to ask the unit manager." On 1/7/11 at 9:40 a.m. surveyor # interviewed CNA-G regarding resident #2. CNA-G stated resident #2 was alert and oriented and able to make his needs known, but was unsure if the resident would know the difference between right and wrong. CNA-G indicated she was aware resident #2 touched resident #3 and #4 inappropriately on their breasts. CNA-G stated she heard in report on 1/6/11 at 6:00 a.m. resident #2 was on 15 minute checks, but she was not responsible for completing documentation. CNA-G stated after resident #2 inappropriately touched resident #4, resident #2 was to stay in his room.