Every finding on record at Geneva Lake Manor

Based on interview and record review the facility did not have evidence all allegations of abuse were thoroughly investigated for 6 of 15 sampled and supplemental residents (R8, R34, R16, R59, R28, and R42). R8 and R34 had a resident-to-resident altercation that was not thoroughly investigated. R16 reported an allegation of neglect and the facility did not complete an investigation. R59 reported an allegation of neglect and the facility failed to conduct a thorough investigation of the allegation. Staff used the grievance process to report an allegation of neglect related to R28 and her hair not being tended to in weeks. The facility failed to conduct a thorough investigation into the allegations. R42's Grievance Form contained an allegation of abuse and the facility failed to conduct a thorough investigation into the allegations. R42's representative filed a grievance containing an allegation of abuse and neglect. The facility did not conduct a thorough investigation into the allegations. This is evidenced by: The facility's policy Abuse, Neglect and Exploitation, dated 10/1/25, states: IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse – mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment. C. Increased supervision of the alleged victim and residents; Example 1 R8 was admitted to the facility on [DATE] with a diagnosis of alcohol-induced persisting dementia. R8's BIMS (Brief Interview for Mental Status) on 8/3/26 has a score of 8, indicating moderate cognitive impairment. R34 was admitted to the facility on [DATE] with a diagnosis of vascular dementia with agitation. R34 has an activated power of attorney. R34's BIMS (Brief Interview for Mental Status), dated 8/3/26, has a score of 10, indicating moderate cognitive impairment. On 7/31/26, R34's nurse progress notes state: Writer was informed by RA (Resident Assistant) about an encounter between this resident and [R8]. Both residents were speaking inappropriately with each other, making sexual comments. Resident had lifted up her shirt to show [R8], exposing her breasts. RA intervened without complications. On 8/6/26, Surveyor requested from NHA A (Nursing Home Administrator) any information regarding the incident between R8 and R34. NHA A presented a file she had prepared after 8/3/26 when she was made aware of the incident that occurred on 7/31/26. On 8/10/26 at 10:05 AM, Surveyor interviewed NHA A. NHA A indicated she was not aware of the incident until 8/3/26. NHA A indicated after she was made aware of the incident from 7/31/26, she moved R8 to another room, updated both residents care plans and had follow up monitoring put in place. NHA A indicated she had interviewed the nurse and RA that were on duty when the incident occurred, but was unable to provide the RA's name and did not have documentation of the staff interviews. NHA A was unable to provide additional information about the incident. Of note, the file did not contain documentation of a thorough investigation. The file only contained information pulled from R8's and R34's medical records; face sheet, care plan, assessments completed on 8/3/26 and after. There was no documentation of any type of assessment immediately following the incident or the following days until 8/3/26. The file did not contain information identifying and interviewing of all involved person, including the alleged victim, alleged perpetrator, witnesses and any others who might have knowledge of the incident. Example 2 On 8/4/26, during initial screening, Surveyor interviewed R16 who stated I was sick, I told the nurse around 1:00 AM. They said, just take your pain med. I waited until 5:00 AM, gasping for breath; I wet myself. It was humiliating. They didn't treat me with respect. R16's Progress notes include: *2/15/26 8:29 PM, recorded as late entry on 2/16/26 8:30 AM, states, in part: 2355-Resident alert able to make needs known per CNA staff resident expressed concerns Regarding having pain upon writers arrival to residents room resident c/o (complain of) pain to legs, abdomen, inability to self transfer in wheelchair around room, as well as self transfer OOB (out of bed), assistance required with all cares, positioning and transfers at this time per resident statement, writer left resident in care of CNA (Certified Nursing Assistant) staff. approximately 12:30 AM resident expressed concerns with staff that accidently spilled water on herself in bed, requested assistance by CNA staff. CNA agreed to provide care to resident while writer present in room. CNA informed resident will provide care to R16 shortly.During the AM while writer performing medication pass to residents throughout the facility, CNA informed writer resident c/o pain, request to see writer right away.I want to know whey the CNA still hasn't helped clean up my bed and my room. I (expletive) pissed on myself, this is so embarrassing, I need to be cleaned up right away, please don't you think I need to be cleaned up, writer unaware cares not provided at that time. *2/16/26 9:32 AM Resident called facility phone at 6:10 AM with complaints of pain, SOB (short of breath), and being ignored by NOC (overnight) shift staff. States she informed staff of her discomfort and needing assistance but did not get the help she needed. On 8/10/26 at 9:59 AM, Surveyor interviewed LPN V (Licensed Practical Nurse) who acknowledged documenting R16's progress note for 2/15/26. Surveyor asked if CNA provided care for R16. LPN V stated I don't know, I don't recall. Surveyor asked if LPN V told anyone about R16's comments regarding lack of care. LPN V stated I know I spoke with DON B (Director of Nursing) in the morning. On 8/10/26 at 11:16 AM, Surveyor interviewed DON B who indicated being unaware of R16's concern. DON B stated it sounds like negligence; the NHA would need to be notified for investigation. I will check for a grievance. No grievance or investigation provided. On 8/10/26 at 11:37 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about process if a resident states they were ignored by staff. NHA A stated we'd need to investigate, do a body assessment, interview all staff and the resident. Surveyor asked if this is potentially an allegation of neglect. NHA A stated yes. Surveyor asked if allegations of neglect need to be reported and investigated. NHA A stated yes. Example 3 R59 was admitted to the facility on [DATE]. R59's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/16/26, indicates R59's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 14 out of 15. R59's Grievance Form, dated 6/15/26, includes: Relationship to resident: Employee. Location of event: R59's room. Concern filed regard which department: nursing. Describe the nature of the concern: Resident reported that her call light was out of reach last night from 8pm on 6/14/26 through 7am this morning, 6/15/26. Resident reported that she sat for 2 hours in pee and poop. On 8/6/26 at 2:41 PM DON B (Director of Nursing) indicated a call light out of reach for 11 hours and a resident left to sit in poop and pee for 2 hours is an allegation of neglect that should be reported to the state agency. DON B indicated other residents were not interviewed and staff interviews were not completed. DON B indicated skin assessments were not conducted on non-interviewable residents. On 8/6/26 at 3:01 PM NHA A and Surveyor reviewed R59's grievance. NHA A indicated this is an allegation of neglect and should have been thoroughly investigated. Example 4 R28 was admitted to the facility on [DATE]. R28's most recent re-admission was on 6/10/26 from the hospital. R28's MDS with ARD of 7/6/26, indicates R28's cognition is moderately impaired with a BIMS score of 12. R28's Grievance Form, dated 6/17/26, includes: date of occurrence: 6/17/26. Time approximately: 12:00 PM. Location of event: resident room. Describe the Nature of the concern: (Staff named) and (Staff named) found R28 with her hair matted to head. Looks like it had not been tended in weeks. We have photo. Very devastating. Witnesses account of the occurrence: Resident with confusion. Investigation: R28's hair was tangled status post transfer back to hospital. Staff had to work diligently to untangle hair. (It is important to note R28 returned from the hospital on 6/10/26 and the facility investigation indicated R28's hair status on 6/17/26 was due to a hospitalization.) On 8/6/28 at 2:54 PM, DON B indicated R28 returned from the hospital on 6/10/26, 7 days before the grievance was filed. DON B indicated a resident should not have to go 7 days without their hair being groomed and that is an allegation of neglect. DON B indicated this allegation should have been investigated thoroughly. DON B indicated there were no other residents or staff interviewed regarding the allegation of neglect. On 8/6/26 at 3:01 PM, NHA A indicated this is an allegation of neglect and this should have been investigated thoroughly. Example 5 R42 was admitted to the facility on [DATE]. R42's most recent MDS with ARD of 8/4/26, indicates R42's cognition is intact with a BIMS score of 15 out of 15. R42's Grievance Form, dated 3/14/26, includes: Date of event: 3/14/26. Location of event: R42's room. Describe the Nature of concern: Had his call light on and CNA (Certified Nursing Assistant) came in touched his sores. He told her to get out! Then she said not to turn on the call light again. On 8/6/26 at 2:41 PM, DON B indicated this is an allegation of abuse that should have been reported to the state agency and should have been investigated. DON B indicated the facility did not conduct a thorough investigation, including interviewing other staff that worked during this time, interviewing other residents who were also assigned to the accused staff, or conducting skin/body assessments of non-interviewable residents. On 8/6/26 at 3:01 PM NHA A indicated R42's grievance contains an allegation of abuse and should have been investigated thoroughly, but it wasn't. Example 6 R42 admitted to the facility on [DATE]. R42's most recent MDS with ARD of 8/4/26, indicates R42's cognition is intact with a BIMS score of 15 out of 15. R42's Grievance Form, dated 7/18/26, includes: . 8:50 AM I called R42 to let him know I was coming. He stated to me that he had been waiting for an hour to use the bathroom. When asked if his light was on, he said it has been. 10:00 AM I arrived at the facility. He was still waiting. 11:00 AM . would go check on him again and. she said he was still waiting and he had a large puddle on the floor. He was extremely upset, soaking wet, in a lot of pain. Agency workers have been nothing but issues ever since they were brought in. There have been very few good workers from agency. They are unable to follow rules set forth by this facility. They are rude, disrespectful, and belittle the residents. Agency workers have said they don't wear name tags because they don't want people knowing who they are and they won't carry walkies because they don't want to be bothered or found. AGENCY NEEDS TO GO! Preferably before someone gets hurt. I do hope that I will get a response to my complaint along with R42. On 8/6/26 at 2:41 PM, DON B indicated this is an allegation of neglect and abuse and the facility should have conducted a thorough investigation but didn't. DON B indicated the facility put the accused staff on the Do-Not-Return list and interviewed R42. DON B indicated the facility did not interview other residents, conduct skin/body checks of non-interviewable residents, or interview other staff who may have knowledge of the events. On 8/6/26 at 3:01 PM NHA A indicated she was not made aware of this grievance, and it contains allegations of abuse and neglect. NHA A indicated the facility is to thoroughly investigate all allegations of abuse and neglect. NHA A indicated if the information had gotten to her, she would have investigated these allegations.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, and including injuries of unknown source, are reported immediately for 6 of 21 sampled and supplemental residents (R8, R34, R16, R59, R28, and R42). R8 and R34 had a resident-to-resident altercation that was not reported to the state agency. R16 reported an allegation of neglect and the facility did not submit a report to the State Agency (SA). R59 reported an allegation of neglect, and the facility did not report the allegation to the state agency. R28's Grievance reported an allegation of neglect related to R28's hair not being groomed for 7 days. The facility did not report the allegation of neglect to the state agency. R42's Grievance Form contained an allegation of abuse. The facility did not report the allegation to the state agency. R42's representative filed a grievance containing an allegation of abuse and neglect. Staff did not report the allegations to NHA A (Nursing Home Administrator) and did not report the allegations to the state agency. This is evidenced by: The facility's policy Abuse, Neglect and Exploitation, dated 10/1/25, states: IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse – mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies. within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. Example 1 R8 was admitted to the facility on [DATE] with a diagnosis of alcohol-induced persisting dementia. R8's BIMS (Brief Interview for Mental Status) on 8/3/26 has a score of 8, indicating moderate cognitive impairment. R34 was admitted to the facility on [DATE] with a diagnosis of vascular dementia with agitation. R34 has an activated power of attorney. R34's BIMS (Brief Interview for Mental Status), dated 8/3/26, has a score of 10, indicating moderate cognitive impairment. On 7/31/26, R34's nurse progress notes state: Writer was informed by RA (Resident Assistant) about an encounter between this resident and [R8]. Both residents were speaking inappropriately with each other, making sexual comments. Resident had lifted up her shirt to show [R8], exposing her breasts. RA intervened without complications. On 8/6/26, Surveyor requested from NHA A (Nursing Home Administrator) any information regarding the incident between R8 and R34. NHA A indicated staff should have reported this incident to DON B (Director of Nursing) or NHA A. NHA A indicated the incident happened on 7/31/26. NHA A indicated she was made aware on 8/3/26 during their morning clinical meeting. NHA A presented a file on the incident but indicated she had not reported this incident to the state agency and had not treated this incident as a resident-to-resident altercation. Example 2 On 8/4/26, during initial screening, Surveyor interviewed R16 who stated I was sick, I told the nurse around 1:00 AM. They said, just take your pain med. I waited until 5:00 AM, gasping for breath; I wet myself. It was humiliating. They didn't treat me with respect. R16's Progress notes include: *2/15/26 8:29 PM, recorded as late entry on 2/16/26 8:30 AM, states, in part: 2355-Resident alert able to make needs known per CNA staff resident expressed concerns Regarding having pain upon writers arrival to residents room resident c/o (complain of) pain to legs, abdomen, inability to self transfer in wheelchair around room, as well as self transfer OOB (out of bed), assistance required with all cares, positioning and transfers at this time per resident statement, writer left resident in care of CNA (Certified Nursing Assistant) staff. approximately 12:30 AM resident expressed concerns with staff that accidently spilled water on herself in bed, requested assistance by CNA staff. CNA agreed to provide care to resident while writer present in room. CNA informed resident will provide care to R16 shortly.During the AM while writer performing medication pass to residents throughout the facility, CNA informed writer resident c/o pain, request to see writer right away.I want to know whey the CNA still hasn't helped clean up my bed and my room. I (expletive) pissed on myself, this is so embarrassing, I need to be cleaned up right away, please don't you think I need to be cleaned up, writer unaware cares not provided at that time. *2/16/26 9:32 AM Resident called facility phone at 6:10 AM with complaints of pain, SOB (short of breath), and being ignored by NOC (overnight) shift staff. States she informed staff of her discomfort and needing assistance but did not get the help she needed. On 8/10/26 at 9:59 AM, Surveyor interviewed LPN V (Licensed Practical Nurse) who acknowledged documenting R16's progress note for 2/15/26. Surveyor asked if CNA provided care for R16. LPN V stated I don't know, I don't recall. Surveyor asked if LPN V told anyone about R16's comments regarding lack of care. LPN V stated I know I spoke with DON B (Director of Nursing) in the morning. On 8/10/26 at 11:16 AM, Surveyor interviewed DON B who indicated being unaware of R16's concern. DON B stated it sounds like negligence; the NHA would need to be notified for investigation. On 8/10/26 at 11:37 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked about process if a resident states they were ignored by staff. NHA A stated we'd need to investigate, do a body assessment, interview all staff and the resident. Surveyor asked if this is potentially an allegation of neglect. NHA A stated yes. Surveyor asked if allegations of neglect need to be reported to SA. NHA A stated yes. There was no report of the allegation of neglect to the SA. Example 3 R59 admitted to the facility on [DATE]. R59's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/16/26, indicates R59's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 14 out of 15. R59's Grievance Form, dated 6/15/26, includes: Relationship to resident: Employee. Location of event: R59's room. Concern filed regard which department: nursing. Describe the nature of the concern: Resident reported that her call light was out of reach last night from 8pm on 6/14/26 through 7am this morning, 6/15/26. Resident reported that she sat for 2 hours in pee and poop. On 8/6/26 at 2:41 PM, DON B (Director of Nursing) indicated a call light out of reach for 11 hours and a resident left to sit in poop and pee for 2 hours is an allegation of neglect that should be reported to the state agency. DON B indicated this allegation was not reported to the state agency. On 8/6/26 at 3:01 PM, NHA A (Nursing Home Administrator) indicated all allegations of abuse and neglect are to be reported to the state agency within 24 hours. NHA A indicated this is an allegation of neglect and the facility should have reported to the state agency. Example 4 R28 admitted to the facility on [DATE]. R28's most recent re-admission was on 6/10/26 from the hospital. R28's MDS with ARD of 7/6/26, indicates R28's cognition is moderately impaired with a BIMS score of 12. R28's Grievance Form, dated 6/17/26, includes: date of occurrence: 6/17/26. Time approximately: 12:00 PM. Location of event: resident room. Describe the Nature of the concern: (name) and (name) found R28 with her hair matted to head. Looks like it had not been tended in weeks. We have photo. Very devastating. Witnesses account of the occurrence: Resident with confusion. Investigation: R28's hair was tangled status post transfer back to hospital. Staff had to work diligently to untangle hair. R28 returned from the hospital on 6/10/26 and the facility investigation indicated R28's hair status on 6/17/26 was due to a hospitalization. On 8/6/28 at 2:54 PM DON B indicated R28 returned from the hospital on 6/10/26, 7 days before the grievance was filed. DON B indicated a resident should not have to go 7 days without their hair being groomed and that is an allegation of neglect. DON B indicated this allegation should have been reported to the state agency. On 8/6/26 at 3:01 PM NHA A indicated an allegation of resident's hair not being tended to in weeks could be an allegation of neglect and should be reported to the state agency. Example 5 R42 admitted to the facility on [DATE]. R42's most recent MDS with ARD of 8/4/26, indicates R42's cognition is intact with a BIMS score of 15 out of 15. R42's Grievance Form, dated 3/14/26, includes: Date of event: 3/14/26. Location of event: R42's room. Describe the Nature of concern: Had his call light on and CNA (Certified Nursing Assistant) came in touched his sores. He told her to get out! Then she said not to turn on the call light again. On 8/6/26 at 2:41 PM DON B indicated this is an allegation of abuse that should have been reported to the state agency and should have been investigated. On 8/6/26 at 3:01 PM NHA A indicated this is an allegation of abuse and should have been reported to the state agency. NHA A stated, I was not here. I would have reported that. Example 6 R42's Grievance Form, dated 7/18/26, includes: . 8:50 AM I called R42 to let him know I was coming. He stated to me that he had been waiting for an hour to use the bathroom. When asked if his light was on, he said it has been. 10:00 AM I arrived at the facility. He was still waiting. 11:00 AM . would go check on him again and. she said he was still waiting and he had a large puddle on the floor. He was extremely upset, soaking wet, in a lot of pain. Agency workers have been nothing but issues ever since they were brought in. There have been very few good workers from agency. They are unable to follow rules set forth by this facility. They are rude, disrespectful, and belittle the residents. Agency workers have said they don't wear name tags because they don't want people knowing who they are and they won't carry walkies because they don't want to be bothered or found. AGENCY NEEDS TO GO! Preferably before someone gets hurt. I do hope that I will get a response to my complaint along with R42. On 8/6/26 at 2:41 PM DON B indicated this is an allegation of neglect and abuse and should have been reported to the state agency and it wasn't. DON B indicated she did not report this to NHA A immediately per the abuse policy and procedure. On 8/6/26 at 3:01 PM NHA A indicated this is an allegation of neglect and of abuse and should be reported to me and then to the state agency. NHA A indicated she has conducted training on abuse reporting and she just can't seem to get staff on board.

Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 4 of 4 residents (R53, R38, R16 and R50) reviewed for grievances from a total sample of 15 residents. R53's grievance from 8/4/26 was not promptly investigated or resolved. R39 voiced a grievance to the facility. Facility did not complete a thorough investigation of the grievance. R16 voiced concerns related to missing a box that contained her banking information and greeting cards. Staff did not fill out a grievance for the missing items and the facility failed to follow up on this concern. R50 voiced concerns to staff related to not wanting to be woke up at night, a resident nearby yelling, and having trouble sleeping. Staff did not fill out grievances related to R50's concerns and the facility did not follow up on R50's concerns. This is evidenced by: The facility's policy Resident and Family Grievances, dated 5/21/26, states: Prompt effort to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance official. b. Written complaint to a staff member or Grievance official. 10. Procedure: b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. i. Take any immediate actions needed to prevent further potential violations of any resident right. c. Forward the grievance form to the Grievance Official as soon as practicable. 12. The facility will make prompt efforts to resolve grievances. Example 1 R53 was admitted to the facility on [DATE] with diagnoses including fracture of upper end of right tibia, fracture of right calcaneus, and fracture of upper and lower end of right fibula. R53's BIMS (Brief Interview for Mental Status), dated 8/5/26, has a score of 15, indicating R53 is cognitively intact. R53 has a physician order for hydromorphone 2 mg tablet, 1 tablet every 6 hours PRN (As Needed). On 8/4/26 at 1:57 PM, Surveyor interviewed R53. R53 stated the facility kept running out of her hydromorphone 2 mg and she was not able to receive it when she asked for it. R53 stated she told the morning nurse on 8/4/26 of her concerns about her pain medication. R53 stated she filed a grievance and was waiting to hear from the facility management. On 8/6/26 at 7:50 AM, Surveyor interviewed LPN L (Licensed Practical Nurse). LPN L stated she worked the morning shift on 8/4/26. LPN L indicated R53 was upset about her pain medications. LPN L stated R53 wanted to talk to DON B (Director of Nursing) but DON B was not in the facility yet. LPN L stated she gave R53 a grievance form to fill out. LPN L stated R53 turned it in at the start of the evening shift. LPN L stated she did not follow up with DON B about R53's concern. On 8/5/26 at 2:00 PM, Surveyor interviewed R53. R53 stated that she still had not heard from DON B regarding R53's concerns about her pain medications. On 8/6/26 at 8:22 AM, Surveyor interviewed DON B regarding grievances. DON B indicated that a resident, family member, or staff can fill out a grievance form on behalf of a resident. DON B stated the grievance form is given to either social services, DON B, or NHA A (Nursing Home Administrator) DON B stated grievances should be addressed immediately. DON B indicated she has not received any grievances this week. Surveyor informed DON B that R53 filed a grievance and handed it to the nursing on 8/4/26 at approximately 2:00 PM. DON B indicated she should have received the grievance form but did not. DON B indicated R53's grievance regarding her pain medication was not acted upon promptly. Example 2 On 8/4/26 at 4:00 PM, Surveyor interviewed R39 during initial screening. R39 stated some agency CNAs (Certified Nursing Assistants) are very rude. Surveyor asked if R39 had told the facility. R39 said yes and they kicked them out. R39's Grievance Form, dated 7/17/26, states, in part: .Describe the Nature of the concern.Two aides came to take care of R39. R39 tried to tell them how to take care of them. Family reported that caregivers were not nice to resident during cares and R39 became upset. They did not follow directives on how R39 likes to be cared for.Investigation: R39 states: The CNAs came in and did not provide care like I wanted. I told them what to do and in what order. They said, We don't have to do that. A (facility) CNA came in to assist me and asked what happened. The Agency CNA's left. The (facility) CNA calmed me down and got me prepared. There is no documentation of the name of the facility CNA and no documentation of interview with the facility CNA or the agency CNAs. On 8/6/26 at 11:40 AM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator). Surveyor asked about the grievance process when a resident states that staff is not nice. DON B stated interview the residents and staff. Surveyor asked if the staff was interviewed. DON B stated they were not. We should have interviewed staff to have a complete grievance. Example 3 R16 admitted to the facility on [DATE]. R16's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/2/26 indicates R16's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. On 8/4/26 at 11:23 AM during an interview, R16 stated, about a month ago, my box of cards and all my banking information went missing. The CNAs (Certified Nursing Assistants) looked, but there was no follow up. I have had a lot of grievances over time and I don't feel they follow up with them. I asked for a hook for my call light about three weeks ago and I haven't gotten it. On 8/6/26 at 10:20 AM CNA I indicated R16 reported to her that she was missing a box of cards about a month ago. CNA I indicated she and another CNA looked for the cards in R16's room and didn't find them. CNA I indicated she did not report the missing box of cards to anyone and did not fill out a grievance form, but she has kept an eye out for the missing cards. On 8/10/26 12:01 PM Corporate DON J indicated she would fill out a grievance and begin looking into the missing cards and banking information. Corporate DON J indicated staff should have reported the missing items and filled out a grievance form when R16 first reported the missing items. Example 4 R50 admitted to the facility on [DATE]. R50's most recent MDS with ARD of 4/10/26 indicates R50's cognition is intact with a BIMS score of 15 out of 15. R50's Nurse Note, dated 3/24/26 at 7:36 PM, includes: R50 called 911 due to resident down the hall yelling. Police department did come to the facility and did not find any issues noted. Director of Nursing notified regarding situation. On 8/10/26 at 12:11 PM NHA A (Nursing Home Administrator) indicated this concern should have been followed up on using the facility's grievance process, but it wasn't. On 8/10/26 at 12:23 PM DON B (Director of Nursing) indicated this concern should have had follow up and could be considered a grievance. R50's Nurse Notes, dated 5/27/26 at 1:44 AM, includes: Resident observed in bed and appeared sleeping. Resident expressed previously he does not want to be disturbed however has medication scheduled for 0001 (12:01 AM) and checks related to his diagnoses that need to be assessed. When explanation provided to R50 justifying checks during night R50 started shouting, swearing and telling staff to get out. Approaches to resident limited to times when he is observed awake, adjusting, or snacking. However resident continues to insist that checks and scheduled cares keep him awake through night. Resident refused. continuing to swear and blame staff for inability to sleep. On 8/10/26 at 12:11 PM, NHA A indicated a concern related to not being able to sleep could be a grievance and should be looked into. On 8/10/26 at 12:23 PM, DON B indicated a concern related to a resident's schedule, sleep patterns, medications, or familiar routine is a grievance and staff should follow up on the concern. DON B indicated the facility did not follow up on R50's concern. R50's Nurse Notes, dated 5/29/26 at 12:29 AM, include: . Resident states he does not sleep well at night however has TV on continually and appears to be resting comfortably with checks at night. Resident requires frequent repositioning. On 8/10/26 at 12:11 PM, NHA A indicated that R50 is voicing concerns in these Nurse Notes, but staff are not addressing his concerns. NHA A indicated staff should use the grievance process for resident concerns. On 8/10/26 at 12:23 PM, DON B indicated R50's concerns related to not being able to sleep at night should have been recorded using the facility's grievance process and followed up on. R50's Nurse Note, dated 6/18/26 at 9:01 AM, includes: . Resident in bed and appeared to sleep at intervals and heard to tell the CNA to get out when offered assistance. Resident often resists cares even when approached awake at night. Resident would benefit with compliance with care plan and staff assist. On 8/10/26 at 12:11 PM, NHA A indicated R50's concern was not addressed, his medication times maybe could have been adjusted, his care plan could have been updated, and his care could have been more personalized. NHA A indicated staff need to use the grievance process. On 8/10/26 at 12:30 PM, DON B indicated R50's concerns were not captured in the grievance process and should have been. R50's Nurse Note, dated 6/19/26 at 9:59 AM, includes: Resident in bed and appeared to sleep at intervals. Report received that resident unaccepting and rude to CNA staff when assigned cares attempted. Resident often resists cares even when approached awake at night. Resident would benefit with compliance with care plan and staff assist. Resident unable to position self effectively in bed and is at risk for impaired skin integrity. R50's Nurse Note, dated 6/20/26 at 2:39 AM, includes: At approximately 2:30 AM R50 requested his door be closed until first shift comes in. This writer asked if he needed anything, stated No. He's never asked to have his door shut from writer in the past. On 8/10/26 at 12:49 PM DON B, Corp DON J, and NHA A indicated staff should put all care concerns in grievance log for tracking and trending and follow the grievance process.

Based on interview and record review, the facility failed to provide adequate supervision to prevent an elopement from occurring for 1 of 3 residents at risk for elopement out of a sample of 12 (R1). R1 has a history of elopement and is at risk of wandering. The facility failed to implement care planned interventions and failed to ensure exits were secured resulting in R1 being able to exit the facility through an exit door without staff knowledge. The facility's failure to supervise a resident and implement care planned interventions allowed R1 to elope from the facility. This created a finding of immediate jeopardy that began on 7/10/26. Surveyor notified Administrator, Director of Nursing (DON), Director of Operations, and the Chief Nursing Officer of the immediate jeopardy on 7/14/26 at 4:10 PM. The immediate jeopardy was removed and corrected on 7/10/26; the deficient practice is being cited as past noncompliance. Findings include: Review of the facility's policy titled, Elopements and Wandering Residents, dated 07/22/25, indicates .The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and ground-level fall. The admission Minimum Data Set with an Assessment Reference Date of 06/30/26 revealed a Brief Interview for Mental Status score of 9 out of 15 indicating R1 was moderately cognitively impaired. R1 was assessed for exhibiting the behavior of inattention and disorganized thinking and wandering occurring daily. R1's Care Plan, dated 06/26/26, included a category of Wander Risk, Elopement Risk. I demonstrate movement behavior that may be interpreted as wandering, pacing, roaming, and/or elopement related to diagnosis of: Alzheimer's. I am unaware of my surroundings and often search for my spouse. I need gentle approach and redirection frequently. Approaches: Validate function of wander device (Code Alert) every 24 hours on day shift. One to one companion staff 24/7 to monitor resident whereabouts until determined that supervision can be reduced. (of note: R1 uses a walker as an assistive device) R1's Progress Notes, dated 07/10/26 at 7:58 AM, stated, Resident eloped at 6:30AM this morning. At 6:20AM writer was notified resident was not in his room. Writer is working on another zone and was receiving report. Writer then had staff check all rooms and bathrooms. As CNAs (Certified Nurse Assistants) were checking another resident notified [sic] that they saw resident going towards rehab exit door. Writer then had staff start to check outside the building. Writer then contacted Assistant Director of Nursing (ADON).then contacted 911. Writer gave description around 6:40AM of resident and where he was last seen. Staff continued to look for the resident. Resident found by law enforcement around 7:20AM. Resident brought back to facility. Resident had no injuries. On 07/14/26 at 10:36 AM, Surveyor spoke with RN1 (Registered Nurse), who was on duty at the time of R1's elopement. RN1 stated about 6:00 AM she had seen R1 awake and wandering near the men's locker room and time clock. RN1 stated she escorted R1 back to the common area. (Of note: RN1 escorted R1 back to the common area and did not provide 1:1, when he was to have 1:1 companion staff 24/7 to monitor resident's whereabouts. The CNA assigned to provide supervision, did not provide supervision to R1) Review of the facility-reported incident (FRI,) submitted on 07/10/26 at 9:12 PM, stated, The Administrator was informed at approximately 6:46 AM that resident (R1) was missing. Staff conducted a comprehensive search. R1's responsible party, attending physician, case worker, and local law enforcement were notified. R1 was found with no injury noted. Upon his return the resident was immediately assessed by licensed nursing staff, with no injuries noted, and was placed one-to-one supervision. Review of the facility's undated Timeline for R1 provided by the facility as part of their investigation revealed the following: -On 07/10/26 at 5:45 AM, CNA1 entered R1's room and observed him in bed. -At 6:05 AM, R1's assigned night shift nurse, RN1, last observed R1 walking near the men's locker room by the time clock. -At 6:25 AM, LA (Laundry Aide), a housekeeping staff member, reported seeing a resident walking eastbound outside the facility. -At 6:35 AM, RN2 discovered the resident was missing, searched the resident's room, and began asking staff if anyone had seen him. -Approximately 6:35 AM, Code [NAME] was initiated. Staff immediately began searching the interior and exterior of the facility. -At 6:46 AM, ADON notified the Administrator that R1 could not be located. Administrator instructed ADON to conduct complete search of the facility, surrounding grounds, and nearby area. Instructions were also given that if the resident was not located promptly, staff were to notify the resident's responsible party, attending physician, and local enforcement. -Prior to 7:20 AM, local law enforcement reported seeing a resident walking within the community. -At 7:20 AM, law enforcement located R1 approximately 0.2 miles from the facility and safely returned him to facility. -Following the incident, staff received education on the facility's Elopement Prevention Policy [dated 07/10/26]. -Education was also provided [on 07/10/26] no staff is allowed to change the schedule unless the DON, ADON, Scheduler or the on-call nurse give directives to staff. -Post-investigation, all exit door alarms were inspected [on 07/10/26]. It was determined that R1 exited through the rehabilitation exit door, which had not been armed; therefore, no alarm sounded to alert staff. sounded to alert staff [sic]. An additional exit door was found to be malfunctioning. A maintenance work order was submitted immediately in TELs (facility work order program). -The Maintenance Director inspected, repaired, and verified the operation of both doors [07/10/26]. Staff received immediate re-education [on 07/10/26] regarding the requirement that exit doors remain armed at all times unless temporarily disarmed for authorized purposes and must be rearmed immediately after use. All cameras that were not activated were activated in the following areas damper exit, main entrance, zone 3 hallway, back patio, rehab hall, and time clock hall. The maintenance director was informed to make sure other areas where residents can exit that camera needed to be installed when installation is completed. During an interview on 07/14/26 at 10:30 AM, CNA1 stated she was scheduled to do one-to-one observation with R1. CNA1 stated she thought (R1) was no longer on one-on-one supervision. There were two of us on the unit and we checked on him frequently. R1 slept throughout night. At 5:45 AM. CNA1 stated she got R1 out of bed, dressed and took him out to the sitting area. CNA1 stated the last time she saw (R1) was in the open common area. CNA1 added that she was aware she should have been compliant with the schedule she was assigned to. On 07/14/26 at 10:55 AM, Surveyor spoke with RN2 who stated it was change of shift and she was getting report. RN2 said she overheard some staff asking where R1 was. RN2 stated she went to R1's room and saw he was not in his room. She stated facility staff started looking through facility and outside. RN2 stated she called the ADON and initiated Code Green. (code green is an alert to notify staff that a resident is missing). She stated when staff couldn't locate R1, they called 911 and had staff start searching outside. On 07/14/26 at 11:09 AM, Surveyor spoke with the Maintenance Director (Mnt Dir) stated when he first received the call that a resident had eloped, he was approximately 20 minutes away from facility. He stated as soon as he arrived at the facility, he started checking all exit doors and alarms. Mnt D stated he found that the rehabilitation unit exit door was programmed wrong, so the alarm would not have been activated. During an interview on 07/14/26 at 12:43 PM, the Laundry Aide (LA) stated she had gone out to the employee parking lot and was sitting in her vehicle around 6:00 AM -7:00 AM when she saw a man walking across the yard next to the road with a walker in street clothes walking on sidewalk. LA was asked why she had not reported seeing this man as soon as she re-entered the facility. LA stated she saw a lot of people out walking at that time and did not realize he was a facility resident. The facility's failure to supervise a resident who was to be on 1:1 supervision and failure to ensure all door alarms were working properly allowed R1 to elope from the facility. This created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy and corrected the deficiency on 7/10/26 when it completed the following: Corrective Actions Resident was immediately assessed by a licensed physician following his return to the facility no in (no injury) The resident's responsible party, case worker, and attending physician were notified. A comprehensive investigation was conducted. Staff interviews were completed. PHQ-9 monitoring was initiated for 72 hours, as appropriate. A BIMS assessment was completed. The resident's elopement risk assessment was reviewed and updated. The resident's person-centered care plan was revised to reflect individualized behaviors, triggers, risks, and interventions. All residents identified as being at risk for wandering or elopement were audited. Wander Guard devices were verified for proper placement and functionality. Door alarm audits were completed on all shifts. Elopement drills were conducted on 7/10/26 and 7/13/26 Staff scheduling practices were reviewed and reinforced to ensure employees do not independently change assignments involving residents requiring continuous supervision without authorization from nursing leadership. Education was provided to all staff, including agency personnel, on :1. 1. Elopement and Wandering Resident Policy (reviewed/revised 7/10/26) 2. Door alarm procedures and response expectations 3. Resident-specific care plan updates 4. Appropriate interventions when a resident is observed outside the building or on facility grounds 5. Schedule expectations 6. Abuse Prevention and Reporting Policy 7. Expectations regarding one-to-one supervision assignments and the requirement that assigned safety interventions must not be altered without approval from nursing leadership 8.Staff were re-educated that they must never assume a resident belongs outside the facility or is visiting someone. Any resident observed outside the building or on facility grounds must be approached immediately, safely redirected back into the facility when appropriate, and reported to the charge nurse for assessment. 9. Ongoing monitoring through supervisory rounds and routine audits has been implemented. Ongoing monitoring of door alarms and Wander Guard functionality. Audits of implementation of care plan interventions for residents at risk of elopement. Ongoing education and competency validation for all staff, including agency personnel. Review audit findings during QAPI meetings and monitor for sustained compliance. Ongoing audits to verify the effectiveness of corrective actions and identify any additional opportunities for improvement. All interventions were verified as completed on 07/15/26 by 4:20 PM.

Based on interview and record review, the facility did not complete a performance review of CNAs (Certified Nursing Assistants) at least every 12 months for 5 of 5 CNAs reviewed. This has the potential to affect all 45 residents.CNA3, CNA4, CNA5, CNA6, and CNA7 did not have a yearly performance review completed. This is evidenced by:The facility's policy Job Descriptions and Performance Evaluations, dated 9/20, includes: Performance evaluations measure the standards against job performance. The objectives of our job descriptions and performance evaluations are to: d. aid management in analyzing and improving the facility's services and structure of its organization; e.and to improve the quality of work performance; CNA3 has a hire date of 2/16/25. CNA3 does not have a yearly performance review completed in the last 12 months. CNA4 has a hire date of 9/21/09. CNA4 does not have a yearly performance review completed in the last 12 months.CNA5 has a hire date of 5/23/25. CNA5 does not have a yearly performance review completed in the last 12 months CNA6 has a hire date of 1/13/20. CNA6 does not have a yearly performance review completed in the last 12 months.CNA7 has a hire date of 12/31/97. CNA7 does not have a yearly performance review completed in the last 12 months.On 7/27/26 at 12:40 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A indicated the facility did not have yearly performance reviews for the CNAs. NHA A indicated the facility should have completed a yearly performance review for the CNAs but did not.

Based on record review and interviews the facility failed to report an allegation of abuse to the state agency (SA) for one of three residents (R8) reviewed for abuse out of 12 sampled residents. R8 reported an allegation of abuse to the NHA (Nursing Home Administrator) this allegation was not reported to the state agency. Findings include: Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 06/23/26, revealed The Administrator or designee will notify the appropriate agencies immediately: as soon as possible, but no later than 2 hours after discovery of the incident. Review of R8's undated Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R8 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses including major depressive disorder, intellectual disabilities, and anxiety. Review of R8's five day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/26, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R8 was cognitively intact. Review of the facility's Incident Report dated 01/19/26 and provided by the facility, revealed This Administrator was notified of potential abuse allegation reported by [R8] on 01/19/26. The initial report indicated that the resident stated an employee, described as African American, tall, skinny and had pinched her on the upper arm on Tuesday 01/13/26. Further review of the facility's soft file on R8's incident report, provided by the facility, revealed that although the facility contacted the local police enforcement, and conducted a thorough investigation, the allegation of physical abuse was not reported to the State Agency. During an interview conducted with the current Administrator on 07/15/26 at 1:07 PM, the Administrator was questioned if R8's allegation of abuse should have been reported. Administrator stated Yes, I would have reported it.

Based on observation, interview and record review, the facility did not ensure 1 (R8) of 2 residents observed while being provided wound treatment had the necessary hand hygiene performed. * Surveyor LPN (Licensed Practical Nurse)-I not perform hand hygiene while providing pressure injury treatment to R8. Findings include:The facility's Handwashing/Hand Hygiene policy dated October 2023 documents:Indications for Hand Hygiene1. Hand hygiene is indicated:Immediately before touching a residentBefore performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device)After contact with blood, body fluids or contaminated surfacesAfter touching a resident After touching the resident's environmentBefore moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removalR8 was admitted to the facility on [DATE] with diagnoses of vascular dementia and cerebral artherosclerosis.R8's quarterly MDS (minimum data set) dated10/1/25 documents that R8 is severely cognitively impaired and is dependent with all ADLs (activity of daily living) and bed mobility. The MDS also documents R8 has an unstageable pressure injury. R8's medical record documents R8 is on hospice due to dementia.R8's Wound NP (nurse practitioner) assessment dated [DATE] documents a sacral/coccygeal stage 3 pressure injury measuring 1.3 cm by 0.9 cm by 0.9 cm (centimeters) consisting of 100% granular tissue and no undermining. The Wound NP assessment also documents the wound is improving. On 12/10/25 at 8:48 a.m., Surveyor observed LPN-I perform pressure injury treatment on R8's coccyx pressure injury. Before touching R8, LPN-I washed her hands and placed gloves on. LPN-I assisted to roll R8 on her right side and R8 was incontinent of bowel. With gloves on, LPN-I cleaned up R8 incontinent episode. LPN-I removed gloves and did not perform hand hygiene. LPN-I then placed a clean pair of gloves on and proceeded to removed the pressure injury dressing. LPN-I removed gloves again but did not perform hand hygiene. LPN-I placed clean gloves on and proceeded to clean the wound. LPN-I removed gloves after cleaning the wound but did not perform hand hygiene and proceeded to place calcium alginate into the wound bed and applied a bordered gauze dressing over the wound. With the same gloves, LPN-I went to get an incontinent brief out of R8 closet and place it on R8. LPN-I removed gloves and place clean gloves on without hand hygiene in between. LPN-I then cleaned up the table she had the supplies on and removed gloves then washed her hands. On 12/10/25 at 11:32 a.m. Surveyor explained to DON-B and NHA-A the concern regarding the lack of hand hygiene during R8 wound treatment. DON-B and NHA-A stated they understood the concern and confirmed hand hygiene needed to be performed after LPN-I cleaned up R8's incontinence episode and before performing R8's pressure injury dressing change. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure 2 (R2 and R7) of 8 residents received their prescribed medications in a timely manner. *On 12/9/2025, R2's morning medications, with a scheduled timeframe of 6AM-10AM, were not given until after 11AM. *R7 is prescribed Ozempic injection weekly for diabetes. R7's August, October and November 2025 MAR (medication administration record) documents weeks when Ozempic injection was not available to administer. Findings include: The Facility's policy titled Administering Medications, with a last revised date of April 2019, documents in part, . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose . 1.) R7 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, obesity and chronic obstructive pulmonary disease (COPD). R7's annual MDS (minimum data set) dated 9/3/25 documents R7 is cognitively intact and is independent with eating and transfers. On 12/9/25 at 1:50 p.m., Surveyor interviewed R7. Surveyor asked R7 if he had any concerns regarding his medications and if they are administered to him on time. R7 stated he had no concerns regarding his medications. Surveyor reviewed R7 August 2025 MAR. R7 has an order for Ozempic 0.5 milligram (mg) to be administered subcutaneous (sq) once a week. R7 was scheduled to receive this injection on 8/6 and 8/13. The MAR documents the medication was not available. Surveyor reviewed R7 October 2025 MAR. R7 has an order for Ozempic 1mg to be administered subcutaneous (sq) once a week. R7 was scheduled to receive this injection on 10/1, 10/8 and 10/22. The MAR documents the medication was not available or unable to locate the medication. Surveyor reviewed R7 November 2025 MAR. R7 has an order for Ozempic 1mg to be administered subcutaneous (sq) once a week. R7 was scheduled to receive this injection on 11/27. The MAR documents the medication was not available. On 12/10/25 at 10:50 a.m. Surveyor interviewed Director of Nursing (DON)-B. DON-B stated she's been a DON at the facility for less than a month. Surveyor explained the concern with R7 Ozempic injections not being administered on the above dates. DON-B stated she thinks the problem was nurses are not ordering the medications on time. DON-B stated that since becoming DON, she has made sure that nurses are ordering the medications on time from pharmacy and ensuring when medications are delivered from pharmacy, nurses ensure all medications listed are delivered. No additional information was provided as to why the facility did not ensure R7 received Ozempic on the above dates per physician orders. 2.) R2 was admitted to the facility on [DATE] with diagnoses which include Parkinson's Disease (a progressive neurological disorder where brain cells producing dopamine die, leading to movement issues like tremors, stiffness, slow movement, and balance problems, alongside non-motor symptoms such as sleep issues, depression, and cognitive changes), Type 2 Diabetes Mellitus (a common, chronic condition where the body either doesn't produce enough insulin or doesn't use it effectively (insulin resistance), leading to high blood sugar (glucose) levels), Acquired absence of right leg below the knee and Type 1 Diabetes Mellitus with hyperglycemia (the autoimmune condition (T1DM) causes the pancreas to not produce enough insulin, leading to glucose building up in the blood (hyperglycemia) because it can't get into cells for energy, causing symptoms like extreme thirst, frequent urination, fatigue, and blurred vision, requiring insulin therapy, dietary management, and exercise to control blood sugar and prevent severe complications like diabetic ketoacidosis). R2's Quarterly Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R2 has intact cognition. The MDS documents that R2 does not exhibit behaviors and that R2 received insulin injections for 6 days of the assessment period. On 12/9/2025, at 9:56 AM, Surveyor interviewed R2. R2 informed Surveyor that R2 only received his 5 AM dose of Parkinsons medication and is still waiting on the rest of the morning medications, including the 9 AM dose of Parkinsons medication and had already eaten breakfast but is supposed to receive insulin as well. Usually, R2 expressed wanting to get up around 530 AM and Surveyor observed a sign on the door indicating R2 to get up at 530AM daily, but R2 was not out of bed until around 9AM and was unsure why. On 12/9/2025, at 10:44 AM, Surveyor interviewed LPN-H. LPN-H informed Surveyor that LPN-H needs to go find the keys for the medication cart from Director of Nursing (DON)-B because DON-B was covering for LPN-H, while LPN-H had to leave the facility for about 15 minutes. LPN-H explained, she is just now getting ready to give R2's morning medications. On 12/9/2025, at 11:00AM, LPN-H came back with the keys for the medication cart and began preparing R2's morning medications. Surveyor asked what medications LPN-H was getting prepared for R2. LPN-H indicated all AM medications, most are scheduled for 6AM-10AM, but had Insulin due at 8AM as well. LPN-H informed Surveyor that R2 already had breakfast and did not receive Insulin or have a blood sugar check because LPN-H has not had time. LPN-H indicated that LPN-H marks in the Medication Administration Record (MAR) the exact time the medication is given. Surveyor then observed LPN-H give R2's the medications. Surveyor reviewed the Facility provided document, titled Physician Order Report, dated 12/10/2025, which documents R2 has the following orders: - Acidophilus (lactobacillus acidophillus) capsule- 1 capsule once per day, 6 AM-10 AM. Surveyor noted no dose listed. - Amantadine HCl- 100 milligrams (mg), once per day, 6A – 10AM. - Amlodipine- 10mg, once per day, 6A – 10AM. - Aspirin- 325mg, once per day, 6A – 10AM. - Ferrous Sulfate- 325mg (65mg iron), once per day, 6A – 10AM. - Jardiance- 10 mg, once per day, 6A – 10AM. - Loratadine- 10 mg, once per day, 6A – 10AM. - Rytary- 48.75-195mg, 2 capsules, 5 times per day, 5 AM, 9AM, 1 PM, 5 PM, 9 PM. Surveyor noted R2's Rytary was unavailable and was awaiting pharmacy. - Entacapone- 200mg, 5 times per day, 4:45 AM- 5:15 AM, 8:45 AM- 9:15 AM, 12:45 PM- 1:15 PM, 4:45 PM – 5:15 PM and 8:45 PM- 9:15 PM. Surveyor reviewed R2's Medication Administration Record (MAR) and noted the following, - Entacapone scheduled dose at 8:45 AM – 9:45 AM was documented as given on time and the 12:45 PM – 1:15 PM scheduled dose was marked as Not Administered: Other Comment: missed charting. - Gabapentin, scheduled dose at 1 PM was marked as given on time. - Acidophilus (lactobacillus acidophillus) was marked as given on time. - Amantadine HCl was marked as given on time. - Amlodipine was marked as given on time. - Aspirin was marked as given on time. - Ferrous Sulfate was marked as given on time. - Jardiance was marked as not available. - Loratadine was marked as given on time. On 12/10/2025, at 9:50 AM, Surveyor interviewed DON-B. DON-B recalls seeing a message sent by LPN-H, via the Facility's electronic messaging system, R2's medical providers. DON-B indicated that on 12/9/2025, at 11:17 AM, LPN-H sent a message regarding R2 receiving morning medications late, having a blood sugar of 300 and asking if it was ok to give both the Lantus and Lispro. DON-B informed Surveyor, DON-B would be expected to be notified right away if a high-risk medication, like insulin, was given incorrectly or outside of scheduled time. DON-B could not explain why the medications would be marked as given on time but administered late and would look into it further. Surveyor informed DON-B of the concerns regarding R2's medications being administered outside of scheduled time frame. On 12/10/2025, at 1:02 PM, Surveyor informed DON-B of R2's late medication administration. No additional information provided.

Based on interview and record review, the facility did not ensure residents who require dialysis receive such services consistent with professional standards of practice, including ongoing communication with the dialysis center before and after treatments for 1 (R10) of 1 resident reviewed for dialysis.*R10 had a history of experiencing unresponsive episodes primarily after hemodialysis sessions. R10 did not have a post dialysis assessment completed after receiving hemodialysis on 11/20/2025 and was experiencing symptoms, however there is no documentation staff were aware of R10's history and or that R10 required additional monitoring.Findings include:The facility policy titled Dialyses Policy and Procedure documents:Procedure:- Communicate with dialysis facility before and after treatment via the Dialysis communication form. - Coordinate Care Plan with dialysis facility: .- Any special considerations.- Who to contact such as dialysis staff, nephrologist, for dialysis related emergencies.R10 was admitted to the facility on [DATE] and has diagnoses that include acute respiratory with hypoxia (low oxygenation), Breast cancer, congestive hear failure, chronic obstructive pulmonary disease, end stage renal disease dependent on hemodialysis, Type 2 diabetes with neurological complications and diabetic kidney complications, major depressive disorder, anxiety disorder, and transient alteration in awareness (temporary, brief change in how someone perceives or interacts with their surroundings.) . Surveyor reviewed R10's hospital discharge paperwork and noted the following:- R10 was hospitalized from [DATE] - 11/12/2025 for complaints of chest pain and shortness of breath. During R10's hospitalization, R10 experienced left sided numbness and unresponsive episodes. - R10 had multiple unresponsive spells during current hospitalization. Mostly happen during hemodialysis. Psychology was consulted and Cymbalta dosage was increased. Several providers on agreement the episodes are functional neurologic syndrome (neurological condition where the brain sends incorrect signals to the body, software problem in the brains communication). - Since (R10) had extensive workup for unresponsive episodes that mostly happen during hemodialysis. Workup revealed these symptoms are of psychogenic origin and/or self-limiting. (R10) needs close monitoring and symptoms resolved on own without any sequalae. Please be mindful not to send (R10) for hospitalization unless new symptoms or concerns arise.Surveyor noted possibility of R10 having unresponsive episodes primarily during hemodialysis is not documented anywhere for facility staff.On 11/21/2025, at 1:18am, in the progress notes licensed practical nurse (LPN)-F documented (LPN-F) came onto shift and was given a report to stop and watch for R10. R10 came back to the facility from dialysis complaining of a headache on arrival. Certified nursing assistant (CNA) placed cold towel on forehead and turned off light. CNA stated R10 was having a hard time talking, prior to R10 leaving for dialysis R10 was talking and alert. vital signs temperature: 99.3 degrees Fahrenheit, pulse oxygenation: 88%, Blood pressure: 194/89, Respirations: 16, and noted rash developing on R10's left arm. LPN-F received order to send R10 to emergency room for further evaluation.Surveyor reviewed the progress notes and did not see documentation when R10 returned from R10's dialysis session. The 24 hour report board was reviewed for 11/21/2025 and documented R10's vitals in the PM section as: temperature: 98.5, respirations: 20, blood pressure: 157/76, pulse oxygenation: 95%, and pulse 70. In the comments nursing documented: Dialysis, complaint of headache, chills, non-verbal response.Surveyor noted a time is not documented to when the vital signs were obtained on 2nd shift.Surveyor reviewed the stop and watch sheet dated 11/20/2025 that documents: seems different than usual, came back from dialysis and had a bad headache, was not talking except to say, my head hurts.On 12/10/2025, at 9:01 AM, Surveyor interviewed licensed practical nurse (LPN)-D who stated LPN-D was working when R10 admitted to the facility. R10 did not recall being aware if R10 had specific restrictions or monitoring during dialysis or any concerns. LPN-D stated dialysis communication sheets are sent with the resident and brought back after the dialysis session. LPN-D stated if the dialysis communication form is not filled out, the nurse needs to call to get report from the dialysis center. LPN-D was not familiar with any other concerns regarding R10.On 12/10/2025 at 11:40 AM, interim nursing home administrator (Interim NHA)-C provided Surveyor with R10's dialysis communication forms from 11/20/2025. Surveyor reviewed R10's Dialysis Communication form for 11/20/2025 and noted the return form was not completed. On the bottom of the form is a message printed: [facility name] nurses: If this form is not filled out when resident returns, please contact dialysis center right away for report! [Dialysis center names and phone numbers]. Surveyor did not see evidence that R10's dialysis center was contacted to get report or if R10's was experiencing any symptoms while at the dialysis center.Surveyor asked interim NHA-C what the facility policy was regarding dialysis communication. Interim NHA-C stated the nurse on duty should have called to get report from the dialysis center especially since R10 was experiencing a headache. Surveyor shared concern the dialysis communication form was not filled out for R10 for continuation of care/ monitoring after R10's dialysis session and facility staff were not aware that R10 had history of experiencing unresponsive episodes primarily after R10's hemodialysis sessions and would require additional monitoring.No additional information was provided as to why R10, whom requires dialysis, did not receive such services consistent with professional standards of practice, including ongoing communication with the dialysis center before and after dialysis treatments.

Based on observation, interviews and record review the facility did not ensure 1 (R2) of 1 resident reviewed for urostomy services, received care consistent with professional standards of practice.*R2's nephrostomy dressing was not applied as ordered. R2's nephrostomy tubing did not have a securement device in place per R2's physician's order. Findings include:R2 was admitted to the facility on [DATE] with diagnoses which include Parkinson's Disease (a progressive neurological disorder where brain cells producing dopamine die, leading to movement issues like tremors, stiffness, slow movement, and balance problems, alongside non-motor symptoms such as sleep issues, depression, and cognitive changes), Type 2 Diabetes Mellitus (a common, chronic condition where the body either doesn't produce enough insulin or doesn't use it effectively (insulin resistance), leading to high blood sugar (glucose) levels), Acquired absence of right leg below the knee, Type 1 Diabetes Mellitus with hyperglycemia (the autoimmune condition (T1DM) causes the pancreas to not produce enough insulin, leading to glucose building up in the blood (hyperglycemia) because it can't get into cells for energy, causing symptoms like extreme thirst, frequent urination, fatigue, and blurred vision, requiring insulin therapy, dietary management, and exercise to control blood sugar and prevent severe complications like diabetic ketoacidosis) and Neurogenic Bladder (a condition where nerve damage from issues in the brain, spinal cord, or peripheral nerves disrupts normal bladder control, leading to problems like urinary incontinence, retention (inability to empty), frequency, urgency, or dribbling, often due to poor communication between nerves and bladder muscles).R2's Quarterly Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R2 has intact cognition. The MDS also documents that R2 does not exhibit behaviors, and that R2 has an indwelling catheter for bladder and an ostomy for bowel. R2's comprehensive care plan documents R2 has an indwelling catheter (bilateral nephrostomy tubes) and includes an intervention of providing care of nephrostomy tubes every shift.Surveyor reviewed the Facility provided document, titled Physician Order Report, dated 12/10/2025, which documents R2 has the following orders:-Bilateral Nephrostomy Tubes: Cleanse insertion site with 1/4 strength Dakins solution and pat dry. Then cover insertion site with Calcium Alginate. Then cover site with 4x4 border gauze (cut piece of border gauze edge off dressing to ensure no adhesive in on tubing) daily and as needed. Start date 11/18/2025 - open ended. Once a day 6 AM - 9AM.-Bilateral Nephrostomy Tubes: Cleanse insertion site with 1/4 strength Dakins solution and pat dry. Then cover insertion site with Calcium Alginate. Then cover site with 4x4 border gauze (cut piece of border gauze edge off dressing to ensure no adhesive in on tubing) daily and as needed. Start date 9/11/2025 - open ended. As Needed; PRN 1, PRN 2, PRN 3.Surveyor reviewed the R2's MAR (Medication Administration Record) and TAR (Treatment Administration Record) for R2, dated 12/1/2025 - 12/9/2025. Surveyor noted a PRN (as needed) order indicating, Replace nephrostomy tube stabilizers/stat locks PRN if soiled or loosing adherence. On 12/9/2025, at 1:52 PM, Surveyor observed LPN-H provide care to R2's nephrostomy tubes. Surveyor noted R2's left, and right nephrostomy sites were covered with large, padded covering, resembling an ABD pad adhered with tape. right nephrostomy tube did not have a securement device in place to help prevent R2's nephrostomy tube from becoming displaced. LPN-H obtained a securement device and applied it to R2's right nephrostomy tube.On 12/10/2025, at 8:02 AM, Surveyor interviewed Director of Nursing DON)-B. DON-B informed Surveyor R2 should always have a securement device in place for R2's nephrostomy tubes and indicated R2's nephrostomy tubing should not be covered by an ABD pad.On 12/10/2025, at 11:45 AM, Surveyor informed DON-B of the Facility above concerns. No additional information was provided.

Based on observation, interview and record review, the Facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R12 & R8) of 3 residents reviewed for pressure injuries. *On 12/9/2025, Surveyor observed R12 in bed without Prevalon boots, per physician orders, for R12's bilateral, heel pressure injuries. *On 12/9/25, Surveyor observed R8 up in her broda chair after breakfast and after lunch. R8's physician order dated 1/28/25 documents R8 is to be laid down after all meals due to pressure injury on coccyx. Findings: 1.) R12 was admitted to the facility on [DATE] with relevant diagnoses of, severe protein-calorie malnutrition, traumatic brain injury, Dementia (general term for a severe decline in mental abilities, like memory, thinking, and reasoning, significant enough to interfere with daily life) and encounter for palliative care. R12's Quarterly Minimum Data Set (MDS), dated [DATE] documents: an attempt to conduct a brief Interview for Mental Status (BIMS) score was not attempted due to R12 rarely/never understood, a staff assessment for mental status indicates moderately impaired cognitive skills for daily decision making, requires substantial/maximal assistance putting on/taking off footwear, is at risk for pressure ulcers/injuries and is receiving hospice care. Surveyor reviewed R12's MAR (Medication Administration History) and TAR (Treatment Administration History), dated 12/1/2025 to 12/9/2025. Surveyor noted a treatment order of Prevalon boots to be worn at all times, while in bed, start date 12/5/2025 – open ended. The Facility provided document, titled Care Plan for R12, indicated R12 has a pressure ulcer/injury with a problem start date of 5/26/2025, edited 9/1/2025. Surveyor noted there R12's Prevalon boots were not indicated in R12's care plan. On 12/9/2025, at 10:18 AM, Surveyor observed R12 laying in bed with no Prevalon boots. On 12/9/2025, at 12:43 AM, Certified Nursing Assistant (CNA)-J brought R12 lunch, Surveyor asked CNA-J if R12 needed to have Prevalon boots on while in bed. CNA-J indicated that CNA-J does not believe R12 has Prevalon boots and has not seen R12 with Prevalon boots. CNA-J looked in R12's closet to go over R12's Care Card, and informed Surveyor that R12's Care Card does not indicate R12 should have Prevalon boots. CNA-J asked Med Tech-K if R12 needs Prevalon boots, Med Tech-K looked through R12's orders in the Facility's Electronic Health System and indicated R12 does have an order for Prevalon boots. Med Tech-K looked for Prevalon boots in R12's room but could not locate any. Med Tech-K then indicated she would call laundry for Prevalon boots for R12. CNA-J returned with Prevalon boots and applied them to R12's feet. On 12/10/2025, at 7:54 AM Surveyor observed R12 in bed with bilateral Prevalon boots. On 12/10/2025, at 8:02 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R12's Prevalon boots. DON-B informed Surveyor R12's care plan needs to be updated to reflect the order for Prevalon boots. The facility was informed of the above concern, and no additional information was provided. 2.) R8 was admitted to the facility on [DATE] with diagnoses of vascular dementia and cerebral artherosclerosis. R8's quarterly MDS (minimum data set) dated10/1/25 documents R8 is severely cognitively impaired and is dependent with all ADLs (activity of daily living) and bed mobility. It also documents R8 has an unstageable pressure injury. R8's physician order dated 1/28/25 documents for R8 to be laid down after all meals due to pressure injury on the coccyx. R8 medical record documents R8 is on hospice due to dementia. R8's Wound NP (nurse practitioner) assessment dated [DATE] documents the sacral/coccygeal stage 3 pressure injury measuring 1.3 cm by 0.9 cm by 0.9 cm (centimeters) consisting of 100% granular tissue and no undermining. The Wound NP assessment documents the wound is improving. On 12/9/25 at 9:53 a.m., Surveyor observed R8 in the broda chair in the TV area. On 12/9/25 at 11:09 a.m., Surveyor observed R8 still in the TV area. On 12/9/25 at 1:00 p.m., Surveyor observed R8 being wheeled out of the dining room. On 12/9/25 at 1:48 p.m., Surveyor observed R8 not in her room. On 12/10/25 at 8:48 a.m. Surveyor observed R8 pressure injury during the daily wound dressing change. Surveyor observed R8 coccyx wound to be small and no odor noted. On 12/10/25 at 11:32 a.m. Surveyor explained to DON-B and NHA-A the concern regarding R8 being observed up in her broda chair after meals when the physician order documents R8 is to be laid down after meals. DON-B and NHA-A stated they understood the concern and had no additional information.

Based on observation, interview and record review, the facility did not ensure 1 (R2) of 8 residents were free of significant medication errors.*On 12/9/2025, R2 did not receive R2's 8 AM ordered dose of Insulin glargine, until after 11 AM.* On 12/9/2025, R2 received R2's Lispro outside of R2's order for special instructions.*On 12/9/2025, R2 did not receive R2's 8 AM scheduled dose of Insulin (Lispro).Findings:The Facility's policy titled Administering Medications, with a last revised date of April 2019, documents: . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose . R2 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease (a progressive neurological disorder where brain cells producing dopamine die, leading to movement issues like tremors, stiffness, slow movement, and balance problems, alongside non-motor symptoms such as sleep issues, depression, and cognitive changes), Type 2 Diabetes Mellitus (a common, chronic condition where the body either doesn't produce enough insulin or doesn't use it effectively (insulin resistance), leading to high blood sugar (glucose) levels), Acquired absence of right leg below the knee and Type 1 Diabetes Mellitus with hyperglycemia (the autoimmune condition (T1DM) causes the pancreas to not produce enough insulin, leading to glucose building up in the blood (hyperglycemia) because it can't get into cells for energy, causing symptoms like extreme thirst, frequent urination, fatigue, and blurred vision, requiring insulin therapy, dietary management, and exercise to control blood sugar and prevent severe complications like diabetic ketoacidosis).R2's Quarterly Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 15, indicating R2 has intact cognition. The MDS also documents that R2 does not exhibit behaviors and that R2 received insulin injections for 6 days of the assessment period.On 12/9/2025, at 9:56 AM, Surveyor interviewed R2. R2 informed Surveyor that R2 only received his 5 AM dose of Parkinsons medication and is still waiting on the rest of the morning medications, including the 9 AM dose of Parkinsons medication and that R2 had already ate breakfast but is supposed to receive insulin as well. Usually, R2 expressed wanting to get up around 530 AM, Surveyor noted a sign on the door indicating R2 to get up at 530AM daily, but R2 was not out of bed until around 9AM and was unsure why.On 12/9/2025, at 10:44 AM, Surveyor interviewed LPN-H. LPN-H informed Surveyor that LPN-H needs to go find the keys for the medication cart from Director of Nursing (DON)-B because DON-B was covering for LPN-H while LPN-H had to leave the facility for about 15 minutes. LPN-H informed Surveyor that LPN-H is just now getting ready to give R2's morning medications.On 12/9/2025, at 11:00AM, LPN-H came back with the keys for the medication cart. Surveyor asked what medications LPN-H was getting prepared for R2. LPN-H indicated all AM medications, most are scheduled for 6AM-10AM, but stated that R2 had insulin due at 8AM as well. LPN-H informed Surveyor that R2 already had breakfast and did not receive insulin or have a blood sugar check because LPN-H has not had time. Surveyor observed LPN-H check R2's blood glucose, which was 300. LPN-H then administered 22 units of Insulin glargine (long-acting insulin) to R2. LPN-H then indicated that R2 receives 8 units of Lispro (short acting insulin) and Lispro via sliding scale based on the blood sugar reading. Surveyor asked LPN-H if LPN-H needs to notify R2's physician prior to giving Lispro and if R2 requires food with the Lispro. LPN-H informed Surveyor that LPN-H is going to hold one of the Lispro's and will let R2's physician know that R2 received the medications late and will recheck R2's blood glucose at lunch time (around noon). Surveyor noted lunch was not being served until noon and R2 was not given any food within 15-20 minutes of receiving the insulin.Surveyor reviewed the document titled, Physician Order Report, dated 12/10/25, shows R2 is receiving the following:- Insulin glargine 22 units at 8 AM-Lispro sliding scale before meals (8AM, 12PM, 5PM)-Lispro 8 units before meals (8AM, 12PM, 5PM)-Insulin glargine 15 units at bedtimeSurveyor reviewed the Facility provided document, titled Medications Administration History dated 12/1/2025 - 12/9/2025 and noted the following:-Insulin glargine 100 unit/mL (milliliter); Amount to administer: 22 units; subcutaneous, once a day, 8AM, start date 9/4/2025 - open ended.Surveyor noted, a late administration note, dated 12/9/2025 at 11:19 AM, indicated comment: Late.-Insulin Lispro 100 unit/mL; start date 9/18/2025 - open ended, Frequency: Before meals, Amount to Administer: Per sliding scale;If Blood Sugar is less than 60, call MD (Medical Doctor)If Blood Sugar is 150 to 200, give 4 units.If Blood Sugar is 201 to 300, give 8 units.If Blood Sugar is 301 to 350, give 12 units.If Blood Sugar is 251 to 400, give 16 units.If Blood Sugar is greater than 400, give 20 units.If Blood Sugar is greater than 400, call MD.Surveyor noted a Not Administered: On Hold note, on 12/9/2025, at 11:19 AM, for the 8 AM dose of Lispro and indicated the 12 PM dose was given.-Insulin Lispro 100 unit/mL; Amount to Administer: 8 units; subcutaneous, start date 10/2/2025 - open ended, Special instructions: Administer 15-20 minutes before meals.Surveyor noted a Not Administered: On Hold note, on 12/9/2025, at 11:19 AM, for the 8 AM dose of Lispro and indicated the 12 PM dose was given. There was no physician order to indicate R2's insulin should have been held.On 12/10/2025, at 9:50 AM, Surveyor Interviewed DON-B. DON-B informed Surveyor that R2 should receive sliding scale insulin (Lispro) and an additional 8 units of Lispro before meals. DON-B recalls seeing a message sent by LPN-H, via the facility's electronic messaging system, to R2's medical providers. DON-B indicated that on 12/9/2025, at 11:17 AM, LPN-H sent a message regarding R2 receiving morning medications late, having a blood sugar of 300 and asking if it was ok to give both the Lantus and Lispro. Surveyor asked DON-B what time R2 normally gets up in the morning. DON-B indicated R2 was getting up around 5:30 AM but recently decided he would like to get up later, around 6- 6:30 AM.DON-B also indicated that LPN-H did leave the building for an emergency, but DON-B could not cover the medication cart for LPN-H, due to needing to gather information for the State Surveyors. DON-B informed Surveyor, DON-B would be expected to be notified right away if a high-risk medication, like insulin, was given incorrectly or outside of scheduled time. DON-B could not explain why the Lispro was marked as held at 8AM but marked as given at noon, if a provider approved and why the Lispro was not given within the special instruction time frame of meals. Surveyor informed DON-B of the concerns regarding R2's missed insulin administration, and administration outside of special instruction time frame.On 12/10/2025, at 1:02 PM, Surveyor informed DON-B that on 12/9/2025, R2 did not receive R2's scheduled glargine at 8AM until after 11 AM. R2 received R2's Lispro outside of R2's order and special instructions, to give R2's Lispro 15-20 minutes before meals, and R2's 8AM Lispro was held without a physician order.No additional information was provided.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) based on their comprehensive assessment for 1 (R1) of 3 residents reviewed.On 9/3/2025, R1 experienced a change of condition with increased lethargy, not wanting to eat, having a small emesis, and no bowel movement for three days. No documentation of an assessment by facility staff including vital signs, was found with the change of condition. No assessment or documentation was found from facility nursing staff of R1 having multiple emesis. No assessment or documentation was found from facility nursing staff indicating R1 had received medication to relieve constipation, what medication was administered, and the results from receiving the medication. No documentation was found from facility staff indicating R1 had a COVID-19 test administered on 9/03/2025 or the results of that test. R1 was seen by Nurse Practitioner (NP)-D on 9/3/2025 who referenced these details in their note and ordered lab work. R1's laboratory results with elevated white blood count of 19.9 were not reported to the NP or attending physician. No documentation was found indicating R1 was monitored each shift for a decline in condition; facility nursing staff did not assess or document vital signs, the general appearance of R1 and the overall health status of R1. On 9/4/2025, 911 was called and R1 was transferred to the hospital. R1 was admitted to the hospital with initial diagnoses of septic shock due to a urinary tract infection, acute hypoxic respiratory failure, and cardiogenic shock. No documentation was found in R1's record prior to R1 being transferred to the hospital of the circumstances as to why 911 needed to be activated for R1.The facility's failure to monitor and assess R1 while R1 was experiencing a change in condition created a finding of immediate jeopardy that began on 9/3/2025. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 11/4/2025 at 3:26 PM. The immediate jeopardy was removed on 11/5/2025, however, the deficient practice continues at a scope and severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan.Findings include:According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider .(b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient .(e) Perform the following other acts when applicable:1. Assist with the collection of data.2. Assist with the development and revision of a nursing care plan.3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction.4. Participate with other health team members in meeting basic patient needs.R1 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Parkinson's Disease, and Gastroesophageal Reflux Disease. R1's Quarterly Minimum Data Set (MDS) dated [DATE] documents R1 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 05. R1 required extensive to total assistance from staff with activities of daily living (ADLs) including toileting, dressing, and bathing. R1 had an activated Power of Attorney (POA).On 8/29/2025 at 1:57 PM, R1's vital signs were as follows: temperature 98.0 degrees, pulse 64, respirations 16, blood pressure 120/82, and oxygen saturation 97%.On 9/1/2025 at 8:25 PM in the progress notes, nursing documented R1's POA signed the fluoxetine (antidepressant Prozac) consent form on 8/29/2025.No documentation was found in R1's progress notes from 9/1/2025 until 9/3/2025.On 9/3/2025 on the food intake record, R1 had a decline of meal percentage eaten; for the three meals, R1 ate 26-50%. Normal intake for R1 ranged from 50-100%.R1's medical record includes a progress note e-signed as an imported record, dated 9/3/2025 at 8:42 PM from NP-D., The chief complaint is documented as lethargy . (R1) presents today for evaluation of lethargy. Nursing staff reported R1 had been more lethargic than baseline over the past few days. R1 had been less responsive during care and activities. R1's daughter, who is the POA, also reported concerns today of R1 being more lethargic, not wanting to eat, and having small emesis that morning. R1's POA also reported R1 had not had a bowel movement in a couple days. Milk of Magnesia was given, with R1 subsequently having a large bowel movement. At the POA's request, a COVID test was completed and was negative. No fever or other acute symptoms had been reported. R1's vital signs have remained stable. There have been no recent falls or injuries since his last evaluation. NP-D documented the following vital signs: blood sugar 125 on 8/25/2025, weight 145 on 2/25/2025, and body mass index (BMI) 22.7 and height 170.2 on 4/14/2021. NP-D documented in the Physical Examination section of the progress note R1's chest expansion was equal bilaterally and breath sounds were clear in all lung fields. The assessment and plan portion of the progress note documented the plan for diagnosis of Other fatigue was to obtain lab work including Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Vitamin D and Vitamin B12 to further assess. NP-D documented R1 would continue to be monitored closely for changes in condition and encourage adequate hydration and nutrition. NP-D documented R1 would be monitored for changes in lethargy and mental status. NP-D's progress note indicated R1 had an emesis, was given Milk of Magnesia, a COVID-19 test was completed with negative results, and vital signs had been stable. Surveyor noted R1's record did not contain any documentation of an emesis, the as needed order for Milk of Magnesia was not signed out by a nurse indicating it was administered, the COVID-19 test standing order was not signed out by a nurse indicating it was administered and no results were entered into R1's record, and no vital signs had been documented since 8/29/2025.Surveyor noted interviews with facility staff, including NP-D, indicate NP-D saw R1 much earlier in the day on 9/3/2025 than the time NP-D documented her note regarding R1. Interviews indicate NP-D saw R1 anywhere from 11:00 am to early afternoon, around 1:30 pm.Surveyor noted no documentation was found in R1's medical record dated 9/3/2025; prior to, or after NP-D's progress note at 8:42 pm, regarding R1's status; no vital signs were documented, no progress notes were entered, and no documentation was found of any assessments being completed by nursing staff.On 9/4/2025 at 2:21 PM in the progress notes, LPN-S documented R1 was admitted to the hospital for septic shock due to a urinary tract infection (UTI), acute hypoxic respiratory failure, and cardiogenic shock. Surveyor noted no progress note or assessment was documented prior to R1 being transferred to the hospital.On 9/4/2025 on the Emergency Medical Services (EMS) transport report, EMS was notified on 9/4/2025 at 6:04 AM of R1 having dyspnea (shortness of breath or difficulty breathing) and altered mental status. The report documents R1 was in bed with nursing staff and R1's daughter present. R1's daughter stated R1's breathing was not normal and R1 was more lethargic than normal. R1's skin color was normal and dry. R1's extremities were cooler to the touch, but R1's core was warm with a temperature of 99.7 degrees. Staff stated R1 had vomited once overnight but was unable to provide a time of the emesis. Staff stated R1 started having difficulty breathing with rales (an audible bubbling noise) in all areas of the chest. EMS documented R1's family arrived, and staff called 911. R1 had audible rales and was breathing at 40 breaths a minute using accessory muscles. R1 was on 4 liters of oxygen per minute via nasal cannula placed by facility staff. Vital signs were taken and R1's blood pressure was low. Two intravenous (IV) catheters were attempted but unsuccessful due to poor vascular access. R1 was placed on oxygen with a non-rebreather mask and nasal cannula for improvement of oxygen saturation. R1's blood pressure improved to 100 systolic and continuous positive air pressure (CPAP) was placed during transport to the hospital. R1's blood pressure dropped, and CPAP was removed and R1 was placed back on a non-rebreather mask at 25 liters of oxygen per minute and nasal cannula at 6 liters of oxygen per minute. EMS documented R1's vital signs at 6:18 AM: blood pressure 65/55, pulse 160, respirations 40 and labored, and oxygen saturation 90% on high concentration oxygen of 10-25 liters of oxygen per minute.On 9/4/2025 at 6:55 AM, R1's Emergency Department hospital paperwork documented R1 arrived via EMS. EMS staff stated that some time overnight R1 vomited and since then has been having difficulty breathing with gurgling sounds. Vital signs at 6:58 AM were blood pressure 84/53, pulse 170, respirations 46, and oxygen saturation 81%. Emergency Department nurse documented R1's family was at bedside and R1's daughter, who works at the facility, stated yesterday R1 was not acting like himself so she had a COVID test done that came back negative. R1's daughter stated R1 was weak, not wanting to eat, and had an emesis. When R1's daughter came to the facility this morning, she found R1 this way and wanted R1 to come in to be evaluated. The physician documented at 7:41 AM R1 was in obvious respiratory distress with gurgling breath sounds and was likely in heart failure secondary to the abnormal heart rhythm for an unknown period of time. R1 was accepted for admission to the intensive care unit (ICU) as R1 had septic shock and severe cardiac failure with respiratory failure and unable to be intubated.On 9/4/2025 at 12:59 PM on the hospital physician note, the hospital physician documented a discussion was had with R1's daughter, wife, and multiple family members present in the ICU. R1's daughter stated R1 was in a nursing home for the last 5 years. R1 had dementia with good and bad days. R1's daughter stated that morning, R1 was breathing heavy and was told by facility staff that R1 had an emesis last night. R1 was looking more tired than at baseline and was brought to the emergency room. The physician documented on initial evaluation in the ICU, R1's blood pressure was 69/51 and assessment of the chest showed air entry was decreased bilaterally, using accessory muscles, and bibasilar rales were present. Palliative care consult was requested. R1 was in acute hypoxic respiratory failure with low oxygen saturation currently requiring BiPAP with 100% oxygen. The prognosis is poor, and the condition is critical.On 9/4/2025 at 1:23 PM on the hospital History and Physical, the physician documented R1 was hemodynamically unstable with a fever of 100.6, hypotensive (low blood pressure) in the 70s, tachycardic (fast heart rate) at 177 beats per minute, tachypneic (fast respiratory rate), and hypoxic (low oxygen) in the 70s on room air. The exam revealed severe respiratory distress breathing 40-45 times per minute, obvious increased work of breathing with all accessory muscles being used, and breath sounds are wet and rattling. A urinalysis was positive for a UTI. R1 was in severe septic shock with likely cardiogenic shock. Additional concerns were ischemic colitis (damage to the intestinal lining from reduced blood flow to the colon), pulmonary embolism (a blood clot in the lungs), and kidney stone obstruction. R1's prognosis was guarded given profound lactic acidosis (lactic acid build up in the blood), leukopenia (low white blood cell count), septic shock (infection throughout the body), and respiratory failure with treatment limitations; recommendation was involving palliative care and preparing family for likely imminent decline.R1 passed away on hospice services in the hospital on 9/6/2025.Review of the laboratory results collected 9/03/2025 at 14:00 (2:00 PM), Received by the lab on 9/03/2025 at 21:51 (9:51 PM), and Reported on 9/03/2025 at 22:28 (10:28 PM) indicates the facility was notified of the results of a complete blood count (CBC) including WBC (white blood cell count) of 19.9 flagged as high. Red blood cell count (RBC) of 4.30 flagged as low. Neutrophils absolute (measurement of WBCs that fight an infection) of 17.3 (flagged as high). Lymphocytes absolute (measurement of immune function in blood) of 1.8 (flagged as low). Monocytes absolute of 1.6 (flagged as high) (a high monocyte count can mean the body is fighting an infection, inflammation, an autoimmune disorder, or a blood disorder).Surveyor noted this information was reported to the facility at 10:28 pm. There is no indication facility nursing staff noted receipt of the laboratory results, consulted with R1's physician or NP-D regarding the results or monitored R1 despite indications R1 was experiencing a continued change in condition.According to AMDA (American Medical Directors Association) a WBC > (greater than) 12,000 should be reported to the MD immediately.A fax was also received from the laboratory, fax time stamped, as being received on 9/4/2025 at 5:33 AM. The fax documented the same CBC lab results reported to the facility at 10:28 PM on 9/03/2025. Surveyor noted additional laboratory documentation indicates the ordered comprehensive metabolic panel (CMP) was cancelled on 9/03/2025 at 21:51 (9:51 PM) with a note explaining hemolyzed specimen. Test not performed. Surveyor noted a hemolyzed specimen is a blood sample where red blood cells have ruptured, releasing their contents and causing the plasma or serum to turn a pink or red color. This is often caused by improper blood collection or handling including using too small of a needle, vigorous shaking, or slow draws impacting accurate results. (Cross-reference F726.)In a phone interview on 10/8/2025 at 9:00 AM, Surveyor asked Laboratory Supervisor-G to verify when the facility had received R1's laboratory test results on 9/3/2025. Laboratory Supervisor-G stated R1's laboratory specimens were picked up at the facility on 9/3/2025 at 2:00 PM. R1's CBC results were received by the laboratory on 9/3/2025 at 9:51 PM and faxed to the facility on 9/3/2025 at 10:28 PM.On 9/04/2025 the hospital history and physical references CBC lab results that include the high lab results of 19.9 reported to the facility on 9/3/2025. Additional WBC counts collected on 9/04/2025 following arrival at the hospital included a WBC of 2.7 at 07:08 (AM) that was flagged and 4.0 at 13:09 (1:09 PM) that was also flagged. Surveyor noted this was a significant decline in the WBC counts. Surveyor noted a rapid drop in white blood cell (WBC) count from \(19.9\) to \(2\) without antibiotics can be due to a phenomenon called pseudoleukopenia, where a severe infection causes WBCs to move from the blood to the site of infection, making a blood sample temporarily appear to have low counts. Other causes include certain viral infections like influenza or HIV, autoimmune disorders, bone marrow suppression from non-antibiotic sources, or issues with the spleen. Pseudoleukopenia Mechanism: During an acute infection, the body rapidly moves white blood cells, primarily neutrophils, from the bloodstream to the infected tissue. This migration can cause a temporary and deceptive drop in the number of white blood cells counted in a blood sample taken at that moment.In a phone interview on 10/8/2025 at 1:15 PM, Surveyor asked Licensed Practical Nurse (LPN)-C, who worked first shift on 9/3/2025, if LPN-C could recall any changes in R1's health status on 9/3/2025. LPN-C recalled on 9/3/2025 at approximately 1:15 PM it was reported by R1's family member to LPN-C that R1 had a small emesis and was experiencing increased fatigue and weakness. LPN-C notified NP-D at that time regarding R1's small emesis and increased fatigue and weakness. NP-D was at the facility and assessed R1. LPN-C stated a COVID-19 test was conducted for R1 at that time with a negative result. NP-D gave orders to LPN-C for laboratory work for R1 including a CBC, a Basic Metabolic Panel (BMP), Vitamin D level and Vitamin B-12 level. Med Tech (MT)-E collected the blood samples from R1 at this time and faxed the facility's contracted laboratory to pick up R1's blood specimens. Surveyor asked LPN-C if they recalled reporting R1's condition or pending laboratory results to the next shift when they left the facility after first shift. LPN-C remembered MT-F was working that unit on 9/3/2025 for the evening shift. LPN-C did not recall giving report to a nurse at that time regarding R1's condition and pending laboratory results. LPN-C stated the laboratory results had not been completed by the end of the shift but if they had been, LPN-C would have reported any abnormal lab results to NP-D.In an interview on 10/8/2025 at 9:30 AM, Surveyor asked MT-F, who was assigned to R1 on 9/3/2025 evening shift, if they had been aware of R1 experiencing a change of condition or awaiting pending laboratory results on 9/3/2025. MT-F responded no staff had mentioned R1 had laboratory results pending or a change of condition had been noted. MT-F added they had heard later R1 went to the hospital on 9/4/2025 early in the morning when R1's family member called 911 but did not know any further details.In an interview on 10/8/2025 at 1:30 PM, Surveyor asked Licensed Practical Nurse (LPN)-H, who worked at the facility on night shift 9/3/2025 into the morning of 9/4/2025 if they recalled R1 while working at the facility. LPN-H responded that prior to R1 going out to the hospital on the morning of 9/4/2025 after R1's family member called 911, they did not recall R1 ever having any serious medical issues. Surveyor asked LPN-H if they had been aware R1 had laboratory results pending on the afternoon of 9/3/2025. LPN-H stated no facility staff member had conveyed that information to them. Surveyor asked LPN-H if a resident had an elevated WBC count of 19.9 if that would be something that should be reported to an NP or physician. LPN-H responded, Absolutely. LPN-H stated if they had been made aware of the pending laboratory results for R1 they would have been sure to monitor the facility's fax machine so they could report the results. Surveyor asked LPN-H if they had taken R1's vital signs or conducted any assessments of R1 on night shift 9/3/2025 into 9/4/2025. LPN-H stated they did not recall taking any vital signs or assessments for R1.In an interview on 10/8/2025 at 11:45 AM, Surveyor asked NP-D if they had been contacted regarding R1's elevated WBC level of 19.9 on 9/3/2025 or 9/4/2025. NP-D stated no one from the facility had contacted them regarding R1's elevated WBC level of 19.9 or the fact R1 went to the hospital on 9/4/2025 after R1's family member had called 911. Surveyor asked NP-D if facility staff should have been monitoring R1's condition including vital signs and nursing assessments due to R1's emesis, fatigue, and weakness on 9/3/2025. NP-D stated they would have expected the facility to have been monitoring R1 closely and have called either themselves or the after hours on call line with any change.On 10/8/2025 at 10:00 AM, Surveyor requested the 24-hour nursing report sheets from the facility for the dates 9/1/2025 through 9/5/2025. The facility was unable to locate any 24-hour nursing report sheets for 9/3/2025 that would indicate whether or not R1 was being monitored by facility nursing staff for follow up after emesis or increased fatigue and weakness on 9/3/2025. In an interview on 11/3/2025 at 2:20 PM, Surveyor asked Certified Nursing Assistant (CNA)-J, who worked with R1 on day shift on 9/3/2025 and night shift 9/3/2025 into the morning of 9/4/2025, what CNA-J could recall about R1 on 9/3/2025 and 9/4/2025. CNA-J stated R1 was a quiet person who had good and bad days. R1 used to try and get out of bed. CNA-J would see R1 at the edge of the bed and CNA-J knew R1 needed to use the bathroom. CNA-J stated CNA-J would round every hour and put eyes on R1 but would not wake R1 up. CNA-J did not have any recollection of R1 having an emesis on 9/3/2025 or 9/4/2025. CNA-J stated on the morning of 9/4/2025, CNA-J was getting R1 up because R1 was a night shift get-up. CNA-J recalled R1 was weaker than normal. CNA-J used a Sara Steady lift to get R1 out of bed and onto the toilet, but when CNA-J tried to get R1 off the toilet, R1 did not have any strength to stand up. CNA-J stated CNA-J got R1's vital signs and gave them to the nurse when CNA-J told the nurse about R1 being weak. CNA-J stated CNA-J left R1 on the toilet when CNA-J went to tell the nurse about R1. CNA-J stated CNA-K, who is also R1's POA, came in and helped CNA-J clean R1 up and get R1 off the toilet and into bed. Surveyor asked CNA-J if CNA-J could recall what R1's vital signs were and if CNA-J charted the vital signs. CNA-J could not recall what the vital signs were. CNA-J stated CNA-J wrote the vital signs down on a piece of paper and gave it to the night shift nurse. CNA-J denied calling 911. CNA-J stated CNA-J knew 911 was called but was not involved in any other aspect of R1's care after getting R1 back to bed. CNA-J stated R1 was not short of breath, just weak. (Cross-reference F726).In an interview on 11/4/2025 at 9:19 AM, CNA-K (also R1's POA) stated R1 was not himself on 9/3/2025. CNA-K stated when CNA-K was in the hallway on 9/3/2025, kitchen staff informed CNA-K that R1 was not eating. When CNA-K went to talk to R1, R1 did not open their eyes and was not answering questions. CNA-K stated this was not R1's baseline. CNA-K stated CNA-K requested from LPN-C to give R1 a COVID test. CNA-K stated NP-D was in the building so CNA-K told NP-D R1 was not doing well and requested from NP-D a COVID test. CNA-K stated NP-D was hesitant and then ordered a test around 11:00 AM or 11:30 AM. CNA-K stated DON-L, who was the assistant DON at the time, told CNA-K that she would do CNA-K a favor and do the COVID test because corporate does not want the test to be given. CNA-K stated the COVID test came back negative. CNA-K stated NP-D ordered blood work. Surveyor asked CNA-K if NP-D did an assessment of R1. CNA-K stated CNA-K did not see NP-D do an assessment but was told R1 did not have a temperature and R1's vital signs were normal. CNA-K stated R1 was the same throughout the afternoon and did not get worse. CNA-K clarified R1 had an emesis in the early morning of 9/3/2025. CNA-K thought R1 maybe should have gone to the hospital at that time, but nothing was showing that R1 was getting worse that afternoon. CNA-K stated CNA-K called the facility in the evening and talked to MT-F who told CNA-K that R1 ate a little and was in bed sleeping. CNA-K forgot to ask MT-F about R1's blood work that had been done earlier in the day and did not know what information was passed to MT-F in the shift report. CNA-K stated in the morning of 9/4/2025, CNA-K saw CNA-J at the nurses' station and asked CNA-J how R1's night was. CNA-K stated CNA-J told CNA-K R1 had an emesis and was not doing well. CNA-K went to R1's room and found R1 on the toilet hanging on the Sara Steady lift, pale and gasping for air, making a gurgling sound. CNA-K helped CNA-J get R1 back to bed and put oxygen on R1. CNA-K stated CNA-K put an incontinence pad and gown on R1 because R1 had been in the bathroom naked. CNA-K stated all staff wear walkie talkies so they can contact other staff without having to leave residents alone. CNA-K stated CNA-J should never have left R1 alone on the toilet. CNA-K stated CNA-J was walking in the hallway like there was no urgency. CNA-K stated the night nurse peeked into R1's room but did not enter. CNA-K stated no one got any vital signs and no nurse came in to assess R1. CNA-K stated the nurse told CNA-K R1's lab results were there and R1 had an infection, but R1 was already in the ambulance when they got the results. CNA-K stated EMS asked if this was the norm for R1 and CNA-K stated no, R1 did not have any lung diseases like chronic obstructive pulmonary disease (COPD). Surveyor asked CNA-K if any other family members were present on 9/4/2025 in the morning. CNA-K stated yes, CNA-K's mother/R1's wife, who also works at the facility, so when R1's wife came to work that morning, she came and checked on R1 and 911 had already been called. Surveyor asked CNA-K who called 911 that morning. CNA-K did not know who called 911, but it was not CNA-K.In an interview on 11/4/2025 at 10:17 AM, Surveyor asked DON-L what the process was for staff giving report at change of shift. DON-L stated CNAs give report to CNAs and nurses give report to nurses. Surveyor asked who gives report to an MT. DON-L stated MTs can listen in on report, but they do not give report to the next shift; they are not directly given report. DON-L stated a MT has a nurse that is their touch point, either on the same unit or on a different unit. DON-L stated if a resident has a change in condition, either the nurse will let the MT know when doing rounds or the MT will find the nurse to let them know. DON-L stated the nurse leaving shift when an MT is coming on, the nurse should report to the oncoming nurse on the other unit. Surveyor asked DON-L where COVID test results were charted. DON-L stated they would be found in the resident record. Surveyor shared with DON-L the only documentation of a COVID test was from 1/9/2025. DON-L stated DON-L did a COVID test on R1 on 9/3/2025 as a favor to CNA-K because they should only be done if a resident is symptomatic. DON-L stated R1's test was negative and must have forgotten to put the test result in R1's record. Surveyor asked DON-L what the expectation of staff is if a resident has an emesis. DON-L stated that resident should be monitored for a few days by putting them on the 24-hour board and the NP or physician should be notified. Surveyor shared with DON-L the statements from staff members that R1 had an emesis on 9/3/2025 and 9/4/2025 with no documentation. DON-L was not aware R1 had an emesis at any time and would have expected R1 to be on report and followed through. Surveyor asked DON-L when vital signs were normally taken for residents. DON-L stated with a change of condition vital signs should be taken and charted in the vital sign section of the record. Surveyor shared with DON-L no vital signs had been documented for R1 since 8/29/2025. DON-L stated some of the agency staff do not know how to chart vital signs so they would write them in the progress notes. Surveyor asked DON-L what is expected of CNAs when there is a change in condition. DON-L stated it depends on the severity of the change of condition. If the change in condition is severe, they should run to the nurse to report the condition and if it is not emergent, then they do fill out a stop and watch form. Surveyor asked DON-L if all nursing staff had walkie talkies. DON-L stated all nursing staff as well as management had walkie talkies. Surveyor asked DON-L if a resident should be left alone on the toilet if there is a change in condition. DON-L stated no.On 11/4/2025 at 11:43 AM, Surveyor shared with NHA-A, DON-L, and Regional Consultant-M the serious concern of R1's change of condition on 9/3/2025 not being monitored, assessed, or documented. R1 did not have any vital signs taken when the change of condition was initially identified, no nursing assessment was completed, and on 9/4/2025, R1 was admitted to the hospital ICU with preliminary diagnoses of septic shock due to UTI, acute hypoxic respiratory failure, and cardiogenic shock. Surveyor shared the concern NP-D documented in a progress note R1 had an emesis, was given Milk of Magnesia, a COVID-19 test was completed with negative results, and vital signs had been stable. Surveyor shared R1's record did not contain any documentation of an emesis, the as needed order for Milk of Magnesia was not signed out by a nurse indicating it was administered, the COVID-19 test standing order was not signed out by a nurse indicating it was administered and no results were entered into R1's record, and no vital signs had been documented since 8/29/2025. Surveyor shared the concern the second shift nursing staff were not aware R1 had a blood draw that day and they should be on the lookout for the results of those tests.On 11/4/2025 at 1:35 PM, Regional Consultant-M stated interviews from all staff were found regarding the concerns with R1 on 9/3/2025 and 9/4/2025. Those interviews were provided to Surveyor. Regional Consultant-M stated CNA-K called 911 so no assessment was done of R1 before EMS arrived. Surveyor noted during interviews with CNA-K, CNA-K indicated they did not call 911. Surveyor also noted at the time of the survey, the facility still did not know how facility staff responded to R1's change in condition.The staff interviews were not dated or signed. The statements did not indicate who obtained the statements. The statements are as follows:CNA-J: R1 was at baseline on the day shift of 9/3/2025. R1 was at baseline on the night shift. R1 was a checked and changed and repositioned per usual. In the morning of 9/4/2025, R1 had an emesis. CNA-J got R1 onto the toilet and R1 seemed weaker than normal. CNA-J informed the nurse and got R1's vital signs. CNA-K came in and got R1 cleaned up and was sent out to the hospital. CNA-K was the one that called 911. The AM nurse helped to send R1 out around 6:45 AM-7:00 AM. (Surveyor noted CNA-J, in a later interview with Surveyor, denied R1 having an emesis.)LPN-H: R1 slept all night 9/3/2025 and was checked and changed per usual. At around 6:55 AM-7:00 AM CNA-J was getting R1 up and said R1 had an emesis and was weak. CNA-J was getting R1's vital signs and CNA-K called 911. LPN-H was leaving at this time, and the day shift nurse was aware of the situation and was helping to get R1 sent out to the hospital. LPN-H was under the impression the day shift nurse was doing the send out. (Surveyor noted no documentation was completed by any staff nurse of R1's condition when being sent out and no transfer documentation that should accompany a resident to the hospital was found.)LPN-N: LPN-N was the day shift nurse coming on shift on 9/4/2025. LPN-N remembered overhearing about R1 being sent out. LPN-N was under the impression that the night shift LPN was doing the send out.LPN-C: LPN-C worked with R1 on 9/3/2025 and discussed R1 with NP-D. NP-D was ordering some labs. R1 was constipated and LPN-C gave R1 Milk of Magnesia and R1 had a bowel movement. R1 did not have any emesis and nothing other than constipation was noted on R1's assessment. (Surveyor noted LPN-C did not sign out the administration of the Milk of Magnesia.)NP-D: CNA-K was concerned about R1. R1 seemed more lethargic and was eating less per CNA-K. NP-D told the nurse on the floor that R1 seemed more lethargic than usual and R1 was not feeling well. NP-D ordered labs.Surveyor noted the night shift nurse thought the day shift nurse was caring for R1 and the day shift nurse thought the night shift nurse was caring for R1 at the change of shift on 9/4/2025. Neither nurse documented anything.In a phone interview on 11/5/2025 at 10:22 AM, NP-D stated the nursing staff as well as CNA-K informed NP-D of R1's change of condition on 9/3/2025. NP-D

Based on interview and record review, the facility did not ensure that 2 (CNA-J, MT-E) of 3 nursing staff reviewed had appropriate competencies and skills sets to assure resident safety and respond to resident needs. This has the potential to affect a total of approximately 25 residents who currently reside in zone 2 and the rehab zone in which certified nursing assistant (CNA)-J and med tech (MT)-E are typically assigned. *CNA-J stated they assessed vitals for R1 while R1 was experiencing a change of condition without proof of competency to collect vitals and without a comprehensive assessment being performed by a registered nurse or monitoring by a licensed practical nurse (LPN)*MT-E did not have evidence of completing required pharmacy education for the last 3 calendar years and did not have evidence of certification to perform blood draws defined under State regulations.Findings include:The facility job description for job title certified nursing assistant documents the CNA will provide patient/resident care as required under the direct supervision of the licensed nurse . completes assigned tasks to ensure timely, efficient, and safe patient/resident care . ability to observe and report patient/resident status . provides direct patient/resident care and reports condition and changes to Registered Nurse (RN) or Licensed Practical Nurse (LPN) . The facility job description for job title certified nursing assistant/med tech documents under the supervision and direction of a licensed nurse, the medication assistant administrators (sic) and records select oral, nasal, transdermal and rectal, inhalant and ophthalmic scheduled medications to residents . trained to measure and record blood pressure, radial pulse, and blood glucose readings by way of a finger stick . must have successfully completed the State of Wisconsin Medication Assistant Training Program . must be a Certified Nursing Assistant in Wisconsin; in good standing . reports to nurse when coming on duty and going off duty . obtains assignments and specific directions from Unit Nurse or RN supervisor . knowledgeable of medication actions, medication effects on body systems and side effects, especially in the geriatric population . R1 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Parkinson's Disease and Gastroesophageal Reflux Disease. R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 6/30/25 documents R1 had a Brief Interview for Mental Status (BIMS) score of 05, indicating R1 had severe cognitive impairment related to daily decision making. R1 required extensive to total assistance from staff with activities of daily living (ADLS) including toileting, dressing and bathing. On 10/8/25, at 1:15 PM, a Surveyor conducted an interview with LPN-C via telephone. A Surveyor asked if LPN-C recalled any changes in R1's health status on 9/3/25. LPN-C recalled on 9/3/25 at approximately 1:15 PM it was reported by R1's family member to LPN-C that R1 had a small emesis (vomiting episode) and was experiencing increased fatigue and weakness. LPN-C notified Nurse Practitioner-D at this time regarding R1's small emesis and increased fatigue and weakness. Nurse Practitioner-D was at the facility at this time and assessed R1. LPN-C told a Surveyor a COVID-19 test was conducted for R1 at this time with a negative result. Nurse Practitioner-D gave orders to LPN-C for laboratory work for R1 including a Complete Blood Count (C.B.C.), Basic Metabolic Panel (B.M.P), Vitamin D level and Vitamin B-12 level. MT-E collected the blood samples from R1 at this time and faxed the facility's contracted laboratory to pick up R1's blood specimens. On 10/8/25, at 1:30 PM, a Surveyor conducted an interview with Agency LPN-H, who worked the night shift at the facility on 9/3/25 into the morning of 9/4/25. Agency LPN-H stated that prior to R1 going out to the hospital on the morning of 9/4/25, they did not recall R1 ever having any serious medical issues. A Surveyor asked Agency LPN-H if they had taken R1's vital signs or conducted any assessments of R1 on night shift 9/3/25 into 9/4/25. Agency LPN-H told a Surveyor they did not recall taking any vital signs or performing an assessment for R1.On 11/3/25, at 2:20 PM, Surveyor interviewed CNA-J who worked with R1 during the night shift on 9/3/25 into 9/4/25. CNA-J stated R1 was a night shift get up, and when CNA-J got R1 up, CNA-J noted R1 transferred onto the toilet normally with a Sara Steady transfer device but then could not get up from the toilet and was weaker than normal. CNA-J stated CNA-J kept R1 on the toilet, reported to the nurse on duty, and then obtained R1's vital signs. CNA-J stated CNA-J wrote the vital signs on a piece of paper and gave them to the NOC (night) shift nurse, Agency LPN-H. Surveyor reviewed R1's electronic medical record and did not locate any nursing assessments or vital signs documented on 9/3/25 or 9/4/25. On 11/3/25, at 3:18 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the process for blood draws. NHA-A stated the facility does not have a phlebotomist and MT-E does all the blood draws for the facility. Surveyor requested evidence that MT-E is certified to perform blood draws. On 11/3/25, at 3:35 PM, NHA-A informed Surveyor that the facility does not have a copy of MT-E's certification to perform blood draws, but MT-E requested transcripts of the course MT-E completed. On 11/3/25, at 3:40 PM, Regional Consultant-M stated the lab that services the facility does not provide any blood draw services, so the facility utilizes their own licensed staff or MT-E to perform blood draws. On 11/4/25, at 9:28 AM, Surveyor interviewed CNA-K who stated if a resident were experiencing a change in condition, CNA-K would get the nurse immediately to obtain vitals, as CNAs are not trained to do vital signs. On 11/4/25, at 10:28 AM, Surveyor interviewed Director of Nursing (DON)-L who stated if there were an emergent situation or change of condition with a resident, the CNA would be expected to get the nurse on duty immediately. DON-L stated if the situation were not emergent, the CNA would fill out a stop and watch form and the nurse would follow up. DON-L stated nurses would take a resident's vitals, or a med tech is trained to take vitals if administering a medication which would require assessment of the resident's vitals. DON-L stated a CNA would not take a resident's vitals. Surveyor shared the concern with DON-L that CNA-J assessed R1's vitals while R1 was experiencing a change of condition and there is no evidence that a comprehensive assessment was completed by a licensed nurse for R1. Surveyor requested to review the required education and hours worked for MT-E for the last 3 years. On 11/4/25, at 1:00 PM, Surveyor reviewed the education hours for 2022, 2023, and 2024 for MT-E. The Wisconsin Department of Health Services Medication Aides: Nursing Homes and Hospices webpage, last revised 4/7/25, documents a medication aide maintains status by completing four hours of pharmacy-related in-service and 100 hours of work each calendar year and by keeping three full years of records showing they completed the 100 hours of work and four hours of in-service. Surveyor noted MT-E worked more than 100 hours each calendar year in 2022, 2023, and 2024. Surveyor noted no education for MT-E was provided for the calendar year 2022. Surveyor noted the following pharmacy-related education courses MT-E completed in the calendar year 2023, totaling 3.54 hours:- Antipsychotic medications, completed 1/25/23 with a total time in course of 1.00 hours- High alert medications, completed 1/28/23 with a total time in course of 0.98 hours- Medication administration, completed 1/28/23 with a total time in course of 0.95 hours- Medication administration: antibiotics, completed 1/28/23 with a total time in course of 0.31 hours- Medication administration: basics, completed 1/28/23 with a total time in course of 0.26 hours- Medication administration: controlled substances, listed as incomplete status on 1/28/23 with a total time in course of 0.04 hours.Surveyor noted the following pharmacy-related education courses MT-E completed in the calendar year 2024, totaling 0.39 hours:- Medication assistance for medication aides, completed 12/20/24 with a total time in course of 0.39 hours.On 11/4/25, at 3:26 PM, Surveyor shared concerns with NHA-A, DON-L, Regional Consultant-M that a CNA obtained vitals for R1, who was experiencing a change of condition, and there is no evidence that a licensed nurse performed an assessment for R1, that MT-E does not have evidence of completing the required 4 hours of pharmacy-related education for calendar years 2022, 2023, or 2024, and that no evidence was provided that MT-E is certified to perform blood draws. No additional information was provided.

Based on interview and record review, the facility did not ensure their abuse policy and procedure was implemented for 1 of 8 employees reviewed for 4-year background checks potentially affecting a portion of the 47 residents.Dietary Aide (DA)-P did not have an up to date background check completed within the four year time frame.Findings include:The facility policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program from (C)MED-PASS dated 2001 revised 4/2021 documents: 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law .On 11/6/2025, Surveyor requested from Nursing Home Administrator (NHA)-A the personnel files for eight employees to review for the required background checks.DA-P was hired on 4/27/2021. The Background Information Disclosure (BID) form, the Department of Justice (DOJ) letter, and the Interagency Border Inspection System (IBIS) form were completed on 4/27/2021. Four years had lapsed since the background check information had been submitted. On 11/6/2025 at 2:15 PM, Surveyor shared with Director of Nursing (DON)-B DA-P's background check forms were completed upon hire on 4/27/2021 and need to be completed every four years so the background check should have been completed by 4/27/2025. DON-B stated DON-B would talk to Human Resources (HR) to see if there is a more recent background check.In an interview on 11/6/2025 at 2:30 PM, HR-O stated HR-O does the background checks for all employees. HR-O stated HR-O would check and see if there was a more recent background check for DA-P and if not, HR-O would complete the background check immediately.On 11/6/2025 at 2:55 PM, NHA-A brought Surveyor the background check forms for DA-P. Surveyor noted the background check forms were dated that day, 11/6/2025, and DA-P was also listed as being an Activity Aide. NHA-A confirmed DA-P worked as both a dietary aide and an activity aide. Surveyor shared with NHA-A the concern DA-P's background check was completed that day and not within the four year time frame. NHA-A agreed it should have been done earlier.

Based on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent development of pressure injuries or received care to promote healing and prevent new ulcers from developing for 6 (R17, R47, R34, R19, R26, and R36) of 6 residents reviewed with pressure injuries or at risk for developing pressure injuries. *R17 did not have a comprehensive skin assessment on admission on 7/19/2024. On 7/26/2024, wound documentation included a Deep Tissue Injury (DTI) to the right lateral foot, a DTI to the right Achilles and heel, a DTI to the coccyx, a DTI to the left heel, and a DTI to the left Achilles. The Right lateral foot, and the coccyx pressure injuries progressed to Unstageable, and the right Achilles and heel progressed to a Stage 4. All areas healed. R17 developed a DTI to the right medial foot on 8/2/2024 that progressed to a Stage 3 and healed. R17 developed Moisture Associated Skin Damage (MASD) on 2/7/2025 to the right and left buttocks that worsened with pressure and are still present. The pressure injury documentation was not accurate, and the wounds were not comprehensively assessed weekly. The Registered Dietician recommendations were not implemented for 2 months. *R47 did not have a comprehensive skin assessment on admission on 10/18/2024. On 10/25/2024, wound documentation included a Stage 2 pressure injury to the right lateral ankle, an Unstageable pressure injury to the right lateral foot, and MASD to the sacrum and medial thighs. Documentation was conflicting as to the right lateral ankle and right lateral heel being assessed as the same area or two separate areas. R47 was readmitted after hospitalization four times with skin assessments not being completed upon return to the facility. The sacrum and medial thighs MASD healed. The right lateral ankle/heel progressed to Unstageable. On 2/7/2025, R47 developed MASD to bilateral buttocks that worsened with pressure and was not staged as a pressure injury. The pressure injury documentation was not accurate, and the wounds were not comprehensively assessed weekly. The Registered Dietician recommendations were not implemented for 2 months. *R34 developed a Stage 3 pressure injury to the right heel on 11/26/2024 that was not comprehensively assessed on discovery. Interventions to prevent the pressure injury to the heel were not in place. The pressure injury documentation was not accurate, and the wounds were not comprehensively assessed weekly. Observations were made of R34's heels on the mattress and the air mattress was not plugged in. The Registered Dietician recommendations were not implemented. *R19 developed a DTI to the right heel on 11/1/2024 that progressed to an Unstageable pressure injury. The pressure injury documentation was not accurate, and the wounds were not comprehensively assessed weekly. Observations were made of interventions not in place. *R26 developed wounds to the abdominal fold that were not comprehensively assessed. *R36 was admitted to the facility on [DATE] with limited mobility related to a left femur fracture. R36 was Non-Weight-Bearing (NWB) to Left Lower Extremity (LLE). R36 was prescribed an immobilizer brace to her LLE to be worn at all times. There is no evidence the facility was removing R36's immobilizer brace and performing skin checks to prevent injuries to the skin. Findings include: The facility policy and procedure titled Prevention of Pressure Injuries from MED-PASS (C) 2001 revised 4/2020 documents: Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly for one month a total of 4 assessments, upon any changes in condition and with each MDS assessment. 2. Under observations use the standardized assessment titled Skin Risk Assessment with Braden Scale to determine and document risk factors, help you identify and initiate preventive interventions and initiate plan of care. 3. Supplement the use of a risk assessment tool with assessment of additional risk factors. Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. 2. During the skin assessment, inspect: a. Presence of erythema. b. Temperature of skin and soft tissue; and c. Edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). for darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. 4. A weekly skin prevalence will be conducted each week over a 24-hour period. See Skin Prevalence process and form. Skin prevalence should be completed the day prior to wound rounds. 5. Weekly RN assessment and documentation completed. Wound rounds must be completed at a minimum of at least once every 7 days. 6. Measurements and documentation to support treatment, interventions, type of wound must be part of the weekly documentation. 7. There must be a current PI care plan in place to support the wound status and all interventions and goals. 8. MD must be notified with any changes in wound. 9. Residents and or their representative must be notified of the status of the wound and current interventions at least weekly and as needed. Prevention: . Nutrition: 1. Conduct nutritional screenings for residents at risk. 2. Conduct a comprehensive nutritional assessment for any resident at risk of pressure injury who is screened to be at risk for malnutrition, and for all adult residents with a pressure injury. 5. Monitor the resident for weight loss and intake of food and fluids. 6. Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. Mobility/Repositioning: 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Support Surfaces and Pressure Redistribution: 1. Select appropriate support surfaces based the [sic] resident's risk factors, in accordance with current clinical practice. Device-Related Pressure Injuries: 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. 2. Monitor regularly for comfort and signs of pressure-related injury. 3. For prevention measures associated with specific devices, consult current clinical practice guidelines. Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 1.) R17 was admitted to the facility on [DATE] with diagnoses of cellulitis of the right and left lower limbs, chronic obstructive pulmonary disease, venous insufficiency (peripheral), congestive heart failure, adult failure to thrive, and xerosis cutis (a skin condition characterized by excessive dryness, roughness, and flaking). R17's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented R17 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had no impairment to the arms or legs. R17 was always incontinent of bowel and bladder, had one Unstageable pressure injury due to a non-removable dressing or device that was present on admission, and four Unstageable pressure injuries that were present on admission. The Pressure Ulcer/Injury Care Area Assessment (CAA) associated with the MDS documented R17 had recently transitioned to hospice care and remains bed bound most of the time. R17 transfers with a Hoyer lift and is dependent in the wheelchair. R17 had skin concerns on the coccyx that was present on admission and the wound nurse continues to monitor. R17 was rotated every two hours and lays on a pressure relieving mattress. R17 had a BIMS of 15 and could state any concerns or needs. R17 did not have an activated Power of Attorney. Prior to admission to the facility, R17 was hospitalized from 7/15/2024 to 7/19/2024 with failure to thrive and worsening bilateral foot wounds. On 7/15/2024, R17 was evaluated by the hospital wound Registered Nurse (RN) and documented R17 had an Unstageable pressure injury to the coccyx that measured 1.3 cm x 0.4 cm x unable to determine with 100% slough, a venous ulceration to the right lateral ankle that was red and moist with a few scattered open areas, and a venous ulceration to the left posterior ankle that was red and moist with one small open area. The RN documented R17 reported not being able to cleanse the legs and only has a bathtub so has not showered in quite some time. R17 had thick build up of epithelial cells and drainage on bilateral ankles/lower extremities; hair was cleansed from the right leg wound. Thick scaly skin was removed with mechanical debridement with cleansing and cocoa butter was applied to help moisten the areas that could not be removed. An Unstageable pressure injury was discovered on the coccyx. R17 was positioned to the right side lying with pillow support as well as placement of a waffle cushion. R17 should be turned every two hours left to right and limit supine/sitting position as much as possible. A photograph of the right lateral ankle wound was included in the hospital documentation. On 7/19/2024 (date of admission to the facility) on the Head-to-Toe Assessment form, the nurse hand wrote See RN document under the skin section for pressure ulcer. The form was not signed. The Skin Condition on the Admission form documented R17 had a bruise to the top of the right hand, a bruise to the left wrist, and a bruise to the left antecubital from blood draws. No areas were circled on the body diagram. This form was not signed. On 7/20/2024 at 3:19 PM in the progress notes, an RN documented R17 was admitted on [DATE] with diagnoses of venous stasis dermatitis with infected ulceration to the right foot and a wound to the coccyx. No documentation of an assessment was found. On 7/22/2024 at 6:00 PM in the progress notes, an RN documented an admission skin assessment was done by the RN and Director of Nursing (DON)-B and R17 had bilateral lower extremity venous stasis dermatitis. The wounds were cleansed with normal saline, patted dry, and xeroform was applied to the affected areas. No measurements or description was documented, and no assessment of the coccyx was documented. On 7/22/2024, R17 got a treatment order to cleanse area with warm water and soap daily. Surveyor noted no location was documented as to where the treatment was to be applied and, if this was for the coccyx wound, the coccyx wound was not treated for three days since admission. R17's At Risk for Skin Breakdown Care Plan was initiated on 7/25/2024 with interventions: -Assess for presence of risk factors; treat, reduce, eliminate risk factors to the extent possible. -Avoid shearing skin during positioning, transferring, and turning. -Check for incontinence episodes often. -Conduct a systemic skin inspection on admission, with cares, and on bath days. -Cushion in wheelchair for protection. -Document episodes of refusals to reposition in progress notes. -Educate on the risk vs benefits of sleeping in recliner vs bed for off loading and pressure relief if indicated. -Educate on the risk vs benefits of staying in bed vs getting up for offloading and position changes to prevent breakdown if indicated. -Encourage fluids every shift. -Encourage physical activity, mobility, and range of motion to maximal potential. -Encourage/assist to make frequent position changes while in chair. -Encourage/assist to turn and reposition frequently. -Float heels to reduce the risk of pressure and friction. -Heel boots on at all times while in bed. -Keep clean and dry as possible; minimize skin exposure to moisture. -Keep linen clean, dry, and wrinkle free. -Provide cushion in recliner if (R17) prefers to sleep in recliner to reduce the risk of skin breakdown. -Report any signs of skin breakdown. On 7/26/2024 at 8:46 AM in the progress notes, an RN documented wound rounds were done with Nurse Practitioner (NP)-N and R17 did not have any open areas to bilateral lower extremities. The RN documented R17 had multiple deep tissue injuries (DTIs): 1.) the right heel measured 8.5 cm x 1 cm with intact skin that was deep purple and appeared to be an old injury unseen related to the thick covering of stasis dermatitis; 2.) the right Achilles measured 14 cm x 5 cm with intact skin that was deep purple and an old wound as stated above; 3.) the coccyx had an open wound measured 4 cm x 9 cm that was 90% dark purple and 10% slough; 4.) the left heel had a DTI that measured 1 cm x 1 cm; 5.) skin discoloring 1.5 cm x 12 cm related to R17 lying on catheter tubing. Surveyor noted the coccyx wound was not staged and did not have a depth measurement, and no location was identified where the skin was discolored from the catheter tubing. On 7/26/2024 at 12:21 PM in the progress notes, DON-B documented an alternating air mattress had been ordered for R17 due to R17's condition. On 7/27/2024, R17 got a treatment order for the coccyx wound to be cleansed with warm water and soap, pat dry, and apply zinc cream to the area twice daily and to turn R17 every two hours to relieve pressure. On 8/4/2024 at 10:44 AM in the progress notes, an RN documented wound rounds were completed on 8/2/2024 with NP-N and R17 had Prevalon boots on but refused to have them Velcro closed. R17 had DTIs to the right thigh, the left heel, the left thigh, the left Achilles and the right thigh (listed twice). -The right heel/Achilles DTI measured 15 cm x 5 cm. -The wound to the coccyx measured 5 cm x 7 cm with 50% epithelial tissue, 10% granulation tissue, and 40% deep purple. -The right medial foot DTI measured 4 cm x 1 cm. -The right calf DTI measured 0.7 cm x 15 cm. -The left lateral foot/Achilles DTI measured 8.5 cm x 7 cm and was boggy and blanchable. Surveyor noted the right heel wound and the right Achilles wound were combined to one measurement, the coccyx pressure injury was not staged and did not have a depth measurement, and multiple new areas had deep tissue injuries that did not include measurements: the right thigh, the left heel, and the left thigh. Surveyor noted the right medial foot wound and the right calf wound were new DTIs. On 8/9/2024 at 5:05 PM in the progress notes, an RN documented wound rounds were done with NP-N and R17 had the following pressure injuries: -The right heel/Achilles DTI measured 13 cm x 4 cm and was now Unstageable with 50% eschar and 50% epithelial tissue. Surveyor noted no depth measurement was documented. -The Coccyx DTI measured 2.5 cm x 2.5 cm and was now Unstageable with slough. Surveyor noted no depth measurement or percentage of slough was documented. -The right medial foot DTI measured 3 cm x 0.9 cm. -The right posterior calf DTI, related to the catheter tubing, measured 0.5 cm x 12 cm. -The left Achilles DTI measured 0.5 cm x 0.5 cm. -The left heel DTI measured 1 cm x 1 cm. -The right lateral foot DTI measured 7.9 cm x 0.5 cm. Surveyor noted the right thigh and the left thigh DTIs from the previous week were not documented on, the left Achilles wound did not include the left lateral foot wound as it did from the previous week, and the left heel wound and right lateral foot wound were new DTIs. On 8/16/2024 at 4:38 PM in the progress notes, an RN documented wound rounds were done with NP-N and R17 had the following pressure injuries: -The right heel/Achilles DTI measured 12 cm x 3.5 cm with eschar. Surveyor noted the pressure injury did not meet the definition of DTI, and no depth measurement or percentage of eschar was documented. -The Coccyx pressure injury measured 3.5 cm x 2 cm with slough. Surveyor noted the pressure injury was not staged, and no depth measurement or percentage of slough was documented. -The right medial foot DTI measured 1.5 cm x 0.4 cm. -The right posterior calf DTI measured 0.5 cm x 10 cm. -The left Achilles DTI resolved. -The left heel DTI resolved. -The right lateral foot DTI measured 2 cm x 0.5 cm. On 8/23/2024 at 3:48 PM in the progress notes, an RN documented wound rounds were done with NP-N and R17's wounds to the left lateral ankle, the left heel, and the left Achilles/heel, and the left lateral ankle had healed. R17 had the following pressure injuries: -The right heel/Achilles pressure injury measured 12 cm x 3.5 cm x unable to determine with 50% eschar and 50% epithelial tissue. Surveyor noted the pressure injury was not staged. -The Coccyx pressure injury measured 2.5 cm x 1.5 cm with 50% slough and 50% epithelial tissue. Surveyor noted the pressure injury was not staged, and no depth measurement was documented. -The right medial foot DTI measured 1 cm x 0.3 cm and was now Unstageable with 100% eschar. Surveyor noted no depth measurement was documented. -The right posterior calf DTI measured 0.5 cm x 10 cm with 100% epithelial tissue. -The right lateral foot DTI measured 2 cm x 0.5 cm and was now Unstageable with eschar. Surveyor noted no depth measurement or percentage of eschar was documented. No documentation for wounds was found from 8/23/2024 until 9/6/2024, two weeks later. R17's Moisture Associated Skin Damage (MASD) on Bilateral Buttocks Care Plan was initiated on 9/2/2024 with the interventions: -Turn every two hours to off load wound area. -treatment to the wound will be done according to provider orders. Surveyor noted no documentation was found in R17's record of having MASD to the buttocks. A timeline of the wound progression is listed for each pressure injury site: the right heel/Achilles, the coccyx, the right medial foot, the right posterior calf, and the right lateral foot. RIGHT HEEL/ACHILLES On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and the right heel pressure injury measured 2.7 cm x 4 cm x unable to determine with dry eschar. Surveyor noted the pressure injury was not staged, and no percentage of eschar was documented. The right Achilles pressure injury measured 5 cm x 1.5 cm x unable to determine with 90% dry eschar and 10% epithelial tissue. Surveyor noted the pressure injury was not staged. On 9/13/2024 on the Wound Management Detail Report, RN-M documented the right Achilles/heel pressure injury measured 11 cm x 3.5 cm x 0 cm with 40% epithelial tissue, 30% eschar, and 30% slough. Surveyor noted the pressure injury was not staged. The right heel and the right Achilles were measured as one. NP-N assessed R17's right heel/Achilles Unstageable pressure injury and documented weekly from 9/20/2024 - 10/11/2024. On 10/18/2024 at 5:40 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 11.5 cm x 4 cm with 40% epithelialization, 20% eschar, and 20% slough. Surveyor noted the pressure injury was not staged, and no depth was documented. The percentage tissue type did not equal 100%. On 10/25/2024 at 6:00 PM in the progress notes, RN-M documented wound rounds were done with NP-V and R17 had a venous stasis ulcer to the right lateral calf that measured 3.5 cm x 2 cm x 0.1 cm. No pressure injuries were assessed or documented. No wound documentation of the pressure injury was found from 10/18/2024 until 11/8/2024. On 11/8/2024, NP-N assessed R17's right heel/Achilles Unstageable pressure injury and documented the wound measured 11 cm x 3.2 cm x unable to determine with 40% epithelial tissue, 20% slough, and 40% granulation and the measurements are post-debridement. On 11/15/2024, NP-N assessed R17's right heel/Achilles Stage 4 pressure injury and documented the wound measured 10.4 cm x 3.2 cm by unable to determine with 40% epithelial tissue, 10% tendon, and 50% granulation. NP-N had debrided the area by removing the eschar on the heel. On 11/22/204 on the Wound Management Detail Report, RN-M documented the pressure injury measured 10.3 cm x 3.0 cm with 40% epithelialization, 50% granulation, and 10% slough. Surveyor noted the pressure injury was not staged, and no depth measurement was documented. No wound documentation of the pressure injury was found from 11/22/2024 until 12/11/2024. On 12/11/2024 on the Wound Management Detail Report, RN-M documented the pressure injury measured 10.4 cm x 2.9 cm x 0 cm with slough. Surveyor noted the pressure injury was not staged, and no percentage of slough was documented. On 12/13/2024 on the Wound Management Detail Report, RN-M documented the Stage 2 pressure injury measured 10 cm x 2.4 cm x 0 cm with 30% epithelialization tissue, 60% granulation, and 10% slough. Surveyor noted the pressure injury was not staged appropriately. NP-N documented the pressure injury was a Stage 4. On 12/20/2024 and 12/27/2024 on the Wound Management Detail Report, RN-M did not document the stage of the pressure injury. On 1/3/2025 on the Wound Management Detail Report, RN-M documented the pressure injury was Unstageable Deep Tissue injury with 100% granulation tissue. The staging did not match the wound description. On 1/10/2025 on the Wound Management Detail Report, RN-M documented the pressure injury was a Stage 3 which was not appropriate staging; a wound cannot get downgraded. RN-M assessed and documented on R17's Stage 4 pressure injury on 1/17/2025. R17's Stage 4 pressure injury was not assessed or documented on from 1/17/2025 until 1/31/2025. RN-M assessed and documented on R17's Stage 4 pressure injury weekly from 1/31/2025 until 2/21/2025 when the wound healed. COCCYX On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and the Stage 3 pressure injury measured 2.5 cm x 2.5 cm x 0.1 with 50% slough and 50% epithelial tissue. Surveyor noted this was the first comprehensive assessment of the wound since admission on 7/19/2024. On 9/13/2024 at 6:34 PM in the progress notes, DON-B documented wound rounds were done with NP-N and the Stage 3 pressure injury measured 0.7 cm x 0.5 cm with dry slough. Surveyor noted no depth measurement or percentage of slough was documented. On 9/20/2024 at 3:20 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the Stage 3 pressure injury measured 0.8 cm x 0.6 cm with 100% granulation tissue. Surveyor noted no depth measurement documented. On 10/1/2024 at 12:52 AM in the progress notes, RN-M documented pressure injury assessments from 9/27/2024: the Stage 3 pressure injury measured 0.8 cm x 0.6 cm with 100% granulation tissue. Surveyor noted no depth measurement documented. On 10/4/2024 at 5:05 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the Buttock/Coccyx pressure injury measured 3 cm x 2 cm. Surveyor noted the pressure injury was not staged, and no depth measurement or description of the wound bed was documented. On 10/11/2024 at 6:25 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the Buttock/Coccyx pressure injury measured 0.7 cm x 1 cm with 100% smooth pink tissue. Surveyor noted the pressure injury was not staged, and no depth measurement was documented. On 10/18/2024 at 5:40 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the Buttock/Coccyx pressure injury resolved. RIGHT MEDIAL FOOT On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and the pressure injury measured 0.3 cm x 0.3 cm with dry eschar. Surveyor noted the pressure injury was not staged, and no depth measurement or percentage of eschar was documented. On 9/13/2024 at 6:34 PM in the progress notes, DON-B documented wound rounds were done with NP-N and the pressure injury measured 1 cm x 0.7 cm with 100% granulation. Surveyor noted the pressure injury was not staged, and no depth measurement was documented. On 9/20/2024 at 3:20 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the Stage 3 pressure injury measured 0.8 cm x 0.6 cm with 100% granulation. Surveyor noted no depth measurement was documented. On 10/1/2024 at 12:52 AM in the progress notes, RN-M documented pressure injury assessments from 9/27/2024: the right medial/anterior foot pressure injury measured 1 cm x 0.7 cm with 100% granulation. Surveyor noted the pressure injury was not staged, and no depth measurement was documented. On 10/4/2024 at 5:05 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the medial/anterior foot pressure injury was not assessed or documented. NP-N documented the right medial/anterior pressure injury resolved. RIGHT POSTERIOR CALF On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and the pressure injury measured 1 cm x 12 cm and was determined to no longer be a DTI, even though the description of the area was dark purple. On 9/13/2024 at 6:34 PM in the progress notes, DON-B documented wound rounds were done with NP-N and the Stage 3 pressure injury healed. Surveyor noted this was the first documentation of the pressure injury being a Stage 3. RIGHT LATERAL FOOT On 9/6/2024 at 1:31 PM in the progress notes, an RN documented wound rounds were done with NP-V and the pressure injury measured 2 cm x 0.6 cm x unable to determine was scabbed over with 100% eschar. Surveyor noted the pressure injury was not staged. On 9/13/2024 at 6:34 PM in the progress notes, DON-B documented wound rounds were done with NP-N and the pressure injury was not assessed or documented. On 9/20/2024 at 3:20 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 2.4 cm x 1.3 cm with 80% eschar and 20% slough. Surveyor noted the pressure injury was not staged, and no depth measurement was documented. On 10/1/2024 at 12:52 AM in the progress notes, RN-M documented pressure injury assessments from 9/27/2024: the right lateral foot pressure injury measured 2.4 cm x 1.3 cm with 80% eschar and 20% slough. Surveyor noted the pressure injury was not staged, and no depth measurement was documented. On 10/4/2024 at 5:05 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 2.4 cm x 1.7 cm x 1.1 cm. Surveyor noted the pressure injury was not staged, and no description of the wound bed was documented. On 10/11/2024 at 6:25 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 2.4 cm x 1.4 cm x 1.1 cm. Surveyor noted the pressure injury was not staged, and no description of the wound bed was documented. On 10/18/2024 at 5:40 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 2.5 cm x 1.5 cm. Surveyor noted the pressure injury was not staged, and no depth measurement or description of the wound bed was documented. On 10/25/2024 at 6:00 PM in the progress notes, RN-M documented wound rounds were done with NP-V and R17 had a venous stasis ulcer to the right lateral calf that measured 3.5 cm x 2 cm x 0.1 cm. No pressure injuries were assessed or documented. No wound documentation of the pressure injuries was found from 10/18/2024 until 11/8/2024. On 11/8/2024 at 6:34 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the Stage 3 pressure injury measured 1.6 cm x 0.9 cm. Surveyor noted no depth measurement or description of the wound bed was documented. On 11/15/2024 at 4:17 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury measured 1.4 cm x 0.8 cm with granulated tissue throughout. Surveyor noted the pressure injury was not staged, and no depth measurement was documented. On 11/22/204 at 4:42 PM in the progress notes, RN-M documented wound rounds were done with NP-N and the pressure injury was not assessed or documented. On 12/13/2024, NP-N assessed R17's right lateral foot Stage 3 pressure injury. NP-N assessed R17 weekly, and the pressure injury resolved on 1/10/2025. This documentation was not available to facility staff and was not in R17's medical record until Surveyor requested a copy of NP-N's notes on 2/27/2025 at 3:01 PM. NUTRITION On 8/8/2024 at 7:54 AM in the progress notes, the Registered Dietician (RD) documented a nutritional assessment was completed and due to the coccyx wound, multiple DTIs, and foot ulceration, R17 had increased nutrient needs and suggested a wound healing supplement like Arginaid daily. Surveyor noted Arginaid was not initiated. On 9/11/2024 at 11:25 AM in the progress notes, the RD documented at previous review, RD recommended Arginaid for wound healing. RD continued to suggest Arginaid to support wound healing. Surveyor noted Arginaid was not initiated. On 10/9/2024 at 11:17 AM in the progress notes, the RD documented a recommendation for Arginaid daily would aid in wound healing. Surveyor noted this was the third month in a row the RD had made that recommendation, and it was not followed up on. On 10/30/2024, R17 had an order for Arginaid initiated. Surveyor noted this was initiated greater than two and a half months after it had been recommended by the RD. In a phone interview on 3/3/2025 at 2:02 PM, Surveyor asked Registered Dietician (RD)-W, the regional supervisor for the dieticians, how the RD was notified of residents with pressure injuries. RD-W stated the RD would receive a wound report form the DON or the wound nurse, and depending on the severity of the situation, the RD would put in a progress note within 24 hours of the notification. Surveyor asked RD-W how often the RD documented in resident records. RD-W stated the RD would document once a month with the weight status and how much the resident was eating as well as the status of the wounds. RD-W stated the RD would make a recommendation to address the nutrition and wound status and then would follow up to see if the recommendation was in place within 48 hours. RD-W stated the RD would be in person at the facility two to three times a month, so their voice was not always being heard. Surveyor shared with RD-W the concern the RD recommendations for R17 were not followed up for over two months. RD-W stated the RD that had been assigned to the facility did not have confidence in getting their recommendations in place. CURRENT WOUNDS - MASD On 2/3/2025 at 4:02 PM in the progress notes, RN-M documented R17 was assessed due to a report of MASD to bilateral buttocks. Inspection revealed two areas of denuded skin bilaterally with a dermatitis related ulcer at the twelve o'clock position of the left MASD wound. The ulcer has 80% granulated tissue with 20% slough, wound edges are irregularly shaped, however firmly attached to the wound bed. Surrounding skin is MASD, denuded, partial thickness wound with blanchable erythema. MASD wound edges are rolled back measuring 3 cm x 2.5 cm, no exudate noted. The right buttock has a partial thickness MASD wound measuring 4 cm x 3.3 cm with irre [TRUNCATED]

Based on interview and record review, the Facility did not ensure a resident received treatment and care in accordance with professional standards of practice to prevent the need for repeated medical interventions. This was discovered with 1 (R13) of 14 residents reviewed for quality of care. In the last 120 days R13 has been sent to the emergency department six times for complications related to nephrostomy tubes (thin, flexible tubes inserted directly into the kidney to drain urine when the natural urinary tract is blocked). Findings include: R13 was originally admitted to the facility on [DATE] and most recently readmitted [DATE] after a hospital stay. R13's pertinent diagnoses include methicillin resistant staphylococcus aureus (MRSA), hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, Parkinsonism, type 2 diabetes mellitus with diabetic nephropathy, and neuromuscular dysfunction of bladder. R13's 5 day Minimum Data Set (MDS), completed 2/27/25, documents R13's Brief Interview for Mental Status (BIMS) score to be 15, indicating R13 is cognitively intact for decision making. R13's MDS also documents Patient Health Questionnaire (PHQ-9) score to be 00, indicating no depression. No behavior concerns are noted. R13 is assessed as making self understood and understands others. The MDS indicates R13 has a catheter for bladder and an ostomy for bowel function. R13 has a care plan for indwelling catheter which started on 06/26/2024. The problem reads R13 requires an indwelling catheter (Bilateral Nephrostomy Tubes) r/t (related to) Neuromuscular dysfunction of bladder and BPH (benign prostate hyperplasia) with the following pertinent interventions: -Abdominal Binder to maintain placement of tubes Created: 01/07/2025 -Assess drainage. Record amount, type, color, odor. Observe for leakage. Keep closed system as much as possible to reduce the risk of infection. Created: 06/26/2024 -Monitor output q (per)/ shift. Flowsheet: I&O (intake & output). Created: 06/26/2024 -Observe for s/s (signs/symptoms) of infection. Document and promptly report s/s. Follow McGeer's unless specified per MD (medical doctor) order with education. Created: 06/26/2024 -Provide catheter care Q shift and as needed. Created: 06/26/2024 -Provide education to reduce the risk of trauma. Created: 06/26/2024 Surveyor notes the following interventions remained on the care plan and should have been updated/removed: -16 FR foley with 10mL balloon. Created: 06/26/2024 -Attempt voiding trial per facility protocol or MD order, unless otherwise specified per MD. Created: 06/26/2024 -Change catheter per facility protocol or MD order. Created: 06/26/2024 Surveyor reviewed the electronic medical record (EMR) and found the following orders related to R13's nephrostomy care: Bilateral Nephrostomy Tubes. Special Instructions: Assess bandages and change if soiled. Imperative to be changed if soiled. Once An Evening 03:00 PM - 07:00 PM start date 01/06/2025. Nephrostomy tubes: Cleanse with NS (normal saline), pat dry, cover with spilt gauze. Change Q 2-3 days and PRN (as needed). Once A Day Every Other Day 06:00 PM - 10:00 PM start date 11/19/2024. Surveyor reviewed the EMR for past 120 days and found six occurrences when R13 was sent out for complications with Nephrostomy tubes. 1st time sent out On 11/28/2024, at 12:34 AM, a progress note was written ambulance arrived to take resident to (name of) hospital for R (right) nephrostomy tube placement. VSS (vital signs stable). No signs of pain at this moment. No s/s of infection from nephrostomy tube insertion site. A second progress note gives more details to the dislocation written on 11/28/2024, at 12:46 AM, writer entered room to perform wound care to find that resident's Nephrostomy had been torn from the stop-cock during transfer via Hoyer lift. Leaving urine to leak freely from the Neph (nephrostomy)-tube. Writer attempted to identify a resolution and without success, called . DON (Director of Nursing). DON had suggested to contact (name of nurse practitioner group) to update and ask to advise. (Name of nurse practitioner group) had advised patient go to the ED (emergency department) for eval (evaluation) and treat. To stop the urine from freely flowing on to patient, a Foley catheter was cut and attached to a leg bag to allow the Nephrostomy tube to be inserted directly inside the Foley to drain into the collecting bag until patient could be transported to the ED for eval and treat . On 11/28/2024, at 04:00 AM, a progress note was written resident returned from (name of) hospital. Hospital stated resident will need to go to (name of different) hospital for new nephrostomy tube. Tube remains to drain but is partially dislodged. VSS (vital signs stable) . The After Visit Summary dated 11/28/24, reads right sided nephrostomy tube partially dislodged internally, but still functional. Continue to empty the bag as per normal protocol. Use caution in transferring the patient to prevent further dislodgement or tubing . An After Visit Summary dated 11/29/2024, contains discharge instructions for the procedure of percutaneous nephrostomy being completed. 2nd time sent out A progress note written on 12/29/2024, at 08:54 AM, reads left nephrostomy tubing stick line is 2 Inches off the insertion site, no c/o (complaints of) pain to site, blood is noted to the tubing about 50 cc of sanguinis (sic) drainage noted, notified (nurse practitioner group) gave order to send out to (name of hospital) in [NAME] to be reinserted ., paramedics arrive at 0916 . On 12/29/2024, at 01:30 PM, a progress note reads pt (patient) back from ED for nephrostomy displacement vitals stable and charted no complaints, IR (interventional radiology) could not place nephrostomy today but referral to IR in place they will be calling us tomorrow but call back tomorrow if they don't reach out, stated to keep it covered, N.O. (new order) for cephalexin 500mg cap (capsule), take 1 cap PO (by mouth) in the AM, noon and evening x10 days per paperwork appear pt received first dose at ED, pt does not meet UTI (urinary tract infection) McGeer criteria, called (nurse practitioner group) to clarify if she would like to continue with ABT (antibiotic) due to pt not meeting criteria . (nurse practitioner group) gave order to continue with ABT prophylactic due to pt having leukocyte in UA (urinary analysis) and for upcoming procedure tomorrow, all order in. pt placed on 24 hour board to keep insertion site covered and to call IR tomorrow . The After Visit Summary dated 12/29/2024, has a diagnosis for visit of nephrostomy tube displacement. The After Visit Summary dated 12/30/2024, shows the nephrostomy tube being replaced. 3rd time sent out A progress note written on 01/28/2025, at 10:18 AM, reads at 0745 (am) CNA (Certified Nursing Assistant) called RN (Registered Nurse) to look at nephrostomy bag. Left nephrostomy tubes attached to the patient and dressing dry and intact. Adaptor where tubing is attached to intact but catheter tubing was out and looks like its clogged with a white object. No other tubing available . On 01/28/2025, at 01:26 PM, the return from ED progress note reads patient returned from (hospital location) BL (bilateral) nephrostomy tubes in place with clear yellow urine. Per patient replaced both tubes . The After Visit Summary dated 1/28/2025, has diagnosis of malfunction of nephrostomy tube. 4th time sent out A progress note written on 02/11/2025, at 02:04 PM, reads CNA found left nephrostomy tube out. RN applied dressing no drainage noted at this time some redness noted. Call placed to NP (nurse practitioner) order to send to (hospital location) ED. The After Visit Summary dated 2/11/2025, has diagnosis listed as nephrostomy tube displacement. 5th time sent out On 2/16/2025, at 01:08 PM, a progress note was written that reads blood tinged urine noted in nephrostomy as well as unequal output. Urine leaking through penis as well with strong foul odor. (Name of medical group) gave orders for resident to be sent to ED for evaluation . Surveyor notes R13 was hospitalized on the 16th and returned to the facility on [DATE]. R13 was kept at the hospital to receive intravenous antibiotics due to a urinary tract infection. The After Visit Summary dated 2/24/25, has a diagnosis of urinary tract infection associated with nephrostomy catheter. A right nephrostomy catheter exchange was ordered on 2/17/25. 6th time sent out A progress note written on 03/01/2025, at 05:57 AM, reads resident returned from hospital this shift. Sent out on PMs for dislodged urostomy tube. Tube remains dislodged. Left tube functioning properly. Instructions sent to make an appointment to schedule urostomy placement. The After Visit Summary dated 3/1/2025 has diagnosis of nephrostomy tube displacement. On 02/26/25, at 12:35 PM, Surveyor interviewed R13 and learned that R13 returned from the hospital Monday (2 days before). R13 was there over a week due to nephrostomy tube being pulled out, R13 got a bacterial infection in the kidneys. On 03/03/25, at 01:11 PM, Surveyor interviewed R13 again regarding the number of times sent out to hospital due to nephrostomy tube issues. Per R13 staff don't take the time to do the job correctly. Some are just not conscientious, R13 will give them instructions if needed to prevent issues with nephrostomy tubes but some just are not willing to learn. On 03/03/25, at 01:50 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F regarding R13's nephrostomy tubes and asked about training given to staff. Per ADON-F there is a nurse and CNA meeting every other week, and training on how to transfer R13 with a Hoyer has been discussed. Surveyor asked about interventions to keep nephrostomy tubes in place and was told the Facility had started using an abdominal binder to hold tubes in place. Also, discussed with NP today if there are other ideas on how to keep tubes in so not pulled out. (Cross-reference F604). On 03/04/25, at 09:30 AM, Surveyor interviewed R13 regarding the abdominal binder, R13 stated they are not using it now because it is so tight that R13 got a rash. R13 decided on own that they did not want the rash so have asked staff not to put it on. On 03/04/25, at 09:39 AM, Surveyor interviewed CNA-K regarding the care used for R13's nephrostomy tubes. CNA-K stated they have gotten a little training from Facility on how to clean around the nephrostomy tubes. It is kinda the same as cleaning the penis. CNA-K stated that when R13 first got the nephrostomy tubes it was discussed at a staff meeting, topics like precautions when transfer with Hoyer, always use a two assist with R13 and both staff should watch the cords. Surveyor asked about R13's abdominal binder and was told ya he wear it. On 03/04/25, at 09:58 AM, Surveyor interviewed Director of Nursing (DON)-B regarding steps taken by facility to prevent pulling of nephrostomy tubes on R13. Per DON-B the first couple times it happened it was during Hoyer transfers, so DON-B got an abdominal binder and stat locks to hold tubes in place. DON-B admits not being aware R13 is not wearing the binder due to rash, stated will have to talk to R13 about skin protection options. Surveyor asked what type of staff training had occurred since R13 got the nephrostomy tubes. DON-B replied that they had talked to staff verbally about transfers and checking tubing so not in a place where the tubes can get pulled out. Surveyor told DON-B this is a concern because R13 has been sent to ED six times in the last 120 days, with some requiring hospitalization . Surveyor notes the Facility Assessment was reviewed and there is no staff competency to care for Nephrostomy tubes included as being assessed. On 03/04/25, at 03:34 PM, Surveyor told DON-B and Nursing Home Administrator-A that there is a serious concern related to R13's nephrostomy tubes and being sent to the ED six times for care issues where R13 developed infections and requiring hospitalization .

Based on interview and record review, the Facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident potentially affecting 53 of 53 residents in the Facility. * The Facility did not designate a charge nurse for each tour of duty on each daily nursing schedule. Findings include: On 02/27/25, at 10:58 AM, Surveyor reviewed 30 days of nursing staff schedules. Surveyor noted that the Facility's nursing staff schedules did not designate who the charge nurse was for each tour of duty. On 02/27/25, at 01:25 PM, Surveyor interviewed Nursing Scheduler-R regarding how to know who the charge nurse is at any given time. Nursing Scheduler-R replied that during the day the Director of Nursing (DON) or Assistant DON are in the building. On PM shift the Nurse Educator is usually in the building otherwise there is an on-call person listed at the bottom of the schedule page who is reachable by phone. Surveyor then asked who is in the building that is labeled as charge nurse during each shift, the answer was staff know to call the on-call person. On 02/27/25, at 03:08 PM, Surveyor informed the Nursing Home Administrator-A, DON-B and Assistant Nursing Home Administrator-D of the concern related to the Facility's schedules not designating who the Facility charge nurse would be for each shift on the Facility's nursing staff schedules. The Facility did not provide any additional information as to why it did not ensure there was a designated charge nurse for each tour of duty.

Based on observation, interview, and record review, the facility did not develop an infection prevention and control program that included preventing, identifying, reporting, and controlling infections and communicable diseases potentially affecting all 53 residents, and providing a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 (R47, R34, R17, and R19) of 12 residents in Enhanced Barrier Precautions (EBP). *Facility outbreaks did not have complete surveillance data on the residents and staff affected. *Monthly infection surveillance data did not have infection rates calculated. *The Water Management Plan did not have a detailed description and diagram of the water system in the facility identifying control measures and how the control measures are monitored. *R47 was in EBP. Observations were made of staff not wearing appropriate Personal Protective Equipment (PPE) when performing cares and wound care. *R34 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care. *R17 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care. *R19 was in EBP. Observations were made of staff not wearing appropriate PPE when performing wound care. Findings include: The facility policy and procedure titled Surveillance for Infections from MED-PASS (C) 2001 revised 9/2017 documents: Policy Interpretation and Implementation: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. Gathering Surveillance Data: 1. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The infection control committee and/or QAPI committee may be involved in interpretation of the data. 5. In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted; for example, focused surveillance data may be gathered for residents with a high risk for infection or those with a recent hospital stay. Data Collection and Recording: 1. For residents with infections that meet the criteria for definition of infection for surveillance, collect the following data as appropriate: a. Identifying information .; b. Diagnoses; c. admitted , date of onset of infection .; d. Infection site .; e. Pathogens; f. Invasive procedures or risk factors .; g. Pertinent remarks Also, record if the resident is admitted to the hospital, or expires; and h. Treatment measures and precautions . 4. For targeted surveillance sing facility-created tools, follow these guidelines: a. DAILY (as indicated): Record detailed information about the resident and infection on an individual infection report form b. MONTHLY: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month (e.g., Line Listing of Infections by Resident or similar form). c. MONTHLY: Summarize monthly data for each nursing unit by site and by pathogen d. MONTHLY/QUARTERLY: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends . e. MONTHLY/QUARTERLY: Compare incidence of current infections to previous data to identify trends and patterns. Use an average infection rate over a previous time period (for example, over the past 12 months) as the baseline. Compare subsequent rates to the average rate to identify possible increases in infection rates. Calculating Infection Rates: 1. Obtain the month's total resident days from the business office. The following data is used as the denominator to calculate the monthly infection rate: a. Total resident days (daily census of each day in the designated time period added together). 2. To determine the incidence of infection per 1000 resident days, divide the number of new healthcare associated infections for the month by the total resident days for the month (obtained from the business office) X 1000. Interpreting Surveillance Data: 1. Analyze the data to identify trends. a. Compare the rates to previous months in the current year and to the same month in previous years, to identify seasonal trends. b. Consider how increases or decreases might relate to recent process changes, events, or activities in the facility 2. Surveillance data will be provided to the infection control committee regularly. 3. The infection control committee will determine how important surveillance data will be communicated to the physicians and other providers, the administrator, nursing units, and the local and state health departments. The facility policy and procedure titled Enhanced Barrier Precautions from MED-PASS (C) 2001 revised 8/2022 documents: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bating/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 1.) On 2/26/2025 at 8:00 AM, Surveyor entered the facility and observed a sign on the front door stating the facility was in a COVID-19 outbreak and anyone entering the facility needed to wear a mask. Surveyor asked for a list of residents in COVID-19 isolation and was told by facility staff that no residents currently have any positive COVID-19 tests, and the facility staff and visitors are wearing masks for the ten days beyond the last symptom to prevent future spread of COVID-19. On 2/26/2025 at 3:00 PM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (Don)-B all outbreak summaries and line lists since the last recertification survey. DON-B stated Assistant DON (ADON)-F is the facility infection preventionist and would provide that information to Surveyor. On 2/27/2025, ADON-F provided Surveyor with two COVID-19 outbreak packets consisting of resident and staff line lists and a summary of the outbreak, two respiratory line lists, and two gastrointestinal line lists. Surveyor noted the gastrointestinal line lists each had one resident listed and therefore did not meet the definition of an outbreak. Surveyor noted the respiratory line list that had current dates of infection was an Influenza outbreak and not a COVID-19 outbreak as was documented on the sign at the facility entrance. Surveyor reviewed the outbreak packet for COVID-19 that started on 10/26/2024 when a staff member tested positive. Another staff member and one resident tested positive on 10/28/2024. Per the line lists, 7 staff members tested positive and 17 residents tested positive totaling 24 individuals being affected by COVID-19. The last positive collected sample was on 11/4/2024. The summary of the outbreak documented the outbreak began on 10/29/2024 with a total of 20 residents and 7 staff members testing positive. Surveyor noted the number of residents on the summary did not match the number of affected residents on the line list. Surveyor reviewed the outbreak packet for COVID-19 that started on 12/4/2024 when three staff members tested positive. Two staff members tested positive on 12/5/2024. A resident tested positive on 12/18/204, thirteen days after the last staff member tested positive. The outbreak should have been concluded on 12/15/2024, ten days after the last staff member tested positive. 1/6/2025-1/22/2025 had two staff members and eight residents positive. The Outbreak Summary Report documented 17 individuals were affected in the outbreak with testing of residents and staff from 12/4/2024-1/6/2025 with the outbreak conclusion being 1/6/2025. The conclusion date does not match the last resident testing positive on 1/22/2025. On 3/3/2025 at 11:14 AM, Surveyor met with DON-B and ADON-F to discuss the facility Infection Prevention (IP) program. ADON-F stated ADON-F had been responsible for the IP program since 10/2024 and was still learning the process. Surveyor shared with ADON-F the concern the outbreak summaries did not match the information on the line lists. ADON-F agreed. 2.) Surveyor reviewed ADON-F's IP binder for the previous months infection surveillance logs listing the residents and infective processes including the use of antibiotics. The monthly sections included line lists and plot maps of the facility. In an interview on 3/3/2025 at 11:14 AM, Surveyor asked ADON-F if monthly rates of infection were calculated. ADON-F stated no. Surveyor asked ADON-F what information was brought to Quality Assessment and Assurance (QAA) meetings for the infection prevention program. ADON-F stated ADON-F brings the binders with the line lists to QAA. Surveyor shared the concern trends in infection could not be determined if rates of infection were not calculated monthly to compare to previous months/years. ADON-F agreed. On 3/3/2025 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern rates of infection were not calculated per infection monthly. DON-B agreed the rates should be calculated. 3.) On 3/3/2025 at 11:14 AM, Surveyor asked ADON-F if ADON-F is part of the Water Management Plan (WMP). ADON-F stated Maintenance Director (MainDir)-L is in charge of the WMP and would have any information Surveyor needed. Surveyor requested ADON-F contact MainDir-L to provide the WMP to Surveyor for review. The facility policy and procedure titled Legionella Water Management Program from MED-PASS (C) 2001 revised 7/2017 documents: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program. 5. The water management program includes the following elements: a. An interdisciplinary water management team; b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including: (1) storage tanks; (2) Water heaters; (3) Filters; (4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers; (7) Hot tubs; (8) Fountains; and (9) Medical devices such as CPAP machines, hydrotherapy equipment; etc. d. The identification of situations that can lead to Legionella growth, such as: (1) Construction; (2) Water main breaks; (3) Changes in municipal water quality; (4) The presence of biofilm, scale or sediment; (5) Water temperature fluctuations; (6) Water pressure changes; (7) Water stagnation and; (8) Inadequate disinfection. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. 6. The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur: a. The control limits are consistently not met; b. There is a major maintenance or water service change; c. There are any disease cases associated with the water system; or d. There are changes in laws, regulations, standards or guidelines. On 3/3/2025 at 11:36 AM, MainDir-L provided to Surveyor the facility Legionella Water Management Program policy and procedure. Surveyor asked MainDir-L for the WMP, which should include diagrams of the water system, control measures, and logs of flushes. MainDir-L stated MainDir-L thought Surveyor just wanted the policy for the WMP. MainDir-L stated MainDir-L would get more information for Surveyor. On 3/3/2025 at 1:34 PM, MainDir-L provided to Surveyor a second copy of the facility Legionella Water Management Program policy and procedure, a checklist for developing a legionella water management program that was not dated, a facility policy and procedure titled Legionella Water Management dated 1/10/2024, and a hand-drawn diagram of the facility with no control measures designated. -The facility policy and procedure titled Legionella Water Management dated 1/10/2024 documented: I. OBJECTIVE: The purpose of this policy is to reduce the risk associated with the control of Legionella to the lowest practical level. II. DEFINITION: Legionella-the bacterium that causes legionnaires' disease, flourishing in air conditioning and central heating systems. III. POLICY: The Legionella Team consisting of the Administrator, Director of Nursing, Maintenance Director, Dietary Manager and Housekeeping Supervisor are to achieve by improving the standard of existing water, implementing safe operational procedures, and ensuring that the design and installation of all new systems conform to the current standards. IV. PROCEDURES: A. NURSING 1. Make sure medical devices such as CPAP and BIPAP machines are cleaned and sanitized on a daily basis. B. HOUSEKEEPING 1. DAILY TASKS: a. Clean and sanitize all showerheads for a minimum of 3 minutes. b. Clean and sanitize all facets [sic] regardless of use. 2. WEEKLY TASKS a. Run water through every showerhead for a minimum of 3 minutes. b. Run water through every facet [sic] for a minimum of 3 minutes. C. DIETARY 1. Clean/drain and sanitize all steam tables daily. 2. Monitor ice machine filters and notify Maintenance when the filter needs to be replaced. 3. Check water temperatures and chemical dispensers on Dishwasher daily. 4. Notify vendor of and repairs. [sic] D. MAINTENANCE 1. Insure [sic] the water heaters are running within the required WI State code guidelines. 2. Flush when required. Surveyor noted the policy did not include the infection preventionist as part of the team and no documentation showed the appropriate time to flush shower heads and faucets to be 3 minutes. Surveyor reviewed with MainDir-L the facility Legionella Water Management Program policy and procedure. Surveyor asked MainDir-L if there was a more detailed drawing or description of the water system showing where control measures were in the building. Surveyor went through each item listed in 5. The water management program includes the following elements: to clarify with MainDir-L what information Surveyor needed to see to assess the facility WMP that was in place. MainDir-L stated the information provided to Surveyor, the policies, the checklist, and the hand-drawn diagram, was the information provided to MainDir-L by the previous maintenance director. MainDir-L stated MainDir-L would get logs that have been completed by kitchen and housekeeping. In an interview on 3/3/2025 at 1:47 PM, Surveyor asked Nursing Home Administrator (NHA)-A who was part of the Water Management team. NHA-A stated the Regional Maintenance Director, MainDir-L, and ADON-F. Surveyor asked NHA-A if NHA-A was part of the team. NHA-A stated no. Surveyor shared the concern with NHA-A that NHA-A should be part of the team per their policy, and the information provided by MainDir-L was not complete or thorough. On 3/3/2025 at 1:52 PM, MainDir-L provided logs that showed six rooms a week were tested for water temperature coming out of the faucets. Surveyor noted the temperatures logged ranged from 94 degrees to 112 degrees. The Centers for Disease Control and Prevention (CDC) guidelines document Legionella grows best between 77-113 degrees; hot water should be stored at temperatures above 140 degrees and hot water in circulation should not fall below 120 degrees. MainDir-L provided logs from the kitchen that documented daily draining and sanitizing steam tables. Surveyor noted not all the boxes had been filled in indicating the task had been completed. In an interview on 3/4/2025 at 8:04 AM, Surveyor asked NHA-A to explain the water temp logs for resident rooms. NHA-A stated temperatures are gotten from six different rooms every week and the rooms are listed on the logs. Surveyor noted it takes about one and a half months to get the temperatures of every room in the facility. Surveyor shared with NHA-A the concern the temperatures taken in resident rooms were below the recommended 120 degrees by the CDC. Surveyor asked NHA-A if they had a policy to show what temperature should be reached and if there was a measure in place to follow if the temperatures were not at the level indicated. NHA-A provided a facility policy and procedure titled Water Temperatures, Safety of dated MED-PASS (C) 2001 revised 12/2009 that documented: 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 115 degrees F. Surveyor noted 115 degrees was hand-written in the policy where a blank had been left. On 3/4/2025 at 10:57 AM, Surveyor measured the temperature of the water coming out of the faucet in room [ROOM NUMBER]. The temperature measured 124 degrees. On 3/4/2025 at 3:32 PM, Surveyor shared with NHA-A and DON-B the concern staff measuring the temperature of the running water did not keep the thermometer in the water for a long enough period of time to come up with an accurate measurement. Surveyor shared the observation of the temperature of the water coming from the faucet in room [ROOM NUMBER]. Surveyor shared the concern NHA-A was not a member of the WMP team and the WMP did not have a detailed description and diagram of the water system in the facility identifying control measures and how the control measures are monitored. 4.) R47 was admitted to the facility on [DATE] and was in EBP due to wounds to the right heel, right lateral foot, and coccyx. On 2/27/2025 at 11:14 AM, Surveyor was with Registered Nurse (RN)-M who was preparing to provide wound care to R47. A sign was observed outside of R47's room indicating R47 was in EBP. RN-M knocked on R47's door prior to entering and told R47 RN-M was there to do wound care. RN-M did not put on a gown prior to entering R47's room. RN-M brought the treatment cart into R47's room rather than leaving it in the hallway and bringing in only the treatment items needed to provide wound care. R47 informed RN-M that R47 had a bowel movement and needed to be cleaned up. RN-M told R47 RN-M would return after R47 had been cleaned. RN-M pushed the treatment cart back into the hallway. Surveyor observed Certified Nursing Assistant (CNA)-K enter R47's room to provide incontinence care. CNA-K did not put on a gown prior to entering the room. CNA-K came out of R47's room with a bag of garbage which CNA-K deposited into a garbage container in the hallway. Surveyor asked RN-M if gowns should be worn in resident rooms when wound care is performed. RN-M stated yes. Surveyor asked RN-M if RN-M should have put on a gown to provide wound care to R47. RN-M stated yes. In an interview on 2/27/2025 at 11:27 AM, Surveyor asked CNA-K if any special PPE needed to be put on when doing incontinence care for R47. CNA-K stated CNA-K did not think any PPE needed to be worn when caring for R47, but maybe for R47's roommate. CNA-K looked at the sign posted on R47's door and stated R47 was in EBP and next time, CNA-K will wear a gown to do cares with R47. On 2/27/2025 at 11:28 AM, Surveyor observed RN-M put on a gown prior to entering R47's room. RN-M pushed the treatment cart into R47's room. R47 asked RN-M why RN-M was wearing a gown since RN-M had never had a gown on to do wound care before. On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern CNA-K did not wear a gown when performing cares on R47 and RN-M put on a gown after a discussion was had regarding R47 being in EBP. Surveyor shared the concern RN-M brought the treatment cart into the room when providing wound care. 5.) R34 was admitted to the facility on [DATE] and was in EBP due to a wound to the right heel. On 2/27/2025 at 10:39 AM, Surveyor was with RN-M who was preparing to provide wound care to R34. A sign was observed outside of R34's room indicating R34 was in EBP. RN-M knocked on R34's door and entered the room pushing the treatment cart into R34's room. RN-M did not put on a gown prior to providing wound care to R34's right heel. After RN-M completed the wound treatment and pushed the cart into the hallway, Surveyor asked RN-M if RN-M should have worn PPE when doing R34's wound treatment. RN-M stated yes. On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern RN-M did not wear a gown when performing wound care on R34 and the concern RN-M brought the treatment cart into the room when providing wound care. 6.) R17 was admitted to the facility on [DATE] and was in EBP due to wounds to the left and right buttocks. On 2/27/2025 at 10:57 AM, Surveyor was with RN-M who was preparing to provide wound care to R17. A sign was observed outside of R17's room indicating R17 was in EBP. CNA-O accompanied RN-M to help position R17 during wound care. RN-M and CNA-O did not put on a gown prior to entering the room to provide wound care. RN-M pushed the treatment cart into R17's room. When RN-M completed R17's wound treatments, RN-M pushed the cart out of R17's room and CNA-O followed. Surveyor asked CNA-O when a resident is in EBP, what PPE should be worn. CNA-O stated they should wear a gown. CNA-O showed Surveyor the bin outside of R17's room that had PPE in the drawers. Surveyor asked CNA-O what would cause a resident to be in EBP. CNA-O stated if a resident has a wound or a catheter, then they are in EBP. Surveyor asked CNA-O if R17 was in EBP. CNA-O stated CNA-O did not know if R17 was on precautions or not so did not wear a gown. On 2/27/2025 at 11:14 AM, Surveyor asked RN-M if gowns should be worn in resident rooms when wound care is performed. RN-M stated yes. Surveyor asked RN-M if RN-M should have put on a gown to provide wound care to R17. RN-M stated yes. On 2/27/2025 at 3:01 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern RN-M and CNA-O did not wear a gown when performing wound care on R17 and the concern RN-M brought the treatment cart into the room when providing wound care. 42037 7.) R19 was admitted to the facility on [DATE] and was in EBP due to a heel wound. On 2/27/2025 at 10:29 AM, Surveyor was with RN-M who was preparing to provide wound care to R19. A sign observed outside of R19's room door indicated R19 was in EBP. RN-M knocked on R19's door and entered the room pushing the treatment cart into R19's room. RN-M did not don a gown prior to providing wound care to R19's heel wound. After RN-M completed the wound treatment RN-M pushed the cart back into the hallway, On 2/27/2025 at 3:10 PM, Surveyor shared with NHA-A and DON-B the concern that RN-M did not don a gown prior to performing R19's wound care. Surveyor shared the concern RN-M brought the treatment cart into the room when providing wound care for R19 who is in EBP. No additional information was supplied by the facility at this time.

Based on interview and record review, the facility did not ensure they implemented their antibiotic stewardship program potentially affecting all 53 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics indicated antibiotic use without documentation of appropriate use of the antibiotic. Findings include: The facility policy and procedure titled Surveillance for Infections from MED-PASS (C) 2001 revised 9/2017 documents: 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. On 3/3/2025 at 11:14 AM, Surveyor met with Assistant Director of Nursing (ADON)-F to discuss the facility Infection Prevention (IP) program. ADON-F stated ADON-F had been responsible for the IP program since 10/2024 and was still learning the process. Surveyor reviewed ADON-F's IP binder for the previous months infection surveillance logs listing the residents and infective processes including the use of antibiotics. Surveyor asked ADON-F what standard of practice for antibiotic stewardship was used. ADON-F stated they use McGeer, and they are trying to get it in place more frequently. (The McGeer criteria are a set of clinical guidelines used for infection surveillance in long-term care facilities, focusing on identifying potential infections and guiding antibiotic stewardship.) Surveyor asked ADON-F what was meant by that. ADON-F stated they are trying to complete the McGeer form for each resident on an antibiotic and then scanning it into the resident record. Surveyor asked ADON-F if each resident has had a McGeer form completed prior to the use of an antibiotic. ADON-F stated that was their goal, but that had not been done for everyone at that time. Surveyor reviewed the monthly line lists for 1/2025, 2/2025, and 3/2025. 1/2025 had 36 resident entries on the line list, 2/2025 had 29 resident entries on the line list, and 3/2025 had 24 resident entries on the line list. Examples from the line list review: -R1 was diagnosed with a urinary tract infection on 3/1/2025 with a culture taken on 3/1/2025; the antibiotic Macrobid was started on 3/2/2025. No documentation was found of a McGeer criteria review being completed prior to the use of the antibiotic. -R151 was diagnosed with a urinary tract infection on 2/17/2025 with a culture taken on 2/17/2025; the antibiotic ciprofloxacin was started on 2/23/2025. On 2/22/2025 at 9:52 AM in the progress notes, nursing documented a call was received from R151's physician regarding the urine culture results and to stop Keflex immediately and start ciprofloxacin. Surveyor noted R151 had not received Keflex, and no documentation was found of a McGeer criteria review being completed prior to the use of any antibiotic. On 3/4/2025 at 3:32 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern residents are put on antibiotics without documentation that the use of the antibiotic meets the McGeer criteria. Antibiotic stewardship relies on the use of a standard of practice to prevent unnecessary antibiotic usage. Surveyor shared with NHA-A and DON-B resident records were reviewed and no documentation was found in the medical record of the McGeer criteria checklist being completed prior to the use of antibiotics.

Based on record review and interviews, the facility did not ensure resident's experiencing a medical change in condition, received appropriate treatment and care, per standards of practice consistent with N6 Wisconsin Nurse Practice Act. This was discovered with 2 (R13 and R6) of 5 residents reviewed with a medical change in condition. * On [DATE], at 3:15 PM, R13 developed a high fever that was not resolved with medication. R13's blood sugar was to high to register on a testing meter. Their pulse and oxygen saturations were erratic. They had rapid gargled breathing. There is no evidence their symptoms were communicated to a medical provider for consultation and treatment. They experienced a cardiac arrest and passed away in the facility on [DATE], at 7:35 PM. The facility's failure to provide medical intervention with a high temperature not resolving, gargled breathing, high blood sugar, erratic pulses and oxygen saturations, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the Director of Operations (DOO)-C and Assistant Nursing Home Administrator (ANHA)-D of the immediate jeopardy on [DATE], at 10:26 AM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of D (no harm/isolated). * R6 on [DATE] experience blood in their urine after completing an antibotic for a UTI on [DATE]. There is no assessment completed of R6 on [DATE], or notification to a medical provider about R6's change in condition, until [DATE]. R6 was taken to the hospital by their family on [DATE] and was diagnosed with a UTI and sepsis. Findings include: The facility policy and procedure Change in a Resident's Condition or Status dated ,d+[DATE]. The policy states: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental conditions and/or status. Under 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. According to the State of Wisconsin Nurse Practice Act: N 6.03 - Standards of practice for registered nurses. (1) General nursing procedures. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. The American Medical Directors Association (AMDA) for clinical practice guidelines for long-term care facilities has guidelines for acute changes in condition that should be reported to a practitioner immediately. This includes a oral temperature over 101 degree Fahrenheit; blood sugar over 430 (or machine registers high) in diabetic patient using sliding scale insulin. 1.) R13 was reviewed as a closed record review. R13 passed away in the facility on [DATE] and had resided in the facility since [DATE]. R13 had diagnoses of aphasia, hemiplegia, gastrostomy, diabetes and severe sepsis with septic shock. R13 is a full code status with a Legal Guardian appointed for decision making. A progress note written by (Licensed Practical Nurse) LPN-L documents: On [DATE], at 9:33 PM, after receiving report from 1st shift nurse, CNA (Certified Nursing Assistant) informed writer that patient feels like he has a fever. Writer assessed patient. Patient was very warm to the touch, diaphoretic with rapid gargle breathing. Temp was taken @1515 (3:15 PM) 101.7. Acetaminophen 650 mg (milligrams) was administered @1530 (3:30 PM). Temp was taken again @1630 (4:30 PM) 103.8. Temp and vitals were taken again @1730 (5:30 PM) Temp was 103.4. B/P (blood pressure) ,d+[DATE], Pulse jumping from 48 to 114 to 128 and back to the 40's. Respirations were 24. Spo2 (oxygen saturation) jumped from 68 to 75 to 85. Multiple attempts were made to obtain a blood glucose reading, the writer could not get a reading except for HIGH. The writer called the on call NP (Nurse Practitioner) at [name of medical group] @1831 (6:31 PM) and was on hold for 27 minutes and 32 seconds. Temp (temperature) was taken again @1841 (6:41 PM) 103.1. Writer and CNAs were in the room with the patient when he expired. 911 was called and CPR (cardiopulmonary resuscitation) was started by writer. EMS (emergency medical staff) arrived and took over doing compressions, AED (automated external defibrillator) was initiated. The patient was pronounced dead @1935 (7:35 PM). The family arrived at 2200 (10:00 PM) to see the patient. The family asked the writer for a covid test to be done on the patient. Writer called DON (Director of Nurses) to see if this is ok to do, DON stated no and that the funeral can give a covid test if they would like to. Charge nurse updated sister/guardian throughout the entire process once CPR had begun. Currently awaiting funeral home arrangement information as of 22:20 (10:22 PM). Surveyor reviewed the blood sugar testing machine instructions. Surveyor noted there is is a bolded important statement documented which reads, if you see Hi displayed, the patient's blood glucose level may be above 600 mg/dl (milligrams/deciliter). Repeat the blood glucose test. If you receive the same result contact the patient's physician or healthcare provider. Surveyor notes R13's medical record does not contain documentation of communication with a medical provider to consult on R13's temperature being over 100 degrees Fahrenheit at 4 different opportunities; with a high blood sugar readings with multiple attempts; low pulse and low oxygen saturations. Surveyor notes there is no comprehensive assessment documented as to R13's change of condition. On [DATE], at 9:26 AM, Surveyor interviewed LPN-L. LPN-L stated they could not recall much from [DATE]. When Surveyor queried about opportunities LPN-L had to communicate with a RN, and/or a medical provider, LPN-L indicated there is never a (Registered Nurse) RN supervisor around on 3rd shift and they were on hold for a NP for a long time. They did (cardiopulmonary resuscitation) CPR and had a staff member call 911. LPN-L stated they did not have any further information about the opportunities for medical provider consultation or interventions. On [DATE], at 9:43 AM, Surveyor interviewed Registered Nurse (RN)-P who was the DON (Director of Nurses) at the time of R13's change of condition. RN-P stated they could not recall much. They remember getting a call about R13 having a high temp and they couldn't get a hold of the (Nurse Practitioner). They directed LPN-L to call 911. There was another RN in the building that they thought looked at R13. Surveyor notes there is no documentation of an assessment or communication with RN-P related to the changes in condition with R13. RN-P stated the RN on that shift quit shortly after this event. RN-P recalls discussing this event with the Nursing Home Administrator (NHA) at the time. RN-P does not recall any details, nor could they provide any documentation of this event. On [DATE], at 3:03 PM, Surveyor spoke with DON-B, Director of Operations (DOO)-C, and Assistant Nursing Home Administrator (ANHA)-D. Surveyor shared the concerns related to R13's change of condition, lack of a thorough assessment, lack of collaboration with a physician and lack of an emergency transfer of R13 to a higher level of care for evaluation and treatment. On [DATE], at 8:29 AM, DON-B and ANHA-D, spoke with Surveyor regarding R13's change of condition. Surveyor was informed there was no documentation in the HUCU (Secured electronic communication system used with providers versus calling the provider directly) communication system with a medical provider related to R13's change in condition. DON-B and ANHA-D did inform Surveyor there were licensed nurses in the facility during this event and there is always a manager on call, which was RN-P (the former DON). On [DATE], at 1:00 PM, Surveyor called the NP's medical group phone number. The message states If this is a medial emergency. Hang up and call 911. Otherwise, you can leave a message and someone will call you back. Surveyor notes the facility uses the HUCU electronic communication system when communicating with providers. On [DATE], at 2:46 PM, Surveyor interviewed CNA-O who worked with R13 during this event. CNA-O stated, I don't recall anything. On [DATE] Surveyor reviewed the EMS report for event that occurred on [DATE] with R13. The EMS report documents on [DATE], at 7:03 PM the facility contacted 911. The report documents EMS found R13 unresponsive and pulseless. R13 was in cardiac arrest. Surveyor notes the facility contacted 911 only after R13 was found unresponsive and pulseless and not with the prior noted change of condition. On [DATE], at 8:58 AM, Surveyor shared concerns related to R13's change in condition, lack of a thorough assessment, lack of consultation with a medical provider, or implementation of other interventions, with DON-B and ANHA-D. No further information was provided. The immediate jeopardy was removed on [DATE] when the facility completed the following: -All nurses were provided education related to recognition of physiological changed of condition as well as reporting of such changes of condition. -Education provided includes interventions, notifications and documentation. The education includes review of facility policy and procedure as it relates to condition changes, response to those changes and appropriate notifications to provider. -Establish a standard for vital signs parameters so that nursing staff call 911 if they are unable to reach a medical provider. -The Stop and Watch Early Warning Tool Interact tool has been implemented. The tool is available electronically within the EHR (Electronic Health Record) and copies have been made and placed in all nursing assistant and ancillary staff work stations. -All direct care staff will be educated on the Stop and Watch Early Warning tool as well as reporting any resident change of condition to a nurse. -Mandatory education is to include agency staff. -Post tests given following education to ensure competency in both notification and treatment responses as well as when to use the Stop and Watch tool. -The Change of Condition policy has been reviewed by the DON and with the Medical Director. Modifications include the addition of: *Examples of change of condition *Use of Interact tools-Stop and Watch *VS (Vital Signs) will be taken immediately or as soon as possible with a change of condition. *Once VS and immediate assessment is completed, MD (Medical Doctor) will be notified. VS will be taken a minimum of every 4 hours and more frequently as indicated by the change in condition or MD order. -All changes of condition will be listed on the 24-hour report board. -The DON and ADON will review progress notes and 24-hour report board daily for any changes of condition to ensure all resident condition changes have been identified and action taken in response to resident condition changes. -Audits will continue and results will be brought to the quality improvement committee for review. 2.) R6 had a readmission to the facility on [DATE] and was discharged to the hospital on [DATE]. R6 was reviewed as a closed record review. R6 has diagnoses of vascular dementia and urinary tract infection. R6 was on a antibiotic for a urinary tract infection from [DATE] - [DATE]. R6's progress notes on [DATE], at 4:17 AM, documented by (Licensed Practical Nurse) LPN-Q documents they were informed by an Aide there was blood in their (R6's) urine. R6 would not let LPN-Q assess them. Surveyor notes there is no documentation of a comprehensive assessment by a RN (Registered Nurse) or communication with a medical provider. There is no further documentation until [DATE], at 2:32 PM, by RN-N. RN-N documents R6 had blood in their urine. Completed a full set of vitals and notified the medical provider. The medical provider was in communication with RN-N through the HUCU text application system starting on [DATE]. Surveyor notes there is no HUCU communication from the facility to the medical provider from [DATE] or [DATE] related to R6's change of condition. Surveyor notes there is no documentation of a comprehensive assessment, or consultation with a with medical provider with R6's onset of blood in the urine on [DATE] On [DATE] the facility, using the HUCU text application, communicates with the physician that R6 is having hemauria ,d+[DATE] (Blood Pressure), 97.7 (temperature), 94% (oxygen saturation). No complaints or urinary symptoms and that she is on Eliquis (blood thinner). The physician ordered stat (immediate) labs to be drawn and to hold the Eliquis the next morning. The facility later sends a message to the physician that they are unable to obtain a blood sample for the stat labs. The physician approved trying again on [DATE] and to push fluids. On [DATE], at 4:37 AM, R6's progress notes document R6 has hematuria of the urine observed during day shift. No hematuria observed or reported on NOC (night) shift. Resident was hallucinating and calling out peoples names at the beginning of NOC shift. Resident also had complaints of pain and could not tell nurse where but was holding upper right chest and shoulder. Vital signs: 97.6, ,d+[DATE], 96% on room air. CBC to be drawn this morning for follow up on hematuria. On [DATE], at 5:48 PM, R6's progress notes document . Family saved urine in toilet for writer to look at and it is cloudy and blood tinged. On [DATE], the facility, using the HUCU text application communicates with the physician indicating the got a blood draw, but there was not enough blood to complete the tests. The facility also communicated the family wanted R6 placed on a antibiotic right away and did not want to wait for tests. The physician declined to start an antibiotic without evidence of an infection. The facility staff did inform the physician R6 was hallucinating and calling out peoplea names at the beginning of noc shift, but this shift had no other symptoms. On [DATE], using the HUCU text application, the facility communicated that R6;s white blood count was within normal limits, and that daughter believes R6 has a UTI and is requesting a u/a Facility staff: CBC results in WBC 10.8 (normal range 4.5 to 11.0) . daughter believes she has UTI, still trying to get u/a. On [DATE], at 5:31 PM, R6's progress notes document UA obtained and sent to lab, results pending. On [DATE], at 2:29 PM, R6's progress notes document at 1:00 PM Pt had 200 cc (cubic centimeters) of dark red urine, daughter at bed side, stated she will not wait for culture to be back and she is taking her straight to the hospital. DON (Director of Nursing) notified, proivder notified. Surveyor notes R6 had a urine analysis, and a CBC (complete blood count) lab, completed on [DATE]. The CBC from [DATE] did not show any infection. The urine culture and sensitivity results were obtained after R6 was in the hospital. R6's family member did not want to wait for the urine culture results and took R6 themselves to the hospital. R6 was diagnosed in the hospital as having a urinary tract infection with acute kidney injury and sepsis. R6 was treated in the hospital however, did not return to the facility. On [DATE], at 10:35 AM, Surveyor interviewed RN-N. RN-N stated R6 did not have any other symptoms. The medical provider ordered labs and R6 has difficult veins. R6's family wanted them to be on antibiotics. R6 did not meet the criteria for infection. R6's family did take R6 to the hospital themselves on [DATE]. R6 did not have any additional symptoms besides blood in the urine. On [DATE], at 12:46 PM, Surveyor interviewed LPN-Q. LPN-Q stated they don't recall anything related to R6 having blood in their urine. On [DATE], at 3:03 PM, Surveyor shared the concerns with R6's change of condition, delay in consultation with a medical provider and obtaining STAT ordered lab work with Director of Nurses (DON)-B, Director of Operations (DOO)-C and Assistant Nursing Home Administrator (ANHA)-D. There was no additional information provided.

Based on observation, interview and record review, the Facility did not ensure that Residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R38 & R300) of 3 Residents reviewed for pressure injuries. * The nurses note dated 12/19/23 at 9:40 a.m. documents Resident noted to have small shearing o/a (open area) under rt (right) buttock. Surveyor noted that Licensed Practical Nurse (LPN)-U nurses notes on 12/20/23 documents Assistant Director of Nursing (ADON)-C assessed the right buttock wound but there is no documented assessment in R38's medical record until 12/22/23 when R38's right ischium is a Stage 3 pressure injury. There was no treatment ordered until 12/22/23 and R38's skin/tissue integrity care plan was not revised until 1/10/24. Surveyor noted ADON-C's nurses note dated 12/29/23 does not include assessment of R38's right ischium. Surveyor also reviewed the Facility's wound management detail report and noted there is no assessment on 12/29/23 of R38's right ischium nor is there any assessment during the week of 12/24/23 to 12/30/23. On 1/5/24 R38 developed a Stage 2 pressure injury to the left heel. On 1/9/24 Surveyor did not observe a dressing on R38's right ischium and R38 was observed not wearing the green pressure relieving boots when sitting in the Broda chair. On 1/10/24, during treatment, Licensed Practical Nurse (LPN)-U indicated R38's blister to the sacrum was opened and explained there was a linear area that was open. There is no comprehensive assessment of this area to the sacrum until 1/12/24. On 1/11/24 LPN/CM-K did not apply sheet of medihoney to R38's right ischium as per MD orders. * There was no Registered Nurse (RN) assessment after R300 was admitted from the hospital on 1/7/24 when the hospital discharge summary documented a Stage 2 pressure injury. On 1/7/24 and on 1/10/24, Licensed Practical Nurses (LPNs) documented the buttock as measuring an open slit to the buttock/upper coccyx which did not include depth. On 1/12/24 when Assistant Director of Nursing (ADON)-C and Physician Assistant looked at there area there was no open area observed. Findings include: The Prevention of Pressure Injuries policy 2001 Med-Pass Inc. (Revised April 2020) documents under skin assessment documents 1. conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors and prior to discharge. Under monitoring documents 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 1. R38's diagnoses includes hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, aphasia, and diabetes mellitus. R38 had a guardian appointed in December 2022. The impaired skin/tissue integrity care plan with a start date of 6/21/23 & edited 1/10/24 documents the following approaches: * Assist with turning and repositioning every 2 hours and as needed. Start date 6/21/23 & edited 9/27/23. * Diet as ordered: NPO (nothing by mouth). Tube feeding per dietitian/MD (medical doctor). Start date 6/21/23 & edited 9/27/23. * Pressure redistributing mattress for the bed. Start date 6/21/23 & edited 9/27/23. * Pressure redistributing cushion for the wheelchair. Start date 6/21/23 & edited 9/27/23. * Specialty mattress. Start date 6/21/23 & edited 9/27/23. * Consult with in house wound nurse/NP (Nurse Practitioner) as needed. Start date 6/21/23 & edited 9/27/23. * Skin assessment weekly with bath/shower. Start date 6/21/23 & edited 9/27/23. * Use turn/draw sheet in bed to reposition and avoid friction and shearing. Start date 6/21/23 & edited 9/27/23. * Keep pressure off of heels while in bed. Start date 6/21/23 & edited 9/27/23. * Treatment as ordered per MD. Zinc topical as ordered. Start date 6/21/23 & edited 9/27/23. * Frequently reposition/off load pressure from elbows and heels. Start date 6/21/23 & edited 9/27/23. * Dietary consult as needed. Start date 6/21/23 & edited 9/27/23. * Air mattress with alternating pressure, check function every shift and post power outage. Start date & edited on 1/10/24. The Pressure injury CAA (care area assessment) under analysis of findings dated 6/29/23 documents; This is a [AGE] year old now long term resident admitted here from the hospital with diagnosis of septic shock due to a UTI (urinary tract infection). He has history of CVA (cerebral vascular accident), he is non verbal and does not respond to commands, diagnosis of aphasia an dysphagia. He has a neurogenic bladder with a chronic Foley catheter, a gastrostomy tube-NPO (nothing by mouth), type 2 diabetes on insulin, HTN (hypertension), seizures and muscle spasms. Continues antibiotic for the UTI and on vancomycin due to suspected C-diff. (cLostridium difficile) He is on a diuretic daily. He was admitted to the facility with stage 1 and 2 pressure areas to right elbow, buttocks/coccyx, heel and toe. There is also some moisture associated skin damage. He has his own teeth. Does not appear to be in pain or discomfort. He did receive lactaid ringers while in the hospital. He receives tube feedings with water flushes daily. Total staff dependent. Triggered for his total dependence, incontinence of bowel, for being at risk for skin breakdown and for the presence of stage 1 and 2 pressure areas. He is at risk for skin breakdown, infections and pain. The Braden assessment dated [DATE] has a score of 10 which indicates high risk. The quarterly MDS (Minimum Data Set) with an assessment reference date of 12/2/23, R38 is assessed for severe impairment for cognitive skills for daily decision making. Speech clarity is assessed as no speech. R38 rarely/never makes self under stood and rarely/never understands others. R38 is dependent for eating, toileting hygiene, mobility rolling left to right & transfers. R38 has an indwelling urinary catheter and is always incontinent of bowel. R38 is assessed as being at risk for pressure injuries and is checked as not having any pressure injuries. R38's physician orders include the following: * Start date 6/20/23, end date open ended House barrier cream to areas of concern to buttocks coccyx, sacral or groin for risk or treatment of skin breakdown PRN (as needed). * Start date 6/20/23, end date open ended May apply Medseptic cream to areas of concern PRN. * Start date 6/20/23, end date open ended May apply skin prep to areas of concern PRN. * Start date 8/25/23, end date open ended Apply zinc past to buttocks and sacral region for protection with cares. Special instructions: maintain skin integrity, Every shift; Day, Evening, Night. * Start date 12/22/23, end date open ended Wound to right ischium-cleanse with NS (normal saline) or wound cleanser, apply skin prep, medihoney sheet, covered with bordered foam dressing, daily and PRN. Once a day; 0700 AM- 0300 PM. * Start date 1/5/24, end date open ended Wound to buttocks - cleanse with soap and water, pat dry, apply bordered foam to bilateral buttocks for protection daily and PRN Once a day; 0630 AM - 10:00 AM. * Start date 1/5/24, end date open ended Wound to left heel - Apply skin prep to area, cover with bordered foam dressing, change 3x(times)/week and PRN, keep boots on at all times for protection Once a day on Mon (Monday), Wed (Wednesday), Fri (Friday); 0700 AM -03:00 PM. The nurses note dated 12/15/23 at 5:15 p.m. includes documentation of Resident's bottom area evaluated by PA (Physician Assistant), no open wounds noted. This nurses note was written by ADON-C. The nurses note dated 12/19/23 at 9:40 a.m. documents, Resident noted to have small shearing o/a (open area) under rt (right) buttock wound bed pale pink no drainage noted, surrounding skin wnl (within normal limit), writer washed with soap h20 (water), patted dry, and applied border foam for protection. ADON to be updated on finding to add resident to wound round list for Friday. This nurses note was written by LPN -U. The nurses note dated 12/20/23 at 8:58 a.m. documents Resident continues to be monitored for rt buttock wound, wound assessed by ADON this AM (morning). This nurses note was written by LPN -U. The nurses note dated 12/20/23 at 11:41 p.m. documents Resident noted to have small shearing o/a under rt buttock wound bed pale pink no drainage noted, surrounding skin wnl (within normal limits), border foam applied for protection, wound is clean dry and intact. This nurses note was written by LPN-BB. The nurses note dated 12/22/23 at 10:47 p.m. documents Dressing to right buttocks c/d/I (clean/dry/intact), no s/s (signs/symptoms) of pain or discomfort, VSS (vital signs stable), sleeping comfortably in his bed, will continue to monitor. This nurses note was written by LPN-H. The nurses note dated 12/22/23 at 3:47 p.m. documents Rounding done with PA (Physician Assistant). Resident has stage 3 pressure to right ischium, 3.5 x 1.5 x 0.1, light serousang drainage, edges attached, well defined, new order to cleanse with NS (normal saline) or wound cleanser f/b (followed by) skin prep, medihoney sheet, cover with bordered foam, change daily and PRN. New orders for wound to left inner eye, apply TAO (triple antibiotic ointment) cover with Band-Aid, change daily and PRN. This note was written by ADON-C. The Wound Care assessment dated [DATE] by PA (Physician Assistant)-FF under physical examination includes documentation of Patient has Broda chair. Recommended foam cushion to offload rear end. Maximum of 3 hours in wheelchair at a time. Recommend patient lay in bed between meals as tolerated. Turning/repositioning q (every) 2 hours. Back, buttock, and scrotum were examined and there are no wounds present .Stage III (3) pressure injury of right ischium. Full-thickness wound measuring 3.5 cm (centimeter) x (times) 1.5 cm x 0.1 cm consisting of 100% granulation tissue. Light serosanguineous drainage. Wound edges are attached, well defined. Periwound appears healthy. Surrounding skin is healthy. No signs of infection. Status: New. Plan: Cleanse with normal saline or wound cleanser. Skin-Prep to periwound. Apply Medihoney sheet and cover with bordered foam dressing. Change daily and as needed. Surveyor noted that LPN-U nurses notes on 12/20/23 documents ADON-C assessed the right buttock wound but there is no documented assessment in R38's medical record until 12/22/23. There was no treatment ordered until 12/22/23 and R38's skin/tissue integrity care plan was not revised until 1/10/24. The nurses note dated 12/24/23 at 1:52 p.m. documents During routine rounds resident sitting up in bed. Resp (respirations) stable, no sob (shortness of breath). Skin clean, dry, and warm to touch. Wound care provided to right buttock per order. No s/s of infection noted. No facial grimacing noting pain. No acute distress noted. Turn and repositioned prn (as needed). This nurses note was written by LPN-GG. The nurses note dated 12/25/23 at 1:16 p.m. documents Patient on board for treatment to buttock, dressing replaced and old dressing had moderate amount of [NAME]-sang drainage and wound bed was pink pearly 70% and sloughy 30%, no odor noted and no s/sx of pain during dressing change. patient has dressing to ABD (abdomen) and wound is not open to air any longer and dry scabbed area intact, area covered with dressing and foam not available, alternative dressing placed. Band-aid applied to eye area per order and we will continue treatments as ordered. Charting completed by LPN-HH. Written by ADON-C. The nurses note dated 12/27/23 at 9:29 a.m. documents Resident continues to be monitored for for wound to under rt buttock, wound bed pink with slough present, scant amount of drainage noted to dsd (dry sterile dressing) removed, surrounding skin wnl, tx (treatment) done per order. This nurses note was written by LPN-U. The nurses note dated 12/28/23 at 10:04 a.m. documents Resident continues to be monitored for left under buttock wound, wound bed superficial scant amount of slough present, scant drainage noted to dressing removed, surrounding skin wnl. This nurses note was written by LPN-U. The nurses note dated 12/29/23 at 2:45 p.m. documents Wound rounding done. Wound to left canthus (corner of eye) 0.5 x 0.5 x 0.1, scant serosanguinous drainage noted, irregular wound edges. Resident seen by dermatology today, Biopsy done, basal cell skin cancer, wound will not heal given diagnosis. New orders to cleanse with water, pat dry, apply Vaseline to open area daily x 2 weeks. Bruising and swelling to eye is to be expected, no tx needed. Seborrheic dermatitis to face, order received to wipe with Cetaphil wipes once daily. May wipe with washcloth. Continue with current treatment for wounds to right ischium and ABD. This nurses note was written by ADON-C. Surveyor noted ADON-C's nurses note dated 12/29/23 does not include assessment of R38's right ischium. Surveyor also reviewed the Facility's wound management detail report and noted there is no assessment on 12/29/23 of R3's right ischium nor is there any assessment during the week of 12/24/23 to 12/30/23. The nurses note dated 12/30/23 at 1:17 p.m. documents Resident has a wound to his buttocks, dressing to site is c/d/i, no s/s of infection, no s/s of pain or discomfort. Will continue to monitor. This nurses note was written by LPN-II. The nurses note dated 12/31/23 at 9:18 p.m. documents dressing changed due to saturation to R inner buttocks per orders, will cont (continue) to monitor. This nurses note was written by LPN-JJ. The nurses note dated 1/5/25 at 4:27 p.m. documents Wound rounding done with PA. Resident tolerated well. New wounds to left buttock. Order to apply skin prep to left heel and cover with border foam dressing 3x/week. Per PA, resident is to have his protective boots on at all times to prevent pressure to lower extremities. New order to cover wound to left buttock with border foam dressing. This nurses note was written by ADON-C The wound care assessment dated [DATE] by PA-FF under physical examination includes documentation of .Patient has Broda chair. Recommended foam cushion to offload rear end. Maximum of 3 hours in wheelchair at a time. Recommend patient lay in bed between meals as tolerated. Turning/repositioning q (every) 2 hours. Back, buttock, and scrotum were examined and there are no wounds present .Stage III (3) pressure injury of right ischium. Full-thickness wound measuring 2.5 cm x 0.4 cm x 0.1 cm, consisting of 50% epithelial and 50% granular tissue. Light serosanguineous drainage. Wound edges are attached, well-defined. Periwound appears healthy. Surrounding skin is healthy. No signs of infection. Status: Improved. Plan: Cleanse with normal saline or wound cleanser. Skin-Prep periwound. Apply Medihoney sheet and cover with bordered foam dressing. Change daily and as needed. MASD (moisture-associated skin damage) of bilateral buttocks with small wound of left buttock. Partial thickness open area measures 1.3 cm x 0.7 cm x 0.1 cm, consisting of 100% smooth pink tissue. Periwound slightly macerated. Surrounding skin is health, mildly erythematous. Status: new. Plan: cleanse with soap and water. Apply bordered foam to bilateral buttocks (for protection and to cover wound). Diligent incontinence cares for stooling. Urinary catheter in place. Stage 2 pressure injury of left heel 2.5 cm x 1.5 cm x utd (unable to determine), wound base is 70% nonblanching erythema and 30% serous filled blister. No drainage. Surrounding skin is healthy. Status: new. Plan skin prep and cover with bordered foam 3x/wk (week) and prn. Keep heel offloading boots in place at all times. On 1/9/24 at 10:48 a.m. Surveyor observed morning cares for R38 with CNA (Certified Nursing Assistant)-CC and CNA-Y. R38 was observed in bed towards the right side with the head of the bed elevated and R38's tube feeding not running. R38 was wearing green pressure relieving boots which were removed. Surveyor observed there is a foam dressing on R38's left inner heel. CNA-Y placed socks on R38 and removed the gown. CNA-CC washed R38's upper body, staff placed a shirt on R38 and lowered the head of the bed. CNA-CC placed pants up to R38's knees, the incontinence product was unfastened and a pillow was removed from the left side. CNA-CC washed R38's frontal perineal area, R38's urinary collection bag was moved from the bed frame, R38 was positioned on the right side and an incontinence product was placed under R38. Surveyor observed two foam dressings dated 1/7 on R38's sacrum. Surveyor noted there has been no previous assessment pertaining to R38's sacrum area. Surveyor did not observe a dressing on R38's right ischium. CNA-CC washed R38's rectal area & buttocks and R38 was positioned the back. CNA-CC removed her gloves, washed her hands and placed gloves on. R38's incontinence product was fastened & R38 was covered with bedding. At 11:19 a.m. CNA-CC & CNA-Y pulled up R38's pants and placed a hoyer sling under R38. At 11:22 a.m. CNA-Y informed R38 they were going to get him up into a chair. At 11:24 a.m. CNA-CC & CNA-Y hook the sling to the hoyer lift and R38 was transferred into the broda chair which is slightly reclined back. The indwelling catheter bag was hooked to the left side of the Broda chair, a pillow was placed under R38's lower extremities and R38's feet are resting on the foot portion of the Broda chair. CNA-CC & CNA-Y removed their gloves and cleansed their hands. R38 was wheeled out of the room into the lounge area. Surveyor observed neither CNA-CC or CNA-Y placed the green pressure relieving boots back on R38. On 1/9/24 at 12:46 p.m. Surveyor observed CNA-P wheel R38 out of the lounge area in the Broda chair down the hall. R38 was returned to the lounge area at 12:49 p.m. Surveyor observed R38 continues not to be wearing the green pressure relieving boots. On 1/9/24 at 12:54 p.m. Surveyor observed R38 continues to be sitting in the Broda chair in the lounge area with AC/DC music playing. Surveyor observed there continues to be a pillow under R38's lower extremities and R38's feet continue to be resting on the foot portion of the Broda chair. R38 is not wearing the green pressure relieving boots. On 1/9/24 at 1:20 p.m. Surveyor observed R38 continues to be sitting in the Broda chair with the back slightly reclined back in the lounge area. There is a pillow under R38's head and the tube feeding is covered with a pillow case. Surveyor observed R38 is still not wearing the green pressure relieving boots. On 1/10/24 at 8:30 a.m. Surveyor observed R38 in bed on his back with the head of the bed elevated. Surveyor observed R38 is wearing the green pressure relieving boots. On 1/10/24 at 9:59 a.m. Surveyor observed CNA-Y wheel R38 into the room after providing R38 with a shower. CNA-LL entered R38's room, placed gloves on and staff hooked up the Hoyer sling to the Hoyer lift. CNA-Y informed R38 he was going up and R38 was transferred into bed. CNA-LL then unhooked R38 from the Hoyer lift. On 1/10/24 at 10:04 a.m. Surveyor observed R38's treatments with LPN-U and CNA-Y. LPN-U with gloves on informed R38 she was going to do his treatments. LPN-U showed Surveyor R38's DTI (Deep Tissue Injury) on R38's left inner heel, wiped the pressure injury with skin prep, dated the foam dressing, and placed the foam dressing over the DTI. LPN-U removed her gloves, cleansed her hands & placed gloves on. Surveyor asked LPN-U how R38 developed the pressure injury. LPN-U replied I can't say but probably pressure. LPN-U informed Surveyor R38 has had boots since admission. At 10:07 a.m. CNA-Y positioned R38 from side to side to remove the Hoyer sling and then washed R38's buttocks. At 10:09 a.m. LPN-U informed Surveyor the treatment for R38's right ischium is to wash with soap & water, pat dry, apply sheet of medihoney and then bordered foam dressing. Surveyor informed LPN-U yesterday (1/9/24) Surveyor did not observe a dressing on R38's right ischium. LPN-U informed Surveyor he should of had one one. Surveyor inquired how R38 developed the pressure injury on the right ischium. LPN-U informed Surveyor she thinks it came from his brief. At 10:10 a.m. Surveyor observed LPN-U wash R38's right ischium pressure injury with soap and water, pat dry, and applied skin prep around the pressure injury. LPN-U stated looks much better and explained the wound bed is pinkish used to have slough. LPN-U asked CNA-Y if she could remove the backing off the honey dressing which CNA-Y was able to do and LPN-U placed the medihoney sheet on R38's right ischium pressure injury. LPN-U then placed a foam dressing over the medihoney sheet. At 10:13 a.m. CNA-Y applied lotion to R38's back while LPN-U removed her gloves, cleansed her hands and placed gloves on. LPN-U informed Surveyor the top one (referring to the sacrum) is skin prep and foam. Surveyor asked if the skin on the sacrum was open. LPN-U replied looks like a blister opened and explained there's a linear area that is open. LPN-U applied a foam dressing on the sacrum, removed her gloves, cleansed her hands and placed gloves on. LPN-U applied medseptic on R38's buttocks, removed her gloves, cleansed her hands and placed gloves on. LPN-U then applied a split dressing around R38's suprapubic catheter site and G (gastrostomy) tube side' CNA-Y positioned R38 on the back and finished dressing R38. On 1/10/24 at 12:29 p.m. Surveyor observed R38 sitting in a Broda chair in the room with a pillow under the left arm. The back of the Broda chair is slightly reclined back and R38 is observed wearing the green pressure relieving boots. The nurses note dated 1/10/24 at 1:13 p.m. documents Writer performed wound care to residents left inner heel, sacrum, and under rt buttock per order, left inner heal has stable DTI (deep tissue injury) skin prep applied f/b (followed by) border gauze, feet elevated on pillow while resident is up in Broda chair, and resident wears booties while in bed. Resident's sacrum wound appears to have been a blister that had popped, skin open in that area, site washed with soap and water, skin prep applied peri wound and border foam applied, under rt buttock wound bed pale pink with scant amount of slough in the middle of the wound bed, site washed with soap and water, skin prep peri wound, medihoney applied to wound bed f/b border gauze. Resident also received RSV vaccine with narn (no adverse reaction noted). This nurses note was written by LPN-U. Surveyor noted there is no RN (Registered Nurse) assessment of the sacrum until 1/12/24. On 1/11/24 at 8:33 a.m. Surveyor asked LPN/CM (Licensed Practical Nurse/Clinical Manager)-K if she goes on wound rounds. LPN/CM-K replied no. Surveyor asked who goes on wound rounds. LPN/CM-K informed Surveyor wound rounds are on Fridays. ADON-C who is new and PA-FF from [Name of medical group] do wound rounds. Surveyor informed LPN/CM-K Surveyor would like to go with her when she does R38's treatments. On 1/11/24 at 8:35 a.m. Surveyor observed R38 in bed on the right side with a pillow under R38's upper left side. The head of the bed is elevated with two pillows under R38's head. Surveyor observed R38 is wearing the green pressure relieving boots. On 1/11/24 at 10:30 a.m. Surveyor observed CNA-LL, CNA-I and LPN/CM-K in R38's room. LPN/CM-K informed Surveyor staff had washed R38 up. CNA-I informed R38 they were going to turn him as the nurse needs to see your bottom. LPN/CM-K asked if R38's dressings were off. CNA-I replied she took them off because he had pooped. LPN/CM-K informed Surveyor she had already washed her hands, placed gloves on, wet a wash cloth and washed R38's sacrum area. Surveyor showed LPN/CM-K R38's pressure injury on the sacrum and asked LPN/CM-K if the area was open. LPN/CM-K replied yes and a little mascerated there. LPN/CM-K applied a foam dressing on the sacrum, removed her gloves and cleansed her hands. At 10:37 a.m. LPN/CM-K asked CNA-I if washed right ischium with soap & water. CNA-I replied yes. LPN/CM-K applied a foam dressing over the right ischium stating she thinks it needs a little calcium alginate and will let ADON-C know. LPN/CM-K then asked why the medihoney is in here (located on bedside dresser), stating didn't the treatment say wash with soap and water. LPN/CM-K removed her gloves, gathered the garbage, CNA-I reminded LPN/CM-K about a sheet and LPN/CM-K left R38's room. Surveyor noted LPN/CM-K did not follow R38's physician order for the treatment of the right ischium as LPN/CM-K did not apply a medihoney sheet over the pressure injury. On 1/11/24 at 12:35 p.m. Surveyor observed R38 in bed on his back with the head of the bed elevated, there is a pillow under the left arm and a pillow under the right arm. R38 is wearing the green pressure relieving boots, the tube feeding of Glucerna 1.5 is running at 98 ml (milliliters) and the urinary collection bag is in a blue bag on the left side of the bed frame. The nurses note dated 1/11/24 at 3:11 p.m. documents Dressing changed to sacral area by writer this morning. Compared to previous notes writer feels wound worsening. Sacral wound measures 4.0 x 1.3. Wound bed appears to be slightly marbled with white slough and pink tissue. Dark purple area to left lateral part of wound and edges lifting. Additional small purple area to the left of open area measuring 1.5 x 1.5. Skin toward anus is slightly macerated. Areas to left ischium drying up. One small area remains slightly open with scant amount of bleeding noted. Attempted HUCU (phone app) with [Name] NP but rounding at this time. Writer contacted [Name] NP who ok'd to change TX to sacral area to wash with soap and water, pat dry. Skin prep surrounding edges. Apply medihoney to wound bed followed by calcium alginate. Also to start MVI (multivitamins) with minerals via tube to promote wound healing along with his current order of Prosource. Patient remains on pressure re-distributing air mattress. Writer asked CNA's to keep patient in bed with frequent repositioning. This nurses note was written by LPN/CM-K. The nutrition note dated 1/11/24 at 3:22 p.m. documents RD (Registered Dietitian) TF (Tube Feeding) and wound review. Resident currently receiving Glucerna 1.5 with Feedings at 1000 and 1800 (6:00 p.m.) for 4 hrs (hours) and 2400 (12:00 a.m.) for 8 hrs. Rate 98mL (milliliter)/hr with 150 mL water flushes before and after each feeding. Tube feed provides 2352 kcals (kilocalories), 129.6g (gram) pro (protein), and 1188 mL free water plus 900 mL water flushes. Blood sugars are stable. ht (height): 71, wt (weight): 191 lbs (stable), BMI (body mass index): 25.9. Resident has multiple wounds (R. buttock, L heel, MASD of L buttock, abscess of L upper abdomen). TF is providing adequate nutrition to meet calorie needs. Currently receiving Prosource BID (twice daily), recommend adding 30 mL more Prosource daily, providing 30 mL Prosource TID (three times daily) with each feeding. This nutrition note was written by Dietician-KK. The nurses note dated 1/12/24 at 9:30 a.m. recorded as late entry on 1/13/24 at 9:33 a.m. documents Wound rounding done with PA. Resident has new wound to sacrum, unavoidable DTI, order to cleanse with NS or wound wash, apply skin prep, cover with bordered foam dressing, change daily and PRN. This nurses note was written by ADON-C. The wound care assessment dated [DATE] by PA-FF under interventions in place documents Reposition in bed every 2-3 hours. Recommend patient lay in bed between feeds as able-though there is only a small window in which patient is able to lay flat. Maximum 3 hours up in wheelchair at a time. Recommend roho WC (wheelchair) cushion in Broda. Bariatric AP mattress now in place. Under physical examination includes documentation of .Stage III (3) pressure injury of right ischium. Full-thickness wound measuring 0.6 cm x 0.3 cm x 0.1 cm, consisting of 100% subcutaneous tissue. Light serosanguineous drainage. Wound edges are attached, well-defined. Periwound appears healthy. Surrounding skin is healthy. No signs of infection. Status: improved Plan Cleanse with normal saline or wound cleanser. Skin -prep to periwound. Apply medihoney sheet and cover with bordered foam dressing. Change daily and as needed. MASD of bilateral buttocks with small wound of left buttocks. Healed. Pressure injury of left heel -DTI (deep tissue injury) (previously was a stage 2 now appears to have a purple hue) unavoidable. 1.5 cm x 0.8 cm x utd, wound base is purple DTI with overlying intact skin. No drainage. Surrounding skin is healthy. Status: stable-measurements improved but now appears to have purplish hue - considered a DTI. Plan: skin prep and cover with bordered foam 3x/wk and prn. Keep heel offloading boots in place at all times. DTI of sacrum - unavoidable 3.5 cm x 4 cm x UTD, wound base is 100% purple DTI with scant serosanguineous drainage. Wound edges are well-defined. Surrounding skin appears healthy, pink, dry. No signs of infection. Status: New-unavoidable-all protective measures are in place. Plan: Cleanse with NS or wound cleanser. Skin prep intact skin. Apply bordered foam - change daily and PRN. Under assessment includes documentation of Care plan discussed with wound RN (Registered Nurse). Will continue to assess weekly. Patient with multiple comorbidities and multiple risk factors for developing and worsening of pressure injuries. Interventions consistent with individual needs, goals and standards of care have been implemented. Revisions to interventions were made as appropriate. Sacral DTI and heel DTI are considered unavoidable and patient is at risk for further worsening or development of additional areas. Unfortunately due to patient's frequent tube feeding he is unable to lay down flat in bed except for a small window of time during the day. He is on bariatric AP mattress and turning schedule is in place, but there is significant pressure to his sacral region because he sits up 30 degrees for the majority of the day. Surveyor was unable to observe R38 on 1/16/24 as R38 had been discharged to the hospital. On 1/16/24 at 12:35 p.m. Surveyor asked ADON-C how she becomes aware if a Resident develops a pressure injury. ADON-C explained if the CNA observes the pressure injury they will either tell the nurse or her. ADON-C informed Surveyor she will go in and look and then will be in contact with the PA who does their wounds. The PA will give her a treatment and then when the PA comes in on Friday they will look at the wound together. They may keep the treatment or change the treatment depending on what the wound look like. Surveyor asked ADON-C when does she go in to assess a pressure injury. ADON-C informed Surveyor usually as soon as she can. ADON-C explained a lot of times they find wounds on the skin sheet so she'll run down when they are doing cares so she doesn't have to disturb the Resident. Surveyor asked if the PA comes every week. ADON-C replied yes on Friday except one week she was on vacation. Surveyor inquired when this was. ADON-C informed Surveyor she thinks it was the week between Christmas and New Years. ADON-C stated I think it was the 29th then stated it was the 29th. Surveyor asked ADON-C if she did wound rounds on 12/29/23. ADON-C replied I did. Surveyor informed ADON-C Surveyor noted an assessment for wound by R38's eye but did not see an assessment for R38's right ischium. Surveyor informed ADON-C R38 developed an open area on the right ischium on 12/19/22 but there was no RN assessment until three days later on 12/22/23. Surveyor informed ADON-C of the observation of R38's open area on the sacrum on 1/10/23 but there is no RN assessment until 1/12/24. ADON-C informed Surveyor she probably didn't put a note in. Surveyor informed ADON-C of the observation of R38 without a dressing on the right is [TRUNCATED]

Based on a complaint received at the Southeastern Regional Office, interview, and record review the Facility did not ensure 2 (R1 & R3) of 3 Residents needing care and treatment of [REDACTED]. * On 7/21/19 an order was requested for calcium alginate PRN (as needed) to R1's 3 and 4th toe for drainage. There was no Registered Nurse (RN) assessment of the area to R1's 3rd and 4th toes. On 7/23/19 Licensed Practical Nurse (LPN)-D documents maceration between R1's 3rd & 4th toes. This was the first note regarding maceration and there was no RN assessment. On 8/19/19 the ulcer to R1's 3rd and 4th toe looked worsened, and there were multiple areas around toes where skin is starting to breakdown and were red in appearance. There was no comprehensive RN assessment including measurements of the area. On 8/21/19 LPN-D documents R1's right 3rd medial toe open area measuring 0.7 x (times) 0.5. Wound bed 100% slough. Edges slightly macerated. Toe slightly red. No increased warmth. Slit behind 4th toe in the crease measuring 1.0 x 0.8. This was the first measurement of R1's right toes and there was no RN assessment. On 8/24/19 the nurses notes indicate R1's wound bed between the 3rd and 4th toes appeared larger with 100% slough. There was no RN assessment and R1's physician was not notified. R1 was hospitalized from [DATE] to 9/12/19. During hospitalization R1 was found to have significant osteo[DIAGNOSES REDACTED] of the third and fourth right toes and required amputation of these toes. * R3 was admitted to the facility on [DATE] with arterial wounds on four toes. The Admission Body Observation documentation dated 9/18/19 indicates R3's right great toe, right 2nd toe, left 3rd & 4th toes have scabs/necrotic tissue. There were no measurements of R3's toes until 9/25/19, eight days later. Findings include: 1. R1's [DIAGNOSES REDACTED]. The potential for impaired skin/tissue integrity with a problem start date of 03/04/2014 & edited 10/1/2019 documents approaches with a start date of 3/4/2014 and edited 8/24/19 of; When resident is out of bed, encourage to change position every 2 hours by toileting, boosting, shifting of weight, ambulating, or returning to bed for rest. Encourage to adequate fluid intake. Assess and record [MEDICAL CONDITION]. Skin assessment weekly with bath/shower. Monitor skin daily and report any red or open areas. Consult in house wound care nurse as needed. Pressure relieving mattress for the bed. Pressure relieving cushion for the wheelchair. Assist rail to the outside of her bed to assist herself with repositioning while in bed. Provide incontinent protection and apply house barrier cream after incontinent episodes as needed. Use of left grab bar for (R1) to promote increased independence with bed mobility. Keep bed sheets loose at night to minimize touching with history of PAD (peripheral artery disease), and leg pain. Diet as ordered: reg (regular)/gen (general), Treatment to right foot per MD order, til closed. The nurses note dated 7/16/19 documents, Redness to right foot traveled up to ankle area. All toes swollen. States painful. Middle toe a light purple. T (temperature) 98.2. Red area slightly warmer to touch. Optum NP (nurse practitioner)-C updated. Ordered CBC (complete blood count) w/ (with) Diff (differential) and BMP (basic metabolic panel) and to start [MEDICATION NAME] (antibiotic) 100 mg (milligrams) BID (twice daily) x (times) 10 days and [MEDICATION NAME] BID x 20 days. Patient does not wish for daughter to be updated stating, don't bother her with that. Initial dose of ABT (antibiotic) started at lunch time for what appears to be [MEDICAL CONDITION]. The annual MDS (Minimum Data set) with an assessment reference date of 7/17/19 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R1 requires supervision with set up help only for transfers, independent with set up help only for bed mobility & bathing, does not ambulate and is independent with no set up help for hygiene. R1 is coded 0 for the number of venous and arterial ulcers. The Optum note dated 7/18/19 under additional notes documents Toenail to second toe, right foot missing. Dressing present, clean, dry and intact. Right foot swollen, red, and painful. The nurses note dated 7/21/19 documents, Cont (continue) on ABT for [MEDICAL CONDITION], rt (right) foot remains red. Fax out to NP-C to request calcium alginate as need to 3 and 4th toe for drainage. This nurses note was written by RN (Registered Nurse)-E. Surveyor noted there is no assessment of the area and/or measurements for the area that is draining. On 10/2/19 at 12:00 p.m. Surveyor spoke with RN-E on the telephone regarding her nurses notes dated 7/21/19. Surveyor asked RN-E if the drainage was new and Surveyor wasn't able to locate a comprehensive assessment. RN-E informed Surveyor she is guessing there was increased drainage or the dressing was saturated and asked for the treatment. RN-E also indicated Optum NP-C may have said if there is an increase in drainage add calcium alginate. The nurses note dated 7/22/19 documents New order to add calcium alginate PRN (as needed) for drainage between 3-4 toes. This nurses note was written by LPN (Licensed Practical Nurse)-D. On 10/2/19 at 12:12 p.m. Surveyor spoke to LPN-D to inquire if the drainage documented on 7/22/19 was new. LPN-D informed Surveyor it must have been and must of gotten a fax back. The nurses note dated 7/22/19 documents, ABT [MEDICAL CONDITION] right foot. No adverse reactions noted. Afebrile. Toes slightly swollen and remain red. Redness travels up to about top of mid foot. Denies pain at time of assessment. Optum NP in to see her this morning and did check out her foot as well, no new orders. Surveyor was unable to locate an Optum note. The nurses note dated 7/23/19 documents, ABT/[MEDICAL CONDITION] right foot. Drainage continues between 3rd and 4th toes which appear slightly macerated between. Washed and dried and calcium alginate applied between. Foot wrapped w/(with) Kerlix to deter patient from picking at it and applying her various lotions in her room which she tends to do. All toes slightly red and slightly swollen. C/O (complained of) pain to foot 3/10 this morning and refused to take anything extra than her scheduled Tylenol. This nurses note was written by LPN-D. Surveyor noted this is the first note regarding maceration and there is no measurement of the area or RN assessment. The nurses note dated 7/24/19 documents, ABT [MEDICAL CONDITION] right foot. No adverse reactions noted. Afebrile. Toes less swollen, slightly red. Moisture/maceration remains between 3rd and 4th toes. No c/o pain. This nurses note was written by LPN (Licensed Practical Nurse)-D. Surveyor noted there are no measurements or RN assessment. The nurses note dated 7/25/19 documents, F/U (follow up) ABT [MEDICAL CONDITION] right foot. Swelling almost completely resolved. Slight redness to all toes, no increased warmth. Continues to have slight maceration, moistness between 3rd and 4th toes. Tx (treatment) as ordered and PRN calcium alginate applied. Denies any pain at time of assessment. LSC (lung sounds clear). No SOB (shortness of breath). Skin warm, slightly dry and pink. Oral mucosa slightly dry. Fluids encouraged. Appetite usually good. Frequently incontinent of urine and occasionally of bowel. ABD (abdomen) soft, non tender. BS (bowel sounds) active. Attends activities of choice. Can become easily agitated, not always that pleasant w/ staff and peers. Tends to dwell on health issues. Family supportive and visit often. Is in a pleasant mood this morning. Denies pain and voices no complaints at this time. The nurses note dated 7/31/19 documents, F/U (follow up) fall. No apparent injury noted. VSS (vital signs stable) as charted. No issues from fall, however on the call light this morning asking to speak w/ (with) the nurse. Asks when is someone going to do something about this foot? Then stated she should go to the hospital, Pertaining to her right foot. Just completed ABT/[MEDICAL CONDITION]. Today foot appears slightly more swollen again and slightly red as well. No increased warmth. Optum NP-F in to see her. Optum NP-F stated this appears more vascular than infection. Ordered to increase [MEDICATION NAME] to TID (three times daily) and stated she will bring in her portable doppler. After complaining of pain to right foot and wanted to go the hospital early morning, Med tech offered PRN Tylenol at breakfast and she declined stating she didn't need it. Surveyor was unable to locate an Optum note. Surveyor reviewed R1's (MONTH) 2019 TAR (Treatment Administration Record). Under start/end date documents 07/22/19 - 08/06/2019 Under order documents, [MEDICATION NAME] to 2nd and 5th toes on right foot f/b dry dressing BID until resolved, may add calcium alginate PRN for drainage between 3-4th toe. Under time documents 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM. Surveyor is unable to determine when R1 received calcium alginate as the order for [MEDICATION NAME] BID is written together with calcium alginate PRN. The nurses note dated 8/6/19 documents, N.O. (new order) to dc (discontinue) [MEDICATION NAME] to 2nd and 5th toe. Continue to cleanse between 3rd and 4th toe and apply cal (calcium) alg (alginate) until resolved. Surveyor was unable to locate an assessment of R1's right toes including measurements of the area that is draining. The Optum note dated 8/7/19 documents, R1 is a [AGE] year old female who was sitting in her room at the time of the monthly physical exam. Member was pleasant, and cooperative during assessment. Denies health complaints. Medications and chart reviewed. Staff without concerns at time of exam. Member is compliant with medications and treatments. Under physical exam for foot exam documents Foot Exam: Assessed No deformities: Yes No Evidence of Infection: Yes. The nurses note dated 8/12/19 documents, Pt. (patient) states no injury from fall, bruising noted to shoulder. Denies pain from fall. Writer asked what happened and she stated I was trying to get up and my wheelchair wheel was not locked, I told them I didn't want that chair. That's the reason I fell . Later at end of shift came up to writer and stated I need to go to the ER (emergency room ). Writer asked why. She states My foot, I don't know what's wrong with it. Writer asked what pain level and for her to describe the pain. Its nothing anyone can fix. Writer asked if she wanted pain medication and she refused. Encouraged her to elevate her foot on pillows and she refused. She mumbled something under her breath and wheeled herself down hall. Was noted to go into her room and slam door. No further complaints. This nurse note was written by LPN-[NAME] On 10/2/19 at 12:36 p.m. Surveyor spoke with LPN-G on the telephone regarding her nurses note dated 8/12/19. Surveyor read LPN-G her nurses note and asked LPN-G if she looked at R1's toes/foot. LPN-G informed Surveyor she looked at R1's foot when R1 stopped her in the hall way about going to the hospital. LPN-G informed Surveyor her foot looked red but didn't document because it didn't have anything to do with her fall. The nurses note dated 8/19/19 documents, Noted during dressing change this shift that ulcer to R (right) 3rd and 4th toe looks worsened, and there are multiple areas around toes where skin is starting to breakdown and are red in appearance. Writer has instructed res (resident) to keep R shoe off since Friday to relieve pressure to toes and prevent moisture but res has been non-compliant. Is often non-compliant with going to apts (appointments) and treatments r/t (related to) feet. Writer asked why she was continuing to wear tight fitting shoes that places pressure on affected toes but res did not answer. Optum NP-C here and wrote new order to R foot to cleanse foot with soap and water and dry well. Then calcium alg (alginate) between toes and prn for increased drainage. Weave gauze loosely and cover with Kerlix. Change daily and PRN, given in report to next nurse who will enter order into TAR (treatment administration record). This nurses note was written by RN-E. Surveyor was unable to locate an Optum note and there is no comprehensive assessment including measurements of R1's toes. On 10/2/19 at 12:00 p.m. Surveyor spoke with RN-E on the telephone regarding her nurses note dated 8/19/19. Surveyor asked RN-E if Optum saw R1 on 8/19/19 when she documented R1's ulcer are worse. RN-E informed Surveyor the Optum nurse was there but can't say 100% if she looked at R1. RN-E indicated she believes the Optum nurse did see R1 but she didn't follow her and she is usually doing her med pass when the Optum nurse is there. The nurses note dated 8/21/19 documents, Right foot wounds: 3rd medial toe open area measuring 0.7 x (times) 0.5. Wound bed 100% slough. Edges slightly macerated. Toe slightly red. No increased warmth. Slit behind 4th toe in the crease measuring 1.0 x 0.8. Areas tender when writer washing. Current TX (treatment) to wash and dry and apply calcium alginate FB (followed by) weaving gauze between remaining toes then wrap. Has been compliant w/not wearing shoes. Appetite good. Fluids encouraged. Will update Optum NP regarding condition of foot w/suggested TX. This note was written by LPN-D. Surveyor noted this is the first measurement of R1's right toes and there is no RN assessment. Surveyor noted the 8/21/19 fax to Optum NP-C includes LPN-D's nurses note dated 8/21/19 along with a handwritten notation of Optum NP-C (first name) Would like to change order to cleanse open areas to (R) (right) foot with soap and water. -Apply skin prep to periwound on 3rd medial toe - FB (followed by) [MEDICATION NAME] to wound bed FB calcium alginate FB small piece of foam - apply calcium alginate to slit to posterior 4th toe wrap foot with kerlix for protection change daily. There is a response from Optum NP-C which documents, Agreed. The nurses note dated 8/22/19 documents, Patient requested PRN Tylenol #3 early this morning for c/o pain to right foot 8/10. Did not show up at breakfast her normal time and CNA (Certified Nursing Assistant) went to answer call light. Sister was in the room and patient on the phone. Apparently R1 was calling her daughter telling her no one was doing anything about her pain and she needed to go to the hospital. Writer contacted Optum NP-C to update. Patient has days where she denies any pain then 1/2 hour later is c/o pain and states no one cares or is doing anything. Was supposed to have appt. (appointment) re STENT placement and patient canceled on her own. NP-C from Optum spoke w/R1's daughter and both agreed it is time to have R1 evaluated for competence to make health care decisions. Dressing changed per new order today. Slight odor detected today. Optum NP-C will be in to see R1 today. Surveyor was unable to locate an Optum note dated 8/22/19. The nurses note dated 8/24/19 documents, Denies dysuria. Dressing changed to right foot per orders. Denies pain during TX. 3rd and 4th toes slightly purple in appearance today. Slight swelling to all toes. Wound bed between 3rd and 4th toes appear larger, 100% white slough. Patient scheduled for appt (appointment) on Tuesday w/ cardiologist regarding STENT placement. Writer feels wounds will not improve w/her circulatory issues. Sisters in room during dressing change, scolding her for canceling her last appointment. Sisters and staff noted R1 becoming more and more forgetful. Will continue to monitor. Surveyor noted this nurses note documents the wound bed is larger but there are no measurements nor is there an RN assessment or notification of R1's physician. On 10/2/19 at 12:50 p.m. Surveyor spoke with Interim DON (Director of Nursing)-B regarding R1. Surveyor asked if there was an RN assessment on 8/24/19. Interim DON-B informed Surveyor RN-Q saw R1's foot. Surveyor informed Interim D ON-B there is no documentation in R1's medical record regarding an RN assessment or R1's physician was notified. Interim DON-B informed Surveyor she thinks RN-Q may be in the building. On 10/2/19 at 1:07 p.m. Surveyor spoke with RN-Q. Surveyor asked RN-Q if she did an assessment on 8/24/19. RN-Q informed Surveyor she doesn't know anything about the 24th. The nurses note dated 8/25/19 documents, Dressing changed to right foot this morning per order. Wounds all around appearing worse, spreading. Almost appears to be some necrotic tissue forming between 3rd and 4th toe. All toes appear purple and traveling up foot. Foot cool to the touch. No pedal or popiteal pulses palpated. Writer had RN in building assess as well. On call Optum NP-H called and updated. Ordered to send to ER (emergency room ) for eval (evaluation) and TX. Optum NP stated she will call and update daughter and hospital for report. Sister here for a visit and aware. All VSS (vital signs stable) as charted. The nurses note dated 8/25/19 documents, Ambulance arrived to pick up R1. Paramedic assessed foot and at that time appeared much less swollen, red (not purple) and he was able to palpate pulse immediately. Paramedics informed patient that LMC was not accepting ambulances at this time as they are full. Both sisters here at that time and decided instead of ambulance they would take R1 to BHM walk-in/ER. R1 wanted to go to Burlington as this is where her cardiologist is out of. Writer did leave message w/ Optum NP to update on R1 going to Burlington instead. Writer did speak w/ daughter about today's events. The nurses note dated 8/25/19 documents, Returned from ER with sisters at 1640 (4:40 p.m.), paper work with order for [MEDICATION NAME] 1-2 tablets every 4 hours PRN. No script sent. Call out to pharmacy, script was sent directly to them. Auth (authorization) requested for the [MEDICATION NAME]. Rates pain 6/10 to the right foot. PRN Tylenol #3 given for pain. States ER MD told her that her foot would be okay until she goes to her appt on Tuesday. On 10/2/19 at 1:07 p.m. Surveyor spoke with RN-Q. RN-Q informed Surveyor she was working on the rehab unit and was asked to see R1 on 8/25/19. RN-Q informed Surveyor she observed R1's foot which was reddish purple, cool, and she couldn't palpate a pedal pulse. RN-Q indicated she asked LPN-D if R1's foot was worse which LPN-D said yes. RN-Q informed Surveyor it wasn't appropriate for R1 to wait 2 days for her appointment. RN-Q informed Surveyor she knew LPN-D was going to call the doctor, send R1 out and beyond this she's not sure. RN-Q informed Surveyor she went back to the rehab unit. Surveyor asked RN-Q if she documented her assessment. RN-Q replied, I did not. The nurses note dated 8/26/19 documents, Seen this am by NP-C from Optum. NP assessed foot during dressing change and stated it appears to be improving. PRN Tylenol 3 given for pain to R foot that was somewhat effective. Will cont. (continue) to monitor. The Optum note dated 8/26/19 under assessment & plan documents for diagnostic statement Non-pressure chronic ulcer of other part of right foot with unspecified severity. Under plan documents, Arterial ulcer present between 3rd and 4th toe on right foot. Wound appears slightly larger. Wound bed with approximately 5% necrotic tissue, 95% slough. Peri-wound red with some maceration due to amount of drainage. Pedal pulse barely palpable. Extremity cool to touch. Does have appt with cardiology 8/27/19. Treatment consists of cleansing with normal saline, pat dry. Skin prep peri wound. Apply [MEDICATION NAME] f/b alginate twice daily. The nurses note dated 8/27/19 documents, Wound care done per orders this shift, wound between 3rd and 4th toes appears worse than when writer last assessed and had foul smell to it. Moderate amount of drainage noted to dressing when taken off. [MEDICATION NAME] given for pain, res appeared sleepy after receiving. Sisters here for part of dressing change and informed writer that they did not believe ER visit did much to benefit res and that staff did not check between her toes. Also stated ER staff had difficult time finding pedal pulse even with doppler and stated the ER MD thought the veins must be experiencing spasms. Top of 3rd and 4th toes and surrounding skin is purple in color and blanchable. Pt. (patient) has apt with cardiology this afternoon. This nurses note was written by RN-E. Surveyor noted this is not a comprehensive assessment as there are no measurements or description of the wound bed. In addition there is no evidence the Optum NP or R1's physician was notified of the decline. On 10/2/19 at 12:00 p.m. Surveyor spoke with RN-E on the telephone regarding her nurses note 8/27/19. Surveyor asked RN-E about her note dated 8/27/19 when she documented the area between the 3rd and 4th toe was worse did she contact the Optum NP or R1's physician with the decline. RN-E informed Surveyor she didn't know and was hard to tell. RN-E informed Surveyor the Optum nurse comes in a couple times a week and she can't say 100% she notified the Optum nurse or physician. The nurses note dated 8/27/19 documents, Returned from appt with cardiologist NP, note written as critical limb ischemia. Call received from clinic with new orders, Angiogram (x-ray of blood vessels with dye) scheduled for 8/30/19, to hold [MEDICATION NAME] for 2 days, losartan until after procedure and to do daily weights and BP (blood pressure) BID (twice daily) which need to be called to clinic on Thur (Thursday) 8/29/19 . BMP (basic metabolic panel) also to be done 8/29/19. Kidney functions are elevated which is why the hold on the [MEDICATION NAME] and losartan and BMP draw. This has been explained to resident who has been in contact with sisters. She is also attempting to arrange transport by sisters to procedure. The nurses note dated 8/28/19 documents, Weekly Wound Documentation: arterial area noted between 3rd and 4th toe of left foot. Writer and NP from Optum had looked at area on Monday this week and no necrotic or purple tissue but presents today with no drgs (dressing) in place since saw md (medical doctor) yesterday. patient reports the doctor took off the drsg at appointment and didn't rewrap it. drsg (dressing) between the toes was still present, saturated with serious drainage. wound continues with foul odor. increase swelling to top of right foot, bilat (bilateral) ankles and redness to top of right foot from toes to mid foot, no warmth. wound appears larger much of wound base with yellow slough and rim of wound with purple discoloration. small amount of brown necrotic tissue to plantar part of 4rd toe. also noted appeared like small fissure to skin on lateral side of foot, but brown necrotic scab to area. area measures 0.5 x 1.5 swabbed with [MEDICATION NAME]. 5th toe on right foot with pale yellow discoloration just near the toenail. writer washed foot with soap and water, current tx of medical grade honey f/b cal (calcium) alg (alginate) and dry drsg. patient with some discomfort with cleansing the wound. Patient reports the new pain med is helping the pain but also making her a bit tired, and staff noticing increase confusion and slurred speech at times. reports she slept all night till 630 in the morning. writer responded that is good but she responded not too good to be soaked in the morning. Writer updated NP-C from Optum on the condition of the wound this afternoon she will be in in the morning to check it out. patient going for angio (angiogram) on the 30th. The Optum note dated 8/29/19 documents, Spoke with: Interim DON (Director of Nursing)-B. Under clinical note documents, NP updated that wound to 3rd and 4th toe has worsened. Resident now with area to tip of 5th toe yellow in color. Looks as though it will eventually open up. Also has fissure like area to lateral side of right foot. Treatment changed to [MEDICATION NAME] f/b alginate. Resident is scheduled to have angiogram with stenting in RLE (right lower extremity) tomorrow (8/30/19) at 4pm at St. Luke's. It is anticipated resident will be kept overnight due to procedure taking place late in the day. The nurses note dated 8/30/19 documents, Resident slept well during the night with no c/o pain or discomfort. VSS as charted Angiogram appt today . R1 was hospitalized from [DATE] to 9/12/19. The hospital discharge summary dated 9/12/19 under discharge [DIAGNOSES REDACTED]. Seen by wound care and podiatry consulted. Patient underwent abscess drainage but was found to have significant osteo[DIAGNOSES REDACTED] of the third and fourth right toes and required amputation, 9/8/2019. Primary closure today. No further ABX (antibiotic) on discharge. The nurses note dated 9/12/19 documents VS (vital signs) as charted, arrived back at the facility at 1520 (3:20 p.m.) via ambulance transport. 2 assist to pivot from gurney to bed. Happy to be back from in the facility. Son arrive with res (resident) then sisters came later. Optum nurses also in to see res, they removed dressing to right foot then applied new dressing. Sutures in place between toes where 3 and 4th toes amputated. No drainage noted. Physician-N in seeing Physician-O's patients, he was able to review orders. Copy left in chart for Physician-O to review as well when he comes in tomorrow. Has denied any pain to foot thus far this shift. The Optum note dated 9/12/19 documents, R1 is an [AGE] year old female being seen for post hospital follow up for acute on chronic diastolic heart failure (now resolved), [MEDICAL CONDITION], and amputation. On 8/30/19 resident underwent [REDACTED]. During observation post procedure, resident with noted shortness of breath and [MEDICAL CONDITION], therefore she was admitted as an inpatient for further observation and testing. It was determined she was in acute on chronic heart failure exacerbation due to withholding of [MEDICATION NAME] prior to procedure. She was followed by nephrology/cardiology and placed on [MEDICATION NAME] drip with [MEDICAL CONDITION] and SOB slowly improving. Weight decreased. Ulcers between the 3rd and 4th toe on right foot appearing to worsen. Wound was foul smelling with [DIAGNOSES REDACTED]. She was started on [MEDICATION NAME] for suspected osteo[DIAGNOSES REDACTED]. MRI unable to complete due to history of stenting. CT scan was completed of which did not show any obvious signs of osteo[DIAGNOSES REDACTED]. Physician-P with podiatry and wound care consulted. Abscess drained but was found to have significant osteo[DIAGNOSES REDACTED] of the third and fourth right toes. She underwent amputation on 9/8/2019. Wound was initially kept open. Sutures placed prior to discharge back to [MEDICATION NAME] Lake Manor on 9/12/19. Resident denies any current complaints. She states she has no pain. Meds, chart and labs reviewed. Resident is compliant with medications. On 10/1/19 at 11:13 a.m. Surveyor spoke with R1. R1 informed Surveyor she has two toes missing. Surveyor asked R1 what happened. R1 informed Surveyor her toes got infected but she wasn't sure how it happened. On 10/1/19 at 2:39 p.m. Surveyor telephoned Physician-P and spoke with his medical assistant who informed Surveyor Physician-P was with patients and would call Surveyor back. Physician-P did not call Surveyor back. On 10/2/19 at 8:19 a.m. Administrator-A informed Surveyor there are no policies and procedures for non pressure areas and the other policies are for pressure ulcers. The Facility did provide Surveyor with a Wound Care policy and procedure from Med-Pass revised (MONTH) 2010 which provides guidelines for providing care of a wound. Surveyor noted under documentation section documents; The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e. wound bed color, size, drainage, etc) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason(s) why. 10. The signature and title of the person recording the data. On 10/2/19 at 12:12 p.m. Surveyor spoke to LPN-D. Surveyor informed LPN-D she has multiple notes written including 7/23/19, 7/24/19, 8/21/19 & 8/24/19 regarding maceration, drainage, and asked if she had an RN assess the area between R1's 3rd and 4th toes. LPN-D informed Surveyor she would have brought this up during the stand up meeting in the morning around 10:00 a.m. On 10/2/19 at 12:50 p.m. Surveyor spoke with Interim DON (Director of Nursing)-B regarding R1. Surveyor showed Interim DON (Director of Nursing)-B R1 July's 2019 TAR where calcium alginate prn was added to the twice daily [MEDICATION NAME]. Surveyor inquired how would Interim DON-B be able to determine when staff applied calcium alginate due to drainage. Interim DON-B informed Surveyor she will look into this and get back to Surveyor. Surveyor informed Interim DON-B when the treatment was requested on 7/21/19 Surveyor was unable to locate an RN assessment of the area. Interim DON-B informed Surveyor she doesn't see one. Surveyor informed Interim DON-B the nurses notes on 7/22/19, 7/31/19 & 8/12/19 references Optum NP seeing R1 but Surveyor was unable to locate any Optum notes. On 7/31/19 the nurses note reference the Optum NP will bring in a portable doppler and inquired if this was done. Interim DON-B informed Surveyor she would look into these dates and get back to Surveyor. Surveyor asked Interim DON-B if there is any RN assessment for 8/12/19 & 8/21/19. Interim DON-B informed Surveyor she wasn't in the building on 8/21/19. On 10/2/19 at 2:09 p.m. Interim DON-B informed Surveyor for the calcium alginate prn order 7/22/19 she can't say when the treatment was applied and is going to alter the way treatments are put in. Optum NP-F is locked out of her computer so Interim DON-B doesn't have any information on whether Optum NP-F brought in the portable doppler and if there is a note on 7/31/19. Interim DON-B informed Surveyor she spoke with Optum NP-C who informed her that sometimes she (Optum NP-C) eye balls R1 but doesn't always make a note. Interim DON-B informed Surveyor there isn't an Optum note for 7/22/19. Interim DON-B informed Surveyor on 8/19/19 Optum NP-C did give the order and eye balled R1 but there isn't a note. Interim DON-B informed Surveyor she did speak with RN-R and asked her if LPN-D asked her to look at R1 on 8/24/19. RN-R informed Interim DON-B she couldn't recall. Surveyor asked Interim DON-B if there was any additional information regarding R1 for Surveyor. Interim DON-B replied no. 2. R3 was admitted to the facility on [DATE] with heart failure, [MEDICAL CONDITION], severe [MEDICAL CONDITIONS], diabetes mellitus. R3 was admitted with arterial wounds on four toes. The Admission Body Observation form dated 9/18/19 under the skin section for describe any additional body marks documents, open areas on BL (bilateral) buttocks surrounded by dry pealing skin, left anterior shin 4 scabs, 2 scabs rt (right) chest just below shoulder, rt great toe and 2nd digit scab/necrotic tissue, left 3rd and 4th goes scab/necrotic tissue. The nurses note dated 9/19/19 documents, MD ok med septic to open areas on left buttocks with cares. Also ok order for [MEDICATION NAME] to left 2nd, 3rd toe. Right great toe & 2nd toe. Order to pain (paint) with [MEDICATION NAME]. Note. Implemented. The nurses note dated 9/22/19 includes documentation of areas to buttocks scabbed and almost resolved. Medseptic is being applied. [MEDICATION NAME] arterial areas to toes. [MEDICAL CONDITION] noted to BLE (bilateral lower extremities).

Based on observation, interview and record review, the facility did not ensure that 1 out of 13 residents reviewed (Resident #8) was free from abuse. Resident #8, who has Dementia, was inappropriately touched on the breast by a cognitively intact male resident, Resident #13 with known sexual inappropriate behavior towards staff members. Although the facility separated the two residents, the facility did not protect this resident (Resident #8) from further incidents of abuse including sexual coercion. A second incident occurred a short time later when the same male resident (Resident #13) forcibly took the hand of a Resident #8 and placed her hand in the male's genital area without consent from the female resident. The facility did not immediately report the first incident to the Administrator. The facility did not adequately supervise the perpetrating resident following the first incident to protect all residents and the victim resident from a second incident of sexually inappropriate behavior. Using the reasonable person concept it is likely that this would lead to chronic or recurrent fear and anxiety. Findings include: On 11/12/2015, Surveyor # and Surveyor # reviewed the facility's policy titled, Resident Abuse, Neglect, Mistreatment Policy and Procedure, revision date 7/22/10. The policy included the following procedures: * Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation, neglect, injuries of unknown source of a resident shall be immediately reported to the Administrator. The Director of Nursing, or designee(s) and the Division of Quality Assurance and local law enforcement should also be notified. * .Because the federal definitions do not specify that the incident has to involve a caregiver, nursing homes are required to submit allegation of mistreatment by anyone, including resident to resident, to DQA immediately . On 11/12/2015 Surveyor # and Surveyor # reviewed the facility's policy titled, Resident to Resident Abuse Policy and Procedure, with a revision date of 06/2012. The policy included the following procedures: * If a resident-to-resident incident occurs, staff should immediately intervene. Separate residents and take them to areas from each other until the situation has subsided * .If the resident is cognitively alert, counsel the resident(s) on proper behavior. * Immediately notify the Administrator and Director of Nursing. * Complete all necessary documentation for reporting the incident. * All incidents are to be documented in each resident's medical record in conjunction with frequent monitoring and documentation to continue for at least 24 hours. * The investigation protocol must be implemented and a report provided to the appropriate agencies as specified by local and federal law and regulations . On 11/12/2015, Surveyor # and Surveyor # reviewed Resident #8's record. Resident #8 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Resident #8's Minimum Data Set (MDS) assessment, dated 08/12/2015, indicates Resident #8 had both short term and long term memory problems. The MDS also indicates that Resident #8 has severely impaired decision making ability and that Resident #8 never/rarely makes decisions. According to Resident #8's medical record, Resident #8 has had a court appointed guardian since 03/22/2013. Resident #8's Care Area Assessment (CAA), dated 05/13/2015, indicates that cognitive loss and dementia were triggered for care planning. Within Resident #8's CAA description of the cognitive loss and dementia it states, Resident with difficulty focusing on one task and does present with disorganized thinking. Resident #8's Care Plan, dated 06/04/2013, with a target date of 11/17/2015, indicates a problem with Impaired thought process related to dementia, depression, [MEDICAL CONDITION] medication use and history [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Goals include, Safety will be maintained despite lack of comprehension, resident will be involved in decision making and self care ((sic)) as she is able, resident will indicate understanding of simple statements or commands by appropriate responses. Interventions include, needs to be anticipated by staff, ask questions with yes or no answers, provide secure environment. Resident #13's closed medical record was reviewed by Surveyor . Resident #13 was admitted to the facility from the hospital on [DATE] after having an [MEDICAL CONDITION] (stroke) that affected the left side of his body. The admission Minimum Data Set (MDS) screen was conducted on 9/24/15. This admission MDS indicated resident to have no cognitive impairment, with a score of 15 on the Brief Interview for Mental Status assessment. The scoring of this assessment revealed a score of 15, which is defined as cognitively intact. The MDS also indicates that Resident #13 has a known history of non-compliance with medications, Hodgkin's [MEDICAL CONDITION], erectile dysfunction with penile prosthesis, [MEDICAL CONDITION]. Resident #13 is described in the MDS information as being alert and oriented with some forgetfulness and impulsiveness and an alarm is used for safety due to poor safety awareness. Resident #13's left upper extremity (arm) is affected by his stroke and he wears a sling. Resident #13 is a pivot transfer and can self-propel his wheelchair. The MDS also indicates that Resident #13 has poor insight into his deficits and left sided neglect. The MDS also identifies in the 9/24/15 Urinary Incontinence review that resident has a penile implant and can be sexually inappropriate at times with staff with effective redirection. Nursing progress notes indicate the following : 9/24/15 - .mild to moderate impulse control problems of a sexual nature 9/25/15 - .inappropriate at times, but easily redirected; 9/27/15 - inappropriate but easily redirected; 10/2/15 - .inappropriate behaviors noted, able to make needs known; 10/5/15 - .inappropriate at times but typically easily redirected; 10/3/15 - .inappropriate behaviors, alert with confusion;10/7/15 - .IDT (interdisciplinary) team met for care conference .the option of moving to the long term care side would be beneficial to resident's needs as well as to decrease behaviors which are noted to decrease with the presence of male staff. Again, his impulsive behaviors and fall risk was noted .; 10/8/15 - .can be sexually inappropriate at times, redirected as needed by staff members; 10/9/15 - .inappropriate at times, impulsive .10/10/15 - .inappropriate at times, impulsive . 10/12/15 - .inappropriate at times, impulsive . 10/16/15 - .extremely impulsive, can be sexually aggressive . 10/18/15 - .is able to propel own w/c (wheelchair), has been traveling the facility .in pleasant mood 10/20/15 - .sexually aggressive, left side affected [MEDICAL CONDITION](stroke) . 10/22/15 - .when writer asked resident if he had any pain, he states, yeh, I had a vasectomy five days ago, you wanna see. Easily redirected . 10/23/15 - .inappropriate sexual behaviors . 10/24/15 - .impulsive, inappropriate behaviors . 10/25/15 10:34 AM- , can be very spontaneous and sexually aggressive verbally. Easily deterred. 10/25/15 10:27 PM, patient noted with inappropriate sexual behavior this evening. Reported to DON/Admin (Director of Nursing/Administrator). Patient was immediately removed from female patient and monitored. Surveyor # and Surveyor # reviewed Resident #8's progress notes on 11/11/2015. The nursing progress note dated 10/25/2015 at 10:30PM states, Patient was noted in living room w/ male patient next to her. Was noted arm was being rubbed w/ possible side of hand on breast. Patient removed and after supper, patient returned to patient and was noted trying to move hand on top of his penis. Removed male patient from (Resident #8). Don (Director of Nursing), Admin (Administrator) updated. No psycho/social behaviors/ harm noted. Resident (#8) did not react. Will continue to monitor, SS ((social services)) to follow up. Surveyors and were provided with two signed witness statements from the facility's investigation. The signed witness statement from Licensed Practical Nurse (LPN)-E dated 10/25/2015 states, Writer was approached by (CNA-F) approximately 1800 (6:00 p.m.) (CNA-F) stated that (Resident #13) had been sitting next to (Resident #8) apparently holding her hand. Upon approach, (CNA-F) realized that Resident #13 was slightly touching (Resident #8)'s breast. (CNA-F) separated residents and reported to writer. Resident #8 remains in day room until bed where she can be watched. (Resident #13) followed writer around much of evening. Approximately 1900 (7:00 p.m.), (CNA-F) reported (Resident #13) gesturing to (Resident #8) to touch his penis. He also attempted to move her hand onto him. (CNA-F) stopped resident, separated, reported to writer. Inappropriateness of behavior reinforced. DON updated. Signed witness statement from CNA-F dated 10/25/2015 states, I was bringing resident from 32B back to her room after dinner. I seen (sic) (Resident 13) next to (Resident #8). (Resident #13) had his arm under hers and was nudging her breast. I immediately went and moved him and told him that it was inappropriate to do that. I then went and notified the nurse right away. A little after 6:30 pm I was walking to the nurses station and noticed (Resident #13) was sitting by (Resident #8) again. This time he touched himself a little nudged her arm and touched himself again, (sic) He then grabbed her hand and went to place it on his penis. I quickly went and moved him again away from the other resident telling him that is not appropriate to do. I went and notified the nurse again. The following are two Investigation Notes from 10/25/2015 that were provided to Surveyors and upon asking for investigation of incident: The investigation notes from 10/25/2015 with no signature indicating author, no date indicating when investigation occurred or when note was written, and no time notes, (Resident #13) attempted to touch female resident on 10/25/2015 in day room. This behavior may result in female resident feeling uncomfortable and contribute to the potential of psychosocial distress. Resident (#13) has a history of left [MEDICAL CONDITION] may contribute to him acting sexually inappropriate. Historically this behavior has only been towards staff. Staff to document on his behavior each shift on the behavior log. Staff to redirect inappropriate behaviors through verbal cues including letting (Resident #13) know that his behavior is inappropriate May do one-on-one nursing if needed .Will continue to monitor behaviors. The second investigation notes page titled, 10/25/2015 Investigation notes, with no signature indicating author, no date indicating when investigation occurred or when note was written, and no time states, (Resident #8) involved in interaction with male resident on 10/25/2015 in day room. Witnessed by CNA reported to nurse, DON, and NHA. (Resident #8) is alert with [MEDICAL CONDITION]. Does have outburst and crying episodes. Resident is able to show her likes and dislikes through her emotional response. After interaction with male resident (Resident #8) did not show any change in her normal behavior, nor did she display any signs of distress. Family was updated and staff continued to monitor (Resident #8)'s mood and behavior. No change noted . Social services followed up with (Resident #8) and did not note any distress or behavior changes . An interview was conducted with the DON-B and Surveyors and on 11/12/14 at 10:40 AM. During this interview, the incident between Residents #13 and #8 was discussed. At this time, it was told to the surveyors that the facility had no evidence resident was inappropriate with any other residents and the sexual inappropriateness was only directed to staff. On 11/12/15, at 1:25pm, Surveyor and interviewed the facility administration about the immediate response taken following this incident. NHA-A and DON-B indicated that LPN-E came and told the DON-B what happened, and DON-B went to the Long Term Care Unit to talk to staff. DON-B stated that Resident #8 had been assisted to bed when she got to the unit. DON-B indicated that CNA-F was the only witness who told LPN-E and LPN-E told DON-B. DON-B noted that she went to investigate, get verbal statements, and got NHA-A right away. DON-B indicated during the interview that the first incident occurred before supper in the living room, and that she did not find out about it until after supper and after Resident #13 was in bed. This was after the second incident. According to DON-B, during the first incident, CNA-F observed Resident #13 with his arm under Resident #8's upper arm from behind possibly making contact with Resident #8's breast. They were both in wheelchairs at the time. CNA-F separated the residents by telling them it was time to go to supper. CNA-F told DON-B that she told Resident #13 that it was inappropriate and both residents propelled to separate dining rooms. DON-B stated that both Resident #13 and Resident #8 got back to the unit after eating independently. CNA-F also witnessed the second incident. DON-B stated that Resident #13 put his hand on himself twice in peri-area, reached for Resident #8's hand, pulled his (hand) back, then touched Resident #8's hand and brought it to him. She stated both were fully clothed. DON-B demonstrated the action of Resident #13, and indicated that Resident #8's hand was placed onto Resident #13's peri-area. According to DON-B, CNA-F separated the residents and Resident #13 was made to follow LPN-E for the rest of the evening for observation. DON-B stated that Resident #8 showed no ill effect including crying, and that Resident #8 did not fight Resident #13 or push Resident #13 away from her. The police were not notified of the situation, and this incident was not reported to DQA (Division of Quality Assurance). After the first act of sexual aggression, facility staff separated the residents but did not put measures in place immediately to prevent a second incident. As a result, Resident #13 was able to approach Resident #8 a second time and commit an act of sexual aggression towards Resident #8. It wasn't until after the second act that the facility responded. A Memo to all staff, dated 10/26/15, was developed by the Administrator and put in place with instructions on monitoring Resident #13's behavior. The directives indicated that: Resident #13 must be supervised around female residents for any inappropriate touching. If Resident #13 is acting sexually inappropriate in any way, remove from situation and redirect to activity or one-on-one with nursing. If sexually inappropriate behavior occurs; remove him from the situation, say to him specifically that is inappropriate, please stop, redirect him to activity, recliner chair, Resident #13 likes to read the newspaper and drink coffee - this is also acceptable redirection, or one-on-one with nursing. Please document any behaviors on behavior log. Copies of the behavior logs were reviewed by Surveyor . These behavior logs indicated that beginning on 10/26/15, the tracking of Resident #13's behavior first began. These logs are titled, Daily Behavior Observation and indicate they were started on 10/26/15. The Target Behavior section of this form indicates the behavior as; A. verbally inappropriate comments directed toward residents and staff and B. Physical/Sexual gestures towards residents, staff and self, and a behavior choice titled X. other. The interventions section of this form indicates 1. Explain to (resident name) that behavior is inappropriate, and please stop. 2. Remove from situation if disruptive/inappropriate towards others, 3. Redirect to activity, recliner, bed and chair. 4. Provide 1:1/provide supervision. 5. Male staff to provide cares, when able. The documentation of the outcome is to be scored on this form as a + for improvement, a - for worsened and a 0 for no change. On 11/12/2015, at 1:37pm, Surveyor # and Surveyor # interviewed Social Worker-G, who indicated that she had a brief interaction with Resident #8 after the 10/25/2015 incident between Resident #8 and Resident #13. During the interaction between Social Worker-G and Resident #8, Resident #8 began crying. Social Worker-G further indicated that she (Social Worker-G) was not able to ask her (Resident #8) about the incident due to the crying episode. Social Worker-G noted that Resident #8 gives very minimal yes and no responses when communicating with others, and she could not specifically recall if anyone else spoke to Resident #8 about how she felt about the incident. Social Worker-G noted that DON-B provided follow up communication with the family of Resident #8 by speaking to Resident #8's son. Although Resident #8 showed minimal response to the incidents that occurred on 10/25/15, using the reasonable person concept it is likely that a vulnerable person who is unable to defend herself could experience chronic or recurrent fear or anxiety when the facility fails to protect her from a sexual predator. According to the Network of Victim Assistance's Webpage found at <http://www.novabucks.org/otherinformation/rape/>: Sexual assault takes many forms including attacks such as rape or attempted rape, as well as unwanted sexual contact or threats. Usually a sexual assault occurs when someone touches any part of another person's body in a sexual way, even through clothes, without that person's consent . .The law generally assumes that a person does not consent to sexual conduct if he or she is forced, threatened or is unconscious, drugged, a minor, developmentally disabled, chronically mentally ill, or believe they are undergoing a medical procedure. Some examples of sexual assault include .Someone touching, fondling, kissing or making any unwanted contact with your body .Since every person and situation is different, victims of sexual assault will respond to an assault in different ways. Many factors can influence an individual's response to, and recovery from, sexual assault . This information was obtained from the Network of Victim Assistance, a member agency of The United Way, and was most recently updated in 2013.

Based on observation, staff interview, and record review, the facility did not ensure that 1 out of 4 residents (Resident #6) received the necessary treatment and services to promote healing of a pressure ulcer that is currently receiving proper treatment. The facility did not update the physician when Resident 6's pressure ulcer was noted to be deteriorating and increasing in size on 10/7/15 (Stage 2) and 10/16/15 (Stage 3). There is no physician/nurse practitioner (NP) update regarding changes in the wound from 10/7/2015 until 10/21/2015. The facility did not consult with the physician regarding the treatment provided to determine if the physician was in agreement with the current treatment at the time of the increased sizes in the pressure ulcer. The physician and NP-C did not document having seen Resident #6 from onset of this pressure noted on 10/1/2015 until 10/28/15. Findings include: The facility policy entitled, Skin Care Policy & Procedure, revised 05/2013, states a purpose to, Promote the prevention of pressure ulcer development and to promote the healing of pressure ulcers that are present The policy states, .The complexity of the resident's condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rationale for continuing the present treatment (for example, why some, or all, of the plan's interventions remain relevant despite little or no apparent healing). The policy also states, The physician's involvement is integral whenever significant changes in the nature of the wound or overall resident condition are identified. Surveyor # reviewed Resident #6's medical record on 11/9 and 11/10/15. Resident #6's medical record indicates Resident #6 has a current [DIAGNOSES REDACTED]. Resident #6's medical record continues to reflect the following: Resident #6 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The hospital discharge summary, dated 09/23/2015,did not indicate skin impairment or a [DIAGNOSES REDACTED]. Resident #6's Pressure Sore Data Collection Skin Assessment Tool dated 09/23/2015 and signed by an Registered Nurse (RN) indicates redness on buttocks upon admission. Resident #6's Minimum Data Set (MDS) assessment, dated 9/29/2015, indicates that Resident #6 is at risk for developing a pressure ulcer, but no current pressure ulcer is present. The interventions in place, according to the MDS, include application of ointments, pressure reducing device for chair and bed, and turning and repositioning for Resident #6. The MDS also indicates that Resident #6 requires extensive assistance for bed mobility, hygiene, and toilet use. Resident #6 was noted as not ambulatory according to the assessment reference date. Resident #6's Care Area Assessment (CAA), dated 09/29/2014, indicates that Resident #6 is at risk for the development of a pressure ulcer but does not list Resident #6 as having a [DIAGNOSES REDACTED]. There is no documentation within the CAA indicating that Resident #6 had an unhealed pressure ulcer at the time of the assessment. Resident #6's Care Plan with a start date of 10/1/15 and edited on 11/10/15, with a target date of 12/23/2015, indicates a problem for Resident #6 as stated, Actual impaired skin/tissue integrity related to pressure area to coccyx initially noted as a slit but progressed to Stage 3. Patient admitted with blanchable red area to buttocks . Interventions include: Treatment as ordered per MD, see matrix for treatment to pressure area to coccyx, encourage and assist with turning and repositioning every 2 hours and as needed, diet as ordered, puree with thin liquids, supplements as ordered, kemps, magic cups, provide incontinence protection-pads as needed, pressure redistributing mattress for the bed, pressure redistributing cushion for the wheelchair, consult in house wound nurse as needed, monitor skin daily with cares and any adverse changes and notify the nurse . Resident #6's Braden Scale assessment dated and signed 10/09/2015 indicates a score of 15 which means Resident #15 is at risk for pressure ulcer development. Resident #6's progress note, dated 9/23/2015 at 8:31pm, states, .Buttocks red, blanchable, barrier cream applied, repositioning. Will continue to monitor . There is no further documentation within the progress notes or skin-Pressure Ulcer Documentation for Resident #6's reddened coccyx until 10/01/2015 at 10:38am which states, .Does have 0.3cm long slit to coccyx. Will apply medseptic TID ((three times a day)) with cares until resolved. Fax sent to update Nurse Practitioner ((NP-C)). Will continue with repositioning q 2 hours, pressure redistributing mattress to bed and pad to broda chair On 10/1/2015, a fax was sent to NP-C updating NP-C on Resident #6's coccyx. The fax states, pt ((patient)) (with) slit to coccyx measuring 0.3cm long. Will apply medseptic TID ((three times daily))(with) cares until resolved. The order was signed and faxed back to facility the same day on 10/01/2015. On 10/3/2015, a fax was sent to NP-C stating, .would like to adjust tx to OA ((open area)) to coccyx from medseptic to cleanse wound (with) ns ((normal saline)) apply skin prep to surrounding skin f/b gentle foam (change) daily and PRN (as needed) till healed. On the top of the fax, it states, Please respond by Monday. The fax was signed and returned back to the facility via fax on 10/05/2015. The nursing progress note, dated 10/04/2015 at 8:46PM, is the first progress note signed by Wound Care Registered Nurse (RN)-D regarding Resident #6's pressure ulcer. It states, drsg changed to coccyx as soiled. Pressure redistributing mattress on bed and cushion in broda chair when up. There are no measurements and staging of the area documented on 10/04/2015. On 10/07/2015 at 1:53pm, Wound Care RN-D documented the first Weekly Wound Documentation note which states, stage 2 to coccyx, area measures 1.0 x 1.0, appears very superficial. Wound bed pink. Reports occ (occasional) discomfort to area. Current treatment of [REDACTED].#6 which states, writer informed (Resident #6) that with the location, and very body (sic) prominence with her positioning often would classify it as pressure. Surveyor # noted that on 10/07/15, the current treatment remains the same treatment as ordered on [DATE]. There is no indication of physician/nurse practitioner being notified regarding the change in the wound after Wound Care RN-D obtained the 10/07/2015 measurements and assessment, indicating it is now a stage 2. On 10/16/2015 at 9:03am, Wound Care RN-D documented the following under Weekly Wound Documentation, continues with wound to coccyx area. Area measures 1.6 x 1.4, wound bed was pink last week and this week half of wound bed with yellow slough to it. Mod (moderate) amount of tan drainage on old drsg (dressing) . Surveyor # noted that on 10/16/15, Resident #6's pressure ulcer has deteriorated, increasing in size since 10/7/15 from 1 x 1 to now 1.6 x 1.4. The area is has yellow slough in it with moderate amount of tan drainage. There is no indication of physician/nurse practitioner notification regarding the change in the wound after Wound Care RN-D obtained the 10/16/2015 measurements and assessment. Surveyor # noted that the 10/7/15 and the 10/16/15 wound treatment remains the same as ordered 10/3/15 which is cleanse wound (with) ns ((normal saline)), apply skin prep to surrounding skin f/b gentle foam (change) daily and PRN (as needed) till healed with no documentation of the rationale for continuing the preset treatment as per the facility Skin Care Policy and Procedure, dated 5/20/13. According to the facility's Skin Care Policy and Procedure, dated 5/20/13, the wound will be measured weekly and documented under the progress notes of the resident's record with any significant change to the wound whether progress or regression .with each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed and: location and staging . Surveyor # noted that the nurses wound assessment documentation dated 10/16/15, does not indicate the stage of this pressure ulcer. Surveyor # also noted that the 10/16/15 wound assessment was not conducted within 7 days of the 10/7/15 wound assessment. On 10/21/2015 at 3:07pm, Wound Care RN-D documented the following under Weekly Wound Documentation, continues with stage 3 to coccyx. Area measures 1.6 x 1.4 x 0.1 ((now with depth)), wound bed with thin yellow slough to it. pinkness noted under. scar tissue to wound edge. Continue with scant brown drainage on old drsg when removed. Writer notified the MD to adjust treatment to [MEDICATION NAME] blue and then gentle foam daily. No complaints of pain to area. Patient has had some improvement over the past week, now up in regular wc with pressure redistributing cushion . On 10/21/2015, a fax was sent to NP-C stating, to OA to coccyx would like to adjust tx to cleanse with saline. Apply skin prep to surrounding skin then [MEDICATION NAME] blue to wound bed f/b gentle foam (change) daily The fax was signed and returned on 10/21/2015 stating, wound care nurse evaluate and treat. On 10/28/2015 at 10:58am, the Wound Care RN-D documented the following under Weekly Wound Documentation, continues with area to coccyx, stage 3. This week wound bed with 100% granulation tissue, improvement in size. Area measures 1.0 x 0.4, very superficial. Current treatment of [REDACTED]. Resident #6's physician assessment, dated 10/28/2015, indicates wound measurements of 1.0 by 0.1 cm per the physician. This is the first documented physician assessment of the wound. The assessment states, Pressure Ulcers: coccyx, healing per nursing. Now shallow. There is no NP or physician update regarding changes in the wound from 10/7/2015 until 10/21/2015. The physician and NP-C did not document having seen Resident #6 from onset of this pressure noted on 10/1/2015 until 10/28/15. On 11/10/2015, at 1:30pm, Surveyors and interviewed Wound Certified RN - D regarding Resident #6's pressure ulcer. Wound Certified RN-D indicated that upon admission (09/23/2015) to the facility, Resident #6 had redness on coccyx and Resident #6 refused to reposition, get out of bed, and refused meals also. Wound Certified RN-D noted that on 10/01/2015, Resident #6 had slit on the coccyx and that medseptic and barrier cream to the area was started as a treatment. Wound Certified RN-D indicated that Resident #6 had a catheter in place until 09/28/2015 when it was discontinued due to the lack of a supporting [DIAGNOSES REDACTED]. After the catheter was discontinued, resident had multiple incontinent episodes at that time. Wound Care RN-D noted that on 10/7/15 that the wound bed was pink and that she had just changed the dressing on 10/03/2015 to a foam dressing since Resident #6 was so boney. She confirmed that the wound would be classified as a stage 2, and stated that wound measured 1cm by 1cm. Wound Care RN-D noted that on 10/16/2015, wound bed showed yellow slough and a medium amount of tan drainage. At this time, Resident #6 was having an overall decline in health and was refusing meals and refusing to get out of bed. Wound Care RN-D noted that on this date the wound measured 1.6 cm by 1.4 cm and stated, yes, stage 3, when asked if she would classify wound as a stage three pressure ulcer according to assessment on 10/16/2015. There is no indication of physician notification of wound measurements or need for change in treatment in the documentation on 10/16/2015. When Wound Care RN-D was asked about not updating the physician on 10/16/2015, she noted that she kept the dressing the same since she had just had the dressing changed to include the foam protection 10 days prior and Resident #6 was having an overall decline. Wound Care RN-D indicated that on 10/21/2015 the wound measured 1.6 cm by 1.4 cm and had thin yellow slough. She also noted that she would classify the wound as a stage 3. Wound Care RN-D noted that she faxed to get a new treatment of [REDACTED].#6 had been changed to a better wheelchair for positioning and a better mattress for pressure reduction. Wound Care RN-D indicated that on 10/28/2015 the wound measured 1.0 cm by 0.4 cm with 100% granulation tissue (new healing tissue). At this time, according to Wound Care RN-D, Resident #6 was improving with her overall condition and was upbeat again. On 11/10/15, Surveyor and Surveyor observed wound care treatment to Resident #6's pressure ulcer. RN-D conducted the wound care and assessment of the wound and indicated the wound was healing. The wound measured 1.0 X 1.0 cm. with a small amount of tan drainage on the old dressing and a white area of scar tissue in the middle of the wound bed, according to Wound Care RN-D's assessment.

Based on record review and interview, the facility did not take measures to prevent and protect residents from potential further abuse, did not thoroughly investigate and did not report two alleged violations of abuse for 2 out of 2 allegations of abuse affecting 2 residents (Resident #8 and Resident #13) out of 13 residents sampled. The facility did not report alleged violations of abuse, and the facility did not report 2 incidents of abuse immediately to the Administrator and the State Survey Agency (SSA). The facility did not submit to the SSA the results of their investigations within 5 working days of the incident. * A Certified Nursing Assistant (CNA) observed Resident #13 touch Resident #8 on the breast before supper and observed Resident #13 grab Resident #8's hand and forcibly place Resident #8's hand on his genitalia after supper on the same day. The facility did not protect Resident #8 (and other residents) from Resident #13 after the first incident. The facility did not thoroughly investigate the first incident of Resident #13 touching Resident #8's breast or the second incident of Resident #13 forcibly placing Resident #8's hand on his genitalia. The facility did not thoroughly investigate the impact these actions had on Resident #8. The facility also did not report these two incidents immediately to the Administrator and to the State Survey Agency. The facility did not sumbit the results of their investigations to the SSA within 5 working days of the incident. * Resident #13 alleged that a nurse yelled at him on 10/28/15, and the facility did not thoroughly investigate the alleged violation and put measures into place to keep Resident #13 and other residents safe during the investigation. The facility did not immediately report this incident to the Administrator and the SSA. The facility did not sumbit the results of their investigations to the SSA within 5 working days of the incident. Findings include: 1. The facility did not remove an alleged abuser and place under supervision to protect other residents while an investigation was in progress. On 11/12/2015, Surveyor # and Surveyor # reviewed the facility's policy titled, Resident Abuse, Neglect, Mistreatment Policy and Procedure, with a revision date 7/22/10. The policy included the following procedures: .Alleged individual(s) must be removed from any immediate resident care area and placed under supervision in a non-resident area during initial interview/investigation to protect the affected resident . On 11/12/2015 Surveyor # and Surveyor # reviewed the facility's policy titled, Resident to Resident Abuse Policy and Procedure, with a revision date of 06/2012. The policy included the following procedures: * If a resident-to-resident incident occurs, staff should immediately intervene. Separate residents and take them to areas from each other until the situation has subsided * All incidents are to be documented in each resident's medical record in conjunction with frequent monitoring and documentation to continue for at least 24 hours. a. On 11/11/2015, Surveyor # and Surveyor # reviewed Resident #8's progress notes. The nursing progress note dated 10/25/2015 at 10:30PM states, Patient (Resident #8) was noted in living room w/ male patient (Resident #13) next to her (Resident #8). Was noted arm was being rubbed w/ possible side of hand on breast. Patient removed and after supper, patient (Resident #13) returned to patient (Resident #8) and was noted trying to move hand on top of his penis. Removed male patient (Resident #13) from (Resident #8). DON (Director of Nursing), Admin (Administrator) updated. No psycho/social behaviors/ harm noted. Resident (#8) did not react. Will continue to monitor, SS ((social services)) to follow up. On 11/12/15 at 1:25pm, Surveyor and interviewed the facility administration about the immediate response taken following the first incident involving Resident #8 and Resident #13. Director of Nursing (DON)-B indicated during the interview that the first incident occurred before supper in the living room, and that she did not find out about it until after supper and after Resident #13 was in bed. This was after the second incident. According to DON-B, during the first incident, CNA-F observed Resident #13 with his arm under Resident #8's upper arm from behind possibly making contact with Resident #8's breast. They were both in wheelchairs at the time. CNA-F separated the residents by telling them it was time to go to supper. CNA-F told DON-B that she told Resident #13 that it was inappropriate and both residents propelled to separate dining rooms. DON-B stated that both Resident #13 and Resident #8 got back to the unit after eating independently. The facility did not immediately identify abuse and protect Resident #8 and other residents from further instances of abuse after a second incident of abuse had occurred on 10/25/2015. On 10/25/15, Resident #13 was separated from Resident #8 after first incident of sexual abuse, but was not supervised and separated from all resident care areas to prevent further sexual abuse. On 10/25/15, Resident #13 was able to return to Resident #8 and sexually abuse Resident #8 a second time in the same location where first incident of sexual abuse occurred. (Cross reference F223.) b. On 11/11/2015, Surveyor # reviewed Resident #13's nursing notes dated 10/28/2015 at 3:09pm which states, .reported by (Certified Nursing Assistant-(CNA)) that resident agitated, threw urinal into hallway because she requested resident he not lean forward in w/c to tie shoe laces, encouraged use of call light. As writer approached resident he stated, I'm gonna slap her next time she yells at me, pointing to nurse (name) as she walked by. Updated (Social worker name) resident's behaviors. The facility did not protect Resident #13 after Resident #13 made an allegation of verbal abuse on 10/28/15 at 3:09 PM by a nurse caring for residents. The facility failed to remove the nurse from the resident care area while an initial investigation was initiated to protect Resident #13 and other residents from potential further abuse. On 11/12/15 at 2:34 PM, Surveyor asked the NHA-A (Nursing Home Administrator) for the investigation related to the incident of yelling allegation from Resident #13. The NHA-A indicated nothing had been written up about that incident and the NHA-A spoke with the nurse about this and that was all that was done regarding investigating this allegation. 2. On 11/12/2015, Surveyor # and Surveyor # reviewed the facility's policy titled, Resident Protection During Abuse Investigation Policy and Procedure, dated 06/2012. The policy stated the following procedures: * All alleged or suspected neglect or abuse; whether physical, verbal, sexual, involuntary, or mental will be cause for a thorough investigation to be conducted immediately by the management of the facility . * .The Director of Nursing ((DON)) or Charge Nurse will complete the investigation form with a written, dated, and signed statement from all persons involved. * The investigation form and written statements from all persons involved will be forwarded to the administrator within 24 hours of the occurrence. An immediate investigation will be conducted by both the Director of Nursing and the Administrator. * A representative from the facility's Social Service Department will also interview the resident regarding the incident. The resident will be assessed for his/her reaction to the situation and will be allowed to express feelings and concerns. Ongoing monitoring by social services will continue until the resident indicates verbal or nonverbal indications of comfort and safety On 11/11/2015, Surveyors and asked for the investigation or incident report from the 10/25/2015 incidents of sexual abuse involving Resident #8 and Resident #13. The investigation notes from 10/25/2015 with no signature indicating author and no date or time indicating when investigation occurred notes, (Resident #13) attempted to touch female resident on 10/25/2015 in day room. This behavior may result in female resident feeling uncomfortable and contribute to the potential of psychosocial distress. Resident (#13) has a history of left [MEDICAL CONDITION] may contribute to him acting sexually inappropriate. Historically this behavior has only been towards staff. Staff to document on his behavior each shift on the behavior log. Staff to redirect inappropriate behaviors through verbal cues including letting (Resident #13) know that his behavior is inappropriate . May do one-on-one nursing if needed .Will continue to monitor behaviors. The second investigation notes page titled, 10/25/2015 Investigation notes, with no signature indicating author and no date or time indicating when investigation occurred notes, (Resident #8) involved in interaction with male resident on 10/25/2015 in day room. Witnessed by CNA reported to nurse, DON, and NHA. (Resident #8) is alert with [MEDICAL CONDITION]. Does have outburst and crying episodes. Resident is able to show her likes and dislikes through her emotional response. After interaction with male resident (Resident #8) did not show any change in her normal behavior, nor did she display any signs of distress. Family was updated and staff continued to monitor (Resident #8)'s mood and behavior. No change noted . Social services followed up with (Resident #8) and did not note any distress or behavior changes . Additionally, Surveyors and were provided with two signed witness statements from the facility's investigation. The signed witness statement from Licensed Practical Nurse (LPN)-E dated 10/25/2015 states, Writer was approached by (CNA-F) approximately 1800 (8:00 p.m.) (CNA-F) stated that (Resident #13) had been sitting next to (Resident #8) apparently holding her hand. Upon approach, (CNA-F) realized that Resident #13 was slightly touching (Resident #8)'s breast. (CNA-F) separated residents and reported to writer. Resident #8 remains in day room until bed where she can be watched. (Resident #13) followed writer around much of evening. Approximately 1900 (9:00 p.m.), (CNA-F) reported (Resident #13) gesturing to (Resident #8) to touch his penis. He also attempted to move her hand onto him. (CNA-F) stopped resident, separated, reported to writer. Inappropriateness of behavior reinforced. DON updated. Signed witness statement from CNA-F dated 10/25/2015 states, I was bringing resident from 32B back to her room after dinner. I seen (sic) (Resident #13) next to (Resident #8). (Resident #13) had his arm under hers and was nudging her breast. I immediately went and moved him and told him that it was inappropriate to do that. I then went and notified the nurse right away. A little after 6:30 pm, I was walking to the nurses station and noticed (Resident #13) was sitting by (Resident #8) again. This time he touched himself a little nudged her arm and touched himself again, (sic) He then grabbed her hand and went to place it on his penis. I quickly went and moved him again away from the other resident telling him that is no appropriate to do. I went and notified the nurse again. The facility did not interview Resident #13 or Resident #8 regarding the incidents and the facility did not interview other residents on the unit to see if further instances of sexual abuse had occurred. Additionally, after the nursing note dated 10/25/2015 at 10:30pm, there was no further monitoring of Resident #8 indicated by either social services or nursing in the nursing notes regarding the potential effect of the sexual abuse. On 11/12/2015, at 1:37pm, Surveyor # and Surveyor # interviewed Social Worker-G, who indicated that she had a brief interaction with Resident #8 after the 10/25/2015 incident between Resident #8 and Resident #13. During the interaction between Social Worker-G and Resident #8, Resident #8 began crying. Social Worker-G further indicated that she was not able to ask her about the incident due to the crying episode. Social Worker-G noted that Resident #8 gives very minimal yes and no responses when communicating with others, and she could not specifically recall if anyone else spoke to Resident #8 about how she felt about the incident. Social Worker-G noted that DON-B provided follow up communication with the family of Resident #8 by speaking to Resident #8's son. 3. The facility did not immediately report the above allegation of abuse and the above occurrence of abuse to the SSA. The facility did not sumbit to the SSA, the results of their investigations within 5 working days of the incident. On 11/12/2015, Surveyor # and Surveyor # reviewed the facility's policy titled, Resident Abuse, Neglect, Mistreatment Policy and Procedure with a revision date 7/22/10. The policy included the following procedures: * Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation, neglect, injuries of unknown source of a resident shall be immediately reported to the Administrator. The Director of Nursing, or designee(s) and the Division of Quality Assurance and local law enforcement should also be notified. * .Because the federal definitions do not specify that the incident has to involve a caregiver, nursing homes are required to submit allegation of mistreatment by anyone, including resident to resident, to DQA immediately . On 11/12/2015, Surveyor # and Surveyor # reviewed the facility's policy titled, Resident to Resident Abuse Policy and Procedure, with a revision date of 06/2012. The policy included the following procedures: * .Complete all necessary documentation for reporting the incident. * All incidents are to be documented in each resident's medical record in conjunction with frequent monitoring and documentation to continue for at least 24 hours. * The investigation protocol must be implemented and a report provided to the appropriate agencies as specified by local and federal law and regulations . On 11/12/2015, at 1:07pm, Surveyors and interviewed NHA-A regarding reporting abuse and allegations of abuse to the SSA. NHA-A indicated that for resident to resident abuse they follow the grid which is on DQA's web page. NHA-A provided a copy of DQA memo 11-032, Dated December 5, 2011. According to NHA-A, the facility did not immediately report the two sexual assult incidents involving Resident #8 and Resident #13 to the State Survey Agency (SSA) and the facility did not immediately report the incident of alleged verbal abuse reported by Resident #13 to the SSA. The facility did not sumbit the results of their investigations to the SSA within 5 working days of the incident. The NHA acknowledged confusion about the reporting requirements based on the memo interpretations.

Based on record review and staff interviews the facility did not provide the necessary care and services to assure 1 of 12 sampled residents (Resident #12), attained or maintained the highest practicable physical well-being, in accordance with their comprehensive assessment and plan of care. On 7/14/14 at 3:00 a.m., Resident #12 had a hypoglycemic reaction and was unresponsive. The LPN administered the last [MEDICATION NAME] (brand name drug for the generic drug [MEDICATION NAME]; a drug administered intravenously, intramuscularly or subcutaneously in emergency situations to treat hypoglycemic reactions) injection that remained in the Hypoglycemic Kit to Resident #12. This left no [MEDICATION NAME] in the Hypoglycemic Kit. Resident #12 remained unresponsive with a low blood glucose. Because [MEDICATION NAME] was unavailable for administration, the LPN administered oral glucose gel to Resident #12, even though Resident #12 was unresponsive. This is contrary to standards of practice and to the warning on the packaging directions for [MEDICATION NAME]. The facility was aware that they were out of [MEDICATION NAME] in the diabetic kit on 7/14/14, but did not ensure that the pharmacy refilled the kit. Neither the Director of Nursing (DON) nor the night LPN was aware that an emergency box in the facility had [MEDICATION NAME]. The DON should have been aware on 7/14/14 that the night LPN had given oral glucose to an unresponsive resident early that morning, but she did not address this issue with the LPN. The [MEDICATION NAME] was not refilled STAT by pharmacy, and was not available in the diabetic kit at 3 AM on 7/15/14 when Resident #12 had another episode of [DIAGNOSES REDACTED] and was unresponsive. The LPN did not call the Director of Nurses for guidance when there was no [MEDICATION NAME] in the diabetic kit; instead, she gave Resident #12 two tubes of oral glucose gel, which caused the resident to aspirate and which did not bring up the resident's blood sugar significantly, thus prolonging the episode. The administration of oral glucose gel to Resident #12 on 7/14/14 and 7/15/14, who was unresponsive, created a potential for choking and aspiration; additionally, the failure to give [MEDICATION NAME] IM on 7/15/14, prolonged the period of the resident's hypoglycemic episode, furthering the possibility for death or serious harm. This situation resulted in a finding of immediate jeopardy, beginning 7/14/14 when the LPN administered a tube of oral glucose gel to an unresponsive resident and facility staff failed to ensure that they immediately replaced the [MEDICATION NAME] available in the diabetic kit. The facility Administrator and Director of Nursing were notified of this finding on 10/08/14 at approximately 1:15pm. The immediate jeopardy was removed on 10/9/14, however, the deficient practice continues at a scope and severity level of an E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan related to the 4 additional facility residents who are diabetic with a potential for a hypoglycemic episode. Findings include: 1. On 10/06/14 Surveyor # reviewed the hospital Discharge Summary, dated 6/28/14. The summary indicates Resident #12 is [AGE] years old, underwent left foot surgery leg 3 days ago, and was admitted for pain control and intravenous antibiotics. The summary indicates the resident had an uneventful stay at the hospital and was being discharged to a nursing facility (not the current nursing facility). The record review indicates Resident #12 was admitted to a nursing facility on 6/28/14 and transferred to the current nursing facility on 7/09/14. The Resident Admission Record indicates the resident has [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. *Accu Check blood glucose monitoring four times per day with sliding scale insulin orders and to call the physician if the blood glucose is greater than 400 or less than 80. *[MEDICATION NAME] 20 units at hours of sleep *Humalog Insulin 4 units at breakfast, 2 units at lunch, 6 units at supper, and additional correction of 1 unit for every 40 greater than 160. *standing order for [MEDICATION NAME] 1 mg vial give intramuscular (IM), intravenously (IV) or subcutaneously (sub-q) as needed for severe hypoglycemic reaction, repeat in 20 minutes if necessary. *There is no standing or current written order for oral glucose gel for treating low blood sugar. The Admission Care Plan, dated 7/09/14, for Insulin Dependent Diabetes mellitus includes interventions to check the blood sugar four times per day, to give medications and diet as ordered, to observe for signs and symptoms of hypo/[MEDICAL CONDITION]. The interventions do not include actions that nursing staff should take for symptoms of hypo/[MEDICAL CONDITION]. The Surveyor reviewed the July 2014 Medication Record (MAR). The MAR indicated [REDACTED]. The record indicates that on 7/13/14, at hours of sleep, the resident's blood glucose was 83. It should be noted that on 7/14/14, Resident #12 was one of 6 insulin dependent diabetic residents. The facility had one Hypoglycemic Kit that contained 2 [MEDICATION NAME] vials for injection and 2 tubes of oral glucose gel. In addition, the facility had an Emergency Contingency Box that contained 2 [MEDICATION NAME] vials for injection, however, neither the DON nor the night nurse were aware on 7/14/14 and 7/15/14 of the availability of [MEDICATION NAME] injections that were in the Emergency Contingency Box. On 7/13/14 at 10:45 p.m., Licensed Practical Nurse (LPN) administered one of the [MEDICATION NAME] injections to Resident #9, leaving one injection in the Hypoglycemic Kit for use in the event of another resident requiring [MEDICATION NAME]. The Resident Progress Note, dated 7/14/14 at 6:20 A.M., states Resident #12 was unresponsive at 4:45 a.m., color ashen, skin warm and dry, and blood glucose was 47. The note indicates the resident was given 1 milligram (mg) of IM [MEDICATION NAME] and 2 tubes of glucose gel sublingual. The note indicates the resident's blood glucose came up to 69 and the resident was starting to respond. The note indicates the blood glucose was rechecked after 10 minutes and was 98. The note indicates the Blood glucose was again checked at 6:00 a.m. and was 119. The note states "Will update MD per fax". The was no evidence that the nurse called the physician to provide notification that Resident #12 was unresponsive or that the nurse called the physician for a blood glucose level of less than 80 so that diabetic treatment approaches could be promptly evaluated and altered if needed. Although the facility called the pharmacy to replace the [MEDICATION NAME], facility staff did not ensure that this occurred. The Progress note, dated 7/14/14 at 10:08 a.m., indicates Resident #12 left the facility for an outpatient appointment. The Physician's Telephone Order, dated 7/14/14 at 11:15 a.m., indicates Resident 12's [MEDICATION NAME] dose was lowered to 16 units at hours of sleep. The July Medication Administration Record [REDACTED]. The Progress Note, dated 7/14/14 at 9:42 p.m., indicates the resident was alert to person, place and time, respirations were unlabored and even, oxygen saturation was in upper 90's with room air and that snacks and medications were given per the resident's schedule. The Resident Progress Note, dated 7/15/14 at 6:31 a.m., indicates that at 3:00 a.m. when staff went to wake Resident #12 up for [MEDICAL TREATMENT], the resident was unresponsive. The note indicates the Certified Nursing Assistant stated the resident was alert and responding one hour earlier. The note indicates the resident had a blood glucose of 42 and the nurse administered 2 tubes of glucose sublingually. The note indicates that 20 minutes later the blood glucose only came up to 47, and the resident remained unresponsive. The note indicates the Director of Nursing (DON) was called and that the DON stated to monitor for a few more minutes and if the resident remains unresponsive to call 911. The note indicates the resident left for the hospital per rescue squad at 4:15 a.m. Because it was not available, the LPN did not administer the injectable [MEDICATION NAME] as ordered; instead, she administered oral glucose gel to an unresponsive resident. The ambulance service Pre-hospital Care Report, dated 7/15/14, indicates the crew arrived on scene at 3:53 a.m. and found Resident #12 unresponsive with audible gurgling upper respiratory noises. The report indicates that the nurse reported giving the resident 2 tubes of oral glucose, under his tongue. The report indicates that the crew verified that the nurse gave an unresponsive resident oral glucose. The report indicates the crew suctioned the resident and cleared the airway of oral glucose. The report indicates that at 3:55 a.m. the resident's blood glucose was monitored and noted to be 21 and the resident's pulse oxygenation was noted to be 87 with room air. The report indicates intravenous (IV) [MEDICATION NAME] 1 amp, was administered, the blood glucose level was rechecked and noted to be 244, the resident remained unresponsive and the resident was transported to the emergency room . The hospital Emergency Department (ED) notes, dated 7/15/14, indicate Resident #12 arrived in the emergency department at 4:37 a.m. The report indicates that the resident was found unresponsive in the nursing home, 2 tubes of oral glucose were given despite the resident being unable to swallow, that the EMS was called, IV [MEDICATION NAME] was given, the resident became more awake, was unable to follow commands, was nonverbal, had grunting with gurgling/coarse breath sounds and non-purposeful combative motions. The Emergency Department Critical Care notes, dated 7/15/14 at 5:05 a.m., indicate the resident was combative, eyes not focusing, nonverbal and unable to follow commands. The ED notes, dated 7/15/14 at 5:45 a.m., and 5:54 a.m., indicate the resident's condition was unchanged and the resident was to be admitted to the hospital for further evaluation and/or workup. The Emergency Department Notes indicate an impression of the primary encounter [DIAGNOSES REDACTED]. The hospital Admission History and Physical indicates a chest X-ray was completed on 7/15/14 with the impression of small bilateral pleural effusions with overlying consolidation and atelectasis (a complete or partial collapse of a lung or lobe of a lung). The Assessment and Plan indicates the likely cause of altered mental status is due to possible [MEDICAL CONDITION] caused by [DIAGNOSES REDACTED] and the resident being post-ictal (the recovery stage following a [MEDICAL CONDITION]). The Assessment and Plan indicate the resident likely does have aspiration pneumonia (Aspiration pneumonia occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs.) The Physician Discharge Summary, dated 7/28/14, indicates a discharge [DIAGNOSES REDACTED]. The longer brain cells lack oxygen, the more damage occurs.) The Discharge summary includes a Hospital course that indicates Resident #12 was admitted on [DATE] with [DIAGNOSES REDACTED] and shortness of breath. The resident was treated for [REDACTED]. The discharge summary indicates the resident was discharged to inpatient rehab with improved mental status and speech. On 10/07/14, at 7:30 a.m., Surveyor # spoke with Licensed Practical Nurse (LPN)-C who worked on the night shift on 7/14/14 and 7/15/14. LPN-C indicated that on 7/14/14 the Certified Nursing Assistant (CNA) came and got her at 3:00 a.m. and informed her that Resident #12 was unresponsive. LPN-C indicated the Resident's blood glucose was checked and was low, IM [MEDICATION NAME] was administered, and she waited 10-15 minutes and rechecked blood glucose and was it was not coming up. LPN-C indicated Resident #12 was moaning and groaning and not talking with staff. LPN-C indicated oral Glucose Gel was put under the Resident's tongue and inside of the mouth at the side. LPN-C indicated the Resident started responding after oral gel was given, stating "I'm coming back." LPN-C indicated the physician was not called regarding the Resident's blood glucose being less than 80 and/or the Resident's unresponsive episode, but was instead notified via a fax. (Cross-reference F157 and F281.) LPN-C indicated that on 7/14/15, the oral glucose gel was administered to the resident because a second dose of [MEDICATION NAME] was not available in the facility. LPN-C indicated only one Hypoglycemic Kit was available for the entire facility, which on 7/14/14 included only one [MEDICATION NAME] vial for injection and 2 tubes of oral glucose gel. LPN-C indicated that on 7/14/14, she reported to the dayshift nurse and the Director of Nursing (DON) that she had used the contents of the only Hypoglycemic Kit in the facility and that the kit needed to be refilled. LPN-C indicated that on 7/15/14 at about 3:00 a.m., CNA-G informed her that resident was again unresponsive. LPN-C indicated the resident was unresponsive, the blood glucose was in the low 40s and that she administered 1 tube of oral glucose gel. LPN-C indicated that after 10 minutes the resident remained unresponsive and that a second tube of oral glucose gel was administered. LPN-C indicated that after 20 minutes the resident remained unresponsive and had a blood glucose of 47. LPN-C indicated that she then called the DON who instructed her to monitor for a few more minutes and if the resident's condition does not change to call 911. LPN-C indicated that after she spoke with the DON, the resident had started having gurgling noises with respiration and 911 was called. LPN-C indicated she administered the oral glucose gel to the unresponsive resident because no injectable [MEDICATION NAME] was available at the facility. LPN-C indicated the pharmacy did not deliver the new Hypoglycemic Kit until 4:30 a.m. on 7/15/14. On 10/06/14 at 9:50 a.m., Surveyor spoke with Registered Nurse (RN)-F who indicated LPN-C informed her on the morning of 10/14/14, that Resident #12 was unresponsive during the night and was given the [MEDICATION NAME] and glucose gel from the Hypoglycemic Kit. RN-F indicated that LPN-C informed her that the Hypoglycemic Kit would need to be replaced, and that the DON was aware of the need to replace the Kit. RN-F indicated that at 9:30 a.m. the [DIAGNOSES REDACTED] Kit was not yet replaced, and the DON was again notified of this during the morning Stand Up meeting. RN-F indicated that the facility had not received the Kit by the end of her shift. On 10/07/14, at 11:00 a.m., Surveyor # spoke with RN-E who worked on the p.m. shift of 7/14/14. RN-E indicated that on the evening of 7/14/14 at 8:00 p.m., the resident was awake, alert and responsive, ate a cheese sandwich, and had no respiratory problems. RN-E indicated he was not aware of the Hypoglycemic Kit needing to be received from pharmacy. On 10/07/14, at 2:50 p.m., Surveyor # spoke with the Pharmacy Consumer Service Nurse-D who indicated resident medication orders are refilled either on a STAT basis or through a regular request. Pharmacy Consumer Service Nurse-D indicated that a medication refill requested as STAT would be received within 4 hours and a medication refill requested as routine would be received within 24 to 48 hours. Pharmacy Consumer Service Nurse-D indicated that on 10/14/14 at 10:45 a.m., the facility called the pharmacy and requested the [DIAGNOSES REDACTED] Kit to be refilled. Pharmacy Consumer Service Nurse-D indicated the request was not a STAT request, but was requested to be sent to the facility by midnight on 7/14/14. Pharmacy Consumer Service Nurse-D indicated the kit was delivered to the facility on [DATE] at 4:30 a.m. On 10/07/14, at 2:10 p.m., Surveyor # spoke with the DON who indicated that on 7/14/14, the contents of the one [DIAGNOSES REDACTED] Kit available at the facility were used. The DON indicated that on 7/15/14 at 10:45 a.m., she called the Pharmacy and informed them that the [DIAGNOSES REDACTED] Kit needed to be refilled by 12 midnight, and that the request for the refill was not requested as STAT. The DON indicated that on 7/15/14 at 3:00 a.m., when Resident #12 was experiencing a hypoglycemic reaction, there was not a Hypoglycemic Kit available in the facility with injectable [MEDICATION NAME]. The DON indicated the [MEDICATION NAME] was not available because it was used on 7/14/14 and not refilled in time. The DON indicated oral glucose gel should not be given to a resident unless the nurse is able to verify that the resident can swallow. The DON also indicated that on 7/14/14, when the resident was unresponsive and had a blood glucose less than 80, the nurse should have called the physician instead of sending the fax. On 10/07/14, the Surveyor reviewed the facility's [MEDICAL CONDITION]/[DIAGNOSES REDACTED] Protocol. The protocol defines [DIAGNOSES REDACTED], provides signs and symptoms of [DIAGNOSES REDACTED] and guidelines for treating [DIAGNOSES REDACTED]. The guidelines include high glucose content foods. The protocol states "per nursing judgment the following guidelines may be used: 1. Give 15g glucose and wait 15 minutes before retesting blood glucose 2. IF blood glucose is still below 60mg/dl; repeat giving another 15g glucose and wait 15 minutes to retest blood sugar. **It is not unusual to repeat the procedure if the blood sugar was less than 60mg/dl. 3. May give [MEDICATION NAME] 1 mg IM (intramuscularly), IV (intravenously), or SubQ (subcutaneously). Repeat in 20 minutes if necessary" The protocol indicates the physician should be called if blood glucose is less than 60mg/dl or greater than 250, unless otherwise specified by the primary physician. Resident #12 had specific orders for the physician to be called if his blood glucose was less than 80mg/dl. The protocol does not include treatment approaches for an unresponsive resident. On 10/06/14, at 2:30 p.m., the surveyor spoke with the DON who indicated the facility's policy is to administer the oral glucose gel and the injectable [MEDICATION NAME] per packaging directions. The packaging directions for the oral glucose gel reads "To treat hypoglycemic reaction before unconsciousness occurs" and "Warning: for oral use only: Do not administer to any person who is unconscious or unable to swallow." On 9/18/14 the Southeastern Regional Office for the Division of Quality Assurance received a call from the wife of Resident #12. During this telephone call, the wife indicated that she finally had the chance to call in a complaint regarding her concerns for Resident #12 given the significant changes that this episode created for Resident #12 and her. She indicated that the Resident was originally admitted for rehabilitation to get him stronger so that he could return back home for her to help him fully recover. The wife indicated that she is very involved in the Resident's care and even while in the facility she still picked him up and took him for his appointments and [MEDICAL TREATMENT] etc. The wife indicated that this episode has left Resident #12 with [MEDICATION NAME] changes including changes in his cognition, speech and physical strength beyond what he was originally rehabilitating from. The facility's failure to ensure that the care provided to Resident #12 during two hypoglycemic episodes was based upon current standards of care and appropriate based upon assessment and care plan for an individual experiencing a hypoglycemic episode created a situation of Immediate Jeopardy. The jeopardy began on 7/14/14 when the facility administered oral glucose gel to Resident #12 who was unresponsive at the time. The facility removed the immediate jeopardy on 10/9/14 when it implemented the following: 1. The facility presented the situation and concerns to QA and Medical Director. The identified plan was to increase the number of hypoglycemic boxes. Nurses educated on location of hypoglycemic boxes and to STAT out order if contents of hypoglycemic are used. 2. The facility ensured that the Pharmacy delivered additional hypoglycemic boxes to the facility. 3. DON educated nurses on the location of the contingency boxes (specifically hypoglycemic box) and the contents of the ebox (including the IM kit). 4. The facility established inservicing via CE-Solutions regarding diabetic residents. 5. The facility reviewed and revised their Hyper/hypoglycemic policy and procedure updated to reflect more definitive guidelines on action to take on a hypoglycemic resident, including but not limited to an unresponsive resident. Will be reviewed by QA committee and revisions will be made as necessary. 6. The facility established a system to ensure that nurses are educated on new Hyper/hypoglycemic policy and procedure. Nurses also are to be in-serviced by Omnicare Pharmacy on diabetic residents focusing on hyper and hypoglycemic episodes. 7. Chart reviews are to be completed and updated physicians orders for Glucose and glucogen were added to insulin dependent diabetic residents. Diabetic care plans were updated on [DATE]th to include actions to take on an insulin dependent resident. All other diabetic care plans (4 residents) to be reviewed starting [DATE]th to be completed no later than October 9th 8. The facility established a system for nurses to check each shift that the seal of the hypoglycemic contingency boxes aren't broken and findings recorded on audit log. Nurse to order new box through pharmacy if seal is broken. 9. The facility established and an education process for nursing staff regarding the policy and procedure of Ordering Contingency Medication Supply. Audits to be done ensuring proper reordering of contingency boxes. The pharmacy was contacted to verify new procedures for ordering contingency medication boxes 10. The facility established and an education process for nursing staff regarding the updated policy procedure on physician notification and RN/DON notification. 11. The facility reinforced their process to ensure nursing communication is done between each shift through a nurse to nurse report utilizing the 24 hour nursing board updated every shift by nurse and reviewed by DON, NHA and kept in file. To be presented and QA and follow through to be done by DON. Stand-up meeting notes to be recorded and reviewed each day by NHA to ensure follow-through is being done. Will present findings at QA. 12. Chart audits on diabetic residents will be completed to ensure doctors are being updated appropriately related to diabetic parameters. To be reviewed at QA

Based upon interview and record review the facility did not ensure that 1 (Resident #12) of 2 residents having hypoglycemic reactions received nursing services and treatment that were provided in accordance with acceptable standards of practice. On 7/14/14 at 3:00 a.m., Resident #12 had a hypoglycemic reaction and was unresponsive. The LPN administered the last [MEDICATION NAME] (brand name drug for the generic drug [MEDICATION NAME]; a drug administered intravenously, intramuscularly or subcutaneously in emergency situations to treat hypoglycemic reactions) injection that remained in the Hypoglycemic Kit to Resident #12, leaving no [MEDICATION NAME] in the Hypoglycemic Kit. Resident #12 remained unresponsive with a low blood glucose. [MEDICATION NAME] was unavailable for administration so the LPN administered oral glucose gel to Resident #12, who was unresponsive. This was contrary to standards of practice and to the warnings on the packaging directions for [MEDICATION NAME]. The facility was aware that they were out of [MEDICATION NAME] in the diabetic kit on 7/14/14, but did not ensure that the pharmacy refilled the kit. Neither the Director of Nursing (DON) nor the night LPN was aware that an emergency box in the facility had [MEDICATION NAME]. The DON should have been aware on 7/14/14 that the night LPN had given oral glucose to an unresponsive resident early that morning, but she did not address this issue with the LPN. The [MEDICATION NAME] was not refilled STAT by pharmacy, and was not available in the diabetic kit at 3 AM on 7/15/14, when Resident #12 had another episode of [DIAGNOSES REDACTED] and was found unresponsive. The LPN did not call the DON for guidance when there was no [MEDICATION NAME] available in the diabetic kit; instead, she gave Resident #12 two tubes of oral glucose gel, which caused the resident to aspirate and which did not bring up the resident's blood sugar significantly, thus prolonging the episode. According to the Oregon Department of Public Health (www.public.health.oregon.gov), when a diabetic is unresponsive, "1. If breathing and pulse are present, assume the person with diabetes is having severe [DIAGNOSES REDACTED]. DO NOT give any food or liquid to a person who cannot swallow or is unconscious/unresponsive. 2. Delegate someone to call 9-1-1 or other emergency response system ... 3. OBTAIN [MEDICATION NAME] EMERGENCY KIT ... Time is critical for administering treatment to ensure recovery. 4. PREPARE AND ADMINISTER [MEDICATION NAME] for injection." The administration of oral glucose gel to Resident #12 on 7/14/14 and 7/15/14, who was unresponsive, created a potential for choking and aspiration; additionally, the failure to give [MEDICATION NAME] IM on 7/15/14, prolonged the period of the resident's hypoglycemic episode, furthering the possibility for death or serious harm. In the situations on 7/14/14 and 7/15/14 involving Resident #12 the nursing care required by Resident #12 exceeded the definitions of basic nursing care (as defined below in the findings). The nursing care needs for Resident #12 should have been assessed and reviewed following the incident that occurred on the morning of 7/14/14 and the facility DON should have recognized that the care needed by Resident #12 was not predictable and Resident #12 was not stable where his needs could be addressed only with basic nursing care delegated to an LPN. The LPN was again found to be in a complex nursing situation on 7/15/14 and the facility failed to recognize the complexity of Resident #12 and ensure that complex care was being provided under the direct supervision on an RN as required under the State of Wisconsin Chapter N6. The failure to follow professional standards of practice resulted in a finding of immediate jeopardy, which started on 7/14/14 when the LPN administered a tube of oral glucose gel to an unresponsive resident. This was completed without direction from a Registered Nurse. The facility Administrator and Director of Nursing were notified of this finding on 10/08/14 at approximately 1:15pm. The immediate jeopardy was removed on 10/9/14, however, the deficient practice continues at a scope and severity level of an E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement their action plan related to the current 4 Residents residing in the facility with the potential for a hypoglycemic episode. Cross Reference F309 Findings include: According to the State of Wisconsin Chapter N6 Standards of Practice for Registered Nurses and Licensed Practical Nurses: N 6.02 Definitions. As used in this chapter, (1) "Basic nursing care" means care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable. (2) "Basic patient situation" as determined by an R.N., physician, podiatrist, dentist or optometrist means the following 3 conditions prevail at the same time in a given situation: (a) The patient's clinical condition is predictable; (b) Medical or nursing orders are not changing frequently and do not contain complex modifications; and, (c) The patient's clinical condition requires only basic nursing care. (3) "Complex patient situation" as determined by an R.N., physician, podiatrist, dentist or optometrist means any one or more of the following conditions exist in a given situation: (a) The patient's clinical condition is not predictable; (b) Medical or nursing orders are likely to involve frequent changes or complex modifications; or, (c) The patient's clinical condition indicates care that is likely to require modification of nursing procedures in which the responses of the patient to the nursing care are not predictable. N 6.04 Standards of practice for licensed practical nurses. (1) PERFORMANCE OF ACTS IN BASIC PATIENT SITUATIONS. In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a physician, podiatrist, dentist or optometrist: (a) Accept only patient care assignments which the L.P.N. is competent to perform; (b) Provide basic nursing care; (c) Record nursing care given and report to the appropriate person changes in the condition of a patient; (d) Consult with an R.N., physician, podiatrist, dentist or optometrist in cases where an L.P.N. knows or should know a delegated nursing or medical act may harm a patient; and, (e) Perform the following other acts when applicable: 1. Assist with the collection of data; 2. Assist with the development and revision of a nursing care plan; 3. Reinforce the teaching provided by an R.N., physician, podiatrist, dentist or optometrist and provide basic health care instruction; or, 4. participate with other health team members in meeting basic patient needs. (2) PERFORMANCE OF ACTS IN COMPLEX PATIENT SITUATIONS. In the performance of acts in complex patient situations the L.P.N. shall: (a) Meet standards under sub. (1) under the general supervision of an R.N., physician, podiatrist, dentist or optometrist. (b) Perform delegated nursing or medical acts beyond basic nursing care under the direct supervision of an R.N., physician, podiatrist, dentist or optometrist. An L.P.N. shall, upon request of the board, provide documentation of his or her nursing education, training or experience which prepare the L.P.N. to competently perform these assignments. On 10/06/14 Surveyor # reviewed the hospital Discharge Summary, dated 6/28/14. The summary indicates Resident #12 is [AGE] years old, underwent left foot surgery leg 3 days ago, and was admitted for pain control and intravenous antibiotics. The summary indicates the resident had an uneventful stay at the hospital and was being discharged to a nursing facility (not the current nursing facility). The record review indicates Resident #12 was admitted to a nursing facility on 6/28/14 and transferred to the current nursing facility on 7/09/14. The Resident Admission Record indicates the resident has [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. *Accu Check blood glucose monitoring four times per day with sliding scale insulin orders and to call the physician if the blood glucose is greater than 400 or less than 80. *[MEDICATION NAME] 20 units at hours of sleep *Humalog Insulin 4 units at breakfast, 2 units at lunch, 6 units at supper, and additional correction of 1 unit for every 40 greater than 160. *standing order for [MEDICATION NAME] 1 mg vial give intramuscular (IM), intravenously (IV) or subcutaneously (sub-q) as needed for severe hypoglycemic reaction, repeat in 20 minutes if necessary. *There is no standing or current written order for oral glucose gel for treating low blood sugar. The Admission Care Plan, dated 7/09/14, for Insulin Dependent Diabetes mellitus includes interventions to check the blood sugar four times per day, to give medications and diet as ordered, to observe for signs and symptoms of hypo/[MEDICAL CONDITION]. The interventions do not include actions that nursing staff should take for symptoms of hypo/[MEDICAL CONDITION]. The Surveyor reviewed the July 2014 Medication Record (MAR). The MAR indicated [REDACTED]. The record indicates that on 7/13/14, at hours of sleep, the resident's blood glucose was 83. It should be noted that on 7/14/14, Resident #12 was one of 6 insulin dependent diabetic residents. The facility had one Hypoglycemic Kit that contained 2 [MEDICATION NAME] vials for injection and 2 tubes of oral glucose gel. In addition, the facility had an Emergency Contingency Box that contained 2 [MEDICATION NAME] vials for injection, however, neither the DON nor the night nurse on 7/14/14 and 7/15/14 were aware of the availability of the [MEDICATION NAME] injections that were in the Emergency Contingency Box. On 7/13/14 at 10:45 p.m., Licensed Practical Nurse (LPN) administered one of the [MEDICATION NAME] injections to Resident #9, leaving one injection in the Hypoglycemic Kit for use in the event of another resident requiring [MEDICATION NAME]. The Resident Progress Note, dated 7/14/14 at 6:20 A.M., states Resident #12 was unresponsive at 4:45 a.m., color ashen, skin warm and dry, and blood glucose was 47. The note indicates the resident was given 1 milligram (mg) of IM [MEDICATION NAME] and 2 tubes of glucose gel sublingual. The note indicates the resident's blood glucose came up to 69 and the resident was starting to respond. The note indicates the blood glucose was rechecked after 10 minutes and was 98. The note indicates the Blood glucose was again checked at 6:00 a.m. and was 119. The note states "Will update MD per fax". The was no evidence that the nurse called the physician to provide notification that Resident #12 was unresponsive or that the nurse called the physician for a blood glucose level of less than 80 so that diabetic treatment approaches could be promptly evaluated and altered if needed. (Cross-reference F157.) Although the facility called the pharmacy to replace the [MEDICATION NAME], facility staff did not ensure that this occurred. The Progress note, dated 7/14/14 at 10:08 a.m., indicates Resident #12 left the facility for an outpatient appointment. The Physician's Telephone Order, dated 7/14/14 at 11:15 a.m., indicates Resident 12's [MEDICATION NAME] dose was lowered to 16 units at hours of sleep. The July Medication Administration Record [REDACTED]. The Progress Note, dated 7/14/14 at 9:42 p.m., indicates the resident was alert to person, place and time, respirations were unlabored and even, oxygen saturation was in upper 90's with room air and that snacks and medications were given per the resident's schedule. The Resident Progress Note, dated 7/15/14 at 6:31 a.m., indicates that at 3:00 a.m. when staff went to wake Resident #12 up for [MEDICAL TREATMENT], the resident was unresponsive. The note indicates the Certified Nursing Assistant stated the resident was alert and responding one hour earlier. The note indicates the resident had a blood glucose of 42 and the nurse administered 2 tubes of glucose sublingually. The note indicates that 20 minutes later the blood glucose only came up to 47, and that the resident remained unresponsive. The note indicates the Director of Nursing (DON) was called and that the DON stated to monitor for a few more minutes and if the resident remains unresponsive to call 911. The note indicates the resident left for the hospital per rescue squad at 4:15 a.m. Because injectable [MEDICATION NAME] was not known to be available, the LPN was not able to give it; instead of calling the DON for guidance or calling 911, she gave oral glucose gel to an unresponsive resident. The ambulance service Pre-hospital Care Report, dated 7/15/14, indicates the crew arrived on scene at 3:53 a.m. and found Resident #12 unresponsive with audible gurgling - upper respiratory noises. The report indicates that the nurse reported giving the resident 2 tubes of oral glucose, under his tongue. The report indicates that the crew verified that the nurse gave an unresponsive resident oral glucose. The report indicates the crew suctioned the resident and cleared the airway of oral glucose. The report indicates that at 3:55 a.m. the resident's blood glucose was monitored and noted to be 21 and the resident's pulse oxygenation was noted to be 87 with room air. The report indicates intravenous (IV) [MEDICATION NAME] 1 amp, was administered, the blood glucose level was rechecked and noted to be 244, the resident remained unresponsive and the resident was transported to the emergency room . The hospital Emergency Department (ED) notes, dated 7/15/14, indicate Resident #12 arrived at 4:37 a.m. The report indicates that the resident was found unresponsive in the nursing home, 2 tubes of oral glucose were given despite the resident being unable to swallow, that the EMS was called, IV [MEDICATION NAME] was given, the resident became more awake, was unable to follow commands, was nonverbal, had grunting with gurgling/coarse breath sounds and non-purposeful combative motions. The Emergency Department Critical Care notes, dated 7/15/14 at 5:05 a.m., indicate the resident was combative, eyes not focusing, nonverbal and unable to follow commands. The ED notes, dated 7/15/14 at 5:45 a.m., and 5:54 a.m., indicate the resident's condition was unchanged and the resident was to be admitted to the hospital for further evaluation and/or workup. The Emergency Department Notes indicate an impression of the primary encounter [DIAGNOSES REDACTED]. The hospital Admission History and Physical indicates a chest X-ray was completed on 7/15/14 with the impression of small bilateral pleural effusions with overlying consolidation and atelectasis (a complete or partial collapse of a lung or lobe of a lung). The Assessment and Plan indicates the likely cause of altered mental status is due to possible [MEDICAL CONDITION] caused by [DIAGNOSES REDACTED] and the resident being post-ictal (the recovery stage following a [MEDICAL CONDITION]). The Assessment and Plan indicate the resident likely does have aspiration pneumonia (Aspiration pneumonia occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs.) The Physician Discharge Summary, dated 7/28/14, indicates a discharge [DIAGNOSES REDACTED]. The longer brain cells lack oxygen, the more damage occurs.) The Discharge summary includes a Hospital course that indicates Resident #12 was admitted on [DATE] with [DIAGNOSES REDACTED] and shortness of breath. The resident was treated for [REDACTED]. The discharge summary indicates the resident was discharged to inpatient rehab with improved mental status and speech. The hospital Final [DIAGNOSES REDACTED]. On 10/07/14, at 7:30 a.m., Surveyor # spoke with Licensed Practical Nurse (LPN)-C who worked on the night shift on 7/14/14 and 7/15/14. LPN-C indicated that on 7/14/14 the Certified Nursing Assistant (CNA) came and got her at 3:00 a.m. and informed her that Resident #12 was unresponsive. LPN-C indicated the Resident's blood glucose was checked and was low, IM [MEDICATION NAME] was administered, and she waited 10-15 minutes and rechecked Blood glucose and was it was not coming up. LPN-C indicated Resident #12 was moaning and groaning and not talking with staff. LPN-C indicated oral Glucose Gel was put under the Resident's tongue and inside of the mouth at the side. LPN-C indicated the Resident started responding after oral gel was given, stating "I'm coming back". LPN-C indicated the physician was not called regarding the Resident's blood glucose being less than 80 and/or the Resident's unresponsive episode, but was instead notified via a fax. LPN-C indicated that on 7/14/15, the oral glucose gel was administered to the resident because a second dose of [MEDICATION NAME] IM was not available in the facility. LPN-C indicated only one Hypoglycemic Kit was available for the entire facility, which on 7/14/14 included only one [MEDICATION NAME] vial for injection and 2 tubes of oral glucose gel. LPN-C indicated that on 7/14/14, she reported to the dayshift nurse and the Director of Nursing (DON) that she had used the contents of the only Hypoglycemic Kit in the facility and that the kit needed to be refilled. LPN-C indicated that on 7/15/14 at about 3:00 a.m., CNA-G informed her that the resident was again unresponsive. LPN-C indicated the resident was unresponsive, the blood glucose was in the low 40s and that she administered 1 tube of oral glucose gel. LPN-C indicated that after 10 minutes the resident remained unresponsive and that a second tube of oral glucose gel was administered. LPN-C indicated that after 20 minutes the resident remained unresponsive and had a blood glucose of 47. LPN-C indicated that she then called the DON who instructed her to monitor for a few more minutes and if the resident's condition does not change to call 911. LPN-C indicated that after she spoke with the DON, the resident started having gurgling noises with respiration and 911 was called. LPN-C indicated she administered the oral glucose gel to the unresponsive resident because no injectable [MEDICATION NAME] was available at the facility. LPN-C indicated the pharmacy did not deliver the new Hypoglycemic Kit until 4:30 a.m. on 7/15/14. On 10/06/14 at 9:50 a.m., Surveyor spoke with Registered Nurse (RN)-F who indicated LPN-C informed her on the morning of 10/14/14, that Resident #12 was unresponsive during the night and was given the [MEDICATION NAME] and glucose gel from the Hypoglycemic Kit. RN-F indicated that LPN-C informed her that the Hypoglycemic Kit would need to be replaced, and that the DON was aware of the need to replace the Kit. RN-F indicated that at 9:30 a.m. the [DIAGNOSES REDACTED] Kit was not yet replaced, and the DON was again notified of this during the morning Stand Up meeting. RN-F indicated that the facility did not receive the Kit by the end of her shift. On 10/07/14, at 11:00 a.m., Surveyor # spoke with RN-E who worked on the p.m. shift of 7/14/14. RN-E indicated that on the evening of 7/14/14 at 8:00 p.m., the resident was awake, alert and responsive, ate a cheese sandwich, and had no respiratory problems. RN-E indicated he was not aware of the Hypoglycemic Kit needing to be received from pharmacy. On 10/07/14, at 2:50 p.m., Surveyor # spoke with the Pharmacy Consumer Service Nurse-D who indicated resident medication orders are refilled either on a STAT basis or through a regular request. Pharmacy Consumer Service Nurse-D indicated that a medication refill requested as STAT would be received within 4 hours and a medication refill requested as routine would be received within 24 to 48 hours. Pharmacy Consumer Service Nurse-D indicated that on 10/14/14 at 10:45 a.m., the facility called the pharmacy and requested the [DIAGNOSES REDACTED] Kit to be refilled. Pharmacy Consumer Service Nurse-D indicated the request was not a STAT request, but was requested to be sent to the facility by midnight on 7/14/14. Pharmacy Consumer Service Nurse-D indicated the kit was delivered to the facility on [DATE] at 4:30 a.m. On 10/07/14, at 2:10 p.m., Surveyor # spoke with the DON who indicated that on 7/14/14, the contents of the one [DIAGNOSES REDACTED] Kit available at the facility were used. The DON indicated that on 7/15/14 at 10:45 a.m., she called the Pharmacy and informed them that the [DIAGNOSES REDACTED] Kit needed to be refilled by 12 midnight, and that the request for the refill was not requested as STAT. The DON indicated that on 7/15/14 at 3:00 a.m., when Resident #12 was experiencing a hypoglycemic reaction, there was not a Hypoglycemic Kit available in the facility with injectable [MEDICATION NAME]. The DON indicated the [MEDICATION NAME] was not available because it was used on 7/14/14 and not refilled in time. The DON indicated oral glucose gel should not be given to a resident unless the nurse is able to verify that the resident can swallow. The DON also indicated that on 7/14/14, when the resident was unresponsive and had a blood glucose less than 80, the nurse should have called the physician instead of sending the fax. On 10/07/14, the Surveyor reviewed the facility's [MEDICAL CONDITION]/[DIAGNOSES REDACTED] Protocol. The protocol defines [DIAGNOSES REDACTED], provides signs and symptoms of [DIAGNOSES REDACTED] and guidelines for treating [DIAGNOSES REDACTED]. The guidelines include high glucose content foods. The protocol states "per nursing judgment the following guidelines may be used: 1. Give 15g glucose and wait 15 minutes before retesting blood glucose 2. IF blood glucose is still below 60mg/dl; repeat giving another 15g glucose and wait 15 minutes to retest blood sugar. **It is not unusual to repeat the procedure if the blood sugar was less than 60mg/dl. 3. May give [MEDICATION NAME] 1 mg IM (intramuscularly), IV (intravenously), or SubQ (subcutaneously). Repeat in 20 minutes if necessary" The protocol indicates the physician should be called if blood glucose is less than 60mg/dl or greater than 250, unless otherwise specified by the primary physician. Resident #12 had specific orders for the physician to be called if his blood glucose was less than 80mg/dl. The protocol does not include treatment approaches for an unresponsive resident. On 10/06/14, at 2:30 p.m., the surveyor spoke with the DON who indicated the facility's policy is to administer the oral glucose gel and the injectable [MEDICATION NAME] per packaging directions. The packaging directions for the oral glucose gel reads "To treat hypoglycemic reaction before unconsciousness occurs" and "Warning: for oral use only: Do not administer to any person who is unconscious or unable to swallow." On 9/18/14 the Southeastern Regional Office for the Division of Quality Assurance received a call from the wife of Resident #12. During this telephone call, the wife indicated that she finally had the chance to call in a complaint regarding her concerns for Resident #12 given the significant changes that this episode created for Resident #12 and her. She indicated that the Resident was originally admitted for rehabilitation to get him stronger so that he could return back home for her to help him fully recover. The wife indicated that she is very involved in the Resident's care and even while in the facility she still picked him up and took him for his appointments and [MEDICAL TREATMENT] etc. The wife indicated that this episode has left Resident #12 with [MEDICATION NAME] changes including changes in his cognition, speech and physical strength beyond what he was originally rehabilitating from. The facility's failure to ensure that the care provided to Resident #12 during two hypoglycemic episodes was based upon current standards of care for an unresponsive individual created a situation of Immediate Jeopardy. The jeopardy began on 7/14/14 when the facility administered oral glucose gel to Resident #12 who was unresponsive at the time. The facility removed the immediate jeopardy on 10/9/14 when it implemented the following: 1. The facility presented the situation and concerns to QA and Medical Director. The identified plan was to increase the number of hypoglycemic boxes. Nurses educated on location of hypoglycemic boxes and to STAT out order if contents of hypoglycemic are used. 2. The facility ensured that the Pharmacy delivered additional hypoglycemic boxes to the facility. 3. DON educated nurses on the location of the contingency boxes (specifically hypoglycemic box) and the contents of the ebox (including the IM kit). 4. The facility established inservicing via CE-Solutions regarding diabetic residents. 5. The facility reviewed and revised their Hyper/hypoglycemic policy and procedure updated to reflect more definitive guidelines on action to take on a hypoglycemic resident, including but not limited to an unresponsive resident. Will be reviewed by QA committee and revisions will be made as necessary. 6. The facility established a system to ensure that nurses are educated on new Hyper/hypoglycemic policy and procedure. Nurses also are to be in-serviced by Omnicare Pharmacy on diabetic residents focusing on hyper and hypoglycemic episodes. 7. Chart reviews are to be completed and updated physicians orders for Glucose and glucogen were added to insulin dependent diabetic residents. Diabetic care plans were updated on [DATE]th to include actions to take on an insulin dependent resident. All other diabetic care plans (4 residents) to be reviewed starting [DATE]th to be completed no later than October 9th 8. The facility established a system for nurses to check each shift that the seal of the hypoglycemic contingency boxes aren ' t broken and findings recorded on audit log. Nurse to order new box through pharmacy if seal is broken. 9. The facility established and an education process for nursing staff regarding the policy and procedure of Ordering Contingency Medication Supply. Audits to be done ensuring proper reordering of contingency boxes. The pharmacy was contacted to verify new procedures for ordering contingency medication boxes 10. The facility established and an education process for nursing staff regarding the updated policy procedure on physician notification and RN/DON notification. 11. The facility reinforced their process to ensure nursing communication is done between each shift through a nurse to nurse report utilizing the 24 hour nursing board updated every shift by nurse and reviewed by DON, NHA and kept in file. To be presented and QA and follow through to be done by DON. Stand-up meeting notes to be recorded and reviewed each day by NHA to ensure follow-through is being done. Will present findings at QA. 12. Chart audits on diabetic residents will be completed to ensure doctors are being updated appropriately related to diabetic parameters. To be reviewed at QA.

Based on record review, interview, and policy review the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident. 1 of 2 sampled Resident's (Resident #12) who needed a Glucagon injection for [DIAGNOSES REDACTED] did not receive it because the facility did not ensure that it was reordered in a STAT (immediate) manner. Additionally the facility had a system in place for standing orders that did not ensure each resident's medications were reviewed for appropriateness or contraindications by their physician. This deficient practice this has the potential to affect all 47 residents. ~ On 7/15/14 Resident #12 needed a Glucagon injection for [DIAGNOSES REDACTED]. The facility had used the last dose of Glucagon from the diabetic kit on 7/14/14 for Resident #12. The facility faxed a request to the pharmacy in the morning of 7/14/14 but did not request it "stat" and it was not available on 7/15/14 when Resident #12 needed it. Instead the Licensed Practical Nurse administered oral glucose gel to Resident #12 who was unresponsive at the time. The administration of oral glucose gel to Resident #12 on 7/15/14 who was unresponsive caused Resident #12 to experience a prolonged hypoglycemic episode, led to Resident #12 aspirating on the glucose gel and led to Resident #12 experiencing anoxic [DIAGNOSES REDACTED]. ~ A standing order book was used in the facility for all residents that included a list of orders per physician. These orders were not individualized per each facility resident nor were they signed for each resident. Findings include: 1.) On 9/18/14 the Southeastern Regional Office for the Division of Quality Assurance received a call from the wife of Resident #12. During this telephone call, the wife indicated that she finally had the chance to call in a complaint regarding her concerns for Resident #12 given the significant changes that this episode created for Resident #12 and her. She indicated that the Resident was originally admitted for rehabilitation to get him stronger so that he could return back home for her to help him fully recover. The wife indicated that she is very involved in the Resident's care and even while in the facility she still picked him up and took him for his appointments and dialysis etc. The wife indicated that this episode has left Resident #12 with lasting changes including changes in his cognition, speech and physical strength beyond what he was originally rehabilitating from. On 10/06/14 Surveyor # reviewed Resident #12's medical record. The Resident Admission Record indicates the resident was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. The Resident Progress Note, dated 7/14/14 at 6:20 A.M., states Resident #12 was unresponsive at 4:45 a.m., color ashen, skin warm and dry, and blood glucose was 47. The note indicates the resident was given 1 milligram (mg) of IM GlucaGen and 2 tubes of glucose gel sublingual. The note indicates the resident's blood glucose came up to 69 and the resident was starting to respond. The note indicates the blood glucose was rechecked after 10 minutes and was 98. The note indicates the blood glucose was again checked at 6:00 a.m. and was 119. The Resident Progress Note, dated 7/15/14 at 6:31 a.m., indicates that at 3:00 a.m. when staff went to wake Resident #12 up for dialysis, the resident was unresponsive. The note indicates the Certified Nursing Assistant stated the resident was alert and had been responding one hour earlier. The note indicates the resident had a blood glucose of 42 and the nurse administered 2 tubes of glucose sublingually. The note indicates that 20 minutes later the blood glucose only came up to 47, and that the resident remained unresponsive. The note indicates the Director of Nursing (DON) was called and that the DON stated to monitor for a few more minutes and if the resident remains unresponsive to call 911. The note indicates the resident left for the hospital per rescue squad at 4:15 a.m. Because there was no GlucaGen in the diabetic kit, the nurse was unable to administer the injectable GlucaGen as ordered; instead she gave oral glucose gel to the unresponsive resident. The ambulance service Pre-hospital Care Report, dated 7/15/14, indicates the crew arrived on scene at 3:53 a.m. and found Resident #12 unresponsive with audible gurgling upper respiratory noises. The report indicates that the nurse reported giving the resident 2 tubes of oral glucose, under his tongue. The report indicates that the crew verified that the nurse gave an unresponsive resident oral glucose. The report indicates the crew suctioned the resident and cleared the airway of oral glucose. The report indicates that at 3:55 a.m. the resident's blood glucose was monitored and noted to be 21 and the resident's pulse oxygenation was noted to be 87 with room air. The report indicates intravenous (IV) dextrose 1 amp, was administered, the blood glucose level was rechecked and noted to be 244, the resident remained unresponsive and the resident was transported to the emergency room . The hospital Emergency Department (ED) notes, dated 7/15/14, indicate Resident #12 arrived in the emergency department at 4:37 a.m. The report indicates that the resident was found unresponsive in the nursing home, 2 tubes of oral glucose were given despite the resident being unable to swallow, that the EMS was called, IV dextrose was given, the resident became more awake, was unable to follow commands, was nonverbal, had grunting with gurgling/coarse breath sounds and non-purposeful combative motions. The Emergency Department Critical Care notes, dated 7/15/14 at 5:05 a.m., indicate the resident was combative, eyes not focusing, nonverbal and unable to follow commands. The ED notes, dated 7/15/14 at 5:45 a.m., and 5:54 a.m., indicate the resident's condition was unchanged and the resident was to be admitted to the hospital for further evaluation and/or workup. The Emergency Department Notes indicate an impression of the primary encounter [DIAGNOSES REDACTED]. The hospital Admission History and Physical indicates a chest X-ray was completed on 7/15/14 with the impression of small bilateral pleural effusions with overlying consolidation and atelectasis. The Assessment and Plan indicates the likely cause of altered mental status is due to possible seizure caused by [DIAGNOSES REDACTED] and the resident being post-ictal. The Assessment and Plan indicate the resident likely does have aspiration pneumonia. The Physician Discharge Summary, dated 7/28/14, indicates a discharge [DIAGNOSES REDACTED].#12 was admitted on [DATE] with [DIAGNOSES REDACTED] and shortness of breath. The summary indicated the resident was treated for [REDACTED]. The discharge summary indicates the resident was discharged to inpatient rehab with improved mental status and speech. The hospital Final [DIAGNOSES REDACTED]. On 10/07/14, at 7:30 a.m., Surveyor # spoke with Licensed Practical Nurse (LPN)-C who worked on the night shift on 7/14/14 and 7/15/14. LPN-C indicated that on 7/14/14 the Certified Nursing Assistant (CNA) came and got her at 3:00 a.m. and informed her that Resident #12 was unresponsive. LPN-C indicated the Resident's blood glucose was checked and was low, IM GlucaGen was administered, and she waited 10-15 minutes and rechecked Blood glucose and was it was not coming up. LPN-C indicated Resident #12 was moaning and groaning and not talking with staff. LPN-C indicated oral Glucose Gel was put under the Resident's tongue and inside of the mouth at the side. LPN-C indicated the Resident started responding after oral gel was given, stating "I'm coming back". LPN-C indicated that on 7/14/15, the oral glucose gel was administered to the resident because a second dose of GlucaGen was not available in the facility. LPN-C indicated only one Hypoglycemic Kit was available for the entire facility, which on 7/14/14 included only one vial of GlucaGen for injection and 2 tubes of oral glucose gel. LPN-C indicated that on 7/14/14, she reported to the dayshift nurse and the Director of Nursing (DON) that she had used the contents of the only Hypoglycemic Kit in the facility and that the kit needed to be refilled. LPN-C indicated that on 7/15/14 at about 3:00 a.m., CNA-G informed her that resident was again unresponsive. LPN-C indicated the resident was unresponsive, the blood glucose was in the low 40s and that she administered 1 tube of oral glucose gel. LPN-C indicated that after 10 minutes the resident remained unresponsive and that a second tube of oral glucose gel was administered. LPN-C indicated that after 20 minutes the resident remained unresponsive and had a blood glucose of 47. LPN-C indicated that she then called the DON who instructed her to monitor for a few more minutes and if the resident's condition does not change to call 911. LPN-C indicated that after she spoke with the DON, the resident had started having gurgling noises with respiration and 911 was call. LPN-C indicated she administered the oral glucose gel to the unresponsive resident because no injectable GlucaGen was available at the facility. LPN-C indicated the pharmacy did not deliver the new Hypoglycemic Kit until 4:30 a.m. on 7/15/14. On 10/06/14 at 9:50 a.m., Surveyor spoke with Registered Nurse (RN)-F who indicated LPN-C informed her on the morning of 10/14/14, that Resident #12 was unresponsive during the night and was given the GlucaGen and glucose gel from the Hypoglycemic Kit. RN-F indicated that LPN-C informed her that the Hypoglycemic Kit would need to be replaced, and that the DON was aware of the need to replace the Kit. RN-F indicated that at 9:30 a.m. the [DIAGNOSES REDACTED] Kit was not yet replaced, and the DON was again notified of this during the morning Stand Up meeting. RN-F indicated that the facility did not receive the Kit by the end of her shift. On 10/07/14, at 11:00 a.m., Surveyor # spoke with RN-E who worked on the p.m. shift of 7/14/14. RN-E indicated that on the evening of 7/14/14 at 8:00 p.m., the resident was awake, alert and responsive, ate a cheese sandwich, and had no respiratory problems. RN-E indicated he was not aware of the Hypoglycemic Kit needing to be received from pharmacy. On 10/07/14, at 2:50 p.m., Surveyor # spoke with the Pharmacy Consumer Service Nurse-D who indicated resident medication orders are refilled either on a STAT basis or through a regular request. Pharmacy Consumer Service Nurse-D indicated that a medication refill requested as STAT would be received within 4 hours and a medication refill requested as routine would be received within 24 to 48 hours. Pharmacy Consumer Service Nurse-D indicated that on 10/14/14 at 10:45 a.m., the facility called the pharmacy and requested the [DIAGNOSES REDACTED] Kit to be refilled. Pharmacy Consumer Service Nurse-D indicated the request was not a STAT request, but was requested to be sent to the facility by midnight on 7/14/14. Pharmacy Consumer Service Nurse-D indicated the kit was delivered to the facility on [DATE] at 4:30 a.m. On 10/07/14, at 2:10 p.m., Surveyor # spoke with the DON who indicated that on 7/14/14, the contents of the one [DIAGNOSES REDACTED] Kit available at the facility were used. The DON indicated that on 7/15/14 at 10:45 a.m., she called the Pharmacy and informed them that the [DIAGNOSES REDACTED] Kit needed to be refilled by 12 midnight, and that the request for the refill was not requested as STAT. The DON indicated that on 7/15/14 at 3:00 a.m., when Resident #12 was experiencing a hypoglycemic reaction, there was not a Hypoglycemic Kit available in the facility with injectable GlucaGen. The DON indicated the GlucaGen was not available because it had been used on 7/14/14 and not refilled in time. The DON indicated oral glucose gel should not be given to a resident unless the nurse is able to verify that the resident can swallow. On 10/9/14 at 10:10 a.m. Surveyor # interviewed Licensed Practical Nurse (LPN) -C to clarify how many GlucaGen injections were used between 7/13/14-7/14/14 and who used the injections. LPN-C stated she gave Resident #9 a glucagon injection out of the hypoglycemic kit on 7/13/14 and did not reorder the medication until the next morning. LPN-C stated she used another Glucagon injection for Resident #12 the morning of 7/14/14. LPN-C stated that there were only 2 injections of Glucagon in the hypoglycemic kit and she used both. LPN-C stated she faxed the order for another hypoglycemic kit the morning of 7/14/14 but did not make it a stat order (which would be delivered to the facility in 4 hours). 2.) On 10/7/14 at 1:45 p.m. Surveyor # observed the standing order book at the nurses station while reviewing the facility's as needed medication process for oral glucose and injectable glucose. Review of this "standing order" book indicates that it contains 3 pages of typed, as needed orders for 29 different physicians that may have residents residing in the facility. Surveyor # asked RN-E about the standing order book. RN-E indicated that, for example, if a resident who has one of the 29 physicians with orders they can go to the physician's orders [REDACTED]. RN-E was asked if he knew if the orders in the book were reviewed with a physician for each individual resident for contraindications or exception at the time of admission of a new resident and RN-E indicated that he did not think so. It was noted upon review of the "standing orders", that no resident names were on the sheets only the physician's name and a signed date. The dates on the orders ranged from 8/26/2012 to 2/5/14. All but one was over a year old (from the date of the survey) and one set of orders was not dated. On 10/7/14 at 3:00 p.m. Surveyor # interviewed the Director of Nurses (DON) who stated that each physician in the building signs a set of standing orders they want for their residents. This set of orders is used for their entire resident case load. The DON also stated that the orders are not verified or spoken with the physician for contraindications before use. The DON stated the orders can be used for 72 hours before calling the physician. On 10/8/14 at 9:55 a.m. Surveyor # interviewed the DON who stated there was no policy regarding standing orders and they have been using this system for [AGE] years. On 10/9/14 at 11:30 a.m. Surveyor # interviewed the facility's pharmacy customer service nurse-D who stated that the facility's current system for standing orders does not meet the regulations and that each resident should have separate standing orders in their medical records. The above findings were shared with the Administrator and Director of Nurses on 10/9/14 at 2:00 p.m. Additional information was requested if available. None was provided.

Based on record review and interviews, facility staff did not ensure one of six resident's (Resident #1) environment remained free of accident hazards, nor did they provide adequate supervision and assistive devices to prevent accidents. Resident #1 is [AGE] years old, admitted to the facility in December, 2010 following surgery for [REDACTED]. Resident #1 fell [DATE] attempting a self-transfer from wheel chair to bed, in another resident's room; alarm sounded. Resident #1 fell on [DATE] again self-transferring from her wheel chair. The alarm batteries, which had been functioning earlier that day, were dead. Staff replaced the clip alarm with a sensor pad, but did not address the issue of monitoring for dead batteries, or increasing supervision since the batteries/alarm did not give the warning sound that the batteries were getting low. Resident #1 fell on [DATE], the day she was supposed to be discharged to home. Staff had raised up Resident #1's bed to assist with morning cares, then stepped away from the bed to get supplies. While the staff was away from the bed with her back turned, Resident #1 fell out of bed and suffered on-going pain in her left hip. Resident #1's discharge to home was canceled. On [DATE], Resident #1 returned from a doctor's appointment at approximately 2:30 p.m. without her wheel chair alarm turned on. At 6:00 p.m. Resident #1 was found on the floor in her room. Resident #1 had gone to the toilet, removed her wet pants, came out of the bathroom and fell to the floor. Resident #1 sustained a left hip fracture requiring surgery. Resident #1 also has a Wanderguard on her wheel chair since she wanders about the facility, and is confused. The Post Fall Analysis Worksheet consisted of a statement from only one staff member, even though Resident #1 was back at the facility for 3 ,[DATE] hours, and is at risk for falls and elopement Findings include: Surveyor # reviewed Resident #1's medical record on ,[DATE]- [DATE]. Resident #1 was admitted to the facility on [DATE] following surgery for [REDACTED]. ASSESSMENTS Surveyor # reviewed Fall Risk Assessments dated [DATE] and [DATE] indicating Resident #1 was at high risk for falls. Resident #1 scored 18; a score of 10 or above represents high risk for falls. Resident #1 was assessed at high risk for falls due to intermittent confusion, history of ,[DATE] falls in past three months, is chair-bound, not able to perform gait/ balance test, medications and predisposing diseases. Fall Risk Assessments dated [DATE], [DATE], and [DATE] indicate Resident #1 scored ,[DATE], the increase due to increased points for 3 or more falls in past three months. Surveyor # also reviewed an Elopement Risk assessment dated [DATE] which indicates Resident #1 has confusion, is alert and oriented X1 (times one- to herself- not place or time), has underlying dementia, moves about in a wheel chair, verbally expresses desire to go home, will try to go out doors- alarms are on, moves about freely, has pain in right hip, and talks about her brothers picking her up. The Elopement Risk Assessment indicates a personal safety alarm device was initiated [DATE] (Wanderguard), exits are alarmed, staff aware of need for frequent monitoring, motion detector when in bed and sensor alarm in wheel chair initiated [DATE]. Surveyor # reviewed Resident #1's Initial MDS (Minimum Data Set) dated [DATE] which indicates Resident #1 had a fall with fracture prior to admission. Surveyor # reviewed a Significant Change in Status Assessment for Resident #1 dated [DATE], indicating Resident #1 had one fall with major injury since previous assessment. The CAA (Care Area Assessment) Analysis of Findings dated [DATE] states: Resident has had multiple falls, fractured her right hip [DATE] (home) then fractured her left hip [DATE] and required surgical repair. Resident is unaware of own safety and remains at risk for further falls with injury. Resident is working with therapy to return to baseline to be able to return hoe with her son. Resident with dementia, forgetful with confusion. CARE PLANS Surveyor # reviewed Resident #1's original Care Plan initiated [DATE] "Risk for Falls" related to high risk assessment score, unsteady gait, impaired physical mobility secondary to right hip fracture, impaired judgement, fall in past 30 days, wandering behavior. Actual Falls/date & approach: fall [DATE]- no injury; Fall [DATE] -no injury, sent to ER for evaluation/treatment status [REDACTED]. The Goal is "will be free from falls with injury". "Approaches" include: Keep call light within reach at all times and answer promptly; non-skid footwear; keep adjustable bed in lowest position for safe transfers; lock bed brakes; encourage to use recommended assistive device in transferring/ ambulation: moderate assist of 2 with pivot disc; encourage to request assist in transfer and ambulation; monitor for change in gait; low bed; follow toileting schedule; do not leave alone in bathroom; motion alarm when in bed; sensor alarm when in wheel chair; monitor during activities and bring to supervised areas during waking hours; add ,[DATE] Wanderguard. Surveyor # reviewed an updated Fall Risk Care Plan with a printed goal date of [DATE], and a hand-written note stating "cont. thru [DATE]". It states: Problems [DATE]- [DATE]: Resident is at risk for falls related to history of falls, high risk fall assessment, unsteady gait, impaired physical mobility secondary to hip fracture, impaired judgement, wandering behaviors and psychotropic drug use. The three above falls are listed/ printed, and staff hand-wrote a fall [DATE]. On [DATE] staff added: Remains at risk for falls with injury. Continue to care plan. "Interventions" include the above, and staff added: "keep bed in low position while resident in bed, string alarm dc'd (discontinued) [DATE], do not leave resident alone in bed without turning alarm on, ask resident if she needs to go to the bathroom and lay down after meals, make sure when resident returns from appointments that her alarm is checked and turned on- also with outings." FALLS On [DATE] Surveyor # asked DON (Director of Nursing)-B for any information regarding Resident #1's falls since admission. DON-B provided Surveyor # with the following: 1.) Surveyor # reviewed Resident #1's Incident / Accident Report dated [DATE] at 8:50 a.m. Resident #1 attempted self-transfer from w/c (wheel chair) to bed, alarm sounded. Aides found (resident) in sitting position with legs straight out, no complaint of pain. Resident was alert and confused. Resident had contact with aid 5 minutes prior to fall and refused toileting. The Fall assessment dated [DATE] indicates Resident #1 was in the wrong room, and the resident's dementia is a contributing factor. The Post Fall Analysis Worksheet and dated [DATE] indicates the string alarm was in place, but it will be shortened so alarm sounds sooner should resident lean forward or attempt standing. 2.) Surveyor # reviewed an Incident / Accident Report dated [DATE] at 2:10 p.m. stating Resident was found laying on floor next to her bed, does not know how it happened. Says she hit her head- denies any pain. No injuries noted. String alarm in place, not functioning. Replaced with sensor pad The Fall assessment dated [DATE] indicates it had been two hours since Resident #1's last meal, but does not indicate who last saw Resident #1, when they saw her, what she was doing, etc. It states: Resident is confused, does not know how she fell . Not aware of safety. Alert, confused. Unsteady gait, unaware of inability to walk. Dementia and psych diagnoses, sundown behaviors. "Patient was likely putting self to bed, transferred self, does not know how it happened due to dementia. Alarm did not sound, replaced with sensor pad. Surveyor # reviewed the Post Fall Analysis Worksheet dated [DATE] which states: Resident tried to stand or self- transfer from w/c and fell to the floor. Resident unable to say what she was doing or what caused the fall. Found on floor next to bed. Alarm had been functioning earlier. At the time of the fall, alarm did not sound- batteries dead. Sensor pad placed. Resident with dementia and increased confusion. Likely trying to lay self down. Interventions Implemented: sensor pad placed. There are no interviews from staff which would provide information regarding where Resident #1 was and what she was doing for the two hours since lunch; if staff had offered toileting, or offered to assist Resident #1 lay down after lunch, if she was agitated, etc. Staff would then use the information to develop new interventions to prevent future falls. There was no documentation indicating staff were monitoring Resident #1's whereabouts, even though she has been assessed as a high fall risk and elopement risk. There is also no documentation indicating staff addressed the issue of the alarm not working- nothing to address the dead batteries. 3.) Surveyor # reviewed an Incident/ Accident Report dated [DATE] at 7:00 a.m. indicating "Pt. (patient) in bed- CNA (Certified Nursing Assistant) turned and walked to sink to get washcloth and heard pt. stated "Can I get up now?" CNA turned around and pt. on the floor- swelling to back of head and c/o (complaint of) left hip pain. Resident alert to self. Additional comments and/or steps taken to prevent recurrence: CNA to leave alarm on and bed in lowest position when stepping away from bed." - Fall assessment dated [DATE]: notes Resident #1 was barefoot in bed, motion sensor was turned off by CNA... "In reviewing above data, what most likely contributed to the fall? Also note any commonalities with previous falls: Dementia- not aware of safety- very fast / spontaneous." -Post Fall Analysis Worksheet dated [DATE]: Resident had been in bed, CNA had turned the alarm off then went to sink to get wash cloth when she turned around, resident was lying on the floor. Exploration of possible causes/ contributing factors? Resident not aware of own safety, moves very quickly. Resident with bare feet and attempted to get up. Alarm had been turned off as CNA was going to get resident up and ready for the day. Interventions Explored: Talk with staff re: keeping bed in lowest position until completely ready, have all supplies at bedside. Interventions Implemented: Staff instructed to turn alarm back on and to leave bed in lowest position when stepping away from the resident. Resident sent to ER (emergency room ) for evaluation. A statement from CNA (Certified Nursing Assistant)-F was included, indicating she was going to assist Resident #1 get up. CNA-F "raised the bed up a little bit and turned around to start the sink, and to get her stockings. I heard (Resident #1) say something, turned my head, and saw her falling, already a couple of inches from the floor. I had turned around for just a few seconds, so she went from a complete laying position, to sitting up, and then standing VERY quickly. I called for help and waited." Surveyor # reviewed a progress note from Resident #1's physician dated [DATE], which contained orders/ instructions to discharge Resident #1 to her son's home on [DATE]. "Ready for discharge- patient doing well." Social Service Notes dated [DATE] state the social worker "had made referral to VNA (Visiting Nurses' Association) last Thursday [DATE] to resume previous services and to add PT (Physical Therapy) upon discharge home today. However, (Resident #1) did fall this a.m. and was sent to ER for evaluation. (Resident #1) did return with all tests negative. DON spoke to son...Resident will remain at facility until Friday..." Nurses' Notes include: [DATE] 2:30 p.m. Returned from ER- Xrays and CT negative. Son aware and agrees to have resident stay at facility until Friday for closer observation- is favoring left leg- and c/o pain- difficult time standing-needed assist. given scheduled Vicodin... [DATE] at 1:00 p.m. and [DATE] at 7:20 p.m. indicate Resident #1 continues to complain of increased pain during transfers- refusing to try to ambulate...no complaint of pain at rest...receiving scheduled Vicodin... [DATE] 10:00 a.m. ...w/c for mobility due to increase pain to left hip, working with therapy... [DATE] 2:00 p.m. and [DATE] at 12:45 p.m. ...continues with increased pain during transfers to left hip- apprehensive with any transfers... Notes almost daily document increased left hip pain. [DATE] 9:00 a.m. ...Writer barely touches left hip and (Resident) yells out- "don't touch me it hurts", follow up appointment with orthopedic surgeon scheduled... (Note: this is more than two weeks after Resident #1's fall on [DATE]). [DATE] 9:30 a.m. ...(also ,[DATE], ,[DATE], ,[DATE]) continues with increased pain during transfers/ repositioning, mainly to left hip... [DATE] ...denies pain at rest, will c/o left hip pain during transfers but does appear to be more under control with scheduled Vicodin...(Note: this is 4 weeks after fall on [DATE].) Surveyor # reviewed daily CNA documentation for the week leading up to her fall on [DATE] which indicated she needed limited assistance of one staff for bed mobility, transfers and walking in room. CNA documentation dated [DATE]-[DATE] indicates Resident #1 needed extensive assistance of one staff for those activities, and Resident #1 did not walk in her room at all. 4.) Surveyor # reviewed an Incident /Accident Report dated [DATE] at 6:00 p.m. indicating Resident #1 "Lost balance upon exiting bathroom. found laying on left side with back against open bathroom door, head toward windows. [DIAGNOSES REDACTED]. Sent to ER- left hip fracture. Steps to prevent recurrence: Residents with alarms returning from appointments or outings should have alarms checked on return. - Fall assessment dated [DATE] at 6:00 p.m. indicates it had been an hour since Resident #1's last meal; alarm did not activate. Resident had toileted self, was attempting to walk out of bathroom and fell landing on left side. [DIAGNOSES REDACTED]. Behavior /Mood problems: dementia with agitation. In reviewing above data, what most likely contributed to the fall? Also note any commonalities with previous falls: Residents with alarms returning from appointments should have alarms checked upon returning to facility. Alarm was apparently deactivated at MD's office and not reactivated. - Post Fall Analysis dated [DATE] indicates Resident #1 toileted self, pants wet which resident had removed, came out of bathroom and fell to floor. Alarm had been turned off while out for urology appointment and wasn't turned back on. Resident denied need to void prior to supper. Current Interventions: sensor pad in w/c, motion alarm in bed. Sent to ER for evaluation and treatment of [REDACTED]. Interventions Implemented: Staff instructed to ensure alarms are turned on- checked with return from appointments/ outings. Staff inserviced. There was only one staff statement, from CNA-G, stating she "took Resident (#1's) roommate to the bathroom, then asked Resident (#1) if she had to go. Resident (#1) refused. Resident (#1) was at a doctor's appointment upon my arrival at 2:00 p.m. I'm not sure at what time she came back from Dr. appointment, but know she was back before supper. During supper she went back to her room at that time tried to toilet herself." No statements from other staff who may have seen and/ or interacted with Resident #1 were included in the fall investigation/ report, even though Resident #1 had been back at the facility for 3 ,[DATE] hours and she is both a high fall risk and elopement risk. No further information was provided regarding Resident #1's activities and whereabouts from 2:30 p.m. to 6:00 p.m. when she was found on the floor. The investigation does not indicate who found Resident #- if they just came upon her or if they heard Resident #1 calling out since the alarm did not sound; or how long she may have been on the floor. Included with the investigation was an "Alarm Check Policy and Procedure" dated [DATE] stating: It is the policy of Geneva Lake Manor that all residents will maintain their safety upon returning from appointments and outings. Procedure: Any patient retuning from an outing or appointment shall be checked for safety by the following: 1. If the GLM driver did a transport he shall update nursing of patient's return. 2. The nurse on duty shall assess the patient that the alarm is on. 3. Assess patient is pain free. 4. Assess patient has no change in medical condition as prior to leaving for appointment. 5. All CNA's shall check patients upon returning from outings or appointments for patient safety that alarm is on. 6. CNA's shall report to nurse of patient's return. 7. Nursing will then document of patient's return. A copy of a notice was included in the investigation stating: To All Nursing/ CNA's: Please note that any patient returning from an appointment or an outing must have their alarm checked by a nurse or CNA. A copy of Inservice Education Minutes sign-in log for "Alarm check policy/ procedure, presented on [DATE] by DON-B is signed by 23 nursing/ CNA staff. A review of the current facility employment roster indicates this is approximately half of their nursing /CNA staff. Surveyor # reviewed Resident #1's nursing notes and observed a note documenting Resident #1 was "found laying on her left side" on [DATE] at 6:00 p. m. The note prior to that note was from [DATE]. Following a series of notes relating to sending Resident #1 to the ER and making notifications is a "late Entry" stating "Patient left facility approximately 1:00 p.m. [DATE] for appointment with urologist via GLM van to transport. Returned approximately 2:30 p.m. in good spirits." Nurses' Notes indicate Resident #1 returned to to facility on [DATE] after surgery to repair her left hip fracture. Surveyor # reviewed a Palliative Care note dated [DATE] from when Resident #1 was in the hospital. It was discovered she may have [DIAGNOSES REDACTED], which can include symptoms of bone pain, and high levels of calcium in the blood, when demineralization of the bones occurs and can lead to unexplained bone fractures, and weakness or numbness in the legs. Given the increased risk of serious injury if Resident #1 falls, it is all more important to do everything possible to prevent falls. On [DATE] at the daily exit meeting, Surveyor # shared the following concerns regarding Resident #1's falls: - When Resident #1 fell on [DATE], staff were aware Resident #1 fell at home in December at home fracturing her right hip, and fell in the facility on [DATE]. Staff determined that while the alarm was functioning earlier in the day, the alarm did not sound when Resident #1 self-transferred from her wheel chair because the alarm batteries were dead. Staff replaced the string alarm with a sensor pad. Surveyor # asked how replacing the string alarm with the sensor pad addressed the issue of monitoring battery life. NHA-A stated they replace alarm batteries every 30 days. Surveyor # asked how they track when the 30 days are up- do they enter a date on the MAR (Medication Administration Record), label the alarm with the date the batteries were installed or when they need to be replaced, or change all on the the first of the month, etc. NHA-A, DON-B, ADON (Assistant Director of Nursing)-E, and LPN (Licensed Practical Nurse)-I, all members of the fall committee, were unaware of how the 30 days is tracked, or if that affects just the string/clip alarms or the sensor pads, too. NHA-A stated the alarm and batteries were working earlier that day. DON-B stated the alarms beep when the batteries are going dead- the beeping gets slower and slower, but that did not happen with Resident #1's alarm- the batteries just died . Surveyor # asked what interventions they instituted to address the batteries just dying with no warning, such as increased supervision of the Resident-especially in regards to Resident #1 who was a high fall and elopement risk. DON-A stated they replaced the string alarm with the sensor pad, which does not address the known malfunction of Resident #1's string alarm or replacing batteries every 30 days. NHA-A provided Surveyor # with manufacturer's information for the Secure Alert-Mate Alarm, which she says was the string alarm Resident #1 was using at the time. The material states "test alarm each time it is used to make sure it functions properly" and it comes with a battery tester. The current chair alarm, the "Economy Attendant" pressure pad alarm, states "Alarm may fail to sound if the product is damaged or if the battery runs low. When battery is low, product will emit a visual warning signal. If so, STOP using the unit and replace the battery immediately." - Regarding Resident #1's fall on [DATE], Surveyor # noted the facility investigation reveals Resident #1 was lying in bed, CNA-F raised the bed in preparation to assist with morning cares, then stepped away to retrieve something, turned her back on Resident #1, and Resident #1 fell to the floor, causing injury to her left hip and swelling to the back of her head. Surveyor # asked why CNA-F did not lower the bed if she was leaving Resident #1 unattended, even for a minute, since staff note how quick and impulsive she is, and has had two falls in the first six weeks she was in the facility. Surveyor # asked if CNA's are trained and expected to lower a Resident's bed if they are leaving the side of the bed. NHA-A stated staff are trained to lower the bed if they are stepping away, but it was not realistic for the CNA to lower the bed to wet a wash cloth at the sink two feet away from the foot of the bed. Surveyor # noted CNA-F's statement also indicates she had her back to Resident #1. - Regarding the fall on [DATE], Surveyor # asked why staff did not check Resident #1's alarm when she returned from her appointment, why there were not interviews from more than one staff who saw or had contact with her in the 3 ,[DATE] hours between the time she returned to the facility and she was found on the floor, how long she may have been on the floor, what staff had seen her and when, who found Resident #1 on the floor, when was the last time she was seen prior to the fall, and did staff offer toileting to Resident #1 after dinner. Resident #1 suffered a left hip fracture in the fall. Surveyor # asked why Resident #1 had to suffer a fracture before staff were instructed and inserviced to check alarms when they return to the facility. Surveyor # asked why only half of the nurses and CNA's were inserviced regarding the new Policy and Procedure. On [DATE] at 9:15 a.m., NHA-A and DON-B provided Surveyor # with additional information regarding Resident #1's falls. NHA-A stated they do not change the alarm batteries every 30 days; the alarms chirp when the batteries are going dead, and staff should replace them, although Resident #1's alarm/ batteries did not give the warning sound, they just went dead. Surveyor # asked what they did to minimize this risk such as increase supervision of Resident #1, look into other alarms, etc. No further information was provided. Regarding the [DATE] fall, they interviewed additional staff on the evening of [DATE] and learned on [DATE] when Resident #1 returned to the facility, the van driver told LPN-J Resident #1 was back. LPN-J was giving report to the oncoming nurse. The driver gave Resident #1's purse to Resident #1's son. CNA-G offered to take Resident #1 to the toilet at approximately 4:00 p.m. Dinner was at 5:00 p.m. After supper, Resident #1 was in the living room area and last seen around 5:45 p.m., and found on the floor in her room at 6:00 p.m. NHA-A stated they knew some of this information prior to the interviews on [DATE], but did not have all of the information, including that her son was at the facility. NHA-A and DON-B stated they posted information regarding the new policy to check alarms when Residents return form appointments, so staff who did not sign the inservice sheet were informed about the policy by the postings. NHA-A and DON-B informed Surveyor # they expect CNA's to check Resident alarms at the beginning of the shift, but Resident #1 was out of the facility at the beginning of the shift, so her alarm was not checked. Surveyor # reviewed a "CNA Orientation Skills Checks" form which requires CNA's demonstrate checking string alarms, motion detectors and door alarms upon hire. NHA-A also informed Surveyor # they re-interviewed CNA-F on [DATE] regarding Resident #1's [DATE] fall from bed. CNA-F stated Resident #1 was calm, not agitated. CNA-F stated she got Resident #1's clothes out of the dresser, got her supplies, turned off the floor sensor alarm, raised up the bed- the bed wasn't in the lowest position, but it was not in the highest position either. CNA-F then went back to the sink to get Resident #1's TED's stockings- only two feet away from the bed. Surveyor # had previously seen Resident #1's room and thought the sink was more than two feet away from the bed. On [DATE] at 10:30 a.m. Surveyor # went to Resident #1's room and measured the distance from the foot of the bed to the sink and it is just under 5 feet. However, Resident #1 was not sitting at the foot of the bed, she was laying in bed; the head of the bed was the farther away from the sink. The bed was against the wall, and the sink was at the foot-end of the bed. The investigation states Resident #1 was lying in bed when CNA-F went to the sink and turned her back on Resident #1. Resident #1 was 8 to 10 feet away from the sink at the time of the fall. CNA-F would have had to skirt around the end of the bed and cover the 8 to 10 feet to get to Resident #1 to prevent her from falling. (Note: this fall prevented Resident #1 from being discharged on [DATE].) Surveyor # reviewed an undated Geneva Lake Manor Fall Assessment Policy. The policy states "Witnesses should be interviewed, to help in completion of the Fall Assessment Investigation form. Any factor that may have contributed to the fall should be circled and it should be noted if the resident uses a chair/ bed alarm and if the alarm was sounding. A narrative will be written with information collected from the witness, resident or from observation by the nurse. The purpose of the detailed descriptions is to help determine the cause and any patterns of the resident's falls, so interventions can be implemented that are specific to resident needs.