Every finding on record at Green Bay Health Services

Based on interview and record review, the facility did not thoroughly investigate allegations of abuse for 2 residents (R) (R30 and R56) of 3 sampled residents. R30 and R56 reported to staff and management potential allegations of abuse/neglect. The facility did not interview other residents or staff during the investigation or provide education to the accused staff member prior to their return to work. Findings include: The facility's Northshore Healthcare Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .The facility will designate a leadership position who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state Survey Agency and other officials in accordance with state law .The facility will provide ongoing oversight and supervision of staff in order to ensure its policies are implemented as written .Investigation of Alleged Abuse, Neglect and Exploitation: An immediate investigation is warranted when allegation or suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur .Providing complete and thorough documentation of the investigation .Reporting/Response: .Taking all necessary actions as a result of the investigation which may include, but are not limited to, the following .Training of staff on changes made and demonstration of staff competency after training is implemented; .Identification of staff responsible for implementation of corrective actions; .The expected date for implementation . Surveyor reviewed R56's medical record. R56 was admitted to the facility on [DATE] and had a diagnosis of colon cancer. A Minimum Data Set (MDS) assessment, dated 7/9/26, stated R56 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 8/10/26 at 9:29 AM, Surveyor interviewed R56 who indicated a night shift nurse (Registered Nurse (RN)-E) is rude and treats them as if they are a burden. R56 stated they are mostly independent but fear for other residents who cannot advocate for themselves. R56 stated they activated their call light because they needed pain medication and there was no one in the hallway. R56 stated RN-E was extremely rude when they arrived. R56 notified staff and was told RN-E would no longer provide care for them. R56 stated they, R30, and another resident left the building for an offsite activity (on an unknown date) and returned at approximately 9:00 PM. When R56 asked for another staff so they could receive a pain medication, RN-E told them they could stand there and wait and they would give them the medication. R56 indicated R30 had also had issues with RN-E. (Surveyor reviewed R56's medical record. R56 had a diagnosis of colon cancer. A Minimum Data Set (MDS) assessment, dated 7/9/26, stated R56 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.) On 8/10/26, Surveyor requested any grievances or facility-reported incidents (FRIs) related to R56 and RN-E. Surveyor received the facility's investigation file and FRI on 8/11/26. Surveyor reviewed the FRI which was submitted to the State Agency (SA) on 6/30/26. The report stated RN-E was accused of being rude and disrespectful and intentionally saying things to provoke R30. During the investigation, staff interviewed R56 who also indicated RN-E was rude to them. RN-E was suspended on 6/29/26 pending the results of the investigation. The FRI indicated education was provided to and signed by all employees. The education contained a letter to all team members, two signature sheets, and the facility's Abuse, Neglect, and Misappropriation policy. The letter to team members included the following: .We require the following education and expectations to be reviewed with all team members and agency team members .Please ensure education has been completed, signed, and returned with acknowledgement and agreement .Expectation for immediate response to an allegation of suspected abuse: .For example: When a resident states staff are rough and rude or disrespectful, this is considered abuse and needs to be reported immediately .When a specific staff member is involved in the alleged event, the person will be removed from resident care immediately, interviewed by the supervisor, asked to provide a written statement, and suspended until the investigation is completed .The education was signed by 63 staff members between 6/30/26 and 7/13/26. The signature acknowledgement sheet indicated 9 additional staff received the education via phone on 7/13/26. Surveyor noted RN-E had not signed the education. Surveyor noted the FRI did not contain a written statement from RN-E. The summary contained an interview with RN-E, however, the interview did not indicate who conducted the interview and when the interview was conducted. The summary mentioned 2 staff who indicated they witnessed R56 and R30 say they were going to do whatever it took to get RN-E fired. The FRI did not contain documented interviews with the staff, including their names, when the observation occurred, and on what date they were interviewed. The FRI indicated RN-E was suspended for one shift and returned to work on 6/30/26 when the facility determined the allegation of verbal abuse was unsubstantiated and was a case of poor communication and a rude bedside manner from RN-E. The FRI contained a Good Bedside Manner education sheet. The sheet contained RN-E's printed name but not a signature. The signature line stated verbal via phone and was dated 7/6/26. (Of note: RN-E returned to work on 6/30/26 and worked several shifts before receiving education on 7/6/26.) The FRI contained 10 resident interviews regarding care by RN-E. Eight interviews were dated 6/30/26 and 2 interviews were dated 7/1/26. The FRI contained 10 staff interviews. Four interviews were dated 6/30/26, 3 interviews were dated 7/1/26, and 3 interviews were dated 7/2/26. (Of note: Multiple interviews were completed after RN-E had already returned to work on 6/30/26.) On 8/11/26 at 9:55 AM, Surveyor again interviewed R56 who stated R30 might know the date RN-E told them to stand there and wait for a pain medication because it was the same day they witnessed RN-E tell R30 they documented their meds as refused, however, R30 wasn't there to refuse them. R56 denied saying they were trying to get RN-E fired. On 8/11/26 at 1:37 PM, Surveyor interviewed R30 who indicated RN-E was not nice and they avoid them. R30 indicated they reported RN-E to Nursing Home Administrator (NHA)-A who did an investigation. R30 stated RN-E rudely said to them nobody was taking to you approximately a month ago when they tried to help another resident. R30 also indicated after they and R56 returned from an offsite activity, RN-E told R30 they marked their medications as refused. R30 stated RN-E says things to provoke them. R30 denied saying they wanted R30 fired but stated they do not want to work with them anymore. (Surveyor reviewed R30's medical record. R30 had diagnoses including major depressive disorder and anxiety. An MDS assessment, dated 7/31/26, stated R30 had a BIMS score of 15 out of 15, indicating intact cognition.) On 8/12/26 at 9:15 AM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-F who was the Cares Champion for R56 and R30. MDSC-F indicated they check on R56 and R30 daily and fill out a checklist regarding their answers and environment. MDSC-F indicated R56 and R30 mentioned concerns with RN-E on 6/24/26. MDSC-F also indicated residents informed them that RN-E was rude and disrespectful to staff. The following week, MDSC-F stated R30 indicated they felt RN-E had potentially abused them. MDSC-F filled out a grievance form after R30 stated RN-E was intentionally rude. MDSC-F indicated they did not take notes or document R56 or R30's statements. (Surveyor noted the FRI did not contain a grievance form.) On 8/11/26 at 3:30 PM, Surveyor interviewed NHA-A who indicated RN E was suspended on 6/29/26 after the night shift and returned to work on 6/30/26. NHA-A indicated they completed the full investigation from 6/29/26 to 6/30/26 and determined the abuse was unsubstantiated prior to RN-E's return. NHA-A indicated RN-E did not receive abuse, neglect, and misappropriation education because they received individual bedside manner education. When asked why RN-E returned to work on 6/30/26 but was not provided education until 7/6/26, NHA-A verified RN-E should have received education before returning to work.

Based on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R1 and R2) of 4 sampled residents received the appropriate care and services to promote healing and/or prevent pressure injuries from developing. R1 was admitted to the facility with pressure injuries on the coccyx and bilateral heel deep tissue injuries (DTIs). Staff did not change R1's coccyx and heel dressings for 7 days after admission and did not initiate wound care orders until 2/4/25. In addition, R1's coccyx dressing was not changed on 2/7/25, 2/12/25, and 2/13/25. R1's heel dressings were not changed on 2/7/25 and 2/13/25.R2 had wounds on the right great toe, right heel, and coccyx. R2's wound care was not documented as completed on 7/31/25.Findings include:The facility's Pressure Injuries and Non Pressure Injuries policy, revised 7/20/22, indicates: .A head-to-toe body evaluation will be completed on every resident upon admission/readmission and will be documented .If skin is compromised: .iii. Ensure primary care physician is aware of wounds/location of wounds and current treatment orders. iv. Ensure appropriate treatment orders for each wound area, as needed. v. Ensure resident/responsible party is aware of wounds and current treatment plan .1. On 8/4/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including multiple rib fractures on the right side, pneumonia, dysphagia, and difficulty with walking. R1's Minimum Data Set (MDS) assessment, dated 2/3/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had intact cognition. R1 was responsible for R1's healthcare decisions.An admission skin assessment indicated R1 had two stage 2 coccyx pressure injuries and DTIs on both heels . The assessment did not contain measurements of the wounds. R1 did not have orders to treat the pressure injuries or DTIs at the time of admission. A care plan, dated 2/4/25, indicated R1 had a pressure injury on the left posterior heel related to impaired mobility. The goal indicated R1would show no signs of infection. The care plan contained the following interventions: Will develop no new areas of skin breakdown; Administer treatment per medical doctor orders; Encourage and assist as needed to turn and reposition; Use assistive devices as needed; and Float heels as able.On 2/4/25, Wound Registered Nurse (WRN)-C assessed R1 and obtained treatment orders for the coccyx and heel wounds to begin on 2/5/25.R1's medical record indicated R1's coccyx dressing changes were not completed on 2/7/25, 2/12/25, and 2/13/25 and R1's heel dressing changes were not completed on 2/7/25 and 2/13/25. On 8/4/25 at 10:54 AM, Surveyor interviewed WRN-C who indicated the facility's procedure is to document wound treatments on the Treatment Administration Record (TAR) following completion of the treatment. WRN-C indicated if a resident with a wound is admitted without a treatment order, the provider should be contacted for an order. On 8/4/25 at 11:15 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R1 did not have wound care orders from admission until 2/4/25 and confirmed staff should have called the provider for orders upon admission. DON-B verified R1's medical record indicated wound care was not consistently completed after the orders were received. DON-B stated DON-B expects staff to provide wound care as ordered. 2. On 8/4/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, dysphagia, diabetes, and gastrointestinal hemorrhage. R2's MDS assessment, dated 6/2/25, had a BIMS score of 4 out of 15 which indicated R2 had severe cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC).R2's medical record indicated R2 had wounds on the right great toe, right heel, and coccyx and had wound care orders. R2's TAR did not indicate wound care was completed for all of R2's wounds on 7/31/25. On 8/4/25 at 12:35 PM and 1:05 PM, Surveyor interviewed DON-B who verified there were no documented wound treatments on 7/31/25 and stated staff should have completed wound care as ordered. DON-B indicated DON-B spoke with Licensed Practical Nurse (LPN)-D who stated wound care was completed that day but was not documented. DON-B indicated LPN-D would document a late entry for completion of wound care on 7/31/25.

Based on staff interview and record review, the facility did not have a Qualified Social Worker. This practice had the potential to affect more than 4 of the 61 residents residing in the facility. Social Services Director (SSD)-D and Social Services Coordinator (SSC)-C did not meet one or both requirements necessary to be considered a Qualified Social Worker in a facility licensed for 125 beds. Findings include: On 6/18/25, Surveyor reviewed the facility's employee list which indicated SSD-D's position was Social Services Qualified Director. On 6/18/25 at 8:41 AM and 9:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated SSD-D was a certified Social Worker and confirmed SSC-C was not a certified Social Worker. NHA-A later corrected NHA-A's previous statement regarding SSD-D's credentials and stated SSD-D was not a certified Social Worker but was a licensed Counselor. During the facility's previous recertification survey, Surveyor interviewed SSC-C on 4/1/24 at 11:23 AM. SSC-C confirmed SSC-C was hired on 2/14/24 as a full-time employee. SSC-C stated SSC-C had a degree in Health Care Administration and previous work experience in behavioral intervention and adolescents with autism. SSC-C confirmed SSC-C was not certified as a Social Worker in the State of Wisconsin and did not have a year of supervised social work experience in a healthcare setting prior to working at the facility. On 6/18/25 at 9:42 AM, Surveyor interviewed Director of Nursing (DON)-B who provided Surveyor with SSD-D's license. Surveyor noted SSD-D was licensed as an Associate Counselor in the State of Arizona. DON-B indicated SSD-D was not licensed in Wisconsin and was currently in the process of getting licensed. On 6/18/25 at 9:46 AM, Surveyor interviewed SSD-D who stated SSD-D was hired in January of 2025 as a full-time employee and was in graduate school in Arizona prior to SSD-D's hire. SSD-D had a master's degree in Mental Health Counseling and a bachelor's degree in Psychology. SSD-D's prior work experience included a 2-semester part-time internship at the University Counseling Center where SSD-D worked with students on mental health coping skills and referrals. SSD-D indicated SSD-D's supervisor was a licensed marriage and family therapist. SSD-D confirmed SSD-D was a licensed Associate Counselor in the State of Arizona and was in the process of obtaining the equivalent license in Wisconsin which was a licensed Professional Counselor-In Training. SSD-D indicated SSD-D needed to complete course credits before SSD-D could be licensed. SSD-D confirmed SSD-D's Arizona license was issued on 6/1/25 and SSD-D was not licensed when hired by the facility. SSD-D was unaware if being licensed was a condition of SSD-D's position. On 6/18/25, Surveyor reviewed SSD-D's job description which was dated 3/8/18 and signed by SSD-D on 1/8/25. The position title was Social Services Director (Licensed). Under Required Education and Experience, the description listed: 1) Bachelor's degree in social work or social welfare from an accredited academic institution; 2) At least one year experience in a healthcare setting; and 3) Current state license as a Social Worker. On 6/18/25 at 3:03 PM, Surveyor interviewed NHA-A who confirmed the facility was licensed for 125 beds. NHA-A confirmed SSD-D was not licensed until 6/1/25 and did not hold a license of certification in the State of Wisconsin. NHA-A acknowledged neither SSD-D or SSC-C met the requirements of a Qualified Social Worker.

Based on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 1 (Hairstylist (HS)-H) of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough caregiver background check was completed for HS-H. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: The components of the facility abuse prohibition plan are discussed herein: I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulation. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement. 2. Screenings may be conducted by the facility itself, a third-party agency, or an academic institution. 3. The facility will maintain documentation of proof that the screening occurred. On 6/16/25, Surveyor requested background check information for a random sample of eight facility and contracted staff, including HS-H. Surveyor reviewed the requested background check information and noted HS-H's hire date was not listed, however, HS-H's Background Information Disclosure (BID) form was dated 6/17/25. The documents provided did not indicate a state background check was completed prior to Surveyor requesting HS-H's background check on 6/16/25. On 6/18/25 at 12:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding HS-H's background check dated 6/17/25. NHA-A stated background checks are completed after an offer for employment is accepted and prior to the first day of work. NHA-A indicated HS-H is not an employee of the facility, therefore, a background check was not completed. NHA-A indicated HS-H provides services to residents as needed and confirmed HS-H is paid via check by the facility. On 6/18/25 at 1:00 PM, Surveyor again interviewed NHA-A who indicated the facility should have completed a background check for HS-H prior to HS-H's first day providing services at the facility. NHA-A indicated NHA-A did not know a date of hire for HS-H but thought HS-H started providing services in the spring of 2024 which was prior to NHA-A's hire date. NHA-A indicated a background check should have been completed per the facility's policy. On 6/19/25 at 12:03 PM, Surveyor interviewed HS-H who indicated HS-H had cut/styled residents' hair at the facility one day a month since 12/3/24. HS-H confirmed HS-H was paid by check from the facility.

Based on observation, staff interview, and record review, the facility did not ensure medications for 2 residents (R) (R34 and R36) in 1 of 2 medication carts were dated appropriately. In addition, the facility did not ensure two open containers of blood glucose test strips were dated appropriately in 2 of 2 medication carts. This practice had the potential to affect more than 4 of the 61 residents residing in the facility. Staff did not label or date R34 and R36's insulin pens in accordance with the facility's policy. The 400 wing medication cart contained an open and undated insulin pen for R34 and two open and undated insulin pens for R36. In addition, the medication cart contained an open and undated container of blood glucose test strips. Staff did not date a container of blood glucose strip in the 200 wing medication cart when opened. Findings include: The facility's Administration of Insulin with Insulin Pen Policy & Procedure. dated [DATE], indicates: Insulin pens must be clearly labeled with the resident's name, physician's name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendations. 1. On [DATE] at 9:12 AM, Surveyor observed the 400 wing medication cart with Registered Nurse (RN)-E and noted three subcutaneous insulin solution pen-injectors did not contain open dates, including one open and undated insulin glargine 100 unit/milliliter (ml) pen for R34 and two open and undated insulin glargine 100 unit/ml pens for R36. In addition, Surveyor and RN-E observed an open and undated container of blood glucose test strips. RN-E verified the insulin pens and blood glucose test strips should had been dated when opened. 2. On [DATE] at 9:42 AM, Surveyor observed the 200 wing medication cart with Licensed Practical Nurse (LPN)-F and noted one open and undated container of blood glucose test strips. LPN-F verified the blood glucose test strips should have been dated when opened. On [DATE] at 10:14 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated all insulin pens and blood glucose test strips should be dated when opened. DON-B verified staff would not know when a medication or medical supply expired if it was not dated when opened.

Based on staff interview and record review, the facility did not ensure the right to make healthcare decisions was extended only to those delegated by the resident and in accordance with applicable law for 1 resident (R) (R24) of 19 sampled residents. R24 was admitted to the facility with a court-ordered temporary guardianship that expired on [DATE]. The facility continued to allow the temporary guardian to make healthcare decisions for R24 after [DATE]. Findings include: Wis. Stat. §54, Guardianships and Conservatorships, states under §54.50(2) Duration and extent of authority: The court may appoint a temporary guardian for a ward for a period not to exceed 60 days, except that the court may extend this period for good cause shown for one additional 60-day period. The court may impose no further temporary guardianship on the ward for at least 90 days after the expiration of the temporary guardianship and any extension. The court's determination and order appointing the temporary guardian shall specify the authority of the temporary guardian and shall be limited to those acts that are reasonably related to the reasons for appointment that are specified in the petition for temporary guardianship. The authority of the temporary guardian is limited to the performance of those acts stated in the order of appointment .§54.50(4) Cessation of powers: The duties and powers of the temporary guardian cease upon the issuing of letters of permanent guardianship, the expiration of the time period specified in sub. (2), or if the court sooner determines that any situation of the ward that was the cause of the temporary guardianship has terminated. From [DATE] to [DATE], Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, dysarthria, epilepsy, schizophrenia, anxiety, and cognitive communication deficit. R24's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R24 had severe cognitive impairment. R24's medical record included a Letters of Temporary Guardianship of Person, dated [DATE], that indicated R24's Family Member ((FM)-I) was R24's temporary guardian. R24's medical record also included an Order of Petition to Extend Temporary Guardianship, dated [DATE], that expired on [DATE]. A progress note, dated [DATE] at 3:54 PM, indicated a message was left for FM-I to call the facility because FM-I needed to sign an admission agreement and vaccine consent/declination. A Social Services note, dated [DATE] at 8:51 AM, indicated FM-I spoke with Social Services Director (SSD)-D and requested a referral be sent to another nursing home for R24. A Social Services note, dated [DATE] at 11:09 AM, indicated SSD-D spoke with FM-I regarding updated guardianship paperwork, consent to treat, consents for vaccinations, and the location for R24's referral. FM-I stated FM-I did not want R24 to receive vaccines and did not want to sign consent at that time. FM-I indicated FM-I would look for a previous signed consent to treat for R24 or would sign the documentation. FM-I stated FM-I would call an attorney/legal representative to seek documentation for a guardianship extension or full guardianship. A Social Services note, dated [DATE] at 3:52 PM, indicated the County (CTY)-K Local Contact Agent (LCA) called SSD-D. The LCA indicated R24's temporary guardianship had been closed and documentation for permanent guardianship was not established, therefore, R24 was R24's own decision maker at that time. The LCA advised the facility to work on the guardianship referral packet and send it to the LCA for review. A Social Services note, dated [DATE] at 4:34 PM, indicated temporary guardian was transferred to Power of Attorney for Healthcare (POAHC) status upon guardian approval. Surveyor noted that between [DATE] and [DATE], FM-I continued to make healthcare decisions for R24. On [DATE] at 12:05 PM and [DATE] at 3:01 PM, Surveyor attempted to contact FM-I but did not receive a return call. On [DATE] at 10:03 AM, Surveyor attempted to interview R24 who provided one-word responses or no response at all to Surveyor's questions. On [DATE] at 2:04 PM, Surveyor interviewed SSD-D who indicated SSD-D attempted to get additional guardianship paperwork from FM-I, however, FM-I did not bring the paperwork to the facility. SSD-D confirmed FM-I continued to be R24's legal representative and decision maker after the guardianship expired.

Based on staff and resident representative interview and record review, the facility did not thoroughly investigate an allegation of misappropriation for 1 resident (R) (R31) of 19 sampled residents. On 4/28/25, R31's guardian reported an allegation of misappropriation that involved a previous guardian who worked at the facility. The facility did not thoroughly investigate the allegation of misappropriation. Findings include: The facility's Northshore Healthcare Abuse, Neglect and Exploitation policy indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written .V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect or exploitation, or a report of abuse, neglect or exploitation occurs . On 6/16/25, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] and had diagnoses including mild cognitive impairment with unknown etiology, congestive heart failure, and type 2 diabetes. R31's most recent Minimum Data Set (MDS) assessment, dated 5/1/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R31 had intact cognition. R31 had a guardian who was R31's decision maker. On 6/16/25 at 1:31 PM, Surveyor interviewed R31's guardian ((GD)-M) who indicated GD-M had concerns regarding potential financial exploitation of R31 by a previous guardian who worked at the facility. GD-M indicated the facility was aware of the issue, however, GD-M was not sure if the facility investigated the issue or filed a report with the State Agency (SA). GD-M indicated GD-M reported the concern to the police and there was an active investigation. GD-M also indicated Adult Protective Services (APS) was aware and APS-N had spoken with the facility. On 6/17/25 at 9:18 AM, Surveyor interviewed Facility Staff (FS)-R who confirmed FS-R used to be R31's guardian and was accused of misappropriation of R31's money. FS-R was unsure when FS-R started working at the facility but indicated FS-R had worked at the facility for a long time and started working on a regular basis last year. FS-R indicated FS-R saw R31 weekly and had been accused of financial exploitation by R31's family. FS-R indicated FS-R was working in the facility at the time of the interview. Surveyor noted FS-R brought items that FS-R intended to give to R31 and visit with R31. R31's plan of care indicated per GD-M as of 1/2/25, FS-R should not to be in R31's room unsupervised or take R31 out of the facility. On 6/17/25, Surveyor requested the facility's investigation regarding the allegation of misappropriation. On 6/17/25 at 12:03 PM, Surveyor interviewed Business Office Manager (BOM)-O who indicated if there was potential misappropriation of R31's finances, the facility should have completed an investigation. On 6/17/25 at 12:21 PM Surveyor interviewed [NAME] President of Success (VPS)-P who indicated VSP-P was the former NHA and was familiar with R31. VPS-P thought the misappropriation occurred before R31 was admitted to the facility. VPS-P indicated if the misappropriation happened in the facility, the facility would investigate it. On 6/17/25 at 1:00 PM, Surveyor interviewed GD-M who indicated GD-M had in person meetings with facility management and recalled stating that FS-R was not allowed to go in R31's room because R31 had gold coins and stimulus money and FS-R was suspected of stealing from R31. On 6/17/25 at 12:21 PM and 5:25 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated an allegation of misappropriation should involve an internal investigation and a report to the SA. NHA also indicated the facility did not have an investigation for the allegation of misappropriation. On 6/18/25 at 8:47 AM, Surveyor received an email from GD-M that contained screenshots of emails between Social Services Coordinator (SSC)-C and APS-N. One screenshot showed SSC-C participating in a conversation regarding R31 and restricting FS-R's visits with R31. On 6/18/25 at 9:28 AM, Surveyor received an email from GD-M that indicated GD-M met with the facility in early January (2025) and indicated FS-R was not allowed in R31's room due to money involvement which was added to R31's care plan. On 6/18/25 at 2:32 PM, Surveyor received an email from APS-N that indicated APS-N's investigation indicated APS-N spoke with SSC-C on 11/11/24 regarding R31's finances with the facility, Medicaid, and a previous guardian (FS-R) stealing R31's money. On 6/18/25 at 1:27 PM Surveyor again interviewed NHA-A who indicated NHA-A was unaware of the potential misappropriation involving R31. When Surveyor shared progress notes from R31's medical record which indicated staff were aware of the allegation, NHA-A indicated NHA-A would have started an investigation if NHA-A was aware.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 resident (R) (R5) of 19 sampled residents. On 6/16/25, Surveyor observed medication on R5's bedside table hours after the AM medication pass. Staff documented the medications as administered. In addition, R5 did not have a self-administration of medication assessment or an order to self-administer medication. Findings include: The facility's Medication Administration Self-Administration by Resident policy, dated 1/2023, indicates: Residents who desire to self-administer medication are permitted to do so with a prescriber's order and if the nursing care center's Interdisciplinary Team has determined that the practice would be safe and the medications are appropriate and safe for self-administration .2. The Interdisciplinary Team determines the resident's ability to self-administer medication by means of a skill assessment conducted as part of the care plan process .3. The results of the Interdisciplinary Team's assessment are recorded on the medication self-administration assessment which is placed in the resident's medical record . The facility's Medication Administration policy, dated 1/2023, indicates: .10. Administer medication and remain with the resident while the medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration . On 6/16/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbance, obsessive compulsive disorder, mood disorder, and depression. R5's Minimum Data Set (MDS) assessment, dated 5/1/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R5 had moderate cognitive impairment. R5's plan of care indicated R5 refused medications and indicated if R5 was having difficulty, staff should re-attempt to administer the medication or try a different nurse (dated 2/20/24). R5's plan of care also indicated medications should be given as ordered/per physician orders (dated 6/14/23). On 6/16/25 at 10:48 AM, Surveyor interviewed R5 and observed two pills on R5's bedside table and an empty plastic medication cup next to the pills. R5 indicated staff left the medications for R5 to take that morning but R5 forgot to take them. R5's medical record did not contain a physician's order to self-administer medication. A medication self-administration assessment, dated 7/19/22, indicated: (R5) should not have any medications left at bedside; Will tend to drop meds on floor or forget to take them and store them in belongings. Staff must witness and assist with medication administration. R5's Medication Administration Record (MAR) indicated the medications were administered on 6/16/25 by Med Tech (MT)-Q. On 6/17/25 at 4:18 PM, Surveyor interviewed MT-Q who confirmed MT-Q administered medication to R5 on the morning of 6/16/25. MT-Q indicated the medications were administered in the dining room and R5 took all the pills. MT-Q could not explain why the medications were discovered in R5's room or why R5 indicated they were left for R5 to take on R5's own. MT-Q indicated MT-Q cannot leave medication for R5 to take independently because R5 will not take them. On 6/18/25 at 1:34 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who indicated LPN-F is not allowed to leave medication in R5's room, however, some staff do because it is difficult to get R5 to take medication. LPN-F indicated LPN-F does not leave R5 medications to take independently because R5 does not have a self-administration of medication order and cannot differentiate between the pills and safely take them. On 6/18/25 at 1:27 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff who administer medication are aware of and should follow medication administration and medication storage policies. NHA-A indicated staff should not leave medication in the room of a resident who is not assessed as able to safely and accurately self-administer medication.

Based on staff interview and record review, the facility did not ensure medically-related social services were provided in order to attain or maintain the highest practicable level of well-being for 1 resident (R) (R24) of 19 sampled residents. R24 was admitted to the facility with a court-ordered temporary guardianship. The facility did not ensure permanent guardianship was completed prior to the expiration date of the temporary guardianship and completed a Power of Attorney for Health Care (POAHC) document with R24 without an assessment to ensure R24 had the cognitive ability to comprehend the document. In addition, the facility did not ensure Social Services staff, who witnessed the signature of R24's POAHC document, met the State of Wisconsin definition for Social Worker. Findings include: WI State Statute chapter 457.01(10) defines Social Worker as an individual who holds a social worker certificate granted by the social worker section .457.01(11) defines Social Worker Section as the social worker section of the examining board. WI State Statute chapter 155.01(10) defines Power of Attorney for Health Care as the designation, by an individual, of another as his or her health care agent for the purpose of making health care decisions on his or her behalf if the individual cannot, due to incapacity .155.01(8) defines Incapacity as the inability to receive and evaluate information effectively or to communicate decisions to such an extent that the individual lacks the capacity to manage his or her health care decisions .155.10(2) states a witness to the execution of a valid power of attorney for health care instrument shall be an individual who has attained age [AGE]. No witness to the execution of the power of attorney for health care instrument may, at the time of the execution, be any of the following: .(d) An individual who is a health care provider who is serving the principal at the time of execution, an employee, other than a chaplain or a social worker, of the health care provider or an employee, other than a chaplain or a social worker, of an inpatient health care facility in which the principal is a patient. From [DATE] to [DATE], Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dysphagia, dysarthria, epilepsy, schizophrenia, depression, anxiety, and cognitive communication deficit. R24's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R24 had severe cognitive impairments. R24's medical record indicated R24 had a tubefeeding for supplemental nutrition needs. A care plan, dated [DATE], stated R24 was at risk for behavior symptoms related to mental illness. The care plan indicated R24 had a BIMS of 6 and at times manipulated and pulled R24's Foley catheter and feeding tube. The care plan also indicated R24 at times smeared feces over R24's bedding and self. R24's medical record included the following: ~ A Letters of Temporary Guardianship of Person, dated [DATE], that appointed Family Member (FM)-I as R24's temporary guardian. ~ An Order of Petition to Extend Temporary Guardianship, dated [DATE], that had an expiration date of [DATE]. ~ A POAHC document, dated and signed by R24 on [DATE], that designated FM-I as R24's primary healthcare agent. ~ An Incapacity Certification, dated [DATE] and signed by R24's primary physician and Advanced Practice Nurse Prescriber (APNP)-J, that indicated R24 was determined to be incapacitated which activated R24's POAHC document and made FM-I R24's healthcare decision maker. A Social Services note, dated [DATE] at 2:28 PM, indicated Social Services Director (SSD)-D spoke with County (CTY)-K Local Contact Agent (LCA) and was informed that R24 was not considered a resident of CTY-K because CTY-K's records did not show that R24 had previously resided within CTY-K limits. SSD-D's review of referral documentation indicated R24 had lived with family at a CTY-K address. SSD-D also noted the current (expired) guardianship paperwork listed CTY-K as the ordering county. The CTY-K LCA stated R24's guardianship documentation had to go through CTY-L which was the county of R24's last documented address. The LCA stated the LCA would investigate more and call SSD-D if more information was found. A Social Services note, dated [DATE] at 3:52 PM, indicated the CTY-K LCA called SSD-D and stated R24's temporary guardianship was closed and no documentation for permanent guardianship was established, therefore, R24 was R24's own healthcare decision maker. The LCA advised SSD-D to work on the guardianship referral packet and send it to the LCA for review. A Social Services note, dated [DATE] at 4:34 PM, stated temporary guardian was transferred to POAHC status upon guardian approval. On [DATE] at 2:04 PM, Surveyor interviewed SSD-D who confirmed R24's temporary guardianship expired on [DATE]. SSD-D indicated SSD-D contacted the CTY-K LCA on [DATE] who stated since R24's guardianship had expired, R24 was R24's own decision maker. SSD-D consulted with Nursing Home Administrator (NHA)-A and APNP-J and the determination was made that since R24 was R24's own decision maker, R24 could complete a POAHC document. SSD-D stated when R24 was asked if R24 wanted FM-I to make healthcare decisions for R24, R24 said yes. SSD-D stated when R24 was asked if R24 wanted anyone else listed as an agent, R24 said no. SSD-D indicated R24 had moments of clarity, however, SSD-D did not complete an assessment and was not aware if an assessment was completed to ensure R24 could understand a legal document. On [DATE] at 3:03 PM, Surveyor interviewed APNP-J who confirmed APNP-J was in the facility on [DATE] when R24 completed the POAHC document. APNP-J indicated APNP-J spoke with R24 and felt R24 had the capacity to choose who should make R24's healthcare decisions, however, R24 lacked insight into R24's medical and health status. APNP-J stated that is why APNP-J signed R24's incapacitation on [DATE] and activated the POAHC. APNP-J indicated APNP-J did not recall completing a formal assessment. On [DATE] at 8:41 AM, Surveyor interviewed NHA-A who confirmed neither SSD-D or Social Services Coordinator (SSC)-C were certified Social Workers. NHA-A acknowledged that only certified Social Workers were authorized to witness POAHC documents as employees of the facility where the resident resides. NHA-A also confirmed the facility did not have documentation to indicate R24's cognition was evaluated to ensure R24 was competent to create a POAHC document. On [DATE] at 9:46 AM, Surveyor completed follow-up interview with SSD-D who confirmed SSD-D was not a certified Social Worker. SSD-D indicated SSD-D was not aware SSD-D and SSC-C were not able to sign as witnesses for POAHC documents.

Based on staff interview and record review, the facility did not ensure weight monitoring was provided for 1 resident (R) (R40) of 2 sampled residents. The facility did not monitor R40's weight per the physician's order and in accordance with the facility's policy. In addition, the facility used R40's previous admission weight (from 1/12/24) to complete a dietary assessment and communicate with dialysis. Findings include: The facility's Weight Monitoring policy, revised 12/21/22, indicates: The Interdisciplinary Team will strive to prevent, monitor, and intervene for undesirable weight change for our residents .Weight Assessment: 1. The nursing staff will measure resident weights on admission, the next 2 days, and weekly for 3 additional weeks thereafter .3. Weights will be recorded in the individual's electronic health record. From 6/16/25 to 6/18/25, Surveyor reviewed R40's medical record. R40 was admitted to the facility on [DATE] and had diagnoses including dependence on renal dialysis, critical illness myopathy, and type 2 diabetes mellitus with hypoglycemia with coma. R40's Minimum Data Set (MDS) assessment, dated 5/6/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R40 had intact cognition. R40 was responsible for R40's healthcare decisions. R40's care plan, dated 4/30/25, indicated R40 was at risk for nutritional status change related to infection and end stage renal disease. The care plan contained interventions to record weight per facility protocol/Medical Doctor (MD) orders; Review weights and notify Registered Dietitian (RD), MD, and responsible party of significant weight change; Will maintain weight as evidenced by no significant weight changes (>/= 5% in 30 days, >/= 7.5% in 90 days, or >/= 10% in 180 days). R40's medical record included the following order for weight monitoring: Weight on admit, daily x 2, weekly x 3, then monthly. Obtain reweight if change of 5 pounds (lbs) since last weight (dated 4/30/25). A Nutritional Assessment, completed by RD-G and dated 5/6/2025 at 10:21 AM, indicated R40 was on a renal diet, regular texture, regular/thin consistency and had a fluid restriction of 1500 milliliters (ml) - 1000 ml dietary and 500 ml nursing. R40 had an average meal intake of 75-100% and ate independently. The assessment indicated R40's current weight was 209.6 lbs (1/12/24 at 11:18 AM). R40's weight history was unknown. The facility's pre-dialysis communication, dated 5/2/25, 5/5/25, and 5/7/25, indicated R40's most recent weight of 209.6 lbs was from 1/12/24 at 11:18 AM. Surveyor reviewed R40's weights and noted the following: ~ On 5/30/25, R40 weighed 181.3 lbs ~ On 5/28/25, R40 weighed 180.4 lbs ~ On 5/27/25, R40 weighed 183.4 lbs ~ On 5/26/25, R40 weighed 187.4 lbs ~ On 5/13/25, R40 weighed 185.6 lbs ~ On 5/8/25, R40 weighed 187.2 lbs ~ On 5/7/25, R40 weighed 187.6 lbs On 6/18/25 at 12:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility's policy is for residents to be weighed on the day of admission. NHA-A acknowledged R40 was not weighed for eight days after admission and R40's weights were not completed per the physician's order. NHA-A also indicated current weights should be used for dietary assessments and dialysis communication.

Based on observation, staff interview and record review, the facility did not provide appropriate catheter care and services for 1 resident (R) (R19) of 3 sampled residents. R19's uncovered catheter bag was observed in direct contact with the floor on 6/16/25, 6/17/25, and 6/18/25. Findings include: The facility's Catheter Care Policy, dated 3/15/23, indicates: It is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .2. Privacy/dignity bags will be available and catheter drainage bags should be covered or shielded at all times while in use. From 6/17/25 to 6/19/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including dementia, weakness, malignant neoplasm of prostate, hemiplegia, urinary retention, and overactive bladder. R19's Minimum Data Set (MDS) assessment, dated 6/2/25, indicated R19 was dependent for transfers, hygiene, dressing, and eating and contained a Brief Interview for Mental Status (BIMS) score 4 out of 15 which indicated R19 was severely cognitively impaired. R19 had an activated Power of Attorney (POA). On 6/16/25 at 11:10 AM, Surveyor toured the facility and observed R19 in bed which was in a low position. R19's uncovered catheter bag was hung on the side of the bed but was in contact with the floor. On 6/17/25 at 8:47 AM, Surveyor observed R19 in bed and noted R19's uncovered catheter bag was on the floor. On 6/18/25 at 9:32 AM and 11:54 AM, Surveyor observed R19 in bed and noted R19's uncovered catheter bag was on the floor. On 6/18/25 at 12:09 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a catheter bag should be put in a clean basin or there should be something underneath the bag so the bag is not on the floor.

Based on staff and resident representative interview and record review, the facility did not report an allegation of misappropriation to the State Agency (SA) for 1 resident (R) (R31) of 19 sampled residents. On 4/28/25 at 10:46 AM, R31's guardian reported an allegation of misappropriation that involved a previous guardian who worked in the facility. The facility documented the conversation but did not report the allegation to the SA. Findings include: The facility's Northshore Healthcare Abuse, Neglect and Exploitation policy indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure its policies are implemented as written .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 (APS), and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury . On 6/16/25, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] and had diagnoses including mild cognitive impairment with unknown etiology, congestive heart failure, and type 2 diabetes. R31's most recent Minimum Data Set (MDS) assessment, dated 5/1/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R31 had intact cognition. R31 had a guardian. R31's plan of care indicated that per R31's current guardian and as of 1/2/25, Facility Staff (FS)-R should not be in R31's room unsupervised and was not allowed to take R31 out of the facility. On 6/16/25 at 1:31 PM, Surveyor interviewed R31's current guardian ((GD)-M) who indicated GD-M had concerns regarding potential financial exploitation from R31's previous guardian who worked in the facility. GD-M indicated the facility was aware of the issue, however, GD-M was not sure if the facility investigated the issue or filed a report with the SA. GD-M indicated GD-M reported the concerns to the police and there was an active investigation. GD-M also indicated Adult Protective Services (APS) was aware and (APS)-N had spoken with the facility. On 6/17/25 at 9:18 AM, Surveyor interviewed FS-R who confirmed FS-R used to be R31's guardian and was accused of misappropriation of R31's money. FS-R was unsure when FS-R started working at the facility but stated FS-R had worked at the facility a long time and started working on a regular basis last year. FS-R indicated FS-R saw R31 weekly and indicated R31's family accused FS-R of financial exploitation. A Social Services progress note, dated 11/11/24 at 2:30 PM, indicated APS-N called with questions about R31's financial situation. A Social Services progress note, dated 4/28/25 at 10:46 AM, indicated GD-M spoke to R31 about FS-R stealing R31's money. On 6/17/25 at 1:00 PM, Surveyor interviewed GD-M who indicated GD-M had in person meetings with facility management and recalled stating that FS-R was not allowed in R31's room because R31 had gold coins and stimulus money and FS-R was suspected of stealing from R31. On 6/17/25 at 12:21 PM and 5:25 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated an allegation of misappropriation should be reported to the SA. NHA-A also indicated there were no facility-reported incidents for R31. On 6/18/25 at 8:47 AM, Surveyor received an email from GD-M that contained screenshots of emails between Social Services Coordinator (SSC)-C and APS-N. One screenshot showed SSC-C participating in a conversation regarding R31 and restricting FS-R's visits with R31. On 6/18/25 at 9:28 AM, Surveyor received an email from GD-M that indicated GD-M met with the facility in early January (2025) and indicated FS-R was not allowed in R31's room due to money involvement which was added to R31's care plan. On 6/18/25 at 2:32 PM, Surveyor received an email from APS-N who indicated there was a note in APS-N's investigation that indicated APS-N spoke with SSC-C on 11/11/24 regarding R31's finances with the facility, Medicaid, and the previous guardian (FS-R) stealing R31's money.

Based on staff interview and record review, the facility did not implement policies and procedures to prohibit and prevent abuse for 2 (Business Office Manager (BOM)-G and BOM-H) of 7 staff reviewed for background checks. The facility did not ensure thorough background checks were completed upon hire for BOM-G and BOM-H. Findings include: The facility's Abuse, Neglect, Mistreatment and Exploitation policy, dated 7/15/22, indicates: .Screening: Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulations .3. The facility will maintain documentation of proof that the screening occurred . On 2/20/25, Surveyor reviewed a sample of employees for background checks, including BOM-G and BOM-H. BOM-G was hired by the facility on 8/10/23. Background check information provided to Surveyor for BOM-G did not include a Department of Justice (DOJ) letter. BOM-H was hired by the facility on 10/20/23. Background check information provided to Surveyor for BOM-H did not include DOJ or Integrated Background Information System (IBIS) letters. On 2/20/25 at 4:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified BOM-G's DOJ letter and BOM-H's DOJ and IBIS letters were missing. NHA-A indicated NHA-A expects DOJ and IBIS letters to be obtained for all staff prior to their first day of work.

Based on staff and resident representative interview and record review, the facility did not ensure funds were safeguarded and managed appropriately for 1 resident (R) (R1) of 6 sampled residents with a Resident Fund Management Service (RFMS) account. R1 had an Irrevocable Burial Trust (IBT) account opened with the facility in March of 2021. In January of 2024, the IBT account was closed and the balance of $7,509 was withdrawn. The facility did not maintain the maximum value of $4500 allowed by Medicaid in R1's IBT account. In addition, the facility did not ensure proper notification was provided to R1's financial Power of Attorney (POA). Findings include: The facility's Business-Resident Trust Fund policy, dated 10/1/23, indicates: The policy is to ensure optimal protection of residents' funds in accordance with regulatory guidelines .Every resident has the right to manage his/her own funds. If the resident chooses to have the facility set up a trust fund in his/her name, the resident or their legal representative must authorize the facility to do so by signing the Resident Trust Fund Authorization form. If state law allows, the Executive Director can sign if the facility is representative payee with the representative payee approval notice from Social Security. By signing this form, the resident .1) Authorizes the facility to hold the resident's funds in a qualified Resident Trust Fund Account. 2) Designates specific individuals who may authorize withdrawals on his/her behalf (i.e., POA, Guardian) as allowed by state law .Note: Signing the Resident Trust Fund Authorization form does not signify the resident's consent to disburse funds. All disbursements and withdrawals from the trust fund must be authorized in writing by the resident or his/her authorized legal representative . Monitoring Fund Balances .The Business Office Manager (BOM) and the Resident Trust Fund Custodian will be responsible for routinely monitoring resident fund balances to: 1) Ensure that no individual resident account is overdrawn at any time. 2) Balances should always be checked before disbursing funds to confirm the amount of the disbursement does not exceed the current account balance. 3) Identify and notify any residents (or their legal representatives) with balances approaching an amount that is $200 less than the Supplemental Security Income (SSI) resource limit for one person or equals or exceed the resource limit when combined with the value of the resident's other non-exempt resources. Quarterly Statements .The Executive Director will ensure a quarterly statement, which includes an itemization and complete description of all trust activity during the quarter, is generated and issued on a quarterly basis to all residents (or their legal representatives) for whom funds are held and managed, or as requested in writing .In addition, the copy of the quarterly statement retained by the facility must contain the initials of the designee, the method of delivery, and the date delivered. Closing Patient Accounts .When a resident whose funds are held and managed by the facility in the Resident Trust Fund expires or is permanently discharged , the Business Office will ensure the balance of the account is refunded and a full accounting provided within 30 days of expiration or discharge (or as required by state law) to the .resident or their legal representative. According to the Wisconsin Medicaid Eligibility Handbook, published in accordance with Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10, and 101 through 109 of the Wisconsin Administrative Code, the asset limit for SSI-related Medicaid for nursing home residents is $2000 for a single person .Medicaid does not count some assets. Those not counted may include the following .Chapter 16.5.1 Irrevocable Burial Trusts .States for Medicaid purposes, Wisconsin law stipulates that such trusts may be made irrevocable as to the first $4,500 of the funds paid under the agreement. The irrevocable amount of such a trust is referred to as an irrevocable burial trust and is an exempt asset. If the total value of an otherwise irrevocable pre-need agreement with a funeral provider exceeds $4,500, the amount over $4,500 is revocable and is a countable asset. Interest and dividends, if any, are exempt only if they accrue to irrevocable burial trusts and the trust agreement specifies that they are irrevocable. From 2/19/25 to 2/20/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including epilepsy, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and anxiety disorder. R1's Minimum Data Set (MDS) assessment, dated 11/9/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 had an activated Power of Attorney((POA)-J) who assisted R1 with healthcare and financial decisions. R1 passed away on 1/23/25. From 2/19/25 to 2/20/25, Surveyor reviewed R1's financial records and RFMS accounts, including R1's IBT account and Resident Trust Account (RTA). In addition to a timeline of accounting provided by the facility, R1's records indicated the following: ~On 3/30/21, the facility notified POA-J that R1's RTA was over the asset limit for Medicaid. POA-J signed an RFMS Authorization and Agreement to Handle Resident Funds and opened an IBT account with the facility. ~On 3/31/21, the facility transferred $1700 from R1's RTA to R1's IBT account. ~On 4/29/22, the facility notified POA-J that R1's RTA was over the asset limit for Medicaid. The facility transferred $1500 from R1's RTA to R1's IBT account. ~On 6/7/22, R1 enrolled in an Managed Care Organization (MCO) with care cost liability to be paid to the MCO beginning 7/1/22. ~On 7/13/22, the facility notified POA-J that R1's RTA was over the asset limit for Medicaid. The facility transferred $500 from R1's RTA to R1's IBT account. ~On 1/5/23, the facility withdrew $3411 from R1's RTA and issued a check to R1's MCO for past due monthly care costs for the October, December, and January billing cycles. ~On 9/13/23, the facility transferred $3800 from R1's RTA to R1's IBT account. ~On 1/23/24, the facility withdrew the total amount of $7509 from R1's IBT account and the account was closed. ~On 1/30/24, the facility deposited $7509 into R1's RTA. ~On 1/31/24, the facility withdrew $8500 from R1's RTA account and issued a check to R1's MCO for past due care costs. On 2/19/25 at 2:15 PM, Surveyor interviewed Director of Revenue and Finance (DRF)-I who stated DRF-I oversaw the regional and facility Business Office Managers. DRF-I was aware of R1's finances and indicated R1's IBT was over the $4500 allowed Medicaid value. DRF-I stated the facility withdrew the money from the account and rolled the money into R1's RTA in January of 2024. DRF-I was not sure why the allowed $4500 was removed from the account instead of just the excess amount. DRF-I stated the facility had not been paying the monthly patient care costs to R1's MCO and received an invoice from the MCO that exceeded $10,000 in unpaid costs in January of 2024. DRF-I indicated the facility withdrew the money from R1's IBT account and put the money in R1's RTA to cover the overdue care costs. DRF-I denied knowledge of why the care costs were not paid monthly to the MCO. DRF-I was unsure if POA-J was notified of the transactions or that R1's IBT account was closed. DRF-I stated the Business Office Manager who was responsible at the time no longer worked for the company. On 2/24/25 at 2:40 PM, Surveyor interviewed POA-J who stated POA-J did not receive quarterly statements from the facility for either of R1's accounts. POA-J stated POA-J was informed that POA-J could request statements. POA-J stated the facility did not inform POA-J that R1's IBT account was closed. POA-J stated because R1's IBT account was closed, POA-J did not have the funds to help pay for R1's funeral expenses. POA-J was aware that R1's MCO had asked for overdue payments. POA-J stated POA-J instructed the MCO to talk to the facility because the facility was the rep-payee for R1.

Based on staff interview and record review, the facility did not ensure neuro checks were completed post-fall in accordance with the facility's policy for 3 residents (R) (R2, R4, and R1) of 3 sampled residents. Neuro checks were not completed per the facility's policy after R2, R4, and R1 had unwitnessed falls. Findings include: The facility's Fall Prevention and Management Guidelines policy, revised 7/18/24, indicates: When any resident experiences a fall the facility will: .2) Neuro checks for any unwitnessed fall or witnessed fall where a resident hits their head: Initially, then every hour x 3; Continue neuro checks every 4 hours x 6; then continue neuro checks every 8 hours x 6 or as indicated by the physician. Alert the Medical Doctor (MD) of any abnormal findings from neuro checks. Do not wait until the series is complete to notify the MD of abnormal findings. 1. On 2/19/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including mild cognitive impairment, cognitive communication deficit, weakness, and difficulty in walking. R2's Minimum Data Set (MDS) assessment, dated 1/31/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R2 had moderately impaired cognition. The MDS assessment also indicated R2 had 2 or more falls without injury since admission. A care plan, dated 10/29/24, indicated R2 was at risk for falls due to weakness, impaired mobility, and impulsivity. The care plan also indicated R2 often self-transferred. R2's medical record and Risk Management Reports indicated the following: ~A Risk Management Report, dated 11/10/24 at 9:30 AM, indicated R2 had an unwitnessed fall. Surveyor noted 9 of 16 neuro checks were completed and there were no documented neuro checks on the day of the fall (11/10/24). The first documented neuro check was on 11/11/24 at 11:22 AM. ~A Risk Management Report, dated 12/14/24 at 12:05 AM, indicated R2 had an unwitnessed fall. Surveyor noted there were 5 neuro checks missing before another fall occurred. ~A Risk Management Report, dated 12/15/24 at 7:09 AM, indicated R2 had an unwitnessed fall. The first documented neuro check was on 12/16/24 at 2:16 AM and 7 additional neuro checks were completed. The last neuro check was completed on 12/21/24 at 1:03 PM. If neuro checks were completed per the facility's policy, neuro checks would have been completed on the 12/18/24 AM shift. Surveyor noted 6 neuro checks were missing. ~A Risk Management Report, dated 12/28/24 at 7:10 PM, indicated R2 had an unwitnessed fall. The first documented neuro check was on 12/30/24 at 9:06 AM. Surveyor noted 2 of 16 neuro checks were completed. ~A progress note, dated 1/18/25 at 5:35 PM, indicated a Certified Nursing Assistant (CNA) entered R2's room and saw R2 sitting on a floor mat. A Risk Management Report, dated 1/18/24 at 7:20 PM, indicated R2 had an unwitnessed fall. There were no documented neuro checks for the fall. 2. On 2/19/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with agitation, cognitive communication deficit, hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following non-traumatic intracerebral hemorrhage affecting the right dominant side, aphasia (a language disorder that affects a person's ability to communicate effectively), epilepsy, weakness, and difficulty waking. R4's MDS assessment, dated 1/21/25, had a BIMS score of 0 out of 15 which indicated R4 was severely cognitively impaired. A falls care plan, dated 1/1/25, indicated R4 was at risk for falls due to impaired mobility, impulsiveness, and a desire to remain as independent as possible. R4's medical record and Risk Management Reports indicated the following: ~A progress note, dated 1/18/25 at 7:30 PM, indicated R4 was found on the floor by a CNA. A Risk Management Report for R4's fall on 1/18/25, dated 1/20/25 at 12:32 AM, indicated the first neuro check was not completed until 1/20/25 at 12:37 PM. Surveyor noted 12 of 16 neuro checks were completed. ~A Risk Management Report, dated 1/31/25 at 10:13 AM, indicated R4 had an unwitnessed fall. Surveyor noted 1 of 16 neuro checks were completed. ~A Risk Management report, dated 2/13/25 at 12:00 AM, indicated R4 had an unwitnessed fall. Surveyor noted 5 of 16 neuro checks were completed. 3. On 2/19/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including epilepsy, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and anxiety disorder. R1's MDS assessment, dated 11/9/24, had a BIMS score of 15 out of 15 which indicated R1 had intact cognition. R1 had an activated Power of Attorney (POA) who assisted with healthcare decisions. R1's Risk Management Reports indicated the following: ~A Risk Management Report, dated 12/26/24 at 8:36 PM, indicated R1 had an unwitnessed fall. R1 hit R1's head and sustained a forehead laceration. The report did not indicate initial neuro checks were completed. In addition, Surveyor noted 4 of 16 neuro checks were not completed. ~A Risk Management Report, dated 1/5/25 at 2:41 PM, indicated R1 had an unwitnessed fall. Surveyor noted 12 of 16 neuro checks were not completed. ~A Risk Management Report, dated 1/10/25 at 7:15 AM, indicated R1 had an unwitnessed fall. Surveyor noted 5 of 16 neuro checks were not completed. On 2/19/25 at 1:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who confirmed neuro check are not always completed. LPN-E indicated neuro checks are supposed to be on a User Defined Assessment (UDA) in the resident's electronic medical record (EMR) and are recorded in the EMR. LPN-E indicated LPN-E has tried to catch up on neuro checks that were not completed timely. LPN-E was not sure how long neuro checks should be completed post fall and indicated neuro checks were an issue with agency staff as well. On 2/19/25 at 1:45 PM, Surveyor interviewed [NAME] President of Success (VPS)-F who indicated neuro checks are completed in the EMR by using UDAs. VPS-F indicated the Interdisciplinary Team (IDT) was educated last week on ensuring UDAs are completed timely, however, floor staff were not educated. VPS-F indicated nursing leaders are assigned different UDAs to complete each day to ensure they are completed timely. (Surveyor noted if a neuro check UDA is not completed timely, one cannot go back and complete it timely.) Director of Nursing (DON)-B was present during the interview and confirmed timely neuro checks should be completed after a fall.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Certified Nursing Assistant (CNA)-C) of 8 staff reviewed for caregiver background checks. CNA-C was hired on 2/27/24 and had lived in two other states within the last three years. CNA-C's background check information did not contain out-of-state criminal or caregiver background checks. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates in part: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks including re-checks, will be completed consistent with applicable state laws and regulations. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement. On 11/11/24, Surveyor reviewed a staff list and requested CNA-C's background check and CNA registry information from Nursing Home Administrator (NHA)-A . Surveyor reviewed CNA-C's background check information and noted CNA-C was hired by the facility on 2/27/24 and had a caregiver background check completed on 2/27/24. The caregiver background check indicated CNA-C had lived in 2 states other than Wisconsin within the last three years. Surveyor reviewed all background check information provided by NHA-A and noted out-of-state criminal and caregiver background checks were not included. On 11/11/24 at 11:17 AM, Surveyor requested CNA-C's out-of-state background checks from NHA-A. On 11/12/24 at 1:30 PM, NHA-A indicated to Surveyor that the facility did not complete out-of-state background checks for CNA-C and did not have any information to provide. NHA-A indicated the facility had conducted an audit and process improvement plan to ensure all employee files were completed. NHA-A confirmed NHA-A had received the employees who had missing information in their files on 10/31/24; however, out-of-state background checks for CNA-C were still not in CNA-C's file.

Based on staff interview and record review, the facility did not ensure PASRR (Pre-Admission Screen and Resident Review) requirements were met for 5 residents (R) (R9, R22, R15, R57, and R43) of 15 sampled residents. R9's medical record indicated R9 had a mental illness (MI) diagnosis upon admission and was prescribed psychotropic medication. R9's PASRR Level I Screen was marked no for major mental disorder, no for signs and symptoms of MI, and yes for intellectual disability (ID). The facility obtained a 30-day county exemption after R9's admission to the facility. The facility did not complete a PASRR Level II Screen when R9 remained in the facility past 30 days. R22's medical record indicated R22 had a history of ID and an MI diagnoses upon admission and was prescribed psychotropic medication. R22's PASRR Level I Screen was marked no for major mental disorder, no for psychotropic medication, and no for history of ID. The facility obtained a 30-day county exemption after R22's admission to the facility. The facility did not complete a PASRR Level II Screen when R22 remained in the facility for long term care. R15's PASRR Level I Screen documented R15 had a serious mental illness and received medication to treat the symptoms of the major mental illness. R15 required a PASRR Level II Screen based on the results of the PASRR Level I Screen. A PASRR Level II Screen was not completed for R15. R57s PASRR Level I Screen did not indicate R57 had a major mental disorder or received medication to treat the symptoms of a major mental disorder; however, R57 had a major mental disorder and received medication to treat the major mental disorder. R57's PASRR Level I Screen was incorrectly completed, therefore a PASRR Level II Screen was not completed for R57. R43's PASRR Level I Screen documented R43 had a serious mental illness and received medication to treat the symptoms of the major mental illness. R43 required a PASRR Level II Screen based on the results of the PASRR Level I Screen. The PASRR Level II Screen was not completed. Findings Include: According to the State of Wisconsin Department of Health Services (DHS), PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an ID/DD (developmental disability) and/or MI. This is called a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require that they receive additional services for their ID/DD and/or MI. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an ID/DD and/or MI for PASRR purposes. This is a Level II Screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. Nursing facilities may seek county exemption (DHS form F-20822), for applicants with ID/DD and/or MI whose stay in the facility is expected to be recuperative care or short-term. 1. Between 5/28/24 and 5/30/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including epilepsy, unspecified intellectual disabilities, anxiety disorder, and depression. R9 had an order for 20 mg (milligrams) of escitalopram oxalate (an antidepressant medication) with a corresponding diagnosis of depression. A PASRR Level I Screen was completed for R9 upon admission; however, R9's Level I Screen indicated R9 did not have an MI but received psychotropic medication. The Level I Screen also indicated R9 had an ID diagnosis. The facility obtained a 30-day county exemption on 4/16/24. The facility did not obtain a PASRR Level II Screen after R9 remained in the facility past 30 days. On 5/30/24 at 12:04 PM, Surveyor interviewed Social Services Coordinator (SSC)-E who acknowledged a county exemption was obtained on 4/16/24 and confirmed a PASRR Level II Screen was not completed for R9. SSC-E stated SSC-E was working with Behavioral Consulting Services (BCS) to obtain a PASRR Level II Screen but the screen was not yet completed. 2. Between 5/28/24 and 5/30/24, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] with diagnoses including epilepsy and depression. R22 had an order for 20 mg of citalopram hydrobromide (an antidepressant medication) with a corresponding diagnosis of depression. A PASRR Level I Screen was completed for R22 upon admission; however R22's Level I Screen was marked no for a diagnosis and/or signs and symptoms of an MI or ID. The facility obtained a 30-day county exemption on 5/22/24. The facility did not obtain a PASRR Level II Screen after R22 remained in the facility past 30 days and R22's status changed to long-term care. On 5/30/24 at 10:50 AM, Surveyor interviewed SSC-E who confirmed R22's county exemption was obtained on 5/22/24 and the facility did not obtain a Level II Screen for R22 to remain in the facility long-term. On 5/30/24, at 2:59 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects staff to complete a PASRR Level I Screen, and if necessary obtain a county exemption, prior to a resident's admission to the facility. NHA-A also stated NHA-A expects staff to complete a Level II Screen prior to the lapse of the county exemption or as soon as the facility is aware the resident will remain in the facility long term. 45943 3. On 5/30/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, vascular dementia with behavioral disturbance, and anxiety disorder. A PASRR Level 1 Screen for R15 was completed on 10/13/23 and indicated R15 was suspected of having a serious mental illness. Within the past six months (of completion of the Level I Screen), R15 received psychotropic medication including divalproex (an anticonvulsant medication), fluoxetine (an antidepressant medication), mirtazapine (an antidepressant medication), and olanzapine (an antipsychotic medication) to treat symptoms of a major mental illness. A 30-day exemption was marked on the Level I Screen but there was no county review of the 30-day exemption. The facility gave Surveyor a PASRR Level II Screen, dated 10/11/22, from a previous facility that indicated yes to nursing home and no to specialized services. The facility did not provide Surveyor with a Level II Screen for R15's 10/9/23 admission. On 5/30/24 at 2:05 PM, Surveyor interviewed SSC-E who indicated as attempt was made to contact the county for county review of the 30-day exemption, but the county individual was out of the office. SSC-E verified the county review was not in R15's medical record and a PASRR Level II Screen was not completed for R15's 10/9/23 admission. SSC-E confirmed a county review of the 30-day exemption should have been done as well as a PASRR Level II Screen. 4. On 5/30/24, Surveyor reviewed R57's medical record. R57 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, anxiety, panic disorder, and depression. A hospital discharge summary, dated 3/8/24, noted diagnoses of generalized anxiety, panic attacks, and suicidal ideation in the setting of Parkinson's disease. R57 was tearful and had anxiety. Initially, R57 had suicidal thoughts and ideation to end things but no plan or intention. Psychiatry was consulted and recommended R57 start sertraline (an antidepressant) for depression. A PASRR Level I Screen was completed on 3/11/24 and indicated R57 did not have a major mental disorder and did not receive medication to treat a major mental disorder; however, R57 was prescribed lorazepam (a sedative medication) for anxiety and quetiapine (an antipsychotic medication) for anxiety related to Parkinson's disease. A 30-day county exemption was not indicated on the PASRR Level I Screen. On 5/30/24 at 12:06 PM, Surveyor interviewed SSC-E who verified R57's PASRR Level I Screen was completed incorrectly. 38793 5. Between 5/28/24 and 5/30/24, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] with diagnoses including vascular dementia, insomnia, anxiety, and post traumatic stress disorder (PTSD). A PASRR Level I Screen was completed on 11/27/23 and was marked yes for a diagnosis and/or signs and symptoms of MI or ID as well as for psychotropic medications, including Seroquel (an antipsychotic medication), sertraline and lorazepam. The facility did not obtain a PASRR Level II Screen. On 5/30/24 at 10:50 AM, Surveyor interviewed SSC-E who confirmed R43's PASRR Level II Screen was not completed. On 5/30/24 at 2:59 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects staff to complete a PASRR Level I Screen, and if necessary obtain a county exemption, prior to a resident's admission. NHA-A stated a PASRR Level II Screen should be completed prior to the lapse of the county exemption or as soon as the facility is aware the resident will remain in the facility long term.

Based on staff interview and record review, the facility did not ensure pharmacy recommendation reports were acted on by a physician for 1 resident (R) (R5) of 9 residents reviewed for unnecessary medications. R5 had monthly pharmacy reviews that included pharmacist recommendations on 12/20/23 and 1/22/24. The facility did not ensure the recommendations were reviewed by a physician or nurse practitioner. Findings include: The facility's Medication Regimen Review and Reporting policy, revised 1/2024, indicates that a record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians, and the care planning team .The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days. R5 was admitted to the facility on [DATE] and had diagnoses including cerebral palsy, epilepsy, and anxiety. On 5/29/24, Surveyor reviewed R5's medical record and noted the following: ~ A consultant pharmacist medication regimen review, dated 12/20/23, indicated recommendations were made to review the clinical pharmacy report. The clinical pharmacy report indicated R5 was prescribed diazepam (an antiseizure/antianxiety medication) as needed with no stop date. The recommendation indicated the order needed to be discontinued or rationale provided. Surveyor noted the physician/prescriber response was not filled out for the review. ~ A consultant pharmacist medication regimen review, dated 1/22/24, indicated recommendations were made to review the clinical pharmacy report. Surveyor noted there was no clinical pharmacy report or physician/prescriber response in R5's medical record. On 5/30/24 at 1:14 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the consultant pharmacist medication regimen review, dated 12/20/23, was not acted upon by the physician. NHA-A verified the consultant pharmacist medication regimen review, dated 1/22/24, indicated recommendations were made to review the report; however, the report was not in R5's medical record and NHA-A was unsure what recommendations were made.

Based on staff interview and record review, the facility did not ensure appropriate care and treatment was provided for 1 resident (R) (R42) of 21 sampled residents. R42 stated R42 was unusually chilled on 4/1/24. The facility did not complete an appropriate assessment or notify the physician timely of R42's change in condition. In addition, R42's medical record indicated wound care was not consistently provided. Findings include: The facility's Change in Condition of the Resident policy, with a revision date of 9/20/22, indicates: A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when .a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .When a resident presents with a possible change of condition .1. Assess the resident's need for immediate care/medical attention .2. Assess/evaluate the resident. This assessment/evaluation could include, but is not limited to, the following: a. Vital signs .3. Notify resident's physician . On 5/28/24, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, congestive heart failure (CHF), and diabetes mellitus. R42's Minimum Data Set (MDS) assessment, dated 3/12/24, stated R42's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R42 had no cognitive impairment. R42's medical record indicated R42 was responsible for R42's healthcare decisions. A nursing progress note, dated 4/2/24 at 1:18 AM, indicated R42 had a temperature 101.2 degrees, a pulse of 114, respirations of 30, an oxygen saturation level of 92% and a blood pressure of 242/140. R42 requested a pain pill. Hydrocodone (used to treat moderate to severe pain) was given. R42 was shaking and stated R42 was cold. R42 had white sputum coming out of R42's nose and mouth and wheezes in the lungs. A physician was notified and R42 was sent to the emergency room (ER). R42's family and Director of Nursing (DON)-B were notified. R42's treatment administration records (TARs) indicated R42 had orders for wound treatments. R42's March 2024 TAR contained no staff initials for wound care on R42's left lower leg and right heel on 3/22/24 and 3/24/24. Wound care for both areas was scheduled to be completed every other day. R42's April 2024 TAR contained no staff initials for wound care on R42's right heel on 4/19/24 and 4/21/24. Wound care was scheduled to be completed every other day. R42's May 2024 TAR contained no staff initials for wound care on R42's right heel on 5/5/24. Wound care was scheduled to be completed every Wednesday, Friday and Sunday. In addition, R42's May 2024 TAR contained no staff initials for wound care on R42's right heel on 5/8/24, 5/18/24, and 5/22/24. Wound care was scheduled to be completed every other day. R42's medical record did not contain documentation that corresponded with the above dates to indicate why R42's wound care was not completed. R42's medical record indicated R42's left lower leg wound was a venous stasis ulcer and was considered healed when R42 returned from a hospital stay on 4/8/24. R42's medical record indicated R42's right heel wound was a pressure injury that showed improvement with the use of a surgical offloading shoe. On 5/28/24 at 11:59 AM, Surveyor interviewed Nurse Practitioner (NP)-H via phone. NP-H reviewed R42's record in the provider group system which indicated the facility contacted the provider group on 4/2/24 just after midnight because the nurse wasn't sure if R42 had a seizure or was shaking from a fever. NP-H stated the on-call provider ordered an ER evaluation. R42's ER record indicated R42 was admitted to the hospital for sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) source unknown. On 5/28/24 at 2:32 PM, Surveyor interviewed R42 who indicated R42 started feeling cool and chilly on the afternoon of 4/1/24 and continued to feel cold after more blankets were provided. R42 stated Certified Nursing Assistant (CNA) staff assisted R42 to bed at approximately 8:30 PM. R42 told CNA staff that R42 felt chilled and stated, They just gave me more blankets. R42 could not recall the name of the staff. When asked if staff provided wound care every other day as ordered, R42 stated, For the most part. R42 stated R42 didn't remember when R42's wound care was last missed. Surveyor noted R42's medical record did not contain vital signs taken on the 4/1/24 PM shift. On 5/28/24 at 3:17 PM, Surveyor interviewed DON-B. When asked about missing initials on R42's TAR, DON-B stated, If blank then wasn't done. DON-B indicated if staff are unable to complete wound care they should document the reason. Following a discussion of R42's change of condition as indicated above, DON-B stated when a resident complains of feeling chilled, staff should check the resident's temperature and update the provider if the resident is running a fever. DON-B stated CNAs should update a nurse because feeling chilled is a change of condition and stated, CNAs are our eyes and ears. Surveyor reviewed the staffing schedule for the 4/1/24 PM shift and noted CNA-I, CNA-J and Licensed Practical Nurse (LPN)-K were scheduled on R42's unit. On 5/28/24 at 4:00 PM, Surveyor interviewed CNA-I via phone. CNA-I stated CNA-I worked the PM shift on 4/1/24 but did not assist R42 to bed. CNA-I stated R42 did not complain of feeling chilled to CNA-I. When asked what CNA-I would do if a resident complained of feeling chilled, CNA-I stated CNA-I would let the nurse know. On 5/29/24 at 1:15 PM, Surveyor interviewed LPN-L via phone. LPN-L stated LPN-L worked the PM shift on 4/1/24 but was not on R42's unit. When asked what LPN-L would do if a resident complained of feeling chilled, LPN-L said LPN-L would take a set of vital signs and stated, My first mind would be infection or something. I would ask a series of questions. Feeling chilled is not a natural feeling. LPN-L stated LPN-L would then call the physician as they usually want us to at least get labs based off assessment findings. On 5/30/24 at 2:30 PM, Surveyor interviewed LPN-K via phone. LPN-K stated LPN-K worked the PM shift on R42's unit on 4/1/24. LPN-K stated no one reported to LPN-K that R42 was feeling chilled and LPN-K did not notice anything unusual with R42 that shift.

Based on observation, staff interview, and record review, the facility did not ensure assistance with nail care for 1 resident (R) (R19) of 21 residents reviewed for activities of daily living (ADL) assistance. Staff did not provide routine nail care for R19. Findings include: The facility's Nail Care Policy, dated 4/20/23, indicates: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .2. Identify conditions that increase the risk for foot or nail problems, such as diabetes .4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift or shower day). Nail care will be provided between scheduled occasions as the need arises .Principles of nail care: a. Nails should be kept smooth to avoid skin injury. On 5/28/24, Surveyor reviewed R19's medical record. R19 had diagnoses including diabetes, encephalopathy, and stroke. R19's Minimum Data Set (MDS) assessment, dated 5/22/24, indicated R19 had severely impaired cognition. R19 had an activated Power of Attorney for Health Care (POAHC) since 11/25/22. R19's plan of care indicated R19 was dependent on staff for all cares. On 5/28/24 at 2:05 PM, Surveyor observed R19 in a wheelchair in the lounge calling for help. Surveyor noted R19's fingernails were approximately a half inch long with a brown substance underneath. R19's left hand was on R19's right arm and R19's fingernails created indents in R19's right arm. On 5/29/24 at 12:10 PM, Surveyor observed R19 sleeping in bed. R19's fingernails were still approximately a half inch long with a brown substance underneath. On 5/29/24 at 12:18 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C regarding daily ADL cares. CNA-C stated R19 was showered on Mondays and nail care should be provided at that time. CNA-C stated if a resident is diabetic, nurses perform nail care. On 5/29/25 at 1:53 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who examined R19's fingernails, verified nail care was not completed, and stated, It looks like two or three weeks of growth. LPN-D stated nail care should be performed with weekly showers. LPN-D verified nurses perform nail care for diabetic residents. On 5/29/24 at 1:59 PM, Surveyor interviewed Director of Nursing (DON)-B who examined R19's nails and stated, It looks like it has been a few weeks since nail care was performed. DON-B stated nail care should be performed weekly with showers.

This is a recited citation. See SOD #6NZO11. Based on staff interview and record review, the facility did not ensure the drug regimen for 1 (resident #1) of 10 sampled residents was free of unnecessary drugs. Resident #1 was [MEDICATION NAME] 5/31/11 through 11/14/11 without a dose reduction or a risks/benefits statement. Findings include: The manufacturer of Ambien, Sanofi Aventis, recommends re-evaluation of the patient if [MEDICAL CONDITION] persists after seven to ten days of use. The Lippincott "Nursing 2011 Drug Handbook" [MEDICATION NAME] a sedative-hypnotic and should be used only for short-term management of [MEDICAL CONDITION], usually seven to ten days. The face sheet, dated 11/9/11, indicated resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. On 7/27/11 the facility's consultant pharmacist faxed resident #1's physician inquiring if a dose reduction of [MEDICATION NAME] be clinically appropriate. On 8/10/11 resident #1's physician faxed the "Note To Attending Physician/Prescriber" form back to the facility. The physician had checked the box marked "disagree". The physician did not indicate the reason why a dose reduction would have been clinically contraindicated as required. As a result of the recertification survey conducted on 10/7/11, the facility was cited for resident #1 receiving [MEDICATION NAME] 5/31/11 without an indication for use and without a dose reduction or risks and benefits statement. Following the recertification survey the facility did not attempt to contact the physician for clarification of "disagree" or to request a dose reduction or a risks/benefits statement. On 11/15/11 at 11:53 a.m. surveyor # interviewed DON (Director of Nursing)-A regarding resident #1. DON-A verified a dose reduction had not been attempted with resident #1'[MEDICATION NAME] a risks/benefits had not been written after the facility had been cited at the recertification survey. DON-A stated the facility was "...trying to get clarification on this" from the physician.

Based on staff interviews and record review, 1 (resident #5) of 18 sampled residents had drug regimes with inadequate monitoring. Additionally, 1 (resident #10) of 18 sampled residents had drug regimes that were not free of unnecessary drugs. Resident #5 had been on a long term regimen of [MEDICATION NAME] (a blood thinner). When the [MEDICATION NAME] prescribed, the facility did not monitor resident #5's PT ([MEDICATION NAME]) and/or INR (International Normalized Ratio-blood tests to measure the body's ability to form blood clots) as recommended by the manufacturer and current standards of practice. Resident #10 had been [MEDICATION NAME] 5/31/11 through 10/6/11 without an indication for use and without a dose reduction or risks and benefits statement. Findings include: 1. The AMDA (American Medical Directors Association) warned, in a current, undated, web-based article regarding Cipro, "Potential for increased effects of [MEDICATION NAME] ([MEDICATION NAME])...Culture and identify microbial pathogen prior to initiation of antibiotic therapy. Consider culture sensitivity screening...quinolone selection should focus on one of the newer agents that has not demonstrated significant impairment of [MEDICATION NAME] metabolism, such as [MEDICATION NAME]. Additionally, microbial pathogen identification and sensitivity prior to antibiotic initiation will decrease the prevalence of unnecessary drug interaction risk. Monitoring/Precautions: INR should be monitored during co-administration of [MEDICATION NAME] with a quinolone. If use of [MEDICATION NAME] is imperative, then monitor INR every other day and adjust [MEDICATION NAME] dose as necessary. Signs and symptoms of an active bleed should be monitored daily with particular attention to the appearance and patterns of bruises..." The face sheet, dated 9/13/11 and contained within the medical record, indicated resident #5 was admitted to the facility on [DATE] and readmitted after hospitalization s on 8/12/11 and 9/13/11 with [DIAGNOSES REDACTED]. A hospital history and physical note, dated 8/9/11, also listed [DIAGNOSES REDACTED].#5. On 7/15/11 a PT/INR was performed for resident #5 with results of 33.3 seconds for PT and 3.33 for INR. The [MEDICATION NAME] dose at that time was 2.5 mg (milligram) six days per week and 3.0 mg one day per week on Fridays. The physician ordered the [MEDICATION NAME] held for twenty-four hours. A follow-up PT/INR was ordered for 7/22/11. The results from the test performed on 7/22/11 were PT 21.0 seconds and INR 2.07. No changes were made to the [MEDICATION NAME] regimen at that time, but a follow up PT/INR was ordered "in one month" (8/22/11). On 8/2/11 resident #5 presented with cloudy, foul smelling urine. A UA (urinalysis) was performed on 8/3/11 and revealed resident #5 had 4+ bacteria in the urine. A preliminary urine culture from 8/3/11 revealed a mixed growth of bacteria >(greater than) 10,000 CFU/ml (Colony Forming Unit per milliliter), < (less than) 100,00 CFU. [MEDICATION NAME] mg twice daily was ordered on [DATE]. A final urine culture result dated 8/3/11 also revealed mixed growth of bacteria. On 10/5/11 at 2:53 p.m. surveyor # interviewed DON (Director of Nursing)-G regarding resident #5. DON-G verified resident #5 presented with only one symptom of UTI (Urinary Tract Infection) on 8/2/11, while the facility policy required catheterized residents to demonstrate two of the following symptoms: fever; flank or suprapubic pain; change in character of urine; change in mental status. DON-G also confirmed that for a previous UTI, on 5/26/11, resident #5 had been [MEDICATION NAME] mg twice daily for seven days with a corresponding order for PT/INR to be drawn one day and four days after initiation of antibiotic therapy. Manufacturer of Cipro, [MEDICATION NAME] Healthcare Pharmaceuticals, stated in information printed about the drug in September 2008, "Quinolones, including [MEDICATION NAME], have been reported to enhance the effects of the oral anticoagulant [MEDICATION NAME] or its derivatives. When these products are administered concomitantly, [MEDICATION NAME] time or other suitable coagulation tests should be closely monitored." A nurses' progress note dated 8/8/11 at 7:05 p.m. revealed resident #5 had "...frank dark red blood in tubing and leg bag, BP (Blood Pressure)-100/40, P (Pulse)-64...last PT 33/INR 3.33...has been [MEDICATION NAME] 5 days...call placed to MD (Medical Doctor)." Later the same day (8/8/11), at 9:54 p.m., the following nurses' note revealed, "Suprapubic Foley cath (catheter) was once again irrigated due to the resident's complaint of inability to void, two clots removed approximately 5 inches long and 2 inches long." A PT/INR was ordered for that night, 8/8/11. On 8/8/11 at 11:00 p.m. a nurses note indicated "...dark hematuria (bloody urine)...tender at abdomen around suprapubic site." On 8/9/11 at 4:16 a.m. nurses' notes documented PT/INR results of 40.6 and 4.14, respectively. At 4:29 a.m. a nurses' note indicated, "Large amount of blood coming from penis...blood tinged drainage coming from around the supra-pubic site...MD gave orders to send resident to ER (emergency room )." The hospital emergency room report for resident #5 dated 8/9/11 indicated the following admitting [DIAGNOSES REDACTED]." The emergency room report also indicated, "We did transfuse 2 units of packed RBC (Red Blood Cells)." A history and physical dated 8/9/11 indicated, "Urology to admit this [MEDICATION NAME] to be held at least 2 more days...I believe that the problem [MEDICATION NAME] with [MEDICATION NAME] is contributing to the patient's problems." A hospital discharge summary dated 8/12/11 indicated resident #5 remained in the hospital and "...continued to have red urine until 8/11/11...was given fresh frozen plasma on 2 separate occasions...it was decided [MEDICATION NAME] can be stopped." During the 10/5/11 at 2:53 p.m. interview with surveyor # regarding resident #5, DON-G [MEDICATION NAME] ordered for and administered to resident #5 beginning on 8/3/11; and the MD did not order a PT/INR until resident #5 presented with hematuria on 8/8/11. DON-G indicated the facility had not notified the physician of the potential irregularity or clarify if the physician wished to order a PT/INR. 2. The Lippincott "Nursing 2010 Drug Handbook" [MEDICATION NAME] a hypnotic indicated for short term use of [MEDICAL CONDITION]. The duration of use is usually seven to ten days. The face sheet, dated 9/13/11, indicated resident #10 was admitted to the facility on [DATE] and re-admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#10 received an order to begin taking [MEDICATION NAME] milligrams at bedtime. The order contained no indication for use. On 7/27/11 the facility's consultant pharmacist faxed resident #10's physician inquiring if a dose reduction of [MEDICATION NAME] be clinically appropriate. On 8/10/11 resident #10's physician faxed the "Note To Attending Physician/Prescriber" form back to the facility with the "no" box checked, a signature and date of 8/10/11. The physician did not indicate any reason why a dose reduction would have been clinically contraindicated as required. On 10/6/11 at 1:28 p.m. surveyor # interviewed DON-G regarding resident #10. The DON verified no dose reduction had been attempted with resident #10's Ambien, and the facility had not obtained an indication for use from the resident's physician.

Based on staff interview and record review, the facility did not ensure 2 (residents #1 and #2) of 11 sampled residents received adequate supervision to prevent accidents. Resident #1 was at high risk for falls due to mobility issues including unsteady and ataxic stance/gait, dizziness, double vision and forgetfulness. After evaluation by Physical Therapy, it was determined resident #1 required the extensive assistance of two staff for transfers and mobility. Although that information was provided to LPN (Licensed Practical Nurse)-C, the LPN did not ensure all caregivers working on resident #1's unit were informed of the same to ensure the adequate supervision and assistance was provided to resident #1. On 7/29/11 CNA (Certified Nursing Assistant)-D entered resident #1's room and began preparing to transfer resident #1 from the bed to the wheel chair with one assist, when resident #1 sustained a fall from the bed sustaining nasal bone fractures. Resident #2 had a plan of care, which directed staff to place an alarm on the resident when the resident was seated in her wheel chair. On 4/27/11 resident #2 was discovered on the floor with the alarm system intact, but not in the on position. The alarm had not sounded to notify staff resident #2 was moving. Findings include: 1. On 8/4/11 surveyor # completed a record review for resident #1. The admission record, dated 7/29/11 and located within the medical record, documented resident #1 was admitted to the facility on [DATE]. The hospital discharge summary dated 7/28/11 documented an extensive hospitalization due to obstructive [DIAGNOSES REDACTED] status [REDACTED]. The patient care summary, dated 7/28/11, documented resident #1 was forgetful at times, was at risk for falls, had blurred/double vision, and required two staff assistance for bathing, ambulation and toileting. The admission clinical health status, dated 7/28/11 at 2:45 p.m., documented resident #1 had long and short-term memory problems, severely impaired vision, which included double vision, and the use of an eye patch to be rotated every two hours. The health status further documented resident #1 could not ambulate or transfer independently, had unsteady balance, had intermittent confusion and a recent history of a fall. The fall risk assessment documented a total score of 14, which indicated high risk (10 or above = high risk). The Immediate Plan of Care At Risk for Falls, dated 7/28/11, documented resident #1 was at risk due to dizziness. Interventions documented included: -Assist with transfer...Ext. (extensive) assist -Call light available -Assist with mobility...one assist -Encourage rest periods daily to avoid overtiring -Gather and document information if resident does fall... -Gait belt with all transfers -Wheelchair...propelled by staff -Institute fall prevention program -Evaluate need for bed alarm, chair alarm -Evaluate, with physician, the potential impact of medications... -Notify rehab for possible assessment The "Care Huddle", dated 7/29/11, documented the following regarding resident #1, "...new admit...Extensive assist with cares/transfers...". The progress notes documented the following: -7/28/11 documented at 3:49 p.m. indicated resident #1 was admitted to the facility via stretcher and was assisted to bed via four staff. -7/29/11 documented at 7:52 a.m. indicated resident #1 did not transfer during the night. -7/29/11 documented at 9:14 a.m. indicated resident #1 appeared slightly confused at times, only able to sit up for approximately thirty minutes before he became nauseous, and required extensive assist with ADLs (Activities of Daily Living) and transfers with two assist and a gait belt. The physical therapy evaluation dated 7/29/11 documented the following precautions: "...Balance precautions include LOB (loss of balance) in sitting and standing w/inability to regain, high fall risk; Safety precautions include transfer w/2 and do not leave unattended sitting on EOB (edge of bed)/mat until dizziness resolves...". On 8/4/11 at 9:00 a.m. surveyor # interviewed PT (Physical Therapist)-H regarding resident #1. PT-H indicated physical therapy and occupational therapy evaluations were completed for resident #1 on 7/29/11 at approximately 9:30 a.m. to 10:00 a.m. PT-H indicated she and the OTR (Occupational Therapist-Registered) worked together to complete both the physical therapy and occupational therapy evaluations. PT-H stated resident #1 was very high risk for falls due to his inability to regain balance while sitting or standing. PT-H stated resident #1 was ataxic (loss of ability to coordinate muscular movement) and demonstrated clonic (alternate involuntary muscular contraction and relaxation in rapid succession) movements. PT-H stated resident #1 required extensive assist of two staff for mobility activities, including sitting on the side of the bed or transfers. PT-H stated she informed LPN-C of her recommendations immediately after the evaluation. PT-H stated she specifically informed LPN-C of the need for two staff for mobility activities for resident #1, including transfers. PT-H indicated she also informed LPN-C resident #1 was not to be left to sit on the edge of the bed unattended. The "Change in Condition Report-Post Fall/Trauma" document regarding resident #1 on 7/29/11 at 12:45 p.m. indicated, "...Falls: Transfer-Unassisted in residents room (CNA was attempting to get res (resident) up for lunch, when she turned around to grab the w/c (wheelchair) and res flopped out of bed onto the floor. Res was found by writer laying flat on his stomach, face first), injuries: Laceration: Face, Other (Both of res lips are swollen from hitting his face on the floor. Ice pack applied)..." The progress notes on 7/29/11 documented at 1:19 p.m. indicated resident #1 fell out of bed. The assessment documented, "Staff was attempting to get res up for lunch. CNA stated she turned to get the w/c and res flopped out of bed and onto the floor, face first...noted to have laceration on lower lip along with swelling of top and bottom lips. Laceration cleansed with normal saline and area stopped bleeding. Ice pack applied. Neuro checks done and are WNL (Within Normal Limits). VSS (Vital Signs Stable) Assessment done by RN...Writer spoke with CNA who was unaware that res was a 2 person transfer at all times...MD (Medical Doctor) updated and no new orders received...Will continue with neuro checks and VS per protocol...". According to the progress notes, resident #1 was subsequently transferred to the hospital at approximately 2:55 p.m. on 7/29/11. The emergency room report, dated 7/29/11, documented the chief complaint was a fall with superficial lacerations to resident #1's bottom lip, some swelling to the upper lip, tenderness over the bridge of the nose and swelling consistent with a fracture. The "Impression" was documented as 1) Fall, 2) Nasal bone fractures, 3) [DIAGNOSES REDACTED]. The CT (computerized tomography) scans completed on 7/29/11 of the resident's facial bones and head documented, "...asymmetry in left inferior nasal turbinate..." and "...some irregularity to the right and left anterior nasal bones which could represent nondisplaced fractures...". During a telephone interview with surveyor # on 8/4/11 at 9:13 a.m., CNA-D recalled the events of 7/29/11. CNA-D stated on the morning of 7/29/11 resident #1 was a new admission, and she had not cared for him prior to that day. CNA-D stated she reviewed the "Care Huddle" book, which was a tool used by the nursing staff to communicate information regarding resident needs/appointments, etc. from the nurse to the CNAs. CNA-D stated she thought the "Care Huddle" book indicated resident #1 required extensive assist of one. CNA-D stated the CNA care card had resident #1's name and shower information on the sheet, but no further information, for instance his transfer ability or amount of staff assistance. CNA-D stated LPN-C told the CNAs assigned to the unit (CNA-D, CNA-E and CNA-F) to leave resident #1 in bed until the therapy evaluation had been completed. CNA-D stated resident #1 had eaten breakfast in his bed that morning; and sometime after breakfast, a therapy evaluation had been completed. CNA-D stated just prior to lunch LPN-C stated that resident #1 could get up for lunch, but LPN-C did not inform her how resident #1 was to transfer, including the number of staff assistance he required. CNA-D stated she took resident #1's lunch tray into his room and found him to be sliding down in bed positioned towards the right side of the bed. The head of the resident's bed was elevated approximately 25-30 degrees, and both positioning bars were elevated. CNA-D stated she set down the lunch tray and decided to assist resident #1 into his wheel chair for lunch. CNA-D stated she asked resident #1 if he wanted to get up into the wheel chair for lunch and then lowered the right positioning bar. CNA-D stated she turned her back towards resident #1 and took two steps to obtain the wheel chair. When she turned around, CNA-D saw resident #1's feet sliding to the floor. The resident's legs were sliding off the bed, and his body followed. The resident landed face down on the floor. CNA-D stated it all happened so quickly she was not able to prevent the fall. CNA-D stated she immediately summoned LPN-C to the room. CNA-D stated at no time, prior to the fall, had LPN-C informed her of the results of the therapy evaluation or that resident #1 required two staff assistance for transfers. On 8/4/11 at 8:10 a.m. surveyor # interviewed CNA-E regarding resident #1 and the fall sustained on 7/29/11. The CNA recalled the events of 7/29/11 involving resident #1. CNA-E stated resident #1 was a new admission and was assigned in CNA-E's group for ADLs. CNA-E stated she asked LPN-C how much assistance resident #1 required. CNA-E stated LPN-C informed her the resident required two staff assistance for transfers, but staff should leave him in bed until the therapy evaluation had been completed. CNA-E stated she could not recall if LPN-C informed her of the required two assist for mobility after the therapy evaluation had been completed, but stated at some point that day, when she questioned LPN-C, she had been informed resident #1 required two staff assistance. CNA-E stated neither she nor CNA-F assisted with any transfers for resident #1 that day. CNA-E stated she was summoned to resident #1's room after the fall occurred. On 8/4/11 at 1:29 p.m. surveyor # completed a telephone interview with LPN-C regarding resident #1 and the fall sustained on 7/29/11. LPN-C stated in the beginning of the shift on 7/29/11 she informed CNA-D, CNA-E and CNA-F to leave resident #1 in bed until after the therapy evaluation to determine his mobility needs. LPN-C stated she called the therapy staff and informed them of the need for an evaluation. LPN-C verified after the physical therapy evaluation, PT-H informed her resident #1 required extensive assist of two staff for transfers, and the resident could not sit at the side of the bed alone for safety reasons. LPN-C stated she informed CNA-E and CNA-F of that information, because they asked her. LPN-C verified she did not inform CNA-D and did not update the plan of care or CNA care card for the current shift to reflect the needs of resident #1. LPN-C stated she told CNA-E, after the therapy evaluation, that resident #1 could get up and go to the dining room for meals. LPN-C stated she was saying that to CNA-E in "general", and was not directing that resident #1 needed to get up into the wheel chair for the lunch meal. LPN-C stated she did not inform CNA-D of the same, but rather thought CNA-D overheard LPN-C informing CNA-E that resident #1 could get up. LPN-C stated she did not direct CNA-D to get resident #1 up, and had not informed CNA-D of resident #1's care needs related to transfers. LPN-C stated CNA-D summoned her to the room at the time of the fall. LPN-C verified CNA-D was the only staff in the room at the time of the fall. LPN-C stated resident #1 had been at high risk for falls related to his poor trunk control and impaired mobility. LPN-C stated she would have expected two staff in the room prior to the transfer, and CNA-D should not have lowered the positioning bar then turned her back towards resident #1 to obtain the wheel chair. During interviews with surveyor # on 8/4/11 at 8:20 a.m., 9:50 a.m. and 10:00 a.m. regarding resident #1 and the fall sustained on 7/29/11, DON (Director of Nursing)-G verified the CNA care card had not been updated to include resident #1's transfer ability or need for two staff until after the physical therapy evaluation. On 7/29/11 the facility updated the CNA care card for the next shift, but had not revised the care card for the current shift working (including CNA-D's care card). DON-G verified the "Care Huddle" sheet only directed "extensive assist with cares/transfers", but did not indicated the number of staff assistance required. DON-G verified LPN-C failed to inform all caregivers on resident #1's unit of the therapy recommendations after the evaluation had been completed. DON-G verified all CNAs on the unit had the potential to provide care/assistance for any resident on the unit, not only the residents assigned on the ADL "group". DON-G verified LPN-C did not update the plan of care after the therapy evaluation to include the extensive assist of two staff for transfers, and not to allow resident #1 to sit on the side of the bed independently. DON-G verified CNA-D stated she was not aware of resident #1's need for two staff assistance with transfers until after the fall occurred. 2. On 8/4/11 surveyor # reviewed resident #2's medical record. The face sheet, dated 5/19/10, indicated resident #2 was admitted to the facility on [DATE]. A hospital history and physical, dated 12/24/10, indicated resident #2 was admitted to the hospital following a fall at the nursing home. The hospital discharge summary, dated 12/27/10, indicated resident #2 was readmitted to the nursing home after a surgical repair for a right hip fracture. The facility completed a "Clinical Health Status", dated 12/27/10, which indicated resident #2 had long and short-memory deficits and required assistance with decision making. The facility completed a "Risk for Falls", dated 4/27/11, which indicated resident #2 had intermittent confusion, had one to two falls in the previous six months, was chair bound, and required assistive devices for gait balance. The facility indicated resident #2 was at risk for falls. The facility developed a plan of care for resident #2 for physical functioning deficit related to self-care and mobility impairment due to fracture, dated 1/6/11. The plan of care indicated resident #2 required wheel chair and bed sensor alarm to alert staff of self-transfers. The nurses' notes, dated 4/27/11, indicated resident #2 fell at 4:45 p.m. and struck her head. The notes indicated resident #2 fell asleep in the wheel chair and fell face-first to the floor. The alarm was intact but not sounding. The notes went on to indicate resident #2 was assisted back to the wheel chair with the assist of two. The alarm was turned on, and resident #2 was placed on neurological checks and fifteen minute checks. Family and physician were updated. New orders were received from the physician to send resident #2 to the emergency room if her condition worsened. The family notified the facility and requested a CT (computerized tomography) scan be completed. Resident #2 was transferred to the emergency room . The emergency room report, dated 4/27/11, indicated resident #2 returned to the facility having been diagnosed with [REDACTED]. On 8/4/11 at 10:00 a.m. surveyor # conducted a telephone interview with RN (Registered Nurse)-I regarding resident #2's fall on 4/27/11. RN-I verified she responded to another resident's call for help that resident #2 had fallen on the floor. RN-I stated she arrived in the lobby area, where resident #2 was lying face down on the floor. The RN indicated resident #2 must have fallen out of her wheel chair. RN-I stated resident #2's alarm was intact on the wheel chair, but was not sounding. RN-I stated the alarm was in the "off" position. On 8/4/11 at 12:10 p.m. surveyor # interviewed DON-G regarding resident #2's fall on 4/27/11. DON-G verified the alarm that was utilized for resident #2 was in the "off" position at the time of the fall on 4/27/11, and that was why the alarm had not sounded. DON-G stated the facility changed the alarm units that were utilized at the facility. Additionally, staff were re-educated related to ensuring the alarm units, for those residents who utilized alarms, were placed in the "on" position for staff notification of resident movements.

Based on observation, staff interview and record review, the facility did not ensure 1 (resident #1) of 12 sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #1 had a history of [REDACTED]. to rise, which were not implemented when the resident sustained [REDACTED]. Following the 12/12/10 fall, the facility added a tabs monitor as a fall intervention for resident #1. The facility did not recognize resident #1 already had an alarm on her fall prevention plan of care, nor did the facility recognize the alarm was not utilized at the time resident #1 fell on [DATE]. Resident #1 sustained another fall from her wheel chair on 3/2/11. The report indicated medications were recently reviewed/adjusted prior to the fall on 3/2/11. No new interventions were implemented. Resident #1 sustained one additional fall from her wheel chair on 3/7/11, which resulted in the resident being transferred to the emergency room . Resident #1 sustained a laceration on her nose and a nasal fracture. Findings include: The facility's policy and procedure for "Falls Management", dated 4/24/06, (without further revision) indicated appropriate interventions would be implemented and the care plan would be updated following a resident's fall. On 3/9/11 surveyor # reviewed resident #1's medical record. The face sheet, dated 6/9/10, indicated resident #1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. On 6/4/10 the facility completed a falls risk assessment for resident #1. The assessment indicated resident #1 was at high risk for falls related to intermittent confusion, three or more falls in the past six months and chair bound. The assessment indicated resident #1 had balance problems while standing and walking, had lower extremity weakness and had predisposing diseases for falls. The fall risk summary indicated resident #1 had mild confusion and an extensive history of falls. On 7/14/10 alarms were added to the resident's bed and wheel chair for safety precautions to alert staff to the resident's attempts to rise. The facility developed a plan of care for "At Risk for Falls" for resident #1 dated 6/15/10. The following were interventions for fall prevention: * Activity programming * Assess for pain * Assess that wheel chair is of appropriate size * Assess need for footrests, anti-tippers * Assess for need to have wheel chair locked/unlocked for safety * Call light or personal items available and in reach or provide reacher * Footwear to prevent slipping * Keep environment well lit and free of clutter * Observe for side effects of medications * Orientation to new room and room mate * Therapy OT (Occupational Therapy) and PT (Physical Therapy) per physician's orders [REDACTED]. The post fall report, dated 10/1/10, indicated resident #1 sustained a fall on that date. The report indicated bed/chair alarms were utilized prior to the resident's fall on 10/1/10. The post fall report, dated 12/12/10, indicated resident #1 was found lying on her left side on the floor. The resident was reaching to pick up some boxes (no boxes were found). The report indicated the resident must have fallen face first out of the wheel chair. Injuries included peri-orbital bruising along with a large hematoma above and below the resident's left eye and a 1 centimeter laceration to the bridge of the resident's nose. The report indicated the identified interventions of the bed and wheel chair alarms were not utilized prior to resident #1's fall on 12/12/10. The report indicated on 12/13/10 the IDT (interdisciplinary team) recommended a tabs monitor be applied for resident #1. The nurses' notes dated 12/12/10 indicated resident #1 was found on the floor with a moderate amount of blood noted on the floor and on the resident's entire face. Once cleaned, resident #1 was found to have a small laceration to the bridge of her nose measuring 1 cm. (centimeter). Resident #1 was also noted to have a golf ball sized hematoma above the left eye, measuring 5 cm by 5.8 cm by 1.0 cm and a small hematoma below the left eye along with peri-orbital bruising. The nurses' notes indicated the resident had been agitated all morning, even prior to the fall. The nurses' notes indicated a tabs alarm was placed on resident #1's wheel chair with bed alarm for safety. According to the falls meeting protocol notes, dated 12/13/10, resident #1 was changed from a sensor pad to a tabs (pull apart alarm) due to shorter strip length. The notes did not indicate if any alarm was sounding when resident #1 fell from her wheel chair on 12/12/10. On 3/10/11 surveyor # interviewed RN (Registered Nurse)-F regarding resident #1's fall risk and plan of care for falls. RN-F verified resident #1 was identified by the facility at high risk for falls on admission. RN-F verified a bed/chair alarm was added to the resident's plan of care for fall prevention on 7/14/10. On 3/10/11 surveyor # interviewed RN-F, DON (Director of Nursing)-B and LPN (Licensed Practical Nurse)-G regarding resident #1's fall on 12/12/10. RN-F, DON-B and LPN-G verified resident #1's plan of care indicated a bed/chair alarm was to have been utilized. DON-G stated when the IDT reviewed the report for the 12/12/10 fall, they did not recognize the alarms were already written on resident #1's plan of care and did not investigate why the alarm had not been utilized on 12/12/10. On 3/2/11 resident #1 sustained another fall. The fall report indicated resident #1 was found lying in front of the wheel chair with the alarm sounding. No apparent injures were noted. The report indicated resident #1 was very agitated and anxious prior to the fall and continued with increased behaviors after the fall. The IDT review and recommendations, dated 3/7/11, indicated medications were adjusted in the five days prior to the fall. The plan of care for falls risk, dated 6/15/10, contained an updated intervention dated 3/2/11, which indicated a medication review, adjustment was completed. No other updated interventions were listed on the plan of care. Progress notes, dated 3/7/11, documented resident #1 was found on the floor in the lobby. Resident #1 was found lying in a fetal position on her right side with copious amounts of blood pouring from the bilateral nares. The tabs alarm was sounding. A pillow and towels were placed under the resident's head/neck for stabilization/alignment and comfort. The bridge of the resident's nose had an abrasion with an approximately 2 X 2 cm area of superficial skin removed. Additionally, the resident sustained [REDACTED]. The resident's nose was visibly displaced to the right. Resident #1 was transferred to the emergency room for evaluation. According to the hospital emergency room report, dated 3/7/11, resident #1 was returned to the facility with [DIAGNOSES REDACTED]. The progress notes, dated 3/7/11, indicated resident #1 returned to the facility from the hospital. The resident had had a CT scan, which confirmed a nasal fracture. The notes indicated the resident had only three sutures to the laceration, because the resident was uncooperative. The progress note indicated resident #1's nose was very swollen with no active bleeding, and her left eye was swollen shut. On 3/10/11 at 8:30 a.m. surveyor # interviewed RN-F, DON-B and LPN-G regarding resident #1's history of falls from her wheel chair. RN-F, DON-B and LPN-G verified resident #1 had a history of [REDACTED]. RN-F, DON-B and LPN-G stated resident #1 had medication changes on 2/26/11 and again on 2/28/11, but there had been no other interventions in an attempt to keep resident #1 safe after the fall on 3/2/11. RN-F, DON-B and LPN-G stated the facility was waiting to see if the medication changes would have been effective for the resident's agitated behaviors. RN-F verified there had not been any significant changes to resident #1's behaviors. Surveyor # asked RN-F, DON-B and LPN-G how the facility attempted to prevent future falls for resident #1 while the facility was waiting to see if the medication changes were effective. RN-F verified there were no additional changes to resident #1's plan of care for fall prevention. DON-B indicated she would look for any additional information regarding resident #1's falls. No additional information was provided. On 3/10/11 at 9:45 a.m. surveyor # observed resident #1. The resident was being assisted by staff with morning cares. The surveyor observed resident #1's bilateral eyes were dark purple in color, with dark purple coloring under resident #1's nose. The top of resident #1's nose had an abrasion with three sutures, bloody dried areas, and the nose was swollen. Resident #1 had a 50-cent sized bruised area under the left eye, and the resident's left eye was observed to be swollen with only a small slit visible. The left side of resident #1's face was yellow/green in color. Three quarters of resident #1's forehead was observed to be yellow/green in color.