Every finding on record at Heritage Health Services

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 32 residents residing in the facility.Staff did not monitor the water temperature of the 3-compartment sink and sanitizing buckets to ensure testing of the parts per million (PPM) of the sanitizing solution was accurate.Staff did not monitor dishwasher rinse and surface temperatures to ensure appropriate sanitization.Findings include:On 6/8/26 at 10:38 AM, Surveyor began an initial tour of the kitchen with Dietary Manager (DM)-E who stated the facility follows the Wisconsin Food Code.The Wisconsin Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure .(K) Employees are properly sanitizing cleaned multi-use equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, chemical concentration, pH, temperature, and exposure time for chemical sanitizing.Three-Compartment Sink/Sanitizing Buckets:The Wisconsin Food Code documents at 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing: (A) In manual warewashing operations, a temperature measuring device shall be provided and readily accessible for frequently measuring the washing and sanitizing temperatures. The Wisconsin Food Code documents at 4-501.19 Manual Warewashing Equipment, Wash Solution Temperature: The temperature of the wash solution in manual warewashing equipment shall be maintained at not less than 110 degrees Fahrenheit (F) or the temperature specified on the cleaning agent manufacturer's label instructions.The Wisconsin Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.The Wisconsin Food Code documents at 3-304.14: (B) Cloths in-use for wiping counters and other equipment surfaces shall be (1) Held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114.The Wisconsin Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times .shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions.Hydrion QT-40 test strips: Product directions state the test solution should be between 65- and 75-degrees F. During an initial tour of the kitchen on 6/8/26 at 10:38 AM, Surveyor observed the logs for the 3-compartment sink and sanitizing buckets. The logs did not indicate the temperature of the water mixed with the sanitizing soloution was monitored. DM-E stated the facility uses Hydrion QT-40 test strips to test PPM of the chemical sanitizer. DM-E stated the facility does not test the water temperature in the 3-compartment sink or sanitizing buckets prior to use. Dishwasher Temperatures:The Wisconsin Food Code documents at 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing: (B) In hot water mechanical warewashing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the utensil surface temperature.The Wisconsin Food Code documents at 4-703.11 Hot Water and Chemical: After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (B) Hot water mechanical operations by being cycled through equipment that is set up as specified under 4-501.15, 4-501.112, and 4-501.113 and achieving a utensil surface temperature of 160 degrees F as measured by an irreversible registering temperature indicator.The Wisconsin Food Code documents at 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures: (A) Except as specified in paragraph (B) of this section, in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 degrees F, or less than: (1) For a stationary rack, single temperature machine, 165 degrees F; or (2) For all other machines, 180 degree F.On 6/9/26 at 12:51 PM, Surveyor observed staff use the facility's high (hot) temperature sanitizing machine to wash dishes. Surveyor noted peak rinse temperatures for three rinse cycles were between 201- and 204-degrees F. DM-E was unsure if the temperature was too high and indicated the facility uses an internal thermometer to verify surface temperatures twice weekly. DM-E also indicated the facility relies on built-in gauges on the dishwasher for day-to-day monitoring. DM-E could not locate an internal thermometer to verify the internal surface temperature of the machine. DM-E stated the temperature on the internal thermometer is usually the same as the rinse temperature displayed on the built-in gauge. DM-E was not aware of the maximum temperature regulations. Surveyor reviewed the facility's dishwashing logs with DM-E and noted the logs did not include monitoring of the internal surface temperature of the dishwasher.

Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water system. This practice had the potential to affect all 32 residents residing in the facility.The facility did not complete daily water temperatures, flush unused faucets, toilets, and shower heads weekly, or complete visual ice machine inspections during November 2025, December 2025, January 2026, and February 2026.Findings include:The facility's Water Management Plan, last reviewed 3/19/26, indicates: Water feeds three water heaters located in the boiler room set to 160 degrees Fahrenheit (F) .Hot water from these heaters also runs through a mixing valve and is circulated to all resident areas in the older section of the building at a temperature of between 105-115 degrees .Water is run through a mixing valve and is distributed to all resident areas in the new section of the building at a temperature between 105-115 degrees .Areas where Legionella could grow and spread include water heaters, pipes, valves, fittings, ice makers, dead legs of the system, expansion tanks, point of use fixtures, eye wash stations, and areas not in use including all of the 100 hall and the old basement laundry room. Control measures and monitoring include water temperatures are sampled and logged daily on TELS during the week, water heater temperatures and operation are checked daily during the week, .flush eye washing stations weekly, run all fixtures weekly that are not in use .Weekly flushes will be done to bring in chlorinated city water to all water fixtures by replacing stagnant water thus reducing the risk of waterborne illnesses including Legionella .Flushing will be done at each faucet or shower head by fully opening water faucets and allowing the water to run for at least one minute .Per regulations, hot water temperature controls shall be maintained to regulate the temperature of hot water delivered to plumbing fixtures used by residents to attain a hot water temperature not less than 105 degrees F and not more than 115 degrees F .Verification process includes log daily water temps with TELS, daily visual of inspections of mechanical systems .On 6/10/26 at 9:37 AM, Surveyor reviewed the facility's daily water temperature and weekly flushing logs and noted logs were not provided for November 2025, December 2025, January 2026, or February 2026. The March 2026 log contained water temperatures on 3/18/26 and 3/30/26. The April 2026 log contained water temperatures on 4/14/26 and 4/28/26.On 6/10/26 at 10:16 AM, Surveyor interviewed Regional Maintenance Director (RMD)-I who indicated flushing and temperatures for November 2025, December 2025, January 2026, and February 2026 as well as the missed dates in March 2026 and April 2026 should have been completed but the facility did not have maintenance staff during that time. RMD-I verified the temperatures should have been taken 5 days a week and the flushes described in the Water Management Plan should have been completed weekly.

Based on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 2 residents (R) (R28 and R40) of 2 sampled residents.R40 received antibiotic therapy in March 2026 for a urinary tract infection (UTI) that did not meet McGeer criteria.R28 received antibiotic therapy in March 2026 for an eye infection that did not meet McGeer criteria.Findings include:The facility's Antibiotic Stewardship Program, revised 11/18/22 indicates: The program includes antibiotic use protocol and a system to monitor antibiotic use .i. Nursing staff shall assess/gather data on residents who are suspected to have an infection and notify the physician .iii. The facility uses the updated McGeer criteria to define infections .Monitoring for antibiotic use .i. Monitor response to antibiotics and laboratory results when available to determine if the antibiotic is still indicated or if adjustments should be made .ii. Antibiotic orders obtained upon admission, whether new or readmission, shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.1. R40 had a diagnosis of history of urinary tract infection (UTI). R40 was prescribed cephalexin (an antibiotic medication) 250 milligrams (mg) on 3/2/26 for a duration of 90 days for a UTI.On 6/10/26, Surveyor reviewed the facility's resident infection line list and McGeer criteria for R40 and noted R40 did not meet the criteria for a UTI. R40's medical record did not indicate the provider was consulted regarding the appropriateness of antibiotic usage since R40 did not meet the criteria of having a UTI.On 6/10/26 at 9:25 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who was also the facility's Infection Preventionist (IP). ADON-C indicated R40 entered the facility on the antibiotic. The facility's policy indicates to contact the provider for a resident on an antibiotic that does not meet McGeer criteria. ADON-C indicated R40 did not have symptoms of a UTI and verified R40's medical record did not indicate the provider was contacted about the appropriateness of the antibiotic. ADON-C stated they contacted the provider about R40's antibiotic therapy but did not document the conversation. ADON-C indicated the facility usually contacts providers verbally if criteria is not met and a resident is prescribed an antibiotic. ADON-C indicated they would not normally document the provider contact in the resident's medical record.2. R28 was started on erythromycin (an antibiotic medication) eye ointment twice daily on 3/10/26.On 6/10/26, Surveyor reviewed the facility's resident infection line list and noted R28 did not meet McGeer criteria for a left eye infection. R28's medical record did not indicate the Veteran Administration (VA) clinic was contacted regarding the appropriateness of antibiotic usage since R28 did not meet the criteria for infection.On 6/10/26 at 10:24 AM, Surveyor interviewed ADON-C who reviewed McGeer criteria for R28's eye infection and verified R28 did not have symptoms and did not meet the criteria. ADON-C indicated they contacted the VA provider via fax but did not receive a response. ADON-C provided a fax cover sheet, dated 3/2/26, that indicated R28 did not meet McGeer criteria for an eye infection and asked if the provider wanted to continue antibiotic therapy. ADON-C did not have confirmation the fax was received and did not document the contact with the VA provider. ADON-C indicated it was not uncommon to not receive a response from the VA provider.

Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R29) of 1 sampled resident.R29 had pancrelipase capsules, D-Mannose tablets, compounded tramadol/lidociane/diclofenac pain cream, Refresh eye drops, and saline nasal spray at the bedside. R29 did not have an order for medication to be left at the bedside or a self-administration of medication assessment that indicated R29 could safely and accurately self-administer medication. In addition, R29's hospital discharge paperwork contained an order for pancrelipase (dated 5/20/26). The order was not transcribed by the facility.Findings include:The facility's Medications Brought to Nursing Care Center by Resident or Responsible Party policy, dated 1/2023, indicates: Medications brought into the nursing care center by a resident or responsible party are accepted only with a current order by the resident's prescriber, after the contents are verified by the nurse, and if the packaging meets the state, federal, and pharmacy's guidelines.The facility's Medication Reconciliation policy, revised 10/24/22, indicates: Pre-admission Process: a. Obtain current medication list from referral source (i.e., hospital .) .b. Compare orders to hospital discharge records, etc. Obtain clarification orders as needed. c. Transcribe orders in accordance with procedures for admission orders. d. Have a second nurse review transcribed orders for accuracy .g. Obtain home list of medications from resident/representative, if possible. Place in chart for physician review and revision of medication regimen, if warranted.R29 was admitted to the facility on [DATE] and had diagnoses including cirrhosis of liver and chronic pain syndrome. R29's Minimum Data Set (MDS) assessment, dated 5/26/26, stated R29 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.From 6/8/26 to 6/10/26, Surveyor reviewed R29's medical record. An admission assessment indicated R29 preferred not to self-administer medication. On 6/8/26 at 10:49 AM, Surveyor interviewed R29 who was in bed. R29 acknowledged the pancrelipase capsules, D-Mannose tablets, Refresh eye drops, and saline nasal spray at the bedside. R29 stated they informed a nurse about the medications when they arrived at the facility. R29 stated they had to take pancrelipase capsules with the first bite of every meal.On 6/8/26 at 1:59 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who verified R29 did not have an order to keep medication at the bedside. LPN-F entered R29's room with Surveyor and observed the pancrelipase capsules, D-Mannose tablets, Refresh eye drops, and saline nasal spray at R29's bedside. LPN-F informed R29 that LPN-F had to remove the medications becuase R29 did not have an order to keep them at the bedside. LPN-F stated they would contact the provider to get an order. R29 informed LPN-F that Assistant Director of Nursing (ADON)-C told R29 they could keep medication at the bedside.On 6/9/26 at 8:37 AM, Surveyor interviewed R29 who stated their spouse brought compounded pain cream to the facility. The cream was at R29's bedside, however, R29 wasn't sure if it could stay there. Surveyor observed the compounded pain cream which contained tramadol, lidocaine, and diclofenac. R29 stated they had stomach pain that was likely due to not taking pancrelipase with meals. R29 stated they had not taken pancrelipase since LPN-F removed it from their bedside the previous afternoon.On 6/9/26 at 8:40 AM, Surveyor interviewed LPN-F who indicated the provider was in the facility and would review R29's medication to determine what they could take. LPN-F indicated the compounded pain cream should not be at R29's bedside and LPN-F would inform the provider.On 6/9/26 at 2:42 PM, Surveyor interviewed ADON-C who was not aware of any medications at R29's bedside.On 6/9/26 at 3:15 PM, Surveyor interviewed R29 who stated the provider did not want to order any of the home medications. R29 stated they could not take pancrelipase from home while in the hospital but the hospital substituted another medication that helped.On 6/9/26 at 3:39 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the provider wants to continue medications that were prescribed from the hospital at discharge.Surveyor reviewed R29's hospital Discharge summary, dated [DATE], which included an order for 2 pancrelipase capsules with meals and 1 capsule with snacks for non-alcoholic steatohepatitis (dated 5/20/26). (Of note: The order was not transcribed in R29's medical record or on R29's Medication Administration Record (MAR).)On 6/9/26 at 4:07 PM, Surveyor interviewed DON-B who verified the pancrelipase order on the discharge summary. DON-B indicated there was a transcription error when staff entered hospital discharge medications from the after-visit summary instead of the discharge orders. DON-B indicated staff should have compared the orders on the discharge summary to the after-visit summary and should have contacted the hospital physician to clarify the orders.

Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Reivew (PASRR) Level II Screen was completed and/or county exemption was received for 3 residents (R) (R7, R30, and R24) of 6 sampled residents.A PASRR Level II Screen was not completed for R7.PASRR Level II Screens were not completed for R30 and R24 prior to admission.Findings include: The facility's Resident Assessment-Coordination with PASRR Program policy, revised 11/10/25, indicates: .1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the state's Medicaid rules for screening .ii. Positive Level I Screen–necessitates a PASRR Level II evaluation prior to admission. b. PASRR Level II–a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has a mental disorder (MD), intellectual disorder (ID), or correlated condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or intellectual disability authority has determined appropriate for admission. 1. R7 was admitted to the facility on [DATE] and had diagnoses including hallucinations, major depressive disorder, and anxiety. R7's Minimum Data Set (MDS) assessment, dated 3/26/26, stated R7 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. R7 had an activated Power of Attorney (POA). An undated PASRR Level I Screen indicated R7 had a mental illness. A PASRR Level II Screen was not completed. On 6/9/26 at 2:56 PM, Surveyor interviewed Social Services Director (SSD)-D who confirmed a PASRR Level II Screen should have been completed for R7. 2. R30 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder and bipolar disorder. R30's MDS assessment, dated 6/2/26, stated R30 had a BIMS score of 11 out of 15, indicating moderately impaired cognition. R30 was their own decision maker. An undated PASRR Level I Screen indicated R30 had a mental illness. A PASRR Level II Screen was not completed prior to admission. R30 did not have a 30-day county exemption. A PASRR Level II Screen was completed 3/11/26. On 6/9/26 at 2:56 PM, Surveyor interviewed SSD-D who confirmed R30 did not have a 30-day county exemption and a PASRR Level II Screen should have been completed prior to admission. 3. R24 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder and anxiety. R24's MDS assessment, dated 3/17/26, had a BIMS score of 8 out of 15, indicating moderately impaired cognition. R24 had an activated POA. An undated PASRR Level I Screen indicated R24 had a mental illness. A PASRR Level II Screen was not completed prior to admission. R24 did not have a 30-day county exemption. A PASRR Level II Screen was completed 3/28/25. On 6/10/26 at 11:15 AM, Surveyor interviewed SSD-D who confirmed R24 did not have a 30-day county exemption and a PASRR Level II Screen should have been completed prior to admission.

Based on observation, staff and resident interview,and record review, the facility did not provide the necessary respiratory services for 2 residents (R) (R4 and R28) of 2 sampled residents.R4 did not receive oxygen via nasal cannula at 1 liter per minute (LPM) as prescribed. R4's oxygen saturation level dropped to 82% and R4 complained of shortness of breath (SOB).R28 used a bilevel positive airway pressure (BiPAP) machine. R28 did not have orders to clean the face mask or tubing.Findings include:The facility's undated Oxygen Equipment Information pamphlet indicates: Your doctor has determined how much extra oxygen you require, which is measured in liters per minute (LPM). Use your oxygen exactly as your doctor has prescribed.The facility's Continuous Positive Airway Pressure policy, dated 6/24/22, indicates: Clean and inspect all components regularly.R4 had a diagnosis of heart failure. R4's Minimum Data Set (MDS) assessment, dated 5/24/26, stated R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS assessment indicated R4 received continuous oxygen. Between 6/8/26 and 6/9/26, Surveyor reviewed R4's medical record which contained the following orders: ~ Oxygen to be administered at 1 LPM via nasal cannula (dated 5/6/26)~ Head of bed (HOB) to be elevated to alleviate shortness of breath (SOB) when lying flat (dated 5/6/26) ~ Check oxygen saturation every shift (dated 5/6/26)(Of note: R4 did not have an order that identified an oxygen saturation level goal.)On 6/9/26 at 3:00 PM, Surveyor observed R4 lying flat in bed without oxygen being administered. R4 complained of SOB and could not reach the call light which was on the bedside table.On 6/9/26 at 3:01 PM, Surveyor interviewed Registered Nurse (RN)-G who indicated R4 should receive 1 LPM of oxygen via nasal cannula and immediately went to R4's room.On 6/9/26 at 3:03 PM, Surveyor observed RN-G place the nasal cannula on R4 and ask why R4 removed the oxygen. R4 stated they had not removed the oxygen. RN-G noted the oxygen concentrator was not on. RN-G turned the oxygen concentrator on and set it to 1 LPM. RN-G and a Certified Nursing Assistant (CNA) repositioned R4 in bed and raised the head of the bed. RN-G put an oxygen saturation monitor on R4's finger. The monitor indicated R4's oxygen saturation level was 82%. RN-G stated R4's oxygen saturation level was usually 94-95% on 1 LPM of oxygen. Surveyor observed the oxygen saturation monitor rapidly increase to 95% with oxygen being administered at 1 LPM. R4 indicated to RN-G that R4 felt better.On 6/9/26 at approximately 3:10 PM, Surveyor interviewed RN-G who indicated R4's oxygen concentrator should have been turned on and R4's nasal cannula should have been in place with oxygen administered at 1 LPM.On 6/9/26 at 3:43 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R4's oxygen should have been on.2. R28 had diagnoses including chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. R28's MDS assessment, dated 3/12/26, stated R28 had a BIMS score of 13 out of 15, indicating intact cognition. The MDS assessment did not indicate R28 used a BiPAP machine.Beween 6/8/26 and 6/10/26, Surveyor reviewed R28's medical record which did not indicate R28's BiPAP mask or tubing were regularly cleaned.On 6/8/26 at 2:34 PM, Surveyor interviewed R28 who indicated they use a BiPAP machine and staff do not clean the mask or tubing. R28 indicated staff change the tubing when it arrives from the Veterans Administration.On 6/9/26 at 9:24 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who verified there were no orders for daily cleaning of CPAP or BiPAP equipment.On 6/9/26 at 3:43 PM, Surveyor interviewed DON-B who indicated R28 did not have orders for their BiPAP mask or tubing to be cleaned. DON-B was not certain if there was a discrepancy between the facility's CPAP policy and the physician's orders. On 6/9/26 4:03 PM, Surveyor interviewed DON-B who indicated R28's BiPAP mask and tubing were not routinely cleaned and the facility was reviewing all residents with BiPAP and CPAP machines to ensure there were orders to clean the equipment.

Based on staff interview and record review, the facility did not ensure staff monitored for adverse reactions to a high-risk medication for 1 resident (R) (R24) of 5 sampled residents.R24 was prescribed lamotrigine (an anticonvulsant medication) for epilepsy. R24's plan of care did not contain monitoring interventions for adverse reactions or side effects of the high-risk medication.Findings include:The facility's Medication with Boxed Warning policy, dated January 2025, indicates: Many medications used by residents may carry a Food and Drug Administration (FDA) issued warning. The boxed warning is a serious type of warning the FDA can require on medication labeling and is important to the health and safety of the resident. Nursing staff shall refer to boxed warning monitoring guidelines .for specific health risk and signs and symptoms for monitoring .3. Nursing staff shall include the appropriate monitoring parameters on the resident specific care plan as appropriate .R24 was admitted to the facility on [DATE] and had a diagnosis of epilepsy. Between 6/8/26 and 6/10/26, Surveyor reviewed R24's medical record which contained the following orders:~ Lamotrigine 25 milligrams (mg), give 2 tablets in the morning/give 1 tablet in the evening.~ Lamotrigine 100 mg tablet, give 1 tablet once daily for epilepsy.R24's medical record did not indicate R24 was monitored for adverse reactions or side effects of the anticonvulsant medication. On 6/10/26 at 11:07 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who reviewed R24's medical record and confirmed R24 was prescribed lamotrigine and did not have monitoring interventions in place.On 6/10/26 at 1:14 PM, Surveyor interviewed [NAME] President of Success (VPS)-H and Director of Nursing (DON)-B who verified R24's medical record did not indicate they were monitored for adverse reactions or side effects of the anticonvulsant medication.

Based on staff interview and record review, the facility did not ensure a written transfer/bed-hold notice was provided or the Ombudsman was notified of hospital transfers for 2 residents (R) (R7 and R30) of 5 sampled residents. R30 was transferred to the hospital on 3/27/26. The facility did not provide R30 with a written transfer/bed-hold notice. R7 was transferred to the hospital on 1/12/26. The facility did not notify the Ombudsman of the transfer. Findings include: The facility's Transfer and Discharge including (Against Medical Advice (AMA)) policy, dated June 2022, indicates: .7: Emergency Transfer/Discharge initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident to notify resident and or representative. J. Provide a notice of the resident's bed-hold transfer to the resident or representative at the time of transfer, as soon as possible, but no later than 24 hours. K. Social Services Director or designee shall provide notice of transfer to a representative of the State-Long Term Care Ombudsman .1. R30 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder and bipolar disorder. R30's Minimum Data Set (MDS) assessment, dated 6/2/26, stated R30 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderately impaired cognition. R30 was their own decision maker.Between 6/8/26 and 6/10/26, Surveyor reviewed R30's medical record and noted R30 was transferred to the hospital on 3/27/26. R30's medical record did not indicate R30 received a written transfer/bed-hold notice.On 6/9/26 at 2:34 PM, Surveyor interviewed Director of Nursing (DON)-B and confirmed a written transfer/bed-hold notice was not completed or provided to R30 for the hospital transfer on 3/27/26.2. R7 was admitted to the facility on [DATE] and had diagnoses including dementia, hallucinations, major depressive disorder, and anxiety. R7's MDS assessment, dated 3/26/26, stated R7 had a BIMS score of 10 out of 15, indicating moderately impaired cognition. R7 had an activated Power of Attorney (POA).Between 6/8/26 and 6/10/26, Surveyor reviewed R7's medical record which indicated R7 fell on 1/12/26 and was transferred to the hospital. R7's medical record did not indicate the Ombudsman was notified of the transfer.On 6/9/26 at 2:43 PM, Surveyor interviewed Social Services Director (SSD)-D and confirmed the Ombudsman was not notified of R7's hospital transfer.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 25 residents residing in the facility. The facility did not maintain infection surveillance logs to assist with the recognition of trends and patterns of infection. In addition, the facility did not monitor residents for signs and symptoms of infection. Hand hygiene was not offered or completed for residents prior to dining. Licensed Practical Nurse (LPN)-E did not complete appropriate hand hygiene during wound care for R1. Findings include: The facility's Infection Prevention and Control Program policy, revised 7/23/24, indicates: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection per accepted national standards and guidelines .3. Surveillance: a. A system of surveillance is used for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement .b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility .c. Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff .for notification of changes and in-house reporting of communicable diseases and infections . The facility's Infection Outbreak Response and Investigation policy, dated 2/26/23, indicates: .h3. Outbreak investigation: .c. A case definition may be developed in order to identify other staff and residents who may be affected. Criteria for developing a case definition include: Person - key characteristics the patients share in common. Place - the location associated with the outbreak. Time - period of time associated with illness onset for the cases under investigation. Clinical features - objective signs and symptoms, such as sudden onset of fever and cough. d. A line list for the outbreak will be maintained. e. The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved . According to the (Centers for Disease Control and Prevention) CDC.Gov website 3/2025: .Key times to wash hands. You can help yourself and your loved ones stay healthy by washing your hands often, especially during these key times when you are likely to get and spread germs: Before, during, and after preparing food; Before and after eating food .Washing hands with soap and water is the best way to get rid of germs in most situations. If soap and water are not readily available, you can use an alcohol-based hand sanitizer that contains at least 60% alcohol . The facility's Hand Hygiene policy, dated 11/2/22, indicates: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations in the facility .2. Hand hygiene is indicated and will be performed .after handling contaminated objects; before applying and after removing personal protective equipment (PPE), including gloves; before and after handling clean or soiled dressings, linens, etc.; before performing resident care procedures; when, during resident care, moving from a contaminated body site to a clean body site; and when in doubt. 1. During the entrance conference on 3/10/25, Nursing Home Administrator (NHA)-A indicated Infection Preventionist (IP)-K was in the process of leaving the position but agreed to stay until the position was filled. NHA-A confirmed IP-K was the facility's IP. From 3/10/25 to 3/12/25, Surveyor was unable to interview IP-K who was not in the facility and was unavailable. On 3/12/25 at approximately 8:30 AM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated Surveyor should interview Director of Nursing (DON)-B in IP-K's absence regarding infection control surveillance and protocol. Surveyor requested staff and resident line lists used for infection surveillance for the previous 120 days. On 3/12/25 at 9:29 AM, Surveyor interviewed DON-B who indicated the facility did not have an IP. DON-B indicated IP-K stepped down a week prior and DON-B had assumed some infection control tracking while the facility figured out who would replace IP-K. On 3/12/25 at 10:16 AM, VPS-D provided Surveyor with resident line lists. Surveyor interviewed VPS-D who indicated DON-B misspoke. VPS-D indicated IP-K was still the acting IP, however, IP-K was ill and not available. On 3/12/25, Surveyor reviewed the resident line lists which were incomplete and missing data needed to document and track infections and identify trends. The missing data included: ~ November: The form did not indicate the year and contained six resident entries. For dates of infection: There were no start dates. For dates of precautions used (contact precautions, airborne precautions, etc.): There were no start or end dates and the form did not contain a spot for the information. For organism identified (i.e., fungal, COVID-19, etc.): It was not listed for four of the six entries. There were also no symptoms or not applicable (NA) listed for five of the six entries. There was no test tracking (i.e., a urinalysis), testing criteria (i.e., McGeer's), results, or test dates and no spot on the form to record the information. In addition, the number of antibiotic-resistangt organisms and the date reported to the Quality Assessment and Assurance (QAA) committee were blank. ~ December: The form contained eight resident entries. For dates of infection: Start dates were listed but no end dates. There were not spots to record end or well dates. For dates of precautions used: There were no start or end dates and the form did not contain spots for the information. For organism identified: It was not recorded for seven of the eight entries. There were no symptoms listed (or NA) for seven of the eight entries. There was no test tracking, testing criteria, results, or test dates and no spot on the form to record the information. The number of antibiotic-resistant organisms and the date reported to the QAA committee were blank. The number of resident days was not recorded and the infection incidence rate was blank. ~ January: The form did not indicate the year and contained thirteen resident entries. For dates of infection: There were start dates but no end dates. The form did not contain spots to record end or well dates. For dates of precautions used: There were no start and end dates and no spot to record them. For organism identified: It was not recorded for eleven of the thirteen entries. There were no symptoms listed (or NA) for seven of the thirteen entries. There were no test tracking, testing criteria, results, or test dates recorded and no spot to record them. The number of antibiotic-resistant organisms and the date reported to the QAA committee were blank. ~ February: There were eleven resident entries. For dates of infection: There were start dates but no end dates and no spot to record end or well dates. For dates of precautions used: There were no start or end dates and no spot to record them. There were no symptoms listed (or NA) for five of the eleven entries. There was no test tracking, testing criteria, results, or test dates and no spot to record them. The number of antibiotic-resistant organisms and the date reported to the QAA committee were blank. The number of resident days was not recorded and the infection incidence rate was blank. ~ March (through 3/12/25): There was one resident entry. For dates of infection: There were start dates but no end dates and no spot to record end or well dates. For dates of precautions used: There were no start or end dates and not spot to record them. For organism identified: There were no entries. There was no test tracking, testing criteria, results, or test dates and no spot on the form to record them. On 3/12/25 at 12:08 PM, Surveyor interviewed DON-B who indicated the line lists should have start and end dates. DON-B indicated it was not possible to know how long residents were on precautions with the information provided. DON-B indicated the IP should be tracking the information and indicated there was no way to effectively track the etiology of infections and infection rates due to the missing information. When asked about the number of resident days and infection incidence tracking, DON-B indicated the information should come from the IP because DON-B had not completed IP training. Surveyor again asked for staff lines lists. On 3/12/25 at 1:12 PM, Surveyor reviewed the staff line lists which were incomplete and missing data needed to document, track, and identify trends in infections, including outbreaks. Surveyor noted the following: ~ November 2024: There was no line list provided. ~ December 2024: There was no line list provided. ~ January 2025: A resident tracking form contained seven entries with staff listed under the resident area. Dates of infection and start dates were listed, however, the form did not contain a spot for well or return to work dates. ~ February 2025: A blank resident tracking sheet was provided. There were no staff entries. ~ March 2025: A blank resident tracking sheet was provided. There were no staff entries. On 3/12/25 at 1:12 PM, Surveyor interviewed DON-B and VPS-D. VPS-D indicated the staff line lists were incomplete. DON-B verified the staff line lists for February and March 2025 were blank and indicated staff call-ins must have been related to car and child issues. 2. On 3/10/25 at 12:14 PM, Surveyor observed lunch and noted there were twelve residents in the main dining room. Staff in the dining room included an LPN, NHA-A, [NAME] (CK)-J, and Regional Manager (RM)-H. Surveyor observed dining service from start to finish and noted there was no hand hygiene offered to residents, including no verbal reminders prior to or after dining. Surveyor noted one dining room table contained a few individual hand sanitizing wipes with sugar packets on the table. On 3/10/25 at 12:32 PM, Surveyor interviewed R15 who indicated staff did not offer hand hygiene prior to the meal. On 3/11/25 at 8:04 AM, Surveyor observed breakfast and noted there were ten residents in the main dining room. Surveyor observed DON-B and CK-J in the dining room. Surveyor did not observe DON-B or CK-J offer hand hygiene to residents or hear DON-B or CK-J ask residents if they washed hands or needed assistance with hand hygiene. On 3/11/25 at 8:20 AM, Surveyor observed an eleventh resident enter the dining room. DON-B assisted the resident with beverages and set up but did not offer hand hygiene. On 3/11/25 at 8:27 AM, Surveyor interviewed R15 who indicated staff did not offer hand hygiene prior to the meal. R15 indicated there was a hand wipe in the sugar dish with packets of sugar. R15 indicated no one asked if R15 washed hands prior to the meal or if R15 needed assistance. On 3/11/25 at 8:32 AM, Surveyor interviewed R9 who indicated staff did not offer hand hygiene prior to the meal. R9 indicated there used to be hand wipes in the dining room. R9 indicated no one asked if R9 washed hands prior to the meal or if R9 needed assistance. On 3/11/25 at 8:33 AM, Surveyor interviewed R25 who indicated staff did not offer hand hygiene prior to the meal. R25 agreed with R9 that there used to be hand wipes on the table. R25 indicated no one asked if R25 had washed hands prior to the meal or if R25 needed assistance. 40342 3. On 3/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia, epilepsy, obsessive compulsive disorder, and excoriation disorder (also known as chronic skin-picking or dermatillomania; a mental illness related to obsessive-compulsive disorder characterized by repeated picking at one's own skin resulting in areas of swollen or broken skin). R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 had a court-appointed Guardian. On 3/11/25 at 9:48 AM, Surveyor observed LPN-E provide wound care to R1 with the assistance of Certified Nursing Assistant (CNA)-F. During wound care, Surveyor observed LPN-E cleanse multiple open areas on R1's right lower leg and apply ointment and a clean dressing with gloved hands. LPN-E then removed gloves. Without completing hand hygiene, LPN-E opened a drawer in the treatment cart, obtained a dressing, and donned gloves. LPN-E opened the dressing, applied the dressing to an open area on R1's right lower leg, and dated the dressing with a pen that was on top of the treatment cart. LPN-E then removed gloves and completed hand hygiene. Surveyor also observed LPN-E cleanse and apply a clean dressing to an area on top of R1's left foot with gloved hands. LPN-E then opened a drawer in the treatment cart with the same gloved hands to obtain a dressing. LPN-E opened the dressing and applied the dressing to an area on top of R1's left foot. LPN-E then removed gloves, completed hand hygiene, and donned new gloves. Surveyor also observed LPN-E apply clean dressings to multiple open areas on R1's bilateral buttocks with gloved hands and put a clean incontinence brief on R1 with the assistance of CNA-F. LPN-E then removed gloves. Without completing hand hygiene, LPN-E donned new gloves and applied ointment and a dressing to an open area on R1's left forearm, LPN-E then removed gloves and completed hand hygiene. On 3/11/25 at 11:13 AM, Surveyor interviewed LPN-E who verified LPN-E missed hand hygiene opportunities during wound care. LPN-E verified staff should complete hand hygiene immediately following glove removal and should not touch objects without completing hand hygiene. On 3/12/25 at 9:07 AM, Surveyor interviewed DON-B who verified LPN-E missed hand hygiene opportunities during wound care. DON-B indicated staff should complete hand hygiene before and after dressing changes as well as before applying and after removing gloves.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and served in a sanitary manner. This practice had the potential to affect all 25 residents residing in the facility. The kitchen cooler and dry storage area contained multiple open and undated food items. Staff did not follow appropriate hand hygiene procedures in the kitchen and while serving food. Findings include: On 3/10/25 at 9:35 AM, Surveyor and Account Manager (AM)-G began an initial kitchen tour. AM-G indicated the facility follows the Food and Drug Administration (FDA) Food Code. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (Celsius) (41 F) (Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. The 2022 FDA Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition: (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). The facility's Labeling and Dating policy, dated 2/2017, indicates: All foods should be dated upon receipt before being stored Food labels must include: The food item name; The date of preparation/receipt/removal from freezer; The use-by date as outlined in the attached guidelines .Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and the use-by date. Leftovers must be labeled and dated with the date they are prepared and the use-by date .Use-By Dating Guidelines: .Day of preparation or opening is considered day 1 when establishing the use-by date .Guidelines apply, regardless of storage location (e.g., kitchen, pantries, etc.) . During an initial kitchen tour that began at 9:35 AM on 3/10/25, Surveyor and AM-G observed the following: Dry Storage: ~ A bag of Toasted Oats (opened 3/7/25) with no use-by date ~ A container of Cheerios (opened 3/7) with no use-by date ~ A container of Corn Flakes (opened 3/28) with no use-by date ~ A container of [NAME] Krispies (opened 2/28) with no use-by date ~ A container of Bran Flakes (opened 2/22) with no use-by date ~ An unsealed 50 pound bag of flour (received 10/25/24) with no open or use-by dates ~ A package of Chinese noodles (opened 1/13/25) with no use-by date ~ A 25 pound bag of dry milk (received 10/25/24) with no open or use-by dates ~ A bag of coconut flakes (opened 3/4/25) with no use-by date ~ A container of flour (dated 11/20/24) with no use-by date ~ A container of sugar (dated 11/10/24) with no use-by date ~ A bulk container of unidentified material (dated 11/20/24) with no use-by date. (At 11:52 AM, Regional Manager (RM)-H labeled the container as flour.) Cooler: ~ A container of cream of chicken prepared 2/3/25 with a use-by date of 2/6/25. AM-G discarded the item. ~ A container of hot dogs (opened 3/3/25) with no use-by date ~ A container of hard boiled eggs (opened 1/7/25) with no use-by date ~ A container of orange juice mix labeled orange (prepared 2/23/25) with no use-by date Freezer: ~ An open, resealed package of English muffins (dated 1/4/25) with no use-by date ~ Two unopened, unlabeled packages of pound cake (per AM-G) (dated 2/24/25) with no use-by dates Surveyor interviewed AM-G who indicated staff should date food with a received date, an opened or prepared date, and a use-by date. On 3/11/25 at 11:52 AM, Surveyor interviewed RM-H who indicated food should be properly labeled and dated and should include a use-by date. RM-H indicated staff should be familiar with and follow the facility's food dating policies. Hand Hygiene: The 2022 FDA Food Code documents at 2-301.14: Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. The 2022 FDA Food Code documents at 3-301.11 Preventing Contamination From Hands: (A) Food employees shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. The facility's Hand Hygiene policy, dated 11/2/22, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations in the facility .6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing them. The Facility's Culinary Professionals Training-Glove Usage policy indicates: When to change or remove your gloves: When they are dirty, torn, damaged, discolored, or contaminated; When taking one step away from your work area; Before going to the restroom; Before starting another job .You must remember to always wash your hands in between gloves .Gloves do not give you the right to not wash your hands .do not keep them on, reuse them or anything else. On 3/10/25 at 12:18 PM, Surveyor observed AM-G serve food to residents. Surveyor observed AM-G pick up residents' plates with bare hands and touch food serving utensils. AM-G then served food on the plates AM-G had touched with bare hands. AM-G repeated the process for all lunch plates served. On 3/10/25 at 12:37 PM, Surveyor observed [NAME] (CK)-I enter the kitchen from the back door. CK-I went through the kitchen, opened a drawer, and applied a beard restraint. CK-I then continued through the kitchen and started kitchen tasks. CK-I did not complete hand hygiene. On 3/11/25 at 1:07 PM, Surveyor observed CK-I enter the kitchen from the hallway door. CK-I went to the stove and began working. CK-I did not complete hand hygiene. On 3/11/25 at 1:08 PM, Surveyor interviewed CK-I who indicated CK-I was in the hallway donning on a beard restraint prior to re-entering the kitchen. When asked if CK-I should have performed hand hygiene upon entering the kitchen, CK-I stated CK-I would perform it now if it would make Surveyor happy. On 3/11/25 at 1:18 PM, Surveyor interviewed AM-G who indicated hand hygiene should be performed after tasks and when changing gloves. AM-G indicated staff should be aware of when to use gloves. AM-G indicated staff should wash hands upon entering the kitchen. AM-G indicated staff should be familiar with and follow the facility's hand hygiene and food dating policies.

Based on staff interview and record review, the facility did not ensure the required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly. This practice had the potential to affect more than 4 of the 25 residents residing in the facility. The facility did not ensure the required members of the QAPI committee met at least quarterly from March 2024 through February 2025. Findings include: The facility's Quality Assurance and Performance Improvement (QAPI) Committee policy, dated 7/11/22, indicates: The Executive Director and the Director of Nursing are responsible and accountable for the development, implementation, monitoring, and leadership of the center's QAPI program. A core team of individuals will be appointed to spearhead the QAPI program and will engage in monthly QAPI meetings which will include the creation/modification of performance improvement plans (PIPs). The center's QAPI Committee may include the following team members: the Executive Director, Director of Nursing, Medical Director, Infection Preventionist, Life Enrichment Director, Social Services Director, Maintenance Director, Housekeeping Director, Business Office Manager, Human Resources Director, Dietary Manager/Registered Dietician, Minimum Data Set (MDS) Coordinator and at least one non-licensed direct care staff. On 3/11/25, Surveyor requested attendance sheets for the previous year (March 2024 through February 2025) of QAPI meetings. Surveyor reviewed the facility's sign-in sheets which included six pages labeled QAPI agenda and meeting minutes for the designated time period. The sheets were dated March 2024, April 2024, June 2024, August 2024, January 2025, and February 2025. There were no QAPI sign-in sheets provided for May, July, September, October, November or December of 2024. Surveyor reviewed the sign-in sheets to ensure each of the following members attended a QAPI meeting at least quarterly: Medical Director (MD), Nursing Home Administrator (NHA) (Executive Director), Director of Nursing (DON), Infection Preventionist (IP), and two additional staff. The March 2024 meeting had signatures for the NHA and two additional staff. The MD participated via phone. The DON and IP were missing. The April 2024 meeting had signatures for the MD, NHA, DON and one additional staff. The IP and one other staff were missing. There was no sign in sheet for May 2024. The June 2024 meeting had signatures for the NHA, DON, IP, and two additional staff. The MD was missing. There was no sign-in sheet for July 2024. The August 2024 meeting had signatures for the NHA, DON, and two additional staff. The MD participated via Teams. The IP was missing. There were no sign-in sheets for September, October, November or December of 2024. The January 2025 meeting had signatures for the NHA, DON, IP, and two additional staff. The MD was missing. The February 2025 meeting had signatures for the NHA, DON, IP, and two additional staff. The MD was missing. On 3/12/25 at 9:29 AM, Surveyor interviewed DON-B who indicated there was not a QAPI meeting in November or December of 2024 because there was no Executive Director/NHA. On 3/12/25 at 10:52 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A could not locate sign-in sheets for the May, July, September, October, November, or December 2024 monthly QAPI meetings. NHA-A indicated the MD attended the meetings via phone for January and February 2025, however, NHA-A was unable to provide proof of attendance. NHA-A indicated there should be signatures of the QAPI meeting attendees. On 3/12/25 at 10:54 AM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated VPS-D could not locate sign-in sheets for the May, July, September, October, November, and December 2024 monthly QAPI meetings. VPS-D indicated it is difficult to show proof of meetings without attendance sheets and indicated the facility could not locate any sign-in sheets at that time.

Based on staff interview and record review, the facility did not ensure vaccinations were offered or administered for 5 residents (R) (R1, R5, R7, R19, and R21) of 5 sampled residents. The facility did not offer R1, R5, R7, R19, or R21 the PCV20(R) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults [AGE] years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The facility's Pneumococcal Vaccine (series) policy, revised 9/18/24, indicates: It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations .1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders. 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization with the education documented in the clinical record .4. The resident/representative retains the right to refuse the immunization. Refusals should be documented in the medical record along with what education was provided and a risk versus benefit discussion . 1. On 3/12/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia, epilepsy, and congestive heart failure. R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 had a court-appointed Guardian. R1's medical record indicated R1 did not receive the PCV13 vaccine. R1 received the PPSV23 vaccine on 4/11/2019. Based on the facility's policy and CDC recommendations, R1 was due to receive the PCV20 vaccine on or after 4/11/20 and should have been offered the vaccine. 2. On 3/12/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including dementia, acute respiratory failure with hypoxia and hypercapnia, and hemiplegia and hemiparesis following cerebral infarction. R5's MDS assessment, dated 12/28/24, indicated R5 was rarely/never understood. R5 had a Guardian. R5's medical record indicated R5 received the PCV13 vaccine on 12/19/16. R5's medical record did not indicate R5 received the PPSV23 vaccine. Based on the facility's policy and CDC recommendations, R5 was due to receive the PCV20 on or after 12/19/17 and should have been offered the vaccine. 3. On 3/12/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, mild cognitive impairment, and obesity. R7's MDS assessment, dated 12/16/24, had a BIMS score of 15 out of 15 which indicated R7 had intact cognition. R7's medical record indicated R7 received the PCV13 vaccine on 3/15/16. R7's medical record did not indicate R7 received the PPSV23 vaccine. Based on the facility's policy and CDC recommendations, R7 was due to receive the PCV20 vaccine on or after 3/15/17 and should have been offered the vaccine. 4. On 3/12/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including mild cognitive impairment, history of cerebral infarction, and cluster headaches. R19's MDS assessment, dated 1/9/25, had a BIMS score of 15 out of 15 which indicated R19 had intact cognition. R19's medical record indicated R19 received the PCV13 vaccine on 11/15/22. R19's medical record did not indicate R19 received the PPSV23 vaccine. Based on the facility's policy and CDC recommendations, R19 was due to receive the PCV20 vaccine on or after 11/15/23 and should have been offered the vaccine. 5. On 3/12/25, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including necrotizing fasciitis, abdominal abscess, and chronic pain. R21's MDS assessment, dated 2/24/25, had a BIMS score of 14 out of 15 which indicated R21 had intact cognition. R21's medical record indicated R21 received the PPSV23 vaccine on 4/25/13 and the PCV13 vaccine on 7/6/15. Based on the facility's policy and CDC recommendations, R21 was due to receive the PCV20 vaccine on or after 7/6/20 and should have been offered the vaccine. On 3/12/25, Surveyor requested vaccination records including offer/declination paperwork for R1, R5, R7, R19, and R21. On 3/12/25 at 9:29 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility did not have an Infection Preventionist (IP). DON-B indicated IP-K had stepped down the week prior to and DON-B had assumed some of the IP duties while the facility looked for a new IP. On 3/12/25 at 10:16 AM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated DON-B was new and misspoke. VPS-D confirmed IP-K was still the acting IP, however, IP-K was ill and not available during the survey. VPS-D indicated IP-K was transitioning to another position but agreed to stay on as IP for the facility. On 3/12/25 at 12:04 PM, Surveyor interviewed VPS-D regarding the facility's infection control program. VPS-D indicated in the absence of IP-K, Surveyor should direct infection control questions to DON-B. On 3/12/25 at 12:08 PM, Surveyor interviewed DON-B who indicated residents are offered vaccines per the facility's policy. DON-B indicated the facility offers the PCV 20 vaccine to residents. DON-B indicated records are kept of vaccines administered or declined. On 3/12/25 at 12:48 PM, Surveyor interviewed VPS-D who indicated staff should follow the facility's vaccination policies for administration and record keeping. On 3/12/25 at 1:12 PM, Surveyor reviewed resident vaccination tracking sheets provided for R1, R5, R7, R19, and R21. The tracking sheets did not indicate the PCV20 vaccine was offered to R1, R5, R7, R19, or R21. In addition, Surveyor was not provided with offer or declination paperwork for R1, R5, R7, R19, or R21.

Based on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R1) of 3 sampled residents with a Guardian when the resident's nursing home stay exceeded ninety days. R1 was admitted to the facility on [DATE] with the consent of a legal Guardian. The facility did not pursue protective placement when the resident's stay exceeded ninety days. Findings include: State Statute Chapter 55.03(4) indicates court-ordered protective placement should be obtained for any resident admitted to a nursing home who has a legal Guardian and whose nursing home stay exceeds ninety days. State Statute Chapter 55.18 indicates protective placement is reviewed annually. On 3/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia, epilepsy, and congestive heart failure. R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 had a court-appointed Guardian. R1's medical record contained guardianship and protective placement documents dated 2/11/98. R1's medical record did not contain the required annual reviews for protective placement to determine if R1 resided in the least restrictive environment. R1's medical record indicated the facility updated R1's Guardian on R1's changes in condition and R1's Guardian made decisions regarding R1's healthcare needs. On 3/11/25 at 11:37 AM, Surveyor interviewed Social Worker (SW)-C who indicated the county sends updated annual reviews to the facility every year and the documents are uploaded into residents' electronic medical records. SW-C indicated SW-C would search for R1's most recent annual review documentation. On 3/12/25 at 10:13 AM, Surveyor interviewed SW-C who indicated R1's managed care organization (MCO) had been trying to contact the county since 2024 regarding protective placement. SW-C indicated SW-C made a referral to Adult Protective Services (APS) on 3/11/25 and was told by APS they would conduct an emergency review. Surveyor reviewed a message from R1's MCO, dated 3/11/25, that indicated R1's MCO had (starting in April of 2024) been routinely contacting the county requesting updates on the status of the protective placement order for R1. On 3/12/25 at 10:23 AM, Surveyor interviewed SW-C who indicated SW-C received an an email from APS that indicated R1's protective placement was discontinued in 2003. SW-C indicated if protective placement is discontinued by the court system, there is no need for protective placement when a resident is admitted to a skilled nursing facility. Surveyor reviewed an undated email from APS that indicated R1's protective placement was discontinued by the court system on 2/19/03. On 3/12/25 at 11:54 AM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated the facility's legal department informed VPS-D the facility does not have a policy that addresses guardianship and protective placement. VPS-D indicated facility should follow state regulations.

Based on staff, resident, resident representative interview and record review, the facility did not ensure 2 residents (R) (R5 and R14) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R5 was transferred to the hospital on 2/21/25. Neither R5 or R5's Guardian received a written transfer notice. R14 was transferred to the hospital on [DATE], 1/8/25, and 2/14/25. R14 did not receive a written transfer notice for any of the transfers. Findings include: The facility's Transfer and Discharge policy, dated 10/26/22, indicates: .7. Emergency Transfers/Discharges initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident: .d) Complete and send with the resident (or provide as soon as practicable) a Transfer Form .f) The original copies of the Transfer Form .Copies are retained in the medical record . 1. From 3/10/25 to 3/12/25, Surveyor reviewed R5's medical record. R5's Minimum Data Set (MDS) assessment, dated 12/28/24, indicated R5 was rarely/never understood. A staff assessment for mental status indicated R5 was severely cognitively impaired. R5 had a Guardian. R5's medical record indicated R5 was transferred to the hospital on 2/21/25 due to hypotension and increased lethargy. R5's medical record did not indicate R5 or R5's Guardian were provided with a written transfer notice. On 3/10/25 at 12:32 PM, Surveyor interviewed R5's Guardian who did not recall receiving a written transfer notice when R5 was transferred to the hospital on 2/21/25. 2. From 3/10/25 to 3/12/25, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including heart failure and high blood pressure. R14's MDS assessment, dated 3/6/25, had a BIMS score of 14 out of 15 which indicated R14 had intact cognition. R14 made R14's own medical decisions. R14's medical record indicated was transferred to the hospital on [DATE], 1/8/25 and 2/14/25. R14's medical record did not indicate R14 was provided with a written transfer notice for any of the transfers. On 3/10/25 at 9:47 AM, Surveyor interviewed R14 who indicated R14 was transferred to the hospital several times over the last year. R14 did not recall receiving any paperwork related to the transfers. On 3/11/25 at 12:15 PM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated VPS-D had not seen transfer notification forms in R5's medical record or paper chart. VPS-D indicated VPS-D would continue to look for the transfer notices. On 3/12/25 at 9:33 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated nurses are responsible for providing residents or their representatives with written transfer notices. DON-B verified there was no documentation that a transfer notice was provided at the time of the transfer. DON-B indicated provision of a transfer notice should be documented if the resident is able to sign or staff should get a verbal confirmation from the resident or their representative and obtain a signature as soon as possible. DON-B confirmed written transfer notices were not provided to R5 and R14 or their representatives. On 3/12/25 at 10:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who confirmed LPN-L does not document if a transfer notice is provided. LPN-L verified nurses are responsible for providing a written transfer notice which should be documented in a resident's medical record.

Based on staff, resident, resident representative interview and record review, the facility did not ensure a bed hold notice was provided for 2 residents (R) (R5 and R14) of 2 sampled residents. R5 was transferred to the hospital on 2/21/25. Neither R5 or R5's Guardian received a bed hold notice. R14 was transferred to the hospital on [DATE], 1/8/25, and 2/14/25. R14 did not receive a bed hold notice for any of the transfers. Findings include: The facility's Transfer and Discharge policy, revised 7/15/22, indicates: .7. Emergency Transfers/Discharges initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident: .i) Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as soon as possible, but no later than 24 hours after the transfer. 1. From 3/10/25 to 3/12/25, Surveyor reviewed R5's medical record. R5's Minimum Data Set (MDS) assessment, dated 12/28/24, indicated R5 was rarely/never understood. A staff assessment for mental status was conducted and indicated R5 was severely cognitively impaired. R5 had a Guardian. R5's medical record indicated R5 was transferred to the hospital on 2/21/25 due to hypotension and increased lethargy. R5's medical record did not indicate a bed hold notice was provided to R5 or R5's Guardian. On 3/10/25 at 12:32 PM, Surveyor interviewed R5's Guardian who did not recall receiving a bed hold notice when R5 was transferred to the hospital on 2/21/25. 2. From 3/10/25 to 3/12/25, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including heart failure and high blood pressure. R14's MDS assessment, dated 3/6/25, had a BIMS score of 14 out of 15 which indicated R14 had intact cognition. R14 made R14's own medical decisions. R14's medical record indicated R14 was transferred to the hospital on [DATE], 1/8/25 and 2/14/25. R14's medical record did not indicate a bed hold notice was provided to R14 for any of the transfers. On 3/10/25 at 9:47 AM, Surveyor interviewed R14 who indicated R14 was transferred to the hospital several times over the last year. R14 did not recall receiving any paperwork related to a bed hold. On 3/11/25 at 12:15 PM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated VPS-D had not seen bed hold notification forms in R5's medical record. VPS-D indicated VPS-D would continue to look for the bed hold notifications. On 3/12/25 at 9:33 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated nurses are responsible for providing residents or their representatives with bed hold notices. DON-B verified there was no documentation that bed hold notices were provided at the time of transfer. DON-B indicated staff should document if a resident is able to sign or get a verbal confirmation from the resident or their representative and obtain a signature as soon as possible. DON-B confirmed bed hold notices were not provided for R5 and R14. On 3/12/25 at 10:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who indicated nurses have residents or their representatives sign if they want the bed held or obtain verbal consent from a resident representative and wait until the representative is able to sign. LPN-L verified nurses are responsible for providing a bed hold notice which should be documented in a resident's medical record.

Based on observation, staff interview, and record review, the facility did not provide the necessary care and treatment to promote healing and/or prevent impaired skin integrity for 1 resident (R) (R1) of 15 sampled residents. R1 was diagnosed with a rare skin condition. R1's care plan indicated staff should not use incontinence briefs for R1. During an observation of care on 3/11/25, staff removed an incontinence brief from R1 and applied a clean brief. Findings include: On 3/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including paraplegia, epilepsy, obsessive compulsive disorder, and excoriation disorder (also known as chronic skin-picking or dermatillomania; a mental illness related to obsessive-compulsive disorder characterized by repeated picking at one's skin resulting in areas of swollen or broken skin). R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1 had a court-appointed Guardian who was responsible for R1's healthcare decisions. Surveyor reviewed R1's care plan and Kardex (an abbreviated care plan used by nursing staff). Both indicated staff should not use incontinence briefs for R1. The care plan indicated staff should use union suits, boxer shorts, long pants, tall socks, and/or wrap R1's body with a bath blanket to prevent self-trauma. On 3/11/25 at 9:48 AM, Surveyor observed Licensed Practical Nurse (LPN)-E provide wound care for R1 with the assistance of Certified Nursing Assistant (CNA)-F. Surveyor observed LPN-E and CNA-F remove an incontinence brief to provide wound care to R1's bilateral buttocks. Surveyor observed multiple open areas on R1's bilateral buttocks and noted the skin surrounding the areas was red. Surveyor noted a reddened area covered almost all of R1's bilateral buttocks and was the same area of skin covered by the incontinence brief. R1 denied pain in the area. LPN-E indicated R1's skin had been like that for years. LPN-E indicated sometimes R1's skin almost heals and then somehow (R1) gets down there and the areas open again. Following wound care, Surveyor observed LPN-E and CNA-F put a clean incontinence brief on R1. LPN-F indicated staff used hypoallergenic soap on R1's skin. (Note: R1's care plan did not indicate what type of soap staff should use on R1's skin.) On 3/11/25 at 11:13 AM, Surveyor interviewed LPN-E who indicated the facility tried different medications to help R1 stop itching, including an anti-itch cream for R1's arms. LPN-E indicated nothing seemed to help. On 3/12/25 at 9:07 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R1's psychiatric provider tried different medications to help R1 stop itching. When asked if any non-pharmacological interventions were tried, DON-B indicated R1's wound care provider tried different lotions. DON-B indicated whenever staff were not with R1, R1 itched R1's skin open. DON-B indicated DON-B started employment at the facility in November of 2024 and was unsure if different soaps or laundry detergents had been tried. DON-B verified staff should not use incontinence briefs for R1 because the briefs hold in too much moisture. DON-B was unaware staff were using incontinence briefs for R1. DON-B indicated when DON-B conducted wound rounds with R1's wound provider, R1 had a shower just prior to wound care and all dressings were off before the assessment began. DON-B indicated the wound provider used a small amount of tape on the skin to hold R1's dressings in place or wrapped R1 in a blanket to prevent R1 from itching R1's skin open.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R1 and R2) of 5 residents observed during the provision of cares. R1 was on enhanced barrier precautions (EBP). On 12/4/24 and 12/5/24, staff did not wear personal protective equipment (PPE) during the provision of care for R1. In addition, staff did not complete appropriate hand hygiene during a dressing change on 12/5/24. On 12/4/24 and 12/5/24, R1 and R2's uncovered catheter drainage bags were in contact with the floor. Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, revised 8/8/24, indicates: EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .High-contact resident care activities include: dressing, transferring, changing linens .EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. The facility's Clean Dressing Change policy, dated 7/20/22, indicates: .9. Remove the existing dressing .10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands, put on clean gloves. 12. Cleanse wound .13. Measure wound .14. Wash hands and put on clean gloves . The facility's Catheter Care policy, revised 3/15/23, indicates: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . 1. From 12/4/24 to 12/5/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including anoxic brain damage, anxiety disorder, neuromuscular dysfunction of bladder, pressure ulcer of right buttock stage 4, paraplegia, and epilepsy. R1's Minimum Data Set (MDS) assessment, dated 9/16/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderate cognitive impairment. R1's care plan indicated R1 had an indwelling urinary catheter. On 12/4/24 at 9:50 PM, Surveyor observed Licensed Practical Nurse (LPN)-F remove unbagged soiled linens from R1's room and carry them to a dirty linen cart down the hall. LPN-F then removed gloves. Without performing hand hygiene, LPN-F retrieved clean linens from a linen closet and carried them to R1's room. On 12/4/24 at 9:52 PM, Surveyor entered R1's room with permission and confirmed with LPN-F that LPN-F carried soiled linens from R1's room down the hall. When Surveyor asked if R1 was on EBP and if LPN-F should wear PPE when providing care for R1, LPN-F indicated LPN-F did not know and continued to dress R1. On 12/4/24 at 10:30 PM, LPN-G confirmed R1 was on EBP related to wounds. On 12/4/24 at 10:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who indicated the facility put specialty precaution bins by residents' doors but CNA-H was unsure why. When Surveyor asked if PPE should be worn prior to entering rooms with specialty precaution bins, CNA-H indicated only if the resident is sick. When Surveyor asked about EBP, CNA-H indicated EBP was proper hand hygiene. On 12/5/24 at 9:10 AM, Surveyor observed Director of Nursing (DON)-B and Nurse Practitioner (NP)-C complete wound care for R1. Surveyor observed NP-C dress R1's buttock wound and remove gloves. Without performing hand hygiene, NP-C donned clean gloves and applied Medihoney to R1's right and left leg wounds and R1's left toe. DON-B and NP-C changed gloves before moving to the next area, but did not perform hand hygiene between glove changes. At 9:25 AM, Surveyor observed NP-C lower R1's bed which put R1's uncovered catheter bag on the floor. DON-B confirmed R1's catheter bag should not be on the floor and raised the bed to lift the bag off the floor. On 12/5/24 at 9:30 AM, Surveyor observed CNA-D and LPN-E enter R1's room without donning PPE to dress and transfer R1 to a wheelchair. When CNA-D and LPN-E began to remove R1's gown and blankets, Surveyor asked CNA-D if R1 was on EBP. CNA-D confirmed R1 was on EBP. CNA-D indicated a gown and gloves should be worn and left the room to don a gown. LPN-E continued to care for R1 without a gown. CNA-D then returned to the room with a gown for LPN-E. On 12/5/24 at 11:28 AM, Surveyor interviewed DON-B who indicated DON-B expects staff to follow the facility's EBP policy which requires staff to don PPE for high-contact resident cares. On 12/5/24 at 1:04 PM, Surveyor interviewed DON-B who indicated hand hygiene should be performed following glove removal. 2. From 12/4/24 to 12/5/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including benign prostatic hyperplasia (BPH), heart failure, and urinary tract infection (UTI). R2's MDS assessment, dated 9/29/24, had a BIMS score of 15 out of 15 which indicated R2 was not cognitively impaired. R2's care plan indicated R2 wore a condom catheter at all times. On 12/4/24 at 9:38 PM, Surveyor noted R2's uncovered catheter drainage bag was in contact with the floor. On 12/4/24 at 10:39 PM, Surveyor interviewed CNA-I who confirmed R2's catheter bag should not be on the floor. On 12/4/24 10:41 PM, Surveyor noted R2's catheter bag was still on the floor. On 12/4/24 at 10:45 PM, Surveyor interviewed CNA-H who indicated catheter bags should not be on the floor. On 12/5/24 at 11:28 AM, Surveyor interviewed DON-B who confirmed catheter bags should be covered and not in contact with the floor.

Based on staff interview and record review, the facility did not have a licensed nurse on duty to meet the needs of residents for approximately 2.5 hours on the [DATE] PM shift. This had the potential to affect 23 of 23 residents (R) residing in the facility. On [DATE], an agency nurse who worked the AM shift left the facility without licensed nurse coverage for the PM shift. The facility was without a nurse for approximately 2.5 hours. Due to not having a licensed nurse on duty, 3 residents (R10, R16, and R7) did not receive blood glucose monitoring in accordance with physician orders. Fourteen residents (R8, R9, R10, R11, R12, R5, R1, R13, R14, R15, R16, R7, R3, and R17) did not receive medication in accordance with physician orders. One resident (R5) was transported by ambulance to the emergency room (ER) without a nurse assessment. Seven residents (R7, R11, R12, R14, R16, R18, and R19) were full-code status and without a cardiopulmonary resuscitation (CPR)-certified nursing staff in the facility. The facility indicated Maintenance Manager (MM)-H was in the building and CPR certified; however, the facility and MM-H were unable to provide proof of CPR certification. All residents in the facility were at risk due to not having a licensed nurse available to assess their healthcare needs. The facility's failure to ensure there was licensed nurse coverage at all times created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA)-A and Regional Manager (RM)-C were notified of the immediate jeopardy on [DATE] at 4:07 PM. The immediate jeopardy was removed and corrected on [DATE]. Findings include: The facility's Cardiopulmonary Resuscitation (CPR) policy, dated [DATE], indicates in part: .2. If a resident experiences a cardiac arrest, facility staff will provide basic life support including CPR prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or B. In the absence of an advance directive or a Do Not Resuscitate order, and c. If the resident does not show obvious signs of clinical death .3. CPR-certified staff will be available at all times. 4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification, which includes an online knowledge component yet still requires an in-person skills demonstration to obtain certification or recertification, is also acceptable. On [DATE], Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease. On [DATE] at 10:22 AM, Surveyor interviewed night (NOC) shift Licensed Practical Nurse (LPN)-I who confirmed there was a date in April in which there was no licensed nurse on duty. LPN-I indicated LPN-I heard that an agency nurse walked out of the facility and left the medication cart keys at the nurses' station. LPN-I indicated MM-H called 911 for R5 when R5 had an episode of unresponsiveness. LPN-I indicated R5 had episodes before and if MM-H would have waited awhile, R5's episode would have resolved. LPN-I indicated R5 slept through parts of shifts due to Parkinson's flare ups and would likely not have needed to be transferred to the hospital. Surveyor reviewed an ambulance report, dated [DATE], that indicated the facility called 911 at 5:10 PM when R5 was not responding. At 5:10 PM, R5's breathing was abnormal and R5 was still unconscious. R5 was transported to the hospital at 5:38 PM. Surveyor reviewed a Police Department report, dated [DATE], that indicated on [DATE] the facility was without staff for several hours because an agency staff left the facility when the agency staff could not get ahold of anyone. An ambulance was called for an unresponsive resident and the only person at the facility was a maintenance staff who called 911. The police officer who wrote the report indicated the officers who responded to the 911 call on [DATE] indicated there were 3 employees at the facility in addition to the maintenance staff. Surveyor reviewed hospital records for R5 which indicated there were no significant medical findings. R5 returned to the facility on the evening of [DATE]. On [DATE] at 11:45 AM, Surveyor interviewed former [NAME] President of Success (VPS)-J who indicated VPS-J was a Registered Nurse (RN) and was employed as the VPS on [DATE]. VPS-J indicated VPS-J lived 15 minutes from the facility and was notified on [DATE] around dinner time that there was no licensed nurse in the facility. VPS-J contacted the facility and instructed staff to hold dinner trays for diabetic residents so VPS-J could check blood sugars when VPS-J arrived. VPS-J confirmed there was not a nurse on duty when VPS-J arrived at the facility. VPS-J arranged for an agency nurse to join VPS-J approximately 20 minutes later. VPS-J and the agency nurse finished the shift. VPS-J verified MM-H and 2 or 3 Certified Nursing Assistants (CNAs) were in the facility when VPS-J arrived. VPS-J confirmed R5 was sent to the hospital by MM-J prior to VPS-J's arrival. On [DATE] at 12:10 PM, Surveyor interviewed Regional Manager (RM)-C who confirmed there was a timeframe on the [DATE] PM shift where there was no licensed nurse in the facility. RM-C provided Surveyor with an investigation that was completed by a former Nursing Home Administrator (NHA) who was employed by the facility at that time. On [DATE] at 12:15 PM, Surveyor reviewed the facility's investigation which included a written statement from MM-H that indicated MM-H made calls/texts to the NHA, Scheduler, and on-call Unit Manager (UM)-Q (all of whom are no longer employed at the facility) at 1:48 PM to alert them that there was no nurse for the PM shift. The facility's investigation also contained a log of text messages within a group text that started with MM-H indicating, There is no nurse for 2 PM; ED (Executive Director (aka NHA)) did not respond. At 2:06 PM, on-call UM-Q responded, I'm not going in .I have been on call 10 out of the last 14 days and I did not take this job to be a floor RN in a long term care center. There are 3 other people that can come up with something. None of them responded to my text either. At 4:01 PM, the NHA first responded to the calls and text messages sent by MM-H and at 4:48 PM, NHA notified VPS-J of the situation. VPS-J contacted the facility and advised staff not to serve supper to diabetic residents; however, the supper trays were already served on the 300 wing per MM-H's statement. The investigation included a Critical Event Analysis and Action Plan Worksheet that indicated both AM shift nurses left the facility without a PM shift nurse replacement and the facility was without a licensed nurse from approximately 3:02 PM until 5:35 PM when VPS-J arrived. The facility's investigation contained a written statement from agency RN-N that indicated LPN-O and RN-N became aware at 1:00 PM that there was no nurse coming in on the PM shift to relieve them. Attempts to call facility management started with no response/resolution. RN-N indicated LPN-O left the facility prior to the end of LPN-O's scheduled shift which left RN-N as the only nurse. RN-N indicated LPN-O did not count narcotics or give report to PM CNA staff. RN-N indicated LPN-O also left the medication cart keys on the counter by the CNAs. RN-N indicated RN-N left the keys on the counter and left the facility at 3:03 PM. There was no nurse to give report to or count narcotics with. RN-N indicated there were 3 CNAs (one agency CNA, one CNA on orientation, and one long-term employee of the facility). RN-N indicated if a resident needed a medication, they would have to wait until a nurse was there. On [DATE] at 12:30 PM, Surveyor interviewed MM-H via phone. MM-H indicated MM-H no longer worked at the facility. MM-H recalled the events from [DATE] and confirmed there was no licensed nurse in the facility. MM-H also confirmed MM-H contacted 911 to send R5 to the hospital. On [DATE] at 3:10 PM, Surveyor reviewed the medical records of R10, R16, and R7 who had diagnoses of diabetes and resided at the facility on [DATE]. R10, R16, and R7's medical records confirmed R10, R16, and R7 did not have their blood sugar checked nor did they receive insulin in accordance with their physician orders on [DATE]. On [DATE] at 3:30 PM, Surveyor reviewed a Medication Administration Audit Report for residents residing at the facility on [DATE]. The report indicated 14 residents (R8, R9, R10, R11, R12, R5, R1, R13, R14, R15, R16, R7, R3, and R17) received their medications outside the range specified in the facility's medication administration policy and/or not in accordance with their physician orders. The facility's undated Liberalized Medication Pass Times policy, indicates: It is the policy of the company to administer medications to residents in a safe manner that coincides with their daily activities of living and normal schedule. The administration window will be one hour prior to the scheduled dose and one hour past the scheduled dose .Any physician orders for specific medication times will supersede the facility's policy for liberalized medication pass times. The following medications were administered between 1.5 and 4 hours outside of the acceptable administration window: R8: ~ Albuterol sulfate 4 mg (milligrams) for shortness of breath ~ Acetaminophen 500 mg for pain ~ Potassium chloride solution 20 mEq (milliequivalents)/15 ml (milliliters) R9: ~ Senna 8XXX,d+[DATE] mg for constipation ~ Simethicone 80 mg for gastroesophageal reflux disease (GERD) R10: ~ Oxybutynin chloride 2.5 mg for bladder spasms ~ Pro Med oral liquid nutritional supplement ~ Boost Plus nutritional supplement ~ A blood sugar check for diabetes scheduled for 4:00 PM was obtained 2 hours and 36 minutes late ~ Insulin aspart 10 units with meals for diabetes scheduled for 5:00 PM was administered 1 hour and 36 minutes late R11: ~ Acetaminophen 325 mg (3 tabs) for pain ~ Flomax 0.4 mg for benign prostatic hypertrophy (BPH) ~ Clozaril 200 mg for schizoaffective disorder ~ Nubeqa 300 mg for malignant neoplasm of prostate ~ Calcium-Vitamin D3 600 mg-10 mcg (micrograms) supplement R12: ~ Gabapentin 600 mg for pain related to diabetes R5: ~ Carbidopa-Levodopa extended release (ER) ,d+[DATE] mg (3 tabs) for Parkinson's disease scheduled for 3:00 PM ~ Carbidopa-Levodopa ER ,d+[DATE] mg (3 tabs) for Parkinson's disease scheduled for 4:00 PM R5 was hospitalized from approximately 5:00 PM to 8:00 PM on [DATE]. Both doses were administered at 8:26 PM. R1: ~ Acetaminophen 650 mg for knee pain ~ Gabapentin 100 mg for polyneuropathy ~ Ocuvite multivitamin for polyneuropathy R13: ~ Vitamin C supplement ~ Baclofen 20 mg for muscle spasm/pain R14: ~ Buspirone HCL (hydrochloride) 10 mg for anxiety ~ Gabapentin 800 mg for pain ~ Pantoprazole 40 mg for stomach protection ~ Apixaban 2.5 mg for history of pulmonary embolism ~ Gabapentin 800 mg for pain ~ Buspirone 10 mg for anxiety R15: ~ Multivitamin supplement ~ Glipizide 2.5 mg for diabetes R16: ~ Fluticasone-salmeterol inhaler for chronic obstructive pulmonary disease (COPD) ~ Blood sugar monitoring for diabetes ~ Insulin lispro 6 units with meals for diabetes ~ Insulin lispro SS (sliding scale) with meals for diabetes R7: ~ Hydralazine HCL 50 mg for hypertension ~ Pantoprazole DR 40 mg for GERD ~ A blood sugar check for diabetes was obtained 1 hour and 31 minutes late ~ Insulin lispro SS for diabetes was administered 2 hours and 31 minutes late R3: ~ Acetaminophen 1000 mg for pain R17: ~ Senna 8.6 mg for constipation ~ Collectable 1000 units for vitamin D deficiency ~ Protein supplement ~ Reguloid oral for constipation ~ Carbidopa-Levodopa 61XXX,d+[DATE] mg for Parkinson's disease ~ Magnesium oxide 400 mg supplement On [DATE], Surveyor reviewed a list of residents who resided in the facility on [DATE] and were full-code status. Seven residents (R7, R11, R12, R14, R16, R18, and R19) were full-code status and without a CPR-certified nursing staff in the facility. On [DATE] at 4:00 PM, Surveyor interviewed RM-C who indicated all nurses who work in the facility are CPR certified. RM-C showed Surveyor a CPR certification on RM-C's phone for CNA-M and indicated CNA-M worked the [DATE] PM shift. When NHA-A later provided Surveyor with CNA-M's timecard, Surveyor noted CNA-M worked the [DATE] AM shift and left the facility at 2:08 PM. RM-C indicated CNA-P worked the [DATE] PM shift and was CPR-certified; however, Surveyor was not provided proof of CNA-P's certification. NHA-A provided CNA-P's timecard which indicated CNA-P worked from 2:00 PM to 10:00 PM on [DATE]. Surveyor also reviewed time sheets provided by Business Office Manager (BOM)-E that did not indicate CNA-M and CNA-P worked the [DATE] PM shift. When Surveyor showed RM-C the time sheets, RM-C confirmed CNA-M and CNA-P were not listed. The time sheets indicated two nurses worked the [DATE] PM during the time frame when there was no nurse in the facility. RM-C was unsure why the time sheets indicated that and confirmed the facility did not have a nurse during the times listed. RM-C later provided an attestation from MM-H that indicated MM-H was CPR-certified, however, proof of certification was not provided. On [DATE] at 4:14 PM, Surveyor interviewed Director of Nursing (DON)-B who was working as a floor nurse on the [DATE] PM shift and confirmed DON-B was covering the shift because there was not a licensed nurse assigned to work the floor that day. DON-B confirmed the facility's plan was to have DON-B cover the floor assignment in the absence of another licensed nurse and indicated DON-B frequently covered floor assignments. The facility's failure to have a licensed nurse for approximately 2.5 hours on the [DATE] PM shift created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when it completed the following: 1. Reeducated staff of the requirement to have a licensed nurse on duty 24 hours per day. 2. Reeducated nurses to remain on assignment until relieved by another nurse. 3. Reeducated nursing staff that only licensed nursing staff have access to medication cart keys. 4. Educated staffing agencies used by the facility of the responsibility of nurses to remain on assignment until another nurse arrives on duty. 5. Clarified with staffing agencies used by the facility the need for notification when agency staff cancel shifts. 6. Developed an agency nurse orientation packet that indicates nurses may not leave the facility until care is handed off to another nurse. 7. Incorporated a process in which there is a designated charge nurse each shift when the DON is not in the facility. The charge nurse or DON will cover any shifts that do not have a nurse.

Based on staff interview and record review, the facility did not ensure an allegation of neglect was reported to the State Agency (SA) when the facility was without a licensed nurse for approximately 2.5 hours on 4/14/24. This had the potential to affect 14 of 23 residents. On 4/14/24, the facility was without a licensed nurse on the PM shift from approximately 3:02 PM until 5:35 PM. Three residents (R10, R16, and R7) did not receive blood glucose monitoring in accordance with physician orders. Fourteen residents (R1, R3, R5, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17) did not receive medication in accordance with physician orders or the facility's policy. One resident (R5) was transported by ambulance to the emergency room (ER) without a nurse assessment to determine R5's medical needs. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a revision date of 7/15/22, indicates: Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .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. Reporting/Response: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .B. The Administrator will follow up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. On 9/12/24, Surveyor reviewed a police department report, dated 4/19/24, that indicated on 4/14/24 the facility was without staff for several hours when an agency staff could not get ahold of anyone and left the facility. The report also indicated an ambulance was called for an unresponsive resident and the only person at the facility was a maintenance staff who called 911. The officers who responded to the call indicated there were 3 employees at the facility in addition to the maintenance staff. Surveyor reviewed an ambulance report, dated 4/14/24, that indicated there was a 911 call from the facility at 5:10 PM that R5 was unresponsive. R5 had abnormal breathing and was still unconscious at 5:10 PM and was transported to the hospital 5:38 PM. On 9/12/24 at 12:10 PM, Surveyor interviewed Regional Manager (RM)-C who confirmed there was a timeframe on the 4/14/24 PM shift when the facility was without a licensed nurse. RM-C provided Surveyor with an investigation that was completed by a former Nursing Home Administrator (NHA) who was employed by the facility at that time. Surveyor reviewed the investigation which included a written statement from Maintenance Manager (MM)-H that indicated at 1:48 PM, MM-H called the NHA, Scheduler and on-call Unit Manager (all of whom are no longer employed at the facility) to notify them there was no nurse for the PM shift. At 4:01 PM, the NHA first responded to the calls and text messages sent by MM-H. MM-H's statement indicated [NAME] President of Success (VPS)-J later contacted the facility and advised staff to not serve diabetic residents supper; however, the 300 wing residents had already been served. The investigation included a Critical Event Analysis and Action Plan Worksheet that indicated the facility was without a licensed nurse from approximately 3:02 PM until 5:35 PM when VPS-J arrived. On 9/12/24, Surveyor interviewed MM-H by phone. MM-H no longer worked at the facility but recalled the events of 4/14/24. MM-H confirmed there was no licensed nurse in the facility on the PM shift and MM-H called 911 to send R5 to the hospital. Surveyor reviewed medical records for diabetic residents who resided at the facility on 4/14/24. R10, R16, and R7's medical records indicated R10, R16, and R7's PM shift blood sugars were not obtained and their insulin was not administered timely or in accordance with their physician orders. Surveyor also reviewed a Medication Administration Audit report for residents who resided at the facility on 4/14/24. The report indicated 14 residents (R1, R3, R5, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17) received medications outside their designated timeframes and/or not in accordance with their physician orders. On 9/12/24 at 4:08 PM, Surveyor interviewed RM-C who confirmed the facility did not report the allegation of neglect to the SA.

Based on staff interview and record review, the facility did not implement their written policies and procedures that prohibit and prevent abuse for 3 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough and timely background check was completed for Licensed Practical Nurse (LPN)-K, LPN-I, and Certified Nursing Assistant (CNA)-L. Findings include: The facility's Abuse, Neglect and Exploitation policy, with a revision date of 7/15/22 indicates: It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .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. On 9/12/24, Surveyor reviewed background check information for 8 facility and contracted staff, including LPN-K, LPN-I, and CNA-L. LPN-K was hired on 10/1/17. LPN-K's Background Information Disclosure (BID) form was dated 9/27/17. LPN-K's Department of Justice (DOJ) and Integrated Background Information System (IBIS) letters were dated 6/12/19. LPN-I was hired on 8/3/18. LPN-I's BID form and DOJ and IBIS letters were dated 3/14/16. CNA-L was hired on 8/5/24. CNA-L's BID form was dated 6/12/23. On 9/12/24 at 2:27 PM, Surveyor interviewed Business Manager (BOM)-E who indicated BOM-E started at the facility on 5/6/24. BOM-E indicated BID forms were part of the application process and the facility obtained DOJ and IBIS letters prior to an employee's hire date. Following a discussion of the above findings, BOM-E indicated CNA-L most likely applied to the facility but was not hired until over a year later. BOM-E verified the facility should have had CNA-L fill out a new BID form prior to hire because CNA-L could have lived out of state during the previous year. BOM-E could not explain why background checks were not obtained for LPN-K and LPN-I prior to their hire dates. On 9/12/24 at 3:16 PM, Surveyor interviewed Regional Manager (RM)-C who indicated the facility had no other background check information for LPN-K, LPN-I, or CNA-L related to their hire dates.

Based on record review and interviews the facility did not ensure an environment that is free from accident hazards and provides supervision and assistive devices to each resident to prevent avoidable accidents for 1 of 1 (R18) Resident reviewed for falls. On 7/29/21, R18 sustained multiple falls while residing in the facility. The facility did not complete a thorough investigation or root cause analysis to determine the cause of the falls, and if care planned interventions were in place at the time of the fall. R18's Care Plan was not revised to prevent further falls. This resulted in R18 having sustained a fall that resulted in a head injury/laceration which required staples. Findings include: R18 admitted to the facility on [DATE] and has diagnoses that include: Dementia, [CONDITION(S)] following Cerebral Infarction, Osteoporois, [CONDITION(S)], Chronic [CONDITION(S)], Hypertension and Depressive Disorder. R18's Admission/Readmission Evaluation dated 4/10/20 documented (in part): Fall risk assessment: Resident is at risk for falls? Yes. Comments: History of falls due to imbalance s/p (status post) [CONDITION(S)] ([CONDITION(S)] Accident). R18's Minimum Data Set with an Annual Reference date of 8/18/21 documented: Section C0100: Should Brief Interview for Mental Status be Conducted? No Staff Assessment for Mental Status: Memory problem Section C1000: Cognitive Skills for Daily Decision Making: Severely impaired. R18's Care Plan documented: Focus: At risk for falls due to: Impaired balance/poor coordination, unsteady gait, nonverbal, hx (history) of falls - date initiated 4/14/20, revision on 4/20/2020. Interventions: FALL RISK (FYI) When up in w/c must be in staff site - date initiated 4/14/20, revision on 4/21/20. Have commonly used articles within easy reach - date initiated 4/14/20. Dycem under WC cushion - wider or double piece - date initiated 4/16/20, revision on 10/13/20. Lay down after meals if not restless - date initiated 6/30/20, revision on 7/21/20. Up at nurse's station or in hallway when restless - date initiated 6/11/20, revision on 10/13/20. Caregivers to assist with eye piece (eye cover) when laying down if available; if not make sure enough cover for her to cover eyes when sleeping - date initiated 11/09/20. Scoop Mattress. Floor mats. Bed against the wall - date initiated 12/23/20. Low bed - date initiated 8/2/2021. Resident prefers removal of pants and socks when laying down for naps - date initiated 8/16/21. Assess for s/s (signs and symptoms) of [CONDITION(S)] (Urinary Tract Infection) - date initiated 8/16/21. Ask resident if she would like to go to bed around 7 PM - date initiated 8/20/21. Turn bed around facing the door - date initiated 8/31/21. Focus: Resident is at risk for falls r/t (related to) Deconditioning/weakness, Gait balance problems - date initiated 2/26/21. Interventions: Offer to lay resident down after meals - date initiated 6/28/20. Anticipate and meet the residents needs. Encourage the resident to always call for assistance - date initiated 2/26/21. Education the resident on fall prevention measures. Assure resident that calling for help is not a bother - date initiated 2/26/21. Ensure that the Resident is wearing appropriate footwear - date initiated 2/26/2021, revision on 2/26/21. Place call light or communication device within reach. Answer call light promptly - always. Date initiated 2/26/21. Anti rollbacks to wc - date initiated 3/4/2021. Resident to remain in highly supervised areas when eating - date initiated 4/11/20. Dycum under wc cushion - date initiated 4/16/20. Behavioral solutions eval - date initiated 4/18/21. Offer TV when restless- resident enjoys Golden Girls - date Initiated 4/20/21, revision on 5/3/21. OT (Occupational Therapy) eval (evaluation) for WC (wheelchair) positioning - date Initiated 6/1/21. Resident to be monitored at nurses station when restless - date initiated 6/9/19 Place bed at lowest position - date initiated 8/16/2021 Use body pillow when in bed - date initiated 9/20/21. Therapy screen. Date initiated: 10/4/20, 12/22/20, 1/26/21, 3/27/21. R18's medical record documented 9 falls occurred between 6/1/21 and 9/24/21. On 10/6/21 at 9:07 AM Surveyor asked Previous Director of Nursing (DON)-B for R18's fall investigations. On 10/7/21 at 10:02 AM Surveyor was provided R18's fall information, which consisted of progress notes and Risk Management forms. Surveyor reviewed the information, which did not include thorough investigations or root cause analysis to determine the cause of R18's falls. Surveyor asked DON-B if there was any more information on R18's falls, and if the facility had any fall investigations for R18. DON-B stated she was not sure, I think that's all we might have, I will look. Surveyor reviewed R18's Risk Management forms provided by the facility which documented: 1. 6/1/21 at 11:43 AM Resident brought back from activities and left in common area outside room per POC (plan of care). Noted by CNA (Certified Nursing Assistant) sliding from WC (wheelchair). Resident attempting to reposition in WC and slid to floor. Staff unable to reach resident in time to prevent slide. Resident assessed for injury, none noted, no s/s pain noted. Assisted back to WC. IDT (Interdisciplinary Team) reviewed resident witnessed slide from WC. Resident brought back from activity, left in common area and was attempting to readjust self in chair, sliding to floor. RN (Registered Nurse) assessed, no injury noted, ROM (range of motion) to all extremities WNL (within normal limits) no s/s pain noted. OT to eval for WC positioning. Surveyor noted the facility did not complete a thorough investigation to include a root cause analysis of the fall. There was no documentation if R18 was incontinent or in need of toileting. The resident is non-verbal, thus she is not able to confirm the inference of the facility documentation that she was attempting to readjust herself in the chair. The only Care Plan revision following this fall was for OT eval for WC positioning - implemented 6/1/21. 2. 7/21/21 at 6:35 PM CNA went into resident's room, found resident laying on right side by side of bed, redness noted to right clavicle. Body check done, no s/sx of pain/discomfort noted, neuros (neurological) WNL, redness noted to right clavicle. IDT review of incident. Resident was not incontinent at the time of the incident. Care plan reviewed and interventions remain appropriate at this time. Surveyor noted the facility did not complete a thorough investigation to include a root cause analysis of the fall. There was no documentation of how R18 was positioned (in chair or bed) prior to the fall, or if R18 was incontinent or in need of toileting. The IDT note documented R18 was not incontinent at the time of the incident, however there is no documentation of this information in the fall documentation. No revisions were made to R18's care plan after this fall. The care plan intervention Lay down after meals if not restless was initiated on 6/30/20 and revised on 7/21/20. This was not a new intervention. 3. On 7/29/21 at 4:00 PM Found on left side end of bed on floor. Was reaching for object bed control was in left hand. Minimal bleeding from laceration to left side of head. Assessed resident, cleansed area to left side. Assisted to bed with 2 staff members. No facial grimacing. IDT review of incident/fall: [CONDITION(S)] noted, resident started on antibiotics. Low bed for resident. Surveyor noted the facility did not complete a thorough investigation to include a root cause analysis of the fall. There was no documentation if R18 was incontinent or in need of toileting. The facility's fall investigation did not include whether previous care planned interventions were in place such as: Whether the resident was restless and needed to be up at the nurses station prior to the fall, whether R18 was wearing their eye piece cover when laying down, and whether R18 was in scoop mattres, if floor mats were present, or if the bed was against the wall. There is no indication when the R18 was last seen and by whom, or if the call light was within reach. There is no indication as to where R18 was when last seen such as in her bed or whether she had been sitting up in her Broda chair. If last in her Broda chair, was R18 positioned correctly in the Broda chair. The fall was not witnessed and R18 is non-verbal, thus she is not able to confirm the inference of the facility documentation that she was reaching for object. The only revision made to R18's care plan was low bed - date initiated 8/2/2021. Facility Progress notes documented: 7/29/2021 at 4:00 PM Found resident on left side at end of bed on floor holding bed control. 1 cm (centimeter) abrasion to left side of head minimal bleeding. Cleaned area and bleeding stopped. Called NP (Nurse Practitioner) updated un-witnessed fall. Report fall to ED (Executive Director) and POA (Power of Attorney). POA stated she fell all the time at home. 7/30/2021 at 3:16 AM Resident is on follow up for: F/U (follow up) Fall, Neuro checks, pain, injury. The current status is VSS (vital signs stable), Neuro checks / WNL (within normal limits), no c/o (complaint of) pain, Abrasion to left side of head 7/30/2021 at 10:45 AM Transfer to Hospital Summary: When writer was giving pt (patient) meds (medications), writer noticed that pt had dry blood all over the left side of her head. Writer cleaned area and noted a laceration appx (approximately) 3/4 in (inches) X 1/4 in. Writer called NP to update, and NO (new order) to send patient out to hospital for evaluation and possible sutures/staples. 7/30/2021 at 3:00 PM Returned from (hospital) via stretcher. New order for [MEDICATION(S)] 500mg (milligrams) po one cap bid (twice daily) for 7 days. [CONDITION(S)]. Has 3 staples to left side of head. Family coming to visit. Subsequent falls did not include thorough investigations or a root cause analysis of R18's falls. 4. 8/13/21 at 3:15 PM Hospice aid was in with the other resident in same room and observed resident slide out of bed onto mat. Assist of 2 transfer back to bed without difficulties. Resident agitated regarding clothing that she was wearing when placed back into bed. 5. 8/15/21 at 5:00 PM Was found laying on right side had rolled out of bed. Had call light in reach with bed control. Laying on mat. 6. 8/16/21 at 3:25 PM Resident found on floor mat next to bed with head towards foot end of bed. Resident fidgeting with the sheets that were still on the bed. VS and ROM WNL. Resident was continent. Intervention: Not to lay resident down after lunch. Order for Urinalysis culture and sensitivity. Care plan revisions: Resident prefers removal of pants and socks when laying down for naps - date initiated 8/16/21. Place bed at lowest position - date initiated 8/16/2021. This was not a new intervention - low bed had already been initiated 8/2/2021. Ask resident if she would like to go to bed around 7 PM -date initiated 8/20/21. This was not an appropriate intervention as none of the previous falls occurred after 7 PM. Assess for s/s of [CONDITION(S)] - date initiated 8/16/21. 7. 8/30/21 at 2:45 PM Found resident laying on left side end of bed on floor. No apparent injuries. No facial grimacing. Was laid down in the afternoon due to sleeping in her chair. Rolled out of bed onto floor mat. Has scoop mattress and bed in low position. Will turn bed around where resident facing doorway instead of wall. Resident on antibiotic for [CONDITION(S)]. Care plan revision: Turn bed around facing the door - date initiated 8/31/21. 8. 9/17/21 at 7:15 PM Resident had rolled out of bed way laying on left side. No apparent injuries. No facial grimacing. Mat was down and has a scoop mattress. Use body pillow when in bed. Care plan revision: Use body pillow when in bed - date initiated 9/20/21. 9. 9/24/21 at 4:00 PM Found resident laying on floor on right side, bed lowest position. Last seen was 3:30 PM and laying in bed on back. Assessed - no apparent injuries. Resident is restless in the afternoon when placed in bed, with resident in the Broda chair intervention is to keep resident up in Broda chair in the afternoon. Surveyor review of R18's medical record revealed evidence in the form of documentation in the facility progress notes and post fall assessments dating back to 2020. R18's post fall assessment dated [DATE] documented: List date and time of 4 most recent falls as 6/9/20 4 PM, 6/28/20 7:30 PM, 4/20/20 1:45 PM and 4/11/20 8 AM. In addition, facility progress notes documented falls occurred on 12/22/20, 1/26/21, 3/4/21/ 3/27/21 and 4/18/21. Surveyor identified no concerns with R18's fall interventions (bed in the low position, gray fall mat on floor, scoop mattress and body pillow on bed) during survey. On 10/11/21 at 9:13 AM Surveyor again asked DON-B for R18's fall investigations. No additional information was received. On 10/11/21 at 10:00 AM Surveyor advised DON-B the information the facility provided on R18's falls did not include thorough investigations as to how the falls occurred, or if R18 was incontinent or in need of toileting. Surveyor advised DON-B there was no evidence the facility completed a root cause analysis of R18's falls to prevent further falls. Surveyor noted the fall information provided did not indicate whether care planned interventions were in place at the time of the fall to assess for the effectiveness of planned interventions. Surveyor noted 8 of the 9 falls occurred while R18 was in their room and during the afternoon and/or on second shift. DON-B reported having asked everyone including the Nursing Home Administrator (NHA)-A and nurses, and searched the DON's office and found nothing else. No additional information was provided to Surveyor. (Of note: DON-B worked for the facility for 2 weeks prior to DON-C assuming duty on the first day of survey.) On 10/11/21 at 2:30 PM during the daily exit meeting with NHA-A and DON-B, Surveyor advised them of the concern R18's fall reports do not include thorough investigations or a root cause analysis to determine the cause of R18's falls to prevent future falls. In addition, R18's Care plan was not revised with appropriate interventions following each fall. R18 sustained a fall on 7/29/21 which resulted in a head injury requiring staples. Surveyor asked NHA-A and DON-B if there was any other information on R18's falls, to please provide to Surveyor for review. On 10/12/21 at 10:32 AM Surveyor again asked DON-B if the facility had any additional information to provide in regard to R18's falls. DON-B stated: No. We've literally looked everywhere. It looks as if the DON's office was cleared out, because it's just too clean in there.

Based on observation, interview, and record review, the facility did not ensure 1 (R4) of 3 residents reviewed for accidents was free of hazards in the environment. R4 was at risk for ingesting inedible objects. No plan of care or interventions to reduce the environmental hazards was in place prior to R4 swallowing a poker chip, despite known previous behaviors of ingesting inedible objects. R4 required surgical intervention to remove the poker chip from the esophagus. Findings: R4 has [DIAGNOSES REDACTED]. Medications include [MEDICATION NAME] (an antipsychotic for organic mood disorder) and [MEDICATION NAME] (an antidepressant for severe mood). R4 was briefly enrolled in hospice care starting on 1/4/2018. R4's BIMS (Brief Interview for Mental Status) score on the Minimum (MDS) data set [DATE] was 00 showing severe cognitive impairment. On 10/16/2017 at 7:01 PM, nursing charted: R4 put artificial leaf in mouth, writer and CNA (Certified Nursing Assistant) finally got it out. On 10/24/2017 at 3:48 PM, nursing charted R4 was eating feces and a portion of the brief. (R4) states she wants to die and has a plan to choke herself. (R4) will not spit out brief and multiple staff has approached her. Send to (hospital) for psych eval. R4 was admitted to the hospital with [REDACTED]. On 11/5/2017 at 8:07 AM, nursing charted R4 was eating feces. On 12/10/2017 at 4:23 AM, nursing charted R4 passed a piece of cloth in the stool measuring 8-10 inches long. On 1/11/2018 at 10:19 PM, nursing charted: (R4) seen with object in mouth trying to push it down her throat. Multiple attempts to retrieve object unsuccessful. Unable to tell exactly what it was, looked about quarter size, plastic and light blue in color. It finally disappeared from sight. (R4) pointed at throat and looked in some distress but was still able to drink and eat. Continually put fingers in mouth in attempts to throw up and was somewhat successful. Day shift nurse, unit manager and DON (Director of Nursing) were also there to observe. Appeared as though (R4) either finally swallowed it or was stuck sideways in throat. Will continue to monitor. No documentation of physician notification at that time was found. On 1/12/2018 at 8:29 AM, nursing charted: Situation: Reported to 1st shift that (R4) may or may not have swallowed a 'disc' of some sort. Background: (R4) has history of swallowing inanimate objects. Was reported to writer that (R4) has had several occasions of stuffing things down her throat. Assessment RN/Appearance LPN: (R4) did not appear to be in distress. However when was up in chair was pointing at her throat on continuous basis. Hospice arrived and assessed (R4) and established that (R4) would need to go to the ER (emergency room ) to see if the object was lodged. Assessment: Hospice nurse completed assessment and wrote paper note- see chart. Response: (R4) sent to ER. Recommendations: ER put (R4) under general anesthesia and took out poker chip out of esophagus. On 1/12/2018, Hospice documented: On arrival writer was receiving report from facility nurse. She reports (R4) swallowed light blue, quarter sized, plastic object yesterday. During report, (R4) rolled out of bed onto floor mattress. (R4) grabbing at throat. No s/s (signs or symptoms) of resp. (respiratory) distress. Hospice updated physician and R4 was transported to the hospital. Hospice completed the Nursing Home to Hospital Transfer Form indicating R4 swallowed an object on 1/11/2018, is grabbing at the throat, and needs to have the object removed. R4's incident report dated 1/11/2018 with a revision date of 1/16/2018 states: (R4) was seen to be licking bingo chips during group activity. It was later found out (R4) had ingested the foreign object. No respiratory distress assessed. (R4) taking in fluids/foods without issue. VSS (vital signs stable). (R4) would not spit out foreign object, when nursing staff attempted to remove object with tongue depressor/gloved hands (R4) would attempt to bite and shake her head. (R4) placed on monitoring and was re-approached by alternate staff to spit it out. (R4) non-verbal. Would shake head no when staff tried to assist with removal of object. (R4) did cry on and off. The physician was notified on 1/12/2018 at 10:03 AM. The interdisciplinary team note dated 1/15/2018 on the incident report stated R4 took a bingo chip from the activity area and later ingested it in the hallway near R4's bedroom. R4 will be care planned to only attend activities with activity staff, no volunteers. The activities will be modified to have no small objects R4 can eat; i.e. bingo cards that can be marked with a marker instead of a poker chip. On 3/12/2018 at 12:42 PM, R4 was observed in the dining room eating lunch. CNA-K was assisting R4 with eating. CNA-K instructed R4 to swallow after each bite of food was placed in the mouth. R4 continually tried to grab the plate of food. R4 was able to hold cup and drink independently. Surveyor interviewed CNA-K in regards to the amount of assistance R4 needed with meals. CNA-K stated someone always feeds R4 because R4 needs to be reminded to swallow. On 3/13/2018 at 11:25 AM, R4 was observed in the dining room with activities. R4 was throwing rings on pegs on a table. R4 was then brought to the back dining room where lunch was served. R4 ate lunch independently using a spoon without difficulty. A nurse was observed going in and out of the dining room during lunch service. On 3/13/2018 at 2:02 PM, R4 was observed propelling in the wheelchair without assistance down the hall. R4 went toward the front door, pushed the handicap button and the door opened. A staff member came to R4's side just as R4 was wheeling toward the open door. The staff member redirected R4 by insisting R4 put on a sweater. Surveyor observed R4's ability to propel the wheelchair throughout the facility increases R4's risk of accessing and ingesting inedible objects. On 3/14/2018 at 9:50 AM, Surveyor interviewed DON-B regarding R4's incident with the poker chip. DON-B stated R4 was attending an activity and put the poker chip into her mouth. DON-B stated R4 was rolling the chip around in her mouth and various staff tried to get R4 to spit it out by offering food in exchange for the chip. Once the chip was no longer visible, R4 did not appear to be in any distress. On 3/14/2018 at 11:05 AM, Surveyor observed R4's room. Artificial flowers were lying on the over-bed table. The top drawer of the dresser was missing exposing string and socks in the second drawer. A small black container with gold foil was sitting next to the sink. A finger rosary was on the dresser next to the TV. A pink bin next to the dresser contained sunglasses, a knit hat, a spiral notebook, a dry erase pen, pen caps, and beads. The behavior of eating foreign objects plan of care was initiated on 1/12/2018. The intervention to monitor R4 and limit objects that R4 may try to ingest is limited to the activity department. The other interventions are all aimed at resident preferences in food, diet, texture, and adaptive equipment to aid in the consumption of food. On 3/15/2018 at 11:00 AM, Surveyor and DON-B discussed R4's behaviors and the plans of care in place. Surveyor pointed out the plan of care for R4's tendency to eat inedible objects wasn't initiated until 1/12/2018 when R4 had ingested objects on 10/16/2017 - an artificial leaf, 10/24/2017 - feces and part of the brief, 11/5/2017 - feces, and 12/10/2017 - a strip of cloth; the plan of care did not address any staff other than activities when the other objects that R4 attempted to eat occurred in other settings besides activities. The physician was not notified on 1/11/18 until the following day on 1/12/18. The hospice nurse's assessment the following day (1/12/18) initiated R4's transfer to the hospital where R4 had to undergo general anesthesia to remove the poker chip from the esophagus. On 3/19/2018 at 4:00 PM, Surveyor went over the information gathered with the Nursing Home Administrator (NHA)-A and DON-B at the exit conference. No further information was provided. (Cross Reference F580 & F656)

Based on interview and record review the facility did not ensure that 1 (R5) of 7 sampled residents were free of significant communication errors. R5 has [DIAGNOSES REDACTED]. R5's blood sugars were not checked twice a day as ordered, and R5 experienced a hypoglycemic episode with a blood sugar of 47. The facility also did not address medication discrepancies on R5's medication paperwork, resulting in R5 receiving medications and dosages different then his discharge summary medications from the hospital. R5's nurse practitioner who assessed the resident at the facility noted different medications and dosages than what R5 was receiving in her progress note. These discrepancies included insulin and blood pressure medications. The facility also did not identify parameters for R5's blood pressure and heart rate as ordered related to R5 receiving medications that affect heart rate. Findings include: Blood Glucose Management- R5 has [DIAGNOSES REDACTED]. R5 was admitted to the facility on [DATE]. R5's facility admission orders [REDACTED]. R5 had no documented blood glucose levels on [DATE]. A blood glucose level of 145 is documented in R5's electronic medical record [DATE]. No blood glucose level is documented in the medical record during the AM of [DATE]. R5 was documented as receiving 24 units of regular insulin 70:30 during the PM shift of [DATE]-[DATE]. R5 was documented as receiving 32 units of regular insulin 70:30 during the AM shift of [DATE]-[DATE]. R5 was seen by NP (nurse practitioner)-G on [DATE]. NP-G documents active problems include type 2 diabetes mellitus, uncontrolled. NP-G documents This afternoon her blood sugar was 47 before lunch; asymptomatic, unfortunately the nursing home has not checked any other blood sugars. She continues on Insulin ,[DATE] as below. A medication list is documented below this note documenting Current Medications The medication list documents INSULIN REGULAR ,[DATE] ([MEDICATION NAME] ,[DATE] KWICKPEN) (,[DATE]) 100 UNIT/ML PEN-INJECTOR Inject 18 units sq in am and 14 units sq in pm. The surveyor noted this list is different than the 24 units of regular insulin 70:30 R5 is documented as receiving during the PM shift of [DATE]-[DATE] and the 32 units of regular insulin 70:30 R5 is documented as receiving during the PM shift of [DATE]-[DATE]. On [DATE] NP-G wrote an order for [REDACTED].>On [DATE] at 8:24 am the surveyor interviewed ADON-D. The surveyor informed ADON-D that orders were noted on [DATE] for blood glucose checks to be performed twice a day. The surveyor shared that she had been unable to locate documentation that this was being completed. ADON-D stated blood glucose levels would be in the MAR (Medication Administration Record). ADON-D reviewed R5's medical record and was unable to find additional blood glucose levels. On [DATE] at 10:49 am the surveyor interviewed NP-G. NP-G informed the surveyor that she recalled seeing that R5 was on insulin and that we needed to get blood sugars so to make sure the facility got them she ordered the blood sugars to be taken. On [DATE] progress notes document .Resident then complained of being dizzy and thought her blood glucose may be low. Blood glucose was taken was 476. On [DATE] at 3:32 pm the surveyor informed Administrator-A and DON (Director of Nursing)-B of the above information. The surveyor asked for any additional information. No additional information was provided to the surveyor. Orders- R5 was hospitalized at Grafton Hospital from [DATE]-[DATE] where cardiac optimization occurred. R5 was then transferred to St. Luke's Hospital for definitive repair due to the complexity of the injury from [DATE]-[DATE]. R5 was admitted to the facility on [DATE]. The Discharge Summaries document provided from the hospital included a discharge summary from the [DATE]-[DATE] hospitalization . This discharge summary included a summary of discharge medications with a disposition that the patient is being discharged to St. Lukes, and is signed [DATE]. R5's Orthopedic Discharge Summary noted with an admission date of [DATE] and a discharge date of [DATE] states discharge instructions, medications, and followup appointment were discussed with the patient and after visit summary was given. The 38 page After Visit Summary- Transition includes a list of discharge medications. The After Visit Summary instructs to start taking [MEDICATION NAME] 500mg twice a day for five days, aspirin 325 mg daily, and [MEDICATION NAME] 17grams daily. The After Visit Summary instructs to CONTINUE taking these medications which have CHANGED which includes carvedilol 25mg ([MEDICATION NAME]) and insulin regular ,[DATE] with instructions to inject 18 units sx (subcutaneously) in am and 14 units sq in pm. The after visit summary also documents to STOP taking these medications, discuss with your Pharmacist. Medications listed include aspirin 81 mg with a note that it was replaced by aspirin 325mg tablet, losartan ([MEDICATION NAME]) 50mg, [MEDICATION NAME] ([MEDICATION NAME]) 1g tablet, and Tylenol 500mg. R5's admission physician orders, signed by the physician [DATE] and signed as reviewed by ADON (Assistant Director of Nursing)-D on [DATE] include orders for losartan 25mg, [MEDICATION NAME] 1g, Tylenol 1500mg twice a day as needed for pain, aspirin 81mg, carvedilol 12.5mg twice a day, and insulin regular 70:30 with instructions to inject 32 units SQ in AM and 24 units SQ in PM. The surveyor noted no order for [MEDICATION NAME] and noted the orders were different then the medications listened on the after visit summary. On [DATE] at 8:24 a.m. the surveyor interviewed ADON-D. The surveyor asked ADON-D what the process is for admission orders [REDACTED]. ADON-D stated she makes sure the resident is familiar with the medications. ADON-D stated she ensures that medications on the discharge summary are the same with the transition of care summary and if discrepancies discuss with the family and update with the nurse practitioner or MD. ADON-D confirmed that she went off the discharge medication list off of the discharge summaries document from the [DATE]-[DATE] hospitalization with a disposition that the patient is being discharged to St. Lukes, and is signed [DATE]. ADON-D stated this may be an example where she didn't catch that this (the medication list) was a discharge summary to St. Luke's. ADON-D confirmed that she went off of the [DATE] medication list and did not discuss the discrepancies between the [DATE] discharge medication list from her [DATE]-[DATE] hospitalization and the After Visit Summary-Transition from her hospitalization at St. Luke's Hospital. A telephone order was placed on [DATE] for 325mg aspirin for [MEDICATION NAME]. R5's Medication Administration Record [REDACTED]. On [DATE] R5 was seen by NP-G. NP-G documents (R5) was admitted to Heritage Nursing and Rehab on [DATE] following a fall at home and subsequent right proximal tibia fracture. She initially presented to Aurora Grafton and was stabilized and then transferred to ALSMC (Aurora St. Luke's Medical Center) d/t (due to) the complexity of the fracture. On [DATE] she had an ORIF (open reduction internal fixation) of the right tibia by (a physician). She was started on aspiring 325mg for [MEDICAL CONDITION] ([MEDICAL CONDITION] prevention .During her inpatient stay her losartan was discontinued d/t (due to [MEDICAL CONDITION], K+ (potassium) on discharge was 5.0. Her [MEDICATION NAME] (carvedilol) dose was then increased. NP-G lists current medications as aspirin 325mg, carvedilol 25mg twice a day, insulin regular ,[DATE] 18 units sq in am and 14 units sq in pm, [MEDICATION NAME] 17 grams by mouth daily. The current medications list does not include losartan or [MEDICATION NAME]. The current medications that NP-G noted are different than the medications that R5 was documented as receiving at that time. On [DATE] at 10:49 am the surveyor interviewed NP-G. NP-G informed the surveyor that she gets the list of medications documented in her note through Aurora's system, not the facility. On [DATE] R5 experienced a change in condition was sent to the emergency department. Emergency department records document that R5's blood glucose was 397 (normal range ,[DATE]), and a markedly elevated potassium of 6.8 (normal range 3XXX,[DATE].1) with notation of Slight hemolysis, result may be falsely increased. R5 experienced a [MEDICAL CONDITION] and expired in the emergency room . Parameters- R5's admission physician orders [REDACTED]. R5 is documented as receiving 25 mg of losartan (also known as [MEDICATION NAME], a medication that lowers blood pressure) daily in the AM, 12.5mg of carvedilol (also known as [MEDICATION NAME], a beta-blocker medication that lowers heart rate and blood pressure) twice a day, and 40mg of [MEDICATION NAME] daily in the am (also known as [MEDICATION NAME], a medication that lowers blood pressure). The surveyor reviewed R5's physician orders [REDACTED]. No parameters were noted. The surveyor reviewed R5's documented vital signs. R5's blood pressures are documented as: [DATE] at 8:26 pm ,[DATE], [DATE] at 2:52 am ,[DATE], and [DATE] at 3:15 pm ,[DATE]. The surveyor noted that R5's blood pressure was not documented as checked prior to receiving the AM dose of losartan, carvedilol, and [MEDICATION NAME] (all medications that affect blood pressure), and was not always documented on the pm shift prior to being administered the pm dose of carvedilol. R5's heart rates are documented as : [DATE] at 8:26 pm as 74, [DATE] at 2:52 am as 76, and [DATE] at 3:15pm as 61. The surveyor noted that R5's heart rate was not always documented as being checked prior to receiving carvedilol (a medication that affects heart rate). On [DATE] R5 experienced a change in condition that included a low blood pressure of ,[DATE]. R5 was sent to the hospital, where they experienced a [MEDICAL CONDITION] and expired. On [DATE] at 8:24 am the surveyor interviewed ADON-D. The surveyor asked ADON-D what the process is for blood pressure and heart rate parameters. ADON-D stated the process is to get parameters and then when giving blood pressure medications have parameters checked, and that this is generally in the MAR. The surveyor noted R5 had no parameters noted in their MAR. On [DATE] at 8:55 am the surveyor interviewed DON-B and Corporate RN-M. The surveyor asked what the expectation was for blood pressure and heart rate to be monitored if on medications that affect them. Corporate RN-M stated that she would have to ask NP-G, as she would decide that. On [DATE] at 10:49 am the surveyor interviewed NP-G. NP-G informed the surveyor that the facility usually asks her what the parameters (for blood pressure or heart rate if on medications that affect them) should be. NP-G stated the facility does not call her for parameters ever time. NP-G stated that she believed the standard of practice is to check heart rate prior to giving a beta-blocker (carvedilol is a beta-blocker). On [DATE] at 3:32 pm the surveyor shared the above interview with NP-G with Administrator-A. The surveyor asked Administrator-A and DON-B what the expectation for staff to monitor heart rate if the resident is on a beta blocker. DON-B did not answer. Administrator-A stated they would look into it. The surveyor shared with Administrator-A and DON-B that no parameters were noted to be put into place related to R5's blood pressure and heart rate despite orders to do so. No additional information was provided to the surveyor.

Based on observation, staff interview, record review and policy review, the Facility did not maintain and implement an infection control program designed to prevent the development and transmission of infection during two outbreaks. (1) The Facility's infection control program failed to prevent the spread of an acute respiratory illness as Residents who exhibited signs and symptoms of an acute respiratory illness on 2/20/17, 2/21/17, & 2/22/17 were not placed in isolation until after Director of Nursing (DON)-B contacted the hospital in the evening of 2/22/17 to inquire about the admitting [DIAGNOSES REDACTED]. (2) On 4/5/17, 3 Residents (R40, R13, & R41) developed loose stools. The Facility did not acknowledge there was a GI (gastrointestinal) outbreak until 4/11/17. A total of 7 Residents became ill GI symptoms. On 2/20, 2/21, and 2/22/17, when Residents exhibited signs & symptoms of acute respiratory infection, the facility did not immediately isolate Residents. These Residents continued their usual routine of dining, activities and therapy. The facility did not develop a line list for staff during the acute respiratory outbreak, allowed a Certifed Nursing Assistant (CNA) with signs & symptoms of an acute respiratory infection to work and staff were allowed to float during the outbreak. On 4/5/17, when Residents exhibited signs & symptoms of an GI illness, the facility did not identify the outbreak until 4/11/17. The facility isolated these Residents but did not institute any other measures to prevent the spread of the outbreak including placing signs to notify visitors & staff. The facility did not develop a Resident line list during the outbreak, did not develop staff line listing during the outbreak, and staff were allowed to float during the outbreak. The failure of the facility to immediately implement appropriate procedures to limit the transmission of disease created a situation of Immediate Jeopardy, which began on 2/21/17 when the facility did not promptly recognize an outbreak of Acute Respiratory Illness at the facility. Administrator-A, DON -B and RN (Registered Nurse) Corporate Consultant-J were notified on 4/18/17 at 3:00 p.m. that an Immediate Jeopardy situation existed. The finding of Immediate Jeopardy was removed on 4/18/17, however; the deficient practice continues at a scope and severity of an F (potential for more than minimal harm that is not immediate jeopardy/widespread) until all components of the facility's plan of correction have been fully implemented, including ongoing monitoring for effectiveness and as evidenced by the following: * Staff did not wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice during 2 (R4 &R12) of 13 sampled Residents and 1 (R27) supplemental Residents. Findings include: Acute Respiratory Illness/Influenza Outbreak: 1. On 4/17/17 at 11:24 a.m., Surveyors conducted the infection control interview with DON-B. During this interview DON-B was asked what she does during an outbreak. DON-B replied that she contacts public health and has a line list for residents. DON-B informed Surveyors that in February 2017 they had a flu outbreak and offered [MEDICATION NAME] to all residents and staff. DON-B stated there were 6 Residents with confirmed influenza and one staff with confirmed influenza and other staff that had signs and symptoms were instructed to stay home until fever free. Surveyor asked if there were any hospitalization s due to influenza. DON-B replied no but explained that there were three deaths during the outbreak. DON-B stated that one resident was on hospice, another the family didn't want the resident to be placed on hospice and the third resident the Medical Director reviewed the medical record and didn't think influenza was the main cause of death. DON-B informed Surveyors that she informed public health of the deaths. At 11:55 a.m., Surveyor informed DON-B that Surveyor had questions regarding the acute respiratory/influenza outbreak and inquired which unit the outbreak started on and when did Residents became ill. DON-B showed Surveyor a two page line list and a three page timeline titled, Influenza Outbreak 2017. Surveyor noted the line list contains Resident's name, gender, onset of illness, first well date, duration in days, room/wing, signs & symptoms, if the Resident was tested with the result and Influenza/flu vaccine date. Surveyor noted this line listing does not indicate the type of isolation instituted. According to the line list on 2/20/17, R21 who resides on wing 2, R20 who resides on wing 3 and R22 who resides on wing 3 exhibited signs and symptoms. On 2/21/17, R26 & R18 both whom reside on wing 2 exhibited signs & symptoms. (The facility should have identified an outbreak on this day as there were three residents ill on wing 2.) On 2/22/17, R19, R32, & R14 all whom reside on wing 3 and R8 who resides on wing 2 exhibited signs & symptoms. On 2/23/17, R33 & R34 both whom reside on wing 2 exhibited signs & symptoms and R35, R36, R37, R1, & R4 all whom reside on wing 1 exhibited signs & symptoms. On 2/27/17, R38 who resides on wing 2 and R39 who resides on wing 1 exhibited signs and symptoms. There are 18 Residents on the Facility's line listing identified as having signs and symptoms for this Respiratory/Influenza outbreak. On 2/23/17, R19, R18, R34, & R32 tested positive for the influenza A virus. On 2/27/17 R48 tested positive for influenza B virus. DON-B informed Surveyor on 2/21/17, R22 was transferred to the hospital. DON-B explained that on the evening of 2/22/17 she called the hospital to get an update on R22 and found out that R22 had tested positive for Influenza A. DON-B informed Surveyor that after finding this out they started to back track, looked at all the residents with signs and symptoms and placed these residents in isolation. Surveyor asked DON-B when they considered there was an outbreak. DON-B informed Surveyor on 2/22/17 after she was informed about R22. Surveyor asked DON-B what was done. DON-B informed Surveyor that residents with signs and symptoms were placed in isolation, signs were placed on the doors, she left a message for public health, and updated the house doctors and nurse practitioner. DON-B informed Surveyor that they treated all the residents with [MEDICATION NAME] and the [MEDICATION NAME] was offered to staff. Surveyor inquired if they continued with large group activities. DON-B replied, yes. Surveyor inquired about the dining room after 2/22/17. DON-B informed Surveyor that residents ate in their room or if they came to the dining room they wore masks. DON-B indicated that for the residents requiring assistance with eating they were in the back portion of the dining room and the Residents were three feet apart. Surveyor inquired about therapy. DON-B informed Surveyor they didn't limit therapy. Surveyor inquired if therapy was in the Resident's room or in the therapy department. DON-B informed Surveyor that she didn't recall. Surveyor inquired if there were any staff that became ill. DON-B informed Surveyor there were. Surveyor asked to see the staff line list. DON-B informed Surveyor that she doesn't have one and informed Surveyor there were five staff that developed signs & symptoms. Surveyor inquired when ill staff were allowed to come back to work. DON-B informed Surveyor they had to be fever free for 24 hours. Surveyor inquired if staff were allowed to float. DON-B informed Surveyor that staff doesn't float. Surveyor asked DON-B, (prior to the hospital informing her on the evening of 2/22/17 of R22's [DIAGNOSES REDACTED]. DON-B replied, Yes. On 4/17/17 at 1:34 p.m., Surveyor asked Rehab Director-BB if they treated Residents during the acute respiratory/influenza outbreak and when they were notified of an influenza/acute respiratory outbreak. Rehab Director-BB replied, On the 23rd. Rehab Director-BB informed Surveyor that they were told that Residents could leave their room as long as residents wore a mask and staff wore a mask. Rehab Director-BB informed Surveyor that they sanitized the equipment after. On 4/18/17 at 11:04 a.m., Surveyor asked DON-B after the acute respiratory outbreak did she review what the Facility did and what the Facility could have done better to prevent another outbreak. DON-B informed Surveyor that she sent something to RN (Registered Nurse) Corporate Consultant-J. Surveyor requested a copy of what was sent to RN Corporate Consultant-J. DON-B informed Surveyor that when they were reviewing residents with signs and symptoms they realized that R21, who exhibited signs and symptoms, first family was in and out of the facility and that they should have instituted precautions. DON-B informed Surveyor that the nurses weren't thinking respiratory. Surveyor informed DON-B that Surveyor is still confused as to why she didn't place Residents in isolation when they exhibited signs and symptoms as they were testing residents for Influenza. DON-B informed Surveyor that public health told her 3 Residents with respiratory symptoms is an outbreak. DON-B stated, I was looking for three positive flu. GI Outbreak: 2. Surveyor was provided with Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long Term Care Facility revised 10/20/09 as the facility's standard of practice. The introduction documents, It is the responsibility of the LTCF (long term care facility) to implement aggressive infection control measures quickly and to notify the appropriate agencies of the outbreak or suspected outbreak. Under the question How can an outbreak of viral gastroenteritis be identified? documents, Facilities are required to maintain an infection prevention and control program that includes a surveillance program for infections common to LTCFs including viral gastrointestinal disease. An outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days. Vomiting may be present in at least half of the ill persons. Other symptoms may include nausea with or without vomiting, abdominal cramping, fatigue, body aches, and occasionally a low grade fever. Facilities should immediately institute aggressive infection control measures anytime an outbreak is suspected. I. Limit transmission when initial cases of viral gastroenteritis are suspected A. Notification 1. Each resident unit should immediately report any resident(s) or staff member(s) with a sudden onset of symptoms suggestive of viral gastroenteritis to the person in-charge and infection control practitioner who should immediately take appropropriate action. The medical director should be consulted anytime the facility suspects an outbreak. 2. New cases should be recorded daily using a line list. 3. Notify the local health department of any suspected or confirmed outbreak. Consult with the local health department about laboratory testing. 4. Notify sister facilities that may share staff/resources with the affected facility so they can put proper control measures in place and monitor for illness. B. Management of Resident and staff 5. Discontinue floating staff from the affected unit to non-affected units, if possible. 7. Consider discontinuing use of common dining areas and instituting in-room dining. II Institute control measures when a viral gastroenteritis outbreak is suspected without waiting for diagnostic confirmation A. Notification: see above. All suspected/confirmed outbreaks must be reported immediately to the local health department. B. Management of Residents 2. Cancel or post group activities for at least 48 hours after the last identified case. 6. For residents experiencing vomiting and/or diarrhea, monitor hydration status to include implementation of intake and output monitoring. C. Management of Staff 1. Staff assignments a. Maintain the same staff to resident assignments, if possible. b. Limit staff from moving between affected and unaffected units. D. Management of Ill Staff 5. A log should be maintained to record ill staff symptoms, date when they became ill, date they became well, and when they returned to work. G. Management of Visitors 1. Post signage that the facility is experiencing an increase in gastrointestinal illness. On 4/17/17 at 11:24 a.m., Surveyors conducted the infection control interview with DON-B. During this interview Surveyor inquired other than the acute respiratory illness/influenza outbreak has there been any other outbreaks identified. DON-B explained there was a GI (gastrointestinal illness) that started on 4/5/17. DON-B explained that there were 3 Residents (R40, R13, & R41) with loose stool on wing 3 and all these residents were placed in isolation. DON-B stated a couple more Residents had GI symptoms on 4/9/17 (R44 & R42), one more Resident on 4/10/17 (R43) and one Resident on 4/11/17 (R45). Surveyor inquired did DON-B consider this a GI outbreak. DON-B replied yes and that she contacted public health on 4/11/17. Surveyor asked DON-B what was the date that the outbreak began. DON-B replied on the 5th when there were three Residents (R40, R13, & R41). Surveyor asked DON-B on 4/11/17 what other measures were implemented to prevent the spread of the GI outbreak and inquired were signs posted about the GI outbreak. DON-B replied no. Surveyor noted when the Survey team entered the Facility on 4/11/17 at 8:00 a.m. no signs were observed nor were there any signs posted during the survey. Surveyor asked DON-B did they do anything else other than contacting public health. DON-B replied no. Surveyor asked DON-B for the GI outbreak Resident line list. DON-B informed Surveyor that she didn't have one and provided Surveyor with a report sheet for wing three. Surveyor inquired if the GI illness spread to other units. DON-B informed Surveyor that it was only on wing 3. Surveyor reviewed the report sheet and noted the following on: 04/05/17, R40, R13, & R41 exhibited signs & symptoms of GI illness, 04/09/17, R42 & R44 exhibited signs & symptoms, 04/10/17, R43 exhibited signs & symptoms, and 04/11/17, R45 developed signs and symptoms. On 4/17/17 at 1:21 p.m., Surveyor met with Rehab Director-BB to inquire if R42, R40, R43, R13, R45, and R44 received therapy during April. Rehab Director-BB informed Surveyor that; R42 receives OT (occupational therapy), PT (physical therapy) & speech and is still on case load, R40 was on therapy and his last covered day was 4/11/17, R43 received OT, PT, & speech and is still on therapy, R13 started speech on 3/25/17 and OT & PT on 3/27/17 and was discharged on [DATE]. R41 receives OT, PT, & Speech and is still on therapy. R45 is on OT, PT, & speech, started these therapies on 4/6/17 and is still receiving therapy, and R44 was receiving speech but was discontinued on 4/15/17 and is still receiving OT & PT. Surveyor inquired if these residents were treated in the therapy department. Rehab Director-BB replied, yes. Surveyor inquired if there is a GI outbreak what would happen? Rehab Director-BB informed Surveyor they would treat the Residents in their room and wipe down the equipment with bleach. Surveyor inquired how is the therapy department usually cleaned? Rehab Director-BB informed Surveyor that there is an arm bike that is used frequently so this is wiped down after each use with a santiwipe and the protocol is every gym surface is wiped down one time a week. Surveyor asked Rehab Director-BB how is her department notified of an outbreak? Rehab Director-BB informed Surveyor during the stand up meeting or if there is an isolation cart outside the room then they will ask nursing. Surveyor asked Rehab Director-BB when she was notified of a GI outbreak. Rehab Director-BB informed Surveyor the first time documentation of loose stools is on the 10th (4/10/17) in morning meeting. Rehab Director-BB showed Surveyor her therapy department communication tool dated 4/10/17 which documents, Nursing wants all pts (patients) see in their room Individuals with loose stool. Residents listed are R42, R41, R46, R28, R40, R13, R47, & R48. On 4/18/17 at 8:57 a.m., Surveyor asked DON-B why she didn't identify the GI outbreak until 4/11/17. DON-B informed Surveyor that they were trying to figure out who had loose stool and what the cause of the loose stool was as a Resident was on milk of magnesia and other ate chocolate. Some CNAs were saying that the Residents had loose stools while other ones said they weren't. DON-B informed Surveyor that she started to have staff each shift document on the TAR (treatment administration record) loose stools. Surveyor inquired when this started. DON-B informed Surveyor on the 4/5/17. DON-B informed Surveyor that they were trying to get a grasp as to who had loose stools and who didn't. Surveyor asked DON-B why she did not develop a line list for the GI outbreak. DON-B informed Surveyor that she has not done a line listing because the survey team entered the Facility. Surveyor asked DON-B if any Residents had loose stools prior to 4/5/17. DON-B replied, not on wing 3 and explained that on wing 1 one Resident had loose stools on and off and on wing 2 there was one resident with one episode of loose stools. Surveyor asked when therapy and other departments were notified. DON-B informed Surveyor on 4/6/17 in the morning meeting. Surveyor informed DON-B that Surveyor had spoken with Rehab Director-BB who had informed Surveyor that they were not informed until 4/10//17. DON-B informed Surveyor that they mentioned the Residents in morning report who had loose stools. Surveyor asked if there was any directions given to the department heads on what should be done differently. DON-B informed Surveyor that they did not inform other department what needs to be done only trying to figure out about the loose stools. DON-B provided Surveyor with clinical follow up tool dated 4/5/17. Surveyor noted R41 is list on this clinical sheet with documentation of self transferred this loose stool ate choc. (chocolate) last night. R40 is also on the clinical follow up tool dated 4/5/17 but there is no mention of loose stool. Documentation is Monitor (L) (left) eye from fall. Quiafenisen DM (diabetes mellitus) PO (by mouth) 10 ml (milliliter) QID (four times daily) x (times) 3 days fell unwitnessed c/o (complained of) pain and decreased (down arrow) ROM (range of motion) L (left) shoulder stat labs 2 view xr (x-ray) UA (urinalysis) (-) (negative). R13 is listed on the 4/5/17 clinical follow up tool but there is no mention of loose stools for R13. Documentation is check (check mark) right heel - Red - still blanchable. Surveyor noted on the clinical follow up tool dated 4/6/17 lists R41 for loose stool. Documentation is clear liquid diet x (times) 24 hrs (hours) then bland diet x 24 hrs then resume normal diet if vomiting recurs, give [MEDICATION NAME] 4 mg (milligrams) x 1 & update NP (nurse practitioner), loose stools, stool for[DIAGNOSES REDACTED] (Clostridium difficile) & Norovirus. Documentation for R46 on 4/6/17's clinical follow up tool is + (positive)[DIAGNOSES REDACTED], [MEDICATION NAME] 500 mg 3x/day x 10 days. Documentation R40 on the 4/6/17 clinical follow up tool is D/c (discontinue) [MEDICATION NAME], re check stool culture D/C Reguloid capsules d/t (due to) loose stools. Surveyor asked if any staff were ill with GI symptoms. DON-B replied that there were 2 staff members. Surveyor inquired if there was a line listing for staff. DON-B replied, no. Surveyor inquired if any of the staff worked on wing 3. DON-B replied, yes. Surveyor informed DON-B the Surveyor is still confused as to why they didn't consider there was a GI outbreak until 4/11/17. DON-B indicated they looked back at the Residents who had loose stools and were trying to figure it out as the Resident's weren't testing positive for the Norovirus. Surveyor informed DON-B that even if they didn't have the Norovirus they still had a GI outbreak. DON-B replied, it's a learning experience. 3. On 4/17/17 at 2:37 p.m., Surveyor interviewed Dietary Manager-O regarding any GI (Gastrointestinal) or Influenza outbreaks at the facility. Surveyor asked Dietary Manager-O if there had been any recent Influenza outbreaks at the facility. Dietary Manager-O informed Surveyor that on 2/24/17 she got sick with Influenza and that on 2/22/17 Cook-N had also been sick with Influenza. Surveyor asked Dietary Manager-O if there were any residents whom were also sick with Influenza that had been eating in the dining room prior to 2/24/17. Dietary Manager-O informed Surveyor that R8 was sick with flu like symptoms the week of 2/19/17 and that on 2/20/17 he was put in isolation precautions and did not eat in the dining room. Dietary Manager-O informed Surveyor that R21 was also sick with flu like symptoms the week of 2/19/17 but that R21 continued to eat in the dining room from 2/19/17 to 2/23/17. Dietary Manager-O informed Surveyor that R26 was also sick with flu like symptoms the week of 2/19/17 and that she was placed on isolation precautions and did not eat in the dining room sometimes during the week of 2/19/17, but that she could not recall the exact date R26 was placed in isolation precautions. On 4/18/17 at 10:50 a.m., Surveyor interviewed Scheduler-P of the scheduling patterns when an outbreak occurs. Surveyor asked Scheduler-P if during an outbreak she maintains staff on designated units and avoids floating staff between units? Scheduler-P informed Surveyor that DON - B informs her of an outbreak and that when there is an outbreak she maintains staff on designated units and avoids floating staff between units as much as possible. Surveyor reviewed the actual staffing for the facility from 2/20/17 to 2/22/17. Surveyor noted that facility staff was floating between units during the Influenza outbreak that occurred from 2/20/17 to 2/22/17 on the following days: 2/20/17- 1 CNA (Certified Nursing Assistant) floating between Wing 1, Wing 2 and Wing 3 during 1st shift. 2/20/17- 1 CNA floating between Wing 1, Wing 2 and Wing 3 during 2nd shift. 2/22/17- 1 CNA floating between Wing 1, Wing 2 and Wing 3 during 1st shift. 2/22/17- 1 CNA floating between Wing 1, Wing 2 and Wing 3 during 3rd shift. Surveyor verified the above staffing patterns with Scheduler-P. Surveyor asked Scheduler-P if DON-B had informed her of the GI outbreak that occurred from 4/5/17 to 4/11/17 and if she had attempted to maintain staff on designated units and avoid floating staff between units? Scheduler-P informed Surveyor that she could not recall if DON-B informed her of the GI outbreak that occurred from 4/5/17 to 4/11/17 and that she (Scheduler-P) did not maintain staff on designated units to avoid floating staff between units from 4/5/17 to 4/11/17. Surveyor reviewed the actual staffing for the facility from 4/5/17 to 4/11/7. Surveyor noted that facility staff was floating between units during the GI outbreak that occurred from 4/5/17 to 4/11/7 on the following days: 4/5/17- 1 CNA floating between Wing 1 and Wing 2 during 1st shift. 4/5/17- 1 CNA floating between Wing 2 and Wing 3 during 2nd shift. 4/6/17- 1 CNA floating between Wing 1, Wing 2 and Wing 3 during 1st shift. 4/7/17- 1 CNA floating between Wing 1, Wing 2 and Wing 3 during 2nd shift. 4/8/17- 1 CNA floating between Wing 1 and Wing 2 during 1st shift. 4/8/17- 1 CNA floating between Wing 1, Wing 2 and Wing 3 during 2nd shift. Surveyor verified the above staffing patterns with Scheduler-P. On 4/18/17 at 1:14 p.m., Surveyor informed DON-B of the above findings. Surveyor asked DON-B if she had informed Scheduler-P of the GI outbreak that occurred from 4/5/17 to 4/11/17 so that Scheduler-P would maintain staff on designated units and avoid floating staff between units. DON-B informed Surveyor that she did not specifically notify Scheduler-P of the GI outbreak from 4/5/17 to 4/11/17 and that she was under the impression that staff would normally stay on specific units and not float between units. No further information was provided. 4. On 4/17/17 at 1:24 p.m., the surveyor interviewed Life Enrichment Director-II. The surveyor asked Life Enrichment Director-II if the facility was currently doing anything different for activities regarding the 300 unit. Life Enrichment Director-II stated, no, we do not exclude them from activities. The surveyor asked Life Enrichment Director-II if she had been instructed recently to do anything different for activities related to the outbreak. Life Enrichment Director-II stated, no. Life Enrichment Director-II stated that if a resident is on isolation she checks with the nurse to see if they could still come to the activity say for example with a mask on. As a result of this deficient practice immediate jeopardy was identified. The Immediate Jeopardy was removed on 4/18/17 when the facility: * Conducted a record review and assessment of residents to ensure any active infections have been identified and treated appropriately. Review to include progress notes in PCC (point click care), MAR (medication administration record), TAR (treatment administration record), POC (plan of care). * Licensed nurses and CNAs (Certified Nursing Assistant) were re-educated on polices and procedures related to GI (gastrointestinal) and respiratory outbreaks specific to what s/sx (signs/symptoms) to identify, proper documentation, what constitutes an outbreak, expectation of who to contact and commingling of residents. * Department heads, therapy, housekeeping and dietary were re-educated on polices and procedures related to GI and respiratory illness. Review of signage on door to see nurse for instructions if unsure why resident on isolation. * DCS to re-educate Director of Nursing and Executive Director on polices, procedures, and guidance related to respiratory and GI outbreaks. Review to include line lists for residents and staff, mapping, posting to public, calling of MD offices and hospitals, contacting the health dept. (department) and medical director for guidance, staff deployment, daily follow up and updates until outbreak is cleared. * Daily monitoring to be completed by review of PCC 24-hour communication to identify potential s/sx of respiratory or GI illness x (times) 2 weeks then 5 x week. Results of monitoring to be presented to QAPI (Quality Assurance Performance Improvement) Committee for further review and recommendation as deemed appropriate. * Staff call ins to be reviewed for GI/Respiratory s/sx to ensure staff do not work with active infections, do not return to work until incubation period has passed, and are recorded as potential for an outbreak. * Daily stand up meeting with department heads to include discussion of residents on isolation, type of isolation, and compromised rooms. * QAPI with center department heads and Medical Director to review and accept above plan of correction as it relates to issued citation. Continued noncompliance at severity level 2 (potential for more than minimal harm) is evidenced by the following: Hand Hygiene: The Hand Hygiene - Plain Soap and Water policy and procedure revised January 2017 under policy documents; Hand hygiene is the most important procedure for preventing Healthcare Associated infections (Refer to CDC (Center for Disease Control), 2002 Hand Hygiene Guideline). Natural nail tips should be kept to 1/4 inch in length. Artificial nails should not be worn when having direct contact with high risk residents. Plain soap is an effective agent. The center requires personnel to use hand hygiene to remove dirt, organic material and transient microorganisms. A plain soap and water will be used: · If hands are visibly soiled · Before eating and after using a restroom · If exposure to spores is suspected or proven e.g., [DIAGNOSES REDACTED] (clostridium difficile) and Norovirus A plain soap and water or an alcohol hand rub may also be used: · If hands are not visibly soiled · Before having direct contact with residents · Before inserting indwelling catheters, peripheral vascular catheters, other invasive devices that do not require a surgical procedure · After contact with a resident's intact skin (e.g., when taking a pulse or blood pressure and lifting a resident) · After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings if the hands are not visibly soiled · During resident care if moving from a contaminated body site to a clean body site · After removing gloves. On 4/18/17 at 9:10 a.m., Surveyor asked DON-B when she would expect staff to wash or cleanse their hands. DON-B replied, before and after taking gloves off. Surveyor asked if staff should wash or cleanse their hands after incontinence cares. DON-B replied, yes because dirty. Surveyor asked if staff are going from a task that's dirty to a clean task what should they do? DON-B informed Surveyor that staff should remove their gloves and wash their hands. Surveyor informed DON-B of the observations with hand hygiene concerns. 5. Surveyor reviewed R4's medical record on 4/11/17 to 4/17/17. The quarterly MDS (minimum data set) with an assessment reference date of 2/22/17 and signed as complete on 2/28/17 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R4 requires extensive assistance with transfers, does not ambulate, is continent of bowel and occasionally incontinent of bladder. R4 is coded as having one Stage 3 pressure injury. On 4/12/17 at 7:22 a.m., Surveyor observed R4 sitting on the edge of the bed wearing a shirt and sweat pants up to R4's knees. CNA (Certified Nursing Assistant)-Y gathered garbage, removed her gloves, and placed gloves on. CNA-Y did not wash or cleanse her hands. At 7:24 a.m. CNA-K and CNA-Z entered, washed their hands and placed gloves on. CNA-Y and CNA-K hooked the sling to the sit to stand lift, CNA-K asked R4 if he had to got to the bathroom, raised R4 off the bed, and wheeled R4 into the bathroom. CNA-Y and CNA-Z removed R4's incontinence product which was contained urine and lowered R4 onto the toilet. CNA-Y and CNA-Z left the bathroom, CNA-Z removed her gloves and washed her hands. CNA-Y did not remove her gloves. At 7:30 a.m. R4 was raised off the toilet and CNA-Y washed R4's frontal perineal area & buttocks and applied protective ointment on R4's buttocks. CNA-Y did not remove her gloves. CNA-Y and CNA-K placed an incontinence product on R4 and pulled up his sweat pants. CNA-K wheeled R4 out of the bathroom, CNA-Y removed her gloves but did not wash or cleanse her hands. CNA-Y placed the wheelchair behind R4 and held onto R4's back as R4 was lowered into the wheelchair. CNA-Y placed gloves on, unhooked the sling from the lift, pulled down his shirt and collected the garbage. R4 stated he needed a comb. CNA-Y removed her gloves, opened the 2nd drawer and handed R4 a brush. CNA-Y then washed her hands. On 4/13/17 at 2:58 p.m., Surveyor observed treatment for [REDACTED]. Surveyor observed the treatment supplies are on an over bed table. RN-AA placed a towel on the floor and removed R4's left shoe & sock. RN-AA stated let me look at it, placed gloves on, and stated to R4, remind me how you got this wound. R4 replied, I don't remember they say from going naked in my shoes, didn't have any socks that fit. RN-AA placed Dakins on a four by four gauze, dabbed the Dakins in the press

Based on observation, record review and interview, the Facility did not ensure that 5 (R4, R12, R13, R5, & R9) of 13 Residents at risk for development of pressure injury received consistent measures to prevent the development of pressure injuries. * R4 developed a pressure injury on his left lateral foot on 12/15/16. There is no assessment or measurements of this area until 12/19/16 when the wound bed is 50% pale pink non granulating and 50% slough. R4's left lateral pressure injury continues to present as a Stage 3 with 75% pale pink nongranulating tissue and 25% slough. The example involving R4 is being cited at a scope & severity of G (actual harm/isolated). * R12 who is at risk for pressure injuries was observed without his heels being offloaded and a Braden assessment completed on 2/27/17 was inaccurate. * R13 who is at risk for pressure injuries was observed without her heels being offloaded. * R5 who is at risk for pressure injuries was observed without her heels being offloaded and a Braden assessment was inaccurate. * R9 who is at risk for pressure injuries was observed without his heels being offloaded. Findings include: The Pressure Ulcer Prevention/Treatment policy and procedure with an effective date of July 2015 documents under policy The center requires the use of the Braden Risk Assessment and Skin Integrity Assessment: Prevention and Treatment Care Plan. All residents will be assessed on admission and weekly for four weeks, quarterly, and with a significant change of condition using the Braden Risk Assessment, and Skin Integrity Assessment: Prevention and Treatment Care plan. The center recognizes it is difficult to describe a set of protocols that would fit every circumstance. However, Braden recommends the following: Manage moisture, Manage nutrition, Manage friction and shear, Manage other general care issues, Select appropriate interventions based on the following: * Braden Risk Assessment score * Skin Integrity Assessment: Prevention and Treatment Care Plan. Surveyor noted At Risk (15-18), Moderate Risk (13-14), High Risk (10-12) and Very High Risk (9 or below) all include the intervention of Reduce pressure to heels. 1.) Surveyor reviewed R4's medical record on 4/11/17 to 4/17/17. R4 has [DIAGNOSES REDACTED]. The care plan for has a venous/stasis ulcer to the left foot r/t (related to) [MEDICAL CONDITIONS] initiated on 1/20/16 and revised on 2/17/17 has interventions of Avoid dry skin initiated 1/29/16 & revised 2/17/17, Complete Braden Scale weekly times 4 wks (weeks) on admission, quarterly, and with change of condition initiated 1/29/16 & revised 2/17/17, Do not massage over bony prominence initiated 1/29/16 & revised 2/17/17, Evaluate wound for: size, depth, margins; peri-wound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify Physician as indicated. initiated 1/29/16 & revised 2/17/17, Maintain good hydration. initiated 1/29/16 & revised 2/17/17. Resolved interventions includeDo not use Do-Nut type devices initiated 1/29/16 & resolved 6/30/16, Document/measure wound weekly and PRN (as needed) initiated 1/29/16 & resolved 6/30/16, Elevate legs when sitting, initiated 1/29/16 & resolved 6/30/16, Minimize skin exposure to moisture due to incontinence, wound drainage or perspiration initiated 1/29/16 & resolved on 6/30/16, Needs pressure relieving cushion while in chair. initiated 1/20/16 & resolved 6/30/16, Reposition every 2 hours while in bed/chair. initiated 1/29/16 & resolved 6/30/16, See ADL (activities daily living)/Mobility Plan of Care initiated 1/29/16 & resolved 6/30/16 and Treat wound as per facility protocol. initiated 1/29/16 & resolved 6/30/16. The care plan for has a pressure ulcer to the left lateral foot complicated by [MEDICAL CONDITION], DM (diabetes mellitus), and [MEDICAL CONDITIONS] dx (diagnosis) initiated on 1/20/16 and revised on 4/17/17 has interventions of Avoid dry skin initiated 1/29/16 & revised 2/17/17, Complete Braden Scale weekly times 4 wks (weeks) on admission, quarterly, and with change of condition initiated 1/29/16 & revised 2/17/16, Do not massage over bony prominence initiated 1/29/16 & revised 2/17/17, Document/measure wound weekly and PRN (as needed) initiated 1/29/16 & revised on 4/17/17, Evaluate wound for: size, depth, margins; peri-wound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify Physician as indicated. initiated 1/29/16 & revised 2/17/17, Maintain good hydration. initiated 1/29/16 & revised 2/17/17, and Treat wound as per facility protocol. initiated 1/29/16 & revised 4/17/17. The potential for pressure ulcer care plan initiated 1/29/16 has interventions dated 1/29/16 of Avoid dry skin, Complete Braden Scale weekly times 4 wks (weeks) on admission, quarterly, and with change of condition., Do not massage over bony prominence., Educate resident/family/caregivers as to cause of skin breakdown: Including: transfer/positioning requirements; importance of taking care during ambulating/mobility; good nutrition; and frequent repositioning., Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Document alternative methods., Keep heels off of bed with frequent repositioning or floating heels., Maintain good hydration., Needs pressure relieving cushion while in chair., Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care., Provide assistance to turn/reposition at least every 2 hours, and as needed or requested., and Refer to ADL/Mobility Care Plan. Additional interventions dated 1/26/17 are Administer medication as ordered. Monitor/document for side effects and effectiveness., Administer treatments as ordered and monitor for effectiveness., Resident was referred to wound clinic at the VA (Veterans Administration) Was seen 1/23/17., Treat wound as per facility protocol., and Monitor/document/report to MD (medical doctor) PRN (as needed) change in skin status: appearance, color, wound healing, signs or symptoms of infection, wound size (length x width x depth), stage. This care plan was canceled on 4/11/17. The annual MDS (minimum data set) with an assessment reference date of 11/22/16 and signed as complete on 11/28/16 has a BIMS (brief interview mental status) score of 15 which indicates R4 is cognitively intact. R4 requires extensive assistance with two plus person physical assist for transfer & dressing, limited assistance with two plus person physical assist for bed mobility, is occasionally incontinent of bowel and frequently incontinent of bladder. R4 is at risk for pressure injuries and is coded as not having any pressure injuries. The pressure ulcer CAA (care area assessment) dated 11/28/16 documents under care plan considerations resident is noted to be at risk for skin breakdown r/t (related to) mobility deficits, he is alert and makes needs known, no [MEDICAL CONDITION] meds used, pain is managed, he is assisted with cares/mobility as needed and is on restorative programs, he is assisted with incontinent cares prn (as needed), typical intake is 51-75%, fluids encouraged, Braden score = (equals) 21 on 11/17/16, he is on a pressure relieving mattress and chair cushion, tx (treatment) to skin tear as ordered, no pressure areas, will follow pocs (plan of care) to promote skin integrity. The SBAR (situation, background, assessment, request) form under the situation section for The change in condition, symptoms or signs I am calling about is/are: documents skin wound or ulcer. For statement This started on: documents 12/15/16. Under section background is checked for wound and description left lateral foot. Under request other new orders (specify) is checked and for Specify other: documents Apply allevyn to ulcer of left lateral foot. Surveyor noted the nursing note section is blank and there is no assessment or measurement of R4's left lateral foot ulcer in R4's medical record. Surveyor also noted there is no indication R4's care plan was reviewed or revised with the skin wound or ulcer finding. The physician's orders [REDACTED]. Change every 3 days until healed. Physician-T. During R4's medical record review which included nurses notes, December 2016 MAR (medication administration record) and TAR (treatment administration record) January 2017 MAR & TAR, February 2017 MAR & TAR, March 2017 MAR & TAR, & April 2017 MAR & TAR Surveyor was unable to locate where the facility staff is conducting diabetic foot checks for R4. The wound assessment details report dated 12/19/16 for the left lateral foot documents under clinical stage Partial Thickness. Under tissue types documents Pale Pink Non-granulating = (equals) 50%, Slough Loosely Adherent =50%. Size documents 2.5 x 2.00 x 0.20 (L (length) x W (width) x D (depth). Under current Plan & Comments documents This wound assessment was not electronically annotated in the WoundRounds system. The quarterly MDS with an assessment reference date of 2/22/17 and signed as complete on 2/28/17 documents a BIMS (brief interview mental status) score of 13 which indicates R4 continues to be cognitively intact with some changes since the annual MDS. R4 requires extensive assistance with two plus person physical assist for transfers, extensive assistance with one person physical assist for dressing, does not ambulate, is continent of bowel and occasionally incontinent of bladder. R4 is at risk of developing pressure injuries and is coded as having one, Stage 3 pressure injury. On 4/13/17 at 2:58 p.m. Surveyor observed treatment for [REDACTED]. Surveyor observed the treatment supplies on an over bed table. RN-AA placed a towel on the floor and removed R4's left shoe & sock. RN-AA stated let me look at it, placed gloves on, and stated to R4 remind me how you got this wound. R4 replied I don't remember they say from going naked in my shoes, didn't have any socks that fit. On 4/18/17 at 12:07 p.m. Surveyor spoke with RN (Registered Nurse) Corporate Consultant-J to inquire why there wasn't any assessment or measurements of R4's left lateral pressure injury when it was discovered on 12/15/16 until 12/19/16 when it presented as a Stage 3. Surveyor also inquired why there are care plans for stasis/venous ulcer as well as pressure injury care plan for the left foot. RN Corporate Consultant-J informed Surveyor that she had seen this also and verified with Surveyor that this area is a pressure injury. Surveyor inquired what interventions were implemented prior to R4 developing this area as Surveyor did not note diabetic foot checks being completed. RN Corporate Consultant-J informed Surveyor that on 12/15/16 Allevyn dressing was started and changed on 12/17/16. On 4/18/17 at 12:42 p.m. DON (Director of Nursing)-B informed Surveyor that they called the unit manager for R4 who is no longer employed at the Facility. Surveyor was informed that per the unit manager, this area started as a blister that opened up. They started a treatment of [REDACTED]. DON-B informed Surveyor that R4 did have protective shoes, wouldn't wear socks but the unit manager convinced R4 to wear socks. Surveyor asked DON-B for documentation regarding the blister. DON-B informed Surveyor that he didn't document the blister and that he didn't put R4 in for wound rounds until the cap came off. 2.) Surveyor reviewed R12's medical record on 4/13/17 to 4/18/17. R12 has a [DIAGNOSES REDACTED]. The Braden assessment dated [DATE] has a score of 15 which indicates low risk. Surveyor noted that this Braden assessment was not accurate as #4 Mobility the ability to change and control body position is coded for very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. #6 Friction & Shear is coded as no apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up. #6 is not assessed correctly as R12 is unable to move in the bed and chair independently and is unable to lift up. The quarterly MDS (minimum data set) with an assessment reference date of 2/28/17 and signed as complete on 3/6/17 documents R12 has short and long term memory problems and is severely impaired for cognitive skills for daily decision making. R12 requires extensive assistance with two plus person physical assist for transfers & bed mobility, does not ambulate, and is always incontinent of bowel & bladder. R12 is at risk of developing pressure injuries and is coded as not having any pressure injuries. On 4/13/17 at 2:00 p.m. Surveyor observed R12 in bed on his left side. Surveyor observed that R12 is wearing socks on his feet and his heels are resting directly on the mattress and are not being offloaded. On 4/13/17 at 3:06 p.m. Surveyor observed R12 continues to be in bed on his left side, his heels continue to be resting on the mattress and are not being offloaded. On 4/13/17 at 7:13 p.m. Surveyor observed R12 asleep in bed on his left side. R12's heels are resting directly on the mattress and are not being offloaded. On 4/13/17 at 7:45 p.m. Surveyor observed R12 continues to be asleep in bed on his left side. R12's heels are resting directly on the mattress and are not being offloaded. On 4/13/17 at 8:42 p.m. Surveyor observed R12 continues to be asleep in bed on his left side. R12's heels are resting directly on the mattress and are not being offloaded. On 4/17/17 at 7:22 a.m. Surveyor observed R12 asleep in bed on his left side. R12 has a pillow between between his knees but his heels are directly on the mattress and are not being offloaded. On 4/17/17 at 8:08 a.m. Surveyor observed R12 in bed on his left side. R12 has bare feet and his heels are resting directly on the mattress. On 4/17/17 at 9:13 a.m. Surveyor observed R12 in bed on his left side. R12 has bare feet and his heels are resting directly on the mattress. On 4/17/17 at 2:32 p.m. Surveyor met with DON (Director of Nursing)-B to discuss R12. Surveyor informed DON-B that the Surveyor doesn't understand the Braden completed 2/26/17 for question number six how this question was assessed that R12 moves in bed and chair independently and has sufficient muscle strength to lift up. Surveyor informed DON-B that R12 is transferred with a hoyer lift, is dependent upon staff, and from Surveyor's observations wouldn't have the muscle strength to lift up. DON-B informed Surveyor that she completely agrees. Surveyor asked DON-B if R12's heels should be offloaded. DON-B replied yes. Surveyor informed DON-B of the observations of R12's heels not being offloaded. On 4/17/17 at 3:15 p.m. during the daily exit conference Administrator-A, DON-B and RN (Registered Nurse) Corporate Consultant-J were informed of the above. 3.) R9 has [DIAGNOSES REDACTED]. R9's most recent minimum data set assessment with an assessment reference date of 3/17/17 documents R9 requires extensive assistance of 2 plus staff for bed mobility, and that R9 is at risk for the development of pressure injuries. The assessment documents rejection of care behavior was not exhibited. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance's Prevention and treatment of [REDACTED].), Cambridge Media: Perth Australia; 2014 the section REPOSITIONING TO PREVENT AND TREAT HEEL PRESSURE ULCERS states The reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. It continues to state under the section Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that the heels are free of the surface of the bed R9's treatment administration record for March and April 2017 document to Float heels while in bed. On 4/11/17 at 3:49 p.m. the Surveyor observed R9 in bed with his left heel on a pillow and his right heel on the mattress. Neither heel was offloaded of pressure. The Surveyor asked R9 if he minded floating his heels or was offered to float his heels. R9 stated that he did not mind, and had not been asked by staff if he wanted his heels floated. On 4/11/17 at 4:09 p.m. the Surveyor observed CNA (certified nursing assistant)-CC and CNA-DD enter R9's room to assist to transfer him into his wheelchair. The Surveyor observed R9's left heel remained on the pillow, and his right heel remained on the mattress. Neither heel was offloaded of pressure. On 4/13/17 at 2:00 p.m. the Surveyor observed R9 in bed on his back with his heels on the mattress and not offloaded of pressure. On 4/17/17 at 3:40 p.m. the Surveyor interviewed ADON (assistant director of nursing)-D. ADON-D confirmed that R9's heels should be floated when in bed. On 4/19/17 at 1:26 p.m. Nursing Home Administrator-A and Director of Nursing-B were informed of the observations of R9 in bed with his heels not offloaded of pressure. 4.) Surveyor reviewed R5's medical record from 4/11/17 to 4/19/17. R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5's admission MDS (minimum data set) dated 3/9/17 documents that R5 has short and long term memory problems and has severely impaired cognitive kills for daily decision making. Section G (Functional Status) documents that R5 requires extensive assist and two person physical assist for her transfer and bed mobility needs. Section G0400 documents that R5 has impairment to both sides of her upper and lower extremities. Section M (Skin Condition) documents that R5 is at risk for the development of pressure injuries. R5's Pressure Ulcers CAA (Care Area Assessment) dated 3/14/17 documents, Resident is noted to be at risk for skin breakdown r/t (related to) mobility and cognitive deficits, she (is) non-verbal, needs anticipated and met ongoing, she is followed by therapies, see notes, no pain indicators, meds (medications) assessed, NPO (nothing by mouth) on tube feedings, receives a multivitamin, provided incontinent cares, she is on a pressure relieving mattress and chair cushion, has ongoing treatment to a pressure area, will follow poc (plan of care) to promote skin integrity. R5's Pressure Ulcers care plan with an initiated date of 3/22/17 documents under the Interventions section, Needs pillows, heel boots to protect the skin while in bed. Keep heels off bed using posey heel protectors. R5's Braden Scale for Predicting Pressure Sore Risk dated 3/23/17 documents a score of 17 indicating that R5 is at low risk for developing pressure ulcers. Surveyor noted that R5's Braden Scale assessment was inaccurate as R5's Braden Scale for Predicting Pressure Sore Risk dated 4/13/17 documents a score of 11 indicating that R5 is at high risk for developing pressure ulcers. Surveyor noted that R5's Braden Scale assessments all differed and had varying scores indicating that R5 was either at low, medium or high risk for developing pressure ulcers. On 4/11/17 at 9:00 a.m., during the initial tour, Surveyor observed R5 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R5 did not have her heels floated while in bed to provide pressure relief to her heels per R5's plan of care. On 4/11/17 at 12:19 p.m., Surveyor observed R5 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R5 did not have her heels floated while in bed to provide pressure relief to her heels per R5's plan of care. On 4/11/17 at 2:16 p.m., Surveyor observed R5 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R5 did not have her heels floated while in bed to provide pressure relief to her heels per R5's plan of care. On 4/11/17 at 3:25 p.m., Surveyor observed R5 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R5 did not have her heels floated while in bed to provide pressure relief to her heels per R5's plan of care. On 4/12/17 at 9:16 a.m., Surveyor observed R5 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R5 did not have her heels floated while in bed to provide pressure relief to her heels per R5's plan of care. On 4/12/17 at 1:00 p.m., Surveyor observed R5 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R5 did not have her heels floated while in bed to provide pressure relief to her heels per R5's plan of care. On 4/12/17 at 3:25 p.m., Surveyor observed R5 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R5 did not have her heels floated while in bed to provide pressure relief to her heels per R5's plan of care. On 4/13/17 at 8:22 a.m., Surveyor observed R5 laying supine in bed wearing heels boots. On 4/13/17 at 1:50 p.m., Surveyor informed ADON (Assistant Director of Nursing)-D and DON (Director of Nursing)-B of the above findings. Surveyor asked ADON-D and DON-B why R5's Braden Scale assessments varied in score and asked which Braden Scale assessment was accurate. ADON-D informed Surveyor that R5's Braden Scale assessments were inaccurate and that she would provide nursing staff more education so that Braden Scale assessments were accurate and consistent. ADON-D informed Surveyor that she would perform a new Braden Scale assessment on R5. Surveyor asked ADON-D and DON-B why R5 did not have her heels floated with boots prior to 4/13/17 per R5's pressure ulcers plan of care. ADON-D informed Surveyor that at times R5 kicks the pillows beneath her legs causing her heels not to be floated. ADON-D informed Surveyor that on 4/12/17, R5's pressure ulcer plan of care was updated and that boots were added to R5's plan of care to keep her heels floated while in bed. Surveyor asked ADON-D if R5 should have her heels floated per R5's pressure ulcers plan of care. ADON-D informed Surveyor that R5 should have her heels floated per R5's pressure ulcers plan of care. On 4/13/17 at 3:02 p.m., during the daily exit conference, Surveyor informed Administrator-A and DON-B of the above findings. On 4/17/17 at 9:33 a.m., ADON-D provided Surveyor a copy of R5's Braden Scale assessment documenting a score of 12 indicating that R5 is at high risk for developing pressure ulcers. No further information was provided as to why the facility did not ensure that R5 received consistent measures to treat and prevent the further development of pressure injuries. 5.) Surveyor reviewed R13's medical record from 4/13/17 to 4/19/17. R13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R13's admission MDS (minimum data set) dated 3/31/17 documents a BIMS (brief interview for mental status) of 4, indicating that R13 is severely cognitively impaired. Section G (Functional Status) documents that R13 requires extensive assist and two person physical assist for her transfer and bed mobility needs. Section G0400 documents that R13 has impairment to both her lower extremities. Section M (Skin Condition) documents that R13 is at risk for the development of pressure injuries. R13's Pressure Ulcers CAA (Care Area Assessment) dated 4/4/17 documents, Resident is noted to be at risk for skin breakdown r/t (related to) mobility deficits, she is alert and makes basic needs known, meds (medications) assessed, denied pain, she is assisted with cares/mobility as needed .no skin breakdown, surgical site (to) right hip healing she is on a pressure relieving mattress and chair cushion, Braden score =18 on 3/31/17, will follow poc (plan of care) to promote skin integrity. Surveyor was unable to locate a skin integrity or pressure ulcer prevention plan of care for R13 in R13's medical record. R13's Braden Scale for Predicting Pressure Sore Risk dated 4/13/17 documents a score of 17 indicating that R13 is at low risk for developing pressure ulcers R13's CNA (Certified Nursing Assistant) Care Delivery Guide dated as updated on 4/11/17 documents under the Safety Device section, Float right heel while in bed. R13's nursing noted dated 4/5/17 documents, Pt's (patient's) right heel was red not last noc (night) but the night before. Pt's heel is always up on pillows when writer is here. Writer updated 24 hours book and waited till today to recheck heel. Right heel seems redder and larger. Area marked with a pen and measure, blancheable, DON (director of nursing) updated. BLE (bilateral lower extremities) kept up on pillow. On 4/17/17 at 7:34 a.m., Surveyor observed R13 sleeping supine in bed with both heels resting directly on the mattress. Surveyor noted that R13 did not have her right heel floated while in bed to provide pressure relief to her heels per R13's plan of care. On 4/17/17 at 8:14 a.m., Surveyor observed R13 sleeping supine in bed with both heels resting directly on the mattress. Surveyor noted that R13 did not have her right heel floated while in bed to provide pressure relief to her heels per R13's plan of care. On 4/18/17 at 9:00 a.m., Surveyor informed ADON (Assistant Director of Nursing)-D of the above findings. Surveyor asked ADON-D if R13 had a skin integrity/pressure ulcers care plan as Surveyor was unable to locate one in R13's medical record. ADON-D informed Surveyor that R13 does not have a skin integrity/pressure ulcers care plan and that she is in the process of developing one for R13 but has not completed it yet. Surveyor asked ADON-D if R13 should have her right heels floated while in bed to provide pressure relief to her heels per R13's plan of care. ADON-D informed Surveyor that R13 should have her right heels floated while in bed to provide pressure relief to her heels per R13's plan of care. On 4/19/17 at 1:02 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not ensure that R13 received consistent measures to treat and prevent the further development of pressure injuries.