Every finding on record at Lasata Care Center

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 73 residents residing in the facility.Staff did not wear masks during an influenza outbreak on unit 1 East (1E).Findings Include:The facility's Nursing Respiratory Disease Outbreak Plan and Pandemic Outbreak, updated 11/2024, indicates: .It is the policy of this facility that outbreak measures will be instituted whenever there is an incident of infections above the standard set by the Division of Public Health as it relates to respiratory disease outbreaks. A respiratory disease outbreak in a Long Term Care Facility (LTCF) is defined as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other who have: .Acute respiratory illness .Laboratory confirmed viral or bacterial infections (including influenza) .Procedure: .2. Management of Residents .d) All staff must wear masks at all times while on the isolated/outbreak unit .On 1/5/26, the Survey team was informed by Director of Nursing (DON)-B of an influenza outbreak on unit 1E. When the survey team asked if staff were required to wear masks during an outbreak, DON-B indicated masks were optional for staff for their own protection if they were not providing care in an affected resident's room.On 1/5/26 at 10:48 AM, Surveyor observed staff on unit 1E without face masks. Surveyor observed personal protective equipment (PPE) carts and signs on several residents' doors.On 1/5/26 at 12:53 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D. When Surveyor indicated most staff were not wearing masks earlier that day and asked if staff were asked to wear masks, LPN-D indicated LPN-D did not feel the best and had been wearing a mask. LPN-D indicated LPN-D was informed that day that unit 1E was in an outbreak.On 1/5/26 at 12:58 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-E and asked if staff were asked to wear masks. CNA-E indicated prior to 1/5/26, staff wore masks on first floor 1 [NAME] (1W) only. CNA-E indicated CNA-E just learned 1E was in an outbreak.On 1/6/26 at 3:29 PM, Surveyor interviewed DON-B regarding Surveyors' observations of staff not wearing face masks on unit 1E. DON-B was unsure when the third resident was diagnosed with respiratory illness and did not know when staff were required to wear masks on the unit. DON-B indicated staff were required to wear face masks at all times on the unit as of 1/5/26 after the Survey team had entered the facility. DON-B indicated DON-B would revisit the topic on 1/7/26 because Infection Preventionist (IP)-C had left for the day.On 1/7/26 at 8:19 AM, Surveyor interviewed IP-C who stated a third resident on unit 1E was confirmed to have influenza on 1/1/26 which indicated unit 1E was in a respiratory outbreak. IP-C indicated staff on unit 1E were informed of the outbreak on 1/1/26 and should have been wearing masks at all times. When Surveyor informed IP-C that Surveyors observed staff on unit 1E without masks on the morning of 1/5/26, IP-C indicated staff should have been wearing masks at all times.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 1 resident (R) (R7) of 22 sampled residents.On 1/5/26, medications were observed on top of a refrigerator near the entrance to R7's room. The medications included Aquaphor, medicated menthol powder, and two tubes of DermaPhor hydrophil petrolatum topical ointment. One tube of the DermaPhor contained a pharmacy label for R7. One tube contained a pharmacy label for someone else. None of the medications had an active physician order and one had been discontinued. In addition, R7 did not have a self-administration of medication assessment or orders to self-administer medication and store medication at the bedside.Findings include:The facility's Self-Administration of Medication policy, dated 2/2025, indicates: .5. Nursing should ensure orders for self-administration list the specific medication(s) the resident may self-administer. Note: It will be documented in the Medication Administration Record (MAR)-may self-administer or okay to leave at bedside .9. Facility staff should document the self-administration of medications on the resident's MAR according to the medication administration schedule. 10. Nursing should document the self-administration of medications in the resident's care plan .The facility's Medication Labeling and Storage policy, dated 2/2025, indicates: .1. All medications from pharmacy must be labeled. The label should include the following: a. resident's name; b. medication name; c. prescribed dose; d. strength; e. expiration date when applicable; f. route of admission; g. if applicable: instructions and precautions (i.e., shake well, take with meals, do not crush, special storage instructions) .On 1/5/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including edema, anxiety, skin infection, stage 4 pressure ulcer, paralytic syndrome following cerebral infarction, and severe protein calorie malnutrition. R7's Minimum Data Set (MDS) assessment, dated 10/27/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 had intact cognition. R7 was R7's own decision maker.On 1/5/26 at 12:32 PM, Surveyor interviewed R7 and observed medication in R7's room, including a container of Aquaphor with a pharmacy label for R7, an unlabeled container of medicated menthol body powder, and two containers of DermaPhor ointment. One container of DermaPhor contained a pharmacy label for R7 and one contained a pharmacy label for someone else. The medications were visible at the entrance of the room and from R7's bedside. R7 indicated the medications were R7's, had been there for a long time, and staff put them on R7. R7 was not aware someone else's DermaPhor was in R7's room. R7 asked Surveyor to have the DermaPhor removed right away.R7's plan of care did not indicate R7 was assessed to self-administer medication or store medication at the bedside. In addition, R7's plan of care indicated Aquaphor was discontinued on 12/29/25.Surveyor reviewed R7's medication orders and noted R7 did not have an order for DermaPhor or medicated menthol powder. Surveyor also noted there was a discontinued order for Aquaphor (dated 12/29/25). Surveyor requested the orders for the medications in R7's room ad R7's two most recent self-administration of medication assessments.On 1/5/26 at 1:03 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who entered R7's room with Surveyor. LPN-D indicated R7 should not have medication at the bedside because R7 was not approved to self-administer medication. LPN-D also verified another person's medication should not be in R7's room. LPN-D indicated residents can keep medication in their room if they are assessed for bedside medication storage. LPN-D indicated the medications in R7's room should not be there and should be removed.On 1/6/26 at 3:13 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should follow the facility's self-administration of medication policy. DON-B indicated the facility had identified self-administration of medication assessments as an area in need of improvement and all residents were assessed at that time. DON-B indicated if residents are not interested in self-administering medication, staff do not complete any more questions on the assessment. DON-B verified medications stored in a resident's room should be included in self-administration of medication and bedside storage assessments. DON-B confirmed medications applied by staff should have active orders. DON-B indicated medications that don't belong to a resident should not be in a resident's room. DON-B verified the medications in R7's room were visible to staff who entered and exited the room and should have been addressed.On 1/7/26 at 8:13 AM, DON-B provided R7's medication orders which did not include medicated menthol powder and DermaPhor ointment. The orders also indicated Aquaphor was discontinued on 12/29/25. Surveyor noted a new order for medicated body powder (menthol 0.80%) topical dose: (1 application) three times a day as needed. For moisture-associated skin damage (MASD), apply to affected skin folds (first date: 1/6/26). DON-B confirmed the facility contacted R7's physician for the order after Surveyor's inquiry on 1/6/26. DON-B provided R7's two most recent self-administration of medication assessments, dated 12/25/25 and 10/17/25. The assessments indicated R7 did not want to self-administer medication. In addition, DON-B confirmed R7 did not have an order to store medication at the bedside.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to law enforcement for 2 residents (R) (R12 and R23) of 22 sampled residents. On 10/7/25, R23 called R12 ugly and slapped R12 on the arm. Law enforcement was not notified of the alleged abuse. Findings include: The facility's Abuse/Mistreatment Policy, revised 9/2024, indicates: .Physical abuse includes but is not limited to hitting, slapping, punching, biting, and kicking .Reporting/Response: The facility shall report all violation and substantiated incidents to the proper state agency, registry/licensing authorities, and local law enforcement as required .In addition to federal and state reporting requirements, the facility must report any reasonable suspicion of a crime against any individual who is a resident or is receiving care from the facility to local law enforcement . From 1/5/26 to 1/7/26, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] and had diagnoses including dementia with mood disturbance and depression. R23's Minimum Data Set (MDS) assessment, dated 11/11/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R23 had severe cognitive impairment. R23 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. From 1/5/26 to 1/7/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including traumatic brain injury, Alzheimer's disease, cerebral vascular accident, and major depression. R12's MDS assessment, dated 10/7/25, had a BIMS score of 3 out of 15 which indicated R12 had severe cognitive impairment. R12 had an activated POAHC for medical decisions. On 1/6/26, Surveyor reviewed a facility-reported incident (FRI) that indicated on 10/7/25 at approximately 1:45 PM, staff witnessed R23 (who was unprovoked) say you're ugly and slap R12 on the right upper arm. Video footage revealed staff immediately separated the residents. Close supervision to prevent further aggression toward others was implemented for R23 when out of R23's room. R23 had behaviors including combativeness with cares, yelling, screaming, crying, cursing, spitting, and throwing things; however, the behaviors were always directed at staff and primarily during cares. Since the end of August (2025), R23's Primary Medical Doctor (PMD), Nurse Practitioner (NP) and an outside agency had made frequent medication adjustments. Medical workups were conducted to rule out infection. Treatment for hemorrhoids and a medication for peri area irritation was initiated for R23. The day prior to the incident, an Advanced Practice Nurse Prescriber (APNP) from an outside agency recommended the facility decrease R23's Lexapro and start Depakote or Neudexta. R23's PMD responded on 10/7/25 with an order for Depakote. R23's care plan had interventions to work in a 2-person buddy system during all direct care and provide close supervision for R23 when out of R23's room. Law enforcement was not notified of R23's abuse toward R12. On 1/6/26 at 12:58 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated R23 displayed aggressive behavior toward staff and R12. CNA-F witnessed R23 slap R12 and push R12's wheelchair in the hallway. On 1/6/26, Surveyor reviewed a FRI submitted to the SA on 12/29/25 that indicated R23 wheeled up to R12 in the hallway on 12/21/25 and grabbed R12 by the shirt because R23 thought R12 was flirting. Staff separated the residents. The FRI indicated R23 had another incident with R12 and seemed to target R12. R12 was moved to another floor to prevent further altercations. On 1/6/26 at 3:30 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the resident-to-resident altercation between R23 and R12 was a witnessed incident which did not result in injury. DON-B indicated R23 and R12 both had BIM scores of 3 and were unaware of what happened. DON-B indicated the facility did not consider the situation abusive and did not notify the police. DON-B verified slapping another individual is a form of abuse but questioned if there was intent to harm. DON-B indicated that police would not come out for a situation like that but verified the police were notified or given the chance to make a determination of abuse. DON-B also indicated the facility had not contacted local law enforcement to develop a working agreement for situations of suspected abuse.

Based on staff interview and record review, the facility did not ensure the accurate submission of mandatory staffing information based on payroll data in a uniformed electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 77 residents residing in the facility. Staffing data for fiscal Quarter 3 (date range: 4/1/24-6/31/24) of the Payroll Based Journal (PBJ) was not submitted accurately to CMS. Findings include: The Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual, dated June 2022, indicates: Chapter 1: .(U) Mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy: Direct care staffing and census data will be collected quarterly and is required to be timely and accurately .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal quarter, date range: (Quarter 1) October 1-December 31, (Quarter 2) January 1-March 31, (Quarter 3) April 1-June 30, (Quarter 4) July 1-September 30. On 9/10/24, Surveyor reviewed the PBJ Staffing Data Report/CASPER Report 1705 D for fiscal year 2024 which indicated Quarter 3 (April 1-June 30) triggered for excessively low weekend staffing, no registered nurse (RN) hours, and failed to have licensed nursing coverage 24 hours/day. On 9/10/24, Surveyor reviewed staff schedules for Quarter 3 and noted staff ratios were appropriate per the Facility Assessment, including multiple RNs on the AM/PM shift and one RN on night (NOC) shift, including weekends. On 9/10/24 at 4:17 PM, Surveyor interviewed Nursing Home Administration (NHA)-A and Director of Nursing (DON)-B who indicated there was always an RN on staff from April to June of 2024. NHA-A indicated Business Office Manager (BOM)-F informed NHA-A that nursing hours were not submitted correctly. NHA-A and DON-B denied low nurse staffing. On 9/11/24 at 8:08 AM, Surveyor interviewed BOM-F regarding the PBJ staffing report for April through June of 2024. BOM-F indicated BOM-F sent nursing employees' identification numbers and hours worked; however, Information Technology (IT)-G was new to IT-G's position and did not submit nursing staff hours which resulted in zero RN hours. Surveyor requested nursing staff hours for the above dates. Surveyor reviewed the facility's nursing hour spread sheets for Quarter 3 and noted the hours were inputted daily. On 9/11/24 at 10:14 AM, Surveyor interviewed IT-G who was not aware of the missing nursing hours for Quarter 3. IT-G stated IT-G was made aware of the missing hours on 9/10/24 when BOM-F contacted IT-G. IT-G indicated IT-G discovered the submitted data contained employee IDs but not hours. IT-G confirmed IT-G was not educated regarding the issue and yesterday was the first IT-G heard about missing hours on the PBJ report. IT-G confirmed all hours should be inputted correctly. On 9/11/24 at 10:26 AM, Surveyor interviewed NHA-A who stated BOM-F was new to BOM-F's position. NHA-A indicated payroll used to submit data to CMS, but IT-G currently completed PBJ submissions. NHA-A confirmed nursing hours were missed and indicated all nursing hours should be entered and submitted correctly. NHA-A was unsure if IT-G had submitted PBJ information before. NHA-A read an email sent from BOM-F which indicated Excel data was completed correctly with all nursing hours; however, when IT-G uploaded the information to be sent, the hours did not go through. NHA-A confirmed the facility became aware of the missing hours on 9/10/24 when Surveyor informed NHA-A. NHA-A indicated NHA-A did not see the payroll and IT-G did not work at the facility. NHA-A indicated NHA-A did not educate IT-G because NHA-A was not involved in the PBJ report. During the course of the survey, Surveyors observed sufficient staffing to complete resident cares. Residents and their representatives had no concerns regarding staffing or the provision of care. Surveyors interviewed multiple staff who stated there were enough staff to meet residents' needs and there was always an RN in the facility.

Based on staff interview and record review, the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 3 residents (R) (R8, R9, and R10) of 11 residents. R8 reported to staff that a Certified Nursing Assistant (CNA) was short with R8 and would not allow R8 to have R8's face cream. The allegation of abuse was not thoroughly investigated. R9 reported to staff that it took 45 minutes for a CNA to respond to R9's toileting request and that the CNA was rude, abrupt and unwilling to do (the CNA's) job. R9 also stated the CNA would not give R9 a bath. The allegations of abuse and neglect were not thoroughly investigated. R10's daughter reported to staff that R10 was crying in R10's room and stated staff were mean and hurt R10. The allegation of abuse was not thoroughly investigated. Findings include: The Facility's Abuse/Mistreatment policy, dated April 2021, indicates: Investigation: Whenever there is an incident, allegation or grievance reported to an employee, they shall immediately protect the resident and notify their supervisor who shall immediately notify the Administrator, or designee. The facility shall start an investigation of all incidents, allegations, concerns, complaints, and grievances immediately. Violations will be thoroughly investigated. Investigations will be thorough and conducted after any reported incident. Investigations must collect information that corroborates or disproves the incident and document the findings of each incident. A thorough investigation may include the following: ~Conduct observations of alleged victim, including identification of any injuries, the location where the alleged incident occurred, interactions and relationships between the staff and the alleged victim and/or other residents, and interactions/relationships between the resident and other residents, as appropriate. ~Interview alleged victims(s) and witness(es). ~Interview the accused individual(s) allegedly responsible for the mistreatment . ~Interview other residents to determine if they have been abused or mistreated. ~Interview staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused. ~Interview staff who worked previous shifts to determine if they were aware of an injury or incident. ~Involve other regulatory authorities who may assist . In the event of an alleged incident of Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of resident property: 1.After protecting the resident and all other residents from further incidents of misconduct or injury, the accused is removed from services immediately (if applicable) . 1. On 4/8/24, Surveyor reviewed R8's medial record. R8 was admitted to the facility on [DATE] with diagnoses including pain, history of right hip arthroplasty, abnormalities of gait and mobility, muscle weakness, and history of falling. R8's Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8's care plan indicated R8 had impaired mobility and loss of independence and required a full body mechanical lift and the assistance of two staff for transfers. The care plan also indicated R8 required set up assistance for grooming. On 4/7/24, Surveyor reviewed a grievance report for R8, dated 1/15/24, that indicated a CNA was short with R8 the previous night. R8 asked for R8's face cream and the CNA said, No. You're in bed and that's where you're going to stay. The staff with the CNA got R8's face cream, but the CNA said, No. The grievance was signed by Director of Nursing (DON)-B on 1/16/24. The Action and Response Taken section of the grievance indicated: Include how resident was protected, how grievance was investigated, who was contacted, and how further potential violations will be prevented while the allegation is being investigated Provide and attach witness statements if appropriate. The grievance contained information that indicated DON-B contacted staff who worked that shift and what two of the staff stated. A wing assignment sheet was attached to the grievance. The Follow Up/Resolution/Conclusion section contained a note that indicated the grievance was unsubstantiated and staff would be re-educated and receive a discipline for not following the care plan. The grievance did not contain resident interviews, witness statements, written staff statements, or further information including how R8 was protected during the investigation. 2. On 4/8/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including brain cancer, polyneuropathy, syncope, osteoarthritis, and weakness. R9's MDS assessment contained a BIMS score of 10 out of 15 which indicated R9 had moderate cognitive impairment. R9's care plan indicated R9 had impaired mobility and required a full body lift and the assistance of two staff for transfers. The care plan also indicated R9 needed staff assistance for bathing. R9's thought process care plan contained interventions to acknowledge R9's perspective, encourage R9 to express feelings regarding the current situation and anticipated changes, give structured environment, and provide reassurance. On 4/7/24, Surveyor reviewed a grievance for R9, dated 12/21/23, that indicated R9 upset with care provided that morning by a CNA. R9 stated it took 45 minutes for the CNA to respond to R9's toileting request. R9 had loose stools due to recent antibiotic treatment. R9 requested to use the bathroom and the CNA stated, I said I can't help you right now. After waiting long enough, R9 stated R9 would take R9's self to the bathroom and the CNA stated, Fine. Take yourself. R9 stated the CNA was rude, abrupt, and unwilling to do the CNA's job. The grievance also indicated the CNA would not give R9 a bath per R9's choice. The CNA said staff would give R9 a shower but only if R9 stopped acting like that (meaning weak). The grievance was signed by DON-B on 12/21/23. The Action and Response Taken section contained a note that indicated the CNA was escorted out of the building and sent home pending the investigation. DON-B and R9's representative were updated regarding the care concerns and start of the investigation. The Follow Up/Resolution/Conclusion section contained a note that indicated the CNA was immediately escorted from the building. DON-B and the Registered Nurse (RN) Manager met with R9. The investigation indicated the CNA was new to the facility and had a poor approach. R9's concern was substantiated and the CNA was terminated. The grievance did not contain resident interviews, witness interviews, written staff statements, or further investigation information. 3. On 4/8/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility with diagnoses including dementia, multiple sclerosis, chronic pain, anxiety disorder, and palliative care. R10's MDS assessment contained a BIMS score of 3 out of 15 which indicated R10 had severe cognitive impairment. R10's care plan indicated R10 could verbalize the location and intensity of pain and required extensive assistance of staff for mobility. The care plan contained interventions to anticipate and treat pain prior to transfer/movement, explain what staff are doing prior to movement, and go slow and gentle because fast repositioning was alarming (dated 3/12/24). On 4/7/24, Surveyor reviewed a grievance initiated by R10's daughter, dated 2/20/24, that indicated R10 was crying in R10's room. Staff had just gotten R10 up via Hoyer lift for an appointment at 1:00 PM. R10 reported to R10's daughter that staff were mean to (R10) and hurt (R10). The Action and Response Taken section contained a note that indicated statements were collected from the CNAs who assisted with cares and the transfer. The statements were attached to the grievance form. The grievance form also indicated R10's care plan was reviewed and updated and an order was obtained for ibuprofen 400 mg (milligrams) for pain. A note indicated unit interviews were completed with no care or transfer concerns. The grievance did not contain resident interviews, witness interviews, or indicate how R10's safety was ensured pending the results of the investigation. On 4/8/24 at 9:58 AM, Surveyor interviewed DON-B who indicated allegations surface when R10's daughter visits. DON-B indicated DON-B believes this is attention-seeking and that R10 is trying to get a response from R10's daughter. DON-B stated, We investigated it. On 4/8/24 at 4:04 PM, Surveyor interviewed DON-B who indicated the above allegations were customer service situations and were not investigated as allegations of abuse or neglect. On 4/8/24 at 9:45 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the allegations were not reported to NHA-A. NHA-A indicated DON-B is the first line of defense in terms of investigating situations.

Based on staff interview and record review, the facility did not ensure all allegations of abuse and neglect were reported to the Nursing Home Administrator (NHA) or the State Agency (SA) for 3 residents (R) (R8, R9, and R10) of 11 sampled residents. In addition, the facility's Abuse/Mistreatment policy contained conflicting information related to reporting allegations of abuse/mistreatment. R8 reported to staff that a Certified Nursing Assistant (CNA) was short with R8 and would not allow R8 to have R8's face cream. The allegation of abuse was not reported to NHA-A or the SA. R9 reported to staff that it took 45 minutes for a CNA to respond to R9's toileting request and the CNA was rude, abrupt and unwilling to do (the CNA's) job. R9 also indicated the CNA would not give R9 a bath. The allegations of abuse and neglect were not reported to NHA-A or the SA. R10's daughter reported to staff that R10 was crying in R10's room and stated staff were mean and hurt R10. The allegation of abuse was not reported to NHA-A or the SA. The facility's Abuse/Mistreatment policy indicates the facility shall report all violations and substantiated incidents to the proper state agency, registry/licensing authorities, and local law enforcement as required; however, regulatory requirements indicate all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property be reported. Findings include: The facility's Grievance policy, dated July 2023, indicates: The Grievance Official or designee will: *Immediately report and take action pertaining to alleged violations involving neglect, abuse, mistreatment, exploitation, injuries of unknown source, and/or misappropriation of resident property in accordance with the facility's abuse policy. The Facility's Abuse/Mistreatment policy, dated April 2021, indicates: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat residents' symptoms. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. 5. The Administrator/designee will report to the DQA (Division of Quality Assurance) all alleged violations involving mistreatment, neglect, exploitation, or abuse .Reporting/Response: Facility shall report all violations and substantiated incidents to the proper state agency, registry/licensing authorities and local law enforcement as required .In the event of an alleged incident of abuse, neglect .1. All employees, contracted individuals, or volunteers are responsible for knowing about the facility's reporting procedures and requirements .All employees, contracted individuals and/or volunteers are required to report observations of abuse or mistreatment, resident complaints, concerns, allegations, injuries, incidents, and grievances immediately to their supervisor. Immediately means reporting should occur as soon as the safety of all residents are secured and all necessary emergency measures are taken, including removing the accused from services immediately. 1. On 4/8/24, Surveyor reviewed R8's medial record. R8 was admitted to the facility on [DATE] with diagnoses including pain, history of right hip arthroplasty, abnormalities of gait and mobility, muscle weakness, and history of falling. R8's Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8's care plan indicated R8 had impaired mobility and loss of independence and required a full body mechanical lift with the assistance of two staff for transfers. The care plan also indicated R8 required set up assistance for grooming. On 4/7/24, Surveyor reviewed a grievance report for R8, dated 1/15/24, that indicated an aide was short with R8 the previous night. R8 stated R8 asked for R8's face cream and the aide said, No. You're in bed and that's where you're going to stay. R8 indicated the staff with the aide was nice and got R8's cream, but the aide said, No. The grievance was signed by Director of Nursing (DON)-B on 1/16/24. 2. On 4/8/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including brain cancer, polyneuropathy, syncope, and weakness. R9's MDS assessment contained a BIMS score of 10 out of 15 which indicated R9 had moderate cognitive impairment. R9's care plan indicated R9 had impaired mobility and required a full body lift and the assistance of two staff for transfers. R9's care plan also indicated R9 required assistance with bathing. R9's thought process care plan contained interventions to acknowledge R9's perspective, encourage R9 to express feelings regarding R9's current situation and anticipated changes, provide a structured environment, and provide reassurance. On 4/7/24, Surveyor reviewed a grievance report for R9, dated 12/21/23, that indicated R9 was upset with cares provided that AM by a CNA. R9 stated it took 45 minutes for the CNA to respond to R9's toileting request. R9 had loose stools due to recent antibiotic treatment, requested to use the bathroom, and was told, I said I can't help you right now. After waiting long enough, R9 stated R9 would take R9's self to the bathroom and the CNA stated, Fine, take yourself. R9 stated the CNA was rude, abrupt, and unwilling to do the CNA's job. The grievance also indicated the CNA would not give R9 a bath per R9's choice. The CNA said staff would give R9 a shower but only if R9 stopped acting like that (meaning weak). The grievance was signed by DON-B on 12/21/23. 3. On 4/8/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dementia, multiple sclerosis, chronic pain, and anxiety disorder. R10's MDS assessment contained a BIMS score of 3 out of 15 which indicated R10 had severe cognitive impairment. R10's care plan indicated R10 required extensive assistance of staff for mobility and was able to verbalize pain and its location and intensity. R10's care plan contained interventions to anticipate and treat pain prior to transfer and movement, provide an explanation prior to moving, and to go slow and gentle because fast repositioning was alarming (dated 3/12/24). On 4/7/24, Surveyor reviewed a grievance initiated by R10's daughter, dated 2/20/24, that indicated R10 was crying in R10's room. Staff had just gotten R10 up via Hoyer lift for an appointment at 1:00 PM. R10 reported to R10's daughter that staff were mean to (R10) and hurt (R10). The grievance indicated Nurse Manager (NM)-C interviewed R10 for further clarification and R10 did not use the word mean. NM-C obtained witness statements from staff, dated 2/19/24. The grievance was signed by DON-B on 2/20/24 On 4/8/24 at 9:55 AM, Surveyor interviewed NM-C who confirmed NM-C received the initial allegation from R10's daughter, investigated the allegation, and reported the allegation to DON-B. NM-C stated the date on the grievance was incorrect and should be 2/19/24. NM-C confirmed the statements initially relayed to NM-C by R10's daughter would be considered abuse. On 4/8/24 at 9:58 AM, Surveyor interviewed DON-B who indicated allegations surface when R10's daughter visits. DON-B indicated DON-B believes this is attention-seeking and that R10 is trying to get a response from R10's daughter. DON-B stated the allegations were investigated. On 4/7/24 at 4:04 PM, Surveyor interviewed DON-B who confirmed the above allegations were not reported to the SA. On 4/8/24 at 9:45 AM, Surveyor interviewed NHA-A who confirmed the above allegations were not reported to NHA-A or the SA. NHA-A indicated DON-B is the first line of defense in terms of investigating situations.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 1 resident reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R1 was transferred to the hospital on 3/27/24. R1 and/or R1's representative were not provided with a written transfer notice. Findings include: The facility's Transfer of Resident to the Hospital policy, with a review date of 5/2021, indicates: A written notification of transfer will be provided to the resident at the time of discharge with the date of discharge and where the resident is going. The nurse is to mark that the resident is being discharged because of a medical emergency. A copy of the discharge notification will be copied and placed in the medical record. The nurse will chart that the written notification of discharge was given. Note: The resident does not need to sign the form. On 4/7/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), pressure injury on the left lower back, coronary artery disease (CAD), and memory impairment. On 3/27/24, R1 sustained a skin laceration during a transfer and was transported to the hospital for evaluation and treatment. R1's medical record did not contain a transfer notice. Surveyor requested a copy of the transfer notice from Director of Nursing (DON)-B which was not provided to Surveyor. On 4/8/24 at 10:30 AM, Surveyor interviewed Social Services (SS)-D who confirmed the facility did not provide a transfer notice other than a bed hold notice. On 4/8/24 at 10:35 AM, Surveyor interviewed DON-B who confirmed DON-B was not aware of the need to provide a written transfer notice to residents.

Based on staff interview and record review, the facility did not ensure allegations of abuse and misappropriation were reported to the State Agency (SA) for 2 residents (R) (R17 and R10) of 2 sampled residents. R17 reported an allegation of physical abuse. The facility did not report the allegation of abuse to the SA. The facility did not submit a 24-hour report to the SA regarding an allegation of misappropriation involving R10. Findings include: The facility's Abuse policy, dated 3/23, contained the following information: All alleged violations of abuse, neglect, exploitation of residents, misappropriation of resident property .must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency and Adult Protective Services where State law provides for jurisdiction in long-term care facilities .Not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property and does not result in serious bodily injury. Results of all investigations of alleged violations must be reported within 5 working days of the incident. 1. On 6/20/23, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses to include chronic heart failure, major depressive disorder, age-related cognitive decline, and unspecified dementia. R17's Minimum Data Set (MDS) assessment, dated 4/8/23, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R17 had moderate cognitive impairment. On 6/20/23, Surveyor reviewed the facility's grievance log. The log contained a grievance submitted via email by Family Friend (FF)-G that indicated R17 told FF-G on 4/5/23 that the staff member who gave R17 a bath was rough, caused R17 pain, and made R17 cry. FF-G reported FF-G observed bruising on R17's left forearm. On 6/20/23 at 1:48 PM, Surveyor interviewed Director of Nursing (DON)-B who stated any suspected abuse is reported to the SA. DON-B verified DON-B did not report R17's allegation of abuse to the SA. On 6/20/23 at 2:41 PM, Surveyor interviewed Social Services Director (SSD)-C regarding R17's allegation of abuse. SSD-C read FF-G's email and verified the email contained an allegation of abuse. 2. On 6/20/23, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder, depressive disorder, and arthritis. R10's MDS assessment, dated 5/8/23, contained a BIMS score of 15 out of 15 which indicated R10 was not cognitively impaired. From 6/19/23 through 6/21/23, Surveyor reviewed a facility-reported incident (FRI) regarding an allegation of misappropriation of medication involving R10. Surveyor noted the FRI did not contain a 24-hour report that was submitted to the SA. On 6/20/23 at 10:59 AM, DON-B provided Surveyor the facility's 5 day report. DON-B stated the previous Nursing Home Administrator (NHA) told DON-B the 24-hour report was submitted to the SA. DON-B stated DON-B believed the previous NHA filled out an incorrect form and the 24-hour report was not submitted. On 6/20/23 at 2:56 PM, Surveyor interviewed Registered Nurse Supervisor (RNS)-E regarding allegations of abuse and misappropriation. RNS-E verified allegations of abuse and misappropriation should be reported right away.

Based on observation, interview and record review, the facility did not provide care consistent with professional standards of practice to prevent pressure injuries from developing for 1 Resident (R) (R41) of 4 sampled residents. R41's plan of care contained an intervention to offload R41's heels while in bed. R41 was observed in bed on multiple occasions with R41's heels in direct contact with the mattress. Findings include: Surveyor requested the facility's pressure injury policy and was provided Pathway Health skin integrity/pressure ulcer care general information which listed general information quoted from the State Operations Manual (SOM) 483.25 for skin integrity. Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] with diagnoses to include dementia, thoracic compression fracture, contractures (left leg), peripheral vascular disease, pressure injury to buttocks (healed), and vascular injury to left great toe. R41's Minimum Data Set (MDS) assessment, dated 5/14/23, contained a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R41 had severe cognitive impairment. A Braden assessment, dated 6/12/23, indicated R41 was at moderate risk for skin breakdown with an additional risk factor can't raise leg in straight position. R41's impaired skin integrity plan of care contained interventions to continue offloading heels and pressure on toes. R41's Certified Nursing Assistant (CNA) care card instructed staff to offload R41's heels. On 6/19/23 at 10:55 AM, Surveyor observed R41 in bed on an air mattress. R41's right leg was crossed over the left leg and the lateral aspect of R41's left heel was in direct contact with the mattress. R41's right leg was straight and the back of the right heel was in direct contact with the mattress. R41 was asleep at the time of the observation. On 6/20/23 at 8:54 AM, Surveyor observed R41 asleep in the same position with the right leg crossed over the left leg and both heels in direct contact with the mattress. On 6/20/23 at 3:13 PM, Surveyor observed R41 with a pillow under the right side of R41's upper back. R41's body faced the left wall and R41's legs were in the same position as the previous observations. On 6/20/23 at 3:14 PM, Surveyor interviewed CNA-J who stated staff repositioned R41 side-to-side with pillows every two hours and placed a pillow between R41's legs because R41 liked to cross R41's legs. CNA-J stated R41 did not like to get out of bed and spent all of R41's time in bed, including meals. CNA-J was unsure if R41 had interventions to protect R41's heels and did not recall using a pillow to elevate R41's heels. Surveyor reviewed R41's medical record which contained a Braden assessment, dated 6/12/23, that indicated R41 was at moderate risk for skin breakdown with additional risk factors documented: can't raise leg in straight position. R41's care plan for impaired skin integrity included interventions of continued off loading of heels and pressure of toes. R41's CNA care card instructed staff to offload R41's heels. On 6/21/23 at 8:09 AM, Surveyor observed R41 in bed on R41's back with the right leg crossed over the left leg and both heels in direct contact with the mattress. At 8:12 AM, CNA-K raised the head of R41's bed and placed a pillow under R41's right side to position R41 for breakfast. On 6/21/23 at 9:19 AM, Surveyor and Licensed Practical Nurse (LPN)-L entered R41's room to observe R41's skin and noted R41's heels were in direct contact with the mattress. Surveyor noted both of R41's heels were red and blanchable when LPN-L felt for bogginess and asked about pain and tenderness. Surveyor also noted R41's left foot was against the foot board of the bed which created a reddened indented area to the lateral aspect of R41's foot. When LPN-L pushed on the area, Surveyor noted skin color changes and R41 denied discomfort. R41 was agreeable when LPN-L offered to offload R41's heels with a pillow. LPN-L positioned R41's right foot and left the room to retrieve a pillow for R41's left foot. On 6/21/23 at 9:48 AM, Surveyor interviewed Wound Care Registered Nurse (WCRN)-M who verified R41 spent most of R41's time in bed and R41's heels should be offloaded when R41 is in bed. On 6/21/23 at 11:00 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R41's heels should be offloaded per R41's plan of care.

Based on staff interview and record review, the facility did not ensure allegations of abuse and misappropriation were thoroughly investigated for 2 Residents (R) (R17 and R10) of 2 sampled residents. R17 reported an allegation of abuse on 4/5/23. The facility did not thoroughly investigate the allegation of abuse or remove the accused staff member from resident care during the investigation. Staff reported a potential allegation of misappropriation involving R10 on 2/28/23. The facility did not thoroughly investigate the allegation of misappropriation. Findings include: The facility's Abuse policy, dated 3/23, contained the following information: It is the policy of this facility that reports of abuse, neglect, exploitation of residents, misappropriation of resident property .are promptly and thoroughly investigated. E. Investigation: a.When an incident of abuse, neglect, exploitation of residents, misappropriation of resident property .is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel .The investigation will include statements from all individuals involved to include: i. Statement from individual reporting the alleged abuse ii. Residents' statements iv. Visitor statements for anyone who may have witnessed the alleged abuse (if applicable) v. All involved staff who have or may have witnessed the abuse viii. A full assessment of the resident to identify any injuries present [NAME]. A complete and thorough documentation of the entire investigation. c.Examples of reportable allegations of misappropriation of resident property that will be investigated include, but are not limited to: 7. Missing medications or diversion F. Protection Procedures must be in place to provide the resident with a safe, protected environment during the investigation: ii. The alleged perpetrator will immediately be removed and the resident protected. Employees accused of alleged abuse .be immediately removed from the facility and will remain removed pending the results of a thorough investigation. 1. On 6/20/23, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses to include chronic heart failure, major depressive disorder, age related cognitive decline and unspecified dementia. R17's Minimum Data Set (MDS) assessment, dated 4/8/23, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R17 had moderate cognitive impairment. On 6/20/23, Surveyor reviewed the facility's grievance log. The log contained a grievance submitted via email by Family Friend (FF)-G that indicated R17 told FF-G on 4/5/23 that the staff member who gave R17 a bath was rough, caused R17 pain, and made R17 cry. FF-G reported FF-G observed bruising on R17's left forearm. On 6/20/23, Surveyor reviewed the facility's investigation regarding R17's allegation of abuse. Surveyor noted the investigation did not contain thorough interviews of staff who cared for or observed R17 on the date of the alleged abuse. The investigation also did not contain interviews with residents who potentially witnessed or experienced similar treatment. Surveyor also noted the accused staff member was not removed from resident care during the investigation. The investigation indicated R17 denied the allegation of abuse and the facility believed the bruising occurred when R17 was combative during cares On 6/20/23 at 1:48 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility investigated the allegation right away. DON-B verified the accused staff member was not removed from resident care pending the results of the investigation. 2. On 6/20/23, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder, depressive disorder, and arthritis. R10's MDS assessment, dated 5/8/23, contained a BIMS score of 15 out of 15 which indicated R10 did not have cognitive impairment. From 6/19/23 through 6/21/23, Surveyor reviewed a facility-reported incident (FRI) regarding a potential allegation of misappropriation of R10's narcotic medication. The FRI indicated staff attempted to reorder narcotic medication for R10 on 2/28/23; however, the pharmacy stated the medication couldn't be reordered because the pharmacy sent a full card of the medication a few days earlier. The FRI did not contain resident or potential witness interviews regarding the allegation of misappropriation. On 6/20/23 at 2:56 PM, Surveyor interviewed Registered Nurse Supervisor (RNS)-E regarding allegations of abuse and misappropriation. RNS-E verified allegations of abuse and misappropriation should be investigated right away.

Based on observations, staff interviews, and record review, the facility did not ensure food was stored, prepared, and served under sanitary conditions. The practices had the potential to affect all 75 residents. The facility stored expired and damaged products in the dry storage area. The facility did not clean equipment between uses. The facility did not follow disinfectant manufacturer contact time instructions. Findings include: On [DATE], during initial kitchen tour beginning at 10:17 AM, Dietary Manager (DM)-G indicted to Surveyor that the facility utilized the Wisconsin (WI) Food Code as its standard of practice. Expired and Damaged Products On [DATE], during initial kitchen tour beginning at 10:17 AM, Surveyor entered dry storage with DM-G and observed a cardboard box with wrinkled texture and dried lines from probable previous moisture exposure. The box was delivery dated [DATE] and contained 20 ounce (oz) containers of iodized salt. Surveyor removed a container from box and found salt inside container to be solid instead of granular. Salt container label was visibly wrinkled and water damage lines were visible on container. DM-G removed additional salt containers from damaged box and determined 12 containers of salt were damaged. Surveyor observed visible debris on top of 6 pound (lb) containers of dessert sprinkle style decorative toppings. DM-G verified debris was on top of dessert sprinkle containers and explained the overhead pipes in the room were recently cleaned. Dry storage products were largely covered but not all products were able to be covered during pipe cleaning process. Dessert decoration containers were further examined and determined to be expired. Five containers of rainbow sprinkles, one of orange sprinkles, one of white sprinkles, and three of lavender decorettes all were beyond best by dates. DM-G was not able to verbalize what system the facility had in place to ensure expired food was removed from dry storage and discarded. Surveyor observed and DM-G verified a clear bag containing 12 black bean burgers, delivery dated [DATE], had an accumulation of frost inside the bag with frost also clinging to the black bean burgers. DM-G was not able to indicated why the product had frost damage in less than 2 months time at the facility. DM-G discarded the black bean burgers at the time of observation. Soiled Equipment WI Food Code 2020 documents at ,d+[DATE].11 (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On [DATE], during initial kitchen tour beginning at 10:17 AM, Surveyor observed and DM-G verified the facility meat slicer was covered by had dried meat residue on the underside of the cutting edge and white crumbs on the meat tray. DM-G was not able to identify what the while crumbles were but guess they may be salt. DM-G estimated the meat slicer was used approximately once per week. Surveyor touched convection oven handle to open oven and felt the handle was tacky. DM-G also touched handle and described area as tacky. DM-G identified the handles may have been tacky from grease accumulation. Surveyor observed a reach in refrigerator in the main kitchen had visible residue in finger print shapes on the exterior doors. The facility can open had dried food residue in red and brown colors died on to the cutting edge and the base. The microwave handle felt greasy and was visually soiled on the handle and around the handle on the door. On [DATE] beginning at 11:15 AM, Surveyor entered 1 West kitchenette with DM-G. Surveyor observed 1 West kitchenette oven was soiled externally and internally. Crumbs and dried yellow splatter were present on the handle and various shades of brown were baked onto the interior floor of the oven. DM-G explained the oven was generally used to hold hot foods and not on a cleaning schedule. Disinfectant Use Disinfectant spray directions indicated surface should be sprayed, debris wiped off then surface sprayed again and kept wet for one minute to sanitize. On [DATE] at 12:54 PM, Surveyor observed Dietary Aide (DA)-H clear 1 West dining tables. DA-H sprayed tables and wiped away debris. DA-H was not able to verbalize contact time of product to Surveyor. Surveyor reviewed instructions on label with DA-H which indicated one minute contact time requirement. On [DATE] at 9:11 AM, DM-G indicated DA-H reported issues with disinfectant spray use to DM-G on [DATE] after interaction with Surveyor. DM-G verified one minute contact time was required and explained in-service education was started with staff following DA-H reporting issue. DM-G explained the facility disinfecting product was changed with supply vendor change in [DATE].

Based on staff interviews and record review, the facility did not ensure agreed upon hospice communication documentation was in a Resident (R) medical record for 1 (R68) of 1 sampled residents reviewed for hospice services. The facility did not ensure R68's hospice visit progress notes and oxygen tubing changes were included in R68's medical record. Findings include: Facility agreement with R68's hospice provider, signed 5/10/17, documented Part V: Medical Records. A. Facility shall prepare and maintain medical records for each Hospice patient receiving services pursuant to this Agreement . The medical records shall consist of at least progress notes and clinical notes describing all inpatient services and events. From 3/7/22 through 3/9/22, Surveyor reviewed R68's medical record which documented R68 enrolled in hospice services on 11/17/21. Surveyor noted R68's most recent hospice generated communication was an updated care plan dated 2/1/22. 2/1/22 updated care plan indicated a hospice nurse was to visit weekly, a hospice nursing aide was to visit weekly and a hospice social worker should visit monthly. Surveyor was not able to locate hospice visit progress notes by hospice nurses, aides, or social workers. Surveyor noted hospice orders did not address oxygen tubing changes. (Refer to F695 for respiratory care concern details related to R68.) On 3/8/22 at 1:34 PM, Surveyor interviewed Registered Nurse (RN)-D regarding R68's hospice service provider communications. RN-D explained R68's hospice provider requests staff to sign confirmation of presence in building on an electronic device. RN-D elaborated that RN-D did not have to sign the hospice device. Certified Nursing Assistance (CNAs) may also sign. RN-D indicated hospice will sometimes verbally debrief RN-D on services provided during hospice visit but if RN-D was unavailable, no verbal report occurred prior to hospice staff exiting the facility. RN-D denied ever receiving written progress note communications from R68's hospice provider. On 3/8/22 at 1:39 PM, Surveyor interviewed RN-C who was RN Manager for R68's unit. RN-C was not aware of who in facility was assigned as hospice coordinator/designee. At the time of interview, RN-C reviewed R68's hospice binder and verified no hospice visit communications were in the binder. RN-C then reviewed the remainder of R68's hard copy portion of medical record and confirmed R68's medical record did not contain hospice visit documentation. RN-C indicated RN-C communicated to R68's hospice provider in the past that hospice staff should let RN-C know when hospice staff are in the building but RN-C indicated R68's hospice staff did not consistently notify RN-C of presence in the facility. On 3/9/22 at 11:59 AM, Nursing Home Administrator (NHA)-A alerted Surveyor that NHA-A contacted R68's hospice provider to follow up on missing hospice visit progress notes. NHA-A was informed R68's hospice provider keeps progress notes in an online portal. Hospice provider indicated to NHA-A that facility had access to online portal. At 12:24, NHA-A disclosed to Surveyor that NHA-A followed-up with facility hospice designees (Social Services (SS)-E and RN-C) and learned facility staff did not have access to hospice online portal. NHA-A expressed an expectation that each hospice resident have up to date hospice information in their medical record.

Based on observation, Resident (R) interview, staff interviews and record review, the facility did not ensure oxygen tubing was changed for 1 (R68) of 1 residents reviewed for respiratory care. Facility staff did not change oxygen tubing and did not have documentation of hospice staff changing R68's oxygen tubing since oxygen was ordered 10/26/21. Findings include: Facility policy titled Nursing Oxygen, revision dated 1/2020, documented All tubing and nasal cannulas/face masks should be changed out every 5 days. From 3/7/22 through 3/9/22, Surveyor reviewed R68's medical record which documented R68 enrolled in hospice services on 11/17/21. R68's orders included a 10/26/21 oxygen order for shortness of breath and comfort. Surveyor noted R68's orders, Treatment Administration Record (TAR), and care plans did not address how often to change R68's oxygen tubing. On 3/7/22 at 12:38 PM, Surveyor observed R68 utilizing oxygen via nasal cannula. R68 revealed to Surveyor that R68 utilized oxygen for some time but was not able verbalize the timeframe when R68 began utilizing oxygen or how often tubing was changed out. Surveyor noted R68's oxygen tubing did not have an affixed dating indicator for when tubing was most recently changed. Surveyor sporadically observed R68 throughout survey from 3/7/22 through 3/9/22. R68 was using oxygen during all observations. On 3/9/22 at 9:30 AM, Surveyor interviewed Registered Nurse (RN)-C, who was unit manager for unit R68 resided on. RN-C explained that facility Supply Aide (SA)-F generally took care of oxygen tubing changes but because R68's tubing was supplied by hospice, RN-C was not certain if tubing change responsibility was handled by hospice or SA-F. At time of interview, RN-C reviewed R68's hospice care plan but was unable to determine responsibility or locate an oxygen tubing change order. At that time, RN-C called SA-F via telephone then conveyed to Surveyor that SA-F doesn't handle tubing for R68. On 3/9/22 at 11:59 AM, Nursing Home Administrator (NHA)-A confirmed R68's hospice documentation available at facility did not include information on oxygen tubing changes. NHA-A expressed an expectation that hospice follow the facility policy to change oxygen tubing every 5 days.

Based on observation, record review and staff interview, the facility did not ensure 1 (R) (R65) of 8 residents reviewed for pressure injuries received appropriate care and services to promote healing and/or prevent pressure injuries from developing. Observations of R65 sitting on sling in wheel chair throughout all 3 days of survey. Findings include: Facility's Skin Care Policy dated 6/21 indicates: To prevent the resident from developing pressure injuries unless clinically unavoidable and to provide care and services consistent with professional standards of practice to : Promote the prevention of pressure injury development Promote the healing of existing pressure injuries and prevent development of additional pressure injury. Prevention Practice: A. Reduce pressure/shearing/friction: 1. Use appropriate pressure reducing or relieving devices-mattress or wheel chair cushion. 6. Avoid wrinkles in clothing, linens, briefs R65 was admitted to facility on 2/13/18 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R65's most recent MDS (Minimum Data Set) dated 2/16/22 indicates that resident requires extensive assist with bed mobility, transfers, dressing, hygiene and bathing. R65 has a history of pressure injury on inner buttocks area that has currently healed, but a dressing is still in place for protection according to RN (Registered Nurse)-I. A Nursing note from 2/23/22 indicated, new area on bilateral buttocks, purple area, interventions in place and updated. A Nursing note from 3/8/22, indicated bilateral buttock reddened/purplish tender to touch. New order for [MEDICATION(S)] per Nurse Practitioner. Surveyor had multiple observations throughout survey of R65 sitting directly on sling that was over cushion in wheelchair in the dining room. 3/7/22 at 11:45 AM 3/8/22 at 11:26 AM 3/9/22 at 12:33 PM On 3/9/22 at 1:25 PM Surveyor observed the buttocks area of R65. Surveyor observed reddened purple area from bilateral buttocks down to mid lateral thigh area. Purple area was blanchable to touch. Surveyor also noted a wound dressing on inner buttocks area. Purple area noted would be consistent with sitting down in a wheelchair. On 3/9/22 at 12:48 PM Surveyor interviewed RN-C. RN-C indicated that the facility did not have assessments of slings in chairs for residents. RN-C indicated that therapy may do an assessment for a lift but not for a sling in a chair. RN-C also indicated that a sling in a chair would not be care planned nor did they obtain a risk benefits statement for use of a sling in a chair which would reduce the effectiveness of the pressure relieving cushion.

Based on observations, interviews and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect (6 of 6) residents residing on the Covid unit where N95 masks are required, (5 of 11) residents residing on the 2 west north unit that require shared use of the hoyer lift, and (6 of 11) residents that require shared used of the shower chair. * Facility does not have a system to ensure N95 masks are not worn more than 5 times as directed in facility policy. * Staff did not clean shared resident equipment according to manufacturer's recommendations. * Staff did not follow safe infection control practice when they held clean residents' clothing against their body. * Staff did not encourage resident in common area to wear a mask. Findings include: N95 mask usage: The facility did not have a procedure specific to N95 to ensure N95's are not worn beyond 5 times. On 1/12/21 at approximately 12:00 PM Surveyor observed the facility Covid unit. Staff were noted to be wearing appropriate PPE (Personal Protective Equipment) including the use of N95 masks. Surveyor observed a table outside the door of the Covid unit which contained many individual brown paper bags with the names of staff written on the bags. Some of the bags were dated, however many were not labeled with dates. On 1/12/21 at approximately 1:30 PM Surveyor interviewed Infection Control (IC) Nurse-C who reported all staff had been fitted for the N95 mask. She stated the N95 mask is worn for 5 shifts unless soiled. The mask is placed in a paper bag at the end of the day for up to 5 times, then decontaminated or disposed of. IC-C stated staff members themselves are responsible for keeping track of the 5 shifts or 5 days the mask is worn. She stated: The name and date on the bag is to help remember when they started using it and they are supposed to date the mask, but not everyone is doing that. Surveyor asked how the facility can be sure staff is only wearing the N95 for 5 shifts or 5 days because there are no dates on many of the bags. IC-C stated: Sometimes they write the date on the mask. The county keeps track of how many decontaminations. On 1/12/21 at approximately 2:00 PM Surveyor interviewed Certified Nursing Assistant (CNA)-E who stated he puts the N95 in the brown paper bag at the end of each day. He reported he wears the N95 mask for 5 days or shifts, and then it goes in for decontamination. On 1/12/21 at approximtely 2:15 PM Surveyor interviewed CNA-F who reported she wears the N95 mask for 5 days, then it goes to be cleaned. She stated she was not sure if the one she is wearing is on the 2nd or 3rd day. CNA-F reported if the mask breaks or gets soiled, she goes to the supervisor. After the 5 days, it goes in the paper bag and is given to the supervisor and she is given a replacement one right away. On 1/12/21 at approximately 2:45 PM Surveyor interviewed CNA-D who reported having received a new N95 yesterday. He stated the mask is turned in every 4-5 days for disinfecting and he is given a new one like a revolving door. CNA-D stated he tries to take off (doff) the mask only on break - two times a day. Surveyor noted there were no dates on many of the bags containing the N95 to indicate the start of use for the N95, so there was no way to verify how many days the masks were in use. On 1/12/21 at approximately 3:00 PM Surveyor spoke with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who reported they follow the Ozaukee County N95 decontamination process which documented: N95 masks should be worn for no more than 5 uses (5 shifts if not actively treating/coming into contact with known or suspected COVID positive personnel). N95 masks should be labeled using a felt-tipped marker with user's name and agency/department on one side and date of first use on the opposite side. At the conclusion of each use, the N95 should be placed in a small paper bag that also indicates the user's name and agency/department. After the 5 use period, the mask and bag should be gathered in an area designated by your department and then returned to Ozaukee County Emergency Management for decontamination. NHA-A advised surveyor she had also been in contact with the Wisconsin Healthcare-Associated (HAI) Prevention Program and created an Infection Prevention and Control Assessment Tool (ICAR) in December 2020, and believed she was following the current recommendations. Disinfection of equipment: The facility did not have a policy and procedure specific to cleaning of shared equipment between residents. The facility provided the following the manufacturer's guidelines as follows: Clorox commercial solutions germicidal bleach. Usage directions for disinfecting: Floors, bathtubs, sinks and showers, 1/2 cup to 1 gallon of water. Pre-wash surface, then mop or wipe with bleach solution. Allow solution to contact surface for at least 5 minutes. Rinse well and air dry. On 1/12/21 at approximately 10:00 AM Surveyor observed CNA-D clean the shower room after completing a shower using the hoyer lift to transfer a resident to the shower chair. CNA-D used a spray bottle labeled bleach to spray the counter, shower bed and shower chair. The solution was left on the surfaces for approximately 1 minute and was then wiped with a dry cloth. CNA-D then sprayed the bleach solution on all surfaces of the hoyer lift and immediately wiped it off with a dry cloth. Surveyor asked CNA-D if he knew the contact time for the bleach solution he used to clean the equipment in the shower room. CNA-D stated he did not know the guidance for the contact time and stated: For my own purpose, I leave it on for about 30 seconds. Surveyor noted the shared equipment in the shower room was not cleaned according to the manufacturer's recommendations. Clothing and hoyer sling carrying: On 1/12/21 at approximately 9:45 AM Surveyor observed CNA-F leave a resident's room carrying a dark piece of clothing against her body, and walked to the shower room. CNA-F then returned to the same resident room, removed a hoyer sling and walked back to the shower room while carrying the hoyer sling against her body. Surveyor spoke with CNA-F and asked her what the dark piece of clothing was that she removed from the resident's room, to which she stated was a pair of residents' pants. Surveyor advised CNA-F of the observation carrying clothing and hoyer sling against her body. CNA-F stated she didn't normally carry it against her body, and didn't realize I had it against my body, usually I carry it away from my body. Resident observation without a mask: On 1/12/21 at approximately 11:00 AM while in the hallway/common area, Surveyor observed R6 seated in her wheelchair not wearing a mask covering her mouth and nose, rather it was pulled down under the residents' chin. Surveyor observed 2 different staff members walk past the resident, neither of which stopped to encourage the resident to replace the mask over her mouth and nose. Surveyor approached the resident and during this time, a nurse approached and did encourage the resident to wear her mask. On 1/12/21 at approximately 5:00 PM Surveyor met with NHA-A and DON-B and advised them of the above observations. No additional information was provided.

Based on staff interview and record review, the Facility did not establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. Percentages of different types of facility-acquired infection rates were not calculated to monitor increased prevalence of those infections within the Facility for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). In addition, (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) were missing infection tracking, trending data and surveillance of infections. This had the potential to affect the 128 Residents residing at the Facility. Findings include: The Infection Prevention and Control Program (IPCP) policy and procedure updated 9/2018 under procedure for Surveillance - Detection and Investigation documents A. Outcome Surveillance - LCC (Lasata Care Center) uses McGeer's criteria to identify and report evidence of a suspected of confirmed HAI (health care associated infection) or communicable disease. B. Data Collection on Infections 1. Concurrent surveillance is preferable to retrospective surveillance. 2. Daily review of 24 hours sheets and line list is preferred. 3. Review of all resident charting monthly. C. The surveillance and tracking of infections is a joint effort that is done by the Infection control practitioner (ICP) and the nursing department. Employees are expected to report unusual trends and occurrences of infectious disease to the nursing supervisor and ICP. Surveillance and tracking is done using the following data gathering tools: 1. 24 hour report sheets and line list. 2. Communication with direct care staff 3. Documentation from the clinical record of the resident with suspicion of an infection such as physician orders/progress notes 4. Laboratory reports 5. X-Ray reports 6. Pharmacy records 7. Antibiotic orders 8. Medication Regimen review reports 9. Infection Control rounds and interviews 10. Resident tracking forms 11. Discharge/Transfer summaries for new or readmitted residents. D. A resident Infection Tracking form (surveillance worksheet) is completed whenever an infection is suspected. The following data is collected 1. Resident's name, room number profile ID (medical record number) 2. Date of onset of infection (may list onset of symptoms or date of physician's antibiotic order) 3. Did infection develop after admission (consider HAI if > (greater) 2 days past admission day) 4. List of all symptoms 5. Site of infection 6. Organism, if identified 7. Culture or x-ray results if applicable 8. Precaution to prevent cross-contamination (i.e. isolation) see isolation policy 9. Was the resident in the room with another infected resident? 10. Was the infection reportable? 11. Well/Resolved date Note: all this information is documented in to ECS (electronic computer system) which generates the surveillance worksheet. G. Infection Rate Calculation 1. Calculate monthly and quarterly. 2. Count only Health care associated infections (HAI) that meet McGeer's criteria for surveillance using the following formula. a. Number of infections X 1000 = number of infections/1000 resident days Total number of residents days in the month i.e. There are 12 infections and the total resident days are 2850. 12 divided by 2850 x 1000 = 4.2 infections/1000 resident days 3. HAI is defined as an infection that begins/is detected on day 3 or after the admitted . The SHEA (Society for Healthcare Epidemiology of America)/APIC (Association for Professionals in Infection Control and Epidemiology) Guideline: Infection Prevention and Control in the Long-Term Care Facility, published in the (MONTH) 2008 issue of AJIC (American Journal of Infection Control), indicates: .To establish baseline infection rates, track progress, determine trends and detect outbreaks, site-specific rates should be calculated . Analysis and reporting of surveillance data: Analysis of absolute numbers is misleading; calculation of rates provides the most accurate information .Infection control data, including rates, then need to be displayed and distributed to appropriate committees and personnel (including administration) and used in planning infection control efforts. The data should lead to specific interventions such as education and control programs. On 1/8/19 at 12:03 p.m. Surveyor met with IP (Infection Preventionist)-D and DON (Director of Nursing)-B to discuss the Facility's infection control program. IP-D explained each manager and/or nursing staff on the wings assess the symptoms of a Resident, place the Resident on isolation if they meet the McGeer criteria, update the physician, start a temporary problem, place the information on the 24 hour sheet and on the back of the 24 hour sheet start a line listing. IP-D informed Surveyor she receives a copy of the 24 hour sheet each day which includes the wing line listing. IP-D informed Surveyor this information is also discussed in morning report. Surveyor inquired what IP-D does with the line listing each wing provides to her. IP-D informed Surveyor she reviews each wing's line listing and reads the Resident's charting. IP-D stated she starts compiling infection notes from the information on the line list, resident's charting, lab reports and physician orders [REDACTED]. IP-D informed Surveyor after all this information is entered into the computer, the computer will generate an infection report. Surveyor noted this report has the infection date, resident's name, unit & room number, infection site, testing & results, treatment, isolation, origin, whether it fits the McGeer criteria, start date of antibiotic, duration of treatment, ordering physician and resolve date. Surveyor inquired if baseline rates of infections are calculated for the Facility's predominate infections. IP-D informed Surveyor these rates of infections are completed after the infection report is done. IP-D provided Surveyor with (MONTH) (YEAR) infection notes, infection worksheets, infection report and rates of infection. Surveyor requested the Facility's infection control binder and informed IP-D Surveyor would review the information. On 01/08/19 at 2:18 p.m. Surveyor reviewed the Facility's infection control binder starting (MONTH) (YEAR) which includes for each month baseline rates of infection, infection report, UTI (urinary tract infection) report, monthly infection notes, and monthly infection control audits through (MONTH) (YEAR). For (MONTH) (YEAR) there are infection notes & monthly infections control audits but there is not baseline rates of infection & infection report. For (MONTH) (YEAR) & (MONTH) (YEAR) there are no monthly infection control notes, baseline rates of infection and infection report. On 1/9/19 at 8:06 a.m. Surveyor asked IP-D for (MONTH) (YEAR) are there are any infection worksheets completed. IP-D replied, I don't have them. Surveyor asked if the (MONTH) (YEAR) infection report and baseline rates of infection were completed. IP-D replied, They weren't done. Surveyor then asked if the (MONTH) and (MONTH) (YEAR) infection notes are done. IP-D replied,No, they aren't completed and explained because the infections notes aren't in the computer there aren't any infection worksheets, infection report and the baseline rates of infections are not calculated.

Based on observation, interview, and record review the Facility did not ensure 5 (R97, R104, R107, R118, & R7) of 6 Residents at risk for pressure injury development received the necessary treatment and services. * R97 did not have pressure relieving interventions implemented while at [MEDICAL TREATMENT]. * R104, R107, & R118 skin integrity care plans did not include an approach to prevent pressure injuries to the heels and their heels were observed not being offloaded. * On 9/14/18, R7 was readmitted to the facility after hospitalization for closed fracture of distal right femur and right knee replacement. R7 was non weight bearing upon readmission and palced on bedrest. On 9/19/18, R7 developed a stage 2 pressure injury on the coccyx. R7 did not have any pressure relieving measures put into place until 9/21/18, after R7 developed a stage 2 pressure injury. Findings include: The Prevention and treatment of [REDACTED]. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. Repositioning for preventing heel pressure ulcers include the following: Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure a state sometimes called 'floating heels'. Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individual who are not likely to keep their legs on pillows. 1. R97's [DIAGNOSES REDACTED]. R97 was admitted with a Stage 2 pressure injury on his coccyx, right buttocks and right & left heels. R97 receives [MEDICAL TREATMENT] three times a week on Tuesday, Thursday, & Saturday. The Braden assessment dated [DATE] has a score of 15. A score of 15-18 indicates mild risk for skin breakdown. The admission MDS (Minimum Data Set) with an assessment reference date of 11/19/18 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R97 requires extensive assistance with two plus person physical assist for bed mobility, transfer and ambulation in room. R97 is at risk for pressure injury development, is coded as having four Stage 2 pressure injuries, and is checked as receiving [MEDICAL TREATMENT]. The impaired skin integrity care plan dated 11/20/18 has approaches also dated 11/20/18 of; Note changes in level of risk for skin breakdown and minimize factors, Consult/assessment with wound care team, Treatment as ordered. Refer to current MAR (medication administration record), Review at NAR and follow recommendations, Braden Scale per schedule and prn (as needed), See other careplan: Self care deficit/impaired mobility (air mattress with pump and prevalon boots); Nutrition; and Alteration in tissue perfusion, Educate resident/family/staff regarding treatment and preventative measures, Monitor lab values and update MD (medical doctor) with results, Note nutrition and hydration status and address sources of deficiency, Assist with hygiene and general skin care. Avoid using hot water for cleansing, If incontinent, clean skin with mild soap and water; pat dry, Reposition every two hours while in bed, Alternate bed/chair time. Inspect skin integrity with AM (morning) and PM (evening) cares. Complete head to toe skin check with weekly bath as able. Report red or open areas to the nurse. and Keep heels elevated in bed. Surveyor noted there was no pressure relieving approach while at [MEDICAL TREATMENT]. The altered renal function ([MEDICAL TREATMENT]) care plan dated 11/20/18 has approaches also dated 11/20/18 of; monitor vital signs as indicated, Administer medications, evaluate for adverse effects and efficacy, Monitor weight, Monitor labs, Monitor respiratory status, Monitor cardiac status, Follow up appointment with Nephrology as recommended, Special Instructions: R97 has [MEDICAL TREATMENT] (Davitias) every Tuesday, Thursday, and Saturday, Report any changes to nurse, Encourage rest periods, Be aware R97 may require increased assist after [MEDICAL TREATMENT] treatment and interventions dated 12/2/18 of 'Monitor for [MEDICAL CONDITION]' & '11/24/18 24 hour urine collection ordered. - completed.' Surveyor noted there was not a pressure relieving approach while at [MEDICAL TREATMENT]. The CNA (Certified Nursing Assistant) care card dated 12/22/18 under the section wheelchair documents, extensive assistance of one to propel w/c (wheelchair) on and off unit. Roho cushion to chair. Under special instructions documents, R97 would like to be called R97 (first name), off loading shoe to right foot for all transfers, shoe is large, strap to residents comfort, R97 should not lift > (greater) 10 pounds, Signs located on outside of bathroom door, on wall next to television, and in bathroom next to toilet that read, R97, Please use your call button to call for assistance when you want to get up or use the bathroom. We don't want you to fall!!!, R97 enjoys cards, bingo, guessing games, reading, TV, specials, parties, church services Masss (Mass) and R97 has [MEDICAL TREATMENT] (Davitias) every Tuesday, Thursday, and Saturday. The Braden assessment dated [DATE] has a score of 18. A score of 15-18 indicates mild risk for skin breakdown. On 1/3/19 at 11:24 a.m., Surveyor observed R97 being wheeled into the elevator by a visitor for his [MEDICAL TREATMENT] appointment. Surveyor observed R97 is sitting on a pressure relieving cushion and has a sneaker on his left foot & a soft shoe on his right. On 1/8/19 at 10:00 a.m Surveyor asked R97 when he goes out for [MEDICAL TREATMENT] does he go out in his wheelchair. R97 replied, yes. Surveyor asked R97 when he is transferred into the [MEDICAL TREATMENT] chair does the [MEDICAL TREATMENT] staff take the Roho cushion from his wheelchair and place the cushion on the [MEDICAL TREATMENT] chair. R97 replied, no, it's just a long chair, not the most comfortable thing to sit on. On 1/8/19 at 1:28 p.m., Surveyor asked IP (Infection Preventionist)-D who is also the wound nurse at the Facility when R97 is at [MEDICAL TREATMENT] does the staff transfer the Roho cushion into the [MEDICAL TREATMENT] chair. IP-D informed Surveyor she asked R97 and he said it was a lot of work. Surveyor asked IP-D if they have spoken to the [MEDICAL TREATMENT] center about R97's Roho cushion. IP-D replied, I did not speak to [MEDICAL TREATMENT]. Surveyor informed IP-D R97 stated he does not sit on the Roho cushion, there is no documentation in R97's medical record indicating anyone spoke with the [MEDICAL TREATMENT] center regarding pressure relief interventions, or on the [MEDICAL TREATMENT] communication sheet and there is not an intervention on the care plan. Surveyor informed IP-D R97 goes out to [MEDICAL TREATMENT] three times a week, leaving the facility around 11:30 a.m. and not returning until approximately until 4:00 p.m. On 1/8/19 at 2:55 p.m. Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above. On 1/9/19 at 8:16 a.m., IP-D informed Surveyor she spoke with the [MEDICAL TREATMENT] center, they will transfer the Roho cushion into his [MEDICAL TREATMENT] chair and when the treatment is completed transfer the Roho cushion back into the wheelchair. IP-D informed Surveyor she spoke with R97 about this and also added this intervention to the care plan. IP-D provided Surveyor with an updated CNA care card dated 1/8/19 which documents under special instructions, R97 has [MEDICAL TREATMENT] (Davitias) every Tuesday, Thursday, and Saturday. R97 is transported by van service to the [MEDICAL TREATMENT] center in his w/c (wheelchair) with Roho cushion in place. The [MEDICAL TREATMENT] center is aware of the need to transfer Roho cushion from w/c to his [MEDICAL TREATMENT] chair while he is receiving treatment and return cushion to his w/c once treatment is completed. The altered renal function ([MEDICAL TREATMENT]) care plan dated 11/20/18 was updated with an approach dated 1/8/19 of Special Instructions: R97 has [MEDICAL TREATMENT] (Davitias) every Tuesday, Thursday, and Saturday. R97 is transported by van service to the [MEDICAL TREATMENT] center in his w/c (wheelchair) with Roho cushion in place. The [MEDICAL TREATMENT] center is aware of the need to transfer Roho cushion from w/c to his [MEDICAL TREATMENT] chair while he is receiving treatment and return cushion to his w/c once treatment is completed. 2. R104 has [DIAGNOSES REDACTED]. R104 was admitted to the Facility with a Stage 4 pressure injury on her right gluteal fold. The impaired skin integrity care plan dated 7/5/18 has approaches also dated 7/5/18 of; Note changes in level of risk for skin breakdown and minimize factors, Educate resident/family/staff regarding treatment and preventative measures, Treatment as ordered. Refer to current MAR (medication administration record), Review at NAR and follow recommendations, Braden Scale per schedule and prn (as needed), See other care plan: Self care Deficient/Impaired Mobility (Roho cushion (cushion), clinitron bed, LUE (left upper extremity) splint, turn and reposition every 2 hours); Nutrition careplan; and Alteration in Tissue Perfusion, Roho cushion if up in chair, Monitor left upper extremity for skin irritation and proper circulation with use of splint, Wound vac to right gluteal pressure injury. Refer to current MAR for instructions and current settings, Alternate placement of wound vac bridge to avoid skin irritation/rash. Refer to current MAR, Administer IV (intravenous) antibiotics as ordered for treatment of [REDACTED]. Refer to current MAR, RUE (right upper extremity) PICC (peripherally inserted central catheter) line discontinued on 7/5/18, Assist with hygiene and general skin care. Avoid using hot water for cleansing, Reposition every two hours while in bed, Inspect skin integrity with AM (morning) and PM (evening) cares. Complete head to toe skin check with weekly bath as able. Report red or open areas to nurse, and If continent, clean skin with mild soap and water; pat dry. An approach dated 8/7/18 documents, P-500 Bed, low air loss mattress; reposition every 2 hours. and approaches dated 8/28/18 of Follow up wound clinic (Physician-I) Refer to consult. & Consult/assessment with wound care team. See wound team notes. Surveyor noted none of R104's care plans include an approach to offload R104's heels. The quarterly MDS (Minimum Data Set) with an assessment reference date of 9/25/18 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R104 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, and does not ambulate. R104 is at risk for pressure injury development and is coded as having one Stage 4 pressure injury. The CNA (Certified Nursing Assistant) care cared dated 12/1/18 under bed mobility documents, Extensive to complete assist of two. Air mattress. Assist with turning and repositioning every 2 hours. Ok for 1/4 rail (positioning device). Touch pad call light to be fastened to clothing on resident chest. At times resident has difficulty touching/activating call light. Place cell phone close to resident when in bed. Phone has voice activation and will call nurse 2ES (east south) cell hone or phone at nurses station when resident needs to contact staff. The Braden scale assessment dated [DATE] has a score of 14 which indicates moderate risk for skin breakdown. On 1/3/19 at 8:30 a.m., Surveyor observed morning cares for R104 who was in bed on her left side with CNA (Certified Nursing Assistant)-J and CNA-K. CNA-J & CNA-K washed their hands, placed gloves on and CNA-J informed R104 they were going to do range of motion first. Staff removed the sheet off R104 and Surveyor observed R104's heels were resting on the mattress and were not being offloaded. Surveyor observed range of motion to R104's bilateral lower extremities and then CNA-J & CNA-K washed & dressed R104. At 8:52 a.m. CNA-J & CNA-K removed their gloves, washed their hands, and CNA-K left R104's room. CNA-J placed a pillow under R104's upper right side and placed a pillow in between R104's knees. Surveyor observed R104's right heel was resting the pillow and the left was on the mattress. R104's heels are not being offloaded. CNA-J raised the head of the bed up, asked R104 when she wanted to brush her teeth which R104 stated when she gets up in the chair, lowered the bed down and placed the phone & call pad in reach. On 1/3/19 at 10:23 a.m., Surveyor observed R104 on her left side. Surveyor asked R104 if Surveyor could look at her feet which R104 gave her permission. Surveyor observed R104's right heel is on the pillow and the left heel is resting directly on the mattress. R104's heels are not being offloaded. On 1/3/19 at 11:55 a.m., Surveyor observed R104 in bed on her left side. There is a pillow between her knees, the right heel is resting directly on the pillow and R104's left heel is on the mattress. R104's heels are not being offloaded. On 1/7/19 at 9:31 a.m., Surveyor observed R104 in bed on her left side. There is a pillow between her knees, the right heel is resting directly on the pillow and R104's left heel is on the mattress. R104's heels are not being offloaded. On 1/8/19 at 10:11 a.m., Surveyor observed R104's wound vac treatment with IP (Infection Preventionist)-D, who is the Facility's wound nurse and RN (Registered Nurse)-L. Surveyor observed R104 is on her left side, there is a pillow between R104's knees and R104's heels are not being offloaded. There were no concerns identified with the wound vac treatment observed. At 10:46 a.m. upon completion of the wound vac treatment, RN-L raised the head of the bed up, placed a pillow between R104's knees and covered R104 with a sheet. Surveyor observed R104's heels are not being offloaded. On 1/8/19 at 1:19 p.m. Surveyor informed IP-D Surveyor did not note any approaches to off load R104's heels and asked why R104's heels are not offloaded. IP-D replied, that's a good question and indicated she will revise R104's care plan. On 1/8/19 at 2:55 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above. On 1/9/19 at 8:18 a.m., IP-D informed Surveyor she spoke with R104 and they are going to float her heels. IP-D informed Surveyor she then spoke with the manager as to why they didn't float R104's heels when she came in. IP-D indicated R104 was on a clinitron bed for quite a while as R104's wound was really bad then they switched over to a higher end air mattress. R104's doctor wanted her switched back to the clinitron bed as her wound wasn't progressing but R104 didn't do physically well as she was sweating and in pain. IP-D indicated they switched R104 back to the mattress she has now. Surveyor asked IP-D when did they switch back to the mattress R104 is currently on. IP-D informed Surveyor 10/19/18 and then provided Surveyor with an updated CNA care card dated 1/8/19 which now includes under bed mobility, Float heels off bed on a pillow. 3. R107's [DIAGNOSES REDACTED]. The Braden scale assessment dated [DATE] has a score of 16 which indicates mild risk. The admission MDS (Minimum Data Set) with an assessment reference date of 11/8/18 has a BIMS (brief interview mental status score of 7 which indicates severe impairment. R107 requires extensive assistance with two plus person physical assist for bed mobility & transfer and does not ambulate. R107 is at risk for developing pressure injuries and is coded as not having any pressure injuries. The potential for impaired skin integrity care plan dated 11/14/18 includes approaches also dated 11/14/18 of: Skin assessment per policy, Note changes in level of risk for skin breakdown and minimize factors, Identify and minimize exposure to mechanical and chemical skin irritants, Weekly skin assessment, Consult/assessment with wound care team if indicated, Review at NAR and follow recommendations, Braden Scale per schedule and prn (as needed), See other careplan: ADL (activity of daily living)/Mobility, Assist with hygiene and general skin care. Avoid using hot water for cleansing, Minimize pressure on bony prominence, Alternate bed/chair time, Inspect skin integrity with AM (morning) and PM (evening) cares. Complete head to toe check with weekly bath as able. Report red or open areas to the nurse, and If incontinent, clean skin with mild soap and water; pat dry. There is an approach dated 12/19/18 of Treatment as ordered. Refer to current MAR (Medication Administration Record.). Surveyor noted none of R107's care plans have an intervention/approach to offload his heels. On 1/2/19 at 10:16 a.m., Surveyor observed R107 in bed on his back with the head of the bed elevated. There is a thick blue mat on the wall along the right side, on the left side on the floor is a maroon colored mat, R107 is receiving oxygen via nasal cannula. Surveyor observed R107 is wearing black socks with his heels resting directly on the mattress and not offloaded. On 1/2/19 at 11:31 a.m., Surveyor observed R107 continues to be in bed on his back with the head of the bed elevated. R107's heels continue to be resting on the mattress and are not being offloaded. On 1/2/19 at 2:06 p.m., Surveyor observed R107 in bed on his back with the head of the bed elevated. R107's heels continue to be resting on the mattress and are not being offloaded. On 1/2/19 at 3:22 p.m., Surveyor observed R107 continues to be in bed on his back with the head of the bed elevated. R107's heels continue to be resting on the mattress and are not being offloaded. On 1/3/19 at 10:04 a.m., Surveyor observed R107 in bed on his right side with the head of the bed elevated. R107 is wearing black socks and has his heels resting directly on the mattress. R107's heels are not being offloaded. On 1/3/19 at 10:39 a.m., Surveyor observed R107 continues to be in bed on his right side with the head of the bed elevated. R107 is wearing black socks and has his heels resting directly on the mattress. R107's heels are not being offloaded. On 1/7/19 at 2:37 p.m., Surveyor observed R107 in bed on his right side with the head of the bed elevated. Surveyor observed R107's heels are resting on the mattress and are not being offloaded. The CNA care card dated 1/8/19 under bed mobility documents, Extensive assist of one (two assist with increased weakness), HOB (head of bed) elevated at 30 degrees, [MEDICAL CONDITION]/oxygen, high/low bed in low position while in bed, mat on floor and next to wall, scoop mattress, make sure resident is at the center of the bed/closer to the wall Bed with right side along wall. On 1/8/19 at 1:22 p.m., Surveyor asked IP (Infection Preventionist)-D, who is the Facility's wound nurse and DON (Director of Nursing)-B what the Facility is doing to prevent pressure injuries from developing on R107's heels. IP-D informed Surveyor there's nothing specific for R107's heels. DON-B informed Surveyor R107's CNA care card doesn't indicate if R107 can move his legs. Surveyor asked IP-D to look into this and get back to Surveyor. On 1/8/19 at 2:55 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above. On 1/9/19 at 8:22 a.m., IP-D informed Surveyor she added to float heels to R107's care card and provided Surveyor with an updated care card dated 1/8/19 which includes, Float heels off the bed with a pillow. under the bed mobility section. 4. R118 was admitted to the Facility with [DIAGNOSES REDACTED]. The Braden scale assessment dated [DATE] has a score of 15 which indicates mild risk for skin breakdown. The admission MDS (Minimum Data Set) with an assessment reference date of 12/19/18 documents R118 requires extensive assistance with two plus person physical assist for bed mobility & transfer and does not ambulate. R118 is at risk for pressure injury development and is coded as not having any pressure injuries. The impaired skin integrity dated 12/19/18 has approaches also dated 12/19/18 of; Treatment as ordered. Refer to current MAR (medication administration record), Evaluate healing process and revise care plan as needed, Skin assessment per policy, Note changes in level of risk for skin breakdown and minimize factors, Identify and minimize exposure to mechanical and chemical skin irritants, Consult/assessment with wound care team if indicated, Review at NAR and follow recommendations, Braden scale per schedule and prn (as needed), See other careplan: ADL (activity daily living)/Mobility, Tissue Perfusion, Assist with hygiene and general skin care. Avoid using hot water for cleansing, If incontinent, clean skin with mild soap and water, Alternate bed/chair time, and Inspect skin integrity with AM (morning) and PM (evening) cares. Complete head to toe skin check with weekly bath as able. Report red or open areas to the nurse. Surveyor noted there are no approaches to offload R118's heels on any care plan. The CNA (Certified Nursing Assistant) care card dated 1/3/19 documents under bed mobility Extensive assist of two. High/low bed in low position while in bed and mat on the floor. Under special instructions documents, maintain right hip precaution, per policy. On 1/2/19 at 9:56 a.m. Surveyor observed R118 in bed on her back with the head of the bed slightly elevated. R118's heels are resting directly on the mattress and are not being offloaded. On 1/2/19 at 11:15 a.m., Surveyor observed R118 continues to be in bed on her back with the head of the bed slightly elevated. R118's heels are resting directly on the mattress and are not being offloaded. On 1/3/19 at 10:43 a.m., Surveyor observed R118 in bed on her back with the head of the bed slightly elevated. R118's heels are resting directly on the mattress and are not being offloaded. On 1/7/19 at 1:43 p.m., Surveyor observed R118 in bed on her back. R118 is wearing black socks and her heels are resting directly on the mattress. R118's heels are not being offloaded. On 1/7/19 at 2:41 p.m., Surveyor observed R118 continues to be in bed on her back. R118's heels are resting directly on the mattress and are not being offloaded. On 1/8/19 at 1:16 p.m., Surveyor asked IP (Infection Preventionist)-D, who is also the Facility's wound nurse, what interventions are being implemented to prevent pressure injuries to R118's heels. IP-D informed Surveyor they are floating her heels with a pillow under her ankles so her heels are floating. IP-D informed Surveyor that's as much as R118 wanted. Surveyor informed IP-D of the observations of R118 heels resting directly on the mattress and during these observations Surveyor did not observe a pillow under R118's ankles/legs. On 1/8/19 at 2:55 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above. The Facility policy entitled, Nursing Skin Care Policy, dated 10/2018, states: .e. II. Skin Care Policies . E. The Following criteria will help identify those at high risk: . 2. Decreased mobility/contractors; 3. Decreased cognitive function; . 8. Chronic liver, renal or [MEDICAL CONDITION]; . 10. Diabetes; . 15. Braden score of 10 or greater; 16. Motor or sensor deficits. IV. Pressure Ulcers 1. Prevention of Pressure Injuries: A pressure injury can occur wherever pressure has impaired circulation to the tissue. 2. Facility will evaluate residents for the following: A. Identify whether the resident is at risk for developing or has a PI (Pressure Injury) upon admission and quarterly and PRN (As Needed); Risk factors include but are not limited to: Impaired/decreased mobility and decreased functional ability; co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes mellitus; drugs such as steroids that may affect healing, impaired diffused or localized blood flow, . B. Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PI; C. Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors . 3. Preventative Practices: A. Reduce pressure/ shearing/friction: 1. Use appropriate pressure reducing or relieving devices-mattress or wheelchair cushion; 2. Use preventative equipment as needed (foot pillows, elbow protectors, foot cradles, ect (excreta) 3. Use draw sheet to reposition/transfer to prevent shearing/friction; 4. Use mechanical lifts as indicated; 5. Teach chair bound residents who are able to shift positions/weight every 15 minutes; 6 Avoid wrinkles in clothing, linens, briefs; 7. Proper Foley catheter tubing placement. B Positioning: 1. Change positions regularly and PRN whether in wheelchair/borda chair or bed; 2. Use pillows and support devices to reduce pressure on bony prominence . 3. Elevate the head of the bed as little and for as short a time as possible except for meals or meds served in bed; 4. Reposition with good body alignment . 5. Choose frequency of turning based on support surface tolerance for skin pressure and individual preference; . 7. Keep heels off of bed with use of pillows if no wounds- and Prevelon boots if wound is present; 8. Ambulate and ROM (Range of Motion) as ordered; 9. If resident is bed bound-start on repositioning program with scheduled; 10. If unable to reposition per self in wheel chair, staff to help resident reposition every 30 minutes; 11. Avoid positioning on areas of [DIAGNOSES REDACTED] (redness) or pressure injury. 5. R7 was admitted to the facility on [DATE], with current [DIAGNOSES REDACTED]. R7's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/21/18, documents: A staff assessment of mental status of 2, indicating R7 is moderately impaired decision making. R7 requires extensive assist of two staff for bed mobility, dressing, toilet use and personal hygiene. R7 has impaired range of motion on both lower and upper extremities on both sides. R7 is at risk for pressure ulcers and R7 has a stage 2 pressure ulcer discovered 9/20/18. R7's Care Plan, dated 9/21/18, states: Fragile skin. Surgical incision/dressing-Resolved. One stage two pressure ulcer to coccyx 9/20/18. Resolved on 11/6/18. Interventions include: (9/24/14) Weekly skin assessment from head to toe with tub bath or shower; (9/24/14) Treatment as ordered. Refer to current MAR (Medication Administration Record); (9/24/14) Review MAR and follow recommendations; (9/24/14) Braden scale per schedule and PRN; (9/21/18) Pressure relieving device(s) for bed, has an air mattress with a pump. Is on bed rest for at least 1 more week per MD (Medical Doctor) orders; . (9/25/18) Consult/ assessment with wound care team. See wound team notes; (9/25/18) Hospice Care-update hospice nurse with any changes in skin integrity; (9/24/18) Assist with hygiene and general skin care. Avoid using hot water for cleansing, alternate bed/chair time as needed, if incontinent, clean skin with mild soap and water; pat dry. R7 was hospitalized from [DATE]-9/14/18 due to a closed fracture of distal right femur and knee replacement. R7's Hospital Discharge Summary, dated 9/14/18, documents: . Follow up instructions: 1. Non weight bearing with walker or 2 crutches until seen by MD; . 5. Continue physical therapy as ordered, no range of motion for 2 weeks then may start as tolerated; . 11. Use knee immobilizer for 2 weeks then can stop; 12. Routine skin care, up to chair. Monitor closely for pressure ulcers. On 9/19/18 at 2:28 AM, R7's medical record documents: open lesion to coccyx 1.4 (cm-centimeters) x 1.2 (cm) reddened. Gentell border dressing x(times) 3 weeks until healed. Returned from hospital with area to coccyx being very superficial. Area increased in size. MD notified. On 9/21/18, R7's medical record documents: Coccyx area 2.0 (cm) x 3.0 (cm) x 0. At this time res (resident) has an air mattress, roho cushion in w/c (wheelchair). This is the first documentation of interventions for skin issues in R7's medical record. On 1/09/19 at 9:38 AM, Surveyor interviewed Infection Preventionist (IF)-D, who stated: She would consider R7 to be at increased risk for development of a pressure injury with the documented change in condition related to the femur fracture, non weight bearing status, need for a splint and bed rest. IF-D stated, residents believed to be at risk for development of pressure injuries she would expect the facility to see if an air mattress was available, evaluate increased protein needs to prevent or promote healing. IF-D stated, she didn't know about R7's fracture right away when she was readmitted but when she did find out she looked to see what needed to be done for R7 to heal the area on the coccyx. IF-D stated, the only documentation available in regards to interventions for R7's pressure injury were documented after the pressure injury was discovered. IF-D stated, an air mattress and wheelchair cushion was documented as being provided on 9/21/18. IF-D could not state what the facility did to prevent R7's pressure injury upon return to the facility on [DATE]. On 1/9/19 Surveyor informed Administrator-A and Director of Nursing-B of the above concern.

Based on record review and interview, the facility did not keep 2 (R17 & R112) of 9 residents reviewed free from unnecessary drugs. * R17 received an incorrect antibiotic when she had an infection that was resistant to the antibiotic being administered. * R112 received an antibiotic when he did not have appropriate signs and symptoms for use of the antibiotic. Findings include: The facility's policy dated as reviewed on (MONTH) (YEAR) and titled, Nursing Guidelines for Determining UTIs (urinary tract infections) documents under the Procedure section, 7. Update MD (medical doctor) on UA (urinalysis) results, also including statement that is our (the facility) to wait until the final C&S (culture and sensitivity) before starting treatment. Update MD with final C&S when available. 1. R17 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R17's Quarterly MDS (Minimum Data Set) dated 10/18/18 documents a BIMS score of 11, indicating that R17 is moderately cognitively impaired. Section H (Bowel and Bladder) had no appliances and is always incontinent of bladder. The Urinary Incontinence CAA Significant Change in status dated 1/26/18 documents under the Risk Factors section, R17 is alert with impaired cognition. She does not communicate her need for toileting. Non ambulatory. Review of bowel and bladder documentation during MDS reference window, indicates multiple episodes of bowel and bladder incontinence without evidence of a pattern. CARE PLAN: Will develop Care Plan. Continue current plan: Toileting Assist. R17's nursing note dated 5/2/18 documents, Resident has complaint of abdominal discomfort with urination. Temp 98.0. R17's nursing noted dated 5/4/18 documents, MD (Medical Doctor) here and viewed. UA (urinalysis)results started ATB (antibiotic) due to results aware of McGeers and wanted ATB started. R17's nursing noted dated 5/4/18 documents,[MEDICATION NAME] mg (milligram) BID (twice a day) x (for) 10 days for UTI. (urinary tract infection). Physician aware of McGeers criteria, wants resident to [MEDICATION NAME], do not wait for C & S (culture and sensitivity) results. R17's (MONTH) (YEAR) MAR (Medication Administration Record) documents that R17 received the above antibiotic on 5/4/18 and 5/5/18. Surveyor was unable to locate any documentation in R17's medical record or R17's medical consult notes that documented a reason as to why R17 was given an antibiotic on 5/4/18 without waiting to received the results of the culture and sensitivity for R17's urinary tract infection, per the facility's policy. R17's nursing note dated 5/5/18 documents, Received C & S (culture and sensitivity) results. Resident not susceptible to Cipro. Per T/O (telephone order) with MD (medical doctor)1. D/C (discontinue) Cipro. 2. Microbid 100 mg 1 tab po BID for 10 days. Writer left message for resident's representative to updated on change in ATB (antibiotic) with no return call thus far. Call received from daughter. R17's (MONTH) (YEAR) MAR (Medication Administration Record) documents that R17 received the above antibiotic from 5/5/18 to 5/15/18. Surveyor was unable to locate any documentation in R17's medical record or R17's medical consult notes that documented a reason as to why R17 was given an antibiotic on 5/4/18 without waiting to received the results of the culture and sensitivity for R17's urinary tract infection, per the facility's policy. R17's nursing noted dated 10/26/18 documents, Call received from Resident representative with concerns for (resident) not being right. She feels like something is going on with her maybe a UTI (urinary tract infection) . Call placed to MD (medical doctor) .MD stated to monitor. R17's nursing note dated 10/28/18 documents, Resident states she has pain with urination, but denies all other pain at this time. Family complaint and assessment for resident. Resident complained of pain with urination, is incontinent with no fever. Aware of McGeers new orders for UA (urinalysis). R17's nursing note dated 10/29/18 documents, UA (urinalysis) results received . new orders received for Bactrim DS BID (twice a day) for 10 days for a UTI (urinary tract infection). MD (medial doctor) aware of McGeers policy. R17's (MONTH) (YEAR) MAR (Medication Administration Record) documents R17 received the above antibiotic on 10/29/18, 10/30/18 and 10/31/18. Surveyor was unable to locate any documentation in R17's medical record or R17's medical consult notes that documented a reason as to why R17 was given an antibiotic on 10/29/18 without waiting to received the results of the culture and sensitivity for R17's urinary tract infection, per the facility's policy. R17's nursing note dated 10/31/18 documents, Spoke with MD (medical doctor) regarding final report of susceptibility for UTI (urinary tract infection). New orders received and noted, dc (discontinue) bactrim ds, start [MEDICATION NAME] 100 mg (milligrams) po (by mouth) bid (twice a day) for 10 days for uti (urinary tract infection). R17's (MONTH) and (MONTH) (YEAR) MAR (Medication Administration Record) documents R17 received the above antibiotic from 10/31/18 to 11/10/18. Surveyor was unable to locate any documentation in R17's medical record or R17's medical consult notes that documented a reason as to why R17 was given an antibiotic on 10/29/18 without waiting to received the results of the culture and sensitivity for R17's urinary tract infection, per the facility's policy. On 1/9/19 at 9:10 a.m., Surveyor informed Infection Preventionist-D of the above findings. Surveyor asked Infection Preventionist D if R17 received an antibiotic that was not necessary and ineffective per the culture and sensitivity reports on both 5/4/18 and 10/29/18. Infection Preventionist-D informed and confirmed to Surveyor that R17 received an antibiotic that was not necessary and ineffective per the culture and sensitivity reports on both 5/4/18 and 10/29/18. Surveyor asked Infection Preventionist-D why R17 received an antibiotic for a suspected UTI on 5/4/18 and on 10/29/18 without waiting to received the results of the culture and sensitivity, per the facility's policy. Infection Preventionist-D informed Surveyor that she believed R17's physician wanted to treat R17 rapidly for a suspected UTI on the above dates prior to the culture and sensitivity results. Infection Preventionist-D confirmed to Surveyor that R17's physician did not document any reason in R17's medical record or in progress notes a reason as to why R17 was being treated with an antibiotic on the above dates prior to the culture and sensitivity results. Infection Preventionist-D informed Surveyor that she would speak with R17's physician and provide education on the facility's policy for antibiotic use only after the culture and sensitivity results have been received. No additional information was provided as to why R17 received an antibiotic for a suspected UTI on 5/4/18 and on 10/29/18 without waiting to received the results of the culture and sensitivity, per the facility's policy. The Guidelines for Determining UTIs (urinary tract infection) under procedures last reviewed 9/2018 documents, UTI includes only symptomatic urinary tract infections. Surveillance for asymptomatic bacteriuria (defined as the presence of a positive urine culture in the absence of new signs and symptoms of UTI) is not recommended, as this represents baseline status for many residents. The following is based on McGeer's definitions for UTI and should be used when determining if the resident qualifies for having a UTI. A suspected urinary tract infection worksheet should be filled out for every suspected UTI. 2. For residents' with an indwelling catheter (both a and b must be present) a. At least 1 of the following signs and symptoms 1. Fevers, rigors, or new-onset [MEDICAL CONDITION], with no alternate site of infection 2. Either acute change in mental status or acute functional decline, with no alternate [DIAGNOSES REDACTED].> 3. New-onset suprapubic pain or costovertebral angle pain or tenderness 4. Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate b. Urinary catheter specimen cultures with at least 100,000 cfu/ml (colony forming units/milliliter) of any organism. 2. R112 has [DIAGNOSES REDACTED]. R112 has a Foley catheter. The nurses note dated 10/24/18 at 5:07 a.m. documents, URINARY FINDINGS: no problems noted Foley catheter intact and patent draining out 400 cc (cubic centimeters) of urine this N[NAME] (night) shift. The nurses note dated 10/24/18 at 1:55 p.m. documents, URINARY FINDINGS: no problems noted. The nurses note dated 10/24/18 at 4:03 p.m. documents, URINARY FINDINGS: Moderate/heavy amount of sediment noted in urine. Fluids encouraged. Resident afebrile at this time. The physician telephone order dated 10/24/18 documents, Obtain urine specimen for a urine culture due to purulent discharge from penis around catheter site and cloudy appearance to urine. The nurses note dated 10/25/18 at 12:05 a.m. documents, URINARY FINDINGS: Distal penis noted to have purulent yellow drainage HS (hour sleep). Temp (temperature) 98.9. Noter (writer) cleansed with soap and water. Order by N[NAME] (Night) nurse-G obtained to culture urine due to heavy amount of sediment and purulent drainage from penis. Noter (writer) changed catheter and drainage bag. Urine specimen needs to be obtained when more urine available for collection. The nurses note dated 10/25/18 at 12:25 a.m. documents, Time: 23:14 (11:14 p.m.) 10/24/18 PHYSICIAN/NP (nurse practitioner) CONTACT: spoke with Physician-H REGARDING: Urine remains cloudy with sediment and purulent drainage noted from the tip of the penis. RESULT: new orders received and noted Obtain urine specimen for a urine culture. The nurses note dated 10/25/18 at 3:53 a.m. documents, URINARY FINDINGS: No discharge noted. Urine is concentrated and cloudy, resident denies pain and discomfort. The nurses note dated 10/25/18 at 2:12 p.m. documents, URINARY FINDINGS: no problems noted. The nurses note dated 10/25/18 at 10:13 p.m. documents, URINARY FINDINGS: no problems noted No drainage noted from penis. The nurses note dated 10/25/18 at 11:44 p.m. documents, URINARY FINDINGS: no problems noted C & S pending Temp 98.4 No penile discharge. The Microbiology-Bacteriology lab report for urine culture collected on 10/25/18 under final report verified 10/27/18 documents, 75,000 cfu/ml Proteus Mirabilis. There were no other organisms identified. The physician telephone order dated 10/25/18 documents, Amoxocillin 500 mg (milligrams) po (by mouth) TID (three times daily) x (times) 7 days dx (diagnosis) UTI (urinary tract infection). On 1/8/19, during the infection control interview with DON (Director of Nursing)-B and IP (Infection Preventionist)-D Surveyor asked how R112 met the Facility's definition for infection when R112's physician ordered Amoxocillin 500 mg on 10/25/18 for seven days. DON-B informed Surveyor they use the McGeers criteria and if the Resident doesn't meet the criteria then they educate the doctors and document. IP (Infection Preventionist)-D informed Surveyor R112 met the criteria by purulent drainage and a lab value greater than 100,000. Surveyor informed IP-D Surveyor didn't think R112's lab value was over 100,000 and asked IP-D to look into this. On 1/9/19 at 8:25 a.m. IP-D provided Surveyor with an infection worksheet for R112 with an infection date of 10/24/18 and informed Surveyor R112 did not meet the criteria. Surveyor asked IP-D when she completed the infection worksheet. IP-D informed Surveyor yesterday (1/8/19). Surveyor asked IP-D if R112 should not have been treated with an antibiotic. IP-D replied yes and informed Surveyor she did not find where the nurse had updated the physician regarding R112 not meeting the criteria for an UTI.

Based on observation, interview, and record review, the facility did not ensure 2 (R106 & R118) of 25 residents reviewed, received treatment and care in accordance with resident's care plan and physician orders. * R106 did not receive a psychological assessment in accordance with physician recommendations. * R118 was observed not wearing ted stockings in accordance with her plan of care. Findings include: 1. R106 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R106's Quarterly MDS (Minimum Data Set) dated 12/26/18, documents a BIMS (Brief Interview for Mental Status) score of 3, indicating that R106 is severely cognitively impaired. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R106 has severely impaired cognitive skills for daily decision making. Section D0600 (Mood/Total Severity Score) documents a score of 10, indicating that R106 experiences depressive symptoms. Section E0200 (Behavioral Symptoms) documents that R106 experiences behavioral symptoms not directed towards others on a daily basis. Section N0410 (Medications Received) documents that R106 received 7 days of both antidepressant and anti-anxiety medication. R106's Behavioral Symptoms CAA (Care Area Assessment) dated 7/5/18 documents under Condition section, Change in behavior indicates behavior, care rejection or wandering has gotten worse since prior assessment. CARE PLAN: Will develop Care plan. R106's Cognitive Loss/Behaviors plan of care dated as initiated 10/2/18 documents under the Problem section, Disease process indicates inevitable decline Confusion/Forgetfulness. Psych ([MEDICAL CONDITION]) med (medication) use; Verbal behavioral symptoms-yells/screams out. Surveyor noted that R106 was currently being monitored for the use of [MEDICAL CONDITION] medication and was being treated by NP (Nurse Practitioner)-M. R106's Optum Progress Notes dated 10/4/18 and written by NP-M documents under the Assessment & Plan section, Diagnostic Statement: Unspecified dementia with behavioral disturbance; Plan: Dementia with behavioral disturbance. Chronic .Staff continue to report calling out behaviors that disturb others, although is calmer at times. Plan: Continue meds (medication) as ordered. Staff to continue to monitor for improvement of behaviors .Refer to psych (psychologist) for f/u (follow up) of behaviors. Diagnostic Statement: Major [MEDICAL CONDITION], recurrent, mild; Plan: Major [MEDICAL CONDITION]. Chronic .Continues to have frequent calling out behaviors, per staff report, although does appear calmer at times .Plan: Meds (medication) as ordered. Continue to monitor mood/behavioral manifestations w/ (with) each NP (Nurse Practitioner). Psych (psychological) eval (evaluation). Diagnostic Statement: Anxiety disorder; Plan: Anxiety. Chronic .Has frequent calling out behaviors, on a daily basis. Is sometimes not easily re-directable. Plan: Meds (medications) as ordered Psych (psychological) eval (evaluation). Surveyor was unable to locate any documentation in R106's medical record that R106 was referred to or had a psychological evaluation completed per NP-M's recommendations. R106's Optum Progress Notes dated 11/13/18 and written by NP-M documents under the Assessment & Plan section, Diagnostic Statement: Unspecified dementia with behavioral disturbance; Plan: Dementia with behavioral disturbance. Chronic .Staff continue to report calling out behaviors that disturb others, although is calmer at times. Plan: Continue meds (medication) as ordered. Staff to continue to monitor for improvement of behaviors .Refer to psych (psychologist) for f/u (follow up) of behaviors. Surveyor was unable to locate any documentation in R106's medical record that R106 was referred to or had a psychological evaluation completed per NP-M's recommendations. R106's Optum Progress Notes dated 12/11/18 and written by NP-M documents under the Assessment & Plan section, Diagnostic Statement: Unspecified dementia with behavioral disturbance; Plan: Dementia with behavioral disturbance. Chronic .Staff continue to report calling out behaviors that disturb others, although is calmer at times. Plan: Continue meds (medication) as ordered. Staff to continue to monitor for improvement of behaviors .Refer to psych (psychologist) for f/u (follow up) of behaviors. Surveyor was unable to locate any documentation in R106's medical record that R106 was referred to or had a psychological evaluation completed per NP-M's recommendations. On 1/8/19 at 12:36 p.m., Surveyor informed SW (Social Worker)-N of the above findings. Surveyor asked SW-N if R106 was was referred to or had a psychological evaluation completed per NP-M's recommendations. SW-N and Surveyor both reviewed R106's medical record and were unable to locate any documentation in R106's medical record that R106 was referred to or had a psychological evaluation completed per NP-M's recommendations. SW-N informed Surveyor that she would be discussing with NP-M her recommendations and would be referring R106 for a psychological evaluation per NP-M's recommendations. On 1/8/19 at 2:58 p.m., during the daily exit, Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. At the time, no additional information was provided. On 1/9/18 at 9:56 a.m., NP-M informed Surveyor that she had forgotten to write a physician order [REDACTED]. NP-M informed Surveyor that moving forward she would ensure that R106 had a psychological evaluation for her behaviors. 2. R118 has a [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) with an assessment reference date of 12/17/18 has a BIMS (brief mental status) score of 3 which indicates severely impaired. R118 requires extensive assistance with two plus person physical assist for transfer & dressing and does not ambulate. The CNA (Certified Nursing Assistant) care card dated 1/3/19 and located inside R118's closet documents TEDS: on in AM (morning), off at HS (hour sleep). On 1/2/19 at 9:56 a.m. Surveyor observed R118 in bed on her back. Surveyor observed R118 was wearing black socks and did not observe ted stockings on R118. On 1/2/19 at 11:15 a.m. Surveyor observed R118 continues to be in bed on her back with the head of the bed slightly elevated. Surveyor observed R118 is not wearing ted stockings. On 1/2/19 at 3:19 p.m. Surveyor observed R118 sitting in a wheelchair in the lounge area with the television. R118 is wearing pants, with the pant leg up, black socks, and sneakers. Surveyor observed R118 is not wearing ted stockings. On 1/7/19 at 9:44 a.m. Surveyor observed R118 sitting in a wheelchair in the lounge with the television. Surveyor observed R118 has black socks on but is not wearing any ted stockings. On 1/7/19 at 1:43 p.m. Surveyor observed R118 laying in bed on her back. R118 has black socks on her feet and is not wearing ted stockings. On 1/7/19 at 1:56 p.m. Surveyor asked CNA (Certified Nursing Assistant)-F if R118 wears ted stockings. CNA-F replied, honestly just notice she wears gripper socks and has regular socks in her drawer. Surveyor asked CNA-F if R118 is suppose to wear ted stockings. CNA-F informed Surveyor she hasn't had R118 too often and she usually works the night shift. On 1/8/19 at 9:37 a.m. Surveyor observed R118 sitting in a wheelchair in the lounge with the television. Surveyor observed R118 is wearing black socks and does not have ted stockings on. On 1/8/19 at 1:57 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on observation, interview and record review the Facility did not ensure 1 (R112) of 1 residents were assessed to self-administer their medications. On 1/2/19 Surveyor observed R112 with a medication cup with medication on his over bed table. R112 did not have a self-administration assessment completed. Findings include: The Medication Administration: Self-Administered Medications policy and procedure dated 10/2018 under purpose documents To ensure that residents are assessed for safety to self-administer medications with MD (medical doctor) orders. Under Procedure documents 1. The interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and appropriate. 2. To ensure safe and appropriate Self-Administration, Nursing should educate residents to ensure that a resident is able to: a. State the name, dose, strength, frequency, and purpose for use of his/her medications; b. Understand the possible side effects of his/her medications and that he/she should notify Facility staff if he/she experiences any such side effects; c. Correctly administer, inject or apply his/her medications; d. Correctly store his/her medications in a locked compartment; e. The resident's physical capacity to swallow without difficulty and to open medication bottles; f. The resident's cognitive status; g. The resident's comprehension of instructions for the medications they are taking, including the dose, timing, and signs of side effects and when to report to the nursing staff; h. The resident's ability to understand what refusal of medication is, the appropriate steps taken by staff to educate when this occurs. Note: the self-administer assessment must be completed in ECS (electronic computer system) to ensure they are safe to self-administer. On 1/2/19 at 10:50 a.m. Surveyor observed R112 eating breakfast in bed. To the right of R112's breakfast tray on the over bed table Surveyor observed a medication cup containing one purple tablet and four white tablets. Surveyor observed there wasn't a licensed nurse in R112's room. Surveyor chatted with R112 for a few moments. During this conversation Surveyor asked R112 if the nurse usually leaves his medication. R112 informed Surveyor the nurse is coming back. On 1/7/19 at 8:56 a.m. Surveyor reviewed R112's paper medical record and was unable to locate a self administration of medication assessment. On 1/7/19 at 1:29 p.m. Surveyor reviewed R112's electronic medical record including the self medication administration assessment which Surveyor clicked on. After clicking on the self medication administration assessment nothing found appeared on the computer screen. On 1/7/19 at 2:28 p.m. Surveyor met with RN (Registered Nurse)/NS (Nursing Supervisor)-C and RN/NS-E. Surveyor asked where the self administration of medication assessment would be found. RN/NS-C informed Surveyor if they have anyone it would be under the assessment section in the chart. Surveyor asked if R112 self administers his medication. RN/NS-E replied no. Surveyor informed RN/NS-C and RN/NS-E of the observation of R112's medication on his over bed table. RN/NS-E stated R112 is not suppose to have it. On 1/7/19 at 3:11 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on record review and interviews, facility staff did not make prompt efforts to actively work toward a resolution of one of three grievances voiced by Residents. Resident #1 reported several times to a CNA (Certified Nursing Assistant) during morning cares on [DATE] that she was worried the night nurse gave her the wrong medication. The CNA reported this concern to the to the night nurse. The night nurse stated she gave the resident the correct medication, and did not pursue the matter further. Resident #1 was found unresponsive at 12:45 p.m. on [DATE] and transported to the hospital. [MEDICATION NAME] was administered to the resident, who became responsive. Since Resident #1 did not have orders for any narcotic medication, an investigation was conducted which concluded Resident #1 most likely received her roommate's medications around 6:00 a.m. on [DATE]. Resident #1 tried to alert staff that she received the wrong medication, but this information was not acted upon, leading to an unresponsive episode with very slow respiration rate. Cross reference F333. Findings include: Resident #1 is [AGE] years old, admitted to the facility on [DATE] with major [DIAGNOSES REDACTED]. On [DATE] and [DATE], Surveyor # investigated a facility self-report and complaint by outside party that Resident #1 was found in her bed on [DATE] at 12:30, unresponsive, with very slow respirations. Staff called the family asking their wishes since Resident #1 was a "No Code". Per family request, staff called an ambulance, who transported Resident #1 to the hospital. At the hospital, Resident #1's blood toxicity screen showed high levels of opiates in her system, and they administered [MEDICATION NAME]. Resident #1 immediately revived from the [MEDICATION NAME]. Resident #1 was not receiving any narcotic medications, so the facility conducted an investigation. The facility investigation includes a statement by RN (Registered Nurse)-E dated [DATE] stating she spoke to CNA-C on the phone regarding Resident #1's condition on [DATE]. CNA-C told RN-E she assisted Resident (#1) up in a.m. During the get-up resident was alert, and repeated more than once she thought she received the wrong pills. At one point, she mentioned the nurse had a stuffed animal with its head off. (CNA-C) states she updated the night nurse, and (RN-D) the a.m. nurse of the concerns (Resident #1) had regarding her medication. Later in the a.m., (CNA-C) assisted (Resident #1) to bed for a nap and states resident was her usual self at that time. CNA-C wrote out a statement dated [DATE] that states "I was getting (Resident #1) up for the day. She told me she had gotten the wrong meds and that the nurse who gave them to her had a stuffed animal (dog) with the head cut off. That was kind of weird behavior for her. She was awake and asked me 2 or 3 more times about getting the wrong meds. I told her I would ask the nurse about this. I told the night nurse and she said she gave her her [MEDICATION NAME]. I do not know what she gets so I said I am just asking because (Resident #1) thinks she got the wrong meds. I brought her out to the breakfast table. I had also told (Registered Nurse RN-D) the day nurse about her weird behavior. Later after breakfast we had toileted and laid (Resident #1) down. She was acting "normal", like her normal behavior, her normal routine. Then we went to check on (Resident #1) and get her up for lunch. This was around 12:30 p.m. She was blue and would not respond to us. We told nurse (RN-D) and then she came in." RN-D's statement dated [DATE] states "On Saturday [DATE] during report night shift to day shift, I noticed (Resident #1) moving away from table propelling toward nurses' station. She was crying. I approached her. She stated the nurse woke me up and gave me two pills, now I'm scared. She also stated the nurse scared her as she showed her a headless stuffed animal. I assured her everything would be OK. I told the night nurse (RN-I); she told me that she only gave (Resident #1) her [MEDICAL CONDITION] medication. At this time, (Resident #1) was calm, completed her breakfast. She was laid down after 10:00 a.m. per usual. At 12:30 p.m., CNA's noted her unresponsiveness. I was called to her room, resident did not respond. Supervisor was alerted, family was called, MD called, ambulance called. In addition, night nurse did see (Resident #1) at breakfast so she did know what Resident I was identifying. The investigation includes additional interviews (see F333), which do not conclusively identify if RN-D and/or RN-F were informed of Resident #1's concerns regarding getting the wrong medication, but RN-I was informed. The investigation indicates RN-I told CNA-C and RN-D Resident #1 did receive the correct medication, but took no further action to address Resident #1's concerns. On [DATE], NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B informed Surveyor # of the steps taken to prevent future medication errors, but did not address the issue of staff not following up on Resident #1's concern of receiving the wrong medication.

Based on record reviews, staff interviews, and review of the WI Division of Public (DPH) Health Person-To-Person Norovirus Outbreak Summary Report Form from, the facility did not maintain an Infection Control Program that investigated, controlled and prevented infections in the facility. An outbreak of gastrointestinal illness went through this facility beginning [DATE], affecting ,[DATE] residents (79%) by the time it ended on [DATE]. Eighty of 250 staffs also became ill during this time. The facility's infection control program failed to prevent the spread of the illness because the facility did not follow its own policy and procedures for recognizing when an outbreak had occurred thereby preventing immediate implementation of appropriate precautions for prevention. Ill and non-ill residents were allowed out of contact precautions to commingle together at meal times and during activities and appropriate precautions were not used by staff caring for ill residents. The facility's failure to have an infection control program that identified and prevented the spread of infection, created a finding of Immediate Jeopardy that began on [DATE]. The facility was informed of the immediate jeopardy on [DATE] and was able to remove the immediate jeopardy on [DATE]. The deficient practice continues at a scope/severity of an F (potential for harm that is not immediate jeopardy/widespread) because all portions of the facility's action plan have not been fully implemented and because of the following example: On [DATE] Resident #4 was observed at a meal time eating at an over the chair table in the dining room while wearing a mask around his neck. Resident #4 was observed to be actively coughing. When the Surveyor reviewed the facility's infection control logs for February 2011 Resident #4 was not included on the facility's February line lists or list of residents with current infections. Findings include; NOROVIRUS IN WI LTC FACILITIES On [DATE], the Department of Health Services, Division of Quality Assurance sent out via email list serve an announcement that directed providers to the link <http://www.dhs.wisconsin.gov/rl_DSL/Publications/pdfmemos/,[DATE]attach.pdf> to view DQA Memo ,[DATE]/Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in WI Long-Term Care Facilities (LTCF). This document notes the following to include but is not limited to: It is the responsibility of the LTCF to implement aggressive infection control measures quickly and to notify the appropriate agencies of the outbreak or suspected outbreak. 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. A. Failure to promptly identify an outbreak 1.) On [DATE], Surveyors # and # reviewed the WI Division of Public Health report titled Communicable Disease Epidemiology Section Person-Person Norovirus Outbreak Summary Report Form for Lasata Care Center. This report noted that ,[DATE] (76%) residents became ill, two were hospitalized and six died . It should be noted that the facility capacity is 180 beds not 185 so the attack rate is ,[DATE] or 79% this report also noted that ,[DATE] (31%) staff became ill with Norovirus and the duration of the outbreak was 55 days. On [DATE] at 10:24 a.m., Surveyor # and Surveyor # interviewed RN-C regarding the facility's infection prevention and control program. RN-C reported that the facility is currently conducting surveillance for Upper Respiratory Infections and Urinary Tract Infections. RN-C explained the facility's system for conducting surveillance for infections. Each of the four units is to identify residents with signs/symptoms of infection on the unit's 24-hour report. RN-C reviews the 24 hour reports on a daily basis and conducts chart review for 180 residents weekly. RN-C reported that she then develops a log based on these reviews. When asked about the Norovirus outbreak, RN-C reported that the 1 West Unit was put in quarantine on [DATE] and the 2 East Unit was put in quarantine the weekend of ,[DATE] and [DATE] when ,[DATE] residents became ill. On ,[DATE] and [DATE], Surveyor # reviewed the facility's infection control policies and procedures. The facility policy titled Guidelines for Determining Gastrointestinal Infections defined a Gastrointestinal Tract Infections as follows; One of the following criteria must be met: a. Two or more loose or watery stools above what is normal for the resident within a 24-hour period b. Two or more episodes of vomiting in a 24 hour period. c. Both of the following: a stool culture for a pathogen (Salmonella, Shigella, E coli, Campylobacter) or a toxin assay positive for [DIAGNOSES REDACTED]icile toxin and: at least one sign or symptom compatible with gastrointestinal tract infection (nausea, vomiting, abdominal pain or tenderness, diarrhea. The facility policy titled Viral Gastroenteritis Prevention and Control of an Outbreak notes "An outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset symptoms of vomiting or diarrhea within one to two days." On ,[DATE] and [DATE], Surveyors # and # reviewed documents titled Norovirus Line Lists provided by RN-C for all four units (1 East, 1 West, 2 East, and 2 West). All 4 line lists started in [DATE] and a total of 142 residents were ill. Symptom abbreviations used on the line lists included; N (nausea), V (vomiting), D (diarrhea), AC (abdominal cramps), Fe (fever), Chills 1 West Unit On [DATE] and [DATE], Surveyor # reviewed the Norovirus Line List for 1 West: Lasata Care Center that noted the following; Resident #9 - Onset of Illness - [DATE] - N, V, D, AC, Fe Resident #10 - Onset of Illness - [DATE] - N, V, D, Resident #15 - Onset of Illness - [DATE] - N, V, Fe Resident #16 - Onset of Illness - [DATE] - N, V, D, Fe, Chills Resident #18 - Onset of Illness - [DATE] - N, V, D, AC, Lab results positive for Norovirus. According to the 1 West Norovirus Line List, the facility should have suspected an outbreak on [DATE], not [DATE], and should have implemented the facility's policy and procedure to immediately isolate the affected residents to their rooms until 48 hours after their symptoms cease. On [DATE], Surveyors # and # reviewed the facility document titled Norovirus Outbreak Time Line ,[DATE] which noted the following; "[DATE](10): It was reported that 4 residents on the 1 West unit were exhibiting signs and symptoms of nausea, vomiting and diarrhea. The residents were immediately placed in contact precautions." "[DATE]: Four additional residents developed s/s within the last 24 hours. The 1 West Unit was immediately placed under quarantine..." According to the 1 West Norovirus Line List, the facility should have suspected an outbreak on [DATE] and should have implemented the facility's policy and procedure to immediately isolate the affected residents to their rooms until 48 hours after their symptoms cease. On [DATE] at 10:07 a.m., Surveyors # and # interviewed RN-C and reviewed the 1 West Norovirus Line List showing RN-C where two residents (#15, #16) on [DATE] exhibited signs and symptoms indicative of a gastrointestinal infection and the facility policy states "an outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset symptoms of vomiting or diarrhea within one to two days." RN-C reported she first realized there was an outbreak on ,[DATE] when staff called her and told her 4 residents in 24 hours were exhibiting nausea, vomiting and diarrhea. Surveyors noted that according to review of the 1 West line list 7 Residents were actually ill with signs and symptoms indicative of Norovirus as [DATE]; not just 4. By [DATE], 12 Residents residing on 1 West were ill with signs and symptoms of Norovirus rather than just the 4 additional Residents as indicated on the facility's Outbreak Time Line. Eventually, 43 Residents residing on the 1 West Unit became ill with signs and symptoms of Norovirus. 2 East The 2 East Line List notes the following; Resident #8 - Onset of Illness - [DATE] - N, V, D, Fe (Note: Should have appeared on the list on [DATE] as the resident had had three episodes of loose stools in two days, as documented in the nurse's notes.) Resident #11 - Onset of Illness - [DATE] - N, V, D (Note: Even though Resident #11 was ill with symptoms that met the facility and WI DHP's definition of a gastrointestinal tract infection in [DATE] ([DATE]-[DATE]) and the beginning of [DATE], as documented in the nurse's notes, Resident #11's name does not appear on the facility's [DATE] infection control log that was reviewed by Surveyor # on [DATE]. Resident #11 was not added to the 2 East Norovirus Line List until [DATE]. Resident #14 - Onset of Illness - [DATE] - N, V, D Resident #17 - Onset of Illness - [DATE] - D - New Admit [DATE] Based on review of the 2 East Line List and the facility's outbreak policy, the facility should have suspected a potential outbreak of viral gastroenteritis on the 2 East Unit on [DATE]. However a review of records for Resident #8 and #11 indicate that the facility should have suspected a potential outbreak even sooner. According to review of the facility's Outbreak Timeline, facility staff did not recognize that an outbreak occurred and did not implement appropriate precautions until [DATE] by which time 15 residents were ill. Eventually, 37 residents on the 2 East Unit became ill. Resident #8 On ,[DATE]-[DATE], Surveyor # reviewed Resident #8's record to include a review of the documents titled Nurse's Notes. Nurse's Notes provided the following information; [DATE] - 22:03 (10:03 pm) - Stool: 1 loose stool noted foul smelling / fatty, x 1 this shift [DATE] - 22:11 (10:11 pm) - Digestive Condition: vomiting small amount at dinner [DATE] - 14:03 (2:03 pm) - Comments: ... 1 episode of loose stools no nausea or emesis [DATE] - 22:14 (10:14 pm) - Stool: Loose stool soft and not formed. Comments: Stool spec collected this shift and sent to the lab to test for[DIAGNOSES REDACTED]. [DATE] - 05:03 (5:03 am) - Stool: Malodorous; gelatinous. [DATE] - 14:28 (2:28 pm) - Digestive Condition: diarrhea, Stool specimen was obtained and sent to the lab; results received today and is positive for c-dif... Resident put on precautions... Resident started to spit up at lunch when eating... [DATE] - 20:53 (8:53 pm) - Digestive Condition: diarrhea, STOOL: Resident had one Large loose stool. [DATE] - 05:07 (5:07 am) - STOOL: foul smelling/fatty [DATE] - 07:55 (7:55 am) - Bowel Continence: Tends to be incontinent daily but has some control present. [DATE] - 14:15 (2:15 pm) - Digestive Condition: ...During lunch resident had large emesis [DATE] - 23:22 (11:22 pm) - B.M. Output: Large loose stool Resident #8's name appears on the 2 East Norovirus Line List with an onset of illness date of [DATE]. Even though Resident #8 was ill with symptoms of N,V, and D, met the facility and WI DPH definition of a gastrointestinal tract infection and the facility took a stool specimen to rule out[DIAGNOSES REDACTED]icile infection on [DATE], Resident #8 was not placed on the 2 East Line List until [DATE]. On [DATE], Surveyor # reviewed the 2 East 24-hour report form for [DATE]. Resident #8's name is not on the report but should be as the 24-hour report is the system that the facility uses to track potential or confirmed infections. Resident #11 On [DATE], Surveyor # reviewed documents titled Nurse's Notes in Resident #11's record which noted the following; [DATE] - 18:19 (6:19 pm) - Bowel Continence: Incontinent 2 or more times this shift [DATE] - 02:32 (2:32 am) - Bowel Continence: Incontinent 2 or more times this shift [DATE] - 10:51 (10:51 am) - Digestive Condition: Seeping unformed brown stool continuous [DATE] - 21:50 (9:50 pm) - Comments: "...had large loose stool earlier, greenish in color..." [DATE] - 02:52 (2:52 am) - Bowel Continence: Incontinent 2 or more times this shift [DATE] - 09:32 (9:32 am) - Bowel Continence: Incontinent 2 or more times this shift [DATE] - 10:12 (10:12 am) - Digestive Condition: diarrhea, seeping stool ...hospice nurse here and updated re: stools [DATE] - 11:37 (11:37 am) - Digestive Condition: Resident has had no loose stools thus far today....Test for[DIAGNOSES REDACTED] was negative. [DATE] - 02:06 (2:06 am) - Skin Problems: Has open lesion(s) present in past 7 days to Rt mid buttock. Contact isolation maintained for MRSA. [DATE] - 10:43 (10:43 am) - Digestive Condition: diarrhea, Fiber lax ineffective thus far for bulking up stools...Call placed to Heartland hospice to update RN on continued loose stools and see if possible prn could be ordered. [DATE] - 11:36 (11:36 am) - Digestive Condition: experiencing pain, experiencing nausea, diarrhea ...Stool: soft and unformed, (like pudding consistency) tarry [DATE] - 10:20 (10:20 am) - ...new order for [MEDICATION NAME] for loose stools [DATE] - 03:30 (3:30 am) - [MEDICATION NAME] ([MEDICATION NAME]) given for moderate loose stool @0145 (1:45 am) Nurse's Notes indicate that Resident #11 received [MEDICATION NAME] for loose stools/diarrhea on [DATE] at 8:37 am, [DATE] at 2:32 am, 8:24 pm, and 9:00 pm. On [DATE], nurse's notes documented that Resident #11 received [MEDICATION NAME] for diarrhea at 2:32 am, 4:16 am, and 9:00 p.m. **It should also be noted that per Surveyor # 's review of the facility Room Move document and the 2 East 24 Hour Report, Resident #11 was moved from the 1 West Unit to the 2 East Unit on [DATE]. On [DATE], nurse's notes documented that Resident #11 received [MEDICATION NAME] 4 mg for nausea at 5:15 pm. There is no charting in the nurses notes after [DATE] about the absence or presence of nausea and/or diarrhea until [DATE] at 5:29 am whereas staff documented "2 loose stools moderate amount." Even though Resident #11 was ill with symptoms that met the facility and WI DPH's definition of a gastrointestinal tract infection in [DATE] and the beginning of [DATE], Resident #11's name does not appear on the facility's [DATE] infection control log that was reviewed by Surveyor # on [DATE]. Resident #11 was not added to the 2 East Norovirus Line List until [DATE]. On [DATE], Surveyor # reviewed the 2 East 24-Hour Report for date [DATE]. Resident #11's name is not on the report and should be as the 24-Hour Report is the system that the facility uses to track potential or confirmed infections. Resident #17 The 2 East 24-Hour Report noted the following; [DATE] - Resident #17 was admitted to the facility [DATE] - PM Update- BM x 2 this shift [DATE] - Day Update - ...Diarrhea x 2, New order [MEDICATION NAME] PRN given @1400 (2:00 pm) [DATE] - PM Update - ...Loose stools x 2... Resident #17's name appears on the 2 East Norovirus Line List as of [DATE] 1 East Unit and 2 West Unit On [DATE] Surveyors # and # reviewed the 1 East and 2 West Unit Norovirus Line Lists. According to the 1 East Unit Norovirus Line List the facility should have suspected a potential outbreak on [DATE] when 2 Residents on [DATE] demonstrated signs and symptoms indicative of Norovirus. According to the 2 West Unit Norovirus Line Lists the facility should have suspected a potential outbreak on [DATE] when 4 Residents on [DATE] demonstrated signs and symptoms indicative of Norovirus It was not until [DATE] when, according to the facility Norovirus Outbreak Timeline; the facility finally placed all of the Resident living units on quarantine despite the fact that the facility should have recognized potential outbreaks of Norovirus on all of the Resident living units on an earlier date. The facility Norovirus Outbreak Timeline documents on [DATE]: "Daily report and rounds conducted throughout the facility. Emergency Department Head Meeting held. The entire facility was placed under quarantine due to the other units being affected ...." B. Failure to implement appropriate precautions and prevent commingling of residents The CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 notes the following; Section III. C. Syndromic and empiric applications of Transmission-Based Precautions. [DIAGNOSES REDACTED]. Since laboratory tests, especially those that depend on culture techniques, often require two or more days for completion, Transmission-Based Precautions must be implemented while test results are pending based on the clinical presentation and likely pathogens. Use of appropriate Transmission-Based Precautions at the time a patient develops symptoms or signs of transmissible infection, or arrives at a healthcare facility, reduces transmission opportunities. The facility policy titled Viral Gastroenteritis Prevention and Control of an Outbreak includes but is not limited to the following; B. Management of Residents and Staff 1. Immediate isolation of the resident and restricting access to affected area is essential. 2. Confine symptomatic residents to their room until 48 hours after symptoms cease. Symptomatic residents should be cohorted (e.g., residents with the same infection may share a room). 3. Exclude non-essential staff from entering the room/unit. What this policy does not include is the WI DPH recommendation to "Consider discontinuing use of common dining areas and instituting in-room dining." C. Institute Control Measures when a viral gastroenteritis outbreak is suspected without waiting for diagnostic confirmation. 1. Minimize movement of residents. Asymptomatic exposed residents should not be moved from an affected to an unaffected resident unit ..... 2. Cancel or postpone group activities for at least 48 hours after the last identified case. 7. Limit new admissions until the incidence of new cases has reached zero for at least 48 hours. If new admissions are being considered, consult with the Infection Control Nurse and the Facility Medical Director. Consider admitting resident(s) to an unaffected unit or to a unit that has no new cases. D. Management of Staff 2. Implement "contact precautions," which includes wearing personal protective equipment (gloves, mask, gown, goggles or face shield if vomitus is present) upon entry into the resident(s) room and when in contact with the symptomatic resident (CDC, 2004). On [DATE] at approximately 7:30 a.m. Surveyor # conducted an interview with RN-D who indicated that she did work during the outbreak that occurred in [DATE] into [DATE]; RN-D indicated that residents did come out of their rooms to eat meals in the dining room on the unit. Staff segregated the dining room with a section for sick residents and a section of well residents. She further indicated that at one time both sick and well residents were in the same dining room. On [DATE] at approximately 8:20 a.m., Surveyor # conducted an interview with RN-E who indicated she also worked during the outbreak of illness that occurred in [DATE]. RN-E also indicated that residents ate in the dining room on the unit. Staff separated sick residents to one area of the dining room and kept the well residents to another area in the dining room. RN-E indicated that during meal service both sick and well residents were in the dining room at the same time, but separated as much as possible. On [DATE] at 7:25 a.m., Surveyor # interviewed RN-C. Surveyor # shared concerns about the facility's policy of letting residents who had suspected or confirmed Norovirus out of their rooms to eat meals as this action was inconsistent with current standards of practice. RN-C reported that she was told by administration that there was a regulation that prohibited residents from eating alone in their room. On [DATE] at 9:00 a.m., Surveyor # met with Staff A and RN-C. Staff A reported that the facility had a long standing policy of not allowing residents to eat in their room due to a previous deficiency related to a resident in isolation. Staff A reported that he just reviewed the WI Division of Public Health's Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in WI Long-Term Care Facilities and understands that the facility's policy of not allowing residents to eat in their rooms was in direct conflict with the DPH recommendations and contact precautions. Specific examples in which residents who were ill were allowed to eat with other residents or to mingle in other parts of the facility include: Resident #5 On ,[DATE]-[DATE], Surveyor # reviewed Resident #5's record and noted the following in the documents titled Nurse's Notes; [DATE] - 20:16 (8:16 pm) - Comments: Resident vomiting and having loose stools throughout shift... [DATE] - 22:41 (10:41 pm) - Digestive Condition: experiencing nausea, vomiting. Vomitus: large amount, x (times) 2 Comments: Resident up in wheelchair in central area at supper time. Had large emesis. T-99.7. CNA's took resident back to room and did all his hs cares... **Resident #5 was added to the 1 West Norovirus Line List on [DATE] for N, V, and D. Even though Resident #5 was added to the 1 West Norovirus Line List because he met the facility and WI DPH definition for a gastrointestinal tract infection, the facility did not maintain Resident #5 in contact precautions and Resident #5 was allowed out of his room for meals. Resident #7 On [DATE], Surveyor # reviewed Resident #7's record and noted the following in the documents titled Nurse's Notes; [DATE] - 13:45 (1:45 pm) - Behavior/Mood - "...Started having bm as she was walking to the bathroom and stepped in it and was unaware it happened...." [DATE] - 23:45 (11:45 pm) - Digestive Condition: ....Incontinent loose stool x 1 [DATE] - 13:34 (1:34 pm) - Digestive Condition: diarrhea x 1... On [DATE], Resident #7 was added to the 1 West Norovirus Line List with symptoms of diarrhea. [DATE] - 09:00 (am) - Digestive Condition: diarrhea, large loose foul smelling stool, incontinent [DATE] - 22:57 (10:57 pm) - Digestive Condition: One small loose stool this shift....Ambulated to and from dining room without difficulty. [DATE] - 22:06 (10:06 pm) - Digestive Condition: ...No loose stools....Ate well for supper on unit...Ambulated to and from central area without difficulty. Even though Resident #7 was added to the 1 West Norovirus Line List because she met the facility and WI DPH definition for a gastrointestinal tract infection, the facility did not maintain Resident #7 in contact precautions and Resident #7 was allowed out of her room for meals. Resident #8 On ,[DATE]-[DATE], Surveyor # reviewed Resident #8's record to include a review of the documents titled Nurse's Notes. Nurse's Notes provided the following information; [DATE] - 22:03 (10:03 pm) - Stool: 1 loose stool noted foul smelling / fatty, x 1 this shift [DATE] - 22:11 (10:11 pm) - Digestive Condition: vomiting small amount at dinner [DATE] - 14:03 (2:03 pm) - Comments: ... 1 episode of loose stools no nausea or emesis [DATE] - 22:14 (10:14 pm) - Stool: Loose stool soft and not formed. Comments: Stool spec collected this shift and sent to the lab to test for[DIAGNOSES REDACTED]. On [DATE], Surveyor # reviewed Resident #8's Activity Attendance Sheet for the month of [DATE]. This document notes on [DATE] Resident #8 attended a Corner Store and Green House activity. [DATE] - 05:03 (5:03 am) - Stool: Malodorous; gelatinous. [DATE] - 14:28 (2:28 pm) - Digestive Condition: diarrhea, Stool specimen was obtained and sent to the lab; results received today and is positive for c-dif... Resident put on precautions... Resident started to spit up at lunch when eating... [DATE] - 20:53 (8:53 pm) - Digestive Condition: diarrhea, STOOL: Resident had one Large loose stool. Even though Resident #8's symptoms met the facility and WI DPH definition of a gastrointestinal tract infection and the facility took a stool specimen to rule out[DIAGNOSES REDACTED]icile infection, Resident #8 was not placed on contact precautions until [DATE] when the stool specimen result came back positive for[DIAGNOSES REDACTED]icile infection. The practice of not instituting precautions until laboratory confirmation is inconsistent with current standards of practice to include the CDC and WI Division of Public Health (DPH) and delays breaking the chain of infection to prevent further transmission. According to the facility's "Clostridium Difficile (C-diff) Policy" reviewed by Surveyor # on [DATE], it notes "It is the policy of Lasata Care Center to use contact precautions for all residents with known or suspected[DIAGNOSES REDACTED]." The policy identifies the clinical symptoms as watery diarrhea and fever. The facility policy further states "Residents with good hygiene, whose infection is contained, may participate in unit activities and may eat in the dining area on the unit..." The facility policy of allowing residents on contact precautions to leave their room for meals and activities is contrary to the 2007 CDC Guideline for Isolation Precautions and the 2008 APIC Guide to the Elimination of Clostridium difficile in Healthcare Settings. Both of these documents recommend limiting transport and movement of patients outside of the room to medically-necessary purposes. Resident #21 - Mail delivery: On [DATE] at approximately 9:00 am Surveyor # spoke with Resident #21 who resides on the 1 East Unit of the facility. Resident #21 stated to Surveyor # that we (the surveyors) had just missed the illness that went throughout the building making everyone really sick. Resident #21 stated that she delivers the mail throughout the building. Surveyor # asked if she delivered the mail when people were sick & Resident #21 indicated that she did still deliver the mail; going room to room, unit to unit. Resident #21 stated that she took it upon herself to wear gloves while delivering the mail just because she didn't want to find out the next day that someone she delivered mail to was sick. Surveyor # asked if she changed her gloves room to room and Resident #21 indicated no. On [DATE] at approximately 9:15 am Surveyor # asked RN-C about Resident #21's statement that she was delivering the mail room to room and accessing units & rooms that were sick during the Norovirus outbreak. RN-C indicated that yes Resident #21 was still delivering the mail although they did try to talk her into just leaving the mail on a table for people to pick up she still went room to room, unit to unit. Having Resident #21 deliver mail to affected units within the facility is contrary to the facility's policy titled Viral Gastrointestinal Prevention and Control of an Outbreak which notes; for the individual who is ill, 1. Immediate isolation of the resident and restricting access to affected area is essential. And that the facility should 3. Exclude non-essential staff from entering the room/unit. Activities: On [DATE] at approximately 11:55 am Surveyor # interviewed Activities Director (AD)-K regarding the activity programs that occurred while the facility was experiencing a Norovirus outbreak. AD-K indicated that when the Residents started to get sick on multiple units the activity staff did go to the units to do activities which is contrary to the facility policy which indicates that the facility should cancel or postpone activities for at least 48 ours after the last identified case. When asked what this involved, AD-K indicated that the staff would go up to the units and gather the Residents together and would do group activities on the individual units. Surveyor # asked how the information regarding the Norovirus was communicated to her. AD-K indicated that she could not recall when she was made aware of the Residents being sick or when units went into "quarantine" but that she thought activity staff were taking precautions even before e-mails came from the infection control nurse. AD-K indicated that staff was wearing masks and that they stopped bringing up the store cart & bookmobile and they canceled the large holiday social. AD-K indicated to Surveyor # that with everything going on they still held group activities on the unit in the common areas/lounge areas. AD-K indicated to Surveyor # that they have a practice of still doing group activities when Residents are sick instead of individual activities in the room because of a previous citation that the facility received many years ago. On [DATE] at approximately 12:50 pm Surveyor # interviewed AD-K to clarify what is involved with activities such as kitchen club. AD-K indicated that the kitchen club is a group activity that the activity staff and Resident's complete in the unit dining area. The activity involves brining a stove to the unit, preparing a snack item, cooking it and then eating it as a group. Surveyor # asked AD-K if this activity was carried out during the facility outbreak. AD-K indicated to Surveyor # that the activity department carried out this activity as a group activity during the outbreak but during the outbreak they may have not had Residents actually preparing the food item to be cooked. AD-K indicated that the Residents would still assist in cooking and eating the item. On [DATE] at 8:32 a.m., Surveyor # interviewed RN-I and RN-J and asked them why they thought most of the residents in the facility got sick. Both RN-I and RN-J responded that the residents shared tables and were very social. Resident #13 On [DATE] Surveyor # reviewed the line lists for the 2 West unit and reviewed the entry information regarding Resident #13. The facility line list reflects that Resident #13 had an onset of Norovirus symptoms including nausea, vomiting, and diarrhea on [DATE]. Surveyor # noted that the line list indicates that Resident #13 did not have a well date until [DATE]. On [DATE] and [DATE] Surveyor # reviewed Resident #13's medical record/nurse's notes regarding illness. The nurse's notes indicate that on [DATE] Resident #13 experienced vomiting. The nurse's notes on [DATE] once again indicate that Resident #13 was experiencing symptoms indicative of Norovirus. Surveyor # 's review of Resident #13's medical record indicates that Resident #13 may have been re-infected with Norovirus symptoms multiple times in December and January as the documentation within the medical record indicates that there were stretches of time where Resident #13 was not experiencing symptoms indicative of Norovirus but then would once again start to experience loose stools and/or vomiting. On [DATE] at approximately 11:55 am, AD-I indicated that during the Norovirus outbreak within the facility residents continued to come together in groups to participate in activities on the units. On [DATE] Surveyor # reviewed the activity attendance sheet for Resident #13 and noted that Resident #13 attended a group snack and chat activity on [DATE] and [DATE] and a group music activity on [DATE]. Resident #13 attended a special program on [DATE]. Surveyor # noted that these group activities took place despite the 2 West unit having Resident's that were displaying symptoms indicative of Norovirus. According to the facility's Norovirus Line List 24 Residents residing on the 2 West unit were ill with Norovirus. Resident #12 On [DATE] Surveyor # reviewed the line list for the 1 East unit and reviewed the entry information regarding Resident #12. The facility line list reflects that Resident #12 had an onset of Norovirus symptoms including nausea, vomiting, diarrhea, abdominal cramps and fever on [DATE]. Surveyor # noted that the line list indicates that Resident #12 did not have a well date until [DATE]. On [DATE] and [DATE] Surveyor # reviewed Resident #12's facility medical record and the 24 hour sheets for the 1 East unit. Review of these records indicates that on [DATE] through [DATE] Resident #12 had episodes of loose stools and on [DATE] through [DATE] Resident #12 experienced a low grade temperature. On [DATE] t