Every finding on record at Little Chute Health Services

Based on observation, interview, and record review, the facility did not ensure adequate supervision and interventions were in place to prevent falls for 2 residents (R) (R1 and R3) of 3 sampled residents from a total sample of 11 residents. R1 sustained multiple falls with injury (including a broken nose and patella fracture) and without injury while on 1:1 supervision and 30-minute checks. Check sheets contained gaps in completion and were missing entries for days which coincided with some of R1's falls. In addition, R1's medical record did not consistently indicate when they were on 1:1 supervision, 15-minute checks, or 30-minute checks. (This example is being cited at a level G.) R3 was left in bed connected to a Hoyer lift without staff in the room to provide supervision. Findings include: The facility's Fall Prevention and Management Guidelines policy, revised 7/18/24, indicates: .Suggested interventions for residents determined to be at higher risk for falls may include: .b. Provide additional interventions as directed by the resident's assessment and based on input from the resident or family members, including but not limited to: .ii. Increased frequency of rounds; iii. Increased supervision, if indicated .The plan of care will be revised as needed and should be communicated to the staff, resident, and resident's family/responsible party. The facility's Safe Lifting and Movement of Residents Policy, revised 11/28/22, indicates: .3. Staff responsible for direct resident care will receive education on transfers including the use of gait belts and mechanical lifts before providing direct care. Staff will be observed for competency in using mechanical lifts and performing manual transfers (one and two-person assist transfers) . 1. R1 was admitted to the facility on [DATE] after a 46-day hospital stay related to recurrent falls and failure to function at home. R1 had diagnoses including Alzheimer's disease with early onset, dementia, fracture of nasal bones, encounter for palliative care, laceration without foreign body of other part of head, repeated falls, anxiety disorder, and right fracture of the patella. An admission Minimum Data Set (MDS) assessment, dated 12/14/25, stated R1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. The assessment also indicated R1 had multiple falls, including one with a major injury. R1 had an activated Power of Attorney for Healthcare (POAHC). R1 was transferred to the hospital after a fall on 2/12/26 and did not return to the facility. R1 remained in the hospital for over 90 days before their family found another facility for them. A hospital Discharge summary, dated [DATE], indicated R1 was admitted to the hospital on [DATE] for recurrent falls and failure to function at home. R1 had diagnoses including Alzheimer's dementia, spinal stenosis, multilevel degenerative changes of the spine, osteoarthritis of the spine, and peripheral neuropathy which were likely causes or contributing factors of the falls. Physical Therapy staff indicated R1 would likely require stand-by-assistance. R1's hospital course was complicated due to their impulsiveness. R1 did not always cooperative with staff and experienced several falls. R1's dementia with agitation also contributed to their severe fall risk because they did not request assistance when ambulating. An activities of daily living (ADL) self-care and functional deficit care plan (initiated 12/8/25) indicated R1 had impaired balance, cognition deficit, and impaired vision. The care plan contained an intervention (dated 1/15/26 to 1/20/26) for 1:1 supervision at all times. A behavior care plan (initiated 1/8/26) contained an intervention (dated 1/20/26 to 2/4/26) for 1:1 supervision at all times. A potential for falls due to impulsive behavior, restlessness, unsteady gait, poor trunk control, impaired cognition, impaired safety awareness, medication side effects, and shuffles feet when walking care plan (initiated 12/8/26) indicated R1 self-transferred, attempted to ambulate without assistance, and did not use the call light for assistance. The care plan indicated R1 would not allow staff to assist them off the floor due to a previous fall involving a full-body lift. R1 often refused assistance from staff, however, staff stood by R1 for safety due to them self-transferring off the floor per their choice. R1 often refused to wear gripper socks. Risks versus benefits education was completed. The care plan indicated R1 could lock their wheelchair without prompting, however, forgot to do so at times due to impulsivity. A physician's discharge summary indicated R1's falls were likely due to a combination of peripheral neuropathy, osteoarthritis of the spine, spinal stenosis, and Alzheimer's dementia. The care plan contained the following interventions: ~ Assist to/from destination when seen attempting to self-transfer (initiated 1/7/26) ~ Bed at transfer height (initiated 1/6/26) ~ Check on and ask if R1 needs to use the restroom prior to meals (initiated 12/16/25); Check on R1 approximately every 2 hours and assist to bathroom when awake, if sleeping do not wake up (initiated 2/2/26) (At this point in time, the care plan indicated R1 was on 1:1 supervision.) ~ Dycem added to the top and below the wheelchair cushion (initiated 12/19/25); Ensure Dycem is on recliner chair (initiated 12/20/25) ~ Encourage to wear gripper socks at all times (initiated 12/8/25); Non-skid clothing encouraged and slippery clothing removed (initiated 12/18/25) ~ Encourage to transfer and change positions slowly (initiated 12/8/25); Monitor orthostatic blood pressure (initiated 1/12/26) ~ Engage in an activity by the nurses' station before supper (initiated 1/12/26) ~ Ensure room is tidy, organized, and clutter free (initiated 12/28/25) ~ Ensure walker is next to R1 when in bed and recliner (initiated 2/11/26); Have commonly used articles within easy reach (initiated 12/9/25); Reacher in room (initiated 1/26/26) ~ If awake, offer to get R1 up for the day around 6:00 AM (initiated 2/2/26); Night shift to encourage toileting and ADLs to get ready for the day if awake between 5:30-6:30 AM (initiated 2/7/26) ~ Offer to go to bed around 8:00-8:30 (PM) (initiated 1/12/26); If still awake in wheelchair after 8:00 PM, offer an activity for R1 to engage in by the nurses' station (initiated 1/12/26) ~ Keep pudding and apple sauce in room (initiated 2/2/26); Offer snacks between meals (initiated 2/2/26) ~ Medication regimen review completed by Hospice (initiated 12/9/25) ~ Nightlight in room and bathroom (initiated 1/28/26); Nightlight was added to bathroom (initiated 2/2/26) ~ Offer to stay outside of room when awake and active, watch movies by the nurses' station, join activities, or visit with family (initiated 12/16/25) ~ Offer toileting and transfer into recliner after supper (initiated 1/12/26); Offer toileting beginning of night shift (initiated 12/23/25); Place urinal in room and demonstrate its use. Provide cueing and reminders as necessary (initiated 2/11/26) ~ Bed moved to other side of room, close to bathroom (initiated 12/10/25) ~ Room near nurses' station (initiated 12/8/25) ~ Sign in room: Lock your wheelchair (initiated 1/8/26) ~ Stay within eyesight when they are using the restroom (initiated 12/16/25) ~ When spouse not at facility, encourage R1 to be at nurses' station from 2:30 PM until supper time. Offer snacks and activity to keep entertained (initiated 2/2/6; revised 2/16/26). R1's medical record contained the following risk versus benefits statements: ~ 1/9/26 - R1 should wear grippy socks or appropriate footwear for transfers, ambulation, and when up in wheelchair. POAHC states they try to have R1 wear grippy socks or footwear which they will often remove themself. Interventions: Ensure R1 has appropriate footwear/grippy socks during care times. If R1 is barefoot, encourage to put grippy socks or footwear on. ~ 12/23/26 - Broda scoot. POAHC states Broda scoot limits R1's ability to move and declined for R1 to be in Broda scoot when POAHC is at the facility. (Child) also involved in discussion and is asking POAHC to reconsider the recommendation. Interventions to minimize risk of not following recommendations/orders: R1 is encouraged to be in common areas when awake and in wheelchair; Dycem to chair. ~ 1/19/26 - Commode over toilet for easier, safer transfers on and off the toilet. R1 will sometimes allow it and at other times will not use the restroom unless it is moved. POAHC aware of preferences. ~ 1/21/26 - Use Hoyer lift to get off of floor after a fall. R1 refuses to do this. POAHC is aware and stated to let R1 do things their way. ~ 1/30/26 - R1 is a one assist for transfers and uses a wheelchair for locomotion. POAHC is aware that R1 self-transfers without calling for help and states that is the way they have always been. Frequent checks; Dycem in wheelchair and recliner; Wheelchair in locked position next to bed; Side rails; Grippy socks. ~ 2/11/26 - Recommend for R1's recliner to be moved closer to the bathroom. R1 has had many falls where they self-transferred from the recliner to the bathroom. Nursing Home Administrator (NHA)-A spoke with R1 and their POAHC about fall prevention. The Interdisciplinary Team (IDT) suggested to move the recliner to the opposite side of the room closer to the bathroom to shorten the distance R1 has to walk from the recliner to the bathroom. POAHC does not want the recliner moved at this time and will talk to R1 about re-arranging the room before the recliner is moved. Surveyor reviewed R1's falls and noted the following: R1 fell on [DATE] at 10:45 AM and 12/9/25 at 2:00 AM and 5:30 PM. On 12/10/25 at 3:00 AM, R1 fell. A Fall Risk Management report indicated R1's nose appeared to be broken. R1 stated they hit their nose on the floor and was sent to the emergency room (ER) for evaluation. (A hospital visit summary, dated 12/10/25, confirmed a mildly displaced nasal fracture.) On 7/28/26 at 9:09 AM, Surveyor interviewed NHA-A who stated 30-minute checks were initiated after R1's fall on 12/10/25. The facility implemented 30-minute check sheets where staff initialed every 30-minutes and documented where R1 was and what they were doing. (R1's care plan was not updated to indicate they were placed on 30-minute checks.) R1 continued to fall. Surveyor compared sign-out sheets and Fall Risk Management reports to determine when R1 was last seen. Survveyor noted R1's 30-minute check sheets contained many blanks and missing days. R1 fell on [DATE] at 2:30 PM, 12/17/25 at 9:30 PM, 12/18/25 at 2:45 PM, 12/19/25 at 10:30 AM, 12/20/25 at 3:40 PM, and 12/21/25 at 10:45 PM. Fall documentation and Fall Risk Management reports indicated the 30-minute check sheets were signed out or R1 was last seen within 30 minutes of the falls. On 12/22/25 at 8:00 AM, R1 had an unwitnessed fall without injury. The 30-minute check sheet was not signed out. A Fall Risk Management report did not indicate the last time R1 was seen. R1 fell on [DATE] at 7:15 AM, 12/25/25 at 9:15 PM, 12/26/25 at 11:55 PM, and 12/27/25 at 3:54 PM. Fall documentation and Fall Risk Management reports indicated the 30-minute check sheets were signed out or R1 was last seen within 30-minutes of the falls. R1 fell on [DATE] at 4:25 PM, 12/30/25 at 8:30 PM, and 1/1/26 at 10:00 PM. The 30-minute check sheets were not signed out at the time of the falls. Fall Risk Management reports did not indicate the last time R1 was seen. On 1/3/26 at 7:00 AM, R1 had an unwitnessed fall. Fall documentation and a Fall Risk Management report indicated the 30-minute check sheet was signed out or R1 was last seen within 30-minutes of the fall. On 1/4/26 11:30 PM, R1 had an unwitnessed fall and was found sitting on the toilet. A Fall Risk Management report indicated R1 was sleeping in bed prior to being found in the bathroom without a wheelchair. R1 had a gash on their forehead that was 3 centimeters (cm) long x 0.25 cm wide with an unknown depth. R1 received 3 stitches at the hospital. A Falls Risk Management report did not indicate the last time R1 was seen. A 30-minute check sheet was not signed out. The facility completed a chart review of R1's falls and noted 30-minute check sheets were missing. The facility provided staff education that included reminders of various interventions, to monitor every 30 minutes (fill out the 30-minute check sheet), and monitor if R1's call light is on. The education was signed by staff on 1/7/26. A Hospice note written by Hospice Registered Nurse (HRN)-G on 1/7/26 indicated staff continued with 30-minute checks. R1 fell on 1/8/26 at 10:00 AM, 1/10/26 at 5:30 PM, and 1/12/26 at 8:15 AM. Fall documentation and Fall Risk Management reports indicated the 30-minute check sheets were signed out or R1 was last seen within 30 minutes of the fall. On 1/13/26 at 6:45 PM, R1 had an unwitnessed fall in the courtyard. The door alarm went off and staff responded. A Fall Risk Management report indicated R1 was last seen approximately 4 minutes prior to the fall. R1 was wearing appropriate footwear and clothing. A progress note indicated R1 had been wandering into residents' rooms and was difficult to redirect. R1 was placed on a 1:1 supervision after the fall and their care plan was updated. (The facility continued to use the same 30-minute check sign-out sheet previously used to document 1:1 supervision.) R1 fell during 1:1 supervision on 1/17/26 at 7:28 PM and 1/25/26 at 5:45 PM. On 1/28/26 at 11:45 PM, R1 had an unwitnessed fall. A Fall Risk Management report indicated the writer and Certified Nursing Assistant (CNA)-K heard a loud bang at the nurses' station and found R1 on the floor on their left side. A skin assessment revealed several skin tears, including one on the left hand that was 2 cm x 0.66 cm, one on the right forearm that was 5 cm x 1 cm and another that was 2 cm x 0.5 cm, one on the right pinky finger that was 1 cm x 1 cm, and one on the right knee that was 2 cm x 1 cm and another that was 1 cm x 1 cm. An IDT note indicated R1 was last seen by CNA-K in bed at 11:00 PM. A 30-minute check sheet last signed out at 11:00 PM indicated R1 was in bed asleep. A Fall Risk Assessment completed on 1/29/26 indicated to increase checks to every 15 minutes. (R1's care plan indicated they should have been on 1:1 supervision at that time.) On 7/28/26 at 1:00 PM, Surveyor attempted to contact Licensed Practical Nurse (LPN)-H via phone regarding the fall on 1/28/26. On 7/28/26, Surveyor requested CNA-K's phone number. NHA-A stated CNA-K worked for an agency and they would contact the agency. The facility did not provide CNA-K's phone number. On 7/28/26 at 9:09 AM, Surveyor interviewed NHA-A who confirmed 1:1 supervison was initiated for R1 after 1/13/26 and discontinued on 2/5/26. NHA-A stated R1's spouse thought the 1:1 staff agitated R1 more. When Surveyor asked about documentation for the fall on 1/28/26 that indicated R1 was not on 1:1 supervision but should have been per their care plan, NHA-A stated there were times when the 1:1 staff agitated R1 more. NHA-A stated if R1 got combative with staff, they backed off and tried to be discreet. NHA-A stated R1's room was near the nurses' station so there was a good chance staff were close by. When Surveyor informed NHA-A that documentation indicated R1 had not been seen for 45 minutes prior to the fall, NHA-A confirmed that even if R1 was combative with staff, they should have checked on them sooner than 45 minutes. Surveyor noted the sign-out sheet for R1's fall on 1/28/26 at 11:00 PM indicated they were in bed asleep. In a later interview on 7/29/26 at 11:52 AM, Surveyor asked NHA-A about LPN-H writing on the Fall Risk Assessment that the immediate intervention was to increase checks. NHA-A was not aware of the intervention. NHA-A stated Fall Risk Assessments are done as needed and not always after each fall. NHA-A confirmed R1's care plan indicated they should have been on a 1:1 supervison and again stated if R1 was agitated, staff should reapproach sooner than 45 minutes. On 2/4/26, the facility discontinued 1:1 supervision for R1 after their POAHC expressed concern that 1:1 supervision might be agitating R1. On 2/5/26, HRN-G wrote a note in R1's Hospice plan of care that indicated R1's confusion varied, they had aggressive behavior toward staff at times, and they continued to frequently fall. R1's 1:1 supervision was discontinued on 2/4/26 because it seemed to agitate them more. (R1's care plan was updated when 1:1 supervision was discontinued.) On 7/28/26 at the end of the survey, Surveyor asked for clarification on when R1 was on 1:1 supervision and when they were on 30-minute checks since their medical record was unclear. In addition, 30-minute check sheets that were signed out did not indicate whether they were for 30-minute checks or 1:1 supervision. On 7/29/26 at 9:00 AM, Surveyor interviewed NHA-A for confirmation of when R1 was on 30-minute checks since their care plan did not indicate they were on 30-minute checks. NHA-A stated R1 was on 30-minute checks from 12/11/25 to 1/13/26 and 1:1 supervision was initiated after the fall on 1/13/26 until 2/4/26. R1 was on 30-minute checks from 2/5/26 until they transferred to the hospital on 2/12/26. (R1's care plan was not updated.) R1 had falls on 2/5/26 at 6:30 AM and 4:20 PM, 2/6/26 at 5:50 AM and 3:15 PM, 2/8/26 at 6:30 AM and 6:35 AM, and 2/10/26 at 8:00 AM and 2:00 PM. R1 had a third fall on 2/10/26 at 7:00 PM that was unwitnessed. R1 attempted to self-transfer to their wheelchair and was found on the floor leaning on the wheelchair. R1 had an abrasion on the left knee and reported pain from the stupid questions. A fall report indicated R1 was last seen in the wheelchair at 6:00 PM (1 hour prior). R1's 30-minute check sheet was blank between 3:00 PM and 9:30 PM. R1 fell on 2/11/26 at 5:00 AM and 9:20 PM. A Fall Risk Assessment on 2/11/26 indicated to increase check frequency which was not updated on R1's care plan or addressed in a Fall Risk Management report. R1 was on 30-minute checks and staff continued to document on the 30-minute check sheet. R1 fell on 2/12/26 at 7:25 AM and 1:00 PM. Following the second fall, R1 was transferred to the ER and did not return to the facility. An X-ray revealed a right patella fracture. An ER note, dated 2/12/26, indicated R1 arrived after increased falls. X-rays of the knees revealed a right non-displaced patella fracture. R1 did not plan to return to the facility and needed placement at another facility. A Hospice note on 2/12/26 indicated R1's spouse and family were overwhelmed and upset with the facility and felt R1's care needs were not adequately met due to numerous falls. On 7/27/26 at 3:47 PM, Surveyor interviewed LPN-H who stated the facility did all they could to keep R1 safe and alwasy had a 1:1 staff available. LPN-H was not aware of a time when R1 was not on 1:1 supervision but should have been. LPN-H stated before the facility officially put R1 on 1:1 supervision, LPN-H sat with R1 because they fell so much. LPN-H stated R1 was fast and impulsive and had behavior toward staff at times. (Surveyor interviewed LPN-H prior to knowing they were the nurse on duty when R1 fell on 1/28/26 when documentation showed R1 was not on 1:1 supervision per their care plan.) On 7/28/26 at 8:45 AM, Surveyor interviewed Hospice Social Worker (HSW)-I who stated R1 was impulsive, challenging, and had poor safety awareness. HSW-I stated the facility eventually implemented 1:1 supervision, however, it took a while to implement after numerous falls. HSW-I did not feel the facility had enough staff to keep R1 safe. HSW-I was not aware of a time when 1:1 supervision was not provided but should have been. On 7/28/26 at 12:17 PM, Surveyor interviewed Ombudsman (OMB)-L who was doing a routine visit at the facility. OMB-L spoke with R1's POAHC who stated the family felt the facility was neglectful and did not provide proper supervision for R1 who had gotten out a door and had multiple falls that resulted in bruises, lacerations, a broken nose, and/or a fractured patella. On 7/28/26 at 2:46 PM, Surveyor interviewed HRN-G who stated the facility put interventions in place after R1's falls. HRN-G stated R1 had frequent checks or 1:1 supervision at different times throughout their stay. HRN-G confirmed 1:1 supervision was discontinued because R1's spouse thought it upset them. HRN-G was not aware of any instances when the 1:1 staff was not present but should have been. HRN-G stated R1 was fast, impulsive, and a difficult case and the facility had multiple interventions in place. HRN-G was not sure what more the facility could have done. On 7/28/26 at 1:34 PM, Surveyor interviewed Former Director of Nursing (FDON)-J who stated R1 was not on 1:1 supervision until the night R1 fell outside. FDON-J stated R1 was put on 1:1 supervision for safety since they were wandering into other residents' rooms. FDON-J stated the facility tried to decrease 1:1 supervison to 30-minute checks multiple times and just attempted 1:1 supervison at certain times of the day. FDON-J confirmed R1's care plan should have been updated timely with fall interventions. R1's medical record was not clear regarding when they were on 30-minute checks and when the facility attempted to reduce 1:1 supervision. Through care plan review and interviews with NHA-A, it was determined that R1 was on 30-minute checks after the fall on 12/10/26 when they broke their nose. R1 remained on 30-minute checks until 1/13/26 after they were agitated, entered other residents' rooms, and fell in the courtyard. R1 was then placed on 1:1 supervision. R1's care plan and Hospice notes indicated R1 remained on 1:1 supervision through 2/4/26 when it was discontinued per their POAHC's request. NHA-A stated R1 was then put back on 30-minute checks. After the fall on 1/4/26 when R1 received 3 stitches at the hospital, the facility reviewed R1's falls and completed staff education that included checking on residents every 30 minutes and ensuring the 30-minute check sign-out form was completed. On 1/28/26, R1 fell again. Their care plan indicated they were on 1:1 supervision. Falls documentation indicated the nurse and CNA heard a loud bang from the nurses' station. A Fall Risk Assessment indicated to increase the frequency of checks to every 15 minutes. On 2/10/26 at 7:00 PM, R1 fell again. The 30-minute check sheet was blank. A Fall Risk Management report did not indicate when R1 was last seen. R1 had more falls and was sent to the ER on [DATE] at 1:00 PM per their POAHC's request due to concerns for their safety. An X-ray at the hospital revealed a patella fracture. Despite the facility completing education for R1's 30-minute checks on 1/7/26, R1 continued to fall, including times when 1:1 supervision was care planned and documentation indicated the 1:1 staff was not present. R1 also fell when they were on 30-minute checks and documentation did not indicate R1 was checked on in the previous 30 minutes. NHA-A acknowledged R1's medical record was not appropriately updated for 30-minute checks or for times when/if the facility attempted to decrease 1:1 supervision. 2. R3 was admitted to the facility on [DATE]. R3 received Hospice services and had diagnoses including alcohol induced dementia and Wernicke's encephalopathy. An MDS assessment, dated 5/13/26, stated R3 had a BIMS score of 0 out of 15, indicating severely impaired cognition. R3's care plan contained an intervention to transfer with the assistance of 2 staff with an Invacare full-body mechanical lift and medium-sized sling (dated 5/21/26). On 7/28/26 at 11:31 AM, Surveyor interviewed HSW-E who stated they observed R3 moaning and groaning in bed in a sling attached to a Hoyer lift. There were no staff in the room. It took HSW-E approximately 10-15 minutes to find staff. HSW-E notified staff and R3's Guardian. On 7/28/26 at 11:53 AM, Surveyor interviewed CNA-F who stated they don't like to leave residents unsupervised in a sling attached to a Hoyer lift to look for a second staff unless the resident is well-minded. (R3 had severely impaired cognition.) On 7/28/26 at 11:41 AM, Surveyor interviewed CNA-R who indicated stated Hoyer lift transfers are completed with two staff. CNA-R stated they would not leave a resident unsupervised in order to find assistance. CNA-R stated a Hoyer lift should not be in a resident's room without staff present. On 7/28/26 at 3:45 PM, Surveyor interviewed NHA-A who confirmed HSW-E notified Unit Manager (UM)-D that R3 was left unsupervised and attached to a Hoyer lift. NHA-A stated by the time UM-D got to the room, R3 had been transferred into their chair. When CNA-F was asked about the incident, CNA-F verified they left R3 in bed in a sling attached to the Hoyer lift and left the room to find assistance. NHA-A stated it is not the facility's standard of practice to leave a resident alone and attached to a Hoyer lift, however, if staff are in the middle of preparation and a resident is in bed, it is understandable since the facility instructs staff that two people are required for a Hoyer transfer. NHA-A stated the last staff education regarding transfers was completed on 2/2/26.

Based on observation, interview, and record review, the facility did not ensure the care plan was followed for 1 resident (R) (R3) of 3 sampled residents.R3 had an order and a care plan intervention for pressure relieving boots to bilateral feet at all times. R3 was observed in bed without pressure relieving boots. Findings include:The facility's Comprehensive Care Plan policy, revised 9/2022, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. R3 was admitted to the facility on [DATE], received Hospice services, and had diagnoses including alcohol induced dementia and Wernicke's encephalopathy. A Minimum Data Set (MDS) assessment, dated 5/13/26, stated R3 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive impairment. R3's medical record and care plan contained an order/intervention for pressure relieving boots to bilateral feet at all times every shift (dated 12/20/25). On 7/27/26 at 9:48 AM, Surveyor observed R3 in bed without pressure relieving boots. A sign on the wall in the room indicated pressure relieving boots should be on at all times when in bed. On 7/27/26 at 10:13 AM, Surveyor interviewed Registered Nurse (RN)-C who verified R3 did not have pressure relieving boots on and put the boots on them. On 7/28/26 at 9:37 AM, Surveyor interviewed Unit Manager (UM)-D who confirmed R3 should have pressure relieving boots on at all times.

Based on observation, interview, and record review, the facility did not have an effective process for labeling items and did not ensure missing laundry was returned or replaced for 3 residents (R) (R4, R10, and R11) of 3 sampled residents.Power of Attorney for Healthcare (POAHC)-N reported R4 was missing pants and shirts. POAHC-N replaced the items when the facility could not find the items and did not provide follow-up communication.R10 informed Laundry Staff (LS)-M they were missing a nightgown. The nightgown had not been found or replaced. R11 was missing underwear and t-shirts which had not been found or replaced.Findings include:The facility's Grievance Policy, revised 7/2022, indicates: When a complaint/grievance report is initiated: .The original form will be forwarded to the department head for which the grievance pertains .(Laundry Supervisor for missing clothing issues). Surveyor requested a policy regarding resident belongings. A policy was not provided.On 7/28/26 at 8:00 AM, Surveyor interviewed LS-M who stated an overwhelming amount of unmarked items end up in laundry and they do not know what happens to them. LS-M stated when residents tell them they are missing something, they put a note on the laundry room wall and look for the item. LS-M stated the facility use labels for marking which do not always stay on and residents report missing items daily. LS-M was not sure who was in charge of labeling residents' clothing but thought it was Social Worker (SW)-Q or nursing staff who were present during the admission. LS-M stated they receive a bag of items with a note to label on occasion. LS-M stated personal laundry is mixed together and sent to the laundry room in a cart. LS-M stated the process could be improved so residents are not missing so many items. Surveyor observed 14 notes with missing items on the laundry room wall. LS-M also showed Surveyor 2 racks and 2 boxes full of unclaimed items from the past 2 weeks. LS-M stated there was also a hanging rack of unlabeled items. On 7/28/26 at 2:11 PM, Surveyor interviewed POAHC-N who stated R4 needed more pants and shirts since they were admitted and POAHC-N brought more that day. R4 had approximately 8 of each when admitted and most were missing. POAHC-N thought the missing items were marked and was not sure what happened to them. (R4 was admitted to the facility on [DATE] and had an activated POAHC.)On 7/29/26 at 11:33 AM, Surveyor interviewed R10 who stated they were missing a nightgown and thought the marker had come off or faded in the laundry. R10 stated LS-M was aware of the nightgown. (A Quarterly Minimum Data Set (MDS) assessment, dated 5/15/26, stated R10 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.) On 7/29/26 at 11:40 AM, Surveyor interviewed R11 who stated they were missing a lot of items and received other residents' items which they returned. R11 stated they started with a 6-pack of underwear and were down to 3 pair. R11 stated they were also missing t-shirts. (R11 was admitted to the facility on [DATE]. An admission MDS assessment, dated 5/10/26, stated R11 had a BIMS score of 15 out of 15, indicating intact cognition.) On 7/28/26 at 3:39 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-O who stated housekeeping staff or hospitality aids typically label residents' items. If they are not present, nursing staff put the items in a bag and attach a label. CNA-O stated CNAs and nursing staff used to label clothing, however, they no longer had access to laundry labels.On 7/28/26 at 3:41 PM, Surveyor interviewed CNA-P who stated laundry staff label residents' clothing. On 7/29/26 at 11:13 AM, Surveyor interviewed SW-Q who stated clothing is labeled by families and laundry staff. For new residents, housekeeping or laundry staff sort the clothes and bring them to the laundry area to be labeled. SW-Q removed fabric labels from their drawer that were used to label items. SW-Q stated they had not received any concerns about missing items. On 7/29/26 at 11:20 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware of the missing items and had not received a laundry grievance in a while. NHA-A stated if a resident/family wants the facility to do their laundry, the facility should label the items. NHA-A stated if housekeeping staff are in the building, they are given the items. If a resident is admitted after housekeeping staff leave for the day, nursing staff know to label the bag and let the Housekeeping Supervisor know in the morning. NHA-A stated if they need more labels, housekeeping staff tell them and they order more.

Based on observation, interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R3) of 1 resident. R3 had an order for oxygen to prevent low oxygen saturation levels. R3 was observed in bed without oxygen. In addition, R3's care plan did not indicate they received oxygen. Findings include: The facility's Comprehensive Care Plan policy, revised 9/2022, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in their comprehensive assessment. R3 was admitted to the facility on [DATE], received Hospice services, and had diagnoses including alcohol-induced dementia and Wernicke's encephalopathy. A Minimum Data Set (MDS) assessment, dated 5/13/26, stated R3 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severe cognitive impairment. R3's medical record contained the following order: ~ Ensure 2 liters of oxygen is on while resting in bed two times daily for hypoxia. Please apply 2 L of oxygen to maintain oxygen (O2) saturation (level) above 90% (dated 7/6/26). (R3's care plan did not include goals or interventions for the use of oxygen.) On 7/27/26 at 9:48 AM, Surveyor observed R3 in bed without oxygen. On 7/27/26 at 10:13 AM, Surveyor interviewed Registered Nurse (RN)-C who verified R3 was not receiving oxygen and stated they would check their care plan to see if oxygen was required. RN-C reviewed R3's orders and verified oxygen should be used when in bed at 2 liters via nasal cannula. On 7/28/26 at 9:37 AM, Surveyor interviewed Unit Manager (UM)-D who stated R3 should wear oxygen anytime they are in bed for a nap. NM-D stated R3's care plan should also reflect the use of oxygen.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R1) of 1 sampled resident. R1's oxygen concentrator was not consistently set in accordance with a physician's order. In addition, R1's care plan did not indicate R1 had a diagnosis of chronic obstructive pulmonary disease (a progressive inflammatory lung disease that obstructs airflow from the lungs making it difficult to breathe). Findings include: The facility's Oxygen Concentrator policy, dated 6/3/22, indicates: .1. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device. 2. Oxygen is administered under orders of the attending physician, except in the case of an emergency .4. Use of the Concentrator: a. Orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.) .k. Keep turned off when set up for use in the resident's room, but not actively in use . Between 5/19/26 and 5/21/26, Surveyor reviewed R1's medical record. R1 was readmitted to the facility on [DATE] and had diagnoses including COPD, congestive diastolic heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and pleural effusions. R1's Minimum Data Set (MDS) assessment, dated 5/8/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R1's plan of care indicated oxygen should be administered per physician orders. R1's plan of care did not indicate R1 had COPD. R1's Medication Administration Record (MAR) contained the following order: ~ Oxygen at 1-2 liters/minute via nasal cannula at rest and with activity to maintain oxygen saturation of 88-92% R1's medical record indicated R1 was hospitalized from [DATE] to 5/1/26 for acute hypoxic respiratory failure secondary to bilateral pleural effusions, COPD/asthma exacerbation, and new atrial fibrillation. On 5/19/26 at 9:28 AM, Surveyor observed an oxygen concentrator in R1's room. R1 was wearing a nasal cannula connected to the concentrator. The oxygen flow rate was set at 3.5 liters/minute. On 5/20/26 at 12:01 PM, Surveyor observed R1 in R1's room wearing a nasal cannula connected to an oxygen concentrator. The oxygen flow rate was set at 3.5 liters/minute. On 5/21/26 at 11:49 AM, Surveyor observed R1 in R1's room wearing a nasal cannula connected an oxygen concentrator. The oxygen flow rate was set at 3.5 liters/minute. Surveyor interviewed R1 who indicated R1 does not touch the oxygen concentrator. R1 indicated staff set the oxygen flow rate and R1 liked the current setting. On 5/21/26 at 12:58 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated oxygen should be reflected on a resident's care plan, including the liters per minute of oxygen flow. LPN-D indicated a resident with orders for 1-2 liters of oxygen per minute should remain on 1-2 liters per minute unless they are in respiratory distress. LPN-D indicated if a resident has an oxygen saturation of less than 89%, the oxygen flow can be increased, however, the nurse should notify the physician of the change in flow rate right away. LPN-D indicated the facility has a 24-hour book to let staff know if a resident's oxygen flow rate has changed until a new order from the physician is obtained. LPN-D indicated R1 was not experiencing distress or low oxygen saturation. LPN-D checked R1's medical record and confirmed R1 had an order for 1-2 liters/minute which is how the concentrator should be set. LPN-D indicated increasing the oxygen flow rate for a resident with COPD can increase the resident's carbon dioxide level. On 5/21/26 at 1:07 PM, Surveyor noted R1's oxygen concentrator was running but R1 was not in the room. The oxygen flow rate was set at 3.5 liters/minute. On 5/21/26 at 1:45 PM, Surveyor and LPN-D entered R1's room. R1 was using a portable oxygen machine and was planning to leave the room. The portable oxygen machine was set correctly. Surveyor and LPN-D observed the oxygen concentrator and noted the machine was still on and the flow rate was set at 3.5 liters/minute. LPN-D indicated the flow rate should be set at 2 liters/minute and the machine should not be left on when not in use. LPN-D shut off the oxygen concentrator and again indicated the flow rate was set too high for R1 since R1 was not in distress. On 5/21/26 at 2:19 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated oxygen orders should be followed as written by the physician. DON-B indicated R1's oxygen concentrator and portable oxygen machine should be correctly set. DON-B indicated staff should check settings for accuracy every time a resident uses oxygen. DON-B stated staff know residents adjust the settings themselves at times and, therefore, need to verify the flow rate with every use. When Surveyor indicated R1's oxygen flow rate was set at 3.5 liters/minute on three occasions instead of 1-2 liters/minute, DON-B indicated the increased rate could cause rebound for R1. DON-B indicated if the oxygen flow rate is too high for a resident with COPD, it can cause a negative effect and shut down the resident's lungs. DON-B indicated COPD should be reflected on a resident's care plan. On 5/21/26 at 2:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated a resident on oxygen therapy with a diagnosis of COPD should have a care plan to reflect that. NHA-A confirmed a resident should receive oxygen therapy as ordered by the physician.

Based on staff interview and record review, the facility did not ensure weight monitoring was provided for 1 resident (R) (R12) of 2 sampled residents.R12 was not re-weighed for weight loss/gain greater than 5 pounds (lbs). R12's provider, Power of Attorney (POA), and the facility's Registered Dietician (RD) were not notified regarding R12's weight loss/gain greater than 5 lbs. In addition, R12's weight was not obtained with a consistent device.Findings include:The facility's Weight Monitoring policy, revised 12/21/22, indicates: Weight Assessment:.5. Team members will follow a consistent approach to weighing and using an appropriately calibrated and functioning scale. Since weight varies throughout the day, a consistent process and technique (e.g., weighing the resident wearing a similar type of clothing, at approximately the same time of day, using the same scale, either consistently wearing or not wearing orthotics or prostheses, and verifying scale accuracy) can help make weight comparison more reliable. 6. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation.10. Nursing staff will notify the individual or responsible party, physician, and Registered Dietitian (RDN) or designee of any individual with an unintended significant weight change.Between 5/19/26 and 5/21/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including dysphagia, constipation, anxiety, major depression, and intracranial injury. R12's Minimum Data Set (MDS) assessment, dated 4/30/26, stated R12 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. R12 was protectively placed in the facility and had a legal Guardian. A care plan, dated 5/3/25, indicated R12 was at risk for nutritional status change related to obese body mass index (BMI) with continued increasing weight trend, impaired cognition from history of traumatic brain injury, need for therapeutic diet for calorie control, diagnosis of dysphagia, and poor dentition with need for mechanically-altered texture. The care plan also indicated R12 was at risk for obesity related to excessive calorie intake and physical inactivity as evidenced by BMI >30. The care plan indicated R12 would have no significant weight changes (>/= 5% in 30 days, >/= 7.5% in 90 days, or >/= 10% in 180 days) while allowing for beneficial loss. The care plan contained the following interventions: Review weights and notify RD, Medical Doctor (MD), and responsible party of significant weight change (dated 5/12/25) and diet education as able (dated 8/4/25).R12 had the following order:~ Weight needed; update MD if weight is 5 lb change since prior weight; one time a day starting on the 1st and ending on the 1st every month (dated 5/7/25)R12's medical record indicated the following:~ On 12/22/25, R12 weighed 256.5 lbs.~ On 1/1/26, R12 weighed 272.0 lbs (wheelchair scale). R12's weight was up 16 lbs. R12's medical record did not contain a progress note regarding R12's weight gain from 12/22/25 to 1/1/26. ~ A weight note, dated 1/14/26, indicated the provider was notified of R12's weight gain of 16 lbs from 12/22/25 to 1/1/26. The note indicated staff would obtain a re-weight on 1/15/26. ~ On 1/15/26, R12 weighed 268.0 lbs (wheelchair scale). ~ A Nutritional Assessment note, dated 1/15/26 and written by RD-E, indicated R12 had a consistent carbohydrate diet, mechanical-alternative texture with average meal intake of 76-100%. R12's BMI was 38.6 with gradual weight change present. R12's carbohydrate-controlled diet was appropriate to try to limit calories although R12's weight continued to increase. The note indicated RD-E would complete more diet education and have staff encourage R12 to limit snacks.~ On 2/5/26, R12 weighed 263.0 lbs (mechanical lift scale). R12's weight was down 5 lbs. ~ A provider note, dated 2/12/26, indicated the need for a dietary consult for diabetic diet education to address weight gain and snacking. An order was not obtained.~ On 3/1/26, R12 weighed 270.0 lbs (mechanical lift scale). R12's weight was up 7 lbs. R12's medical record did not contain a progress note regarding R12's weight gain from 2/5/26 to 3/1/26.~ A provider note, dated 3/3/26, indicated the need for a dietary consult for diabetic diet education to address ongoing weight gain. An order was not obtained.On 5/20/26 at 2:29 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated nurses document weights in a resident's medical record. LPN-D indicated nursing staff obtain a re-weight if the resident's weight is greater than 5 lbs from the last weight and call the provider.On 5/20/26 at 3:22 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated nurses should re-weigh a resident using a consistent scale if there is a 5 lb weight differential. DON-B indicated if a resident has a 5 lb weight loss or gain from the previous weight, the nurse should update the provider. On 5/20/26 at 3:22 PM, Surveyor interviewed Unit Manager (UM)-C and reviewed the provider's documentation regarding R12's need for diet education. UM-C indicated nurses transcribe orders from provider notes. UM-C indicated the order for a dietary consult for diabetic diet education to address ongoing weight gain was not transcribed from the provider's notes on 2/12/26 and 3/3/26. On 5/21/26 at 10:42 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated RD-F and RD-E provided services to the facility prior to the newly assigned RD who started in March 2026.On 5/21/26 at 10:52 AM Surveyor interviewed RD-F who indicated RD-F was an as needed dietitian for the facility to fill in when the assigned dietitian was not available. RD-F indicated RD-F received email communication from the facility if there was an order requiring diet education. RD-F indicated RD-F did not receive communication from the facility regarding R12's order for diet education. On 5/21/26 at 11:00 AM, Surveyor interviewed RD-E who indicated RD-E provided services to the facility until March 2026. RD-E indicated staff notified RD-E of orders for dietary education via email or in weekly Interdisciplinary Team (IDT) meetings. RD-E did not recall an order for dietary education for R12 and stated RD-E did not provide R12 with dietary education. (Of note: RD-E's nutritional note on 1/15/26 indicated RD-E planned to provide education.) On 5/21/26 at 11:45 AM, Surveyor interviewed DON-B who indicated the provider was notified of R12's 1/1/26 weight gain on 1/15/26 and gave an order to limit snacks. DON-B confirmed an RD completed dietary assessments on 1/15/26 and 4/24/26. DON-B confirmed R12 did not have an active or discontinued order for dietary education as suggested in the provider's documentation on 2/12/26 and 3/3/26. DON-B indicated DON-B did not see RD-E's note regarding dietary education for R12.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Certified Nursing Assistant (CNA)-G) of 8 employees reviewed for caregiver background checks. The facility did not complete an out-of-state background check for CNA-G. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees .Background checks, including re-checks, will be completed consistent with applicable state laws and regulation .2. Screenings may be conducted by the facility itself, a third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred . On 5/21/26 Surveyor requested background check information, including Background Information Disclosure (BID) forms, Department of Justice (DOJ) and Governmental findings letters, references, and license information for 8 staff. Surveyor noted CNA-G was hired by the facility on 4/14/26. CNA-G's BID form indicated CNA-G lived outside of Wisconsin within the previous three years. Surveyor requested CNA-G's out-of-state background check. On 5/21/26 at 12:48 PM, Surveyor interviewed Guest Services Coordinator (GSC)-H who assisted with human resources and employee onboarding. GSC-H indicated an out-of-state background check was not completed for CNA-G prior to hire. GSC-H indicated GSC-H thought a previous HR staff had requested the out-of-state background check, however, GSC-H couldn't find it and indicated it had not been completed. GSC-H provided an out-of-state background check for CNA-G that was completed on 5/21/26. GSC-H indicated the out-of-state background check should have been completed prior CNA-G's hire. On 5/21/26 at 2:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility should complete all background check and pre-employment screening prior to employment, including out-of-state background checks when applicable.

Based on staff interview and record review, the facility did not provide care and services to maintain the highest practicable physical well-being when they did not recognize and appropriately respond to a change in condition for 1 resident (R) (R1) of 6 sampled residents. On 12/23/25, R1 was admitted to the facility following a C3-C4 laminectomy (major spinal surgery in which part of the vertebra is removed). R1 was alert and oriented upon admission. From 12/24/25 to 12/29/25, R1 experienced a change in condition including decreased cognition, an oxygen saturation level of 79% which required continuous supplemental oxygen, an episode of hypoglycemia (low blood sugar) that required 2 doses of glucose gel, and abnormal vital signs. During a care conference on 12/29/25, R1's family reported concerns to staff regarding R1's overall condition. On 12/30/25, R1 was unresponsive when a Registered Nurse (RN) attempted to administer medication. The RN did not assess R1, alert medical staff, or check R1's blood sugar. R1's family called Emergency Medical Services (EMS) who transported R1 to the hospital and noted R1's blood sugar was 42. R1 was admitted to the hospital and diagnosed with severe hypoglycemia with coma requiring emergent intravenous (IV) glucose administration, sepsis secondary to acute cystitis, depressed Glasgow Coma Scale (GCS) (a tool used in the assessment of those with acute brain injury and impaired consciousness) with decreased responsiveness, and acute kidney injury. The facility's failure to recognize and appropriately respond to a change in condition for a resident who experienced decreased cognition, a need for supplemental oxygen, low blood sugar, and abnormal vital signs for a period of days following surgery led to a finding of immediate jeopardy that began on 12/30/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 1/15/26 at 4:00 PM. The immediate jeopardy was removed on 1/16/26; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Change in Condition of the Resident policy, dated 9/2022, indicates: When a resident presents with a possible change of condition .or noted changes in mental or physical functioning: 1. Assess the resident's need for immediate care/medical attention. Provide emergency care as needed. 2. Assess/evaluate the resident. This assessment/evaluation could include, but is not limited to the following: a. vital signs, oxygen saturation, blood glucose level .f. Alteration in level of consciousness, ability to respond .3. Notify resident's physician: a. Immediate notification for any symptom .i. Acute or sudden onset . Aspiration, as defined by the Mayo Clinic, is the unintentional entry of foreign matter into the airways and lungs, which can lead to various pulmonary disorders. It is particularly concerning for older patients, those with neurological disorders, and those with a history of head and neck cancer or structural abnormalities. Chronic aspiration can lead to recurrent pneumonia, bronchiectasis, and malnutrition .Silent aspiration, often unrecognized without objective evaluation, contributes substantially to disease burden. Effective management requires a multidisciplinary approach to preserve quality of life and prevent life- threatening complications. From 1/14/26 to 1/15/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including C3-C4 laminectomy, cervical spondylosis, diabetes, hypertension, hypothyroidism, atrial fibrillation, and congestive heart failure. R1's Minimum Data Set (MDS) assessment, dated 12/29/25, indicated R1 had moderately impaired cognition. R1was responsible for R1's medical decisions. A progress note, dated 12/23/25 at 9:16 PM, indicated R1 was alert and oriented x 4 (person, place, time, and situation) and able to make R1's needs known. R1 had a Foley catheter that was patent of clear amber urine. R1's lung sounds were clear on room air with no shortness of breath. Progress notes, dated 12/24/25 at 11:45 AM and 1:27 PM, indicated R1 was drowsy and hard of hearing. R1 and R1's family voiced concerns regarding pain management, diet, and bed positioning/repositioning. R1's diet was downgraded to pureed per R1's choice. A progress note, dated 12/25/25 at 2:45 AM, indicated R1's oxygen saturation level was 79%. R1's oxygen saturation level rose to 84% after deep breathing. An on-call Advance Practice Nurse Prescriber (APNP) was notified and gave an order to start 2-5 liters of oxygen. R1 was placed on 2 liters of oxygen. A progress note, dated 12/25/25 at 2:34 PM, indicated R1 slept throughout the shift. R1's medication was crushed because R1 had difficulty swallowing. A progress note, dated 12/26/25 at 6:25 PM, indicated R1 was alert and oriented x 2 (which indicated a decrease in cognition from 12/23/25) and spent a lot of time sleeping. Progress notes, dated 12/27/25 at 8:32 AM and 12:34 PM, indicated R1's blood sugar was 45 and two doses of 40% glucose gel were administered. R1 was alert and oriented x 2-3 and had involuntary jolting arm movements consistent with hypoglycemia. An on-call APNP was notified. An order was given to decrease the frequency of R1's Vicodin from every 4 hours to every 8 hours and update if no improvement in mental status. A progress note, dated 12/27/25 at 2:48 PM, indicated a change in condition evaluation noted R1 had abnormal vital signs (low/high blood pressure, heart rate, respiratory rate, weight change), food and/or fluid intake (decreased or unable to eat and/or drink adequate amounts), and other changes in condition, including talks/communicates less, tired, weak, confused, and/or drowsy. A progress note, dated 12/28/25 at 12:43 PM, indicated R1 had a slight cough. A progress note, dated 12/28/25 at 9:01 PM, indicated an on-call APNP was notified that R1 had a low blood pressure of 94/52. An order was given to hold R1's hydralazine dose (a medication to treat high blood pressure). A progress note, dated 12/29/25 at 1:57 AM, indicated R1 remained on 2 liters of oxygen via nasal cannula and had an oxygen saturation level of 93%. R1's blood sugar was monitored throughout the night due to poor eating. R1 received sips of orange juice throughout the night and had a productive cough with mucus. On 12/29/25, R1's family attended a care conference and shared concerns about R1's eating, confusion, and overall medical condition with Director of Nursing (DON)-B. A progress note, dated 12/30/25, indicated R1's family member called EMS to have R1 sent to the emergency room (ER) due to not eating/drinking for several days. On 1/14/26 at 8:57 AM, Surveyor interviewed Family Member (FM)-P who stated when RN-C entered R1's room on 12/30/25 at 8:10 AM, R1's blood pressure was 102/53. RN-C tried to administer R1's medications in pudding; however, R1 was totally out of it and did not drink or open R1's eyes. FM-P stated RN-C left the room and did not return. FM-P also stated there was no output from R1's catheter. FM-P approached the nurses' station at 9:30 AM and notified RN-C that FM-P was extremely concerned and going to call 911. RN-C stated, I understand. An ambulance arrived at approximately 10:00 AM and EMS asked about R1's blood sugar level. DON- B stated the facility did not know. FM-P stated EMS checked R1's blood sugar in the ambulance which was 42 (According to www.diabetes.org,uk, a blood sugar level below 54 milligrams/deciliter (mg/dL) is a cause for immediate action.) On 1/14/26, Surveyor reviewed an emergency room report, dated 12/31/25, that indicated R1 required critical care and was diagnosed with severe hypoglycemia with coma requiring emergent IV glucose administration, sepsis secondary to acute cystitis, depressed GCS with decreased responsiveness, and acute kidney injury. On 1/14/26 at 1:35 PM, Surveyor interviewed RN-C who stated RN-C was not familiar with R1 and had only known R1 for approximately 3 hours on 12/30/25. RN-C indicated blood sugars are usually obtained between 7:00-9:00 AM and are usually taken before meals. RN-C stated R1's blood sugar order was in the Treatment Administration Record (TAR) instead of the Medication Administration Record (MAR) and indicated orders in the TAR are completed by Certified Nursing Assistants (CNAs). RN-C stated RN-C obtained R1's vital signs at 8:10 AM. RN-C noted R1's blood pressure was low and was going to hold R1's blood pressure medication. RN-C attempted to administer R1's medications but was unable to arouse R1. RN-C verified that FM-P informed RN-C that R1 was not eating or drinking and was concerned. RN-C verified R1's medications were held the day before because R1 was not swallowing and staff were swabbing R1's mouth to provide fluids. On 1/14/26 at 3:51 PM and 1/15/26 at 12:21 PM, Surveyor interviewed DON-B who stated staff should look at both the MAR and TAR for orders. DON-B indicated RN-C should have initiated a change in condition and responded to R1's medical condition promptly. DON-B indicated the response time should be immediate. DON-B verified FM-P reported concerns about R1's condition at a care conference on 12/29/25 and stated staff were reviewing R1's condition. DON-B confirmed a change in condition should have been initiated a few days earlier for R1. The failure to recognize a change in condition for a resident who declined over a period of days following surgery and required hospitalization for critical care created a reasonable likelihood for serious harm and thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 1/16/26, however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement the following action plan: 1. Reviewed current residents with like diagnoses to ensure appropriate monitoring/interventions were in place.2. Reviewed the last fourteen days of residents' progress notes and vital signs completed on 1/15/26 to identify residents with a potential change in condition that required provider notification, care plan changes, or additional monitoring.3. Educated licensed nurses on the need to promptly recognize, assess/evaluate, and report a change in condition. Education included the importance of implementing appropriate follow-up monitoring. 4. Educated CNAs on recognizing and reporting changes in condition to a licensed nurse.5. Initiated audits to ensure monitoring protocols are in place for new admissions with diabetes.6. Initiated audits of nursing documentation to ensure changes in condition are promptly identified, pertinent and accurate medical information is communicated to the physician, and appropriate monitoring interventions are implemented.

Based on observation, staff and resident interview, and record review, the facility did not ensure adequate supervision, positioning, and assistive devices were provided during a meal for 1 resident (R) (R2) of 3 sampled residents.R2 had a history of aspiration. R2's care plan indicated R2 required 1:1 supervision for meals. The care plan contained interventions to encourage R2 to take small bites and clear mouth before the next bite, to seal R2's lips around the cup opening until R2 swallowed, and to be seated upright during meals and have a neck pillow in place for proper positioning. R2 was hospitalized from [DATE] to 12/22/25 for sepsis caused by urinary tract infection (UTI) and aspiration. On 1/15/26, Surveyor heard R2 coughing and observed R2 eating alone in R2's room with the curtain drawn and the head of the bed at 45 degrees. Staff were not in R2's room or in the hallway outside the room providing supervision. There was a large amount of food on R2's dignity cover and juice spilling out the right side of R2's mouth. The facility's failure to provide adequate supervision, positioning, and an assistive device during meal time for a resident at risk of aspiration led to a finding of immediate jeopardy that began on 1/15/26. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 1/15/26 at 4:00 PM. The immediate jeopardy was removed on 1/16/26; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement its action plan.Findings include:The facility's Dining Experience policy, revised 7/27/25, indicates: Individuals will be positioned comfortably for the meal in a way that will assist with independent eating (i.e., promote safe swallowing) and that positioning and assistance must be appropriate for individual needs. Individuals should eat in an upright position and be positioned properly. Beds will be at the appropriate height and position for those eating in bed (as close to 90 degrees as possible). Staff will provide cueing, prompting, or assistance as needed to prevent a decline in eating ability. On 1/15/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, dysphagia, expressive aphasia, and anxiety. R2's most recent Minimum Data Set (MDS) assessment, dated 11/13/25, indicated R2's Brief Interview for Mental Status (BIMS) score was not assessed. R2 was R2's own decision maker. Per staff interview, R2 was able to appropriately answer yes/no questions and used a communication application on a tablet.A progress note, dated 11/23/25, indicated R2 coughed and had food coming out of R2's mouth during lunch. The head of R2's bed was elevated to sitting. Staff assisted R2 with finishing the meal and provided cues to take small bites and clear R2's mouth. There were no further episodes or signs/symptoms of aspiration.R2's comprehensive care plan, revised 11/26/25, indicated R2 was at risk for nutritional status change related to dysphagia with need for mechanically-altered texture and thickened liquids. The care plan contained a goal that R2 would not exhibit chewing or swallowing problems as evidenced by no signs or symptoms of aspiration, choking, or complaints of difficulty eating. The care plan contained interventions including 1:1 supervision for all meals, encourage small bites and clear mouth before next bite, encourage (R2) to seal lips around cup opening until swallow is completed (11/7/25), insert neck pillow for proper neck positioning for all meals (11/14/25); and position (R2) upright in wheelchair for meals (11/26/25). A progress note, dated 12/13/25 at 10:04 PM, indicated R2 refused supper and did not drink much. When asked if R2 was okay, R2 said R2 did not know and R2's lungs felt funny. An assessment indicated R2's lung sounds were mostly clear with crackles.A progress note, dated 12/14/25 at 5:15 AM, indicated R2 vomited during the night shift. The on-call physician ordered Zofran (an antiemetic), light and bland meals for 12/14/25, and to monitor R2 for nausea/emesis.A progress note, dated 12/14/25 at 5:56 PM, indicated R2's vital signs changed during the shift. R2's oxygen saturation level was 89% on room air, respirations were 24, and pulse was 123. R2's lung sounds included rhonchi (low-pitched, rattling, snoring-like sounds heard during breathing caused by mucus or secretions in the larger airways and often indicative of bronchitis or pneumonia). R2 was transferred to the hospital.A progress note, dated 12/22/25 at 11:34 PM, indicated R2 was on new admission follow-up and required honey-thick liquids and full assistance with feeding.On 1/15/26, Surveyor reviewed R2's hospital paperwork for R1's 12/14/25 to12/22/25 stay. An Occupational Therapy (OT) evaluation, dated 12/14/25, indicated R2's swallowing precautions included upright positioning, one sip or bite at a time, alternate liquids and solids, and 1:1 supervision during meals. A computed tomography (CT) scan (a non-invasive imaging procedure that uses X-rays to create detailed cross-sectional images of the body) completed on 12/14/25 revealed focal infiltrate (localized areas in tissue with abnormal density that indicate the collection of pus, fluid, or abnormal cells and commonly signal infection/inflammation) or atelectasis (the collapse of part or all of a lung that prevents normal gas exchange and is often caused by airway blockage) in the dependent portion of the right lung. An initial physician exam, dated 12/14/25, indicated R2 was admitted with acute onset of hypoxemia (low oxygen saturation) and a low-grade fever after an episode of vomiting. Imaging revealed right lower lobe infiltrate typical of aspiration. R2 was treated with levofloxacin (an antibiotic). R2 was also treated for septic shock (a life-threatening, advanced stage of sepsis where infection causes severe, persistent low blood pressure and cellular dysfunction, resulting in over 40% mortality) in the Intensive Care Unit (ICU) from 12/15/25 to 12/17/25. R2 discharged back to the facility on [DATE] with an additional seven day course of oral antibiotics.On 1/14/26 at 11:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-M who wrote the 11/23/25 progress note and observed R2 coughing during lunch. LPN-M recalled the coughing episode and stated the information was reported at a morning meeting on 11/24/25. LPN-M was not sure if anything was done after that and verified LPN-M did not notify the physician. LPN-M stated R2 required direct supervision during meals because R2 ate quickly and needed reminders to slow down, alternate sips, and take breaths. LPN-M stated R2 also needed to be seated as close to 90 degrees as possible during and for a while after meals. LPN-M indicated R2 required constant supervision when eating in R2's room. On 1/14/26 at 11:55 AM, Surveyor interviewed Advanced Practice Nurse Prescriber (APNP)-H regarding R2's coughing episode on 11/23/25. APNP-H did not recall being notified. APNP-H stated APNP-H would want to be notified and would want to ensure staff assessed R2's respiratory status (vital signs, lung sounds, etc.) at least each shift. A Speech Therapy (ST) progress note, dated 12/11/25, indicated R2 required prompting to improve oral containment and bolus management. Safety precautions were emphasized with staff, including upright posture. A ST evaluation, dated 12/31/25, indicated R2's precautions included pureed texture and honey-thick liquids. It was recommended that R2 eat in a wheelchair with total supervision and be upright for meals. ST recommendations for swallowing strategies included positioning R2 upright during meals and upright posture for at least 30 minutes after meals.A ST progress note, dated 12/11/25, indicated R2 required prompting to improve oral containment and bolus management. Safety precautions were emphasized with staff, including upright posture. A ST treatment note, dated 1/13/26, indicated R2 was on a pureed diet with honey-thick liquids. It was recommended that R2 eat in a wheelchair with total supervision and be upright for meals.A ST encounter note, dated 1/14/26, indicated Speech Therapist (ST)-L reviewed R2's Videofluoroscopic Swallow Study (VFSS) (a real-time X-ray procedure conducted by a speech-language pathologist and radiologist to evaluate oral, pharyngeal, and esophageal swallowing functions) done on 12/16/25 which indicated R2's airway was invaded by nectar-thick liquids during 1 of 2 opportunities. R2 also presented with poor posture and an inability to sense penetration/aspiration. On 1/15/26 at 8:40 AM, Surveyor was walking towards R2's room and overheard several deep, congested coughs from R2 before R2's airway was cleared. Surveyor observed R2 in bed eating breakfast. The head of the bed was at 45 degrees and R2 did not have a neck pillow in place. R2's dignity cover contained multiple bites of food and there was juice spilling out the right side of R2's mouth. There were no staff in the room or in the hallway. When Surveyor asked if staff had been in the room to assist or check on R2 since breakfast began, R2 shook R2's head no. When Surveyor asked if staff usually sat in R2's room to provide supervision and/or assistance during meals, R2 shook R2's head no. On 1/15/26 at 9:01 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-J and CNA-K who were assigned to R2's wing. Both staff indicated they assist R2 with meal set-up and look in R2's room every 15 to 20 minutes. Both staff stated they would notify the nurse immediately if R2 was coughing.On 1/15/26 at 9:23 AM, Surveyor interviewed Registered Nurse (RN)-C who verified R2 should be directly supervised when eating which is indicated on R2's Kardex (an abbreviated care plan used by nursing staff). RN-C stated R2 typically eats in R2's room.On 1/15/26 at 9:39 AM, Surveyor interviewed ST-L regarding R2's positioning and supervision during meals. ST-L stated R2 should be seated as close to 90 degrees as possible during meals and at least 30 minutes afterward to reduce the risk of aspiration. ST-L stated while R2 may be more appropriate for general supervision during meals with additional adaptive equipment, R2's care plan stated total supervision. On 1/15/26 at 10:14 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R2's supervision and positioning during meals as well as follow-up for R2's coughing episode on 11/23/25. DON-B verified staff should be with R2 when R2 is eating in R2's room and should watch for signs/symptoms of aspiration. Regarding follow-up for R2's coughing episode on 11/23/25, DON-B indicated the Interdisciplinary Team (IDT) discussed the incident on 11/24/25 and updated R2's care plan with an intervention to get R2 up/out of bed and in a chair or dining room for meals. On 1/15/26 at 12:22 PM, Surveyor observed ST-L in R2's room providing supervision and cueing during the lunch meal. Surveyor observed R2 sitting at 90 degrees in a chair with a neck pillow in place. ST-L confirmed that R2 eats better and maintains best positioning when provided cues during a meal.The facility's failure to provide proper supervision, positioning, and an assistive device during meal time for a resident with a history of aspiration created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy on 1/16/26, however, the deficient practice continues at scope/severity level D (potential for harm/isolated) as the facility continues to implement the following action plan: Reviewed R2's care plan, dietary orders, and ST recommendations and made appropriate updates/revisions.Reviewed current residents to identify those who require supervision, assistance, cueing, or monitoring during meals due to aspiration risk.Educated staff on R2's care plan and supervised meals and snacks for residents at risk for choking or aspiration. Nursing staff were also instructed to verify diet orders and supervision levels prior to serving meals, document the supervision provided, and promptly report swallowing concerns and condition changes.Observed meal service to ensure compliance with general supervision recommendations.Initiated record review and observation audits to ensure ST recommendations are documented in residents' care plans and are being followed by staff.

Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent the development of avoidable pressure injuries and/or promote healing for 2 residents (R) (R1 and R2) of 5 sampled residents. R1 was admitted to the facility on [DATE] without any pressure injuries. A Braden Scale assessment completed upon admission indicated R1 was at high risk for the development of pressure injuries. R1 was admitted to the hospital on [DATE] with a bilateral sacral pressure injury with serosanguineous (a fluid mixture of serous fluid (clear plasma) and blood, appearing as thin, watery, pinkish or light red indicating mild capillary bleeding) drainage, a right posterior thigh pressure injury, and a right heel pressure injury. The facility was unaware of the pressure injuries. A skin integrity care plan for R1 was not initiated until 1/5/26 (which was six days after R1 was admitted to the hospital.) This example is being cited at a level G (actual harm/isolated). R2 was admitted to the facility on [DATE] with a stage 4 sacral pressure injury and had an order for an alternating air mattress to be set at 250 pounds alternating. On 1/14/26, R2's air mattress was set at 350 pounds alternating. On 1/15/26, R2's air mattress was set at 350 pounds static (not alternating). In addition, R2's most recent weight was 156 pounds which indicated the air mattress should have been set at 200 pounds per manufacturer's guidelines. Findings include: According to the National Pressure Injury Advisory Panel: Deep tissue pressure injury remains one of the most serious forms of pressure injury. The pressure is exerted at the muscle-bone interface but due to the resiliency of the skin, the color change is not immediate, in contrast to a bruise. The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin tears. Within another week, the wound bed is often necrotic. The lag between the pressure event and the change in color of the skin makes the root cause analysis complex. It is important to be aware that 48 hours prior to the patient's skin being deep red, maroon, or purple, he/she may not have been in your facility. The facility's Pressure Injuries and Non Pressure Injuries policy, dated 7/2022, indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity .Care Planning: A comprehensive skin integrity care plan is based on resident history, skin assessments, Braden Scale scoring, nutritional assessments, resident and family interviews, and staff observations. Consider the areas of risk, as well as the overall risk assessment score of the Braden Scale. Communicate identified risk factors and interventions to direct care staff. 1. Develop interventions based on subsets of the Braden Scale .A stage 4 pressure injury includes full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer, slough (yellow, white, or gray dead tissue, fibrin, proteins, and white blood cells that form in the wound bed acting as a barrier that slows or prevents healing) or eschar (dark, hard scab of dead tissue that forms over a deep wound acting as a protective barrier but also potentially hindering healing by trapping bacteria) .For residents admitted with a pressure injury, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries. 1. From 1/14/26 to 1/15/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including C3-C4 laminectomy, cervical spondylosis, diabetes, and congestive heart failure. R1's Minimum Data Set (MDS) assessment, dated 12/29/25, indicated R1 had moderately impaired cognition. R1was responsible for R1's medical decisions. On 1/14/26, Surveyor reviewed R1's progress notes, care plan, and Treatment Administration Record (TAR) which indicated the following: ~ Hospital transfer orders, dated 12/23/25, did not contain any wounds aside from R1's C3-C4 cervical surgery site. ~ A note, dated 12/23/25 at 9:05 PM, indicated an admission assessment was completed with no wounds. ~ A note, dated 12/23/25 at 5:08 PM, indicated a Braden Scale Assessment was completed with a score of 15 which indicated R1 was at high risk for the development of pressure injuries. Documented wounds included: cervical surgical incision, left hand (back) bruising, left antecubital bruising, and bilateral wrist bruising. ~ A care plan, initiated 12/23/25, did not contain a focus area or interventions to prevent alteration in skin integrity. (Of note: A skin integrity care plan was initiated on 1/5/26 which was 6 days after R1 was admitted to the hospital.) ~ Nursing documentation from 12/23/25 to 12/30/25 did not contain skin integrity information or skin assessments other than the Braden Scale assessment completed upon admission. ~ A note, dated 12/24/25 at 9:13 PM, indicated R1 had been in bed since arriving at the facility. ~ R1's TAR contained daily documentation of diabetic foot checks at bedtime. Hospital wound care notes, including an initial assessment of R1's wounds (dated 12/30/25 at 11:00 AM) and complete wound assessments (dated 12/31/25 at 5:05 PM) indicated: ~ R1 had a bilateral sacral pressure injury classified as a deep tissue injury that measured 11 centimeters (cm) (length) x 9 cm (width) x 0.l cm (depth) with a small amount of serosanguineous drainage. ~ R1 had a right posterior thigh pressure injury classified as a deep tissue injury that measured 9.3 cm x 10.5 cm with no drainage. ~ R1 had a right heel pressure injury classified as a deep tissue injury that measured 2.7 cm x 3.6 cm with no drainage. On 1/15/26 at 8:39 AM, Surveyor interviewed Registered Nurse (RN)-F who stated RN-F obtains vital signs and does a head-to-toe assessment during the admission process. RN-F stated R1 had bilateral hand edema. RN-F stated RN-F would have assessed R1's coccyx if there were any wounds documented on the Braden Scale assessment. RN-F did not recall if R1 had a specialty mattress upon admission or if one was added later. On 1/15/26 at 4:19 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who stated LPN-D does not complete skin assessments because they are done on the AM shift when residents are changed. LPN-D stated R1 had many bruises due to intravenous (IV) therapy in the hospital. On 1/15/26 at 8:27 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who stated R1 had a bowel movement on 12/26/25 and there was a dressing on R1's coccyx. CNA-E did not know who applied the dressing and stated the dressing was clean and not removed during cares. CNA-E indicated staff offered to reposition R1 every two hours; however, R1 occasionally refused. CNA-E did not recall if R1 had a specialty mattress. On 1/15/26 at 12:09 PM, Surveyor interviewed LPN-G who stated LPN-G assisted with repositioning R1 but did not recall if R1 had any skin injuries. LPN-G stated staff applied zinc to R1's coccyx. On 1/14/26 at 12:03 PM and 1/15/26 at 12:41 AM, Surveyor interviewed Advanced Practice Nurse Prescriber (APNP)-H who completed R1's admission assessment on 12/24/25 but did not recall if R1 had any wounds. APNP-H reviewed hospital wound photos and documentation and stated R1's coccyx wound appeared to be older than 24 hours, however, the thigh and heel wounds were questionable. On 1/15/26 at 11:42 AM, Surveyor interviewed Director of Nursing (DON)-B who stated nursing staff completed a Braden Scale assessment for R1 upon admission and noted no wounds other than a surgical incision. DON-B was not aware that staff applied a dressing to R1's coccyx and was not aware that a skin integrity care plan focus area was added on 1/5/26. DON-B indicated if R1's skin was fragile, anything could develop in a short period of time. 2. On 1/15/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, dysphagia, expressive aphasia, anxiety, and a stage 4 sacral pressure injury. R2's MDS assessment, dated 11/13/25, indicated R2's Brief Interview for Mental (BIMS) score was not assessed. R2 was R2's own decision maker. Per staff interview, R2 could appropriately answer yes/no questions and used a communication application on a tablet. A care plan, dated 11/10/25, indicated R2 was admitted with a stage 4 pressure injury on the sacrum. The care plan contained interventions for a pressure redistribution cushion on chair and an air mattress set to 250 pounds alternating on the bed. R2's TAR contained an order to check the function and setting of the air mattress every shift: 250 pounds alternating. A wound assessment, dated 1/13/26, indicated R2 had a stage 4 pressure injury on the coccyx that measured at 1.2 cm x 1 cm x 0.3 cm. On 1/14/26 at 10:07 AM, Surveyor observed R2 in bed. R2's air mattress was set at 350 pounds alternating. On 1/15/26 at 8:46 AM, Surveyor observed R2 in bed. R2's air mattress was set at 350 pounds static (versus alternating as care planned). On 1/15/26, Surveyor reviewed R2's TAR for 1/14/26 and 1/15/26 and noted staff documented that R2's air mattress was set appropriately at 250 pounds on the 1/14/26 AM, PM, and night (NOC) shifts and the 1/15/26 AM shift. On 1/15/26, Surveyor reviewed the manufacturer's guidance regarding air mattress settings. The manual stated the number was to be set as close as possible to the resident's current weight to ensure proper pressure relief. R2's most recent weight was 156 pounds on 1/10/26. According to ProCare Medical Equipment: When an air mattress is set too firmly, it loses its ability to provide the pressure redistribution therapy it was designed for. The cells become firmer than a standard mattress and all pressure reduction qualities go by the wayside .This is avoidable with appropriate settings. On 1/15/26 at 9:02 AM, Surveyor interviewed LPN-I regarding R2's air mattress setting and order. RN-I stated staff check R2's air mattress setting each shift and document it in the TAR. If the setting is incorrect, staff correct it and notify DON-B and/or the wound nurse. On 1/15/26 at 11:11 AM, Surveyor interviewed DON-B regarding R2's pressure injury and air mattress setting. DON-B verified R2's air mattress was set too high and should be at set at approximately 200 pounds based on R2's most recent weight. DON-B also verified R2's air mattress was not set to alternating on 1/15/26. DON-B stated R2's order and care plan were updated on 1/15/26 and DON-B would update the wound nurse and provide education to staff on checking air mattress settings appropriately.

Based on staff interview and record review, the facility did not ensure physician visits were completed timely for 1 resident (R) (R6) of 3 sampled residents. R6 was admitted to the facility on [DATE]. R6 was not seen by a physician at least once every 30 days for the first 90 days after admission.Findings include:The facility's Physician Visits and Physician Delegation policy, revised 7/27/25, indicates: .2. The physician should: a. See resident within 30 days of initial admission to the facility. b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission .On 1/20/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, hemiplegia, cerebral infarction, and diabetes. R6's Minimum Data Set (MDS) assessment, dated 12/30/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R6 had severe cognitive impairment.Surveyor reviewed R6's physician visits after admission and noted R6 was not seen by a physician within 30 days of admission (including a 10 day grace period) and every 30 days after for the first 90 days. Surveyor noted R6's initial visit was completed by an Advance Practice Nurse Prescriber (APNP) on 2/20/25. R6 was seen by a physician on 4/8/25 and 6/10/25. On 1/20/26 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R6 was not seen by a physician for the initial visit and was missing a physician visit in May of 2025.

Based on observation, staff interview, and record review, the facility did not ensure the appropriate care and treatment regarding dressing changes and lab work was provided for 2 residents (R) (R3 and R9) of 3 sampled residents.Staff did not complete R3's peripherally inserted central catheter (PICC) line dressing change as ordered. In addition, R3's weekly labs were not completed as ordered.Staff did not complete R9's PICC line dressing change as ordered. Findings include:The facility's Dressing Change for Vascular Access Devices policy, revised 10/2024, indicates: Purpose: To prevent local and systemic infection related to the intravenous (IV) catheter .A sterile dressing is maintained on all peripheral and central vascular access devices to protect the site, provide a microbial barrier, and to provide vascular access device securement .3. Central venous access device and peripheral midline dressings are changed every 7 days and immediately if the integrity of the dressing is compromised, if moisture, drainage, or blood is present, or for further assessment if infection is suspected. Transparent semi-permeable membrane dressings are changed every 7 days and as needed (PRN). 4. Initial dressings after catheter placement will be changed PRN if saturated, and 24-48 hours post insertion of midlines, PICCS, or other central venous access devices if gauze is present under the dressing and/or there is blood/drainage under the dressing. Initial dressing with Biopatch/Guardiva at the site may be left in place for 7 days unless it is saturated or the dressing is otherwise compromised. 1.On 7/23/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis of right tibia and fibula, infection of amputation stump and right lower extremity, and acquired absence of right leg below the knee. R3's Minimum Data Set (MDS) assessment, dated 5/22/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R3 had intact cognition. R3 had a Power of Attorney for Healthcare (POAHC). R3's medical record contained the following order:~ PICC dressing change: Change catheter site dressing with transparent dressing as needed and one time a day every Monday (initiated 5/15/25).R3's Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained orders for a weekly PICC line dressing change. Staff documented PICC line dressing changes on 5/19/25 and 5/26/25. There was no documentation that dressing changes were completed on 6/9/25 and 6/16/25. R3's PICC line dressing was changed at the infectious disease clinic on 6/2/25. On 7/23/25 at 10:15 AM, Surveyor interviewed Infectious Disease Registered Nurse (IDRN)-F and confirmed R3's PICC line dressing was changed at R3's infectious disease appointment on 6/16/25.On 7/23/25 at 11:48 AM, Surveyor interviewed Director or Nursing (DON)-B who confirmed R3's PICC line dressing was changed by facility staff on 5/19/25 and 5/26/25 but was not changed by facility staff the week of 6/9/25 or 6/16/25. DON-B confirmed R3's PICC line dressing was changed by clinic staff on 6/2/25 and was due to be changed on 6/9/25. DON-B indicated PICC line dressings should be changed weekly or as needed and stated R3's PICC line was discontinued on 6/23/25. 2. R3's medical record contained the following laboratory orders:~ Hospital discharge order (start date 5/15/25): Weekly lab draw CBC w/ diff, Creatinine, ALT, CRP, ESR.~ Infectious disease order (start date 6/2/25): Continue weekly labs.~ Facility order (start date 5/20/25): Lab Draw: CBC w/ diff, Creatinine, ALT, CRP, ESR every day shift every Tuesday until 6/16/25. R3's medical record indicated labs were drawn on 5/19/25, 5/27/25, 6/3/25, and 6/10/25 and results were received. R3's medical record did not indicate labs were drawn the week of 6/16/25. On 7/23/25 at 11:48 AM, Surveyor interviewed DON-B who confirmed R3's labs were not drawn the week of 6/16/25 because the order staff entered was discontinued in error on 6/16/25. DON-B indicated the facility received an order from the infectious disease clinic on 6/2/25 to continue weekly labs with no end date. On 7/23/25 at 2:00 PM, Surveyor interviewed DON-B who indicated the facility does not have a policy for laboratory orders and drawing lab work. 2. On 7/23/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including bacteremia and atrial fibrillation. R9's MDS assessment, dated 6/11/25, had a BIMS score of 14 out of 15 which indicated R9 had intact cognition. R9 was responsible for R9's healthcare decisions.R9's medical record contained the following order:~ Change PICC line dressing per sterile technique one time a day every 7 day(s) for PICC line maintenance (start date 6/17/25; discontinued 7/1/25).R9's MAR and TAR contained orders for a weekly PICC line dressing change on Mondays and as needed. There was no documentation that R9's PICC line dressing was changed on 6/18/25 or 6/25/25.On 7/23/25 at 12:27 PM, Surveyor interviewed DON-B who indicated R9's PICC line dressing was changed by Registered Nurse (RN)-D on 6/18/25 and 6/26/25 but the dressing changes were not documented. DON-B indicated if a dressing change is not documented it is considered not completed. DON-B indicated PICC line dressings should be changed weekly or as needed if the dressing is soiled.

Based on staff and resident interview and record review, the facility did not ensure adequate supervision was implemented for 1 resident (R) (R2) of 8 sampled residents.On 7/1/25, R8 reported to Registered Nurse (RN)-E that R2 rubbed R8's arm and made sexual statements to R8 including What size are your breasts? and Can I feel your breasts? The facility did not place R2 on supervision to prevent reoccurrence. On 7/13/25, RN-E witnessed R2 rubbing R1's arm. RN-E intervened and R1 indicated that R1 squeezed R2's breasts. R2 was placed on 1:1 supervision following the incident.Findings include:The facility's Abuse, Neglect and Exploitation policy, dated 7/15/22, indicates the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves .B. Identifying, correcting, and intervening in situations in which abuse .is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff to meet the needs of the resident and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms .D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .Possible indicators of abuse include but are not limited to .5. Verbal abuse of a resident overheard, or inappropriate verbal conducted overheard.On 7/23/25, Surveyor reviewed a facility-reported incident (FRI) that indicated RN-E observed R2 rubbing R1's arm on 7/13/25. RN-E observed the interaction from down the hall and immediately intervened and separated R1 and R2. RN-E interviewed R1 who stated R2 had hands on me like this and visually squeezed R1's breasts with R1's hands. R2 was placed on 1:1 supervision. From 7/23/25 to 7/24/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including schizophreniform disorder. R1's Minimum Data Set (MDS) assessment, dated 5/28/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R1 had moderately impaired cognition. R1 had a Guardian for healthcare decisions.From 7/23/25 to 7/24/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia with other behavioral disturbance, depression, and anxiety disorder. R2's MDS assessment, dated 4/22/25, had a BIMS score of 9 out of 15 which indicated R2 had moderately impaired cognition. R2 had a Guardian for healthcare decisions. A care plan, revised 8/7/24, indicated R2 was at risk for behavior symptoms related to depression/anxiety, impaired cognition with history of touching staff inappropriately during personal cares and had a history of making sexual comments to staff due to sexual dysfunction and advancing dementia. A care plan, revised 2/4/25, indicated R2 had a history of inappropriate verbal and physical behavior related to cognitive impairment and displayed the following behaviors: Asking female staff to get in bed with R2; Asking female staff to lift up their shirt; Physically touching female staffs' breasts, pubic region, and buttocks. The care plan also indicated R2 had a history of entering a female resident's room without permission and touched the resident's leg without permission. A progress note in R2's medical record, dated 7/1/25 and written by RN-E, stated R2 rubbed the back of R8's hand and stated, What size are your breasts? R8 stated to R2, You are very inappropriate. R2 then asked, Can I feel your breasts? R8 reported the incident to RN-E.From 7/23/25 to 7/24/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including spinal stenosis, type 2 diabetes, congestive heart failure, and insomnia. R8's MDS assessment, dated 6/11/25, had a BIMS score of 15 out of 15 which indicated R8 had intact cognition. R8 was responsible for R8's healthcare decisions.On 7/23/25 at 11:21 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the 7/1/25 note written by RN-E was inaccurate. NHA-A indicated R2 and R8 brushed past each other in their wheelchairs in the hallway. NHA-A indicated Assistant Director of Nursing (ADON)-C followed-up with RN-E on proper documentation and Director of Nursing (DON)-B followed-up with R8 who stated R2 never touched R8 and the statements R2 made occurred a long time ago, not on 7/1/25. On 7/23/25 at 11:51 AM, Surveyor interviewed R8 who stated R2 made inappropriate statements to R8 in the past, but not recently. R8 denied R2 touched R8 recently. R8 indicated R8 was not concerned with R2, denied any distress, and stated staff were usually with R2. On 7/23/25, Surveyor reviewed facility documentation that indicated DON-B followed-up with R8 on 7/2/25. R8 stated R2 did not touch R8 but did say that R8 had large breasts. R8 denied any mental or emotional distress regarding interactions with R2. R8 indicated to DON-B that R2 was old and did not know any better. On 7/23/25 at 2:46 PM, Surveyor interviewed NHA-A and DON-B. DON-B stated R8 verified that R2 made inappropriate statements to R8, however, R8 indicated the statements were made in the past. On 7/23/25 at 3:02 PM, Surveyor interviewed RN-E via phone. RN-E stated RN-E did not witness anything on 7/1/25 but charted what R8 reported to RN-E. RN-E indicated R8 denied that R2 touched R8 but confirmed that R2 made inappropriate statements on 7/1/25. RN-E stated R8 was not distressed by the events and told R2 the statements were inappropriate. RN-E reported the event to ADON-C. On 7/23/25 at 3:18 PM, Surveyor interviewed ADON-C who confirmed RN-E informed ADON-C of the incident on 7/1/25 and ADON-C was on the phone with RN-E when RN-E interviewed R8. ADON-C stated R8 indicated R2 touched R8 on the arm years ago. ADON-C stated R8 confirmed that R2 made inappropriate statements on 7/1/25.R2's care plan goals, revised 7/1/25, indicated R2 would reduce the number of sexual comments made to staff, would not initiate contact of a sexual nature with residents, and would not make sexual comments to residents. The care plan did not include safety measures or interventions following the incident on 7/1/25. On 7/24/25 at 9:11 AM, Surveyor interviewed NHA-A who stated no new interventions were implemented following the incident on 7/1/25 because R2's care plan already contained appropriate interventions and the facility did not think additional interventions were needed. NHA-A stated R8 is alert and oriented and able to report that nothing occurred on 7/1/25. NHA-A stated R2 stays in R2's room the majority of the day and staff are aware they should keep an eye on R2 when R2 is out of the room. NHA-A stated education was provided to RN-E on proper documentation. NHA-A acknowledged the facility could have done more following the incident on 7/1/25, including having RN-E document clarification of the note in R2's medical record to prevent miscommunication.

Based on staff interview and record review, the facility did not revise the comprehensive plan of care to reflect personal care needs for 1 resident (R) (R2) of 1 sampled resident. R2's care plan did not reflect specialized techniques of care that R2 required with activities of daily living. Findings include: The facility's Comprehensive Care Plan policy, revised 9/23/22, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .5. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each Comprehensive and Quarterly Minimum Data Set (MDS) assessment and as needed with change in condition . On 6/13/25 at 9:20 AM, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including cerebral vascular accident with right-sided hemiplegia, dysphagia, aphasia, depression, cognitive communication deficit, and epilepsy. R2's MDS assessment, dated 3/24/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R2 had severe cognitive impairment. On 6/13/25 at 10:22 AM, Surveyor interviewed R2 who indicated staff were not gentle with R2 during cares. R2 did not want Surveyor to observe cares and did not want to provide any further details. On 6/13/25 at 12:22 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated R2 had right-sided weakness and staff should be careful during care since R2 had right arm pain with movement. CNA-D indicated R2 had same routine every day. CNA-D indicated CNA-D described each step of care to R2 during the process and carefully lifted R2's right arm due to R2's complaints of right arm pain with movement. CNA-D indicated R2 became easily frustrated if R2 was rushed and had confusion at times. CNA-D indicated it was important to ask if R2 needed a rest during cares. CNA-D indicated R2 often refused cares and only complained of right arm pain with movement. On 6/13/25 at 12:30 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated R2 had right-sided weakness and staff needed to work slowly and provide step-by-step explanation to R2 during care. On 6/13/25 at 1:13 PM, Surveyor interviewed CNA-F who indicated R2 required explicit explanation with each action during personal care because R2 got worked up with what to do next. CNA-F indicated R2's arm could be sore so it was necessary to monitor for pain and inform R2 whenever the arm would be lifted. CNA-F indicated R2 built up anxiousness during personal cares and the process could scare R2. CNA-F indicated once personal cares were completed, R2 had no complaints of pain. CNA-F indicated R2's personal care needs could be shared in shift report, however, CNA-F could not identify where specific actions to take during R2's cares were documented. On 6/13/25 at 2:05 PM, Surveyor interviewed CNA-G who indicated R2 tried not to move the right side if possible. CNA-G indicated it was important to talk through the care process while completing cares. CNA-G indicated R2 did not complain of right arm pain, however, CNA-G would contact the nurse if R2 reported any pain. On 6/13/25 at 2:09 PM, Surveyor interviewed CNA-H who indicated it was important to be extra careful with R2's right arm during personal cares because R2's right arm was sore. Surveyor noted R2's care plan, dated 6/11/25, indicated R2 had a right-sided deficit but did not provide patient-centered care technique specific to R2's needs during personal cares including to provide a detailed explanation prior to each step of the process, to provide care slowly and gently, to offer breaks during care, and to monitor for signs of increased frustration. The care plan also indicated R2 had muscle spasms and at times could shake R2's head yes/no when asked if having pain, however, R2 was inconsistent with reporting pain. A risk for difficulty in communication section contained an intervention for staff to explain each activity prior to starting it. On 6/13/25 at 1:50 PM, Surveyor interviewed [NAME] President of Success (VPS)-C, Director of Nursing (DON)-B, and Nursing Home Administrator (NHA)-A. VPS-C indicated R2's care plan addressed following personal choices. DON-B indicated staff were trained on techniques to provide care to a resident with deficits and R2 could express pain. NHA-A stated R2's mood goal indicated to offer choices to enhance a sense of control.

Based on observation, staff and resident interview, and record review, the facility did not ensure nail care was provided for 1 resident (R) (R21) of two sampled residents. R21's fingernails were not trimmed per R21's request. Findings include: From 3/30/25 to 4/1/25, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had a diagnosis of quadriplegia. R21's most recent Minimum Data Set (MDS) assessment, dated 3/14/25, indicated R21 had intact cognition. R21's plan of care, dated 3/20/25, indicated R21 had an activity of daily living (ADL) self-care deficit and was dependent on staff to complete ADLs due to physical limitations secondary to transverse myelitis quadriplegia. R21's plan of care also indicated R21 was at risk for alteration in skin integrity related to impaired mobility and contained interventions for personal hygiene assist of one, bathing/showering assist of one, and to be extra careful when trimming R21's nails due to abnormal nails and build-up under the nails. R21 had a nursing order, dated 3/16/25, for weekly vital signs, weight, and nail care every Sunday. On 3/30/25 at 11:14 AM, Surveyor interviewed R21 who indicated R21 asked staff to trim R21's fingernails on 3/29/25. R21 indicated R21's fingernails were not trimmed and were longer than R21 preferred. R21 indicated R21 left the facility for a family gathering on 3/30/25 and wanted R21's nails trimmed prior to the gathering. On 4/1/25 at 11:20 AM, Surveyor interviewed R21 who indicated R21 asked several staff members to trim R21's fingernails over the previous several days. R21 indicated R21's fingernails still had not been trimmed and were longer than R21 preferred. On 4/1/25 at 12:23 PM, Surveyor interviewed Registered Nurse (RN)-G who had completed nail care for R21 in the past but had not trimmed R21's nails in several months due to a change in job duties. RN-G indicated all nurses can provide nail care and nursing staff are expected to address nail care on shower days as part of the bath care check list. RN-G confirmed R21 asked RN-G to trim R21's nails on 3/29/25, however, RN-G did not provide nail care for R21. On 4/1/25 at 1:33 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility does not have a policy specific to nail care or grooming. DON-B indicated nail care is not routinely documented. DON-B indicated staff should complete nail care on shower days and confirmed R21's shower days were Thursday and Sunday. On 4/1/25 at 4:40 PM, Surveyor observed R21's fingernails and noted they extended approximately two millimeters past the fingertip. R21 confirmed staff had not yet trimmed R21's nails which were longer than R21 preferred. R21 referred to R21's fingernails as claws.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R7 and R16) of 6 sampled residents were monitored for adverse reactions to high-risk medications. R7 was prescribed furosemide (a diuretic medication) for edema (swelling). R7 was not monitored for adverse reactions to the high-risk medication. R16 was prescribed cefazolin (an antibiotic medication) for infection. R16 was not monitored for adverse reactions to the high-risk medication. Findings include: The facility's Medication Management policy, dated 1/2025, indicates: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug: .for excessive duration, without adequate monitoring .in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combination of these reasons. Medication management is based on the care process and includes recognition or identification of the problem/need .management/treatment, monitoring, and revising interventions .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use .The facility's medication management supports and promotes .evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify the underlying cause(s), including adverse consequences of medications; selection and use of medications in doses and for the duration appropriate to each resident's clinical conditions, age, and underlying causes of symptoms and based on assessing relative risks and benefits .permit use to the lowest possible dose or allow medication to be discontinued; and the monitoring of medications for efficacy and adverse consequences. To address the issue of antimicrobial stewardship, the center has developed an antimicrobial stewardship program that will optimize the treatment of infections while reducing the adverse events associated with antibiotic use .The facility assures that residents are being adequately monitored for adverse consequences . The facility's Antibiotic Stewardship Program policy, revised 11/18/22, indicates: .3. Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. 4. The program includes antibiotic use protocols and a system to monitor antibiotic use .b) Monitoring antibiotic use: i. Monitor response to antibiotics .iv. Monitor during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic . 1. From 3/30/25 to 4/1/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including heart failure, high blood pressure, and diabetes. R7's Minimum Data Set (MDS) assessment, dated 2/13/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R7 was not cognitively impaired. R7 was responsible for R7's healthcare decisions. R7's medical record contained a physician order for furosemide 20 milligrams once daily for edema. On 3/31/25 at 3:18 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated monitoring for adverse reactions to furosemide should be in R7's care plan. DON-B indicated the facility was in the process of changing high-risk medication monitoring from medication administration records (MARs) and treatment administration records (TARs) to residents' care plans. On 4/1/25 at 1:32 PM, Surveyor requested a diuretic/congestive heart failure/high blood pressure management policy. [NAME] President of Success (VPS)-C indicated the facility does not have a policy specific to diuretic/congestive heart failure/high blood pressure management. 2. From 3/30/25 to 4/1/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including intraspinal abscess and granuloma (spinal cord bacterial infection and inflammation), end stage renal disease, and dependence on renal dialysis. R16's MDS assessment, dated 3/5/25, had a BIMS score of 8 out of 15 which indicated R16 had moderately impaired cognition. R16 was responsible for R16's healthcare decisions. R16's medical record indicated R16 was prescribed cefazolin 2 grams on Tuesdays and Thursdays and 3 grams on Saturdays administered at dialysis. R16's medical record did not indicate staff monitored R16 for adverse reactions to the antibiotic medication. On 3/31/25, Surveyor reviewed R16's MAR which contained monitoring for adverse reactions to antibiotic medication with a start date of 3/31/25 at 10:00 PM. On 3/31/25 at 3:16 PM, Surveyor interviewed DON-B who verified there was no antibiotic monitoring in R16's medical record prior to 3/31/25.

Based on staff interview and record review, the facility did not ensure an as needed (PRN) psychotropic medication order for 1 resident (R) (R7) of 5 sampled residents was discontinued after 14 days. R7 was prescribed lorazepam (an anti-anxiety medication) for anxiety. R7's PRN lorazepam order was not discontinued after 14 days and did not contain a stop date. Findings include: The facility's Medication Management policy, dated 1/2025, indicates: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug: .for excessive duration, without adequate monitoring .in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combination of these reasons. Medication management is based on the care process and includes recognition or identification of the problem/need .management/treatment, monitoring, and revising interventions .In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use .The facility's medication management supports and promotes .evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify the underlying cause(s), including adverse consequences of medications; selection and use of medications in doses and for the duration appropriate to each resident's clinical conditions, age, and underlying causes of symptoms and based on assessing relative risk and benefits .permit use to the lowest possible dose or allow medication to be discontinued; and the monitoring of medications for efficacy and adverse consequences .Additional specific guidelines are applied to psychotropic drugs which are defined as any drugs that affect brain activity associated with mental processes and behavior. This includes .anti-anxiety and hypnotics .1. Based on a comprehensive assessment of a resident, the facility must ensure: PRN (as needed) psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order .The intent of the requirement is that: .PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited .When monitoring residents receiving psychotropic medication, the facility must evaluate the effectiveness of the medication as well as look for potential adverse consequences .The facility assures that residents are being adequately monitored for adverse consequences . From 3/30/25 to 4/1/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including depression, anxiety, and schizoaffective disorder. R7's Minimum Data Set (MDS) assessment, dated 2/13/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R7 was not cognitively impaired. R7 was responsible for R7's healthcare decisions. R7's medical record contained a physician order for lorazepam 1 milligram, give 1 tablet by mouth every 24 hours as needed for anxiety. The order was started on 1/24/25 and did not contain a stop date. On 3/31/25, Surveyor reviewed a fax from R7's Primary Care Provider ((PCP)-N), dated 2/20/25, that indicated a message was sent to PCP-N to discontinue PRN lorazepam for R7 due to non use The request to discontinue R7's PRN lorazepam was not addressed. On 3/31/25 at 3:18 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility was struggling to obtain a stop date for R7's PRN lorazepam from PCP-N. DON-B indicated staff faxed PCP-N's office but PCP-N's office wanted staff to email instead; however PCP-N did not respond with a stop date.

Based on observation, staff and resident interview, and record review, the facility did not ensure food was served in a manner that conserved palatability and temperature for 1 resident (R) (R21) of 14 sampled residents. The facility served R21's meals at an unappetizing temperature. Findings include: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.16: Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone of 5 degrees Celsius (C) to 57 degrees C (41 degrees Fahrenheit (F) to 135 degrees F) too long. From 3/30/25 to 4/1/25, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had a diagnosis of quadriplegia. R21's most recent Minimum Data Set (MDS) assessment, dated 3/14/25, indicated R21 had intact cognition. A care plan, dated 3/20/25, indicated R21 was at risk for nutritional status change related to congestive heart failure and quadriplegia and was dependent on staff for oral intake. On 3/30/25 at 11:14 AM, Surveyor interviewed R21 who indicated meals are rarely served hot and food is typically lukewarm. R21 indicated R21's meal tray is delivered and left on the bedside table until a staff is available to assist. R21 indicated meal trays have been on R21's bedside table for up to an hour before staff arrived to feed R21. On 4/1/25, Surveyor reviewed the facility's posted meal service times and noted breakfast for R21's unit was scheduled to be delivered at 7:50 AM. Surveyor noted R21's unit was the first unit to receive meal trays. On 4/1/25 at 8:05 AM, Surveyor noted a breakfast tray was delivered to R21's room and was on the bedside table. On 4/1/25 at 8:28 AM, Surveyor observed Certified Nurse Assistant (CNA)-K enter R21's room to feed R21. CNA-K indicated meal trays are delivered to all residents before staff assist residents with eating. On 4/1/25 at 8:31 AM, Surveyor observed Dietary Manager (DM)-L temp a cup of milk (which was at 43 degrees F) on R21's breakfast tray. DM-L confirmed milk should be held at less than 41 degrees F. R21 indicated the waffle on R21's breakfast tray was not warm. On 4/1/25 at 9:06 AM, Surveyor interviewed CNA-M who indicated meal trays on R21's unit are the first trays delivered. CNA-M confirmed all trays are delivered prior to CNAs assisting residents with eating. On 4/1/25 at 9:11 AM, Surveyor interviewed CNA-F who confirmed R21's unit is the first unit to receive meal trays. CNA-F confirmed all meal trays are distributed before residents are assisted with eating. CNA-F indicated several residents reported their food got cold while they waited for assistance. CNA-F indicated R21 reported on multiple occasions that R21's food got cold while R21 waited to be fed. CNA-F did not assist R21 with filing a grievance for the cold food. CNA-F indicated CNA-F took R21's tray back to the kitchen on several occasions to reheat the food prior to feeding R21. On 4/1/25 at 9:41 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility does not have a policy specific to feeding assistance. DON-B indicated CNAs should leave meal trays covered and in the service cart until staff are ready to assist residents. DON-B was not aware R21 had concerns about meal trays left on R21's bedside table for extended periods of time.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R138) of 14 sampled residents. R138 was on enhanced barrier precautions (EBP) which require staff to wear personal protective equipment (PPE) during high-contact resident cares. On 3/31/25, staff provided care, transferred, and disconnected R138's tube feeding without donning the appropriate PPE. In addition, there was not an EBP sign posted on or near R138's door. Findings include: The facility's Enhanced Barrier Precautions policy, revised 8/8/24, indicates: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs) .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .3. Implementation of EBP .b. Personal protective equipment (PPE) for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room .4. High-contact resident care activities include: a. dressing, b. bathing, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use: central lines, urinary catheters, feeding tubes .5. EBP should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. In general, gowns and gloves would not be recommended when performing transfers in common areas such as dining or activity rooms where contact is anticipated to be shorter in duration .EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. From 3/30/25 to 4/1/25, Surveyor reviewed R138's medical record. R138 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke), dysphagia, retention of urine, gastrostomy, and myocardial infarction (heart attack). R138 had an indwelling Foley catheter and percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube). R138's Minimum Data Set (MDS) assessment, dated 3/27/25, indicated R138 had severely impaired cognition. R138 had a Guardian. R138's medical record contained a physician order for a nothing per oral (NPO) diet and an enteral feeding order for continuous feed (dated 3/21/25). R138's medical record also contained an order for EBP due to PEG tube (dated 3/22/25). On 3/30/25 at 10:24 AM, Surveyor observed a PPE cart outside R138's door but did not observe an EBP sign on or near R138's door. On 3/31/25 at 9:56 AM, Surveyor noted R138's tube feeding was paused. Rehab Director (RD)-P and Certified Nursing Assistants (CNA)-F and CNA-O were present. CNA-F and CNA-O were completing cares and preparing to transfer R138 from bed to wheelchair. On 3/31/25 at 10:01 AM, Surveyor observed Licensed Practical Nurse (LPN)-E complete hand hygiene and don gloves prior to entering R138's room to disconnect R138's tube feeding from the PEG site so staff could transfer R138. LPN-E did not don a gown. On 3/31/25 at 10:03 AM, Surveyor interviewed LPN-E, RD-P, CNA-F, and CNA-O and asked if R138 was on precautions. LPN-E and CNA-O initially indicated R138 was not on precautions. LPN-E indicated R138 had an indwelling Foley catheter but did not have an infection and was not on precautions. When Surveyor asked about EBP, LPN-E indicated R138 should be on EBP due to R138's Foley catheter and PEG tube. LPN-E confirmed none of the staff present had on the appropriate PPE except gloves. LPN-E and CNA-F confirmed there was not an EBP sign outside R138's door. On 3/31/25 at 11:20 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R138 was on EBP. DON-B indicated staff should follow EBP guidelines and don the appropriate PPE due to R138's Foley catheter and PEG tube. On 4/1/25 at 10:27 AM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A who indicated staff education for EBP was started yesterday prior to Surveyor informing DON-B about Surveyor's observations on 3/30/25 and 3/31/25. On 4/1/25 at 1:31 PM, Surveyor interviewed DON-B regarding when EBP education started on 3/31/25. DON-B indicated EBP education was started between 7:00 AM and 7:30 AM when DON-B realized there was not an EBP sign outside R138's door. DON-B confirmed the EBP education sheet contained a date but did not contain a time.

Based on staff interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R89) of 1 resident reviewed for elopement. Upon admission on 2/5/24, R89 was assessed to be at risk for elopement and a wanderguard (a security device that triggers an alarm if the wearer exits the facility) was placed on R89's right ankle. On 2/10/24 at 9:00 AM, a community member altered staff that R89 was a few blocks away from the facility. Staff were unaware R89 left the facility but were able to locate R89 and bring him back to the facility. An assessment indicated R89 had no injuries. The failure to provide adequate supervision created a finding of Immediate Jeopardy (IJ) which began on 2/10/24. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 3/25/24 at 3:30 PM. The immediate jeopardy was removed and corrected on 2/10/24. Findings include: The facility's Elopement/Unsafe Wandering policy, with a review date of 8/9/22, indicates: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . On 3/25/24, Surveyor reviewed R89's medical record. R89 was admitted to the facility on [DATE] with diagnoses including cellulitis (infection of the skin and the soft tissues underneath) of both upper limbs, Alzheimer's disease, diabetes mellitus (a disease in which blood sugar levels are too high,) and superficial frostbite of both hands. R89's Minimum Data Set (MDS) assessment, dated 2/12/24, contained a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R89 had severe cognitive impairment. R89's medical record indicated R89's Power of Attorney for Healthcare (POAHC) was responsible for R89's healthcare decisions. R89 was discharged from the facility on 2/26/24. R89's care plan, initiated on 2/5/24, indicated R89 was an elopement risk/wanderer and a wanderguard was placed on R89's right ankle. R89's care plan was revised on 2/6/24 with the following interventions: provide structured activities as (R89) allows, redirect/reorient as needed/appropriate, and (R89) has 1-on-1 staff and must be within eyesight at all times through review date, except when (R89) is in (R89's) room. At that time, designated staff can sit outside (R89's) door as (R89) has a private room and private bathroom with only one exit door. R89's care plan was revised on 2/10/24 and contained the following intervention: (R89) has a 1-on-1 staff placed. On 3/25/24, Surveyor reviewed the facility's investigation which indicated: Upon admission to the facility, R89's wander risk assessment indicated R89 was at risk for wandering. A wanderguard was placed on R89. On 2/6/24 (the day after admission), R89 kissed another resident upon that resident's request .R89 was placed on 1:1 supervision related to the event as R89 adjusted to a new setting. 1:1 supervision was initiated while R89 was awake. At night, a motion sensor was placed on R89's door to alert staff if R89 exited the room .On 2/10/24 at approximately 9:00 AM, a neighbor of the facility came to the facility and spoke with Business Office Manager (BOM)-C. The neighbor stated they saw a person walking behind a wheelchair down the road and asked if it was a resident of the facility. Upon receiving the report, BOM-C informed nursing staff and requested a CNA (Certified Nursing Assistant) ride with BOM-C to identify the person. A head count was done. Approximately 10 minutes later, BOM-C and the CNA returned with R89 who was dressed in pants, shirts, a jacket, socks, one shoe on one foot, and a gripper sock on the other foot. The weather was sunny and 35 degrees. R89 did not present with any signs of injury. BOM-C stated upon entering the facility through the front doors, R89's wanderguard alarmed. R89 was placed on 1:1 supervision and the nurse completed an assessment. R89 did not sustain any injury. BOM-C checked the alarm panel at the nurse's station and noted the clear box that covered the panel was removed and the switch for the back door (leading to the parking lot) was disengaged. BOM-C engaged the switch and placed the clear box over the panel. BOM-C then went to the door and noted the alarm box on the top right corner of the door was shut off. The alarm was placed to provide a louder decibel when the door was opened. The disengaged alarm panel was on a door that staff used to take the garbage out. BOM-C turned the alarm box on. Immediate education was initiated and was ongoing. NHA-A and the Director of Nursing (DON) reviewed the schedule to identify staff who were assigned to provide 1:1 supervision for R89. NHA-A and the DON did not see that a staff member was assigned to provide 1:1 supervision .Scheduler (SCH)-H received immediate education related to the expectations when scheduling 1:1 supervision. The investigation indicated police were notified, other residents were reviewed and assessed for elopement risk, and staff were interviewed. The investigation contained proof the Scheduler and all staff were educated on the 1:1 process and the trash removal process, including a new process where only certain staff are allowed to disable alarms and staff must be placed at the door for security if the alarms aren't functioning. Elopement drills were conducted and 1:1 schedule audits were completed on each shift. The investigation did not include the address of the house where R89 was found. On 3/25/24 at 12:11 PM, Surveyor opened the back door and activated the alarm. Surveyor observed staff respond immediately to the alarm and wait for a manager to silence the alarm. The investigation included BOM-C's signed statement, dated 2/10/24, that indicated: Upon arriving on [NAME] Street, R89 was spotted walking on the side of the road pushing R89's wheelchair and approaching a person in their driveway. R89 walked up the driveway and started talking to the person. BOM-C and the CNA introduced themselves to the person R89 was talking to and stated they were from the facility. BOM-C and the CNA offered R89 a ride back to the facility. R89 did not appear to have any injuries and accepted the ride. The investigation included SCH-H's signed statement, dated 2/10/24, that indicated: I was notified that (R89) needed to be scheduled with a 1:1 staff for the foreseeable future on 2/6/2024 following an incident with (R89) and another resident. In attempts to get the 1:1 covered, I was not able to get a facility staff member or agency staff member to pick up the shift on Saturday morning, but had the schedule filled for the remainder of the weekend and Monday as a 1:1 with (R89). I did not realize that scheduling the 1:1 placed with (R89) at all times took precedence over scheduling CNAs to care for all of the other residents in the building. On 3/25/24, Surveyor reviewed a map of Little Chute and noted there was a wooded area behind the facility (on the side of the facility where R89 exited) and a river beyond the wooded area. The map indicated [NAME] Avenue was approximately three blocks from the front entrance of the facility. On 3/25/24 at 10:56 AM, Surveyor interviewed BOM-C who could not recall the address of the house where R89 was found but indicated the house was approximately 4 blocks from the facility. BOM-C stated the house was blue and near the intersection of [NAME] Avenue and Roosevelt Street. BOM-C indicated the house was on the opposite side of [NAME] Avenue and verified R89 had to cross [NAME] Avenue at some point. BOM-C indicated the weather on 2/20/24 was sunny, partly cloudy, and cold. BOM-C verified R89 willingly came back to the facility. On 3/25/24 at 1:27 PM, Surveyor interviewed CNA-D who verified CNA-D went with BOM-C to assist R89 back to the facility. CNA-D indicated CNA-D was assigned to R89's unit on 2/10/24. CNA-D indicated CNA-D assisted R89 to the dining room (which was in the same hall as the door R89 exited through) at approximately 8:00 AM. CNA-D stated R89 attempted to go into the kitchen several times, needed to be redirected, and was super quick. CNA-D could not recall when CNA-D started assisting other residents back to their rooms after breakfast and could not recall if any staff members were in the dining room during that time. CNA-D indicated CNA-D did not know R89 was gone from the facility until the neighbor informed staff. CNA-D stated R89 was found approximately three or four blocks from the facility and verified R89 came back to the facility willingly. CNA-D stated, (R89) was freezing. As far as I know, (R89) was wearing a bigger sweatshirt. I don't recall (R89) having a jacket on. CNA-D indicated R89 was wearing sweatpants and a sweatshirt with a shoe on one foot and a gripper sock on whatever foot (R89) had toes amputated. CNA-D indicated it was not made clear to CNA-D that someone had to stay with R89 at all times. CNA-D indicated whoever was scheduled on 1:1 duty for R89 never showed and nothing was communicated to CNA-D that CNA-D needed to stay with R89. On 3/25/24 at 2:00 PM, Surveyor interviewed CNA-G who verified CNA-G worked the AM shift on 2/10/24. CNA-G indicated the last time CNA-G saw R89 before CNA-G was notified that R89 left the facility without staffs' knowledge was before breakfast when CNA-G observed R89 sitting by the nurses' station. CNA-G verified the staff assigned to 1:1 duty for R89 did not show up for work. CNA-G did not recall a discussion about adjusting duties or tasks to provide 1:1 supervision for R89. CNA-G indicated CNA-G was not assigned to R89's wing. On 3/25/24 at 2:36 PM, Surveyor interviewed [NAME] President of Success (VPS)-E who indicated after talking to all staff involved, NHA-A and DON-B determined R89 was out of the building for approximately 10 minutes. On 3/25/24 at 4:00 PM, Surveyor drove to the house near the intersection of [NAME] Avenue and Roosevelt Street as described in the above interview with BOM-C. Surveyor reviewed Maps on Surveyor's phone which indicated the house was 0.3 miles from the facility. The walking time between the facility and the house was listed as six minutes. Surveyor observed sidewalks on both sides of all streets in the area. The failure to provide adequate supervision for R89 created a reasonable likelihood for serious harm which created a finding of immediate jeopardy. The facility removed and corrected the jeopardy on 2/10/24 when it completed the following: 1. Initiated 1:1 supervision for R89. 2. Ensured door alarms were engaged and functioning. 2. Interviewed and assessed other residents for elopement risk. 3. Interviewed and educated staff on 1:1 scheduling and the 1:1 process, the trash removal process, and the new alarm process. 4. Completed elopement drills and 1:1 schedule audits on each shift.

Based on staff interviews, outside provider interviews, and record review the facility did not ensure a physician was immediately notified and consulted with when a significant change in condition was identified for 1 of 4 sampled residents (R), R1. R1, who was receiving [MEDICATION(S)] (a high-risk anticoagulant medication/blood-thinner), experienced new bruising and nosebleed on 4/30/22. RN-C did not immediately notify and consult with a physician to determine if [MEDICATION(S)] should be held or new laboratory test should be ordered. Doses of [MEDICATION(S)] continued until 5/3/22 when laboratory value International Normalized Ratio (INR) was 7.2 (measures time for blood to clot), which was above R1's therapeutic INR goal range of 2 to 3. Facility failure to immediately notify and consult with a physician when R1 experienced a significant change in condition and a need to alter treatment created a finding of immediate jeopardy that began on 4/30/22. Regional Field Operations Supervisor (RFOS) notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 5/26/22 at 11:30 AM. The facility removed the jeopardy on 5/27/22. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: Facility policy titled High Risk Medications - Anticoagulants, revision dated 5/26/22, documented Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool) b. Fall in hematocrit (percentage of red cells in blood) or blood pressure. c. [CONDITION(S)] (blood clot). Facility policy titled Change in Condition of the Resident (Observing, Recording, and Reporting) Policy, revision dated 10/6/21, documented Notify resident's physician - use INTERACT Change in Condition: When to report to the MD (Medical Doctor)/ NP (Nurse Practitioner)/PA (Physician's Assistant) as a guideline. a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: i. Acute or sudden in onset, and: ii. A marked change (i.e., more severe) in relation to usual symptoms and signs, or iii. Unrelieved by measures already prescribed requires a phone call to the provider (do not fax for issues requiring immediate notification). If no response from provider and condition warrants, call the center medical director. If no response from the center medical director, contact the DON (Director of Nursing) for further guidance. INTERACT Change in Condition, Copyright 2014-2021 Version 4.5, documents, Medication side effects- Immediate (notification) - Any abrupt symptoms or significant changes in condition that might be associated with one or more medications According to the National Institute of Health ([MEDICATION(S)] Plus), [MEDICATION(S)] may cause severe bleeding that can be life-threatening and even cause death. From 5/25/22 through 5/27/22, Surveyor reviewed R1's medical record which documented R1 was on anticoagulant medication at the time R1 transferred to facility from another Skilled Nursing Facility (SNF) on 2/4/19. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS), dated [DATE], Brief Interview for Mental Status (BIMS) assessment score was 10 (moderately cognitively impaired). R1 had an activated Power of Attorney (POA) for healthcare and was not responsible for medical decision making. R1's INR (calculation of blood clotting/coagulation factors) therapeutic range was 2.0 through 3.0. Anticoagulation clinic ordered R1's [MEDICATION(S)] held on 4/29/22 when R1's INR was 4.6. Anticoagulation clinic confirmed R1's [MEDICATION(S)] administration was in evening and instructed staff to monitor closely. R1's [MEDICATION(S)] administration orders changed to hold on 4/29/22 and then give 1.5 mg Sundays, Tuesdays, and Saturdays and 2 mg all other days; obtain new INR on 5/2/22. Timeline per R1's medical record beginning 4/29/22: 4/29/22 - INR 4.60 - [MEDICATION(S)] HELD - with orders to monitor closely for bleeding/bruising. 4/30/22 at approximately 4:30 PM, staff discovered new abruise on R1's labia (vaginal opening) measuring 5 centimeters (cm) by 1 cm. - Unknown time between 4:30 PM and 8:23 PM, R1 had a nosebleed which stopped. - 7:19 PM, Registered Nurse (RN)-C administered 1.5 mg [MEDICATION(S)] to R1. - 11:45 PM, RN-C faxed notification marked for review of R1's INR 4.6, new bruise, and nosebleed 5/1/22 - administered [MEDICATION(S)] 1.5 mg to R1 5/2/22 - administered [MEDICATION(S)] 2 mg to R1. Drawing INR unsuccessful during four attempts. Communicated to anticoagulation clinic. Anticoagulation clinic documented facility staff denied R1 had new bruising or bleeding. 5/3/22 - INR 7.20 - [MEDICATION(S)] HELD. Medical Doctor (MD)-D examined R1's bruise and documented INR is quite elevated at the time of the exam and that may be a contributing factor in bruising. 5/4/22 - INR 6.10 - [MEDICATION(S)] HELD 5/5/22 -INR 6.10 - [MEDICATION(S)] HELD. Nursing notes documented bruising down back of right leg on outer area. 5/6/22 - INR 6.90 - [MEDICATION(S)] HELD - Hemoglobin critically low at 5.6. (Per Mayo Clinic: normal range for women is 11.6 to 15 grams per deciliter.) R1 sent to Emergency Department (ED) sent to lab for critical PT/INR and Complete Metabolic Panel (CMP) lab values. 5/6/22 ED discharge notes document critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Circulatory failure and shock. R1 had large area of bruising to right labia majora that extended from perineum up to the suprapubic abdomen and large bruising to medial and lateral aspect of right thigh. ED documented hemoglobin of 5.2. R1 developed a temperature of 102.5 degrees Fahrenheit and [CONDITION(S)]. Fecal occult blood test was positive. ED administered vitamin K (helps clot blood), one unit of blood, two units of packed red blood cells, 500 milliliters normal saline, and one liter of fluid to R1. 5/7/22 ED transferred R1 to different hospital's Intensive Care Unit (ICU). ICU documented chief complaint as [CONDITION(S)] and GastroIntestinal (GI) bleed. Upper and lower endoscopy (instrument put in body for internal view) completed. ICU determined stomach ulcers as likely source of internal bleeding. [MEDICATION(S)] held after discharge on 5/11/22 until 5/16/22. On 5/26/22 at 10:50 AM, Surveyor interviewed anticoagulation clinic RN-E via telephone. RN-E verified being the anticoagulation contact on 4/29/22 when R1's [MEDICATION(S)] was held for the day and ordered to resume on 4/30/22. RN-E explained anticoagulation clinic protocols are followed when changing [MEDICATION(S)] orders and staff were supposed to monitor for bruising and bleeding, especially since R1's INR values were trending up. RN-E recalled conversing with Licensed Practical Nurse (LPN)-F regarding R1 and LPN-F denying any new bruising or bleeding at the time orders were reviewed on 4/29/22. RN-E denied receiving a fax notification of R1's bruising and nosebleed on 4/30/22. RN-E reviewed clinic fax number with Surveyor and discovered facility RN-C did not fax directly to anticoagulation clinic. RN-E explained that because 4/30/22 was a Saturday, RN-C should have called the anticoagulation clinic phone number, which has coverage during all hours on all days, or called R1's designated on-call provider. RN-E explained that even if RN-C's fax went to the correct number, no one would have reviewed the fax message until Monday, 5/2/22. In R1's case, the facility staff person who conveyed R1's INR blood draw failed four times on 5/2/22 also denied new bruising or bleeding during consultation, probably because that staff person saw RN-C sent a fax notice of R1's bruising and nosebleed on 4/30/22. If RN-E had been aware of R1's new bruising and nosebleed, a different protocol would have come into play and [MEDICATION(S)] would likely have been held pending laboratory testing. On 5/25/22 at 3:50 PM, Surveyor interviewed MD-D regarding R1's 4/30/22 bruising and nosebleed. MD-D explained that if MD-D had been consulted with on 4/30/22, MD-D would have ordered a Complete Blood Count (CBC) and INR laboratory assessments and evaluated R1. [MEDICATION(S)] probably would have been held until at least the INR lab values were available for review. MD-D felt R1's overall situation on the weekend of 4/30/22 was preventable if communication was made via telephone. MD-D was not certain hospitalization could have been prevented because R1 was experiencing [CONDITION(S)] with low hemoglobin, but MD-D expressed frustration that staff faxed R1's bruise and nosebleed information on the weekend, when the anticoagulation clinic was not open to receive and review the information. MD-D verbalized an expectation that telephone contact be made on weekends for changes requiring immediate notification and consultation. MD-D explained there are on-call physicians available and MD-D acted as facility medical director and could be contacted if an on-call provider was not able to respond timely. MD-D indicated MD-D felt staff were focused on the location of R1's bruise as possible abuse and lost sight of R1's INR level and new bruising and nosebleed as possible medication concerns. On 5/25/22 at 1:05 PM, Surveyor interviewed RN-C via telephone. RN-C explained RN-C assessed R1's new bruise on 4/30/22 and faxed nosebleed and bruise information together. RN-C could not recall if R1's nosebleed happened before or after administration of [MEDICATION(S)]. RN-C indicated RN-C faxed change of condition information because RN-C felt fax was appropriate at the time. RN-C explained that R1 did not have a change in behaviors and was consuming food and beverage without concerns. RN-C denied knowing when fax would be reviewed and guessed fax may be reviewed on Monday, 5/2/22. RN-C commented that R1 was fragile to start with so RN-C wondered what could (MD-D) have done? On 5/25/22 at 1:38 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R1's 4/30/22 situation. DON-B revealed DON-B was not notified of R1's new bruising until 6:30 PM. DON-B explained that through investigating R1's injury of unknown origin (bruise on labia), DON-B discovered physician was notified via fax. DON-B explained R1's situation should have been telephoned to an on-call provider for consultation, especially since INR was 4.60 on 4/29/22. Failure to promptly consult with a physician following a significant change in condition created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. [NAME] G. Hart, [NAME] S. [NAME] and [NAME] C. [NAME] (1995). Oral Anticoagulants and Intracranial Hemorrhage. Stroke. 26(8), 1471-1477. https://doi.org/10.1161/01.STR.26.8.1471 documents Anticoagulation . increases the risk of intracranial hemorrhage 7- to 10-fold . Most (70%) anticoagulant-related intracranial hemorrhages are intracerebral hematomas (approximately 60% are fatal); the bulk of the remainder are subdural hematomas. Predictors of anticoagulant-related intracerebral hematoma are advanced patient age, prior ischemic stroke, hypertension, and intensity of anticoagulation. In approximately half of anticoagulated patients with intracerebral hematoma the bleeding evolves slowly over 12 to 24 hours, and emergency reversal of anticoagulation is crucial. Nobuhiro Akuzawa and Masahiko Kurabayashi (2018). Multiple Spontaneous Hemorrhages After Commencing [MEDICATION(S)] Therapy. SAGE Open Medical Case Reports. https://doi.org/10.1177/ 13X 380 documents Bleeding associated with over-anticoagulation can occur in patients taking [MEDICATION(S)], the annual frequency of this complication reportedly being 15%-20%, including 1%-3% of fatal bleeding events. The facility removed the jeopardy on 5/27/22, when it completed the following: 1. Facility audited timeliness of physician notification for residents with identified change in condition. 2. Facility reviewed and revised policy for High Risk Medications-Anticoagulants. 3. Facility provided education to licensed nurses on High Risk Medications-Anticoagulants Policy and INTERACT guidance for physician updates including when to telephone versus when to fax an update.

Based on record review and staff interview, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being when a change in condition occurred for 1 Resident (R) (R1) of 5 residents. R1 experienced a change in mental status approximately four days after admission. A UA (urinary analysis) was ordered on [DATE], but not completed in a timely manner. On 1/16/21, the facility was notified R1 tested positive for a UTI (urinary tract infection); however, R1 was actively dying and not able to swallow medication to treat the UTI. R1 passed away the following day. Findings include: On 1/27/21, the Surveyor reviewed R1's medical record. Prior to admission, R1 received hospice services at home due to increased weakness following a hospital stay. R1 was admitted to the facility with hospice services and had [DIAGNOSES REDACTED]. R1's Admission MDS (Minimum Data Set), dated 1/14/21, indicated R1's BIMS (brief interview for mental status) was not assessed; however, an admission progress note, dated 1/08/21, stated R1 was alert and oriented to person and situation. In addition, the MDS indicated R1 required extensive assistance of staff for bed mobility, transfers and most ADLs (activities of daily living). A hospice note, dated 1/08/21, stated HRN (Hospice Registered Nurse)-F assisted with R1's admission. The note indicated R1 was alert and oriented to person, place and time, had increased physical weakness over the last week and was able to make needs known. The note stated R1 was nervous at the beginning of the move, but appeared relaxed and calm by the end of the visit. A hospice note, dated 1/10/21, stated HRN-H spoke with the facility after receiving word that R1 was not adjusting well. The note indicated R1 was confused why R1 was still at the facility as R1 thought R1 was admitted for respite care and would be returning home. HRN-H spoke with FM (Family Member)-G who expressed concern regarding lack of communication from the facility. The note indicated RN (Registered Nurse)-N declined a hospice visit for R1 and stated R1 was calm and doing well. A hospice note, dated 1/10/21, stated HRN-I arrived at the facility at 11:58 PM after notification that R1 slid out of a recliner. The note indicated R1 had increased confusion, but was in good spirits and talking about books R1 read and wanted to borrow. An SBAR (Situation, Background, Assessment, Recommendation) note, dated 1/11/21 at 10:04 AM, stated R1 incurred a change in condition in regard to mental status and displayed symptoms of agitation, [MEDICAL CONDITION] and increased confusion. A progress note, dated 1/12/21 at 9:47 AM, stated, Call from (FM-G). Stated, '(R1) and I were just talking on the phone and (R1) is not sounding (R1's) normal self. (R1) is agitated and is sounding completely abnormal'. A progress note, dated 1/12/21 at 3:38 PM, stated, (HRN-F) here to evaluate resident due to apparent increase in confusion .(HRN-F) stating (R1) has typical confusion with different concerns and feels it may be related to the change in environment and routine. (HRN-F) will call and speak with (FM-G). A hospice note, dated 1/12/21, stated R1 was alert and oriented to person, place and time, but had increased confusion following R1's admission to the facility. The note stated R1's unfamiliar environment and change in routine were possible factors. A UA with culture and sensitivity order was faxed to MD (Medical Doctor)-J for signature to rule out a UTI. FM-G was in agreement. On 1/27/21 at 12:00 PM, the Surveyor interviewed HRN-F regarding the visit on 1/12/21. HRN-F stated R1 had slight confusion prior to admission. HRN-F visited R1 on 1/12/21 because staff said (R1) was confused. HRN-F stated R1 answered HRN-F's questions, but then veered off on different topics. HRN-F stated, I told staff I wasn't sure if it was due to a change in (R1's) surroundings and if (R1) needed a familiar face. HRN-F stated FM-G requested a UA. HRN-F stated an order was faxed to MD-J from the facility before the visit ended. HRN-F asked staff if HRN-F could call MD-J for a verbal order, but staff stated they needed a signature. HRN-F stated at that time, Nothing stood out that caused me any concern. A progress note, dated 1/13/21 at 3:02 PM, stated, Writer contacted (a named Hospice agency) to inquire about yesterdays request for UA order per (FM-G). A progress note, dated 1/13/21 at 3:49 PM, stated, Hospice faxing order for UA. A hospice note, dated 1/14/21 at 6:38 AM, stated HRN-E was called to the facility to assess R1's low blood pressure. The note stated R1 was minimally responsive; however, that was normal when R1 was aroused from sleep. Staff reported R1 was either not responsive or did not make sense when responsive. The note stated the UA was still pending and staff reported they would get the urine specimen on the AM shift. An Unwitnessed Fall Report, dated 1/14/21, stated Hospice and (FM-G) both noted a change in condition since (R1's) admission. The report indicated RN-L and CNA (Certified Nursing Assistant)-M checked on (R1) at least every hour. The report indicated R1 was found on the floor at approximately 4:00 AM. The report indicated R1's words and sentences did not make sense and stated, Call placed to hospice nurse reporting low blood pressure and inability to obtain UA by clean catch (R1) noted to be incontinent at time of incident .After (R1) placed back in bed, (R1) became unresponsive .Stuporous .responsive only to vigorous stimulation. On 1/27/21 at 11:22 AM, the Surveyor interviewed CNA-M regarding the incident. CNA-M stated CNA-M checked on R1 on a regular basis throughout the NOC (night) shift because R1 was restless. CNA-M stated at approximately 4:30 AM, CNA-M observed R1 on the floor and notified the nurse. CNA-M was unaware if a urine specimen needed to be or was obtained. On 1/27/21 at 2:00 PM, the Surveyor interviewed RN-L regarding the incident. RN-L stated RN-L believed the facility was waiting on a straight cath order for R1's UA from HRN-E. RN-L stated, When I gave report, I know that I reported we needed the cath urine order . On 1/28/21 at 7:09 AM, the Surveyor interviewed HRN-E regarding the visit on 1/14/21. HRN-E stated HRN-E was called to the facility in the early morning hours for a low blood pressure concern. HRN-E stated HRN-E was not informed that R1 fell out of bed. HRN-E stated HRN-E was not asked to obtain a straight cath order or a urine specimen and was told the facility would obtain the urine sample later that morning. A progress note, dated 1/14/21 at 8:00 AM, stated, (R1) very sluggish. Does not respond to verbal/tactile stimulus Hands very dark blue, unable to get (oxygen) saturation . A progress note, dated 1/14/21 at 12:21 PM, stated, Resident remains sluggish and not responding to commands. Did say 'bathroom' once but was unable to void on bedpan . A hospice note, dated 1/14/21 at 6:01 PM, stated HRN-D was called to the facility by RN-C who reported R1 was not doing well. The note indicated R1 was alert and oriented upon arrival and stated, (RN-C) also noted that they did not catheterize (R1) for urine sample as they did not feel they needed to, but would rather wait for writer to come to do so. Writer reiterated the fact that (R1) needed the test done and they had the order since Thursday (1/13/21) at approximately (3:00 PM). (RN-C) noted once again that hospice should be coming out to perform the catheterization. Writer .catheterized (R1) .Writer then took the specimen to Thedacare Encouraged fluid intake. On 1/27/21 at 2:20 PM, the Surveyor interviewed RN-C regarding R1. RN-C stated RN-C was informed via report that R1 needed a urine specimen; however, when facility staff changed R1, R1 was barely damp. RN-C stated DON (Director of Nursing)-B asked if RN-C cathed R1 and said the facility needed a urine specimen. RN-C stated, (DON-B) stated I should have cathed (R1), but I needed an MD order for that. If I knew (R1) needed one and it was my responsibility, I could've called and got an order. RN-C stated, It wasn't written on a board or a slip that we needed to get (the urine specimen) or I would've called for an order .(R1) came in and had been doing crosswords, watching TV, very oriented .(R1) was discombobulated when (R1) was here .Family mentioned (R1) must have a UTI. RN-C stated R1 displayed symptoms of altered mental status and was combative during R1's stay. RN-C stated RN-C thought obtaining a urine specimen was more of an afterthought and if staff could get one, they should get one. RN-C stated, I didn't think we had to do one. (R1) was actively dying . On 1/27/21 at 11:45 AM, the Surveyor interviewed HRN-D regarding the visit on 1/14/21. HRN-D stated RN-C called to say (R1) had a change in condition and wasn't doing well. HRN-D stated HRN-D phoned the facility prior to arrival to inquire about R1's UA result. HRN-D stated RN-C indicated the facility didn't do the UA. HRN-D stated RN-C indicated the facility didn't need to do the UA because hospice was supposed to do it. HRN-D stated HRN-D assumed the facility's nursing staff would obtain the urine specimen since they received the order over twenty four hours prior. HRN-D stated had HRN-D known the facility wasn't going to obtain the specimen, HRN-D would have obtained the specimen on 1/13/21. HRN-D stated, (FM-G) was very upset the UA wasn't done when it was ordered. A hospice note, dated 1/16/21 at 9:07 AM, stated R1's UA culture results were still pending. The note also stated R1 hadn't eaten or taken medication since 1/14/21 and would occasionally open eyes to touch, but had no other responses. A hospice note, dated 1/16/21 at 3:56 PM, indicated R1 was lethargic with cyanotic lips and toes and stated, Confirmed UTI. (R1) is unable to swallow without choking. (FM-G) at bedside and fully advised that (R1) will pass without treatment. Declining to have antibiotics at this time due to choking .(FM-G) is fully aware (R1) will pass from the UTI. (FM-G) agrees (R1) would not be able to swallow pills and that (R1) is comfortable and in no pain. On 1/26/21 at 5:08 PM, the Surveyor interviewed FM-G regarding the complaint. FM-G stated when FM-G and FM-K spoke with R1 on 1/10/21, R1 was hysterical and out of (R1's) head. FM-G stated FM-G told FM-K to call the facility because FM-G believed R1 had a UTI. FM-G stated, That wasn't (R1). (R1) brought books (to the facility), (R1) was playing jeopardy (prior to admission). (R1) didn't have dementia . FM-G also stated during a [MEDICATION NAME] care visit on 1/15/21, R1's water was not within reach. FM-G stated the facility confirmed R1 had a UTI on 1/16/21. FM-G stated, Hospice said (R1) couldn't take pills The hospice nurse said she thought it was too late to give (R1) the medication. I called hospice back on (1/16/21) and said we wanted the antibiotics administered, but (R1) passed away before (R1) received them. FM-G stated despite R1's hospice status, death was not imminent when R1 entered the facility. FM-G stated, (R1) suffered because (R1) wasn't treated for [REDACTED]. certificate. FM-G stated FM-G did not yet have the certificate in hand; however, the funeral home informed FM-G that R1's cause(s) of death were listed as diabetes, hypertension and [MEDICAL CONDITION]. On 1/27/21 at 10:00 AM and 4:00 PM, the Surveyor interviewed DON-B regarding R1. DON-B stated R1 struggled during R1's first few days of admission with the change in surroundings. DON-B stated nursing staff debated whether R1 experienced a change in condition, but believed R1's behavior was at baseline. DON-B stated the facility updated HRN-F who didn't think R1's confusion was a new symptom and indicated it was typical. DON-B stated, We updated hospice because better safe than sorry .We were concerned because (FM-G) was concerned. When asked if staff needed a signed order to obtain a urine specimen as indicated by HRN-F's interview, DON-B verified staff could obtain a urine specimen via a verbal order which would have allowed staff to obtain the sample on 1/12/21 when the UA was initially requested. On 1/27/21 at 10:25 AM and 12:56 PM, the Surveyor interviewed RNC (Regional Nurse Consultant)-O regarding R1. RNC-O stated RNC-O was at the facility on 1/14/21 when HRN-D obtained R1's urine sample. RNC-O stated RNC-O thought nursing staff attempted to obtain a sample on the AM shift, but were unsuccessful because R1 was incontinent. RNC-O stated RNC-O wasn't sure why facility staff did not obtain a straight cath order at that time or on 1/13/21 when the UA order was received. When asked if staff needed a signed order to obtain a urine specimen as indicated by HRN-F's interview, RNC-O verified staff could obtain a urine specimen via a verbal order which would have allowed staff to obtain the sample on 1/12/21 when the UA initially requested.

Based on observation, record review and staff interview, the facility did not ensure 3 (Resident 6, Resident 9 and Resident 11) of 8 sampled residents received the necessary care and services to attain or maintained the highest practicable physical well-being. Resident 6 is diagnosed with [REDACTED]. On 10/3/16, Resident 6's blood sugar in the morning was 67 mg/dl and the resident received 30 units of [MEDICATION NAME], outside of the physician's parameters. On 10/4/16, Resident 6's morning blood sugar was 62 mg/dl and the resident was given 30 units [MEDICATION NAME] outside of the physician's parameters. LPN (Licensed Practical Nurse)-F, who had administered the [MEDICATION NAME]to Resident 6 did not ensure the resident ate within 15 minutes of giving the short acting insulin per manufacturer's guidelines/current standards of practice and did not monitor the resident post-administration of the [MEDICATION NAME]. Resident 6 became unresponsive and was sent to hospital emergency room to be treated for [REDACTED]. The failure of the facility to ensure that Resident 6 - whose blood sugar was already low and who received [MEDICATION NAME]without first consulting the physician - ate within 15 minutes of receiving short acting insulin and the failure to monitor the resident post-insulin administration resulted in Resident 6 requiring emergency hospital treatment for [REDACTED]. On 10/4/16 the NHA (Nursing Home Administrator) was formally notified that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 10/4/16, however the deficient practice continues at a scope/severity level of D (Isolated/Potential for Harm) related to the following examples: Staff administered short-acting insulin to Resident 9 and Resident 11 without ensuring the residents had eaten within 15 minutes of administration per manufacturer's guidelines and current standards of practice. Findings Include: The Facility's policy on Glucose Management/[DIAGNOSES REDACTED] indicates: Protocol: 4.1 Assess resident's current medication regime as it relates to blood glucose management. if current regime is working for resident, leave it alone. 4.2 Blood Glucose Emergency Treatment Options A. [DIAGNOSES REDACTED] is defined as a blood glucose level less than 70 mg/dl. It is important to recognize and treat low blood sugar immediately because it can come on very quickly. It may be dangerous when your blood sugar is very low because you could pass out or have convulsions if your brain is not receiving enough sugar to work properly. A low blood sugar reaction can happen when: ~ You take your medication, but don't eat on time. ~ You don't eat enough for the medication that you have taken. ~ You skip a meal. <http://www.bd.com/us/diabetes/page.aspx?cat=7001&id=7238> [DIAGNOSES REDACTED] can lead to shakiness, nervousness, dizziness or light-headedness, sleepiness, confusion, anxiety, and [MEDICAL CONDITION]. [DIAGNOSES REDACTED] can also lead to coma and, in rare cases, death. Novo [MEDICATION NAME], the manufacturer of [MEDICATION NAME], in the package insert revised 2/2015 indicates, [MEDICATION NAME] has a more rapid onset of action and shorter duration of activity than regular human insulin. An injection of [MEDICATION NAME] should be immediately followed with a meal within 5 to 10 minutes. 1. Resident 6 was admitted to facility on 9/30/16 with a left [MEDICAL CONDITION] relating to complications with diabetes. [DIAGNOSES REDACTED]. According to resident admission assessment dated [DATE], Resident 6 required supervision and one-person physical assist to eat. Resident 6's medications included [MEDICATION NAME] (an anti-diabetic medication) 10 mg (milligrams) in the morning, [MEDICATION NAME] (insulin) 30 units to be given in the morning with specific physician parameters of calling the physician if blood glucose is noted of less than 70 mg/dl and greater than 400 mg/dl. On 10/3/16 at 8:43 a.m., Resident 6's documented blood sugar was 67 mg/dl. Resident 6 was given 10 mg [MEDICATION NAME] and 30 units [MEDICATION NAME] by LPN-F. LPN-F did not consult with the resident's physician with regard to Resident 6's blood sugar being lower than physician parameters prior to administering the [MEDICATION NAME]. LPN-F did not follow up to ensure Resident 6 ate within 15 minutes of receiving [MEDICATION NAME]. On 10/4/16 at 9:47 a.m., Resident 6's documented blood sugar was 62 mg/dl. LPN-F again administered [MEDICATION NAME] 10 mg and [MEDICATION NAME] 30 units without consulting Resident 6's physician regarding the resident's low blood sugar before administering [MEDICATION NAME]. LPN-F acknowledged resident had not eaten prior to medication administration but indicated encouraging the resident to eat. LPN-F indicated she had not follow up with Resident 6 until the CNAs (Certified Nursing Assistants) commented Resident 6 was being difficult and wouldn't get up for therapy. LPN-F went to check on Resident 6 at approximately 11:00 a.m. and LPN-F could not identify if Resident 6 had eaten yet and did not re-check resident's blood sugar. LPN-F indicated she felt resident was alert at the time. On 10/4/16 at 12:20 p.m., documentation indicated LPN-F was alerted by CNAs that Resident 6 was unresponsive. LPN-F checked resident's blood sugar and determined it was 28 mg/dl. LPN-F notified physician and an order for [REDACTED]. At 12:47 p.m., Resident 6 received the second [MEDICATION NAME] injection with a follow-up blood glucose of 55 mg/dl. Resident 6 remained unresponsive. The physician was notified and the physician ordered to send Resident 6 to the hospital emergency room . Resident 6 was transported to the hospital at approximately 1:10 p.m., slightly responsive at that time. On 10/5/16 at approximately 10:15 a.m., Surveyor interviewed LPN-F regarding Resident 6. LPN-F indicated she worked with Resident 6 on 10/3/16 and 10/4/16. LPN-F verified the resident's blood sugar was 67 mg/dl on 10/3/16 and 62 mg/dl on 10/4/16. LPN-F verified administering the [MEDICATION NAME] 10 mg and 30 units [MEDICATION NAME]to Resident 6 on those mornings. LPN-F indicated she did not read the entire physician's orders [REDACTED]. LPN-F indicated she felt the blood sugar was low, but thought parameters were to call the physician with a blood sugar less than 60 mg/dl. LPN-F indicated she didn't mean for it to happen, stating: Had I known the parameters, I wouldn't have given the insulin. The facility's failure to administer insulin to Resident 6 within the physician's blood sugar parameters, failure to ensure the resident ate within 15 minutes of receiving short-acting insulin and failure to monitor the resident post-insulin administration resulted in Resident 6 requiring emergency hospital treatment for [REDACTED]. The facility removed the jeopardy on 10/4/16, by which time it had completed the following: ~ Licensed staff educated on Atrium Policies and Procedures as they relate to Physician Notification and Diabetes Management-Hypoglycemic Protocol (which includes monitoring and follow-up) were initiated to all licensed staff prior to providing any direct patient care. ~ Licensed staff prior to start of shift were given education on signs and symptoms of [DIAGNOSES REDACTED] and Protocol for Adequate Intervention, Adherence to Resident Blood Glucose Parameters and Insulin Administration. ~ Licensed staff were provided The INTERACT Reporting Change of Condition to the Physician documents and educated of their use as a guideline. ~ Regional Director of Clinical Operations conducted audit on all residents to identify those with an active [DIAGNOSES REDACTED]. Out of the 21 residents, 12 are insulin dependent (this is what will determine the individuals who could be affected). All 21 residents have been reviewed to ensure that blood glucose parameters, HgbA1c (hemoglobin A1c is a measure of your blood sugar control over the past 2 to 3 months) lab draws and emergency [MEDICATION NAME] kit orders were appropriately listed within the physician's orders [REDACTED]. Addressed all identified discrepancies. ~ 10/05/16, Regional Dietician reviewed all diabetic residents to ensure there was a separate diabetic care plan in place, ensured HS (bedtime)snacks were care planned for all insulin dependent diabetic residents and ensured that all residents had their blood glucose parameters indicated on their written plan of care. ~ 10/05/2016, Omni Pharmacy contacted and updated on noted occurrences; Consultant Pharmacist and Nurse Consultant to review noted concerns and develop additional training materials and audits as deemed necessary. ~ October and September MARs to be reviewed for the all diabetic residents; specifically, Regional Director of Clinical Operations reviewed documented blood glucose levels and ensured that any levels noted outside individual parameters had appropriate follow-up and notification documented. All insulin dependent diabetic residents will have HS snack offered and documented by the nurse in the MAR indicated [REDACTED]. ~ Head-to-Toe Assessment and skin observation on all residents with a [DIAGNOSES REDACTED]. Identified Changes of Condition from baseline will be communicated appropriately to the physician. ~ Mandatory nurses meetings on 10/06/16 to reinforce diabetic management education, glucose management protocol: [DIAGNOSES REDACTED], Diabetes Medication Review, physician notification requirements, and all necessary information related to current situation. ~ Medical Director updated on Correction and Removal Plan as well as the occurrences of which this Plan relates to. ~ Audits developed and completed per designated audit schedule, to include: Diabetic Monitoring, Medication Administrations Skills Checklist, HS Snack Review and Change of Condition/physician's Notifications. Discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined and if issues are identified, re-education will be done. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as needed. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as evidenced by: 2. On 10/4/16 at 7:11 a.m., Surveyor observed RN (Registered Nurse)-E prepare medications to be administered to Resident 9. [MEDICATION NAME] Insulin 100 units/ml (milliliter), 2 units was drawn up into a syringe and injected subcutaneously to the resident at 7:20 a.m. RN-E informed the surveyor at that time, breakfast would be served between 8 and 9 a.m. On 10/4/16 at 10:05 a.m., Surveyor interviewed RN-E, who confirmed [MEDICATION NAME] was a short acting insulin and patients should eat immediately after receiving the injection, within 15 minutes. When asked when Resident 9 ate, RN-E indicated not knowing when the resident ate, but knew Resident 9 was going to the dining room right after the administration of the insulin. On 10/4/16 at 9:05 a.m., Surveyor interviewed DA (Dietary Aide)-J, who verified breakfast was not served until 8:00 a.m. On 10/4/16 at 2:00 p.m., Surveyor interviewed Resident 9 who verified the resident ate breakfast after 8:00 a.m. that morning. 3.(NAME)Lilly and Company in the patient instructions most recently revised: 11/2015, indicated, Humalog starts acting fast, so inject it up to 15 minutes before or right after you eat a meal. On 10/4/16 at 7:30 a.m., Surveyor observed LPN (Licensed Practical Nurse)-F prepare medications for Resident 11. LPN-F injected 2 units of Humalog insulin subcutaneously into Resident 11 who was in bed and not dressed for the day. On 10/4/16 at 9:05 a.m., Surveyor interviewed DA (Dietary Aide)-J who verified breakfast was served not served until 8:00 a.m. On 10/4/16 at 9:05 a.m., Surveyor observed Resident 11 leaving the dining room. On 10/4/16 at 10:10 a.m., Surveyor interviewed LPN-F who confirmed the LPN did not know how soon after the insulin was given that Resident 11 ate breakfast. Additionally, LPN-F was not sure if Humalog was short or long acting but the LPN thought a resident would have to eat within an hour of receiving short acting insulin.

Based on record review and staff interview, the facility did not ensure that 1 (Resident 6) of 13 sampled residents was free from significant medication errors. Resident 6 has a [DIAGNOSES REDACTED]. On 10/3/16 and 10/4/16 resident's morning blood glucose levels were 67 and 62 respectively. Resident was given 30 units [MEDICATION NAME] by LPN-F on both mornings with no physician notification of low blood glucose levels. This significant medication error resulted in an Immediate Jeopardy situation, which began on 10/3/16. On 10/4/16 the NHA (Nursing Home Administrator) was formally notified that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 10/4/16, however the deficient practice continues at a scope/severity level of D (Isolated/Potential for Harm). Findings Include: The Facility's policy on Glucose Management: [DIAGNOSES REDACTED] indicates: Protocol: 4.1 Assess resident's current medication regime as it relates to blood glucose management. if current regime is working for resident, leave it alone. 4.2 Blood Glucose Emergency Treatment Options A. [DIAGNOSES REDACTED] is defined as a blood glucose level less than 70 mg/dl. It is important to recognize and treat low blood sugar immediately because it can come on very quickly. It may be dangerous when your blood sugar is very low because you could pass out or have convulsions if your brain is not receiving enough sugar to work properly. A low blood sugar reaction can happen when: ~ You take your medication, but don't eat on time. ~You don't eat enough for the medication that you have taken. ~ You skip a meal. <http://www.bd.com/us/diabetes/page.aspx?cat=7001&id=7238> [DIAGNOSES REDACTED] can lead to shakiness, nervousness, dizziness or light-headedness, sleepiness, confusion, anxiety, and [MEDICAL CONDITION]. [DIAGNOSES REDACTED] can also lead to coma and, in rare cases, death. 1. Resident 6 was admitted to facility on 9/30/16 with a left [MEDICAL CONDITION] relating to complications with diabetes. [DIAGNOSES REDACTED]. According to resident admission assessment dated [DATE], Resident 6 required supervision and one-person physical assist to eat. Resident 6's medications included [MEDICATION NAME] (an anti-diabetic medication) 10 mg (milligrams) in the morning, [MEDICATION NAME] (insulin) 30 units to be given in the morning with specific physician parameters of calling the physician if blood glucose is noted to be less than 70 mg/dl and greater than 400 mg/dl. On 10/3/16 at 8:43 a.m., Resident 6's documented blood sugar was 67 mg/dl. Resident 6 was given 10 mg [MEDICATION NAME] and 30 units [MEDICATION NAME] by LPN-F. LPN-F did not consult with the resident's physician with regard to Resident 6's blood sugar being lower than physician parameters prior to [MEDICATION NAME] administration. On 10/4/16 at 9:47 a.m., Resident 6's documented blood sugar was 62 mg/dl. LPN-F again administered [MEDICATION NAME] 10 mg and [MEDICATION NAME] 30 units without consulting Resident 6's physician regarding the resident's blood sugar being lower than physician ordered parameters for medication administration. LPN-F acknowledged resident had not eaten prior to medication administration but indicated encouraging the resident to eat. LPN-F indicated she had not follow up with Resident 6 until the CNAs (Certified Nursing Assistants) commented Resident 6 was being difficult and wouldn't get up for therapy. LPN-F went to check on Resident 6 at approximately 11:00 a.m. and LPN-F could not identify if Resident 6 had eaten yet and did not re-check resident's blood sugar. LPN-F indicated she felt resident was alert at the time. On 10/4/16 at 12:20 p.m., documentation indicated LPN-F was alerted by CNAs that Resident 6 was unresponsive. LPN-F checked resident's blood sugar and determined it was 28 mg/dl. LPN-F notified physician and an order for [REDACTED]. At 12:47 p.m., Resident 6 received the second [MEDICATION NAME] injection with a follow-up blood glucose of 55 mg/dl. Resident 6 remained unresponsive, the physician was notified and the physician ordered to send Resident 6 to the hospital emergency room . Resident 6 was transported to the hospital at approximately 1:10 p.m., slightly responsive at that time. On 10/5/16 at approximately 10:15 a.m., Surveyor interviewed LPN-F regarding Resident 6. LPN-F indicated she worked with Resident 6 on 10/3/16 and 10/4/16. LPN-F verified the resident's blood sugar was 67 mg/dl on 10/3/16 and 62 mg/dl on 10/4/16. LPN-F verified administering the [MEDICATION NAME] 10 mg and 30 units [MEDICATION NAME]to Resident 6 on those mornings. LPN-F indicated she did not read the entire physician's orders [REDACTED]. LPN-F indicated she felt the blood sugar was low, but thought parameters were to call the physician with a blood sugar less than 60 mg/dl. LPN-F indicated she didn't mean for it to happen, stating: Had I known the parameters, I wouldn't have given the insulin. The facility's failure to administer insulin to Resident 6 within the physician's blood sugar parameters, failure to ensure the resident ate 15 minutes before or after receiving short acting insulin and failure to monitor the resident post-insulin administration resulted in Resident 6 requiring emergency hospital treatment for [REDACTED]. The facility removed the jeopardy on 10/4/16, by which time it had completed the following: ~ Licensed staff educated on Atrium Policies and Procedures as they relate to Physician Notification and Diabetes Management-Hypoglycemic Protocol (which includes monitoring and follow-up) were initiated to all licensed staff prior to providing any direct patient care. ~ Licensed staff prior to start of shift were given education on signs and symptoms of [DIAGNOSES REDACTED] and Protocol for Adequate Intervention, Adherence to Resident Blood Glucose Parameters and Insulin Administration. ~ Licensed staff were provided The INTERACT Reporting Change of Condition to the Physician documents and educated of their use as a guideline. ~ Regional Director of Clinical Operations conducted audit on all residents to identify those with an active [DIAGNOSES REDACTED]. Out of the 21 residents, 12 are insulin dependent (this is what will determine the individuals who could be affected). Addressed all identified discrepancies. ~ 10/05/16, Regional Dietician reviewed all diabetic residents to ensure there was a separate diabetic care plan in place, ensured HS (bedtime)snacks were care planned for all insulin dependent diabetic residents and ensured that all residents had their blood glucose parameters indicated on their written plan of care. ~ 10/05/2016, Omni Pharmacy contacted and updated on noted occurrences; Consultant Pharmacist and Nurse Consultant to review noted concerns and develop additional training materials and audits as deemed necessary. ~ October and September MARs to be reviewed for the all diabetic residents; specifically, Regional Director of Clinical Operations reviewed documented blood glucose levels and ensured that any levels noted outside individual parameters had appropriate follow-up and notification documented. All insulin dependent diabetic residents will have HS snack offered and documented by the nurse in the MAR (Medication Administration Record) to validate that their snacks are being offered. ~ Head-to-Toe Assessment and skin observation on all residents with a [DIAGNOSES REDACTED]. Identified Changes of Condition from baseline will be communicated appropriately to the physician. ~ Mandatory nurses meetings on 10/06/16 to reinforce diabetic management education, glucose management protocol: [DIAGNOSES REDACTED], Diabetes Medication Review, physician notification requirements, and all necessary information related to current situation. ~ Medical Director updated on Correction and Removal Plan as well as the occurrences of which this Plan relates to. ~ Audits developed and completed per designated audit schedule, to include: Diabetic Monitoring, Medication Administrations Skills Checklist, HS Snack Review and Change of Condition/physician's Notifications. Discrepancies identified during completion of these audits will be immediately addressed. All audits, reviews and interviews will be forwarded to the Center's QAPI (Quality Assurance Performance Improvement) Committee to identify patterns and trends of noncompliance and to determine if further action is necessary. Frequency of continued audits will be determined and if issues are identified, re-education will be done. If any trends are identified, systems will be assessed to determine effectiveness. A plan will be developed and revisions will be made as needed.

Based on interview and record review, the facility did not ensure 1 (resident #1) of 11 residents reviewed for diabetes received care in accordance with professional standards of practice. RN (Registered Nurse)-J was caring for resident #1, an insulin-dependent diabetic, when the resident became unresponsive. The RN did not perform a blood glucose test timely and was not aware of the facility's protocol for [DIAGNOSES REDACTED]. This led to a delay of appropriate emergency care for a resident suffering a hypoglycemic episode. Facility failure to follow professional standards of practice to include blood glucose monitoring as part of a nursing assessment when a resident receives scheduled insulin created a finding of immediate jeopardy that began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Findings include: According to chapter N 6 in the Wisconsin Board of Nursing Administrative code for RNs dated 2006, RNs should follow the nursing process of assessment, planning, interventions, and evaluation. Assessment includes analysis of data regarding the health status of a patient, planning includes recognizing patient priorities, interventions include implementing appropriate interventions based on patient needs, and evaluation should include a determination of the patient's progress or lack of progress towards a goal. According to the facility's "Emergency Intervention Insulin Shock/[DIAGNOSES REDACTED]" policy and procedure dated [DATE], insulin dependent residents with diabetes must be closely monitored for diabetes. The procedure listed multiple symptoms including weakness, vision difficulties, jitteriness, dizziness, hunger, and changes to pulse and respirations. The procedure indicated a blood glucose of 60 mg/dl or less can indicate a diabetic emergency and staff should "Notify physician immediately if symptoms exist" and "continue to observe resident as directed by the physician." Resident #1's face sheet, dated [DATE], documented the resident was admitted to the facility on [DATE] for rehabilitation following an humerus/arm fracture. The resident had multiple [DIAGNOSES REDACTED]. Resident #1's physician's orders [REDACTED]. Resident #1's blood glucose monitoring logs and nurse's charting indicated the resident did not have any episodes of [DIAGNOSES REDACTED] (low blood sugar) from the time of admission until [DATE] and then again on [DATE]. The facility's investigation dated [DATE] documented RN-F was caring for resident #1 on [DATE], during the night shift. According to the investigation, around 2:20 a.m. resident #1 was displaying weakness while walking and difficulty holding an eating utensil. RN-F determined resident #1 had suffered a hypoglycemic episode. This was not documented or reported to the resident's physician. Nutrition documentation indicated the resident had a decreased appetite and intake throughout the day on [DATE]. Despite the hypoglycemic episode the previous night and the low intake during the day, the ,[DATE] MAR (Medication Administration Record) noted that staff gave the scheduled insulin doses as previously ordered. There had been no contact with the physician regarding this change. Resident #1 then suffered a more severe hypoglycemic event on [DATE] around 5:00 a.m., when the resident was found to be unresponsive. On [DATE] at 2:10 p.m., surveyor # interviewed phlebotomist-I regarding resident #1. Phlebotomist-I stated she arrived at the facility on [DATE] at 4:48 a.m. and left at 5:34 a.m.. Phlebotomist-I stated she found resident #1 unresponsive with white foam coming out of the mouth. Phlebotomist-I indicated she could not arouse the resident so she reported this to RN-J. Phlebotomist-I did not know the exact time, but stated resident #1 was one of the first residents she drew blood on that day and that she did several residents after resident #1 prior to leaving the facility at 5:34 a.m.. RN-J created a timeline which indicated phlebotomist-I notified staff on [DATE] at 5:20 a.m. that resident #1 was unresponsive. On [DATE] at 1:34 p.m., surveyor # interviewed RN-J. RN-J indicated she believed approximately 30 minutes had passed from when the resident was found unresponsive to when 911 was called. RN-J indicated the resident's vital signs were checked and were normal except for a low oxygen level. RN-J stated she left the room to get oxygen, applied the oxygen, went to get a suctioning machine from the oxygen room, went to get tubing from the treatment room, and suctioned a foam like substance from the resident's mouth. RN-J indicated she then rechecked the resident's vital signs, which were all normal. This time she also checked the resident's blood glucose level. RN-J stated there was confusion over the blood glucose result because it was said to be 29 mg/dl, but she remembered it to be 49 mg/dl. RN-J verified both numbers were very low and that she was not familiar with facility protocol, so she called DON (Director of Nursing)-B for direction, since there were no other nurses working at that time. RN-J verified that DON-B gave direction to have staff call 911 and DON-B called the physician for a [MEDICATION NAME] order. During this time, CNA (Cerified Nursing Assistant)-L found the resident to not be breathing or have a pulse and the CNA started CPR. On [DATE] at 10:15 a.m., surveyor # and surveyor # observed the Fox Valley Metro Police's response to a 911 call on [DATE], video for resident #1. The video showed RN-J clearly stating resident #1's blood glucose was 29 mg/dl and it (blood sugar) had been checked one hour before the police officers arrival, when the resident was found to be unresponsive. The police report dated [DATE], documented the officers were dispatched at 5:43 a.m. and arrived at the facility at 5:45 a.m.. The police report verified that staff stated the resident had a blood glucose of 29 mg/dl at approximately 4:45 a.m.. On [DATE] at 12:00 p.m., surveyor # interviewed CNA-L. CNA-L indicated staff could not locate the crash cart because it had been moved earlier that day. Staff were notified that the crash cart had been moved, but it was not passed along to night shift staff. CPR was done on the mattress and without oxygen because the crash cart could not be located for several minutes. The RN should have been aware that resident #1 was diabetic and should have included blood glucose monitoring with the initial assessment. The RN did not know what to do when the resident's blood glucose level was extremely low and the resident was unresponsive. The RN was unfamiliar with the facility's policies and procedures pertaining to [DIAGNOSES REDACTED]. These system failures led to the delay in emergency treatment for [REDACTED]. The immediate jeopardy was removed on [DATE] when the facility: 1. All residents were assessed for any change of condition and physicians notified. 2. All residents electronic health records were reviewed for the past 24 hrs to see if they have experienced a change of condition and their physician were to be notified. 3. DON/Designee reviewed all electronic health record charting/progress notes in Point Click Care daily to ensure that if a resident is experiencing a change of condition that appropriate notifications have been completed. 4. All nursing staff and CPR certified personal will be educated prior to administering any resident care on the following: a. Proper identification of Diabetic residents in Point Click Care. b. Diabetic Parameters and location within Point Click Care. c. Notification of Physician and family of changes of condition. d. Obtaining proper diabetic orders for diabetic residents upon admission/readmission. e. When it is appropriate to call 911 f. How to perform CPR effectively 5. DON/Designee completed daily audits as stated above for 30 days and share results at monthly QAPI. Any issues were immediately addressed upon discovery. 6. Licensed staff identified as having deficient practices during audits will be issued progressive corrective discipline and one on one reeducation to correct deficient practices. 7. No rendering of care will take place by any licensed staff until they have been educated and signed off that they understand education received for all of the above.

Based on observation, interview, and record review, the facility did not immediately consult with 3 (residents #1, #8, and #9) of 28 sampled resident's physicians when there was a significant change in the resident's conditions. Resident #1 experienced a symptomatic hypoglycemic (low blood sugar) episode early in the morning on [DATE]. The resident was found to have a blood glucose level of 57 mg/dl (milligrams per deciliter). Staff treated the resident's symptoms at that time and did not notify the resident's physician of the blood glucose level. The facility made no changes to the resident's diabetic medications or monitoring following this episode. On [DATE], the resident experienced an additional hypoglycemic episode early in the morning. The resident was found unconscious and staff at the time, indicated the blood glucose result was 29 mg/dl. Staff then later recalled the blood sugar results to be 49 mg/dl. The resident did not recover from this episode and expired on the morning of [DATE]. Facility failure to notify the physician regarding resident #1's significant change in condition created a finding of immediate jeopardy that began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan, and as evidenced by: Resident #9's blood glucose results were 50 mg/dl on [DATE]. At the time, resident #9 was complaining of double vision and "not feeling well." Staff provided a protein shake and within 30 minutes, resident #9's blood glucose results were 90 mg/dl. Resident #9's physician was not notified of the resident's low blood glucose results with symptoms of double vision and "not feeling well." Resident #8's blood glucose results were 50 mg/dl on [DATE]. Resident #8's medical record did not include additional documentation and/or an assessment of the resident on [DATE] when the resident's blood glucose results were 50 mg/dl. In addition, the resident's physician was not notified of the low blood glucose results. Findings include: The facility's "Emergency Intervention Insulin Shock/[DIAGNOSES REDACTED]" policy and procedure dated [DATE] states insulin dependent residents with diabetes must be closely monitored for diabetes. The procedure listed multiple symptoms including weakness, vision difficulties, jitteriness, dizziness, hunger, and changes to pulse and respirations. The procedure indicated a blood glucose of 60 mg/dl or less can indicate a diabetic emergency and staff should "Notify physician immediately if symptoms exist" and "continue to observe resident as directed by the physician." The facility's "Physician Notification by Nursing" policy and procedure dated [DATE] indicates physician notification is to be completed "immediately" with any significant change in condition. The policy defined significant change in condition as a change from a resident's baseline status. The procedure directed staff notify the resident's physician immediately, begin "symptom pursuit" documentation and assessments, monitor the resident, and update the physician as necessary. 1. Resident #1's face sheet, dated [DATE], noted that Resident #1 was admitted to the facility on [DATE] for rehabilitation following an humerus/arm fracture. The resident had multiple [DIAGNOSES REDACTED]. Resident #1's physician's orders and medication administration orders for February 2015 noted scheduled long-acting insulin every morning, scheduled short-acting insulin three times daily before each meal, and extra insulin doses before each meal based on blood glucose results and a sliding scale order. Resident #1's blood glucose monitoring logs and nurse's charting indicated the resident did not have any episodes of [DIAGNOSES REDACTED] (low blood sugar) from the time of admission until [DATE]. The facility's investigation dated [DATE] documented RN (Registered Nurse)-F was caring for resident #1 on [DATE], during the night shift. The investigation noted that around 2:20 a.m. resident #1 was displaying weakness while walking and difficulty holding an eating utensil. RN-F checked the resident's blood glucose with results of 57 mg/dl. RN-F gave resident #1 one sugar supplement and one protein supplement, monitored the resident, and rechecked the blood glucose level thirty minutes later. The blood glucose level had increased to 78 mg/dl and the resident verbalized feeling better. RN-F did not notify or update the resident's physician at that time; subsequently no changes were made to the resident's insulin regimen. RN-F did not document the event of weakness with the blood glucose results of 57 mg/dl or that the resident was provided supplements that improved symptoms and resulted in an improvement of the resident's blood sugar. RN-F did not make changes to the resident's blood glucose monitoring and did not place resident #1 on the facility's 'symptom pursuit' protocol. No analysis was done to determine the cause of this hypoglycemic event. On [DATE] at 11:00 a.m., surveyor # interviewed RN-F regarding resident #1. RN-F verified the physician was not notified that resident #1 had a hypoglycemic incident on [DATE]. In addition, RN-F verified not documenting the hypoglycemic incident in the nurse's notes and not placing resident #1 on 'symptom pursuit' and commented "should have been." RN-F stated resident #1's hypoglycemic incident was reported to RN-C, who worked the day shift on [DATE]. On [DATE] at 2:45 p.m., RN-C surveyor # interviewed RN-C regarding resident #1. RN-C indicated RN-F had notified her of the resident's hypoglycemic incident during the early morning hours on [DATE]. RN-C verified the incident on [DATE] was not documented, the physician was not updated, and because the resident's blood glucose had come back up, no changes to the resident's care were made. Nutrition documentation indicated the resident had a decreased appetite and intake throughout the day on [DATE]. Despite the hypoglycemic episode the previous night and the low intake during the day, facility staff did not consult with the physician. The ,[DATE] MAR (Medication Administration Record) noted that staff gave the scheduled insulin doses as previously ordered. Resident #1 suffered a more severe hypoglycemic event on [DATE] around 5:00 a.m., when the resident was found to be unresponsive. Resident #1's nurse's note dated [DATE] documented the resident was found unresponsive and with a blood glucose of 49 mg/dl. The nurse's note did not include what time the resident was found unresponsive or what time the resident's blood glucose was checked. The nurse's note documented resident #1 expired that day at 6:20 a.m. On [DATE] at 10:15 a.m., surveyor # and surveyor # observed the Fox Valley Metro Police's response to a 911 call on [DATE], video for resident #1. The video showed RN-J clearly stating resident #1's blood glucose was 29 mg/dl and it (blood sugar) had been checked one hour before the police officers arrival. The police report dated [DATE], documented the officers were dispatched at 5:43 a.m. and arrived at the facility at 5:45 a.m.. The police report verified that staff stated the resident had a blood glucose of 29 mg/dl at approximately 4:45 a.m.. On [DATE] at 11:30 a.m., surveyor # interviewed physician-G regarding resident #1. Physician-G was resident #1's attending physician while in the facility. Physician-G confirmed that staff did not notify him that resident #1 had a hypoglycemic incident on [DATE]. Physician-G stated he was aware the resident had expired and the resident had low blood glucose at that time. Physician-G indicated if he had been informed of resident #1's hypoglycemic incident that occurred on [DATE], he would have decreased or stopped the resident's scheduled insulin, continued with the sliding scale insulin, and had staff increase the frequency of the resident's blood sugar monitoring. Physician-G confirmed his expectation was for staff to call if a resident had a blood glucose level of less than 70 mg/dl. On [DATE] at 12:40 p.m., surveyor # interviewed physician-H, the medical director of the facility. Physician-H indicated that staff are expected to call the physician if a resident's blood sugar results were less than 60 mg/dl or if their blood sugar results were less than 80 mg/dl and the resident had symptoms. Physician-H indicated if staff informed him that a resident had a low blood glucose level, he would evaluate the situation, determine the cause, and adjust the insulin dose. On [DATE] at 9:15 a.m., surveyor # interviewed DON (Director Of Nursing)-B. DON-B confirmed not knowing resident #1's low blood sugar results that occurred during the night on [DATE], until the morning hours of [DATE], after the resident suffered another hypoglycemic episode and expired. Failure to immediately consult with the physician when resident #1 had a significant change in condition created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] by which time it had implemented or begun the following: 1. The residents identified in the citation were audited for documented blood sugar results dating back to [DATE]. Any blood sugars found below 60 per policy were identified and physician was to be notified. 2. All residents had a head to toe assessment completed to determine if they are experiencing a change of condition that requires physician notification. If any resident was found to have a change of condition, their physician was to be notified. 3. DON/Designee reviewed all electronic health record charting/progress notes in Point Click Care daily to ensure that if a resident is experiencing a change of condition that appropriate notifications had been completed. 4. Nurses were educated prior to administering any resident care on the following: a. Proper identification of Diabetic residents in Point Click Care. b. Diabetic Parameters and location within Point Click Care. c. Notification of Physician and family of changes of condition. d. Obtaining proper diabetic orders for diabetic residents upon admission/readmission. e. When it is appropriate to call 911. f. How to perform CPR effectively. 5. DON/Designee will complete daily audits as stated above for 30 days and share results at monthly QAPI (Quality Assurance and Improvement). Any issues will be immediately addressed upon discovery. 6. No rendering of care will take place by any licensed staff until they have been educated and signed off that they understand education received for all of the above. The deficient practice continues at a severity level 2 (potential for harm that is not immediate jeopardy) as evidenced by: 2. Resident #9's current admission record indicated the resident has type II diabetes, requiring insulin and blood glucose level monitoring three times per day. Resident #9's medical record included documentation that on [DATE] at 8:45 a.m., RN-C obtained resident #9's blood glucose level. The resident's blood sugar results were 50 mg/dl. The nurse's note at that time included documentation that 120 cc (cubic centimeter) of a protein shake was given. No additional documentation was noted in resident #9's medical record regarding the resident's blood sugar results of 50 mg/dl. On [DATE] at 9:00 a.m., surveyor # interviewed RN-C regarding resident #9's blood glucose results on [DATE]. RN-C stated resident #9 had not been feeling well for a few days and reported double vision at the time the blood glucose level was obtained on [DATE]. RN-C stated resident #9 was crying due to the vision disturbance. RN-C stated she provided resident #9 with a protein shake and resident #9's blood glucose level rose to 90 mg/dl within 30 minutes. RN-C confirmed she did not update resident #9's physician regarding the low blood glucose level or the resident complaining of visual disturbance and she did not begin a 'Symptom Pursuit' form, per the facility policy. 3. Resident #8's medical record included documentation that the resident was admitted to the facility on [DATE]. The resident #8's [DIAGNOSES REDACTED]. Resident #8's blood glucose is monitored twice a day. Resident #8's current physician orders include set dosage amounts of humalog and [MEDICATION NAME] daily. Resident #8's physician's orders did not include blood glucose monitoring parameters. Resident #8's record indicated on [DATE] at 16:13 (4:13 p.m.), the resident's blood glucose was obtained and documented at 50 mg/dl. No additional documentation was located in the resident's medical record. On [DATE] at 12:06 p.m., surveyor # interviewed DON-B regarding resident #8's low blood glucose of 50 mg/dl on [DATE]. DON-B verified resident #8's blood glucose was 50 mg/dl and stated her expectations were that "symptom pursuit" would be initiated and resident #8's physician would be notified. DON-B stated staff did not initiate "symptom pursuit" for resident #8 on [DATE] and resident #8's physician was not notified of the low blood glucose level on the same date. DON-B verified the facility utilizes blood sugar results of 60 mg/dl as an indicator of low blood glucose levels when a resident does not have specific physician ordered parameters.

Based on record review and staff interviews, the facility did not ensure 2 (resident #1 and #21) of 11 residents reviewed for diabetes received the necessary care and services to attain or maintain the highest practicable well-being. Resident #1 had diabetes and required insulin multiple times each day. The facility did not have orders in place for emergency [MEDICATION NAME], to raise the resident's blood glucose during a hypoglycemic event. On [DATE], the resident suffered a hypoglycemic event, however no action was taken to determine the cause, prevent another episode, or provide additional monitoring to the resident. On [DATE], resident #1 was found unresponsive after having another hypoglycemic event, which preceded cardiopulmonary arrest and the need for staff to perform CPR (Cardiopulmonary Resuscitation) on the resident. When staff found the resident unresponsive with a low blood glucose level, staff waited between 23 and 60 minutes to call 911 for assistance. When the resident was found to be in cardiopulmonary arrest, staff initiated CPR, without following appropriate CPR procedures. Staff performed CPR compressions on resident #1 while the resident remained in bed, on a soft mattress. In addition, staff was not able to locate the facility crash cart, and staff unnecessarily stopped CPR for 28 seconds and again for 33 seconds. The failure to provide appropriate care created an immediate jeopardy situation that began on [DATE]. The facility was notified of the immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan, and as evidenced by: Resident # 21 has diabetes and requires insulin daily. The facility did not have orders in place for emergency [MEDICATION NAME] or [MEDICATION NAME] to raise resident #21's blood glucose during a hypoglycemic event or have blood glucose parameters to indicate when resident #21's physician should be notified, despite education provided on [DATE] to nurses to obtain these orders. Additionally, the facility did not follow its policy/procedure to ensure code status of 3 (resident #12, #22, and #26) of 9 residents reviewed for code status preferences were consistently documented. Findings include: 1. Resident #1's face sheet dated [DATE] noted that Resident #1 was admitted to the facility on [DATE] for rehabilitation following an humerus/arm fracture. The resident had multiple [DIAGNOSES REDACTED]. Resident #1's physician's orders [REDACTED]. Resident #1's blood glucose monitoring logs and nurse's charting indicated the resident did not have any episodes of [DIAGNOSES REDACTED] (low blood sugar) from the time of admission until [DATE]. The facility's investigation, dated [DATE], noted RN (Registered Nurse)-F was caring for resident #1 on [DATE], during the night shift. The investigation documented that around 2:20 a.m. resident #1 was displaying weakness while walking and difficulty holding an eating utensil. RN-F checked the resident's blood glucose with results of 57 mg/dl. RN-F gave resident #1 one sugar supplement and one protein supplement, monitored the resident, and rechecked the blood glucose level thirty minutes later. The blood glucose level had increased to 78 mg/dl and the resident verbalized feeling better. RN-F did not notify or update the resident's physician at that time; subsequently no changes were made to the resident's insulin regimen. RN-F did not document the event of weakness with the blood glucose results of 57 mg/dl or that the resident was provided supplements that improved symptoms and resulted in an improvement of the resident's blood sugar. RN-F did not make changes to the resident's blood glucose monitoring and did not place resident #1 on the facility's 'symptom pursuit' protocol. No analysis was done to determine the cause of this hypoglycemic event. Nutrition documentation indicated the resident had a decreased appetite and intake during the day on [DATE], consuming ,[DATE]% of breakfast, ,[DATE]% of lunch, ,[DATE]% of supper, and did consume a bedtime snack. Although the resident had suffered a hypoglycemic event and had decreased intake throughout the day on [DATE], the facility did not consult with the physician and, according to the MAR (Medication Administration Record) dated February 2015, still administered the scheduled insulin doses as previously ordered. Resident #1's blood glucose levels on [DATE] were documented as 160 mg/dl at 7:38 a.m., 74 mg/dl at 12:31 p.m., and 112 mg/dl at 5:20 p.m.. There was no documentation of a hypoglycemic incident on [DATE] in the resident's medical record. Review of resident #1's physician's orders [REDACTED]. On [DATE] at 11:00 a.m., surveyor # interviewed RN-F regarding resident #1. RN-F verified the physician was not notified that resident #1 had a hypoglycemic incident on [DATE]. In addition, RN-F verified not documenting the hypoglycemic incident in the nurse's notes and not placing resident #1 on 'symptom pursuit' and commented "should have been." RN-F stated resident #1's hypoglycemic incident was reported to RN-C, who worked the day shift on [DATE]. On [DATE] at 2:45 p.m., RN-C surveyor # interviewed RN-C regarding resident #1. RN-C indicated RN-F had notified her of the resident's hypoglycemic incident during the early morning hours on [DATE]. RN-C verified the incident on [DATE] was not documented, the physician was not updated, and because the resident's blood glucose had come back up, no changes to the resident's care were made during the day on [DATE]. On [DATE] at 11:30 a.m., surveyor # interviewed physician-G regarding resident #1. Physician-G was resident #1's attending physician while in the facility. Physician-G confirmed that staff did not notify him that resident #1 had a hypoglycemic incident on [DATE]. Physician-G indicated if he had been informed of resident #1's hypoglycemic incident that occurred on [DATE], he would have decreased or stopped the resident's scheduled insulin, continued with the sliding scale insulin, and had staff increase the frequency of the resident's blood sugar monitoring. Physician-G confirmed his expectation was for staff to call if a resident had a blood glucose level of less than 70 mg/dl. Resident #1's nurse's notes dated [DATE], documented resident #1 was found unresponsive and with a documented blood glucose of 49 mg/dl. The note did not indicate a time the resident was found unresponsive or a time the blood glucose was checked, but it did indicate the resident expired that day at 6:20 a.m.. On [DATE] at 2:10 p.m., surveyor # interviewed phlebotomist-I regarding resident #1. Phlebotomist-I stated she arrived at the facility on [DATE] at 4:48 a.m. and left at 5:34 a.m.. Phlebotomist-I stated she found resident #1 unresponsive with white foam coming out of the mouth. Phlebotomist-I indicated she could not arouse the resident so she reported this to RN-J. Phlebotomist-I did not know the exact time, but stated resident #1 was one of the first residents she drew blood on that day and that she did several residents after resident #1 prior to leaving the facility at 5:34 a.m.. RN-J created a timeline which indicated phlebotomist-I notified staff resident #1 was unresponsive at 5:20 a.m. on [DATE]. On [DATE] at 1:34 p.m., surveyor # interviewed RN-J. RN-J indicated she believed approximately 30 minutes had passed from when the resident was found unresponsive to when 911 was called. RN-J indicated the resident's vital signs were checked and were normal except for a low oxygen level. RN-J stated she left the room to get oxygen, applied the oxygen, went to get a suctioning machine from the oxygen room, went to get tubing from the treatment room, and suctioned a foam like substance from the resident's mouth. RN-J indicated she then rechecked the resident's vital signs, which were all normal. This time she also checked the resident's blood glucose level. RN-J stated there was confusion over the blood glucose result because it was said to be 29 mg/dl, but she remembered it to be 49 mg/dl. RN-J verified both numbers were very low and that she was not familiar with facility protocol, so she called DON (Director of Nursing)-B for direction, since there were no other nurses working at that time. RN-J verified that DON-B gave direction to have staff call 911 and the DON called the physician for a [MEDICATION NAME] order. During this time, CNA (Certified Nursing Assisstant)-L found the resident to not be breathing or have a pulse and the CNA started CPR. RN-J stated the injection given to resident #1 during CPR was 1 mg (milligram) of [MEDICATION NAME]. On [DATE] at 12:00 p.m., surveyor # interviewed CNA-L. CNA-L indicated staff could not locate the crash cart because it had been moved earlier that day. Staff were notified that the crash cart had been moved, but it was not passed along to night shift staff. CPR was done on the mattress and without oxygen because the crash cart could not be located for several minutes. The police report dated [DATE], documented the officers were dispatched at 5:43 a.m., and arrived at the facility at 5:45 a.m.. The police report verified that staff stated the resident had a blood glucose of 29 mg/dl at approximately 4:45 a.m.. On [DATE] at 10:15 a.m., surveyor # and surveyor # observed the Fox Valley Metro Police's response to a 911 call on [DATE], video for resident #1. The video showed RN-J clearly stating resident #1's blood glucose was 29 mg/dl and it (blood sugar) had been checked one hour before the police officers arrival when the resident was found to be unresponsive. The video showed police officers arriving at the facility finding resident #1 laying in bed with a pillow behind the head and CNA-L stepping away from the resident with gloved hands. The CNA reported to the officers that "well over 200 compressions" were done on the resident. The CNA began unbuttoning the resident's shirt and resumed compressions after having stopped for 28 seconds. The CNA resumed compressions for just 16 seconds and unnecessarily stopped again for 33 seconds while the officer applied the AED (Automated External Defibrillator) [MEDICATION NAME] on the resident. The officer took over compressions and the AED repeatedly directed "push harder." The resident was on a soft mattress and did not have a compression board placed under the resident's back to enable more effective compressions. The resident's body was observed to be bouncing on the mattress while compressions were provided. Staff did not have a compression board or bag mask available. At approximately 5:47 a.m., RN-J was observed administering an injection to resident #1. RN-J stated they could not locate the crash cart which housed these items. At 5:50 a.m., staff located the crash cart and brought it into the room at which time staff assembled the ambu bag and after one and a half minutes staff began providing oxygen to the resident. At 5:53 a.m., paramedics arrived and placed the resident on a hard surface before applying an automated compression device. CPR continued in the facility by the paramedic until a physician ordered CPR to stop and the time of death was called at 6:20 a.m.. Failure to immediately provide the care and services consult with the physician when resident #1 had a significant change in condition created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] by which time it had implemented or begun the following: 1. All diabetic residents were checked for blood sugars and head to toe assessment completed on [DATE]. 2. All diabetic residents have been identified. Physician orders [REDACTED]. 3. Medical Director has written a standing order identifying diabetic parameters and [MEDICATION NAME] use for all new admissions and residents without orders. 4. Care plans and MAR indicated [REDACTED]. CNA Kardex will identify diabetic residents. 5. Advanced Directives will be clearly identified in Resident Home Page of Point Click Care, Point of Care, Care Plans and CNA Kardex. 6. Resident choosing Full Code will be identified using Heart Stickers on Resident Door Name Plate and Wheelchair tag. 7. All nursing staff and CPR certified personel were educated prior to start of shift on the following policies: a. Proper identification of Diabetic residents in Point Click Care. b. Diabetic Parameters and location within Point Click Care. c. Notification of Physician and family of changes of condition. d. Obtaining proper diabetic orders for diabetic residents upon admission/readmission. e. When it is appropriate to call 911 f. How to preform CPR effectively 8. DON/designee will run CPR preference report in Point Click Care 1x/month to audit for CPR preference status to ensure all areas identified above have been completed. Results will be taken to the monthly QAPI (Quality Assurance Improvement) meeting. 9. Advanced Directives will be reviewed at Quarterly care conference for all residents. 10. DON or designee will audit electronic medical record 1x/week for 3 months to insure proper blood sugar parameters and [MEDICATION NAME] orders for diabetic residents and results will be taken to monthly QAPI. 11. No rendering of care took place by any licensed staff until they had been educated and signed off that they understand education received for all of the above. The deficient practice continues at a severity level of 2 as evidenced by: 2. On [DATE], surveyor # reviewed resident #21's medical record. Resident #21 is an insulin dependent type 2 diabetic with orders for [MEDICATION NAME] (insulin) injections 20 units once daily and [MEDICATION NAME] 5 units once daily. Resident #21's orders also included [MEDICATION NAME] HCL ([MEDICATION NAME]) 1000 mg tablet twice daily for diabetes management. Resident #21's blood glucose is monitored twice daily. Resident #21's orders did not include blood glucose parameters for contacting a physician. Resident #21's record did not include an order for [REDACTED]. On [DATE], surveyor # reviewed the facility's self-report dated [DATE] regarding resident #1's primary low blood glucose episode. Included in the self-report, dated [DATE], was "Mandatory Nurse in-Service February 4, 2015" which documented "Any diabetic in the facility should have MD orders for [MEDICATION NAME], their own meter, blood sugars PRN (as needed) and scheduled if on any medication according to MD orders, parameters for blood sugars, and scheduled HS (bedtime) snacks." On [DATE] at 10:48 a.m., surveyor # interviewed RN-E regarding diabetic residents. RN-E opened a medicine cart drawer and surveyor # observed individual resident labeled emergency [MEDICATION NAME] and [MEDICATION NAME]. RN-E stated nurses received training (on [DATE]) to notify physicians if blood glucose was under 60 mg/dl. RN-E stated the facility contacted physicians last night ([DATE]) for all resident with diabetes to establish individualize parameters. On [DATE] at 10:58 a.m., DON-B verified residents on diabetic medications should have a standing order for emergency [MEDICATION NAME] or [MEDICATION NAME]. Code Status According to a memo sent to all staff on [DATE], full code (decision to have cardiopulmonary resuscitation) residents will be identified with heart sticker after their name on their name plate outside their room and on their wheelchair/walker. The facility also had a procedure in place to document code status of a resident in the electronic medical record plan of care; resident profile sheet, and on the CNA Kardex so all staff would have easy access to the information. 1. Resident #12 was admitted to the facility on [DATE]. Review of the resident's profile sheet, located in the electronic medical record, indicated that code status for the resident was not listed. Surveyor # observed the resident's wheel chair and name plate on the bedroom door, both of which contained a red heart. The electronic medical record POC (plan of care) and the CNA Kardex both indicated the resident was a full code. 2. Resident #22 was admitted to the facility on [DATE]. Review of the resident's profile sheet, located in the electronic medical record, indicated code status for the resident was not listed. On [DATE] at 9:20 a.m., surveyor # interviewed RN-C. RN-C verified that resident #22's profile sheet did not contain code status. Surveyor # observed the resident's wheel chair and name plate on the bedroom door, both of which contained a red heart. The electronic medical record POC and the CNA Kardex both indicated the resident was a full code. 3. Resident #26 was admitted to the facility on [DATE]. Review of the resident's profile sheet, located in the electronic medical record, indicated code status for the resident was not listed. Review of the resident's electronic POC and CNA Kardex both indicated, "Code Status-CPR (Cardiopulmonary Resuscitation). Code Status- DNR (Do Not Resuscitate). The surveyor noted a heart on the resident's wheel chair and on the name plate of the resident's bedroom door. On [DATE] at 9:30 a.m., surveyor # interviewed DON-B. DON-B verified to the surveyor that the facility's procedure regarding resident code status was to note the status on the resident profile sheet in the electronic medical record, to note the status on the POC and the CNA Kardex, and if a resident was a full code, a heart was to be placed on their bedroom door name plate and their wheel chair or walker. On [DATE] at 10:45 a.m., surveyor # interviewed NHA (Nursing Home Administrator)-A. NHA-A verified to the surveyor that the facility's procedure regarding resident code status was to note the status on the resident profile sheet in the electronic medical record, to note the status on the POC and the CNA Kardex, and if a resident was a full code, a heart was to be placed on their bedroom door name plate and their wheel chair or walker. NHA-A also verified that an audit of the heart stickers had been completed sometime after [DATE], but that audit did not include reviewing the electronic resident profile sheet, POC or CNA Kardex for accuracy.

Based on staff interview, record review and policy review, the facility did not maintain and implement an infection control program designed to prevent the development and transmission of infection for 52 (residents #1 to #52) of 70 residents who resided at the facility. The facility practices had the potential to affect all 70 residents. The facility did not recognize an outbreak of GI (gastrointestinal) illness at the facility when the staff illness line list indicated two staff developed signs/symptoms of GI illness on 1/2/11; additionally, one staff became ill on each of the following days: 1/3/11, 1/5/11, 1/6/11 and 1/8/11. The facility also did not recognize an outbreak of GI illness when the resident GI illness line list indicated one resident developed GI symptoms on 1/4/11. On 1/8/11 one additional resident became ill (according to medical record review), and on 1/9/11 additional residents became ill. The facility did not promptly inform the Public Health Department when an outbreak was suspected. The facility did not minimize movement of residents when asymptomatic, exposed residents who required assistance with dining were allowed to consume meals in a common dining area with other residents. Group activities continued despite the evidence of GI illness among staff and residents. Facility staff did not wear proper personal protective equipment when caring for residents who had active signs/symptoms of Norovirus. The facility did not disinfect equipment that was shared by residents with appropriate disinfectants that were effective against Norovirus. The failure of the facility to immediately implement appropriate procedures to limit the transmission of disease created a situation of Immediate Jeopardy, which began on 1/9/11 when the staff and resident line lists revealed six staff had become ill and three residents began with signs/symptoms of Norovirus. The facility was formally notified on 3/24/11 that an Immediate Jeopardy situation existed. The Immediate Jeopardy was not removed by the conclusion of the survey on 3/24/11. Findings include: 1. The WDPH (Wisconsin Division of Public Health) "Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities", revised 10/20/09, indicates 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. The recommendations direct the facility to notify the local Health Department of any suspected or confirmed outbreak. The recommendations further direct the facility to post signage that the facility is experiencing an increase in gastrointestinal illness, and visits to symptomatic residents should be discouraged. On 3/22/11 surveyor # reviewed the facility "Viral Gastroenteritis Control and Surveillance Policy", dated 5/6/09. The policy documented, "It is the facility policy to implement infection control measures to identify, control and notify the appropriate agencies of a viral gastroenteritis outbreak or suspected outbreak...Identification of a viral gastroenteritis outbreak: A) When two or more resident and/or staff develop new onset of vomiting and/or diarrhea within one to two days. Vomiting may be present in at least half of the ill persons. B) Other symptoms may include nausea with or without vomiting, abdominal cramping, fatigue, body aches and occasionally a low grade fever. -Limit transmission when "initial" cases of viral gastroenteritis are suspected....The medical director should be consulted anytime the facility suspects an outbreak...Notify the local health department of any suspected or confirmed outbreak. Consult with the local health department about laboratory testing." On 3/22/11 at 9:40 a.m. surveyor # interviewed DON (Director of Nursing)-A regarding GI illness. DON-A indicated the facility utilized the "Viral Gastroenteritis Control and Surveillance Policy" and also utilized the WDPH recommendations as their standard of practice and followed the appropriate guidelines. On 3/22/11 surveyor # reviewed the resident and staff GI line lists. The resident line list from 1/4/11 to 1/20/11 indicated fifty-two residents had signs/symptoms of Norovirus. The staff line list from 1/2/11 to 1/30/11 indicated twenty-four staff presented with signs/symptoms of Norovirus, with seven staff presenting with re-occurring illness. The resident line list indicated residents from all four units, residents #1 to #52, developed signs/symptoms of Norovirus between the dates of 1/4/11 to 1/20/11. During the 3/22/11, 9:40 a.m. interview with surveyor # , DON-A verified the first staff person, CNA (Certified Nursing Assistant)-B, presented with signs/symptoms of gastroenteritis on 1/2/11; and the first resident, resident #1, presented with signs/symptoms of gastroenteritis on 1/4/11. DON-A stated ill residents were isolated in their rooms until forty-eight hours after symptoms subsided, and staff were not allowed to return to work until forty-eight hours after symptoms subsided. DON-A stated the units were quarantined, and group dining and activities were canceled. DON-A was not able to recall the dates the quarantines were in effect and was unable to provide the date when group activities and dining were canceled. During the interview with surveyor # on 3/22/11 at 9:40 a.m., DON-A stated a GI outbreak would have been considered if two or more residents/staff develop GI symptoms (vomiting and/or diarrhea) within one to two days. DON-A and surveyor # reviewed the resident and staff GI illness line lists. DON-A verified the staff line list documented two staff, CNA-B and CNA-C, developed gastrointestinal illness on 1/2/11. Additionally, the resident line list indicated resident #1 on the "American Drive" unit presented with signs/symptoms on 1/4/11. The resident line listing indicated on 1/9/11 resident #2 and resident #3 presented with signs/symptoms. Resident #2 resided on the "Forest Trail" unit, and resident #3 resided on the "Oceanside" unit. On 3/24/11 surveyor # reviewed the medical record for resident #3. According to the nurses' notes, resident #3 developed sudden onset of vomiting after the supper meal on 1/8/11 and developed diarrhea on 1/9/11. During an interview with surveyor # on 3/24/11 at 9:02 a.m., DON-A verified resident #3's date of onset of illness should have been documented as 1/8/11 on the line listing rather than 1/9/11, if vomiting began on 1/8/11. During the 3/22/11 interview with surveyor # , DON-A indicated she notified the Public Health Department , but could not recall the date of the notification. DON-A stated three resident stool samples were obtained and were tested for Norovirus (residents #5, #6, #7). DON-A verified she was notified by the Public Health Department on 1/20/11 that all three resident stool samples were positive for Norovirus. DON-A stated the facility placed signs on the entrances to the facility informing and restricting visitors related to the outbreak of GI illness on 1/13/11. On 3/22/11 at 10:47 a.m. surveyor # contacted the Public Health Department and spoke to the PHNS (Public Health Nurse Supervisor)-D. PHNS-D stated the facility notified the Public Health Department of the suspected outbreak on 1/13/11. PHNS-D stated stool samples were collected on 1/15/11 for three residents and were submitted to the State laboratory for testing. PHNS-D stated the final results of the samples were reported to the facility on [DATE]. PHNS-D stated all three samples were positive for Norovirus-Genotype II. Surveyor # reviewed the line list for residents and staff. By 1/13/11, when initial Public Health notification was completed, the facility had twenty-seven residents and nine staff who had become ill with GI symptoms. On 3/24/11 at 9:02 a.m. surveyor # interviewed DON-A and NHA (Nursing Home Administrator)-S regarding identification of the outbreak. DON-A and NHA-S verified, per the facility policy and WDPH guidelines, an outbreak should have been suspected at the time two staff became ill with GI symptoms (1/2/11). DON-A and NHA-S verified again an outbreak should have been suspected, per guidelines, when on 1/3/11 an additional staff became ill, and on 1/4/11 when a resident became ill. On 1/6/11 an additional staff became ill; and on each, 1/8/11 and 1/9/11, two additional residents became ill. DON-A and NHA-S verified an outbreak was not identified until 1/13/11, when Public Health and the Medical Director were contacted. DON-A stated she did not feel resident #1 (on 1/4/11) presented with GI illness, but rather a seizure that induced vomiting. On 3/24/11 surveyor # reviewed the medical record for resident #1. According to the [DIAGNOSES REDACTED]. The medical record did not document any history of seizures. The progress notes on 1/4/11 at 5:40 p.m. documented resident #1 had a large amount of watery stool at 5:15 p.m. and had vomiting. The progress notes on 1/4/11 at 10:28 p.m. documented at 8:40 p.m. resident #1 was sitting up on the side of the bed vomiting, when she began "starring into space" and went "unresponsive". At 9:45 p.m. resident #1 sat up and began vomiting again. The physician was contacted, and an order for [REDACTED]. The progress notes on 1/5/11 at 10:57 a.m. documented, "...resident denies nausea stating-'i am better today. I had the stomach flu'..." On 3/24/11 at 10:35 a.m. surveyor # interviewed RN (Registered Nurse)-T. RN-T stated she was not aware of resident #1 having any seizures in the past and was not aware of any seizure type disorder. During an interview with surveyor # on 3/24/11 at 9:02 a.m., NHA-S stated the facility posted "Under the Weather" signs at the front entrance and symptomatic resident rooms on 1/11/11, but the sign did not limit visitors or indicate GI illness was occurring within the facility. NHA-S stated the "Gastrointestinal" signage and limitation of visitors was not implemented until 1/13/11. 2. The WDPH recommendations indicate a facility should cancel or postpone group activities for at least forty-eight hours after the last identified case. Facilities are directed to minimize movement of residents. Asymptomatic, exposed residents should not be moved from an affected to an unaffected resident unit. Additionally, the recommendations indicate a facility should consider discontinuing use of common dining areas and instituting in-room dining. The facility "Viral Gastroenteritis Control and Surveillance Policy", dated 5/6/09, directed staff to "... Institute control measures when a viral gastroenteritis outbreak is "suspected" without waiting for diagnostic confirmation...Cancel or postpone group activities for at least 48 hours after the last identified case..." On 3/22/11 at 9:30 a.m. surveyor # interviewed AD (Activity Director)-E. AD-E verified group activities continued in the beginning of January 2011, when residents and staff presented with GI illness. AD-E stated she recalled, at some point, one unit was quarantined; and those residents did not attend, but asymptomatic residents from other units did attend activities. On 3/22/11 at 10:35 a.m. AD-E informed surveyor # that on 1/14/11 all group activities were canceled, and activities were provided on individual units. According to the facility line list, on 1/14/11 thirty-one residents had been ill with GI symptoms. AD-E confirmed group activities continued from 1/2/11 to 1/13/11. AD-E stated symptomatic residents did not attend, but non-symptomatic residents from each unit were able to attend the activities until 1/14/11. During the 3/22/11, 9:40 a.m. interview, surveyor # questioned DON-A about co-horting of residents after the first residents presented with signs/symptoms on 1/4/11. DON-A stated ill residents were isolated within their rooms, and group activities and dining were postponed. DON-A was not able to provide a date when the group activities and dining were canceled. On 3/22/11 at 11:05 a.m. surveyor # interviewed DM (Dietary Manager)-L regarding the cancellation of group dining. DM-L stated on 1/9/11 dietary staff began sending room trays for all independent asymptomatic and symptomatic residents. DM-L stated asymptomatic residents from all units, who required assistance with dining, continued to be served together in the dining room. DM-L verified some of the assisted residents who resided on units with symptomatic residents attended the group dining situation. On 3/22/11 at 2:00 p.m. DM-L informed surveyor # that on 1/14/11, beginning at the noon meal, all residents (including residents who required assistance with dining) were served in their rooms, and all group dining was discontinued. On 3/24/11 at 10:05 a.m. DM-L provided surveyor # a list of residents who continued to eat in the main dining room from 1/9/11 to 1/14/11. The list consisted of a total of twenty residents from all four resident living units. Surveyor # reviewed the assisted dining list and the resident line listing for GI symptoms. The line listing documented the following: -resident #14 developed GI symptoms on 1/10/11 -resident #8 developed GI symptoms on 1/11/11 -resident #16 developed GI symptoms on 1/12/11 -resident #13 developed GI symptoms on 1/12/11 -resident #7 developed GI symptoms on 1/12/11 -resident #17 developed GI symptoms on 1/13/11 -resident #12 developed GI symptoms on 1/14/11 -resident #4 developed GI symptoms on 1/15/11 -resident #9 developed GI symptoms on 1/16/11 -resident #11 developed GI symptoms on 1/16/11 -resident #10 developed GI symptoms on 1/17/11 -resident #15 developed GI symptoms on 1/17/11 During the 3/24/11 interview at 9:02 a.m. with surveyor # , NHA-S and DON-A verified all units were isolated on 1/13/11. NHA-S and DON-A verified that non-symptomatic residents from all units, who required assistance with dining, ate in the main dining room until the noon meal on 1/14/11. NHA-S and DON-A verified group activities were not postponed until 1/14/11. 3. The WDPH recommendations indicate facility staff should wear personal protective equipment to include gloves and gowns upon entry to the room and when in contact with the symptomatic resident, and masks/goggles if vomitus is present. The facility's "Viral Gastroenteritis Control and Surveillance Policy", dated 5/6/09, directed staff to "...Wear personal protective equipment to include gloves, and gown (mask and goggles if vomitus present) upon entry to room and when in contact with symptomatic resident...". During the 3/22/11, 9:40 a.m. interview with surveyor # , DON-A indicated nursing staff used gloves and strict hand washing when providing care for ill residents. DON-A stated gowns and masks were optional, and not mandated to be utilized. During an interview on 3/22/11 at 9:15 a.m. with surveyor # , CNA-F stated staff were required to utilize gloves and strict hand washing when caring for ill residents. CNA-F stated gowns were not utilized. During an interview on 3/22/11 at 11:10 a.m. with surveyor # , RN-G stated staff were required to utilize gloves and masks (if coughing) when caring for ill residents, but gowns were not mandated. During an interview on 3/22/11 at 11:20 a.m. with surveyor # , CNA-H stated staff were required to utilize gloves and masks when caring for ill residents, but gowns were not mandated. During an interview on 3/22/11 at 11:25 a.m. with surveyor # , CNA-I stated staff were required to utilize gloves when caring for ill residents, masks and gowns were encouraged, but gowns were not mandated. During an interview on 3/22/11 at 9:29 a.m. with surveyor # , CNA-J stated staff were required to utilize gloves and masks when caring for ill residents. CNA-J stated gowns were available but were not mandated to be utilized. On 3/22/11 at 8:35 a.m. during an interview with surveyor # , HSK (Housekeeper)-M stated gowns were not utilized by Housekeeping staff while cleaning rooms for symptomatic residents during the outbreak of GI illness. HSK-M stated the Housekeeping staff each had two resident units to clean, and would clean one unit then proceed to the next. HSK-M stated she was never instructed to utilize gowns while cleaning resident rooms, including those rooms which had ill residents. On 3/22/11 at 8:40 a.m. during an interview with surveyor # , HSK-N stated gowns were not utilized by Housekeeping staff while cleaning rooms for symptomatic residents during the outbreak of GI illness. HSK-N stated the Housekeeping staff each had two resident units to clean, and would clean one unit then proceed to the next. HSK-N stated she was never instructed to utilize gowns while cleaning resident rooms, including those rooms which had ill residents. HSK-N stated she was only informed to utilize gloves and masks. On 3/22/11 at 8:50 a.m. surveyor # interviewed HSKS (Housekeeping Supervisor)-O. HSKS-O verified Housekeeping staff were not required to utilized gowns while cleaning resident rooms, including symptomatic resident rooms. 4. The WDPH recommendations indicate facility staff should use only chlorine bleach or a U.S. Environmental Protection Agency approved disinfectant in controlling Norovirus outbreaks. The recommendations direct staff to clean and disinfect all equipment including, but not limited to blood pressure cuffs, stethoscopes, electronic thermometers and transfer lifts before using for another resident. The recommendations indicate Norovirus may remain viable for up to twelve days in carpeting or other environmental surfaces. Therefore, a thorough cleaning of carpets, curtains, walls and all equipment is essential. Steam cleaning should be used for all carpeting and soft furnishings. Dry vacuuming has the potential to re-circulate the viruses and is not recommended. The recommendations also indicate enhanced cleaning and disinfection should continue for at least seventy-two hours after the last documented case. On 3/22/11 at 8:35 a.m. surveyor # interviewed HSK-M. HSK-M stated during the facility outbreak of Norovirus, enhanced cleaning efforts were completed. HSK-M stated dry vacuuming was done in all resident rooms and hallways daily, including at the time of the outbreak. HSK-M stated the bathroom floors were mopped with Ecolab Finished Floor Cleaner. HSK-M verified no bleach solution was utilized for the floor in the resident bathrooms. HSK-M stated the staff could utilize either Virex TB or Lemon Lift cleaner for hard surfaces within the resident's room, bathrooms and hallways. When questioned if the Virex TB had to stay on the surface for a certain amount of time, HSK-M responded, "No, I just spray it on and wipe it off right away." HSK-M verified the Housekeeping staff were assigned to clean two separate units. HSK-M stated she did not sanitize her housekeeping cart between units and verified she utilized the same cart from one unit to the next. On 3/22/11 at 10:22 a.m. surveyor # completed a telephone interview with JDCR (Johnson Diversity Customer Representative)-P. Johnson Diversity is the manufacturer of the Virex TB. JDCR-P stated the Virex TB was an effective product against the Norovirus if left to dwell on the surface for at least thirty seconds. On 3/22/11 surveyor # reviewed the MSDS (Material Safety Data Sheet) for the following products: *Sanicloth HB - the MSDS indicated the product did not contain bleach solution. On 3/22/11 at 10:15 a.m. surveyor # interviewed PDICR (Professional Disposables International Customer Representative)-K. Professional Disposables International was the manufacturer of Sanicloth HB wipes. PDICR-K verified Sanicloth HB wipes did not contain any bleach and were not effective against Norovirus. *The MSDS for Ecolab Neutral Disinfectant Cleaner, Ecolab 20 Neutral Disinfectant Cleaner, Ecolab Disinfectant Cleaner 2.0 and Ecolab Bathroom Disinfectant Cleaner indicated the products did not contain a bleach solution, and Norovirus was not listed as an organism the products were effective in eradicating. On 3/22/11 at 2:25 p.m. surveyor # completed a telephone interview with the Ecolab Representative (ER)-Q. ER-Q stated the Lemon Lift product did contain bleach, but the PPM (parts per million) of bleach in the solution was not high enough to be effective in killing the Norovirus. ER-Q stated none of the Ecolab products noted above were registered antimicrobial products effective against Norovirus, including the Ecolab Finished Floor Cleaner On 3/22/11 at 8:40 a.m. surveyor # interviewed HSK-N. HSK-N stated during the GI illness outbreak Housekeeping staff were assigned to clean two separate resident living units. HSK-N stated she utilized the same cart from one unit to the next, and had not sanitized the cart when proceeding from one unit to the next. HSK-N stated Virex TB was utilized for hard surfaces. When questioned if the Virex TB had to stay on the surface for a certain amount of time, HSK-N responded it could be utilized either way, either wipe it off right away or leave it on the surface for a minute. HSK-N verified the resident rooms and hallways were vacuumed daily in every room/hallway and on every unit. HSK-N stated the resident bathroom floors were mopped with the Ecolab floor cleaner. HSK-N verified no bleach solution was utilized for the floor. On 3/22/11 at 8:50 a.m. surveyor # interviewed HSKS-O. HSKS-O stated during the GI outbreak, Virex TB was utilized for hard surfaces. HSKS-O stated the Virex TB needed to remain on the surface for approximately one minute to be effective. HSKS-O stated the facility carpets (in every resident room and hallway) were dry vacuumed daily during the outbreak. HSKS-O stated the facility carpets were cleaned with a host dry cleaning agent. HSKS-O stated only visibly soiled areas were cleaned with Virex TB, and the rest of the carpeting was cleaned with the host dry cleaning agent. HSKS-O verified the carpets had not been steam cleaned, and the host dry cleaning agent did not contain a bleach solution. HSKS-O verified Housekeeping staff were assigned to clean two resident units per housekeeper. HSKS-O verified he had not instructed his staff to sanitize the housekeeping carts between units. HSKS-O verified the resident bathroom floors, (only non-carpeted area on each resident unit) were cleaned with an Ecolab disinfectant. HSKS-O verified the Ecolab disinfectant did not contain bleach. During an interview with surveyor # on 3/22/11 at 8:45 a.m., CNA-U stated during the GI outbreak resident-shared equipment (i.e. lifts, blood pressure cuffs, stethoscopes) were sanitized between resident use with Sanicloth HB wipes. CNA-U was not aware of efforts to sanitize bathrooms (most bathrooms shared by four residents) between resident use. During an interview with surveyor # on 3/22/11 at 9:15 a.m., CNA-F stated during the GI outbreak resident-shared equipment was sanitized utilizing the Sanicloth HB wipes. CNA-F stated resident sinks/toilets were wiped with Sanicloth HB wipes between resident use. During an interview with surveyor # on 3/22/11 at 11:20 a.m., CNA-H verified resident-shared equipment was sanitized with Sanicloth HB wipes between resident use. CNA-H stated resident-shared bathrooms (toilets and sinks) were wiped with Sanicloth HB wipes between resident uses. During an interview with surveyor # on 3/22/11 at 9:20 a.m., CNA-J verified resident-shared equipment was sanitized with Sanicloth HB wipes between resident use. CNA-H stated resident-shared bathrooms (toilets and sinks) were wiped with Sanicloth HB wipes between resident uses. During an interview with surveyor # on 3/22/11 at 11:25 a.m., CNA-I verified resident-shared equipment was sanitized with Sanicloth HB wipes between resident use. CNA-I stated resident-shared bathrooms (toilets and sinks) were wiped with Sanicloth HB wipes between resident uses. During an interview with surveyor # on 3/22/11 at 3:12 p.m., CNA-X verified resident-shared equipment was sanitized with Sanicloth HB wipes between resident use. CNA-X stated resident-shared bathrooms (toilets and sinks) were wiped with Sanicloth HB wipes between resident uses. During an interview with surveyor # on 3/22/11 at 11:10 a.m., RN-G stated during the GI outbreak resident-shared equipment was sanitized with Sanicloth HB wipes between resident use. RN-G verified the medication carts were wiped with the same Sanicloth wipes after being taken onto resident units for medication passes. During an interview with surveyor # on 3/22/11 at 9:25 a.m., RN-W stated during the GI outbreak resident-shared equipment was sanitized with Sanicloth HB wipes between resident use. RN-W verified the medication carts were wiped with the same Sanicloth wipes after being taken onto resident units for medication passes. RN-W verified one medication cart was utilized for two separate resident units (American Drive and Forest Trail). RN-W stated the cart was sanitized with the Sanicloth HB wipes between units. During an interview with surveyor # on 3/22/11 at 3:25 p.m., RN-Y stated during the GI outbreak resident-shared equipment was sanitized with Sanicloth HB wipes between resident use. RN-Y verified the medication carts were wiped with the same Sanicloth wipes after being taken onto resident units for medication passes. RN-Y verified one medication cart was utilized for two separate resident units (American Drive and Forest Trail). RN-Y stated the cart was sanitized with the Sanicloth HB wipes between units. During an interview with surveyor # on 3/22/11 at 11:00 a.m., DA (Dietary Aide)-V stated during the facility GI outbreak room trays were delivered to the units via meal carts. DA-V stated Nursing staff passed the trays on each unit, then sent the cart back to the kitchen. DA-V stated the carts were sanitized in the kitchen utilizing an Ecolab Neutral cleaner and disinfectant. DA-V verified no bleach solution was utilized. 5. The WDPH recommendations indicate the facility should limit new admissions until the incident of new cases has reached zero for at least forty-eight hours. If new admissions are being considered, consult with the ICN (Infection Control Nurse) and MD (Medical Director) first. The recommendations indicate facility staff, in consultation with their MD, should consider closing the unit or facility to new admissions. On 3/22/11 at 9:40 a.m. DON-A stated to surveyor # she had spoken with the Medical Director regarding the Norovirus outbreak, and the Medical Director did not have any further recommendations. DON-A stated the facility suspended admissions during the time of the outbreak, but verified resident #4 was admitted on [DATE]. DON-A was not aware of a discussion with resident #4 or the family regarding postponing the admission until after the outbreak was resolved. DON-A indicated surveyor # should speak to the SW (Social Worker) regarding any discussion with regard to the postponing of the admission of resident #4. On 3/22/11 at 1:55 p.m. surveyor # interviewed SW-R regarding resident #4's admission. SW-R stated she could not recall any specific discussion with resident #4 or her daughter regarding postponing of the admission until the outbreak had resolved. SW-R stated resident #4 and her daughter toured the facility prior to admission and would have seen the signs posted on the entrance regarding the outbreak. SW-R was not aware the facility signage was not posted until 1/13/11, three days after resident #4's admission. On 3/24/11 at 11:45 a.m. surveyor # interviewed SW-Z. SW-Z verified SW-R completed the admission process for resident #4. SW-Z stated she did not have any contact with resident #4 or her family prior to admission to the facility. On 3/24/11 surveyor # completed a record review for resident #4. According the the face sheet, dated 3/16/11, resident #4 was admitted to the facility on [DATE]. Resident #4 was admitted to the Oceanside unit. At the time of the admission, the Oceanside unit had one symptomatic resident. Resident #4's progress notes dated 1/10/11 to 1/14/11 did not document any signs or symptoms of GI illness. On 1/15/11 progress notes documented resident #4 began experiencing diarrhea. During an interview with surveyor # on 3/24/11 at 9:02 a.m., NHA-S and DON-A verified admissions were not suspended until 1/13/11, when the facility recognized the outbreak. NHA-S and DON-A verified resident #4 had been admitted to the facility on [DATE], prior to identification of the outbreak. The resident and staff line listings, as of 1/10/11, indicated seven residents and seven staff had experienced illness. 6. The WDPH recommendations indicate Norovirus outbreaks can be detected early by recognizing the typical symptoms of illness, and can be controlled by promptly implementing aggressive infection control measures to prevent the virus from being transmitted from person-to-person. When appropriate prevention and control measures are not implemented immediately, outbreaks can continue for weeks causing many illnesses, some hospitalization s and the occasional death from dehydration and other complications of vomiting and diarrhea. The recommendations indicate it is the responsibility of the Long Term Care Facility to implement aggressive infection control measures quickly. During the 3/22/11, 9:02 a.m. interview with surveyor # , DON-A and NHA-S stated on 1/13/11 the facility placed the WDPH recommendations at the nurses' station and the facility break room for staff to read. NHA-S verified the facility did not require staff to provide any type of verification that they had indeed read the information. NHA-S provided surveyor # a copy of the facility infection control inservice, which had been completed on 11/17/10 and 11/18/10. No further verification of training related to Norovirus was provided. The facility line listing for residents and staff indicated fifty-two residents were affected with GI illness from 1/4/11 to 1/20/11, and twenty-four staff were affected from 1/2/11 to 1/30/11. The failure of the facility to appropriately implement procedures to limit the transmission of infection created a situation of Immediate Jeopardy. Although there were no new cases of noro virus or noro-virus like illness after 1/30/11, immediate jeopardy continued because the facility had not revised its policies/procedures or trained staff on preventing the spread of illness. Conditions remained such that another outbreak could occur if an infection was introduced.

On 3/24/11 the facility was notified that an Immediate Jeopardy existed at F441 Infection Control. This was cited at a scope/severity level L (Immediate Jeopardy/widespread) on a Statement of Deficiencies (Event ID 1). Based on observations, staff interviews and record review on 3/29/11, it was determined that the Immediate Jeopardy was removed as of 3/24/11; however, the facility remains out of compliance with F441 at scope/severity of F (no actual harm with potential for more than minimal harm/widespread). This is evidenced by: Based on observations, staff interviews and record review on 3/29/11, it was determined that the facility had removed the Immediate Jeopardy at F441 on 3/24/11, by which time the facility had completed or had begun to implement the following: *initiated training to all staff related to recognition of potential infectious outbreaks; *trained staff on limiting contact between residents, visitors and non-essential staff during periods of outbreak; *trained staff on the appropriate use of personal protective equipment; *trained staff on environmental cleaning and appropriate, effective cleaning products; and *trained staff on the management of new admissions during an outbreak or suspected outbreak. The deficient practice continues at a scope/severity of F (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy/widespread) until all portions of the facility's action plan have been fully implemented, tested and monitored.