Every finding on record at Maplewood of Sauk Prairie

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice (N6 Wisconsin Nurse Practice Act) to meet each resident's physical needs for 1 of 3 sampled residents (R1). R1 experienced a change in condition with no bowel movements for five (5) days which lead to a distended abdomen, nausea and vomiting, severe constipation, ileus (a condition where the intestine slows down or stops pushing food and waste through the body) requiring a nasogastric tube (a tube passed through the nose and into the stomach for decompression) and aggressive bowel regimen. The facility did not assess, notify the provider, or implement aggressive interventions to prevent severe constipation and ileus, resulting in R1 being hospitalized . Evidenced by: According to N6, Wisconsin Nurse Practice Act, An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. The facility policy, Bowel Maintenance, revised June 2025, states in part, as follows: Purpose: It is the policy of the facility to assure that all residents' bowels are functioning regularly to prevent constipation and additional complications which may be associated with improperly functioning bowels. It is also the policy to provide all residents with a bowel management regime to promote regular bowel movements and maintain resident comfort related to bowels. 1. Each wing nurse is responsible to ensure that all residents on that unit are having regular bowel movements. When it is noted that a resident is not having regular bowel movements, actions will be taken to promote a bowel movement and to assure resident comfort and bowel functioning. 3. CNAs (Certified Nursing Assistants) record resident's bowel movements. CNAs are to report any problems that are noted with elimination, such as hard stools, loose stools, unusual incontinence, or complaints of abdominal discomfort or constipation to wing nurse. 4. Each shift, the wing nurse will check resident bowel movements to look for residents whom have not had a bowel movement in the last two days. 5. Residents that are noted to have not had a bowel movement: a. In the last two days: will be offered and encouraged to take a laxative, prunes or prune juice may also be offered b. For 3 or more days: will again be offered a laxative and the need for a suppository or enema will be addressed by wing nurse. 6. If no bowel movement is noted after 3 days, wing nurse is to perform additional observations and may include a digital exam, auscultation of bowel sounds, palpation of abdomen. 7. If needed, MD (Medical Doctor) will be contacted for additional or different orders.Number of days since last bowel movement and Action to take:1 day: Provide prunes, prune juice, or apricot juice2 days: Provide prunes, prune juice, or apricot juice; Provide PRN (as needed) laxative (MOM-Milk of Magnesia, senna, DSS-Docusate Sodium)3 days: Provide prunes, prune juice, or apricot juice; Complete abdominal observation: Bowel sounds, Palpation of abdomen, Digital exam; Provide PRN laxative (suppository, enema)Greater than 3 days: Repeat abdominal observation, Provide prunes, prune juice, or apricot juice, Provide additional laxative, Notify charge nurse and determine if MD update is needed. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, quadriplegia status post traumatic brain injury following a fall, vascular disorder of intestine, and aphasia due to traumatic brain injury. R1 requires extensive staff assistance for all cares. R1 has an APOAHC (Activated Power of Attorney for Health Care). R1's comprehensive care plan, dated 7/22/26, documents the following: I would like: to continue to live at this care facility because I receive the services I need here. I show this by: traumatic brain injury requiring 24-hour nursing care I need my nurses to: Provide care as appropriate/ordered, ensure comfort, update guardian as needed, communicate with hospice provider. My goal is to: remain at the facility or a long-term care setting through end of life and to pass with peace, comfort, and dignity. Goal time: 10/3/26. R1 does not have a care plan for constipation. R1's MAR (Medication Administration Record) documents R1 received the following bowel medications per physician orders:Lactulose 30ml (milliliters) /20g (gram) by mouth twice per day. Sennosides-Docusate Sodium 8.6mg-50 mg 2 tabs by mouth three times per day.Metamucil 4 in 1 fiber (psyllium 51.7% packet dose) - 1 packet AM(of note: R1 received his bowel medication on the appropriate days)R1's bowel monitoring documentation is as follows:On 6/27/26 (PM) Large softOn 6/28/26 (Night) Large softOn 6/28/26 (AM) No BM (bowel movement) is markedOn 6/28/26: (Night) Large soft On 6/29/26: (AM) no BM is markedOn 6/29/26 (PM) no BM is marked Of note: 6/29/26, is the first day R1 has gone without having a BM On 6/30/26 (Night) No BM is markedOn 6/30/26 (AM) No BM is markedOn 6/30/26 (PM) No BM is marked (of note: on 6/30/26, R1 has gone 2 days without a BM) On 7/1/26 (Night) R1 is marked as no BMOn 7/1/26 (PM) R1 is marked as no BMOn 7/1/26 at 11:58 PM, R1's Progress Notes document as follows: GI/Digestive: Bowel Sounds: Active x 4. (Note, no GI assessment including palpation of R1's abdomen is documented.)(As of 7/1/26 R1 has gone 3 days without having a bowel movement)On 7/2/26, R1's APOAHC took R1 to a walk in urgent care clinic as the mobile x-ray was unable to get to the facility on 7/1/26. It is important to note; there is no reference to R1 not having bowel movements or that a GI (Gastrointestinal) assessment was completed.The physician documents, in part, as follows: Assessment and Plan 1. Recurrent aspiration pneumonitis: Plan: Chronic, secondary to TBI (Traumatic Brain Injury) neuromuscular weakness with subsequent chronic respiratory insufficiency, oropharyngeal dysphagia, chronic aspiration. Repeat 2V CXR (chest x-ray) today visualizing right midlung and left basilar scarring and atelectasis similar to prior exam, stable cardio mediastinal silhouette, no other acute abnormality. He does have expiratory wheezing on exam. R1's APOAHC brought with her today a video of audible wheezing from yesterday evening. R1 is afebrile, oxygenating well on room air, no tachycardia. No other evidence for a secondary bacterial infection. Will treat with prednisone taper starting today. Although I had a lengthy discussion with R1's APOAHC my concerns are that medical management unfortunately will not change the underlying cause. Revisited updating a swallow study which she is agreeable to, order placed a faxed to coordinate scheduling with Speech Therapy. R1's APOAHC was quite tearful during these conversations, understandably so. Voices concern that the swallow study will likely show aspiration and he will be recommended to cease oral nutrition and pursue tube feedings which would significantly impact his quality of life. Although is in agreement current quality of life is significantly impacted by recurrent aspiration. R1's APOAHC did inquire if R1 was at a point where he would be meeting hospice criteria. I do not think he is at that point currently, although he likely will proceed in that direction if he continues to aspirate. On 7/2/26 (Night) No BM is marked.On 7/2/26 (AM) No BM is marked.(7/2/26 is the 4th day that R1 has gone without having a BM)On 7/2/26 at 4:52 PM, R1's Progress Notes do not document bowel sounds. (Note, no GI assessment or palpation of R1's abdomen is documented.) On 7/3/26 at 12:08 AM, R1's Progress Notes document as follows: GI/Digestive: Bowel Sounds: Active x 4 (Note, no GI assessment or palpation of R1's abdomen is documented until he is sent to the emergency department.) 7/3/26 (PM) Large soft (while EMS was at the facility to transport R1 to ED (emergency department)). EMS did not take R1 to ED due to having a BM. The facility did not recognize or notify the provider of R1 not having a bowel movement for five (5) days. On 7/3/26 at 6:39 PM, R1's Progress Notes document as follows: Physician on call was given resident vitals were reviewed and symptoms of not eating supper and being almost sent out today for possible bowel obstruction. Physician states can monitor him here for now as he doesn't seem to think it warrants sending him out at this time. Vitals BP 146/86, Pulse 115-124, Temp 100.4, and 2 emesis this shift. On 7/3/26 at 11:48 PM, R1's Progress Notes documents as follows: This writer to Resident's room to assess Resident. VS B/P (blood pressure) 162/106, P (Pulse) 108, RR (Respiratory Rate) 26-28, O2 sats (oxygen saturation) 94%, T99.1 AX (axillary). Small liquid emesis at this time brownish tan in color. Lung sounds with scattered wheezes. Previous nurse reports ambulance called earlier this am for ???obstruction. Lg (large) BM (bowel movement) reported early this morning. Abdomen distended, sluggish bowel sounds. Resident's (family member name) contacted with update and asked if I could send him to ER (emergency room) after I got an order. Permission given by family member. On call for physician notified of finding and order given to send to ER. Ambulance arrived at 11:15 PM and resident taken to ER. Paperwork sent with EMS (Emergency Medical Services) staff. ER nurse updated that I was sending this patient. R1's hospital report documents as follows: R1 with quadriplegia s/p (status post) TBI (Traumatic Brain Injury) and multiple comorbidities who presented on 7/4/26 with acute hypoxic respiratory distress, N/V (nausea/vomiting), and acute lactic acidosis (lactate 2.6). On admission SIRS 2/2 (clinical criteria that satisfies the definition for Systemic Inflammatory Response Syndrome signaling a generalized inflammatory response in the body) severe aspiration pneumonitis. Started IV (intravenous) Zosyn (antibiotic), IV steroids, and bronchodilators, leading to rapid resolution of his hypoxia and acidosis by HD2. Concurrently, he suffered severe abd (abdominal) pain 2/2 suspected ileus, requiring medically necessary urgent NGT (nasogastric tube) decompression and aggressive bowel regimen, which successfully resolved his symptoms. Also concern for NSTEMI (peak [NAME] 51.22) and sinus tachycardia 2/2 resp distress. A SLP (Speech Language Pathologist) eval (evaluation) on 7/6/26 confirmed severe dysphagia with high aspiration risk on all consistencies and poor rehab potential. Following a multidisciplinary GOC (Goals of Care) discussion, his wife declined PEG (feeding tube) placement and opted for comfort-focused feeding. He is discharging to hospice as a DNR (Do not resuscitate).Acute abdominal pain: Diagnosis Ranking (Secondary)Plan: Acute Abdominal pain, suspect severe constipation vs (versus) ileus. No bowel obstruction bowel thickening or free fluid or free air noted on CT (computed tomography) abdomen. No aortic aneurysm or dissection noted. Patient does have a history of chronic constipation and last known bowel movement was 5 days before this large bowel movement day prior to admission [DATE]).NG (Nasogastric) tube in place to suction, minimal secretions notedBowel regimenIV (intravenous) hydrationAs needed Tylenol for pain On 7/5/26 R1's hospital physician documented as follows: Suspect this was secondary to severe constipation as patient's abdominal pain and distention has remarkably improved after large bowel movements. NG tube was removed per patient request he is doing well today. Continue aggressive bowel regimen. Acute Abdominal Pain/Severe Constipation/Suspected Ileus: Required urgent NGT (Nasogastric tube) placement for decompression and aggressive inpatient bowel regimen. While the NGT was removed quickly per his request, the initial intervention and ongoing monitoring were medically necessary to resolve his acute distention and pain and rule out surgical pathology.Moderate nausea and vomiting: Diagnosis Ranking: SecondaryPlan: PRN IV (intravenous) ondansetron and Compazine (both medications are used to treat severe nausea and vomiting); Continue NGT (Nasogastric tube) Plan: Goals of Care / Hospice Transition: Multidisciplinary family meeting held today with his APOAHC and SW (Social Worker). APOAHC reports his overall condition and functional status have been steadily declining over the past several months. After discussing prognosis and options, APOAHC declined PEG/enteral feeding tubes. Consensus reached to transition him to hospice care upon discharge. Continue with buprenorphine patient is on buprenorphine 10 mcg (microgram) patch weekly, switch to 2 mg (milligram) sublingual twice daily. Continue with baclofen. R1 was discharged back to the facility on 7/7/26. R1 expired on 8/2/26. On 8/19/26 at 8:50 AM, Surveyor contacted R1's APOAHC. R1's APOAHC did not return Surveyor's call. On 8/19/26 at 2:05 PM, Surveyor spoke with ADON C (Assistant Director of Nursing) and NHA A (Nursing Home Administrator). Surveyor asked ADON C, does R1 have a history of bowel obstructions. ADON C stated yes. Surveyor asked ADON C, what additional interventions were put in place for R1 and lack of bowel movements between 6/29 - 7/3/26. ADON C stated on 7/1/26, the facility contacted the physician to obtain an order for a check x-ray (note, this was unrelated to R1's lack of bowel movements). Mobile x-ray was unable to get to the facility the same day so R1's APOAHC took R1 to the clinic (walk in urgent care) on 7/2/26 (note, this was also unrelated to R1's lack of bowel movements). ADON C stated on day 3 without a bowel movement, staff should update the provider regarding no bowel movements per our policy. NHA A stated maybe staff spoke with NP H (Nurse Practitioner) in passing as she is at the facility a lot. Surveyor asked NHA A when staff notify a provider should that be documented. NHA A stated yes. Surveyor asked ADON C, on day 3 with no bowel movement, would you expect staff to not only be assessing bowel sounds but to complete a complete GI assessment including palpation of R1's abdomen. ADON C stated yes. Surveyor asked ADON C, did staff complete a full GI assessment for R1 including palpation of R1's abdomen. ADON C stated no. Surveyor asked ADON C, should staff have completed a full GI assessment and palpated R1's abdomen. ADON C stated yes. On 8/19/26 at 2:55 PM, Surveyor spoke with NP H (Nurse Practitioner). NP H reviewed R1's EMR (Electronic Medical Record) per request of Surveyor. Surveyor reviewed with NP H R1 had no BM on 6/29, 6/30, 7/1, 7/2, and 7/3 had a large BM as EMS (Emergency Medical Services) was at the facility ready to transport R1 to the ED (emergency department). NP H stated 7/2/26 would been an opportune time for the facility to contact her regarding R1's lack of BMs and she would have ordered an x-ray. NP H stated the facility should have started interventions by day 3 and notified her on 7/2/26. NP H stated the facility has a policy regarding BMs and should have been following the instructions; NP H added, each day without a BM has separate instructions and a RN (Registered Nurse) should have performed a thorough GI assessment and notified her. NP H reviewed R1's clinic and hospital records. NP H stated there is no documentation the facility contacted either NP H or the physician regarding R1's lack of BMs. NP H stated R1 was brought into the walk in urgent care clinic on 7/2/26 by R1's APOAHC (for wheezing/breathing concerns) however there is no mention of lack of bowel movements in the physician visit notes or GI assessment.NP H stated on 7/3/26 the facility called her after hours as R1's APOAHC was demanding R1 be sent to the ED. NP H stated she gave orders for R1 to be sent to the ED. NP H stated R1 had a BM while EMS was in the facility ready to take him to the ED. Of note, R1's APOAHC turned the ambulance away as R1 had one (1) BM. NP H stated if R1 had an ileus it must have been much higher. NP H stated R1 did not have a bowel obstruction. NP H stated on 7/3/26 when the facility called her after hours to discuss R1, they did not discuss R1's bowels or lack of bowel movements. NP H stated that could have been contributing too, and she was not getting the full picture from the facility. NP H stated, I think that would have been important. NP H added that no bowel movements and a heart rate that is elevated could have been a better picture and should have been part of the conversation. R1 experienced a change in condition with no bowel movements for five (5) days, the facility did not assess, notify the provider, or implement aggressive interventions to prevent severe constipation and ileus, resulting in R1 being hospitalized and requiring a nasogastric tube and aggressive bowel regimen.

Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 1 resident (R3) reviewed for medication errors out of a sample of 3.R3 had sliding scale orders for her insulin lispro administration. R3's PM blood sugar reading fell outside of the order parameters, but R3 was administered insulin lispro without a provider being contacted one hour before dinner was scheduled to start. This resulted in actual harm when R3's became hypoglycemic, and after multiple failed interventions, was required to go to the ED (Emergency Department) for IV (intravenous) fluids.This is evidenced by:The facility's policy, titled Insulin Administration Policy, implemented 02/2011, states in part: Policy: It is the policy.to provide timely administration of insulin in order to meet the needs of each resident and to prevent adverse effects on a resident's condition. Policy Explanation and Compliance Guidelines: 1. All insulin will be administered in accordance with physician's orders.4. Insulin administration will be coordinated with mealtimes and bedtime snacks unless otherwise specified in the physician's orders. Insulin will be scheduled about 1/2 hour prior to meal serving times.R3 admitted to the facility on [DATE] with diagnoses that include, in part: type 2 diabetes mellitus without complications. R3's physician orders include, in part:*Blood glucose check: four times a day 7:00 AM, 11:30 AM, 4:00 PM, 8:00 PM. Notify physician if blood glucose > 400. Notify physician if blood glucose < 70. *Insulin Lispro (1 unit dial) 100 unit/mL solution pen-injector sub-q (subcutaneous) dose: (2 unit) - (8 unit) variable three times per day AM, midday, PM / First date: 7/10/26 / For: Type 2 Diabetes Mellitus.151-200 = 2 units201-250 = 4 units251-300 = 6 units301-350 = 8 unitsAdministration instructions: Slide Scale dose to be given with meals. Prime pen with 2 units before every injection. Entry date: 8/11/26. Of note: insulin lispro is a rapid-acting insulin. According to the CDC (Centers for Disease Control and Prevention), the onset time is 15 minutes, the peak time is 1 hour, and it is typically taken right before eating a meal (https://www.cdc.gov/diabetes/about/how-to-use-insulin.html). Surveyor reviewed R3's MAR (Medication Administration Record) for August 2026. On 8/13/26, R3's PM blood sugar was 391 and R3's PM administered dose of insulin lispro was 8 units. Of note: a blood sugar reading of 391 was outside of the sliding scale range listed in R3's insulin lispro order. Surveyor reviewed R3's progress notes:On 8/13/26 at 6:30 PM - RN D (Registered Nurse): Purpose for note: progress note 1545 (3:45 PM) BG (blood glucose) 391 by meter 1600 (4:00 PM) lispro SS (sliding scale) 8 units SQ (subcutaneous) give. 1700 (5:00 PM) CNA (Certified Nursing Assistant) assisting Res (resident) for beginning of meal reported Res 'sweating', nurse in to see Res, Res drowsy, slow to respond, BG check 33. 1705 (5:05 PM) OJ (orange juice) w/ 3 packets of sugar attempted to give Res, slow sip response. 1715 (5:15 PM) Glucose gel 40% given, Res able to swallow, HOB (head of bed) ^ 45 degrees. 1720 (5:20 PM) BP (blood pressure) 158/81 HR (heart rate) 75 RR (respiration rate) 18 POX (pulse oximetry) 95% RA (room air) T (temperature) 97.9. 1723 (5:23 PM) Repeat BG 38. 1731 (5:31 PM).NP (Nurse Practitioner) contacted, updated on Res status and interventions, New Order: Glucagon 1 mg IM (intramuscular) given. 1750 (5:50 PM) BP 153/78 HR 78 RR18 POX 97% RA T 97.7. Res alert, able to respond to nurse and CNA, moving all extremities. 1754 (5:54 PM) BG 84. 1756 (5:54 PM).NP contacted, updated on Res BG and status, no new orders. On 8/13/26 at 11:22 PM - RN D: Purpose for note: Late Entry for: Time: 7:45 PM 1945 (7:45 PM) HS BG (at bedtime) check 31, Res drowsy, BP 149/72 HR 83 RR 18 POX 96% RA T 97.3. Report that dinner intake minimal. Res slow to drink OJ sips. CNA w(with)/Res, nurse to charge office. 1955 (7:55 PM).on-call NP contacted, updated on Res status and B (blood glucose) and VS (vital signs), New Order #1: Glucagon 1 mg IM now x 1. #2 Call 911 for Res to be seen in ED. 2000 (8:00 PM) Glucagon 1 mg IM x 1 given. 2003 (8:03 PM) 911 called, papers readied. 2010 (8:10 PM) EMS (Emergency Medical Services) BG check 187, Res responding to questions, moving extremities. Res transferred to gurney, O2NC (oxygen via nasal cannula) on. 2030 (8:30 PM) EMS departure w/Res to.hospital. On 8/19/26 at 5:22 PM, Surveyor interviewed RN D. RN D confirmed he had been working with R3 on the evening of 8/13/26. Surveyor asked RN D to explain what happened that evening before R3 had been sent to the ED. RN D relayed the following information: he checked R3's blood sugar around 4:00 PM and it was approximately 390. RN D administered insulin right after that according to R3's sliding scale orders. RN D rechecked R3's blood sugar around 5:00 PM after noting that she was sweaty and it had dropped to 33. A tube of glucose did not bring R3's blood sugar up. RN D updated the NP and administered glucagon, which brought R3's blood sugar up to 84. R3 was one-on-one with staff. Around 7:45 PM, a CNA reported that R3 had not eaten much for dinner; her blood sugar was rechecked and had dropped again. RN D updated the NP again and administered glucagon and called 911, as instructed by the NP. EMS arrived and inserted an IV for R3 and began a 10% glucose IV solution. R3's blood sugar recheck before leaving the facility was 87 and she was transported to the ED around 8:00 PM. R3 returned to the facility around 11:00-11:30 PM after her blood sugar had stabilized in the 120s - 150 at the hospital. RN D indicated blood sugars are typically taken one hour before dinnertime - around 4:00 PM. Insulin is then typically administered to residents right at the dinner table around 5:00 PM. Surveyor asked if an hour gap between taking a blood sugar and administering insulin is the standard of practice. RN D indicated it is done that way because of the way the orders are scheduled in the system. Surveyor asked RN D why 8 units of insulin were administered when R3's ordered sliding scale insulin parameters only went up to 350. RN D indicated he reviewed R3's sliding scale parameters and took the highest parameter and went with that. Since R3's blood sugar was at 390, which was out of her normal range, RN D indicated he administered the insulin right away to try to get her blood sugar down to an acceptable level by dinnertime. Surveyor asked RN D if he should have contacted the doctor since R3 did not have an order to administer insulin for a range higher than 350. RN D indicated R3's blood sugar is never in this range and said he believed the provider did not set the parameter past 350 because the provider never thought R3's blood sugar would get that high. RN D indicated that the facility's standing orders are to contact a provider if blood sugars are below 70 or above 400, and a blood sugar of 390 did not meet that criteria. Surveyor reviewed R3's provider documentation note, dated 8/13/26 at 8:00 PM written by NP G, which states, in part: Assessment: [R3] is a.female with recurrent severe hypoglycemia while in a facility, with blood glucose values in the 30s despite prior treatment with glucagon and transient improvement. The episode occurred after administration of 8 units of sliding scale insulin for hyperglycemia (blood glucose 391) earlier the same day, with minimal oral intake reported. She is reported to be conscious, but the persistence and recurrence of blood glucose in the 30s indicates a high risk for rapid clinical deterioration. Overall presentation is most consistent with insulin-associated hypoglycemia in the setting of poor oral intake requiring emergency evaluation. Surveyor reviewed R3's ED Discharge summary, dated [DATE]: Patient Visit Information: You were seen today for: Hypoglycemia. Activity Restrictions or Additional Information: [R3] had low blood sugars this evening that required IV treatment with D10 (10% dextrose) saline infusion.Please hold on any further insulin dosing tonight and contact primary prescriber tomorrow morning before giving any insulin tomorrow. On 8/19/26 at 4:50 PM, Surveyor interviewed RN E. RN E indicated each diabetic resident has his or her own glucometer, alcohol, lancets, and test strips. The glucometers are calibrated whenever a new set of strips is opened. RN E reviewed R3's insulin lispro sliding scale orders. RN E indicated that she would call the doctor if R3 had a blood sugar reading of 391. On 8/19/26 at 4:55 PM, Surveyor interviewed LPN F (Licensed Practical Nurse). LPN F reviewed R3's insulin lispro sliding scale orders. LPN F indicated that she would call the doctor if R3 had a blood sugar reading of 391. On 8/19/26 at 4:50 PM, Surveyor interviewed ADON C (Assistant Director of Nursing). ADON C indicated R3's blood sugars had fluctuated while she was at the facility, and she had been working with doctors on this. ADON C also indicated that R3 did not eat well. Surveyor asked about glucometers. ADON C indicated that each resident has an individual glucometer in his or her room. ADON C reviewed R3's insulin order and indicated she was aware of it, as she had revised the order on 8/13/26 to read Sliding scale insulin to be given with meals from the original order, which read Slide scale dose to be given with meals. ADON C reviewed the sliding scale parameters for R3's insulin lispro with Surveyor. ADON C acknowledged that the order was missing a blood sugar sliding scale range of 351-399. Surveyor asked what nursing staff should do with a blood sugar of 391. ADON C indicated they should call the doctor, as it falls outside of the order set. ADON C reviewed R3's progress notes and MAR entries from 8/13/26. ADON C acknowledged that a provider had not been notified before the nurse administered 8 units of insulin. ADON C indicated that she would have expected a doctor to be contacted. On 8/19/26 at 5:43 PM, Surveyor asked ADON C how long staff members should wait before obtaining a resident's blood sugar and administering insulin. ADON C indicated she had always practiced that insulin should be administered within a 15-minute window of obtaining a blood sugar reading. On 8/19/26 at 6:01 PM, Surveyors discussed the concern with R3's insulin administration on 8/13/26 with NHA A (Nursing Home Administrator) and ADON C. NHA A and ADON C acknowledged the concern and did not have any follow up questions. R3 was given 8 units of insulin without provider notification or orders to administer 8 units. R3's insulin was administered greater than 15 minutes prior to consuming food, resulting in a low blood sugar requiring R3 to be sent to the ED for intervention to bring R3's blood sugar back up.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 Residents reviewed. R1 made an allegation of sexual abuse, and the facility did not report this to law enforcement.This is evidenced by:The Facilities Policy and Procedure entitled Abuse, Neglect, and Exploitation dated 06/2025, documents in part: . Sexual Abuse is non-consensual sexual contact of any type with a resident .VII. Reporting/Response A. Facility will have written procedures that include: a. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse .Per facility reported incident investigation R1 stated if they would leave me alone and if [accused name] would stop raping me. When staff asked R1 who [accused name] was R1 stated an old friend. Per investigation R1 continued to cry and yell out [accused name] stop hurting me. This incident was not reported to law enforcement.On 7/15/26 at 1:41 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if rape is an allegation of sexual abuse, DON B said yes. Surveyor asked DON B if sexual abuse is a crime, DON B replied yes. Surveyor asked DON B should law enforcement have been contacted related to this allegation, DON B stated yes.On 7/15/26 at 1:51 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if rape is an allegation of sexual abuse, NHA A said yes. Surveyor asked NHA A if sexual abuse is a crime, NHA A replied yes. Surveyor asked NHA A should law enforcement have been contacted related to this allegation, NHA A stated yes but this case isn't black and white, and we felt that the police contact would only escalate R1's condition.

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R3) reviewed for wandering and elopement potential out of a sample of 6 Residents.R3 was identified as having a behavior of exit seeking. R3's elopement risk assessment was not accurate or complete and R3's care plan did not contain interventions or goals related to exit seeking.When R3 eloped, staff did not follow the facility policy and procedures for a missing resident, for wandering/elopement, and for a code alert.The facility's failure to assess, care plan, and supervise a resident who was at risk for elopement, created a finding of immediate jeopardy that began on 3/16/26. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 6/23/26 at 1:21 PM. The immediacy was removed and corrected on 3/18/26; the deficient practice is being cited as past noncompliance. Evidenced by:Facility policy, titled Elopement and Wandering Residents Policy, revised 6/2025, includes: Monitoring and managing residents at risk for elopement or unsafe wandering: Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team. The interdisciplinary team will evaluate the unique factors contributing to risk such as diagnoses, mental status, medications, and residents' physical appearance in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions and document accordingly. See the Missing Resident Policy for more information regarding elopements and the procedures to be followed when they do occur. See Code Alert Policy for the protocol for the use of the code alerts.Facility policy, titled Missing Resident Policy, revised/reviewed 6/2025, includes: Any staff member observing a resident attempting to leave the premises shall with proper conduct attempt to prevent such departure. When an exit alarm goes off, staff will respond in a timely manner and look for the source that triggered the alarm. If the source is not immediately found, it is a good idea for staff to leave the alarm sounding until additional staff come to aide in the search and can assist with notification of the charge nurse. Staff will walk around the immediate area of the building and grounds if the source for triggering the alarm is not found in the area of the alarm. If source for the alarm is found, staff will report this to the charge nurse. Upon notification that a resident has indeed left the premises or a resident is noted to be missing, the charge nurse shall alert all staff, via overhead page, to conduct a thorough search of the facility, including all resident rooms, bathrooms, closets, etc., and the exterior premises for the missing resident. Should this initial search of the facility and the premises or a resident is noted to be missing, the charge nurse shall alert the Administrator and Director of Nursing. While the charge nurse is notifying the Director of Nursing and Administrator, other staff will initiate a more extensive search of the surrounding area. If after 30 minutes the extensive search proves unsuccessful, the following people shall be notified: family, physician, local police department.Facility policy, titled Code Alert Policy, reviewed/revised 6/2025, includes: Each resident who is deemed an elopement risk will have a code alert bracelet placed on their person, walker, or wheelchair. Assessment: an elopement risk assessment is completed on each resident on admission, annually, and with a significant change. The elopement risk assessment is located in the electronic charting system under the charting tab topic elopement risk. If a resident is determined to be at risk for elopement based on assessment, a code alert unit will be placed.Facility's Agency Orientation Packet, undated, includes, wandering and elopement policy, missing resident policy, and code alert policy. Indicating that new staff are educated on these operations.R3 admitted to the facility on [DATE] with diagnoses of unspecified dementia, Major Depressive Disorder, Alzheimer's disease, Chronic Obstructive Pulmonary Disease, and Insomnia.R3's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 3/13/26 indicates R3's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 3 out of 15.R3's Comprehensive Care Plan, initiated 7/14/23, includes: I am forgetful and need reminders because I have progressing Alzheimer's disease/dementia. I show this by: exhibiting poor short/long term memory, disorientation, decreased safety awareness, forgetfulness, reduced ability to recall prior events or conversations, statements of having poor memory, short attention span/distractibility, periodic exit seeking, insomnia/trouble falling asleep or staying asleep, benefitting from memory care programming with structured daily activities and care, mood lability. I need staff to . offer reminders as needed, establish/maintain consistent routine, encourage participation in daily cognitively stimulating activities, assess for potential physiologic causes of increased confusion, report any changes in overall care/status, offer simple choices,.R3 is noted to have periodic exit seeking behaviors, but R3's care plan does not contain interventions and goals related to exit seeking.R3's Medical Doctor Note, dated 12/17/25, includes: Seen today for a nursing home visit. Nursing staff has noted no concerns other than that she has had some elopement behaviors. They have just done more checks. No changes in medication. She was alert and appropriate today although did not recognize me, although with my stethoscope I think she determined that I was her doctor. She is obviously forgetful related to her dementia.Nursing staff demonstrated awareness of potential elopement as evidenced by the update given to the physician.R3's Elopement Risk Assessment, dated 1/23/26, includes: cognitively impaired: yes. Resident has a history of or attempted elopement while at home: no. Resident has a history of or attempted leaving the facility without informing staff: no. Resident has verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door: no. Resident wanders: no. Wandering behavior is a pattern or goal directed: no Resident wanders aimlessly or non- goal directed, confused, moves without purpose, may enter other's rooms and explore other's belongings: no. potential interventions: secured unit.The risk assessment is not complete as there is no score and is missing answers to some questions at the end.On 6/23/26 at 11:12 AM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator). NHA A, DON B, and Surveyor reviewed R3's elopement assessment, dated 1/23/26. NHA A and DON B indicated the elopement risk assessment is incomplete and inaccurate. NHA A and DON B indicated it is their expectation that assessments are to be accurate and complete. NHA A and Surveyor reviewed R3's comprehensive care plan noting R3 has a known behavior of periodic exit seeking but does not have interventions or goals related to the behavior. NHA A indicated R3's care plan should have contained goals and interventions related to exit seeking.R3's Nurse Notes, dated 3/16/26 at 11:34 PM, states, Resident was last seen by this nurse in another resident's room at approximately 8:15 PM on this day. She was sitting on another resident's bed having a conversation. This nurse left that area to continue the medication pass. This nurse was in a resident's room when I heard the back door alarm go off. This nurse went to check on the alarm. The door was open so I looked to see someone [sic]. There were no footprints or snow disturbance. I could not see anyone in the area. I pulled the door shut and turned the alarm off. CNA C (Certified Nursing Assistant) asked me where R3 was about 8:30 PM. I responded that the last time I saw her she was in another resident's room. CNA C and I looked in everyone's room and could not find her. That is when I tried to notify the charge nurse. (This note was written by LPN F (Licensed Practice Nurse).)R3's 15 minute check sheet, dated 3/16/26, indicates staff observed her every 15 minutes until 8:45 PM despite staff reporting they were unable to locate R3On 6/22/26 at 2:10 PM, Surveyor interviewed CNA C. CNA C indicated she was on break at the time R3 eloped. CNA C stated, I initialed R3's 15-Minute Check Sheet without checking on R3 because LPN F said she saw her and knew where she was. CNA C indicated R3 has tried to get out of the doors before this incident, but she usually tried to go out of the other door of the unit.Facility's Misconduct Incident Report, dated 3/18/26, includes: Date occurred: 3/16/26. Time occurred: 8:25 PM. Briefly describe the incident: R3 exited the west emergency exit from the secured memory care wing. She knocked on a neighbor's door and asked to come in and sit and to have a tissue. The neighbor contacted the police and they escorted R3 to the hospital by ambulance. Staff were notified by the neighbor around 9:10 PM, stating that R3 was at their home and being transported to the hospital for evaluation. Describe the effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident: R3 assumably, became disoriented after visiting with another resident. She exited the west wing emergency door and walked outside. She appeared confused once she was outside in the cold. She continued to walk through the parking lot. She knocked on the neighbor's door (apartment down the street) because she wanted to sit down and needed a tissue per statement from neighbor. R3 has abrasions on her head and her fifth finger was deformed. She was confused and appeared disoriented. Explain what steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct: Two agency staff were on the wing at the time the emergency exit door opened and the alarm sounded. Both did not respond for over two minutes. Once LPN F responded she noticed the door ajar. Neither LPN F or CNA G looked outside to ensure no residents had eloped. The door was pulled shut and the alarm reset. CNA C was on break when the incident occurred. When CNA C returned from break she was notified that the door was opened and the alarm sounded. CNA C asked if checks were completed. Both LPN F and CNA G stated no. CNA C did welfare checks on all residents and found R3 was missing. A call was received from [NAME] H stating her sister had R3 at her house at the apartments down the street. CNA C told LPN F to inform Charge Nurse I. Charge Nurse I was notified that a resident fell at the apartments. There was no explanation of which or where the apartments were. He went over to the RCAC on facility campus assuming that was the apartments. Police Report, dated 3/16/26, included: The reporting party was advising that an elderly female was knocking on her apartment door. Additionally, the reporting party advised that the elderly female had appeared to have fallen. While enroute, . County dispatch did page an ambulance to the above address. Upon arrival, (the officer) made contact with the reporting party and the elderly female. (The reporting party) advised that she heard a faint knocking at the main door to the apartment lobby. When she looked out she noticed R3. She noticed some scratches on R3's face and that she appeared to be cold. She had R3 sit on the steps inside the lobby and wrapped her in a blanket. She attempted to speak with R3 but she was only able to say her first name. R3 was unsure where she lived, what month it was, her last name or where she currently was. R3 did advise her feet hurt and that she did fall at some point. Officer observed her to have several facial scratches and bruising on her right hand pinky finger. EMS (Emergency Medical Services) did arrive on scene and began to care for R3. The facility could not provide any information on what time R3 left the facility and it appeared most of the staff was unaware she was missing at all. At the time of the call temperatures were approximately 16 degrees. R3 was approximately 0.4 miles from the facility.Ambulance Report, dated 3/16/26: Per EMS, R3 was found wandering around with no coat on for around 30-45 minutes, has likely fallen due to scrapes on forehead.ER (Emergency room) Report, dated 3/16/26: . female patient lives at (facility) memory unit, wandered outside unbeknownst to staff and wandered about a half a mile away from (the facility). She knocked on somebody's apartment door and they called the police 911. Police called ambulance. Patient apparently fell because she has some abrasions on her forehead and face and some injury to her right fifth finger and left index finger she denies headache neck pain chest pain shortness of breath. Her temperature was only 95.8. temp (taken) orally by EMS. Clinical Impression: Exposure to environmental cold, Fall, Forehead contusion, Abrasion of face, Abrasion of right little finger, Contusion of left patella, Hypothermia, Odontoid fracture with type II morphology, Anterior displacement and delayed healing.According to The National Weather Service, on 3/16/26 at 8:00 PM, (the facility's location) experienced strong, brisk winds from the north/northwest, with sustained wind speeds of 25 to 35 miles per hour and frequent gusts ranging between 40 and 45 miles per hour. The estimated windchill was between 5 degrees F (Fahrenheit) and 10 degrees F. Snowfall accumulation ranged from 8 to 12 inches with winds causing drifts. In these conditions, frostbite can set in on exposed skin in 30 minutes or less. For an elderly woman, the risk is highly elevated because seniors and older adults lose core body heat much faster than younger adults, meaning hypothermia is an immediate and life-threatening concern even before frostbite occurs. A core body temperature drop to 95 degrees F or lower constitutes medical hypothermia.On 6/23/26 at 11:12 AM, NHA A and Surveyor reviewed R3's 15-Minute Check Form, dated 3/16/26. NHA A indicated CNA C signed out the form without having visualized R3.On 6/23/26 at 11:12 AM Surveyor interviewed DON B and NHA A. NHA A indicated LPN F and CNA G did not even step foot outside of the building when LPN F closed the door and deactivated the door alarm and the doorbell alarm. NHA A indicated the facility has camera footage and she would play it for surveyors. NHA A stated, You will see the staff did not follow the Missing Resident Policy, didn't follow the Wandering and Elopement Policy, and they didn't follow the Code Alert Policy.On 6/23/26 at 11:48 AM, surveyors reviewed video footage, dated 3/16/26. Surveyors observed the surroundings to have about 8 inches of snow, but the sidewalk and the parking lot had been plowed. Surveyors observed the sidewalk and parking lot to have patches of snow/ice on them. Surveyors observed R3 exit the building at 8:27:56 PM. R3 was observed to be wearing well fitted shoes, pants, and a sweatshirt. R3 walked down the sidewalk, stepped over a pile of snow left by the plow, and entered the parking lot. The parking lot had no cars in it. At 8:30 PM, surveyors observed R3 to still be in the parking lot under a tall light and at the same time, surveyors observed an unknown staff member close the door without stepping outside. Surveyors observed the unknown staff member's shadow in the window, but the door never reopened. Surveyors observed R3 to continue walking out of the facility's parking lot and onto the street.The failure to accurately assess, create a care plan with goals and interventions, provide supervision, and follow facility policies and procedures created a reasonable likelihood for serious harm for R3, thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on 3/18/26 and corrected the citation , when it had completed the following:NHA A implemented 15-minute checks on all residents residing on the (secured unit).NHA A removed both CNA G and LPN F (agency contracted staff) from working at the facility.Maintenance Manager ensured all alarms on doors were working correctly.Interdisciplinary Team verified that all staff carried a communication radio for immediate communication between staff.NHA A spoke with R3's family member at the hospital to follow up on R3's conditionNHA A viewed video footage of the incident and noted the proper procedures for wandering; potential eloped residents were not followed by CNA G and LPN F on wing.NHA A contacted staff that worked during the shift and completed a witness statement.NHA A spoke with RN I regarding situation and his knowledge of it.Director of Nursing ordered alarms on R3 upon return from hospital.Maintenance conducted alarms checks for all egress doors. All alarms are working correctly.Human Resources implemented a mandatory uniform requirement to have a radio on their person for immediate communication between staff, for residents' safety. Reminder signs posted at all nurse/CNA stations and break rooms.Director of Nursing B and Social Services conducted elopement assessments for all residents in the facility. Completed by nursing and social services.NHA A and Director of Nursing B posted and required employee signature of acknowledging Elopement and Wandering, Missing Resident Code Alert Policy and Procedures. This was placed in scheduling/Daily book. To be completed before start of next shift working.Interdisciplinary Team made a consideration to move the secured unit from Evergreen to Elm. DON B created a Plans Moving Forward presented to IDT leadership. (Consequently, this change was not completed due to logistical complications.)Activities Dept was instructed to apply 3D appliques to the exit and entrance doors to create a distractive facade for future elopement risk.Administrator reached out to DHS DQA - Life Safety to discuss use of appliques on doors or frosted glass. - given approval if view at eyesight level was clear beyond the door.Maintenance instructed to apply a frosted film to the back Evergreen exit door to distract the look of the door.Maintenance placed black rubber mat next to door exit to further distract elopements.NHA A created Power Point education for Managing Wandering and Restlessness with residents.This education is included with all new employee orientationsDirector of Nursing B and NHA A developed an extensive Elopement Prevention and Management Policy for use on all resident wings.Social Services, to follow up on all care plans, and elopement risks for residents on Evergreen.Interdisciplinary Team brainstormed ideas discussed for ways to improve alerts for higher risk residents.Interdisciplinary Team implemented on going elopement and wandering auditsNHA A conducted elopement audit on each shift at 12:00am, 11:25 am, and 1630p,NHA A met with Board of Directors to discuss options to prevent further elopement risks.Board Member posed utilizing a fenced in area outside the door to slow the exit or wandering of an eloped resident.Fence was priced out and ultimately purchased. Fence was installed.Medical Records, Director of Nursing, and Social Services worked with the Electronic Health Record to updates to include elopement risk on the KardexMaintenance placed additional frosted film to the [NAME] wing exit door (just outside of the Evergreen wing) to distract from the use of the door.Clinical Managers assigned to each wing to ensure staff are following newly implemented and corrected procedures regarding resident risks for wandering, elopement, and restlessness.Interdisciplinary Team conducted QAPI meeting. Addressed need for procedural changes for staff and residents assessed as a high elopement wandering risk.Administrator conducted elopement drillStaff continue to conduct 15-minute checks on all Evergreen residents.Board of Directors President signed invoice for fence and gate to be constructed on the west emergency exit egress.Driftless Fence Solutions installed 36' fence line with a 5' gate entrance along west emergency exit egress on EvergreenOn 6/22/26 and 6/23/26, surveyors observed the facility's action plan items to be in place.

Based interview and record review, the facility did not include as part of its compliance and ethics program an effective way to communicate the program's standards, policies, and procedures through a training program for 5 of 5 CNAs (Certified Nursing Assistants) randomly sampled. This had the potential to affect all residents who reside in the facility.CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented yearly compliance and ethics in-service training.Evidenced by:The Facility Assessment, last reviewed 1/2026, states in part:. Staff Training/Education, and Competencies/Recruitment/Retention: 3.4 Staff will be provided with training and education to assure competent care is provided to residents in the facility. Training/education will be provided upon hire with the orientation process, routinely on a yearly basis and as needed if issues arise. The following training topics will be included in this process (this is not an all-inclusive list):*Communication.*Resident Rights.*Abuse.*Infection Control.*Culture Change.The following competencies be reviewed (this is not an all-inclusive list):*Person-centered care.*Activities of Daily Living.*Disaster.*Infection Control.*Caring for persons with Alzheimer's or another Dementia. On 7/02/26 at 1:00PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor reviewed the Nurse Aide In-Service Records for CNA J, CNA K, CNA L, CNA M, and CNA N with NHA A. Surveyor asked NHA A if CNA yearly in-service/education should include compliance and ethics. NHA A indicated yes.

Based interview and record review, the facility did not ensure the continuing competence of nurse aides must be no less than 12 hours per year and did not include dementia management training and resident abuse prevention training for 5 of 5 CNAs (Certified Nursing Assistants) randomly sampled. This had the potential to affect all residents who reside in the facility.CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented yearly 12 hours of continuing education including dementia management and abuse prevention training. Evidenced by:The Facility Assessment, last reviewed 1/2026, states in part:. Staff Training/Education, and Competencies/Recruitment/Retention: 3.4 Staff will be provided with training and education to assure competent care is provided to residents in the facility. Training/education will be provided upon hire with the orientation process, routinely on a yearly basis and as needed if issues arise. The following training topics will be included in this process (this is not an all-inclusive list):*Communication.*Resident Rights.*Abuse.*Infection Control.*Culture Change.The following competencies be reviewed (this is not an all-inclusive list):*Person-centered care.*Activities of Daily Living.*Disaster.*Infection Control.*Caring for persons with Alzheimer's or another Dementia. On 7/02/26 at 1:00PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked how many in-service/education hours are required yearly for CNAS. NHA A indicated 12 hours. Surveyor reviewed the Nurse Aide In-Service Records for CNA J, CNA K, CNA L, CNA M, and CNA N with NHA A. NHA A agreed the total hours on the Nurse Aide In-Service Record sheets did not meet the 12 hours required yearly. Surveyor asked NHA A if CNA yearly in-service/education should include dementia and abuse NHA A indicated yes.

Based on interview and record review, the facility did not include as part of its QAPI (Quality Assurance and Performance Improvement) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 5 of 5 randomly sampled Certified Nursing Assistants (CNA). This had the potential to affect all residents who reside in the facility.CNA J, CNA K, CNA L, CNA M, and CNA N did not receive and have documented mandatory yearly QAPI in-service training. Evidenced by:The Facility Assessment, last reviewed 1/2026, states in part:. Staff Training/Education and Competencies/Recruitment/Retention: 3.4 Staff will be provided with training and education to assure competent care is provided to residents in the facility. Training/education will be provided upon hire with the orientation process, routinely on a yearly basis and as needed if issues arise. The following training topics will be included in this process (this is not an all-inclusive list):*Communication.*Resident Rights.*Abuse.*Infection Control.*Culture Change.The following competencies be reviewed (this is not an all-inclusive list):*Person-centered care.*Activities of Daily Living.*Disaster.*Infection Control.*Caring for persons with Alzheimer's or another Dementia.Surveyor noted that QAPI training was not included in the topics in the training plan.On 7/02/26 at 1:00PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked how many in-service/education hours are required yearly for CNAs. NHA A indicated 12 hours. Surveyor reviewed the Nurse Aide In-Service Records for CNA J, CNA K, CNA L, CNA M, and CNA N with NHA A. Surveyor asked NHA A if CNA yearly in-service/education should include QAPI. NHA A indicated yes. NHA A indicated the facility does not provide QAPI training directly titled QAPI but presents interventions and actions put in place for issues identified.

Based on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. This has the potential to affect the census (76).The facility staff line lists do not monitor specific symptoms.The facility staff line lists do not record dates of last symptoms or return to work dates.Evidenced by:The facility policy, entitled Infection Control Policy, dated 6/2025, states, in part: . Policy: It is the policy of Maplewood of Sauk Prairie to ensure the Infection Control Program is designed to provide a safe, sanitary, and comfortable environment that helps prevent the development and transmission of disease and infection.The Infection Control Program will:Investigate, control, and prevent, to the extent possible, infections in the facility.Surveillance: .Outcome surveillance will be used to identify and report evidence of an infection.c. If a pattern or grouping of infections is questionable for an outbreak situation is occurring, the charge nurse will follow the appropriate policy (i.e. possible GI outbreak, the gastroenteritis policy will be followed) and will notify the infection control nurse as soon as able. Both staff and resident illness is kept up to date on white boards in charge office, so potential outbreaks can be identified. Surveillance of employee health status.b. Employee call ins are monitored. The reason for call ins are tracked to determine possible outbreaks or possible exposure to residents. The facility policy entitled Gastroenteritis (Norovirus) Policy, dated6/2025, states, in part: . Policy Explanation and Compliance Guidelines:All staff is to monitor for signs and symptoms and take appropriate actions to prevent the spread of illness and complications from the illness. Signs and symptoms include:Sudden onset of vomiting and diarrhea. 5. Management of Staff: . b. Management of ill staff:i. Staff illness is monitored by DON (Director of Nursing). All call ins are recorded on a log.ii. Any staff suspected of having viral gastroenteritis should be excluded from resident care and/or food service duties at the onset of symptoms including nausea, vomiting, abdominal pain, and/or diarrhea. These exclusions shall remain in affect until the employee is asymptomatic and free of symptoms for 48 hours. The facility provided staff surveillance line lists for November 2025, December 2025, and January of 2026. The line lists include: Staff Name, Date of First Symptom, Date of Call In, Symptoms, Did They go to the Doctor, Treatment prescribed, Tests Done, and Date Infection Resolved/Work return date. The line lists are incomplete.Of Note there is no recording of the date of last symptom to determine return to work dates. The staff surveillance line list for November 2025 shows there were 7 call ins.Three call ins listed nausea/vomiting for symptoms: The first one dated 11/2/25. One call in lists nausea, vomiting and diarrhea as symptoms.Two call ins list diarrhea as symptoms. There are no dates of last symptom listed. There are no return-to-work dates listed. The list will state as example, off or off 11/3/25. The month of December 2025 shows there were 26 call ins.Three of the call ins listed nonspecific symptoms: sick, respiratory, and metabolic disorder. These are not specific symptoms to track.Seventeen do not list return to work dates. Eight show return to work dates without a date of last symptom to be able to determine when return to work dates would be. There is no evidence to show that the facility knew if staff were returning to work at the appropriate times. The month of January 2026 shows there were 23 call ins.Seventeen call ins list Return with improved signs and symptoms. Four call ins list Back after 48 hours after last symptom.There are no dates of last symptoms listed to determine their return-to-work dates.Two call ins list Return when feeling better.Five call ins list sick as their symptom. On 2/11/26 at 1:04 PM, Surveyor interviewed DON B (Director of Nursing) and asked what standard of practice the facility follows for infection control. DON B indicated CDC (Centers for Disease Control). Surveyor reviewed the staff surveillance list with DON B and asked DON B how return to work dates are determined for gastroenteritis symptoms. DON B indicated 48 hours after last symptom. Surveyor asked if the date of the last symptom should be on the surveillance lists. DON B indicated yes, to determine the return-to-work dates. Surveyor asked DON B if the return-to-work dates are on the staff surveillance list, and DON B indicated no. Surveyor asked DON B, do we know if staff returned to work at the appropriate time looking at the staff surveillance lists. DON B indicated no. Surveyor asked if DON B would expect specific symptoms to be tracked and monitored on the surveillance lists. DON B indicated yes, she would expect specific symptoms to be documented on the surveillance lists. Surveyor asked if sick was a specific symptom, and DON B indicated no. Surveyor asked if respiratory symptoms or metabolic symptoms are specific symptoms. DON B indicated no. DON B indicated she has just recently taken over the infection control program just weeks ago, and she has a lot of changes to make.

Based on observation, interview, and record review, the facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This has the potential to affect 1 of 2 residents (R49) reviewed for activities. Per Surveyor interview with R49 and staff, R49 could not leave her room for activities due to her roommate being on isolation for gastroenteritis symptoms. R49 was not offered any activities in her room during this time. R49 participated in activities regularly prior. Evidenced by: The facility policy entitled Activities Policy, dated 6/2025, states, in part: . It is the policy of Maplewood of Sauk Prairie to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. Policy Explanation and Compliance Guidelines: .2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Create opportunities for each resident to have a meaningful life. e. Promote or enhance emotional health.f. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence.i. Reflect choices of the residents. 4. Activities may be conducted in different ways: a. One-to-One Programs.b. Person Appropriate- activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for.c. Program of Activities- to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend.12. Activities can occur at any time and are not limited to formal activities provided by the activities staff and can include other facility staff members, volunteers, residents, and family members. R49 admitted to the facility on [DATE] and has diagnoses that include cerebrovascular disease (comprises various conditions that disrupt blood flow to the brain-such as stroke, stenosis, and aneurysms) and aphasia (a communication disorder caused by brain damage, usually from a stroke or tumor affecting language expression, comprehension, reading, and writing, though not intelligence).R49's Quarterly Minimum Data Set (MDS) Assessment, dated 12/12/25, shows that R49 has a BIMS (Brief Interview of Mental Health) score of 12 indicating R49 has moderate cognitive impairment. R49's Care Plan, dated 12/03/25, states, in part: . I have been enjoying attending more and new activitiesBecause I: am getting to know more people (aphasia following a CVA (cerebrovascular accident) in 2012,I show this by: accepting invitations to more activities.I need my aides to: ask me about my day, talk with me about current events.I need Social Services to: encourage my family to get involved in my care, help me feel as if I have a sense of control over my care, help me realize my strengths.I need Activity staff to: know that I like games (dice and cards), Protestant church, music programs, outdoor visits, pet visits, and 1:1 interaction.My Goal is to: spend time doing things I enjoy.Goal Time: three months 3/2/26.Evaluation: I met my goal- continue goal. R49's Guideline for Daily Care, dated 2/11/26, states, in part: . Activities: I need my aides to: ask me about my day, talk with me about current events. I need Activity staff to: know that I like games (dice and cards), Protestant church, music programs, outdoor visits, pet visits, and 1:1 interaction. R49's Activity Attendance Log for the last 3 months shows R49 participated in activities: -Month of December 2025- 10 times.-Month of January 2026- 22 times.-Month of February (2/2/26- 2/9/26) 7 times. The last time 2/9/26- two days before R49 could not leave her room due to her roommate being on isolation for gastroenteritis symptoms. On 2/10/26, at 1:31PM, Surveyor interviewed R49. R49 was able to answer Surveyor's questions by nodding her head yes or no and by gestures. Surveyor asked R49 if the facility offers activities she enjoys. R49 nodded her head yes. Surveyor asked R49 if she attends activities daily. R49 nodded no and pointed to roommate. Surveyor asked R49 if she can leave her room. R49 nodded no. Surveyor asked R49 if she would typically go to activities before when she was able to leave her room. R49 nodded yes. Surveyor asked R49 if it is difficult for her not being able to leave her room for activities. R49 nodded her head yes. Surveyor asked R49 if she misses being able to go to activities. R49 nodded head yes. Surveyor asked R49 if staff or the activity staff bring activities into her room for her. R49 nodded head no. Surveyor asked what R49 does during the day. R49 pointed at the television. Surveyor asked R49 if the staff explained to her why she could not leave her room. R49 nodded her head yes. Surveyor asked R49 if the staff asked her if she was ok with not being able to leave her room. R49 nodded no.On 2/11/26 at 11:27 AM, Surveyor interviewed CNA D (certified nursing assistant) and asked if R49 can leave her room to attend activities. CNA D indicated no due to R49's roommate being sick. Surveyor asked CNA D if R49 is sick. CNA D indicated no, but staff put a mask on due to R49's roommate being sick. Surveyor asked CNA D if R49 is isolated to her room, and CNA D indicated yes since Monday. Surveyor asked CNA D if R49 typically would go to activities. CNA D indicated yes. On 2/11/26 at 11:37 AM, Surveyor interviewed RN F (registered nurse) and asked if R49 is on precautions. RN F indicated no, R49's roommate is. Surveyor asked RN F if R49 can leave her room to attend activities. RN F indicated the staff keep R49 in her room due to her roommate being sick. Surveyor asked RN F if R49 is sick also. RN F indicated no. Surveyor asked RN F if R49 would typically attend activities, and RN F indicated yes. RN F indicated it was explained to R49 why she could not leave her room. Surveyor asked RN F if R49 gets out of bed. RN F indicated not being 100 % sure. RN F indicated when she has passed by her room lately R49 is in bed. Surveyor asked RN F if R49 is typically in bed during the day. RN F indicated R49 would typically be in her wheelchair tootling around on her own. On 2/11/26 at 12:10 PM, Surveyor interviewed AD E (Activity Director) and asked if R49 attends activities regularly. AD E indicated yes, R49 attends most activities. Surveyor asked AD E what kinds of activities R49 likes. AD E indicated R49 likes dice, cards, music, and anything we do in activities. Surveyor asked AD E if R49 has been able to attend activities recently, and AD E indicated no due to her roommate being isolated. Surveyor asked AD E if she has offered activities for R49 in her room while she has not been able to attend activities. AD E indicated no. AD E indicated there is an activity cart the nursing staff can offer, it has coloring items and puzzles on it. Surveyor asked AD E if R49 likes those types of activities and would benefit from them. AD E indicated no R49 does not like coloring or puzzles. R49 would not benefit or enjoy coloring or puzzles. On 2/11/26 at 2:03 PM, Surveyor interviewed DON B (Director of Activities) and asked if R49 is on precautions. DON B indicated no. Surveyor asked DON B if R49 is isolated to her room. DON B indicated R49 should not be isolated to her room. Surveyor informed DON B that R49 and staff have told Surveyor that R49 can not leave her room due to her roommate being sick and on isolation. DON B indicated R49 can leave her room. DON B indicated she will talk to staff because there may be some confusion. Surveyor informed DON B that staff has indicated R49 has been isolated to her room and not able to attend activities since Monday. Surveyor asked DON B if R49 would typically go to activities. DON B indicated yes. Surveyor informed DON B that Surveyor has a concern regarding R49 being isolated to room and not able to attend activities.

Based on interview and record review the facility did not establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 Supplemental Resident (R98) and 1 of 1 sampled resident (R4). R4 and R98 were treated with antibiotics without meeting McGeers Criteria. The facility did not have an antibiotic stewardship conversation with R4 and R98's Provider. Evidenced by:The facility's policy entitled Antibiotic Stewardship Program Policy, dated 7/2025, states, in part: . Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.Policy Explanation and Compliance Guidelines: .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: . ii. Laboratory testing shall be in accordance with current standards of practice.iii. The facility uses the (CDC's NHSN (National Healthcare Safety Network) Surveillance Definitions, updated McGeer criteria) . b. Monitoring antibiotic use:i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made.iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. Example 1:R4 is on the January 2026 line list for UTI (urinary tract infection). R4's listed symptoms are increased agitation, hallucinations and combativeness. Treatment prescribed was sulfamethoxazole trimethoprim 800-160 mg (milligrams) twice a day. Per McGeer criteria for UTI without indwelling catheter: . Must fulfill both 1 and 2.At least one of the following sign or symptom:*Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate*Fever or leukocytosis, and > 1 of the following: -Acute costovertebral angle pain or tenderness -Suprapubic pain -Gross hematuria -New or marked increase in incontinence -New or marked increase in urgency -New or marked increase in frequency*If no fever or leukocytosis, then > 2 of the following: - Suprapubic pain -Gross hematuria -New or marked increase in incontinence -New or marked increase in urgency -New or marked increase in frequency 2. At least one of the following microbiologic criteria:->100,000 cfu (colony forming unit)/ mL (milliliter) of no more than 2 species of organisms in a voided urine sample- >100 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter. R4's urine culture, dated 1/30/26, shows bacteria, Escherichia coli >100,000 CFU/mL. On 2/11/26 at 1:04 PM, Surveyor interviewed DON B (Director of Nursing) and asked what standard of practice the facility uses for antibiotic stewardship. DON B indicated McGeers and CDC (Centers for Disease Control). Surveyor asked DON B how the facility determines if an infection meets the criteria for the standard of practice. DON B indicated by following the McGeers chart and reviewing documentation, such as lab results. Surveyor asked DON B by following McGeers criteria did R4 meet that criteria to treat the uti with an antibiotic. DON B indicated by following McGeers no, R4 should not have been treated with an antibiotic. DON B indicated in these cases the facility would typically talk with the provider about treating an infection without meeting criteria. Surveyor asked if there was documentation to show there was a conversation with a provider. DON B indicated she is unable to see any documentation in R4's medical record. Surveyor asked DON B if she would expect documentation to be in R4's chart, DON B indicated yes. Example 2:R98 is on the November 2025 line list for UTI. R98's listed symptoms are frequency, decreased urine output, hematuria, and temperature of 99.3 Fahrenheit. Treatment prescribed was Macrobid 100 mg (milligrams) twice a day for 5 days.R98's urine culture dated, 11/16/2025, shows Escherichia coli 50,000 - 60,000 cfu/mL. Per McGeer criteria for UTI without indwelling catheter: . Must fulfill both 1 and 2.At least one of the following sign or symptom:*Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate*Fever or leukocytosis, and > 1 of the following: -Acute costovertebral angle pain or tenderness -Suprapubic pain -Gross hematuria -New or marked increase in incontinence -New or marked increase in urgency -New or marked increase in frequency*If no fever or leukocytosis, then > 2 of the following: - Suprapubic pain -Gross hematuria -New or marked increase in incontinence -New or marked increase in urgency -New or marked increase in frequency 2. At least one of the following microbiologic criteria:->100,000 cfu (colony forming unit)/ mL (milliliter) of no more than 2 species of organisms in a voided urine sample- >100 cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter. On 2/11/26 at 1:04 PM, Surveyor interviewed DON B (Director of Nursing) and asked what standard of practice the facility uses for antibiotic stewardship. DON B indicated McGeers and CDC (Centers for Disease Control). Surveyor asked DON B how the facility determines if an infection meets the criteria for the standard of practice. DON B indicated by following the McGeers chart and reviewing documentation, such as lab results. Surveyor asked DON B if R98 met McGeers criteria with Escherichia coli 50,000 - 60,000 cfu/mL. DON B indicated the Escherichia coli should be greater than 100,000 to treat. DON B indicated the facility would typically talk with the provider about treating an infection without meeting criteria. Surveyor asked if there was documentation to show there was a conversation with a provider. DON B indicated she is unable to see any documentation in R98's medical record. Surveyor asked DON B if she would expect residents to meet criteria before treating them with antibiotics. DON B indicated yes.

Based on interview and record review, the facility did not ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for 1 of 5 residents (R29) reviewed for immunizations.R29 was not offered the pneumococcal vaccine. The facility does not have a declination or consent for the pneumococcal vaccine for R29.Evidenced by:The facility policy, titled Immunization/Vaccination Policy, dated 6/2025, states, in part: . Policy: It is the policy of Maplewood to minimize the risk of acquiring, transmitting or experiencing complications from infectious disease by offering our residents, staff members, and volunteer workers immunization/vaccination against such diseases.Policy Explanation and Compliance Guidelines: .2. Immunizations will follow current CDC (Center of Disease Control) guidance and scheduling based on the specific vaccinations.3. Residents, staff, and volunteer workers will be offered immunizations against infectious diseases as per current federal, state and local guidance.4. Residents, staff, and volunteer workers will be screened prior to receiving any immunization.8. Staff, volunteer workers, residents or resident representatives will be required to sign a consent form prior to administration of the vaccine(s). The completed, signed, and dated record will be filed in the individual's medical record, or the staff or volunteer's medical file.10. The resident's medical record or staff/volunteer's medical file will include documentation that the staff, volunteer, resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization(s), and that the resident received or did not receive the immunization(s) due to medical contraindication or refusal. R29 admitted to the facility on [DATE].R29 had Pneumovax Vaccines documented as follows: Pneumovax 23 on 10/20/1993. Prevnar 13 on 8/11/15. Pneumovax 23 on 12/12/16.R29 was not offered the PCV 20 or the PCV21 5 years after the last pneumococcal vaccination per CDC recommendations. There is no documentation that R29 was offered the next pneumococcal vaccine. Per Pneumo Recs Vax Advisor, the recommendation for R29's age group is to give 1 dose of PCV20 or PCV21 at least 5 years after last dose of PPSV23.R26 did not receive PCV20 or PCV21 therefore Pneumococcal vaccinations are not complete.On 2/11/26 at 1:04 PM, Surveyor interviewed DON B (Director of Nursing) and asked if pneumococcal vaccines were offered to R29. DON B could not provide documentation to show pneumococcal vaccines were offered to R29. Surveyor reviewed the Pneumo Recs Vax recommendation and DON B agreed the PCV20 or the PCV21 should have been offered to R29.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 1 abuse allegations involving a resident (R1).On 11/6/25, an allegation of sexual abuse toward R1 from a staff member was reported to the facility and the facility did not report the allegation of abuse to the State Agency.The facility's abuse policy states, in part:*An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.*The facility will have written procedures that include: reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a.) Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b.) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.* The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: increased supervision, room or staffing changes, and protection from retaliation. R1 was admitted to the facility on [DATE]. She discharged from the facility on 10/14/25. On 11/6/25, the facility received an allegation of sexual abuse from an outside agency providing care to R1. R1 alleged that a CNA (Certified Nursing Assistant), described as bald, brown-skinned man with a black beard was assisted [sic] her after dinner one evening. R1 stated she was naked in the tub and the male nurse was washing only her breasts. R1 stated the CNA did not touch any other area of her body, only her breasts, then left the room. On 11/13/25 at 1:08 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing). DON B stated that because the allegation came in nearly a month after R1 discharged from the facility, had only one bath with a male CNA on 9/23/25 and no person perfectly fit the description of the alleged perpetrator, she and NHA A did not feel they could do anything about it. NHA A stated that, in hindsight, the facility should have reported the incident to the State Agency.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are thoroughly investigated for 1 of 3 residents (R1) reviewed for abuse. On 11/6/25, an allegation of sexual abuse toward R1 from a staff member was reported to the facility and the facility did not investigate the allegation. The facility's abuse policy states, in part:*An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.*The facility will have written procedures that include: reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a.) Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b.) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.* The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: increased supervision, room or staffing changes, and protection from retaliation. R1 was admitted to the facility on [DATE]. R1 discharged from the facility on 10/14/25. On 11/6/25, the facility received an allegation of sexual abuse from an outside agency providing care to R1. R1 alleged that a CNA (Certified Nursing Assistant), described as bald, brown-skinned man with a black beard was assisted [sic] her after dinner one evening. R1 stated she was naked in the tub and the male nurse was washing only her breasts. R1 stated the CNA did not touch any other area of her body, only her breasts, then left the room. On 11/13/25 at 1:08 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing). DON B stated that because the allegation came in nearly a month after R1 discharged from the facility, had only one bath with a male CNA on 9/23/25 and no person perfectly fit the description of the alleged perpetrator, she and NHA A did not feel they could do anything about it. DON B and NHA A indicated that they did not investigate the allegation. They indicate they did not gather interviews of residents or staff to determine who the alleged perpetrator could have been. DON B and NHA A indicated they did not interview or assess other residents to ensure other residents' safety. NHA A stated that, in hindsight, the facility should have reported the incident to the State Agency and questioned staff and residents.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are thoroughly investigated for 3 of 3 residents reviewed for abuse (R4, R5, and R6). R4 filed a grievance regarding R5 verbally abusing R4. Staff observed R5 throw a cup of soup across the room and swear. Then staff observed R4, who was in the room at the time to be in an upset state. The facility did not conduct a thorough investigation including interviewing other residents who may have knowledge of R5's behavior or the incident. R6 voiced an allegation of a male coming into her room and attacking her, pulling off her stockings and pants without notice, and leaving her to feel violated. The facility failed to conduct a thorough investigation including interviewing all staff who worked with R6 recently or other residents who may have knowledge of the alleged incident. Findings include: The facility's policy, titled Abuse Prevention and Investigation Policy and Procedure, reviewed 7/2024, includes: . The facility will not tolerate abuse, neglect, or misappropriation of resident's property. All allegations of abuse, neglect, or misappropriation and any injury of which the source cannot be identified will be investigated. The result of the investigation will be reported as required by state and federal laws and this policy and procedure . Verbal abuse: refers to any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Sexual abuse: is nonconsensual sexual contact of any type with a resident. This includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Physical abuse- includes hitting, slapping, pinching, kicking . it also includes controlling behavior through corporal punishment . upon a complaint or observation of suspected resident abuse the following steps will be taken . a resident or family member may report an allegation of misconduct to any employee. Upon receiving an allegation the employee will immediately take the necessary steps to protect the resident As per state regulations the notification of necessary authorities will take place in appropriate time frames . notification will be made too the office of caregiver quality immediately via the completion of the online form . law enforcement agency will be notified if there is any reasonable suspicion of a crime . Time frames for reporting: any incident/allegation involving abuse or serious bodily injury will be reported to both state agency and law enforcement within two hours of knowledge of the incident/allegation. Any other allegation or incident will be reported within 24 hours. The employee whom received the allegation or was a witness to a reportable incident will compose a written statement detailing the alleged incident as reported by the resident or as witnessed. The resident with the complaint will be interviewed and a written statement will be composed. The employee or employees involved will be interviewed with such interview being documented. A written response to the allegations will be requested from the accused employee. Any other persons who may have additional information will be interviewed as well with written statements obtained if able. Investigation is to be done within 5 working days of the incident . it is important to note that abuse can occur by staff, family members, friends, visitors, other care providers, or buy another resident. Any abuse from any source will be handled in the same manner . Example 1 R5 admitted to the facility on [DATE]. Her diagnoses include: major depressive disorder, hypertension (high blood pressure), atrial fibrillation (irregular and rapid heart beat), and asthma. R4 admitted to the facility on [DATE]. Her diagnoses include: hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (stroke), aphasia (language disorder) following cerebral infarction, and anxiety disorder. Grievance, dated 1/24/25, includes: Complaint made by R4 . Nature of complaint: repeated rude, negative, verbally abusive language from roommate, roommate repeatedly calling R4 names, roommate throwing items at R4/throwing items towards R4's side of the room, prohibiting her right to watch/listen to TV. Investigation/Findings: Social Services has brought to attention of DON B (Director of Nursing) and NHA A (Nursing Home Administrator), instructed wing staff/nurses to document any inappropriate behavior/language from roommate, instructed to document changes in R4's mood due to roommate's behavior. Documentation has been collected, wing staff sharing ongoing concern. Corrective Action Taken: Administration/Leadership looking at options to separate the 2 ladies as soon as able. Currently no other room available. Staff to intervene immediately, ensure R4's safety, encourage out of room activities. Nurse Notes, dated 1/24/25, include: Wing nurse requested writer to intervene as R5 upset, swearing, throwing items in room, verbally aggressive towards staff and roommate. Writer did observe R5 throw a cup with tomato soup in it across the room causing it to spill. Writer counseled R5 for half hour, discussing her behavior. R5 was pleasant and calm with writer . R5 shared she threw her cup as she had a chunk in the straw of the tomato soup and was not able to drink it Writer overheard R5 talking to herself in her room, seeming upset. Writer visited with R5 who seemed very confused, concern that no one else was home, where did her family go, she could not find them. R5 also upset sharing she was the only one who did all the work in the house, but she felt bad as she was not able to do the work/chores because her legs no longer worked. R5 crying, upset, began to hit the wall, sharing she was so upset she just wanted to smash everything in sight . [NAME] called to R fours room as nurse stating R4 was upset, crying, due to roommate calling R4 inappropriate names, throwing items across the room . writer did visit with R4 to offer support/reassurance. Informed R4 the interdisciplinary team was looking at plans to rectify the situation. R4 pointing to roommate shaking head stating no no no. Writer asked our four if she wished to file a grievance on her roommate due to her behavior towards her and our four shook her head and stated yes. Writer clarified what R4 wished to have in the grievance. As writer leaving for day, writer passing by R4's room, observed her roommate throw a cup of soup across the room, swearing. R4 once again upset. Once again writer intervened offering support/reassurance. On 2/17/25 at 11:36 AM, DON B (Director of Nursing) and Surveyor reviewed Grievance, dated 1/24/25. DON B indicated this grievance contains an allegation of abuse, both verbal abuse and mental abuse. DON B indicated staff witnessed R5 throwing items and swearing and R4 in an upset state, but the facility did not follow the facility's abuse policy. DON B indicated throwing items, swearing, name calling, being rude, being negative, and using verbally abusive language could be intimidating and is an allegation of abuse that should have been investigated thoroughly. DON B indicated the two residents were separated when a room became available. DON B indicated no other residents were interviewed and only one staff member was interviewed. On 2/17/25 at 1:00 PM NHA A (Nursing Home Administrator) and Surveyor reviewed Grievance, dated 1/24/25. NHA A indicated throwing items, swearing, and verbally aggressive behavior are all allegations of abuse and could be intimidating. NHA A indicated the words verbally abusive were recorded and this is an allegation of abuse that should have been reported to the state agency within 2 hours of the facility becoming aware. NHA A indicated no other residents were interviewed regarding this exchange and only the staff who witnessed the event were interviewed. NHA A indicated residents were eventually separated when a room became available. Example 2 R6 admitted to the facility on [DATE] with the following diagnoses: mild cognitive impairment, chronic pain, major depressive disorder, and sleep disorder. Facility investigation, dated 12/12/24, includes: Staff statement: R6 walked down (hall) around 3:05 AM looking for (named Manager). I told her (named Manager) was not here as it was 3:00 AM, but if she needed something (named Nurse) was down (another hall). R6 stated that she was attacked last night by a tall man named (insert male name). R6 thought he was from the therapy department. I stated I did not know a (insert male name) but she wanted to speak to the nurse on the other hall . I walked her towards (other hall) and she said she had it from there . Staff statement: Around 3:15AM Writer saw R6 standing in hallway by dining area . Writer went to assist with R6 stating that she had woke up crying at 3:00 AM remembering that someone had violated her at 9:50 PM. She stated she remembers the time because she was watching a tv show. She went on to tell writer she doesn't feel safe. Writer assisted her back to her room and questioned her more. She stated again around 9:50 PM a big guy, tall with white hair came in and pulled her stocking off and then pulled her pants down to look at her bottom. She stated he didn't explain anything . I questioned if it could have been the skin check we do and she stated if it was they explained nothing. Also questioned if possibly a dream since writer had been in 2 other times this night and she made no mention . She stated it was not a dream and she felt violated . stated was afraid we would try to cover this up. Told her we took this serious . DON B . voicemail . NHA A updated . told R6 this was going to be looked into and NHA was aware . Staff statement: I talked with resident. She was good with assessment at time . I gave her trazadone about 8:00 PM to 9:00PM . Resident statements: 7:12 AM . they ripped my ted hose off. Physical therapy was rough and ripped my ted hose . I felt violated .I was dreaming, it was a bad dream . I don't know who he was, then Physical Therapy rushed in here and scared me at 9:50 PM . He woke me up from sleeping and took all my clothes off . On 2/17/25 at 11:36 AM, DON B (Director of Nursing) indicated R6 had come to the facility for rehab. She had come out into the hallway and was scared. She told staff a therapy man, a big guy came in and ripped her stockings and pants off to check her skin. DON B indicated this could be an allegation of sexual misconduct, citing the definition of sexual abuse as nonconsensual sexual contact of any kind. DON B indicated an investigation was completed but it did not include other residents who may have been in earshot or eyeshot of the incident. On 2/17/25 at 1:00 PM, during an interview, NHA A indicated a resident stating that they had been attacked, been violated, not feeling safe, and had a man come in and pulled her pants down to look at her bottom could be an allegation of sexual misconduct and this should have been investigated thoroughly. NHA A indicated this incident was investigated but the investigation did not include interviews of other residents who may have been in earshot or eyeshot of the incident. The facility did not thoroughly investigate these allegation of abuse.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the State Survey Agency for 3 of 3 residents reviewed for abuse (R4, R5, and R6). R4 filed a grievance regarding R5 verbally abusing R4. Staff observed R5 throw a cup of soup across the room and swear. Then staff observed R4, who was in the room at the time to be in an upset state. The facility did not report the resident to resident allegation/verbal abuse to the state agency. R6 voiced an allegation of a male coming in her room and attacking her, pulling off her stockings and pants without notice, and leaving her to feel violated. The facility failed to report this allegation of abuse to the state agency. Findings include: The facility's policy, titled Abuse Prevention and Investigation Policy and Procedure, reviewed 7/2024, includes: . The facility will not tolerate abuse, neglect, or misappropriation of resident's property. All allegations of abuse, neglect, or misappropriation and any injury of which the source cannot be identified will be investigated. The result of the investigation will be reported as required by state and federal laws and this policy and procedure . Verbal abuse: refers to any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Sexual abuse: is nonconsensual sexual contact of any type with a resident. This includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Physical abuse- includes hitting, slapping, pinching, kicking . it also includes controlling behavior through corporal punishment . upon a complaint or observation of suspected resident abuse the following steps will be taken . a resident or family member may report an allegation of misconduct to any employee. Upon receiving an allegation the employee will immediately take the necessary steps to protect the resident As per state regulations the notification of necessary authorities will take place in appropriate time frames . notification will be made too the office of caregiver quality immediately via the completion of the online form . law enforcement agency will be notified if there is any reasonable suspicion of a crime . Time frames for reporting: any incident/allegation involving abuse or serious bodily injury will be reported to both state agency and law enforcement within two hours of knowledge of the incident/allegation. Any other allegation or incident will be reported within 24 hours. The employee whom received the allegation or was a witness to a reportable incident will compose a written statement detailing the alleged incident as reported by the resident or as witnessed. The resident with the complaint will be interviewed and a written statement will be composed. The employee or employees involved will be interviewed with such interview being documented. A written response to the allegations will be requested from the accused employee. Any other persons who may have additional information will be interviewed as well with written statements obtained if able. Investigation is to be done within 5 working days of the incident . it is important to note that abuse can occur by staff, family members, friends, visitors, other care providers, or buy another resident. Any abuse from any source will be handled in the same manner . Example 1 R5 admitted to the facility on [DATE]. Her diagnoses include: major depressive disorder, hypertension (high blood pressure), atrial fibrillation (irregular and rapid heart beat), and asthma. R4 admitted to the facility on [DATE]. Her diagnoses include: hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (stroke), aphasia (language disorder) following cerebral infarction, and anxiety disorder. Grievance, dated 1/24/25, includes: Complaint made by R4 . Nature of complaint: repeated rude, negative, verbally abusive language from roommate, roommate repeatedly calling R4 names, roommate throwing items at R4/throwing items towards R4's side of the room, prohibiting her right to watch/listen to TV. Investigation/Findings: Social Services has brought to attention of DON B (Director of Nursing) and NHA A (Nursing Home Administrator), instructed wing staff/nurses to document any inappropriate behavior/language from roommate, instructed to document changes in R4's mood due to roommate's behavior. Documentation has been collected, wing staff sharing ongoing concern. Corrective Action Taken: Administration/Leadership looking at options to separate the 2 ladies as soon as able. Currently no other room available. Staff to intervene immediately, ensure R4's safety, encourage out of room activities. Nurse Notes, dated 1/24/25, include: Wing nurse requested writer to intervene as R5 upset, swearing, throwing items in room, verbally aggressive towards staff and roommate. Writer did observe R5 throw a cup with tomato soup in it across the room causing it to spill. Writer counseled R5 for half hour, discussing her behavior. R5 was pleasant and calm with writer . R5 shared she threw her cup as she had a chunk in the straw of the tomato soup and was not able to drink it Writer overheard R5 talking to herself in her room, seeming upset. Writer visited with R5 who seemed very confused, concern that no one else was home, where did her family go, she could not find them. R5 also upset sharing she was the only one who did all the work in the house, but she felt bad as she was not able to do the work/chores because her legs no longer worked. R5 crying, upset, began to hit the wall, sharing she was so upset she just wanted to smash everything in sight . called to R4's room as nurse stating R4 was upset, crying, due to roommate calling R4 inappropriate names, throwing items across the room . writer did visit with R4 to offer support/reassurance. Informed R4 the interdisciplinary team was looking at plans to rectify the situation. R4 pointing to roommate shaking head stating no no no. Writer asked R4 if she wished to file a grievance on her roommate due to her behavior towards her and R4 shook her head and stated yes. Writer clarified what R4 wished to have in the grievance. As writer leaving for day, writer passing by R4's room, observed her roommate throw a cup of soup across the room, swearing. R4 once again upset. Once again writer intervened offering support/reassurance. On 2/17/25 at 11:36 AM DON B (Director of Nursing) and Surveyor reviewed Grievance, dated 1/24/25. DON B indicated this grievance contains an allegation of abuse, both verbal abuse and mental abuse. DON B indicated staff witnessed R5 throwing items and swearing and R4 in an upset state, but the facility did not follow the facility's abuse policy. DON B indicated throwing items, swearing, name calling, being rude, being negative, and using verbally abusive language could be intimidating and is an allegation of abuse that should have been reported to the state agency within 2 hours of the facility becoming aware. On 2/17/25 at 1:00 PM NHA A (Nursing Home Administrator) and Surveyor reviewed Grievance, dated 1/24/25. NHA A indicated throwing items, swearing, and verbally aggressive behavior are all allegations of abuse and could be intimidating. NHA A indicated the words verbally abusive were recorded and this is an allegation of abuse that should have been reported to the state agency within 2 hours of the facility becoming aware. Example 2 R6 admitted to the facility on [DATE] with the following diagnoses: mild cognitive impairment, chronic pain, major depressive disorder, and sleep disorder. Facility investigation, dated 12/12/24, includes: Staff statement: R6 walked down (hall) around 3:05 AM looking for (named Manager). I told her (named Manager) was not here as it was 3:00 AM, but if she needed something (named Nurse) was down (another hall). R6 stated that she was attacked last night by a tall man named (insert male name). R6 thought he was from the therapy department. I stated I did not know a (insert male name) but she wanted to speak to the nurse on the other hall . I walked her towards (other hall) and she said she had it from there . Staff statement: Around 3:15 AM Writer saw R6 standing in hallway by dining area . Writer went to assist with R6 stating that she had woke up crying at 3:00 AM remembering that someone had violated her at 9:50 PM. She stated she remembers the time because she was watching a tv show. She went on to tell writer she doesn't feel safe. Writer assisted her back to her room and questioned her more. She stated again around 9:50 PM a big guy, tall with white hair came in and pulled her stocking off and then pulled her pants down to look at her bottom. She stated he didn't explain anything . I questioned if it could have been the skin check we do and she stated if it was they explained nothing. Also questioned if possibly a dream since writer had been in 2 other times this night and she made no mention . She stated it was not a dream and she felt violated . stated was afraid we would try to cover this up. Told her we took this serious . DON B . voicemail . NHA A updated . told R6 this was going to be looked into and NHA was aware . Staff statement: I talked with resident. She was good with assessment at time . I gave her trazadone about 8:00 PM to 9:00 PM . Resident statements: 7:12 AM . they ripped my ted hose off. Physical therapy was rough and ripped my ted hose . I felt violated .I was dreaming, it was a bad dream . I don't know who he was, then Physical Therapy rushed in here and scared me at 9:50 PM . He woke me up from sleeping and took all my clothes off . On 2/17/25 at 11:36 AM, DON B (Director of Nursing) indicated R6 had come to the facility for rehab. She had come out into the hallway and was scared. She told staff a therapy man, a big guy came in and ripped her stockings and pants off to check her skin. DON B indicated this could be an allegation of sexual misconduct, citing the definition of sexual abuse as nonconsensual sexual contact of any kind. DON B indicated she thought at the time of the incident that this should be reported to the state agency and maybe local law enforcement, because of the resident saying she felt violated. DON B indicated she called the previous NHA (Nursing Home Administrator) and was advised she did not need to file a self report so she didn't. On 2/17/25 at 1:00 PM, during an interview, NHA A (Nursing Home Administrator) indicated a resident stating that they had been attacked, been violated, not feeling safe, and had a man come in and pulled their pants down to look at their bottom could be an allegation of sexual misconduct and this should have been reported to the state agency within 2 hours of facility becoming aware of allegation. NHA A indicated the facility should have reported this to the local law enforcement also so they could decide if allegations warranted an investigation. NHA A indicated staff consulted with the previous NHA and he advised not to report voiced allegations to the state agency.

Based on observation, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly air-dried plates prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 31 of 31 residents who resided on 2 of 4 hallways out of a total census of 71. Findings include: Review of the facility's policy titled, Manual Ware Washing, dated 10/13/14, revealed, Purpose: To ensure dishes are properly cleaned and sanitized during manual ware washing. III. Procedure: .7. Allow dishes to air dry . Example 1 During an observation and interview on 9/23/24 at 9:40 AM of the kitchenette serving area located on the Oak hallway the Dietary Manager (DM) confirmed three plates were found to be wet. These plates had been placed in the cabinet for use. The DM stated, They were put away wet, they should have been left out to air dry longer. The Oak hallway had a census of 15. Example 2 During an observation and interview on 9/23/24 at 9:51 AM of the kitchenette serving area located on the Evergreen hallway the Dietary Manager (DM) confirmed four plates were found to be wet. These plates had been placed in the cabinet for use. The DM stated, They should have been left out to air dry longer. The Evergreen hallway had a census of 16.

Based on observation, interviews, and staffing document review, the facility failed to ensure daily posted staffing requirements were in place to include the census, number of staff, and number of staff hours for 71 of 71 residents residing at the facility. This failure had the potential to affect the ability of residents and families to view the staffing information daily. Findings include: During an observation and interview on 9/24/24 at 3:46 PM, there was a book located at the nursing station that contained a staffing assignment sheet. The assignment sheet listed the name of the facility, the names of the staff, and the current date. The Director of Nursing (DON) stated this assignment sheet, located in the book was their posted staffing sheet. She stated she kept a tally of hours in her office but the sheet in the book was used as a live staffing assignment listing. The sheet contained the names of the staff working in the halls. She confirmed the sheets lacked the census, number of Certified Nurse Aides (CNAs), number of Licensed Practical Nurses (LPNs), number of Registered Nurses (RNs), and the number of working hours. During an interview on 9/25/24 at 9:24 AM, the DON stated they did not have a policy for the posted nurse staffing. During an interview on 9/25/24 at 11:52 AM, the Administrator confirmed they did not have a policy. He stated they had created a new sheet to include the required components and would post it in a more visible location.

Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 3 residents reviewed for grievances (R1). The facility's Social Worker (SW) documented that R1's spouse had concerns with Activities of Daily Living (ADLs), fluid intake, soiled bed linens, and staffing; these concerns were not documented as grievances, investigated as grievances, or had a resolution provided to R1's spouse. Evidenced by: The facility's policy titled Grievance Policy and Procedure no date, states in part .Grievances can include things such as concerns about care and treatment provided or not provided, behavior of staff or other residents and any concerns related to the resident's stay in the facility .3. To file a grievance, the resident and/ or resident representative shall contact the facility grievance officer(s). The grievance can be filed orally, in writing, or by completing a Grievance Report Form. a. [facility name] grievance officers with be either social service representative .7. Grievance record keeping a. All grievance decisions will be documented to include the date that the grievance or grievance form was received, a summary statement of the grievance and a copy of the grievance form, steps taken to investigate the grievance, a summary of pertinent findings or conclusions regarding the concern, if the grievance was confirmed or not confirmed, any corrective action taken as a result of the grievance, and the date the written decision was issued. Example 1 R1 was admitted to the facility on [DATE] with diagnoses that include traumatic brain injury, epilepsy, major depressive disorder, and hyponatremia. R1's most recent Minimum Data Set (MDS) dated [DATE] indicates that R1 is barely/ never understood and that R1 is dependent on staff for all ADLs, transfers, and positioning/ transportation. On 4/10/24 at 3:09 PM, SW C documented, in part, the following note: Late entry from 4/8/24. Meeting with [R1's spouse], ombudsman, IDT (Interdisciplinary Team) including writer, DON (Director of Nursing), LTCM (Long Term Care Manager). [R1's spouse] requested ombudsman be present as she did not have any family/ friends who could attend with her/ wished for a neutral party to be present sharing she feels ganged up at meetings .[R1's spouse] shared ongoing concerns about R1's fluid intake, sodium levels, not getting his teeth brushed, wet linens .Encouraged [R1's spouse] to communicate her concerns with DON or point person. [R1's spouse] continuing to share her dissatisfaction . On 4/10/24 at 3:16 PM, SW C documented, in part, the following note: .Later in afternoon writer and DON met with [R1's spouse] . [R1's spouse] shared that her only concern about R1 this day is not having consistent wing staff .noting her dissatisfaction with agency staff . On 5/24/24 at 3:24 PM, SW C documented, in part, the following note: Writer and DON met with [R1's spouse] this day per her request as she shared her upset and disbelief that R1 was not placed in bed until 10:00 PM last night .Writer offered reassurance noting wing staff are well aware of [R1's spouse] ongoing concerns, therefor are hypersensitive to R1's needs .[R1's spouse] also noting she has observed R1 to be 'soaked' when she arrives, also noting that he did not eat last night as he did not know who was feeding him. Writer once again reiterated the importance of R1 and new staff needing time to get to know each other, thus R1 does need to work with new staff in order to build that rapport. Writer also reassured writer continues to check on R1 and his room throughout the days during the week to ensure R1 is receiving cares, and his room is clean and orderly. [R1's spouse] noting writer not here on weekends to do such. On 6/20/24 at 1:00 PM, Surveyor interviewed SW C, who is also the facility's grievance officer. Surveyor asked SW C what the process was for grievances, SW C stated that she encourages residents and family member to come to her or another member of leadership with hopes that they can address their concerns before it rises to a grievance. Surveyor asked SW C if a concern would be considered a grievance, SW C stated that it depends on the level and that a grievance is a repeated act. SW C reported to Surveyor that she has offered R1's spouse to fill out a grievance form. Surveyor asked SW C if R1's spouse expresses a concern, is she required to fill out a grievance form in order for her concerns to be addressed and is it the resident and/ or family member's responsibility to follow the facility's grievance policy, SW C stated that she would have to check with the Administrator. Surveyor asked SW C what concerns has R1's spouse reported, SW C stated she had concerns with hydration, oral intake, if R1's bed is not made, if R1 is not in bed at a certain time, range of motion, and ADLs. Surveyor asked SW C if these concerns were written up as grievances, SW C stated no. Surveyor asked if R1's spouse was provided with a written resolution, SW C stated no. On 6/20/24 at 1:59 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her understanding of a grievance is, DON B stated that a grievance can be anything such as a concern or a lost item. Surveyor asked DON B if she would expect R1's spouse's concerns to be a grievance, DON B stated yes and no, yes but we don't write them down. She (R1's spouse) has repetitive concerns and brings up complaints from four years ago. It is important to know that SW C and DON B reported that the facility had zero grievances.

Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 resident (R3) observed during screening. R3 was observed to have her medications left at the bedside. This is evidenced by: The facility's policy titled Addendum: Self Administration of Medications, undated, states in part, . Policy: Prior to allowing a resident to administer medications without direct supervision by licensed nursing staff, the resident's ability to do so will be assessed and doctor's order will be obtained . 2. Physician will be updated with resident's desire to administer medications without direct staff supervision, following set up of the medications by nursing. If physician is in agreement with the assessment made by staff and is okay with the resident taking medications without direct supervision, an order shall be obtained . R3 was admitted to the facility on [DATE] with diagnoses that include acquired absence of right leg below knee, major depressive disorder (a severe and persistent low mood, profound sadness, or a sense of despair), type 2 diabetes mellitus with hyperglycemia (characterized by high levels of sugar in the blood), chronic diastolic congestive heart failure (the heart has trouble supplying the body's organs and tissues with oxygen-rich blood they need and the hallmarks are shortness of breath with exertion or when lying down; swelling in the legs, ankles, or abdomen, unexplained fatigue, or a bulging jugular vein), acute embolism (a condition that results from a blood clot) and thrombosis of deep veins of left upper extremity, end stage renal disease (a medical condition in which the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), dependence on renal dialysis, unspecified dementia, acute kidney failure, acute respiratory failure with hypoxia, hallucinations (an experience involving the apparent perception of something not present). R3's most recent Minimum Data Set (MDS) dated [DATE] states that R3 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R3 is cognitively intact. R3's medical record does not contain a Self-Administration Assessment. R3's current plan of care does not indicate that R3 is to self-administer any medications. R16's physician orders do not indicate a Self-Administration order. On 6/20/24 at 9:08 AM, Surveyor observed R3's morning medication on her bedside table in a medication cup. Surveyor asked R3 if that was her medication, she indicated that they it was and that they normally leave it there. R3 further indicated that she normally takes her medication after breakfast, and that breakfast was later today. Surveyor asked R3 how many medications were in the cup, she indicated she thought there were 14 medications. On 6/20/24 at 9:15 AM, Surveyor observed R3 being taken to the shower room by staff and the morning medication was left on R3's bedside table in the medication cup. On 6/20/24 at 9:21 AM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor walked with LPN D and obtained R3's medication cup with her medications and returned to the medication cart. Surveyor asked LPN D if R3 had a self-administration order, she indicated she did not see an order and she normally leaves her medication at R3's bedside. LPN D further indicated that she should have not left R3's medications at her bedside. Surveyor and LPN D verified each medication consisting of Sentry senior multivitamin 1 tablet, Creon DR 36000 units 2 capsules, Vitamin D 1000 International Unit (IU) 2 capsules, amlodipine 10 mg 1 tablet, fluoxetine 20mg 1 tablet, pantoprazole 40mg 1 tablet, loperamide 2mg 1 capsule, carvedilol 12.5mg tablet, potassium extended release 10 milliequivalent 2 capsules, bumetanide 2mg 1 capsule, and aspirin enteric coated 325mg 1 capsule (14 tablets/capsules total). LPN D then placed the medication in a paper envelope and labeled with R3's name and date and reported she would administer them after R3 was finished with her shower. On 6/20/24 at 10:12 AM, Surveyor interviewed R3 and asked if she had taken her medication and she indicated she did. On 6/20/24 at 2:06 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if medications should be left in a resident's room unattended, she indicated no, and that the resident should have a self-administration order. Surveyor asked DON B if R3 has a self-administration order, she indicated R3 did not have a self-administration and that R3 should have had an order to self-administer her medications.

Based on interview and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents reviewed (R1) for falls. R1 had multiple falls while at the facility. Facility staff did not update the care plan after each fall, notify the physician promptly after a fall with a head injury, and complete and document neurological checks timely. This is evidenced by: The facility's policy titled Fall Prevention and Assistive devices for Fall Prevention last updated on [DATE], states in part: .Procedure: 1. Each resident will have a fall risk assessment tool completed (located within [EHR (Electronic Health Record)] upon admission, quarterly, with a significant change, following a fall and at the nurses' discretion .3. Each resident who is at risk for falls based on the falls assessment tool will have a falls care plan .5. Each resident will have an individualized interventions put into place to help achieve the goals of care .6. Post Fall Management: .e. Charge nurse or other RN (Registered Nurse) is to be called to the room if significant injury is suspected and further assessment should be completed. i. The nurse will complete resident post fall evaluation. The charge nurse would notify the MD (Medical Doctor) if fall resulted in a head or major injury. Neurological checks to be initiated with any fall where the resident was known to hit their head AND with any unwitnessed fall .i. Root cause analysis should occur to identify cause of fall if able. j. Current interventions should be evaluated for appropriateness and changed as needed with NEW intervention put into place in attempt to prevent future issues .Additional Interdisciplinary Responsibilities Nursing Staff: The Wing Nurse ensures that all fall prevention interventions are placed on the guidelines to daily care and assure that they are followed by CNA (Certified Nursing Assistant) staff . The facility's document titled [Facility] Neurological Checklist states in part: When a resident strikes his/ her head and requires neurological check please complete as followed: q (every) 15 minutes for 1 hour post fall, the q 1 hour for the next 4 hours and then q 4 hours thereafter until 24 hours post fall. If a resident has an UNWITNESSED fall, please complete neuro checks every 4 hours until 24 hours post fall. R1 was admitted to the facility on [DATE] with diagnoses that include non-ST-elevation myocardial infarction (NSTEMI; a type of heart attack that usually happens when your heart's need for oxygen can't be met), acute respiratory failure with hypoxia, diastolic heart failure, thrombocytopenia (a low number of platelets in the blood), and a history of transient ischemic attacks (TIAs; mini stroke). It is important to note that R1's diagnosis list states that R1 had a long-term use of anticoagulants and long-term use of aspirin. R1 was taking aspirin 81 mg by mouth daily. R1's Minimum Data Set (MDS) dated [DATE] states that R1 has a Brief Interview of Mental Status (BIMS) of 11 out of 15, indicating that R1 has moderate cognitive impairment. The MDS also indicates that R1 requires partial to moderate assist with bed mobility and transfers. R1's Fall risk assessment dated [DATE] states that R1's fall risk score is 11, indicating that R1 is at risk for falls. R1's Guidelines for Daily Care dated [DATE] states in part: .Mobility: I transfer with the help of 1 person, transfer me with a gait belt . This was appended on [DATE] to say: I transfer with 2 people, transfer me with a gait belt .Walking/ Moving: I walk: I use a standard walker with the help of 1 person . This was appended on [DATE] to say: I walk: I use a standard walker with the help of 2 people and gait belt . Under the box titled Safety Interventions dated [DATE] states low bed and floor mat. It is important to note that there were no fall interventions listed on the Guidelines for Daily Care until [DATE]. R1's Care Plan dated [DATE] states in part: .Safety I: have the potential to fall down and hurt myself .I show this by not being able to move around like I used to, tiring easily, getting short of breath, taking diuretic .Approach I need my nurses to ---remind me to ask for help. I need my aides to---frequently check on me, make sure my important items are within my reach, make sure I can reach my glasses, remind me to get up and move slowly, keep my room well-lit when I'm up, report signs that I'm in pain to my nurse, remind me to ask for help .Goal my goal is to : stay safe while I'm moving about without falls . It is important to note that R1's care plan was not updated after any of his falls. On [DATE] at 8:45 PM, R1 had a fall out of his lift recliner. Facility documentation states in part: .Actions/ New Interventions: encourage use of bed at night .Physician notification: no need to notify .Description of Incident: Found resident lying on his right side in front of the recliner which was all the way up. Found by [staff member], Hoyer lifted off floor into bed. Vitals stable, neuros wnl (within normal limits), no visible injury. Resident statement: I must've hit the wrong button and put the chair all the way up . R1's neuro checks were subsequently completed at: [DATE] at 12:49 AM [DATE] at 5:15 AM No additional neuro checks were completed. It is important to note that the intervention was not added to the care plan or the Guidelines for Daily Care document. Additionally, there is no evidence that the facility assessed R1 to be able to safely use a lift recliner. On [DATE] at 7:15 PM, R1 was lowered to the floor during a transfer. Facility documentation states in part: .Description of events: Resident was transferring from recliner to w/c (wheelchair), and then resident sat in w/c it moved and [CNA] lowered him to the floor on his knees and then to a sitting position. Bumped his head on the door frame when he was lowered. Assisted up off the floor via Hoyer lift and 2 CNAs, head to toe assessment completed with no apparent injury. Vitals stable, Neuro checks stable .Resident statement: I fell . R1's neuro checks were subsequently completed at: [DATE] at 9:21 PM [DATE] at 10:46 PM [DATE] at 10:49 PM [DATE] at 10:51 PM [DATE] at 10:53 PM [DATE] at 10:55 PM [DATE] at 10:57 PM [DATE] at 11:21 PM [DATE] at 12:23 AM On [DATE] at 2:50 AM, R1 had a fall out of bed. The facility's documentation states in part: .Injury: bruising to right forehead 1 x 1.2 cm (centimeters), right cheek 1.4 x 2.5 cm, right eye 0.75 x 1.0 cm, right hand 4.5 x 3.0 cm .Did resident hit head: yes, neuro assessment initiated .Physician notification: no need to notify. Family notification: will update in the morning .Description of Incident: resident found lying on stomach on the floor next to his bed. Neuro checks initiated and wnl. Hoyer lifted off floor and into bed. Bruising noted to right hand, right forehead, right cheek, and right eyelid and superficial scrape to left shin. Left shin cleansed and bandaid [sic] applied. Vital signs stable . R1's neuro checks were subsequently completed at: [DATE] at 3:41 AM [DATE] at 3:44 AM [DATE] at 3:46 AM [DATE] at 3:51 AM [DATE] at 4:54 AM [DATE] at 5:56 AM On [DATE] at 7:00 AM, R1 had a change in condition. Nurse's notes state in part: Writer was called down to R1's room around 7 AM to find R1 very minimally responsive and labored with his breathing (using accessory muscles), Pulse was 43 and irregular. BP (Blood Pressure) ,d+[DATE], oxygen 100% on O2 (oxygen), respirations 18 and labored. Writer noted a sweet smell to his breath, Pupils are quite large but reactive to light and PERRLA (Pupils are equal, round, and reactive to light and accommodation) is intact. Writer tried to ask R1 how he was feeling but R1 responded with grunts. Physician Contact: spoke with physician on call .regarding R1's falls and changes in his neurological checks. MD agreed that given his history to speak with family and see about comfort measures, due to concerns of a possible brain bleed . R1 was placed on comfort measures after speaking with the family. It should be noted R1 was on Coumadin (an anticoagulant/blood thinner) prior to admission to the facility this medication was discontinued just prior to R1 being admitted to the facility. R1 did expire; however, R1's death certificate indicates R1 expired from a stroke not a brain bleed. On [DATE] at 10:45 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C what the facility's policy was for falls, RN C stated that if the resident hit their head it was q 15 minutes x 4, then q 1 hour x 4, then q 4 hours, if the resident did not hit their head it was q 4 hours x 24 hours, and if the fall was unwitnessed and the resident said that they didn't hit their head it was q 4 hours x 24 hours. Surveyor asked RN C if the resident hits their head, should the MD be notified, RN C stated that if there is no serious injury then they will follow up in the morning. Surveyor asked if bruising to the face and head be considered a head injury, RN C stated yes. Surveyor asked RN C if a head injury would warrant a call to update the physician, RN C stated typically yes, but she couldn't remember the exact circumstances around R1's falls. On [DATE] at 12:57 PM, Surveyor spoke with MD D. Surveyor asked MD D if he would expect facility staff to immediately notify himself or the on-call MD if a resident had a fall with a head injury, MD D stated yes. On [DATE] at 1:31 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R1's fall on [DATE] was unwitnessed, DON B stated yes. Surveyor asked DON B if she would expect neuro checks to be completed, DON B stated yes. Surveyor asked DON B if the intervention listed in the fall documentation should have been added to R1's care plan and Guidelines for Daily Care document, DON B stated yes. Surveyor discussed R1's fall on [DATE] with DON B. Surveyor asked DON B if knowing that R1 hit his head, what her expectations were for neuro checks to be completed, DON B stated she would expect them to be completed q (every) 15 minutes for 1 hour post fall, the q 1 hour for the next 4 hours and then q 4 hours for 24 hours post fall. Surveyor asked DON B if she expects staff to have timely documentation of neuro checks, DON B stated yes. Surveyor discussed R1's fall on [DATE] with DON B. Surveyor asked DON B if given R1's head injury she would expect the nurse to have updated the MD, DON B stated yes. The facility failed to create a robust fall care plan for a resident at risk for falls, update the care plan after each fall, complete and document neuro checks timely, and notify the physician about R1's falls with hitting head/head injury.

Based on interview and record review the facility failed to immediately provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident requiring emergency care and failed to immediately notify emergency medical personnel for 1 of 3 total sampled Residents (R1). R1 was found pulseless and not breathing on [DATE]. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to immediately initiate CPR and immediately contact emergency medical personnel. Facility failure to immediately begin cardiopulmonary resuscitation and immediately summon emergency medical personnel, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and LTCM H (Long Term Care Manager) of the immediate jeopardy on [DATE] at 3:58 PM. The immediate jeopardy was removed on [DATE]. However the deficient practice continues at a scope/severity at an E (potential for harm that is not immediate jeopardy/pattern) for the 9 residents who are full code as the facility continues to implement its action plan. This is evidenced by: Per CMS (Centers for Medicare and Medicaid Services) Cardiopulmonary resuscitation (CPR) refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. Per The American Heart Association, all potential rescuers are to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer. Per CMS, when addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition), facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services. Facility Policy entitled 'Cardiopulmonary Resuscitation (CPR),' revised on [DATE], states, in part: Purpose: Allow resident (or legal representative) to make an informed decision regarding his/her wishes to have or not to have CPR should [CONDITION(S)] occur. Policy: All residents will be questioned upon admission regarding their desire for life sustaining measures. This issue will be readdressed with resident and/or legal guardian as needed. Such wishes will be communicated sufficiently to necessary staff, to ensure that wishes are followed should a [CONDITION(S)] occur. Procedure: 1. The resident and/or legal representative will be provided with the Cardiopulmonary Resuscitation (CPR) Information Sheet (see attached.) 2. Social Worker or admitting nurse will question the resident and/or legal representative regarding his/her choice for CPR or NO CPR. Opportunity will be given for questions and staff will be sure that the resident and/or legal representative are fully understanding and informed of what the decision means. 3. The choice will be indicated on the CPR form (see attached), with the appropriate box signed and dated by the resident or his/her legal representative. The physician will then sign this form in the future when he/she makes rounds in the facility. 4. The admitting nurse will assure the resident's choice and the initial MD (Medical Doctor) order for CPR or NO CPR match. If they do not, the MD will be contacted, in order to obtain correct order. 5. The MD order will be entered into ECS (an electronic health record). This will then show upon the resident's MAR (Medication Administration Record) and the resident's Guidelines to Daily Care. A copy of the signed CPR form will be placed with the Guidelines to daily care in the room for easy and quick staff reference. To make reference even quicker, residents who choose YES CPR will have this copy made on blue paper and NO CPR will have this copy made on red paper. 6. Residents who choose to have CPR will also be provided with a blue bracelet. Some residents do choose not to wear this and this is the hung by the guidelines to daily care in the room. 7. Residents who choose to have CPR will be provided such if/when a [CONDITION(S)] occurs. If a resident is found without pulse/breathing the nurse shall immediately verify CPR status by checking the form that is with the guidelines to daily care. 8. If/when a [CONDITION(S)] occurs, 911, will be contacted immediately, while CPR is initiated, in order to assure quick transport to an acute care facility. Other life sustaining measures such as initiating a ventilator or intubation are not performed within this facility. 9. All nurses will be trained in CPR and will be recertified every 2 years. 10. The facility has an AED in the facility. (See AED policy and procedure) 11. The facility will not initiate CPR on a resident only if a. They have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .e. rigor mortis, dependent lividity, decapitation, trans-section, or decomposition) are present. c. Initiating CPR could cause injury or peril to the rescuer Following a three (3) day hospital stay, R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary includes the following: R1 is an [AGE] year-old male with a history of severe left ventricular dysfunction with an EF (ejection fraction) of 30 to 35%, variable control diabetes mellitus type 2, history of [CONDITION(S)], significant [CONDITION(S)] followed by urology, but refuses indwelling Foley, and chronic kidney disease stage IIIb, follows with nephrology, who presented today to the emergency room from home, where he presently lives alone. R1 has become progressively weaker. 1. Acute on chronic systolic heart failure with reduced ejection fraction, improving. Continues diuresis, strict I's and O's (Intake and Output), daily weights and fluid restriction. Monitor electrolytes and renal function. 2. AKI (acute kidney injury) on CKD IIIb, improving. Cr (Creatinine) 1.,d+[DATE].6 (baseline 1.5). Suspect cardiorenal/decompensated CHF (Congestive Heart Failure). 3. [CONDITION(S)]: Noted on recent imaging. May be congestive hepatopathy, which would portend a poor prognosis for the patient, and notes that he may not respond well to diuretics, which may explain why he is having resistance to increase in [MEDICATION(S)] (medication to remove excess fluid) by nephrologist. May need GI (gastrointestinal) evaluation as outpatient. Follow LFT's (liver function tests) as outpatient. Code Status at Discharge: Full Follow-up Recommendations: 1. Follow up with MD (Medical Doctor) in 1 week 2. Repeat electrolytes and liver enzymes 2. Continue fluid restrictions 1500 ml (milliliters) per day. 3. Daily weight. If weight increases by more than 2 lbs (pounds) over 24 hours, call MD. R1's Admission MDS (Minimum Data Set) was not completed. R1 is his own person and elected to be a full code (CPR). The facility's Resident Advance Directive Regarding Cardiopulmonary Resuscitation states as follows: The following is a statement of the resident's wishes regarding the initiation of cardiopulmonary resuscitation. If signed by the attending physician, this document may be considered as a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The issue of Cardiopulmonary Resuscitation (CPR) has been thoroughly discussed and considered by this Resident or the Resident's surrogate. Resident or Resident's surrogate has retained a copy of the facility's CPR versus comfort measures policy and procedure. Basic CPR is defined as rescue breathing, whether done mouth-to-mouth or with a special breathing mask and bag, and chest compressions, which is external cardiac massage, or AED placement. On [DATE] R1 signed the Resident Advance Directive Regarding Cardiopulmonary Resuscitation. R1's advance directives state: It has been decided that CPR should (should is circled) be initiated in the event of a cardiac or respiratory arrest. I understand that this directive may be rescinded at any time. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Guidelines for Daily Care, kept in the resident room behind the door states, in part: Code Status: CPR, Cognition: short term memory ok long term memory ok, Communication: Speaks well understands when spoken to Bed mobility 1 assist, Bathing 1 assist, Dressing 1 assist, Transfer 2 assist with walker, Toilet/Transfer 1 assist ambulates to bathroom, Therapies PT and OT, Hallway ambulation unable to ambulate R1's [DATE] MAR (Medication Administration Record) states, in part: Code Status: CPR R1's [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . It is important to note this is signed out every shift, and most recently by LPN D (Licensed Practical Nurse) on [DATE] PM shift and again on [DATE] NOC shift. Per interview (below) with CNA C, R1 was not wearing a blue wristband indicating he was a full code. CNA C also checked behind R1's door and did not see a band hanging on the Command hook. On [DATE] at 4:19 AM, R1's progress notes state the following: IMPORTANT NOTE: R1 last seen well around 12:30 AM when CNA emptied urinal. He was sleeping and comfortable. Around 3:00 AM, CNA and writer in room to check on R1 again with rounds. R1 found to be cold and with poor color, not responding. Charge nurse notified and present to room. {SIC} On [DATE] at 4:45 AM, R1's progress notes state the following: Around 3:00 AM, writer called to room and notified resident was not responsive. Resident is YES CPR status as noted under guidelines. CPR initiated. Writer instructed CNA to call 911. Staff did continue CPR, completing likely several rounds at which time the Ambulance arrived shortly thereafter and took over CPR. When ambulance crew took over CPR, writer placed call to family. Did call twice before son answered. Writer updated him on situation, he was aware that ambulance crew was still doing CPR at that time and writer would call back with any updates. Writer back to room and ambulance crew had completed several more rounds of CPR and then did call the ER (emergency room ) physician to update on situation. They were instructed to stop CPR by ER physician. Writer called son back to inform him that his dad was gone and CPR was stopped per instructions of ER physician. Son thanked writer for call. IMPORTANT NOTE: Call placed to coroner around 3:45 AM. Stated he would be on his way from Baraboo. Around 4:25 AM coroner arrives in facility. Does review chart and pronounce the death around 4:32 AM. Son is called again when coroner present to ask which funeral home he would like. Coroner okay'd release of body to funeral home. IMPORTANT NOTE: Funeral home called at 4:45 AM. The EMS report documents their unit was notified on [DATE] at 3:08 AM. The EMS narrative states, in part: Assessment: Initial assessment by first responding EMT-As revealed an 84 y/o (year old) male in full [CONDITION(S)] with CPR being performed by staff. Upon ambulance staff arrival pt. (patient) was reassessed and found to be in cardiac/respiratory arrest. Visual rhythm analysis revealed an asystole rhythm. Skin was cool and pale. Pupils were fixed and dilated. Ventilation assisted at 12/minute and later at 10/minute after intubation. Vital signs revealed no pulse or respiratory effort and low skin temperature. Accu check at 32. All screen checks at ,d+[DATE] minute marks revealed an asystole rhythm with no pulses .Medical Doctor authorized termination of resuscitation at 3:39 AM. [NAME] (time of death) 3:39 AM. EMS Timeline of Events: On [DATE] at 3:08 AM, the facility notified EMS. On [DATE] at 3:12 AM, EMS was enroute to the facility. EMS arrived to the facility at 3:15 AM; at 3:17 AM EMS was at patient's bedside. EMS departed at 3:53 AM. Ambulance back in service at 4:04 AM. On [DATE] at 12:30 PM, Surveyor spoke with CNA C (Certified Nursing Assistant) who has been employed at the facility for five (5) years. CNA C stated she works primarily on the Oak wing where R1 resides. CNA C stated around 12:30 AM she emptied R1's urinal and remembers he was snoring when she was in his room. CNA C stated she returned to R1's room after break around 2:,d+[DATE]:00 AM and noted R1 was, Cold to touch and gone. CNA C stated she reported this to LPN D. Note, CNA C's timesheet indicates she punched back in from break at 2:45 AM. CNA C stated LPN D notified RN E that R1 had expired. CNA C stated, RN E checked R1's heart and heard something, after a while there was nothing. Surveyor asked CNA C if she is CPR certified. CNA C stated yes, she is CPR certified as are all CNAs, LPNs and RNs in the building. Surveyor asked CNA C were you aware that R1 was a full code. CNA C stated, No, I had no clue he was CPR. Surveyor asked CNA C how do you know if a resident is a full code or DNR (do not resuscitate). CNA C stated, R1 had no blue wristband to indicate he was a full code and there was no wristband hanging behind the door on a Command hook. CNA C stated R1 should have been wearing a blue bracelet that indicates he is a full code or it should have been behind his door if he declined to wear the bracelet. CNA C stated, I now know to check the blue sheet hidden behind the care plan in residents' rooms that indicates each resident's code status. CNA C added, It's (code status) basically just behind the care plan I learned. CNA C stated the only sign R1 was a full code was the blue sheet behind the care plan and CNA C stated, I didn't know what the blue sheet meant. CNA C stated after LPN D and RN E listened to R1's heart RN E left R1's room. CNA C stated that she and LPN D started cleaning up R1. CNA C stated approximately 2 minutes after RN E left R1's room she returned and stated R1 is a full code and started doing compressions (CPR) at this time. CNA C stated the radios/walkie talkies the staff use to communicate with one another were not working on this shift and are frequently not charged, not working, or staff accidentally take them home. Surveyor asked CNA C have you or other staff received any education/training following this incident. CNA C stated, Not at all. Surveyor asked CNA C did anybody stay with R1 when you left his room to locate LPN D. CNA C stated, Nope, no one. Surveyor asked CNA C how much time elapsed from the time you found R1 cold and not breathing to when RN E started CPR. CNA C stated, Twenty (20) - thirty (30) minutes. CNA C stated LPN D and RN E went back and forth listening to his heart. CNA C stated, I guess it didn't dawn on them that he might be a full code. CNA C stated she did not check R1's code status under the care plan and added, I'm used to the blue wristband. Surveyor observed CNA C's timecard for ,d+[DATE] and [DATE]. On [DATE] at 8:45 PM, CNA C punched in for her shift. On [DATE] at 2:15 AM, CNA C punched out for lunch. It is important to note on [DATE] at 2:45 AM, CNA C punched back in from break. Note, the window of time CPR could have been performed is from approximately 2:45 AM - 3:08 AM when the facility notified EMS. Note, this is a total time of approximately 23 minutes. On [DATE] at 2:10 PM, Surveyor spoke with the Charge Nurse, RN E (Registered Nurse). Surveyor asked RN E to describe the events that occurred the morning of R1's death. RN E stated she is new to the Charge Nurse position. RN E stated she was in the charting office (nurses station) when LPN D called to say that R1 passed. RN E went to R1's room, auscultated heart and lung sounds for about 30 seconds and did not detect a heartbeat. CNA C and LPN D remained in R1's room when RN E exited R1's room and returned to the nurse's station. While at the nurses station RN E realized that R1 is a full code. RN E ran to R1's room and started CPR. Surveyor asked RN E when you went to the nurse's station to check R1's code status how much time elapsed from when you left R1's room to when you returned and started CPR. RN E stated, ,d+[DATE] minutes if that. RN E stated when LPN D called me I should have asked staff if R1 was a full code. RN E stated, I had to leave the room to check R1's code status. RN E stated she regrets not asking CNA C and LPN D about R1's code status before leaving the room and going to the nurse's station to verify. RN E stated while at the nurses station she told LPN F (Licensed Practical Nurse) who was working on a different wing to call 911 and grab the AED (Automated External Defibrillator). Surveyor asked RN E did the facility provide training to you and other staff following R1's death. RN E stated DON B (Director of Nursing) talked with her about where to check a resident's code status in resident's room and always remember to ask coworkers. Surveyor asked RN E how you verify a resident's code status while in their room. RN E stated she will now look behind the resident's room door or check online. RN E stated, as the RN on duty, I should always know my residents' code status. On [DATE] at 3:30 PM, Surveyor spoke with LPN F (Licensed Practical Nurse). Surveyor asked LPN F to describe the events that occurred the morning of R1's death. LPN F stated she was working on Elm and Birch units. RN E asked me to get the backboard and AED. LPN F stated when she arrived to R1's room RN E and LPN D were doing CPR. Surveyor asked LPN F were they doing compressions on R1 while he was in bed. LPN F stated, Yes. LPN F indicated there was no backboard under R1 while staff were performing CPR. LPN F stated RN E and LPN D continued CPR while she hooked up the AED. LPN D and RN E followed the AED's instructions. LPN F stated when the ambulance arrived we moved him to the floor. LPN F stated each shift nurses are to sign out on the TAR if the blue band is present. Surveyor asked LPN F if R1 was wearing a blue CPR band. LPN F stated no, but he was wearing it the night before. Surveyor asked LPN D have you or any staff had training following this incident. LPN F stated, Not that I was aware. Surveyor asked LPN F how you tell if a resident is a full code. LPN F stated she checks the sheet behind the resident's care plan. LPN F added, blue means full code and red means DNR. On [DATE] at 8:38 AM, Surveyor spoke with LPN D. Surveyor asked LPN D to describe the events that occurred the morning of R1's death. LPN D stated when CNA C noted R1 was cold and not breathing she located her in a resident room. Surveyor asked LPN D how long did it take for CNA C to locate you. LPN D stated, It wasn't long ,d+[DATE] minutes. LPN D stated she went to R1's room looked at him and touched his skin. LPN D stated R1's face was a different color. LPN D stated she touched R1's face and it felt cold. LPN D stated she pulled R1's covers back, touched his stomach and feet and noted they were cold. LPN D stated there was no change in color in R1's stomach and feet only in his face. LPN D stated CNA C got RN E. LPN D stated RN E arrived to R1's room ,d+[DATE] minutes later. LPN D stated RN E was out of breath when she arrived and thinks she was running. LPN D stated RN E auscultated R1's heart sounds. LPN D stated RN E thought she heard something and handed the stethoscope to LPN D to listen. LPN D stated she did not hear anything. Surveyor asked LPN D, was RN E aware of R1's code status. LPN D stated, I don't want to say that she knew or didn't know R1's code status. Surveyor asked LPN D, did you know R1 was a full code. LPN D stated, No, I don't recall. LPN D stated, after RN E auscultated R1's heart sounds RN E walked out of the room. LPN D stated she did not know why RN E left the room or where she was going. LPN D stated, I don't know why CPR wasn't started. Approximately 4 minutes later RN E ran back to R1's room and started CPR on R1 in bed. LPN F then entered the room with the backboard and AED. Staff put the backboard under R1, transferred him to the floor and continued CPR. Surveyor asked LPN D how many cycles of CPR did you and RN E complete while R1 was in bed before the backboard was put under him and R1 was moved to the floor. LPN D stated a lot. Note, R1 was not on an air mattress. Surveyor asked LPN D if all nurses CPR certified. LPN D stated, yes all CNAs, LPNs, and RNs are CPR certified. Surveyor asked LPN D where you verify a resident's code status. LPN D stated she would verify in the MAR (Medication Administration Record). LPN D stated, I would check there because the office is quite a ways away. LPN D stated all original code status documentation is kept at the nurse's station. LPN D stated residents that are a full code are supposed to wear a blue bracelet and there should be a blue sheet behind the resident's door. Surveyor asked LPN D how staff communicate with one another in this facility. LPN D stated we have walkie talkies that we're supposed to use. LPN D stated, I have a walkie talkie and a lot of times there are no batteries or they're not charged or go home with staff. LPN D stated the facility gave her a personal walkie talkie that she keeps. LPN D stated she also has a walkie talkie on her cart that sometimes goes home with staff. Surveyor asked LPN D did CNA C have a working walkie talkie on the shift that R1 expired. LPN D stated, I don't recall if CNA C had one. Surveyor asked LPN D how much time elapsed from the time CNA C found R1 to when RN E started CPR. LPN D stated, Ten (10) minutes, seven (7) minutes. LPN D stated, the code felt slow motion fast. Note, per interview with CNA C, she did not have a functioning walkie talkie in order to communicate with other staff members on the shift that R1 expired. The lack of staff knowledge regarding R1's code status and a non-functioning communication system at the facility contributed to a significant delay in R1's receiving CPR and emergency medical care timely. Surveyor asked LPN D did the facility provide any training to you and other staff regarding code status. LPN D stated the facility gave us a paper we had to read about ,d+[DATE] days ago. Note, this was after survey and the IJ citation. Surveyor asked LPN D, if a resident coded today where would you check code status. LPN D stated, I would check their arm for a blue bracelet (full code) or look for the paper on the back of their door (blue full code, red DNR). On [DATE] at 3:43 PM, Surveyor spoke with (Charge) RN G (Registered Nurse). Surveyor asked RN G to talk about the process of advance directives and code status. RN G stated if a resident comes from the hospital they will have a CPR/DNR order upon admission. Upon admission we discuss code status with the resident and have them sign their own code status or their APOAHC (Activated Power of Attorney for Health Care) signs. RN G stated if a resident is a full code we put a blue bracelet on them; if the residents refuses to wear the bracelet we hang it behind their door on a 3M hook (Command). RN G stated this process is the same for all halls (long term care and rehab). Surveyor asked RN G if a resident is a full code how soon should CPR be started. RN G stated immediately. The Coroner's Report, dated [DATE], indicates R1's Cause of Death: Sudden Cardiac Death; Due to Conditions: Acute Heart Failure, [CONDITION(S)], and Diabetes. The facility did not ensure that R1 was wearing a wrist band indicating the resident was full-code (per facility policy) and did not have the bracelet hanging on the back of the resident's door. As a result, CNA C who found this resident incorrectly assumed the resident did not want CPR. Staff delayed providing CPR anywhere from ,d+[DATE] minutes to 23 minutes. The failure to immediately begin cardiopulmonary resuscitation and failing to immediately call 911, created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: 1. In-house audit completed immediately to ensure all residents with a full code status have the blue bracelet in place on their person or hanging on the door near the guidelines for daily care. 2. All nursing staff to be educated prior to their next shift on Cardiopulmonary Resuscitation Use of Life Sustaining Measures Policy and Procedure. 3. Education to specify that the blue bracelet will be placed on the resident's person or hanging on the door near the guidelines for daily care. Additional education regarding the signed CPR form and the distinction between a blue form (Full Code and a red form (DNR). 4. Nurses will be educated/reminded that the location of the bracelet must be documented and signed off in in the Treatment Administration Record (TAR). 5. Care Plans audited to ensure full code status is stated to confirm all documentation accurately reflects resident's wishes.

Based on interview and record review, the facility failed to ensure each resident is free from verbal abuse by a registered nurse for 1 of 7 residents reviewed for abuse (R1). Findings include: The facility's abuse policy states: -All residents have the right to be free from any type of mistreatment or abuse. The facility will put into place policies and procedures that assure the residents of the facility are safe, comfortable and free from abuse. -The facility will assure through screening, training, and identification, that all residents are free from abuse. This facility will not tolerate abuse, neglect, or misappropriation of a resident's property. All allegations of abuse, neglect, or misappropriation and any injury of which the source cannot be identified will be investigated. The results of the investigation will be reported as required by state and federal laws and this policy and procedure. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Even though a resident may have a cognitive impairment, he/she could still commit a willful act. -Verbal abuse refers to any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. -Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. R1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R1's care plan states she is required to have 2 staff members perform cares at all times due to a history of accusatory statements. She resides on the Elm wing of the facility. Surveyors attempted to speak with R1 on 1/26/21. R1 did not appear agitated, but did not seem to understand what Surveyors were asking her. On 1/6/21 the facility submitted a self-report to the state. The report states that on 1/6/21, MA J (Medication Aide) told DON B (Director of Nursing) that on 1/2/21, RN F (Registered Nurse) had been inappropriate with R1. MA J stated to DON B that CNA G (Certified Nursing Assistant) and CNA H would have further information. On 1/26/21 at 2:05 PM, Surveyor interviewed CNA H regarding the incident. CNA H regularly works the Elm wing and has worked frequently with R1. CNA H stated that on 1/2/21, she was walking past R1's room around 7 PM and noticed R1 sitting on the floor mat next to her bed, which was lowered to the floor. CNA H stated that because R1 is a 2 assist at all times, she got RN F to assist her with cares as CNA G was currently assisting another resident. CNA H stated that as soon as RN F entered R1's room, the situation turned into a nightmare. CNA H stated RN F immediately began yelling at R1, stating, You s**t your pants. That's f***ing disgusting and stop playing with your poop as R1 was touching her feces. CNA H stated that when RN F began yelling, she froze. CNA H stated she had never heard a staff member treat a resident that way. CNA H stated she wanted to intervene but didn't want to yell at RN F and make the situation worse. CNA H stated R1 was embarrassed and kept saying, I'm so sorry to make you take care of me like this. Do you forgive me? CNA H stated she was worried about R1's emotional well-being. CNA H stated that approximately 5 minutes into the incident, CNA G came to the room and relieved RN F. CNA H stated that as RN F was leaving the room, she made a barfing sound and said, That was f***ing disgusting. CNA H stated RN F made the comment very loudly and, although R1 is hard of hearing, it was loud enough for anybody to hear. CNA H stated she and CNA G got R1 back into bed and that is when CNA H noticed R1 crying. CNA H stated R1 is very sensitive to soiling herself. CNA H also stated that any reasonable person, including herself, would feel horrible having listened to RN F's comments. CNA H said, I felt awful and felt as if I let R1 down. I didn't do enough. CNA H stated that R1 has many behaviors but crying is not one of them. CNA H also stated that R1 was not having behaviors at the time of the incident and didn't have any the rest of the evening. CNA H stated she and CNA G told the charge nurse, RN I, about the situation in detail at the end of the shift, approximately 10:30 PM. CNA H stated that RN I said she would talk to DON B, but was not sure if she did. On 1/26/21 at 1:20 PM, Surveyor interviewed CNA G regarding the incident on 1/2/21. CNA G stated that she was teamed up with CNA H, as is common, to work the Elm wing. At the time of the incident, CNA G states she was finishing up with another resident's cares when she could hear yelling from across the hall. She approached the sound, which was coming from R1's room. Upon arriving to R1's room, CNA G stated RN F was yelling, That's f***ing disgusting as R1 was laying on the floor mat next to her low bed. CNA G could see R1 had become incontinent and it had come out of her brief. RN F continued to say, Don't dig in there when R1 began touching her feces. CNA G stated R1 began to cry, which she (CNA G) had never seen before. CNA G stated she had never seen R1 so upset before and believed it was due to RN F's yelling. CNA G stated she took over for RN F and finished cleaning R1 up with the help of CNA H. While performing these cares, CNA G stated R1 was crying and stating, I'm sorry, I didn't mean to do it. CNA G stated R1 has many behaviors including calling out, throwing items at staff, combativeness, and resistive to cares. However, CNA G, like CNA H, stated crying is not one of her behaviors and R1 was not exhibiting any behaviors at the time of the incident. CNA G stated she believed once RN F left the room, R1 was safe and she and CNA H waited until the end of the shift at approximately 10:30 PM to approach the charge nurse, RN I, to report what had happened. CNA G stated CNA H described the incident, in detail, to RN I. According to CNA G, RN I said she didn't know what she was supposed to do. CNA G stated she told MA J a few days later, who then reported the incident to DON B. On 1/26/21 at 2:51 PM, Surveyor interviewed MA J regarding the incident. MA J stated that on 1/5/21 at approximately 8:30 PM, CNA G told her about an incident that occurred on 1/2/21 in which RN F was swearing at R1. MA J stated that because DON B was not in the building at the time, she would just wait until her next shift, which was the next morning (1/6/21). MA J stated that R1 has many behaviors including hallucinations, accusatory statements, throwing items, and combativeness but crying was not one of her behaviors. CNA G and CNA H reported to Surveyor it was not normal behavior for R1 to cry. Both CNA's felt R1's crying was directly related to the verbal abuse she received from RN F. R1 was unable to be interviewed regarding the incident, however, the reasonable person would be fearful and feel dehumanized, humiliated, embarrassed and/or ashamed. R1 began to cry and repeatedly apologized during this encounter. CNA G, CNA H and MA J all stated they had no previous experience, nor were they aware of, RN F mistreating other residents. Surveyors were unable to speak with RN F after repeated attempts to contact her. RN F did not return to the facility and was terminated on 1/25/21. Before RN F was placed on administrative leave on 1/6/20, she worked 1/3, 1/4, and 1/6, having worked on the Birch and Oak Court wings in addition to the Elm and Evergreen wings. 70 residents resided on these 4 wings at the time of the incident.

The facility did not ensure that a resident receives care, consistent with professional standards of practice for 2 of 6 sampled residents (R5 and R2). R5 developed multiple wounds the physician was not consulted per standards of practice, the wounds were not assessed and measured consistently. R5's wounds deteriorated and becamed infected requiring intravenous (IV) antibiotics. R5 [MEDICAL CONDITION] and was hospitalized . R2 had a skin tear requiring a dressing and treatment order. The facility did not not notify R2's Physician of need for treatment, did not complete dressing changes timely and did not notify R2's Activated Power or Attorney for Health Care (APOAHC.) This is evidenced by: R5 was a long term resident of the facility. R5 had the following Diagnoses: [REDACTED]. The facilities Policy and Procedure entitled Skin Care and Pressure Ulcer Prevention dated 3/5/19, documents, in part: .receive necessary treatment and services to promote healing, attempt to prevent infection and prevent new sores from developing .Skin observations will be performed weekly .5. Pressure injuries will be measured every 7 days, documented on and assessed for response to current treatment . The facilities Policy and Procedure entitled Wound Care Team dated 3/13/18, documents, in part: Objective: .strives to reduce .or traumatic injuries that may impact the resident's quality of life .2. Team will meet either weekly or every other week on a designated day of week. 3. Team will discuss current wounds in house, including measurements, location, pain . The facilities Policy and Procedure entitled Wound Care Procedure dated January 2012, documents, in part: .16. Document procedure completed, appearance of wound, type and amount of drainage, etc. Note: All treatments ordered should be done per physician's orders [REDACTED]. R5's Physician order [REDACTED]. 1/21/20 [MEDICATION NAME] Skin Protectant 50% ointment topical daily as needed. 6/4/20 Apply Hydraguard Barrier Skin cream to bilateral gluts (gluteal region) for protection TID (three times a day.) 8/20/20 Left upper glute: Cleanse with wound wash and pat dry. Apply [MEDICATION NAME] alginate to wound bed. Skin prep to surrounding intact skin. Apply bordered silicone dressing over, change every 2 days. 8/26/20 Bilateral upper glutes open areas: Cleanse with wound wash and pat dry. Apply [MEDICATION NAME] alginate to wound bed. Skin prep to surrounding intact skin. Apply bordered silicone dressing over, changed every 2 days. 9/17/20 Left thigh: Apply Iodosorb gel followed by [MEDICATION NAME] and then cover with silicone dressing with border, change 3 times per week (Mon, Wed, Fri.) 9/17/20 Glutes: Apply Puracol followed by [MEDICATION NAME] and then cover with silicone dressing with border, change 3 times per week (Mon, Wed, Fri.) It is important to note that the facility has no documentation of consultation with a Physician for wound treatment order changes for 8/26/20 or 9/17/20. Only signed Physician order [REDACTED]. R5's Braden Scale (a tool used to determine skin breakdown evaluating mobility, friction/shear, activity, moisture, nutrition, and sensory perception) dated 8/2/20 documents a score of 17 which indicates R5 is at mild risk for skin breakdown. R5's care plan includes the following, in part: Self Care Deficit .05/06/16 .she declines sleeping in her bed and chooses to sleep in her recliner. Risks and benefits are explained to her by nursing, but thus far skin is okay . (SIC) Potential for Impaired Skin Integrity and Pressure Ulcer .9/13/19 .chooses to sleep in her recliner .Nursing does check her glutes daily and apply [MEDICATION NAME] if needed .4/29/20 wound care RN (Registered Nurse) does spend time with R5 this date to explain risks and potential issues with her change in mobility and need to ask for assist if incontinent or needing assist with mobility. Intakes have been good, and R5 continues to desire to sleep in her recliner. Has a waffle cushion in place in her recliner . (SIC) R5's CNA (Certified Nursing Assistant) care plan, with a review date of 7/15/20, includes in part: .Skin Care [MEDICATION NAME], Nurse/CNA to check glutes daily, Waffle cushion, Hydraguard TID .) R5's most recent MDS (Minimum Data Set) dated 7/10/20 documents the following: R5 transferred with 1 assist and required moderate assistance, was at risk for pressure injuries but did not have any, utilized a pressure reducing device for chair and was occasionally incontinent of urine. It is documented that R5's BIMS (Brief Interview of Mental Status) score was a 14, which indicates she was cognitively intact. R5 Nurse's Notes include the following: 8/1/20, 8/2/20, 8/4/20 document General Skin Condition: Hydraguard applied to gluts (SIC) 08/06/2020 08:46 PM Weekly Skin Observation: resident glutes red but intact . (SIC) 8/7/20-8/16/20 document General Skin Condition: or Note: Hydraguard applied to gluts (SIC) 08/17/2020 12:50 AM General Skin Condition: [MEDICATION NAME] was applied to gluts this noc (night shift) (SIC) 08/18/2020 05:39 AM Note: [MEDICATION NAME] applied to gluts (SIC) 08/20/2020 01:52 PM Skin Problems: two open areas on left glute, Writer cleansed well and covered with silicone boarder dressing. Charge nurse and wound nurse updated, 08/20/2020 03:59 PM Assessment Type: follow-up assessment, Area 1: left upper glute., Wound Type: eschar/sloughing, Wound Tissue: yellow 100% slough tissue present., Surrounding Tissue: reddened, intact and blanchable, small open present, Healing Progress: not applicable (new area), Description: sloughing occurring, Pain related to Wound: no pain reports occasionally it stings, Body Position when Measured: standing, Area: width (cm) .4, length (cm) .5, Length x Width (SQ CM)= 0.2, Area 1 L X W Score: < 0.3 (1), Area 1 Exudate Amount: light (1) serous, Area 1 Tissue Type Score: slough (3), Area 1 PUSH Score: 5, Comments: Follow up assessment this date to glutes region. Writer notes open wound to upper left glute region, that is consistent of 100% slough tissue, writer will place order for [MEDICATION NAME] to this area. Writer noted that R5 has an waffle cushion in her recliner. Writer has educated R5 the risks of not repositioning and the benefits of repositioning. No s/s (signs and symptoms) of infection present at this time. Will place order for dressing at this time. Charge nurse is updated on this new open area. (SIC) It is important to note on 8/20/20 when wounds were discovered, only 1 wound was measured and there is no evidence that R5's Physician was consulted 08/22/2020 09:47 PM Skin Problems: writer cleansed and dried gluts this pm shift, writer applied hydroguard around dressing on left glut, dressing remains intact, clean and dry. Right glut appears intact with pinkness, blanches. Open area observed, scant amount of yellowish drainage around site. Area appears approximately size of a pea. Writer updated on-coming wing nurse .upon findings (SIC) 08/23/2020 03:33 AM General Skin Condition: Hydroguard barrier cream applied to gluts for protection .01:48 PM Glutes are reddened applied hydraguard. Applied treatment as ordered. Treatment site appears red and slightly tender with a white spot in middle. No drainage on dressing .07:42 PM writer cleansed and dried gluts this pm shift, writer applied hydroguard around dressing on left glut, dressing remains intact, clean and dry. Right glut appears intact with pinkness, blanches. Open area observed, to left mid (middle) glut region, scant amount of yellowish drainage around site. Area appears approximately size of a pea. (SIC) 08/24/2020 02:23 AM General Skin Condition: Hydroguard barrier cream applied to gluts for protection .07:08 AM [MEDICATION NAME] applied to left glut two open areas. Noticed one superficial open area to right glut, writer applied [MEDICATION NAME] to that area as well .11:56 PM Hydroguard barrier cream applied to gluts for protection (SIC) It is important to note on 8/24/20 it is documented there is a wound on R5's right gluteal region and treatment was applied, there is no documented assessment or measurement of this new area and R5's Physician was not consulted about new area or treatment. 08/25/2020 02:05 PM Note: Writer noticed this morning a few new open areas to left and right gluts while was doing treatment to the left glut. Wound nurse .assess the gluts, R5 mentioned that she just started using the heat in her recliner for about a week. Resident was encouraged to stop using the heat. Hydrogurd cream applied, open areas covered with [MEDICATION NAME] follow with silicone dressing. (SIC) It is important to note on 8/25/20 it is documented there are a few new areas to bilateral gluteal regions, there is no documented assessment or measurement of these new areas and R5's Physician was not consulted about new areas or treatment. 08/26/2020 09:24 AM General Skin Condition: hydraguard applied to gluts .09:36 AM Follow up assessment on 8/25/2020. Writer assessed bilateral gluts regions, noting two open areas not noted to the right glut, one small open area noted to the left glut, and generalized redness noted throughout gluts. Writer notes upon standing R5 that her lower back is rather warm, however R5's face does not feel the same temperature. Writer asks R5 if she is feeling okay, she states she feels fine. R5 then goes on to say she has been using the heating element on her recliner that she has been using since last week. Writer feels that the heat is most likely the contributing factor to these areas that are presenting as shallow blisters. R5 is educated on not to use the heating part of the recliner in efforts to help these areas. Writer no longer feels these areas are related to pressure, although writer does spend some time educating R5 about using a bed to lay down in. R5 reports that she cannot sleep in a bed due to comfort and that she feels that she gets back far enough in her recliner to offload. Writer further educates R5 that she has incontinence also that may contribute to skin irritation to her gluts. R5 states she will be sure to alert staff if she feels that she had an incontinence episode. Writer explains to R5 the changes with PH (scale used to specify the acidity or basicity of a solution) in skin with incontinence and then adding heat also poses a risk for infection and further breakdown. Will place out three day EMR at this time to help determine any incontinence patterns. Will also initiate tx (treatment) for [MEDICATION NAME] to open areas followed by foam dressing .11:15 AM Open areas covered with [MEDICATION NAME], silicone dressing applied. (SIC) It is important to note on 8/26/20 WCC, RN changes wound treatment, there is no documentation that R5's Physician was consulted about this treatment change. 08/27/2020 02:49 AM General Skin Condition: Hydraguard barrier cream applied to gluts for protection .12:03 PM General Skin Condition: Follow up assessments this date to bilateral gluts, writer notes that these area healing nicely since the stopping of heat to the recliner chair. Dressings changed this date per orders with improvement noted. Two open areas noted to left glut and one open area noted to right glut, less slough noted as well. Will continue with [MEDICATION NAME] and [MEDICATION NAME] .09:55 PM .Gluts appear with intact dressing to left and right gluts at this time, remain dry, with no drainage noted, resident denies any pain or discomfort to glut region. Hyrdoguard applied to gluts around dressing at this time .11:55 PM Hydraguard applied to gluts as ordered (SIC) It is important to note on 8/27/20 all wounds should have been measured per current standard of practice. 08/28/2020 07:44 AM General Skin Condition: treatment done to both gluts as ordered, open areas getting smaller, some drainage noted on previous dressing. encouraged this resident not to use heat on recliner. (SIC) 08/29/2020 03:05 AM Note: hydraguard applied to gluts as ordered (SIC) 08/30/2020 02:31 AM Note: hydraguard applied to gluts as ordered (SIC) 08/31/2020 05:26 AM Note: hydraguard applied to gluts as ordered (SIC) 09/01/2020 09:44 AM MD (Medical Doctor) Rounds: .MD updated on 'burns' on her gluts from using the heating element in her recliner. Areas are improving and R5 is no longer using the heating function .MD gives NNO (no new orders) this day .02:02 PM Note: dressings changed to inner gluts areas cleansed [MEDICATION NAME] applied to open areas and covered with silicone border dressings. (SIC) 09/02/2020 09:41 AM General Skin Condition: hydraguard applied to glutes, 09:56 AM Note: dressings changed 9/1/20 according to charting. Dressings in place to bilateral glutes .04:31 PM Assessment Type: follow-up assessment, Area 1: left glut, Wound Type: burn type lesion, Wound Tissue: yellow 75%, 25% pink tissue noted, Surrounding Tissue: reddened, Healing Progress: improving, Description: becoming smaller appears more clean, Pain related to Wound: no pain, Body Position when Measured: standing, Area: length (cm) .4, width (cm) .3, Length x Width (SQ CM)= 0.12, Area 1 L X W Score: < 0.3 (1), Area 1 Exudate Amount: light (1) serous, Area 1 Tissue Type Score: slough (3), Area 1 PUSH Score: 5, Comments: Follow up assessment this date to bilateral glut regions. Writer notes open areas on both gluts, approximately the same in size. Open area on right glut has 40% slough and 60% pink tissue noted. R5 reports she had not been using the heating element part of her reclining chair. No s/s of infection noted to either of these areas. Writer continues to provide education related to offloading and pressure reduction. R5 continues to have an waffle cushion in her reclining chair. R5 continues to decline wanting to use a bed in her room, again risks discussed as well . (SIC) 09/ 0 03:21 AM General Skin Condition: Hydraguard barrier cream applied to gluts for protection (SIC) It should be noted on 9/3/20 all wounds should have been measured per current standard of practice. 09/04/2020 01:50 AM General Skin Condition: Hydraguard barrier cream applied to gluts for protection .01:34 PM Note: [MEDICATION NAME] intact to bilateral glutes changed 9/3/20, 11:55 PM General Skin Condition: Hydraguard barrier cream applied to gluts for protection (SIC) 09/05/2020 11:30 PM General Skin Condition: Hydraguard barrier cream applied to gluts for protection (SIC) 09/06/2020 11:43 PM General Skin Condition: Hydraguard barrier cream applied to gluts for protection (SIC) 09/08/2020 01:23 AM General Skin Condition: Hydraguard barrier cream applied to gluts for protection, several superficially open areas .07:57 AM Note: Writer noticed that both gluts a multiple scattered small open areas, similar to blisters open up. treatment done to both gluts as ordered. (SIC) It should be noted on 9/8/20 it is documented that there are several wounds present, there is no documentation of assessment or measurements of these areas and R5's Physician was not consulted about these areas. 09/09/2020 10:20 AM Both gluts have multiple scattered small open areas. They appear to be blister like. Silicone border dressing replaced. Open areas were bleeding .10:37 PM General Skin Condition: Writer observed gluts to find dressing on left glut, but right glut is open, firm, and actively bleeding. Bilateral gluts have multiple fragile areas and what appears to be boils. Resident does c/o (complain of) pain during assessment. Wound bed to area on right glut is red with slough noted to all edges. Writer cleansed, applied [MEDICATION NAME] and silicone dressing. Writer did discuss with R5 the importance of offloading, but resident states she has not slept in a bed in [AGE] years and only sleeps in her recliner. Resident does have a waffle cushion in her chair at this time. Will continue with current tx. (SIC) 09/10/2020 12:39 AM General Skin Condition: Hydraguard barrier cream applied to gluts for protection .08:49 AM Weekly Skin Observation: .new dressings put on to both glutes with skin break down and multiple open areas .09:04 PM [MEDICATION NAME] 325 MG (milligrams) Tablet (2 tablet/650 mg) pain/discomfort, Pain Level Before Med: 5/10, Location: in both glutes (SIC) It should be noted on 9/10/20 all wounds should have been measured per current standard of practice. 09/11/2020 01:28 AM PRN (as needed) Med Given: [MEDICATION NAME] HCl 50 MG (1 tablet/ 50 mg) given for pain, Pain Level Before Med: 7/10, Location: gluts, PRN Med Result: 02:28 AM no further complaints, 01:28 AM PRN Med Given: [MEDICATION NAME] 325 MG (milligrams) Tablet (2 tablet/650 mg) given for pain, Pain Level Before Med: 7/10, Location: gluts, PRN Med Result: 02:28 AM no further complaints, 02:29 AM Note: hydraguard applied to gluts as ordered. foam dressing intact to each glut., 12:34 PM Nurse Contact: writer is updated by DON B (Director of Nursing) on open areas on R5's bottom that appear to be infected. suggests ABX (antibiotics) as well as opticell and AG foam dressing. Physician Contact: writer contacts Dr (Doctor) .regarding worsening areas to glutes, increased pain, purulent drainage, overall discomfort, and requesting to lay in bed. writer informs Dr .R5 has not bed in a bed for years as she has requested to sleep and rest in her recliner. Physician Response: Dr .gives orders to begin [MEDICATION NAME] (antibiotic) TID for 1 week. Dr .agrees with WCC (wound care certified) nurse dressing suggestion. Dr .does request R5 come into office to be seen by himself or WCC nurse in clinic. writer does inform him that R5 most likely will not want to come in as out of facility appointments cause such exhaustion but will update and inform resident on his request. new orders received and noted .04:45 PM Important Note: writer is requested by Dr .to be able to view the areas on R5's glutes, Physician Response: After viewing R5's glutes, Dr .orders writer to send to ER (emergency room ) because he feels she has [MEDICAL CONDITION] and abscesses. orders received and noted .Important Note: Ambulance leaves with R5 at approximately 245. (SIC) 09/12/2020 11:12 AM Nurse Contact: writer speaks with .RN at .Hospital acute care, who give writer an update on R5: R5 was admitted for [MEDICAL CONDITIONS]. her WBC (white blood cell) 15.7 and hemoglobin 6.6. R5 is receiving 1 unit of blood and is on IV (intravenous) ABX. States she is in good spirits and no having much pain at this time . (SIC) 09/16/2020 12:07 PM Important Note: R5 returned from stat at .Hospital this date. Was admitted to .Hospital on 9/11. Resident appears exhausted and frail .Was able to view bottom only during transfer and noted that a [MEDICATION NAME] in place, will do full wound assessment after lunch when resident is in bed for easier viewing and wound care .(SIC) R5 was hospitalized from [DATE]-9/16/20. Hospital notes from 9/12/20 state in part; .Skin Additional Details: Patient has the following wounds to her buttocks and gluteal folds: Wound 1: Left gluteal fold has an open stage III pressure wound, with fat layer exposed, and measures 2.1 cm (centimeter) long x 1 cm wide and .8 cm deep with tunneling of .5 cm between 1300 (1 o' clock) and 1500 (3 o' clock). There is yellowish drainage and adherent slough. This wound was debrided and the tissue base is pink. Wound 2: Right buttocks has a clustered wound that is 2.5 cm x 2.5 cm. This wound is covered in adherent yellowish slough and is unstageable. There is no drainage present. Wound 3: Right buttocks wound 2 cm x 2 cm. This wound is unstageable, but appears to be a full thickness wound with wound base covered in black adherent slough. Wound 4 and wound 5 are also located on the right buttocks and each measure 1 cm x 2 cm and are stage II pressure wounds. These wounds are red in color and have minimal serosanguineous drainage. Overall the wounds are tender and rated as a 2-3 in terms of pain on a scale of 1-10. The greater periwound areas are bright red and excoriated and appear to be fungal in nature. (SIC It should be noted on 9/16/20 R5 returns from hospital and there is not an assessment or measurements documented. 09/17/2020 10:45 AM Physician Contact: Writer placed phone call and spoke with Dr .updating MD on residents return from the hospital, current condition and staff concerns this morning- hallucinations, refusals of medications, shortness of breath and making comments of wanting to die .MD and writer review Wound Culture, [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) .02:39 PM Assessment Type: follow-up assessment, Area 1: back of left thigh, Onset/Discovery Date: 09/16/2020, Wound Type: eschar/sloughing, Wound Tissue: yellow, Surrounding Tissue: reddened, Healing Progress: not applicable (new area), Description: tenderness present sloughing occurring, Pain related to Wound: pain present (describe): resident c/o pain with touch/wound care; Area 2: perineum, Onset/Discovery Date: 09/16/2020, Wound Type: abscess, Wound Tissue: pink, Surrounding Tissue: purple colored area, Healing Progress: improving .Description: becoming smaller, Pain related to Wound: pain present (describe): resident c/o pain with touch/wound care; Area 3: left pubic bone area, Wound Type: open lesion from previous abscess, clean non granulation tissue present, Wound Tissue: pink, Surrounding Tissue: WNL (within normal limits), Healing Progress: improving, Description: becoming smaller, Pain related to Wound: pain present (describe): resident c/o pain with touch/wound care; 04:05 PM Physician Contact: Writer speaks with Dr ., updating on new wound care orders per WCC, RN and MD relates that his is fine with WCC, RN making recommendations for treatment .10:36 PM Weekly Skin Observation: .multiple open areas noted to bilateral gluts. gluts cleansed with NS (normal saline) open two open areas to right glut and three to left glut covered with silicone dressing (SIC) It should be noted on 9/17/20 one wound is documented but not the other 4 wounds and there are no measurements. 09/18/2020 06:39 PM Physician Contact: Writer spoke with Dr .regarding the resident agitation, falls and current condition .Physician Response: Dr .agrees that comfort measures is a great option given the resident health and agrees to sign the order and send them back. new orders received and noted, 08:07 PM [MEDICATION NAME] HCl 50 MG Tablet (1 tablet/50 mg) pain/discomfort Pain Level Before Med: 5/10, Location: all over . (SIC) 09/19/2020 02:07 PM Medicare Charting: .R5 made comments earlier in the day that I just want to die.03:08 PM Behavior: .I just want to die please let me die.Where is Ernie I want my Ernie.06:35 PM Physician Response: Dr .agrees that comfort measures are appropriate to continue and that we can stop all of her medications at this time. New ordered received and noted. (SIC) 09/20/2020 01:49 PM Current Pain Level: 06/10 severe .02:16 PM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for pain, Pain Level Before Med: 6/10, Location: in back and neck, 05:29 PM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for pain, Pain Level Before Med: 5/10, Location: all over, 08:57 PM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for pain, Pain Level Before Med: 5/10, Location: all over (SIC) 09/21/2020 12:46 AM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for pain/discomfort, SOB (shortness of breath) with drinking, labored respirations, Pain Level Before Med: 5/10, Location: all over, 12:48 AM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for pain/discomfort, Pain Level Before Med: 6/10, Location: all over, 01:58 AM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for pain/discomfort, labored breathing, restlessness, Pain Level Before Med: 5/10, 0315 AM PRN Med Result: 03:15 AM med effective, resident is fidgeting in bed but is less restless, 06:21 AM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for general discomfort end of life, restlessness, labored breathing, Pain Level Before Med: 5/10, Location: all over, 02:17 PM note: resident appears comfortable in bed this shift, given [MEDICATION NAME] around 12;30 pm. resident is unresponsive . (SIC) 09/22/2020 10:28 PM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for end of life care, 11:03 PM PRN Med Result: 11:03 PM resting (SIC) 09/23/2020 12:32 AM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for agitation agitated, 03:30 AM PRN Med Given: [MEDICATION NAME] (Concentrate) 20 MG/ML (milliliter) Solution given for agitation agitated. 04:00 AM PRN Med Result: 04:00 AM sleeping, 06:26 AM Physician Response: Writer called down to resident's room around 0550 to find no signs of visible life noted. Writer calls on call MD, Dr .and gets order to release the body to the funeral home (SIC) It should be noted from 9/18/20 through 9/23/20 when R5 passes away, there is no documentation regarding her wounds. On 10/5/20 at 1:33 PM, Surveyor interviewed CNA C. Surveyor asked CNA C what she could tell me about R5's skin problems, CNA C said randomly all of a sudden she had these areas that looked like boils. Surveyor asked CNA C what her skin looked like just before that, CNA C said it was really red. Surveyor asked CNA C what she knew about R5's recliner, CNA C replied that R5 had been using the heat function and the nurses thought that was part of skin concern. Surveyor asked CNA C what was done so that R5 couldn't use heat function any longer, CNA C stated we told her not to use it and she didn't, R5 was able to follow directions well. Surveyor asked CNA C if R5's treatment was completed as ordered, CNA C I only work AM shift and our nurses made sure it was done. On 10/5/20 at 3:14 PM, Surveyor interviewed Minimum Data Set Coordinator D (MDS Coordinator). Surveyor asked MDSC D what she could recall in relation to R5's wounds. MDSC D explained that the Previous Wound Care Certified Registered Nurse (WCC, RN)came to her to discuss the wounds but at the time, she hadn't seen them, R5 had some more frequent urinary incontinence episodes as of late. Surveyor asked MDSC D if a Physician should be consulted for wound treatment orders, MDSC D said Previous WCC, RN wrote orders because the Physician's were ok with it. Surveyor asked MDSC D where the recliner came into play with the wounds, MDSC D said the recliner is hers but R5 just started using the heat function and then these wounds were discovered. Surveyor asked MDSC D if R5 always had that recliner, MDSC D said yes, R5 has had that recliner the whole time; MDSC D went onto explain R5 had a waffle cushion in recliner. Surveyor asked MDSC D if she saw R5's wounds at any point, MDSC D stated when I saw them, it was after her hospitalization and there were 5-6 pencil eraser size perfect circles to her bilateral gluteal regions. On 10/5/20 at 4:08 PM, Surveyor interviewed MS E (Maintenance Supervisor). Surveyor asked MS E if he was familiar with R5's recliner, MS E stated R5 is always in that recliner, it has been in there forever. Surveyor asked MS E if she ever had to work on R5's recliner, MS E said no. Surveyor asked MS E if he does safety checks on the furniture residents bring in, MS E said no, not if it's their personal property, if there's an electrical issue with it, I'll put a lockout/tagout on it so that it is not used. Surveyor asked MS E if he was asked to look R5's recliner in August or September, MS E stated no. Surveyor asked MS E where the manufacturer's recommendations for R5's recliner might be, MS E said if the chair has pockets, likely in there otherwise we send them home with the family so that they don't get lost. On 10/5/20 at 4:21 PM, Observation of R5's recliner with MDSC D and NHA A (Nursing Home Administrator) present. R5's recliner was in empty room on Cedar wing. Recliner was plugged in, MDSC D pushed the Heat button, after 10-15 minutes, lowest cushion tuft on back of recliner that meets the seat cushion was warm. Area was not hot. No other areas of recliner were noted to be warm. On 10/5/20 at 5:22 PM, Surveyor interviewed Previous WCC, RN F. Surveyor asked Previous WCC, RN F what she could recall about R5's wounds, Previous WCC, RN F stated she had a few circular spots that came and went to bilateral gluteal regions and we determined they developed from her using the heat from her recliner, I think that was in July or August, the area improved once R5 stopped using the heat. Surveyor asked Previous WCC, RN F what the wounds looked like, Previous WCC, RN F explained the one wound had 100% slough present so she ordered [MEDICATION NAME] to clean it up; she went on to explain R5 didn't use a bed but she had a waffle cushion in her recliner, In the beginning of my assessment I noticed R5's skin was warm, I touched the chair- it wasn't burning hot but warm, no blistering noted but I felt the warmth combined with the moisture were factors in the wounds. Surveyor asked Previous WCC, RN F what size the wounds were, Previous WCC, RN F said they were insignificant less than a cm. On 10/5/20 at 5:45 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if he would expect wounds to be measured regularly, NHA A said yes, I would expect the normal protocol for measurements to be done. Surveyor asked NHA A if he would expect a Physician to be consulted for order changes and updates on wounds, NHA A stated yes, prior to administering the treatment. Surveyor asked NHA A if these wounds were thought to be burns, would anything have been done differently, NHA A explained that an investigation would have been done and they would have looked into whether or not R5 was appropriate to operate recliner with heat in it. On 10/12/20 at 1038 AM, Surveyor interviewed DON B. Surveyor asked DON B what she could recall about R5's wounds, DON B stated Previous WCC, RN F was the wound nurse when R5's wounds were discovered, she felt the recliner heat caused the areas, she ordered a treatment and sometime after Previous WCC, RN F had left, R5 requested a bed, then DON B assessed; DON B went on to explain after she assessed she viewed these areas as abscesses, the Dr was called and she was sent to ER then admitted to the hospital. Surveyor asked DON B what did R5's wounds look like upon her return, DON B said great improvement with IV antibiotics. Surveyor asked DON B should the WCC, RN F consult a Physician for order changes and updates on wounds, DON B stated yes she should have updated MD. Surveyor asked DON B is she was aware that Previous WCC, RN F was not consulting Physician, DON B stated no, I was not aware. Surveyor asked DON B when she would expect wounds to be measured and assessed, DON B replied weekly, I've been trying to get the nurses to do this for quite a few weeks. Surveyor asked DON B if there is anyone in facility currently that has wound care certification (WCC) DON B stated yes, myself and a NOC shift nurse as well. Surveyor asked DON B if there was anything else about R5's wounds she could think of, DON B replied R5 had the waffle cushion in her recliner because she was in it all the time, we explained risk versus benefits with her and R5 wanted just the recliner; DON B went on to say R5's wounds were clearly abscesses, they were the same shape and size, developed from heat and incontinence, and were greatly improved after hospitalization with IV antibiotics. Surveyor asked DON B if the risks versus benefits were verbal or if there was something that R5 signed for that, DON B said they are verbal only. (TRUNCATED)

Based on observation, interview and record review, the facility did not ensure that a resident who enters the facility without a PI (Pressure Injury) does not develop a PI and a resident with a PI receives appropriate care, treatment, and preventative interventions to promote healing for 1 of 3 residents reviewed (R2). R2 was admitted to the facility without a PI and was identified to be at risk for PI development. R2 is paraplegic and does not have sensation from his low back to his feet. R2 was observed to have multiple layers of linens on his air mattress and was known to enjoy sitting in his wheelchair for long periods of time. R2 developed redness on his buttocks and new interventions were not immediately put into place. The facility staff did not follow physician orders [REDACTED]. This is evidenced by: The National Pressure Ulcer Advisory Panel (NPUAP) at www.NPUAP.com defines PI's in the following category: Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. The NPUAP guidelines, dated 6/13/12, recommends use of positioning devices and incontinence pads that are compatible with the support surface and to limit the amount of linen and pads placed on the bed. They also direct clinicians not to leave moving and handling equipment under the individual after use. (Of note, the facility was leaving the Vanderlift sling under R2 until 7/16/19.) The facility's policy Skin Care and Pressure Ulcer Prevention, with a revision date of 3/5/19, includes, in part: Procedure: 5. Pressure Injuries will be measured every 7 days; Preventative Measures will be provided including: 3. Maintaining good body alignment and proper positioning of residents. Avoid direct contact between bony prominences. 4. Encourage and assisting residents to change position at least every 2-3 hours day and night to stimulate circulation and prevent ulcers and deformities. 9. Nurse observes skin at least weekly. 18. Proper incontinence care after each incontinent episode. 22. Educate residents about need for position changes and shifting weight to prevent pressure related problems. The facility's Infection Control Policy and Procedure, updated 7/2013, includes, in part: Hand Hygiene: Consistent and proper hand hygiene practices are critical in preventing the spread of infection. 1. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal cares. j. Before and after assisting a resident with toileting (hand washing with soap and water). R2 was admitted to the facility, on 6/18/19, with [DIAGNOSES REDACTED]. R2's Admission MDS (Minimum Data Set), dated 6/25/19, indicates R2 is cognitively intact based on a BIMS (Brief Interview for Mental Status) score of 13. R2 requires extensive assist with 2 for bed mobility and R2 was deemed at risk for PI and did not have a PI upon admission. R2's CAA (Care Area Assessment) worksheet for Pressure Ulcer, dated 7/1/19, includes, in part: no pressure ulcers, but is at risk with his limited mobility and [MEDICAL CONDITION] and incontinence of bowels. Prone to bruise easily with his anticoagulant therapy. [MEDICATION NAME] Factors: Immobility and Incontinence. medications: [REDACTED]. Treatments/ Other Factors: Newly admitted /readmitted . Description of Problem: Is at risk for skin breakdown. Care Plan: Will develop Care Plan and maintain skin integrity. Review of R2's Braden (skin breakdown risk), dated 6/18/19, indicated a score of 15, indicating R2 is at mild risk for skin breakdown. Review of R2's Braden, dated 6/24/19, 7/1/19, 7/8/19 and 7/15/19, indicated scores of 16, indicating R2 is at mild risk for skin breakdown. (Of note, the section under mobility indicates: very limited - makes occasional slight changes in body /extremity position, can't make frequent /significant changes alone.) R2's Comprehensive Care Plan At risk for impaired skin integrity (Pressure Ulcer), dated 6/19/19, includes, in part: Goal: dated 7/5/19, skin will remain intact. No skin breakdown. Approach: dated 7/5/19, Nurses-R2 has limited mobility r/t (related to) T - 10 vertebral Fracture. Encourage participation in therapy and reposition every two hours. R2 is incontinent of bowel at times and has a urinary catheter in place. Routine skin checks weekly. Braden scale assessment on admission to determine risk factor areas. Braden scale assessment done weekly for 4 weeks post admission and thereafter monthly. [MEDICATION NAME] ointment use PRN (as needed) for skin protection. Keep skin clean and dry. Monitor need for specialized cushion or mattress. Update RN (Registered Nurse) with changes in skin integrity. Nurse Aides: dated 7/5/19 - Assist with ADL's and report any changes in skin integrity to nurse immediately. Reposition every 2 hours. Utilize lotions and barrier ointments PRN. Float heels off surfaces. Ensure provided cushion in place in wheelchair. CNA (Certified Nursing Assistant) Care Plan, dated 7/8/19, includes, in part: Bed mobility - 1 assist has trapeze. (Of note, R2's MDS indicates R2 requires extensive assist with 2 staff.) Skin Care - [MEDICATION NAME], Reposition every 2 hours. Reposition every 1 hour, was updated 7/22/19. Remove Vander sling from w/c (wheelchair) and recliner, updated 7/15/19. Not to be up in w/c or recliner longer than 1 hour at a time, updated 7/22/19. ROHO cushion in w/c, 7/22/19. R2's Initial Nursing History and Assessment form, dated 6/18/19 at 1:15 PM, includes, in part: Skin Condition, pink, warm and dry. The body diagram is blank indicating there is no sign impairment and is signed by LPN G (Licensed Practical Nurse). (Of note, this assessment does not address bed mobility and the section on Transfer / Ambulation is left blank.) R2 was originally placed on an Advantage Flippable Mattress. Manufacture's recommendations include, in part: High resiliency foam for extended wear. Provides pressure redistribution. Nylon cover reduces shear and friction. R2 was originally given a Waffle cushion for his wheelchair. Manufacture's recommendations include, in part: redistributes pressure and minimizes shear and friction. Physician Orders, signed and dated 6/19/19, includes, in part: Treatment Skin - [MEDICATION NAME] Protective Skin Ointment daily and PRN. Apply to affected areas. (Of note, R2's care plan indicates the [MEDICATION NAME] should be used PRN when the Physician order [REDACTED].) Physician's Progress Notes, dated 6/19/19, includes, in part: R2's decreased mobility will be an incredible detriment for him. Review of Weekly Skin Observation Notes, dated 6/26/19 at 9:33 PM, includes, in part: skin intact, glutes redness but blanchable. Review of Weekly Skin Observation Notes, dated 7/16/19 at 11:19 AM, includes, in part: [MEDICATION NAME] applied to superficial area on left glute. physician's orders [REDACTED]. physician's orders [REDACTED]. (Buttocks) Check placement of [MEDICATION NAME] every day; change every three days and PRN. Review of General Skin Condition Notes, dated 7/16/19 at 2:40 PM, by Wound Care Certified (WCC) RN D includes, in part: noted a diffuse rash to right inner glute region. Left upper glute has 3 circular areas, one most distal is intact pink area that blanches appropriately, just above this is what appears to be some darker open area that appear more deep red in color. As if the skin was pinched with friction, this area entirely measures at 1 cm (centimeter) x (by) 1 cm, [MEDICATION NAME] had been rubbed over this area. RN D attempted to remove to assess area closer, RN D gently removed [MEDICATION NAME] with a cloth wipe and note part of skin is removed away from area leaving area open slightly not entirely - no exudate is noted. R2 has no feeling to his legs / torso so he denies any real pain to this general area. Darker skin area does appear to be irregular and jagged and given location / description is slightly raised. RN D concludes area was most likely from friction. RN D feels if the areas were pressure related they would be more circular and over direct bony prominence. R2 is a Vanderlift, RN D added order and guideline to remove sling from under R2 when in his w/c and recliner. R2 has a waffle cushion in his w/c already. Will continue to monitor this area. Will place a [MEDICATION NAME] over this area for ongoing monitoring. Physician's Progress Notes, dated 7/17/19, includes, in part: R2 has [MEDICATION NAME] and ongoing skin treatments for left gluteal superficial skin irritation, but no marked skin breakdown. We have to be careful with the Vanderlift to not cause further irritation. Review of Weekly Skin Observation Notes, dated 7/17/19 at 10:58 PM, includes, in part: Glutes and pressure area present. Foam dressing no longer in place with another barrier cream to be started. Review of Weekly Skin Observation Notes, dated 7/21/19 at 11:32 PM, includes, in part: Dressing changed to coccyx; this is due to R2 returning from an MD (Medical Doctor) appointment and had been incontinent of bowel. Wound is worsening due to pressure. R2 encouraged to lie on sides completely but R2 refuses stating, to feel more comfortable lying on his back. (Of note, per interview with R2 and FM [NAME] (Family Member), they both indicated R2 does not refuse to be turned and repositioned as R2 and FM [NAME] want these wounds to heal. physician's orders [REDACTED]. Apply Enluxtra (wound dressing) dressing over entire area, ensuring overlapping 2 cm to surrounding intact skin. Cover with Duoderm or [MEDICATION NAME] dressing. Check placement every day and change every other day and PRN. Wound Assessment, dated 7/22/19 at 11:39 AM, includes, in part: Area 1: left upper glute now spreading to right upper glute as well. Wound Type: Eschar / sloughing unstageable, 30% slough tissue adhered more too distal left glute, where areas were noted last week. The rest of the wound appears to be intact dark purple in color spreading to right upper glute as well. Wound Tissue: yellow 30% slough, 70% necrotic tissue that is intact. Healing Progress: Area is larger. Length: 3.5 cm x Width 6 cm. R2 has 2 hour repositioning in place, however, will also add that R2 only be allowed to be up in w/c for 1 hour at a time. RN D spoke with R2 to see what has been different in the last week or so. R2 indicated he was up in his w/c more often than prior, as therapy has been working with positioning. R2 has a waffle cushion since admission. RN D will look for an alternative cushion such as a ROHO. RN D feels incontinence is playing a huge roll into skin integrity and R2 is not able to tell you when he has to or goes. RN D will place R2 on a check and change every 2 hours. RN D does classify area as pressure. (Of note, on 7/22/19, the facility added the Lumex air mattress to R2's bed. Manufacture's recommendations include, in part: Provides pressure displacement and redistribution to assist in the prevention and treatment of [REDACTED]. The facility changed R2's waffle cushion to a ROHO cushion today. ROHO manufacture's guidelines include, in part: adjustable cushion with a multi - cellular, air filled design adjusts to contours of the patient for maximum support and reduce the risk of ischemic ulcers.) Wound Assessment, dated 7/25/19 at 10:56 AM, includes, in part: Area 1: right glute (previously documented as left glute as RN D misinterpreted R2's position while lying in bed). Wound Type: Eschar / sloughing. Wound Tissue: 5% pink, 70% eschar and 25% slough tissue. Healing Progress: improving. Length: 3.5 cm x Width 3.8 cm RN D indicates this wound has debrided since last assessment. R2's wound did have some slight odor prior to cleansing. Improvement noted after cleansing. Wound does have some eschar tissue that was underneath the skin that had debrided. Wound appears shallow in nature at this time. RN D implemented 2 hour check and change, air mattress, and ROHO cushion in w/c, limiting time up to only 1 hour at a time and twice weekly skin checks. Wound Assessment, dated 7/25/19 at 10:56 AM, includes, in part: Area 2: left glute (previously mistaken as right glute). Wound Type: Eschar / sloughing healing (presents as Stage 2) Wound Tissue: 100% pink. Healing Progress: improving. Length: 2cm x Width 1cm RN D notes an improvement to left upper glute region from earlier in the week when area was dark / discolored intact skin. This area now has 100 % pink tissue noted after debridement. Comprehensive Care Plan At risk for Skin Integrity (Pressure Ulcer), updated 7/25/19, includes, in part: Left glute area? Trauma / infection. (Unstageable at this time 7-22-19). Nurses - now has a ROHO cushion and limited time up to 1 hour at a time. Nurses now doing 2 times a week skin checks. Tumex (SIC) air mattress applied this date as well. Check and change every 2 hours and PRN (every three hours at night) due to R2's incontinence. Wound Assessment, dated 7/29/19 at 5:17 PM, includes, in part: Area 1: bilateral upper glutes. Wound Type: Eschar/sloughing Wound Tissue: 70% thin/soft eschar, 25% slough tissue, 5% pink tissue mixed with slough tissue. Healing Progress: area has increased slough present and wounds are measured together this date as there was no distinct difference of intact skin between ulcerations. Length: 4 cm x Width 5 cm RN D indicates both areas measured together, increase amounts of necrotic tissue. No signs of infection present at this time. R2 indicates he was up in his w/c for an appointment today for a few hours, however, is abiding by recommendations. On 7/30/19 at 9:20 AM, Surveyor asked LPN C to describe the wound. LPN C indicated the wound was on both sides of R2's upper buttock crease and it looked like dark necrotic tissue. LPN C indicated the facility now only lets R2 be up in his wheelchair for 1 hour at a time. LPN C indicated R2 does not have any sensation in his buttocks. LPN C indicated R2 used to sit up in his wheelchair for long periods at a time. LPN C indicated the facility turns R2 every 2 hours and he now has a ROHO cushion in his wheelchair. On 7/30/19 at 9:33 AM, Surveyor observed R2 positioned on a Lumex air mattress set at the 7 O'clock mark. R2 was lying in bed diagonal on his left side. Surveyor asked R2 if he was having any pain. R2 indicated his pain was ok and rated it a 5-6. R2 indicated he has chronic back pain. R2's FM [NAME] indicated R2 does not have any feeling in his low back down to his feet. Surveyor asked R2 if she could observe his wound treatment if the dressing would need to be changed. R2 agreed. FM [NAME] indicated R2's sore started here. FM [NAME] indicated R2 sat in his wheelchair a lot and does not understand why the facility did not find the wound sooner. FM [NAME] indicated the facility has to change R2 when he is incontinent. FM [NAME] asked Surveyor if she would like to see a picture of the wound when the facility found it. FM [NAME] showed Surveyor two pictures that were on her cell phone. FM [NAME] indicated R2 asked to have the pictures taken so he could see the wound. Surveyor observed an L shaped wound that appeared dark purple / black. The wound was on R2's right buttock extending to the crease. R2 had multiple open excoriated areas on his left buttock via picture. Surveyor asked FM [NAME] for the date of the pictures. FM [NAME] indicated the wounds were found on 7/22/19. On 7/30/19 at 11:21 PM, Surveyor observed CNA H and CNA I reposition R2. R2's dressing was soiled with stool. CNA H used wipes to provide pericare to R2. CNA H's gloves were visibly soiled. CNA H touched the wipes package, then went to R2's bathroom and removed the container of [MEDICATION NAME] from the basin with personal care items. CNA H opened the container of [MEDICATION NAME], reached in the container and applied [MEDICATION NAME] to R2 buttocks below the soiled dressing. CNA H replaced the cap on the container and placed it back in the basin with the personal care items. CNA H then removed one glove from her right hand and donned a new glove without washing her hands. CNA I removed her gloves and left the room to notify LPN C that R2's dressing was soiled. CNA I came back into R2's room and donned gloves. CNA H pulled R2's [MEDICATION NAME] up his lower legs, straightened R2's undershorts with the original gloves and touched her own scrub top. LPN C entered R2's room. Washed her hands, donned gloves and placed two paper towels on the tray table. LPN C indicated she previously cleaned the scissors. Surveyor did not observe the sanitizing of the scissors. LPN C filled a basin with warm water. Per LPN C, she indicated she cleaned the basin earlier. LPN C put two pumps of [MEDICATION NAME] Foam (cleansing foam for total body cleansing) into the water in the basin. LPN C indicated R2's wound can be cleaned with soap and water or saline. (Of note, the physician's orders [REDACTED].) CNA H and CNA I slid R2 across the bed, with the sheet, to position R2 on his right side for the wound treatment. LPN C removed her left glove and sanitized her hand, then donned a new glove. LPN C removed R2's soiled dressing and disposed of it in the garbage can. LPN C removed her glove from her left hand only and did not wash her hands after removing the soiled dressing. LPN C donned a new glove and used a gauze pad to clean R2's wound with the [MEDICATION NAME] Foam / water solution. LPN C placed the paper towels on R2's bed and opened 2 [MEDICATION NAME] dressings and placed them on the paper towel. LPN C described R2's wound as 70 % eschar and 30% slough. LPN C removed one glove from her left hand and applied sanitizer to her left hand and donned a new gloved. LPN C measured the wound as 6 cm wide x 4 cm length. LPN C then cut the Enluxtra dressing to fit the wound. LPN C then placed the 2 [MEDICATION NAME] dressings over the top of the Enluxtra to secure it in place. LPN C removed her gloves and used sanitizer. LPN C did not wash her hands. (Of note, the dressing was soiled with stool, requiring hand hygiene with soap and water.) CNA H and CNA I placed a clean brief on R2. CNA I left the room to get the Vanderlift and CNA K returned with the Vanderlift. CNA H slid R2 across the mattress with the sheet. CNA K placed the Vanderlift sling under R2 and CNA H rolled R2 over to get the sling in position. (Of note, CNA H continues to wear the same gloves.) CNA K and CNA H transferred R2 into his wheelchair that had a ROHO cushion in place. CNA H and CNA K removed the sling that R2 was sitting on. CNA K indicated the staff now remove the sling from under R2 and do not leave it there. FM [NAME] propelled R2 to the dining room. CNA H made R2's bed, then removed her gloves, used hand sanitizer and left R2's room. On 7/30/19 at 11:55 AM, Surveyor interviewed CNA H regarding R2 cares and wound treatment. CNA H immediately stated, I forgot to wash my hands or use the sanitizer. Surveyor asked CNA H when she should have washed her hands. CNA H indicated she should have removed her gloves after providing peri care to R2 and washed her hands. CNA H indicated she should have put on new gloves before she grabbed the [MEDICATION NAME]. CNA H indicated she should have removed her gloves and washed her hands or at least used the hand sanitizer after applying the [MEDICATION NAME] to R2. On 7/30/19 at 2:05 PM, Surveyor interviewed CNA J regarding Vanderlift slings. CNA J indicated, if a resident is difficult to transfer, the facility usually leaves the sling under the resident. CNA J indicated the facility will remove the sling for most people. On 7/30/19 at 2:15 PM, Surveyor interviewed Maintenance F regarding the process for the setting for an air mattress pump. Maintenance F indicated he will look at the resident and, if they are around 150 pounds, he will set the pump at medium. If the resident looks larger, he will set the pump firmer. Maintenance F indicated the CNA's can always change the firmness. On 7/30/19 at 2:30 PM, Surveyor interviewed RN D regarding the process for the setting for an air mattress pump. RN D indicated there are no recommendations for the setting to use. RN D indicated whatever is comfortable for the resident. The facility usually sets it in the middle based on comfort. On 7/30/19 at 2:45 PM, Surveyor interviewed RN D regarding R2 and his wounds. Surveyor asked RN D if the facility removed the sling under R2, after he was transferred. RN D indicated no, as R2 had back pain, so the facility left the sling in place. Surveyor asked RN D if she was concerned when R2 developed redness to his glutes, on 6/26/19, and not having any sensation from the low back down. RN D indicted she was never told about the redness and was not aware that R2 did not have feeling in his lower back to his feet. Surveyor asked RN D if the facility had Shower Sheets or CNA Skin Documentation Sheets. RN D indicated the facility does not use a tool or separate sheet to document that a shower was given. RN D indicated the CNA's document if a shower is given vs (versus) personal hygiene on the CNA Progress Notes. RN D provided Surveyor documentation that R2 had a shower on 7/20/19 at 11:05 AM. Documentation includes: R2 is dependent plus 1 physical assist. Hair shampooed. RN D indicated if skin issues were to occur, the CNA would tell the nurse. RN D indicated R2 would go out for appointments and sit in his wheelchair for long periods of time. Surveyor asked if the facility gave R2 a better cushion or if there was education provided to off load his sitting surface. RN D could not provide documentation. Surveyor asked for risks benefits that were given to R2 for sitting in his wheelchair for long periods of time. RN D could not provide any risks/ benefits. RN D indicated when R2's glutes became red, she recommended the sling be removed from R2 after his transfer. RN D indicated she did not think R2's wound was pressure at first because R2 eats well. RN D indicated she thought it was friction. RN D indicated she had to wait until a better cushion became available, as the facility does not have extra ROHO cushions and RN D was not going to take a ROHO from another resident. RN D indicated the wound became Unstageable and the facility is limiting R2's time in the wheelchair and repositioning him every 2 hours. Surveyor asked RN D what should be used to clean R2's wound. RN D indicated soap and water or normal saline. Surveyor reviewed the physician's orders [REDACTED]. Surveyor reviewed R2's wound care observation provided by LPN C. RN D indicated she would have to look at the [MEDICATION NAME] Foam that was used for the treatment. Surveyor reviewed LPN C only removing one glove and not washing her hands. RN D said LPN C should have removed both gloves, washed her hands or sanitized prior to donning gloves. Surveyor reviewed R2's peri care provided by CNA H. RN D indicated CNA H should have removed her gloves and washed her hands with soap and water after performing peri care when R2 was incontinent of stool. RN D indicated R2's personal care items are not contaminated and she will be educating CNA H. The facility failed to ensure that a resident who enters the facility without a PI does not develop a PI and a resident with a PI receives appropriate care, treatment, and preventative interventions to promote healing. The facility failed to follow physician's orders [REDACTED].

Based on interview and record review, the facility did not ensure that the policy and procedures that prohibit mistreatment, abuse, and neglect of residents were implemented for 3 residents (R3, R10 and R11) with the potential to affect 72 female residents out of a total of 105 residents that reside in the facility. The facility did not immediately report allegations of abuse to the administrator and/or to the State Agency (R3, R10, R11), and did not fully investigate allegations of abuse and put measures in place to protect residents while an investigation was occurring (R3, R10, R11). The failure of the facility to implement its abuse policy and procedure created a situation where further abuse could occur and led to the finding of immediate jeopardy, which started on 3/29/18. The facility was notified of the IJ on 5/17/18 at 12:40 PM. It was determined that the immediacy was removed on 5/17/18, but not yet corrected. The deficiency continues at a scope/severity level E (potential for harm/pattern) because the facility has yet to fully implement, educate, and to evaluate the effectiveness of its action plan. This is evidenced by: The facility's policy and procedure for Abuse Prevention and Investigation, last reviewed 5/2017, includes, in part: All residents have the right to be free from any type of mistreatment or abuse .This facility will not tolerate abuse, neglect, or misappropriation of a resident's property. All allegations of abuse, neglect, or misappropriation and any injury of which the source cannot be identified will be investigated. The results of the investigation will be reported as required by state and federal laws and this policy and procedure . Upon a complaint or observation of suspected resident abuse the following steps will be taken. 1. A resident or family member may report an allegation of misconduct to any employee. Upon receiving an allegation, the employee will immediately take the necessary steps to protect the resident from possible subsequent incidents of misconduct or injury and then alert his or her immediate supervisor of the complaint. 2. The immediate supervisor, upon learning of the incident, will assure that the immediate actions to protect the resident from possible subsequent incidents of misconduct or injury are appropriate and sufficient. The immediate supervisor will then begin an investigation. 3. The employee, whom received the allegation, will compose a written statement detailing the alleged incident as reported by the resident. 4. The designee will be notified immediately of the resident's allegation. a. The designee is the person to notify of the situation and the order is as follows. If the first is not present in the facility, go on to the next. i. Administrator ii. Director of Nursing iii. QA nurse iv. Charge nurse 5. The designee will initiate a full investigation of the matter, which will include, but may not be limited to . a. The resident with the complaint will be interviewed and a written statement will be composed. b. The employee(s) involved will be interviewed, with such interview being documented. A written response to the allegations will be requested from the employee(s). c. Any other persons whom may have additional information will be interviewed as well, with written statements obtained. d. All aspects of the investigation will be documented. 6. Notification of necessary authorities will take place and will include a. Notifying the Office of Caregiver Quality immediately via the completion of the online form Alleged Nursing Home Resident Mistreatment Report. i. Immediately is as soon as possible but not to exceed 24 hours following the incident. http://www.dhs.wisconsin.gov/library/F- .htm b. After investigation is complete, DQA form F- should be completed and sent to DQA. This is to be done within 5 working days of the incident. c. Additional agencies may be notified as needed, such as law enforcement, if there are reasonable grounds to believe that a crime has been committed. 7. Throughout the entire investigation, from the time the initial observation is made or the alleged complaints received, actions will be taken to assure that the resident and all other residents are safe and protected from any possible subsequent misconduct. 8. When investigation is complete, the administrator shall determine whether the allegation is substantial or not and shall take appropriate action with respect to the involved employee or person. This final action shall be in accordance with state and federal law. 9. Abuse can occur by staff, a family member, friend or other visitor, by other care providers or by other residents. Any abuse from any source will be investigated. Other information regarding the specific source of the abuse my include . a. Abuse by other residents or visitors of other residents i. Upon completion of investigation, offending party shall be counseled regarding the rights of all residents to be free from abuse and the obligation of the facility to ensure that such abuse does not occur. ii. The facility will take such action as is reasonably necessary to avoid further incidents of abuse, including but not limited to: 1. Change of room assignment 2. Restrictions on contact with abused resident by offending party. 3. Discharge or transfer of offending resident 4. Referral of matter to state or county agencies 5. Referral of matter to law enforcement agencies The facility did not implement its policy and procedure related to abuse and abuse prevention as follows: Facility policy indicates 6(c). Additional agencies may be notified as needed, such as law enforcement, if there are reasonable grounds to believe that a crime has been committed and 9(a)(ii) The facility will take such action as is reasonably necessary to avoid further incidents of abuse ., Facility policy does not reflect the requirements of the regulation at F608 (42 CFR 483.12(b)(5)(A) and (B)) which state that (A) Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. (B) Each coved individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Facility policy indicates: 5. The designee will initiate a full investigation of the matter, which will include, but may not be limited to . a. The resident with the complaint will be interviewed and a written statement will be composed. b. The employee(s) involved will be interviewed, with such interview being documented. A written response to the allegations will be requested from the employee(s). c. Any other persons whom may have additional information will be interviewed as well, with written statements obtained. d. All aspects of the investigation will be documented. Facility policy also indicates at 9(a)(ii), The facility will take such action as is reasonably necessary to avoid further incidents of abuse . The facility did not initiate a full investigation of an allegation of abuse and did not take action as reasonably necessary to prevent further incidents of abuse as follows: 1. On 4/13/18 R11 alleged that a man had come into her room during the night, twisted her arm and touched her privates. She described the man as a doctor and as R1 (whose room is next to hers). The facility's investigation concluded that R11's arm pain occurred when a CNA had repositioned the resident during the night; the investigation did not address the resident's allegation that she had been touched in her private area. Further, the investigation did not include interviews of other residents to determine if they had been inappropriately touched or possibly handled roughly during cares. The facility did not fully investigate this allegation and did not put measures in place to prevent further potential abuse. The facility archived the documentation of this report so it could not be read by those without special rights. 2. On 3/29/18 SW (Social Worker) E informed NHA (Nursing Home Administrator) A that R10 reported DON (Director of Nursing) B stated to her I want you the F*** out of here just as much as you want out of here. This incident was not fully investigated. On 5/30/18 at 1:40 PM Surveyor interviewed NHA A. NHA A stated in hindsight the interaction between R10 and DON B could have been abuse and should have been fully investigated and reported to the State Agency as per facility policy. 3. On 5/9/18 R3 told CNA F that R1 had come into her room and touched her in the genital area. CNA F immediately reported this allegation to SW E. R3's Nursing Progress Notes include, in part, the following: 5/14/18, 8:54 PM: Late entry for 5/9/18. Around 11:45 AM (R3) makes comment to CNA that the men are fresh around here. She then informs CNA that a man had touched her inappropriately. CNA immediately reported statements. Writer to room to talk with (R3). It is apparent that (R3) is speaking of another resident in the facility. (R3) provided with much support and 1:1 throughout the day by both writer and social services, (SW D), as well as other staff. Writer does explain to (R3) that the police will be alerted as to the actions that occurred against her. She is understanding of this and later on when police in the building she is agreeable to talking with them. Writer present for support at that time as well .Writer asks (R3) several times throughout the day if she feels safe and reassures her that nothing like that will happen again and that the man is being dealt with and removed from the facility. (R3) does express that she was scared of the man but feels safe and secure since she informed staff of what occurred. During activities she does seem quiet with activities staff asking her what is wrong with her only stating that she is thinking of bad things. They offer additional support . On 5/17/18 at 8:50 AM Surveyor interviewed CNA F. Surveyor asked CNA F where R1 was when she informed SW E. CNA F stated R1 was on the unit in the dining area eating lunch. CNA F stated he was at the table with other female residents, no one informed her to monitor his whereabouts. CNA F stated after lunch was done, R1 independently went down the hall and around the corner to the next hall, CNA F stated she did not see any staff with him or observing him. It is important to know there is no documentation/evidence that after the facility was informed of the inappropriate touching that R1 was supervised throughout the facility, therefore there is no evidence immediate actions were taken to protect all residents in the facility as per facility policy. 4. On 5/15/18 at 3:23 AM, RN II charted (R11) yelled at roommate abusively over an hours duration for reading a book and having the light on. There is no indication staff intervened per facility policy. Cross reference F610. Facility policy indicates 4. The designee will be notified immediately of the resident's allegation. a. The designee is the person to notify of the situation and the order is as follows. If the first is not present in the facility, go on to the next. i. Administrator ii. Director of Nursing iii. QA nurse iv. Charge nurse Facility policy says 6. Notification of necessary authorities will take place and will include a. Notifying the Office of Caregiver Quality immediately via the completion of the online form Alleged Nursing Home Resident Mistreatment Report. i. Immediately is as soon as possible but not to exceed 24 hours following the incident. http://www.dhs.wisconsin.gov/library/F- .htm b. After investigation is complete, DQA form F- should be completed and sent to DQA. This is to be done within 5 working days of the incident. Facility policy does not reflect the regulation at F609 (CFR 42.483.12(c)(1)), which requires staff to report immediately to the administrator all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property. Reporting to the State Agency and/or to local law enforcment shall be within 2 hours if the allegation involves abuse or results in seious bodily injury Facility staff did not immediately report allegations of abuse to the administrator. The facility did not immediately report allegations of abuse to the Office of Caregiver Quality (State Agency) or to local law enforcement within 2 hours. 1. On 5/9/18 R3 told CNA F that R1 had come into her room and touched her inappropriately down her pants. CNA F immediately reported this allegation to SW E. R3's Nursing Progress Notes include, in part, the following: R3's Nursing Progress Notes include, in part, the following: 5/14/18, 8:54 PM: Late entry for 5/9/18. Around 11:45 AM (R3) makes comment to CNA that the men are fresh around here. She then informs CNA that a man had touched her inappropriately. CNA immediately reported statements. Writer to room to talk with (R3). It is apparent that (R3) is speaking of another resident in the facility. (R3) provided with much support and 1:1 throughout the day by both writer and social services, (SW D), as well as other staff. Writer does explain to (R3) that the police will be alerted as to the actions that occurred against her. She is understanding of this and later on when police in the building she is agreeable to talking with them. Writer present for support at that time as well .Writer asks (R3) several times throughout the day if she feels safe and reassures her that nothing like that will happen again and that the man is being dealt with and removed from the facility. (R3) does express that she was scared of the man but feels safe and secure since she informed staff of what occurred. During activities she does seem quiet with activities staff asking her what is wrong with her only stating that she is thinking of bad things. They offer additional support . On 5/17/18 at 10:55 AM, Surveyor spoke with Lieutenant Y. Surveyor asked Lieutenant Y what time the facility called the police department. Lieutenant Y stated the police department dispatch was contacted by the facility on 5/9/18 at 2:52 PM. It is important to know that this is longer than the 2 hours required. Cross reference F600 2. On 4/13/18 R11 alleged that a man had come into her room during the night, twisted her arm and touched her privates. She described the man as a doctor and as R1 (whose room is next to hers). The facility's investigation concluded that R11's arm pain occurred when a CNA had repositioned the resident during the night; the investigation did not address the resident's allegation that she had been touched in her private area. The facility did not report this allegation to the State Agency. On 5/30/18 at 1:40 PM Surveyor interviewed NHA A regarding R11's situation. NHA A indicated they should have reported the incident first and then investigated. 3. On 3/29/18 SW (Social Worker) E informed NHA (Nursing Home Administrator) A that R10 reported DON (Director of Nursing) B stated to her I want you the F*** out of here just as much as you want out of here. This incident was not fully investigated. On 5/30/18 at 9:05 AM Surveyor interviewed R10. R10 stated a few months ago DON (Director of Nursing) B came into her room and yelled at her. DON B stated You need to get the F*** out of here. R10 stated SW (Social Worker) E knew about the encounter. R10 stated she feels ignored by staff after this incident. R10 stated she does not trust DON B or NHA (Nursing Home Administrator) A, especially after this incident; I think they told staff to ignore me. On 5/30/18 at 1:40 PM Surveyor interviewed NHA A. NHA A stated in hindsight the interaction between R10 and DON B could have been abuse and should have been reported to the State Agency as per facility policy. Cross reference F609. The failure to implement its policies and procedures to ensure that residents were free from abuse created a finding of immediate jeopardy. The facility removed the immediacy on 5/17/18 but it was not yet corrected. The facility will be corrected when: 1. Education will be provided to all staff prior to their next shift on the following items: - All residents have the right to be free from any form of abuse. Residents at this facility are a very at risk and vulnerable population. - Abuse definitions and what constitutes abuse as defined in the Abuse Policy - Staff have the duty to protect all residents from any form of abuse - If any abuse or suspicion of abuse is noted the staff will immediately stop the abuse and protect the resident. The staff will also assure that actions taken will protect all other residents as well. - Staff will then immediately report any abuse or suspicion of abuse to their supervisor who MUST report to the DON and Administrator. Should any actual abuse or serious bodily injury occur, DON and/or Administrator will report within 2 hours to the state agency and law enforcement. - Within 2 hours, staff are required to immediately report to law enforcement the reasonable suspicion of a crime where there is abuse or bodily harm. - All allegations of abuse will be immediately investigated and the abuse policy followed - Sexual behavior intervention training 2. Resident and staff interviews were completed to determine if any remaining residents pose a risk of abusing others in any manner. This was completed on 5/10/18. 3. On 5/10/18, a resident was identified as having inappropriate sexual behaviors towards staff and thus could potentially pose a risk to others. This resident's care plan was reviewed /revised and interventions put in place on 5/10. The care plan was once again reviewed/revised on 5/17/18. 4. Abuse policy updated to include all referrals/potential residents having a CCAP and sex offender registry search done prior to admission. 5. Abuse policy updated to include if abuse or serious bodily injury occurs law enforcement and state agency will be contacted in 2 hours 6. On 5/14 a CCAP and sex offender registry search was completed on all current residents. QA: 1. Interviews will be completed 3x/week, for a period of 4 weeks, with residents to assure that they feel safe, determine if there are any other residents whom they feel threatened by or have a concern with, or any staff that they feel threatened by or have a concern with. After this 4 week period interviews will be completed weekly, for a period of 3 additional months, and then monthly thereafter for a total period of 1 year. 2. Interviews will be completed 3x/week, for a period of 4 weeks, with staff to determine if there are any residents showing behaviors that have not been identified previously that may pose a risk to other residents. Interviews will also include questions about what constitutes abuse, what actions should be taken if allegations are made or abuse observed and what the reporting requirements are. After this 4 week period interviews will completed weekly, for a period of 3 additional months, and then monthly thereafter for a total period of 1 year.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment all alleged violations were thoroughly investigated, and that steps were taken to prevent further potential abuse for 3 residents (R3, R10, and R11) with the potential to affect 72 female residents out of a total 105 residents that reside in the facility. On 5/9/18 R3 reported that R1 had come into her room and touched her inappropriately. The facility did not put immediate measures in place to monitor R1's whereabouts. Staff report he was in the dining room and hallways afterwards and was not being supervised. On 3/29/18 SW (Social Worker) E informed NHA (Nursing Home Administrator) A that R10 reported DON (Director of Nursing) B stated to her I want you the F*** out of here just as much as you want out of here. This incident was not fully investigated. On 4/13/18 R11 alleged that a man had come into her room during the night, twisted her arm and touched her privates. She described the man as a doctor and as R1 (whose room is next to hers). The facility did not fully investigate this allegation and did not put measures in place to prevent further potential abuse. The facility archived the documentation of this report so it could not be read by those without special rights. The failure of the facility to fully investigate allegations of abuse and to put measures in place to prevent further potential abuse led to the finding of immediate jeopardy (IJ), which started on 3/29/18. The facility was notified of the IJ on 5/17/18 at 12:40 PM. It was determined that the immediacy was removed on 5/17/18, but not yet corrected. The deficiency continues at a scope/severity level E (potential for harm/pattern), as the facility continues to fully implement, educate, and to evaluate the effectiveness of its action plan and as evidenced by: On 5/15/18 at 3:23 AM, RN II charted R11 yelled at roommate abusively over an hours duration for reading a book and having the light on. On 5/16/2018 at 8:07 AM this progress noted is indicated as being archived, with DON B's initials. There is no indication this allegation staff intervened per facility policy to protect R11's roommate. This is evidenced by: The facility's policy and procedure for Abuse Prevention and Investigation, last reviewed 5/2017, includes, in part: All residents have the right to be free from any type of mistreatment or abuse .This facility will not tolerate abuse, neglect, or misappropriation of a resident's property. All allegations of abuse, neglect, or misappropriation and any injury of which the source cannot be identified will be investigated. The results of the investigation will be reported as required by state and federal laws and this policy and procedure . 1. A resident or family member may report an allegation of misconduct to any employee. Upon receiving an allegation, the employee will immediately take the necessary steps to protect the resident from possible subsequent incidents of misconduct or injury and then alert his or her immediate supervisor of the complaint. 2. The immediate supervisor, upon learning of the incident, will assure that the immediate actions to protect the resident from possible subsequent incidents of misconduct or injury are appropriate and sufficient. The immediate supervisor will then begin an investigation. 3. The employee, whom received the allegation, will compose a written statement detailing the alleged incident as reported by the resident. 4. The designee will be notified immediately of the resident's allegation. a. The designee is the person to notify of the situation and the order is as follows. If the first is not present in the facility, go on to the next. i. Administrator ii. Director of Nursing iii. QA nurse iv. Charge nurse 5. The designee will initiate a full investigation of the matter, which will include, but may not be limited to . a. The resident with the complaint will be interviewed and a written statement will be composed. b. The employee(s) involved will be interviewed, with such interview being documented. A written response to the allegations will be requested from the employee(s). c. Any other persons whom may have additional information will be interviewed as well, with written statements obtained. d. All aspects of the investigation will be documented . 7. Throughout the entire investigation, from the time the initial observation is made or the alleged complaints received, actions will be taken to assure that the resident and all other residents are safe and protected from any possible subsequent misconduct. 8. When investigation is complete, the administrator shall determine whether the allegation is substantial or not and shall take appropriate action with respect to the involved employee or person. This final action shall be in accordance with state and federal law. 9. Abuse can occur by staff, a family member, friend or other visitor, by other care providers or by other residents. Any abuse from any source will be investigated. Other information regarding the specific source of the abuse my include . a. Abuse by other residents or visitors of other residents i. Upon completion of investigation, offending party shall be counseled regarding the rights of all residents to be free from abuse and the obligation of the facility to ensure that such abuse does not occur. ii. The facility will take such action as is reasonably necessary to avoid further incidents of abuse, including but not limited to: 1. Change of room assignment 2. Restrictions on contact with abused resident by offending party. 3. Discharge or transfer of offending resident 4. Referral of matter to state or county agencies 5. Referral of matter to law enforcement agencies Example 1 On 5/9/18 R3 told CNA F that R1 had come into her room and touched her in the genital area. CNA F immediately reported this allegation to SW E. R3's Nursing Progress Notes include, in part, the following: 5/14/18, 8:54 PM: Late entry for 5/9/18. Around 11:45 AM (R3) makes comment to CNA that the men are fresh around here. She then informs CNA that a man had touched her inappropriately. CNA immediately reported statements. Writer to room to talk with (R3). It is apparent that (R3) is speaking of another resident in the facility. (R3) provided with much support and 1:1 throughout the day by both writer and social services, (SW D), as well as other staff. Writer does explain to (R3) that the police will be alerted as to the actions that occurred against her. She is understanding of this and later on when police in the building she is agreeable to talking with them. Writer present for support at that time as well .Writer asks (R3) several times throughout the day if she feels safe and reassures her that nothing like that will happen again and that the man is being dealt with and removed from the facility. (R3) does express that she was scared of the man but feels safe and secure since she informed staff of what occurred. During activities she does seem quiet with activities staff asking her what is wrong with her only stating that she is thinking of bad things. They offer additional support . On 5/17/18 at 8:50 AM Surveyor interviewed CNA F. Surveyor asked CNA F where R1 was when she informed SW E. CNA F stated R1 was on the unit in the dining area eating lunch. CNA F stated he was at the table with other female residents, no one informed her to monitor his whereabouts. CNA F stated after lunch was done, R1 independently went down the hall and around the corner to the next hall, CNA F stated she did not see any staff with him or observing him. It is important to know there is no documentation/evidence that after the facility was informed of the inappropriate touching that R1 was supervised throughout the facility, therefore there is no evidence immediate actions were taken to protect all residents in the facility as per facility policy. Example 2 R11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R11's admission MDS (minimum data set) with a target date of 4/4/2018, indicates R11 has a BIMS (brief interview of mental status) of a 15 which indicates R11 is cognitively intact. R11 requires a 2 person physical assist with bed mobility, transfers and one of her lower extremities is impaired. The MDS indicates R11 uses a wheel chair for locomotion, and she did not ambulate during this time. LPN (Licensed Practical Nurse) OO's statement signed and dated 4/13/18 indicates: writer observed R1 enter R11's doorway and exit within a few seconds. Writer then observed R1 enter R11's room again and exit rather quickly. LPN OO discussed with management the best ways to re-direct R1 to have him stay out of other people's rooms. management stated usually just telling R1 not to enter another Residents room is effective. Writer asked if it was a good time to talk with R1 stated yes. LPN OO questioned if R1 knew it was unacceptable to enter other Residents bedrooms. R1 became very defensive yelling that b***h needs to shut the f**k up. LPN OO stated if R1 has an issue with other Residents he needs to use call light or get help from staff. R1 stated I won't go in that b****'s room again. now you get the f*** out of my room you fat f***ing b***h. writer exited R1's room. LPN OO's second statement signed and dated 4/13/18 indicates: writer was assisting R11 with transfer out of bed with another staff member CNA NN when Res was sitting on toileted R11 stated I don't like that man. I don't want men in my bedroom. writer asked R11 if she was safe and to describe what happened. R11 again repeated, I don't like that man. writer went to discuss issue with management. writer was paged back to R11 room and staff stated R11 told them during the night a man doctor came in and twisted her arm. writer got a member of management to Residents room to help with questioning Resident. R11 stated at first nothing happened with a man. then when questions about a doctor stated, a doctor man came in during the night and twisted my arm, it hurt. writer encouraged R11 to utilize call light if another Resident enters her bedroom some residents don't remember where their homes are and need our help. Questioned Resident if she felt safe and Resident responded yes. writer did not observe any new bruises or injuries. Res. always has complained of pain but no new complaints of pain at this time. On 5/29/18 at 12:12 PM, Surveyor interviewed LPN OO regarding situation at facility. LPN OO indicated to Surveyor that she could not remember the exact dates, but had given written statements. LPN OO indicated that if the facility doesn't like the charting they delete it. LPN OO indicated to Surveyor that she saw R1 coming out of R11's room which was a red flag, went in saw me and came right out and LPN OO reported it to RN Q and LPN V. Asked them what to do feel it's inappropriate and went down to R11's room because she was paged. Told by her she liked it until he twisted my arm and he was playing with privates. RN Q indicated it was reportable and wrote statements. LPN OO indicated she never heard a word, then DON B indicated it was a night CNA not R1. LPN OO indicated she is not sure how long R1 was in R11's room as she just started her shift. R11 said a man came in room, saw him come in room twice day before, got management, said didn't like what the man did down there, couldn't document it, told RN Q and LPN V. LPN OO stated everyone in building was aware of it. On 5/30/18 at 9:30 AM Surveyor interviewed CNA NN regarding R11 situation. CNA NN indicated R1 is a daily bath and is given a shower by 5:30 AM. CNA NN indicated R11 was scared when she first came and would holler out then apologizes. CNA NN indicated they would reassure R11 she was safe. CNA NN indicated she came in that morning (couldn't remember exact date) to the shower room which is now on Elm. R1 was very upset indicated couldn't sleep due to a woman hollering and was referring to R11. CNA NN indicated R1 told her he yelled at her to be quiet. Told R1 she would inform the nurse. CNA NN indicated CNA MM helped get R11 ready and stated that man came in my room last night, I know I was yelling, I just couldn't help it, indicated he pulled my right arm, he hurt my right arm, he hurt me. R11 indicated wearing green shift or jacket, CNA NN got nurse RN Q, and LPN OO came in room. CNA NN indicated we reported it. The facility also interviewed CNA RR and CNA SS (who had worked with R11 that night), CNA MM, CNA NN, speech therapist LL, and RN JJ. The facility concluded that R11 was referring to CNA RR (who is tall, has a beard and was wearing scrubs) and that the arm pain was from being repositioned. There was no investigation or conclusion as to whether someone had touched R11's privates as she alleged. R11's care plan dated 4/17/18 indicated R11 had been making inappropriate sexual comments towards staff providing peri cares and accusing staff of pinching her. Care plan also indicated R11 yells at staff and calls them stupid idiots during repositioning. On 5/30/18 at 1:40 PM Surveyor interviewed NHA A regarding R11's situation. NHA A indicated they should have reported the incident first and then investigated. NHA A indicated they could have interviewed other Residents and other staff on different wings. On 5/30/18 at 2:00 PM Surveyor interviewed R11 regarding her arm. R11 indicated her arm was hurt a long time ago by a doctor, or someone faking to be a doctor and that she told staff. R11 indicated to Surveyor not really anymore, have too many guys here when asked if she felt safe. R11 indicated she hasn't told anyone that she doesn't feel safe because she doesn't want to get anyone in trouble. (Surveyor informed Social worker.) Example 3 R10's [DIAGNOSES REDACTED]. R10 is her own decision maker. R10's most recent MDS of 4/6/18 indicates R10 is cognitively intact and is dependent on 2 assist for transfers. On 5/30/18 at 9:05 AM Surveyor interviewed R10. R10 stated a few months ago DON (Director of Nursing) B came into her room and yelled at her. DON B stated You need to get the F*** out of here. R10 stated SW (Social Worker) E knew about the encounter. R10 stated she feels ignored by staff after this incident. R10 stated she does not trust DON B or NHA (Nursing Home Administrator) A, especially after this incident; I think they told staff to ignore me. On 5/30/18 at 9:50 AM Surveyor interviewed SW E. SW E stated R10 did speak with R10 about an interaction involving DON B. R10 stated DON B told her she wanted her the F*** out of the facility just as much as she wanted to get the F*** out of here. SW E stated the Ombudsman had called her and told SW E that R10 told her the same thing. SW E stated she told the Ombudsman that she felt she could not go to NHA A or DON B because there is too much I will take care of it and then it is dropped. SW E stated she did tell NHA A and he stated he was going to let DON B and the Ombudsman handle the situation. NHA A stated to SW E he did not appreciate what SW E charted on the situation. NHA A stated to SW E the charting was still there, however it is not visible to staff or surveyors. SW E stated to her knowledge the interaction was not investigated. SW E stated that the morning that the incident took place DON B had sent a chat through the charting system stating she said I want you the F*** out just as much as you want the F*** out. It is important to know that the charting system chat disappears as soon as it is viewed. SW E stated SW D also got the chat. SW E stated the interaction was an allegation of abuse and should have been fully investigated and reported to the State Agency. On 5/30/28 at 10:35 AM Surveyor interviewed SW D. SW D stated she did receive a chat through the charting system stating she said I want you the F*** out just as much as you want the F*** out. On 5/30/18 at 10:50 AM Surveyor observed the following archived charting in R10's medical record. It is important to know that archived charting is only visible to users who have rights to it. The facility does not give Surveyors this right. 3/29/18, 3:32 PM: Social Service Progress Note: Call from (Ombudsman) requesting an investigation of allegations of verbal abuse reported to her yesterday during her meeting with (R10) against another staff member. Writer had also been approached by (R10) today and reported to writer that she feels that the staff are retaliating against her. She reported to writer that the DON stated to her I want you the F*** out of here just as much as you want out of here. (R10) reported that staff come in her room and do not give her choices or options and it makes her feel like a child. Per (Ombudsman), (R10) reported that the DON had gone and made a decision about her muscle relaxer and scheduled it versus involving (R10) in on the medication and when it is given. Writer did let (R10) know that writer will follow procedure and let the Administrator know about report. Writer did inform Administrator that Ombudsman spoke with writer about allegations made by (R10) and administrator was going to call (Ombudsman). (Ombudsman) asked writer to keep her updated and on the resolution. On 5/30/18 at 1:40 PM Surveyor interviewed NHA A. NHA A stated he had a conversation with the Ombudsman regarding the interaction voiced by R10 with DON B. NHA A stated there were inconsistencies between the Ombudsman's information and SW E's charting regarding the interaction between R10 and DON B, so it was discussed and the charting was archived. NHA A stated in hindsight the interaction between R10 and DON B could have been abuse and should have been fully investigated. The failure to fully investigate allegations of abuse and to put measures in place to ensure resident safety while an investigation is underway created a finding of IJ. The facility removed the immediacy on 5/17/18 when it began implementing the following: 1. Education will be provided to all staff prior to their next shift on the following items: - All residents have the right to be free from any form of abuse. Residents at this facility are a very at risk and vulnerable population. - Abuse definitions and what constitutes abuse as defined in the Abuse Policy - Staff have the duty to protect all residents from any form of abuse - If any abuse or suspicion of abuse is noted the staff will immediately stop the abuse and protect the resident. The staff will also assure that actions taken will protect all other residents as well. - Staff will then immediately report any abuse or suspicion of abuse to their supervisor who MUST report to the DON and Administrator. Should any actual abuse or serious bodily injury occur, DON and/or Administrator will report within 2 hours to the state agency and law enforcement. - Within 2 hours, staff are required to immediately report to law enforcement the reasonable suspicion of a crime where there is abuse or bodily harm. - All allegations of abuse will be immediately investigated and the abuse policy followed QA: Interviews will be completed 3x/week, for a period of 4 weeks, with staff to determine if there are any residents showing behaviors that have not been identified previously that may pose a risk to other residents. Interviews will also include questions about what constitutes abuse, what actions should be taken if allegations are made or abuse observed and what the reporting requirements are. After this 4 week period interviews will completed weekly, for a period of 3 additional months, and then monthly thereafter for a total period of 1 year. The deficient practice continues at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan and as evidenced by the following: Example 4 On 5/15/18 at 3:23 AM, RN II charted R11 yelled at roommate abusively over an hours duration for reading a book and having the light on. On 5/16/2018 at 8:07 AM this progress noted is indicated as being archived, with DON B's initials. There is no indication this allegation was clarified, reported immediately, investigated, or staff intervened per facility policy. On 5/30/18 at 2:30 PM, Surveyor spoke with an Anonymous QQ regarding R11's. Anonymous QQ indicated R11 has threatened her roommate's life which has been reported over and over again. Anonymous QQ indicated R11 has not shown signs to act upon her threats to her roommate. Indicated men in room is an automatic trigger for R11's behaviors. Anonymous QQ indicates R11 would hit staff. Verbal abuse indicated as being reported verbally between nurses and indicated would redirect when verbal abuse present, separate and find what triggered the abuse. If physical abuse would report immediately and call cops. On 5/30/18 at 2:54 PM, Surveyor interviewed RN KK regarding R11. RN KK indicated R11 was moved after a couple reports of R11 verbally being rude to roommate. RN KK indicated she kept putting in report to Social Worker that she was yelling at her roommate for her TV being on or a light. RN KK indicated if verbal abuse was occurring she would say to Resident it's not appropriate, and if continues would move Resident into another room. RN KK indicated monitoring R11's verbal behaviors. RN KK, indicated that it depends if the verbal abuse stopped after indicating it wasn't appropriate whether she would report the verbal abuse or not, if it got physical then would let social services know. RN KK indicated she did not know what the facility policy says regarding abuse. On 5/30/18 at 3:36 PM, Surveyor interviewed RN JJ regarding charting on 5/15/18. RN JJ indicated they moved R11 to a different hallway and that the social worker was talking with previous roommate and that she never voiced a concern. RN JJ indicated expects progress note of abuse to be investigated and reported. RN JJ indicated R11 yells and has been moved 3 times now, and has behaviors, they're care planned and is on the behavior watch list. RN JJ is not aware of any investigation or that R11 threatened her roommate's life. (Please note R11 currently does not have a roommate, but at the time of the progress note dated 5/15/18, R11 did have a roommate and was on another wing)

Based on interview and medical record review, the facility did not revise care plans, to accurately reflect the comprehensive needs for 1 of 9 residents, out of a total sample of 11 (R1). This had the potential to affect the 72 female residents in the facility, out of a total of 105 residents. R1 is a registered sex offender. On 2/5/18 R1 was observed with his penis out trying to lure R2 to him and sometime in (MONTH) (YEAR) R1 asked confused female resident R4 if she wanted to have sex with him, asking if R4 would like to touch him or if he could touch R4. R1's care plan was not updated to monitor inappropriate sexual behaviors, actions or comments until 3/7/18 but this plan was not specific and its approaches were not placed on the CNA (certified nursing assistant) care plan. The facility failed to revise R1's care plan to monitor R1's whereabouts throughout the facility, protecting all residents from R1's inappropriate and illegal sexual behaviors. On 5/9/18 R3 informed staff R1 had come into her room the day before and touched her between her legs inappropriately. This was not consensual. The facility's failure to revise care plan the monitoring of R1's inappropriate sexual behavior and movements throughout the facility, especially around vulnerable females, created a finding of Immediate Jeopardy (IJ) beginning on 2/5/18. On 5/17/18 at 12:40 PM NHA (Nursing Home Administrator) A and DON (Director of Nursing) B were informed of the IJ. The IJ was removed on 5/17/18. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. Evidenced by: R1 was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. R1 is his own decision maker. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/9/18 indicates R1 is cognitively intact and is independent with transfers and locomotion on and off the unit. In addition the MDS indicates R1 has no behaviors. Multiple staff knew R1 was a registered sex offender, that he harassed staff, and was frequently in or outside the rooms of female residents. (Cross reference F600.) Despite this knowledge, the facility did not develop a specific plan to monitor R1's behaviors and whereabouts and to protect female residents. Incident 1 with R2. R2's [DIAGNOSES REDACTED]. R2 is not her own decision maker. R2's most recent MDS with an ARD of 3/9/18 indicates R2 has severe cognitive impairment, has no behaviors and needs extensive assist of one person to transfer. On 5/17/18 at 5:00 PM Surveyor interviewed CNA U. CNA U stated he was working on 2/5/18 when he observed R1 with his penis out of his pants, wheeling himself in the hallway towards R2, saying come here to R2. CNA U stated R1 had a smirk on his face. CNA U stated he immediately removed R2 from the area and reported the incident to the nurse. CNA U stated the nurse had him write a report of what happened and then DON B had contacted him via Facebook to ask about the incident. R1's Social Service Progress Notes include, in part, the following: 2/6/18, 12:29 PM: Behavior: Writer made aware of behavior issue last PM shift. A resident was wheeling about in the hallway going the direction away from (R1's) room. CNA staff (CNA U) observed (R1) a distance behind the resident saying come here and he noted that (R1) had his penis out of his pants. (R1) made no contact with the other resident and resident was not even aware of the behavior. CNA immediately approached (R1) and suggested he get ready for bed. (R1) was monitored the remainder of the shift and had no further inappropriate behaviors and was in his room. Staff alerted writer to the behavior. Writer did instruct staff to continue to monitor (R1's) behaviors very closely and to document any inappropriate behaviors, as well as alert writer immediately. Writer does speak with social services. (SW (Social Worker) D) who works with (R1) and his wife often. (SW D) did speak with (R1) this AM. (R1) denied that he did anything intentionally and make reference to his pull up getting messed up sometimes. CNA that observed (R1) did feel that the behavior was intentional and not any type of issue with clothing/pull up. Targeted behaviors added as well at this time. Social services will continue to work with (R1) as well. 2/6/18, 2:46 PM, Social Services Progress Note: DON informed writer of alleged inappropriate behavior observed by wing staff last PM shift. A resident was wheeling self in hallway headed toward the hub/center of (facility). (R1) was reported to be wheeling behind at some distance stating come here: which appeared to be directed at that resident. The wing staff observed (R1) to have his penis visible out of his pants. Staff then interrupted and redirected (R1) to get ready for bed at that time. The other resident was not aware of the situation. Staff monitored (R1) more closely remainder of shift. Writer spoke with (R1) regarding the staff's observation this morning. (R1) did remember the resident being in front of him, however, stated he was not showing his penis. He did share he may have adjusted himself as his depends get tight at times. He also does not recall clearly if such behavior did occur it is not appropriate. Staff to continue monitoring (R1's) behavior to ensure no further incidents It is important to know there is no documentation in R2's medical record regarding this incident. R1's care plan was not revised immediately after the 2/5/18 incident. On 5/17/18 Surveyor interviewed DON B. DON B stated she was aware of R1 exposing himself to R2 on 2/5/18. DON B stated she was told that R2's back was to R1 and she could not see him. DON B stated she was not convinced R1 was exposing himself to R2 because R1 stated his brief moved. DON B stated she knew that CNA U's perception was R1 was exposing himself, but DON B was not convinced either way. DON B stated she did not report this behavior, did not have a care plan made regarding inappropriate sexual behavior because it was staff perception. DON B stated the night of the incident R1 was put on 15 minute checks. (It is important to know there is no evidence this was done.) DON B stated she was not sure if all staff were informed they should be monitoring R1's inappropriate sexual behavior. DON B stated she was unsure if the incident was discussed in any interdisciplinary meeting, but did remember discussing it with SW D. DON B stated she did not think there was any effect on R2; however she did not follow up on any charting for R2. Incident 2 with R4 R4's [DIAGNOSES REDACTED]. R4 is not her own decision maker. R4's most recent MDS with an ARD of 4/13/18 indicates R4 has moderate cognitive impairment, has no behaviors and transfers with extensive assist of one person. On 5/17/18 at 5:00 PM Surveyor interviewed CNA U. CNA U also stated he observed R1 and R4 in the dining room in March, (YEAR). They were sitting at the same table talking about sexual things. CNA U stated he overheard R1 asking R4 if she would like to have sex with R1, if R4 would like to touch R1 and if R1 could touch R4. CNA U stated he immediately removed R4 from the table and reported the incident to the nurse. CNA U stated R1 and R4 lived on the same wing and even after this incident continued to have contact with each other, including R1 visiting R4 in her room unsupervised. On 5/16/18 at 10:05 AM Surveyor interviewed SW D. SW D stated LPN H had informed her that R1 was talking to R4 in an inappropriate manner in R4's room. SW D stated she talked with R1 and told him to stay out of R4's room. SW D stated R1 told her they were talking, having fun. SW D stated she talked with R4 and R4 is very hard of hearing. SW D stated she is unsure if R4 understood her questions, but she said they were having fun. SW D stated she did not do any further follow up with the situation. It is important to know there is no documentation in R1's or R4's medical record regarding this incident. The facility revised R1's care plan on 3/7/18 to include: 3/7/18: Problem: Potential for disruptive behaviors. (R1) may become frustrated at times when he is unable to control his situation or when abruptly directed to do a task. He does have targeted behaviors of inappropriate sexual behaviors, actions or comments which staff monitor. Approach: 3/7/18: Nurses: . chart targeted behaviors, foreshadow events/cares, build rapport, establish boundaries, maintain consistency. 3/7/18: Nurse Aides: . chart targeted behaviors, report any changes in behaviors. 3/7/18: SocServ: .encourage and assist staff in instituting appropriate boundaries and interventions as needed . This plan does not give specific proactive approaches for monitoring R1's behaviors or whereabouts and to protect female residents. Further, it is important to know that on R1'sGuidelines for Daily Cares/ dated 4/15/18, which is found in each resident's rooms so CNAs (Certified Nursing Assistants) know how to care for the resident, there is nothing indicated under Behavior or Mood sections. Incident 3 with R3 R3's [DIAGNOSES REDACTED]. R3 is her own decision maker. R3's most recent MDS with an ARD of 4/6/18 indicates R3 has cognitive impairment, transfers with extensive assist of two or more, and has no behaviors. R3's Nursing Progress Notes include, in part, the following: 5/14/18, 8:54 PM: Late entry for 5/9/18. Around 11:45 AM (R3) makes comment to CNA that the men are fresh around here. She then informs CNA that a man had touched her inappropriately. CNA immediately reported statements. Writer to room to talk with (R3). It is apparent that (R3) is speaking of another resident in the facility. (R3) provided with much support and 1:1 throughout the day by both writer and social services, (SW D), as well as other staff. Writer does explain to (R3) that the police will be alerted as to the actions that occurred against her. She is understanding of this and later on when police in the building she is agreeable to talking with them. Writer present for support at that time as well. (R3's) son was updated on situation by writer and social services (SW D). Writer does then assist (R3) to speak on the phone to her son. Writer asks (R3) several times throughout the day if she feels safe and reassures her that nothing like that will happen again and that the man is being dealt with and removed from the facility. (R3) does express that she was scared of the man but feels safe and secure since she informed staff of what occurred. During activities she does seem quiet with activities staff asking her what is wrong with her only stating that she is thinking of bad things. They offer additional support. Writer does later speak with son once again and he states that (R3) sounded good on the phone and did not bring up the situation. He does state that he did not bring it up either, as he did not want to upset her. Writer does reassure him that staff are working closely with (R3) to assure that she feels safe and secure. 5/14/18, 8:59 PM: Important Note: Late entry for 5/10/18: Writer in to check on (R3). (R3) reports that she is doing fine. Writer asks her if she is feeling safe and she states that she is. She does state that she did have dreams last night about it but she states that she slept well and it did not keep her from getting her rest. Writer asks her if she is wanting to talk or discuss the situation that was reported the day prior any more or if she felt that she needed any further support or help from anyone. She declines, stating that she is fine. Writer reassures her once again that the man has been removed from the facility and that she is safe. She is very appreciative. Writer does go back to her a bit later in the day to discuss incident again, as law enforcement is requesting a non-consent form. Writer reviews such with (R3) explaining that the form is stating that she did NOT give the man permission to touch her. (R3) states clearly that she did not give him permission and is agreeable with the form and signing it. She additionally signs a medical release form for (Local Police Department) for her medical records, as per their request. On 5/17/18 Surveyor interviewed DON B. DON B stated she was unaware that R1 was a registered sex offender until staff informed her on 5/15/18. DON B stated she did know that R1 would visit other residents in the hallways, was unaware R1 was going into other resident rooms unsupervised to visit and no concerns R1 was touching anyone were brought to her. DON B stated she should have been informed that R1 was a registered sex offender, R1 should have had a care plan for his sexual inappropriateness, at least on 2/5/18 after he exposed himself, should have had increased supervision, should not have been allowed to visit other residents unsupervised in their rooms, and should have informed the local police department to inform them a had a registered sex offender in the building, especially because the facility is across the street from a grade school. (Note: On 5/16/18 at 10:05 AM when Surveyor interviewed SW D (Social Worker), SW D stated that she informed NHA A and DON B a few months ago that R1 was a registered sex offender. SW D stated she did not think there was anything she could do as R1 was a resident of the facility. SW D stated she did not write a care plan regarding how to keep other residents safe.) The facility's failure to fully revise R1's care plan to monitor R1's inappropriate sexual behavior and movements throughout the facility, especially around vulnerable females, created a situation of IJ, which was removed on 5/17/18, when the facility implemented the following action plan: *All nursing staff will be educated on creating new care plans with changes in condition and behavior. They will further be educated on adjusting existing care plans to reflect the changes in condition and behavior. *On 5/10/18, a resident was identified as having inappropriate sexual behaviors towards staff and thus could potentially pose a risk to others. This resident's care plan was reviewed/revised and interventions put into place on 5/10/18. The care plan was once again reviewed/revised on 5/17/18. *Residents identified with behaviors will have care plan audits completed weekly for a period of 3 months, then monthly for a total period of 1 year. Audits will assure all behavior issues are addressed with appropriate interventions, staff are aware of and using the interventions, and that the care plan and bedside CNA guideline are matching appropriately.

Based on interview and record review, administration was not promoting the highest practicable mental and psychosocial well-being of residents by failing to develop a plan to monitor the whereabouts of a known sex offender (Resident 1) and by intimidating staff to limit the information shared with State Agency staff. This has the potential to affect all 72 female residents in the facility out of a census of 105 residents. Multiple staff was aware that Resident (R) 1 was a registered sex offender and Social Worker D indicates she told both the administrator and the Director of Nurses (DON) of this several months ago. The facility did not put measures in place on 2/5/18 to monitor R1 or to ensure the safety of other residents after R1 attempted to lure R2 towards him when he had his penis out, when he was overheard in (MONTH) (YEAR) asking confused female resident R4 if she wanted to have sex with him, touch him or let him touch her, or when R11 alleged that R1 had come into her room and touched her privates. Subsequently, on 5/8/18, R1 went into R3's room and touched her in the genital area while R3 was in bed. Additionally, as survey staff attempted to investigate this complaint, the administrator and the DON attempted to intimidate staff by telling them to limit the amount of information they gave to surveyors and threatening them with their jobs if they said too much. The facility's failure to develop a plan for monitoring R1 and ensuring the safety of female residents and its failure to ensure all staff were not intimidated by administration, not feeling able to freely speak to Surveyor staff or there would be negative consequences up to losing their jobs, created a finding of Immediate Jeopardy (IJ) beginning on 2/5/18. On 5/17/18 at 12:40 PM NHA (Nursing Home Administrator) A and DON (Director of Nursing) B were informed of the IJ. The IJ was removed on 5/17/18. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement its action plan. Evidenced by: Example 1 As noted in F600, multiple staff were aware that R1 was a registered sex offender. On 5/16/18 at 10:05 AM Surveyor interviewed SW D. SW D stated that she became aware that R1 was a registered sex offender a few months ago. SW D stated that she informed NHA A and DON B at that time. SW D stated she did not think there was anything she could do as R1 was a resident of the facility. SW D stated she did not write a care plan regarding how to keep other residents safe. On 5/17/18 at 10:00 AM Surveyor again interviewed SW D. Surveyor asked SW D if she informed the local police department that R1 was a resident of the facility when she realized he was a registered sex offender. SW D stated no she did not inform the local police department that R1 was in the facility. SW D stated she thought that since she informed NHA A and DON B they would have informed the local police department. SW D stated to her knowledge no one informed the local police department. SW D stated many staff knew already that R1 was a registered sex offender and were monitoring him on their own. SW D stated she was aware that staff who were not [AGE] years old were not allowed to work with R1 because he was a registered sex offender. On 5/17/18, Surveyor interviewed DON B. Even though SW D stated she had told the DON and the Administrator a few months ago that R1 was a registered sex offender, DON B denied knowing that R1 was a registered sex offender until staff informed her on 5/15/18. DON B stated she did know that R1 would visit other residents in the hallways, was unaware R1 was going into other resident rooms unsupervised to visit and no concerns R1 was touching anyone, were brought to her. DON B stated SW D did not inform her that R1 was a registered sex offender. DON B stated she had no knowledge that staff under the age of 18 could not work with R1. DON B stated she did not give that direction. DON B stated she should have been informed that R1 was a registered sex offender, R1 should have had a care plan for his sexual inappropriateness, at least on 2/5/18 after he exposed himself, should have had increased supervision, should not have been allowed to visit other residents unsupervised in their rooms, and should have informed the local police department to inform them a had a registered sex offender in the building, especially because the facility is across the street from a grade school. Despite knowledge that R1 was a registered sex offender, administration did not ensure that the facility had a plan for monitoring R1 and for ensuring the safety of residents. On 5/9/18 R3 informed staff R1 had touched her between her legs inappropriately the previous day. Upon further investigation it was learned that R1 also exposed himself to R2 on 2/5/18 and had touched R2 inappropriately on an undetermined date. In addition, on or around 3/7/18 R1 also had asked R4 if she wanted to have sex with him and talking about sexual things with R4. On 4/13/18, LPN OO observed R1 going in and out of R11's room; R11 subsequently alleged that he had touched her privates. R1's whereabouts within the facility and his visits in other resident rooms were not monitored during his entire 12 month stay, even after he exhibited inappropriate sexual behavior. Cross reference F600, F610 and F657. As the survey team attempted to investigate this complaint, multiple staff stated they were told by administration to limit the information they gave to surveyors and threatened their jobs if they said too much. Example 2 On 5/17/18 at 11:15 AM Surveyor interviewed SW E. SW E stated NHA A informed staff in the morning stand up meeting on 5/17/18 that all staff need to watch themselves, what we say as the survey was not going well. SW E stated she felt intimidated by NHA A. On 5/30/18 at 9:50 AM Surveyor again interviewed SW E. SW E stated staff was informed they were not to give any further information up to Surveyor staff. Example 3 On 5/16/18 at 11:15 AM Surveyor interviewed CNA G. CNA G stated she was sitting at the charting desk and LPN V was at the cart within 3 feet of her. DON B came up to LPN V and asked what she told Surveyor staff about R1 and R2. DON B told LPN V not to say anything more about R1's activities, CNA G stated LPN V seemed scared. CNA G also stated she is sure NHA A and/or DON B will speak with her because she is speaking to Surveyor staff. CNA G stated they have been asking staff what Surveyor staff is asking them and she is sure she is next. CNA G stated they will find a way to get rid of/fire staff who say too much. CNA G was sure she is on their list, but that it is time the truth comes out. CNA G stated she is intimidated and afraid of retaliation. Example 4 On 5/23/18 at 12:00 PM Surveyor interviewed LPN H via telephone. LPN H stated in (MONTH) DON B stated in a nursing meeting that no one should volunteer any additional information about any residents, especially R1's activities. Staff are to answer only what Surveyor staff ask with yes/no, no further information. DON B stated to staff in the meeting that this would be best for everyone involved. LPN H stated many staff are scared of retaliation if we say too much, may even lose our jobs. Example 5 On 5/17/18 at 8:50 AM Surveyor interviewed CNA F. CNA F stated DON B came to her after she spoke with Surveyor on 5/16/18, asking what CNA F told Surveyor. DON B told CNA F to watch herself, she better be careful. CNA F stated DON B scared her, threatening her job. CNA F stated she has a family to feed and will need to look for another job as she will probably get fired for speaking with Surveyor. CNA F stated DON B and NHA A are following Surveyors and speaking to staff after Surveyor staff speak to staff, asking what we talked about, saying we need to watch ourselves. Example 6 On 5/30/18 at 9:25 AM Surveyor interviewed LPN S. LPN S stated DON B was following Surveyor staff and speaking with facility staff, asking what staff tells Surveyors if DON B could not over hear the conversation. DON B said to LPN S that she had to know what was said, had the right to know. LPN S stated she felt her job was on the line if she said too much. On 5/17/18 at 10:00 AM NHA A and DON B are informed that the staff do not want to talk with Surveyor staff and do not want to be seen speaking with Surveyor staff because they are afraid of losing their jobs, feel threatened, feel they will be retaliated against if they say too much by NHA A and DON B. NHA A and DON B did not respond to the above information. Example 7 On 5/30/18 Surveyor interviewed Anonymous staff member PP who indicated to Surveyor that jobs are threatened here. this staff member indicated being afraid to be seen talking with Surveyor for too long, as the facility doesn't need a reason to fire you. Anonymous staff member indicated the facility deletes charting on a daily basis. Example 8 On 5/30/18 at 2:30 PM, Surveyor interviewed Anonymous QQ who indicated being afraid of retaliation to Surveyor. The facility's failure to ensure that residents were safe from R1 and that all staff were not intimidated by administration, not feeling able to freely speak to Surveyor staff or there would be negative consequences up to losing their jobs, created a situation of IJ. This was removed on 5/17/18, when the facility implemented the following action plan: *Staff interviews will be conducted weekly by a non management staff liaison to determine if staff feel comfortable reporting any concerns, allegations or suspicions of abuse to administrative staff without fear of retaliation. This will continue for a period of 3 months, then monthly for a total period of 1 year. Additionally, in relation to R1, the facility began implementing the following action plan: *Education will be provided to all staff prior to their next shift on the following items: All residents have the right to be free from any form of abuse. Residents at this facility are a very at risk and vulnerable population. Abuse definitions and what constitutes abuse as defined in the Abuse Policy. Staff have the duty to protect all residents from any form of abuse. If any abuse or suspicion of abuse is noted the staff will immediately stop the abuse and protect the resident. The staff will also assure that actions taken will protect all other residents as well. Staff will then immediately report any abuse or suspicion of abuse to their supervisor who MUST report to the DON and/or administrator will report within 2 hours to the state agency and law enforcement. Within two hours, staff are required to immediately report to law enforcement the reasonable suspicion of a crime where there is abuse or bodily harm. All allegations of abuse will be immediately investigated and the abuse policy followed. Sexual behavior intervention training. *All administrative staff will be educated prior to their next shift on: How to facilitate a supportive environment in which, staff and others report all allegations of abuse, neglect, or misappropriation *All nursing staff will be educated on creating new care plans with changes in condition and behavior. They will further be educated on adjusting existing care plans to reflect the changes in condition and behavior. *Resident and staff interviews were completed to determine if any remaining residents pose a risk of abusing others in any manner. This was completed on 5/10/18. *On 5/10/18, a resident was identified as having inappropriate sexual behaviors towards staff and thus could potentially pose a risk to others. This resident's care plan was reviewed/revised and interventions put into place on 5/10/18. The care plan was once again reviewed/revised on 5/17/18. *Abuse policy updated to include all referrals/potential residents having a CCAP (Consolidated Court Automation Programs) and sex offender registry search done prior to admission. *Abuse policy updated to include if abuse or serious bodily injury occurs law enforcement and state agency will be contacted in 2 hours. *On 5/14/18 a CCAP and sex offender registry search was completed on all current residents. *On 5/15/18 two meetings were held: One meeting with staff to brief them on the situation and provided Q and A (question and answer) time, support and education. One meeting with residents/family to brief them on the situation provide Q and A, support and new actions being taken (CCAP and sex offender registry checks. *A resident behavior watch list will be maintained in the charge office. This will include any resident with a behavior that all staff should be aware of for monitoring purposes. The information included will be resident name, unit, room number, behaviors and interventions. *Daily report will include the names on the resident behavior watch list. This is to ensure all staff are aware of who is on the list. If someone new has been placed on the list, any staff can go to the list and review what behaviors are being monitored and what interventions should be initiated in response to behaviors. *Interviews will be completed 3x (3 times) / week, for a period of 4 weeks, with residents to assure that they feel safe, determine if there are any other residents whom they feel threatened by or have a concern with, or any staff that they feel threatened by or have a concern with. After this 4 week period interviews will be completed weekly, for a period of 3 additional months, and then monthly thereafter for a total period of 1 year. *Interviews will be completed 3x/week, for a period of 4 weeks, with staff to determine if there are any residents showing behaviors that have not been identified previously that may pose a risk to other resident. Interviews will also include questions about what constitutes abuse, what actions should be taken if allegations are made or abuse observed and what the reporting requirements are. After this 4 week period interviews will be completed weekly, for a period of 3 additional months, and then monthly thereafter for a total period of 1 year. *Residents identified with behaviors will have care plan audits completed weekly for a period of 3 months, then monthly for a total period of 1 year. Audits will assure all behavior issues are addressed with appropriate interventions, staff are aware of and using the interventions, and that the care plan and bedside CNA guideline are matching appropriately. *Staff interviews will be conducted weekly by a non-management staff liaison to determine if staff feel comfortable reporting any concerns, allegations or suspicions of abuse to administrative staff without fear of retaliation. This will continue for a period of 3 months, then monthly for a total period of 1 year.

Based on interview and record review, the facility failed to prevent sexual abuse affecting 1 resident (R3) of a total 105 in the facility. R1 is a registered sex offender. R1 was observed going in and out of female residents' rooms independently throughout his stay at the facility. On 5/9/18, R3 informed staff that R1 had touched her between her legs inappropriately. R1's whereabouts within the facility and his visits in other resident rooms were not monitored during his entire 12 month stay. The facility's failure to keep residents free from sexual abuse created a finding of Immediate Jeopardy (IJ) beginning on 5/8/18. On 5/17/18 at 12:40 PM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The IJ was removed on 5/17/18. The deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Evidenced by: Resident 1 R1 was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. R1 is his own decision maker. R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/9/18 indicates R1 is cognitively intact and is independent with transfers and locomotion on and off the Unit. In addition, the MDS indicates R1 has no behaviors. R1's most recent care plan, dated 3/9/18, includes, in part, the following: 5/15/17: Problem: Self Care Deficit. Approach: 12/22/17: (R1) is a long term resident here now who came to us from home. He is familiar with facility layout and routines as he has been a resident here previously. He is alert and oriented times three, but does have poor safety awareness and impaired cognition that he is able to cover well. His speech is clear and he is able to make his needs known. 11/15/17: Transferring: Modified independent with a 4 WW (wheeled walker) within parameters of SNF (Skilled Nursing Facility) room. 12/22/17: Ambulation: Modified independent within parameters of SNF room with 4 WW and in halls with 4 WW. Distance to pt (patient) tolerance. 3/9/18: Problem: Activities: . His moods have been a bit worse and he is easily angered/annoyed at times. Behaviors in act (activity) groups are monitored as he has had inappropriate behaviors towards other female residents and staff. There are no Approaches related to this problem. 3/7/18: Problem: Potential for disruptive behaviors. (R1) may become frustrated at times when he is unable to control his situation or when abruptly directed to do a task. He does have targeted behaviors of inappropriate sexual behaviors, actions or comments which staff monitor. Approach: 3/7/18: Nurses: . chart targeted behaviors, foreshadow events/cares, build rapport, establish boundaries, maintain consistency. 3/7/18: Nurse Aides: . chart targeted behaviors, report any changes in behaviors. 3/7/18: SocServ: .encourage and assist staff in instituting appropriate boundaries and interventions as needed. (It is important to know that on R1'sGuidelines for Daily Cares, dated 4/15/18, which is found in each resident's rooms so CNAs (Certified Nursing Assistants) know how to care for the resident, there is nothing indicated under Behavior or Mood sections.) Multiple staff told the surveyor they were aware that R1 was a registered sex offender: On 5/16/18, Surveyor interviewed CNA F. Surveyor asked CNA F if she knew R1 was a registered sex offender. CNA F stated yes, we all knew. On 5/16/18 at 10:05 AM, Surveyor interviewed SW D (Social Worker). SW D stated that she became aware that R1 was a registered sex offender a few months ago. SW D stated that she informed NHA A and DON B at that time. SW D stated she did not think there was anything she could do as R1 was a resident of the facility. SW D stated she did not write a care plan regarding how to keep other residents safe. On 5/17/18 at 10:00 AM, Surveyor again interviewed SW D. Surveyor asked SW D if she informed the local police department that R1 was a resident of the facility, when she realized he was a registered sex offender. SW D stated no she did not inform the local police department that R1 was in the facility. SW D stated she thought that since she informed NHA A and DON B they would have informed the local police department. SW D stated to her knowledge no one informed the local police department. SW D stated many staff knew already that R1 was a registered sex offender and were monitoring him on their own. SW D stated she was aware that staff who was not [AGE] years old was not allowed to work with R1 because he was a registered sex offender. On 5/16/18 at 10:15 AM, Surveyor interviewed SW E. SW E stated she was aware that R1 was a registered sex offender. On 5/16/18 at 11:15 AM, Surveyor interviewed CNA G. CNA G stated she knew R1 was on the registered sex offenders list. On 5/16/18 at 11:40 AM, Surveyor interviewed LPN H (Licensed Practical Nurse). LPN H stated she was informed by other staff that R1 was a registered sex offender. On 5/16/18 at 1:30 PM, Surveyor interviewed HK I (Housekeeper). HK I stated she knew R1 was a registered sex offender; she was made aware of this by HS J (Housekeeping Supervisor). On 5/16/18 at 2:00 PM, Surveyor interviewed HS J. HS J stated she was aware R1 was a registered sex offender. HS J stated she informed her staff to not get too friendly with R1 and to keep an eye on him when he was admitted in April, (YEAR). HS J stated she was informed by staff after the incident in February, (YEAR), to keep an eye on him. On 5/16/18 at 2:30 PM, Surveyor interviewed CNA K. CNA K stated she was aware R1 was a registered sex offender. CNA K stated she was not [AGE] years old. CNA K stated he was not allowed to work with R1, because he was a registered sex offender and staff had to be 18 or older to work with him. CNA K stated the scheduler would not put her on R1's Unit as she knew CNA K was not [AGE] years old. On 5/16/18 at 2:35 PM, Surveyor interviewed CNA L. CNA L stated he was aware R1 was a registered sex offender. On 5/16/18 at 2:40 PM, Surveyor interviewed CNA M. CNA M stated she was aware R1 was a registered sex offender. CNA M stated she turned 18 in December, (YEAR). CNA M stated she could not work with R1 until she turned [AGE] years old, because he was a registered sex offender. CNA M stated the scheduler did not put her on R1's Unit. On 5/16/18 at 2:45 PM, Surveyor interviewed RN N (Registered Nurse). RN N is also a Charge Nurse. RN N stated he knew staff, who was under the age of [AGE] years old, could not work with R1. On 5/16/18 at 4:00 PM, Surveyor interviewed CNA R. CNA R stated she worked on R1's Unit and with R1. CNA R stated she was informed by a co-worker in (MONTH) that R1 was on the sex offender registry. On 5/17/18 at 3:15 PM, Surveyor interviewed CNA T via telephone. CNA T stated he was only [AGE] years old and was not allowed to work with R1. CNA T stated he was informed that R1 was a registered sex offender by other CNA's and RN II when he first started in September, (YEAR). (It is important to know RN II is also a Charge Nurse.) Multiple staff told the Surveyor that R1 would make sexual comments to them and/or make them feel uncomfortable, that he would make sexual comments about residents, and that he was in and out of residents' rooms: On 5/16/18 at 9:40 AM, Surveyor interviewed RA C (Resident Assistant). RA C stated R1 harassed her, stating comments that he wishes they were the same age and followed her into rooms. RA C stated R1 cornered her by her cart one time, asking her to go into his room with him so he could show her something. RA C stated she was very uncomfortable with this request and declined. RA C stated R1 pulled down his shirt during this interaction. RA C stated she informed SW D and HS J. RA C stated SW D told her to walk away from any interactions with R1 and tell him that you have a boyfriend or husband. RA C stated HS J went to R1 and told him to leave RA C alone. According to the Social Service Progress Note on 10/25/17, 11:02 AM: Writer also received report through Wing Nurse that (R1) has appeared to be following a newer residential helper around and watching her, which has caused her discomfort. Writer did speak with (R1) about the issue. Per (R1), he states she looks familiar and he thought she was in his grandson's class and she marched with him in the band. He stated he was trying to place her. Writer encouraged (R1) to verbally ask the res (resident) helper if he had a specific question versus following her, as that behavior may make others feel uncomfortable. (R1) stated he would not follow her any longer. On 5/16/18 at 11:15 AM, Surveyor interviewed CNA G. CNA G stated R1 was inappropriate with her, he would [MEDICATION NAME] at her, make rude/inappropriate comments about her bottom. CNA G stated there was an incident during the summer of (YEAR) when she observed R1 outside of R3's room. R1 made a comment about R3's big boobs and he wouldn't mind getting into her pants. CNA G stated she reported it to the nurse, but was not asked to write a statement and nothing changed to her knowledge regarding monitoring R1 and R3. CNA G stated R1 was in and out of other resident's rooms all the time, including females. CNA G stated later in the summer she was informed that R1 was no longer allowed in R4's room. CNA G stated she was not told why. CNA G stated R1 would sit in his room naked, with the door open, touching himself. On 5/16/18 at 11:40 AM, Surveyor interviewed LPN H. LPN H stated she did talk with SW D about R1 and his inappropriate sexual behaviors, as he was in female resident's rooms. LPN H stated staff was told to keep an eye on him, monitor his inappropriate sexual behaviors and comments. LPN H stated she was told by RA C that R1 was verbally inappropriate with her. LPN H stated she told RA C to keep her guard up, watching out for herself. LPN H stated the Charge Nurses were aware of R1's inappropriate sexual behaviors. On 5/16/18 at 1:30 PM, Surveyor interviewed HK I. HK I stated there was one time when she observed R1 in front of a room staring at R3. R3 was in bed, she did not have any covers on and her gown was not fully covering her. HK I stated she went into the room, covered R3 and informed the nurse of her observations. On 5/16/18 at 3:10 PM, Surveyor interviewed RN Q. RN Q stated R1 was very social. RN Q often saw R1 outside other resident rooms. Despite knowledge that R1 was a registered sex offender, that he harassed staff, that he was very social and often seen in or outside female residents' rooms, the facility did not have a specific plan in place to monitor R1 and to ensure residents were free from potential sexual abuse. R1's MAR (Medication Administration Record), dated 2/2018, includes, in part, the following: Entry Date: 2/6/18: Behavior symptoms: Inappropriate sexual behaviors, actions or comments. 2/6, 2/20 and 2/28. AM Shift indicates 1 on each of these dates. There is no documentation to show what the inappropriate sexual behavior, action or comment was. R1's Interdisciplinary Notes include, in part, the following entry: 2/6/18, 12:29 PM: Behavior: Writer made aware of behavior issue last PM shift. A resident was wheeling about in the hallway going the direction away from (R1's) room. CNA staff (CNA U) observed (R1) a distance behind the resident saying come here and he noted that (R1) had his penis out of his pants. (R1) made no contact with the other resident and resident was not even aware of the behavior. CNA immediately approached (R1) and suggested he get ready for bed. (R1) was monitored the remainder of the shift and had no further inappropriate behaviors and was in his room. Staff alerted Writer to the behavior. Writer did instruct staff to continue to monitor (R1's) behaviors very closely and to document any inappropriate behaviors, as well as alert Writer immediately. Writer does speak with Social Services. (SW D) who works with (R1) and his wife often. (SW D) did speak with (R1) this AM. (R1) denied that he did anything intentionally and makes reference to his Pull Up getting messed up sometimes. CNA that observed (R1) did feel that the behavior was intentional and not any type of issue with clothing/Pull Up. Targeted behaviors added as well at this time. Social Services will continue to work with (R1) as well. On 5/17/18 at 5:00 PM, Surveyor interviewed CNA U. CNA U stated he was working on 2/5/18 when he observed R1 with his penis out of his pants, wheeling himself in the hallway towards R2, saying come here to R2. CNA U stated R1 had a smirk on his face. CNA U stated he immediately removed R2 from the area and reported the incident to the nurse. CNA U stated the nurse had him write a report of what happened and then DON B had contacted him via Facebook to ask about the incident. On 5/17/18, Surveyor interviewed DON B. Even though SW D stated she had told the DON and the Administrator a few months ago that R1 was a registered sex offender, DON B stated she was unaware that R1 was a registered sex offender until staff informed her on 5/15/18. DON B stated she did know that R1 would visit other residents in the hallways, was unaware R1 was going into other resident rooms unsupervised to visit and no concerns R1 was touching anyone, were brought to her. DON B stated SW D did not inform her that R1 was a registered sex offender. DON B stated she had no knowledge that staff under the age of 18 could not work with R1. DON B stated she did not give that direction. DON B stated she should have been informed that R1 was a registered sex offender, R1 should have had a care plan for his sexual inappropriateness, at least on 2/5/18 after he exposed himself, should have had increased supervision, should not have been allowed to visit other residents unsupervised in their rooms, and should have informed the local police department to inform them a had a registered sex offender in the building, especially because the facility is across the street from a grade school. Sexual assault R3's [DIAGNOSES REDACTED]. R3 is her own decision maker. R3's most recent MDS with an ARD of 4/6/18 indicates R3 has cognitive impairment, transfers with extensive assist of two or more, and has no behaviors. On 5/16/18 at 11:00 AM, Surveyor interviewed R3. R3 stated a man had come into her room last week and touched her between her legs. R3 stated she pulled away, he didn't say anything, just touched me. R3 states she didn't want the man touching her. R3 stated she was afraid of the man and didn't want to ever see him again. R3's Nursing Progress Notes include, in part, the following: 5/14/18, 8:54 PM: Late entry for 5/9/18. Around 11:45 AM (R3) makes comment to CNA that the men are fresh around here. She then informs CNA that a man had touched her inappropriately. CNA immediately reported statements. Writer to room to talk with (R3). It is apparent that (R3) is speaking of another resident in the facility. (R3) provided with much support and 1:1 throughout the day by both Writer and Social Services, (SW D), as well as other staff. Writer does explain to (R3) that the police will be alerted as to the actions that occurred against her. She is understanding of this and later on when police in the building she is agreeable to talking with them. Writer present for support at that time as well. (R3's) son was updated on situation by Writer and Social Services (SW D). Writer does then assist (R3) to speak on the phone to her son. Writer asks (R3) several times throughout the day if she feels safe and reassures her that nothing like that will happen again and that the man is being dealt with and removed from the facility. (R3) does express that she was scared of the man but feels safe and secure since she informed staff of what occurred. During activities she does seem quiet with activities staff asking her what is wrong with her only stating that she is thinking of bad things. They offer additional support. Writer does later speak with son once again and he states that (R3) sounded good on the phone and did not bring up the situation. He does state that he did not bring it up either, as he did not want to upset her. Writer does reassure him that staff are working closely with (R3) to assure that she feels safe and secure. 5/14/18, 8:59 PM: Important Note: Late entry for 5/10/18: Writer in to check on (R3). (R3) reports that she is doing fine. Writer asks her if she is feeling safe and she states that she is. She does state that she did have dreams last night about it but she states that she slept well and it did not keep her from getting her rest. Writer asks her if she is wanting to talk or discuss the situation that was reported the day prior any more or if she felt that she needed any further support or help from anyone. She declines, stating that she is fine. Writer reassures her once again that the man has been removed from the facility and that she is safe. She is very appreciative. Writer does go back to her a bit later in the day to discuss incident again, as Law Enforcement is requesting a non-consent form. Writer reviews such with (R3) explaining that the form is stating that she did NOT give the man permission to touch her. (R3) states clearly that she did not give him permission and is agreeable with the form and signing it. She additionally signs a medical release form for (Local Police Department) for her medical records, as per their request. 5/14/18, 9:06 PM: Important Note: Writer checks in with (R3) this day . Writer asks if she has had any further dreams about the man that had come into her room. She states the bad man? Writer confirms that this is what Writer is asking about. (R3) states that she has not had any further dreams and has been sleeping well. She states that she was scared of him but she feels safe and secure now. (It is important to note the above 2 entries were documented 5 days after the incident occured). 5/15/18, 11:05 AM: Behavior: (R3) was noted to be tearful this shift. She was also noted by activity staff to be grabbing at her shirt to make sure that it was closed at the top. Resident appears to be sad and withdrawn at times during the past 3 - 4 day. Writer has noticed that she has had a decrease in appetite. Writer noted that on 5/12/18 she did not eat any breakfast or lunch. Also noted that on 5/11/18 that resident slept for most of the AM shift. 5/16/18, 4:20 AM: Behavior: Resident had one tearful episode during the Night shift, was heard crying out - when Writer entered the room it had appeared resident had been dreaming, as resident still sleeping. Resident picking at nose at one point causing a mild bloody nose - became tearful over this. Reassurance provided. 5/16/18, 1:20 PM: Behavior: (R3) has had a fairly good shift. She was noted to have 2 - 3 episodes of picking her nose to the point that she would have a nose bleed. Writer is not sure if this is a behavior that is related to anxiety or not. 5/16/18, 4:16 PM: Important Note: Writer meets with (R3) this AM around 8:15 (AM). Writer asks her about her mood and again how she is doing since the man had come into her room. She states that she is doing ok and perhaps seems a bit more down today than in Writer's prior contacts with her. Incident Report The facility Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 5/9/18, includes, in part, the following: Date Occurred: 5/8/18. Time Occurred: Approximate 2:30 PM. Date Discovered: 5/9/18. Brief Summary of Incident: Around 11:45 AM, (CNA F) was making (R3's) bed and she stated that the men sure are fresh around here. CNA asked resident what happened and she reported that a man touched her down her pants. CNA immediately reported statement. Upon Writer's initial interview with (R3) it was apparent that she was talking about another resident (R1). At this time (R1) is being supervised to assure safety of all residents. Investigation continues and police notification forthcoming. The facility's Misconduct Incident Report, dated 5/9/18, includes, in part, the following: Date Occurred: 5/8/18. Time Occurred: approximately 2:30 PM. Date Discovery: 5/9/18. Briefly describe the incident: Resident (R3) reported to (CNA F), that the men are fresh around here. Upon further questioning it is found that (R3) is speaking about another resident and an incident that occurred the day prior on 5/8 in the afternoon. (R3) is reporting that this other resident (identified as R1) touched her inappropriately. Describe the effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident: (R3) has verbalized that she is troubled by the incident. She states that she has had some dreams regarding it but does report that she is not losing sleep and feels safe . Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Upon receiving the complaint, resident (R1) is provided with supervision. Staff assure that (R1) remains within eye sight and observe all of his whereabouts to assure safety of all residents. Police are notified and later that evening (R1) was taken into custody and removed from the facility. 5/9/18. Approximately 11:45 AM. Writer made aware by (CNA F) that (R3) had made a statement about men around here being fresh. When asked about this by CNA, (R3) stated further that a man touched her. Per (CNA F), (R3) did call the man by name (R1), but states that (R3) had said that she could not remember the man's last name. (CNA F) at this time immediately reported statements. Writer to room to speak with (R3). Upon questioning, (R3) reports to Writer that a man got fresh with her. When Writer asks her what she means by this, (R3) motions to Writer's lap with her hand. Writer attempts to clarify with (R3) by asking, so he went like this? (while patting her leg, as this is the motion that (R3) made towards Writer.) (R3) laughs at Writer and states haven't you ever been with a man? Writer apologizes but explains that Writer needs clarification about what exactly happened. (R3) states that the man touched her between her legs inappropriately. Writer asks (R3) about the man and if he walked into the room or what he may have looked like. She states that the man was in a wheelchair. Writer does ask when this happened and she states that it happened yesterday afternoon. Writer asks her if anything else like this had ever happened to her while she was at (Facility) and she states that it had not. Writer explains to (R3) that Writer is here to make sure that she is safe and that nothing further would happen to her. (R3) has her lunch in front of her at the time and talks about her lemonade being too sour. Writer offers to get sugar for her and she wishes to have that. Writer obtains sugar for (R3). Writer speaks with Social Services (SW D) about the concerns who does then speak with (R3) in more depth. At the time of (R3's) report to (CNA F), resident (R1) was eating his lunch. Writer alerts staff immediately that (R1) is to have a staff member supervising him at all times. Staff do assure that (R1) remains within sight at all times from that moment on. (R1) finishes his lunch and returns to his room, where he spends the remainder of the afternoon in his recliner. As Social Services (SW D) speaks further with (R3), Writer begin to contact staff who worked with (R3) prior to her reports to (CNA F). When Writer speaks with (LPN S) who worked the previous day shift, she reports that she did see (R1) in (R3's) room the previous day (5/8/18) talking to (R3). (LPN S) reports this was approximately 2:30 PM. At that time (LPN S) talked with (CNA AA) about (R1) being in the room and wondered if it was odd for him to be in there. (CNA AA) at that time went to the room and informed (R1) that she needed to assist (R3) and asked that he leave. (CNA AA) reports that she did not observe any physical contact being made at that time. She states that (R1) and (R3) were talking like they were friends. She states that when providing care at that time and again during the evening, (R3) did not talk about any physical contact occurring, nor did she talk about (R1) at all. See attached statements by (LPN S) and (CNA AA). Staff that subsequently worked with (R3) between 2:30 PM (on 5/8/18), when (R1) was noted in the room and 11:45 AM (on 5/9/18) when (R3) reported the incident to (CNA F), stated that (R1) did not mention the interaction, nor did she make any concerning comments. Staff felt that she was per her norm during that time period and no physical injuries have been noted. The facility staff interviews related to the 5/9/18 Misconduct Incident Report include, in part, the following: LPN S interview, dated 5/10/18: I was waiting to see who was the nurse and found out she was listening to report. I was coming up (name of hallway) and saw nurse, we went to count the narcs (narcotics) on (name of hallway). Nurse asked what rooms residents were in. I began to tell her and said (room number) and turned to see (R1) sitting next to (R3's) bed (in R3's room), in his wheelchair. All I could see was the back of his wheelchair and the back of his head. I could hear talking but could not hear what was being said specifically. I commented to CNA and nurse that this was odd. (CNA AA) went to the room. On 5/16/18 at 2:15 PM, Surveyor interviewed LPN S. LPN S stated she had never seen R1 on the Unit before alone. LPN S stated she thought R1 in R3's room seemed odd, so she asked CNA AA to go in and make some reason up to have him leave. LPN S stated that she had heard sometime last fall that R3 was following a female resident around the facility. LPN S stated she does not work with R1, she did not know who the female resident was. On 5/30/18 at 9:25 AM, Surveyor interviewed LPN S. LPN S stated when she saw R1 in R3's room she reported it to RN JJ and RN KK. RN JJ and RN KK are Nurse Managers. LPN S stated RN JJ and RN KK told her that residents have the right to visit other residents in their rooms. LPN S stated she had never been informed to monitor R1's behaviors. CNA AA interview, undated: (LPN S) came up to Nurse's Station, where I was and stated that (R1) was in (R3's) room and this was odd and didn't think that he should be in there. I went to the room and saw (R1) sitting next to (R3's) bed. I did not see him physically touch her but they were having a conversation. I did not hear what they were saying but seemed to be that they were talking like friends would. I went in and told (R1) that I needed to provide (R3) with cares then he left. (R3) never said anything to me about (R1) or their interaction. When I got done providing cares and came out, I did not see (R1) anywhere around. He did come back down to the Unit to eat in the dining area but then left and went back to his Wing. I did not see him again after that. (R3) seemed her normal self throughout the night. She was talkative and did call out help a few times, which is per her norm but made no comments about (R1). CNA F interview, dated 5/9/18, I went in to make resident's bed in room (R3's room number) on (name of hallway). As I was making the bed resident stated the men sure are fresh around here. I said what are you talking about? I said did someone say something to you and resident stated no, not that way, and resident said that man (R1) who was in here touched me down my pants; she stated she did not know his last name. On 5/16/18, Surveyor interviewed CNA F. CNA F stated she had come to assist on the Hallway while the other CNA went on break. CNA F stated she noticed R3's bed was not made, so she went in to make it. While making the bed R3 stated to CNA F are all the men so fresh around here. CNA F stated she asked R3 what she meant. R3 answered R1 had touched her inappropriately down there and on her breast. CNA F stated she got RA C to stay with R3 while she informed SW E. (PO BB) and (PO CC) (Police Officers) interviewed R1 on 5/9/18 and noted: . (R1) appears very nervous and is quite talkative. (R1) does bring up a female resident during his statements, whom he calls **** and states that she used to be in room ** when he was on the (name of hallway) and that she recently moved to room ** or **. (R3) was in fact in room ** up until 5/7, at which time she moved to room **. It is very apparent that the resident whom (R1) is calling ****is indeed (R3). Police begin to question (R1) specifically about visiting with other residents in their room and if he does this, as all of (R1's) statements thus far have been regarding group activities and who is generally there. (R1) again bring up some male residents that he visits by stopping by their rooms and talking. (R1) again brings up *** and states he had talked to her the day prior. Police ask if he had talked to her in her room. (R1) initially informs police that he did not enter her room but talked with her from her doorway, then it changes to he was 2 - 3 feet into the door and then with further police questioning (R1) admits to touching (R3). He states that he may have touched her shirt. Police question why he would have touched her shirt and initially he does not answer this directly. Then he states he may have accidently touched her boob. With further questioning (R1) goes on to describe that he touched (R3's) breast on the outside of her shirt and when she didn't say anything he did reach under her shirt and touch her nipple rolling it in his fingers. Police question regarding any touching of ****'s vagina or down her pants and (R1) denies this. He is questioned about the length of time that this touching may have occurred and (R1) reports that he believes it not to be longer than 30 seconds. (R1) is questioned if there has ever been any other resident(s) that he touched during his stay here. (R1) states that there may have been one other. He is asked who this resident was and he reports that it was a resident from when he was on (name of hallway). He states that it was also a resident named **** or something like that and turns to (SW D) for clarification on the name of the resident he described as a lady who really doesn't talk much but is out and about in the hallway. (SW D) questions if he is referring to (R2) and (R1) states, oh yes (R2). He states that he may have touched her breast. Police ask if he touched her on top of the clothing or under the clothing. He states that he touched her on top of the clothing. (R1) is asked when this occurred and he states it occurred when he lived on (name of hallway) but cannot give any type of specific time. Writer asks (R1) about a time several months ago in which a staff member had observed (R1) with his penis out of his pants in the hallway, at which time that particular resident was 10 - 15 feet away from him, with her back to him. (R1) once again, as he did at that time, denies that this occurred stating that he was adjusting himself. (R1) does not recall if this is anywhere near the time that he touched her breast. Police question (R1) further if he has had any contact with any other residents and he denies this. Police do inform (R1) that charges may be brought against him. Police interview is completed and officers begin necessary action steps in order to determine outcome and if (R1) will be taken into custody. (R1) remains in conference room during that time with supervision by (SW D). Staff interviews indicate that facility staff did not immediately begin to monitor R1 after being made aware of what had occurred on 5/8/18. On 5/17/18 at 8:50 AM, Surveyor interviewed CNA F again. Surveyor asked CNA F where was R1 when she informed SW E? CNA F stated R1 was on the Unit in the

Based on interview and record review the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status nor inform the resident or the resident's physician of laboratory results with a need to alter treatment significantly for 1 of 10 residents (Resident 1). Resident 1 was being treated for [REDACTED]. Resident 1's physician was not updated regarding the changes in condition. The facility did not follow up on laboratory tests and notify Resident 1 and/or Resident 1's physician with the results. This is evidenced by the following: The facility's "Policy and Procedure: MD and Family Update: Change of Condition," reference the American Medical Directors Association, signed 10/31/11, indicates the following: *Vital signs: Systolic blood pressure greater than 210 mmHg or less than 90 mmHg - Immediate within 1 hour. Blood pressure out of parameters but not out of immediate parameters and without symptoms-Non Immediate within shift. *Consciousness, altered: Sudden change in level of consciousness or responsiveness-Immediate within 1 hour. Gradual but persistent recent change in level of consciousness or responsiveness-Non immediate within shift. *Lab Reports-Any abnormal lab results not requiring immediate notification-Non immediate within shift. *Weakness arm or leg-Abrupt onset of noticeable change in strength or use-Immediate within 1 hour. Gradual recent onset not resolving spontaneously-Non immediate within shift. Example 1 Resident 1 was initially readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 is alert and oriented and is her own decision maker. Resident 1's physician orders, signed 7/12/12, include blood pressure parameters systolic blood pressure less than 90 or greater than 180. Resident 1's nursing notes includes the following: 7/12/12-10:19 AM Resident 1 is independent in her room now. Spoke about discharge plans. 8/1/12-6:21 AM On call physician updated on Resident 1 being sluggish to respond and a temperature of 100.2, oxygen saturations 86% on room and 93% with 2 liters of oxygen. Orders were received. -1:39 PM Resident 1 appears more alert at this time, staff did assist with lunch due to lethargy. 8/3/12-6:37 PM Physician updated on laboratory results which [MEDICAL CONDITION] (Multi-drug Resistant Staphylococcus Aureus). Antibiotic started and put on isolation. 8/4/12-7:21 AM blood pressure 84/41 charge nurse updated, [MEDICATION NAME] held -7:36 AM physician called and updated on out of parameter blood pressure. -3:52 PM blood pressure 84/41 (no physician notification noted) 8/5/12-7:26 AM [MEDICATION NAME] held, blood pressure 90/60 -2:21 PM blood pressure 90/60, pulse 89 -2:33 PM Resident 1 lethargic and slightly confused today. Resident 1 needed assistance with breakfast and lunch. Resident 1 twitching frequently today and having uncontrollable movements with arms and legs. Blood pressure 90/60 temperature 97.8. Resident 1 did not get out of bed today oncoming shift updated to use vander for transfers today if resident does want to get out of bed. Resident 1 is currently being treated for [REDACTED]. (signed by Licensed Practical Nurse D). -3:15 PM 9:10 AM call to physician updated on rash bilateral axillas new order for [MEDICATION NAME] cream. (signed by Registered Nurse C) 8/6/12-8:37 AM [MEDICATION NAME] held, blood pressure 92/67 -1:02 PM writer notes resident to be lethargic and very shaky this shift. Resident 1 has not offered any complaints of pain or discomfort just stating she is very weak and has no control over her arms or legs. Resident was assisted with transfers via vander lift and assisted with all meal intake. -2:23 PM Resident 1's family called concerned with Resident 1's responses on the phone. Resident 1 seems to be declining to family, less responsive, more tremulous, weaker and family is very concerned. Writer updated family on recent decline in therapies as well with transfers now back to the vander lift once again. -3:12 PM Resident 1's husband has come to the facility and is requesting to take Resident 1 to the hospital at this time for evaluation. Resident 1's husband was going to take Resident 1 via car but realized this was not possible and requested an ambulance to transfer Resident 1 to the hospital. -4:19 PM Later (SIC) entry for early afternoon- call to Resident 1's physician "on the gradual change in condition, which (physician's name) has been aware of somewhat, but with no improvement since being placed on the Bactrim [MEDICAL CONDITION]" in the urine. Writer updated physician that Resident 1's husband wants her sent to hospital at this time for evaluation. -5:00 PM call from hospital Resident 1 is being admitted . On 9/18/12, at 2:58 PM, Surveyor interviewed Registered Nurse (RN) C. RN C confirmed she entered the note for Resident 1 on 8/5/12 at 3:15 PM. RN C reviewed her note and stated she only talked with Resident 1's physician about getting [MEDICATION NAME] cream for Resident 1. RN C stated if she would have spoken with the physician about any other concerns she would have written it in her notes. RN C stated shift to shift report is done via tape recorder and is then taped over and she could not recall if any concerns with Resident 1 were in the shift to shift report. RN C could not remember anything about Resident 1 on 8/5/12. On 9/18/12, at 3:06 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated Licensed Practical Nurse (LPN) D would not have called the physician because she is a LPN and LPNs are to report to the charge nurse and the charge nurse is to call the physician if needed. DON B confirmed there is no documentation that the physician was notified on 8/4/12 with the second low blood pressure or on 8/5/12. Surveyor asked DON B if the physician should have been notified and DON B did not verbally respond but shrugged and nodded yes. Resident 1's hospital history and physical for 8/6/12 indicates the following: Chief Complaint: Lethargy, shaking and weakness. History of Present Illness: Patient is unable to provide any pertinent history due to confusion. Resident 1 was discharged from the hospital on [DATE] with [DIAGNOSES REDACTED]. (Reference F327) Example 2 Resident 1 was readmitted to the facility on [DATE] following a stay in the hospital for a urinary tract infection [MEDICAL CONDITION] and dehydration. On 8/15/12, the facility received orders for Resident 1 including a BMP (Basic Metabolic Panel) and Hematocrit in 2 weeks on 8/29/12. On 8/29/12 Resident 1's physician made a telephone order to do a urinalysis and culture and sensitivity today and may discharge home with home health when ready. Urinalysis and culture and sensitivity sent to lab. On 9/1/12 at approximately 10:00 AM Resident 1 was discharged home. Resident 1's nursing notes indicate on 9/2/12, Resident 1's husband called the facility and was upset that Resident 1 was sent home in the condition she was in. "Writer told him that a urine culture had been sent in on the 30th of August and that she would call the lab to find the results of it." The lab stated Resident 1 had E Coli and the test was being confirmed. Writer called Resident 1's husband back and stated would call the physician and ask him to get a prescription for Resident 1. Prior to Resident 1's husbands call to the facility there was no follow up on the lab testing done before discharge.

Based on record review and interview the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health for 1 of 10 residents (Resident 1). Resident 1 has a history [MEDICAL CONDITION] and was treated for [REDACTED]. Resident 1 was sent to the hospital and treated for [REDACTED]. This is evidenced by the following: The facility's policy "Monitoring Intake and Output", March 2011, states the objective as: Residents may need to have fluid intake and/or output monitored and recorded closely to further evaluate a medical condition or to monitor if he/she is at risk of a fluid imbalance or dehydration. Monitoring intake and output can alert staff to a potential or actual problem and can provide the MD with additional information when evaluating a resident. The policy does not indicate who should be on intake and output monitoring. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge notes indicate Resident 1 was admitted with a creatinine of 3.58 with mild [MEDICAL CONDITION] of 5.6 and a discharge creatinine of 1.32. On 6/17/12 a dietary assessment was completed that indicates Resident 1's estimated fluid need is 2700 cc (cubic centimeters) per day. Resident 1's laboratory tests include the following results: 6/11/12--BUN (blood urea nitrogen) 25, creatinine 1.4 7/3/12--BUN 34, creatinine 1.5 7/18/12--BUN 48, creatinine 1.6 Resident 1's physician orders [REDACTED]. -[MEDICATION NAME] 40 mg (milligrams) daily. A telephone order, dated 7/27/12 indicates to hold the [MEDICATION NAME] if systolic blood pressure is less than 100. -Telephone order on 8/3/12 for Bactrim DS twice a day for 7 days. Resident 1's nursing notes indicate: 7/18/12: Resident 1's physician's nurse updated on the labs with writer noting the upward trend of the BUN/creatinine. No new orders received. 8/1/12-6:21 AM On call physician updated on Resident 1 being sluggish to respond and a temperature of 100.2, oxygen saturations 86% on room and 93% with 2 liters of oxygen. Orders were received. -1:39 PM Resident 1 appears more alert at this time, staff did assist with lunch due to lethargy. 8/3/12-6:37 PM Physician updated on laboratory results which [MEDICAL CONDITION] (Multi-drug Resistant Staphylococcus Aureus). Antibiotic started and put on isolation. 8/4/12-7:21 AM blood pressure 84/41 charge nurse updated, [MEDICATION NAME] held -7:36 AM physician called and updated on out of parameter blood pressure. -3:52 PM blood pressure 84/41 8/5/12-7:26 AM [MEDICATION NAME] held, blood pressure 90/60 -2:21 PM blood pressure 90/60, pulse 89 -2:33 PM Resident 1 lethargic and slightly confused today. Resident 1 needed assistance with breakfast and lunch. Resident 1 twitching frequently today and having uncontrollable movements with arms and legs. Blood pressure 90/60 temperature 97.8. Resident 1 did not get out of bed today oncoming shift updated to use vander (lift) for transfers today if resident does want to get out of bed. Resident 1 is currently being treated for [REDACTED]. (signed by Licensed Practical Nurse D). -3:15 PM 9:10 AM call to physician updated on rash bilateral axillas new order for [MEDICATION NAME] cream. (signed by Registered Nurse C) 8/6/12-8:37 AM [MEDICATION NAME] held, blood pressure 92/67 -1:02 PM writer notes resident to be lethargic and very shaky this shift. Resident 1 has not offered any complaints of pain or discomfort just stating she is very weak and has no control over her arms or legs. Resident was assisted with transfers via vander lift and assisted with all meal intake. -2:23 PM Resident 1's family called concerned with Resident 1's responses on the phone. Resident 1 seems to be declining to family, less responsive, more tremulous, weaker and family is very concerned. Writer updated family on recent decline in therapies as well with transfers now back to the vander lift once again. -3:12 PM Resident 1's husband has come to the facility and is requesting to take Resident 1 to the hospital at this time for evaluation. Resident 1's husband was going to take Resident 1 via car but realized this was not possible and requested an ambulance to transfer Resident 1 to the hospital. -4:19 PM Later entry for early afternoon- call to Resident 1's physician "on the gradual change in condition, which (physician's name) has been aware of somewhat, but with no improvement since being placed on the Bactrim [MEDICAL CONDITION]" in the urine. Writer updated physician that Resident 1's husband wants her sent to hospital at this time for evaluation. -5:00 PM call from hospital Resident 1 is being admitted . Resident 1's documented intakes in milliliters/cc (note amounts are not totaled in charting): 7/26/12-Lunch 300, dinner 180 =480 7/27/12-dinner 180 7/28/12-lunch 300, dinner 380=680 7/29/12- lunch 240 7/30/12- no data 7/31/12-dinner 180 8/1/12- dinner 0 (refused) 8/2/12-dinner 180 8/3/12-180 8/4/12-dinner 225 8/5/12- dinner 200 8/6/12- lunch 180 out to hospital before dinner Resident 1's care plan was updated on 8/1/12 and includes the problem area of "Potential for Fluid Volume Deficit" related to daily use of diuretic and manifested by recent urinary tract infection [MEDICAL CONDITION] and altered intake. Approaches include: encourage fluid intake, provide fluids at meal time, medication pass and at bedside, document intake by percent at meal times liquids and solids, is independent with use of bed side water jug. The hospital admission note, 8/6/12, indicates: Physical exam: Constitutional: Resident 1 appears lethargic. She is cooperative. She has a sickly appearance. She appears ill. Mouth/Throat: Mucous membranes are dry. Dried blood around lips. Lab values from 8/6/12--BUN 86, creatinine 3.98, sodium 139, potassium 6.7 The hospital discharge note, on 8/14/12, state Resident 1 "was admitted acutely ill with dehydration, acute kidney injury, [MEDICAL CONDITION], altered mental status and urinary tract infection." Resident 1 was treated with intravenous fluids, antibiotics and supportive care. Her renal function improved and her mental status improved. Creatinine was 1.36 at discharge. Resident 1 was readmitted to the facility on [DATE]. Resident 1's care plan for fluid volume deficit was not updated. Resident 1's documented intakes are: 8/16/12-dinner 120 8/17/12-dinner 300 8/18/12-dinner 200 8/19/12-dinner 240 8/20/12-lunch 420 8/21/12-lunch 300 8/22/12-lunch 420 8/23/12-lunch 300, dinner 180=480 8/24/12-lunch 200, dinner 180=380 8/25/12-lunch 360 8/26/12- lunch 300, dinner 200=500 8/27/12-dinner 300 8/28/12-dinner 160 8/29/12-no data 8/30/12-no data 8/31/12-lunch 240, dinner 160=400 On 9/18/12, at 1:25 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated intakes/outputs are only done on residents if they are needed and there would be a physician's orders [REDACTED]. Surveyor asked DON B to clarify a nursing concern. DON B stated it could be if they have an infection or they are not independently taking in fluids. DON B stated the certified nursing assistants document meal intakes on everyone and if a resident is on an intake/output that is recorded on the medication administration record. DON B confirmed there was not an intake/output order for Resident 1 and intake/outputs were not being monitored. DON B stated the intakes the certified nursing assistants' record are reviewed with the quarterly staffing. On 9/18/12, at 2:55 PM, Surveyor again interviewed DON B regarding Resident 1's intake documentation. DON B stated Resident 1 was not on an intake/output so what was documented in the record is okay. DON B stated looking back now she would expect an intake/output to be done on Resident 1. At 3:06 PM, Surveyor pointed out the missing meal times. DON B stated she did not notice the sporadic intake documentation for Resident 1. DON B stated they have noted the missing information in the past within the facility and addressed it with those staff. On 9/18/12, at 3:45 PM, during a meeting with the facility Surveyor asked if the facility monitors someone's fluids who comes from the hospital with a [DIAGNOSES REDACTED]. Registered Nurse E stated the facility does not document breakfast intake on anyone and that breakfast is not included in the dietary recommendations. The facility did not monitor Resident 1's fluid intakes when she was first admitted due to dehydration nor after she was readmitted for another episode of dehydration.