Every finding on record at Maryhill Manor

Based on observation, interview, and record review, the facility did not ensure an allegation of abuse was reported to Nursing Home Administrator (NHA)-A or their designee for 1 resident (R) (R1) of 5 sampled residents.On 6/11/26, Certified Nursing Assistant (CNA)-C observed an incidence of verbal abuse directed toward R1 by CNA-E. The abuse was not reported to NHA-A.Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 9/30/25, indicates: .Verbal abuse means the use of oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Reporting/Response: 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 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.R1 was admitted to the facility on [DATE] and had diagnoses including neurocognitive disorder with Lewy bodies, vascular dementia, unspecified with anxiety, and traumatic brain injury. R1's Minimum Data Set (MDS) assessment, dated 4/9/26, stated R1 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the assessment could not be completed. A comment on the assessment indicated R1 stopped answering. The MDS assessment and R1's care plan indicated R1 required staff assistance for activities of daily living (ADLs).On 6/16/26, Surveyor reviewed R1's medical record. A progress note, dated 6/11/26 at 3:22 PM, indicated R1 slept most of the morning. At approximately 12:00 PM, R1 was combative during cares and hit/tried to kick staff. Following cares, R1 was adamant that they did not want to get out of bed. R1 remained in bed and slept the rest of the shift.On 6/16/26 at 10:50 AM, Surveyor interviewed CNA-C who indicated they were called to assist CNA-D and CNA-E in R1's room last Thursday (6/11/26) at approximately 12:00 PM. R1 was in bed and was combative toward CNA-D and CNA-E. CNA-C indicated R1 hit CNA-E whose eyeglasses flew off. CNA-C stated they saw CNA-E get down in (R1's) face and call R1 a motherfucker. CNA-C indicated they did not see CNA-E physically abuse R1; however, R1 later told CNA-C staff were forcing R1 to get up and broke R1's watch. R1 pointed to scratch marks on their wrist while talking about the incident. CNA-C confirmed they saw R1's broken watch. CNA-C indicated they did not report the abuse to the nurse on duty or management. CNA-C thought Registered Nurse (RN)-F knew about the broken watch because RN-F brought R1 a different watch. CNA-C saw a yellow bruise on R1's stomach after the incident in addition to the scratches on R1's wrist. CNA-C confirmed CNA-E continued to work scheduled shifts following the incident.Surveyor reviewed nursing schedules which indicated CNA-E worked until 2:00 PM on 6/11/26 and worked AM shifts (5:30 AM to 2:00 PM) on 6/13/26 and 6/14/26.On 6/16/26 at 11:40 AM, Surveyor interviewed RN-F who was aware that R1's watch was broken and R1 was given another watch. RN-F was also aware that R1 was combative with staff on the 6/11/26 AM shift. RN-F was not aware of the allegation of abuse or the scratches and bruise observed on R1's wrist and stomach.On 6/16/26 at 1:06 PM, Surveyor observed R1's left wrist and noted 3 scratches (less than 1 inch). R1 was not wearing a watch. Surveyor observed a watch on R1's nightstand. On 6/16/26 at 1:14 PM, Surveyor observed CNA-G enter R1's room with a lift. When Surveyor asked if R1 had a bruise on their stomach, CNA-G was unsure and stated they would check during the transfer. Following the transfer, CNA-G confirmed R1 had a yellow bruise. Surveyor noted the bruise was above the waistband of R1's pants and was approximately 3 inches long and 1 inch wide.On 6/16/26 at 1:30 PM, Surveyor interviewed CNA-D who confirmed R1 was combative during cares on 6/11/26. CNA-D indicated they and CNA-E were trying to wash R1's bottom when R1 hit CNA-E in the face and bent their glasses. CNA-D told CNA-E to report the incident because CNA-E should not have to pay to get their glasses fixed. CNA-D stated R1's watch was broken during the incident and may have gotten caught on something or flipped off R1's wrist when R1 hit CNA-E. CNA-D did not recall scratches on R1's wrist. CNA-D used a pager to request additional help during the incident and CNA-C provided assistance. CNA-D denied observing verbal or physical abuse toward R1.On 6/16/26 at 2:09 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-H whose office was near R1's room. ADON-H stated staff did not report abuse toward R1. ADON-H indicated RN-F reported during morning meeting on 6/12/26 that R1's watch was broken and they were being given another watch until it could be fixed. There was no mention of abuse or other incidents with staff. On 6/16/26 at 2:21 PM, Surveyor interviewed CNA-E who confirmed R1 was combative on 6/11/26 but denied that R1 hit them in the face or glasses. CNA-E indicated they were hit by another resident on the unit prior to caring for R1. CNA-E indicated R1 clawed CNA-E's arm. CNA-E confirmed R1's watch was broken during the incident and thought CNA-E's finger got stuck underneath the watch. CNA-E indicated R1 wanted to get up and was calm and in a good mood, however, R1 sometimes gets mad when staff roll or move them. CNA-E stated R1's mood changed when CNA-E was almost finished with incontinence cares. CNA-E stated staff could not step away because R1 was naked and they and their bed were soaked. CNA-E confirmed CNA-C provided assistance after being called to help. CNA-E denied swearing at R1 and denied any verbal or physical abuse toward R1. CNA-E was not aware of scratches or bruises on R1's wrist and stomach and verified R1 remained in bed after the incident. On 6/16/26 at 2:40 PM, Surveyor interviewed NHA-A who indicated they had not received any reports of abuse from R1 or staff. On 6/16/26 at 7:47 PM, Surveyor interviewed R1's Power of Attorney for Healthcare ((POAHC)-I) via phone. POAHC-I stated R1 had recently mentioned to them that R1's watch was upside down. POAHC-I did not know the watch was broken at the time. R1 also indicated three people held R1 down. POAHC-I stated they did not make sense of it at the time but wondered if it had something to do with the incident on 6/11/26.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 46 residents residing in the facility. The facility did not test the temperature of the sanitizing solution used in sanitizing buckets and the 3-compartment sink per manufacturer's recommendations. In addition, the facility did not monitor parts per million (PPM) of the sanitizing solution. The facility did not consistently label resident food with use-by dates and ensure timely disposal of expired items. Findings include: On 3/23/26 at 10:40 AM, Surveyor completed an initial tour of the kitchen with Interim Dietary Manager (DM)-D who stated the facility follows both the Wisconsin Food Code and the Federal Food Code, whichever is stricter. Sanitizing Solution: The Wisconsin Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure .(K) Employees are properly sanitizing cleaned multi-use equipment and utensils before they are reused through routine monitoring of solution temperature and exposure time for hot water sanitizing and chemical concentration, pH, temperature, and exposure time for chemical sanitizing. The Wisconsin Food Code documents at 4-501.116, Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Hydrion QT-40 test strips: Product directions state the test solution should be between 65 and 75-degrees Fahrenheit. During an initial tour of the kitchen with DM-D on 3/23/26 at 10:40 AM, Surveyor reviewed the facility's 3-compartment sink and sanitizing bucket log. The log contained staffs' initials but did not indicate the PPM or temperature of the sanitizing solution. DM-D could not confirm if staff test the temperature of the sanitizing solution used in the sink and sanitizing buckets. On 3/24/26 at 12:19 PM, Surveyor interviewed DM-D who acknowledged the facility's logs should contain PPM of the sanitizing solution and the temperature of the sanitizing solution when PPM are tested. Dating/Labeling: Foodsafety.gov (a gateway to food safety information provided by government agencies) indicates prepared egg dishes should be consumed or discarded within 3-4 days if refrigerated; Ham salad should be consumed or discarded within 3-4 days if refrigerated; and cabbage should be consumed or discarded within 1-2 weeks if refrigerated. The Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under paragraph 3-502.12, and except as specified in paragraph (E), (F), and (H) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. Commercially processed food open and held cold (B) Except as specified in paragraphs (E)-(H) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, shall indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. During an initial tour of the kitchen with DM-D on 3/23/26 at 10:40 AM, Surveyor observed the following items in the main cooler: ~ A container of sliced eggs, dated 3/18~ A container of ham salad, dated 3/19~ An open to air and undated half head of cabbage On 3/24/26 at 12:19 PM, Surveyor interviewed DM-D who stated the facility's previous practice was to discard all food after 3 days; however, it was recently changed to 7 days. DM-D acknowledged the concerns with labeling and discarding food based on food safety guidelines.

Based on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 3 residents (R) (R58, R7, and R20) of 14 sampled residents.R58 was admitted to the facility on [DATE]. The facility did not ensure R58's name was accurately and consistently reflected on all of R58's transmitted MDS assessments.R7's Pre-admission Screening and Resident Review (PASRR) Level II (used to identify individuals with mental illness and/or intellectual or developmental disability to ensure appropriate placement), dated 1/8/25, indicated R7 had a mental illness. R7's MDS assessment, dated 3/28/25, did not indicate R7 had a mental illness. R20's MDS assessment, dated 3/11/26, indicated R20 received anticoagulant medication. R20 did not have an order for anticoagulant medication and did not receive anticoagulant medication. Findings include: The facility's Minimum Data Set (MDS) policy, revised 7/22/25 indicates: Residents are assessed using a comprehensive assessment process in order to identify care needs and develop an interdisciplinary care plan .1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate, and standardized assessment of each resident's functional capacity using the Resident Assessment Instrument (RAI) specified by the state. 1. Between 3/23/26 and 3/25/26, Surveyor reviewed R58's medical record. R58 was admitted to the facility on [DATE]. R58's Entry Tracking MDS assessment, dated 12/13/24, and Comprehensive MDS assessment, dated 12/26/24, were transmitted with a different first name than R58's subsequent PPS Part A Discharge MDS assessment, dated 1/8/25, Quarterly MDS assessments, dated 3/27/25 and 6/26/25, and Death Tracking MDS assessment, dated 6/30/25. On 3/24/26 at 2:53 PM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-C who was not aware R58's first name was changed in the MDS system. MDSC-C confirmed the name used for MDS assessments should reflect the resident's legal name. 2. Between 3/23/26 and 3/25/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including psychotic disorder, major depression, and visual and auditory hallucinations. R7's PASRR Level II Screen, dated 1/8/25, indicated R7 met the federal definition of a serious mental illness. A Significant Change MDS assessment, dated 3/28/25, indicated R7 did not have serious mental illness. On 3/25/26 at 9:25 AM, Surveyor interviewed MDSC-C who who verified R7's PASRR Level II Screen indicated R7 met the federal definition of a serious mental illness. MDSC-C verified R7's 3/28/25 MDS assessment was coded incorrectly at Section A1500. 3. Between 3/23/26 and 3/25/26, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including colon cancer and arthritis. R20 had an order for aspirin (an antiplatelet medication) 81 milligram (mg) tablet delayed release. R20's MDS assessment, dated 3/11/26, indicated R20 received anticoagulant medication. Surveyor reviewed R20's Medication Administration Record (MAR) and noted R20's latest anticoagulant medication was enoxaparin syringe 40 mg, inject daily for 20 days for deep vein thrombosis prevention. The order was started on 9/3/25 and discontinued on 9/22/25. On 3/25/26 at 9:31 AM, Surveyor interviewed MDSC-C who reviewed R20's 3/11/26 MDS assessment with Surveyor and verified the assessment was coded incorrectly at Section N.

Based on staff interview and record review, the facility did not ensure timely transmittal of a Resident Assessment Information (RAI)/Minimum Data Set (MDS) assessment for 1 resident (R) (R23) of 14 sampled residents. The facility did not transmit a Discharge MDS assessment for R23 in a timely manner when R23 was transferred to the hospital and did not return to the facility. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2025, indicates: All Medicare and/or Medicaid-certified nursing homes must transmit required MDS records to the Centers for Medicare and Medicaid Services (CMS) .Required MDS records include: Admission, Quarterly, Annual, and Discharge assessments and Entry Tracking records .Transmitted means electronically transmitting an MDS record that passes CMS' standard edits and is accepted into the system within 14 days of the assessment reference date (ARD) (last day of the resident assessment period). Between 3/23/26 and 3/25/26, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE]. On 12/5/25, R23 was transferred to the hospital and did not return to the facility. Between 3/23/26 and 3/25/26, Surveyor reviewed the facility's MDS submissions and noted a Discharge MDS assessment was not transmitted for R23's hospitalization. On 3/24/26 at 2:51 PM, Surveyor interviewed MDS Coordinator (MDSC)-C who confirmed a Discharge-Return Anticipated MDS assessment was not completed or transmitted when R23 was transferred to the hospital or when R23 did not return to the facility. MDSC-C confirmed it is the facility's practice to transmit Discharge MDS assessments when residents are discharged from the facility.

Based on observation, staff and resident interview, and record review, the facility did not ensure enhanced barrier precautions (EBP) were implemented during high-contact cares for 2 residents (R) (R1 and R4) of 2 sampled residents. R1 had an order for EBP due to open wounds. The facility did not ensure EBP was implemented for R1 during a transfer and toileting.R4 had an order for EBP due to an open wound. The facility did not ensure EBP was implemented for R4 during wound care. Findings include: The facility's Enhanced Barrier Precautions policy, revised 7/17/25, indicates: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs) .b. An order for EBP will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) .even if the resident is not known to be infected or colonized with an MDRO .3.Implementation of EBP: a. Make gowns and gloves available immediately near or outside the resident's room. Note: Face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). B. Personal protective equipment (PPE) for EBP is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room .4. High-contact resident care activities include the following: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, central line, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, peripherally inserted central catheter (PICC) lines, midline catheters, and wound care: any skin opening requiring a dressing . The facility's Hand Hygiene policy, revised 7/17/25, indicates: Hand hygiene will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .Hand Hygiene Table: .Before applying and after removing personal protective equipment (PPE), including gloves .Before and after handling clean or soiled dressings, linens. 1.On 2/4/26, Surveyor reviewed R1's medical record. R1 had diagnoses including displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, other osteoporosis with current pathological fracture right femur, subsequent encounter for fracture with routine healing, and venous insufficiency (chronic) (peripheral) with bilateral lower extremity (BLE) venous stasis ulcers requiring wound care. R1's Minimum Data Set (MDS) assessment, dated 1/6/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 had intact cognition. R1 made R1's own healthcare decisions. R1's medical record contained the following orders: ~ Cleanse venous ulcers right and left anterior lower leg with saline wash, pat dry, apply adaptic (non-adhesive dressing) to wound bed, cover with ABD pad (a highly absorbent dressing), and apply knee-high compression stockings to both legs. May leave on at night while dressings are in place two times per week on Tuesday and Friday (dated 1/14/26). ~ Enhanced barrier precautions (EBP) related to vascular ulcers to BLE every shift: day, evening, and night (dated 12/30/25). On 2/4/26 at 9:09 AM, Surveyor observed Certified Nursing Assistant (CNA)-D enter R1's room and close the door. CNA-D did not don PPE prior to entering the room. Surveyor observed CNA-D exit R1's room at 9:13 AM. Surveyor interviewed CNA-D who stated CNA-D did not wear PPE because CNA-D assisted R1 with toileting and a transfer which did not require EBP. CNA-D indicated wound care was the only high-contact care that required staff to don PPE for EBP. On 2/4/26 at 9:48 AM, Surveyor interviewed R1 who stated R1 had wounds with dressings on both legs. R1 stated staff complete wound care twice weekly and wear gloves, but do not wear a gown or a face shield/mask. R1 also indicated staff transfer R1 on and off the toilet and assist with personal hygiene without wearing a gown. (See interview under example 2.) 2. On 2/4/26, Surveyor reviewed R4's medical record. R4 had diagnoses including pressure ulcer of unspecified buttock stage 2, opioid dependence, and non-displaced fracture of sacrum. R4's MDS assessment, dated 11/12/25, had a BIMS score of 15 out of 15 which indicated R4 had intact cognition. R4's medical record contained the following order: ~ Enhanced barrier precautions (EBP) related to pressure area to left buttock (dated 1/6/25.) On 2/4/26 at 12:11 PM, Surveyor observed Registiered Nurse (RN)-E provide wound care for R4 who was on EBP. RN-E donned gloves, but not a gown or a face shield/mask. RN-E removed a dressing (dated 2/3/25) from R4's left buttock that contained yellow drainage. RN-E sprayed the wound with wound cleanser, wiped the wound with a washcloth, and completed wound care. On 2/4/26 at 12:17 PM, Surveyor interviewed RN-E who confirmed R4 was on EBP and RN-E should have worn a gown during wound care. On 2/4/26 at 1:30 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed RN-E should have worn a gown during wound care for R4. On 2/4/26 at 1:20 PM, Surveyor interviewed Infection Preventionist (IP)-C confirmed R1 and R4 have orders for EBP and a gown and gloves are required for all residents on EBP. IP-C indicated a face shield/mask is required for cares (including wound care) where splash may occur. IP-C verified high-contact cares include bed changes, transfers, walking, toileting assistance, shaving, bathing, and wound care. IP-C indicated staff are educated on EBP during orientation, stand-up meetings, and annually. IP-C stated a binder at the nurses' station identifies residents who are on precautions. IP-C stated staff know the facility's policy/procedure for EBP and should adhere to it.

Based on observation, staff interview, and record review, the facility did not provide the appropriate care and treatment to prevent the development of pressure injuries and/or promote healing for 1 resident (R) (R4) of 1 sampled resident.R4 had a stage 2 pressure injury on the left buttock. During an observation of wound care, Registered Nurse (RN)-E did not remove gloves and cleanse hands appropriately. In addition, RN-E used a gloved finger to apply ointment to R4's wound.Findings include:The facility's Clean Dressing Change policy, revised 1/22/24, indicates: For wound cleaning and dressing applications, use a no-touch technique to remove ointments and cream from their containers (i.e., use tongue blade or applicator) .Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from center of the wound). Pat dry with gauze .Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered.On 2/4/26, Surveyor reviewed R4's medical record. R4 had diagnoses including pressure ulcer of unspecified buttock stage 2, opioid dependence, and non-displaced fracture of sacrum. R4's Minimum Data Set (MDS) assessment, dated 11/12/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 had intact cognition.R4's medical record contained the following order:~ Santyl ointment 250 unit/gram thin layer topical to left upper buttock. Cleanse with wound cleanser. Apply Santyl to wound and cover with Mepilex padded dressing. (The pressure injury was identified on 10/14/25 and was doucmented as a stage 2.)On 2/4/26 at 12:11 PM, Surveyor observed RN-E don gloves, wipe R4 after toileting, and remove gloves. Without cleansing hands, RN-E donned clean gloves, removed a dressing (dated 2/3/25) from R4's left buttock that contained yellow draingage, and removed gloves. Without cleansing hands, RN-E donned clean gloves, sprayed the wound with wound cleanser, and wiped with the wound with a washcloth. While wearing the same gloves, RN-E put Santyl on a gloved finger, applied the ointment to the wound, and removed gloves. Without cleansing hands, RN-E donned clean gloves, applied a Mepilex dressing to the wound, dated and initialed the dressing, and removed gloves. On 2/4/26 at 12:17 PM, Surveyor interviewed RN-E who indicated it made sense not to apply ointment to the wound bed with a soiled glove.On 2/4/26 at 1:30 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should complete hand hygiene between glove changes. DON-B also indicated RN-E should have wiped the cleanser with a clean or sterile 4 x 4 gauze and applied Santyl with a clean or sterile cotton applicator.

Based on staff interview and record review, the facility did not ensure a care plan was reviewed and revised for 1 resident (R) (R2) of 4 sampled residents. R2's care plan was not updated with interventions to address aggressive behavior, resident-to-resident altercations, and the impact of loud noise on R2. Findings include: The Facility's Abuse, Neglect and Exploitation policy, dated 3/5/25, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .VI. Protection of Resident: .G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse . On 3/10/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 1/16/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R2 had severely impaired cognition. R2 had an activated Power of Attorney for Healthcare (POAHC). On 3/10/25, Surveyor reviewed a facility-reported incident (FRI) that involved an altercation between R2 and R1 (who were roommates) on 2/20/25 in which R2 was identified as the aggressor. The FRI indicated R2 placed a pillow over R1's head to silence R1 from yelling out. Staff separated the residents and moved R2 to a different room. On 3/10/25, Surveyor reviewed R2's plan of care which did not contain behavioral interventions to address aggressive behavior, resident-to-resident altercations, or the impact of loud noise on R2. On 3/10/25 at 12:11 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated staff moved R2 to another room to separate R2 and R1 and promote safety. CNA-C was not aware of a care plan or Kardex (an abbreviated care plan used by nursing staff) that addressed R2's aggressive behavior. CNA-C stated staff just watch R2 consistently. On 3/10/25 at 1:51 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. NHA-A indicated R2's POAHC informed staff that R2 becomes more agitated with loud noise. DON-B confirmed R2's plan of care did not include interventions to address noise reduction or provide a private room to reduce R2's aversion to loud noise. DON-B verified R2's plan of care should have been updated.

Based on staff interview and record review, the facility did not notify a physician when 1 resident (R) (R2) of 4 sampled residents was physically aggressive toward another resident. R2 had a history of making threats to suffocate R1 with a pillow. On 2/20/25, R2 placed a pillow over R1's face in an attempt to quiet R2. R2's physician was not notified of the incident. Findings include: The facility's Clinical Change of Condition policy, dated 9/28/23, indicates: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a clinical change of condition .Procedure: 1. Upon identification of an actual or suspected change in resident status, the licensed nurse will assess the resident to determine their physical, emotional, or mental status change. 2. Notify the physician of the change and assessment. On 3/10/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, psychotic disturbance, mood disturbance, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 1/16/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R2 had severely impaired cognition. R2 had an activated Power of Attorney for healthcare (POAHC). On 3/10/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, dementia, neurocognitive disorder with Lewy bodies, and anxiety. R1's MDS assessment, dated 12/26/24, had a BIMS score of 3 out 15 which indicated R1 had severely impaired cognition. On 3/10/25, Surveyor reviewed a facility-reported incident that indicated staff heard R1 yell that R1 could not breathe on 2/20/25 and discovered R1 had a pillow over R1's head. R2 (who was R2's roommate) was observed moving to R2's side of the room in a wheelchair. Interviews with staff indicated R2 had a history of making statements that R2 wanted to put a pillow on R1's head and was observed attempting to do so in the past. R1's physician was notified of the incident on 2/26/25, however, R2's physician was not notified of R2's change in behavior. On 3/10/25 at 1:51 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. NHA-A indicated the facility was focused on R1 as the impacted resident and did not think to notify R2's physician. NHA-A and DON-B verified R2's physician should have been notified of R2's significant behavior change.

Based on staff interview and record review, the facility did not ensure confidentiality of medical records for 2 residents (R) (R4 and R5) of 5 sampled residents. Registered Nurse (RN)-D requested a copy of RN-D's personnel file after RN-D's last day of employment on 10/30/23. The information provided to RN-D contained protected health information (PHI) from R4 and R5's medical records. Findings include: The facility's Release of Medical Records policy, revised 6/1/23, indicates medical records will be released with a valid request and in accordance with state and federal laws .authority to access or release records is only granted by the resident or the resident's legal representative. The policy indicates the following have access rights to medical information: the resident (current), resident's family, facility personnel (current), other healthcare agencies caring for the resident, surveying agencies, outside government agencies (with authorization), the Ombudsman, insurance companies, lawyers, law enforcement agencies, and news media (with authorization). On 12/28/24, Surveyor reviewed RN-D's personnel file which indicated RN-D's last day of employment was 10/30/24. RN-D's personnel file included: ~ Five pages of a fall report for R4, dated 10/25/24. The report contained R4's age, room number, physician, diagnoses list, description of fall event, plan of care, vital signs, and treatment orders. ~ One page of a Treatment Administration Record (TAR) for R5, dated May 2023. The TAR contained R5's wound and behavior orders, diet orders, diagnoses, room number, physician, and date of birth. On 12/18/24 at 12:23 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding RN-D's personnel file. NHA-A verified RN-D requested a copy of RN-D's personnel file. NHA-A indicated R4's fall report was likely included in RN-D's file (and submitted to an outside government agency) due to a workman's compensation claim. NHA-A was not sure why or how R5's TAR was included in RN-D's file. When Surveyor asked if resident/representative permission was required to release R4 and R5's records to RN-D (or other outside agencies) as part of RN-D's file, NHA-A stated NHA-A was not sure of NHA-A's responsibilities. NHA-A verified R4 and R5 (or their representatives) were not informed of or asked about released medical records to a former employee or outside government agency.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. The practice had the potential to affect all 45 residents residing in the facility. Staff did not monitor and document food cooling temperatures. Staff did not serve food in a manner that protected residents from cross-contamination. Staff did not perform appropriate hand hygiene and safe food handling practices when serving food. Findings include: On 11/5/24 Dietary Manager (DM)-D indicated the facility followed the Wisconsin Food Code. Food Cooling Logs: The 2022 Wisconsin Food Code documents at section 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit) (F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The 2022 Wisconsin Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial kitchen tour that began on 11/4/24 at 9:13 AM, Surveyor observed the following previously cooked and cooled foods in the walk-in cooler and freezer: ~ Several frozen bags labeled Ground Sausage dated 10/29/24 ~ One container labeled Pork dated 10/4/24 ~ One container labeled Ground hamburger dated 10/3/24 ~ One steam table container labeled Chicken A La King dated 11/3/24 ~ Several small containers labeled Liquid diet vegetables dated 11/3/24 ~ One container labeled BLT salad dated 11/3/24 ~ One container labeled Plain Pork dated 11/4/24 ~ One container labeled Roast Beef dated 11/3/24 ~ Mechanically ground beef dated 10/30/24 ~ One unlabeled container of contents dated 10/29/24 Surveyor interviewed DM-D who confirmed the foods listed above were pre-cooked for meals or leftovers from meals saved for future resident consumption. DM-D indicated the unlabeled container (dated 10/29/24) was leftover soup that would be used in beef stew for a future meal. During a continuous kitchen observation that began at 10:34 AM on 11/5/24, Surveyor also interviewed DM-D who confirmed staff did not document the food cooling process. DM-D indicated the facility did not have a process for documenting food cooling and did not have cooling logs for the foods listed above in the walk-in cooler and freezer. Cross-Contamination: The 2022 Wisconsin Food Code documents at 4-602.11 Equipment Food/Contact Surfaces and Utensils: (A) Equipment food/contact surfaces and utensils shall be cleaned .(5) At any time during the operation when contamination may have occurred. During a continuous kitchen observation that began at 10:34 AM on 11/5/24, Surveyor observed [NAME] (CK)-E scoop items from 2 containers in the steam table with the same scoop. CK-E did not clean the scoop between uses. Surveyor interviewed CK-E who verified one container was mashed potatoes and the other container was fortified mashed potatoes. Surveyor also observed CK-E leave the steam table during lunch service and observed CK-F take CK-E's place. Surveyor also observed CK-F scoop mashed potatoes and fortified mashed potatoes with the same scoop without cleaning the scoop between uses. On 11/5/24 at 1:47 PM, Surveyor interviewed DM-D who indicated one resident (R27) had a lactose intolerance that was indicated on their diet order. Surveyor reviewed the label of the fortified powder used in the mashed potatoes. The label indicated the powder contained milk. DM-D indicated DM-D was not aware the same scoop was used for both foods and verified there was a potential for cross-contamination of the potatoes for R27 who was lactose intolerant. (Surveyor reviewed R27's medical record which indicated R27 was ordered a lactose-free diet due to lactose intolerance.) Hand Hygiene: The 2022 Wisconsin Food Code documents at 3-301.11: (B) Except when washing fruits and vegetables as specified under S 3-302.15 or as specified in (D) of this section, Food Employees may not contact exposed, ready to eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment . The 2022 Wisconsin Food Code documents at 3-304.15 Gloves, Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready to eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. During a continuous kitchen observation that began at 10:34 AM on 11/5/24, Surveyor observed CK-E serve lunch from the steam table. Surveyor observed CK-E touch food scoops, meal tickets, plates, and food covers with gloved hands. With the same gloved hands, Surveyor observed CK-E put dinner rolls and buttered bread on residents' plates. Surveyor observed CK-E continue to use the same gloved hands without completing hand hygiene or glove changes. During a continuous kitchen observation that began at 10:34 AM on 11/5/24, Surveyor observed CK-F serve lunch from the steam table. Surveyor observed CK-F touch food scoops, meal tickets, plates, and food covers with gloved hands. With the same gloved hands, Surveyor observed CK-F put dinner rolls and buttered bread on residents' plates. Surveyor observed CK-F continue to use the same gloved hands without completing hand hygiene or glove changes throughout the meal service. CK-F then left the steam table to obtain an item from a drawer. With the same gloved hands, CK-F returned to the steam table and resumed meal service. CK-F continued to touch food scoops, meal tickets, plates, and food covers, and put dinner rolls and buttered bread on residents' plates. With the same gloved hands, CK-F cut a resident's vegetables into bite-sized pieces by holding the vegetables with gloved hands. With the same gloved hands, CK-F then continued lunch service at the steam table. On 11/5/24 at 1:47 PM, Surveyor interviewed DM-D who indicated all cooks and dietary aides were trained on appropriate hand hygiene while serving at the steam table and during food prep. DM-D confirmed the facility's policy indicated food should only be touched with a single-use glove or tongs. DM-D also confirmed appropriate hand hygiene was not followed during lunch service at the steam table.

Based on staff interview and record review, the facility did not ensure vaccinations were administered for 1 resident (R) (R3) of 5 sampled residents. R3 was not offered the PCV20(R) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults [AGE] years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The facility's Pneumococcal Vaccine (series) policy, with a revision date of 7/26/24, indicates: It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations .Pneumococcal Vaccine schedules for adults aged >[AGE] years: Vaccine received previously at any age: Both PCV13 and PPSV23 (any order), and the PPSV23 was administered at age >[AGE] years. Schedule option A (PVC 20 available). Together with the patient, vaccine providers may choose to administer a single dose of PCV20 to adults age 65 or older who already have received PCV13 at any age and PPSV23 at age 65 or older. The interval should be greater than 5 years since the last PCV13 or PPSV23 dose. On 11/5/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including cerebrovascular disease, dementia, and epilepsy. R3's Minimum Data Set (MDS) assessment, dated 10/3/24, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R3 had severely impaired cognition. R3 had an activated Power of Attorney for Healthcare (POHCA). R3's medical record indicated R3 received a PCV13 vaccine on 9/16/16 and a PPSV23 vaccine on 8/16/19. Based on the facility's policy and the CDC's guidelines, R3 was due to be offered the PCV20 vaccine on or after 8/16/24. On 11/5/24 at 12:17 PM, Surveyor interviewed Infection Preventionist (IP)-C who indicated IP-C did not offer the PCV20 vaccine to R3 and didn't realize IP-C should do so. IP-C indicated IP-C mistakenly interpreted the CDC recommendations on when to offer the PCV20 vaccine and who was responsible to offer it. IP-C stated IP-C thought the discussion was between the resident and their physician. On 11/6/24 at 11:30 AM, Surveyor interviewed IP-C who indicated IP-C contacted R3's POAHC who indicated they wanted R3 to receive the PCV20 vaccine if R3's physician was agreeable. On 11/6/24 at 11:30 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects staff to offer vaccines per CDC recommendations and the facility's policy.

Based on staff interview and record review, the facility did not ensure the resident environment remained free from abuse for 2 residents (R) (R2 and R4) of 5 sampled residents. R2 reported to Activity Aide (AA)-D on 6/6/24 that R1 had touched R2's breast in the hallway that morning. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B reviewed camera footage on 6/6/24, interviewed both residents, and determined the allegation did not occur. Monitoring interventions were not implemented for R1. On 6/7/24, Social Services Director (SSD)-C informed NHA-A and DON-B that SSD-C had seen R1 and R2 in the lounge after lunch on 6/6/24. NHA-A and DON-B again reviewed camera footage and determined R1 had touched R2 inappropriately on 6/6/24 at approximately 1:04 PM. NHA-A and DON-B completed a subsequent investigation during which another resident, R4, reported that R1 had touched R4's breast on 6/5/24. R4 stated R4 did not report the allegation sooner because R4 felt ignorant. SSD-C verified a previous facility had provided paperwork prior to R1's admission that indicated R1 had a history of inappropriate sexual behavior and had been accused of sexual abuse by a former roommate, however, staff did not read the paperwork and did not put monitoring interventions in place to supervise R1 and protect other residents. The facility's failure to read admission documentation and supervise a resident with a history of sexually inappropriate behavior and a previous accusation of sexual abuse and its failure to keep residents free from sexual abuse created a finding of immediate jeopardy that began on 6/5/24. Surveyor notified NHA-A of the immediate jeopardy on 6/14/24 at 2:28 PM. The immediate jeopardy was removed on 6/14/24, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 5/1/24, states: I. Screening .B. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide the necessary care and services .an assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission .III. Prevention of abuse, neglect, and exploitation .The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is likely to occur .and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms .D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict . On 6/14/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including history of stroke, type 2 diabetes, chronic pain, and insomnia. R1's most recent Minimum Data Set (MDS) assessment, dated 6/7/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderate cognitive impairment. R1 was R1's own decision maker. R1's care plan did not contain any sexually inappropriate behavior concerns until 6/7/24. On 6/14/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dementia, dysphasia, epilepsy, and depression. R2's most recent MDS assessment, dated 4/11/24, had a BIMS score of 8 out of 15 which indicated R2 had moderate cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC). On 6/14/24, Surveyor reviewed R5's medical record. R5 is R1's spouse. R5 was admitted to the facility on [DATE] with diagnoses including dementia, pneumonia, and chronic obstructive pulmonary disorder (COPD). R5's most recent MDS assessment, dated 5/29/24, had a BIMS score of 14 out of 15 which indicated R5 had no cognitive impairment. R5 was R5's own decision maker. On 6/14/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including stroke, kidney disease, dementia, depression, and cognitive communication deficit. R4's most recent MDS assessment, dated 5/31/24, had a BIMS score of 8 out of 15 which indicated R4 had moderate cognitive impairment. R4 had an activated POAHC. On 6/14/24, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the State Agency (SA) on 6/7/24. The FRI indicated: On 6/6/24 at 6:20 PM, R2 reported to AA-D that R1 had touched R2's breast. When AA-D asked when the incident occurred, R2 stated the incident occurred that morning while R2 was sleeping in R2's wheelchair in the C wing (secured dementia unit) hallway. On 6/6/24 at 6:25 PM, AA-D reported the allegation to NHA-A. At 6:45 PM, NHA-A and DON-B arrived at the facility to investigate the allegation. On 6/6/24 at 7:15 PM, NHA-A interviewed R2 regarding the allegation of abuse. R2 verified R1 touched R2's breast in the hallway that morning while R2 was half asleep. DON-B reviewed the facility's camera footage from the C wing hallway. DON-B reviewed the footage from when staff assisted R2 to the dining room at 6:42 AM until R2 was brought to the dining room for lunch at approximately 11:47 AM. DON-B determined R2 did not have any unsupervised male contact on the morning of 6/6/24. On 6/6/24 at 7:45 PM, NHA-A and DON-B interviewed R1 regarding the allegation of abuse. R1 denied touching R2's breast. R1 stated R1 did not know who R2 was and understood that touching someone without their consent was wrong. On 6/6/24 at 8:00 PM, NHA-A and DON-B discussed the camera footage and interviews with R1 and R2. NHA-A and DON-B determined the camera footage did not show any interaction between R1 and R2 during the timeframe of R2's allegation. NHA-A and DON-B reviewed R2's care plan which indicated R2 had behavioral symptoms, including accusations toward staff (particularly male staff), making inappropriate sexual comments, delusions, and paranoia. Due to R1's recent admission, the facility had not yet completed a comprehensive care plan. R1's baseline care plan did not indicate R1 had sexually inappropriate behavior. NHA-A and DON-B stated R1 was courteous, pleasant, and always appropriate during a previous stay at the facility. On 6/6/24 at 8:15 PM, NHA-A and DON-B determined R2's allegation of sexual abuse was unsubstantiated and left the facility. The allegation of abuse was not reported to local law enforcement or the SA at that time. On 6/7/24 at 7:30 AM, NHA-A and DON-B notified SSD-C of the allegation involving R2 and R1 from 6/6/24. SSD-C stated SSD-C had seen R1 and R2 together in the C wing lounge on the afternoon of 6/6/24. On 6/7/24 at 8:30 AM, NHA-A, DON-B, and SSD-C reviewed camera footage for the C wing lounge on the afternoon of 6/6/24 and noted at approximately 1:04 PM, R1 and R2 were in the lounge with no other residents present. R2 appeared to be asleep and R2's head hung down toward R2's chest. R1 watched AA-D leave the lounge and then watched R2 for approximately 17 seconds. R1 put R1's left hand on R2's leg for approximately 30 seconds and then moved R1's left hand up the side of R2's body toward the collar of R2's shirt. R1 then put R1's right hand inside R2's shirt. R2 woke up and made a T (timeout) signal with R2's hands. R1 removed R1's hand from R2's shirt and left the lounge at approximately 1:21 PM. On 6/7/24 at 8:30 AM, R1 was placed on 1:1 supervision. Staff were informed of the incident and R1's increased supervision. R1 was moved off the secured dementia unit to a private room on another wing. At 9:56 AM, the facility notified local law enforcement of the incident. On 6/7/24 at 10:01 AM, a police officer arrived at the facility and reviewed the camera footage. The officer interviewed R2 regarding the incident and R2 stated R2 felt insulted when R1 touched R2 inappropriately. The officer interviewed R1 regarding the incident and R1 denied the incident occurred. R1 was shown the camera footage and denied it was R1 but stated the resident in the video looked like R1. On 6/7/24 at 10:30 AM, NHA-A interviewed R5 (R1's roommate/spouse). R5 stated that R1 was never sexually inappropriate with R5. On 6/7/24, SSD-C and DON-B spoke with R5 who was upset about the allegation against R1 and that R1 was moved to another room. When SSD-C brought R5 to visit R1 in R1's new room, R5 asked R1, Did you do this? and Did you do this again, like at that other place? When SSD-C asked R5 what R5 meant, R5 stated the same thing happened at another facility, but nothing came of it. From 6/7/24 through 6/10/24, the facility completed staff interviews. Certified Nursing Assistant (CNA)-G reported that R1 made sexually inappropriate comments to CNA-G during R1's shower on 6/3/24. Hospitality Aide (HA)-E reported that R1 made sexually inappropriate comments to HA-E on 6/5/24. CNA-I reported while CNA-I was getting R2 ready for bed on the evening of 6/6/24, R2 stated R2 was scared but could not verbalize why. CNA-J reported that R1 made sexually inappropriate comments to CNA-J on 6/9/24. None of the comments or behavior were reported to administrative staff prior to the interviews. On 6/10/24, all residents were interviewed as part of the investigation. At 8:15 AM, R4 reported to staff that R1 had touched R4 inappropriately approximately 1 week prior. R4 stated R4 did not report the incident because R4 felt ignorant. On 6/14/24, Surveyor reviewed a FRI submitted to the SA on 6/10/24 regarding R4's allegation of sexual abuse involving R1. The FRI indicated: On 6/10/24 at 8:15 AM, R4 reported to SSD-C that R1 acted like a doctor and felt inside R4's shirt and touched R4's breast approximately 4-7 days ago in the C wing lounge when no one else was present. R4 stated R4 did not report the incident to anyone because R1 felt ignorant. On 6/10/24 at 8:41 AM, the facility notified the local police department. Surveyor reviewed the police report and noted the following: On 6/10/24 at 12:27 PM, an officer arrived at the facility and interviewed R4 regarding the allegation. R4 reported that R1 stated R1 really liked R4 and shoved R1's hand down R4's shirt and touched R4's breast. R4 stated R4 told R1 no and R1 stopped. R4 verified R4 did not give R1 permission to touch R4's breast. R4 also stated R1 stared at R4 in the dining room and made R4 uncomfortable the day before the incident. SSD-C showed the officer the camera footage from the C wing lounge on 6/5/24 at approximately 8:40 PM. The footage showed R4 working on a puzzle while talking to another resident while R1 was in the lounge. After the other resident left the lounge, R1 talked to R4, touched R4's chest, pulled on R4's shirt while looking down, and moved R1's hand around R4's chest. On 6/10/24, R1 was removed from the facility by the police and charged with fourth degree sexual assault. Surveyor reviewed pre-admission documents that were scanned into R1's medical record and noted a continuity of care document from a previous facility with a care plan goal that indicated R1 will be redirected from sexual comments/attempts to touch inappropriately. Progress notes from the previous facility indicated R1 was closely monitored for behaviors prior to discharge. R1's medical record also contained a physician progress note, dated 5/16/24 and written by Medical Director (MD)-H, that was scanned into R1's medical record on 5/30/24 (the day prior to R1's admission). The note stated MD-H was asked to re-evaluate R1 due to R1's inappropriate comments to staff and R1's roommate who accused R1 of inappropriate sexual contact. On 6/14/24 at 12:26 PM, Surveyor interviewed NHA-A regarding the allegations of abuse. NHA-A verified the facility did not have any concerns with R1 prior to 6/6/24 because R1 was pleasant during R1's previous stay at the facility. NHA-A verified if R2's allegation of abuse was thoroughly investigated when it was reported and if other residents were interviewed, the allegation would have been verified sooner. NHA-A also stated if R1's pre-admission paperwork was thoroughly reviewed, R1 would have not been placed on a unit with vulnerable residents and would have had a care plan for inappropriate sexual behavior. On 6/14/24 at 12:53 PM, Surveyor interviewed SSD-C regarding R1's admission documents and history of sexually inappropriate behavior. SSD-C verified the documents were in the facility's possession upon R1's admission to the facility. SSD-C stated the admission documents were read, but SSD-C did not recall reading about R1's sexually inappropriate behavior. SSD-C stated if SSD-C was aware of the behavior, R1 would not have been placed on the secured dementia unit with a vulnerable population of residents and would have had increased supervision and care planning to mitigate the risk to other residents. After Surveyor's investigation was completed on 6/14/24, the facility initiated facility-wide education regarding the admission of new residents, including review for inappropriate behaviors or concerns. The failure to supervise a resident with a history of inappropriate sexual behavior and an allegation of abuse from a former roommate created a reasonable likelihood for serious harm for R2 and R4 which created a finding of immediate jeopardy. The facility removed the jeopardy on 6/14/24 when it completed the following: 1. Removed R1 from the secured dementia unit on 6/7/24 2. Initiated facility-wide education related to sexual behaviors/signs of predator beginning on 6/10/24 3. Initiated facility-wide education related to new admissions with inappropriate behaviors beginning on 6/14/24

Based on staff interview and record review, the facility did not ensure an allegation of sexual abuse was reported to the State Agency (SA) or local law enforcement in a timely manner for 2 residents (R) (R1 and R2) of 5 sampled residents. On 6/6/24, R2 told staff that R1 had touched R2 inappropriately without R2's consent. The facility did not report the allegation of sexual abuse to the SA or to local law enforcement within the accepted regulatory timeframe. Findings include: The facility's Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, revised 5/1/24, states that the facility will report all allegations of abuse/neglect/exploitation or mistreatment .immediately to appropriate agencies in accordance with current state and federal regulations within prescribed timeframe .5. Alleged violation is defined as a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the federal requirements .8. Reporting/response: the facility will report all alleged violations and all substantiated incidents to the State Agency and to all other agencies as required. Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: .2. The Administrator, Director of Nursing (DON), or designee will: a. Notify the appropriate agencies immediately .In the case of an allegation of abuse, no later than 2 hours after discovery or forming the suspicion. On 6/14/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including history of stroke, type 2 diabetes, chronic pain, and insomnia. R1's most recent Minimum Data Set (MDS) assessment, dated 6/7/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderate cognitive impairment. R1 was R1's own decision maker. R1's care plan did not contain any sexually inappropriate behavior concerns until 6/7/24. On 6/14/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dementia, dysphasia, epilepsy, and depression. R2's most recent MDS assessment, dated 4/11/24, had a BIMS score of 8 out of 15 which indicated R2 had moderate cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC). On 6/14/24, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the SA with a local police report. The FRI indicated on 6/6/24 at approximately 6:20 PM, R2 reported to Activity Aide (AA)-D that R1 had touched R2's breast without R2's consent. When AA-D asked when the incident occurred, R2 stated it occurred earlier that day while R2 was sleeping in R2's wheelchair. The police report indicated the allegation of sexual abuse was not reported to local law enforcement until 6/7/24 at 9:58 AM. The Misconduct Incident Report indicated the allegation of sexual abuse was not reported to the SA until 6/7/24 at 3:12 PM. On 6/14/24 at 11:43 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A did not initially report the allegation of abuse because the facility did not substantiate the allegation after they reviewed camera footage and interviewed R1 and R2. NHA-A verified other resident and staff interviews were not completed before the facility determined R2's allegation was unsubstantiated. NHA-A stated after NHA-A and DON-B spoke with Social Services Director (SSD)-C and the incident was discovered on camera footage the next day (6/7/24), the allegation of sexual abuse was reported to the SA and local law enforcement.

Based on staff interview and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 2 residents (R) (R1 and R2) of 5 sampled residents. On 6/6/24, R2 told staff that R1 had touched R2 inappropriately without R2's consent. The facility did not thoroughly investigate the allegation of sexual abuse before they determined the allegation did not occur and later discovered the allegation did occur. Findings include: The facility's Abuse, Neglect, and Exploitation policy, revised 5/1/24, states that an immediate investigation is warranted when reports of abuse occur. Investigations will include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. On 6/14/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including history of stroke, type 2 diabetes, chronic pain, and insomnia. R1's most recent Minimum Data Set (MDS) assessment, dated 6/7/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 had moderate cognitive impairment. R1 was R1's own decision maker. R1's care plan did not contain any sexually inappropriate behavior concerns until 6/7/24. On 6/14/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including dementia, dysphasia, epilepsy, and depression. R2's most recent MDS assessment, dated 4/11/24, had a BIMS score of 8 out of 15 which indicated R2 had moderate cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC). On 6/14/24, Surveyor reviewed a facility-reported incident (FRI) that was submitted to the State Agency (SA) with a local police report. The FRI indicated on 6/6/24 at approximately 6:20 PM, R2 reported to Activity Aide (AA) - D that R1 had touched R2 inappropriately and without consent. AA-D asked when the incident occurred and R2 stated the incident occurred earlier that day while R2 was sleeping in R2's wheelchair. The investigation included interviews with R1 and R2 and a review of the facility's video camera footage from when staff assisted R2 to the dining room at 6:42 AM until R2 was brought to the dining room for lunch at approximately 11:47 AM. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B determined the allegation did not occur because they did not see the incident during the initial camera footage review. The investigation did not include interviews with other residents and staff. Upon review of the Misconduct Incident Report, the allegation of abuse was not reported to the SA until 6/7/24 at 3:12 PM. When NHA-A and DON-B notified Social Services Director (SSD)-C of R2's allegation on the morning of 6/7/24, SSD-C stated SSD-C had seen R1 and R2 together in the C wing lounge on the afternoon of 6/6/24. NHA-A, DON-B, and SSD-C reviewed the camera footage beyond 11:47 AM on 6/6/24 and witnessed the incident. The allegation was then reported to the SA and a subsequent investigation was initiated. During that investigation, another resident, R4, reported that R1 had touched R4's breast on 6/5/24. The incident was not previously reported to staff. On 6/14/24 at 11:43 AM, Surveyor interviewed NHA-A regarding the thoroughness of the investigation. NHA-A verified NHA-A and DON-B initially dismissed R2's allegation of abuse on the evening of 6/6/24 because they were not able to verify the incident with video camera footage and R1 denied the incident. NHA-A verified no further investigation (including staff and resident interviews) was going to be completed until after SSD-C reported that R1 and R2 were together in the C wing lounge on 6/6/24. NHA-A agreed if more camera footage was reviewed and additional interviews were completed, the facility may have been able to substantiate R2's allegation of abuse on 6/6/24 instead of 6/7/24 which resulted in a delayed report, a delayed investigation, and delayed interventions to prevent further abuse.

Based on observation, staff interview, and record review, the facility did not ensure menu serving sizes for regular and pureed diets were followed for 42 of 42 residents residing in the facility. The facility did not follow menu serving sizes to ensure the nutritional needs of residents were met. Findings include: The facility's Food Preparation Guidelines policy, last revised on 8/1/23, included the following: .1. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes . During the lunch meal on 9/26/23, staff served smaller serving sizes than the menu indicated for roast pork, baked beans, carrots, mashed potatoes, and BBQ (for residents on regular diets) as well as pureed carrots and pureed pork (for residents on mechanically altered diets). The facility's extended menu contained the lunch meal serving sizes for regular portions and mechanically altered food. On 9/26/23, Surveyor reviewed the lunch menu (cycle week 1/6, day 2) and noted the following serving sizes: -BBQ on a bun: 4 ounces (oz) -French fries: 3 oz. -Baked beans: 3 oz. -Under the sea salad: 4 oz. -Roast pork with gravy: 4 oz. -Mashed potatoes: 3 oz. -Carrots: 4 oz. -Dessert: 1-2x3 inches On 9/26/23 at 10:40 AM, Surveyor observed Cook (CK)-G pour pureed pork into four serving containers (three smaller containers and one larger container). The pork servings were not measured. Surveyor also observed CK-G pour pureed carrots into four serving containers (three smaller containers and one larger container). The pureed carrot servings were not measured. Surveyor observed both CK-G and Dietary Manager (DM)-D use the same spoodles for each plate served with BBQ, baked beans, and carrots. Surveyor noted residents received one scoop (spoodle) each of BBQ, baked beans, and carrots. Surveyor also noted CK-G and DM-D served the french fries with tongs. Surveyor observed unequal portion sizes of french fries throughout the meal service. Surveyor also noted the mashed potatoes were served with what appeared to be an ice cream scoop. For residents who received mashed potatoes, one scoop was placed on each plate. Surveyor noted the roast pork with gravy was served with a black plastic serving spoon and each plate served contained varied serving sizes. Surveyor observed CK-G and DM-D serve either one spoonful, one and a half spoonfuls or two spoonfuls of roast pork on top of bread. The under the sea salad was not served during the meal. On 9/26/23, Surveyor interviewed DM-D who verified the spoodles used for the BBQ, baked beans, and carrots were 2 oz. DM-D verified a 2 oz. serving size scoop was used for the mashed potatoes. When Surveyor asked DM-D about the black plastic serving spoon used for the roast pork and gravy, DM-D stated the facility didn't have a 3 oz. scoop and could not verify a portion size for the black spoon. When Surveyor referred to the identified serving sizes on the menu and noted the actual servings were smaller, DM-D stated the residents eat less in this facility. On 9/27/23 at 9:04 AM, Surveyor interviewed CK-G who stated the person who serves the food is responsible for obtaining the appropriate utensils that coincide with the serving sizes on the menu. CK-G was unsure why smaller serving sizes were served during the lunch meal and stated, Some residents want less.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 42 of 42 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled with open or use-by dates. Residents' food in snack/nourishment refrigerators did not contain expiration dates to prevent the potential for foodborne illness. Staff did not wear hair restraints consistently throughout the kitchen. Findings include: On [DATE], Dietary Manager (DM)-D indicated the facility follows the Wisconsin Food Code as their standard of practice. 1. Open/Unlabeled/Undated/Expired Food: The Wisconsin Food Code 2020 documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under S ,d+[DATE].12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5C (Celsius) (41F (Fahrenheit)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition. (A) A food specified under ,d+[DATE].17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17 (A) Except time that the product is frozen; (2) Is in a container or package that does not bear a date or day. The facility's Date Marking for Food Policy, last reviewed on [DATE], included the following: .1. Refrigerated, ready-to-eat, time/temperature control for safety food (i.e., perishable food) shall be held at a temperature of 41 F or less for a maximum of 7 days. 2. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 3. The marking system shall consist of a sticker/label/masking tape the day/date of opening. 4. We discard on day 7 of any open items in cooler not used. Dry items follow dry list. 5. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 6. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed . During an initial tour of the kitchen with DM-D on [DATE] at 9:54 AM, Surveyor observed the walk-in freezer and noted the following items: -Chicken in broth dated ,d+[DATE] with no use-by date. -Chili dated ,d+[DATE] with no use-by date. -Approximately 20 one gallon bags of repackaged vegetables with received dates, but no label of contents and no use-by dates. -One container of cookies dated ,d+[DATE] with no label of contents, and no use-by date. -One clear bag of square food items not in the original packaging, with no label of contents, no received date, and no use by-date. The bag also contained a hole and an item fell out. -One clear bag of light brown food items with no label of contents, no received date, and no use-by date. -One clear bag of oblong tapered food items with no label of contents, no received date, and no use-by date. -One clear Ziploc bag of burgundy colored food items with no label of contents, no received date, and no use-by date. -Several clear bags of pink colored food items with no label of contents, no received dates, and no use-by dates. -Several clear bags of food items labeled turkey with no received dates, and no use-by dates. On [DATE], Surveyor interviewed DM-D who verified food items should be labeled and dated. DM-D stated staff use a pricing gun to place stickers on items with the date received. DM-D stated the facility uses the first in, first out method of stock rotation. DM-D stated the unidentified square food items were fish nuggets and removed the bag and the piece that fell out. DM-D stated the light brown food items were chicken nuggets, the oblong tapered food items were fish fillets, the burgundy colored food items were bacon pieces, and the pink colored food items were either ground ham or bologna. On [DATE], Surveyor observed the walk-in cooler with DM-D and noted the following items: -One nearly full shallow pan of food covered in plastic wrap dated ,d+[DATE] with no label of contents, and no use-by date. -One half full shallow pan of food covered in plastic wrap with no date made, no label of contents, and no use-by date. -One open container of Top the Tater Fiesta Dip with a reduced for quick sale sticker with a manufacturer best- by date of [DATE], and no open date. -One half full 1 gallon container of [NAME] Mayonnaise with no received date, no open date, no use-by date, and no manufacturer's best-by date. On [DATE], Surveyor observed the dry storage with DM-D and noted the following items: -Two unopened 1 gallon containers of [NAME] Mayonnaise with no received dates, no use-by dates, and no manufacturer's best-by dates. -One box of muffin mix received ,d+[DATE] with no open or use-by dates. The box contained an open box top and an open bag inside the box. -One open container of rainbow sprinkles with a best-by date of [DATE]. On [DATE], Surveyor interviewed DM-D regarding the walk-in cooler and dry storage items. DM-D stated DM-D did not know what was contained in the shallow pan covered with plastic wrap. DM-D asked another staff who stated the item was cheesecake. DM-D stated the half full shallow pan contained peanut butter cookie bars that were baked on [DATE]. DM-D verified the 1 gallon containers of [NAME] Mayonnaise did not contain dates. When asked how staff ensure dry goods are used by the use-by date if they are only marked with a received date, DM-D stated the kitchen goes through stock fast and they don't go past the use-by dates. 2. Labeling and Dating in Nourishment Refrigerators: The facility's Use and Storage of Food Brought in by Family and Visitors policy, last reviewed on [DATE], included the following: .1. Family members or other visitors may bring the resident food of their choosing. 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff. d. The facility will not be responsible for maintaining any reusable items. 3. All food items brought in that are manufactured and do not require refrigeration, may be kept in the resident room inside a lock tight container that is provided by the resident. 4. It is the responsibility of the resident and/or resident representative to maintain said container and items in the container. 5. All items not maintained are subjected to being thrown away if not removed by the resident and/or resident representative. 6. If any part of this policy is not followed, the facility reserves the right to protect others by not allowing food items to be brought into the facility for a resident. 7. The facility staff will assist residents in accessing and consuming food that is brought in by resident and family or visitors if the resident is not able to do so on their own . On [DATE] at 8:00 AM, Surveyor noted the following items in the 100 wing kitchenette: -One unopened half gallon container of whole milk dated ,d+[DATE] with a manufacturer's best-by date of ,d+[DATE]. -One Tupperware container of resident food without a content label, received date or use-by date. -Two containers labeled Chich Zoccuhini and chick Zucchini with no received or use-by dates. On [DATE] at 8:15 AM, Surveyor noted the following items in the 300 wing kitchenette: -One opened box of [NAME] Dean french toast and sausage with no dates. -One opened half gallon jug of whole milk dated ,d+[DATE] with a best-by date of ,d+[DATE]. -One opened container of Philadelphia cream cheese with no dates. -One Ziploc bag of resident food with no content label, received date, or use-by date. On [DATE], at 8:30 AM, Surveyor interviewed DM-D regarding resident food brought in by family and visitors. When Surveyor asked about the printed label on food in the kitchenettes, DM-D stated, That is what the nurses put on the food that is brought in for the residents or bought by the residents. When asked if food in the kitchenettes is supposed to be dated and labeled with the contents in addition to the printed label, DM-D stated, Yes. DM-D also stated milk in the kitchenette is put in the refrigerator by kitchen staff and usually checked every morning by the cook. On [DATE] at 8:45 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who stated, Anyone who puts food in the kitchenette is responsible for dating it. On [DATE] at 9:54 AM, Surveyor observed the same opened half gallon of whole milk in the 100 wing kitchenette dated ,d+[DATE] with a manufacturer's best-by date of ,d+[DATE]. Surveyor noted the container was ,d+[DATE] full. 3. Hair Net Use: The Wisconsin Food Code, Hair Restraints documents at ,d+[DATE].11 Effectiveness.(B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. On [DATE] after lunch service, Surveyor observed DM-D walk through the kitchen from the dining entrance past the serving area to DM-D's office without a hairnet or hair covering. Following the observation on [DATE], Surveyor interviewed DM-D who stated DM-D learned in class that you only need a hairnet on when stirring a pot or preparing food, but not just to walk through the kitchen. On [DATE] at 12:05 PM, Surveyor observed DM-D and other staff in the walk-in freezer without a hairnet or hair covering.

Based on observation, staff and resident interview, and record review, the facility did not notify a physician after a change of condition for 1 Resident (R) (R31) of 15 sampled residents. The facility did not update R31's physician until two days after R1 experienced a change in condition and developed a productive cough. Findings include: R31 was admitted to the facility in February of 2023 with diagnoses including acute and chronic respiratory failure with hypoxia (deprived of oxygen), nonrheumatic tricuspid valve insufficiency, hypertensive heart disease with heart failure, and chronic obstructive pulmonary disease (COPD) with acute exacerbation. R31's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31 had an oxygen concentrator set for three liters of oxygen via nasal cannula. On 6/25/23, a chest X-ray indicated R31 had left lower lobe pneumonia. On 9/25/23 at 10:28 AM, Surveyor interviewed R31 who had an audible, wet cough. R31 indicated the cough began on 9/24/23 and stated R1 occasionally coughed up phlegm. R31 stated the facility tested R31 for COVID-19, but R31 did not know the result. Registered Nurse (RN)-J was outside of R31's room and stated R31's COVID-19 test was negative. On 9/26/23 at 12:28 PM, Surveyor interviewed Infection Preventionist (IP)-E who stated R31 had COPD, was on oxygen, had a rescue inhaler, and there were no concerns with R31's oxygen saturation levels. IP-E stated R31 was assessed that morning (9/25/23) at approximately 9:20 AM and R1's condition was discussed in report. IP-E stated R31's assessment revealed a few crackles in the upper lobes of the lungs which was R31's baseline. IP-E also stated R31's COVID-19 test was negative, R31 was afebrile (no increase in temperature), and R31 was administered one dose of an expectorant (cough medication to thin and loosen mucus) that morning. IP-E stated IP-E would ask for additional testing, such as a respiratory panel, if R31 had an increase in respiratory illness or a fever, or if R31's condition worsened. R31's nursing notes contained the following information: A nursing note written by RN-J, dated 9/25/23 at 10:36 AM, indicated: (R31) having increased cough with mucous. Afebrile. Temperature 98.1; Pulse 76; Respiration rate 20. Blood pressure 118/74. Oxygen saturation level 88% on room air, 93% on oxygen at 3 liters per minute via nasal cannula. COVID test negative. Surveyor noted this was the first nursing note related to R31's newly developed cough. A nursing note written by Assistant Director of Nursing (ADON)-C, dated 9/26/23 at 9:23 AM, indicated: (R31) with occasional cough stated, I cough up phlegm sometimes. Has oxygen on continuously related to COPD/chronic lung problems and stats remain greater than 90% on 2 liters per minute. No shortness of breath, chest pain, or edema. Lungs with few crackles bilateral upper lobes. No wheezing noted at this time. Has been tested for COVID-19 and is negative. Does become winded with exertion, but that is (R31's) norm due to chronic lung problems. No distress noted. Telephone order received for guaifenesin liquid 400 milligrams by mouth every 4 hours as needed for cough/congestion .(R31) is aware of new order and was given a dose of guaifenesin. A nursing note, dated 9/26/23 at 7:01 PM, indicated R31's cough/congestion was ongoing and R31 was administered cough medicine as ordered. A nursing note, dated 9/27/23 at 3:03 AM, indicated: (R31) continues to report cough/congestion. Cough syrup given per order. (R31) stated the flowers that were in (R31's) room may have caused the congestion. Will continue to monitor. A nursing note written by RN-J, dated 9/27/23 at approximately 12:00 PM, indicated: Temperature 97.7; Pulse 64; Respirations 20; Blood pressure 120/66; Oxygen saturation level 90% with oxygen at 3 liters per minute via nasal cannula; Oxygen level 84% on room air. (R31) requested an antibiotic and stated, I am coughing up green mucous. Writer observed a small amount of white cloudy mucous. (R31) was administered Geri-Tussin (brand name for guaifenesin) this AM to assist in suppressing cough and bringing up mucous. (R31) has an ongoing loose/wet cough related to COPD and has had an increased cough the past couple of days. Continues to be afebrile. Vital signs within normal limits for (R31). Appetite and fluid intake continues to be good. COVID-19 test on 9/25/23 was negative. RSV (respiratory syncytial virus), influenza A and B and another COVID-19 test today via nasal swab .MD updated. On 9/27/23 at 10:35 AM, Surveyor interviewed ADON-C who stated ADON-C activated the standing order for guaifenesin, but did not update the physician when R31 developed a cough. On 9/27/23 at 10:42 AM, Surveyor interviewed R31 who indicated R31's baseline cough is not like R31's new cough and stated, It's like something is going around. R31 stated R31 did not have any other symptoms aside from being tired because the cough kept R31 up at night. On 9/27/23 at 10:56 AM, Surveyor interviewed RN-J who exited R31's room and stated R31 always has a cough but it's a little more and that R31 has COPD. RN-J stated RN-J had not updated R31's physician, but was going to do so. On 9/27/23 at 11:33 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R31 received guaifenesin at the following times: ~9/26/23 at 9:23 AM with follow-up at 10: 59 AM that indicated R31's cough continued with productive white sputum and R31's oxygen saturation level was at 95%. ~9/26/23 at 2:47 PM, no follow-up on effectiveness. ~9/26/23 at 7:36 PM, no follow-up on effectiveness. ~9/27/23 at 1:39 AM, no follow-up on effectiveness. ~9/27/23 at 8:45 AM, no follow-up on effectiveness. On 9/27/23 at 11:37 AM, Surveyor interviewed DON-B who stated DON-B considered R31's cough a change from baseline because the cough was not previously there. DON-B also stated staff should perform a complete assessment and update the physician in order to be proactive instead of reactive. DON-B stated R31's physician should have been updated due to the possibility of infection as well as the possibility of an exacerbation of COPD which may have required further treatment. DON-B also stated the facility should have obtained a second COVID-19 test forty eight hours after the first test.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection for 1 Resident (R) (R31) of 15 sampled residents. The facility did not implement transmission-based precautions (TBP) until two days after R31 developed a new cough. In addition, the facility did not test R31 forty eight hours after the first negative antigen COVID-19 test after R31 developed a new cough. Findings include: The facility's Transmission-Based (Isolation) Precautions policy, revised 6/15/23, indicates: .1 Facility staff will apply transmission-based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission .10. Droplet Precautions: a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e., respiratory droplets that are generated by a resident who is coughing, sneezing, or talking). The facility's COVID-19 Prevention, Response and Reporting policy, revised 6/1/23, indicates: .13. The facility will perform viral testing for SARS-CoV-2 as per national standards such as CDC (Centers for Disease Control and Prevention) recommendations .ii. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken forty eight hours after the first negative test . R31 was admitted to the facility in February of 2023 with diagnoses including acute and chronic respiratory failure with hypoxia (deprived of oxygen), hypertensive heart disease with heart failure, and chronic obstructive pulmonary disease (COPD) with acute exacerbation. R31's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31 had an oxygen concentrator set for three liters of oxygen via nasal cannula. A chest X-ray on 6/25/23 indicated R31 had left lower lobe pneumonia. On 9/25/23 at 10:28 AM, Surveyor interviewed R31 who had an audible, wet cough. R31 indicated the cough began on 9/24/23 and R31 occasionally coughed up phlegm. R31 stated the facility tested R31 for COVID-19, but R31 did not know the result. Registered Nurse (RN)-J was outside R31's room and stated R31's COVID-19 test was negative. R31 was not on TBP at the time of the interview. On 9/26/23 at 12:28 PM, Surveyor interviewed Infection Preventionist (IP)-E who stated R31 had COPD, was on oxygen, had a rescue inhaler, and R31's oxygen saturation levels were good. IP-E stated R31 was assessed that morning (9/25/23) at approximately 9:20 AM and discussed in report. IP-E stated R31 had crackles in the upper lobes of the lungs which was baseline for R31. IP-E indicated R31's COVID-19 test was negative, R31 was afebrile (without fever), and R31 was administered an expectorant (cough medication to thin and loosen mucus) that morning. IP-E stated IP-E puts a resident on TBP and asks for additional testing, such as a respiratory panel, when there is an increase in respiratory illness, if the resident has a fever, or if the resident's condition worsens. IP-E stated the facility is not in outbreak status, but IP-E is aware of an increase in COVID-19 in the community. IP-E indicated nurses have a surveillance binder that is discussed at shift change and stated all nurses can implement TBP. R31's medical record contained the following nursing notes: A nursing note written by RN-J, dated 9/25/23 at 10:36 AM, indicated R31 had an increased cough with mucous, but was afebrile. R31 oxygen saturation level was 88% on room air and 93% while using 3 liters per minute of oxygen via nasal cannula. R31's COVID-19 test was negative. A nursing note written by Assistant Director of Nursing (ADON)-C, dated 9/26/23 at 9:23 AM, indicated R31 had an occasional cough and coughed up phlegm sometimes. R31 used oxygen continuously related to COPD/chronic lung problems. R31 did not experience shortness of breath, wheezing, chest pain, or edema. R31's lungs contained crackles in the upper lobes. An order for guaifenesin liquid every 4 hours as needed was initiated for cough/congestion. R31 was advised of the guaifenesin order and administered a dose. Nursing notes, dated 9/25/23, 9/26/23, and 9/27/23, indicated R31 continued with a wet, productive cough. A nursing note written by RN-J, dated 9/27/23 at approximately 12:00 PM, indicated R31 requested an antibiotic due to coughing up green mucous. RN-J noted the mucous was white and cloudy. R31 had an ongoing loose, wet cough related to COPD, with an increased cough in the last few days. R31 was administered Geri-Tussin (brand name for guaifenesin) to assist with suppressing the cough and bringing up mucous. R31 was afebrile and R31's vital signs were within normal limits. The note indicated R31 had a negative COVID-19 test on 9/25/23 and would undergo further testing, including RSV (respiratory syncytial virus), influenza A and B and another COVID-19 test that day. R31 was placed on droplet precautions and the MD was updated. On 9/27/23 at 10:35 AM, Surveyor interviewed ADON-C who stated the facility would not place a resident on TBP in order to maintain the resident in the least restrictive environment unless there was a diagnosis that required TBP or no improvement of a cough with cough syrup. On 9/27/23 at 10:42 AM, Surveyor interviewed R31 who indicated R31's baseline cough is not like R31's newly developed cough and stated, It's like something is going around. R31 stated R31 did not have any other symptoms besides being tired because the cough kept R31 awake at night. At the time of the interview, R31 was not on TBP. On 9/27/23 at 11:37 AM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should have obtained a second COVID-19 test forty eight hours after R31's first test. On 9/27/23 at 12:00 PM, Surveyor noted R31 was placed on droplet precautions and continued with a wet cough. The privacy curtain was closed in R31's room which separated R31 from R31's roommate. On 9/27/23 at 12:15 PM, DON-B provided documentation of a negative antigen COVID-19 test obtained on 9/27/23 at 11:00 AM.

Based on record review and staff interview, the facility did not ensure the required Minimum Data Set (MDS) assessment data was completed/encoded/transmitted for 4 Residents (R) (R5, R2, R4 and R1) of 4 residents reviewed for MDS process completion. R5's Death in Facility tracking record was not completed and subsequently not transmitted as required, related to R5's death in facility on 7/8/22. R2's MDS assessment dated [DATE] was not transmitted until 8/29/22. R4's MDS assessment dated [DATE] was not transmitted until 8/29/22. R1's Death in Facility tracking record was not completed and subsequently not transmitted as required, related to R1's death in facility on 5/15/22. Findings include: Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2017 stated, . 5.2 Timeliness Criteria In accordance with the requirements at 42 CFR S483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: o. Completion Timing: . For Entry and Death in Facility tracking records, the MDS Completion Date (Z0500B) must be no later than 7 days from the Event Date (A1600 for an entry record; A2000 for a Death in Facility tracking record) . - Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). - Tracking Information Transmission: For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date (A1600 + 14 days for Entry records and A2000 + 14 days for Death in Facility records) . Centers for Medicare and Medicaid Services (CMS) survey process system alerted Surveyors that, as of 8/25/22, the most recent transmitted MDS assessments for R5, R2, R4 and R1 were over 120 days old. On 8/31/22, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 passed away at the facility on 7/8/22. The most recent MDS assessment in R5's medical record was dated 4/25/22 for a Significant Change in Status. There was not a Death in Facility MDS tracking record located in R5's medical record. On 8/31/22, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS assessment in R2's medical record was dated 7/26/22 for a Quarterly assessment. On 8/31/22, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS assessment in R4's medical record was dated 7/22/22 for a Quarterly assessment. On 8/31/22, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnose to include Seizures (sudden, uncontrolled electrical disturbance in the brain). R1 passed away at the facility on 5/15/22. The most recent MDS assessment in R1's medical record was dated 4/5/22 for a 14-day Admission assessment. There was not a Death in Facility MDS tracking record located in R1's medical record. On 8/31/22 at 12:09 PM, Surveyor interviewed MDS Nurse (MDS)-C who indicated MDS-C had been working full-time completing MDSs at facility since October 2021. During discussion and review of the above information, MDS verified R5's medical record did not contain a Death in Facility tracking record, indicated R2's Quarterly assessment dated [DATE] was closed on 8/1/22 and transmitted by MDS-C on 8/29/22, indicated R4's Quarterly MDS assessment dated [DATE] was closed on 7/27/22 and transmitted by MDS-C on 8/29/22, and verified R1's medical record did not contain a Death in Facility tracking record. MDS-C verified Death in Facility tracking records should have been completed and transmitted for R5 and R1. MDS-C verified R2's and R4's Quarterly assessments were not transmitted timely. MDS-C stated, With staffing crisis, I have had to work the floor (as a staff nurse), too (in addition to full-time MDS duties). On 8/31/22 at 12:28 PM, Surveyor interviewed Director of Nursing (DON)-B who, following discussion of the above information, stated, I don't believe we have a policy for MDSs and transmission. DON-B verified above detailed completions/transmissions should have occurred.

Based on resident and staff interview and record review, the facility did not ensure 1 Resident (R) (R2) of 1 sampled resident with a guardian was provided services following State Statute Chapter 55.055(1)(b.) Guardian of ward found incompetent in another state may admit to facility for up to 60 days for recuperative and other care if ward is resident of Wisconsin; if longer stay, petition to transfer foreign guardianship and petition for protective placement must be filed within 60 days after admission. Also State Statute Chapter 55.03(4). The law requires a court ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds ninety days. The facility could not provide documentation that R2's guardianship from the State of Michigan was appropriately reviewed for transfer to the state of Wisconsin since R2 had been residing at a Wisconsin facility in 2012 and R2's co-guardians also reside in Wisconsin. Findings include: R2 was admitted to the facility 7/18/12 with related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was admitted to the facility with a Guardianship already in place. R2's Minimum Data Set (MDS) (a comprehensive assessment done at regular intervals or upon a significant change of condition) dated 7/26/22 indicated R2 had a Brief Interview of Mental Status Score (BIMS) (a brief verbal test that indicates one's level of cognition) of 15/15 (which indicates that R2 is cognitively intact). R2 was assessed on this same MDS in Section B0700 as usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time, and Section B0800, usually understands - misses some part / intent of message but comprehends most conversation. On 8/29/22 at 12:35 PM, Surveyor interviewed R2 as part of the Long Term Care Survey Process. R2 was noted to be in quarantine since 8/20/22 due to being unvaccinated for Covid-19 and being exposed to a positive staff member (CDC guidelines indicate unvaccinated and exposed residents must remain in quarantine for 14 days.) During this interview R2 indicated that R2 was the youngest resident at the facility and it really bothers me I have to be stuck in this room. R2 indicated R2 enjoyed many activities in the facility, especially bingo. R2 further indicated that R2 was thinking of getting the Covid-19 vaccination, but R2's family (guardians) did not want R2 to get it because they don't know the long term effects. R2 indicated to surveyor, it's really hard being on lockdown. Between 8/29/22 and 8/31/22, Surveyor reviewed R2's Guardianship paperwork the facility provided. R2's Guardianship paperwork is from the State of Michigan Probate Court and is titled Letters of Guardianship. R2's Letters of Guardianship relieve the previous guardian of their duties and appoint new co-guardians for R2. The facility also provided a letter from the county probate court in Michigan dated 9/5/18. This letter indicated the following: ~This letter will confirm that the Michigan Estates and Protected Individuals Code, MCL700.1101 .does not require the coordination of APS annual reviews for continued protective placement of residents at skilled nursing facilities when the individual is subject to a continuing legal guardianship. The court reviews an annual report of the guardian and may conduct a hearing on the record if determined appropriate by the court or requested by an interested party. On 8/30/22 at 9:23 AM, Surveyor interviewed Social Worker (SW-D) who indicated that all the facility had for guardianship paperwork is the paperwork designated above and the letter from the state of Michigan indicating Michigan does not require an annual protective placement review for ongoing guardianships. SW-D indicated SW-D had requested the remainder of the paper file in medical records to see if there was any other paperwork. SW-D confirmed that R2 gets extremely bored with having to be on quarantine due to being unvaccinated for Covid-19 and has indicated that R2 would like to get the Covid-19 vaccination but co-guardians do not want R2 to do this due to not knowing the long term affects. SW-D indicated the regional Ombudsman had just been consulted and the facility and resident were in the process of working through the concern. On 8/31/22 at 9:58 AM, Surveyor interviewed SW-D, who indicated the facility could not find any further paperwork regarding R2's Guardianship or Protective Placement from Wisconsin. SW-D indicated that R2 has not had a formal or thorough cognitive evaluation outside of the regular and required Doctor visits and has not had a formal screening such as an MMSE (Mini Mental Status Exam) since there was no annual review of protective placement due to the guardianship still being in Michigan. SW-D indicated R2 had improved so much with therapy after R2's accident and since admission to the facility. SW-D indicated R2 loves to be involved in programming in the facility but does get bored because R2 is so young. Surveyor showed SW-D the Wisconsin State Statute Chapter 55.055 (1) (b)regarding transferring guardianship from one state to the next if a resident is in a facility longer than 60 days (R2 has resided in the facility for over [AGE] years). SW-D confirmed a transfer had not been completed and was not aware a transfer had been inquired about but would be looking into it.

Based on record review, resident and staff interviews, the facility did not ensure the resident environment remained free of accident hazards for 1 (Resident 1) of 13 sampled residents. The facility was aware Resident 1 was visually impaired and did not want the facility's pet cat Gerry in her room. The facility did not implement interventions and attempt to keep the cat out of Resident 1's room. The cat entered the resident's room and Resident 1 attempted to move the cat out of the room, causing Resident 1 to lose balance and fall to the floor, fracturing resident's hip and arm. As a result of the fracture, Resident 1 has sustained increased pain requiring narcotic pain medications to be administered and was readmitted to the facility from the hospital with a stage 2 pressure injury on the right buttock. Findings include: On 07/07/16, Surveyor reviewed Resident 1's medical record. According to the face sheet dated 06/30/16, Resident 1 was own decision maker. The MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 04/08/16, documented Resident 1 is alert and oriented, balance during transitions and walking are steady at all times and had moderate vision impairment related to macular degeneration. Osteoporosis was not indicated as an active [DIAGNOSES REDACTED]. Resident 1's care plan included the problem of Impaired vision related to macular degeneration with start date of 4/21/15 that included interventions as follows; ~ Provide for environment that accommodates impaired vision; adequate lighting, clutter-free hallways, furniture positioned unchanged ~ Monitor for further visual decline and notify MD ~ Glasses ~ Ambulate to all meals with four wheeled walker, SBA (stand by assist)/gait belt per therapy (note this was a undated handwritten entry). Resident 1's care plan included, Very Important to do activities, depends on some assistance due to poor vision with start date of 4/21/15 that included interventions as follows; ~ Depends on assistance during activities due to poor vision. ~ Very important to resident: talking books, listen to music, attend group activities . ~ Dislikes pet visits. According to IDN (Interdisciplinary Notes) dated 06/16/16 documented at 6:53 p.m., Resident 1 verbalized (resident) was trying to get Gerry the cat out of (resident's) room at approximately 2:30 p.m. The resident put .call light on but chose not to wait for assistance. The resident was standing near the closet with a four wheeled walker and tried to 'shoo' (move) the cat out of the room when (resident) lost balance and fell against the closet. Fall was witnessed. Writer responded to the room. Resident 1 was lying on (resident's) right side with knees flexed in a fetal position. The right arm and shoulder hyperextended. Resident complained of pain to the right bicep area and right upper leg .MD's (Medical Doctor) office was called and due to multiple areas of pain reported, the facility was advised to transport the resident to the hospital for evaluation/treatment. The facility completed an investigation dated 06/17/16, which contained a witness statement that was completed on 06/16/16. The witness indicated on the afternoon of Thursday, 06/16/16 witness was walking down the B wing hallway towards the nurses station, and when witness passed (the room where Resident 1 resided) and heard a sound like a door hitting. The witness turned and saw the resident slump off the door onto the floor. The witness looked down the hallway where there were two or three CNAs (Certified Nursing Assistants) talking and said I need help, (resident) just went down. The witness entered the room and asked Resident 1 if resident was ok and the resident responded I don't want that cat in here - oh my shoulder - get that cat out of here - oh my shoulder. At this time the CNAs arrived and the witness stepped back. Somebody asked what happened and Resident 1 stated I tried to get up and get rid of the cat and I fell . The nurse then entered the room. The investigation contained a root cause analysis that indicated Resident 1 was trying to get Gerry the cat out of her room and the plan was to keep the cat out of the room. The CT (computerized tomography) lower extremity without contrast and 3 D (dimensional) results of the right hip was completed at the hospital on [DATE]. Impression: Nondisplaced fracture of the femoral neck at the head neck junction with impaction of the proximal femoral neck into the femur and avulsion of the lesser trochanter. This report does not include documentation relating to osteoporosis. The x-ray of the right humerus (upper arm bone) was completed at the hospital on [DATE]. Impression: Comminuted impacted fracture (the bone is splintered or crushed, with three or more fragments; fracture in which one fragment is firmly driven into the other) of the right humeral neck. The Hospital Discharge Summary dated 06/24/16, documented Resident 1 presented to the Emergency Department (ED) on 06/16/16 after falling trying to swoosh a cat out of her room. The resident fell on (resident's) right side and had immediate onset of right arm and right hip pain. (Resident) had no head trauma had no precipitating lightheadedness or syncope. In the ED (resident) was found to have a right proximal humerus fracture and right hip fracture as previously noted. The resident was admitted to the surgical floor with pain control initially with Dilaudid and orthopedic surgery was consulted. The resident's right arm was placed in a sling and swathe and nonoperative management was advised. The resident underwent [REDACTED]. Postoperatively (resident) initially received Dilaudid for pain which transitioned to oral pain medications. The hospital Physician's Discharge Order dated 06/24/16, listed the principal [DIAGNOSES REDACTED]. The resident's activity level was reduced to toe touch weight bearing and new medications included were Flagyl (antibiotic) for clostridium difficile (a bacterium that causes diarrhea and more serious intestinal conditions such as colitis), ceftin (antibiotic) for pneumonia, and niferex for anemia. The Orthopedic Consultation dated 06/16/16, documented the patient is a very pleasant (resident) who resides at a local nursing home and states that (resident) was doing well up until today. (Resident) actually has been suffering from right sciatic pain and had undergone recently an epidural injection for the pain and therefore was actually doing quite well. (Resident) notes that at the nursing home there is a cat, which (resident) does not like. The cat came into (resident's) room. The patient was seated in .wheelchair and stood up to swipe at it (cat), and then (resident) suddenly fell to the ground. This was a mechanical fall (a fall that is caused by the environment) with the patient falling onto (resident's) right side. (Resident) notes immediate right arm and hip pain that were quite severe. (Resident) denies any loss of consciousness and denies any head trauma or lightheadedness prior to the event. (Resident) notes that the pain is more prominent in the right hip, groin, and upper arm (Resident) rates the pain an 8 out of 10 in the right arm Assessment and Plan: Right humerus fracture and right hip fracture status [REDACTED]. The Operative Report dated 06/18/16, (noted to include This is not a chartable copy) documented the preoperative [DIAGNOSES REDACTED]. This report did not include documentation in the description of the procedure that indicated the resident's hip bone was osteroporotic. The IDN dated 06/24/16, documented Resident 1 was readmitted to the facility and the hospital report that was called to the facility indicated the resident acquired a stage 2 pressure injury to the sacrum and the bilateral heels were red. The report also indicated the resident was positive for Clostridium difficile. New medications include Flagyl and ceftin. On 07/07/16, Surveyor interviewed CNA-A regarding Resident 1 disliking the facility cat. CNA-A indicated staff were aware Resident 1 did not want the cat in resident's room. CNA-A stated staff would watch to try and deter the cat from entering Resident 1's room, but it was unrealistic to always know location of the cat in the facility. CNA-A indicated the direction was to remove the cat from Resident 1's room if the cat was in the room. CNA-A stated there had never been a barrier in the doorway in attempt to keep the cat from entering Resident 1's room. CNA-A stated Resident 1's door was shut at night to keep the cat out. CNA-A commented she heard Resident 1 fell because resident was swatting at the cat, trying to get the cat out of her room. CNA-A stated the cat has since been removed from the facility. On 07/07/16 at 10:20 a.m., Surveyor interviewed RN (Registered Nurse)-E regarding Resident 1's fall. RN-E stated Resident 1 fell when resident was swatting at the cat to get the cat out of resident's room and indicated as a result of the fall, Resident 1 fractured the right humerus and right hip. RN-E stated Resident 1 is capable of putting on the call light and asking to get the cat out of the room, but instead, the resident stood up and fell . RN-E indicated staff were aware Resident 1 did not like the cat prior to the fall, but the cat lived at the facility so was able to roam. RN-E stated doorway barriers were not attempted prior to the fall in attempt to prevent the cat from entering the resident's room. On 07/07/16 at 10:40 a.m., Surveyor interviewed CNA-B, who verified staff were aware Resident 1 did not like the cat. CNA-B indicated the direction was to remove the cat from Resident 1's room if the cat went in the room. CNA-B stated she was aware the cat would enter the resident's room and indicated Resident 1's door was closed at night to keep the cat out of her room, but during the day there were no barriers to deter the cat from entering Resident 1's room. CNA-B stated Resident 1 told her resident was shooing the cat out of resident's room with the TV remote control, lost balance and fell . On 07/07/16 at 10:50 a.m., Surveyor interviewed Resident 1. Resident 1 stated resident does not like cats and the facility was aware of that fact. Resident 1 indicated the concern of the cat being in resident's room was discussed in a Resident Council meeting shortly before resident fell . Resident 1 stated resident also told other staff resident did not like cats. Resident 1 stated the response received from facility was other residents like the cat. Resident 1 indicated the cat came into resident's room all the time, I think that cat knew I didn't like cats. Resident 1 indicated at times resident would shoo the cat out of the room and other times staff would remove the cat. Resident 1 indicated the facility cat was deaf so resident could not yell at the cat to get out and resident has macular degeneration, so the cat is hard to see. Resident 1 stated the day resident fell , the cat was in resident's room and resident grabbed the television remote control, stood up, bent down to shoo the cat out and fell . Resident 1 indicated resident broke hip and arm because of the fall. Resident 1 stated resident had the call light on, but no one came, so resident decided to try and get the cat out alone. Resident 1 indicated resident had right sided pain prior to the incident, but recently had an epidural and the pain level was much better so resident was able to walk with a walker independently. Resident 1 stated now has more pain, but the pain resolves as long as resident does not move. Resident 1 indicated now has to wait for staff assistance. Resident 1 became very tearful during the interview. Resident 1 (while crying) stated, I don't know why they had a cat that was able to go in rooms of residents that don't like cats. On 07/07/16 at 11:00 a.m., Surveyor interviewed AD (Activity Director)-D regarding a Resident Council meeting in which Resident 1 discussed resident did not want the cat in resident's room. AD-D verified a Resident Council meeting was held and Resident 1 brought up the concern that resident did not want the cat in the room. AD-D stated there was a discussion with Resident 1 that resident should put the call light on when the cat goes into the room and staff would come and remove the cat. AD-D stated she told Resident 1 the cat did not know any better not to go in the resident's room. AD-D provided the Resident Council minutes dated 06/14/16. There was a section on the form that says Residents rights review of them and where to find the form if they need a new one. What our residents say: (Resident 1) To not have cat in my room. The notes contain a section for This month concerns, but did not address Resident 1's concern of having the facility cat in resident's room. On 07/07/16 at 1:00 p.m., Surveyor interviewed DON (Director of Nursing)-G, who stated she was not aware Resident 1 did not like cats and indicated after the incident, DON-G went and asked the MDS nurse if the resident did not like cats and the MDS nurse indicated she was also not aware Resident 1 disliked cats. With regard to the incident, DON-G indicated Resident 1 was shooing the cat out of the room, fell and resident fractured hip and arm. DON-G stated when Resident 1 returned to the facility from the hospital, the cat was again discovered in resident's room and the family was upset. DON-G stated the facility then tried a barrier screen, but that did not work and the cat was still able to enter the room. DON-G indicated the facility did post signs by Resident 1's room that stated, No Cats. DON-G stated the family was so upset, the facility removed the cat from the premises to allow for a cool down period. DON-G stated another resident council meeting was held and the residents that attended requested to get another cat. The Resident Council notes dated 6/27/16, were provided to Surveyor . The notes have 14 residents that were listed in attendance (Resident 1 was not present in the meeting.) Resident 11 indicated resident is allergic to cats. Resident 11 states resident has been hospitalized in the past from a cat allergy and has not had any allergies [REDACTED]. Resident 14 stated, I like cats. I just don't like him on my window sill. The notes included the facility is working on a few interventions with regard to how to keep the cat out of rooms where cat is not wanted. Reminder to residents to use call lights when the cat gets in their room and to wait for staff to get cat out. The cat has no claws and is deaf. Some residents would like a sign outside of their door that states, No Cats. Plan is to keep the cat and have him put in the activities room at night. On 07/07/16 at 10:30 a.m., Surveyor interviewed NHA (Nursing Home Administrator)-F regarding the facility cat. NHA-F stated the cat is gone now but there was another Resident Council meeting held after Resident 1 fell . NHA-F indicated there are more residents that want a cat so the facility has decided to get another de-clawed cat. NHA-F stated Resident 1's hip fracture was pathological per the operative report. Surveyor reviewed Resident 1's MAR's (Medication Administration Record) for 6/2016 and 7/2016 as follows: ~ June - Resident 1's pain was assessed each shift and from 06/01/16 through 6/16/16, the resident indicated (resident) was in pain 19 shifts and was not in pain 26 shifts. Resident 1 did not receive scheduled pain medications and Tylenol 650 mg (milligrams) was administered 12 times from 06/01/16 through 06/15/16. Resident 1 received Norco 7.5 mg/325 mg once on 06/16/16 at 3:00 p.m. Surveyor did not receive the June MAR after Resident 1 returned from the hospital on [DATE]. ~ July - Resident 1 was assessed to have pain every shift from 07/01/16 through 07/07/16 (date of this investigation.) Resident 1 did not receive scheduled pain medications. Resident received Norco 5 mg/325 mg 12 times from 07/01/16 through 07/07/16 (date of this investigation.) Surveyor reviewed the policy and procedure titled Pets dated 08/23/11. The policy and procedure did not contain any procedure of how to prevent the facility cat from entering resident rooms for residents that do not wish to have the cat in their room.

Based on staff interviews and record review the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 9 sampled residents (resident #1). Resident #1 had a history of [REDACTED]. During a transfer on 2/10/12 staff had not approached resident #1 from the left side as directed by the CNA (Certified Nursing Assistant) care card, and had not provided physical assistance on resident #1's impaired left side. While resident #1 was seated at the edge of the bed, she began to lean towards the left side, and subsequently fell to the floor. As a result of the fall, resident #1 sustained a left tibial fracture. Findings include: On 2/27/12 surveyor # completed a record review for resident #1. According to the facility face sheet, dated 2/15/11, resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge summary dated 5/31/07, documented resident #1 had left sided hemiparesis. The facility completed a quarterly MDS (Minimum Data Set) assessment with a reference date of 1/23/12. The MDS documented resident #1 had impaired long and short term memory, impaired cognitive skills for decision making, and required extensive staff assistance with bed mobility and transfers. The MDS further noted resident #1 had functional limitations in ROM (range of motion) of the upper and lower extremities on one side. The MDS indicated resident #1 was only able to stabilize balance during surface to surface transfers with human assistance. The facility completed a fall risk assessment dated [DATE]. The risk assessment noted a score of 16, which indicated high risk for falls (a score of 10 or above indicated high risk). A therapy screen report, dated 11/23/11, documented resident #1 was unable to stand or walk, and required total assist of 1-2 for sit to stand transitions. The plan of care dated 4/20/11, documented resident #1 had a history of [REDACTED]. The plan of care directed staff to leave the room if resident #1 was safe when resident #1 was physically abusive, to attempt another time, and to alternate caregivers. The plan of care indicated resident #1 required the use of a sara lift (a mechanical sit to stand lift) with assist of two staff, and noted resident #1 had left sided weakness. The CNA care card, not dated, directed staff to approach resident #1 from the left side. The Interdisciplinary (ID) Notes dated 2/10/12 at 1:53 p.m. documented the following: "At 1230 (12:30 p.m.) during cares, res. (resident) was sitting at the side of the bed, proceded (sic) to hit and was agitated, fell on to the floor. Hit her head, apprx. (approximately) 1 inch lump noted to left eyebrow area. approx. 1.5 inch lump noted to shin area. res. ref. (refused) ice packs and cool packs to those areas. good rom (range of motion)/her usual...also scratches noted to left outer back area..." The ID notes on 2/11/12 at 4:28 a.m. noted slight bruising to resident #1's left ankle, and some swelling noted on the left lower leg. On 2/11/12 at 12:42 p.m., the ID note indicated resident #1's left outer ankle was light purple and swollen. The physician was contacted, and resident was sent to the hospital for an x-ray. The hospital discharge summary, dated 2/16/12 documented resident #1 was admitted to the hospital on [DATE] following a fall at the nursing home the day prior to admission (2/10/12). The discharge summary noted resident #1 had sustained a left tibial fracture. On 2/27/12 at 9:03 a.m. surveyor # interviewed CNA-A (Certified Nursing Assistant). CNA-A verified she and CNA-B were assisting resident #1 into bed on 2/10/12, when resident #1 sustained the fall. CNA-A stated resident #1 had been combative when CNA-A and CNA-B assisted the resident from the wheelchair onto the commode utilizing the sara lift. CNA-A stated resident #1 was yelling that she needed to have a bowel movement, and believed that need may have been contributing to resident #1's agitated behavior. CNA-A stated after resident #1 was finished on the commode, CNA-A stood on resident #1's right side and provided perineal care as resident #1 was standing with the lift. CNA-A stated CNA-B maneuvered resident #1 in the lift from the commode to the bed, and lowered resident #1 to a sitting position on the side of the bed. CNA-A stated she continued to stand at resident #1's right side, despite resident #1 striking out at her with the resident's right hand/arm. CNA-A verified she had not approached or assisted resident #1 on her left side, although CNA-A was aware resident #1 had left sided weakness and could only make minimal movements of the left side of her body. CNA-A stated as she was standing at resident #1's right side, she detached the sling from the lift. CNA-A indicated resident #1 continued to strike out with her right arm, and the resident began to lean towards her left side. CNA-A stated resident #1 began to fall towards her left side, and fell on to the floor. CNA-A stated she was unable to provide enough physical assistance to prevent resident #1 from falling to the floor. CNA-A demonstrated the height of the bed at the time of the fall to be approximately 18 inches from the floor. CNA-A stated she believed resident #1 lost her balance due to her striking out behaviors. CNA-A verified she had been trained to stand on a resident's impaired side when providing transfer assistance, but verified during the event with resident #1, she had not done so. During an interview with surveyor # on 2/27/12 at 12:05 p.m. , CNA-A indicated she usually did approach resident #1 from the left side due to behaviors of striking out and weakness on the left. CNA-A stated resident #1 was not physically able to strike out with her left arm, and indicated she may have had better control over resident #1's body movement had she been on resident #1's left side during the transfer on 2/10/12. On 2/27/12 at 9:15 a.m. surveyor # interviewed CNA-B. CNA-B verified she had been assisting CNA-A with resident #1's transfer on 2/10/12 when the fall occurred. CNA-B verified she had been the person maneuvering the lift, and CNA-A was standing on resident #1's right side. CNA-B verified resident #1 was combative and striking out at CNA-A as CNA-A was trying to remove the sling from the lift. CNA-B stated after the sling as removed, resident #1 began to lean towards her left side, and subsequently fell to the floor. CNA-B verified resident #1 had left sided impairments. CNA-B verified she had been trained to stand on a resident's impaired side during transfers to provide support for any residents who have one sided weakness/impairments. On 2/27/12 at 10:07 a.m. surveyor # interviewed RN-F (Registered Nurse). RN-F verified resident #1 had significant impairments of the left side of her body. RN-F indicated staff should have always supported resident #1's left side during transfers. On 2/27/12 at 10:12 a.m. surveyor # interviewed CNA-E. CNA-E indicated resident #1 had significant impairments of the left side of her body. CNA-E stated during transfers, staff would support resident #1 on the left side, and resident #1 was only able to hold onto the lift with her right hand. CNA-E indicated resident #1 was not able to maintain balance when seated at the side of the bed without staff's physical assistance. CNA-E indicated resident #1 would lean towards the left; therefore staff would provide physical assistance on that side. CNA-E verified she had been trained to always assist residents with impairments on the side of greatest weakness. On 2/27/12 at 10:35 a.m. surveyor # interviewed CNA-G. CNA-G verified she had been trained to always assist residents with impairments on the side of greatest weakness during transfers. During an interview with surveyor # on 2/27/12 at 12:10 p.m., ADON-D (Assistant Director of Nursing). ADON-D indicated she provides the facility training regarding transfers to the CNAs, including the use of a lifts and transferring residents with impairments. ADON-D stated she trains staff to always assist on the side of the impairment during transfers, due to weakness, the resident needs additional support on the impaired side. ADON-D verified resident #1 was flaccid on her left side due to a history of a stroke. ADON-D verified resident #1's right side was strong, and indicated the resident could hold onto the lift with her right hand only (not the left). ADON-D stated staff should have always assisted on the side of the impairment (left side) during transfers. On 2/27/12 at 10:40 a.m. surveyor # interviewed DON-C (Director of Nursing). DON-C stated that each year the CNAs are trained on transfers, including transfers with lifts. DON-C indicated staff are trained to always provide physical support on a resident's side of impairment/weakness. DON-C verified CNA-A should have supported resident #1's left side during the transfer on 2/10/12. DON-C stated resident #1 had significant impairments on the left side, and could not maintain balance without support. DON-C further stated due to resident #1 striking out from the right side, if CNA-A would have been on resident #1's left side, the CNA would have been able to provide additional support to maintain the resident's balance. DON-C indicated resident #1's plan of care directed staff to approach from the left side due to a history of striking out behaviors, and noted the plan of care indicated left sided weakness under the approach for transfers with the sara lift and two staff assistance. DON-C verified although the facility re-educated staff regarding management of behaviors and approaches for combative/agitated behaviors, the facility had not provided re-education regarding assistance on a person's side of impairment during transfers following the event of 2/10/12.

Based on record review and staff interview, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (resident #1) of 9 sampled residents who were identified as a wandering risk, with the potential to affect all 9 (residents #2, #3, #4, #5, #6, #7, #8, and #9) residents at risk for elopement. Resident #1 was confused, had a history of [REDACTED]. The facility placed a wanderguard bracelet on resident #1's w/c or person to alert staff when resident #1 exited a door which was utilizing the wanderguard alarm system. Resident #1 exited the building unassisted and was discovered seated in the parking lot outside of the facility. His body temperature was 95.2 and he complained of being cold. The facility was unsure which door resident #1 exited. Resident #1 hadn't had the wanderguard on his person or his w/c when he exited the building, so the alarm had not sounded when resident #1 exited. The facility also utilized an additional alarm that sounded at the nurses' station when the door was opened. On 11/14/11 at approximately 10:50 p.m., the alarm sounded at the nurses' station. Staff did not respond to the alarm and assumed other staff had checked the door. With respect to resident elopement, facility staff: * Did not ensure that the door alarms on the front and back door were turned on at 10:30 p.m. * Did not ensure that Resident #1 was wearing his wanderguard bracelet * Did not immediately respond to the door alarm that sounded * Turned off the door alarm without investigating to determine that no one was outside and that all residents were accounted for * Did not ensure the main alarm on the door that facility staff exited to retrieve Resident #1 was turned on, as nursing personnel were able to exit without setting off the alarm. * Did not ensure that the secondary alarm on the dining room door was functioning The above created a situation of Immediate Jeopardy that began on 11/14/11, when resident #1 exited the facility without staff knowledge and was discovered seated outside in the parking lot sometime between 11:15 p.m. and 11:30 p.m.. The facility was informed of the Immediate Jeopardy on 11/30/11. The Immediate Jeopardy was removed on 11/22/11, but the deficient practice continued at a scope and severity level of E (potential for harm that is not Immediate Jeopardy/pattern) because the facility has yet to complete training and has not had mock drills to ensure that staff respond to alarms as they have been trained. Findings include: On 11/23/11 and 11/29/11, surveyor # reviewed resident #1's medical record. According to the face sheet, dated 1/17/08, resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility developed a plan of care for "Inability to Care for Self", without a date when initiated, but indicated on 4/14/11 a chair alarm was placed in his w/c. The facility developed a plan of care for "Progressive Dementia/Alzheimer's....", without a date when initiated, but indicated on 5/30/11 a wanderguard was placed and directed staff to check placement and function every shift related to safety, elopement attempt. The facility completed an MDS (minimum data sheet) dated 9/12/11 that indicated that resident #1 had severe cognitive impairment, demonstrated wandering behavior, required extensive assistance with transfers, and limited assistance with locomotion on/off the unit and was not steady and only able to stabilize with human assistance when moving from a seated to standing position, walking, turning around and surface to surface transfer. On 11/29/11 at 10:40 a.m. surveyor # and DON (Director of Nursing)-A toured the facility to review the facility exit doors. The facility has 10 exit doors. All exit doors have an alarm system that sounds at the nurses' station when the door is opened. Each individual door can have the alarm turned off/on at the panel located at the nurses' station. The panel for each door has a light which signifies if the alarm is on or off. A green light means the alarm is off and a red light means the alarm is on. Five of the 10 doors have a wanderguard system alarm also. ? front exit ? A wing ? C wing ? Corridor to the patio ? Back door Two of the 10 doors have a secondary alarm attached to the door, so the door makes a loud screeching noise when opened. The system has a unit attached to the door and the door frame, and when the metal from each part makes contact (door closed) the system is activated. ? Dining room door ? Chapel door Three of the 10 doors do not have an additional alarm system. ? Activity room ? Therapy room ? Chapel corridor exit Each door has a button in the panel at the nurses' station that needs to be pressed to silence the alarm if the alarm sounds. The light turns green, which means the alarm is not on. The button needs to be pressed again to turn the alarm on and the light will turn to red. Surveyor # reviewed the facility's policy and procedure for "Door Alarm Panel", revised 8/30/11. The policy and procedure indicated the front and rear electric door will be turned on at 8:00 p.m. by the group 2 charge nurse. Surveyor # interviewed DON-A on 11/29/11 at 10:45 a.m. regarding the alarm system panel at the nurses' station. DON-A indicated the alarms are activated 24 hours a day except for the front and back door which are turned on at the beginning of night shift (10:30 p.m.). DON-A verified no specific staff had been assigned to turn the alarm system on. Surveyor # questioned the facility policy and procedure which indicated the alarm was activated at 8:00 p.m. and DON-A stated the policy was not accurate and would need to be changed. Surveyor # reviewed the facility's policy and procedure for "Wandering Resident Protocol", revised 7/11. The policy and procedure indicated "when the alarm goes off, staff is to immediately go to the door and check both the area surrounding the door inside and the exterior of the building prior to re-setting the alarm". Surveyor # reviewed the IDN (Interdisciplinary notes) located in resident #1's medical record. The notes that were entered into the computer documentation system, dated 11/15/11 at 1:15 a.m. indicated, sometime after 2315 (11:15 p.m.) a CNA (Certified Nursing Assistant) alerted writer and Nocs and PM RN's (Registered Nurse) that resident #1 had fallen in the rear parking lot. RN's and writer immediately headed for the area to assess the situation. Resident #1 was sitting in the parking lot with blood on hands and clothing. Three small abrasions noted to right knee. His wanderguard was not on his leg or attached to is w/c. Resident #1 denied hitting his head and was quickly helped to his w/c and brought to his room since it was cold outside. Resident was assessed and has a laceration measuring 2.1 cm (centimeters) on his right palm below his fifth digit along with a bruise on the lateral side of his right wrist. Resident has bruises to the tips of his fingers on the right hand. Neuro checks were within normal limits. Resident was asked where he was going and stated that he was going home.......Was seen in his w/c at the nurses station at the beginning of the shift. It was determined that resident gained access to the rear parking lot via the dining room door since his w/c was found close to the door. The Vital Sign Record for resident #1 indicated on 11/14/11 at 2325 (11:25 p.m.) resident #1's temperature was recorded at 95.2 with a follow up temperature (unknown of the time span between the temperature readings) was 97.3. The Vital Sign Record indicated resident 1's baseline temperature prior to 11/14/11 was between 97.1 - 98.2 as recorded between the dates of 9/13/11 and 11/11/11. Surveyor # reviewed resident #1's treatment record for November 2011. The treatment record contained an entry for staff to check wanderguard function every shift. Staff documented they had checked the functioning of the wanderguard every shift. On 11/21/11, the facility added that the wanderguard to have been placed on resident #1's left ankle. According to the Ford Airport located in Kingsford Michigan (approximately five miles from the facility) the air temperature was recorded at 42 degrees with a wind chill factor of 37 degrees. This temperature was recorded at 10:00 p.m. on 11/14/11. On 11/23/11 at 9:55 a.m., surveyor # interviewed NHA (Nursing Home Administrator)-F and DON-A regarding the incident that had occurred on 11/14/11 with resident #1. NHA-F stated resident #1 was confused and self propelled his w/c in the facility. NHA-F indicated resident #1 was identified as a wandering risk. NHA-F indicated resident #1 traveled down the B wing into the dining room and exited the building through the dining room door. NHA-F stated the secondary alarm on the dining room door hadn't sounded and staff had to have manually turned the door alarm off at the panel that was located at the nurses' station. NHA-F indicated she interviewed all staff that were in the building at the time of the incident and stated no staff would admit to turning off the door alarm. NHA-F stated all nurses stated they never heard the door alarm. NHA-F indicated during the facility's investigation they had discovered the magnetic strips for the secondary alarm on the dining room door did not have enough pressure applied so the alarm was not activated. NHA-F indicated the facility would be applying the wanderguard system to the remaining five doors that didn't have the wanderguard system. DON-A indicated the policy and procedure that indicated the front/back door alarms were to have been activated at 8:00 p.m. was not accurate and the policy would need to be changed, as the doors were not alarmed until the night shift. DON-A stated the wanderguard was to have been on resident #1's w/c and verified the wanderguard bracelet was not attached to the w/c or resident #1 when he had exited the building. DON-A indicated it was possible that resident #1 self transferred to another resident's w/c. Surveyor # questioned if a w/c was located that had a wanderguard bracelet attached and DON-A indicated the facility had not checked for the w/c. DON-A stated the facility didn't have a system in place to identify which w/c belonged to which resident. DON-A indicated on 11/15/11 the facility provided training to staff regarding checking the door and surrounding area when a door alarm sounded prior to disengaging the alarm and regarding the wanderguard bracelet system. On 11/23/11 at 11:00 a.m., surveyor # completed a telephone interview with RN-B regarding the incident which occurred on 11/14/11. RN-B verified she was working PM shift and had remained in the building after her shift to complete documentation. RN-B stated resident #1 was confused and self propelled his w/c in the facility, but usually stayed on the C wing in which he resided. RN-B stated she was unsure if resident #1 had the capability to ambulate independently, but was capable to stand unassisted and was not safe with unassisted standing. RN-B she was at the nurses' station and she had not seen resident #1, as she was completing documentation. RN-B indicated she recalled a CNA ask another CNA if she saw resident #1, but hadn't heard the response. RN-B indicated she was not alarmed by the question because it was common for a CNA to ask if they saw someone. RN-B stated she could not recall the time she had heard the CNA asking about resident #1. RN-B indicated she did not hear a door alarm sound at the nurses' station, but at some point she had used the bathroom and might not have heard the alarm. RN-B stated she first heard of resident #1 having been outside when the CNA came to the nurses' station and stated he was outside. RN-B stated she and two other nurses went to the door and she stayed inside the building while the other two nurses went to assess resident #1. RN-B indicated she was concerned about resident #1's body temperature when he was brought back into the building. RN-B stated she thought it was 95.2 and told the other nurses that resident #1 needed to be warmed to ensure his body temperature rose. RN-B stated resident #1 "looked chilled". RN-B stated she did not hear the door alarm at the nurses station when the CNA's exited the building or returned and she was seated at the nurses' station at the time. RN-B re-iterated she did not turn off the door alarm at the nurses' station when resident #1 exited the building as she did not hear the alarm. RN-B verified the facility had completed training to staff regarding that the door alarm was not to be turned off until the door and outside area was checked for residents, and to ensure residents were wearing wanderguard bracelets. On 11/23/11 at 11:15 a.m., surveyor # completed a telephone interview with LPN (Licensed Practical Nurse)-C regarding the incident that occurred on 11/14/11 with resident #1. LPN-C verified she was working night shift on 11/14/11. LPN-C stated resident #1 was confused, self propelled his w/c, and able to independently ambulate short distances but was unsteady. LPN-C stated most of the time resident #1 wore his wanderguard bracelet on his leg but at times it was on his w/c. LPN-C stated she had last seen resident #1 by the nurses' station at approximately 10:30 p.m.. LPN-C indicated she was in/out of the nurses' station area assisting other residents after 10:30 p.m. and hadn't heard a door alarm sound at the nurses' station. LPN-C indicated at approximately 11:15 p.m. to 11:25 p.m., CNA-D came to the nurses' station and said resident #1 was outside in the parking lot and also indicated she had heard a door alarm earlier. LPN-C stated sometime between 10:30 p.m. and 11:00 p.m. she had noted at the panel at the nurses' station that the back and front door alarm system was not on and she had turned the alarm system on. LPN-C indicated she had not turned the alarm off as she had never heard the door alarm sound. LPN-C stated she immediately went outside when CNA-D stated resident #1 was located outside. LPN-C indicated resident #1 was observed to have been seated on the pavement in the parking lot. Blood was noted on his right and left hands. Resident #1 was wearing a hospital type gown which tied in the back and was wearing gripper socks. LPN-C indicated resident #1 had a 2.1 cm laceration on his right palm and three abrasions under his right knee. Resident #1's skin felt cool and he was scared and confused. LPN-C stated she thought resident #1's body temperature was 97 something. LPN-C indicated RN-E assessed resident #1 and then was taken to his room inside the facility. LPN-C stated it was chilly outside on 11/14/11. LPN-C stated she was at the nurses' station when the CNA reported resident #1 was outside the facility. LPN-C indicated she hadn't heard the door alarm sound at the nurses' station when the CNA's exited or entered the building. LPN-C re-iterated she had engaged the alarm system prior to resident #1 having been found outside. LPN-C indicated staff were wondering how resident #1 exited the building and assumed it was through the dining room door. Staff opened the dining room door multiple times after the incident and the secondary alarm hadn't sounded with their attempts. LPN-C stated on 11/25/11 she was checking the exit doors to ensure the alarms were working and when she checked the chapel door (which had the secondary alarm attached to the door), the alarm sounded. LPN-C indicated she had to retrieve a key at the nurses' station to turn the alarm off and when she returned to the door the alarm had shut off. LPN-C stated the alarm could not have been shut off without the key and the only key available to staff was at the nurses' station. LPN-C indicated the alarm had to shut off by itself. On 11/23/11 at 12:45 p.m., surveyor # completed a telephone interview with CNA-G regarding the incident which occurred on 11/14/11 with resident #1. CNA-G stated resident #1 was confused, self propelled his w/c in the facility but usually only went to the nurses' station during the night shift. CNA-G indicated resident #1 had the capability of propelling his w/c throughout the facility. CNA-G stated resident #1 wore a wanderguard bracelet on his ankle because he would go towards the exit doors. CNA-G stated she wasn't sure if the bracelet was ever on his w/c. CNA-G verified she was working the night shift of 11/14/11. CNA-G indicated she was working on A wing when she heard a door alarm sound at the nurses' station. CNA-G stated the alarm sounded for less than one minute and was silenced, but hadn't observed if any person had silenced the alarm. CNA-G stated she had not responded to the alarm because it was facility protocol for whoever silenced the alarm would check the door which sounded or delegate the task. CNA-G stated she was passing ice water and completing vital signs for residents when the alarm sounded. CNA-G indicated when the alarm was silenced she continued the task she was doing and verified she had not responded to the alarm. CNA-G stated the alarm sounded at approximately 10:55 p.m.. CNA-G indicated at approximately 11:15 p.m. she had went to C wing and CNA-D just returned from break and asked if she had seen resident #1 and CNA-G replied she wasn't aware he was out of bed. CNA-G stated she also replied that she had heard a door alarm earlier and she hoped someone had checked. CNA-G indicated she and CNA-D began searching for resident #1 and was looking into other resident rooms as they walked down B wing. CNA-G stated they saw CNA/LPN-H (was a LPN but working as a CNA for night shift on 11/14/11) and told her resident #1 was missing. CNA/LPN-H joined the search. CNA-G indicated CNA/LPN-H checked the dining room and hadn't observed any residents, then CNA-G and CNA-D went out the back door and they had heard a chair alarm once outside the building. CNA-G stated when they went around the corner of the building, they observed resident #1 sitting on the pavement in the parking lot; he was approximately 20-30 feet away from the w/c. CNA-G stated resident #1 was wearing gripper socks, hipsters and a hospital type gown which tied in the back with a t-shirt underneath. CNA-G indicated resident #1 had a small amount of blood covering his fingertips and had scrapes on his knees. CNA-G stated resident #1 was stating he was cold. CNA-G indicated it was very dark outside so she was unable to see him well. CNA-G stated CNA-D stayed with resident #1 while she went inside the building to get a nurse. CNA-G indicated she told the nurses and they immediately went outside to assess resident #1. CNA-G stated resident #1 was not wearing the wanderguard bracelet nor was the bracelet on the w/c. CNA-G indicated she thought resident #1 exited the building by the dining room door as his w/c was outside the door. CNA-G stated the dining room door had a secondary alarm on the door that was to have sounded when the door was opened. CNA-G stated staff opened the door of the dining room after the incident and the secondary alarm hadn't sounded. CNA-G stated resident #1 was discovered outside the facility at approximately 11:20 p.m.. CNA-G verified she had received training regarding the wanderguard system and the alarm system at the nurses' station since the incident. On 11/23/11 at 1:20 p.m., surveyor # completed a telephone interview with CNA/LPN-H regarding the incident that occurred on 11/14/11 with resident #1. CNA/LPN-H stated she was a LPN but was working as a CNA for the night shift of 11/14/11. CNA/LPN-H stated resident #1 was confused and self propelled his w/c in the facility. CNA/LPN-H indicated resident #1 had the capability to self transfer and ambulate independently. CNA/LPN-H stated resident #1 utilized a wanderguard bracelet and had a chair alarm in his w/c. CNA/LPN-H verified the wanderguard was not on resident #1 or his w/c on 11/4/11 at the time of the incident. CNA/LPN-H stated resident #1 utilized the wanderguard bracelet because he had a history of [REDACTED].#1 seated in his w/c at the nurses' station at 10:30 p.m.. CNA/LPN-H stated that at approximately 11:20 p.m., she had heard staff state that resident #1 was missing. CNA/LPN-H indicated she assisted in the search to locate resident #1. CNA/LPN-H stated resident #1 was located outside the facility sitting on the pavement with his legs stretched out in front of him. CNA/LPN-H indicated resident #1 was wearing a hospital type gown, t-shirt underneath, underwear with hipsters over and gripper socks or maybe shoes as she wasn't sure about the footwear. CNA/LPN-H indicated resident #1's left knee was scraped and was saying he was cold. CNA/LPN-H indicated it was dark outside and difficult to see resident #1. CNA/LPN-H stated it was chilly outside. CNA/LPN-H indicated she thought resident #1 exited the building through the dining room door as his w/c was outside the door. CNA/LPN-H stated she had checked the dining room door after the incident and discovered the secondary alarm that was on the door had not sounded when opened. CNA/LPN-H verified she had received training since the incident. On 11/29/11 at 10:18 a.m., surveyor completed a telephone interview with CNA-D regarding the incident which occurred on 11/14/11 with resident #1. CNA-D verified she was working the night shift on 11/14/11 when resident #1 exited the building. CNA-D stated she was working on the C wing where resident #1 resided and was responsible for resident #1's care. CNA-D stated resident #1 was very confused, had a history of [REDACTED].#1 from the exit doors at times. CNA-D stated resident #1 would speak of going home. CNA-D indicated she saw resident #1 seated in his w/c at the nurses' station at 10:30 p.m.. CNA-D stated resident #1 was wearing a hospital type gown which tied in the back, a t-shirt underneath, underwear with hipsters over and gripper socks. CNA-D stated she was on C wing and heard a door alarm sound at the nurses' station at approximately 11:00 p.m. and indicated the alarm was sounding for less than one minute. CNA-D stated that the alarm had to be manually turned off. CNA-D stated she assumed it was another CNA locking the door and verified she had not responded to the alarm. CNA-D indicated she had not observed which staff had silenced the alarm at the nurses' station. CNA-D stated she went on break at 11:00 p.m. and returned from break at 11:15 p.m.. CNA-D indicated she assumed the nurse was watching resident #1 when she went on break. CNA-D indicated she noticed resident #1 was not at the nurses' station, when she returned from her break, so she began searching for him. CNA-D stated during her search she had asked other CNA staff if they had seen resident #1 and they also joined in the search. CNA-D indicated she checked resident rooms and went out the back door and heard a chair alarm sounding. CNA-D stated resident #1 was observed sitting on the pavement with his legs extended in the back parking lot. CNA-D indicated resident #1's hands and knees were scraped and he was slightly bleeding from the areas. CNA-D stated resident #1 was repeatedly saying he was cold and wanted to get back inside. CNA-D indicated resident #1's w/c was not near the dining room door, the w/c was observed in the parking lot, and resident #1 was approximately 100 feet from the w/c. CNA-D stated she stayed with resident #1 while CNA-G went to get the nurse. CNA-D indicated she wasn't sure if resident #1 exited the building through the dining room door or the back door. CNA-D stated resident #1 was to have been wearing a wanderguard bracelet, but neither the w/c nor resident #1 had a wanderguard bracelet on. On 11/29/11 at 12:15 p.m., surveyor # interviewed LPN-I regarding resident #1's plan of care indicated for staff to check placement and function of the wanderguard bracelet. LPN-I stated there is no way to check functioning of the bracelet unless the resident goes to a wanderguard door. LPN-I indicated she had not checked functioning of the bracelet and only checked placement. On 11/29/11 at 12:45 p.m., surveyor # completed a telephone interview with CNA-K regarding the incident which occurred on 11/14/11 with resident #1. CNA-K stated she was with another resident when she heard the door alarm sound at the nurses' station. CNA-K indicated the alarm sounded between 10:50 p.m. and 10:55 p.m. and only sounded for a few seconds. CNA-K verified she had not responded to the alarm as she was with another resident that could not have been left alone. CNA-K stated she took a break at 11:15 p.m. and the next she heard was that resident #1 was outside of the facility in the parking lot. CNA-K indicated she looked out the window from the dining room and observed resident #1 in the parking lot. CNA-K also indicated resident #1's w/c was located in the parking lot. CNA-K stated resident #1 was confused and had a history of [REDACTED]. CNA-K indicated that staff had to remove resident #1 from the exit doors in the past. CNA-K stated resident #1 was capable to self propel his w/c in the facility. On 11/29/11 at 12:50 p.m., surveyor # and Maintenance-J measured the distance from the nurses' station to the dining room exit door. The distance measured was approximately 205 feet. The facility removed the immediate jeopardy on 11/22/11. On 11/29/11 at 3:22 p.m., surveyors # and # interviewed NHA-F and DON-A regarding what the facility had implemented since resident #1's elopement on 11/14/11. DON-A stated training had been provided regarding facility policy and procedure for a missing resident, wanderguard placement, response to alarms and for making sure that staff are aware of residents whereabouts at all times. DON-A indicated if the CNA staff are busy, then the nurse was to assume responsibility to know where residents are. DON-A indicated staff were trained in ensuring the doors with the secondary alarm are activated. DON-A verified the manufacturer of the panel door alarm system had not completed an assessment to ensure the system was working properly. DON-A stated after the incident the nurse also checks the doors on weekends to ensure proper functioning, and maintenance has always checked the door alarms daily prior to the incident to ensure proper functioning. DON-A stated nurses must document nightly at the beginning of the night shift that the door alarms are all engaged.