Every finding on record at Masonic Center for Health & Rehab Inc.

Based on record review and staff interviews, the facility did not ensure they conducted a thorough investigation of 1 of 2 facility reported incidents (FRIs) involving R2 and R1.On 1/4/26, at approximately 2:00 pm, R2 was observed to have his hand on top of the brief of another resident (R1) while they were sitting, watching television in the living room area. Review of the facility's investigation did not provide evidence of a thorough investigation of the incident. The investigation did not include interviews with additional residents and staff members who may have had knowledge of this incident or any previous interactions and to ensure no other residents may have experienced similar abuse.Findings include:Review of the facility policy titled Freedom from Abuse, Neglect and Exploitation Policy and Procedure (undated) indicates:Investigation componentsAbuse Policy requirements: It is the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of property) are promptly and thoroughly investigated.Procedure: The facility will immediately protect the resident(s) and begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident and document the findings for the incident. The investigation is the process to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. A thorough investigation is an investigation that adequately addresses the circumstances of the allegation. The investigation will include the facts necessary to form a reasoned (sic) conclusion as to what happened. The facility will document the investigation and the reasons for conclusion.iv. Involved staff and witness statements of events1. Identifying and interviewing other staff or residents in the immediate area at the time of the incident who may have witnessed what occurred.2. Interviewing staff who worked previous shifts to determine if they were aware of an injury or incident.On 1/29/26, Surveyor conducted a review of a facility reported incident (FRI) involving R1 and R2. The FRI documented the incident occurred on 1/4/26 at 2:00 PM. Details of the incident include, (R2), who has a diagnosis of Alzheimer's dementia, was seen (sic) to have his hand on the top of the brief of (R1), who also has dementia, in a resident living room. Per witness statement, (R1) did not seem to be aware of what was happening and (R2) responded what? when witness asked what he was doing. (R1) and (R2) were immediately separated, and law enforcement was contacted.Surveyor conducted further review of the facility's investigation. The investigation contained 1 staff interview from Activities Director- C who witnessed (R2) touching (R1) and immediately separated the 2 residents. The statement documented that Activity Director- C was gathering residents for an activity when she noticed (R2's) hand was partially down the top of (R1's) pants/ brief and moving back and forth. (R1's) shirt had been partially lifted as well. Activity Director- C documented she gently lifted (R2's) hand and placed it on his own lap in which (R2) replied what? Activity Director- C stated, you need to keep your hands here. Activity Director - C stated she brought (R1) with her and separated from (R2) and reported the incident to the nurse on duty.The facility's investigation did not include additional interviews from staff or other residents who may have had knowledge of or also witnessed the incident. The facility did not interview other individuals (residents or staff) to determine if they had ever witnessed R2 touching other peers inappropriately before this incident, if there were any other behaviors or statements of a sexual nature demonstrated by R2, or if there was a pattern of behavior or interactions to help determine the extent of the interaction between R2 and R1 and how long it may have been going on. The facility also did not determine if any other residents may have been effected by R2's behavior as part of their investigation.On 1/29/26 at 12:38 PM, Surveyor interviewed Administrator- A and Director of Nursing- B regarding the investigation of the 1/4/26 incident involving R2 and R1. Surveyor asked if the facility had interviewed any other potential witnesses to the incident on 1/4/26. Administrator- A stated they got a statement from the Activities Director who witnessed the incident and separated R2 and R1. Surveyor asked Administrator- A if she was aware if any other staff had witnessed the incident, as they were found in a common living area. Administrator- A was unable to answer. Surveyor asked Administrator- A if there were any other residents in the living area at the time of the incident. Administrator- A was unable to provide an answer. Surveyor asked if R2 had ever been inappropriate with any other peers. Director of Nursing - B stated that this was the first time and that they monitor all the residents for changes in their behavior so they would know if something happened to them. After Surveyor and Administrator- A and Director of Nursing - B spoke with Surveyor, Administrator- A did conduct interviews with staff who were working on 1/29/26. Staff were asked have you ever seen (sic) any residents inappropriately touch one another, if so, what would you do and who would you report to if you did?As of the time of exit on 1/29/26, the facility was not able to provide any additional evidence that they had conducted a thorough investigation by interviewing additional staff and residents regarding the incident that took place on 1/4/26 between R1 and R2.On 2/3/26 the facility submitted additional documentation to review regarding the 1/4/26 incident regarding R2 and R1. The facility information confirms any interviews with facility residents and staff occurred on 1/29/26, during or after the survey regarding the incident. The facility provided details of staff training regarding abuse, reporting, and investigating incidents on 2/2/26, following the survey.

Based on observation, staff interview, and record review, the facility did not sanitize dishware in accordance with professional standards for food service safety. This practice had the potential to affect all 41 residents residing in the facility. The facility did not monitor utensil surface temperatures with an irreversible registered temperature indicator for four unit dishwashers used to wash and sanitize residents' dishes. Findings include: During an initial kitchen tour on 6/2/25 at 9:30 AM, Director of Dining (DOD)-I confirmed the facility follows the Wisconsin Food Code and the Food and Drug Administration (FDA) Food Code as their standards of practice. The Wisconsin Food Code defines a highly susceptible population as: persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care .hospital or nursing home. The Wisconsin Food Code Code indicates: ~ At 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing: .(B) In hot water mechanical warewashing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the utensil surface temperature. ~ At 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: .(2) For a stationary rack, dual temperature machine, 150 degrees Fahrenheit (F); (3) For a single tank, conveyor, dual temperature machine, 160 degrees F. ~ At 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures: (A) . in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 degrees F, or less than: .(2) For all other machines, 180 degrees F. ~ At 4-7 Sanitization of Equipment and Utensils: F-703.11 Hot Water and Chemical: After being cleaned, equipment surfaces and utensils shall be sanitized in: .(B) Hot water mechanical operations by being cycled through equipment that is set up as specified under 4-501.15, 4-501.112, and 4-501.113 and achieving a utensil surface temperature of 160 degrees F as measured by an irreversible registering temperature indicator. The FDA Food Code documents at 4-703.11: If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Pressures below the specified limit will result in incomplete coverage of the heat-conveying sanitizing rinse across utensil surfaces. During the initial kitchen tour with DOD-I on 6/2/25, DOD-I indicated the facility uses hot water (versus chemical) for sanitization of dishes. Surveyor reviewed wash and sanitization temperature logs for the kitchen dishwasher for May and June of 2025. Temperatures for the wash and sanitization cycles were documented three times per day (each meal). In addition, the temperature log contained a surface temperature monitor strip tab next to each date of the month that measured the surface temperature of dishes washed in the kitchen dishwasher. DOD-I indicated each of the four resident care units also had a dishwasher where plates, cups, glasses, and utensils used for residents' meals were washed and sanitized via hot water. DOD-I indicated dishes for residents who ate in their rooms were washed in the kitchen dishwasher, however, most residents ate in the unit dining rooms. DOD-I indicated the kitchen dishwasher was primarily used for cooking and baking dishes and utensils. On 6/2/25 and 6/3/25, Surveyor observed dishwashing on three of the four units and reviewed the temperatures logs for washing and sanitizing dishes on all four units. The unit dishwasher logs did not contain surface temperature strips and Surveyor did not observe staff use surface temperature strips. On 6/3/25 at 11:55 AM, Surveyor interviewed DOD-I who confirmed surface temperatures were not checked in the unit dishwashers. DOD-I again confirmed dishes washed on the units were used for residents' meals in the unit dining rooms. On 6/3/25 at 1:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility did not have a specific dishwasher policy. DOD-I and NHA-A indicated surface temperatures strips will be used on the four resident care units moving forward.

Based on observation, staff interview, and record review, the facility did not ensure staff followed enhanced barrier precautions (EBP) for 2 residents (R) (R5 and R149) of 3 sampled residents observed during the provision of care. In addition, the facility did not ensure staff followed catheter care infection control practices for 1 resident (R32) of 1 sampled resident. R5 was on EBP due to a pressure injury. On 6/3/25, Certified Nursing Assistant (CNA)-E and CNA-F did not wear personal protective equipment (PPE) while transferring R5 from bed to wheelchair. R149 was on EBP due to the presence of a central line (a dialysis access site for hemodialysis). On 6/3/25, CNA-J did not wear PPE during pericare and while transferring R149 from toilet to wheelchair. R32's night time catheter bag was stored in R32's bathroom during the day. On 6/4/25, the catheter bag was observed without a protective cap on the insertion tip to prevent cross-contamination. Findings include: The facility's undated Enhanced Barrier Precautions Policy & Procedure indicates: It is the policy of this facility to initiate enhanced barrier precautions (EBP) when a multidrug-resistant organism (MDRO) is identified and isolation is not appropriate. EBP is an approach to use personal protective equipment (PPE) to reduce the transmission of MDROs between residents .1. EBP is initiated for residents with any of the following: .b. Wounds and or medical devices. 2. Use of gown and gloves during high-contact resident care activities . The facility's posting placed outside rooms of residents on EBP indicates staff are required to wear a gown for high-contact resident cares including transferring, providing hygiene, changing briefs, and assisting with toileting. 1. On 6/2/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia and cerebral infarction (also known as stroke). R5's Minimum Data Set (MDS) assessment, dated 5/14/25, indicated R5 was rarely/never understood. R5 had a Power of Attorney for Healthcare (POAHC) who was responsible for R5's healthcare decisions. R5's medical record indicated R5 was dependent on staff for personal hygiene and required a full mechanical lift for transfers. On 6/2/25 at 10:48 AM, Surveyor observed a sign posted near R5's room that indicated R5 was on EBP. The sign indicated staff were to wear a gown and gloves for high-contact activities, including transfers. On 6/3/25 at 10:43 AM, Surveyor observed CNA-E and CNA-F provide pericare and transfer R5 to a wheelchair via mechanical lift. During the provision of incontinence care, CNA-E and CNA-F (who wore gowns and gloves) changed gloves and completed hand hygiene appropriately. Following pericare, Surveyor observed CNA-E and CNA-F remove gowns and gloves and complete hand hygiene. Without donning new gowns and gloves, CNA-E and CNA-F repositioned and placed a lift sheet under R5. During the process, Surveyor noted CNA-E's uniform top was in contact with R5's bed linens. Surveyor then observed CNA-E and CNA-F transfer R5 from bed to wheelchair via mechanical lift. CNA-F then handed CNA-E R5's water pitcher. CNA-E assisted R5 with taking sips of water by holding the pitcher with a straw while CNA-F adjusted R5's bed linens. CNA-E then combed R5's hair. CNA-E and CNA-F then complete hand hygiene. On 6/3/25 at 10:45 AM, Surveyor interviewed CNA-H in the hallway who indicated staff must wear a gown and gloves during showers and incontinence care for residents on EBP. CNA-H indicated staff do not need to wear a gown or gloves during transfers. On 6/3/25 at 10:59 AM, Surveyor interviewed CNA-F and reviewed with CNA-F the EBP sign outside R5's door. CNA-F indicated CNA-F thought a gown and gloves were not needed for transfers. CNA-F verified the EBP sign indicated a gown and gloves should be worn while transferring R5. On 6/3/25 at 12:04 PM, Surveyor interviewed Infection Preventionist (IP)-D who indicated staff should wear a gown and gloves during high-contact care activities because there is a possibility of contact with a resident's skin or a staff's uniform during care, toileting, emptying urinary catheters, and transferring residents. On 6/4/25 at 8:57 AM, Surveyor interviewed IP-D and Nurse Manager (NM)-C. Following a discussion of the above observation, NM-C indicated CNA-E and CNA-F should not have removed gowns and gloves to transfer R5 from bed to wheelchair. NM-C verified transfers are part of direct contact activities listed on the EBP sign outside R5's door. 45943 2. On 6/3/25, Surveyor reviewed R149's medical record. R149 was admitted to the facility on [DATE] and had diagnoses including dementia, congestive heart failure (CHF), end stage renal disease (ESRD), anxiety, and rheumatoid arthritis. R149's MDS assessment, dated 5/20/25, had a BIMS score of 15 out of 15 which indicated R149 had intact cognition. The MDS also indicated R149 required substantial/max assistance with toileting. R149 made R149's own health care decisions. A care plan. dated 6/2/25, indicated R149 had a self care deficit related to ESRD and was at risk for MDROs with a central line. The care plan contained an intervention for EBP (dated 6/2/25). On 6/3/25 at 1:38 PM, Surveyor observed CNA-J complete pericare for R149 while R149 was on the toilet. CNA-J wore gloves but did not wear a gown. CNA-J completed hand hygiene and donned clean gloves but did not don a gown prior to transferring R149 to a wheelchair. Surveyor observed an EBP sign and a PPE cart outside R149's door. On 6/3/25 at 1:41 PM, Surveyor interviewed CNA-J who verified CNA-J wore gloves but forgot to wear a gown during high-contact resident cares for R149. On 6/4/25 at 12:29 PM, Surveyor interviewed NM-C who verified CNA-J should have worn a gown while providing pericare and transferring R149 who had a dialysis access device. 49563 3. On 6/4/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including dementia, hematuria, retention of urine, and chronic kidney disease (CKD) stage 3. R32's MDS assessment, dated 4/22/25, had a BIMS score of 9 out of 15 which indicated R32 had moderate cognitive impairment. R32 had an activated POAHC for healthcare decisions. A care plan, initiated 11/15/24, indicated R32 had an indwelling catheter with a risk of infection related to obstructive uropathy. The care plan contained interventions, dated 11/15/24, for a leg bag change using aseptic technique, store the drainage bag and leg bag with cap on tubing end to prevent cross contamination, and place 30 cubic centimeters (ccs) of vinegar/water (1:4 ratio) in the leg bag when not in use. On 6/4/25 at 9:37 AM, Surveyor observed R32's night time catheter bag in R32's bathroom closet. The bag was stored in a basin without a protective cover on the insertion tip of the bag. On 6/4/25 at 9:37 AM, Surveyor interviewed CNA-G who indicated the insertion tip of the catheter bag should be covered with a cap but the cap must have been lost. On 6/4/25 at 11:54 AM, Surveyor interviewed NM-C who verified staff reported the missing protective cap to NM-C that morning. NM-C indicated a protective cover should be on the catheter insertion tip to prevent cross- contamination.

Based on observation, interview and record review the facility did not ensure that 2 of 6 residents (R35, R37) at risk for falls and 1 of 1 (R3) resident at risk for elopement received adequate supervision and assistance devices to prevent falls. R35 was at risk for falls. R35 had 2 falls that resulted in a fractured rib and fractured finger when his care plan interventions were not implemented. This caused actual harm to R35. R37 was transferred using the Sara Steady Lift. A gait belt was not used per the care plan. R3's elopement risk was not re-assessed after a (MONTH) (YEAR) psych consult determined that R3 had a significant lack of safety awareness and his POA-HC (Power of Attorney for Health Care) was activated in (MONTH) (YEAR). R3 eloped from the facility on 8/17/18. Findings include: 1.) R35 is [AGE] years old and has a [DIAGNOSES REDACTED]. R35 had a Fall Care Plan dated 5/9/13 with the following interventions: bed in low locked position; not to be left in his wheel chair when in his room - transfer to bed or recliner when in room. R35 also had a Resident Interdisciplinary Care Plan that was used by the CNAs. It was dated 6/1/17 and noted that R35 was to have a gripper mat in his wheelchair and recliner. R35 had 2 falls in which his Fall Care Plan interventions were not implemented and 1 fall in which the facility did not thoroughly assess R35's risk for falls. Fall 8/22/17 On 8/22/17 at 7:25 am, R35 fell out of his wheelchair landing on his left side. R35 sustained no injury. According to the facility's 8/22/17 fall investigation summary it was determined that the gripper material was not present in R35's wheelchair when he fell . R35 had been known to throw the gripper material away. The gripper material was replaced and staff were reminded to check for the gripper material in the wheelchair. According to the 6/1/17 Resident Interdisciplinary Care Plan, the gripper material should have been in R35's wheelchair when he fell on [DATE]. Fall 9/28/17 On 9/28/17 at 5 PM R35 was found on the floor, lying on his left side. The facility's 9/28/17 fall investigation summary contained a statement from a CNA. The CNA said that normally R25 would have been in his recliner for the meal; but his recliner had been cleaned and was still wet and so R35 was in his wheelchair in his room. An X-ray was completed. R35 sustained a fracture of his 8th or 9th rib with no other complications. According to his 5/9/13 care plan, R35 was not to be left in his wheel chair when in his room. He was to be transferred to his bed or recliner when in his room. Fall 1/27/18 On 1/27/18 at 9:50 am R35 had wheeled himself back to his room after breakfast. He was attempting to reach for something in his closet and fell on his left side. Upon assessment, R35's left middle finger appeared broken. R35 was sent to the hospital emergency room where it was confirmed that he had sustained a fracture to his left finger. The facility's 1/27/18 fall investigation summary noted that R35 had snacks in his closet and he may have been attempting to get them. It was determined that his snacks would be placed in a closet in the hallway so that staff could assist him. The facility did implement this fall intervention. The investigation also noted that R35 would attempt to transfer himself. R35 had self-locking wheelchair brakes. It was determined that maintenance should check R35's wheelchair to ensure that the brakes were functioning correctly. On 09/10/18 at 12:05 PM, Director of Nursing - B (DON - B) was interviewed. DON - B had a copy of the work order indicating that on 1/29/18 maintenance staff had checked R35's wheelchair. However, the work order did not indicate whether of not there was a problem with R35's self-locking brakes. The DON said that the maintenance staff did not document narrative information on the work order. When asked, DON - B did not know if R35's self-locking brakes had required repair on 1/29/18. Additionally, the fall investigation summary did not address the fact that R35 was in his room in his wheelchair. It noted that he had wheeled himself to his room after breakfast. His 5/9/13 care plan directed that he be in his recliner or bed when in his room. It was not clear if staff were responsible for monitoring his whereabouts at this time and if staff should have transferred him to his bed or wheelchair. Current Observations on 9/10/18 At 8:31 am R35 was asleep in bed. His bed was not in the low position as noted on his 5/9/13 care plan. At 10:28 am R35 was seated in his recliner in his room. There was no gripper material in his recliner in accordance with his 6/1/17 care plan. CNA - T was in the room at the time and was interviewed. CNA - T confirmed that R35 did not have the gripper material in his recliner. CNA - T said that she had not transferred R35 to his recliner, but that she was in his room because R35 had turned his call light on. At 11:44 am R35 was seated in his recliner in his room. He was now seated on a cloth pad in the recliner. The surveyor was unable to see if R35 had gripper material in his recliner. Hospice CNA - U was in the room at the time. CNA - U was asked to check to see if R35 had gripper material on the seat of his recliner. CNA - U checked beneath the cloth pad and said that R35 did not have the gripper material in his recliner. At 11:57 am Hospice CNA - U showed the surveyor some black gripper material that she said she had found on the floor beneath R35's recliner. After this, CNA - U showed RN - K the black gripper material that she had found. At 12:27 PM, the surveyor observed R35 seated in his recliner in his room. Because he was seated on a cloth pad, the surveyor could not determine if the gripper material was in the recliner beneath the cloth pad. RN - K was interviewed and said that staff had placed the gripper material in R35's recliner. RN - K said that R35 will often pull the gripper material out of his recliner. On 09/11/18 at 1:45 PM, Administrator - A, DON - B, and RN Consultant - C requested to meet with the surveyor. These staff indicated that the facility had identified a problem with the incidence of falls in the facility and had initiated a Performance Improvement Plan in (MONTH) (YEAR) with updates in (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). The facility was informed that although they had identified the problem and intimated an improvement plan; the survey team had current observations of non-compliance (see above on 9/10/18 and Example #2). DON - B provided the following information related to R35's fall on 9/28/17. When R35 could not be seated in his recliner, staff had attempted to keep R35 safe by having him sit in the doorway of his room so that staff in the hallway could monitor him. 2.) R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The wandering/elopement care plan not dated includes approaches of Identify R3 as potential/actual risk to wander/elope through wandering/elopement risk assessment dated [DATE], (MONTH) refer to missing persons procedure. dated 3/24/16, Place wanderguard bracelet - on bottom of w/c (wheelchair) dated 3/24/16, Put resident picture at reception and med room. dated 3/24/16, Notify restorative therapy to place resident on wanderer list. dated 3/24/16, R3 to be monitored/observed during each shift. dated 3/24/16, Inform/educate family members/resident representative to the wanderguard system, resident safety concerns and notify MD (medical doctor) if appropriate. dated 3/24/16, Encourage R3 to participate in scheduled activities. dated 3/24/16, Encourage family to bring in familiar pictures, personal items, etc as form of comfort and/or redirection. dated 3/24/16, Remind R3 to notify staff when he is leaving the building. dated 6/14/16, Resident is to wear yellow safety vest or hat when he goes outside. dated 6/14/16, Remind R3 to dress appropriately according to the weather. dated 6/15/17, R3 has an orange flag on his wheelchair. dated 6/1/18, and Res. (Resident) to remain n (in) Freedom Park while unsupervised. With fam (family)/visitor/volunteer can go out on campus. dated 9/5/18. The behavior care plan dated 6/16/16 under problem documents Resident enjoys spending time outdoors; he self propels himself to see campus nature, including trees, the fountain and enjoys watching traffic from the safety of a parking space at the guest house. Resident owned his own tree business and spent the majority of his working life outside. At times resident displays inappropriate behaviors while out on the path such as urinating in the grass, defecating in the grass by removing his solid (soiled) brief and going beyond the designated safety areas. Under approaches documents Remind resident to wear his yellow safety vest. dated 6/16/16, Provide regular opportunities to go outdoors with/without supervision; weather permitting. dated 6/16/16. On 8/17/18 without was crossed off. Remind resident to notify staff prior to going outside. dated 6/16/16, Ask visitors to notify staff if they plan to take resident out. dated 6/16/16. Remind resident of safety concerns related to propelling to other parts of campus without supervision. dated 8/26/16, Remind resident to dress appropriately according to weather. dated 12/14/16, Remind resident of safety limits; time of day, weather, location, remaining seated, propelling forward and saying hydrated. dated 6/13/17, Resident to wear a watch in order to know the time to return for meals. dated 6/13/17, Remind resident to toilet prior to going outside and that if he is incontinent he is to return to the facility dated 5/30/18, Review risk vs benefit agreement related to going outside unsupervised; quarterly. dated 5/30/18, and Resident to remain in freedom park while unsupervised & with family/visitor/volunteer can go out on campus. The wander/elopement risk assessment dated [DATE] is checked yes for the following questions Does the resident have a pertinent [DIAGNOSES REDACTED].?, Is the resident ambulatory or able to self propel in wheelchair?, Does resident have a history of wandering?, and Does the resident wander aimlessly either goal directed or non goal directed? At risk is checked and under statement/plan documents continues to wander throughout facility. The nurse's note dated 5/16/18 documents Went out courtyard off dining room, then found a gate not lock (sic) went through it and wandered off and was by the maintenance building. The psych consult dated 5/16/18 documents staff reports pt (patient) doing well. Under treatment recommendations no change is circled with handwritten notation of no change (triangle) monitor psychology consult. The social service note dated 5/21/18 documents SW (social worker) met with R3 to review his outdoor Risk vs Benefit agreement. SW reviewed the concerns and risks of him going outside independently and discussed recommendations to decrease these risk if he decides to go outside. Resident signed agreement; please see in chart. SW also spoke with R3 about not pushing on the gate in Freedom Park and that if it were to come open he could place others at risk; he stated he wouldn't push on it anymore. R3's outdoor risk and benefit agreement dated 5/21/18 & signed by R3 documents I understand that by going outside, onto the walking path independently, I am placing myself at risk of the following: 1. Veering off the path and tipping my wheelchair or falling out of my wheelchair. 2. Losing control of my wheelchair placing me at risk of tipping over, bumping into things, hitting a car or wheeling into the pond/river. 3. Losing the strength to get myself back to the HCC (health care center). 4. Getting heat exhaustion or sunburn. 5. Losing the ability to call for assistance. 6. Getting hit by a car if I choose to wheel further than the guest house parking space towards the road. I understand that I can take the follow actions to keep staff informed of my whereabouts and prevent injury while outside independently: 1. Place my outside pass card on the concierge desk. (With Nurse at nurses station). 2. Remain on the path at all times. 3. Remain seated in my wheelchair at all times. 4. Pedal forward at all times. (except when going up slope to re-enter the building). 5. Don't go too far; avoid crossing the bridge. (No further than the laundry building-no bridge). 6. Don't go outside when weather is not permitting. 7. Wear sunscreen. 8. Do not go further than the guest house parking space. 9. Wear neon safety vest. 10. Only go out when the sun is out. No nighttime outings. (only go out between the time from of 6 am- 11. Family could bring in a cell phone for his use when outside. (walkie talkie). Surveyor noted this is the same outdoor risk and benefit R3 signed on 8/8/17. The social service note dated 5/24/18 documents SW (social worker) was informed that resident was in Freedom Park and had urinated and taken his brief off outside. SW approached R3 outside; his brief was soiled with BM (bowel movement) and laying on the grass; he was in his wheelchair. R3 informed SW that he had the urge for BM and soiled his pants so he stood up and took the brief off. SW asked R3 what he could have done differently; he stated Nothing. SW spoke with R3 about other options, that after realizing he had a BM he could have got himself back to the facility so he could inform staff and they could assist him in getting cleaned up. SW explained he dangers of him standing on his own, and the inappropriateness of him taking off a soiled brief outside where people can see him and leaving his soiled bried (brief) on the lawn outside. R3 closed his eyes and verbalized and understanding. SW spent time talking with R3 reminding him that staff here want him to continue to have freedom to go outside unsupervised but when he does things like this it makes us worry about his poor judgement and question if it's safe for him to be outside independent. SW assisted R3 into the building and took him to his unit to get cleaned up. SW updated his wife/POA-Q and explained that this behavior could very well be his dementia creating poor judgement and that there may come a time when we no longer feel it's safe for him to be outside alone. Wife/POA-Q agreed that she feels this is dementia related because he was never like this and would have never done something like that. Wife/POA-Q understood staff concern and was in agreement with whatever staff decide. The incident report dated 5/28/18 under describe the incident documents Staff observed resident propelling himself on the path along the river outside of MCHR. Staff went and returned resident to building, taken to his room for assessment Under resident's description documents When told by staff that he should not be outside alone stated Well you caught me. Under staff actions documents Returned resident to his room, body check and vs (vital signs) assessed by RN (Registered Nurse). The nurses note dated 5/30/18 includes documentation of Quarterly assessment note Resident remains alert and orientated to person, place, and time. He has some short term memory loss at times due to his dementia and at times does not make safe choices. The wander/elopement risk assessment dated [DATE] is checked yes for the following questions Does the resident have a pertinent [DIAGNOSES REDACTED].?, Is the resident ambulatory or able to self propel in wheelchair?, Does resident have a history of wandering?, and Does the resident wander aimlessly either goal directed or non goal directed? At risk is checked and under statement/plan documents wanderguard in place. The psych consult dated 6/16/18 under narrative documents Staff reports pt (patient) with lack of insight on venturing outside of bldg (building) on own, lack of safety awareness. Under treatment recommendations no change is circled with handwritten notation of Pt. (patient) with signf (significant) lack of safety awareness re (regarding) activities around ___. On 9/11/18 at 2:29 p.m. Surveyor asked RN (Registered Nurse) Manager-J if she was able to read the word after around. RN Manager-J wasn't able to determine what this word. Surveyor noted after this psych consult there was no change in R3's wandering or behavior care plan and R3 was allowed to continue to go out on the campus unsupervised. The nurses note dated 6/17/18 documents Resident trying to use front door to exit building multiple times on PM (evening) shift. Multiple staff redirected resident back onto the unit. Lots of wandering onto other halls through out the shift. Got out of bed and redressed 3 times and was wheeling backwards in the hallway. Behaviors were redirectable. Resident currently in bed sleeping, no complaints of pain or discomfort noted. R3's POA (power of attorney) was activated 6/22/18. The nurses note dated 6/29/18 documents Due to extreme heat advisory this weekend, wander guard placed on resident's wheelchair. Wife notified. The 72 hour monitoring sheet dated 7/11/18, 7/12/18 & 7/13/18 under day 2 7/12/18 for day shift documents Pt (patient) goes outside frequently without telling staff. The nurses note dated 7/15/18 documents Resident was outside in freedom park and took of (off) brief and shorts to defecate on the grass and urinate on sidewalk. Resident was asked why he didn't come in and ask for assistance and he stated he would not have made it in time. Resident assisted back into the building and toileted. Resident also making statements about making it all the way to 18 and 67 today. Not sure if resident actually was outside of the campus or not because he would not answer when questioned about that statement. The nurses note dated 7/30/18 documents Resident OOB (out of bed) at 0120 (1:20 a.m.), went in cafeteria and opened one of the alarmed door, even after just being told that the doors are alarmed. Back in bed at this time. The nurses note dated 8/17/18 documents Resident was on campus grounds per his care plan and he exceeded his boundaries and left campus grounds. He propelled his wheelchair 30-40 feet from campus driveway and was on gravel shoulder of roadway. Resident was returned to grounds by staff within four minutes, no injury or negative effect to resident. Meeting held with COO (Chief Operating Officer), this writer, wife (HCPOA) (health care power of attorney) and resident. Resident stated his boundaries and verbalized that he purposefully broke them because he wanted to see 18 & 67. Resident understands the possible danger of his decision to exit the campus and stated I know it was not safe. Resident agreed for his safety to use only freedom park unless he is accompanied by his wife or a friend/volunteer is supervising him. Risk benefit will be updated with above to include resident's agreement to remain in freedom park for his safety. The Facility self reported this incident to the State agency which includes a statement from Lifestyles Specialist-R dated 8/20/18 which documents On Friday, (MONTH) 17th (YEAR), I was driving down hwy (highway) 18 when I say (saw) R3 going down the gravel on the side of the road. I pulled my car over and jumped out to see where he was going. He stated, I'm going to Church. On 9/5/18 at 9:07 a.m. during the screen process, Surveyor entered R3's room to speak with R3. Surveyor observed R3 sitting in a wheelchair at the sink in his room. R3 informed Surveyor he had just finished shaving. During the conversation with R3, R3 informed Surveyor he had gone down to Highway 67 & Highway 18. Surveyor asked what he was doing at Highway 67 & Highway 18. R3 informed Surveyor he was looking at traffic. Surveyor inquired if there is a sidewalk by the highway. R3 informed Surveyor there isn't a sidewalk along the road but there is a side walk on campus. R3 stated they weren't really happy. Surveyor asked R3 when he went down to Highway 67 & 18. R3 informed Surveyor about a week ago and a month ago. Surveyor observed a bright yellow vest on a chair in R3's room and asked R3 if he wears this vest when get goes outside. R3 replied sometimes. On 9/5/18 at 10:24 a.m. Surveyor asked CNA (Certified Nursing Assistant)-F if R3 is allowed to go outside by himself. CNA-F explained R3 can go to the freedom park which is an enclosed area outside the dining room but can't go out the front door. CNA-F informed Surveyor R3 knows where he can go. Surveyor asked CNA-F if R3 ever went out the front door. CNA-F informed Surveyor not that she was aware of. On 9/5/18 at 12:20 p.m. Surveyor observed R3 sitting in his wheelchair outside in freedom park. On 9/06/18 at 7:36 a.m. Surveyor observed R3 sitting in his wheelchair in the dining room. Surveyor observed there is an orange flag attached to R3's wheelchair and there is an alarm on the left side of R3's wheelchair. On 9/11/18 at 8:04 a.m. Surveyor asked US (Unit Secretary)-G if R3 lets her know when he goes outside. US-G replied no and explains she knows R3 is going outside as the alarm sounds when he goes through the door and then she shuts off the alarm. US-G informed Surveyor other residents lets her know when they are going outside. US-G informed Surveyor she is able to monitor how long R3 is outside as the alarm will go off when he comes back in. On 9/11/18 at 10:19 a.m. Surveyor met with DON (Director of Nursing)-B to discuss the nurses note dated 5/16/18. DON-B informed Surveyor R3 did not technically elope as he used a delayed egress gate on freedom park and R3's care plan has he can self propel on walking path. DON-B stated that gate is connected to walking path and is alarmed. This alarm activates at their CBRF (community based residential facility). DON-B informed Surveyor R3 should have come in and gone out front door. DON-B indicated they don't want R3 to use the gate as its for emergency purposes. DON-B informed Surveyor the staff from the CBRF responded to the alarm, saw R3 and knew R3 was allowed to be outside. Surveyor then asked about the incident report dated 5/28/18 and asked if R3 was allowed to be outside unsupervised why did staff bring him back in. DON-B informed Surveyor the nurse wasn't following the care plan. Surveyor asked about the incident when R3 was found on the gravel along Highway 18. DON-B informed Surveyor they considered this incident an elopement because R3 left their campus. R3 had crossed the bridge to the assisted living and left their campus. Surveyor inquired why R3 has a wanderguard on his wheelchair. DON-B informed Surveyor they were concerned about the temperatures when it got so hot this summer. DON-B informed Surveyor R3 continues to have the wanderguard because he's not allowed to go outside unsupervised and can only go to the freedom park. DON-B indicated R3 has agreed to this. Surveyor asked if anyone reviews the psych consults. DON-B replied yes and informed Surveyor the nurse manager or nurse on the floor would. Surveyor inquired why there wasn't any change in R3's plan of care in regards to him being allowed to go outside unsupervised after the psych consult on 6/16/18 documented R3 has significant lack of safety awareness. DON-B informed Surveyor they considered this but it as important for him to go outside both to him and his power of attorney. Surveyor informed DON-B Surveyor had reviewed the wander/elopement risk assessment dated [DATE] & 6/1/18 which indicates R3 is at risk. DON-B informed Surveyor she can't say R3 wasn't at risk but it was an important part of his care plan. Surveyor asked when R3 was allowed to go outside on the campus by himself did he have to sign out. DON-B replied yes. Surveyor asked what did R3 have to do. DON-B informed Surveyor R3 had to verbally alert the staff he was going out. Surveyor asked if there was a sign out form. DON-B replied no and explained they tried that at first but R3 wouldn't do it. DON-B informed Surveyor the wanderguard worked because he would alarm and they would know R3 was going out. Surveyor asked DON-B on 5/16/18 & 5/28/18 did R3 let anyone know he was going outside. DON-B informed Surveyor she didn't know. On 9/11/18 at 10:50 a.m. Surveyor along with another member of the survey team accompanied DON-B outside to the Freedom park where R3 exited through the emergency gate. DON-B then showed Surveyors the maintenance shop where she was told R3 went which was located around the corner from the freedom park. The Surveyors and DON-B walked along the long path through the campus to the bridge across the river which R3 crossed to the assisted living section of the campus. The Surveyors and DON-B walked through the assisted living parking lot which has camera to the entrance along Highway 18. DON-B showed Surveyors the gravel area along Highway 18 where R3 was found by staff. Surveyor noted R3 was located approximately 100 feet from the intersection of Highway 18 and 67. This area has been under construction with construction vehicles and lane closures. DON-B informed Surveyors across Highway 18 from where R3 was located is the church where R3 and his wife went. On 9/11/18 at 12:56 p.m. Surveyor informed POA-Q Administrator-A had informed Surveyor POA-Q would like to speak with Surveyor. POA-Q informed Surveyor the care is outstanding and staff are so kind. POA-Q indicated her husband loves to be outside and sometimes he would go too far. Surveyor asked if she knew why R3's POA was activated in June. POA-Q informed Surveyor it was just a formality as she's been the one the facility would speak to and they wanted to have it in print. Surveyor asked if the Facility spoke with her about her husband going outside without anyone. POA-Q informed Surveyor they have been talking about this since last summer because her husband would like to go down to the fountains. POA-Q indicated that she would take her husband there and last summer they decided it was better if someone was with him to go down to the fountains. POA-Q informed Surveyor they wanted her husband to enjoy the outside. Surveyor inquired which summer this was discussed. POA-Q informed Surveyor (YEAR). Surveyor then asked POA-Q about when R3 went through the gate to the maintenance shop around the corner from the freedom park. POA-Q informed Surveyor the maintenance shop her husband would go to is through the woods and across the street from the corn fields. Surveyor asked if the corn field is located across from Highway 18. POA-Q replied yes. POA-Q explained her husband likes to look at the corn field and sometimes he would be tired so the maintenance men would bring him back but it's safe. Surveyor asked POA-Q about when her husband was found by the river on 5/28/18. POA-Q stated to her husband would have been fine if you had someone with you. We didn't want you to do that that's why we worked with the staff. POA-Q emphasized to Surveyor how much the facility meant to them. On 9/11/18 at 3:35 p.m. Surveyor was provided with a social service note dated 9/11/18 for event date 6/22/18 which documents Late Entry: SW met with POA-Q, Res. Rep (resident representative) on either Friday 6/22 or Monday 6/25 to discuss the fact that R3's HCPOA (health care power of attorney) was activated on 6/22/18. SW explained to POA-Q what this meant and that moving forward we will continue to talk with her about any medical changes or updates and she would now be the one to give consent to start any new treatment. SW spent time talking with POA-Q about R3 continuing to go outside unsupervised; she stated she doesn't want to change anything we've put in place at this time. POA-Q commented that If he were to die outside, he would be dying in the place that he loved. 3.) R37's ADL (activities daily living) Function/Rehab Potential care plan not dated includes an approach dated 1/10/14 of Transfer ability and assistive device- 1 assist, GB (gait belt) & sara steady. R37's Resident interdisciplinary care plan dated 6/21/18 under the transfer section is checked for gait belt and assist of one (1). R37's quarterly MDS (minimum data set) with an assessment reference date of 7/19/18 documents R37 has short & long term memory problems and is moderately impaired for cognitive skills for daily decision making. R37 is coded as requiring extensive assistance with two plus person physical assist for transfers. On 9/6/18 at 7:18 a.m. Surveyor entered R37's room with CNA (Certified Nursing Assistant)-L. CNA-L raised the height of R37's bed up and informed R37 she has her warm clothes. CNA-L washed her hands, placed gloves on, wet a disposable cloth and informed R37 she was going to change her underwear. CNA-L unfastened R37's product, washed R37's frontal perineal area, positioned R37 on her right side and washed her buttocks. CNA-L removed her gloves, washed her hands, and placed gloves on. CNA-L applied barrier cream and incontinence product on R37, removed her gloves telling R37 she would get her warm clothes and washed her hands. CNA-L placed jeans, socks & shoes on R37, placed the sara steady over by the bed and sat R37 up in bed so R37 was sitting on the edge of the bed. CNA-L asked R37 if she was ok and informed R37 she was going to put a sweater on her. CNA-L removed the gown and placed a sweat shirt on R37. CNA-L placed the sara steady lift in front of R37, locked the brakes on the sara steady lift, and told R37 to hold onto the bar. CNA-L then assisted R37 to stand by holding under her arm and back. CNA-L pulled up R37's pants, placed the seat pads down which supported R37's buttocks and informed R37 she was going to get in her wheelchair. R37 wheeled the sara steady lift over to the wheelchair, placed the seat pads back up, and assisted R37 with sitting in the wheelchair. Surveyor observed during this observation CNA-L did not place a gait belt around R37. The CNA (Certified Nursing Assistant) worksheet last revised on 9/10/18 under column 4 documents Transfers and Ambulation/Mobility: Transfer ability and assistive device- 1 Assist with sara steady for all transfers and toileting. Non-ambulatory. Transfer ability and assistive device- 1 assist, GB (gaitbelt) & sara steady Use 1 assist, GB & sara steady. On 9/10/18 at 10:10 a.m. Surveyor asked CNA-F when they transfer R37 with the sara steady lift do they use a gait belt. CNA-F replied yes and explained that R37 pulls up while holding onto the lift and they hold onto the gait belt to help R37 to stand up.

Based on observation of 1 of 1 medication storage rooms, interviews and policy reviews, the facility did not ensure that medications are disposed of properly upon resident discharge from the facility. 2 Residents (R66 and R611's) of 70 resident's medications were found to still be in the medication refrigerator after the residents had been discharged . Findings include; On 09/11/18 at 8:25 a.m., Surveyor made observations with LPN-I (licensed practical nurse) of the medication storage room located on the rehab unit. Noted in the medication refrigerator was a box that contained the medication Cathflo [MEDICATION NAME] 2mg intra-catheter solution ( medication used to clear blood clots in catheters) identified by the label on the front, to belong to R611. When questioned, LPN-I was not sure as to the discharge date of R611. A review of the EHR (electronic health record) it was noted that R611 had been discharged from the facility to home on 05/11/18 and the medication remains in the refrigerator as of this date. The second observation noted Basagler 100u/ml kwick pen (used for insulin injection) identified to belong to R66 who was discharged to home on 09/10/18 around 12:09 p.m. On 09/11/18 at 9:30 a.m. Surveyor requested to review the facility procedure for the disposition of medications to which the DON stated, we return all medications to the pharmacy. Surveyor shared observations with the DON at this time. At 12:30 p.m. DON provided a un-dated copy of Admissions, Transfers and Discharge Rights Policy and Procedure and under the procedure for discharge summary #2.c.iv. it states All non narcotic medications will be returned to pharmacy. The policy does not identify a time line for the return of the medications to the pharmacy.

Based on interview and record review, the facility did not ensure that 1 (R265) of 5 reviewed residents that were receiving a [MEDICAL CONDITION] medication, were free from unnecessary drugs. * R265 was administered a PRN (as needed) anti-anxiety medication that did not have a documented rationale or that indicated the duration of the PRN order beyond 14 days. Findings include: 1. R265 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R265 admission MDS (Minimum Data Set) dated 8/24/18 documents A BIMS (Brief Interview for Mental Status) score of 15, indicating that R265 is cognitively intact. Section E (Behavior) documents under Section E0200 (Behavioral Symptoms) that R265 displays no behavior symptoms as described in Section E0200. R265's [MEDICAL CONDITION] Drug Use CAA (Care Area Assessment) with a date of 8/24/18 documents under the Description of Problem section, Resident triggered for [MEDICAL CONDITION] drug use because she does receive an antianxiety medication for a [DIAGNOSES REDACTED]. R265's physician order [REDACTED]. Give 1 mg (milligram) by mouth nightly as needed for anxiety. R265's (MONTH) MAR (Medication Administration Record) documents that R265 was currently receiving and received the above medication on 9/1/18, 9/2/18, 9/3/18, 9/5/18, 9/8/18 and 9/9/18. Surveyor was unable to locate any documentation in R265's medical record that documented a duration and or rationale for R265's continued PRN [MEDICATION NAME] use beyond 14 days. On 9/11/18 at 1:39 p.m., Surveyor informed RN (Registered Nurse) Manager- E of the above findings. Surveyor asked RN Manager-E if R265 had a documented rationale or physician documentation for R265's continued PRN use of the anti-anxiety medication [MEDICATION NAME] beyond 14 days as of 9/1/18. RN Manager-E reviewed R265's medical record in front of Surveyor and informed Surveyor that he could not locate any documentation that documented a rationale for R265's continued PRN [MEDICATION NAME] use as of 9/1/18. On 9/11/18 at 2:56 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. DON-B informed Surveyor that she could provide no further information as to why R265 had no documented rationale or a physician documentation for R265's continued PRN use of the anti-anxiety medication [MEDICATION NAME] beyond 14 days as of 9/1/18.

Based on observation and interview the Facility did not provide a sanitary environment to prevent the development and transmission of infection for 1 (R38) of 1 Residents with an indwelling catheter. *R38's Foley catheter bag was observed on the floor next to the personal type recliner without a barrier. Findings include: During R38's record review Surveyor noted R38 was transferred to the hospital on [DATE] and subsequently admitted with a [DIAGNOSES REDACTED]. On 9/10/18 at 10:08 a.m. Surveyor observed R38 sitting in a personal type recliner in his room. On the floor by the recliner on the right side Surveyor observed the urine collection bag. Surveyor observe the collection bag is resting directly on the floor and is there was no barrier observed. On 9/10/18 at 11:11 a.m. Surveyor observed R38 asleep in his personal type recliner. Surveyor observed the urine collection bag is now attached to the garbage can. On 9/10/18 at 1:14 p.m. Surveyor observed R38 sitting in a personal type recliner in his room. On the floor by the recliner on the right side Surveyor observed the urine collection bag. Surveyor observe the collection bag is resting directly on the floor and is there was no barrier observed. On 9/10/18 at 3:34 p.m. Surveyor observed R38 sitting in a personal type recliner in his room. Surveyor observed the urine collection bag continues to be on the floor by R38's recliner. Surveyor observe the collection bag is resting directly on the floor and is there was no barrier observed. On 9/11/18 at 12:35 p.m. Surveyor asked RN (Registered Nurse) Manager-J if R38's Foley collection bag should be directly on the floor. RN Manager-J replied no and explained the collection bag should hand on the bed frame. Surveyor informed RN Manager-J of the observations of R38's urine collection bag being on the floor. RN Manager-J asked Surveyor if there was a barrier. Surveyor replied no.

Based on interview and record review, the Facility did not ensure 1 (R3) of 1 Residents was free of significant medication errors. On 7/12/18 R3 was prescribed [MEDICATION NAME] 20 mg 1 hour before meal daily. The order was incorrectly transcribed and R3 received [MEDICATION NAME] 20 mg three times a day before meals. R3 received 37 extra doses of [MEDICATION NAME] 20 mg before the error was discovered on 8/1/18. Findings include: The physician's orders [REDACTED]. - dyspepsia/dysphagia. (2) CBC (complete blood count) with next lab draw. Review of R3's (MONTH) (YEAR) MAR (medication administration record) revealed R3 received [MEDICATION NAME] 20 mg twice on 7/12/18 and [MEDICATION NAME] 20 mg three times a day from 7/13/18 through 7/31/18 with the exception on the evening shift on 7/14/18, 7/18/18, & 7/24/18 when R3 refused this medication. R3 received 35 extra doses of [MEDICATION NAME] 20 mg in (MONTH) (YEAR). R3 received 36 extra doses of [MEDICATION NAME] 20 mg in July. Review of R3's (MONTH) MAR indicated [REDACTED]. R3 received 1 extra dose of [MEDICATION NAME] 20 mg in August. APNP (Advanced Practice Nurse Prescriber)-O progress note dated 8/1/18 includes documentation of Entry error/ [MEDICATION NAME] ordered po qd 1 hr prior to meal. Entered as tid (three times daily). D/C (discontinue) [MEDICATION NAME] 20 mg po tid. Start [MEDICATION NAME] 20 mg qd. The incident report dated 8/1/18 documents 7/12/18 [MEDICATION NAME] 20 mg po qd before meals was transcribed as [MEDICATION NAME] 20 mg po tid before meals. Error was discovered by (APNP-O) 8/1/18 when reviewing meds with POAHC (Power of Attorney Health Care). Under staff actions at time of incident documents Med (medication) error was corrected and rewritten correctly 8/1/18. DON (Director of Nursing) aware and this writer spoke with US (Unit Secretary)-G who was the original transcriber. Reviewed order transcription with US-G. Co-signer/2nd signature was RN (Registered Nurse)-P. On 9/11/18 at 12:40 p.m. Surveyor spoke with RN Manger-J to inquire what the process is when a physician or NP (nurse practitioner) writes an order. RN Manager-J explained US-G can transcribe the order for the first part and the second signature is a nurse who makes sure everything is accurate. RN Manager-J informed Surveyor the evening supervisor spoke with RN-P about the order and reviewed the process as the second signature should be the fail safe. Surveyor asked if other nurses were inserviced regarding the process for physician orders. RN Manger-J informed Surveyor to her knowledge only RN-P was inserviced.

Based on record review and interview the Facility did not notify the resident and resident representative of the transfer or discharge in writing for 1 (R38) of 2 Residents who where transferred to the hospital. Findings include: R38's nurse's note dated 6/30/18 documents Resident had a change in condition this shift. Increased SOB (shortness of breath) at rest and even worse with activity. Resident needs to conserve energy and should not be self propelling to meals anymore. CNA's aware of this change and resident agreed. Resident also not interested in eating meals at this time. VSS (vital signs stable). Audible wheezes noted during lung assessment. RR(respiratory rate) 24 95% on room air, BP (blood pressure) 144/69 HR (heart rate) 67 Tempt (temperature) 97.8. NP (Nurse Practitioner)-M contacted and voice message left. Resident did not want daughter contacted at this time. The nurse's note dated 6/30/18 documents Resident's vital signs declined. Resident in agreement with transport to hospital for further evaluation. Received order for transport from NP and Daughter updated. 911 called. The nurse's note dated 7/1/18 documents OMH (Oconomowoc Memorial Hospital) called and res (resident) status questioned- res has been admitted -status reflected in census. The nurse's note dated 7/1/18 documents Writer called OMH to ask RN (Registered Nurse) about status of resident. RN on his unit relayed that he has a UTI (urinary tract infection) but seems to be doing well and is receiving IV (intravenous) abx (antibiotic). The nurse's note dated 7/5/18 documents Resident returned to facility. Discharge medications verified with (NP-M) and faxed to pharmacy. On 9/10/18 at 3:32 p.m. Surveyor asked LPN (Licensed Practical Nurse)-N if she has to transfer a Resident to the hospital would she notify the resident and their representative in writing the reason for transfer/discharge. LPN-N informed Surveyor that's not something she is aware of. LPN-N informed Surveyor she would call the doctor to send them out and call their family members. On 9/10/18 at 4:07 p.m. Surveyor asked SW (Social Worker)-H if she is involved with notifying the resident and their representative in writing the reason for transfer/discharge to the hospital. SW-H replied no and informed Surveyor that would be nursing. On 9/11/18 at 9:59 a.m. Surveyor asked US (Unit Secretary)-G who would notify the resident and their representative in writing the reason for the transfer/discharge to the hospital. US-G informed Surveyor RN (Registered Nurse) Manager-J. On 9/11/18 at 12:24 p.m. Surveyor asked RN Manager-J where Surveyor would be able to locate the written transfer notice to R38 and his representative when R38 was transferred to the hospital on [DATE]. Surveyor informed RN Manager-J this transfer notice would include the reason for transfer/discharge, date of transfer/discharge, location of transfer/discharge and a statement regarding the appeal rights. RN Manager-J informed Surveyor she will get back to Surveyor. On 9/11/18 at 12:49 p.m. Surveyor asked R38 if he remembers when he was transferred to the hospital on [DATE] if he was provided with a written notice which would include the reason, date, location for the transfer and his appeal rights. R38 informed Surveyor he couldn't remember. On 9/11/18 at 12:52 p.m. RN Manager-J informed Surveyor she doesn't have anything regarding the transfer notice and this is something they have will to inservice the nurses on. RN Manager-J then asked Surveyor if this is part of the mega rule.

Based on staff interview and record review the Facility did not provide 1 (R38) of 2 Residents reviewed for bed hold notice and policy their bed hold notice and policy until 5 days after discharge. Findings include: R38's nurse's note dated [DATE] documents Resident had a change in condition this shift. Increased SOB (shortness of breath) at rest and even worse with activity. Resident needs to conserve energy and should not be self propelling to meals anymore. CNA's aware of this change and resident agreed. Resident also not interested in eating meals at this time. VSS (vital signs stable). Audible wheezes noted during lung assessment. RR(respiratory rate) 24 95% on room air, BP (blood pressure) ,[DATE] HR (heart rate) 67 Tempt (temperature) 97.8. NP (Nurse Practitioner)-M contacted and voice message left. Resident did not want daughter contacted at this time. The nurse's note dated [DATE] documents Resident's vital signs declined. Resident in agreement with transport to hospital for further evaluation. Received order for transport from NP and Daughter updated. 911 called. The nurse's note dated [DATE] documents OMH (Oconomowoc Memorial Hospital) called and res (resident) status questioned- res has been admitted -status reflected in census. The nurse's note dated [DATE] documents Writer called OMH to ask RN (Registered Nurse) about status of resident. RN on his unit relayed that he has a UTI (urinary tract infection) but seems to be doing well and is receiving IV (intravenous) abx (antibiotic). The social service note dated [DATE] documents Resident on unpaid bed hold through T-19 up to 15 days; if beyond 15 days family will re-evaluate. Surveyor noted R38's paper medical record contained a Bed hold policy letter which is checked for I wish to have bed held and understand it will cost ___ per day. There is a handwritten notation for the cost of T-19 for up to 15 days. Will reevaluate if beyond 15 days. For signature documents R38's representative via telephone and date documents [DATE]. The nurse's note dated [DATE] documents Resident returned to facility. Discharge medications verified with (NP-M) and faxed to pharmacy. On [DATE] at 4:07 p.m. Surveyor informed SW (Social Worker)-H during R38's record review Surveyor noted R38 was transferred to the hospital on [DATE] and noted the bed hold policy letter & her social service note dated [DATE] and inquired why this wasn't done until 5 days after discharge and on the date when R38 was readmitted back to the Facility. SW-H informed Surveyor she knows she was off on the 4th, looked at her charting in the computer, and informed Surveyor she doesn't have anything documented as to why it wasn't done until the 5th. Surveyor asked SW-H if she was responsible for the bed hold notification. SW-H replied yes. SW-H informed Surveyor she keeps notes in a notebook, will see if she has any notes as to why notification wasn't done until (MONTH) 5th and get will back back to the Surveyor. On [DATE] at 8:25 a.m. SW-H informed Surveyor she doesn't have any information as to why she didn't notify R38's representative until (MONTH) 5th. SW-H informed Surveyor if a Resident is transferred to the hospital over the weekend her process is to call the Resident's representative the first business day after the transfer. SW-H also informed Surveyor there is a bed hold letter in the packet that goes to the hospital. On [DATE] at 9:59 a.m. Surveyor spoke with US (Unit Secretary)-G regarding when a Resident is transferred to the hospital. US-G informed Surveyor when a resident is transferred to the hospital they are suppose to send the Resident's face sheet, bed hold policy notice & letter, all their insurance information, power of attorney information and CPR (cardiopulmonary resuscitation) paperwork. Surveyor informed US-G R38 was transferred to the hospital and then admitted on [DATE] and asked where it would be documented that R38 or his representative was provided with the bed hold notice & policy. US-G informed Surveyor there should be a note in R38's record indicating the paper work was sent with him. US-G looked at the computer and informed Surveyor there's nothing and indicated there isn't a note the paperwork was sent with R38. Surveyor asked US-G if there should be a note written. US-G replied yes and explained when a Resident is transferred/discharged during the day she or the nurse manager does it but if transfer/discharge is on the evening or night shift the nurses are responsible. Surveyor informed US-G R38 was transferred on the evening shift on [DATE]. On [DATE] at 12:49 p.m. Surveyor asked R38 if he remembers when he was transferred to the hospital on [DATE] if he was provided with the Facility's bed hold notice & policy R38 informed Surveyor he couldn't remember.

Based on observation and interview the Facility did not ensure that services were provided to meet professional standards of quality for 1 (R38) of 1 Resident receiving an inhaler. R38 was not instructed to rinse his mouth after inhaling [MEDICATION NAME] 250/50. Findings include: On 9/6/18 at 7:56 a.m. Surveyor observed RN (Registered Nurse)-K prepare R38's medication which consisted of one tablet of [MEDICATION NAME] 600 mg (milligrams), one tablet of Calcium 600 mg & Vitamin D IU, one tablet of [MEDICATION NAME], 2 tablets of [MEDICATION NAME] 325 mg, one tablet of [MEDICATION NAME] 5 mg, one tablet of [MEDICATION NAME] 20 mg, one tablet of Vitamin B-12 100 mcg (micrograms) and [MEDICATION NAME] 250/50. At 7:59 a.m. Surveyor verified with RN-K there were eight pills in the medication cup. After verifying the number of pills, RN-K wheeled R38 into the hall bathroom. At 8:00 a.m. RN-K administered [MEDICATION NAME] 250/50 to R38 and then placed the [MEDICATION NAME] back in the medication cart. RN-K did not have a glass of water with her to have R38 swish and spit after inhaling the [MEDICATION NAME]. At 8:02 a.m. R38 administered the medication whole from a teaspoon with apple juice. After R38 received his medication, RN-K washed her hands. On 9/10/18 at 9:50 a.m. Surveyor asked RN-K after she administers [MEDICATION NAME] to a Resident does she have them swish and spit. RN-K informed Surveyor she doesn't have them spit but has them at least drink something. Surveyor informed RN-K Surveyor did not observe her instruct R38 to swish and spit after she administered [MEDICATION NAME] to him. RN-K replied oh. According to www.[MEDICATION NAME].com, under the section How should I use [MEDICATION NAME] Diskus documents Rinse your mouth with water without swallowing after each dose of [MEDICATION NAME] DISKUS. This will help lessen the chance of getting a yeast infection (thrush) in your mouth and throat. On 9/10/18 at 2:49 p.m. during the daily exit conference Surveyor asked for the Facility's policy and procedures regarding inhaler administration. Surveyor then informed Administrator-A and DON (Director of Nursing)-B of the above observation. On 9/11/18 at 9:59 a.m. DON-B provided Surveyor with Best Practice Guidelines for Medication Administration which is not dated. Under Specific Guidelines for Safe and Accurate Medication Administration documents for #9 Inhalers come in three varieties: [MEDICATION NAME][MEDICATION NAME]/[MEDICATION NAME], and steroids. Sequence of inhaler administration- [MEDICATION NAME][MEDICATION NAME] are given first, [MEDICATION NAME]/anticolinergics are given second. Steroid inhalers are always given last and never on a PRN (as needed) basis. Immediately following inhalation of the steroid, the resident needs to rinse their mouth thoroughly with water.

Based on observation, interview and record review the Facility did not ensure 1 (R38) of 1 Residents who are unable to shave themselves receives assistance with their hygiene. Findings include: The quarterly MDS (minimum data set) with an assessment reference date of 7/25/18 and signed as complete on 8/2/18 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R38 is coded as requiring extensive assistance with one person physical assist for hygiene. On 9/5/18 at 11:06 a.m. Surveyor asked R38 who was sitting in a personal type recliner in his room if staff helps him with his ADL's (activities daily living). R38 informed Surveyor he can't do anything himself. On 9/5/18 at 11:17 a.m. Surveyor informed R38 Surveyor noted he has a growth of facial hair and asked if he likes to be clean shaven. R38 replied I would like that and then informed Surveyor some of the nurses shave him. On 9/5/18 at 1:44 p.m. Surveyor observed R38 sitting in a personal type recliner in his room with his eyes closed. Surveyor observed R38 has not been shaved. On 9/5/18 at 3:34 p.m. Surveyor observed R38 sitting in a personal type recliner in his room watching TV. Surveyor observed R38 continues to have facial hair and has not been shaved. On 9/6/18 at 7:09 a.m. Surveyor observed R38 awake in bed on his back. Surveyor observed R38 continues to have a growth of facial hair and was not shaved on 9/5/18. On 9/6/18 at 11:25 a.m. Surveyor observed R38 wheeling himself out of his room and down the hallway. Surveyor observed R38 continues to have a growth of facial hair and has not been shaved. On 9/6/18 at 2:35 p.m. Surveyor observed R38 sitting in a personal type recliner in his room. Surveyor observed R38 continues to have a growth of facial hair and has not been shaved. Surveyor informed R38 Surveyor had heard he had a shower this morning. R38 replied yes. Surveyor asked R38 if the CNA (Certified Nursing Assistant) spoke to him about shaving him. R38 replied no. On 9/6/18 at 2:38 p.m. Surveyor asked CNA-F if she gave R38 a shower this morning. CNA-F replied yes. Surveyor asked CNA-F who would be responsible for shaving R38. CNA-F replied they are and explained she typically shaves Residents in the morning. Surveyor informed CNA-F R38 had informed Surveyor he likes to be clean shaven and observed R38 still has a growth of facial hair. CNA-F stated to Surveyor did I forget? I can shave him before I leave.

Based on observation, interview, and record review, the facility did not ensure that 2 of 2 residents (R5, R38) were provided with care to prevent pressure injuries. R5 was seated in her Broda wheelchair for approximately 6 hours without being repositioned in accordance with her care plan. R38 was observed seated in his recliner without a pressure relief cushion. Findings include: 1.) R5 is [AGE] years old and has a [DIAGNOSES REDACTED]. The Care Area Assessment summary dated 12/12/17 noted that R5 had a significant decline and had elected hospice care. She was dependent for transfers and mobility. R5 was incontinent and had a history of [REDACTED]. She was noted to be at risk for further decline. R5's Pressure Ulcer care plan was dated 5/31/17. It noted that she was to be turned and repositioned every 2-3 hours and as needed while in bed. The following observations were made on 9/10/18, showing that R5 had not been repositioned for 6 hours from 8:31 am - 2:31 PM. At 8:31 am, R5 was up in her Broda chair in the dining room. She was eating breakfast. At 9:20 am, R5 was up in her Broda chair in her bedroom. At 10:07 am, R5 was up in her Broda chair in her bedroom. At 10:28 am, R5 was up in her Broda chair in her bedroom. At 11:43 am, R5 was up in her Broda chair in her bedroom. At 12:23 PM R5 was up in her Broda chair in the dining room. She was eating lunch. At 1:03 PM, R5 was up in her Broda chair in the dining room. At 1:23 PM, R5 was up in her Broda chair in the dining room. At 2:31 PM R5 was lying down in her bed in her room. CNA - T and Pool CNA - S were present and reported that they had just laid R5 down. When asked, CNA - T and CNA - S said that they had not gotten R5 out of bed this morning. When asked if they were assigned to care for R5, the CNAs reported that they were working as a team and responsible for assisting all residents who required 2 staff for daily cares. CNA - T and CNA - S confirmed that they had not repositioned R5 until now. 2.) The quarterly MDS (minimum data set) with an assessment reference date of 7/25/18 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R38 requires extensive assistance with two plus person for bed mobility, requires extensive assistance with one person physical assist for transfer, ambulation, and toilet use. R38 is checked as having an indwelling catheter and is always incontinent of bowel. R38 is at risk for developing pressure injuries and is coded as not have any pressure injuries. Under skin and ulcer treatments pressure reducing device for chair and pressure reducing device for bed are checked. The Braden assessment dated [DATE] has a score of 18. According to this assessment if a resident has a score of 16 or less consider him/her high risk for pressure ulcer development. On 9/5/18 at 11:11 a.m. Surveyor observed R38 sitting in a personal type recliner in his room. Surveyor asked R38 if he has a cushion in the recliner. R38 replied no On 9/5/18 at 11:34 a.m. Surveyor checked R38's recliner after he left the room. Surveyor did not observe a pressure relieving cushion in the recliner. On 9/5/18 at 1:44 p.m. Surveyor observed R38 sitting in a personal type recliner in his room. Surveyor did not observe a pressure relieving cushion in the recliner. On 9/5/18 at 3:34 p.m. Surveyor observed R38 sitting in a personal type recliner in his room watching TV. Surveyor did not observe a pressure relieving cushion in the recliner. On 9/6/18 at 11:22 a.m. Surveyor observed R38 sitting in a personal type recliner in his room. Surveyor did not observe a pressure relieving cushion in the recliner. On 9/6/18 at 2:36 p.m. Surveyor observed R38 sitting in a personal type recliner in his room. Surveyor did not observe a pressure relieving cushion in the recliner. Surveyor asked R38 if anyone ever spoke to him about having pressure relieving cushion in his recliner. R38 replied no. The CNA (Certified Nursing Assistant) worksheet last revised 9/10/18 documents for skin precautions Turn and reposition resident every 2-3 hours while in bed/chair. Pressure reduction sitting/W/C (wheelchair) surface, type & date applied: wc cushion applied on admit. Elevate heels off the bed. On 9/10/18 at 7:17 a.m. Surveyor checked R38's personal type recliner and did not observe a pressure relieving cushion in the chair. On 9/10/18 at 8:52 a.m. Surveyor observed R38 sitting in the personal type recliner in his room with his eyes closed. Surveyor did not observe a pressure relieving cushion in the recliner. After leaving R38's room Surveyor observed R38's wheelchair in the hallway with a pressure relieving cushion in the wheelchair. On 9/10/18 at 10:08 a.m. Surveyor observed R38 continues to be sitting in the personal type recliner in his room with his eyes closed. Surveyor did not observe a pressure relieving cushion in the recliner. On 9/10/18 at 11:10 a.m. Surveyor observed R38 continues to be sitting in the personal type recliner in his room. Surveyor did not observe a pressure relieving cushion in the recliner. R38's wheelchair continues to be in the hallway with a pressure relieving cushion in the wheelchair. On 9/10/18 at 1:14 p.m. Surveyor observed R38 sitting in the personal type recliner in his room. Surveyor did not observe a pressure relieving cushion in the recliner. On 9/10/18 at 3:34 p.m. Surveyor observed R38 continues to be sitting in the personal type recliner in his room watching tv. Surveyor did not observe a pressure relieving cushion in the recliner. On 9/11/18 at 8:01 a.m. Surveyor asked CNA-F if there is a pressure relieving cushion in R38's personal type recliner. CNA-F replied no, that's the way it is. On 9/11/18 at 12:29 p.m. Surveyor met with RN (Registered Nurse) Manager-J to discuss R38. Surveyor informed RN Manager-J Surveyor has observed a cushion in R38's wheelchair and has observed R38 sit in the personal type recliner in his room when he is not in the dining room. Surveyor informed RN Manager-J Surveyor has not observed a pressure relieving cushion in the recliner and ask if there is information from the manufacturer the recliner provides pressure relieve. Surveyor inquired what the Facility is doing to prevent pressure injuries. RN Manager-J informed Surveyor they usually transfer the cushion from the wheelchair into the recliner. Surveyor informed RN Manager-J Surveyor noted the cushion in R38's wheelchair while he was sitting in the recliner. RN Manager-J informed Surveyor their standard of practice is to change position every 2 to 3 hours. On 9/11/18 at 1:25 p.m. RN Manager-J informed Surveyor a cushion was placed in R38's recliner.

Based on observation, interview, and record review, the facility did not ensure that 1 of 2 residents (R5) who were reviewed for bladder incontinence, received appropriate care and treatment in accordance with the plan of care. R5 was incontinent of bladder. Her care plan said that she should be checked and changed every 2 - 3 hours and as needed. On 9/10/18 R5 was not checked or changed for 6 hours. Findings include: 1.) R5 is [AGE] years old and has a [DIAGNOSES REDACTED]. R5's Incontinence care plan dated, 3/1/17, noted that she was to be checked and changed every 2-3 hours and as needed. The following observations were made on 9/10/18, showing that R5 had not been checked or changed for 6 hours from 8:31 am - 2:31 PM. At 8:31 am, R5 was up in her Broda chair in the dining room. She was eating breakfast. At 9:20 am, R5 was up in her Broda chair in her bedroom. At 10:07 am, R5 was up in her Broda chair in her bedroom. At 10:28 am, R5 was up in her Broda chair in her bedroom. At 11:43 am, R5 was up in her Broda chair in her bedroom. At 12:23 PM R5 was up in her Broda chair in the dining room. She was eating lunch. At 1:03 PM, R5 was up in her Broda chair in the dining room. At 1:23 PM, R5 was up in her Broda chair in the dining room. At 2:31 PM R5 was lying down in her bed in her room. CNA - T and Pool CNA - S were present and reported that they had just laid R5 down. When asked, CNA - T and CNA - S said that they had not gotten R5 out of bed this morning. When asked if they were assigned to care for R5, the CNAs reported that they were working as a team and responsible for assisting all residents who required 2 staff for daily cares. CNA - T and CNA - S confirmed that they had not checked and changed R5 until now. CNA - T did confirm that R5 was incontinent of bladder at this time.

Based on record review and interview, the facility did not keep 1 (R19) of 5 residents reviewed free from unnecessary drugs. * R19 received an antibiotic when he did not have appropriate signs and symptoms for use of the antibiotic. Findings include: The facility's constitutional criteria for infection titled Urinary Tract Infection-Includes only symptomatic UTI (Urinary Tract Infection)'s No Indwelling Catheter documents: MUST HAVE 1 of the following: a. Acute dysuria or pain, swelling, or tenderness of the testes, epididymis or prostate. b. Fever or leukocytosis and at least 1 of the following: i. Acute costovertebral angle pain or tenderness ii. Suprapubic pain iii. Gross hematuria iv. New or marked increase in incontinence v. New or marked increase in urgency vi. New or marked increase in frequency c. In the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract sub criteria: i. Suprapubic pain ii. Gross hematuria iii. New or marked increase in incontinence iv. New or marked increase in urgency v. New or marked increase in frequency MUST HAVE 1 of the following microbiologic sub criteria: a. 105,000 cfu (colony forming units)/ml (milliliter) of no more than 2 species of microorganisms in a voided urine sample. b. 102 cfu/ml of any number of organisms in a specimen collected by in-and-out catheter. Fever: 1. Single oral temp (temperature) greater 100 (degrees Fahrenheit) OR Repeated oral temp greater than 99 (degrees Fahrenheit) OR Repeated rectal temp greater than 99.5 (degrees Fahrenheit) OR Single temp greater than 2 (degrees Fahrenheit) from baseline from any site (oral, tympanic, axillary; This category includes only symptomatic urinary tract infections. Because many residents have bacteria in their urine as a baseline status, surveillance for asymptomatic bacteriuria is not recommended. 1. R19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R19's Quarterly MDS (Minimum Data Set) dated 6/20/18 documents a BIMS (Brief Interview with Mental Status) score of 13, indicating that R19 is cognitively intact. Section H (Bowel and Bladder) documents that R19 is frequently incontinent of bladder and does not have any appliances (urinary catheter) in place. R19's Final Report laboratory results dated [DATE] documents under the Result section, WBC (white blood cell)> (greater than) 50. R19's Laboratory Report Final dated 5/25/18 documents under the Result section Susceptibility: > (greater than) 100,000 CFU (colony forming units)/ mL (milliliter) [DIAGNOSES REDACTED] Pneumonie. R19's nursing note dated 5/22/18 at 6:32 a.m. documents, Resident slept well this N[NAME] (Nocturnal shift). Up to toilet with one assist. Used call light appropriately. No behaviors noted. R19's nursing note dated 5/22/18 at 10:42 a.m. documents, Resident had no behaviors noted. Has been transferring as 1/2 sara steady based on weakness. Continue to monitor. R19's nursing note dated 5/23/18 at 9:17 a.m. documents, IDT (interdisciplinary team) discussed concerns related to R19 and his transferring status and his decline in cognition. Team discussed doing stat (immediate) labs to see if he has something going on medically. Surveyor was unable to locate any documentation in R19's medical record that documented increased confusion or a decline in R19's cognition. R19's nursing note dated 5/23/18 at 4:21 a.m. documents, Res (resident) used call light to req (request) assist w/ (with) toileting. Transferred w/ 1 assist and sara steady- tol (toileted) well- voided in toilet. No neg (negative) behavior. R19's nursing note dated 5/23/18 at 10:58 a.m. documents, Call placed physician's office, give update on resident condition, increased confusion, increase impatience with staff, needing increased assistance but refusing therapy which is not resident's norm (normal) .resident seen to be seen by physician on rounds. Surveyor was unable to locate any documentation in R19's medical record that documented increased confusion or a decline in R19's cognition. R19's physician consultation notes dated 5/24/18 documents, No F (fever)/chills, no abdominal pain, stable. Surveyor was unable to locate any documentation in R19's physician notes that documented increased confusion or a decline in R19's cognition. R19's physician telephone order dated 5/24/18 documents, Bactrim DS 800 mg-160 mg tablet- 1 tablet by mouth twice daily. R19's (MONTH) (YEAR) MAR (Medication Administration Record) documents R19 received the above medication from 5/24/18 to 6/4/18. Surveyor was unable to located in R19's medical record any documentation that R19 was experiencing any of the following signs and symptoms on 5/24/18: Acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostate, fever, acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence,new or new or marked increase in urgency. Surveyor was unable to locate in R19's medical record any documentation that R19 had an acute change in mental status or acute costovertebral angle pain or tenderness. Surveyor was unable to locate in R19's medical record any documented indications that R19 fit the facility's Constitutional Criteria for Infection for antibiotic use for a suspected urinary tract infection when R19 was administered an antibiotic on 5/24/18. On 9/11/18 at 11:29 a.m., Surveyor informed RN (Registered Nurse) Manager-D of the above findings. Surveyor asked RN Manager-D if R19 fit the facility's Constitutional Criteria for Infection for antibiotic use for a suspected urinary tract infection, as Surveyor was unable to locate any signs and symptoms that indicated R19 had proper indications for the treatment of [REDACTED]. RN Manager-D informed Surveyor that she did not know if R19 fit the criteria for being treated with an antibiotic for a suspected UTI on 5/24/18. RN Manager-D informed Surveyor that she would look in R19's medical record and speak with R19's physician and let Surveyor know. On 9/11/18 at 1:43 p.m., RN Manager-D provided Surveyor with additional documentation documenting that R19 had an increase urinary incontinence from 5/20/18 to 5/24/18 in which R19 was found to be incontinent six times. RN Manager-D informed Surveyor that although R19 had an increase in urinary incontinent from 5/20/18 to 5/24/18, she could not locate any additional signs and symptoms that indicated R19 had proper signs and symptoms for the treatment of [REDACTED]. RN Manager-D informed Surveyor that R19 did not fit the facility's Constitutional Criteria for Infection antibiotic use for a suspected urinary tract infection when R19 received antibiotic on 5/24/18. RN Manager-D informed Surveyor that the facility had not provided any education to R19's physician regarding antibiotic use on 5/24/18 but that she would consult with R19's physician and let Surveyor know. On 9/11/18 at 2:56 p.m., Surveyor informed Administrator-A and DON (Director of Nursing)-B of the above findings. At the time, RN Manager-D provided Surveyor with a statement for R19's physician dated 9/11/18 that documented, Review of urine testing/treatment from 5/23/18 made. Aware patient did not have symptoms that met McGeer criteria for treatment of [REDACTED]. Despite this, I treated R19 for UTI based on urine testing . and symptoms of confusion. Surveyor again reviewed R19's medical record and could not locate any symptoms of increased confusion that were documented for R19 from 5/20/18 to 5/24/18.

Based on observation, interview, and record review the facility failed to ensure that Residents did not develop avoidable pressure injuries, or promote the prevention of pressure injury development for 4 (R3, R4, R8, R9) of 13 Residents reviewed who were at risk for the development of pressure injuries. R3 had no pressure injuries. On 8/14/16, R3 had a fall that resulted in a fracture to her left ankle. This resulted in the resident having a change of condition, requiring increased assistance for mobility, and documented increased risk for the development of pressure injuries. Subsequently, R3 developed an avoidable Stage 4 pressure injury to her right heel following the facility's failure to: *Update interventions in the plan of care to prevent the development of pressure injuries on 8/17/16, when R3 was documented to be at increased risk for the development of pressure injuries. *Off-load R3's heels of pressure despite R3 requiring extensive assistance of 2+ staff for bed mobility, and [DIAGNOSES REDACTED]. *Assess, measure, and monitor the wound weekly. *Ensure the heel was consistently offloaded. *Conduct daily foot checks on a diabetic resident. The pressure injury to R3's right heel deteriorated to the point that R3 required IV antibiotics, a bone debridement, and a skin graft. R3 was also observed during a treatment to have her wound cleansed with a cleansing agent that was not designated for use by a single resident. R3 was observed to have her wound cleansed with normal saline that was noted to have another resident's name on it. The facility's failure to provide necessary treatment and care to prevent R3's pressure injury and prevent it from worsening created a finding of Immediate Jeopardy for R3 beginning on 8/17/16. Administrator-D and RN Consultant-C were informed of the Immediate Jeopardy and substandard quality of care on 7/17/17 at 11:46 a.m. The Immediate Jeopardy was removed on 7/20/17; however, the deficient practice continues at a scope and severity level of D (potential for more than minimal harm/isolated) for R4, R8, and R9 as evidenced below. *R4 was observed with her heels not being offloaded per her plan of care *R8 was observed with her heels not being offloaded per her plan of care, and subsequently acquired a stage 1 pressure injury *R9's treatment to her pressure injury was observed not being done in accordance with physician's orders [REDACTED].>Findings include: 1. R3 has [DIAGNOSES REDACTED]. On 8/14/16, R3 was lowered to the floor in the bathroom. The facility's investigation of the fall documents, Resident had no pain at the time of incident or after, during checks on 8/15/16 it was noted her swelling and change in transfer status prompting an X-ray to be ordered. X-ray was completed in the early morning on 8/16/16 showing that she had a left ankle fx (fracture). R3's Minimum Data Set Assessment (MDS) with an assessment reference date of 8/22/16 documents R3 required increased assistance for bed mobility now requiring extensive physical assistance of 2 plus persons; this compared to her previous assessment dated [DATE] when she only required the assistance of one person. R3 is documented to also require increased assistance in transfers requiring total dependence of two plus persons physical assistance; this compared to her previous 5/23/16 assessment documenting extensive assistance of one person's physical assistance. R3 was also documented to have been ambulatory on her previous 5/23/16 assessment, and on the 8/22/16 ambulation is documented as not occurring. R3's Pressure Injury Care Area Analysis documented as completed 8/26/16 documents, Resident is at facility for LTC (long term care). Resident had a change of condition with a fall and left ankle fx (fracture) dx (diagnosis) per OMH (hospital) eval/tx (evaluation/treatment). Has a cast on left foot, skin and CMS (circulation, moisture, sensation) assessed every shift and PRN (as needed) to left foot. Resident required a blood transfusion when out to OMH. Resident has a dx of Breast CA (cancer) hx (history). Resident requires assist of 2 with a FBL (full body lift) for transfers. Is non-ambulatory. Requires EA (extensive assistance) from staff for completions of ADL's (activities of daily living) Resident is incontinent of B&B (bowel and bladder). Resident has no pressure skin breakdown. Skin is assessed weekly and PRN by licensed staff. Causes and Contributing factors are documented as Immobility secondary to left ankle fx. R3's Braden Scale for Predicting Pressure Sore Risk score on 5/19/16 was scored 21. On 8/17/17, R3's risk score was documented to have an increased risk for the development of pressure injuries with a score of 16. Per the assessment If the residents total is 16 or less, consider him/her at risk for pressure ulcer development. R3's Pressure ulcer care plan signed as completed 8/24/16 documents no new interventions despite R3 being less mobile and being identified to be at increased risk for the development of pressure injuries. On 8/26/16, R3 developed a pressure injury. Prior to the development of the pressure injury R3 had no interventions in place to offload the heels of pressure, despite her [DIAGNOSES REDACTED]. On 8/26/16 the care plan documents interventions for EZ boots to the right heel, and to elevate feet off bed. On 7/12/17 at 1:57 p.m., the surveyor interviewed RN (registered nurse) Manager-U. RN Manager-U confirmed prior to 8/26/16 there were no interventions in place to offload R3's heels of pressure. RN Manager-U confirmed it would be on the care plan if done. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance's Prevention and treatment of [REDACTED].), Cambridge Media: Perth Australia; 2014 section REPOSITIONING TO PREVENT AND TREAT HEEL PRESSURE ULCERS states, The reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. It continues to state under the section Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that the heels are free of the surface of the bed. On 7/12/17 at 1:57 p.m. the surveyor interviewed RN Manager-U. The surveyor asked if the facility did diabetic foot checks. RN Manager-U stated the facility does daily heel checks for all residents, not just diabetics which should be documented in the TAR (Treatment Administration Record). On 7/12/17, the surveyor reviewed R3's medical record and was unable to find documentation of heel checks being completed. On 7/13/17 at 11:19 am, the surveyor interviewed RN Manager-U and informed her that surveyor had been unable to find documentation that daily heel checks had been completed for R3. RN Manager-U confirmed there was no documentation that daily heel checks had been completed for R3. The surveyor asked RN Manager-U what is the facility's process for diabetic foot checks. RN Manager-U informed the surveyor all residents on admission should have an order for [REDACTED].>On 8/26/16, R3 is documented to have a 2.5cm x 2cm intact pressure ulcer purple in color to her right heel. The wound is incorrectly staged as a stage 2. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance's Prevention and treatment of [REDACTED].), Cambridge Media: Perth Australia; 2014 under Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. On 8/31/16, the wound is documented to be 2.5 x 2 intact pressure ulcer purple in color. The wound remains incorrectly staged as a stage 2 despite meeting the definition of a deep tissue injury. On 9/2/16, the wound is documented to be 2.5 x 2 intact pressure ulcer purple in color. The wound remains incorrectly staged as a stage 2 despite meeting the definition of a deep tissue injury. On 9/7/16, the wound is documented to be 2.1 x 2.8 blood filled intact blister. The wound remains incorrectly staged as a stage 2 despite meeting the definition of a deep tissue injury. On 9/9/16, the wound is documented to be 2.1 x 2.8 blood filled intact blister. The wound remains incorrectly staged as a stage 2 despite meeting the definition of a deep tissue injury. On 9/15/16, the wound is documented to be 2.2 x 2.8 blister draining sero/sang (serosanguinous) drainage. On 9/21/16, the wound is documented to be 2 x 2.8 with minimal drainage. On 9/28/16, the wound is documented to be 2 x 2.8 with minimal drainage. On 9/29/16, the wound deteriorated and documented to be 2.4 x 3.2 x .4 with minimal drainage-Wound bed has large area fixed necrotic eschar over wound bed loosened from wound edges. Area had undermining into tissue .6cm (@10 am) 1.0 cm (@2pm) periwound red and warm. The wound is incorrectly documented as a stage 2. On 10/3/16, R3 was seen by a wound clinic. The ulcer was documented to probe to subcutaneous tissue. The wound required sharp debridement. On 10/10/16, R3 was seen by the wound clinic. A [DIAGNOSES REDACTED]. On 10/24/16, the facility assesses the wound to be 4.5 x 5.7 x 0cm. The wound is documented as Wound bed has large area fixed necrotic eschar at approx. 6 o'clock. Appears to span the width of the heel. Foul odor from heel noted. Wound edges at approx. 11 o'clock appears to be rolled under. Lots of yellow slough noted to wound bed. The wound is incorrectly documented as a stage 2. On 7/11/17 at 2:53 p.m., the surveyor interviewed RN Manager-U. The surveyor asked RN Manager-U why R3's wound was staged as a stage 2 despite the documentation of slough, depth, and necrotic tissue. RN Manager-U stated she believed a wound was staged at what it was found as, and that she couldn't say anything more without looking into it. The surveyor asked why R3's wound was staged as a stage 2 despite documentation of intact purple skin. RN Manager-U stated she couldn't say. On 10/24/16, the wound clinic documents the wound to measure 4cm x 4cm x 0.6cm. On 10/28/16, R3 underwent a bone debridement of the right root. On 11/3/16-12/15/16 a wound vac was placed to the wound. On 11/28/16, wound clinic notes document the wound to measure 8.5 x 4 x 0.1cm and that the ulcer probes bone right heel. The wound was sharply debrided with post debridement measurements of 8.5 x 4 x 0.7. On 12/28/16 wound clinic notes document, ulcer right, foot measures right heel 15.5 x 4.5 x 1.5cm 1cm undermining at 12 O'clock with necrotic tendon. Ulcer base is granular with surrounding [DIAGNOSES REDACTED] .Ulcer probes tendon right heel. The wound was sharply debrided with post debridement measurements 16.5 x 4.55 x 1.5. On 12/29/16, R3 required IV antibiotic due to the right Achilles tendon becoming infected, continuing until 2/6/17. R3 continued to be seen by the wound clinic weekly. Wound clinic notes on 3/15/17 document, Pt (patient) broke her left ankle 6 months ago. She has been bed bound and developed heel ulcers. She is s/p (status [REDACTED]. Pt has had no pain. She has not always been wearing her prevlon boots. The wound is documented to be 2.8 x 2.8 x 0.1 with granular tendon and ulcer probes tendon right heel. The plan is documented to Start daily dressing changes. Urged continued offloading. Wound clinic notes on 3/22/17 document, She has not always been wearing her prevlon boots. On 3/30/17, R3 had a consult for a skin graft. Consult notes document, She developed a right heel decubitus. It has been static for some time and he is requesting a split thickness skin graft. There is good arterial perfusion. It is a warm extremity, good capillary refill, good quick venous return. She has granulation tissue that is somewhat pale, but viable. The ulcer measures 3 x 4 x 0.1. Wound clinic notes on 4/5/17 document, She has not always been wearing her prevlon boots. The notes continue to document, Ulcer right, foot measures right heel 2.5 x 3 x 0.1cm. Ulcer base is granular .Ulcer probes tendon right heel. There is a hyperkeratotic rim at the peri ulcer site indicative of chronic pressure. The wound was sharply debrided. Wound clinic notes on 4/12/17 document, She has not always been wearing her prevalon boots. The notes continue to document, Ulcer right, foot measure right heel 3 x 3 x 01 cm. There is invagination of the epithelium at the plantar aspect of the heel ulcer from probable chronic pressure.Ulcer probes tendon right heel. There is a hyperkeratotic rim at the peri ulcer site indicative of chronic pressure The wound was sharply debrided with post debridement measurements of 3 x 3 x 0 right heel. The plan is documented as Continue daily dressing changes. Urged continued offloading. Wound clinic notes on 4/19/17 document, Ulcer right, foot measures 3 x 3 x 0.1cm. There is invagination of the epithelium at the plantar aspect of the heel ulcer from probable chronic pressure. On 7/13/17 at 10:15 a.m., the surveyor interviewed DPM (Doctor of Podiatric Medicine)-V from the wound clinic. The surveyor shared the notes written related to R3 not always wearing prevalon boots and asked how DPM-V gained that information. The surveyor asked if R3 had gone to the wound clinic without prevalon boots on. DPM-V stated, yes, and that he could tell that pressure had been on the wound based off its presentation. DPM-V informed the surveyor that the wound had indications of pressure such as callouses and increased size. DPM-V stated that he had also been provided information from R3's family that she had not always had the boots on when they went to visit her. On 4/24/17, R3 underwent a split thickness skin graft for a pre-op [DIAGNOSES REDACTED]. Wound clinic notes on 5/10/17 document the wound to measure 1.5 x 2 x 0.1cm. An antibiotic was started due to increasing [DIAGNOSES REDACTED] (redness) and low grade temperature. Wound clinic notes on 5/15/17 document the wound to measure 3 x 3 x 0.1. Wound clinic notes on 5/24/17 document the wound to measure 3.5 x 3.5 x 0.1cm. R3 was not seen again by the wound clinic until 6/7/17. The wound is documented to measure 3.4 x 3 x 0.1cm. The wound was sharply debrided. Notes document will follow in two weeks. The facility had no documented assessments of the wound from 5/24/17-6/7/17 (2 weeks). R3 was seen two weeks later by the wound clinic on 6/21/17. The wound is documented to measure 3.4 x 3 x 0.1cm. The ulcer is documented to probe to subcutaneous right heel. The facility had no documented assessments of the wound from 6/7/17-6/21/17 (2 weeks). R3 was seen two weeks later by the wound clinic on 7/5/17. The wound is documented to measure 3.4 x 3.2 x 0.1cm. The ulcer is documented to probe to subcutaneous right heel. The documented plan includes Consider debridement of bone if healing is still stagnant. The facility had no documented assessments of the wound from 6/21/17-7/5/17 (2 weeks). The facility's Interdisciplinary Wound Care Team Policy and Procedure signed by the Medical Director on 9/27/16 states, The Wound Care Team will make weekly rounds on residents, who include but are not limited to, those who have pressure ulcers or may be at high risk, wounds that may be followed by a Wound Clinic, or an altered skin condition that may require weekly monitoring/ treatment/ evaluation. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance's Prevention and treatment of [REDACTED].), Cambridge Media: Perth Australia; 2014 section Pressure Ulcer Assessment 1. Assess the pressure ulcer initially and re-assess it at least weekly .1.1 Document the results of all wound assessments .A two-week period is recommended for evaluating the progress toward healing. However, weekly assessments provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly. On 7/11/17 at 12:56 p.m., the surveyor interviewed RN (registered nurse) Manager-U, who oversees the facility's wounds. The surveyor asked RN Manager-U if she measures R3's wounds. RN Manager-U stated R3 is seen by the wound clinic weekly, and confirmed that she does not measure R3's wounds. On 7/11/17 at 3:03 p.m., the surveyor interviewed NP (nurse practitioner)-W regarding R3's wound. NP-W informed the surveyor it is her knowledge that R3's wounds are assessed weekly at the wound clinic. The surveyor informed NP-W recently R3 had been only going to the wound clinic every other week. On 7/11/17 at 3:20 p.m., the surveyor interviewed DON (Director of Nursing)-B. The surveyor asked how does staff know if R3's wound is deteriorating without documented assessments. DON-B stated she would look into it, and that she could not answer at this time without looking into it. No additional information was provided to the surveyor. On 7/12/17 at 8:20 a.m., the surveyor observed LPN (licensed practical nurse)-X perform a treatment on R3's wound. The surveyor observed LPN-X remove the old dressing, and cleanse the wound with a saline wash spray. The surveyor observed a different resident's last name on the saline spray bottle. The surveyor observed LPN-X complete the treatment. At 8:34 a.m., the surveyor interviewed LPN-X. The surveyor asked if residents should have their own dedicated wound supplies. LPN-X stated yes. The surveyor pointed out the other resident's last name on the bottle. LPN-X stated she did not see that. The surveyor observed R3's last name also on the same saline spray bottle. On 7/12/17 at 3:15 p.m. during the daily exit meeting with the facility the surveyor asked DON-B if residents should have their own dedicated wound treatment supplies. DON-B stated yes. The surveyor shared the above observation of R3's wound treatment with DON-B. No additional information was provided. The facility's failure to provide necessary treatment and care to prevent R3 from developing an avoidable pressure injury and appropriate care to the pressure injury created a finding of Immediate Jeopardy for R3 beginning on 8/17/16. The Immediate Jeopardy was removed on 7/20/17 when: *Individualized interventions for the residents identified were reviewed and revised for appropriateness/effectiveness of off-loading. Alternative means for off-loading pressure areas were assessed and individualized per resident. Individual care plans were updated to reflect interventions. *All residents were evaluated through head-to-toe body checks for any current or new skin concerns. The Braden Risk Assessment for Skin will be done for all residents to determine risk and need for preventative measures. Changes, if indicated, will be made on the care plans. *In-Service education provided to professional Nursing staff and CNA staff on pressure sore preventions. *Weekly wound rounds are completed by RN. Wound Care RN will assure that appropriate interventions are in place. Weekly Interdisciplinary Skin Meeting will then be conducted to review all current pressure sores and interventions and effectiveness of treatment and off-loading. *At risk residents will be reviewed at the Interdisciplinary Skin Meeting quarterly or with change in condition in coordination with completion of MDS. This meeting will include a review of care plan appropriateness and effectiveness of interventions and off-loading, Braden score and risk factors (ie: Diagnosis, Nutritional status, labs). *Found at risk residents per unit will be audited in the first month of implementation to ensure care plans are current, appropriate and being followed. Three at risk residents per unit will be audited in the second and third month of implementation to ensure the care plans are current, appropriate and being followed. Audits will be completed by Nurse Manager or designee. Audit findings will be reported at QAPI (Quality Assurance Program Improvement) Meetings. Additional audits will be determined by members of QAPI. *Plan of correction will be overseen by Administrator and Director of Nursing. The deficient practices continues at a scope/severity of D (potential for more than minimal harm/isolated) based upon the following examples. 2. R4 had [DIAGNOSES REDACTED]. R4's most recent MDS (Minimum Data Set assessment) with an assessment reference date of 5/11/17 documents that R4 requires extensive assistance of 2 plus staff's physical assistance for bed mobility and is at risk for the development of pressure injuries. R4's Resident Interdisciplinary Care Plan under skin management instructs to elevate heels off bed with pillow. On 7/11/17 at 9:01 a.m., the surveyor observed R4 in bed on her back with her heels on the mattress. The surveyor observed no pillow in the bed to be used to elevate R4's heels. On 7/11/17 at 9:20 a.m. and 9:40 a.m. the surveyor observed R4 in bed on her back with her heels not elevated off the bed. The surveyor reviewed R4's medical record and was unable to find documentation that R4 declined to have her heels offloaded. On 7/17/17 at 11:40 a.m. during a meeting with Administrator-D and RN Consultant-C the surveyor shared the above observation with the facility. No additional information was provided. 3. Surveyor reviewed R8's medical record on 7/10/17 to 7/13/17. The pressure ulcer care plan not dated includes an intervention dated 11/7/13 of Position body with pillows/support devices, protect bony prominences. The quarterly MDS (Minimum Data Set) with an assessment reference date of 4/17/17 and signed as complete on 4/20/17 documents a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R8 is dependent upon staff with two plus person physical assist for transfers, does not ambulate, requires extensive assistance with two plus person physical assist for bed mobility, is always incontinent of bowel and frequent incontinent of bladder. R8 is at risk for pressure injuries and is coded as not having any pressure injuries. The Resident interdisciplinary care plan dated 4/19/17 located inside R8's closet under the section skin management is checked for turn q2 (every two) hours in bed, Elevate heels off bed w/(with) pillows, lotion, side to side only in bed, Treatment by nurse and nap daily with a handwritten notation of or per request. The Braden assessment dated [DATE] has a score of 14. A score of 16 or less is considered high risk for pressure injury development. On 7/10/17 at 2:20 p.m., Surveyor observed CNA (Certified Nursing Assistant)-Q and CNA-R transfer R8 from the Broda chair into bed using a Hoyer lift. CNA-Q & CNA-R unhooked the sling from the lift, CNA-R removed R8's black shoes, and moved the bed away from the wall. CNA-Q & CNA-R removed the sling from under R8. CNA-R removed R8's pants and CNA-Q unfastened R8's incontinence product stating want you to have air. CNA-Q placed a pillow under R8's lower legs with R8's heels resting on the pillow, R8 was positioned on her right side and CNA-R placed a pillow under R8's upper left side. R8 was covered with bedding, the head of the bed was elevated, and the bed lowered down. Surveyor noted R8's heels are not being off loaded. On 7/10/17 at 2:55 p.m., Surveyor observed R8 continues to be in bed on her right side. R8's heels continue to be resting on the pillow and are not being off loaded. On 7/10/17 at 4:16 p.m., Surveyor observed R8 continues to be in bed on her right side. R8's heels continue to be resting on the pillow and are not being off loaded. On 7/11/17 at 6:51 a.m., Surveyor observed R8 awake in bed on her back. Surveyor observed R8 has bare feet and her heels are resting directly on the mattress. R8's heels are not being off loaded. On 7/11/17 at 7:54 a.m., Surveyor observed R8 continues to be in bed on her back, with her knees flexed, and heels resting directly on the mattress. R8's heels are not being off loaded. On 7/11/17 at 8:29 a.m., Surveyor observed R8 continues to be in bed on her back, with her knees flexed, and heels resting directly on the mattress. R8's heels are not being off loaded. On 7/11/17 at 9:13 a.m., Surveyor observed R8 in bed on her back informing Surveyor the CNA came in to ask her what she wanted for breakfast. Surveyor observed R8's heels continue to be on the mattress and are not off loaded. On 7/11/17 at 10:20 a.m., Surveyor observed R8 continues to be in bed on her back with the head of the bed elevated. R8's heels continue to be resting directly on the mattress. On 7/11/17 at 11:19 a.m., Surveyor observed CNA-P enter R8's room, place gloves on, and ask R8 if she wants to get up. R8 informed CNA-P she wants to stay in bed. CNA-P asked R8 if she could check her brief and change her. CNA-P lowered R8's head of the bed and removed the bedding. Surveyor observed there pillows under R8's knees and lower legs but R8's heels are resting directly on the mattress and are not being off loaded. CNA-P unfastened the incontinence product and washed R8's frontal perineal area with a wet wipe. CNA-P informed R8 she was going to roll her towards the wall and assisted R8 with positioning on her left side. CNA-P washed R8's rectal area to remove the stool, removed the product placing the product in a plastic bag, removed her gloves, cleansed her hands, and placed a cleaned incontinence product under R8. During this observation, Surveyor observed R8's heels were red and asked CNA-P if she could press on the heels. CNA-P pressed on R8's right heel and Surveyor observed the area was non blanachable. CNA-P informed Surveyor she was going to get EZ boots for R8, positioned R8 on her right side & then onto her back to straighten out the product and fastened the incontinence product. CNA-P removed her gloves, cleansed her hands, and informed R8 she was going to get her some cream & blue boots to put on her feet. At 11:30 a.m., CNA-P placed a pillow under R8's lower legs to float her heels, covered R8 with bedding, raised the head of the bed, lowered the bed down, and informed R8 she would be right back. At 11:37 a.m., RN( Registered Nurse)-U and CNA-P entered R8's room. RN-U informed R8 she was going to turn her on her side to look at her skin. R8's incontinence product was unfastened and R8 was positioned on her left side. RN-U assessed R8's skin on her buttocks, removed her gloves, washed her hands, stated she needed to get a mirror and left R8's room. CNA-P placed barrier cream on R8's buttocks and fastened the incontinence product. At 11:46 a.m., RN-U returned with a mirror, washed her hands, placed gloves on, and assessed R8's right and left heels. RN-U informed R8 she was going to give her special boots. Surveyor informed RN-U R8's heels were not off loaded this morning. RN-U and CNA-P positioned R8 up in bed, R8 was positioned on her right side and placed a pillow under R8's upper left side. CNA-P placed pressure relieving boots on R8, placed a pillow between R8's legs & under her lower legs. CNA-P covered R8 with a sheet and lowered the bed down. The nurses note dated 7/11/17 at 12:45 p.m. documents, Res. (Resident) has non blanachable redness to L/R (left/right) heels. See skin tab. Areas are not open/no blister/not painful to res. MD (medical doctor) and POAHC (power of attorney health care) updated wit the same. Will treat with EZ boots con't (continue) measures to off load pressure. POC (plan of care) updated. The skin evaluation form dated 7/11/17 for site documents, left heel, for type documents, pressure ulcer, and for treatment documents EZ boots/off load pressure/positioning/float heels. Description is documented as Persistent redness to L (left) heel/non blanachable [DIAGNOSES REDACTED], no OA (open area). Under size Length is documented as 4.0 cm (centimeters), Width 7.0 cm and depth 0 cm. The skin evaluation form dated 7/11/17 for site documents right heel, for type documents, pressure ulcer, and for treatment documents EZ boots/offload pressure/floating heels. Description is documented as Persistent redness to heel. No OA (open area). Under size Length is documented as 3.4 cm (centimeters), Width 5.5 cm, and depth 0 cm. On 7/13/17 at 2:40 p.m. during the daily exit conference Interim Administrator-A, DON (Director of Nursing)-B and RN Consultant-C were informed of the above. 4. Surveyor reviewed R9's medical record from 7/10/17 to 7/17/17. R9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R9's admission MDS (Minimum Data Set) dated 6/29/17 documents a BIMS (brief interview for mental status) score of 15, indicating that R9 is cognitively intact. Section G (Functional Status) documents that R9 requires extensive assist and a two person physical assist for her bed mobility and transferring needs. Section G0400 documents that R9 has impairment to one side of her lower extremities. Section M (Skin Conditions) documents that R9 is at risk for the development of pressure ulcers and has one stage 2 pressure ulcer. R9's Pressure Ulcer CAA (Care Area Assessment) with a reference date of 6/29/17 documents under the Description of Problem section, Resident is at facility for rehab (rehabilitation) following hospitalization for a fall resulting in a femur fracture .Resident requires staff assist of 2 with a sit to stand device for transfers. Is non-ambulatory with nursing at this time .Resident has a blister to right heel that has ETOH (alcohol) treatment per order and pressure reduction interventions in place. R9's Skin Integrity related to her Right Heel with a goal date of 7/30/17 documents under the Other Interventions section, ETOH (alcohol) wipe BID (twice a day) right heel. R9's Braden Scale for Predicting Pressure Sore Risk on 7/11/17 documents a score of 13, indicating that R9 is at risk for the development of pressure ulcers. R9's physician orders [REDACTED]. Swab eschar area with alcohol swab BID (twice a day) SITE: R (right) heel. On 7/12/17 at 7:39 a.m., Surveyor observed RN (Registered Nurse)-G perform a wound treatment on R9's right heel. On 7/12/17 at 7:40 a.m., Surveyor observed RN-G enter R9's bathroom, wash her hands, soak a soft cloth with water and antibacterial soap and put on gloves. On 7/12/17 at 7:44 a.m., Surveyor observed RN-G remove R9's heel boots and cleanse R9's right heel pressure injury with the soft cloth she previously soaked with water and antibacterial soap. Surveyor observed RN-G then press on R9's right heel pressure injury with her right gloved hand. Surveyor noted that RN-G did not wipe R9's right hee

Based on observation, interview, and record review the Facility did not implement effective infection control procedures to prevent the spread of infection during a respiratory outbreak, did not maintain a completed tracking and trending log of infections with required information and did not ensure effective hand hygiene for 1 (R9) of 13 sampled residents. * The facility has 4 resident units. During the survey, the Rivers and Woods units were closed as a result of residents experiencing an illness due to Rhino virus. 8 of 24 residents on the Rivers unit were ill and 9 of 24 residents on the Woods unit were ill. During the outbreak, the Meadows unit had 3 residents who were ill, however, the unit was not closed. During the survey, staff from various departments were observed entering the Rivers unit without wearing a mask as required. Staff on the Rivers unit were observed entering R21, R22, & R23 without a mask. These residents were identified as being ill with the Rhino virus. R21 was observed multiple times in the hallway without a mask coughing. Well Residents were also in the hallway. *Facility staff was observed entering R11's room without wearing without wearing PPE (personal protective equipment) while she was on isolation due to a respiratory infection outbreak on the Woods unit. * Through March 2017 the Facility's infection control preventionist completed a tracking and trending log of the infections with the required information. The infection control preventionist has not completed this log for April 2017, May 2017, June 2017, and July 2017. A report from the computer lists only the onset date, site, and where acquired. This report does not consistently have the organism, does not list type of isolation, and date of the infections were resolved. * RN (Registered Nurse)-G was observed not use proper hand hygiene when performing a wound treatment on R9's right heel. This deficient practice has the potential to affect all 76 Residents. Finding include: 1. On 7/10/17 at 8:00 a.m. upon entrance for the Facility's recertification survey, Surveyor observed a signed taped to the receptionist desk which documented, We are currently experiencing a higher than normal rate of respiratory illness on Woods wing and Rivers wing. Please see nurse before visiting. Wash your hand and wear a mask. Thank you. On 7/10/17 at 9:24 a.m., DON (Director of Nursing)-B informed Surveyor the Rivers unit in which Surveyor is going to tour is on isolation for the Rhino virus and when ever Surveyor goes into the unit the Surveyor should wear a mask. DON-B explained the staff working on the unit do not have to wear a mask unless they go into a Resident's room who is on droplet isolation as they are only assigned to this unit. DON-B informed Surveyor staff from other departments or units that have to come into the unit need to wear a mask. DON-B informed Surveyor the Residents with the respiratory illness are identified with a green sign which is placed above or below their name. DON-B informed Surveyor ill Residents are kept in their room or if they come out they need to wear a mask and these Residents eat in their room. Surveyor observed the doors to this unit are closed and outside the door is a box of mask and a container of hand sanitizer. On 7/10/17 at 11:18 a.m., Surveyor observed CNA (Certified Nursing Assistant)-Z enter R21's room without a mask and ask R21 what she wants for lunch. R21 has a green sign outside the door and is identified as being ill with the respiratory illness. On 7/10/17 at 11:20 a.m., Surveyor observed CNA-Z enter R22's room without a mask and inquire about lunch. R22 has a green sign outside the door and is identified as being ill with the respiratory illness. On 7/10/17 at 12:44 p.m., Surveyor observed R21 sitting in the hallway without a mask on. R21 was coughing stating, I feel terrible. Surveyor noted the staff in the hallway did not offer R21 a mask. On 7/10/17 at 12:58 p.m., Surveyor observed R21 continues to be in the hallway without a mask on. R21 is eating her lunch facing R6. On 7/10/17 at 1:05 p.m., Surveyor observed R21 continues to be sitting in the hallway without a mask coughing. CNA-Q stated to R21 Thank you for covering your mouth. CNA-Q did not cleanse R21's hands nor did she offer R21 a mask. On 7/10/17 at 1:07 p.m., Surveyor observed CNA-Q cleanse her hands and enter R23's room without a mask. R23 has a green sign outside the door and is identified as being ill with the respiratory illness. CNA-Q moved R23 who was sitting in her wheelchair closer to the over bed table with her lunch on and informed R23 would turn tv on maybe then you'll eat. On 7/10/17 at 1:13 p.m., Surveyor observed CNA-Q enter R23's room without a mask. CNA-Q asked R23 how she was doing, cut R23's sandwich, told R23 she will come check on her, cleansed her hands and left the room. On 7/10/17 at 1:20 p.m., Surveyor observed R21 sitting in a chair in the hallway coughing stating, oh god. R21 was not wearing a mask. On 7/10/17 at 1:25 p.m., Surveyor observed CNA-Z ambulating with R21 down the hallway into her room. Surveyor observed neither CNA-Z or R21 were wearing a mask. On 7/10/17 at 1:30 p.m., Surveyor observed CNA-Z and R21 ambulating down the hall. Surveyor observed neither R21 or CNA-Z are wearing masks. On 7/10/17 at 2:19 p.m., Surveyor observed R21 sitting in a chair in the hallway. Surveyor observed R21 is not wearing a mask. On 7/11/17 at 8:08 a.m., Surveyor observed DSM (Dining Services Manager)-I enter the unit with a cart speaking with Residents in the hallway. Surveyor observed DSM-I was not wearing a mask. On 7/11/17 at 9:12 a.m., Surveyor observed US (Unit Secretary)-BB on the unit without a mask. US-BB was going room to room delivering magazines. On 7/11/17 at 9:41 a.m., Surveyor observed Maintenance-CC enter the unit without a mask on, walk to the far end of the unit and then leave the unit. On 7/11/17 at 2:42 p.m., Surveyor observed R21 sitting in a chair in the hallway outside room [ROOM NUMBER] without a mask on. On 7/12/17 at 10:17 a.m., during the infection control interview with DON (Director of Nursing)-B, who is the infection control preventionist, DON-B explained the Rhino virus outbreak affecting the Woods and Rivers unit. Surveyor informed DON-B of the observations on the Rivers unit of staff not wearing masks when entering Residents rooms who were ill, staff from other departments entering the unit without masks and R21 coughing in the hallway without a mask and staff not offering a mask to R21. On 7/13/17 at 2:40 p.m. during the daily exit conference Interim Administrator-A, DON -B and RN (Registered Nurse) Consultant-C were informed of the above. 2. On 7/12/17 at 9:30 a.m., Surveyor conducted the Infection Control interview with DON (Director of Nursing)-B who is the infection control preventionist at the Facility. Surveyor asked DON-B when she started being responsible for infection control. DON-B informed Surveyor January 2017. Surveyor asked DON-B to explain how she tracks and trends the infections in the Facility. DON-B explained when ever an antibiotic or infection is entered in AOD (answers on demand) she receives an e-mail and they also discuss infections in morning report. DON-B stated she adds the Residents to the line listing and maps the infection. Surveyor inquired how often she does the line listing. DON-B informed Surveyor every day. Surveyor asked DON-B to see the monthly infection logs. DON-B was able to provide Surveyor the monthly logs for January 2017, February 2017, and March 2017 but did not have logs after March 2017. DON-B explained there is information in various systems such as AOD, care tracker, and IQI. DON-B informed Surveyor she was trying to do things a different way that made sense to her. DON-B informed Surveyor before RN (Registered Nurse) Consultant-C came to the Facility she didn't know what she needed to do. Surveyor asked what training she received. DON-B informed Surveyor she didn't receive any training from the person prior because she left. DON-B informed Surveyor she is able to pull an infection report in AOD which the Surveyor requested. Surveyor noted this report lists the Resident's name, date of onset, where the infection was acquired and site. This report lists the date resolved as 00/00/0000 for all Residents, does not consistently list the organism, does not indicate if isolation is required and if so the type of isolation. 3. On 7/11/17 at 7:51 while on the Woods unit, the surveyor observed CNA (certified nursing assistant)-AA enter R11's room. The surveyor observed a sign below R11's name on the door frame stating, Please see nurse before entering. The surveyor observed CNA-AA enter the room and did not gown any personal protection equipment including mask, which were located outside of the room. The surveyor observed CNA-AA go within three feet of the resident, and move his walker and bedside table with no mask or glove on. CNA-AA then used hand sanitizer and left the room The surveyor reviewed R11's medical record and noted that R11 was on droplet isolation for respiratory symptoms. On 7/13/17 during the daily exit meeting with Interim Administrator-A and DON (Director of Nursing)-B the surveyor shared the above observation. No additional information was provided. Hand Hygiene: 4. On 7/12/17 at 7:39 a.m., Surveyor observed RN-G perform a wound treatment on R9's right heel. On 7/12/17 at 7:40 a.m., Surveyor observed RN-G wash her hands and put on a pair of gloves and proceed to R9's bed side. Surveyor observed RN-G use her left gloved hand to touch the bed then raise the bed using the bed's control. Surveyor noted that RN-G did not remove her gloves or wash her hands after touching R9's bed control and bed with her left gloved hand. On 7/12/17 at 7:41 a.m., Surveyor observed R9 cough and request a Kleenex tissue from RN-G. Surveyor observed RN-G provide R9 with a Kleenex tissue and then observed R9 spit sputum into the Kleenex tissue and hand it to RN-G. Surveyor observed RN-G grab the Kleenex tissue that contained R9's sputum with her left gloved hand and then throw it in the garbage container. On 7/12/17 at 7:44 a.m., Surveyor observed RN-G perform a wound treatment on R9's right heel with the same gloves she had handled R9's sputum and bed control. Surveyor noted that noted that RN-G did not remove her gloves or wash her hands after handling the Kleenex tissue that contained R9's sputum or touching R9's bed control. Surveyor observed RN-G use her left gloved middle finger to press down on R9's pressure injury while wearing the same gloves she had handled R9's sputum and bed control. Surveyor noted that RN-G did not remove her gloves or wash her hands after handling the Kleenex tissue that contained R9's sputum or touching R9's bed control. On 7/12/17 at 10:45 a.m., Surveyor informed RN Manager-H of the above findings. Surveyor asked RN Manager-H if RN-G should have removed her gloves and washed her hands after handling the Kleenex tissue containing R9's sputum and before directly touching R9's pressure injury. RN Manager-H informed Surveyor that RN-G should have removed her gloves and washed her hands after handling the Kleenex tissue containing R9's sputum and before directly touching R9's pressure injury. Surveyor asked RN Manager-H a copy of the facility's policy and procedure on hand hygiene. On 7/12/17 at 2:56 p.m., during the daily exit conference, Surveyor informed Interim Administrator-A and DON (Director of Nursing)-B of the above findings. At the time, no further information was provided. On 7/13/17 at 1:05 p.m., the facility provided Surveyor with a copy of the facility's policy on hand hygiene. The policy titled, Hand Hygiene with no effective dated documents under the Purpose section, Appropriate hand hygiene is essential in preventing transmission of infectious agents. Under the Policy section it documents, Hand hygiene must be performed after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn; immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment and/or the environment. Specific examples include but are not limited to: 14. Before and after touching wounds of any kind .22. After contact with a resident's mucous membranes and body fluids or excretions .25. After handling soiled equipment or utensils. No further information was provided as to why the facility did not implement effective infection control procedures to prevent the spread of infection during R9's wound treatment.

Based on staff interview and record review the Facility did not offer the Prevnar 13 immunization to 6 (R6, R7, R16, R15, R4, & R9) of 6 residents eligible to receive the Prevnar 13 vaccination, from a total sample of 16 Residents reviewed. The remaining 10 sampled residents either received the Prevnar 13 prior to admission or were not eligible to receive it. In addition, the Facility does not have a policy and procedure for the Prevnar 13. Findings include: On 4/27/16, the State of Wisconsin, Public Health Chief Medical Officer and State Epidemiologist for Communicable Diseases sent a memorandum regarding new guidance on administering vaccines to older adults for Pneumonia (pneumococcal conjugate vaccine/PCV13 and pneumococcal [MEDICATION NAME] vaccine/PPSV23), with recommendations for adults aged [AGE] years and older. This memorandum was sent to all Long Term Care facility directors. This memorandum indicated the new standards of practice indicated by the Federal Centers for Disease Control (CDC). This memorandum includes Recommendation for immunocompetent adults which states in part: Adults aged = [AGE] years who have not previously received pneumococcal vaccine or whose previous vaccination history is unknown should receive a dose of PCV 13 first, followed by a dose of PPSV23 ideally = 1 year later . Adults aged = [AGE] years who have previously received =1 dose PPSV23 also should receive a dose of PCV13 if they have not yet received it. A dose of PCV13 should be given =1 year after receipt of the most recent dose of PPSV23 . For adults who previously received PPSV23 when aged <[AGE] years and for whom an additional dose of PPSV23 is indicated when aged = [AGE] years, this subsequent PPSV23 dose should be given = 1 year after PCV13 and = 5 years after the most recent dose of PPSV23 . PVC13 and PPSV23 should not be co-administered . During 2014, the Federal Centers for Disease Control and Prevention (CDC) published the recommendations of the Advisory Committee on Immunization Practices (ACIP) pertaining to pneumococcal vaccination of immunocompetent adults aged over [AGE] years: a subsequent clarification of the interval between doses was published during 2015. Accordingly, the current ACIP recommendation is that adults aged over [AGE] years now receive the pneumococcal conjugate vaccine (PCV13, Prevnar-13®) followed by the pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME]®23) 1 year later. This memorandum indicated the newest recommendations for immunizing older adults. This memorandum indicates that the State of Wisconsin Public Health Department is recommending that providers should take the following four steps to encourage their adult patients to receive all of the recommended vaccines: 1. Screen adult patients for their vaccination status during each visit. 2. Recommend the needed vaccines to their patients during each visit. 3. Administer the needed vaccines, or refer the patient to a provider who is able to vaccinate. 4. Document the vaccination in the patient's medical record and submit this information to the WIR (Wisconsin Immunization Registry). 1. On 7/12/17 at 9:30 a.m., Surveyor met with DON (Director of Nursing)-B, who is the Facility's Infection Control Preventionist, to conduct the infection control task. At 10:37 a.m. Surveyor asked DON-B if she was also responsible for the immunization program. DON-B informed Surveyor she was. Surveyor asked DON-B to explain the immunization program at the Facility. DON-B explained when a Resident is admitted the admitting nurse will check the hospital records for the immunizations. If they can't find information regarding the immunization status the Wisconsin registry will also be checked. DON-B informed Surveyor the MDS (Minimum Data Set) nurses double check this information because they input the immunizations into the assessment. On 7/12/17 at 10:50 a.m., Surveyor informed DON-B Surveyor was provided with a policy & procedure for the influenza vaccine program and the administration of [MEDICATION NAME] vaccine. Surveyor inquired if there is a policy and procedure for the Prevnar 13 vaccine. DON-B replied, I gave you what I have. We follow the pharmacy recommendation when to administer Prevnar 13 versus 23. Surveyor asked if there is a pharmacy policy and procedure. DON-B replied, I can get it. On 7/12/17 at 12:31 p.m., DON-B provided Surveyor with an Omnicare Pharmacy Services memorandum dated September 9, 2015 with the subject line Additional Changes to Pneumococcal Vaccine Recommendation in Older Adults. This memo includes the 7 following questions; Who is a candidate for PCV13 (Pneumococcal vaccine 13)?, Why are both PCV13 and PPSV23 (Pneumococcal [MEDICATION NAME] vaccine) vaccines needed in adults aged > [AGE] years?, Has PCV13 been shown to be effective in adults aged > [AGE] years?, Can PCV13 (Prevnar 13) be co-administered with other vaccines?, Are they are contraindications to PCV13 (Prevnar 13)?, Should the Pneumococcal Vaccine Information Sheet (VIS) be provided to patients with the consent form prior to administration of PCV13?, and Has ACIP recommendations changed for PVC13 in adults aged > [AGE] years? On 7/17/17 at 11:04 a.m., Surveyor asked RN (Registered Nurse) Consultant-C where Surveyor could find DON-B. RN Consultant-C informed Surveyor DON-B had stepped out of the building and asked Surveyor what the Surveyor needed. Surveyor informed RN Consultant-C that DON-B had provided Surveyor with an Omnicare memo regarding Prevnar 13 but not a policy and procedure for Prevnar 13. Surveyor asked RN Consultant-C if there is a Prevnar 13 policy and procedure. RN Consultant-C informed Surveyor she would look for one. On 7/17/17 at 11:21 a.m., RN Consultant-C informed Surveyor she couldn't find anything else. Surveyor asked RN Consultant-C you don't have a Prevnar 13 policy? RN Consultant-C shook her head no. 2. Surveyor reviewed R6's medical record on 7/10/17 to 7/13/17. R6 was admitted to the facility on [DATE], is [AGE] years old, and has an activated power of attorney. The electronic medical record under the immunization section documents R6 received the influenza vaccine on 10/27/16 and the Pneumococcal 23 on 3/30/2005. Surveyor did not note any documentation that Prevnar 13 was offered to R6's legal representative. On 7/12/17 at 10:43 a.m., Surveyor asked DON (Director of Nursing)-B who is the infection control preventionist at the Facility if the Prevnar 13 vaccine was offered to R6's legal representative. DON-B replied, I don't have Prevnar 13. 3. Surveyor reviewed R7's medical record on 7/10/17 to 7/12/17. R7 was admitted to the facility on [DATE], is [AGE] years old and has an activated POA (power of attorney). The electronic medical record under the immunization section documents R7 received the influenza vaccine on 11/1/16. There is no documentation R7 received the Pneumococcal 23 or Prevnar 13 prior to admission nor is there any documentation the Facility offered the Pneumococcal 23 or Prevnar 13 to R7's legal representative. On 7/12/17 at 10:45 a.m., Surveyor informed DON (Director of Nursing)-B during R7's record review the Surveyor was unable to locate any information regarding R7's immunization status for Pneumococcal 23 or Prevnar 13 and asked DON-B if R7's POA was offered these vaccines. DON-B replied, no. Surveyor asked DON-B what the process is for determining a Resident's immunization status. DON-B informed Surveyor the admitting nurse is suppose to fill out a form and forward the form to the infection preventionist. Surveyor asked DON-B if she has been getting these forms as she is the Facility's infection preventionist. DON-B replied, no, its a broken process. 4. Surveyor reviewed R16's medical record on 7/13/17 & 7/17/17. R16 was admitted to the facility on [DATE] and discharged on [DATE]. R16 is [AGE] years old. The electronic medical record under the immunization section documents R16 received the Pneumococcal 23 immunization on 9/22/10. This immunization section does not include Prevnar 13. The nurses note dated 6/8/17 documents, Resident A&Ox3 (alert and orientated times three), able to make needs known. Has HCPOA (health care power of attorney) but not activated. DNR (Do No Resuscitate) code status. Here for rehab following L (left) humerus Fx (fracture). L arm wrapped and in a sling, NWB (non weight bearing). Has indwelling Foley catheter in place, draining clear yellow urine. Has brace on L leg for [MEDICAL CONDITION]. Transfers with 2 assist pivot, needs extensive assistance with ADLs (activities daily living). Continent of bowel. Consistent carb (carbohydrate) diet. Surveyor reviewed all R16's nurses notes from 6/8/17 to 7/6/17, the date of discharge, and was unable to locate any information whether Prevnar 13 had been offered to R16. On 7/17/17 at 7:51 a.m., Surveyor met with DON (Director of Nursing)-B to discuss R16's immunization status. Surveyor informed DON-B during R16's record review Surveyor noted R16 had received the Pneumococcal 23 but was unable to locate documentation R16 had received or was offered the Prevnar 13 vaccine. Surveyor inquired if DON-B had the form which the admitting nurse completes. This form has an immunizations/TB ([MEDICAL CONDITION]) status section which includes the questions Have you had a [MEDICATION NAME], Have you ever had the Prevnar 13 vaccine, and Did you get the Influenza vaccine this year with a box for yes or no and the date. DON-B informed Surveyor she didn't know if they have it as she had asked medical records for the entire record. On 7/17/17 at 11:40 a.m. during the daily exit conference Administrator-D and RN (Registered Nurse)- Consultant-C were informed of the above. Surveyor was not provided with any information regarding Prevnar 13 for R16. 5. Surveyor reviewed R15's medical record on 7/17/17. R15 was admitted to the facility on [DATE] and discharged on [DATE]. R15 was [AGE] years old and had an activated power of attorney. The form completed by the admitting nurse which is not titled dated 7/11/16 at 1430 (2:30 p.m.) under the section immunizations/TB ([MEDICAL CONDITION]) status section for the questions Have you had a [MEDICATION NAME] yes is checked. For the question Have you ever had the Prevnar 13 vaccine No is checked. The electronic medical record under the immunization section documents R15 received the Pneumococcal 23 immunization on 6/24/15 and the influenza vaccine on 12/13/16. This immunization section does not include Prevnar 13. Surveyor reviewed R15's nurses notes from 7/1/16 to 6/30/17 and was unable to locate any information if R15 was administered Prevnar 13 prior to admission or Prevnar 13 was offered to R15's POA (power of attorney). On 7/17/17 at 9:44 a.m., Surveyor met with DON (Director of Nursing)-B to discuss R15's immunization status. Surveyor informed DON-B during R15's record review Surveyor noted R15 received the influenza vaccine on 12/13/16 and the Pneumococcal 23 on 6/24/15 but was unable to locate Prevnar 13. DON-B informed Surveyor she did not have the Prevnar 13. DON-B stated, It's a problem I'll have to address. It's a process we need improvement on. 6. R4 was most recently admitted to the facility on [DATE]. R4 is over the age of 65. R4's immunization report documents that R4 received the Pneumococcal (PPSV23) immunization 10/01/10. The surveyor reviewed R4's medical record and was unable to find documentation that R4 had been offered the Prevnar-13 immunization (pneumococcal conjugate vaccine). On 7/11/17 at 3:20 p.m. during the daily exit meeting with Interim Administrator-A and DON-B, the surveyor informed the facility that she had been unable to locate that R4 was offered the Prevnar-13 immunization, and asked for any additional information. No additional information was provided. 7. Surveyor reviewed R9's medical record from 7/10/17 to 7/17/17. R9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R9's admission MDS (Minimum Data Set) dated 6/29/17 documents a BIMS (brief interview for mental status) score of 15, indicating that R9 is cognitively intact. R9's discharge record dated 6/22/17 did not document the immunization status for R9's influenza, Pneumococcal and Prevnar 13 immunizations. Surveyor was unable to locate R9's immunization status in both R9's electronic and paper medical records. Surveyor could not locate any documentation in R9's nursing notes or medical record that R9 had been approached or offered any immunization upon admission to the facility. On 7/12/17 at 10:45 a.m., Surveyor informed RN (Registered Nurse) Manager-H of the above findings. Surveyor asked RN Manager-H what R9's immunization status was as Surveyor was unable to locate R9's immunization status in either R9's electronic and paper medical records. RN Manager-H informed Surveyor that R9 refuses to have any immunization and that she (RN Manager-H) approached R9 today (7/12/17) and offered information on the Pneumococcal immunizations. RN Manager-H informed Surveyor that she did not know what R9's immunization status was and that she would look in R9's medical record to obtain more information and let Surveyor know. On 7/12/17 at 12:49 p.m., RN Manager-H informed Surveyor that she was unable to locate R9's immunization status and that she would document R9's immunization refusals in R9's nursing notes. Surveyor asked RN Manager-H if facility staff should have documented or investigated R9's immunization status to determine if R9 had received the Pneumococcal, influenza and Prevnar 13 immunizations or if they were medically contraindicated or refused. RN Manager-H informed Surveyor that facility staff should have documented or investigated R9's immunization status to determine if R9 had received the Pneumococcal, influenza and Prevnar 13 immunizations or if they were medically contraindicated or refused. RN Manager-H informed Surveyor that the facility usually obtains the resident's immunization record from the discharge summary and that the facility needed a better system to track and document the immunization status of residents upon admission. On 7/12/17 at 2:56 p.m., during the daily exit conference, Surveyor informed Interim Administrator-A and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not document or investigate R9's immunization status to determine if R9 had received the Pneumococcal, influenza and Prevnar 13 immunizations or if they were medically contraindicated or refused.

Based on interview and record review, the Facility did not ensure that 6 (R6, R7, R3, R1, R13, & R12) of 6 residents reviewed for hydration fluids were monitored to ensure they were provided with sufficient fluids to meet assessed needs. Findings include: 1. Surveyor reviewed R6's medical record on 7/10/17 to 7/13/17. R6 was admitted to the facility on [DATE] and has a [DIAGNOSES REDACTED]. The nurses note dated 6/25/17 documents Resident alert, confused, and pleasant. Resident is unable to make her needs known. Resident's needs are anticipated. Resident getting around in her wheel chair, propelling herself. Staff attempted to feed resident and resident had only eaten a few bites of supper. Resident fidgets with things around her like her necklaces, news papers, and gripper socks. Resident is incontinent of bladder. The nutrition care assessment dated [DATE] documents under estimated fluid needs 1740cc/day (cubic centimeter per day). Under the section nutritional findings, nutrition diagnosis, monitoring, & intervention documents Resident is alert but very confused. Res. (Resident) does not respond appropriately to most questions. Res. has been making attempts to leave the table while eating in the D.R. (dining room). Res. needs constant redirection @ (at) meals so she is sitting @ a table where staff are available throughout the meals to cue, redirect & assist as needed. Under interventions document Serve diet as ordered & honor preferences. Weekly wts (weights). Record food/Bev (beverage) intake @ all meals. Encourage fluid at & between meals. The admission MDS (minimum data set) with an assessment reference date of 7/1/17 and signed as complete on 7/6/17 documents R6 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. Under the communication section R6 is coded as having unclear speech, rarely makes self understood and rarely understands others. R6 requires extensive assistance with one person physical assist for eating. The Resident interdisciplinary care plan dated 7/6/17 under the dietary section is checked for set tray up and for diet documents General Encourage Fluids. The nutritional status care plan dated 7/10/17 includes an intervention dated 7/10/17 of Provide at least 1500ml (milliliters) fluid per day. On 7/13/17 at 10:37 a.m. Surveyor asked RN (Registered Nurse) Consultant-C where fluids consumed would be documented for a Resident. RN Consultant-C explained dietary does the food & fluids and there is a binder that the dietitian reviews. RN Consultant-C explained fluids given by the nurse would be documented in the MAR (medication administration record), the CNA's (Certified Nursing Assistants) put fluids consumed in care tracker and there is another form for in between. Surveyor asked RN Consultant-C who monitors on a daily basis and reviews all these different areas where fluids are documented to ensure that a Resident is meeting their recommended fluid intake. RN Consultant-C replied right now it's the dietitian. RN Consultant-C explained for concerns with meal consumption this would be placed on the twenty four hour report but doesn't address the fluids and dietary isn't able to go into the CNA's care tracker. RN Consultant-C indicated dietary would pull all the pieces together and inform nursing. On 7/13/17 at 10:53 a.m. Surveyor asked Dietitian-O who monitors on a daily basis and reviews all the different areas where fluids are documented to ensure that a Resident is meeting their recommended fluid intake. Dietitian-O replied really can't tell you how it's done and explained they don't have a specific tool between dietary services and the CNAs. Dietitian-O informed Surveyor a hydration assessment is completed quarterly and if a Resident is assessed for level 2 hydration they offer more fluids. Surveyor asked Dietitian-O when does she review a Resident's fluid intake. Dietitian-O informed Surveyor upon admission, quarterly, annually and if there is a significant change. On 7/13/17 at 2:40 p.m. during the daily exit conference Interim Administrator-A, DON (Director of Nursing)-B and RN Consultant-C were informed of the above. 2. Surveyor reviewed R7's medical record on 7/10/17 to 7/12/17. R7 has a [DIAGNOSES REDACTED]. The nutritional status care plan dated 3/25/16 includes an intervention also dated 3/25/16 of Provide at least 1500 - 2000 ml (milliliters) fluid per day. The quarterly MDS with an assessment reference date of 6/26/17 and signed as complete on 6/30/17 has a BIMS (brief interview mental status) total score of 2 which indicates severe impairment. Under the communication section R7 is coded as having unclear speech, sometimes makes self understood and sometimes understands others. R7 requires extensive assistance with one person physical assist for eating. The plan of care reviewed evaluation note dated 6/26/17 documents POC (plan of care) reviewed. Goal met. Resident has had a fair appetite at meals. She is not always meeting calorie and protein requirements from food/beverage consumed at meals. Will reinstate 90cc (cubic centimeters) Protein shake if resident has a trend of weight loss or if she has a sig (significant) wt (weight) loss in a short period. Weight has been stable this past quarter. Resident is not meeting minimum fluid requirement. An additional 120cc fluid will be offered q (every) shift to increase opportunities to drink liquids and prevent fluid volume deficit. Hydration assessment did not indicate increased risk for fluid volume deficit. Goal and approaches are appropriate and are extended. The quarterly nutrition assessment note dated 6/26/17 documents Resident consumed ~(approximately) 60% food/beverage/at meals this past week which averages 1320 cal (calorie)/day. Caloric intake was ~200cal/day less than requirement of 1424 cal/day so weight loss is expected if calorie intake continues at current rate. Will reinstate 90 cc (cubic centimeter) Protein shake if resident has a trend of weight loss or if she has a significant weight loss in a short period. Weight hast been stable this past quarter. She consumed ~200 cc fluid/meal this past week which averages 600cc fluid/day. A maximum of 665cc fluid is present in food served at meals each day. Since resident consumed at least 60% of food at meals this past week, at least ~400 cc/day (60% of 665cc) of water was present in the food she consumed. Total fluid intake from water contained in food she eats and from the fluid she drinks at meals was ~1000cc/day. This does not include the water she is offered from hydration cart each AM (morning), PM (evening), and HS (hour sleep). It does not include the additional fluid she is drinking with her meds. Resident is also offered beverages at the activities she attends. Resident is not always meeting minimum fluid requirements. Hydration assessment did not indicate increased risk for fluid volume deficit. An additional 120cc fluid will be offered q (every) shift to increase opportunities to drink liquids and prevent fluid volume deficit. She consumed at least 50gm (grams) protein from the food/milk at her meals. She is meeting minimum protein requirement of 50 gm/day. Skin is intact. Braden scale score indicates resident is at risk of developing a pressure ulcer. Goal of no significant weight loss on risk for alteration in nutrition/hydration POC (plan of care) is still realistic and will continue with current approaches. The Resident interdisciplinary care plan located inside R7's closet dated 6/28/17 under the dietary section is checked for set tray up and extensive assist-also cue. On 7/10/17 at 12:50 p.m. Surveyor observed RA (Restorative Aide)-N feeding R7 lunch in the hallway. Surveyor observed R7's lunch meal consisted of fish, mashed potatoes, dessert, milk and red juice. On 7/10/17 at 1:03 p.m. Surveyor observed RA-N continues to be feeding R7 lunch. On 7/10/17 at 1:19 p.m. Surveyor observed R7 ate approximately 75 percent of her meal and drank approximately 90 cc of her milk and red juice. On 7/13/17 at 10:37 a.m. Surveyor asked RN (Registered Nurse) Consultant-C where fluids consumed would be documented for a Resident. RN Consultant-C explained dietary does the food & fluids and there is a binder that the dietitian reviews. RN Consultant-C explained fluids given by the nurse would be documented in the MAR (medication administration record), the CNA's (Certified Nursing Assistants) put fluids consumed in care tracker and there is another form for in between. Surveyor asked RN Consultant-C who monitors on a daily basis and reviews all these different areas where fluids are documented to ensure that a Resident is meeting their recommended fluid intake. RN Consultant-C replied right now it's the dietitian. RN Consultant-C explained for concerns with meal consumption this would be placed on the twenty four hour report but doesn't address the fluids and dietary isn't able to go into the CNA's care tracker. RN Consultant-C indicated dietary would pull all the pieces together and inform nursing. On 7/13/17 at 10:53 a.m. Surveyor asked Dietitian-O who monitors on a daily basis and reviews all the different areas where fluids are documented to ensure that a Resident is meeting their recommended fluid intake. Dietitian-O replied really can't tell you how it's done and explained they don't have a specific tool between dietary services and the CNA's. Dietitian-O informed Surveyor a hydration assessment is completed quarterly and if a Resident is assessed for level 2 hydration they offer more fluids. Surveyor asked Dietitian-O when does she review a Resident's fluid intake. Dietitian-O informed Surveyor upon admission, quarterly, annually and if there is a significant change. On 7/13/17 at 2:40 p.m. during the daily exit conference Interim Administrator-A, DON (Director of Nursing)-B and RN Consultant-C were informed of the above. 3. R3 has [DIAGNOSES REDACTED]. R3's care plan for Risk for Altered Nutritional/Hydration Status Related to: low HGB/HCT (hemoglobin/hematocrit), increased nutrient needs to promote healing of Ankle FX (fracture), caloric and protein intake < (less than) requirements, increased nutrient needs to promote healing or pressure ulcer on left heel. Interventions include PROVIDE AT LEAST 1500 ML FLUID PER DAY. Other interventions include to Assess individual resident fluid requirements base on accepted standards of practice and create a plan of care to meet or exceed those needs. From 7/11/17-7/17/17 the surveyor reviewed R3's medical record. The surveyor was unable to find any assessment calculating R3's total daily fluid intake to ensure that she was meeting at least 1500mL of fluid daily. On 7/17/17 at 11:40 a.m. the surveyor asked Administrator-D for R3's fluid intake for July. On 7/17/17 at approximately 12:30p.m. Dietitian-O provided the surveyor with fluid intakes for R3 from multiple sources. The surveyor noted that there was no documented assessment calculating to ensure that R3 meets her assessed fluid intake daily. On 7/17/17 during the exit with Administrator-D and DON-B, the facility was informed of the concern related to R3 having no documented total daily fluid intake to determine if she is meeting her fluid requirements. No additional information was provided. 4. Surveyor reviewed R12's medical record from 7/12/17 to 7/1717. R12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R12's quarterly MDS (Minimum Data Set) dated 5/1/17 documents a BIMS (Brief Interview of Mental Status) of 15, indicating that R12 is cognitively intact. R12's Nutritional Status CAA (Care Area Assessment) dated 10/31/16 documents under the Care Plan Reason section documents, Approaches are in place to offer foods and liquids that are safe for resident to chew and swallow to prevent aspiration. See approaches on potential for aspiration POC (plan of care). R12's nutritional status care plan dated 1/6/16 documents under the action section, Encourage at least 1500 ml (milliliters) of fluid per day. R12's Quarterly Nutrition Assessment Note dated 5/1/17 documents, Total fluid intake from Magic Cups and thickened beverages consumed at meals this past week was approximately 1300-1400 cc (cubic centimeters)/day. Surveyor reviewed R12's fluid intake in R12's medical record and was unable to locate R12's total amount of fluid intake for the following dates: 7/5/17 to 7/8/17. On 7/13/17 at 11:22 a.m., Surveyor requested R12's fluid intake monitoring from Dietitian-O. On 7/13/17 at 2:20 p.m., Dietitian-O provided Surveyor with R12's fluid intake from 7/5/17 to 7/8/17. Surveyor asked Dietitian-O how facility staff monitor R12's fluid intake. Dietitian-O informed Surveyor that facility staff record R12's fluid intake in three different locations which were care tracker, a dietary binder and CNA (Certified Nursing Assistant) monitoring on a paper form. Surveyor asked Dietitian-O how she performs an accurate assessment as locating R12's fluid intake was difficult as Surveyor was unable to locate the total amount of fluid intake for R12 from 7/5/17 to 7/8/17. Dietitian-O informed Surveyor that CNAs don't accurately and consistently monitor R12's fluid intake and that she monitors R12's fluid intake approximately every two weeks. Surveyor asked Dietitian-O how facility staff would monitor an acute change in a resident's fluid intake status if it occurred before the two week period Dietitian-O reviews a resident's fluid intake Dietitian-O informed Surveyor that the facility needs a better system to monitor for dehydration and acute changes in a resident's fluid intake status. On 7/13/17 at 2:30 p.m., Surveyor reviewed R12's fluid intake from 7/5/17 to 7/8/17. Surveyor noted that R12's documented fluid intake on the following dates were as follows:7/5/17- 995 cc, 7/6/17- 800 cc, 7/7/17- 60 cc, 7/8/17- 240 cc. On 7/17/17 at 9:17 a.m., Surveyor informed Dietitian-O of the above findings. Surveyor and Dietitian-O confirmed the fluid intake for R12 on the above dates. Surveyor asked Dietitian-O how she accurately monitors R12's fluid intake as Surveyor gathered information from all the sources provided and struggled to obtain a total fluid intake as the CNA monitoring for every meal on the above dates was not complete. Dietitian-O informed Surveyor that she averages R12's fluid intake and attempts to monitor R12 daily when she encounters R12 during meals in the dinning room. Dietitian-O informed Surveyor that she has will attempt to implement a new system to monitor R12's fluid intake as the current system for fluid monitoring is not consistent or accurate. On 7/17/17 at 11:37 a.m., during the daily exit conference, Surveyor informed Administrator-D and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not accurately monitor R12's fluid and hydration intake. 5. R1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R1's Care Plan for Nutritional Status dated 4/25/17 states, Provide at least 1500 - 2000 ml (milliliters) fluid per day. Review of R1's I (intake) / O (output) by Day Chart indicated fluid intake is not consistently recorded. Surveyor review of fluid intake for dates 7/1/17 - 7/11/17 indicated no documentation of fluid intake. Review of R1's Medication Administration Record [REDACTED]. Review of R1's Food/Fluid Intake Record revealed each 2 sided page covered a 2 week period. Surveyor noted the day of the week is not dated, therefore it is difficult to determine actual dates. R1's Food/Fluid Intake Record for June 25th - July 11th 2017 documented fluid intake per meal, though it was not consistently documented for each meal and did not have a total listed for each 24 hour period. Review of R1's Medical Record documented no evidence that staff analyzed R1's daily fluid intake, as the facility staff did not consistently total R1's 24 hour fluid intake. Surveyor was unable to locate any documentation to indicate that staff was aware if R1 was meeting fluid goals as documented in the Care Plan. On 7/12/17 at 2:30 pm, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated fluid intake is found in Caretracker, MAR, and intake record binder in the kitchen. Surveyor asked DON-B how the facility monitors if a resident is meeting their daily fluids as indicated on their Care Plan. DON-B reported the Dietitian reviews resident's fluid intake weekly. DON-B stated, Nurses can look at the binder in the kitchen or Caretracker, I guess, to see how residents are drinking. DON-B reported staff can also find fluid documentation in the MAR. Surveyor reviewed the kitchen binder with DON-B. DON-B stated the sheet was confusing, and was unable to confirm specific dates for R1's fluid intake. DON-B reported there is no real system in place to monitor if residents are meeting their Daily fluids except for the Dietitian review, which DON-B reported is weekly. 6. R13 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R13's Care Plan for Nutritional Status dated 5/15/17 states, Provide at least 1500 - 2000 ml (milliliters) fluid per day. Review of R13's I (intake) / O (output) by Day Chart indicated fluids are not consistently recorded. Surveyor review for the month of June 2017 documented fluid intake of 480 ml (milliliters) on 6/28/17 only. No other fluids are recorded on the Resident I/O by Day Chart for the month of June 2017. Review of R13's Medication Administration Record [REDACTED]. Review of R13's Food/Fluid Intake Record revealed each 2 sided page covered a 2 week period. Surveyor noted the day of the week is not dated, therefore it is difficult to determine actual dates. R13's Food/Fluid Intake Record for May 28th - June 24th 2017 documented fluid intake per meal, though it was not consistently documented for each meal and did not have a total listed for each 24 hour period. Review of R13's Medical Record documented no evidence that staff analyzed R13's daily fluid intake, as the facility staff did not consistently total R13's 24 hour fluid intake. Surveyor was unable to locate any documentation to indicate that staff was aware if R13 was meeting fluid goals as documented in the Care Plan. On 7/12/17 at 2:30 pm Surveyor interviewed Director of Nursing (DON)-B. DON-B stated fluid intake is found in Caretracker, MAR, and intake record binder in the kitchen. Surveyor asked DON-B how the facility monitors if a resident is meeting their daily fluids as indicated on their Care Plan. DON-B reported the Dietitian reviews resident's fluid intake weekly. DON-B stated Nurses can look at the binder in the kitchen or Caretracker, I guess, to see how residents are drinking. DON-B reported staff can also find fluid documentation in the MAR. Surveyor reviewed the kitchen binder with DON-B. DON-B stated the sheet was confusing, and was unable to confirm specific dates for R13's fluid intake. DON-B reported there is no real system in place to monitor if residents are meeting their Daily fluids except for the Dietitian review, which DON-B reported is weekly.

Based on observation, interview, and record review the Facility did not ensure that an allegation of mistreatment was immediately reported and injuries of unknown source were thoroughly investigated and reported to the State agency for 3 (R8, R15, & R11) of 16 sampled Residents and 1 (R17) of 7 supplemental Residents. In addition, the suspicion of a crime posting did not contain all the required information relating to filing a complaint. * On 7/10/17, R8 reported an allegation of mistreatment to CNA-Q. At the end of CNA-Q's shift Surveyor asked CNA-Q if she had reported R8's allegation to anyone. CNA-Q informed Surveyor she did not and probably should have. * R15's bruise to his buttocks which measures approximately 5 x (times) 5 identified on 11/10/16 was not investigated or reported to the State agency. * R17's allegation of potential abuse was not reported to the State agency. * R11's injury of unknown source was not investigated or reported to the State agency. Findings include: The Freedom from Abuse, Neglect, and Exploitation policy and procedure which is not dated under the section reporting and response components documents, Abuse Policy Requirements: It is the policy of the facility that abuse allegation (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported per federal and state law. The facility will ensure that all alleged violations involving abuse are reported immediately. For crimes resulting in serious bodily injury a report must be made no later than two (2) hours after the allegation is made. Other reports must be made no later than twenty-four (24) hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. These reports are made to the Administrator or designee of the facility and DQA (Department Quality Assurance) in accordance with state law through established procedures. In addition, local law enforcement (Village of Summit Policy Department - 262.567.1134) will be notified of any reasonable suspicion of a crime against a resident in the facility. Under procedure documents, 1. Internal Reporting a. Employees, contractors, volunteers, resident and resident representatives will receive orientation and education on the facility Abuse Policy and reporting requirements. Staff must always report any abuse or suspicion of abuse immediately to the Administrator or designee. *Note: Failure to report can make employee just as responsible for the abuse in accordance with state law. 1. Surveyor reviewed R8's medical record on 7/10/17 to 7/13/17. The quarterly MDS (Minimum Data Set) with an assessment reference date of 4/17/17 and signed as complete on 4/20/17 documents a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R8 is dependent upon staff with two plus person physical assist for transfers, does not ambulate, requires extensive assistance with two plus person physical assist for bed mobility, is always incontinent of bowel and frequent incontinent of bladder. On 7/10/17 at 11:41 a.m., Surveyor observed CNA (Certified Nursing Assistant)-S and LPN (Licensed Practical Nurse)-T transfer R8 from the Broda chair into bed using a Hoyer lift. After R8 was transferred into bed, CNA-S provided continence care to R8. The incontinence product was removed and a new incontinence product was placed on R8. At 11:59 a.m., LPN-T indicated that someone had taken the lift, removed her gloves & mask and left R8's room. At 12:01 p.m., CNA-Q entered R8's room with a Hoyer lift. CNA-S and CNA-Q attached the sling to the Hoyer lift and R8 was transferred back into the Broda chair. CNA-S & CNA-Q unhooked the sling from the lift and removed the sling from under R8. At 12:07 p.m., CNA-S removed her gloves, washed her hands, and left R8's room with the Hoyer lift. At 12:08 p.m., R8 informed CNA-Q that she had a lady the other evening that pulled her leg and was rough. R8 stated she was agency. CNA-Q asked R8 Did you scare her off? R8 replied, I don't want to be hurt. R8 informed CNA-Q she was jerking her leg hard and she was a heavy set gal. CNA-Q informed R8 you have to be comfortable with who takes care of you. CNA-Q combed R8's hair and then left the room. On 7/10/17 at 1:38 p.m., Surveyor observed R8 sitting in a Broda chair in her room. Surveyor asked R8 if Surveyor could talk to her about what she had spoken to CNA-Q earlier regarding the agency aide and asked R8 if she could explain what happened. R8 explained that the CNA grabbed her leg. R8 stated she said ow and told the CNA that her leg was sore. R8 stated after that, the CNA went after her and did what she wanted to do. R8 stated all I said was ow. Surveyor asked when this was. R8 replied, Wednesday or Thursday night when putting me to bed. R8 informed Surveyor she told the CNA she didn't want to see her again. Surveyor asked R8 if she reported this to anyone. R8 informed Surveyor that she told a nurse and she thinks the CNA is from an agency. Surveyor asked if R8 remembered the name of the nurse she reported this to. R8 informed Surveyor she didn't and stated there are so many of them. R8 informed Surveyor that if she wasn't such a lady she would have called the CNA a expletive. R8 stated, She just didn't care if she hurt me or not. It was like she was out to get me. I wasn't going to report her but then I thought she shouldn't do this to someone else. R8 informed Surveyor when the CNA grabs you, you go what ever direction she wants you to. R8 informed Surveyor, If you have aches and pains you should be treated gently. On 7/10/17 at 2:32 p.m., Surveyor asked CNA-Q if she reported what R8 had told her this morning to anyone. CNA-Q replied, no I did not. I probably should of. CNA-Q then informed Surveyor its hard to distinguish if it's true what R8 is saying as she sometimes goes back in time. CNA-Q stated sometimes don't know how to take it. Surveyor informed CNA-Q when a Resident makes an allegation she needs to report this immediately. Surveyor asked CNA-Q how long she has been working at the Facility. CNA-Q informed Surveyor she has been working at the Facility since the end of December after she graduated and this is her first CNA job. Surveyor asked CNA-Q if she has received training on abuse. CNA-Q replied, yes. On 7/10/17 at 2:45 p.m., Surveyor asked LPN (Licensed Practical Nurse)-T, who was the day nurse on R8's unit, if staff reported an allegation of mistreatment involving R8 to her. LPN-T replied, no. On 7/10/17 at 2:45 p.m., Surveyor informed DON (Director of Nursing)-B of R8's allegation and that R8 had informed CNA-Q this morning but CNA-Q did not report this allegation. DON-B informed Surveyor she would do an investigation. On 7/11/17 at 3:26 p.m. Interim Administrator-A, DON-B and RN (Registered Nurse) Consultant-C were informed of the above. 2. Surveyor reviewed R15's medical record on 7/17/17. The admission MDS (Minimum Data Set) with an assessment reference date of 7/18/16 and signed as complete on 7/20/16 documents R15 has a BIMS (brief interview mental status) score of 0 which indicates severe impairment. R15 requires extensive assistance with one person physical assist for bed mobility, extensive assistance with two plus person physical assist for transfers & ambulation, is occasionally incontinent of bowel and frequently incontinent of bladder. The nurses note dated 11/11/16 documents, Voice message left for POA (power of attorney) to update on large bruise on buttock noted by hospice aide during cares. Staff will verbalize and assist resident to slowly lower into w/c (wheelchair) or toilet to prevent any further injury/bruises. Denied any pain or discomfort regarding bruise. On 7/17/17 at 9:48 a.m., Surveyor asked RN (Registered Nurse) Consultant-C if she had an investigation for R15's injury of unknown source. RN Consultant-C informed Surveyor she didn't have any investigations as she was not here in November 2016. RN Consultant-C indicated she came to the Facility February 2017 and investigations are one of the things they are working on. On 7/17/17 at 9:50 a.m., Surveyor asked Administrator-D if she had an investigation for R15's bruise to his buttocks in November 2016. Administrator-D informed Surveyor she would look. On 7/17/17 at 9:57 a.m., Surveyor asked SW (Social Worker)-K if she had any investigations for injuries of unknown source. SW-K replied, no, that would be nursing. On 7/17/17 at 11:40 a.m. during the daily exit conference Surveyor informed Administrator-D and DON (Director of Nursing)-B Surveyor still has not received an investigation for R15's injury of unknown source. On 7/17/17 at 1:29 p.m., Surveyor was provided R15's three page incident report for incident date of 11/10/16 completed by LPN (Licensed Practical Nurse)-M. Under describe the incident documents, Hospice CNA (Certified Nursing Assistant) found large bruise approx (approximately) 5x5 in diameter on upper left buttocks during cares in the AM (morning). Under Resident's description documents, I don't know. Under staff actions at time of incident documents, Staff were doing cares on other residents. Under the section investigation/follow up dated 11/11/16 documents under notes, Verbalize and assist resident to slowly lower to W/C (wheelchair) or toilet to prevent further injury/bruising. On 7/17/17 at 2:27 p.m., Administrator-D informed Surveyor she does not have an investigation for R15's injury of unknown source. Surveyor asked Administrator-D if a Resident had a bruise on their buttocks is this something the Facility would investigate. Administrator-D informed Surveyor unless they would be able to say how it happened the bruise would have to be investigated. Surveyor noted R15's injury of unknown source was not investigated and not reported to the State agency. 3. On 7/17/17 at 8:30 a.m., as a part of the Abuse Prohibition Survey Task, Surveyor reviewed R17's investigation alleging that a male had molested R17 while R17 was in her bed. The investigation dated 3/3/17 documents under the concern section, CNA-FF informed SW (social worker)-K that R17 just told her a male just molested her. She (R17) said he was picking things of his clothes and put it on her (sic). The investigation contained 13 staff statements that all indicated facility staff had no knowledge of R17's allegation. Under the Follow up section it documents, SW-K interviewed R17, nursing staff, unit secretary at Rotunda, staff member at front desk and contacted her (R17's) Health Care Power of Attorney. (See all attached witness statements). Nobody saw R17 with a male during this time frame. Daughter believes it was a Delusion/Hallucination. 3/14/17-update- see attached; families updated as to conclusion. The investigation contained an attachment dated 3/14/17 that documented under the Conclusion section, It was discovered that on the date of concern report 3/3/17; a confused female resident entered R17's room, thinking it was hers, while R17 was in bed. She approached the bed in her wheelchair and was found by staff patting the top of the bed with her hands to see if anyone was in the bed; with the plan to try and get into the bed and take a nap. Staff was able to redirect the resident out of R17's room and explained to R17 at that time that it was another resident they were taking out. Staff member reports later overhearing R17 tell this same resident that a man was in her room touching her. Staff reminded R17 it was another resident not a man. On 7/17/17 at 8:34 a.m., Surveyor informed Administrator-D of the above findings. Surveyor asked Administrator-D why the facility did not report the above allegation to the State Agency. Administrator-D informed Surveyor that she was not the administrator at the time of the above allegation and directed Surveyor to speak with SW-K. On 7/17/17 at 9:05 a.m., Surveyor informed SW-K of the above findings. Surveyor asked SW-K why the facility did not report the above allegation to the State Agency. SW-K informed Surveyor that the previous facility Administrator had the final determination as to what investigations and allegations were reported to the State Agency and had decided not to report the above allegation to the State Agency. On 7/17/17 at 11:37 a.m., during the daily exit conference, Surveyor informed Administrator-D and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not immediately report to the State Agency and submit investigative findings within 5 working days of the alleged allegation of abuse by R17. 4. Surveyor reviewed R11's medical record from 7/10/17 to 7/17/17. R11 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R11's annual MDS (Minimum Data Set) dated 4/17/17 documents a BIMS (Brief Interview for Mental Status) score of 1, indicating that R11 is severely cognitively impaired. R11's nursing note dated 11/10/16 documents a skin tear to R11's right forearm. The nursing note does not document an origin, description or an action that caused R11's right forearm skin tear. On 7/13/17 at 3:07 p.m., during the daily exit conference, Surveyor requested from Interim Administrator-A the investigation for R11's injury of unknown origin as described above. On 7/17/17 at 8:08 a.m., the facility provided Surveyor with a copy of R11's incident report for R11's skin tear obtained on 11/10/16. The Incident report documents under the Describe the Incident section, Resident noted to have a small skin tear of R (right) forearm. Seated in reclined with bedside table next to resident. Old bruising noted to area. Under the Resident's Description section it documents, Unable to describe, alert to self only at baseline. Under the Staff Actions at Time of Incident section it documents, Cleansed, measured, 2 steri-strips applied followed by dry gauze secured with paper tape. Under the Investigation/Follow-Up section it documents, Res. (Resident) has fragile skin, area cleaned will monitored. Will encourage res to wear long sleeves. Surveyor noted that the incident report did not contain any staff statements or any investigation to determine how resident obtained a skin tear to his right forearm. Surveyor was unable to locate any measurements of R11's skin tear and was unable to locate any documentation that indicated or described how R11 obtained a skin tear to his right forearm. On 7/17/17 at 9:33 a.m., Surveyor informed RN (Registered Nurse) Consultant-C of the above findings. Surveyor asked RN Consultant-C why the facility did not investigate R11's skin tear as an injury of unknown origin as Surveyor was unable to locate any documentation that indicated or described how R11 obtained a skin tear to his right forearm. RN Consultant-C informed Surveyor that the facility administrator at that time should have investigated and reported to the State Agency the injury of unknown origin to R11 on 11/10/16. On 7/17/17 at 11:37 a.m., during the daily exit conference, Surveyor informed Administrator-D and DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not thoroughly investigate or immediately report to the State Agency and submit investigative findings within 5 working days of the injury of unknown origin to R11 on 11/10/16. 5. On 7/11/17 at 9:00 am, Surveyor reviewed the posting for the Elder Justice information which was located on the right side next to the staff time clock. Surveyor noted that the notice was missing the statement, An employee may file a complaint with the Secretary against a LTC (Long Term Care) facility that violates the provisions of this subsection and information with respect to the manner of filing a complaint. On 7/12/17 at 2:30 pm, Surveyor informed Interim Administrator-A about the missing statement. Interim Administrator-A stated he was not aware the posting did not have the required statement. Administrator-A stated he would look at the regulations and get it fixed.

Based on record review and staff interview, the facility did not implement its written policy to prevent verbal and physical abuse for residents living on the Woods Unit. The Woods Unit is one of three living units at the facility. Resident #1, who lives on the Woods Unit, was verbally and mentally abused by LPN - C on 4-27-13. The abuse was witnessed by CNA - D and CNA - E who did not immediately report the allegation, in accordance with facility policy. Because the allegation was not immediately reported, the facility was unable to prevent further potential abuse, in accordance with its policy. LPN - C worked the following day, 4-28-13, when she again verbally and mentally abused - and also physically abused - Resident #1. This deficient practice had the potential to affect all residents living on the Woods Unit, which is where LPN - C, CNA - D, and CNA - E worked. The deficient practice created a finding of Immediate Jeopardy, which began on 4-27-13. The Immediate Jeopardy was removed on 5-6-13. The deficient practice continues at a scope/severity level of C (Potential for no more than minimal Harm/Widespread) until the facility updates its written policy to be consistent with the training that was provided. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 5-14-13 at 2:25 PM, by Surveyor # . Findings include: FACILITY PROCEDURE The facility's policy titled, "Investigation of Abuse, Neglect, Mistreatment of [REDACTED].# . The policy had an effective date of 1999 and a Revision Date of "5/10." Surveyor # interviewed the Administrator on 5-9-13 and he confirmed this was the Abuse Policy that was in effect prior to the allegation of abuse that occurred on 4-27-13 and 4-28-13. The section titled "Procedure" states: "1. All staff will immediately report any occurrences, situations or persons including residents, suspected of resident abuse, neglect, mistreatment or misappropriation of resident property..." "2. All reports will be directed to the Team leader who is responsible for that resident. Reports can also be directed to nurse management or to the Administrator." "3. The person(s) named in the complaint will be immediately separated from the residents. Have this person(s) wait in an area where they do not have resident, staff, or visitor contact." "10. If necessary, suspend the person named in the complaint pending the results of the investigation..." FACILITY INVESTIGATION The facility's investigation, of LPN - C allegedly abusing Resident #1, was reviewed 5/09 - 5/14/13 by Surveyor # . SATURDAY APRIL 27, 2013 On 4-27-13 at approximately 11:30 am, CNA - D and CNA - E witnessed LPN - C verbally abuse Resident #1. LPN - C called Resident #1 a "[***] ," a "f...ing dumb ass" and a "f...g retard" and threatened to have alarms put on her so she could not get out of bed. Cross Reference F223 Neither CNA - D nor CNA- E immediately reported the abuse that day, April 27, 2013, in accordance with facility policy. SUNDAY APRIL 28, 2013 CNA - D and CNA - E witnessed LPN - C verbally and physically abuse Resident #1 on 4-28-13 at approximately 11:30 am. CNA - D and CNA - E witnessed the abuse at approximately 11:30 am. LPN - C called Resident #1 a "psycho [***] " and a "crazy [***] ," physically struck Resident #1 on the hand, wrist, and forearm, and threatened to have Resident #1 sent to a "f...ing psych ward." LPN - C also put a fist up to Resident #1's face and threatened her and made mocking faces at her later in the shift. (Cross Reference F223) They did not immediately report the alleged abuse to the Team leader, nurse management, or the Administrator, in accordance with the Abuse Procedure. CNA - D and CNA - E, waited until the end of their shift on 4-28-13, and called Human Resources to report the incident. They left a voice mail for the Human Resources Director. Because the abuse was not immediately reported on 4-27-13, the facility was unable to prevent further potential abuse, in accordance with the Abuse Procedure. LPN - C worked the following day, 4-28-13. LPN - C was not immediately separated from the residents, on either 4-27-13 or 4-28-13. LPN - C was not suspended on 4-27-13, pending the results of the investigation. MONDAY APRIL 29, 2013 The facility did not learn about the alleged abuse until the morning of 4-29-13. At that time the investigation began. LPN - C was not working. She was called to the facility and interviewed by the Administrator and DON. LPN - C was then suspended pending the facility's investigation. INTERVIEW WITH CNA - D AND CNA - E On 5-9-13 at 2 PM, Surveyor # interviewed CNA - D. CNA - D said that she did not immediately report the alleged abuse because the accused person was her supervisor, LPN - C. CNA - D said that she did not feel comfortable reporting the allegation to another nurse who was working, because she thought that LPN - C and the nurse were friends. CNA - D said that if it had occurred during the week, she would have reported the allegation to the Administrator. CNA - D said that she and CNA - E felt comfortable reporting the incident to Human Resources and so CNA - E called Human Resources on Sunday 4-28-13 and reported the incident. CNA - D said that, after the incident, she had been told by management at the facility that she should have immediately reported the allegation to the "on-call nurse." On 5-10-13 at 8:40 am, Surveyor # interviewed CNA - E. CNA - E said that she did not report the allegation immediately on 4-27-13, as she did not feel comfortable reporting LPN - C to another nurse who was working. CNA - E thought that LPN - C and the other nurse were friends. CNA - E said that she immediately reported the alleged abuse when she found someone that she felt comfortable reporting to. CNA - E said that she later learned that she should have immediately reported the allegation to the "on-call nurse." The facility's failure to ensure that staff implemented its policies and procedures to immediately report allegations of abuse and prevent further potential abuse led to further abuse the following day, which escalated to include physical abuse. This led to the determination of Immediate Jeopardy, which began on 4-27-13. The facility removed the Immediate Jeopardy on 5-6-13 by revising its policies and procedures and retraining staff. After the allegation of abuse, the facility updated their policy titled, "Abuse, Neglect, and Mistreatment of [REDACTED]." It is dated 5-8-13. The following changes were made. The section titled "Procedure" states: "1. All staff will immediately report any occurrences, situations, or persons, including residents, suspected of resident abuse, neglect, mistreatment or misappropriation of resident property. Reports should be made by directly speaking to the person directly or by phone. No voice mails or emails." "2. All reports will be directed to the Administrator, Director of Nursing, Social Worker or Director of Human Resources immediately. (Phone numbers can be found on the staff directory) The team leader who is responsible for that resident should also be notified at that time." The facility retrained all staff staff regarding the facility's Abuse Prevention Policy, specifically reminding staff that all allegations must be reported immediately to the "on-call nurse," a supervisor, or management. During the complaint investigation, Surveyor # interviewed staff on 5-13-13 and determined that staff were able to implement the facility's Abuse Prevention Policy, by immediately reporting the incident to the on-call nurse, a supervisor, or management. Staff knew where to locate the phone numbers for the "on-call nurse," supervisors and management. The deficient practice continues at a scope/severity level of C (Potential for no more than minimal harm/Widespread) because the facility's written policy is not consistent with the re-training the facility provided for staff. When retraining staff, the facility directed that abuse be reported to the "on-call nurse", manager, or department supervisor. The facility's written Abuse Policy directs staff to report allegations to the Administrator, Director of Nursing, Social Worker, or Director of Human Resources and to also inform the Team leader who is responsible for the resident. The written policy does not include the on-call nurse.