Every finding on record at Middle River Health and Rehabilitation Center

Based on record review, observation, and interview, the facility did not ensure the resident's environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R) reviewed. (R1)R1's motion sensor alarm was not turned on when R1 was in bed, as indicated in R1's care plan to prevent falls. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with early onset, dementia with agitation. R1's Brief Interview Mental Status (BIMS) score is 00/15 indicating severe cognitive impairment. R1's care plan indicates R1 is high risk for falls related to confusion and is unaware of safety needs. On 3/12/26, R1 had a witnessed fall. On 04/23/26, R1's care plan was updated to have a motion sensor on the floor while R1 is in bed on exit/door side to alert staff when R1 moves their legs over the side of the bed, per POA request. On 06/16/26 at approximately 10:00 AM, Surveyor observed R1 upside down in bed with legs hanging off the side of the bed. R1 was moving legs back and forth at times and their feet would touch the floor. Surveyor noted a motion detector on the floor facing where R1's feet were, and no alarm was sounding. R1 did not answer Surveyor's questions but did not appear distressed. Surveyor then waved in front of the motion detector, and it did not alarm. Surveyor noted R1's bed was low to the ground and fall mats were placed on both sides of the bed. On 06/16/26 at approximately 10:00 AM, Surveyor requested Licensed Practical Nurse (LPN) D come to R1's room. Surveyor asked LPN D about motion detector use and functioning status. LPN D replied R1's motion detector was not on. Surveyor asked LPN D how would staff know if R1 got out of bed and if R1 was at risk for falls. LPN D stated they would not know, R1 is at risk for falls, and the motion detector should have been turned on. On 06/16/26 at 10:09 AM, Surveyor interviewed Unit Manager/RN E, who reported the expectation would be that the motion detector be turned on when R1 is in bed. On 06/16/26 at approximately 12:00 PM, Surveyor interviewed NHA A, who agreed R1's motion monitor should have been turned on while R1 was in bed and by not having the sensor turned on, this had the potential to increase R1's risk of falling.

Based on observation, interview, and record review, the facility did not ensure 1 of 4 residents reviewed (R1) received adequate supervision and assistance devices to prevent accidents.Certified Nursing Assistant (CNA) C did not use stand aid correctly causing a fall resulting in R1 sustaining a fracture.Findings include:R1 was admitted to the facility on [DATE].On 09/30/25, R1 had a Brief Interview for Mentals Status (BIMS) score of 6/15, which indicates severe cognitive impairment.Care plan includes in part: a focus of self-care deficit related to polyneuropathy, frequent falls, failure to thrive, weakness, and decreased mobility with interventions of high fall risk last revised on 11/22/25. Transfers: stand aid assist of 1. Toileting: 2 assist before morning cares, at bedtime, and every 2-3 hours while awake and upon request.On 01/18/26 at 1:45 PM, CNA C entered R1's room for incontinence care. CNA C assisted R1 to a standing position in the stand aid with no other staff assistance. While R1 was standing in the stand aid, CNA C attempted to pull down R1's pants to change incontinent brief. R1 stated R1 could no longer stand and R1's feet slipped off the stand aid platform. CNA C stated CNA C attempted to assist R1 by placing R1's feet back on the platform, but was unable to, and CNA C had to lower R1 to the floor. CNA D was walking past room and noticed the door was shut and opened it. CNA D called Licensed Practical Nurse (LPN) E to the room. LPN E assessed R1. CNA C, CNA D, and LPN E assisted R1 back to bed with the use of the Hoyer lift.On 01/18/26 at 7:30 PM, R1 reported pain in the right ankle/foot. Registered Nurse (RN) F assessed R1. Provider ordered x-rays.On 01/20/26, R1 was sent to the emergency room (ER) for x-rays and assessment. R1 was found to have an acute comminuted, minimally displaced, extra-articular fracture of the right posterior calcaneal tuberosity.On 01/20/26, R1 returned to the facility from the hospital. R1 previously was a 1 person assist with the stand aid and 2 assist with stand aid for toileting before the fall, and since return from the hospital, diagnosis of right posterior calcaneal tuberosity fracture, is now non-weight bearing on the right foot and requires the use of a Hoyer lift for all transfers with assist of 2 staff. R1 wears a prevalon protective boot when in bed, and a CAM boot when up out of bed.On 02/03/26 at 11:15 AM, Surveyor interviewed R1. R1 is not a good historian. R1 reported falling and breaking R1's foot but was unable to recall the events or staff present at the time of the incident.On 02/03/26, Surveyor reviewed the stand aid competency checklist for CNA C, which indicates CNA C has demonstrated use of the stand aid and could use it correctly dated 01/12/26.On 02/03/26 at 1:23 PM, Surveyor observed CNA C and CNA G transfer R2 with the stand aid. No concerns.On 02/03/26 at 1:30 PM, Surveyor interviewed CNA G about lift use and toileting. CNA G stated if a resident's care plan stated they were an assist of 1 for transfers, but an assist of 2 with toileting, CNA G would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 1:32 PM, Surveyor interviewed CNA C. CNA C stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA C would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 2:51 PM, Surveyor interviewed Rehab Director (RD) J. RD J stated the stand aid is only to be used as a way to transfer a resident and should not be used to stand a resident who requires changing their incontinent products.On 02/03/26 at 4:27 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated it would be NHA A's expectation that the staff would follow the resident's plan of care and acknowledged CNA C should have had assistance with incontinence care for R1.The facility did not provide education for the staff. Facility did not interview any other residents. R1's care was delayed because an RN did not assess R1 after the LPN assessed R1. An RN, RN F, did not assess R1 for 6 hours after the fall had occurred.

Based on interview and record review, the facility did not ensure 1 of 4 residents reviewed (R1) received person-centered care according to the comprehensive care plan.-A facility staff member did not follow R1's care plan for toileting resulting in a fall.Findings include:R1 was admitted to the facility on [DATE].On 09/30/25, R1 had a Brief Interview for Mentals Status (BIMS) score of 6/15 which indicates severe cognitive impairment.Care plan includes in part; Transfers: stand aid assist of 1. Toileting: 2 assist before morning cares, at bedtime, and every 2-3 hours while awake and upon request.On 01/18/26 at 1:45 PM, Certified Nursing Assistant (CNA) C entered R1's room for incontinence care. CNA C assisted R1 to a standing position in the stand aid with no other staff. While R1 was standing in the stand aid, CNA C attempted to pull down R1's pants to change incontinent brief. R1 stated R1 could no longer stand and R1's feet slipped off the stand aid platform. CNA C stated CNA C attempted to assist R1 put R1's feet back on the platform, but was unable to, and had to lower R1 to the floor.On 02/03/26 at 11:15 AM, Surveyor interviewed R1. R1 is not a good historian. R1 reported falling and breaking her foot but was unable to recall the events or staff present at the time of the incident.On 02/03/26 at 11:41 AM, Surveyor interviewed CNA C. CNA C stated each resident has a care plan which CNAs can access on their charting program in the computer and there is also a book at the desk they can review if unsure about care. CNA C stated they get verbal report when changes are made as well.On 02/03/26 at 11:50 AM, Surveyor interviewed Registered Nurse (RN) H. RN H stated care plans are updated by nurses or Director of Nursing (DON) as changes occur. RN H showed Surveyor the binder at the nurse's station that includes all resident care plans. RN H stated all CNAs have access to this if they are unsure and also get verbal report of changes to resident care.On 02/03/26, Surveyor reviewed stand aid competency checklist for CNA C which indicates CNA C has demonstrated use of the stand aid and could use it correctly.On 02/03/26 at 1:23 PM, Surveyor observed CNA C and CNA G transfer R2 with the stand aid. No concerns.On 02/03/26 at 1:30 PM, Surveyor interviewed CNA G. CNA G stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA G would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 1:32 PM, Surveyor interviewed CNA C. CNA C stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA C would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 2:51 PM, Surveyor interviewed Rehab Director (RD) J. RD J stated the stand aid is only to be used as a way to transfer a resident and should not be used to stand a resident that requires changing of incontinent products.On 02/03/26 at 4:27 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated it would be NHA A's expectation staff would follow the resident's plan of care and acknowledged CNA C should have had assistance with incontinent care for R1.

Based on observation, interview, and record review, the facility did not provide evidence that all alleged violations are thoroughly investigated for an injury of unknown cause.-Facility did not conduct interviews for other staff and residents.-Facility did not complete education in relation to the incident-Facility did not ensure a Registered Nurse (RN) completed an assessment after a Licensed Practical Nurse (LPN) completed the initial assessment.-Facility did not investigate further after becoming aware of fracture.Findings include:R1 was admitted to the facility on [DATE].On 09/30/25, R1 had a Brief Interview for Mentals Status (BIMS) score of 6/15 which indicates severe cognitive impairment.R1's care plan in part includes a focus of self-care deficit related to polyneuropathy, frequent falls, failure to thrive, weakness, and decreased mobility with interventions of high fall risk last revised on 11/22/25. Prior to the incident R1's care plan stated R1 required assist of 1 with the stand aid for transfers and assist of 2 with stand aid for toileting.Surveyor reviewed staff interviews:CNA C stated CNA C was finishing last rounds and went into R1's room and noticed R1 needed to be changed. CNA C got R1 in the stand aid and stated R1 couldn't stand any longer and R1's feet slipped off the stand aid platform. CNA C reported trying to help R1 get R1's feet back on the stand aid platform but was unsuccessful so CNA C eased R1 to the floor. CNA C stated CNA D then came in to help CNA C.CNA D stated CNA D was on the way to change R2 when CNA D noticed R1's room door was shut and stopped to open it. CNA D observed R1 on the floor and CNA C present in the room. CNA D stated CNA C was trying to move R1 before LPN E could assess R1. CNA C stated CNA C stated not to get LPN E because R1 did not fall and did not need blood pressure checked. CNA D went and notified LPN E of the fall.LPN E stated LPN E was notified to go to R1's room. Upon entry to R1's room, LPN E observed R1 sitting upright on the floor. LPN E stated R1 showed no signs of distress and had no complaints of pain. Certified Nursing Assistant (CNA) C reported to LPN E that R1 had been standing on the stand aid when R1's legs/knees became week causing R1 to go down onto R1's knees. CNA C reported CNA C could not hold R1 up and lowered R1 to the floor in a controlled manner. CNA C reported CNA C was in the process of pulling down R1's pants to change R1's brief at the time of the incident. After R1 had been assisted via Hoyer lift and 3 staff, LPN E completed an assessment of R1. LPN E stated R1 did not complain of pain and vitals were stable. DON B was notified, and a voicemail was left for POA.On 02/03/26 at 11:15 AM, Surveyor interviewed R1. R1 is not a good historian. R1 reported falling and breaking her foot but was unable to recall the events or staff present at the time of the incident.On 02/03/26 at 11:41 AM, Surveyor interviewed CNA C. CNA C stated each resident has a care plan which CNAs can access on their charting program in the computer and there is also a book at the desk they can review if unsure about care. CNA C stated they get verbal report when changes are made as well.On 02/03/26 at 11:48 AM, Surveyor observed CNA C talking with R1. CNA C stated, You remembered to tell her how you were glad I was there to help you, right? Because I would never let you fall. R1 replied, I just told her I jumped off the bed.On 02/03/26 at 11:50 AM, Surveyor interviewed RN H. RN H stated care plans are updated by nurses or Director of Nursing (DON) as changes occur. RN H showed Surveyor the binder at the nurse's station that includes all resident care plans. RN H stated all CNAs have access to this if they are unsure and also get verbal report of changes to resident care.On 02/03/26, Surveyor reviewed stand aid competency checklist for CNA C which indicates CNA C has demonstrated use of the stand aid and could use it correctly and was dated 01/12/26.On 02/03/26 at 1:23 PM, Surveyor observed CNA C and CNA G transfer R2 with the stand aid. No concerns.On 02/03/26 at 1:30 PM, Surveyor interviewed CNA G. CNA G stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA G would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 1:32 PM, Surveyor interviewed CNA C. CNA C stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA C would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 2:51 PM, Surveyor interviewed Rehab Director (RD) J. RD J stated the stand aid is only to be used as a way to transfer a resident and should not be used to stand a resident that requires changing of incontinent products.On 02/03/26 at 3:45 PM, Surveyor interviewed CNA D. CNA D stated CNA D walked into R1's room on 01/18/26 because the door was closed and R1 is a fall risk. CNA D stated R1 was on the floor and CNA C was present. CNA D stated CNA C told CNA D not to get a nurse and R1 did not need a blood pressure check. CNA D stated CNA D went and got LPN E because CNA C was trying to move R1 prior to being assessed by a nurse. CNA D reported not being sure if CNA C would have reported the incident if CNA D had not entered the room. CNA C did not call for assistance. CNA D stated if a resident's care plan stated 1 assist for transfer and 2 assist for toileting, CNA D would not change a resident's incontinence brief alone, as that is considered toileting.LPN E was unavailable for interview.On 02/03/26 at 3:49 PM, Surveyor interviewed DON B. DON B stated DON B's expectations include nurses reporting incidents to management immediately. DON B stated RNs are sometimes hard to come by but DON B would expect an LPN to have an RN assess the resident as soon as possible after the LPN completed their initial assessment. DON B stated DON B is working with staff in knowing their roles and scopes of practice. DON B stated DON B was informed of this incident on 01/18/26 at 5:30 PM that day. DON B acknowledged that CNA C did not follow R1's care plan and further investigating should have been completed. DON B stated no education related to the incident had been completed at this time but DON B was in the process of putting together education for nurses and planned to have a meeting for CNAs this week. DON B acknowledged other potentially affected residents and other staff should have been interviewed after the incident. DON B stated the reporting and investigation process in long term care is new to DON B and acknowledged the need to improve.On 02/03/26 at 4:27 PM, Surveyor interviewed Nursing Home Administrator (NHA) A with Nursing Consultant (NC) I present. NHA A stated the initial report was submitted on 01/20/26 as that was the day the facility was aware of an injury. NHA A stated the facility did not investigate the incident as an abuse allegation as NHA A believed CNA C had followed the care plan. NHA A acknowledged CNA C had followed the care plan for transfers, but not for toileting. NHA A acknowledged from the information in the interview with CNA D, further investigation should have been completed regarding the incident. NHA A acknowledge further interviews and education should also have been completed. NHA A was made aware of conversation between CNA C and R1 on day of survey.

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicate and Medicaid [NAME] (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system. This has the potential to affect all 45 residents residing in the facility.Findings:Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows:Fiscal Quarter, Date range: October 1 - December 31 (quarter 1), January 1 - March 31 (quarter 2), April 1 - June 30 (quarter 3), July 1 - September 30 (quarter 4).PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal Year Quarter 2 2025 (January 1- March 31) indicate the following: Excessively low weekend staffing and 8 hour registered nurse coverage on the date specified 02/23/2025.On 08/12/2025 at 8:46 AM, Surveyor asked Director of Nursing (DON) B to explain the report provided for only 7.45 hours of RN coverage and low weekend staffing noted on 02/23/2025. DON B replied, The issue that we found was that our system works on 30-minute intervals and if the nurse would not provide that she worked her lunch she would only get credit for 7.45 hours worked and that would trigger this even though she worked the full 8 hours. The program automatically removes a lunch break for the staff.On 08/13/2025 at 10:00 AM, DON B informed Surveyor the nursing staff shifts will now overlap. So instead of 6:00 to 2:00 the shifts now run from 6:00 to 2:30 to make sure this does not happen again.

Based on record review and interview, the facility did not ensure each resident (R), or their representative had the right to participate in the care planning process for 7 of 13 residents (R3, R5, R25, R42, R1, R4, R11) reviewed for care conferences. This is evidenced by: Facility policy titled Resident Care Conference, revised 5/25, states in part: Policy: To have a multi-disciplinary approach to evaluate and make assessments of a resident's needs and goals and to implement the assessment into a resident's total plan of care.Procedure. All residents shall have a care conference every quarter or more if necessary. a reminder will be sent to the resident and/or their responsible party when the care conference is scheduled. Each department gives a brief report of how the resident is doing. The resident and/or their responsible party is welcome to ask questions or for clarification on anything discussed during the care conference. The staff attending the care conference will evaluate the effectiveness of the care plan and make any necessary changes to the document. The facility policy titled, Care Plans- Comprehensive, reviewed 5/2025, states in part:.10. The resident has the right to refuse to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies. Example 1 R3 was admitted on [DATE] with diagnoses that include cerebral infarction, aphasia, type II diabetes mellitus, expressive language disorder, epilepsy, vascular dementia, anxiety disorder, and metabolic encephalopathy. R3's most recent Minimum Data Set (MDS) of 7/26/25 indicated impairment on one side, uses walker and a wheelchair, is independent in repositioning ambulation and transfers. R3 scored a 10/15 on a Brief Interview for Mental Status (BIMS), which indicates moderate impaired cognition. On 8/11/25 at 12:04 PM, Surveyor interviewed R3, who indicated she has not had any care plan meetings to discuss her care goals, needs, or accommodations. R3 reports no one in the facility asked if she wanted to attend a meeting to discuss her goals for her future. R3's medical record showed her last a care conference meeting was on 1/30/24 with no subsequent meetings. R3's care plan was reviewed and updated on 8/9/2024, 11/11/2024, 2/11/2025, 5/9/2025, and 8/8/2025. A multidisciplinary care conference note from 8/14/25 indicated dietary was the only team member included on the note. Surveyor noted various documentation and reports from dietary, nursing, therapies, and activity staff but no evidence of a multidiscipline care conference or evidence that resident or her representatives were invited to and/or refused to participate in a care conference over the past year. On 8/12/25, Surveyor requested documentation from Assistant Director of Nursing (ADON) C to support R3 has had quarterly care conference meetings or evidence to show resident and/or resident's representative was invited to and/or refused to be included on quarterly care conferences. Example 2 R5 was admitted to facility on 01/30/25. The facility completed an admission MDS dated [DATE] with a care conference held with IDT on 02/12/25. R5 and/or representative was not in attendance and facility was unable to support if R5 was invited or declined invitation The facility completed a quarterly MDS on 05/03/25 with a care conference held with IDT on 04/08/25 prior to completion of the MDS. R5 was not in attendance and facility was unable to provide evidence if R5 and/or representative was invited or declined invitation. The facility completed a significant change MDS on 06/01/25 with no care conference held with the Interdisciplinary Team (IDT) until 07/01/25. R5 was not in attendance and facility was unable to show evidence if R5 and/or the representative was invited or declined invitation. Example 3 R25 was admitted to facility 8/30/23. The facility completed a quarterly MDS dated [DATE]. No documentation to support a care conference was held with IDT, wherein R25 was in attendance and/or facility was unable to support if R25 and/or representative was invited or declined invitation The facility completed a quarterly MDS dated [DATE]. No documentation to support a care conference was held with IDT, wherein R25 was in attendance and/or facility was unable to support if R25 and/or representative was invited or declined invitation. Example 4 R42 was admitted to facility on 11/08/21. R42 had 5 MDS's completed since last survey (Quarterly MDS dated [DATE], Quarterly MDS dated [DATE], Annual MDS dated [DATE], Quarterly MDS dated [DATE], Quarterly MDS dated [DATE]) with no documentation to support a care conference was held with IDT and/or R42 and/or representative was invited or declined invitation. Example 5 R1 was admitted to facility on 12/27/20. The facility completed a quarterly MDS assessment on 07/08/25 with no care conference held by Interdisciplinary Team (IDT). The facility completed a comprehensive MDS assessment on 03/01/25 with a care conference not held with IDT until 05/30/25. R1 and/or representative were not in attendance and no supporting documentation if R1 and/or representative were invited or declined invitation. The facility completed a quarterly MDS assessment on 12/16/24 with no facility documentation of care conference held by IDT. The facility completed a quarterly MDS assessment on 09/13/24 with no facility documentation of care conference held by IDT. The facility completed a quarterly MDS assessment on 06/21/24 with no care conference held by IDT. Last documented care conference held by IDT was 09/05/23 with no supporting evidence R1 was in attendance. Facility has documentation that R1's representative was connected via phone for conference. Example 6 R4 was admitted to facility on 07/22/20 The facility completed a Quarterly MDS Assessment on 06/02/25. A care conference with IDT was held on 05/12/25 with no supporting documentation that R4 and/or representative were in attendance, invited, or declined invitation to attend conference. The facility completed a quarterly MDS assessment on 02/25/25 with no facility documentation of care conference held by IDT. The facility completed a quarterly MDS assessment on 12/16/24 with no facility documentation of care conference held by IDT. The facility completed a Comprehensive MDS Assessment on 09/05/24 with no facility documentation of care conference held by IDT. The facility completed a quarterly MDS assessment on 06/09/24. A care conference was held by IDT on 06/05/25 with R4's representative in attendance via phone. No supporting documentation if R4 was in attendance, invited, or declined invitation. Example 7 R11 was admitted on [DATE]. Th facility completed a quarterly MDS assessment on 07/26/25. No facility documentation of care conference held by IDT. The facility completed a quarterly MDS assessment on 04/26/25. Care conference was held with IDT on 04/10/25 with no supporting documentation by facility indicating R11 or R11's representative was in attendance, invited, or declined invitation to attend care conference. The facility completed a quarterly MDS assessment on 11/08/24. No facility documentation of care conference held by IDT. The facility completed a quarterly MDS assessment on 08/12/24. A care conference was held by IDT on 07/23/24 with R11 and R11's representative in attendance after the assessment had been completed. On 8/13/25 at 12:24 PM, Surveyor interviewed ADON C and Registered Nurse (RN) G, regarding R3's care conferences. ADON C reported care conferences should be done quarterly before care plans are revised and should include the resident and when possible the family/representative. ADON C reports the facility does not have documentation to support this is being offered and/or refused. RN G reported care conferences that include the resident and/or representative and a multidisciplinary team, are not being done for many of the residents in the facility. RN G reported the facility is aware of this and has implemented a performance improvement plan as of 2/2025 to work on correcting this.

Based on observation, staff interview and record review, the facility did not ensure drugs and biologicals were stored under proper temperature controls. This practice had the potential to affect 5 of 5 residents.Staff were not monitoring the refrigerator temperatures for both first and third floor medication rooms.Findings:Form titled Temperature Log for Refrigerator- Fahrenheit stated in part: Monitor temperatures closely1. Write your initials below in Staff initials: and note the time in exact time.2. If using a temperature monitoring device that records min/max temps document current and min/max once each workday, preferably in the morning. If using a temperature monitoring device that does not record min/max temps, document current temps twice, at beginning and end of each workday. On 08/11/2025 at 2:13 PM, Surveyor noted the refrigerator temperatures were missing on the first-floor refrigerator temperature log. Dates in July missing temperatures were: 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, 31. The August log has no entries. R15 had a FlexTouch 100-unit insulin pen and R8 had Latanoprost 0.05% eye drops in this refrigerator. Surveyor asked Registered Nurse (RN) D, Who is supposed to monitor and document the temperatures for the refrigerators in the medication room? RN D replied, That is the nursing staff's job for both the AM and PM shifts.On 08/11/2025 at 2:28 PM, Surveyor noted the refrigerator temperatures were missing on the third-floor refrigerator temperature log. Dates in July missing temperature documentation were: 1-8, 11-14, 17-31. August missing temperature dates: 1-6, 10 and 11. R33 had a Shingrix vaccine, R42 had Lantus 100 units insulin and R41 had Latanoprost 0.05% eye drops in this refrigerator.On 08/12/2025 at 8:51 AM, Surveyor interviewed Director of Nursing (DON) B regarding observations of temperature log being incomplete on the first and third floor medication rooms. Surveyor asked DON B, Who is responsible to monitor and document the refrigerator temperatures in the medication rooms? DON B replied, It is the nursing staff's responsibility.

Based on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed in the bed hold notice. This has the potential to affect 1 of 2 residents (R), R51.R51 received a bed hold notice with no daily rate documented.Findings:R51 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 14 which indicated that R51 was cognitively intact (but this did decline while in the facility). R51 had diagnoses of dementia, Alzheimer's, hallucinations, irritability and anger.R51 had a care plan for behaviors indicating physical/verbal aggression dated 7/5/25.R51 had a minimum data set (MDS) dated [DATE] titled Discharge Return Anticipated.On 07/11/25 at 10:41 PM, progress note revealed R51 became aggressive with staff both physically and verbally and police were notified. At 8:20 PM, R51 left the facility with officers and went to the emergency room.On 08/12/25 at 2:14 PM, Surveyor asked Nursing Home Administrator (NHA) A for a copy of the bed hold.On 08/12/25 at 3:44 PM, Surveyor was provided a copy of the bed hold signed and dated 07/11/25, which indicated, I choose to hold my bed on all incidents of hospitalizations or therapeutic leaves from the facility. Surveyor noted there was no dollar amount on this bed hold form indicating how much the resident would be charged.On 08/13/25 at 8:00 AM, Surveyor interviewed R51's Power of Attorney (POA) who indicated that R51 had declined mentally very quickly. R51's POA also indicated that she did not even notice if there was a dollar amount on the bed hold.On 08/13/25 at 8:00 AM, Surveyor interviewed Director of Nursing (DON) B regarding the dollar amount not placed on the bed hold notice. DON B showed Surveyor a draft of their new bed hold to include the dollar amount, where the resident will go, reason for the transfer and how to appeal the transfer.

Based on interview and record review, the facility did not ensure development and implementation of a comprehensive person-centered care plan to address the resident's history of recurring urinary tract infections (UTI), for 1 of 13 residents (R) R27 whose care plans were reviewed, This is evidenced by:The facility's policy titled: Care Plans - Comprehensive, states in part: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Section 3 states, each resident's comprehensive care plan is designed to: (a) Incorporate identified problem areas.(e) Reflect treatment goals, timetables, and objectives in measurable outcomes, and (i) Reflect currently recognized standards of practice for problem areas and conditions. R27 was admitted to the facility on [DATE] and has diagnoses that include acute renal failure, morbid obesity, diabetes, and urinary tract infections.R27's Minimum Data Set (MDS) assessment, dated 06/26/25, indicated that R27 has a BIMS of 15/15, meaning cognitively intact. R27 was identified to have frequent urinary incontinence, and no urinary toileting program was in effect. Surveyor reviewed R27's medical record and found R27 has had 5 urinary tract infections since January 2025, three since admission to facility in March 2025. Each UTI incidence has required R27 to be treated with oral antibiotics. Provider note, dated 08/13/25 at 7:15 AM, states in part, R27 has been dealing with on and off dysuria (burning with urination) and has had urine frequency and incontinence. Surveyor reviewed R27's medical record finding no implementation of care plan recognizing R27 as high risk for urinary tract infections and no interventions for treatment and prevention were established. Last care plan revision for R27 was done 06/26/25.On 08/13/25 at 1:20 PM, Surveyor interviewed Director of Nursing (DON) B and asked what expectations are for prevention/intervention of residents who have a diagnosis of UTIs. DON B stated, There should be at least a temporary care plan in place. DON B stated after personal review of R27's medical record, there was no current or recovered care plan developed recognizing R27's recurrent UTIs.

Based on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (R42 and R11) reviewed. R42's record review noted an unwitnessed fall when staff did not implement interventions of a fall mat per plan of care resulting in an emergency room (ER) visit. R42 was observed being transferred with a mechanical lift with an assist of 1 staff member. R42 requires assistance of 2 per plan of care. R11 had a fall where staff did not follow the facility protocols to do a complete assessment post fall. This is evidenced by: The facility policy titled Falls and Fall Risk, managing, states: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under section titled Prioritizing approaches to managing falls and fall risk, states in part, .6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions .to try to minimize serious consequences of falling. Example 1 R42 was admitted to facility on 11/08/21 with diagnoses that include Alzheimer's disease. R42's Minimum Data Set (MDS) quarterly assessment, dated 07/12/25, indicated that R42 is dependent on staff for transfers. R42's Activities of Daily Living Care Plan, initiated on 11/08/21, with a target date of 08/11/25, indicates interventions of Transfers - Sit to stand with two-assist. Dated 08/29/24. Mat onto bed while in bed for safety. Dated 01/21/23. Record review indicated that R42 had an unwitnessed fall on 10/13/24, wherein R42 fell from bed onto floor hitting head, no visible injuries; however, R4 complained of neck pain and was sent to ER for evaluation (of note, no negative outcome noted). Nursing assessment at time of fall indicated R42 did not have a floor mat or bed in lowest position per plan of care. This intervention was listed on the care plan and not in place at the time of the fall. On 08/12/2025 at 1:50 PM, Surveyor observed Certified Nursing Assistant (CNA) E, transfer R42 from wheelchair to and from toilet with a sit to stand lift with assist of another staff member. On 08/13/2025 at 9:52 AM, Surveyor interviewed CNA E regarding how R42 should be transferred. CNA E stated R42 is transferred with a sit to stand lift. Surveyor asked how many staff members are required. CNA E stated she believed R42 was a 1 person assist, unless it changed. Surveyor asked CNA E how staff are aware of care plan approaches, and CNA E stated it is in the computer. CNA E showed Surveyor computer which stated R42 requirement of 2-person assist with transfers and sit to stand lift since 08/09/24. CNA E stated the expectation would be to follow the plan of care. On 08/13/2025 at 1:35 PM, Surveyor shared above observation with DON B, observation of CNA E and concerns regarding R42's fall on 10/13/24, wherein fall mat was not in place per plan of care. DON B stated the expectation would be to follow the plan of care to prevent falls. Example 2 R11 was admitted to facility on 12/27/20. On 08/12/25 at 7:25 AM, record review indicates R11 sustained a fall forward out of wheelchair onto the floor while reaching down to pick up a dropped object on 08/11/25 at 4:23 PM. R11 had blunt trauma to right side of forehead and was sent to the Emergency Department (ED) via ambulance for further evaluation. There is no further documentation in R11's medical record following return to facility from the ED for post fall assessments or physician orders. On 08/12/25 at 8:00 AM, R11 was observed by Surveyor to be in room sitting in wheelchair with large hematoma to right forehead region with one steri-strip in place. On 8/12/25 at 7:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H on what follow up assessments staff is doing for R11's post fall with head trauma. LPN H stated there is paper documentation for neuro checks and R11's Eliquis (anticoagulant) is to be held for 24 hours. Surveyor asked LPN H how these orders are communicated to staff when no documentation is in the chart. LPN H stated the night nurse gave verbal report. On 08/13/25 at 1:15 PM, Surveyor interviewed DON B what the expectations of staff are for assessing residents post fall per the facility fall protocols. DON B stated there are standing orders post falls including notifying MD immediately, neuro checks, and documenting assessments and/or physician orders in medical record. DON B was aware there is no documentation in chart following R11's return from the ED on 08/11/25. DON B stated, We have a traveling nurse working that shift and have had problems with her.

Based on interview and record review, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents (R27) reviewed. The facility failed to follow up on recommendation for urology consult due to history of frequent UTIs. This is evidenced by:R27 was admitted to the facility on [DATE] and has diagnoses of acute renal failure, morbid obesity, type II diabetes and urinary tract infections.R27's Minimum Data Set (MDS) assessment, dated 06/26/25, indicated that R27 is frequently incontinent and has no urinary toileting program. R27 has a BIMS score of 15/15, meaning cognitively intact.R27's care plan, dated 06/05/25, states that R27 has functional bladder incontinence related to activity intolerance. The identified Intervention/Tasks states in part. R27 prefers a bedpan while in bed. monitor/document/report PRN any possible causes of incontinence: bladder infection. loss of bladder tone, decreased bladder capacity, diabetes.R27's nurses notes, dated 06/09/25 at 5:13 PM, stated R27 had complaint of urinary frequency and pain with urination and R27 stated she gets UTIs all the time. R27's nurses notes, dated 06/11/25 at 8:42 AM, stated in part, Received orders from provider.Consider urology referral due to repeat UTI.R27's physician orders notes, dated 08/11/25 at 8:00 PM, indicated physician orders for oral antibiotic for recurrent UTI.On 08/12/25 at 1:17 PM, Surveyor interviewed R27 asking if a urology referral was offered. R27 stated no urology referral was offered nor was there a urology consult conducted at any time during stay at facility.On 08/12/25 at 2:28 PM, Surveyor interviewed Director of Nursing (DON) B and asked if a urology referral was provided for R27. DON B stated R27 was seen by a covering provider on 06/11/25 as R27's preferred provider was out of office. DON B stated there was no referral placed by preferred provider's office, yet provider was aware of urology suggestion. DON stated no follow up by facility staff was done to inquire about urology consult in consideration of repeat UTI since 06/11/25.

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 48 residents (R). Physical Therapy Assistant (PTA) C and Registered Nurse (RN) O entered R5's room without proper Personal Protective Equipment (PPE) who is on airborne precautions for parainfluenza infection. Findings include: Surveyor reviewed facility policy titled, Isolation-Initiating Transmission Based Precautions, states in part, .-Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. #5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need . Surveyor reviewed facility policy titled, Personal Protective Equipment, states in part, .- Objectives: 1. To prevent the spread of infections; 2. To prevent soiling of clothing with infectious material; -Miscellaneous: 1. Use gowns only once and then discard into an appropriate receptacle inside the exam or treatment room. 2. Clean reusable or disposable gowns may be worn in most circumstances. 3. Use gowns only when indicated or as instructed. 4. Follow established handwashing procedures. 6. When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident. 7. Gowns shall be large enough to cover all of the wearer's clothing, and they must be tightly cuffed at the sleeves. 8. After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. 10. Soiled gowns must not be worn in break rooms, lobbies, or into any area in which contamination of equipment is likely to occur . R5 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, polyneuropathy, diabetes mellitus type 2, bacterial infection unspecified, and heart failure. Surveyor reviewed R5's progress notes, which state in part, -On 06/23/25 at 1:26 PM, R5 having a cough this morning, Robitussin administered, COVID tested and negative, DON notified, R5 placed on droplet precautions. -On 06/24/25 at 9:45 AM, Writer obtained nasal swab for respiratory panel ordered per provider, sent to lab. -On 06/24/25 at 6:48 PM, Received respiratory panel back today, parainfluenza 3 virus detected. R5 on droplet precautions and will remain on for 7 days until 07/01/25. On 06/24/25 at 9:17 AM, Surveyor observed PTA C enter R5's room with no PPE on. PTA C started working with R5 in room on Physical Therapy (PT) exercises. On 06/24/25 at 9:28 AM, Surveyor observed RN O standing outside R5's room. Surveyor interviewed RN O and asked RN O what precautions R5 is on. RN O reported to Surveyor that R5 is on droplet precautions. Surveyor informed RN O that PTA C is in R5's room with no PPE on. RN O immediately reported to Surveyor that PTA C is supposed to have PPE on before entering R5's room. RN O called PTA C out of R5's room and explained to PTA C that PTA C needs mask, shield, gown, and gloves on when providing cares in R5's room. PTA C reported to RN O that she did not realize this and PTA C applied PPE and entered back into R5's room. On 06/24/25 at 9:33 AM, Surveyor observed PTA C exit R5's room and doffed gown, face shield, and gloves. Surveyor observed PTA C continue walking down hallway and exited the unit without proper hand hygiene or removing face mask from R5's room. On 06/24/25 at 9:36 AM, Surveyor observed RN O donning a face shield, gown, and gloves. RN O entered R5's room to swab R5 for a respiratory panel. Surveyor did not observe RN O apply a face mask under the face shield before entering R5's room. On 06/24/25 at 9:45 AM, Surveyor observed RN O exit R5's room and doffed PPE. Surveyor did not observe RN O doff a face mask. Surveyor interviewed RN O and asked if RN O was supposed to have placed a mask on under the face shield when in R5's room on droplet precautions. RN O reported to Surveyor that RN O applied face mask while inside R5's room but should have applied outside room before entering R5's room to decrease chances of spreading infection. On 06/24/25 at 10:18 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what the expectations are for proper PPE usage with R5 on droplet precautions. DON B reported to Surveyor that all staff are to use appropriate PPE such as mask, face shield, gown, and gloves with droplet precautions. Surveyor informed DON B of observation of RN O and PTA C not utilizing appropriate PPE when entering R5's room. DON B reported that staff should have worn the appropriate PPE before entering R5's room and when exiting doffing the PPE entirely and sanitizing hands before walking onto the next task.

Based on interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being by not assessing and/or treating a post-medication error for 1 out of 3 residents (R) reviewed for medication errors, R8. -R8 was given the wrong medications of Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. R8 was not assessed every 4 hours for 24 hours as per physician order. Findings include: Example 1 R8 was admitted to the facility on [DATE], with diagnoses including Parkinson disease, Alzheimer's disease unspecified, unspecified dementia, irritable bowel syndrome with constipation, essential hypertension, obstructive sleep apnea, and spinal stenosis. Surveyor reviewed medication error, dated 06/14/25, which stated, in part, incident details include R8 was given wrong medications listed as Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. The resolution for this error was that R8's provider gave an order for monitoring R8 every 4 hours for the next 24 hours. Surveyor reviewed vitals and assessments for R8, which states in part, -On 06/15/25 at 4:07 AM, R8 is monitored for medication error. Baseline neurologically, vital signs blood pressure 106/69, heart rate 71, respirations 20, and oxygen 97% on room air. R8 has no complaints at this time and will continue to monitor. Surveyor found no other documentation of vitals and assessments completed every 4 hours for the next 24 hours for R8. On 06/24/25 at 3:40 PM, Surveyor interviewed DON B and asked DON B what the expectation is for staff to monitor R8 after a medication error as provider orders stated monitor every 4 hours for the next 24 hours. DON B reported to Surveyor that the nursing staff should have monitored R8 every 4 hours for 24 hours including vital signs and head to toe assessment. DON B reported to Surveyor that the assessments and vitals were not completed for R8 every 4 hours as ordered.

Based on interview and record review, the facility did not ensure medications were administered under professional standards of clinical practices for 3 of 3 residents (R) reviewed for medication errors, R6, R8 and R7. -R6 received ciprofloxacin 500 mg twice a day for 3 days and should have received 250 mg twice a day for 3 days, and ciprofloxacin did not have an expiration label on it. -R8 received the wrong medications, including Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. -R7's self-administration assessment stated R7 required assistance and nurse left Eliquis, melatonin, omeprazole, and metoprolol in a medicine cup at R7's bedside, left the room, and did not ensure R7 took the medications. Example 1 Surveyor reviewed medication error, dated 06/16/25, which stated, in part, R6 received the wrong dose of ciprofloxacin 500mg twice a day on 06/14/25, 06/15/25, and 06/16/25. R6 was supposed to receive ciprofloxacin 250 mg twice a day for 3 days. Incident details include Registered Nurse (RN) I, who transcribed physician orders incorrectly with no expiration date placed in the Electronic Health Record (EHR). Licensed Practical Nurse (LPN) F administered extra doses of ciprofloxacin twice a day on 06/14/25, 06/15/25, and 06/16/25. The resolution for this error was that education was given to RN I and LPN F about residents' rights of medication administration. On 06/24/25 at 10:10 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what kind of education RN I received pertaining to R6's medication error of incorrect dose and no expiration label for ciprofloxacin. DON B reported to Surveyor that on the medication error report, DON B noted that resident's rights of medication administration education was given to RN I and LPN F. Surveyor asked DON B if RN I was educated on the transcription error, as it was not documented on the medication incident report form. DON B reported to Surveyor that DON B did not document that transcription education was provided but would go provide education to RN I and document this education. Example 2 Surveyor reviewed medication error, dated 06/14/25, which stated, in part, that R8 received wrong medications. R8 received Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. Incident details include R8 was given the wrong medications but had no effects, vitals stable, and sleeping. The resolution was that R8's provider gave an order for the nurse to monitor R8 every 4 hours for the next 24 hours. Surveyor did not find any documentation of vital signs being monitored every 4 hours for the next 24 hours and any education provided to LPN G after the medication error. On 06/24/25 at 10:10 AM, Surveyor interviewed DON B and asked DON B if any education was provided to LPN G. DON B reported that documentation of education was not on the medication incident report, but education was completed. On 06/24/25 at 10:19 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A if any education was provided to LPN G. NHA A reported to Surveyor that this event was not the first incident LPN G had, so LPN G was terminated at some point after finding multiple medication errors. Evidence of education was not provided to Surveyor. Example 3 R7 was admitted to the facility on [DATE], with diagnoses including essential hypertension, end stage renal disease, contracture of left and right hand, anxiety disorder, noncompliance with medication regimen, unstable angina, diabetes mellitus type 2, and congestive heart failure. R7's minimum data set (MDS) assessment, completed on 05/20/25, confirmed R7 scored 15/15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R7 requires supervision and set-up assistance with eating and oral hygiene. R7 requires substantial maximal assistance with transferring, dressing lower body, putting on/taking off footwear, personal hygiene, showering/bathing, and toileting. Surveyor reviewed R7's self-administration of medication assessment which stated in part, .-On 03/02/25, all questions such as administering of medications answer- b) Assistance required . Surveyor reviewed medication error, dated 06/20/25, which stated, in part, incident details include R7 has order for self-administration of medications, nurse left night medications at bedside, and did not follow up to check that R7 took medications of Eliquis, melatonin, omeprazole, and metoprolol. The resolution was educating nurse on self-administration orders and to follow up in one hour to ensure R7 received medications. On 06/24/25 at 3:40 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B process for self-administering medications. DON B reported to Surveyor that nurses are supposed to assess residents first to make sure they can safely administer their own medications. Surveyor asked DON B if R7 had a self-administer assessment completed. DON B reported to Surveyor that R7 has a physician order that R7 can self-administer medications, but that DON B would investigate the self-administering further. DON B reviewed self-administer medication assessment completed on 03/02/25 and reported to Surveyor that DON B reviewed and R7 was deemed to require assistance with medications. DON B reported to Surveyor that DON B will have staff re-evaluate self-administering abilities and update R7's chart as needed. DON B reported to Surveyor that staff should have followed up with R7 to make sure R7 did not miss R7's important medications.

Based on observation, interview and record review, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to reconcile accurately. This affected 12 out of 49 residents (R) in the facility. (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) The facility did not ensure medications were administered under professional standards of clinical practices for residents. This had the potential to affect all residents on 1 of 2 floors in the facility. Findings include: Facility policy titled, Administering Medications, dated 2019, states in part, .#22. The individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. #23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: g. The signature and title of the person administering the drug . Facility policy titled, Documentation of Medication Administration, dated 2022 reviewed on, states in part, .#2. Administration of medication is documented immediately after it is given. #3. g. initials, signature and title of the person administering the medication . Example 1 Surveyor reviewed medication errors for the past 6 months. -On 03/30/35, medication error report indicates staff did not give R7 Lorazepam medication as it was not signed out on narcotic count sheet. Director of Nursing (DON) B indicated staff to not sign out medication on the narcotic book until medication is given to R7. - On 03/30/35, medication error report indicates staff did not give R4 Clonazepam medication as it was not signed out on narcotic count sheet. DON B indicated staff to not sign out medication on the narcotic book until medication is given to R4. -On 04/13/25, medication error report indicates staff gave R5 an extra dose of oxycodone due to staff prepping medication in advance and another nurse not knowing it was prepped ahead and gave another 1/2 dose to R5. DON B educated nurses on not prepping medications ahead of time before administering. -On 04/13/25, medication error report indicates R6 was given an extra dose of tramadol. One nurse set up medication and the second nurse went to administer medications and took out an extra tramadol tab. DON B educated nurses on not prepping medications ahead of time before administering and only administering medications in which the individual nurse prepares themselves. DON B indicated to sign out medication on the narcotic book when the narcotic is removed from the pill pack. Surveyor reviewed facility's investigation pertaining to narcotic diversion that occurred on 03/03/25. Facility reviewed R1, R8, R9, R10, R11, R12, R13, R14, and R4's MAR from 03/03/25 and found controlled medications signed out, which indicated that Licensed Practical Nurse (LPN) L administered R1, R8, R9, R10, R11, R12, R13, R14, and R4's-controlled medications to residents on 03/03/25. Through investigation, the facility found R1 who was in hospital on 03/03/25, and R8, R9, R10, R11, R12, R13, R14, and R4 did not receive the controlled medications signed out by LPN L on 03/03/25 as documented. Facility called police and notified Department of Health Services within two hours of the facility knowing that there were missing narcotics. Police found LPN L had oxycodone, lorazepam, and hydrocodone in LPN L's possession. Facility terminated LPN L and began pain assessments on R8, R9, R10, R11, R12, R13, R14, and R4. Facility found no concerns with R8, R9, R10, R11, R12, R13, R14, and R4's pain levels. DON B started narcotic reconciliation audits weekly. On 04/28/25 at 12:43 PM, Surveyor observed LPN D sitting at the nurse's station with two narcotic books on desk and LPN D signing out narcotics and documenting quantity of narcotics left in locked narcotic box. On 04/28/25 at 12:45 PM, Surveyor interviewed LPN D and asked what LPN D was doing with the narcotic books. LPN D indicated that LPN D gave narcotics to several residents and was currently signing out R4's Clonazepam. Surveyor asked LPN D what the normal process is for signing out narcotics after giving narcotics to residents. LPN D stated, I know this process isn't right and I should have signed the narcotics out as I gave each one to each resident. LPN D indicated that LPN D just knows when LPN D gave the controlled medications and leaves sticky notes for self on the medication cart across the nurse's station if LPN D forgets. Surveyor asked LPN D to show Surveyor the locked narcotic box located in the medication cart across from the nurse's station. LPN D got up from the nurses' station and walked across the nurse's station to the medication cart and unlocked the narcotic box. Surveyor asked LPN D to show Surveyor R4's Clonazepam card. Surveyor observed R4's Clonazepam card that was labeled with 30 tabs on the card. Surveyor asked LPN D to show Surveyor R4's Clonazepam count sheet out of the narcotic book. Surveyor observed on R4's Clonazepam count sheet quantity started with 30 tabs and noted LPN D signed out, Gave 1 tab of Clonazepam at 12:00 PM. Surveyor asked LPN D how there were 30 tabs accounted for in R4's Clonazepam card, but the count sheet that LPN D signed, indicated 29 tabs of Clonazepam left in R4's Clonazepam card. LPN D immediately apologized to Surveyor and stated, Well I did not give this medication yet, but I was signing it out. LPN D indicated that LPN D did the documentation incorrectly and was going to go back and give the Clonazepam but did not yet. Surveyor asked LPN D it was normal to sign controlled medications out of the count book before pulling from the card. LPN D indicated that LPN D performed the wrong process and knows that LPN D should not have done that, but LPN D stated, It has just been so busy here today. LPN D indicated that facility process is to sign out the narcotic or controlled medication once the medication is pulled and administered to R4. LPN D indicated that LPN D should not have signed out before giving the medication. On 04/28/25 at 2:35 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what is DON B's expectation for signing out narcotic count sheets when administering a controlled medication. DON B indicated that LPN D approached DON B and let DON B know that LPN D messed up by signing out a controlled medication before giving the controlled medication making the count off in the narcotic book. DON B indicated that DON B's expectation is that nurses do not prep medications ahead of time or sign out medications that have not been given first. DON B's expectation was that LPN D give R4's Clonazepam and sign out the medication in the narcotic book once the medication was administered. DON B indicated that LPN D should have counted how many tabs were left in R4's Clonazepam card then documented the correct quantity on narcotic count sheet. Surveyor asked DON B how often DON B audits to make sure the narcotic count sheets are accurate, and they are being signed out appropriately. DON B indicated that audits started back in beginning of March 2025, and DON B performs the audits weekly. Surveyor tried reviewing narcotic count sheets and DON B indicated the narcotic count sheets were being audited as we were speaking. Surveyor asked DON B if there are any discrepancies with the narcotic sign out count sheets. DON B indicated that in fact there were some missing signatures on narcotic count for shift change. Surveyor requested a copy of the narcotic sign out sheet. DON B indicated that DON B understands that LPN D still is not utilizing the correct process for narcotic count to prevent narcotic diversion and will handle the situation immediately. Surveyor asked if DON B thinks there is still an issue with narcotic count and facility's process. DON B indicated that DON B has educated staff, but DON B can see that staff are still having issues and DON B will reeducate. On 04/28/25 at 2:55 PM, Surveyor reviewed narcotic sign out sheets and observed on 04/10/25 missing second signature on night shift for narcotic count. On 04/25/25, day shift was missing two signatures for narcotic count. Example 2 On 04/29/25 at 10:42 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A if facility was aware of any delegation of tasks, treatments, and/or administering of medications from nurses to Certified Nurse Assistants (CNA)s. NHA A indicated there was a recent event in March where a resident observed LPN C delegating medication administration to a CNA. NHA A indicated that Trained Medication Aide (TMA) M was acting as a CNA on 03/19/25 but then stayed about two hours after day shift to help LPN C pass medications. On 04/29/25 at 10:47 AM, Surveyor interviewed LPN C and asked if LPN C had ever delegated medication administration to a CNA. LPN C indicated that LPN C has never allowed a CNA to pass medications. LPN C indicated the facility has TMAs. LPN C indicated that on 03/19/25 LPN C was overwhelmed with a recent fall on that evening shift and asked TMA M to stay and help pass medications. LPN C indicated that LPN C prepped all medications and would hand them to TMA M to administer the medications to whichever residents LPN C delegated the medication pass. Surveyor asked LPN C if LPN C followed TMA M in the rooms while TMA M passed medications. LPN C stated, Well I was in close proximity like in the room next to the other room [TMA M] was in. I did not physically go into the rooms [TMA M] administered medications but that shouldn't matter as [TMA M] is trained to administer medications. Surveyor asked LPN C what the process is for preparing and administering medication to residents. LPN C indicated that medications are to be prepared right when LPN C is about to administer the medications to residents and should be the nurse who is prepping the medication to administer the medication. Surveyor asked if LPN C remembers which residents TMA M administered medications to on 03/19/25. LPN C indicated that LPN C had TMA M help with most of all medications needing to be administered. Surveyor asked LPN C who signed out the medications in the MAR. LPN C indicated that LPN C documented that LPN C administered all medications on the evening shift of 03/19/25. Surveyor asked LPN C if LPN C did not administer the medications, why was it documented that LPN C administered the medications. LPN C indicated that LPN C knew better, and TMA M should have signed the medications that TMA M administered. Surveyor asked LPN C what the process for medication administration is and not falsifying documentation. LPN C indicated that LPN C should have had TMA M prep, administer, and document the medications that TMA administered. LPN C indicated next time LPN C will not prepare medications ahead and delegate someone else to give the medications. On 04/29/25 at 11:43 AM, Surveyor interviewed DON B and asked DON B's expectation for medication administration. DON B indicated nurses are to follow facility policy. Surveyor asked DON B if it was acceptable for LPN C to prepare residents medications and then delegate TMA M to administer the medications. DON B indicated that TMA M can administer medications as TMA M is trained. Surveyor asked DON B what the process or expectation for documenting medications when administered to residents. DON B indicated that LPN C should have not prepared medications ahead and delegated TMA M to administer medications and LPN C should not have documented that LPN C gave the medications when TMA M is the one who administered the medications.

Based on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs. Behavioral monitoring was not completed as outlined in the comprehensive care plan to determine effectiveness of the medication for 1 of 3 residents (R) reviewed (R2). Findings include: The facility policy titled, Behavioral Assessment, Intervention, and Monitoring, dated 03/2019, states in part: .Management -#1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care. -#10. When medications are prescribed for behavioral symptoms, documentation will include: b. potential underlying causes of the behavior, c. other approaches and interventions tried prior to use of antipsychotic medications. e. specific target behaviors and expected outcomes. h. monitor for efficacy and adverse consequences. Monitoring -#1. If the resident is being treated for altered behavior or mood, the team will seek and document any improvements or worsening in the individual's behavior, mood, or function. -#2. New or emergent symptoms will be documented and reported. -#3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment . R2 was admitted to the facility on [DATE] and had diagnosis that include unspecified dementia, mild with behavioral disturbance, ischemic cardiomyopathy, and congestive heart failure. R2's Minimum Data Set (MDS) assessment, dated 08/16/24, indicated that R2 has a Brief Interview for Medical Status of 00, which indicates R2 has a severe impairment. R2's care plan included the following interventions: BEHAVIORS care plan: -Update provider on progressing dementia behaviors of wandering, invading other personal space initiated on 11/16/22. -Re-direct R2 from going into other rooms/spaces, re-direct R2 from other residents at the table when eating initiated on 06/07/24. -Administer behavior medications as ordered by provider. Assess for effectiveness and for side effects on medication on-going, update provider as needed initiated on 09/14/24. -Discuss with family best approaches initiated on 09/14/24. -Provide diversional activities during episodes of inappropriateness/disruptive behavior initiated on 09/14/24. -Re-direct R2 from male residents, when sitting at table, do not place her next to male, only across the table initiated on 09/14/24. -Refer to interdisciplinary team for review as needed initiated on 09/14/24. R2's doctors' orders read: -Monitor and document any increased behaviors due to Seroquel decrease every shift. -Behavior monitoring: targeted behavior: wandering, getting into others personal space leading to altercations, kicking at staff, history of slapping to others, Interventions: Redirect from others, offer food, reassure her. If behavior is present, document in nurses' notes: Behavior, interventions used and effectiveness of the interventions every shift. -Lorazepam give 0.5mg by mouth every 4 hours as needed for anxiety/behavioral disturbances related to Dementia. -Lorazepam give 0.5mg by mouth in the afternoon related to Dementia. -Citalopram Hydrobromide 10 mg tab by mouth in the evening related to Dementia. -Seroquel 25mg tab, give 12.5 mg by mouth two times a day related to Dementia with mild behavioral disturbances. Surveyor reviewed R2's medication administration record (MAR) and Treatment Administration Record (TAR) for September, October, November, and December. Documentation on MAR and TAR for all 4 months periodically present that R2 had behaviors but no documentation found on specific behaviors, interventions utilized, and the effectiveness of the interventions. Surveyor reviewed R2's progress notes for September, October, November, and December. R2's progress notes did not have documentation noted when behaviors occurred, what behaviors were assessed, what interventions were implemented, and how effective were the interventions put into place to decrease R2's behaviors. On 12/02/24 at 9:25 AM, Surveyor interviewed R3 and asked R3 if R3 ever had any residents wander into R3's room or any inappropriate behavior occur to R3. R3 indicated that R3 has a stop sign velcroed to door because other residents wander into R3's room, but sometimes R2 blows right through the door into R3's room. R3 indicated that last night on 12/01/24 in the evening time R2 wheeled into R3's room and began trying to rub R3's hand and kissing R3's arm. R3 told R2 no and to leave. R3 indicated R3 told staff shortly after R2 wheeled back out of R3's room. On 12/02/24 at 11:50 AM, Surveyor interviewed Registered Nurse (RN) C and asked if RN C knew of any instances of inappropriate behaviors and wandering with R2 in the past and from 12/01/24 in the evening into R3's room. RN C indicated that earlier in the afternoon on 12/01/24 RN C was walking into R3's room to pass medications. RN C stated, [R2] did wander into [R3's] room and [RN C] redirected [R2] out of [R3's] room, and then [RN C] wheeled [R2] out of [R3's] room. RN C indicated that R2 always wanders into other rooms, and that the floor is a memory care unit. Surveyor asked RN C why this episode was not charted in the nurse progress notes or on the MAR/TAR. RN C indicated that RN C's usual process is RN C will monitor for inappropriate behaviors and wandering from R2 and then redirect if need be and document the behaviors in the Electronic Health Record (EHR). RN C indicated that since RN C was right there with R2 that RN C felt the behavior was observed and did not need to be charted. Surveyor asked RN C if it was facility policy to not document behaviors. RN C indicated the facility policy is that behaviors are documented in the MAR/TAR and then a progress note will be attached to that documentation so that progress notes show intervention being utilized and if effective for that set behavior. On 12/02/24 at 12:15 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what expectation was for behavior charting and monitoring inappropriate behaviors to decrease incidents from happening. DON B indicated that it is DON B's expectation that all behaviors are documented in the TAR and then in the progress notes the exact behavior needs to be documented with what intervention was implemented, and how effective was the intervention. DON B indicated documentation of behaviors assists the team with ordering and changing psychotropic medications to make sure the medications are working properly. Surveyor asked DON B if DON B was aware of R2 wandering into R3's room on 12/01/24 and the lack of documentation noted in the EHR. DON B indicated that DON B was not aware but conversed with RN C who admitted that RN C did not document in R2's chart the behavior from 12/01/24. Surveyor asked DON B why R2 has yes documented in the MAR/TAR for behaviors throughout September, October, November, and December chart but no other documentation on what the behavior was at that time, what interventions were placed, and how effective the intervention was that was implemented. DON B indicated that DON B did not realize staff were not documenting accurately as provider ordered for R2.

Based on interview and observation, the facility failed to have qualified onsite dietary manager. This has the ability to affect 40 out of 40 residents. Facility has not had a Dietary Manager since 07/06/2023. Findings include: On 08/29/23 at 10:50 a.m., Surveyor entered kitchen and Cook D stated if Surveyor was looking for the dietary manager, the facility does not have one. On 08/29/23 at 12:30 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the Dietary Manager. NHA A stated the facility has not had a Dietary Manager since 07/06/23. NHA A stated NHA A checks on dietary and has Human Resources (HR) L supervise dietary part-time. NHA A and HR L do not have a dietary certification. NHA A stated Dietary Aide (DA) M orders food for the dietary department and updates the resident tray tickets regarding diets and likes/dislikes. NHA A stated NHA A consults and refers to the facility Dietician as needed, and the Dietician is onsite at the facility every two weeks. NHA A stated the Dietician works remotely as well and reviews changes in resident conditions, updates diets, etc. NHA A stated a Dietary Manager will be starting in two weeks. NHA A stated the Dietary Manager is in a program for certification and has a preceptor, but has not completed the program.

Based on observation, interview and record review, the facility did not prepare, store, or distribute foods in a safe and sanitary manner. The facility practices have the potential to affect all 43 residents. Facility staff do not cover beverages that are poured by staff on the wings and delivered to residents in their rooms. Cook Q did not allow the thermometer to air dry after wiping with alcohol and before inserting into resident foods. Dietary Aide (DA) T used alcohol-based hand rub (ABHR) as a means to sanitize her hands in the kitchen. ABHR is not an approved means to sanitize hands when food handling in the kitchen. The refrigerators and freezers where resident foods are brought into the facility do not have complete logs of monitoring for safe storage temperatures. The freezer on the first floor showed evidence of melted ice cream in the freezer. The temperature of the refrigerator was outside parameters for safe storage of foods. The facility did not monitor water temperatures for the water heater that is stored in the basement and circulates water to the basement kitchen and basement laundry area. Surveyor monitored water temperatures and identified fluctuations within conditions where Legionella and other opportunistic pathogens grow best (77-108 degrees Fahrenheit). This is evidenced by: Example 1 On 06/05/23 at 11:52 AM, Surveyor observed meal service for lunch on the first floor. Surveyor observed Certified Nursing Assistants (CNA) H and CNA I preparing resident food trays at the food cart. CNA H and CNA I poured beverages of milk, juice and coffee and placed the beverages on the trays of the residents served in the dining room. CNA H and CNA I proceeded to pour beverages for resident room trays. The beverages were placed on resident trays and transported to them in their room up the hallway. The beverages were not covered during distribution to residents in their rooms. On 06/06/23 at 8:18 AM, Surveyor observed meal service on the first floor for breakfast. Surveyor observed staff, including Medical Records/CNA F distribute trays and the beverages were not covered when distributed to residents in their rooms. Beverages included milk, juice, and coffee. Following the observation, Surveyor spoke with CNA F about the observation. CNA F expressed she assists with passing of trays on an ability basis. The beverages that are poured on the wing are not covered during transport to residents in their rooms as there is nothing sent up from the kitchen on the cart to cover them with. CNA F expressed this has been the facility procedure since she can remember and has been on staff a couple of years. On 06/07/23 at 9:12 AM, Surveyor spoke with Dietary Manager (DM) R and Nursing Home Administrator (NHA) A about the observations. DM R expressed the facility will be looking at different means of distributing resident room trays. Staff should not transport resident meal trays up the hall without foods and fluids being covered as it poses a risk of contamination. Surveyor requested and received a list of residents who routinely eat in their rooms that the observed practice could potentially affect. Surveyor was provided a list including the following residents (R26, R32, R28, R244, R38, R29, R9, R7, R31, R14, R36, R21, R13, R33, R16, R24, R19, R39, R6, R23, R20, R37 and R12). Surveyor requested the facility policy on safe food distribution. At time of exit nothing was provided. Example 2 On 06/06/23 at 7:10 AM, Surveyor observed Cook Q placing foods on the steam table in preparation for breakfast service. Cook Q used a thermometer to take the food temperatures. Surveyor observed Cook Q wipe the thermometer with an alcohol preparation pad and immediately insert into food items to check the temperatures. Surveyor asked Cook Q if she needed to allow the thermometer probe to air dry after wiping with alcohol and before inserting into foods. Cook Q responded she was not aware of the need to wait and has never seen a policy about needing to air dry the thermometer before inserting into foods. Cook Q expressed she has been on staff 6-7 months, comes from a restaurant background and has received little to no training since starting. On 06/06/23 at 1:29 PM, Surveyor spoke with DM R about the observation. DM R expressed she had just started employment a few weeks ago and her background is in restaurants. DM R further expressed she would expect the probe to be fully air dried with no residual alcohol. She would expect staff to wait 10-15 seconds to allow the thermometer to air dry of alcohol before inserting into resident foods to prevent contamination. Surveyor requested and received the facility policy titled Food Temperatures dated 02/25/2019. The policy states in part: Food temperatures will be taken and recorded when food is removed from oven or refrigerator, at the start and end of service at each meal. Wipe thermometer with alcohol pad and wait 10 seconds before putting in foods. Example 3 On 06/06/23 at 7:10 AM, Surveyor observed Dietary Aide (DA) T with readying foods and other items in preparation of breakfast meal service. DA T removed her gloves and used ABHR to clean her hands after filling pitchers with water and proceeding to another task. Surveyor asked DA T about the observation. DA T indicated she is trained in safe serve food handling and believes hand sanitizer is an okay method for hand hygiene in the kitchen. On 6/06/23 at 1:13 PM, Surveyor spoke with DM R about the observation. DM R indicated she believes the facility uses Wisconsin Food Code for the kitchen policies. The expectation is for staff to wash their hands using soap and water in the kitchen per the food code. Surveyor requested and received the kitchen's staff hand washing procedure titled Hand Washing dated 06/25/2012. The policy in part states: Policy: Food service employees shall keep their hands clean. The procedure outlines hand washing with the use of soap and water. The policy does not include the use of ABHR as a means for food service workers to clean their hands. Example 4 On 06/06/23 at 1:58 PM, Surveyor and NHA A observed the first-floor freezer/refrigerator where resident foods are stored. The freezer showed dried residual melted ice cream on the bottom and side shelves. The refrigerator with resident food items thermometer read 50 degrees Fahrenheit. Surveyor and NHA A proceeded to the third floor and observed the refrigerator and freezer clean and temperatures within safe storage range. Surveyor requested and reviewed the logs of the first and third floor refrigerator/freezer temperatures that were logged. The logs noted Temperature standards: 40 degrees Fahrenheit or below for cooler and 0 degrees Fahrenheit or below for freezer. The logs were void of any recorded temperatures for the months of March and April 2023. The logs for May 2023 noted the following: First floor: recorded 14 of 31 days with temperatures above the noted temperature standards as: 05/04/23, 05/15/23 and 05/17/23: freezer at 10 degrees Fahrenheit. 05/06/23: Freezer at 14 degrees Fahrenheit. 05/07/23: Freezer at 12 degrees Fahrenheit. 05/22/23: Freezer at 6 degrees Fahrenheit. 05/25/23: Freezer at 8 degrees Fahrenheit. Third floor: recorded 13 of 31 days with temperatures above the noted temperature standards as: 05/07/23, 05/16/23 and 05/21/23: freezer at 8 degrees Fahrenheit and 05/22/23 at 10 degrees Fahrenheit. 05/04/23: Refrigerator above 40 degrees Fahrenheit 11 of the 13 days recorded ranging from 42-52 degrees Fahrenheit. On 6/07/23 at 9:12 AM, Surveyor spoke with DM R and NHA A about the observation. DM R indicated dietary staff should be checking the refrigerators daily for cleanliness and appropriate temperatures. If the refrigerators and freezers are not clean bacteria, germs and mold can grow and contaminate residents' foods. Temperatures should be logged when they are checked to ensure the storage temperature is safe. If the temperature is out of range, it needs to be reported immediately and action taken. DM T further stated she needs to establish a routine where staff monitor the refrigerators and freezers daily and communicate any concerns so action can be taken immediately to ensure residents foods are stored safely. Surveyor reviewed the policy titled Water Management, Legionella Testing which is dated as most recently reviewed on 10/2022. The policy in part states: The facility handles and maintains its water supply in accordance with recommendations of the CDC (Centers of Disease Control). The community will demonstrate measures to minimize the risk of Legionella and other opportunistic pathogens in the building water systems through a documented water management program. Surveyor requested and received the CDC publication titled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated 06/05/2017. The publication in part reads: Legionnaires Disease is a serious type of pneumonia caused by bacteria called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from buildings water systems that are not adequately maintained. Factors internal to buildings that lead to Legionella growth: Water temperature fluctuations: Provide conditions where Legionella grows best (77-108 degrees Fahrenheit). Water Pressure changes: Can cause biofilm to dislodge. On 06/06/23 at 7:05 AM, Surveyor entered the kitchen and proceeded to the hand washing sink to wash hands. Surveyor noted the water temperature to be cooler than expected. Surveyor allowed the water to run for one minute and checked the temperature of the water. The water temperature was noted as 81 degrees Fahrenheit. Surveyor observed Cook Q and Dietary Aide (DA) T wash their hands in the sink several times. Surveyor asked Cook Q and DA T to allow the water to run and again checked the temperature. The temperature ranged from 80-85 degrees Fahrenheit. Surveyor observed Cook Q using a sink near the food preparation area. The water temperature was checked and noted to be 105 degrees Fahrenheit after allowing the water to run. Surveyor observed the dishwasher machine log of wash and rinse temperatures and noted wash and rinse temperatures which were much higher and within the acceptable hot water dish machine temperatures. Surveyor asked Cook Q and DA T what other sinks are used in the kitchen. Cook Q expressed the 3-compartment sink is not used as it leaks. Surveyor spoke with Cook Q and DA T about the water temperatures in the sinks observed. Both indicated the water temperatures fluctuate and have been low for several months. Cook Q expressed she has been on staff 6-7 months and the water has been like that since she started. DA T indicated she has been on staff a few years and the water issues were worse before they replaced a water heater several months ago. The water has not improved with replacing the water heater. Surveyor asked Cook Q and DA T if they had reported the water concerns to anyone. Both indicated their manager had just started a few weeks ago. They did not report the concern to their former or current manager. Surveyor asked if either had reported the concern to maintenance and both reported they had not. During the observation Surveyor observed DA T filling water pitchers intended for resident consumption from the sink in the kitchen. On 06/06/23 at 8:52 AM, Surveyor and Maintenance Director (MD) U reported to the kitchen. Surveyor asked MD U about acceptable water temperatures. MD U indicated the water temperatures in the building should be 110 degrees Fahrenheit for Legionella prevention. The facility's water management plan indicates water temperatures should be 110-115 degrees Fahrenheit. Surveyor took the temperature of the sink in the food preparation area and the temperature fluctuated between 97-99 degrees Fahrenheit after a good run of water. The hand washing sink in the dish room ranged from 82-84 degrees Fahrenheit after running the water. The hand washing sink in the kitchen was much the same in fluctuation as noted above when checked by the Surveyor. MD U expressed this is the first hearing of sink water temperature concerns in the kitchen. MD U expressed several months ago the facility had issues with the water temperatures. The facility replaced the water heater several months ago and he was not aware the water temperatures were a problem after replacing the water heater. Surveyor requested and received the facility policy for water management. On 06/06/23 at 1:15 PM, Surveyor spoke with Dietary Manager (DM) R about the water temperatures. DM R confirmed she had started employment a couple weeks ago and was aware of the cold-water issues but had not contacted maintenance about the water. Surveyor requested and received an invoice showing the facility was billed for installing one hot water heater on 01/01/23. On 06/07/23 at 9:45 AM, MD U spoke with Surveyor while touring the basement water system. MD U showed Surveyor where the water heater and water holding tank were located. MD U explained the facility had previously had two water heaters that fed the basement laundry and kitchen. When the hot water heater had issues several months ago two water heaters were replaced with one. The building's basement is supposed to operate with two. MD U suspects that when the laundry wash machine is running it is pulling the hot water from the holding tank that is being circulated as it is closest to the tank. Surveyor observed the tank to be located just outside the laundry department. The water that remains in the tank circulating has to travel 65-70 yards to feed the kitchen. The water temperatures are fluctuating and not being maintained above the requirement to prevent the spread of Legionella as the one water heater is not sufficient to do so.

Based on record review and interviews, the facility did not implement their abuse policy in regard to screening for 7 of 8 employees. Caregiver and criminal background checks were not completed for Certified Nursing Assistant (CNA) (CNA H, I, J, and K), Licensed Practical Nurse (LPN) L, Dietary Manager (DM) M, and Laundry Aide (LA) N. Out of state background checks were not completed for DM M and LA N. Findings include: The facility policy, entitled Abuse Prevention Program, Screening of Employees with a last revised date of 08/2022 reads in part, Background checks are completed per state guidelines on each employee. On 06/05/23, Surveyor requested Caregiver and Criminal background checks for a sample of 8 employees. On 06/06/23, the employee background information was reviewed. CNA H, J, and LPN L were all hired on 10/01/22. Caregiver and criminal background checks were not completed until 06/05/23. The Background Information Disclosure (BID) was not completed by the employees until 06/05/23. CNA K was hired on 10/25/22. Caregiver and criminal background checks were not completed. CNA I was hired on 11/10/22. Caregiver and criminal background checks were not completed until 06/05/23. The BID was not completed by the employees until 06/05/23. DM M was hired on 05/22/23 and indicated on the BID they had lived in Florida and Arizona. Surveyor requested the background checks for the other states from the Business Office Manager (BOM) G. BOM G was not aware that the other states needed to be checked. LA N was hired on 05/15/23 and indicated on the BID that they lived in Indiana. Surveyor requested the background check for the other state from BOM G. BOM G was not aware that the other states needed to be checked. On 06/06/23 at about 11:15 AM, Surveyor interviewed BOM G and asked if they ran the background checks for the employees after Surveyor gave them the sample of eight staff. BOM G indicated yes. On 06/06/23 at about 11:30 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the background checks being run upon hire. NHA A indicated that they were hired on 03/06/23 as a contract staff and was not aware the background checks were not completed until an employee requested to look at their personal file and things were missing. NHA A indicated that they started an audit on all employee files but were not able to complete it before we entered.

Based on observation, interview and record review, the facility did not ensure nutritional values are maintained when altering food consistencies to minced and moist and pureed consistencies. This has the potential to affect 12 of 43 sampled and supplemental residents who eat this food consistency (R5, R8, R2, R4, R35, R24, R18, R20, R41, R15, R25 and R292). Cook Q was observed pureeing scrambled eggs and bacon using hot water as a thinning agent. Cook Q expressed there are no recipes, no policy or any directions that tell her what she is to use to modify food to ensure nutritional value. This is evidence by: On 06/06/23 at 7:10 AM, Surveyor observed Cook Q pureeing scrambled eggs and bacon. Cook added the eggs to the robocoup to puree then proceeded to the hot water thermos to pour water to pitcher. Cook Q did not measure the water and added it to the eggs to puree the consistency. Cook Q repeated this process with bacon. Surveyor asked Cook Q how she knows what and how much liquid she needs to add to foods to modify the consistency. Cook Q expressed the facility is in the process of updating menus and recipes. There are no directions on what to use and how much to use to modify the food consistency. Cook Q further expressed she uses hot water to modify all hot foods to maintain the temperature of the foods. Surveyor asked Cook Q how she knows she is maintaining food's nutritional values. Cook Q indicated she has had no training on modifying foods and what and how much liquid should be used. Cook further expressed she does not know, and her background is in restaurants with starting in nursing home approximately 6-7 months ago. The Dietary Manager recently started employment and the former manager did not train her. On 6/06/23 at 1:29 PM, Surveyor and Dietary Manager (DM) R reviewed the recipes used in the kitchen and noted the recipes do not include any instructions on modifying food items to ensure the proper nutrition is maintained. DM R expressed the recipes should include instructions for both the minced and moist and puree diets. DM R further expressed she has not been trained on recipes needed to modify food consistencies as her background is in the restaurant field. DM R expressed there are no other directions in the kitchen to direct staff on proper methods needed to modify food consistency to maintain nutritional values. Surveyor requested a list of residents who receive these diets. On 6/06/23 at 2:23 PM, Surveyor spoke with the facility's consulting Registered Dietician (RD) S who has consulted for the facility 6 years. Surveyor asked RD S about diet modifications of consistency and what should be used to modify the diets to maintain nutritional values. RD S indicated recipes should show directions on amount of food used for servings and the items needed to be added to maintain or improve nutritional values when foods are modified. The recipes should be with all recipes in a book in the kitchen, so the cooks know what to use and how much is needed. Surveyor asked RD if hot water should be used to modify all hot foods. RD S expressed the menus/recipes are reviewed and signed by a RD to approve and ensure nutritional values are maintained. RD S further expressed the cooks at the facility were making decisions daily on what and how to cook. In December, new menus and recipes were approved which should have included recipe modifications. Food items need to be the proper texture and proper nutrition. Hot water for everything does not sound right. Water is not proper, staff should use something with nutritional value like bread or dairy products. Not water. Staff should have recipes for food items, they need to be printed and in book to be available to the cooks. That's a problem. Guidance and training in kitchen have been an issue. Staff are not ensuring nutritional values for residents. Surveyor requested the facility policy related to diet modifications and any recipes the facility may have for diet modifications. On 06/06/23 at 2:53 PM, Nursing Home Administrator (NHA) A informed Surveyor no recipes or policy was found and will be put in place going forward. On 06/07/23 at 9:30 AM, DM R provided Surveyor with recipe for scrambled eggs she obtained from the facility's food vendor. The recipe indicates whole milk should be used with scrambled eggs when modifying the constancy. The recipe includes instructions on amount of eggs and milk to use when pureeing scrambled eggs. Surveyor reviewed the list of residents receiving a minced and moist or puree diet. The list included R5, R8, R2, R4, R35, R24, R18, R20, R41, R15, R25 and R292.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 5 Residents (R) reviewed, Resident R8. The facility was not monitoring Nurse Practitioner (NP) F's notes requesting lab orders. Lab collections were not obtained timely resulting in a resident being hospitalized and treated with intravenous antibiotics for a urinary tract infection ([CONDITION(S)]) eleven days after NP F requested a urinalysis due to R8 exhibiting symptoms of a [CONDITION(S)]. This is evidenced by: R8 admitted to the facility on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/20/22, at 9:35 AM, Surveyor interviewed Nurse Practitioner (NP) F about resident appointments. NP F stated on 08/10/22, an order was written for R8 to have a UA done due to R8 having symptoms of a urinary tract infection ([CONDITION(S)]). NP F reviewed R8's medical file and was not able to see any results from her order on 08/10/22. Surveyor reviewed the medical record and could not find a lab report indicating that a UA was obtained per the orders of NP F. R8 was exhibiting signs/symptoms of a [CONDITION(S)] when the order was written. R8 did not receive the requested lab test required in order to provide treatment. Eleven days later, on 08/21/22 at about 2:50 pm, R8 was sent by ambulance because of escalating behaviors to St. Luke's Hospital for evaluation. The resident was then admitted to the hospital. On 08/22/22, Director of Nursing (DON) B contacted the hospital, which indicated R8 had a [CONDITION(S)] and required intravenous (IV) antibiotics for treatment due to the severity of the infection. The hospital indicated within a few hours of receiving IV antibiotics R8's behaviors improved. On 09/20/22, at 9:40 AM, Surveyor interviewed Registered Nurse (RN) E about resident appointments. RN E stated the facility procedure was to write the resident appointments on the calendar at each nurses station when appointments were scheduled. RN E stated that was the nursing supervisor's responsibility. RN E stated she had quit her job at the facility and had just returned to the position in the past week. During her absence they were without a nursing supervisor, and several resident appointments were missed.

Based on interview and record review, the facility failed to have sufficient nurse staffing to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being. This has the potential to affect all 48 residents. *The facility failed to meet staffing requirements, resulting in unlicensed staff working as Med Techs (MT) also known as a Medication Aide (a nursing assistant who has been certified in Wisconsin to pass medications) without a licensed staff member in the building. One of those aides was not certified as a medication aide in the state of Wisconsin. *The facility failed to meet staffing requirements, resulting in the Director of Nursing (DON) having to work as the charge nurse/floor nurse filling regularly scheduled shifts from 6:00 a.m. to 6:00 p.m. or 6:00 a.m. to 2:00 p.m. *The facility was deficient in providing adequate nurse staffing to cover available shifts resulting in the facility not having a full time DON. *The facility failed to meet staffing requirements, resulting in Certified Nursing Assistants (CNA) having to work inadequately staffed for resident acuity in the facility. Facility failure to have sufficient staff with appropriate competencies to ensure resident safety and to attain/maintain each resident's highest practicable well being, created a finding of immediate jeopardy that began on 8/01/22. DON B was notified of the immediate jeopardy on 8/18/22 at 3:43 PM. The immediate jeopardy has not yet been removed. Findings include: On 08/16/22 at 7:45 a.m., Surveyor entered the building and met with the DON, who was working the floor as the charge nurse/RN. Surveyor toured the facility to determine present staffing. The first floor of the facility had 1 RN, who was the DON, working the floor as the charge nurse/RN, 1 CNA (Certified Nursing Assistant) and 1 Nurses Aide, who is not certified yet for 25 residents on this floor. The second floor of the facility is closed. The third floor of the facility had 1 LPN (Licensed Practical Nurse) and 1 CNA working on the floor for 21 residents. On 08/16/22 at 8:00 a.m., Surveyor requested the Daily Assignment sheets and Staff Postings from 07/21/22 to present. DON B stated she had no clue how to get those but directed Surveyor to the office receptionist (OR), who could assist. Surveyor asked DON B if the NHA (Nursing Home Administrator) was in today. DON B stated NHA A was not in the facility today (08/16/22). Surveyor asked OR L for the daily Assignment sheets and Staff Postings. Surveyor received only the Daily Assignment sheets requested. Surveyor reviewed the daily staffing sheets for 07/21/22 through 08/16/22. For the dates 08/16/22, 08/15/22, 08/14/22, 08/11/22, 08/09/22, 08/07/22, 08/02/22, 07/31/22, 07/30/22, 07/29/22, 07/28/22, 07/26/22, and 07/21/22, DON B was listed as the nurse for the AM shift 6 a.m.-2 p.m. For the dates 08/13/22, 08/05/22, 07/23/22, and 07/22/22, DON B was listed as the nurse for the shift 6 a.m.-6 p.m. For the date 08/01/22, DON B was listed as the nurse for the shift 2 p.m.-6p.m. DON B worked 18 days on the floor as the nurse out of 27 days reviewed by Surveyor. Surveyor reviewed the daily staffing sheets for 07/21/22 through 08/16/22. The facility uses Med Techs as part of their staffing for licensed nurses. The following shows the staffing of the staff identified on the schedule as Med Techs: 08/16/22 CNA M (who is not a registered med tech in the state of Wisconsin) 6 p.m.-10 p.m. in facility working with LPN Q and CNA M 10 p.m.-6 a.m. working alone in facility in the licensed nurse capacity with no licensed nurse in the building. 08/15/22 MT N 2 p.m.- 6 p.m. and CNA M 6 p.m.-10 p.m. working with LPN Q. CNA M 10 p.m.-6 a.m. working alone in facility in the licensed nurse capacity with no licensed nurse in the building. 08/14/22 CNA M 10 p.m.-6 a.m. working alone in facility in the licensed nurse capacity with no licensed nurse in the building. 08/13/22 CNA M 6 p.m.-10 p.m. working with LPN Q. CNA M 10 p.m.-6 a.m. working alone in facility in the licensed nurse capacity with no licensed nurse in the building. 08/12/22 MT N 2 p.m.-6 p.m. and CNA M 6 p.m.-10 p.m. working with LPN Q. MT M 10 p.m.-6 a.m. working alone in facility in the licensed nurse capacity with no licensed nurse in the building. 08/11/22 CNA M 6 p.m.-10 p.m. working with LPN Q. CNA M 10 p.m.-6 a.m. working alone in facility in the licensed nurse capacity with no licensed nurse in the building. 08/10/22 MT N 2 p.m.-6 p.m. working with LPN Q working in the med tech role. 08/08/22 CNA M 6 p.m.-10 p.m. working with LPN Q. CNA M 10 p.m.-6 a.m., working with LPN R working in the med tech role. 08/07/22 CNA M 10 p.m.-6 a.m. working with LPN R in the med tech role. 08/06/22 CNA M 6 p.m.-10 p.m. working with LPN Q; CNA M 10 p.m.-6 a.m. working alone in facility in the licensed nurse capacity with no licensed nurse in the building. 08/5/22 CNA M 6 p.m.-10 p.m. working with LPN Q and LPN R. CNA M 10 p.m.-6 a.m. working with LPN R in med tech role. 08/01/22 MT N 6 p.m.-10 p.m. working with LPN Q. MT N 10 p.m.-6 a.m. working alone in facility in the licensed nurse capacity with no licensed nurse in the building 07/27/22 MT N 2 p.m.-6 p.m. working with LPN Q in the med tech role. Surveyor reviewed the daily staffing schedules for 07/21/22 through 08/16/22 and documentation shows the facility only had one CNA and one nurse on the third floor to meet 21-23 residents' needs on 08/16/22, 08/14/22, 08/13/22, 08/10/22, and 08/02/22. Documentation on the daily staffing schedules shows one CNA and one nurse on the first floor to meet 25-28 residents' needs on 07/23/22, and 07/22/22. On 08/25/22 at 9:50 a.m., Surveyor interviewed R10, and asked about call lights, staffing, and meeting of needs. Resident stated the facility does not have enough staff, but she doesn't blame them. Resident stated they do the best they can. Resident stated call lights are answered as soon as the staff has time. Sometimes it is quite awhile because the staff is so busy. On 8/25/22 at 9:59 a.m., Surveyor interviewed R5 Surveyor asked if residents needs are met, if staffing was adequate, and if call lights were answered timely. R5 stated the facility does not have enough supplies of wipes or briefs. R5 stated facility does not have enough staff. R5 stated the staff that are working are so busy, they can't get everything completed. R5 stated call lights can take from 35 minutes on up to be answered and at times it results in R5 urinating self due to the wait time. Surveyor asked resident about meal times. R5 stated the staff is trying and the times of the meals are better. On 08/25/22 at 10:30 a.m., Surveyor interviewed R22, and asked about call lights, staffing, and meeting of needs. R22 stated call lights are answered, but it takes time. R22 stated the facility does not have enough staff. R22 stated they (the staff) are so busy all the time. R22 did not have complaints about the meals. On 08/16/22 at 12:30 p.m., Surveyor asked DON B for the Facility Assessment. DON B stated she did not have a clue. DON B stated she has been working the floor so much she has not been able to learn the DON position. Surveyor asked HR G for the Facility Assessment and HR G stated she would inquire about it. Surveyor asked HR G when the last date was that NHA A was in the facility. HR G stated NHA A was in the facility 08/12/22. Surveyor asked DON B about inadequate staffing. DON B stated she has let the corporation know, but they won't increase the staffing because they state the facility must increase the resident census. DON B stated she told the corporation the facility can't take any new resident admissions because there is not enough staff to meet their needs. DON B stated it is landing on deaf ears. Surveyor asked DON B about the facility policy on Med Techs and supervision. DON B stated it was her understanding an RN (Registered Nurse) only had to be available, not in the building for them to work. DON B stated the Med Techs call if there is an issue with medications or other problems since she is on-call 24/7 anyway. The facility is unable to provide full time NHA coverage. The facility is unable to provide full time DON coverage. The facility is unable to meet the residents' needs or staffing requirements, due to DON filling shifts as an RN to have RN coverage and nurse coverage on the floor in the facility. The facility is unable to provide adequate RN supervision of the Med Techs when they are on duty. The facility was utilizing CNAs in the med tech role with no licensed nurses in the building. The facility is unable to provide staffing to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being. Examples: On 08/18/22 at 5:40 AM, Surveyor interviewed CNA N, who stated she worked at the facility as a Medication Aide. CNA N stated she would be working from 6:00 AM through 8:00 PM today. CNA N stated she was asked to work a longer shift due to limited staff available and that was a frequent occurrence. CNA N stated sometimes the Medication Aides were asked to work in the facility on the evening or night shift when there was no nurse working in the building. CNA N stated this evening she and another medication aide were scheduled to work from 3:00 PM until 8:00 PM when there was not a nurse scheduled to be in the building. CNA N stated DON B would probably stay for a while, but CNA N was not sure how long since DON B had been working since 3:00 AM. CNA N stated this evening after CNA MT N leaves at 8:00 PM, the other CNA will be working as the only person passing medications until 10 PM. CNA N stated she had done that in the past, but CNA N often refused when asked because she was not comfortable working as a Medication Aide in the building when there was no nurse present. CNA N stated it had happened on multiple shifts in the past few weeks that some of the other Medication Aides worked in the facility without a nurse present in the building. They were told it was legally okay because a nurse was available to them by phone and the DON did not live very far away. On 08/18/22 at 6:15 AM, Surveyor interviewed CNA F, who stated they are frequently working short staffed throughout the building. CNA F stated the past 7 shifts she worked without another aide on the third floor to assist with cares on the day shift. CNA F stated there were currently twenty one residents she was responsible for on the third floor. CNA F stated many of those residents required extensive assistance with toileting and Activities of Daily Living (ADL). CNA F stated one resident on the third floor required two staff members to assist with transfers using a mechanical lift. CNA F stated on the shifts she worked alone on the unit, that resident had to wait until the nurse or Medication Aide was available to assist them with a transfer. On 08/18/22 at 7:25 AM, CNA N informed Surveyor they were still accepting new admissions to the facility even though they did not have enough staff to properly care for them. CNA N stated they admitted a new resident some time last week, and they still did not have a paper chart put together on the unit because staff was too busy to put it together. CNA N thought the admission paperwork that should be on the unit was probably in the DON's office on the 2nd floor waiting for DON B to have time to put the paper chart together. On 08/18/22 at 5:00 AM, Surveyor entered the facility and met with DON B who was working 1st floor as the floor nurse. Surveyor was told the census was 48. Surveyor asked DON B how many staff were working with her. DON B indicated 2 CNAs plus 1 training. Review of daily staffing schedules identified from 8/1/22 to 8/18/22 there were eight night shifts where the only staff person on duty to administer medications to residents was a Med Tech (MT) also known as a Medication Aide (a nursing assistant who has been certified in Wisconsin to pass medications). The schedule showed there were no licensed staff in the building during those shifts. The following shows the staffing of the Med Techs (MT): 08/01/22 10 p.m.-6 a.m. CNA N worked in the facility as a medication aide with two other CNAs. No licensed nurse was in the building. 08/06/22 10 p.m.-6 a.m. CNA M worked in the facility as a medication aide with two other CNAs. No licensed nurse was in the building. 08/11/22 10 p.m.-6 a.m. CNA M worked in the facility as a medication aide with two other CNAs. No Licensed nurse was in the building. 08/12/22 10 p.m.-6 a.m. CNA M worked in the facility as a medication aide with two other CNAs. No Licensed nurse was in the building. 08/13/22 10 p.m.-6 a.m. CNA M worked in the facility as a medication aide with two other CNAs. No Licensed nurse was in the building. 08/14/22 10 p.m.-6 a.m. CNA M worked in the facility as a medication aide with two other CNAs. No Licensed nurse was in the building. 08/15/22 10 p.m.-6 a.m. CNA M worked in the facility as a medication aide with two other CNAs. No Licensed nurse was in the building. 08/16/22 10 p.m.-6 a.m. CNA M worked in the facility as a medication aide with two other CNAs. No Licensed nurse was in the building. Upcoming schedule: 08/19/22 1 a.m.-6 a.m. Nurse Aide (NA) P was scheduled to work in the facility as a medication aide with two other CNAs. No licensed staff was on the schedule to work during that time frame. 08/20/22 10 p.m.-6 a.m. NA P was scheduled to work in the facility as a medication aide with two other CNAs. No licensed staff was on the schedule to work during that time frame. Per DHS website, Medication aides work under the delegation of an RN. The RN will determine what level of supervision is required based on what they are delegating to the medication aide and under what circumstances. There is no documentation that such delegation occurred. The schedule showed CNA M started working at the facility on 08/05/22 as a medication aide. CNA M trained with a licensed nurse from 6 p.m. to 6 a.m. on that date. CNA M trained with a licensed nurse from 6 p.m. to 10 p.m. on 08/06/22 and then began working as a medication aide with no licensed nurse in the building from 10 p.m. to 6 a.m. The schedule showed CNA M had worked six other night shifts as a medication aide with no licensed nurse in the building on 08/11, 08/12, 08/13, 08/14, 08/15, and 08/16/22. CNA M completed coursework as a Medication Aide in Minnesota from a school that was not a State of Wisconsin approved training program for providing medication aide courses. CNA M was not certified as a medication aide in Wisconsin and legally cannot administer medications to nursing home residents in Wisconsin. Records indicated CNA M administered routine medications and had also given prn (as needed) medications, including [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Because CNA M was working as a medication aide without a licensed nurse in the building, there was no nursing assessment of these residents before the prn medications were given. CNA M was first placed on the Wisconsin Nurse Aide Registry on 06/13/22, and had been a certified nursing assistant in Wisconsin for only two months. On 08/29/22 at 3:30 PM, Surveyor reviewed the facility staffing sheets from 08/25/22-08/28/22. Based on the Surveyor's review, the facility had no RN coverage within the building to perform assessments on 08/28/22. On 08/29/22 at 4 PM, interview with office receptionist (OR) L, who is in charge of staff scheduling, confirmed that no RNs had been working on 08/28/22. On 08/29/22 at 12:31 PM, Surveyor interviewed CNA EE who had worked on 08/28/22 at the facility. CNA EE expressed concerns about staffing. CNA EE stated that today she was called to come in early at 4PM and that after 6PM today she is the only CNA on duty on the first floor until 6AM. CNA EE stated that the nurse works with her to help but that it is difficult to try and meet the residents' needs. CNA EE stated it's crazy around here until at least 10 PM when some residents go to sleep. Record review of the first-floor resident census and condition report (CMS 672) dated 08/30/22 as provided by RN U documents the following information about the first-floor residents. The census of the first-floor is 23 residents. All 23 require assistance for dressing, 22 require assistance for transferring, 23 require assistance for toilet use, and 6 require assistance with eating. 20 residents are occasionally or frequently incontinent of bladder and are on a urinary toileting program, 6 are occasionally or frequently incontinent of bowel and are on a bowel toileting program. 19 residents are in a chair all or most of the time. 4 of the residents have contractures. 16 of the 23 residents have signs and symptoms of depression, 6 have psychiatric diagnosis (excluding dementias and depression) and 8 have dementia. 1 has a pressure ulcer and 2 have behavioral healthcare needs. On 08/29/22 at 2:30 PM, Surveyor interviewed CNA Z who worked the weekend at the facility. Review of the schedules revealed CNA Z worked on the third floor on Saturday, 08/27/22 from 6 PM to 6 AM and on Sunday, 08/28/22 from 6 PM to 6 AM. CNA Z stated that at times they only have one aide on the floor working days or PMs with 1 nurse. CNA Z stated that they didn't feel that is safe to have only 1 CNA with the behaviors that residents have. CNA Z stated there was only 1 CNA working on each floor this morning when they left the facility at 6 AM. Record review of the third- floor census and condition report (CMS 672) dated 08/30/22 as provided by RN U documents the following information about the third-floor residents. The census on the third-floor is 21 residents. 18 residents require assistance for dressing, 17 require assistance for transferring, 19 require assistance for toilet use, and 15 require assistance with eating. 2 residents have catheters, 14 residents are occasionally or frequently incontinent of bladder and are on a urinary toileting program, 9 are occasionally or frequently incontinent of bowel and are on a bowel toileting program. 13 residents are in a chair all or most of the time. 2 of the residents have contractures. 9 of the 21 residents have signs and symptoms of depression, 5 have psychiatric diagnosis (excluding dementias and depression) and 15 have dementia. 1 has a pressure ulcer and 4 have behavioral healthcare needs. On 8/30/22 at 8:30 AM, Surveyor interviewed RN Y. RN Y stated she was hired by the facility on 08/16/22 and has worked every day except last weekend. RN Y stated whenever she is scheduled to work, they always ask her to stay longer. RN Y stated that they frequently schedule 1 nurse and 1 aide on each floor. RN Y stated it is not possible to get it all done with that kind of staffing levels, even when you are running all day. RN Y stated she hasn't even been able to punch in-to the time clock yet because there is no one here to enter her into the facility's system. Facility's failure to ensure competent and adequate nurse staffing created a finding of immediate jeopardy that began on 08/01/22. The facility has not yet removed the immediate jeopardy.

Based on observation, interview, and record review, the facility Governing Body failed to implement policies related to the management and operation of the facility and were not actively engaged and involved in the daily operations of the facility, which affected the quality of life for all 48 residents. The facility has had frequent turnover of administrative staff over the past 8 months and is currently without an administrator in the building. The facility has had 5 different Directors of Nursing (DON) since February of this year, and the current DON is unable to fulfill the DON duties due to working to cover nursing shifts on the floor. The facility has had chronic problems with inadequate staffing and supplies over the past few months. Failure of the Governing Body to manage and operate the facility with adequate supplies and have sufficient staff with appropriate competencies to ensure resident safety and to attain/maintain each resident's highest practicable level of well-being, created a finding of immediate jeopardy that began on [DATE]. DON B was notified of the immediate jeopardy on [DATE] at 3:43 PM. The immediate jeopardy is not yet removed. This is evidenced by: Administration: The facility has had four changes in Nursing Home Administrators (NHA) since [DATE]. The current NHA was not in the building during this survey. The NHA was not in the building when Surveyor arrived on [DATE] and did not arrive during that day. Human Resources (HR) G informed Surveyor the NHA was last in the building on [DATE]. The NHA was not in the building when Surveyors arrived on [DATE]. Surveyor interviewed Director of Nursing (DON) B on [DATE] about the NHA's presence in the building during the week. DON B stated she thought the NHA was out for the week for some appointments and was not sure when the NHA was due to return. Surveyor asked DON B if anyone from corporate was coming to the building to offer support and assistance with administrative tasks in the NHA's absence. DON B stated, No, it is just me trying to manage the building while working the floor to cover nursing shifts. DON B stated no one from corporate had been in the building since the NHA's absence and she did not anticipate anyone coming to help. DON B stated she had spoken to corporate staff multiple times about needing help but received no support. Director of Nursing: From [DATE] to the present, the facility identified 5 different RNs (Registered Nurses) as their DON: - RN T from [DATE] - [DATE] (4 days) - RN U from [DATE] - [DATE] (9 days) - RN V from [DATE] - [DATE] (92 days) - RN W from [DATE] - [DATE] (31 days) - DON B from [DATE] to present The facility was cited at F727 on [DATE] for lack of a full time DON and did nothing to correct the situation. At that time, DON B who was listed as the DON was working full time as the staff nurse to cover shifts on the floor due to inadequate nurse staffing. DON B stated she had not received any training in the role of DON and did not agree to fill the position until adequate nursing staff could be hired. Surveyor reviewed the daily staffing sheets for [DATE] through [DATE]. For the dates [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], DON B was listed as the nurse for the AM shift 6 a.m.-2 p.m. For the dates [DATE], [DATE], [DATE], and [DATE], DON B was listed as the nurse for the shift 6 a.m.- 6 p.m. For the date [DATE], DON B was listed as the nurse for the shift 2 p.m.- 6p.m. DON B worked 18 days on the floor as the nurse out of 27 days reviewed by Surveyor. On [DATE] at 12:30p.m. Surveyors interviewed DON B about staffing and the role of DON. DON B stated she had been working the floor so much she had not been able to learn the DON position. DON B stated she had let the corporation know there was not adequate staff to care for the current residents, but they told her they won't increase the staffing without an increase in the resident census. The facility currently does not have a waiver for full time DON coverage. See F727 for details. Inadequate staffing and supplies to meet resident needs: The facility was cited at F837 for lack of payment of vendors on [DATE]. The corporate governing body's financial situation and lack of payment to many vendors, resulted in the facility receiving notice of suspension for services such as electricity, heat, hot water, air conditioning, telephone service, recycling, general maintenance or discontinuation of supply delivery notices for food/dairy, medical supplies, and cleaning products. The facility was revisited on [DATE] and that deficiency was not corrected due to ongoing unpaid vendors and staff reports of late payroll checks. On [DATE], the facility was cited at F835 for inadequate supplies, such as soap, Kleenex, disposable gloves, and incontinent supplies for resident cares, and inadequate staffing to meet resident toileting and Activities of Daily Living (ADL) needs. During this current complaint survey, conducted from [DATE] through [DATE], it was apparent the facility made no improvement in the staffing and supply concerns. Multiple staff members reported inadequate supply of gloves and incontinent products to meet resident needs. Observations were made of limited quantities of supplies and gloves in supply rooms and resident rooms during the survey. Staff reported purchasing incontinent supplies and gloves with their own money due to inadequate supply provided by the facility. The facility was cited again at F835 for inadequate supplies. Review of the staff schedules and observations of staffing during the current survey identified the staffing situation had not improved since the survey on [DATE], and in fact it had deteriorated. The inadequate staffing resulted in unqualified, unlicensed staff working shifts as the only staff administering medications to residents. There were eight overnight shifts from [DATE] through [DATE] staffed with one Medication aide and two Certified Nursing Assistants (CNAs). Seven of those shifts were staffed by a medication aide who was not certified in the State of Wisconsin to administer medications to nursing home residents. The 3 CNA staff members on those shifts were responsible for the care of 46 to 48 residents scattered between two units on the first and third floors of the building. There was not a licensed nurse in the building during those shifts, and the DON on call for consultation or emergencies was 15 minutes away from the facility. See F725 for details. Review of staff qualifications for the shifts that were staffed with unlicensed medication aides, identified seven of the shifts mentioned above were staffed by caregivers who were unqualified to provide CPR for residents. 14 of the 48 residents in the facility had advanced directives indicating they wanted CPR if they suffered a cardiopulmonary arrest. See F678 for details. Failure of the Governing Body to manage and operate the facility with adequate supplies and have sufficient staff with appropriate competencies to ensure resident safety created a reasonable likelihood for serious harm, resulting in a finding of immediate jeopardy that began on [DATE]. The facility has not yet removed the immediate jeopardy.

Based on interview and record review, the facility did not ensure that facility staff is able to provide emergency basic life support immediately when needed, including Cardiopulmonary Resuscitation (CPR,) to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related Physicians Orders and the resident's advance directives for 14 of 48 residents (R) in the facility (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18). The facility did not have licensed staff available on nine shifts, from [DATE] through [DATE], who could immediately initiate CPR should any of the 14 residents who desired CPR have a cardiopulmonary arrest. The direct care staff did not have access to a resident's CPR status seven days after they were admitted to the facility. This affected 1 of 48 residents reviewed. (R21) Failure to have staff available on a 24-hour basis to initiate CPR and the failure to document a resident's code status led to a finding of immediate jeopardy that began on [DATE]. The facility was informed of the immediate jeopardy on [DATE] at 3:43 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity level of E (potential for more than minimal harm, pattern) as the facility continues to implement its action plan. Findings include: Per CMS S & C ,d+[DATE], nursing homes must have staff certified in CPR on duty every shift. These individuals must provide CPR for any resident who becomes pulseless and non-breathing unless: (1) the resident has a do not resuscitate (DNR) order. (2) the resident has obvious signs of clinical death (e.g., rigor mortis, dependent lividity [pooling of the blood that occurs after death and may look blue, purple or black and is similar to bruising], decapitation, transection, or decomposition) or (3) the initiation of CPR could cause injury or peril to the rescuer. The facility procedure entitled, Emergency Procedure-Cardiopulmonary Resuscitation, stated in part, .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS [Basic Life Support] shall initiate CPR . The procedure also stated, .Select and identify a CPR Team for each shift in the case of an actual cardiac arrest .The CPR team in this facility shall include at least one nurse, one LPN/LVN [Licensed Practical Nurse/Licensed Vocational Nurse] and two CNAs [Certified Nursing Assistants], all of whom have received training and certification in CPR/BLS . Surveyor reviewed the daily staffing sheets for [DATE] through [DATE]. Certified Nurse Assistant (CNA) M and Nurse Aide (NA) P completed a med tech course in Minnesota, but were not accredited in the State of Wisconsin as Med Techs. The facility scheduled CNA M and NA P in licensed nurse positions although neither were qualified. [DATE] 10 p.m.-6 a.m. CNA M worked in the facility with two other CNAs. No licensed nurse was in the building. [DATE] 10 p.m.-6 a.m. CNA M worked in the facility with two other CNAs. No licensed nurse was in the building. [DATE] 10 p.m.-6 a.m. CNA M worked in the facility with two other CNAs. No licensed nurse was in the building. [DATE] 10 p.m.-6 a.m. CNA M worked in the facility with two other CNAs. No licensed nurse was in the building. [DATE] 10 p.m.-6 a.m. CNA M worked in the facility with two other CNAs. No licensed nurse was in the building. [DATE] 10 p.m.-6 a.m. CNA M worked in the facility with two other CNAs. No licensed nurse was in the building. [DATE] 10 p.m.-6 a.m. CNA M worked in the facility with two other CNAs. No licensed nurse was in the building. [DATE] 1 a.m.-6 a.m. NA P was scheduled to work in the facility with two other CNAs. No licensed staff was on the schedule to work during that time frame. [DATE] 10 p.m.-6 a.m. NA P was scheduled to work in the facility with two other CNAs. No licensed staff was on the schedule to work during that time frame. On [DATE], Surveyor requested documentation of CPR certification for all the Med Techs who worked in the facility. No documentation of CPR certification was received for CNA M or NA P. Surveyor interviewed Human Resources (HR) G, who stated they were trying to get documentation of CPR certification for those two staff members. HR G stated they did not have documentation of CNA M or NA P's CPR certification in their personnel files. On [DATE], Surveyors reviewed the medical records of all 48 residents in the building. 14 of the residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, and R18) had Advanced Directives on their medical records identifying those residents wished to have CPR performed if they required it. On [DATE] at 10:05 AM, Surveyor interviewed Director of Nursing (DON) B about the facility's expectation for staff to initiate CPR for residents who requested full code when there was not a licensed staff member in the building. DON B thought all the Med Techs who worked without a nurse in the building were certified in CPR and would expect them to initiate CPR if a resident who was full code required it. Surveyor referenced the facility policy for CPR that stated, .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS [Basic Life Support] shall initiate CPR . DON B stated she was not aware of that policy and if that was the case, DON B would instruct the Med Tech over the phone to initiate CPR and DON B could get to the building in about 15 minutes to take over. Example 2: On [DATE] at 7:03 AM, Surveyor asked DON B where the staff would look to determine a resident's CPR status. DON B stated as far as she knew they would look at the advanced directives document on the resident's paper chart on each unit. On [DATE] at 7:25 AM, Surveyor was reviewing the CPR status on all the paper medical records on the third-floor unit. Surveyor was not able to locate a paper medical record for R21 on the unit. Surveyor asked MT where the paper chart for R21 was located. MT stated R21 was admitted to the facility some time last week, and staff must not have had time to put the paper chart together yet. MT stated the paper documents from R21's admission might be in the DON's office on the second floor. On [DATE] at 7:30 AM, Surveyor reviewed R21's electronic medical record. The record identified R21 was admitted to the facility on [DATE]. There was no documentation on the electronic medical record that identified R21's CPR status. On [DATE] at 1:08 PM, Surveyor asked MT N where they would look to determine a resident's CPR status if the resident was found unresponsive and not breathing. MT N stated they would look at the advanced directive form on the paper chart at the nurse's station. On [DATE] at 1:20 PM, Surveyor asked CNA S where they would look to determine a resident's CPR status if the resident was found unresponsive and not breathing. CNA S stated they would look at the advanced directive form on the paper chart at the nurse's station. On [DATE] at 1:29 PM, Surveyor asked CNA F where they would look to determine a resident's CPR status if the resident was found unresponsive and not breathing. CNA F stated they would look at the advanced directive form on the paper chart at the nurse's station. Surveyor requested documentation of R21's CPR status. At [DATE] at 1:48 PM, DON B provided a copy of the advanced directive document signed by R21 and dated [DATE]. The document was marked Do Not Resuscitate. DON B stated the document was with R21's admission documents on the second floor. DON B stated they had been too busy to put the paper chart together and get it to the third-floor unit. The failure to provide licensed staff who were certified to provide CPR on all shifts, and the failure to provide direct care staff access to a resident's CPR status, created a reasonable likelihood for serious harm, which led to a finding of immediate jeopardy that began on [DATE]. The facility removed the jeopardy on [DATE], when it had completed the following: The Director of Nursing or designee will ensure all licensed employees receive and maintain the CPR Certification by [DATE]. The DON and Interim Administrator were inserviced on the Do Not Resuscitate and CPR Certification Policy and Procedure on [DATE]. The Administrator was reeducated by the RN Nurse consultant on [DATE] on ensuring the CPR certifications are maintained and that 1 person per shift must be certified to provide CPR in the event a resident would code by [DATE]. The facility will ensure going forward a licensed nurse, certified in CPR, is in the building at all time by [DATE]. All licensed nurses will be reeducated by [DATE] on ensuring they maintain their CPR status by the Administrator-RN. The Human Resource Department was reeducated on [DATE] by the VPO on ensuring all licensed nurses have their CPR Certification upon hire and renewed every 2 years thereafter.

Based on observation, interview, and record review, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers, and a resident who has had a history of [REDACTED].#1, #7, #6, #3, and #4). 1. Resident #1 had a re-occurring pressure ulcer on his right buttock. The facility did not put preventative measures in place to prevent a third reoccurrence of the pressure ulcer. The pressure ulcer occurred a third time and the facility did not provide any new interventions to promote healing when the ulcer was discovered. The most recent ulcer deteriorated to a stage 4. Resident #1 was hospitalized twice with an infected stage 4 pressure ulcer. During observations of wound care, the nurse did not place a clean barrier under wound care supplies during wound care. The failure to have a system in place for pressure ulcer preventative care, new interventions to promote healing, and a lack of proper hand washing and poor wound care techniques, created an Immediate Jeopardy situation. The jeopardy began 05/13/13, when Resident #1 presented with symptoms suggestive of an infected wound. The facility was notified on the Immediate Jeopardy on 11/14/13. The facility removed the Immediate Jeopardy on 11/14/13. The deficient practice continues at a scope/severity level of E (Potential for harm/pattern) as evidenced below. 2. Resident #6 has a facility-acquired pressure ulcer, which is tunneling and most recently measured at 2.8 centimeters deep. His care plan and physician's orders [REDACTED]. On 11/11/13, Resident #6 got up before lunch, and did not lie down until after supper. Resident #6 has a firm pressure pad on his bed, which was observed as being directly under his pressure ulcer. Resident #6, who is on an air mattress, also had several layers of linens between him and the air mattress, which had the potential to increase pressure on the pressure ulcer. When wound care was observed by the surveyor, the nurse did not place a clean barrier under her wound care supplies, did not wash or sanitize her hands appropriately, did not clean a metal clamp before using it to pack Resident #6's tunneling ulcer, and applied the wrong cream to Resident #6's peri wound. 3. Resident #7 was admitted to the facility with a stage 1 pressure ulcer to the sacrum, which developed into an unstageable pressure ulcer. The surveyor observed wound care that was not provided according to professional practice. 4. Resident #3 has pressure ulcers caused by shearing on his buttocks. Preventative measures were not taken to assist in wound healing and prevention of additional pressure ulcers. When wound care was observed by the surveyor, the nurse did not place a clean barrier under her wound care supplies, and did not remove her gloves or sanitize her hands between removing the old dressing, nor after cleaning the wound, nor before applying the clean dressing. Resident #3 developed a new area of shearing on his other buttock during the survey. 5. Resident #4 received wound care on her pressure ulcer from a nurse who did not place a clean barrier between the clean dressing supplies and the bedside table. This is evidenced by: 1. Surveyor reviewed Resident #1's medical record on 11/11/13, 11/12/13, and on 11/13/13. Resident #1 has resided at the facility for the past five years. He has [DIAGNOSES REDACTED]. He also has a history of a pressure ulcer on his sacrum (the bony area between the base of the spine and the tailbone), a history of an infected right hallux (big toe), a history of [MEDICAL CONDITION], and a history of [MEDICAL CONDITION] (MRSA). Resident #1 also has a current infection of Carbapenem-resistant [MEDICATION NAME] (CRE) in his urine, and a current ischial decubitis (area on the buttock and hip bone) stage 4 pressure ulcer. Resident #1 requires the use of continuous oxygen and he is incontinent of his bowels. He requires the use of a mechanical lift with staff assistance in order to transfer. Resident #1 does not ambulate. Resident #1 was identified as being a high risk for developing pressure ulcers on his Minimum Data Set (MDS), dated [DATE]. Resident #1 developed a stage 2 open area on his right buttocks on 10/20/12, which healed on 11/18/12. One week later, on 11/25/12, the pressure ulcer re-developed as a stage 2 pressure ulcer. On 12/10/12, Resident #1's care plan was updated to include staff offering assistance to lay Resident #1 down for an hour after lunch and supper, and to use side-to-side positioning when in bed. This pressure ulcer healed on 02/03/13. Despite having had two pressure ulcers in this area, the facility did not revise the care plan with new approaches to prevent the re-development of another pressure ulcer. The resident continued to have a pressure-relieving mattress with a raised edge, the care plan continued to call for two-hour repositioning, and there was no discussion of limiting the amount of time the resident was up in his wheelchair. On 03/12/13, nurses' notes indicate Resident #1 had six fluid filled pustules along his right inner buttock. As of 03/17/13, four of the pustules opened, and Resident #1's physician was updated. The facility received orders to continue to monitor. On 03/18/13, a nurse's note indicates Resident #1 was up in a wheelchair for meals only. The note did not specify how long Resident #1 was to remain in his wheelchair for meals, and this was not added to his care plan. Resident #1's physician evaluated the open area on 03/28/13. The physician's note states, in part, "...he has developed a folliculitis-like rash on the buttocks and in the sacral region. That has rapidly progressed and was treated with Keflex, but he has developed a pressure sore now in the intergluteal fold and onto the right buttocks. This is fairly extensive and it is probably quite serpiginous (a slowly progressive medical condition, usually leaving scar tissue below the area), but it is at least 30 cm (centimeters) long from the far left side to the pole of the right buttocks lesion...The lower right buttocks lesion has eschar so it is technically unstageable. He has a portion that shows stage II sore...PLAN: I suspect that this wound has developed because of the dosing of the [MEDICATION NAME] (steroid medication) and the folliculitis subsequently developed." It is noted a resident taking [MEDICATION NAME] medication is at greater risk for having skin issues, and delays the wound healing process. This was also confirmed by the Director of Nursing (DON) during an interview with Surveyor , on 11/13/13 at 9:36 a.m. On 03/28/13, the physician changed the amount of insulin Resident #1 received, and gave orders for a wound care consultation. The nurses' notes also state the facility would continue with repositioning Resident #1 side-to-side and he would be up for meals only. No new interventions were put into place at this time. A review of Resident #1's facility wound assessment, dated 04/01/13, indicates Resident #1 had [MEDICAL CONDITION] to his right buttock. The assessment states the wound was larger with the area spreading to the coccyx (tailbone) and left inner buttock. The wound measured 15 cm by 4.8 cm. It is also documented the wound bed had yellow exudate (drainage which is produced by the body in response to tissue damage). Resident #1 went to the wound clinic for an appointment on 04/02/13. The wound clinic ordered new treatment orders for the wound, and ordered Resident #1's time be limited while he is up in the wheelchair. The wound clinic physician's note states, in part, "PLAN: I discussed with (Resident #1's name) that he clearly has a pressure ulcer. His caregivers report that he spends a significant amount of time in his wheelchair...The importance of avoiding prolonged sitting was reviewed. During the acute phase of this ulcer we will limit his time in his chair to two-hour intervals..." Resident #1's care plan was updated at this time, to indicate Resident #1 was to be up in his wheelchair for no more than two hours at a time. According to the National Pressure Ulcer Advisory Panel (NPUAP), the current standard of practice is to reposition a resident with a pressure ulcer more frequently than every two hours to relieve pressure to the affected area. On 04/14/13, the nurses' notes indicate Resident #1's physician was updated in regards to the wound getting bigger. At this time, an appointment was made for Resident #1 to return to the wound care clinic. On 04/18/13, a facility occupational therapist (OT) spoke with a representative from the National Seating and Mobility company regarding Resident #1's wheelchair cushion. The representative recommended having Resident #1's wheelchair reclined for five minutes, for every hour Resident #1 sat up in his wheelchair. Surveyor noted this was not documented in Resident #1's medical record, but was provided to Surveyor on 11/13/13 by the DON. According to the NPUAP, reclining an individual with a pressure ulcer does not meet professional standards of practice. Reclining an individual with a pressure ulcer on the buttocks should not be used as a repositioning technique; and it does not physically relieve pressure from an individual's buttocks. Surveyor interviewed Certified Nursing Assistant (CNA) E on 11/14/13. Surveyor asked if staff were currently reclining Resident #1 in his wheelchair for five minutes, for every hour the resident is up in his wheelchair. CNA E stated staff were currently doing this practice. This is also listed as a current intervention on Resident #1's care plan, at the time of the survey. On 04/23/13, the wound clinic provided new treatment orders for Resident #1's pressure ulcer. On 04/30/13, the nurses' notes indicate Resident #1 has an unstageable ulcer, which measured 8.2 cm by 3 cm. On 05/13/13, the facility wound assessment indicates Resident #1's pressure ulcer measured 8.4 cm by 4 cm, and the depth as 2.6 cm. The ulcer is described as having gray/brown slough (layer of dead tissue separating from the living tissue) at the base of the wound, with moderate gray/green drainage. The ulcer is also documented as having a foul odor. This is the first documentation by the facility which measures the depth of the pressure ulcer. The facility did not document Resident #1's vital signs on 05/13/13, despite having symptoms of a possible infection. The facility also did not consult the physician in regards to the ulcer having a foul odor. On 05/14/13, the facility received new orders from the wound clinic to change the treatment to Dakin's solution, twice a day. On 05/18/13, nurses' notes document Resident #1 had an elevated temperature of 99.7 degrees at 8:21 a.m.; and the pressure ulcer continued to have a foul odor. On 05/19/13, Resident #1's physician ordered an oral antibiotic, [MEDICATION NAME], "...to cover a UTI (Urinary Tract Infection) and possible wound infection." Resident #1 returned to the wound care clinic on 05/21/13. The wound clinic notes indicate the wound has necrotic tissue at the base, and the wound will need surgical debridement (medically removing dead or infected tissue in order to improve the healing potential of the wound). Nurses' notes from 05/24/13 indicate Resident #1's pressure ulcer has brownish/yellow exudate with some blood-tinged drainage on the wound dressing. On 05/24/13 at 8:00 p.m., nurses' notes indicate Resident #1 was lethargic and had a temperature of 100.4 degrees. Resident #1 was then sent to the emergency room and was admitted to the hospital. Resident #1's history and physical assessment, dated 05/25/13, states Resident #1 has an infected decubitis ulcer, which was confirmed by a wound culture. Resident #1 was started on intravenous [MEDICATION NAME] and Meropenum (antibiotic medications), and his wound was surgically debrided. At this time, Resident #1 was referred to a plastic surgeon and an infectious disease physician regarding the pressure ulcer. The history and physical assessment also states Resident #1 has had an indwelling catheter for the past five years. On 06/03/13, Resident #1 was readmitted to the facility, and was given a hospital pressure reduction air mattress. Nurses' notes from 06/03/13 do not address or identify the status of Resident #1's pressure ulcer. Nurses' notes from 06/04/13 measure Resident #1's pressure ulcer as 7.8 cm by 7cm, with a depth of 4.9 cm. It was also noted a large amount of serosanguineous drainage was coming from the wound. On 06/11/13, the facility wound assessment identifies Resident #1's wound is a stage 4 pressure ulcer. Also on this date, Resident #1's care plan was updated with the intervention of a low air loss mattress. On 06/13/13, dietary notes indicate recommendations for Resident #1 to have a protein powder, one scoop, twice a day, to promote wound healing. On 07/16/13, the wound clinic ordered Resident #1 have a wound vac (vacuum dressing to promote healing). As of 07/22/13, the wound vac was discontinued due to the vacuum dressing not adhering to the wound effectively. On 08/12/13, dietary notes indicate the recommendation to increase Resident #1's protein powder supplement to three times a day. Nurses' notes from 08/20/13 indicate Resident #1 had diarrhea, with a temperature of 100.0 degrees. It is also documented there was a new, 1 cm long, excoriated area to Resident #1's right buttock. On 09/10/13, Resident #1 returned to the wound care clinic. Wound clinic notes state the ulcer has extensive excoriation surrounding the wound, with some undermining (tunneling) of the ulcer. The wound clinic ordered the ulcer to be packed with a dressing, twice a day, and ordered the wound needed to air-out more frequently. On 09/17/13, Resident #1 was admitted to the hospital with [REDACTED]. Four days later, on 09/21/13, Resident #1 was readmitted to the facility with orders for an oral antibiotic medication. The hospital discharge summary assessment, dated 09/21/13, states in part, "Principal D/C (discharge) Dx (diagnosis): Gram-positive [MEDICAL CONDITION] (sepsis) with gram-negative [MEDICAL CONDITION] probably urogenic (urine related) but decubitis ulcer is a potential source as well." Resident #1 continued to have the stage 4 ulcer upon his re-admission. No wound culture was completed during Resident #1's hospitalization , which could have ruled out a wound infection as it related to [MEDICAL CONDITION] diagnosis. On 10/20/13, Resident #1, per nurses' notes, had a new stage 2 pressure ulcer on his coccyx. On 10/23/13, Resident #1's protein powder was increased to four times a day to promote wound healing. On 11/14/13 at 7:25 a.m., Surveyor interviewed the DON. The above timeline regarding Resident #1's wound care, care plan updates and interventions for his pressure ulcer were discussed and reviewed. The DON confirmed all of the events and documentation on the above timeline. On 11/12/13, Surveyor interviewed Resident #1 regarding the pressure ulcer. Resident #1 stated he does not feel the pressure ulcer due to his paraparesis, but he did indicate he has had some pain from the ulcer in the past. Resident #1 also indicated he is able to reposition himself in bed, but his MDS, dated [DATE], indicates the resident needs extensive assistance from one to two staff members for bed mobility. This was also confirmed by the DON during an interview on 11/13/13 at 7:30 a.m. On 11/14/13 at 9:50 a.m., Surveyor , Surveyor , and Surveyor interviewed Physician P. Physician P stated in order to avoid a pressure ulcer, like Resident #1 currently has, the facility would have to be careful about the timing of repositioning, adding nutritional supplements, and adding pressure relief. Surveyor observed Licensed Practical Nurse (LPN) F provide wound care for Resident #1's pressure ulcer on 11/12/13 at 9:35 a.m. LPN F donned gloves in the hall without first sanitizing her hands, and donned a clean disposable gown. She entered Resident #1's room and opened the closet door to look for wound care supplies. LPN F opened Resident #1's disposable incontinence brief to expose the dressing over his pressure ulcer. Resident #1's buttocks were very red, and the surveyor visualized the pressure ulcer on his right ischial tuberosity after LPN F removed the old dressing. LPN F did not wash or sanitize her hands after removing the dressing. She then opened the wound care supplies, placing them on Resident #1's bed with no clean barrier beneath them. LPN F opened the closet door, then went to the sink to get a box of disposable gloves, and placed the box and a bottle of hand sanitizer on the tray table. LPN F then sprayed the pressure ulcer with normal saline wound cleanser, holding a gauze 4 X 4 under the pressure ulcer, and then dabbed the pressure ulcer with the gauze, and placed it onto an open package of gauze. She then opened a new package of gauze to dab the pressure ulcer dry. LPN F then removed her gloves, sanitized her hands, and donned clean gloves. She picked up a small piece of calcium alginate and placed it onto the pressure ulcer. While wearing the same gloves, LPN F covered the pressure ulcer with a [MEDICATION NAME] foam bandage dressing. The edge of this dressing was within 1/2 inch of Resident #1's anus. Surveyor asked LPN F what treatment would be provided to Resident #1's very red, raw buttocks. LPN F stated, "We're leaving it dry for now. He's got Jergen's soap that they use on his skin - it's more mild." The above observation was discussed with the DON on 11/12/13 in a meeting which started at 1:20 p.m. Surveyor asked the DON if she observes the nurses doing wound care as part of the Quality Assurance process, and the DON stated she does not. She stated that none of the nurses are wound care certified, and that pressure ulcers are not discussed at any type of residents-at-risk meetings. The facility was aware on 08/24/12 that Resident #1 was at high risk for pressure ulcer development. The facility did not implement new interventions after Resident #1 had already had two recurring pressure ulcers on his right buttock in October and November 2012. When pustules developed on Resident #1's buttock on 03/12/13, the facility did not closely monitor the area or implement new interventions. The facility continued with the same care plan even after Resident #1 had a 30 cm long folliculitis-like rash with a pressure ulcer on the gluteal fold and right buttock on 03/28/13. Staff allowed Resident #1 to be up in the wheelchair for extended periods of time, thus allowing direct pressure on the area. Staff did not reposition the resident according to current standards of practice when up, and instead, continued to tilt Resident #1 back in the wheelchair. The dietician and dietary staff did not provide nutritional interventions until after the resident had been hospitalized and the wound debrided on 06/13/13. Resident #1 developed an infected stage 4 pressure ulcer and required hospitalization (for ten days) in May and June 2013; and required hospitalization for an infection for four days in September 2013. Advancing Excellence states, in part, "Pressure ulcers can be dangerous and painful for a resident, in part, because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: ?Decrease in bowel and bladder function ?More incontinence ?Decrease in ability to move without help ?Decrease in mental capacity ?Increase in pain ?Increased risk for infection ?Less participation in activities" On 11/13/13, Surveyor requested any additional information regarding Resident #1's pressure ulcer, interventions, care plan updates, etc. As of 11/13/13 at 9:36 a.m., the DON stated she had no additional information to provide to the Surveyor. The Immediate Jeopardy was removed on 11/14/13 when the facility hired Pathways Health Consulting for consultation and training. The Pathways staff inserviced all staff on wound care, wound management and evaluation. All care plans of residents with wounds were reviewed and the dietician was involved in nutritional needs assessment. 2. Resident #6's medical record states he has a tunneling pressure ulcer on his sacrum, which he has had since August of 2012, and most recently measured as 2.8 centimeters deep. He also has a history of a pressure ulcer on his heel, and in August of 2013, facility staff discovered a new area of breakdown on his coccyx, which has since healed. Resident #6's care plan states he "IS TO BE UP BID (twice per day) IN HIS WHEEL CHAIR FOR HIS NOON & EVENING MEAL - NO MORE THAN ONE HOUR AT A TIME." Resident #6's physician orders [REDACTED]." He has a physician's orders [REDACTED]. On 11/11/13 at 12:00 - 12:45 p.m., Surveyor observed that Resident #6 was in his wheelchair in the lower level dining room. He returned to his room at approximately 12:50 p.m. Surveyor again observed Resident #6 in his wheelchair at 4:00 p.m. Resident #6 stated he had been up since before dinner (the noon meal), and stated, "I am feeling it too." Surveyor clarified that Resident #6 had discomfort in his sacral area from sitting so long and he said yes. Surveyor asked Resident #6 if he would be lying down before supper, and Resident #6 said that he would probably be staying up now until after supper. Surveyor then interviewed CNA J, and asked about Resident #6's being up since before dinner. CNA J said that he was up because he had "wanted to go to music" which took place at 2:00 p.m. Surveyor discussed the concern of Resident #6's care plan instruction of only being up for one hour at a time, and the above observation, with the DON on 11/12/13 at 1:20 p.m. The DON stated, "That shouldn't have happened." The DON told Surveyor on 11/13/13 that she had spoken with the CNA who got Resident #6 up on 11/11/13 (CNA K), and said that after lunch, CNA K gave Resident #6 the choice of lying down, or going to the musical program, and Resident #6 had chosen to attend the program. She stated that CNA K told her that she had put Resident #6 in the sit to stand lift and raised him to a standing position so she could change his disposable brief and perform peri care, and then put him back into his wheelchair. The DON stated there would have been time for Resident #6 to lie down for approximately an hour before the musical program started. Resident #6 told Surveyor on 11/12/13 at 9:00 a.m. that he had sat in his wheelchair until after supper the previous night and when he went to bed, "my butt hurt." Surveyor observed CNA K perform personal cares for Resident #6 beginning at 9:50 a.m. on 11/12/13. Surveyor observed that Resident #6 had a firm plastic pressure sensor pad with ridges under his sacral area. CNA K stated this pad was supposed to be "up further" under him. Resident #6 also had an air mattress, but on this mattress, between the mattress and Resident #6's skin, were the bottom sheet, the pressure sensor pad, a folded draw sheet, a quilted cloth pad, a disposable chux pad, and his disposable brief. This concern was discussed with the DON on 11/12/13 during an interview that began at 1:20 p.m. The DON agreed that normal standards for pressure reduction are to not add too many layers between the resident and the air mattress. The above observation continued, and Resident #6 had been incontinent of a very large, soft bowel movement in the bed. CNA K had a washbasin on a towel barrier and used the water in the basin to cleanse the fecal material from Resident #6. She had a plastic bag on the back of Resident #6's wheelchair, over his handles, and she used several washcloths to clean Resident #6, and then put the soiled washcloths in the plastic bag. CNA K then emptied the washbasin at 10:00 a.m., when LPN F entered the room to perform wound care. LPN F tore strips of tape and stuck them to the side of the tray table, without first sanitizing the tray table. The same towel barrier was still on the tray table. LPN F placed her wound care supplies, including a metal clamp, which resembled a scissor, onto the towel barrier. LPN F opened her supplies, and then assisted CNA K to scoot Resident #6 up in bed, using the draw sheet. She opened the nightstand under the television, took out a bottle of normal saline, and poured some of the normal saline onto thin packing strip, and poured some on a gauze 4 by 4. LPN F then donned gloves without first sanitizing her hands. She removed the old dressing from Resident #6's sacrum, pulled out the old packing, which was stained brown and several inches long, and placed it in the garbage. LPN F then removed her gloves, sanitized her hands, and donned gloves. She used normal saline spray and gauze to wash the outside of the pressure ulcer. LPN F removed her gloves, reached into a box to take more gloves out, and placed them on the towel barrier next to the metal clamp. She then sanitized her hands, and donned a pair of gloves from the towel barrier. LPN F then used the metal clamp, without first sanitizing it, to pack Resident #6's pressure ulcer. After this, LPN F placed the metal clamp back on the towel barrier. The above observation continued, and LPN F then picked up a medicine cup, which contained a pink creamy substance, and used her gloved hand to spread it around the peri wound. Surveyor asked LPN F what the pink substance was, and LPN F stated, "It's [MEDICATION NAME]." While wearing the same gloves, LPN F opened another gauze 4 by 4 and placed it over Resident #6's pressure ulcer, which is within inches of his anal area. She then used the strips of tape on the tray table to tape the dressing in place. She removed her gloves but did not wash or sanitize her hands. She began to pick up the wound care supplies and place them in a pink bin, which holds Resident #6's ted stockings and his personal care supplies. She then realized the wound care supplies did not belong in this bin, and took them out and placed them in the bottom drawer of the nightstand under the television. LPN F then washed her hands and cleaned the clamp with an alcohol pad. She then took the clamp and a bottle of normal saline wound spray to the nurses' station. Surveyor walked to the nurses' station with LPN F and observed her putting the clamp into the treatment cart drawer, which holds other clamps and scissors. Surveyor questioned LPN F about using this clamp to pack Resident #6's pressure ulcer. LPN F picked the clamp back up, opened it, and stated, "Sometimes I open it like this and just use one side (which is jagged with small metal teeth) to pack it, since the opening is so small." LPN F put the normal saline wound spray in the treatment cart, and then washed her hands for four seconds. She stated she did not need to use this spray, as Resident #6 had his own bottle. Surveyor reviewed Resident #6's physician's orders [REDACTED].#6's peri wound. This, as well as the above observation, was discussed with the DON on 11/12/13 in the above interview. On 11/13/14, Surveyor asked RN C to show the difference between [MEDICATION NAME] cream and BLC ointment. RN C showed the containers to Surveyor at 11:05 a.m., showing that the [MEDICATION NAME] is a pink cream and is supplied in a tube, and the BLC ointment, which had Resident #6's name on the label, was not pink, and is supplied in a jar. Surveyor noted that the facility staged Resident #6's tunneling ulcer as a stage 3. Normally tunneling ulcers are staged as a stage 4, since the tunneling is usually into the muscle layer. Surveyor interviewed Physician P on 11/14/13 beginning at 9:48 a.m., and asked Dr. P about the staging of Resident #6's pressure ulcer. Dr. P stated that, depending on the depth, if a pressure ulcer was tunneling horizontally under the skin, it could be staged at a stage 3. 3. Resident #7 was admitted to the facility on [DATE] from another nursing facility with a stage 1 pressure ulcer to the sacrum. On 11/13/13 at 9:20 a.m., Surveyor observed LPN B and Registered Nurse (RN) C providing wound care to Resident #7. The facility's hand washing policy provided by the DON to Surveyor on 11/12/13 at 9:00 a.m. instructs staff to wash hands for a minimum of 15 seconds, using a rotary motion and friction. LPN B washed hands for approximately five seconds, applied gloves, sanitized the tray table, then removed gloves and sanitized her hands. LPN B did not place a barrier on the tray table. Then LPN B opened the dressings and placed the open packages on the tray table. LPN B pulled Resident #7's pants down and removed the dressing. LPN B cleansed the wound with derma klenz. The wound was noted to be odorous and had a large amount of slough. LPN B removed gloves and washed hand for approximately six seconds. LPN B applied gloves, wet the gauze with normal saline and applied the two 2 X 2 fold gauze pads to the wound. LPN B was going to apply the [MEDICATION NAME] tape over the wound, until RN C directed LPN B to apply a dry 4 X 4 gauze pad over the wound before applying the [MEDICATION NAME] tape. LPN B removed gloves and washed hands for approximately five seconds. Surveyor 4. Resident #3's medical record states that he is diagnosed with [REDACTED]. His care plan dated 06/29/11 states that he has potential for alteration in comfort related to excoriation on his buttocks, as evidenced by occasional complaint of pain. His care plan also states that he has a potential for impaired skin integrity related to his [DIAGNOSES REDACTED]. He is to have a pressure relief mattress with raised edges and a geomat cushion in his wheelchair. His care plan states that he requires assistance for bed mobility, and is to be repositioned every two hours and as needed. He is frequently incontinent of bladder and continent of bowel. Resident #3 recently complained of hip pain, and after an x-ray, it was determined that the hardware in his hip may be out of place. Resident #3's medical record states that he has had new areas of excoriation, or open areas, or pressure ulcers on: 08/12/13 - Dr. (P) updated of new buttock open area and larger area of existing buttocks excoriation. Physician P discontinued the [MEDICATION NAME] and ordered BLC cream to left and right buttock excoriations until healed. He was started on protein powder for wound healing on 08/14/13. 08/28/13 - Resident has new wound over right buttock stage 2 with granulated tissue. Dr. (P) undated and changed treatment to [MEDICATION NAME] dressings. 09/03/13 - Body audit completed upon returning from leave of absence (with his son). Right buttock now with 2 open areas. Previously documented area now measures 1.3 X 0.7 cm, (had been 2.0 X 0.5 cm). New open area just below previous area measures 1. X 0.2 cm. Open area on left