Every finding on record at Muskego Health and Rehabilitation Center

Based on observation, interview and record review, the facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing for 3 (R1, R15, R16) of 4 residents reviewed for pressure injuries from a sample of 12 residents. *On 2/26/25, R1 was admitted to the facility and assessed to be at high risk for the development of pressure injuries. On 7/23/25 during wound rounds R1was assessed to have developed a facility acquired, unstageable pressure injury to the left heel. R1's care plan did not include an intervention to wear a pressure relieving boot to the left foot until 12/05/25. R1's care plan did not address R1's preference to wear shoes. The facility did not provide R1 or their responsible party with the risks and benefits of not removing their shoes which Director of Nursing (DON-B) attributes as the root cause of the development of the unstageable pressure injury to the left heel. R1's care plan does not document interventions to address R1's refusal to remove their shoes. *R15 observed not to have the ordered treatment in place for R15's healed right hip pressure injury. R15 observed not having heel offloaded while in bed and no heel boot in place for pressure injury prevention, per physician orders. On 7/6/2026, Surveyor observed R15's stage 1, right ischial tuberosity (hip) pressure injury to be open, wound was not assessed until 7/8/2026. *R16 was admitted on [DATE] with a pressure ulcer of sacral region, stage 4. R16's pressure ulcer was not assessed with measurements and description until 3/20/26. Findings Include: The facility policy titled, Pressure Injury and Management, revised 5/27/26, documented in part, .Guideline: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure/ulcers/injuries. Explanation and Compliance Guideline: . 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment: intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk: . c. Licensed nurses will conduct a full body skin assessment on all resident upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented. 4. Interventions for Prevention and to Promote Healing: a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care. f. Interventions will be documented in the care plan and communicated to all relevant staff. d. An IDT (Interdisciplinary Team) Root Cause Analysis will be performed on each pressure injury that develops in the facility. Findings will be reported in the monthly QAA (Quality Assurance and Assessment) Committee Meeting.6. a. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner. b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include i. Changes in residents' degree of risk for developing a pressure injury. ii. New onset or recurrent pressure injury development. iii. Lack of progression towards healing. iv. Resident non-compliance. v. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1.) R1 was admitted to the facility on [DATE]. R1's diagnoses included metabolic encephalopathy, immunodeficiency due to conditions, chronic multifocal osteomyelitis, diabetes mellitus, peripheral vascular disease, congestive heart failure, cardiac pacemaker, amputation of left great toe, protein calorie malnutrition, gout, stroke, polyneuropathy, and hypertension. R1's admission Minimum Data Set (MDS) assessment, dated 3/3/25, documented R1 is at risk for developing pressure injuries. R1's MDS documented R1 had one stage 2 pressure injury upon admission, no foot issues, and a surgical wound. R1 required substantial/maximal assistance for bed mobility and set up assistance with eating. R1's admission Care Area Assessment (CAA), dated 3/3/25, documented, R1 had a pressure relief mattress and w/c (wheelchair) cushion and R1 is assisted with repositioning Q (every) 2 hours and prn (as needed). R1's skin is observed daily with cares and weekly with shower. R1's treatment is performed daily to a stage 2 pressure ulcer. Plan of Care (POC) developed to promote healing as well as (sic) further breakdown R1's Skin Impairment Care Plan, created 3/4/25, documented, R1 has actual skin impairment . Interventions include. Educate resident/family/caregivers of causative factors and measures to prevent skin injury, dated 3/4/25, Encourage and assist to turn and/or reposition every 2-3 hours, dated 3/4/25, Encourage good nutrition and hydration in order to promote healthier skin, dated 3/4/25, Float heels while in bed, dated 3/4/25, Keep skin clean and dry. Lotion skin with cares, dated 3/4/25, Monitor skin during cares. Report to nurse any changes, dated 3/4/25, Pressure reduction mattress dated 3/4/25. Pressure reducing cushion to protect the skin while up in wheelchair, dated 3/4/25, and weekly licensed nurse skin evaluation, dated 3/4/25. On 6/12/25 the care plan was revised to include: Complete physician wound care orders as prescribed R1's Diabetic Care Plan, dated 3/4/25, documented, R1 has Diabetes Mellitus. Interventions include: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, dated 3/4/25, Dietary consult for nutritional regimen and ongoing monitoring, dated 6/4/25, Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness, dated 3/4/25. R1's Nutritional Note dated 7/2/25 at13:28 (1:28 PM) documented in part, .Text: Nutritional Assessment: toe amputated (2/13/25), immunodeficiency, NSTEMI (non-ST segment elevation myocardial infarction) (a type of heart attack) . hospitalized r/t (related to) septic shock 2/2 (secondary to) UTI (urinary tract infection). AKI (acute kidney injury) also noted.Continues on LCS (low concentrated sweets) diet with regular texture, thin liquids. Able to feed self. Appetite and intake remain good, consuming 75-100% of meals this month per documentation. Taking Arginaid BID (twice a day), consuming 100% at most offerings. Occasional refusals noted, but agreeable to continue as wounds are improving/healing well. R1's Wound Assessment, dated 7/23/25, documented, wound acquired after admission to the facility, pressure wound, left heel unstageable wound, measuring 1.0 [centimeters] x 0, no abnormalities noted to wound edges/peri-wound, no wound exudate or odor, The resident exhibits the following conditions: diabetes. The resident receives two or more treatments that increase the likelihood of the development of an unavoidable (sic): no. Resident demonstrates signs/symptoms that increases the likelihood of the development of an unavoidable wound: no. Risk factors: poor skin turgor, pale skin. Treatments in place: yes. Check all treatments that apply bed pressure reduction/redistribution mattress, chair pressure reduction/redistribution cushion, wound treatment/application of dressing, and wound clinic/wound physician consulted. This assessment was completed by Licensed Practical Nurse (LPN)-R. R1's Multi Wound Chart Details assessment dated [DATE], documented wound number 6 LT (left) heel, pressure ulcer measuring 1.0 x (times) 1.0 x 0.0, NPIAP (National Pressure Injury Advisory Panel) Stage: Unstageable. Treatment Recommendations: The plan for the pressure ulcer is to cleanse with wound cleaner and the peri wound area with wound cleanser. Primary dressing: 1. Betadine. This treatment will be done daily by facility staff. This treatment can be changed to PRN (as needed) if soiled or dislodged.Justification for any treatment order/dressing changes: New wound to L (left) heel. Patient has not been wearing Prevalon boots-placed on patient during visits. Discussed offloading and repositioning while in bed and in wheelchair. Nutrition: Educated on food rich in protein and protein supplements in the form of a protein drink to help support wound healing. Surveyor notes R1's care plan was not revised with new interventions to promote healing, and prevent infections when R1's left heel, unstageable pressure injury was identified on 7/23/25. R1's care plan was not revised to include the intervention of Prevalon boots until 12/5/25. R1's care plan interventions included a pressure reduction mattress not an offloading mattress as recommended. Surveyor also noted that R1 was prescribed nutritional support supplements of Arginaid BID (twice daily) on 2/27/25 and no new supplements were assessed or added to ensure R1 received food rich in protein and the protein drink R1 had been receiving was adequate with this recommendation & development of an unstageable pressure injury. On 7/7/26 at 2:43 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked who discovered R1's unstageable pressure injury to the left heel. DON-B stated they assumed it was discovered during wound rounds by Nurse Practitioner (NP)-P on 7/23/25 while they were assessing R1's other skin issues. DON-B stated when R1's unstageable left heel pressure injury was discovered on 7/23/25, it was very small and had dark redness on the left heel. R1's Treatment Administration Record (TAR) for July 2025, documents, Diabetic foot check: Visual check of skin condition of both feet, toes, and heels, including color and temperature. Surveyor notes the task was not documented as completed on 7/19/25 and 7/22/25.Surveyor noted R1's unstageable left heel pressure injury was not identified by staff during daily foot checks as indicated in R1's plan of care but during a weekly wound assessment completed by the Nurse Practitioner. On 7/8/26 at 2:43 PM, Surveyor asked DON-B why they think R1 originally developed an unstageable left heel pressure injury on 7/23/25. DON-B stated they believe R1 developed the unstageable left heel pressure injury because R1 would frequently refuse to take off their shoes and all of their previous health issues. DON-B stated at the time R1 developed the unstageable, left heel pressure injury, R1 was still receiving physical, occupational and speech therapy and the therapists were trying to work on R1's functional mobility. DON-B stated R1 would always want to be prepared to walk, even though R1 could not walk independently. Surveyor asked DON-B if there is any documented refusals for R1 not wanting to take off their shoes and DON-B stated, no. Surveyor asked if there are any specific interventions to try to have R1 agree to removing shoes or addressing R1's refusals and DON-B stated, no. On 7/8/26 at 8:59 AM, Surveyor asked Registered Nurse (RN)-N if they could recall if R1 would refuse to take off his shoes. RN-N stated, yes, R1 used to sometimes refuse to take off their shoes and wanted to keep them on even while in bed as R1 stated they wanted to be able to get up and walk. RN-N stated they would always try to get R1 to remove shoes but sometimes they would not. RN-N stated now that R1 has declined, R1 does not ever wear shoes, and they remain in bed most of the time. R1's Multi Wound Chart Details dated July 30, 2025, documented wound number 6 LT heel, pressure ulcer, wound status: worsening, measuring: 1.5 x 1.3 x 0.1, unstageable, exudate amount: moderate, exudate type: serous, odor: not malodorous, wound margin: poorly defined, peri wound: macerated, necrotic material: over 50%, granulation: between 0%-25%- confluent-pale, friable, not debrided. Treatment recommendations: The plan for the pressure ulcer is to cleanse the area with wound cleanser. Primary dressing: 1. Calcium Alginate. Secondary dressing: 1. Bordered foam. This treatment will be done 3/week by facility staff. This treatment can be changed to PRN if soiled or dislodged. The pressure ulcer is to be offloaded using offloading mattress, Prevalon Boot, Repositioning and wheelchair. Nutrition: Educated on food rich in protein and protein supplements in the form of a protein drink to help support wound healing. Surveyor noted the order to use offloading mattress, and Prevalon boot continue not to be addressed in R1's plan of care or physician orders. Surveyor noted R1's care plan for repositioning is not individualized and continued to be every 2-3 hours. R1's Multi Wound Chart Details dated August 6, 2025, documents wound number 6 LT heel, pressure ulcer, wound status: worsening, measuring: 2.1 x 1.3 x 0.1, unstageable, exudate amount: moderate, exudate type: serous, odor: not malodorous, wound margin: poorly defined, peri wound: macerated, necrotic material: over 50%, granulation: between 0%-25%- confluent-pale, friable, not debrided. Treatment/physician orders: The plan for the pressure ulcer is to cleanse the area with wound cleanser, wound filler: Iodosorb paste. Secondary dressing: 1. bordered foam. This pressure ulcer was not debrided. The pressure ulcer is to be offloaded using offloading mattress, Prevalon boots, repositioning, and wheelchair. Surveyor notes R1's care plan or physician orders did not include an intervention for Prevalon boots, individualized repositioning, or an offloading mattress as ordered by NP-S. R1's Multi Wound Chart Details dated August 13, 2025, documents wound number 6 LT heel, pressure ulcer, wound status: worsening, measuring: 2.4 x 2.8 x 0.1 unstageable, exudate amount: moderate, exudate type: serous, odor: not malodorous, wound margin: poorly defined, peri wound: macerated, necrotic material: over 50%, granulation: between 0%-25%- confluent-pale, friable, not debrided. The treatment and orders for offloading and use of an offloading mattress, Prevalon boot & repositioning remain the same as the August 6th assessment and orders. Surveyor noted R1's left heel wound was assessed to be worsening, and the facility continued to fail to implement the ordered interventions. R1's Multi Wound Chart Details dated August 20, 2025, documents wound number 6 LT heel, pressure ulcer, wound status: worsening, measuring 3.5 x 3.3 x 0.1, unstageable, exudate amount: moderate, exudate type: serous, odor: not malodorous, wound margin: poorly defined, peri wound: macerated, necrotic material: over 50%, granulation: between 0%-25%- confluent-pale, friable. Nutrition: Educated on food rich in protein and protein supplements in the form of a protein drink to help support wound healing. The treatment order was changed to cleanse the area with wound cleanser, wound filler: Iodosorb paste. Primary dressing: Calcium Alginate. Secondary dressing 1. Bordered foam and newly added to the treatment was: 2. Rolled gauze. Documented is: Justification for any treatment order/dressing changes: Wound to left heel open due to moisture. Increased maceration surrounding tissue. Iodosorb to help dry out wound and antimicrobial component. Patient to utilize Prevalon boots while in bed and wheelchair to decrease pressure to heel. A Procedure note dated 8/20/25 documented: Procedure: Debridement; skin or debris. Pressure Ulcer-LT heel. The pressure ulcer is located on the lt (left) heel. The ulcer measures 3.5 cm (centimeters) x 3.3 cm x 0.1 cm. There is over 50% nonviable material of eschar quality. The ulcer bed has exposed subcutaneous tissue. This is a full thickness ulcer. The area was prepped and draped in the usual manner. The procedure was performed in a clean field. I debrided the wound sharply with a #10 blade devitalized tissue and biofilm excised. The material debrided included necrotic skin. Orders dated 8/20/25 were: Iodosorb paste Primary dressing: Calcium Alginate; Secondary dressing: 1. Bordered foam, 2. Rolled gauze. Treatment was ordered to be done 3 times a week for 1 month and PRN. The pressure ulcer is to be offloaded using offloading mattress, Prevalon boot, repositioning and wheelchair. R1's Multi Wound Chart Details dated August 27, 2025, documented wound number 6 LT heel, pressure ulcer, wound status: unchanged, measuring 2.5 x 3.1 x 0.1, unstageable, exudate amount: moderate, exudate type: serous, odor: not malodorous, wound margin: poorly defined, peri wound: macerated, necrotic material: 100%. R1's Multi Wound Chart Details dated September 3, 2025, documented wound number 6 LT heel, pressure ulcer, wound status: unchanged, measuring 2.9 x 4.3 x 0.1, unstageable, exudate amount: moderate, exudate type: serous, odor: non malodorous, wound margin: poorly defined, peri wound: macerated, necrotic material: 100%, tissue exposed: subcutaneous, Treatment recommendations/physician orders: The plan for the pressure ulcer is to cleanse the area with wound cleaner and the peri wound. Wound filler: Iodosorb paste. Primary dressing: Calcium Alginate. Secondary dressing: 1. Bordered foam, 2. Rolled gauze. This treatment will be done 3 times per week for 1 month. The pressure ulcer was not debrided. The pressure ulcer is to be offloaded using offloading mattress, Prevalon boot, repositioning and wheelchair. Justification for any treatment order/dressing changes: Wound starting to form dry eschar with use of Iodosorb Surveyor noted R1's care plan continues to document R1 has a pressure reduction mattress verses the recommended offloading mattress. Prevalon boot is still not implemented as ordered or added to the care plan. R1's actual skin impairment care plan is revised to add: New supplement ordered – Arginaid BID (twice daily) and House shake TID (three times daily). R1's Multi Wound Chart Details dated September 10, 2025, documents wound number 6 LT heel, pressure ulcer, wound status: worsening, measuring: 3.2 x 4.7 x 0, tunnels: 1, max (maximum) depth of deepest tunnel (cm) 1.30 cm at 10 o'clock, unstageable, exudate amount: moderate, exudate type: serous, odor: malodorous, wound margin: poorly defined, peri wound: macerated, excoriated, necrotic material: 100%, not debrided. Treatment recommendations/physician orders: The plan for the pressure ulcer is to cleanse the area with wound cleanser and the peri wound area with wound cleanser. Wound filler: Iodosorb paste, Primary dressing: Calcium Alginate, Secondary Dressing 1. ABD (abdominal) pad, 2. Rolled gauze, 3. Medipore tape. This treatment will be done daily for 1 month.The pressure ulcer was not debrided. The pressure ulcer is to be offloaded using offloading mattress, Prevalon boot, repositioning and wheelchair. Patient needs to offload ankle as much as possible to allow for wound healing. Justification for any treatment order/dressing changes: Wound with increased serosang (serosanguineous) drainage from 10:00 position. Currently on ABX (antibiotics). Goal is to dry out wound-will increase dressing changes to daily. Nutrition: Educated on food rich in protein supplementation in the form of protein drink to help support wound healing. This is the last assessment and orders from NP-S. Surveyor noted following this assessment the weekly evaluations were completed by facility staff. Surveyor notes the wound status is worsening with tunneling assessed and the area is malodorous. The recommended intervention of Prevalon boots and offloading mattress have not been added to the plan of care, repositioning has not been assessed or increased in frequency from the original intervention of every 2-3 hours, and there is no new intervention for offloading R1's ankle as much as possible. On 9/17/26 an X-ray was obtained of R1's left heel. R1's Patient Report for diagnostic evaluation (X-ray), dated 9/17/25, documented, Reason: Left foot pain, non-healing wound on left heel. Findings: No fracture or dislocation is identified. Bony mineralization is maintained. Severe hammertoe deformities noted. Diffuse degenerative changes noted. Vascular calcifications are seen. Impressions: No acute osseous findings. Diffuse degenerative changes in joints of foot with severe hammertoe deformities, Small plantar calcaneal spur. On 7/8/26 at 1:09 PM, Surveyor asked DON-B what prompted the facility to order an X-ray on 9/17/25. DON-B stated because the left heel pressure injury was not healing, and facility wanted to see if R1 had osteomyelitis. DON-B stated the X-ray was negative for osteomyelitis, but it did reveal R1 had degenerative joint disease with severe hammertoe deformities and planter calcaneal bone spur on left heel. Surveyor asked DON-B if there were any new physician orders or new interventions related to the X-ray results. DON-B stated there were no new orders following the X-ray on 9/17/25 when R1 was diagnosed with the bone spurs. Surveyor asked DON-B why there were no new orders, and they stated they were doing everything possible to treat R1 and the care plan was very detailed including nutritional, diabetic, skin, pressure injury, interventions, etc. Surveyor noted upon review of R1's hospital discharge/admission to the facility records, R1 was noted to have the presence of the hammertoes & bone spur at the time of admission to the facility and was a new finding on the 9/17/25 X-ray. R1's Wound Assessment Details Report dated 9/24/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: bright pink or red= 10%, slough loosely adherent = 40%, necrotic soft, adherent = 50%, exudate amount: heavy, serosanguineous, peri wound: maceration. Signs of infection: no, patient on antibiotics: yes. Measurements: 3.0 x 4.40 x .20, undermining present: 12 o'clock to 1 o'clock/ 2.50 cm., tunneling: none. Continue current treatment. Surveyor noted R1's left heel pressure injury is now assessed to have undermining of 2.50 cm at 12-1 o'clock and no tunneling vs the prior assessment that indicated tunneling at 1.30 cm at 10 o'clock and there is no change to the treatment. R1's Wound Assessment Details Report dated 10/1/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: bright pink or red= 10%, slough loosely adherent = 40%, necrotic soft, adherent = 50%, exudate amount: heavy, serosanguineous, peri wound: maceration. Measurements: 3.40 x 5.0 x 0.40, undermining none, tunneling, none. Current plan and comments: Bleeding from 9 to 3. The assessment is documented as performed by Licensed Practical Nurse (LPN)-T on 10/1/25 at 8:50 AM. The section for RN review Comments is blank. Surveyor noted R1's 10/1/25 left heel pressure ulcer assessment is completed by an LPN (T) and does not identify undermining or tunneling as previously identified in prior assessments and there is no documentation of the treatment to be applied. R1's Wound Assessment Details Report dated 10/8/25 documents, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: bright beefy red = 20%, necrotic soft, adherent = 80%. Exudate amount: heavy, serosanguineous, peri wound: maceration. Measurements: 2.5 x 5.0 x 0.40, no undermining, no tunneling. Current Plan & Comments: : Medi honey to necrotic (sic) calcium alginate to follow cover with ABD and secure with roll gauze and tape. This assessment was completed by DON-B. R1's Wound Assessment Details Report dated 10/15/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: Bright beefy red = 20%, necrotic soft adherent = 80%. Exudate amount: heavy, serosanguineous, peri wound: maceration. Measuring 4.80 x 5.00 x 0.40 with no undermining, no tunneling. Current Plan & Comments: apply medi honey, abd and wrap with gauze. The assessment is documented as performed by Licensed Practical Nurse (LPN)-T on 10/15/25 at 10:07 AM. The section for RN review Comments is blank. Surveyor noted LPN-T completed this assessment. R1's wound has worsened with larger measurements documented. The treatment was changed, and calcium alginate is no longer being used. There is no indication an RN assessed R1's heel at this time. R1's Wound Assessment Details Report dated 10/22/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: Bright beefy red = 20%, necrotic soft adherent = 80%. Exudate amount: heavy, serosanguineous, peri wound: maceration. Measuring 4.45 x 3.60 x 0.40, no undermining, no tunneling. Outcome: probable improvement. Current plan & comments: Cleanse with ww (wound wash) calcium alginate F/B (followed by) ABD and kerlix. Surveyor noted LPN-T completed this assessment on 10/22/25 at 9:57 AM. The section for RN Review Comments is blank. Surveyor notes this assessment was completed by LPN-T and the treatment was changed to include calcium alginate and medi honey is no longer being used. R1's Wound Assessment Details Report dated 10/29/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: Bright beefy red = 20%, necrotic soft adherent = 80%. Exudate amount: heavy, serosanguineous, peri wound: maceration. Measuring 3.40 x 4.50 x 0.40, no undermining, no tunneling. Outcome: probable improvement. Current plan & comments: Cleanse with ww apply medi honey to wound bed followed by calcium alginate F/B foam bordered, secure with wrap. On 10/29/25 R1's care plan for actual skin impairment was revised to now include Resident prefers to wear shoes. Encourage resident to only wear when necessary. Date initiated & created is 10/29/25 by DON-B. Surveyor noted R1's wearing of shoes was noted to be the root cause of why R1 developed an unstageable pressure injury in July of 2025, and it was only addressed on R1's care plan on 10/29/25. R1's Wound Assessment Details Report dated 11/5/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: Bright beefy red = 20%, necrotic soft adherent = 80%. Exudate amount: heavy, serosanguineous, peri wound: maceration. Measuring 3.0 x 4.50 x 2.00. Outcome: probable improvement. Undermining: present, location: 3 o'clock to 6 o'clock /3.00 cm. Tunneling: none. Cleanse with ww apply medi honey to wound bed followed by calcium alginate F/B foam bordered, secure with wrap. This was completed by DON-B. Surveyor noted that R1's left heel pressure injury has declined with greater depth and undermining of 3.00 cm from 3-6 o'clock being assessed. On 11/8/225 R1's care plan for actual skin impairment was revised to add intervention to apply moisturizer to toes daily. R1's Wound Assessment Details Report dated 11/12/25 documents, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: Bright beefy red = 20%, necrotic soft adherent = 80%. Exudate amount: moderate, bloody, peri wound: maceration. Measuring 3.50 x 5.0 x 1.50. Outcome: probable improvement. Undermining: none. Tunneling: none. Current plan & comments: Cleanse with ww apply medi honey to wound bed followed by calcium alginate F/B abd secure with wrap. Surveyor noted LPN-T completed this assessment on 11/12/25 at 11:58 AM. The section for RN Review Comments is blank. R1's Wound Assessment Details Report dated 11/19/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: Bright beefy red = 40%, necrotic soft adherent = 60%. Exudate amount: moderate, serosanguineous, peri wound: maceration. Measuring 3.50 x 5.0 x 1.50. Outcome: probable improvement. Undermining: none. Tunneling: present, location 5 o'clock / 2.00 cm. Current Plan & comments: Cleanse with ww apply medi honey to wound bed followed by calcium alginate F/B abd, secure with wrap. Surveyor noted LPN-T completed this assessment on 11/19/25 at 11:09 AM. The section for RN Review Comments is blank. R1's Wound Assessment Details Report dated 11/26/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: Bright beefy red = 20%, necrotic soft adherent = 80%. Exudate amount: light, serosanguineous, peri wound: maceration. Measuring 3.50 x 4.50 x 0.50. Outcome: probable improvement. Undermining: present, location 6 to 7 o'clock /1.00 cm. Tunneling: none. Current Plan & comments: Cleanse with ww apply medi honey to wound bed followed by calcium alginate F/B abd, secure with wrap. Surveyor noted LPN-T completed this assessment on 11/26/25 at 8:05 AM. The section for RN Review Comments is blank. R1's care plan for increased nutrient needs created on 3/3/25 was revised on 12/1/25 to include: Monitor/record/report to MD PRN s/sx (signs/symptoms) of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. (pounds) in 1 week, > (greater than) 5% in 1 month, > 7.5% in 3 months, > 10% in 6 months. This intervention was created and initiated on 12/1/25. R1's Wound Assessment Details Report dated 12/3/25 documented, left heel pressure ulcer, facility acquired, date identified: 7/23/25. Unstageable, tissue type: Bright beefy red = 30%, necrotic soft adherent = 70%. Exudate amount: light, serosanguineous, peri wound: Maceration. Odor: Yes. Measuring 3.50 x 4.50 x 0.50. Outcome: probable improvement. Undermining: present: location 6 to 7 o'clock /1.00 cm. Tunneling: none. Current Plan & Comments: Cleanse with ww apply medi honey to wound bed followed by calcium alginate F/B abd, skin prep (sic) peri wound, secure with wrap. This assessment was completed by NP-P. Surveyor noted this is the first assessment of R1's heel pressure injury by a NP since 9/10/25. Surveyor noted R1's care plan was updated on 12/5/25 with interventions that include LAL (Low Air Loss) mattress to bed and pressure relieving boot to the left foot as ordered and as tolerated. Both interventions were created and initiated on 12/5/25. On 7/8/26 at 12:08 PM, DON-B provided Surveyor with a wound summary completed by NP-P that documented in part .due to labile blood sugars from diabetes, wound has had extremely slow progress. Sliding scale has been adjusted several times. Due to immunodeficiency and presence of foley catheter, R1 has been treated for several urinary tract infections and completed several courses of antibiotics which have had an impact on healing. Due to polyneuropathy, R1 is unable to feel sensations in left heel, making position change due to pain, difficult. R1 has little appetite and protein calorie malnutrition has made wound progress slow and difficult, even with the use of supplements such as liquid protein. Due to presence of atherosclerosis, di

Based on interview and record review, the facility did not ensure that 5 of 5 Certified Nursing Assistants (CNAs) reviewed had an annual performance review completed every twelve months.CNA-E, CNA-G, CNA-H, CNA-I and CNA-J did not have an annual performance review.This deficient practice had the potential to affect all 36 residents residing in the facility as the CNAs work with residents throughout the facility.Findings include:The facility policy, entitled Competency Evaluation dated as revised 8/21/24, documents:Guideline: It is the guideline of this facility to evaluate each employee to ensure they meet appropriate competencies and skills for performing their job.Explanation and Compliance Guidelines:1.The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process.2. Evaluating competency of staff is accomplished through the facility's training program.3. Initial competency is evaluated during the orientation process.4. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations.8. Employee competency forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file.The facility policy entitled, Nurse Aide Training Program dated as revised 12/2/25, documents:Guideline: This facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides.5. Additional training will be provided to each nurse aide based on areas of weakness as determined in the nurse aide's performance reviews.a. The Director of Nursing shall communicate the educational needs of the employee to the Human Resource Director upon final review of the annual performance appraisal.b. Education that is needed based on the performance appraisal will be completed within 90 days of the appraisal, unless otherwise specified in the appraisal.8.[NAME], periodic audits and/or interviews will be performed throughout the year as part of the facility's QAPI program to verify retention of information and continued competency.On 7/6/26, at 1:43 PM, Surveyor reviewed 5 randomly selected CNA's (CNA-E, CNA-G, CNA-H, CNA-I, & CNA-J) annual performance reviews.On 7/6/26, at 1:57 PM Surveyor provided CNA-E, CNA-F CNA-H, CNA-I & CNA-J's names to Administrator-A and requested their annual performance reviews.CNA-E was hired on 1/11/16.CNA-G was hired on 5/4/06.CNA-H was hired on 3/26/21.CNA-I was hired on 7/16/24.CNA-J was hired on 3/26/24.On 7/7/2026, at 7:45 AM, Surveyor noted that CNA-E, CNA-G, CNA-H, CNA-I, CNA-J had not had an annual performance review completed in the last twelve months.On 7/8/2026, at 9:23 AM, NHA-A informed Surveyor that NHA-A was unable to locate any completed annual performance for CNA-E, CNA-G, CNA-H, CNA-I, and CNA-G.NHA-A stated that CNA-E and CNA-G's performance reviews were completed this morning (7/8/26) and the reviews for CNA-H, CNA-I and CNA-J would be completed soon. NHA-A confirmed that all five CNAs had contact with residents throughout the facility.Surveyor verified with NHA-A that the annual performance reviews for CNA-E, CNA-G, CNA-H, CNA-I, and CNA-G had not been completed in the last twelve months as required.

Based on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, for 1 of 2 medication carts observed.*Surveyor observed 6 expired stock medications and 63 loose medications in the medication carts.Findings:On 07/07/2026, at 1:37 PM, Surveyor observed the side 2 medication cart with Registered Nurse (RN)-N. Surveyor observed two stock, over the counter medications labeled Calcium vitamin D and Complete Multivitamin Adult 50+, with manufacturer expiration dates of 06/2026. Surveyor also observed 35 loose pills scattered throughout the drawers of the medication cart. RN-N informed Surveyor that loose pills and two expired stock medications should be put into the drug buster, located in the medication room. The drug buster is used to remove and dispose of expired medications. RN-N informed Surveyor that all nurses are responsible for cleaning the medication carts and does not recall ever being trained on or the task being assigned to RN-N.On 07/07/2026, at 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B regarding Surveyor's observations of the side 2 medication cart. DON-B indicated that pharmacy comes once a quarter to review and clean out medication carts and the medication room. DON-B informed Surveyor that the facility does not currently have a process for cleaning out medication carts to remove expired medications outside of pharmacy coming in quarterly. On 07/06/2026, at 3:15 PM, Surveyor informed the facility of the above findings.

Based on observation, interviews, and record reviews, the facility did not ensure each resident was treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 2 (R22 and R24) of 10 residents reviewed for dignity during mealtime in the dining room.*Director of Nursing (DON)-B and Certified Nursing Assistant (CNA)-F were observed during the lunch meal standing over and feeding R22. CNA-F did not engage in conversation with R22 during the lunch meal.*Certified Nursing Assistant (CNA)-E was observed during the lunch meal standing over and feeding R24. CNA-E did not engage in conversation with R24 during the lunch meal.Findings include:The facility policy, entitled Promoting/Maintaining Resident Dignity During Mealtimes dated as revised 7/12/25, documents:Guideline: It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident.Explanation and Compliance Guidelines:1. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes.4. Focus on the resident while talking to him/her and addressing him/her individually.5. All staff will be seated, if possible, while feeding a resident.11. Allow adequate time for resident to complete meal. Do not rush.1.) R22 was admitted to the facility on [DATE] with diagnoses of other specified intracranial injury and unspecified dementia, severe with anxiety.R22's Annual Minimum Data Set (MDS) completed 4/16/26 documented that both R22's short and long-term memory was impaired and R22 demonstrated severely impaired skills for daily decision making. R22's MDS also documented that R22 was assessed to be dependent for eating.R22's activities of daily living (ADL) self-care performance deficit due to confusion, limited mobility care plan revised on 2/17/26 documents: Interventions: Eating: Assist of 1; Eating: DependentR22's Swallowing difficulty due to motor causes as evidenced by need for altered texture diet, and potential for inadequate oral intake due to mood disorders, diagnosis of dementia as evidenced by variable oral intakes (PO) at times care plan dated as revised 6/8/26 documents under the Interventions section: Monitor/document/report as needed (PRN) any signs/symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, Refusing to eat, Appears concerned during meals; Initiated 3/2/26 Provide and serve diet as ordered - regular, puree, thin liquids; Initiated 10/9/24 Provide set up and assistance with all intake.On 7/6/2026, at 12:20 PM, Surveyor observed DON-B standing over R22 attempting to encourage R22 to eat with a spoon of pureed food and encouraging R22 to drink from a straw in a milk carton. R22 was in a reclining wheelchair during mealtime. On 7/6/2026, at 12:25 PM, CNA-F took over assisting R22. Surveyor observed CNA-F standing over the left side of R22 while feeding R22. Surveyor observed that CNA-F did not engage in conversation with R22 while feeding R22.On 7/8/2026, at 9:35 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A confirmed that standing over residents while feeding them was not the policy of the facility. NHA-A stated it mostly likely occurred because space was challenged in the dining room.NHA-A understood that standing over R22 while feeding them was not dignified. 2.) R24 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebrovascular disease (CVA) affecting right side, and vascular dementia.R24's Quarterly Minimum Data Set (MDS) completed 6/14/26 documented both R24's short-and long-term memory was impaired and that R24 demonstrated severely impaired skills for daily decision making. R24's MDS also documented that R24 assessed as dependent on staff for eating:R24's activities of daily living (ADL) self-care performance deficit due to hemiplegia status post CVA (cerebrovascular accident), impaired cognition care plan dated as revised 3/25/25 documents the following interventions:Eating: Assist x; revised 12/19/25R24 also had a care plan dated as revised 6/10/26 that stated the potential for inadequate oral intake due to dementia, unable to make needs known at times,variable by mouth (PO) intakes at times, dependance on staff for feeding/drinking, self-feeding difficulty due to cva bilateral upper extremity contractures as evidenced by need for assistance and/or cueing with meals/intake, and swallowing difficulty due to cva status post dysphagia as evidence by need for mechanically altered diet per speech therapy, history of pocketing/holding boluses.Under the Interventions section it documented: Provide and serve diet as ordered - regular, ground texture, thin liquids; Initiated 1/5/26 Provide assistance for all meals/intakes; Initiated 9/17/25 Provide assistance with feeding as needed and ensure resident is in the dining room for 2 out of 3 meals every day.; Initiated 3/3/26R24's Nutritional Evaluation dated 6/10/26 and completed by Registered Dietitian (RD)-M documented that R24 required assistance at all meals.On 7/6/2026, at 12:25 PM, Surveyor observed CNA-E assisting R24 with the lunch meal. Surveyor observed CNA-E holding R24's plate in left hand, while using a spoon with CNA-E's right hand to feed R24. Surveyor observed CNA-E standing over the left side of R24 while assisting R24 with eating. Surveyor observed CNA-E not conversing with R24 during the lunch meal. Surveyor observed CNA-E put R24's plate down and stand over R24 while CNA-E hand rested on CNA-E's left hip.On 7/7/2026, at 2:02 PM, Surveyor interviewed CNA-E. Surveyor asked CNA-E what the proper way was to feed residents. CNA-E stated the proper way to feed a resident was to be sitting while assisting a resident. Surveyor asked CNA-E why CNA-E was standing when feeding R24. CNA-E stated CNA-E did not know why CNA-E was standing while feeding R24.On 7/8/2026, at 9:35 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A confirmed that standing over residents to feed was not the policy of the facility. NHA-A stated it mostly likely occurred because space was challenged in the dining room.NHA-A understood that CNA-E standing over R24 while feeding them was not dignified.

Based on observation, interview and record review the facility did not ensure 1 (R15) of 12 sampled residents , received necessary care and treatment based on an assessment.*Surveyor observed a border gauze dressing in place to R15's right knee. There was no assessment of the wound and no order for treatment.Findings include: R15 was admitted to the facility on [DATE] and has diagnoses including multiple sclerosis, contractures, urine retention, need for assistance with personal cares and non-pressure chronic ulcer of skin.R15's Annual Minimum Data Set (MDS), dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, no behaviors or rejection of care, has impairment on both sides of upper and lower extremities, dependent on staff to roll left to right, is at risk for pressure injuries and has an indwelling urinary catheter.On 07/06/2026, at 8:45 AM, Surveyor observed Certified Nursing Assistant (CNA)-F providing cares for R15. Surveyor observed a dressing in place to R15 right knee.Surveyor reviewed R15's physician orders and noted there is no treatment order for R15's right knee.Surveyor reviewed wound notes and weekly skin checks for R15 and noted no assessment of R15's right knee wound.R15's last skin assessment, dated 7/1/2026, indicates R15 has intact skin.On 07/06/2026, at 12:40 PM, Surveyor interviewed Registered Nurse-O regarding R15's right knee. RN-O indicated that R15's right knee is currently covered with a foam border dressing but there is no order in R15's electronic health record. RN-O informed Surveyor that RN-O will notify Director of Nursing (DON)-B and Nurse Practitioner (NP)-P and they will complete wound rounds later today. On 07/06/2026, at 1:17 PM, DON-B informed Surveyor that R15 is not currently being seen by the wound team for any wounds and only has preventative treatment to the right hip and offloading heels. Nurses provide the treatment and complete weekly skin checks. Surveyor reviewed Nurse Practitioner (NP)-P's note, dated 7/6/2026, which indicated the following: R15has neurogenic bladder from multiple sclerosis and has suprapubic catheter in place. Catheter site does not show signs/symptoms of infection, urine yellow, denies pain or spasm.R15's right knee wound check:- Staff noted today right knee wound - Partial thickness wound abrasion/shear 1.0 centimeters (cm) x 1.5cm x 0.1 cm (length x width x depth)- Wound is pink, no drainage, peri wound is normal, no erythema or maceration- Site covered today with xeroform gauze and border gauzeOn 07/07/2026, at 8:53 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B informed Surveyor that Nurse Practitioner (NP)-P assessed R15's right knee wound yesterday and determined it to be an abrasion. DON-B's expectation is that any new open wounds identified should be reported to the provider and DON-B to ensure proper and timely assessment.

Based on observation, interview, and record review the facility did not ensure a resident received routine dental services for 1 (R29) of 1 resident reviewed for dental services.On 11/11/25 a dental referral for R29 was initiated due to cracked teeth and jaw pain. R29 was not evaluated until 6/15/26 by the dentist.Findings Include:The facility policy, entitled Dental Services reviewed/revised 11/12/24, stated:Policy:It is the policy of this facility to assist residents in obtaining routine and emergency dental care.Policy Explanation and Compliance Guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment processes and are addressed in each resident's plan of care.a. Oral/dental status shall be documented according to assessment findings.c. Referrals to dietician, speech therapist, physician, or dental provider shall be made as appropriate2. Residents and/or resident representatives, during the admission process, are notified of dental services available under the State plan, and of the potential charges that may apply in the case of routine or emergency dental care provided by outside resources.a. The facility will assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.3. The Social Services Director maintains contact information for providers of dental services that are available to facility residents at a nominal cost.4. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location.7. In the case of an acute dental condition, the facility will take measures to ensure residents are still able to eat and drink while awaiting dental services. Interventions include, but are not limited to:a. Notifying physician of pain or other needsb. Modifying diet consistencyc. Providing room temperature liquids for heat/cold sensitivityd. Referring to dietitian for food preferences during the interime. Referral to speech therapist for chewing or swallowing problems.9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.R29 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side, depression, major depressive disorder, and anxiety disorder.On 11/11/25 a dental referral was completed for R29's cracked teeth and jaw pain.On 7/6/2026, at 9:47 AM, R29 informed Surveyor that prior to admission to the facility, a dentist had informed R29 that R29 had 4 cracked crowns, 2 on the left and 2 on the right. R29 stated that R29 was also missing 2 teeth. In the hospital, speech was working with R29 on chewing food completely, but R29 was not able to, due to the dental issue. R29 stated they had some pain depending on if it was the wrong food or wrong spot when eating. R29 stated they did have difficulty chewing. R29 informed Surveyor that they had been telling Social Worker (SW)-C for several months that they needed to be seen by a dentist for the issue of pain associated with the cracked crowns. R29 stated that they have had no follow-up.R29's nutritional evaluation dated 4/27/26 documented R29 was on a regular, thin liquid diet. R29's nutritional evaluation did not address R29's dental status or difficulty chewing.R29's Quarterly Minimum Data Set (MDS) assessment, dated 5/18/26, indicated that R29's Brief Interview for Mental Status (BIMS) score was 14, which indicated R29 did not have cognitive concerns. R29's MDS documented R29 had no dental concerns.On 7/8/2026, at 10:26 AM, Surveyor interviewed Minimum Data Set Nurse (MDSN)-D via telephone. MDSN-D explained that MDSN-D completed all resident assessments out of the facility. MDSN-D was not aware of R29 having dental concerns. MDSN-D would be provided with the information of R29 having dental issues from SW-C.On 6/5/26, Nurse Practitioner (NP)-P documented R29 reported 4 cracked caps.On 6/12/26, Speech Therapist (ST)-R documented R29 had stated they broke another crown or tooth yesterday when eating an egg roll. R29 unable to reliably state which tooth it was, pointing generally to upper left side of mouth. Per Social Worker (SW-C), dentist would be coming 6/15/26.R29's dental consult dated 6/15/26 documented R29 was evaluated and R29 had 2 missing teeth along with multiple fractures of their teeth.Surveyor noted R29 was not evaluated from the initial dental referral on 11/11/25 until 6/15/26.On 7/7/2026, at 9:38 AM, Surveyor interviewed SW-C. SW-C confirmed that SW-C was responsible for making dental referrals for residents. SW-C would contact the company and make a referral. SW-C explained when a resident is examined by the dentist, the documented report is sent to SW-C, Director of Nursing (DON)-B, Medical Record/Receptionist (MR)-K, and Nursing Home Administrator (NHA)-A just got added. If there was a recommendation it would be discussed as an Interdisciplinary Team (IDT). Nursing would receive any recommendations and follow-up. SW-C informed Surveyor that SW-C believes MR-K follows-up on any recommendations. SW-C was unable to answer why it took so long for R29 to receive dental services.On 7/7/2026, at 9:51 AM, Surveyor shared the concern with NHA-A and SW-C that there had been no follow-up with a dental consultation after the initial 11/11/25 until 6/15/26. NHA-A stated the facility would look for the documentation of follow-up to the initial 11/11/25 dental referral.On 7/7/26, at 1:11 PM, Director of Nursing (DON)-B documented that R29 complains of pain to molars when chewing due to having cracked crowns that occurred prior to admission from his dog sitting on his jaw. The dentist noted this and suggested that R29 brush theirteeth more often.On 7/8/2026, at 8:21 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who was very familiar with R29. CNA-E was never informed of R29 having dental concerns.On 7/8/2026, at 11:31 AM, Surveyor interviewed R29 again. R29 stated they remained very frustrated that R29 had not been seen by the dentist. R29 informed Surveyor that it was hard to chew some food items and sometimes it could be painful depending on what eating and where it hits.On 7/8/26, at 8:26 AM, Surveyor interviewed MR-K. MR-K stated MR-K was responsible for appointments. MR-K explained that MR-K reviewed resident hospital summaries and recorded the appointments, confirm the appointments and arrange transportation. MR-K confirmed that MR-K did receive the dental consultations. MR-K explained that MR-K would glance at the dental consults but did not really read the whole consult. I am not a nurse to understand everything. I would scan the consults into the resident electronic medical record (EMR). SW-C was part of the clinical review that was being completed of the dental consults. MR-K confirmed that SW-C completes the initial referral. MR-K stated the interdisciplinary team formalized the process yesterday. It was decided that MR-K will review carefully for clinical information, send it to the physician's office if needed and get outside orders for consultation if required.On 7/8/2026, at 9:03 AM, NHA-A informed Surveyor the facility did not have documentation as to why it took so long for dental follow-up for R29. NHA-A understood the concern that the dental follow-up should have been initiated after the 11/11/25 referral but was not completed until 6/15/26.

Based on observation, interviews, and record review, the facility did not ensure 1 (R29) 1 sampled resident with hearing impairment received proper treatment and assistive devices including arrangements for an audiology (ear doctor) evaluation.The facility did not follow up on an audiology consult dated 10/25/25 after recommending wax in both ears be removed to complete a hearing evaluation.Findings Include:The facility policy, entitled Hearing and Vision Services reviewed/revised 7/12/25, documents:Guideline: It is the guideline of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated.Explanation and Compliance Guidelines:2.Staff should refer any identified need for hearing or vision services/appliances to the social worker/social service designee.3. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources, for the provision of the vision and hearing services the resident needs.4. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation.6. Assistive devices to maintain hearing include, but not limited to, hearing aids and amplifiers.R29 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side, depression, major depressive disorder, and anxiety disorder.R29's Quarterly Minimum Data Set (MDS) assessment, dated 5/18/26, indicated that R29's Brief Interview for Mental Status (BIMS) score was 14, which indicated R29 was cognitively intact. R29's MDS documented that R29 was assessed as having no concerns with hearing.On 7/6/2026, at 9:49 AM, R29 informed Surveyor that R29 was to have R29's hearing tested, but it could not be done because R29 had extreme wax build-up in both ears. R29 informed Surveyor that R29 was to receive treatment to clear the wax and then have R29's hearing re-tested. R29 stated there had been no follow-up from the facility. R29 informed Surveyor that R29 had informed Social Worker (SW)-C that R29 had noticed a decrease in R29's hearing ability. R29 stated that R29 believed the wax had been removed but had no follow-up audiology assessment after the ear wax removal.Surveyor was unable to locate a care plan for R29's hearing/audiology in R29's medical record.Surveyor noted that on 10/22/25, it is documented that an audiology referral for R29 was made due to a complaint of decreased hearing.R29's audiology exam dated 10/25/25 could not be completed due to wax being so deep that it needed to be removed from both ears before the exam could occur.On 6/5/26, Nurse Practitioner (NP)-P documented that R29 was complaining of cerument impaction in bilateral ears and NP-P used debrox to soften the wax. NP-P documented R29 had ear discomfort occasionally. Surveyor noted that NP-P had not addressed the wax build-up in R29's bilateral ears prior to 6/5/26.On 7/7/2026, at 9:38 AM, Surveyor interviewed Social Worker (SW)-C regarding R29's hearing concern. SW-C stated SW-C was responsible for making the referral for audiology services for residents as SW-C would contact the company and make a referral. SW-C informed Surveyor that when a resident is examined by audiology, the documented report is sent to SW-C, Director of Nursing (DON)-B, Medical Record/Receptionist (MR)-K, and Nursing Home Administrator (NHA)-A just got added. SW-C stated that if there were any recommendations, they would be discussed as an Interdisciplinary Team (IDT).SW-C stated that nursing would receive any recommendations and follow-up. SW-C informed Surveyor that SW-C believed that MR-K follows-up on any audiology recommendations. SW-C was unable to answer why R29 had not received an audiology consult after 10/25/25.On 7/7/2026, at 9:51 AM, Surveyor informed NHA-A and SW-C that Surveyor was unable to locate any documentation that R29's audiology consult recommendations regarding R29's ear wax were followed up on. NHA-A stated the facility would look for the documentation of follow-up to the initial audiology consult on 10/25/25.On 7/8/2026, at 8:21 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who was very familiar with R29. CNA-E confirmed that R29 was hard of hearing. On 7/8/2026, at 11:31 AM, Surveyor interviewed R29 again. R29 confirmed R29 still has hearing loss and would like to be tested.On 7/8/2026, at 10:26 AM, Surveyor interviewed Minimum Data Set Nurse (MDSN)-D via telephone. MDSN-D explained that MDSN-D completed all resident assessments out of the facility. MDSN-D was not aware of R29 having difficulty hearing as MDSN-D would be provided with the information of R29 having difficulty hearing from SW-C.On 7/8/26, at 8:26 AM, Surveyor interviewed MR-K. MR-K stated MR-K was responsible for setting up medical appointments. MR-K explained that MR-K reviewed resident hospital summaries and recorded the appointments, confirmed appointments and arranged transportation. MR-K confirmed that MR-K received audiology consultations. MR-K explained that MR-K would glance at the audiology consults but did not really read the whole consult. MR-K stated: I am not a nurse to understand everything. I would scan the consults into the resident electronic medical record (EMR). SW-C was part of the clinical review that completed audiology consult recommendations. MR-K stated the interdisciplinary team formalized a process yesterday (7/7/26) and that itwas decided that MR-K will review consults carefully for clinical information, send it to the physician's office if needed and get outside orders for consultation if required.On 7/8/2026, at 9:03 AM, NHA-A informed Surveyor the facility did not have documentation of any audiology assessment follow-up for R29. NHA-A stated that MR-K would be getting an audiology consult scheduled. NHA-A stated that an audiology follow-up should have been initiated and completed for R29 after the initial consult on 10/25/25 and after R29's ears were cleaned of wax on 6/5/26.

Based on interview, record review, and review of the facility policy, the facility failed to document in the medical record family notification for two out of four falls for one resident (Resident (R) 1) in a total sample of five residents. This failure placed the resident at risk of his family not being notified or the resident consented to the notification.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses that included Osteomyelitis (bone infection) of the left foot, diabetic foot ulcers, and Parkinson's disease (a neurological disease).Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 10/22/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15 which indicated R1 was moderately impaired in cognition.Review of the 10/16/25 Fall Care Plan revealed, The resident is at risk for falls, accidents and incidents r/t [related to] Parkinson's disease, weakness, NWB LLE [non weight bearing left lower extremity], forgetfulness.Review of the 12/02/25 IDT [interdisciplinary team] FALL located in the Progress Notes tab of the EMR revealed, Resident stated that he rolled from bed .no injuries noted. Root cause revealed that the resident was repositioning in bed and rolled from the bed .There was no documentation in the IDT FALL note that indicated R1 was asked if he wanted his family updated regarding the fall or not.Review of the 12/15/25 IDT FALL located in the Progress Notes tab of the EMR revealed, Resident was found on [sic] holding onto the bar in the bathroom squatting against the wall. Resident stated, 'I was trying to get on the toilet .' Assessment and neuro check completed WNL [within normal limits]. VSS [vital signs stable]. No injuries noted.There was no documentation in the IDT FALL note that indicated R1 was asked if he wanted his family updated regarding the fall or not.During an interview on 01/27/26 at 12:47 PM, the Director of Nursing (DON) stated, R1 did not have a POA [power of attorney] and he was his own person. I see in the record that his son was notified of one of the four falls, and his daughter was here for one of the falls, but staff did not document that he wanted his family notified or not for the other two falls.Review of the facility policy titled, Notification of Changes, dated 01/3/31/25 revealed, .The purpose of this guideline is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Competent individuals .The facility must still contact the resident's physician and notify resident's representative, if known When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident .

Based on interview, record review, and facility policy review, the facility failed to ensure the medical record was complete and accurate for three residents (Residents (R)1, R2, and R3 in a total sample of five residents. The facility failed to ensure weekly weights, meals, incontinent care, and skin assessments were documented for R1, failed to ensure weekly skin assessments, and incontinent care was documented for R2, and failed to ensure incontinent care was documented for R3. These failures placed residents at risk for unmet care needs and a diminished quality of life.Findings include:1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R1 was admitted to the facility on [DATE] with diagnoses that included diabetic foot wounds, diabetes, and Parkinson's disease (a neurologic disease).Review of the admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an assessment reference date (ARD) of 10/22/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 12 out of 15 which indicated R1 was moderately impaired in cognition, was independent with eating, had a foot infection and diabetic foot ulcers, was frequently incontinent of bladder and was always incontinent of bowel, and weighed 175 pounds (lbs.) without any swallowing difficulties.Review of the Weekly Skin Assessments located in the Evaluations tab of the EMR revealed the following missing skin assessments from admission to discharge on [DATE] revealed the following:October 2025: 10/23/25; 10/30/25.November 2025: 11/20/25; 11/27/25.December 2025: 12/04/25; 12/11/25; 12/28/25; 12/25/25,January 2026: 01/01/26 and 01/08/26.Review of the Weekly Weights located in the Weights and Vitals tab of the EMR revealed the following missing weights from admission to discharge.October 2025: 10/24/25; 10/31/25.November: 11/07/25; 11/14/25; 11/21/25; 11/28/25.December: 12/26/25.January 2026: 01/02/26. Review of Meal Percentage Eaten located in the Tasks tab of the EMR revealed the following with no documentation that a meal was served or refused:October 2025: 10/18/25; 10/21/25; 10/24/25; 10/25/25; 10/26/25; 10/27/25; and 10/31/25.November 2025: 11/1/25; 11/07/25; 11/08/25; 11/09/25; 11/10/25; 11/11/25; 11/13/25; 11/14/25; 11/15/25; 11/16/25; 11/17/25; 11/22/25; 11/23/25; 11/24/25; 11/26/25; 11/28/25; 11/29/25 and 11/30/25.December 2025: 12/02/25; 12/04/25; 12/07/25; 12/08/25; 12/12/25.January 2026: 01/01/26; 01/02/26; 01/03/26; 01/04/26; 01/05/26 and 01/10/26.Review of the Incontinent Care located in the Tasks tab of the EMR revealed the following days in which incontinent care was not documented:December 2025: 12/02/25; 12/04/25; 12/07/25; 12/08/25; 12/12/25; 12/13/25; 12/26/25; 12/28/25.January 2026: 01/01/26; 01/02/26; and on 01/11/26 in which the documentation showed it was not applicable as R1 had an indwelling urinary catheter.2. Review of the admission Record located in the Profile tab of the EMR revealed that R2 was admitted to the facility on [DATE] with a diagnosis of a brain injury.Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 11/20/25 revealed that R2 had a staff assessed BIMS score of three out of 15 which indicated R2 was severely impaired in cognition, was always incontinent of bowel and bladder, and had no skin issues.Review of the Weekly Skin Assessments located in the Evaluations tab of the EMR revealed the following missing assessments from October 2025 to January 2026:October 2025: 10/03/25; 10/10/25; 10/17/25; 10/24/25; 10/31/25.November 2025: 11/14/25; 11/28/25.December 2025: 12/05/25; 12/13/25; 12/19/25; and 12/26/25.January 2026: 01/09/26.Review of the Incontinent Care located in the Tasks tab of the EMR revealed the following dates in which no incontinent care was documented as having been provided in the last 14 days:01/16/26; 01/26/26.Documentation that showed R2 was only provided with incontinent care one time per day:01/17/26; 01/18/26; 01/19/26; 01/22/26 and 01/23/26.3. Review of the admission Record located in the Profile tab of the EMR revealed R3 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (a neurological disease).Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 12/29/25 revealed R3 had a BIMS score of 14 out of 15 which indicated R3 was cognitively intact, was always incontinent of bowel and bladder and had no pressure ulcers.Review of the Incontinent Care located in the Tasks tab of the EMR had the following days in which no incontinent care was provided:November 2025: 11/01/25; 11/07/25; 11/08/25; 11/09/25; 11/10/25; 11/13/25; 11/15/25; 11/16/25; 11/17/25; 11/21/25; 11/22/25; 11/23/25; 11/24/25; 11/26/25; 11/28/25; 11/29/25.In addition, the Incontinent Care documentation revealed the following days in which incontinent care was only provided once on the 7:00 AM to 3:00 PM shift:11/2/25; 11/04/25; 11/05/25; 11/06/25; 1/11/25; 11/14/25; 11/19/25; 11/27/25.During an interview on 01/28/26 at 11:06 AM, Certified Nurse Aide (CNA)1 stated, The documentation needs to be accurate, but we have a lot of CNAs who are agency and they may not do it [documentation.]During an interview on 01/28/26 at 2:00 PM, the Administrator and the Director of Nursing (DON) confirmed that there was missing documentation in resident records.Review of the facility policy titled, Documentation in Medical Record, dated 05/01/25 revealed, .Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation .Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service provided .

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 1 abuse investigation involving 1 of 1 Residents (R1). The facility became aware of an abuse allegation on the evening of 10/8/25 at approximately 9:00 PM and did not report to state agency until 10/9/25 at 8:09 PM. Evidenced by:The facility policy entitled Abuse, Neglect and Exploitation, dated 7/01/25, states, in part: . It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has zero tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response:A. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. R1 admitted to the facility on [DATE] and has diagnoses that include chronic obstructive pulmonary disease (a chronic lung disease that causes ongoing inflammation and narrowing of the airways, making it difficult to breathe), hypertension (high blood pressure) and hypothyroidism (underactive thyroid, a condition that happens when your thyroid gland doesn't make or release enough hormone into your bloodstream). R1's Quarterly Minimum Data Set (MDS) Assessment, dated 9/9/25 shows that R1 has a Brief Interview of Mental Status (BIMS) score of 14 indicating R1 is cognitively intact. The facility Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, states, in part: . Summary of Incident: Allegation type Abuse: Hitting, slapping, threats of harm, assault, humiliation Name - Affected Person: R1. Is date and time when occurred known? YesDate occurred: 10/8/25Time Occurred: 9:00PMIs occurred date and time estimated? YesDate discovered? 10/09/25 Brief Summary of Incident:On 10/09/25 at approximately 6:45PM it was reported to the facility's social worker by R1 that last night, she believes, the night nurse came in her room and attempted to give her medication while she was on the toilet. Per R1 she voiced that she was not happy to the nurse and the nurse reportedly stated that, he would not come in and give her medication. R1 stated that she took the medication. R1 states that she feels safe in the facility but no longer wants to work with this nurse. The nurse was identified as LPN E (licensed practical nurse) who was immediately suspended pending investigation at approximately 7:00PM and his statement was received. Facility initiated the investigation.Report Submitted Date: 10/09/25 8:09:17 PM. The facility's Investigation regarding R1, dated 10/09/25, states, in part: . Action taken:*Statement was received from R1 -Statement indicated that LPN E attempted to give her medication while she was on the toilet, that he did not explain who he was. She indicated that she was scared and shaking. She also stated that LPN E would not tell her who he was and that he stated, I'll tell you, the next time I hand out pills I'm going to pass right over you. In other words, he's not going to give me my pills. Investigation conclusions:After conducting this investigation, the allegation of verbal abuse toward R1 was not witnessed by any other staff member. CNA F (certified nursing assistant) did state that the night she worked with R1, she did have to console R1, but she did not witness the interaction. CNA F's statement, undated, states: When I went to put R1 in bed R1 was shaking and nervous. She stated that earlier when she was in the bathroom LPN E walked in and was forcing her to take her pills. You know R1 likes to do her things her own way she can be slow, but that's okay. I did not witness the interaction. This was what R1 told me after it happened. On 10/27/25 at 12:45 PM, Surveyor interviewed SW G (social worker) who indicated she received a call from NHA A (Nursing Home Administrator) on 10/09/25 between 6:00 PM- 6:30 PM stating R1 wanted to talk to someone. NHA A did not say what R1 wanted to talk about but felt it was something that needed to be discussed. SW G indicated R1 told her LPN E came in her room the evening of 10/08/25 and while R1 was on the toilet she sees this big hand come at her with meds. R1 indicated she could not take those meds as she was about to wipe and did not have any water. R1 indicated she told LPN E she could not take the meds right then and LPN E took the med cup and put water in it and told R1 to take the pill. R1 indicated LPN E did not tell her who he was at that time or knock on her door. R1 asked LPN E who he was, and LPN E indicated I am the nurse. R1 indicated she took the pill and after CNA F came in her room and had to calm R1 down. R1 indicated LPN E came back to R1 later and stated You don't want to see me anymore? Next time I pass meds I will pass over you. SW G indicated R1 was afraid of LPN E. SW G indicated after she talked with R1 she phoned NHA A and reported it at 6:45 PM-6:52 PM. NHA A phoned DON B (Director of Nursing) and had DON B come to facility to get statement from LPN E before his shift started at 7:00PM and then suspend LPN E pending investigation. On 10/27/25 at 1:14 PM, Surveyor attempted to phone CNA F but was unable to reach her. Surveyor left a voicemail message asking CNA F to return phone call. Note: CNA F never returned the phone call. On 10/27/25 at 2:50 PM, Surveyor interviewed NHA A who indicated she received a call from the resident care coordinator on 10/9/25 that R1 wanted to talk to someone tomorrow (10/10/25). NHA A phoned SW G and asked her to talk with R1 right away. SW G spoke with R1 and SW G phoned NHA A back at 6:35 PM and informed her of the incident that happened with LPN E on the evening of 10/8/25. R1 was on the toilet and LPN E came in without knocking and told R1 to take her pills. NHA A indicated it was reported to her that LPN E told R1 next time pills are passed he would pass R1 by. NHA A indicated she phoned DON B right away and had her come to facility and get LPN E's statement and suspend LPN E pending investigation. DON B obtained LPN E's statement before his shift started at 7:00PM on 10/9/25 and LPN E was suspended. NHA A indicated CNA F was given education on 10/14/25 on reporting allegations of abuse immediately due to R1 indicated to CNA F what had happened with LPN E on 10/8/25 and CNA F did not report it. NHA A indicated the facility has two hours to report an allegation of abuse to the state. NHA A indicated it was not reported until the next day. On 10/27/25 at 3:15 PM, Surveyor interviewed R1. R1 indicated she was on the toilet that night getting ready for bed and without any warning a big hand comes through the bathroom door and this big man told me to take a pill. R1 indicated she asked who he was, and the man would not answer. R1 indicated she was scared because he was a big man and was shocked at this big hand in front of her face. R1 indicated she told the man she couldn't take the pill right then because she was about to wipe herself and she also did not have any water. R1 indicated the man took the pill in his hand and filled the med cup with water and told her to take it. R1 indicated she was so scared as she had never seen this man before, so she took the pill. Surveyor asked R1 if the man identified his self to her and R1 said afterwards he did. CNA F came in R1's room afterwards and seen R1 was shaking and asked R1 what was wrong. R1 indicated she told her what had happened. R1 indicated LPN E came back into R1's room again and asked R1 if she has issues with him and R1 indicated yes. LPN E indicated to R1 if that is the way R1 feels, the next time LPN E is passing meds he will pass R1 by. R1 indicated she told LPN E she did not want him coming near her or giving her meds. R1 indicated she told CNA F, and the next day the SW G came to talk with R1. The facility did not report an allegation of abuse within the 2-hour timeframe to the state agency.

Based on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (R2) observed for wound care.The facility staff did not wear proper PPE (Personal Protective Equipment) when providing wound care to R2.This is evidenced by:The facility's policy Enhanced Barrier Precautions, dated 9/9/25, includes: It is the guideline of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. 4. High-contact resident care activities include: h. Wound care: any skin opening requiring a dressing.R2 admitted to the facility on [DATE] with a pressure ulcer of left hip, stage 4.R2's physician orders, printed on 10/27/25, include: Left hip: Clean with wound cleanser, apply Hydrofera blue into wound, cover with bordered gauze. Change three times weekly and as needed.Enhanced barrier precautions r/t (Related To) woundsOn 10/27/25 at 12:57 PM, Surveyor observed LPN C (Licensed Practical Nurse) complete R2's left hip dressing change. Surveyor observed the following: LPN C brought gathered supplies to R2's room. LPN C donned gloves and proceeded with changing R2's left hip dressing. When LPN C completed the dressing change, she removed the dirty gloves, grabbed the trash bag and exited the room. LPN C walked down the hallway and outside to throw the trash bag in the dumpster. LPN C reentered the building and used hand sanitizer for hand hygiene. Of note, LPN C did not wear a gown for the dressing change procedure.On 10/27/25 at 1:15 PM, Surveyor interviewed LPN C regarding the dressing change observation. Surveyor asked LPN C about the signage regarding enhance barrier precautions hanging on the door frame of R2's door. LPN C indicated R2 was on EBP for her wound. LPN C indicated she followed the EBP by wearing gloves. Surveyor and LPN C reviewed the signage together where the sign stated a gown should be worn during high contact activities. LPN C indicated she did not wear a gown for the dressing change.On 10/27/25 at 2:46 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding wound care. NHA A indicated the facility staff should follow standards of practice in regard to infection control and enhanced barrier precautions during wound care. NHA A indicated she would expect the staff to follow the facility's policy.

Based on interview, and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 sampled resident (R1) reviewed for medications. R1 did not receive medications that included, a blood pressure medication, a thyroid medication and a pain medication 5 days during the months of September and October. Evidenced by: The facility policy entitled Medication Error Reporting and Counseling Procedure, dated 4/09/25, states, in part: . Guideline: It is the expectation of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. Explanation and Compliance Guidelines:1. The facility shall ensure medications will be administered as follows:a. According to physician's orders. 4. The facility will consider factors indicating errors in medication administration, including, but not limited to: a. Medication administered not in accordance with the prescriber's order. Examples include, but not limited to: . ii. Medication omission. 7. To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration; b. Right resident and right documentation. R1 was admitted to the facility on [DATE] and has diagnoses that include gastro-esophageal reflux disease (happens when stomach acid flows back up the esophagus and causes heartburn), hypertension (high blood pressure) and hypothyroidism (underactive thyroid, a condition that happens when your thyroid gland doesn't make or release enough hormone into your bloodstream).R1's Quarterly Minimum Data Set (MDS) Assessment, dated 9/9/25 shows that R1 has a Brief Interview of Mental Status (BIMS) score of 14 indicating R1 is cognitively intact. R1's Care Plan dated 8/21/22 states, in part: . Focus: R1 has hypothyroidism. Date Initiated: 8/21/22.Interventions: *Give thyroid replacement therapy as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 8/21/22.Focus: R1 has GERD &Chronic gastric ulcer. Date Initiated: 5/07/23.Interventions: .*Give medications as ordered. Monitor/document side effects and effectiveness. Date Initiated: 5/07/23.Focus: Pain.Interventions: . Administer pain medications as ordered and monitor for effectiveness/side effects. Date Initiated: 8/21/22. R1's Physician Orders dated 10/27/25, states, in part: . Amlodipine besylate oral tablet 10 mg (milligrams): Give 10 mg by mouth one time a day for hypertension related to Essential Hypertension. start date: 11/21/23. Gabapentin Oral Capsule 100 mg. Give 100 mg by mouth two times a day for pain. start date: 6/30/23. Levothyroxine Sodium Oral Tablet 75 mcg (micrograms). Give 1 tablet by mouth in the morning every Mon, Tue, Wed, Thu, Fri, Sat related to Hypothyroidism. Start Date: 8/08/25. Pantoprazole Sodium Oral Tablet Delayed Release 40 mg. Give 1 tablet by mouth two times a day related to Gastro-Esophageal Reflux Disease. Start Date: 5/17/23 Potassium Chloride ER (extended release) Oral Tablet. Give 10 mEq (milliequivalents) by mouth in the morning related to Hypokalemia (low potassium levels in the blood which is essential for proper nerve, muscle, and heart function) . R1's MAR for September 2025 shows R1 did not receive the following medications on these days by showing blanks where the medications should be signed off: -Amlodipine 10 mg on September 9th and 13th -Levothyroxine 75 mg on September 9th 13th and 19th -Potassium Chloride 10 mEq on September 9th 13th and 19th -Gabapentin 100 mg 0n September 9th 13th and 19th -Pantoprazole 40 mg on September 9th 13th and 19th R1's MAR for October 2025 shows R1 did not receive the following medications on these days by showing blanks where the medications should be signed off: - Amlodipine 10 mg on October 7th - Levothyroxine 75 mg on October 1st and 7th - Potassium Chloride 10 mEq on October 1st and 7th - Gabapentin 100 mg on October 1st and 7th - Pantoprazole 40 mg on October 1st and 7th On 10/27/25, at 3:40 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked what blanks on the MAR mean. LPN C indicated if it was not charted it was not administered. On 10/27/25, at 3:45 PM, Surveyor asked NHA A (Nursing Home Administrator) what blanks on the MAR indicated, and NHA A indicated the medication was not administered. NHA A indicated it would be a medication error.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PIs) from developing and/or worsening or to promote healing of PIs for 1 of 1 residents (R2) reviewed for PIs out of a sample of 5 residents.R2's treatment orders were not followed and hand hygiene was not performed during wound care for R2's pressure injury.This is evidenced by:The facility's policy Clean Dressing Change, dated 2/14/23, includes: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. 7. Wash hands and put on clean gloves. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered. Pat dry with gauze. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands.R2 admitted to the facility on [DATE] with a pressure ulcer of left hip, stage 4.R2's physician orders, printed on 10/27/25, include: Left hip: Clean with wound cleanser, apply Hydrofera blue into wound, cover with bordered gauze. Change three times weekly and as needed.R2's NP D (Nurse Practitioner) note, dated 10/23/25, includes: Pressure injury of left hip.Continue to pack wound with Hydrofera blue soaked with wound wash and cover with bordered gauze.On 10/27/25 at 12:57 PM, Surveyor observed LPN C (Licensed Practical Nurse) complete R2's left hip dressing change. Surveyor observed the following: LPN C donned gloves, removed the old dressing, clean the wound with wound cleanser and gauze, removed dirty gloves, and don clean gloves. LPN C packed R2's left hip wound with Theraform blue soaked in Dakin's solution, apply bordered gauze, remove dirty gloves, grab the trash bag and exit the room. LPN C walked down the hallway and outside to throw the trash bag in the dumpster. LPN C reentered the building and used hand sanitizer for hand hygiene. Of note, LPN C missed hand hygiene opportunities after removing the old dressing, after cleaning the wound, after applying the packing to the wound, and after completing the dressing change.On 10/27/25 at 1:15 PM, Surveyor interviewed LPN C regarding the dressing change observation. LPN C indicated she did not perform hand hygiene appropriately. LPN C indicated R2's orders were to pack the left hip wound with Dakin's soaked Theraform blue. Surveyor asked LPN C if wound cleanser should have been used to soak the Theraform blue instead of Dakin's solution. LPN C insisted R2's orders were for Dakin's solution.On 10/27/25 at 3:14 PM, Surveyor interviewed NP D (Nurse Practitioner) regarding R2's wound care. NP D indicated she had previously ordered Dakin's solution but R2's wound had improved and no longer needed the Dakin's solution. NP D indicated LPN C should have used wound cleanser and not Dakin's solution. NP D indicated she expected the facility staff to follow the orders she writes.On 10/27/25 at 2:46 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding wound care. NHA A indicated she expects the facility staff to follow the order that the provider has given for wound care. NHA A indicated the facility staff should follow standards of practice in regards to hand hygiene and would expect the staff to follow the facility's policy.

Based on interview and record review, the facility did not resolve a grievance for 1 (R1) of 3 residents reviewed for grievances.*On 05/23/2025, R1 filed a grievance involving Certified Nursing Assistant (CNA)-E. The Facility documented that CNA-E would not work with R1 moving forward. Surveyor noted, CNA-E cared for R1 since the incident on multiple occasions.Findings included:Surveyor reviewed the Facility provided document, titled Grievance Summaries reported by R1, dated 05/23/2025. R1 reported that R1 had concerns with how CNA-E spoke while providing cares for R1. The Facility documents that after investigating the concern, CNA-E will not work on R1's line up moving forward and that information was communicated to the scheduler.On 08/04/2025, at 12:43 PM, Surveyor interviewed R1 regarding any care concerns. R1 indicated that R1 did have an issue with CNA-E and had informed the Facility of the concern. R1 denied any further issues with CNA-E and is unsure if CNA-E has cared for R1 since then.Surveyor reviewed R1's Electronic Health Record and noted for the month of July, CNA-E provided incontinence cares for R1 on 07/07/2025, 07/08/2025, 07/19/2025, 07/22/2025 and 07/25/2025.On 08/04/2025, at 1:01 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R1's grievance. NHA-A indicated that NHA-A did the investigation for R1's grievance and concluded R1 did not want CNA-E caring for R1.On 08/04/2025, at 1:49 PM, Surveyor interviewed Social Services-C. Social Services-C indicated that Social Services-C was the scheduler for nursing staff for May 2025 through August 4, 2025. Social Services-C informed Surveyor that if there were any staff that could not work with a certain resident, NHA-A or Director of Nursing (DON)-B would inform Social Services-C and Social Services-C would move the schedule around to ensure that staff member would not be scheduled with a resident. Surveyor asked Social Services-C if there were any staff Social Services-C was made aware of that could not work or care for a particular resident. Social Services-C was not made aware of any staff member that could not care for or work with a resident.On 08/04/2025, at 3:14 PM, Surveyor interviewed CNA-E regarding R1's grievance. CNA-E informed Surveyor that CNA-E currently cares for and works with R1 but will have another CNA come with CNA-E while providing cares. On 08/04/2025, at 3:30 PM, Surveyor informed NHA-A of the concern regarding the follow through of the Facility's grievance resolution for R1. NHA-A informed Surveyor that there was an oversight within the resolution process and communicating the information to the scheduler. NHA-A indicated that NHA-A now does the scheduling and moving forward any conflicts with staff/residents will be reviewed for scheduling purposes.No further information provided at time of write up.

Based on interview and record review the facility did not ensure 1 (R1) of 3 residents needing assistance with Activities of Daily Living (ADL), received the necessary services to receive cares.*R1 did not receive weekly showers.Findings include:The Facility's policy, titled Resident Showers, with a last review date of 06/11/2025, documents in part, Explanation and Compliance Guidelines: 1. Residents will be provided with showers as per request and within reasonable accommodation, or as per facility schedule protocols (at least offered weekly) and based upon resident safety.R1's admission Minimum Data Set, dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 12, indicating R1 has moderate cognitive impairment, has functional limitation in upper and lower extremities, requires substantial/maximal assistance with shower/bathing and documents it is very important for R1 to choose between a tub bath, shower, bed bath or sponge bath.R1's document, titled Care Plan Report documents R1 requires the assistance of 1 staff for bathing/showers.R1's Kardex, documents R1's bathing schedule is Tuesday mornings.On 08/04/2025, at 11:27 AM, R1 informed Surveyor that R1 has not received a shower in over 2 weeks and expressed wanting a shower and not just bed baths.On 08/04/2025, at 11:50 AM, R1's family member came into R1's room and expressed that R1 has only been receiving bed baths and R1 had R1's first shower since admission, about 2 weeks ago. R1 informed Surveyor that R1 prefers morning showers and is supposed to have them on Tuesdays.Surveyor reviewed R1's Tasks in the Facility's Electronic Health Record (EHR) and noted R1 received 1 shower within the last 30 days. Surveyor noted R1 did not have any refusals of showers.On 08/04/2025, at 1:01 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R1's showers. NHA-A indicated they met with R1's family last week and made changes to R1's shower time. NHA-A indicated that R1 should be receiving weekly showers. Surveyor informed NHA-A that R1 had 1 shower in the last 30 days and had no refusals of showers. NHA-A informed Surveyor that NHA-A would look into R1's showers.On 08/04/2025, at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked DON-B how often residents are offered showers. DON-B indicated that residents should be getting weekly showers.On 08/04/2025, at 3:24 PM, Surveyor informed NHA-A and DON-B of the concern R1 has only had 1 shower in 30 days. DON-B informed Surveyor that there is no reason that R1 should not have been given a shower. NHA-A indicated that R1 should be given a preference as to if R1 receives a shower or a bath and it is not acceptable to offer only bed baths to R1.No further information provided at time of write up.

Based on record review, and interview, the facility failed to ensure that bilateral heel protectors for one Resident (R7) of three residents reviewed for pressure injuries were worn according to physician orders. This failure had the potential to increase the bilateral heel sores in size for R7 and negatively affect other residents that remain in the facility that have pressure sores. Findings include: Review of admission Record, located under the tab Profile in the electronic medical record (EMR) indicated, R7 was admitted to the facility on [DATE] with a diagnosis of spinal cord injury, morbid obesity, quadriplegia, and [NAME]-Walker syndrome (a rare brain malformation that occurs before birth, affecting the cerebellum and fourth ventricle). R7 was discharged from the facility on 04/07/25. Review of (name of wound physician group) Evaluation and Management Summary, dated 03/19/25, located under the tab Misc in the EMR indicated, .right heel: unstageable 1.5 x 2 x .1, 100% eschar, developed 03/12/25 and left heel unstageable deep tissue injury (DTI) 1 x 1, intact with purple/maroon discoloration, developed 03/12/25. Review of Order Summary, dated 03/22/25, located under the tab Orders in the EMR indicated, .Review of Heel protectors on bilateral heels at all times. May remove for shower and activities of daily living (ADL) and replace every 12 hours. Review of Treatment Administration Record (TAR), dated 03/22/25, located under tab Orders in the EMR indicated Heel protectors on bilateral heels at all times. May remove for shower and ADL and replace every 12 hours. There is no evidence that R7's bilateral heel protectors were placed on him except for 7:00 AM-7:00 PM on 03/23/25 and 03/27/25 otherwise all evidence reviewed indicated no. Review of TAR, dated April 2025, located under tab Orders in the EMR indicated Heel protectors on bilateral heels at all times. May remove for shower and ADL and replace every 12 hours. No evidence that R7's bilateral heel protectors were placed on him every 12 hours. During an interview on 05/29/25 at 2:20 PM, the Director of Nursing (DON) confirmed that in March 2025 R7's heel protectors were always not on his bilateral heels except for 7:00 AM-7:00 PM 03/23/25 and 03/27/25. The DON confirmed that in April 2025, there was no evidence of the heel protectors being on at all until his discharge on [DATE]. The DON stated in February 2025 that the facility had a recertification and afterwards had a complaint survey. The state survey agency (SSA) cited the facility with pressure sores, and the facility's plan of correction date was 03/19/25, which they had a desk revisit. The DON said that last week the interdisciplinary team (IDT) met on Wednesday and decided to do a skin sweep on Thursday and do daily audits for documentation. She said that the documentation was not back up to the level that the IDT needed it to be.

Based on observation, interview, and record review, the facility did not ensure that the daily nursing staff posting contained accurate information for the skilled nursing facility (SNF). This deficient practice has the potential to affect a pattern of all 37 Residents residing in the facility. The facility nursing staff posting included community based residential facility (CBRF) hours and the skilled nursing facility hours were either blank with no certified nursing assistants (CNAs) assigned on nights or the number of CNAs was inaccurate. Findings include: On 2/20/25, at 1:01 PM, Receptionist (RC)-O confirmed that RC-O is responsible for the daily nursing staff posting. Surveyor requested nursing schedules and nursing staff postings from 1/28/25-2/20/25. On 2/25/25, at 9:52 AM, Surveyor conducted an interview with Director of Nursing (DON)-B. DON-B stated there is always 2 CNAs assigned on nights to work in the SNF. Surveyor and DON-B went over the nursing staff postings and DON-B confirmed that the CBRF hours are listed and should not be on the posting. Surveyor and DON-B reviewed the nursing staff postings which documented multiple times there was only 1 CNA listed as being assigned to the SNF. DON-B is confused why there is only 1 CNA listed for nights for SNF when there is always 2 CNAs. DON-B explained that if a CNA is assigned to the CBRF the CNA can also cover the 3 SNF rooms downstairs. Surveyor again requested the daily working schedules of the nursing staff and what assignment the staff had. On 2/25/25, at 10:03 AM, RC-O explained that RC-O gets the daily schedule on a spreadsheet from DON-B and completes the nursing staff posting. RC-O confirmed RC-O includes the CBRF hours on the SNF posting. RC-O stated, maybe it needs to be clarified. I was following what the person did before me. On 2/25/25, at 11:05 AM, DON-B informed Surveyor that the facility does not have daily nursing schedules of who worked and what their assignment was. DON-B stated that the practice has been to write it on the dry erase board by the nurse's station each day and then erased. DON-B does not have any documentation of assignments from the past. DON-B stated that going forward we will keep written schedules with assignments. On 2/25/25, at 12:08 PM, DON-B informed Surveyor that the facility changed to writing the staff and assignments on the white board about a year ago. DON-B agreed that the CBRF hours should not be co-mingled with the SNF hours. Again, DON-B stated there is always 2 CNAs on nights, however, understands the concern that there are multiple days where it is documented on the nursing staff postings that there was no CNAs working nights in the SNF. On 2/25/25, at 12:15 PM, Surveyor conducted a record review of the daily nursing postings from 1/18/25-2/25/25 and the actual time clock punches of staff working. Surveyor notes there are 14 days that there is inaccurate nursing staff hours that were documented on the daily nursing postings during that time period. On 2/25/25, at 1:21 PM, Surveyor reviewed the concern with DON-B and Director of Operations (DO)-C that the daily nursing SNF postings were inaccurate based on actual staff time punches and that the postings included CBRF hours. DON-B and DO-C understands the concern and provided no further information at this time.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 4 (R3, R4, R7, & R2) of 4 Residents. * There was not an enhanced barrier precaution sign on R3's door, (Licensed Practical Nurse) (LPN)-N did not wear appropriate PPE (personal protective equipment) during a treatment observation and appropriate hand hygiene was not observed during the treatment observation. * R4 was admitted to the facility on [DATE] with multiple non pressure areas. An enhanced barrier sign was not observed on R4's door on 2/20/25 until 2:56 p.m. * Appropriate hand hygiene was not observed during treatment and incontinent cares for R7. * The nurse did not wear appropriate PPE for R2 who is on enhanced barrier precautions when flushing R2's tube and did not perform hand hygiene prior to leaving R2's room. Findings include: The facility's policy titled, Enhanced Barrier Precautions and dated 12/23/22 under policy documents It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism. Under definitions documents Enhanced barrier precautions: refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO (multi drug resistant organism) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Under Policy Explanation and Compliance Guidelines for 1. Prompt recognition of need: documents c. Clear signage will be posted on the door on wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high contact resident care activities that require the use of gowns and gloves. The facility's policy titled, Hand Hygiene and dated 10/24/22 under policy documents All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Under Policy Explanation and Compliance Guidelines for 6. Additional considerations: documents a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. On 2/25/25, at 11:48 a.m. Surveyor interviewed Director of Nursing (DON)-B regarding infection control. DON-B is the Infection Preventionist for the facility. Surveyor asked DON-B what is her expectation for when staff should perform hand hygiene. DON-B informed Surveyor when hands are visibly soiled, in & out of rooms, between cares and providing meals. Surveyor asked DON-B after removing their gloves? DON-B replied yes. Surveyor asked asked after performing incontinence cares and before going to a clean task should staff perform hand hygiene. DON-B replied yes. Surveyor asked if a resident has multiple wounds, after the nurse completes one area should she remove her gloves and perform hand hygiene before going to the next wound. DON-B replied that would be best practice. Surveyor asked if a resident has an order for enhanced barrier precautions should they be placed on EBP (enhanced barrier precautions). DON-B replied yes. Surveyor asked if a resident is admitted with non pressure skin impairments when would the EBP sign be placed on the door. DON-B informed Surveyor after the resident is admitted . Surveyor asked how would staff know a resident is on EBP. DON-B informed Surveyor there should be a sign on the door and an order in the chart. 1.) R3's diagnoses includes end stage renal disease, peripheral vascular disease, morbid obesity, fournier gangrene, diabetes mellitus, and idiopathic aseptic necrosis of right finger. R3's physician orders dated 1/22/25 documents Enhanced Barrier Precautions r/t (related to) wounds. On 2/19/25, at 9:32 a.m., Surveyor observed there is not an Enhanced Barrier Precaution sign outside R3's room. On 2/19/25, at 11:56 a.m. Surveyor observed Licensed Practical Nurse (LPN)-N enter R3's room wearing a mask & gloves and placed the treatment supplies on the over bed table. LPN-N was not wearing the appropriate PPE as she was not wearing a gown. LPN-N asked R3 if she could do his treatment, removed her gloves and washed her hands. LPN-N placed gloves on, lowered R3's pants and removed the incontinence product. LPN-N removed her gloves & placed gloves on. LPN-N did not perform any hand hygiene. LPN-N sprayed wound cleanser on four by four gauze and cleansed R3's left scrotum stitches, repeating this process three times. LPN-N removed her gloves and placed gloves on. LPN-N did not perform any hand hygiene. LPN-N sprayed puracyn plus on abd pad, stated have to wipe up from bottom, and dabbed R3's stitches from the bottom of R3's scrotum up to the end of the suture line. LPN-N applied skin prep around the stitches. LPN-N ripped the calcium alginate placing pieces of calcium alginate over the suture line. LPN-N asked R3 if there is any kerlix. R3 informed LPN-N there are treatment supplies in the dresser. LPN-N opened the drawer, stated she will go grab an abdominal pad and will be back in less than 2 seconds. LPN-N removed her gloves and left R3's room. LPN-N did not perform any hand hygiene prior to leaving R3's room. LPN-N returned a few seconds later, cleansed her hands and placed gloves on. LPN-N folded the abdominal pad and placed this pad between R3's left thigh and scrotum. LPN-N taped the abdominal pad onto R3's scrotum at the top & bottom. LPN-N placed an incontinence product & pulled up R3's pants by having R3 roll himself on the left & right side. LPN-N removed her gloves and washed her hands. On 2/19/25, at 1:57 p.m., Surveyor observed there is still not an EBP sign on or around R3's door. On 2/19/25, at 2:08 p.m., Surveyor asked Registered Nurse (RN)-J how staff knows if a resident is on EBP (enhanced barrier precautions). RN-J informed Surveyor there would be a sign on the door and explained a resident is on EBP for wounds, catheter, etc. Surveyor asked RN-J where PPE (personal protective equipment) is kept. R-J replied in the room but there should be a cart outside. On 2/20/25, at 7:31 a.m. Surveyor observed there is still not an EBP sign on or around R3's door. On 2/20/25, at 10:23 a.m. Surveyor observed there is still not an EBP sign on or around R3's door. On 2/25/25, at 7:45 a.m., Surveyor observed there is not an EBP sign on R3's door. Surveyor noted R3 had been moved to a new room. On 2/25/25, at 11:48 a.m., following the above interview with DON-B Surveyor informed DON-B of the observation of R3 not having an EBP sign on his room doors and concerns regarding hand hygiene during R3's treatment observation. 2.) R4 was admitted to the facility on [DATE] with multiple non pressure areas with treatments to R4's left knee, left ankle, abdomen, left iliac crest, left medial foot, and right plantar foot. Surveyor reviewed R4's physician orders and was unable to locate an order for enhanced barrier precautions. On 2/19/25, at 10:43 a.m., Surveyor did not observe an enhanced barrier sign on or around R4's door alerting staff R4 is on enhanced barrier precautions. On 2/19/25, at 12:12 p.m., Surveyor did not observe an enhanced barrier sign on or around R4's door alerting staff R4 is on enhanced barrier precautions. On 2/19/25, at 2:09 p.m., Surveyor did not observe an enhanced barrier sign on or around R4's door alerting staff R4 is on enhanced barrier precautions. On 2/19/25, at 2:56 p.m., Surveyor observed there is now an enhanced barrier sign on R4's door. 3.) R7's diagnoses which include diabetes mellitus, hypertension, and morbid obesity. R7 has left hip pressure injury, left lateral knee pressure injury, right heel pressure injury, and left fifth toe pressure injury. On 2/20/25, at 10:45 a.m., Surveyor observed Certified Nursing Assistant (CNA)-V place a gown & gloves on and asked R7 if she was ready to get up. CNA-V filled a wash basin and placed the basin & towels on the over bed table. CNA-V informed R7 she was going to wash her upper body, removed R7's gown and washed R7's upper body. CNA-V applied nystatin powder under R7's breasts, placed a shirt on R7, unfastened R7's incontinence product & removed R7's pressure relieving boots. CNA-V placed pants on R7 then using a disposable wipe, wiped under R7's abdomen and frontal perineal area. CNA-V removed the incontinence product which contained urine and placed the product in the garbage. CNA-V assisted R7 with positioning on her side, using a disposable wipe, washed R7's buttocks & rectal area. Surveyor observed BM (bowel movement) on the wipe. CNA-V did not remove her gloves or perform any hand hygiene. CNA-V placed an incontinence product under R7, informed R7 she can come back to her back and fastened the incontinence product. CNA-V placed the soiled linen in a clear bag, removed her gloves, removed gloves from a box, and placed gloves on. CNA-V informed R7 she was going to put the sling under her & then will get someone to help transfer her. Surveyor observed CNA-V did not perform any hand hygiene after removing her gloves. CNA-V stated to R7 let me pull up your pants and pulled up R7's pants. CNA-V removed her gown & gloves then stated to Surveyor make sure you tell them I washed my hands before and after. CNA-V then washed her hands. On 2/20/25, at 3:02 p.m., Surveyor observed CNA-X and RN-Y enter R7's room, wash their hands and place PPE (personal protective equipment) on. CNA-X and RN-Y transferred R7 from the wheelchair into bed using a Sara lift. CNA-X removed R7's shoes, asked R7 if she can turn to remove her clothes. R7 rolled on her left side & CNA-X lowered R7's pants. RN-Y asked CNA-X to stand by the side of the bed so she can move the bed away from the wall. CNA-X then removed her PPE, performed hand hygiene, and left R7's room. Surveyor observed the air mattress is set at firm. At 3:10 p.m., RN-Y removed the dressings from R7's left hip and left lateral knee. RN-Y removed her gloves, brought the garbage can closer to the bed, washed her hands and placed gloves on. At 3:11 p.m. RN-Y informed R7 she was going to do her hip first. RN-Y poured 1/2 strength Dakin's on gauze and cleansed the wound bed. RN-Y did not remove her gloves or perform any hand hygiene after cleansing the wound. RN-Y poured 1/2 strength Dakin's on gauze and packed the gauze into R7's left hip pressure injury. RN-Y then applied border foam dressing & dated the dressing. After completing the left hip pressure injury treatment, RN-Y did not remove her gloves or perform hand hygiene. At 3:16 p.m. RN-Y poured 1/2 strength Dakin's on gauze and cleansed the left lateral knee pressure injury. RN-Y removed her gloves and placed gloves on. RN-Y did not perform any hand hygiene. RN-Y placed three pieces of calcium alginate on the wound bed, opened the dresser drawer to remove tape, covered the pressure injury with two ABD pads and taped the pads. Surveyor observed RN-Y did not wrap the left lateral knee with gauze according to physician orders. RN-Y asked if she still has no pain. R7 replied no I have a very high pain tolerance. RN-Y informed R7 she was all finished. R7 asked about her right heel. RN-Y asked R7 what's going on with your heel and then moved the bed back against the wall. RN-Y removed R7's sock and foam dressing. RN-Y removed her gloves and placed gloves on. RN-Y did not perform any hand hygiene. RN-Y fastened R7's incontinence product and pulled up her pants. RN-Y removed her PPE and washed her hands. 38829 2.) R2 was admitted to the facility on [DATE] with diagnoses of Other Nontraumatic Intracerebral Hemorrhage, Hemiplegia and Hemiparesis Affecting Right Dominant Side, Chronic Kidney Disease, Stage 4, and Depression. R2's Admission Minimum Data Set (MDS) completed 1/23/25 documents a Brief Interview for Mental Status (BIMS) score of 0, indicating R2 demonstrates severely impaired skills for daily decision making. R2's MDS documents R2's Patient Health Questionnaire (PHQ-9) score to be 12, indicating moderate depression. R2's MDS also documents R2 is always incontinent of bowel and bladder and has range of motion (ROM) impairment on both sides of upper and lower extremities. R2's MDS documents R2 is dependent for dressing, eating, transfers, mobility, hygiene, and showers. At the time of the MDS, R2 was nothing by mouth (NPO), and received complete nutrition through a gastrostomy g-tube. R2 currently has a G-Tube still in place and should be on Enhanced Barrier Precautions(EBP). R2's care plan documents: R2 requires tube feeding due to low body mass index(BMI). Initiated 1/22/25 Intervention-Enhanced Barrier Precautions due to Peg Tube. Initiated 1/22/25 On 2/19/25, at 10:50 AM, Surveyor observed Licensed Practical Nurse (LPN)-N with a surgical mask on, and gloves. LPN-N is not wearing a gown. LPN-N came out of R2's room with a syringe and container. Surveyor asked LPN-N what LPN-N had done for R2, and LPN-N stated that LPN-N had been flushing R2's G-Tube. Surveyor then observed LPN-N walk down the hallway with the syringe and container. Surveyor observed LPN-N with the same gloves on and did not take the gloves off upon exiting R2's room and perform hand hygiene. Surveyor notes there is no indication that R2 requires EBP. On 2/20/25, at 7:16 AM, Surveyor observes no indication that R2 requires EBP. On 2/25/25, at 7:22 AM, Surveyor observed Certified Nursing Assistant (CNA)-L in R2's room and was assisting roommate with breakfast. Surveyor asked CNA-L if anyone in the room required EBP. CNA-L stated, Oh I don't know. Surveyor asked CNA-L where is the personal protective equipment(PPE) kept. CNA-L was able to locate 2 gowns in R2's closet. CNA-L confirmed that CNA-L was not aware any of the Residents in R2's room required EBP. CNA-L and Surveyor then were able to locate an EBP sign that was placed on the opposite side of R2's room door which only would be visible to anyone entering the room when the door is closed. Surveyor has only observed R2's room door to be open. CNA-L informed Surveyor, I guess (R2) would be with the tube. On 2/25/25, at 11:47 AM, Surveyors interviewed Director of Nursing (DON)-B in regards to EBP. DON-B confirmed that DON-B is also the Infection Control Preventionist. DON-B explained that there should be a physician's order when a Resident is on EBP and a sign on the door. DON-B confirmed that if someone has a G-Tube, EBP should be initiated. DON-B stated that PPE are kept in the Resident closets if on EBP and gloves are always in the room. Surveyor shared the observation of LPN-N not wearing a gown, and not completing hand hygiene after flushing R2's G-Tube. DON-B confirmed that LPN-N should have been wearing a gown when flushing R2's G-Tube. On 2/25/25, at 1:21 PM, Surveyor shared the EBP concerns of not wearing a gown when flushing R2's G-Tube and not completing hand hygiene when done flushing with DON-B and Director of Operations (DO)-C. Both DON-B and DO-C understands the concern and provided no further information at this time.

Based on interview and record review the facility did not implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of residents property by having a system in place to ensure nurses have a current nursing license and allegations of verbal abuse are reported and investigated and/or investigated timely. * The facility did not have a system in place to check licensed nurses to ensure their license remain valid. Licensed Practical Nurse (LPN)-Q held a multistate license from Texas. On [DATE] the Texas Board of Nursing revoked LPN-Q's license. LPN-Q worked at the facility on [DATE] & [DATE] after her license was revoked. * R7 reported an allegation of verbal abuse by LPN-Q and the allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. The allegation of verbal abuse was not investigated in a timely and thorough manner. * 3 staff members reported to NHA-A allegations of Certified Nursing Assistant (CNA)-H being verbally abusive to R6. The allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. The facility did not conduct an investigation of the allegation of verbal abuse. * R8 reported to a CNA that R8 was missing money on [DATE]. The allegation of misappropriation was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. * R2's allegation of verbal abuse was not thoroughly investigated timely. Findings include: The facility's policy titled, Pre & Continuous Employment Background investigations and last reviewed [DATE] under procedure documents Licensure and Certification validation will be monitored through our payroll software. Reports will be run by the Human Resource Director bi-weekly reporting to the Administration any expired or expiring credentials and notifying the employee proactively. The facility policy titled Abuse, Neglect, and Exploitation and dated [DATE] documents: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under section V Investigation of Alleged Abuse, Neglect an Exploitation documents A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g. not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and other who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing completed and thorough documentation of the investigation. Under Section VII Reporting/Response documents A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1.) On [DATE], at 8:22 a.m. Surveyor searched the DSPS (Department of Safety & Professional Services) for Licensed Practical Nurse (LPN)-Q's license. Surveyor received the following message No records to display. On [DATE] Texas Board of Nursing revoked LPN-Q's license. LPN-Q worked at the facility through an agency on [DATE] and [DATE]. On [DATE], at 11:42 a.m., Surveyor asked Human Resource (HR)-K to explain the process for agency personnel. HR-K explained if they are a [Name] employee [agency name] HR will send everything over to them when on boarding is complete. Surveyor inquired what is sent to the facility. HR-K informed Surveyor their application, BID (background information disclosure), HR revolution, DOJ (Department of Justice), and their TB (tuberculosis) test if applicable. Surveyor inquired about references. HR-K informed [agency name] will send them. HR-K explained when they receive the paperwork they will print it and put it in a file. Surveyor inquired if the paper work is reviewed. HR-K informed Surveyor herself and Director of Nursing (DON) will take a look to see if they have any certifications & their background information. After this information is reviewed they are invited to pick up shifts. Surveyor asked if there are any charges listed on their DOJ what is the process. HR-K informed Surveyor for their employees they will review the charges and they talk about it and for [agency name] their HR will look at the charges. Surveyor inquired what if they indicate they have lived outside Wisconsin on the BID or their license is from another state. HR-K informed Surveyor [agency name] HR will look up the license. On [DATE], at 1:27 p.m., Surveyor spoke with Talent Acquisition Director [name] Agency (TAD)-AA on the telephone to inquire on their background process. TAD-AA informed Surveyor their onboarding process includes application, consent for background check & verification, license, CPR (cardiopulmonary resuscitation) and TB. They use HR revolution with prerequisites set up which gives them a green light, yellow light and red light. TAD-AA explained a green light means they met all requirements, yellow there are questions which their team reviews and red is a hard no. Surveyor inquired if the applicant completes a BID. TAD-AA replied yes. Surveyor inquired what occurs when the DOJ has charges listed. TAD-AA explained they will look at the BID to see if the applicant indicated this and then will review what the charges and dispositions were. Surveyor asked TAD-AA how they verify nurses licenses. TAD-AA informed Surveyor most of the nurses in Wisconsin have Wisconsin license, if they are from a compact state they will run their license as well. Surveyor asked TAD-AA how they become aware if a nurses licenses as been revoked. TAD-AA informed Surveyor they rely on the individual to let them know if their license is revoked. On [DATE], at 8:35 a.m. Surveyor telephoned TAD-AA and inquired if LPN-Q is still a current employee. TAD-AA replied no. Surveyor inquired why LPN-Q is no longer an employee. TAD-AA explained the HR assistant was notified over the weekend her license was revoked. Surveyor verified with TAD-AA worked on [DATE] and [DATE] at the facility. On [DATE], at 9:16 a.m., Surveyor asked HR-K how often they check the licenses for licensed nurses. HR-K informed Surveyor for their staff they do monthly license checks, explaining they have reports when their license is going to expire. HR-K informed Surveyor they are now checking license on a daily basis. Surveyor inquired when this started. HR-K informed Surveyor [DATE]. Surveyor asked HR-K why they started the daily checks. HR-K informed Surveyor its a new policy from Director of Operations-C. Surveyor asked HR-K prior to [DATE] were you checking agency nurses licenses. HR-K replied no not routinely. Surveyor asked HR-K what she meant by routinely. HR-K informed Surveyor when an agency nurse came on she would check their documents. Surveyor asked HR-K after the initial check did she check the licensed nurses license. HR-K replied after that, no. On [DATE], at 9:23 a.m. Director of Operations-C and DON-B met with Surveyor. Surveyor was informed LPN-Q's license is no longer valid. Surveyor inquired how they found this out. Director of Operations-C informed Surveyor DON-B was notified on Sunday the 16th by another agency nurse her license was revoked. DON-B informed Surveyor she verified this happened and removed LPN-Q. She also notified HR, [name of] agency HR and removed LPN-Q from their system. DON-B informed Surveyor she reviewed in house resident's records for change of condition. On Monday ([DATE]) the medical director was notified , an ad hoc QAPI (quality assurance performance improvement) meeting was held. Every licensed nurses and CNA's license/certificates were checked as well as therapy. Director of Operations-C informed Surveyor she filed a complaint with the Texas Board of Nursing. 2.) The facility did not implement their abuse policy for R7. R7 reported an allegation of verbal abuse to HR-K and the allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. The allegation of verbal abuse was not thoroughly investigated timely. Cross reference F609 & F610. 3.) The facility did not implement their abuse policy for R6. Three staff members reported to NHA-A allegations of Certified Nursing Assistant (CNA)-H being verbally abusive to R6. The allegation of verbal abuse was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. The facility did not conduct an investigation of the allegation of verbal abuse. Cross reference F609 & F610. 4.) The facility did not implement their abuse policy for R8. R8 reported to a CNA that R8 was missing money on [DATE]. The allegation of misappropriation was not reported immediately to Nursing Home Administrator (NHA)-A and to the State Survey Agency. Cross reference F609. 5.) The facility did not implement their abuse policy for R2. R2's allegation of verbal abuse was not thoroughly investigated timely. Cross reference F600 and F610.

Based on interview and record review the facility did not ensure that 1 (R1) of 1 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change. *R1 transferred to another room on an unknown date and there is no documentation R1 and/or guardian received prior written notice and gave consent for the reason for the transfer. On 2/14/25, R1 was transferred to yet another room and there is no documentation R1 and/or guardian received prior written notice and gave consent for the reason for the transfer. Findings Include: The facility's policy Change of Room or Roommate implemented 3/7/23 documents: .Policy: It is the policy of this facility to conduct changes to room and/or roommate assignments when considered necessary and/or when requested by the Resident or Resident representative. Policy Explanation and Compliance Guidelines: 4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as Residents and their representatives, will be given advance notice of such a change as is possible. 5. The notice of a change in room or roommate will be provided in writing, in a language and manner the Resident and representative understands and will include the reason(s) why the move or change is required. 6. The social service staff can assist the Resident to adjust to the new room or roommate by: a. Informing the Resident and family as soon as possible of the room or roommate change b. Involving the Resident in the decision and selection of a room or roommate when possible c. Allowing the Resident to ask questions about the move d. Showing the Resident where the room is located e. Introducing the Resident to his/her new roommate and sharing information about the new roommate while maintaining confidentiality regarding medical information in order to help the Resident become acquainted f. Introducing the Resident to employees who will be providing care g. Explaining to the Resident why the change is necessary; reassuring the Resident his/her personal possessions will be safeguarded . The facility's policy Notification of Changes implemented 10/24/25 and last revised 8/27/24 includes notice of room changes. R1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction due to Thrombosis of Right Middle Cerebral Artery, Hemiplegia and Hemiparesis Affecting Left Non-Dominant Side, Dysphagia, Anemia, Encephalopathy, Bipolar Disorder, Anxiety Disorder, and Schizophrenia. R1 has a legal guardian. R1's Admission Minimum Data Set (MDS) completed on 1/23/25 documents R1 has a Brief Interview for Mental Status (BIMS) score of 13, indicating R1 is cognitively intact for daily decision making. R1's Patient Health Questionnaire (PHQ-9) is 10 indicating R1 has moderate depression. The only behavior documented on R1's MDS is verbal behaviors. R1 is always incontinent of bowel and bladder. R1 has range of motion (ROM) impairment on one side of both upper and lower extremity. R1 is dependent for showers, dressing, hygiene, mobility, and transfers. R1's electronic medical record (EMR) documents R1 was admitted to room (100 range room number) and transferred to room (200 range room number) on 2/14/25. Surveyor reviewed R1's electronic medical record (EMR) and was not able to locate documentation of the room change. On 2/19/25, at 10:29 AM, Surveyor left a message for R1's legal guardian with no return call. On 2/19/25, at 1:50 PM, Surveyor interviewed Unit Manager/Social Services/Licensed Practical Nurse/Business Office Manager(UM/SS/LPN/BOM)-D. UM/SS/LPN/BOM-D informed Surveyor that R1 was transferred upstairs because R1 opened up the door downstairs and was found exiting through the door, out of the facility. UM/SS/LPN/BOM-D stated a room change form should have been completed and will look for it. On 2/20/25, at 11:02 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E via telephone who informed Surveyor that R1 had been in room (different 200 range room number) but was transferred downstairs to room (100 range room number). People told them it wasn't a good idea to transfer R1 downstairs. LPN-E does not know why R1 was transferred downstairs. On 2/20/25, at 11:10 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-L via telephone regarding R1. CNA-L stated R1 was admitted to room (different 200 range room number) and transferred downstairs to room (100 range room number) and then transferred back upstairs to room (200 range room number). CNA-L is not sure why R1 was transferred to different rooms two times. On 2/20/25, at 1:11 PM, Surveyor interviewed UM/SS/LPN/BOM-D again regarding R1's room transfers. UM/SS/LPN/BOM-D stated who ever is responsible for the room transfer completes the room change form and obtains consent. UM/SS/LPN/BOM-D recalls room (100 range room number) not being ready when R1 was admitted and so R1 was admitted to room [ROOM NUMBER]. UM/SS/LPN/BOM-D does not recall when R1 transferred from (different 200 range room number) to (100 range room number). UM/SS/LPN/BOM-D confirmed a room change form should be completed and contacting the responsible party to obtain consent should be done. On 2/20/25, at 3:33 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Operations (DO)-C the concern that R1 was transferred to two different rooms with no documentation that R1 and R1's legal guardian were given advance notice and consented to the room transfer, and roommates were given notice. No further information was provided by the facility at this time.

Based on interviews, record review, and policy review, the facility failed to protect 2 residents (R) from physical abuse. R4 has a diagnosis of dementia and a history of striking out at his roommates while residing in other facilities. This information was disclosed to the facility prior to his admission. Despite this information, R4 shared a room with R6. Records indicate R4 sat on R6's chest and that R6 felt R4 was going to kill him. After that incident, the facility allowed R9 to share a room with R4. R4 punched R9 in the face 2 times while R9 was sleeping. Staff interview found that R4 was easily agitated and had instigated altercations with other residents. Facility failure to protect R6 and R9 from abuse created a finding of immediate jeopardy that began on 6/13/22. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on 11/14/22 at 4:13 p.m. The immediate jeopardy was removed on 11/16/22 but remains at a D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement their action plan. Findings include: Review of the facility's policy titled Abuse Policy dated 10/24/22 indicated, Purpose: To provide protections for the health, welfare and rights of each resident residing in the facility. Our facility has developed written policies and procedures to prohibit and prevent abuse .The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation ., Increased supervision of the alleged victim and residents . R4 was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's Disease. R4's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of zero out of 15 indicating the resident had severe cognitive impairment. R4's Care Plan dated 11/10/22, did not include any updates to the care plan after aggressive behaviors were discovered after the 06/13/22 or 10/14/22 incidents. Example 1: R9 was originally admitted on [DATE] with a primary diagnosis of Multiple Sclerosis. R9's Total Plan of Care indicated as of 04/18/22, R9 was alert and oriented to person and place with confusion. Plan of care did not indicate that R9 had any aggressive behaviors. R9's Discharge MDS dated [DATE] revealed a BIMS score of 5 out of 15 which indicated R9 had severe cognitive impairment, and a discharge date of [DATE]. Surveyor reviewed the facility's investigative document dated 06/13/22 at 12:00 AM which indicated R4 had hit R9 in the face twice. Immediately after R9 was punched in the face, he was removed from his room and placed in another room to ensure his safety. Additionally, the report indicated on 06/13/22, R4 caused redness and bruising to R9's face. R4's Progress Notes dated 06/13/22 at 12:00 PM revealed R4 punched his roommate in the face twice while R9 was sleeping in his bed. R9 reported to a CNA (Certified Nursing Assistant) that he was scared it would happen again and R9 was moved to a different room. R9 no longer resides in the facility. Example 2: R6 was admitted on [DATE] with a primary diagnosis of Degenerative Disease of Nervous System. R6's Quarterly MDS dated [DATE] revealed a BIMS of 10 out of 15 which indicated the resident had moderate cognitive impairment. R6's Care Plan dated 11/02/22 indicated R6 had encephalopathy with dementia which required staff assistance for safe transfers, bed mobility, and wheelchair mobility. Review of the facility's investigative document dated 10/14/22 at 2:00 PM, revealed R4 sat on R6's bed. R6 felt afraid of R4 and that R4 was going to kill him. On 11/9/22 at 1:25 PM, Surveyor spoke with R6 about the incident with R4. R6 reported that R4 had sat on his chest on an unknown date. R6 stated he was afraid of R4 and thought R4 was going to kill him, so he (R6) pushed R4 away and then put each other in a head lock. On 11/10/22 at 11:19 AM Surveyor spoke with CNA F, and asked about the incident between R4 and R6 on 10/14/22. CNA F reported that she heard gagging coming from R4 and R6's room. She entered and saw R4 and R6 had each other in a head lock. CNA F stated she separated R4 and R6. CNA F stated R4 had a history of being easily agitated and instigating altercations with other residents. The facility's investigative document did not contain any information regarding R4 sitting on R6's chest, that they had each other in a head lock, or that CNA F separated them. Surveyor spoke with R4's family member on 11/11/22 at 10:22AM. The family member was aware that R4 had punched his roommate. The family member stated R4 has a history of waking up in the night with confusion and would think the other person in a bed was a stranger. R4's family member stated this had happened before while R4 resided at multiple other facilities. R4's family member stated she made the facility aware of his need for his own room when he was admitted to the facility. During an interview on 11/11/22 at 1:28 PM, DON B (Director of Nursing) stated on 10/14/22 R6 told her that he was scared that R4 was going to crush him. DON B stated in the past, the facility had discussed finding placement for R4 at a more appropriate facility. DON B stated that R4 was placed in the room with R6 on 10/10/22. After the 10/14/22 altercation, DON B further stated that they moved R4 to another room downstairs for closer monitoring. The facility's failure to provide the supervision necessary to ensure residents are free from abuse created a finding of immediate jeopardy. The immediate jeopardy was removed on 11/16/22 when the facility implemented the following removal plan: 1. The residents who are residing in the facility and identified in this immediate jeopardy had behavioral evaluations completed and care plan updates to assist in preventing resident to resident abuse. 2. Center residents were evaluated for behavioral risk by the DON (Director of Nursing) and/or designee. 3. Center residents determined to be at risk for abuse or abusive behaviors were reviewed by the DON and/or designee and appropriate interventions were implemented, and care plans were updated. 4. Staff were re-educated by the DON/designee prior to their next scheduled shift on the topics of abuse; freedom from abuse, neglect, and exploitation; and, process for abuse investigations/root cause analysis 5. The DON/designee reviewed all new admissions, residents with a change in condition through daily clinical review and identified any new risks and ensured appropriate interventions were put into place and care plans were updated. 6. Champion's Regional Directors reviewed investigations of allegations of abuse to ensure they are thorough. 7. DON/designee audited daily clinical notes to ensure any new behavior risks were identified, assessed, and care planned. 8. Random audits occurred on all staff to ensure re-education was effective related to abuse, abuse prevention and abuse reporting. 9. Ad hoc QAPI meeting was held with the IDT and Medical Director to review the above plan, Facility Assessment, and Policy and Procedures which included abuse and freedom from abuse, neglect, and exploitation.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure that the environment was free of hazards for 2 of 12 residents reviewed. Resident (R) 2, while in his wheelchair, entered an unlocked, unsupervised stairwell on the 2nd floor and fell down the stairs. R2 was found at the bottom of the stairs at 11:00PM on 08/21/22 by the night nurse with his wheelchair on top of him. Although the length of time R2 laid in the stairwell is unknown, it was found that R2 missed a meal and 2 medication passes. There was no lock and/or alarm on the door to the stairwell. R2 was transported the emergency room and was found to have cut on his face, black eye, bump on his head, fractured femur near his hip and two fractured vertebrae. R2 did not return to the facility after hospital discharge. Facility failure to provide supervision and/or safety devices created a finding of immediate jeopardy that began on 8/21/22. Administrator A was notified of the immediate jeopardy on 11/14/22 at 4:13 PM. The immediate jeopardy was removed on 11/16/22 but continues at a scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement and monitor their action plan. R3 required the use of a Hoyer lift and 2 staff assistance for transfers. On 9/4/22, R3 fell from the Hoyer while being transferred with the assistance of 1 staff. Findings include: Example 1: R2 was admitted for rehabilitation on 8/12/22 after falling down his stairs at home. Diagnoses include encephalopathy, left below knee amputation, and alcohol induced disorder. Review of R2's closed record revealed an initial Fall assessment dated [DATE] showed a high score of 20. Review of the Elopement Risk Assessment on 08/15/22 showed low to no risk for elopement. The initial Minimum Data Set (MDS) with an Assessment Reference Date of 08/17/22 indicated R2 had a BIMS (Brief Interview for Mental Status) score of 10 of 15 which indicated R2 had moderate cognitive impairment. R2 required supervision/oversight for locomotion on the unit. Review of R2's initial care plan dated 08/14/22 revealed the facility identified the following problem areas: at risk for falls, accidents and incidents related to confusion, gait/balance problems and unaware of safety needs, unaware of all/some ADLs, impaired memory, and impaired balance. Interventions included monitoring of mobility, maintaining equipment as needed, and referral to therapy or restorative program for evaluation. On 8/22/22, the facility submitted a self report which stated, During rounds, CNA heard someone yelling for help. Resident (R2) was founding laying on the first landing within the stairwell with the wheelchair laying on top of him. Resident uses wheelchair as main mode of transportation throughout facility while still working with therapies for strengthening and conditioning. Residents room on lower level of facility. Brought up to activity room daily for monitoring due to moderate-severe cog (cognitive) deficits and not being safety oriented. This incident is listed as occurring on 8/21/22 at 11:30 p.m. The facility's investigation included a written statement from Certified Medication Aide (CMA) K which stated R2 had been .trying to get out, he said he had to leave .the only time he was calm was at lunch time then he started up again. So at three thirty I was going home .I told the nurse taking over for me that he was in the activity room. Review of Incident Information Statement dated 08/21/22 from Certified Nursing Assistant (CNA) H indicated she was doing safety checks and heard someone yelling and then she saw R2. The document did not indicate what time or location R2 was found. Review of Incident Information Statement dated 08/21/22 from CNA I indicated she was with CNA H when they found R2 laying at the bottom of the stairwell (next to door 10) between 11:00 PM - 11:30 PM The Incident Investigation Form dated 08/21/22 included a witness statement from Licensed Practical Nurse (LPN) J, who documented that she had not seen R2 the entire evening shift on 08/21/22. As part of the investigation, Director of Nursing (DON) B documented an interview with R2's roommate who indicated he had not seen R2 all day. R2's roommate also stated that R2 had made comments about leaving the facility. CNA L was assigned to R2's care but had not seen him all shift and did not know what he looked like. Review of R2's Emergency Department Impression documentation, dated 08/22/22 at 12:14 AM included contusion of right lung, closed wedge compression fracture of T4 (thoracic) vertebra, closed compression fracture of L2 vertebra, closed displaced fracture of greater trochanter of left femur, closed displaced fracture of right clavicle with routine healing, unspecified part of clavicle, abnormal abdominal CT scan - density by bladder wall, fall down stairs, and periorbital contusion of left eye. Interview with family member on 11/10/2022 at 9:41 AM indicated R2 had been at the facility for about a week when he fell down the stairs. He came to the facility for rehab after a fall down the stairs at home. The plan was for R2 to return home after rehab. On 11/11/22 at 11: 30 AM, Surveyor spoke with Nursing Home Administrator (NHA) A who stated she had worked at the facility for over [AGE] years and no other residents had sustained any falls prior to R2's fall down the stairwell. During interview with the Social Services Director (SSD) on 11/11/2022 at 1:15 PM, SSD verified there was no lock or alarm on the door leading to the stairs. On 11/12/22 at 1:30 PM, Surveyor requested the contact information for the above staff. No contact information was provided. The facility's failure to provide the supervision and assistance necessary to ensure residents' environment is as free of accident hazards as possible created a finding of immediate jeopardy. The immediate jeopardy was removed on 11/16/22 when the facility implemented the following removal plan: 1. The Director of Nursing (DON) and/or designee assessed all center residents for their risk for falls and elopement. 2. Center residents determined to be at risk for falls and elopement were reviewed by the DON and/or designee for appropriate interventions and care plans were updated accordingly. 3. The DON/designee re-educated all staff prior to his/her next scheduled work shift on the following areas: -Assessing and Care Planning for Fall Risk -Assessing and Care Planning for Elopement Risk -Missing Person Protocol -Steps to take if a Resident voices a desire to go home. 4. The DON/designee reviewed new admissions and residents with a change of condition through the daily clinical review and identified any new risks and ensured appropriate interventions were in place and updated care plans. 5. Champion's regional director reviewed all completed investigations into accident/incidents to assure a thorough investigation was completed. 6. DON/designee audited clinical notes, new admissions, and readmissions to ensure fall and elopement risks were identified, assessed, and care planned. 7. Elopement drills were completed by the DON/designee to ensure all staff were aware of the policy and procedure for missing residents. 8. AD HOC Quality Assurance Performance Improvement meeting was held with the IDT and Medical Director and the above plan, facility assessment, and policy and procedures, which included: Falls Clinical Protocol, Elopement Guidelines for Missing Residents were reviewed. The deficient practice continues at a scope and severity of D (potential for harm/isolated) as the facility continues to monitor the effectiveness of their removal plan and as evidenced by: Example 2: R3's was currently readmitted to the facility on [DATE] with diagnoses of cerebral infarction and psychotic disorder with delusions. The MDS with an ARD of 11/02/22 revealed a BIMS score of 15 of 15 which indicated R3 was cognitively intact. R3's Care Plan initiated on 08/25/22 revealed a problem Alteration in Mobility dated 08/25/22 with interventions included transfer with Hoyer and assist of two. Record review revealed R3 was dropped during a Hoyer lift transfer when CNA M (Certified Nursing Assistant) transferred R3 alone on 09/04/22 in her room. There were no injuries noted. This was her only fall in the last year. Review of the facility's investigative documents dated 09/04/22 revealed the resident was lowered to the floor when the Hoyer lift tilted. CNA M reported on her incident information statement when transferring R3 with Hoyer alone, Hoyer tipped over. Lowered to floor. Called nurse to assess. On 11/11/22 at 11:30 AM, NHA A was asked about the incident when R3 was dropped during a one person Hoyer lift transfer. NHA A stated that she has conducted an in-service education with the staff who dropped R3 that day. NHA A stated she continues to do spot checks of Hoyer transfers to ensure the correct number of staff are used for the transfer and that the transfer was conducted with the proper transfer techniques.

Based on interview, observation and record review, the facility did not ensure 1 (R17) of 2 residents reviewed for pressure injuries received care, consistent with professional standards of practice, to prevent pressure ulcers and not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. * R17 had bilateral hand contractures. In January and February of 2022, R17 developed a pressure injury to her left hand (1/21/22), third finger due to the contracture. R17 saw Occupational Therapy (OT) who worked to develop interventions and devices to prevent further skin breakdown including a hand splint, carrot roll and palm protectors. On 4/25/22, R17 developed an unstageable pressure injury to her left thumb due to the contracture. On 4/25/22, the wound to the left thumb was infected and needed to be treated with antibiotics. On 4/27/22 the wound size to the left thumb was 0.8 X 1 X not measurable cm, with a recommendation for small hand grip. On 5/4/22 the wound deteriorated and was assessed to be unstagable (due to necrosis) 2 X 2 X not measurable with thick black necrotic tissue with the need for ongoing debridement. During survey (6/22 - 6/8/22) R17 was observed without a hand splint, carrot roll and palm protectors. Staff interviewed gave conflicting information as to whether the hand protectors/splints (carrot roll) was to be applied. According to RN-H when the wound developed about a month ago, staff started leaving the splints off. RN-H also indicated she had not ordered smaller splints when the first pair of splints was noted to be too big for R17. There was no further care planned intervention as to what should be done in regards to the prevention of pressure from R17's hand contractures. Findings include: Surveyor reviewed facility's Pressure Ulcer, Care and Prevention policy with no date. Documented was: .PURPOSE To prevent and treat further breakdown of pressure ulcers . GENERAL GUIDELINES FOR ASSESSMENT MAY INCLUDE, BUT ARE NOT LIMITED TO: . - Skin at risk - General condition of skin . - Mobility status - Limited in range of motion and deformities . EQUIPMENT: . 8. Other devices as ordered by Physician . TREATMENT: treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers . R17 was admitted to the facility on [DATE]. R17's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's admission MDS (Minimum Data Set) with an assessment reference date of 5/19/20 indicates R17 is severely cognitively impaired with daily decision making skills. R17 requires total dependence with 2 staff physical assist with bed mobility and transfers. R17 is also noted to have functional limitations with range of motion on both sides for both upper and lower extremities. The MDS indicate R17 is at risk for the development of pressure injuries, has no unhealed pressure injuries and utilizes pressure reducing devices in bed, chair, and on turning repositioning program. R17's 2/14/22 Annual MDS indicates R17 is severely cognitively impaired with daily decision making skills. R17 requires total dependence with 2 staff physical assist with bed mobility and transfers. R17 is also noted to have functional limitations with range of motion for on both sides for both upper and lower extremities. The MDS indicate R17 is at risk for the development of pressure injuries, has no unhealed pressure injuries and utilizes pressure reducing devices in bed, chair, and on turning repositioning program. Surveyor reviewed R17's quarterly MDS with an assessment reference date of 4/26/22. Documented under Cognitive Skills Daily Decision Making was 3. Severely impaired - never/rarely made decisions. Documented under Functional Status for Bed Mobility and Transfer Status was 4/3 which indicated Total dependence - full staff performance every time during entire 7-day period; Two plus persons physical assist. Documented under Skin Conditions was Risk of Pressure Ulcer/Injuries was 1. Yes. Documented under Unhealed Pressure Ulcers/Injuries was 0. No. Surveyor reviewed OT's Plan of Care with a start date of 1/21/22 completed by Former OT-I. Documented was: .TREATMENT diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Reason For Referral: Pt referred to OT due to developing worsening contractures to [bilateral upper extremities (BUE's)] and resulting in open area to [left (L)] middle finger due to second fingernail into side of middle finger, Therapy Necessity: Therapy necessary for manual techniques to increase tolerance to [passive range of motion (PROM)] to BUE's and decrease contracture development, assess for appropriate splints for BUE's and establish splint program, train staff for carryover to promote skin integrity and prevent further deformity. Without the patient at risk for skin breakdown, pain and worsening contracture. Documented by OT-I for R17 on 2/14/22 in Daily Treatment Notes was: [Patient (Pt)] seen for prolonged stretch and PROM to BUE shoulders, elbows extension, Wrists extension, fingers extension to decrease contracture development and increase tolerance to splint program .Therapist established written recommendations and instruction to nursing staff for carryover of splint donning and wearing schedule for [right (R)] hand/wrist splint and L carrot/or roll splint to improve skin integrity and prevent further deformity; pt to wear 4-6 hours per shift and alternate with use of palm guards to protect skin when not wearing splints. Surveyor reviewed MD orders for R17. Documented with a start date of 2/14/22 was: R hand/wrist comfy + L hand CARROT or roll splint 6 hours per shift; palm protectors in between splint wearing times. Surveyor reviewed R17's Comprehensive Care Plan. Added to the care plan for Skin Integrity on 2/14/22 and most recently reviewed on 4/25/22 was: 2/14/22 R hand/wrist comfy splint L hand carrot roll on 6 [hour] per shift palm protectors in between clean/dry/assess hands prior to application. Surveyor reviewed Progress Notes for R17. Documented on 4/25/22 was called to room to assess resident with serosanguineous drainage to L hand thumb when attempting to place carrot roll . measuring 1.5 cm in circumference noted to L thumb. [MD] aware, [new order (NOR)] and noted to start oral [antibiotics (ABT)] X 1 week . Surveyor reviewed MD orders for R17 with a start date of 4/25/22. Documented was [MEDICATION(S)] 500 mg [orally] [three times a day] X 1 week; infected L thumb and Consult [Wound MD-G] for wound to L thumb. Surveyor reviewed R17's Comprehensive Assessment/History and Physical (H&P) with a date of 4/25/22. Documented under Skin Condition was followed by [Wound MD-G] . new area to L thumb - ABT started (4/25) hand splits to bilateral hands. Surveyor reviewed Wound Evaluation & Management Summary documented by Wound MD-G. Documented on 4/27/22 was: Unstageable [deep tissue injury (DTI)] of the Left, first finger partial thickness. Etiology: Pressure. Duration > 1 day. Objective: Healing, medical device related, (hand grip to prevent contraction). Wound Size (L x W x D): 0.8 x 1 x not measurable cm . Additional wound detail: recommend smaller hand grip . Documented on 5/4/22 was: Unstageable (Due to Necrosis) of the Left, first finger full thickness. Etiology: Pressure. MDS 3.0 Stage: Unstageable necrosis. Duration > 7 days. Objective: Healing, medical device related, hand grip to prevent contraction), Wound Size (L x W X D): 2 x 2 x not measurable cm . Exudate: Moderate Serous, Thick adherent black necrotic tissue (eschar): 100%, Wound progress: deteriorated. The wound had to be surgically debrided due to unvitalized tissue by Wound MD-G. The wound subsequently had to be surgically debrided on 5/11/22, 5/18/22 and 5/25/22. The wound was not debrided on 6/1/22 because the visit was virtual. The Objective of Healing, medical device related (hand grip to prevent contraction) was documented by Wound MD-G on 5/11/22, 5/18/22, 5/25/22 and 6/1/22. The resident continued to have the unstageable left first finger pressure injury during Recertification Survey from 6/6/22 through 6/8/22. Surveyor observed R17 in bed without splints, carrot rolls or palm protectors on hands on 6/6/22 at 9:35 AM, 10:48 AM, 12:48 PM and 2:19 PM and on 6/7/22 at 10:02 AM and 11:54 AM during survey. On 6/7/22 at 12:54 PM Surveyor interviewed Certified Nursing Assistant (CNA)-E. Surveyor asked if R17 wore hand protectors or splints. CNA-E stated Registered Nurse (RN)-H told her not to put them on because of the L thumb wound and because she screams out in pain when they are on. On 6/7/22 at 2:00 PM Surveyor interviewed RN-D. Surveyor asked if R17 wore hand protectors or splints. RN-D stated she normally does. Surveyor asked if she knew why they were not on. RN-D was unaware why. RN-D stated I am going to redress the wound and put them on her. Surveyor noted CNA-E stated RN-H told her not to put them on because of the L thumb wound and because she screams out in pain when they are on. RN-D stated if that was the case no one updated her on this, and she was unaware. Surveyor asked if she should be wearing the splints/hand protectors. RN-D stated yes. On 6/8/22 at 9:43 AM Surveyor interviewed RN-H charged with wound care and documentation. Surveyor asked about R17's hand splints. RN-H stated she had some but the first one was too big. Surveyor asked when this was. RN-H stated in February when OT saw her. RN-H stated when the wound happened about a month ago, they started leaving the splints off. Surveyor asked if that was documented anywhere. RN-H stated no. Surveyor asked if anyone ordered smaller splints if the first ones were too big. RN-H stated we talked about smaller ones but no one ordered any. Surveyor asked whose responsibility that would be to order the smaller splints. RN-H stated it would be mine. RN-H stated the wound is healing but it is uncomfortable for her to put something in between. We stopped using the hand splints when she got the wound. Surveyor asked about the etiology of the wound. RN-H stated it was from pressure of her fingers together due to her contracture. Surveyor asked why they would take the splints away that are the intervention to prevent pressure from the contracture. RN-H stated the splints were hurting her. Surveyor asked what other intervention was put in place to prevent pressure injuries to her contracted hands. RN-H stated we put a bandage on her thumb. On 6/7/22 at 2:05 PM Surveyor observed a band-aid to her thumb which would not be considered a pressure relieving bandage. On 6/8/22 at 10:55 AM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked about R17's hand splints. DON-B stated she was not 100% familiar with them. Surveyor noted the observations of R17 not having them on during survey and no documentation of pain or refusals. DON-B stated staff should have documented that she was refusing or if it was hurting. Surveyor noted the OT order for comfy splint/carrot roll/palm protectors. DON-B stated that is a very specific order and the staff should be following that order. DON-B stated if R17 was in pain she could see how they would leave them off. Surveyor asked about any other interventions put in place if staff were not going to use the splints. DON-B stated something should have been done and care planned and orders should have been updated. Surveyor noted RN-H stating they needed smaller ones. DON-B stated then someone should have ordered them.

Based on record review, interview and observation, the facility did not follow professional standards of practice and its own written policies and procedures designed to help prevent the development and transmission of COVID-19, potentially affecting all 36 residents who resided at the facility at the time of the survey. * Facility staff were observed not wearing full PPE (personal protective equipment) per CDC (Centers for Disease Control) guidelines when working with a positive COVID-19 (Coronavirus Disease 2019) resident (R7). * Facility staff and a contractor were observed not wearing appropriate PPE when entering the COVID-19 positive wing. * Facility staff and contractors were observed to not wear appropriate PPE when entering the mixed living wing where both COVID-19 positive and COVID-19 negative residents resided. * Facility staff were not actively screening facility visitors at the entrance to the facility. The thermometer at the entrance of the facility was observed to not function properly and a Surveyor was able to enter the facility without having her temperature taken. The facility's failure to implement an infection prevention and control measures to prevent the spread of COVID-19 created a finding of immediate jeopardy that began on 10/12/20. The DON (Director of Nursing)-B was notified of the immediate jeopardy on 10/13/20 at 10:10 a.m. The immediate jeopardy was removed by the facility on 10/13/20. The deficient practice continues at a scope and severity of an F (potential for harm/widespread) as the facility continues to implement its action plan. Findings include: The facility's policy dated as revised on 10/12/20 and titled, COVID-19 (Coronavirus 2019) Policy documents under the Purpose section; MHCC (Muskego Health Care Center) is aware that a new respiratory disease-coronavirus disease 2019 (COVID-19) has become a global pandemic. With the declaration of a public health emergency in the state of Wisconsin and the Safer at Home order in place, it is of utmost importance that MHCC provides its very high-risk and vulnerable residents with the necessary assessment, care, education, monitoring, and prevention to maintain an environment free from active COVID-19 infection and to promptly and properly slow/stop the spread of the infection if it is to arise, while facilitating the appropriate care to those that are affected in accordance with the guidelines set forth from the CDC (Centers for Disease Control) and DHS (Department of Health Services). Section (3.) documents; COVID-19 Facility Exposure Management after a suspected or confirmed case of COVID-19: (a.) Resident Management- (i.) Resident should be placed in immediate isolation in his/her room with privacy curtains drawn and door closed at all times; (ii.) Initiate droplet and contact precautions with isolation carts, supplies and signs in place; (vi.) Direct care staff is to wear all recommended PPE (gown, gloves, eye protection, facemask) if resources allow; (xvi.) The designated COVID-19 wing will have signage posted identifying it as such and reminding all those that enter that they must wear eye protection and an N-95 at all times while on the unit. Gloves and gowns should be added when entering resident rooms. (xvii.) Full PPE (personal protective equipment) should be worn in mixed units. The CDC (Centers for Disease Control)'s recommendation updated on June 25, 2020 and titled, Preparing for COVID-19 (Coronavirus Disease 2019) in Nursing Homes documents, Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The health department can assist with decisions about testing of asymptomatic residents. The CDC's recommendation updated on July 15, 2020 and titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documents, Personal Protective Equipment: HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. On 10/12/20 at 9:57 a.m., Surveyor interviewed DON (Director of Nursing)-B, who is the Infection Control Coordinator, regarding the infection control practices implemented by the facility to prevent the spread of COVID-19. DON-B informed Surveyor that the facility was experiencing an active outbreak of COVID-19 and that it had 19 residents residing at the facility who were currently positive for COVID-19. DON-B informed Surveyor that while the facility had a dedicated COVID-19 wing, over the weekend a number of residents had tested positive for COVID-19, which caused the facility to have COVID-19 positive residents residing on the same wing as COVID-19 negative residents. DON-B informed Surveyor that residents whom had tested positive for COVID-19 had been placed in rooms with other positive COVID-19 residents. DON-B informed Surveyor that the rooms with COVID-19 positive residents had signs on the door alerting staff to take isolation precautions. Surveyor asked DON-B what type of PPE (personal protective equipment) facility staff had to wear when entering the COVID-19 wing and or rooms with residents who were COVID-19 positive. DON-B informed Surveyor that facility staff should be wearing eye protection (goggles or a face shield), an N95 mask, a gown and gloves when entering the COVID-19 wing and or when working with residents who were COVID-19 positive. Surveyor asked DON-B about the status of the facility's PPE supplies. DON-B informed Surveyor that the facility did not have any PPE shortages and that the facility was currently under a conventional capacity strategy with their PPE supplies. DON-B confirmed to Surveyor the inventory count of PPE supplies available to the facility as of 10/12/20: 120 N95 Masks, 200 face shields and 500 washable and reusable gowns available for staff. R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7 was found to be COVID-19 positive on 10/12/20. Due to R7's positive COVID-19 status, and per the facility's policy and CDC guidelines, Surveyor noted that staff should be wearing a gown, eye protection and an N95 mask when entering R7's room. 1. Personal Protective Equipment (PPE) Use with COVID-19 positive Residents: On 10/12/20 at 8:48 a.m., Surveyor observed a sign outside of R7's room that stated the room was on isolation precautions and that staff needed to wear a gown, eye protection and an N95 mask to enter R7's room. On 10/12/20 at 8:52 a.m., Surveyor observed MT (Maintenance Technician)-D, who at the time was working as a CNA (Certified Nursing Assistant), enter R7's room wearing only a face mask. Surveyor noted that MT-D was not wearing an N95 mask, eye protection or a gown when he (MT-D) entered R7's room. (Surveyor could not see if MT-D was wearing gloves.) On 10/12/20 at 9:05 a.m., Surveyor observed MT-D again enter R7's room wearing only a face mask. Surveyor noted that MT-D was not wearing an N95 mask, eye protection or gown when he (MT-D) entered R7's room. On 10/12/20 at 9:12 a.m., Surveyor observed MT-D enter R11 and R12's room, which is on the same unit as R7's room, wearing just a face mask. Surveyor noted that R11 and R12 were both COVID-19 negative and that MT-D entered their (R11 and R12) room without wearing an N95 mask, gown or eye protection. Surveyor noted that MT-D was not wearing appropriate PPE (Personal Protective Equipment), which included an N95 mask, eye protection and a gown, when he had entered a COVID-19 positive room (R7's room). Surveyor noted that after entering a COVID-19 positive room without proper PPE, MT-D then entered a room with COVID-19 negative residents (R11 and R12), potentially exposing COVID-19 negative residents to COVID-19. On 10/12/20 at 9:34 a.m., Surveyor observed MT-D enter R7's room wearing only an N95 mask. Surveyor observed that MT-D was not wearing a gown or eye protection when he entered R7's room. On 10/12/20 at 10:02 a.m., Surveyor asked DON-B why R7 had an isolation sign outside his room. DON-B informed Surveyor that she did not know. DON-B informed Surveyor that over the weekend, facility staff may have forgotten to remove the isolation sign outside of R7's room as some residents were moved rooms after testing positive for COVID-19. On 10/12/20 at 11:57 a.m., DON-B informed Surveyor that R7 had tested positive for COVID-19. At the time, Surveyor informed DON-B that he had observed MT-D enter R7's room without wearing appropriate PPE per CDC and facility guidelines. DON-B informed Surveyor that she would perform a rapid test for COVID-19 on MT-D. On 10/12/20 at 12:02 p.m., Surveyor asked MT-D if he had assisted R7 earlier in the morning. MT-D informed Surveyor that he had entered R7's room to pick up R7's food tray earlier in the morning. Surveyor asked MT-D if he had worn an N95 mask when he entered R7's room to pick up R7's food tray. MT-D informed Surveyor that he did not wear an N95 mask when he entered R7's room because he was not aware that R7 was positive for COVID-19. MT-D informed Surveyor that when he picked up R7's breakfast food tray, R7 had requested assistance in getting dressed. MT-D informed Surveyor that he did not assist R7 in getting dressed because at the time, he was focused on helping other residents on the wing. MT-D informed Surveyor that when he was in R7's room, R7 did not have any signs or symptoms of COVID-19 and that R7 looked fine. MT-D informed Surveyor that he (MT-D) told R7 that he would return to get him (R7) dressed and then exited R7's room and proceed to help other residents on R7's wing. Surveyor asked MT-D which residents he assisted on R7's wing after he was in R7's room. MT-D informed Surveyor that he helped every resident down R7's wing with continence cares or repositioning after he was in R7's room. Surveyor asked MT-D if he returned to assist R7 in getting dressed after assisting the remaining residents on R7's wing. MT-D informed Surveyor that he did return to assist R7 in getting dressed, but that when he did, he was wearing an N95 mask. Surveyor noted that due to staffing shortages, observations and per the facility's actual working schedule, MT-D was the only staff member working as a CNA on R7's wing on the morning shift of 10/12/20. Surveyor noted that MT-D could have potentially exposed 17 residents who resided on R7's wing to COVID-19 after MT-D was in R7's room without proper PPE. On 10/12/20 at 1:59 p.m., Surveyor informed DON-B of the above findings. DON-B informed Surveyor that MT-D had a rapid test completed and had tested negative for COVID-19. DON-B informed Surveyor that MT-D should have been wearing full PPE (N95 mask, gown, eye protection) when he entered R7's room as the sign outside R7's room informed staff that they should be wearing an N95 mask, a gown and eye protection when entering R7's room. 2. Observations on the COVID-19 Wing On 10/12/20 at 8:45 a.m., Surveyor observed a sign at the entrance of the COVID-19 wing at the facility that documented, 1. Wear eye protection; 2. Wear N95 Mask; 3. Wear gown and gloves. (Note: This sign and facility policy are not in agreement. Facility's written policy, as noted in Section 3 (xvi) above notes: The designated COVID-19 wing will have signage posted identifying it as such and reminding all those that enter that they must wear eye protection and an N-95 at all times while on the unit. Gloves and gowns should be added when entering resident rooms.) On 10/12/20 at 9:13 a.m., Surveyor observed Housekeeper-E enter the COVID-19 wing wearing a gown, N95 mask and gloves. Surveyor observed that Housekeeper-E was not wearing any eye protection per facility written policy. Surveyor then observed Housekeeper-E enter R9 and R10's room, who were both COVID-19 positive, wearing a gown, gloves and an N95 mask. Surveyor noted that Housekeeper-E was not wearing eye protection when he entered R9 and R10's room, contrary to CDC and facility guidelines. On 10/12/20 at 9:18 a.m., Surveyor observed LT (Laundry Technician)-F enter the COVID-19 wing wearing a gown, N95 mask and gloves. At 9:21 a.m., Surveyor observed LT-F refill the reusable gown containers located throughout the COVID-19 wing. Surveyor observed that LT-F was not wearing any eye protection, contrary to facility policy. On 10/12/20 at 9:26 a.m., Surveyor observed LT-F exit the COVID-19 wing without removing the gown she was wearing when she refilled the gown containers on the COVID-19 wing. Surveyor then observed LT-F walk down the mixed unit wing while wearing the same gown she had worn on the COVID-19 wing. Surveyor noted that LT-F did not remove her PPE (personal protective equipment) when exiting the COVID-19 wing or before entering the mixed (COVID-19 positive and COVID-19 negative) wing. On 10/12/20 at 9:31 a.m., Surveyor observed MT-D enter the COVID-19 positive wing with OC (OTIS Contractor)-G. Surveyor observed MT-D to enter the unit wearing an N95 mask. Surveyor observed MT-D to not be wearing a gown or gloves when entering the COVID-19 wing (contrary to the sign on the door to the unit) and not wearing eye protection (contrary to the sign on the door and the facility's written policy). Surveyor observed OC-G enter the COVID-19 positive wing while wearing just a blue facemask. Surveyor observed OC-G to not be wearing an N95 mask, a gown, or gloves (contrary to the sign on the door to the unit) and not wearing eye protection (contrary to the sign on the door to the unit and the facility's written policy). While MT-D and OC-G were entering the COVID-19 positive wing, Surveyor heard AD (Activities Director)-H tell MT-D. How's he (OC-G) going to get in (referring to the COVID-19 positive unit)? to which MT-D was heard stating, We're (MT-D and OC-G) not going into any rooms, he's (OC-G) is going on to the elevator. Surveyor noted that when OC-G entered the COVID-19 wing, there were 14 COVID-19 positive residents residing on the COVID-19 wing. Surveyor noted that when OC-G entered the COVID-19 wing, the entrance door to the unit was open. Surveyor also observed the doors of all the rooms on the COVID-19 wing to be open. Surveyor could also hear audible coughing coming from the rooms on the COVID-19 wing when OC-G entered the COVID-19 wing. On 10/12/20 at 2:30 p.m., Surveyor informed DON-B of the above findings. Surveyor asked DON-B if facility staff should be wearing full PPE (N95 mask, gown, eye protection) when entering the COVID-19 wing. DON-B informed Surveyor that facility staff should be wearing full PPE when entering the COVID-19 wing. DON-B informed Surveyor that staff should also be removing their gowns, gloves, and disinfecting their eye protection when exiting the COVID-19 wing. Surveyor asked DON-B if facility staff should ensure that contractors and non-staff members wear appropriate PPE when entering the COVID-19 unit. DON-B informed Surveyor that facility staff should ensure that contractors and non-staff members wear appropriate PPE when entering the COVID-19 unit. 3. Observations on Mixed (COVID-19 Positive and COVID-19 Negative) Wing On 10/12/20 at 8:06 a.m., Surveyor observed MT-D working on the mixed wing wearing only a facemask. On 10/12/20 at 9:15 a.m., Surveyor observed Dietician-K on the mixed wing wearing only a facemask. On 10/12/20 at 9:27 a.m., Surveyor observed Housekeeper-E on the mixed wing wearing an N95 mask. On 10/12/20 at 9:33 a.m., Surveyor observed Dietician-K on the mixed wing wearing only a facemask. On 10/12/20 at 9:57 a.m., Surveyor informed DON-B of the above findings. When Surveyor asked DON-B if facility staff should be wearing full PPE (N95 mask, gown, and eye protection) when working on the mixed wing, DON-B agreed and stated she would inform facility staff and would implement full PPE on the mixed wing. On 10/13/20 at 8:02 a.m., Surveyor observed Bell Ambulance EMT (Emergency Medical Technician)-I and Bell Ambulance EMT-J enter the mixed wing wearing only facemasks. Surveyor noted that Bell Ambulance EMT-I and Bell Ambulance EMT-K were not wearing N-95 masks, gowns or eye protection per the facility's policy and CDC guidelines. On 10/13/20 at 8:08 a.m., Surveyor observed Bell Ambulance EMT-I and Bell Ambulance EMT-J transport R8 out of the facility from the mixed wing. Surveyor noted that Bell Ambulance EMT-I and Bell Ambulance EMT-K were not wearing an N-95 mask, gowns or eye protection when walking through and exiting the mixed wing, per the facility's policy and CDC guidelines. On 10/13/20 at 10:10 a.m., Surveyor informed DON-B of the above findings. When Surveyor asked DON-B if facility staff should ensure that contractors and non-staff members wear appropriate PPE when on the mixed wing, DON-B agreed that facility staff should ensure contractors and non-staff members wear appropriate PPE when on the mixed wing. 4. Facility Screening Facility policy, under the Procedure section, documents; 2. Active Screening for All Resident and Essential HCP (health care providers) entering the facility: (a) Active Screening: Take temperature, assess for any respiratory symptoms, assess for any possible exposure to confirmed COVID-19; (c) For essential HCP (Health Care Providers) (both direct and non-direct patient care staff) entering the facility: Active screening to be conducted at the start of each shift as employee enters through door 2. On 10/12/20 at 8:02 a.m., Surveyor entered the facility thought the main entrance. Surveyor did not observe any facility staff actively screening visitors at the main door. While Surveyor observed a thermometer and a sign in sheet asking for signs and symptoms of COVID-19, Surveyor noted that the thermometer at the entrance was not functional. After some adjustment with the thermometer and getting it to reset, Surveyor was able to get a temperature reading on the thermometer before entering the facility. Surveyor noted that while the thermometer had reset, facility staff members were not actively screening visitors at the entrance to the facility. Surveyor was unsure if the thermometer remained functional after it was reset. On 10/12/20 at 8:59 a.m., another Surveyor was able to enter the facility through the main entrance without having her temperature taken. Surveyor noted that the thermometer at the entrance of the facility was not working at the time. Once the Surveyor was inside the facility, RN (Registered Nurse)-C came into the conference room and requested that she take the temperature of the Surveyor. On 10/12/20 at 9:08 a.m., Surveyor observed the entrance to the facility continue to not have any facility staff actively screening visitors at the main door. Surveyor noted that per the facility's policy and CDC recommendations, facility staff should be actively screening visitors for signs and symptoms of COVID-19. On 10/12/20 at 2:30 p.m., Surveyor informed DON-B of the above findings. DON-B informed Surveyor that she would set up a donning and doffing station at the entrance of the facility along with a working thermometer. The facility's failure to implement infection prevention and control measures to prevent the spread of COVID-19 created a finding of immediate jeopardy because of the ease with which [MEDICAL CONDITION] can spread and because of the serious effects it can have on the elderly and those with compromised systems. The immediate jeopardy was removed on 10/13/20 when the facility took the following action: - Reviewed the facility's COVID-19 policy to ensure it is current. - All nurses/designee have been educated on proper screening of staff and visitors entering the building. A new thermometer has replaced the thermometer that was not working correctly. - Staff were educated on what Personal Protective Equipment (PPE) to wear and how to wear it properly, including donning and doffing PPE, when working with residents who have been tested positive for Covid-19 and residents who do not have Covid-19. - Signs were placed at the front door regarding wearing PPE on all units. Staff were educated on the importance of following all guidance (regarding PPE) listed on the signs. - Staff were educated on ensuring Residents who are positive for Covid-19 have the doors to their rooms closed. - A Quality Assurance Committee Designee will conduct random audits on Resident Units ensuring staff are wearing the appropriate PPE and wearing it correctly. - Audits will be done on the screening of staff and visitors to ensure the screening is being done correctly. - Audits will be performed daily times for 2 weeks, then weekly for 8 weeks and then monthly for 3 months.

Based on record review and staff interview, the facility did not immediately inform a resident's physician and POA-HC (Power of Attorney for Healthcare), with a clinical change of condition. This was observed with 1 (Resident #12) of 15 supplemental resident reviews. * On 3/29/16 at 11:30 p.m., Resident #12 had an elevated temperature, pulse and respiratory rate, along with body shakes and a decreased oxygen saturation. Resident #12 received treatments of oxygen and [MEDICATION NAME]. Resident #12's physician and the POA-HC were not immediately notified of this change in condition and was not treated with antibiotics until 12 1/2 hours later in the hospital. Resident #12's physician was not notified of Resident's change in condition until 3/30/16 at 11:00 a.m. (11 1/2 hours later). Resident #12 was transported from the facility to the hospital on [DATE] at 12:00 p.m. (12 1/2 hours later.) Findings include: The CDC's (Centers for Disease Control and Prevention) current standards of practice [MEDICAL CONDITION], includes that this occurs most often in people [AGE] years and older.[MEDICAL CONDITION] is a complication caused by the body's overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure and death. The symptoms [MEDICAL CONDITION] include: shivering, fever, short of breath and high heart rate.[MEDICAL CONDITION] is usually treated in the hospital with antibiotics to prevent the infection from causing damage to the body. Resident #12's medical record was reviewed by Surveyor # . Resident #12 is [AGE] years old with [DIAGNOSES REDACTED]. The complaint indicated that the POA-HC was not notified of a change in condition. Resident #12 was currently receiving [MEDICATION NAME] for chest congestion that was prescribed on 3/24/16. Resident #12's Nurses note, by LPN-L (Licensed Practical Nurse) on 3/29/16 at 11:30 p.m., indicates Resident #12 was in bed shaking uncontrollably, temperature of 102.8 degrees Fahrenheit, pulse 112, respiration rate 32, blood pressure 148/88 and oxygen saturation of 86% on room air. Resident #12 was placed on oxygen at 2 liters a minute and received [MEDICATION NAME]. The Nurses note indicates the physician was paged, however, does not include physician response. The Nurses note does not include that the legal representative was notified of these symptoms and the treatment. Resident #12 Nurses note, by LPN-L on 3/30/16 at 1:30 a.m. indicates Resident #12 was found on the floor during rounds trying to go to the bathroom. Resident #12's temperature was 99 degrees Fahrenheit, pulse 102, oxygen saturation of 93% on 2 liters of oxygen. Resident #12 required staff assist to the bathroom due to inability to stand unassisted. Resident #12's physical functioning included standing on own and self ambulation. Resident #12 received a small size hematoma on the left elbow and a scratch on the right elbow. Resident #12's Fall Investigation Form, completed by LPN-L on 3/30/16 at 1:30 a.m. indicates the physician and legal representative were notified of the fall. There is no documentation that includes the physician and legal representative were made aware of Resident #[MEDICAL CONDITION] symptoms or inability to stand unassisted. Resident #12's Nurses note on 3/30/16 at 11:00 a.m., indicates Resident #12 was noted to have increased temperature with possible rigors, temperature 98.9 degrees Fahrenheit, oxygen at 2 liters a minute, confused and combative. The physician was contacted and Resident #12 was sent to the hospital emergency room . The legal representative was notified of the hospital transfer. Resident #12's Nurses note on 3/30/16 at 12 p.m. indicates Bell Ambulance present to transfer to (hospital name.) Resident #12's Nurses note on 3/31/16 at 11:00 a.m. indicates Resident #12 was admitted to the hospital with [REDACTED]. Resident #12's Transfer Form for Resident #12's hospital transfer on 3/30/16, indicates symptoms of tremors, temperature, lethargic and increased confusion. Resident #12's typical mobility status is independent with toileting and ambulation. Resident #12 did not return to the facility and elected a different nursing home. On 10/27/16 at 11:46 a.m., Surveyor # spoke with DON-C (Director of Nurses) with MR-G (Medical Records) during the facility's Infection Control program task. Surveyor # showed DON-C Resident #12's Nurses note on 3/29/16 with symptoms of [MEDICAL CONDITION] and not being sent out for treatment until 12 hours later on 3/30/16. DON-C indicated they would look into it what occurred and the facility's policy and procedure for change of condition was requested. On 10/27/16 at 3:15 p.m., DON-C provided the facility's policy and procedure for Change in Condition dated 12/12/11. The Change in Condition procedures includes, contacting the physician and responsible party with in 1 hour of the change; significant changes in condition require immediate reporting to a RN (Registered Nurse). These procedures were not followed with Resident #12's change of condition. DON-C indicated that LPN-E (Licensed Practical Nurse) was trying to get a hold of LPN-L that worked on 3/29/16, otherwise did not have additional information at this time. On 10/31/16 at 10:40 a.m., LPN-E spoke with Surveyor # . LPN-E was not able to contact LPN-L who worked on 3/29/16 and doesn't know why they didn't address the change in condition. LPN-E indicated the facility contacts the physician and POA (power of attorney) with changes of condition. LPN-E did not have additional information, nor was the Nurse able to be contacted. On 10/31/16 at 3:50 p.m. at the facility exit meeting Surveyor # shared the concerns with Resident #12's change of condition. No additional information was provided.

Based on observation, record review and staff interviews, the facility did not provide appropriate care with a resident change in condition, and appropriate care, with services, for residents with dementia to maintain their highest practicable physical, mental, and psychosocial well-being, along with a comprehensive assessment and plan of care. This was observed with 1 (Resident #12) of 15 supplemental residents and 5 (Resident #9, #11, #6, #3 and #8) of 11 sampled residents. * Resident #12 had a change of condition on 3/29/16 at 11:30 p.m. that was not comprehensively assessed for appropriate interventions, along with administering treatment without a physician order. Resident #12 was hospitalized 12 1/2 hours later [MEDICAL CONDITION] on 3/30/16 at 11:00 a.m. * Resident #11 has dementia with behaviors that were not comprehensively assessed, and was not care planned with individualized approaches developed, including behavioral interventions for staff to consistently follow. Resident #11 had a behavioral episode on 10/2/16 that resulted in a facial injury (nose bleed with negative nasal fracture X-ray) during an altercation with facility staff on 10/2/16. The facility staff had no behavioral interventions to follow to deter or safely manage adverse resident behavior. The facility was relying on psychoactive medication to control resident behaviors. The lack of assessment and care planning to assist resident's behaviors resulted in actual harm to Resident #11. Resident #9, #6, #3 and #8 are receiving anti-psychotic medications for dementia care and do not have a comprehensive assessment of their dementia, along with an individualized plan of care. Example 1, regarding Resident #12, rises to a scope and severity level of a G (actual harm/isolated). Findings include: 1. The CDC (Centers for Disease Control and Prevention) current standards of practice [MEDICAL CONDITION], includes that this occurs most often in people [AGE] years and older.[MEDICAL CONDITION] is a complication caused by the body's overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure and death. The symptoms [MEDICAL CONDITION] include: shivering, fever, short of breath and high heart rate.[MEDICAL CONDITION] is usually treated in the hospital with antibiotics to prevent the infection from causing damage to the body. Resident #12's medical record was reviewed by Surveyor # due to a complaint intake. Resident #12 is [AGE] years old with [DIAGNOSES REDACTED]. Resident #12 was currently receiving [MEDICATION NAME] for chest congestion that was prescribed on 3/24/16. Resident #12 Nurses note, by LPN-L (Licensed Practical Nurse) on 3/29/16 at 11:30 p.m., indicates Resident #12 in bed shaking uncontrollably, temperature of 102.8 degrees Fahrenheit, pulse 112, respiration rate 32, blood pressure 148/88 and oxygen saturation of 86% on room air. Resident #12 was placed on oxygen at 2 liters a minute and received [MEDICATION NAME]. The Nurses note indicates the physician was paged, however; does not include physician response. The Nurses note does not include an RN assessment or notification of these symptoms. The LPN-L applied oxygen treatment without physician orders, and failed to contact an RN and physician, with a change in Resident #12 medical condition. Resident #12 had a physician visit on 3/24/16. Resident #12's vital signs this week were: temperature of 98.6 degrees Fahrenheit, pulse 76, respirations 19, blood pressure 120/60 and oxygen saturation 96% on room air. The physician note does not include use of oxygen therapy. The monthly physician plan of care of medications and treatments, does not include oxygen treatment orders. Resident #12's Nurses note, by LPN-L on 3/30/16 at 1:30 a.m. indicates Resident #12 was found on the floor during rounds trying to go to the bathroom. Resident #12's temperature is 99 degrees Fahrenheit, pulse 102, oxygen saturation of 93% on 2 liters of oxygen. Resident #12 required staff assist to the bathroom due to unable to stand unassisted. Resident #12's physical functioning included standing on own and self ambulation. Resident #12 received a small size hematoma on the left elbow and a scratch on the right elbow. Resident #12's Fall Investigation Form on 3/30/16 at 1:30 a.m. indicates the physician and legal representative were notified of the fall. There is no documentation that includes the physician and legal representative were made aware of Resident #12'[MEDICAL CONDITION] symptoms or inability to stand unassisted. Resident #12's Nurses note on 3/30/16 at 11:00 a.m., indicate Resident #12 noted to have increased temperature with possible rigors, temperature 98.9 degrees Fahrenheit, oxygen at 2 liters a minute, confused and combative. The physician was contacted and Resident #12 was sent to the hospital emergency room . The legal representative was notified of the hospital transfer. Resident #12's Nurses note on 3/30/16 at 12 p.m. indicates Bell Ambulance present to transfer to (hospital name.) Resident #12's Nurses note on 3/31/16 at 11:00 a.m. indicate Resident #12 was admitted to the hospital with [REDACTED]. Resident #12's Transfer Form for Resident #12's hospital transfer on 3/30/16, indicates symptoms of tremors, temperature, lethargic and increased confusion. Resident #12's typical mobility status is independent with toileting and ambulation. Resident #12 did not return to the facility and elected a different nursing home. This was information provided by the complaint intake and Discharge Summary in Resident #12's medical record. On 10/27/16 at 11:46 a.m., Surveyor # spoke with DON-C (Director of Nurses) with MR-G (Medical Records) during the facility's Infection Control program task. Surveyor # showed DON-C Resident #12's Nurses note on 3/29/16 with symptoms of [MEDICAL CONDITION] and not being sent out for treatment until 12 hours later on 3/30/16. DON-C indicated they would look into it what occurred and the facility's policy and procedure for change of condition was requested. On 10/27/16 at 3:15 p.m. DON-C provided the facility's policy and procedure for Change in Condition dated 12/12/11. DON-C indicated that LPN-E (Licensed Practical Nurse) was trying to get a hold of LPN-L that worked on 3/29/16, otherwise did not have additional information at this time. The Change in Condition procedures include, contacting the physician and responsible party with in 1 hour of the change; significant changes in condition require immediate reporting to a RN (Registered Nurse). These procedures were not followed with Resident #12's change of condition. On 10/31/16 at 10:40 a.m., LPN-E spoke with Surveyor # . LPN-E was not able to contact LPN-L who worked on 3/29/16 and doesn't know why they didn't address the change in condition. LPN-E indicated the facility contacts the physician and POA (power of attorney) with changes of condition. LPN-E did not have additional information, nor was LPN-L able to be contacted for information. On 10/31/16 at 3:50 p.m. at the facility exit meeting Surveyor # shared the concerns with Resident #12 change of condition. No additional information was provided. 2. Resident #9's medical record was reviewed by Surveyor # . Resident #9 has resided in the facility since 8/19/16 with [DIAGNOSES REDACTED]. There was no comprehensive assessment, and no individualized plan of care, related to these diagnoses, except medication. Resident #9 Admission MDS (Minimum Data Set) assessment, completed on 9/7/16, does not indicate any mood or behaviors. The MDS indicates moderate cognitive impairment and received 7 days of anti-psychotic medications. The CAA (Care Area Assessment) for [MEDICAL CONDITION] Medication indicates Resident #9 receives anti-psychotic and [MEDICAL CONDITION] medication for delusional disorder and organic mood disorder. The CAA does not include a comprehensive assessment of the indicators for the medication related to the diagnoses, and what behaviors they are needed for. Resident #9's assessment does not contain a history, and use, of the medications with these diagnoses. Resident #9's plan of care for Psychoactive Drug Use, dated 8/29/16 and 9/5/16, indicates Resident #9 diagnoses, [MEDICAL CONDITION] and anti-psychotic medication. The plan of care does not identify what Resident #9 behaviors are regarding delusional disorder, dementia and organic mood disorder, or for the use of anti-psychotic and [MEDICAL CONDITION] medications. The plan of care does not include non-pharmacological or other interventions to be used for Resident's behaviors. Resident #9 Behavior /Intervention Monthly Flow Record for October 2016 was reviewed by Surveyor # . The behavior indicated is Hallucinations, along with the definition of a hallucination. The log does not contain specific behaviors, nor individualized interventions for the behavior. The log does not show any behaviors of hallucinating for the month of October. The log does not include any other behaviors or interventions. Resident #9's Psychoactive Medication Assessment Form, completed 8/29/16, does not include any behaviors related to the use for [MEDICAL CONDITION] and anti-psychotic medication, nor behavior interventions besides medication. This includes Resident #9 [DIAGNOSES REDACTED]. The medications used are [MEDICATION NAME] 12.5 milligrams every day and [MEDICATION NAME] 125 milligrams twice a day for these diagnoses. On 10/31/16 at 10:25 a.m., Surveyor # spoke with RN-H (Registered Nurse) and LPN-E (Licensed Practical Nurse). Surveyor # shared Resident #9's assessment and plan of care for [DIAGNOSES REDACTED]. LPN-E indicated that everything is in the medical record and there is no additional information elsewhere. On 10/31/16 at 3:50 p.m. at the facility exit meeting Surveyor # shared the assessment and plan of care concerns with Resident #9's [DIAGNOSES REDACTED]. 3. Resident #11's medical record was reviewed by Surveyor . Resident #11 has a [DIAGNOSES REDACTED]. Resident #11 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), dated [DATE] indicates resident is having behavioral episodes that include physical behavior symptoms towards others. The plan of care dated 8/5/16 indicates Resident having problems with mood, behavior and psychosocial well being. The goal is that resident will be comfortable with placement without increase or signs/symptoms of [DIAGNOSES REDACTED]. The interventions listed on this care plan speak to Resident daily documentation of behaviors via flow sheets and if behavioral interventions are unsuccessful, to administer as needed medications as ordered. There is no evidence that a comprehensive assessment into resident's Dementia has been conducted in order to formulate individualized behavioral interventions for Resident #11. The plan of care indicates to administer pyschopharmacological medications if the behavioral interventions are unsuccessful, however; there have been no individualized behavioral interventions formulated to assist Resident #11 with preventing behavior or coping with his behavioral problems before there is acting out behavior towards others. On 3/30/16, Resident #11 had dosage increases of [MEDICATION NAME] and [MEDICATION NAME] with an order to give [MEDICATION NAME] as needed. Social services documentation indicated that Resident #11 was on a wait list with the Veterans Administration (VA) for a memory care unit. The VA had indicated to the guardian that resident presented to the VA for a zombie-like state. The facility documented that resident was having combative behaviors at the facility necessitating medication increase to control behaviors. Social services documented concerns that the VA would continue to decrease medications and the nursing facility team was concerned about everyone's safety. On 5/11/16, Resident #11 was seen by a psychiatrist which describes resident's behaviors to all be under good control, with no signs of thought disorder, [MEDICAL CONDITION] nor no emergent new onset of organic mental disease. Mood is described as stable. A reduction of the [MEDICATION NAME], an antipsychotic medication, was attempted from 25 mg twice daily to 25 mg one time a day. This dose reduction did not get initiated until 7/7/16. On 7/16/16, Resident had behavior escalation and was sent to the hospital. The [MEDICATION NAME] dosage was increased back to 50 mg twice daily and resident was started on an Anti anxiety medication, [MEDICATION NAME] at this time along with [MEDICAL CONDITION] medications. The October Medication Administration Record [REDACTED]. On 10/2/16, Resident had a behavioral episode at 8:30 PM in the activity room. Resident became combative and caused a self injury to his nose, causing it to bleed. The incident was described as resident was taken back to his room by nurse aide CNA-Q, resident continued to swing his arms and resident struck self while being taken back to his room. The CNA was trying to redirect resident. On 11/01/16 at 3:09 PM, Surveyor interviewed CNA-Q about this incident. CNA-Q told Surveyor that every time resident becomes combative, it would just happen and the staff try to keep him away from other residents. CNA-Q told Surveyor that Resident #11 became agitated in the dining room and punched CNA-Q in the stomach as CNA-Q was getting resident ready for bed. CNA-Q said he was warned by another nursing assistant that resident was agitated and when CNA-Q approached resident, the resident walked up to him and punched him. CNA-Q then began to take resident to his room to lay him down. CNA-Q told Surveyor that he was moving resident down the hallway and when they had gotten down toward his room, the resident began to swing at CNA-Q and CNA-Q was standing behind him while CNA-Q was catching his (Resident's) arms. CNA-Q said after he got resident into his room, CNA-Q then pivot transferred him (resident) onto the bed and resident then began to stop fighting with CNA-Q and that is when CNA-Q noticed Resident's nose to be bleeding. A review of the behavioral sheets for this date, 10/2/16, indicate no adverse behaviors documented. There is also documentation that on 10/22/16 at 4:30 PM, Resident #11 had a behavioral occurrence where resident was in the supervised dining room, resident removed his shoe and went over to a staff member and began hitting the staff member with his shoe, then backed up and sat down. The police were called related to this incident but refused to take resident to the emergency room . The resident was seen at the VA and resident was diagnosed with [REDACTED]. The hospital record indicated resident had been increasingly agitated over the last few days, exhibiting aggressive violent behavior towards staff. The resident was described as very agitated when evaluated and exhibiting physical aggression towards nursing staff. The VA indicated resident had a long standing history of advanced Alzheimers Dementia with organic mood disorder, depression and delusional. There is documentation in the hospital record that the nursing home refused readmission because there was not enough staffing to accept patient until morning. Resident was monitored for agitation, requiring a 1:1 sitter for handful of hours until resident could be discharged . On 10/25/16, Resident was discharged back to the nursing home with recommendations from the hospital to please keep a good sleep/wake cycle with patient, lights on at 6:30 AM and off at 9:00 PM and minimize stimuli during sleeping hours. On 10/31/16, Surveyor reviewed the medical record and found no revision of the plan of care, no instructions for staff on how to safely manage Resident #11's behaviors since this period of agitation and aggressive episodes on 10/2/16 and 10/22/16. 4. Resident #6's medical record was reviewed 10/25/16-11/1/16 by Surveyor . Resident #6 has a [DIAGNOSES REDACTED]. Resident #6 was admitted to the facility at the end of March, 2016, and receives kidney [MEDICAL TREATMENT] 3 times a week for the last [AGE] years. Resident was then discharged back to the hospital in July of 2016 [MEDICAL CONDITION] with altered mental status and [MEDICAL CONDITION] that is gradually improving. While hospitalized , resident developed confusion and unresponsiveness and the geriatric physician wrote on 7/28/16 that resident had been expressing behavior symptoms such as yelling out multiple times, but when answered, she answers appropriately. At the time of this hospitalization , this physician recommended a dose of Risperidal. 0.25mg, twice a day only on an as needed basis for significant agitation during hospitalization . This physician assessment indicated resident was having delerium that was improving. This physician also recommended non-pharmacological (no drugs) interventions and a small dose of pharmacological intervention like [MEDICATION NAME] as needed and [MEDICATION NAME] (antianxiety medication). Other behavior documented in the hospital record indicated that resident was agitated, shouting out loudly that she wants to go home. A review of Resident's current medication regime was conducted during this survey. Resident is receiving [MEDICATION NAME] 0.5 mg twice daily and scheduled, this dose has been in place since 9/8/16. This is twice the dosage she received in the hospital in July, 2016. Surveyor also observed no current quantitative behavior monitoring occurring in the medical record during the month of September with identified target behaviors being monitored or number of episodes behavior was occurring. There is no evidence the facility assessed the resident's underlying conditions, current signs and symptoms, preferences and goals for treatment to deliver care that is not dependent on the use of antipsychotic medications for a resident with Dementia. There is no evidence of a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized, person-centered care interventions outside of the use of antipsychotic medications to assist Resident #6 in managing her behavior. On 9/9/16 a Behavior Care Area Assessment (CAA) was completed following a MDS assessment. This CAA indicated that resident calls out when daughter is not present and resident was having physical behaviors such as resisting cares. The analysis of the problem includes resident having [DIAGNOSES REDACTED]. Resident strikes out during cares and screams help me when daughter is not present. Resident is able to speak clearly and express needs. The care plan considerations indicate that resident will be comfortable and at ease with current placement and will express her needs in an appropriate manner X 90 days. The goal does not address how the facility will plan care to minimize behaviors without the use of psychoactive medications for this resident with Dementia. On 9/26/16, Resident #6 denied any pain when assessed and continues to receive [MEDICAL TREATMENT] 3 times a week, receiving narcotic pain medication prior to [MEDICAL TREATMENT]. Monthly documentation titled, review of care indicates in August, September and October of 2016, resident had increased agitation when daughter is not present, calling out repeatedly when daughter not present with calling out repeatedly with difficulty to redirect at times. A review of October, 2016 behavior monitoring sheets has no daily behaviors being documented. There is no quantitative documentation in the current medical record. All of the behavior sheets are blank and there is no listed behavior for staff to observe for and no way to indicate how often or when these behaviors are occurring. The plan of care dated 9/26/16 for Resident #6 identifies a problem listed for Resident #6 that resident has a need for psychoactive medications and therefore a potential for discomfort secondary to side effects. The care plan also addresses resident having a [DIAGNOSES REDACTED]. The plan of care indicates resident's use of anti anxiety medications, Duloxetine, [MEDICATION NAME], anti depressant medications, Trazadone and the use of [MEDICATION NAME]. The plan of care also indicates resident to have a psychiatric consult as needed. A consent to see a psychiatrist was signed by on 7/29/16 the family, however; there is still no evidence resident has yet to be seen by a psychiatrist. Interventions listed on the plan of care indicate that resident should be removed from situations causing distress if possible and if behavioral interventions are not successful in reduction of problem behaviors, then to administer as needed medications as ordered. The plan of care does not address any behavioral interventions for staff to follow to assist resident to reduce behaviors in a non pharmacological method as recommended by the geriatric physician while resident was hospitalized in July, 2016. On 10/26/16 at 4:15 PM, Surveyor interviewed the family that visits Resident #6 and discussed resident behaviors with the family. The family acknowledged resident becoming agitated when family was not around and knew of this behavior. The family indicated that interventions such as music may help resident as resident enjoyed listening to music, southern gospel and church hymns prior to coming to the nursing home. The family member indicated she thought the facility was doing this for Resident #6 and the facility was going to bring in music for her to listen to. An interview was conducted with the Activity Therapist - M on 10/31/16 at 11:35 AM. Activity Therapist indicated that the facility has received a grant for the music and memory initiative and the therapist has 8 iPods and shares them between residents. The therapist indicated having different music genre's on the iPods and the therapist has a list of residents that are involved in this program. The therapist indicated that for resident's having agitation, she has spoken with family members to find out the music that the residents like. The therapist then indicated that the iPods are available from 8-4:30 each day, then she locks them up because 2 of them have been stolen. The therapist indicated that these could be made available after 4:30 PM, but she had not thought of that for residents having evening behaviors. Activity Therapist-M indicated she had attempted to have Resident #6 listen to Christian music on one of the iPods, but she thinks it was a Christian rock style music and it agitated resident. The Activity Therapist indicated that resident enjoyed singing songs in activity sessions such as sing along songs. Activity Therapist indicated she had not tried sensory stimulation type activities and resident did not do well in group activities because she calls out for her daughter. On 9/5/16 a social services notation indicated that resident continues to have episodes of yelling out when daughter is not present and daughter is requesting resident to stay in the facility. There is no documentation of quantitative targeted behaviors in September on the MAR. There are no behavioral interventions to assist resident with behavior reduction outside of the use of psychoactive medications. 5. Resident #3's medical record was reviewed 10/25 - 11/1/16 by Surveyor # . Resident #3 has a [DIAGNOSES REDACTED].#3 was being monitored for delusions that were evidenced by: increased irritability, statements of suspicions, refusal of cares, and striking out at staff. Resident #3 was currently receiving the anti-psychotic medication, [MEDICATION NAME], to treat his behaviors. (See F329) Surveyor # reviewed Resident #3's medical records to determine what non-pharmacological approaches were being used to address Resident #3's behavior. There was no evidence that the facility had comprehensively assessed Resident #3's Dementia and related behaviors. Resident #3 had a Significant Change Minimum Data Set (MDS) completed on 1/11/16. Resident #3 was noted to have verbal behaviors. This triggered a further assessment of his behaviors. The Behavioral Symptoms Care Area Assessment (CAA) was completed by the facility on 1/19/16. The assessment was not complete. The following areas were blank: Nature of the behavioral disturbance; Behaviors; Factors that can cause or exacerbate the behavior; and Other considerations. The Analysis of Findings section indicated: .He has history of behaviors, none recently. Resident #3 had a Quarterly MDS completed on 8/19/16, indicating that he had no behaviors. There was no other assessment of Resident #3's Dementia and related behaviors in the medical record. There was no evidence that the facility had developed a care plan with individualized approaches to address Resident #3's behaviors associated with his Dementia. Resident #3's behavior care plan, dated 6/6/16, had a goal that his wandering, resistance to cares, inappropriate touching, and yelling out would not increase. The care plan did not provide specific approaches for staff to use when Resident #3 displayed these behaviors. The interventions were general and not specific to Resident #3: Provide reassurance and redirection as needed. Redirect and Re-approach as needed. Encourage resident to attend activities of choice. Provide an explanation of care prior to beginning. One of the approaches that was listed was an assessment and not an intervention that could be used when Resident #3 displayed behaviors: Learn personal history, past routines, likes/dislikes and what is comforting to the resident. This assessment information should have been obtained prior to the development of the care plan and listed in the care plan. This information was shared with Administrator - A and Director of Nursing - C (DON - C) on 10-31-16 at 3 PM. Administrator - A and DON - C were unable to provide information to show that the facility had comprehensively assessed Resident #3's Dementia and associated behaviors and had developed an individualized care plan to address these behaviors. 6. Resident #8's medical record was reviewed 10/31 - 11/1/16 by Surveyor # . Resident #8 has a [DIAGNOSES REDACTED].#8 was being monitored for delusions that were evidenced by: increased irritability, statements of suspicions, refusal of cares, and striking out at staff. Resident #8 was currently receiving the anti-psychotic medication, [MEDICATION NAME], to treat her behaviors. (See F329) Surveyor # reviewed Resident #8's medical records to determine what non-pharmacological approaches were being used to address Resident #8's behavior. There was no evidence that the facility had comprehensively assessed Resident #8's Dementia and related behaviors. Resident #8 had a Readmission Minimum Data Set (MDS) completed on 1/18/16 noting that Resident #8 displayed the following behaviors: physical, verbal, other, and rejects care. This triggered further assessment and the Behavioral Symptoms Care Area Assessment (CAA) was completed by the facility on 2/23/16. The assessment was not complete. The assessment did not address the Nature of the behavioral disturbance; Behaviors; Factors that can cause or exacerbate the behavior; and Other considerations. Resident #8 had a Quarterly MDS completed on 8/19/16, indicating that the following behaviors continued: physical, verbal, other, and rejects care. There was no other assessment of Resident #8's Dementia and related behaviors in the medical record. There was no evidence that the facility had developed a care plan with individualized approaches to address Resident #8's behaviors associated with her Dementia. Resident #8's behavior care plan, dated 8/19/16, had a goal that her wandering and resistance to cares would not increase. The care plan did not provide specific approaches for staff to use when Resident #8 displayed these behaviors. The interventions were general and not specific to Resident #8: Provide reassurance and redirection as needed. Redirect and Re-approach as needed. Encourage resident to attend activities of choice. Provide an explanation of care prior to beginning. One of the approaches that was listed was an assessment and not an intervention that could be used when Resident #8 displayed behaviors: Learn personal history, past routines, likes/dislikes and what is comforting to the resident. This assessment information should have been obtained prior to the development of the care plan and listed in the care plan. This information was shared with Administrator - A and Director of Nursing - C (DON - C) on 10-31-16 at 3 PM. Administrator - A and DON - C were unable to provide information to show that the facility had comprehensively assessed Resident #8's Dementia and associated behaviors and had developed an individualized care plan to address these behaviors.

Based on record review and staff interview, the facility did not ensure that the resident environment remains as free from accident hazards as is possible for 2 (Resident #3 and #1) of 6 sampled residents. The facility did not investigate 2 of 2 resident accidents (Resident #3 and Resident #1) to determine the cause of the accident and implement interventions that addressed the causes. * Resident #3 uses a Broda chair for mobility. On 6/06/15 the resident was being assisted with mobility from the activity room to the bedroom. The resident sustained [REDACTED]. The facility did not evaluate and analyze the information gathered to identify the underlying cause of the laceration. * The facility did not thoroughly investigate the fall Resident #1 sustained on 8/18/15 and did not interview staff to assess the root cause or circumstances surrounding this fall. Example 1 regarding Resident #3 rises to a scope and severity level of G (harm/isolated.) Findings include: 1. On 1/26/16, Surveyor # reviewed Resident #3's closed medical record. The record indicates the Resident has Multiple Sclerosis with [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE], indicate Resident #3 is cognitively intact, is dependent on 2 staff for transfers, and utilizes a wheelchair for mobility. The Total Plan of Care (original date of 11/14/14 and updated on 1/28/15, 4/21/15, 5/29/15 and 8/17/15) indicates the Resident is non-weight bearing and uses a Broda chair for mobility. The Nurses Notes dated 6/06/15 at 2:00 p.m., indicates Registered Nurse (RN)-E was called to the Resident's room to evaluate bleeding to the Resident's left foot. The note indicates the RN noted a laceration on the undersides of the left second, third and fourth toes. The note indicates a pressure dressing was applied, the physician was notified and the Resident was sent to the hospital emergency room . The Emergency Department notes, dated 6/06/15 at 3:49 p.m., indicate the resident had near amputation of 2nd and 3rd toes with laceration to last digit. The notes indicate that per the Resident, the facility drove the wheelchair into something. The Nurses Noted dated 6/06/15 at 8:50 p.m. indicates the Resident returned from the hospital with stitches to the laceration that are to be removed in 7-10 days. The Incident Investigation Form, dated 6/06/15, indicates that on 6/06/15 at 1:30 p.m., the Resident was being transported to her room by a Certified Nursing Assistant (CNA) in Broda Chair when her chair bumped into the doorway. One Incident Report Witness Statement was obtained. The obtained statement, dated 6/06/15, was completed by CNA-F was reviewed. The description of the incident states while taken the Resident to her room the front of her chair hit the door cutting her left toes. There was no additional documentation that would indicate the facility thoroughly investigated the cause of the laceration; and evaluated and analyzed the information gathered to identify the underlying cause of the laceration. On 1/27/16 at 10:25 a.m., Surveyor # spoke with RN-E who indicated that on 6/06/15 the resident sustained [REDACTED]. RN-E indicated the laceration occurred when the Resident was being pushed into her room in the Broda chair. RN-E indicated that the CNA called her to assess the Resident immediately after the occurrence. RN-E indicated that when she went to assess the Resident, the Resident was in the Broda chair, with both of the Resident's legs properly positioned on the chair's leg rest, and that the left foot was observed to be bleeding. On 1/27/16 at 11:00 a.m., Surveyor # spoke with Certified Nursing Assistant (CNA)-F who indicated on 6/06/15, when he was pushing the Resident's Broda Chair from the Activity Room to the Resident's bedroom, the Resident toes hit the wall or the backside of the door. CNA-F indicated the Resident's legs and feet were on the Broda chair at the time of the occurrence. CNA-F indicated the resident's feet shifted over and the resident sustained [REDACTED]. CNA-F indicated he was not sure how the Resident's toes got lacerated. On 1/28/16 at 9:00 a.m., Surveyor # spoke with Maintenance Director-G who indicated he was notified that the resident sustained [REDACTED]. Maintenance Director-G indicated that he fixed a loose plastic strip on the lower right corner of the Resident's doorframe. Maintenance Director-G indicated there was no documentation of the repair or the date it was repaired. On 1/28/16 at 9:30 a.m., Surveyor # and Maintenance Director-G observed the room Resident #3 resided in. The frame to the doorway was smooth and had no sharp edges. There was a small nail in the bottom right corner that was used to secure a plastic strip (the resident's laceration was on the bottom of the left foot) On 1/28/16 at 10:45 a.m., Surveyor # spoke with Director of Nurses-(DON)-B who indicated that on 6/06/15, the Resident's foot fell off the Broda Chair leg rest while CNA-F was transporting the Resident into her room. DON-B indicated it was determined that the resident sustained [REDACTED]. DON-B indicated the facility completed an incident Investigation Form and obtained a witness statement from CNA-F. DON-B indicated that a statement was not obtained from the Resident or from other staff working on the unit. DON-B indicated there was no documentation regarding the notification of the need to evaluate the condition the doorframe or the work completed by the maintenance department. DON-B indicated there was no additional documentation that would indicate the facility thoroughly investigated the cause of the laceration; and evaluated and analyzed the information gathered to identify the underlying cause of the laceration. 2. On 1/26/16, Surveyor # began investigation of complaint related to Resident #1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Significant change and Quarterly Minimum Data Set assessments ((MDS) dated [DATE] and 11/11/15 indicate Resident #1 had a BIMS (Brief Interview for Mental Status) score of 5, with cognitive impairment noted. The complainant alleged that on 8/18/15, Resident #1 fell out of her wheelchair while in the activity room with a puddle of urine found under her wheelchair at the time of her fall. The complainant is concerned that Resident #1 was not being properly supervised. Surveyor # reviewed Incident Investigation Form dated 8/18/15 which indicates Resident #1 had sustained a fall (no injury) in a supervised room. The Incident Investigation Form/report indicates that Resident #1 was sitting in her wheelchair when a (CNA) Certified Nursing Assistant turned to adjust the TV, then found the Resident lying on the floor on her right side with a puddle of urine observed under her wheelchair. The Incident Investigation Form/report does not include any statements from staff or attempts to obtain a statement from the Resident. The circumstances of the fall are unclear and how it may have been prevented. The Incident Investigation Form/report also does not indicate when the last time the Resident was toileted, if the Resident was wet at the time of the fall, and where the urine came from that was observed under her wheelchair. There is also no indication of Resident #1's behavior prior to the fall or if she had requested to be toileted prior to the fall. On 1/26/16 at 3:00 p.m., Surveyor # interviewed DON-B who indicated that she had no additional information related to the fall sustained by Resident #1 on 8/18/15. DON-B also indicated that the facility only takes statements from staff after a fall if the fall was witnessed. On 1/28/16 at 12:44 p.m., Surveyor # conducted a phone interview with CNA-H who was present in the activity room at the time of the fall. CNA-H indicated that she and the nurse were in the activity room when she went to change the channel on the TV while the nurse was passing medications. CNA-H stated that when she turned back to Resident #1 she was standing up in her wheelchair and eased herself onto the floor. CNA-H also indicated that she does not recall seeing a puddle of urine under the CNA-H stated Resident was not wet at the time she picked her up from the floor. CNA-H also stated that the Resident was always trying to get up. At 12:59 p.m., Surveyor # conducted a phone interview with RN (Registered Nurse)-I who indicated that she was in the activity room with Resident #1 who was a frequent faller. RN-I stated that when CNA-H turned to change the TV channel, they both turned back around and found that Resident #1 was out of her wheelchair and had fallen on the floor. RN-I indicated that she immediately began assessing Resident #1 for any injuries and observed a puddle of urine under her wheelchair. RN-I also indicted that Resident #1 was very wet so CNA-H took her to the bathroom to change her at this time. RN-I also indicated that she had interviewed CNA-H about when the last time Resident #1 was toileted and she stated not too long ago. RN-I said she believes that the brief Resident #1 was wearing wasn't too good so the urine came right out of the side of the brief. RN-I indicated that the chair alarm was sounding at the time of Residents fall. Surveyor # reviewed the initial care plan for Resident #1, which had no initiation date indicated but was updated on 11/6/15 and indicated that Resident #1 is to be toileted every 2 hours, as well as before and after meals, with briefs for incontinence. The CNA care card for Resident #1 was updated on 8/18/15 with new the intervention of shortening string on alarm and the repeated previous intervention of toilet after supper. The facility did not thoroughly investigate the fall Resident #1 sustained on 8/18/15 and did not interview staff to assess the root cause or circumstances surrounding this fall. The facility was notified of these findings upon exit on 1/28/16.