Every finding on record at New Glarus Home

Based on interview and record review, the facility did not ensure that Residents were free of significant medication errors for 1 (R1) of 6 sampled residents. The facility failed to ensure a prescribed weekly Methotrexate regimen was accurately entered, verified, and administered according to the prescriber's intended frequency for R1. Evidenced by: Review of R1's discharge MDS (minimum data set), with an ARD (Assessment Reference Date) of 07/14/26, indicates R1 was admitted to the facility on [DATE] with diagnoses including arthropathic psoriasis, Type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, polyneuropathy, restrictive lung disease, and recent right conversion total hip arthroplasty with hardware removal performed on 04/09/26. R1's discharge MDS shows a BIMS (Brief Interview for Mental Status) score of 14 out of 15, indicating R1 was cognitively intact. Review of R1's Order Summary Report, revealed a prescriber order date of 04/15/26, with a start date of 04/17/26, directing nursing staff to administer six 2.5 mg [milligram] Methotrexate tablets by mouth every Friday morning for psoriatic arthrosis. The order was discontinued on 04/17/26 and rewritten to administer Methotrexate every Saturday morning beginning 04/18/26 because the medication was unavailable on the originally scheduled date. On 04/21/26, Registered Nurse (RN)1/Unit Manager entered a verbal order directing nursing staff to administer six 2.5 mg Methotrexate tablets by mouth in the evening for psoriatic arthrosis, with a start date of 04/21/26. Of Note: The 04/21/26 order did not include the intended weekly administration frequency. Review of R1's MAR (Medication Administration Record) for April 2026, revealed staff administered six 2.5 mg Methotrexate tablets to R1 on 04/21/26, 04/22/26, and 04/24/26. R1 received Methotrexate three times within four days rather than once weekly as intended by the prescriber. Review of hospital records, including the History and Physical dated 04/25/26 and a Discharge summary dated [DATE], showing a diagnosis of Accidental methotrexate poisoning, initial encounter. The records documented R1 was hospitalized following an accidental Methotrexate overdose. The hospital Discharge summary dated [DATE] documented R1 received a total of 60 mg of Methotrexate over four days rather than the intended 15 mg once-weekly regimen. Poison Control was contacted and recommended close monitoring and treatment with Leucovorin. R1 received Leucovorin 25 mg every six hours. (Leucovorin belongs to the folate analog drug class and acts as an antidote to Methotrexate toxicity.) Poison Control recommended completing 14 days of treatment and holding Methotrexate until treatment was completed. Hospital staff monitored R1's laboratory results, including complete blood count (CBC) and Methotrexate levels. R1 developed a white blood cell [NAME] (lowest point of a patient's blood cell count), with laboratory values subsequently trending toward normal, and was discharged back to the facility in stable condition. On 04/25/26, Poison Control further recommended continuing Leucovorin every six hours for three days and obtaining daily CBCs with differential to monitor the absolute neutrophil count and Methotrexate level. The hospital initially administered sodium bicarbonate to maintain a urine pH greater than 7 and later discontinued the medication per Poison Control recommendation. Initial laboratory testing revealed a hemoglobin level of 7.4, compared to a reported baseline of 7.8, and an International Normalized Ratio (INR) of 1.7. The basic metabolic panel (BMP) and lactic acid level were reported as normal. During an interview on 08/19/26 at 5:01 PM, Registered Nurse (RN)1 stated the facility required a second nurse to review and verify admission orders. RN1 stated the amended 04/21/26 Methotrexate order omitted the weekly frequency and that the omission was not identified before multiple doses were administered. RN1 stated Methotrexate became available on 04/21/26 and she contacted Nurse Practitioner (NP)1 because she did not want R1 to wait until the next scheduled administration date. RN1 stated NP1 approved changing the administration day from Saturday to Tuesday. RN1 stated she modified the existing order to Tuesday administration but did not complete the order-entry process necessary to designate Methotrexate as a once-weekly medication. RN1 stated the medication subsequently populated on the MAR as a daily medication. RN1 stated the medication error was identified on 04/25/26 when RN3/Charge Nurse discovered the error and completed the incident form. RN1 stated that RN3 then contacted the on-call provider, who directed staff to transfer R1 to the emergency department. RN1 acknowledged she did not specify in the amended order that Methotrexate was to be administered once weekly on Tuesdays. During a telephone interview on 08/20/26 at 3:51 PM, NP1 stated she approved administration of the first Methotrexate dose on Tuesday, 04/21/26, because the medication had not been available on the originally scheduled date and she wanted to avoid another missed dose. NP1 stated the medication was to continue thereafter on a once-weekly Tuesday schedule. NP1 stated she was unaware staff administered additional doses after 04/21/26. NP1 stated administration of multiple Methotrexate doses within one week rather than according to the prescribed once-weekly regimen could result in life-threatening toxicity. During an interview on 08/21/26 at 1:15 PM, Director of Nursing (DON)1 stated the facility's process at the time of the event required a second nurse to review and verify all new admission orders. DON1 stated the omission of the weekly administration frequency was not identified before staff administered multiple Methotrexate doses. DON1 stated the facility subsequently revised its process to require a second nurse to review and verify all new, amended, and changed medication orders before release from pending status. DON1 stated administration of a high-risk medication outside the intended schedule constituted a significant medication error. R1 received Methotrexate more frequently than prescribed and received 60 mg over four days rather than the intended 15 mg once-weekly dose. The medication error resulted in an accidental Methotrexate overdose requiring hospitalization, Poison Control consultation, Leucovorin rescue therapy, laboratory monitoring, and treatment for Methotrexate toxicity.

Number of residents sampled:Number of residents cited: effects the censusBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 95 residents who reside in the facility. Surveyor observed unsealed food in the freezer. Surveyor observed expired milk in circulation. Surveyor observed kitchen staff take the temperatures of food without properly cleaning the food thermometer probe. Surveyor observed kitchen staff serving food without taking the temperature. Surveyor observed food serving utensils not being used in a sanitary manner. Surveyor observed uncovered drinks being transported down the hallway during lunch tray delivery. Surveyor observed staff going into the main kitchen without beard nets on. Surveyor observed the dishwashing process. A dining aide failed to ensure proper hand washing was completed when going from dirty items to clean items in the kitchen. Surveyor observed staff wet stacking dishes and using a towel on clean dishes while observing the dishwashing process. Surveyor observed kitchen staff not knowing how to test sanitizing solution for cleaning tables to ensure the correct ppm (parts per million) sanitizer concentration. Surveyor observed Mighty Shakes to be in the refrigerator without a thaw date. This is evidenced by: Example - Unsealed foodFacility policy, titled, Food Safety Requirements, implemented 1/5/26, states in part: .c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include:. v. Keeping foods covered or in tight containers. On 3/17/26 at 9:22 AM, Surveyor completed an initial tour of the kitchen with FSD F (Food Service Director). Surveyor observed an open bag of frozen chicken breast in a box and an open bag of frozen carrots on a shelf in the freezer. FSD F said he would expect these items to be sealed. FSD F pulled them from the freezer, wrapped them in plastic wrap so they were sealed, and put them back in the freezer. Example - Expired milkFacility policy, titled, Food Safety Requirements, implemented 1/5/26, states in part: .c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include:. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded.On 3/17/26 at 9:22 AM, Surveyor completed an initial tour of the kitchen with FSD F (Food Service Director). Surveyor observed several gallons of milk that were open but not dated in the kitchen refrigerator. FSD F indicated milk is used so frequently in the facility that the process is to have staff date any open gallons of milk at the end of the day because they would have been opened that morning. Three gallons of Vitamin D milk were open and had a use by date of 3/14/26. FSD F pulled all three gallons from the refrigerator to discard the milk. FSD indicated per their process, the milk must have been opened and used that morning since it had not been dated the night before. FSD F indicated this milk should not have been used past the date of 3/14/26.On 3/18/26 at 12:00 PM, FSDM G (Food Service District Manager) indicated FSD F had started an in-service training with staff regarding food labeling and dating.On 3/19/26 at 10:21 AM, Surveyor observed a partially used gallon of skim milk in the refrigerator on the 500 wing of the facility with a use by date of 3/18/26.On 3/19/26 at 10:25 AM, Surveyor met with FSD F and told him about the expired milk. FSD F indicated he would have expected staff to throw it away and not use it that morning. Example - Improper thermometer useFacility policy, titled, Record of Food Temperatures, implemented 1/5/26, states in part: .14. Food temperatures will be verified using a thermometer which is both cleaned, sanitized and calibrated to ensure accuracy. The facility also provided a handout given to employees from the USDA (United States Department of Agriculture), titled Use That Thermometer!, which instructs in part: Clean and sanitize thermometer after each temperature check.On 3/18/26 at 11:47 AM, Surveyor observed lunch being prepared on the 500 wing of the facility. Surveyor observed DA I (Dining Aide) in the middle of taking food temperatures. DA I stuck the thermometer in the garlic bread, stated the temperature, and moved the thermometer straight to the lasagna. DA I cleaned the thermometer probe before putting it back into the cover. Surveyor asked DA I if she cleaned the thermometer between taking the garlic bread and lasagna temperatures. DA I said she did not and indicated she had never been told to do that. Surveyor also observed FSCS H (Food Service Corporate Support) taking the temperature of chicken. FSCS H did not clean the thermometer probe before taking the temperature of the chicken. On 3/18/26 at 1:04 PM, FSCS H was observing dishwashing with Surveyor. FSCS H admitted that she had forgotten to clean the thermometer probe earlier in the day.On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager). FSD F indicated he would expect the thermometer to be swabbed with an alcohol wipe every time the cap is taken off, every time staff switches food products for taking temperatures, and after using it. FSDM G indicated they would put together education on taking temperatures and would talk through the proper procedure with DA I. Example - Temperature not taken for food prior to servingFacility policy, titled, Record of Food Temperatures, implemented 1/5/26, states in part: .1. Food temperatures will be checked on all items prepared in the dietary department. 2. Hot foods will be held at 135 degrees Fahrenheit or greater.6. Measure and record the temperatures for each food product and milk at all meals. Record temperature on temperature log .On 3/18/26 at 11:47 AM, Surveyor observed lunch being prepared on the 500 wing of the facility. Fish and chicken were being served as alternate options for lunch that day and were being held in trays on the steam table. DA I (Dining Aide) was getting ready to serve the fish and chicken. Surveyor asked if she had taken the temperature of the fish or chicken when taking the food temperatures prior to serving lunch. DA I said she did not take the temperature of the fish or chicken because it was only for one person. Surveyor asked if she could take the temperatures. The temperature of the fish was 128 degrees Fahrenheit. The temperature of the chicken was 124 degrees Fahrenheit. The fish and chicken were microwaved separately and the temperature of each was retaken until it reached 135 degrees Fahrenheit.On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager) and addressed this concern. Example - Utensils Facility policy, titled, Food Safety Requirements, implemented 1/5/26, states in part: .6. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination.On 3/18/26 at 11:47 AM, Surveyor observed lunch being prepared on the 500 wing of the facility. Surveyor observed DA I (Dining Aide) place a serving utensil in the lasagna, then onto the counter, and back into the lasagna. FSCS H (Food Service Corporate Support) was assisting with lunch preparations and told DA I to keep the utensil in the food instead of taking it out and placing it on the counter. On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager). FSD F confirmed utensils should not be removed from the food and placed on the counter when serving meals. FSDM G indicated DA I knows that she shouldn't do that. Example - Uncovered drinksFacility policy, titled, Food Safety Requirements, implemented 1/5/26, states in part: .5. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination. Strategies include, but are not limited to: a. Covering all foods when traveling a distance (i.e., down a hallway, to a different unit or floor.).On 3/18/26 at 11:47 AM, Surveyor observed lunch being prepared in the kitchenette on the 500 wing of the facility. Staff members were preparing lunch trays to take down the hallway for residents who eat in their rooms. While the food on the lunch trays was covered, staff were filling drink cups at the kitchenette with milk, water, and juice and carrying the trays to rooms down the hallway with the drinks uncovered.On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager). FSD F confirmed that anything on the trays that is being prepared in the kitchenette should be covered when it is being taken down the hallways to resident rooms, including drinks. Example - [NAME] netsFacility policy, titled, Food Safety Requirements, implemented 1/5/26, states in part: .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint to prevent hair from contacting food.On 3/18/26 at 12:40 PM, Surveyor observed [NAME] K in the kitchen putting food away. [NAME] K had a beard. [NAME] K was wearing a hair net but was not wearing a beard net.On 3/18/26 at 1:04 PM, Surveyor observed [NAME] K wearing a beard net. Surveyor observed DA M (Dining Aide) in the kitchen. DA M had a beard. DA M was wearing a hat but was not wearing a beard net. FSCS H (Food Service Corporate Support) was also in the kitchen and asked Surveyor if DA M should be wearing a beard net. FSCS went to talk to DA M and DA M put a beard net on.On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager). FSD F indicated he hadn't been sure what length of facial hair must be covered with a beard net but said this would be addressed. FSDM G confirmed that [NAME] K and DA M had their hair covered but not their beards. Example - HandwashingFacility policy, titled, Handwashing Guidelines for Dietary Employees, implemented 1/5/26, states in part: .6. Frequency of Handwashing: Dietary employees shall clean their hands and exposed potions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations:. b. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc.On 3/18/26 at 1:04 PM, Surveyor observed DA J (Dining Aide) clearing food off dirty dishes in the kitchen with gloves on. DA J removed her gloves, put new gloves on, and touched clean dishes from the dishwasher to put them away. Surveyor asked DA J if she washed her hands before touching the clean dishes. DA J said she only changed her gloves, asked if she should wash her hands, then went to the handwashing sink to wash her hands. Surveyor observed a sign on the wall next to the dishwasher that stated, *Must* wash hands when going between dirty and clean dishes.On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager). FSD F confirmed hands should be washed before handling clean dishes and indicated DA J was recently hired at the facility. Example - Towel use and wet stacking dishesFacility policy, titled, Dishwasher Temperature, implemented 1/5/26, states in part: .7. Dishes should be air dried on the dish racks, not dried with towels.On 3/18/26 at 1:04 PM, Surveyor observed dishwashing in the kitchen. Surveyor observed DA J (Dining Aide) removing clean dishes from the dishwasher immediately with a towel and stacking them in bins while wet. FSCS H (Food Service Corporate Support) was also in the kitchen observing dishwashing. FSCS H spoke with DA J and told her not to use a towel with clean dishes and to let them air dry for a bit before putting them away. DA J stopped using the towel and let the rest of the dishes air dry for a few minutes before putting them away.On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager). FSD F said he spoke with DA J and asked her why she was using a towel for the clean dishes. DA J said the dishes were too hot, as she was grabbing them off of the rack immediately after they came out of the dishwasher. FSD F told her to let the items sit before putting them away, as she shouldn't be stacking wet dishes, and not to use the towel. Example - Sanitizing solution Facility policy, titled, Sanitation Inspection, implemented 1/5/26, states in part: .6. The dietary manager shall develop and provide food service personnel with standard operating procedures for sanitation and daily inspections. The facility also provided a handout given to employees for sanitation range testing, which provides instructions for using a paper test strip to dip into the solution and compare with the colors on the test strip package to determine the ppm (parts per million) of the sanitizing solution. Per the handout, the range should be between 150-400 ppm (www.chemnet-systems.com). On 3/18/26 at 1:40 PM, Surveyor observed DA L (Dining Aide) filling up a sanitation bucket in the kitchen. Surveyor asked DA L if she could demonstrate how to test the sanitizing solution in the bucket. DA L said they don't do that. FSCS H (Food Service Corporate Support) was also in the kitchen at the time. She stepped in and showed DA L how to test the sanitizing solution with a paper test strip. The sanitizing solution was in the appropriate ppm range.On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager). FSD F indicated the sanitizing buckets are being tested three times per day and said staff should be aware of how to do this. FSDM G indicated kitchen staff would be educated about this process. Example - Mighty ShakesManufacturer's recommendations for use: store frozen. Thaw at or below 40 degrees Fahrenheit. Use thawed product within 14 days. Keep refrigerated.On 3/18/26 at 2:05 PM, Surveyor observed three Mighty Shakes in the 500 wing kitchenette refrigerator. One vanilla shake had a facility label dated 10/15, one vanilla shake had a facility label dated 04/24, and one chocolate shake had a facility label dated 06/25. All of the shakes appeared to be thawed. Surveyor observed more Mighty Shakes with date labels on them in the freezer on the 500 wing kitchenette.On 3/18/26 at 2:13 PM, Surveyor met with FSD F (Food Service Director) and FSDM G (Food Service District Manager). FSD F said the labels on the Mighty Shakes should be the use by date. They are supposed to be labeled with a 14 day use by date once they leave the freezer and are put into the refrigerator. FSD F indicated he would look at the Mighty Shakes in the kitchenette, as it didn't sound like they were labeled correctly. On 3/19/26 at 10:21 AM, Surveyor observed four Mighty Shakes in the 500 wing kitchenette refrigerator. Three chocolate shakes had facility labels dated 07/06, 07/06, and 10/15. One vanilla shake had a facility label dated 10/15.On 3/19/26 at 10:25 AM, Surveyor met with FSD F and told him about the Mighty Shake labels. FSD F said the nurses on the unit should be dating the shakes when they are moved from the freezer to the refrigerator, but it appears this isn't being done. FSD F indicated the labels on the Mighty Shakes in the freezer are most likely the date they were taken from the main kitchen freezer. The shakes are being placed in the kitchenette freezer and they are never being relabeled with a 14 day use by date when they are moved to the refrigerator. FSD F said he will work with another staff member to provide education to the nursing staff and will look at the process so it can be streamlined to eliminate confusion.

Based on interview and record review, the facility did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible, or resident preferences indicate otherwise for 1 of 5 residents (R6) reviewed for nutritional status. R6 was assessed to be at risk for dehydration. The facility failed to update R6's care plan and did not implement monitoring or documenting fluid intake. Evidenced by:The facility's policy titled Hydration date implemented 1/5/26 states in part .Compliance Guidelines: 1. The facility will utilize a systemic approach to optimize the resident's hydration states: a. Identifying each resident's hydration status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of intervention and revising them as necessary.R6 was admitted to the facility on [DATE] with diagnoses that include dementia, hypertension (high blood pressure), and muscle weakness. R6's most recent MDS (Minimum Data Set) dated 3/13/26, Section C states that R6 is severely impaired-never/rarely made decisions.On 2/24/26 the facility performed a N Adv- Dehydration Risk Evaluation. Findings include Dehydration risk findings: Dx: Dementia, CHF, DM, Renal Disease or Liver Disease. Dehydration risk findings: Medication: diuretic, psychotic or laxative. Dehydration risk findings: Incontinence (bowel or bladder). Dehydration Risk Score: 5.0. When the Score Value is 4 or above the Resident is at Risk for Dehydration.Of note, Surveyor reviewed R6's care plan. R6's care plan does not address risk of dehydration.Of note, Surveyor reviewed R6's Medication Administration Record/Treatment Administration Record (MAR/TAR) and R6's Certified Nursing Assistant (CNA) task documentation and there was no monitoring or documentation of R6's fluid intake.On 3/18/26 at 1:36 PM, Surveyor interviewed RN D (Registered Nurse). Surveyor asked RN D how staff knows if a resident is at risk for dehydration, RN D stated that they look at the charting. Surveyor asked RN D what the process is if a resident is at risk for dehydration, RN D stated that they would monitor the resident, put in orders, and offer fluids. Surveyor asked RN D if R6 is on the list of residents that are at risk of dehydration, RN D stated no. Surveyor asked RN D if there is any monitoring for fluids on R6's MAR/TAR, RN D stated no. Surveyor asked RN D who is responsible for documenting fluid intake, RN D stated the CNAs and the nurses.On 3/19/26 at 8:38 AM, Surveyor interviewed NM E (Nurse Manager). Surveyor asked NM E who is responsible for filling out quarterly and monthly assessments, NM E stated that the floor staff were responsible. Surveyor asked NM E who is responsible for reviewing the information, NM E stated that the MDS does, and the information is used for the quarterly MDS assessments. Surveyor asked NM E who is responsible for recognizing if there is a change in the assessments, NM E stated that they were unsure. Surveyor asked NM E what the expectation is if a resident triggers to be at risk for dehydration, NM E stated that interventions would be put in place, the provider would be updated, and the POA (Power of Attorney) would be updated. Surveyor asked NM E if interventions were put in place for R6, NM E stated that they would have to check with DON B (Director of Nursing). Surveyor asked NM E if they could find documentation of any fluid monitoring for R6, NM E stated no. Surveyor asked NM E if they would expect staff to be monitoring R6's fluids, NM E stated that they would have to check with DON B.On 3/19/26 at 10:19 AM, Surveyor interviewed DON B. Surveyor asked DON B what the process is for quarterly/monthly assessments, DON B stated that either the floor nurses or the Nurse Manager completes them. Surveyor asked DON B if they would expect interventions to be implemented and care plan to be updated after a resident is assessed to be at risk for dehydration, DON B stated yes. Surveyor asked DON B if they would expect staff to be monitoring R6's fluid intake, DON B stated yes.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 2 Residents (R31) observed for administration of eye drops.RN C (Registered Nurse) had a breach in infection control when RN C did not wear gloves for administration of eye drops.Evidenced by: The facility's Infection Prevention and Control Program policy, dated 2/5/25, states, in part: This facility has established and maintains 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 as per accepted national standards and guidelines.4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.The facility's Administration of Eye Drops or Ointments policy, dated 4/9/25, states, in part: Eye medications are administered as ordered by the physician and in accordance with professional standards of practice. 3. Wash hands or utilize alcohol-based hand rub and apply gloves.On 3/17/26 at 12:02 PM, Surveyor observed RN C (Registered Nurse) use bare hands to administer eye drops to R31. Surveyor asked RN C if there are guidelines for administration of eye drops. RN C stated don't touch the dropper tip to anything; your hands, their eye/body. Surveyor asked if any PPE (personal protective equipment) was needed. RN C stated no, I don't think so. Surveyor asked if there was any chance of contact with bodily fluid with administration of eye drops. RN C stated yes, if you touch their eye; that is why I hold their lower lid with a Kleenex.On 3/18/26 at 3:42 PM, Surveyor interviewed DON B (Director of Nursing) who stated that gloves are needed for administration of eye drops.

Based on observations, interviews and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident. This affected 1 of 3 residents (R2) reviewed for abuse. R1 has a documented history of touching other male residents inappropriately. On 4/27/25, a resident woke to R1 in his room with R1 having his hands in the resident's brief, touching his penis. On 4/28/25, it was reported by a resident that R1's hand was in his crotch. This resident reported that R1 touched his genitals but did not hurt him. R1 was placed on 1:1 (one on one) supervision following these incidents. In the following months the facility decreased R1's supervision from 1:1 to 15-minute checks, to one-hour checks, to two-hour checks and finally discontinuing R1's supervision on 12/12/25. On 01/18/26, R1 was found by staff in R2's room inappropriately touching him in his private area. The facility placed R1 on 15-minute checks when in bed or his recliner and 1:1 supervision when out of his room. The facility's failure to provide adequate supervision and protect residents from sexual abuse created a reasonable likelihood for serious psychosocial harm, thus resulting in a finding of Immediate Jeopardy (IJ) that began on 1/18/26. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the Immediate Jeopardy on 2/2/26 at 3:57 PM. The immediacy was removed and corrected on 1/19/26. Evidenced by:The facility's Abuse, Neglect, and Exploitation policy, dated 3/25/25, includes, in part, the following: Policy Statement: 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.Policy Explanation and Compliance Guidelines:The facility will develop and implement written policies and procedures that:Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property;Establish policies and procedures to investigate any such allegations; andInclude training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse preventions.III. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms;D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;H. Assign responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:Responding immediately to protect the alleged victim and integrity of the investigation;Increased supervision of the alleged victim and residents.VII. Reporting and Response: 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: b. Define how care provisions will be changed and/or improved to protect residents receiving services;c. Training of staff of changes made and demonstration of staff competency after training is implemented;d. Identification of staff responsible for implementation of corrective actions;f. Identification of staff responsible for monitoring the implementation of the plan. R1 admitted to the facility on [DATE]. R1's diagnoses include hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following a cerebral infarction (stroke), diabetes mellitus, hypertension (high blood pressure), difficulty walking, muscle weakness, pain, history of myocardial infarction (heart attack), atherosclerotic heart disease (plaque buildup in the artery walls), and peripheral vascular disease (narrow or blocked blood vessels).R1's Minimum Data Set (MDS), dated [DATE], indicates R1 has a Brief interview for Mental Status (BIMS) of 10, indicating moderate cognitive impairment. R1's behaviors listed include physical and verbal behaviors directed towards others, occurring 1-3 days in a 7-day period. R1 uses a sit-to-stand lift for transfers but once in wheelchair is able to self-propel.R1's Care Plan includes in part the following:Focus: R1 has an ADL (activities of daily living) self-care performance deficit r/t (related to) admission from ALF (assisted living facility) for increased care needs, CAD (coronary artery disease), A Fib (atrial fibrillation), Type 2 diabetes, HTN (hypertension), GERD (gastroesophageal reflux disease), constipation, hx (history) of CVA (cerebral vascular accident), initiated 4/14/25. Interventions: Walking: unable to walk at this time, revision 10/13/25. Transfer: 1A (1 assist) EZ stand (sit to stand lift), revision 10/13/25. I move about the unit: in w/c (wheelchair) 1A. I can self-propel short distances, no w/c leg rests when self-propelling, revision 11/13/25. Special Precautions: Provide cares in pairs, revision 8/25/25.Focus: The resident has a behavior problem of inappropriate sexual conduct with other residents and inappropriate comments to staff. 1/18/26-inappropriately touched another resident, revision 1/18/26. Interventions: 1:1 with staff until back in his room for the evening on 1/18/26, revision 1/21/26. 15-minute checks when in bed or recliner, revision 1/21/26. If you see me in another residents room, stop and intervene remove the resident from the room update the nurse immediately and stay with the resident, initiated 1/20/26. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate locations as needed, initiated 4/29/25. Resident has a sensor alarm on his door and at ground level due to inappropriate sexual behavior, revised 1/23/26. Resident has frequent checks due to inappropriate sexual behaviors, initiated 4/29/25. Staff supervision 1:1 when up in and mobile in his wheelchair. (which includes any part of the facility when resident is in his wheelchair as he can independently propel self), revision 1/21/26. Staff will ensure safety and consent of all residents involved in any sexual activity, initiated 4/29/26.R2 was admitted [DATE]. R2's diagnoses include Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Sepsis, Alzheimer's Disease, and Hypertension. R2's MDS with an Assessment Reference Date (ARD) of 1/4/26 includes in part the following: R2 understands and is understood, is cognitively intact, has no behaviors. R2 transfers with a walker independently. Facility Reported Incident from 1/18/26 states in part.On 1/18/26, it was reported to the NHA (Nursing Home Administrator) that R2 was inappropriately touched by R1. It was witnessed by Activity Assistant. R2 stated that the touching was not consensual. R2's skin check was negative, and he reported no injury and no pain. Police notified. Statements are being taken. R1 was placed on 15-minute checks. R2 is alert and oriented and own person. R1 has activated Power of Attorney. MDs and family notifications are being made.R1's progress note dated 1/18/26 at 1830 (6:30 PM) states. Resident witnessed in another resident's room with hand placed towards inner thigh. Resident immediately taken back to his room. Resident remained calm, denied pain or injury. Skin assessment completed, no new concerns noted. Resident agreeable to go back to room. NHA, DON, Charge Nurse, HCPOA (Healthcare Power of Attorney) notified. Resident placed on 15-minute checks. Confirmed room door alarm is functioning properly.R1's Treatment Administration Record (TAR) states in part . January 2026: Progress note on Behaviors and 15min (15-minute) checks when in room and in bed and or recliner, if up and mobile he should be immediate supervision during shift, mood, appetite, behaviors during your shift. Every shift for behavior monitoring mood and appetite add progress note every shift, start 1/21/26. February 2026: Progress note on Behaviors and 15min (15-minute) checks when in room and in bed and or recliner, if up and mobile he should be immediate supervision during shift, mood, appetite, behaviors during your shift. Every shift for behavior monitoring mood and appetite add progress note every shift, start 1/21/26.R1's progress notes from 1/21/26 to present in Electronic Health Record (EHR) indicate that R1 continues on 15-minute checks when in bed and recliner and 1:1 when up in wheelchair.Observations and interviews completed on 2/2/26 by Surveyors show R1 was 1:1 when up in wheelchair and on 15-minute checks when in bed or recliner.Surveyor attempted to contact R2 on 2/2/26 at 1:46 PM without success. Message left for R2 to return call to Surveyor but Surveyor never received a call back.Because this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm - dehumanization, and humiliation - as a result of the sexual abuse.On 2/2/26 at 9:00 AM, Surveyor interviewed RN H (Registered Nurse). Surveyor asked RN H what the alarm that was sounding at the nurses' station was for. RN H stated the alarm was activated by a motion sensor alarm that was in R1's door. Surveyor asked why R1 needed a motion sensor alarm on his door. RN H stated R1 had a history of touching other residents and the alarm would let staff know if R1 came out of his room or if other residents wandered into R1's room. On 2/2/26 at 9:10 AM, Surveyor interviewed Scheduler K. Surveyor asked Scheduler K where staff document R1's 15-minute checks. Scheduler K showed Surveyor a clipboard with R1's 15-minute check documentation. Surveyor and Scheduler K reviewed R1's documentation, dated 2/2/26. On 2/2/26 at 11:45 AM, Surveyor interviewed RN G. Surveyor asked RN G what she does if there is a report of abuse. RN G stated, I would separate the residents, keep residents safe, report the incident, and assess for any injury. Surveyor asked RN G about R1's behavior. RN G indicated that R1 had behaviors of being sexually inappropriate with an incident occurring last spring or summer. Surveyor asked RN G if she had any recent education. RN G stated, yes, recent education on abuse, consensual relationships, reporting, and R1's care plan changes for 1:1 and 15-minute checks.On 2/2/26 at 11:45 AM, Surveyor interviewed RN H. Surveyor asked RN H what she does if there is a report of abuse. RN H indicated she would separate residents, assess for injury, and report to administrator and/or DON. Surveyor asked RN H about R1's behavior. RN H stated R1 is known to be sexual with other residents, usually male residents. Surveyor asked RN H if she knew what interventions are in place for R1. RN H stated R1 is on 1:1 when he is up in his wheelchair. R1 has an alarm on door and is 15-minute checks when in bed or recliner. Surveyor asked RN H who completes the documentation that 15-minute checks are being completed. RN H stated the CNAs and Nurses complete the documentation on 15-minute checks. On 2/2/26 at 12:20 PM, Surveyor interviewed CNA I (Certified Nursing Assistant). Surveyor asked CNA I what she does if she identifies abuse. CNA I stated she would report to the nurse, separate residents, and keep safe. Surveyor asked CNA I about R1's behaviors and what they were. CNA I stated R1 can get handsy with males. Surveyor asked CNA I what interventions are in place for R1. CNA I stated R1 is on 15-minute checks when in his room in his bed or in recliner and 1:1 when up in his wheelchair. On 2/2/26 at 12:45 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B who completes R1's 15-minute check documentation. DON B stated the person assigned to R1 should ensure the 15-minute documentation is completed around the clock. On 2/2/26 at 1:38 PM, Surveyor interviewed CNA C. Surveyor asked CNA C about the incident with R1 and R2. CNA C indicated she was down the hall helping another resident. When I got done with that, I was at the nurses' station when AA F (Activities Assistant) came up to me and said that I might want to check on R1 and R2. I went down to R2's room and when I walked in, I said R1's name and R1 quickly moved his hand away from R2. I then removed R1 from R2's room. Surveyor asked CNA C where R1's hand was when she entered R2's room. CNA C stated R1's hand was in R2's private area under R2's clothing. Surveyor asked CNA C how staff know who the staff is that is designated to be 1:1 with R1. CNA C indicated the master schedule that is located on the 100, 200, and 300 wings list the staff member who is to provide 1:1. Surveyor asked CNA C who is responsible for completing the 15-minute check sheets on R1. CNA C stated all staff who work with R1 are responsible for completing.On 2/2/26 at 1:47 PM, Surveyor interviewed RN/CN D (Charge Nurse). Surveyor asked RN/CN D if she could tell me about the incident involving R1 and R2 on 1/18/26. RN/CN D stated she was called to the unit by the floor nurse. When I came onto the unit, I noticed that R1 was in his room and saw the back of R2 in his room. RN/CN D then went to the nurses' station where I was informed of the incident. I notified the DON and NHA. I went down and made sure R2 was okay and assessed both residents. R2 then requested to come out to the dining room for dinner. I spoke with the AA who provided her account of what happened. I then updated R1's son/POA (Power of Attorney). Surveyor asked RN/CN D how staff know who is the designated 1:1 staff member for R1. RN/CN D stated that the master schedule that is located on the 100, 200, and 300 units has that information. There is also a copy of the schedule located on each unit but unsure if that always has a specific person designated on it. RN/CN D indicated that she only works every other weekend so is unsure of current practice for 1:1. Surveyor asked RN/CN D what interventions are in place for R1. RN/CN D stated R1 is on 15-minute checks when in bed and recliner and 1:1 when up in wheelchair. Surveyor asked RN/CN D if she has had any recent education. RN/CN D stated we had recent education on a lot of things but some of those included residents at risk, reporting, abuse, voicing concerns, and intervening.On 2/2/26 at 2:00 PM, Surveyor interviewed RN E. Surveyor asked RN E if she could describe the events from 1/18/26 between R1 and R2. RN E stated AA F came to the nurses' station to report that R1 was in R2's room, R1 was touching R2's thigh. Myself and the CNAs went down to R2's room, one of the CNAs removed R1 from the room. When I walked into the room, I was unable to see where R1's hand was. R1 was in his wheelchair with his back to me. I then called the RN/CN D to the unit. Surveyor asked RN E who is responsible for completing the 15-minute check sheets on R1. RN E indicated that the CNAs fill them out or whomever is doing 1:1, it is everyone's responsibility. Surveyor asked RN E if she had recently received any education. RN E stated she had education within the last couple of weeks on abuse, reporting, consensual relationships, the plan for R1's 1:1 and 15-minute checks, and intervening.On 2/2/26 at 2:16 PM, Surveyor interviewed CNA J via telephone and asked CNA J to describe what occurred on 1/18/26 between R1 and R2. CNA J stated AA F came to the nurses' station and stated R1 was in R2's room. R1 was sitting next to R2 who was sitting in the recliner with his feet up. CNA J went immediately to R2's room and observed R1 sitting next to R2. R1's hand was inside R2's pants, R1 was touching R2's penis and upper thigh. CNA J immediately removed R1 from R2's room and took R1 to his room. CNA J returned to R2's room, asked R2 if he was alright. R2 stated he was alright and that he had not consented to have R1 touch him under his pants. CNA J state a nurse assessed R1 and R2 following the interaction.Surveyor asked CNA J if she was educated after the incident between R1 and R2. CNA J stated there was written education on abuse at the nurses' station that she read and signed. The education included what to do if seeing abuse or inappropriate interactions between residents including separating immediately, making the residents safe, and reporting the incident to the nurse. Surveyor asked CNA J what staff is doing to ensure no further resident to resident interactions occur with R1. CNA J stated R1 is on 15-minute checks when in his room in bed or recliner and is 1:1 when in his wheelchair. CNA J stated the 15-minute documentation is to be completed by the staff who is assigned to R1.On 2/2/26 at 4:35 PM, Surveyor interviewed AA F. Surveyor asked AA F if she can tell Surveyor about the incident on 1/18/26 between R1 and R2. AA F stated that she had gone by R2's room a couple of times on her way to do a resident's nails and then again on her way to do an activity. R1 was in R2's room and they appeared to be talking both times. AA F stated that when she was returning to the unit from the activity, she noted that R1 was close to R2 and then noticed R1 had his hand between R2's thighs. AA F stated that when she saw this she immediately went to report to the nurse. Surveyor asked AA F if she had received any recent education. AA F stated that HR (Human Resources) provided her with education and instructed her to immediately intervene, separate the residents, and ensure they are safe. AA F stated that she had just finished completing her Relias training prior to this interview on abuse.The facility's failure to provide adequate supervision and protect residents from sexual abuse by R1 created a reasonable likelihood for serious psychosocial harm, thus leading to a finding of immediate jeopardy which began on 1/18/26. The facility removed and corrected the immediate jeopardy on 1/19/26 when it completed the following:Residents were separated and it was reported to the NHA on 1/18/2026Staff that were working on 1/18/2026 gave statements. If further information was needed, staff were interviewed.An officer came to the facility and interviewed R1 and R2 on 1/18/2026.Both R1 and R2's mood, behavior, and appetite were monitored.Both R1 and R2 had skin assessments completed.Both R1 and R2 MDs were updated. R2's POA was updated. R1 was his own decision maker and declined notification.All residents on the 500 with a BIMS of less than 7 had a skin check-started and completed by the 5 day.All residents with a BIMS greater than 7 were interviewed-started and completed by the 5 day. R1 was placed on 1:1 when up in wheelchair which started on 1/18/2026. This is ongoing.R1 is on 15 minute checks when in bed or recliner which started on 1/18/2026. This is ongoing.R1 has alarms on his door and at ground level to alert staff. R1 and R2's psychosocial well being care plans were updated.R1 and R2 had a resident relationship, intimacy and sexuality history completed. Both deny wanting a relationship.Education began with staff regarding abuse with an emphasis on sexual abuse, 1:1 definition/expectations, individual interventions for R1, and 15 minute checks. The charge Nurse made sure staff were educated prior to the start of their next shift. Facility Leadership team ensured their staff were educated prior to the start of their shift.1/19/2026R1 and R2 were interviewed by the social worker and both state they feel safe.R2 was interviewed by DON and VP of Nursing and states he feels safe.Both R1 and R2 were offered BCS services and declined.R1 was offered materials to help with hypersexuality and declined.Care plan meeting with R1, facility, POA to discuss behaviors, plan moving forward, and activities of interest (books, crossword, word searches.)Medical Director updated regarding incident between R1 and R2.1/21/2026-R2 was discharged from the facility to his ALF. This was a planned discharge and not due to the incident.

Based on interview, observation, and record review, the facility failed to protect 1 of 3 sampled resident's (R1's) right to be free from sexual abuse by a resident.Staff witnessed R2 touch R1 on the breast. As a result of the incident, the facility placed interventions on R2's care plan to prevent further incidents from occurring. These interventions were observed not to be in place and staff were not aware of the care planned interventions. This is evidenced by:R1 admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) of 1, indicating severe cognitive impairment. R1's diagnoses include in part, dementia, severe, with other behavioral disturbance, hypertension, dorsalgia, and muscle weakness.R2 admitted to the facility on [DATE]. R2 has a BIMS of 3, indicating R2 has severe cognitive impairment. R2's diagnoses include in part, vascular dementia with other behavioral disturbance, diabetes mellitus type 2, cerebral atherosclerosis, depression, muscle weakness, and history of TIA (transient ischemic attack).The facility completed an initial Incident Report on 9/15/25. The report indicated that R2 had been witnessed by staff touching R1 on the breast. Staff initially interviewed R2 at the time of the incident at which time R2 admitted that he had touched R1 on the breast. R2's care plan states in part. Focus: The resident has a psychosocial well-being problem actual r/t (related to) inappropriately touching another resident, initiated 9/15/25. Interventions: 1:1 supervision 9/15/25, initiated 9/15/25, revised 9/21/25. 9/16/25-Motion sensor alarm placed on doorway to room and bathroom to alert staff of whereabouts.Note: R2's Kardex (CNA care plan) does not include the interventions from the care plan.Nurses Note in R2's chart from 9/15/25 at 16:46 (4:46 PM), states: This resident was seen touching another resident inappropriately in the dining room, they were separated and educated but this resident was mad that this writer stopped him. The Nurse Manager was notified. Nurses Note from R1's chart from 9/16/25 at 16:34 (4:34 PM), states: Resident's POA (Power of Attorney) husband [name] requested to meet with writer. [POA name] asked for the name of the resident from the incident involving his wife on 9/15/25 so he could just observe when he is around. Writer explained that we cannot share that info (information) for HIPPA (Health Insurance Portability and Accountability Act) reasons. Writer had DON (Director of Nursing) join our conversation and she explained the same thing to him. DON stated that the male resident is currently on 15 mins (minute) check when in his room and 1:1 with staff when out of his room and has a door sensor on his door. DON also stated they ordered an alarm pad for bed and chair in his room. [POA name] was good with those things and stated this is a great facility and I know you guys are doing the right things.Facility telephone interview with RN on 9/15/25 at 16:40 (4:40 PM) states: RN was asked if there was an incident between two residents on 400. RN said yes there was, so I asked her to let me know what happened. I was at the Nurses station between 12:30pm and 1:00pm when I noticed R2 was close to R1. R1 was in the recliner facing the Nurses station and R2 was in his wheelchair. R2 moved his left hand toward R1 and with an open hand touched her left breast. I told him to stop, and he did. There was no fondling or other touching of the breast. I told R2 it was inappropriate. Reminded R1 that she was married, and she said right. There were no other witnesses to this. I did tell the CNAs, but they told me they didn't know if I had to report it or not. The residents had been separated immediately since that incident. When I was giving report to the oncoming Nurse, she told me I had to report this. At around 4:00pm, I reported it to the Nurse Manager, [name].On 10/1/25 at 11:50 AM, Surveyor observed R2 to be sitting at the dining room table. CNA C (Certified Nursing Assistant) was sitting at the next table assisting a resident with eating. R1 was standing at a table kitty corner from R2 with an activities assistant.Note: R2's plan of care indicates he is 1:1 supervision. On 10/1/25 at 12:20 PM, Surveyor observed CNA C and CNA/Med Tech D (Medication Technician) picking up trays at the nurses station and in the kitchenette with their backs to R2. On 10/1/25 at 12:27 PM, Surveyor interviewed CNA C. Surveyor asked CNA C how long she has worked for the facility. CNA C stated she had only been back from FMLA (Family Medical Leave Act) for around 2 weeks but has worked in the facility for 7 years. Surveyor asked CNA C if she had received any education since returning from FMLA. CNA C stated, none that I can think of. Surveyor asked CNA C if R1 has any behaviors. CNA C stated, R1 does have behaviors with dressing and toileting. R1 can get physical with staff but only during those times. Surveyor asked CNA C about R2's behaviors. CNA C stated, R2 can be very behavioral at times. R2 is resistive of care. R2 has an alarm in his room on the doorframe so we know when R2 is on the move. We check on him every 15 minutes and more frequent checks. I think before I returned on 9/16/25, R2 may have been 1:1. Surveyor asked CNA C if she has ever witnessed R2 be inappropriate with other residents. CNA C stated she has never seen R2 be inappropriate with other residents.On 10/1/25 at 12:34 PM, Surveyor observed the door alarm going off at the end of the unit. CNA C responded to the alarm and shut the alarm off. Surveyor observed R2 in the dining room and R1 was walking the unit with the activities assistant. There were no other staff on the unit.On 10/1/25 at 12:37 PM, Surveyor interviewed CNA/Med Tech D. Surveyor asked CNA/Med Tech D if R1 has any behaviors. CNA/Med Tech D stated none that I am aware of just wandering. She is what I would call pleasantly confused. Surveyor asked CNA/Med Tech D if R2 has any behaviors that staff monitor. CNA/Med Tech D stated, R2 is more aggressive, hitting and swatting at staff, refuses care and medications, just does not want to be bothered. Surveyor asked CNA/Med Tech D if she has had any education since returning from leave. CNA/Med Tech D stated, I have not had any education since I came back on 9/16/25. Surveyor asked if there is any increased monitoring for R2. CNA/Med Tech D stated, we just keep an eye on him. Check on R2 when the alarm on his doorframe sounds and check periodically. The alarm is not to restrict just to know he is up moving. Surveyor asked CNA/Med Tech D if R2 has been noted to ever be inappropriate with other residents. CNA/Med Tech D stated she had never seen R2 be inappropriate with other residents. CNA/Med Tech stated if R2 is in the common area and gets to close to other residents he is redirected away. Surveyor asked CNA/Med Tech D how many staff are on the unit this shift. CNA/Med Tech D stated there was just her and CNA C on the unit. Surveyor asked CNA/Med Tech D how many residents require assistance of 2 staff on the unit. CNA/Med Tech D stated, 2 residents use full body lifts and require 2 staff to transfer. Of note, if the unit has two staff members and both are in a room completing a transfer there would not be staff on the unit supervising R2.On 10/1/25 at 12:47 PM, Surveyor observed R2 walk out of his room into the hallway without the doorframe alarm sounding. Surveyor interviewed CNA C about the alarm not sounding. CNA C stated that the alarm did not catch R2 coming out, but it did when he went back into his room with her.On 10/1/25 at 1:50 PM, Surveyor interviewed CNA/Med Tech D. Surveyor asked CNA/Med Tech D who updates resident care plans. CNA/Med Tech D stated that the MDS Nurse updates the care plan. Surveyor asked CNA/Med Tech D how staff are made aware of changes made to the care plan. CNA/Med Tech D stated that management will let us know if changes occur, there is a care plan hanging in each residents closet and the care plan in the computer, which I haven't figured out how to access yet. Surveyor showed CNA/Med Tech D R2's care plan and asked what type of supervision the care plan indicates R2 requires. CNA/Med Tech D stated, 1:1, meaning we should always be with R2.On 10/1/25 at 2:10 PM, Surveyor interviewed CNA E. Surveyor asked CNA E who updates resident care plans. CNA E indicated that the SW (Social Worker) updates the care plans. The SW updates the care plan from notes by the nurse. The SW decides what is put on the care plan. Surveyor asked CNA E if a resident care plan indicates 1:1 should that be included on the CNA Kardex (care plan). CNA E indicated that this would be on the CNA care plan. Surveyor asked CNA E what 1:1 means. CNA E stated, 1:1 means supervision and safe at all times. Someone should always be with them, eyes on them all times. Surveyor asked CNA E if she has received any education in the last couple of weeks. CNA E indicated she does not remember if she has been provided any education. Surveyor asked CNA E if R2 has any increased supervision. CNA E stated that R2 has a doorbell motion sensor. If the doorbell goes off, we are to check on him. On 10/1/25 at 2:20 PM, Surveyor interviewed CNA C. Surveyor asked CNA C who updates resident care plans. CNA C stated that staff let the nurse manager or MDS nurse know what changes need to be made. Surveyor asked CNA C how staff are made aware of any care plan changes. CNA C stated any changes are passed on in report.On 10/1/25 at 2:25 PM, Surveyor interviewed NM/LPN G (Nurse Manager/Licensed Practical Nurse). Surveyor asked NM/LPN G who updates resident care plans with changes. NM/LPN G stated that anything pertinent is added by staff to the care plan. Surveyor asked NM/LPN G about R2's care planned intervention for 1:1. NM/LPN G stated that the care plan reads as if R2 should be on 1:1. On 10/1/25 at 2:45 PM, Surveyor interviewed MDS/RN F (Minimum Data Set/Registered Nurse). Surveyor asked MDS/RN F who updates resident care plans. MDS/RN F stated, I do some of the updates, I do the baseline care plans. Updates are made by the DON (Director of Nursing), SW (Social Worker), Activities, NM, and me. Surveyor asked MDS/RN F how it is determined if something is added to the CNA Kardex. MDS/RN F stated items are added to the CNA Kardex if it affects resident care. Surveyor reviewed R2's care plan with MDS/RN F. Surveyor asked MDS/RN F about 1:1 and what that would mean. MDS/RN F states that 1:1 means that 1 person should be with R2. Surveyor asked MDS/RN F if this is something that should be added to the CNA Kardex. MDS/RN F stated it should be on the CNA Kardex. We document that on the TAR (Treatment Administration Record) as well. The nurses have access to that, but the CNAs do not. Surveyor asked MDS/RN F about R2's alarm. MDS/RN F stated alarms are usually placed on the TAR for the nurse to check but the CNAs should also know. It would be expected that this would be passed on to them in report. On 10/1/25 at 3:05 PM, Surveyor interviewed DON B. Surveyor asked DON B who updates the resident plan of care with changes. DON B states that the NM, SW, DON, and MDS nurse make those changes. Surveyor asked DON B how staff are made aware of changes made to the care plan. DON B stated that updates to the CNA Kardex are printed and put in the CNA binder. There is a tab in the CNA binder with CNA Kardex care plan updates - care plan is highlighted. Surveyor asked DON B what interventions were put into place for R2 following the incident with R1 and R2. DON B indicated that a sensor was placed on the door. R2 was 1:1 until we got the sensor in place. Surveyor reviewed R2's care plan with DON B. DON B indicated that the care plan should have been revised, it looks like he is still 1:1. The sensor is used to let staff know when R2 leaves his room. There is a shared bathroom, so it goes off when he goes to the bathroom as well. We have also ordered pad alarms for R2's bed and chair so it will not distract R2 as much. Surveyor reported observation of seeing R2 leave his room and the alarm not sounding to alert staff he was out of his room.Surveyor reviewed facility reeducation completed for this incident. The facility has 107 Nurses and CNAs listed on their staff list with only 31 signed names on the education sheet.R2 touched R1 on the breast. As a result of the incident the facility placed interventions on R2's care plan to prevent further abuse incidents from occurring. These interventions were observed not to be in place and staff were not aware of the interventions.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 resident (R12) reviewed for handwashing. The facility staff did not complete proper hand hygiene while performing wound care. This is evidenced by: The facility's policy titled Clean Dressing Change, dated 5/4/25, states in part: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard in appropriate receptacle. 11. Wash hands and put on clean glvoes. 12. Cleanse the wound as ordered .14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered . 16. Secure dressing. 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. The facility's policy titled Hand Hygiene, dated 5/21/25, states in part: All staff will perform proper hand hygiene to prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. R12's physician orders include Wound care to left knee: Remove old dressing. Cleanse, Dry, apply Medi honey (an ointment that helps wounds heal) to wound bed, apply island dressing every day shift for wound care. On 5/21/25 at 8:30 AM, Surveyor observed RN C (Registered Nurse) perform wound care for R12. Surveyor observed the following: RN C performed hand hygiene. RN C set up the wound care supplies in R12's room. RN C donned (put on) gloves and a gown. RN C removed R12's old bandage from her left knee. RN C removed her gloves, did not perform hand hygiene, and donned new gloves. RN C cleansed the wound and dried the wound. RN C removed her gloves, did not perform hand hygiene, and donned new gloves. RN applied Medi honey and covered the wound with a dressing. RN C removed her gloves, did not perform hand hygiene, reached into her pocket and pulled out a marker. RN C dated the dressing on R12's left knee. RN C donned gloves and picked up the wound care supplies from R12's room. RN C removed her gloves and gown and then performed hand hygiene. On 5/15/25 at 8:40 AM, Surveyor interviewed RN C regarding hand hygiene during wound care. RN C indicated she did not perform hand hygiene after removing her gloves. RN C indicated hand hygiene should be done immediately after removing gloves and she did not. On 5/15/25 at 8:45 AM, Surveyor interviewed DON B (Director of Nursing) regarding hand hygiene during wound care. Surveyor reviewed the observations made during RN C's performance of wound care for R12. Surveyor asked DON B if hand hygiene should have been performed after removing gloves. DON B indicated hand hygiene should have been completed each time after RN C removed her gloves. DON B indicated she expects hand hygiene to be completed appropriately and agrees RN C did not perform appropriate hand hygiene during wound care for R12.

Based on interview and record review, the facility did not complete a performance review of every nurse aide at least once every 12 months for 2 of 5 Certified Nursing Assistants (CNAs) reviewed. CNA L did not have an annual performance evaluation completed. CNA M did not have an annual performance evaluation completed. This is evidence by: Example 1 CNA L's hire date was 5/3/23. CNA L did not have an annual performance evaluation completed for 2024. Example 2 CNA M's hire date was 2/10/23. CNA M did not have an annual performance evaluation completed for 2024. On 3/31/25 at 1:30 PM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B how often are CNA evaluations to be done. DON B indicates, yearly. Surveyor asked if DON B would expect all CNA's to have a yearly performance evaluation. DON B indicates, yes.

Based on observation, interview, and record review, the facility does not have an effective infection control program to control the spread of infectious disease, in this case COVID-19; this has the potential to affect all 87 residents residing at the facility. The facility is experiencing an extensive COVID outbreak that started on 12/30/24 when three (3) residents and one (1) staff member tested COVID positive. The outbreak has affected 6 of 6 units. As of 1/15/25, 38 residents and 18 staff members (total of 56) tested COVID positive during this ongoing outbreak. The facility failed to do the following: Staff were observed exiting COVID positive room with PPE on and doffing PPE in the hallway. While removing PPE in the hallway, staff contaminated clean PPE with dirty PPE. The facility is not documenting COVID positive residents' signs and symptoms on the line list or elsewhere. The facility is not fit testing agency staff for N95s. On 12/30/24, the facility identified they were in a COVID outbreak when three (3) residents tested COVID positive. On 12/30/24, LPN/IP C stated two additional residents, R16 and R19, had nasal symptoms. The facility did not test R16 and R19 for COVID until 12/31/24 (1 day later). On 12/31/24, R16 and R19 both testing COVID positive. Evidenced by: The facility's policy, Coronavirus Surveillance Policy, dated 2/13/23, indicates, in part, as follows: The facility will implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during a declared public health emergency for the illness. Definitions: Coronavirus is a virus that causes mild to severe respiratory illness. COVID-19 is a respiratory disease caused by SARS-CoV-2, a coronavirus discovered in 2019. The virus spreads mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks. Procedure: 1. The Infection Preventionist will monitor the status of COVID-19 outbreak through the CDC (Centers for Disease Control) website, and will monitor for changes in prevention, treatment, isolation, or other recommendations. 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19. These include, but are not limited to, screening visitors, staff, and residents. 3. Screening for visitors and staff: a. Symptoms of COVID-19; b. Close contact with someone with SARS-coV-2 (for visitors) or a higher-risk exposure (for healthcare personnel). 7. New Admissions and Residents with known exposure to Covid will be monitored for signs and symptoms of coronavirus illness: fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, fatigue, congestion or runny nose, nausea or vomiting, diarrhea. The physician will be notified immediately, if evident. Staff shall follow established procedures when COVID-19 is suspected. 8. The Infection Preventionist, or designee, will track the following information: a. The number of residents and staff who have fever, respiratory signs/symptoms, or other signs/symptoms related to COVID-19. e. Employee compliance with hand hygiene f. Employee compliance with standard and transmission-based precautions h. Supply of personal protective equipment, cleaning/disinfection supplies, alcohol-based hand rub, and other relevant supplies. 9. Surveillance data will be used for reporting to local health departments, CDC, staff, residents, and resident representatives. a. The local health department will be notified of resident or staff with suspected or confirmed COVID-19, residents with severe respiratory infection resulting in hospitalization or death, or > or equal to 3 residents or staff with new-onset respiratory symptoms within 72 hours of each other. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic | CDC Archive 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection The IPC recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing. Duration of Empiric Transmission-Based Precautions for Symptomatic Patients being Evaluated for SARS-CoV-2 infection. The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test. If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Respirators should be used in the context of a comprehensive respiratory protection program, which includes medical evaluations, fit testing and training in accordance with the Occupational Safety and Health Administration's (OSHA) Respiratory Protection standard (29 CFR 1910.134) Duration of Transmission-Based Precautions for Patients with SARS-CoV-2 Infection The following are criteria to determine when Transmission-Based Precautions could be discontinued for patients with SARS-CoV-2 infection and are influenced by severity of symptoms and presence of immunocompromising conditions. Patients should self-monitor and seek re-evaluation if symptoms recur or worsen. If symptoms recur (e.g., rebound), these patients should be placed back into isolation until they again meet the healthcare criteria below to discontinue Transmission-Based Precautions for SARS-CoV-2 infection unless an alternative diagnosis is identified. In general, patients who are hospitalized for SARS-CoV-2 infection should be maintained in Transmission-Based Precautions for the time period described for patients with severe to critical illness. In general, patients should continue to wear source control until symptoms resolve or, for those who never developed symptoms, until they meet the criteria to end isolation below. Then they should revert to usual facility source control policies for patients. Patients with mild to moderate illness who are not moderately to severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved Patients who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: At least 10 days have passed since the date of their first positive viral test. Patients with severe to critical illness and who are not moderately to severely immunocompromised: At least 10 days and up to 20 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved The test-based strategy as described for moderately to severely immunocompromised patients below can be used to inform the duration of isolation. The facility has not documented COVID signs/symptom monitoring on the COVID line list or elsewhere for any residents that tested COVID positive. The facility does not complete N95 mask fit testing for any agency staff. On 1/15/25 at 2:40 PM, Surveyor spoke with LPN/IP C (Licensed Practical Nurse/Infection Preventionist). LPN/IP C stated she just took over the IP role on 12/31/24, LPN/IC C completed the Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training Course on 11/18/24. Surveyor asked LPN/IP C, what standard of practice the facility follows for COVID. LPN/IP C stated, CDC (The Centers for Disease Control) many residents had no symptoms until 2-3 days after testing COVID positive. R16 and R19 had stuffy noses the day before we tested but, nothing on the day we tested . Surveyor asked LPN/IP C, were R16 and R19 tested on the day, 12/30/24, they had stuffy noses. LPN/IP C stated, no. Note, the facility recognized they were in a COVID outbreak on 12/30/24. R16 and R19 should have been tested on [DATE] when they were symptomatic. LPN/IP C stated, R16 had a bunch of family come in to visit before he tested COVID positive on 12/31/24. LPN/IP C stated, R16 visits R1 and R19. R12 propels around the 100, 200, and 300 halls. LPN/IP C stated, R18 and R16 probably passed COVID around. Surveyor asked LPN/IP C, who is responsible for N95 fit testing. LPN/IP C stated, the prior IP. Surveyor asked LPN/IP C, when were staff and agency/contracted staff last fit tested . LPN/IP C stated, she is going to check. Surveyor asked LPN/IP C, have you educated staff regarding PPE (Personal Protective Equipment). LPN/IP C stated, as a group, no. LPN/IP C stated, if she sees any staff member in need of help, she will go educate them. LPN/IP C stated. the facility is completing broad-based testing and was able to complete some contact tracing (see above). Surveyor asked LPN/IP C, are COVID positive residents' symptoms being documented and monitored. LPN/IP C stated, no, she was not aware she needed to document symptoms on her line list and will implement this immediately. On 1/15/25 at 4:55 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated, she followed up with the previous IP (Infection Preventionist). The previous IP stated, the facility fit tests their own employees annually and provided documentation. The previous IP stated, the facility does not fit test any agency/contracted staff. DON B stated, the facility should be COVID testing all residents upon symptom onset in addition to the broad-based testing they are doing. DON B stated, R16 and R19 should have been tested on [DATE] when they each presented with a stuffy nose. DON B stated, the facility did not provide LPN/IP C with the training she should have had before beginning her IP role. DON B stated, LPN/IP C is doing a very good job considering she is new to this role. DON B stated, she will work with LPN/IP C regarding infection control. 50228 On 1/15/24 at 9:28 AM, Surveyor observed DoA D and LEC E exiting the shared room of R14 and R15 wearing gown, gloves, N95 mask, and face shield. DoA D and LEC E closed the door and stood next to the isolation cart in the hall outside the resident room. Signage on the door to the room stated contact/airborne precautions (a set of practices used to prevent the spread of infectious illness). DoA D and LEC E removed their used gown and gloves and set it on top of the isolation cart next to bags containing N95 masks and a container of disinfectant. LEC E removed her N95 mask and placed it under her upper arm, against her shirt. LEC E took a new surgical mask from the isolation cart and applied it to her face. Surveyor asked DoA D and LEC E if they had just exited the room of a COVID positive resident. DoA D and LEC E stated yes. Surveyor asked if PPE was to be worn into the hallway. DoA D stated no, it is to be removed inside the resident room. Surveyor asked if used PPE should be placed on the isolation cart. DoA D stated no, it should have been disposed of in the garbage inside the resident room. Surveyor asked if the isolation cart was contaminated by the used PPE. DoA D stated yes. Surveyor asked if a used N95 mask should be held against a staff member's clothing. LEC E stated no. Surveyor asked if hand hygiene had been performed prior to application of a new surgical mask. LEC E stated no. Surveyor asked if hand hygiene should have been completed. LEC E stated yes. On 1/15/25 at 2:02 PM, Surveyor interviewed IP C and asked where PPE should be removed when exiting the room of a COVID positive resident. IP C indicated that gown and gloves should be removed prior to leaving the resident room and hand hygiene should be performed. Face shield and mask should be removed at doorway, where face shield should be disinfected and placed into a bag and N95 mask should be placed into a bag, followed by hand hygiene, prior to application of a new surgical mask. Surveyor asked if PPE should be removed prior to leaving the room of R14 and R15. IP C stated yes. Surveyor asked if placing used PPE on top of the isolation cart would be considered contamination / a breach in infection control. IP C stated yes. Surveyor asked if holding a used N95 mask under your arm against your shirt would be considered contamination. IP C stated yes. Surveyor asked if hand hygiene should be performed after removal of PPE, prior to applying a new surgical mask. IP C stated yes. On 1/15/25 at 2:11 PM, Surveyor interviewed DON B and asked where PPE should be removed when leaving the room of a COVID positive resident. DON B stated PPE should be removed in the resident room and hand hygiene should be performed. Surveyor asked if facility would expect staff to remove PPE prior to leaving the room of R14 and R15. DON B stated yes. Surveyor asked if placing used PPE on top of the isolation cart would be considered contamination / a breach in infection control. DON B stated yes. Surveyor asked if holding a used N95 mask under your arm against your shirt would be considered contamination. DON B stated yes. Surveyor asked if hand hygiene should be performed after removal of PPE, prior to applying a new surgical mask. DON B stated yes.

Based on interview and record review, the facility failed to thoroughly investigate an accusation of physical abuse for 1 of 6 residents (R3) reviewed for abuse. R3 was found in R2's room sitting on edge of bed with R2's depends unfastened, fondling R2 between the butt cheeks. Facility did not put anything in place to prevent this from happening again. Facility did not provide abuse education to all staff. Evidenced by: The facility policy entitled, Abuse, Neglect, and Exploitation Policy & Procedures, dated 2/25/23, states, in part: . Policy Statement: It is the policy of New Glarus (referred to as the facility herein) is 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. Definitions: . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Sexual Abuse is non-sensual sexual contact of any type with a resident. Procedure: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and . III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports .establishing policies and protocols for preventing sexual abuse . D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. E. Ensuring the health and safety of each resident . VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include . C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator . G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency . within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The Facility Self Report dated 11/26/24, states, in part: . Summary of Incident: Allegation type: Other: Reportable incident that is not misconduct related. Name- Affected Person: R2 Name of Accused Person: R3 . Is Date and time when occurred known? NO Date occurred .: BLANK. Time occurred: BLANK. Is occurred date and time estimated: BLANK. Date discovered: 11/26/24. Brief Summary of Incident: On [DATE], at 9:15 am, it was reported to NHA A, Interim Administrator, that R3, resident, was found sitting on the edge of the bed of R2. CNA (certified nursing assistant) stated that R2's brief was pulled down; R3 was sitting on the bed touching R2 in his private area. R3 was extremely confused at the time of the incident; R2 remained asleep through the incident. R3 was immediately removed. R2 did not have any s/sx (signs/symptoms) of pain or emotional disturbances. R3 was assisted in wheelchair to dining room and placed on 15-minute checks. R2's assessment was negative for skin and pain. Both residents have activated POAs (Power of Attorney). R3's BIMS 5/15 and R2's BIMS 3/15. Neither resident is interviewable. POAs and physicians were notified. Police Department is being contacted. Statements being taken. Investigation has begun. On 12/17/24 at 2:15 PM, Surveyor interviewed DON B (Director of Nursing) and asked regarding the incident on 11/26/24 with R2 and R3, what was put into place to ensure residents' safety from R3. DON B indicated at the time of the incident R2 and R3 were separated and staff were to keep an eye on R3. Surveyor asked what that includes specifically and DON B indicated staff was to make sure R3 did not go back into R2's room and to always monitor R3's whereabouts. Surveyor asked if R3 was on 1:1 to ensure staff knew R3's whereabouts and DON B indicated no. Surveyor asked DON B if staff were documenting R3 was being monitored and DON B indicated no. Surveyor asked DON B if anything was put into place for other residents' safety. DON B indicated not that she was aware of. Surveyor asked if there should have been, and DON B indicated yes. Surveyor asked DON B if R3 or R2's Care Plans had been updated after incident. DON B indicated the last time R3's Care Plan was revised was 11/20/24; no updates or new interventions were put into place regarding 11/26/24's incident. Surveyor asked if DON B would expect a new intervention to be placed after incident and DON B indicated yes. DON B indicated no interventions were put into place for R2 after the incident and there should have been. Surveyor asked DON B if R3 was put on 15-minute checks immediately after the incident, and DON B indicated she could not find anything in R3's medical record indicating R3 was placed on 15-minute checks or showing R3 is currently on 15-minute checks. Surveyor asked DON B if she would expect all staff to receive abuse education after an incident as this between R2 and R3. DON B indicated yes. On 12/17/24 at 2:53 PM, Surveyor interviewed NHA A (Nursing Home Administrator) Surveyor asked NHA A if education was provided to all staff after this incident and NHA A indicated NHA A felt it was an isolated incident that wouldn't involve all staff in the rest of the building. NHA A indicated she considered the incident to be a resident-to-resident altercation. Surveyor asked NHA A as of today has there been any interventions put into place to prevent this incident from happening again, NHA A indicated no. On 12/17/24 at 3:15 PM, DON B walked in NHA A's office while Surveyor conducting the interview. NHA A asked DON B if at this time if anything was put into place to prevent this incident from occurring again between R2 and R3 and DON B indicated no. DON B indicated nothing has been done to closely monitor R3 and R2 to prevent this from occurring again.

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 though established procedures for 1 of 6 abuse investigations (R3) reviewed. Facility became aware of an abuse allegation on 11/26/24 at 4:30 AM and was not reported to State Agency until 11/26/24 at 10:39 AM. Evidenced by: The facility policy entitled, Abuse, Neglect, and Exploitation Policy & Procedures, dated 2/25/23, states, in part: . Policy Statement: It is the policy of New Glarus (referred to as the facility herein) is 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. Definitions: . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Sexual Abuse is non-sensual sexual contact of any type with a resident. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency . within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . The Facility Self Report dated 11/26/24, states, in part: . Summary of Incident: Allegation type: Other: Reportable incident that is not misconduct related. Name- Affected Person: R2 Name of Accused Person: R3 . Is Date and time when occurred known? NO Date occurred .: BLANK. Time occurred: BLANK. Is occurred date and time estimated: BLANK. Date discovered: 11/26/24. Brief Summary of Incident: On [DATE], at 9:15 am, it was reported to NHA A, Interim Administrator, that R3, resident, was found sitting on the edge of the bed of R2. CNA (Certified Nursing Assistant) stated that R2's brief was pulled down; R3 was sitting on the bed touching R2 in his private area. R3 was extremely confused at the time of the incident; R2 remained asleep through the incident. R3 was immediately removed. R2 did not have any s/sx (signs/symptoms) of pain or emotional disturbances. R3 was assisted in wheelchair to dining room and placed on 15-minute checks. R2's assessment was negative for skin and pain. Both residents have activated POAs (Power of Attorney). R3's BIMS 5/15 and R2's BIMS 3/15. Neither resident is interviewable. POAs and physicians were notified. Police Department is being contacted. Statements being taken. Investigation has begun. Person Preparing This Report: Name: NHA A (Nursing Home Administrator) Report Submitted Date: 11/26/24 10:39:49 AM . RN C's statement, dated 11/26/24, states, in part: . At approximately 4:30 AM, CNA P working on the 400-hall called myself over to 500 hall and asked me to come over the unit. CNA P told me that she found R3 in the room with R2, whose brief was pulled down, sitting on the bed, and touching R2 in his private area. An email from DON B (Director of Nursing) to NHA A (Nursing Home Administrator) sent Tuesday, December 3, 2024, 12:16 PM, states, On November 26, 2024, at 6:17 AM, I received a phone call from RN C (Registered Nurse) regarding an incident involving two residents on the 400-wing, R3 and R2. She reported the staff was alerted by a call light going off in R2's room and found R3 touching R2 inappropriately after having removed R2's depends. Staff immediately removed R3 from the room. They did cares on R2 and reapplied depend. The staff said R2 slept through the entire incident. I asked RN C to have staff monitor R3, so he didn't return to R2's room. She assured me this would be done. I also asked her to write up a statement and give it to me when I got to work between 7:45 and 8 am. I reported this to NHA A on 11/26/24 at 9am. On 12/17/24 at 2:53 PM, Surveyor interviewed NHA A and asked when an abuse allegation should be reported to state. NHA A indicated within 2 hours. Surveyor asked NHA if the incident from 11/26/24 involving R2 and R3 was reported within 2 hours. NHA A indicated the facility was looking at this as a resident-to-resident altercation and as an isolated incident. Surveyor had NHA A look at time report that was submitted to state and the time incident occurred and asked if it was submitted within 2 hours. NHA A indicated the incident could be considered abuse and it was not submitted within the 2 hours.

Based on interview and record review, the facility did not ensure that residents were free from sexual abuse perpetrated by a resident for 1 of 6 sampled residents (R2). R3 was found in R2's room sitting on the edge of the bed with R2's Depends unfastened and fondling R2 between the butt cheeks. Evidenced by: The facility policy titled, Abuse, Neglect, and Exploitation Policy & Procedures, dated 2/25/23, states, in part: . Policy Statement: It is the policy of New Glarus (referred to as the facility herein) 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. Definitions: . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology . Sexual Abuse is non-consensual sexual contact of any type with a resident. Procedure: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and . III. Prevention of Abuse, Neglect, and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports .establishing policies and protocols for preventing sexual abuse . D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. E. Ensuring the health and safety of each resident . VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include . C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator . G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency . within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . R3 admitted to the facility on [DATE] and has diagnoses that include vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). R3's Admission Minimum Data Set (MDS) Assessment, dated 11/11/24, shows that R3 has a Brief Interview for Mental Status (BIMS) score of 5 indicating R3 has severe cognitive impairment. R3's Care Plan, dated 11/17/24, states, in part: Focus: The resident has a behavior problem (agitation, anxious, irritability, sexually inappropriate, potential to become aggressive) r/t (related to) dementia and depression. Date Initiated: 11/17/24. Revision on: 11/20/24. Goal: The resident will have fewer episodes of: Anxiousness, irritability, sadness, aggressive, sexually inappropriate behavior by review date. Date Initiated: 11/17/24. Revision on: 11/20/24. Target Date: 2/10/25. Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 11/17/24. -Anticipate and meet the resident's needs. Date Initiated: 11/17/24. -Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date Initiated: 11/17/24. -Explain all procedures to the resident before starting and allow the resident time to adjust to changes. Date Initiated: 11/17/24. Revision on: 11/17/24. -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date Initiated: 11/17/24. -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 11/17/24. -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. Date Initiated: 11/17/24. -Praise any indication of the resident's progress/improvement in behavior. Date Initiated: 11/17/24. Note: No new interventions were put into place on or after 11/26/24. R2 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia. R2's Quarterly MDS Assessment, dated 8/6/24 shows that R2 has a BIMS score of 5 indicating R2 has severe cognitive impairment. The Facility Self Report dated 11/26/24, states, in part: . Summary of Incident: Allegation type: Other: Reportable incident that is not misconduct related. Name - Affected Person: R2 Name of Accused Person: R3 . Is Date and time when occurred known? NO Date occurred .: BLANK. Time occurred: BLANK. Is occurred date and time estimated: BLANK. Date discovered: 11/26/24. Brief Summary of Incident: On [DATE], at 9:15 am, it was reported to NHA A (Nursing Home Administrator), Interim Administrator, that R3 was found sitting on the edge of the bed of R2. CNA (Certified Nursing Assistant) stated that R2's brief was pulled down; R3 was sitting on the bed touching R2 in his private area. R3 was extremely confused at the time of the incident; R2 remained asleep through the incident. R3 was immediately removed. R2 did not have any s/sx (signs/symptoms) of pain or emotional disturbances. R3 was assisted in wheelchair to dining room and placed on 15-minute checks. R2's assessment was negative for skin and pain. Both residents have activated POAs (Powers of Attorney). R3's BIMS 5/15 and R2's BIMS 3/15. Neither resident is interviewable. POAs and physicians were notified. Police Department is being contacted. Statements being taken. Investigation has begun. Person Preparing This Report: Name: NHA A . Report Submitted Date: 11/26/24 10:39:49 AM . R2 & R3 - Resident to Resident Altercation 11/26/24, Investigation Summary, states, On [DATE], at 9:15 am, it was reported to NHA A, Interim Administrator, that R3, resident, was found sitting on the edge of the bed of R2. CNA P and CNA D stated that R2's brief was pulled down; R3 was sitting on bed touching R2 in his private area. R3 was extremely confused at the time of the incident. RN C (Registered Nurse) was called to the 400 wing and assessed both residents and R3 was immediately removed. R2 did not have any s/sx (signs/symptoms) of pain or emotional disturbances. R3 was assisted in wheelchair to dining room and placed on 15-minute checks. R2's assessment was negative for skin and pain. RN C notified DON B (Director of Nursing). Both residents have activated POAs R3's BIMS 5/15 and R2's BIMS 3/15. Neither resident is interviewable. POAs and physicians were notified. Police Department is being contacted. Statements being taken. Investigation has begun . Care Plans were reviewed/updated as appropriate. Other residents on secure 400 wing were interviewed . RN C's statement, dated 11/26/24, states, in part: . At approximately 4:30 AM, CNA P working on the 400-hall called myself over to 500 hall and asked me to come over to the unit. Once I arrived, I saw R3 from room [421] sitting on the edge of R2's bed accompanied with the 2 CNAs working. The CNAs told me that R3 would not get up and leave the room. At which time I got R3's wheelchair and offered him a snack and drink which he was agreeable to and let us assist him into the wheelchair and out to the dining area. Once R3 was situated, CNA P told me that she found R3 in the room with R2, whose brief was pulled down, sitting on the bed, and touching R2 in his private area. CNA P also said that as she was leaving the room to call me, R3 slapped her on the butt and said, Now you get out of here. R3 seemed extremely confused at the time of the incident and was easily redirected when I arrived. R2 remained asleep through the incident and did not have any s/sx of pain or emotional disturbances. R3 was immediately placed on 15-minute checks . Email from DON B (Director of Nursing) to NHA A (Nursing Home Administrator) sent Tuesday December 3, 2024, 12:16 PM, states, On November 26, 2024, at 6:17 AM, I received a phone call from RN C regarding an incident involving two residents on the 400-wing, R3 and R2. She reported the staff was alerted by a call light going off in R2's room and found R3 touching R2 inappropriately after having removed R2's depends. Staff immediately removed R3 from the room. They did cares on R2 and reapplied depend. The staff said R2 slept through the entire incident. I asked RN C to have staff monitor R3, so he didn't return to R2's room. She assured me this would be done. I also asked her to write up a statement and give it to me when I got to work between 7:45 and 8 am. I reported this to NHA A on 11/26/24 at 9am. Abuse, Neglect, and Exploitation Policy and Procedure Training from 12/6/24 provided to Surveyor shows 117 staff out of 175 received this training. On 12/17/24 at 10:57 AM, Surveyor interviewed CNA D and asked CNA D to tell Surveyor about the incident that occurred on 1/26/24 between R2 and R3. CNA D indicated R3 and R2's rooms were adjoined by a bathroom. R3 had gotten up and walked through the bathroom into R2's room. CNA D indicated she knew this because CNA D and CNA P were sitting at the kitchen table and would have seen R3 if he would have been out in the hallway. CNA D indicated hearing movement and both CNA D and CNA P went to check and found R3 sitting on R2's edge of the bed. R2's depend was unfastened on one side and R3 was fondling R2's bottom with his hand between R2's butt cheeks. CNA D asked R3 what he was doing and informed R3 that R2 was a man. CNA D indicated R3 asked, That is a man? CNA D indicated R2 was full of BM (bowel movement) and R3's hand had BM all over it. CNA P moved R3 to his room into his recliner while CNA D stayed with R2 and cleaned R2 and applied a depend. CNA D indicated R2 was awake when both CNAs entered the room. Surveyor asked if R2 appeared to be scared or upset with what happened, and CNA D indicated no. CNA D indicated the CNAs called RN C right away, when RN C arrived CNA D indicated she left the room and CNA P stayed and took over. Surveyor asked if CNA D had received abuse training and CNA D indicated before she started at facility which was 90 days prior. On 12/17/24 at 11:53 AM, Surveyor interviewed RN C and asked RN C to tell Surveyor about the incident that occurred on 11/26/24 between R2 and R3. RN C indicated CNA D & CNA P called RN C around 4:00 AM. RN C indicated when she arrived to R2's room, R2 was sleeping in his bed and R3 was sitting on the edge of R2's bed. CNAs reported R3 would not leave R2's room. RN C offered R3 a snack trying to get R3 out of R2's room. RN C retrieved R3's wheelchair and R3 did get into wheelchair. RN C took R3 out to the dining room and gave him a snack then went back into R2's room when CNAs informed her they had entered R2's room to find R3 sitting on edge of R2's bed with R2's depend unfastened and R3 was fondling R2 in R2's private parts. RN C indicated the CNAs informed her R2 slept through the incident. RN C indicated she assessed R2's mental status and pain. Surveyor asked if RN C assessed R2's skin at that time and RN C indicated no due to R2's brief was on. RN C asked the CNAs if they had seen anything different when they cleaned R2 up. CNAs indicated no. RN C indicated she started R3 on 15-minute checks immediately. RN C indicated R3 was confused, and she assessed his needs and checked neuros (neurological checks). RN C indicated everything checked out ok. Surveyor asked when RN C had received abuse training and she indicated she was agency and received abuse training before she could pick up a shift at facility. RN C could not recall when abuse education was received. On 12/17/24 at 2:15 PM, Surveyor interviewed DON B (Director of Nursing) and asked regarding the incident on 11/26/24 with R2 and R3, and what was put into place to ensure residents' safety from R3. DON B indicated at the time of the incident R2 and R3 were separated and staff were to keep an eye on R3. Surveyor asked what that includes specifically and DON B indicated staff was to make sure R3 did not go back into R2's room and to always monitor R3's whereabouts. Surveyor asked if R3 was on 1:1 to ensure staff knew R3's whereabouts and DON B indicated no. Surveyor asked DON B if staff were documenting R3 was being monitored and DON B indicated no. Surveyor asked DON B if anything was put into place for other residents' safety. DON B indicated not that she was aware of. Surveyor asked if there should have been, and DON B indicated yes. Surveyor asked DON B if R3 or R2's Care Plans had been updated after the incident. DON B indicated the last time R3's Care Plan was revised was 11/20/24; no updates or new interventions were put into place regarding 11/26/24's incident. Surveyor asked if DON B would expect a new intervention to be placed after incident and DON B indicated yes. DON B indicated no interventions were put into place for R2 after the incident and there should have been. Surveyor asked DON B if R3 was put on 15-minute checks immediately after the incident, and DON B indicated she could not find anything in R3's medical record indicating R3 was placed on 15-minute checks or showing R3 is currently on 15-minute checks. Surveyor asked DON B if she would expect all staff to receive abuse education after an incident such as what occurred between R2 and R3. DON B indicated yes. On 12/17/24 at 2:53 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked when an abuse allegation should be reported to the State Agency. NHA A indicated within 2 hours. Surveyor asked NHA A if the incident from 11/26/24 involving R2 & R3 was reported within 2 hours. NHA A indicated the facility was looking at this as a resident-to-resident altercation and as an isolated incident. Surveyor had NHA A look at time report that was submitted to state and the time incident occurred and asked if it was submitted within 2 hours. NHA A indicated the incident could be considered abuse and it was not submitted within the 2 hours. Surveyor asked NHA A if education was provided to all staff after this incident and NHA A indicated NHA A felt it was an isolated incident that wouldn't involve all staff in the rest of the building. NHA A indicated she considered the incident to be a resident-to-resident altercation. Surveyor asked NHA A if education was provided to RN C and DON B due to the reporting time frames. NHA A indicated there was an email to DON B, but nothing documented for RN C. Surveyor asked NHA A if reporting abuse in the required 2 hours is part of abuse training. NHA A indicated yes abuse training should have been given to all staff due to the reporting factor of this incident. NHA A provided staff education on abuse from 12/6/24. Surveyor informed NHA A it would be looked at. Surveyor asked NHA A as of today have there been any interventions put into place to prevent this incident from happening again, NHA A indicated no. On 12/17/24 at 3:15 PM, DON B walked in NHA A's office while Surveyor was conducting the interview. NHA A asked DON B if at this time anything was put into place to prevent this incident from occurring again between R2 and R3 and DON B indicated no. DON B indicated nothing has been done to closely monitor R3 and R2 to prevent this from occurring again. No protections were put into place to prevent an incident from occurring again between R3 and R2 after staff found R3 in R2's room fondling R2 between the butt cheeks.

Based on interview and record review, the facility did not ensure the residents right to receive visitors of his or her choosing at the time of his or her choosing for 2 of 6 residents (R1 and R4). R1's medical record banner states R1's son, daughter, and daughter-in-law cannot visit. The facility posted a sign at the nurses' station indicating R1's son, daughter, and daughter-in-law are not allowed to visit. R4's medical record banner states R4 cannot receive visits from FM E (Family Member). The facility posted a sign at the nurses' station indicating R4 is not allowed visits from FM E. This is evidenced by: The facility Residents' Rights handout, undated, states, in part: .You retain the ability to exercise any rights that you do not delegate to a representative .You have the right to spend private time with visitors. The facility must permit your family, your representative(s), your physician, a representative of the state, and your Long-Term Care Ombudsman to visit you at any time . The facility provided an untitled and undated handout with headings of Dignity, Privacy, Grievances, Access, Notification and Transfer of Discharge that states, in part: You have the right to: .Private and unrestricted visits and communication with any person of your choice . Example 1 R1 admitted to the facility on [DATE] with diagnoses including vascular dementia, relationship distress with spouse or intimate partner, and depression. R1's 11/20/24 Brief Interview for Mental Status (BIMS) score is 13, indicating R1 is cognitively intact. R1's comprehensive care plan, printed on 12/17/24, includes the following: -Special Instructions: ***Per R1's POA H (Power of Attorney) [Wife Name] - Son [FM G (Family Member)], daughter in law [Name] & daughter [Name] are not allowed to visit or take R1 out of the facility***Please call Administrator, [NHA A] if they are in the building or trying to take him out*** -Focus: I have the following Advanced Directives on record Healthcare POA (Power of Attorney) . Goal: My Advanced Directives are in effect, and they will be carried out in accordance with my wishes on an ongoing basis . Interventions: My appointed health care representative will make all my health care decisions if I am incapacitated . -Focus: Per POA H: Son, daughter, and daughter in law are not to visit resident or take him out of facility at any time Goal: Son, daughter, and daughter in law will not visit resident or take him out of facility. They are allowed to send presnt's [sic] and cards. Interventions: Staff will ask son, daughter, and daughter in law to leave. If they do not leave staff are to call administrator. R1's Durable Power of Attorney for Health Care and Living Will dated 6/12/24, states, in part: .This advance directive form is an official document where you can write down your preferences for your health care. If someday you can't make health care decisions for yourself anymore, this advance directive can help guide the people who will make decisions for you. R1's Advance Directive Certification dated 7/28/22 states, in part: We certify that the principal is unable to receive and evaluate information effectively or to communicate decisions to such an extent that the principal lacks the capacity to manage his or her health care decisions. Of note, the activation of the Power of Attorney for Health Care only allows the POA to make health care decisions. This means the POA does not have authority to restrict R1's visitors. The facility posted sign at the nurses' station states: R1 was found to be incapacitated on 7/28/22. Power of Attorney is [Name]. I [POA H] do not want [FM G, daughter, and daughter in law] to be visiting R1 at the facility or taking R1 out of the facility. The first signature line was signed by POA H on 11/14/24. The second signature line was signed by SS F (Social Services) on 11/14/24. Handwritten at the bottom of the sign states: [POA H] is aware that we cannot monitor this 24/7. Signed by POA H on 11/14/24. R1's progress note dated 11/15/24 at 11:32 AM, written by SS F, states: Residents POA [Name] met with writer and stated that per her wishes that their son [Name] and his wife [Name] and their daughter [Name] are no longer allowed to visit Resident in the facility or take the Resident out of the facility. Document signed by POA and uploaded to [Electronic Health Record] labeled POA Visitor wishes. This was also put into [Electronic Health Record] under Special Instructions. [Name of POA] was made aware that we cannot monitor this 24/7. Writer and Administrator called [FM G] and [Daughter] to inform them of the POA's wishes. [FM G] stated that he would let his wife [Name] know. On 12/17/24 at 10:27 AM, Surveyor interviewed R1 regarding visitations. R1 indicated he would like to visit with his son, daughter, and daughter in law. On 12/17/24 at 10:10 AM, Surveyor spoke with FM G (Family Member, R1's son). FM G indicated the facility called him and said FM G, R1's daughter and daughter in law were no longer allowed to come to the facility to visit R1 because of POA H's wishes. FM G indicated he would like to visit with his dad. Example 2 R4 admitted to the facility on [DATE] with diagnoses including dementia, mild cognitive impairment, and depression. R4's comprehensive Minimum Data Set (MDS) assessment dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 10, indicating R4 has moderate cognitive impairment. R4's Power of Attorney for Health Care Document, dated 9/2/21, signed by R4, states, in part: .you may sign this legal document to specify the person whom you want to make health care decisions for you if you are unable to make those decisions personally . Designation of Health Care Agent .If I am no longer able to make health care decisions for myself, due to my incapacity, I hereby designate POA O to be my health care agent for the purpose of making health care decisions on my behalf. If he or she is ever unable to unwilling to do so, I hereby designate FM E (Family Member) to be my alternate health care agent . R4's Power of Attorney for Health Care Statement of Incapacity, dated 6/21/24, states, in part: I have personally examined R4 and certify that the patient meets the statutory definition of incapacity, in that the patient is unable to receive and evaluate information effectively or to communicate decisions to such an extent that the patient lacks the capacity to manage his or her health care decisions . Of note, the activation of the Power of Attorney for Health Care only allows the POA to make health care decisions. This means the POA does not have authority to restrict R4's visitors. On 8/20/24, the facility mailed a letter to FM E that states, in part: I am writing to inform you that the Power of Attorney for R4 has requested that you do not visit with her while she is a resident of the facility. This is a request we are legally obligated to honor, and we respectfully request that you refrain from visiting the [Facility Name] . R4's comprehensive care plan printed on 12/17/24 states in part: -Special Instructions: Per POA, FM E cannot have contact with resident-Contact Administrator, if FM E will not leave when asked by staff . -Focus: I have the following Advanced Directives on record healthcare POA . Goal: My advanced directives are in effect, and they will be carried out in accordance with my wishes . Interventions: My appointed health care representative will make all my health care decisions if I am incapacitated. On 12/17/12 at 10:03 AM, Surveyor interviewed CNA K (Certified Nursing Assistant) regarding visitations. CNA K indicated POA O requested FM E not be allowed to visit R4. CNA K stated there is a picture of FM E at the nurses' station and staff were instructed to ask her to leave and if FM E does not leave, staff are to call the administrator. On 12/17/24 at 10:13 AM, Surveyor interviewed LPN L (Licensed Practical Nurse) regarding visitations. LPN L indicated if R4 requested to see FM E, LPN L would talk to the DON (Director of Nursing) first because R4's POA does not want FM E to visit. On 12/17/24 at 10:19 AM, Surveyor interviewed CNA M regarding visitations. CNA M indicated FM E could not visit R4. CNA M indicated if R4 requested to visit with FM E, CNA M would have to speak with SS F because CNA M is unsure of the rules. On 12/17/24 at 10:36 AM, Surveyor interviewed CNA I regarding visitations. CNA I indicated residents can have visitors unless the POA or chart says different. CNA I indicated if there were visitation restrictions, a sign would be posted at the nurses' station. On 12/17/24 at 10:42 AM, Surveyor interviewed LPN N regarding visitations. LPN N indicated residents can have visitors unless the POA doesn't want them to. LPN N indicated a note would be posted at the nurses' station indicating any restrictions on visitation. On 12/17/24 at 10:58 AM, Surveyor interviewed MT J (Medication Technician) regarding visitations. MT J indicated residents could have visitors unless there was a situation where you would need to call the POA for approval. On 12/17/24 at 11:32 AM, Surveyor interviewed SS F regarding visitations and POA decision making abilities. SS F indicated that POA's care notified of medication consents, medication changes, care plan conferences and call to update them on everything. SS F indicated residents maintain their rights even if they have an activated POA. Surveyor asked if the POA has the authority to restrict who is able to visit with a resident and SS F indicated she did not know if the POA could make that decision or not. On 12/17/24 at 2:22 PM, Surveyor interviewed DON B regarding visitations and the decision-making authority POAs have. DON B indicated POAs have authority over finances and health care depending on the type of POA. DON B indicated POA for either finances or healthcare does not have the authority to restrict resident's visitors. DON B indicated it is the resident's rights to see whomever they want. On 12/17/24 at 2:53 PM, Surveyor interviewed NHA A regarding visitations and POA authority on decision making. NHA A indicated the POA should do what is in the best interest of the resident and the decisions should align with what the resident wants. NHA A indicated the POA has decision making authority in regard to finances or healthcare depending on the type of POA. NHA A indicated it is the residents' right to visit with whomever they want and a POA does not have the authority to restrict visitors.

Based on observation, interview, and record review, the facility did not ensure residents maintain acceptable parameters of nutritional and hydration status for 1 of 1 Residents (R11) reviewed for nutritional status. R11 did not have appropriate interventions put into place to prevent continued weight loss. R11 had a weight loss of 20.6 pounds/12.86% over 2 months and 10 days, indicating a severe weight loss. This is evidenced by: Facility policy titled, Weight Policy, undated, states in part, Goal: To evaluate and meet the nutritional needs of our residents. Objective: Obtain weights as ordered or specified by this policy to monitor changes in weight, weight patterns, and implement appropriate interventions as needed. Procedure: . 3. Each resident will have weight measured at least monthly, unless on hospice. Weight may be obtained weekly, bi-weekly, or daily, depending on the specific needs of an individual resident . 5. If the current weight is +/- 4# (pounds) different than previous weight, resident must be re-weighed. Re-weight must be noted on the weight sheet. If weight changes persist, assess: . For Loss: Changes in condition, chewing or swallowing difficulty, change in diet/appetite/intake, denture fit, oral problems, changes in diuretic medications . 8. Weights are to be recorded on the daily/weekly/monthly weight sheets, located at the nurses station. 9. Each month, the RN (registered nurse) and RD (registered dietician) will assess the weights of the resident's and document this If unexplainable or not anticipated weight changes are significant, (resident gains or loses 5% of their body weight in 30 days or 10% in 180 days) they will be added to New Glarus Home: Critical At Risk monitored to be reviewed by RN/RD. R11 was admitted to the facility on [DATE], with diagnosis that include, in part: Bipolar II disorder (mental illness that cycles through high and low moods), weakness, Major Depressive Disorder, morbid obesity, aortic aneurysm (weak spot in the aorta that begins to bulge), and Type 2 Diabetes Mellitus (chronic insulin resistance or insufficient insulin production). R11's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/24 states in part, R11 has a Brief Interview for Mental Status (BIMS) of 9 out of 15, indicating that R11 has a moderate cognitive impairment. E0100 indicates the resident does not exhibit symptoms of hallucinations or delusions. E0800 also indicates that the resident did not refuse cares during the observation period. GG0115 indicates the resident has no impairment in her upper extremities with bilateral lower extremity impairment. GG0130A states the resident only requires assistance with setup or clean-up. K0100 indicates the resident did not exhibit signs of a possible swallowing disorder. K0300 indicates the resident has had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months that was not a physician-prescribed weight-loss regimen. R11's Comprehensive Care Plan, states, in part: Focus: [Resident Name] has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) arthritis, I am overweight, hx (history) of bipolar, depression, diabetes. Goal: The resident will maintain current level of function in my ADLs through the review date. Date Initiated: 1/29/24. Revision on: 9/11/24. Target Date: 12/8/24. Interventions/Tasks: . EATING: without help if you set out what I need I would like small portions. Help me to put my glasses on before I eat. Date initiated: 2/8/24. (Of note: After all of R11's weight changes and being added to the facility's Critical at Risk Monitoring meetings, R11's care plan still indicates she is overweight. Additionally, R11 does not have a specific care plan related to her nutrition status or nutrition risk,) R11's Physician Orders state, in part: High Protein/High Calorie diet, Regular texture, Regular/Thin consistency. Start date: 8/29/24. House Supplement (Shakes). Start date: 2/1/24. R11's Meal Card for breakfast on Friday, 12/6/24, indicates the resident has a regular diet, with regular texture and thin fluids. (Of note: R11's previous diet was a carbohydrate control diet as treatment for her type 2 diabetes). R11's weights were documented as follows: 7/1/24: 160.2 lbs. (pounds) 8/22/24: 144.9 lbs. 9/11/24: 139.6 lbs. 10/1/24: 140.9 lbs. 10/2/24: 140.9 lbs 10/19/24: 142 lbs. 10/28/24: 137.8 lbs. 10/31/24: 139 lbs. (Of note: from July 2024 through survey entrance date of 12/2/24, these are all the weights that had been assessed for R11. Facility policy states the resident should be weighed at least monthly, however R11 did not have a recorded weight for November). R11's meal intake documentation indicates, in part: 11/6/24 at 1:58 PM: 51%-75% 11/7/24 at 1:57 PM: 75%-100% 11/7/24 at 9:09 PM: 25%-50% 11/8/24 at 9:00 AM: 51%-75% 11/8/24 at 1:00 PM: 51%-75% 11/9/24 at 11:28 AM: 51%-75% 11/9/24 at 1:00 PM: 51%-75% 11/10/24 at 10:00 AM: 51%-75% 11/10/24 at 1:00 PM: 51%-75% 11/10/24 at 9:56 PM: 75%-100% 11/11/24 at 9:00 AM: 25%-50% 11/11/24 at 1:00 PM: 25%-50% 11/12/24 at 10:20 AM: 51%-75% 11/12/24 at 1:00 PM: 75%-100% 11/13/24 at 9:00 AM: 75%-100% 11/13/24 at 1:00 PM: 75%-100% 11/14/24 at 11:19 AM: 25%-50% 11/14/24 at 1:00 PM: 25%-50% 11/14/24 at 6:00 PM: 51%-75% 11/15/24 at 10:31 AM: 25%-50% 11/15/24 at 1:39 PM: 51%-75% 11/16/24 at 11:00 AM: 51%-75% 11/16/24 at 1:51 PM: 51%-75% 11/16/24 at 8:36 PM: 0%-25% 11/17/24 at 1:35 PM: 75%-100% 11/18/24 at 10:26 AM: 51%-75% 11/18/24 at 12:00 PM: 51%-75% 11/18/24 at 6:00 PM: 25%-50% 11/19/24 at 10:16 AM: 51%-75% 11/19/24 at 1:00 PM: 0%-25% 11/19/24 at 6:00 PM: 25%-50% 11/20/24 at 1:59 PM: 51%-75% 11/20/24 at 9:09 PM: 75%-100% 11/21/24 at 8:54 AM: 25%-50% 11/21/24 at 1:29 PM: 25%-50% 11/21/24 at 9:46 PM: 25%-50% 11/22/24 at 10:35 AM: 0%-25% 11/22/24 at 1:30 PM: 25%-50% 11/22/24 at 6:00 PM: 25%-50% 11/23/24 at 9:56 AM: 51%-75% 11/23/24 at 1:00 PM: 25%-50% 11/23/24 at 9:32 PM: 51%-75% 11/24/24 at 10:44 AM: 25%-50% 11/24/24 at 1:00 PM: 0%-25% 11/24/24 at 8:49 PM: Resident Refused 11/25/24 at 6:00 PM: 75%-100% 11/26/24 at 1:44 PM: 51%-75% 11/26/24 at 7:40 PM: 51%-75% 11/27/24 at 9:42 AM: 51%-75% 11/27/24 at 1:22 PM: 51%-75% 11/27/24 at 6:00 PM: 51%-75% 11/28/24 at 1:47 PM: 75%-100% 11/29/24 at 9:48 AM: 75%-100% 11/29/24 at 1:32 PM: 75%-100% 11/30/24 at 9:00 AM: 25%-50% 11/30/24 at 1:00 PM: 25%-50% 11/30/24 at 6:00 PM: 0%-25% 12/1/24 at 10:28 AM: 0%-25% 12/1/24 at 1:47 PM: 25%-50% 12/1/24 at 6:00 PM: 0%-25% 12/2/24 at 9:00 AM: 25%-50% 12/2/24 at 1:00 PM: 0%-25% 12/2/24 at 9:12 PM: 25%-50% 12/3/24 at 9:31 AM: 51%-75% 12/3/24 at 1:22 PM: 75%-100% 12/3/24 at 9:01 PM: 25%-50% 12/4/24 at 11:00 AM: 0%-25% 12/4/24 at 1:55 PM: 25%-50% (Of note: The facility was only able to provide meal intake data for the past month. Data provided included all recorded meals from 11/6/24 through a partial day on 12/5/24. 16 meals provided to this resident had no recorded intake. 32 of the 84, or 38% of the recorded meals indicated R11 consumed less than 50% of the meal. No dietary interventions were added in November 2024 or December 2024.) On 7/29/24 at 10:59 AM, a Progress Note was written by RD O (Registered Dietician). This note states, Ate 50% or less for 2 or more meals in the day. RD aware. Weight continues to remain stable and within baseline weight range. Will continue to monitor. (Of note, the last recorded weight for this resident was 7/1/24, limiting the RD's ability to determine if R11's weight was stable or not.) On 7/29/24 at 2:22 PM, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware and continues to monitor. On 8/5/24 at 1:13 PM, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware and is continuing to monitor her weight status. (Of note: Even after three notes within seven days regarding R11's poor oral intake, R11 was not reweighed until 8/22/24. Additionally, no notes were written regarding R11 refusing to be weighed.) On 8/22/24 at 10:29 AM, a Progress Note was written by RD O. The note states: Ate 50% or less for 2 or more meals in the day. RD continues to remain aware and following weight status. On 8/22/24 R11 weighed 144.9 lbs. (This is a 15.3 pound or 9.55% loss since 7/1/24, this amount of weight loss is considered severe.) On 8/26/24 at 4:03 PM, a Progress Note was written by RD O. The note states: Ate 50% or less for 2 or more meals in the day. RD continues to monitor and follow. On 8/26/24 at 4:08 PM, a Progress Note was written by RD O. This note indicates R11 has had a weight of 144.9 which is a 15.3 lbs. change from her previously recorded weight. The note also states: RD noting significant weight loss over the last 1.5 months. RD updating MD (medical doctor) now, along with requesting the start of House Supplements BID (twice a day) and ordering a High Protein/High Calorie diet. Will additionally add to CAR (Critical At-Risk) monitoring. On 8/29/24 at 10:38 AM, a Progress Note was written by RD O. The note indicates that the reason for monitoring is R11's significant weight loss. It also indicates that the resident has been noted to have lower meal intakes between 25-75% for most recorded meals. RD O recommends offering R11 alternative options if she does not eat enough of her meal. RD O also indicates she has no concern for R11's ability to swallow and make meal preferences known. On 8/29/24 at 10:39 AM, an assessment titled, Mini Nutritional Assessment is conducted in which R11 scores an 8 out of 14, indicating she is at risk for malnutrition. This assessment was completed by RD O. (Of Note, nothing additional was put into place after assessing R11 as being at risk for malnutrition.) On 9/11/24 R11 weighed 139.6 lbs. (12.85% weight loss in a little over 2 months.) On 9/12/24 at 7:31 AM, a Progress Note was written by RD O. The note indicates that the reason for monitoring is R11's significant weight loss. It also indicates R11's meal intakes continue to be lower, between 25%-75%. Additionally, RD O recommends Mirtazapine (antidepressant and appetite stimulant medication). This note indicates RD O sent this recommendation to the MD to consider. (Of note: This medication recommendation never comes up again in RD O notes, MD notes, or NP notes.) On 9/12/24 at 7:32 AM, a Progress note is written by RD O. The note indicates R11 has a weight of 139.6 lbs., which is an additional weight loss of 5.3 lbs. since the previous weight on 8/22/24. The note states, in part: RD aware and continuing to monitor closely at Critical At Risk. RD did fax MD with update. On 9/12/24 at 7:33 AM, a Progress note is written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware and continues to monitor. On 9/12/24 at 7:31 AM, a Progress Note was written by RD O. This note states, in part: . Current weigh is at 139.6# (from 9/11, however no new weight checks since this time) . On 10/14/24 at 11:05 AM, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware. Continue to monitor resident closely at Critical At Risk. On 10/17/24 at 10:26 AM, a Progress Note was written by RD O. This note states, in part: . Current weigh is at 140.9# (10/2) . On 10/21/24 at 12:56 PM, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware, with resident continuing to be monitored at weekly Critical At Risk. On 10/24/24 at 10:58 AM, a Progress Note was written by RD O. This note states, in part: . Her family does desire comfort for her, however comfort care measures have not been ordered. RD will continue to monitor and follow closely at Critical At Risk, until nutritional status stabilizes. On 10/24/24 at 10:58 AM, a Progress Note was written by RD O. This note states, in part: . Current weight is at 137.8# (down 5# x 1 wk (week)) . She does continue with weekly weight check orders . On 10/31/24 at 11:13 AM, a Progress Note was written by RD O. The note indicates R11 has a weight of 137.8 lbs., which is a weight loss of 10.4% over 180 days. The note states, in part: RD aware and continues to monitor resident closely at Critical At Risk monitoring. On 10/31/24, R11 weighed 139 lbs. which is a 13.23% weight loss in less than 120 days. No documentation/evidence that new interventions were put in place to prevent further unintentional weight loss from occurring for R11 despite being monitored weekly by the RD and IDT team. On 11/8/24 at 9:39 AM, a Progress Note was written by RD O. This note states, in part: . Current weight is at 139.8# . She does continue with weekly weight check orders . R11 was not weight the week of November 3rd thru the 9th. On 11/11/24 at 11:24, a Progress Note was written by RD O. This note states: Ate 50% or less for 2 or more meals in the day. RD aware, with resident continues to monitor resident closely at Critical At Risk. R11 was not weighed the week of November 10th thru the 16th On 11/14/24 at 9:55 AM, a Progress Note was written by RD O. This note states, in part: . Current weight is at 139.8# (from 10/31/24), . She does continue with weekly weight check orders . R11 was not weighed the week of November 17th thru the 23rd On 11/21/24 at 10:24 AM, a Progress Note was written by RD O. This note states, in part: . Last obtained weight check was at 139.8# (from 10/31/24, no new weight checks), . She does continue with weekly weight check orders . On 11/25/24 at 12:24 PM, a Progress Note was written by RD O. This note states, in part: . Last obtained weight check was at 139.8# (from 10/31/24, no new weight checks), . She does continue with weekly weight check orders . R11 was not weighed the week of November 24th thru the 30th. On 12/2/24 at 10:41 PM, a BIMS evaluation is conducted on R11 that indicates she has a score of 4 out of 10 indicating severe cognitive impairment. On 12/2/24, an assessment titled, Mini Nutritional Assessment is conducted in which R11 scores a 9 out of 14, indicating she is at risk for malnutrition. This assessment was completed by RD O. (Of note: At no point was the facility recording weekly weights or documenting resident refusals to obtain weekly weights. RD O made no further recommendations besides the mirtazapine in which there is no documented follow-up.) Surveyor reviewed nutritional assessments located in R11's current electronic medical record and can find no indication of R11's preferred foods or a repeat ability assessment following the change in her BIMS score from 9 (moderate cognitive impairment) to 4 (severe cognitive impairment) on 12/2/24. (Of note: Surveyor has concerns with R11's ability to state meal preferences due to the recent BIMS decline and Surveyor's observations of R11 feeding herself.) On 12/5/24 at 9:44 AM, Surveyor interviewed CNA P (Certified Nursing Assistant). Surveyor asked CNA P how she knows which residents need to be weighed each day. CNA P indicates the nurses tell her who needs to get weighed, but they are also on sheets at the nurses' station. CNA P also indicates she is aware every resident is weighed at least monthly and knows every resident needs to be weighed the first of the month. On 12/5/24 at 10:00 AM, Surveyor interviewed CNA Q. Surveyor asked CNA Q how she knows which residents need to be weighed each day. CNA Q indicates the nurses give the CNAs the list before breakfast and does not think it is written down anywhere. Surveyor asked CNA Q if there is a list or any written papers that list which residents need to be weighed. CNA Q states she does not think so. On 12/5/24 at 10:10 AM, a Progress Note was written by RD O. This note states, in part: . Last obtained weight check was at 139.0# (from 10/31/24, no new weight checks), . She does continue with weekly weight check orders . On 12/5/24 at 10:15 AM, Surveyor observed two binders on the nurse's station desk. The first binder, titled, 300 CNA Binder contained information about resident transfer statuses, and special instructions, however Surveyor could not locate weight frequency in this binder for any resident. The second binder, titled, 300 Wing- Nurse Report Book had residents listed with different weight schedules, such as daily weights. However, no special instruction was given to provide weekly weights to R11. R11 was not weighed December 1st through December 5th, until Surveyor asked staff to weigh R11. On 12/5/24 at 10:28 AM, Surveyor observed CNA P and CNA R weigh the resident utilizing a Hoyer lift. R11 was agreeable to getting weighed and the process was conducted following current standards of practice. R11 weighed 133.7 lbs. at this time, which is another 5.3 lbs. of weight loss since her last weight on 10/31/24. On 12/5/24 at 10:30 AM, Surveyor interviewed CNA R. Surveyor asked CNA R how she knows which residents need to be weighed each day. CNA R indicates the nurses give the CNAs the list. CNA R also indicates she knows every resident is weighed at least monthly and knows every resident needs to be weighed the first of the month. On 12/5/24 at 10:34 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what interventions the facility has in place to prevent R11 from losing more weight. DOB B indicates R11 is involved in facility Clinical At Risk meetings and has been for the past 13 weeks, she is receiving a house supplement three times a day and is consuming 75%-100% of those. Surveyor asked DON B to describe the Critical At Risk meetings. DON B indicates herself, the registered dietician, the MDS coordinator, and wound nurse are involved in the meetings and they monitor wounds and weight loss in the meetings. Surveyor asked DON B how recommendations from the registered dietician are communicated and put into the electronic medical record. DON B indicates the registered dietician will email her with the recommendation, and if it is a standing order they can approve it right away and then the registered dietician will also fax the doctor for order approval, if required. Surveyor asked DON B how frequently R11 should be weighed. DON B states she should be weighed weekly. DON B indicates she believed R11 had weekly weights scheduled for Fridays, but searched the electronic medical record and was unable to locate the order. Surveyor asked DON B if R11 should have been weighed weekly. DON B states, yes. On 12/5/24 at 12:56 PM, Surveyor observed R11 eat her lunch meal in her room. R11 received her tray placed on her bedside table, over her lap so that it was accessible, at 12:59 PM. R11 was able to pick up, open, and eat a package of crackers by herself. After eating all her crackers, R11 began sticking her fingers into her cake, swirling her fingers around in the frosting, and periodically licking the frosting from her fingers. After two minutes, CNA S walked into the room. When the CNA introduced herself to the resident, R11 asked what the cake was, and CNA S explained to the resident that it was cake, and asked R11 if she needed help. R11 repeated the phrase, I don't think I need it, whenever CNA S asked if she needed help. CNA donned gloves and stood over the resident asking if R11 wanted any of her stew or vegetables. R11 could not see or did not realize there were vegetables on the plate to the side of her bowl of stew, as she asked, What are those? CNA S explained there was broccoli and cauliflower on her plate and assisted R11 with rearranging the tray so that the vegetables were visible to R11, moving the vegetables from the side of the bowl to the front of the bowl, closer to R11. CNA S then handed R11 her spoon and proceeded to assist R11's roommate. Surveyor observed R11 being able to use the spoon to feed herself the stew, however she appeared to be straining her neck as not to spill stew on her clothes. On 12/5/24 at 1:11 PM, Surveyor interviewed CNA S. Surveyor asked CNA S if R11 needs assistance eating. CNA S indicates that she usually doesn't need help eating, but that there are foods she struggles with eating. Surveyor asked CNA S if she always goes in to assist R11 eat. CNA S indicates she only goes in to check on her periodically. On 12/5/24 at 3:50 PM, Surveyor interviewed RD O. Surveyor asked RD O if R11 was meeting her required nutritional needs. RD O states, no. RD O also indicates the facility has added R11 to the Critical At Risk meetings, added nutritional interventions starting in August 2024, changed R11's diet to high protein and high calorie, and started tracking weekly weights and nutritional intake. RD O also indicates that R11 refuses to eat meals at times and the family is still considering comfort cares. Surveyor asked RD O how often R11 should be getting weighed. RD O states she should be getting weighed weekly, but also notes R11 has a tendency to refuse weights and has refused RD assessments. Surveyor asked RD O if RD O has assessed R11's ability to feed herself. RD O states she has and indicates there are days where R11 is alert and very capable of feeding herself and there are days where R11 is very sleepy and needs more help. RD O also indicates that R11 could use all the encouragement and cues she can get. Surveyor asked RD O if she knew what came of her recommendation for mirtazapine. RD O indicates she is unable to specifically recall, however she believes it was trialed and R11 did not like it or it may have been due to comfort cares. Surveyor asked RD O what she believes is the cause of R11's weight loss. RD O indicates it is a combination of a lack of appetite and overall decline. Surveyor asked RD O if she was aware of the BIMS score of 4 out of 15, obtained on 12/2/24. RD O indicates she was not. Surveyor asked RD O if she would have reassessed R11's capacity to feed herself if she was made aware of the significant decline in BIMS score. RD O indicates she would have reassessed. (Of note, there is no documentation in progress notes or MDS data indicating R11 is refusing weights. There is a single instance of R11 refusing a meal within the 30 days prior to record review. Additionally, Surveyor has reviewed the past 6 months of available nutritional assessments, all of which are complete. There is no documented response to the mirtazapine recommendation.) On 12/5/24 at 4:46 PM, Surveyor interviewed DON B. Surveyor asked DON B if the Mirtazapine recommendation was followed up on with a provider. DON B indicates the physician also saw R11 on 9/12/24, the same day the recommendation was made, however there is no mention of the recommendation in his notes. Surveyor asked DON B if this recommendation should have been followed up on. DON B states, yes. Surveyor described the observation made of R11 eating that is detailed above. Surveyor asked DON B what her conclusion is from hearing this observation. DON B states, somebody should be in there to assist her to eat. Surveyor asked DON B why the house supplement was not increased. DON B states R11 has been three times a day since February 2024 and the facility did not increase this because the supplement they use is ideally given in between meals so it doesn't take up food space in between. Surveyor asked DON B if the facility had assessed R11's preferred foods. DON B searched for a specific nutrition assessment that asked for food preferences. DON B indicates dietary is in charge of this assessment and describes it as a dietary profile, however upon searching, DON B is unable to locate this assessment. (Of note: Some food preferences are listed on a nutrition assessment from 12/8/17, that was found in a different electronic medical record than the one currently being used by the facility. There is no documentation indicating staff are offering R11 her preferred foods to help increase meal intakes.) R11 had severe weight loss due to a decline in nutritional intake. Staff were not monitoring R11's weights and did not consistently monitor meal intakes to ensure she was meeting her estimated daily needs. The facility did not implement appropriate interventions or a care plan to prevent R11 from experiencing further weight loss. Recommendations from the registered dietician did not have a documented response, or trial period from R11's physician. The registered dietician was not informed of R11's cognitive decline to allow for further assessment and any new interventions that may be needed. This resulted in R11 experiencing a sever weight loss in less than 6 months.

Based on observation, interview, and record review, the facility did not ensure 1 resident (R2) of 2 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R2 was at risk for pressure injury (PI) development. R2 developed a Stage 3 PI to the right ischium. Facility staff did not ensure PI interventions were in place and did not implement appropriate offloading interventions until after the PI was discovered. The facility policy, Pressure Injury Prevention and Management, updated 7/18/23, indicates, in part, as follows: The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to health [sic] the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, residents goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Procedure: There are multiple terms used to describe this type of skin damage, including pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. For purposes of this policy, pressure injury, as the current standard terminology, will be used. 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. Interventions for Prevention and to Promote Healing: 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. 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). Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Redistribution pressure (such as repositioning, protecting and/or offloading heels, etc.); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces . Findings Include: R2 was admitted to the facility 5/15/13 with diagnoses including, but not limited to: cerebral palsy (group of movement disorders that affect movement, muscle tone, and/or posture), schizophrenia (mental illness characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), and malignant neoplasm of endometrium (cancer of the uterine lining). R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/24 indicates a Brief Interview of Mental Status (BIMS) score of 10 indicating she is moderately cognitively impaired. Section GG of the MDS indicates R2 is dependent on staff to roll left and right. Section M of the MDS indicates R2 has a facility acquired Stage 3 PI. R2 is at risk for pressure injuries. Surveyor attempted to speak with R2. R2 did not respond. R2 has an Activated Power of Attorney for Health Care (APOAHC). R2's comprehensive care plan with discontinued entries, dated 12/5/24, documents R2 had no skin interventions in place prior to the development of a Stage 3 PI. On 1/2/24. R2's Progress Notes document the following: Admission: Skin Problems: has no skin condition. R2's Braden Scale for Predicting Pressure Sore Risk are as follows: 1/12/24: 12 (10-12=High Risk) - On 1/12/24 the facility determined R2 is at high risk of PI and did not implement skin interventions until after the PI is discovered at a Stage 3 on 1/18/24. Braden Scale: Sensory Perception: slightly limited - responds to verbal commands, can't alwayscommunicate pain or need to reposition. Moisture: constantly moist - related to perspiration, urine, etc. - dampness noted every time resident is moved or turned. Activity: chairfast - ability to walk is severely limited or none, can't bear weight and/or is assisted to chair or wheelchair. Mobility - very limited - makes occasional slight changes in body/extremity position, can't make frequent/significant changes alone. Nutrition: Adequate - eats more than 1/2 of most meals, eats 4 proteins per day, occasionally refuses a meal, usually take a supplement. Friction/Shear: poblem - moderate/maximum assistance to move, can't lift without sliding on sheets, slides in bed/chair, constant fiction. Score: 12 Risk Category: 10-12= high risk of skin breakdown. It is important to note, on 1/12/24, the facility is aware that R2 is at high risk for developing a pressure injury. The facility did not implement skin interventions until after the PI developed. 3/21/24: 13 (13-14=Moderate Risk) 4/25/24: 12 (High Risk) 7/21/24: 9 (9 or below=Very High Risk) 10/22/24: 14 (Moderate Risk) On 1/18/24 at 10:20 PM, R2's Progress Notes document the following assessment by a Registered Nurse: Area 1: Right ischial area; Assessment Type: Initial assessment; Onset/Discovery Date: 1/18/24; Origin: Noted after admission; Initial Stage: stage 3; Tissue Type: granulation; Wound Tissue: pink; Granulation Tissue: Percentage is blank; 100% NECROTIC TISSUE: none viable; Shape of Wound: Irregular; Wound Edges: Distinct, outline clearly visible, attached, even with wound base; Undermining: none present; Tunneling: no tunneling; Surrounding Wound Tissue: Macerated; Surrounding Wound Edema: No swelling or edema; Surrounding Wound Induration: none present; Exudate: Serosanguineous; Exudate Amount: moderate - wound tissues are wet; drinage involves more than 25-75% of the dressing; Condition of the dressing: No dressing; Pain at Pressure Injury Site: unable to answer, no non-verbal signs or symptoms of pain present; Healing Progress: not applicable (new area); Depth/Thickness: depth 0.3 cm Length 2.7 cm Width: 3.0 (Standard Charting: 2.7 cm x 3.0 cm x 0.3 cm) Pressure Injury Infection: non s/s (signs/symptoms) of infection present. Action: Call placed to POA (Power of Attorney) without answer-will await a return response. Therapy referral made for positioning. On 1/19/24 at 11:03 PM, R2's Progress Notes document the following assessment: Incident type: other: skin integrity r/t issues. New open area to R (right) gluteal area to buttock. Ruddy colored skin patchy white colored superior side and inferior lateral side of irregular shaped 2.7 cm x 3.0 cm x 0.3 cm. RN (Registered Nurse) staff nurse also view redness and curled skin edges per circumference. Serosang (Serosanguineous) drainage; Measurement: 2.7 x 3.0. Location on Body: R (right) gluteal cleft/fold of buttock 0.3 depth Stage 3 ulcer per Physician (Physician V). Witnesses: none; Functional Level: visual impairment; Impulsive decision maker, cognitive impairment; Derm incontinence and circulation r/t (related to) issues; Transfer/Assistive Devices: EZ lift; Resident Interviewable: no; Pertinent Diagnosis/Meds/Labs: fragile skin, derm incontinence. Root Cause of Injury: fragile skin and derm incontinence brief irritated skin; Interventions in place to prevent further injury: Resident to lay down off R (right) side post meal time and HS (bedtime). No brief while in bed. Follow up with wound care MD (Medical Doctor) and Primary MD. MD Notification: Physician V; Date Notified: 1/18/24; Time Notified: 10:22 PM; .Teaching Done: none/not applicable. New orders received. R2's current wound care order: Rt (right) ischium - cleanse/dry, apply collagen sheet to wound bed, cover with calcium alginate, cover with gauze island dressing every evening and night shift AND as needed for missing or soiled dressing On 2/8/24, the wound physician assessed R2 for the first time. The physician's assessment is as follows: 2/8/24: Stage 3 Pressure Wound of the Right Ischium Full Thickness Etiology: Pressure Stage: 3 Duration: Greater than 18 days Objective: Healing/Maintain Healing Wound Size: 2.5 x 3.0 x 0.2 cm Exudate: Moderate Sero-sanguinous Thick adherent devitalized necrotic tissue: 20% Granulation tissue: 80% Wound Progress: Not at goal Surgical Excisional Debridement Procedure completed Dressing Treatment Plan: Primary Dressing: Alginate calcium with silver apply once daily for 30 days. Secondary Dressing: Gauze island with bdr (border) apply once daily for 23 days. On 11/4/2024 at 10:42 PM, R2's Progress Notes document the following: Administration Note Note Text: wound care: Rt ischium - cleanse/dry, apply iodosorb to wound bed, cover with calcium alginate, cover with gauze island dressing every evening and night shift wound left open to air this PM shift. Wound dressing becomes saturated with urine and the urine is trapped against skin. Resident is demonstrating greater skin break down at this time. On 12/4/24 at 10:15 AM, Surveyor observed R2's PI. Surveyor asked LPN D (Licensed Practical Nurse) if R2's PI has improved. LPN D stated, it has improved quite a bit and the physician just changed the treatment. LPN D stated, R2 had a foley catheter in for a while as urine would keep going into that area. LPN D stated, R2 was previously on a chux in bed and now they put briefs on R2 while in bed and that seems to be pulling more moisture away from her skin. LPN D added, R2 has a cyst that also drains and she may have cancer. LPN D stated, R2's APOAHC does not want any further interventions done. On 12/5/24 at 1:47 PM, Surveyor spoke with CNA C (Certified Nursing Assistant). CNA C has worked at the facility for one (1) year. Surveyor asked CNA C, did you get R2 up this morning. CNA C stated, yes. Surveyor asked CNA C, was R2's dressing in place when you got her up. CNA C stated, no. Surveyor asked CNA C, did you tell anybody. CNA C stated, it was at shift change and she told both the NOC (night) nurse and LPN D (Licensed Practical Nurse), the AM shift nurse. CNA C stated, usually R2's dressing is on but she has noticed an issue with NOC shift and the dressing not being on when she comes on for the AM shift. CNA C stated, sometimes when she arrives at 6:00 AM, R2 is already up and dressed for the day and we don't realize her dressing is off until later that day. CNA C stated, she does not know if there's miscommunication on the NOC shift or they forget. CNA C stated, usually throughout the day if the dressing is soiled or off we tell the nurse on duty. CNA C stated, the nurse will put the dressing on before the next meal or whenever she has time. Surveyor asked CNA C, how often do you notice that R2's dressing is off. CNA C stated, 2-3 days out of the week R2's dressing is not on. CNA C added, it varies depending on the nurse on. Surveyor asked CNA C, if she has noticed any correlation with the dressing being off and the nurse on duty. CNA C stated, yes, most often when agency staff are working that's when she notices the dressing off. CNA C added, there's more agency on NOC shift than other shifts. On 12/5/24 at 1:50 PM, Surveyor observed R2's dressing in place. On 12/5/24 at 1:15 PM and 4:20 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, when was R2's PI discovered. DON B stated, 1/18/24. Surveyor asked DON B, when was the physician notified. DON B stated, 1/18/24. Surveyor asked DON B, if a resident is at risk of PI's (Braden) would you expect interventions to be in place. DON B stated, yes. Surveyor asked DON B, what stage was R2's PI when it was discovered. DON B stated, a Stage 3. Surveyor asked DON B, did the facility complete a root cause analysis for R2's PI. DON B stated, she has no idea it was before she was working at the facility. Surveyor asked DON B, what skin interventions were in place prior to the PI being discovered. DON B stated, none. DON B stated, that's not a good thing. Surveyor asked DON B, would you expect staff to find a PI before it reaches this point. DON B stated, yes. DON B checked to see if R2 had gone out to the hospital prior to the PI being discovered and stated the resident had not been out to the hospital. Surveyor asked DON B if their wound care nurse is wound care certified. DON B stated, yes, she is. Surveyor asked DON B, did the facility provide education to staff following this PI being discovered. DON B stated, she hasn't seen anything and she has been through the file cabinet in her office. DON B reached out to the facility's wound care nurse regarding training. The facility did not provide any additional information. Surveyor asked DON B, when was R2's last skin assessment prior to the PI being discovered on 1/18/24. DON B stated, the facility does not complete bath sheets and she is unsure. DON B stated, she will check. Surveyor showed DON B the progress note from 11/4/24 indicating, .wound left open to air this PM shift. Wound dressing becomes saturated with urine and the urine is trapped against skin. Surveyor asked DON B, is it acceptable for staff to leave a PI uncovered. DON B stated, no. Surveyor asked DON B, why is it important to keep PI's covered. DON B indicated for infection control. Surveyor asked DON B, is it also important for wound healing. DON B stated, absolutely. DON B stated, she has been told that this nurse doesn't like to change R2's dressing. Surveyor asked DON B, have you provided education to this nurse. DON B stated, no, she has not had a chance.

Based on observation, interview, and record review, the facility did not establish and maintain an Infection Control Program designed to provide a safe environment to help prevent the development and transmission of disease and infection (such as Legionella). This has the potential to affect all 90 residents who reside in the facility. The facility did not maintain a water management program to prevent the spread of Legionella. The facility did not ensure laundry services were being conducted according to current standards of practice to prevent the transmission of communicable diseases between residents. One resident was not added to the line list after showing signs and symptoms of an infection according to facility policy and procedure. This is evidenced by: Example 1: The facility policy titled, Infection Prevention and Control Program Policy, dated 2/13/23, states in part: .Water Management: a. A water management program has been established as part of the overall infection prevention and control program. b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. c. The Maintenance Director serves as the leader of the water management program . The facility policy titled, Water Management Program Policy, undated, states in part: Policy Statement: It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens . in the facility's water systems based on nationally accepted standards . Procedure: 1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing . 2. The Maintenance Director maintains documentation that describes the facility's water system. A copy is kept in the water management program binder. 3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements: A. Premise plumbing . b. Clinical equipment .c. At-risk population - The facility's entire population is at risk. High risk areas shall be identified through the risk assessment process. Supporting documentation of any areas or resident population that exhibit greater risk than the general population shall be kept in the water management program binder . 5. Based on the risk assessment control points will be identified. The list of identified points shall be kept in the water management program binder. 6. Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. The measures shall be specified in the water management action plan . 8. The water management team shall regularly verify the water management program is being implemented as designed . 9. The effectiveness of the water management program shall be evaluated no less than annually . The facility policy titled, Legionella Surveillance Policy, undated, states in part: Policy Statement: It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections . Procedure: 1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems . 5. Primary prevention strategies: . c. Physical controls: i. Cooling towers and portable water systems shall be routinely maintained. ii. At-risk medical equipment shall be cleaned and maintained in accordance with manufacturer recommendations. iii. Non-portable water systems shall be routinely cleaned and disinfected. iv. Nebulization devices shall be filled only with sterile fluid . d. Temperature controls: i. Cold water shall be stored and distributed below 68F (Fahrenheit). ii. Hot water shall be stored above 140F and circulated at a minimum return temperature of 124F . Surveyor requested to review the facility's water management program. Upon request, Surveyor was provided with the policies detailed above along with a document titled, Legionella Test Results Summary Log, dated 8/21/24. The test log indicates all 10 locations tested , that include three resident rooms, four resident showers, a laundry room, and two ice machines; all tests were negative for the presence of Legionella. On 12/5/24 at 9:13 AM, Surveyor interviewed MD N (Maintenance Director). Surveyor asked MD N if he had the actual water management program, including the binder detailed in the facility policy, flush logs, temperature logs, or any other components that are supposed to be included in the water management program. MD N stated the facility does not have a water management program, and the binder was thrown out by the previous Maintenance Director that is no longer employed by the facility. Surveyor asked MD N who is included in water management team meetings. MD N described an outside company that comes in to do testing, however, indicated that there is no active water management team within the facility. On 12/5/24 at 3:13 PM, Surveyor interviewed IP T (Infection Preventionist). Surveyor asked IP T if she participates in the facility's water management team. IP T indicated she works with MD N and an outside company to complete testing, however, did not indicate the facility conducts routine meetings to discuss water management and infection control risks. Example 2: The facility policy titled, Infection Prevention and Control Program Policy, dated 2/13/23, states in part: .Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be separated from soiled linen at all times. d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets . On 12/2/24 at 11:10 AM, Surveyor observed the laundry cart being transported uncovered by HK U (Housekeeping) in an elevator, then through the resident common area, and towards the 400 hall. On 12/2/24 at 11:55 PM, Surveyor conducted the laundry tour with HK U. Surveyor noted a single door entering the laundry room. Surveyor asked HK U if both dirty and clean clothes go through the same door. HK U indicates that they do. Surveyor asked HK U what personal protective equipment she utilizes when handling dirty laundry. HK U stated she only wears gloves because she does not have aprons or gowns available for her to use. Surveyor observed a single laundry room with a small storage area adjacent to the left of the laundry room. A clothes rack with clean clothes hanging and stacked on shelves is uncovered and located in between the washers and dryers, with only a few feet between the shelves and either appliance. Surveyor asked HK U if she covers clean laundry when she delivers it to the residents. HK U stated that in all the years she has been there she has never covered the clean laundry. On 12/2/24 at 12:04 PM, Surveyor observed HK U exit the laundry room, with clean laundry hanging from the back of a grocery cart, uncovered, and within close proximity to her work uniform. On 12/5/24 at 9:36 AM, Surveyor observed HK U delivering clean laundry to the 400 hallway in the same manner. The clothing was uncovered and hanging from an old grocery cart, in close proximity to her work uniform. On 12/5/24 at 3:13 PM, Surveyor advised IP T of her observations and asked what the expectation was for delivering laundry. IP T indicated it should be covered. Survey asked IP T if gowns or aprons were available for laundry staff to use while handling dirty linens. IP T indicated staff should have gowns available to use, and they should be using them. Example 3: R38 admitted to the facility on [DATE]. R38's Nurses Note, dated 11/15/2024, includes: Note Text: Resident noted with undigested emesis on clothes. VSS (Vital Signs Stable) low grade temp at 99.9 (F) assisted back into bed and cleaned up. Call to (Named) Hospice sent to report and for orders if any. (It is important to note R38 was not included on the facility's infection control line list even though he presented with a low grade temperature and an emesis.) On 12/5/24 at 3:13 PM, Surveyor interviewed IP T. IP T indicated staff did not make her aware of R38's symptoms to add to the line list, but any resident with symptoms should be included.

Based on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director, or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member, or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 90 residents residing within the facility. Quality Assurance and Performance Improvement (QAPI) meetings did not consist of the required attendees/members for the months of February and June, 2024. This is evidenced by: The facility QAPI plan, titled (Facility Name) QAPI Plan, undated, states in part: .(Facility Name) will establish a quality management committee that consists of the following members: Administrator/Executive Director, Director of Nursing/Director of Quality Improvement and Education, Medical Director of designee, Consulting Pharmacist, three general staff members representing disciplines directly involved in resident care . Of note, the plan does not list the Infection Preventionist as being a member of the committee. The facility policy, titled QAPI Policy and Procedure, dated 2/23/23, states, in part: . Policy Explanation and Guidelines: . 2. The QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall: a. Consist at a minimum of: i. The Director of Nursing Services ii. The Medical Director or his/her designee. iii. At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member, or other Individual in a leadership role; and iv. The Infection Preventionist . On 12/5/24 at 9:10 AM, Surveyor reviewed the facility's QAA committee meeting sign in sheets and noted the following: The QAPI sign in sheet dated 2/19/24 (Quarter 1), did not include Director of Nursing (DON) or Infection Preventionist (IP). The QAPI sign in sheet dated 6/19/24 (Quarter 2), did not include the DON or IP. The QAPI sign in sheets dated 8/14/24 (Quarter 3) and 11/13/24 (Quarter 4), had all required members. On 12/5/24 at 5:53 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked who should be on the QA committee. NHA A stated, The members should be listed on the QAPI plan. NHA A told Surveyor who regularly attends the meetings and stated the following: DON, Executive Director, Maintenance, NHA, Medical Director, Pharmacist, unit managers, Activities. Of note, NHA A did not mention the Infection Preventionist. Surveyor showed NHA A the attendance from the two meetings where the DON and IP were not present. NHA A confirmed the sign in sheets would have been accurate for who was in attendance.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 90 residents who reside in the facility. Surveyor observed multiple staff in food preparation areas, while food was being prepared, without donning hair restraints. Surveyor observed staff not allowing dishes to air dry completely before stacking them. Surveyor observed dented cans in circulation. Surveyor observed opened and undated food. Surveyor observed unclean stored equipment in facility's main kitchen. Evidenced by: Example 1 Facility policy, titled Uniform Dress Code, revised 1/24, includes: . Wear approved hair restraint when on duty regardless of length or presence of hair . On 12/2/24 at 10:11 AM, Surveyor observed DM L (Dietary Manager) in the facility's main kitchen, in the food preparation area without a hair restraint. Surveyor asked DM L about her hair restraint and DM L indicated she should have one on and she is sorry. On 12/5/24 at 8:20 AM, Surveyor observed CNA X (Certified Nursing Assistant) enter the kitchen, in the food preparation area while food was being prepared and served without a hair restraint. CNA X and Surveyor made eye contact and she left through the kitchen door. On 12/5/24 at 9:00 AM Surveyor observed DS Y (Dietary Supervisor) inside the facility's main kitchen, setting up a cart of beverages for residents' breakfast meal. DS Y did not have on a hair restraint. Surveyor asked DS Y about her hair restraint. DS Y indicated she should have on a hair restraint but she forgot. On 12/5/24 at 9:27 AM, Surveyor observed RDD M (Regional Dietary Director) walk into the food preparation area with a full beard and no hair restraint to cover it. Surveyor asked RDD M about his beard restraint. RDD M stated, I am just dropping something off quickly. I am sorry about that. Surveyor informed RDD M that he was the 4th staff member to enter the kitchen, in the food preparation area, while food was being prepared without donning a hair restraint. Example 2 Facility policy, titled Storage of Pots, Dishes, Flatware, and Utensils, revised 1/23, includes: air dry all food surfaces . Do not stack or store when wet . On 12/5/24 at 9:40 AM, Surveyor observed Dining Room Attendant Z placing wet residents' coffee mugs and water pitchers upside down on plastic trays. Dining Room Attendant Z then took the tray of mugs and cups and placed them upside down onto a metal shelving unit in the dining room. Surveyor asked Dining Room Attendant Z to turn some of the mugs and cups over for observation. Surveyor observed mugs and cups to have a white film build up inside them or have condensation in them due to the seal being created when the cups and mugs are turned upside down. Example 3 Facility policy, titled Food and Supply Storage, revised 1/24, includes: . Maintain designated area for items that are damaged such as dented cans . On 12/2/24 at 10:11 AM, during initial tour of the kitchen, Surveyor observed 5 dented cans in circulation including a tomato heavy puree, a Concord grape jelly, and 3 cans of evaporated milk. Example 4 Facility policy, titled Food and Supply Storage, revised 1/24, includes: . cover, label, and date unused or opened packages . On 12/2/24 at 10:11 AM, Surveyor observed an opened gallon of white 2 percent milk with no open date. Surveyor also observed a package of whole grain brown rice to be opened and undated and veggie patties to be opened, removed from original packaging and undated. DM L indicated the milk should have an open date, the rice should have an open date, and the veggie patties should have a label on them and a use by date. Example 5 Facility policy, titled Equipment Cleaning, revised 1/24, includes: Director assigns daily cleaning responsibilities in each position workflow . Mixers, choppers, slicers, and peelers are disassembled when cleaned . On 12/2/24 at 10:11 AM, during initial tour of the kitchen Surveyor and DM L (Dietary Manager) observed a stored large mixer to have food particles on the undercarriage and to be covered in plastic, a stored small mixer to have food particles on the blades and cover, and a microwave to have food particles of two colors speckled on the inside roof. DM L indicated the food should be covered in the microwave, but staff do not always do this. DM L indicated both mixers should have been cleaned after they were used and before they were stored. On 12/5/24 at 9:51 AM, RDD M and DM L indicated opened foods should be sealed and have a date on it of when it was opened or when it should be used by. DM L and RDD M indicated dirty equipment should be cleaned before storing and the microwave should be cleaned after use if a mess was made. RDD M and DM L indicated all staff should have hair nets on when entering the food preparation area. DM L and RDD M indicated staff should all cups and mugs to air dry before turning them upside down on a surface. DM L and RDD M indicated dented cans should be removed from stock. On 12/5/24 at 5:02 PM, NHA A (Nursing Home Administrator) indicated dented cans should be removed from the shelf, equipment should be cleaned before stored, dishware should be allowed to air dry completely, hairnets should be donned by all staff who enter the food preparation area, and opened food should be sealed and dated.

Based on observation, interview, and record review, the facility did not ensure snacks were offered at bedtime daily when there are more than 14 hours between the evening meal and breakfast. This has the potential to affect 90 of 90 residents and 6 of 6 units. R40, R19, R16, R70, and R2 voiced concerns that residents were not consistently being offered a snack at bedtime. These residents reside on the following hallways: 200 hall, 600 hall, and 300 hall Staff on the following hallways reported to the Survey team that bedtime snacks were not being offered to all residents: 500 hall, 300 hall, 600 hall, 400 hall, 200 hall, and 100 hall. There were more than 14 hours between the evening meal and breakfast and the facility staff were not offering snacks to all residents. Evidenced by: Facility policy, titled Resident Food Service: Snacks, revised 1/24, includes: .All residents must be offered daily snack at bedtime unless otherwise specified in resident's plan of care. Nursing: Offer bedtime snacks to all residents. Facility's Posted Mealtimes and Locations are as follows: Breakfast 0745 - 400 &500 Wings 0800 - Main Dining Room 0815 - 600 Wing 0830 - Room Service Lunch 1145 - 400 & 500 Wings 1200 - Main Dining Room 1215 - 600 Wing 1230 - Room Service Dinner 1645 - 400 & 500 Wings 1700 - Main Dining Room 1715 - 600 Wing 1730 - Room Service (It is important to note dinner and the following breakfast meal are scheduled 15 hours apart.) On 12/3/24 at 7:50 AM, Surveyor observed the serving of breakfast on the 500 wing. At 8:25 AM, the food arrived on the unit. At 8:31 AM, food was starting to be served. At 8:40 AM, the last resident was served in dining room. It's important to note this is 55 minutes past the scheduled serving time. On 12/3/24 at 2:00 PM, during Resident Council Task, R40, R19, R16, R70, and R2 indicated meals are often served late and residents are not offered snacks at bedtime. On 12/4/24 at 3:37 PM, CNA G (Certified Nursing Assistant) indicated she works on the 600 hall and staff get residents a snack between meals if they ask for one. CNA G indicated staff do not offer every resident a snack at bedtime. On 12/4/24 at 4:30 PM, CNA H indicated she works on different halls including the 100, 200, and 300 hall. CNA H indicated if there is a staff member available they offer a snack at the beginning of her shift, but not at bedtime. CNA H indicated the facility used to have a snack cart that went around but they do not anymore. On 12/4/24 at 4:35 PM, RN I (Registered Nurse) indicated he works on the 600 hall and they don't do snacks at night usually. RN I indicated staff do not go around and ask all residents if they want a snack at bedtime. On 12/4/24 at 4:41 PM, CNA J indicated she works on the 500 hall and staff do not offer snacks to all residents at bedtime or any time after supper. On 12/5/24 at 9:51 AM, DM L (Dietary Manager) indicated there are 15 hours between the supper meal and the next day's breakfast meal. DM L and Regional Food Service Director M indicated the nursing staff are to be offering all residents in house a snack at bedtime, but they are not consistently doing this. Surveyor shared Surveyors observations with DM L and Regional Food Service Director M of breakfast being served 55 minutes late during this survey. (Refer to F802 for additional information.) On 12/5/24 at 12:51 PM, CNA K indicated she works on the 400 hall and residents can have a snack outside of mealtime if they ask for it, but CNA K indicated a snack is not offered to all residents at bedtime. On 12/5/24 at 5:03 PM, Surveyor and NHA A (Nursing Home Administrator) reviewed the facility's scheduled mealtimes, noting 15 hours between supper and the following breakfast. NHA A and Surveyor reviewed the facility's snack policy, noting all residents are to be offered a snack at bedtime. Surveyor shared resident and staff interviews with NHA A. NHA A indicated staff are to be offering all residents in house a snack at bedtime. Residents are not being offered a snack at bedtime when there are 15 hours between the evening meal and breakfast meal.

Based on interview and record review, the facility did not ensure grievances and recommendations discussed during resident group meetings (Resident Council) were acted upon promptly, according to facility policy, and that residents were allowed to meet without staff present. This has the potential to affect more than a limited number of residents residing in the home. During Resident Council Task, 10 of 12 members voiced concerns that they do not receive follow up from voiced concerns, complaints, or suggestions for a whole month, until the next meeting. These residents indicated the facility policy states the management team will get back to them in 10 business days. During Resident Council Task, 10 of 12 members indicated the management team comes when they are not invited and at times the council wants to meet without staff present. Evidenced by: Facility policy, entitled Resident Council, undated, includes: All residents become members of Resident Council when they are admitted to the (facility named) . Resident Council is a formal advisory body, independent of the facility and other councils. Resident Council meetings provide the opportunity for residents to actively participate in matters that affect their daily lives and where they can exercise decision making autonomy. Our facility recognizes the value and influence of our Resident Council in sustaining a mutually supportive community where residents have a stronger collective voice and a reciprocal cooperative relationship with their home's management team . Resident Council objectives are to: . identify actual or potential issues early on when it is easier to address them . The home's management team is required to document, investigate and respond to the Resident Council representative within 10 business days of receiving a concern, complaint, or recommendation. If the situation cannot be investigated and resolved within the time frame, the homes management team needs to inform the resident council in writing within 10 business days of receiving the concern or complaint or recommendation, indicating that they are aware of the issue and detailing a plan or steps involved, in attempt to work together toward resolution. Then give a date before the next scheduled council meeting as to when the council can expect a solution and follow up response. A written response, along with any further updates will be shared at the next resident council meeting. Both parties are working together proactively in good faith to deal with the issue together . staff and the management team only attend council meetings when invited . On 12/3/24 at 2:00 PM, during Resident Council Task/Resident Council Meeting with Surveyors, 12 residents were in attendance. 10 of the 12 residents in attendance voiced concerns with the facility not reporting resolutions to the committee in 10 business days per the facility policy. Residents indicated staff report resolutions at the following Resident Council meeting which is the following month. During this meeting, 10 of 12 residents voiced concerns that they are not allowed to meet without staff present and the previous administrator came to meetings he was not invited to attend. Resident Council Minutes, dated 9/9/24, does not include how many residents were in attendance or who was in attendance. It does include the following: Residents not getting their water or drinks with the meal. Would like water available right away at meals and programs involving food . resident commented on the newer help getting (medication) very early or very late and it is not consistent. Worried that is not what the doctor ordered . agency staff in particular mentioned as the perceived issue . Grievance Form, dated 9/9/24, includes: Residents stated at resident council that they do not get their drinks with their meals . they arrive 10 to 15 minutes after the meal . Summary of investigation- staff educated to provide drinks prior to or with delivery of meal not after meal is served . Resolution- staff educated to provide drinks prior to or with delivery of meal not after meal is served . Resident and or representative notified of resolution- yes . on 10/7/24. Grievance Form, dated 9/9/24, includes: at resident council residents were concerned that they are getting their medications way too early or way too late. R34 stated that she is concerned she gets her evening medications late. Summary of investigation/Resolution- nurses reeducated on time frames for giving medications. One hour before to one hour after the scheduled times unless the order states differently . Resident and or representative notified of resolution- yes . on 10/7/24. Resident Council Minutes, dated 10/7/24, include: 14 residents in attendance . Residents state that it takes 30 to 55 minutes after getting call light turned on before someone responds. Having to sit on the toilet for 2 1/2 hours to have someone return to get off . it is hurting residents when they sit that long . residents concerned about the length of fingernails caregivers have . residents are concerned about caregivers not washing their hands or putting hand sanitizer on . when you go to the kitchen to get a meal it can take anywhere from 15 to 55 minutes to get their meal . residents state that they have been asking for over six months and nothing is done about distributing alexas around the building . Residents feel that administration wants to change resident council and how it is run. Residents state that they feel they are a number here and not a person. Residents state that everything they say does not matter. Residents are upset that they live here and they don't get what they would like. Administration came to the last meeting that he was not invited. Resident feels that drinks need to be served before any food is served for meals, snacks, and activities. Snack cart is not going around right now. Residents feel that activities should help with doing the snack cart. Residents feel that we are understaffed on the floor and they want to know why there are not enough staff to care for them. Resident Council Minutes, dated 11/4/24, include: 15 residents in attendance . Residents feel it takes a lot longer than it used to for people to respond to call lights. It used to take 3 to 5 minutes and now it can take up to an hour. When on the toilet should not have to listen to 45 minutes of people talking out in the hallway and not responding to them. Resident was given a hard time for yelling out when water was spilt over him and on to the floor and they did not take care of cleaning it up. CNA (Certified Nursing Assistant) told him to keep his mouth shut. Neighbor of resident heard everything that transpired and how resident was treated. Grievance Form, dated 11/5/24, includes: reporting individual- resident council . call lights can take up to one hour for staff to respond . Summary of investigation-call light audit done and found some lights on longer than others . staff educated to answer call lights in a timely manner . Resolution- random call I audits will be completed . Resident and or representative notified of resolution- yes . on 12/2/24. Grievance Form, dated 11/5/24, includes: reporting individual- resident council . activities staff that are CNA's did not help a resident when she needed help when the activity staff member was asking the resident if she wanted to go to an activity . Summary of investigation- discussed with activity staff and stated that when activity staff are gathering residents for activities they cannot stop to provide activity of daily life assistance for residents. They can put on the call light to alert CNA staff of need for assistance. Resolution- responded to resident council on resolution of grievance. Resident and or representative notified of resolution- yes . on 12/2/24. Grievance Form, dated 11/5/24, includes: reporting individual- resident council . resident on toilet for 45 minutes and can hear people talking in the hallway and not responding to her . Summary of investigation-spoke with staff and reeducated to check on residents they assist to toilet and to answer call lights in a timely manner . Resolution- remedy staff to answer call lights promptly . Resident and or representative notified of resolution- yes . on 12/2/24. On 12/4/24 at 2:08 PM, SW F (Social Worker) indicated resolutions are shared with the Resident Council at the next monthly meeting. SW F and Surveyor reviewed the facility's policy, titled Resident Council. SW F indicated the facility should follow the facility policy of notifying residents within 10 business days. SW F indicated residents have the right to meet without staff present. On 12/5/24 at 8:09 AM, NHA A (Nursing Home Administrator) indicated the residents have the right to organized meetings without staff present and it was the previous administrator who attended the Resident Council Meeting without being invited and residents were not happy with this. NHA A indicated the facility should follow the facility's policy of notifying residents and/or representatives within 10 business days if that is how the policy reads. The facility failed to allow residents to organize meetings without staff present and failed to notify residents/representatives within 10 business days of complaint/concern resolutions, in accordance with facility policy.

Based on observation, interview, and record review, the facility did not ensure residents have an environment free of hazards and did not provide adequate supervision and assistive devices for 2 of 5 total sampled residents (R2 & R1). R2's care plan was not followed, resulting in a fall with left distal femur fracture on 7/10/24. R1 was an elopement risk and wears a WanderGuard. R1 was known to make attempts to follow others out of the building. On 7/18/24, R1 eloped from the facility and was found by Witness T approximately 0.3 miles down the road across the street from the church. R1's WanderGuard did not alarm when she exited the Memory Care Unit (MCU) and staff were not aware R1 exited the building. Evidenced by: The facility policy entitled Safe Resident Handling/Transfers, dated 7/15/23, states, in part: . Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines:1. The Interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. 3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies .13. Staff members are expected to maintain compliance with safe handling/transfer practices .14. Resident lifting and transferring will be performed according to the resident's individual plan of care. This plan of care is to be reviewed and transfer status verified prior to performance of the mechanical lift/transfer . The facility policy entitled Fall Prevention Program, dated 4/4/23, states, in part: .Policy Statement: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . Policy: .3. The nurse will indicate on the care plan, the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed . Example 1: R2 was admitted to the facility on [DATE], and has diagnoses that include unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), repeated falls, osteoporosis (a condition in which bones become weak and brittle), and primary generalized osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). R2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shows R2 has a Brief Interview of Mental Status (BIMS) score of 7 out of 15, indicating R2 has severe cognitive impairment. R2's Care Plan, dated 2/1/24, states, in part: .Focus: (R2) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) admission from hospital (11/18/23-11/22/23) for AMS/slurred speech following an unresponsive episode at [Aster ALF], Hx (history) of dementia, CAD (coronary artery disease), arthritis, osteoporosis, depression, HTN (hypertension), HLD (hyperlipidemia), DM2 (Type 2 Diabetes Mellitus), cervicala spondylosis. Date Initiated: 2/1/24 Revision on: 5/9/24. Goal: (R2) will maintain her abilities to participate in her ADLs through the review date. Date Initiated: 2/27/24. Revision on: 7/10/24. Target Date: 8/27/24. Interventions: . *Transfer: EZ Lift 1 assist Date Initiated: 5/9/24 *Transfer: EZ Lift 2 Assist Date Initiated: 2/1/24 Revision on: 7/16/24 . Focus: (R2) is at Low Risk for falls r/t Fall Risk Assessment. Falls: 7/10. Date Initiated: 2/1/24. Revision on: 7/11/24.Goal: (R2) will be free of falls through the review date. Date Initiated: 2/1/24. Revision on: 7/10/24. Target Date: 8/27/24 . *Anticipate and meet the resident's needs. Date Initiated: 2/1/24 . *Follow facility fall protocol. Date Initiated: 2/1/24 . *Staff education provided on proper assistive devices for transfers for resident safety. Date Initiated: 7/11/24 . R2's Fall Report, dated 7/10/24, states, in part: . Incident Location: Resident's room . Incident Description- Nursing Description: Resident was being assisted to pivot transfer into recliner when her knees gave out and CNA (certified nursing assistant) assisted her to the floor . Immediate Action Taken: Description: Vitals obtained and WNL (within normal limits), AROM (active range of motion) in all extremities, assisted into recliner with 2 staff. Resident Taken to Hospital: N (no) . Injury Type: No Injuries observed at the time of incident . Predisposing Environmental Factors: None Predisposing Physiological Factors: None Predisposing Situation Factors: None Other Info: Failure to follow care plan . Notes: 7/18/24 - IDT (Interdisciplinary Team) met and discussed fall- x-rays obtained- fracture noted- transferred to hospital had surgery. Staff educated on transfer status. 7/18/24 - Incident reported to state as SRI (self-reported incident). Allegation substantiated. Employee terminated via progressive disciplinary process . for failure to follow plan of care/Kardex resulting in negative patient outcome. (CNA transfered R2 via stand pivot transfer and did not use the EZstand to transfer R2 per the care plan.) R2's Progress Notes: Dated 7/10/23 at 19:26 (7:26 PM) Type: Communication- with Physician Situation: Resident was lowered to the floor during a pivot transfer after supper. Resident's knees buckled during transfer . Assessment (RN (Registered Nurse))/Appearance (LPN (Licensed Practical Nurse)): Resident sitting on floor in front of recliner. Resident was grimacing d/t (due to) pain in bilateral knees and wanted off of the floor. Vitals WNL, AROM in all extremities. Recommendations: (Physician Name) on call, gave verbal order for Diclofenac Sodium Topical Gel 1% every 6 hours as needed to affected areas for pain. On 7/11/24 at 11:11 AM, Type: Communication- with Physician: .Recommendations: Update NP (Nurse Practitioner) of left leg pain with transfers- x-ray to left leg ordered. On 7/11/24 at 1:42 PM Type: Transfer to Hospital Summary. Note Text: Resident was noted to have fallen on the PM shift on 7/10; resident complaining of left leg pain when transferring with the EZ stand but not when sitting; x-ray order for whole left leg noted fracture; POA (Power of Attorney)(name) called and agreed with transfer to (hospital name) ER (emergency room ) . R2's Facility Reported Incident, dated 7/18/24, states, in part: .Summary of Incident: Allegation Type: Neglect: Intentionally withholding care, disregard of policy or care plan. Name Affected Person- (R2) .Date occurred: 7/10/24. Time Occurred: 6:00 PM . Brief Summary of Incident: On 7/11/24, it was discovered during review of clinical records that at approximately 18:00 (6:00 PM) on 7/10/24, resident (R2) became weak during a transfer and was lowered to the floor with staff assistance. Resident (R2) was immediately assessed and began to complain of leg pain; a stat x-ray was ordered, revealing the resident had sustained a fracture. The involved staff member was immediately suspended pending the outcome of the investigation. POA and MD (Medical Doctor) were notified, and orders were received to send the resident to the ER for further evaluation and treatment. Investigation initiated, final report to follow . Summary of Incident: .Briefly Describe the incident .On 7/11/24, it was discovered during review of clinical records that at approximately 18:00 on 7/10/24, resident (R2) became weak during a transfer and was lowered to the floor with staff assistance. Resident (R2) was immediately assessed and began to complain of leg pain; a stat x-ray was ordered, revealing the resident had sustained a fracture. Describe the effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident . : Post incident (R2) was complaining of leg pain. POA and MD notified; MD gave orders to apply topical pain-relieving gel every 6 hours as needed for pain, which was effective for the remainder of the day. On 7/11/24, resident (R2) continued to complain of pain in the left leg. The MD was notified, and stat x-rays of the left leg were ordered. Results indicated a mildly displaced, oblique fracture to the left leg, corresponding clinically with osteopenia. The MD was again notified, and this time gave orders for resident (R2) to be sent to the hospital for further evaluation and treatment, as needed. (R2) was admitted and underwent surgical repair to the fracture, returning to the facility on [DATE]. Based on a review of the hospital records, (R2) has a left distal femur fracture due to a combination of osteoporosis and trauma, as trauma alone would not have caused the fracture. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct . :A further review of the incident revealed that the CNA performed a pivot-style transfer on resident (R2); it was further noted that the transfer status orders for resident (R2) was for an assist of one person using an EZ Stand mechanical lift. This was discovered prior to the CNA reporting to work that day; the CNA was disciplined using the facility's progressive disciplinary process, resulting in termination of employment from the facility on 7/12/24. The CNA did not provide any care to the residents on that day as the termination happened prior to the commencement of the shift . R2's Radiology Report, dated 7/11/24, states, in part: . Femur Min 2 Views, Left: Results: Mildly displaced, oblique fracture through the distal femur metadiaphysis .Conclusion: Mildly displaced, oblique fracture through the distal femur metadiaphysis . R2's Orthopedic Surgery History & Physical, dated 7/11/24, states, in part: . admitted : 7/11/24 7:01 PM .Chief Complaint: Left leg pain. History: . history including dementia, HTN, hyperlipidemia presents today with a complaint of left leg pain. She apparently had fallen yesterday and was complaining of pain. She doesn't remember how she had fallen. She had some x-rays of the left femur done at an outside facility showing she had a distal femur fracture . Date of Injury: 7/10/24 Location (pain): left leg Quality/description (pain): nothing at rest to sharp with movement Severity: (1-10): 0-6/10 Modifying factors: None Associated signs and symptoms: unable to bear weight . Patient Active Problem List: . Closed fracture of left femur, unspecified fracture morphology, unspecified portion of femur, initial encounter . Imaging: I personally reviewed the x-rays of the left femur which demonstrate non-displaced distal femur fracture . Assessment: Left distal femur fracture due to a combination of osteoporosis and trauma . Plan: -Indicated operation: Retrograde nailing of left femur by (Physician name) -Date of operation: 7/12/24 . R2's Discharge Summary, dated 7/15/24, states, in part: .Date of Admission: 7/11/24 Date of Discharge: 7/15/24 Clinical Resume: (R2) . female who suffered the following injury prior to admission: left distal femur fracture . She was evaluated by the orthopedic service and left femur retrograde nailing was recommended . She was taken to the operating room on 7/12/24 where the above procedure was performed .By post-op day number 3, she was found to be both medically and orthopedically stable but not appropriate to return home independently. Therefore, she is being sent to a nursing home for proposed short term nursing home care and therapy . On 8/1/24 at 10:08 AM, Surveyor interviewed CNA I who indicated staff follow resident care plans and Kardex's to care for residents. CNA I indicated staff should never use less assistance than what a resident is care planned for, and no staff should use a pivot transfer if a care plan says to use an EZ stand. On 8/1/24 at 10:13 AM, Surveyor interviewed CNA J who indicated staff follow the Kardex/care plans to care for the residents. CNA J indicated staff should never use less assistance than what the care plan indicates. On 8/1/24 at 12:55 PM, Surveyor interviewed LPN C (Licensed Practical Nurse) and asked LPN C to tell Surveyor about the events on 7/11/24 that led to sending R2 to the ER. LPN C indicated when she came onto shift, she saw the fall report on R2 on 7/10/24 that indicated R2 had fallen from a pivot transfer. LPN C indicated R2 was an EZ stand transfer. LPN C indicated the CNAs reported to her that morning that R2 was complaining of left knee pain with morning care. LPN C indicated she had asked other staff if R2 had been sent out to ER from fall and was told no, the MD had been notified and an order was received to use Voltaren Gel. Surveyor asked if R2 had pain in her knees prior to fall and LPN C indicated no. LPN C indicated she asked RN D (Registered Nurse), who is one of the charge nurses, if facility could get an order for an x-ray. LPN C indicated the facility uses Mobile X that comes to facility to x-ray. An order was obtained from nurse practitioner and Mobile X arrived at facility around 11:00 AM to x-ray R2's left leg. LPN C indicated R2 had stayed in bed after breakfast up until transfer to ER due to pain with any movement to left leg. At 1:30 PM, after receiving the x-ray results the MD was phoned, and orders were received to send R2 to ER. On 8/1/24 at 1:15 PM, Surveyor interviewed RN D and asked what R2's transfer status was at the time of the fall on 7/10/24, and RN D indicated R2 was assist of 1 with an EZ stand. Surveyor asked RN D at the time of the fall how was R2 transferred, and RN D indicated she was not here at the time of the fall but in the clinical meeting it was discussed, and R2 was transferred with assist of 1 pivot transfer. RN D indicated LPN C had come to her the morning of 7/11/24 and indicated R2 was having pain when standing and no pain with resting. RN D sent an urgent email to NP and received orders to x-ray at facility. Surveyor asked RN D if she had assessed R2 and RN D indicated no, it was discussed at the clinical meeting with three nurse managers, DON B (Director of Nursing), and NHA A (Nursing Home Administrator) to get x-ray order. On 8/1/24 at 4:30 PM, Surveyor interviewed DON B and asked if she would expect staff to follow care plans and DON B indicated yes. Surveyor asked DON B if a resident is care planned to transfer with an EZ stand and 1 assist would you expect that to be followed and DON B indicated yes. Surveyor asked DON B if she would have expected an RN to assess R2 for pain the morning R2 was complaining of left leg pain and DON B indicated yes. Surveyor asked DON B what the facility has done at this point to ensure staff are following the care plans and DON B indicated the care plans and Kardexs have been reviewed and updated. Surveyor asked DON B since R2's fall on 7/10/24 has DON B observed any transfers with staff and DON B indicated yes but they are not documented. DON B indicated the facility will be doing audits on transfers. On 8/1/24 at 2:15 PM, Surveyor interviewed NHA A. NHA A indicated he has been working on a PIP (Performance Improvement Plan) regarding R2's fall on 7/10/24 FRI (Facility Reported Incident). NHA A indicated education on Safe Resident Handling and Policy was put out on the work web for staff on 7/19/24. NHA A indicated this will be going to QAPI (Quality Assurance and Performance Improvement) on 8/14/24. NHA A indicated the audits have not been started yet. Of note: Six staff were working on 8/1/24 that had not yet been educated on following the care plan related to R2's fall with fracture. On 8/5/24 at 3:15 PM, Surveyor interviewed RN R. RN R indicated the CNA did not follow R2's care plan and should have. RN R indicated the CNA had came and asked RN R to assist R2 off the floor as she had to lower her to the floor. RN R indicated the CNA had transferred R2 by pivot transfer and R2 should have been a one assist with an EZ stand transfer. RN R indicated she checked ROM to lower extremities and all checked out. RN R indicated R2 was able to lift left leg just not as high as right leg. RN R indicated R2 had no complaints of pain anywhere but in her knees. RN R had phoned the MD and son, received orders for Voltaren gel. Voltaren gel and tylenol was administered to R2 by RN R and was effective. The facility did not follow R2's care plan while transferring R2 resulting in R2 obtaining a left distal femur fracture. The following example is isolated, no actual harm potential for minimum: 30992 Example 2: The facility policy, Elopement and Wandering, last revised 6/5/24, indicates the following: The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Procedure: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Monitoring and Managing Resident at Risk for Elopement or Unsafe Wandering .e. Interventions to staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. F. Adequate supervision will be provided to help prevent accidents or elopements. Procedure for Post-Elopement .e. Staff may be educated on the reasons for elopement and possible strategies for avoiding such behavior. The facility's Memory Care Unit (MCU) is unlocked and equipped with Wanderguard sensors at each exit. R1 was admitted to the facility on [DATE] with diagnoses that include severe dementia without behavioral disturbance, encephalopathy, muscle weakness, chronic kidney disease stage 3, disorders of bone density and structure. R1's Admission Minimum Data Set (MDS) dated [DATE] indicates R1 has a Brief Interview of Mental Status (BIMS) of a 3 out of 15, which indicates she is severely cognitively impaired. R1 has an Activated Power of Attorney for Health Care (APOAHC). R1's Comprehensive Care Plan indicates the following: Focus: I am at risk for elopement as evidenced by a history of wandering r/t Dementia. Goal: I will not leave the facility unescorted through next review. Interventions: (Date Initiated: 7/15/24) Move resident to memory care unit (Date Initiated: 7/22/24) Monitor Wanderguard placement and function every 4 hours. If Wanderguard i s not functioning properly, replace it. (Date Initiated: 7/22/24) If Wanderguard system is not functioning/alerting properly, provide frequent checks on residents at elopement risk, Initiate batch order in TAR (Treatment Administration Record) and monitor until system is functioning properly. (Date Initiated: 7/22/4) I wear a Wander Guard on ankle (Date Initiated: 7/1/24) Anticipate my needs to the extent possible to help alleviate my wandering and exit seeking. (Date Initiated: 7/1/24) Ensure I do not accidentally follow visitors out of the building (Date Initiated: 7/1/24) [NAME] my room door with a familiar object, photo, etc. to aid in remembering its location. (Date Initiated: 7/1/24) Provide me reassurance and comfort when I am anxious. (Date Initiated: 7/1/24) Reassess my elopement at least quarterly. (Date Initiated: 7/1/24) Use diversional activities that I enjoy when exit-seeking behavior is occurring (i.e.: offer snacks, provide tactile stimulation, listen to music with me, etc.) (Date initiated: 7/1/24) Use verbal cues and gentle touch to redirect my exit-seeking behaviors. R1's Elopement Risk Evaluation dated 7/1/24 documents a score of 2, indicating R1 is At Risk of elopement. A score of greater than or equal to 1 = At Risk. R1's Elopement Risk Evaluation dated 7/18/24 documents a score of 4, indicating R1 is At Risk of elopement. On 7/18/24 the facility completed a Self-Report Is the date and time when occurred known: Yes Date occurred: 7/18/24 Time occurred 6:00 PM Is occurred date and time estimated: Yes Date discovered: 7/18/24 Briefly describe the incident: It was reported by facility staff that at approximately 6:00 PM on 7/18/24 staff were alerted to a resident outside the facility. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: At approximately 5:45 PM, as staff were rounding the unit, it was noted that resident (R1) was no longer in her room. A more thorough search of the unit and immediate area did not reveal the location of R1. A facility-wide search was initiated and the family and Administrator were notified. At approximately 6:00 PM, the facility was notified that R1 was found to be at the Baptist church immediately adjacent to the facility property. The resident was returned to the facility and immediately assessed. There were no obvious signs or symptoms of physical, mental, or psychosocial distress nor new complaint of pain. The POA (Power of Attorney) and MD (Medical Doctor) were notified, and no new orders were received. Resident (R1) was placed on increased staff observation for the remainder of the evening. The facility's Self Report documents the following staff have Information about incident: CNA L (Certified Nursing Assistant), CNA M (Certified Nursing Assistant), RN Q (Registered Nurse) Maintenance Director N, FM O (Family Member) and FM P (Family Member). CNA L's (Certified Nursing Assistant) wrote the following statement: R1 had been in her room with her family member (FM P - Family Member) eating. FM P left to go help her other family member. R1 came to dining room and sat with another resident. R1 went to her room around 5-5:15 PM and had not been seen by myself as I had been feeding other residents, CNA M (Certified Nursing Assistant) was helping a sick resident in his room, RN Q (Registered Nurse) was passing meds (medications). No alarms sounded to alert us to anything wrong. CNA M (Certified Nursing Assistant) wrote the following statement: R1 was here. FM P brought her supper. She left after FM P went home. We did not hear any alarms going off. RN Q (Registered Nurse) wrote the following statement: R1 was reported to last be seen in dining room at about 5:15 PM. Was alerted to resident not being at NGH (New Glarus Home - the facility) by LPN C (Licensed Practical Nurse). LPN C stated that the resident was at the church. R1 was known to be with FM P for dinner at 4:30 PM, seen by me. 6:10 PM, FM P was called for whereabouts of resident (R1) was not with FM P. 6:25 PM DON B (Director of Nursing) was contacted. No alarms were activated on unit from 3:00 PM until R1 was returned to the 400 unit. On 7/18/24 at 7:53 PM, Maintenance Director N sent the following email to NHA A (Nursing Home Administrator). Hello (NHA A's name), After receiving your call at 6:37 PM, I came in to check the Wanderguard system for the 400 wing. I spoke with RN Q (Registered Nurse) who was stationed there and he said it never went off during his shift which started at 3pm. I was in my office until 6pm and I did not hear the Wanderguard go off during that timeline. I asked if I could take her tag (Wanderguard) to test it, however they said they didn't know if they had another band for her. I used our testing tag on the North side of the 400 wing (the side they said she must have left from), and I was unable to get out of the door approximately 7 times that I tested it. I then placed the tag inside my boot. At this point I was able to get through the door without setting the alarm off. I proceeded to test this approximately 3 more times with two more escape successes. I then proceeded to look at the control box and confirm the sensor settings were correct. The sensor sensitivity was set at almost the maximum frequency. I went back into the hallway and adjusted the motion sensor to be more fixated on the door. I proceeded to test the door with the tag in my boot and noticed going back into the 400 the alarm did not go off. I tested the door a few more times with at least one more success. I proceeded back into the control box and this is when I noticed the antenna was hanging from a wire and the sheath was on the floor. I was able to put the antenna back without further damage to it and proceeded to test the door approximately 10 more times. Each time the alarm went off. I tested going fast as well as multiple times going very slowly. Additionally, for a frame of reference, while going slow, I had the door about 1/3rd of the way open before the alarm would go off. At approximately 7:17 (pm), I called Accutech to have a technician to come out and inspect the system to confirm it is working properly. It is after hours, so I left a message for them to come out. Additionally, I purchased a plastic crate to put over the control box to deter damage from happening to the antenna (scheduled to arrive Monday July 22nd). Until a technician comes out with a new antenna and checks over the system to confirm it is working properly, I will do daily checks of the Wanderguard system. (Of note, the technician came out on 7/19/24 and the issue was resolved at that time.) Note there is no statement from FM P (Family Member) in the investigation. On 8/1/24 at 12:20 PM Surveyor spoke with RN Q (Registered Nurse). Surveyor asked RN Q if he put a new Wanderguard on R1. RN Q stated, no, because when we tested it after she returned to the facility it was working. RN Q reiterated that no alarms sounded at the time R1 eloped from the facility. RN Q stated, when she was brought back through the Wellness Center that door alarmed. When we tested her alarm through both doors on the 400 unit, R1's Wanderguard alarmed both times. RN Q stated, he did not change out the Wanderguard because it was working after she returned to the facility. On 8/1/24 at 12:38 PM, Surveyor spoke with FM P (Family Member). Surveyor asked FM P to tell surveyor about R1 and what occurred on 7/18/24. FM P stated she took care of R1 prior to her admission to the facility. FM P stated, R1 is more of a handful with her memory. FM P stated, R1 never wandered away from her home prior to moving to the facility. FM P stated, when R1 was still living at home she found her trying to open a bottle of toilet bowl cleaner that R1 verbalized she was going to to put in her mouth. Surveyor asked FM P, does R1 have decreased safety awareness. FM P stated, Oh god, yes! FM P stated R1 is in excellent physical shape and she used to walk 2 1/2 miles every day. FM P stated, R1 fell at home many times, cracked her head on a TV stand but never broke any bones. FM P stated, on 7/18/24 she brought R1 Culvers and they had dinner together in R1's room. FM P stated, I told them (staff) I was leaving. FM P stated, she suspects that R1 saw her leave the facility and attempted to follow her. FM P stated, she was home for 45 minutes before she received a call from the facility asking if R1 was with her. FM P stated, It was very messed up. FM P stated, RN Q (Registered Nurse) told her, We don't know where R1 is. FM P stated, hearing that the facility does not know where R1 is made her feel, Really, really, really upset. FM P stated, she can easily see R1 going for a walk in the woods next to the facility. FM P stated, R1 does not like to be alone, she likes to talk with others. FM P stated, she later found out a couple found R1 near the Baptist church down the road from the facility and they returned her safely to the facility. FM P stated, her understanding from the facility is if the bracelet (Wanderguard) is exposed it works if covered by a pant leg it would not work. FM P stated, R1 will make statements that She wants to go home and that she's Going home. FM O (Family Member) is R1's APOAHC (Activated Power of Attorney for Health Care). Surveyor attempted to speak with FM O without success. On 8/1/24 at 1:50 PM, Surveyor spoke with LPN C (Licensed Practical Nurse). Surveyor asked LPN C to tell surveyor about what occurred on 7/18/24. LPN C stated, she was working on the 100 and 200 units and took the phone call. LPN C stated, she received a phone call from Activ Asst S (Activity Assistant) who was not working at the time. Activ Asst S's family member, Witness T, saw R1 walking down the road near the church and contacted Activ Assist S to see if she knew R1. Activ Asst S told Witness T, R1 lives at the facility to bring her back to the facility to the Wellness Center (Rehab entrance) and wait until a staff member meets them at the door. Activ Asst S reiterated, she told Witness T to not leave R1 until somebody comes to get her. Activ Asst S stated, That's a long walk, thank god she didn't get hurt. Surveyor requested Witness T's name and phone number. Activ Asst S provided Witness T's name and phone number. On 8/1/24 at 2:06 PM, Surveyor spoke with MR U (Medical Records). Surveyor asked MR U to describe her system for Wanderguards. MR U stated, the only things she does is to purchase the bands and tags and when she receives a tag she uses a tester box. MR U stated she does not have a spreadsheet or any system to know which resident has what Wanderguard or to know when they expire. MR U stated, when staff report a Wanderguard is not working they give it to her or leave it in her mailbox and she returns it to the manufacturer. On 8/1/24 at 2:47 PM, Surveyor spoke with Witness T. Surveyor asked Witness T to tell Surveyor what happened on 7/18/24. Witness T stated, she and her family were going to church for supper. Witness T stated, she saw R1 walking slowly by the church and She couldn't walk well. Witness T stated, R1 looked out of place. Witness T stated, I was worried she was really hunched over. Witness T asked R1 if she needed help crossing the street. R1 told Witness T she was trying to get home and lives by the Landhaus (Chalet Landhaus Inn). Witness T stated, R1 said, I walked down the hill but my legs are so tired. Witness T offered to give R1 a ride home. R1 [TRUNCATED]

Based on observation, interview and record review the facility did not assess the safety risks of using an air mattress in combination with enabler bars affixed to the bed or whether the enabler bar was needed for 7 of 7 sampled residents (R311, R42, R13, R20, R10 R49 and R43) and 6 of 6 supplemental residents (R361, R25, R3, R54, R35 and R1) utilizing enabler bars with an air mattress. R311 was found entrapped in the enabler bar. R42 injured her hand on the enabler bar and R43 had a 4 gap between the mattress and the enabler bar. The facility's failure to attempt alternatives prior to installation of the enabler bars, assess residents for risk entrapment prior to installation, review risk and benefits, obtain informed consent, ensure bed dimensions are appropriate for resident size and specification for installing and maintaining bed rails in combination with an air mattress created a finding of immediate jeopardy that began on [DATE]. Surveyor notified (NHA) Nursing Home Administrator A and (DON) Director of Nursing B of the immediate jeopardy on [DATE] at 1:05 PM. The immediate jeopardy was removed on [DATE]. However, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan and as evidenced by R13, R20, R10, R49 R361, R25, R3, R54, R35 and R1 who had air mattresses and enabler bars without safety assessments but who had no incidents or observed gaps between the enabler bars and the mattress. This is evidenced by: Manufacturer's instructions for the Drive DeVilbiss alternating pressure mattress replacement system include, but are not limited to, the following information under the heading of Warning: The risk of entrapment may occur when mattresses are placed on bed frames that do not properly fit and leave gaps between the mattress and head panel, foot panel and bed or side rails. This system is NOT to be used when such gaps are present User/Facility staff are responsible for ensuring that all mattresses properly fit the bed frames Health care professionals assigned to each patient should make the final determination whether side or assist rails are warranted after assessing patient risks based on the individual's needs and condition An optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety Additionally, the Drive DeVilbiss Healthcare support surfaces are designed as mattress replacement systems. The risk of entrapment may occur when mattresses are placed on bed frames that do not properly fit and leave gaps between the mattress and head panel, foot panel and bed or side rails. This system is NOT to be used when such gaps are present. User/Facility staff are responsible for ensuring that all mattresses properly fit the bed frames. Health care professionals assigned to each patient should make the final determination whether side or assist rails are warranted after assessing patient risks based on the individual's needs and condition. An optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety. The assessment should be conducted in compliance with the state and federal guidelines related to the uses of restraints and bed system entrapment guidance including but not limited to the below: 1) US FDA Entrapment Guidelines. A Guide to Bed Safety, https://www.fda.gov/medical-devices/ hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-care-facts 2) US FDA Hospital Bed System Dimensional and Assessment Guidance to Reduce Bed Entrapment, https://www.fda.gov/regulatory-information/search-fda-guidance-documents/hospital-bed-systemdimensional-and-assessment-guidance-reduce-entrapment According to a retrospective review of reported deaths due to bed rails and air mattresses published in the American Geriatrics Society, Compression of the mattress allowed an off-center person to slide against the rail where re-expansion of the mattress kept the person compressed against the rail. Two patterns were seen. In one, the mattress bunched up behind a person who was lying on the side of the bed, pushing the neck against a bedrail. In the second type, a patient died after sliding off the bed and having the neck or chest compressed between the rail and bed. Manufacturers attributed the deaths to poor clinical decision-making or inadequate monitoring. (Emphasis added.) https://pubmed.ncbi.nlm.nih.gov/ 076/#:~:text=Manufacturers%20attributed%20the%20deaths%20to,and%20risk%20awareness%20by%20clinicians. According to a 2013 article in the Chicago Tribune, The Food and Drug Administration, which regulates bed rails that qualify as medical devices, has received 901 reports of patients caught, trapped, entangled or strangled in hospital bed rails, including 531 deaths, since 1985. The Consumer Product Safety Commission has collected reports of 160 incidents related to portable bed rails - including 155 adult fatalities - between 2003 and 2012. Patients have died when their neck or chest becomes compressed between the rail and the bed, according to research published by [NAME] Miles in the Journal of the American Geriatrics Society. In some cases, the patient can't inhale, said Miles, a professor at the Center for Bioethics at the University of Minnesota who in 1995 became one of the first to alert federal regulators to deaths involving bed rails. 'They can't even scream; air is squeezed out of the lungs,' he said. 'The problem is worse because this mostly happens to small people who can go into slots between the mattress and the rail. They don't have the strength to extricate themselves or are confused and demented.' https://www.chicagotribune.com/news/ct-xpm-[DATE]-ct-met-bed-rail-safety- 707-story.html Per the U.S. Department of Health and Human Services, Food and Drug Administration, and the Center for Devices and Radiological Health. Guidance for Industry and FDA Staff, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, Issued on [DATE], states in part: The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in death and serious injuries. FDA received approximately 691 entrapment reports over a period of [AGE] years from [DATE], to [DATE]. In these reports, 413 people died , 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Entrapments have occurred in a variety of patient care settings, including hospitals, nursing homes, and private homes. Long-term care facilities reported the majority of the entrapments. FDA uses the term bed rails frequently throughout this document. Commonly used synonymous terms are side rails, bed side rails, grab bars and safety rails. Bed rails are rigid bars that are attached to the bed and are available in a variety of sizes and configurations from full length to half, one-quarter, and one-eighth length and are used as restraints, reminders, or as assistive devices. On [DATE] at 8:33 AM Surveyor observed 8 resident beds between the 300 and 500 units with enabler bars and low air loss mattresses R54, R3, R10, R1, R361, R49, R20 and R43. On [DATE], at 8:35am, Surveyor requested from Nursing Home Administrator A (NHA A) and Director of Nursing B (DON B), the policy and procedure for bed rails or enabler bars. No policies or procedures were received. Example 1 Resident (R311) was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R311 entered into Hospice on [DATE] and R311 expired on [DATE]. R311's Minimum Data Set (MDS) assessment, dated [DATE], indicated that R311 had a Brief Interview for Mental Status score (BIMS) of 99, meaning R311 was severely cognitively impaired. Per staff her mentation waxed and waned. R311's functional assessment identified R311 required extensive assistance of two staff with bed mobility and transfers. R311's care plan, dated [DATE], states: R311 is at risk for falls with interventions that include to keep an eye on my behaviors, keep my bed low to the ground and to keep the wheels locked. R311's Care Plan, dated [DATE], states R311 is at risk for skin injury and that R311 has actual skin tears and bruises. Interventions include R311 uses a pressure reducing air mattress. I have fallen x4 (four times) in the last month. R311's CNA Guidelines for Daily Care indicates for repositioning: reposition me at least every 2 hours, I use a pressure redistribution mattress . On [DATE], at 2:02 PM, Surveyor interviewed R21 who stated to Surveyor that they heard last month a resident got their head stuck in the rail of their bed and their head was the only thing that kept her from falling all the way out of bed. I think her name was (R311 name) and she passed away within the last month. On [DATE], at 5:12 PM, Surveyor interviewed Anonymous Staff Member (ASM) who notes, Resident (R311) recently passed away but before R311 had passed away R311 was having some anxiety related to passing away. The few weeks before R311 passed away, R311 was doing some unsafe things. R311 is the resident that was caught in her bed rail. ASM requested to not be mentioned by name because I don't know if I will even still have a job after they hear I spoke to you. On [DATE], at 9:13 AM, Surveyor interviewed Certified Nursing Assistant N (CNA) who notes R311 went into hospice and had episodes of spazzing out and R311 could not get comfortable. R311 hand was swollen once I think from hitting it on the wheelchair and once time she fell out of bed, R311 was laying on her side and her hands and chest were in the bedrail. The bedrail was stopping her from falling and her feet were out of the bed. R311 could not get out of the bedrail as it was physically holding R311 in. R311's progress notes, dated [DATE], at 12:08 PM, state in part Resident calling out for help while in recliner in room. Call light on resident lap, but unable to recall how to use. Resident unable to describe needs other than I feel rotten and I need to get out. R311 has had a number of similar events over the past few months with confusion, word salad and has been evaluated in the Emergency Department. At 3:41 PM, the Nurse Practitioner progress notes contact spoke with: nurse practitioner . acute change this afternoon .R311 having increased confusion, and calling out . R311's progress notes for family/guardian contact on [DATE] at 12:28 AM state change in condition knew of pt (patient) restlessness, anxiety, voiding and not voiding, and now is quite sullen, mumbling, unable to grasp hands, nor answer verbally. Daughter does not wish any further hospitalization , nor heroic measures, is hopefully going to qualify for palliative care soon. At 12:42 AM progress notes Resident was screaming out and grimacing and request to use bathroom. Resident was taken to the bathroom . Staff changed out bed to a low bariatric bed due to increased restlessness and noted changes for safety. Consciousness level assessment: disoriented, resident unable to follow simple commands . resident could not squeeze with her R (right) hand . R311 pulled off nasal cannula and was half off the bed. Staff switched bed and provided a low bariatric bed. Called Registered Nurse (RN) Supervisor to the unit to update and for RN to observe the neurological changes. At 1:19 AM, physician contact states suggest that daughter begin Power of Attorney Health Care due to medical changes resident is unable to anticipate her own needs. At 3:25 AM progress notes patient has been in almost constant motion since 2:00AM rolling back and forth in bed, attempting to get out, self-transfer, drinking liquids, unable to finish sentences, does call out for help. This writer sat with pt. for approximately 1 ½ hours, holding hands and praying . At 4:39 AM progress notes physician/NP contact R311 had a change in condition. Resident thus far greater portion of night shift has been screaming and yelling out. One to one staff was provided by RN . R311 is not able to make need known . At 6:44 AM, progress notes family/guardian contact, R311 has had a change in condition called family to update from this night, informed of R311 constant and continued movements, attempts at self-transfer, staff staying with her to ensure her overall safety and constant pain . hopeful outcome for R311 I'll do whatever it takes to keep her comfortable and attain peace. R311's progress notes on [DATE] at 5:30 AM show that R311 was unable to verbalize needs throughout the night. R311 had increased restlessness and groaning after early morning cares . At 1:06 PM progress note states no new bruising or bleeding reported . At 1:10 PM progress note state resident remains in bed on this shift, unable to track or hold conversation, appeared restless and startled at start of shift, MS ([MEDICATION(S)]) given at 8:10 AM, and [MEDICATION(S)] given at 9:15 AM for continued yelling out and restlessness. R311 was able to settle and rest with family at bedside. MS given again at 12:30 PM for increased restlessness and prior to turning in bed. No intake on this shift. At 9:51 PM progress notes show Increased restlessness and yelling out . R311's progress notes on [DATE] at 12:39 AM state no problems noted tolerating current med (medication) regimen well. Continues palliative care . skin tear continues to observe . At 10:57 AM progress notes of physician NP contact, show a message was left for R311's primary care provider due to her right wrist and knuckles were swollen and tender, slightly reddened on middle and thumb. Painful to touch, provided ice and elevation . daughter at bedside. At 1:11 PM progress notes physician/NP contact state new orders received for STAT (statism, urgent) Xray of right wrist and hand. R311's family at bedside and updated on plan, consult for re-eval (re-evaluation) of hospice services. At 4:45 PM progress notes state x-ray taken of right wrist and hand. At 9:24 PM progress notes state restless at beginning of shift, medicated with MS04 ([MEDICATION(S)] sulfate) and [MEDICATION(S)], R311 responded well to medication . At 10:08 PM progress notes state mental status is decreased safety awareness; risk assessment indicates resident is at risk of falling. At 10:11PM progress note of assessment for use: other supportive device: side rail enabler, x2 (two), Benefits/Purpose: enable bed mobility. R311's Radiology report, dated [DATE], shows no acute fracture and dislocation of hand or wrist, the conclusion is no acute findings. R311's nursing progress notes, dated [DATE], at 3:28am, indicate physician/NP contact, show the facility called to hospice services, R311's ongoing pain is not managed with current PRN's in place. Resident calling out continuously 1hr after last [MEDICATION(S)] ([MEDICATION(S)] sulfate immediate release) administration. Expressing unchanged pain to right shoulder, now upper neck and back and right upper extremity hand to elbow. R311's Nursing progress notes, dated [DATE], at 11:02 AM state R311 attempted to get out bed this morning and was found standing at bed side bracing herself with bed handle and window seal. Staff helped resident back into bed, redirected her that she can be cleaned up in bed and use her bed pan. R311 has been resting comfortably in bed with daughter at bedside. R311's Nursing progress notes, dated [DATE], at 5:39 AM state R311 has been awake all night and yelling out at times as well as kicking her legs over the side of the bed causing her to be sideways in bed. She has been repositioned several times and given PRN (as needed) and scheduled [MEDICATION(S)] and [MEDICATION(S)]. R311 appears to be terminally restless this shift. Will continue to observe and call (hospice company) if needed to make a visit to assess her. R311's hospice notes on [DATE] at 1:00 PM states Facility RN mentioned that pt has been having some restless nights and trying to get out of bed multiple time- Facility RN mentioned that tried putting R311 in her recliner one night, which did not seem to help. Facility RN mentioned that R311 tends to hit the radiator a lot of times when trying to get out of bed . On [DATE] at 11:32 AM Surveyor interviewed R311's Family Member R (FM) who identified that she was notified on [DATE] that R311 had a bump on the top of the hand and that two of her fingers were swollen. The facility had an x-ray taken and it was negative. FM R notes that R311 would sometimes need to go to the bathroom and the bed was moved to the wall to prevent R311 from falling out of the bed. R311's bed had two bed rails on the top of the bed. Surveyor asked FM R if the facility ever discussed the risk and benefits or dangers to having a rail on a bed? FM R replied no and that R311 could not move the bedrail at all. Surveyor asked FM R if the facility had shared risk and benefits. FM R stated no. On [DATE], at 9:22 AM, Surveyor interviewed Registered Nurse Q (RN), who notes, related to R311 and the fall. I was not here during that episode. The background on R311 is that during her passing she was very restless and uncomfortable. In the moment of time when R311 was caught in the enabler bar I don't think she was injured. She had the enabler bars to use before when she wasn't declining. Sometimes R311 could hold on to them but she had more days that R311 could not hold on. R311 did have an air mattress on her bed and I think it was a low bed. On [DATE] at 11:50 AM, Surveyor interviewed Hospice RN S who identified that R311 was given a low air loss mattress by Hospice. On [DATE] at 12:20 PM, Surveyor interviewed Maintenance Supervisor T (MS) and Maintenance Worker U (MW) who identified that they do safety rail inspections if the rails look like they are loose or falling off to make sure nothing is broke. Surveyor asked MS T and MW U how often Bed rails are inspected? MS T and MW U reply that a new plan had just started in [DATE] and they are to do the inspections once per year. On [DATE] at 1:37 PM, Surveyor interviewed Hospice Social Worker V (SW) and Hospice RN P who noted that R311 was known to be restlessness and that R311 was at risk for falls and this is assessed at every visit. Surveyor asked SW V and RN P the manufacturer of the air mattress. Hospice Social Worker V and Hospice RN P replied the manufacturer is Drive, and it is a low air loss mattress with a maximum weight of 350 pounds. Surveyor asked SW V and RN P if hospice installed the assist/enabler rail on R311's bed? SW V and RN P replied no, the rails are provided by the facility. On [DATE] at 3:13 PM Surveyor interviewed RN W who identified that on [DATE], R311 was very anxious and trying to get out of bed. She was found lying sideways in the bed. RN W notes that R311 was anxious all night. R311's bed is next to the wall and R311 would put her feet on the wall, R311 was just trying to get out. At times R311 had her feet hanging over and upper body on the side of the bed. Surveyor questioned if RN W ever heard about R311 being entrapped in her bed rail. RN W replied, no and was not familiar with the incident. Surveyor asked RN W where was R311's torso. RN W replied, R311 was upside down in the bed R311's head was where her feet should have been. RN W further identified that R311 was vomiting, anxious, and hospice was called because RN W thought R311 was at end of life. RN W replied R311's status was varying, calm one night then completely confused. On [DATE] at 4:12 PM, Surveyor asked DON B if DON B is aware of and incident of R311 resting against the bed rail with her feet off. DON B answered no. On [DATE] at 12:09PM Surveyor asked DON B for the enabler bar policy. DON B replied, I know I wrote an enabler policy back in March because they started doing yearly checks on those. Note: DON B was never able to find the enabler bar policy during the survey. It should be noted the facility did not assess the use and safety of an enabler/bed rail, the facility did not assess if the air mattress on R311's bed was safe to use together according with manufacturer's recommendations, the facility did not assess for any risk of entrapment, the facility did not consult with the resident or family member to get consent for a enabler bed rail after reviewing the risks and benefits of using an enabler bed rail. The facility did not measure or test the dimensions of the bed based on R311's size and weight. The facility did not perform regular scheduled maintenance to R311's bed and rails and the facility did not ensure that R311's bed, rails, and air mattress were used within the manufacturer's recommendations. Example 2 Resident (R42) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R42's MDS quarterly assessment, dated [DATE], indicated that R42 has a BIMS score of 15, meaning R42 is cognitively intact. R42 is able to be understood and can be understood when speaking. R42's Functional Assessment shows that R42's bed mobility and transfers require extensive physical assistance of one-person. R42's functional range of motion shows R42 has an impairment on one side of both the upper and lower extremities. R42's pain assessment indicated R42 is almost constant pain and is receiving a scheduled and prn medication for pain. R42's Care Plan, dated [DATE] states: R42 is at risk for skin conditions and at risk for pressure ulcers, R42 has the potential for skin injury. Interventions include: Reduce pressure and friction between myself and my bed or chair elevate my heels . Use skin protective devices Elbow protectors on when in W/C (wheelchair) or recliner. R42's Care plan shows R42 is at risk for falls- Have potential for fall down and hurt myself. On [DATE] at 10:59 AM, Surveyors observed R42 room. R42 has a bed with an air mattress, 2 enabler bars that are padded with a blue pool noodle R42 was sitting in a wheelchair and had a bandage on the left forearm. Surveyor interviewed R42 who stated I was reaching through the grab bar while in bed to answer my phone and I rubbed up against the grab bar scraping my wrist, that's why they added the blue pads (pool noodles). R42's Nursing progress notes, dated [DATE], at 3:48 PM, state: Left lateral side of Left wrist- resident stated must have bumped her arm against the bedside grab bar reaching for her phone in bed when sitting in her recliner. R42's nursing progress note, dated [DATE], at 12:27 PM, states: Steri strips intact over skin tear to left elbow. No s/sx (signs/symptoms) of infection. Writer called and updated HCPOA (Health Care Power of Attorney)-discussed foam elbow protectors to protect elbows. Voicemail left with DON, On [DATE] at 4:12 PM, Surveyor interviewed DON B who identified that she was not aware of R42's arm injury when R42 received a skin tear reaching through her enabler bed rail. On [DATE] at 12:50 PM, Surveyor interviewed RN Supervisor M (RN) who notes that R42 moves around and bumps her arms. RN M identified that she is not aware of R42 reaching through the grab bar. Surveyor asked RN M who would assess for safety of the enabler bars. RN M replied, the Registered Nurse Case Manager RN H. Surveyor asked RN M where the incident reports are located. RN M replied, the incident reports are in the computer. Note Surveyor reviewed the EHR (Electronic Health Record) for R42 and was unable to find the incident reports for R42 getting her arm entrapped in the enabler bed rail. The facility did not assess the use and safety of an enabler/bed rail even after R42's arm was injured after being entrapped in the enabler bed rail. The facility did not assess if the air mattress on R42's bed was safe to use in combination with the enabler bars. The facility did not assess for any risk of entrapment, the facility did not consult with the resident or family member to get consent for an enabler bed rail after reviewing the risks and benefits of using an enabler bed rail. The facility did not measure or test the dimensions of the bed based on R42's size and weight. The facility did not perform regular scheduled maintenance to R42's bed and rails and the facility did not ensure that R42's bed, rails, and air mattress were used within the manufacturer's recommendations. Example 3 On [DATE] at 2:13 PM Surveyor and Registered Nurse C (RN) observed R43's bed to have about a 4 inch gap between the air mattress and her enabler bars. Surveyor measured the gap with her fingers and could fit four fingers in the gap. RN C indicated R43 does not use the enabler bars much, but every bed in the facility has them attached to the bed. RN C indicated the gap changes in size depending on where R43 is positioned on her bed. The facility's failure to identify the enabler bars with the use of an air mattress as a risk for entrapment, utilize alternative modalities, perform safety assessments, obtain informed consent, complete risk and benefits, ensure manufacturer's recommendations were followed and ensure bed dimensions are appropriate for residents' size and weight created a reasonable likelihood for serious harm, which led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it completed the following: Identified residents involved and those who have the potential for similar outcomes: The facility removed all enabler bars as of [DATE] at 4:00 PM. Facility will do an assessment for enabler bars on admission, change of conditions, and at least quarterly if an enabler bar is being used. Assessment will be in the computer and enabler bar will be care planned. Assess the risk/benefits of using a bedrail/enabler bar and review with resident or responsible party prior to installation and sign before an enabler bar is put on the bed and will be kept under the care plan section of the hard chart. All enabler bar assessment will begin on [DATE]. No enabler bars will be utilized until assessments completed. All parts including risk and benefits and inform consent complete. Facility will immediately identify and use appropriate alternatives prior to installing a bed rail: Facility will immediately assess the resident for risk of entrapment prior to installing a bed rail. Obtain informed consent for the installation and use of bed rail/entrapment prior to installation. Immediately ensure appropriate dimensions of the bed, based on the resident's size weight. Ensure correct use of an installed bed/or side rail or enabler bar; ensure scheduled maintenance of any bedrail in use according to manufacturer's recommendations and specifications. Resident assessment should consider but not limited to: Medical dx (diagnosis), conditions, symptoms and/or behavioral symptoms; size/weight, sleep habits, medications, acute medical/surgical intervention, underlying, medicals conditions, existence of [CONDITION(S)], ability to toilet self safely, cognition, communication, mobility, risk of falling, in addition must include an evaluation of the alternative to the use of a bed rail that were attempted and how these alternative failed to meet the residents' assessed needs. All staff will be educated prior to their next working shift starting on [DATE]: Immediately report any instance of injury, potential entrapment concerns, the type of specific direct monitoring and supervision provided during the use of the bed rails, including documentation of the monitoring. Need to identify and use appropriate alternative prior to installing a bed rail, assess for risk for entrapment, how to complete an assessment tool, assess risk and benefit of using bedrail/enabler bars, policy for bedrails/enabler bars, need to complete informed consent prior to installation and use of bedrail/entrapment prior to installation' ensure appropriate dimension of bed based on resident size and weight, ensure correct use of an installed bed and enabler bar, completion of a scheduled maintenance of any bedrail in use of according to manufactures recommendation and specifications. DON or designee will determine a specific direct monitoring and supervision provided during the use of the bed rails, including documentation and monitoring, on going assessments to ensure bedrail is used to meet resident needs, on going evaluations for risk, the identification and pri of who can determine bedrail may by discounted. DON or designee will monitor for one year documentation of all residents with enabler bars to ensure no concerns for entrapment and bring to QAPI. DON or designee will monitor for one year to ensure appropriate alternatives were tried and bring to QAPI. DON or designees will monitor for one year for entrapments. DON or designee will review assessment tools for one year. DON or designee will assess risk and benefits for one year. DON or designee will assess informed consent for one year, correct use of rails for one year. size of bed for one year, scheduled maintenance for one year, and care plans for one year. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as evidenced by the following examples of residents with air mattresses and safety bars with no assessments but who had not had episodes of entrapment or observed gaps between the mattress and the enabler bar(s). Example 4 Resident (R13) was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's quarterly MDS on [DATE] indicates R13 has a BIMS score of 13 indicating they are cognitively intact and that R13's is able to be understood and to understand others. R13's functional assessment identified R13 requires extensive physical assistance of one staff for bed mobility and extensive assistance of two staff for transfers. R13's Fall assessment indicates R13 had one fall with no injury since admission. R13's CNA Guidelines for Daily Care indicate repositioning: reposition me at least every 2 hours I use a pressure redistribution mattress . On [DATE], at 8:35am, Surveyor interviewed NHA A and DON B and requested the following information related to the use of Enabler Bed Rail for R13: The bedrail/enabler bar safety assessment R13's enabler bar care plan Any consents for use of an enabler bar/bed rail The risks and benefits of using an enabler bar/bed rail The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Any alternative attempted prior to the use of a bed rail DON B identified the facility did not have this information for R13. Example 5 R20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's quarterly MDS, dated [DATE], indicates R20 had a BIMS score of 10 indicating they were moderately impaired, but is able to understand and to be understood. R20's functional assessment shows R20 requires limited physical assistance of two staff with bed mobility and total dependence of two staff with transfers. R20's range of motion assessment indicates R20 is impaired on both sides in the lower extremity. R20's CNA Guidelines for Daily Care indicate repositioning: reposition me at least every 2 hours use pillow to position me comfortably APP mattress to bed .[TRUNCATED]

Based on observation, interview and record review, the facility did not ensure that a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, prevent new ulcers from developing, and a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable in 2 of 5 residents reviewed for pressure injury concerns (R43 and R44). R43 was at risk for pressure injury (PI) development due to a malformed extremity. The facility failed to ensure interventions were in place to prevent pressure, follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R43 developed an unstageable PI. R44 was admitted to the facility with reddened heels. There was no care plan intervention to offload the heels. R44 developed blisters on his right ankle on 6/10/22 there is no intervention to prevent pressure to this mallelous the mallelous worsened to a stage II pressure injury on 6/15/22. Evidenced by: Facility policy, entitled Pressure Ulcers/Skin Breakdown, revised April 2018, includes, the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers . In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue . pain assessment . resident's mobility status . current treatments, including support surfaces . all active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident or substitute decision maker . The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Example 1 R43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R43's current signed Physician Orders, include, in part: start date 5/31/22 skin: apply skin prep to bottom of second toe on right foot, and wedge cotton between knuckles. Twice a day . end date: open Blue suspension boot to right foot at all times . check three times a day administer until resolved . end date: open R43's Comprehensive Care Plan, printed 6/14/22, includes in part: skin care: reduce pressure and friction between myself and my bed or chair . use pressure redistribution devices mattress, gel cushion, right blue suspension boot . help me with hygiene and general skin care .avoid using hot water for washing and use moisturizer on my skin . help me reposition at least every one to two hours while I'm in bed keep good padding around my bony areas . offer me fluids when I change position . elevate my heels in bed . use skin protective devices . skin barrier cream after each incontinence episode . use pillows for supporting me . help me stay clean and dry . R43's CNA Care Card, dated 6/14/22, includes in part: skin care: reduce pressure and friction between myself and my bed or chair . use pressure redistribution devices mattress, gel cushion, right blue suspension boot . help me with hygiene and general skin care .avoid using hot water for washing and use moisturizer on my skin . help me reposition at least every one to two hours while I'm in bed keep good padding around my bony areas . offer me fluids when I change position . elevate my heels in bed . use skin protective devices . skin barrier cream after each incontinence episode . use pillows for supporting me . help me stay clean and dry . R43's Medical Record includes, in part: 5/6/22 Nurse Note: . this morning resident reported that her toes hurt, the first 2 on right foot and great toe on left . right great toe is reddened, no warmth, slightly swollen, foot cradle put back on bed to reduce pressure to feet . 5/8/22 Nurse Note: . right great toe red, R43 denied discomfort/pain to area . no s/sx of infection foot cradle used to reduce pressure to feet. 5/9/22 Nurse Note: . foot cradle in place, sleeping well, no nonverbal, signs of pain present during assessment. 5/11/22 Nurse Note: . denies discomfort to great toe cradle in use in bed . 5/23/22 Nurse Note: late entry for 6:31 PM on 5/22/22 Resident c/o mild pain to toes R foot . Toe #2 edematous/erythematous. [CONDITION(S)] extends from tip of toe to PIP joint (extends slightly beyond PIP joint when foot in dependent position) . Blanchable except over distal / ventral surface of toe where is a C shaped dark purple area noted. Toe tender to light palpation. No increased temperature of skin to affected area. No palp pedal/PT pulse R foot. Weak PT pedal pulse palpable left foot Great toe pink dorsal surface, toe #3 dark pink distal portion . Hospice RN notified arrived to evaluate resident at 9:40 pm family notified related to change in condition. RN orders continue using bed cradle to protect feet or leave feet uncovered when in bed, may wear socks. Apply skin prep to toe #2 every shift. Physician contact- Hospice triage . 5/24/22 Nurse Note: . R foot monitored, dark pink slightly reddened. Continue to reposition resident to keep weight of blankets off of bilateral feet. Preventative to maintain skin integrity. Offer and provide fluid intake. 5/24/22 right second toe sore, dark purple on plantar side, skin prep applied . 5/25/22 Nurse Note: .tx per orders, D2 plantar side dark purple with surrounding skin drying, no spreading redness, further breakdown, or drainage noted. Tolerated well foot cradle in place to assist with maintaining skin integrity . dark pink in color/reddened skin R foot second digit toe. Plantar side old darked purple color bruise . 5/26/22 Nurse Note: . skin issues noted, RLE D2 plantar area darkened purple, dark pink surroundings, no warmth, or temp changes noted from other digits, bed cradle in place to reduce pressure from blankets . 5/27/22 Nurse Note: . writer placed call to Hospice Registered Nurse at 3:30 PM to report that residents right toe 2nd has worsened since her last visit in the past two hours, toe rubbing on foot rest . thin layer of skin/blister opened and resident had a scant sanguineous discharge continues to be painful . [Hospice Name] placed low air loss mattress on resident's bed, the alternating pressure mattress and pump was returned . right second toe continues to increase in redness and swelling, may have had superficial blister on plantar aspect which opened when resident rubbed foot on foot rest, increased pain and warmth, hospice notified . (It is important to note, this is the first mention of the blister being open and caused by pressure/shearing from her footrest. Of note there is no measurements of this area.) 5/28/22 Nurse Note: . reddened 2nd toe right foot plantar aspect dark in color skin prep applied sensitive to touch swollen . Rt second digit plantar side, dark in color, hard center, skin periwound red, skin prep applied per order 5/29/22Nurse Note: . New order for skin issues noted right 2nd foot, continues to be dark in color, hard upon palpation, resident reports tenderness, skin prep applied . right second toe, area cleansed with normal saline, skin prep applied, reported tenderness to area during skin treatment, on antibiotics for skin infections . right second toe continues with black eschar bottom side of toe, peri skin continues to be red, toe is tender to touch, normal temp. Res started on antibiotics for skin infection, skin prep applied after cleansing toe. 5/30/22 Nurse Note: .skin issues noted, right second toe red; black eschar area to the pad of toe (underside), tender touch, cleansed with normal saline, skin prep applied, continues oral antibiotics. 5/31/22 Nurse Note: .continues antibiotic for skin infection to right foot second toe, toes are cool, underside of toe continues with black eschar area 0.5 cm x 0.5 cm cleansed site area with skin prep. 5/31/22 Initial Wound Assessment . onset discovery date: 5/24/22 noted after admission . initial stage: suspected deep tissue injury . tissue type: necrotic/eschar . wound tissue: black . necrotic tissue: firmly adherent, hard, black eschar . necrotic tissue amount: 75% - 100% wound covered . shape of wound: oval/round . wound edges: distinct, outline clearly visible, attached, even with wound base . surrounding wound tissue: bright red and/or blanches to touch . surrounding wound induration: non-pitting [CONDITION(S)] extends less than 4 cm around wound . length: 0.8 cm . width: 0.8 cm . interventions: remains on antibiotic . other support surfaces: heel lifts or heels suspension device . minimize risk for shear and friction . physician notified . skin treatment done per order . (It is important to note the wound was measured twice this day 0.5 x 0.5 and 0.8 x 0.8. This is the first time since the area was discovered that the wound was measured.) 5/31/22 Physician Order, includes, in part: start date 5/31/22 . skin: apply skin prep to bottom of second toe on right foot, and wedge cotton between knuckles. Twice a day . end date: open Blue suspension boot to right foot at all times . check three times a day administer until resolved . end date: open 5/31/22 Hospice Progress Note, includes, in part: Registered Nurse performed focused visit related to decline in condition and wound assessment . collaborated with facility wound care nurse . Patient sleeping on and off throughout visit. Patient on antibiotics, missed 3 doses on Saturday, has not missed any since then. Writer collaborated with daughter . active wounds: pressure injury plantar pressure . placement date: 5/22/22 .site toe; right foot second toe . primary wound type: pressure injury . wound description: pressure injury . 0.8cm x 0.8cm moist, painful, red . wound surface area: 0.64cm R43's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (It is important to note the facility had no investigation conducted regarding the missed doses of medication.) 6/6/22 Hospice Progress Note, includes, in part: Assessment: Patient reports I hurt a lot and points to right knee and leg . Changes reported from prior assessment: Black necrotic appearing scab noted to second toe, measurements noted to be 1.3 cm x 1.0 cm, surrounding skin dry, intact, and red . Based on assessment, notified provider for: continuing current plan of care . 6/7/22 Wound Follow Up Assessment note, includes, in part: onset: 5/24/22 . noted after admission . initial stage: Suspected Deep Tissue Injury . wound tissue: necrotic/eschar 100% . necrotic tissue: firmly adherent, hard, black eschar . necrotic tissue amount:100% wound covered . shape of wound: oval/round . wound edges distinct outline, clearly visible, attached, even with wound base . surrounding wound tissue: dark red or purple and non-blanchable . surrounding wound [CONDITION(S)]: non-pitting [CONDITION(S)] extends less than 4 cm around wound . length: 1.5 cm x 1.0 cm .healing process: worsening . interventions: . minimize risk for shear and friction . other supportive surfaces: heel lifts or heel suspension device . On 6/13/22 at 1:38 PM Surveyor observed R43 in bed with a suspension boot on her right foot. The boot extended pass her toes by approximately 3 inches Surveyor could see R43's toes in the boot and her second toe curled downward. No cotton was observed between R43's toe knuckles. On 6/14/22 at 2:13 PM RN C (Registered Nurse) and Surveyor observed R43's right foot second toe. RN C described what she observed, round black necrotic area on second toe of the right foot. R43 stated, It hurts something fierce too. RN C indicated the wound is a deep tissue injury caused by pressure from being up in Broda chair without shoes on. RN C indicated R43's second digit is curled under so the tip of toe was in direct contact with the wheelchair's footrest. Surveyor asked RN C if R43's curled toe is in direct contact with her suspension boot? RN C stated, Yes, it is and especially when she is up in chair. RN C indicated she would loosen the strap on R43's suspension boot so the boot does not put pressure on R43's curled toe. Surveyor observed no cotton wedged between R43's knuckles per Physician order. On 6/15/22 at 7:47 AM Surveyor observed R43 in bed with her feet elevated and uncovered. R43 had a blue suspension boot on her right foot that came out 3 inches pass the end of R43's toes. The suspension boot had two straps secured tightly with Velcro: one over the top of her foot and one over her ankle. Surveyor observed R43's second toe on the right foot curled under and this toe was in direct contact with blue suspension boot. On 6/15/22 at 7:56 AM RN O and Surveyor observed R43's toe together. RN O indicated she observed R43's second toe on right foot to be in direct contact with the boot and this could be causing pressure to R1's toe. RN O indicated she could loosen the suspension boot. Surveyor observed RN O rotate R43's foot and place in boot so her toe was not touching the boot and RN O did not secure the Velcro tightly on the top of R43's foot. RN O indicated 43's second toe on her right foot had a dime size black eschar covered area on the end and side of it and this all started when she had her foot rubbing on the foot pedals of her wheelchair. RN O indicated she did not see cotton or gauze between R43's toes or knuckles. Surveyor asked if RN O has ever seen cotton or gauze used with R43's toes. RN O replied she hadn't, but she thought she would call R43's MD and see if he wants to try this. RN O indicated she was unaware the current order was for cotton to be wedged between the knuckles. (It is important to note RN O was unaware of the current order to wedge cotton between R43's knuckles. It is also important to note the boot extended pass R43's toes by three inches and was secured tightly to her foot causing pressure to her one curled toe.) On 6/15/22 at 8:00 AM DON B (Director of Nursing) and Surveyor observed R43's toes. DON B indicated she did not see any cotton wedged in between R43's knuckles and she was unaware this was the current Physician order. DON B indicated she would expect cotton to be in place if that is what the order says. On 6/15/22 at 10:30 AM Surveyor and DON B reviewed R43's current Physician orders. DON B indicated she would expect to see wound measurements completed on 5/27 if blister opened on 5/27. DON B indicated the blister could be a deep tissue injury from shearing, but she has not had time to read any nurses notes regarding the wound. On 6/16/22 at 3:08 PM During an interview, Hospice Registered Nurse P indicated she was unaware that the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to put interventions in place to protect R43's malformed toe, R43 developed an unstageable PI, failed to measure the pressure injury once discovered, ensure antibiotics were administered as prescribed, follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Example 2 R44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R44's progress note dated 5/7/22 as part of the initial skin assessment states in part; skin issues noted on back of left heel, reddened, heels elevated with pillow off mattress. Progress notes on 5/17/22 documents heels no longer red. (It's important to note there is no skin documentation regarding the reddened heels from 5/7/22 to 5/17/22.) R44's Skin Care Plan does not have an intervention for floating heels. On 6/14/22 at 11:00 AM, Surveyor spoke with RN C (Registered Nurse). RN C said if a resident is admitted with reddened heels-there should be a full skin assessment, nutrition assessment, low air loss mattress and boots should be applied. I was not made aware of this res with reddened heels. Surveyor asked RN C if R44 received all these interventions. RN C said no. On 6/10/22 at 1:52 PM, R44's skin care note documents .right ankle (lateral side), two blisters' measurements (1.7 x 1.3) and .5 x .5) cm (centimeters). Areas cleansed, dried, and two foam dressing applied over areas. Both appear to be where side of shoe would rub up against. On 6/14/22 at 3:05 PM, Surveyor spoke to RN I. Surveyor asked RN I when you did the dressing change this morning for R44's right ankle how did it look? RN I said it was flat, no drainage. Surveyor asked RN I, what color is the wound? RN I said the wound was pink. On 6/15/22 at 9:29 AM Surveyor observed R44's right ankle wound with DON B (Director of Nursing). There was no dressing on wound when socks removed. The periwound skin was pink and there was an open area with yellow wound bed on right malleolus. DON B did not measure the wound. Surveyor asked DON B what the wound was. DON B said she had not seen it before, and she will have to review the documentation before she says what the wound is. Surveyor asked DON B how she thought the wound happened. DON B said she was not sure; the resident shoes were a little large and may have rubbed on his feet. On 6/16/22 at 1:18 PM, Surveyor spoke to DON B. the wound on R44's right ankle was a blister and now it's a stage II pressure injury (PI) and his shoe has rubbed on that part of the foot because the shoe is a little too big. R44 developed a facility acquired pressure injury to the malleolus which worsened to a stage 2. The facility failed to ensure aggressive PI interventions were in place to prevent PI development or worsening of the PI.

Based on interview and record review the facility failed to ensure Hospice collaboration and communication processes were established to ensure continuity of care between Hospice and the facility for 4 of 4 Hospice residents out of a total sample of 21 Residents (R36, R53, R42, R18). R36's plan of care was not provided to the facility ensuring coordination of care for R36. The Facility and Hospice were not working collaboratively to ensure coordination of care including ensuring appropriate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility and Hospice failed to implement appropriate interventions to prevent PI development and to prevent worsening of R36's PI. The failure to work collaboratively and create, implement, revise and evaluate R36's plan of care led to R36 acquiring an avoidable PI which worsened to a stage 3. In addition the facility failed to notify the physician and AHPOA (Activated Healthcare Power of Attorney) when the PI deteriorated. There is no documentation in R36's medical record to indicate the facility and Hospice Provider communicated changes in R36's PI, who would be completing wound measurements and who would be contacting the physician and AHPOA with changes. R53's plan of care was not provided to the facility ensuring coordination of care for R53. The Facility and Hospice were not working collaboratively to ensure coordination of care including ensuring appropriate care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no evidence in the medical record to indicate the facility and Hospice Provider worked collaboratively to create, implement, revise and evaluate R53's plan of care for the PI which deteriorated. In addition the facility failed to notify the physician when the PI deteriorated. The Hospice charts kept in the facility for R36, R53, R42, and R18 did not contain the Hospice Plan of Care. The Facility's Service Agreement indicates the former Facility Administrator as the Hospice Coordinator. The facility was unable to identify a Hospice Coordinator within the facility. Hospice Charts at the facility contained no documentation of pressure injury wound measurements, physician and AHCPOA notifications of wounds and wound changes. This is evidenced by: Facility Policy entitled 'Hospice Policy,' undated, states, in part: Purpose: Hospice care is designed to provide comfort and support to terminally ill patients during the final days of their lives. The end of a person's life is a difficult time for the patient and their family, both physically and emotionally. Hospice care can focus on comfort rather than a cure provided at this very personal time. Hospice services are an option available to the residents as the end of their life draws near. Policy: Resident dignity will be maintained in our facility at all times for all residents that choose to implement a Hospice philosophy, as evidenced by: Hospice services will be coordinated throughout the resident's stay with the facility and the Hospice provider. It is generally the responsibility of the Hospice agency to manage the resident's care in conjunction with (Name of Facility). The terminal illness and related conditions will be directed by the Hospice team including: A. An appropriate Hospice Plan of Care will be developed for the patient with documentation in the patient's chart with each nursing visit. C. the Hospice agency will provide medical direction, nursing and clinical management of the terminal illness along with appropriate documentation. E. a. The facility will provide the resident personal care and nursing needs in coordination with the Hospice agency. b. The Plan of Care will be updated as needed. Facility Contract/Agreement, for Hospice states, in part: 1. Definitions . I Plan of Care means a written care plan established, maintained, and reviewed at minimum every 15 days. Hospice and Facility will jointly develop and agree upon a coordinated Plan of Care. The Plan of Care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care. 2. Responsibilities of Facility: c. Comply with Hospice Patient's Plan of Care and ensure Hospice Patients are kept comfortable, clean, well-groomed, and protected i. Hospice and Facility will communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients needs are met 24 hours per day. ii. Design Plan of Care . In accordance with applicable federal and state laws and regulations. Facility will collaborate with Hospice in developing a Plan of Care for each Hospice Patient. iii. Modification of Plan of Care . Facility will participate with periodic, collaborative reviews and modifications of the Plan of Care. Changes to the Plan of Care will only be made in collaboration with Hospice. Hospice will determine the appropriate level of hospice care provided to each Hospice Patient. iv. Notification of Change in Condition . Facility will immediately inform Hospice of change in the condition of a Hospice Patient. This includes, without limitation, a significant change in a Hospice Patient's physical, mental, social or emotional status, clinical complications. e. Policies and Procedures . In providing services to Hospice Patients, Facility will abide by Hospice's policies and procedures, palliative care protocols and Plans of Care. 6. Records. a. Creation and Maintenance of Records . Facility will prepare and maintain complete and detailed records concerning each Hospice Patient receiving Facility Services under this Agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state laws and regulations and Medicare and Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Hospice Patient, including evaluations, treatments, progress notes, authorizations to admission to Hospice and/or Facility. 13. Miscellaneous Provisions. m. Agreement Implementation . Both Facility and Hospice shall designate individuals who shall be responsible for the implementation of the provisions of the Agreement. The current Facility and Hospice Representatives are identified at the end of this Agreement. Example 1: R36 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's admission MDS (Minimum Data Set), dated 1/25/18, indicates R36 was admitted without pressure injuries. R36's quarterly MDS from 2/11/21 indicates that R36 requires extensive assistance with bed mobility, transfers, dressing, toileting and bathing. R36 was admitted to Hospice on 8/02/19. R36's Hospice Facility Care Plan, printed 4/08/21, states in part: Problem: Patient and Family Support. Goal: Facility and Hospice Provider effectively communicate to support care coordination through end of life. The facility care plan, dated 2/23/21, states in part . I: Need some assistance moving around in bed with bathing eating with bathroom use with dressing. Because I: My health is declining, was admitted to Hospice 8/05/19. Special Precautions: I am on Hospice care with (Hospice Provider Name) services I am a DNR (Do Not Resuscitate). Note: The facility does not have a specific care plan for Hospice care with measurable goals and interventions. The Hospice care plan was not available to the facility until after Surveyor requested the care plan on 4/8/21. R36's Hospice Plan of Care update report, from 4/08/21, starting 10/07/19, states, in part: Problem: Patient Facility Coordination. Goal: Patient Facility Coordination Goal. Description: Facility and Hospice Provider effectively communicate to support care coordination through end of life. Intervention: Agency Care Plan: Provide copy of updated care plan to LTC facility. Intervention: Documentation Copies Facility: Description: Hospice Provider staff provides documentation to facility (method, frequency and doc needed): Documentation requirements. Fax completed visit notes after each visit. Fax care plans initially, quarterly and with changes. R36's Hospice Facility Care Plan, printed 4/08/21, states in part: Problem: Wound Management: Goal: Wound Management: Description: Manage wounds per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention: Assess/Perform Pressure Reduction Strategies: Description: Pressure reduction strategies developed: air mattress and cushion for broda chair. Intervention: Perform Weekly RN Wound Assessment. Description: Weekly RN wound assessment and documentation with active wound regimen. The facility care plan, dated 2/23/21, states in part . I have a skin injury. In the past: I have had pressure areas, possible shingles, MASD (Moisture Associated Dermatitis). I need my nurses to: Check my skin weekly, elevate my heels when I'm in bed, blue suspension boots, wound care as ordered per TAR (Treatment Administration Record). I need my aides to: Help me reposition every 1-2 hours while I'm in bed and every 1 hour while in chair, elevate my heels with blue suspension boots, use pressure redistribution devices APP mattress, Roho cushion in wheelchair. Note: Facility Care Plan from 1/19/18 indicates pressure redistribution device, pressure reducing mattress. Hospice pressure injury notes and measurements indicate R36 had no pressure injuries (PI) on 10/27/20. R36 re-developed a pressure injury on 11/04/20, measuring L (Length) 0.2 cm (centimeters) x W (Width) 0.2 cm x D (Depth) 0.1 cm. After the development of the PI the Hospice agency and facility failed to work collaboratively to create, implement, revise and evaluate R36's plan of care. This failure to create a collaborative plan of care led to R36 acquiring an avoidable PI which worsened to a stage 3. R36's pressure injury worsened to a stage 3 with 75% slough on 1/23/21, measuring L 2.0 cm x W 0.2 cm x D 0.2 cm. Note: APP mattress is a mattress overlay. The manufacturer does not indicate if the overlay is appropriate for pressure injuries or what stage pressure injury to use the overlay. The Surveyor was provided a copy of the APP mattress User Manual by the facility. The user manual does not indicate what stage pressure injury the mattress is good to or through. On 4/08/21 at 10:45 AM, Surveyor interviewed Manufacturer of R36 mattress overlay. Manufacturer indicates they are not able to indicate what stage pressure injury the mattress is good for; that would have to come from a Physician. Of note there is no indication in R36's medical record indicating the Hospice Provider and the facility coordinated care for R36 regarding the on use of the overlay mattress. Neither Hospice Provider nor the facility was aware if the overlay mattress was an appropriate intervention for a stage 3 pressure injury (PI). The following shows PI assessment discrepancies between facility and the Hospice Provider and lack of coordination of care. Neither the facility nor the Hospice Provider recognized the discrepancies. Discrepancies are noted as listed below: Hospice Nurse Coccyx Wound Measurements On 1/11/21, L (Length) 3 cm x W (Width) 1 cm x D (Depth) 0.1 cm Facility Coccyx Wound Measurements On 1/12/21, L 2.0 cm x W 0.2 cm x D 0.2 cm: Granulation Tissue: Pink, and/or dull, dusky red and/or fills less than or equal to 25% of wound. Unchanged Hospice Nurse Coccyx Wound Measurements On 1/18/21, L 2 cm x W 1.5 cm x D 0.1 cm, On 1/18/21, Note to MD from Hospice RN F, Provider Communication: Wound appears to be a little less macerated. Facility Coccyx Wound Measurements On 1/23/21, L 1.5 cm x W 0.3 cm x D 0.2 cm: Granulation Tissue: 75% slough and 25% granulation, unchanged Of note, R36's progress notes indicated R36's PI worsened on 1/23/21. There is no evidence in R36's record indicating the Hospice provider and facility staff coordinated care for R36 when the PI was documented as deteriorated or discussed, revised or implemented additional interventions to prevent further deterioration of the PI or update the physician consistently and timely regarding the PI deteriorating. Hospice Nurse Coccyx Wound Measurements On 1/25/21, L 2 cm x W 1.5 cm x D 0.1 cm Facility Coccyx Wound Measurements On 1/29/21, L 1.5 cm x W 0.3 cm x D 0.2 cm: Granulation Tissue: Slough 75% and Granulation 25%, unchanged Hospice Nurse Coccyx Wound Measurements On 2/01/21, L 2 cm x W 2cm x D 0.1 cm On 2/01/21, Note to MD from Hospice RN F, Provider Communication: Please see wound assessment On 2/04/21, L 2 cm x W 2cm x D 0.1 cm On 2/09/21, L 2.5 cm x W 1.3 cm x D 0.3 cm On 2/09/21, Note to MD from Hospice RN F, Provider Communication: Reporting increase size in wound Facility Coccyx Wound Measurements On 2/09/21, L 2.1 cm x W 1.5 cm x D 0.3 cm: Granulation Tissue: 50% granulation and 50% slough, worsening Of note this is the first time the facility and Hospice Provider completed the PI assessment on the same date. Even on the same date there are discrepancies in the PI measurements. Hospice Nurse Coccyx Wound Measurements On 2/16/21, L 2.5 cm x W 1.4 cm x D 0.3 cm. On 2/16/21: Note to MD from Hospice RN F, Provider Communication: Wound is measuring a little smaller than last week. Facility Coccyx Wound Measurements On 2/16/21, L 2.3 cm x W 2.1 cm x D 0.3 cm: Granulation Tissue: 50% granulation and 50% slough, physician notified, treatment changed Of note the facility and Hospice provider complete PI documentation on the same day. Please note the discrepancy in PI documentation. Hospice states the PI is a little smaller although the facility documentation show it has slightly increased in size. Hospice Nurse Coccyx Wound Measurements On 2/19/21, L 2.5 cm x W 1.4 cm x D 0.3 cm Facility Coccyx Wound Measurements On 2/23/21, L 2.0 cm x W 2.6 cm x D 0.2 cm. Granulation Tissue: Granulation and slough, worsened There is no indication the Hospice Provider or physician was notified of the worsening of the PI. Hospice Provider updated the physician on 2/26/21 with the following note: Hospice Nurse Coccyx Wound Measurements On 2/26/21, L 3 cm x W 3.5 cm x D 0.1 cm. On 2/26/21: Note to MD from Hospice RN F, Provider Communication: Wound is measuring longer and wider, but depth has improved. (Treatment changed) Facility Coccyx Wound Measurements On 3/02/21, L 2.5 cm x W 1.9 cm x D 0.2 cm. Granulation Tissue: with bright, beefy red; less than 75% and greater than 25% of wound filled. Necrotic tissue amount: 25%-50% wound covered. Hospice Nurse Coccyx Wound Measurements On 3/05/21, L 3 cm x W 4 cm x D 0.3 cm Facility Coccyx Wound Measurements On 3/09/21, L1.4 cm x W 1.7 cm x D 0.2 cm. Tissue Type: 75% Slough and 25% Granulation, Improving Of note, on 3/09/21, R36's wound declined showing 75% Slough and 25% Granulation Tissue. Although the facility documents improvement in size, the amount of slough had increased. There is no documentation the Physician or Hospice provider was updated on this change. Notes indicate the last Physician notification was on 2/26/21 when treatment was changed. Hospice Nurse Coccyx Wound Measurements On 3/11/21, No Measurements On 3/11/21, Note to MD from Hospice RN F, Provider Communication: Wound care done per POC (Plan of Care). Hospice Nurse Coccyx Wound Measurements On 3/18/21, L 3 cm x W 3 cm x 0.3 cm Of note there is no facility wound documentation again until 3/24/21. Facility Coccyx Wound Measurements On 3/24/21, L1.7 cm x W 1.6 cm x D 0.2 cm. Tissue Type: 75% Slough and 25% Granulation, no change Hospice Nurse Coccyx Wound Measurements On 3/25/21, L 3 cm x 3 cm x 0.2 cm On 3/25/21: Note to MD from Hospice RN F, Provider Communication: Wound care done with facility nurse. Please see wound documentation for details. Facility Coccyx Wound Measurements On 3/30/21, L 1.5 cm x W 1.2 cm x D 0.2cm. Tissue Type: 75% Slough and 25% Granulation, improving Hospice Nurse Coccyx Wound Measurements On 4/01/21, L 2.8 cm x 3 cm x 0.2 cm Note: There is no documentation indicating Facility staff and Hospice Provider communicated changes in the R36' wound. There is no indication the facility or Hospice Provider recognized the discrepancies in PI documentation and lack of coordination into communicating with the physician when a PI worsened. On 4/07/21 at 4:26 PM, Surveyor interviewed Hospice RN F. Surveyor asked Hospice RN F about documentation in R36's chart. Hospice RN F stated, the facility has access to all physician notifications, notes, and care plans in EPIC (electronic record). Surveyor asked RN F if she provided those documents to the facility to keep in the Hospice patient's chart. Hospice RN F stated, No, but they can print them. Surveyor asked if wound measurements were provided to the facility to have in the chart. Hospice RN F stated, I have never been asked that before, I am not sure we can provide that information. Of note, not sharing PI measurements and discussing the PI or discrepancies in documentation demonstrates lack of coordination of care. On 4/07/21 at 4:52 PM, Surveyor interviewed DON B. Surveyor asked DON B where Surveyor would be able to locate R36's care plans, notes, wound measurements and physician notifications. DON B indicated those would have to be obtained from the hospice nurse but the facility care plan was located in the EMR (Electronic Medical Record). On 4/08/21 at 10:31 AM, Surveyor interviewed DON B. Surveyor asked DON B who is the Hospice Coordinator for the facility was. DON B stated, We don't have one. Surveyor indicated to DON B that each facility should have a Hospice Coordinator. DON B stated, I think that should be ADON I. On 4/08/21 at 10:41 AM, Surveyor interviewed ADON I. Surveyor asked ADON I if she was aware of who the Hospice Coordinator for the facility was. ADON I stated, I don't think we have one. I do some referrals along with RN J but that is all. On 4/08/21 at 10:31 AM, Surveyor interviewed Hospice RN F what the process was for wound care at the facility. Hospice RN F stated, I request the orders and RN H and I do the wound assessments together and talk about what we have tried and haven't tried and what we're going to try next. Wounds with hospice are tricky as they are not easy to heal as sometimes they do and sometimes they don't. Of note, the wound documentation for the facility and the Hospice Provider are performed on different dates and demonstrate inconsistencies in size. There is no indication in R36's medical record to indicate coordination of care, communication with the Hospice provider regarding R36's PI. The Facility and Hospice failed to implement appropriate treatment and interventions to prevent PI development and worsening of R36's PI. The failure to coordinate care, create, implement, revise and evaluate R36's plan of care led to R36 acquiring an avoidable PI which worsened to a stage 3. Example 2 R53 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission MDS (Minimum Data Set), dated 8/13/19 indicates R53 was admitted with 1 stage 2 pressure injury. Each of R53's MDS from his admission until his current MDS on 3/4/21 indicate R53 requires extensive assistance with bed mobility, transfers, eating, dressing, toileting and bathing. R53 was admitted to hospice on 3/2/20. R53's hospice care plan, under Durable Medical Equipment, shows R53 has a mattress overlay, which was implemented on 2/10/21 by the Hospice Provider. The facility was unable to provide manufacturer documentation indicating if the mattress was appropriate for a stage 3 pressure injury. Of note, it is unclear why Hospice provided this overlay prior to the resident being admitted to Hospice. The Hospice RN nor facility were able to provide detail as to how this occurred. It should also be noted this care plan was not in R53's medical record and was only received in the facility after Surveyor requested a copy of the Hospice care plan. R53 was admitted with a history of pressure injuries (PI). R53's medical record indicates R53 had an open area to the coccyx on 12/15/20. R53's medical record notes a small open area on 2/4/20 and on 2/9/20 the facility documents R53 has a stage 3 pressure injury. Although R53 is not noted to be on Hospice caseload until 3/2/20. R53's Hospice care plan indicates an overlay was provided for R53 on 2/10/21. R53's medical record indicates R53 was admitted to Hospice on 3/2/21. R53's progress notes indicated R53's PI worsened on 3/2/21. There is no evidence in R53's record indicating the Hospice provider and facility staff coordinated care for R53 when the PI was documented as deteriorated or discussed, revised or implemented additional interventions to prevent further deterioration of the PI or update the physician regarding the PI deteriorating. On 4/06/21 at 9:45 AM, Surveyor interviewed RN H. Surveyor asked RN H if she can explain how wound care is completed in the facility. RN H stated, Wound rounds are done weekly in the facility. The Hospice Nurse and I try to do them together but that is not always possible. Hospice RN F is not always here on the day the measurements are due, so I will complete them without her. On 3/29/21 R53's progress notes indicate R53's stage 3 PI worsened measuring 0.1 centimeters (cm) x 1.9 cm x 0.6 cm, with 25% slough and 75 % granulation. Tan, serosanguineous exudate, no pain wound worsened. There is no evidence in R53's record indicating the Hospice provider and facility staff coordinated care for R53 when the PI was documented as deteriorated or discussed, revised or implemented additional interventions to prevent further deterioration of the PI or update the physician regarding the PI deteriorating. On 4/07/21 at 3:17 PM, Surveyors interviewed RN F, who is the Hospice nurse. RN F stated that R53 was admitted to Hospice on 3/2/20 and, since that time, had not seen or been aware of any open areas on R53's coccyx until 2/9/21. According to RN F, it was at that time that she (RN F) contacted the doctor and received orders for wound treatment. RN F stated she measures the wounds but does not stage them or provide detailed wound information. The facility's wound-certified nurse provides details. Additionally, RN F stated the facility is to contact Hospice and then Hospice contacts the doctor on behalf of Hospice residents. RN F stated she had not been aware of any contact related to an open area on R53's coccyx until 2/9/21. RN F stated she conducts skin assessments on hospice residents once every 14 days and documents issues by exception. If wounds are identified, she assesses those wounds weekly. Of note, the facility nor the Hospice Provider can provide details of why the Hospice Provider was updated on 2/9/21 or why Hospice was providing services prior to the Hospice admitted [DATE]. On 4/07/21 at 3:47 PM, Surveyor interviewed Hospice RN F. Surveyor asked Hospice RN F about documentation in R36 and R53's charts. Hospice RN F states, the facility has access to all physician notifications, notes, and care plans in EPIC. Surveyor asked RN F if she provided those documents to the facility to keep in the Hospice patient's chart. Hospice RN F stated, No, they are not given to the facility to have on hand but they should be able to print them. Surveyor asked if wound measurements were provided to the facility to have in the chart. Hospice RN F stated, I have never been asked that before, I am not sure we can provide that information. Surveyor asked Hospice RN F how often she updates the physician. Hospice RN F states, I update the MD every 14 days regardless of changes. On 4/07/21 at 4:52 PM, Surveyor interviewed DON B. Surveyor asked DON B where Surveyor would be able to locate R36 and R53's care plans, notes, wound measurements and physician notifications. DON B indicated those would have to be obtained from the hospice nurse but the facility care plan was located in the EMR (Electronic Medical Record). On 4/08/21 at 10:31 AM, Surveyor interviewed DON B. Surveyor asked DON B who the Hospice Coordinator for the facility was. DON B stated, We don't have one. Surveyor indicated to DON B that each facility should have a Hospice Coordinator. DON B stated, I think that should be ADON I. Surveyor asked DON B what she could tell Surveyor about the mattress overlay being used for R36 and R53. DON B indicated Hospice provides the overlay and Surveyor would have to discuss mattress with them. Surveyor then asked DON B for a copy of the Manufacturers Guidelines for the mattress overlay being used for R36 and R53. On 4/08/21 at 10:41 AM, Surveyor interviewed ADON I. Surveyor asked ADON I if she was aware of who the Hospice Coordinator for the facility was. ADON I stated, I don't think we have one. I do some referrals along with RN J but that is all. On 4/08/21 at 10:45 AM, Surveyor interviewed Manufacturer of R36 and R53's mattress overlay. Manufacturer indicates they are not able to indicate what stage pressure injury the mattress is good for that would have to come from a Physician. On 4/08/21 at 11:20 AM, Surveyors interviewed Hospice RN F. Surveyor asked Hospice RN F if she could help the Surveyor understand the process for care planning with the facility. Hospice RN F stated, It is a fluid conversation. In stand up meetings in the facility we discuss anything that needs to be added to ECS and it is then added by the staff here in the facility. Care plans are sent to the facility Social Worker and should be kept in the Hospice binder/chart. Surveyor asked Hospice RN F if she has ever verified that the care plans from Hospice are in the Hospice chart. Hospice RN F stated, No. I just brought a copy of R36 and R53's care plans with me, they should be in the chart. Surveyor asked Hospice RN F how often care plans are sent to the facility to place in the chart. Hospice RN F stated, They are faxed quarterly and changes are faxed but I am not responsible for sending them. On 4/08/21 at 11:20 AM, while interviewing Hospice RN F, DON B was present and stated, We are missing the care plans and wound flow sheets. We will have to implement a check with UC K and Hospice RN F to make sure they are being received. On 4/08/21 at 11:20 AM, Surveyor asked Hospice RN F what the process was for wound care at the facility. Hospice RN F stated, I request the orders and RN H and I do the wound assessments together and talk about what we have tried and haven't tried and what we're going to try next. Wounds with Hospice are tricky as they are not easy to heal as sometimes they do and sometimes they don't. Surveyor asked Hospice RN F about R36 an R53's mattress overlay and where recommendations for their use comes from. Hospice RN F stated, I know you asked for manufacturers recommendations. I know we probably have an algorithm for the Braden Scales and we use our judgement and implement the mattresses or overlays. We have an algorithm a PI has to be a stage 3 or 4 to qualify for an air mattress R36 and R53 do not have an air mattress due to the PI not being a stage 3 or 4. Surveyor asked Hospice RN F if she was aware of what stage R36 and R53's wounds were. Hospice RN F stated, R36 and R53 have stage 2. Surveyor asked Hospice RN F if stage 3 is full thickness and if stage 2 can have slough. Hospice RN F stated, No. Surveyor asked Hospice RN F if a wound with 50% or more slough should be a stage 3. Hospice RN F stated, Yes. Surveyor asked Hospice RN F if once slough was present the wound should be a stage 3. Hospice RN F stated, Yes. Surveyor asked Hospice RN F if she could describe the appearance of slough. Hospice RN F stated, Slough can be creamy, yellow, sticky or creamy. Surveyor asked Hospice RN F if she and RN H discuss the wound bed during treatments. Hospice RN F stated, We talk about the dressing and treatments, I don't think we've had a conversation about the wound bed. Surveyor asked Hospice RN F if a NP (Nurse Practitioner) or MD (Medical Doctor) have seen R36's wound. Hospice RN F stated, Not sure, probably when seen last by her physician. The goal is to maintain the wound from getting bigger or infected. Her wound has been pretty stagnant for a while. Surveyor asked Hospice RN F about R53's wound and if Triad cream is appropriate for an open wound due to it containing [MEDICATION(S)]. Hospice RN F stated, Facility carries it and Hospice doesn't have it in their formulary. Hospice RN F indicated she completes wound care with RN H however there are many inconsistencies noted in the PI documentation between the facility and Hospice including dates of completing wound care. There were no Hospice care plans in the facility for R36 or R53. There is no evidence the facility recognized lack of inconsistencies between Hospice PI documentation and facility PI documentation. There is no evidence the facility coordinated care including to discuss potential revision of the PI plan of care when R36 and R53's wound deteriorated. Neither the facility nor the Hospice provider communicated who would be responsible for updating the physician when a PI deteriorates. Neither the facility nor Hospice Provider knew if the overlay mattress was an appropriate choice for a stage 3 PI or addressed whether this overlay should continue to be utilized after a PI was at a stage 3. The facility and Hospice Provider failed to coordinate care, revise, re-evaluate and implement appropriate care plan interventions led to the development and/or deterioration of PI's for R36 and R53. The facility and Hospice provider failed to coordinate care, evaluate and revise R36 and R53's care plans, and ensure the physician was updated and/or updated timely. Hospice RN F states she attends stand up meetings in the facility one time each week to discuss PI's. There is no evidence of Plan of Care evaluations, revisions or documentation to support coordination of patient care. Example 3: R18 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 was admitted to Hospice Services on 4/10/19. On 4/7/21 and 4/8/21 Surveyor noted that R18 did not have a Care Plan for Hospice in his Medical Record at the facility. On 4/8/21 at 8:00 AM, Surveyor asked DON B (Director of Nursing) for R18's Hospice Care Plan. On 4/8/21 at 11:20 AM, Surveyor interviewed Hospice RN F (Registered Nurse) and Director of Nursing B (DON) regarding R18's Care Plan. Hospice RN F indicated communication of R18's plan of care is a fluid conversation and anything that needs to be added to R18's care plan is added into the electronic record by the facility staff. Hospice RN F indicated the Hospice Care Plans are sent over by their Social Worker and the care plans should be kept in the Hospice binder/chart for each resident. Hospice RN F indicated Hospice does not verify the care plans are in the record. Hospice RN F indicated she just brought a copy R18's Care Plan in today, and it should be in the chart. Hospice RN F indicated Care Plans are faxed quarterly and with any changes. DON B indicated at this time the facility is missing the care plans and wound flow sheets out of their Hospice patient records. DON B indicated the facility will need to implement a new process to ensure they're being received from Hospice. Surveyor was provided a copy of R18's [TRUNCATED]

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent pressure injuries (PI) from developing or worsening for 2 of 3 resident reviewed for PIs, out of a sample of 21 residents (R36 and R53). R36 developed an avoidable pressure injury (PI). The facility did not implement appropriate interventions to prevent PI development or prevent the PI from worsening and did not notify the physician timely when the PI deteriorated. R36 developed a stage 3 pressure injury. R53 developed an avoidable PI on his coccyx and the facility did not implement interventions to prevent PI development or worsening and did not notify the physician when PI discovered or when worsened. R53 developed a stage 3 pressure injury. Findings include: Per the National Pressure Injury Advisory Panel, Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. The facility Policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised 4/2018, states in part . Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. b. Pain assessment. c. Resident's mobility status. d. Current treatments, including support surfaces; and e. All active diagnoses. 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Treatment/Management: 2. Physician will help identify medical interventions related to wound management; for example treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. Monitoring: 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. b. Current approaches should be reviewed for whether they remain pertinent to the resident/patient's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident/patient or a substitute decision-maker The facility's Hospice Policy states, An appropriate Hospice Plan of Care will be developed for the patient with documentation in the patient's chart with each nursing visit .the Hospice agency will provide medical direction, nursing and clinical management of the terminal illness along with appropriate documentation. Example 1 R36 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's admission MDS (Minimum Data Set), dated 1/25/18, indicates R36 was admitted without pressure injuries. R36's quarterly MDS from 2/11/21 indicates (R36) requires extensive assistance with bed mobility, transfers, dressing, toileting and bathing. R36 was admitted to Hospice on 8/02/19. R36 has a history of pressure injuries. R36 had a healed stage 3 pressure injury on 10/27/20. On 11/04/20, R36 had a coccyx pressure injury (PI) present as L (length) 0.2 cm x W (width) 0.2 cm x D (depth) 0.1 cm. Facility Coccyx Wound Measurements starting on 1/12/21 were as follows . On 1/12/21, L 2.0 cm x W 0.2 cm x D 0.2 cm: Granulation Tissue: Pink, and/or dull, dusky red and/or fills less than or equal to 25% of wound. Unchanged The facility has a Care Plan from 1/19/18 indicating pressure redistribution device, pressure reducing mattress. R36 currently has an APP mattress. This is a mattress overlay not an air mattress; the manufacturer does not indicate if the overlay is appropriate for pressure injuries or what stage pressure injury to use the overlay. The Surveyor was provided a copy of the APP mattress User Manual by the facility. The user manual does not indicate what stage pressure injury the overlay mattress is good to or through. On 4/08/21 at 10:45 AM, Surveyor interviewed Manufacturer of R36 mattress overlay. Manufacturer indicates they are not able to indicate what stage pressure injury the mattress is good for that would have to come from a Physician On 1/23/21, L 1.5 cm x W 0.3 cm x D 0.2 cm: Granulation Tissue: 75% slough and 25% granulation, unchanged. There is no documentation in the medical record indicating the physician or Hospice provider were made aware the PI has worsened to a stage 3 with slough in the wound bed. On 1/29/21, L 1.5 cm x W 0.3 cm x D 0.2 cm: Granulation Tissue: Slough 75% and Granulation 25%, unchanged On 2/09/21, L 2.1 cm x W 1.5 cm x D 0.3 cm: Granulation Tissue: 50% granulation and 50% slough, worsening R36's Hospice Comprehensive Visit, dated 2/09/21, and signed by Hospice RN F (Hospice Registered Nurse), states, in part: Braden Scale, Score 11, Moderate risk for skin impairment. On 2/16/21, L 2.3 cm x W 2.1 cm x D 0.3 cm: Granulation Tissue: 50% granulation and 50% slough, physician notified, treatment changed On 2/23/21, L 2.0 cm x W 2.6 cm x D 0.2 cm. Granulation Tissue: Granulation and slough, worsened. There is no indication in the medical record the physician or Hospice Provider was notified of the worsening of the PI on 2/23/21. The facility care plan, dated 2/23/21, states in part . I have a skin injury. In the past: I have had pressure areas, possible shingles, MASD (Moisture Associated Dermatitis). I need my nurses to: Check my skin weekly, elevate my heels when I'm in bed, blue suspension boots, wound care as ordered per TAR (Treatment Administration Record). I need my aides to: Help me reposition every 1-2 hours while I'm in bed and every 1 hour while in chair, elevate my heels with blue suspension boots, use pressure redistribution devices APP mattress, Roho cushion in wheelchair. On 3/02/21, L 2.5 cm x W 1.9 cm x D 0.2 cm. Granulation Tissue: with bright, beefy red; less than 75% and greater than 25% of wound filled. Necrotic tissue amount: 25%-50% wound covered. On 3/09/21, L1.4 cm x W 1.7 cm x D 0.2 cm. Tissue Type: 75% Slough and 25% Granulation, Improving The facility documented R36's wound had 75% Slough and 25% Granulation Tissue this is a deterioration in the wound bed yet the facility documented the wound was improving. The wound did show improvement in measurements but a decline in wound bed appearance. There is no documentation that the Physician was updated on this change. Of note there is no facility PI documentation, measurements or assessments from 3/9 until 3/24/21 fifteen days later. On 3/24/21, L1.7 cm x W 1.6 cm x D 0.2 cm. Tissue Type: 75% Slough and 25% Granulation, no change On 3/30/21, L 1.5 cm x W 1.2 cm x D 0.2cm. Tissue Type: 75% Slough and 25% Granulation, improving Hospice Nurse Coccyx Wound Measurements starting on 1/11/21 were as follows . On 1/11/21, L (Length) 3 cm x W (Width) 1 cm x D (Depth) 0.1 cm On 1/18/21, L 2 cm x W 1.5 cm x D 0.1 cm, On 1/18/21, Note to MD from Hospice RN F, Provider Communication: Wound appears to be a little less macerated. On 1/25/21, L 2 cm x W 1.5 cm x D 0.1 cm On 2/01/21, L 2 cm x W 2cm x D 0.1 cm On 2/01/21, Note to MD from Hospice RN F, Provider Communication: Please see wound assessment On 2/04/21, L 2 cm x W 2cm x D 0.1 cm On 2/09/21, L 2.5 cm x W 1.3 cm x D 0.3 cm On 2/09/21, Note to MD from Hospice RN F, Provider Communication: Reporting increase size in wound On 2/16/21, L 2.5 cm x W 1.4 cm x D 0.3 cm. On 2/16/21: Note to MD from Hospice RN F, Provider Communication: Wound is measuring a little smaller than last week. On 2/19/21, L 2.5 cm x W 1.4 cm x D 0.3 cm On 2/26/21, L 3 cm x W 3.5 cm x D 0.1 cm. On 2/26/21: Note to MD from Hospice RN F, Provider Communication: Wound is measuring longer and wider, but depth has improved. (Treatment changed) On 3/05/21, L 3 cm x W 4 cm x D 0.3 cm On 3/11/21, No Measurements On 3/11/21, Note to MD from Hospice RN F, Provider Communication: Wound care done per POC (Plan of Care). On 3/18/21, L 3 cm x W 3 cm x 0.3 cm On 3/25/21, L 3 cm x 3 cm x 0.2 cm On 3/25/21: Note to MD from Hospice RN F, Provider Communication: Wound care done with facility nurse. Please see wound documentation for details. On 4/01/21, L 2.8 cm x 3 cm x 0.2 cm Of note there are no wound measurements from Hospice Provider on 3/11/21. There is no documentation R36's AHCPOA (Activated Healthcare Power of Attorney) was notified of the PI worsening. Facility measurements and Hospice Provider Measurements are not consistent and show discrepancies in documentation. There is no documentation indicating that Facility staff and Hospice Provider communicated changes in the R36's wound, who was responsible for completing wound measurements and who would be contacting the Physician and AHCPOA with any changes. On 4/06/21 at 9:45 AM, Surveyor interviewed RN H. Surveyor asked RN H if she can explain how wound care is completed in the facility. RN H stated, Wound rounds are done weekly in the facility. The Hospice Nurse and I try to do them together but that is not always possible. Hospice RN F is not always here on the day the measurements are due, so I will complete the assessment and wound care. On 4/07/21 at 3:47 PM, Surveyor interviewed Hospice RN F. Surveyor asked Hospice RN F about documentation in R36's chart. Hospice RN F states, the facility has access to all physician notifications, notes, and care plans in EPIC. Surveyor asked RN F if she provided these documents to the facility to keep in the Hospice patient's chart. Hospice RN F stated, No, they are not given to the facility to have on hand but they should be able to print them. Surveyor asked if wound measurements were provided to the facility to have in the chart. Hospice RN F stated, I have never been asked that before, I am not sure we can provide that information. Surveyor asked Hospice RN F how often she updates the physician. Hospice RN F states, I update the physician every 14 days regardless of changes. On 4/07/21 at 4:52 PM, Surveyor interviewed DON B (Director of Nursing) and Hospice RN F. Surveyor asked DON B where Surveyor would be able to locate R36's care plans, notes, wound measurements and physician notifications. DON B indicated those would have to be obtained from the hospice nurse but the facility care plan was located in the EMR (Electronic Medical Record). DON B stated, We are missing the care plans and wound flow sheets. We will have to implement a check with UC K (unit clerk) and Hospice RN F to make sure they are being received. On 4/07/21 at 4:52 PM, Surveyor interviewed Hospice RN F on the process for wound care at the facility. Hospice RN F stated, I request the orders, RN H and I do the wound assessments together, and talk about what we have tried and haven't tried and what we're going to try next. Wounds with hospice are tricky as they are not easy to heal as sometimes they do and sometimes they don't. Surveyor asked Hospice RN F about R36 mattress overlay and where recommendations for the use comes from. Hospice RN F stated, I know you asked for manufacturers recommendations. I know we probably have an algorithm for the Braden Scales and we use judgement and implement them. We have an algorithm that has to have a stage 3 or 4 to qualify for an air mattress. The overlay is used due to not being a stage 3 or 4. Surveyors asked Hospice RN F if she was aware of what stage R36 PI was. Hospice RN F stated, R36 has a stage 2. Surveyors asked Hospice RN F if stage 3 is full thickness and if stage 2 can have slough. Hospice RN F stated, No. Surveyors asked Hospice RN F if a wound with 50% or more slough should be a stage 3. Hospice RN F stated, Yes. Surveyors asked Hospice RN F if once slough was present the wound should be a stage 3. Hospice RN F stated, Yes. Surveyors asked Hospice RN F if she could describe the appearance of slough. Hospice RN F stated, Slough can be creamy, yellow, sticky or creamy. Surveyor asked Hospice RN F if she and RN H discuss the wound bed during treatments. Hospice RN F stated, We talk about the dressing and treatments, I don't think we've had a conversation about the wound bed. Surveyors asked Hospice RN F if a NP (Nurse Practitioner) or MD (Medical Doctor) have seen R36's wound. Hospice RN F stated, Not sure when the MD or NP would have seen it last. The goal is to maintain the wound from getting bigger or infected. R36's wound has been pretty stagnant for a while. Of note, RN F, the Hospice Nurse, and RN H have PI measurements completed on different days, Hospice does not provide PI measurements or documentation to the facility. The facility nor the Hospice Provider were aware of discrepancies in Pi measurements even when measurements are completed on the same day. The physician and AHCPOA are not notified timely of PI deterioration. There is no evidence in R36's record the facility and Hospice agency evaluated R36's PI plan of care, implemented interventions when appropriate and re-evaluated the effectiveness of R36's plan of care. R36's Hospice Facility Care Plan, printed 4/08/21, states in part: Problem: Wound Management: Goal: Wound Management: Description: Manage wounds per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention: Assess/Perform Pressure Reduction Strategies: Description: Pressure reduction strategies developed: air mattress and cushion for Broda chair. Intervention: Perform Weekly RN Wound Assessment. Description: Weekly RN wound assessment and documentation with active wound regimen. Of note this care plan was not in R36's medical record until the Surveyor requested the care plan on 4/8/21. Example 2 R53 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His admission MDS (Minimum Data Set), dated 8/13/19 indicates R53 was admitted with 1 stage 2 pressure injury. Each of R53's MDS from his admission until his current MDS on 3/4/21 indicate R53 requires extensive assistance with bed mobility, transfers, eating, dressing, toileting and bathing. Facility documentation indicates R53 has a historical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R53 was admitted to hospice on 3/2/20. R53 has a standing physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R53's most recent MDS, dated [DATE], shows R53 has a stage 3 pressure ulcer which was not present upon admission. Additionally, R53's skin care plan states, I need my aides to .reduce pressure and friction between myself and my bed or chair, use pressure redistribution devices mattress. R53's hospice care plan, under Durable Medical Equipment, shows R53 has a mattress overlay, which was implemented on 2/10/21. The facility was unable to provide manufacturer documentation indicating if the mattress overlay was appropriate for a stage 3 pressure injury. Surveyor interviewed the manufacturer of the mattress overlay on 4/8/21 at 10:45 AM. The company was unable to provide any information on the overlay's ability to provide support for a stage 3 pressure injury. The company stated that information regarding ratings as it relates to pressure injuries would have to come from a physician. R53 was observed on 4/5/21 and 4/8/21 in his bed. He was lying on an overlay mattress. The facility recorded the following progress notes for R53: December 2020 12/1, 2:22 PM: skin intact 12/2, 10:52 AM: skin intact 12/2 7:54 PM: skin issues noted to coccyx area. Area red in color, [MEDICATION(S)] applied. Resident complaining of pain to area. (Of, note there is no evidence the facility checked for blanching, a test to check if skin is blanchable, and a non-blanchable area indicates stage 1 pressure injury (PI). 12/3, 10:08 AM: area red in color, [MEDICATION(S)] applied 12/4, 11:33 AM: small dry patch to coccyx area/no open areas noted 12/5, 10:16 AM: coccyx area dry, flakey, no open areas noted 12/6, 7:03 PM: skin intact 12/7, 9:38 AM: skin intact 12/8, 7:46 AM: skin issue noted, area reddened 12/8, 9:46 PM: Skin issue noted, dry patch noted to coccyx area 12/10, 10:35 PM: skin is dark pink patchy proximal coccyx area 12/12, 10:29 PM: light pink area to coccyx, no open areas 12/13, 10:05 AM: coccyx area pink in color 12/15, 8:04 PM: small open area middle of coccyx, area cleaned, and triad applied per order 12/16, 12:34 AM: Presents with minute size open area on coccyx 12/16, 10:44 PM: skin intact, continue to monitor minute size opening, no complaints of pain 12/18/20, 9:21 PM: minute size enclosing opening dark pink skin peri wound bed, resident opens up old slit. On 4/07/21 at 2:00 PM, Surveyors interviewed RN G (Registered Nurse), RN G documented the progress note on 12/15/20 regarding R53's open area on coccyx. RN G stated she would normally contact a doctor if a reddened area was worsening or opened but did not contact a doctor on 12/15/20 as R53 had a standing order for open areas. Between 12/19/20 and 1/9/21, facility progress notes regarding R53's coccyx do not mention any open areas, but frequently mention reddened, pink, or dry. On 1/9/21 and 1/10/21, nursing notes state R53's skin is ruddy with a small slit to coccyx. From 1/11/21 until 2/4/21, nursing notes do not mention any open areas to R53's coccyx, but frequently state skin intact, skin issues, and/or no open areas. The following progress notes were documented for February 2021. 2/4, 9:59 PM: skin issues noted, blood adhere to brief. Coccyx presents with small opening, excoriated skin. 2/5, 6:41 PM: skin issues noted, to coccyx, barrier cream applied per orders. 2/7, 11:01 AM: barrier cream to buttocks, skin issues noted, small opening to coccyx 2/8, 10:17 PM: skin issues noted, continues with open area to coccyx, treatment per order Between 12/15/20 and 2/9/21, no documentation or evidence was provided that there was any measuring of the open area on R53's coccyx or R53's physician was notified of the wound. Progress notes show R53's physician was notified regarding other non-related health concerns, but nothing related to skin. On 2/9/21, the facility notes, as an initial assessment, R53 to have a stage 3 pressure injury on his gluteal cleft, measuring at .2 cm (depth) x 4 cm (length) x .3 cm (width). The wound was noted to be pink, reddened, yellow, 75% granulation, 25% slough with bloody sanguineous exudate. The physician was notified on 2/9/21 and treatment was ordered for triad to coccyx twice daily. A house supplement was also ordered three times each day for additional nutritional support. The assessment states the wound was discovered on 2/4/21. Of note the physician was not notified and treatment was not ordered for 5 days later according to the assessment date of PI discovery 2/4/21. On 2/16/21, progress notes regarding R53's coccyx wound state the wound is a stage 2 with 75% granulation and 25% slough. The wound measured at .2cm x 3.3cm x .3cm. Of note there is no downsizing of a PI. If a PI presents as a stage 3 it remains a stage 3. The facility continued with weekly wound treatment, documenting: 2/23/21: stage 3, 75%-100% of wound filled and/or tissue overgrowth, .3cm x 1.7cm x .3cm, no signs of infection, no pain, wound improving 3/2/21: stage 3, .3cm x 1.8cm x .6cm, tissue type: granulation slough, 75-100% of wound bed covered. Yellow, brown, tan serosanguineous exudate, resident has pain. Wound worsened. Of note, there is no indication in the medical record the MD was notified of the pressure injury (PI) worsening. 3/9/21: stage 3, .3cm x 1.9cm x .6 cm, 100% granulation, no exudate, no pain or signs of infection, wound improving 3/16/21: stage 3, .2cm x 1cm x .3 cm, 100% granulation, no exudate, no pain or signs of infection, wound improving 3/24/21: stage 3, .1cm x .9cm x .3 cm, wound improving 3/29/21: stage 3, .1cm x 1.9cm x .6 cm, 25% slough, 75% granulation. Tan, serosanguineous exudate, no pain, wound worsened Of note, there is no documentation indicating that Facility staff and Hospice Provider coordinated care for R53 when the PI was documented as deteriorating or discussed, revised or implemented additional care plan interventions to prevent continued PI deterioration. On 4/07/21 at 4:52 PM, Surveyor asked Hospice RN F about R53's wound and if Triad cream is appropriate for an open wound as Triad contains [MEDICATION(S)]. Hospice RN F stated, Facility carries it and Hospice doesn't have it in their formulary. Of note, RN F, the Hospice Nurse, and RN H have wound measurements completed on different days and Hospice is not providing this documentation. The Hospice agency is not assessing the wound and there is no documentation in the facility notes or Hospice notes indicating the facility and Hospice are coordinating care regarding R36's PI. There is no evidence in R36's record the facility and Hospice agency evaluated R36's PI plan of care, implemented interventions when appropriate and re-evaluated the effectiveness of R36's plan of care. On 4/6/21: stage 3, .1cm x 1.4cm x .2 cm, 100% granulation, no exudate, no pain or signs of infection, wound improving On 4/06/21 at 9:39 AM, Surveyors observed wound and treatment. The facility has shower/bath record sheets that describe any skin issues when showers or baths are given weekly. A picture of a blank body, both front and back, is shown so CNA staff can mark where skin issues appear. When a skin issue is identified, nursing staff are to assess the wound further. R53's shower/bath record shows staff marked an x on the pictured body on the coccyx area on 12/7/20, 12/14/20 and 12/21/20. However, no details were written on the document as to what the area looked like. R53's shower/bath sheet was not filled out again until 1/4/21, 1/14, 1/18 and 1/25, all of which indicate R53 had no skin concerns and his skin was intact. No shower sheets were conducted again until 2/15/21 and were done weekly until 4/6/21, all of which indicated no skin concerns and that skin was intact. On 4/07/21 at 2:00 PM, Surveyors interviewed RN G who documented the progress note on 12/15/20 regarding R53's open area on coccyx. RN G stated she would normally contact a doctor if a reddened area was worsening or opened but did not contact a doctor on 12/15 as R53 had a standing order for open areas. On 4/07/21 at 3:17 PM, Surveyors interviewed RN F, who is the Hospice nurse. RN F stated R53 was admitted to Hospice on 3/2/20 and, since that time, had not seen or been aware of any open areas on R53's coccyx until 2/9/21. (Of note, it is unclear why the Hospice Provider was involved in R53's care prior to the Hospice admitted [DATE].) According to RN F, it was at that time she (RN F) contacted the doctor and received orders for wound treatment. RN F stated she measures the wounds but does not stage them or provide detailed wound information. The facility's wound-certified nurse provides details. Additionally, RN F stated the facility is to contact Hospice and then Hospice contacts the doctor on behalf of Hospice residents. RN F stated she had not been aware of any contact related to an open area on R53's coccyx. RN F stated she conducts skin assessments on hospice residents once every 14 days and documents issues by exception. If wounds are identified, she assesses those wounds weekly. On 4/8/21 at 11:20 AM, RN F stated to Surveyors that R53's pressure injury was a stage 2, but stated that once a pressure injury has slough, it becomes a stage 3. RN F then stated she was unaware if R53's mattress overlay was sufficient for a stage 3 and Hospice has an algorithm to determine if a Hospice resident would receive an air mattress, if the resident's pressure injury is less than a stage 3. On 4/07/21 at 4:52 PM, Surveyor asked Hospice RN F about R53's wound and if Triad cream is appropriate for a stage 3 PI as it is a [MEDICATION(S)] based formula. Hospice RN F stated, Facility carries it and Hospice doesn't have it in their formulary. Of note, there is no documentation in the facility notes or Hospice notes indicating the facility and Hospice are coordinating care regarding R53's PI. There is no evidence in R53's record the facility and Hospice agency evaluated R53's PI plan of care, implemented interventions when appropriate and re-evaluated the effectiveness of R53's plan of care. On 4/7/21 at 2:30 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated on 12/15/20 when RN G observed the open area on R53's coccyx, she should have notified someone, hospice or a doctor, and measured the wound. DON B stated she believed R53 had a previous stage 3 pressure injury on his coccyx and therefore the current opened wound would be a stage 3. On 4/8/21 at 11:20 AM, DON B stated to Surveyor the facility was missing wound flow sheets and care plans for R53. DON B was unaware R53's open area had not been measured until 2/9/21 despite having been opened in December and on 2/4/21. The facility was aware R53 was at risk for pressure injuries as he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not report or measure R53's wound to his coccyx once it was identified on 12/15/20 and, again, did not measure or report the wound when identified and documented on 2/4/21. The wound was reported on 2/9/21 at which point the injury was a stage 3. The facility did not notify the physician upon finding the wound had worsened on 3/2/21 and 3/29/21 and was unaware if the mattress overlay for R53 was appropriate for a stage 3 pressure injury. The facility was not regularly assessing R53's skin and did not have wound/skin assessments and information, as well as care plans, from Hospice. The facility and hospice failed to coordinate care to ensure the MD was notified when the PI worsened, failed to coordinate care for R53 to ensure appropriate interventions were in place to prevent PI from worsening.

Based on interview, and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 15 residents (R12) reviewed. R12 was admitted with a [DIAGNOSES REDACTED]. When Resident 12 did not have bowel movements and began complaining of abdominal pain that had kept him up at night, the facility did not assess his abdomen or call the physician. R12 was admitted to the hospital with [REDACTED]. R12 expired 4 days later due to small bowel obstruction. Facility failure to assess R12's complaints of abdominal pain created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on [DATE] at 12:00 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its corrective action plan. Findings as follows: R12's most recent admission to the facility was on [DATE] with [DIAGNOSES REDACTED]. R12's quarterly MDS dated [DATE] includes a BIMS score of 15, which indicates R12 continues to be cognitively intact. Section H0400 Bowel continence indicates that R12 is always continent. R12's Comprehensive Care Plan Alteration in health maintenance dated [DATE] includes in part; related to dx (diagnosis) [DATE] admitted for resolving small bowel obstruction and constipation. Interventions include: Nurses - Monitor BM (bowel movement) regularly, low residue diet. Nurse Aide - Report no BM for 3 days to nurse, hx (history) of small bowel obstruction ,[DATE], report c/o (complaints of) abdominal pain. Bowel patterns have been frequent, formed or soft stool in past month. R12's physician's orders [REDACTED]. Mix with ,[DATE] oz. of liquid. [MEDICATION NAME] 5 mg tablet 1 daily prn (as needed) for constipation. [MEDICATION NAME] 10 mg suppository 1 daily rectal prn constipation. Standing order administration if no BM in 3 days. Milk of Magnesia 2400 mg daily prn constipation. Standing order. Review of R12's BM record includes the following pattern: [DATE] - 0 [DATE] - 2 both medium. [DATE] - 1 small. [DATE] - 1 medium. [DATE] - 2 both medium. [DATE] - 1 medium [DATE] - 3 1 small, 2 medium. [DATE] - 1 medium. [DATE] - 1 large. [DATE] - 2 medium [DATE] - 1 medium. [DATE] - 0 [DATE] - 0 Review of nursing notes dated [DATE] at 4:43 PM by RN H states, Drowsy this morning, reported that he was up until 3 AM, with stomach pain. 'I ate an orange last night that upsets his stomach'. Resident ate bites for breakfast and 60 ml (milliliters) of fluid, reported to writer wanted to sleep. Vital signs Blood pressure ,[DATE], Pulse 68, Oxygen saturation 98% on room air, Pain - denied pain score ,[DATE]. There is no documentation of an abdominal assessment, bowel sounds, vital signs, pain assessment when R12 was experiencing stomach pain while it was occurring at night or when RN H became aware of what had occurred. Review of nursing notes dated [DATE] at 4:59 PM by RN H states, POA daughter (daughter name) called facility concerned about father and possible bowel obstruction. Reported to writer that resident stated to her last night he felt aweful (sic) , writer stated to POA that our in house Nurse Practitioner (NP) D assessed him and as reported by NP D resident did have hypoactive bowel sounds, abdomen soft non tender, last bowel movement within 3 days. Writer reported to POA would update NP with the (new) information given and would contact POA back. Writer entered resident's room early afternoon and denied pain, opened his eyes and stated to writer 'I am ready to get up', resident assisted out of bed and offered a snack, ate rice krispy treat and appeared comfortable. Spoke with POA (POA Name) this late afternoon regarding resident feeling better at this time and that if resident has further complaints we will contact the MD office. On [DATE] at 2:35 PM, Surveyor interviewed NP D via phone regarding Resident 12 and the abdominal assessment that was documented as being performed by NP D. NP D indicated that R12's spouse reported to her the symptoms he was having. NP D indicated that she told RN H to call MD C as she is not allowed to see Resident 12. Surveyor asked NP D if she assessed R12's abdomen, bowel sounds, bowel record. NP D indicated she did not assess R12. It is important to know there is no documentation of the abdominal assessment by either the nurse or the NP with R12's known history of bowel obstructions, furthermore it was documented that there was hypoactive bowel sounds and there is no follow up on that symptom. Review of nursing notes dated [DATE] at 2:55 PM, state, Resident refused to get up this early morning for breakfast, reported to writer that he was up late last night with stomach pain, but felt better this morning, denied any pain later this morning. Resident encouraged to get out of bed did agree to early afternoon. Denied any stomach pain early afternoon reported to writer was hungry and provided a snack. There is no documentation of an abdominal assessment, bowel sounds, vital signs, pain assessment when R12 was experiencing stomach pain while it was occurring at night. Even though R12 felt better in AM, the RN did not assess his abdomen especially since R12 is known to have bowel obstructions. On [DATE] at 3:37 PM, nursing note states, Digestive C/O- experiencing pain later this afternoon, belching as reported by daughter. Last BM [DATE] medium type 4 like a sausage or snake like, smooth and soft. Resident requires no help from staff for eating in resident's room this day 0%, intake 450 Ml this day. At 3:40 PM a nursing notes states, Alert and awake, X3 this day lethargic past two days requesting to stay in bed until early afternoon this day. On [DATE] at 3:42 PM, a nursing note states, POA daughter (name) in this day requesting resident be sent to (hospital name) ER to rule out bowel obstruction resident has hx asymptomatic condition but later found to have a partial obstruction. On [DATE] at 9:58 PM, nursing note by RN N includes in part, R12 sent to ER (emergency room ) for evaluation this shift. Vitals signs temp 99.0, 02 (oxygen) sats 97% on room air, blood pressure ,[DATE], pulse 82, respirations 24. Review of R12's meal and fluid intake record includes the following: [DATE] - 480 ml (ate 100% for breakfast, 75% lunch, 100% dinner). [DATE] - 240 ml (ate bites for breakfast, 75% dinner. No lunch documentation). [DATE] - 180 ml (0% for breakfast, 0% lunch). This notes a significant decrease in food consumption. Review of the Physician's office documentation dated [DATE] at 3:44 PM, includes in part, RN N from the facility is calling stating R12 has been feeling ill the past two days. R12 has not had a BM since the night before last, not eating, low grade temperature of 99.0. R12 has a history of bowel obstruction. Bowels are hypoactive BP is ,[DATE], R 24, P 82, 02 sat on room air (without oxygen) is 97%. RN N is calling for an order as family is hoping for Resident 12 to go to the ER. Clinic nurse returned call to the facility on [DATE] at 3:48 PM. Family wants R12 seen in the ER. Verbal order given to RN N. On [DATE] at 10:24 AM, nursing note by RN H includes in part, notes received from the hospital indicate that R12 was admitted with a SBO RLQ (right lower quadrant). He died at the hospital four days later. On [DATE] at 6:15 PM Surveyor interviewed MD C via phone regarding R12. MD C indicated the cause of death was the SBO, R12 also had pneumonia. MD C indicated that a person could develop pneumonia due to not taking in deep breaths if they are having abdominal pain. MD C indicated that the SBO set all of this into action. On [DATE] at 4:25 PM, Surveyor interviewed R12's FM E regarding R12's abdominal pain at the facility in [DATE]. Surveyor asked FM E if she spoke to R12 on the phone or in person. FM E indicated that she came to visit every day as she lived down the street. Surveyor asked FM E if she recalls R12 having abdominal pain prior to his last hospitalization . FM E indicated that R12's pain was gradual similar to the last time he was hospitalized with the bowel obstruction. Surveyor asked FM E if she recalled talking to NP D about R12. FM E indicated that she did talk to NP D regarding R12's symptoms. Surveyor asked FM E if NP D looked at R12. FM E indicated that she did not recall seeing the NP D look at R12. Surveyor asked FM E if she ever saw the nurse's listen to R12's abdomen with a stethoscope. FM E indicated that she never saw this happen. Review of the Hospital Discharge [DIAGNOSES REDACTED]. 1. Small Bowel Obstruction. 2. Systolic Heart Failure. 3. Acute Kidney Injury. 4. Urinary Tract Infection. 5. Right Lower Lobe Pneumonia. 6. [MEDICAL CONDITION]. 7. Death. The failure to assess R12's complaints of abdominal pain, bowel movements, and lack of appetite created a fining of immediate jeopardy. The facility removed the immediacy on [DATE] when the facility: *Facility authored a policy and procedure using standard of practice as outlined in the AMA Clinical Practice Guidelines for acute changes of condition. The procedure to include AMDA Data Collection System, and by using a collective format for Primary Practitioner Notification. *Facility will educate the RN and LPN staff in Assessment and Evaluation for Abdominal pain using the AMDA Know it all before you call Data collection system-for abdominal pain, distention and/or discomfort. *Facility will implement a PCP notification Form detailing onset, duration, frequency, and severity of symptoms, current medication list (including recent changes), recent food and fluid intake, current diet current [DIAGNOSES REDACTED]. *Facility will implement monthly QAPI meetings, and DON or designee will review 5 charts per week for 3 months for proper documentation and looking for any acute changes of conditions. Cross reference F157

Based on interview and record review, the facility did not consult with the resident's physician when there was a change in the resident's physical condition or a need to alter treatment for 1 of 15 residents (R12) reviewed. R12 was experiencing abdominal pain, decreased oral intake and had a known history of bowel obstruction. R12 began experiencing abdominal pain; there is not documentation in the medical record the facility consulted with the physician regarding R12's abdominal pain. R12's wife was concerned and asked a Nurse Practitioner (NP) D to look at R12. The NP D told the floor nurse to call the MD but no MD call was made until [DATE] when family insisted that R12 be transported to the ER to rule out bowel obstruction. R12 was diagnosed with [REDACTED]. Facility failure to promptly consult with the physician created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A was notified of the immediate jeopardy on [DATE] at 12:00 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its corrective action plan. This is evidenced by: The facility's policy Change in a Resident's Condition or Status dated 2014, includes in part, Our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition or status. 1. d. A significant change in the resident's physical/emotional/mental condition. R 12's recent admission to the facility was on [DATE] with [DIAGNOSES REDACTED]. R12 is his own decision maker. Review of nursing notes dated [DATE] at 4:43 PM by RN H states, Drowsy this morning, reported that he was up until 3 AM, with stomach pain. 'I ate an orange last night that upsets his stomach'. Resident ate bites for breakfast and 60 ml (milliliters) of fluid, reported to writer wanted to sleep. Vital signs Blood pressure ,[DATE], Pulse 68, Oxygen saturation 98% on room air, Pain - denied pain score ,[DATE]. Review of nursing notes dated [DATE] at 4:59 PM by RN H states, POA daughter (daughter name) called facility concerned about father and possible bowel obstruction. Reported to writer that resident stated to her last night he felt awful, writer stated to POA that our in house NP D assessed him and as reported by NP D resident did have hypoactive bowel sounds, abdomen soft non-tender last bowel movement within 3 days. Writer reported to POA would update NP D with the (new) information given and would contact POA back. Writer entered resident's room early afternoon and denied pain, opened his eyes and stated to writer 'I am ready to get up', resident assisted out of bed and offered a snack, ate rice krispy treat and appeared comfortable. Spoke with POA (POA Name) this late afternoon regarding resident feeling better at this time and that if resident has further complaints we will contact the MD office. It is important to know that NP D, via phone interview on [DATE] at 2:35 PM, reported that R12's family member spoke to NP D, while NP D was in the facility, and relayed the symptoms R12 was experiencing. Family Member E shared this concern with NP D as NP D formerly provided care for R12. Surveyor asked NP D if she assessed R12. NP D indicated that she did not assess R12 but told RN H to contact the physician for direction. The physician was not contacted regarding R12's abdominal pain and poor oral intake. Review of nursing notes dated [DATE] at 2:55 PM, state, Resident refused to get up this early morning for breakfast, reported to writer that he was up late last night with stomach pain, but felt better this morning, denied any pain later this morning. Resident encouraged to get out of bed did agree to early afternoon. Denied any stomach pain early afternoon reported to writer was hungry and provided a snack. Facility staff did not consult with the physician when R12 experienced pain that kept him up late. On [DATE] at 3:42 PM, a nursing note states, POA daughter (name) in this day requesting resident be sent to (hospital name) ER to rule out bowel obstruction resident has hx asymptomatic condition but later found to have a partial obstruction. On [DATE] at 9:58 PM, nursing note by RN N includes in part, R12 sent to ER (emergency room ) for evaluation this shift. Vitals signs temp 99.0, 02 (oxygen) sats 97% on room air, blood pressure ,[DATE], pulse 82, respirations 24. On [DATE] at 6:15 PM Surveyor interviewed MD C via phone regarding R12. MD C indicated that he has known R12 for a very long time and last saw him on [DATE]. MD C reported that R12 was doing well. MD C indicated Resident was feeling good and in better spirits. Surveyor asked MD C if he would have expected to be notified that R12 was having abdominal pain. MD C indicated yes. MD C indicated that the facility has his personal cell phone number and the nursing staff is aware they can call him at any time. MD C indicated that R12 has a history of bowel obstruction. Surveyor asked MD C if NP D is seeing R12. MD C indicated that the clinic does not use the services of NP D any longer. MD C indicated they did allow NP D in the past to round on the residents. Surveyor asked MD C what he would have done if notified of R12's abdominal pain. MD C indicated he would have sent R12 to the emergency room to be evaluated due to his history. MD C indicated that his office was first contacted regarding R12 having abdominal pain on [DATE] at 3:46 PM. MD C indicated that his nurse responded to the message at 3:49 PM and gave the ok to have R12 sent to the hospital for evaluation. At the hospital, R12 was found to have a small bowel obstruction (SBO). R12 expired 4 days later MD C indicated the cause of death was the SBO, R12 also had pneumonia. MD C indicated that a person could develop pneumonia due to not taking in deep breaths if they are having abdominal pain. MD C indicated that the SBO set all of this into action. On [DATE] at 4:25 PM, Surveyor interviewed R12's FM E regarding R12's abdominal pain at the facility in ,[DATE]. Surveyor asked FM E if she spoke to R12 on the phone or in person. FM E indicated that she came to visit every day as she lived down the street. Surveyor asked FM E if she recalls R12 having abdominal pain prior to his last hospitalization . FM E indicated that R12's pain was gradual similar to the last time he was hospitalized with the bowel obstruction. Surveyor asked FM E if she recalled talking to NP D about R12. FM E indicated that she did talk to NP D regarding R12's symptoms. Surveyor asked FM E if NP D looked at R12. FM E indicated that she did not recall seeing the NP D look at R12. Surveyor asked FM E if she ever saw the nurse's listen to R12's abdomen with a stethoscope. FM E indicated that she never saw this happen. Review of the clinic documentation indicates the first call to the clinic came in on [DATE] at 3:44 PM as POA O was insisting R12 be transferred to the hospital. The failure to ensure a physician was consulted when a significant change of condition occurred for R12 created a finding of immediate jeopardy. The facility removed the immediacy on [DATE] when the facility: *Facility authored a policy and procedure using standard of practice as outlined in the AMA Clinical Practice Guidelines for acute changes of condition. The procedure to include AMDA Data Collection System, and by using a collective format for Primary Practitioner Notification. *Facility will educate the RN and LPN staff in Assessment and Evaluation for Abdominal pain using the AMDA Know it all before you call Data collection system-for abdominal pain, distention and/or discomfort. *Facility will implement a PCP notification Form detailing onset, duration, frequency, and severity of symptoms, current medication list (including recent changes), recent food and fluid intake, current diet current [DIAGNOSES REDACTED]. *Facility will implement monthly QAPI meetings, and DON or designee will review 5 charts per week for 3 months for proper documentation and looking for any acute changes of conditions. Cross reference F309