Every finding on record at Newcare

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 17 residents (R) residing in the facility. R11 was not initially placed on precautions when R11 developed signs and symptoms of a respiratory infection, including a fever, increased cough, and increased wheezing, and was not included on the facility's respiratory surveillance line list. In addition, staff did not follow transmission-based precautions while caring for R11.R13 tested positive for influenza A on 8/6/25. R13's symptoms resolved date was not included on the facility's respiratory surveillance line list.R29 tested positive for influenza A on 8/4/25. R29's symptoms resolved date was not included on the facility's respiratory surveillance line list.Staff did not follow influenza outbreak precautions by wearing a mask at all times.Findings include:The facility's Infection Prevention and Control Manual: Transmission Based Precautions policy, dated 6/11/25, indicates: Contact precautions .require the use of appropriate personal protective equipment (PPE), including a gown and gloves upon entering the room or contacting the resident or resident environment. When leaving the room, PPE will be removed and hand hygiene performed. Droplet precautions .require the use of a face mask upon entry into a resident's room with respiratory droplet precautions .It is essential both to communicate transmission-based precautions to all healthcare personnel and for personnel to comply with the requirements. Pertinent signage and verbal reporting between staff can enhance compliance with transmission- based precautions to help minimize the transmission of infections within the facility .The facility will identify the type of transmission-based precautions required and anticipate duration dependent upon the infectious agent or organism involved .The facility should document in the medical record the rationale for the selected transmission-based precautions .Healthcare personnel caring for residents on contact precautions should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning PPE before room entry and discarding PPE before exiting the resident's room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination .Documentation in the medical record should include: type of precautions in place, location of infection/colonization, and infectious agent; Resident's cognitive status in the ability to follow hygiene instructions; Any contained drainage, secretions, or secretions; Resident transport - limit transport and movement of resident outside of the room to medically necessary purposes.The facility's Influenza, Prevention and Control of Seasonal policy, revised 8/14/25, indicates: .1. Contact and droplet precautions are implemented for residents with suspected or confirmed influenza for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Precautions may be applied for longer periods based on clinical judgment. If the resident needs to leave their room, they will wear a mask.The facility's Influenza-Like Policy and Procedure, revised 8/12/25, indicates: Acute respiratory illness is defined as illness characterized by any two of the following: Fever, cough, rhinorrhea or congestion, sore throat, malaise .Respiratory disease outbreak in a long term care facility is defined by the Centers for Disease Control and Prevention (CDC) and Department of Health as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other and who have pneumonia, acute respiratory infection, or laboratory confirmed viral or bacterial infection .Caregivers and visitors should adhere to the appropriate precautions when in the presence of a resident with a suspected or confirmed respiratory illness. Until the cause of an acute respiratory illness (ARI) outbreak is determined, both droplet and contact precautions should be initiated. Droplet precautions - Healthcare workers will wear a mask, gloves, and gown for close contact with all ill residents. PPE is donned upon entry in the room and removed before exiting the room .Residents on droplet precautions who must be transported outside of their room shall wear a mask if tolerated and practice respiratory hygiene/cough etiquette. Contact Precautions - Healthcare staff will wear gowns and gloves for all interactions that may involve contact with the resident or potential contaminated areas in the environment .Don PPE upon room entry and discard before exit to contain pathogens implicated in the transmission through environmental contamination .Duration of Contact/Droplet Precautions - When a resident is confirmed or suspected to have influenza, the resident should remain on droplet precautions for seven days or until 24 hours after the resolution of fever (without fever reducing medications) and respiratory symptoms, whichever is longer after the onset of illness. For other respiratory illnesses, the resident should remain on appropriate precautions for the duration of illness, defined as 24 hours after the resolution of fever (without fever reducing medications) and respiratory symptoms.1. From 8/18/25 to 8/20/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive, pulmonary disease (COPD), chronic respiratory failure with hypoxia, chronic combined systolic and diastolic heart failure, and type 2 diabetes. R11's Minimum Data Set (MDS) assessment, dated 6/18/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R11 had intact cognition. R11 was responsible for R11's medical decisions.R11's medical record contained the following temperatures:~ On 8/19/25 at 4:18 AM: 98.2 Fahrenheit (F) ~ On 8/18/25 at 7:00 PM: 101.6 F ~ On 8/18/25 at 4:47 PM: 100.9 F~ On 8/18/25 at 10:02 AM: 98.9 F~ On 8/18/25 at 4:00 AM: 97.7 F~ On 8/17/25 at 7:40 PM: 99.6 F~ On 8/17/25 at 6:39 PM: 101.6 F~ On 8/17/25 at 12:14 PM: 97.7 FA physician visit note, dated 8/18/25, indicated R11 was seen by the physician due to increased cough, increased fatigue, and increased oxygen demands. The physician noted R11 had experienced increased fatigue for two days, had increased wheezing, and had wheezes in the right lower lung base. The physician ordered labs, influenza A and COVID-19 tests, a chest X-ray, and DuoNebs for 5 days.On 8/18/25 at 10:33 AM, Surveyor observed R11 smoking outside and observed staff push R11 in a wheelchair into the building. R11 was not wearing a mask. Staff put an oxygen canister on R11's wheelchair, assisted R11 with applying the nasal canula, and wheeled R11 to R11's room. On 8/18/25 at 4:40 PM, Surveyor observed R11 outside smoking and then observed staff push R11 in a wheelchair into the building. R11 was not wearing a mask. Staff put an oxygen canister on R11's wheelchair, assisted R11 with applying the nasal canula, and then wheeled R11 to R11's room. On 8/19/25 at 8:30 AM, Surveyor did not observe a precautions sign on R11's door or a PPE cart next to R11's room.On 8/19/25 at 10:05 AM, Surveyor observed contact and droplet precaution signs on R11's door.The droplet precautions sign stated: Stop. Droplet Precautions. Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry (the sign contained two pictures, one of a person in a full face shield and one of a person in a disposable mask over the nose and mouth and goggles over the eyes). Remove face protection before room exit.The contact precautions sign stated: Stop. Contact Precautions. Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reuseable equipment before use on another person. On 8/19/25 at 11:29 AM, Surveyor observed a therapist sitting on R11's bed with a mask on but no gown or gloves. Surveyor observed the therapist stand up and work with R11 to lift a bar up and down. On 8/19/25 at 11:34 AM, Surveyor interviewed Registered Nurse (RN)-M who indicated R11 was tested for influenza A on 8/18/25 due to a fever that started on 8/17/25. RN-M indicated all staff providing care to R11 should wear a mask, gown, and gloves prior to entering R11's room.On 8/19/25 at 3:34 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated Influenza outbreak precautions started in the facility on 8/4/25 and were currently in place. DON-B indicated R11 had a fever on 8/17/25 and should have been placed on precautions that day. DON-B indicated R11 was seen by the physician on 8/18/25 due to a fever and respiratory symptoms, was tested for influenza A and COVID-19 on 8/18/25, and was started on contact and droplet precautions on 8/19/25. DON-B verified R11 was not included on the facility's respiratory surveillance line list. DON-B was aware therapy staff worked with R11 without wearing a gown and gloves and indicated the therapist received PPE education. On 8/19/25 at 4:32 PM, Surveyor observed Certified Nursing Assistant (CNA)-L answer R11's call light and walk into R11's room with a mask on but no gown, gloves, or eye protection. CNA-L did not complete hand hygiene prior to entering the room. R11 handed a water cup to CNA-L who exited the room with the cup in hand. CNA-L took the cup to the dining room, filled the cup with water and ice, and walked back to R11's room.On 8/19/25 at 4:34 PM, Surveyor interviewed CNA-L who indicated CNA-L should have completed hand hygiene when entering and exiting R11's room and should have gotten R11 a new water cup since R11 was on contact precautions. CNA-L also indicated CNA-L should have donned the proper PPE prior to entering R11's room.On 8/20/25 at 12:15 PM, Surveyor observed Certified Nursing Assistant (CNA)-E enter R11's room with a food tray. CNA-E wore a disposable face mask and gloves but did not wear eye protection or a gown. Surveyor observed CNA-E dispose of the mask and gloves before exiting the room. CNA-E did not complete hand hygiene before donning another mask.On 8/20/25 at 12:16 PM, Surveyor interviewed CNA-E regarding contact and droplet precautions for R11. CNA-E indicated CNA-E was told by Registered Nurse (RN)-G that CNA-E only needed to wear gloves to bring the meal tray into R11's room. On 8/20/25 at 12:20 PM, Surveyor interviewed RN-G who confirmed RN-G stated CNA-E only needed to wear gloves to set the tray down in R11's room. When Surveyor asked if R11 was on contact and droplet precautions, RN-G indicated RN-G was told by Nursing Home Administrator (NHA)-A that staff only need to wear gloves to deliver trays to residents. When Surveyor asked if the information from NHA-A was for residents on contact and droplet precautions, RN-G was unsure and stated RN-G thought it was for residents on isolation.On 8/20/25 at 12:22 PM, Surveyor interviewed NHA-A who indicated staff should wear a gown, gloves, a mask, and goggles when entering the room of a resident on contact and droplet precautions even if only to deliver a food tray. NHA-A indicated no one should enter the room without the appropriate PPE. NHA-A indicated NHA-A did not tell staff to deliver trays with just gloves. NHA-A indicated staff were provided education on transmission-based precautions but needed more education.2. From 8/18/25 to 8/20/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including influenza A, Alzheimer's disease, dementia, and muscle weakness. R13's MDS assessment, dated 8/13/25, did not include a BIMS score. R13 had an activated Power of Attorney for Healthcare (POAHC).R13's medical record indicated was symptomatic for influenza A and tested positive on 8/6/25. R13 was included on the facility's respiratory surveillance line list on 8/6/25.On 8/19/25 at 3:34 PM, Surveyor interviewed DON-B who indicated an Influenza outbreak was identified in the facility on 8/4/25 and DON-B had not yet finished completing the resident respiratory surveillance line list. DON-B indicated R13's symptoms resolved date was blank on the line list. DON-B indicated DON-B usually documents the date a resident can come off precautions in the resident's chart but was unsure if DON-B documented the date in R13's chart. 3. From 8/18/25 to 8/20/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including influenza A, acute cough, weakness, and acute chronic combined systolic and diastolic heart failure. R29's MDS assessment, dated 8/6/25, had a BIMS score of 12 out of 15 which indicated R29 had moderately impaired cognition. R29 was responsible for R29's healthcare decisions.R29's medical record indicated R29 was symptomatic for influenza A and tested positive on 8/4/25. R29 was included on the facility's respiratory surveillance line list on 8/4/25.On 8/19/25 at 3:34 PM, Surveyor interviewed DON-B who indicated the facility identified an Influenza outbreak on 8/4/25 and DON-B had not yet finished filling out the resident respiratory surveillance line list. DON-B verified R29's symptoms resolved date was blank on the line list. DON-B indicated DON-B usually documents the date a resident can come off precautions in the resident's chart but verified DON-B did not document the date in R29's chart. 4. On 8/18/25 at 9:17 AM, Surveyor observed US (Unit Secretary)-N at the nurses' station with a mask around US-N's neck and off US-N's face. Surveyor noted the facility was in an influenza outbreak that began on 8/4/25.On 8/18/25 at 9:20 AM, Surveyor interviewed US-N who indicated US-N did not need to wear a mask behind the nursing desk. On 8/19/25 at 3:34 PM, Surveyor interviewed DON-B who indicated the facility was currently in an influenza outbreak and all staff were required to wear a mask in the building at all times.

Based on observation, staff and resident interview, and record review, the facility did not develop and/or implement an individualized, comprehensive care plan for 4 residents (R) (R11, R16, R6, and R13) of 14 sampled residents. R11 smoked and received oxygen therapy. R11 also received diuretic medication and was on contact and droplet precautions. The facility did not develop a comprehensive care plan that included interventions related to smoking, the use of diuretic medication, or infection prevention precautions. R16 smoked and received oxygen therapy. The facility did not develop a comprehensive care plan that included interventions related to smoking. R6's activities of daily living (ADL) and nutritional care plans did not include recommended approaches for staff to use when R6 refused to eat meals in a Broda chair or the dining room.R13 had an order for a WanderGuard for safety. R13's plan of care did not indicate R13 had a WanderGuard or contain intervetions for safety.Findings include: The facility's Care Plans, Comprehensive Person Centered policy, revised March 2022, indicates: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .e. Reflects currently recognized standards of practice for problems areas and conditions .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change . The facility's smoking policy for residents, revised October 2023, indicates: .6. Resident smoking status is evaluated upon admission .8. A resident's ability to smoke safely is re-evaluated quarterly and when determined by staff .9. Smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues . 1.From 8/18/25 to 8/20/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and type 2 diabetes. R11's Minimum Data Set (MDS) assessment, dated 6/18/25, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R11 had intact cognition. R11 received continuous oxygen. A smoking assessment was completed on 6/12/25. Surveyor noted R11's most recent plan of care did not indicate R11 smoked and did not include interventions or safety measures for smoking; however, staff were aware of and implemented safety measures for R11. On 8/19/25 at 3:20 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a resident who smokes should have a care plan related to smoking. DON-B indicated residents should be assessed for smoking upon admission, quarterly, and with changes in the resident's status. When asked how staff know the smoking protocol for R11, DON-B indicated there used to be a list of residents who smoke near the nurses' station; however, the list did not contain smoking interventions for R11. On 8/19/25 at 3:32 PM, Surveyor interviewed MDS Coordinator (MDSC)-C who indicated residents who smoke should have a smoking care plan. MDSC-C indicated MDSC-C should have included smoking on R11's care plan. 2. Surveyor also noted R11 received diuretic medication and had the following order: ~ Torsemide 10 milligrams (mg) 1 tablet by mouth daily. R11's medical record did not contain orders to monitor for side effects (i.e., dizziness, dehydration, hypotension, vertigo, headache, restlessness, abdominal pain, nausea, vomiting, rash, muscle spasms, increased urination, increased thirst, severe diuresis, or electrolyte depletion) of diuretic use; however. staff monitored R11 for diuretic use. Surveyor also noted R11's plan of care did not mention diuretic use or contain interventions to monitor for side effects of diuretic use. On 8/19/25 at 3:20 PM, Surveyor interviewed DON-B who indicated residents who receive diuretic medication should have a care plan for diuretic use. DON-B confirmed staff should be aware of side effects so they can monitor R11 for safety and effectiveness. On 8/19/25 at 3:32 PM, Surveyor interviewed MDSC-C who indicated residents on high-risk medications including diuretics should have a care plan for the medication. MDSC-C indicated MDSC-C usually developed resident care plans, including care plans for medications with a black box warning with side effect monitoring. 3. R11's medical record indicated R11 had signs and symptoms of a fever, increased fatigue, increased cough, and increased oxygen needs on 8/17/25. R11 was placed on contact and droplet precautions on 8/19/25. R11's care plan did not indicate R11 was on contact or droplet precautions. On 8/19/25 at 3:34 PM, Surveyor interviewed DON-B who indicated precautions and infection should be added to a resident's care plan the day the resident is symptomatic. DON-B verified infection interventions, including precautions, should have been added to R11's care plan on 8/17/25. On 8/19/25 at 4:32 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who indicated CNA-L uses a resident's comprehensive care plan to provide care and for updates on providing care. CNA-L also indicated CNA-L relies on a resident's care plan and signage on the resident's door for guidance on the appropriate personal protective equipment to use when providing care. 4. From 8/18/25 to 8/20/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, chronic respiratory failure with hypoxia, COPD, and chronic kidney disease. R16's MDS assessment, dated 8/6/25, contained a BIMS score of 12 out of 15 which indicated R16 had moderate cognitive impairment. R16 received continuous oxygen. A smoking assessment was completed on 5/5/25. Surveyor noted R16's most recent plan of care did not indicate R16 smoked or contain interventions related to safe smoking On 8/19/25 at 3:20 PM, Surveyor interviewed DON-B who indicated a resident who smokes should have a care plan for smoking. DON-B indicated a resident should also be assessed for smoking on admission, quarterly, and with changes in the resident's status. DON-B indicated MDSC-C completes smoking assessments for residents. When asked how staff know the smoking protocol for R16, DON indicated there used to be a list of residents who smoke near the nurses' station; however, the list did not contain smoking interventions for R16. On 8/19/25 at 3:32 PM, Surveyor interviewed MDSC-C who indicated residents who smoke should have a smoking care plan. MDSC-C indicated MDSC-C should have included smoking on R16's care plans. When asked if R16 was overdue for a quarterly smoking assessment, MDSC-C indicated DON-B completed smoking assessments for residents. MDSC-C reviewed the most recent assessments for all residents who smoked and noted the assessments were all completed by DON-B. On 8/19/25 at 3:38 PM, Surveyor interviewed DON-B who indicated DON-B completes smoking assessments for residents upon admission and quarterly. DON-B indicated DON-B cannot remember all of the things DON-B does but verified DON-B completed resident smoking assessments and was aware that R16's smoking assessment was overdue for completion. 5. From 8/18/25 to 8/20/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including alcohol dependence with alcohol induced dementia, mood disorder, major depression, anxiety, and weakness. R6's Minimum Data Set (MDS) assessment, dated 8/6/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R6 had moderate cognitive impairment. R6 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. A care plan, dated 1/30/25, indicated R6 had potential for limited abilities to complete ADLs without substantial assistance from staff. The care plan indicated R6 was alert and oriented x 2 and able to make R6's wants and needs known and contained an intervention to encourage R6 to get into Broda chair or go to the dining room for meals as R6 preferred to eat meals in bed. A nutritional care plan indicated R6 was on a therapeutic mechanical soft diet with thin liquids, received a house supplement of 120 milliliters (ml) three times daily, and enjoyed meals in R6's place of choice. The care plan contained interventions to encourage R6 to consume 100%, encourage R6 to consume 50-70% of meals and adequate fluids at and between meals, offer a clothing protector, and help wash and sanitize hands prior to meals and when necessary. R6's medical record did not contain physician or therapy orders for R6 to get out of bed for meals. A nursing progress note, dated 7/1/25 at 13:41 PM and written by Licensed Practical Nurse (LPN)-H, indicated R6 was uncooperative before lunch and refused to stand in the sit-to-stand lift or bend at the knees and put R6's feet on the stand. R6 stated R6 didn't need to bend R6's knees and didn't want to get up. A Hoyer lift was used to transfer R6 to a Broda chair for safety. R6's mood improved when R6 was in the Broda chair. On 8/18/25 at 12:57 PM, Surveyor interviewed R6 who indicated R6 was required to get up for lunch and staff made R6 get up when R6 didn't want to. On 8/20/25 at 9:43 AM, Surveyor again interviewed R6 who indicated staff state R6 must get up and sit in the chair at lunch time. R6 indicated when R6 tells staff that R6 does not have to get up, staff haul R6 out of bed which makes R6 angry and not want to eat. R6 also stated staff tell R6 what R6 is going to do and R6 has no say which makes R6 feel like a piece of meat. R6 indicated liked to eat meals in bed. On 8/20/25 at 10:14 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who indicated sometimes it takes persuading to get R6 up for meals. CNA-I indicated R6 usually allows staff to get R6 up once per day. CNA-I indicated CNA-I does not force R6 to get up because it's not worth the swearing. CNA-I indicated CNA-I had not witnessed staff get R6 up without R6's consent unless it was to obtain R6's weight. CNA-I indicated CNA-I was involved in the incident on 7/1/25 and staff put R6 back into bed and later got R6 up in the Broda chair. On 8/20/25 at 10:23 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who indicated R6 used to get up in the Broda chair, however, R6's care plan was changed because R6 was discovered choking on thin liquids during breakfast. LPN-H indicated R6 needs to be in the Broda chair for meals or staff have to stay with R6. LPN-H indicated R6 yelled and was uncooperative on 7/1/25 and LPN-H had to assist another staff member. LPN-H verified R6 had the right to refuse care but indicated R6 had alcoholic dementia and did not understand. On 8/20/25 at 1:50 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R6's care plan should indicate to get R6 out of bed for meals for safety measures and include interventions for staff to use to encourage compliance. DON-B indicated the way LPN-H documented the incident was not accurate because R6 was transferred back to bed and then transferred into the Broda chair later. DON-B indicated the facility did not complete risk versus benefit education with R6. 6. On 8/18/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and dementia with anxiety. R13's MDS assessment, dated 5/13/25, had a BIMS score of 0 out of 15 which indicated R13 had severe cognitive impairment. R13 had an activated POAHC for medical decisions. R13 had a physician order, dated 5/28/25, to use a WanderGuard daily and test function every Friday. R13 also had a physician order, dated 7/18/25, to check placement of the WanderGuard on the right ankle every shift. A care plan, dated 8/15/22, indicated R13 was at risk for falling related to generalized weakness. The care plan indicated R6 will self-transfer/ambulate at times, especially if R13 needs to use the bathroom and contained an intervention to make sure R6's chair and bed alarm are in place when in wheelchair, bed, or recliner per POAHC's request. A care plan indicated R13 had potential for behavioral symptoms-sundowning and increased anxiety and indicated R13 lacked safety awareness and was impulsive. The care plans did not indicate R13 had a Wanderguard or contain interventions to check placement and function of the WanderGuard. On 8/18/25 at 1:10 PM, Surveyor interviewed POAHC-K who indicated R13 had a history of getting up independently and fell a couple of months ago. Following R13's fall, the family requested that R13 have chair alarms and a Wanderguard.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 4 sampled residents. On 5/23/25, staff witnessed R2 strike R1 in the chest multiple times. Following the altercation, staff were not provided education to prevent further abuse among residents. Findings include: On 6/18/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, disorder of psychological development, diabetes, and anxiety. R1's Minimum Data Set (MDS) assessment, dated 6/3/25, included a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R1 had severe cognitive impairment. R1 had a legal Guardian for healthcare decisions. On 6/18/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with agitation, unspecified mood disorder, anxiety, and major depression. R2's MDS assessment, dated 3/18/25, included a BIMS score of 6 out of 15 which indicated R2 had severe cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. On 6/18/25, Surveyor reviewed a facility-reported incident (FRI) that indicated on 5/23/25 at approximately 9:15 PM, a Certified Nursing Assistant (CNA) saw R2 standing above R1. R1's blankets were pulled off and R1 was lying on the ground. R2 looked up at the CNA and then looked down at R1 and struck R1 on the chest with an open hand four to five times. The CNA immediately removed R2 from the vicinity and then brought R1 to R1's room. R1 cried and expressed fear after the incident. R1 was interviewed the next day and indicated an incident occurred that made R1 afraid. The investigation did not include and the facility did not provide documented staff education to ensure all staff were educated to prevent further altercations. Surveyor reviewed R2's nursing progress notes. Documentation on 5/26/25 at 7:00 PM indicated R2 became erratic and took a butter knife from R2's tray and held it in the air as though R2 was going to use it for something other than cutting food. A staff member redirected R2 and removed the knife from R2's hand. After supper, R2 tried to enter R1's room. Staff held the door shut so R2 could not enter, however, R2 then attempted to enter R1's room from the shared bathroom. Staff redirected and toileted R2 and brought R2 back to the dining room to watch TV. R2's fifteen minute checks were extended for two weeks after the incident and continued until 6/10/25. Kitchen and dietary staff were notified of the incident. It was decided that R2 would not receive a butter knife on R2's tray which did not affect R2's ability to eat independently. On 6/18/25 at 11:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who indicated LPN-D had not witnessed R2 be aggressive toward other residents, however, R2 was aggressive toward staff during cares and needed redirection. LPN-D indicated R2 attempted to get in R1's room after the initial incident between R1 and R2. LPN-D indicated R2's treatment plan contained an intervention to keep R2 and R1 separated but denied staff education was provided on abuse or aggression prevention. On 6/18/25 at 11:17 AM, Surveyor interviewed Registered Nurse (RN)-C who indicated education was not provided to staff on abuse or aggression prevention, however, RN-C knew to keep R1 and R2 separated. On 6/18/25 at 12:47 PM, Surveyor interviewed CNA-E who indicated CNA-E was not present when the altercation between R2 and R1 occurred. CNA-E denied receiving education on abuse or aggression prevention but knew to keep R1 and R2 separated. On 6/18/25 at 12:54 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated following the incident between R1 and R2, a sign was posted at the nursing station and a treatment plan was updated to keep R1 and R2 separated. DON-B denied providing staff education on abuse or aggression prevention.

Based on staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R1) of 4 sampled residents. On 5/23/25, staff witnessed R2 strike R1 in the chest with an open hand multiple times. The facility did not report the incidence of abuse to local law enforcement. Findings include: The facility's Resident Abuse, Neglect and Misappropriation/Exploitation policy, dated 8/2024, indicates: .3. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a. Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation/exploitation of resident property, are reported immediately, but not later than 2 hours after the allegations is made, if the event that causes the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the event that causes the allegation does not involve abuse and does not result in serious bodily injury, to the Administrator of the facility and to other officials (including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures . On 6/18/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, disorder of psychological development, diabetes, and anxiety. R1's Minimum Data Set (MDS) assessment, dated 6/3/25, included a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R1 had severe cognitive impairment. R1 had a legal Guardian for healthcare decisions. On 6/18/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia with agitation, unspecified mood disorder, anxiety, and major depression. R2's MDS assessment, dated 3/18/25, included a BIMS score of 6 out of 15 which indicated R2 had severe cognitive impairment. R2 had an activated Power of Attorney for Healthcare (POAHC) for medical decisions. On 6/18/25, Surveyor reviewed a facility-reported incident (FRI) that indicated on 5/23/25 at approximately 9:15 PM, a Certified Nursing Assistant (CNA) saw R2 standing above R1. R1's blankets were off and R1 was lying on the ground. R2 looked up at the CNA and then looked down at R1 and stuck R1 on the chest with an open hand four to five times. The CNA immediately removed R2 from the vicinity and then brought R1 to R1's room. R1 cried and expressed fear after the incident. R1 was interviewed the next day and indicated an incident occurred that made R1 scared. Surveyor noted the facility's investigation of the altercation between R1 and R2 did not indicate the facility notified local law enforcement of the abuse. On 6/18/25 at 12:02 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed one resident hitting another resident was considered abuse and verified law enforcement was not notified.

Based on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 4 residents (R) (R11, R16, R21, and R22) of 5 sampled residents. The facility did not offer R11, R16, R21, and R22 the Prevanr20(R) (PCV20) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults [AGE] years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The facility's Infection Prevention and Control Manual Pneumococcal Vaccine Program indicates: It is the policy of this facility that residents will be offered immunization(s) against pneumococcal disease in accordance with Advisory Committee on Immunization Practices (ACIP) recommendations .Refer to https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html for more details. 1. Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, atrial fibrillation, congestive heart failure, and human metapneumovirus pneumonia. R11 had an activated Power of Attorney (POA) for medical decisions. R11's medical record indicated R11 received a PCV13 vaccine on 10/12/15 and a PPSV23 vaccine on 3/7/17. R11 was due to receive the PCV20 vaccine as of 3/7/22 (five years after the last vaccine). R11's medical record did not indicate R11 was offered or administered the PCV20 vaccine. 2. Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, congestive heart failure, pneumonia, and chronic obstructive pulmonary disease (COPD). R16 did not have an activated POA. R16's medical record indicated R16 received a PCV13 vaccine on 9/9/16 and a PPSV23 vaccine on 4/10/06. R16 was due to receive the PCV20 vaccine as of 9/9/21. R16's medical record did not indicate R16 was offered or administered the PCV20 vaccine. 3. Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, type 2 diabetes, supplemental oxygen dependence, and obstructive sleep apnea. R21 had an activated POA for medical decisions. R21's medical record indicated R21 did not receive the PCV13 vaccine, the PPSV23 vaccine, or the PCV20 vaccine. R21 refused the PCV13 and PPSV23 vaccines on 4/18/21. R21's medical record did not indicate R21 was offered or administered the PCV13, PPSV23, or PCV20 vaccines after 4/18/21. 4. Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, congestive heart failure (CHF), and COPD. R22 had an activated POA for medical decisions. R22's medical record did not contain information regarding the PCV13 vaccine. R22 received the PPSV23 vaccine on 9/30/19. R22 was due to receive the PCV20 vaccine as of 9/30/20 (one year after the initial vaccine). R22's medical record did not indicate R22 was offered or administered the PCV20 vaccine. On 6/18/24 at 12:51 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility's vaccination consent/refusal form was not updated and did not include PCV20 as an offered vaccine. DON-B stated the facility had not offered or administered any PCV20 vaccines yet. DON-B stated the facility offers and administers PCV13 and PPSV23 vaccines for residents. On 6/18/24 at 2:10 PM, Surveyor interviewed DON-B who stated DON-B was not aware the facility should offer the PCV20 vaccine until Surveyor discussed it with DON-B earlier that day. On 6/19/24 at 9:37 AM, Surveyor interviewed DON-B who stated DON-B did not know the facility should offer immunizations annually. On 6/19/24 at 12:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects staff to offer vaccines per CDC recommendations and the facility's policy.

2. On 6/18/24, Surveyor reviewed R29's medical record. R29 had diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, and adjustment disorder with mixed disturbance of emotions and conduct. R29's most recent MDS assessment, dated 4/10/24, documented a BIMS score of 1 out of 15 which indicated R29 had severe cognitive impairment. R29 had an activated Power of Attorney (POA) for medical decisions. A behavior care plan, initiated on 7/21/22 and updated on 3/19/24, stated R29 will not exhibit socially inappropriate/disruptive behavior through the next review period and indicated: R29 will often greet other residents by touching or rubbing their arm or leg in a friendly manner. R29 has become more affectionate toward male residents with no regard for personal privacy. Please redirect R29 when this is happening. R29 has also been lifting R29's top and exposing R29's self to male residents and visitors. Make sure R29 has a camisole, bra, or long t-shirt tucked into R29's pants so R29 is not able to lift R29's top. R29's medical record indicated the following: A progress note, dated 3/21/24, indicated: R29 reached out to an ambulatory resident when the resident passed by. R29 touched the resident's knee and the resident told R29 to stop. R29 also passed the residents' room, stopped, and looked in at the resident. A progress note, dated 3/21/24, indicated: R29 sought out R94 in the dining room when staff left to deliver a meal tray. After R29 was redirected, R29 reached back and kissed R94 on the lips. R29 was redirected to the dinner table and R94 was moved closer to R94's room. R29 again sought out R94 and was redirected. Staff initiated 1:1 supervision for R29 until R29 was assisted to bed that evening. A progress note, dated 3/22/24, indicated: Staff observed R29 exit R94's room. When staff walked away from the nurses' station, R29 entered R94's room. R29 was redirected away from R94 because R29 got too close and R94 showed signs of being uncomfortable. A progress note, dated 4/5/24, indicated: R29 was redirected away from R94 after R29 was observed touching/ rubbing R94's knee. A progress note, dated 4/6/24, indicated: R29 was redirected away from R94 after R29 was observed touching/ rubbing R94's knee. On 4/24/24, Staff observed R29 lean over and kiss R94 on the mouth near the nurses' station. R29 and R94 were separated. On 6/19/24 at 7:55 AM, Surveyor interviewed LPN-C who stated R29 had frequent sexual behaviors but did not have them as often. LPN-C stated R29 previously targeted R94 but redirection usually worked. LPN-C stated there were no interventions besides redirection for R29's sexual behaviors. On 6/19/24 at 8:05 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who stated R29 touchesd and/or slightly rubbed other residents' arms and legs. CNA-F stated CNA-F did not see any resident become upset by the touching and stated redirection was the only intervention CNA-F was aware of. Surveyor noted R29's care plan did not contain monitoring interventions for R29's behavior toward other residents and, aside from brief 1:1 monitoring initiated on 3/21/24, did not include monitoring interventions implemented after the above documented incidents. On 6/18/24 at 10:38 AM, Surveyor interviewed DON-B and NHA-A regarding R29's behavior. DON-B and NHA-A stated R29's care plan stated to redirect R29. DON-B also stated R29's care plan stated R29 should wear a camisole or tank top due to flashing visitors and other residents. When Surveyor asked DON-B and NHA-A about R29's documented sexual behaviors and what interventions were added to prevent future incidents of unwanted touch, DON-B stated R29's behavioral interventions and care plan were last updated on 3/19/24. On 6/19/24 at 9:45 AM, Surveyor interviewed DON-B who stated DON-B did not know what interventions to put in place for supervision for R29 because staff indicated R29 could leave the unit and make it to the other side of the building in fifteen minutes which made fifteen minute checks pointless. DON-B also stated DON-B discussed R29's behavior with department heads and indicated the only suggestion was for staff to monitor R29; however, there were no specifications for monitoring. 49010 Based on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R142) of 2 sampled residents. In addition, the facility did not implement appropriate monitoring interventions for 1 (R29) of 2 sampled residents who displayed sexual behavior toward other residents. R142 was a known smoker. Staff did not complete a smoking assessment for R142. R29 displayed sexual behavior toward other residents. Staff did not implement behavioral or monitoring interventions following incidents documented in R29's medical record. Findings include: The facility's Smoking Policy for Residents indicates: It is the policy of NEWCare Inc. that all residents that smoke will go through the NEWCare Smoking Assessment for safe handling of smoking materials. The facility's Care plan, Comprehensive Person Centered policy, last revised March 2022, indicates: .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area(s), and their causes, and relevant clinical decision making .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change . The facility's Behavioral Assessment, Intervention and Monitoring policy, last revised March 2019, indicates: Behavioral or Psychological Symptoms of Dementia (BPSD) describe behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause .3. Current guidelines recommend the use of non-pharmacological interventions for BPSD .1. The interdisciplinary team will evaluate behavioral symptoms .Safety strategies will be implemented .to protect the resident and others from harm .8. Interventions and approaches will be based on detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situation and environmental reasons for the behavior. The care plan will include: .b. Targets and individual interventions for the behavioral .symptoms, the rational for the interventions and approaches .and how the staff will monitor for effectiveness of the interventions. 1. On 6/18/24, Surveyor reviewed R142's medical record. R142 was admitted to the facility on [DATE] with diagnoses including liver cell carcinoma, claustrophobia, agoraphobia with panic disorder, anxiety, autism, and mild intellectual disabilities. A Minimum Data Set (MDS) assessment was not yet completed due to R142's recent admission. R142's medical record contained an activated Power of Attorney for Health Care (POAHC) document that indicated R142's POAHC was responsible for R142's medical decisions. A baseline care plan, completed on 6/14/24, indicated: Resident's daily routine and preferences: Will smoke per facility policy or with family. R142's medical record did not indicate a smoking assessment was completed. On 6/18/24 at 10:05 AM, Surveyor observed staff ask R142 if R142 wanted to smoke and retrieved R142's smoking materials. On 6/18/24, Surveyor requested a copy of R142's smoking assessment from Director of Nursing (DON)-B who provided the assessment on 6/18/24 at 6:20 PM. The smoking assessment was created on 6/18/24 at 5:47 PM. On 6/19/24 at 7:49 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated a smoking assessment should be completed before a resident smokes at the facility. NHA-A confirmed R142's smoking assessment should have been completed prior to 6/18/24. On 6/19/24 at 10:13 AM, Surveyor interviewed DON-B who confirmed DON-B completed 142's smoking assessment on 6/18/24. DON-B stated a smoking assessment should be completed within 48 hours and verified R142's smoking assessment was not completed timely. On 6/19/24 at 12:52 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who stated R142 smoked daily at the facility since R142 was admitted .

Based on staff interview and record review, the facility did not report an allegation of sexual abuse to the State Agency (SA) for 2 residents (R) (R29 and R94) of 2 sampled residents. On 3/21/24, staff observed R29 seek out R94 after redirection and kiss R94 on the lips. The facility did not report the allegation of sexual abuse to the SA. Findings include: The facility's Resident Abuse, Neglect, and Misappropriation/Exploitation of Property Policy and Procedure, with a revision date 5/1/24, indicates: It is the policy of NEWCare, Inc. that residents be maintained in a safe, protective, and humane environment free from mistreatment, neglect, verbal, sexual, physical, and mental abuse .All possible attempts will be made to identify residents whose personal histories render them at risk of abusing other residents and when identified, care plans will include intervention strategies to prevent occurrences of abusive behavior. Allegations that abuse of any type has occurred will be handled as identified in the following procedure .Reporting: 1. The Nursing Home Administrator, Director of Nursing, and Social Services Designee shall be informed within two hours of suspected abuse .2. Once the facility administration becomes aware of any alleged violations, the facility must report to the designated state agency within 24 hours if deemed a reportable incident. 3. After the facility submits a report of an alleged violation, the facility must conduct a thorough investigation, prevent any other incident from occurring throughout the investigation and report the results of the investigation to the state agency within five working days. On 6/18/24, Surveyor reviewed R29's medical record. R29 had diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, and adjustment disorder with mixed disturbance of emotions and conduct. R29's most recent Minimum Data Set (MDS) assessment, dated 4/10/24, documented R29 had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R29 had severe cognitive impairment. R29 had an activated Power of Attorney (POA). A behavior care plan, initiated 7/21/22 and updated on 3/19/24, stated R29 will not exhibit socially inappropriate/disruptive behavior through the next review period and indicated the following: R29 will often greet other residents by touching or rubbing their arm or leg in a friendly manner. R29 has become more affectionate toward male residents with no regard to personal privacy. Please redirect R29 when this is happening. R29 has also been lifting R29's top and exposing R29's self to male residents and visitors. Make sure R29 has a camisole, bra, or long t-shirt tucked into R29's pants so R29 is not able to lift R29's top. A progress note, dated 3/21/24, indicated: R29 sought out R94 in the dining room when staff left to deliver a meal tray. After staff redirected R29, R29 reached back and kissed R94 on the lips. R29 was redirected to the dinner table and R94 was moved closer to R94's room. R29 sought out R94 again and was redirected. Staff initiated 1:1 supervision for R29. On 6/18/24 at 2:36 PM, Surveyor interviewed Registered Nurse (RN)-E who witnessed the incident on 3/21/24 and wrote the progress note. RN-E stated RN-E redirected R29 from R94 after RN-E returned to the dining room after delivering a meal tray. After R29 was redirected, RN-E stated R29 self-propelled R29's wheelchair back to R94's table and kissed R94 on the lips. RN-E stated R29 and R94 were separated and staff initiated 1:1 supervision for R29 until R29 was assisted to bed that evening. RN-E stated 1:1 supervision was initiated to ensure the safety of R94 throughout the night. RN-E stated RN-E updated Director of Nursing (DON)-B either that evening or the following morning and indicated behavioral incidents are documented in R29's chart as they occur. On 6/18/24, Surveyor reviewed R94's medical record. R94 had diagnoses including encounter for palliative care, cerebral palsy, anxiety disorder, major depressive disorder, and unspecified intellectual disabilities. R94's MDS assessment, dated 3/27/24, documented R94 had a BIMS score of 0 out of 15 which indicated R94 had severe cognitive impairment. R94 had a court-appointed guardian for healthcare decisions. On 6/18/24 at 10:26 AM, Surveyor interviewed Social Services Director (SSD)-D who was a part of the team that reports and investigates allegations of abuse. SSD-D stated SSD-D was not aware of the incident between R29 and R94 on 3/21/24. SSD-D stated SSD-D was aware R29 had sexual behaviors and targeted R94 and verified R29 and R94 were unable to consent to sexual contact. SSD-D confirmed allegations of sexual abuse should be reported to the SA. On 6/18/24 at 10:38 AM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A who stated they were not aware of the incident between R29 and R94 on 3/21/24 and did not report the incident to the SA. DON-B stated DON-B would look at the documentation and provide Surveyor with information on the allegation and investigation and if the incident should have been reported. On 6/19/24 at 8:10 AM, Surveyor interviewed DON-B who remembered updating R29's physician regarding R29's behaviors and requested an order for a medication that was previously discontinued due to R29's refusals. DON-B stated R29's sexual behaviors were less when R29 was prescribed the medication. DON-B again stated DON-B was not aware of the incident on 3/21/24. DON-B stated staff document behaviors on a behavioral sheet and the unit nurse is responsible for documenting behaviors in the resident's medical record. DON-B stated documentation is reviewed and discussed during daily team meetings. On 6/19/24 at 9:45 AM, Surveyor interviewed DON-B regarding the review of daily documentation. DON-B confirmed the documentation was reviewed and DON-B was uncertain how it slipped through their minds to report the incident of potential sexual abuse between R29 and R94 because previous and post incidents were reported and investigated. DON-B confirmed the incident of sexual contact between R29 and R94 on 3/21/24 should have been reported to the SA.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 2 residents (R) (R1 and R21) of 2 sampled residents. R1 and R21 resided in the same room. Signs posted outside R1 and R21's room indicated droplet precautions, airborne precautions, and contact precautions were in place. On 6/19/24, staff did not don the appropriate personal protective equipment (PPE) prior to entering R1 and R21's room to complete cares. Findings include: The facility's Infection Prevention and Control Manual Transmission-Based Precautions indicates: - Contact Precautions: The purpose of contact precautions is to prevent transmission of infections that are spread by direct (e.g., person-to-person) or indirect contact with the resident or environment. Contact precautions require the use of appropriate personal protective equipment (PPE), including a gown and gloves upon entering the room or contacting the resident or resident environment. When leaving the room, PPE will be removed and hand hygiene performed. - Droplet Precautions: The purpose of droplet precautions is to prevent respiratory droplets containing viruses or bacteria particles from spreading to another individual when those droplets are generated during coughing, sneezing, talking, or certain procedures .A private room is preferred but if not available, cohort with a resident with the same infectious agent or for a resident with limited risk factors. Separate residents at least 3 feet and draw the curtain between beds. Droplet precautions require the use of facemasks upon entry (i.e., within three feet of a resident) into a resident's room or cubicle with respiratory droplet precautions. If substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield in place of goggles) should be worn. - Airborne Precautions: Infectious organisms are contained in tiny droplet nuclei and can remain suspended in the air for extended periods of time and may be dispersed over long distances A susceptible host can contract the infection by inhaling these organisms. Staff must wear a fit-tested N95 or higher respirator donned before entering the room. On 6/19/24 at 7:55 AM, Surveyor observed Certified Nursing Assistant (CNA)-G sanitize hands and enter R1 and R21's room. CNA-G did not don a respirator, a gown, or gloves prior to entering the room. CNA-G exited the room wearing gloves at 8:05 AM with a clear plastic bag that contained what appeared to be an incontinence brief and soiled wipes. Surveyor observed three signs posted on the wall just outside the room and a PPE cart near the door. The signs posted near the door read: 1. Stop: Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put gloves on before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. 2. Stop: Airborne Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Put on a fit tested N95 or higher level respirator before room entry. Remove respirator after exiting the room and closing the door. 3. Stop: Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose, and mouth are fully covered before room entry. Remove face protection before room exit. On 6/19/24 at 8:06 AM, Surveyor interviewed CNA-G who confirmed CNA-G completed personal cares and changed an incontinence brief in R1 and R21's shared room. CNA-G verified CNA-G did not don a respirator or gown prior to entering the room or during the completion of cares. CNA-G initially stated CNA-G thought the precaution signs were for R21, but then stated CNA-G thought the precaution signs were for R1 and R21. CNA-G stated staff should reviewed a resident's plan of care if staff are unsure which precautions are in place. CNA-G stated CNA-G should have donned the appropriate PPE prior to entering R1 and R21's room and should have followed the signs posted outside of the room. After speaking with Surveyor, CNA-G reentered the room to speak with one of the residents. CNA-G did not don the appropriate PPE or perform hand hygiene prior to entering the room. On 6/19/24 at 12:38 PM, Surveyor interviewed Director of Nursing (DON)-B who stated staff should be aware of and follow transmission-based precautions (TBP) signs. DON-B stated all staff receive infection control and TBP education upon hire, annually, and as needed. DON-B stated R21 had active respiratory signs and symptoms and was placed on airborne, droplet, and contact precautions pending test results and a diagnosis. DON-B stated DON-B expects staff who enter TBP rooms to follow the signs as indicated.

Based on staff interview and record review, the facility did not ensure an allegation of sexual abuse was investigated for 2 residents (R) (R29 and R94) of 2 sampled residents. The facility did not investigate an allegation of sexual abuse involving R29 and R94. Findings include: The facility's Resident Abuse, Neglect, and Misappropriation/Exploitation of Property Policy and Procedure, with a revision date of 5/1/24, indicates: It is the policy of NEWCare, Inc. that residents be maintained in a safe, protective, and humane environment free from mistreatment, neglect, verbal, sexual, physical, and mental abuse .by staff as well as other residents throughout their stay in the facility .All possible attempts will be made to identify residents whose personal histories render them at risk of abusing other residents and when identified, care plans will include intervention strategies to prevent occurrences of abusive behavior. Allegations that abuse of any type has occurred will be handled as identified in the following procedure .Investigation of abuse allegation: An investigation by the abuse team which includes the Nursing Home Administrator, Director of Nursing, and Social Services Designee will start immediately upon notification of an alleged event .The facility will document investigation findings, including witness statements, corrective action findings, and conclusions in an administrative file. The abuse team is responsible for notifying the resident and/or resident representative of any investigational findings and outcomes as allowable within privacy standards. Collect and preserve physical and documentary evidence and always include the following: 1. The initial complaint report will be reviewed. 2. Regulatory authorities that may assist .will be contacted for involvement and assistance. 3. The incident will be discussed with the individual initiating the complaint to determine whether all parties involved with the incident have been identified. 4. The perpetrator will be informed that an allegation has been made. 5. All individuals involved with the incident: witness(s), victim(s), and alleged perpetrator(s)will be interviewed and written signed statements from each party will be taken. 6. In the case of an abuse allegation, the charge nurse and another staff member will examine the resident. 7. The abuse team will collect and review the investigation material and determine whether the alleged abuse is substantiated. 8. Random resident reviews will be conducted with each investigation. 9. A summary of the finding will be written upon completion of the investigation and will be maintained in the Social Services office with all complaint reports and written statements from all staff members involved .Analysis: The abuse team will meet within five days of the initial report to reevaluate the incident and any potential factors leading to the incident that require changes to policy or procedure or any discipline within the facility to prevent further incident. Within the facility ability, changes will be implemented immediately . On 6/18/24, Surveyor reviewed R29's medical record. R29 had diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, and adjustment disorder with mixed disturbance of emotions and conduct. R29's most recent Minimum Data Set (MDS) assessment, dated 4/10/24, documented a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R29 had severe cognitive impairment. R29 had an activated Power of Attorney (POA). A behavior care plan, initiated on 7/21/22 and updated on 3/19/24, stated R29 will not exhibit socially inappropriate/disruptive behavior through the next review period and indicated the following: R29 will often greet other residents by touching or rubbing their arm or leg in a friendly manner. R29 has become more affectionate toward male residents with no regard for personal privacy. Please redirect R29 when this is happening. R29 has also been lifting R29's top and exposing R29's self to male residents and visitors. Make sure R29 has a camisole, bra, or long t-shirt tucked into R29's pants so R29 is not able to lift R29's top. A progress note, dated 3/21/24, indicated the following: R29 sought out R94 in the dining room when staff left to deliver a meal tray. After staff redirected R29, R29 reached back and kissed R94 on the lips. R29 was redirected to the dinner table and R94 was moved closer to R94's room. R29 sought out R94 again. R29 was redirected and staff initiated 1:1 supervision for R29. On 6/18/24 at 2:36 PM, Surveyor interviewed Registered Nurse (RN)-E who witnessed the incident on 3/21/24 and wrote the progress note. RN-E stated RN-E redirected R29 from R94 after RN-E returned to the dining room after delivering a meal tray. After R29 was redirected, RN-E stated R29 self-propelled R29's wheelchair back to R94's table and kissed R94 on the lips. RN-E stated R29 and R94 were separated and staff initiated 1:1 supervision for R29 until R29 was assisted to bed that evening. RN-E stated 1:1 supervision was initiated to ensure the safety of R94 throughout the night. RN-E stated RN-E updated Director of Nursing (DON)-B either that evening or the following morning and indicated behavioral incidents are documented in R29's chart as they occur. A progress note, dated 3/22/24 and written by Director of Nursing (DON)-B, indicated: Consulted Medical Doctor (MD)-H regarding R29's behaviors. R29 was better when R29 took citalopram (an anti-depressant medication). An order was received to start citalopram liquid 10 mg (milligrams) daily. On 6/18/24 Surveyor reviewed R94's medical record. R94 had diagnoses including encounter for palliative care, cerebral palsy, anxiety disorder, major depressive disorder, and unspecified intellectual disabilities. R94's MDS assessment, dated 3/27/24, documented a BIMS score of 0 out of 15 which indicated R94 had severe cognitive impairment. R94 had a court-appointed guardian for healthcare decisions. On 6/18/24 at 10:26 AM, Surveyor interviewed Social Service Director (SSD)-D who is part of the team that reports and investigates allegations of abuse. SSD-D stated SSD-D was not aware of the incident between R29 and R94 on 3/21/24. SSD-D stated SSD-D was aware R29 had sexual behaviors and targeted R94 and verified R29 and R94 were unable to consent to sexual contact. SSD-D confirmed allegations of sexual abuse should be thoroughly investigated. On 6/18/24 at 10:38 AM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A who stated they were not aware of the incident between R29 and R94 on 3/21/24. DON-B stated DON-B would look at the documentation and provide Surveyor with information on the allegation and investigation. On 6/19/24 at 8:10 AM, Surveyor interviewed DON-B who stated DON-B remembered updating R29's physician regarding R29's behaviors and requested an order for a medication that was discontinued due to R29's frequent refusals. DON-B stated R29's sexual behaviors were less when R29 was prescribed the medication. DON-B again stated DOB-B was not aware of the incident between R29 and R94 on 3/21/24. DON-B stated staff document a resident's behavior on a behavioral sheet and the unit nurse is responsible for documenting the behavior in the resident's medical record. DON-B stated all documentation is reviewed and discussed at a daily team meeting. DON-B stated DON-B did not receive a call regarding the incident on 3/21/24 which is why the incident was not investigated. On 6/19/24 at 9:45 AM, Surveyor interviewed DON-B regarding the review of daily documentation. DON-B confirmed the documentation on 3/21/24 was reviewed and DON-B was uncertain how it slipped through their minds to investigate the incident because previous and post incidents were investigated. DON-B confirmed the incident of sexual contact between R29 and R94 should have been thoroughly investigated.

Based on staff interview and record review, the facility did not ensure the accurate administration of medication for 1 Resident (R) (R1) of 8 sampled residents. R1's medical record contained a physician's order to administer furosemide (used to remove excess fluid from the body) as needed based on R1's weight changes. The facility did not administer the medication as ordered by R1's physician. Findings include: On 2/7/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (also known as stroke), atrial fibrillation (an irregular and often rapid heart rate), hypertension (high blood pressure) and edema (swelling due to excess fluid accumulation in body tissues). R1's Minimum Data Set (MDS) assessment, dated 8/2/23, contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1 had severe cognitive impairment. R1's medical record indicated R1's Power of Attorney for Healthcare (POAHC) was responsible for R1's healthcare decisions. R1 received Hospice services throughout R1's stay and passed away at the facility on 8/29/23. R1's medical record contained the following physician's orders: ~furosemide tablet; 20 mg (milligrams); oral twice daily ~furosemide tablet; 40 mg; amount: 1/2 tablet = 20 mg; oral special instructions: daily as needed if weight up 3 pounds in one day Surveyor noted R1's medical record did not contain a daily weight for 9 of the 34 days R1 resided in the facility. Of the weights obtained, Surveyor noted the following weight increases of 3 pounds or more: ~On 7/30/23, R1's weight was 105.5 pounds. R1's weight was not obtained on 7/31/23. On 8/1/23, R1's weight was 112 pounds (which was a 6.5 pound increase from the previous weight). ~On 8/1/23, R1's weight was 112 pounds. On 8/2/23, R1's weight was 115.5 pounds (which was a 3.5 pound increase from the previous weight). ~On 8/2/23, R1's weight was 115.5 pounds. On 8/3/23, R1's weight was 120.5 pounds (which was a 5 pound increase from the previous weight). ~On 8/8/23, R1's weight was 117.5 pounds. On 8/9/23, R1's weight was 120.5 pounds (which was a 3 pound increase from previous weight). R1's medical record indicated staff administered as needed furosemide doses on 8/25/23 at 12:00 PM and 8/27/23 at 8:35 AM. No doses were documented as administered based on the above weight changes. R1's medical record contained the following nursing progress notes: ~On 8/25/23: (R1) was given PRN (as needed) furosemide at noon for 2 (pound) weight increase. Edema to hands and lower extremities . ~On 8/27/23: . A PRN dose of furosemide was given with AM meds for edematous (fluid retained in body) arms. On 2/7/24 at 11:45 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff don't always obtain daily weights for residents who receive Hospice services. DON-B verified R1's order for as needed furosemide was based on daily weights. DON-B indicated staff should have clarified the as needed furosemide order with the Hospice nurse and R1's physician. DON-B verified, based on the as needed furosemide order, staff should have administered as needed furosemide to R1 on 8/1/23, 8/2/23, 8/3/23 and 8/9/23 based on R1's weight changes.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R28) of 1 resident received adequate supervision to prevent elopement. R28 was admitted to the facility on [DATE] and assessed to be at risk for elopement. R28 had diagnoses of schizophrenia and mild cognitive impairment. R28 wore a wanderguard, but was allowed to sit outside the front of the building while supervised by staff inside the building. On 10/10/22, R28 was observed by a Dietary Manager still on facility grounds, but beyond the adjacent Assisted Living facility. On 11/2/22, R28 was observed walking down the driveway toward the road. On 11/7/22, R28 was found at an apartment complex three blocks from the facility. The facility was unaware R28 eloped until contacted by the police. The facility's failure to supervise a resident who was assessed as an elopement risk and eloped without the facility's knowledge created a finding of Immediate Jeopardy that began on 11/7/22. Surveyor notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy on 5/18/23 at 8:55 AM. The Immediate Jeopardy was removed and corrected on 11/9/22. Findings include: The facility's Wandering and Elopement policy contained the following information: .4. When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident's legal representative (sponsor); d. notify search teams that the resident has been located; e. complete and file an incident report; and f. document relevant information in the resident's medical record. On 5/15/23, Surveyor reviewed R28's medical record. R28 had a Guardian and was admitted to the facility in 2022 with diagnoses that included cerebrovascular accident (CVA) (stroke), aphasia (brain damage in the area that affects language), schizophrenia, and mild cognitive impairment. R28 was ambulatory and did not use assistive devices to ambulate. R28 was mostly independent, and required minimal assistance and cueing with activities of daily living (ADLs). Upon admission, R28 was assessed to be at risk for elopement. R28's Admission Minimum Data Set (MDS) assessment, dated 8/9/23, contained a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R28 had severely impaired cognition. R28's Quarterly MDS assessment, dated 11/8/23, contained a BIMS score of 4 out of 15 which indicated R28 had severely impaired cognition. R28's Quarterly MDS assessments, dated 2/7/23 and 5/9/23, contained BIMS scores of 3 out of 15 which indicated R28 had severely impaired cognition. R28's medical record contained a behavioral telehealth note, dated 11/17/22, that stated R28 had the mentality of a 5-year old. The note also included R28's Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R28 had severely impaired cognition. R28's Elopement Care Plan, initiated on 8/3/22, indicated R28 ambulates independently, does not comprehend all instructions and may exit the building. Per R28's Guardian (Guardian (GD)-S), R28 had a wanderguard at a previous facility. A revision on 8/5/22 indicated R28 had a wanderguard in place and a history of wandering into unsafe areas. A revision on 2/6/23, indicated R28 displayed behavior(s) that may indicate an attempt to leave, including body language, that indicated an elopement may be forthcoming. The most current approach, dated 5/15/23, stated: I do like to wander about the facility independently. Please check where I am frequently. I am not to sit out in front of the building without supervision. I will attempt to go out in front, please redirect me to the Arise patio where I can go independently. If unable to find me I like to go up to the atrium or in the puzzle room. R28's ADL plan of care, dated 8/3/22, indicated R28 had diagnoses of mild intellectual deficits and aphasia (loss of ability to understand or express speech.) and was difficult to understand due to garbled speech. The care plan indicated R28 ambulated independently with a shuffled gait that was weaker on the right side due to a CVA. R28 was at risk for falls related to the CVA. R28's care card, located in a Certified Nursing Assistant (CNA) charting binder and in R28's room, dated May 2023, included the following interventions: cannot sit alone out in front of building; may sit alone on Arise patio; check on me frequently. R28's medical record contained the following progress notes related to potential/attempted elopements: ~8/14/22 at 3:25 PM: R28 was found outside on the sidewalk by the doors speaking with another resident. R28 was redirected back into the building. Will continue to monitor. ~9/15/22 at 2:26 PM: R28 mentioned wanting to 'go home' and people being 'bossy.' R28 has been going outside the front entrance. Staff asked R28 to sit at the table or come inside. R28 was observed walking down the sidewalk. Will continue to watch R28 closely when outdoors. ~9/17/22 at 9:10 PM: R28 repeatedly went out the front door onto the sidewalk in front of the building with another resident on AM shift and tried to continue the same on PM shift. R28 was redirected as there weren't enough staff to cover the area. R28 was upset and redirected to the back patio. Before dinner, R28 exited the front door without the code sounding. A CNA saw R28 walking on the sidewalk in front of the cafeteria. ~10/10/22 at 2:43 PM: At approximately 2:25 PM, R28 was sitting outside in the front of the building and checked on by staff. Shortly afterward, the Dietary Manager called to let Social Services Designee (SSD)-G know R28 was walking down the sidewalk beyond the Assisted Living facility. SSD-G met with R28 and educated R28 on the importance of staying where staff could see R28. The note stated R28 would no longer sit outside by R28's self due to safety issues. The note also stated the facility did not consider this an elopement because staff were aware R28 was going outside and R28 usually stayed put in a chair. ~11/2/22 at 12:05 PM: R28 was observed walking down the driveway toward the road. R28 was brought back into the facility and educated related to not wandering away from where staff can see R28. A progress note, written by Director of Nursing (DON)-B on 11/7/22 at 12:30 PM, contained the following information: Received call from local police that R28 was found at local apartment complex a few blocks down the road about 11:15 AM. R28 did go outside to sit in front of facility about 11:00 AM. R28 is usually able to be outside unattended as R28 has never wandered off of the campus grounds before. R28 does have a wanderguard on and it is working. R28's photo is posted in the front of the MAR (Medication Administration Record). Guardian and physician were updated. R28 did not verbalize anything about going anywhere or wanting to walk away from facility. R28 has been in a good mood all morning. R28 has schizophrenia which has been managed with medications and redirection/activities. R28 will be encouraged to sit in the enclosed patio when R28 desires to sit outside. If R28 desires to sit outside in front of building, R28 will need to be accompanied by staff or family. On 5/16/23 at 3:04 PM, Surveyor interviewed GD-S who was unsure if R28 left the facility intentionally to go to the apartment complex and stated, You just don't know with (R28). (R28) lived there over twenty years ago. On 5/17/23 at 1:29 PM, Surveyor interviewed NHA-A who stated R28 loved to sit in front of the building on the patio and color at the table. NHA-A stated on 11/7/23, R28 was sitting outside the front entrance. Approximately fifteen minutes after R28 went outside, staff became aware R28 was no longer sitting outside when the police department called and asked if R28 lived at the facility. R28 was found at an apartment building three blocks from the facility. The manager of the apartment building recognized R28 as a previous tenant and contacted the police. NHA-A stated R28 was confused and thought the apartment complex was still R28's home. GD-S was contacted and came to the facility to calm R28. GD-S stated R28 previously lived at the apartment complex and used to walk around town. On 5/17/23, Surveyor reviewed an Event Report, dated 11/7/22 at 12:28 PM. The report indicated R28 was sitting outside and wandered off campus grounds. At approximately 11:15 AM, R28 was found at an apartment building a few blocks from the facility. A body check was performed. No bruising, scrapes, or open areas were noted. R28 denied falling. Interventions included: Will not allow R28 to sit outside unattended; R28 will be encouraged to sit outside in the enclosed patio when unattended. May go out front of building with family, friends or staff. R28 will still attempt to go outside of building, has wanderguard on and it is working. Will encourage and redirect back into facility when R28 exits. R28 has never wandered off campus grounds before this incident nor did R28 verbalize the intent to do so. Immediate plan of care for elopement initiated. On 5/17/23 at 3:10 PM, Surveyor interviewed NHA-A who stated NHA-A did not know the address of the apartment complex, but stated to get to the apartment complex, Surveyor should take a left out of the facility's parking lot, go two blocks, turn right and go one more block. NHA-A stated PM shift was aware R28 was not allowed to sit outside the front entrance unsupervised after front office staff left for the day. NHA-A showed Surveyor DON-B's office and the window that overlooked the front sidewalk/patio. Surveyor noted another front office that had a door facing the front entrance did not have a direct view from the desk to the entrance. Surveyor also noted NHA-A's office did not have a direct view of the front entrance. On 5/17/23 at approximately 4:15 PM, Surveyor followed NHA-A's directions to the apartment complex. Surveyor noted R28 had to cross three streets. Surveyor did not encounter a stop sign or traffic light on the first street heading toward the apartment complex. Surveyor then encountered a two way stop sign at an intersection of a city street and county highway. Four vehicles passed before Surveyor could cross the highway. Surveyor encountered a four way stop sign at the next intersection of two city streets and took a left. Surveyor drove one block and encountered a two way stop sign at an intersection of two city streets. Four vehicles passed before Surveyor could cross the city street. One block ahead, the street turned into the apartment complex's parking lot. There was a river behind the apartment complex and two blocks from the facility. On 5/18/23 at 11:25 AM, Surveyor interviewed DON-B who did not recall what R28 was wearing on 11/7/22, but stated likely a jacket because the weather was warm for November. DON-B stated the Receptionist let R28 outside the front entrance to sit and color at the table. DON-B stated whoever let R28 outside let front office staff know so they could check on R28 every few minutes and take turns. DON-B stated if office staff could not see R28 from inside the building, staff went outside and looked for R28. DON-B verified there was not direct, constant supervision of R28 when R28 was outside the front entrance. DON-B stated DON-B could not visualize R28 when R28 was sitting at the table, but could visualize R28 if R28 walked down the sidewalk by DON-B's window. DON-B stated the Receptionist could see R28 if the Receptionist looked out the Receptionist's office door and out the window at the table. Surveyor observed the Receptionist's office and noted the desk was placed in a position where the Receptionist had to get up and look out the office door to visualize R28 outside. DON-B stated on 11/7/22, R28 was in a good mood and did not express a desire to leave the facility. Prior to R28's elopement on 11/7/22, R28 was not on one-to-one supervision while sitting outside the front entrance. R28's care plan was updated on 11/9/22 following R28's elopement to indicate R28 needed direct supervision when R28 was outside the front entrance. DON-B stated R28 did not attempt to elope prior to 11/7/22, but walked the sidewalk or driveway at times. On 5/22/23 at 12:42 PM, Surveyor interviewed Police Chief (PC)-J who referenced the report of the incident involving R28 on 11/7/22 and provided Surveyor the following timeline of events: 10:54 AM call came in 10:56 AM officers dispatched 11:07 AM officers in route 11:11 AM officers arrived on scene 11:22 AM closed call out On 5/31/23 at 9:50 AM, NHA-A stated R28 was allowed to sit on the fenced-in Arise patio; however, on occasion, R28 became upset and agitated. NHA-A made the decision to allow R28 to sit outside the front entrance as a means to calm R28 down. NHA-A stated NHA-A was the only one who made that decision and it was done so on a case-by-case basis. Following R28's elopement on 11/7/22, a meeting was held with the Interdisciplinary Team (IDT) who were immediately educated that R28 was no longer allowed to sit in front of the building under supervision from within the building. Education was completed and R28's plan of care was updated. The failure to supervise a resident who eloped from facility property created a reasonable likelihood for serious harm which created a finding of Immediate Jeopardy. The facility removed and corrected the jeopardy on 11/9/22 when it completed the following: 1. The IDT met and reviewed the policy and procedure for wandering/elopement. 2. Education was conducted regarding supervision for residents at risk for elopement. 3. The IDT reviewed and updated R28's care plan on 11/9/22. 4. Daily, weekly and monthly audits to ensure residents at risk for elopement are not left outside unattended unless in the enclosed patio.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 41 residents residing in the facility. The facility did not monitor and document dishwashing wash cycle temperatures. Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Cook (CK)-E did not wash hands after performing tasks that contaminated CK-E's hands. Food cooking appliances (ovens, toaster, steam table) and kitchen food prep areas were not cleaned and sanitized. Findings include: During an initial tour of the kitchen on 5/15/23 at 8:05 AM, Dietary Manager (DM)-D informed Surveyor the facility followed the Wisconsin Food Code for dietary services. Monitoring of Dishwasher Wash Cycle Temperatures Wisconsin Food Code 2022 documents at 4-501.110 (B) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 49 degrees Celsius (C) or 120 degrees Fahrenheit (F). During an initial tour of the kitchen on 5/15/23 at 8:05 AM, Surveyor observed dishwashing. Surveyor noted the dishwasher temperature gauge displayed a washing temperature of 120 degrees F and a final rinse temperature of 120 degrees F. On 5/15/23 at 11:33 AM, Surveyor reviewed the facility's Dish Machine Temperature log, dated May 2023, which contained no documentation of wash temperatures. Surveyor then interviewed DM-D who stated wash cycle temperatures are obtained, but rinse cycle temperature are not obtained or documented. Surveyor requested copies of the May 2023 and April 2023 Dish Machine Temperature Logs from DM-D. On 5/17/23, Surveyor reviewed the facility's April 2023 and May 2023 Dish Machine Temperature Logs which indicated the following: Temperatures must be recorded a minimum of once per shift. Record temperature-wash cycle 120-140 F, rinse cycle 120-140 F. Surveyor verified no wash cycle temperatures were documented. Sanitizing Solution Testing The Quaternary test strip package insert directions state the test solution should be between 65 and 75 degrees F at the time of testing. During an initial tour of the kitchen on 5/15/23 at 8:05 AM, DM-D stated staff used sanitizer buckets to clean kitchen prep and surface areas. DM-D confirmed the facility used TMA Quaternary sanitizing solution. Surveyor observed the Dish Machine Temperature Log and noted Quat Sanitizer was listed on the form and documented PPM (parts per million) of the sanitizer buckets within normal range. On 5/15/23, Surveyor conducted a continuous kitchen observation beginning at 11:33 AM. Surveyor interviewed DM-D regarding the process for preparing and ensuring the sanitizing solution is tested per manufacturer's instructions. DM-D verified the recommended PPMs for the sanitizer buckets by showing Surveyor the Quat testing strips and documentation of the correct PPMs on the Dish Machine Temperature Log. DM-D stated sanitizer and water are mixed in the sanitizing bucket and tested with a Quaternary test strip to ensure the sanitizer is within the manufacturer's recommended PPM range. DM-D stated if the PPM is out of range, the process is repeated. DM-D verified the water is not tested to ensure a temperature of 65-75 degrees F prior to testing the sanitizing solution. Surveyor and DM-D verified the Quaternary test strips and Dish Machine Temperature Log both indicated the Quat Sanitizer check solution temperature must be between 65-75 degrees F. DM-D verified the facility was not performing temperature checks per manufacturer's directions to ensure appropriate PPM for the sanitizing solution used for kitchen equipment and food prep areas. Hand Hygiene Wisconsin Food Code 2022 documents at 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles .(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks .(I) After engaging in other activities that contaminate the hands. On 5/15/23, Surveyor conducted a continuous kitchen observation beginning at 11:33 AM. Surveyor observed CK-E prepare hamburgers for lunch at the tray line. CK-E removed gloves, washed hands in the kitchen hand washing sink and donned new gloves. Immediately after donning gloves, CK-E walked to the cooler, opened the door with a gloved hand, removed a bag of sliced cheese, and closed the door with a gloved hand. CK-E then walked to the tray line and opened the bag of sliced cheese. With the same gloved hands, CK-E removed cheese slices from the bag and placed the slices on hamburgers to be served for lunch. On 5/16/23, DM-D verified to Surveyor that CK-E should have performed hand hygiene prior to placing cheese slices on hamburgers. Cleanliness of Food Contact Surfaces and Equipment Wisconsin Food Code 2022 documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations Wisconsin Food Code 2022 documents at 4-602.12 Cooking and Baking Equipment. (A) Food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. Wisconsin Food Code 2022 documents at 4-602.13 Nonfood-Contact Surfaces. Non-food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During an initial tour of the kitchen on 5/15/23 at 8:05 AM, Surveyor observed the following: -The front of the oven contained various yellow, red, and white dry food particles, greasy smudges and brown food particles on the oven handles -The toaster contained dried brown and black food particles on the front, left and right sides as well as on the bottom of the toaster drawer. In addition, the inside of the toaster contained multiple brown and black food particles. -A spice jar was observed under the stove/oven. -A can opener contained white dried food particles and food label particles under the blade -The food prep counter back splash contained multiple brown, red, and yellow food spills and particles. The area under the food prep counter where food equipment items were stored was dusty and had multiple brown/red food spills. -The steam table contained multiple brown, red, yellow, and white food spills and food particles dried to the steam table surfaces. Surveyor reviewed the cleaning schedule located in the kitchen and noted staff initials and check [NAME] which indicated appliances, equipment and food prep areas were cleaned daily on each shift. Surveyor requested copies of kitchen cleaning lists from April 1, 2023 to the present. On 5/16/23 at 7:32 AM, Surveyor and DM-D verified the unsanitary and unclean kitchen equipment and food prep areas noted above as well as the following observation: -The right side of the stove/oven was covered with a white, crusted food spill. On 5/16/23, Surveyor reviewed the April 2023 and May 2023 kitchen cleaning schedules which indicated appliances, equipment and food prep areas were cleaned daily on each shift from April 1, 2023 through May 15, 2023. Surveyor noted May 15, 2023 was initialed by CK-E as completed on the first shift and initialed by CK-F on the second shift and indicated the following items were cleaned: wipe countertops, steam table, front of stove, prep table, sweep kitchen and wash can opener.

Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 37 opportunities which resulted in an 5.41% medication error rate affecting 2 Residents (R) (R23 and R34) of 4 residents observed during medication pass. R23 had a physician order for Miralax (used to treat and prevent constipation). During an observation of medication administration, Registered Nurse (RN)-C administered a partial dose of Miralax to R23 and left R23 with the remaining medication. R23 was not assessed to safely self-administer medication and did not receive the complete dose. In addition, R23's physician order for Miralax included the instruction to mix in eight ounces of water. RN-C mixed R23's Miralax in approximately five ounces of water. R34 had a physician order for polyth glyc (generic name for Miralax). During an observation of medication administration, RN-C administered a partial dose of Miralax to R34 and left R34 with the remaining medication. R34 was not assessed to safely self-administer medication and did not receive the complete dose. Findings include: The facility's Administering Medications policy, revised April 2019, contained the following information: Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with Prescriber orders .Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely . On 5/16/23, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia without behavioral disturbance. R23's Minimum Data Set (MDS) assessment, dated 3/28/23, contained a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R23 had severe cognitive impairment. R23's Power of Attorney for Healthcare (POAHC) document, dated 5/28/19 and activated 4/6/22, indicated R23's POAHC agent was responsible for R23's healthcare decisions. R23's medical record did not contain a self-medication administration assessment. R23 had physician order for Miralax 17 grams by mouth every AM mixed with 8 ounces of water. On 5/16/23, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia without behavioral disturbance. R34's MDS assessment, dated 5/2/23, contained a BIMS score of 4 out of 15 which indicated R34 had severe cognitive impairment. R34's POAHC document, dated 6/15/22 and activated 7/7/22, indicated R34's POAHC agent was responsible for R34's healthcare decisions. R34's medical record did not contain a self-medication administration assessment. R34 had a physician order to mix 17 grams of Polyth glyc (powder) in adequate liquid and give by mouth once daily for constipation. On 5/16/23 at 7:32 AM, Surveyor observed RN-C prepare and administer R23's morning medications which included 17 grams of Miralax which RN-C mixed with water in a small plastic glass. Surveyor observed RN-C assist R23 with sips of Miralax at a table in the dining area to facilitate the swallowing of R23's other AM medications. Surveyor observed RN-C leave the remaining Miralax at the table with R23. RN-C's medication cart was located in the hall adjacent to the dining area. RN-C then prepared medications for another resident with RN-C's back to the dining area. On 5/16/23 at 7:39 AM, Surveyor observed RN-C prepare and administer R34's morning medications which included 17 grams of Miralax which RN-C mixed with water in a small plastic glass. At a table in the dining area, Surveyor observed RN-C assist R34 with sips of Miralax to facilitate the swallowing of R34's other AM medications. Surveyor noted RN-C left the remaining Miralax at the table with R34 along with a small plastic glass that contained a chocolate supplement drink. The majority of the Miralax dose remained in the glass which was approximately three-quarters full. On 5/16/23 at 7:40 AM, Surveyor observed RN-C ask R23, Are you ready for another drink? Surveyor observed RN-C assist R23 with taking a sip of Miralax. RN-C then returned to the medication cart. On 5/16/23 at 7:46 AM, Surveyor observed R34, who finished the chocolate supplement drink, push the empty glass from the supplement drink into the plastic glass containing the remaining Miralax (without drinking any more of the Miralax) which caused the remaining Miralax to flow onto the table. On 5/16/23 at 7:50 AM, Surveyor observed RN-C leave the medication cart to administer medications to a resident down the hallway. There were no staff in the dining room area at that time. On 5/16/23 at 7:54 AM, Surveyor observed RN-C return to the medication cart. On 5/16/23 at 7:56 AM, Surveyor observed RN-C leave the medication cart to assist another staff in a room with the door closed. There were no staff in the dining area at that time. On 5/16/23 at 7:58 AM, Surveyor observed R34 tip both plastic glasses upside down on the table and move them around through the spilled Miralax which caused some liquid to spill onto the floor. On 5/16/23 at 8:04 AM, Surveyor observed staff wipe up the Miralax from R34's table and surrounding floor and place the empty cups in the garbage. On 5/16/23 at 8:08 AM, Surveyor observed RN-C state to R23, You need to finish your water. Surveyor observed RN-C assist R23 with taking a sip of Miralax. RN-C then returned to the medication cart. On 5/16/23 at 8:10 AM, Surveyor observed RN-C leave the medication cart and walk down hallway out of sight. There were no staff in the dining area at that time. On 5/16/23 at 8:12 AM, staff delivered a meal tray cart to the dining area. Surveyor observed staff set up R23's breakfast meal tray and set the glass with the remaining Miralax to the side of the tray. On 5/16/23 at 8:14 AM, Surveyor observed RN-C return to the medication cart and move the medication cart down the hall and out of sight. On 5/16/23 at 8:28 AM, Surveyor observed RN-C return to the dining area. RN-C assisted R23 with sips of Miralax after RN-C administered medications to R23's tablemate. RN-C placed the glass with the remaining Miralax on R23's meal tray. Surveyor then observed RN-C assist another resident with meal intake. On 5/16/23 at 9:00 AM, Surveyor observed RN-C leave the dining area. One staff member was present in the dining area and started to clear meal trays. On 5/16/23 at 9:02 AM, Surveyor observed staff remove R23's tray and place it in the meal cart. Surveyor noted approximately one-third of the Miralax dose remained in a glass on R23's meal tray. On 5/16/23 at 9:46 AM, Surveyor and RN-C observed the bottom of the plastic glasses used to prepare Miralax doses. RN-C verified the imprint on the bottom of the glass indicated a total of five ounces of fluid could be contained in the glass. On 5/16/23 at 10:08 AM, Surveyor interviewed RN-C who verified R23's Miralax was not mixed with eight ounces of water as ordered which RN-C verified was considered a medication error. Following a discussion of the above observations, RN-C verified R23 and R34 did not receive their entire doses of Miralax and should not have been left alone with their Miralax unfinished. RN-C verified R23 and R34 needed to be assessed for safe self-administration of medication before being left alone with medication. On 5/16/23 at 11:40 AM, Surveyor interviewed Director of Nursing (DON)-B via phone who verified R23 and R34 did not receive their complete doses of Miralax which were considered medication errors. On 5/16/23 at 11:57 AM, Surveyor again interviewed DON-B via phone who verified R23 and R34 were not assessed to self-administer medications. DON-B stated, We do self (medication) administration assessment if a resident wants to take their own meds. DON-B stated it would not be appropriate for R23 and R34 to self-administer medications related to severe cognitive impairment as indicated by their BIMS scores.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R28) of 1 resident who had a Guardian received services to ensure a court-ordered protective placement was obtained. R28 was under Guardianship. The facility did not ensure R28 had a court-order to be protectively placed at the facility. Findings include: On 5/15/23 at 1:36 PM, Surveyor reviewed R28's medical record. R28 was admitted to the facility in 2022 with diagnoses that included cerebrovascular accident (CVA) (stroke), aphasia (brain damage in the area that affects language), schizophrenia, and mild cognitive impairment. R28 had a Guardian of person. Surveyor was unable to locate protective placement documentation in R28's medical record. On 5/16/23 at 9:00 AM, Surveyor interviewed Social Services Designee (SSD)-G who stated the only Guardianship document the facility had for R28 was the original letter of Guardianship, dated 8/19/81. SSD-G stated the County usually initiates a resident's annual protective placement by calling SSD-G. SSD-G stated SSD-G thought R28 was protectively placed at the facility, but would call the County. On 5/16/23 at 9:46 AM, Surveyor interviewed SSD-G who verified R28 was not protectively placed at the facility. SSD-G verified that upon admission, the facility should have contacted the county to initiate R28's protective placement.

Based on staff interview and record review, the facility did not ensure a resident suspected of having a mental illness and/or intellectual/developmental disability was screened through the Pre-Admission Screen and Resident Review (PASRR) Level 2 process to determine if nursing home placement was appropriate and if specialized services were required for 1 Resident (R) (R28) of 12 sampled residents. The facility did not complete a PASRR Level 2 screen upon R28's admission to the facility or follow-up after a PASRR Level 2 was submitted when Zoloft (anti-depressant medication) was added to R28's medication regimen. Findings include: On 5/15/23 at 2:21 PM, Surveyor reviewed R28's medical record. R28 was admitted to the facility in 2022 with diagnoses that included cerebrovascular accident (CVA) (stroke), aphasia (brain damage in the area that affects language), schizophrenia, and mild cognitive impairment. R28's medical record indicated R28 had a Guardian. Surveyor noted R28's medical record did not contain a PASRR Level 2 screen. On 5/16/23 at 8:47 AM, the facility provided a PASRR Level 1 screen, dated 2/14/22, that indicated R28 had diagnoses of mental illness (MI) and intellectual disability (ID) which were schizophrenia and mild intellectual disabilities. Written on page two of the document was a side note that indicated R28 started a new medication (Zoloft) on 11/17/22 for depression. The noted indicated the Level 1 screen was faxed on 11/17/22 to (designated state authority who reviews PASRRs). A cover sheet, dated 11/17/22, indicated R28 started Zoloft. In the section that stated email to send level II, an email was not listed. The document was signed by Registered Nurse (RN)-N. No further documentation or information was noted in R28's medical record. On 5/16/23 at 9:38 AM, Surveyor interviewed RN-N who stated, I was going to call them soon. I don't have it in my records and I don't recall. I usually download them and haven't looked if there's one sent in email. RN-N stated R28 was admitted from another long-term care facility which was the origin of R28's original PASRR screen. RN-N verified the facility did not send for a Level 2 screen until R28 was prescribed Zoloft. On 5/16/23 at 12:03 PM, Surveyor interviewed a staff member from the designated state authority for PASRRs who verified they did not have record of a PASRR Level 1 screen for R28 from either facility. On 5/17/23 at 11:06 AM, Surveyor interviewed RN-N who stated probably not when asked if RN-N followed up after faxing the updated PASRR Level 1 when R28 started Zoloft.

Based on staff interview and record review, the facility did not ensure a complete baseline care plan was developed within 48 hours of admission for 1 Resident (R) (R92) of 1 sampled resident reviewed for new admission. R92 was admitted to the facility on [DATE] with orders to receive four different high-risk medications. R92's baseline care plan did not address the use of the high-risk medications. Findings include: On 5/16/23, Surveyor reviewed R92's medical record. R92 was admitted to the facility on [DATE] with diagnoses to include duodenal ulcer (small holes or erosions in the lining of the upper section of the small intestine just below the stomach) with hemorrhage (bleeding) and perforation (opening to the outside), chronic kidney disease, multiple rib fractures, major depressive disorder and anxiety disorder. R92's medical record contained a Power of Attorney for Healthcare (POAHC) document, dated 1/16/20 and activated 4/28/23, that indicated R92's POAHC agent was responsible for R92's healthcare decisions. R92's medical record contained the following physician orders: ~ Eliquis (apixaban) (used to help prevent the formation of blood clots) tablet; 5 mg (milligrams); amt (amount): 1 tab; oral twice daily ~ hydrocodone-acetaminophen (used to treat moderate to severe pain) - Schedule II tablet; 5-325 mg; amt: 1 tab; oral special instructions: q (every) 6 hrs (hours) prn (as needed) for pain ~ citalopram (used to treat depression) tablet; 20 mg; amt: 1 tab; oral once daily ~ buspirone (used to treat anxiety) tablet; 5 mg; amt: 1 tab; oral twice daily On 5/17/23, Surveyor reviewed R92's baseline care plan, dated 5/4/23, which did not mention use of any of the above high-risk medications or any interventions related to monitoring for side effects of the high-risk medications. On 5/17/23 at 11:22 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified high-risk medications should be addressed on residents' baseline care plans, including instructions to alert staff to monitor for side effects.

Based on observation, staff and resident interview, and record review, the facility did not provide necessary respiratory care and services for 1 Resident (R) (R24) of 1 sampled resident. The facility did not clean R24's continuous positive airway pressure (CPAP) machine per manufacturer's instructions. Findings include: The facility's CPAP/BiPAP Support policy, revised March 2020, contained the following information: General Guidelines for Cleaning .1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device .7. Masks, nasal pillows and tubing: Cleaned daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dray between uses. The Air Fit ResMed Mask User Guide contained the following information: Cleaning your mask: mask and headgear should only be handwashed by gently rubbing in warm (approximately 86 F (Fahrenheit)/30 C (Celsius)) water using mild soap. All components should be rinsed well with drinking quality water and allowed to air dry out of direct sunlight .Daily/After each use: Disassemble the mask components according to the disassembly instructions. Handwash the separated mask components (excluding headgear and soft sleeves). To optimize the mask seal, facial oils should be removed from the cushion after use. Use a soft bristle brush to clean the vent .Inspect each component and, if required, repeat washing until visually clean. Rinse all components well with drinking quality water and allow to air dry out of direct sunlight. When all components are dry, reassemble according to the reassembly instructions. On 5/15/23, Surveyor reviewed R24's medical record. R24 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen, dependence on other enabling machines and device and sleep apnea. R24's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R24 did not have impaired cognition. R24's MDS also indicated R24 required extensive assistance of one staff for activities of daily living (ADLs), transfers, and ambulation. R24's care plan instructed staff to make sure R24's CPAP was on at night and set at 2 liters of oxygen. The care plan contained interventions to clean tubing and O2 tubing per facility policy/procedure. On 5/15/23 at 8:56 AM, Surveyor interviewed R24 who stated R24 used a ResMed Air Sense 10 CPAP machine nightly. R24 verified R24 needed the CPAP nightly otherwise R24 could die, my sleep apnea is very bad. R24 also stated R24's CPAP was not cleaned enough. R24 stated the CPAP tubing and mask were washed maybe once a month. Surveyor noted R24's CPAP tubing appeared clean and R24's CPAP machine appeared dust free. Surveyor observed a CPAP mask on R24's bed. The mask appeared dirty and contained a greasy film with white particles on the part of the mask that provides a seal with R24's face to appropriately provide airway therapy. On 5/16/23 at 8:55 AM, Surveyor interviewed Registered Nurse (RN)-C who stated R24's CPAP machine, tubing and mask were cleaned once weekly by RNs on the Sunday AM shift and documented in the facility's treatment book. Surveyor reviewed a treatment flowsheet that stated: Clean CPAP machine on Sunday AM. Surveyor also noted R24's medical record contained an order, dated the day of R24's admission, to clean R24's CPAP equipment once weekly on Sundays. On 5/16/23 at 9:01 AM, Surveyor observed R24's CPAP mask with tubing attached on R24's bed. Surveyor noted the mask appeared dirty and contained a greasy film with white dried particles on the mask and the silicone seal around the mask. On 5/16/23 at 1:00 PM, Surveyor confirmed with RN-C that R24's CPAP mask was last cleaned on 5/14/23 and was scheduled to be cleaned on 5/21/23. RN-C confirmed R24's CPAP machine was cleaned once weekly, but verified the mask should be washed daily.

Based on record review and staff interviews, the facility did not ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failing to conduct a thorough background check for 2 facility staff (Licensed Practical Nurse (LPN)-D and Certified Nursing Assistant (CNA)-E) of 8 facility staff reviewed for background checks. The facility did not ensure an out-of-state background check for LPN-D and CNA-E were conducted. Findings Include: Facility policy titled Resident Abuse, Neglect and Misappropriation/Exploitation of Property with a revision date of 1/2022 read as follows: Screening of Employees: It is the policy of the facility to screen potential employees for a history of abuse, neglect or mistreating residents by: 5. Background check completed including the Wisconsin Department of Justice Criminal Check and State of Wisconsin Department of Health and Family Services, Department of Regulation and Licensing. If the employee has resided in a state other than Wisconsin in the past three years, a criminal background check will be requested from all prior states of residence within the past three years. Any applicant who has been found guilty of abusing, neglecting or mistreatment residents in a court of law will not be employed. On 5/23/22, the Surveyor selected a sample of employees to review for background check compliance, including LPN-D and CNA-E. LPN-D was hired by the facility on 2/24/22. On 5/23/22, the Surveyor reviewed LPN-D's Background Information Disclosure (BID) form dated 2/24/22 where LPN-D indicated having resided in the state of Illinois within the past 3 years prior to hire at the facility. LPN-D's records did not contain an out-of-state background check. CNA-E was hired by the facility on 1/4/22. On 5/23/22, the Surveyor reviewed CNA-E's BID form dated 1/4/22 which indicated CNA-E resides in the state of Michigan currently and had within the past 3 years prior to hire at the facility. CNA-E's records did not contain an out-of-state background check. On 5/23/22 at 4:10 PM, Surveyor interviewed Human Resource Director (HR)-C who stated, I do not know how to look up other states other than Wisconsin and Michigan. On 5/24/22 at 8:49 AM, Surveyor interviewed HR-C who confirmed having double checked employee files and does not have an out-of-state background check for LPN-D or for CNA-E. On 5/24/22, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated that NHA-A would work with HR-C to become familiar with how to conduct out-of-state background checks on potential new employees who have resided outside the state of Wisconsin within 3 years prior to hire. On 5/25/22, HR-C presented Surveyor with out-of-state background checks dated 5/24/22 for LPN-D and CNA-A and explained that the facility now has access to an out-of-state background screening process and will begin conducting out-of-state background checks on potential new hires who have lived outside of Wisconsin within 3 years prior to hire.

Based on observation, record review and interview, the facility did not ensure that 1 Resident (R) (R235) of 4 sampled residents reviewed for falls had adequate assistive devices and interventions in place to prevent accidents. R235 admitted to the facility on [DATE]. Admission assessments indicated R235 was at-risk for falls. Despite being at-risk for falls, fall prevention interventions were not incorporated into R235's baseline plan of care upon admission. R235 subsequently fell on [DATE] and sustained a fracture to the right hip. Findings include: On 5/17/21, Surveyor reviewed the medical record for R235. R235 admitted to the facility 4/23/21 with diagnoses to include unspecified dementia (collective term used to describe various symptoms of cognitive decline), stage 4 [CONDITION(S)] (a condition characterized by a gradual loss of kidney function over time), bilateral [CONDITION(S)] of the knee (type of arthritis that occurs when flexible tissue at the ends of bones wears down), [CONDITION(S)] (difficulty urinating and completely emptying the bladder), generalized muscle weakness, and a history of falling. R235's most recent Minimum Data Set (MDS) assessment, dated 5/7/21, indicated in Section G (Functional Status) that R235 required physical assistance from one staff to complete the majority of R235's activities of daily living (ADLs). R235 required extensive assistance from one staff in the areas of bed mobility, transferring, dressing, toilet use, and personal hygiene. R235's Brief Interview of Mental Status (BIMS) assessment documented a score of 11 of 15, indicating R235 had moderate cognitive impairment. Surveyor reviewed nursing progress notes from R235's day of admission to the facility, 4/23/21, and noted R235 was R235's own decision-maker and was able to make R235's wants and needs known to staff. Surveyor reviewed R235's admission Fall Risk (Acuity) Observation Report, dated 4/23/21. Per the assessment, R235's total fall risk score was 13, indicating R235 was at-risk for falls (score of 10 or higher represents a high risk for falls). On 5/17/21 at 1:42 PM, Surveyor interviewed R235 about R235's care at the facility. Upon entering R235's room, Surveyor observed R235 lying in bed and a floor mat on the floor next to R235's bed. R235's call light was in reach. When asked about falls at the facility, R235 indicated R235 had fallen once and had slipped when transferring from R235's recliner to R235's wheelchair. Surveyor further reviewed R235's medical record and noted a nursing progress note from 4/25/21 at 6:50 PM which indicated R235 had sustained an unwitnessed fall when attempting to self-transfer from R235's recliner to R235's wheelchair and then to bed. R235 had plain socks on at the time of the fall. R235 was assessed by nursing staff. R235's vitals were within normal limits, neurological checks were started, and R235 expressed no complaints of pain at that time. Progress notes from 4/27/2021 documented that R235 began expressing pain in R235's right hip and leg area and presented with decreased strength in that area. R235's physician was updated and an x-ray was ordered. The x-ray results were positive for right hip fracture, and R235 was transferred to the emergency room for evaluation and treatment. R235 readmitted to the facility on [DATE] with diagnosis of right hip intertrochanteric fracture. R235's right leg was put into an immobilizer and surgical dressings were in place on the right hip. On 5/19/21, Surveyor requested and Director of Nursing (DON)-B provided R235's fall investigation report from 4/25/21 and a copy of R235's baseline care plan. The fall investigation report documented interventions put into place after R235's fall included moving R235's recliner remote, ensuring appropriate footwear, reminders to call for assistance, and a lighted floor mat. On R235's baseline care plan, Surveyor noted R235 was marked yes under the area titled Fall Risk. Surveyor also noted that the initial care plan stated that if yes was marked under Fall Risk, safety measures were to be implemented. Safety Measures on the baseline care plan included boxes for bed alarm, chair alarm, sensor, grab bar, floor mat, and a box to write in any additional interventions. None of the boxes were checked to indicate safety measures were implemented. On 5/19/21 at 1:46 PM, Surveyor interviewed Registered Nurse/MDS Coordinator (RNMDS)-E. RNMDS-E verified that RNMDS-E had filled out R235's baseline care plan. RNMDS-E explained that baseline care plans are typically completed by the admitting nurse but that RNMDS-E assists in filling baseline care plans out for residents if needed. Surveyor asked RNMDS-E if the safety measures were blank on the baseline care plan if that indicated those measures were not put into place for the resident. RNMDS-E verified that if safety measures are put in place, they should be included on the baseline care plan or the boxes should be checked. RNMDS-E explained that when RNMDS-E helps to fill out the baseline care plan, the admitting nurse would verify the information on the baseline care plan is correct.

Based on staff interview and record review, the facility did not ensure Quality Assessment and Assurance (QAA) committee met quarterly with the Medical Director (MD)-K for 3 out of 4 quarterly meeting attendance records reviewed. This had the potential to effect all 29 residents at the facility. The facility did not ensure MD-K participated in quarterly QAA meetings held on 4/16/20, 7/16/20, and 12/17/20. Findings include: On 5/17/21, during entrance conference beginning at 8:57 AM, Nursing Home Administrator (NHA)-A disclosed that facility QAA meetings held quarterly did not include MD-K in person, telephonically, or via video call. NHA-A explained that Director of Nursing (DON)-B would update MD-K with meeting minutes after the meeting but MD-K was not in person at meetings due to COVID-19 pandemic and NHA-A did not take into account telephone or video participation as possibilities. On 5/18/20, Surveyor reviewed QAA sign-ins for past 12 months which documented MD-K did not attend QAA meetings held on 4/16/20, 7/16/20, and 12/17/20 (3 out of 4 meetings in past year).

Based on staff interview and policy and record review, the facility did not maintain and implement an infection control program designed to prevent the development and transmission of infection for 11 (residents # 1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) of 54 residents who resided at the facility. The facility practices had the potential to affect all 54 residents in the facility. ~ The facility did not recognize that an outbreak of GE (Gastroenteritis) had occurred when the GE line list and staff sick list indicated 2 residents (#1 and #2) and 2 staff had developed GE symptoms between 3/19/15 and 3/20/15. ~ The facility did not promptly identify that an outbreak had occurred and did not implement aggressive measures to prevent the spread of the infection. ~ The facility did not promptly inform the WDPH (Wisconsin Division of Public Health) when an outbreak was apparent. ~ The facility did not minimize movement of residents as symptomatic and asymptomatic, exposed residents were allowed to consume meals in a common dining area with other residents and in group activities. ~ Facility staff did not wear proper PPEs (personal protective equipment) when caring for residents who had active signs/symptoms of GE. ~ The facility did not increase the frequency of cleaning throughout the time period of the outbreak. ~ The facility did not have an infection preventionist who was adequately trained during the time of the outbreak. ~ The facility did not have complete policies and procedures to include surveillance when managing an infectious disease. The failure of the facility to immediately implement appropriate procedures to limit the transmission of disease created a situation of Immediate Jeopardy. Ultimately 20% of residents became ill and one went to the hospital for five days. The jeopardy began on 3/20/15 when the resident line list and sick staff tracking list revealed 2 residents and 2 staff members demonstrated signs/symptoms of GE within the previous 24 hours. On 4/8/15 at 2:20 p.m., (Nursing Home Administrator)-F was formally notified that an Immediate Jeopardy situation existed. The Immediate Jeopardy was determined to have been removed, but not corrected, on 3/27/15; the deficiency continues at a scope/severity level of F (potential for harm that is not immediate jeopardy/widespread) as the facility continues to implement their removal plan. Findings include: The facility's undated GE policy documented the main symptoms of viral GE include sudden onset of vomiting and diarrhea. Vomiting is usually prominent but may be infrequent or absent. Diarrhea tends to be watery, short-lived, and less severe than that which results from GE caused by bacteria. In addition to vomiting and/or diarrhea, a person may present with headache, fever, chills, or abdominal cramping. GE is generally mild and of short duration (one or two days). Facilities are required to maintain an infection prevention and control program that includes a surveillance program for GE. An outbreak of viral GE should be suspected when 3 or more residents and/or staff develop new onset of vomiting and/or diarrhea within 72 hours. A person is suspected of having GE when they experience 3 or more loose stools in a 24 hour period. Vomiting may be present. Other symptoms may include nausea, abdominal cramping, fatigue, body aches, and fever. Facilities should immediately institute aggressive infection control measures any time an outbreak is suspected. The facility policy states: ~ Staff should immediately report any resident or staff member with a sudden onset of symptoms suggestive of GE to the person in charge and the infection control practitioner who should immediately take appropriate action. The medical director should be consulted. ~ New cases should be recorded daily using the line list. ~ Notify the WDPH of any suspected outbreak. ~ Notify sister facilities. ~ Post signage stating that the facility is experiencing an increase in GE illness. ~ Immediate isolation and restricting access to affected areas is essential. ~ Confine symptomatic residents to their rooms until 48 hours after their symptoms cease. ~ Require symptomatic staff to stay home until they have been symptom free for 48 hours. ~ Discontinue "floating" staff from affected units to unaffected units. ~ Consider discontinuing common dining areas and instituting in-room dining. ~ If any resident is transferred to the hospital or other facility, notify the facility of the outbreak of GE. ~ Implement contact precautions for affected residents. ~ A log should be maintained to record ill staff, symptoms, onset and well dates, and return to work dates. ~ Increase the frequency of environmental cleaning. Enhanced cleaning should continue for 72 hours after the last documented GE case. The Wisconsin Division of Public Health's (WDPH's) "Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities," revised 12/15/10, indicated an outbreak of viral gastroenteritis should be suspected when three or more residents and/or staff develop new onset of vomiting and/or diarrhea within 72 hours. Each resident unit should immediately report any resident with a sudden onset of symptoms suggestive of viral GE to the infection control practitioner or person in charge. The recommendations also direct the facility to notify the WDPH of any suspected or confirmed outbreak. 1. The facility's resident line list, entitled "Appendix 4 Sample Case Log (Line list) of Staff During Outbreaks of Gastrointestinal (GI) Illness" included categories for the following information: Name, Age, Sex, Assignment, Onset, Well, Nausea, Vomiting, Diarrhea, Abdominal Cramping, Fever, Chills, Return to work date, hospitalization , and Lab results. (The document was indicated to be a line list for staff, however in this case, the line list was utilized to record GI illness of residents and staff.) The "Age" category was incomplete, the "Assignment" category listed the department or unit worked by the staff person included on the list or the unit the resident resided on (excluding the room number). The "Lab Results" section of the document was used to document miscellaneous information to include how many "episodes" (of vomiting or diarrhea) occurred, resident hospitalization , or last worked date by staff. The line list was incomplete in that it did not include the first two residents who became ill, residents #1 and #2. The line list combined staff and residents, excluding some staff and residents who did actually become ill during this outbreak. The line list was incomplete or inaccurate and did not include resident room numbers, onset dates, or well dates for all residents. Return to work dates, symptoms, or onset dates were not included for some staff. 2. According to the facility's line list, on 3/19/15- FO (Facility Owner)-A developed vomiting and diarrhea and had "multiple episodes." (FO-A last worked on 3/18/15 moving from her original office located near the dining room, that residents from the 200 and 300 units had to pass to enter the dining room, to another office located on the 100 unit). FO-A had a well date of 3/20/15. No return to work date was noted. According to the facility's Sick Staff Tracking form, on 3/19/15 CNA (Certified Nursing Assistant)-H developed vomiting and had 3 episodes of vomiting. CNA-H's assigned unit was 200. CNA-H was well on 3/19/15 and returned to work on 3/21/15. According to a nurse's note, recorded as a late entry on 3/31/15, on 3/20/15, resident #1 had "a couple episodes of vomiting in the morning, many (episodes of vomiting) in the afternoon, and more after this writer left the room." Resident #1's name was placed on the line list, however the name was crossed off and no information was placed on the line list regarding resident #1. Resident #1 resided on the 200 unit. According to a nurse's note, recorded as a late entry on 3/23/15, on 3/20/15, resident #2 had 1 episode of vomiting. Resident #2 was not included on the line list. Resident #2 resided on the 200 unit. Based on the nursing notes and resident and staff line lists, FO-A, CNA-H, Resident #1 and Resident #2 developed a new onset of vomiting and/or diarrhea between 3/19/15 and 3/20/15. On 3/20/15, the facility should have suspected a GE outbreak, based on the facility's policy as well as the WDPH GE guidelines. At this time the facility should have implemented the infection control policy of quarantining the affected unit, unit 200, ceasing group dining, activities, and therapies, notifying sister facilities of a potential outbreak, implementing increased cleaning practices, posting signs to alert visitors of a possible outbreak, and contacting the WDPH. This did not occur. 3. The WDPH recommendations indicate a facility should immediately isolate symptomatic residents and restrict access to affected areas. Group activities should be canceled or postponed for at least forty-eight hours after the last identified case. Facilities are directed to minimize movement of residents. Asymptomatic, exposed residents should not be moved from an affected to an unaffected resident unit. On 4/7/15 at 2:10 p.m., surveyor # interviewed DON (Director of Nursing)-G regarding the GE outbreak. DON-G stated the facility continued group dining, group activities, and the use of the therapy department until 3/27/15, at which time the facility determined there was a GE outbreak, affecting all three units in the facility. DON-G stated residents were confined to their rooms for only 24 hours after the last symptom. The whole building was quarantined on 3/27/15 and residents began dining in their rooms, group activities were canceled, signage was posted alerting visitors of a GE outbreak, and therapy was completed in resident rooms, rather than in the therapy department, if necessary. On 4/9/15 at 8:00 a.m., surveyor # interviewed RN (Registered Nurse)-I regarding the outbreak. RN-I indicated she was previously the infection control preventionist. On 3/23/15, RN-I entered the facility and observed resident #4 and resident #5 outside of their rooms. Resident #4 had eaten a meal in the dining room. RN-I stated she believed the facility had an outbreak at this time and reported that to NHA-F and DON-G. RN-I stated she did not observe any residents on isolation on 3/23/15. RN-I indicated she was in the building on 3/26/15 and still did not see any residents on isolation, nor were any units quarantined. 4. The WDPH recommendations indicate to increase the frequency of routine environmental cleaning including bathrooms and the area surrounding the resident's living space. Particular attention should be given to cleaning objects that are frequently touched such as faucets, door handles, light switches and bed rails. Enhanced cleaning and disinfection should continue for at least 72 hours after the last documented case. On 4/7/15 at 12:40 p.m., surveyor # interviewed ES (Environmental Services)-K regarding environmental cleaning. ES-K confirmed the facility only cleaned each room, including the bathroom, one time per day and no increase in the frequency of cleaning was initiated when the outbreak occurred. ES-K stated the only thing that was done differently during the outbreak was going into isolation rooms last and respecting the quarantine by not moving cleaning carts onto or off of the last quarantined unit of 100. On 4/7/15 at 1:10 p.m., surveyor # interviewed ESM (Environmental Services Manager)-J regarding environmental cleaning during the outbreak. ESM-J confirmed that the facility did not increase cleaning frequency. Additionally, increased frequency in cleaning was not continued for 72 hours after the last documented episode of GE. On 4/8/15 at 9:00 a.m., surveyor # interviewed resident #8 regarding cleaning during the outbreak. Resident #8 reported that the resident's roommate, resident #2, had developed diarrhea and stomach pains and was in the bathroom four times with the diarrhea, during the outbreak. Resident #8 indicated neither staff nor housekeeping cleaned the toilet after each use by resident #2. Resident #8 confirmed using the same toilet as resident #2 when the resident was ill. (Resident #8 developed GE symptoms after resident #2 during this outbreak.) 5. According to the facility's policies and procedures and the recommendations from the Wisconsin Division of Public Health, the facility should restrict staff from floating between units when an outbreak has occurred. This did not happen. On 4/7/15 at 9:48 a.m., surveyor # conducted a group interview with CNA-L, CNA-M, and CNA-N regarding the GE outbreak. The CNAs confirmed that staff on PMs and Nights floated to all units to assist with transfers before and after the quarantine was placed on the facility. Only 2 CNAs work during the night shift requiring CNAs to float between units to assist with transfers. 6. The WDPH recommendations indicated that if any resident, regardless of symptoms, is transferred to a hospital or other facility, notify the facility (and EMS or private ambulance service if used) that the resident is coming from a facility at which an outbreak of viral gastroenteritis is occurring. During the facility's GE outbreak, 8 residents left the facility for outside appointments. The outside agencies were not notified of the GE outbreak. 3/20/15 - Resident #11, #14, and #15 left the facility for appointments. 3/23/15 - Resident #16 left the facility for an appointment. 3/24/15 - Resident #12 and #17 left the facility for appointments. 3/25/15 - Resident #10 and #13 left the facility for appointments. On 4/7/15 at 12:10 p.m., surveyor # interviewed DON-G regarding notification of outside facilities during the outbreak. DON-G confirmed that no outside facilities were notified of the GE outbreak until 3/26/15, when resident #6 left the facility. From that time forward, outside facilities were notified of the GE outbreak. The infection spread subsequent to the onset of the outbreak on 3/20/15 as follows, and ultimately affected 11 of 54 residents (20%): ~ Resident #3 was placed on the line list. No onset of symptoms date was noted, the well date was 3/21/15. Resident #3 developed "several episodes" of vomiting and diarrhea while on a LOA (leave of absence) (no date regarding LOA was present on the line list). Resident #3 resided on the 200 unit. According to a nurse's note dated 3/20/15, resident #3 left the facility for a LOA on 3/20/15, and returned to the facility on [DATE]. A subsequent nurse's note dated 3/22/15, stated resident #3 had several episodes of diarrhea and vomiting along with a bloody nose and blood in the vomit on 3/21/15. ~ 3/22/15- CNA-B worked the 200 unit and had "numerous episodes," however no symptoms were actually marked on the line list. A well dated was noted of 3/23/15. No return to work date was noted on this line list. According to the Sick Staff Tracking form, CNA-B returned to work on 3/25/15. ~ 3/23/15- Resident #4 developed 2 episodes of diarrhea. No well date was noted. Resident #4 resided on the 200 unit. RN-I documented a nurse's note dated 3/23/15, which stated resident had 1 soft, unformed stool and one watery stool at 2:58 p.m., and at 4:44 p.m., a second nurse's note was made that stated resident #4 had another watery stool. ~ 3/23/15- Resident #5 developed nausea and 2 episodes of diarrhea. A well date of 3/24/15 was noted. Resident #5 resided on the 200 unit. ~ 3/23/15- CNA-C developed "several episodes" of diarrhea, chills, and fever. CNA-C worked the 200 unit. CNA-C had a well date of 3/24/15. No return to work date was noted on this line list. According to the Sick Staff Tracking form, CNA-C returned to work on 3/26/15. ~ 3/26/15- Resident #6 developed fever and diarrhea. Resident #6 was hospitalized on this date. A well date of 3/27/5 was noted, however the resident did not return from the hospital until 3/31/15. Resident #6 resided on the 300 unit. According to the hospital transfer summary, dated 3/31/15, resident #6 was admitted to the hospital on [DATE] and was diagnosed with [REDACTED]. Resident #6 was treated with IV (Intravenous) antibiotics and IV fluids while in the hospital. ~3/26/15- Resident #7 developed vomiting, diarrhea, and fever. No well date was noted. Resident #7 resided on the 100 unit. ~ 3/26/15- Resident #8 developed "several episodes" of diarrhea. Resident #8 resided on the 200 unit. A well date of 3/27/15 was noted. ~ 3/28/15- AA (Activity Aide)-E developed vomiting (2 episodes) and diarrhea (4 episodes). A well date of 3/27/15 (although the sick date was 3/28/15) was noted. AA-E returned to work on 4/1/15. This information was not on the line list, but was located only on the Sick Staff Tracking form. ~ 3/29/15- Resident #9 developed diarrhea. A well date of 3/30/15 was noted. Resident #9 resided on the 100 unit. ~ 3/29/15- Resident #10 developed diarrhea. A well date of 3/30/15 was noted. Resident #10 resided on the 100 unit. ~ 3/30/15- Resident #11 developed vomiting and diarrhea. A well date of 3/30/15 was noted. Resident #9 resided on the 100 unit. ~ 3/31/15- ES-D developed vomiting. A well date of 3/31/15 was noted. No return to work date was noted on this line list, however, the Sick Staff Tracking form indicates ES-D became ill on 3/26/15, was well on 4/2/15 and returned to work on 4/2/15. On 4/7/15 at 11:10 a.m., surveyor # interviewed DON-G regarding the outbreak. DON-G indicated the resident and staff line lists were initially not being maintained on a daily basis and residents were not immediately placed on isolation. NHA-F and DON-G began developing the resident and staff line list and the GE timeline on 3/23/15. DON-G confirmed resident and staff were combined on the same line list. Additionally, DON-G confirmed that the staff/resident line list excluded some staff as well as some residents and was incomplete. DON-G confirmed the facility's infection control nurse was not present on 3/19/15, during the time of the outbreak, nor was a person delegated to function as the infection preventionist until 3/23/15, when DON-G assumed that role. DON-G stated no one was keeping track of ill residents or staff until 3/23/15, when DON-G was made aware of residents with GE symptoms. DON-G confirmed she was functioning as the infection control preventionist during the time of this outbreak, however she had not had any training and was not familiar with the facility's infection control policies and procedures. DON-G stated she could not find a policy related to surveillance as part of the infection control program. DON-G stated no staff education was provided regarding infection control practices since the outbreak occurred. DON-G confirmed the WDPH was not notified of a the outbreak until 3/27/5. According to the undated outbreak timeline completed by DON-G, the following people had presented with GI symptoms including vomiting and/or diarrhea and/or loose/liquid stools by 3/23/15: FO-A, resident #2, resident #1, resident #3, resident #4, resident #5, and CNA-C. The timeline did not include CNA-H. The timeline indicated the Medical Director was contacted, who instructed the DON and NHA to "monitor." The timeline then indicated resident #6, #7, and #8 developed new onset of GE symptoms on 3/26/15, affecting residents on all three units at this time. Resident #6 was hospitalized due to decreased responsiveness following multiple episodes of vomiting and diarrhea. On 3/27/15, the facility quarantined all units, the medical director was notified, sister facilities were notified, the WDPH was notified, and stool samples were obtained. According to http://www.flu.gov/at-risk/seniors/index.html," As you age, your immune system weakens. This weakening makes seniors-adults [AGE] years and older- more susceptible to the flu. For seniors, the seasonal flu can be very serious, even deadly. Ninety percent of flu-related deaths and more than half of flu-related hospitalization s occur in people age 65 and older. " (In context, those 65 and older constitute 14.1% of the US population yet accounted for 90% of all flu-related deaths.) <http://www.flu.gov/about_the_flu/seasonal/index.html> The failure of the facility to appropriately implement procedures to limit the transmission of infection created a situation of Immediate Jeopardy. The Immediate Jeopardy was removed on 3/27/15, after the facility had implemented many of the precautions recommended by the WDPH as well as the facility's policy and had completed or begun implementing the following: ~ Housekeeping increased level of cleaning and disinfecting of resident and public bathrooms, handrails, door knobs.... ~ As GE symptoms occurred residents were isolated to their room ~ Residents affected ate meals in their room on disposable containers and utensils ~ Staff were re-educated and reminded verbally on the importance of good hand hygiene and the use of personal protective equipment ~ Hospital discharge planners were notified of outbreak and readmits were detained from the facility ~ No admissions were accepted during quarantine ~ DON received additional infection control training

Based on observation, staff and resident interviews, and record review the facility did not provide the necessary care and treatment for [REDACTED]. Resident #1 was assessed as requiring podiatry care on admission on 3/17/13 due to overgrown 6 cm (centimeter) long uncut toe nails. On 5/8/13 resident #1 was found to have developed 2 unstageable pressure ulcers on her toes related to the pressure of these nails on her skin. Findings include: Review of resident #1's medical record by surveyor # on 5/8/13 showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was noted to be alert and oriented and made her own health care decisions. On admission resident #1 indicated she wanted involvement with Health Drive for podiatry care and had her friend/agent sign the consent for her due to her weakness on admission. A nurses note and assessment on 3/17/13 indicated: Small open area measuring approximately .5 cm in diameter noted to mid vertebrae, note sent to the wound nurse for evaluation. Toes on bilateral feet are thick, yellow, and overgrown curling under toes, also thick brown "debris" noted between all toes on bilateral feet. CNA (certified nursing assistant) cleansed both feet with soap and water, no open areas noted. Podiatry referral to be made. The facility's Braden Skin Assessments dated 3/17/13 with a score of 17 and 4/17/13 with a score of 18 (15 - 18 = at risk) showed resident #1 was at risk for skin breakdown. Resident #1's MDS (minimum data set) dated 3/22/13 showed she had a cognitive score of 8 (8 - 12 = moderate impairment), was at risk for pressure ulcers, had one unhealed stage II ulcer (on her spine), and no other ulcers. Notes from RN - B (registered nurse - wound nurse) dated 3/19/13 indicated she addressed the open area on the spine. Further notes dated 3/25/13 indicated this wound healed and a note on 4/2/13 indicated this area was resolved with no further treatment necessary. There was no documentation addressing any areas of concern with resident #1's toes. The facility's treatment records for resident #1 showed CNA's assessed her skin twice a day per protocol from admission on 3/17/13 through 5/7/13 with no concerns identified other than the initial open area on her spine that healed on 3/25/13. Skin assessments by the charge nurses from 3/17/13 through 5/7/13 did not indicate any concerns with resident #1's feet except for periodic trace [MEDICAL CONDITION] in her ankles. Notes from resident #1's physician visits on 3/19/13 and 4/10/13 indicated no knowledge of any concern with the overgrowth of resident #1's toe nails or the pressure areas on her toes. Resident #1's care plan from 3/17/13 addressed that she was at high risk for skin breakdown. An update on 4/3/13 indicated her open area on her spine had healed on 3/25/13. There was no mention in resident #1's care plan of the condition of her feet and need for intervention with her very long toe nails which were growing into her skin. An e-mail from DON (Director of Nursing) - A dated 5/6/13 to Health Drive indicated podiatry was overdue by one month. An e-mail from Health Drive to DON - A dated 5/7/13 indicated they would get a podiatrist scheduled. These e-mails did not mention specific residents and made no mention of any urgency to have resident #1's toe nails addressed. On 5/8/13 at 9:10 a.m. surveyor # and CNA - D asked resident #1 for permission to check her feet and she agreed. CNA - D removed resident #1's socks to reveal thick curling toe nails extending from the big toes and wrapping around the toes next to them. The toe nails were cutting and growing into resident #1's skin on both feet. In an interview with surveyor # at the time of this observation resident #1 indicated she wanted care of her toe nails and had told the facility that. She indicated sometimes they were painful but not bad and she had no concerns with the pain. Resident #1 said that no one had asked her about her toe nails in awhile and indicated she still wanted them taken care of. On 5/8/13 at 9:18 a.m. surveyor # asked DON - A and RN - C to observe resident #1's feet. On removal of resident #1's socks DON -A indicated, "Oh my God! I had no knowledge they were like this. This should have been taken care of immediately." She indicated that obviously this (the condition of her toe nails and feet) has been going on forever and resident #1 should have been sent out for treatment. RN - C, who indicated she was the unit manager, said she had no knowledge of the condition of resident #1's toe nails and the resulting open areas to her toes until now. On 5/8/13 at 10:35 a.m., surveyor # observed RN-C remove resident #1's socks/slippers to assess resident #1's toenails. Resident #1's left great toenail was observed to have been curling laterally and applying pressure to the superior aspect of resident #1's second and third digit of the left foot. According to RN-C, resident #1's left great toenail was 6.0 cm in length and was 0.5 cm thick. The 2nd toe nail measures 2 cm, the 3rd was 1 cm, and the 5th was .6 cm. RN-C measured the 4th toe nail which was thick and curling under the toe but was unable to measure and to assess the skin under the nail as it was touching the posterior side of the toe. RN-C measured resident #1's right great toenail which was curling laterally and extending 6.5 cm across the toes. RN-C stated the thickness of the toenail was 1.0 cm. The 2nd toenail was curled laterally with 3 cm in length and .5 cm thickness. The 3rd, 4th, and 5th had minimal length but were in need of trimming with .8 cm length average for these three toenails. On 5/8/13 at 1:15 p.m., surveyor # interviewed CNA-D regarding resident #1's feet. CNA-D stated she had worked with resident #1 since admission to the facility. CNA-D indicated resident #1's toenails have been in that condition since admission, but didn't think the bottom of the toenails were touching other digits, but she wasn't sure as she only observed the toenails from the top. CNA-D stated she wasn't aware of any pressure ulcers under the toenails. CNA-D indicated she had told a nurse shortly after admission, regarding the condition of the toenails (couldn't recall who), but was told resident #1 was having a podiatry referral. On 5/8/13 at 1:20 p.m., surveyor # interviewed DON-A regarding her conversation with the physician today. DON-A indicated the physician assessed resident #1's toenails this AM and indicated the toenails were years and years of growth. DON-A indicated the physician told her he did not feel a podiatrist would help and was referring resident #1 for a surgical consult. DON-A stated the physician was told of resident #1's need for a podiatry consult upon admission to the facility, but was not told of the severity of the problem. On 5/8/13 at 1:50 p.m., surveyor # observed RN-B assess resident #1's pressure ulcers under bilateral great toenails. RN-B stated she had assessed resident #1's right great toe earlier in the day when she was told of the concern, but indicated she had not assessed resident #1's left foot as she was not made aware of any concerns. RN-B stated resident #1 had an unstageable pressure ulcer that measured 0.4 cm X 0.3 cm on the third digit of the left foot. RN-B stated resident #1 had an unstageable pressure ulcer on the fourth digit of the right foot which measured 0.5 cm X 0.5 cm and a stage one pressure ulcer on the third digit which measured 0.4 cm X 0.3 cm. The facility had failed to obtain the podiatry consult requested on 3/17/13 and the necessary care and treatment for [REDACTED]. In an interview with surveyor # on 5/8/13 at 1:10 p.m., SW (social worker) - F verified that resident #1 said she wanted involvement with Health Drive, including podiatry services, on admission to the facility on [DATE]. SW - F indicated resident #1 is her own person but had her friend/agent sign the form for her due to weakness. In an interview with surveyor # and # on 5/8/13 at 1:15 p.m. DON - A confirmed that there was no documentation of any concerns with resident #1's feet other than the original admission assessment from 3/17/13 that addressed the thick, curling, toe nails and need for a podiatry consult. DON - A confirmed that resident #1 had not been seen by a podiatrist as needed. The facility had not notified resident #1's physician of the severity of the condition of her toe nails on admission on 3/17/13 with the possibility of causing pressure ulcers to her toes. During the 5/8/13 interview at 1:15 p.m. DON - A confirmed that she spoke with resident #1's physician, MD (Medical Director) -E on 5/8/13 and notified him of the open areas on resident #1's feet related to pressure from her overgrown toe nails. DON - A said MD - E indicated he was not aware of the severity of the condition of resident #1's toes until today. After observing them on 5/8/13 MD - E told DON - A that resident #1 likely needed surgical intervention for treatment of [REDACTED].

Based on observations, interviews, and record reviews, the facility did not consistently provide 1 of 15 sampled residents with sufficient fluids to maintain proper hydration and health. Resident #4 was assessed by the Registered Dietician as requiring 2200cc (cubic centimeters) of fluids per day. Facility staff would document Resident #4's intakes for meals and during medication pass, but there was no evidence that staff would calculate daily totals or analyze the data collected. Record review found that Resident #4 frequently had intakes well below her assessed needs. Resident #4 was hospitalized and diagnosed with [REDACTED]. Upon discharge from the hospital, the facility did not diligently assess her intakes and conduct a critical nursing analysis to determine if Resident #4 was meeting her fluid needs. This is evidenced by: Resident #4 has medical [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #4: ~Is totally dependent on staff for mobility and eating; ~Has both short-term and long-term memory deficits; ~Is moderately impaired for daily decision-making; ~Has a Stage 3 pressure ulcer on her right buttocks; ~Receives a pureed diet with thickened liquids; and, ~Currently weighs 176 pounds. Surveyor # reviewed Resident #4's MDS dated [DATE] and noted that Resident #4's weight at that time was 184 pounds. On 3/24/11 Resident #4's primary physician saw her. According to the progress note, last labs were reviewed from 2/24/11 and indicates [MEDICAL CONDITION] (low sodium levels) related to [MEDICATION NAME] use. Resident #4 generally runs a sodium level of 134. Her BUN (Blood Urea Nitrogen) was 15, and Creatinine was 0.8. On 7/14/11 Resident #4's physician saw her and according to the progress note, Resident #4 was doing "quite well," appetite was good, needs increased assistance at meals, weight 185, and her vitals signs were blood pressure 110/60 and pulse 70. The physician noted Resident #4 just returned from the flea market where she purchased a few items. On 9/7/11 the physician again saw Resident #4. The progress note states that Resident #4 "...has been going down-hill...she is talking less, is more sluggish, and seems to hang her head. The patient also has been pocketing food more often...weight 176 lbs, B/P 118/60, Pulse 62..." The physician described Resident #4 as being "...frail-appearing...alert, sitting up in her wheelchair with her head hanging down, looking around but rarely speaks..." The physician decreased the dosage of the resident's antidepressant, [MEDICATION NAME], to 20 milligrams daily related to the sluggishness and difficulty eating. On 10/1/11 an open area was noted to Resident #4's right buttocks and the facility updated the physician. On 10/12/11 the Wound Nurse assessed Resident #4's right buttocks and described the wound to be unstageable, as the wound was 100 % covered with yellow nonviable tissue. On 10/19/11 a Foley indwelling catheter was placed to allow for wound healing. The Speech Therapist (ST) also reviewed the resident during the breakfast meal, and noted Resident #4 to be holding food in her mouth and having difficulty initiating swallow. Education to staff was conducted for cueing Resident #4. The ST documented that Resident #4 is at a risk for [MEDICAL CONDITION] and dehydration due to her progression of dementia. Also on 10/19/11, the physician ordered a decrease in the [MEDICATION NAME] to 125 mg (milligrams), 2 tablets three times daily related to weight loss and swallowing problems. He also ordered Prosource Plus, 1 ounce daily to promote wound healing. There were no updates made to Resident #4's care plan as it relates to hydration, even though several risk factors had been identified. On 10/24/11, the facility sent a fax to the physician updating him on a steady weight decline, poor intakes, and that Resident #4 is accepting the supplements. The physician returned the fax asking how the resident could have lost 10 lbs in one week and wrote, "That is not eating anything plus dehydration." He then ordered labs to be drawn. There were no updates made to Resident #4's care plan even though the physician indicated the weight loss was related to dehydration. On 12/1/11 at 9:38 a.m., Surveyor # spoke with LPN-D (Licensed Practical Nurse) and asked who monitors and assesses resident fluid intakes. LPN-D stated that nursing tallies the input from the CNA flow sheet and what was given during medication pass as a total for the shift. This is then documented on the VS (Vital Sign) Record. In reviewing the VS, Surveyor # noted inaccuracies. For instance, the total from the CNA (Certified Nursing Assistant) flow sheets and the MARs (Medication Administration Record) do not equal what is documented on the VS flow sheets. There is no clear indication that staff know the amount of fluids taken in by Resident #4 in any given 24-hour period. The following intakes were documented for Resident #4: 11/1/11: -CNA flow sheet, 1050cc -MAR, 240cc -Total of 1290cc -VS report total, 780cc 11/2/11: -CNA flow sheet, 870cc -MAR, 240cc -Total of 1110cc -VS report total, 900cc 11/3/11: -CNA flow sheet, 1290cc -MAR, 240cc -Total of 1530cc -VS report total, 720cc 11/4/11: -CNA flow sheet, 1170cc -MAR, 240cc -Total of 1410cc -VS report total, 810cc On 11/4/11, the RD (Registered Dietician) assessed Resident #4 and documented that on 10/31/11, the resident weighed 163 lbs., a weight loss of 11% in 90 days, and that she required 2200cc of fluid per day based on this weight. The RD documented that Resident #4 had an unintended weight loss likely due to the progression of dementia with inadequate oral intake, increased nutritional needs for wound healing, and impaired swallowing as demonstrated by holding food in her mouth. The RD recommended providing Resident #4 with Med Pass supplement 90 ml (3 ounces) three times daily and to increase Prosource to 30 ml twice daily (an increase from 30 ml once daily). Review of the care plan found no new approaches or updates related to hydration. 11/5/11: -CNA flow sheet, 1650cc -MAR, 240cc -Total of 1890cc -VS report total, 660cc Using the total from the MAR and the CNA flow sheet, Resident #4 had a fluid intake deficit of 310cc. 11/6/11: -CNA flow sheet, 1380cc -MAR, 180cc -Total of 1560cc -VS report total, 1020cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 640cc. 11/7/11: -CNA flow sheet, 1230cc -MAR, 180cc -Total of 1410cc -VS report total, 240cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 790cc. 11/8/11: -CNA flow sheet, 1470cc -MAR, 240cc -Total of 1710cc -VS report total, 740cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 490cc. Also on this date, the physician ordered the facility to follow the above noted RD recommendations; increase the Prosource to 90cc twice daily, and increase Med Pass Supplement to 90cc three times daily. 11/9/11: -CNA flow sheet, 1530cc -MAR, 240cc -Total of 1770cc -VS report total, 660cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 430cc. 11/10/11: -CNA flow sheet, 1530cc -MAR, 360cc -Total of 1890cc -VS report total, 760cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 310cc. Also on this date, the physician saw Resident #4. The progress note indicates Resident #4's blood pressure was 130/72, pulse 68 and weight 160 pounds. The physician's note indicates Resident #4 had an additional 3 pound weight loss in 6 days. 11/11/11: -CNA flow sheet, 1410cc -MAR, 240cc -Total of 1650cc -VS report total, 930cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 550cc. 11/12/11: -CNA flow sheet, 1410cc -MAR, 360cc -Total of 1770cc -VS report total, 630cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 430cc. 11/13/11: -CNA flow sheet, 1410cc -MAR, 360cc -Total of 1770cc -VS report total, 840cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 430cc. 11/14/11: -CNA flow sheet, 1410+cc -MAR, 360cc -Total of 1770+cc -VS report total, 1080cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 430cc. 11/15/11: -CNA flow sheet, 1590cc -MAR, 240cc -Total of 1830cc -VS report total, 780cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 370cc. 11/16/11: -CNA flow sheet, 1110cc -MAR, 360cc -Total of 1470cc -VS report total, 960cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 730cc. 11/17/11: -CNA flow sheet, 1590cc -MAR, 360cc -Total of 1950cc -VS report total, 540cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 250cc. 11/18/11: -CNA flow sheet, 1110cc -MAR, 360cc -Total of 1470cc -VS report total, 420cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 730cc. Also on this date, the facility faxed the physician indicating Resident #4 had a low-grade temperature of 99.0 degrees and her urine was dark and cloudy. A urine dip test was done with findings of specific gravity of 1.030, 3+ bilirubin, + protein, and a ph of 5. The physician replied with a fax ordering "1. CBC (complete blood count), 2. CMP (Complete Metabolic Panel), 3. Urinalysis, 4. Does she have a Foley cath? and 5. Appears by urine and temp and urine that she is very dry. Sp grav (Specific Gravity) = 1.030 !!" This is the second indication by the physician that Resident #4 could be experiencing dehydration or fluid volume deficit. However, no changes were made to Resident #4's care plan related to hydration. 11/19/11: -CNA flow sheet, 810cc -MAR, 320cc -Total of 1130cc -VS report total, 340cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 1070cc. 11/20/11: -CNA flow sheet, 570+cc -MAR, 120+cc -Total of 690+cc -VS report total, 420cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 1510cc. On 11/20/11 the facility faxed Resident #4's physician indicating that the on-call physician was notified of Resident #4's temperature of 100.0 degrees, difficulty swallowing, and refusing to eat. An antibiotic was ordered by the on-call physician. Resident #4's primary physician returned the fax stating, "noted." On 11/21/11, Resident #4 was admitted to the hospital. The admitting B/P was documented as being 143/67, pulse 91, respirations 20. Her mucous membranes were dry and skin turgor was decreased. Labs included: Creatinine at 1.1, (Resident #4's baseline is 0.7) Sodium 161 (normal is 136 -145) **Resident #4's baseline sodium is 134 due to [MEDICATION NAME] induced [MEDICAL CONDITION] Potassium 2.9 (normal is 3.6-5.2) Chloride 122 (normal is 98-108) [MEDICATION NAME] 2.5. (normal is 3.1-5) BUN 48 (normal is 8-21) Phosphorus 1.8 (normal is 2.5-4.6) The emergency room report indicated Resident #4 had a free-water deficit of 6.3 liters, which they were in process of replacing. Labs drawn on 11/22/11 after hydration therapy found: Hemoglobin 11.0 (normal is 11.7-15.5) Hematocrit 34 (normal is 36-46) The Discharge Summary dated 11/23/11, diagnosed Resident #4 as having Profound Dehydration, a Urinary Tract Infection, [MEDICAL CONDITION] (high sodium levels), and Acute Kidney Injury second to Dehydration. On 11/23/11 the hospital physician handwrote orders for the facility. Included in this note was the following directive: "Keep oral fluid intake high (only with assist)." The hospital also held the resident's scheduled Furosamide (diuretic/fluid depleting) and [MEDICATION NAME] (used to treat high blood pressure). After Resident #4 returned to the facility, the facility made no changes to Resident #4's care plan related to hydration, or how staff were to monitor and analyze her fluid intakes. The intakes continued to be documented on various flow sheets and reports. 11/24/11: -CNA flow sheet, 1230cc -MAR, 360cc -Total of 1590cc -VS report total, 660cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 610cc. 11/25/11: -CNA flow sheet, 1290cc -MAR, 360cc -Total of 1650cc -VS report total, 1200cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 550cc. 11/26/11: -CNA flow sheet, 9900cc -MAR, 360cc -Total of 1350cc -VS report total, 1080cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 850cc. 11/27/11: -CNA flow sheet, 1100cc -MAR, 360cc -Total of 1470cc -VS report total, 960cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 730cc. 11/28/11: -CNA flow sheet, 1290cc -MAR, 420cc -Total of 1710cc -VS report total, 1920cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 490cc. 11/29/11: -CNA flow sheet, 1470cc -MAR, 360cc -Total of 1830cc -VS report total, 1140cc Using the MAR and CNA flow sheet totals, Resident #4 had a fluid intake deficit of 370cc. On 12/1/11 at 9:00 a.m., Surveyor # interviewed the DM (Dietary Manager) and DON (Director of Nursing) regarding the monitoring of fluid intakes on Resident #4. Both staff indicated the Registered Dietician (RD) is in the building once monthly and does the resident calculations of dietary food and fluid needs. Surveyor # asked how staff monitor and assess whether Resident #4 is meeting her calculated fluid intake needs. Both staff indicated the CNAs (Certified Nursing Assistants) calculate what they have given the resident at meals and in between meals on a log in the resident's room. They also stated that nurses give fluids with medication passes and they calculate the intakes on the Medication Administration Record (MAR). The DON indicated that when a resident is noted to not be taking fluids offered, the physician is updated and supplements are added and the RD then becomes involved, or speech therapy may be consulted to conduct swallow studies. The DON and DM indicated that residents with fluid intake risks are reapproached and reoffered fluids continually throughout the day in order to encourage intakes. Surveyor # requested any additional documentation of Resident #4's fluid intakes. Surveyor # also asked for evidence that the resident's fluid intakes are being monitored and analyzed. On 12/1/11 at 9:28 a.m., Surveyor # asked CNA-B how they document fluids accepted by residents. CNA-B stated they document all the fluids they have given a resident on the flow sheet. CNA-B indicated these intakes include fluids with meals and in-between meals. On 12/1/11 at 9:38 a.m., Surveyor # asked LPN-D how nursing monitors and assesses resident fluid intakes. LPN-D stated nursing tallies the input from the CNA flow sheet and what was given during medication pass as a total for the shift. This is then documented on the VS Record. (This was not accurately completed as demonstrated above.) On 12/1/11 LPN-D stated the RD is the person who calculates whether a resident is meeting the assessed needs. She also stated the RD is in the building once a month. LPN-D stated nursing does not do the fluid assessment each shift to determine if needs are or are not being met. On 12/1/11 at 10:50 a.m., Surveyor # was approached by the DON and NHA for clarification on what was requested earlier. Documentation was presented indicating physician orders [REDACTED].# already reviewed. Surveyor # stated Resident #4 is a high risk for further dehydration, and since hospitalized for [REDACTED].#4 is meeting the RD's estimated fluid intake needs. The NHA and DON both indicated this is not being done and there is no policy on how to conduct this monitoring. They stated staff do not assess from shift to shift or on a daily basis, only that resident intakes are put into the computer on the VS Report at the end of each shift. In reviewing the above presumed fluid intake recordings, the evaluator cannot determine if what is documented on the MAR includes that from the CNA flow sheet or fluids given at other times throughout the day. There is no true nursing evaluation of what Resident #4 had actually taken in on any given day. One cannot clearly summarize true fluid intake, as fluids are documented in various places (VS Record, CNA Flow Sheet, and MAR), and nursing does not conduct true Intake and Output assessments by compiling data, recording total intake, and then formulating a nursing analysis and a plan on how the facility will increase fluid intake.