Every finding on record at North Central Health Care

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This had potential to affect all 28 residents (R). -The facility did not have an accurate and complete infection surveillance process in place for months the reviewed of March 2026-August 2026.-R32 was not added to the line list for their related respiratory infection in April 2026.Findings include:Facility policy titled, Infection Prevention & Control Plan, with revision date of 12/10/2025, states: 4.2 The Infection Control Practitioner (ICP) will:4.2.7 Collection and analysis and documentation of infection data from surveillance, prevention, and control activities to be used for improving outcomes. Surveyor noted that this policy does not outline when and what is surveilled. Facility policy titled Antibiotic Stewardship, with revision date of 4/2/2025, states in part: B. SURVEILLANCE OF ANTIBIOTIC UTILIZATION and ORGANISMS1. Two (2) line lists of residents will be maintained.a. A confidential line list of residents known to carry an MDRO (multi-drug-resistant organism).b. A real time' line list of antibiotics ordered in the facility.2. Monthly Surveillance includes:a. Antibiotics orderedb. Micro-organism prevalencec. Susceptibility patternsd. Ordering physicianse. Duration of treatmentf. Proximity of like organisms On 8/26/26 at 9:02 AM, Surveyor reviewed the Infection Prevention Line List. The facility's line list includes columns to track the following pieces of data: resident name, room number, date of onset, type of infection, site of infection, date of culture, pathogen identified, antibiotic resistance, antibiotic received, antibiotic start and end dates, number of days on antibiotics, met infection definition, the isolation type, and if McGeer's criteria was met. Line lists reviewed had missing data. There was no tracking of signs and symptoms, date of symptom onset, exposed individuals, if reported to public health, when precautions were removed, or symptoms resolved.~ There was no tracking of signs and symptoms for illnesses being monitored March 2026 - August 2026. All line list entries with date of onset have a date that match date an antibiotic was started. ~ 42 out of 42 illnesses in March did not include tracking of the site of infection, date of infection onset, if there was a culture yes or no and the results, date resolved, isolation type implemented, or if the illness met or did not meet McGeer's criteria for the listed type of infection.~ 47 out of 48 illnesses in April did not have the date of infection onset tracked. No entry tracking if a culture was taken or the pathogen identified if applicable, or the isolation type implemented. 34 out of 48 illnesses did not have documentation if infection met McGeer's criteria for the listed type of infection.~ 5 out of 8 illnesses tracked in May did not document if McGeer's Criteria was met. All 8 did not track the site of infection, date of onset, if a culture was taken or the pathogen identified if applicable, date infection resolved, or type of isolation precautions implemented.~ 25 of 25 illnesses tracked in June did not track if a culture was taken or the pathogen identified if applicable, date infection resolved, or the type of isolation implemented. One list entry did not mark if it met McGeer's criteria or not~ 27 out of 27 illnesses tracked in July did not track if a culture was taken or the pathogen identified if applicable, date infection resolved, or the type of isolation implemented. ~16 out of 16 illnesses tracked in August did not track the date the illness resolved. 9 out of 16 did not track the date of onset. 14 out of 16 did not document the isolation type implemented. 13 out of 16 did not track if a culture was taken or the pathogen identified if applicable. On 8/26/26 at 11:02 AM, Surveyor interviewed current Infection Control Practitioner (ICP) H and Nurse Manager (NM) I regarding the Infection Control Line-List and how the data is used. The current ICP H stated the names are identified for the line list by running the Antibiotic Stewardship report, reviewing the McGeer's screening sheet nurses complete determining interventions related to symptoms, and via information shared during morning report. ICP H stated anybody on an antibiotic is placed on the line list, even if they don't meet McGeer's criteria but the provider still ordered an antibiotic. ICP H stated anybody who meets McGeers, even if they don't want to be treated. If a resident is symptomatic the updated McGeer's criteria form is completed. Surveyor asked what is tracked on the line list. IPC H and NM I stated when the antibiotic started and ended, what antibiotic the resident was on, if they met McGeer's criteria, and what precautions (isolation type) was used. NM I stated they monitor the sheets completed and the line list to watch for potential outbreaks, paying close attention to the column titled unit. ICP H stated they watch for increasing numbers. ICP H state they share monthly data with the Infection Prevention Committee. Surveyor reviewed surveillance logs with ICP H and NM I. NM I stated all illness and data should be entered for surveillance purposes.Example 2R32 was admitted to the facility on [DATE] with COPD, chronic pulmonary edema and tracheostomy.R32's quarterly Minimum Data Set (MDS) assessment, dated 07/28/26, noted a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was unable to be completed. R32 has no speech and limited ability to make requests. R32 is dependent on all Activities of Daily Living (ADLs), receives tracheostomy care and respiratory therapy.On 04/22/26, R32 was transferred to the hospital with symptoms of increased secretions and shortness of breath.Surveyor reviewed hospital records, dated 04/23/26, noted R32 presented with tachypneic respirations in the 30s, hypoxic with oxygen saturation of 88-92% on room air, and in moderate-severe respiratory distress. Lab work was completed and noted positive for Respiratory Syncytial Virus (RSV). R32 was admitted to the hospital with diagnoses of pneumonia with sepsis secondary to acute RSV bronchiolitis and treated with IV antibiotics. R32 was discharged back to the facility on [DATE].Surveyor reviewed infection surveillance line lists for April 2026, and R32 was not on the surveillance list related to R32's RSV infection which resulted in hospitalization.On 8/26/26 at 11:02 AM, Surveyor interviewed current Infection Control Practitioner (ICP) H and Nurse Manger (NM) I regarding the Infection Control Line-List. Surveyor asked ICP H and NM I if residents who are diagnosed and treated while in the hospital are still placed on the line list. NM I stated if they come back from the hospital, NM I still adds them to the list, because they usually are still sick. Surveyor reviewed the line list with ICP H and NM I. NM I stated R32 should have been on the list. NM I stated they never thought they could miss someone with the multiple ways we identify them.On 8/26/26 at 11:34 AM, Surveyor interviewed Director of Nursing (DON) B who stated, actual infections should be on the line list, whether they are treated or not. DON B stated if a resident has been validated by McGeer, it should be on the line list. Surveyor asked DON B if residents would be placed on the line list if they are sent to the hospital, diagnosed and treated before they come back. DON B stated the illness is noted. If they meet criteria for infection, they belong on the line list.

Based on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's (R) choices for 1 of 6 residents (R32) reviewed for immunizations and 1 of 1 resident (R10) reviewed for hospice services of a sample of 28 residents. R32's Power of Attorney (POA) signed a consent for RSV (respiratory syncytial virus) vaccination on 03/17/26. The facility did not review eligibility for vaccination or attempt to administer the vaccination until after survey exit on 08/26/26.R10 did not have a hospice care plan. There was no documentation of communication between hospice provider and the facility related to R10's care. This is evidenced by: Example 1 Facility policy titled, Vaccination Program Policy, dated 09/2025, states: 3.2 [Facility Name] Residents and patients.3.2. 1. Pneumococcal, RSV and shingles vaccines will be offered to all residents for the SNF (Skilled Nursing Facility) programs. 3.2. 1.1 IP (Infection Preventionist) will track vaccinations for SNF residents.SNF's will obtain consents from residents and POA's (Power of Attorney). IP or NH (Nursing Home) staff will then administer vaccinations once consents are completed/received. R32 was admitted to the facility on [DATE] with COPD (chronic obstructive pulmonary disease), chronic pulmonary edema, and tracheostomy. R32's quarterly Minimum Data Set (MDS) assessment, dated 07/28/26, noted a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was unable to be completed. R32 has no speech and had limited ability to make requests. R32 is dependent on staff for all Activities of Daily Living (ADLs), receives tracheostomy care and respiratory therapy. Surveyor reviewed R32's medical record and noted a vaccination consent, dated 03/17/26, signed by R32's activated Power of Attorney (APOA) for Coronavirus (COVID), Tetanus-Diphtheria and Pertussis (TDAP), Prevnar 20, Shingrix, and Respiratory Syncytial Virus (RSV). No documentation was noted verifying R32's eligibility for RSV vaccination. On 08/25/26, Surveyor reviewed R32's Wisconsin Immunization Record (WIR) and noted RSV vaccination had not been completed and 'recommended now.' On 04/22/26, R32 was transferred to the hospital with symptoms of increased secretions and shortness of breath. Surveyor reviewed hospital records, dated 04/23/26, noted R32 presented with tachypneic respirations in the 30s, hypoxic with oxygen saturation of 88-92% on room air, and in moderate-severe respiratory distress. Lab work was completed and noted positive for RSV. R32 was admitted to the hospital with a diagnosis of pneumonia with sepsis secondary to acute RSV bronchiolitis and treated with IV (intravenous) antibiotics. R32 was discharged back to the facility on [DATE]. On 08/25/26 at 3:14 PM, Surveyor interviewed Infection Preventionist (IP) H regarding resident vaccination status monitoring. IP H stated being new to this role and had only been in the role for the past 2 weeks and was not sure who was monitoring completion of vaccinations for residents. On 08/25/26 at 3:22 PM, Surveyor interviewed Director of Nursing (DON) B and Nurse Manager (NM) I regarding resident vaccinations. DON B stated the nurse admitting the resident would review the WIR for vaccination status and reach out to the provider for an order, after the resident is assessed for eligibility, allergies and availability of vaccine. Surveyor asked who was responsible for monitoring completion of vaccinations. NM I stated it used to be them prior to moving into this new manager role and the IP would ensure a consent is signed and then follow-up to put an order in to administer it. Surveyor asked NM I what the expectation would be after signing a vaccination request to receive the vaccine. NM I stated if it is available then the expectation would be to administer the vaccine/s within 2 weeks of receiving consent. Surveyor asked NM I why R32's RSV consent was signed but the vaccination was not administered. NM I stated the consent wasn't received from the POA until May, even though the POA dated it 03/17/26, but it was somehow missed. Surveyor asked if there was any documentation regarding this in R32's record. NM I and DON B stated no. On 08/26/26 at 9:09 AM, Surveyor interviewed Nurse Practitioner (NP) J regarding R32's RSV vaccination. Surveyor asked NP J about the importance of vaccinations. NP J stated the residents in skilled nursing are vulnerable to infections and the goal is to prevent hospitalization and minimize symptoms. Surveyor asked NP J if R32 would be considered vulnerable to contracting infections like RSV without the vaccination. NP J stated R32 is at higher-risk and should get the RSV vaccination, if able. After survey exited, the facility provided additional documentation. Progress note, dated 08/26/26, the facility contacted R32's POA for verbal consent for RSV vaccine. POA gave their consent. RSV vaccine was ordered and entered into R32's record an alert was flagged noting R32 had an allergy to Tubersol, which is a component in the RSV vaccination. POA was contacted and declined the RSV vaccination. The facility failed to ensure vaccinations were administered per resident or POA wishes. The facility did not attempt to administer the vaccine until it was brought to the facility's attention by the Surveyor. The vaccine was withheld due to contraindications which were not discovered until after survey was completed. Example 2 The facility's policy titled Hospice Services, read in part, Develop Care Plan, in collaboration with Hospice Staff, identify problems, goals, and discipline specific interventions to be incorporated into Facility Care Plan. R10 was admitted to the facility on [DATE], diagnoses including chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). R10's Power of Attorney (POA) was activated on 08/13/26. R10's Brief Interview for Mental Status (BIMS) score was 11/15, indicating moderately impaired cognition. Resident was admitted to hospice on 07/02/26 following a hospitalization for COPD exacerbation. R10's care plan did not include hospice services. On 08/25/26 at 11:53 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C. Surveyor asked CNA C where a resident's hospice care plan would be located. CNA C stated there were no hospice care plans. Surveyor asked CNA C if there were resident care plans outlining services hospice would provide. CNA C stated, For CNAs, we don't have that. On 08/25/26 at 12:01 PM, Surveyor interviewed Licensed Practical Nurse (LPN) D. LPN D stated the facility does have hospice care plans in binders behind the nurses' station. LPN D stated, Some hospice providers are better than others. Surveyor asked LPN D what that meant, and LPN D stated some hospice providers are good about placing information in a resident's hospice binder and some are not. During this interview Surveyor heard Nurse Manager (NM) E contact LPN D on the walkie talkie and ask LPN D if the facility had hospice binders. Surveyor and LPN D walked to the unit R10 resides on. Surveyor observed NM E looking at the nurses' station for hospice binders. Surveyor observed approximately four or five hospice binders. LPN D paged through all the binders and indicated R10 did not have a binder. Surveyor asked LPN D how hospice providers and facility staff communicated and LPN D stated they communicated verbally with each other. Surveyor interviewed NM E about hospice services. NM E stated they were not sure which hospice service provided services for R10. Surveyor asked NM E how often the hospice provider visits or provides services to R10, NM E stated they were not sure, but hospice usually visits facility daily. On 08/25/26 at 1:09 PM, Surveyor interviewed Director of Nursing (DON) B. DON B brought Surveyor hospice binders from other units. DON B stated R10 did not have a binder but brought the other hospice binders for Surveyor to review. DON B did not know where R10's binder was or why it was not present in facility. DON B confirmed hospice communication with facility is usually completed verbally. Surveyor reviewed hospice communication binders for residents residing on other units and did not have concerns.

Based on interview and record review, the facility failed to obtain doctor's orders for the size of the PEG tube and mls to fill the balloon or complete a care plan with interventions for nursing staff to follow for 1 of 2 residents (R5) reviewed with a feeding tube out of a sample of 28 residents. Findings:R5 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 13 which indicated R5 was cognitively intact. R5 had diagnosis of gastrostomy. R5 had doctor's order dated 04/22/2026 for Percutaneous Endoscopic Gastrostomy (PEG) Tube stated: Change tri-funnel gastrostomy tube ____Fr, ____ml balloon, pig tail, mushroom.R5's care plan for alteration in nutrition did not include specific interventions for nursing staff to follow regarding the PEG tube.On 08/26/2026 at 9:19 AM, Surveyor interviewed Registered Nurse (RN) F and asked if the PEG tube became dislodged where they would find in R5's medical chart, the size of the tube and how many milliliters (mls) of air to put in the balloon once inserted. RN F was unable to find the feeding tube size in the medical chart under the doctor's orders or care plan but indicated it may be in the hard chart.On 08/26/2026 at 9:24 AM, Surveyor interviewed Nurse Manager (NM) G and asked where the nurses would find the PEG tube size or the amount of air to fill the balloon. NM G stated if they couldn't find it in the doctor's order or care plan, they would look at the documents when R5 came in February. NM G then called the Health Unit Coordinator (HUC) L who assisted NM G to try and find this information. Neither NM G nor HUC L could find this information. Surveyor asked NM G, the longer you wait to replace this tube as a floor nurse is trying to find this information, what can happen. NM G stated, You can lose the track of the PEG tube.On 08/26/2026 at 11:01 AM, Surveyor interviewed Director of Nursing (DON) B and asked if a resident has a PEG tube should the order and care plan contain the size of the tube and the amount of air in the balloon. DON B stated yes that the physician's order and care plan should include the size of the catheter and the amount of air to instill in the balloon.

Based on interview and record review, the facility did not maintain medical records on each resident which are complete, accurately documented, readily accessible, and systematically organized for 1 of 6 residents (R) for immunizations from a sample of 28 residents (R32).The facility did not ensure R32's medical record included complete documentation of communication with Power of Attorney (POA) regarding vaccination consent.This is evidenced by:Facility policy titled, Medical Record - Content Procedure, with an issued date of 06/23/20, states: 2.2 The medical record shall contain sufficient information identify the individual, support the diagnosis and condition, justify the care, treatment, and services, and document the course and results accurately.R32 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic pulmonary edema, and tracheostomy.R32's quarterly Minimum Data Set (MDS) assessment, dated 07/28/26, noted a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was unable to be completed. R32 has no speech and limited ability making requests. R32 is dependent with all Activities of Daily Living (ADLs), receives tracheostomy care and respiratory therapy.R32's medical record noted a vaccination consent, dated 03/17/26, signed by R32's activated Power of Attorney (APOA) for Coronavirus (COVID), Tetanus, Diphtheria and Pertussis (TDAP), Prevnar 20, Shingrix, and Respiratory Syncytial Virus (RSV). Surveyor was unable to find documentation of the RSV vaccination being administered.On 08/25/26 at 3:22 PM, Surveyor interviewed Director of Nursing (DON) B and Nurse Manager (NM) I regarding R32's RSV vaccination. NM I stated R32's POA frequently delayed in returning forms to the facility and R32's vaccination consent was not received until 05/04/26 - which is the date in R32's medical record of the consent being uploaded. Surveyor asked if this was documented in R32's medical record. DON B and NM I stated no. Surveyor asked if staff had reached out to R32's POA via telephone to obtain verbal consent. DON B and NM I stated yes but thought consent had to be written. Surveyor asked if these conversations with R32's POA were documented in R32's medical record. DON B and NM I stated no. DON B stated these communications should have been documented to demonstrate that staff were following-up with R32's POA and ensuring R32's vaccination status was being addressed timely.

Based on interview and record review, the facility did not conduct a thorough investigation of resident (R) R1's missing money of $115.00 as reported by R1 on 02/13/26. The facility did not interview other residents on unit to ensure no other concerns, risks or trends were identified. The facility policy titled: Nursing Home Abuse, Neglect, Misappropriation, Exploitation, Resident to Resident Altercations, Injury of Uknown Origin, and Caregiver Misconduct, last reviewed on 08/07/25, states in part: 4.3. Prevention and Monitoring: Monitoring will include the identification of any department, caregiver, and/or resident trends. On 01/07/2026, R1 was admitted to facility for orthopedic aftercare. R1's admission Minimum Data Set (MDS) indicated R1 had a Brief Interview for Mental Status (BIMS) score of 14/15 (cognitively intact). On 02/13/26 at approximately 5:30 PM, R1 reported $115.00 was missing from wallet to facility licensed nurse. R1 indicated last time saw the $115.00 was a week prior. The facility immediately reported and initiated an investigation and reported to police department. A thorough search of R1's room was conducted and staff who worked unit between 02/06/26 and 02/13/26 were interviewed. Money was not found. On 03/17/26, Surveyor reviewed the facility's investigation into R1's missing $115.00 and noted the facility did not interview other residents on the unit to ensure additional missing money/property, concerns, risks or trends were identified during the time period. On 03/17/26 at 9:18 AM, Surveyor interviewed R1 regarding missing money. R1 indicated that facility was unable to locate money, but facility did put a lock on bedside drawer if needed. On 03/17/26, Surveyor interviewed R2, R3, and R4 regarding missing money or property with no concerns identified. On 03/17/26, Surveyor observed R2, R3, and R4's bedside drawers with installed locks. On 03/17/26 at 10:51 A.M, Surveyor interviewed Nursing Home Administrator (NHA) A and Social Services (SS) B regarding investigation of R1's missing money and if interviews were conducted with other residents on the unit for potential missing money/property during same time period. NHA A and SS B indicated that residents were not interviewed specifically on this investigation.

The facility did not provide adequate supervision to prevent accidents for 2 of 4 sampled residents (R51 and R3).R51 sustained four falls without adequate supervision or a root cause being determined, the last fall resulted in R51 suffering major injury, causing R51's overall decline and admission to hospice services. This is being cited at actual harm. R3 had multiple falls, the care plan was not updated with the interventions to prevent falls. Findings include: The facility's policy, titled Nursing Home Falls Prevention and Management, revision dates 09/21/23 and 07/31/25, read in part, Fall Huddle is a brief meeting immediately after the fall that includes staff caring for the individual who fell and their family, if able to participate. Implementing interventions, this process includes communicating the interventions to relevant staff, documenting interventions, and ensuring interventions are put into action. Care plan interventions will be monitored for effectiveness and modified as needed. Interventions should be implemented correctly and consistently. [MVCC] will provide adequate supervision to mitigate accidents and falls. The facility's procedure, titled Nursing Home Fall Prevention and Management Procedure, revision dates 09/21/23 and 07/31/25, read in part, Post Fall Review and Management; Interventions must be: Balanced with other priorities of/for the individual. Fall interventions must be put into place to prevent future falls. Team will add any interventions based on the root cause of the fall. Ensure documentation has been completed appropriately, and plan of care has been updated. Example 1 R51 is an [AGE] year-old-female who fell at home, resulting in a right ankle fracture. R51 was hospitalized from [DATE]-[DATE], for a surgical procedure to repair her right ankle. R51's hospital discharge instructions indicated R51 to be non-weight bearing for eight weeks, with a cast to her right ankle. R51 was admitted to the facility on [DATE] for short-term rehab with a goal to return home. Upon admission, R51 was alert and oriented to self and her surroundings but was forgetful at times. R51's diagnoses included dementia, Alzheimer's, depression, and insomnia. On 12/04/24, the facility completed a fall risk assessment, which confirmed R51 was at high risk for falls. R51's base line care plan, dated 12/04/24-12/06/24, included the following: -Skin integrity: Interventions (as applies): dependent for repositioning -ADL status, self-care deficit: Interventions (as applies): bed mobility substantial/maximum assistance, transfers with full body lift and two staff, dressing dependent, hygiene dependent, shower dependent, toileting dependent, wheelchair mobility dependent. -Nutritional Status -Psychotropic drug use -Sleep -Discharge -Bowel and Bladder: Interventions: Bed pan, incontinence briefs, toilet. Resident can express need to void. Prompt to toilet to decrease incontinence. (Note, R51's baseline care plan did not include an area for falls). On 12/05/24 at 4:00 PM, R51 was found on the floor in front of her recliner. R51 stated she didn't like a piece of tape that was on her right ankle cast and was trying to pull it off, she then slid forward onto her buttocks and onto the floor. There was no injury noted. Hoyer sling and chux pad were on the chair underneath R51 at the time of the fall. New Intervention: remove sling and chux pad when in chair. On 12/05/24, following R51's fall, the facility completed a fall risk assessment and R51 continued to be at high risk for falls. On 12/12/24, R51's care plan was updated to include: -FALLS: INTERVENTIONS: Keep call light in reach, keep personal items in reach, low bed, floor mat, occupy resident with meaningful distraction, remove chux and hoyer sling when in recliner. On 01/16/24, R51 attended an orthopedic appointment. R51's cast was removed, with instructions to wear an orthopedic walking boot when up. R51's transfer status was changed from hoyer lift to pivot stand transfer with assistance of one. Staff assistance of one with ADLs. R51 was able to ambulate short distances with walker and staff assistance or use manual wheelchair for mobility. Due to R51 no longer having a cast, and transfer status change from hoyer to pivot transfer, the following were discontinued from her care plan, remove sling and chux when in chair and floor mat. R51's care plan dated 01/01/25-01/30/25 included the following: -12/12/25, FALLS: INTERVENTIONS: keep all light in reach. -12/12/25, keep personal items and frequently used items within reach. -12/12/25, occupy resident with meaningful distractions. On 02/08/25 at 7:00 AM, R51 had her call light on. Staff went to answer and found R51 sitting on the floor next to her bed. R51 stated she ambulated herself to the bathroom and then walked back to her bed. When she went to sit she underestimated the bed and slid to the floor. Upon assessment a skin tear to the back of R51's right hand was noted. An x-ray was ordered and was negative for injury. On 02/10/25, progress notes indicated a new intervention to encourage R51 to call for assistance. Note, this intervention was not added to R51's care plan. On 02/10/25, the facility completed a fall risk assessment, which showed R51 to be a high fall risk. On 02/20/25, R51 was moved from short term rehabilitation to long term care, as discussion with R51/POA/staff, it was determined R51 was not safe to return home. On 02/28/25, R51 attended an orthopedic appointment. R51's walking boot was discontinued. Orders included, R51 may use walking boot as needed for ambulation on uneven ground, weight bearing as tolerated, and continue with therapies. On 02/28/25, R51's care plan included FALLS: -02/28/25, Follow accident and safety standards of care. (Safety and Accident Prevention, Standards of Practice: Falls, use gait belt, keep bed at transfer height, ensure bed wheels are locked before helping resident in/out of bed, lock wheelchair before transfer, use wheelchair pedals for long distances, offer grippy socks or shoes for walking/transferring, maintain a clutter free environment, call light and personal items within reach). (Note, this change was a facility wide change to all resident care plans. The accident and safety standards of care are facility practices and not resident specific. There is no root cause to determine if the fall was related to R51's toileting needs). -02/28/25, See CNA Care Card for resident specific interventions. On 03/08/25, R51's CNA Care Card included FALLS/SAFETY: -Interventions: low bed. On 07/28/25 at 8:45 AM, staff found R51 on the floor next to her bed with her back up against the frame towards the foot of bed and sitting on her butt. R51 stated she just got back from going to the bathroom and was trying to get self up out of bed and slid to the floor. No injuries noted. Progress notes read, Resident is known to self-transfer and not appropriate for a low bed and a mat. Grippy socks were worn during incident. Reminders for resident to use call light for any transfers. Note, this intervention was not added to R51's care plan, R51's care plan was unchanged with no revisions until 08/14/25. There is no root cause to determine if R51 needed a change in her toileting schedule, as again she was trying to get to the bathroom. On 07/28/25, the facility completed fall risk assessment. R51 remained a high fall risk. On 07/30/25, a new BIMS assessment was completed and R51 scored 05/15, indicating severe cognitive impairment. On 08/12/25 at 11:50 PM, R51 was found lying on the floor next to her bed. She was lying on her back with her feet facing the head of the bed. Resident was hoyered back into bed. Bruising noted to right knee 8cm x 4cm blue/purple in color. Bruising to right medial ankle 7cm x 3cm brown/blue in color. Left elbow blood blister dark purple in color 2 cm x 0.3 cm. Left posterior forearm bruise 1cm x 0.7cm red/purple in color. Resident reports pain 10/10 to left hip, unable to move the leg. Provider notified with orders to send to emergency room (ER) for evaluation. On 08/13/25, PROGRESS NOTE: Resident will be returning to facility shortly as family has elected to not pursue surgical option but instead enroll in Aspirus Hospice. Hospice team is not expected until this evening to admit. On 08/13/25, HOSPITAL DISCHARGE SUMMARY: Pt to have significant femur fracture and closed fracture of left pelvis. Orthopedic team was updated on pts wishes and was already considering conservative management for this pt due to severe dementia and advanced age. Will send pt back to facility with a few days of Roxanol and Ativan for pain control. Hospice team will assume care from here on. Hospice orders: d/c'd all oral meds, ordered morphine scheduled every four with as needed dose available every two hours. Ativan scheduled every four hours, with as needed dose every four hours also available. Oxygen via nasal cannula, as needed. On 08/14/25, R51's care plan included FALLS: -02/28/25-08/14/25, Discontinued, Follow Accident and Safety Standards of Care. D/c reason, problem discontinued. -02/28/25-08/14/25, Discontinued, See CNA Care Card for resident specific interventions. D/c reason, problem discontinued. Note, no other changes related to falls on R51's care plan and no root cause determined as to why R51 was getting out of bed. PROGRESS NOTES: -08/14/25, resident has been in bed all day per the orders of hospice. Resident taking comfort meds. She has not appeared to be in any pain, only when staff reposition her. Continues O2 via nasal cannula. Has not had much oral intake, just a few sips of water and juice with medications. -08/14/25, Resident continues to call out during repositioning. Staff were informed to round following pain medication administration to minimize repositioning-related discomfort. Oral care provided during rounding, and a cool washcloth applied to forehead for comfort. -08/15/25, Resident has been mouth breathing. Resident only appears to be in a lot of pain with movement. However, does moan and groan with slight movement as well. No intake of food this shift, and liquids were minimal. -08/18/25, appears to be comfortable, however repositioning is somewhat painful. Hospice remains attentive and did bring in an airbed, however, is not in place yet due to painful repositioning. he does not appear to be in pain at rest but continues to exhibit facial grimacing and moaning during repositioning. On 08/18/25 at 11:00 AM, Surveyor observed R51 in bed. Observed low bed, mattress on floor. R51 was wearing O2 via NC, and R51's door states to speak with family (located in adjacent room, before visiting R51). On 08/18/25 at 11:05 AM, Surveyor interviewed R51's family. Family reported the facility has updated the family after each fall and that interventions were put into place. Family reported R51 was very social, attended all activities, had many friends at the facility, and often encouraged other residents to attend activities. The family will be holding a facility birthday party for R51 on 08/20/25, as they do not believe R51 will live until her 90th birthday, which is at the end of the month. On 08/20/25 at 7:43 AM, Surveyor interviewed hospitality assistant (HA) I. HA I has worked at the facility approximately one year. HA I stated she was familiar with R51. HA I stated HAs are informed after resident care plans are updated, such as after a fall. HA I stated the interventions for R51 were staff reminders for her to call for help, check on her frequently, ask her if she needs to use the bathroom. HA I stated the facility was not using a low bed prior to R51's most recent fall. On 08/20/25 at 7:57 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J. CNA J stated R51 was one assist with cares, would use her call light and sometimes she would self-transfer. CNA J stated, We tried to monitor her often and get in her room right away. CNA J stated staff would lock R51's wheelchair next to her bed, remind her to use her call light, and make sure her shoes are close to bed. Surveyor asked CNA J how she knows these are interventions, and she stated, I guess I don't know to be honest. CNA J reported staff did not use low bed prior to most recent fall. On 08/20/25 at 8:03 AM, Surveyor interviewed Registered Nurse (RN) K. RN K stated R51's interventions were R51 is supposed use call light, staff remind R51 to use call light. RN K stated, Mostly reinforcement to call for help. We have a fall huddle after each fall. A nurse might update care plan or the unit manager. There should be an intervention after each fall, I don't know why they are not in there (EHR). On 08/20/25 at 10:06 AM, Surveyor interviewed Unit Manager (UM) L and Director of Nursing (DON) B. UM L and DON B reported the facility has a performance improvement plan (PIP) in place from 07/30/25, due to identified inconsistencies in falls, appropriate interventions, documentation, and follow through pertaining to falls. Corrective actions: Fall huddles to be completed immediately after fall, Interdisciplinary Team (IDT) review interventions at morning meeting, made changes to fall event template in electronic record on 07/30/25, updated Falls Prevention and Management Procedure 07/31/25. Staff meeting on 08/06/25, discussed PIP. UM L stated they did not update individual resident care plans, specifically did not update R51's fall care plan after 07/30/25. On 08/20/25 at 3:28 PM, Surveyor interviewed RN M, who was the nurse present at the time of R51's fall with major injury. RN M reported she was on another unit when the incident occurred and was updated by the CNA working on the unit. RN M assessed R51, stating R51 was trying to get up when she came into the room. R51 did complain of pain to her hip and provider was updated and ordered to send R51 to ER. RN M stated R51's interventions were low bed, wheelchair next to bed, ensure a clear pathway, and frequent monitoring. RN M stated frequent monitoring on NOC shift is not an appropriate intervention, as there is only a nurse and a CNA on NOC shift, and there are currently 20 residents on the unit. RN M reported R51's bed was in low position when the fall occurred. RN M stated nurses update the care plan with a new intervention, however RN M did not update the care plan as R51 was sent to ER, and that was the immediate intervention. On 08/21/25 at 8:00 AM, DON B provided Surveyor with updated PIP and correction of all resident fall interventions were reviewed and updated as of 08/20/25. On 08/21/25 at 8:52 AM, Surveyor interviewed R51's physician assistant (PA) U. PA U stated she was not aware of R51's multiple falls as she started with the facility in 05/2025. Surveyor discussed with PA U R51's multiple falls with lack of interventions and lack of increased supervision to prevent falls. Surveyor asked PA U if the lack of increased supervision and care plan interventions could have contributed to R51's fall, serious injury, and overall decline. PA U replied, Yes, I see that as a risk. There should be interventions in place. Example 2 R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia with other behavioral disturbance, anxiety disorder, and adjustment disorder with depressed mood. Most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 3/15, which indicates R3 is severely cognitively impaired. On 02/09/25, R3 had an unwitnessed fall in the dining room while leaning in wheelchair to pick up a dropped item. On 02/10/25, a progress note shows an intervention of remind R3 to ask for assistance with picking up dropped items. The intervention was added to the care plan on 03/12/25. On 04/26/25, R3 had an unwitnessed fall while self-transferring to the toilet. On 04/27/25, a progress note shows an intervention of post signage in room to remind R3 to ring for assistance. This intervention was not added to care plan. On 05/10/25, R3 had an unwitnessed fall in the dining room. On 05/11/25, progress notes show interventions of frequent monitoring, continues grippy socks/proper footwear at all times, special cushion properly placed in wheelchair, and remind resident to not lean forward in wheelchair. Frequent monitoring and footwear interventions were not new, and the cushion positioning and reminders not to lean forward, were not added to the care plan. On 06/13/25, R3 had an unwitnessed fall in R3's room. R3 had been incontinent but could not tell staff what R3 was doing when the fall occurred. On 06/13/25, a progress note shows and intervention of remind R3 to use call light for assistance. This intervention was not added to the care plan. R3 has a BIMS of 3, showing severe cognitive impairment. R3 would not be able to recall to use the call light. On 06/13/25, a progress note indicates facility would request a psych medication review. No indication this was completed. On 06/14/25, a progress note shows and intervention of frequent checks. This intervention is not new and does not define frequent. On 06/24/25, R3 had an unwitnessed fall out of bed. On 06/24/25, a progress note showed an intervention of prompt R3 for toileting every 90 minutes and decrease Cyclobenzaprine. These interventions were not added to the care plan. The interventions were marked effective, but the Cyclobenzaprine had not changed yet. On 06/27/25, an intervention of prompt R3 for toileting assist of 1 with instruction. On 08/12/25, R3 had an unwitnessed fall from wheelchair while putting on slippers. On 08/13/25, progress notes indicated interventions of physical therapy and occupational therapy to evaluate and treat and change Cyclobenzaprine to AM shift. These interventions were added to the care plan on 08/20/25, one week after the fall. Of note interventions not added to the care plan are not available for Certified Nursing Assistants (CNAs) to see on the resident care profile. This prevents CNAs from having the knowledge of current interventions to assist R3 to prevent future falls.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. This had the potential to affect all 119 residents in the facility.-Clean linens were not covered in the facility's laundry room where dirty fans were blowing on the linens. Findings:The facility's policy titled Processing of Laundry and Linens, reads in part, . Linens stored in the laundry will be on covered carts. Clean linens will not be stored in areas that contain environmental contamination (air conditioners, chairs, etc.) . On 08/21/25 at 9:16 AM, Surveyor observed an uncovered cart containing clean laundry in clean laundry area. This area had large fans with fuzzy, dirty debris blowing directly down onto the clean, uncovered laundry in a cart. On 08/21/25 at 9:19 AM, Surveyor interviewed Laundry Team Coordinator CC, who stated the clean laundry should have been covered, the fans are dirty and should not be blowing directly on clean laundry. Laundry Team Coordinator CC stated the laundry was just put in there that day and she didn't know why it wasn't covered.On 08/21/25 at 9:24 AM, Surveyor interviewed Environmental Services Manager (ESM), C. ESM C verbalized understanding and stated the expectation would be that the clean laundry would be covered and agrees the fans need to be cleaned and should not be blowing on the clean laundry.

Based on record review and interview, the facility did not ensure each resident (R), or their representative had the right to participate in the care planning process after each Minimum Data Set (MDS) assessment for 4 of 4 residents (R6, R2, R3, and R48) reviewed for care conferences.This is evidenced by:The facility's policy titled Person centered Service Policy dated 04/01/24, read in part. 2. Definitions, Care Plan: An individual plan for each resident describing goals, interventions, approaches built by the Interdisciplinary team (IDT) with input from the resident or resident representative.Resident's Goal: The resident's desired outcomes and preferences for admission, which guide decision making during care planning. Resident's goals may change throughout their nursing home stay and are reviewed quarterly at care conferences.Care conferences for each resident are held annually, change of condition, or other times specified by the IDT or family/resident.Example 1R6 was admitted to the facility on [DATE]. R6's current diagnoses include paraplegia, neuromuscular dysfunction and malignant neoplasm of left kidney. MDS with the assessment reference date (ARD) of 07/22/25 an annual assessment documented a Brief Interview Mental Status (BIMS) score of 10/15, meaning R6 had moderate cognitive impairment.Review of R6's medical record documented MDS assessments were completed with the ARD of 07/16/24 an annual assessment. The IDT care conference meeting met with R6 on 08/29/24.Review of MDS with the ARD of 09/27/24 a significant change in status assessment, 12/16/24, 02/03/25, and 05/01/25 quarterly review assessments and 07/22/25 an annual assessment. R6's medical record did not document R6 was invited or declined a care conference meeting for each MDS. On 08/18/25 at 3:49 PM, Surveyor interviewed R6 about attending care conferences. R6 stated they have not been asked to go to care conferences.Example 2R2 was admitted to the facility on [DATE]. R2's current diagnoses include cystitis, osteoarthritis, chronic pain, nutritional anemia, pressure ulcer of other site, bladder-neck obstruction, disease of intestine, reduced mobility, and insomnia.MDS with ARD of 10/15/24 an annual assessment, 01/09/25 and 04/08/25 quarterly assessments were completed. R2's medical record did not document R2 or resident representative was invited or participated with the care conference meetings for each MDS.Example 3R3 was admitted to the facility on [DATE]. R3's current diagnoses include Alzheimer's disease, dementia, dysphagia, atrial fibrillation, anxiety disorder, adjustment disorder with depressed mood, and benign prostatic hyperplasia.Review of MDS with the ARD of 08/20/24, 02/07/25, 05/06/25, and 07/30/25 quarterly assessments were completed. R3's medical record did not document R3 or resident representative was invited or participated with the care conference meetings for each MDS. Example 4R48 was admitted to the facility on [DATE]. R48's current diagnoses include coronary artery disease, renal insufficiency, and diabetes mellitus.Review of MDS with the ARD of 11/16/24 and 12/12/24 are 5 day assessments, 06/10/25 and 08/15/25 are quarterly assessments completed. R48's medical record did not document R48 or resident representative was invited or participated with the care conference meetings for each MDS. On 08/20/25 at 10:49 AM, Surveyor interviewed Director of Nursing (DON) B, Manager of Nursing Services (MN) Y, and Nursing Home Administrator (NHA) A about care conference meetings involving residents and their representative. DON B stated the care conference meetings are conducted with the resident with the annual assessment. MN Y stated the facility had just started doing in person care conferences. On 08/20/25 at 11:11 AM, Surveyor interviewed Social Worker (SW) H about residents being invited to care conferences. SW H stated invites are for annual, change of condition and admissions. They always have done in person. They have not invited everyone since COVID for quarterly assessments. They don't invite residents on quarterly care conferences. Surveyor asked for documentation of invitations and if residents declined. SW H stated they don't consistently document when invited and declined.

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This had the potential to affect 45 residents who eat on the second floor of the north wing out of 119 residents that reside in the facility.Facility staff did not conduct appropriate hand hygiene and were observed touching foods with contaminated gloved hands. Findings include:Facility's policy titled, Safe Food Handling and Sanitation Policy revised 5/31/2023, states in part, 4. General Procedure.Hands will be washed with warm water, per WI food code . Examples of when hands must be washed: .Any change in task from dirty to clean . touching face or hair.Facility's policy titled, Hand Hygiene revised 8/8/2024, reads in part, 4.1.1 Staff must perform hand hygiene (even if gloves are used): .4.1.1.4 After removing personal protective equipment (e.g., gloves.) 4.2. All staff shall use the hand-hygiene techniques, as set forth in the following procedure: . 4.2.4 Before applying gloves.On 08/19/2025 at 12:04 PM, Surveyor observed Dietary Aide (DA) BB wash hands and apply gloves. With gloved hands, DA BB touched bread bag to set on counter, opened refrigerator door, touching handles, took out container of butter, opened drawer and took out utensils, opened bread bag and with same gloved hands, took out 2 pieces of bread and held them while buttering before placing on griddle. DA BB then opened cheese container, and with same gloved hands, touched two pieces of cheese and placed on bread. DA BB then opened drawer and grabbed spatula. Surveyor observed DA BB wiping her face with gloved hands and then went back into fridge to take out a container of oatmeal, dish it up, put on covers and place in microwave. DA BB then touched surface of microwave. After taking out plates and serving utensils to dish up residents' food, and handing dishes to staff to serve, DA BB then removed her gloves, did not wash her hands, took grilled cheese off the griddle with spatula and plated. DA BB then applied new gloves without washing her hands. On 08/19/2025 at 12:22 PM, Surveyor interviewed DA BB about touching foods after touching unsanitary surfaces. DA BB reported she wasn't told that she had to change gloves after touching surfaces and then touching resident food directly. Surveyor asked DA BB if she was to wash her hands before applying new gloves. DA BB reported yes and stated she did not wash her hands after removing or before applying gloves and should have done so. On 08/20/2025 at 12:50 PM, Surveyor interviewed Dietary Manager (DM) AA who reported the expectation of staff is that they wash their hands before applying gloves, after removing gloves, and that hand hygiene preformed and gloves would be changed after touching face and/or touching contaminated surfaces and before directly touching residents' food.

Based on interview and record review, the facility did not complete the proper discharge process for 5 of 5 residents (R) reviewed for discharge. (R124, R6, R2, R43, R126) R124 transferred out of the facility and did not receive written discharge documentation.R6 was transferred to the hospital on [DATE] and 01/17/25 did not receive written notice of transfer or bed hold reserve payment notice.R2 was transferred to the hospital on [DATE] and did not receive written notice of transfer or bed hold reserve payment notice.R43 was not given a notice of transfer when sent to the hospital on 6/22/25.The ombudsman was not notified of R126's discharge. According to federal regulation 483.15(c)(3), resident/representative needs to be provided with a written Notice of Transfer (and/or discharge as appropriate) in a manner they could understand, and which meets all the notice requirements. Example 1 R124 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes, and heart failure. R124 was discharged to the hospital on [DATE]. R124's Minimum Data Set (MDS) assessment, dated 06/06/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. R124 requires set up help for eating and is dependent on staff for bed mobility, transfers, and toileting hygiene. Surveyor reviewed R124's electronic health record (EHR) and found a progress note dated 08/06/25 at 8:25 AM, stating CNA entered room to assist R124 with AM cares. R124 complained of difficulty breathing. Oxygen saturation was in the 60's, nurse placed on oxygen, called 911, and sent R124 to the emergency room for further evaluation. Family was called and updated. R124 was transferred to the hospital via ambulance; however, there was no written notice of transfer. On 08/20/25 at 1:12 PM, Surveyor interviewed Nurse Manager (NM) G and asked for the written transfer notice for R124's hospitalization on 06/06/25. NM G stated they have not been using a transfer form in writing for the residents for hospital transfers. NM G stated they will develop one and use it going forward. Example 2 R6 was admitted to the facility on [DATE]. R6's current diagnoses include paraplegia, neuromuscular dysfunction and malignant neoplasm of left kidney. R6 was transferred to the hospital and was admitted to the hospital on [DATE] for a change in condition and on 01/17/25 for surgical procedure. Review of R6's medical record documented a bed hold notice for 07/24/24 and 01/21/25 that was signed by Social Worker (SW). The notices were not signed by R6 and was not documented the notice was given to R6. R6's medical record did not document a written reason for transfer/discharge notice was given to R6. On 08/18/25 at 3:49 PM, Surveyor interviewed R6 about receiving written notice of bed hold and reason for transfer. R6 stated have been hospitalized many times and does not recall receiving bed hold notice and only verbally told and understood why going to hospital and needed to go. Example 3 R2 was admitted to the facility on [DATE]. R2's current diagnoses include cystitis, osteoarthritis, chronic pain, nutritional anemia, pressure ulcer of other site, bladder-neck obstruction, disease of intestine, reduced mobility, and insomnia. R2 was transferred to the hospital and was admitted to the hospital on [DATE] for a change of condition. Review of R2's medical record documented a bed hold notice dated 06/30/25 was signed by SW. The notice was not signed by R2 or R2's representative and did not document the notice was given to R2 or R2's representative. R2's medical record did not document a written reason for transfer/discharge notice was given to R2 or R2's representative. On 08/20/25 at 10:49 AM, Surveyor interviewed Director of Nursing (DON) B and Manager of Nursing (MN) Y about written notice of transfer and bed hold notices. MN Y stated will get the information from Social Worker (SW) H. On 08/20/25 at 12:00 PM, SW H provided Surveyor with bed hold notices for R6 and R2 with SW H's signature. On 08/20/25 at 1:25 PM, Surveyor interviewed DON B about the notice of transfer was not given to Surveyor only the bed hold notice. DON B asked what is contained in the notice of transfer and stated the notice probably was not given. Surveyor requested a copy of the facility's policy for notice of transfer. DON B stated there is no policy. Example 4 R43 was transferred to the hospital on [DATE]. On 08/18/25, Surveyor reviewed bedhold notice in R43's electronic record. Surveyor noted the bedhold notice was signed by the facility's social worker (SW) and was unable to find evidence R43 or R43's representative had been notified of the bedhold notice. Surveyor was not able to locate a notice of transfer provided to R43 or his representative in R43's record. On 08/19/25 at 8:15 AM, Surveyor interviewed SW V. SW V reported for residents receiving Medicaid (MA), MA will automatically hold a resident's bed for 15 days. The facility did not provide bedhold notice to R43 or his representative as he receives MA and his bed was automatically held for 15 days. SW V stated if R43's hospital admission would have extended past the 15 days, the facility would have updated R43 or his representative to see what they would like to do. SW V stated R43 would likely not have been able to pay for a bedhold after 15 days, so they would have discharged R43 but allowed him to re-admit. Staff interviews indicated the facility was not completing notice of transfer agreements. Example 5 R126 was admitted to the facility on [DATE], for short-term rehab after surgical repair for right hip fracture. Appropriate discharge planning in place for resident to return to an assisted living facility on 07/17/25. R126 was discharged on 07/17/25. Progress note on 07/17/25, stated in part that R126 was discharged following completion of her rehabilitation program at the facility. Discharge summary completed and signed by resident. No notification to ombudsman of discharge. 0n 08/20/25 at 1:09 PM, Surveyor interviewed Executive Assistant (EA) N. EA N stated they only notify the ombudsman for hospitalizations or emergency room visits.

Based on observations, interviews and record reviews, the facility did not provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 24 residents (R1) reviewed. The facility did not ensure Registered Nurse (RN) E completed training before working on the ventilator unit where R1 resides.R1 was admitted on [DATE] and then readmitted on [DATE], with diagnoses in part: acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, pneumonia, cerebral vascular accident with advance brain injury, Alzheimer's disease unspecified, chronic obstructive pulmonary disorder, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, and persistent vegetative state. R1's respiratory care plan, dated 06/24/25, states,- Maintain patent airway, and adequate ventilation.- Maintain good pulmonary hygiene, keep O2 sats >90%.- Monitor respiratory status with assessments, ventilator management, with use of pulse oximetry, bronchodilator therapy and oxygen therapy as needed.- Suctioning as needed, daily and prn trach care, scheduled and prn trach tube changes.Interviews and Observations On 08/19/25 at 1:15 PM, Surveyor observed Certified Nurse Assistant (CNA) D enter R1's room. R1 was sleeping soundly on ventilator. Surveyor observed tan colored secretions running down R1's edge of mouth and chin. CNA D wiped R1's mouth and continued cares on R1. When CNA D completed cares, CNA D exited R1's room and walked down the hall to next resident.Surveyor never observed CNA D report the secretions coming down R1's mouth unto chin. On 08/19/25 at 1:51 PM, Surveyor interviewed CNA D and asked what CNA D's process is when CNA D sees extra secretions coming out of R1's mouth down chin. CNA D reported to Surveyor that CNAs are trained to suction with visual secretions around lips and outside of mouth. CNA D reported to Surveyor that CNA D didn't feel R1 needed suctioning so just wiped secretions out of R1's mouth. Surveyor asked CNA D does CNA D report the secretions to a nurse at all. CNA D reported that CNA D should have reported this to the nurse on duty but didn't think much of the secretions coming out of R1's mouth. On 08/19/25 at 2:01 PM, Surveyor interviewed RN E and asked if R1 had secretions dripping down face, and CNA D observed this, what would RN E's expectation be. RN E reported to Surveyor that RN E would want CNA D to report this to RN E. Surveyor asked if RN E would then go suction R1's secretions out. RN E reported to Surveyor that RN E would not suction as RN E does not feel comfortable with suctioning. RN E would then call Respiratory Therapist (RT) to come suction. Surveyor asked RN E did RN E receive any training on ventilator and suctioning. RN E reported that RN E did not receive training on this unit and so RN E would not be suctioning R1 if need be. On 08/20/25 at 2:18 PM, Surveyor interviewed Respiratory Therapist (RT) F and asked RT F who trains staff on ventilator unit for ventilator usage and suctioning. Surveyor asked RT F how often the staff is trained. RT F reported to Surveyor that RT F trains all new staff upon hire and annually on ventilator and trach cares. Surveyor asked RT F is its common practice for an RN such as RN E to not be comfortable suctioning a resident on trach and ventilator and to not have the training completed prior to working on the ventilator unit. RT F reported that all nurses are to be trained before they work on the ventilator unit. Surveyor asked RT F if RN E has received ventilator and suctioning training. RT F reported to Surveyor that RT F cannot recall if RN E has received training or not. On 08/20/25 at 2:21 PM, Surveyor interviewed Nurse Manager G and asked how often staff are trained on the vent unit for ventilator and suctioning. Nurse Manager G reported to Surveyor that staff are trained upon hire and annually. Surveyor asked for RN E's training on the ventilator unit. Nurse Manager G reported to Surveyor that Nurse Manger G will gather RN E's training.On 08/20/25 at 3:01 PM, Surveyor received RN E's training from Nurse Manager G. Nurse Manager G reported to Surveyor that RN E did not complete the ventilator and suctioning training before working on the ventilator unit. Nurse Manager G reported the training should have been completed before RN E worked the ventilator unit for her first shift.

Based on observation, interview and record review, the facility failed to ensure standards of practice were followed for verification of gastrostomy placement before medication administration for 1 of 3 residents (R) reviewed for tube feeding. (R105) Registered Nurse (RN) E did not check placement of the G-tube (A G-tube is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) according to professional standards of practice prior to administering medications. Findings include:Surveyor reviewed the facility protocol titled Enteral Feeding, last reviewed on 10/15/21, which states in part, .2.2. Assessment- Checking Feeding Tube Placement: Feeding tubes require initial and ongoing verification to minimize complications. -The position of a gastric feeding tube must be checked:-Prior to each feed.-Before each medication administration.-Before putting anything doe the tube. Gastrostomy Tube (GT)- Correct placement of the feeding tube should be confirmed by:-Checking insertion site at the abdominal wall/-Observing the patient for abdominal pain or discomfort.-Obtaining a gastric aspirate. Checking placement:-Obtain equipment: 60 ml catheter tip, changed every 24 hours, and gloves.-Put tip of the 60 ml syringe into your feeding tube with the plunger in the down position.-Gently pull back on the plunger. You should see stomach fluid(residual) go into your syringe. Gastric aspirate is clear, off white, or grassy green.-Re-instill aspirate. R105 was admitted to the facility on [DATE] with diagnoses in part, acute respiratory failure with hypoxia, multiple sclerosis, quadriplegia, interstitial emphysema, encounter for attention to gastrostomy, retention of urine, dependence on respirator [ventilator] status, dysphagia, pneumothorax bilateral, constipation, unspecified, and contracture, unspecified joint of the hand and lower leg. R105's minimum data set (MDS) assessment confirmed R105 is totally dependent on staff for all cares.Surveyor reviewed R105's care plan, which states in part, *Nutritional Status care plan last reviewed on 06/12/25:-Has noted allergy to nuts- do not provide nut or foods that may contain.-Monitor tube feeding tolerance and adjust as needed.-Monitor weight trends, discuss nutritional approaches with IDT and resident/guardian as needed.-Weight as ordered, monitor labs as needed, report significant weight changes to RD and MD, provide tube feeding and water flushes as ordered.Surveyor reviewed physician orders:-On 06/18/25, Peg tube feeding formula Jevity 1.2 at 45mls/hr continuous every 4 hours.-On 03/22/23, Peg tube feeding residual gastric contents every 4 hours then re-instill.-On 11/19/24, NPO.-On 07/23/25, Metoclopramide hcl 10mg give 10mg three times a day through gastric tube for gastric motility.-On 07/30/25. Simethicone liquid 125mg via gastric tube three times a day for gas and bloating.Interviews/ObservationsOn 08/19/25 at 2:15 PM, Surveyor observed RN E enter R105's room with 4 different liquid medicine cups. Surveyor asked RN E what RN E was doing. RN E reported to Surveyor that RN E needs to administer these medications to R105 via gastric tube. RN E took 60ml syringe of water and pushed through R105's G-tube. Surveyor observed R105 grimace and squint eyes. RN E administered medications and then flushed again with another 60ml syringe of water. RN E exited R105's room. Surveyor did not observe RN E check for tube placement or gastric residuals per facility policy.On 08/19/25 at 3:02 PM, Surveyor interviewed RN E and asked what RN E's process is prior to administering medications through G-Tube. RN E reported to Surveyor that RN E flushed G-Tube with 60 ml of water first, then administered medications and then flushed again with 60ml when all done. Surveyor asked RN E if RN E knows that the facility policy states, To verify tube placement with G-Tube, the G-Tube must be checked prior to each feed, and before each medication. RN E reported to Surveyor that RN E did not realize verifying placement was a must before administering medications. RN E apologized to Surveyor that RN E did not perform this task.On 08/19/25 at 3:22 PM, Surveyor interviewed Nurse Manager G and asked Nurse Manager G's expectation for Tube Feeding (TF) procedure and if expectation is for nursing staff to check residuals before administering medications or providing feedings. Nurse Manager G reported to Surveyor that all nurses are trained in verifying placement of G-tube by aspirating gastric contents and checking residuals before administering medications or jevity. Nurse Manager G reported that RN E should have checked resident's residuals before administering medications. Surveyor requested the TF policy.

Based on observation, interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections from the catheter, for 1 of 3 residents (R), (R2) reviewed with a Foley catheter.This is evidenced by:Facility policy titled Urinary Catheters revised date 08/06/25, read in part.General Care. Follow enhanced barrier precautions, perform handy hygiene before and after.Emptying of Bag.Disinfect the drainage port with an alcohol-based wipe after each use.R2 was admitted to the facility on [DATE]. R2's current diagnoses include cystitis, bladder-neck obstruction, disease of intestine, and reduced mobility. Minimum Data Set (MDS) dated [DATE] a significant change assessment documented R2's Brief Interview of Mental Status (BIMS) score of 6/15 meaning severe cognitive impairment. R2 is dependent on staff for toilet hygiene and has a urinary catheter.R2 had a hospital admission on [DATE] with diagnoses of urinary tract infection (UTI) and septic shock. On 08/15/25, R2 was seen by urology and was placed on an antibiotic for UTI. On 08/20/2025 at 8:16 AM, Surveyor observed Certified Nursing Assistant (CNA) Z provide R2's morning cares. CNA Z sanitized hands, applied gown and gloves, and entered room. CNA Z gathered basin water, washcloth and soap. CNA Z picked up the fall mat from the floor to move the mat to the side. CNA Z removed pillows between R2's legs and under left arm. CNA Z completed R2's upper body cares. With the same gloves, CNA Z washed R2's groin and penis. CNA did not complete cleaning of the urinary catheter tubing. CNA Z rolled R2 to the right side and washed buttocks. CNA Z called for a nurse to look at buttock wound and to apply cream. CNA Z did not remove gloves and sanitize hands after peri care. CNA Z applied R2's sock and went to the bathroom to get a urinal and alcohol wipes. CNA Z place the urinal directly on the floor. With the same contaminated gloves, CNA Z removed the catheter port from catheter bag, wiped the port with an alcohol wipe and emptied the urine into the urinal. With the same alcohol wipe, CNA Z cleaned the catheter port and placed the port back into the catheter bag holder. CNA Z measured urine to be 475 cc yellow urine and emptied the urine into toilet and rinsed urinal. CNA Z removed gloves and washed hands. CNA Z rinsed hands, turned the faucet off with clean hands and then sanitized hands. On 08/20/25 at 9:10 AM, Surveyor interviewed CNA Z about hand hygiene after providing peri care. CNA Z stated should have removed gloves and sanitized hands after peri care. Surveyor asked CNA Z if a barrier should have been placed under the urinal when placed on floor and emptying the catheter bag. CNA Z stated a barrier should have been placed under the urinal on the floor. Surveyor asked when cleaning the catheter port with an alcohol wipe is it appropriate to use the same alcohol wipe to clean the port after emptying. CNA Z stated had not been trained to use another wipe to clean the port and it is okay to use the same alcohol wipe. On 08/21/25 at 11:40 AM, Surveyor interviewed Director of Nursing (DON) B and Manager of Nursing (MN) Y about catheter care and hand hygiene practices during cares. DON B stated expectation of hand hygiene after peri care, use of barrier, and a clean alcohol wipe to be used after emptying catheter bag.

Based on observations, interviews and record reviews, the facility did not ensure a resident with limited range of motion (ROM) received the appropriate treatment and services to maintain or prevent further reduction in ROM for 1 of 3 residents (R). (R13)-R13's restorative plan was not implemented. R13 did not receive right hand splint for 10 of the last 19 days. The facility policy, titled Restorative Nursing, dated 01/11/23, states: . Programs are to be planned, scheduled, and documented in the medical record.Team member will complete the Restorative Program as indicated in the Comprehensive Care Plan. Documentation will be completed in Matrix. R13 was admitted to the facility on [DATE], with diagnoses that include stroke with one sided paralysis, Parkinson's disease, encephalopathy, epilepsy, and COPD. R13 had a Brief Interview for Mental Status (BIMS) on 07/15/25 indicating severe cognitive impairment. Minimum Data Set (MDS) assessment, dated 07/21/25, indicates R13 has impaired range of motion (ROM) to all extremities. R13 is dependent on staff for all bed mobility, transfers, toileting hygiene, and eating.On 08/18/25 at 12:15 PM, Surveyor observed R13 in reclining high back wheelchair. Fingers curled tight to both hands and right hand was held tight against R13's chest. No brace or cloth was placed in either hand.Between 08/18/25 through 08/20/25, Surveyor made numerous spot observations, and on 08/20/25 made a continuous observation from 7:00 AM to 12:30 PM, and found R13 had no brace applied to right hand, and no staff attempted to apply the brace. R13's care plan with a revision date of 07/22/25 indicates: Resident requires splint/brace assistance to right hand up to 7 days. Nursing will apply gentle passive ROM to right hand then [NAME] Palm Guard splint into right hand in AM and removal at HS, up to 7 days per week. CHART TIME IT TOOK TO DO ROM, APPLY BRACE AND REMOVE BRACE.Surveyor reviewed care instructions in R13's closet. The care instructions made no mention of hand brace application or removal. Surveyor requested proof that R13 received right hand splint. Staff provided print out for August 2025. 10 of the last 19 days, entries note that it is unanswered or not performed.On 08/20/25 at 8:43 AM, Surveyor interviewed Certified Nursing Assistant DD who was assigned to R13 on that day. Surveyor asked how they are informed of resident's restorative needs. CNA DD replied that it is in the care plan, and the nurses let them know. Surveyor asked to demonstrate where it is documented when completed. CNA DD demonstrated on facility computer: noted under care assessment, under restorative, shows ROM for nurses to complete. Surveyor asked CNA DD to show how CNA DD signs it out, and CNA DD said they cannot because the nurses are to complete it. On 08/20/2025 at 9:32 AM, Surveyor interviewed Licensed Practical Nurse (LPN) EE who reported there is no resident on my unit that the nurses complete ROM for. The CNAs assigned to each resident are responsible to ensure the restorative is completed. Surveyor asked if there is supposed to be a hand splint on R13. LPN EE showed Surveyor a therapy order written on 06/30/22 and verified R13 is supposed to have a right-hand splint on. On 08/20/2025 at 9:32 AM, Surveyor interviewed CNA FF and CNA GG who reported CNAs or nurses can do ROM. R13 should have something in her hands all the time because her hands are so tight, and fingers dig in. R13 has a right-hand splint that goes on during the day and off at night. Sometimes this gets missed because we switch units a lot. We know who needs restorative because it pops up in blue in the computer if something is undone.On 08/20/2025 at 12:33 PM, Surveyor interviewed Director of Nursing (DON) B and Nurse Manager (NM) G was present. Surveyor explained R13's care plan identifies R13 is to receive a splint on right hand on during the day and off at night. None was noted during multiple periodic and continuous checks. Surveyor showed R13's splint sign out sheet for the month of August 2025, R13 did not receive right hand splint for 10 of the last 19 days. DON B asked NM G if they were aware the staff was not completing this. NM G stated they were not aware and would address the issue.

Based on observations, interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being. The facility did not ensure a resident received gastrointestinal (GI) assessments and treatment promptly for bowel issues for 1 of 24 residents (R) reviewed. (R105)Surveyor reviewed the facility protocol titled Bladder and Bowel Management, last reviewed on 08/06/25, which states in part, .Bowel Management-Each shift to review EMR documentation an devaluate need for interventions. If no BM by AM Day 2: Offer/encourage prune juice and increase fluid intake. If not effective by PM Day 2: Offer oral laxative per MD order. If not effective by AM Day 3: Check for stool in rectum, give suppository or enema per MD order. If constipation persists: Evaluate possible contributing factors and initiate interventions. And consult with MD for possible stool softener, etc.R105 was admitted to the facility on [DATE] with diagnoses in part, acute respiratory failure with hypoxia, multiple sclerosis, quadriplegia, interstitial emphysema, encounter for attention to gastrostomy, retention of urine, dependence on respirator [ventilator] status, dysphagia, pneumothorax bilateral, constipation, unspecified, and contracture, unspecified joint of the hand and lower leg. R105's minimum data set (MDS) assessment confirmed R105 is totally dependent on staff for all cares.Surveyor reviewed R105's care plan, states in part, *ADL Care plan last reviewed on 06/12/25:-Toileting assist x1 dependent, undergarments size and type medium. *Respiratory care plan last reviewed 06/12/25:-Monitor respiratory status with assessments, ventilator management, pulse oximeter as needed, suctioning, bronchodilator therapy and O2 therapy as needed, maintain trach with daily prn trach care and tube changes as needed.Surveyor did not find a bowel and bladder care plan. The previous one referred to following standards of care and was discontinued on 03/09/25. CNA care plan:- Toileting assist x1 dependent, undergarments size and type medium.Surveyor reviewed physician orders:-On 03/22/23, Bisacodyl suppository 10mg, give rectal for constipation as needed.-On 03/22/23, Miralax 17gram/dose, give 17 grams for constipation through gastric tube as needed.-On 06/18/25, Peg tube feeding formula Jevity 1.2 at 45mls/hr continuous every 4 hours.-On 03/22/23, Peg tube feeding residual gastric contents every 4 hours then re-instill.-On 06/27/23, Miralax 17 gram/dose, give 16 grams for constipation daily. -On 06/11/25, Docusate sodium liquid 50mg/5ml, give 10ml's three times a day through gastric tube for constipation.-On 11/19/24, NPO.-On 01/27/25, Morphine concentrate 100mg/5ml, give 0.4ml (8mg) sublingual for dyspnea and pain three times a day.-On 06/08/25, Morphine concentrate 100mg/5ml, give 0.4ml (8mg) sublingual for dyspnea as needed.-On 07/08/25, Rectal decompression using 30 fr foley, lubricate and insert as far as possible. Place patient on side for 15-30min, massage stomach, repositioning halfway through. Continue until flatus stops or slows down as needed.-On 07/23/25, Metoclopramide hcl 10mg give 10mg three times a day through gastric tube for gastric motility.-On 07/30/25. Simethicone liquid 125mg via gastric tube three times a day for gas and bloating.Surveyor reviewed R105's Bowel Movement (BM) list:-On 07/18/24-07/22/24: No BM documented.-On 07/23/24-07/26/24: No BM documented. -On 08/13/24-08/16/24: No BM documented. -On 08/21/24-08/24/24: No BM documented.-On 09/06/24-09/09/24: No BM documented. -On 09/09/24-09/13/24: No BM documented. -On 10/04/24-10/06/24: No BM documented. Surveyor did not find a GI assessment completed with tube feeding administration.-On 10/09/24-10/13/24: No BM documented. -On 10/19/24-10/21/24: No BM documented. -On 10/25/24-10/28/24: No BM documented. -On 10/30/24-11/02/24: No BM documented. -On 11/09/24-11/11/24: No BM documented. -On 11/21/24-11/26/24: No BM documented. -On 12/19/24-12/21/24: No BM documented. Surveyor did not find a GI assessment completed with tube feeding administration.-On 03/17/25-03/20/25: No BM documented. Surveyor did not find a GI assessment completed with tube feeding administration. -On 04/01/25-04/03/25: No BM documented.Surveyor did not find a GI assessment completed with tube feeding administration. -On 04/05/25-04/08/25: No BM documented. -On 04/09/25-04/11/25: No BM documented. -On 06/05/25-06/07/25: No BM documented. -On 06/30/25-07/02/25: No BM documented.Surveyor reviewed progress notes, which state in part: -On 07/08/25 at 1:18 PM, Received order for chest x-ray via flat plate due to abdominal distension. Resident did have a large BM on night shift. Abdomen has hypoactive bowel sounds, abdomen distended, not soft to palpation.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/08/25 at 5:53 PM, Resident had breathing episode this afternoon that lasted 1.5 hours. Resident required manual ventilation almost entire time. Each time writer attempted to place resident back on ventilator, his tidal volumes would drop low and he would get gray in color. RN, RN manager, and RT manager all observed at different points during episode. Resident finally settled in after RN placed rectal tube. Abdominal x-ray was also completed during this time. Resident appears comfortable at this time.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/08/25 at 8:47 PM, ABD Xray reads, Colonic ileus. -On 07/08/25 at 10:40 PM, [Recorded as Late Entry on 07/09/2025 00:34]Results for abdominal xray received and send to provider. Patient has a colonic ileus. New order received for patient to be NPO and start IV 0.9 normal saline 1000ml at 100ml/hr; give MOM 30ml x 1 dose, give suppository x1, and to repeat KUB after fluids are done infusing and patient has had bowel movements.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/09/25, Nurse Practitioner note: ***Chief Complaint***Abdominal distention with ventilator desynchrony***Subjective***[AGE] years old male, is seen today for an acute care visit. Over the last 24 hours, he has experienced worsening abdominal distention associated with further increase in ventilator dyssynchrony. He has been having loose bowel movements. Abdominal imaging suggested ileus. His examination shows a distended abdomen, but he does have faint bowel sounds. There is otherwise no change in his mental status.Previously, the patient was seen on 05/28/2025 for worsening spastic episodes and contractions requiring breakthrough dosing of morphine. He has a history of chronic hypoxemic respGASTROINTESTINAL- abdomen distended, but does not appear tender he does have faint bowel sound***Assessment and Plan**** Paralytic ileus *: Patient experiencing worsening abdominal distention associated with ventilator desynchrony. Has been having loose bowel movements. Abdominal imaging suggested ileus. Examination shows distended abdomen with faint bowel sounds present. Will plan to repeat abdominal x-ray imaging today to make sure he does not progress to potential obstruction. Due to his inability to tolerate oral intake will be placed on continuous maintenance IV fluids for the next 48 hours as well. In addition we will check labs today including CBC, BMP, lipase and also lactic acid. His lactic acid is elevated we sent to the emergency department for CT scan imaging of the abdomen pelvis. In the interim if he does have absent bowel sounds or worsening respiratory failure or abdominal distention will also be sent to the emergency room. Will continue with her aggressive bowel regimen IV fluids and bowel rest with daily imaging in the meantime Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/09/25 at 11:31 AM, ABD Xray reads Mild intestinal ileus.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/10/25 at 5:40 PM, GI: Has had 2 large and 1 small BM today. Bowel movements are loose, liquid. Bowel sounds remain hypoactive, abdomen is distended. Tube feeding has been restarted at a rate of 30ml/hr continuously. Will be increased if able to tolerate.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/11/25 at 4:50 AM, GI: Patient continues to have hypoactive bowel sounds in all 4 quadrants. Patient has not had any bowel movements nor urine output from 1800 to current time. TF held x1 for positive residual. Does not appear to be in any pain and sleeping all night long.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/11/25 at 9:08 AM, GI: Has been tolerating tube feeding at a rate of 30ml per hour. Had 5ml residuals. Bowel sounds remain hypoactive but are improving. Abdomen is less distended today. Has f/u KUB this morning.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/14/25 at 7:41 PM, lab results and KUB and chest x-ray with no significant changes noted from previous labs/tests. Labs taken d/t increased edema to right arm, edema in left elbow upper arm (left forearm is contracted and typically curled above his chest), 3+ edema to BLE. Tolerating tube feeding well. Abdomen appears bloated. Continues to have urinary retention and currently has 280cc in bladder. Bowel sounds active. Had large bowel movement early this a.m. Lung sounds has some wetness, however, nothing, unusual for this resident. He does have increased secretions in what sounds tracheal and at times will have secretions pool in his posterior throat/mouth. We will ask our in house provider to take a closer look. VS 97.4-64-18, b/p= 130/73, oxygen sat = 95%, 1 lpm via trach & vent.On 07/17/25 at 4:00 PM, afebrile today. Redness to thigh, trunk comes and goes and is redder at times and lesser at others. No signs of distress today. No bm. Cont to have pitting edema to BLLE and to right arm/hand and distended abdomen. Bowel sounds present. Voiding - foley cath patent.Surveyor did not find a GI assessment completed with tube feeding administration. Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 07/21/25, documented dated 07/16/2025***Chief Complaint***This morning he is awake and alert. His abdomen remains distended but soft compared to the week prior, and he has been having bowel movements.Previously, the patient was seen on 07/09/2025 for abdominal distention with ventilator desynchrony. Abdominal imaging at that time suggested ileus, which appears to have improved with treatment.***Physical Examination***GASTROINTESTINAL- abdomen distended but soft, bowel sounds present***Assessment and Plan**** Paralytic ileus *: Patient's abdominal distention has improved compared to last week. Abdomen remains distended but soft, and patient is having bowel movements. Recent blood work was normal. Will continue with current management including bowel regimen. In addition today we will add in Reglan to see if he can get his bowels moving a little bit more***Follow-up***Facility did not initiate a bowel care plan or implement any new non-pharmacological interventions for routine bowel regimen. -On 08/18/25 at 3:00 PM, Resident resting in bed, appears calm and had 2 very large bowel movements. Earlier today had significant respiratory distress. Resident has history of bearing down and stressful resistance against vent. he typically recovers with suctioning, calm approach, mso4, bagging at times. He required greater time today. He appears to have recovered well.A chest x-ray has been completed to rule out respiratory factors. A KUB was also completed as resident does have history of bowel complications as well. Resident has been having bowel movements regularly.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen affecting respiratory status on ventilator. -On 08/18/25 at 6:46 PM, ABD Xray reads Colonic ileus.Facility did not initiate a bowel care plan or implement any new interventions for routine bowel regimen. -On 08/19/25 at 1:40 AM, KUB and chest xray results received and send on HUCU. Chest x-ray negative. Kub showed colonic ileus, new orders to hold tube feeding and flushes for 24hrs, give IV 0.9NS at 75ml/hr, CBC and BMP in the morning. PIV 22g inserted to right hand, and fluids initiated per order. Resident tolerated well.Interviews/ObservationsOn 08/18/25 at 12:06 PM, Surveyor observed R105's call light going off rainbow colored. Surveyor observed Registered Nurse (RN) W enter R105's room in a rush.On 08/18/25 at 12:08 PM, Surveyor observed Respiratory Therapist (RT) F enter R105's room; R105 was in respiratory distress. Surveyor observed alarms sounding and flashing in R105's room. RT F asked RN W if R105 is constipated, or when was R105's last BM. RN W reported that RN W did now know when last BM was. RT F stated to Surveyor, I know that if [R105] doesn't have a BM for a while he tends to bear down like his body is trying to have a BM and [R105] tends to fight the ventilator. RT F reported to Surveyor that these episodes are becoming increasingly frequent. On 08/18/25 at 1:10 PM, Surveyor observed RT F exit R105's room, and RT F reported to Surveyor that a chest x-ray needs to be ordered right away. On 08/18/25 at 1:47 PM, Surveyor observed ventilator settings going off for R105. RT F, RN W, and Physician Assistant (PA) U entered R105's room. PA U assessed R105's lungs, heart, and BM sounds. PA U ordered chest x-ray and a KUD of the abdominal to see if R105 is full of BM. PA U stated, I understand [R105] has issues fighting ventilator when trying to have a BM. Let's order a KUD to make sure this isn't causing [R105] respiratory issues. On 08/19/25 at 3:22 PM, Surveyor interviewed Nurse Manager G and asked Nurse Manager G how often R105 should have BMs. Nurse Manager G reported to Surveyor that R105 should be having BMs every day since being tube fed, and if not, staff need to report this finding to physician on call, especially since R105 has had bowel issues in the past that effect R105's respiratory status and fighting the ventilator. Surveyor asked Nurse Manager G what expectation is for having a care plan set in place for R105 for bowel management. Nurse Manager G reported that R105 does not have a BM regimen care plan and R105 should have one in place since R105 was admitted with constipation issues. Surveyor asked Nurse Manager G if there was any direction on nursing staff administering the rectal tube to decrease gas in the abdomen for R105 to possibly decrease the extra work R105 is producing when needing to have a BM. Nurse Manager G reported to Surveyor that the order just says use rectal tube decompression as needed with no other parameters. Nurse Manager G reported that Nurse Manager G should notify physician and get that order clarified for better use with R105.

Based on observation, interview and record review, the facility did not ensure 2 of 24 residents (R) reviewed (R18, R19) were provided the necessary services to maintain personal hygiene.-The facility did not develop and implement interventions in accordance with R18's needs related to toileting and repositioning.-The facility did not implement interventions in accordance with R19's assessed needs related to toileting and repositioning.Findings include:R18 was admitted to the facility on [DATE].The Minimum Data Set (MDS) shows a Brief Interview for Mental Status (BIMS) score of 3/15 which indicates R18 is severely cognitively impaired.Facility document titled, Bowel and Bladder Standards of Practice, created on 12/13/24, reads in part: Prompt, offer or assist with toileting with rounding.Facility document titled, Skin Care Standards of Practice, created on 12/13/24, reads in part: Know if your resident has or is at risk of a pressure injury.Keep skin and linens clean, dry, free of wastes, moisture, and drainage.R18's care plan includes a problem of alteration in skin integrity related to decreased mobility and bowel and bladder incontinence with an approach of follow skin standards of care created on 02/27/25.R18's care plan includes a problem containing frequent incontinence of bladder and bowel with an approach of follow bowel and bladder standards of care created on 02/27/25R18's care plan includes a problem of resident specific direct care staff interventions for activities of daily living (ADLs) with an approach of prompted repositioning and assist of 2 for toileting created on 02/27/25. No frequency listed for toileting.Progress note on 08/17/2025 indicated R18 has Moisture Associated Skin Damage (MASD) to left gluteal area, and a reddened groin.On 08/19/25 at 10:19 AM, Surveyor observed R18 sitting in same chair and position since prior to breakfast.On 08/19/25 at 11:08 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O. CNA O stated usually they try to toilet/reposition residents at a minimum of every 2 hours. CNA O confirmed resident was toileted at 10:19 AM. CNA O stated that night shift had gotten R18 up before 6:00 AM and this was the first time R18 was toileted/repositioned on AM shift. CNA O also stated CNA O would try to take R18 to the bathroom one more time before end of CNA O's shift between 1:30 PM and 2:00 PM. Surveyor requested to observe the next toileting.On 08/19/25 at 1:53 PM, Surveyor observed CNA O and CNA P toilet R18. Surveyor observed open/macerated area to buttocks. Red spot comparable in size to a pencil eraser. CNA O stated they have cream that gets applied to R18's bottom. Surveyor observed no cream applied after toileting hygiene completed. R18 assisted back to geri-recliner.On 08/20/25 at 7:35 AM, Surveyor interviewed CNA R. CNA R stated residents are toileted/offered toileting when they get up in the morning and before and after meals. CNA R also stated there are care cards inside each resident's closet door and the nurses update them as needed.On 08/20/25 at 7:40 AM Surveyor interviewed CNA Q. CNA Q stated staff toilet residents every 2 hours or as close as they can to that. CNA Q stated they do rounds and either lay residents down to be changed if they don't use the toilet, or assist residents to the toilet. CNA Q stated they do a check/change on some residents. CNA Q also stated there are care cards inside each resident's closet door or in electronic charting program and they update the nurse with anything different/new.On 08/20/25 at 7:42 AM, Surveyor interviewed Licensed Practical Nurse (LPN) T. LPN T stated that each resident has a toileting care plan, and the expectation is for the CNAs to follow them. LPN T also stated LPN T would expect that if a CNA was falling short on time, they would get LPN T, and LPN T would either find help or provide help. LPN T stated due to some resident's dementia, they may only go to the bathroom once per shift. LPN T stated each care plan is different. LPN T also stated the general rule for toileting is before and after meals and before bedtime. LPN T stated each resident has a care profile in their room/closet and they include everything a CNA would need to know to take care of that resident. LPN T stated the nurses update the care profiles and replace them with new ones as needed. On 08/20/25 at 10:30 AM, Surveyor interviewed Unit Manager (UM) L. UM L stated the CNAs perform routine rounding for toileting which includes when resident gets up in the morning, before and after meals, before bed, and several times at night. UM L stated they do not have actual time frames they use. UM L stated each resident falls into a category for toileting. Independent residents can toilet themselves when needed. Prompted residents are encouraged or prompted to use the toilet at routine round times. Dependent residents are toileted by staff at routine rounding times. UM L was unsure if this is listed on the care profiles for CNAs. Surveyor reviewed care profile for R18. No indication of independent, prompted, or dependent list. Care profile indicates R18 requires assist of 2 for transfers with stand aide, and toileting of 1 assist.Example 2R19 was admitted to the facility on [DATE].MDS shows BIMS score of 9/15 which indicates R19 is moderately cognitively impaired.R19's care plan includes a problem of alteration in skin integrity requiring staff assistance with repositioning with an approach of follow skin standards of care and see CNA care card plan for interventions, created on 02/27/25.R19's care plan includes a problem of risk for alteration in elimination pattern related to decreased mobility and dementia with an approach of follow bowel and bladder standards of care and see CNA care card plan for resident specific interventions, created on 02/27/25R19's care plan includes a problem of resident specific direct care staff interventions for ADLs with an approach of dependent for repositioning, bed mobility, and toileting assist of 2 when asleep and assist of 1 when awake.On 08/19/25 at 7:45 AM, Surveyor observed R19 in bed.On 08/19/25 at 10:54 AM, Surveyor observed R19 remained in bed. On 08/19/25 at 11:06 AM, Surveyor interviewed CNA P. CNA P reported CNA P likes to take residents to the bathroom before and after breakfast and before and after lunch. CNA P stated R19 is sometimes wide awake in the morning, and sometimes R19 is up during the night then likes to sleep in. CNA P stated the last time R19 was changed/repositioned was at 9:00 AM.On 08/19/25, Surveyor observed R19's room from 10:54 AM to 12:36 PM.On 08/19/25 at 12:36 PM, Surveyor observed CNAs O and P enter R19's room to begin cares.Surveyor reviewed resident care profile which indicated assist of 1/dependent, 2 assist at night. No other specific interventions listed.On 08/20/25 at 7:38 AM, Surveyor interviewed R19. R19 stated R19 does not use the bathroom and wears a brief. R19 stated R19 just eliminates in the brief and when staff has time, they come change it. R19 stated it depends who is working on how long of a wait it is. R19 stated R19 only gets changed when in bed. R19 stated once being up in the recliner, R19 usually stays there for several hours.

Based on interview and record review, the facility did not ensure that the PASRR (Pre-admission Screen and Resident Review) Level I screen for 1 of 1 resident (R82) reviewed was conducted accurately for having mental illness or developmental disability.R82's PASRR Level I screen was not completed accurately, resulting in the screen not being submitted to the appropriate agency for further review. Findings Include:The Pre-admission Screen and Resident Review (PASRR) Level 1, revised in 7/2017, states the following: Federal law requires that all persons requesting admission to a nursing facility must be screened to determine the presence of a major mental illness and/or developmental disability. If on the Level 1 a resident is marked for Yes in section A, under Current Diagnosis, then the Level I must be referred to PASRR Contractor for a Level II Screen.R82 was admitted to the facility on [DATE] and has diagnosis of Post Traumatic Stress Disorder (PTSD), depression, alcohol abuse, seizures. R82 has a BIMS of 8/15, meaning moderate cognitive impairment, and a POA for healthcare.R82's Minimum Data Set (MDS) admission assessment, dated 10/19/20, indicated an active diagnosis of PTSD 16100. At time of MDS assessment, R82's BIM score was 15.R82's PASRR Level I Screen, completed on 10/12/20, Section A, part 1 (Current Diagnosis), indicated NO for person having a major mental disorder. No Level II Screen was done.R82's recent care plan, dated 06/11/25, with a target date of 09/30/25, states: Psychosocial Well-Being - I have a Dx of PTSD related to my military service in Vietnam. I am aware of my Dx, have done counseling in the past. I decline discussing my sx or dx further at this time. Approach includes: CNA: Be aware I have a Dx of PTSD. Report to nursing changes in mood, routine, responses to environment, approach or interactions. Identify potential sx such as appearing to feel unsafe, withdrawal, uncharacteristic responses to environment, approach.Surveyor reviewed R82's History and Physical and Hospital Discharge summary, dated [DATE], which indicated a Past Medical History of PTSD and Depression. In reference to the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, PTSD is recognized as a major mental illness.On 08/20/25 at 7:52 AM, Surveyor interviewed Social Worker (SW) H and asked if a PASRR Level I screening was done for a resident with a diagnosis of PTSD, would Section A, be answered as a yes for major mental illness. SW H stated, Yes, it would. Surveyor asked SW H if a Level II screening would be done on a resident admitted with a diagnosis of PTSD. SW H stated, Yes. SW H confirmed R82 had a diagnosis of PTSD upon admission to the facility based off hospital discharge summary and history and physical done 10/12/20. SW H confirmed the Level I was completed inaccurately, and a Level II screen was not done.

Based on interview and record review, the facility did not immediately report to the physician on call for a change in respiratory patterns and gastrointestinal (GI) issues for 1 out of 12 residents (R) (R105) reviewed for change in condition. -Facility did not notify physician on call for the numerous events of Respiratory Therapist (RT) F manually bagging R105 during respiratory distress for long periods of time. -Facility did not notify physician on call for the numerous times R105 had no Bowel Movement (BM) and signs of abdomen distention. Findings include:Surveyor reviewed the facility protocol titled Notification of Change, last reviewed on 07/23/25, which states in part, The nurse will immediately notify the residents physician for the following:-A significant change in residents physical, mental, or psychosocial status (that is deterioration in the health, mental, or psychosocial status in either life threatening conditions or clinical complication).-A need to alter treatment significantly (that is a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment) . R105 was admitted to the facility on [DATE] with diagnoses in part, acute respiratory failure with hypoxia, multiple sclerosis, quadriplegia, interstitial emphysema, encounter for attention to gastrostomy, retention of urine, dependence on respirator [ventilator] status, dysphagia, pneumothorax bilateral, constipation, unspecified, and contracture, unspecified joint of the hand and lower leg. R105's minimum data set (MDS) assessment confirmed R105 is totally dependent on staff for all cares.Surveyor reviewed R105's care plan, which states in part, *ADL Care plan last reviewed on 06/12/25:-Toileting assist x1 dependent, undergarments size and type medium. *Nutritional Status care plan last reviewed on 06/12/25:-Has noted allergy to nuts- do not provide nut or foods that may contain.-Monitor tube feeding tolerance and adjust as needed.-Monitor weight trends, discuss nutritional approaches with IDT and resident/guardian as needed.-Weight as ordered, monitor labs as needed, report significant weight changes to RD and MD, provide tube feeding and water flushes as ordered. *Respiratory care plan last reviewed 06/12/25:-Monitor respiratory status with assessments, ventilator management, pulse oximeter as needed, suctioning, bronchodilator therapy and O2 therapy as needed, maintain trach with daily prn trach care and tube changes as needed.Surveyor did not find a Bowel and Bladder care plan. Previous one referred to following standards of care and was discontinued on 03/09/25. CNA care plan:- Toileting assist x1 dependent, undergarments size and type medium.Surveyor reviewed physician orders:-On 03/22/23, Bisacodyl suppository 10mg, give rectal for constipation as needed.-On 03/22/23, Miralax 17gram/dose, give 17 grams for constipation through gastric tube as needed.-On 06/18/25, Peg tube feeding formula Jevity 1.2 at 45mls/hr continuous every 4 hours.-On 03/22/23, Peg tube feeding residual gastric contents every 4 hours then re-instill.-On 06/27/23, Miralax 17 gram/dose, give 16 grams for constipation daily. -On 06/11/25, Docusate sodium liquid 50mg/5ml, give 10ml's three times a day through gastric tube for constipation.-On 11/19/24, NPO.-On 01/27/25, Morphine concentrate 100mg/5ml, give 0.4ml (8mg) sublingual for dyspnea and pain three times a day.-On 06/08/25, Morphine concentrate 100mg/5ml, give 0.4ml (8mg) sublingual for dyspnea as needed.-On 07/08/25, Rectal decompression using 30 fr foley, lubricate and insert as far as possible. Place patient on side for 15-30min, massage stomach, repositioning halfway through. Continue until flatus stops or slows down as needed.-On 07/23/25, Metoclopramide hcl 10mg give 10mg three times a day through gastric tube for gastric motility.-On 07/30/25. Simethicone liquid 125mg via gastric tube three times a day for gas and bloating.Surveyor reviewed R105's Bowel Movement (BM) list:-On 07/18/24-07/22/24: No BM documented.-On 07/23/24-07/26/24: No BM documented.-On 08/13/24-08/16/24: No BM documented.-On 08/21/24-08/24/24: No BM documented.-On 09/06/24-09/09/24: No BM documented.-On 09/09/24-09/13/24: No BM documented.-On 10/04/24-10/06/24: No BM documented.-On 10/09/24-10/13/24: No BM documented.-On 10/19/24-10/21/24: No BM documented.-On 10/25/24-10/28/24: No BM documented.-On 10/30/24-11/02/24: No BM documented.-On 11/09/24-11/11/24: No BM documented.-On 11/21/24-11/26/24: No BM documented.-On 12/19/24-12/21/24: No BM documented.-On 03/17/25-03/20/25: No BM documented.-On 04/01/25-04/03/25: No BM documented.-On 04/05/25-04/08/25: No BM documented.-On 04/09/25-04/11/25: No BM documented.-On 06/05/25-06/07/25: No BM documented.-On 06/30/25-07/02/25: No BM documented.The MD was not notified on the above incidents when R105 did not have a bowel movement. Surveyor reviewed progress notes, which state in part: On 11/12/24 at 11:48 AM, Resident's ventilator has been alarming on and off since start of the shift at 0600. Resident has required frequent suctioning. Also have removed resident from ventilator and manually bagged 2 different times. 2nd time RT and other staff with resident for about 30 minutes. Resident was clamping down breathing so hard that vent was reading circuit disconnect, even though circuit was intact. RN provided morphine. Resident has complaints of abdominal discomfort and appears somewhat bloated/distended. RN manager also assisting with assessing stomach. Resident eventually calmed down and able to place back on ventilator. Breathing appears to be comfortable and achieving adequate tidal volumes. No further needs.Facility did not notify physician on call of R105's respiratory change during ventilation that required 30 minutes of manual bagging. -On 12/22/24 at 3:46 AM, Vent alarming, writer went to check. Vt 50-80, writer suctioned for moderate amounts of pale yellow. Vt still not returning to baseline. Writer manual vented resident for several minutes. attempted to put back on vent, resident didn't respond. Writer informed RN and RN gave breathing medicine. Writer again manually ventilated. Resident was boosted in bed and resident was placed back on vent with Vt and Vte at baseline. Total time was 30 minutes. Facility did not notify physician on call of R105's respiratory change during ventilation that required 30 minutes of manual bagging. -On 01/18/25 at 3:44 PM, Recorded as Late Entry on 01/31/2025 12:40] 01/18/2025 at 3:44 PM, called to residents room shortly after neb tx was given 30min ago. resident had bronchospasms, very diminished breath sounds, purple in the face. took resident off and bagged until bagging became easier, suctioned small to moderate yellow to clear secretions, breath sounds clear throughout at this point. placed resident back on vent, good return VT/MV. resident comfortable at this point. Respiratory Therapy RT.Facility did not notify physician on call of R105's respiratory change during ventilation that required unknown time of manual bagging or change in lung sounds and respiratory status. -On 01/24/25 at 6:02 PM, Resident had 2 episodes today of being asynchronous with the ventilator. The first episode lasted about 45 minutes. Writer provided suction, cuff adjustment, manual ventilation with Ambu bag, prn albuterol. RT manager assisted and RN provided morphine. Eventually resident was able to synch with vent. RT manager did note suction catheter was more challenging to pass at one point. Readjusted tube and this seemed to resolve the issue. Resident had 2nd episode following his shower. Provided scheduled nebulizer and replaced trach ties. Did deflate cuff and suctioned large amounts of oral secretions. Reinflated cuff and placed washcloth under wye adaptor. Ventilation seems adequate at this time.Facility did not notify physician on call of R105's respiratory change during ventilation that required unknown time of manual bagging or change in lung sounds and respiratory status. -On 01/27/25 at 4:37 PM, Resident vent alarm was alarming overhead. Writer went in to find vent alarming low tidal volume. Writer started by suctioning resident which yielded moderate amount of pale-yellow secretions. Vent was still alarming low tidal volume, so writer adjusted trach tube/trach ties with still no luck. Writer started to bag resident. RN and RN manager came in and helped by giving breathing meds. Resident was still not syncing with vent. After 20 minutes of bagging with no luck, writer called RT manager to help. RT manager took over bagging while writer suctioned. Resident was placed back on vent but still had low tidal volumes and vent started to alarm circuit disconnect. RT manager and writer looked but saw no disconnect. Suctioned again and catheter was not able to pass. Listened to lung sounds which were diminished with little air movement going through. Writer started up scheduled albuterol nebulizer to hopefully open up airways. VS after treatment on RA were O2 94/ HR 73/ RR 18. Tidal volumes continued to be low. Kept bagging resident while trying to suction and catheter still was not passing. RT manager decided to try to change trach tube with writer assisting. After new trach tube was placed, resident was placed back on vent and shortly after vent started alarming low tidal volume again. Began bagging again. RT manager went to get nurse to possibly get x-ray. RN came in to help while getting more VS. Resident was put on 3L of O2 because could not get saturations above 90. RN gave another dose on meds to resident and about 5 minutes later, tidal volumes were back up to 600s and resident was resting comfortably. Will continue to monitor. Total time was 1 hour and 20 minutes.Facility did not notify physician on call of R105's respiratory change during ventilation that required 1 hour and 20 minutes of manual bagging or change in lung sounds and respiratory status. -On 04/28/25 at 5:47 PM, Resident had 2 episodes late afternoon with being found out of synch with ventilator. Writer suctioned trach, provided oral suction, deflated and reinflated cuff, and provided manual ventilation for periods of time. This seemed to resolve his discomfort. No further intervention needed at this time, resting comfortably of ventilator.Facility did not notify physician on call of R105's respiratory change during ventilation that required unknown time of manual bagging or change in lung sounds and respiratory status. -On 05/10/25 at 11:07 AM, Responded to resident's ventilator alarming. Resident attempting to talk and in attempts to do this, was cutting off the ventilator. Deflated cuff and resident asked where his wife was. Writer informed resident that she was unsure. RN also in room to assist and found resident to have bounding heartbeat that seemed irregular. PRN morphine given by RN. After short period of time, HR went back to a normal rhythm. Resident did require manual ventilation for short period of time as well. Eventually settled back into [NAME] with ventilator. No further needs.Facility did not notify physician on call of R105's respiratory change during ventilation that required unknown time of manual bagging or change in heart sounds and respiratory status. -On 05/10/25 at 12:48 PM, Reassessed resident at 1115 and found him to be pale in color. Resident not responsive to resident's attempts to arouse him. Suctioned large amount of white secretions. Pulse oximeter applied to ear and found SpO2 86%, HR to be in 130-140 range. Called RN to room. At this point ventilator started alarming low VTE, min vent, and circuit disconnect. Circuit completely intact. Resident removed from ventilator and manually ventilated. 2nd RN came to assist, obtained albuterol which was given via in-line ventilator circuit. HR came down to 110-120, SpO2 98%. Once treatment was done, SpO2 dropped to 70s and HR went back into 130s. Initiated manual ventilation again. Also used trach tube obturator to verify trach placement, which was appropriate placement. Did several attempts of placing back on ventilator and each time resident not in synch with vent. Started 2nd albuterol treatment and after about 2-3 minutes of treatment, SpO2 dropped to 77%. Manual ventilation started again. After short period of time, resident placed back on vent and able to ventilate appropriately. Stable at this time. Left on 4 L O2, SpO2 98%, HR 115. Checked resident frequently and each time HR was lower. At 1240 oxygen turned off. SpO2 98%, HR 78. Assessed again at 1300 and SpO2 96%, HR 77, RR 18.Facility did not notify physician on call of R105's respiratory change during ventilation that required unknown time of manual bagging or change in heart/lung sounds and respiratory status. -On 05/10/25 at 6:00 PM, TACHYCARDIC EVENT:10:40- Writer responded to RT request to assess resident's HR. Apical and radial pulses palpated and found to be bounding, rapid, and Irregular. Continued for approximately 10 minutes. Abruptly, residents HR returned to normal rhythm and rate. Writer had given PRN MS04 0.2ml about 10 minutes prior. RN from neighboring unit assisted with assessment and plan of care.11:20- RT alerted writer that resident's HR was elevated after hooking him up to ear sat. HR in the 140's, O2 sat maintaining in high 90's on manual ventilation as resident was not syncing with ventilator. Heart sounds auscultated and in normal rhythm. BP 146/88. Pupils pinpoint and not responsive to light. Tongue slightly protruding from mouth. Eyes closed, non-responsive to voice. No indication that resident was in distress.11:40- Scheduled MS04 0.4ml administered. HRR ranging 110-120 on manual ventilation. Pupils 2-3mm, non-responsive to light. Skin returning to normal color. No indication that resident was in distress.12:10- Resident synced with the ventilator, remained on 3Loxygen. O2 sats continue in high 90's. HRR ranging in low 100's. No indication that resident was in distress.12:30- HRR ranging in the 80's. No signs of distress, lying in bed appearing comfortable with eyes closed.12:50- Oxygen removed. HRR ranging in the 70's. No signs of distress, lying in bed appearing comfortable with eyes closed.Resident remained stable rest of shift. Responsive to voice and environment by opening his eyes per his usual.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required unknown time of manual bagging or change in heart/lung sounds and respiratory status. -On 05/26/25 at 5:31 PM, Resident had 3 episodes of being asynchronous with ventilator today. Each time resident required manual ventilation in order to settle back on to ventilator. Resident appears to have increased discomfort due to his neck sore. RN and RT worked together to assess and change dressing to back and side of neck today.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required unknown time of manual bagging or change in heart/lung sounds and respiratory status. -On 05/29/25 at 2:30 AM, Writer responded to resident's vent alarming overhead for low tidal volume, low minute ventilation. He has required inline suction frequently the last few days to maintain tidal volumes above 300mL. His saturation with ear probe registered at 83% on RA. Writer saline lavage and suctioned resident, with difficulty passing closed-suction catheter past end of tracheostomy tube. Writer completely deflated resident's cuff, attempting to pass suction catheter again, with moderate but successful difficulty. Thick clear secretions were yielded; however, resident's color turned to purple. Writer removed resident from ventilator and bagged on flush supplemental oxygen for 2 minutes, returning to 99% SpO2, then on room air while still being bagged for 3 more minutes, resulting with a saturation of 94%. RN administered morphine to relieve desynchrony with ventilator. Writer inspected resident's trach ties to discover that his tracheostomy tube was sticking out from his neck 3/4. History has shown that this leads to vent desynchrony when his trach tube is not flush with his neck. Despite the fact that resident is being treated for a wound under his trach ties, tightening them was necessary to preserve resident's breathing. Writer adjusted resident's trach ties ensuring trach was centered with stoma. Writer placed resident back on ventilator and inflated his cuff with saline to attain an adequate tidal volume and peak flow. Resident was also boosted in bed to alleviate any stress on his diaphragm. He is now resting comfortably.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required unknown time of manual bagging or change in heart/lung sounds and respiratory status until 06/04/25. -On 06/04/25 at 6:38 PM, MD in for rounds today and updated on resident's respiratory status and increased spasms. N.O received for clonazepam BID. reviewed labs and decreased Magnesium to once daily. Writer called and left message for guardian for starting clonazepam. waiting for return call. -On 06/09/25 at 1:30 PM, Resident having episode this morning starting around 10am and lasted for 45min. resident was bagged with O2 due to skin purple in color, suctioned moderate amounts of yellow secretions. would be placed back on vent but would still not have good values on vent. continue bagging thru another episode of discoloration, purple of the face. After doing 3 rounds of bagging, and being placed back on vent, resident then turned pale white in the face requiring more bagging, but not before O2 saturation bottomed out into the 77-83% range. during bagging pink hue returned to face, resident placed back on the vent with 3L O2 added bleed in with saturation at 94%. resident now [NAME] in the low 300s for VT, MV >5lpm.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required unknown time but more than 45 minutes of manual bagging in one episode or change in heart/lung sounds and respiratory status. -On 07/07/25 at 11:02 AM, Resident seems to be having unsettled morning, PRN meds given for breathing as well as bagging for several minutes. VS stable during but Vt drops to 50-150ml needing extra support from writer. Over the weekend it was reported that resident needed to be bagged several times.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required unknown time of manual bagging or change in heart/lung sounds and respiratory status. -On 07/07/25 at 4:57 PM, [resident name] has been having some episodes of increased muscle tensing which is interfering with adequate ventilation and the respiratory therapists are needed to bag him for several minutes. He is being given prn morphine at these times. RT feels the episodes are increasing and staff will be keeping note in case this is indicative of a change. -On 07/08/25 at 1:54 AM, alerted to residents room, return Vt low, suctioned a few times with bagging, after 5 min of manual bagging volumes increased. -On 07/08/25 at 12:11 PM, Resident having difficulty breathing following being changed and repositioned by CNAs. Resident required manual ventilation for several minutes. Suctioned large amounts of pale yellow secretions and copious clear oral secretions. Attempted to placed resident back on ventilator 2 different times after manual ventilation and he would become agitated and out of synch with vent. After 3rd time of manual ventilation, resident relaxed and fell asleep. Placed back on vent and ventilation returned to acceptable tidal volumes. RN also provided resident with prn morphine.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required unknown time of manual bagging or change in heart/lung sounds and respiratory status. -On 07/08/25 at 12:46 PM, Responded to vent alarming again. Resident not achieving adequate tidal volumes. RT manager assisted writer with manual ventilation while writer suctioned trach tube. Suction large white secretions. Provided manual ventilation for several minutes. Placed resident back on vent and tidal volumes consistently high 300 to low 400s. Will continue to monitor.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required unknown time of manual bagging or change in heart/lung sounds and respiratory status. -On 07/14/25 at 7:41 PM, lab results and KUB and chest x-ray with no significant changes noted from previous labs/tests. Labs taken d/t increased edema to right arm, edema in left elbow upper arm (left forearm is contracted and typically curled above his chest), 3+ edema to BLE. Tolerating tube feeding well. Abdomen appears bloated. Continues to have urinary retention and currently has 280cc in bladder. Bowel sounds active. Had large bowel movement early this a.m. Lung sounds has some wetness, however, nothing, unusual for this resident. He does have increased secretions in what sounds tracheal and at times will have secretions pool in his posterior throat/mouth. We will ask our in house provider to take a closer look. VS 97.4-64-18, b/p= 130/73, oxygen sat = 95%, 1 lpm via trach & vent.Facility did not notify physician on call of R105's abdomen appearing bloated. -On 07/22/25 at 1:51 PM, Resident had multiple episodes of not syncing with vent today. Suctioning, bagging, morphine, and repositioning trach were all tried. The only time resident looked comfortable and was syncing with vent was when resident got tired out and was asleep. Writer spent about 1 hour in the morning and 1 hour after lunch trying to get resident to sync. Resident is currently in room, sleeping. VSS HR 63/ RR 18/ O2 98.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required 1 hour each episode of manual bagging or change in heart/lung sounds and respiratory status. -On 07/29/25 at 10:04 PM, entered room for vent alarm, resident bearing down having difficulties obtaining appropriate VT / MV. resident was bagged and suctioned but no improvement, catheter hard to pass due to residents anatomy when bearing down, residents head was slightly lowered and tube readjusted without pulling, resident then relaxed and was able to get appropriate volumes.Facility did not notify physician on call of R105's significant respiratory change during ventilation that required unknown time of manual bagging or change in heart/lung sounds and respiratory status. -On 07/30/25 at 5:05 PM, Resident de-stated to 85% increased to 4lpm, Sp02 rose to 97% will continue on 4lpm.Facility did not notify physician on call of R105's significant respiratory change. -On 08/18/25 at 3:00 PM, Resident resting in bed, appears calm and had 2 very large bowel movements. Earlier today had significant respiratory distress. Resident has history of bearing down and stressful resistance against vent. he typically recovers with suctioning, calm approach, mso4, bagging at times. He required greater time today. He appears to have recovered well.A chest x-ray has been completed to rule out respiratory factors. A KUB was also completed as resident does have history of bowel complications as well. Resident has been having bowel movements regularly. -On 08/18/25 at 4:30 PM, RT note, late entry-- resident having difficulty synching with the vent, having obstruction passing suction catheter, bad return volumes on ventilator, paradoxal breathing on the right side of chest and no breath sounds. resident spasming causing possible bronchospasm as well and throat muscles causing bend in tube which could be why catheter is hard to pass. first suctioning was performed, did not produced any large amounts which would cause the vent values, next trach was changed in effort to bypass obstruction. this was only temporary and resident able to bend tube causing lesser volumes. Albuterol treatment was given to relax bronchials and had no affect, finally after repositioning resident and bagging for an additional 20min, resident was able to be placed back on vent where normal chest excursion returned to bilateral as well as Vt in high 400's to 500. resident more comfortable at this time and resting.Surveyor reviewed notes from communication to provider on 08/18/25, which state in part: .-On 08/18/25 at 1:04 PM, Provider is notified. Resident has been having problems syncing with the vent. Request CXR. RT and nursing in room bagging.-On 08/18/25 at 1:11 PM, Resident has been given PRN and scheduled at 12:40 PM, nurse is thinking may need to give extra dose, can you possibly come talk with nurse.-On 08/18/25 at 1:43 PM, Provider ordered stat KUB due to abdominal distention along with STAT CXR.-On 08/18/25 at 11:43 PM, Provider ordered hold tube feeding and flushes x 24 hours now. Start PIV and infuse 75ml/hr. Daily KUB.Facility did not notify physician on call of R105's significant respiratory change with assessment of paradoxal breathing during ventilation that required 2.5 hours of manual bagging R105 until 1:04 PM which is an hour after manually bagging began. Interviews/ObservationsOn 08/18/25 at 12:06 PM, Surveyor observed R105's call light going off rainbow colored. Surveyor observed Registered Nurse (RN) W enter R105's room in a rush.On 08/18/25 at 12:08 PM, Surveyor observed Respiratory Therapist (RT) F enter R105's room; R105 was in respiratory distress. Surveyor observed alarms sounding and flashing in R105's room. RT F began manually bagging R105. Surveyor entered R105's room to observe respiratory distress and RT F working with R105 in room manually bagging. Surveyor observed many attempts from RT F in manually bagging R105 and trying to reconnect R105 to ventilator. RT F was conversing with RN W in room on what each one thought was going on while manually bagging R105. On 08/18/25 at 12:31 PM, Surveyor observed RT F look around for finger oximeter and then placed on R105's finger. O2 sats were 91% and heart rate 34. RT F continued to manually bag R105 and stated, That is not accurate reading. You must make sure the lines on the screen on the side are flowing consistently for it to be accurate. RT F continued assessing oximeter reading and manually bagging R105.On 08/18/25 at 12:58 PM, RN W called for backup to help manually bag R105 while RT F stepped out to supply room. RN X arrived, placed EBP PPE on and entered room. RT F exited room for more supplies. On 08/18/25 at 12:59 PM, Surveyor heard another staff member in hallway state, I am going to call the doctor now.On 08/18/25 at 1:10 PM, Surveyor observed RT F exit R105's room and report to Surveyor that a chest x-ray needs to be ordered right away. RT F reported that R105 is stable at this moment but during assessment RT F assessed paradoxical in rise and fall of R105's chest. RT F reported to Surveyor that for now we have to wait for chest x-ray and is going to exit and continue down RT F's to do list. Surveyor observed RT F and RN exit R105's room. On 08/18/25 at 1:47 PM, Surveyor observed ventilator settings going off for R105. RT F, RN W, and Physician Assistant (PA) U entered R105's room. PA U assessed R105's lungs, heart, and BM sounds. PA U ordered chest x-ray and a KUD of the abdominal to see if R105 is full of BM. PA U stated, I understand [R105] has issues fighting ventilator when trying to have a BM. Let's order a KUD to make sure this isn't causing [R105] respiratory issues. On 08/18/25 at 2:09 PM, Surveyor observed R105 get back to regular peep, tidal volume on ventilator. Staff repositioned R105. RT F reported to Surveyor that x-ray will be at facility around 2:45 PM/2:50 PM. Concerns of possible Pneumothorax or infection. Surveyor observed RT F exit room while waiting on x-ray. RT F reported that R105 was back to baseline on ventilator breathing and ok for now.On 08/19/25 at 2:57 PM, Surveyor interviewed RT F and asked RT F at what point does RT F contact the physician on call for manually bagging R105. RT F reported to Surveyor that RT F does not notify physician on call and RT F thought nursing staff oversees this with any changes. RT F reported again that RT F does not report to physician on call unless absolutely needing to and that physician on call trusts RT F's judgement to make decisions without physician on call's input. RT F reported to Surveyor that RT F does not have a policy or parameters in place for how long RT F manually bags R105 for, before notifying the physician on call. RT F reported that RT F just continues to manually bag until R105 becomes in sync with ventilator and is stable. On 08/19/25 at 3:22 PM, Surveyor interviewed Nurse Manager G and asked Nurse Manager G what the expectation is for staff to notify physician on call of changes per residents. Nurse Manager G reported that any significant change needs to be reported to physician on call within 15-30 minutes of significant change in status. Surveyor asked Nurse Manager G how often R105 should have BMs. Nurse Manager G reported to Surveyor that R105 should be having BMs every day since being tube fed, and if not, staff need to report this finding to physician on call, especially since R105 has had bowel issues in the past that effect R105's respiratory status and fighting the ventilator. Surveyor asked Nurse Manager G if Nurse Manager G has a policy in place explaining the steps in manually bagging a resident and for how long manually bagging precedes before notifying the physician on call. Nurse Manager G reported to Surveyor that reporting regardless of the change should be completed within 15-30mins of the significant change. Nurse Manager G reported to Surveyor that RT F, RN W, and/or RN X should have notified physician on call within 15-30 minutes of RT F manually bagging R105 on 08/18/25. Nurse Manager G stated, Staff should not be going that long without notifying physician while manually bagging.

Based on interview and record review, the facility failed to ensure a resident utilizing a Hoyer lift for transfers received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R) (R1.) On [DATE], staff transferred R1 utilizing the incorrect sling type during a Hoyer lift transfer from chair to bed. As a result, R1 fell out of the incorrect Hoyer sling, hitting the right side of her face on the leg of the Hoyer lift. R1 had injuries of a nosebleed, and bruising to both eyes, forehead, and cheekbone. R1 expired on [DATE]. The medical examiner documented the cause of death as consequence of witnessed fall and complications of closed head injury. The facility's failure to ensure R1 had the correct type of sling for a safe Hoyer transfer created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on [DATE] at 4:15 PM. The facility took steps on [DATE], immediately after the incident, to correct the deficient practice and to ensure compliance. The immediate jeopardy was removed on [DATE] and the deficient practice was corrected on [DATE]. Based on this determination, the citation issued is past non-compliance. Findings include: The facility policy, entitled Safe Patient Handling and Movement, last revised on [DATE], section 3.5: Common Devices used at NCHC for full body lift states in part, Staff should always ensure correct sling size and type are used .see care plan for specific resident details. On [DATE], Surveyor reviewed R1's medical record. R1 was admitted on [DATE] with admission diagnoses of post femur fracture and anemia. R1 scored ,d+[DATE] during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. In February 2024, staff identified a decline in resident's status. R1 was placed on hospice for failure to thrive, osteoporosis, and weight loss. On [DATE], R1's care plan was updated from a stand pivot transfer to a Hoyer lift transfer with an hourglass sling. This change was made due to increased weakness and R1's inability to support own body weight. On [DATE], R1's care plan was updated from using an hourglass sling to a split leg sling, due to being unsafe because of the way R1 leans forward. On [DATE], R1's Power of Attorney (POA) was updated on R1 being more confused. R1's progress note, dated [DATE] at 6:30 PM, documents Registered Nurse (RN) C and Certified Nursing Assistant (CNA) D transferred R1 from chair to bed using an hourglass sling instead of a split leg sling. R1 leaned forward and fell out of the hourglass Hoyer sling hitting right side of face on the leg of the Hoyer, which resulted in bleeding from the nose. R1 was transferred back to bed, oxygen was administered, and hospice was updated. Vital signs at the time of the incident BP ,d+[DATE], P 156, Temp 102.1, resp 24, and O2 saturation 83%. Oxygen was administered at 2l/min and O2 saturation did not change so it was titrated up to 4l/min. Hospice arrived on [DATE] at 8:15 PM. Hospice talked to family about a possible broken nose. Hospice nurse called on call doctor about the fall and informed the POA/family that R1 was not a surgical candidate. POA/family opted not to send R1 to hospital for x-rays or evaluation. The facility documentation states an investigation began immediately, identifying the wrong type of sling was used for the transfer. The police were called at this time. On [DATE] at 2:27 AM, progress notes indicate R1 had dark purple bruising to both eyes, forehead and cheekbone, nosebleed and appeared swollen and purple with a small cut on the bridge, and signs of pain (grimacing). On [DATE] at 12:27 PM, R1 was placed on bed rest and nothing by mouth except for liquids for comfort due to decline. On [DATE] at 7:15 AM, R1 expired at the facility. On [DATE] at 8:30 AM, Surveyor interviewed CNA D over the phone and asked CNA D to explain the incident regarding R1's fall from the Hoyer lift. CNA D stated R1's daughter approached CNA D to lay R1 down as R1 was having trouble breathing. RN C started oxygen on R1 while R1 was sitting in the recliner. RN C felt R1 would be more comfortable in bed. CNA D stated not being aware of the sling type change because CNA D does not usually work that wing very often. The sling type was not discussed in 72-hour report. On [DATE], Surveyor attempted to contact RN C but was unsuccessful. On [DATE], Surveyor contacted medical director who stated inability to give details as the medical director was out of the country at the time and directed Surveyor to contact hospice. On [DATE] at 2:50 PM, Surveyor interviewed NHA A who had completed a reenactment of the incident. NHA A stated that R1 fell from the lift approximately 2 feet to the floor, hitting head on the leg of the Hoyer lift. On [DATE] at 12:55 PM, Surveyor interviewed Hospice Executive Director (ED) E via phone who stated that ED E was made aware of incident and at time of call did not have a copy of the death certificate or knowledge of medical examiner's result. On [DATE] at 1:00 PM, the facility received a fax of a Wisconsin Death Office Copy. Surveyor reviewed the document dated [DATE] by the medical examiner. The form documents manner of death: Accident Immediate cause: Complication of closed head injury due to or as a consequence of a witnessed fall. The facility's failure to ensure a resident utilizing a Hoyer lift for transfers received adequate supervision and assistance devices to prevent accidents created a reasonable likelihood that serious harm or death would occur, leading to a finding of immediate jeopardy that began on [DATE]. On [DATE], the facility identified the deficient practice when the staff used the incorrect sling type. The facility took steps to correct the deficient practice and ensure compliance on [DATE]. The immediate jeopardy was removed on [DATE] and corrected on [DATE], when the facility completed the following: Corrective actions were immediately put into place on [DATE], to ensure all residents who require mechanical lift transfers have the appropriate sling type and size. Removed Hoyer lift from service to be checked over by Biomed before using again. Removed staff involved from conducting any resident transfers pending investigation. Immediate education provided to all staff working on [DATE] and education continued for all staff as they came onto their shift. Removed full body lift from service to be checked over by Biomed before using again. Education started immediately via a read and sign on PSST (position, sling, size, type) importance of walking rounds and communication. Implemented sling audit to be completed at each shift change during walking rounds to verify correct sling continues to be used. The audit is ongoing and will be evaluated at QAPI. All residents requiring a full body lift or sit to stand lift were audited to validate that the care plan and the sling in the room matched. Educated all staff that slings should be laundered on the unit to always ensure availability of correct slings on the units. Signs were placed in all soiled linens rooms reminding staff to NOT send to central laundry to ensure correct sling size always available. Added hooks to the back of resident room doors to store slings in an easily accessible area. A visual of the sling types was posted on each full body lift. Online education-module was assigned to all nurses and CNAs including agency staff which included lifting techniques and sling details and had acknowledgment of understanding through a post module exam. This education was completed on [DATE], correcting the deficiency. Based on this determination, the citation is issued as past non-compliance.

Based on observation, interview and record review, the facility did not store, prepare and distribute foods in a sanitary manner. The facility's practices have the potential to affect 111 residents who eat orally. Cook F's facial hair/mustache was observed uncovered in the facility's kitchen where foods are prepared and stored. Equipment in the kitchen was observed uncovered while not in use in areas where food is prepared which has the potential for contamination of the equipment. Findings include: Example 1 The facility's policy titled Safe Food Handling and Sanitation dated 5/31/23 in part read: General Procedure: Personal Appearance and Hygiene: Food service employees or any employees serving food to clients/residents .Hairnets shall cover 100% of the hairline, beard nets worn if not shaved. On 6/04/24 at 8:54 AM, Surveyor conducted an initial tour of the kitchen with Cook F. Surveyor and Cook F toured all food preparation and storage areas in the facility kitchen. Cook F was observed wearing a beard net that was worn below a full mustache that was not covered by the net. At no point during the tour did Cook F cover his mustache. Following the tour Surveyor asked Cook F about the facility expectation related to covering of facial hair in the kitchen including his mustache. Cook F responded it is expected all facial be covered in the kitchen including his mustache. On 6/05/24 at 10:43 AM, Surveyor spoke with Supervisor of Nutritional Services (SNS) G and Director of Nutritional Services (DNS) H about the observation with Cook F and the facility expectation related to hair restraint in the kitchen including facial hair. Both SNS G and DNS H indicated it is expected all hair including facial hair be covered in the kitchen. Example 2 The facility's policy titled Safe Food Handling and Sanitation dated 5/31/23 in part read: Definitions: Cross-contamination means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces . Food contamination: means the unintended presence of potentially harmful substances, including but not limited to microorganisms, chemicals or physical objects in food. Cover all equipment with a garbage bag when no in use and at the end of the business day: this includes but not limited to small and large equipment (utensils, can openers, mixers, blenders etc.) On 6/04/24 at 8:54 AM during the initial tour, Surveyor observed a can opener and blender stored on the food preparation sink counter near the sink that has a garbage disposal in the sink. Both were not in use or covered. On the counter in another food preparation area Surveyor observed a small blender and can opener on the counter. Both were not in use and are not covered. Surveyor observed a steam jacket/kettle and robo-coup food processor that was not in use or covered. Surveyor asked Cook F about the equipment that was not in use and not covered. Cook F responded, Good point to cover. Surveyor asked Cook F if not covering the equipment when not in use has the potential for contamination, and Cook F responded there is a potential for contamination. On 06/04/24 at 9:30 AM, Surveyor spoke with SNS G about the expectation of covering equipment in the kitchen when it is not in use. SNS G responded equipment has the potential for contamination and should be covered if not in use. On 06/05/24 at 10:43 AM, Surveyor spoke with DNS H about the facility expectation of covering equipment when it is not in use. DNS H indicated all equipment in the kitchen needs to be covered when not in use.

Based on record review, policy review, and interview the facility did not provide respiratory care for 1 (R1) out of 12 ventilator dependent residents. The systemic failure of all staff to respond to R1's ventilator alarm or call light and to accurately assess the ventilator function placed all 12 ventilator dependent residents at a reasonable expectation for serious harm or death. R1's ventilator alarms were sounding low battery beginning on [DATE] at approximately 6:00 p.m. At 9:30 p.m., R1's ventilator shut off due to power failure. At 9:31 p.m., R1 put his call light on. Staff did not respond to the ventilator alarms or R1's call light once the ventilator turned off. R1 was found unresponsive seated in an electric wheelchair at 9:50 p.m. R1 was pronounced dead at 10:12 p.m. The failure to ensure R1's ventilator was functioning by failing to respond to warning alarms and to R1' call light created a finding of immediate jeopardy, which began [DATE]. The Regional Field Operations Director notified the NHA (Nursing Home Administrator), DON (Director of Nursing), and Regional Administrator of the immediate jeopardy on [DATE] at 11:00 a.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. This is evidenced by: On [DATE], North Winds ventilator unit was staffed with 2 RN (Registered Nurses), 1 RN in training, 2 RTs (Respiratory Therapists), and 3 CNAs (Certified Nursing Assistants) to care for 21 residents. Twelve of the 21 residents were ventilator dependent, including R1. The North Winds call light system and ventilator alarm system were visible and audible out in the hallways on overhead marquees and at the 2 charting stations. The ventilator alarms are gray for low priority, yellow for medium priority, and red for high priority. In addition to the hallway marquees displaying resident needs, the 2 RT staff carried a mobile pager that would signal for any unanswered ventilator alarm. The signal would repeat itself every 2 minutes until the signal was cleared by the RT. According to the facility policy titled Respiratory Procedure-Ventilator Management . RT will carry mobile vent alarm pager which will alert RT if a vent alarm remains on for greater than 2 minutes to provide timely intervention. The pager will not be cleared until after ventilator alarm has been addressed and resolved .Respond to all alarms immediately. R1 was admitted to the facility on [DATE] for long term ventilator dependent care due to DMD (Duchenne [DIAGNOSES REDACTED]). R1 also suffered with [MEDICAL CONDITION] and [DIAGNOSES REDACTED] (heart muscle failure). R1 was dependent on a mechanical ventilator at all times. DMD is a progressive childhood disease ending in death in the 4th decade of life. The cause of death is usually associated with [MEDICAL CONDITION] or a respiratory infection. DMD affects multiple systems as the muscle functions progressively cease. A mechanical ventilator provides life sustaining assistance by breathing in and out for the resident. Upon admission, R1 elected Do Not Resuscitate directives. R1 was capable of making own decisions. R1 was able to make self understood and understand others. R1 was independent in the use of the soft touch call light as well as the sip and blow call light. Review of the care plan initiated in June, 2018 noted R1 required total staff assist for all ADLs (activities of daily living) including eating, toilet use, dressing, hygiene, and bathing. R1 required 2 staff and a mechanical lift for transfers from bed to electric wheelchair. Once in the wheelchair, R1 enjoyed independent mobility throughout the facility. R1 also enjoyed spending time on the computer gaming and on social media sites. The facility submitted a FRI (facility reported incident) to the SA (state agency) on [DATE] which indicated R1 had expired on [DATE] unexpectedly with cause under investigation. The facility conducted a thorough investigation into R1's death and determined R1's death was caused by RT (Respiratory Therapist)-F failure to accurately identify ventilator function and respond to ventilator alarms sounding since approximately 6:00 p.m. on [DATE]. A contributing factor in R1's death was RN-G did not respond to R1's call light. At 9:30 p.m., the ventilator turned off due to power depletion. R1 put on his call light at 9:31 p.m., but no staff responded to the call light until 9:50 p.m. Based on facility interviews, RN-G was at the nurse charting area and aware of R1's call light. At 9:50 p.m., CNA (Certified Nursing Assistant)-H responded to R1's call light and found him unresponsive and without signs of life. CNA-H called for help and a Code Blue was called. RT-F, RN-G, RN-I, and RN-J attempted to resuscitate R1. RT-F stated the ventilator was operating when she removed R1's ventilator connection at the [MEDICAL CONDITION]. RT-F stated she provided rescue breathing via an ambu bag, while RN-G and RN-J assessed for a pulse. RN-I attempted to turn on the ventilator but the screen flashed red as did the battery then turned off again. RN-I noted the power cord was on top of the ventilator. RN-I plugged in the ventilator machine and again turned the machine on. The ventilator machine began to function again and RT-F connected the ventilator machine to R1's [MEDICAL CONDITION]. RN-G telephoned the on call physician who pronounced R1 dead at 10:12 p.m. RT-F disconnected the ventilator machine. The facility interviewed RT-F regarding care provided to R1 on [DATE]. RT-F stated shortly after 6:00 p.m., RT-F entered R1's room and added humidification to his oxygen flow per R1's request. RT-F stated R1 was seated in the electric wheelchair on his computer. At approximately 6:25 p.m., RT-F stated she conducted a respiratory assessment on R1. RT-F stated she noted R1's ventilator was plugged into the wall outlet. This was not accurate as the electrical cord was on top of the ventilator. In addition, the ventilator machine had a green light that turns on when the ventilator was plugged into the electrical outlet and the ventilator screen displayed no battery usage as well. Also, the display window on the ventilator had alarms indicating low detachable battery. RT-F reset these alarms and did not identify the depleting battery situation. RT-F stated she suctioned R1 per his request at 8:30 p.m. and again at 9:30 p.m. According to RTM (Respiratory Therapy Manager)-E, R1's ventilator logs did confirm the 8:30 p.m. suction, but did not confirm the 9:30 p.m. suction. R1's ventilator display window continued to show R1 was using the internal battery, the detachable battery was depleted, and the machine was not plugged into a power source. This information was visible to any RT or RN who interacted with R1 from 6:20 p.m. until when the ventilator turned off at 9:30 p.m. On [DATE] at 10:45 p.m., RTM-E arrived at the facility. RTM-E immediately secured R1's ventilator machine and began reviewing ventilator alarm logs from R1's machine. According to R1's ventilator logs and the facilities investigation, the external or detachable battery was depleted at 6:20 p.m. At that time, R1's ventilator transferred the power source to the internal battery. This battery was the last source of power for the machine. This battery had a life expectancy of approximately 3 hours based on resident usage. R1's ventilator begin to alarm low battery medium priority at 9:08 p.m. when there was 20 minutes of battery life remaining. This alarm rang every 10 seconds for 10 minutes. At 9:18 p.m. the priority of the alarm elevated to high and rang every 5 seconds for 10 minutes. The internal battery was depleted and R1's machine shut off at 9:30 p.m. on [DATE]. Based on the ventilator alarm logs, RTM-E noted R1's ventilator was not plugged into the wall outlet since approximately 7:00 a.m. on [DATE]. RTM-E noted the external detachable battery was depleted at approximately 6:23 p.m. and the internal battery was depleted at approximately 9:30 p.m. and the ventilator turned off. RTM-E confirmed the ventilator was not on and functioning at 9:50 p.m. as RT-F stated. RTM-E noted the ventilator machine sounded low battery alarms for both batteries every 10 seconds for 10 minutes, then every 5 seconds for 10 minutes before turning off, then every 1.5 seconds for 5 minutes after the ventilator turned off due to no battery/power. Review of the call light logs noted R1 activated his call light at 9:31 p.m. The call light remained on and unanswered for greater than 20 minutes before R1 was found unresponsive at 9:50 p.m. R1 expired on [DATE] at 10:12 p.m. due to [MEDICAL CONDITION]. The facility removed the immediate jeopardy on [DATE] when it had completed the following: Education on the responsibility and accountability of each persons role in alarm response, battery usage and AC vent plug in. Initiated maintaining visual of the alarms on the marquee and auditory awareness of alarms when not providing cares. Initiated rounding and vent audit for respiratory therapists and nurses to include q2 hour dual signature review of internal and detachable vent battery life and vent AC plugged in. Ensured alarm volumn and vent settings were appropriate on all residents that require ventilation. Policy updated concerning if resident is placed on heated humidity, vent to be placed back on stand and AC power of ventilator should be connected to the wall ensuring that the cord is intact from vent to wall. Updated and included ventilation power status to be recorded on each ventilator check. This check includes AC power connected, detachable battery bar level, internal battery bar level and battery cycle both internal and detachable. Policy updated concerning the need to document suctioning in the EMAR after each suctioning episode. Policy updated concerning RT mobile vent alarm pager. Pager will alert RT if a vent alarm remains on for greater than 2 minutes to provide timely intervention. The pager will not be cleared until after ventilator alarm has been addressed and resolved. Mobile pager will be handed off at report

Based on observation, record review, staff interviews, the facility did not ensure 1 of 4 sampled residents (R147) reviewed for ventilator/respiratory care received appropriate care consistent with professional standards of practice. This placed R147 at risk for serious harm or death. R147 is dependent on a ventilator for breathing and wishes to receive CPR (cardio [MEDICAL CONDITION] resuscitation). On [DATE], at 2:11 a.m., R147's ventilator began to alarm. RT-B (Respiratory Therapist) did not respond immediately to the alarm as the ventilator log shows the alarm sounded until 2:17 a.m. when RT-B responded and reconnected the ventilator. Although RT-B reconnected the ventilator, there is no evidence RT-B completed an assessment of R147 or took appropriate action until another staff entered the room and turned on the lights to find R147 unresponsive, blue and with eyes fixed. The immediate jeopardy began on [DATE] when RT-B failed to respond to R147's ventilator alarm timely and appropriately and was identified on [DATE]. The NHA (Nursing Home Administrator) and DON (Director of Nursing) were notified of the immediate jeopardy on [DATE] at 12:00 p.m. The immediate jeopardy was removed [DATE], but noncompliance remained at the lower scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its correction plan. This is evidenced by: The facility's policy and procedure, Respiratory Procedure - Ventilator Management/ Weaning Protocol states, Respond to all alarms immediately. If the problem cannot be corrected immediately, remove the resident from the ventilator and artificially ventilate using a resuscitation bag until the problem is corrected. R147 was admitted to the facility on [DATE]. He has [DIAGNOSES REDACTED]. The admission MDS( Minimum Data Set) assessment dated [DATE] indicates R147: ~was able to make self understood and understands others; ~receives oxygen therapy by ventilator; ~Shortness of breath with any exertion, sitting/rest and lying flat. On [DATE], R147 signed the facility CPR Consent indicating he wanted to receive CPR. This was in effect until [DATE], when R147 changed his preference to no CPR and was signed by R147's physician. [DATE] at 6:59 a.m., Surveyor observed R147 during cares. Staff lowered the head of the bed and R147 began to turn grayish/blue, and was in respiratory distress within 15 seconds of lowering the head of bed during reposition change. This demonstrates R147 can desaturate quickly. The facility submitted a self-report to the Department of Health Services on [DATE]. The self-report indicated R147's ventilator disconnected and was alarming for nearly 6 minutes before RT-B responded. On [DATE], Surveyor requested the full completed self report for Alleged Nursing Home Mistreatment, Neglect, and Abuse Report. Surveyor noted the following: ~The ventilator logs validated that on [DATE], R147's ventilator alarm sounded from 2:11:34 a.m. to 2:17:04 a.m. (total of 5.30 minutes) then sounded again from 02:19:05 a.m. to 02:25:40 a.m. ~At the time R147's alarm was sounding, RT-B was on the computer and charting R147's alarm was sounding. RT-B should have known R147 was alarming at the time of chart entry and did not respond. ~CNA-H (Certified Nursing Assistant) stated she saw R147's call light on. RT-B exited R147's room and said something wasn't right, something came unplugged. The lights were off. I turned on the lights .he was blue and his eyes were fixed . CNA-H stated she alerted nursing and grabbed the crash cart. ~RT-B stated in her interview that she didn't realize he was unresponsive . RT-B's statement is not consistent with CNA-H's statement. Based on the facility's investigation, RT-B did not respond immediately to R147's alarm, did not turn on the lights when she entered the room, and did not perform an appropriate assessment if she was unable to determine if R147 was unresponsive. Surveyor reviewed RT-B's note in R147's chart which stated, I was walking down the hallway to check on another resident, when I heard a vent alarm going off, and a humidifier alarm, I entered R147's room and found him disconnected. I reconnected, and he kept alarming low volume and minute volume. I then took him off the vent and started to bag with oxygen at 15+lpm (liter per minute). He was dusky, and had no adaptable pulse, so a code was called, and after one compression he become more responsive, a pulse was found, and he became alert. Lung sounds were barely heard on the right. Ambulance was called and he was taken to hospital. Alarms on the vent were loud and plugged into the wall. RT-B's documentation in R147's chart is not consistent with staff statements in the facility's investigation, the time stamps on R147's ventilator logs and computer documentation logs. On [DATE], RN-A (Registered Nurse) documented a late note from [DATE]. .Resident was disconnected from the ventilator. CNA alerted writer that resident 'didn't look good' RT bagging resident when writer walked into the room. Resident remained alert to name when called but drowsy and lethargic. Pulse was difficult to palpate on left wrist, breath sounds diminished especially in right side. Writer and (a second) RT .began removing pillows and laying head flat, headboard removed and placed behind resident to prepare for chest compressions. RT who was not bagging attempted to give one chest compression and resident grimaced heavily and mouthed the words 'ouch that hurts stop!' Write had pulse oximeter on and saturation read ,[DATE]% and heart rate ,[DATE] bpm (beats per minute). Ambulance arrived and resident transported to ED for evaluation. Resident returned at 0600 (6:00 a.m.) on [DATE]. On [DATE] at 10:05 a.m., Surveyor spoke with the RTM (Respiratory Therapist Manager). Surveyor asked the RTM what the standard of practice is if a resident's ventilator alarm is sounding. RTM stated first thing is to turn the light on if the room is dark so you can clearly see the resident. Directly go to the resident to visualize, listen for any disconnection. Try to arouse resident if unconscious using hands on, if unresponsive, discolored, check pulse. Depending on response will need to bag the resident. On [DATE] 9:45 a.m., Surveyor spoke with RN-A who works the night shift on the unit where R147 resides. RN-A confirmed she worked the night of [DATE]. RN-A stated she was unaware if RT-B did a hands on physical assessment. On [DATE] at 2:18 p.m., Surveyor interviewed CNA-H via phone. CNA-H verified that she worked the night shift on [DATE] on R147's unit. CNA-H stated that she was helping another staff on the other wing and was coming back to answer R147's call light. CNA-H stated RT-B was coming out of R147's room and met me in the hallway. I entered the room and immediately turned the light on and saw that R147 was not responsive and was blue. The only light that was on was by the entry doorway. I asked RT-B if R147 was a code or not. RT-B did not know, I then checked the door frame and he had a heart indicating he was CPR. RT-B was standing by him and asking him, touching his head, shoulder and arm trying to arouse him. I called for RN-A. RT-B did not immediately start bagging him until RN-A walked into the room. The ventilator alarm remained on. I have seen emergency situations before and this should have been an emergency. On [DATE] at 7:55 a.m., Surveyor spoke with RT-F who has worked the day shift on the vent unit for 9 years. RT-T stated if we hear a ventilator alarm, our standard of practice is to assess the resident first, then trouble shoot. If the ventilator is disconnected we reconnect and look at the resident to see if they are unresponsive if so disconnect the ventilator hose and us the ambu bag to administer oxygen. On [DATE] at 8:35 a.m., Surveyor interviewed RT-D regarding answering ventilator alarms. RT-D stated she would look at the resident for color and response, assess why the alarm was on, if the hose was disconnected, reconnect and reset the alarm. You would have to have a light on to see the resident. On [DATE] at 8:41 a.m., Surveyor interviewed RT-C who normally works the night shift. RT-C stated alarms go off a lot. If R147's alarms go off, we check right away. If an alarm goes off, I would have to have the light on to actually look at the resident. If the ventilator is disconnected I would reconnect while looking at the resident. Flip the call light on and get someone to help correct the problems if the alarm goes off again. We have to follow up to see if something else is wrong like the tubes. If there is a problem we would bag immediately to give breaths if not a code. If a code we call a Code Blue which is an medical emergency. Stabilize resident, send out by 911. On [DATE] at 1:32 p.m., Surveyor spoke with the NHA, DON and Nurse Manager for R147's unit. All agreed the initial alarm sounded for nearly 6 minutes. When asked why there was a second alarm at 2:19 a.m., the DON indicated that was presumably when RT-B disconnected the ventilator to begin bagging the resident. This is indicative of RT-B further delaying appropriate care for an additional 2 minutes. The immediate jeopardy that began on [DATE] was removed on [DATE] when the facility 1. Made changes to R147's ventilator circuit to reduce the risk of disconnection; 2. Added speakers to the call system at both nurse's stations of the unit; 3. Educated staff that adequate visualization is necessary to complete an assessment; and 4. Educated staff in immediate alarm response.

Based on interviews and record reviews, the facility did not ensure 1 of 5 staff reviewed for appropriate licensure (Staff-A) had the credentials to work as a Registered Nurse (RN), resulting in the potential for serious harm, injury or death to approximately 100 residents on 3 of 7 units in the facility on which this individual worked. Staff-A was hired to work as an RN in the facility. The Human Resources Recruiter who hired Staff-A did not validate Staff-A's license prior to her start date of 11/2/15. Staff-A left employment on 4/29/16. The facility did not know they had hired an individual who had used another person's nursing license and credentials until contacted by another facility on 8/23/16. The failure to verify the license and credentials of Staff-A created a finding of immediate jeopardy, which began on 11/2/15. The NHA was notified of the immediate jeopardy on 10/13/16 at 2:00 p.m. The immediate jeopardy was removed on 4/29/16 and corrected on 8/23/16, prior to the start of the survey. This is being cited as Past Noncompliance. This is evidenced by: On 8/23/16 the facility HR-Q (Senior Executive of Human Resources) received a call from another health care facility's Vice President of Clinical Practice informing her that a former employee (Staff-A) had worked in the facility under another RN's identity and credentials. They were told that Staff-A had committed identity theft of a Wisconsin Licensed Registered Nurse currently residing in the Milwaukee area. The facility immediately lodged an investigation into the issue and contacted the Division of Quality Assurance and the local police department on 8/25/16. On 10/12/16 at 9:50 a.m., Surveyor # interviewed the Nursing Home Administrator (NHA), HR-Q (Senior Executive of Human Resources) and HR-R (Senior Executive of Compliance and Clinical Services) regarding this incident. The 3 staff acknowledged previous issues with a former Human Resources Recruiter, HRR-S. The 3 staff explained to the Surveyor that HRR-S did the recruiting for Staff-A and did not verify credentials according to the facility policy. As a result, Staff-A worked in the facility as a Registered Nurse from the time period of 11/2/15 through 4/29/16, at which time her employment was terminated because of attendance issues. The 3 staff also explained a complete investigation was started on 8/23/16 after hearing the allegation of identify theft. The 3 staff stated that HRR-S did not identify the differences in the real RN with Staff-A's background check. There were two notable differences with Staff-A and the real Wisconsin Licensed RN. First, the middle initial of Staff-A's was L and the real RN's was Y. Secondly, Staff-A spelled her last name with an E at the end, and the real RN did not have an E at the end of her name. This generated a more detailed verification process from HR. HR-Q stated it was always a procedure in the facility to obtain references and check them, as well as former employment status. HRR-S failed to conduct this step upon hiring Staff-A. The 3 staff stated Staff-A normally worked a 10 a.m.- 6 p.m. shift with another RN on duty on the floor. Occasionally, Staff-A worked on the Northwinds Unit, a ventilator unit and the Long Term Care Unit, but this was rare. The Surveyor verified this information and noted the following: Staff-A worked the following: ~ November 2015: 11/2/15 - 11/24/15- Orientation with another nurse: 14 days 3/29 shifts on her own as a floor nurse ~ December 2015: 14/31 shifts as a floor nurse ~ January 2016 15/31 shifts on her own ~ February 2016 17/29 shifts on her own ~ March 2016 18/31 shifts on her own ~ April 2016 9/29 shifts on her own During the interview on 10/12/16 at 9:50 a.m., Nursing Home Administrator (NHA), HR-Q (Senior Executive of Human Resources) and HR-R (Senior Executive of Compliance and Clinical Services) indicated HRR-S had also not verified that a Nurses Aide had tested and passed the Pearson Vue Certification for Nursing Assistants Exam. The facility was contacted by the state's Office of Caregive Quality indicating the Nurses Aide was not yet on the CNA (Certified Nursing Assistant) Registry and since a year had lapsed, was required to retake the training program. As a result of HRR-S's failure to verify the credentials, she was terminated. The immediate jeopardy that began on 11/2/15 was removed on 4/29/16 when the facility terminated Staff-A. The deficient practice was corrected on 8/23/16 when the facility: ~Implemeted a double check system for all potential licensed and/or certified employees. By this, she stated, the first HR person would obtain the required credentials, match them with the complete name of the staff person and date of birth. A second HR staff would then double verify that the credential matched the employee. ~Reviewed and verified credentials of all existing employees. ~Conducted an audit of all resident records that Staff-A was responsible for as a nurse and looked for possible neglect, abuse, and events or occurrences, such as falls, medication errors, etc. Surveyor # selected 5 random licensed staff hired around November 2015 and after August 2016. All staffs' credentials were verified and up-to-date.

Based on observation, interview, and record review, the facility failed to provide care and services to promote the healing and/or prevent the development of pressure ulcers resulting in the development of an avoidable stage IV pressure ulcer with osteo[DIAGNOSES REDACTED] and destruction of the underlying bone structure for 1 of 16 residents (Resident #16). Resident #16 was admitted to the facility very compromised with multiple co-morbidities including [MEDICAL CONDITION] (paralysis of all 4 limbs) after an accident in which Resident #16's suffered a cervical (neck) fracture. According to staff, Resident #16 had no feeling or sensation from the nipple line down. Upon admission, Resident #16 had an existing pressure ulcer. Resident #16 was at extremely high risk for the development of pressure ulcers. Despite this, the facility identified Resident #16 on admission to be at low risk for the development of a pressure ulcer and did not aggressively pursue pressure ulcer prevention strategies. On 10/5/13, Resident #16 developed a stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough...or bruising) pressure ulcer on the right ischium (buttock bone). By 10/27/13, the pressure ulcer had deteriorated to a stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed), by 2/8/14, the pressure ulcer was defined as a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle...Often includes undermining and tunneling). On 5/1/14, Resident #16 was seen by the wound clinic. The wound clinic identified the probability of osteo[DIAGNOSES REDACTED] (an infection of the bone). On 6/6/14, Resident #16 had a bone scan and x-ray completed. Both were conclusive of osteo[DIAGNOSES REDACTED] with destruction to the underlying bone. During this period of time, Resident #16 also developed 2 DTIs (Deep Tissue Injuries): One to the left scapula (shoulder blade), and one to the left trochanter (top part of the thigh bone). Beginning 10/5/13 through 8/26/14, the facility did not: ~Identify and correctly stage Resident #16's pressure ulcers; ~Consistently and accurately assess Resident #16's pressure ulcers; ~Implement a resident specific care plan based on Resident #16's unique needs to direct staff on how to manage Resident #16's skin; ~Critically analyze why Resident #16's wounds continued to deteriorate; ~Implement new interventions to off-load Resident #16's areas of pressure when deterioration was evident; ~Ensure treatments for the pressure ulcers were designed to promote healing; ~Set-up and and monitor a specialized air bed to ensure it was functioning properly; ~Track and care plan off-loading devices in order to determine what devices were effective and what devices were not. In addition, they failed to provide necessary care and services to prevent development, prevent recurrence, and/or promote the healing of pressure ulcers to an additional 5 of 16 sampled residents reviewed for pressure ulcer care (Residents #18, #4, #28, #8, and #10): 2. Resident #18 was admitted to the facility with a stage III pressure ulcer after a lengthy hospital stay following a cervical (neck) fracture which resulted in [MEDICAL CONDITION]. While the facility identified the pressure ulcer on admission and implemented pressure re-distribution measures on admission the facility did not: ~ Make changes in Resident #18's plan of care when the pressure ulcer began to deteriorate; ~ Consistently and accurately complete and document a comprehensive assessment of Resident #18's pressure ulcer according to current standards of practice; ~ Complete a treatment according to manufacturer's specifications. Resident #18's stage III pressure ulcer subsequently deteriorated to a stage IV pressure ulcer. 3. Resident #4 developed a stage II pressure ulcer on the left buttock/upper thigh on 12/08/13 which healed on 4/24/14. The facility did not update Resident #4's care plan to include approaches to prevent redevelopment of the pressure ulcer. On 6/10/14, the area reopened. The facility did not complete weekly comprehensive assessments and did not make any changes to Resident #4's plan of care. The pressure ulcer progressed to an infected unstageable pressure ulcer (full thickness loss in which actual depth of the ulcer is completely obscured by slough...and/or eschar...in the wound bed). 4. Resident #28 developed 2 DTIs (Deep Tissue Injury) on the right heel on 05/28/14. The facility was not assessing these ulcers at least weekly. Observations found Resident #28's heels were not floated off the bed surface. Resident #28 also developed a stage II sacral ulcer on 06/10/14. The facility had not assessed the stage II sacral pressure ulcer at least weekly prior to Resident #28 being hospitalized . Resident #28 was hosptalized on [DATE] with a discharge summary [DIAGNOSES REDACTED]. 5. Resident #8 reopened with a pressure ulcer in the same area in March of 2014 that had healed 3 months prior. There was no evidence of a change in the plan of care to prevent this reopening. 6. Resident #10's pressure ulcer doubled in size over a 2-week period before the facility upgraded her wheelchair seating surface. Upgrading pressure relief for this resident is integral as Resident #10 frequently declines offers to lay in bed to relieve pressure. This is evidenced by: Example #1: Resident #16 was admitted to the facility on [DATE] following a lengthy hospitalization . Admitting [DIAGNOSES REDACTED]. Resident #16 was also admitted with a stage III pressure ulcer to the sacrum. According to staff, Resident #16 had gross upper extremity movement and no sensation (feeling) or movement from the nipple line down. The admission MDS (Minimum Data Set) assessment, dated 9/10/13, indicated Resident #16: -Had a BIMS (Brief Interview for Mental Status) score of 15, indicating Resident #16 was cognitively intact; -Required total assistance of 1 to 2 staff persons for all aspects of care; -Had a Foley catheter; -Was always incontinent of bowel; -Was 6 feet 2 inches tall and weighed 114 pounds; -Was fed via a feeding tube; -Was at risk for the development of a pressure ulcer; and -Had one stage III pressure ulcer. Resident #16's CAA (Care Area Assessment) for pressure ulcers was dated 9/13/13. The CAA indicated Resident #16 had one stage III pressure ulcer, had a "...frail body frame increasing risk for pressure ulcers..." required the assistance of staff for any repositioning, was to be repositioned every hour, have bowel incontinence managed, and have heels floated. Resident #16's admission skin care plan was dated 9/3/13. The skin care plan indicated, "...Low Risk - Potential for impaired skin integrity. Braden scale score 15-16..." Approaches also dated 9/3/13 include, "...Observe for turning/repositioning effectiveness; Observe for healing/improvement; Ensure wheelchair cushion is in place; Ensure pressure relieving mattress is in place...keep resident's nails short, keep linen clean, dry, and wrinkle free; Keep skin clean and dry; Inspect skin every shift with cares..." Surveyor # requested all nursing notes containing a comprehensive wound assessment for Resident #16. Surveyor # received and completed a review of Resident #16's comprehensive wound notes (marked with ~) and noted the following: SACRUM ~9/6/13, "...Pressure Stg. (Stage) 3...left sacrum...right sacrum...Length: 4mm (millimeters) Width: 4.3mm...small area to sacrum, surrounding tissue is reddened..." This was the first measurement completed after Resident #16 was admitted . This was 3 days after admission. This pressure ulcer was noted as healed on 10/9/13. RIGHT ISCHIUM ~10/5/13, "02:50 PM (2:50 p.m.)...initial...Pressure Stg.2...granulation 100%...Surrounding Tissue: reddened...Length: 0.5 cm Width: 0.4 cm Depth: < (less than) 0.1 cm...Orders Received: cleanse with normal saline, apply skin prep to periwound and [MEDICATION NAME] to wound...resident has been getting up more in wheelchair for meals and with family. Therapy has special cushion for wheelchair to keep legs separated, this cushion was remove and replaced with appropriate cushion d/t (due to) wound, education provided to resident about repositioning and decreasing amount of time in wheelchair..." ~10/5/13, "...06:38PM (6:38 p.m.)...Initial...pressure Stg. [MEDICATION NAME] tissue 100%..." Documenting 100% [MEDICATION NAME] tissue would indicate the pressure ulcer has healed. ~10/9/13, "...friction/shearing...right ischium...Therapy has been trialing slide board for transfers. Wound was found shortly after trial. Therapy aware of wound. Trial of slide board is on hold. d/c (discontinue) charting as Stage II pressure ulcer and chart as shearing...New ROHO cushion in place. Continue q (every) 1 hours repo (repositioning)..." There was no further comprehensive assessment completed of Resident #16's right ischial pressure ulcer until 10/16/13. This was 11 days after the initial assessment. ~10/16/14, "...Pressure Stg. 2...granulation 100%...Length: 0.5 cm Width: 0.4 cm Depth: <0.1 cm..." ~10/24/13, "...Pressure Stg. 2...granulation tissue; 50%[MEDICATION NAME] tissue: 50%...Length: 4.5 cm Width: 3 cm (3.0 cm)..." According to the nursing note dated 10/24/14, Resident #16's right ischial pressure ulcer had significantly increased in size. The charting however indicated one half of the wound had granulation tissue indicating healing and the other half was healed with a fragile layer of skin. ~10/26/14, "...Stage II...slough: 100%...wound treatment changed to Santyl...Length: 5 (5.0 cm) open area Width: 2.4 (2.4 cm) open area...Length: 4.8 (4.8 cm) purple area Width: 2.5 (2.5 cm) purple area...purple area...worsening...education on limiting time in w/c (wheelchair), lay down between meals and therapies...Has pressure relieving device for chair...waffle cushion..." According to current standards of practice, a wound covered with slough in which the wound base is not clearly visible is considered an unstageable pressure ulcer. It is critical to stage pressure ulcers correctly as the stage determines treatment. According to the nursing notes, in 2 days Resident #16 went from a healing stage II pressure ulcer to an unstageable pressure ulcer with DTI which had again increased in size. ~10/27/13, "...Pressure Stg. 3...purple, reddened...Length: 5 cm Width: 2.4 cm Length: 4.8 cm...purple area...Width: 2.5 cm...purple area...worsening...changed cushion to waffle cushion..." ~10/29/13, "...Pressure Stg. 3...granulation tissue: 30% slough 70%...Length: 4.5 Width: 5 Depth: 0.2 cm...worsening...becoming larger..." On 10/29/13 the facility obtainED a Dolphin Fluid Immersion Simulation System mattress. According to the facility's time lines, the waffle cushion was discontinued on 10/29/13 and a Dolphin air cushion was implemented. Surveyor # completed a review of the manufacturer's instructions "User-Service Manual Joerns Support Surface Dolphin Fluid Immersion Simulation System." The instructions indicated, "...Comfort Adjust...caregivers can press the Comfort Adjust arrows to manually adjust comfort settings. It is recommended that manual adjustments of more than one...step up or down from the system profile be avoided...Monitor skin conditions regularly...and consider adjunct or alternative therapies for high acuity patients. Early interventions may be essential to preventing serious skin breakdown..." ~10/30/13, "...often will refuse to lay down during the day as he is better able to breath when up in wheelchair...when in bed he will not allow staff to lay him facing the window...is on Q 1 hr (every one hour) repositioning..." Care plan approaches were updated to include, "...air dolphin mattress..." dated 10/30/13 and "...Q 1 hr (every one hour) repositioning..." dated 11/1/13. According to the nursing notes, Resident #16 had been on every one hour repositioning since at least 10/9/13 so therefore, would not be considered a new intervention. ~11/5/13, "...Pressure Stg. 3...slough 40% granulation tissue: 60%...Length: 5 Width 2.5 Depth: 0.1...improving..." ~11/11/13, "...Pressure Stg. 3...slough 75%...Length: 5 cm Width: 3.5 cm Depth: 0.1 cm...improving..." Increase in size and amount of slough would show deterioration. ~11/12/13, "...Pressure Stg. 3...slough 70%...Length: 4.5 Width: 3 Depth: 0.1 cm...improving..." Despite the continued slough in Resident #16's right ischial wound, the facility continued to identify it as a stage III pressure ulcer. According to the facility's time lines, on 11/12/13 the Dolphin air cushion was discontinued and a ROHO cushion with foam underneath was implemented. On 11/12/13, Resident #16 was seen in the wound clinic. Wound clinic progress notes dated 11/12/13 indicated, "...right ischial wound is measured at 4.4 x 2.4 (4.4 cm by 2.4 cm). It is yellow with 1 center part that is dark purple..Patient has no fatty tissue at all present and so it is skin over bone...The right ischial area is debrided down to subcutaneous fat including subcutaneous fat of nonviable tissue. Post-op measurements are 4.5 x 3.2 x 1 cm depth...does not appear to be infected..." The wound clinic identified dark purple tissue in the center of the wound. This had not been documented as part of the facility's comprehensive wound assessment since 10/27/13. Dark purple tissue was indicative of prolonged and sustained pressure to the right ischial wound. ~11/21/13, "...Pressure Stg. 3...slough 75% deep red/black...Length: 4.6 Width: 2.1...macerated...Order changed...rinse with dakins, apply santyl..." ~11/22/13, "...Pressure Stg. 3...slough 75%...Wound Edges: unattached...worsening...becoming larger...Length: 5 Width: 2.3..." ~11/26/13, "...Pressure Stg. 3...slough 75%...Length: 5 cm Width: 3 cm Depth: 0.1 cm Length: 0.8 cm...Width: 0.8 cm...Depth: 0.8 cm...inferior to (below) right ischial wound..." This note indicates Resident #16 now developed a second wound. On 11/26/13, Resident #16 was again seen in the wound clinic. Wound clinic progress notes, dated 11/26/13 indicated, "...wheelchair with an underlying foam and then a ROHO on top...To the right ischium there is an extension and new wound developed. The area had been debrided and 100% pink the last time I saw him. It now has a yellow base again as well as the extension. The wound at the left ischium is debrided to the level of nonviable tissue. Post-op measurements...6.2 x 2.9 x 0.2...noninfected wound...pressure mapping did indicate good pressure relief with the current wheelchair system...Did ask the facility to make sure he is in the best offloading bed that they have available..." ~12/3/13, "...Pressure Stg. 3...granulation tissue: 80%...Length: 5 Width: 2.9 Depth: 0.1 cm..." ~12/10/13, "...Pressure Stg. 3...slough 40%granulation tissue: 60%...Length: 5.5 Width: 4 Depth: 0.1 cm...improving..." According to the measurements as noted, from 12/3/13 until 12/10/13, Resident #16's wound had deteriorated and not improved. It was larger and contained more slough. On 12/15/13, Resident #16 was hospitalized . Resident #16 returned to the facility on [DATE]. ~12/31/13, "...Pressure Stg. 3...granulation tissue: 80% slough 20%...Length: 3.5 Width: 2.7 Depth: 0.1 cm...did not get out of bed today. Repo q 1 hour..." ~1/7/14, "...Pressure Stg 3...granulation tissue: 75% slough 25%...Length: 3.5 Width: 2.7 Depth: 0.1..." ~1/10/14, "...Pressure Stg. 3...granulation tissue: 75% slough: 25%...Length: 4.2 Width: 2.5..." On 1/11/14 Resident #16 was again hospitalized . Resident #16 returned to the facility on [DATE]. On 2/5/14, Resident #16's care plan was updated to include "...Avoid rubbing area ...Lay down between meals..." ~2/6/14, "...Pressure Stg. 3...granulation: 75% slough: 25%...Wound edges: unattached...Length: 3 cm Width: 3 cm Depth: 0.2 cm...worsening...becoming larger..." ~2/8/14, "...Full thickness of skin and subcutaneous tissue lost, exposing muscle and/or bone...Pressure Stg 4...granulation tissue: 75% While (sic) tendon present...Length: 3.4 cm Width: 3.4 cm Depth: 1 cm...worsening..." Resident #16's pressure ulcer deteriorated from an unstageable pressure ulcer to a Stage IV pressure ulcer with exposed tendon. ~2/11/14, "...Pressure Stg. 4...Surrounding tissue: WNL (within normal limits)...granulation tissue: 75%...Wound Edges: attached...Length: 3.4 Width: 3.4 Depth: 0.1 cm..." On 2/14/14, Resident #16 was hospitalized . Surveyor # completed a review of Resident #16's hospital records dated 2/17/14. The hospital records indicated, "Wound and Skin...Right ischium unstageable pressure ulcer, present on admission: 3cm x 2.2cm x 0.4cm. The wound bed is pale pink and moist with visible subQ (subcutaneous) tissue. No tunneling or undermining. Mid wound, (approximately) 30% of wound surface covered with moist yellow adherent slough...Peri wound without warmth, induration, [DIAGNOSES REDACTED] (redness) or fluctuance (presence of pus)...Coccyx stage II pressure present on admission, 10cm x 6 cm of non blanchable [DIAGNOSES REDACTED] extending onto bilateral buttocks...There is also scattered brawny dry skin...Peri wound without warmth, induration, or fluctuance..." Of note: The stage II pressure ulcer identified by the hospital on admission was not identified/documented by the facility. Resident #16 returned to the facility on [DATE]. ~2/22/14, "...reddened area to sacrum but skin is intact...Pressure Stg. 4...slough 75% granulation 25%...Wound Edges: attached...Length: 3.5 cm Width: 2.9 cm Depth: 0.5cm..." ~2/25/14, "...Pressure Stg. 4...granulation: 70% slough 30%...Length: 3.5 Width: 2.6 Depth: .3 (0.3 cm)..." ~3/4/14, "...Pressure Stg. 4...granulation tissue: 75% slough: 25%...Length: 3.4 Width: 2.3 Depth: 0.7 cm...no change..." ~3/6/14, "...Pressure Stg. 4...Wound Tissue: pink, white...Wound Edges: attached...Surrounding tissue: slightly reddened...Length: 4 cm Width: 3.5 cm Depth: 0.5 cm..." ~3/12/14, "...Pressure Stg. 4...granulation: 70% slough: 25% dark crusty tissue: 5%...Wound Tissue: pink/yellow/black Surrounding Tissue: macerated Wound Edges: attached...Length: 2.8 Width: 2.8 Depth: 0.2 cm..." The measurements of 3/6/14 and 3/12/14 were significantly different. On 3/12/14, the wound base was also observed to have black tissue in the wound bed. This was indicative of deterioration. There were no changes made to Resident #16's plan of care. ~3/18/14, "...Pressure Stg. 4...granulation: 90% slough: 10%...Length: 3.2 Width: 2.3 Depth: 1cm...worsening...becoming deeper..." ~3/25/14, "...Pressure Stg. 4...granulation 75% slough: 25%...Surrounding Tissue: WNL...Wound Edges: attached...Length: 3 Width: 2.5 Depth: 1.25 cm...smaller but deeper..." ~4/1/14, "...Pressure Stg. 4...granulation tissue: 75% slough: 2% (sic)...Surround tissue: WNL...Wound Edges: attached...Length: 4 Width: 3.3 Depth: 0.8 cm..." From 4/1/14 through 4/15/14, there were no wound notes received, a period of 14 days. ~4/15/14, "...Pressure Stg 4...slough: 80% granulation 2% (sic)...Surround Tissue: WNL Wound Edges: attached...Length: 3.9 Width: 2.8 Depth: 0.6 cm...worsening...becoming deeper..." The facility again indicated Resident #16's wound was deteriorating. There were no changes made to Resident #16's plan of care. ~4/22/14, "...Pressure Stg. 4...granulation: 75% slough: 25%...Surround Tissue: reddened...Wound Edges: attached...Length: 3.4 Width: 3.3 Depth: 1.4...Healing process: no change...wound not healing...not getting worse but not getting better...Orders Received: change dressing to pack with didaksol (dakins)..." ~4/24/14, "...Pressure Stg. 4...granulation tissue: 75% slough: 25%...Surrounding Tissue: WNL...Wound Edges: unattached...approximate 1 cm tunneling (area of tissue deterioration under the skin that radiates from the primary wound) area between 2-4 o'clock..." Resident #16's wound continued to show signs of deterioration. The edges of the wound are no longer attached to the base and there was "tunneling" between 2 o'clock and 4 o'clock. There were no changes made to Resident #16's care plan aside from a treatment change. ~4/30/14, "...Pressure Stg. 4...granulation: 80% slough: 20%...Surrounding Tissue: WNL...Wound Edges: attached...Length: 3.5 Width: 3.4 Depth: 1.6...some undermining noted @ (at) 1400 (2 o'clock) .5 cm...worsening..." It would be impossible for the tissue surrounding Resident #16's wound to be normal with attached wound edges with undermining and/or tunneling present. Resident #16's wound was clearly deteriorating. There were no changes made to Resident #16's plan of care. On 5/1/14, Resident #16 was seen by the wound clinic. Resident #16 was last seen in the wound clinic on 11/26/13. The wound clinic progress notes indicated, "...significant deterioration of the right ischial wound, now measuring 3 x 2.8 with a 2.5 depth and tracking at 10-4 ( 10 o'clock to 4 o'clock) of 4 cm...an increase of 3 cm depth down to the ischial bone...present now with a stage 4 pressure ulcer to the right ischial and possible osteo[DIAGNOSES REDACTED]...continue to turn...every hour. A new bed appropriate for a stage 4 will be ordered..." ~5/3/14, "...Pressure Stg. 4...granulation: 80% slough: 20%...Surrounding Tissue: WNL Wound Edges: attached...Length: 3.5 Width: 3.4 Depth: 1.6...Undermining/Tunneling: .5 cm...worsening...becoming deeper and undermining starting..." ~5/6/14, "...Pressure Stg. 4...granulation: 70% slough: 30%...Surrounding Tissue: WNL Wound Edges: tunneling...Length: 3.8 Width: 3.9 Depth: 1.3 Undermining/Tunneling: @0900 (at 9 o'clock) 2.0...@1200 1.3...@1500 (at 3 o'clock) 2.4...worsening...becoming larger becoming deeper, undermining on 3 sides..." Resident #16 was hospitalized from [DATE] until 5/18/14. ~5/20/14, "...Pressure Stg. 4...granulation tissue: 30% slough: 70%...Surrounding Tissue: reddened Wound Edges: tunneling...Length: 3 cm Width: 3 cm Undermining/Tunneling 5.5 cm 9-2 o'clock...worsening...becoming deeper..." Resident #16's pressure ulcer continues to deteriorate. There were no changes made to Resident #16's plan of care. There was no timely documentation of Resident #16's wound. ~6/3/14, "...Pressure Stg. 4...granulation tissue: 70% slough: 30%...Wound Edges: attached...Length: 3.4 Width: 2.8 Depth: 1.4 Undermining/Tunneling @0900 3cm...@1200 4.3 cm @1500 1.1 cm..." On 6/5/14, Resident #16's care plan was updated to include, "...Impaired skin integrity...High Risk...Stage 4 pressure ulcer..." ~6/6/14, "...Pressure Stg. 4...granulation tissue: 100%...Wound Edges: attached...Length: 3 cm Width: 2.2 cm Depth: 2 cm, 5 cm at 12 o'clock Undermining/Tunneling: undermining, 3 cm with the deepest 5 cm at 12 o'clock...bone scan done today..." ~6/10/14, "...Pressure Stg. 4...granulation tissue: 100%...Surrounding Tissue: reddened...Wound Edges: attached...Length: 2.5 cm Width: 3 cm Depth: 1.50 cm Undermining/Tunneling: 4.5 cm at 12 o'clock...2 cm at 7 o'clock...1 cm at 3 o'clock...1 cm @ 9 o'clock..." ~6/17/14, "...Pressure Stg. 4...granulation tissue: 100%...Surrounding Tissue: WNL Wound Edges: attached...Length: 2.8 Width: 3 Depth: 2 Undermining/Tunneling: @0900 = 1.5...@1200 = 5.4...@1500 = 1.9..." On 6/19/14, Resident #16 was again seen in the wound clinic. Wound clinic progress notes dated 6/19/14 indicated, "...has developed a severe right ischial...ulcer...currently measure 3.3 x 2.5 x 2.0 cm...the ulcer does track down approximately 4 cm to the right ischium, and there is palpable bone...bone scan performed on June 6, 2014...findings consistent with osteo[DIAGNOSES REDACTED] involving the right ischium...x-ray of the pelvis taken June 6, 2014, showed new destructive changes of the right ischium. Pattern was consistent with osteo[DIAGNOSES REDACTED]..." Since 10/5/13, Resident #16's wound had deteriorated from a stage II to a stage IV pressure ulcer including osteo[DIAGNOSES REDACTED] with destruction of the right ischial bone. Despite Resident #16's significantly complex medical condition, there had been no indication the facility critically analyzed why Resident #16's wound continued to deteriorate aside from looking at the complexity of his medical condition. There had been no new interventions implemented in attempt to off-load Resident #16's right ischium and promote healing since 11/12/13 a period of 7 months and 7 days. ~6/24/14, "...Pressure Stg.4...granulation tissue: 100%...Wound Edges: attached...Length: 3.3 Width: 3.0 Depth: 1.4 Undermining/Tunneling: @0900 2.8 cm...@1200 4.5 cm...@1500 1.1 cm..." ~6/25/14, "...Pressure Stg.4...Length: 2.7 Width: 2.5 Depth: 1.8 Undermining/Tunneling: @0900 = 2.8...@1200 = 4.9...@1500 = 1.4..." ~6/30 14, "...Pressure Stg.4...granulation tissue: 100%...Wound Edges: attached...Length 3 cm Width: 3 cm Depth: 5 cm from 11 o'clock to 1 o'clock...1 cm around, deepest depth is 5 cm at 11 o'clock to 1 o'clock..." ~7/1/14, "...Pressure Stg. 4...granulation tissue: 100%...Wound Edges: undermining...Length: 2.5 c, Width: 2 cm Undermining/Tunneling: 10 o'clock: 4.5 cm...7 o'clock: 2.5 cm..." ~7/8/14, "...Pressure Stg.4...granulation tissue: 100%...Wound Edges: attached...Length: 2 cm Width: 2.5 cm Depth: 2 cm Undermining/Tunneling: 11 o'clock: 5 cm...7 o'clock: 2 cm..." ~7/14/14, "...Pressure Stg. 4...granulation tissue: 100%...Wound Edges: epibole...Length: 2.8 cm Width: 2.4 cm Depth: 3 cm...healing..." According to Wound Care Education Institute (WCEI), 2011, " ...If [MEDICATION NAME] tissue migrates over the wound margin (Epibole), further wound healing will not occur. The body's response will be that the wound is healed. The margins must be re-injured to renew the wound healing cycle..." There were no changes in Resident #16's care plan directing staff on the appropriate care of the epibole in order to regenerate healing. ~7/27/14, "...Pressure Stg. 4...granulation 100%...Wound Edges: unattached, epibole...Length: 2 cm Width: 2.5 cm Depth: 4 cm tunneled area from 11 o'clock to 1 o'clock...improving..." ~7/28/14, "...Pressure Stg. 4...granulation tissue: 100%...Length: 2.75 Width: 2.75 Depth: .75 Undermining/Tunneling: @1200 2.5...becoming smaller..." ~8/5/14, "...Pressure Stg. 4...granulation tissue: 100%...Wound Edges: epibole...Length: 2.8 Width: 2.2 Depth: 1 Undermining/Tunneling: @0900 = .3...@1200 = 3.4...improving..." ~8/11/14, "...Pressure Stg. 4...granulation tissue: 100%...Wound Edges: unattached, tunneling...Length: 2.3 cm Width: 3 cm Depth: 4 cm from 12 o'clock to 2 o'clock...improving..." ~8/13/14, "...Pressure Stg. 4...granulation tissue: 100%...Wound Edges: unattached, tunneling...Length: 2 cm Width: 2.8 cm Depth: 3.8 cm from 12 o'clock to 2 o'clock...improving..." Resident #16's most current skin risk assessment was dated 8/18/14. The assessment had a cumulative score of 14, indicating Resident #16 was at moderate risk for the development of a pressure ulcer. Despite Resident #16's complex medical problems, pressure ulcer identified on admission and current pressure ulcers, the facility determined Resident #16 was at moderate risk for the development of a pressure ulcer. ~8/20/14, "...Pressure Stg.4...granulation 100%...Wound Edges: attached...Length: 1.9 cm Width: 3 cm Undermining/Tunneling: 12 o'clock; 3.8 cm...2 o'clock; 1.9 cm..." Surveyor # had requested all of Resident #16's comprehensive wound assessments since admission. Surveyor # received nursing notes regarding the right ischial pressure ulcer. Scattered throughout the nursing notes received, Surveyor # noted the following entries: LEFT SCAPULA Resident #16's care plan, dated 6/5/14, was updated to include, "...Impaired skin integrity...High Risk...Stage 1 area to left scapula..." ~6/24/14, "...Has open lesion...left scapula...unable to visualize, dressing not changed...fluid filled blister to left scapula, friction...purple reddened..." According to the nursing note, Resident #16 developed a DTI to the left scapula and should not be referred to as a stage I ~6/25/14, "...fluid filled blister to left scapula, friction...purple, reddened...improving..." ~7/1/14, "...fluid filled friction shearing injury...left scapula...unable to visualize, dressing not changed..." ~7/8/14, "...fluid filled friction shearing injury...left scapula...unable to visualize, dressing not changed..." ~7/12/14, "...left mid back...purple, pink..." ~7/28/14, "...left mid back...closed [MEDICATION NAME] tissue: 100%...reddened...Length: 2.5 Width: 2.5..." The nursing note dated 7/28/14 was the first note that included measurements of the SDTI. ~7/31/14, "...left scapula...closed. boggy/mushy...purple, non-blanchable...Length: 4 cm Width: 4 cm...Healing Progress: unknown, initial assessment..." The nursing note dated 7/31/14 indicated the wound had deteriorated and gotten larger. Although identified on the care plan, there were no changes to Resident #16 plan of care. There were no further comprehensive wound notes received of the SDTI of Resident #16's left scapula. Surveyor # was unable to determine when the left scapula SDTI developed or when it was healed. LEFT TROCHANTER ~6/10/14, "...SDTI (Suspected Deep Tissue Injury)...Location: Left Trochanter...left anterior thigh/pelvis...unable to visualize, dressing not changed..." According to the nursing notes, Resident #16 now had a DTI on the left trochanter/anterior thigh/pelvis. These are 3 different anatomical locations. The trochanter is located at the top of the femur bone just below the head of the femur. The pelvis contains multiple different bone structures. It would be impossible for the practitioner to know anatomically where this pressure ulcer was located. ~6/17/14, "...SDTI...Left Trochanter...left anterior thigh/pelvis...unable to visualize, dressing not changed..." ~6/24/14, "...SDTI...left anterior thigh/pelvis trochanter...unable to visualize, dressing not changed..." ~6/25/14, "...SDTI...left anterior thigh/pelvis trochanter...closed [MEDICATION NAME] tissue: 100%...slight bruise noted but skin intact..." ~7/1/14, "...SDTI...left anterior thigh/pelvis trochanter...unable to visualize, dressing not changed..." ~7/8/14, "...SDTIZXX

Based on observation, record review, and interviews, the facility did not ensure that 2 out of 17 residents reviewed for range of motion received care and services to increase or prevent decline in range of motion. Resident #4 had a functional decline in lower extremity range of motion from 2/2014 to 5/2014. The care plan indicated Resident #4 was to receive range of motion. Resident #4 reported there had been no range of motion exercises provided. Resident #28 had a range of motion program to both upper and lower extremities according to the care plan. Surveyor # did not observe any range of motion provided to Resident #28. CNA-L (Certified Nursing Assistant) confirmed no range of motion was completed. Resident #28 also confirmed staff had not provided range of motion exercises. This is evidenced by: Example #1: During the initial facility tour which began on 08/19/14 at 10:35 a.m., RN-K (Registered Nurse) informed Surveyor # that Resident #4 was bed bound and under hospice care. Resident #4 was admitted to the nursing home in November 2013 for rehabilitation which was unsuccessful. Resident #4 was currently under hospice care. The facility completed an admission MDS (Minimum Data Set) assessment for Resident #4 on 11/15/13 with the following data noted: ~Able to make self understood and understands others; ~BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicative of no cognitive deficits; ~No impairments in functional range of motion of the upper or lower extremities; ~Actively participating in physical and occupational therapy 5 days per week. The facility completed a quarterly MDS assessment for Resident #4 on 05/09/14 with the following data noted: ~Able to make self understood and understands others; ~BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicative of no cognitive deficits; ~Lower extremity impairment on one side; ~Was not participating in therapy or restorative nursing programs for range of motion. The facility completed a significant change in status MDS assessment for Resident #4 on 08/15/14 with the following data noted: ~Able to make self understood and understands others; ~BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicative of no cognitive deficits; ~Lower extremity impairment on one side; ~Was not participating in therapy or restorative nursing programs for range of motion. Review of the CNA care plan noted Resident #4 was to receive active range of motion to right and left upper extremities as well as passive range of motion to right and left lower extremities. The care plan does not include the frequency of these exercises. On 08/25/14 at 9:15 a.m., Surveyor # interviewed Resident #4 regarding range of motion exercises. Resident #4 stated he does get active range of motion exercise of his upper extremities, but staff does not "ever" provide him with any passive range of motion of his lower extremities. On 08/25/14 at 2:00 p.m., Surveyor # interviewed CNA-M who identified himself as a consistent caregiver and familiar with Resident #4's care. CNA-M stated Resident #4 does use his upper extremities to aid in bed mobility. CNA-M stated Resident #4 does not receive any lower extremities passive range of motion exercises. On 08/26/14 at 11:00 a.m., Surveyor # interviewed PTA-Q (Physical Therapy Assistant). PTA-Q stated he had worked with Resident #4 for a few months beginning in December 2013. PTA-Q stated Resident #4 was able to stand, take a few steps on the parallel bars or with his walker, and improve his transfer status from a mechanical lift to a 2 person pivot transfer. PTA-Q stated Resident #4 was able to complete the home exercise program independently upon discharge. On 08/26/14 at 11:10 a.m., Surveyor # interviewed PT-R who stated she had worked with Resident #4. PT-R stated at the time of discharge, Resident #4 was able to transfer with 2 staff. PT-R stated Resident #4's goal was to transfer independently and safely so he could return home. PT-R stated Resident #4 was not able to consistently and safely transfer or stand. PT-R stated Resident #4 was independent in completing a home exercise program upon discharge from therapy. On 08/26/14 at 1:15 p.m., Surveyor # interviewed PT-S regarding Resident #4's evaluations and therapy services from December 2013 through May 2014. PT-S stated during the evaluations that were completed on 12/18/13 and 02/18/14, Resident #4 had functional range of motion of the ankles, knees, and hips. PT-S stated Resident #4 was discharged from therapy on 04/29/14 on an independent home exercise program. PT-S stated she had completed another evaluation for Resident #4 on 05/28/14 and noted Resident #4 had severe limited range of motion of both lower extremities. Example #2: During the facility tour which began on 08/19/14 at 10:35 a.m., RN-K informed Surveyor # that Resident #28 was a quadriplegic due to a spinal cord injury. RN-K stated Resident #28 had resided at the facility for a very long time and was totally dependent on staff for all of his daily cares. Resident #28 was admitted to the facility for long term care in June 2002. Resident #28 had multiple [DIAGNOSES REDACTED]. The facility completed a quarterly MDS assessment for Resident #28 on 04/14/14 and an admission MDS assessment for Resident #28 on 07/05/14 with the following data noted: ~Able to understand others and make self understood; ~Functional range of motion limited on both sides of the upper and lower extremities; ~A BIMS score of 14 and 13 respectively out of 15, indicative of mild cognitive deficits. On 01/30/14, the nurse practitioner ordered for therapy evaluation to work with Resident #28's upper extremity contractures. According to the therapy note dated 02/06/14, Resident #28 declined therapy services as he was already participating in daily passive range of motion. Review of the CNA care plan noted Resident #28 was to receive active range of motion to both upper and lower extremities; however the care plan does not include the frequency of these exercises. The care plan also reads under the "Special Needs" section "Passive ROM (range of motion) to all extremities after meals per resident request." On 08/25/14 beginning at 10:10 a.m., Surveyor # observed CNA-L provide total staff assistance for hygiene and dressing to Resident #28. During the observation, Surveyor # noted Resident #28's shoulders, elbows, and hands were contracted and held tight to his chest. CNA-L lifted Resident #28's arms to provide hygiene under the arm and Resident #28 winced in pain. Surveyor # observed Resident #28's left thumb was in a permanent hyperextended position. CNA-L left Resident #28's room to retrieve the mechanical lift and another staff person. Surveyor # asked Resident #28 if he experienced pain when his arms were moved and he stated yes. Surveyor # asked Resident #28 if he ever received any exercises of his arms and legs. Resident #28 stated staff used to complete range of motion exercises, but that was a long time ago. Resident #28 further stated he was supposed to receive range of motion exercises to his arms and legs twice a day, but that has not happened for a long time. On 08/25/14 at 1:55 p.m., Surveyor # interviewed CNA-L who identified herself as a consistent caregiver for Resident #28. CNA-L stated she had not completed range of motion exercises for Resident #28 during her shift. CNA-L stated Resident #28's care plan instructed staff to complete range of motion to both arms 3-5 repetitions or as he can tolerate. CNA-L stated she does not do any range of motion to Resident #28's legs. On 08/25/14 at 1:50 p.m., Surveyor # interviewed the DON (Director of Nurse) regarding range of motion. The DON stated staff are to complete range of motion during cares or whenever it works into the resident's schedule, and that range of motion should be completed in accordance with the care plans.

Based on observations, record review, and interviews, the facility did not ensure that 4 out of 8 samled residents reviewed for pressure ulcers received care and services to prevent the development of pressure ulcers. ~Resident #10 developed a pressure ulcer to his buttocks region. The areas healed but no approaches were implemented to prevent recurrence. The pressure ulcer reopened and healed numerous times without changes to the care plan to prevent recurrence. In addition, there was inconsistent documentation regarding the wound. ~Resident #26 developed a stage II sacral pressure ulcer in January 2012. The area had healed and reopened six times from 08/12/12 through 08/04/13. The facility did not make any changes to the care plan or treatment plan when the stage II sacral pressure ulcer reopened. The facility had not identified a stage II pressure ulcer even though it was on a bony prominence. The facility was not documenting the pressure ulcer in accordance with the facility policy and current standards of practice. The facility did not complete at least weekly assessments, which would include the measurements of the wound, a description of the wound bed, staging of the wound, the presence of exudate, and the effectiveness of the treatment. In addition, staff did not consistently follow Resident #26's care plan. ~Resident #12 developed a stage III sacral pressure ulcer on 02/22/13, which healed on 03/06/13. The facility did not implement approaches to prevent recurrence. The stage III pressure ulcer reopened on 09/03/13. The facility treated this stage III pressure ulcer with a topical barrier cream. This treatment choice for a stage III pressure ulcer was not in accordance with current standards of practice. The facility was not documenting the pressure ulcers in accordance with the facility policy and current standards of practice. The facility did not complete at least weekly assessments that included the measurements of the wound, a description of the wound bed, staging of the wound, the presence of exudate, and the effectiveness of the treatment. In addition, staff did not consistently follow Resident #12's care plan. ~RN-A (Registered Nurse) did not cleanse and change the dressing of Resident #4's pressure ulcer in a manner consistent with standards of care. This is evidenced by: According to the standards of practice outlined by the NPUAP (National Pressure Ulcer Advisory Panel), the US Department of Public Health's Agency for Health Care Policy and Research, and the "Nurses Clinical Guide to Wound Care" published in 1995, the assessment and documentation of a wound is to include: ~Location of the wound using the correct anatomical descriptors. ~Shape of the wound. ~Documentation of the anatomical position of the person during measuring as this can alter measurements. ~Measurements as Length x Width x Depth in centimeters. ~Measurements using the clock system with 12:00 being the person's head and 6:00 the person's feet. ~Note any undermining. ~Note any tunneling. ~Assess and record the wound base and record the types of tissue using percentages. ~Drainage type and odor if applicable. ~The wound edges. ~The surrounding tissue at least 4 centimeter out. ~Presence of pain. The NPUAP also recommends that this documentation take place at least weekly and whenever the wound is visible as with a dressing change. The NPUAP also outlines that a 2-hour turning schedule is not sufficient practice for a person at high risk to develop a pressure ulcer, much less a person with a known history. On 09/10/13, Surveyor # requested and reviewed the facility policy titled "Skin Assessment/Prevention/Care." The policy read "Mount View Care Center has a certified Wound Care Nurse who will oversee wound care management." The policy further read "Measure weekly each wound...Done every Tuesday by designated shift nurse completing treatment...Measure length, width, depth of each wound/area. Identify type and stage of wound. Exudate present. Odor present. Wound tissue color. Appearance of surrounding tissue...Complete Braden Scale. reviewed/updated Care plan." The policy also read the wound care nurse should assess each resident with pressure ulcers at least weekly. Example #1: Resident #10 has [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment, dated 7/5/13, indicated Resident #10 is totally dependent on staff to meet his most basic daily tasks of bathing, personal hygiene, transfers, toileting, and mobility; and, scored a 2/15 on the Brief Interview of Mental Status (BIMS), indicating severe cognitive deficit. Resident #10 was originally admitted to the facility on [DATE]. At that time, the resident's skin was intact. The facility implemented a 2-hour repositioning schedule and a pressure relieving device for the resident's bed, as well as a wheelchair cushion. From 2/22/12 through 8/5/12, documentation indicated Resident #10 had multiple open areas that healed and reopened at later dates. On 8/5/12, Resident #10 developed 2 new abrasions to the underside of the scrotum as a result of being pinched. On 8/9/12, it was documented that Resident #10 developed excoriated areas to his coccyx crease that measured 2 cm length x 2 cm width. The wound tissue was pink and without drainage. The documentation indicated there were pressure-relieving devices for the bed and chair, but did not indicate what devices were in place. The documentation also indicated ointments were applied but did not indicate what ointment. On 8/10/12, documentation stated: "...excoriated areas to scrotum and sacrum continue... " This is the first documentation of excoriation to the sacrum. Also, there are no measurements or clear descriptions of this new area. In reviewing further documentation, it appears the excoriation referred to in the above entry, is the coccyx crease. On 8/13/12, an air mattress and A & D Ointment were initiated for the scrotum, and Calazyme remained the treatment for [REDACTED]. On 8/14/12, documentation indicated Resident #10's scrotum worsened and developed an open wound to the underside of the left scrotum that measured 0.9 cm length x 0.7 cm width. There were no new interventions initiated. On 8/16/12, documentation indicated the therapy department would be bringing the resident a new cushion for his wheelchair. From 8/9/12 - 8/18/12, there were no measurements or clear descriptions of the coccyx open area. On 8/19/12, the facility documented open areas to Resident #10's left mid buttock and right mid buttock, as well as the gluteal crease. These are new areas of the body. There were no measurements, no precise anatomical location, and no clear descriptions. There also were no changes made to the plan of care. On 8/20/12, a wedge cushion was being used in bed to keep the legs separated and the scrotum elevated. On 8/21/12, the left mid buttock was measured as being 1.3 cm length x 1.3 cm width x < (less than) 0.1 cm deep, superficial and denuded. On 8/22/12, the measurements of the left mid buttock were 0.9 cm length x 0.4 cm width x 0.1 cm deep. 8/25/12 documentation again showed denuded areas to right and left sacrum, and gluteal crease. Still, there were no measurements of the body surface area which this denuded tissue covers. 8/29/12, denuded "kissing buttocks" is documented for the left and right mid buttocks. Later that day, the nurse documented incontinent related [MEDICAL CONDITION] to the area. No measurements and no changes to the care plan were initiated. From 8/29/12 - 9/9/12, documentation continued to state the open areas to the left and right mid buttock, but there were no measurements or clear descriptions given. There also were no changes made to the plan of care. On 9/5/12, Red Cap cream was initiated for the resident's scrotum. On 9/24/12, treatment to the left mid buttock/right mid buttock wound was changed to [MEDICATION NAME]. The facility and family initiated Palliative Care for Resident #10 on this date. Various medications were discontinued. There still were no measurements of the surface area of the wound. On 10/2/12, there was noticeable decline in the "denuded" left and right mid buttocks wound. There was the development of necrotic tissue. This tissue was described in the documentation as being "black and deep red with scant amount of tan slough." The removal of the [MEDICATION NAME] dressing revealed yellow slime. The wound was described as becoming larger and deeper. On 10/3/12, the wounds were measured at 9:18 a.m.: Left Mid Buttock: 4.2 cm length x 2.4 cm width x 0.1 cm deep, unstageable. Right Mid Buttock: 6 cm length x 1.8 cm width x 0.1 cm deep, unstageable. Later that same morning (10:58 a.m.) another nurse documented: Left Buttock: "> (greater than) 50% necrotic tissue and >25% beefy red/purple tissue with scant tan slough." The wound was odorous with a light Serosanguineous (mixture of clear and bloody drainage) with scant amount tan drainage. The wound had macerated edges and measured 7.3 cm length x 2.9 cm width. Right Buttock was measured as being 6.5 cm length x 2.9 cm width, >75% necrotic and >25% beefy red tissue with tan slough, odorous tan drainage and surrounding tissue was documented as being reddened. The treatment was changed to cleanse wounds with normal saline, apply Santyl ointment to wound base and open tissue, cover with gauze every day and as needed. All other interventions remained the same. Note: according to documentation, different nurses were documenting different sites of the body where the wound was. Some nurses were charting left and right sacrum and some were documenting left or right mid buttocks. The facility utilizes a body chart system to determine anatomical positioning. The left and right mid buttock numbers were listed as being 166 and 167 respectfully, whereas the left and right sacrum are numbered 162 and 163 respectfully. Between 10/3/12 and 10/9/12, the wound began to improve with the removal of the necrotic tissue and slough. On 10/9/12, the wound was documented as being "Full thickness of skin lost exposing the SubQ (subcutaneous) tissue..." to the left and right sacrum with 50% granulation and 50% slough and a moderate amount of tan mixed Serosanguineous drainage. There was mild pain with the dressing change and the wound was measured as being 7 cm length x 5.4 cm width x 0.1 cm deep. The resident was seen by the Nurse Practitioner (NP) and a wound debridement was conducted. The NP ordered to continue with the Santyl with the addition of [MEDICATION NAME] powder to the dressing. On 10/9/12, a cushion was added to the back of Resident #10's wheelchair. From the time period of 10/9/12 - 11/7/12, the wound began to improve both in appearance and size. However, on 11/8/12, the wound developed 5% necrotic tissue with 95% granulation tissue. By the late evening shift, the nurses documented that the wound progressed to 50% black necrotic and 50% pink granulation tissue. No changes to the treatment or the plan of care were initiated. On 11/13/12, the morning nurse documented the wound as having 100% granulation, but the afternoon nurse documented 80% slough with 20% granulation. Again, there are inconsistencies with the documentation. On 11/13/12, the wound measured 5.5 cm length x 1.8 cm width x <0.1 cm deep with 80% slough and 20% granulation. No new interventions initiated. From 11/13/12 - 11/28/12, the wound showed improvement both in the description of the wound and the size (11/20/12, it measured 3.7. length x 2 cm width x <0.1 deep). However, on 11/29/12, the measurements were documented as being 5.5 cm length x 1.8 cm width x <0.1 cm deep. The wound again increased in size. From 11/30/12 - 12/01/12, the wound had 50% slough and 50% granulation. No changes were made to the plan of care. On 12/2/12, the wound was 25% slough and 75% granulation tissue. The staff continued to document that the wound was healing. On 12/4/12, the staff documented that the wound was filling in and instead of one large wound, there were two small wounds. The staff documented these as: First open area: 2.8 mm length x 0.8 mm width x 0.9 mm deep. Second open area: 1.3 mm length x 1.6 mm width x 0.3 mm depth. Note: The standard of practice is to document using a clock method so the practitioner who assesses the wound next, would have a precise location of each wound. On 12/11/12, the wound was measured as being 5 cm length x 2 cm width. There was no depth measurement recorded. The wound was described as being 50% slough, 50% granulation with pink edges. The resident also developed another open area to the "left butt cheek" that measured 1 cm length x 0.5 cm width. There were no new interventions implemented. From 12/11/12 - 12/24/12, the wound was documented as healing with granulation. However, no measurements were taken until 12/25/12, when the nurse documented the wound was 3.0 cm length x 1 cm width. Drainage was serous (clear) to light Serosanguineous. On 1/1/13, the wounds (staff went back to documenting two wounds) measured: Right Sacrum: 1 cm x 0.7 cm (no note on which is length or width). Left Sacrum: 1.5 cm x 0.4 cm (no note on which is length or width). The documentation again indicated there was [MEDICATION NAME] tissue as well as granulation tissue with slight Serosanguineous drainage. On 1/8/13, the wound measured: Right Sacrum: 1.8 cm length x 0.5 cm width (no depth recorded). Left Sacrum: 0.8 cm length x 0.4 cm width (no depth recorded). Note: This is an increase in the size of the Right Sacrum and a decrease in the size of the Left Sacrum. There is concern over whether the correct locations were documented, as the sizes, if reversed, are similar to what was documented the week before. On 1/18/13, the dressing was changed to a [MEDICATION NAME]. From 1/29/13 - 2/5/13, the wound was documented as being pink and without drainage. From 2/6/13 - 2/11/13, documentation appeared to be that of the dressing and that it's intact. On 2/12/13, Resident #10 was seen by the NP. The wound measurements were: 0.5 cm length x 0.2 cm width x 0.1 cm depth. The wound was 100% reddened granulation with a light serous drainage. The wound was described as being shallow and becoming smaller. On 2/19/13, the wound again increased in size: "...3.5 cm length x 0.5 cm width x On top by coccyx 0.5 m x 0.25 cm..." Despite the fact that the wound had increased in size, there was no change to the care plan. However, documentation from 3/12/13 - 4/15/13, indicated the wound continued to heal with a decrease in size and granulation occurring. Measurements on 4/10 were: 1 length x <0.5 width x 0.1 deep. On 4/16/13, the wound again worsened. The measurements were 2.7 cm length x 4.3 cm width x 0.5 cm depth. There was also a small slit above the wound that measured 1.5 cm length x 0.5 cm width. There were no changes to the treatment or new approaches to the plan of care. On 4/23/13, the measurements were: 2.75 cm length x 0.75 cm width x 0.3 cm depth. Again healing began to occur and on 4/29/13, the wound was documented as being 1 cm length x 0.5 cm width x 0.1 cm depth. On 5/7/13, the facility documented that the wound bed had three areas open and bleeding. On 5/14/13, the wound was 1.9 cm length x 0.4 cm width x <0.1 cm depth. On 5/21/13, the wound was measured in the form of a clock. The measurements were: Wound #1: 12 O'clock - 6 O'clock 0.4 cm length x 0.2 cm width x <0.1 cm depth. Wound #2: 12 O'clock - 6 O'clock 0.3 cm length x 0.2 cm width x <0.1 cm depth. On 5/28/13, the wound again increased in size: Wound #1: 0.7 cm length x 0.3 cm width x <0.1 cm depth Wound #2: 0.5 cm length x 0.2 cm width x <0.1 cm depth No changes were made to the plan of care. On 6/2/13 the wound was described as "2 superficial open areas, superior area [MEDICATION NAME] tissue: 100% appears as an indentation inferior area with small open region granulation tissue: 100%..." There was scant amount of Serosanguineous drainage and the wounds measured: Superior opening: 1 cm length x 0.2 cm width x 0.1 cm depth. Inferior opening: 1 cm length x 0.4 cm width x 0.1 cm depth. Again, documentation indicated the wound began to show signs of healing. On 6/11/13, the wound was: Superior: 0.3 cm length x 0.2 cm width x 0.1 cm depth. Inferior: 0.4 cm length x 0.4 cm width x 0.1 cm depth. The NP assessed the wound and ordered to irrigate the wound with Normal Saline, then to apply Gentamyacin Ointment to the wound and cover with a [MEDICATION NAME] dressing. Between 6/17/13 - 7/15/13, it appeared as if the wound was nearly healed over with documentation being 100 % granulation or 90/10 granulation/[MEDICATION NAME] tissue. On 7/16/13, the area was open again, measuring 0.3 cm length x 0.3 cm width x no depth. On 9/1/13, the wound measured 4 mm length x 1.5 mm width and no depth. Note: This wound began on 2/12/12 with denuded areas and continued to be open. On 9/9/13, Surveyor # observed the treatment to Resident #10's wound at 1:52 p.m. by RN-CC. The wound appeared clean and granulation was occurring. It measured approximately 2.0 mm length x 1.0 mm width and depth was superficial. The surrounding skin was pink approximately 2.0 cm surrounding the wound. Further periwound was the development of white scar tissue approximately another 2 cm surrounding the pinkened area. On 9/11/13 at 9:32 a.m., Surveyor # met with RN-J (Registered Nurse and MDS Coordinator for Resident #10) regarding the timeline of events for the treatment of [REDACTED]. RN-J went through the timeline and in reviewing the documentation regarding the resident's wound, admitted that with the 8/29/12 charting, the nurse should not have documented incontinent related [MEDICAL CONDITION], as this was incorrect verbiage. RN-J stated it was a pressure ulcer during that period of time and should have been documented as such. RN-J also stated the staff did not incorporate new approaches with the worsening of the wound, except where listed above. RN-J admitted the documentation regarding Resident #10's wound "flips back and forth and we are aware of our charting system needing work." RN-J did state that on 10/15/12, the RD (Registered Dietician) had approached her and requested Vitamin C and Zinc be added to his medication regimen, but that the physician had refused it related to the resident being on Palliative Care and the fact that he had also been refusing medications. RN-J also stated Resident #10 preferred to lay on his back and often refused repositioning, kicking or hitting at staff with the attempts. However, this is not documented excessively in his record, only on occasion is it noted. RN-J stated, "We should have caught the [MEDICAL CONDITION] and risk factors earlier and started the air mattress sooner than we did." Example #2: Resident #26 was admitted to the facility in June 2010 for long term care due to Alzheimer's dementia. Review of the "Resident Care Summary" for Resident #26 noted she needed 2 assist for ambulation and transfers, assist with repositioning and eating, was confused and impaired cognition, was incontinent of bladder and bowel, and was to have incontinence brief open when lying in bed. Review of the care plan titled "Potential for impaired skin integrity..." dated 01/30/13, had a goal of no skin breakdown. The care plan problem included decreased mobility, incontinence, and a red area present on a bony prominence. The approaches were to "treat as ordered, see treatment sheets. Assess per skin care evaluation sheet every week. Notify of significant changes: Physician, Dietician..." The facility completed 7 Braden scales (pressure ulcer risk assessments) from 10/20/12 through 06/28/13, and noted Resident #26 was at low risk for pressure ulcers. The Braden scales noted Resident #26 had impaired mobility, had potential for shear/friction, had moisture problems, and impaired sensory perception. Review of the nurse's notes starting on 08/12/12, noted Resident #26 had a slit along rectal crease which was due to moisture. The current treatment was Stoma powder twice daily and as needed. The Stoma powder was first ordered on [DATE]. Surveyor # reviewed all of the nurse's notes from 08/12/12 through 09/10/13, and was not able to locate any staging of the wound, only rare measurements of the wound, only rare descriptions of the wound bed, etc., in accordance with current standards of practice and the facility policy. On 09/08/12, the nurse's notes read "Chronic slit to gluteal crease continues and is deeper and wound bed redder than when last seen by this writer." The physician was not notified of this change. There was no change in the treatment of [REDACTED]. On 10/19/12, the nurse's notes read "slit along rectal crease from chronic moisture. New treatment started today but some improvement noted since started Foley catheter. New treatment with [MEDICATION NAME] powder covered with opsite..." On 10/23/12, the nurse's notes read "slit along rectal crease improving slowly some surround tissue redness. Will continue with treatment powder [MEDICATION NAME] but no dressing, slit along rectal crease improved but surround skin irritated likely from adhesive..." Resident #26 continued to receive [MEDICATION NAME] powder as the current treatment. On 10/27/12, the nurse's notes read "Appx (approximately) 2.5 cm superficial slit..." On 11/19/12, the nurse's notes read "Slit to gluteal crease longer in length since writer last assessed..." The physician was not notified and there was no change in the treatment of [REDACTED]. On 11/25/12, the sacral pressure ulcer was healed. On 11/27/12, the sacral pressure ulcer reopened. The physician was not notified, there were no changes to the treatment, and there were no changes to the care plan. On 11/29/12, the nurse,s notes read "Area is reddened 2.5 cm slit..." On 12/02/12, the sacral pressure ulcer was healed. On 12/06/12, the sacral pressure ulcer reopened. The physician was not notified, there were no changes to the treatment, and there were no changes to the care plan. On 01/13/13, the sacral pressure ulcer was healed. On 01/20/13, the sacral pressure ulcer reopened. The physician was not notified, there were no changes to the treatment, and there were no changes to the care plan. On 04/07/13, the sacral pressure ulcer was healed. On 04/21/13 the sacral pressure ulcer reopened. The physician was not notified, there were no changes to the treatment, and there were no changes to the care plan. On 05/12/13, the sacral pressure ulcer was healed. On 05/26/13, the sacral pressure ulcer reopened. The physician was not notified, there were no changes to the treatment, and there were no changes to the care plan. On 06/23/13, the nurse's notes read "slit gluteal fold 1.5 cm, moist, pink..." On 07/14/13, the sacral pressure ulcer was healed. On 08/04/13, the sacral pressure ulcer reopened. The physician was not notified, there were no changes to the treatment, and there were no changes to the care plan. On 08/18/13, the sacral pressure ulcer was healed. On 09/06/13 at 8:16 a.m., Surveyor # observed CNA-T (Certified Nursing Assistant) provide total assistance with hygiene and dressing. Resident #26 was noted to be lying in bed with the incontinence brief fastened, which is not in accordance with the care plan. RN-V (Registered Nurse) was called into the room by CNA-T to provide skin care. RN-V gathered supplies, washed hands, donned gloves and applied [MEDICATION NAME] spray skin protectant to Resident #26's sacral area just above the rectum, then applied [MEDICATION NAME] powder to the same area. The area was closed, but with pink fragile skin noted. RN-V stated Resident #26 has had an open slit above the rectum for a long time. RN-V stated the area had healed and reopened numerous times over the past year. RN-V stated the area was due to excessive moisture related to bladder and bowel incontinence. On 09/11/13 at 10:16 a.m., Surveyor # interviewed CNA-T regarding care provided to Resident #26 on 09/06/13. CNA-T confirmed Resident #26 had her incontinence brief fastened when in bed. CNA-T was able to verbalize her role in pressure ulcer prevention for Resident #26 including good incontinence care, assist with repositioning, and assist with eating. On 09/10/13 at 2:35 p.m., Surveyor # interviewed RN-Z who identified herself as one of the wound certified nurses. RN-Z stated she was not aware Resident #26 had any pressure ulcers. RN-Z stated if the licensed nurse on the unit does not contact the wound care nurses, the resident does not get assessed by the wound care nurses. RN-X approached Surveyor # during the above interview and identified herself as the other wound certified nurse. RN-Y stated she had never assessed Resident #26. RN-Y stated she was unaware Resident #26 had any pressure ulcers. On 09/12/13, the facility provided a physician progress notes [REDACTED]. The Medical Director diagnosed Contact [MEDICAL CONDITION] for Resident #26's raised rash which was adjacent to the anus on the left buttock. On 09/12/13 at 3:23 p.m., Surveyor # telephoned the facility and spoke with RN-HH. RN-HH identified herself as the nurse who assisted the Medical Director in examining Resident #26's skin. RN-HH stated the Medical Director examined Resident #26's buttock area and because the sacral pressure ulcer was currently healed, the Medical Director made no changes to the current treatment. RN-HH stated the Medical Director diagnosed Contact [MEDICAL CONDITION] for the red rash on the left buttock, not the sacral crease. Example #3: Resident #12 was admitted to the facility in September 2012 for long term care related to arthritis, memory loss, kidney disease, and [MEDICAL CONDITION]. Review of the "Resident Care Summary" noted Resident #12 required total assist with positioning, was incontinent of bladder and bowel, was to be repositioned every hour, was to lay side to side, and lay down after meals. The facility completed a care plan for Resident #12 titled "High-Risk -Potential for impaired skin integrity..." dated 02/22/13. The care plan identified risk factors of decreased mobility, incontinence, impaired sensory perception, and rejection of cares for skin breakdown. The care plan also noted a history of denuded sacrum and 2 small superficial areas along the bony prominence of Resident #12's spine. The goal was to heal wounds. The approaches were to reposition every 1 hour and to provide incontinence care including the application of barrier cream to the buttocks. The facility completed a Braden scale on 02/18/13 and noted Resident #12 to be at low risk for pressure ulcers. The risk factors noted were limited mobility, potential for shear/friction, and problems with moisture. The facility completed another Braden scale on 09/05/13 and noted Resident #12 to be at moderate risk for pressure ulcers. The risk factors noted were mobility, moisture, poor nutrition, limited activity, and potential for friction/shearing. Review of the nurse's notes on 02/22/13, noted Resident #12 had a stage III pressure ulcer on the sacrum that measured 1.0 cm by 0.6 cm. The treatment ordered was [MEDICATION NAME] a topical barrier cream. The facility added an air mattress and increased the repositioning to every hour. Surveyor # reviewed all of the nurse's notes from 02/22/13 through 09/05/13 and was not able to locate consistent staging of the wound, only rare measurements of the wound, only rare descriptions of the wound bed, etc., in accordance with current standards of practice and the facility policy. On 02/25/13, RN-Z documented a stage II pressure ulcer on the sacrum, but did not measure the wound. RN-Z back-staged the sacral wound, which was not in accordance with the National Pressure Ulcer Advisory Panel standards. RN-Z was the wound care nurse. On 03/06/13, the sacral pressure ulcer was documented as healed. On 09/03/13, the sacral pressure ulcer reopened. The facility continued with the same topical treatment. The facility did not consult with the physician or change the care plan. There was no documentation to indicate when the sacral pressure ulcer healed. On 09/06/13, Surveyor # observed the area to have intact skin. On 09/03/13, the nurse's notes read "Two small circular open areas along spine...Superior area has smooth tan slough base, edges slight pink. Inferior spot base is pink granulating tissue...Gently cleansed and barrier cream applied...Will have NP (Nurse Practitioner) assess areas in the morning..." On 09/04/13, the [MEDICATION NAME] spine pressure ulcers were covered with a dry dressing. On 09/06/13 at 7:40 a.m., Resident #12 was observed lying in bed on his right side. Surveyor # noted a dressing in place on the [MEDICATION NAME] spine area. On 09/06/13 at 8:40 a.m., Resident #12 was provided total staff assistance with hygiene and dressing by CNA-T and CNA-U. Resident #12 requested to stay in bed and CNA-T and CNA-U honored that request. Surveyor # asked CNA-T to expose Resident #12's buttock area and the Surveyor observed the skin to be intact. On 09/10/13 at 9:15 a.m., Surveyor # observed CNA-T assist Resident #12 to his room. CNA-T raised Resident #12's shirt and the Surveyor noted a proximal (above) stage III pressure on the [MEDICATION NAME] spine that measured approximately 0.5 cm (centimeters) and had yellow slough in the wound bed. The periwound (skin around the ulcer) was pink. The Surveyor also observed another pressure ulcer just below the stage III. The distal (below) [MEDICATION NAME] spine pressure ulcer was a stage II that measured approximately 0.3 cm and had a pink wound bed and pink periwound. Both pressure ulcers were open to air. On 09/10/13 beginning at 9:35 a.m., Surveyor # conducted a continual observation of Resident #12. Resident #12 was observed lying in bed slightly rolled to the right and off of his back. At 11:20 a.m., Resident #12 yelled "help" and CNA-FF and RN-GG entered Resident #12's room and repositioned him. Resident #12 went 1 hour and 45 minutes before he was repositioned. Resident #12's care plan states to reposition every hour. On 09/10/13 at 2:35 p.m., Surveyor # interviewed RN-Z who identified herself as one of the wound certified nurses. RN-Z stated she had assessed Resident #12 once, but not recently. RN-Z stated if the licensed nurse on the unit does not contact the wound care nurses, the resident does not get assessed by the wound care nurses. The Surveyor asked if a topical barrier cream was an appropriate treatment choice for a stage III pressure ulcer. RN-Z stated a stage III ulcer should be covered with a dressing, and that a topical cream was not an appropriate treatment choice. RN-Y approached Surveyor # during the above interview and identified herself as the other wound certified nurse. RN-Y stated she had never assessed Resident #12. RN-Y stated she was unaware Resident #12 had any pressure ulcers. Example #4: On 9/6/13 at 8:33 a.m., Surveyor # observed RN-A cleanse the stage II pressure ulcer on Resident #4's left lateral malleolus (left outer ankle). RN-A cleansed the wound with normal saline on a Q-tip and applied a skin preparatory spray to the skin around the wound, while a CNA held up the Resident's calf and ankle. As RN-A changed her gloves and cleansed her hands with antimicrobial gel, the CNA set Resident #20's wound directly on the mattress as the resident indicated he was uncomfortable with his leg raised. RN-A then applied the new dressing without cleaning the now recontaminated wound. Surveyor # reviewed the facility's policy and procedure for wound care, dated July 2012. The policy is titled "Nursing Home - Dressing Changes/Wound Care." The policy does not expressly direct staff to keep the wound base free of contamination after cleansing or to re-clean a wound should it become rec