Every finding on record at North Ridge Health and Rehabilitation Center

Based on observation, staff interview, and record review, the facility did not ensure food was served under safe and sanitary conditions. This practice had the potential to affect more than 4 of the 56 residents residing in the facility. Staff did not use utensils while plating lunch items, including diced tomatoes, shredded lettuce, shredded cheese, soft shell tortillas, and bread. R14, R15, and R16's medical records indicated they were allergic to tomatoes. R14, R15, and R16 received potentially cross-contaminated lunch items on 4/14/26. Findings include: The 2022 Federal Food and Drug Administration (FDA) Food Code indicates: Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: Improper holding temperatures; Inadequate cooking, such as undercooking raw shell eggs; Contaminated equipment; Food from unsafe sources; and Poor personal hygiene 2-301.14 When to Wash: .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (I) After engaging in other activities that contaminate the hands .3-304.15 Gloves, Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation .2-103.11 Person in Charge: The person in charge shall ensure that: .(N) Except when approval is obtained from the regulatory authority as specified in 3-301.11(E), Employees are preventing cross-contamination of ready-to-eat food with bare hands by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment; .(O) Employees are properly trained in food safety, including food allergy awareness, as it relates to their assigned duties. Food allergy awareness includes describing foods identified as major food allergens and the symptoms that a major food allergen could cause in a sensitive individual who has an allergic reaction .On 4/14/26 at 11:48 PM, Surveyor observed [NAME] (CK)-C don single-use gloves to plate meals for residents. The 4/14/26 lunch meal consisted of flour tortilla tacos with taco meat, shredded lettuce, diced tomatoes, shredded cheese, refried beans, and gelatin with topping. Sour cream was available in individual servings. Food and items touched throughout food service by CK-C with single-use gloves included a container of shredded lettuce, a container of diced tomatoes, a container of shredded cheese, a bag of soft shell tortillas (inner and outer packaging), a loaf of bread (inner and outer packaging and the bread itself), individually packaged sour cream containers, plates, a plate warmer, a taco meat scoop, a refried beans scoop, dessert bowls, trays, and meal tickets. Surveyor noted CK-C wore the same gloves to plate all meals for residents eating in the dining room, all residents eating on the 200 unit, and most of the 500 unit. CK-C continued plating meals for residents on the 600 unit as Surveyor observed delivery of the 500 unit meal cart. CK-C changed gloves once during plating of meals for the 500 unit. At that point, the lettuce, tomatoes, and cheese were contaminated. 2. On 4/14/26, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had a diagnosis of traumatic spinal cord dysfunction. R14's Quarterly Minimum Data Set (MDS) assessment, dated 1/16/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R14 had intact cognition.R14's medical record contained a diet order for regular texture and thin liquids. R14's 4/14/26 lunch meal ticket included entree substitute, starch substitute, vegetable substitute, and sour cream. On 4/14/26, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had a diagnosis of non-traumatic brain dysfunction. R15's Quarterly MDS assessment, dated 4/7/26, had a BIMS score of 15 out of 15 which indicated R15 had intact cognition.R15's medical record contained a diet order for low concentrated sweets (LSC), pureed texture, and MT2 (IDDSI - International Dysphagia Diet Standardization Initiative - mildly thick) nectar thick liquids. R15's 4/14/26 lunch meal ticket included taco meat with bread, refried beans, and sour cream. R15's meal was pureed by CK-C prior to meal service.On 4/14/26, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had a diagnosis of neurological condition. R16's Quarterly MDS assessment, dated 2/20/26, had a BIMS score of 11 out of 15 which indicated R16 had moderately impaired cognition.R16's medical record contained a diet order for a regular diet, soft and bite sized (IDDSI SB6 soft and bite sized) texture. R16's 4/14/26 lunch meal ticket included taco meat with bread, refried beans, and sour cream.On 4/14/26 at 1:38 PM, Surveyor reviewed a list of all residents' allergies. R14, R15, and R16 were identified as having a tomato allergy which was confirmed upon review of R14, R15, and R16's medical records. Upon identifying residents with a tomato, lettuce, dairy/cheese, or gluten allergy, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Through interview, it was determined the tomato allergies listed were not allergies but were the residents' preferences. Since there was no place to list preferences on meal tickets, preferences were noted in the allergy section of a resident's medical record and reflected on the resident's meal ticket. NHA-A and DON-B indicated kitchen staff plate food based on meal tickets. It was not identified by CK-C that a resident with a tomato allergy had the potential to be exposed to tomato due to cross-contamination of the lettuce, cheese, soft shells, bread, or any equipment that came in contact with tomatoes and could transfer to a resident with a true tomato allergy. Surveyor reviewed the weekly menus for each of the following diet types: ~ Diet: Regular/Texture: Regular (R14): taco with flour tortilla, refried beans, shredded lettuce, diced tomato~ Diet: LCS/Texture: Pureed (R15): taco meat and bread, refried beans, vegetable assorted frozen, gelatin with topping~ Diet: Regular/Texture: Soft and Bite Sized (SB6) (R16): taco meat and bread, refried beans, vegetable assorted frozen, gelatin ST (slightly thickened per IDDSI), thickenedOn 4/15/26 at 3:28 PM, Surveyor interviewed FSD-D who verified CK-C should have used utensils to plate food items instead of gloves. FSD-D understood the cross-contamination concern with the food items including the risk with tomato listed as an allergy on residents' meal tickets.On 4/15/26 at approximately 3:30 PM, Surveyor interviewed CK-C regarding what R14, R15, and R16 received for lunch since Surveyor did not observe meal plating for the 600 unit. CK-C stated R14 received lettuce and cheese, but did not receive tomatoes. CK-C did not know why R14's menu indicated an entree substitute because R14 ate tacos and that is what CK-C served R14. CK-C stated R15 did not receive lettuce or tomatoes in the puree' however, CK-C blended taco meat with cheese. CK-C stated R15 used to eat tomatoes but no longer did which was why tomatoes were listed as an allergy. (Of note, CK-C stated R15's lunch meal was pureed prior to meal service. CK-C did not have tongs for the shredded cheese.) CK-C stated R16 received taco meat, bread, and refried beans. CK-C stated R16 could not eat tomatoes due to stomach acid issues and did not receive tomatoes. (Of note, R16's meal was prepared using potentially cross-contaminated bread.) CK-C verified CK-C should have used tongs to serve shredded lettuce, diced tomatoes, and shredded cheese instead of gloves. CK-C acknowledged the potential consequences of cross-contamination. FSD-D stated the facility followed the FDA Food Code and confirmed tongs should have been used to avoid cross-contamination.

Based on observation, staff and resident interview, and record review, the facility did not ensure food preferences were honored for 1 resident (R) (R9) of 4 sampled residents.R9's 4/14/26 lunch ticket listed R9's meal preferences. R9 was served two items R9 requested not to receive.Findings include: From 4/13/26 to 4/14/26, Surveyor reviewed R9's medical record. R9 was readmitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), morbid obesity, type 2 diabetes mellitus, and congestive heart failure (CHF). R9's Quarterly Minimum Data Set (MDS) assessment, dated 1/19/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9's cognition was intact. R9 was R9's own decision maker.R9's medical record contained a diet order, dated 10/10/25, for limited concentrated sweets (LSC), regular texture, regular/thin consistency. On 4/14/26 at 11:48 PM, Surveyor observed [NAME] (CK)-C plate meals for residents. CK-C informed Surveyor that each resident's meal ticket is personalized. CK-C stated the facility honors food preferences through the use of individualized meal tickets. On 4/14/26 between 12:13 PM and 12:28 PM, Surveyor observed CK-C plate R9's meal. CK-C added two soft shells with taco meat and put shredded lettuce, diced tomatoes, and shredded cheese on R9's plate. CK-C also put a bowl of refried beans on the tray. Food Services Director (FSD)-D stated R9 requested gelatin without topping. Surveyor noted the gelatin was pre-prepared and put in small plastic containers with lids. CK-C handed FSD-D two gelatin cups that contained whipped topping. CK-C informed FSD-D there was not any gelatin without topping. CK-C scraped the whipped topping off the gelatin and put the gelatin in a new container. R9's lunch tray was placed in the delivery cart.On 4/14/26 at 12:28 PM, Surveyor observed Dietary Aide (DA)-E deliver the meal cart to R9's unit. Staff immediately began meal service.On 4/14/26 at 12:31 PM, Surveyor observed Certified Nursing Assistant (CNA)-F deliver R9's meal tray. When CNA-F left R9's room, R9 and Surveyor compared R9's meal ticket with the food received. Surveyor and R9 verified R9's meal ticket indicated R9 wanted two tacos with refried beans in a bowl, diced tomatoes, and gelatin without topping. R9's plate contained shredded lettuce. R9 took the cover off the gelatin and asked if Surveyor could see the white spots of whipped topping that appeared to be scraped off. R9 stated R9 would not eat the gelatin. R9 removed the tomatoes from the pile of lettuce and put them on the tacos. On 4/14/26 at 3:28 PM, Surveyor interviewed FSD-D who stated residents receive a weekly meal plan. Residents make choices and indicate their preferences on the meal plan. When the kitchen receives the weekly meal plan, FSD-D prints the meal ticket and writes or highlights the resident's preference for the meal being served. The meal tickets are used to serve the meal to ensure accuracy. When Surveyor informed CK-C and FSD-D that R9 received lettuce for lunch and noticed white spots on the gelatin, CK-C stated CK-C did not notice R9 did not want lettuce and apologized for the oversight. CK-C and FSD-D acknowledged the topping was scraped off the gelatin and should not have been.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 42 of 53 residents residing in the facility. (Eleven residents received nutrition via tube feeding). Staff did not monitor wash or rinse temperatures for the low-temp chemical sanitizing mechanical warewashing machine.The mixer was not covered.Staff working in the kitchen did not consistently cover facial hair.Findings include:On 12/8/25 at 9:37 AM, Surveyor began an initial kitchen tour with Dietary Manager (DM)-I who indicated the facility followed the Wisconsin Food Code.The Wisconsin Food Code documents at 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature: (B) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120 degrees Fahrenheit (F).On 12/10/25 at 1:15 PM, Surveyor observed [NAME] (CK)-L complete dishwashing. Surveyor observed 2 racks of dishes go through the facility's low-temp chemical sanitizing dishwasher. The wash temperature reached 100 degrees F and the rinse temperature reached 108 degrees F for each load. When Surveyor asked what the temperature should be, CK-L did not know. Surveyor observed a sticker on the dishwasher that stated the minimum wash and rinse temperature was 120 degrees F. On 12/10/25 at 1:19 PM, Surveyor observed a poster on the wall where clean dishes emerge from the machine that indicated: Low-temp warewashing instructions: Check the water temperature gauge for the correct temperature: 120-140 degrees F. On 12/10/25 at 1:20 PM, Surveyor reviewed the facility's dishwasher logs and noted staff documented the chemical sanitizer but not the dishwasher temperature. DM-I confirmed dishwasher temperatures were not documented and indicated DM-I needed to find a new log.2. The Wisconsin Food Code documents at 2-402.11: .Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. On 12/9/25 at 11:30 AM, Surveyor observed lunch preparation and service. Surveyor noted Dietary Aide (DA)-J had chin hair but was not wearing a beard net. Surveyor informed Nursing Home Administrator (NHA)-A of the observation during the exit conference on 12/9/25.On 12/10/25 at 11:00 AM, Surveyor entered the kitchen and asked DA-J when dishwashing would begin. DA-J was not wearing a beard net. DA-J stated a beard net did not fit and removed a surgical mask from DA-J's pocket. DA-J stated DA-J should be wearing the mask.3. The Wisconsin Food Code documents at 4 903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored .(1) In a self-draining position that allows air drying; and (2) Covered or inverted.During the initial kitchen tour on 12/8/25, Surveyor observed an uncovered large mixer bowl on the mixer. When Surveyor asked DM-I about the bowl, a staff nearby informed DM-I that the facility was out of bags used to cover the mixer bowl. DM-I indicated DM-I would order more bags. On 12/10/25 at 11:00 AM, Surveyor entered the kitchen and noted the mixer bowl was still uncovered. DM-I confirmed in a later interview that the bowl was still uncovered.

Based on staff interview and record review, the facility did not ensure a WanderGuard (a security device that triggers an alarm if the wearer exits the facility) was consistently checked for placement, function, and skin integrity underneath for 1 resident (R) (R42) of 1 sampled resident.R42's Treatment Administration Record (TAR) contained orders to check for WanderGuard placement, function, and skin integrity. The checks were not consistently completed.Findings include: The facility's Elopements and Wandering Residents policy, revised [DATE], indicates: .1. The facility is equipped with door locks/alarms to help avoid elopements .3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4 .e) Charge nurses and unit managers will monitor the implementation of interventions and response to interventions and document accordingly .adequate supervision will be provided to help prevent accidents or elopements. From [DATE] to [DATE], Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses including fracture of skull and right facial bones, diabetes, and alcohol dependence. R42's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R42 had severe cognitive impairment. R42 had an activated Power of Attorney for Healthcare (POAHC). A care plan, initiated [DATE] and revised [DATE], indicated R42 was at risk for elopement related to exit-seeking behavior and verbalization to leave the facility. The care plan also indicated R42 was at risk for falls, accidents, and incidents related to weakness and decreased mobility. On [DATE] at 11:48 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-K regarding how staff ensure R42's WanderGuard is in working order. LPN-K indicated there is a tester box to check the WanderGuard which is checked on the night shift. On [DATE] at 12:12 PM, Surveyor reviewed R42's [DATE] and [DATE] TARs and noted the following orders: ~ Elopement risk .check skin integrity, function, placement, and expiration every shift, replace immediately if found to be expired, in ill repair, or non-functioning. The order was not documented as completed on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. ~ Check placement every shift. The order was not documented as completed on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. ~ Check skin integrity under WanderGuard to right ankle every shift, document. The order was not documented as completed on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 12:59 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed there was missing documentation to check R42's WanderGuard for function, placement, and skin integrity in October and November. DON-B indicated checks for all dates in the TAR should have been completed and documented to ensure R42's safety.

Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R31) of 19 sampled residents.Medications were left at R31's bedside for R31 to self-administer. R31 did not have a self-administration of medication assessment, a physician order, or a care plan that indicated R31 could safely and accurately self-administer medication.Findings include:The facility's Resident Self-Administration of Medication policy, dated 2/22/24, indicates: A resident may only self-administer medications after the facility's Interdisciplinary Team (IDT) has determined which medications may be self-administered safely .4. The results of the IDT assessment are recorded on the Medication Self-Administration Assessment Form which is placed in the resident's medical record .14. The care plan must reflect resident self-administration and storage arrangements for such medicationsFrom 12/8/25 to 12/10/25, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, atrial fibrillation, gout, heartburn/reflux, cellulitis of left lower limb, and resistance to multiple antimicrobial drugs. R31's Minimum Data Set (MDS) assessment, dated 11/20/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31 made R31's own healthcare decisions.On 12/10/25 at 8:48 AM, Surveyor observed Licensed Practical Nurse (LPN)-K leave a cup of medications on R31's bedside table. When Surveyor asked what the medications were, LPN-K stated LPN-K thought one was bumetanide but could not recall the others. LPN-K checked the computer on the medication cart and indicated R31 received acetaminophen, allopurinol, bumetanide, apixaban, lactobacillus, and Pepcid. LPN-K indicated R31 had a self-administration of medication assessment completed. Surveyor noted R31 had the following physician orders: ~ Bumetanide 1 milligram (mg) by mouth twice daily for urination related to chronic systolic (congestive) heart failure (ordered 11/8/25)~ Acetaminophen extra strength 500 mg twice daily for pain (ordered 11/19/25)~ Apixaban 5 mg by mouth twice daily for blood thinner related to unspecified atrial fibrillation (ordered 11/5/25)~ Allopurinol 100 mg once daily for gout (ordered 9/10/24)~ Lactobacillus oral capsule once daily for supplement (ordered 7/9/25) ~ Pepcid 20 mg once daily for heartburn/reflux (ordered 11/5/25)R31's medical record did not contain a self-administration of medication assessment, a physician order, or a care plan that indicated R31could self-administer medication.On 12/10/25 at 12:28 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R31 did not have a self-administration of medication assessment, physician order, or care plan to self-administer medication.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R7) of 1 sampled resident with a Guardian was protectively placed in the facility. R7 was admitted to the facility on [DATE] and had a legal Guardian of person and estate beginning 9/11/20. The facility did not have protective placement determination for R7. Findings include: State Statute Chapter 55.055(10)(b) requires court-ordered protective placement for any resident admitted to a nursing home who has a legal Guardian and whose nursing home stay exceeds sixty days. Protective placement is reviewed annually (State Statute Chapter 55.18) to determine if placement continues to be the least restrictive and in the best interest of the individual.On 12/8/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including intellectual disability, bipolar disorder, and diabetes. R7's Minimum Data Set (MDS) assessment, dated 9/17/25, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R7 had severely impaired cognition. R7 had a Guardian for healthcare decisions. Surveyor noted R7's medial record did not contain protective placement paperwork.On 12/9/25 at 1:33 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and requested protective placement documentation and an annual review of the protective placement ([NAME] Review) for R7. NHA-A indicated R7 was not protectively placed in the facility and did not need to be protectively placed based on the State's findings.On 12/9/25 at 2:55 PM, Surveyor interviewed Social Worker (SW)-H who indicated the facility did not have protective placement paperwork for R7. SW-H indicated R7 was privately placed under Guardianship of person and estate and protective placement was not needed at the time of admission. SW-H indicated unless R7 was enrolled in a family care organization, R7 did not require protective placement. SW-H stated SW-H spoke to R7's Guardian who referred SW-H to an Adult Protective Services (APS) designee. SW-H communicated with the APS designee via email who informed SW-H that protective placement was not needed at the time of admission. Since R7 was not enrolled in a family care organization, SW-H was not certain that protective placement was needed. SW-H was not aware of the state statute that requires protective placement in order to reside in a nursing home if a resident has a legal Guardian. Surveyor referred SW-H to Wisconsin State Statute Chapter 55 which requires court-ordered protective placement for nursing home residency for individuals with Guardians. Surveyor also referred SW-H to the State Corporate Guardianship Program Coordinator for further guidance.

Based on observation, staff interview, and record review, the facility did not ensure freedom from physical restraints imposed for the purpose of discipline or convenience and not required to treat medical symptoms for 1 resident (R) (R49) of 1 sampled resident. The facility's Restraint Free Environment policy, revised 2/5/25, indicates: The resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use .a physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints include .applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove .physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner .the facility is responsible for the appropriateness of the determination to use a physical restraint. Before a resident is physically restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints and determine: a. How the use of restraints would treat the medical symptom(s). b. The length of time the restraint is anticipated to be used, who may apply the restraint, and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during the use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being .The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions to address any risks related to the use of the restraint. Potential negative outcomes should also be reviewed, including but not limited to: decline in physical functioning, decrease in muscle condition, contractures, increased risk for infection, pressure ulcers/injuries, delirium, agitation, incontinence, accidents, loss of autonomy/dignity, or withdrawal. From 12/8/25 to 12/9/25, Surveyor reviewed R49's medical record. R49 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, history of stroke, chronic obstructive pulmonary disease (COPD), dysphagia, anxiety, hemiplegia of the right side, and schizophrenia. R49's most recent Minimum Data Set (MDS) assessment, dated 9/4/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R49 had severe cognitive impairment. On 12/8/25 at 10:13 AM and 12/9/25 at 9:15 AM, Surveyor observed a hand mitt on R49's left hand. R49's most recent comprehensive care plan, revised 9/4/25, did not include risks, goals, or interventions related to the restraint mitt. R49's medical record did not include any restraint assessments since R49's admission or an order for the restraint mitt. On 12/9/25, Surveyor reviewed paperwork from R49's most recent hospitalization on 11/12/25 that indicated R49 was hospitalized due to dislodging R49's feeding tube at the facility. The discharge summary did not mention a restraint mitt. On 12/9/25, Surveyor reviewed visit notes from Nurse Practitioner (NP)-C. On 11/24/25 and 11/26/25, NP-C stated R49 had a mitt on the left hand. Staff reported that R49 was pulling on R49's feeding tube. On 12/9/25 at 9:18 AM, Surveyor interviewed agency Registered Nurse (RN)-D who verified R49 was wearing a restraint mitt but was not sure why. On 12/9/25 at 9:50 AM, Surveyor interviewed RN-E who indicated the restraint mitt was used to prevent R49 from pulling on R49's feeding tube. On 12/9/25 at 10:02 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who verified the restraint mitt was used to prevent R49 from pulling on R49's feeding tube and trach. CNA-F was not sure who put the mitt on R49 that morning. On 12/9/25 at 11:22 AM, Surveyor interviewed Director of Nursing (DON)-B who stated R49 must have come back from the hospital with the restraint mitt which has happened when residents who pull on their tubes go the hospital. DON-B thought nursing staff might be using the restraint mitt. DON-B verified that R49 did not have an order, assessment, or care plan related to the restraint mitt. DON-B indicated the restraint mitt was not necessary because the position of R49's tube feeding was changed during R49's last hospitalization. DON-B removed the mitt from R49's room after the interview. On 12/9/25 at 11:50 AM, Surveyor interviewed NP-C verified NP-C observed the restraint mitt on R49's left hand during visits on 11/24/25 and 11/26/25. NP-C indicated NP-C did not order the restraint mitt and confirmed it should be included in R49's care plan. NP-C stated the restraint mitt was likely due to R49 pulling on R49's feeding tube.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R42) of 5 sampled residents met the Preadmission Screening and Resident Review (PASRR) requirements.R42 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R42 received a qualifying diagnosis and was prescribed medication. Findings include:The Wisconsin Department of Health Services (DHS) PASRR for current or prospective nursing home residents Level II Screen facesheet indicates: .nursing home should retain a copy of this facesheet and attached documentation in the person's current medical record. If the person's condition or diagnoses change so that he/she later may meet the federal definition of a developmental disability or a serious mental illness, the nursing home will need to submit an updated Level II Screen to the appropriate PASRR contract agency. This can be found at https://www.dhs.wisconsin.gov/pasrr/resources.htm.From 12/8/25 to 12/10/25, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses including fracture of skull and right facial bones, diabetes, and alcohol dependence. R42's Minimum Data Set (MDS) assessment, dated 10/23/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R42 had severe cognitive impairment. R42 had an activated Power of Attorney for Healthcare (POAHC). R42's medical record contained a diagnosis of anxiety (dated 10/8/25 which was the date of R42's admission). R42's MDS assessment, dated 10/23/25, indicated R42 received antipsychotic and antianxiety medications. R42's medical record did not contain a PASRR Level II Screen.On 12/9/25 at 1:23 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who indicated R42 did not have a mental illness diagnosis prior to admitting to the facility, therefore, a Level II Screen was not completed. When Surveyor indicated R42's medical record indicated R42 was diagnosed with anxiety on 10/8/25, NHA-A indicated Social Worker (SW)-H would have more information about the PASRR process.On 12/9/25 at 2:42 PM, Surveyor interviewed SW-H who indicated a PASRR Level II Screen should have been submitted for R42 with a new mental illness diagnosis of anxiety on 10/8/25. SW-H verified R42 was diagnosed with anxiety at the facility on 10/8/25 and was not aware that a Level II Screen was needed.

Based on staff interview and record review, the facility did not ensure assessments, vital signs, and weights were consistently completed pre- and post-dialysis and communicated to the dialysis facility for 1 resident (R) (R9) of 1 sampled resident.Staff did not consistently obtain R9's pre- and post-dialysis vitals signs and weight or check R9's access port. In addition, staff did not consistently complete R9's dialysis communication sheets and Treatment Administration Record (TAR).Findings include:The facility's Hemodialysis policy, dated 12/22/24, indicates: This facility will provide the necessary care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis .This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility .Ongoing communication and collaboration with the dialysis center regarding dialysis care and services .c) Documentation requirements are met to assure treatments are provided as ordered by the nephrologist, attending practitioner, and dialysis team .8) The nurse will monitor and document the status of the resident's access site upon return from the dialysis treatment to observe for bleeding or other complications .14) The nurse will ensure the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill .From 12/8/25 to 12/10/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease and dependence on renal dialysis. R9's Minimum Data Set (MDS) assessment, dated 9/22/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 had intact cognition.R9's TAR contained the following physician orders with multiple missing entries:~ Dialysis: Check access site for bleeding every shift (start date 9/9/25). R9's TAR did not indicate the order was completed on: 9/16/25, 9/19/25, 9/26/25, 9/29/25, 10/6/25, 10/14/25, 10/15/25, 10/17/25, 10/22/25, 10/23/25, 10/24/25, 10/31/25, 11/14/25, 11/15/25, and 11/16/25.~ Dialysis: Check shunt for bruit/thrill every shift (start date 9/9/25). R9's TAR did not indicate the order was completed on: 9/16/25, 9/19/25, 9/26/25, 9/29/25, 10/6/25, 10/14/25, 10/15/25, 10/17/25, 10/22/25, 10/23/25, 10/24/25, 10/31/25, 11/14/25, 11/15/25, and 11/16/25.~ Dialysis: Daily weight, every day shift (start date 9/10/25; discontinued 10/27/25). R9's TAR did not indicate the order was completed on: 9/16/25, 9/19/25, 9/26/25, 10/14/25, 10/15/25, 10/19/25, 10/22/25, and 10/23/25.~ Dialysis: Weight, vital signs taken before and after dialysis two times daily every Monday, Wednesday, and Friday (start date 10/24/25; discontinued 12/5/25). R9's TAR did not indicate the order was completed on: 10/24/25, 10/31/25, 11/7/25, 11/12/25, 11/14/25, and 11/19/25~ Dialysis: Communication form one time a day every Monday, Wednesday, and Friday. R9's TAR did not indicate the order was completed on: 9/19/25, 9/25/25, 10/15/25, 10/22/25, 10/31/25, and 11/14/25~ Vital signs prior to sending to dialysis every dayshift (start date 10/1/25; discontinued 12/9/25). R9's TAR did not indicate the order was completed on: 10/15/25, 10/22/25, 10/24/25, 10/31/25, and 11/14/25.~ Vital signs upon returning from dialysis every evening shift every Monday, Wednesday, and Friday (start date 10/1/25). R9's TAR did not indicate the order was completed on: 10/15/25, 10/17/25, 10/22/25, and 11/14/25.Surveyor reviewed R9's dialysis communication binder and noted missing documentation on R9's communication forms for pre-dialysis vital signs on the following dates: 10/1/25,10/3/25, and 10/22/25. Surveyor noted missing documentation on R9's communication forms for post-dialysis vital signs on the following dates: 10/1/25, 10/6/25, 10/8/25, 10/13/25, 10/15/25, 10/17/25, 10/22/25, 10/31/25, 11/3/25, 11/5/25, 11/10/25, 11/12/25, 11/14/25, 11/17/25, 11/19/25, 11/26/25, 11/28/25, 12/3/25, and 12/8/25.On 12/9/25 at 3:17 PM and 3:36 PM, Surveyor interviewed Registered Nurse (RN)-G who indicated R9's vital signs, weight, and port assessment should be completed prior to leaving for dialysis by the night (NOC) shift nurse and should be documented in R9's medical record. RN-G indicated RN-G documented in R9's medical record but did not fill out R9's dialysis communication binder.On 12/10/25 at 9:25 AM, Surveyor interviewed Director of Nursing (DON)-B who verified staff did not consistently check R9's pre- and post-dialysis vital signs or weight, check R9's port, or document on R9's TAR. DON-B indicated NOC shift nurses complete pre-dialysis assessments and AM shift nurses complete post-dialysis assessments. DON-B indicated staff should consistently assess a resident's vital signs, weight, and port pre- and post-dialysis. DON-B also confirmed R9's dialysis communication forms were not consistently completed.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of medication for 4 residents (R) (R1, R5, R4, and R3) of 9 sampled residents. In addition, the facility did not ensure narcotic medication was consistently reconciled. These practices had the potential to affect more than 4 of the 57 residents residing in the facility.R1, R5, R4, and R3's medications were not administered in accordance with the ordered administration time and facility policy.Nursing staff did not complete controlled substance counts at shift change.Findings include:The facility's undated Medication Administration policy indicates: .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.The facility's undated Liberalized Medication Administration policy indicates: Medication Administration Timeframes: .c) Twice daily, Three or More Times Daily: Administer within 30 minutes to 1 hour before or after scheduled time or as directed by provider and/or pharmacist.1. On 10/7/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF), morbid obesity, chronic pulmonary edema, lymphedema, chronic pain, anxiety disorder, and obstructive sleep apnea. R1's Minimum Data Set (MDS) assessment, dated 7/17/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was responsible for R1's healthcare decisions. On 10/7/25, Surveyor reviewed R1's medication orders which included:~ Furosemide oral tablet 40 milligrams (mg), give 1 tablet by mouth twice daily (BID) for CHF (dated 11/16/24)R1's Medication Administration Record (MAR) indicated furosemide should be administered at 6:00 AM and 11:00 AM. Surveyor reviewed R1's MAR for 9/1/25 to 10/6/25 and noted furosemide was administered at the following times:~ 9/6/25 - 3:41 PM and 3:43 PM~ 9/12/25 - 4:24 PM and 4:25 PM~ 9/25/25 - 9:22 AM and 10:08 [NAME] 10/7/25 at 1:50 PM, Surveyor interviewed R1 who indicated the AM medication pass is from 6:00 AM to 10:00 AM. R1 indicated residents can receive medications 1 to 2 hours after the ordered medication administration time. R1 stated R1 receives medications 2 or more hours after the ordered medication administration time. 2. On 10/7/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including chronic respiratory failure, chronic ostructive pulmonary disease (COPD), anxiety, CHF, thrombocytopenia, rheumatoid arthritis, and dependence upon a ventilator. R5's MDS assessment, dated 8/11/25, had a BIMS score of 12 out of 15 which indicated R5 had moderate cognitive impairment. R5 was responsible for R5's healthcare decisions. On 10/7/25 at 9:30 AM, Registered Nurse (RN)-D administered the following medications to R5. The medications were scheduled to be administered at 6:00 AM: ~ Atorvastatin 40 mg, give 1 tablet daily for hyperlipidemia~ Buspirone HCL 10 mg, give 1 tablet BID for anxiety~ Ferrous sulfate 325 mg, give 1 tablet daily~ Folic acid 5 mg, give 1 tablet daily~ Gabapentin 300 mg, give 1 tablet 3 times daily (TID) for neuropathy~ Hydroxyzine HCL 50 mg, give 1 tablet TID~ Lidocaine 4% apply to back once daily for chronic pain~ Polyethylene 3350, give 17 grams (gm) daily for constipation~ Quetiapine fumarate 25 mg, give 1.5 tablet daily for mood~ Senna-S 8.6-50 mg BID for constipation~ Spironolactone 25 mg, give 1/2 tablet daily for edema3. On 10/7/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, COPD, anxiety, hypotension, schizoaffective disorder, depression, and dependence upon a ventilator. R4's MDS assessment, dated 8/14/25, indicated R4 was rarely/never understood. R4 had an activated Power of Attorney for Healthcare (POAHC).On 10/7/25 at 10:03 AM, RN-D administered the following medications to R4. The medication were scheduled to be administered at 6:00 AM: ~ Midodrine 2 mg TID for hypotension~ Valproic acid 250 mg/5 ml daily~ Tramadol 100 mg, give 1 tablet TID ~ Benztropine 2 mg, give 1 tablet BID~ Eliquis 2.5 mg, give 1 tablet daily~ Folic acid 800 mg, give 1 tablet daily~ Methenamine, give 1 gm BID~ Polyethylene glycol 3350, give 17 gm BID for constipation4. On 10/7/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including hemiplegia right side, chronic respiratory failure, dysphagia, Parkinson's disease, atrial fibrillation, metabolic encephalopathy, CHF, and dependence upon a ventilator. R3's MDS assessment, dated 6/28/25, indicated R3 was rarely/never understood. R3 had an activated POAHC.On 10/7/25 at 10:22 AM, RN-D administered the following medications to R4. The medications were scheduled to be administered at 6:00 AM: ~ Furosemide 20 mg, give 1 tablet daily for edema~ Eliquis 5 mg BID for atrial fibrillation~ Docusate sodium 100 mg daily for constipation~ Iron liquid-ferrous sulfate 220 mg/5 ml daily~ Metoprolol tartrate 25 mg, give 1/2 tablet BIDOn 10/7/25 at 1:35 PM, Surveyor interviewed RN-D who verified the medication order administration times for the medications RN-D administered to R3, R4, and R5 were 6:00 AM. RN-D indicated RN-D typically starts administering morning medications at 6:30 AM and is finished with the 6:00 AM medication pass at approximately 10:00 AM on the 200 wing. RN-D stated RN-D responds to ventilator alarms between administering medications. On 10/7/25 at 1:35 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated medication administration times are listed on residents' orders. DON-B indicated nurses have up to 2 hours after the ordered administration time to administer medications. DON-B stated if an order states to administer a medication at 6:00 AM, the nurse has until 8:00 AM to administer the medication.5. On 10/7/25 at 1:40 PM, Surveyor reviewed the facility's Controlled Substance Record Book for 9/1/25 to 10/6/25. Surveyor noted the following missing signatures in the 500 wing Controlled Substance Record Book 2:~ 9/1/25 - missing signatures for all shifts~ 9/2/25 - missing evening to night shift nurse signatures~ 9/3/25 - missing night to day shift nurse signatures; missing day to evening shift nurse signature; missing evening to night shift nurse signatures~ 9/4/25 - missing night to day shift nurse signature ~ 9/5/25 and 9/6/25 - missing signatures for all shifts~ 9/7/25 - missing night to day shift nurse signature; missing day to evening shift nurse signatures; missing evening to night shift nurse signature~ 9/10/25 - missing day to evening shift nurse signature; missing evening to night shift nurse signatures~ 9/11/25 and 9/12/25 - missing signatures for all shifts~ 9/13/25 - missing night to day shift nurse signature~ 9/18/25 - missing day to evening shift nurse signature; missing evening to night shift nurse signatures~ 9/19/25 - missing signatures for all shifts~ 9/20/25 - missing night to day shift nurse signature; missing day to evening shift nurse signature; missing evening to night shift nurse signatures~ 9/21/25 missing night to day shift nurse signatures; missing day to evening shift nurse signatures; missing evening to night shift nurse signature~ 9/26/25 - missing night to day shift nurse signature; missing day to evening shift nurse signature~ 10/1/25 - missing evening to night shift nurse signatures~ 10/2/25 - missing signatures for all shifts~ 10/3/25 - missing day to evening shift nurse signatures; missing evening to night shift nurse signatures~ 10/4/25 - missing signatures for all shifts~ 10/5/25 - missing night to day shift nurse signature; missing day to evening shift nurse signaturesSurveyor observed the following missing signatures in the 500 wing Controlled Substance Record Book 3:~ 9/1/25 - missing night and day shift nurse signatures~ 9/2/25 - missing evening to night shift nurse signatures~ 9/3/25 - missing signatures for all shifts~ 9/4/25 - missing night to day shift nurse signatures; missing day to evening shift nurse signatures~ 9/5/25 and 9/6/25 - missing signatures for all shifts~ 9/7/25 - missing night to day shift nurse signature~ 9/10/25 - missing evening to night shift nurse signature~ 9/11/25 - missing night to day shift nurse signature~ 9/12/25 - missing night to day shift nurse signatures; missing day to evening shift nurse signatures; missing evening to night shift nurse signature~ 9/13/25 - missing night to day shift nurse signature; missing day to evening shift nurse signature~ 9/14/25 - missing day to evening shift nurse signature; missing evening to night shift nurse signature~ 9/19/25, 9/20/25, 9/21/25 - missing signatures for all shifts~ 9/26/25 - missing night to day shift nurse signatures; missing day to evening shift nurse signature~ 10/2/25, 10/4/25, and 10/5/25 - missing signatures for all shiftsSurveyor observed the following missing signatures in the 600 wing Controlled Substance Record Book:~ 9/18/25 - missing day to evening shift nurse signatures; missing evening to night shift nurse signature~ 9/19/25 - missing signatures for all shifts~ 9/23/25 and 9/25/25 - missing night to day shift nurse signature~ 9/26/25 - missing night to day shift nurse signature; missing day to evening shift nurse signatures; missing evening to night shift nurse signatures~ 9/29/25 - missing night to day shift nurse signature; missing day to evening shift nurse signature; missing evening to night shift nurse signature~ 9/30/25 - missing night to day shift nurse signature; missing day to evening shift nurse signature~ 10/1/25 - missing evening to night shift nurse signature~ 10/2/25 - missing night to day nurse signatures; missing day to evening shift nurse signature~ 10/4/25 - missing night to day shift nurse signatureOn 10/7/25 at 1:30 PM, Surveyor interviewed RN-E who indicated the nurse ending the shift and the nurse starting the shift are responsible for counting narcotics in the medication cart and signing the Controlled Substance Record Book. RN-E indicated the book should be signed each day at each change of shift. On 10/7/25 at 1:35 PM, Surveyor interviewed DON-B who indicated education regarding signing the Controlled Substance Record Book was completed with all nursing staff on 9/12/25. DON-B provided an undated list of 10 nurse signatures and education material. The education indicated: It is imperative at the beginning of your shift when taking narcotic keys from the nurse who is ending their shift, that you both sign the nurse to nurse controlled substance count verification sheet after narcotics have been counted. This is located in the back of your narcotic record book. This is mandatory on both state and federal levels regarding narcotics. Not completing this will result in progressive disciplinary action that could lead up to and include termination.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R1) of 6 sampled residents received the appropriate care and services to promote healing and/or prevent pressure injuries from developing. R1 had a stage 3 presure injury on the coccyx upon admission. R1's wound care was not provided in accordance with a physician's order on 7/6/25. R1 developed a wound infection that required intravenous (IV) antibiotics and debridement.Findings include: The facility's Wound Treatment Management policy, revised 12/3/24, indicates: .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .On 8/6/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy due to carbon monoxide poisoning, hemiplegia and hemiparesis, tracheostomy, and pressure ulcer of sacral region stage 3. R1's Minimum Data Set (MDS) assessment, dated 6/16/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R1 had severely impaired cognition. R1 had a Guardian for healthcare decisions. A care plan, dated 6/10/25, indicated R1 had potential for infection related to trach and wounds and had a history of methicillin-resistant Staphylococcus aureus (MRSA) The goal indicated R1would remain free of complications related to infection. The care plan contained the following interventions: Contact precautions; Monitor/document/report as needed (PRN) any signs/symptoms of infection, including fever, redness, drainage or swelling around wounds or catheter site, cough, respiratory symptoms, dysuria, hematuria, flank pain, and foul-smelling urine; Monitor/document/report PRN abnormal laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures).Upon admission on [DATE], R1's wound measured 8.0 centimeters (cm) (length) x 3.0 cm (width) x 0.1 cm (depth) and was classified as a stage 3. A hospital Discharge summary, dated [DATE], indicated the wound was terminal. R1 had a treatment order to cleanse with normal saline and cover with a dry dressing every day one time a day for wound care (dated 6/9/25). Advanced Practice Nurse Prescriber (APNP)-E documented on 6/16/25 that R1's wound measured 5.0 cm x 0.8 cm x 0.1 cm. R1 had the following treatment order: Cleanse with normal saline or wound wash and pat dry. Apply honey gel to the wound bed and cover with a bordered foam dressing; Change 3 times per week and PRN. One time a day every Monday, Wednesday, and Friday (dated 6/16/25). APNP-E documented on 6/23/25 that R1's wound measured 5.0 cm x 1.5 cm x 0.1 cm. R1 had the following treatment order: Cleanse with normal saline or wound wash and pat dry. Apply Hydrofera blue foam to open area. Zinc to peri wound. Cover both with ABD (abdominal) (pad) and tape. One time a day for wound care (dated 6/23/25). APNP-E documented on 6/30/25 that R1's wound was stable and measured 5.4 cm x 2.4 cm x 0.1 cm. R1 had the following treatment order: Cleanse with normal saline or wound wash. Apply honey to wound and cover with Aquacel AG. Cover both with foam border. One time a day for wound care (dated 6/30/25). APNP-E documented on 7/7/25 that R1 had the wrong dressing in place. R1's wound had worsened, had a strong odor, and measured 11.0 cm x 9.0 cm x (unable to determine). R1 had the following treatment order: Cleanse with normal saline or wound wash. Apply Iodosorb to wound and cover with ABD. Two times a day for wound care (dated 7/7/25).R1's medical record indicated R1 had a temperature of 102 degrees Fahrenheit (F) and increased respirations on 7/7/25. Wound culture results were positive for MRSA and E-coli. R1 was started on IV cefepime and linezolid (antibiotic medications) on 7/8/25 for 7 days. A sacral X-ray was negative for osteomyelitis. R1 was started on Juven (a nutrition powder used to promote wound healing) and a vitamin D supplement. R1 was administered IV fluids on 7/9/25 and 7/10/25. On 7/11/25, a wound clinic appointment was scheduled for 7/17/25. At the request of Family Member (FM)-F, R1 was transported to hospital on 7/11/25 for evaluation and admitted to the Intensive Care Unit (ICU) with diagnoses of sepsis, wound infection, dehydration, and surgical debridement of wound. On 8/6/25 at 3:57 PM, Surveyor interviewed APNP-E who indicated on 7/7/25, R1's wound had changed drastically from the last visit. APNP-E documented in R1's treatment notes that the wound contained the wrong dressing on 7/7/25, however, APNP-E did not feel the wrong dressing would have made that significant of a change in the condition of the wound or impacted R1's outcome. On 8/7/25 at 10:08 AM, Surveyor interviewed FM-F who indicated Wound Registered Nurse (WRN)-G informed FM-F on 7/7/25 that R1's wound was getting worse. WRN-G indicated R1's wound contained the wrong dressing and staff were using the wrong kind of honey. FM-F indicated R1 had a condom catheter that consistently fell off. FM-F requested an indwelling catheter for R1. FM-F alerted staff on 7/7/25 that R1 was sick and had a temperature of 102 degrees F. FM-F stated a grievance was filed with Director of Nursing (DON)-B on 7/7/25.On 8/7/25 at 3:10 PM, Surveyor interviewed FM-C who indicated FM-C assisted with repositioning R1 on 7/6/25. FM-C indicated when R1 was rolled to the side, FM-C noted R1's coccyx dressing was saturated with urine and rolled up in a ball. FM-C indicated Licensed Practical Nurse (LPN)-D indicated the dressing should be water- and urine-proof. LPN-D left the room to obtain a new dressing and returned with a heart-shaped bandage. FM-C stated LPN-D applied something to the bandage and secured the bandage to R1's coccyx without cleansing the wound. LPN-D indicated to FM-C that it was LPN-D's first time working with R1.On 8/7/25 at 11:21 and 11:30 AM, Surveyor interviewed LPN-D who did not recall what type of dressing LPN-D applied to R1's coccyx on 7/6/25 and indicated LPN-D would have followed R1's order. LPN-D indicated FM-C stated the wound looked way worse than it had. LPN-D notified DON-B that FM-C was upset about the wound.On 8/7/25 at 4:42 PM, Surveyor interviewed WRN-G who indicated WRN-G and APNP-E assessed R1's wound and changed the dressing on 7/7/25. WRN-G indicated R1's dressing was intact at the time of the assessment but was not the dressing that was ordered. WRN-G indicated to FM-F that R1's wound was getting worse and an incorrect dressing was applied. WRN-G indicated WRN-G identified residents with incorrect and undated dressings on multiple occasions during wound rounds.On 8/8/25 at 9:53 AM, Surveyor interviewed DON-B who indicated upon finding a resident with a non-intact dressing, staff should cleanse the wound and apply the proper dressing. DON-B indicated when staff identify that a resident has the wrong dressing, staff should notify DON-B, apply the correct dressing, and document the findings in a progress note. DON-B indicated when agency staff work at the facility, DON-B assesses their comfort level with wounds and assigns them to a unit that is less acute at first. DON-B stated DON-B was not informed that staff were not dating residents' dressings and would have done education and audits if notified.

Based on staff and resident interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R2) of 1 resident reviewed for elopement. An elopement risk assessment, dated 1/31/25, indicated R2 was at risk for elopement. A WanderGuard (a security device that triggers an alarm if the wearer exits the facility) was placed on R2's left ankle. On 6/12/25 at 3:10 AM, R2 eloped from the facility and was found at approximately 3:55 AM approximately two miles from the facility. An investigation determined R2 exited the facility through the 200 wing door which had an alarm that sounded, however, staff were unable to hear the alarm because they were in residents' rooms providing care. Staff did not respond to the alarm until approximately 3:15 AM. The facility's failure to provide adequate supervision for a resident assessed to be at risk for elopement created a finding of immediate jeopardy that began on 6/12/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 6/20/25 at 3:52 PM. The immediate jeopardy was removed on 6/20/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Elopements and Wandering Residents policy, dated 2/20/23, indicates: .1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner .4 .Adequate supervision will be provided to help prevent accidents or elopements. On 6/20/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including paranoid schizophrenia, epilepsy, panic disorder, anxiety, and depression. R2's Minimum Data Set (MDS) assessment, dated 5/6/25, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R2 had severely impaired cognition. R2 had a Guardian. A care plan, revised on 6/12/25, indicated R2 was at risk for elopement and wandering. R2 had a WanderGuard due to impaired cognition and exit-seeking behavior. The care plan also indicated R2 was at moderate risk for falls due to the use of assistive devices, decrease in muscle coordination, and a history of multiple falls in the facility. On 6/20/25, Surveyor reviewed R2's nursing progress notes for history of elopement/exit seeking behaviors and noted the following: ~ On 9/16/24, staff responded to a door alarm and noted R2 was attempting to exit and stated R2 needed to get to the parking lot and go home. ~ On 12/27/24, R2 exit sought throughout the day, walked fast to the front of the building, and tried to exit the front door. R2 was difficult to redirect. ~ On 1/31/25, R2 eloped out the 500/600 wing exit and was found almost a mile away from the facility. R2 had an unwitnessed fall during the elopement that resulted in scrapes and bruising to R2's right knee. ~ On 2/6/25, R2 attempted to open the 200 wing door and stated R2 wanted to leave. ~ On 3/25/25, R2 attempted to the leave the facility for the seventh time and was redirected on several occasions. ~ On 4/20/25, R2 exhibited signs of anxiety, paced back and forth, attempted to exit the facility, and wandered off the unit several times. Surveyor reviewed the facility's investigation which indicated on 6/12/25 at approximately 3:10 AM, R2 exited the facility through the 200 wing door. At approximately 3:15 AM, staff called a code white (missing resident) after determining R2 was not in the facility. Staff searched the immediate vicinity of the facility but were unable to locate R2. At 3:40 AM, NHA-A notified the local police. At 3:55 AM, Registered Nurse (RN)-M located R2 approximately two miles from the facility. R2 was returned to the facility and placed on 1:1 supervision. R2 was unable to answer questions about where R2 was going. According to weatherunderground.com, the temperature at the time R2 left the facility was approximately 55 degrees. Surveyor reviewed a map of the city and noted Lake Michigan was less than 300 feet from where R2 was found. Surveyor noted R2 walked approximately two miles east down a busy four lane street, through a busy intersection ([NAME] Street and Highway 42), and across Highway 42 before R2 was found by staff. On 6/20/25 at 6:36 AM, Surveyor interviewed RN-M who was assigned to the 200/300 wings on the 6/11/25-6/12/25 night (NOC) shift. RN-M stated RN-M was assisting Certified Nursing Assistant (CNA)-L with cares in a resident's room on the 300 wing. CNA-L left the room before RN-M and then came back and stated the 200 wing door was alarming. RN-M verified RN-M could not hear the alarm while in the resident's room because the door was closed and the resident had a ventilator. RN-M instructed CNA-L to look for R2 due to R2's history of exit seeking. When staff noted R2 was not in R2's room, RN-M called a code white and conducted a head count of residents. RN-M stated when NHA-A and Director of Nursing (DON)-B arrived at the facility, RN-M got in RN-M's car to look for R2 and found R2 approximately two miles away on a concrete path next to Highway 42. RN-M convinced R2 to get in the car and took R2 back to the facility. RN-M confirmed that staff should respond immediately to door alarms. On 6/20/25 at 11:12 AM, Surveyor interviewed CNA-L who was assigned the 200/300 wings on the 6/11/25-6/12/25 NOC shift. CNA-L stated CNA-L was on the 300 wing taking care of a resident. When cares were completed, CNA-L exited the room and heard the door alarm on the 200 wing. CNA-L looked out the 200 wing, did not see any residents, and reported the door alarm to RN-M. CNA-L then checked for R2 on the 600 wing due to R2's frequent wandering and exit seeking but could not locate R2. CNA- L was not sure how long the alarm was sounding before CNA-L heard it. CNA-L verified CNA-L was not able to hear the alarm while in a resident's room with the door closed and confirmed that staff should respond immediately to door alarms. On 6/20/25 at 11:20 AM, Surveyor interviewed CNA-N who was assigned to the 600 wing on the 6/11/25-6/12/25 NOC shift. CNA-N stated CNA-N last saw R2 in bed between 1:00 and 2:00 AM. CNA-N stated CNA-L entered the unit at approximately 3:20 AM, asked where R2 was, and indicated an alarm was sounding on the 200 wing. CNA-N stated CNA-N could not hear the 200 wing door alarm because it was on the other side of the building. On 6/20/25 at 11:25 AM, Surveyor interviewed CNA-O who was assigned to the 500 wing on the 6/11/25-6/12/25 NOC shift. CNA-O stated CNA-O was not aware that R2 was missing until a code white was called at approximately 3:15 AM. CNA-O verified the fire door alarms on each wing (200, 300, 500, and 600) and WanderGuard alarms were hard to hear while in a resident's room with the door closed. On 6/20/25 at 2:14 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-P who was assigned to the 500/600 wings on the 6/11/25-6/12/25 NOC shift. LPN-P stated LPN-P was either at the nurses' station or in a resident's room when R2 eloped. LPN-P verified LPN-P would not have been able to hear the 200 wing door alarm which was on the other side of the building. LPN-P stated it is hard to hear any of the alarms when in a resident's room with the door closed. LPN-P stated LPN-P typically leaves room doors open and uses the curtain to provide privacy so LPN-P can hear if an alarm sounds or if anyone needs help. A statement from RN-R obtained by the facility on 6/12/25, indicated RN-R was in a resident's room on the 300 wing administering medication. RN-R stated RN-R did not see R2 on the 200 wing at all. When RN-R exited the resident's room, RN-R heard CNA-L state the 200 wing door was alarming. When staff could not locate R2, RN-R notified DON-B that R2 was missing and began conducting a head count and searching for R2. Surveyor reviewed R2's 1:1 supervision and 15 minute checks documentation and noted R2 was on 1:1 supervision from 6/12/25 to 6/16/25 and then placed on 15 minute checks. Surveyor noted R2's 15 minute check sheets were missing documentation on 6/17/25 from 7:15 PM to 9:45 PM. The facility's investigation included weekly door alarm/WanderGuard audits as well as all staff education which included ensuring staff respond immediately to door alarms and immediately check to ensure no residents have eloped. The education indicated the reaction must be instantaneous and there was no room for a delay in response to an alarm. The investigation indicated random audits would be completed to ensure knowledge and compliance. On 6/20/25 at 2:18 PM, Surveyor interviewed NHA-A who verified staff should respond to door alarms immediately. NHA-A stated NHA-A was not aware staff could not hear door alarms while in residents' rooms. NHA-A stated the only way to make the alarms louder was to install a new alarm system and verified during the survey that there was nothing in process to correct the issue. On 6/20/25, Surveyor observed R2 multiple times during the AM and PM shifts and noted a functioning WanderGuard on R2's left ankle. Surveyor also noted the facility's WanderGuard and door alarm systems were armed and functioning. The failure to provide adequate supervision for a resident at risk for elopement and follow the elopement procedure when a door alarm sounded created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 6/20/25 when it had completed the following: 1. Assigned staff to post at each nursing station where door alarms can be clearly heard immediately upon activation to ensure timely response. 2. Ordered a Safety Technology International STI-6402 105dB Exit Stopper (Multifunction Door Alarm) to be installed upon arrival. NHA-A and/or designee to complete validation of the alarm volume to ensure staff can hear the alarm sounding in any resident room or area where the doors is closed. Assigned stationary staff will remain in place until validation occurs. 3. Completed an elopement investigation that included review of R2's care plan as well as new BIMS, trauma, skin, pain, and elopement evaluations. 4. Completed elopement evaluations for all in-house residents. 5. Provided staff education on the facility's elopement policy, responding to alarms timely, and 1:1 supervision expectations. 6. Implemented Stop signs on egress doors to deter residents from using exit doors 7. Implemented audits to ensure comprehension of the education and to ensure staff respond to alarms in a timely manner.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 39 of the 54 residents residing in the facility. There were 15 residents who received nutrients exclusively via tube feeding. Staff did not wear hair restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not follow appropriate hand hygiene procedures when they prepared and served food. Resident food and beverages were not served at appropriate temperatures. Findings include: Hair Restraints: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 2-402.11 Hair Restraints: (A) Except as provided in (B) of this section, Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens, and unwrapped single-service and single-use articles. The facility's Maintaining a Sanitary Tray Line policy, revised 11/6/24, indicates: .Wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food . The facility's Food Safety Requirements policy, revised 3/26/25, indicates: .Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food .Hairnets should be worn when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad . On 6/20/25 at 7:30 AM, Surveyor observed a sign near the entrance to the kitchen that indicated all staff entering the kitchen must have their hair covered by a hair restraint. On 6/20/25 at 7:31 AM, Surveyor observed [NAME] (CK)-F with a hair restraint on CK-F's head and a beard restraint on CK-F's face, however, the hair and beard restraints did not cover all of CK-F's hair and the back sides of CK-F's beard were exposed while CK-F prepared and served residents breakfast from 7:31 AM to 8:27 AM. On 6/20/25 at 7:31 AM, Surveyor observed Dietary Aide (DA)-G with a hair restraint on DA-G's head, however, DA-G's hair was uncovered on both sides of the hair restraint near DA-G's ears. Surveyor observed DA-G prepare residents' meal trays and move throughout the kitchen with DA-G's hair not fully covered from 7:31 AM to 8:27 AM while breakfast was being prepared and served. On 6/20/25 at 12:04 PM, Surveyor observed CK-F with a hair restraint on CK-F's head and a beard restraint on CK-F's face, however, the hair and beard restraints did not cover all of CK-F's hair and the front of CK-F's beard net was pulled down which left CK-F's mustache and part of CK-F's beard exposed. In addition, the back sides of CK-F's beard were also exposed while CK-F served residents food from 12:04 PM to 12:29 PM. On 6/20/25 at 12:29 PM, Surveyor interviewed CK-F who verified CK-F's hair and beard should be fully covered. CK-F indicated CK-F could not breathe well with the beard restraint on and forgot to fully cover CK-F's facial hair during lunch service. On 6/20/25 at 1232 PM, Surveyor interviewed Director of Dining (DD)-E who indicated staffs' hair and facial hair should be fully covered while in the kitchen. Cleanliness: The 2022 FDA Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. The 2022 FDA Food Code documents at 4-602.12 Cooking and Baking Equipment: (A) Food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. The 2022 FDA Food Code documents at 4-602.13 Nonfood-Contact Surfaces: Non-food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. The facility's Food Safety Requirements policy, revised 3/26/25, indicates: .All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination .Staff shall follow facility procedures for dishwashing and cleaning of fixed cooking equipment . On 6/20/25 from 7:31 AM to 8:30 AM and from 12:04 PM to 12:40 PM, Surveyor observed the kitchen and noted the floors were dirty and contained debris. Surveyor also observed numerous shelves in the cook, prep, and serve areas that contained debris. On 6/20/25, Surveyor reviewed copies of the kitchen's cleaning logs and noted the logs were not thoroughly filled out. Daily tasks were assigned, however, most of the tasks were not signed off. Surveyor noted there were 117 spots assigned (16 daily x 7 days) but only 26 were signed as completed. The assignment sheet for Dietary Aides also contained 117 assignments for the week, however, only 14 assignments were marked as completed. Surveyor reviewed several weeks of cleaning assignments with similar results. On 6/20/25 at 12:32 PM, Surveyor interviewed DD-E who indicated staff should complete their cleaning assignments daily. Hand Hygiene: The 2022 FDA Food Code documents at 2-301.14: Food Employees shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. The 2022 FDA Food Code documents at 3-301.11 Preventing Contamination from Hands: (A) Food Employees shall wash their hands as specified under § 2-301.12. (B) Except when washing fruits and vegetables as specified under §3-302.15 or as specified in (D) and (E) of this section, Food Employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. The facility's Maintaining a Sanitary Tray Line policy, revised 11/6/24, indicates: .Wear gloves when handling food items, particularly when direct contact between the hands and food occurs or when handling ready to eat foods such as salads, fruits, sandwiches, breads, etc .Use gloves that fit properly .Wash hands before and after wearing or changing gloves .Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the work station .Change gloves after sneezing, coughing or touching face, hands, or hair with gloved hands . The facility's Food Safety Requirements policy, revised 3/26/25, indicates: .Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects .Staff shall wash hands according to facility procedures .Gloves will be worn when directly touching ready to eat foods and when serving residents who are on transmission-based precautions. On 6/20/25 at 7:31 AM, Surveyor observed CK-F cook and serve breakfast and touch residents' plates with a bare left hand. At 8:06 AM, Surveyor observed CK-F wipe CK-F's hands on CK-F's clothing and continue to serve food and touch plates with a bare hand. At 7:57 AM, 7:59 AM, 8:02 AM, 8:05 AM, 8:08 AM, 8:13 AM, and 8:15 AM, CK-F adjusted CK-F's glasses with a bare left hand. At 8:17 AM, CK-F washed hands and continued to serve food and touch residents' plates with a bare hand. At 8:22 AM, CK-F again adjusted CK-F's glasses and touched a resident's plate with a bare hand. On 6/20/25 at 12:04 PM, Surveyor observed CK-F serve residents lunch with gloved hands. CK-F picked up plates with CK-F's left hand and plated food per residents' meal tickets. At 12:10 PM, CK-F adjusted CK-F's glasses and used then used the same gloved hand to pick up residents' plates. At 12:22 PM, CK-F changed gloves and indicated there was a resident who was allergic to fish. CK-F began to don another pair of gloves with completing hand hygiene, dropped the left glove on the floor, and then picked up the next resident's plate with a bare left hand. After plating food for the resident, CK-F donned a new left glove without completing hand hygiene. On 6/20/25 at 12:29 PM, Surveyor interviewed CK-F who verified CK-F should complete hand hygiene between glove changes. On 6/20/25 at 12:32 PM, Surveyor interviewed DD-E who indicated staff should complete hand hygiene between glove changes and should be aware of the facility's policy. Food and Beverage Temperatures: The 2022 FDA Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, for Hot and Cold Holding: Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees Fahrenheit (F) to 135 degrees F too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control .(1) At 135 degrees F or above or (2) At 41 degrees F or less. The facility's Maintaining a Sanitary Tray Line policy, revised 11/6/24, indicates: .This facility prioritizes tray assembly to ensure foods are handled safely and held safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness .Periodically monitor food temperatures throughout the meal service to ensure proper hot (at or above 135 degrees) or cold holding temperatures (at or below 41 degrees) are maintained . The facility's Food Safety Requirements policy, revised 3/26/25, indicates: .Cooking - foods shall be prepared as directed until recommended temperatures for the specific foods are reached. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed .Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed .Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include, but are not limited to: .Timely distribution of all meals/snacks. The facility's Food Preparation Guidelines policy, revised 12/17/24, indicates: .Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: .Serving hot foods/drinks hot and cold food/drinks cold .Addressing resident complaints about food/drinks . On 6/20/25 at 7:48 AM, Surveyor observed CK-F temp scrambled eggs from the steamer and record the temperature on the cooking temperature log and the hot holding/steam table log. Surveyor observed CK-F place food in the steam table and noted steam table/holding temperatures were not obtained. Surveyor also observed DD-E ask CK-F for temperatures of the other foods. CK-F indicated the temperature of the pureed eggs was 184 degrees, the pureed sausage was 184 degrees, the sausage was 178 degrees, the bacon was 183 degrees, and the oatmeal was 205 degrees. Surveyor observed DD-E record the temperatures on the cooking temperature log and the hot holding/steam table log. Surveyor noted the numbers reported by CK-F were not actual temperatures because CK-F did not temp the food. During breakfast service, Surveyor noted milk and juice were placed in covered cups in tubs. Surveyor observed pieces of ice on top of the cups and above the fluids in the cups. (The ice pieces did not touch the sides of the cup and there was no ice in between the cups.) On 6/20/25 at 12:10 PM while CK-F served food, Surveyor observed the cooking temperature log and the hot holding/steam table log and noted CK-F recorded 176 degrees on both logs for the meat and mechanical soft meat. There were no other temperatures recorded for any of the foods being served. Surveyor observed CK-F finish lunch service and noted CK-F did not obtain or record any food temperatures. During lunch service, Surveyor noted milk and juice were placed in covered cups in tubs. Surveyor observed pieces of ice on top of the cups and above the fluids in the cups. (It appeared as if one scoop of ice was put on top of the cups. There was no ice in the tubs or in contact with the sides of the cups.) On 6/20/25 at 12:29 PM, Surveyor interviewed CK-F who indicated the temperatures were good out of the oven, however, CK-F forgot to temp the potatoes (2 types) and forgot to record the temperatures. Surveyor then observed CK-F record temperatures on the cooking temperature log and the hot holding/steam table log without obtaining the temperatures of the food at that time. Surveyor noted CK-F wrote the same temperature for each of the foods on the cooking temperature log and the hot holding/steam table log. CK-F verified temperatures should be obtained and recorded right away. On 6/20/25, Surveyor noted beverage temperatures were often not obtained/recorded on the logs. On 6/20/25 at 8:51 AM, Surveyor requested and received a breakfast test tray. Surveyor temped the foods and beverages on the tray and noted the following: ~ Eggs - 110.1 degrees ~ Oatmeal - 129.5 degrees ~ Cottage cheese - 55.7 degrees ~ Orange juice - 60.2 degrees ~ Milk - 61.7 degrees ~ Coffee - 139.5 degrees (within range) The hot and cold foods, with the exception of the coffee, were not within the appropriate ranges in accordance with the FDA Food Code and the facility's policy. On 6/20/25 at 12:44 PM, Surveyor requested and received a lunch test tray. Surveyor temped the foods and beverages on the tray and noted the following: ~ Chicken patty - 110.6 degrees ~ Fish patty -139.2 degrees (within range) ~ Mashed potatoes and gravy - 120.7 degrees ~ Potato coins - 117.4 degrees ~ Coleslaw - 60.0 degrees ~ Lemonade - 58.4 degrees ~ Milk - 58.8 degrees ~ Cheesecake - 60.8 degrees ~ Coffee - 146.9 degrees (within range) The hot and cold foods, with the exception of the fish patty and coffee, were not within the appropriate ranges in accordance with the FDA Food Code and the facility's policy. On 6/20/25, Surveyor reviewed resident grievances and noted several food concerns regarding cold food served warm and hot food served cold. On 6/20/25, Surveyor reviewed resident council meeting minutes and noted several food concerns including cold food served warm and hot food served cold. On 6/20/25 at 12:32 PM, Surveyor interviewed DD-E who indicated food temperatures should be obtained and recorded at the time they are taken. DD-E indicated it is not acceptable for staff to make up temperatures and record them. DD-E was unsure why DD-E recorded temperatures on the cooking temp log and the holding/steam table temp log for CK-F during breakfast when DD-E saw that CK-F was not taking the temperatures. DD-E indicated staff must obtain oven or cook temperatures as well as steam table temperatures and was aware that was not occurring. DD-E verified there are safety concerns when food and beverages are not served at the correct temperatures and confirmed the importance of obtaining and recording correct cooking and holding temperatures. On 6/20/25 at 4:17 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was aware of food temperature issues and complaints. NHA-A indicated there had been concerns for as long as NHA-A had been there and there were still ongoing issues. NHA-A verified kitchen staff should follow the FDA Food Code and the facility's policies regarding food temperatures, hand hygiene, kitchen cleanliness, and hair restraints. NHA-A indicated NHA-A saw Surveyor's breakfast test tray that morning and indicated NHA-A would not have eaten the food either. NHA-A indicated the facility is working on getting better food service for residents.

2. On [DATE], Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of glottis, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and tracheostomy status. A care plans, initiated on [DATE], indicated R6 had a Clostridioides difficile (C. diff) infection (a highly contagious bacterium that causes diarrhea and colitis) and was on contact precautions. On [DATE] at 1:25 AM, Surveyor observed CNA-R and CNA-S enter R6's room without donning PPE. Surveyor observed a sign posted on R6's door that indicated R6 was on contact precautions. Surveyor observed CNA-R and CNA-S prepare to transfer R6 from bed to wheelchair. CNA-S applied R6's socks and shoes while CNA-R retrieved R6's wheelchair and a gait belt. CNA-R then applied the gait belt and assisted R6 to the wheelchair. CNA-R unhooked R6's trach hose, assisted R6 to a sitting position, then reapplied the hose. Registered Nurse (RN)-M then entered room without donning PPE and straightened R6's bed and tidied the room. When CNA-R and CNA-S exited the room, Surveyor asked if R6 was on contact precautions. CNA-R answered yes and confirmed CNA-R should have worn PPE in R6's room. When RN-M exited R6's room at 1:32 AM, Surveyor asked RN-M if R6 was on contact precautions. RN-M confirmed R6 was on contact precautions and indicated RN-M should have worn PPE in R6's room. On [DATE] at 3:30 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed staff should don PPE for residents on contact precaution. NHA-A indicated contact precautions require staff to don a gown and gloves prior to entering the room. Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R10 and R6) of 2 sampled residents. During an observation of incontinence care for R10, Certified Nursing Assistant (CNA)-C did not complete hand hygiene in between glove changes and prior to applying barrier cream and did not complete thorough pericare. R6 was on contact precautions. On [DATE], multiple staff entered R6's room and provided care without donning appropriate personal protective equipment (PPE). Findings include: The facility's Hand Hygiene policy, revised [DATE], indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .Before applying and after removing personal protective equipment (PPE), including gloves .During resident care when moving from a contaminated body site to a clean body site . The facility's Perineal Care policy, revised [DATE], indicates: It is the practice of this facility to provide perineal care to all incontinent residents .2. Gather supplies .c. Separate the resident's labia with one hand, and cleanse perineum with the other hand by wiping in direction from front to back .d. Repeat on opposite side using separate section of wash cloth or disposable wipe. e. Clean urethral meatus and vaginal orifice .f. Pat dry .g. Turn resident .h. Clean and dry the anal area . The facility's Transmission-Based Precautions (TBP) policy, dated 2025, indicates: It is our policy to take appropriate precautions to prevent transmission of pathogens based on the pathogens' modes of transmission .1. Facility staff will apply TBP, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission .10. Contact Precautions - A. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment .Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment .Donning PPE upon entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination . 1. On [DATE], Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including myotonic muscular dystrophy, chronic respiratory failure, encephalopathy, and heart failure. R10's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 13 of 15 which indicated R10 had intact cognition. A care plan, dated [DATE], indicated R10 required the assistance of 1 staff for toileting and personal hygiene and the assistance of 2 staff with a full body lift. On [DATE] at 1:28 PM, Surveyor observed CNA-C and Licensed Practical Nurse (LPN)-D apply PPE prior to entering R10's room and observed CNA-C and LPN-D transfer R10 from wheelchair to bed via full body lift. Surveyor noted the blanket on R10's wheelchair was wet and R10 informed CNA-C and LPN-D that R10 had urinated in R10's brief. CNA-C retrieved disposable wipes and barrier cream. LPN-D assisted R10 onto R10's right side while CNA-C removed R10's wet brief, wiped R10's buttocks from front to back, and applied barrier cream to R10's buttocks. CNA-C removed gloves, completed hand hygiene, donned clean gloves, and tucked a clean brief underneath R10. CNA-C assisted R10 onto R10's left side. LPN-D adjusted the brief and assisted R10 into a supine position. CNA-C pulled the brief over R10's anterior peri area without cleansing the area and removed gloves. Without completing hand hygiene, CNA-C donned clean gloves, put on R10's heel boots, and removed gloves. Without completing hand hygiene, CNA-C donned clean gloves, removed R10's soiled gown, and put a clean gown on R10. CNA-C then placed pillows under R10's head and knees and ensured R10's bed was at a 45 degree angle. LPN-D and CNA-C each put a blanket on R10. LPN-D then removed PPE and washed hands. CNA-C removed CNA-C's gown, changed R10's garbage, and removed gloves. Without completing hand hygiene, CNA-C donned clean gloves and cleaned the lift with Sani wipes. CNA-C then removed gloves and washed hands. On [DATE] at approximately 1:48 PM, Surveyor interviewed R10 who indicated it did not seem like CNA-C washed R10's frontal peri area but indicated it seemed to be clean. On [DATE] at 1:58 PM, Surveyor interviewed CNA-C who verified CNA-C should have completed hand hygiene between gloves changes. CNA-C indicated CNA-C did not provide full perineal care because R10 was not soiled with stool. CNA-C indicated CNA-C should have donned clean gloves prior to applying barrier cream. On [DATE] at approximately 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated CNA-C should have completed hand hygiene between glove changes and should have changed gloves prior to putting barrier cream on R10. DON-B verified staff should cleanse a resident's entire perineal area during soiled brief changes.

Based on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition for 1 resident (R) (R4) of 13 sampled residents. R4 was diagnosed with yeast in the urine and had an order for antibiotic treatment. R4's Power of Attorney for Healthcare (POAHC) was not notified of the change in condition or antibiotic treatment. In addition, R4 had low blood pressure readings on 5/10/25 and 5/11/25. R4's physician and POAHC were not notified. Findings include: The facility's Notification of Changes policy, revised 3/31/25, indicates: The purpose of this guideline is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Changes of condition require an evaluation .and ensures proper documentation and notification has been made .2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications, c. Critical lab values. 3. Circumstances that require a need to alter treatment may include: a. New treatment, b. Discontinuation of current treatment due to: i. Adverse consequences, ii. Acute condition, iii. Exacerbation of a chronic condition .Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify the resident's representative, if known .When a resident is mentally competent, a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident . On 6/20/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including quadriplegia, diabetes mellitus type 2, and pressure ulcer of sacral region stage 4. R4's Minimum Data Set (MDS) assessment, dated 5/9/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 had intact cognition. R4 had an activated POAHC who was responsible for R4's healthcare decisions. On 6/20/24 at 8:38 AM, Surveyor interviewed R4's POAHC (POAHC-H) who indicated POAHC-H was not informed about the results of a second urine test ordered for R4 or any treatment from the result. POAHC-H indicated the next time POAHC-H was notified of any changes was on 5/11/25 when R4 was going to be transferred to the hospital. POAHC-H indicated POAHC-H did not know when the facility received the results or what the facility was doing for R4's infection. R4's medical record indicated R4 had increased confusion on 5/8/25 that was documented by Registered Nurse (RN)-I. The physician was updated and ordered a urinalysis (UA) and urine culture (UC). R4's medical record indicated POAHC-H was updated on the order to obtain a UA/UC. The UA/UC results indicated R4 had an infection of yeast in the urine. R4's medical record did not indicate POAHC-H was updated on the result. A progress note, dated 5/8/25 at 10:29 PM by RN-J, indicated R4 was prescribed fluconazole (an antifungal medication) 200 milligrams (mg) daily for 14 days for a candidal urinary tract infection (UTI). R4's medical record did not indicate POAHC-H was notified of the fluconazole order. A clinical summary documentation, dated 5/9/25 at 10:15 AM by Assistant Director of Nursing (ADON)-K, indicated R4 had a new order for an antifungal medication due to a candidal UTI. The documentation did not indicate POAHC-H was notified. R4's medical record contained the following low blood pressure readings: ~On 5/10/25 at 5:03 PM - 83/47 millimeters of mercury (mmHg) ~On 5/10/25 at 6:32 PM - 89/52 mmHg ~On 5/11/25 at 8:18 AM - 88/56 mmHg R4's medical record did not indicate R4's physician or POAHC-H were notified of R4's low blood pressure readings. R4's medical record indicated POAHC-H was notified on 5/11/25 when R4 was unresponsive to verbal or touch stimuli and was transferred to the hospital. On 6/20/25 at 12:20 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated POAHC-H was notified of R4's UA, UTI, and treatment which was documented in the facility's McGeer's tracking assessment. Surveyor reviewed McGeer's infection symptom tracking documentation completed by DON-B that was a late entry with an effective date of 5/9/25 and a signed date of 5/19/25. The documentation indicated POAHC-H was notified on 5/9/25. On 6/20/25 at 12:40 PM, Surveyor interviewed DON-B and reviewed R4's low blood pressure readings. When asked if R4's physician and POAHC-H were notified of the low blood pressure readings, DON-B indicated R4's physician and POAHC-H were not notified but should have been. DON-B also indicated the nurse should have questioned the blood pressure readings. On 6/20/25 at 3:37 PM, Surveyor interviewed ADON-K who verified ADON-K did not notify POAHC-H of the antifungal order because ADON-K was not the one who received the order. ADON-K indicated RN-J received the order and should have notified POAHC-H. ADON-K verified the physician should be updated if a resident has a low blood pressure reading. ADON-K indicated the facility's standing order on blood pressure is to notify the physician if the systolic number (top) is less than 90 or greater than 180 and the diastolic number (bottom) is greater than 90. On 6/20/25 at 4:04 PM, Surveyor again interviewed POAHC-H who indicated POAHC-H was aware the facility was going to do another UA for R4, however, the facility did not follow-up with the results of the UA and did not notify POAHC-H of any new orders. POAHC-H did not recall DON-B updating POAHC-H on 5/9/25 with the UA results and treatment and indicated POAHC-H would have remembered being notified. POAHC-H indicated the next tine POAHC-H was notified about anything was on 5/11/25 when R4 was transferred to the hospital.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection as observed during the provision of care for 7 Residents (R) (R36, R2, R9, R17, R11, R16, and R4) of 10 residents. On 8/12/24, staff did not complete appropriate hand hygiene during wound care for R36. On 8/12/24 and 8/13/24, staff did not wear masks or complete hand hygiene appropriately during the provision of care for R2. On 8/13/24, staff did not wear appropriate personal protective equipment (PPE) during a therapy session with R9 who was on enhanced barrier precautions (EBP). On 8/13/24, staff did not complete appropriate hand hygiene or wear required PPE during a transfer for R17 who was on EBP. On 8/12/24, staff did not complete proper hand hygiene while administering medication to R11, R16, and R4. Findings include: The facility's Hand Hygiene policy, dated October 2022, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table. The hand hygiene table attached to the policy indicated before applying or after removing personal protective equipment, including gloves, staff should either use soap and water or an alcohol-based hand rub. Hand hygiene should be completed before and after handling soiled dressings, after handling items potentially contaminated with bodily fluids, and when moving from a contaminated body site to a clean body site. The facility's Enhanced Barrier Precautions policy, with a copyright of 2024, indicates: .Implementation of Enhanced Barrier Precautions (EBP): .b. Personal protective equipment (PPE) for EBP is only necessary when performing high contact care activities . The facility's COVID-19 Prevention, Response and Reporting policy indicates: .10. Broader use of masking should be determined by the facility as to how and when to implement . 1. From 8/12/24 to 8/14/24, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] with diagnoses including anoxic brain injury, persistent vegetative state, anxiety, diabetes, and pressure injuries. R36's Minimum Data Set (MDS) assessment, dated 5/14/24, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R36 had severely impaired cognition. On 8/12/24 at 9:33 AM, Surveyor observed Advance Practice Nurse Prescriber (APNP)-G provide wound care for R36's stage 3 coccyx (area at the base of the spine just above the buttocks) pressure injury. APNP-G removed R36's soiled dressing and noted there was a moderate amount of drainage. APNP-G cleansed the wound and surrounding area with gauze and wound wash and noted there was stool present. APNP-G stated the wound measured 0.6 cm (centimeters) x 0.5 cm x 1.8 cm. Surveyor observed APNP-G insert a gloved finger in R36's wound bed to check for tunneling which was 2 cm at the 3-4 o'clock position. APNP-G then packed R36's wound with saline-soaked gauze and covered the wound with a foam border dressing. Without removing gloves and cleansing hands, APNP-G touched R36's pressure-relieving boots, blankets, lift sheet, and feet to conduct a heel check. On 8/12/24 at 11:12 AM, Surveyor interviewed APNP-G who stated if a wound is open or if a resident is incontinent during wound care, APNP-G changes gloves when going from dirty to clean by removing APNP's soiled gloves, completing hand hygiene, and applying new gloves. On 8/13/24 at 9:25 AM, Surveyor interviewed Director of Nursing (DON)-B who verified APNP-G should have removed soiled gloves and completed hand hygiene prior to measuring R36's wound and applying a clean dressing. DON-B also verified APNP-G should have completed hand hygiene and applied clean gloves prior to touching R36's wound bed. 50467 2. On 8/12/24 from 8:39 AM to 8:42 AM, Surveyor noted staff either did not wear masks or did not wear masks appropriately on the 500 and 600 wings. Surveyor noted Certified Nursing Assistant (CNA)-M's mask was below CNA-M's chin while CNA-M assisted R2 with breakfast in R2's room. On 8/12/24 at 9:00 AM, Surveyor observed CNA-M assist R2 with breakfast and noted CNA-M's mask was still below CNA-M's chin. Surveyor confirmed with Registered Nurse (RN)-K that a mask should be worn at all times. RN-K then informed CNA-M that a mask should be worn at all times. During the entrance conference on 8/12/24 at 9:11 AM, Nursing Home Administrator (NHA)-A confirmed masks on the 500 and 600 wings were initiated by DON-B due to a COVID-19 positive resident. On 8/12/24 at 10:05 AM, Surveyor noted CNA-M's mask covered CNA-M's mouth but left CNA-M's nose exposed. On 8/12/24 from 11:47 AM to 11:50 AM, Surveyor observed RN-L in the 600 wing hallway by the medication cart and near residents without a mask. Surveyor also observed CNA-M push a resident in the 500 wing hallway without a mask. On 8/13/24 at 8:32 AM, Surveyor observed CNA-M on the 600 wing and noted CNA-M's mask was below CNA-M's chin while CNA-M was in the hallway with residents present. On 8/13/24 at 10:47 AM, Surveyor noted RN-N and CNA-M's masks were below their chins in the 500 and 600 hallways with residents present. On 8/14/24 at 1:45 PM, Surveyor interviewed DON-B who confirmed surgical masks should be worn at all times on the 500 and 600 wings due to a COVID-19 positive resident. 3. On 8/13/24 at 1:23 PM, Surveyor observed RN-K apply cream to a R2's buttock, remove gloves, don clean gloves, and apply powder. RN-K did not complete hand hygiene after RN-K removed soiled gloves and donned clean gloves. On 8/13/24 at 1:45 PM, Surveyor interviewed DON-B who confirmed RN-K should have completed hand hygiene after RN-K removed soiled gloves and before RN-K donned clean gloves. 4. On 8/14/24 at 7:47 AM, Surveyor observed Physical Therapist (PT)-T provide therapy for R9 who was on EBP for carbapenem-resistant Acinetobacter baumannii (CRAB). Surveyor noted an EBP sign on R9's door. PT-T had direct contact with R9 during the therapy session and wore gloves, but did not wear a gown. On 8/14/23 at 9:40 AM, Surveyor interviewed DON-B who confirmed R9 was on EBP and verified PT-T should have worn a gown during the therapy session. On 8/14/24 at 9:51 AM, Surveyor interviewed PT-T who confirmed PT-T did not wear a gown during therapy with R9. 45942 5. From 8/12/24 to 8/14/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including quadriplegia, diabetes mellitus type 2, pressure ulcer of sacral region stage 4, and extended-spectrum beta lactamase (ESBL) resistance. R17 had an indwelling urinary catheter. R17's MDS assessment, dated 5/10/24, had a BIMS score of 14 out of 15 which indicated R17 had intact cognition. On 8/13/24 at 1:52 PM, Surveyor observed a sign outside R17's room that stated EBP was needed during cares and transfers. Surveyor observed RN-N and CNA-O transfer R17 via Hoyer lift from wheelchair to bed and reposition R17. RN-N and CNA-O wore gloves and a mask during the transfer; however, RN-N and CNA-O did not wear a gown as indicated on the EBP sign. On 8/13/24 at 1:59 PM, Surveyor observed RN-N exit R17's room with the Hoyer lift without removing gloves and cleansing hands. RN-N then re-entered R17's room, removed gloves, and completed hand hygiene. On 8/13/24 at 3:00 PM, Surveyor interviewed RN-N who verified RN-N and CNA-O should have worn gowns during the transfer and RN-N should have removed gloves and completed hand hygiene prior to leaving R17's room with the lift. On 8/13/24 at 3:03 PM, Surveyor interviewed DON-B who stated full PPE should be worn during transfers as indicated on R17's EBP sign. 49563 6. On 8/12/24 at 9:20 AM, Surveyor observed Licensed Practical Nurse (LPN)-U prepare medication for R11. After medication preparation, LPN-U donned gloves without completing hand hygiene. LPN-U administered R11's medication and then prepared to suction R11. LPN-U removed gloves, donned a gown, and donned gloves a second time without completing hand hygiene. 7. On 8/12/24 at 9:35 AM, Surveyor observed LPN-U prepare medication for R16. LPN-U did not complete hand hygiene prior to medication preparation. 8. On 8/12/24 at 9:50 AM, Surveyor observed LPN-U prepare medication for R4. LPN-U did not complete hand hygiene prior to donning gloves. On 8/12/24 at 9:59 AM, Surveyor interviewed LPN-U who stated hand hygiene should be completed before medication is prepared and after medication is administered. LPN-U verified LPN-U did not complete hand hygiene after medication preparation and prior to donning gloves. On 8/13/24 at 12:24 PM, Surveyor interviewed DON-B who verified LPN-U did not complete appropriate hand hygiene during medication administration. DON-B stated staff should perform hand hygiene prior to medication preparation, after medication preparation, and after medication administration.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 33 of 47 residents residing in the facility. (Fourteen residents received nutrition exclusively via tube feeding.) Kitchen equipment and food service areas were not kept in a clean and sanitary condition to prevent cross contamination. Staff did not perform appropriate hand hygiene and safe food handling practices when cooking and serving food. Staff did not document food holding temperatures. The resident refrigerator and reach-in cooler contained food and beverages that were past the discard date or not labeled with a discard date. Findings include: On [DATE] at 8:55 AM, Surveyor began an initial tour of the kitchen with the Dietary Manager (DM)-E who stated the facility followed the State and Federal Food Codes. Cleanliness: The 2022 Food and Drug Administration (FDA) Food Code documents at ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. The 2022 FDA Food Code documents at ,d+[DATE].13 Nonfood-Contact Surfaces: Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. The 2022 FDA Food Code documents at ,d+[DATE].12 Cooking and Baking Equipment: (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. During an initial kitchen tour that began on [DATE] at 8:55 AM, Surveyor observed the following: ~ Dust, dried food debris, and unidentified substances on the top, bottom, sides, and drawer frames of two plastic storage bins of serving and cooking utensils ~ A broken top on a bin of serving and cooking utensils that exposed the items to air ~ Food debris and spilled liquids on food preparation services, including the tray line conveyor, cooktop, and kitchen floor ~ An open Ziploc bag of sausage links on top of visibly soiled scissors and tinfoil ~ Dried yellow food debris on the interior top and sides of the microwave During a follow-up visit to the kitchen on [DATE] at 11:25 AM, Surveyor observed the following: ~ Two visibly soiled oven mitts on the eye wash station next to the handwashing sink ~ Two visibly soiled oven mitts on a shelf with containers of food for resident consumption ~ Three clipboards and a three-ring binder against/on shelves with clean kitchenware ~ Two clipboards and a box of gloves on top of clean water mugs On [DATE] at 1:22 PM, Surveyor interviewed DM-E who stated cleaning tasks were assigned on the daily schedule; however, staff did not complete a cleaning log or sign off when cleaning tasks were completed. DM-E stated DM-E completed a daily checklist that included verifying the completion of cleaning tasks. Hand Hygiene: The 2022 FDA Food Code documents at ,d+[DATE].15 Gloves, Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The 2022 FDA Food Code documents at ,d+[DATE].14 When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single use articles and: .(E) After handling soiled clean equipment and utensils. On [DATE] at 11:25 AM, Surveyor observed [NAME] (CK)-P prepare lunch in the kitchen and noted the following: ~ On six instances, CK-P touched the conveyor shelf with gloved hands. ~ On ten instances, CK-P touched and served biscuits with gloved hands. ~ On two instances, CK-P touched potatoes with gloved hands. ~ On one instance, CK-P touched steamed vegetables with a gloved hand. During the 42 minute observation, CK-P completed the above tasks with the same pair of gloves and did not change gloves or complete hand hygiene. On [DATE] at 1:27 PM, Surveyor interviewed CK-P who stated staff are expected to change gloves and complete hand hygiene whenever they leave the trayline. CK-P stated kitchen staff receive hand hygiene education with nursing staff, but CK-P was uncertain how often the education occurred. On [DATE] at 10:18 AM, Surveyor interviewed DM-E who stated staff are expected to complete hand hygiene if they leave the trayline, touch a contaminated surface (such as opening the oven door), or if a resident has a known allergy. DM-E acknowledged concerns with CK-P's hand hygiene during meal service. Holding Temperatures: The 2022 FDA Food Code documents at ,d+[DATE].16 Time/Temperature Control for Safety Food, for Hot and Cold Holding indicates: Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees Fahrenheit (F) to 135 degrees F too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control .(1) At 135 degrees F or above or (2) At 41 degrees F or less. On [DATE] at 10:18 AM, Surveyor interviewed DM-E who stated staff complete one set of temperatures which is done when the food in still in the oven or while cooking to ensure internal temperatures are met. DM-E stated the food is then placed in the steam table and served. DM-E stated staff do not complete holding temps unless an audit is being completed. Open and Undated/Expired Food Items: The 2022 FDA Food Code documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .(B) Except as specified in (E)-(G) of this section, refrigerated, Ready-to-Eat Time/Temperature Control for Safety Food Prepared and Packaged by a Food Processing Plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. During an initial kitchen tour that began on [DATE] at 8:55 AM, Surveyor and DM-E observed the following items in the reach-in cooler that were not labeled or discarded by the discard date: ~ A pitcher of mixed pink lemonade with an open date of [DATE] and a discard date of [DATE] ~ A pitcher of mixed pink lemonade with an open date of [DATE] and a discard date of [DATE] ~ Pre-thickened cranberry juice with an open date of [DATE] that did not have a discard date During an initial kitchen tour that began on [DATE] at 8:55 AM, Surveyor and DM-E observed a resident refrigerator that contained the following item that did not have a discard date: ~ A box of one piece of pizza with a date of [DATE] and no discard date

Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. Three of 4 medication carts were observed unlocked and unattended. In addition, 2 of 2 medication carts and 1 of 2 mediation storage rooms contained expired medication and medical supplies. This practice had the potential to affect multiple residents in the facility. Medication carts on the 500, 600, and 300 wings were unlocked and unattended on 8/12/24 and 8/13/24. Medication carts and the medication storage room on the 200 and 300 wings contained expired medications and medical supplies. Findings include: The facility's Medication Storage policy, dated 1/2024, indicates: Medications and biologicals are stored properly, following manufacturers' or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication .4. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access .14. Outdated, contaminated, and discontinued medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock . Medication Cart: On 8/12/24 at 8:58 AM, Surveyor observed a medication cart unattended and unlocked on the 500 wing with a computer screen on top of the medication cart that was open to residents' health information. The medication cart faced toward the hallway and exposed the drawers and computer screen while Registered Nurse (RN)-K was in R38's room. On 8/12/24 at 10:05 AM, Surveyor noted the 600 wing medication cart was unlocked in the hallway. On 8/12/24 at 10:07 AM, a Certified Nursing Assistant (CNA) located RN-L in the nursing station. RN-L confirmed the medication cart should be locked when unattended. RN-L locked the cart after the discussion. On 8/12/24 at 12:54 PM, Surveyor noted the 300 wing medication cart was unlocked and unattended. RN-N then exited a resident's room and prepared medication for another resident. At 1:03 PM, RN-N again left the medication cart unlocked and unattended during the administration of medication. Immediately following the observation, Surveyor interviewed RN-N who stated RN-N must have forgotten to lock the cart and verified medication carts should be locked when unattended. On 8/13/24 at 7:45 AM, Surveyor noted the 500 wing medication cart was unlocked in the hallway. On 8/13/24 at 7:45 AM, Surveyor interviewed RN-K who confirmed the medication cart should be locked. On 8/13/24 at 1:45 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed medication carts and computer screens should be locked when not attended. Expired Medications and Supplies: On 8/12/24 at 2:20 PM, Surveyor observed 2 of 4 medication carts and 1 of 2 medication storage rooms and noted the following: 200 Wing Medication Cart: ~ Two boxes of Smartemp probe covers with an expiration date of 5/4/21 ~ Five 25 g (gram) syringes with expiration dates of 1/5/23 ~ A bottle of stye medication that was opened on 6/30/24 and expired on 7/30/24 ~ Three bottles of Artificial Tears with expiration dates of 7/30/24 ~ A bottle of aspirin with an expiration date of 7/2024 ~ A bottle of Geri-Mox with an expiration date of 7/2024 300 Wing Medication Cart: ~ A bottle of vitamin B6 100 mg (milligrams) with an expiration date of 7/2024 ~ An unlabeled tube of Diclofenac gel with an open date of 7/30/24 ~ An unlabeled tube of PeriGuard ointment with an open date of 7/12/24 ~ An open, unlabeled, and undated tube of lubricating jelly ~ An open, unlabeled, and undated tube of Triple Antibiotic ointment 200/300 Wing Medication Storage Room: ~ A box of self-adhesive dressing retention sheets with expiration dates of 1/2023 ~ A bottle of Geri-Mox with an expiration date of 7/2024 ~ One and a half boxes of 25 g syringes with expiration dates of 1/5/23 ~ Undated pudding for medication pass in the refrigerator ~ A tube of stye eye ointment with an expiration date of 6/2023 ~ A bottle of zinc sulfate 220 mg (milligrams) with an expiration date of 3/2024 ~ Five bottles of meclizine 12.5 mg with expiration dates of 7/2024 ~ Two bottles of flaxseed oil 1000 mg with expiration dates of 7/2024 On 8/12/24 at 2:38 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-U and LPN-V who verified the above findings. LPN-V stated night shift nurses should monitor the medication carts and storage rooms for expired medications and supplies. On 8/13/24 at 12:24 PM, Surveyor interviewed DON-B who verified the medication carts and storage rooms contained expired medication and supplies. DON-B stated expiration dates should be reviewed when staff load medication carts and night shift nurses should monitor the medication carts and storage rooms for expired medication and supplies.

Based on staff interview and record review, the facility did not ensure guardianship and protective placement orders were obtained and advance directive wishes were followed for 4 Residents (R) (R31, R43, R39, and R30) of 17 sampled residents. R31 had a legal guardian at the time of admission on 11/4/22. R31's medical record contained petitions for guardianship and protective placement, dated 9/28/22; however, R31's medical record did not contain guardianship or protective placement orders. R43 had a legal guardian at the time of admission on 4/17/24. R43's medical record contained an Order and Notice of Hearing on Guardianship and Protective Placement, dated 3/23/24, with a hearing date of 5/6/24; however R43's medical record did not contain guardianship or protective placement orders. R39 had a legal guardian at the time of admission on 10/13/23. R39's medical record contained petitions for guardianship and protective placement, dated 6/27/23; however, R39's medical record did not contain guardianship or protective placement orders. R30 completed a Power of Attorney for Healthcare (POAHC), dated 10/23/20, prior to admission. R30's advance directive contained no to nursing home placement. R30's choice to not be admitted to a nursing home was not honored. Findings include: State Statue Chapter 154.03(2) indicates: The choices in this document were made by a competent adult. Under the law, the patient's stated desires must be followed unless belief that withholding or withdrawing life-sustaining procedures or feeding tubes would cause the patient pain or reduced comfort and that the pain or discomfort cannot be alleviated through pain relief measures. If the patient's stated desires are that life-sustaining procedures or feeding tubes be used, this directive must be followed. State Statute Chapter 55.03(4) indicates: The law requires a court-ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds sixty days only be extended with court approval (State Statute Chapter 55.05(b)). Protective placement is reviewed annually (State Statute Chapter 55.18) to determine if the placement continues to be the least restrictive and in the best interest of the individual. 1. On 8/12/24, Surveyor reviewed R31's medical record. R31 had a court-ordered guardianship and a diagnosis of persistent vegetative state. R31's Minimum Data Set (MDS) assessment, dated 6/28/24, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R31 had severe cognitive impairment. R31's medical record contained petitions for guardianship and protective placement, dated 9/28/22. R31's medical record did not contain guardianship or protective placement orders. 2. On 8/12/24, Surveyor reviewed R43's medical record. R43 had a court-ordered guardianship and a diagnosis of dementia. R43's MDS assessment, dated 7/27/24, had a BIMS score of 0 out of 15 which indicated R43 had severe cognitive impairment. R43's medical record contained an Order and Notice of Hearing on Guardianship and Protective Placement, dated 3/23/24, with a hearing date of 5/6/24. R43's medical record did not contain guardianship or protective placement orders. 3. On 8/12/24, Surveyor reviewed R39's medical record. R39 had a court-ordered guardianship and a diagnosis of anoxic brain injury and persistent vegetative state. R39's MDS assessment, dated 7/12/24, had a BIMS score of 00 out of 15 which indicated R39 had severe cognitive impairment. R39's medical record contained petitions for guardianship and protective placement, dated 6/27/23. R39's medical record did not contain guardianship or protective placement orders. On 8/12/24 at 12:17 PM, Surveyor requested updated and current guardianship and protective placement paperwork for R31, R43, and R39. On 8/13/24 at 9:21 AM, Surveyor received documentation for R31, R43, and R39 from Social Worker (SW)-D and noted the documentation was the same documentation Surveyor observed in R31, R43, and R39's medical records. On 8/13/24 at 1:35 PM, Surveyor interviewed SW-D who stated protective placement paperwork was completed yearly and guardianship paperwork was obtained upon admission. SW-D was unsure who to obtain the paperwork from and stated the facility did not receive or obtain guardianship or protective placement paperwork after the facility was notified by the court that a hearing was scheduled. SW-D stated when notice and order of hearing paperwork is received, the paperwork is scanned into the resident's medical record and no further action is completed by the facility. SW-D stated the facility does not have a process in place to ensure guardianship and protective placement paperwork is obtained and documented in residents' medical records. SW-D confirmed R31 and R43's medical records did not contain orders for guardianship or protective placement and R39's medical record did not contain a current protective placement order. 45942 4. On 8/12/24, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, congestive heart failure, and dependence on renal dialysis. R30's MDS assessment, dated 6/19/24, had a BIMS score of 12 out of 15 which indicated R30 had moderately impaired cognition. Upon admission to the facility, R30 was R30's own decision maker. R30's POAHC was activated on 5/10/22. R30's medical record indicated R30 signed POAHC paperwork on 10/23/20 that indicated: My health care agent may admit me to a nursing home or community-based residential facility for short-term stays for recuperative care or respite care. Agent Authority to admit me to a nursing home or community-based residential facility for long-term care. If I check No I cannot be admitted to a Wisconsin long-term care facility without a court order. R30 checked the box that indicated: No, my health care agent does not have the authority to admit me to a nursing home or a community-based residential facility for a long-term stay. On 8/12/24 at 2:21 PM, Surveyor interviewed SW-D who verified R30's POAHC paperwork was marked No for nursing home placement. SW-D stated R30 was admitted to the facility before SW-D was employed by the facility and SW-D had not seen that indicated on a resident's POAHC paperwork. SW-D stated if a resident checks No to nursing home admission on POAHC paperwork, the resident should not be admitted to the facility since that is not the resident's wish. SW-D stated SW-D is not involved in the admission process and the hospital should have fixed it prior to R30's admission to the facility. On 8/12/24 at 2:48 PM, Surveyor interviewed Business Office Staff (BOS)-Q who used to work in admissions when R30 was admitted . BOS-Q stated BOS-Q was unsure what to do if a resident marked No to nursing facility on POAHC paperwork and needed medical care. On 8/12/24 at 2:51 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated if a resident marks No to nursing home admission on POAHC paperwork, the facility would review it and not admit the resident.

Based on observation, staff and resident interview, and record review, the facility did not ensure 3 Residents (R) (R11, R16, and R41) of 3 sampled residents were assessed as able to safely and accurately self-administer medication. On 8/12/24, License Practical Nurse (LPN)-U left medication with R11 for R11 to self-administer after breakfast. R11 did not have a physician's order, self-administration of medication assessment, or care plan that indicated R11 could safely and accurately self-administer medication. On 8/12/24, LPN-U left medication at R16's bedside for R16 to self-administer. R16 did not have a physician's order, self-administration of medication assessment, or care plan that indicated R16 could safely and accurately self-administer medication. On 8/12/24, Registered Nurse (RN)-K prepared a nebulizer treatment for R41 to self-administer. R41 did not have a physician's order, self-administration of medication assessment, or care plan that indicated R41 could safely and accurately self-administer medication. Findings include: The facility's Resident Self-Administration of Medication policy, dated 5/1/24, indicates: It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medication after the facility's Interdisciplinary Team has determined which medication may be self-administered safely .4. The results of the Interdisciplinary Team assessment are recorded on the Medication Self-Administration Assessment Form which is placed in the resident's medical record .13. The care plan must reflect resident self-administration and storage arrangements for such medications. The facility's Bedside Medication Storage policy, dated 1/2024, indicates: .2. A written order for the bedside storage of medication is present in the resident's medical record . 1. From 8/12/24 to 8/14/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF), chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and ventilator dependency. R11's Minimum Data Set (MDS) assessment, dated 5/31/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 had intact cognition. R11's medical record indicated R11 was responsible for R11's healthcare decisions. On 8/12/24 at 9:20 AM, Surveyor observed LPN-U leave a medication cup for R11 that contained two 500 mg (milligram) tablets of calcium carbonate (an antacid medication). LPN-U stated R11 saves the medication for after breakfast. R11's medical record did not contain a physician's order, self-administration of medication assessment, or care plan that indicated R11 could safely and accurately self-administer medication. 2. From 8/12/24 to 8/14/24, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, morbid obesity, asthma, anxiety, tracheostomy, and ventilator dependency. R16's MDS assessment, dated 6/3/24, had a BIMS score of 9 out of 15 which indicated R16 had moderate cogitative impairment. R16's medical record indicated R16 had an activated Power of Attorney for Healthcare (POAHC). On 8/12/24 at 9:35 AM, Surveyor observed LPN-U leave a medication cup with two 250 mg tablets of ethosuximide (an anticonvulsant medication) at R16's bedside. R16's medical record did not contain a physician's order, self-administration of medication assessment, or care plan that indicated R16 could safely and accurately self-administer medication. On 8/12/24 at 12:56 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R11 and R16 did not have physician orders, self-administration of medication assessments, or care plans that indicated R11 and R16 could safely and accurately self-administer medication. 50467 3. From 8/12/24 to 8/14/24, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] with a history of emphysema (lower respiratory tract disease), acute respiratory failure with hypoxia (lack of oxygen), muscle weakness, and myxedma coma (severe hypothyroidism resulting in a decompensated metabolic state and mental status change). R41's MDS assessment, dated 7/16/24, had a BIMS score of 15 out of 15 which indicated R41 had intact cognition. On 8/12/24 at 9:03 AM, Surveyor observed a nebulizer solution in a nebulizer cup in R41's room. R41 stated RN-K brought the nebulizer solution into R41's room and set up the nebulizer machine for R41 to self-administer the medication. R41's medical record did not contain a physician's order, self-administration of medication assessment, or care plan that indicated R41 could safely and accurately self-administer medication. On 8/12/24 at 9:51 AM, Surveyor interviewed RN-K who confirmed RN-K left the nebulizer solution in R41's room for R41 to self-administer. On 8/13/24 at 1:45 PM, Surveyor interviewed DON-B who confirmed R41 did not have a physician's order, self-administration of medication assessment, or care plan prior to 8/13/24 that indicated R41 could safely and accurately self-administer medication.

Based on record review, complainant and staff interviews, the facility did not properly notify a physician when 1 (Resident (R) 1) of 9 sampled residents experienced a significant change in physical status nor did the facility provide all pertinent information when the on-call physician's services were contacted. R1 fell out of bed and sustained a head injury on [DATE] at 10:05 P.M. The facility notified the on-call PA (Physician's Assistant) of R1's fall without informing the PA that R1 had sustained a laceration to the head. Furthermore, the facility did not notify a physician timely at 6:20 AM on [DATE] when R1 was noted to have increased swelling, bruising, and pain at the laceration site. R1 was diagnosed with [REDACTED]. R1 passed away on [DATE]. The facility's failure to thoroughly and accurately notify and consult with the physician in a timely manner after R1 fell and sustained a head injury created a finding of immediate jeopardy that began on [DATE]. The NHA (Nursing Home Administrator) was notified on [DATE] of the immediate jeopardy. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope and severity of a D (potential for more than minimum harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's current policy titled Fall Reduction Policy issued [DATE], stated residents will be evaluated for change in condition post-fall for a period of 72-hours or until condition is stable. It further stated nursing staff should keep the attending physician aware of fall-related complications. The facility was unable to provide the Surveyor with the facility's policy or standard of practice that was utilized by Nursing staff regarding the frequency of neurological checks after a head injury. According to an article titled Neurological Checks for Head Injuries from the newsletter LTC (Long Term Care) Clinical Pearls: Powered by HCPro's Long-Term Care Nursing Library, states to: 2. Observe the resident for obvious injuries to the scalp, including lacerations, bruises, or contusions; confusion; memory loss; difficulty speaking; gait or balance problems; headache . 3. Perform frequent neurologic assessments every: ~ 15 minutes for 2 hours ~ 30 minutes for 2 hours ~ 60 minutes for 4 hours ~ 8 hours for 16 hours (until at least 72 hours have elapsed and resident is stable) On [DATE], the Surveyor reviewed R1's medical record and it included documentation that R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent MDS (Minimum Data Set) assessment, dated [DATE], documented the resident's cognition was severity impaired, had history of falls and required extensive assistance with all ADL's (Activities of Daily Living). R1's most recent fall risk assessment, dated [DATE], indicated R1 was a moderate risk for falls. R1's medical record included documentation that the resident had a history of [REDACTED]. R1's MARs (Medication Administration Record) included documentation that R1 received [MEDICATION NAME] (anticoagulant/blood-thinning medication) daily and R1's most recent lab report documented an elevated [MEDICATION NAME]-time (blood clotting time) of 16.8 seconds (reference range 9XXX,[DATE].5 seconds). R1's ,[DATE] MAR indicated [REDACTED]. R1's most current care plan included the resident's risk for abnormal bleeding related to taking an anticoagulant with interventions to include report any symptoms of unusual bleeding or bruising and update MD (medical doctor) PRN. A Nursing note written by LPN (Licensed Practical Nurse)-H on [DATE] at 10:05 PM documented .resident is on the floor. Writer went to resident's room and found resident face down on the left side of her bed with her head up by the night stand with a pool of blood under her head. Writer had (RN (Registered Nurse)-J) come into room for assessment. Resident has a 1 cm (centimeter) laceration to the top left of her forehead, bleeding stopped after applying pressure, steri strip in place and ice pack applied. Neuro's wnl (within normal limits) .no c/o (complaints of) pain or discomfort. On call for (MD-I) was (PA-F). Son/POA (Power of Attorney) was updated. On [DATE] at 12:30 PM, the Surveyor interviewed LPN-H regarding R1's fall and head injury. LPN-H stated she had called the on-call PA (PA-F) and informed him R1 had an unwitnessed fall out of bed, reviewed the neurological status and vital signs, informed the PA (R1) was taking [MEDICATION NAME]. LPN-H stated PA-F informed her to monitor R1 and call back with any changes. LPN-H verified she did not clarify what changes PA-F wanted staff to notify the physician or how often to monitor R1. On [DATE] at 8:31 AM, the Surveyor interviewed PA-F regarding R1. PA-F stated the nurse told him R1 had an unwitnessed fall out of bed. When PA-F asked the facility staff if R1 was on [MEDICATION NAME] and facility confirmed this. PA-F verified he was not aware R1 had a head injury and stated based on an assessment of increased swelling, bruising, and pain around the laceration, he would have expected to be updated and would have sent R1 out. R1's medical record included documentation that staff completed neurological status and vital sign checks on [DATE] at 10:05 PM, 10:30 PM, 11:00 PM, 11:30 PM and on [DATE] at 12:30 AM, 1:30 AM, 2:30 AM, 3:30 AM. The 8:00 AM status and vital sign check had been documented in the medical record at 11:01 AM, and indicated increased bruising. The Nursing note by RN-J dated [DATE] at 6:20 AM stated .c/o of pain when touching laceration and surrounding [MEDICAL CONDITION] (swelling). Ice to that area most of the night. Laceration would ooze some when dressing and ice off. (Resident) sometimes would try rubbing it. Bruising now extends across her forehead and starting to go down to eyes. Continue to monitor. RN-J did not consult with the physician even though PA-F had said to call back with any changes. On [DATE] at 11:32 AM, the Surveyor interviewed MD-I's office staff, LPN-N regarding R1's fall and head injury. LPN-N indicated based on RN-J's assessment of R1's apparent head injury and R1 taking [MEDICATION NAME], she would have expected R1 to be sent to the hospital for an evaluation. On [DATE] at 11:22 AM, the Surveyor interviewed the complainant, who stated on [DATE], R1's family had noticed R1 appeared lethargic and was slurring words. The complainant indicated R1's POA (Power of Attorney) had called MD-I between 11:30 AM and 12:30 PM, to request that R1 be sent to the hospital. The complainant informed the Surveyor R1 was given Vitamin K (used to reduce blood clotting time, considered a reversal agent of [MEDICATION NAME]/[MEDICATION NAME]) after the CT (computed tomography) scan revealed the brain bleed. On [DATE], the Surveyor reviewed the facility self-report submitted to the State Survey and Certification Agency on [DATE]. The report included documentation that Resident (R1) had a fall on the evening of [DATE]. On [DATE] a police officer came to the facility stating the resident's family called concerned about possible elder abuse. Investigation was initiated. Interview with CNA-G indicated on [DATE], R1 was increasingly active, trying to get out of her wheelchair and required increased supervision by staff. On the night of [DATE] after the fall, R1 had ice reapplied to the forehead several times as the laceration would ooze. Also (resident) was rubbing at the area .Bruising was noted across (resident's) forehead and started going down into her eyes. A statement from LPN-K documented on [DATE], R1's family was concerned since R1 was so sleepy. LPN-K informed R1's family that R1 was up all night (due to) neuro checks and trying to get the bleeding to stop. A statement documented by DON (Director of Nursing)-D, dated [DATE] at 10:30 AM, indicated that she was aware of R1's use of [MEDICATION NAME] and asked (LPN-K) to make sure we update her primary MD/APNP (Advanced Practice Nurse Prescriber) to ensure they were aware of her fall last night and the extent of her bruising. The investigation further indicated APNP (Advanced Practice Nurse Practitioner)-L was paged at 11:46 AM related to R1's increased bruising and called the facility at 12:00 PM, but did not address R1's fall or change in condition. At 12:57 PM, MD-I ordered R1 to be sent to the emergency department to rule out any injury or brain bleed. The statement from DON-D verified MD-I had already been contacted by R1's family at that time and the family requested R1 be sent to the hospital. The investigation concluded with R1 being sent to the hospital on [DATE] at 2:00 PM, via ambulance and admitted to the hospital with [REDACTED]. On [DATE] at 3:02 PM, the Surveyor interviewed DON-D regarding R1's fall and the notification of the physician. DON-D stated there was no significant change in condition that warranted a call to the physician. DON-D stated she just had an uneasy feeling and had advised LPN-K to update the APNP/MD to see if they wanted R1 to be sent out, not based on an assessment, but rather to be safe than sorry. DON-D verified R1 was unreliable at reporting pain so staff assessed the resident for non-verbal signs. On [DATE] at 4:21 PM, the Surveyor interviewed RN-J regarding R1's fall with head injury. RN-J indicated she .did not think that (the bruising) was unusual. RN-J further indicated that there was nothing worth updating the doctor about, since neuro checks and vital signs were normal. This was verified by the statement from RNC (Registered Nurse Consultant)-M, who documented a statement which read The nurse (RN-J) felt the bruising would be considered normal according to (R1's) injury, age, and less adipose tissue. According to the article [MEDICATION NAME] and the Apparent Minor Head Injury, from the Emergency Medicine Journal 1996, The risk of intracranial hematoma is increased 10-fold in patients on anticoagulants .It is three times more likely to occur in women .Patients over the age of 50 with a duration of treatment of [REDACTED]. It further states Patients with apparent minor head injury who are on anticoagulants .should be admitted for standard neurological observation following an apparent minor head injury .patients who develop persisting or increasing neurological symptoms or signs after an apparently minor head injury will have an urgent CT scan .In a developing intracranial hematoma, headache is the most common symptom. Based on an article titled [MEDICAL CONDITION], Cerebral Hemorrhage, and Hemorrhagic Stroke: Management and Treatment from the Cleveland Clinic website (2017), Any type of bleeding inside the skull or brain is a medical emergency. It is important to get the person to a hospital emergency room immediately to determine the cause of the bleeding and begin medical treatment. Based on an article titled Risk of Traumatic [MEDICAL CONDITION] (tICH) in Patients with Head Injury and Pre-injury [MEDICATION NAME] or [MEDICATION NAME] Use from the Academy of Emergency Medicine (2014) emphasized the importance of rapid [DIAGNOSES REDACTED].with medications. Patients with delayed reversal of anticoagulation have increased morbidity and mortality. Upon review of R1's medical record and interviews with staff, the Surveyor noted the facility staff did not accurately notify PA-F of R1's fall with a head injury and did not update/consult R1's physician when R1's condition changed at 6:20 AM on [DATE], that included pain, increased swelling and extensive bruising. R1's change in condition was acted upon after R1's family contacted MD-I and informed MD-I of these changes and MD-I called the facility at 12:57 PM and ordered R1 to be sent to the emergency room . The facility's failure to promptly and accurately notify R1's physician after the resident had a fall with a head injury created an immediate jeopardy situation that was removed on [DATE] when the facility implemented the following action plan: ~ Ad Hoc QA (quality assurance) meeting held to educate entire leadership team on plan and follow-up ~ Policies reviewed and updated to include notification to on-call physicians for after hours and primary physician next business day of falls with injuries and any change of condition post fall or injuries. Updated policies to include sending any resident on anticoagulants with a head injury to the ER (emergency room ) for further evaluation. ~ Educated all licensed staff currently on shift an/or prior to next working shift on facility's policy changes. ~ Updated PCC (Point Click Care) for falls, to automatically trigger/prompt the nurses to complete scheduled assessments with fall risk management reports. ~ DON to review the past 30 days of Risk management incident reports for falls with injury or suspected injury to ensure the primary MD was made aware of the incident that occurred. ~ Fall reduction policy updated and education to all licensed nurses regarding procedure when an unwitnessed fall or fall with injury or suspected injury occurs. MD will be updated immediately following an unwitnessed fall or fall with injury. If after hours, notify the on-call MD at the time of the incident and then notify the primary physician or APNP at the beginning of next business day. ~ E-interact assessment will be set up to trigger with all falls. ~ DON/designee will review the ,[DATE] hour report, risk management reports and bring any new falls to clinical Monday thru Friday meeting to review and investigate. ~ DON/designee will complete audits for all falls for 4 weeks to ensure MD or APNP had been notified and that the fall had been added to the Risk management incident report. All audits will be brought to QAPI for review and continued follow up as needed.

Based on record review, complainant and staff interviews, the facility did not ensure 1 (R (Resident) 1) of 9 sample and supplemental sampled residents were provided the necessary care and services in accordance with professional standards of practice, the comprehensive assessment and person-centered plan of care related to nursing assessment and a change in condition R1 fall out of bed and sustained a head injury. The facility's failure to properly monitor and assess R1's change in condition caused actual physical and psychosocial harm to R1. R1 passed away on [DATE]. The facility's failure to thoroughly and accurately assess and monitor R1 after the resident fell out of bed and sustained a head injury created a finding of immediate jeopardy that began on [DATE]. The NHA (Nursing Home Administrator) was notified on [DATE] of the immediate jeopardy. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a scope and severity of a D (potential for more than minimum harm/isolated) as the facility continues to implement it's action plan. Findings include: On [DATE], the Surveyor reviewed R1's medical record and it included documentation that R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent MDS (Minimum Data Set) assessment, dated [DATE], documented the resident's cognition was severity impaired, had history of falls and required extensive assistance with all ADL's (Activities of Daily Living). R1's most recent fall risk assessment, dated [DATE], indicated R1 was a moderate risk for falls. R1's medical record included documentation that the resident had a history of [REDACTED]. R1's MARs (Medication Administration Record) included documentation that R1 received [MEDICATION NAME] (anticoagulant/blood-thinning medication) daily and R1's most recent lab report documented an elevated [MEDICATION NAME]-time (blood clotting time) of 16.8 seconds (reference range 9XXX,[DATE].5 seconds). R1's ,[DATE] MAR indicated [REDACTED]. R1's most current care plan included the resident's risk for abnormal bleeding related to taking an anticoagulant with interventions to include report any symptoms of unusual bleeding or bruising and update MD (medical doctor) PRN. R1's care plan included high risk for falls with an intervention to initiate neurochecks per facility policy. The facility's current policy titled Fall Reduction Policy issued [DATE], stated residents will be evaluated for change in condition post-fall for a period of 72-hours or until condition is stable. It further stated nursing staff should keep the attending physician aware of fall-related complications. The facility was unable to provide the Surveyor with the facility's policy or standard of practice that was utilized by Nursing staff regarding the frequency of neurological checks after a head injury. A Nursing note written by LPN (Licensed Practical Nurse)-H on [DATE] at 10:05 PM documented .resident is on the floor. Writer went to resident's room and found resident face down on the left side of her bed with her head up by the night stand with a pool of blood under her head. Writer had (RN (Registered Nurse)-J) come into room for assessment. Resident has a 1 cm (centimeter) laceration to the top left of her forehead, bleeding stopped after applying pressure, steri strip in place and ice pack applied. Neuro's wnl (within normal limits) .no c/o (complaints of) pain or discomfort. On call for (MD-I) was (PA-F). Son/POA (Power of Attorney) was updated. On [DATE] at 8:31 AM, the Surveyor interviewed PA-F regarding R1. PA-F stated the nurse told him R1 had an unwitnessed fall out of bed. When PA-F asked the facility staff if R1 was on [MEDICATION NAME] and facility confirmed this. PA-F verified he was not aware R1 had a head injury and stated based on an assessment of increased swelling, bruising, and pain around the laceration, he would have expected to be updated and would have sent R1 out. On [DATE] at 12:30 PM, the Surveyor interviewed LPN-H regarding R1's fall and head injury. LPN-H stated she had called the on-call PA (PA-F) and informed him that R1 had an unwitnessed fall out of bed, reviewed the neurological status and vital signs, and informed the PA R1 was taking [MEDICATION NAME]. LPN-H stated PA-F informed her to monitor R1 and call back with any changes. LPN-H verified she did not clarify what changes PA-F wanted staff to notify the physician or how often to monitor R1. R1's medical record included staff completed neurological status and vital sign checks on [DATE] at 10:05 PM, 10:30 PM, 11:00 PM, 11:30 PM and on [DATE] at 12:30 AM, 1:30 AM, 2:30 AM, 3:30 AM. The 8:00 AM status and vital sign check had been documented in the medical record at 11:01 AM, and indicated increased bruising. According to an article titled Neurological Checks for Head Injuries from the newsletter LTC (Long Term Care) Clinical Pearls: Powered by HCPro's Long-Term Care Nursing Library, states to: 2. Observe the resident for obvious injuries to the scalp, including lacerations, bruises, or contusions; confusion; memory loss; difficulty speaking; gait or balance problems; headache . 3. Perform frequent neurologic assessments every: ~ 15 minutes for 2 hours ~ 30 minutes for 2 hours ~ 60 minutes for 4 hours ~ 8 hours for 16 hours (until at least 72 hours have elapsed and resident is stable) The Nursing note by RN-J dated [DATE] at 6:20 AM stated .c/o of pain when touching laceration and surrounding [MEDICAL CONDITION] (swelling). Ice to that area most of the night. Laceration would ooze some when dressing and ice off. (Resident) sometimes would try rubbing it. Bruising now extends across her forehead and starting to go down to eyes. Continue to monitor. The facility was unable to provide additional documentation that R1 had been monitored and/or assessed by staff from 3:30 AM, the last neurological check until 6:20 AM. In addition, R1's medical record did not include documentation that staff completed a thorough neurologic assessment at 6:20 AM, when R1 displayed a significant change in condition that included pain, increased swelling and extensive bruising. R1's change in condition was not addressed by MD-I until 12:57 PM, after the family had contacted MD-I's office. On [DATE] at 11:32 AM, the Surveyor interviewed MD-I's office staff, LPN-N regarding R1's fall with a head injury. LPN-N indicated based on RN-J's assessment of R1's apparent head injury and R1 receiving [MEDICATION NAME], she would have expected R1 to be sent to the hospital for an evaluation. On [DATE] at 11:22 AM, the Surveyor interviewed the complainant, who stated on [DATE], R1's family had noticed R1 appeared lethargic and was slurring words. The complainant indicated R1's POA had called MD-I between 11:30 AM and 12:30 PM on [DATE], to request that R1 be sent to the hospital. The complainant indicated R1 had been given Vitamin K (used to reduce blood clotting time, considered a reversal agent of [MEDICATION NAME]/[MEDICATION NAME]) at the hospital after the CT (computed tomography) scan revealed the brain bleed. On [DATE], the Surveyor reviewed the facility self-report submitted to the State Survey and Certification Agency on [DATE]. The report included documentation that Resident (R1) had a fall on the evening of [DATE]. On [DATE] a police officer came to the facility stating the resident's family called concerned about possible elder abuse. Investigation was initiated. Interview with CNA-G indicated on [DATE], R1 was increasingly active, trying to get out of her wheelchair and required increased supervision by staff. On the night of [DATE] after the fall, R1 had ice reapplied to the forehead several times as the laceration would ooze. Also (resident) was rubbing at the area .Bruising was noted across (resident's) forehead and started going down into her eyes. A statement from LPN-K documented on [DATE], R1's family was concerned since R1 was so sleepy. LPN-K informed R1's family that R1 was up all night (due to) neuro checks and trying to get the bleeding to stop. A statement documented by DON (Director of Nursing)-D, dated [DATE] at 10:30 AM, indicated that she was aware of R1's use of [MEDICATION NAME] and asked (LPN-K) to make sure we update her primary MD/APNP (Advanced Practice Nurse Prescriber) to ensure they were aware of her fall last night and the extent of her bruising. The investigation further indicated APNP (Advanced Practice Nurse Practitioner)-L was paged at 11:46 AM related to R1's increased bruising and called the facility at 12:00 PM, but did not address R1's fall or change in condition. At 12:57 PM, MD-I ordered R1 to be sent to the emergency department to rule out any injury or brain bleed. The statement from DON-D verified MD-I had already been contacted by R1's family at that time and the family requested R1 be sent to the hospital. The investigation concluded with R1 being sent to the hospital on [DATE] at 2:00 PM, via ambulance and admitted to the hospital with [REDACTED]. See F580 for additional reference articles titled [MEDICATION NAME] and the Apparent Minor Head Injury and [MEDICAL CONDITION], Cerebral Hemorrhage, and Hemorrhagic Stroke: Management and Treatment. The facility's failure to promptly and accurately monitor and assess R1 based on current standards of practice and to recognize and respond to R1's change of condition at 6:20 AM on [DATE] that included pain, increased swelling and extensive bruising after the resident had a fall with a head injury created an immediate jeopardy situation that was removed on [DATE] when the facility implemented the following action plan: ~ Ad Hoc QA (quality assurance) meeting held to educate entire leadership team on plan and follow-up. ~ Assessed residents with recent falls in the past 30 days, 2 out of 12 residents were noted to have hit their head per nursing documentation and incident reports, both residents had neuro checks completed and physicians were notified. ~ Reviewed all residents with current prescribed anticoagulants. ~ Policies reviewed and updated to include new neuro check procedure and post fall procedure. ~ Educated all licensed staff currently on shift an/or prior to next working shift on facility's policy for neuro checks and fall reduction which include head injuries, neuro checks and scheduled assessments. ~ Scheduled assessments in PCC (Point Click Care) for all falls were updated to automatically trigger with fall risk management reports to prompt nurses to complete. ~ DON created a timeline and follow up with all staff that were deficient in practice per the policy. ~ DON to audit most recent fall risk assessments completed on all residents in the facility to identify residents at moderate/high risk for falls. ~ Education to all licensed nurses regarding procedure when an unwitnessed fall or fall with head injury occurs. Incidents must be completed and include detailed statements from all present staff. Neuro check policy and scheduled assessments in PCC to be updated to include every 15 minutes times 4, every 30 minutes times 4, every 1 hour times 4, every 4 hours times 4 then every 8 hours times 48. ~ The following assessments will be set up to trigger with a fall: E-interact, neuro checks, pain assessment, clinical follow-up and fall risk assessment. ~ Education with DON and UM (unit manager) to ensure IDT (Interdisciplinary team) is reviewing all to make sure all necessary components were completed per the policy including a thorough investigation. ~ DON will be notified for all falls at the time they occur. DON/UM or designee will assess all residents with a fall with head injury as soon as possible. ~ DON/designee will review the ,[DATE] hour report, PCC dashboard and risk management reports and bring any new falls to clinical Monday thru Friday meeting for full review and investigation. ~ DON/designee will complete audits for all falls times 4 weeks to ensure accuracy of assessments and neuro checks and follow up as needed. All audits will be brought to QAPI for review and continued follow up as needed.

Based on record review and staff interviews, the facility did not provide 1 of 6 residents reviewed for hydration (resident #6) with sufficient fluid intake to maintain proper hydration and health. Resident #6 presented with a fever, decreased appetite, decreased intake of oral fluids and emesis and loose stools. The resident was dependent on staff for intake of foods and fluids; was on thickened liquids due to dysphagia related to [MEDICAL CONDITION]; and was on a daily diuretic due to [MEDICAL CONDITIONS]. The facility had assessed the resident to be at risk of dehydration prior to the above presenting symptoms. The facility initiated a dehydration plan of care and a fluid intake and output record for the resident the day following symptom presentation. The facility failed to complete physical assessments related to hydration status; failed to calculate the total intake of fluids for the resident every 24 hours; failed to identify an issue with hydration when the resident's documented weight had declined significantly in a short amount of time; and continued to administer a daily dose of diuretic medication. As a result, the resident was hospitalized from [DATE]-1/10/15 and required IV (intravenous) fluid therapy due to [MEDICAL CONDITION] (high sodium levels), dehydration with resultant acute renal (kidney) failure. The facility's failure to complete hydration assessments when resident #6 presented with changes in appetite, fever, decrease in oral intake of fluids at which time the resident had tested positive for Norovirus, and the facility's failure to alter resident #6's course of treatment resulted in a finding of immediate jeopardy, which began on 12/31/14. The facility was notified of the immediate jeopardy on 2/12/15. The immediate jeopardy was removed on 2/12/15; however, the deficient practice continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy and procedure regarding hydration/prevention and treatment of [REDACTED]. Intake will be documented in the medical records for those residents whom have individualized interventions for I&) (intake and output). Aides will report changes in fluid or food intake to charge nurses. If potential inadequate intake and/or signs and symptoms of dehydration are observed, interventions will be initiated and incorporated into the plan of care. The Dietician, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Orders for medications that may exacerbate dehydration (e.g., diuretics) will be reviewed and held if medically appropriate. Laboratory tests may be ordered to assess hydration if intake and symptoms indicate possible significant dehydration. If laboratory results are consistent with actual dehydration, the physician may initiate IV hydration. hospitalization will be recommended, if necessary. The facility's policy entitled, "Measuring and Documenting Fluid Intake," dated 1/1/14 indicated a purpose to accurately determine the amount of liquid a resident consumes in a 24 hour period. An order should be obtained only if it is medically indicated for the resident to be on I&O. At the end of the shift, total the amounts of all liquids the resident consumed. Nursing will monitor and document fluid intake and the Dietitian will be kept informed of the status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. The Evidence-Based practice Guideline entitled, "Hydration Management," published in February of 2004 by the University of Iowa College of Nursing Research Translation and Dissemination Core indicated older individuals are at increased risk for hydration problems for a variety of reasons. First, as an individual ages, his/her total body water decreases from 50-70% to 40-50% of body weight. Second, older individuals tend to lose muscle mass, which increases the proportion of fat cells to muscle cells. Fat cells are known to contain less water than muscle cells which decreases overall intracellular fluids. Third, the risk of hydration problems is further increased with other age-related change involving the hormonally regulated thirst mechanism. Elderly individuals do not experience thirst as intensely as younger individuals, in fact their thirst is not proportional to metabolic needs in response to dehydrating conditions. Finally, a myriad of other clinical factors that are more likely to occur as one ages, also contribute to increased risk. These include renal dysfunction/decline, cardiovascular disease, diabetes, multiple medical problems, malnutrition, and medical usage, to name a few. Hypertonic dehydration, also known as intracellular dehydration/ hypernatremic dehydration, is depletion in total body water content due to pathologic fluid losses, diminished water intake or a combination of both. It results in [MEDICAL CONDITION] in the extra cellular fluid compartment with draws water from the intracellular fluids. The water loss is shared by all body fluid compartments and relatively little reduction in extra cellular fluids occurs. Thus, circulation is not compromised unless the loss is very large. Research-based risk factors in long term care setting include age of over [AGE] years; functionally more dependent; dependent with eating; 4 or more chronic conditions; [MEDICAL CONDITION] of other dementias; few fluid ingestion opportunities; inadequate nutrient intake; use of diuretics; swallow problems; communication issues; and fever. Associated medical conditions with subsequent hospitalization s due to dehydration include gastroenteritis (10.4%) and frailty (20.3%). Literature-based risk factors for dehydration in all settings include vomiting or diarrhea,and cognitive impairment. Components of physical assessment that are essential include vital signs including temperature, pulse, respirations, orthostatic blood pressure; height and weight; review of systems or head to toe assessment. Make sure to include an assessment of the oral cavity and mucous membranes. Approximate ranges of laboratory tests for hydration status include dehydration as defined by BUN (Blood Urea Nitrogen)/Creatinine ratio of greater than 25; serum sodium of greater than 150; less than 800 ml (milileters) of urine out put in 24 hours. Any resident who develops a fever, vomiting, diarrhea or a non febrile infections should be closely monitored by implementing intake and output records and provision of additional fluids as tolerated. According to Mayoclinic.com, dehydration can be diagnosed on the basis of physical signs. Early symptoms include dry sticky mouth; listlessness or sleepiness; cotton mouth; loss of appetite; and weakness. Dehydration in residents taking a diuretic can include high or low blood sodium levels and elevated BUN levels. A sub clinical sign of dehydration can include a loss of 1-2% of body weight due to fluid loss. Recent rapid weight loss is often an important clue because it may reflect progressive depletion of fluid volume. Resident #6's admission face sheet dated 6/7/08 indicated the resident had [DIAGNOSES REDACTED]. The resident's age was listed as 94. The facility conducted an MDS (minimum data set) on the resident and assessed the resident to score a 3 of 15 on the cognition screen (the higher the score, the more cognizant); assessed the resident to be totally dependent on staff to perform all activities of daily living to include ingestion of food and fluids; and was totally incontinent of bowel and bladder. A nutrition plan of care dated 2/6/14 and updated on 12/15/14 indicated interventions to include notifying Dietician of any signs/symptoms of dehydration; monitor/evaluate weight/weight changes; to notify Dietician of weight changes; to encourage fluids at mealtimes and between meal; to monitor for signs/symptoms of dehydration; concentrated urine, dry mucous membranes, poor skin turgor, increased weakness, change in mentation, abnormal labs, decreased urine output; and hydration pass at snack times. The interventions in place did not include that the resident had been placed on a care to drink program. Laboratory findings included in the resident's medical record dated 11/11/14 indicated the resident had a normal BUN, Creatinine (indicator of kidney functioning), sodium and GFR (Glomerular Filtration Rate. An indicator of how well the kidney filter is working). The resident was edentulous and required nectar thickened liquids. The resident's medical medical record indicated the resident had the diuretic medication [MEDICATION NAME] 40 mg (milligrams) daily included in the medication regieme. The facility completed a hydration risk assessment for the resident on 12/11/14 which indicated the resident was at mild risk for dehydration. A nutritional assessment completed for the resident on 12/15/14 indicated that the resident weighed 126 pounds and estimated the resident required greater than 1500 ml of fluids per day. The assessment noted, "Adequate oral intake at meals. Does receive supplement and fortified foods due to history of weight loss and poor oral intake. Although weight is up 10 pounds in the last 6 months, current weight of 126 pounds is consistent with weight of 126.4 pounds 1 year ago." Review of the resident's medical record indicated on 12/27/14 the resident's weight was 124 pounds. The resident was 59 inches tall. The facility experienced an outbreak of Norovirus on 12/29/14. Most of the affected residents resided on resident #6's unit and on the unit adjacent to the resident's unit. Review of the resident's nursing notes, TAR (treatment administration records), MAR (medication administration record), CNA (Certified Nursing Assistant) flow sheets; and weight and vital summaries indicated the following: * 12/30/14 at 11:00 p.m. One large emesis and one large loose foul smelling brown-green stool. Stool specimen for Norovirus collected related to Norovirus outbreak criteria. No hydration assessment completed. Temperature 98.1 (oral) degrees F (Fahrenheit). Blood pressure 170/78. Pulse 84. Incontinent of urine twice during each three shifts (no quantifying amounts to include small, medium or large amounts). * 12/31/14 at 3:30 a.m. Episode of diarrhea. Denies nausea/vomiting. Will continue to monitor. * 12/31/14 at 10:30 a.m. Temperature 99.1 degrees (axilla). Blood pressure 132/84. Took small amount of breakfast. NP (Nurse Practitioner) aware of diarrhea. Tylenol for temperature. Is on contact isolation precautions. Will continue to monitor. Initiation of a Gastroenteritis Care plan completed to include interventions of symptomatic charting every shift. Note should include but not limited to: abdominal assess, description of stool/vomit and how many times, hydration assess and any other pertinent information. Monitor of signs and symptoms of dehydration, e.g. dry lips, dry mucous membranes, poor skin turgor, and abnormal labs. Assess resident for fluid depleting drugs/laxatives and update physician. Intake and output records were initiated. (It was noted that resident #6's intake form did not identify what the resident's specific daily fluid intake needs were). Inform nurse of poor appetite and fluid intake every shift. Fluid intake per CNA charting = 840 ml. Supplements and hydration fluid intake per TAR= 180 ml. Total intake of fluids calculated by surveyor # and had not calculated by staff =1020 ml. No hydration assessment completed. The resident received the daily dose of [MEDICATION NAME] 40 mg on 12/31/14. * 12/31/14 at 4:54 p.m. Decreased appetite. Taking fluids with encouragement. Blood pressure 148/62. Pulse 56. Temperature 99 degrees (axilla). No documented hydration assessment noted. * 1/1/15 at 12:01 a.m. Temperature 99.8 axillary. Blood pressure 180/80. Pulse 80. No hydration assessment documented. * 1/1/15 at 12:20 p.m. Temperature 98.9 oral. Pulse 92. Blood pressure 176/80 (sitting). No nausea, vomiting or diarrhea this shift. No documented hydration assessment completed. The resident received the daily dose of [MEDICATION NAME] 40 mg. * 1/1/15 at 9:15 p.m. Temperature 98.1 Blood pressure 166/72. Pulse 94. Adequate fluids. No documented hydration assessment had been completed. Fluid intake per CNA charting = 840 ml. Supplements and hydration fluid intake per TAR= 480 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 1560 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). *1/2/15 at 5:00 a.m. Vitals stable. No nausea/vomiting diarrhea. No documented hydration assessment completed. * 1/2/15 at 11:00 a.m. Temperature 99 degrees oral. Pulse 94. Blood pressure 166/72. Has poor appetite. No documented hydration assessment completed. The resident spit out the daily dose of [MEDICATION NAME] 40 mg. * 1/2/15 at 6:00 p.m. Temperature 98.6 axillary. Pulse 92. Blood pressure 144.74. No nausea/vomiting noted. No documented hydration assessment completed. Fluid intake for 1/2/15 per CNA charting = 840 ml. Supplements and hydration fluid intake per TAR= 480 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 1320 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). A documented weight of 115.5 pounds was noted. No reweigh was documented to verify if weight was accurate. No indication was noted in the medical record that the Dietician had been notified of the significant weight decline. From 1/3/15 through 1/7/15, there was no documented weight for the resident. After the entry dated 1/2/15 at 6:00 p.m., no further nursing entries and no documented vital signs were noted in the nursing notes in the resident's medical record after the eveing shift on 1/2/15 through the evening shift on 1/7/15. * 1/3/15. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/3/15 per CNA charting = 600 ml. Total intake of fluids not calculated by staff =120 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 720 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). * 1/4/15. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/4/15 per CNA charting = 600 ml. Supplements and hydration fluid intake per TAR= 120 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 720 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). * 1/515. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/5/15 per CNA charting = 840 ml. Supplements and hydration fluid intake per TAR= 150 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 990 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). Gastroenteritis plan of care was discontinued. * 1/6/15. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/6/15 per CNA charting = 960 ml. Supplements and hydration fluid intake per TAR= 120 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 1080 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). * 1/7/15. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/7/15 per CNA charting =480 ml. Supplements and hydration fluid intake per TAR= 120 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 700 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). An emergency room document dated 11:00 p.m. on 1/7/15 indicated resident #6 had been transported to the emergency room for evaluation of a protrusion in the left abdominal wall. The emergency room physician documented, "Labs showed sodium of 168 (normal is 135-145). The resident looks quite dry and quite dehydrated. Mouth is dry, skin is tenting. Looks chronically ill but certainly debilitated. Chloride is high. Has some pre renal indices with creatinine climbing quite a bit." The resident's weight was listed as 122 pounds (unknown if this was before or after IV fluids had been initiated). Laboratory findings included BUN of 89 (normal 8-26), Creatinine of 2.97 (normal 0.6-1.5), and a GFR of 16 (normal greater than 60). Assessment and plan indicated, "Significant dehydration. Patient is significantly dehydrated she is very dry appearing she has been on [MEDICATION NAME] for heart failure and it appears that maybe she was not eating as well, drinking as well as limited access to fluids that she is not able to get them for herself. She has already received 1 Liter of normal saline. Hold diuretic for now. [MEDICAL CONDITION]. Patient has already received a liter of normal saline will change her to 5% [MEDICATION NAME] half normal saline at 125 ml per hour. Will likely need hydration over the next few days to get sodium back down. Abdominal discomfort. Patient has minimal symptoms but cognition is poor with being dehydrated. Would certainly consider ischemic [MEDICAL CONDITION]. The abdomen is quite soft and there is no free air there and no fluid levels on KUB (Kidney, urethra, bladder X-Ray). Hydration at this point and try to get fluid balances more normal. Acute [MEDICAL CONDITION] secondary to dehydration. Again, gentle hydration as has already received a liter of fluids. Hypertension. At this point because of acute [MEDICAL CONDITION], will hold [MEDICATION NAME] (antihypertensive) and resume when kidney function is improved. Is expected to require at least a two midnight stay in the hospital." The resident was hospitalized until 1/11/15 and returned to the facility on that day at 2:00 p.m. On 1/9/15, the resident's stool culture results indicated a positive Norovirus result. A physician's note dated 1/14/15 and located in the resident's medical record indicated, "Resident returns from hospital following admission for dehydration. Had Norovirus about 2 weeks ago but recovered. Probably this contributed to dehydration along with diuretic therapy and inability to feed self or express thirst." On 2/10/15 at 2420 p.m., surveyor # interviewed RN (Registered Nurse)-G. RN-G verified to the surveyor that no documented hydration assessments were noted in resident #6's medical record after 12/11/14. RN-G also verified to the surveyor that no additional dietary evaluations had been completed for resident #6 after 12/15/14 RN-G stated, "A dietary slip should have been made out on 1/2/15 when (#6) had a documented weight decline. There is no such slip in (#6) chart. The resident was taken off symptomatic charting after her vomiting and diarrhea had cleared. Symptomatic charting is done for 3 days after symptoms present. After 1/2/15, there is no nursing documentation in (#6) medical record at all." On 2/10/15 at 3:20 p.m., surveyor # interviewed NP (Nurse Practitioner)-K. NP-K verified to the surveyor that she was one of resident #6's primary care providers and was the on-call practitioner for the facility Monday through Friday during the day time hours. NP-K indicated that she had not been made aware of resident #6's change in condition from 1/1/15-1/7/15. On 2/11/15 at 8:20 a.m., surveyor # interviewed LPN (Licensed Practical Nurse)-L. LPN-L stated, "I'm not sure who is supposed to tally resident's 24 hour intake of fluids if they are on I&O. If the aides note an intake of less than 1000 ml/24 hours for several days, they are to tell the nurse. If the nurses give additional fluids (other that what is included during meal times), they tell the aides and the aides add it to their intake sheets. The aides document urine output on the flow sheet record. If the resident isn't voiding, the aides report that to the nurse. Also, if they notice a downward trend in the number of voids, they are to tell the nurse, but we don't review that flow sheet every shift." On 2/10/15 at 2:20 p.m., surveyor # interviewed RN-J regarding the documented weight loss for resident #6 dated 1/2/15. RN-J stated, "Nursing should be notifying the Dietician when weight declines are noted. That weight loss was never evaluated. Hydration assessments are to include monitoring mucous membranes, urine out put and oral intake of fluids. That information is then to be documented in the nurses notes. Normally, we don't do orthostatic vitals unless ordered by the physician, especially with resident's who can't stand. If they can't stand, we don't do lying and sitting vitals. A stool culture was ordered for (#6) because of the Norovirus outbreak, not because a physician was notified. That was done as part of our outbreak protocol." On 2/10/15 at 2:30 p.m., UC (Unit Clerk)-I verified to surveyor # that I&O was initiated for resident #6 on 12/31/14. On 2/11/15 at 8:50 a.m., surveyor # interviewed RD (Registered Dietician)-M. RD-M verified to the surveyor that staff had not notified her of resident #6's documented weight decline on 1/2/15. RD-M stated, "If I knew about the low weight, I would have suggested a re weigh. I would have looked at the nurses notes, previous weights, intakes, talked with the nurses about hydration status and any recent illness, would have reviewed the medication list for diuretic use, and suggest the nurse notify the physician. The physician and myself would suggest interventions. I would look at the hydration assessments and make sure staff are checking and charting hydration of the resident." On 2/11/15 at 9:35 a.m., surveyor # interviewed MD (Medical Doctor)-N. MD-N is one of resident #6's primary care providers. MD-N verified to the surveyor that he had been unaware of resident #6's condition and stated, "(#6) is difficult to get fluids into due to her dementia to begin with." ON 2/11/15 at 9:40 a.m., surveyor # interviewed DON (Director of Nursing)-F. DON-F verified to the surveyor that no inservicing regarding hydration assessments and nursing evaluations of 24 hour oral intake of fluids when a resident was on I&O had been completed for staff and could not recall the last time inservicing relating to those topics had been discussed. DON-F stated, "It is the R.N.'s responsibility to do hydration assessments if someone is on a hydration plan of care due to illness and to look at the 24 hour intake and output record for that resident to make sure their daily fluid requirements are being met." According to a study published by the National Institute of Health (<http://www.ncbi.nlm.nih.gov/pubmed/ 084>), an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. This increased to 33.3% for those whose sodium levels were 151-153 and to 71.4% for those whose sodium level exceeded 154. Failure to ensure that Resident #6 received proper hydation created a finding of immediate jeopardy. The facility removed the jeopardy on 2/12/15 by which time it had implemented or begun the following: 1. Ensured resident identified has current and appropriate orders related to clinical need 2. Immediate hydration assessments for all residents 3. All I&O residents will have documented intake totaled at the end of each day with follow up to physician as needed and placed on the 24hr report. If the totals fall below recommended intake, then licensed nurse will assess for hydration and notify physician of abnormal findings. 4. Education for necessary staff regarding hydration, change in condition, SBAR Interact and physician notification. 5. Any resident at clinical risk for a change in condition related to a loss of hydration would have an updated hydration assessment done to determine the necessary course of treatment. 6. QA meeting held to educate entire leadership team on plan and follow-up

Based on record review and staff interviews, the facility did not immediately consult with the physician for 1 of 15 sampled residents (resident #6) when the resident had a significant change in physical, mental, or psychosocial status or when there was a need to alter treatment significantly. During an outbreak of Norovirus in the facility, resident #6 presented with a fever, decreased appetite, weight loss, and decreased intake of oral fluids. The resident was dependent on staff for intake of foods and fluids; was on thickened liquids due to dysphagia related to [MEDICAL CONDITION]; and was on a daily diuretic due to [MEDICAL CONDITIONS]. The resident continued to have a decline in oral intake of fluids and continued to present with a poor appetite. The resident's physician was not consulted about the resident's condition to determine if a change in her medical treatment/plan of care was warranted. Ultimately, the resident was hospitalized for [REDACTED]. Facility failure to notify the physician regarding resident #6's significant change in condition created a finding of immediate jeopardy that began on 12/21/14. The facility was notified of the immediate jeopardy on 2/12/15. The immediate jeopardy was removed on 2/12/15, however, the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy entitled, "Change in Condition" dated 1/1/14 indicated the purpose of the policy was to ensure prompt notification of the attending physician of changes in the resident's physical, psychosocial and/or mental condition and/or status. The policy included specific information that requires prompt notification to include but not limited to: * Significant weight change. * A significant change in the resident's physical condition. * A need to alter the resident's medical treatment significantly. The facility's policy entitled, "Hydration/Prevention and treatment of [REDACTED]. Physician will be informed. The Dietician, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. Orders for medications that may exacerbate dehydration (e.g., diuretics) will be reviewed and held if medically appropriate. Laboratory tests may be ordered to assess hydration of intake and symptoms indicate possible significant dehydration. If laboratory results are consistent with actual dehydration, the physician may initiate IV (Intravenous) hydration. hospitalization will be recommended, as necessary. Resident #6's admission face sheet dated 6/7/08 indicated the resident had [DIAGNOSES REDACTED]. The resident's age was listed as 94. The facility conducted an MDS (minimum data set) on the resident and assessed the resident to score a 3 of 15 on the cognition screen (the higher the score, the more cognizant); assessed the resident to be totally dependent on staff to perform all activities of daily living including eating and drinking; and was totally incontinent of bowel and bladder. A nutrition plan of care dated 2/6/14 included notify Dietician and physician of any signs/symptoms of dehydration; monitor/evaluate weight/weight changes; to notify Dietician and physician of weight changes; encourage fluids at mealtimes and between meal; monitor for signs/symptoms of dehydration; concentrated urine, dry mucous membranes, poor skin turgor, increased weakness, change in mentation, abnormal labs, decreased urine output; and hydration pass at snack times. The interventions in place did not include that the resident had been placed on a care to drink program. Laboratory findings included in the resident's medical record dated 11/11/14 indicated the resident had a normal BUN (blood urea nitrogen), Creatinine (indicator of kidney functioning), sodium and GFR (Glomerular Filtration Rate. An indicator of how well the kidney filter is working). The resident was edentulous and required nectar thickened liquids. The resident's medical medical record indicated the resident received the diuretic medication [MEDICATION NAME] 40 mg (milligrams) daily included in the medication regime. (A diuretic rids the body of excess fluid and salt.) The facility completed a hydration risk assessment for the resident on 12/11/14, which indicated the resident was at mild risk for dehydration. A nutritional assessment completed for the resident on 12/15/14 indicated that the resident weighed 126 pounds and estimated the resident required greater than 1500 ml of fluids per day. The assessment noted, "Adequate oral intake at meals. Does receive supplement and fortified foods due to history of weight loss and poor oral intake. Although weight is up 10 pounds in the last 6 months, current weight of 126 pounds is consistent with weight of 126.4 pounds 1 year ago." Review of the resident's medical record indicated on 12/27/14, the resident's weight was 124 pounds. The resident was 59 inches tall. The facility experienced an outbreak of Norovirus on 12/29/14. Most of the affected residents resided on resident #6's unit and on the unit adjacent to the resident's unit. On 12/30/14, resident #6 presented with one emesis and one large loose green brown foul smelling stool. On 12/31/14, the resident presented with an additional episode of diarrhea, and now had a fever and decreased appetite. A Gastroenteritis plan of care and an I&O (intake and output) flow sheet was initiated. The plan of care indicated to monitor for signs/symptoms of dehydration, e.g. dry lips, dry mucous membranes, poor skin turgor, and abnormal labs. Assess resident for fluid depleting drugs/laxatives and update physician. Physician to be notified of change in condition and lack of response to treatment if applicable and documented in notes. The above care plan was discontinued on 1/5/15. A stool specimen, per the facility Norovirus outbreak policy was collected from resident #6. On 1/9/15, the stool culture results indicated the resident was positive for Norovirus. Review of nursing notes, MAR's (Medication Administration Record), I&O flow sheets and vital signs flow sheet indicated the following: * 12/30/14 at 11:00 p.m. One large emesis and one large loose foul smelling brown-green stool. Stool specimen for Norovirus collected related to Norovirus outbreak criteria. Temperature 98.1 (oral) degrees F (Fahrenheit). Blood pressure 170/78. Pulse 84. Incontinent of urine twice during each three shifts (no quantifying amounts to include small, medium or large amounts). * 12/31/14 at 3:30 a.m. Episode of diarrhea. Denies nausea/vomiting. Will continue to monitor. 10:30 a.m. Temperature 99.1 degrees (axilla). Blood pressure 132/84. Took small amount of breakfast. NP (Nurse Practitioner) aware of diarrhea. Tylenol for temperature. Is on contact isolation precautions. Will continue to monitor. Initiation of a Gastroenteritis Care plan completed. Fluid intake per CNA charting = 840 ml. Supplements and hydration fluid intake per TAR= 180 ml. Total intake of fluids calculated by surveyor # and had not calculated by staff =1020 ml. The resident had received the daily dose of [MEDICATION NAME] 40 mg on 12/31/14. 4:54 p.m. Decreased appetite. Taking fluids with encouragement. Blood pressure 148/62. Pulse 56. Temperature 99 degrees (axilla). The physician was not notified of the resident's low intake of fluids to determine if [MEDICATION NAME] should be continued or if any other changes in the resident's plan of care/treatment should be initiated. * 1/1/15 at 12:01 a.m. Temperature 99.8 axillary. Blood pressure 180/80. Pulse 80. 12:20 p.m. Temperature 98.9 oral. Pulse 92. Blood pressure 176/80 (sitting). No nausea, vomiting or diarrhea this shift. The resident had received the daily dose of [MEDICATION NAME] 40 mg. 9:15 p.m. Temperature 98.1 Blood pressure 166/72. Pulse 94. Adequate fluids. Fluid intake per CNA charting = 840 ml. Supplements and hydration fluid intake per TAR= 480 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 1560 ml. The resident had voided twice every shift (no quantifying amounts to include small, medium or large amounts). The physician was not notified of the resident's persistent fever. *1/2/15 at 5:00 a.m. Vitals stable. No nausea/vomiting diarrhea. 11:00 a.m. Temperature 99 degrees oral. Pulse 94. Blood pressure 166/72. Has poor appetite. The resident had spit out the daily dose of [MEDICATION NAME] 40 mg. 6:00 p.m. Temperature 98.6 axillary. Pulse 92. Blood pressure 144.74. No nausea/vomiting noted. Fluid intake for 1/2/15 per CNA charting = 840 ml. Supplements and hydration fluid intake per TAR= 480 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 1320 ml. The resident had voided twice every shift (no quantifying amounts to include small, medium or large amounts). A documented weight of 115.5 pounds was noted. No reweigh was documented to verify if weight was accurate. No indication was noted in the medical record that the Dietician or physician had been notified of the significant weight decline or that the physician had been notified of the resident's continued low grade fever. From 1/3/15 through 1/7/15, there was no documented weight for the resident. After the entry dated 1/2/15 at 6:00 p.m., no further nursing entries and no documented vital signs were noted in the nursing notes from the evening shift on 1/2/15 through the evening shift on 1/7/15. * 1/3/15. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/3/15 per CNA charting = 600 ml. Total intake of fluids not calculated by staff =120 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 720 ml. The resident had voided twice every shift (no quantifying amounts to include small, medium or large amounts). The physician was not notified of the resident's low intake of fluids and to determine if [MEDICATION NAME] should be continued or if any other changes in the resident's plan of care/treatment should be initiated. * 1/4/15. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/4/15 per CNA charting = 600 ml. Supplements and hydration fluid intake per TAR= 120 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 720 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). The physician was not notified of the resident's low intake of fluids and to determine if [MEDICATION NAME] should be continued or if any other changes in the resident's plan of care/treatment should be initiated. * 1/515. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/5/15 per CNA charting = 840 ml. Supplements and hydration fluid intake per TAR= 150 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 990 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). Gastroenteritis plan of care was discontinued. The physician was not notified of the resident's low intake of fluids and to determine if [MEDICATION NAME] should be continued or if any other changes in the resident's plan of care/treatment should be initiated. * 1/6/15. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/6/15 per CNA charting = 960 ml. Supplements and hydration fluid intake per TAR= 120 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 1080 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). The physician was not notified of the resident's low intake of fluids and to determine if [MEDICATION NAME] should be continued or if any other changes in the resident's plan of care/treatment should be initiated. * 1/7/15. The resident received a daily dose of [MEDICATION NAME] 40 mg. Fluid intake for 1/7/15 per CNA charting =480 ml. Supplements and hydration fluid intake per TAR= 120 ml. Total intake of fluids which were calculated by the surveyor and had not been calculated by staff = 700 ml. The resident voided twice every shift (no quantifying amounts to include small, medium or large amounts). The physician was not notified of the resident's low intake of fluids and to determine if [MEDICATION NAME] should be continued or if any other changes in the resident's plan of care/treatment should be initiated. It was noted by surveyor # that from 12/31/14-1/7/15, no documented hydration assessments were noted in resident #6's medical record. An emergency room document dated 11:00 p.m. on 1/7/15 indicated resident #6 had been transported to the emergency room for evaluation of a protrusion in the left abdominal wall. The emergency room physician documented, "Labs showed sodium of 168 (normal is 135-145). The resident looks quite dry and quite dehydrated. Mouth is dry, skin is tenting. Looks chronically ill but certainly debilitated. Chloride is high. Has some pre renal indices with creatinine climbing quite a bit." The resident's weight was listed as 122 pounds (unknown if this was before or after IV fluids had been initiated). Laboratory findings included BUN of 89 (normal 8-26), Creatinine of 2.97 (normal 0.6-1.5), and a GFR of 16 (normal greater than 60). Assessment and plan indicated, "Significant dehydration. Patient is significantly dehydrated she is very dry appearing she has been on [MEDICATION NAME] for heart failure and it appears that maybe she was not eating as well, drinking as well as limited access to fluids that she is not able to get them for herself. She has already received 1 Liter of normal saline. Hold diuretic for now. [MEDICAL CONDITION]. Patient has already received a liter of normal saline will change her to 5% [MEDICATION NAME] half normal saline at 125 ml per hour. Will likely need hydration over the next few days to get sodium back down. Abdominal discomfort. Patient has minimal symptoms but cognition is poor with being dehydrated. Would certainly consider ischemic [MEDICAL CONDITION]. The abdomen is quite soft and there is no free air there and no fluid levels on KUB (Kidney, urethra, bladder X-Ray). Hydration at this point and try to get fluid balances more normal. Acute [MEDICAL CONDITION] secondary to dehydration. Again, gentle hydration as has already received a liter of fluids. Hypertension. At this point because of acute [MEDICAL CONDITION], will hold [MEDICATION NAME] (antihypertensive medication) and resume when kidney function is improved. Is expected to require at least a two midnight stay in the hospital." The resident was hospitalized until 1/11/15 and had returned to the facility on that day at 2:00 p.m. On 2/10/15 at 2420 p.m., surveyor # interviewed RN (Registered Nurse)-G. RN-G stated, "A dietary slip should have been made out on 1/2/15 when (#6) had a documented weight decline. There is no such slip in (#6) chart and the Dietician has not assessed the resident since 12/15/14." On 2/10/15 at 3:20 p.m., surveyor # interviewed NP (Nurse Practitioner)-K. NP-K verified to the surveyor that she was one of resident #6's primary care providers and was the on call practitioner for the facility Monday through Friday during the day time hours. NP-K indicated that she had not been made aware of resident #6's change in condition from 1/1/15-1/7/15. NP-K stated, "If the staff would have called me with (#6's) symptoms, I would have done labs and come and assessed (#6). I would have absolutely changed the course of treatment if I would have been made aware of the decreased intake of fluids, weight loss and poor appetite. I am on call for the facility during the daytime hours Monday through Friday and I see (#6) every other month for compliance visits." On 2/11/15 at 9:35 a.m., surveyor # interviewed MD (Medical Doctor)-N. MD-N stated, "I agree with (NP-K) and the fact that when (#6) had a decline in her fluids etc. that a practitioner should have been alerted and the resident should have been evaluated. It is difficult to get fluids into (#6) due to dementia to begin with." MD-N verified to the surveyor that the facility had not consulted with him when resident #6 had a decline in weight, fluid intake, appetite and persistent low grade fever. Failure to immediately consult with the physician when Resident #6 had a significant change in condition created a finding of immediate jeopardy. The facility removed the jeopardy on 2/12/15 by which time it had implemented or begun the following: 1. Ensured resident identified has current and appropriate orders related to clinical need 2. Immediate hydration assessments for all residents 3. All I&O residents will have documented intake totaled at the end of each day with follow up to physician as needed and placed on the 24hr report. If the totals fall below recommended intake, then licensed nurse will assess for hydration and notify physician of abnormal findings. 4. Education for necessary staff regarding hydration, change in condition, SBAR Interact and physician notification. 5. Any resident at clinical risk for a change in condition related to a loss of hydration would have an updated hydration assessment done to determine the necessary course of treatment. 6. QA meeting held to educate entire leadership team on plan and follow-up