Every finding on record at North Shore Healthcare at Marshfield

Based on staff interview and record review, the facility did not ensure Protective Placement Services (PPS) received notification of discharge for 1 resident (R) (R72) of 4 sampled residents. R72 was protectively placed in the facility and had a court-appointed Guardian. The facility failed to obtain written consent from the Guardian prior to R72's discharge. Findings include: The facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, revised 7/15/22, indicates: The care and services provided to each resident is dependent on the individual resident and circumstances present at the time .6. Non-emergency transfers or discharges initiated by the facility, return not anticipated: a. Document the reason for the .discharge in the resident's medical record .b. At least 30 days before the resident is transferred or discharged , the Social Services Director or designee will notify the resident and the resident's representative in writing in a language and manner they understand .c. Contents of the notice must include: i. The reason for the discharge; ii. The effective date of the discharge; iii. The location to which the resident is discharged ; .g. Orientation for discharge must be provided and documented to ensure a safe and orderly discharge from the facility, in a form and manner that the resident can understand .R72 was admitted to the facility on [DATE] and discharged home on 2/7/26. R72 had diagnoses including schizophrenia, diabetes, carcinoma of the scalp, and obesity. R72's Minimum Data Set (MDS) assessment, dated 1/26/26, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. R72 had an court-appointed Guardian who assisted with healthcare decisions. A Hospital admission summary, dated [DATE], indicated R72 was hospitalized due to being found at home with bedbugs and maggots in a cancer wound. During the hospitalization, a cognitive evaluation revealed R72 did not have decision-making capacity. A neuropsychology evaluation on 10/9/25 and re-evaluation on 11/20/25 confirmed R72's inability to make decisions and a Guardianship process was completed. R72 was transferred under Guardianship and protectively placed in the facility on 1/20/26.On 6/4/26 at 11:20 PM, Surveyor interviewed Social Services Director (SSD)-K who verified the facility discharged R72 on 2/7/26 without notifying the court prior to discharge. SSD-K indicated Adult Protective Services (APS) was notified of the discharge on [DATE] which was two days after R72 discharged . SSD-K received an email from APS on 2/13/26 regarding the discharge. SSD-K tried to contact APS twice but was unable to reach them. SSD-K verified the facility did not receive written consent from R72's Guardian prior to the discharge.On 6/4/26 at 2:41 PM, Surveyor interviewed Adult Protective Services Manager (APSM)-N who became aware of R72's discharge when SSD-K sent an email on 2/9/26 informing APSM-N of the facility's concerns with the home where R72 was discharged . APSM-N emailed back and asked why APS wasn't notified before the discharge and why a 10-day discharge wasn't initiated if the facility had concerns. APSM-N stated they needed more information on why R72 was able to go home.On 6/4/26 at 2:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility should have received written consent from R72's Guardian and should have notified the court of a 10-day discharge prior to R72's discharge. NHA-A indicated staff needed reeducation on the facility's discharge process.

Based on staff interview and record review, the facility did not ensure proper documentation and communication for discharge was provided for 1 resident (R) (R72) of 4 sampled residents. The facility did not provide sufficient written documentation to ensure a safe and orderly discharge from the facility for R72. Findings include: The facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, revised 7/15/22, indicates: .The care and services provided to each resident is dependent on the individual resident and circumstances present at the time .6. Non-emergency transfers or discharges initiated by the facility, return not anticipated: a. Document the reason for the transfer or discharge in the resident's medical record. In the case of necessity for the resident's welfare and if the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, the facility's attempts to meet the needs, and the service available at the receiving facility to meet the needs. Document any danger to the health or safety of the resident or other individuals that failure to transfer or discharge would pose .b. At least 30 days before the resident is transferred or discharged , the Social Services Director or designee will notify the residentand the resident's representative in writing in a language and manner they understand .c .Contents of the notice must include: i. The reason for transfer or discharge; ii. The effective date of transfer or discharge; iii. The location to which the resident is transferred or discharged ; iv. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and v .The name, address (mailing and email) and telephone number of the Office of the State Long Term Care Ombudsman .g. Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the Interdisciplinary Team . R72 was admitted to the facility on [DATE] and discharged from the facility on 2/7/26. R72 had diagnoses including schizophrenia, diabetes, carcinoma of the scalp, and obesity. R72's Minimum Data Set (MDS) assessment, dated 1/26/26, stated R72 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. R72 had an court-appointed Guardian who assisted with healthcare decisions. A Nurse Practitioner (NP) note, dated 2/3/26, indicated: Date of discharge: [DATE]. Ambulatory distance/assistive devices needed: No new ambulatory equipment needed. Ambulating functional distances with a 2-wheeled walker. Diet: Regular. Follow-up issues to address: Please follow-up hygiene at home, assess home safety. (R72) has some new areas on the right side of the scalp which appear as scaly patches or new growths .Will attempt to wash hair tonight and tomorrow with a shower cap and see if they come off. Please closely follow-up any home needs, including signs of neglect, abuse, etc. Coordinate with home health services. Review with Adult Protective Services (APS) if any issues are noted. (Of note: R72's medical record did not contain a discharge plan.)On 6/4/26 at 11:20 AM, Surveyor interviewed Social Service Director (SSD)-K who spoke to R72's Guardian the week prior to discharge and stated the plan was for R72 to go to their friend's home. SSD-K verified they did not document the conversation with the Guardian in R72's medical record. SSD-K verified R72's medical needs and a discharge plan were not discussed with the Guardian again. SSD-K indicated a referral for homecare was made prior to R72's discharge, however, the facility did not complete a home evaluation for safety. SSD-K was unsure if it was the facility's or the home care provider's responsibility to complete a home evaluation. SSD-K was not aware of any follow-up for safety, neglect, abuse, or home conditions for R72. SSD-K indicated there was no contact with APS other than a referral sent by SSD-K on 2/9/26 and an email received from APS on 2/13/26. SSD-K tried to contact APS a couple times after 2/13/26 via phone.On 2/4/26 at 11:45 AM, Surveyor interviewed Director of Nursing (DON)-B who stated R72 discharged home with home health services. DON-B stated an APS referral was made due to potentially unsafe living arrangements, however, DON-B had no further knowledge of the referral. DON-B indicated therapy staff complete home evaluations which are processed with SSD-K. DON-B verified R72 did not have a discharge plan in place at the time of discharge.On 2/4/26 at 12:00 PM, Surveyor interviewed Director of Rehab (DOR)-L who reviewed R72's physical therapy (PT) notes which indicated R72 received therapy services from 1/20/26 to 2/6/26. R72's PT discharge summary, completed on 2/6/26, did not contain a referral for a home evaluation. DOR-L verified a PT note, dated 2/6/26, expressed concerns over home cleanliness and safety. DOR-L indicated therapy staff should have addressed the concerns with SSD-K and offered a home evaluation.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R9) of 1 sampled resident was provided restorative services to maintain physical abilities.Therapy developed a restorative program for R9 that indicated R9 shoud walk daily. The restorative program was not implemented. Findings include:The facility's Activities of Daily Living (ADLs) policy, dated 7/26/22, indicates: The facility will provide a maintenance and restorative program as applicable to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment.R9 had diagnoses including osteoarthritis, history of thrombosis and embolism, and mild cognitive impairment. R9's Minimum Data Set (MDS) assessment, dated 5/8/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS assessment indicated R9 had no refusals of care and did not participate in a restorative program.On 6/1/26 at 10:40 AM, Surveyor interviewed R9 who indicated they needed more help with ADLs now and it had been a while since they walked with staff.An ADL care plan, dated 5/15/26, did not indicate R9 had a restorative program.Surveyor reviewed R9's behavior monitoring for the last 30 days which did not indicate R9 rejected care.A physical therapy discharge note, dated 5/12/26 and written by Physical Therapist (PT)-H, indicated R9 made minimal improvement with bed mobility and transfers but improved significantly with ambulation with a front-wheeled walker. Therapy had communicated a walking program to nursing staff.On 6/3/26 at 11:27 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who was not sure if R9 had a restorative program and needed to check R9's care plan.On 6/3/26 at 11:39 AM, Surveyor interviewed PT-H who had developed a restorative program for R9. PT-H provided a Therapy Plan of Care-Interdisciplinary Team (IDT) Recommendations form for R9, dated 4/27/26, that indicated to reinstate R9's walking program with a two-wheeled walker, wheelchair following and contact guard assist to walk from cone-to-cone daily. The form indicated R9 required minimal to moderate assistance to stand.On 6/3/26 at 1:31 PM, Surveyor interviewed CNA-I who stated R9 was not on a restorative program at that time.On 6/3/26 at 1:33 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R9 had started a restorative program; however, DON-B could not find the restorative program in R9's medical record or Treatment Administration Record (TAR). DON-B stated DON-B would enter the restorative program in R9's medical record to ensure the program was started.

Based on observation, staff 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 3 residents (R) (R3, R7, and R35) of 10 residents observed during medication administration. Medication Technician (MT)-D did not complete hand hygiene prior to or after administering medication to R3, R7, and R35.Findings include:The facility's Hand Hygiene policy, dated 11/2/22, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table: Between resident contacts; Before preparing or handling medication. During observations of medication administration on 6/2/26 that began at 11:06 AM, Surveyor noted MT-D did not complete hand hygiene before or after oral medication administration for R3, R7, and R35. On 6/2/26 at 1:02 PM, Surveyor interviewed MT-D who indicated MT-D usually completes hand hygiene when leaving a resident's room. On 6/2/26 at 1:09 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should complete hand hygiene before and after medication administration between residents.

Based on staff and resident interview and record review, the facility did not ensure treatments were provided as ordered for 1 resident (R) (R7) of 4 sampled residents. R7 had a non-pressure chronic ulcer of the right foot and peripheral artery disease of the right leg. R7's Treatment Administration Record (TAR) contained multiple missing entries for treatments in March and May of 2026. Findings include:The facility's Pressure Injuries and Non-Pressure Injuries policy, revised 7/20/22, indicates: For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity.R7 was admitted to the facility on [DATE] and had diagnoses including non-pressure chronic ulcer of the right foot and peripheral artery disease of the right leg. R7's Minimum Data Set (MDS) assessment, dated 5/18/26, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition.Surveyor reviewed R7's TAR which contained the following orders:~ Right third toe: Cleanse and apply Xeroform to wound bed and cover with bordered 2x2 dressing every other day. Once daily. Discontinue when healed (started 5/20/26). (Of note: R7's TAR indicated the order was not completed on 5/22/26.)~Vancomycin 1% topical solution, apply to right ankle/inner shin topically once daily for wound care. Use 1/4-inch strip gauze with vancomycin solution wet to damp dressing over Endoform leaving Endoform in place. Cover with 2x2 gauze (started 4/25/26; discontinued 5/7/26; restarted 5/16/26). (Of note: R7's TAR indicated the order was not completed on 5/3/26 and 5/22/26.)~ Apply ace wrap to right lower extremity after wound care. Ace wrap can come off at bedtime. Two times daily for wound care, scheduled for early morning and bedtime (HS) (started 3/6/26; discontinued 3/15/26; restarted 3/15/26; discontinued 5/8/26). (Of note: R7's TAR indicated the order was not completed on 3/13/26 (EM) and 5/3/26 (EM).)~ Monitor wound to right great toe for increased redness/pain/abnormal drainage/odor twice daily .If symptoms are present, progress note to be completed with findings (started 3/24/26). (Of note: R7's TAR indicated the order was not completed on 5/3/26, 5/22/26, and 5/28/26.) On 6/3/26 at 3:09 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the above dates in R7's TAR were blank. DON-B indicated blank dates in a resident's TAR means the order/treatment wasn't completed or documnented. DON-B indicated if a resident refuses a treatment, the TAR should contain code 2 and the staff's initials. On 6/3/26 at 3:42 PM, Surveyor interviewed Registered Nurse (RN)-M who worked on 5/3/26 and was unsure why R7's TAR indicated treatments weren't completed. RN-M indicated when the TAR is blank, it appears the treatment wasn't completed. RN-M stated if R7 refused or had an appointment, the nurse should initial the TAR and document in a progress note why the treatment wasn't completed.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R8) of 4 sampled residents received the necessary care and services to prevent pressure injuries from developing and/or promote healing.R8 had a pressure injury on the right heel. During an observation of wound care, Licensed Practical Nurse (LPN)-J used soiled scissors to cut gauze that was directly applied to the pressure injury on R8's right heel. Findings include: The facility's Pressure Injuries and Non-Pressure Injuries policy, revised 7/20/22, indicates: For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. R8 had diagnoses including diabetes and heart failure. R8's Minimum Data Set (MDS) assessment, dated 4/15/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS assessment indicated R8 had a stage 2 pressure injury. On 6/1/26 at 2:10 PM, Surveyor interviewed R8 who indicated they had 2 wounds on their feet and went to the wound clinic regularly. R8 stated facility staff provided daily wound care. R8's medical record contained the following orders from the wound clinic: ~ Alternate tobramycin and vancomycin onto wound gauze, then ABD dressing, then Kerlix, Tubigrips, Circaid wraps, and HeelMedix to right heel with follow-up in 1 week (dated 4/28/26) ~ Continue current wound care and always ensure HeelMedix to right heel except when transferring (dated 5/5/26) On 6/2/26 at 9:19 AM, Surveyor interviewed R8 who indicated their wounds were healing. Surveyor observed a boot on R8's right foot and Circaid wraps on both legs. R8 had no concerns with wound care and stated they hadn't missed any treatments. On 6/3/26 at 10:06 AM, Surveyor observed LPN-J and Director of Nursing (DON)-B don gowns, enter R8's room, cleanse the bedside table, and place wound care items on the table. LPN-J and DON-B completed hand hygiene and donned gloves. LPN-J removed scissors from a pencil pouch that contained various items and opened a package of sterile gauze. LPN-J cut 2 pieces of gauze with the scissors, put the gauze in vancomycin solution, and put the scissors back in the pouch. LPN-J removed R8's right leg wraps, retrieved the scissors, and cut/removed Kerlix from R8's right leg/ankle. LPN-J removed gloves, completed hand hygiene, donned clean gloves, and cleansed the right heel wound with a 4x4 gauze and wound cleanser. LPN-J removed gloves, completed hand hygiene, donned clean gloves, and put a strip of vancomycin soaked gauze on the right heel pressure injury. LPN-J put an ABD pad over the gauze and wrapped R8's heel/foot/ankle with Kerlix. LPN-J applied a leg wrap and HeelMedix following wound care. On 6/3/26 at approximately 10:25 AM, Surveyor interviewed LPN-J who was not sure if the scissors used during wound care were cleaned prior to cutting the sterile gauze. On 6/3/26 at approximately 10:25 AM, Surveyor interviewed DON-B who indicated the best practice is to clean scissors after using them and indicated it was uncertain if the scissors were cleaned prior to use. DON-B stated DON-B would educate staff about cleaning scissors before use during wound care.

Based on staff interview and record review, the facility did not ensure influenza vaccines were offered and/or administered for 2 residents (R) (R41 and R5) of 5 sampled residents.Findings include:The facility's Influenza Policy, revised 9/5/25, indicates: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering our residents, staff, and volunteer workers annual immunization against influenza .9. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal .1. R41 was admitted to the facility on [DATE] and had diagnoses including post-surgical digestive care and morbid obesity. R41's Minimum Data Set (MDS) assessment, dated 2/6/26, stated R41 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R41 made their own medical decisions. Surveyor observed an undated signed consent form that indicated R41 wished to receive the influenza vaccine. R41's medical record did not indicate the vaccine was administered.(See interview under example 2.)2. R5 was admitted to the facility on [DATE] and had a diagnosis of vascular dementia. R5's MDS assessment, dated 5/26/26, stated R5 had a BIMS score of 7 out of 15, indicating severely impaired cognition. R5 had an activated Power of Attorney (POA) to assist with medical decisions. R5's medical record did not indicate R5 was offered or administered an influenza vaccine.On 6/3/26 at 1:05 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated Infection Preventionist (IP)-C was responsible for immunization consents and administration of vaccines. On 6/3/26 at 1:49 PM, Surveyor interviewed IP-C who indicated IP-C offered and educated residents on receiving influenza, COVID-19, and pneumococcal vaccines. IP-C indicated IP-C did not have completed consent or declination forms for the influenza vaccine for R41 or R5.On 6/4/26 at 3:48 PM, Nursing Home Administrator (NHA)-A verified via email the facility did not have completed consent or declination forms or education regarding the benefits or potential side effects of the influenza vaccine for R41 or R5.

Based on staff interview and record review, the facility did not provide the necessary care and services to prevent the development of pressure injuries and/or promote healing for 1 resident (R) (R1) of 2 sampled residents. R1 developed a stage 3 pressure injury on the sacrum. The facility did not implement interventions to prevent the pressure injury from developing and did not monitor the pressure injury after it was identified. Findings include: The facility's Pressure Injuries and Non-Pressure Injuries policy indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries .For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity .Stage 3 pressure injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present .Moisture-associated skin damage (MASD): Inflammation of the skin and erosion from prolonged exposure to moisture and its contents. Common sources of moisture include urine and stool, perspiration, wound exudate .Upon admission: a. A head-to-toe body evaluation .ii. If non-pressure: Initiate the Non-Pressure Injury Tracker UDA (User-Defined Assessment) .B. Complete the Braden Scale to assess risk of development of a pressure injury .i. Upon admission/re-admission .C. Initiate the baseline plan of care related to current skin status and skin risk level. When determining skin risk status and appropriate interventions, consider the following: i. Braden Scale Score ii. Co-morbid conditions .diabetes mellitus .x. Exposure of skin to urinary and fecal incontinence .2. Weekly: a. Complete a head-to-toe skin check and document findings on the Skin Review .If new areas are present: Notify MD .iii. Initiate treatment per order .v. Update plan of care .B. Assess current wounds at least every seven days .A comprehensive skin integrity care plan is based on resident history, review of the Skin Assessment, Braden Scale .Consider the areas of risk, as well as overall risk assessment score of the Braden Scale .1. Develop interventions based on subsets of Braden Scale that may include: Sensory perception .moisture .activity .mobility .Develop turning/repositioning schedule based on resident's needs and risk factors .2. Develop interventions based on individual risk factors .The care plan should be updated to reflect the resident's choice and what interventions will be in place to minimize the risk to the resident .On 7/7/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including encounter for orthopedic aftercare (post-surgical incision to lower back), diabetes, heart failure, chronic kidney disease, and obstructive sleep apnea. R1 had an activated Power of Attorney for Healthcare (POAHC) who assisted with medical decisions. R1's admission Minimum Data Set (MDS) assessment, dated 6/18/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderately impaired cognition. The MDS assessment indicated R1 was at risk for pressure injuries but did not have a pressure injury, did not not have a pressure reducing device in bed or chair, was not on a turning/repositioning program, and required moderate assistance with rolling left and right and going from a sitting to a lying position. The MDS also indicated R1 had moisture-associated skin damage (MASD) but did not have any surgical wounds and did not receive surgical wound care. R1 had an activated Power of Attorney for Healthcare (POAHC). R1 was currently hospitalized for a surgical incision infection.An admission Assessment, dated 6/12/25, indicated R1 had a macerated area that measured 0.1 centimeters (cm) x 0.1 cm on the left inner buttock.A Braden Scale (skin integrity impairment risk), completed upon admission on [DATE], indicated R1 was at risk for impaired skin integrity.A care plan, dated 6/13/25, indicated R1 had limited mobility and needed the assistance of 1 staff with bed mobility.A baseline care plan, initiated 6/13/25 with revisions on 6/18/25, did not indicate R1 was at risk for skin impairment or contain skin impairment focus area. The baseline care plan also did not indicate interventions were implemented to prevent a pressure injury or prevent further injury after a stage 3 pressure injury was identified on 6/20/25.A non-pressure weekly tracker, dated 6/13/25, indicated R1 was admitted to the facility with a surgical wound on the lower back. No other wounds or MASD were identified.A hospital discharge record, dated 6/17/25, indicated R1 had a diagnosis of decubitus ulcer and an infectious disease workup showed leukocytosis and elevated inflammatory markers likely from underlying cellulitis around the sacral ulcer and contribution from postsurgical changes.A weekly skin assessment, dated 6/17/25, indicated R1 had an open area on the coccyx, blanchable redness to the buttocks, and a surgical incision on the spine with redness around the incision. A note, dated 6/17/25 at 9:15 AM and written by Nurse Practitioner (NP)-I, indicated R1 had a pre-existing decubitus ulcer on the sacrum and was started on Augmentin (an antibiotic). The wound had extended in size slightly but was not deeper. A non-stick dressing was applied in the hospital. A Braden Scale Assessment, completed on 6/18/25, indicated R1 was at risk for impaired skin integrity.A care plan revision, dated 6/18/25, indicated R1 had limited physical mobility, needed to be log rolled into and out of bed, should not engage in low back bending or twisting, and required the assistance of 1 staff for bed mobility.A weekly tracker, dated 6/20/25, contained a surgical wound assessment that indicated R1 had a small amount of drainage. No other wounds or MASD were identified. A wound clinic visit note, dated 6/20/25, indicated R1 had a stage 3 sacral pressure injury that measured 3.0 cm (length) x 1.3 cm (width) x 0.2 cm (depth) with a small amount of exudate. The note contained instructions to continue offloading the pressure injury and apply zinc oxide to the peri-wound twice daily (BID) and as needed with incontinence.On 7/7/25 at 9:08 AM, Surveyor interviewed Family Member (FM)-M who indicated R1 would not be returning to the facility from the hospital. FM-M indicated R1 had a surgical wound infection and a wound vac was applied. FM-M was told the bacteria found in the surgical incision indicated the infection resulted from R1 laying in urine. On 7/7/25 at 11:19 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated R1 called staff every 10 to 15 minutes to roll R1 back and forth. CNA-F indicated CNA-F checked on and repositioned R1 if R1 did not call and also checked on R1 every couple of hours because R1 was a heavier wetter. CNA-F indicated R1 always required assistance with transfers which was noted on the care card on the back of R1's door. CNA-F indicated R1 did not refuse to be repositioned or changed and had only been incontinent of urine (not stool) when CNA-F cared for R1. CNA-F did not recall if R1 had a wheelchair cushion or specialty bed. CNA-F indicated R1 had a surgical incision from the tailbone that extended 4 inches up and had a sore below the surgical wound when R1 was admitted to the facility. On 7/7/25 at 11:29 AM, Surveyor interviewed Registered Nurse (RN)-G who indicated R1 had a surgical wound on admission and a penny size open area on the left inner buttock to which staff applied barrier cream. RN-G indicated Director of Nursing (DON)-B was wound care certified and had assessed the open area. RN-G indicated R1 was able to move independently, however, staff assisted with repositioning R1 from side-to-side. RN-G indicated R1 needed assistance with repositioning until side rails were installed on R1's bed. RN-G indicated R1 did not have a specialty bed and recalled a blue foam cushion in R1's wheelchair. RN-G indicated orders from R1's neurosurgery appointment on 6/20/25 recommended R1 be seen by the wound clinic for a coccyx wound. RN-G looked at the wound on 6/20/25 and thought the wound looked the same as upon admission. RN-G stated R1 was seen by the wound clinic on 6/20/25 and RN-G would provide the notes to Surveyor. On 7/7/25 at 1:39 PM, Surveyor interviewed DON-B who verified DON-B was wound care certified and indicated the macerated area in R1's gluteal crease that was noted upon admission to the facility should have been monitored daily. DON-B indicated the area was small but should have been measured. DON-B observed the macerated area a day or two before R1 went to the wound clinic (but did not document the assessment) and stated the area was not a pressure injury. DON-B did not assess the area when R1 returned from the wound clinic on 6/20/25 or any time thereafter. DON-B stated nursing staff should be looking at wounds and if a wound looks worse or there is drainage, the nurse should document the findings. (Note: The facility did not implement monitoring, treatment, or care plan revisions and interventions after R1 returned from the wound clinic on 6/20/25 with a diagnosis of a stage 3 sacral pressure injury).On 7/7/25 at 2:40 PM, Surveyor interviewed Wound Clinic (WCRN)-H who indicated R1 was seen for the first time on 6/20/25 and had a stage 3 pressure injury. WCRN-H indicated R1 was referred to the clinic during a recent hospital visit on 6/17/25. WCRN-H indicated the wound clinic attempted to see R1 in the hospital, however, R1 was leaving and returning to the facility so an appointment was made for 6/20/25. WCRN-H indicated there was an order to apply zinc oxide to the peri-wound twice daily and as needed and stated the order was either faxed or sent with R1 back to the facility. WCRN-H indicated zinc oxide should have been started the night of 6/20/25 or the next morning. WCRN-H indicated WCRN-H had not received communication from the facility that the facility did not agree with the diagnosis of a stage 3 pressure injury (as indicated by DON-B above). WCRN-H indicated R1 was still hospitalized and was still followed by the wound clinic. WCRN-H indicated the wound was still a stage 3 pressure injury and was being treated with zinc oxide around the peri-wound.Surveyor reviewed R1's June 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) and noted the 6/20/25 order from the wound clinic to apply zinc oxide to the peri-wound twice daily and as needed was not on R1's MAR or TAR. In addition, the MAR and TAR did not contain monitoring for MASD or the sacral wound. On 7/7/25 at 4:02 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who assessed R1 with DON-B on 6/17/25 when R1 returned from the hospital. ADON-C indicated ADON-C observed an excoriated, superficial area no bigger than a nickel that was red with white edges and stated DON-B was going to speak to R1's family about R1 being seen by the facility's wound doctor. ADON-C was not aware R1 went to the wound clinic on 6/20/25. ADON-C stated staff send a folder with the resident to an appointment and the clinic fills out the paperwork and sends it back with the resident. ADON-C did not recall any orders from the wound clinic on 6/20/25 and indicated if zinc oxide was a treatment, it needed to be applied by the nurses. ADON-C stated if a resident does not return with documentation from an appointment, the nurse should call the clinic to get notes or orders. ADON-C confirmed wound monitoring is entered on a resident's MAR or TAR. On 7/7/25 at 4:37 PM, Surveyor interviewed R1's POAHC (POAHC-N) who indicated the facility arranged for a cab to bring R1 to the wound clinic on 6/20/25. On 7/7/25 at 4:43 PM, Surveyor interviewed Medical Records (MR)-J who did not recall R1's 6/20/25 wound clinic appointment. MR-J indicated if MR-J is aware of an appointment a week or more in advance, MR-J arranges transportation with the shared van, however, if the appointment is unexpected, MR-J schedules a cab at the nurses' station but does not keep track of the transportation. On 7/8/25 at 2:45 PM, Surveyor interviewed POAHC-N who indicated after R1's wound clinic appointment on 6/20/25, POAHC-N went to the facility and described to a nurse what occurred during R1's neurosurgery and wound clinic appointments. POAHCH-N stated DON-B joined the conversation and POAHC-N described both appointments to DON-B as well. On 7/9/25 at 1:55 PM, Surveyor received additional information from Nursing Home Administrator (NHA)-A who provided a note by Clinical Reimbursement Specialist (CRS)-K, dated 6/24/25, that indicated the Interdisciplinary Team (IDT) reviewed R1's skilled therapy, functional mobility, and discharge planning. The noted indicated the MASD in R1's gluteal crease had macerated edges and staff applied zinc oxide 20% twice daily (which was not indicated on R1's June 2024 MAR or TAR). NHA-A also provided hospital wound care notes, dated 6/25/25, that indicated R1 had a stage 3 sacral pressure injury that measured 2.0 cm (length) x 0.5 cm (width) x 0.2 cm (depth) with a small amount of exudate and pain at a level 2 out of 10. The hospital plan indicated R1 was last seen on 6/20/25 and the wound had improved with a decrease in size and improved overall tissue quality. At that time, R1 had a specialized immersion mattress and was turned and repositioned on a regular basis. The note indicated the treatment was still zinc oxide twice daily and as needed to the wound and peri-wound. On 7/10/25 at 9:43 AM, Surveyor received documentation from R1's neurosurgery clinic visit on 6/20/25 that indicated R1 complained of burning and stabbing pain to the coccyx wound. After R1's family asked for an opinion on the wound, the provider indicated based on pictures in R1's medical record from 6/16/25 and R1's diagnosis of diabetes, R1 needed to be seen by the wound clinic and staff needed to keep R1 off the coccyx as much as possible and keep the wound clean and dry. An additional note from the neurosurgery clinic, dated 6/22/25, indicated R1's surgical incision wound culture identified a multidrug-resistant organism (MDRO) (Proteus mirabilis) and the facility was updated on 6/23/25.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection for 1 resident (R) (R8) of 1 resident observed during the provision of care.During the provision of care for R8, Certified Nursing Assistant (CNA)-E did not remove soiled gloves after incontinence care and did not wash or sanitize hands before touching R8 and objects in R8's room.Findings include:The facility's Hand Hygiene Policy, revised 11/02/22, indicates: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Hand hygiene is indicated and will be performed under the conditions listed in the hand hygiene table which include: Before applying and after removing personal protective equipment (PPE) including gloves; Before and after handling clean or soiled dressings, linens .; After handling items potentially contaminated with blood, body fluids, secretions, or excretions; When during resident care, moving from a contaminated body site to a clean body site; After assistance with personal body functions (e.g., elimination, hair grooming, smoking).On 7/7/25 at 3:14 PM, Surveyor observed cares for R8. Prior to cares, CNA-D and CNA-E completed hand hygiene and donned gloves. CNA-D unfastened R8's brief and pulled the brief down between R8's legs. Surveyor noted R8 was incontinent of urine. CNA-E provided peri-care with soap and water and then removed gloves. Without completing hand hygiene and donning clean gloves, CNA-E assisted R8 on R8's right side by holding R8's legs and back and picked up a tube of barrier cream. CNA-E did not complete hand hygiene until Surveyor inquired about hand hygiene. On 7/7/25 at 3:25 PM, Surveyor interviewed CNA-E who verified CNA-E did not complete hand hygiene after providing peri-care and removing gloves. CNA-E also verified CNA-E touched R8's legs, back, and tube of barrier cream with uncleansed hands.On 7/7/25 at 5:00 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated CNA-E should have completed hand hygiene and donned clean gloves after peri-care and before touching R8 or items in R8's room.

Based on staff interview and record review, the facility did not ensure a Minimum Data Set (MDS) assessment was accurate for 1 resident (R) (R1) of 1 sampled resident.R1 was admitted to the facility with a surgical incision that was not represented to R1's admission MDS assessment. R1 also had a stage 3 pressure injury that was not represented on R1's Discharge MDS assessment. Findings include: The facility's Conducting an Accurate Resident Assessment policy, dated 4/28/25, indicates: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment…3. The appropriate, qualified health professional will correctly document the resident’s medical, functional, and psychosocial problems and identified strengths to maintain or improve medical status, functional abilities, and psychosocial status. On 7/7/25, Surveyor reviewed R1’s medical record. R1 was admitted to the facility on [DATE] and had diagnoses including encounter for orthopedic aftercare (post-surgical incision to lower back), diabetes, heart failure, chronic kidney disease, and obstructive sleep apnea. R1's admission MDS assessment, dated 6/18/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderately impaired cognition. The MDS assessment indicated R1 was at risk for pressure injury but did not have a pressure injury, did not have pressure reducing devices for bed or chair, and was not on a turning/repositioning program. The MDS assessment also indicated R1 did not have any surgical wounds, did not receive surgical wound care, and needed moderate assistance with rolling left and right and going from a sitting to lying position. R1 had an order, dated 6/12/25, to assess the lumbar spine incision twice daily and update neurosurgery for wound dehiscence, drainage, streaking, or a temperature greater than 101 degrees Fahrenheit. R1 also had an order, dated 6/20/25, to paint the low back incision with Betadine, cover with an abdominal (ABD) pad, and secure with paper tape twice daily. A wound clinic visit note, dated 6/20/25, indicated R1 had a stage 3 sacral pressure injury that measured 3.0 cm (length) x 1.3 cm (width) x 0.2 cm (depth) with a small amount of exudate. A Discharge MDS assessment, dated 6/24/25, indicated R1 did not have any unhealed pressure injuries. On 7/7/25 at approximately 12:45 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the surgical incision should have been identified on R1's admission MDS assessment. On 7/7/25 at 1:01 PM, Surveyor interviewed MDS Registered Nurse (MDSRN)-L who confirmed the surgical incision should have been identified on R1's admission MDS assessment and the pressure injury should have been identified on R1's Discharge MDS assessment. On 7/7/25 at 2:40 PM, Wound Clinic RN (WCRN)-H verified R1 was diagnosed with a stage 3 pressure injury during a wound clinic visit on 6/20/25.

Based on staff interview and record review, the facility did not ensure a complete baseline care plan was developed within 48 hours of admission for 1 resident (R) (R1) of 1 sampled resident.R1 had a surgical incision and was at risk for pressure injury upon admission. The facility did not develop a baseline care plan that indicated R1 had impaired skin integrity or included interventions for treatment and prevention. Findings include: The facility's Baseline Care Plan policy, revised 9/22/22, indicates: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident…b. Including the minimum healthcare information necessary to properly care for a resident including, but not limited to: ii. Physician orders…2…b. Interventions shall be initiated that address the resident’s current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk…3. A supervising nurse or Minimum Data Set (MDS) nurse/designee shall verify within 48 hours that a baseline care plan has been developed. 4…c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility… On 7/7/25, Surveyor reviewed R1’s medical record. R1 was admitted to the facility on [DATE] and had diagnoses including encounter for orthopedic aftercare (post-surgical incision to lower back), diabetes, heart failure, and chronic kidney disease. R1's admission Minimum Data Set (MDS) assessment, dated 6/18/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderately impaired cognition. The MDS assessment also indicated R1 was at risk for pressure injuries but did not indicate R1 had pressure reducing interventions for bed or chair or was on a turning/repositioning program. In addition, the MDS assessment indicated R1 had moisture-associated skin damage (MASD). R1 had an activated Power of Attorney for Healthcare (POAHC) who assisted with medical decisions. admission orders, dated 6/12/25, indicated R1 had a surgical incision and included an order to assess R1's lumbar spine incision twice daily and update neurosurgery for wound dehiscence, drainage, streaking, or temperature greater than 101 degrees Fahrenheit (F). A skin assessment, completed during R1's admission assessment on 6/12/25, indicated R1 had a surgical incision and macerated area on the left inner buttock that measured 0.1 centimeters (cm) x 0.1 cm. Braden Scale Assessments (used to assess pressure injury risk), completed on 6/12/25 and 6/18/25, indicated R1 was at mild risk for developing pressure injuries. A weekly skin assessment, dated 6/17/25, indicated R1 had an open area on the coccyx, blanchable redness on the buttocks, a surgical incision on the spine with redness, and scattered bruises on the body. R1's medical record indicated R1 was admitted to the hospital on [DATE]. Hospital discharge paperwork, dated 6/17/25, indicated R1 had a decubitus ulcer. A wound clinic note, dated 6/20/25, indicated R1 had a stage 3 (a deep wound that has gone through the skin and into the fat layer) pressure injury on the sacral region. On 7/7/25 at approximately 9:05 AM, Surveyor reviewed R1’s plan of care (dated 6/12/25) which did not indicate R1 was at risk for or had a pressure injury; did not indicate R1 had MASD; did not indicate R1 had a surgical incision; and did not contain any corresponding interventions. R1's plan of care also did not indicate R1 had impaired skin integrity. The facility updated R1's plan of care on 6/24/25 (which was R1’s last day in the facility) to indicate R1 had a surgical wound infection with interventions to administer medications as ordered, encourage R1 to use clean hygiene techniques to avoid cross-contamination, monitor for side effects from antibiotic therapy and report to physician, monitor lab work and report results to physician, and report to physician worsening signs/symptoms of infection, lack of infection, or lack of improvement for treatment. An additional revision on 6/24/25 indicated R1 had bowel/bladder incontinence, required assistance with toileting. and had a goal to remain free from skin breakdown due to incontinence. Interventions included to monitor and document intake and output, monitor for signs/symptoms of urinary retention, and monitor/document for signs/symptoms of urinary tract infection (UTI). On 7/7/25 at 1:01 PM, Surveyor interviewed MDS Registered Nurse (MDSRN)-L who indicated anything listed in the skin section of a resident's MDS assessment is added to the resident's plan of care by whoever completes the assessment. MDSRN-L indicated R1's surgical incision should have been on the admission MDS assessment and included in R1’s plan of care.

Based on observation, staff interview and record review, the facility did not assess the risk for entrapment, review the risks and benefits, and obtain consent for the use of side rails for 1 resident (R) (R2) of 3 sampled residents.R2's bed contained side rails. The facility did not complete an assessment or obtain consent for side rails from R2's Power of Attorney (POA).Findings include: The facility's Proper Use of Side Rails policy, revised 9/23/22, indicates: .1. In conjunction with the review of a resident's comprehensive assessment, a side rail assessment will be completed in the electronic medical record. 2. The facility will attempt to use alternatives prior to using side/bed rails. Consider referral to therapy for bed mobility assessment .3b. Assess the resident for risks of entrapment and other risks associated with the use of side/bed rails .3c. i. If rail is determined to meet the definition of a restraint, obtain informed consent from the resident or the resident representative and physician order prior to installation/use.On 7/7/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including encounter for other orthopedic after care, vascular dementia, insomnia, use of anticoagulants, weakness, reduced mobility, and rheumatoid arthritis. R2's Minimum Data Set (MDS) assessment, dated 5/15/25, had a Brief Interview for Mental Status (BIMS) score of 12 out 15 which indicated R2 had moderately impaired cognition. R2 had an activated POA.On 7/7/25 at 10:03 AM, Surveyor interviewed R2 who was in a wheelchair in R2's room. Surveyor observed side rails on R2's bed. When asked about the care that R2 received, R2 stated R2 could not remember because R2 had dementia.Surveyor noted R2's medical record did not contain an assessment or consent from R2's POA for the use of side rails.On 7/7/25, Surveyor requested an assessment and consent for side rail use from Nursing Home Administrator (NHA)-A.On 7/7/25 at 12:00 PM, NHA-A confirmed the facility did not have an assessment or consent from R2's POA for the use of side rails on R2's bed.

Based on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 1 (Registered Nurse (RN)-C) of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough caregiver background check was completed for RN-C. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised [DATE], indicates: Potential employees will be screened for history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulation . On [DATE], Surveyor requested background check information for a random sample of eight facility and contracted staff. On [DATE] at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Business Office Assistant (BOA)-D when the above requested documents were provided. NHA-A indicated NHA-A wanted to point out our mistake. NHA-A indicated Certified Nursing Assistant (CNA)-E's background check was expired which was discovered when BOA-D completed an audit on [DATE]. NHA-A indicated CNA-E was aware a new background check was needed before CNA-E could work again. NHA-A indicated CNA-E worked the night shift on [DATE] when another CNA asked CNA-E to cover the shift which was not the facility's usual practice. NHA-A indicated CNA-E's employment ended after the facility made attempts to have CNA-E complete the required background check information. NHA-A indicated the facility's process was changed to suspend any employee who has not completed required background check information timely. Surveyor reviewed the requested background check information for the eight facility and contracted staff, including RN-C. RN-C's hire date was listed as [DATE]. RN-C's Background Information Disclosure (BID) form, dated [DATE], indicated RN-C resided in South Carolina from 2014 to 2022. The documents provided did not indicate an out of state background check was completed. On [DATE], Surveyor reviewed an audit document, dated [DATE], that indicated no in a column titled Resided Outside Wisconsin in last 3 years for RN-C. On [DATE] at 1:25 PM, Surveyor interviewed BOA-D who indicated BOA-D should have completed a South Carolina background check for RN-C before RN-C's hire date of [DATE]. BOA-D verified the error was also missed during the audit completed on [DATE].

Based on observation, staff and resident interview, and record review, the facility did not ensure smoking interventions were followed for 2 residents (R) (R36 and R45) of 3 sampled residents. R36's smoking assessment and care plan indicated R36's smoking materials should be stored at the nurses' station. The smoking assessment and care plan were not consistently followed. R45's care plan contained interventions to sign out when R45 went outside to smoke and to return smoking materials to the nurses' station. The interventions were not consistently followed. Findings include: The facility's Smoking Policy, revised 9/10/24, indicates: .5. Residents who smoke or use nicotine or e-cigarettes will be further assessed, using the Nicotine Assessment UDA, to determine whether supervision is required for smoking, or if the resident is safe to smoke at all .9. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan .12. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Residents not requiring supervision will be offered the opportunity to have their smoking materials maintained by nursing staff. If they decline, residents shall maintain their materials in a secure fashion. Residents not requiring supervision who fail to maintain security of their smoking materials will require interventions, up to and including the requirement that the resident's smoking materials must be maintained by nursing staff .14. Documentation to support decision making will be included in the medical record . 1. From 3/24/25 to 3/26/25, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including alcohol dependence with alcohol induced persisting amnesic disorder, nicotine dependence-cigarettes, emphysema, and depression. R36's Minimum Data Set (MDS) assessment, dated 1/6/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R36 had intact cognition. R36 was responsible for R36's medical decisions. R36's plan of care (dated 1/23/25) contained interventions to sign out when going outside to smoke (initiated 3/16/25) and smoking materials to be left at the nurses' station (initiated 7/21/24). On 3/24/25 at 1:57 PM, Surveyor interviewed R36 who indicated R36 had smoked after lunch. Surveyor noted R36 had cigarettes and a lighter in R36's room. R36 indicated R36 picks up cigarettes and a lighter from the nurses' station in the morning when R36 gets up and turns them in in the evening before R36 goes to bed. A Nicotine Assessment, completed on 3/16/25 by the Director of Nursing (DON) indicated: .Storage of smoking materials - resident agrees to allow staff to maintain control of materials. On 3/25/25 at 12:39 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff and residents should follow the smoking policy. On 3/25/25 at 12:46 PM, Surveyor interviewed DON-B who indicated staff and residents are supposed to follow the smoking policy. DON-B indicated staff should keep R36's smoking materials which should not to be kept on R36's person. DON-B indicated R36 should sign out before smoking and staff should provide R36's smoking materials. DON-B indicated R36 should sign back in and give R36's smoking materials to staff when R36 is finished smoking. Surveyor and DON-B observed a sign in/sign out sheet at the nurses' station. R36 signed out and in on 2/24/25 and signed out on 3/24/25 but did not sign back in. There were no other entries. DON-B indicated R36 smoked multiple times per day and should sign in and out each time. On 3/25/25 at 12:55 PM, Surveyor observed R36 enter the facility after smoking and go to R36's room. R36 did not sign in or turn in R36's smoking materials. Surveyor observed staff in the vicinity and at the nurses' station. Surveyor noted staff did not ask for R36's smoking materials or ask R36 to sign in. On 3/25/25 at 1:00 PM, Surveyor interviewed DON-B and asked to see R36's smoking materials. DON-B could not provide the smoking materials because R36 had them. DON-B did not retrieve the smoking materials from R36 or ask staff to retrieve them. On 3/26/25 at 8:14 AM, Surveyor observed R36 in R36's room and noted two packs of cigarettes on the table. R36 confirmed R36 also had a lighter. On 3/26/25 at 8:16 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-F who indicated R36's smoking materials should be kept at the nurses' station. ADON-F was unable to find R36's smoking materials at the nurses' station and did not retrieve the smoking materials from R36. 50467 2. From 3/24/25 to 3/26/25, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] and had diagnoses including osteoporosis, type 2 diabetes, long term insulin use, and gastric ulcer. R45's MDS assessment, dated 2/10/25, had a BIMS score of 15 out of 15 which indicated R45 had intact cognition. R45's care plan (dated 3/16/25) indicated R45's smoking materials should be left at the nurses' station and R45 should sign out when R45 goes outside to smoke. On 3/24/25 at 11:18 AM, Surveyor interviewed R45 who confirmed R45 smokes daily and is an independent smoker. R45 indicated R45 keeps R45's smoking materials. On 3/25/25, Surveyor reviewed R45's sign in/sign out log for 11/28/24 to 3/20/25. The log indicated R45 signed out on 14 occasions and signed back in on 6 occasions. On 3/25/25 at 12:39 PM, Surveyor interviewed NHA-A who confirmed staff and residents should follow the smoking policy. On 3/25/25 at 12:46 PM, Surveyor interviewed DON-B who indicated staff and residents should follow the smoking policy. DON-B confirmed R45 should sign in and out on the log and store R45's smoking materials with staff.

Based on observation, staff interview, and record review, the facility did not provide appropriate catheter care and services for 1 resident (R) (R15) of 3 sampled residents. R15 had a history of urinary tract infections (UTIs) and was diagnosed with a UTI on 3/11/25. On 3/25/25, R15's Foley catheter drainage bag and catheter tubing were observed on the floor. Findings include: The facility's Catheter Care policy and procedure, dated 3/15/23, does not address the positioning/placement of catheter tubing or drainage bags. On 3/26/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, morbid obesity, and urinary tract infection. R15's Minimum Data Set (MDS) assessment, dated 2/18/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R15 had intact cognition. R15 was responsible for R15's healthcare decisions. R15's medical record indicated R15 had a history of UTIs. R15 was diagnosed with a UTI on 3/11/25 and treated with antibiotics. On 3/25/25 at 12:29 PM, Surveyor observed R15 in a wheelchair. R15's catheter drainage bag was in a pillowcase and attached to the underside of the wheelchair. The pillow case and catheter tubing were dragging on the floor. On 3/25/25 at 12:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who verified the pillow case and catheter tubing were dragging on the floor and adjusted the tubing. The pillow case remained on the floor but served as a barrier between the floor and the bag. On 3/26/25 at 9:15 AM, Surveyor interviewed Registered Nurse (RN)-D who indicated catheter bags and tubing should not touch the floor. On 3/26/25 at 11:33 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated catheter bags and tubing should not drag on the floor.

Based on staff interview and record review, the facility did not ensure enteral feedings were provided as ordered for 1 resident (R) (R34) of 1 sampled resident. R34 was not administered supplemental feedings via enteral tube as ordered. Findings include: The facility's Enteral Tubes policy, dated 1/2025, indicates: The nursing care center assures the safe and effective administration of enteral formulas and medication. Selection of enteral formulas, routes, and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident's condition in consultation with the physician, dietitian, and pharmacist. From 3/25/25 to 3/26/25, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of brain, aphasia, and hemiplegia. R34's Minimum Data Set (MDS) assessment, dated 3/4/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R34 had severe cognitive impairment. R34 had an activated Power of Attorney for Healthcare (POAHC). R34 had an order for supplemental tube feedings based on percentage of meals eaten. The physician order, dated 7/24/24, indicated three times a day enteral nutrition via gravity or bolus: Jevity 1.5 hold feeding if meal intake is 51% or greater, provide 0.5 carton (119 milliliters (ml)) if meal intake is 26-50%, provide 1 carton (237 ml) if meal intake is 0-25%. Surveyor reviewed Certified Nursing Assistant (CNA) Nutrition Amount Eaten task documentation and R34's medication administration record (MAR) for March 2025 and noted the following: ~ On 3/6/25, R34 ate 26-50% for lunch and should have received 119 ml of enteral supplement. No enteral supplement was provided. ~ On 3/14/25, R34 ate 26-50% for dinner and should have received 119 ml of enteral supplement. No enteral supplement was provided. ~ On 3/21/25, R34 ate 26-50% for dinner and should have received 119 ml of enteral supplement. No enteral supplement was provided. ~On 3/22/25, R34 ate 26-50% for dinner and should have received 119 ml of enteral supplement. No enteral supplement was provided. ~ On 3/23/25, R34 ate 26-50% for lunch and should have received 119 ml of enteral supplement. No enteral supplement was provided. ~ On 3/24/25, R34 ate 26-50% for breakfast and should have received 119 ml of enteral supplement. No enteral supplement was provided. On 3/26/25 at 7:46 AM, Surveyor interviewed CNA-C who indicated CNAs assist R34 with eating, document how much R34 eats, and notify the nurse who determines if R34 requires an enteral supplement. On 3/26/25 at 9:09 AM, Surveyor interviewed Registered Nurse (RN)-D who indicated enteral feedings are based on how much R34 eats per meal. RN-D indicated CNAs notify nurses of the amount R34 eats at each meal. RN-D indicated nurses determine if supplemental feeding is required and provide a tube feeding as a gravity bolus after the meal. RN-D indicated nurses document in the MAR if a supplemental feeding is provided. On 3/26/25 at 11:23 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated CNAs should inform nurses of the amount R34 eats and nurses should administer the correct amount of feeding. DON-B verified inaccurate supplemental feedings were provided for the above listed dates.

Based on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 2 residents (R) (R38 and R156) of 24 sampled residents. On 3/24/25, Surveyor observed medication at R38's bedside. R38 did not have a physician's order for the medication. In addition, R38 did not have a physician's order to self-administer medication and was assessed as not able to self-administer medication. On 3/24/25, Surveyor observed three medications at R156's bedside. R156 did not have a physician's order for one of the medications. In addition, R156 did not have a physician's order to self-administer medication and was assessed as not able to self-administer medication. Findings include: The facility's Medication Administration General Guidelines policy dated 1/2025, indicate: .3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record .Medications are administered in accordance with written orders of the prescriber. The facility's Self-Administration by Resident policy, dated 1/2023, indicates: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team (IDT) has determined that the practice would be safe and the medications are appropriate and safe for self-administration .1. If the resident desires to self-administer medication, an assessment is conducted by the IDT of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process. 2. The IDT determines the resident's ability to self-administer medication by means of a skill assessment conducted as part of the care plan process .3. The results of the IDT assessment are recorded on the Medication Self-Administration Assessment which is placed in the resident's medical record. 4. If the resident demonstrates the ability to safely self-administer medication, a further assessment of the safety of bedside medication storage is completed . The facility's Bedside Medication Storage policy, dated 1/2024, indicates: Bedside medication storage is permitted for residents who are able to self-administer medication upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing care center's interdisciplinary resident assessment team .2. A written order for the bedside storage of medication is present in the resident's medical record. 3. Bedside storage of medication is indicated on the resident's medication administration record (MAR) for the appropriate medications .4. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into rooms of, or room with, residents who self-administer. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required .5. All nurses or nursing aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage and to give unauthorized medication to the charge nurse .7. The nurse will oversee storage security and accountability of bedside medication . 1. From 3/24/25 to 3/26/25, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease, hypothyroidism, cellulitis, lymphedema, and dermatitis. R38's Minimum Data Set (MDS) assessment, dated 2/5/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R38 had intact cognition. On 3/24/25 at 11:27 AM, Surveyor interviewed R38 and observed a bottle of Deep Sea Saline Solution on R38's bedside table. R38 indicated Registered Nurse (RN)-G gave R38 the Deep Sea Saline Solution a couple of weeks ago for R38's dry nasal areas. R38 indicated R38 took the medication independently and it helped. R38's medical record did not contain a physician's order for Deep Sea Saline Solution or an order to self-administer Deep Sea Saline Solution. A Medication Self-Administration Assessment, dated 1/30/25, indicated R38 could not self-administer medication. R38 did not have a care plan for self-administration of medication or bedside medication storage. On 3/25/25 at 11:50 AM, Surveyor noted the bottle of Deep Sea Saline Solution was still on R38's bedside table. On 3/25/25 at 3:19 PM, Surveyor interviewed RN-G who confirmed RN-G gave R38 the Deep Sea Saline Solution for dry nasal passages a week or two prior. RN-G indicated RN-G should have made sure R38 had an order before providing the medication. RN-G indicated all medications should have a physician's order before they are administered. RN-G also indicated residents should be assessed as able to self-administer medication and have a self-administration of medication order. RN-G thought RN-G attempted to get an order but was unable to provide proof. RN-G was unaware R38's Medication Self-Administration Assessment indicated R38 was not able to self-administer medication. RN-G indicated RN-G obtained an order for the Deep Sea Saline Solution on 3/24/25 after Surveyor had asked about it. On 3/25/25, Surveyor noted R38's medical record contained an order for Saline Spray Nasal Solution. The order, created by RN-G, had a start date of 3/24/25 at 2:00 PM. R38's medical record also contained a Medication Self Administration Assessment, dated 3/24/25 at 1:36 PM, that indicated R38 was able to make R38's own decisions and could self-administer medication. The assessment was created and signed by RN-G. Surveyor did not note an order for self-administration from the physician. On 3/25/25 at 3:55 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated residents must have orders for all medications. DON-B indicated R38 should have had an order for the Deep Sea Saline Solution and a self-medication assessment that determined R38 was capable to self-administer medication. DON-B also indicated R38 should have had a physician's order to self-administer the Deep Sea Saline Solution and an order for bedside medication storage. DON-B indicated the orders should have been initiated before R38 was given the medication. 2. From 3/24/25 to 3/26/25, Surveyor reviewed R156's medical record. R156 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease with acute exacerbation, respiratory failure with hypoxia, heart disease with heart failure, and anxiety. R156's MDS assessment, dated 3/21/25, had a BIMS score of 15 out of 15 which indicated R156 had intact cognition. On 3/24/25 at 11:08 AM, Surveyor interviewed R156 and observed medications on a bedside table and on the floor near R156's bed. Surveyor observed 2 bottles of Remedy antifungal powder and a tube of Voltaren diclofenac 1% gel on R156's bedside table. Surveyor observed a container of Incruse Ellipta - umeclidinium inhalation powder on the floor near R156's bed. R156 indicated R156 self-administered the Ellipta inhalation powder. R156 indicated staff applied Voltaren cream to R156's tailbone and Remedy antifungal powder in R156's skin folds. R156 indicated the medications were regularly kept on R156's bedside table. R156's medical record did not contain a physician's order for Remedy antifungal powder. R156 had physician orders for Incruse Ellipta and Voltaren gel. R156's medical record did not contain a self-administration of medication order for Incruse Ellipta or an order to keep medication at the bedside. A Medication Self Administration Assessment, dated 3/17/25, indicated R156 was not able to make R156's own decisions and could not self-administer medication. R156 did not have a care plan for self-administration of medication or bedside medication storage. On 3/25/25 at 3:55 PM, Surveyor interviewed DON-B who indicated residents should have orders for all medications. DON-B indicated residents should have a self-administration of medication assessment to determine if they are capable of self-administering medication. DON-B indicated residents who wish to self-administer medication should have a physician's order to self-administer medication. On 3/26/25 at 8:10 AM, Surveyor noted R156 still had 2 bottles of Remedy antifungal powder in R156's room. The Incruse Ellipta and Voltaren gel were not observed. On 3/26/25, Surveyor reviewed R156's MAR and noted there were no orders for Remedy antifungal powder or to self-administer medication. On 3/26/25 at 11:00 AM, Surveyor interviewed RN-H who indicated all medications should have an order. RN-H confirmed any medication left at the bedside should have a bedside medication order. RN-H confirmed all residents who self-administer medication should be assessed as able to do so via a self-medication assessment. On 3/26/25 at 11:08 AM, Surveyor interviewed DON-B who indicated R156's self-administration of medication assessment was incorrect because R156 was alert and oriented. DON-B indicated staff were educated on the protocol but were not following the facility's policy. On 3/26/25 at 11:20 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated nursing staff are aware of and should follow the facility's medication administration and storage policies.

Based on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 resident (R) (R42) of 24 sampled residents. R42 had an order for daily weights and to notify the physician if R42's weight increased more then 3 pounds in a day or 5 pounds in a week. R42 was not weighed on 3 occasions between 3/1/25 and 3/22/25. In addition, the physician was not notified on 3 occasions when R42's weight was outside the ordered parameters. Findings include: From 3/24/25 to 3/26/25, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), morbid obesity, atherosclerotic heart disease, atrial fibrillation, and acute on chronic diastolic heart failure. R42's Minimum Data Set (MDS) assessment, dated 1/2/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R42 was not cognitively impaired. R42's medical record indicated R42 was on a fluid restriction and diuretic medication. R42 had an order for daily weights and to update the physician if R42's weight changed 3 pounds overnight or more then 5 pounds in one week. R42's cardiovascular status related to heart failure and atrial fibrillation care plan contained interventions for daily weights and to call the physician if R42's weight changed 3 pounds in 1 day or more than 5 pounds in 1 week (initiated 6/29/24). R42's weight documentation, medication administration record (MAR), and nursing notes for 3/1/25 to 3/25/25 indicated the following: ~ On 3/5/25, R42 had a gain of 3.5 pounds. The heart failure clinic (HFC) was updated and R42 was seen virtually. ~ On 3/8/25, R42 had a gain of 3.6 pounds. There was no documentation that the physician was notified. ~ On 3/10/25, R42's weight was not obtained. ~ On 3/12/25, R42 had a gain of 3 pounds. There was no documentation that the physician was notified. ~ On 3/14/25, R42's weight was not obtained. ~ On 3/15/25, R42 had a gain of 4 pounds. There no documentation that the physician was notified. ~ On 3/16/25, R42 had a gain of 9 pounds. Staff faxed the HFC. There was no documentation of a reply. ~ On 3/17/25, staff documented R42's weight increase and the HFC was notified via fax and phone. ~ On 3/17/25, wound care orders were received for R42's right lower extremity. ~ On 3/17/25, the HFC increased R42's diuretic via a faxed order that was noted on 3/18/25 at 9:06 AM and started on 3/18/25 at 12:00 PM. Staff were to follow-up with the HFC on 3/21/25. ~ On 3/18/25, R42 was sent to the Emergency Department (ED) for leg pain and returned with a diagnosis of left thigh and groin pain. ~ On 3/19/25, R42 was seen by the HFC and was sent to the ED. R42 was diagnosed with cellulitis of the right lower extremity and prescribed antibiotics. ~ On 3/21/25, R42 had a gain of 7.1 pounds. R42's MAR indicated a congestive heart failure (CHF) assessment was obtained and there was follow-up with the HFC. There was no documentation of the CHF assessment or what information was sent to the HFC. ~ On 3/22/25, R42's weight was not obtained. On 3/25/25 at 1:58 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-F who confirmed R42's weight was managed by the HFC and R42 was supposed to be weighted daily. ADON-F verified the physician should be notified if R42's weight was not within the ordered parameters and confirmed the above timeline was correct.

Based on staff interview and record review, the facility did not ensure protective placement was obtained for 3 Residents (R) (R11, R12, and R14) of 3 sampled residents. R11 had a court-ordered guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R11's stay exceeded 60 days. R12 had a court-ordered guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R12's stay exceeded 60 days. R14 had a court-ordered guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R14's stay exceeded 60 days. Findings include: WI state statute chapter 55.055(1)(b) contains the following information: The guardian of an individual who has been adjudicated incompetent may consent to the individual's admission to a nursing home or other facility not specified in par. (a) for which protective placement is otherwise required for a period not to exceed 60 days. In order to be admitted under this paragraph, the individual must be in need of recuperative care or be unable to provide for his or her own care or safety so as to create a serious risk of substantial harm to himself or herself or others. Prior to providing that consent, the guardian shall review the ward's right to the least restrictive residential environment and consent only to admission to a nursing home or other facility that implements that right. Following the 60-day period, the admission may be extended for an additional 60 days if a petition for protective placement under s. 55.075 has been brought, or, if no petition for protective placement under s. 55.075 has been brought, for an additional 30 days for the purpose of allowing the initiation of discharge planning for the individual. 1. On 1/2/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), compression fracture of lumbar spine, critical limb ischemia right lower extremity with gangrene, intellectual disability, and peripheral vascular disease (PVD). R11's most recent Minimum Data Set (MDS) assessment, dated 12/26/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R11 had moderately impaired cognition. R11's medical record contained a court order, dated 2/19/17, that appointed guardianship of person for R11; however, R11's medical record did not contain a petition or court order for protective placement in the facility. 2. On 1/3/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] with diagnoses including genetic-related intellectual disability, bipolar disorder, and anxiety disorder. R12's most recent MDS assessment, dated 10/21/23, contained a BIMS score of 7 out of 15 which indicated R12 had severely impaired cognition. R12's medical record contained a court order from 1991 that appointed guardianship of person for R12; however, R12's medical record did not contain a petition or court order for protective placement in the facility. 3. On 1/3/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] with diagnoses including pervasive developmental disorder (refers to a group of conditions that affect average development), epilepsy, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and post cerebrovascular disease (a condition that impacts the blood vessels in the brain) affecting right dominant side. R14's most recent MDS assessment, dated 11/26/23, contained a BIMS score of 10 out of 15 which indicated R14 had moderately impaired cognition. R14's medical record contained a court order from 2012 that appointed guardianship of person for R14; however, R14's medical record did not contain a petition or court order for protective placement in the facility. On 1/3/24 at 11:21 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R11, R12, and R14 did not have protective placement orders. Per NHA-A, the facility tried to rectify the situation between 1/2/24 and 1/3/24. NHA-A verified protective placement for R11, R12 and R14 was not reviewed prior to 1/2/24 and stated the facility did not have a policy. NHA-A indicated Social Services Director (SSD)-C was responsible for reviewing and obtaining protective placement. On 1/3/24 at 11:29 AM, Surveyor interviewed SSD-C who verified R11, R12 and R14 did not have protective placement orders and indicated SSD-C was unsure of the facility's process for reviewing and obtaining protective placement. On 1/3/24 at 11:43 AM, Surveyor again interviewed SSD-C and NHA-A. SSD-C stated to obtain protective placement, residents have to be involved with an attorney and the County, and the facility has to ensure the County can meet with residents at the facility on an annual basis. Per NHA-A, R11, R12, and R14 had examination appointments on 1/5/24 to initiate protective placement.

Based on staff interview and record review, the facility did not ensure smoking assessments were completed for 1 Resident (R) (R42) of 2 residents reviewed. R42 was an active smoker and had a diagnosis of nicotine dependence. The facility did not complete smoking assessment for R42 per their policy. Findings include: The facility's Smoking Policy, with a reviewed/revised date of 7/14/22, indicated residents who smoke or use smokeless tobacco products will have a Nicotine Assessment completed upon admission, quarterly, annually, and as needed. During the entrance conference on 1/2/24, Nursing Home Administrator (NHA)-A identified R42 as a smoker. On 1/3/24, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] with diagnoses that included nicotine dependence. R42's medical record indicated R42 had intact cognition and required limited assistance with activities of daily living (ADLs). A Significant Change Minimum Data Set (MDS) assessment completed on 10/28/23 indicated R42 developed a pressure injury and required the use of a cane and wheelchair for mobility. R42's medical record contained a Nicotine Assessment, dated 5/28/23. Surveyor noted no other Nicotine Assessments in R42's medical record. On 1/3/24 at 10:20 AM, Surveyor observed R42 in the smoking area. On 1/3/24 at 1:48 PM, NHA-A verified R42's last Nicotine Assessment was completed on 5/28/23. NHA-A indicated Nicotine Assessments should be completed upon admission, quarterly, and annually. On 1/3/24 at 2:29 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R42's last two quarterly Nicotine Assessments were missed. DON-B completed a Nicotine Assessment for R42 on 1/3/24.

Based on observation, interview, and record review, the facility did not ensure that a resident who enters the facility without a pressure ulcer receives the necessary treatment and care to prevent new ulcers from developing for 1 (Resident #6) of 4 residents reviewed with new or worsened pressure ulcers. Resident #6 was admitted to the facility with a Cervical Collar and was assessed to be at high risk for pressure ulcer development. The hospital notified the facility of the existence of reddened areas under the collar and the need to pad and collar. The facility did not develop a care plan to prevent the development of pressure ulcers. Resident #6 developed 2 avoidable Stage 2 pressure ulcers on her left clavicle and left chin after being admitted to the facility with a cervical fracture. This is evidenced by: The National Pressure Ulcer Advisory Panel publicized in February 2013 the "Best Practices for Prevention of Medical Device Related Pressure Ulcers" which included, "Choose the correct size of the medical device(s) to fit the individual. Cushion and protect the skin with dressings in high risk areas...Remove or move the device daily to assess skin...." Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's Facility Transfer Nursing Report from the hospital dated 12/03/13, noted: ~Skin/Wound Condition and Care: Collar Care needs to be done daily. Extra pads for collar will be sent with patient. Reddened areas under front of collar are covered with duoderm to prevent breakdown of skin. Resident #6's admission MDS (Minimum Data Set) indicated: ~Requires extensive assist of 2 staff for bed mobility; ~Transfer occurred 2 or fewer times with that assist of 2; ~Resident is at risk for developing pressure ulcers; and ~Unhealed pressure ulcers=0. Resident #6;s Care Area Assessment noted: ~Problems resident is at risk for: complications of immobility such as pressure ulcers...Description of problem: Resident is currently extensive to total assist with all her ADLs (activities of daily living) due to C-2/C-3 (neck) fracture. She has extensive debilitating DJD ([MEDICAL CONDITION] Joint Disease) which has caused her to have problems with pain control even prior to her neck fracture. She is working with therapies but this will be an extensive short term rehab to see if she can become functional enough to return home. Will proceed with a short term plan of care at this time. Care Plan: Will develop care plan. Resident #6's CNA (Certified Nursing Assistant) Communication Sheet noted: ~Mobility: Resident to remain in bed until able to tolerate sitting at EOB (edge of bed). Skin Integrity: Encourage side to side lying. Even though the facility was informed by the hospital of the need to pad the collar and that reddened areas existed under the collar, the facility did not develop a care plan to prevent the development of pressure ulcers under the C-Collar. Resident # 6's Integumentary (skin) note for 12/04/13 indicated: ~12/04/13: Pressure Ulcer Risk: Clinical Assessment done. Summary of findings: No pressure ulcer. No lower extremity ulcers, no skin problems. No signs of infection. Meds as ordered. Pressure relief devices, pressure reducing devices, update physician as needed. Resident #6's Treatment Records were reviewed with the following treatments noted: December 2013: ~12/17/13: Wear collar at all times x 8-12 weeks except for collar care. Place resident in flat supine position and provide personal hygiene to front and back of neck and change pads on collar. Ensure pads are changed on collar daily. Hand wash pads daily with mild soap, rinse and air dry. PM: First date noted as completed with initials in box is 12/27/13. The next Integumentary (skin) note for Resident #6 noted: ~12/27/13: Pressure Ulcer: Unstageable, describe: wound bed cannot be visualized d/t (due to) hard eschar covering it. Location: across left clavicle. Size: Length/CM: 0.2, Width/CM: 1.2. Wound Margins: defined. Tissue condition: Necrosis present. Necrotic Tissue: Yes, firmly adherent, Eschar: black, brown, tan. Summary: Unstageable ulcer located on left clavicle. Resident is a recent cervical fracture (fx) with a Miami collar..Plan: Unstageable ulcer to left clavicle. Cleanse with wound cleanser, pat dry, apply alginate [MEDICATION NAME] dressing. Change every three days and as needed. Complete Nutritional Risk checklist. Pressure Ulcer: Stage 2. Location: Left lower chin, first layer of skin is broken, very small amount of bleeding, area is between Miami collar and chin. Size: Length/CM: 0.3 round. Wound Margins: Regular. Wound Perimeter: attached, [DIAGNOSES REDACTED] present. Summary: New pressure ulcer. Plan: Area padded with gauze. Continue current plan of care. Resident #6's physician order [REDACTED]. ~12/27/13: Tx (treatment to L(left) clavicle is cleanse with wound cleanser, pat dry, apply alginate [MEDICATION NAME], change every three days and as needed. Resident #6's Treatment Records were reviewed with the following treatments noted: ~12/27/13: Unstageable ulcer to left clavicle; cleanse with wound cleanser, pat dry, apply alginate [MEDICATION NAME]. Change every three days and prn (as needed). Initialed as completed 12/27/13 and 12/30/13. January 2013: ~Wear collar at all times x 8-12 weeks except for collar care. Place resident in flat supine position and provide personal hygiene to front and back of neck and change pads on collar. Ensure pads are changed on collar daily. Hand wash pads daily with mild soap, rinse and air dry. PM: Initialed daily as completed. ~Unstageable ulcer to left clavicle; cleanse with wound cleanser, pat dry, apply alginate [MEDICATION NAME]. Change every three days and prn (as needed). Thin [MEDICATION NAME] ( 1/9/14). Initialed as completed 1/2/14, 1/5/14, 1/8/14 and 1/14/14. ~Cleanse L posterior chin with wound cleanser, pat dry then apply a thin [MEDICATION NAME]. Change every three days and prn. Initialed as completed 1/2/14, 1/5/14, 1/8/14 and 1/14/14. On 12/30/13, the Integumentary (skin) documentation for Resident #6 noted: ~ Pressure Ulcer: Stage 2. Location: Left clavicle. Size: Length/CM: 2.0 cm, Width/CM: 2.0cm: Depth/CM: less than 0.1cm. Wound Margins: Irregular, defined. Wound perimeter: attached pink tissue. Wound bed: beefy red, moist. Tissue condition: granulation present. Summary: Area this week is larger in size but no necrotic tissue is noted at this time. Area is beefy red moist granulation tissue. Last week area was covered with necrosis thus being unstageable. This week however area is free of necrosis and is a stage 2 pressure ulcer. Plan: continue treatment as ordered. Continue to address on care plan. Continue current plan of care. Will continue [MEDICATION NAME] treatments until Miami J collar is discontinued for extra protection. ~12/30/13: Pressure Ulcer: Unstageable, unable to visualize wound bed related to tannish brown firmly adherent. Location: posterior chin. Size: Length/CM: 0.4 cm, Width/CM: 0.8cm: Depth/CM: unable to visualize related to tannish brown necrotic tissue. Summary: Area at this time is covered with a tannish brown necrotic tissue that is firmly adherent. Area surrounding wound is pink blanchable intact healthy tissue. Plan: Will start the following treatment: cleanse with wound cleanser, pat dry and apply a bordered [MEDICATION NAME] changing every three days and as needed. Will keep the [MEDICATION NAME] in place until Miami J collar is discontinued for extra protection. The following order was noted on the Physician order [REDACTED]. ~12/30/13; TX (treatment) to L (left) posterior chin is to cleanse with wound cleanser, pat dry, apply bordered [MEDICATION NAME] and change every 3 days and as needed Integumentary (skin) notes continue as follows: ~12/31/14: Physician notified of both pressure ulcers to the left clavicle and left chin. ~01/02/14: Skin Committee meeting note: Summary of findings and weekly skin condition were reviewed. No changes at this time. Will continue current plan of care. ~01/08/14: Pressure Ulcer: Stage 2. Location: Left clavicle. Size: Length/CM: 1.0 cm, Width/CM: 0.2cm: Depth/CM: superficial. Summary: Healing pressure ulcer. Area this week is pink moist granulation tissue. No necrotic tissue is noted at this time. Area surrounding wound continues to be pink healthy intact blanchable tissue...She continues to wear her Miami J collar at all times except for cleansing and changing the inner pads. Plan: Monitor for two weeks. Continue TX (treatment) as ordered. Continue to address on current plan of care, will also add mole skin to the top and bottom of the Miami J collar for added protection. Summary of findings: pressure ulcer to left posterior chin is healed at this time with pink fragile intact skin. Plan: Monitor for two weeks. Continue treatment as ordered. On 1/8/14, the facility developed a Skin Integrity care plan for Resident #6 with approaches that include: ~01/08/14 - Nurses: Pad C-Collar with mole skin top and bottom, change once weekly. Skin notes continue: ~1/14/14: Summary of findings: Area to the left posterior chin remains healed at this time. Summary of findings: Area to the left clavicle is healed at this time with pink fragile intact tissue. On 1/14/14, Resident #6's care plan was updated to include: ~Nurses: treatment as ordered, cleanse clavicle ulcer with wound cleanser, pat dry and apply a bordered [MEDICATION NAME], changing every three days for protection. ~Nurses: Treatment as ordered, cleanse left posterior chin ulcer with wound cleanser, pat dry, and apply a bordered [MEDICATION NAME], changing every three days for protection. Resident #6's medical chart also included a letter from Neuro Surgery. The letter indicates: Please review and enact the following guidelines for the care of Resident #6, specifically regarding her cervical fractures and cervical collar wear and care. Resident #6 must wear the collar at all times to proper fit for the next 8-12 weeks, with the exception of up to 20 minutes of daily collar care, when the patient should be placed in flat supine position, cervical spine precautions enacted and personal hygiene to patients front and back of neck, as well as changing of the pads... The letter is dated and initialed by the DON (Director of Nursing) on 12/27/14. On 1/16/14 at 1:00 p.m., Surveyor # met with the NHA (Nursing Home Administrator) the DON (Director of Nursing) and RN-A. Surveyor # asked when the the facility first noted areas of pressure on Resident #6. RN-A responded the areas on Resident's left clavicle and chin were first noted on 12/27/14. Surveyor # asked what the facility did at the time of admission to address the reddened areas under front of collar as noted on the Facility Transfer Nursing Report from the hospital (dated 12/03/13). The DON stated when the facility received the Transfer Nursing Report, contact was made with Resident #6's physician to seek clarification in orders. The facility did not receive instruction until a fax was received on 12/17/13 from the Neurosurgery Department via letter outlining care. The DON further expressed follow-up should have been done immediately. Surveyor # asked the facility to explain why Resident #6's Treatment Record did not address the clarification until 12/27/13. The DON indicated she would need to check to see if nursing completed the treatment daily prior to 12/27/13 and get back to Surveyor # . Surveyor # asked the DON what her expectation related to care plan approaches related to Resident #6's guidelines ordered by the hospital Neurosurgery Department. The DON expressed a care plan should have been developed immediately to address Resident #6's care and treatment to address pressure ulcer prevention. At the time of exit no additional information was provided to Surveyor # .

Based on observations, staff interviews and record review, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection as it related to influenza. 42 of the facility's residents were directly affected; however, the failures have the potential to affect all residents in the facility. 42 of the facility's residents became symptomatic of influenza-like illness (ILI) beginning [DATE]: 1. Three residents presented with symptoms of ILI on the 600 unit within a 24-hour period ([DATE] to [DATE]). The facility did not identify that an outbreak had occurred and did not implement immediate aggressive actions to prevent the spread of infection. The facility did not curtail communal dining and activities and there was no evidence that the facility implemented outbreak control measures including placing those residents with suspected ILI in droplet precautions. 2. During the outbreak in the facility, direct care staff was allowed to float from affected to unaffected units. This practice increased the likelihood of cross contamination of illness. 3. The on-call Medical Director was not informed of the outbreak and the facility's outbreak measures until [DATE]. 4. The Department of Health was notified of the outbreak on [DATE] with the facility reporting 23 suspected residents affected and no staff, even though the facility line list identifies 7 staff up to [DATE]. 5. The first doses of [MEDICATION NAME] were not received until [DATE] at 1:30 a.m. for treatment of [REDACTED]. No other efforts to obtain the [MEDICATION NAME] could be ascertained in the facility records. 6. [MEDICATION NAME] initiation did not begin until 5:00 p.m. on [DATE], at which point 36 residents were affected, some for as long as one week. 7. Staff-E (Social Worker) was noted to return to work prior to being symptom-free for at least 24 hours. 8. Observations of staff not following proper precautions and wearing appropriate personal protective equipment as indicated were made on [DATE] and [DATE]. During the outbreak, a total of 42 residents and 18 staff were documented as presenting with signs and symptoms. 3 residents were hospitalized . 1 resident died due to failure to thrive and influenza. The failure to immediately identify an outbreak and to immediately implement measures to prevent the spread of infection until 2 days later, the failure to implement appropriate precautions during the outbreak, and the failure to more promptly initiate treatment, created a finding of Immediate Jeopardy, which began on [DATE] when the facility identified 3 residents presenting with symptoms on the same unit within a 24-hour period and did not take appropriate actions. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 4:00 p.m. The immediate jeopardy was removed on [DATE], but noncompliance remained at the lower scope and severity level of F (potential for more than minimal harm/widespread) as the facility still needs to fully implement their corrective plans. This is evidenced by: The CDC guidance for Influenza Outbreak Management in Long-Term Facilities identifies an outbreak of influenza-like illness as: one laboratory-confirmed influenza case or suspected (2 or more ill residents) influenza. It should be noted that this is for reporting purposes only. The CDC guidance further states: Preventing transmission of influenza viruses and other infections agents within health care settings requires a multi-faceted approach that includes the following: Surveillance: When there is activity in the local community, active daily surveillance for influenza should be conducted among all residents, staff and visitors. Testing: Influenza testing should occur when any resident has signs and symptoms of influenza-like illness. Implement standard and droplet precautions for all residents with suspected or confirmed influenza. ~Standard precautions include: Wearing gloves and gown if contact with potentially contaminated surfaces or respiratory secretions is anticipated. ~Droplet precautions include: placing ill residents in a private room, if not available place residents suspected of having influenza with one another. If resident movement or transport is necessary have the resident wear a mask. Antiviral treatment and [MEDICATION NAME]: All long-term facility residents who have confirmed or suspected influenza should receive treatment immediately. All eligible residents in the entire long-term care facility should receive antiviral [MEDICATION NAME] as soon as an influenza outbreak is determined. Antiviral [MEDICATION NAME] can be considered or offered to unvaccinated personnel who provide care to persons at high risk for complications is required. Consider the additional measures to reduce transmission among resident and health care personnel: Have symptomatic residents stay in their rooms as much as possible, restricting from common activities, with meals served in their rooms if possible; limit large group activities; serving all meals in resident rooms when the outbreak is widespread; avoid new admissions or transfers to wards with symptomatic residents; limit visitation and exclude ill person from visiting via posted notices. Monitor personnel and exclude those with influenza-like illness from work until 24 hours after they no longer have a fever; restrict personnel movement from areas of the facility having illness to areas not affected by the outbreak; administer the current season's influenza vaccine to unvaccinated residents and health care personnel. On [DATE] at 3:00 p.m., Surveyor # received and reviewed the facility's line list of residents and staff during the outbreak of influenza-like illness and noted the following: * On [DATE], 1 resident was documented with ILI (influenza-like illness). -Resident #7 from hall 100 presented with fever, cough, runny nose/stuffy nose, muscle aches and fatigue with hospitalization for pneumonia from [DATE] through [DATE]. Based on Resident #7's signs and symptoms, staff should have suspected Resident #7 as having influenza and placed the resident in droplet precautions. Resident #7's care plan was reviewed. There was no evidence that Resident #7 was placed on droplet precautions. * On [DATE], 2 residents reported with ILI: -Resident #10 from hall 100 presented with cough. -Resident #11 from the 500 hall presented with fever, cough, muscle aches and fatigue. Per the facility's timeline for influenza outbreak, there was no evidence to identify that Resident #10 and Resident #11 were placed on standard or droplet precautions with presentation of symptoms consistent with ILI. * On [DATE], 2 staff reported with ILI: -SW-E (Social Worker) with fever, chills, cough, sore throat, runny/stuffy nose, muscle aches, headache and fatigue, also reported by the facility as returning to work the same day as her well date of [DATE]. According to the staff line list, SW-E works all units. SW-E's well date is documented as [DATE] on the staff line list. SW-E is identified as returning to work on [DATE], which is not consistent with the facility's guidance of staff remaining off work 24 hours after being symptom-free. -AA-F (Administrative Assistant) presented with all symptoms reported for previous staff without runny/stuffy nose. According to the staff line list, AA-F works D unit (500 and 600). The NHA (Nursing Home Administsrator) informed Surveyor # on [DATE] at 3:00 p.m., that efforts were made to minimize staff floating between units during the outbreak; however, given the number of ill residents, staff floating between units could not be avoided. Additionally, staff working on a unit, float to other units to cover for breaks. * On [DATE], 1 resident with ILI: -Resident #12 from the 300 hall presented with cough and runny/stuffy nose, with a confirmed case of Influenza A. There was no evidence of Resident #12 being placed on standard and droplet precautions when presenting with symptoms on [DATE]. * On [DATE], 2 residents and 2 staff with ILI: -Resident #13 from 600 hall. -Resident #14 from 600 hall was diagnosed with [REDACTED]. There was no evidenced to identify when Resident #13 and Resident #14 were placed on standard and droplet precautions when presented with symptoms. -CNA-G (Certified Nursing Assistant) working the 500 and 600 hall. -RN-H (Registered Nurse) worked 500 and 600 hall as well as rooms #1 through #13. * On [DATE], 3 residents and 1 staff with ILI: -Resident #15 from the 300 hall with a confirmed case of Influenza A. -Resident #16 from the 500 hall with a positive chest x-ray for pneumonia. -Resident #8 from 600 hall was hospitalized from [DATE] through [DATE] with bilateral pneumonia. There was no evidence to identify when Resident #15, 16 and 8 were placed on standard and droplet precautions. -RN-I documented as working all units. Using the facility's guidance of 3 residents presenting on the same unit with ILI in a 72-hour period (Resident #13, Resident #14 and Resident #8), the facility should have identified an outbreak. The outbreak control measures of ceasing communal dining and activities, and alerting visitors should have been initiated. There was no evidence the facility initiated these actions prior to the notation made [DATE] on the facility's timeline for influenza outbreak. Because influenza-like illness can spread quickly, immediate aggressive intervention is required to curtail the spread of influenza-like illness when an outbreak occurs. The facility did not identify that an outbreak had occurred and did not initiate immediate aggressive intervention to limit the spread of an infection until two days later. * On [DATE], 2 residents identified with ILI: -Resident #17 and #6 from the 500 hall. Resident #6 had a positive culture for Influenza A, expired due to influenza on [DATE]. There is no evidence of the facility placing Resident #17 and #6 on precautions. * On [DATE], 8 residents and 1 staff identified with ILI: -Resident #18 from 300 hall was diagnosed with [REDACTED]. -Residents #19 and #20 from the 400 hall. -Residents #4, #21, #22, #23 from 500 hall. Residents #4 and #22 were confirmed with Influenza A. Resident #23 was confirmed with Influenza B. -Resident #2 from the 600 hall. Resident #2 was confirmed with Influenza A. -CNA-J working the 300 and 400 halls presented with influenza-like illness. This is the first date that the facility suspected an outbreak of ILI. It was not until this time that the facility initiated its outbreak control plan by ceasing communal dining and activities, alerting visitors and having staff wear masks, using proper handwashing, and using droplet and contact precautions as necessary. However, there was no evidence the facility initiated antiviral medications to all residents of the facility as recommended. * On [DATE], 9 residents and 1 staff were reported with ILI: -Residents #24, #9, #25, and #26 from 300 hall. Resident #9 was diagnosed with [REDACTED]. -Residents #27, #28, and #29 from the 400 hall. -Residents #30 and #31 from the 500 hall. -CNA-K working the 500 and 600 halls presented with influenza-like illness. On [DATE], the facility first contacted the local Health Department and acting Medical Director. * On [DATE], 8 residents were reported with ILI: -Residents #33, and #34 from 200 hall. -Residents #32, and #35 from the 300 hall. Resident #35 was transported to the emergency room and diagnosed with [REDACTED]. -Resident #39 from the 400 hall. -Resident #36 from the 500 hall. -Resident #37 from the 600 hall. -Resident #38 was noted on the line list as expiring on [DATE] with cause of death unknown. -No staff were noted on the line list with symptoms. At 1:30 a.m., the first delivery of the antiviral [MEDICATION NAME] was received with treatment to residents identified by the facility as priority. At 5:00 p.m., the receipt of [MEDICATION NAME] for treatment was noted for residents on 300, 400, 500 and 600 halls, with additional delivery of [MEDICATION NAME] expected. Surveyor # could not ascertain when the facility received additional [MEDICATION NAME] for treatment of [REDACTED].#13. * On [DATE], 1 resident and 2 staff were reported with ILI: -Resident #40 from the 500 hall. -CNA-L worked the 300 and 400 halls. -CNA-M worked the 500 and 600 halls. * On [DATE], 3 residents and 1 staff were reported with ILI: -Residents #41 and #42 from the 100 hall. -Resident #43 from the 200 hall. -LPN-C (Licensed Practical Nurse) from the 300 and 400 halls. * On [DATE], 2 staff were reported with ILI: -LPN-N worked the 100, 200, 300 and 400 halls. -WC-O (Ward Clerk) worked all halls. * On [DATE], 1 resident and 3 staff were reported with ILI: -Resident #44 from 200 hall. Resident #44 was confirmed with Influenza B. -RN-P working rooms #1 through #13. -RN-Q working 500 and 600 halls. -DON working all halls. This is when the facility initiated [MEDICATION NAME] for all new and re-admissions to the facility. * On [DATE], 1 staff was reported with ILI: -CNA-R worked the 500 and 600 halls. * On [DATE], 2 staff reported with ILI: -CNA-S worked all halls. -1 staff reported as working no halls. A new employee who had not yet started work. * On [DATE], 1 resident was reported with ILI: -Resident #45 from the 600 hall. Resident #45 is the last reported person with ILI. On [DATE] at 10:30 a.m., Surveyor # interviewed the DON (Director of Nursing) who is also the Infection Control Preventionist and NHA (Nursing Home Administrator). Surveyor # asked the DON when she suspected an outbreak of Influenza-like illness in the facility. The DON responded on [DATE], when 11 or 12 residents from the 500 and 600 halls presented with upper respiratory symptoms. Surveyor # asked the DON to explain what outbreak measures were put in place. The DON explained on [DATE] residents were kept to their units and meals were served in their rooms. Surveyor # asked the DON what standard of practice the facility uses to identify an outbreak. The DON responded the corporate policy is used, which defines an outbreak as 3 residents from the same unit presenting with influenza-like illness within a 72-hour period. The surveyor stated the CDC guidelines defines an outbreak as 2 or more residents. The DON expressed she was unaware of the CDC definition and questioned why the corporate policy was not consistent with the CDC guidelines. The DON further explained the Department of Health was notified on [DATE], informing them of the residents who were ill. The DON further expressed no staff were reported to the Department of Health as it was not significant at the time. Surveyor # asked the DON about expectations of staff during the outbreak. The DON indicated staff are to wear PPE (Personal Protective Equipment) in resident rooms, remove the PPE in the room and wash hands prior to exiting the room. Surveyor # requested the resident and staff rates of vaccination, the facility's outbreak control plan, information related to residents being placed on precautions, and information related to increased frequency of cleaning during the outbreak. No information was provided related to resident specific precautions and when they were started. Example #1: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing notes were reviewed by Surveyor # which revealed the following: ~[DATE], 3:29 p.m., fever noted, Nurse Practitioner notified with orders for chest x-ray and influenza swab obtained. ~[DATE], 12:50 a.m., fever of 100.7 noted, 3:17 a.m. physician notified with order to send to the emergency room for evaluation and treatment. Resident presenting with upper respiratory congestion, increased lethargy, increased pain through the body, elevated temperature, elevated pulse, hypotension and increased confusion. ~[DATE], wheezing of right and left upper lobes, non-productive cough, Power of Attorney updated on positive influenza swab and start of [MEDICATION NAME]. ~[DATE], no change in symptoms noted. ~[DATE], crackles, congestion, non-productive cough, hacking. ~[DATE], decrease bed mobility, neck tender, sore throat, respiratory symptoms. ~[DATE], decrease fluid intake, decreased appetite, start [MEDICATION NAME] 500mg two times a day times 7 days due to diminished lower lobes, confusion. Lethargy... ~[DATE], continues to decline, no response with movement or questions, keeping comfortable, unresponsive, stopped eating and drinking, unable to swallow, no food or fluids times three days, actively dying, naturally dehydrating. Family requests no rehydration. Resident is on comfort measures only, family declined Hospice. ~[DATE], Resident pronounced dead at 6:02 p.m. ~[DATE], Physician report of cause of death as failure to thrive, influenza. Resident #6's care plan was reviewed. Infection control was not noted on the care plan and no mention of precautions that staff needed to take when working with Resident #6. Facility records for Resident #6 indicated she last received the [MEDICATION NAME] inactivated influenza vaccine (flu shot) on [DATE] and the pneumonia vaccination on [DATE]. Resident #6's onset of influenza-like illness was noted on [DATE], several days after influenza-like illness was prevalent in the community and facility. There was no evidence of specific precautions that staff needed to take when working with Resident #6. Example #2: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's nursing notes and physician orders [REDACTED]. ~,[DATE]//12, Resident O2 stats at 74% on 2 liters of through bi-pap, diaphoretic, drowsy, decreased level of consciousness, did respond to verbal stimuli but would quickly fall back to sleep. Temperature 101.8 and would not be relieved with apap, lungs with fine crackles in bases. Family phoned, MD notified. Physician order [REDACTED]. ~[DATE], hospital discharge summary notes resident was admitted with hypotension, sepsis and pneumonia. Resident #7's care plan was reviewed. Infection control was not noted on the care plan and no mention of precautions that staff needed to take when working with Resident #7. Facility records for Resident #7 indicated she last received the [MEDICATION NAME] inactivated influenza vaccine (flu shot) on [DATE] and the pneumonia vaccination on [DATE]. Example #3: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's nursing notes and physician orders [REDACTED]. ~[DATE], resident noted with dry, productive and weak cough with physician notification of the same. ~[DATE], productive cough noted. ~[DATE], hacking, congested. ~[DATE], hacking, congested, non-productive cough, Power of Attorney notified of start of [MEDICATION NAME]. ~[DATE], diminished right and left lower lobes. ~[DATE], diminished lower lobes. ~[DATE], [DATE] and [DATE] no change. ~[DATE], coarse crackles right lower lobes, fine crackles right upper lobe. ~[DATE], resident currently being monitored for her cough, this has been getting progressively worse and now excessive and causing hypoxia and pain in left side. Sent to ER (emergency room ) for evaluation per physician. ~[DATE], hospital discharge summary notes pneumonia sepsis secondary to pneumonia, hypoxia secondary to pneumonia and supratherapeutic INR. Resident #8's care plan was reviewed. Infection control was not noted on the care plan and no mention of precautions that staff needed to take when working with Resident #8. Facility records for Resident #8 indicated she last received the [MEDICATION NAME] inactivated influenza vaccine (flu shot) on [DATE] and the pneumonia vaccination on [DATE]. Although Resident #8 presented with influenza-like illness on [DATE], there was no evidence that specific precautions were put in place for staff working with Resident #8. Additionally, communal dining and activities continued and there was no evidence to demonstrate if Resident #8 was excluded from these activities. Example #4: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's nursing notes and physician orders [REDACTED]. ~[DATE], resident noted with productive cough. ~[DATE], productive cough noted. ~[DATE], productive cough, diminished air flow. ~[DATE], 11:45 a.m. pt (patient) calls for assistance because she "couldn't breathe," 86% oxygen saturation and resident cough getting progressively worse since a.m. Cough very tight and color poor. Power of Attorney notified, sent to the emergency room for evaluation stating "couldn't breathe." ~[DATE], returned from ER 6:45 p.m. with orders for [MEDICATION NAME] nebulizer treatment up to 4 times a day and as needed, also placed on oxygen via nasal cannula at 2 liters, and [MEDICATION NAME]. Resident line list indicated Resident #9 with positive culture for Influenza B and pneumonia. Resident #9's care plan was reviewed. Infection control was not noted on the care plan and no mention of precautions that staff needed to take when working with Resident #9. Facility records for Resident #9 indicated she last received the [MEDICATION NAME] inactivated influenza vaccine (flu shot) on [DATE] and the pneumonia vaccination on [DATE]. Example #5: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's nursing notes were reviewed by Surveyor # which revealed the following: ~[DATE], resident noted with wheezing and fine crackles of upper lobe, left and right sided, and right lower lobe. ~[DATE], [MEDICATION NAME] treatment. ~[DATE], resident treated with [MEDICATION NAME] due to nursing home outbreak. ~[DATE] resident with non-productive cough. Resident #2's care plan was reviewed. Contact and droplet isolation was noted under self-care problem as of [DATE]. Facility records for Resident #2 indicated no record of when she last received the [MEDICATION NAME] inactivated influenza vaccine (flu shot). She received the pneumonia vaccination on [DATE]. On [DATE] at 8:40 a.m. upon initial tour of the facility, Surveyor # noted contact and droplet precautions at the doorway to Resident #2's room. On [DATE], the DON provided Surveyor # with a resident list indicating Resident #2 was on contact and droplet precautions for MRSA in wound and positive Influenza. On [DATE] at 10:15 a.m., Surveyor # observed CNA-B in room [ROOM NUMBER] taking Resident #2's blood pressure. CNA-B recorded information on a clipboard, proceeded to the sink, washed her hands and exited room [ROOM NUMBER]. CNA-B placed the blood pressure cuff in the isolation cart outside Resident #2's room. CNA-B did not have on a gown or gloves. After CNA-B exited room [ROOM NUMBER], she walked up the hallway and placed the clipboard at the nurses' station. Surveyor # interviewed CNA-B directly after the observation. Surveyor # asked CNA-B what PPE is required when assisting Resident #2. CNA-B responded, "It depends what you are going to do." Surveyor # asked CNA-B if direct contact with Resident #2 is made, what precautions needed to be followed. CNA-B responded if Resident #2 is coughing you would wear PPE for droplet precautions. Surveyor # asked CNA-B how can you anticipate when Resident #2 is going to cough. CNA-B responded, "I haven't heard her cough all morning." Surveyor # interviewed the DON on [DATE] at 10:25 a.m. Surveyor # asked the DON when droplet precautions are required. The DON explained with any transmittable or potentially transmittable illness or condition, you try to contain the transmission by wearing a mask and containing residents to their rooms. Surveyor # asked the DON when contact precautions are required. The DON indicated contact precautions being required as a barrier to include gowning, wearing gloves, removing PPE prior to exiting the room, and washing hands with soap and water. Surveyor # interviewed the LPN-C on [DATE] at 3:45 p.m. Surveyor # asked LPN-C to explain the process of staff taking resident vitals such as blood pressure. LPN-C explained staff take needed equipment to resident rooms along with a clipboard containing resident vital information. Staff proceed to take vitals, record vitals on the clipboard and then proceed to the next resident or return the information to the nurses' desk for nurse to have available. Surveyor # asked LPN-C if a resident is on precautions, is the process different. LPN-C responded residents should have their own equipment maintained in isolation carts outside their rooms and record the information outside the resident room. Example #6: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing notes were reviewed by Surveyor # which revealed the following: ~[DATE], healing abdominal wound, precautions droplet and contact due to fungal lung infection. Resident #3's care plan was reviewed. Contact and droplet isolation was noted under self-care problem as of [DATE]. On [DATE] at 8:40 a.m. upon initial tour of the facility, Surveyor # noted a sign for contact and droplet precautions at the doorway to Resident #3's room. On [DATE], the DON provided Surveyor # with a resident list indicating Resident #3 was on contact and droplet precautions for fungal lung infection. On [DATE] at 9:00 a.m., Surveyor # observed PT-D (Physical Therapist) ambulating with Resident #3 in the hallway outside the conference room/100 hall. Both PT-D and Resident #3 were wearing masks. PT-D returned to Resident #3's room and exited the room with a computer and paperwork in her hands. PT-D did not wash her hands prior to exiting the room. PT-D was not wearing a gown or gloves and did not use the alcohol-based hand gel on the isolation cart outside Resident #3's room. PT-D proceeded up the hallway to the therapy area, placing her computer and papers on a table. Surveyor # interviewed PT-D directly after the observation. Surveyor # asked PT-D what precautions are required when working with Resident #3. PT-D responded Resident #3 is on contact precautions related to abdominal incision. Surveyor # asked PT-D about hand washing requirements related to Resident #3. PT-D indicated she intended to wash her hands prior to contact with her next resident. On [DATE] at 10:15 a.m., Surveyor # again spoke with PT-D. PT-D indicated she had made a gross error in not following proper precautions when working with Resident #3 on [DATE]. PT-D indicated she failed to wear a gown, gloves and wash her hands prior to exiting Resident #3's room. PT-D further expressed she had misunderstood the information she was provided for Resident #3, and was under the assumption Resident #3 was on contact precautions due to abdominal wound, even though he had postings at his door for contact and droplet precautions. Surveyor # interviewed the DON on [DATE] at 10:25 a.m. Surveyor # asked the DON when droplet precautions are required. The DON explained with any transmittable or potentially transmittable illness or condition, to try and contain the transmission by wearing a mask and containing residents to their rooms. Surveyor # asked the DON when contact precautions are required. The DON indicated contact precautions being required as a barrier to include gowning, wearing gloves, removing PPE prior to exiting the room and washing hands with soap and water. The immediate jeopardy that began on [DATE] was removed on [DATE] by which time the facility had: ~Increased cleaning; ~Implemented outbreak precautions; ~Outbreak reported to local health department and Medical Director; ~Began to administer antivirals; ~Began and continued active surveillance; ~Began and continued facility-wide droplet precautions; ~Updated facility policy and procedure to reflect current standards of practice; ~Educated DON and NHA on ILI surveillance and control; ~Educated all staff on ILI surveillance and control; and ~Developed audit methods to ensure compliance to policy and procedure.