Every finding on record at Oak Park Place of Janesville

Based on interview and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (R33) reviewed for accidents out of a sample of 17 Residents. R33 received a laceration (that required 10 stitches) during a transfer that was done with 1 assist and R33 required 2 assist. This is evidenced by: The Facility's Policy and Procedure entitled Safe Lifting and Movement of Residents dated July 2017 documents in part: .3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. R33 was admitted to the facility on [DATE] with the following diagnoses: wedge compression fracture of third lumbar vertebra, restless leg syndrome, unspecified diastolic (congestive) heart failure, localized edema, cognitive communication deficit, difficulty in walking not elsewhere specified, need for assistance with personal care, and repeated falls.R33's comprehensive Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/8/26, documents R33 is cognitively intact, with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. R33's care plan documents in part: .Focus: Decreased ability to perform ADL's (Activities of Daily Living) related to compression fractures in lumbar spine/TLSO (thoracolumbosacral orthosis (back brace)) present.Transfer: ext (extensive) 2a (assist), 2WW (wheeled walker). Intervention implemented: 4/28/26. R33's progress notes documents in part: 6/21/26 21:30 (9:30 PM) Laceration to left lower leg U shaped with muscle and fatty tissue exposed. R33 was in wife's room sitting in her recliner. Was 2120 (9:20pm) and wife wanted to go to bed R33 was restless and was trying to get out of recliner. Call light on for staff [sic] get him into wheelchair to transport him to his room. CNA G (Certified Nursing Assistant) came into room. Said she would get him into bed. CNA G got resident.stood up no gait belt wife said R33's foot got caught behind smallwheel in back of foot pedal. R33 was placed in wheelchair and screamed. Call to room blood on floor lifted his pj bottoms and R33 had laceration R33's NP (Nurse Practitioner) called sent R33 to ER (emergency room) after 911 called called [sic] 6/22/26 06;07 (6:07 AM) Following an investigation of the incident, it was determined that the (CNA) instructed R33 that she would assist him in transferring to a wheelchair and accompany him back to his room since he was in his wife's room at the time. R33 was informed that she would return with a second staff member to provide additional assistance. However, he expressed that he would not wait and would transfer himself. At that moment, CNA G made the decision to assist R33 herself, as she believed that leaving the room to obtain a second staff member posed a greater risk of potential falls compared to the risks associated with assisting R33 alone. Following the incident, further education and training were proved to the CNA G to address the situation appropriately. [sic] Surveyor reviewed the Facility's investigation of the incident. The incident documents, in part: .R33 is care planned for 2 persons assist with transfers. R33 had attempted unsuccessfully to self-transfer from the recliner to his wheelchair. R33 put on the call light for assistance. When CNA G responded to the call light, CNA G explained to R33 that CNA G cannot transfer him safely on her own, CNA G will need to get a second staff to assist with transferring him. R33 said to CNA G that he is not waiting for her to get someone and will self-transfer. CNA G was not able to leave the room to get a second person to assist her with the transfer. R33 was at risk for falling if he self-transferred. CNA G made the decision to assist R33 to the wheelchair without the second person. In the process, R33 had sustained a laceration to his leg. Laceration measured 12 cm (centimeters), required 10 stitches. Investigation summary: R33 was in spouse's room. Spouse asked him to go back to his room so that she could go to sleep .CNA G had locked the brakes on the wheelchair and guided him to the wheelchair. As R33 got to the wheelchair, his foot got caught behind the small wheel in the back of the foot pedal. R33 sustained a laceration to his leg. CNA G sat him down on the wheelchair and yelled out for assistance. RN H (Registered Nurse) came to assist CNA G. RN H assessed resident and notified R33's NP (Nurse Practitioner). R33 was sent to the ER (Emergency Room) to be evaluated and treated for the laceration. R33 received stitches and was returned to the facility. CNA G's statement from Facility's investigation documents the following: R33 was in his wife's room. R33 call light was on, I went into the room. R33 was sitting in the recliner; he was trying to get up. I asked how I can help him, he said that he wanted to go back to his room so that his wife can sleep. I explained to him that I can help him, however, I need to get another staff member to help me transfer him. R33 said that he can't wait for another person, he wants to go. R33 said that he would get himself off up [sic] and in his wheelchair. I told him that its not safe for him to do that. I said to him again that let me get someone to help me transfer him so that he can be transferred safely. He wouldn't wait and I couldn't leave him. I was afraid, he may fall if he tries to get himself up. I made the judgement call to transfer R33 myself, its less of a risk that to leave the room and have him fall trying to get up and get into his wheelchair. I saw that he was struggling to stand so I asked him to put his arm around my shoulder so that he doesn't fall. He got to the wheelchair, and I noticed his foot was stuck behind the wheel. I sat him down in the wheelchair and helped fix his leg and I noticed blood on his pants, I called out to the nurse to come in to help. RN H came into room and looked at his leg and saw that he had a cut. I kept pressure on his leg while supplies were obtained to secure the wound. The wheelchair was moved out of the room and put away for maintenance to inspect. A different wheelchair was used to transfer him to his room. [sic] Surveyor reviewed the Facility's Disciplinary Action Form, dated 6/26/26, for CNA G, the staff that transferred R33 independently when R33 sustained a laceration requiring stitches. The form documents, in part: .Description of Infraction: Employee, in good faith, made error in discretion when she transferred a two person assist resident by herself from the recliner to the wheelchair. The incident resulted in bodily injury. Corrective Action: Employee is expected to reactivate pendant call to alert additional staff for assistance with two persons transfers. On 6/22/26 the Facility recognized the deficient practice and immediately implemented a corrective action plan as evidenced by:- All necessary notifications were made 6/21/26-6/22/26- Investigation initiated 6/22/26- R33's wheelchair was inspected by maintenance 6/22/26- CNA G received education on resident transfers and completed a skills checklist on resident transfers 6/22/26- Interviewed other staff 6/22/26- Interviewed other residents, no concerns noted 6/22/26- R33 had a Trauma History Evaluation completed 6/22/26- R33 had a Mood assessment completed (PHQ9) completed 6/22/26- R33 had a new BIMS completed= 12, 6/22/26- All wheelchairs were inspected 6/23/26- CNA G's personnel file was reviewed to include; CNA registry verified, background check, and orientation from hire 6/23/26- DON B (Director of Nursing) verified transfer status from the resident responses to each corresponding resident care plan 6/23/26.- All Nursing staff were provided education on transfer status 6/26/26- CNA G received disciplinary coaching 6/26/26 On 7/28/26 at 11:51 AM, Surveyor interviewed CNA C. Surveyor asked CNA C where you can verify a residents transfer status, CNA C said on the kardex, in the computer. Surveyor asked CNA C if a resident is a 2 assist to transfer, are you required to use 2 assist, CNA C stated yes. Surveyor asked CNA C if a resident is a 2 assist but is attempting to self-transfer, what is your best course of action, CNA C explained they'd try to talk to them, put call light on, holler if they know someone is in hall. Surveyor asked CNA C if they received any education on transfers recently, CNA C stated yes. On 7/28/26 at 12:36 PM, Surveyor interviewed CNA D. Surveyor asked CNA D where you can verify a residents transfer status, CNA D said on the kardex, labeled transfer. Surveyor asked CNA D if a resident is a 2 assist to transfer, are you required to use 2 assist, CNA D stated yes. Surveyor asked CNA D if a resident is a 2 assist but is attempting to self-transfer, what is your best course of action, CNA D explained they'd try to re-direct resident, look for help but keeping an eye on them. Surveyor asked CNA D if they received any education on transfers recently, CNA D stated yes. On 7/28/26 at 2:39 PM, Surveyor interviewed CNA E. Surveyor asked CNA E where can you verify a residents transfer status, CNA E said on the Kardex. Surveyor asked CNA E if a resident is a 2 assist to transfer, are you required to use 2 assist, CNA E stated yes. Surveyor asked CNA E if a resident is a 2 assist but is attempting to self-transfer, what is your best course of action, CNA E explained they'd try to report to nurse, if resident is determined that they need help right now, yell for help. Surveyor asked CNA E if they received any education on transfers recently, CNA E stated yes. On 7/28/26 at 3:30 PM, Surveyor interviewed DON B. Surveyor asked if CNA G should have transferred R33 with 2a, DON B stated yes however, R33 was attempting to get up on his own and she made the decision to stay with R33 and assist versus leaving him to fall and potentially be hurt worse. CNA G did not follow R33's care plan for 2 assist for transfers, and transferred R33 by herself, resulting in a laceration to R33's leg which required stitches.

Based on interview and record review the facility did not document grievance or document prompt efforts by the facility to resolve grievances for 1 of 1 Residents (R1) reviewed for grievances.R1's AHCPOA (Activated Health Care Power of Attorney) voiced concerns to the NHA (Nursing Home Administrator) via email communication. The facility failed to follow their grievance policy by thoroughly investigating, following up, and documenting the concerns and resolution.Evidenced by:The facility policy, Grievance Program, hand dated, 5/15/24, indicates, in part: .Process: 1. Grievances - grievances are formal written or verbal complaints made to the facility when prompt or bedside resolution to the satisfaction of the person making the objection was not possible.When there is a grievance, it will be: Documented on the facility Comment/Concern Forms. Routed to the Grievance official. Listed on the appropriate facility Tracking Log. Discussed with the appropriate individuals .as warranted. Investigated accordingly.The grievance written decisions will include the following: dates, summary statement of resident's grievance, correction actions as indicated, and the date that the written decision was issued to the person filing the grievance.R1 was admitted to the facility on [DATE] with diagnoses that include, in part: Cerebral infarction (stroke) without residual effects; Dysarthria and Anarthria (motor speech disorders caused by neurological damage).R1 was also admitted into hospice services on admission to facility.On 1/21/26 Surveyors reviewed email communications between NHA A (Nursing Home Administrator) and AHCPOA C that were provided by the facility. An email dated 12/3/25, from AHCPOA C to NHA A, noted the following list of concerns from AHCPOA C regarding R1:1. Wearing dirty clothes. 2. Laundry bag full. 3. Face not cleaned or shaven. 4. Right eye very red. - drops need to be given more than twice a day. 5. Upon my arrival at 10:30am my father was sitting unattended in the dining room. He needs to have a snack mid morning [sic] instead of dipping saltines in jelly. He was calling out for something to drink. Why is it so difficult to get a cup of coffee or juice for him? 6. No evidence of juice cups in his room. My dad is thirsty. 7. Eyeglasses in trash receptacle. 8. No hearing aids.Surveyor requested and reviewed the grievance log for the facility and did not locate a grievance for R1.On 1/21/26 at approximately 12:30 PM, Surveyors interviewed NHA A. During the interview NHA A indicated that if a grievance comes to her, she will initiate the grievance form, work through it to see what is needed, and follow-up with the person that brought the concern, whether resident or family, and give them the resolution. Surveyors reviewed the information from the email above with NHA A. NHA A indicated they had so many repetitive concerns she just started to think of this as just part of the day to day care of R1 and not as grievances and just addressed them as they came. NHA A indicated she did not complete a grievance, does not have documentation of an investigation into the concerns, follow-up for the items in the email or resolutions provided or accepted by AHCPOA C and should have.The facility did not follow their grievance process.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 24 of 25 residents. Surveyor observed staff going into the main kitchen and kitchenette without hairnets on. Surveyor observed food that had been removed from original containers and not labeled with a use by date. Surveyor observed a dented can to be in circulation. Surveyor observed food that was uncovered and/or not labeled in a kitchenette freezer and refrigerator. The freezer temperature in one of the kitchenettes is not being consistently monitored or recorded. Surveyor observed shelves with dried on substances, food particles, pieces of candy without wrappers, opened food without use by dates and expired food in circulation in the facility's kitchenette. Evidenced by: Example - Staff not wearing hairnets Facility policy entitled Hair Restraints with a revised date of 10/29/24 states, in part: .Hair must be pulled back and properly restrained when working with food. Hairnets or bouffant caps may be required for long or full fair not completely restrained by a hat . On 5/28/25 at 8:47 AM, Surveyor arrived to the main kitchen for the initial tour. During the start of the tour with Surveyor and DM N (Dietary Manager), RMD R (Regional Maintenance Director) walked into the kitchen without a hairnet to talk to DM N. Surveyor asked RMD R if he should have a hairnet on when in the kitchen and RMD R stated yes, he should. On 5/28/25 at 12:22 PM, during lunch meal observation, Surveyor observed DON B (Director of Nursing) enter the kitchenette attached to the Main Dining Room without a hairnet during the meal service. Surveyor interviewed DON B and asked if she would expect a hairnet to be worn in the kitchenette area. DON B indicated she would expect staff to wear a hairnet in the kitchenette if food is present. It is important to note food was being prepared by dietary staff and lunch was being served to the residents from the kitchenette area at the time DON B entered the kitchenette. Example - Unlabeled package of food Facility policy entitled, Food Labeling and Dating with a revised date of 11/27/24, states in part: .Oak Park Place uses a dating system to identify when foods must be consumed or discarded by indicating date of preparation, or date of first item used by date as indicated on WI Food Code .Dry food products will be labeled with delivery date unless it has an expiration date printed on the product . On 5/28/25 at 8:55 AM, during initial tour of the kitchen, Surveyor observed in dry food storage an opened package of granola that was removed from its original packaging and did not have a use by date. DM N (Dietary Manager) indicated food opened and/or removed from their original packaging should be labeled with a use by date. Example - Dented can in circulation On 5/28/25 at 9:00 AM, Surveyor and DM N observed a dented can of jellied cranberry sauce in the dry food storage area in circulation. DM N indicated the dented can should not be there, removed the can and labeled it to be returned. Example - Unlabeled, expired, and/or uncovered food in Kitchenette freezer and refrigerator Facility policy entitled, Food Brought to Residents from the Outside with a revised date of 10/9/24 states, in part: .Foods must be labeled with the resident's name and date .Foods not consumed within 3 days will be discarded .Any foods not labeled or dated will be discarded . On 5/28/25 at 3:55 PM, Surveyor toured the kitchenette at Creative Expressions 1 South, the kitchenette near the nurses station. Surveyor observed in the freezer an opened container of Blue Bunny ice cream without a name on it and 2 sundae cup plastic containers with an orange substance inside of them without lids, not covered, and not labeled. These containers had ice crystals formed on the top of the product inside. Surveyor observed in the kitchenette refrigerator the following: dried on purple substance on the inside on the bottom 2 shelves, 5 Styrofoam cups with green straws inside containing liquid without names or dates, a chocolate meal replacement shake with a best by date of 4/16/25, an opened bottle of Starbucks Frappuccino without a name on it, an unopened bottle of ginger ale without a name on it, and a container of food with a resident name on it and room number without a date. Of note, it was discovered during record review that the name on the container of food was a resident who discharged from the facility on 5/15/25. On 5/28/25 at 4:46 PM, Surveyor interviewed DC S (Dietary Cook) who was in the main kitchen and showed him the kitchenette. DC S indicated he was not sure who was responsible for cleaning that kitchenette and stated it should be added to a weekly checklist. DC S indicated the kitchenette should be cleaned and items needed to be taken care of. On 5/28/25 at 4:53 PM, Surveyor interviewed DON B and showed her the items in the kitchenette. DON B stated housekeeping cleans that room, but she is not sure who is responsible for cleaning the kitchenette cupboards and refrigerator. DON B indicated dietary and maintenance would share responsibility, maintenance oversees housekeeping and stated she would check to see who is responsible. DON B stated she would make sure that room and refrigerator got cleaned right away and discarded the expired and not labeled items. On 5/29/25 at 10:09 AM, Surveyor interviewed DM N about who was responsible for cleaning the kitchenette. DM N indicated he thought nursing staff cleaned that room, stated he has never looked at that refrigerator. DM N indicated there is no policy or procedure for cleaning this area and stated he would talk to nursing about coordinating a plan for monitoring and cleaning that kitchenette. Example - Kitchenette freezer temperatures not being consistently monitored and recorded On 5/28/25 around 4:00 PM, Surveyor observed the temperature logs for May 2025 for the refrigerator and freezer in the kitchenette Creative Expressions 1 South, the kitchenette by the nurses station. There are no freezer temperatures recorded for the month of May 2025. Surveyor also reviewed the temperature log for March and April and the month of April has 14 days of missing freezer temperatures. On 5/29/25 at 10:09 AM, Surveyor interviewed DM N about the freezer temperatures. DM N indicated dietary staff haven't been checking the temperatures of that freezer and will coordinate with nursing staff to ensure it gets monitored. Example - Unclean kitchenette cupboards with unlabeled and expired food in circulation Facility policy entitled, Food Labeling and Dating with a revised date of 11/27/24, states in part: .Oak Park Place uses a dating system to identify when foods must be consumed or discarded by indicating date of preparation, or date of first item used by date as indicated on WI Food Code .Dry food products will be labeled with delivery date unless it has an expiration date printed on the product . Facility policy entitled, Food Brought to Residents from the Outside with a revised date of 10/9/24 states, in part: .Foods must be labeled with the resident's name and date .Foods not consumed within 3 days will be discarded .Any foods not labeled or dated will be discarded . On 5/28/25 at 3:55 PM, Surveyor toured the kitchenette by the nurses station called Creative Expressions 1 South. In the cupboard above the microwave, Surveyor observed several Skittles candies scattered on the bottom shelf, a dried on brown substance on the bottom shelf, a bag of [NAME] brand sugar on the bottom shelf with a best by date of 9/5/23, opened without a name on it. Surveyor also observed an opened bottle of Hershey syrup without a name on it, opened bottle of red food coloring dated 1/25 with a best by date of 8/1/22. Surveyor observed in the cupboard between the sink and microwave an opened box of cream of wheat cereal with no name on it, an opened box of wheat crackers with a best by date of 2/14/25 and no name on it, and several crumbs on the shelves. On 5/28/25 at 4:46 PM, Surveyor interviewed DC S (Dietary Cook) who was in the main kitchen and showed him the kitchenette. DC S indicated he was not sure who was responsible for cleaning that kitchenette and stated it should be added to a weekly checklist. DC S indicated the kitchenette should be cleaned and items needed to be taken care of. On 5/28/25 at 4:53 PM, Surveyor interviewed DON B and showed her the items in the kitchenette. DON B stated housekeeping cleans that room, but she is not sure who is responsible for cleaning the kitchenette cupboards and refrigerator. DON B indicated dietary and maintenance would share responsibility, maintenance oversees housekeeping and stated she would check to see who is responsible. DON B stated she would make sure that room and cupboards got cleaned right away and discarded the expired and not labeled items. On 5/29/25 at 10:09 AM, Surveyor interviewed DM N about who was responsible for cleaning the kitchenette. DM N indicated he thought nursing staff cleaned that room. DM N indicated there is no policy or procedure for cleaning this area and stated he would talk to nursing about coordinating a plan for monitoring and cleaning that kitchenette.

Example 2 On 5/28/25 at 9:15 AM, Surveyor interviewed R73. Surveyor noted that R73's breakfast tray was on the bedside table and had plastic silverware and foam cups used for the beverages. Surveyor asked R73 if they are using plastic silverware for all meals, R73 stated that they are even using plastic silverware in the dining room because staff reported that they are unable to find regular silverware. Example 3 On 5/28/25 at 9:32 AM, Surveyor observed R1 in her room. Surveyor noted that R1's breakfast tray was on the bedside table. R1 was attempting to use plastic fork and knife to cut up her breakfast and was unsuccessful. Surveyor observed that all R1's beverages were in foam cups. Example 4 On 5/28/25 at 9:22 AM, Surveyor interviewed R13. Surveyor noted that R13 had used plastic silverware and foam cups during breakfast. Surveyor asked R13 if the facility always gives plastic silverware for meals, R13 stated that he is provided plastic silverware almost all the time. Surveyor asked R13 if the facility provides real cups and glasses for drinks, R13 reported that the drinks are almost always in foam cups.Example 5 On 5/28/25 at 10:40 AM, Surveyor observed R174 in his room. R174 had a Styrofoam cup with a straw in front of him on his bedside table. Example 6 On 5/28/25 at 11:50 AM, Surveyor observed residents in the dining room. The dining room tables were set with napkins, silverware and cups. Surveyor observed CNA K (Certified Nursing Assistant) passing drinks in the dining room. CNA K was using Styrofoam cups to give resident's their drinks. Surveyor observed DON B (Director of Nursing) provide a resident with a drink in a Styrofoam cup. R172 and R173 were in the dining room. R172 and R173 received their mealtime drink in a Styrofoam cup. Example 7 On 5/29/25 at 8:49 AM, Surveyor observed CNA K delivering meal trays down the hallway. CNA K provided plastic ware for utensils. There was no regular silverware on the meal tray cart. Example 8 R16 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, need for assistance with personal care, weakness, and other specified depressive episodes. R16's most recent Minimum Data Set (MDS), dated [DATE], states that R16 has a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating that R16 is cognitively intact. On 5/28/25 at 8:50 AM, Surveyor observed R16 eating breakfast in her room using plastic silverware. R16 stated that it can sometimes be hard to cup up a pancake or sausage using plastic silverware, and that she would prefer to be given real silverware, even when eating in her room. Example 9: R6 was admitted to the facility on [DATE] with diagnoses that include chronic pain syndrome, need for assistance with personal care, weakness, other specified anxiety disorders, and other specified depressive episodes. R6's most recent MDS, dated [DATE], states that R6 has a BIMS score of 15 out of 15, indicating that R6 is cognitively intact. On 5/28/25 at 12:16 PM, Surveyor observed R6 eating lunch in the dining room using a Styrofoam cup. On 5/28/25 at 2:24 PM, Surveyor interviewed R6 in her room about her dining preferences. R6 stated that sometimes they get regular cups, and she would prefer to use a regular cup instead of a Styrofoam cup. Example 10: R223 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder, recurrent, unspecified, Type 2 Diabetes Mellitus, and chronic pain. R223 had not had an MDS with BIMS completed at time of survey. On 5/28/25 at 12:16 PM, Surveyor observed R223 eating lunch in the dining room using a Styrofoam cup. On 5/28/25 at 2:26 PM, Surveyor interviewed R223 in her room about her dining preferences. R223 stated that yes, she would prefer to be served with a regular cup, and she didn't understand why they were giving them Styrofoam cups in the dining room. On 6/2/25 at 11:03 AM, Surveyor interviewed CNA M (Certified Nursing Assistant) and asked her why the residents were being served with Styrofoam cups in the dining room. CNA M stated that she didn't know why. Surveyor asked CNA M if she considered using Styrofoam cups in the dining room to be a dignified dining experience for the residents. CNA M stated she wasn't sure. Surveyor asked CNA M if she used Styrofoam cups at home. CNA M stated no, not usually. Based on observation, interview, and record review, the facility did not ensure residents were treated with dignity and respect in an environment that promotes an enhanced quality of life which affected 6 of 15 sampled Residents (R174, R1, R172, R13, R223, and R73), 3 of 5 supplemental Residents (R173, R16, and R6), and 1 of 1 dining room. Surveyors observed residents who were dining in the main dining room to have Styrofoam cups instead of regular glasses. Surveyors observed meal trays for residents dining in their rooms to contain plastic silverware instead of metal silverware and Styrofoam cups instead of regular glasses. R73 was observed using plastic silverware and foam cups while eating breakfast in her room. R1 was observed using plastic silverware and foam cups in her room while eating breakfast. R13 was observed having plastic silverware and foam cups in his room while eating breakfast. Surveyor observed R16 eating breakfast in her room using plastic silverware. Surveyor observed R6 eating lunch in the dining room using a Styrofoam cup. Surveyor observed R223 eating lunch in the dining room using a Styrofoam cup. R174 were observed with a Styrofoam cup. R172 and R173 were observed in the dining room using Styrofoam cups. Evidenced by: The facility's policy entitled Resident Rights last revised on 2/2021 states in part, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . Example 1 On 05/28/25 at 11:51 AM, Surveyors were making an observation of the lunch meal in the main dining room. Surveyor noted staff to be serving residents drinks using Styrofoam cups instead of regular glasses for cold drinks. On 6/2/25 at 10:02 AM, Surveyor interviewed DM N (Dietary Manager) and asked about residents using Styrofoam cups and plastic silverware on room trays and residents using Styrofoam cups in the main dining room. DM N indicated he doesn't know why staff would be giving residents disposable glasses and silverware. DM N stated facility has plenty of regular glasses and silverware. On 6/2/25 at 10:37 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) about staff using Styrofoam cups and plastic silverware for meals. CNA D indicated they don't have enough regular cups or silverware for all of the residents. CNA D indicated they start with regular cups and silverware, then switch to disposable when they run out. CNA D stated she always tells the kitchen manager whenever they don't have enough silverware or cups. CNA D indicated she most recently told DM about running out of regular silverware on 6/1/25. On 6/2/25 at 10:45 AM, Surveyor interviewed DON B (Director of Nursing) about staff using disposable cups and silverware for meals. DON B indicated they usually use regular cups and silverware, when they run out, they use disposable cups and silverware. On 6/3/25 at 7:55 AM, Surveyor interviewed RDM O (Regional Dietary Manager) and NHA A (Nursing Home Administrator) about the facility use of Styrofoam cups and plastic silverware for meals. Both indicated they have a backup supply of silverware in DM N's file cabinet in his office and they have extra regular cups in a storage room in the basement. RDM O stated DM N put more silverware in circulation the previous week and indicated staff should have enough silverware and regular cups for the residents. Surveyor asked RDM O if staff have ever told her they didn't have enough cups or silverware. RDM O stated no one has told her but she observed, about 2 months ago, staff using plastic silverware at a meal service and asked staff why they were using plastic silverware. RDM O indicated they told her they ran out of regular silverware. RDM O doesn't recall the staff person's name who she asked. RDM O stated she ordered more silverware on 4/3/25 to replenish the backup supply and put the backup supply in circulation at that time. On 6/3/25 at 8:00 AM, Surveyor observed boxes of extra silverware in DM N's file cabinet. On 6/3/25 at 8:05 AM, Surveyor asked RDM O what their process is for getting dishware and utensils to the dining room for meals and room trays. RDM O explained a Dietary Aide (DA) or CNA (Certified Nursing Assistant) brings dirty carts down to the kitchen. RDM O stated Dietary staff brings up the clean dishes on the dining carts and Dietary staff stock dining carts with the number of dishes/utensils that were brought down on the carts when dirty. RDM O stated they don't count if they have enough silverware and dishware before bringing the carts upstairs. RDM O and NHA A both indicated they should start counting to make sure they have enough on the carts for all the residents. RDM O stated she will order more silverware again now to have a bigger backup supply. NHA A indicated she would make sure they take out more regular glasses from storage and put them in circulation

Based on observation, interview, and record review, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 4 of 12 sampled residents (R12, R172, R223, and R224) and 2 supplemental residents (R5 and R171). R5, R171, and R172's room were not clean. Surveyor observed R12's bed to be unmade, dust bunnies under the bed, and flakes of debris on the floor near the wall. Surveyor observed R223's bed to be unmade and garbage can to be full. Surveyor observed the bed unmade, dust bunnies under the bed, a garbage can overflowing with a glove on the floor, and dried stool on the back of the toilet seat. This is evidenced by: The facility's policy titled Cleaning and Disinfection of Environmental Surfaces, dated 8/19, includes the following: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. Example 1 On 5/28/25 at 9:00 AM, Surveyor observed R5's room. R5 was not in her room. R5's bed was not made. There was a mechanical lift next to R5's bed. A soft blue boot was on the floor near the dresser, with a plastic cap near the boot. The trash can was overflowing with trash and an Ensure drink container was next to the trash can. There were crumbs and dark colored flakes scattered throughout the room on the floor. Under the bed there was a plastic drink lid with a straw through it, a dirty napkin crumpled up, and a clump of dust. The pillow did not have a pillowcase on it. In the bathroom, the trash bag was on the floor with a soiled adult depends. There was a used glove on the floor near the trash bag. At 9:31 AM, Surveyor returned to R5's room. The room was unchanged. On 5/28/25 at 9:35 AM, Surveyor interviewed PT L (Physical Therapist). PT L was bringing R5 back to her room. PT L indicated the room was not clean nor homelike. PT L indicated when she sees a room like this, she will stop and clean it up. On 5/28/25 at 9:40 AM, Surveyor interviewed RN F (Registered Nurse) regarding R5's room. RN F indicated the room is not clean nor homelike. On 5/28/25 at 10:30 AM, Surveyor interviewed R5 regarding her room. R5 indicated her room was a mess. R5 stated she liked her room clean and feel the staff should clean her room. On 5/29/25 at 8:22 AM, Surveyor observed R5's room. Under R5's bed, the plastic drink lid with a straw through it, the dirty napkin that was crumpled up, and the clump of dust, was still there. The crumbs and dark colored flakes were still scattered throughout the room on the floor. On 5/29/25 at 8:26 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) regarding R5's room. CNA D indicated R5's room is not clean. On 5/29/25 at 8:40 AM, Surveyor interviewed HK J (Housekeeper) regarding the schedule of cleaning rooms. HK J indicated she had last cleaned R5's room on 5/25/25. Example 2 On 5/29/25 at 8:19 AM, Surveyor observed R171's room. Surveyor observed a dirty depends in a garbage bag sitting on top of a meal tray lid on a pillow in R171's chair. There was a dirty glove next to the trash can on the floor. Surveyor observed a package of incontinent wipes with the lid left open on R171's over-bed table. The inside of the wipes had a brown substance smeared on it. On 5/29/25 at 8:26 AM, Surveyor interviewed CNA D regarding R171's room. CNA D indicated the brown substance was likely feces. CNA D indicated R171's room was not clean nor homelike. Example 3 On 5/29/25 at 8:22 AM, Surveyor observed R172's room. R172's room had a scrap of paper on the floor near her bed, a plastic wrapper on the floor near the dresser and a cluster of rubber bands in the middle of the floor. On 5/29/25 at 8:26 AM, Surveyor interviewed CNA D regarding R172's room. CNA D indicated R172's room is not homelike nor clean. On 5/29/25 at 8:31 AM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R5, R171, and R172's rooms. NHA A indicated the rooms would not be considered clean. On 5/29/25 at 8:37 AM, Surveyor interviewed HKS I (Housekeeping Supervisor) regarding the cleaning of rooms. HKS I indicated the rooms are not clean. HKS I indicated the housekeeping staff does not have a schedule in place for when rooms are to be cleaned nor do they have a system in place for documenting when rooms are cleaned. Example 4: R12 was admitted to the facility on [DATE] with diagnoses that include hypertension, need for assistance with personal care, muscle weakness, and difficulty walking. R12's most recent Minimum Data Set (MDS), dated [DATE], states that R12 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating that R12 is cognitively intact. On 5/28/25 at 9:52 AM, Surveyor observed R12 in her room with her bed unmade, dust bunnies under the bed, and flakes of debris on the floor near the wall. R12 indicated that she has to ask housekeeping if she wants to get her room cleaned. R12 stated that one month they did not come in and clean at all. R12 stated that there had been dried skin all over the floor from having her cast removed, and spilled soda that stayed on the floor for three weeks. R12 indicated that she asked HK C (Housekeeper) and he came and cleaned her room, even though he was not assigned to clean the rooms on her hall. R12 stated that she felt embarrassed because she liked to have visitors and didn't want them to see her room dirty. Example 5: R223 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder, recurrent, unspecified, Type 2 Diabetes Mellitus, and chronic pain. R223 had not had an MDS with BIMS completed at time of survey. On 5/28/25 at 11:35 AM, Surveyor observed R223 in her room with the bed unmade and the garbage can full. R223 stated that she has to ask staff to clean her room and make her bed. R223 indicated that every once in awhile the staff will come into the room while she is at lunch and take out the garbage but not make the bed. R223 stated she had never had her sheets changed, and that it would be nice to have clean sheets after taking a shower. R223 stated that it feels like the staff at the facility just don't care. R223 stated that the housekeeper would leave a note on the bulletin board with her name and the date of the last time she cleaned the room. Surveyor observed a note on R223's bulletin board that stated, HK J (Housekeeper) 5/25/25, indicating this was the last time the room had been cleaned. Example 6: R224 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus, muscle weakness, need for assistance with personal cares, repeated falls, and malignant tumor of kidney. R224's most recent MDS, dated [DATE], states that R224 has a BIMS score of 11 out of 15, indicating that R224 has mild cognitive impairment. On 5/28/25 at 11:46 AM, Surveyor observed R224's bed unmade, dust bunnies under the bed, a garbage can overflowing with a glove on the floor, and dried stool on the back of the toilet seat. R224 indicated that his room had never been cleaned since he was admitted . On 5/29/25 at 10:36 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) about the cleanliness of the rooms. CNA D stated that she has seen the housekeepers clean the rooms, but she was not sure how often each room got cleaned. Surveyor and CNA D went to R224's room and looked at the toilet seat. The dried stool had been cleaned off, but the toilet seat was stained a dark orange in places. CNA D stated that she has seen the housekeepers try to clean R224's toilet seat, but that it was stained from R224's frequent diarrhea. On 5/29/25 at 10:48 AM, Surveyor interviewed HK C and asked him how often each resident's room was cleaned. HK C stated that it would depend on how busy they were and if they were short staffed. HK C indicated that he tries to clean each resident's room at least every other day. Surveyor asked HK C if he had noticed the stains on R224's toilet seat. HK C indicated that R224's room was not normally on his hall to clean, but that yes, he had seen the stains on the toilet seat. Surveyor asked HK C how long it would take stool to stain a white toilet seat like R224's. HK C stated that he wasn't sure, but that if it was cleaned up right away then it wouldn't cause the toilet seat to stain like that.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (R1) reviewed for hospice. R1 was receiving hospice services, and the facility failed to obtain hospice documentation. Evidenced by: The facility policy titled Hospice Program revised date 7/2017 states in part .12. Our facility has designated (Name) (Title) to coordinate care provided to the resident by our facility staff and the hospice staff .He or she is responsible for the following: .d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election form; (3) Physician certification and recertification of the terminal illness specific to each resident .13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well- being .15. The coordinated care plan shall be revised and updated as necessary to reflect the resident's current status including, but not limited to: a. diagnosis; b. problem list; c. symptom management *pain, nausea, vomiting, etc.); d. bowel and bladder care; e. nutrition and hydration needs; f. oral health; g. skin integrity; h. spiritual, activity, and psychosocial needs; and i. mobility and positioning . R1 was admitted to the facility on [DATE] with diagnoses that include anxiety disorder, major depressive disorder, and acute on chronic heart failure. R1's most recent MDS (Minimum Date Set) dated 3/29/25 states that R1 has a BIMS (Brief Interview of Mental Status) of 8 out of 15, indicating that R1 has moderate cognitive impairment. The MDS also indicates that R1 is dependent on staff for transfers and toilet hygiene and requires substantial assist with personal hygiene, dressing, and bed mobility. R1 was receiving hospice services prior to admitting to the facility and received orders for hospice services on the day of admission. R1's hospice diagnosis is acute on chronic heart failure with preserved ejection fraction (Heart failure occurs when your heart doesn't pump enough blood to meet your body's needs or when the heart doesn't relax enough and pressures inside the chambers can rise. This can cause fatigue, breathing difficulties, and fluid buildup in your tissues). Surveyor reviewed R1's EHR (Electronic Health Record) and was not able to find any documentation of R1's hospice enrollment, admission assessment, care plan, orders, or visit notes. Additionally, the facility did not have their own care plan for R1 being on hospice. On 5/29/25 at 10:36 AM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F how staff was made aware that a resident is receiving hospice services, RN F stated that when they open the resident list, it will show who is on hospice. Surveyor asked RN F where they find the hospice care plan and visit notes, RN F stated that the care plan and visit notes are faxed to the facility and then scanned into the resident's EHR under the misc. (miscellaneous) tab. Surveyor and RN F reviewed R1's EHR for hospice care plan and visit notes, as well as the facility's care plan for hospice. RN F reported that there was only 1 hospice note dated 3/23/25 scanned into the system, and that she was unable to locate the hospice care plan. Surveyor asked RN F if there was a hospice care plan in the facility's care plan, RN F stated no. On 5/29/25 at 11:33 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how staff is made aware that a resident is receiving hospice services, DON B stated that the hospice provided communicates with the staff every day they come in. Surveyor asked where staff would be able to find documentation of the hospice visit, DON B stated it would be under the misc. tab. Surveyor asked where staff would find the hospice plan of care, DON B states that the residents receiving hospice services have binders on the unit with the hospice documentation. Surveyor requested R1's hospice plan of care and visit notes. DON B provided documentation that was printed on 5/29/25 at 12:52 PM. On 6/2/25 at 12:52 PM, Surveyor interviewed DON B. Surveyor asked DON B if facility staff should have had access to R1's hospice documentation prior to 5/29/25, DON B reported that she had just thinned R1's binder and sent the information via the cloud and then IT (Information Technology) scans it into the resident's EHR. Surveyor asked DON B if the facility has a care plan addressing hospice for R1, DON B stated yes. It is important to note that the facility initiated a hospice care plan for R1 on 5/29/25. On 6/2/25 at 3:05 PM Surveyor interviewed Hospice RN Q. Surveyor asked Hospice RN Q what the process is when visiting a resident in the facility, Hospice RN Q stated that R1 is visited weekly, he performs an assessment, manages symptoms, and adjusts the care plan based on the assessment. Surveyor asked Hospice RN Q how the documentation gets to the facility, Hospice RN Q reported that they do not fax visit notes, but will send an email with updates or orders, but if he went for a routine visit, he wouldn't fax anything. Surveyor asked Hospice RN Q if they had ever faxed a care plan to the facility, Hospice RN Q stated that they were asked for the care plan and the last 3 months of visit notes last week.

Based on interview and record review, the facility did not develop a discharge plan for 1 of 3 residents (R13) reviewed for discharge planning. R13 does not have a discharge care plan, nor has he had a care conference to discuss his discharge goals. Evidenced by: The facility's policy titled Care Plans, Comprehensive Person- Centered revised 12/2016 states in part .4. Each resident's comprehensive care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process .e. participate in establishing the expected goals and outcomes of care .5. The resident will be informed of his or her right to participate in his or her own treatment . R13 was admitted to the facility on [DATE] with diagnoses that include paraplegia (paralysis of the legs and lower body), anxiety disorder, PTSD (Post Traumatic Stress Disorder), and recurrent depressive disorders. R13's most recent MDS (Minimum Data Set) dated 3/28/25 states that R13 has a BIMS (Brief Interview of Mental Status) of 14 out of 15, indicating that R13 is cognitively intact. R13 is his own decision maker. Surveyor reviewed R13's medical record and found no documentation regarding R13 having a care conference or a care plan regarding discharge. On 5/28/25 at 9:22 AM, Surveyor interviewed R13. Surveyor asked R13 if the facility has discussed discharge planning with him, R13 stated that he knows that he needs more therapy, but no one has spoken with him regarding discharge planning. Surveyor asked R13 if he has participated in a care conference, R13 stated no. On 6/2/25 at 9:08 AM, Surveyor interviewed SW U (Social Worker). Surveyor asked SW U what the process is for discharge planning, SW U stated that they typically set up a care conference on admission within 5-7 days to meet with the resident and their family to discuss goals. Another meeting would be set up 1-2 weeks later to determine if DME (Durable Medical Equipment) would be needed, schedule any appointments needed, and determine what supports are in place for the resident. Surveyor asked SW U if residents should have a care plan in place regarding their discharge plan and goals, SW U stated yes. Surveyor asked SW U where care conferences are documented, SW U reported that they are documented under the assessments tab. Surveyor and SW U reviewed R13's medical record for documentation of care conferences, as well as a discharge care plan. Surveyor asked SW U if R13 should have a care plan in place regarding discharge, SW U stated yes. Surveyor asked if R13 should have had a care conference, SW U stated yes.

Based on observation, interview and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services for 2 of 2 residents (R1 and R174) reviewed for catheters. R1 had a catheter placed without an appropriate diagnosis and does not have a care plan for the catheter. R174's catheter bag was uncovered and viewable from the hallway. Evidenced by: The facility's policy titled Indwelling Catheter Evaluation/ Removal revised on 6/27/16 states in part Policy: It is the policy of [Facility Name] to ensure that residents receive care and services to prevent the use of an indwelling catheter, unless clinically necessary .4. When there is not supporting diagnosis for the use of the indwelling urinary catheter, the nurse will obtain an order from the physician or physician extender to remove. Example 1 R1 was admitted to the facility on [DATE] with diagnoses that include anxiety disorder, major depressive disorder, and acute on chronic heart failure. R1's most recent MDS (Minimum Date Set) dated 3/29/25 states that R1 has a BIMS (Brief Interview of Mental Status) of 8 out of 15, indicating that R1 has moderate cognitive impairment. The MDS also indicates that R1 is dependent on staff for transfers and toilet hygiene and requires substantial assist with personal hygiene, dressing, and bed mobility. R1's physician orders are as follows: 1/28/25: Catheter (indwelling) (16) French, with (10cc (cubic centimeter)) balloon, inflate to continuous drainage for diagnosis of (hospice/ comfort) change PRN (as needed) for blockage or unable to be flushed. As needed for catheter change PRN if dislodged or occluded. Of note, R1 does not have a care plan for the indwelling urinary catheter. On 5/29/25 at 11:39 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the diagnosis was for R1's catheter, DON B stated that she would have to look. Surveyor asked DON B if she would expect a resident with a catheter to have a care plan for it, DON B stated yes. On 6/2/25 at 12:52 PM, Surveyor interviewed DON B. Surveyor asked DON B what the rationale is for R1's catheter, DON B stated that R1 is on hospice, and it is for comfort. Surveyor asked if the facility documentation of the rationale and diagnosis for the catheter, DON B stated that it was in the hospice notes. Example 2 R174 admitted to the facility on [DATE] with a foley catheter. R174's care plan includes position catheter bag and tubing below the level of the bladder and away from entrance room door or cover for privacy. On 5/29/25 at 10:08 AM, Surveyor observed R174's catheter bag hanging on the bed frame, facing the door and was visible from the hallway. R174's catheter bag was not covered. On 5/29/25 at 10:35 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) regarding R174's catheter. CNA D indicated she had just been in R174's room providing personal cares with R174. CNA D indicated she hung the catheter bag on the bed frame. CNA D indicated she did not cover the catheter bag, nor did she place the bag away from the entrance room door. On 5/29/25 at 11:42 AM, Surveyor interviewed DON B (Director of Nursing) regarding R174's catheter. DON B indicated the catheter bag should be covered. DON B indicated R174's care plan intervention should be followed. DON B indicated R174's catheter bag should have been covered or placed away from the entrance room door.

Based on record review and interview, the facility did not ensure 1 of 1 resident (R13) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. R13 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions. This is evidenced by: The facility's policy titled Trauma- Informed and Culturally Competent Care revised 8/2022 states in part .Resident Assessment: 1. Assessment involves an in- depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. 2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. 3. Use assessment tools that are facility approved and specific to the resident population. Resident Care Planning: 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re- traumatize the resident. 3. Recognize the relationship between past trauma and current health concerns . R13 was admitted to the facility on [DATE] with diagnoses that include paraplegia (paralysis of the legs and lower body), anxiety disorder, PTSD (Post Traumatic Stress Disorder), and recurrent depressive disorders. R13's most recent MDS (Minimum Data Set) dated 3/28/25 states that R13 has a BIMS (Brief Interview of Mental Status) of 14 out of 15, indicating that R13 is cognitively intact. R13's MDS Section D indicates that R13 will sometimes socially isolate. Surveyor reviewed R13's care plan and there was not a care plan addressing R13's diagnosis of PTSD. Surveyor reviewed R13's Social Service Trauma History Evaluation dated 3/21/25. The assessment states in part .C .5. As a child or teenager, were you ever physically beaten or physically abused by siblings, relatives, or peers? A. yes . It is important to note that the assessment has 6 sections, some sections have several questions. R13's assessment only has 2 sections that are completely filled out. On 6/2/25 at 9:08 AM, Surveyor interviewed SW U (Social Worker). Surveyor asked SW U what the process is for residents that are admitted with a diagnosis of PTSD, SW U reported that they will complete a trauma assessment and identify any abuse, bullying, or history of trauma. Surveyor asked SW U if a resident with a diagnosis of PTSD should have a trauma assessment completed in its entirety, SW U stated yes. Surveyor asked SW U if a resident with the diagnosis of PTSD should have a care plan that addresses the resident's trauma, triggers, and interventions, SW U stated yes. Surveyor reviewed R13's care plan and SW U reported that R13 does not have a care plan that addresses his PTSD diagnosis.

Based on observation, interview and record review the facility did not ensure that all drugs and biologicals used in the facility were labeled with an open date or expiration date in 1 of 1 medication rooms. The facility failed to ensure an open vial of tuberculin solution located in the medication room contained an open date and/or expiration date. Evidenced by: The facility's policy titled Medication Labeling and Storage dated 2/2023 states in part .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date. On 6/2/25 at 2:11 PM Surveyor and RN P (Registered Nurse) went to the medication room. Surveyor observed an open vial of Tuberculin solution in the refrigerator, in a bag without an open date or expiration date. Surveyor interviewed RN P. Surveyor asked RN P if the medication vial should be dated. RN P responded yes, and I might as well throw it out if not dated. Surveyor asked RN P whose responsibility is it to make sure medications are dated. RN P indicated that everyone is responsible. On 6/2/25 2:19 PM Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she was aware of the TB solution that was in medication room with no open date or expiration date. DON B replied she thought that most of the Tuberculin vials are single use vials. On 6/2/25 2:25 PM Surveyor called the pharmacy that the facility uses. Surveyor talked to PA T (Pharmacy Assistant). Surveyor asked PA T if Tuberculin vials came in single dose use. PA T replied all Tuberculin vials they have are multi dose vials.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 of 2 resident (R4 and R174) with observed breeches in transmission-based precautions. Staff entered R174, who is COVID-19 positive, without proper personal protective equipment (PPE). Surveyor observed staff perform tracheostomy care on R4 without proper hand hygiene and not using enhanced barrier precautions. This is evidenced by: The facility's policy titled Isolation - Categories of Transmission-Based Precautions, dated 9/22, includes the following: 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and the on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC (Center for Disease Control) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. The facility's policy titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment, dated 9/22, includes the following: 4. When caring for a resident with suspected or confirmed SARS-CoV-2 infection: a. Personnel who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection adhere to standard precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. The facility's policy entitled Enhanced Barrier Precautions dated 8/2022 states, in part: .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs (Enhanced Barrier Precautions) include: g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) .10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE (Personal Protective Equipment) required . The facility's policy entitled Handwashing/Hand Hygiene date revised 8/2019 states, in part: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: e. Before and after handling an invasive device .m. After removing gloves . Example 1 R174 admitted to the facility on [DATE] with a diagnosis of COVID-19. R174's physician orders include Isolation - single room droplet precautions with a start date of 5/23/25. On 5/28/29 at 9:30 AM, Surveyor observed droplet precaution signage and a bin for PPE outside R174's door. On 5/29/25 at 9:06 AM, Surveyor observed LPN H (Licensed Practical Nurse) in R174's room. LPN H was not wearing a mask, gown, gloves, or eye protection. Surveyor immediately interviewed LPN H. LPN H indicated R174 has COVID-19 and is on droplet precautions. LPN H indicated she should have worn the appropriate PPE when entering R174's room and did not. On 5/29/25 at 11:42 AM, Surveyor interviewed DON B (Director of Nursing) regarding R174's COVID-19 status and isolation requirements. DON B indicated staff should wear proper PPE when entering a COVID-19 positive room. DON B was made aware of Surveyor's observation of LPN H not wearing any PPE when in R174's room. DON B indicated LPN H should have worn the proper PPE. On 5/29/25 at 12:59 PM, Surveyor interviewed ADON E (Assistant Director of Nursing) regarding precautions and PPE. ADON E indicated she is the facility's infection preventionist. ADON E indicated staff should wear the proper PPE based on the resident's transmission-based precautions. Example 2 The facility's policy entitled Enhanced Barrier Precautions dated 8/2022 states, in part: .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs (Enhanced Barrier Precautions) include: g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) .10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE (Personal Protective Equipment) required . The facility's policy entitled Handwashing/Hand Hygiene date revised 8/2019 states, in part: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: e. Before and after handling an invasive device .m. After removing gloves . R4's physician orders include, in part: . Trach care: Inner cannula cleaning to be done daily, using trach care kit. Step by step directions are in his room for guidance. Ensure skin around trach is clean and checked daily. Change drain sponge daily. Change trach ties weekly or as needed. One time a day for Trach care . On 5/28/25 at 9:41 AM, during screening, Surveyor observed a sign outside of door and a cart indicating R4 is on enhanced barrier precautions and staff should wear a gown and gloves for direct care activities. On 5/29/25 at 12:42 PM, Surveyor observed RN F (Registered Nurse) perform tracheostomy care for R4. Surveyor observed the following: RN F performed hand hygiene. RN F set up the tracheostomy care supplies in R4's room with bare hands. RN F then donned gloves but did not don a gown. RN F removed R4's old tracheostomy tubing then removed her gloves, did not perform hand hygiene, and donned new gloves. RN F inserted a new trach tube. RN F removed her gloves, did not perform hand hygiene, and donned new gloves. RN F finished tracheostomy care. RN F removed her gloves then performed hand hygiene. On 5/29/25 at 12:56 PM, Surveyor interviewed RN F regarding hand hygiene during tracheostomy care. RN F indicated she did not perform hand hygiene after removing her gloves during care. RN F indicated hand hygiene should be done immediately after removing gloves and she did not. Surveyor also interviewed RN F about enhanced barrier precautions for R4. RN F indicated she should have worn a gown and gloves for the tracheostomy care and did not. On 5/29/25 around 1:00 PM, Surveyor interviewed ADON E (Assistant Director of Nursing) regarding hand hygiene during wound care. Surveyor reviewed the observations made during RN F's performance of tracheostomy care for R4. Surveyor asked ADON E if she would expect hand hygiene to be completed after removing gloves and ADON E indicated hand hygiene should have been completed each time after RN F removed her gloves. ADON E also indicated enhanced barrier precautions should have been implemented for R4's tracheostomy care.

Based on interview and record review, the facility did not ensure a thorough investigation of abuse was completed for 4 of 5 Residents (R1, R2, R3, and R4) reviewed for abuse. On 4/17/25, the facility became aware of an injury of unknown origin (IUO) for R1. The facility did not complete a thorough investigation regarding this IUO. On 2/17/25, R2 notified the facility of staff being rough with cares and feels she is being neglected. The facility did not complete a thorough investigation for R2's concerns. On 1/29/25, R3 had a verbal altercation with her family member. The facility did not thoroughly investigate this altercation. R4 verablized staff did not provide desired care the facility did not complete a thorough investigation. This is evidenced by: The facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, states, in part: Policy: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from . verbal, mental, sexual or physical abuse . Policy Interpretation and Implementation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members . i. visitors; and/or j. any other individual . 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements . The facility policy titled, Abuse Policy, dated 6/18/18, states, in part: . 10. The facility will identify and investigate all suspicion of or allegation of abuse (such as suspicious bruising of residents); review the occurrence and identify patterns and trends that may constitute abuse and that will be used to determine the direction of the investigation . Example 1: R1 was admitted to the facility on [DATE], with diagnoses that include, in part: cerebral infarction (stroke), difficulty in walking, cognitive communication deficit, type 2 diabetes, essential tremor, congestive heart failure, and muscle weakness. R1's most recent Quarterly Minimum Data Set (MDS), with Assessment Reference Date of 1/9/25, states that R1 has a BIMS (Brief Interview for Mental Status) of 5 out of 15, indicating that R1 is severely cognitively impaired. R1's Physician Orders indicate, in part: Aricept (Medication that improves nerve cell function) Tablet 5 MG (Donepezil HCl) Give 1 tablet by mouth at bedtime for Aphasia (Difficulty comprehending or formulating language following damage to the brain). Start Date: 3/27/25. Appointment: Neurology. Date: 4/8/25. Time: 1:00 PM . (Of note: R1 did not have a physician order for a urinary catheter). R1's Comprehensive Care Plan indicates, in part: Focus: R1 has impaired visual function r/t (related to) age related vision loss. She wears glasses and wears appropriately, able to maneuver environment. Date Initiated: 3/14/25. Interventions/Tasks Ensure appropriate visual aids (glasses) are available to support participation in ADL's (Activities of Daily Living). Date Initiated: 3/14/25. On 4/3/25, a document titled, Skin Observation Weekly - V 2 was made effective. This document states, no new skin concerns. No wounds, lacerations, tears, or bruising noted on this document. On 4/8/25 at 12:36 PM, a Progress Note is written that states, in part: Pt (patient) was picked up by [Facility Name] transport to take to her 1:00pm appointment . Leaving in good condition. On 4/8/25 at 1:46 PM, a document titled, After Visit Summary was printed from a Neurology appointment. This document indicates the resident was seen for a Hospital Follow-up. On 4/8/25 at 2:32 PM, a Progress Note is written that states, in part: Pt returned with [Facility Name] transport driver in good condition. Received AVS (After Visit Summary) . Surveyor provided with a document titled, Driver Daily Ride Manifest for Appointments, dated 4/8/25, that indicates R1 left the facility at 12:30 PM for her Neurology Appointment. Drop Off time is indicated to be 12:40 PM. The document does not indicate when R1 was picked up from her appointment, however R1's AVS was printed at 1:46 PM. R1 is then documented to be dropped off at 3:00 PM (Of note: Surveyor utilized a program to estimate the drive time from the facility to the clinic office, which was estimated to take 10 minutes. This time is reflected in the document with a leave time of 12:30 PM and a drop off time of 12:40 PM. However, R1's AVS was printed at 1:46 PM. (AVS is a document printed just prior to a patient leaving an appointment and contains a summary of the appointment). Drop off time for this resident is indicated to be 3:00 PM. Utilizing a pick-up time of 2:00 PM, this is a transport time difference of 50 minutes between the transport to the facility and transport back to the facility. (Of note: This time difference was not noted in the facility's investigation). R1's Medication Administration Record indicates in April 2025, R1's pain ranged from 0-3 until 4/10/25. On this date, R1 reports pain of 10 out of 10, 6 out of 10, and 6 out of 10. (Of note: This information does not appear in the facility's investigation). On 4/10/25 at 17:45 (5:45 PM), an ED (Emergency Department) Nursing Note is written that states, Pure wick applied per request of patient. (Of note: A pure wick is an external urinary device that allows patients to urinate without getting out of bed. No part of this device is inserted into the patient.) On 4/11/25, a Hospitalist Note is written by a Nurse Practitioner that states, in part: .Labial (external structures of female genitalia) bruising with vaginal tears - Noted with straight cath (catheter) 4/11. Patient denies sexual activity or abuse. Discussed with aHCPOA (Activated Healthcare Power of Attorney), declined SANE (Sexual Assault Nurse Examiner) exam or further intervention. Social work to notify APS (Adult Protective Services) of concerns . (Of note: Records indicate these injuries were observed prior to any external device insertion by hospital staff. Additionally, R1 did not have orders for a urinary catheter at the facility.) The facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, was initially sent to the State Survey Agency on 4/17/25 at 2:43 PM. This document notes that R1 is alleged to have an injury of unknown source, that was discovered while R1 was admitted to the hospital. The injury was reported to the facility on [DATE] by a police officer investigating the concern. NHA A (Nursing Home Administrator) reported to the State Survey Agency and initiated an investigation following notification. Under the section titled, EXPLAIN what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct ., it states, in part: The Director of nursing has initiated education regarding catheterization catheter care. Abuse could not be substantiated. [Resident Name] was admitted to the hospital on 04/10/2025 and injury was not noted by the hospital until 04/11/2025. This is not a criminal investigation, and no concerns have been brought to the attention of the facility by the resident or her family . This document indicates the report was submitted by NHA A on 4/21/25 at 1:49 PM. On 4/23/25, Surveyor reviewed the facility's investigation file for R1's injury of unknown origin. A document titled, Investigative Summary, is included in the file that describes the facility's notification of the injury, police case number, and the overall summary of the investigation. Also included were staff interviews from nursing, dietary, therapy, and maintenance employees, including DR D (Driver). DR D confirms he transported R1 to her appointment on 4/8/25, and reports the transport was without incident and was a very brief trip, and that he denies misconduct of any type with R1. The education included in the file was on Catheter Care which included a sign-in sheet including six CNA's (Certified Nursing Assistants) and one RN (Registered Nurse). Two documents titled, Catheter Care Competency Check-Off were reviewed, and were found to be signed and dated by staff but not filled out as to whether staff passed or failed each skill check. On 4/23/25, Surveyor requested all documentation related to resident skin checks following the report of an injury of unknown origin. Surveyor was provided with documentation for six residents out of a census of 22 on 4/23/24. Of the six residents, three were completed on 4/17/24, three were completed on 4/18/24, and R6's skin check was not completed until 4/20/24. Surveyor also notes R6 has a BIMS of 3 out of 10, which indicates severe cognitive impairment. On 4/23/25 R 2:05 PM, Surveyor interviewed NHA A (Nursing Home Administrator) DON B(Director of Nursing), and RN C (Regional Nurse). Surveyor asked NHA A what she understood regarding R1's injury of unknown origin. NHA A indicates a police officer came to the facility and reported he was conducting a non-criminal investigation into an injury reported to the police department by the hospital. The police officer was provided with all requested documentation regarding DR D. NHA A then initiated a self-report and her investigation. Surveyor asked should skin checks be conducted on all residents following possible abuse/injury of unknown origin. DON B indicates staff does skin checks with showers, during cares, and before leaving for an appointment as well as DON B conducting weekly skin checks. DON B also indicates she went room to room on 4/17/25 to interview residents but didn't do skin evaluations on residents who are alert. Surveyor asked DON B if the alert residents should have been asked about completing a skin assessment. DON B said no, because they are alert so it would be inappropriate to ask. Surveyor asked NHA A when she would expect these skin assessments to be conducted. NHA A indicates, right away. Surveyor asked if education should have been conducted regarding abuse and injuries of unknown origin. DON B indicates that she does not believe the injury occurred in the facility after reading the report so she assumed it could be from catheter care since R1 is elderly with fragile skin. Surveyor asked DON B if she was aware that R1's neurology appointment had been cancelled prior to 4/8/25. NHA A and DON B indicate, no. Surveyor asked what the expectations are for drivers. DON B indicates she expects drivers to be competent to drive the van, secure residents in the van, and if there is some kind of issue, they should call the facility to let us know. Surveyor asked NHA A if she would expect a driver to call her if transport was going to take longer than expected. NHA A indicates, yes. Surveyor asked NHA A if drivers undergo any training from the facility. NHA indicates staff are provided with a lot of education but does not know the specifics about drivers. Surveyor asked NHA A if she would expect the drivers to have training and competency checks. NHA A indicates, yes. Surveyor asked RN C if they noticed the time differences in the transportation log from 4/8/24. RN C indicates they did not. Surveyor showed NHA A, DON B, and RN C the transportation log, and asked specifically about the 50-minute time difference in transport times. RN C proposes it may have been due to DR D having multiple appointments around that time but did not know for sure. Surveyor asked NHA A if their vans have GPS units or dash cameras. NHA A indicates, no. Surveyor asked NHA A if any contracted staff, such as agency or hospice nurses, were interviewed regarding this injury of unknown origin. NHA A indicates that one of the staff interviewed was agency staff, but no hospice nurses were interviewed. 41788 Example 2 R4 was admitted to the facility on [DATE] and has diagnoses that include cellulitis of left lower limb (potentially serious skin infection) and acute respiratory failure (occurs when the lungs can't properly exchange gases, causing abnormal levels of carbon dioxide and/or oxygen in the arteries). R4's Admission Minimum Data Set (MDS) Assessment, dated 1/8/25, shows R4 has a Brief Interview of Mental Status score of 14 indicating R4 is cognitively intact. R4's Physician Orders, dated 1/25/25 include: -Pain monitoring every shift using 1-10 narrative or FACE scale. Resident Pain Goal is: (4) every shift for pain. Order Date: 1/03/25. Start Date: 1/03/25. -Acetaminophen ER (extended release) Oral Tablet Extended Release 650 mg (milligrams)- Give 2 tablets by mouth every 4 hours as needed. May give for mild to moderate pain/fever do not exceed more than 4000 mg/day of all acetaminophen containing products. Order Date: 1/16/25. Start Date: 1/16/25 . -Oxycodone HCI (hydrochloride) oral tablet 5 mg- Give 2.5mg by mouth every 12 hours as needed for pain management/severe pain until 2/16/25 23:59. Order Date: 1/16/25. Start Date: 1/16/25 . R4's care plan dated 1/04/25, states, in part: . Focus: R4 has acute pain r/t (related to) left lateral lower extremity hematoma. Date Initiated: 1/04/25. Goal: R4 will voice a level of comfort of 3 out of 10 through the review date. Date Initiated: 1/04/25. Interventions/Tasks: -Anticipate the resident's needs for pain relief and respond as quickly as possible to any complaint of pain. Date Initiated: 1/04/25 . R4's Resident's Rights Concern/Grievance Report, dated 1/30/25, states, in part: . Date: 1/30/25 Time the concern was reported: 10 am initiated/completed 11:00am . Give a Detailed Description of the Concern: Over pm (1/29- 9pm-1 am) pt. was requesting pain meds but did not receive. Pt placed call light on again, but hadn't been answered, Staff would come in, turn off and leave. Pt began yelling for help and hitting flashlight against bed for help- staff then closed resident's door and pulled the curtain- as she was still waiting for assist/meds. Pt reports calling son around 1am- tearful and upset. Date and Time Incident Occurred: 1/29/25 pm approx. 9pm. Does the person initiating the concern feel they are being abused or neglected? If yes, notify NHA (Nursing Home Administrator) or supervisor immediately. Yes What was done immediately after learning of concern? Assisted pt. with current needs and filled out grievance. Brought to manager for follow up . What system or procedure was implemented to resolve this concern and to prevent further similar concerns? Employee was identified and terminated . Facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report states, in part: Summary of Incident: Allegation Type- Neglect: Intentionally withholding care, disregard of policy or care plan . Date Discovered: 1/30/25 . Brief Summary of Incident: A SNF (skilled nursing facility) resident . made an allegation of neglect regarding care provided . Report Submitted Date: 1/30/25 1:38:18 PM . The facility's Misconduct Incident Report, dated 2/6/25, states. In part: . Summary of Incident: Date Discovered: 1/30/25 Briefly describe the incident . R4 verbalized a concern towards an agency nurse during the NOC shift 1/30/25. She was asking for pain medications. She stated the staff came and turned her call light off and did not return. R4 verbalized to the Regional Nurse she did not want that nurse taking care of her. Describe the effect that the incident had on the affected person . R4 was not happy with the interaction with this nurse. She did not sustain a change of condition from this interaction. Review of her MAR confirms she received her lidocaine patch and extended-release acetaminophen for pain. When Administration followed up with her she did not feel abused or neglected. She did feel that the response from the nurse was poor customer service. R4 is happy and feels that her needs are being met. Explain what steps the entity took upon learning of the incident to protect the affected person and others from further potential misconduct . 1. The facility contacted clipboard agency and request the agency nurse not to return as a contracted worker at Oak Park Place Janesville. 2. Regional Nurse followed up with her daily for psycho-social support and she was happy with the follow up . Report Submitted Date: 2/6/25 9:28:21 PM. Of Note: There is no documentation of other residents being interviewed regarding concerns of missed medications/cares, education provided to staff, or documentation of Regional Nurse's daily follow ups with R4. On 4/23/25, at 2:05 PM, Surveyor interviewed RN C (Regional Nurse), NHA A (Nursing Home Administrator) and DON B (Director of Nursing) on the Facility Self Report regarding R4, dated 1/30/25. Surveyor asked RN C if he was familiar with this Facility Self Report and RN C indicated yes. Surveyor asked RN C if he felt this was a thorough investigation and RN C indicated yes. Surveyor asked RN C if other residents were interviewed regarding missed medications or cares. RN C indicated he remembers interviewing other residents but is unable to locate them. Surveyor asked RN C if education was provided to staff regarding the concern and RN C indicated yes but is unable to locate the documentation. RN C indicated the interview with the agency nurse was completed. RN C indicated the nurse interview is unable to be located as well. RN C indicates the prior NHA may have taken the documentation or placed it somewhere they are unable to locate. RN C indicated he remembered interviewing R4 and R4's family and both had no further concerns and indicated they were happy with the outcome of the investigation. Surveyor asked without the supporting documentation would this Facility Self Report be considered a thorough investigation. RN C indicated no. Surveyor asked RN C if the supporting documentation should be with the investigation and RN C indicated yes. 49436 Example 3 The facility submitted a self-report to the state on 2/17/25 regarding R2. On 4/23/25, Surveyor requested the entire self-report regarding R2. NHA A (Nursing Home Administrator) indicated the file handed to the surveyor was the completed investigation for R2's report of neglect and rough care. The facility's Misconduct Incident Report, dated 2/17/25, includes the following: R2 made an allegation of general neglect. She was unable to pinpoint a specific staff member, but did feel that her needs are not being met and she feels isolated, especially during the NOC (night) shift. OT E's (Occupational Therapist) written statement states in whole: On 2/17/25, R2 and daughter-in-law presented concerns regarding her recent care. R2 expressed frustration with long call light wait times and rushed care when care is provided. When caregivers do not answer her call light, she feels ignored, isolated, forgotten and neglected. Stated last night she slept with a light on in her room because a caregiver forgot to turn the light off and then did not come back to check on her. Feels there needs to be more caregivers checking on her at night, so this does not happen again. States there is mistreatment by a certain caregiver, name unknown, who is not friendly, often barks orders at her, and handles her roughly during cares. This writer listened to all of R2's concerns and assisted R2 and [Daughter-in-law] to fill out a concern report for further investigation and resolution. When asked if she feels she is abused or neglected, R2 affirms she feels she is being neglected and doesn't want this to happen to others. Resident's Rights Concerns/Grievance Report reviewed. The Resident's Rights Concerns/Grievance Report is not completed. The form includes the following: Date 2/17/25 11:00 AM. Give a detailed description of the concern: Timing of response to call lights. Pt (R2) feels isolated when they do not answer call light. A caregiver (name unknown) barks commands and is rough during care. Do not fell she is being checked on enough at night. Does the person initiating the concern feel they are being abused or neglected? If yes, notify NHA (Nursing Home Administrator) or supervisor immediately: Y is circled. Feels she is being neglected. Grievance Confirmed: Blank What was done immediately after learning of the concern? Blank Date Manager Submitted form to Responsible Manager: Blank Manager Responsible for Concern: Blank What system or procedure was implemented to resolve this concern to prevent further similar concerns: Blank The resident/family/person initiating the concern must be contacted to inform of the concern follow-up and their satisfaction with the resolution: Blank CNA F's (Certified Nursing Assistant) written statement includes: Upon arrival this am 2/17/2025 at 6:30 AM CNA answered call light in room [R2]. Upon walking into the room call light was in reach of resident, door was open and resident appeared disoriented to time place and surroundings and was trying to sit up on the edge of the bed naked. Orientated to self only. CNA reorientated resident assisted into w/c (wheelchair) and bathroom washed up, dressed and got ready for breakfast. After reorientating resident appeared to be more orientated to situation but not fully orientating to time place and surroundings, Resident did not mention any foul play had gone on or that she needed anything when asked. Of note, the facility's investigation does not include other resident interviews, staff interviews, education, or in-services provided to staff. On 4/23/25 at 2:05 PM, Surveyors interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RN C (Regional Nurse) regarding the facility's investigation of R2's concerns of neglect and rough care. Surveyor asked if the facility could produce documentation of an investigation, interviews of residents and staff, skin assessments, or education. All three indicated the facility does not have any further documentation regarding this concern and stated the facility's investigation of R2's concerns is not a thorough investigation. Example 4 The facility submitted a self-report on 1/29/25 regarding R3. On 4/23/25, Surveyor requested the report the facility submitted to the state regarding R3. Surveyor was provided a file that contained only the Misconduct Incident Report. The facility's Misconduct Incident Report, dated 1/29/25, states in part: Administration was contacted regarding a family member speaking loudly towards a resident. When administration came to the room the sister/POA (Power of Attorney) was speaking loudly in a negative tone towards the resident. The resident did appear in distress. The POA was escorted off the premises immediately and P.D (Police Department), Adult Protective Services, and the Regional Ombudsman were notified. The facility has begun an investigation. On 4/23/25 at 2:05 PM, Surveyors interviewed NHA A (Nursing Home Administrator), DON B (Director of Nursing), and RN C (Regional Nurse) regarding the facility's investigation of R3. Surveyor asked for documentation of an investigation, interviews of residents and staff, skin assessments, education, or training to staff on how to handle disruptive visitors. NHA A, DON B, and RN C indicated there is no documentation of the investigation, interviews, skin assessments, psychosocial assessment and stated the facility's investigation of R3's incident is not a thorough investigation.

Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of three residents (R3 and R1) of 8 sampled residents. The facility failed to assess and monitor R3's diuretic medication and provide supplemental medication to prevent critical laboratory values which caused R3 to be hospitalized due to the critically low blood levels. In addition, the facility failed to monitor and document R1 and R3's physician ordered weights. These failures placed the residents at increased risk of health complications and hospitalization . R3 is being cited at severity level 3 (actual harm). R1 is being cited at severity level 2 (potential for more than minimal harm). Findings include: Review of the facility's policy and procedure titled, Weighing and Measuring the Patient, dated March 2011, revealed .The purposes of this procedure are to determine the resident's weight and height to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition . Example 1 Review of R3's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included congestive heart failure. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/27/24 revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R15 was cognitively intact and always continent of bowel and bladder. Review of the Special Instructions banner located across the bottom of the undated Face Sheet in the EMR, revealed .Acutely decompensated HF [heart failure-a serious medical condition that occurs when the heart can't pump blood effectively, causing a sudden or gradual worsening of heart failure symptoms] DAILY WEIGHT, LE [lower extremity] edema .Fluid restriction 2L [liters] per day . Review of the Discharge Summary, dated 11/22/24 and located in the Miscellaneous tab of the EMR revealed that R3 had been admitted to the hospital with several days of increased swelling in his lower legs which made it difficult for him to walk. He was sent to the hospital for evaluation and treatment which found that he had decompensated HF [heart failure]. R3 was discharged to the nursing facility with a physician order for Furosemide (a loop diuretic medication which cause the kidneys to excrete potassium and sodium) 40 mg twice daily. According to the National Library of Medicine dated 03/06/19 and located at doi:10.1152/ajprenal.00614.2018 titled, Potassium-sparing effects in mice on high potassium diets, revealed .Loop diuretics, such as furosemide, are widely used to reduce fluid overload in patients and are well known for their renal K [potassium]-wasting effects that often produce hypokalemia [low potassium levels] .K wasting results from inhibition of Na [sodium] reabsorption . According tothe National Library of Medicine dated 5/22/23 and located at https://www.ncbi.nlm.nih.gov/books/NBK546656 /Adverse Effects: Adverse effects for loops diuretics typically occur from electrolyte imbalances secondary to the diuresis effects, which include: hyponatremia (low sodium) hypokalemia (low potassium) .Monitoring: Prescribers must be cautious when it comes to dosing to achieve diuresis. A black box warning states each loop diuretic is a potent diuretic and, at higher dosages, could lead to a profound diuresis with water and electrolyte depletion. Careful medical supervision is necessary as adjustments to these drugs should be according to the patient's needs. Electrolyte disturbances, including hyponatremia, hypokalemia . can lead to serious cardiac arrhythmias (fatal heart rhythms). Electrolytes require monitoring periodically to assess diuretic tolerance. According to Drugs.com dated 10/4/23 and found at https://www.drugs.com/sfx/furosemide-side-effects.html. Furosemide is a loop diuretic used to treat fluid retention (edema) in people with congestive heart failure .Furosemide may cause other serious side effects. Side effects signs of an electrolyte imbalance - increased thirst or urination, constipation, muscle weakness, leg cramps, numbness or tingling, feeling jittery, fluttering in your chest. Dosing Information Usual Adult Dose for Edema associated with Congestive Heart Failure: Oral: Initial dose: 20 to 80 mg orally once; may repeat with the same dose or increase by 20 or 40 mg no sooner than 6 to 8 hours after the previous dose until the desired diuretic effect has been obtained. Maintenance dose: Administer the dose that provided the desired diuretic effect once or twice a day (e.g., at 8 am and 2 pm). Comments:Edema may be most efficiently and safely mobilized by giving this drug on 2 to 4 consecutive days each week. When doses greater than 80 mg/day are given for prolonged periods of time, careful clinical observation and laboratory monitoring are particularly advisable. Furosemide works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention and helps lower high blood pressure. Furosemide tablets are sometimes called water pills as they increase how much you urinate. Review of the November 2024 Medication Administration Record (MAR) located in the Orders tab of the EMR, revealed Furosemide 40mg [milligrams] twice daily. Start date: 11/23/24 and discontinued date of 01/07/25. It should be noted R3 was not on potassium supplementation despite being on 40 milligrams of Furosemide BID. Facility staff should have calrified orders for labratory electrolyte monitoring frequency with the physician based on R3's Furosemide dosage. It should be noted the facility was not monitoring R3's labs despite R3 receiving 40 milligrams of Furosemide BID. Progress note dated 12/11/2024 at 10:56 PM, states in part: Late entry. Note text: PC (Per Call) to (NP1), NP1 explained the symptoms patient was experiencing, fatigue, confusion, eating with a straw, urinating frequently and large amounts of incontinence when usually continent. Orders for UA and labwork were recevied. Review of the Laboratory Values, dated 12/12/24 and located in the Results tab of the EMR, revealed Sodium (Na) 118 [normal values 136-145] and Potassium (K+) 2.4 [normal values 3.5-5.1] R3 was transferred to the hospital due to the critically low lab values. Of note, the critically low lab levels are a direct result from being on Furosemide a loop diuretic which will cause potassium and sodium to be excreted through the kidneys. Facility staff should have known the side effects of Furosemide and clarified whether R3 should have been on a potassium supplement and how frequently they should monitor labs as a result of receiving 40 milligrams of Furosemide twice a day. During a follow-up interview on 01/09/24 at 4:00 PM, the DON was asked why the blood work was done on 12/12/24. The DON stated, [R3] is on routine psychotropic medications and his CSP requires this for monitoring purposes. Actually, the bloodwork was to have been done on 12/08/24 or 12/09/24. However, the requisition was found in a pharmacy drawer, along with other orders on 12/12/24, when the bloodwork was done. Review of the Discharge Transfer Orders, dated 12/17/24 and located in the Miscellaneous tab of the EMR, revealed Stop taking Furosemide 40mg. In addition, the Discharge Transfer Order included Daily weights. Review of the December 2024 MAR located in the Orders tab of the EMR, revealed the Furosemide 40 mg twice daily continued and was not discontinued per the physician order. Review of the Physician Visit Note, dated 12/26/24 and located in the Miscellaneous tab of the EMR, revealed Heart failure .furosemide previously, discontinued in the hospital due to hyponatremia .Resume Lasix 20mg daily and check BMP [basic metabolic panel] in 1 week. During an interview on 01/09/24 at 3:01 PM, the Assistant Director of Nursing (ADON) stated, I am responsible to do admission and review the transfer orders. I will have to look into why the Lasix was not discontinued on 12/17/24, per the transfer order. During a follow-up interview on 01/09/24 at 4:00 PM, the DON stated, On 12/17/24, when [R3] was readmitted to the facility, the ADON had a personal issue going on and after she did the admission, she went home with the transfer orders so they couldn't be put into the system. When she did this, there was no second check of the orders, so the stopping of the Lasix was not found, and he continued on the Lasix 40 mg BID. The DON was asked about the Physician Note, dated 12/26/24 where he indicated that the Lasix was to be restarted at 20mg q day and why this order was not processed. The DON stated, It was missed. The physician reviewed R3's medication list on [hospital electronic medical record] which showed the discontinued Lasix. However, he did not review the facility medication list which would have shown that the Lasix had continued at 40mg twice daily. Review of the Laboratory Values, dated 01/03/25 and located in the Results tab of the EMR, revealed Sodium 132 and Potassium 2.2. The Nurse Practitioner (NP1) was notified of the critical potassium level. Review of the Nursing Progress Notes, dated 01/03/25 and located in the Progress Notes tab of the EMR, revealed .Lab with critical test results of Potassium = 2.2 (critical low). PC [per call] to NP1. Orders received to start potassium tonight, hold tomorrow [01/04/25] 0800 [8:00 AM] dose of Lasix and get a BMP on Monday 1/6/25 to reassess . Review of the Telephone Orders located in the Miscellaneous tab of the EMR, revealed the following Physician Orders. Potassium Chloride ER [extended release] 20 MEQ [milliequivalents] give one tablet four times a day on 01/04/25 and then give 20 MEQ three times a day until 01/06/25. In addition, the order stated, BMP must be drawn on 01/06/25 and Furosemide (Lasix) 40mg twice daily. Review of the 01/06/25 Laboratory Values, dated 01/06/25 and located in the Miscellaneous tab of the EMR, revealed Sodium 134 and Potassium 2.9. Review of the current Order Summary located in the Orders tab of the EMR, revealed an 01/08/25 Physician order for Furosemide (Lasix) 40mg daily and a BMP to be drawn on 01/09/25. During an interview on 01/09/25 at 1:32 PM, R3 stated, I am feeling better now. R3 was asked if he remembered why he was sent to the hospital. R3 stated, My CHF [congestive heart failure]. R3 was asked if they were weighing him daily. R3 stated, No, I am not getting weighed every day, they miss days. Review of the Weights and Vitals tab in the EMR revealed the following dates that R3 had no documented weights, per the Physician Orders. -For November 2024: 11/23/24, 11/24/24, 11/25/24, 11/27/2. -For December 2024: 12/02/24, 12/05/24, 12/06/24, 12/07/24, 12/08/24, 12/09/24, 12/10/24, 12/11/24, 12/18/24, 12/19/24, 12/20/24, 12/25/24, 12/26/24, 12/29/24. -For January 2025: 01/01/25, 01/02/25, 01/06/25, 01/07/25, and 01/08/25. During an interview on 01/09/25 at 2:40 PM, the Director of Nursing (DON) stated, I know the CNA [Certified Nurse Aide] does them [weights] and she gives them to the nurse however, the nurse does not always finish her charting. The DON confirmed that the daily weights need to be entered into the EMR daily. Example 2 Review of R1's Admission Record located in the Profile tab of the EMR revealed R1 was admitted to the facility on [DATE] with diagnoses of T-cell lymphoma (a rare form of cancer), skin cancer, and diabetes. Review of the admission MDS located in the MDS tab of the EMR with and ARD of 10/29/24 revealed that R1 had a BIMS score of 14 out of 15 which indicated R1 was cognitively intact. Review of a Physician Order, dated 10/25/24 and located in the Orders tab of the EMR, revealed .Weight daily x 3 days, weekly x 4 weeks, then monthly . Review of the Weights and Vitals tab of the EMR revealed the following dates that weights were obtained and documented by nursing staff. 10/30/24: 183.6 and 10/26/24: 181.0. R1 had been discharged to the hospital on 11/18/24. Are R1 missed roughly 4 scheduled weights according to physician orders. R1 missed 2 daily weights and 2 weekly weights. During an interview on 01/09/25 at 2:40 PM the DON stated I know the CNA (Certified Nursing Assistant) does them [weights] and then gives them to the nurse however, the nurse does not always finish her charting. The nurses may put them on the daily assignment sheet, but my expectation is they are documented as having been done in the EMR. Cross-reference: F725: Sufficient Staffing.

Based on interviews, record review, and document review, the facility failed to ensure sufficient nurse staffing to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents and/or representatives (R8), Family Member (FM1) FM2, and FM3 out of a census of 20 residents. Findings include: 1. Review of the Facility Assessment, provided by the Administrator, revealed the assessment was updated on 08/24/24. The total number of beds available was 35. The average daily census was 19 for short-stay residents and zero for long-term residents. The average number of residents that were admitted to the facility per day was one to two on weekdays and zero to one on the weekends. The average number of resident discharges was zero to one per day. In addition, the Facility Assessment revealed that there are six full-time Registered Nurses (RN)s, three full-time Licensed Practical Nurses (LPN)s and 25 full-time Certified Nurse Aide (CNA) positions available. Based on condition/acuity, and census the following was the number of staff necessary for care of the residents: one Nurse Manager on the first shift; one RN/LPN on each shift and on weekends/holidays; and one to three CNAs on first and second shift and one to two CNAs on the third shift. In addition, there were one to three CNAs on the weekends. 2. Review of the Nurse Staffing Schedule provided by Human Resources (HR) revealed the following staffing from 01/09/25 to 01/11/25: a. 01/09/25: First Shift (6:00 AM to 2:00 PM): one RN for eight hours and two CNAs for eight hours. One CNA, who was scheduled but called off and did not work. Second Shift (2:00 PM to 10:00 PM): One RN for four hours and one LPN for four hours. There were three CNAs for eight hours. Third Shift (10:00 PM to 6:00 AM): One LPN for eight hours, one CMT (Certified Medication Technician) and one CNA for eight hours. b. 01/10/25: First shift: one RN for eight hours; one staffing agency LPN for eight hours due to the regularly scheduled LPN having called off, and two CNAs as the third CNA did not show up for work. Second shift: One staffing agency LPN for four hours. There was no RN or LPN identified to have worked from 6:00 PM to 10:00 PM. There were two CNAs for eight hours. Third shift: No RN or LPN was identified to have worked in the skilled unit from 10:00 PM to 6:00 AM. There was one CMT for eight hours and one CNA for eight hours. c. 01/11/25: First shift: One staffing agency RN for eight hours and two CNAs for eight hours. One CNA had called off and did not work. Second shift: One staffing agency RN for four hours, one staffing agency LPN for four hours and three CNAs for eight hours. Third shift: one staffing agency LPN for eight hours, one CMT for eight hours, and one CNA for eight hours. 3. During an observation and interview on 01/11/25 at 9:45 AM, the call light was observed to have been activated. R8 was asked why she turned on her call light. R8 stated, I need to go to the bathroom. R8 was asked if her call light was answered timely. R8 stated, No, it does take a long time, but they do work their butts off, but it does take a long time. During a continuous observation of R8's call light response time, the light was answered in 22 min. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 11/19/24 revealed R8 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated she was cognitively intact. 4. During an interview on 01/09/25 at 1:27 PM, FM1 stated, After dinner and up to around 8:00 PM, there just isn't enough staff. Sometimes it takes up to 45 minutes to get assistance to use the toilet. During an interview on 01/10/25 at 1:10 PM, FM2 was asked if there was enough staff to meet R5's needs. FM2 stated, No, there isn't. Call lights are not answered timely, and he ends up wetting himself because it's taken too long. During an interview on 01/11/25 at 9:25 AM, FM3 stated, There are so many call lights going on during the night and the CNAs are working like crazy to get them answered, but there isn't enough staff. 5. During an interview on 01/10/25 at 1:29 PM, CNA1 was asked if there were enough staff to care for the residents. CNA1 stated, No, there isn't. CNA1 further stated, We are only two CNAs today but was supposed to have three. We have to answer the call lights first, get the showers done, make sure everyone is fed, there just isn't enough time. During an interview on 01/10/25 at 2:15 PM, the Occupational Therapist (OT) was asked if she felt there was enough staff to meet the needs of the residents. The OT stated, These residents are in a state of transition from being in the hospital and their needs can be much. No, I think they could use more help. During an interview on 01/10/25 at 2:43 PM, the Assistant Director of Nursing (ADON) was asked if she felt there was enough staff to meet the needs of the residents. The ADON stated, I agree, there just isn't enough staff for the residents. During an interview on 01/11/25 at 9:54 AM, Registered Nurse 2 (RN-staffing agency) stated, I have only worked here one other time. RN2 was asked if she helped answer call lights. RN2 stated, No, I don't have time as I am too busy with passing medications and doing treatments. During an interview on 01/11/25 at 10:05 AM, CNA2 stated, I work in the Memory Care Unit but was pulled down to the skilled area today. CNA2 was asked how she got everything done when there were only two CNAs working. CNA2 stated, We just try and go with flow. I have a pager and when I hear the call light go off, I will try and answer it. During an interview on 01/11/25 at 10:10 AM, CNA3 was asked if she felt there was enough staff to meet the needs of the residents. CNA3 stated, We just try and make sure everyone is fed, toileted, their beds are made, and the call lights are answered, it's a lot of work. CNA3 was asked if she worked in the skilled area regularly. She stated, No, I was pulled from the Assisted Living area to work here today. During an interview on 01/10/24 at 4:00 PM, the Administrator and Regional Clinical Nurse were asked if there was enough staff to meet the residents' needs. The Administrator stated, Our staffing numbers exceed the State of Wisconsin minimum requirements. The Regional Nurse then stated, It appears that we are not utilizing the staff effectively. Cross-reference: F677: ADL's (activities of daily living) for dependent residents.

Based on interview and record review, the facility failed to ensure a hospital transfer was documented in the medical record and appropriate information was communicated to the receiving hospital for 1 of 1 resident (R1) of eight sample residents. Findings include: Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses that included T-cell lymphoma (a rare type of cancer), skin cancer, and diabetes. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/29/24 revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R1 was cognitively intact and had no skin issues. Review of the Communication with Physician (non-COC-change of condition), dated 11/18/24 and located in the Progress Notes tab of the EMR, revealed [R1] continues to have generalized weakness and is failure to thrive . The physician feels that there is no more we can do for [R1] here aside from the suggestion of hospice. [R1] is not eating or drinking well, his skin is worsening .The physician suggest which (sic) is to get [R1] to the hospital for diagnostic and lab testing and from there [Name] (clinic) could send a helicopter to take him to Rochester, MN as this would be the best way for [R1] to comfortably travel this distance in his current condition . Review of the discharge-return anticipated MDS located in the MDS tab of the EMR with an ARD of 11/18/24 revealed, R1 had the following documented pressure ulcers: One Stage 4 pressure ulcer (full thickness tissue loss extending to the muscle, tendon, or bone) to the sacrum, one unstageable pressure ulcer to the scrotum (full-thickness pressure injuries in which the base (of the ulcer) is obscured by necrotic tissue (dead cells) and one deep tissue injury (a soft tissue injury) to his heels. Review of a Nursing Progress Note, dated 11/19/24 and located in the Progress Notes tab of the EMR, revealed .Received call from [Name] clinic informing writer that resident was admitted to [Name of Clinic] with Septic Shock [a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection] . Review of the SNF/NF [skilled nursing facility/nursing facility] to Hospital Transfer Form, provided by the Regional Clinical Nurse, dated 11/18/24, revealed the following information to the receiving hospital was left blank regarding R1's condition upon discharge: 1. Who was notified of the transfer and if they were aware of the clinical condition. 2. Respiratory status. 3. Skin/wound care. 4. Rehabilitation Therapy. In addition, the Transfer Form did not contain information that was to be sent with R1 to the hospital to include: 1. A face sheet (includes R1 demographic information). 2. Personal Belongings identified on the resident. 3. Current medication list. 4. Advanced Directive (living will or power of attorney). 5. Advanced Care Orders (code status). 6. Most recent History and Physical. 7. Any recent hospital discharges. 8. Recent MD/NP orders. 9. Flow sheets to include diabetic and wound care. 10. Relevant x-ray results. During an interview on 01/11/25 at 12:17 PM, the Regional Clinical Nurse stated, The transfer form to the hospital was not completely filled out including the wounds. My expectation would be that the entire form was filled out when a resident was transferred to the hospital.

Based on observations, interviews, record review, and review of the facility procedure, the facility failed to ensure activities of daily living (ADLs) were provided according to the plan of care for 1 of 3 residents (R5) of 8 sampled residents. Findings include: Review of the facility's procedure titled, Bath Tub/Shower, dated 2001, revealed The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Review of R5's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R5 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive and a need for personal care. Review of the Five-day PPS (Prospective Payment System-a Medicare reimbursement) located in the Minimum Data Set (MDS) assessment tab with an Assessment Reference Date (ARD) of 01/11/25 revealed R5 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated she was moderately impaired in cognition. Review of the Activities of Daily Living Care Plan, dated 01/02/25 and located in the Care Plan tab of the EMR, revealed The resident has an ADL self-care performance deficit r/t [related to] dx [diagnosis] of LE [left extremity] cellulitis [a bacterial skin infection.] Approaches included but not limited to: Bathing/Showering: The resident requires extensive one person assistance for bathing/showering bi-weekly and as necessary. In addition, Personal Hygiene: The resident requires limited one person assistance with personal hygiene and oral care. Dressing: The resident requires extensive one person assistance to dress. During an initial observation on 01/09/25 at 1:15 PM, R5 was seated at the dining table (the noon meal was finished) with two other residents who were listening to music. R5's blue sweatshirt was covered with white flakes, had on Christmas flannel pajama pants and slippers. Her chin hair was approximately one-half inch long and was below the chin. Her lip hair was also long touching the top of her upper lip. In addition, her hair appeared greasy. R5 was asked if she was taking her showers and getting help with looking nice. R5 nodded, Yes. During a second observation on 01/10/25 at 1:06 PM, R5 was sitting at the dining table, just having finished the noon meal. R5 was wearing the same blue sweatshirt covered in white flakes, the same pajama pants and slippers. The chin and lip hairs and the greasy hair were the same as the day before. Review of the POC [point of care] Response History [CNA-certified nurse aide documentation] located in the Tasks tab of the EMR, revealed that since admission on 12/30/24, there had been no documented showers. During an interview on 01/10/25 at 1:29 PM, CNA1 stated, The showers are pre-set by someone, I don't know who though, but it is on my shower sheet. CNA1 pulled her resident list out of her pocket and stated, [R5] gets therapy showers, but I don't know if they are giving them or not. CNA1 was asked what occurred when she gave a shower to a resident. CNA1 stated, I do skin checks, wash their hair and body. I do nail care, but only after the shower. CNA1 was asked about R5's long chin and lip hair. CNA1 stated, The chin hair, I don't know when that had been addressed, I haven't shaved her though shaving is part of the shower. CNA1 further stated, I will admit that I have not given her a shower. CNA1 stated, I don't believe she has any other clothes to wear either. CNA1 was asked if she had mentioned this to the nurse or R5's family. CNA1 stated, No, I didn't know I could do that. During an interview on 01/10/25 at 1:57 PM, Occupational Therapist (OT) stated, We do have a list for the showers we give, and we share this with nursing. The residents may refuse or don't want the shower on a particular day. We try and document this when they refuse, and we try to communicate with staff. OT further stated, [R5] had a light sponge bath on 01/03/25 with therapy however, she declined any sponge bath this week. I had asked R5 about her chin and lip hair and she told me they were not a priority. We also tried to wash her hair, but she refused. Review of the OT ADL GET UPS located on a clip board inside the nursing station, revealed, On 01/06/25, [R5] preferred sponge baths, but she declined one on this day. During an interview on 01/10/25 at 2:43 PM, the Assistant Director of Nursing (ADON) was asked if she had observed R5's long chin and lip hair, clothing, and greasy hair. The ADON stated, I was not here when [R5] was admitted to the facility. The ADON then went to the dining room where R5 was seated at the table. The ADON stated, Yep, I see what you mean. The ADON was asked if R5 had enough clothes, as CNA1 explained she did not have any other clothes other than what she was wearing. The ADON stated, There is a lost and found closet, and the family should have been called to bring in additional clothing. The ADON stated, If [R5] had been refusing, we at least should have been encouraging her to take a shower. During a phone interview on 01/11/25 at 12:13 PM, the Director of Nursing (DON) stated, Staff have been educated over and over again about shower documentation. They should not be putting 'not applicable' if a resident refuses. The POC should be accurate. Cross-reference: F725: Sufficient Staffing.

Based on interview and record review the facility failed to consistently assess and monitor pressure ulcers and wounds. In addition, the facility failed to inform the provider upon admission and when wound care was refused for 1 of 2 residents (R4) reviewed for wounds out of 8 sampled residents. Findings include: Review of the facility's policy and procedure titled, Wound Care, dated October 2010, revealed .DOCUMENTATION .The following information should be recorded in the resident's medical record .The type of wound care given .The date and time the wound care was given .The position in which the resident was placed .The name and title of the individual performing the wound care .Any change in the resident's condition .All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound .How the resident tolerated the procedure .Any problems or complaints made by the resident related to the procedure .If the resident refused the treatment and the reason(s) why .The signature and titled of the person recording the data .REPORTING .Notify the supervisor if the resident refuses the wound care .Report other information in accordance with facility policy and professional standards of practice . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R4 was admitted to the facility on [DATE] with diagnoses that included pressure ulcers, a scalp burn, colon cancer, and osteomyelitis (a bone infection) of the left ankle and foot. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/25/24 revealed R4 had a Brief Interview of Mental Status (BIMS) score that was staff assessed as moderately independent. In addition, R4 had one stage 3 pressure ulcer, one deep-tissue injury and a scalp wound due to a burn he sustained at home and was administered intravenous antibiotics daily during the observation period. Review of the Nursing Admission Form, dated 12/20/24 and located in the Assessments tab of the EMR, revealed documentation of R4's wound and skin issues. However, there were no measurements or assessments of the wounds documented. Review of the admission Physician Orders located in the Orders tab of the EMR, revealed: -Wound Care to Shallow Leg Ulcers (LEFT): cleanse w/ normal saline. Change 3x weekly & PRN [as needed]. Cover with Mepilex/foam dressing. Dated 12/21/24. -Wound Care to Lateral LEFT Foot: change dressing 3x/weekly & PRN. Flush with normal saline. Exufiber AG onto wounds. Cover with Mepilex/foam dressing. Dated 12/21/24. -Wound Care to Scalp: BID flush w/ normal saline. Apply Silvadene onto some dampened gauze (use saline to dampen). Cover surface with ABD pad(s). May use silicone tape or cohesive wrap to hold dressing in place. Two times per day. Dated: 12/21/24. -Ceftriaxone (an antibiotic medication given intravenously) 2 grams one time a day for Diabetic Foot Infection for 14 days. Start Date: 12/21/24 End Date: 01/04/24. Review of a Health Status Note, dated 12/20/24 and located in the Progress Notes tab of the EMR, revealed Resident will not allow staff to change wound dressings. Resident stated, 'If they aren't bleeding, they do not need to be changed.' LPN [Licensed Practical Nurse] educated resident that wound dressings need to be changed PRN [as needed] especially when they are soiled and leaking. The resident stated, 'I don't care, it's not needed.' LPN attempted another time to change wound dressings and resident still refused dressing changes Will continue to monitor and educate. The Health Status Note did not show documentation that the provider was notified of R4's continued refusal to have wound dressings changed. Review of the Nursing Progress Note, dated 12/21/24 and located in the Progress Notes tab of the EMR, revealed Resident took his bandage off of his head and writer attempted to rebandage head and resident started to yell at writer and said he does not need a bandage on his head if it's not bleeding. Resident is refusing to use call light and attempting to self-transfer (sic) himself in his room. Review of a Nursing Progress Note, dated 12/21/24 and located in the Progress Notes tab of the EMR, revealed Has open areas largest being the top of his head, area on top of head cleansed and Medi honey applied. According to the admission Physician Orders, dated 12/20/24, for the scalp wound, Silvadene was to be applied and not Medi-honey. Review of the 12/26/24 Skin and Wound Evaluation assessment form, dated 12/26/24 and located in the Assessments tab in the EMR, revealed the Director of Nursing (DON) had measured and assessed the wounds (six days after admission). The following wounds were documented: -A deep-tissue injury, pressure located on the right medial Achillies heel of unknown duration which measured 1.8 x 2.4 cm (centimeters). -Dry, pink areas on left buttock of unknown duration. -An abrasion to a kneecap of unknown duration which measured 1.4 x 0.9 cm. -A pressure ulcer, stage 3 (full-thickness loss of tissue), left mid foot which measured 2.6 x 4.7 x 1.9 cm of unknown duration. -Burn which measured 11.6 x 11.2cm. In addition, there was no documentation on the Skin and Wound Evaluation to show that the provider had been updated on the wounds. Review of the Nursing Progress Notes did not show any additional documentation regarding the wounds. Review of the Physician Orders located in the Orders tab of the EMR revealed, Ceftriaxone 2 grams intravenously was to be continued from 01/04/25 to 01/18/25. Review of the January 2025 Treatment Administration Record (TAR) located in the Orders tab of the EMR, revealed between 01/01/25 and 01/10/25, R4 refused wound care two times, was in the hospital one time and accepted wound care two out of five opportunities. There was no documentation in the Nursing Progress Notes to show the provider had been updated and was aware of R4's refusal to have wound care performed. During an interview on 01/11/25 at 8:45 AM, the Regional Clinical Nurse was asked why there was no assessment and monitoring for R4's wounds. The Regional Nurse stated, The DON keeps a spreadsheet on wounds however, when I contacted the DON regarding her wound documentation, she did not return my call. It's safe to say, the assessment and monitoring of the wounds was not done. As for lack of Provider notification, it's safe to say that wasn't done either.

Based on interview and record review the facility must provide pharmaceutical services to meet the needs for 1 (R6) of 8 sampled residents. R6 did not receive his Trazadone per R6's preference and physician's orders resulting in a timing error. Review of R6's Admission Record located in the Profile tab of the EMR. revealed R6 was admitted to the facility on [DATE] with diagnoses that included a left leg fracture, Parkinson's disease, and dementia. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 11/15/24 revealed R6 had a BIMS score of 13 out of 15 which indicated he was cognitively intact and was administered an antidepressant medication during the seven-day observation period. Review of the Physician Orders located in the Orders tab of the EMR revealed Trazadone (an antidepressant medication) 50mg. Give one tablet my mouth in the evening at 1800 [6:00 PM]. Start Date: 12/28/24. Review of the Special Precautions on the banner located on the undated Face Sheet, revealed .Meds to be given between 6:30-7:00 PM d/t (due to) preference to go to bed around 7pm . During an interview on 01/10/25 at 2:25 PM, FM1 stated, He did not get medication on time last night for his Parkinson's. It was supposed to be given to him between 6:30 PM and 7:00 PM but, it was after 7:30 PM. He was sleepier this morning. FM1 was asked if she had mentioned her concerns to the staff. FM1 stated, Yes, I spoke to the Regional Nurse about it, and he stated he would take care of it. During an interview on 01/11/25 at 9:25 AM, FM1 was asked if R6's medication was given between 6:30 PM and 7:00 PM. FM1 stated, No he didn't. FM1 stated that an agency nurse was on duty last night who did not know what to do and did not give the medication until 7:15 PM. FM1 further stated, He did not even get his afternoon medications until 7:15 PM either. FM1 was asked if she had informed the Regional Nurse regarding this issue. She stated, Yes, I did. He gave me his phone number personally if there was an issue with the timing of [R6's] medications. During an interview on 01/11/25 at 10:30 AM, the Regional Clinical Nurse confirmed that R6's medications had been administered late. He stated, My expectation is the medications are to be administered, according to the special precautions banner.

Based on interviews and record reviews, the facility failed to maintain a complete and accurate medical record for 2 (R1 and R4) of 8 sample residents. The facility failed to ensure the daily Medicare and/or Skilled Charting documentation contained skin/wound documentation for R1. In addition, the daily Medicare and/or Skilled Charting assessments were not completed daily, as required for R4. This failure placed the residents at risk of unmet care needs. Findings include: Example 1 Review of R1's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed, R1 was admitted to the facility on [DATE] with diagnoses which included T-cell Lymphoma (a rare type of cancer), skin cancer, and diabetes. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/29/24 revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated he was cognitively intact and had no skin issues. Review of the Skin/Wound assessments, dated 11/14/24 and located in the Skin/Wound tab in the EMR, revealed the following identified wounds and pressure ulcers. -Stage four (a full-thickness loss of tissue with exposed muscle, tendon, or bone) on the sacrum. -An unstageable pressure ulcer (a full thickness-loss of tissue with the wound bed containing necrotic tissue (dead tissue) on the scrotum. -A deep-tissue injury on the heels. Review of the daily Medicare and/or Skilled Charting documentation (a required document for all residents who have Medicare/Insurance as their primary payor source) located in the Assessments tab of the EMR, revealed no documentation regarding R1's skin/wounds on the 11/14/24, 11/15/24, 11/16/24, 11/17/24 and 11/18/24 Medicare and/or Skilled Charting forms. In addition, a review of the Nursing Progress Notes located under the Progress Notes tab of the EMR did not contain documentation regarding R1's skin or pressure wounds. During an interview on 01/10/24 at 10:36 AM, the Assistant Director of Nursing (ADON) was asked what the expectation was regarding completing the daily Medicare and/or Skilled Charting by the nursing personnel. The ADON stated, Anything out of the ordinary is to be documented on the Medicare and/or Skilled Charting or the Nursing Progress Notes. The ADON was shown the Medicare and/or Skilled Charting forms for the above dates and the lack of documentation regarding the skin/wounds. The ADON stated, I was not aware that the nurses' had not documented the wounds, they definitely should have. Example 2 Review of R4's Admission Record located in the Profile tab of the EMR revealed R4 was admitted to the facility on [DATE] with diagnoses that included colon cancer, stage 3 ulcers, and diabetes. Review of the admission MDS located in the MDS tab of the EMR with an ARD of 12/25/24 revealed R4 had a staff assessed BIMS of moderately independent, had one stage 3 pressure ulcer, one deep-tissue injury, and was on intravenous antibiotic therapy for a wound infection. Review of the Medicare and/or Skilled Charting located in the Assessments tab of the EMR, revealed on 12/25/24, 12/30/24, 01/04/25, 01/05/25 and 01/09/25 there was no documentation that nursing personnel had documented R4's care. During an interview on 01/10/25 at 12:20 PM, the ADON was asked what the expectation was regarding the daily Medicare and/or Skilled Charting documentation. The ADON stated, The 'Medicare and/or Skilled Charting' documentation is to be done daily and updated with any new issue the resident develops.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 12 residents who reside in the facility. Facility staff were observed working in the kitchen without beard nets on. Chef Q was observed placing dirty pans in a rack and then removing and organizing clean metal pans without wearing gloves or washing his hands. The metal pans were wet stacked on a drying rack. Thermometer probe was not being sanitized between temping resident food. Chef Q was observed putting garbage and gloves in the garbage can without washing his hands prior to going back to cooking dinner. KM P (Kitchen Manager) observed dishing up lunch from the steam table with gloves on. KM P stepped away from the steam table and made a phone call. KM P returned to the steam table with the same gloves on and continued dishing up the lunch meal. Surveyor observed undated food in the cook's refrigerator and in the refrigerator in the first-floor kitchenette. Surveyor observed Lead Activity Assistant E serving R2 and R4 their lunch with soiled gloves on. Evidenced by: Example - Staff and beard net Facility policy, entitled Hair Restraints, revised date 10/29/2023, includes, Beard nets are required for facial hair longer than a half inch. On 5/20/24 at 11:15 AM, Surveyor observed Chef Q and DA R (Dietary Aide) preparing food without a beard net on. On 5/20/24 at 1:36 PM, Surveyor interviewed KM P who indicated that Chef Q and DA R should be wearing a beard nets. Example - Dishwashing Facility policy, entitled Recording of Dish Machine Temperatures, revised date 9/10/2023, includes procedure . Allow all dishes /utensils and equipment to air dry prior to storage. Avoid touching food contact surfaces when touching clean equipment. On 5/19/24 at 12:54 PM, Surveyor observed Chef Q placing dirty metal trays in a rack and then removing and organizing clean metal pans without wearing gloves or washing his hands when going from dirty to clean. Surveyor observed the metal pans being wet stacked on a drying rack. On 5/20/24 at 1:36 PM, Surveyor interviewed KM P, who indicated that Chef Q should have been wearing gloves and an apron while rinsing and placing dirty trays in the rack. KM P indicated that Chef Q should have removed his gloves and washed his hands before touching the clean trays and while arranging the trays in the drying rack to avoid wet stacking. Example - not sanitizing thermometer before temping food. On 5/19/24 at 11:45 AM, Surveyor observed Chef Q temping food and not disinfecting the temperature probe between food items. On 5/20/24 at 1:36 PM, Surveyor interviewed KM P, who indicated that Chef Q should be disinfecting the probe before temping each food item. Example - Hand washing On 5/19/24 at 11:35 AM, Surveyor observed Chef Q empty a bag of potatoes into a kettle, take his gloves off and open the garbage can with his hands and put the garbage and gloves into the garbage can. Chef Q was then observed going back to preparing dinner without washing his hands. On 5/20/24 at 1:36 PM, Surveyor interviewed KM P, who indicated that Chef Q should have washed his hands before he started preparing dinner. On 5/19/24 at 12:31 PM, Surveyor observed KM P dishing up lunch from the steam table with his gloves on. KM P stepped away from the steam table and made a phone call. KM P returned to the steam table with the same gloves on. On 5/20/24 at 1:36 PM, Surveyor interviewed KM P, who indicated that he should have removed his gloves, washed his hands, and put on new gloves. Example- Undated food items Facility policy, entitled Food Labeling & Dating, revised date 7/1/2023, includes, All PHF that are not consumed within 24 hours must be dated. Refer to WI food code, WI Food code fact sheet to proper marking techniques. Oak Park places uses a dating system to identify when food must be consumed or discarded by indicating date of preparation, or date of first item used date as indicated on WI food code Containers will be labeled with the date opened and discarded according to FDA. On 5/19/24 at 10:00 AM, surveyor observed no open dates on an opened jar of chopped garlic, an open container of yellow mustard, an opened package of butter, and an open container of milk. On 5/19/24 at 11:58 AM, Surveyor observed in the facility's dining room: an opened and undated half gallon of white milk, an opened and undated half gallon of chocolate milk, an opened and undated box of thickened cranberry juice, and an open and undated box of thickened apple juice. Surveyor interviewed [NAME] E (Lead Activity Assistant), who indicated there are no open dates on the chocolate milk, the white milk, the thickened cranberry juice, or the thickened apple juice and she is not sure how long these products are good for after they have been opened. On 5/20/24 at 1:36 PM, Surveyor interviewed KM P who indicated care givers are trained upon hire, and have been told they are to be putting open dates on items. KM P indicated the items should have been dated. 38882 Example - Hand Hygiene R2 admitted to the facility on [DATE] with diagnoses including wedge compression fracture of the second lumbar vertebra, benign paroxysmal vertigo, malignant neoplasm of the left breast, low back pain, edema, and chronic kidney disease stage 3. R4 admitted to the facility on [DATE]. On 5/19/24 between 11:58 AM and 12:45 PM Surveyor observed Lead Activity Assistant E wearing gloves and serving food. Lead Activity Assistant E used her gloved hands to knock on doors, open doors, touch her person, set up R2's and R4's lunch plates and serve R2's and R4's lunch plate to them without removing her gloves and washing her hands after touching dirty surfaces and before food handling. On 5/19/24 at 12:45 PM, During an interview Lead Activity Assistant E indicated she should have removed her gloves and washed her hands after touching her own shirt, after opening door to the kitchen, after knocking and opening resident doors, and before handling food. On 5/20/24 at 2:48 PM, during an interview RN G (Registered Nurse) indicated staff do not need to wear gloves to pass drinks and meals. RN G indicated staff would have to treat their gloves like their bare hands in that after they touched dirty surfaces or their person, they would need to remove gloves and wash hands. On 5/20/24 at 3:16 PM, DON B (Director of Nursing) indicated she also observed Lead Activity Assistant E wearing the same gloves throughout the dining experience and she was touching dirty surfaces, her own clothing, door knobs, and she was handling food without washing her hands or removing her soiled gloves. DON B indicated she is in the process of educating staff on hand hygiene with food handling.

Based on interview and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents (R1) reviewed for falls. R1 has a history of multiple falls. Facility staff did not implement appropriate fall interventions and provide adequate supervision. R1 had a fall that resulted in a displaced right inferior pubic ramus fracture (a break in part of the pelvis). Evidenced by: The facility's policy titled, Falls Policy and Prevention Program dated 6/29/21, states in part; .all residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls . R1 was admitted to the facility on [DATE] with diagnoses including pneumonia, need for assistance with personal care, difficulty in walking, dysphasia, cognitive communication deficit, dementia, major depressive disorder, anxiety disorder, muscle weakness, and altered mental status. R1's most recent MDS (Minimum Data Set) dated 3/19/24, states that R1 has a BIMS (Brief Interview of Mental Status) of 00 out of 15 indicating R1 is severely cognitively impaired. R1's MDS dated [DATE], also states .Bowel and Bladder section H, frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). R1's Comprehensive Care Plan states, in part; .Toilet use: The resident requires ext. (extensive) 2A (assistance of 2 staff) for toileting: SPT (stand pivot transfer) wc (wheelchair), grab bar. Do not leave unattended on toilet revision on: 4/4/24 .Resident is at HIGH risk for falls r/t (related to) generalized weakness, recent COVID illness, poor safety awareness, cognitive deficits, frequent falls prior to admission, deconditioning, and need for assistance with ADLs (activities of daily living), and toileting. Date Initiated: 3/15/24. Resident will not sustain serious injury through the review date. Date Initiated 3/15/24. Interventions/Tasks: HIGH FALL RISK date initiated 3/15/24. All staff to monitor that the resident is wearing appropriate footwear or non-skid socks when ambulating or mobilizing in w/c (wheelchair) 3/14/24. Anticipate and meet resident's needs as much as possible to prevent unsafe self-initiation 3/14/24. Assess/observe regularly for a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; personal items within reach 3/14/24. Be sure call light is within reach and encourage the resident to use it for assistance as needed 3/14/24. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs 3/14/24. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility 3/14/24. Ensure resident has his hearing aids in and/or utilizes his pocket talker device 3/21/24. Follow facility fall protocol if a fall occurs 3/14/24. PT evaluate and treat as ordered or PRN 3/14/24. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes 3/15/24. Upon admission, resident was placed in a room close to the nurse's station for increased monitoring and visualization d/t poor safety awareness and knowledge of h/o (history of) prior falls 3/14/24. Gripper socks on at all times 3/15/24. Low bed 3/14/24. Anti-roll back device on w/c 3/20/24. Encourage to come to common areas while awake 3/15/24. Bed against wall for spatial awareness 3/14/24. Resident had fall: 3/14/24 RCA (Root Cause Analysis): Failed self-transfer attempt. Intervention: Keep wheelchair at bed side with brakes on, so if he wants to get up, he can do so safely. 3/14/24 RCA: new environment, new admission to SNF w/dementia dx (diagnosis) and recent delirium: Intervention signs up in room as visual cues/reminders to use call light and await staff assistance to decrease risk of falls & falls with injury. 3/15/24 RCA: Failed self-transfer attempt intervention: keep bed at knee height. 3/17/24 RCA failed self-transfer. Intervention: anti-roll back locking device added to w/c. 3/19/24 RCA: Failed self-transfer. Intervention: Encourage to participate in activities of interest. Have activity meet with resident to discuss. 3/19/24 RCA: Failed self-transfer. Intervention: Continue with previous interventions. 3/19/24 RCA: Failed self-transfer. Intervention: Beveled matt landing strip. 3/24/24 RCA: Failed self-transfer. Intervention: 1:1 supervision at all times . R1 had eight falls from 3/14/24 - 3/24/24. Fall Reports state, in part: .Date 3/14/24 16:15 .Nursing description: Pt (patient) was found on the floor with his head up against the bedside dresser and bleeding from his scalp in two places. He was laying on his left side. Resident description: Resident unable to give description. Description: was able to safely get patient off the floor with a Hoyer. Wound was cleaned and steri strips were placed on the small wounds .Injury Type: Laceration .top of scalp .Environmental factors: Other. Physiological factors: confused, gait imbalance, impaired memory, recent illness, weakness. Situation factors: admitted within last 72h (72 hours), ambulating without assist .No witnesses found. It is important to note, Advanced Practice Nurse Prescriber was notified of fall, note states, in part; 3/14/24 staff did notify me of fall day of admission. Fall occurred around 4:15pm. Profound dementia pt and is ambulatory and tried to toilet self. Is on 2 blood thinners and likely hit his head .Intervention added keep wheelchair at bed side with brakes on, so if he wants to get up, he can do so safely. Date 3/14/24 20:35 .Nursing description: Patient found on floor by CNA (Certified Nursing Assistant), self-transfer attempt to bed and fell . Resident description: Resident unable to give description. Description: Neuro checks WNL (Within Normal Limits), RN, DON in room to assist with transfer back to bed via Hoyer after assessing mobility. Injury type: No injuries observed at time of incident. Environmental factors: blank. Physiological factors: confused, gait imbalance. Situation factors: admitted within last 72hr, ambulating without assist. No witnesses found. Intervention added, signs up in room as visual cues/reminders to use call light and await staff assistance to decrease risk of falls and falls w/injury (with injury). **It is important to note, R1's most recent MDS indicates R1 has a BIMS score of 00. Date 3/15/24 10:31 .Nursing description: Patient was found in his room laying on the floor by his bed with a skin tear on his left elbow. Unable to determine if he hit his head or not. Difficult to communicate with resident due to hearing loss and garbled speech. Resident description: No description given. Description: Lifted off the floor with 2A with the Hoyer lift and placed back into bed. Was subsequently sent to hospital via ambulance to be evaluated after this being his 3rd fall in less than 24 hours per primary. Injury type: skin tear left elbow. Environmental factors: None. Physiological factors: confused, impaired memory, weakness. Situation factors: admitted within last 72hr, ambulating without assist. No witnesses found. Intervention added, Keep bed at knee height. **It is important to note, low bed is still an active intervention as well. Date 3/17/24 14:25 .Nursing description: Patient was found on the floor near the bathroom laying on his back after he was heard yelling for help. Has a 2-inch cut to the back of his head that was bleeding a little bit. Patient is very hard of hearing, so it was difficult to find out what he was doing. Resident description: Unknown. Description: Patient was checked for injuries and only the cut to the back of his head was noted. Hoyer lifted to his bed and then was sent to hospital via ambulance to be checked out further. Injury type: No injuries observed at time of incident. Environmental factors: None. Physiological factors: confused, gait imbalance, weakness. Situation factors: ambulating without assist. No witnesses found. Intervention added, Anti-roll back locking device added to w/c. **It is important to note despite resident being found near bathroom, no intervention regarding toileting schedule was discussed/added to care plan. Date 3/19/24 11:05 .Nursing description: Pt was found on the floor in the middle of his room. His head was near the bathroom and feet towards his window. He was laying on his right side. Resident could not explain what happened. Did deny pain when asked. Used a Hoyer to get pt into a wheelchair. Pt had a small 1-inch laceration to his right eyebrow at the far end by side of face. Resident description: Resident unable to give description. Injury type: laceration face. Environmental factors: None. Physiological factors: confused, gait imbalance, impaired memory, weakness. Situation factors: ambulating without assist. No witnesses found. Intervention added, encourage to participate in activities of interest. Have activity meet with resident to discuss. Date 3/19/24 13:12 .Nursing description: Pt yelled for help. RN found pt lying on his stomach on the floor in the bathroom. His head was towards the bathroom door and his feet were near the shower. His depend was in its appropriate place but his pants were down around his ankles. No urine on the floor. He denied any pain or being hurt. RN and another staff member rolled him over to his back to be able to assess him better. Resident description: Resident unable to give description. Injury type: No injuries observed at time of incident. Environmental factors: Blank. Physiological factors: confused, gait imbalance, impaired memory, weakness. Situation factors: ambulating without assist. No witnesses found. Intervention added, Continue with previous interventions. **It is important to note despite resident being found in bathroom, no intervention regarding toileting schedule was discussed/added to care plan. Date 3/19/24 21:43 .Nursing description: CNA notified this nurse of resident on floor at 21:43. Resident found lying supine on floor next to bed with a pillow under him. Resident description: Resident unable to give description. Description: assessed for injury, no new injury observed. Assisted off floor via 2A Hoyer. Vitals obtained and neuro assessment started. DON notified; PCP (primary care provider) faxed notification of fall. Injury type: No injuries observed at time of incident. Environmental factors: poor lighting. Physiological factors: confused, drowsy, gait imbalance, impaired memory, weakness. Situation factors: active exit seeker, improper footwear, ambulating without assist. No witnesses found. Intervention added, Beveled matt landing strip. **It is important to note there was no education/discussion regarding improper footwear despite being care planned for R1 to have gripper socks on at all times. Date 3/24/24 11:30 .Nursing description: Pt found perpendicular to his bed lying on his back on the floor mats. Head near the bed. Resident description: Pt states he was trying to get to his wheelchair and slid to the floor. He kept stating I did not fall. Injury type: no injuries observed at time of incident. Environmental factors: None. Physiological factors: confused, gait imbalance, impaired memory. Situation factors: ambulating without assist. No witnesses found. Intervention added, 1:1 supervision at all times. Patient Report x-ray, states, in part; .Date of Service 3/25/24 .Reason .Numerous falls in the last week, Pain, Bruising bilateral on buttocks and both sides of hips, Pain in left leg femur area and also in right leg in femur area .Findings .Pelvis 1 view History: history of multiple falls, pain .Impression: nondisplaced avulsion fracture lucency across the ischial bone on the right side inferiorly as noted . On 4/11/24 at 4:58PM, RN C (Registered Nurse) indicated R1 has had several falls since R1's admission. RN C indicated the first few falls the facility was still getting to know R1 and all notifications were made regarding R1's falls. RN C and Surveyor reviewed R1's Fall Reports. RN C indicated Fall Reports do not include a lot of information. RN C indicated all of R1's Fall Reports state, failed self-transfer. Surveyor asked RN C if failed self-transfer indicates why R1 self-transferred in the first place? RN C indicated RN C understands what Surveyor is stating and that failed self-transfer does not explain the root cause of R1's falls. RN C indicated the facility is working on the process for falls and discussion regarding the root cause of a fall. RN C indicated R1's falls on 3/14/24 at 4:15pm, 3/17/24 at 2:25pm, 3/19/24 11:05am, and 3/19/24 at 1:12pm all indicated that R1 was possibly attempting to use the bathroom. RN C indicated R1's fall interventions did not include a toileting schedule (ex: assistance to bathroom every two hours, before/after meals, etc.) or any support regarding assisting R1 to the bathroom. RN C indicated interventions and updates to R1's care plan regarding a toileting schedule could have prevented some of R1's falls. RN C indicated on 3/28/24 the facility implemented 1:1 staff support for R1. RN C indicated this was implemented after R1 was discharged from the hospital having been diagnosed with a pelvic fracture. RN C indicated, I will be implementing a toileting schedule as soon as I leave this room. On 4/11/24 at 5:15PM, RN D (Regional Registered Nurse) indicated failed self-transfer does not explain the root cause of R1's falls. RN D indicated R1's fall interventions, Educate the resident about safety reminders .and signs up in room as reminders to use call light and await staff assistance .are not ideal fall interventions for a resident with a BIMS score of 00. RN C and RN D indicated for R1's fall on 3/19/24 9:43pm improper footwear was marked as a factor and there was not any education or discussion with staff regarding this as being a factor for R1's fall despite it stating on care plan gripper socks on at all times 3/15/24. Surveyor asked RN C and RN D about the interventions, low bed 3/14/24 and keep bed at knee height 3/15/24, and asked which intervention is the correct intervention since both are on R1's care plan. RN C and RN D indicated understanding that both interventions contradict each other. On 4/11/24 at 5:46PM, DON B (Director of Nursing) indicated the facility is currently working on updating their process for falls and they have all staff training scheduled. DON B indicated the staff education for fall interventions has not yet been completed. DON B indicated DON B did not realize R1's MDS states R1 is incontinent. DON B indicated that the interventions low bed and knee-high bed contradict each other and did not realize both interventions were on care plan. DON B indicated R1 would not be able to be educated regarding safety awareness because R1 would not remember discussion/education. DON B indicated DON B would expect the intervention to align with the root cause of the fall. The facility failed to ensure there was a robust discussion around root causes for each of R1's falls. The facility failed to identify patterns, failed to educate staff when an intervention wasn't followed, and failed to reassess R1's fall interventions. R1 had eight unwitnessed falls from 3/14/24-3/24/24, one resulting in a displaced right inferior pubic ramus fracture.

Based on interview and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 4 residents (R2) reviewed for falls. R2 has a history of multiple falls. Facility staff did not implement appropriate fall interventions and provide adequate supervision. R2 had a fall that resulted in a head laceration requiring seven (7) sutures. This is evidenced by: The facility's policy titled Falls Policy and Prevention Program dated 6/29/21 states in part, .All residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls . According to Superior Health Quality Alliance, Root Cause Analysis (RCA) is a problem-solving method to investigate an actual or potential problem, incident or concern. A team looks beyond an immediate solution to understand the underlying cause(s) of the problem. Those causes are then changed to prevent the problem from happening again . Root Cause Analysis Toolkit for Long Term Care (superiorhealthqa.org) R2 was admitted to the facility on [DATE] with diagnoses that include: acute bronchiolitis due to Respiratory Syncytial Virus (RSV), difficulty walking, cognitive communication deficit, muscle weakness, and repeated falls. Resident discharged from the facility on 3/11/24. R2's most recent Minimum Data Set (MDS) dated [DATE] states that R2 has a Brief Interview of Mental Status (BIMS) of 7 out of 15, indicating that R2 is severely cognitively impaired. R2's care plan initiated on 1/13/24 and revised on 1/16/24 states in part, .R2 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) dx (diagnosis) RSV and Sepsis due to UTI (Urinary Tract Infection) .Interventions/Tasks .Ambulation: with therapy only due to safety concerns extensive 1A (1 assist) with 2 ww (wheeled walker) .Mobility/Locomotion: The resident is mobile via 1A w/c (wheelchair) .Toilet Use: The resident requires ext (extensive) assist of 1 staff for toileting .Transfer: The resident is able to: transfers limited 1A with 2 ww . R2 has had several falls since admission with fall risk assessments completed using the Morse Fall Risk Assessment. Per the Morse Fall Risk Assessment form, a score of 45 and higher is a high fall risk, 25-44 is a moderate fall risk, and 0-24 is a low fall risk. The following are R2's fall risk assessment scores: 1/23/24: 80 1/27/24: 80 1/27/24: 75 1/30/24: 90 2/2/24: 65 2/4/24: 65 2/4/24: 75 2/8/24: 75 2/8/24: 65 2/9/24: 65 2/16/24: 90 2/24/24: 105 2/25/24: 75 2/26/24: 75 3/11/24: 90 R2's falls documentation are as follows: 1/23/24 at 9:45 PM: .Patient found in hallway right outside her doorway laying on the floor on her stomach, states she was looking for her room .Notes: 1/24/24 RCA (Root Cause Analysis): Failed self-transfer. Intervention: Continue with current interventions. 1/27/24 at 12:50 AM: .Patient found lying on her stomach in her bathroom doorway while attempting to take herself to the bathroom she fell .Notes: 1/28/24 RCA: Failed self-transfer. Intervention: Staff to encourage her to be out with others during waking hours. 1/27/24 at 5:20 PM: .Heard patient yell and a loud sound from the hallway. When RN (Registered Nurse) entered room pt (patient) was lying on her right arm between her stomach and side on the floor near the large wardrobe. Wheelchair was across the room against the far wall. Resident description: States she was sitting in her wheelchair and was bending over to try and open the wardrobe bottom drawer and could not, so she stood up slightly. Then when she went to sit back down her wheelchair moved and she lost her balance and fell to the floor hitting the right side of her forehead on the floor. Denies any other injuries or pain other than her forehead was throbbing and her right arm hurt because she was laying on it .Notes: 1/27/24 RCA: Failed attempt to stand. Intervention: Ensure that her personal items are within reach. 1/30/24 at 3:20 AM: .This RN and CNA (Certified Nursing Assistant) heard yelling while in the nurse's station. Resident found down in her room seated on the floor resting against her bed. Resident description: Resident states that she went to the bathroom without assistance and fell while trying to get back to bed . Notes: 1/30/24 RCA: Failed self-transfer. Intervention: Ensure every 2-3 hours toileting/checks. 2/2/24 at 5:30 PM: .Paramedics were called here for another patient and saw this patient on the floor in the cafeteria when they passed by. The paramedics stated that they picked her up and placed her back in her wheelchair then continued to the room they were called for. The patient stated that she tried to stand up from her wheelchair and lost her balance and fell to the floor catching herself with her hands . Notes: 2/3/24 RCA: Failed attempt to self to stand up. Intervention: Anti-roll back lock to w/c. 2/4/24 at 8:30 AM: .Patient was found on the floor in her room next to the closet. She was laying on her buttocks and on her shoulder. Resident description: Stated she was trying to pack things up in the closet when she lost her balance and fell on to her butt. She then fell backward and bumped her head on the floor . Notes: 2/4/24 RCA: Failed attempt to stand independently. Intervention: Anti roll back locking device to be added to chair. It is important to note that this was the same intervention assigned to the fall on 2/2/24. 2/4/24 at 6:10 PM: .[R2] was yelling help. RN found her sitting with her back against the bedrail on the floor facing the door. Feet straight out in front of her. Resident description: Said she was going to do the dishes and slipped and fell . She had her supper dishes in her wheelchair. The brakes were on. She stated she was trying to push the wheelchair to the sink to do dishes and slipped and fell . She did have gripper socks on as well. Call light was within reach too .Notes: 2/5/24 RCA: Failed self-transfer. Intervention: Ensure that resident needs are being met in a timely manner. 2/8/24 at 5:55 AM: .This RN called to resident room due to being found on the floor. Resident description: Resident states that she was going to the restroom and fell .Notes: 2/9/24 RCA: Failed self- transfer attempt. Intervention: Offer toileting resident on rounds to prevent her from getting up on her own. 2/8/24 at 1:30 PM: .Patient found on floor next to her bed. No c/o (complaint) of pain or injury. Resident description: Stated she dropped the TV (television) remote while sitting on the edge of the bed and was reaching down to pick it up when she lost her balance and fell to the floor .Notes: 2/9/24 RCA: Reaching for remote control on the floor, fell out of w/c. Intervention: Ensure all items are within reach prior to leaving room. It is important to note that this is the same intervention assigned to the fall on 1/27/24. 2/9/24 at 4:00 PM: .Resident observed laying floor of the hallway outside of another resident's room. Resident description: Resident reported that she slipped when trying to enter through the doorway. Resident reported that she removed her shoes prior to going out into the hallway . It is important to note that there was not a RCA or intervention completed for the fall on 2/9/24. 2/15/24 at 3:45 PM: .resident was found sitting on her buttocl [sic] with legs fully extended on front of her with her back against the wheelchair in the dining room. Denies hitting her head. Resident description: I was going home .Notes: 2/15/24 RCA: Failed self- transfer. Intervention: Keep [R2] in common areas while awake for easy monitoring by staff. It is important to note that this is a similar intervention assigned to the fall on 1/27/24. Additionally, R2 was in the common area (dining room) when this fall occurred, as was the fall on 2/2/24. 2/24/24 at 6:37 PM: .Writer called to resident's room where she was noted to be lying in her bathroom on her left side, parallel to the toilet. Resident description: I was going to the toilet and my knee gave out .Notes: 2/24/24 RCA: Failed self-transfer d/t knee buckling on her. Intervention: Staff to ensure that resident is toileted after meals, to reduce the risk of her attempting to toilet herself. It is important to note that the facility has already implemented toileting every 2-3 hours on 1/30/24 and toileting on rounds on 2/8/24. 2/25/24 at 10:35 AM: .Patient was yelling for help from her room. She was found on the floor almost face down with a small pool of blood around her head. Upon examination she was noted to have a 2-3 inch cut across her forehead. Resident description: Stated she was trying to put some clothes away when she somehow slipped and fell , striking her head against the floor .911 was called and the paramedics picked her up and put her on the stretcher then took her to [Hospital name] for evaluation and treat .Notes: 2/25/24 RCA: Lost her balance. Intervention: Staff to continue to anticipate her needs. The hospital After Visit Summary dated 2/25/24 states in part: .Diagnosis: Fall .Contusion of right hip .Laceration of forehead .Instructions: .2. Have sutures removed in 5-7 days . Nurse's note dated 2/25/24 at 2:47 PM states, Patient fell and hit her head at approximately 10:35. She was taken via ambulance to [Hospital Name] for a laceration across her forehead. She returned from the hospital at about 2:45 PM. diagnosed with a contusion of right hip and laceration of forehead where 7 stitches were placed . 2/26/24 at 3:00 AM: .This RN heard resident yelling from nurse's station. When I arrived at the doorway the resident was noted to be lying on her left side facing the window with her feet towards the bathroom door. Resident description: Resident states she was going to the bathroom and slipped .Notes: 2/26/24 RCA: Failed self-transfer attempt. Intervention: Staff to offer toileting t/o (throughout) the night. It is important to note that the facility has already implemented toileting every 2-3 hours on 1/30/24 and toileting on rounds on 2/8/24. 2/26/24 at 11:09 AM: .Writer heard a staff member yell that they needed a nurse because there was a resident found down in her room. Writer rushed down to find [R2] on the floor up against the wall by her window with her head propped up against the wall underneath the window. Resident description: I got up to move from one chair to the other when I slid down to the floor. I forgot to lock my chair. I did hit my head .Immediately notified POA (Power of Attorney) .Notified NP (Nurse Practitioner) .who was here at facility seeing other residents and gave order to send her out b/c (because) of hitting her head, and fall being unwitnessed .Notes: 2/26/24 RCA: Failed self-transfer. Intervention: Continue current plan of care. 3/11/24 at 3:15 AM: .Safety check made on patient and found her up in her room walking, patient lost her balance as writer entered her room. Patient description: Patient had to pee and was looking for the bathroom, forgot to use her call light that was pinned to her shirt .Notes: 3/17/24 RCA: Failed self-transfer attempt. Intervention: discharged . The facility implemented increased toileting interventions on 1/30/24 - ensure every 2-3-hour toileting/checks, 2/9/24 - offer toileting resident on rounds to prevent [R2] from getting up on her own, and on 2/24/24 - staff to ensure that resident is toileted after meals, to reduce the risk of [R2] attempting to toilet herself. Facility CNA documentation for task titled ADL - Toilet Use only requires staff to document one time per shift and does not capture the frequency of toileting or whether R2 urinated or had a bowel movement. Documentation times are as follows: 1/30/24: 9:57 AM, 9:41 PM 1/31/24: 5:59 AM, 10:34 AM 2/1/24: 3:14 AM, 7:21 AM 2/2/24: 4:26 AM, 10:36 AM 2/3/24: 1:19 AM, 7:06 AM, 8:13 PM 2/4/24: 1:21 AM, 7:34 AM 2/5/24: 4:15 AM, 11:07 AM 2/6/24: 10:01 AM, 8:29 PM 2/7/24: 10:44 AM 2/8/24: 8:03 AM, 9:59 PM 2/9/24: 1:41 AM 2/10/24: 11:23 AM, 9:07 PM 2/11/24: 9:44 AM 2/12/24: 3:59 AM, 9:56 AM, 9:17 PM 2/13/24: 11:18 PM, 1:06 AM 2/14/24: 11:25 AM 2/15/24: 11:01 AM, 9:44 PM 2/16/24: 9:36 AM, 11:41 AM 2/17/24: 12:20 AM, 9:49 PM 2/18/24: 3:56 AM, 9:37 AM, 11:55 PM 2/19/24: 5:06 AM, 7:38 AM, 9:07 PM 2/20/24: 10:45 AM, 9:59 PM 2/21/24: 10:28 AM 2/22/24: 3:20 AM, 6:44 AM 2/23/24: 2:54 AM, 9:50 AM 2/24/24: 6:52 AM 2/25/24: 9:45 AM, 9:44 PM 2/26/24: 7:52 AM, 7:49 AM 2/27/24: 1:48 AM, 9:43 AM 2/28/24: 2:00 AM, 9:51 AM 2/29/24: 2:00 AM, 9:38 AM, 9:20 PM 3/1/24: 10:16 AM, 7:52 PM 3/2/24: 3:22 AM, 10:00 AM, 6:14 PM 3/3/24: 3:16 AM, 1:45 PM, 8:38 PM 3/4/24: 2:00 AM, 10:02 AM, 9:45 PM 2/5/24: 7:48 AM, 9:29 PM 3/6/24: 1:59 PM, 8:44 PM 3/7/24: 7:27 AM, 8:26 AM 3/8/24: 4:26 AM, 10:06 AM, 9:25 PM 3/9/24: 9:29 AM, 9:59 PM 3/10/24: 9:33 AM, 9:59 PM 3/11/24: 8:03 AM; R2 discharged on this day. There is no documentation indicating that staff increased R2's toileting schedule and took her to the bathroom frequently. On 3/25/24 at 1:58 PM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C what interventions were in place for R2. RN C stated that staff always had R2 with them, put her in the dining room for increased supervision, taking her to the bathroom after each meal, and have her in the hallway watching people. Surveyor asked RN C if the facility uses any types of alarms, RN C stated no. Surveyor asked RN C if R2 was placed on 15-minute checks, RN C stated no. Surveyor asked RN C if there was a staff member always on the hall to monitor R2, RN C stated no. It is important to note that R2's room was on the far hallway of the unit and was not near frequently used staff areas. On 3/25/24 at 2:15 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D to explain R2's fall interventions. CNA D stated that R2 has a low bed, frequent checks, have personal items within reach, take her to the bathroom, and have R2 follow staff down the hallway. Surveyor asked CNA D how often checks were made on R2. CNA D stated more than every 2 hours. Surveyor asked CNA D if she documented the frequent checks? CNA D stated that she didn't know where to document that. On 3/25/24 at 2:44 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if they determine what the root cause of a fall is. DON B stated that it depends on where the resident is and that most root causes would be a failed self-transfer because they shouldn't be up by themselves. Surveyor asked DON B if a resident is attempting to go to the bathroom and falls, would the attempt to go to the bathroom be the root cause? DON B stated no, the root cause would be the self-transfer. Surveyor asked DON B if care plan interventions were re-assessed for effectiveness. DON B stated that 90% of falls are due to cognition and impulsiveness. Surveyor asked DON B if there was documentation that toileting was being completed as indicated in the care plan? DON B stated that she would have to look in the computer. Surveyor asked DON B if staff increased the frequency of checking on R2? DON B stated that if staff were walking past R2's room, they were to check on her. Surveyor asked if the frequent checks were documented anywhere, DON B stated no. It important to note that the facility did not provide evidence of increased supervision or increased toileting as care planned, root cause analysis was determined to be failed self-transfers not, R2 continued to have falls with no evidence of increased supervision to prevent falls. R2 fell and required seven (7) stitches to her forehead.