Every finding on record at Oakridge Gardens Nur Ctr, Inc

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R39) of 9 sampled residents.R39 had an open wound on the right medial malleolus with drainage that required a dressing change. R39 was not on enhanced barrier precautions (EBP). During an observation of care, staff did not wear the required personal protective equipment (PPE) while assessing R39's wound.Findings include:The facility's Enhanced Barrier Precautions (EBP) policy, revised 4/15/26, indicates: Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the transmission of multidrug-resistant organisms (MDROs) to residents. 2. EBP employs targeted gown and glove use in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing high-contact resident care .3. Examples of high-contact resident care requiring the use of gown and gloves for EBP include: .h. Wound care (any skin opening requiring a dressing).The facility's EBP sign indicates: Use EBP for residents with indwelling medical devices, wounds, or those who are colonized by or infected with a multidrug-resistant organism (MDRO). Use EBP when: .providing wound care. Between 8/10/26 and 8/12/26, Surveyor reviewed R39's medical record. R39 had diagnoses including non-pressure chronic ulcer of right ankle and right lower leg, localized edema, and congestive heart failure (CHF). A Minimum Data Set (MDS) assessment, dated 7/7/26, stated R39 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition.A care plan, initiated 6/3/26, indicated R39 had impaired skin integrity due to venous wound of the right medial malleolus related to venous stasis, CHF, and impaired mobility. The care plan contained interventions to document the location of the wound, amount of drainage, peri-wound area, pain, edema, and circumference measurements per policy (revised 6/3/26); Weekly treatment documentation to include measurement of each area of skin breakdown - width, length, depth, type of tissue and exudate and any other notable changes or observations (revised 6/3/26); and enhanced barrier precautions (revised 8/12/26). From 8/10/26 at 10:24 AM to 8/12/26 at 8:30 AM, Surveyor did not observe an EBP sign or PPE cart outside R39's room. On 8/11/26 at 2:40 PM, Surveyor interviewed R39 who indicated staff do not wear gowns when they assist them with care, including wound dressing changes, but do wear gloves at times. R39's medical record contained the following orders: ~ Wound Care = 2 Layers: (Skin tear/left upper back arm) Clean with (normal saline), pat dry, apply Adaptic gauze, and cover with foam bordered dressing (every) 3 days until healed. Once daily for 3 days (dated 8/7/26).~ Wound Care = 1 Layer: (Non-blanchable area/right outer foot) Apply skin prep to area twice daily until resolved (dated 8/5/26).~ Wound Care = (Shearing/left buttock) Apply Calmoseptine to shearing on left buttock every shift and as needed until resolved (dated 8/4/26).~ Wound Care = 3 (or more) Layers: (Skin tear/left side of intergluteal cleft) Cleanse area with normal saline, apply skin prep to peri-wound, apply thin layer of leptospermum honey to wound bed, and cover with foam border dressing. Change once daily and as needed if soiled or saturated (dated 8/4/26).~ Wound Care = 3 (or more) Layers: (Venous wound/right medial ankle) Cleanse wound with normal saline, apply skin prep to peri-wound, apply thin layer of leptospermum honey to wound bed, and cover with foam border dressing. Change once daily and as needed if saturated, soiled, or dislodged (dated 6/3/26).R39's medical record contained the following wound assessments:~ 8/5/26 - Right medial malleolus wound: 0 centimeters (cm) x 0.99 cm x 0.87 cm with moderate serous drainage.~ 7/29/26 - Right medial malleolus wound: 0 cm x 0.58 cm x 0.43 cm with moderate serous drainage.~ 7/22/26 - Right medial malleolus wound: 0 cm x 0.38 cm x 0.37 cm with minimal serous drainage.~ 7/15/26 - Right medial malleolus wound: 0 cm x 0.94 cm x 0.64 cm with moderate serous drainage.~ 7/8/26 - Right medial malleolus wound: 0 cm x 0.94 cm x 0.64 cm with moderate serous drainage.~ 7/1/26 - Right medial malleolus wound: 0 cm x 0.95 cm x 0.63 cm with minimal serous drainage.On 8/12/26 at 8:30 AM, Surveyor observed License Practical Nurse (LPN)-D assess R39's right outer foot and left buttock. LPN-D donned gloves and pulled back the Mepilex dressing on R39's right outer foot. LPN-D was not wearing a gown. Surveyor did not observe an EBP sign or PPE cart outside R39's room. LPN-D indicated R39 did not need to be on EBP because the wound was not draining. On 8/12/26 at 8:45 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R39 did not require EBP because their wounds were not draining. DON-B stated the facility's EBP policy indicates EBP is required for wounds that are draining. On 8/12/26 at 10:20 AM, Surveyor interviewed Infection Preventionist (IP)-C who indicated R39's wounds have had and continue to have minimal drainage. IP-C stated R39 did not require EBP and indicated the facility's policy indicates wounds with heavy drainage require EBP.On 8/12/26 at 10:58 AM, Surveyor interviewed DON-B regarding the faciity's EBP policy and R39's wound assessments. DON-B was not aware that R39's wounds were draining and verified R39 should be on EBP.

Based on interview and record review, the facility did not ensure 1 resident (R) (R64) of 5 sampled residents from a total sample of 12 residents was provided a pneumococcal vaccine as indicated.R64 and their Guardian gave consent to administer a pneumococcal vaccine. The facility did not administer the vaccine. Findings include: The facility's Pneumococcal Vaccine policy indicates: Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series .7. Administration of pneumococcal vaccines are made in accordance with Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. According to the CDC PneumoRecs VaxAdvisor, the recommendation for R64's age group is to give 1 dose of PCV20 (pneumococcal conjugate vaccine) or PCV21 at least 5 years after the last pneumococcal vaccine dose. Between 8/10/26 and 8/12/26, Surveyor reviewed R64's medical record. R64 was admitted to the facility on [DATE] and had diagnoses including acute respiratory failure, sleep apnea, and Alzheimer's disease. R64 had a Guardian.A Comprehensive Minimum Data Set (MDS) assessment, dated 3/25/26, indicated R64's pneumococcal vaccination was not up to date and they were not eligible for the vaccine due to a medical contraindication.A Quarterly MDS assessment, dated 7/6/26, indicated R64's pneumococcal vaccination was not up to date and R64 was offered but declined the vaccine. A Wisconsin Immunization Record (WIR) in R64's medical record indicated they received a Prevnar 13 vaccine on 3/12/15 and a Pneumovax 23 vaccine on 5/2/08. According to current CDC recommendations, R64 was eligible for one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine based on shared clinical decision making.A Vaccine Documentation and Consent Form, signed 3/10/26, contained consent and authorization to administer pneumococcal, influenza, COVID-19, and RSV vaccines to R64.R64's March 2026 Medication Administration Record (MAR) indicated the following:~ An influenza vaccine was administered on 3/13/26. ~ A respiratory syncytial virus (RSV) vaccine was administered on 3/18/26.~ A COVID-19 vaccine was administered on 3/18/26. On 8/12/26 at 3:12 PM, Surveyor interviewed Director of Nursing (DON)-B who stated Infection Preventionist (IP)-C enters a detailed progress note regarding immunizations upon a resident's admission. DON-B and Surveyor reviewed a progress note written on 3/17/26 that indicated R64's orders were updated to reflect their preferred time for administration on 3/18/26. On 8/12/26 at 3:43 PM, Surveyor interviewed DON-B and IP-C who provided the documents used upon admission to document immunization information. After reviewing the documentation, DON-B and IP-C verified R64 did not receive a PCV20 or PCV21 vaccine.

Based on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associates or higher level degree in food service management or hospitality. This practice had the potential to affect all 66 residents residing in the facility. Dietary Manager (DM)-F was not enrolled in an approved Dietary Manager training course. Findings include: On 5/12/25 at 8:34 AM, Surveyor interviewed [NAME] (CK)-E who indicated Dietary Manager (DM)-F oversaw the kitchen but was on vacation. CK-E indicated Registered Dietitian (RD)-G was at the facility once weekly on Wednesdays. Surveyor requested DM-F's certification and was provided with a copy of a ServSafe Food Protection Manager Certification that was completed on 2/18/22 but is not an approved Dietary Manager course. On 5/13/25, Surveyor requested further certification such as a Dietary Manager or Food Service Manager Certification or a Food Service Management or Hospitality associates degree for DM-F from Nursing Home Administrator (NHA)-A. NHA-A indicated DM-F did not have any other certification. Surveyor noted DM-F's hire date was 5/3/2022. On 5/13/25 at 2:45 PM, Surveyor interviewed NHA-A who indicated the facility had not filed a waiver for the Dietary Manager position. On 5/14/25 at 10:41 AM, Surveyor interviewed DM-F via phone who indicated DM-F had ServSafe certification. DM-F indicated DM-F did not complete any other certification and was not currently enrolled in a certification program. DM-F confirmed RD-G was at the facility once weekly.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect more than 4 of the 66 residents residing in the facility. The facility did not ensure food was dated/stored in a manner to ensure food safety. Findings include: Food Labeling/Storage: The facility's Food Receiving and Storage policy, dated 4/4/25, indicates: Food shall be received and stored in a manner that complies with safe food handling practices .Dry Storage: .4. Dry foods that are stored in bins and removed from the original packaging, labeled, and dated (use-by date) .Refrigerated/Frozen Storage: 1. All foods in the refrigerator or freezer is covered, labeled, and dated (use-by date). The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5º C (Celsius) (41º F) (Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. The 2022 FDA Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition: (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17 (A). On 5/12/25 at 8:34 AM, Surveyor conducted an initial kitchen tour with [NAME] (CK)-E who indicated Dietary Manager (DM)-F was on vacation. Surveyor observed the following items in the cooler, freezer, and dry storage areas: Cooler: ~ One container of chicken noodle soup dated 5/9 with no use-by date ~ One container of sliced cheese dated 5/7 with no use-by date ~ One open container of shredded mozzarella cheese dated 4/16 with no use-by date ~ One open container of shredded mozzarella cheese dated 5/4 with no use-by date ~ One unlabeled package of lettuce (per CK-E) dated 5/6 with no use-by date ~ One unlabeled package of hard boiled eggs (per CK-E) dated 5/9 with no use-by date ~ One open container of sour cream with no open or use-by dates ~ One open container of cottage cheese dated 5/5 with no use-by date ~ One open package of pre-cooked bacon strips with no open or use-by dates ~ One open container of olives dated 5/5 with no use-by date ~ One open container of Italian dressing dated 5/6 with no use-by date ~ One open container of barbeque sauce dated 3/4 with no use-by date ~ One open container of pickles dated 4/5 with no use-by date ~ One container of pizza sauce dated 5/4 with no use-by date ~ One container of peas dated 5/7 with no use-by date ~ One unlabeled container of diced ham (per CK-E) dated 5/8 with no use-by date ~ One unlabeled container of sliced turkey (per CK-E) dated 4/27 with no use-by date ~ One container of ham dated 5/2 with no use-by date ~ One container of deli meat dated 4/25 with no use-by date ~ Two unlabeled and undated pans of sweet potatoes (per CK-E) ~ One pan of cake with a made date of 5/10 and no use-by date Freezer: ~ One package of baked biscuits dated 5/6 (made date per CK-E) with no use-by date ~ One unlabeled and undated package of tater tots (per CK-E) ~ One package of donuts dated 5/5 with no use-by date ~ One open and undated package of pre-cooked pasta ~ One pan of taquitos and flautas dated 5/5 with no use-by date ~ One unlabeled and undated package of raw frozen chicken breasts (per CK-E) Dry Storage: ~ One container of breadcrumbs dated 3/5 with no use-by date ~ One open container of dry mashed potatoes dated 5/9 with no use-by date ~ One open package of brown gravy powder dated 4/25 with no use-by date ~ One container of Special K dated 2/2 with no use-by date ~ One container of Raisin Bran dated 5/8 with no use-by date ~ One container of Cinnamon Toast Crunch dated 3/30 with no use-by date ~ One container of Fruit Loops dated 4/28 with no use-by date ~ One unlabeled container of Frosted Flakes (per CK-E) dated 4/17 with no use-by date ~ One container of Cheerios dated 4/13 with no use-by date ~ One container of Corn Flakes dated 3/18 with no use-by date ~ One container of [NAME] Krispies dated 4/28 with no use-by date ~ One open package of cake mix dated 1/24 with no use-by date ~ One open package of oats dated 5/12 with no use-by date ~ One open package of Cream of Wheat Farina dated 2/27 with no use-by date ~ Two open packages of [NAME] Wheats dated 1/11 and 3/11 with no use-by dates ~ One open package of croutons dated 4/10 with no use-by date ~ One package of graham cracker crumbs dated 4/29 with no use-by date ~ One container of Raisin Bran with an open date of 1/5/25 (per CK-E) and no use-by date ~ One container of crisp rice cereal with a received date of 11/5/24 (per CK-E) and no open or use-by dates ~ One open and unlabeled pack of brown gravy mix (per CK-E) with an open date of 12/30/24 and no use-by date ~ One open package of bread crumbs with a received date of 11/27/24 (per CK-E) and no open or use-by dates During the initial kitchen tour on 5/12/25 at 8:34 AM, Surveyor interviewed CK-E who was not sure how long items should be stored and was not aware of use-by dates. CK-E stated many items in the refrigerator were kept for three days but some were kept longer. When asked how long dry cereal can be used after opening, CK-E was not sure. CK-E also could not specify how long other open dry goods and freezer items should be stored. CK-E was not aware of a specific food storage policy but indicated CK-E may have received training after CK-E was hired. On 5/14/25 at 10:41 AM, Surveyor interviewed DM-F via phone who indicated kitchen staff should know appropriate food storage and dating policies and procedures.

Based on observation, staff interview, and record review, the facility did not ensure medications for 3 residents (R) (R270, R62, and R57) in 3 of 6 medication carts were labeled and/or dated appropriately and that expired medical supplies were removed from storage. In addition, the facility did not ensure expired supplies were removed from storage in 2 of 4 medication storage areas. This practice had the potential to affect more than 4 of the 66 residents residing in the facility. Medication carts contained open, unlabeled and undated inhalers, eye drops, and nasal sprays and expired medical supplies. Medication storage areas contained expired items. Findings include: The facility's Specific Medication Administration Procedures IIB1: Administration Procedures for all Medications, revised 1/2018, indicates: .D. Check expiration date on package/container . On [DATE] at 11:05 AM, Surveyor observed the [NAME] Rehab medication cart and noted the following: ~ One Tegaderm film 1622W dressing with an expiration date of [DATE] Following the observation, Licensed Practical Nurse (LPN)-O confirmed the above item was expired. On [DATE], Surveyor observed the North medication cart and noted the following: ~ One bottle of fluticasone nasal spray for R270 with no open date ~ One bottle of 0.004% travoprost eye drops for R62 with an expiration date of [DATE] ~ One box of Filac probe covers with an expiration date of [DATE] ~ Open and undated duo nebulizer vials for R57 (foil opened) ~ Five Povidone-iodine UAP pads with expiration dates of 12/2023 ~ Two Tegaderm film 1622W dressings with expiration dates of [DATE] ~ One Mepilex border post AG dressing with an expiration date of [DATE] Following the observation, LPN-O verified the above items were expired. On [DATE] at 10:42 AM, Surveyor observed the medication room on the Rehab unit and noted the following: ~ One box of CoaguChek XS PT test strips with an expiration date of [DATE] ~ One first aid essentials kit with an expiration date of [DATE] On [DATE] at 11:00 AM, Registered Nurse (RN)-N confirmed the above items were expired. On [DATE], Surveyor observed the North medication storage room and noted the following: ~ Two G2 Gatorade low sugar bottles with expiration dates of [DATE] ~ One bottle of 0.005% Lantanoprost eye drops for R62 with an expiration date of [DATE] ~ One vac granufoam dressing with an expiration date of [DATE] ~ One central line dressing change tray with an expiration date of [DATE] Following the observation, LPN-O verified the above items were expired. On [DATE] at 2:05 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated there should not be expired items in the medication storage areas or medication carts. DON-B confirmed items should be dated with an open date.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 66 residents residing in the facility. Staff line lists did not contain last symptom dates or times and/or return to work dates for 14 staff. In addition, the facility allowed 7 staff with gastrointestinal (GI) illness symptoms to return to work earlier than recommended per the facility's policy and the Centers for Disease Control and Prevention (CDC) guidelines. The facility also allowed 1 staff who tested positive for influenza to return to work earlier than recommended per the facility's policy. R172 was on contact precautions. On 5/12/25, Physical Therapist (PT)-H provided care in R172's room without a gown and gloves. Staff did not sanitize the vitals machine after use for R33. The facility did not ensure R268 was kept on enhanced barrier precautions (EBP) related to a chronic history of multidrug-resistant organisms (MDROs). Findings include: The facility's Influenza, Prevention and Control of Seasonal policy, revised 3/2022, indicates: The facility follows current guidelines and recommendations for the prevention and control of seasonal influenza .Symptomatic Healthcare Workers: 1. The Infection Preventionist and/or designee monitors and manages ill healthcare personnel. 2. Staff who develop fever and respiratory symptoms are: .b. excluded from work until at least 24 hours after they no longer have a fever (without the use of fever-reducing medicines such as acetaminophen). Those with ongoing respiratory symptoms will be considered for evaluation by the Infection Preventionist and/or designee to determine appropriateness of contact with residents. c. considered for temporary reassignment or exclusion from work for 7 days from symptom onset or until the resolution of symptoms, whichever is longer, if returning to care for immunocompromised residents. 3. Staff with fever alone will follow the general policy for staff with fever until a more specific cause of fever is identified or until fever resolves. The facility's Norovirus Prevention and Control policy, revised 10/2011, indicates: The facility will implement strict infection control measures to prevent the transmission of norovirus infection .21. Healthcare personnel who have symptoms consistent with norovirus infection will adhere to sick leave policies. 22. Ill personnel will be excluded from work for a minimum of 48 hours after the resolution of symptoms. The facility's Coronavirus Disease (COVID-19)-Work Restrictions and Return to Work Criteria for Staff policy, revised 6/2023, indicates: Staff who have symptoms of COVID-19 or have tested positive for SARS-CoV-2 infection follow CDC guidelines and the facility's policy for work restrictions and return-to-work-criteria. Work Restrictions for Asymptomatic Staff Following a Higher-Risk Exposure: 2. If work restrictions are implemented, staff can return to work: .e. after day 7 following the exposure (day 0) if they do not develop symptoms and all viral testing as described for asymptomatic staff with higher risk exposure is negative; or f. After day 10 following the exposure (day 0) if viral testing is not performed and if they do not develop symptoms .Return to Work Criteria for Asymptomatic Staff with SARS-CoV-2 Infection: .5. Staff who are asymptomatic throughout their infection and are not moderately to severely immunocompromised may return to work if at least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). Work Restrictions for Staff with Symptoms of COVID-19: 1. Staff with even mild symptoms of COVID-19 are prioritized for viral testing with nucleic acid or antigen detection assays. 2. Symptomatic staff are restricted for work pending the results of testing. a. Staff who do not test positive for COVID-19 but have symptoms follow the symptom based strategy for returning to work. A second test may be performed at the discretion of the practitioner evaluating the situation. b. Symptomatic staff who test positive for COVID-19 follow the symptom-based strategy for returning to work. Return to Work Criteria for Symptomatic Staff with SARS-CoV-2 Infection: .4. Staff with mild to moderate illness who are not moderately to severely immunocompromised may return to work after the following criteria are met: a. At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7); and b. At least 24 hours have passed since the last fever without the use of fever-reducing medications; and c. Symptoms have improved. The CDC (dated 3/21/24), 42a. category IB recommends healthcare personnel with gastrointestinal (GI) illnesses, particularly those with symptoms like vomiting or diarrhea, be excluded from work for a minimum of 48 hours after their symptoms have resolved. The facility's Isolation-Categories of Transmission Based Precautions policy, revised 10/2018, indicates: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; And is at risk of transmitting the infection to other residents .4. Staff and visitors will wear clean, non-sterile gloves when entering the room .5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room . 1. On 5/12/25, Surveyor reviewed the facility's staff line list and noted the following staff did not have documented resolved symptom dates and/or return to work dates: ~ Certified Nursing Assistant (CNA)-V had nausea and a headache with an onset date of 5/13/25. The line list did not contain a last symptom date or time or return to work date. ~ CNA-W had nausea with an onset date of 4/18/25. The line list did not contain a last symptom date or time or a return to work date. ~ Laundry Aide (LA)-X had a headache, fever, and a cough with an onset date of 4/14/25. The line list did not contain a last symptom date or time or a return to work date. ~ CNA-S had vomiting and nausea with an onset date of 2/17/25 and a return to work date of 2/18/25. The line list did not contain a last symptom date or time. ~ CNA GG had a fever, body aches, a headache, and a sore throat with an onset date of 2/18/25 and a last symptom date of 2/21/25. The line list did not contain the time of the last symptom or a return to work date. ~ Dietary Aide (DA)-Z had a fever with an onset date of 2/11/25 and a return to work date of 2/13/25. The line list did not contain a last symptom date or time. ~ CNA-AA had nausea, vomiting, a headache, and body aches with an onset date of 2/11/25 and a last symptom date of 2/11/25. The line list did not contain the time of the last symptom or a return to work date. ~DA-Y had vomiting with an onset date of 2/8/25 and a return to work date of 2/9/25. The line list did not contain a last symptom date or time. ~ CNA-BB had nausea, vomiting, and diarrhea with an onset date of 1/30/25. The line list did not contain a last symptom date or time or return to work date. ~ CNA-HH had a cough, body aches, a headache, and a sore throat with an onset date of 1/29/25. The line list did not contain a last symptom date or time or a return to work date. ~ LA-CC had a fever and body aches with an onset date of 1/26/25 and a return to work date of 1/27/25. The line list did not contain a last symptom date or time. ~ CNA-DD was COVID-19 positive on 12/31/25 with a return to work date of 1/7/25. The line list did not contain a last symptom date or time. ~ CNA-EE had a sore throat, cough, and a headache with an onset date of 12/14/24 and a return to work date of 12/15/24. The line list did not contain a last symptom date or time. ~ CNA-FF was COVID-19 positive on 11/15/24 with a return to work date of 11/21/24. The line list did not contain a last symptom date or time. On 5/12/25, Surveyor reviewed the facility's staff line list and noted the following staff with GI symptoms returned to work earlier than recommended: ~ Licensed Practical Nurse (LPN)-II had nausea and diarrhea with an onset date of 4/27/25, a well date of 4/28/25, and a return to work date of 4/29/25. ~ CNA-JJ had nausea with an onset date of 4/17/25, a well date of 4/17/25, and a return to work date of 4/18/25. ~ LPN-KK had vomiting, diarrhea, and abdominal pain with an onset date of 3/16/25, a well date of 3/17/25, and a return to work date of 3/18/25. ~ Hospitality Aide (HA)-LL had vomiting with an onset date of 2/15/25, a well date of 2/16/25, and a return to work date of 2/17/25. ~ CNA-MM had vomiting with an onset date of 2/15/25, a well date of 2/15/25, and a return to work date of 2/16/25. ~ CNA-NN had vomiting and a headache with an onset date of 1/21/25, a well date of 1/21/25, and a return to work date of 1/22/25. ~ Registered Nurse (RN)-OO had vomiting and diarrhea with an onset date of 1/6/25, a well date of 1/7/25, and a return to work date 1/8/25. On 5/12/25, Surveyor reviewed the facility's staff line list and noted the following staff tested positive for influenza and returned to work the same day their symptoms resolved: ~ LPN-J was positive for influenza on 2/11/25 with a well date and return to work date of 2/19/25. On 5/13/25 at 3:32 PM, Surveyor interviewed and reviewed the line lists with Infection Preventionist (IP)-U who verified the line lists were not completed correctly and were missing information. On 5/14/25 at 11:29 AM, Surveyor interviewed and reviewed the line lists with Director of Nursing (DON)-B who verified the line lists were not completed correctly and were missing information.3. On 5/12/25 at 9:15 AM, Surveyor observed CNA-K obtain R33's blood pressure, temperature. and pulse oximeter reading. CNA-K then took the vitals machine down the hallway, plugged the machine in, and walked away. Surveyor stopped CNA-K and asked if the machine should be sanitized after use. CNA-K confirmed yes. DON-B passed in the hallway and reminded CNA-K to sanitize the vitals machine after use. 4. On 5/12/25 at 11:03 AM, Surveyor observed an isolation cart outside R268's room and garbage cans inside the door. R268 did not have a precautions sign on or near R268's door. On 5/12/25 at 1:16 PM, Surveyor interviewed LPN-P who indicated IP-U removed R268 from precautions that morning because R268's catheter was removed and R268 no longer needed to be on EBP. On 5/13/25, Surveyor reviewed R268's medical record which indicated R268 was a carrier of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA) with a onset date of 5/6/25. R268's Hospital Discharge summary, dated [DATE], indicated MRSA and MSSA were added to R268's diagnoses list on 6/12/24. On 5/13/25 at 3:37 PM and 3:54 PM, Surveyor interviewed DON-B who confirmed a resident with a chronic history of MRSA or MSSA should be on EBP. DON-B indicated R268 should not have been taken off of EBP. DON-B indicated R268 was taken off of EBP because R268's catheter was removed on (5/9/25). DON-B indicated R268 should have remained on EBP. On 5/14/25 at 9:21 AM, Surveyor noted R268 was still not on EBP. 2. On 5/12/25, Surveyor reviewed R172's medical record. R172 was admitted to the facility on [DATE] and had diagnoses including extended spectrum beta lactamase (ESBL), abnormal findings of blood chemistry, bacteremia, and unspecified Escherichia coli (E. coli). R172's Minimum Data Set (MDS) assessment, dated 5/10/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R172 had intact cognition. R172's medical record indicated R172 was on contact precautions due to ESBL. On 5/12/25 at 11:12 AM, Surveyor observed a contact precautions sign near the door to R172's room. The sign indicated: Stop. Contact precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 5/12/25 at 11:33 AM, Surveyor observed PT-H enter R172's room without completing hand hygiene or donning a gown and gloves. PT-H left the door partially open. From the hallway, Surveyor heard PT-H provide care and talk with R172 about the care being provided. On 5/12/25 at 11:46 AM, Surveyor observed PT-H exit R172's room. Surveyor interviewed PT-H who indicated PT-H had been providing in-room physical therapy for R172. PT-H indicated PT-H was still providing services and needed to retrieve something. Surveyor observed PT-H cleanse hands with hand sanitizer and exit the area. On 5/12/25 at 11:47 AM, Surveyor observed PT-H return to the entrance of R172's room and don a gown and gloves. Surveyor interviewed PT-H who confirmed PT-H did not wear a gown or gloves while providing physical therapy in R172's room earlier. PT-H indicated PT-H was donning personal protective equipment (PPE) because PT-H was going to assist R172 to the bathroom. On 5/12/25 at 12:00 PM, Surveyor interviewed PT-H who was unsure if PT-H should wear PPE during physical therapy for R172. PT-H indicated PT-H worked for an agency and all facilities were different. When asked if PT-H was familiar with contact precautions, PT-H stated PT-H watched multiples videos and should be. PT-H read the contact precautions sign outside 172's room and indicated PT-H should have worn a gown and gloves to provide physical therapy for R172. PT-H indicated precautions were confusing. PT-H did not understand why PT-H needed to wear PPE in the room to provide therapy but could take it off to bring R172 down the hallway to provide therapy outside R172's room. On 5/13/25 at 3:51 PM, Surveyor interviewed DON-B who indicated staff should wear PPE to provide any care for R172, including physical therapy. DON-B indicated DON-B was strict and PPE should be worn for anybody within three feet of R172 or any resident on contact precautions. DON-B indicated all staff including agency staff are aware of transmission based precautions (TBP) including contact precautions and there is no excuse for not following them. DON-B indicated DON-N provided additional training for staff to understand the difference between contact and enhanced barrier precautions.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R50 and R57) of 23 sampled residents had the appropriate signatures on their Emergency Care Do Not Resuscitate Order (DNR) forms (Department of Health Services (DHS) Division of Public Health F-44763) thus rendering the DNR orders invalid. R50 had an activated Power of Attorney for Healthcare (POAHC). R50's DNR form was not signed by R50 or R50's POAHC. R57's DNR form was not signed by R57 or R57's POAHC. Findings include: Chapter 155.05(2) Wisconsin Statute indicates: .(2) Unless otherwise specified in the power of attorney for healthcare instrument, an individual's power of attorney for healthcare takes effect upon a finding of incapacity by 2 physicians, as defined in s. 448.01 (5), or one physician and one licensed psychologist as defined in s. 445.01 (4) who personally examine the principal and sign a statement specifying that the principal has incapacity. The statute also indicates: A copy of the statement, if made, shall be appended to the power of attorney for healthcare instrument. Emergency Care Do Not Resuscitate Order (DNR) form (Department of Health Services (DHS) F-44763) indicates on the signature portion: Signature - Patient or Legal Guardian or Healthcare Agent of an incapacitated patient (Circle title of who is signing this request). The facility's Do Not Resuscitate Order policy, dated 3/2025, indicates: .2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate as permitted by state law) and placed in the front of the resident's medical record . 1. On [DATE], Surveyor reviewed R50's medical record and noted R50's DHS F-44763 form was signed by a staff nurse. R50's medical record contained documentation that indicated R50 had an activated Power of Attorney for Healthcare (POAHC). On [DATE] at 10:21 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R50's DNR form was not signed by R50's POAHC. DON-B indicated the admission team reviews the code status of residents verbally, however, a new process will be put in place to use the actual DNR document. 2. On [DATE], Surveyor reviewed R57's medical record. R57 was admitted to the facility on [DATE]. R57's consent for Emergency Care-Do Not Resuscitate (DNR) form (DHS F-44763) was signed on [DATE] by Person (PRN)-M. The DNR form was signed by the attending physician on [DATE]. R57's medical record indicated POAHC-L was R57's POAHC. A Social Service assessment, dated [DATE] at 7:58 PM, noted R57's activated POAHC was POAHC-L and R57 had a code status of DNR. On [DATE] at 3:05 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-I who verified POAHC-L was R57's POAHC. ADON-I was not sure who PRN-M was. On [DATE] at 3:25 PM, Surveyor interviewed ADON-I who stated POACH-L was not able to sign R57's paperwork at the time of admission related to shoulder surgery. ADON-I provided Surveyor with documentation, dated [DATE] at 2:34 PM, that indicated a nurse called POAHC-L who had shoulder surgery on [DATE] and stated POAHC-L would be in the facility within the next couple of days. The code status was reviewed and POAHC-L's wish was for R57 to not have CPR. The facility had PRN-M sign the paperwork instead of POAHC-L on [DATE]. ADON-I confirmed the form was a legal document and required POAHC-L's signature to be valid.

Based on observation, staff interview, and record review, the facility did not follow the plan of care during a transfer for 1 resident (R) (R45) of 2 sampled residents. R45 had a history of falls. R45's plan of care contained an intervention to use a gait belt and a 2-wheeled walker during transfers. On 5/12/25, staff transferred R45 without a gait belt or 2-wheeled walker. Findings include: The facility's Safe Program Lifting and Movement of Residents policy, revised 7/2017, indicates: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .2. Manual lifting of residents shall be eliminated when feasible .4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. On 5/12/25, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, right pubis fracture, fracture of nasal bones, and history of falls. R45's Minimum Data Set (MDS) assessment, dated 4/15/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R45 had severely impaired cognition. The MDS assessment also indicated R45 required partial to moderate assistance from a sitting to standing position. (This is defined as the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.) R45 had a Power of Attorney for Healthcare (POAHC) was responsible for R45's healthcare decisions. R45's care plan, dated 4/19/24, indicated R45 had limited physical mobility related to history of a right hip fracture. The care plan contained a goal that R45 would maintain R45's current level of mobility through the review date. The care plan contained an intervention to transfer with one assist with a 2-wheeled walker and a gait belt in and out of bed and to the toilet (initiated 9/6/23). A fall risk assessment, dated 4/11/25, indicated R45 required hands-on assistance to move from place to place, exhibited loss of balance while standing, and used an assistive device. Surveyor reviewed R45's fall history and noted R45 fell on 1/12/25 and 4/16/25. On 5/12/25 at 11:24 AM, Surveyor witnessed Certified Nursing Assistant (CNA)-R transfer R45 from wheelchair to scale. CNA-R put CNA-R's left arm under R45's right axillary area and assisted R45 to a standing position by pulling up on R45's left arm. CNA-R did not use a gait belt during the transfer. CNA-R went behind the wheelchair and put hands on R45's bilateral hips to guide R45 to a seated position in the wheelchair. On 5/12/25 at 11:24 AM, Surveyor interviewed CNA-R who stated R45 required one staff to assist with transfers. CNA-R acknowledged CNA-R did not use a gait belt to assist R45 from the wheelchair to a standing position and from a standing position to the wheelchair. CNA-R verified CNA-R should have used a gait belt during the transfer. On 5/13/25 at 12:37 PM, Surveyor interviewed Registered Nurse (RN)-T who indicated R45 was a pivot transfer with one assist. RN-T stated staff should use a gait belt and a 2-wheeled walker to transfer R45. On 5/13/25 at 1:02 PM, Surveyor interviewed CNA-S who indicated R45 was a pivot transfer with one assist. CNA-S stated staff should use a gait belt for all transfers with R45. On 5/14/25 at 2:24 PM Surveyor interviewed Director of Nursing (DON)-B who indicated staff should use a gait belt when transferring any resident, including R45. DON-B indicated R45 did not refuse use of a gait belt.

Based on observation, staff interview, and record review, the facility did not ensure the medication error rate was below 5%. During medication administration, Surveyor observed 4 errors out of 27 opportunities which resulted in an error rate of 14.81%. This affected 3 residents (R) (R36, R172, and R33) of 5 residents observed during medication administration Staff did not ensure intravenous (IV) medications were administered within the scheduled time frame for R36 and R172. Staff did not ensure R33's blood pressure was within the ordered parameters prior to administering medication. Findings include: The facility's Specific Medication Administration Procedures IIB2: Oral Medication Administration policy, revised 1/2018, indicates: .Review and confirm medication orders for each individual resident on the Medication Administration Record (MAR) prior to administering medications to each resident. Review Medication Administration Record for any test or vital signs that need to be determined prior to preparing the medications . The facility's Specific Medication Administration Procedures IIB2: Administration Procedures for all Medications policy, revised 1/2018, indicates: .Check for vital signs and other tests to be done during/prior to medication administration. 1. On 5/12/25 at 8:39 AM, Surveyor observed Licensed Practical Nurse (LPN)-J prepare ceftriaxone (an antibiotic medication) 25 milligrams (mg) in 50 milliliters (ml) of normal saline to be administered intravenously to R36. LPN-J the took constituted IV bag and tubing into R36's room. LPN-J ran the tubing in the machine but did not start the IV. LPN-J indicated LPN-J would notify Assistant Director of Nursing (ADON)-I that the IV was ready and prepped. LPN-J left R36's room with the medication hung on an IV pole. On 5/12/25 at 8:55 AM, LPN-J informed Surveyor that ADON-I was in a meeting and it would be a while before ADON-I could start the IV. On 5/12/25, Surveyor reviewed R36's MAR which indicated R36 should receive ceftriaxone sodium 2 grams (gm) intravenously once a day for infection to bone and bone marrow. Inject 2000 mg into vein once daily with sodium chloride 0.9% solution 50 ml. The IV was scheduled for 7:30 AM. On 5/12/25 at 9:53 AM, Surveyor observed ADON-I enter R36's room. On 5/13/25 at 8:38 AM, Surveyor reviewed a medication administration audit report that indicated LPN-J initialed administration of R36's antibiotic at 9:50 AM. 2. On 5/12/25 at 8:55 AM, Surveyor observed LPN-J set up an IV for R172. On 5/12/25 at 8:57 AM, Surveyor observed LPN-J prep ertapenen 1 gm in 100 ml of normal saline to administer intravenously to R172. LPN-J took the IV bag and tubing into R172's room. LPN-J ran the tubing in the machine but did not start the IV. LPN-J indicated LPN-J would notify ADON-I that the IV was ready and prepped. LPN-J left R172's room with the medication hung on an IV pole. On 5/12/25, Surveyor reviewed R172's MAR which indicated R172 should receive ertapenem sodium injection solution reconstituted 1 gm intravenously once daily for extended-spectrum beta-lactamase (ESBL). The IV was scheduled for 8:00 AM. On 5/12/25 at 9:38 AM, Surveyor noted R172's IV was still not started. On 5/12/25 at 9:57 AM, Surveyor interviewed R172 who confirmed the IV was not started. On 5/12/25 at 10:03 AM, Surveyor observed ADON-I enter R172's room to obtain a blood sample from the port. On 5/12/25 at 10:13 AM, Surveyor observed ADON-I start R172's IV. On 5/13/25 at 8:38 AM, Surveyor reviewed a medication administration audit report that indicated LPN-J administered R172's IV antibiotic at 10:20 AM. 3. On 5/12/25 at 9:08 AM, Surveyor observed LPN-J prepare medication for R33 which needed to be administered prior to R33's dialysis appointment. On 5/12/25 at 9:15 AM, Surveyor observed Certified Nursing Assistant (CNA)-K wheel R33 out of R33's room to go to dialysis. LPN-J administered R33's medications. After the medications were administered, CNA-K obtained R33's vital signs including blood pressure. On 5/12/25, Surveyor reviewed R33's medical record which contained an order for furosemide 80 mg 2 tablets to total 160 mg, if systolic blood pressure (SBP) is under 100 mg give 80 mg instead of 160 mg. R33 also had an order for isosorbide mononitrate extended release (ER) 60 mg once daily for hypertension, if SBP is under 100 hold isosorbide. On 5/13/25 at 2:05 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed vital signs should be taken prior to medication administration if needed. DON-B indicated LPN-J was not formally trained to administer an IV which is why ADON-I administered the flush and started the medication. DON-B confirmed medications with a scheduled time can be administered up to 1 hour before or after the scheduled time. DON-B indicated the resident's physician should be notified if the medication is administered late.

Based on staff interview and record review, the facility did not ensure the required Minimum Data Set (MDS) assessment data was transmitted timely for 3 residents (R) (R16, R175, and R174) of 3 sampled residents. R16 and R175s' Discharge MDS assessments were not completed or submitted. R174's Discharge MDS assessment was not submitted. Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.1, dated 10/2023, indicates: All Medicare and/or Medicaid-certified nursing homes must complete and transmit required Minimum Data Set (MDS) records to the Centers for Medicare and Medicaid Services' (CMS') Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. Required MDS records include: Admission, Quarterly, Annual, Discharge Assessments, Death, and Entry Tracking records .Comprehensive MDS assessments include: Admission, Annual, Significant Change .The MDS completion date must be no later than 14 days after the assessment reference date (ARD) .Non-comprehensive assessments include: Quarterly, Significant Correction to Prior Quarterly Assessment, Discharge Assessment-Return not Anticipated, and Discharge Assessment-Return Anticipated .The ARD of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent assessment .The MDS assessment must be transmitted (submitted and accepted into QIES) electronically no later than 14 calendar days after the MDS completion date .A Death in Facility Tracking Record must be completed when the resident dies in the facility within 7 days after the resident's death and submitted within 14 days of the resident's death. The facility's MDS Completion and Submission Timeframes policy, with a review date of July 2024, indicates: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 1. The assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments are based on the current requirements published in the Resident Assessment Instrument Manual . 1. On 5/13/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus and mycobacterial infection. R16 had a planned discharge to the community on 12/16/24. A Discharge Assessment was not completed or submitted for R16. 2. On 5/13/25, Surveyor reviewed R175's medical record. R175 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure and surgical aftercare. R175 had a planned discharge on [DATE]. R175's medical record contained a completed, but not accepted, Discharge-Return Not Anticipated Assessment, dated 9/18/23. 3. On 5/13/25, Surveyor reviewed R174's medical record. R174 was admitted to the facility on [DATE] and had diagnoses including hypothyroidism and vertebrae fracture. R174 had a planned discharge on [DATE]. A Discharge Assessment was not completed or submitted for R174. On 5/13/25 at 3:12 PM, Surveyor interviewed MDS Coordinator (MDSC)-C who did not know why R16, R175, and R174 were discharged without a Discharge Assessment completed. MDSC-C indicated MDSC-C was not doing MDS assessments at that time and was filling the position temporarily for MDSC-D. MDSC-C indicated MDSC-D would call surveyor regarding the missing assessments. On 5/14/25 at 10:42 AM, Surveyor interviewed MDSC-D via telephone. MDSC-D indicated R16's Discharge Assessment was missed. MDSC-D was unsure if R16 was a last minute discharge. MDSC-D indicated MDSC-D completed a Discharge Assessment for R175 but thought there was a computer or program malfunction and the MDS was not submitted. MDSC-D indicated it was MDSC-D's mistake for not completing the Discharge Assessment for R174. MDSC-D indicated there was some confusion on R174's admission Assessment and stated when MDSC-D fixed the admission Assessment, MDSC-D deleted the Discharge Assessment and missed MDSC-D's double check to do a Discharge Assessment. MDSC-D was aware of the MDS regulations, expectations, and timeline submissions and confirmed R16, R174, and R175's assessments were overdue and should have been completed. On 5/14/25 at 2:51 PM, Surveyor noted R16, R174, and R175's Discharge Assessments were completed and submitted by MDSC-D and were accepted.

Based on staff interview and record review, the facility did not thoroughly investigate an allegation of abuse for 2 residents (R) (R2 and R1) of 2 sampled residents. R2 reported an allegation of physical abuse on 1/19/25 that involved Certified Nursing Assistant (CNA)-E. The facility did not ensure CNA-E was removed from or supervised during resident care pending the results of the investigation. R1 reported to a nurse on 11/29/24 that R1 was recently raped by an unknown male staff. The facility did not thoroughly investigate the allegation of sexual abuse. Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated 9/3/24, indicates: Investigating Allegations: 1. All allegations are thoroughly investigated .7. The individual conducting the investigation at a minimum: a. Reviews the documentation and evidence. b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident. c. Observes the alleged victim, including his or her interactions with staff and other residents. d. Interviews the person reporting the incident. e. Interviews any witnesses to the incident. f. Interviews the resident (as medically appropriate) or the resident's representative. g. Interviews the resident's attending physician as needed to determine the resident's condition. h. Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .l. Documents the investigation completely and thoroughly. 1. On 2/7/25, Surveyor reviewed R2's medical record. R2 had diagnoses including dementia, hip fracture and other multiple trauma, and arthritis. R2's Minimum Data Set (MDS) Assessment, dated 11/19/24, contained a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R2 had severely impaired cognition. On 2/7/25, Surveyor reviewed a facility-reported incident (FRI) that indicated R2 reported to a nurse on 1/19/25 that CNA-E slapped R2's hand and indicated R2 was stinky. The FRI indicated CNA-E was removed from the floor until Nursing Home Administrator (NHA)-A was contacted and provided further instructions. On 1/19/25, NHA-A interviewed CNA-E via phone. Following the conversation, CNA-E was moved to different unit and allowed to provide resident care. NHA-A spoke to R2's Power of Attorney for Healthcare (POAHC) who indicated staff should not interview R2 until 1/20/25 when R2's POAHC could speak to R2. R2's POAHC also indicated the facility should not call the police until 1/20/25. The FRI also indicated NHA-A only interviewed 3 (including CNA-E) of the 17 staff who were working when the incident occurred. On 2/7/25 at 2:06 PM, Surveyor interviewed NHA-A who indicated CNA-E was immediately removed from resident care after the allegation and NHA-A was notified. NHA-A indicated R2's POAHC did not want the facility to call or do anything until the morning when R2's POAHC could talk to R2. NHA-A indicated with the information NHA-A had at the time, NHA-A decided to move CNA-E to a different unit to care for other residents. NHA-A did not feel CNA-E was a threat to other residents. NHA-A also confirmed only 3 staff who were working when the incident occurred were interviewed. 2. On 2/7/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including severe vascular dementia with mood disturbance, anxiety, and cognitive communication deficit. R1's MDS assessment, dated 12/10/24, contained a BIMS score of 4 out of 15 which indicated R1 was severely cognitively impaired. R1 had a corporate Guardian (initiated on 1/23/25). R1 had a family member as Guardian at the time of the alleged incident. On 2/7/25, Surveyor reviewed a FRI that indicated R1 reported to a nurse on 11/29/24 that R1 was recently raped by a male staff. R1 could not describe the male staff. R1 also stated R1 thought R1 was dreaming and it was dark, but the male touched (R1) and then left. During a subsequent interview, R1 stated R1 thought the male was R1's husband, but then knew it was not. The nurse assessed R1 and noted no trauma or bruising. Surveyor reviewed the facility's investigation and staff schedule from 11/29/24 and noted 6 staff who were working on the PM shift when the allegation was made were not interviewed, including 2 male staff. On 2/7/25 at 2:07 PM, Surveyor interviewed NHA-A who indicated not all staff on the shift were interviewed. Surveyor and NHA-A reviewed the 11/29/24 schedule which included 6 staff who were not interviewed, including Licensed Practical Nurse (LPN)-C and CNA-D who were male. NHA-A indicated LPN-C and CNA-D were not interviewed because they were on a different unit than R1. When Surveyor asked how NHA-A can be sure staff have no knowledge of the alleged incident if they are not interviewed, NHA-A indicated NHA-A did not interview staff who were not on the same unit as R1. Surveyor noted all units were easily accessible to staff.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 73 of 73 residents residing in the facility. Staff did not date items with open dates and received dates. Staff did not ensure food was stored in a sanitary manner. Staff did not wash hands when moving from dirty to clean activities. Staff did not wait two minutes to take microwave reheated food temperatures to ensure food was heated evenly. In addition, staff did not ensure microwaved foods reached the food safety temperature prior to serving. Findings include: Undated Items: The Food and Drug Administration (FDA) Food Code 2022 documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition (A): A food specified in 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). During an initial kitchen tour that began on 4/1/24 at 8:19 AM with Dietary Manager (DM)-K, Surveyor noted undated food items in the dry storage area and walk-in freezer. Surveyor also noted items that were open, unsealed, and did not contain open dates. Surveyor noted the following open, unsealed, and undated items: Dry Storage Area: ~Four open, unsealed, and undated bags of snack chips. ~Six open and undated bags of individual snack chips. ~One open, unsealed, and undated bag of brown sugar. ~One open and undated bag of cereal. ~One open and undated box of Cream of Wheat ~Two unopened and undated boxes of Cream of Wheat ~Two bags of undated marshmallows. Walk-In Freezer: ~One open and undated case of turkey pot pie. ~One unopened, undated case of turkey pot pie. ~One undated box of whipped topping. ~Eleven boxes that contained the following items: open pizza boxes with undated individual pizzas; undated hot dog and hamburger buns; undated frozen vegetables; undated chicken strips; various undated frozen foods. Surveyor interviewed DM-K who indicated the facility's process is to ensure all items are labeled with a received date or best-by date. DM-K indicated that the process for opening an item is to ensure an open date is placed on the item when opened. DM-K confirmed the items in the dry storage area and walk-in freezer did not contain received, best-by, or open dates. Sanitary Food Storage: The FDA Food Code 2022 documents at 3-305.11 Food Storage: (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. During the initial kitchen tour on 4/1/24, Surveyor observed eleven boxes of food items stacked on the floor of the freezer. Surveyor also observed an open case of frozen pizzas with individual pizzas stacked between the boxes on the floor. Surveyor interviewed DM-K who indicated food was delivered on 3/29/24 and indicated food is stored on the floor of the freezer because staff do not put the boxes away. DM-K confirmed the boxes should be removed from the floor and placed on shelves. Surveyor observed several open spaces in the freezer where boxes could be stored. Hand Hygiene: The FDA Food Code 2022 documents at 2-301.14 When to Wash: Food Employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: .(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination. During a continuous food service observation at the rehab dining room steam table that began on 4/2/24 at 7:25 AM, Surveyor observed Cook (CK)-L serve food from the steam table onto resident meal trays. Surveyor observed CK-L drop tongs from the sausage and bacon container on the kitchenette floor, put the tongs in the sink, and return to food service at the steam table without completing hand hygiene. With the same gloved hands, Surveyor observed CK-L put two pieces of bacon from of the steam table on a resident's plate. CK-L then picked up a piece of banana bread and put the banana bread on a resident's plate. With the same gloved hands, CK-L toasted and buttered a piece of bread and put the toast on a resident's plate. CK-L then removed gloves, cleansed hands, donned clean gloves, and continued preparing residents' trays at the steam table. Surveyor also observed CK-L complete the following activities during meal service without removing gloves and completing hand hygiene: ~CK-L took clean plates from the steam table to prepare residents' breakfast trays. While moving between the steam table and the stove, CK-L touched food items with the same gloved hands. ~CK-L put two pieces of bacon from the steam table on a resident's plate. CK-L then walked to the stove, cracked an egg, and touched a stove knob, cooking utensil, and a pan. CK-L then threw an egg in the garbage, finished cooking the egg on the stove, and placed the egg on a resident's plate. ~CK-L put a piece of banana bread on resident's plate. CK-L then toasted and buttered a piece of bread and placed the bread on a resident's plate. ~CK-L put two sausage links from the steam table on a resident's plate. CK-L then toasted and buttered a piece of bread and put the bread on a resident's plate. CK-L then touched items in a drawer, removed a pepper packet from a box in the kitchenette, and put the packet on a resident's plate. CK-L then returned to the steam table and continued with food service. ~CK-L put a piece of banana bread on a resident's plate. CK-L then picked up two pieces of bacon from the steam table and placed the bacon on a resident's plate. ~CK-L put a piece of banana bread on a resident's plate. CK-L then put two sausage links from the steam table on a resident's plate. ~CK-L put a piece of banana bread on a resident's plate. CK-L then scooped oatmeal from the steam table and put the oatmeal on a resident's plate. Surveyor noted the last food trays were delivered at 8:25 AM. On 4/2/24 at 1:30 PM, Surveyor interviewed DM-K regarding hand hygiene. DM-K stated DM-K provided previous education to CK-L to remain at the steam table to ensure cross contamination does not occur. DM-K also provided education that CK-L should use a tongs or scoop when serving food and obtain a clean utensil if a utensil is unavailable or dropped during service. DM-K stated CK-L was previously told to not use CK-L's hands to put food on residents' plates. Microwave Reheating/Food Safety Temperature: The FDA Food Code 2022 documents at 3-403.11 Reheating for Hot Holding: (A) Except as specified under (B) and (C) and in (E) of this section, time/temperature control for safety food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees Celsius (C) (165 degrees Fahrenheit (F)) for 15 seconds. (B) Except as specified under (C) of this section, time/temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. The FDA Food Code 2022 documents at section 3-403.11: .(C) and (D) Food that is taken from a commercially processed, hermetically sealed container or intact package cooked to a temperature of 135 degrees F. During a continuous food service observation at the rehab dining room steam table that began on 4/2/24 at 7:25 AM, Surveyor observed CK-M cook or reheat the following food in the microwave: ~CK-M microwaved Cream of Wheat for thirty seconds, stirred the Cream of Wheat, and microwaved the Cream of Wheat for another thirty seconds. CK-M stirred the Cream of Wheat again and put the Cream of Wheat in a bowl on a resident's tray. CK-L did not temp the Cream of Wheat after it was covered or allow the Cream of Wheat to stand for two minutes to obtain a safe temperature. ~CK-M microwaved Cream of Wheat for thirty seconds and put the Cream of Wheat in a bowl on a resident's tray. CK-M did not temp the Cream of Wheat after it was covered and allow the Cream of Wheat to stand for two minutes to obtain a safe temperature. ~CK-M microwaved a breakfast burrito for 20 seconds and put the burrito on a resident's plate. CK-M did not obtain a temperature to ensure the burrito reached 165 degrees F or allow the burrito to stand covered for two minutes prior to service. ~CK-M obtained a coffee cup from a resident in the dining room who stated the coffee was cold. CK-M microwaved the coffee for thirty seconds and gave the coffee to the resident. On 4/2/24 at 1:30 PM, Surveyor interviewed DM-K regarding microwaving food, not obtaining food temperatures when cooking or reheating food, and not covering and letting the food stand for two minutes prior to service. DM-K confirmed DM-K expected staff to follow the procedure to ensure foods are reheated properly and to a safe temperature.

Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 Resident (R) (R50) of 2 residents. R50 was observed laying across another resident in their bed without clothes on. The potential allegation of abuse was not reported to the State Agency (SA) or local law enforcement. Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, with a revised date of September 2023, indicates: 1. If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and/or designee and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency responsible for surveying/licensing the facility 3. Law enforcement officials. On 4/2/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and vascular dementia. R50's Minimum Data Set (MDS) assessment, dated 1/11/24, contained a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R50 was severely cognitively impaired. A behavior progress note, dated 9/28/23 at 6:30 AM, indicated: Writer was notified by Certified Nursing Assistant (CNA) around 1:00 AM that (R50) was out of (R50's) room. (R50) was found laying in another resident's room without any clothes on. (R50) was laying on top of the other resident's legs when found. (R50) was agreeable to redirection and escorted back to (R50's) room. (R50) was cooperative but confused. On 4/2/24, Surveyor requested information on the above incident which the facility was unable to provide. On 4/2/24 at 2:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who indicated progress notes are reviewed daily in morning meeting, but R50's 9/28/23 behavior note was missed. NHA-A confirmed the potential allegation of abuse was not reported to the SA or local law enforcement. NHA-A indicated if NHA-A was aware of the incident prior to 4/2/24, NHA-A would have reported the incident.

Based on staff and resident interview and record review, the facility did not ensure consistent communication for 1 Resident (R) (R24) of 1 resident who received dialysis services. The facility did not provide R24 with a dialysis communication binder prior to routine dialysis appointments and did not have evidence of communication between the facility and the dialysis center on R24's dialysis days. Findings include: The facility's Care of Hemodialysis policy, with a revision date of January 2024, indicates: Purpose: To ensure the needs of the resident receiving hemodialysis are met by both the facility and the dialysis center. Residents receiving hemodialysis are transported routinely out of the facility. Communication is essential for continuity of care. Procedure: -Facility will provide ongoing assessment of the resident's condition and will monitor for complications before and after each dialysis treatment received at a certified dialysis facility. -Facility will have ongoing communication and collaboration with the dialysis facility The facility's Hemodialysis policy, with a revision date of January 2024, contained the following information: Dialysis Communication Record: -To be completed by the facility: -List the medications given within the last six hours prior to sending the resident for dialysis treatment. -Assessment of vascular access site -Time of last meal -Last weight at the facility, date of last weight -Note of any changes or information to resident's condition below. Include information on resident's compliance with fluid and diet restrictions. -Facility nurse signature -To be completed by the Dialysis Center: -List the medication given during/after the dialysis treatment (other than heparin). -Weights: Pre-treatment, Post-Treatment -Vital signs Pre-treatment, Post-Treatment -List what foods and how much the individual ate/drank, if applicable. -Special instructions/comments and/or changes in resident's condition. Include any lab results drawn and resident's tolerance to dialysis procedure. -Provide a copy of the Registered Dietitian's nutritional recommendations, if applicable. -Dialysis Center nurse signature/date From 4/1/24 to 4/3/24, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] with diagnoses including end stage renal disease and diabetes with chronic kidney disease. R24 was dependent on dialysis and attended dialysis on Tuesday, Thursday and Saturday. R24's Minimum Data Set (MDS) assessment, dated 1/11/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R24 had intact cognition. Surveyor noted R24's medical record did not contain dialysis communication documentation. On 4/2/24 at 1:20 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility does not have formalized communication with the dialysis center because the dialysis center does not fill out the data consistently and appropriately. DON-B stated DON-B started a new program in which the dialysis center sends lab reports with updates. DON-B stated the new program started on 3/20/24, however, reports were not provided for R24. On 4/2/24 at 2:58 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated the facility obtains a resident's vital signs and weight, and checks the resident's fistula (access port for dialysis) and medication prior to their dialysis appointment and upon their return. LPN-F thought there was a communication binder but verified there was not. LPN-F stated the dialysis center calls the nursing facility if there is a change in the resident's condition. On 4/2/24 at 4:02 PM, Surveyor interviewed dialysis center Registered Nurse (RN)-G via phone who stated the dialysis center has a communication form that is shared with the facility. RN-G stated if a resident doesn't arrive with a communication form, the dialysis center generates one. RN-G stated RN-G did not fill out a form for R24 and the facility did not send a form with R24. RN-G also stated the dialysis center would like a resident's Medication Administration Record (MAR) upon arrival. RN-G reviewed the dialysis center's electronic record which included a call from Medical Doctor (MD)-H on 4/1/24 to ask if R24 could have a general diet since R24 was refusing a renal diet (specific diet for dialysis patients). On 3/30/24, an RN called to remove a fluid restriction due to R24's refusals. On 2/29/24, the dialysis center faxed an order to the facility to make sure R24 received midodrine (a blood pressure medication) a half hour before R24's dialysis appointments. On 4/3/24 at 9:51 AM, Surveyor interviewed dialysis center Clinic Manager (CM)-I who stated DON-B called CM-I on 3/20/24 regarding lack of communication between the facility and the dialysis center. DON-B stated DON-B would create a communication binder to be sent between the dialysis center and the facility. Since the call, CM-I stated CM-I did not receive a binder or hear anything from the facility. CM-I verified the dialysis center has a communication form that is used when the facility does not send one. On 4/3/24 at 11:26 AM, CM-I called Surveyor and verified after speaking with other dialysis staff members that the dialysis center has not seen a binder from the facility. CM-I stated the dialysis center and the facility communicate via phone calls. CM-I again stated the dialysis center has a document the center can fill out and send to the facility. On 4/3/24 at 1:15 PM, Surveyor interviewed DON-B who stated DON-B was aware of the facility's hemodialysis policy which states the facility will have ongoing communication and collaboration with the dialysis center and lists the pre-dialysis and post-dialysis communication requirements.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R34) of 3 residents with a diagnosis of dementia received the appropriate care and services to attain or maintain their highest practicable well being. R34 had a diagnosis of dementia and exhibited physically and verbally aggressive behavior. The facility did not revise R34's plan of care in an attempt to provide effective dementia treatment and behavioral interventions to enhance R34's quality of life. Findings include: On 4/2/24, Surveyor reviewed R34's medical record. R34 had a diagnosis of dementia, moderate with agitation. R34's most recent Quarterly MDS (Minimum Data Set) assessment, dated 3/26/24, contained a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R34 had severe cognitive impairment. R34 had an activated power of attorney (POA). R34 had an activity of daily living (ADL) self-care performance deficit related to aggressive behavior and Alzheimer's disease care plan, dated 2/25/24. The care plan indicated R34 required the assistance of one staff with the use of a wheelchair and had impaired cognitive function/dementia or impaired thought process related to dementia. The care plan contained the following interventions: ask R34 yes or no questions; communicate with R34/family/caregivers regarding R34's capabilities and needs; use R34's preferred name; identify self during interactions; reduce distractions; provide R34 with necessary cues; stop and return if R34 is agitated; cue, reorient and supervise R34 as necessary; keep R34's routine consistent; present one thought, idea or question at a time. R34's medical record contained the following progress notes: A progress note, dated 3/10/24, indicated R34 was verbally aggressive toward another resident and struck the resident in the arm. R34's POA and physician were notified. The progress note indicated R34's POA noticed R34 was more aggressive lately. Surveyor noted R34's care plan did not indicate R34 had verbal or aggressive behavior and did not contain interventions to assist R34 with those behaviors. Surveyor also noted there were no interventions added to R34's care plan following the incident. A progress note, dated 3/29/24, indicated R34 was paranoid, suspicious, and mistrustful of staff. R34 swore at a Certified Nursing Assistant (CNA) and yelled help police in the hallway. The CNA attempted to redirect R34 but was unsuccessful. R34 remained in a doorway in the hallway and stated Watch her. I don't trust her, Be careful you are in danger, and I will tell you what is going on, but I can't trust you right now. R34 remained in the hallway for approximately one hour and 45 minutes then went back to bed and would not allow staff to assist R34 or R34's roommate. Surveyor noted R34's care plan did not indicate R34 had verbal or paranoid behavior and did not contain interventions to assist R34 with those behaviors. Surveyor also noted there were no interventions added to R34's care plan following the incident. On 4/1/24 at 2:30 PM, Surveyor requested a copy of R34's care plan and progress notes, dated 3/10/24 and 3/29/24, from Director of Nursing (DON)-B. On 4/2/24 at 10:00 AM, Surveyor reviewed R34's care plan and noted an intervention, dated 4/1/24, that indicated R34 had a behavior problem related to being suspicious of staff. The care plan indicated R34 yells and is resistant with cares and contained interventions to anticipate R34's needs, provide opportunity for positive interactions, explain procedures, monitor behavioral episodes and attempt to determine the underlining cause, and document behavior and potential causes. Surveyor noted the care plan did not contain interventions to assist with physically aggressive behavior or de-escalation of behavior. On 4/2/24 at 1:05 PM, Surveyor interviewed DON-B regarding dementia care and a behavioral care plan for R34. DON-B indicated R34 did not have a behavioral care plan. DON-B confirmed DON-B updated R34's care plan after Surveyor requested a copy of the care plan on 4/1/24. DON-B indicated R34's behaviors were identified and documented and stated the facility did not initiate care plan interventions to assist R34. DON-B indicated R34's behaviors were escalating and verbal, paranoid, and physically aggressive behaviors were observed. DON-B stated word of mouth is how nursing staff, including agency staff, are trained and informed on how to intervene and provide care to R34 during periods of aggressive and paranoid behavior.

Based on staff interview and record review, the facility did not thoroughly investigate a potential allegation of abuse for 1 Resident (R) (R50) of 2 residents. R50 was observed laying across another resident in their bed without clothes on. Facility administration was not aware the incident occurred and a thorough investigation was not completed. Findings include: The facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, with a revised date of September 2023, indicates: Investigating Allegations: 1. All allegations are thoroughly investigated. 7. The individual conducting the investigation at a minimum: a. Reviews the documentation and evidence. b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident. c. Observes the alleged victim, including his or her interactions with staff and other residents. d. Interviews the person reporting the incident. e. Interviews any witnesses to the incident. f. Interviews the resident (as medically appropriate) or the resident's representative. g. Interviews the resident's attending physician as needed to determine the resident's condition. h. Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. l. Documents the investigation completely and thoroughly. On 4/2/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and vascular dementia. R50's Minimum Data Set (MDS) assessment, dated 1/11/24, contained a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R50 was severely cognitively impaired. A behavior progress note, dated 9/28/23 at 6:30 AM, indicated: Writer was notified by Certified Nursing Assistant (CNA) around 1:00 AM that (R50) was out of (R50's) room. (R50) was found laying in another resident's room without any clothes on. (R50) was laying on top of the other resident's legs when found. (R50) was agreeable to redirection and escorted back to (R50's) room. (R50) was cooperative but confused. On 4/2/24, Surveyor requested the facility's investigation of the incident which the facility could not provide. On 4/2/24 at 2:26 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who indicated progress notes are reviewed daily in morning meeting, but R50's 9/28/23 progress note was missed. NHA-A and DON-B were not sure which resident R50 was found in bed with. NHA-A and DON-B confirmed an investigation was not completed and protections were not put in place because they were not aware the incident occurred. NHA-A and DON-B confirmed an investigation should have been completed.

Based on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 73 residents residing in the facility. IP-J did not complete specialized training for infection prevention and control. Findings include: The facility's Infection Preventionist policy and procedure, last reviewed September 2023, indicates: Specialized Training: 1. The infection preventionist has obtained specialized IPC (infection prevention and control) training beyond initial professional training or education prior to assuming the role, including in the following topics .2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation . On 4/3/24 at 2:39 PM, Surveyor interviewed IP-J who verified IP-J started as the IP in August of 2023 and did not have specialized infection control training. IP-J stated IP-J was informed about the required training on 4/2/24. On 4/3/24 at 2:57 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B was aware of the IP specialized training and stated IP-J and DON-B will complete the Centers for Disease Control and Prevention (CDC) training modules.

Based on staff interview and record review, the facility did not ensure proper foot care was provided for 1 Resident (R) (R1) of 5 residents reviewed for appointment accommodations. On 4/17/23, Doctor of Podiatric Medicine (DPM)-E recommended R1 return for a follow-up appointment in two weeks to discuss the next steps for amputation of R1's toes. A follow-up appointment was not scheduled until 6/1/23 and R1 did not see DPM-E until 6/7/23. Findings include: R1 was admitted to the facility on [DATE] with diagnoses including hypothermia of bilateral hands and feet, rhabdomyolysis (breakdown of skeletal muscle), acute kidney injury (AKI), and diabetes mellitus (DM) type 2. R1's Minimum Data Set (MDS) assessments, dated 3/23/23 and 6/23/23, contained Brief Interview for Mental Status (BIMS) scores of 14 out of 15 which indicated R1 had intact cognition. On 8/31/23, Surveyor reviewed R1's medical record and noted the following: On 4/17/23, R1 was seen by DPM-E who discussed amputation of R1's left foot 5th digit and right foot great toe. DPM-E's note indicated R1 wanted to think about the amputation for two weeks before making a decision. A Report of Consultation, completed by DPM-E and dated 4/17/23, indicated R1 should return to the clinic in two weeks to discuss amputation. A fax from DPM-E's office, dated 4/19/23, included two pages from R1's 4/17/23 appointment and indicated: .Discussed with (R1) that we will have (R1) return to clinic in 2 weeks as an amputation would be very beneficial and (R1) relates that (R1) understands. A nursing note, dated 5/26/23 at 6:52 PM, indicated: (R1) returned from ID (Infectious Disease) with new order for an X-ray of bilateral feet to be completed prior to next ID (appointment), (appointment) needs to be scheduled immediately with podiatrist .and return to clinic in 2 weeks. On 6/7/23, R1 had appointment with DPM-E. A Report of Consultation, dated 6/7/23, indicated: .Discussed amputation and (R1) agreeable .Consent signed, will schedule ASAP (as soon as possible). On 6/23/23, R1's left foot 5th digit and right foot great toe were amputated. On 8/29/23 at 2:20 PM, Surveyor interviewed Nurse (NS)-C, who entered the nursing note on 5/26/23, via telephone. NS-C stated NS-C put the appointment sheet in the appointment box on the Cedar nursing unit on 5/26/23. On 8/31/23 at 1:19 PM, Surveyor interviewed DPM-E's Receptionist, (RCP)-F, who verified R1's appointments with DPM-E were on 4/17/23, 6/7/23, and 6/23/23. RCP-F stated R1's appointment on 6/7/23 was scheduled on 6/1/23. RCP-F verified R1 did not have any appointments scheduled between 4/17/23 and 6/7/23. On 8/31/23 at 12:25 PM, Surveyor interviewed Patient Coordinator (PC)-D who reviewed the appointment calendar in R1's medical record and verified R1 had appointments with DPM-E on 4/17/23, 6/7/23, and surgery for amputation on 6/23/23. PC-D stated the facility's procedure is for staff to provide PC-D with communication related to scheduling appointments. PC-D stated staff should place a copy of paperwork requesting a follow-up appointment for a resident in PC-D's mailbox, on PC-D's desk, or in a folder on the Cedar nursing unit. PC-D then schedules appointments. PC-D stated when R1 returned from R1's podiatry appointment on 4/17/23 at 4:00 PM, PC-D did not recall if anyone gave paperwork to PC-D and stated it was possible PC-D did not get the information. PC-D did not recall seeing a document requesting a follow-up appointment for R1. PC-D stated if PC-D was given the document, PC-D would have scheduled the appointment. On 8/31/23 at 2:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who agreed the system for scheduling appointments needed improvement and indicated they had a plan to improve the process.

Based on observation, staff interview, and record review, the facility did not ensure the provision of a physician ordered diabetic diet for 1 Resident (R) (R1) of 3 sampled residents. The facility did not ensure R1 was provided a diabetic diet. Findings include: According to Diabetes/Manage Blood Sugar information listed on the Centers for Disease Control and Prevention (CDC) website, it's important to keep blood sugar levels in the target range as much as possible to help prevent or delay long-term, serious health problems, such as heart disease, vision loss, and kidney disease .Carbs in food make blood sugar levels go higher .Counting carbs in foods and drinks is an important tool for managing blood sugar levels. The CDC and the American Diabetes Association (ADA) list the following typical blood sugar targets for someone with diabetes: ~Before a meal: 80 to 130 mg (milligrams)/dL (deciliter) ~Two hours after the start of a meal: Less than 180 mg/dL On 4/18/23, Surveyor reviewed R1's medical record and noted R1 had a diagnosis of diabetes. R1's admission orders, dated 11/11/22, included an order for a diabetic diet. On 4/18/23 at 12:18 PM, Surveyor observed R1's lunch meal and noted the meal included a full piece of garlic bread and a whole piece of frosted banana cake. Surveyor noted the facility's extended diet for the 4/18/23 lunch meal indicated residents on a diabetic diet should receive half a piece of garlic bread and half a piece of frosted banana cake as opposed to a whole piece of both for residents on a regular diet. On 4/18/23 at 12:30 PM, Dietary Manager (DM)-D observed R1's meal with Surveyor and confirmed R1 was served the regular diet serving sizes of garlic bread and frosted banana cake. At 12:37, DM-D reviewed R1's meal ticket which indicated R1 was on a regular diet. DM-D located R1's original diet communication slip. DM-D stated the slip was signed by a nurse DM-D did not recognize and said the facility sometimes had an influx of agency staff. Surveyor noted CHO Controlled (carbohydrate controlled - typical diet for diabetes) was not checked on the communication slip. Surveyor reviewed R1's blood sugars and noted the following: ~ 4/12/23 - 437 mg (milligrams)/dL (deciliter) ~ 4/01/23 - 410 mg/dL ~ 3/20/23 - 435 mg/dL ~ 3/02/23 - 404 mg/dL ~ 2/23/23 - 435 mg/dL ~ 2/20/23 - 437 mg/dL ~ 2/16/23 - 443 mg/dL On 4/18/23 at 1:22 PM, Nursing Home Administrator (NHA)-A confirmed the facility had a standing order to notify the MD if a resident's blood sugar was less than 70 mg/dL or greater than 400 mg/dL. On 4/18/23 at 2:27 PM, NHA-A confirmed R1 had an order for a diabetic diet. NHA-A reviewed R1's kitchen order sheet and verified CHO Controlled is typically marked for diabetic diets.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 of 8 employees reviewed for background checks. Certified Nursing Assistant (CNA)-E's last completed background check forms were dated 8/21/18. Findings include: The facility's Background Screening Investigations policy, revised March 2022, contained the following information: The director of personnel, or designee conducts background checks, reference checks, and criminal conviction checks on all potential direct access employees and contractors. On 4/18/23, Surveyor reviewed of a sample of employee background checks and noted CNA-E's most recent Background Information Disclosure (BID) form, Department of Justice (DOJ) letter, and Department of Health Services (DHS) letter were dated 8/21/18. CNA-E was hired by the facility in a different position (prior to turning [AGE] years old) and transitioned to the CNA position on 6/18/19. On 4/18/23 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding CNA-E's background check information. NHA-A stated the facility repeats background checks every four years for all staff and if a staff member is under the age of 18 at the time of hire, the facility completes a background check when the staff member turns 18. NHA-A verified the facility did not re-run CNA-E's background check when CNA-E turned 18 and CNA-E's background check forms were out of date.

Based on observations, record review and staff interviews, the facility did not ensure that 3 (residents #10, #5 and #3) of 11 sampled residents reviewed for pressure ulcers received necessary services to prevent pressure ulcers from developing, prevent infection and promote healing. Resident #10 developed a stage IV avoidable pressure ulcer from a mesh transfer sling that was left under the resident's buttocks and over the resident's pressure redistribution cushion while sitting in the wheelchair. The pressure ulcer required surgical debridement twice, use of a [DEVICE] and the introduction of antibiotics into the resident's medication regime relating to an infection. An individualized assessment had not been completed to determine the risks and/or benefits of the continued use of the sling under resident #10 and additional residents that were allowed to sit on transfer slings. Failure of the facility to implement appropriate preventative and treatment interventions for resident #10 resulted in an avoidable stage IV pressure ulcer. This created a situation of Immediate Jeopardy, which began on 9/2/15 when the pressure ulcer increased in size and there were no changes to the care plan. NHA (Nursing Home Administrator)-X and DON (Director of Nursing)-A were formally notified on 12/3/15 that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 12/4/15, however the deficient practice continues at a scope/severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) as evidenced by the following: Resident #10 was at risk for pressure ulcer development and had a history of [REDACTED].#10's written plan of care included to float heels off mattress. Observations were made of resident #10's bilateral heels placed directly on the mattress rather than free floating. Resident #5 had a stage 3 pressure ulcer to the coccyx and spent the majority of time in bed. The resident's CNA (Certified Nursing Assistant) Report Sheet included an intervention to float heels. That intervention was not consistently implemented. Resident #3 was at risk for the development of pressure ulcers. The resident's care plan directed staff to free float heels. That intervention was not consistently implemented. Findings Include: A National Pressure Ulcer Advisory Panel (NPUAP) White Paper (March 2015) entitled Do Lift Slings Significantly Change the Efficacy of Therapeutic Support Surfaces? examined the risks and benefits of leaving a sling under a resident/patient. When lift slings are used in combination with therapeutic support surfaces, critical thinking needs to increase. The fabric or composition of the device is important, as some may have less impact than others on the therapeutic functions of the support surface. The assessment of the patient should be reviewed against the physical features of the sling to be utilized. Healthcare clinicians for each individual patient must critically review the impact, both the risk and the benefit, of leaving a sling beneath a patient. The NPUAP White Paper concluded, The decision regarding placement/removal of Safe Patient Handling and Mobility (SPHM) equipment between uses must balance the putative risk (decreased efficacy of a therapeutic support surface) and potential benefit (easier repositioning increasing frequency and/or efficacy) on pressure ulcer prevention. Without evidence regarding the effect of slings upon support surface performance, the clinical recommendation is based on expert opinion to be found within the Guidelines combined with clinical assessment and an individualized plan of care by the team of health care professionals at the bedside. According to the NPUAP 2014 Quick Reference Guide, Stage III and Stage IV pressure ulcers are classified as below: Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown is classified as full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stage (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Category/Stage IV: Full thickness tissue loss (muscle/bone visible) is classified as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling. Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/;or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] likely to occur. Exposed bone/muscle is visible or directly palpable. Examples: 1. Resident #10's admission face sheet dated 9/28/15 indicated the resident was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Resident #10's MDS (Minimum Data Set) quarterly assessment dated [DATE] documented the resident was assessed to score 0 of 15 on the cognitive screen (the higher the score, the more cognizant), required extensive assistance for bed mobility and transfers, and did not ambulate. Resident #10 had range of motion deficits in bilateral lower extremities and was at risk for pressure ulcers having a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device. The resident had a pressure reducing device for bed and chair. Resident #10's annual MDS assessment dated [DATE] indicated the resident had a Stage 4 pressure ulcer that measured 5.0 cm (centimeter) long, 4.0 cm width and was 7.0 cm in depth with granulation tissue. Resident #10's Braden skin risk score assessment (scale for predicting pressure sore risk), dated 8/5/15, indicated the resident was at mild risk with a score of 15 for the development of pressure ulcers. The resident has very limited mobility, is chairfast with the ability to walk severely limited/none, skin is occasionally moist requiring an extra linen change approximately once daily, and sensory perception is slightly limited being able to respond to verbal commands, but can't always communicate pain or the need to reposition. Resident #10's current plan of care, dated 11/24/14, indicated the resident was at risk for skin breakdown related to immobility and incontinence manifested by previous pressure ulcers. The care plan approaches included full body skin check weekly, institute preventative measures as needed and involve WCC (wound care certified) nurse in wound care recommendations. The resident had a previous pressure ulcer on the coccyx, special attention to this area during skin checks. Monitor turning and check/change program. The care plan for mobility dated 11/24/14, indicated the resident had impaired physical mobility. The CNA approach with a date of 7/1/14, indicated the resident was a total body lift (Hoyer) with two staff assist. Facility practice was to leave the sling under the resident. Resident #10's medical record included documentation that the resident has a history of a pressure ulcer on the left gluteal fold, which opened and healed in November 2014 and again in July 2015 with a healed date of 7/15/15. Resident #10's medical record included nursing entries and additional documentaiton as follows relating to the progression of the pressure ulcer to the gluteal fold: ~ 7/30/15- presented with a small superficial open area to the left gluteal fold - applying barrier cream. ~ 8/5/15- Superficial open are to left gluteal fold measuring approximately 0.3 cm x (by) 0.5 cm. Area was cleansed with normal saline and covered with [MEDICATION NAME] related to small amount of serosanguineous drainage. ~ 8/12/15- Duoderm intact to gluteal fold. No new skin issues noted. ~ 8/19/15- Dressing to left gluteal fold intact. No new skin issues noted. ~ 8/31/15- Left gluteal fold has two open areas. Unable to measure due to causing resident discomfort. Peri tissue around both wounds has a dark gray appearance. Cleansed with normal saline and covered with [MEDICATION NAME]. Putting on calendar for WCC nurse to assess. ~ 9/2/15- WCC nurse assessment of left gluteal fold revealed wound bed is 100 percent black moist eschar. Irregular in shape and measures 4.5 cm x 2.5 cm with undetermined depth due to eschar. Fax out to physician with update and requesting orders for Santyl to eschar daily. Despite the increase in size, there was no change to the care plan. ~ 9/7/15- Large wound to left ischium (same area as documented as left gluteal fold). Cleansed, Santyl applied to slough, non-adherent dressing applied with 4x4 gauze over and [MEDICATION NAME] to secure. Wound to left gluteal fold saturated with 100 percent serosanguineous drainage with foul odor. Area cleansed and new dressing applied. On 9/10/15, a fax was sent to the physician's office indicating resident #10's wound to left gluteal fold looked worse. Wound bed covered with slough and looks deeper/larger in size. WCC to assess tomorrow. On 9/10/15 a CNA approach was added to the resident's care plan which indicated CNAs were to reposition on side frequently to keep pressure off bottom/gluteal folds. An individualized assessment of the resident had not been completed related to the use of the transfer sling at this time to determine if the sling left in the chair contributed to the development of the pressure ulcer. ~ 9/13/15- Left gluteal fold wound bed is 90 percent covered with tan slough. Dressing saturated with serosanguineous drainage. Wound measures 5.7 cm long x 6 cm wide. No change in care plan indicated even though the wound had increased in size. ~ 9/16/15- Left gluteal fold wound is coming deep and covered with slough with foul odor. Old dressing saturated 100 percent with green drainage. WCC nurse called to assess. Will assess wound on Friday. ~ 9/17/15- Left gluteal fold wound measures 6.0 cm long x 6.0 cm wide. No change in care plan noted. ~ 9/19/15- Started antibiotic today for infection of left gluteal fold wound. ~ 9/21/15- A fax was sent to the physician which indicated resident #10 has wound to left gluteal fold that is not healing well. Resident is incontinent of urine. May we try to insert Foley catheter until wound healed? The catheter was inserted after the physician gave the order. ~ 9/22/15- According to a fax the facility sent to surveyor# on 12/3/15 after exit from the facility, resident #10 was changed to a three to four person blanket lift from the mesh sling with commode hole used prior that was left under the resident while seated in the wheelchair. ~ 9/23/15- Physician note indicated nursing is nursing skin breakdown on the buttocks. Script written for [MEDICATION NAME] 5/325 mg (milligram) one every eight hours as needed for pain. Nursing progress notes indicated the gluteal fold wound measured 4 cm long x 5 cm wide and 2.7 cm deep at the deepest measurable area with a patch of tannish tissue at the proximal portion of the wound. CNA notes indicated the resident was transferred with the Hoyer lift for morning transfers. ~ 9/27/15- the unstageable left gluteal fold wound is covered with a large amount of gray slough to the center of the wound bed. Slough is moist and loose. Requires debridement. Will contact wound clinic. ~ 10/1/15- seen at the wound clinic by APNP (advanced practice nurse prescriber)-EE. The progress note written by APNP-EE indicated the resident's family member came to the appointment and reported the resident has a history of pressure ulcers and is nauseated due to the narcotic given for pain. The resident is unable to reposition self, was lifted by Hoyer onto exam table and reported pain related to ulcers. Ulcer was observed to left buttock area and measured 2 cm length x 5 cm wide x 4-5 cm deep with slough to base. Able to palpate calcified tissue at base. Debridement to left buttock ulcer completed with removal of at least 50 percent of slough. Plan for wound vac discussed. Pressure ulcer of buttock, left, Stage IV was included in the area of [DIAGNOSES REDACTED]. ~ 10/2/15- Late entry for 10/1/15. Left gluteal wound is 4.8 cm long x 4.5 cm wide x 3 cm deep at the deepest measurable area. Wound vac placed on left buttock area. ~ 10/4/15- Wound to left gluteal fold. Wound vac dressing intact and working properly. CNA notes indicated the resident was transferred with the Hoyer lift for morning transfers. ~ 10/7/15- Left gluteal fold wound measures 5.3 cm long x 4.7 cm wide x 3.7 cm deep at the deepest measurable site. Tissue inside the wound is black in color. Wound clinic updated with request for further instruction. ~ 10/8/15- CNA notes indicated the resident was transferred with the Hoyer lift for afternoon transfers. ~ 10/20/15- evaluated by GS (General Surgeon)-FF for the left buttock (gluteal fold) pressure ulcer. GS-FF indicated the resident is wheelchair bound at best and does spend a marked amount of time in wheelchair. The resident is up for meals and up in chair most of the day. On examination of the left ischial area, the resident has a large 4 cm wide x 5 cm long by nearly 8 cm deep ulcer. The depth is down to the ischium. GS-FF debrided some of the [MEDICATION NAME] material sharply. ~ 10/25/15- Left gluteal wound is 6.0 cm long x 4.7 cm wide with the deeper wound of 3.5 cm wide and 4.3 cm long within that area, and the depth being 7 cm at the deepest. Tunneling 2 cm at 1200 (on a clock), 3.6 cm at 0900 and 4 cm at 0300 to almost 0600. ~ 10/29/15- Left buttock wound is 5 cm long x 4 cm wide with the deeper opening being 2.9 cm wide x 2.7 cm long. The depth is 4 cm deep at the center and 7 cm at the deepest. ~ 10/29/15- CNA approaches were added to the care plan which indicated the resident had a low air loss alternating lipped mattress and a thin gel overlay cushion was used in the wheelchair. The CNAs were to report reddened skin to a nurse. The resident was not to be up in wheelchair for more than two hours at a time (except may get up for activity programs as resident desires). Float heels off mattress. ~ 11/3/15- seen by GS-FF who indicated in a note to the facility the resident's ischial ulcer is much improved. The wound will continue to take another several months to heal. Will see the resident again in January 2016. ~ 11/4/15- Dressing changed to coccyx (buttock, gluteal fold, ischium) area. The wound measures approximately 4 cm x 4 cm with tunneling at 12:00 o'clock 3.8 cm and at 8:00 o'clock 6.5 cm. ~ 11/10/15- Wound to left gluteal fold. Wound bed pink in color and continues to be deep in size. ~ 11/11/15- Wound to coccyx area measures approximately 3.8 cm x 3.5 cm with tunneling at 12:00 o'clock 2.7 cm and at 0800 5.6 cm. ~ 11/18/15- The left gluteal wound is 3.5 cm wide on the skin surface x 3.0 cm long and has a deeper area in the center that is 2.0 cm long x 3.0 cm wide with a depth of 3.5 cm in the center. Tunneling at 12:00 o'clock is 9.0 cm. ~ 11/23/15- According to a fax the facility sent to surveyor# on 12/3/15 after exit from the facility, resident #10 was changed to a full body fabric sling with no commode hole from a three to four person blanket lift due to healing of the pressure ulcer and for safety. ~ 11/25/15- Wound to left gluteal fold is 3.5 cm x 2 cm. The depth is 2 cm in center and 7.5 cm tunneling at 12:00 o'clock. On 12/1/15 at 11:35 a.m., resident #3 stopped surveyor # in the hallway. The resident was observed sitting in the wheelchair with a sling under the resident which was placed over the pressure redistribution cushion. Resident #3 stated don't like sling with the hole under me. Don't need .have a catheter. No one seems to care about it except me. (The sling) is uncomfortable .hurts me. The resident verified the sling is always left in the wheelchair under the resident and over the pressure redistribution cushion. On 12/1/15 at 12:20 p.m., surveyor # observed resident #10 sitting in the wheelchair in the dining room with a fabric sling placed under the resident and over the pressure redistribution cushion. On 12/2/15 at 10:00 a.m., LPN-GG changed the dressing on the left gluteal fold wound and measured the wound to be 2.5 cm long x 2.5 cm wide. The depth is 1.9 cm at center and tunneling at 12:00 o'clock is 4.2 cm. LPN-GG verified the resident had a Foley catheter placed to assist with healing of the Stage IV pressure ulcer. On 12/2/15 at 11:42 a.m., surveyor # interviewed LPN-GG regarding resident #10's pressure ulcer. LPN-GG verified the pressure ulcer on the left gluteal/buttock/ischial area was a Stage IV pressure ulcer. LPN-GG also verified the resident was transferred with a mesh sling with commode hole prior to the development of the pressure ulcer. After development, the resident was changed to a solid sling for transfers. LPN-GG indicated both slings were left under the resident on top of the pressure redistribution cushion while the resident was up in wheelchair. On 12/2/15 at approximately 12:13 p.m., surveyor # and surveyor # observed 10 residents including resident #10 sitting in wheelchairs/Broda chairs with a lift sling under each resident and over each resident's pressure redistribution cushion. On 12/2/15 at 3:45 p.m., surveyor # interviewed DMR (Drive Medical Representative)-II manufacturer of the mesh sling regarding resident #10 sitting on mesh sling via the telephone. DMR-II indicated sitting on a mesh or fabric sling while in a wheelchair could increase the risk of developing a pressure ulcer. DMR-II indicated placing the sling over a pressure redistribution cushion takes away the qualities of the cushion increasing the risk of developing a pressure ulcer. On 12/2/15 at 4:02 p.m., surveyor # interviewed CNA-HH regarding resident #10. CNA-HH verified the resident sits up for the evening meal approximately one and one-half hours each evening during the meal with the full fabric sling placed over the pressure redistribution cushion on the seat of the wheelchair. On 12/2/15 at 4:05 p.m., surveyor # interviewed LPN-GG regarding resident #10 sitting in the wheelchair. LPN-GG verified the resident sits up in the wheelchair for the noon and evening meals with the full fabric sling over the pressure redistribution cushion for approximately two hours at each meal. On 12/2/15 at 4:10 p.m., surveyor # interviewed DON-A regarding resident #10. DON-A verified the resident has a history of pressure ulcers on the gluteal/buttocks/ischial areas. DON-A also verified the resident sat on the mesh sling with commode hole over the pressure redistribution cushion in the wheelchair before the development of the left gluteal fold pressure ulcer. Once the pressure ulcer developed, the resident was changed to a full fabric sling without a commode hole which was also left under the resident and placed over the pressure redistribution cushion while the resident was in the wheelchair. When asked if the pressure ulcer was avoidable, DON-A stated don't know .case of what came first, the chicken or the egg? DON-A also verified the facility only changed the sling on resident #10 and maybe one other resident, not all residents with slings were assessed. According to the manufacturer (Invacare) of the full fabric sling, solid polyester slings should not be left under the resident for extended periods as the padding retains body heat. For residents that are seated on a pressure reduction cushion, note that the effectiveness of the cushion is diminished when solid padded slings are left under the resident. On 12/3/15 at 2:46 p.m., the facility sent a fax to surveyor # which indicated resident #10's CNA report sheet (care plan) was changed to indicate the sling must be removed when resident is sitting in chair. On 12/3/15 at 3:20 p.m., surveyor # interviewed APNP-EE via telephone regarding resident #10. APNP-EE verified the resident was seen at the wound clinic and had a Stage IV pressure ulcer on the left buttock when seen. APNP-EE then stated if I can see bone and palpate bone, it is for sure a Stage IV pressure ulcer. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopary/isolated) as evidenced by the following: ~ Resident #10 was removed from sling on 12/2/15. ~ Nursing staff were educated through verbal education on 12/2 and 12/3/15 and through a memorandum on 12/4/15, stating as an immediate intervention all slings will be removed once a resident is in the chair or bed. ~ All other residents that utilize a sling for transfers were assessed for risk and appropriateness of use related to potential for skin breakdown. On 12/7/15, surveyor # was advised the facility had assessed all the other residents sitting on lift slings on the day of exit and on 12/4/15, the facility had finished educating staff on removing all slings from under residents when sitting in wheelchairs. The Quick Reference Guide entitled, Pressure Ulcer Prevention, published by the NPUAP in 2009 indicated high pressures over bony prominences, for a short period of time, and low pressures over bony prominences, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to. Ensure that the heels are free of the surface of the bed. Heel protection devices should elevate the heel, completely off loading them. The second edition published in 2014, entitled Prevention and treatment of [REDACTED]. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called 'floating heels.' Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows. The facility's Pressure Ulcer Risk Assessment policy, dated February 2014, states: 5. Risk Factor - Immobility .c. When in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. 2. Resident #10 (identified above) was at risk for pressure ulcer development and had a history of [REDACTED].#10's written plan of care included to float heels off mattress. On 12/2/15 at 10:00 a.m., surveyor # observed resident #10 laying in bed with the right heel placed directly on the mattress. The left foot had a soft plaid boot on and was placed directly on the mattress inside the soft non-pressure boot. The resident remained in the same position when observed by surveyor # at 10:35 a.m., 10:45 a.m., 10:55 a.m., 11:00 a.m., and 11:02 a.m., when LPN (Licensed Practical Nurse)-GG and CNA- K entered the resident's room to change the pressure ulcer dressing. LPN-GG and CNA-K verified the resident's heels were placed directly on the mattress and indicated the resident's heels do not need to be free floated while in bed. At 11:25 a.m., resident #10 remained laying in bed with the right heel placed directly on the mattress and the left heel in the soft plaid boot placed directly on the mattress. 3. On 12/1/15, surveyor # reviewed the medical record of resident #5. The resident had [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. The resident's Impaired Skin Integrity plan of care dated 11/23/15, included interventions to note changes in level of risk for skin breakdown and minimize factors and to see CNA Report notes. The CNA Report Sheet for resident #5, dated 12/1/15, contained an intervention to float heels. On 11/30/15 at 10:25 a.m. and 1:52 p.m., surveyor # observed resident #5 wearing gripper socks in bed with both heels in direct contact with the mattress. On 11/30/15 at 2:07 p.m., surveyor # observed RN (Registered Nurse)-Q and LPN-R perform wound care for resident #5. At 2:33 p.m., the resident was positioned on the resident's left side with a pillow underneath the resident's right side. A pillow was placed between the resident's knees leaving both of the resident's heels in direct contact with the mattress. Surveyor # then interviewed RN-Q and LPN-R regarding the positioning of the resident's heels after the resident was repositioned. RN-Q removed the resident's socks and surveyor # noted the skin on the resident's heels was intact with no redness. Following the observation, RN-Q and LPN-R positioned the resident with the right heel floating and the left heel/ankle resting on a pillow placed vertically between the resident's knees. When surveyor # asked if both of resident #5's heels should be free floated, RN-Q and LPN-R re-adjusted the pillow to ensure both heels were free floating. On 12/1/15 at 9:00 a.m., surveyor # observed resident #5 in bed with the right heel in direct contact with the mattress and the left foot/heel under a pillow placed between the resident's knees. The left foot and heel were in direct contact with the mattress. On 12/1/15 at 9:50 a.m., surveyor # observed resident #5 in bed with a pillow placed underneath the resident's calves. Both of the resident's heels were in direct contact with the mattress. On 12/1/15 at 9:52 a.m., surveyor # observed CNA-T provide toileting care for resident #5. During the observation, surveyor # inquired about positioning for resident #5. CNA-T stated (Resident #5) needs (resident #5's) heels free floated. When asked if the resident used heel boots, CNA-T stated I'm not sure if heel boots have been tried. We just use the pillow. On 12/2/15 at 11:00 a.m., surveyor # observed resident #5 in bed with a pillow underneath the resident's calves. The resident's left heel was in contact with the mattress and the right foot/heel was resting on the pillow. Surveyor # interviewed CNA-U at that time regarding the resident's positioning. CNA-U stated, (Resident #5's) heels aren't touching anything. CNA-U then verified the resident's position did not allow the resident's heels to free float and stated We can try 2 pillows underneath (resident #5's) heels. 4. On 11/30/15, surveyor # reviewed resident #3's medical record. The resident's most recent annual MDS (Minimum Data Set) assessment dated [DATE], documented the resident was at risk for the development of pressure ulcers, required extensive assistance from staff for bed mobility and ADL (Activities of Daily Living) and listed diagnoses, some of which included: [MEDICAL CONDITION], [MEDICAL CONDITIONS] and history of pressure ulcers. A wound clinic progress note dated 11/24/15, indicated resident #3 was seen for a chronically non-healing venous stasis ulcer to the left lateral (outside) leg, previously had diminished ankle-brachial indices (measures) .and underwent invasive [MEDICATION NAME] to further evaluate the severity of (resident's) [MEDICAL CONDITION]. On 9/4/15 patient had stenting and angioplasty of left superficial femoral artery and ulcer debridement .Referred to wound clinic for evaluation for wound vac (vacuum) and possible cellular tissue graft. The resident's 9/24/15 Braden score was 17, indicating resident #3 was at risk for developing pressure ulcers. The document indicated the resident was chairfast (Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into wheelchair.) and mobility was very limited (Makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently). According to the plan of care last revised 11/30/15, resident #3 had an open area (wound) on a foot when admitted to the facility. The plan of care instructed staff to Float heels in bed .elevate legs as tolerated, turn in bed every 2-3 hours, moon boot to bilateral (both) feet in bed, no shoes to bilateral feet On 11/30/15 at 1:15 p.m., surveyor # observed lift transfer and perineal cares provided to resident #3 by CNA-W and CNA-V. When cares were completed, CNA-V placed plaid pillow-type boots, which covered the heels, onto the resident's feet, then put a small pillow under the resident's knee and a larger pillow under the resident's calves. Resident #3 expressed concern regarding the pillow touching the left lateral leg wound, so CNA-V and CNA-W lifted the resident's legs and moved the pillow under the resident's heels before leaving the room. On 12/1/15 at 7:44 a.m., surveyor # observed LPN-P provide wound care to resident #3. As LPN-P lifted the bed covers from resident #3 and the foot cradle (holds covers off of the feet) at the foot of the bed, LPN-P indicated that the resident had a history of [REDACTED]. Surveyor # observed the resident's feet in plaid, pillow-type boots, which covered the heels and rested upon pillows, on top of the mattress. There was no pillow or support under the left calf where the resident had a wound wrapped in gauze. After wound care was completed, LPN-P placed the plaid boots on resident and placed a pillow under the right and left calf to elevate the heels. Resident #3 objected stating: I can't have anything under that wound, put my feet on the pillow. LPN-P told resident #3 that having a pillow under the heels would put pressure on the heels and placed a pillow lengthwise under the left lower leg, floating the heel and with no pillow surface touching the wound. Resident #3 replied okay. On 12/1/15 at 8:10 a.m., after the above observation, LPN-P verified to surveyor # that resident #3 sometimes doesn't remember the importance of off-loading the heels and would expect CNA staff to remind her. (resident #3) is okay with keeping heels free-floated if you explain it. On 12/2/15 at 8:32 a.m., surveyor # observed resident #3 in bed with both feet in the plaid pillow-type boots that covered the heels, resting directly onto pillows, which were on the resident's mattress. Resident #3 indicated the nurse had just performed the left leg dressing change and stated My heel hurts today, more than the wound. On 12/2/15 at 8:36 a.m., surveyor # and CNA-Y observed the (above) positioning of resident #3 and confirmed That is how we put (resident #3) in bed. On 12/2/15 at 8:45 a.m., LPN-R confirmed recently performing the resident's dressing change and verified resident #3's care plan instructed to float the resident's heels (with the plaid boots), and stated: We .keep moon boots on to protect the heels and place (heels) on pillow. The care plan says float heels. If the moon boots are on and the pillow under, they (heels) are floated; not touching mattress. On 12/2/15 at 10:30 a.m., surveyor # interviewed RNM (Registered Nu

Based on observations, record review, staff and resident interviews, the facility did not provide the necessary care and services to attain the highest practicable physical well-being for 1 (resident #7) of 16 sampled residents. Resident #7 had increased pain in the hands and feet. The physician was updated and a uric acid level was obtained, which was elevated. The facility did not receive a response from the physician regarding the level for 22 days, at which time the facility re-faxed the uric acid results to the physician. At that time, the physician ordered [MEDICATION NAME] to treat the elevated uric acid level. The facility did not update the physician regarding resident #7's continued pain. As a result, the resident's pain and underlying problem of an acute gout flare up was left untreated for [REDACTED]. Findings Include: The current electronic [DIAGNOSES REDACTED].#7 had [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 8/19/14, indicated resident #7 cognition was slightly impaired, has limited range of motion in the right ankle (due to a fracture), and had no current pain at the time of the assessment. Resident #7's medical record indicated the resident has complaints of occasional leg pain. The Potential for Alteration in Comfort plan of care, dated 8/26/14, indicated resident #7 had chronic shoulder pain. The plan of care had interventions to include: investigate other causes of pain, and notify physician of changes or ineffective pain relief with current pain regimen. Resident #7's nurse's notes documented the following: * 8/30/14 at 4:30 a.m.- reported pain in the left wrist, rating the pain at 4/10 (4 out of 10). The resident received 650 mg (milligrams) of [MEDICATION NAME] (Tylenol). Follow up on pain indicated the resident had no further complaints. * 8/30/14 at 12:16 p.m.- reported pain in hands and arms to the elbow, rating the pain at 9/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain indicated the resident had no further complaints. * 8/30/14 at 7:34 p.m.- reported pain in the left wrist, rating the pain at 9/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain indicated the resident was asleep. * 8/31/14 at 6:28 a.m.- reported pain in the hands (level not documented). The resident received 650 mg of [MEDICATION NAME]. Follow up on pain indicated the resident had no further complaints. * 8/31/14 at 10:20 a.m.- complained of pain in the hands and feet, rating the pain at 9/10. The resident received 2 tablets of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain indicated the resident had no further complaints. * 8/31/14 at 5:13 p.m.- reported pain in the right hand, rating the pain at 7/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain indicated the resident reported the pain had been reduced to 4/10. * 9/1/14 at 9:44 a.m.- reported pain in the arms and legs, rating the pain at 9/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg Follow up on pain indicated the resident reported the pain had been reduced, but was still present. * 9/2/14 at 9:22 a.m.- reported pain "all over," rating the pain at 9/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain indicated the resident reported the pain had improved, but was still present. * 9/2/14- the primary care physician was updated via fax. The fax stated the resident had been recently complaining of pain in hands and feet. The resident's son reported to staff that when resident #7 had resided with him, prior to admission to the facility, the resident had been taking [MEDICATION NAME] daily, for gout. The fax also informed the physician of pain, redness, and warmth observed in resident #7's left hand. At this time, the physician ordered a uric acid level to be drawn. * 9/3/14 at 9:36 a.m.- reported pain "all over," rating the pain at 9/10. The resident received 650 mg of [MEDICATION NAME]. No follow up pain assessment was noted. * 9/3/14, the resident's uric acid level was elevated at 9.3 (normal levels fall between 3.0 and 7.0) The results of the uric acid level was faxed to the resident's physician. * 9/4/14 at 3:02 p.m.- LPN (Licensed Practical Nurse)-B documented, "No c/o (complaints of) breakthrough pain today. Hands continue to have some warmth and the left has some ruddy discoloration yet as well." * 9/5/14 at 2:09 p.m.- LPN-B documented, "No complaints of breakthrough pain noted or reported. (Resident #7's) hands remain warm but no swelling noted. Some discoloration of left hand yet." * 9/8/14 at 7:56 a.m.- complained of pain in both feet, rating the pain 8/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain indicated the resident had no further complaints. * 9/11/14 at 12:27 a.m.- complained of discomfort and received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. The pain level was not documented. No follow up pain documentation was noted. * 9/11/14 at 7:51 p.m.- complained of pain in both legs, rating the pain 6/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain indicated the resident was asleep. * 9/14/14 at 3:37 a.m.- complained of back pain, rating the pain 10/10. The resident received two tablets of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. No follow up on pain medication was documented. * 9/20/14 at 9:13 a.m.- complained of pain in both feet (no pain rating was documented). The resident received two tablets of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain stated the medication was effective. * 9/21/14 at 8:19 a.m.- complained of pain in "bilateral lower extremities." The resident received two tablets of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. No pain rating was documented. Follow up on pain stated the medication was effective. * 9/22/14 at 7:44 a.m.- reported pain in both hands, with a pain level of 9/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain stated the resident had no further complaints of pain. * 9/22/14 at 7:34 p.m.- reported pain in both hands and feet, with a pain level of 8/10. The resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain stated the resident was asleep. * 9/23/14 at 12:14 p.m.- reported pain to bilateral hands and feet (no pain level was documented) and the resident received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. No follow up on pain was documented. * 9/24/14 at 9:23 a.m.- complained of pain "all over," with a pain rating of 9/10. The resident received two tablets of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain stated the resident had no further complaints of pain. * 9/24/14 at 2:09 p.m.- complained of pain in the left wrist with a pain rating of 9/10. Follow up on pain stated the resident had no further complaints. On 9/24/14 between 9:00 a.m. and 10:00 a.m., surveyor # conducted a resident interview with resident #7. During the interview, resident #7 reached for the activity calendar on the bed with the left hand. the resident winced with movement of the left wrist and grasped the left wrist with the right hand and stated the left wrist "just aches" and has been aching for a few weeks. Resident #7 informed surveyor the left wrist was warm to touch and instructed the surveyor to place her hand on the resident's wrist to feel the temperature. Resident #7's wrist was warm to touch and the surrounding areas of the hand and forearm were cool to touch. Surveyor # informed LPN-B that resident #7 complained the left wrist was "warm and aching." LPN-B entered resident #7's room and inquired about the pain to the left wrist. Resident reported a pain level of 10/10. LPN-B informed resident #7 that 10 means the resident is experiencing the worst pain she has ever experienced in her life and stated "So, it's (left wrist pain) a 10/10?" Resident #7 then stated she thought her left wrist pain was more of a 9/10 after LPN-B explained the pain scale. LPN-B informed surveyor # that resident #7 has been complaining of joint pain in the hands and feet, related to an acute flare up of gout for the past couple of weeks and the physician did not want to do anything about the elevated uric acid level. LPN-B indicated she did not inform resident #7's physician regarding the resident's continued complaints of pain. On 9/24/14 at 9:23 a.m., LPN-B documented in the nurse's notes that resident #7 complained of pain "all over," with a pain level of 9/10. Resident #7 received two tablets of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. Follow up on pain stated resident #7 had no further complaints of pain. This nurse's note did not document that resident #7 had complained of left wrist pain that felt warm to touch. On 9/24/14 at 1:50 p.m., surveyor # interviewed DON (Director of Nursing)-A regarding resident #7's elevated uric acid level that had been faxed to the physician on 9/3/14 and what the physician's response was to the fax. DON-A indicated she was not aware of the physician's response. On 9/24/14 at 3:50 p.m., surveyor # interviewed DON-A regarding the 9/3/14 fax that was sent to resident #7's physician indicating the elevated uric acid level. DON-A stated she did not know what happened and confirmed the lab value results were faxed to the physician according to documentation in a nurses note. DON-A indicated no response was obtained from the physician regarding the uric acid level. DON-A stated she re-faxed resident #7's physician regarding the elevated uric acid level and is awaiting a response. On 9/25/14 at 8:16 a.m., the nurse's note documented resident #7 complained of pain "all over," with a pain rating of 7/10. Resident #7 received two tablets of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. This nurse's note did not include additional follow up of pain documentation. On 9/25/14, resident #7's physician faxed an order that the resident is to receive [MEDICATION NAME] 100 mg, one daily and re-draw a uric acid level in 3 months. On 9/25/14 at 9:45 a.m., surveyor # interviewed PA (Physician's Assistant)-E regarding resident #7's elevated uric acid level and the persistent pain. PA-E stated she was not the PA for resident #7, but would be willing to answer any questions. PA-E stated based on the elevated uric acid level and characteristic location of pain (joints, especially hands and feet), it appears resident #7 is suffering from an acute gout flare up. PA-E stated resident #7 would need treatment with an anti-[MEDICAL CONDITION], for example an NSAID (non steroidal anti-[MEDICAL CONDITION] drug) or [MEDICATION NAME] to eliminate the pain. PA-E stated [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg would not be effective in eliminating the inflammation which is the cause of the pain. On 9/25/14 at 2:25 p.m., DON-A confirmed she did not update the physician regarding resident #7's continued pain between 9/3/14 - 9/25/14. On 9/26/14 at 9:31 a.m., the nurse's note documented resident #7 had complaints of pain in the legs and one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg was given. The level of resident #7's pain was not documented, nor was a follow up on effectiveness of the pain medication. On 9/26/14 at 12:49 p.m., the nurse's note documented resident #7 had increased weakness to the right arm and hand and was unable to lift the right arm or hand. "Resident told that she is having the weakness due to pain to the arm. (Resident #7's) uric acid level was elevated. (Resident #7) started on [MEDICATION NAME] 100 mg today." Resident #7 was transferred to the ER (emergency room ) for evaluation. The ER Report, dated 9/26/14, documented resident #7 received an x-ray of the right shoulder and chest, and also an MRI (Magnetic resonance imaging) and CT (Computed tomography) scan. Resident #7 was diagnosed with [REDACTED]. On 9/26/14 at 9:52 p.m., the nurse's note documented resident #7 complained of the "worst pain of my life," rating the pain 10/10 in the right arm and leg. Two tablets of [MEDICATION NAME] 5/325 mg were given. No follow up pain assessment was documented. On 9/27/14 at 9:23 a.m., the nurse's note documented resident #7 complained of pain in the shoulder and hand. One tablet of [MEDICATION NAME] 5/325 mg was given. Resident #7's pain level was not documented. Follow up of resident #7's pain indicated resident #7 had no further complaints. On 9/27/14 at 4:11 p.m., the nurse's note documented resident #7 had complaints of pain "all over" and one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg was given for a pain level of 8/10. On 9/28/14 at 11:54 a.m., the nurse's note documented resident #7 complained of pain in the right hand and right 5th finger. One tablet of [MEDICATION NAME] 5/325 mg was administered. Follow up pain evaluation stated resident #7 had no further complaints. On 9/28/14 at 2:15 p.m., the nurse's note documented resident #7 continued to complain of pain in the right 5th digit and redness and swelling were noted to the digit. Pain medication was administered at this time. On 9/28/14 at 10:16 p.m., the nurse's note documented resident #7's right 5th digit remained red and swollen. On 9/29/14 at 6:25 a.m., the nurse's note documented resident #7 complained of pain in the "right finger" and "all over ache." Resident #7 rated the pain 6/10 and received one tablet of [MEDICATION NAME] with [MEDICATION NAME] 300 mg/30 mg. The follow up pain evaluation indicated the medication was effective for resident #7's pain. On 9/29/14 at 7:19 a.m., the nurse's note documented resident #7's 2nd knuckle of the 5th digit of the right hand was tender to touch or bending of the finger, "pink," and swollen. On 9/29/14 at 10:50 a.m., surveyor # interviewed resident #7 who reported she had terrible pain in her right hand, arm, and shoulder and was sent to the ER because the facility thought she had a stroke. Resident lifted her hand to surveyor # and instructed the surveyor to look at the redness and swelling of the right 5th digit. Surveyor # observed the 2nd and third joints of the 5th digit to be red and swollen. Resident #7 stated the pain is "terrible" and goes all the way up the right arm. On 9/29/14 at 11:30 a.m., surveyor # interviewed CNA (Certified Nursing Assistant)-C regarding resident #7's hand and feet pain. CNA-C stated she is the primary CNA for resident #7, works with the resident regularly, and knows the resident well. CNA-C stated resident #7 has been complaining of hand and feet pain on a daily basis and the complaints started a few weeks ago. On 9/26/14 CNA-C observed resident #7 drop a bowl during a meal because the resident was unable to hold the bowl due to pain and weakness in the right hand. On 9/29/14 at 12:54 p.m., surveyor # interviewed NP (Nurse Practitioner)-D regarding resident #7's acute gout pain. NP-D stated she was covering for the resident's primary care physician today. NP-D was informed of the above information. NP-D stated since the [MEDICATION NAME] is not helping to alleviate the inflammation and resulting pain quickly enough, a low dose [MEDICATION NAME] is recommended for a week or two to relieve the resident's symptoms. Surveyor # informed DON-A of the above interview and recommended DON-A contact NP-D to discuss resident #7's treatment plan. The facility did not follow up with resident #7's physician after the initial fax was sent regarding the resident's elevated uric acid level and no response was obtained. The resident had reoccurring, unnecessary pain without appropriate treatment for [REDACTED]. Although, the facility was providing pain medication that was effective for pain control, the facility did not appropriately report or treat resident #7's acute gout pain and inflammation, therefore the resident required additional and unnecessary treatment of [REDACTED].

Based on observation, record review, staff and family interviews, the facility did not ensure that 1 (resident #4) of 16 sampled resident's were able to make meaningful choices related to aspects of their life in the facility. Resident #4 and resident #4's APOAHC (activated Power of Attorney Health Care)-S expressed disapproval and concerns regarding the use of a chair and bed alarm. Documentation indicated resident #4 would scream, shake, cry, pull her hair, and become upset upon hearing the noise from the bed and chair alarm. The facility continued to use the chair and bed alarm and did not follow up with resident #4 or resident #4's APOAHC-S regarding their wishes not to use the chair and bed alarm. Findings include: Resident #4's face sheet, contained within the medical record and dated 9/12/14, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was moderately cognitively impaired, and had no falls since admission or the prior assessment. Resident #4's current plan of care dated 9/8/14 indicated "Resident #4 is at risk for falls related to cognitive deficits, communication problems and gait instability." An approach listed on the fall plan of care dated 8/31/14 stated, "Alarms: Pressure alarm in bed, Pressure alarm in chair." The CNA (Certified Nursing Assistant) report sheet for resident #4, dated 9/24/14, and utilized by direct care staff indicated, "pressure alarm in bed and pressure alarm in chair...SPECIAL INSTRUCTIONS: DO NOT speak loudly, keep music and TV soft. Loud voices and noises startle resident #4 and make her more agitated." Resident #4's nursing notes documented the following: 9/2/14- "Mostly pleasant, crying episode times two, seems upset about needing staff assist and alarms." 9/5/14- "Upset alarms in bed when tries to self transfer." 9/6/14- "Resident self transferred herself to the bathroom. Writer's hands were full when entering room due to hearing the alarm going off, and tried to ask her to sit back on her bed until hands were free to help. Resident cried because of the alarm ringing and shoved past writer stating, "I hate this stupid alarm..." 9/12/14- "Resident was up and down most of the shift, she was crying when she heard the alarm going off." 9/14/14- "Multiple self transfer attempts...seems frustrated by alarm." 9/15/14- "Resident agitated, resident throwing alarm..." 9/20/14- "Call received from resident #4's FM (Family Member)-R. FM-R expressing her feelings about alarms, allowed to vent." On 9/23/14 at 1:30 p.m., surveyor # observed resident #4 in her room sitting in the wheelchair, with a sensor alarm. At this time, CNA-M informed surveyor # that resident #4 "gets agitated with loud sounds." On 9/23/14 at 2:30 p.m., surveyor # observed resident #4 lying in bed with a sensor alarm attached to the bed rail. On 9/24/14 at 8:00 a.m., surveyor # observed resident #4 lying in bed with a sensor alarm attached to the bed rail. On 9/24/14 at 9:20 a.m. surveyor # observed resident #4 in her room sitting in the wheelchair with a sensor alarm. On 9/29/14 at 9:15 a.m., surveyor # interviewed FM-R via phone regarding resident #4. FM-R stated "My biggest and only complaint was the chair and bed alarm. The alarms are upsetting to her, and during her (resident #4) entire stay at the facility she had the alarms. When I came to visit I watched her (resident #4) scream and pull her hair out, because the sound of the alarm made her upset. I talked to multiple staff at the facility that I did not like the alarms; nurses, AC (Admission Coordinator)-Q, and DON (Director of Nursing)-A. All I was told, was that it was company policy, end of story, there was nothing else they could do. Her (resident #4) son who is the APOAHC talked to DON-A regarding not wanting resident #4 to have the alarms." On 9/29/14 at 9:30 a.m., surveyor # interviewed APOAHC-S via phone regarding resident #4. APOAHC-S stated, "My only complaint was the alarms. I came to visit resident #4 every day, and she (resident #4) would tell me she hated the alarms. Every time I was there, the alarm would go off, and it would upset her (resident #4) to no end. She (resident #4) would shake, grab her hair, and say why do I need these alarms. I talked to a lot of staff at the facility about not wanting the alarms. I even talked to DON-A about not wanting the alarms. I told DON-A I would sign a legal wavier or go to an attorney to sign something so that the facility would not be responsible for any injuries. I just wanted the alarms off of her (resident #4), but my concerns went no where." Resident #4's medical record indicated the resident was discharged from the facility to an assisted living facility on 9/24/14. Surveyor # was unable to interview resident #4. On 9/29/14 at 8:30 a.m., surveyor # interviewed RN (Registered Nurse)-L regarding resident #4. RN-L verified she talked to FM-R via the phone on 9/20/14. RN-L stated, "FM-R did not like resident #4's bed and chair alarm. FM-R was told about the facility's policy, and the use of the chair and bed alarm was for resident #4's safety." On 9/29/14 at 9:45 a.m., surveyor # interviewed CNA-M regarding resident #4's bed and chair alarm. CNA-M stated resident #4 made comments all the time that she (resident #4) did not like the alarms. CNA-M stated, "Resident #4 could not stand the alarms, the alarm produced a lot of anxiety and frustration for her. As soon as she (resident #4) heard the alarm go off, her mood would change from being pleasant to being angry, upset and weepy." CNA-M stated the nurses were aware of resident #4's dislike of the bed and chair alarm, but was told it was a liability issue." On 9/29/14 at 9:50 a.m., surveyor # interviewed CNA-P regarding resident #4's bed and chair alarm. CNA-P stated, "Resident #4 did not like the alarms. Every time the alarm would beep, it would frustrate her...The alarms would beep a lot." On 9/29/14 at 9:55 a.m., surveyor # interviewed CNA-N regarding resident #4's bed and chair alarm. CNA-N stated, "she (resident #4) hated the bed and chair alarm. She would throw it across the room. The sound of the alarm would make her more agitated." On 9/29/14 at 9:55 a.m., surveyor # interviewed CNA-O regarding resident #4's bed and chair alarm. CNA-O stated, "She (resident #4) hated the alarms with a [MEDICATION NAME]. When the alarm would go off she (resident #4) would start crying and become upset." On 9/29/14 at 10:05 a.m., surveyor # interviewed AC-Q regarding resident #4's bed and chair alarm. AC-Q indicated the use of the bed and chair alarm was an intervention from nursing. AC-Q verified FM-R called the facility "a week or so ago" and expressed concerns about not liking the alarms and planned to take their mother to another facility. AC-Q stated she told FM-R the bed and chair alarm was for resident #4's safety. On 9/29/14 at 10:40 a.m., surveyor # interviewed DON-A regarding resident #4's chair and bed alarm. DON-A indicated the bed and chair alarm was added to resident #4's plan of care due to a fall at home, and being at risk for falls. DON-A verified she had conversations with resident #4's APOAHC-S and FM-R during resident #4's stay at the facility, and their concerns of not wanting the bed and chair alarm. DON-A stated "The two options I gave resident #4's APOAHC-S were to move resident #4 to another unit with more staff, or wait until therapy could give better recommendations. APOAHC-S did not want resident #4 moved to another room...the only appropriate intervention was the bed and chair alarm."