Every finding on record at Odd Fellow Home

Based on observation, interview, and record review, the facility did not ensure 1 resident (R) (R15) of 3 sampled residents was appropriately supervised to prevent accidents and abuse. R15 wandered in the facility and into residents' rooms uninvited. On 7/6/26, R15 wandered into R4's room, looked through their personal belongings, and hit them on the arm. R15's care plan did not contain appropriate interventions and levels of supervision to prevent future occurrences. Findings include: The facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, indicates: .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan includes measurable objectives and timeframes .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .and reflects currently recognized standards of practice for problem areas and conditions .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.Assessments of residents are ongoing and care plans are revised as information about the residents and their condition changes .The IDT reviews and updates the care plan .when the desired outcome is not met . On 7/20/26, Surveyor reviewed R15's medical record. R15 had a diagnosis of dementia. A Quarterly Minimum Data Set (MDS) assessment, dated 6/16/26, stated R15 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. On 7/20/26 at 9:15 AM, Surveyor observed R15 self-propel a wheelchair in the hallway. On 7/20/26 at 9:40 AM, Surveyor interviewed R48 who had stop sign on their door frame. R48 stated the resident rolling in the hallway (and pointed to R15) comes into their room all the time even when the door is closed and brings the stop sign into the room with them. R48 stated R15 goes through their personal items and drawers. R48 recently accepted the stop sign to deter R15 from entering their room uninvited. R48 stated they call staff or push R15's wheelchair out of the room if staff do not come in time. R48 stated the stop sign does nothing and staff know R15 enters their room because they have to frequently remove them from the room. (R48's medical record indicated they had diagnoses including cognitive communication deficit, depression, other specified disorders of the brain, and severely impaired cognition.) On 7/20/26 at 11:58 AM, Surveyor interviewed R4 who stated R15 often wanders into their room and wanders into a lot of peoples' rooms uninvited. R4 stated R15 entered their room and smacked them on the arm when they told R15 to leave as they were rummaging through all my stuff. R4 stated the facility put a stop sign on their bedroom door, however, R15 continues to enter their room uninvited. R4 stated the stop sign does not deter R15 from entering and said R15 comes into the room carrying the stop sign. R4 stated staff do redirect R15, however, they continue to enter their room. On 7/20/26, Surveyor reviewed R4's medical record. R4 had diagnoses including post-traumatic stress disorder (PTSD) and major depressive disorder. A Quarterly MDS assessment, dated 6/16/26, stated R4 had a BIMS score of 15 out of 15, indicating intact cogntion. A progress note, dated 7/7/26, indicated R4 was sitting in a chair when R15 entered their room and started picking through personal items on their table. When R4 asked R15 to stop, R15 struck their on the left arm. R4 and R15 were separated and assessed for injuries. Nursing Home Administrator (NHA-A) was notified. A progress note, dated 7/8/26, indicated Social Services staff spoke with R4 following the incident. R4 stated they felt frightened and anxious and were concerned R15 would return to their room. They discussed placing a stop sign at the entrance of the room as a non-restrictive intervention to deter unwanted entry. R4 was encouraged to let staff know if there were further concerns or if R15 entered their room. On 7/20/26 12:16 PM, Surveyor observed Certified Nursing Assistant (CNA)-U assist R15 who was behind the nurses' station. CNA-U transported R15 to the common area and left. On 7/20/26 at 12:45 PM, Surveyor interviewed CNA-U who verified they found R15 in the nurses' station by themself and stated R15 should not be behind the nurses' station alone. CNA-U stated staff get busy and R15 wanders, including into other residents' rooms. CNA-U stated R15 is redirected easily and does not have behaviors. CNA-U verified R15 likes to have a doll and stated staff redirect R15 and document when they wander. Staff also give R15 a snack and sit with them at times. CNA-U confirmed R15 can self-propel a wheelchair. CNA-U indicated R15's behavioral interventions are for staff to redirect, distract, or sit with them. On 7/21/26 at 11:59 AM, Surveyor interviewed NHA-A who stated they had not completed audits to determine if the stop signs on R4 and R48's doors deterred R15 from entering their rooms. NHA-A stated they knew the stop signs worked. NHA-A was not aware that R15 continued to enter R4 and R48's rooms and confirmed the stop sign was not sufficient to provide supervision and deter potential accidents or abuse.

Based on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R1) of 4 sampled residents.R1 was prescribed Eliquis (blood thinning medication) 2.5 milligrams (mg) twice daily for one week following surgery. The dose was to be increased to 5 mg twice daily on 12/26/25. The dose was not increased until 12/27/25 which resulted in R1 receiving two incorrect doses of the medication.The facility's Administering Medications policy, revised 12/10/25, indicates: Medications should be administered in accordance with prescriber's orders. On 2/2/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including post-hip arthroplasty, osteoarthritis, atrial fibrillation, and panic disorder. R1's most recent Minimum Data Set (MDS) assessment, dated 12/25/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. On 2/2/26, Surveyor reviewed R1's hospital discharge paperwork and admission orders, dated 12/19/25. R1's discharge paperwork contained an order for Eliquis 5 mg tablet - take 1 tablet (5 mg total) by mouth two times daily (BID) for deep vein thrombosis (blood clot) prevention. Give 2.5 mg BID for the first week (7 days) post-op. Surveyor reviewed a physician communication, dated 12/23/25, where nursing staff requested clarification for R1's Eliquis order. Physician Assistant (PA)-C indicated R1 should receive 2.5 mg BID through 12/25/25 and 5 mg BID starting on 12/26/25.A nursing note, dated 12/23/25, indicated R1's Eliquis order was changed to 2.5 mg BID for 1 week (ending on 12/25/25) and 5 mg BID starting on 12/26/25. R1's family was updated.Surveyor reviewed R1's December 2025 Medication Administration Record (MAR) and noted R1 received Eliquis 2.5 mg BID from 12/19/25 through 12/26/25 (a total of 8 days). R1 began receiving Eliquis 5 mg BID on 12/27/25. On 2/2/26 at 1:34 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R1's order indicated Eliquis should have been increased on 12/26/25 instead of 12/27/25. NHA-A indicated there may have been a transcription error when the order was entered.

Based on observation, staff and resident interview, and record review, the facility did not ensure administration of medication in accordance with physician orders for 1 resident (R) (R2) of 1 sampled residentR2's AM and PM medications were administered late on multiple occasions. Findings include:The facility's Administration of Medication policy, dated April 2019, indicates: .Medications are administered in a safe and timely manner, and as prescribed .3. Staffing schedules are arranged to ensure medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). On 11/18/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including osteomyelitis left ankle non-healing wound, epilepsy, peripheral vascular disease (PVD), depression, and osteoarthritis. R2's most recent Minimum Data Set (MDS) assessment, dated 11/11/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 had intact cognition. The MDS assessment also indicated R2 required assistance with activities of daily living (ADLs). R2 was R2's own decision maker.On 11/18/25 at 9:06 AM Surveyor interviewed R2 who stated R2's medications were late most days, including R2's epilepsy medications. R2 indicated R2 had not yet received R2's AM medications. On 11/18/25 at 9:26 AM, Surveyor observed Registered Nurse (RN)-C administer medications to residents. Surveyor interviewed RN-C who indicated RN-C was running late with medication pass and was going to administer R2's medications next. RN-C indicated R2 prefers to receive medication at 8:30 AM, however, RN-C was running late. RN-C verified R2's medications were scheduled for 8:00 AM and indicated staff can administer medication up to an hour before or after the scheduled time. RN-C confirmed that R2 has expressed concerns about receiving medications late.Surveyor reviewed R2's Medication Administration Record (MAR) which indicated R2's medications were administered late 8 times from 10/29/25 to 11/18/25.R2 was scheduled to receive the following medications at 8:00 AM: multivitamin 1 tablet; aspirin 81 mg 1 tablet; vitamin D 25 micrograms (mcg) 2 tablets; probiotic 1 capsule twice daily; levetiracetam (an antiepileptic medication) 1,000 mg 2.5 tablets twice daily; amlodipine 5 mg 1 tablet daily, gabapentin 400 mg 3 capsules 3 times daily; clopidogrel 75 mg 1 tablet daily; and meropenem intravenous solution reconstituted 2 grams (gm) 1 dose intravenously (IV) every 8 hours. R2's MAR indicated the medications were administered late on the following dates: ~ 10/31/25 - administered at 9:30 AM~ 11/1/25 - administered at 10:03 AM~ 11/6/25 - administered at 10:06 AM~ 11/11/25 - administered at 9:26 AM~ 11/14/25 - administered at 9:10 AM~ 11/15/25 - administered at 9:11 AM~ 11/18/25 - administered at 9:26 AM R2 was scheduled to receive the following medications at 8:00 PM: mirtazapine 15 mg 1 tablet at bedtime; levetiracetam 1,000 mg 2.5 tablets twice daily; probiotic 1 capsule twice daily; gabpentin 400 mg 3 capsules 3 times daily; atorvastatin 20 mg 1 tablet at bedtime; and topiramate 25 mg 1 tablet at bedtime.R2's MAR indicated the medications were administered late on the following date:~ 10/29/25 - administered at 11:04 PMOn 11/18/25 at 11:25 AM, Surveyor interviewed Nusing Home Administrator (NHA)-A who indicated nurses have an hour before or after the prescribed time to administer medications to residents.

Based on staff and resident interview and record review, the facility did not report allegations of abuse to the State Agency (SA) for 2 residents (R) (R1 and R8) of 2 sampled residents.R1 had a witnessed fall on 10/17/25. The facility determined abuse occurred. The facility's 5-day investigation was not submitted to the SA within the required timeframe.R8 reported that a Certified Nursing Assistant (CNA) was abusive to R8. The facility initiated a grievance form but did not report the allegation of abuse to the SA.Findings include: The facility's Patient Protection Program Freedom from Abuse, Neglect, and Exploitation policy, initiated 3/15/24, indicates the Nursing Home Administrator (NHA) or designee will report abuse to the State Agency per state and federal requirements .The facility will ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment .will be reported no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including the State Survey Agency) in accordance with state law through established procedures .The policy indicates follow-up investigative notes will be submitted via the Wisconsin (WI) Department of Health Services (DHS) Misconduct Incident Reporting System (MIRS) within 5 working days of the initial report. 1. On 11/18/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including diffuse large b-cell lymphoma, dysphagia, cognitive communication deficit, Huntington's disease, dementia, depression, retention of urine, dystonia, anxiety, and repeated falls. R1 had an activated Power of Attorney for Healthcare (POAHC) who assisted with medical decision making. R1's Minimum Data Set (MDS) assessment, dated 10/1/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderately impaired cognition.On 11/18/25, Surveyor reviewed a faciity-reported incident (FRI) that indicated R1 had a witnessed fall on 10/17/25. The Interdisciplinary Team (IDT) determined abuse had occurred based on Licensed Practical Nurse (LPN)-E's progress note of the incident. LPN-E was called to R1's room by CNA-F and discovered R1 on R1's knees in front of the bed facing the window. R1's pants were pulled down and R1 was defecating on bed linens. The initial report was submitted to the SA on 10/17/25. The 5-day investigation was due on 10/24/25 but was not submitted until 10/27/25.On 11/18/25 at approximately 12:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who acknowledged the due date for the 5-day investigation was 10/24/25. NHA-A indicated the report was not submitted on 10/24/25 because NHA-A was still waiting for an additional staff statement related to the incident. 2. On 11/18/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF), respiratory failure, bipolar disorder, falls, and osteoarthritis with pathological falls. R8 made R8's own healthcare decisions. R8's MDS assessment, dated 11/4/25, had a BIMS score of 15 out of 15 which indicated R8 had intact cognition. On 11/18/25, Surveyor reviewed a grievance provided by NHA-A that indicated R8 reported to staff on 10/24/25 that R8 was upset about cares during the PM/night (NOC) shift. R8 indicated a CNA man-handled R8 and flopped my legs and they are still tender. R8 also indicated the CNA was rude, just not kind after the CNA rolled R8 in bed and R8 stated R8 felt unsafe. The grievance findings indicated R8 had a prolonged hospital stay due to a change in condition and did not recall the incident when R8 returned to the facility. R8 stated R8 felt safe at the facility upon return. Staff were educated on taking time with residents and to follow-up when needed. The education was signed by Assistant Director of Nursing (ADON)-D on 11/7/25. The grievance form was signed by NHA-A on 11/17/25.On 11/18/25 at approximately 1:30 PM, Surveyor interviewed NHA-A who verified the allegation of abuse should have been reported to the SA.

Based on staff and resident interview and record review, the facility did not ensure allegations of abuse were thoroughly investigated for 2 residents (R) (R1 and R8) of 2 sampled residents.R1 fell on [DATE]. The facility determined abuse occurred. The allegation of abuse was not thoroughly investigated and inaccurate staff education was provided. R8 reported a Certified Nursing Assistant (CNA) was abusive to R8. The allegation of abuse was not thoroughly investigated.Findings include: The facility's Care Plans, Comprehensive Person-Centered policy, revised March 2022, indicates each resident's comprehensive person-centered care plan is consistent with the resident's right to .g. Receive the services and/or items included in the plan of care .The facility's Grievance Policy and Procedure, dated 3/18/24, indicates the resident has a right to voice grievances with respect to treatment or care that is or fails to be furnished .The facility will undertake prompt efforts to resolve any grievances residents may have .Alleged incidents of caregiver misconduct, allegations of abuse, neglect, and or misappropriation of resident property must be reported to a supervisor and the Administrator immediately. The facility's Patient Protection Program Freedom from Abuse, Neglect, and Exploitation policy, initiated 3/15/24, indicates that immediately upon receiving a report of alleged abuse, the Administrator or designee will coordinate delivery of appropriate medical and/or psychological care and attention to the involved resident. The designated personnel will begin the investigation immediately upon identification of alleged abuse. A root cause investigation and analysis will be completed including who was involved, the resident's statement, the resident's roommate's statement, involved staff and witness statements of events .Ensuring safety and well-being for the vulnerable individual, their roommate, and if applicable other residents with the potential to be affected. Procedures are in place to provide the resident with a safe, protected environment during the investigation, including removing the alleged perpetrator and employees accused of alleged abuse immediately from the resident's area pending the result of a thorough investigation. The facility will examine, assess, and interview the resident and other residents potentially affected as soon as possible to determine any injury and identify any immediate clinical interventions.1. On 11/18/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including diffuse large b-cell lymphoma, dysphagia, cognitive communication deficit, Huntington's disease, dementia, depression, retention of urine, dystonia, anxiety, and repeated falls. R1 had an activated Power of Attorney for Healthcare (POAHC) who assisted with medical decision making. R1's Minimum Data Set (MDS) assessment, dated 10/1/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderately impaired cognition.On 11/18/25, Surveyor reviewed a faciity-reported incident (FRI) that indicated R1 had a witnessed fall on 10/17/25. The Interdisciplinary Team (IDT) determined abuse had occurred based on Licensed Practical Nurse (LPN)-E's progress note of the incident. LPN-E was called to R1's room by CNA-F and discovered R1 on R1's knees in front of the bed facing the window. R1's pants were pulled down and R1 was defecating on bed linens. The investigation did not contain statements from CNA-F or LPN-E. The facility provided abuse education to staff on 10/21/25. Upon review of the signatures, Surveyor noted 39 of 172 employees, including agency employees, signed the education. Surveyor reviewed an event summary that indicated LPN-E provided education to CNA-F after the fall, including gait belt and proper footwear use and indicated further transfers should be completed with the assistance of 2 staff or the assistance of 1 staff with a second staff as a standby assist; however, R1's care plan indicated R1 required a sit-to-stand lift for transfers at the time of the fall. Nursing Home Administrator (NHA)-A provided a care plan with a revision date of 10/23/25 (which was after the incident) that indicated R1 transferred via pivot transfer with a front-wheeled walker with the assistance of 2 staff. On 11/18/25 at 11:49 AM, Surveyor interviewed NHA-A who verified R1's care plan at the time of the fall indicated R1 should have been transferred with a sit-to-stand lift and that LPN-E's education to CNA-F did not accurately reflect the correct transfer technique for R1. NHA-A indicated NHA-A did not feel lack of following the care plan was the primary cause of R1's witnessed fall. 2. On 11/18/25, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF), respiratory failure, bipolar disorder disorder, falls, and osteoarthritis with pathological falls. R8's MDS assessment, dated 11/4/25, had a BIMS score of 15 out of 15 which indicated R8 had intact cognition. Surveyor reviewed the facility's grievance file and noted R8 filed a grievance on 10/24/25 that indicated R8 was upset about PM/night shift cares. R8 indicated an unnamed CNA man-handled R8 and flopped my legs and they are still tender. R1 also stated the CNA was rude, just not kind when R8 told the CNA that R8 did not feel safe. The grievance indicated R8 had a prolonged hospital stay due to a change in condition and did not recall the incident when R8 returned to the facility. R8 stated R8 felt safe in the facility and the investigation was completed on 11/7/25. Staff were educated on taking their time with residents and to follow-up when needed. The education was signed by Assistant Director of Nursing (ADON)-D on 11/7/25. The grievance form was signed by NHA-A on 11/17/25. A thorough investigation was not completed in accordance with the facility's policy which indicates to investigate abuse allegations immediately, identify the root cause, interview other potentially affected residents, and obtain witness statements from involved staff. On 11/18/25 at approximately 1:30 PM, NHA-A indicated the facility did not have staff education signatures or further investigative documentation for R8's allegation of abuse.

Based on observation, staff interview, record review, and policy review, the facility did not ensure fall interventions were in place for 1 resident (R) (R1) of 4 sampled residents.R1 was assessed to be at high risk for falls and had a history of falls. R1's care plan contained interventions for fifteen-minute safety checks and grip strips on the floor near R1's bed. The interventions were not consistently implemented. Findings include: The facility's Falls and Fall Risk, Managing policy, dated March 2018, indicates: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors: .2. Resident conditions that may contribute to the risk of falls include: .c. delirium and other cognitive impairment; .e. lower extremity weakness; f. functional impairments; .k. incontinence 3. Medical factors that contribute to the risk of falls include: .d. neurological disorders; and e. balance and gait disorders, etc. Resident-Centered Approaches to Managing Falls and Fall Risk: .5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable .Monitoring Subsequent Falls and Fall Risk: .3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. R1's Resident Profile indicated R1 was admitted to the facility on [DATE] and received Hospice services effective 8/5/25. R1 had diagnoses of muscle weakness, unsteadiness on feet, unspecified intellectual disabilities, unspecified dementia (a decline in cognitive function), unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), cognitive communication deficit, and repeated falls. A Significant Change in Status Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/5/25, contained a Staff Assessment of Mental Status that indicated R1's cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The MDS assessment also indicated R1 demonstrated inattention and disorganized thinking and R1's behavior, care rejection, and wandering were worse than the prior assessment (admission MDS, dated [DATE]). The MDS review period indicated R1 required substantial/maximal assistance for functional mobility, was always incontinent of bladder, and had two or more falls since the Admission/Entry Assessment (dated 7/3/25) with no injury and one fall with injury. A care plan, initiated 7/1/25, indicated R1 was at high risk for falls related to confusion, deconditioning, weakness, and frequent falls. Interventions included: Fifteen-minute safety checks while sleeping (initiated 7/23/25); Grip strips to floor near bed (initiated 8/7/25); R1 needs to be evaluated for and supplied appropriate adaptive equipment or devices as needed. Re-evaluate and as needed for continued appropriateness and to ensure least restrictive device or restraint (initiated 7/1/25). A Fall Risk Evaluation, dated 8/2/25, contained a score of 18 which indicated R1 was at high risk for falls. The evaluation indicated prevention protocol should be initiated immediately and documented on the care plan. A Safety Check log (15-minute safety checks), indicated 15-minute safety checks were not completed between 4:30 PM and 7:45 PM on 9/7/25. R1 had an unwitnessed fall in R1's room on 9/7/25 at 7:45 PM. An Incident Report, dated 9/7/25 at 7:45 PM, indicated the incident location was R1's room. A nursing description of the incident indicated R1 was discovered face down on the floor in front of R1's Broda chair and had lacerations on the top of the head. During an observation on 10/6/25 at 10:21 AM, R1's room did not have grip strips (or a fall mat, rubber flooring, or rubber treads) at the bedside to provide traction and reduce slips or falls. R1 was not present in the room. During a continued observation outside R1's room, R1 was seated in a Broda chair (specialized therapeutic wheelchair) with poor posture. It appeared that R1's body had moved forward and down in the chair from an upright position. The Assistant Activities Director (AAD) wheeled R1 through the 300 hallway and called down the hall that someone might want to help (R1). (R1) is sliding down and needs help. During an observation and attempted interview on 10/7/25 at 5:27 PM, R1 was in bed on R1's back and could not participate in a meaningful interview. R1 provided eye contact when R1's name was spoken. During an interview on 10/6/25 at 1:46 PM, the Director of Nursing (DON) stated R1 required stand-by assistance (SBA) with ambulation during rehab. The DON stated R1 had a decline in physical functioning, increased dependence for activities of daily living (ADLs), and multiple witnessed falls after R1 transferred to the long-term care (LTC) unit. The DON said R1 tripped over R1's feet because R1's shoes did not fit. R1's Guardian was asked to bring better fitting shoes. Grippy socks were implemented for safety. During an interview on 10/8/25 at 10:56 AM, Licensed Practical Nurse (LPN)1 stated R1 moved around in a wheelchair, was compulsive, had no safety awareness, and would get up from a seated position. R1 did not follow verbal redirection. LPN1 said LPN1 assisted staff after R1 sustained a fall from a wheelchair in R1's room. During an interview on 10/8/25 at 3:41 PM, the DON stated R1 was impulsive, unaware of R1's limitations, and 15-minute safety checks were implemented from 8/12/25 to 9/14/25. The DON said the facility did not use fall mats and occasionally put residents on 1:1 supervision if requested by a nurse. The DON confirmed non-skid strips were not placed beside R1's bed when R1 changed rooms on 8/18/25. During an interview on 10/8/25 at 4:00 PM, the Assistant Director of Nursing (ADON) stated the purpose of 15-minute checks is to ensure R1's safety by having staff visually monitor R1 at regular intervals to prevent falls, including early intervention to assess R1's mood, behavior, and environment. The ADON said 15-minute checks were completed at times but not listed as a care plan intervention because the Certified Nurse Aides (CNAs) did whatever they wanted. The ADON indicated staff were re-educated on how to complete 15-minute safety checks.

Based on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. This had the potential to affect all 59 residents residing in the facility. IP-C and Director of Nursing (DON)-B shared infection prevention duties for the facility since of March 2025. IP-C did not complete specialized training and DON-B had not begun specialized training. Nursing Home Administrator (NHA)-A indicated a permanent IP was hired and had started infection prevention and control training on 5/5/25. Findings include: Centers for Medicare & Medicaid Services (CMS) Memo QSO-22-19-NH, revised 6/29/22, indicates: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities which was implemented in three phases: .Phase 3 (11/28/19) .regulations which require nursing homes to have an Infection Preventionist who has specialized training onsite at least part-time to effectively oversee the facility's infection prevention and control program. The facility did not have an infection prevention and control policy that outlined the facility's infection prevention and control program, provided a description of the Infection Preventionist's training requirements, or identified the number of hours or time needed for infection prevention and control in the facility. On 5/6/25 at 9:32 AM, Surveyor interviewed NHA-A, DON-B, and IP-C who all indicated the previous IP left the facility unexpectedly in March of 2025. A new IP was hired but was on leave until 5/5/25 when the new IP started training. NHA-A indicated the new IP was completing the Centers for Disease Control and Prevention (CDC) IP training this week and wound care training next week. NHA-A indicated IP-C was asked to fill the IP role and complete wound nurse rounds until the new IP completed training. NHA-A indicated IP-C started duties in March of 2025 and worked 1-2 days per week and DON-B assisted with IP duties. IP-C indicated IP-C started the CDC IP training modules but had not completed them. DON-B did not have IP training and was not currently completing IP training. Surveyor was provided with IP-C's progress in the CDC training program which included 24 modules of training. Surveyor noted IP-C completed 10 modules with the last module completed on 3/26/25. On 5/6/25 at approximately 9:45 AM, Surveyor reviewed staff infection line lists from December 2024 through May 2025. Surveyor identified 8 instances where staff returned to work prior to the CDC recommendations for staff with COVID-19 illness. Surveyor identified 2 instances where staff returned to work early after gastrointestinal (GI) illness symptoms of nausea, vomiting and/or diarrhea. (See F880 for further information.) On 5/7/25 at 11:30 AM, Surveyor interviewed NHA-A, DON-B, and IP-C regarding antibiotic therapy concerns for 3 residents. (See F881 for further information.) DON-B indicated the facility does not currently have a trained IP that can train the new IP so there are gaps in the process. On 5/8/25 at approximately 1:30 PM, Surveyor reviewed the Facility Assessment which did not specify the number of hours or time needed for the IP position.

2. R39's medical record indicated R39 had chronic diabetic wounds. On 5/5/25 at 10:40 AM, Surveyor observed 3 staff (2 therapy staff and one CNA) transfer R39 without wearing PPE. R39's room did not contain a sign on or near the door that indicated R39 was on EBP. On 5/6/25 at 8:15 AM, Surveyor noted an EBP sign was on R39's door. On 5/6/26 at 10:26 AM, Surveyor interviewed DON-B who indicated PPE should be worn during high-contact cares such as hygiene, dressing, linen changes, and cares involving open areas and and body fluids for residents who are on EBP. DON-B indicated residents with wounds should be on EBP and confirmed R39 should be on EBP. On 5/6/25 at 1:07 PM, Surveyor observed CNA-R assist R39 to the restroom without PPE. When Surveyor asked CNA-R if PPE was required, CNA-R indicated no because R39 did not have any open wounds. Surveyor then interviewed CNA-T who indicated PPE should be worn if toileting or transferring a resident on EBP. On 5/6/25 at 2:30 PM, Surveyor observed DON-B and Medical Doctor (MD)-S complete wound care for R39. DON-B and MD-S donned gowns and gloves. During the observation, Surveyor noted DON-B and MD-S kneeled on the floor without a barrier. When wound care was finished, Surveyor interviewed DON-B who confirmed there should have been a barrier on the floor. MD-S and DON-B indicated R39's wounds were present upon admission. DON-B confirmed R39 should have been on EBP since R39 was admitted on [DATE]. 3. On 5/5/25 at 8:43 AM, Surveyor observed RN-F administer medication to R25 who was on EBP. R25 complained of pain in the right fifth toe. RN-F removed R25's sock and assessed R25's right fifth toe without gloves or a gown. When RN-F left R25's room, RN-F confirmed R25 was on EBP for a right ankle infection in the hardware. When Surveyor asked if RN-F should have donned gloves and a gown prior to touching R25's right foot, RN-F indicated PPE was only needed when toileting R25 due to something in R25's urine. 4. On 5/5/25 at 9:01 AM, Surveyor observed RN-F attempt to obtain R4's blood pressure with a vitals machine which was not successful. RN-F then attempted to obtain R4's blood pressure with a wrist cuff from the mediation cart which was also not sucsessful. RN-F then obtained a manual cuff and stethoscope from the medication cart and successfully obtained R4's blood pressure. RN-F then put the wrist and manual cuffs and stethoscope back in the medication cart without sanitizing them and did not sanitize the vitals machine. On 5/5/25 at 9:19 AM, Surveyor interviewed RN-F after RN-F finished administering medication to R4 and had moved on to the next resident. When Surveyor asked if the blood pressure cuffs and stethoscope should have been sanitized, RN-F indicated they should have been but did not sanitize them. Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 59 residents residing in the facility. Seven staff who tested positive for COVID-19 and two staff with gastrointestinal (GI) symptoms returned to work earlier than recommended by the Centers for Disease Control and Prevention (CDC) and/or the Wisconsin Department of Health Services (DHS) whose guidelines the facility followed. R39 had chronic diabetic wounds that were present upon admission and was put not on enhanced barrier precautions (EBP) until 5/6/25. Staff did not did not wear the appropriate PPE during cares and knelt on the floor without a barrier during wound care. R25 was on EBP. Staff did not ensure proper personal protective equipment (PPE) was worn when assessing R25's toe. Staff did not ensure a vitals machine, blood pressure equipment, and a stethoscope were sanitized after use for R4 Findings include: The CDC webpage COVID-19, last updated on 3/18/24, contains an article titled Interim Guidance for Managing Healthcare Personnel (HCP) with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 that indicates: The following are criteria to determine when HCP with SARS-CoV-2 infection could return to work .HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: ~ At least 7 days have passed since symptoms first appear 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 ~ At least 24 hours have passed since the last fever without the use of fever-reducing medications and symptoms (e.g., cough, shortness of breath) have improved. Either NAAT (molecular) or antigen testing may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later Per the Wisconsin DHS website, last updated 3/18/25, webpage titled Preventing and Controlling Respiratory Illness Outbreaks in Long-Term Care Facilities and Other Health Care Settings .Long Term Care Facilities are strongly encouraged to maintain and update a line list during an acute respiratory illness (ARI) outbreak to organize case information .DHS recommends facilities continue to share them with public health as part of shared outbreak response . The Wisconsin DHS online booklet Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities, dated 12/2017, indicates: .A staff illness policy should be developed and implemented, and all employees should be educated about the policy. The policy should clearly outline staff responsibilities for when and how to inform management of illness .and should outline the policy for returning to work (48 hours after signs and symptoms subside) .Staff should exclude themselves from resident care and food service duties at the onset of symptoms, including nausea, vomiting, abdominal pain, and/or diarrhea. Such exclusions shall remain in effect until the employee is asymptomatic and free of diarrhea and vomiting for 48 hours . The facility's Enhanced Barrier Precautions Policy, dated 1/2025, indicates: The purpose of this policy is to reduce the transmission of multidrug-resistant organisms (MDROs) and other infectious agents within the facility by implementing enhanced barrier precautions (EBPs) for residents at increased risk for infection or colonization .Infection control practices requiring the use of persona protective equipment (PPE) during certain high-contact resident care activities, even when standard isolation precautions are not indicated. High-Contact Resident Care Activities: activities involving potential exposure to infectious agents, including dressing, bathing/showering, transferring, providing hygiene (toileting), changing lines, device care or use, and wound care .EBP must be implemented for residents known or suspected to be colonized or infected with MDROs or those at risk for such colonization (e.g., residents with indwelling devices, open wounds, or recent hospitalizations). 2 .Healthcare personnel (HCP) must wear gloves and gowns during high-contact care activities .5 .Place signage outside residents' rooms to indicate the implementation of EBPs and the required PPE for care .7 .High-touch surfaces and equipment in residents' care areas should be cleaned . 1. On 5/6/25 at approximately 9:45 AM, Surveyor reviewed staff infection line lists from December 2024 through May 2025. The line list header titles included: staff name, illness type, illness start date, positive test date, symptoms, unit last worked, COVID retest date (48 hours prior to return), and return to work date. Surveyor noted staff with COVID-19 completed 1 retest prior to returning to work. The December 2025 staff infection line list indicated 7 staff tested positive for COVID-19 and 6 staff returned to work prior to the CDC recommendations: ~ Certified Nursing Assistant (CNA)-I had COVID-19 with a first symptom date of 12/22/24. CNA-I was retested on [DATE] and returned to work on 12/30/24. ~ Registered Nurse (RN)-J had COVID-19 with a first symptom date of 12/20/24. RN-J was retested on [DATE] and returned to work on 12/27/24. ~ CNA-K had COVID-19 with a first symptom date of 12/22/24. CNA-K was retested on [DATE] and returned to work on 12/29/24. ~ CNA-L had COVID-19 with a first symptom date of 12/21/24. CNA-L was retested on [DATE] and returned to work on 12/31/24. ~ CNA-M had COVID-19 with a first symptom date of 12/30/24. CNA-M was retested on [DATE] and returned to work on 1/7/25. ~ CNA-N had COVID-19 with a first symptom date of 12/30/24. CNA-N was retested on [DATE] and returned to work on 1/9/25. The January 2025 staff infection line list indicated 1 staff had GI symptoms of nausea, vomiting, and diarrhea and returned to work prior to DHS recommendations of 48 hours from the last GI symptom: ~ RN-P had GI illness with a first symptom date of 1/15/25 and returned to work on 1/17/25. (The line list did not indicate the date of RN-P's last symptom.) The March 2025 staff infection line list indicated 1 staff tested positive for COVID-19 and returned to work prior to the CDC recommendations: ~ Hospitality Aide (HA)-Q had COVID-19 with a first symptom date of 3/8/25. HA-Q was retested on [DATE] and returned to work on 3/14/25. The April 2025 staff infection line list indicated 1 staff had GI symptoms of vomiting and returned to work prior to DHS recommendations of 48 hours from the last GI symptom: ~ CNA-R had GI illness with a first symptom date of 4/13/25 and returned to work on 4/16/25. (The line list did not indicated the date of CNA-R's last symptom.) On 5/7/25 at 12:03 PM, Surveyor interviewed Infection Preventionist (IP)-C, Director of Nursing (DON)-B, and Nursing Home Administrator (NHA)-A and reviewed the staff line list concerns. DON-B stated the staff infection line list return-to-work dates were not correct as listed. NHA-A stated the facility's previous IP was still learning the role and left unexpectedly; therefore, the previous IP's documentation was incorrect. DON-B indicated DON-B would provide time clock punches for staff with COVID-19 to verify if the previous IP's documentation was correct for return-to-work dates. When Surveyor asked about the facility's return-to-work policy for staff with GI illness, IP-C indicated staff with GI illness can return to work 48 hours after the last GI symptom. DON-B indicated the facility does not have a GI policy that includes criteria for return to work and stated the facility follows the CDC and WI DHS guidelines. When Surveyor asked where the facility documents staffs' last GI symptom in order to determine when staff should return to work, no response was provided. DON-B indicated DON-B would also provide time clock punches for staff with GI symptoms to determine when they returned since the line list might be incorrect. On 5/7/25 at approximately 2:00 PM, DON-B provided staff time punches and new staff infection line lists for December 2024 through May 2025. The new line lists correlated with the time punches; however, they did not provide the dates of last symptoms. On 5/7/25 at 2:52 PM, Surveyor interviewed DON-B who verified staff with COVID-19 completed one COVID-19 antigen test 48 hours prior to returning to work. The CDC COVID HCP return-to-work guidelines indicated 2 antigen tests should be completed prior to returning to work, if both antigen tests are negative staff can return after day 7 since the start of symptoms but if 1 of the 2 tests is positive, staff cannot return until after day 10. Since the facility did not follow the guidelines for the completion of 2 tests prior to returning to work, staff were not able to return until after day 10.

Based on observation, staff interview, and record review, the facility did not ensure medications for 8 residents (R) (R13, R30, R26, R46, R14, R263, R20, and R0) in 1 of 2 medication carts were labeled and/or dated appropriately. In addition, the facility did not ensure expired treatment supplies were removed from storage in 1 of 4 medication storage areas and did not ensure medication was stored appropriately. Medication was left unattended on top of the medication cart. A medication storage area contained undated and expired resident and stock medications and medical supplies. A medication cart contained unlabeled, undated, and expired resident and stock medications. Findings include: The facility's Administering Medications policy, dated 2001, indicates: The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. The facility's Medication Labeling and Storage policy, dated 2001, indicates: .3. If the facility has discontinued, outdated, or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying the items .4. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. The facility's Ophthalmic Medications policy, dated 6/2021, indicates: If the manufacturer states a specific expiration date upon opening this date should be used to determine when to discard the eye preparation. If a manufacturer is unable to provide an expiration date once the medication is open, current standards of practice generally recommend discarding the eye drop after 28 days because sterility cannot be guaranteed beyond that point. On [DATE] at 8:43 AM, Surveyor observed License Practical Nurse (LPN)-O during medication administration and noted a Med Pass 2.0 supplement on the medication cart did not contain an open date. LPN-O verified the container of Med Pass should have been dated when opened. On [DATE] at 9:01 AM, Surveyor observed medication on top of a medication cart in the hallway. When Registered Nurse (RN)-F returned to the cart, RN-F stated RN-F supposed Surveyor wrote RN-F up for leaving medications on the cart. Surveyor confirmed with RN-F that medication should not be left unattended on the cart when RN-F is in a resident's room. On [DATE] at 9:20 AM, Surveyor noted R13's Arnuity Ellipta inhaler (commonly used to manage asthma) did not contain an open date. A pharmacy label indicated the inhaler expired 42 days after opening. Surveyor also noted R13's Lantus insulin (a long-acting insulin used to manage blood sugar levels) did not contain an open date. On [DATE] at 8:45 AM, Surveyor observed the medication storage room and noted the following: ~ Twenty BD Vacutainer Luer-Lok access devices with expiration dates of [DATE] ~ Sixteen Cardinal Health lubricating jelly 0.11 ounce (oz) packets with expiration dates of [DATE] ~ One purple vial blood tube with an expiration date of [DATE] ~ Two red top tubes with expiration dates of [DATE] ~ Nine light blue top tubes with expiration dates of [DATE] ~ One Sol-Care Luer Lock safety syringe 3 milliliter/without needle with an expiration date of [DATE] ~ One 22 gauge x 1 inch in BD Insyte Autoguard needle with an expiration date of [DATE] ~ One bottle of zinc 50 milligrams (mg) with an expiration of 4/2025 ~ An open and undated package of DuoNeb vials for R30 ~ Five bottles of Air Power guaifenesin expectorant 200 mg for R26 with expiration dates of [DATE], [DATE], [DATE], [DATE], and [DATE] ~ One bottle of Medline Remedy Phytoplex skin repair cream with an expiration date of 3/2023 ~ One 19 oz container of fiber powder with an expiration date of 4/2025 ~ One female urinary specimen kit with an expiration date of [DATE] ~ One Dri-[NAME] hearing aid dehumidifier with an expiration date of [DATE] On [DATE] at 9:41 AM, Surveyor interviewed LPN-O who verified the above items were expired. On [DATE] at 12:18 PM, Surveyor observed a medication cart and noted the following: ~ An open, unlabeled, and undated Symbicort inhaler for R26 ~ Open and undated bottles of fluticasone prop nasal spray for R46, R14, R13, and R263 ~ A bottle of Artificial Tears for R26 with an open date of [DATE] ~ An open and undated bottle of Artificial Tears for R14 ~ A bottle of Artificial Tears for R13 with an open date of [DATE] ~ A bottle of Bausch and Lomb Muro 128 5% eye drops for R26 with an expiration date of [DATE] ~ An open and undated bottle of Rocklatan eye drops for R14 ~ A bottle of Assure Prism control solution with an expiration date of [DATE] ~ An open and undated bottle of ProSource ~ An open and undated bottle of Deep Sea nasal spray for R14 ~ An open and undated albuterol inhaler for R13 ~ An open and undated package of DuoNebs for R20 with one remaining vial ~ An open and undated package of DuoNebs for R0 with six vials in the bottom of the box and four vials in open foil ~ An open and undated bottle of hydrogen peroxide 3% USP 10 volume On [DATE] at 1:04 PM, Surveyor interviewed LPN-E who verified the above items were unlabeled, undated, and/or expired. On [DATE] at 10:26 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated medications such as eye drops, inhalers, and nebulizer packets should be dated when opened. Regarding eye drop and inhaler expiration dates, DON-B provided Surveyor with expiration sheets. DON-B confirmed expired items should be disposed of. DON-B stated the facility does audits and indicated staff should check dates before use.

Based on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 3 residents (R) (R19, R122, and R264) of 6 sampled residents. R19 did not meet McGeer's criteria for a urinary tract infection (UTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R19 did not meet the criteria for a UTI. R122 did not meet McGeer's criteria for a skin and soft tissue infection (SSTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R122 did not meet the criteria for an SSTI. R264 did not meet McGeer's criteria for a respiratory tract infection (RTI) but received antibiotic therapy. The physician was not asked if the antibiotic should have been continued when R264 did not meet the criteria for an RTI. Findings include: The facility's Antibiotic Stewardship policy, revised 12/2016, indicates: .11. When a culture and sensitivity (C&S) is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued . The facility's Antibiotic Stewardship-Orders for Antibiotics policy, revised 12/2016, indicates: .3. Appropriate indications for use of antibiotics include: a. criteria met for clinical definition of active infection or suspected sepsis; and b. pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending) . 1. From 5/5/25 to 5/7/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including abscess of abdominal wall, anemia, malignant neoplasm of endometrium, methicillin- resistant Staphylococcus aureus (MRSA) infection, and fibromyalgia. R19's Minimum Data Set (MDS) assessment, dated 3/10/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R19 had intact cognition. R19's medical record included McGeer's criteria for a UTI that indicated the date of infection was 12/10/24. The form indicated R19 met the criteria for a UTI without an indwelling catheter. Upon review of R19's culture, it was noted the culture grew 50,000 organisms per milliliter which did not meet McGeer's criteria of more than 100,000 organisms per milliliter. R19 took nitrofurantoin (an antibiotic medication) for 5 days. The facility did not update the physician that R19 did not meet the criteria for infection and antibiotic use. On 5/7/25 at 2:23 PM, Surveyor interviewed Director of Nursing (DON)-B and Infection Preventionist (IP)-C who did not comment when Surveyor asked if R19 met McGeer's infection criteria and if the physician was notified. 2. From 5/5/25 to 5725, Surveyor reviewed R122's medical record. R122 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of duodenum, bacterial infection, and stage 2 pressure ulcer of the sacral region. R122's MDS assessment, dated 4/30/25, had a BIMS score of 14 out of 15 which indicated R122 had intact cognition. R122's medical record included a McGeer's SSTI criteria form that indicated the date of infection was 5/2/25. The form indicated R122 met the criteria for infection, however, only 2 of 4 required new or increasing signs or symptoms were identified which indicated R122 did not meet infection criteria. Surveyor also noted R122 was not on the May 2025 resident infection line list. R122 received cephalexin (an antibiotic medication) twice daily for 10 days from 5/2/25 to 5/11/25. The facility did not update the physician that R122 did not meet the criteria for infection. On 5/6/25 at 12:05 PM, Surveyor interviewed IP-C who indicated R122 must have been forgotten on the resident infection line list. IP-C agreed R122 did not meet the criteria for infection based on the fact that R122 had only 2 of 4 required new or increasing signs or symptoms. On 5/7/25 at 11:30 AM, DON-B indicated resident infection line lists are not filled out until the end of each month when they are brought to Quality Assurance Performance Improvement (QAPI) meetings and are reviewed. On 5/7/25 at 1:39 PM, IP-C provided Surveyor with a revised McGeer SSTI infection criteria form and indicated R122 did meet McGeer's criteria. Surveyor reviewed the updated McGeer SSTI criteria form and noted R122 met 3 of 4 required criteria but still did not meet all criteria for infection. 3. From 5/5/25 to 5/7/25, Surveyor reviewed R264's medical record. R264 was admitted to the facility on [DATE] and had diagnoses including unspecified injury of head, chronic obstructive pulmonary disease, and atherosclerotic heart disease. R264's MDS assessment, dated 2/19/25, had a BIMS score of 13 out of 15 which indicated R264 had intact cognition. R264's medical record included a McGeer's common cold symptoms or pharyngitis criteria under the RTI topic that did not document any signs or symptoms but contained sinus infection handwritten. The form did not indicate if the criteria for infection was met. R264 was prescribed amoxicillin (an antibiotic medication) for 10 days. R264's physician was not notified that R264 did not have any cold symptoms or signs of pharyngitis and did nor meet the criteria for infection. On 5/7/25 at 2:18 PM, Surveyor interviewed DON-B and IP-C who did not comment when Surveyor asked about R264's use of an antibiotic without signs or symptoms of infection or follow-up with the physician.

Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was submitted for a Level II Screen when a 30-day hospital exemption expired for 2 residents (R) (R56 and R49) of 18 sampled residents. R56 and R49 were identified on their PASRR Level I Screens as suspected of having a serious mental illness. The facility did not submit for PASRR Level II Screens when R56 and R49's 30-day hospital exemptions expired. Findings include: 1. On [DATE] Surveyor reviewed R56's medical record. R56 had a diagnosis of anxiety disorder and was prescribed Ativan (an anti-anxiety medication). R56's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R56 was not cognitively impaired. R56's medical record indicated R56 was screened for mental illness, developmental disabilities, and intellectual disabilities on [DATE] and granted a 30-day hospital exemption for a PASRR Level II Screen. R56's medical record did not indicate there was submission for a PASRR Level II Screen after R56's 30-day exemption expired. 2. On [DATE], Surveyor reviewed R49's medical record. R49 had diagnoses of insomnia, depression, and anxiety disorder. R49 was prescribed zolpidem tartrate (a sedative/hypnotic medication), Zoloft (an antidepressant medication) and oxazepam (a sedative medication used to treat anxiety). R49's MDS assessment, dated [DATE], had a BIMS score of 8 out of 15 which indicated R49 had moderate cognitive impairment. R49's medical record indicated R49 was screened for mental illness, developmental disabilities, and intellectual disabilities on [DATE] and granted a 30-day hospital exemption for a PASRR Level II Screen. R49's medical record did not indicate there was submission for a PASRR Level II Screen after R49's 30-day exemption expired. On [DATE] at 3:00 PM, Surveyor requested PASRR Level I and Level II Screens for R56 and R49 from Director of Nursing (DON)-B. On [DATE] at 11:06 AM, Surveyor reviewed R56's updated PASRR Level I Screen which was dated [DATE] and R49's updated PASRR Level I Screen which was dated [DATE]. On [DATE] at 1:02 PM, Surveyor interviewed Admissions Coordinator (AC)-D who confirmed AC-D was responsible for completing PASRRs for residents. AC-D indicated R56's PASRR Level I Screen was completed on [DATE] with a 30-day hospital exemption and should have been submitted for a Level II Screen when the 30-day exemption expired. AC-D verified R49's PASRR Level I Screen was completed on [DATE] with a 30-day hospital exemption and should have been submitted for a Level II Screen when the 30-day exemption expired.

Based on staff interview and record review, the facility did not ensure ongoing communication with the dialysis center or ensure ongoing monitoring of the fistula site for 1 resident (R) (R6) of 1 sampled resident. R6 received dialysis three times weekly. The facility did not ensure ongoing communication with the dialysis center or routinely monitor R6's fistula site. Findings include: The facility's Dialysis policy, revised 7/2018, indicates: There should be a pulse, buzzing, or thrill feeling in the fistula or graft. This is the blood rushing through the area. Check the fistula or graft daily. The facility's Hemodialysis Catheters-Access and Care of policy, revised 2023, indicates: Care of arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) .Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access. From 5/5/25 to 5/7/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic neuropathy. R6's Minimum Data Set (MDS) assessment, dated 3/20/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R6 had moderate cognitive impairment. R6's care plan indicated R6 received hemodialysis three times weekly related to end stage renal disease. R6's care plan and Medication Administration Record (MAR) did not indicate the facility monitored R6 for bruit/thrill daily. In addition, R6's medical record contained only eight dialysis communication entries from 6/22/24 through 2/18/25. (The entries were dated: 2/18/25, 1/30/25, 1/21/25, 7/4/24, 6/29/24, 6/27/24, 6/25/24, and 6/22/24.) On 5/6/25 at 1:30 PM, Surveyor interviewed Licensed Practical Nurse (LPN)- E who confirmed monitoring for bruit/thrill was not on R6's MAR or Treatment Administration Record (TAR). LPN-E indicated bruit/thrill should be monitored each shift. On 5/6/25 at 10:26 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility's policy should be followed along with the physician's orders. On 5/6/25 at 2:15 PM, Surveyor requested R6's aftercare visit instructions related to a fistulagram (an X-ray procedure used to evaluate dialysis access). DON-B provided Surveyor with a radiology pre-procedure note, not the aftercare visit instructions for care of the fistula. On 5/7/25 at 11:15 AM, Surveyor interviewed DON-B who indicated bruit/thrill is managed by the dialysis center. Surveyor requested the last visit sheet from dialysis. On 5/7/25 at 11:44 AM, Surveyor interviewed Registered Nurse (RN)-F about communication with the dialysis center. RN-F was not sure what information was sent with R6 but assumed R6's weight and vital signs were sent. RN-F was unsure if the facility received a report from the dialysis center upon R6's return. On 5/7/25 at 12:02 PM, Surveyor interviewed Unit Coordinator (UC)-G who indicated R6 should be sent to each dialysis appointment with an envelope containing a face sheet, appointment sheet, and medication list. UC-G indicated weights and vital signs are not normally sent with residents. UC-G indicated the dialysis center calls or faxes the facility if new orders are given. UC-G indicated appointment sheets are scanned in residents' medical records. On 5/7/25 at 12:20 PM, Surveyor interviewed Dialysis RN (DRN)-H who indicated the facility does not send anything with R6. When Surveyor indicated staff said an envelope with a face sheet, appointment sheet, and medication sheet are sent to each dialysis appointment, DRN-H indicated the dialysis center does not receive that information and they do not have a communication binder for R6. DRN-H indicated if the dialysis center issues new orders, the dialysis center calls or faxes the facility. When Surveyor asked if bruit/thrill should be monitored daily, DRN-H indicated that is the facility's decision, but it should be done daily and especially before and after dialysis.

Based on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R13) of 4 residents observed during medication administration During the AM medication pass on 5/5/25, R13 received Senna-Plus instead of Senna. Findings include: The facility's Administrating Medications policy, dated 2001, indicates: .4. Medication are administered in accordance with prescriber orders .10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. On 5/5/25 at 9:20 AM, Surveyor observed Registered Nurse (RN)-F administer R13's medication. One of the medications administered was Senna-Plus (which is a mixture of sennosides (a stimulant laxative) and docusate sodium (a stool softener)). On 5/6/25 at 8:00 AM, Surveyor reviewed R13's Medication Administration Record (MAR) which indicated R13 should have received Senna 8.6 milligrams (mg) daily for constipation. Surveyor noted RN-F administered Senna-Plus to R13 instead of Senna. On 5/6/25 at 10:26 AM and 11:17 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated medication should be administered per the order.

[NAME] 1/9/25 Based on observation, staff interview, and record review, the facility did not ensure care plans were reviewed and revised for 3 residents (R) (R11, R5, and R3) of 13 sampled residents. R11, R5, and R3's care plans were not updated with interventions related to leaving Hoyer slings underneath R11, R5, and R3. Findings include: The facility's Lifting Machine, Using a Mechanical Policy, dated July 2017, indicates: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device .Steps in procedure: .20. Carefully remove the sling from under the resident. Be mindful of the resident's position and balance, and skin . 1. On 1/9/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, history of left above the knee surgical amputation, osteomyelitis of left foot, and diabetes. R11's Minimum Data Set (MDS) assessment, dated 11/21/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R11 had moderate cognitive impairment. R11 had an activated Power of Attorney for Healthcare (POAHC). R11 had a care plan for actual impairment to skin integrity related to fragile skin on bilateral buttock and hips. A Braden Scale assessment, dated 11/20/24, contained a score of 12 out of 23 which indicated R11 was at high risk for skin breakdown On 1/9/25 at 11:30 AM, Surveyor observed R11 in a Geri chair with a Hoyer lift sling underneath R11. R11 had a specialty mattress on R11's bed and cushion in R11's Geri chair. On 1/9/25 at 11:30 AM, Surveyor interviewed R11 who indicated the Hoyer sling was left under R11 in the Geri chair and removed when R11 was in bed. R11 denied any discomfort from the sling. On 1/9/25 at 1:46 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who verified a Hoyer sling was left underneath R11 in the Geri chair. CNA-G indicated staffs' usual practice was to leave Hoyer slings underneath residents in Geri chairs and wheelchairs and remove the slings when residents transfer into bed. On 1/9/25 at 1:59 PM, Surveyor interviewed CNA-H who indicated Hoyer slings remain underneath residents while they are in Geri chairs and wheelchairs and are removed when residents are transferred into bed. 2. On 1/9/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE]. R5 received Hospice services and had diagnoses including history of fracture of left femur. R5's MDS assessment, dated 12/16/24, had a BIMS score of 0 out of 15 which indicated R5 had severe cognitive impairment. R5 had an activated POAHC. R5 had a care plan for potential impairment to skin integrity related to immobility and was at risk for moisture-associated skin damage (MASD) due to frequent bladder incontinence. A Braden Scale assessment, dated 12/31/24, contained a score of 18 out of 23 which indicated R5 was at moderate risk for skin breakdown. On 1/9/25 at 2:05 PM, Surveyor observed R5 in a recliner with a Hoyer sling underneath R5. R5 had a pressure reduction mattress on R5's bed and a cushion in R5's wheelchair. On 1/9/25 at 2:05 PM, Surveyor interviewed R5 who indicated the Hoyer sling was left underneath R5 in the recliner and wheelchair. R5 indicated the sling did not cause irritation or discomfort. On 1/9/25 at 1:46 PM, Surveyor interviewed CNA-G who verified a Hoyer sling was left underneath R5. CNA-G indicated staffs' usual practice was to leave Hoyer slings underneath residents in Geri chairs and wheelchairs and remove the slings when residents transfer into bed. On 1/9/25 at 1:59 PM, Surveyor interviewed CNA-H who indicated Hoyer slings remain underneath residents in Geri chairs and wheelchairs and are removed when residents are transferred into bed. On 1/9/25 at 2:45 PM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A. DON-B indicated Hoyer slings are left underneath residents in Geri chairs and wheelchairs if the residents don't mind. DON-B verified the facility's policy states slings should be removed. NHA-A indicated a company representative provided an inservice to staff last week and instructed staff that leaving Hoyer slings underneath residents in Geri chairs and wheelchairs is an acceptable practice. NHA-A did not have the literature or documentation from the representative or manufacturer to support the practice. 43361 3. On 1/9/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following nontraumatic intracranial hemorrhage affecting the left non-dominant side, weakness, type 2 diabetes, acquired absence of right leg above knee, and need for assistance with personal care. R3's MDS assessment, dated 12/26/24, had a BIMS score of 15 out of 15 which indicated R3 was not cognitively impaired. R3 had a care plan for potential impairment to skin integrity related to immobility with left sided weakness, recent intracranial hemorrhage, and occasional bowel and bladder incontinence. The care plan contained an intervention to leave the lift sling underneath R3. R3's medical record indicated R3 did not have any pressure injuries. On 1/9/25 at 11:17 AM, Surveyor observed staff transfer R3 from bed to recliner via Hoyer lift. When staff completed the transfer, staff left the sling underneath R3. On 1/9/25 at 11:53 AM, Surveyor interviewed R3 who confirmed staff leave the Hoyer sling underneath R3 which was fine with R3. R3 indicated R3 slept in a recliner at night and the sling remained under R3 while R3 slept. R3 stated R3 asked staff to place a blanket between R3 and the sling at night because sleeping on the sling was uncomfortable.

Based on observation, staff interview, and record review, the facility did not provide appropriate care and services for 2 residents (R) (R10 and R12) of 6 sampled residents with an indwelling catheter. On 1/9/25, R10 and R12's catheter drainage bags were observed in contact with the floor. Findings include: The facility's Catheter, Urinary Policy, dated August 2022, indicates: The purpose of this procedure is to prevent urinary-associated complications, including urinary tract infections .Infection Control: .2. Be sure the catheter tubing and drainage bag are kept off the floor . 1. On 1/9/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including history of supracondylar fracture of the left femur, right tibial fracture, and hypertension. R10's Minimum Data Set (MDS) assessment, dated 12/23/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R10 had moderate cognitive impairment. R10's medical record indicated R10 was responsible for R10's healthcare decisions. On 1/9/25 at 11:20 AM, Surveyor observed R10 and noted R10's catheter bag was covered by a dignity shield and attached to the side of R10's bed which was in the lowest position. R10's dignity shield and catheter bag were laying on the floor. On 1/9/25 at 11:25 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who verified R10's catheter bag was on the floor. CNA-E indicated when CNA-E put R10's bed in the lowest position, CNA-E did not notice that R10's catheter bag was in contact with the floor. CNA-E verified catheter bags should not touch the floor. 2. On 1/9/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including history of hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), anemia, and gross hematuria. R12's MDS assessment, dated 11/21/24, had a BIMS score of 5 out of 15 which indicated R12 had severely impaired cognition. R12 had an activated Power of Attorney for Healthcare (POAHC). On 1/9/25 at 11:40 AM, Surveyor observed R12. Surveyor noted R12's dignity covered catheter bag was attached to R12's wheelchair frame below the seat. R12's catheter bag and dignity shield were dragging on the floor. On 1/9/25 at 11:50 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who verified R12's catheter bag was in contact with the floor. LPN-F raised R12's catheter bag and verified catheter bags should not touch the floor. On 1/9/25 at 12:02 PM, Surveyor interviewed Director of Nursing (DON)-B who verified catheter bags should not touch the floor. DON-B indicated DON-B expects staff to adjust catheter bags so they do not touch the floor.

Based on staff interview and record review, the facility did not ensure the adequate use of assistive devices to prevent injury for 1 resident (R) (R3) of 2 sampled residents. R3 indicated the lift battery often died while R3 was mid-transfer and R3 was left hanging in the lift while staff replaced the battery. Findings include: On [DATE], Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following nontraumatic intracranial hemorrhage affecting the left non-dominant side, weakness, type 2 diabetes, acquired absence of right leg above the knee, and need for assistance with personal care. R3's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was not cognitively impaired. R3's care plan indicated R3 was a 2 person Hoyer lift transfer when R3's left leg prosthesis was off. If R3's left leg prosthesis was on, R3 was a pivot disk transfer. On [DATE] at 11:53 AM, Surveyor interviewed R3 who indicated the lift battery often died while R3 was in the air mid-lift. R3 stated staff needed to leave the room to get a new battery. R3 stated staff recently left R3 hanging in the lift to get another battery. R3 indicated R3 talked to maintenance staff because R3 knew of a place that rebuilt batteries. R3 indicated the facility stated they had ordered new batteries. On [DATE] at 4:11 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who usually worked the night (NOC) shift. CNA-L confirmed lift batteries died mid-transfer. When Surveyor asked if a lift battery had ever died during a transfer with R3, CNA-L indicated the lift battery died that morning while R3 was mid-transfer. CNA-L indicated one of the staff left the room to get another battery because there was another lift outside the door. CNA-L indicated CNA-L had recently received lift training and it was a split second decision not to use the manual while the battery was changed because there was a lift outside R3's room. On [DATE] at 2:15 PM, Surveyor interviewed CNA-N who indicated the lift indicates how much battery is left, however, CNA-N did not check the battery life. CNA-N indicated batteries are changed when they are low and not on a scheduled basis. On [DATE] at 1:42 PM, Surveyor interviewed Maintenance Director (MD)-M and Nursing Home Administrator (NHA)-A who indicated MD-M had just ordered two batteries which should arrive on [DATE]. MD-M indicated if staff have problems with a battery, MD-M tests the battery to see if it holds a charge. MD-M indicated batteries last approximately 6 months. MD-M indicated there were two chargers on each unit that held at least 2 extra batteries and at least 4 Hoyer lifts and 4 EZ stand lifts. Surveyor, MD-M, and NHA-A observed the batteries and chargers on one of the wings. Surveyor noted there was one battery in the charger. MD-M indicated the facility was waiting for the new batteries. NHA-A indicated when a lift is turned on, the lift shows the remaining battery power. NHA-A indicated the lift company recently completed training with staff. NHA-A indicated there is a manual release that staff should use if a battery dies mid-transfer. NHA-A indicated staff should lower the resident with the manual release, changed the battery, and complete the transfer. NHA-A confirmed residents should not be left hanging in the lift if a battery dies during a transfer.

Based on observation, staff interview, and record review, the facility did not ensure a prescribed diet was followed for 1 resident (R) (R3) of 3 sampled residents. R3 was prescribed a consistent carbohydrate hydro-oligomeric diet (CCHO) (a diet designed to manage blood sugar levels in individuals with diabetes or prediabetes). R3's diet order was not consistently followed. Findings include: The facility did not have a policy regarding following diets. On 1/9/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes. R3's Minimum Data Set (MDS) assessment, dated 12/26/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was not cognitively impaired. R3's medical record indicated R3 was prescribed a CCHO diet. During in interview with R3 on 1/9/25 at 12:06 PM, staff delivered R3's meal tray. R3 took the dessert but declined the rest of the tray because R3 had ordered out for lunch. Surveyor reviewed R3's meal ticket and tray. R3's meal ticket stated R3 was on a CCHO diet and indicated R3 should have received a half piece of cake. Surveyor noted R3 had received a full piece of cake which R3 accepted. When Surveyor stated R3's meal ticket indicated R3 should have received a half piece of cake, R3 indicated R3 was okay with a larger piece of cake that day. On 1/9/25 at 12:32 PM, Surveyor interviewed [NAME] (CK)-I and Dietary Aid (DA)-J who were serving lunch in the dining room. Surveyor observed 2 trays of desserts on a cart. The top tray had a mix of cake sizes and the bottom tray had one smaller piece of dessert. When asked the reason for the different cake sizes, CK-I indicated there wasn't a reason. CK-I indicated some pieces of cake were too big and CK-I cut them so they were not so big. CK-I and DA-J indicated some residents asked for smaller pieces so there were a few smaller pieces in case someone asked. Surveyor showed R3's meal ticket to CK-I and DA-J who indicated R3 may have requested a full piece of cake since a couple days prior to the meal staff asked residents what they would like. When Surveyor indicated R3's meal ticket said a half piece of cake, CK-I and DA-J indicated they give residents what they want. On 1/9/25 at 2:11 PM, Surveyor interviewed Dietary Manager (DM)-K who confirmed R3 should have received a half piece of cake due to R3's CCHO diet. DM-K indicated the facility did not have a policy regarding following appropriate diets, however, staff were expected to follow residents' diet cards.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R13) of 13 residents observed during the provision of cares. R13 was on enhanced barrier precautions (EBP) which required staff to wear personal protective equipment (PPE) during high-contact cares. On 1/9/25, staff transferred and provided wound care for R13 without wearing PPE. In addition, Surveyor observed staff exit R13's room with a vital signs machine. Staff did not appropriately disinfect the machine after use. Findings include: The facility's Enhanced Barrier Precautions (EBP) policy, dated 5/1/24, indicates: .EBP: Infection control practices requiring the use of personal protective equipment (PPE) for certain high-contact resident care activities, even in the absence of standard indications for isolation. 2. High-Contact Resident Care Activities: Activities that involve potential exposure to infectious agents such as: dressing .transferring .wound care . The facility's Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised October 2018, indicates: .Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). On 1/9/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including severe sepsis with septic shock, lymphoma, candidiasis (yeast infection), open wound right ankle, open wound left ankle, open wound of the left buttock, stem cell transplant, bone marrow transplant, and need for assistance with personal care. R13's medical record contained an order, dated 1/8/25, for EBP: wounds every shift infection control. R13 also had an order, dated 1/7/24, for EBP: open wound left flank and left gluteal . On 1/9/25 at 12:05 PM, Surveyor observed R13's room and noted an EBP sign on the door. Licensed Practical Nurse (LPN)-C was in the room. When LPN-C opened the privacy curtain, Surveyor noted LPN-C was not wearing PPE. Surveyor interviewed LPN-C who stated LPN-C completed wound care for R13 prior to exiting the room. LPN-C confirmed LPN-C did not wear PPE during wound care. When Surveyor asked if LPN-C should have worn PPE, LPN-C indicated PPE was not needed. When Surveyor asked about the EBP sign on R13's door, LPN-C indicated the sign meant LPN-C needed to wash hands before and after leaving the room. On 1/9/25 at 12:08 PM, Surveyor knocked and entered R13's room. CNA-D was in the room and had just assisted LPN-C with wound care. CNA-D was also not wearing PPE. Surveyor then observed CNA-D transfer R13. CNA-D assisted R13 to stand with a gait belt and walker, pulled up R13's pants, and walked across the room to R13's recliner. CNA-D made R13's bed and adjusted a pillow behind R13's back. CNA-D performed hand hygiene prior to exiting the room with a vital signs machine. On 1/9/25 at 12:15 PM, Surveyor observed CNA-D put the vital signs machine in the hallway and walk away. Surveyor stopped CNA-D and asked if the machine needed to be sanitized. CNA-D indicated the machine would need to be sanitized depending on which resident used it last. CNA-D confirmed CNA-D obtained R13's vital signs. When Surveyor asked CNA-D if R13 was on EBP, CNA-D indicated R13 was on EBP but CNA-D was not sure why. When Surveyor asked if PPE should be worn when assisting with wound care and transfers, CNA-D indicated PPE only needed to be worn during cares like showering and washing a resident. On 1/9/25 at 1:33 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who confirmed staff should wear PPE during high-contact cares. DON-B also confirmed durable medical equipment should be sanitized between each resident use.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R5 and R6) of 13 sampled residents. The facility did not report a resident-to-resident altercation between R5 and R6 to the State Agency (SA) in a timely manner because staff did not report the incident timely to administration. The facility could not provide proof of education for the staff who were working when the resident-to-resident altercation occurred. Findings include: The facility's Patient Protection Program Freedom from Abuse, Neglect, and Exploitation policy, dated 3/2025, indicates: The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation, and mistreatment: Take appropriate corrective action, because of investigation findings .Internal Reporting. A. Employees must always report any abuse or suspicion of abuse immediately to the Administrator or Abuse Coordinator Designee. External Reporting: Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. On 10/7/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including degeneration of nervous system due to alcohol, weakness, and cognitive communication deficit. R5's Minimum Data Set (MDS) assessment, dated 9/9/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker. On 10/7/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance. R6's MDS assessment, dated 7/5/24, indicated R6 was severely cognitively impaired. R6 had an activated decision maker. On 10/7/24, Surveyor reviewed a facility-reported incident (FRI) that indicated on the 7/19/24 PM shift, R5's roommate called staff into R5's room and said there was an incident between R5 and R6. R5 reported to staff that R6 yelled and rammed R6's wheelchair into R5 while R5 was in the activity room watching TV. R5 also reported that staff removed R6 from the activity room. R5 could not recall the name of the staff or the time of the incident. Staff immediately reported R5's allegation to a nurse; however, the nurse did not notify administration of the incident. The nurse filled out a grievance form and left a message for the Social Worker regarding the incident. Surveyor reviewed the facility's investigation which indicated staff were aware of the incident on the 7/19/24 (Friday) PM shift; however, administration did not become aware of the incident until 7/22/24 (Monday). An investigation was initiated and the incident was reported to the SA on 7/22/24 which was beyond the 24 hour reporting requirement. The investigation indicated the facility was not able to determine which staff intervened to remove R6 from the activity room during the incident. Surveyor reviewed education, dated 7/23/24 to 7/25/24, related to reporting incidents to administration in a timely manner. Surveyor reviewed the education sign-in sheets and compared the sign-in sheets to the PM shift schedule on 7/19/24. Surveyor noted Certified Nursing Assistant (CNA-D), CNA-E, and Hospitality Aid (HA-F) were not on the sign in-sheets but had worked on 7/19/24. The facility indicated additional abuse training, including reporting requirements, was completed on 8/26/24 and 8/27/24; however, Surveyor could not locate CNA-D, CNA-E, or HA-F's names. On 10/7/24 at 2:17 PM, Surveyor interviewed Nursing Home Administrator (NHA)-C who could not provide proof that education was completed for CNA-D, CNA-E, and HA-F. NHA-C confirmed education should have been completed since CNA-D, CNA-E, and HA-F were working when the incident occurred.

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 all 50 residents residing in the facility. Staff did not ensure time/temperature control foods were labeled with open or use-by dates. Staff did not wear hair restraints consistently throughout the kitchen. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff did not properly heat food in the microwave that was served to residents. Staff did not follow safe food cooling protocols. Staff were unaware of temperature requirements when testing parts per million (PPM) of the sanitizing solution. Staff did not perform appropriate hand hygiene and safe food handling practices while cooking and serving food Findings include: On [DATE] at 9:25 AM, Dietary Manager (DM)-O indicated the facility follows the Wisconsin Food Code as their standard of practice. 1. Open/Unlabeled/Undated/Expired Food: The Wisconsin Food Code 2020 documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under S ,d+[DATE].12, and except as specified in (E), (F), and (H) 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 and time combination of 5 degrees C (Celsius) (41 degrees F (Fahrenheit)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition. (A) A food specified under ,d+[DATE].17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17 (A) Except time that the product is frozen; (2) Is in a container or package that does not bear a date or day. The facility's undated Date Food and Nutrition Services Dating and Policy and Procedure indicates: 1. Staff will immediately check for dating on arrival of new product to the facility. If there is no identifying date, one must be written on in permanent marker. 2. When opening a food item, each item must contain the use by dating and/or date open .A. Date product with current date opened. B. When using the UBD (use-by dating) use the current (contractor) maintenance dating chart and/or Foodkeeper App. During an initial tour of the kitchen with DM-O on [DATE] at 9:25 AM, Surveyor observed the following: Dry Storage -An unlabeled, undated half full 8 quart covered container of taco seasoning (per DM-O). -An 18 quart container of milk powder (10 quarts full) with an open date of [DATE] and no use-by date. -A container of breadcrumbs with no use-by date. -An unlabeled, undated ,d+[DATE] full 22 quart container of dry peas (per DM-O). -An unlabeled, undated 22 quart container Panko breadcrumbs (per DM-O). -An unlabeled, undated ,d+[DATE] full 32 ounce (oz.) package of powdered sugar. -An undated ,d+[DATE] full 24 oz. Cherry Jello. -An undated ,d+[DATE] full 24 oz. lemon pie filling. -An undated ,d+[DATE] full cheese cake mix. -A half full 5 pound package of spaghetti noodles with no use-by date. -A 12 oz. package of gluten free elbow noodles with no use-by date. -An open, undated container of liquid lemon extract with no use-by date. -An open, undated container of liquid vanilla with no use-by date. -A bulk container of oats that was labeled and dated inaccurately (per DM-O). -A bulk container of flour with an inaccurate label and no use-by date (per DM-O). Walk-In Cooler -An open package of 6 hard-boiled eggs with no use-by date. -An open package of Heath candy crumbles with no use-by date. -An unlabeled, undated 4 oz. container of rotten salad (per DM-O). -An open 2 pound package of Hillshire Farms sliced ham with no use-by date. -An open 2 pound package of Hillshire Farms sliced turkey with no use-by date. Reach-In Cooler -Approximately 3 inches of cheese slices with no use-by date. -An open 5 pound package of shredded cheese with no use-by date. -A 4 quart container of chicken chili with no use-by date. -Three pans of unlabeled, undated 2 oz. disposable containers of sour cream and tartar sauce (per DM-O). -An open and undated container of cottage cheese. -An open gallon of mayonnaise with no use-by date. -An open (dated [DATE]), ,d+[DATE] full gallon container of thousand island dressing with no use-by date. -A container of cooked pasta (made [DATE]) with no use-by date. Freezer -An open, unsealed, undated half-full 3 pound bag of spaetzle dumplings. -An open, unlabeled, undated package of fish fillets (per DM-O). [NAME] Kitchenette Refrigerator/Freezer -An open, unlabeled, undated packaged of waffles. -An unlabeled, undated package of buns. -3 unlabeled, undated fruit cups. Main Kitchenette Refrigerator/Freezer -An open, unlabeled, undated package of waffles. -3 unlabeled, undated containers of what appeared to be salads. -1 unlabeled, undated container of what appeared to be macaroni and cheese. -7 unlabeled, undated containers of what appeared to be cottage cheese. During an initial kitchen tour on [DATE], Surveyor interviewed DM-O who verified the facility uses a FIFO or first in/first out food storage process. DM-O indicated staff are supposed to date items with an open or made date as well as a use-by date. DM-O stated DM-O would dispose of many of the unlabeled, undated items. Surveyor observed DM-O dispose of several items during the tour. During a subsequent kitchen visit on [DATE] at 10:41 AM with Regional Manager (RM) N, Surveyor noted the dried peas, taco seasoning, 2 pastas and Panko breadcrumbs listed above were still in the dry storage area without labels or dates. RM-N indicated the items should have dates. 2. Hair Net Use: The Wisconsin Food Code, Hair Restraints documents at ,d+[DATE].11 Effectiveness.(B) .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. On [DATE] at 8:14 AM, Surveyor observed Cook (CK)-P in the dish area. CK-P wore a hairnet over a headband. Surveyor noted the back of the headband was halfway up the back of CK-P's head which left the lower half of CK-P's hair exposed. On [DATE] at 9:03 AM, Surveyor observed Dietary Aide (DA)-S serve food and operate equipment in the kitchenette of the main dining room. Surveyor noted DA-S was not wearing a hairnet or a beard guard. On [DATE] at 10:59 AM, Surveyor observed DA-S walk into the main kitchen without a hairnet or beard guard. Regional Manager (RM)-N told DA-S to put a hairnet on. On [DATE] at 11:20 AM, Surveyor observed DA-S prepare silverware in the kitchen with a hairnet, but no beard guard. On [DATE] at 12:06 PM, Surveyor observed CK-U in the main kitchen by the hand washing station. CK-U was not wearing a hairnet or a beard guard. RM-N asked CK-U to put on a hairnet and beard guard on. On [DATE] at 12:40 PM, Surveyor observed CK-P serve food in the main dining room kitchenette. CK-P wore a hairnet over a headband. Surveyor noted the back of the headband was halfway up the back of CK-P's head which left the lower half of CK-P's hair exposed. When asked, CK-P pulled the hairnet down. On [DATE] at 1:15 PM, Surveyor observed CK-U in the main kitchen by the prep table. CK-U was wearing a beard guard that was below CK-U's mouth and did not cover CK-U's facial hair. On [DATE] at 3:54 PM, Surveyor observed CK-U cook food in the main kitchen by the grill. CK-U was wearing a beard guard that hung down around the back of CK-U's neck and did not cover CK-U's facial hair. On [DATE] at 11:28 AM, Surveyor interviewed DA-S who indicated DA-S did not know there were beard guards. On [DATE] at 1:11 PM, Surveyor interviewed CK-P who stated CK-P was having CK-P's hair shaved that night and pulled the hairnet down over CK-P's hair. CK-P stated CK-P knew CK-P needed to wear a hairnet that covered CK-P's hair and stated CK-P had so much hair CK-P didn't know what to do with it. On [DATE] at 1:15 PM, Surveyor interviewed CK-U who stated CK-U worked in the facility for a couple of months and never wore a beard guard before [DATE]. CK-U stated CK-U's facial hair was not a violation and CK-U did not feel CK-U needed to wear a beard guard. 3. Cleanliness: The Wisconsin Food Code documents at ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The Wisconsin Food Code documents at ,d+[DATE].12 Cooking and Baking Equipment. (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. The Wisconsin Food Code documents at ,d+[DATE].11 Equipment, Utensils, Linens, and Single Service and Single Use Articles. (B) Clean equipment and utensils shall be stored .(2) Covered or inverted. During the initial kitchen tour on [DATE], Surveyor observed the following: Main kitchen - -The inside of the microwave contained food debris on the walls and ceiling. -The front of the grill contained food debris. -The large mixer was not covered -The shelves below the prep area contained food debris and were not clean On [DATE] at 10:32 AM, Surveyor observed the same cleanliness issues in the main kitchen. On [DATE] at 8:36 AM, Surveyor observed the following: Kitchenette, Main Dining Room- -The inside of the microwave contained food debris on the walls and ceiling. -The refrigerator contained food debris and spills. On [DATE] at approximately 10:00 AM, Surveyor interviewed DM-O who confirmed the microwave was not clean. DM-O lifted the pans that covered the grill and confirmed the grill was not clean. DM-O stated DM-O expected staff to clean the grill after use. DM-O stated the grill was not used often and thought the grill had not been used in months. DM-O stated the shelves were cleaned weekly on Sundays and confirmed the shelves would be cleaned that day. On [DATE] at 10:32 AM, Surveyor interviewed RM-N who confirmed the microwave was still not clean. On [DATE] at 10:34 AM, Surveyor interviewed DM-O who confirmed the grill was still not clean. DM-O stated the grill was not cleaned on [DATE] because staff had too many things on their to do list. On [DATE], Surveyor reviewed the daily cleaning check list and noted the cleaning check list for March was not filled out and contained multiple empty spots. 4. Microwave Protocol: The Wisconsin Food Code 2022 documents at section ,d+[DATE].11 Reheating for Hot Holding. (A) Except as specified under (B), (C), and (E) of this section, Time/Temperature control for food 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 C (165 F) for 15 seconds. (B) Except as specified under (C) of this section, Time/Temperature control for food 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 C (165 F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. On [DATE] at 9:03 AM, Surveyor observed DA-S prepare and serve food in the main dining room kitchenette. Surveyor observed DA-S cook a pastry in the microwave. DA-S then removed the pastry from the microwave and delivered the pastry to a resident. DA-S did not obtain the temperature of the pastry when removed from the microwave and did not wait two minutes to obtain the reheated food temperature to ensure the food was heated evenly. On [DATE] at 9:09 AM, Surveyor observed DA-S cook a second pastry in the microwave. DA-S then removed the pastry from the microwave and delivered the pastry to a resident. DA-S did not obtain the temperature of the pastry when removed from the microwave and did not wait two minutes to obtain the reheated food temperature to ensure food was heated evenly. Surveyor noted a policy on the front door of the microwave in the main dining room kitchenette that stated: Microwaving food: All food needs to be in a microwave safe bowl and must be covered. After reheating food, it must sit for two minutes so the heat can disperse . 5. Safe Cooling: The Wisconsin Food Code 2022 documents at section ,d+[DATE].14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The Wisconsin Food Code 2022 documents at section ,d+[DATE].15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S ,d+[DATE].14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. On [DATE], Surveyor reviewed the facility's Cooling Down Foods-Tracking Chart. The policy for cooling was listed at the top of the chart. The policy indicated staff are supposed to chart food cooled including initial temperature and hourly temperatures while cooling and then verify with a manager. The chart for March was blank. On [DATE] at 10:43 AM, Surveyor reviewed the facility's cooling log. DM-O stated the cooling log was empty for March because the fall and winter menu doesn't have pasta or potato salad or things that need to be cooled. On [DATE] at 10:44 AM, Surveyor interviewed RM-N regarding the cooling log. When Surveyor asked about food items in the reach-in cooler, including the white chicken chili and pasta made on [DATE], RM-N confirmed the items should have been cooled within 6 hours and tracked on the cooling log. On [DATE] at approximately 10:48 AM, Surveyor interviewed DM-O regarding the cooling log. DM-O stated DM-O doesn't cool much. When asked about the white chicken chili and pasta from the reach-in cooler, DM-O stated, I guess that should have been cooled. I guess they all would. RM-N then interjected and stated, Anything cooked needs to be cooled and be on the log. 6. Sanitizing Solution Log: The Wisconsin Food Code 2022 documents at section ,d+[DATE].116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The facility's Sanitizer Test Strip Log states employees will record the reading before using the sanitizer bucket and record any corrective action if taken. According to the manufacturer, the sanitizing bucket needs to be redone with every meal service or if the appropriate concentration is not reached. The facility used Quat sanitizer. The manufacturer directions indicated the PPM for appropriate sanitization was ,d+[DATE] PPM for the sanitization buckets and for cookware, dishes, and utensils for manual dishwashing. The test strip package insert for test strips used to test the PPM of sanitizing solution in sanitizing buckets and sinks indicated the water temperature should be between ,d+[DATE]-degrees F for testing. On [DATE] at 8:25 AM, Surveyor observed a green sanitizer bucket in the [NAME] kitchenette. On [DATE] at 8:36 AM, Surveyor observed a green and a red sanitizer bucket in the main dining kitchenette. On [DATE] at 8:40 AM, Surveyor observed two sanitizer buckets in the main kitchen and asked to review the sanitizer testing log which was provided by CK-R. Surveyor noted the log was filled out for 8 of 12 days in March and was not filled out on [DATE]. [DATE], [DATE], and [DATE]. CK-R then ran a test strip under the sanitizer dispenser, briefly flashed the test strip at Surveyor, said the sanitization level was good, and tossed the the strip in the garbage. Surveyor noted there were sanitizer buckets in the kitchen being used by staff that were not tested . On [DATE] at 8:42 AM, Surveyor interviewed CK-R and asked how the sanitizer was tested . When Surveyor asked if the temperature of the water was taken or if the PPM were recorded, CK-R indicated CK-R was not aware that either needed to be completed. Surveyor noted CK-R recorded all of the entries on the current sanitizer test strip log. On [DATE], Surveyor reviewed the sanitizer test strip log and noted staff should mark ok if the strip reveals the appropriate concentration. The log contained 3 times slots for each day, however, only 1 time slot was filled out for the 9 days that were addressed. There were no staff initials. Surveyor also noted there were no spots to record the PPM concentration or the water temperature which were both imperative to determine if the sanitizer was at an appropriate concentration for use. 7. Hand Hygiene: The Wisconsin Food Code Chapter 2 Personal Cleanliness at ,d+[DATE].14 titled When to Wash indicates: Food employees shall clean their hands and exposed portions of their arms as specified under ,d+[DATE].12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in ,d+[DATE].11 (B); (D) Except as specified in ,d+[DATE].11 (B) After coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw food and working with ready-to-eat food; (H) Before putting on gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. The facility's contracted company's Maintenance Handwashing policy indicates: Hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1. When to wash hands: A. When entering the kitchen at the start of the shift. B. After touching bare human body parts other than clean hands and wrists. C. After using the restroom. D. After caring for or handling sercie animals or aquatic animals. E. After coughing, sneezing, using a tissue, using tobacco, eating or drinking. F. After handling soiled equipment or utensils. G. During food preparation as often as necessary to remove soil or contamination and prevent cross contamination when changing tasks. H. When switching between working with raw food and working with ready to eat food. I. Before donning disposable gloves for working with food and after gloves are removed. J. After engaging in other activities that contaminate the hands . The facility's Handwashing/Hand Hygiene policy, dated ,d+[DATE], indicates: .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; b. After contact with a resident with infection .7. Use alcohol based hand rub containing at least 62% alcohol or, alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; .f. Before and after donning sterile gloves; .m. After removing gloves; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals . On [DATE] at 9:03 AM, Surveyor observed DA-S prepare food in the main dining room and kitchenette with gloved hands. DA-S then delivered food to residents in the dining room. DA-S touched DA-S' pants while delivering food and continued to serve and deliver food with the same gloved hands. Surveyor did not observed DA-S change gloves or perform hand hygiene between tasks or residents. On [DATE] at 11:23 AM, Surveyor observed DA-Q scoop mandarin oranges from a can into cups with gloved hands. DA-Q put the scoop down, reached into the can of oranges, grabbed an orange with a gloved hand, and put the orange in DA-Q's mouth. DA-Q then left the room and came back with one gloved hand. DA-Q poured the rest of the can of oranges into a container, covered and labeled the contained, and placed the container in the refrigerator. DA-Q then removed DA-Q's glove and moved to another task without performing hand hygiene. On [DATE] at 12:02 PM, Surveyor observed CK-P cook food in the main kitchen. CK-P then walked into the dish area and changed gloves, but did not perform hand hygiene. On [DATE] at 12:12 PM Surveyor observed CK-P temp food in the main kitchenette. CK-P removed gloves, picked up plate covers, and brought them to the sink. CK-P then changed gloves and began to serve food. CK-P did not perform hand hygiene between tasks or glove changes. On [DATE] from 12:24 to 12:59 PM, Surveyor observed DM-O who was watching CK-P temp and serve food. DM-O was on the opposite side of the serving area. DM-O touched DM-O's hair (with a hairnet on), and touched DM-O's face and lips multiple times DM-O's bare left hand. At 12:36 PM, DM-O touched DM-O's nose with a bare hand. At 12:58 PM, Surveyor observed DM-O help residents remove plastic wrap from their cake with bare hands. DM-O did not perform hand hygiene after touching DM-O's self and changing tasks. On [DATE] at 12:26 PM, Surveyor observed CK-P serve food in the kitchenette. CK-P removed one pair of gloves and put on a new pair of gloves. CK-P did not do perform hand hygiene between glove changes. On [DATE], Surveyor observed 17 residents in the main dining room during the breakfast meal (from entrance, to meal service, to exit) and noted none of the residents were offered hand hygiene. On [DATE], Surveyor observed 22 residents in the main dining room during the lunch meal (from entrance, to meal service, to exit) and noted none of the residents were offered hand hygiene. On [DATE] at 11:30 AM, Surveyor interviewed RM-N who stated staff eating food out of a container while prepping food was unacceptable. On [DATE] at 1:26 PM, Surveyor interviewed DA-Q who verified DA-Q picked an orange out of the can with DA-Q's gloved hand and ate it because it was just so little and cute. DA-Q apologized when asked about food contamination. When asked why DA-Q did not complete hand hygiene, DA-Q said, I forgot. I'm sorry darling. On [DATE] at 2:03 PM, Surveyor interviewed RD-V, RM-N, and DM-O. When Surveyor asked what the expectation is for staff who touch their face, lips, hair, and nose with bare hands, DM-O stated staff should wash their hands and rewash them every time they touch themselves. DM-O stated if staff are wearing gloves, staff should wash their hands after removing gloves and should change gloves between tasks.

Note: Amended SOD issued to edit IJ removal dates. Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation), in accordance with the resident's directives, for 1 of 7 Residents (R) (R1). A total of 15 residents who resided in the facility were designated to be Full Code on the date CPR was not initiated for R1. R1's guardian signed an Advance Directive for R1 that instructed facility staff to provide R1 with CPR and provide emergency life support services if R1's heart stopped beating or R1 stopped breathing. On [DATE], staff found R1 without a pulse and not breathing. Nursing staff did not initiate CPR or contact emergency services despite R1's Advance Directive that CPR be initiated and emergency services be notified (call 911) if R1 did not have a pulse or was not breathing. The facility failure to ensure R1 received basic life support, including CPR, in accordance with R1's Advance Directive created a finding of Immediate Jeopardy (IJ) that began on [DATE]. NHA (Nursing Home Administrator)-A was informed of the IJ finding on [DATE] at 4:15 PM. The Immediate Jeopardy was removed on [DATE], but not yet corrected. The deficiency continues at a scope/severity level [NAME] (potential for harm/pattern) as the facility continues to implement its action plan. This was evidenced by the following: The facility policy entitled Code Status Policy and dated [DATE], documented on day of admission the residents or resident representatives will be asked what the resident's wishes are regarding code status. Code status is stated on the admission Cardio-Pulmonary Resuscitation (CPR) form, the Face Sheet and the MAR (Medication Administration Record). If a resident checks CPR, the Face Sheet and MAR indicated [REDACTED]. 0. 1. R1's Face Sheet with a print date of [DATE] indicated R1 was admitted to the facility with [DIAGNOSES REDACTED]. Additionally, the Face Sheet documented R1 had Advance Directives in place; R1's Advance Directive was Full Code. R1's code status was documented on the CPR admission form as Yes Code - Start CPR. Call 911. Transfer to nearest hospital where advance cardiac life support procedures will continue if R1 was found with no pulse and no respirations. R1's guardian signed this form the day after admission to the facility. Additionally, R1's Full Code status was documented on the Face Sheet and the MAR. R1's progress notes on [DATE] at 9:40 AM, documented at 4:20 AM, CNA (Certified Nursing Assistant)-C, who had been sitting with R1, notified RN (Registered Nurse)-D of a change in R1's respirations and noted pauses in respirations. At 4:25 AM, RN-D verified absences of signs/symptoms of respirations and apical pulse (pulse over the top of the heart) for 60 seconds. Immediately after verifying the absence of respirations and apical pulse for 60 seconds, RN-D called R1's guardian from R1's bedside. The guardian was notified of the absence of vital signs, that R1 had died , but R1's code status was listed as a Full Code. Therefore, RN-D asked the guardian if the guardian wanted RN-D to start CPR and/or call 911 to send R1 to the hospital by ambulance. The guardian requested no CPR be completed at that time. On [DATE], NHA-A documented at about 8:30 AM, NHA-A received a call from RN-D who stated R1's guardian had approached RN-D and asked RN-D why RN-D did not provide CPR or call 911 when R1 did not have a pulse or was not breathing. RN-D explained to the guardian it was a nursing judgement and that RN-D didn't feel it was humane to break R1's ribs with compressions when R1 was already dead. NHA-A and DON (Director of Nursing)-E then spoke with R1's guardian. R1's guardian asked why the Full Code form R1's guardian signed on admission was not followed. NHA-A and DON-E explained the policy and procedure would be reviewed, and changes would be made if necessary to ensure there would not be a similar instance in the future. On [DATE] at 10:15 AM, NHA-A and DON-E interviewed RN-D regarding R1. RN-D stated at about 4:20 AM, CNA-C notified RN-D because CNA-C had been sitting with R1 and noted a change in condition of the resident. CNA-C stated that R1 had, stopped breathing or there was a long time between breaths like apnea. Even though time is of the essence, RN-D printed R1's Face Sheet and asked CNA-C to make a copy of R1's emergency contacts. RN-D retrieved the cordless phone and arrived in R1's room at approximately 4:25 AM. RN-D stated, (R1) looked dead. RN-D listened for a pulse and breath sounds for over a minute, There weren't any. RN-D then asked CNA-C to get the pulse oximeter to check for a pulse. RN-D called R1's guardian at approximately 4:27 AM and told the guardian R1 was not breathing and did not have a pulse. RN-D stated to R1's guardian that R1's body was still warm and asked if the guardian wanted CPR started and/or 911 called. RN-D advised the guardian if CPR was started, RN-D would probably break (R1's) ribs. The guardian stated, No, don't do that. When NHA-A and DON-E asked RN-D why 911 was not called and CPR was not started, RN-D stated R1 had no pulse and (R1) had a lot of co-morbidities. RN-D stated, I didn't grab the AED (automated external defibrillator) because (R1) didn't have a shockable rhythm. On [DATE] at 7:50 AM, the Surveyor interviewed CEO (Chief Executive Officer)-B regarding RN-D not providing CPR to R1. CEO-B confirmed R1 was a Full Code, and stated RN-D didn't do CPR and should have initiated CPR prior to calling the guardian. On [DATE] at 8:30 AM, the Surveyor called CNA-C and left a message for CNA-C to return call. CNA-C did not return call to the Surveyor. On [DATE] at 11:15 AM, the Surveyor interviewed RN-D by telephone. RN-D verified RN-D was CPR certified. RN-D confirmed R1 was a Full Code and CPR was not initiated because, Being a hospice nurse came in to play, I didn't want to mutilate a corpse. On [DATE] at 6:11 PM, HRD (Human Resources Director)-F emailed RN-D's CPR card to Surveyor which indicated RN-D's CPR certification had expired in (MONTH) (YEAR). There were two other RN's working in the facility with current CPR certification that RN-D could have called to provide CPR to R1. The facility's failure to administer CPR to R1 when R1 was found without a pulse or was not breathing created a situation of IJ. The facility removed the IJ on [DATE], when it had completed the following: ~ Provided education to all nursing staff regarding code status. ~ Updated care plans to include code status. ~ Completed initial audits of action the plan.

Based on observations, interviews, and record reviews, the facility did not ensure that 5 of 8 residents reviewed for pressure ulcers, received appropriate care and treatment to heal existing pressure ulcers and/or to prevent redevelopment of pressure ulcers. Resident #10 currently had a stage II pressure ulcer on her coccyx. According to Resident #10's medical record, the pressure area has healed and re-opened. Despite this, there were no changes made to Resident #10's care plan to prevent further pressure ulcers from occurring. Resident #1 currently had a stage II pressure ulcer to her right buttock. According to Resident #1's medical record, the pressure ulcer has healed and re-opened. No changes were made to Resident #1's plan of care to prevent further pressure ulcers from occurring. Resident #1's plan of care for repositioning every 2 hours was not implemented. In this citation, Resident #10 and #1 are considered actual harm, isolated (G level); Resident #3, #4 and #5 are considered less than actual harm, isolated (D level). Resident #3 is at high risk for the development of pressure ulcers. Resident #3 has a care plan directing staff to reposition Resident #3. Despite this, on 2 separate occasions, Resident #3 was observed in the same position up in her wheelchair for 2 hours and 25 minutes and 3 hours and 5 minutes respectively. Resident #4 was admitted to the facility with an unstageable pressure ulcer to his coccyx that presented as a stage III after care and treatment. Resident #4 has an alternating air bed which is to be set according to the resident's weight. Resident #4's bed was at the incorrect setting. Resident #5 has a stage II pressure ulcer on her heel. During a dressing change, it was observed staff did not use appropriate hand hygiene. This is evidenced by: Example #1: Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #10's most current admission MDS (Minimum Data Set), dated 11/29/14, indicated: ~Long and short-term memory was impaired; ~Extensive assistance was required from staff for bed mobility, transfer, ambulation, toilet use and bathing. ~Was frequently incontinent of bladder; ~Was at risk for the development of pressure ulcers; and ~Had no current pressure ulcers. Resident #10's skin care plan was dated 12/04/14. The care plan indicated the following: Problem: Skin integrity at risk due to incontinence, need for assist with transfers, malnutrition, history [MEDICAL CONDITION], (questionable re-occurrence). Has [MEDICAL CONDITION]. No areas of breakdown present. Goal: Skin will remain clear and intact during the next three months ... Approaches: Avoid rubbing skin, pat skin dry. Check pressure points (coccyx, elbows, back, heels) during a.m. and p.m. cares and as needed. Massage lotion and notify nurse if any redness or abnormalities are present. Assist with repositioning every 2 hours. Report reddened or open areas to nurse as soon as possible. Nurse or dietician to assess need for protein. Dietician to evaluate values and report concerns to nurse. Put wheelchair cushion on wheelchair when resident is up in wheelchair. Specialty mattress on bed at all times. Suspend heels over the edge of pillow when resident in bed. Resident #10's CNA care card was reviewed and indicated the following: ~Elimination: Incontinent of bowel and bladder. Toilet approximately AC=before meals, PC=after meals, HS=at hour of sleep, 2:00 a.m. and as per her request. Positioning: Turn every 2 hours, pressure reducing mattress, and wheelchair cushion, suspend heels over edge of pillow in bed. Resident #10's nursing notes were reviewed with the following noted: ~11/22/14: admitted to the facility ...Skin intact. ~12/28/14: Stage II pressure ulcer to coccyx measuring 0.6 cm (Centimeter) L (length) x 0.6 cm W (width) x 0.1 cm D (depth). No drainage, no odor, skin around area is warm, pink, moist and blanchable. Wound bed is 100% red. ~1/04/15: Wound assessment to coccyx wound. Open area measures: 0.1 cm L x 0.1 cm W x 0.1 cm D, stage II. Wound bed 100% pink. No odor, no drainage. Surrounding skin is pink, blanchable and dry. Incontinent of bladder at times. Repositioning encouraged. Treatment includes duoderm, changed every 5 days. ~1/13/15: Stage II pressure ulcer measuring 0.1 cm L x 0.1 cm W x 0.1 cm depth to coccyx area. Skin around area is warm, pink, moist and blanchable, 100% wound bed. No drainage, no odor. ~1/17/15: Unchanged. ~1/25/15: Pressure wound to coccyx, no longer open, is stage I. Pink non-blanchable area measuring 0.8 cm x 0.5 cm no depth. Surrounding skin is pink and warm... No drainage or odor. ~1/28/15: Med pass supplement started. ~2/1/15: Stage II pressure ulcer to coccyx measuring 0.1 cm L x 0.1 cm W x 0.1 cm D. Treatment is duoderm to be changed every 5 days. ~02/06/15: Coccyx wound is healed. Skin intact, pink and slow to blanch. Some discoloration to skin indicative of scar tissue. Review of Resident #10's care plan found no updates to prevent recurrence of the pressure ulcers. Nurse's notes continue: ~02/08/15: Previously healed pressure wound to coccyx now open area. Measures: 0.3 cm W x 0.6 cm L x 0.1 cm D. Stage II. Surrounding edges macerated, pink, warm ...100% pink. No drainage and no odor. Covered with duoderm, to be changed every 5 days and as needed. ~2/15/15: Open wound to coccyx is healed again. Review of Resident #10's care plan found no updates to prevent recurrence of the pressure ulcers. ~2/21/15: Resident's coccyx area re-opened measuring 0.5 cm L x 0.5 cm W x 0.1 cm D. Surrounding skin is pink, warm, and blanchable, edges appear to have white maceration. Wound bed is 100% pink granulation. No odor, no drainage. Duoderm applied. ~02/28/15: 1.0 cm L x 0.5 cm W x 0.1 cm D. Stage II pressure ulcer. 100% pink granulation. No drainage, no odor. Surrounding skin is pink, warm, moist and blanchable. Treatment is duoderm to be changed every 5 days and as needed. Although the wound is larger, there is no evidence of care plan revisions to promote healing. ~03/04/15: Coccyx wound continues. Measurements: 0.8 cm L x 0.4 cm W x 0.1 cm D. Surrounding skin is natural tone, warm, blanchable and moist related to incontinence. Wound bed is 100% pink with even edges. On 3/05/14 at 4:00 p.m., Surveyor # spoke with RN-A and RN-B (Registered Nurse) regarding Resident #10's wound, wound treatment, and approaches in her care plan to promote healing and prevent recurrence of her pressure ulcer. RN-A explained the facility initiated a snack pass in the afternoon on 2/02/15 to increase calories and protein for all residents at risk for weight loss and pressure ulcers. This snack pass was an initiative through the facility's Quality Assurance Program as the facility had noted an increased incidence of weight loss and pressure ulcers. RN-A indicated there were no individual approaches added to Resident #10's plan of care. Example #2: Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #1's most current quarterly MDS (Minimum Data Set), dated 2/13/15, indicated: ~Long and short-term memory was impaired; ~Extensive assistance was required from staff for bed mobility, transfer, ambulation, toilet use personal hygiene and bathing; ~Was frequently incontinent of both bowel and bladder; ~Was at risk for the development of pressure ulcers; and ~Had 1 current stage II pressure ulcer. Resident #1's most recent Braden Scale for predicting pressure ulcer risk was dated 2/16/15 and indicated the following: ~Sensory Perception: Slightly limited, responds to verbal commands but cannot always communicate discomfort or need to be turned... ~Moisture: Occasionally moist, skin is occasionally moist... ~Activity: Chair fast, ability to walk is severely impaired or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. ~Mobility: Very limited, make occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. ~Nutrition: Probably inadequate. ~Friction and Shear: Potential problems. Resident #1's skin care plan was dated 11/20/13. The care plan indicated the following: Problem: At risk for skin breakdown due to urinary and fecal incontinence and need for assistance with repositioning, transfers and ambulation. Impaired cognition. Appears to have stress and functional incontinence. Has skin wound on buttocks. Goal: Current skin wound will heal and no new areas will occur over the next 3 months. Approaches: Check pressure points during cares and report abnormalities to nurse. Braden Scale for routine assessment of risk level. Assist with incontinent care routinely and as needed. See CNA plan of care. Encourage adequate oral intake to promote skin integrity, provide no added salt diet as ordered. RNP (Restorative Nursing Program) as recommended to promote circulation. Report any reddened and or open areas to nurse as soon as possible. Med pass 2.0 90 CC four times a day per order. Wound care per Medication Administration Record [REDACTED] Resident #1's CNA care card was reviewed and indicated the following: ~Elimination: Incontinent of bowel and bladder. Toilet approximately AC=before meals, PC=after meals, HS=at hour of sleep and as per her request. Positioning: Assist with turning every 2 hours, pressure reducing mattress, and wheelchair cushion, suspend heels over edge of pillow in bed. Resident #1's nursing notes were reviewed with the following noted: ~12/19/14: Monitor red area, right buttocks, and red blanchable. Duoderm for protection, toileting schedule, wheelchair cushion in place, reposition every 2 hours. ~12/30/14: Open wound-right buttock, stage II, duoderm, and change every 5 days. ~01/04/15: Stage II, right buttocks measuring 0.9 cm (centimeter) length x 1.0 cm width x 0.1 cm depth. ~1/13/15: Stage II, right buttocks measuring 2.0 cm length x 1.0 cm width x 0.1 cm depth. ~1/19/15: Stage II, right buttocks measuring 1.0 cm length x 0.7 cm width x 0.1 cm depth. Reposition frequently by staff, frequently moist. ~1/24/15: Stage II, right buttocks measuring 1.0 cm length x 0.7 cm width x 0.1 cm depth. Incontinent of bowel and bladder, frequently repositioned. ~2/04/15: Right buttock wound healed. ~2/11/15: Right buttock wound remains healed. Resident #1's care plan reflected no change in approaches to prevent recurrence of the pressure ulcer. ~2/12/15: Right buttock open area measuring: 0.6 cm (centimeter) length x 0.5 cm width x 0.1 cm depth, advised to keep duoderm in place once healed, reposition every 2 hours. Assist of one with E-Z stand... ~2/17/15: Stage II, right buttocks measuring 0.6 cm length x 0.5 cm width x 0.1 cm depth. ~2/22/15: Stage II, right buttocks measuring 0.6 cm length x 0.5 cm width x 0.1 cm depth. ~2/27/15: Stage II, right buttocks measuring 0.5 cm length x 0.5 cm width x 0.1 cm depth. Incontinent of bowel and bladder, frequently repositioned. On 3/4/15 at 7:15 a.m., Surveyor # observed Resident #1 in her wheelchair in her room. At 8:30 a.m., Resident #1 was transported to the dining room where she remained in her wheelchair until 9:00 a.m. Resident #1 was then transported to the therapy room where she remained in her wheelchair until being transported back to her room at 9:25 a.m. Resident #1 remained in her room in her wheelchair until 10:15 a.m. At 10:15 a.m., CNA-C (Certified Nursing Assistant) and CNA-E entered Resident #1's room and asked if she needed to use the bathroom. Resident #1 declined. CNA-C and CNA-E transferred Resident #1 to the bed and covered her with blankets. Neither CNA-C nor CNA-E checked Resident #1 for incontinence or performed incontinent care. Surveyor # spoke with CNA-C and CNA-E regarding Resident #1's care. CNA-C indicated she had gotten Resident #1 up from bed between 6:30 a.m. and 7:00 a.m. on 3/4/15. CNA-C confirmed Resident #1 had not been repositioned until 10:15 a.m. Surveyor # asked CNA-C about Resident #1's repositioning schedule. CNA-C indicated repositioning should occur every 2 hours unless otherwise charted. CNA-C further expressed that Resident #1 should have been laid down sooner, gotten up later or repositioned in her chair. CNA-E indicated every 2-hour repositioning is standard unless a pressure ulcer is present. Surveyor # asked CNA-C and CNA-E if Resident #1 had a current pressure ulcer. Both CNAs were uncertain if Resident #1 had a current pressure ulcer. Surveyor # inquired about Resident #1's continence and toileting schedule. CNA-C and CNA-E were not certain of Resident #1's toileting plan. CNA-C referenced her CNA care card, which was found in a closet on the unit. CNA-C further indicated she was not familiar with the abbreviations noted on Resident #1's care card as it related to her toileting plan. Neither CNA reentered Resident #1's room to check for incontinence or provide incontinent care. On 3/05/14 at 4:00 p.m., Surveyor # spoke with RN-A and RN-B regarding Resident #1's wound, wound treatment, and approaches in her care plan in order to promote healing and prevent recurrence of her pressure ulcer. RN-A reiterated the facility's initiation of calorie dense and high protein snacks being offered to Resident #1 in the afternoon. RN-A further expressed no individual approaches were added to Resident #1's plan of care when her pressure ulcer reoccurred. Surveyor # informed RN-A and RN-B of the observation noted above. RN-A responded that Resident #1 should be repositioned every 2 hours. RN-A further expressed that staff are expected to check Resident #1 for incontinence when repositioning and provide incontinent care as needed. Example #3: Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #3's most current quarterly MDS (Minimum Data Set), dated 1/23/15, indicated: ~Long and short-term memory was impaired; ~Cognitive skills were moderately impaired; ~Total dependence on staff for bed mobility, transfer, toilet use, and bathing; ~Did not walk; ~Was always incontinent of both bowel and bladder; ~Was at risk for the development of pressure ulcers; and ~Had no pressure ulcers. Resident #3's skin care plan was dated 5/10/13. The care plan indicated the following: Problem: Potential alteration in skin integrity related to decreased mobility, requires more and more assistance with ADLs (activities of daily living). Has poor trunk control. Has decreased food intake. Is incontinent of bowel and bladder. Appears to have stress and functional urinary incontinence. Goal: Skin will remain clear and intact during the next 3 months. Approaches: Check resident every 2 hours for incontinence and change as needed, if dry toilet. Resident #3's CNA care card was reviewed and indicated the following: Elimination: Incontinent of bowel and bladder, check and change every 2 hours. Positioning: Assist with turning every 2 hours. On 3/4/15 at 7:15 a.m., Surveyor # observed Resident #3 in her wheelchair in the lobby outside the facility's dining room. Resident #3 remained in the lobby in her wheelchair until 8:20 a.m. when she was transported to the dining room. Resident #3 remained in her wheelchair in the dining room until she was transported back to her room. Staff entered Resident #3's room at 9:40 a.m. and laid her down in bed. On 3/5/15, Surveyor # again observed Resident #3. At 7:05 a.m. Resident #3 was up in her wheelchair in her room until transported to the dining room at 7:40 a.m. where she remained until being transported back to her room. At 9:30 a.m., Resident #3 was observed in her room in her wheelchair when CNA-D entered the room at 10:10 a.m. and transferred Resident #3 to bed. Resident #3 was observed to be up in her wheelchair for greater than 3 hours. On 3/5/15, Surveyor # spoke with CNA-D after she had finished caring for Resident #3. CNA-D indicated it is usual for Resident #3 to get up each day at approximately 7:00 a.m. and lay down about the same time each day. CNA-D further expressed that Resident #3 should be repositioned sooner but staff are unavailable to lay residents down until staff are finished in the dining room. CNA-D indicated Resident #3 is at risk for the development of pressure ulcers as she cannot change positions and is incontinent. On 3/5/15 at 4:00 p.m., Surveyor # spoke with RN-A and RN-B regarding the length of time between staff repositioning Resident #3 more timely. RN-A indicated Resident #3 should be repositioned every 2 hours. RN-A further indicated that one staff person remains on the units for response to call lights; however, many residents cannot alert staff to their needs. RN-A and RN-B stated they may have to look at a different way to monitor when residents arise so they can be repositioned more timely. Example #4: Resident #4 has [DIAGNOSES REDACTED]. Resident #4 was admitted to the facility on [DATE] with an unstageable pressure ulcer to his coccyx that measured 3.0 cm (centimeters) L (length) by 3.0 cm W (width). There was surrounding red/purple colored tissue measuring 8.0 cm diameter that was excoriated and draining a moderate amount of Serosanguinous fluid. The wound was documented as being covered in 90% slough and 10% beefy red tissue. A pressure reduction cushion to the wheelchair and recliner chair, as well as a pressure reduction mattress on the bed were initiated. Slough is a loose, stringy necrotic (non-viable, or dead) tissue. The presence of slough indicates full thickness tissue damage. Following were measurements and interventions implemented to Resident #4's plan of care: ~ 11/29/14: Coccyx: 3.0 L by 3.0 W by 2.0 D (depth). The wound documentation was essentially the same as above except there was a 4.0 cm deep purple area at 4 o'clock on the wound. This purple area measured 4.5 cm L by 1 cm W and was nonblanchable. Note: Wound descriptions are measured in the form of a clock face, with 12 o'clock being towards the head of the patient and 6 o'clock being towards their feet. If a wound is covered with slough, the examiner would not be able to correctly determine the depth of the wound as it would not be visible. ~12/2/14: In reviewing the documentation for Resident #4, the wound was now separated into three regions of the left buttocks and the right buttocks. They were: Left Buttocks: 3 cm L by 2.2 cm W by 0.1 cm D. Right Buttocks: 4 cm L by 0.9 cm W by 0.1 cm D. Coccyx: 1.6 cm L by 2.1 cm W by 1.7 cm D. Unstageable with 100% slough. One cannot determine the depth of a wound if it is covered in slough. A referral to the Wound Clinic was made and the facility initiated 60 milliliters of MedPass supplements four times daily for wound healing. ~ 12/8/14: Left Buttocks: 2.8 cm L by 1.0 cm W by 0.1 cm D. Right Buttocks: 3.0 cm L by 0.5 cm W by 0.1 cm D. Coccyx: 2.2 cm L by 1.8 cm W by 1.1 cm D. Unstageable. Once again a correct depth cannot be measured if there is slough covering the wound. On 12/14/14, the resident was sent to the hospital for [MEDICAL CONDITION] activity and diagnosed with [REDACTED]. The air mattress is to be set according to the weight of the patient. In this case, Resident #4 weighed 167 pounds and the mattress was to be set on alternating air when he was in bed. Staff could then adjust the bed to "static" settings when repositioning the resident or doing dressing changes, as the static setting makes the mattress firm. It was then to be adjusted back to "alternating" once cares were completed. ~ 12/16/14: Left Buttocks: 3.0 cm L by 1.0 cm W by 0.1 cm D with 100% pink granulation. Right Buttocks: 3 cm L by 0.3 cm W by 0.1 cm D with 100% pink granulation. Coccyx: 2.5 cm L by 2.0 cm W by 1.0 cm D. "Unstageable" with 100% pink granulation. Once again, a wound cannot be 100% granulation if it is unstageable as one would not be able to see the wound bed in an unstageable wound to visualize the tissue and amount of tissue damage occurring. On 12/19/14, Resident #4 began treatment for [REDACTED]. ~ 12/22/14: A [DEVICE] was placed on Resident #4 for wound healing according to the Wound Clinic. Coccyx: 2.2 cm L by 1.4 cm W by 1.0 cm D with a 1.9 cm Sinus Track at 12 o'clock. Note: A tunneling wound or sinus tract is a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation. ~ 12/26/14: Coccyx: 2.5 cm L by 2.5 cm W by 1.9 cm "at deepest point." The facility continued to stage this wound at a stage II, even tunneling/sinus tracks are at a minimum of a stage III related to its effect on underlying subcutaneous tissues. ~ 12/29/14: 2.1 cm L by 1.4 cm W by 1.5 cm D. On 1/5/15, the [DEVICE] was held related to the development of new slough. The wound continued to decrease in size until 1/24/15. ~ 1/24/15: 2.5 cm L by 2.0 cm W by 2.3 cm D. The [DEVICE] was restarted on 1/26/15. ~ 2/2/15: 2.0 cm L by 2.3 cm W by 1.4 cm D. Stage III was now documented with tunneling that measured 1.3 cm at 12 o'clock. The wound began to decrease in size once again until 2/25/15, when it measured 2.1 cm L by 2.9 cm W by 2.0 cm D. The last recorded measurement was on 3/2/15 in which case it measured 1.6 cm L by 2.0 cm W by 1.4 cm D with tunneling of 1.6 cm at 12 o'clock. On 3/4/15 at 3:05 p.m., Surveyor # entered Resident #4's room to greet resident. He was asleep. The surveyor noted the resident to be laying on an air mattress. The controls were set for a resident in excess of 400 pounds and "static" indicating the air is not being alternated throughout the pressure points of the resident's body. The resident had two pillows positioned under his thighs which elevated the legs, causing pressure to the coccyx/sacrum. There was also a pillow placed on his right side. His buttocks were against the mattress. ~ 3/4/15 at 4:30 p.m.: The resident's position was unchanged from above, as well as the air mattress settings. ~ 3/5/15 at 6:45 a.m.: Resident #4 was in bed laying on his back with his legs slightly elevated. The air mattress settings were set to over 400 pounds and "static." ~ 3/5/15 at 7:30 a.m.: CNA-H (Certified Nursing Assistant) was placing the resident's dentures in his mouth and indicated to the Surveyor that they will be transferring him to the wheelchair for the morning meal. She stated all his cares were completed earlier and that she did no further cares other than his dentures. The resident remained on his back as previously noted. ~ 3/5/15 at 9:30 a.m.: Resident #4 was in bed half laying on his left side but the lower half of his body, or his buttocks, was firmly against the mattress. The mattress settings were set to over 400 pounds and "static." On this same date at 10:00 a.m., Surveyor # asked CNA-M about the repositioning of Resident #4. CNA-M stated Resident #4 should be positioned side-to-side when in bed and they reposition him every two hours. ~ 3/5/15 11:45 a.m.: Surveyor # entered Resident #4's room with RN-L (Registered Nurse) to observe the changing of the [DEVICE] and dressings. The resident's bed was set to over 400 pounds and "static." The Surveyor asked RN-L what the settings should be set at. RN-L stated it should be adjusted to the resident's weight and "alternating." RN-L stated it should be set at maximum inflation and "static" when conducting cares or dressing changes, but then returned to the appropriate settings afterwards. On this same date at 1:45 p.m., Surveyor # approached CNA-I, who had been working with Resident #4 on this day. CNA-I stated she never adjusts Resident #4's bed and was never informed of what the settings should be. She stated, "I just leave it at whatever it's set at..." At 3:00 p.m., Surveyor # met with the MDS Coordinator, and both Nurse Managers (RN-A and RN-B). The MDS Coordinator stated Resident #4's mattress settings should be indicated on the CNA care plan. The Surveyor provided Resident #4's CNA care plan and Comprehensive nursing care plan to all three staff. The settings for the mattress were not indicated on either care plan. At 4:10 p.m., Surveyor # asked RN-A what the expectation is of repositioning Resident #4. RN-A stated he should be strictly side-to-side in bed and on his back only for meals. She stated Resident #4 never refuses any cares by staff. ~ 3/5/15 at 4:15 p.m.: Resident #4 was in bed. He was lying half on his right side but his buttocks were firmly against the mattress. At 4:20 p.m. on this same date, Surveyor # approached CNA-N regarding the positioning of Resident #4. CNA-N stated the resident is to be positioned off his sore and only side-to-side in bed. Surveyor # took CNA-N into Resident #4's room and asked her if he was correctly positioned off the sore. She indicated that he was and "he has a pillow under there..." indicating at his back. The Surveyor then approached RN-A and asked her to observe Resident #4's positioning. At 4:25 p.m. RN-A stated, "No, he's not correctly positioned, he's laying right on his sore. That's not side-to-side..." She immediately educated the staff on the unit. Example #5: Resident #5 has medical [DIAGNOSES REDACTED]. On 2/7/15, documentation indicates the development of a stage II pressure ulcer to the resident's left heel that measured 4 cm L by 2 cm W by 0.2 cm D. Heel protectors, a foot cradle, and occupational therapy was ordered for positioning and heel offloading. On 3/3/15 at 3:30 p.m., Surveyor # observed RN-J (Registered Nurse) change the dressing to the open area of the left heel. The procedure went as follows: ~ RN-J washed her hands and donned a pair of gloves. ~ She then removed the old dressing, which contained a small amount of yellowish drainage. ~ Without removing her gloves and washing or sanitizing her hands, RN-J cleansed the wound with wound cleanser and wiped it dry with a clean piece of gauze. ~ RN-J then placed a new foam dressing over the wound, then removed her gloves and washed her hands. On 3/6/15 at 12:00 p.m., Surveyor # approached the Director of Nursing (DON) on the expectation of hand hygiene during dressing changes. RN-J was unavailable during this time for interview. The DON stated the correct procedure would be to initially wash or sanitize the hands before a treatment is started. She then stated staff are to set out the equipment they need to perform the treatment, then wash or sanitize and glove. They are then to remove the old dressing, remove gloves and wash or sanitize their hands again, and place a clean pair of gloves on. The staff are then to wash the wound, remove gloves, wash or sanitize, and place another clean pair of gloves on. Then staff are to place the new dressing. The DON stated anytime they go from one area to another area, or from a dirty task to a clean task, they should be washing or sanitizing their hands and putting on a new pair of gloves.

Based on record review and staff interviews, the facility did not ensure that 1 (resident #5) of 8 residents reviewed for weight loss, maintained acceptable parameters of nutritional status such as body weight and protein levels. Resident #5 was admitted to the facility on [DATE]. Resident #5's weight was documented to be 143.2 lbs at that time. On 4/10/12, resident #5 weighed 112.5 lbs. Resident #5's weight continued to decline until 9/11/12, when resident #5 weighed 88.7 lbs. Although an RD (Registered Dietician) initially assessed resident #5 on 4/1/12, another assessment by the dietician did not occur until 10/2/12, after resident #5 had a PEG (Percutnaeous Endoscopic Gastrostomy) tube surgically placed for enteral nutrition. Although an oral liquid nutritional supplement was initiated 4/12/12, no additional measures were put into place to address resident #5's significant weight loss. Findings include: On 11/12/12 surveyor # reviewed the medical record of resident #5. The 7/9/12 face sheet contained within the medical record revealed resident #5 was admitted to the facility 3/26/12. The Diseases Index Report, dated 10/4/12, indicated resident #5 was admitted due to a fall with multiple fractures including, humerus, hip, right tibia and fibula and left fibula. Additionally, resident #5 presented with hypertension, [MEDICAL CONDITION] arthritis, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], history of pneuomonitis, AV-([MEDICAL CONDITION] ventricular) heart block and pacemaker placement. The admission MDS (Minimum Data Set) assessment dated [DATE] and the quarterly MDS dated [DATE] indicated resident #5 was alert and oriented with no cognitive impairment and was her own decision-maker. Additionally, the MDS' indicated resident #5 had been independent with eating and had no swallowing or chewing difficulty. Monthly weights for resident #5: Admission: 3/26/12, 142.7 lbs. 4/10/12, 112.5 lbs 5/10/12, 109.5 lbs 6/7/12, 107.5 lbs 7/9/12, 103.9 lbs 8/9/12, 94.7 lbs 9/11/12, 88/7 lbs 10/1/12, (re-admission after hospitalization ) 91.6 lbs 10/9/12, 91.6 lbs 11/12/12 97.7 lbs A Nutrition Screen Assessment for resident #5, completed by RD (Registered Dietician)-B on 4/1/12 indicated resident #5 weighed 142.7 lbs when admitted , that resident #5 tolerated her general diet well, had no swallowing or chewing difficulties, was independent with eating, and that her [MEDICATION NAME] (protein) which was tested [DATE], was low at 2.2. Nutritional concerns identified at that time by RD-B included, "adequate nutrition needed for healing...encourage adequate oral intake, will monitor appetite, weight, oral intake, and plan of care. Additionally, RD-B identified resident #5's ideal body weight to be between 126 and 154 lbs, resident #5's caloric intake goal to be between 1625 and 1950 Kilo-calories, and protein needs to be between 65 and 78. Based on this screen, RD-B documented that resident #5 "was at risk for [MEDICAL CONDITION]." The written plan of care for resident #5 dated 4/1/12 for "Increased nutritional needs to promote healing," directed only the following intervention: "Provide regular diet, taking resident meal preferences into consideration." No additional assessments to be performed, monitoring to be conducted, or interventions were documented at that time. IPN (Interdisciplinary Progress notes) did not address resident #5's nutrition risk. Standing admission orders weekly weights on p.m. shift on Monday". The MAR (Medication Administration Record) onto which the weights were recorded, indicated that sometime during the week of 4/2/12 and 4/9/12, (date not specific), resident #5 weighed 112.5 lbs. On 4/16/12, resident #5 weighed 113 lbs., on 4/17/12, resident #5 weighed 114 lbs. The MAR indicated [REDACTED]. The faxes and IPN's found in resident #5's medical record did not reflect physician consultation regarding resident #5's significant weight loss. The medical record did include a physician's progress note dated 4/25/12, that documented resident #5's "weight 112.5 lbs". Resident #5's medical record included initial documentation by FSS (Food Services Supervisor)-K on 5/24/12, "(resident #5) has lost 38 lbs per RD-B admission note and last weeks weight...(resident #5) did have [DIAGNOSES REDACTED].(resident #5) stated she can't understand the weight loss as she feels fine. She also reported her normal weight was about 125 lbs. Will continue to monitor need for supplements and consult with RD. RD-B and FSS-K believe admit weight to be a possible error." No additional information was documented in resident #5's medical record to indicate that staff researched resident #5's weight from hospital records or validated the most recent weight from her attending physician's office. The MAR, dated 5/9/12, indicated resident #5 weighed 108 lbs, on 5/14/12, 110 lbs, on 5/21/12, 105 lbs. and on 5/28/12 107 lbs. The written plan of care, faxes to the physician, and IPN's did not address diet, nutrition, caloric intake, or an investigation into the possible reason for the significant weight loss of resident #5. A physician's progress note dated 5/23/12 indicated, "resolved C-dif," no other mention of weight loss, diet, nutrition or appetite. The MAR indicated [REDACTED]. The MAR, dated 6/4/12, indicated resident #5 weighed 105.6 lbs, 6/11/12, 108 lbs, 6/18/12, 107 lbs and 6/25/12, 107 lbs. The written plan of care and IPN do not address weight loss, diet, nutrition or appetite assessment or interventions. A physician's progress, note dated 6/27/12, indicated "weight 107.5 (down 5 lbs)...plan: will check lipids." The MAR indicated [REDACTED]. The MAR, dated 7/4/12, revealed resident 35 weighed 103.9 lbs, and on 7/9/12, 102.6 lbs. A fax to resident #5's physician dated 7/6/12 indicated "resident weight is 102.6 lbs as of 7/5/12, was 107 last month. Is on Med pass 60 ml twice daily, appetite is 25 % to 75%. Resident #5 states her weight is normally between 125 - 129 lbs...any new orders?" A physician's progress note dated 7/11/12 indicated, "staff reports weight loss to 102.6 lbs." No changes to the written plan of care were noted. The MAR indicated [REDACTED]. No additional documentation of assessments, interventions related to weights, diet or nutrition were noted in the IPN until a quarterly note by FSS-K on 7/17/12. This note stated, "Resident #5's weight of 102 lbs does give her a decrease of 6 lbs of the month, (5.5%) Dr. was notified...on Med pass supplement twice daily...is on a general constancy diet...exhibits no chewing swallowing or mouth pain problems...care plan current." IPN documented by FSS-K dated 7/25/12 revealed, "(resident #5) is showing a weight loss of 7.9% in the last 3 months. Her June to July weight recorded a 4 lb (3.7%) decrease. May to June recorded a 1.8% decrease (2 lb) and April to May recorded 2.6 % (3 lb) decrease...she reported to the physician she did not like the food...does not have an appetite...daughter stated resident always had a good appetite until her fall ...antidepressant has been discontinued per her request...will continue to monitor." No additional documentation was located in resident #5's medical record by FSS-K since 7/25/12. A nurse's fax to resident #5's physician, dated 7/24/12, indicated, "resident reported her mood has been good, resident credits the (antidepressant) [MEDICATION NAME]. She stated before she would cry at the drop of a hat and since taking it she felt much better mood. Could you start the [MEDICATION NAME] again, when she requested fewer meds she stated she didn't mean that one and would like it started again...." The MAR, dated 8/6/12, indicated resident #5 weighed 94.7 lbs, on 8/20/12, 92 lbs, on 8/27/12, 91 lbs. A fax to resident #5's physician dated 8/5/12, indicated, "weight is decreasing, 107.2, 103.9, 102.6, 101.6, 101.3, 98.1, 99.8, 97.8, 94.7 on 8/6/12. Appetite is poor to fair. Is taking Med pass supplement twice daily." A physician progress notes [REDACTED]." No changes to the written plan of care or further IPN's regarding weight loss and nutrition were found. The MAR, dated 9/3/12, indicated resident #5 weighed 89.4 lbs, on 9/17/12, 90.2 lbs and on 9/24/12, 88.6 lbs. Resident #5 was admitted to the hospital on [DATE]. A pacemaker and PEG tube were surgically placed. Resident #5 was readmitted to the facility 10/1/12. A nurse's fax to resident #5's physician, dated 9/7/12, indicated, "resident's appetite has been severely decreased recently. Weight has been steadily decreasing since admission. Was seen by speech language pathologist and suggested an appetite stimulant..." RD-B's documentation on 10/2/12 (the first note since the admission assessment) included that resident #5 was "readmitted status [REDACTED]. Readmit weight 91.6." RD-B's documentation on 10/3/12 included "...gave suggestion for free water flush to meet fluid needs...". RD-B's documentation on 10/18/12 included ".... continues to tolerate tube feeding....[MEDICATION NAME] provides 1728 Kcal...". No changes to resident #5's written plan of care were made regarding nutrition, from 4/1/12 to 9/26/12, when resident was admitted to hospital. Resident #5's plan of care was updated on 10/19/12 and included: "Administer tube feeding and free water flushes, checking residuals for any intolerance's, and follow tube feeding tolerance and make nutritional recommendations accordingly." RD-B's documentation on 11/12/12 included "...also requested to start [MEDICATION NAME] powder for additional protein...and continue to monitor tolerance/nutrition status." On 11/14/12 at 7:50 a.m., surveyor # interviewed resident #5. Resident #5 stated she lost weight because her heart problems caused her to have a poor appetite. Resident #5 indicated she felt much better since her pacemaker insertion. On 11/14/12 at 11:23 a.m., surveyor # interviewed RD-B regarding resident #5. RD-B indicated she recalled being somewhat involved with resident #5 and recommended the Med pass supplement, but more intensive involvement with resident #5 did not occur until the resident returned from the hospital with the PEG tube. RD-B verified she was in communication with the facility and the physician related to the most recent enteral nutrition orders. RD-B offered no further information about care-planning and interventions for resident #5 when her risk for [MEDICAL CONDITION] was first identified and when the initial significant weight loss occurred on 4/6/12.