Every finding on record at Peabody Manor

Based on interview and record review, the facility did not initiate or resolve a grievance for 1 resident (R) (R1) of 1 sampled resident. R1 reported to staff that they were not being ambulated daily per physical therapy recommendations. The facility did not thoroughly document, investigate, or resolve the grievance.Findings include: The facility's Long Term Care (LTC) Resident Complaints and Grievances Policy, dated 3/15/26, indicates: The purpose of the policy is to establish the standards and processes for: (1) Promptly managing and resolving resident complaints and grievances; (2) Resolving complaints and grievances in a manner that assures quality and resident-centered care and services .(6) Communicating with the resident and/or their legal representative during the complaint and grievance process .A grievance is a written or verbal complaint made by a resident and/or their legal representative that is not resolved prior to discharge, transfer, or termination of services .All residents and/or their legal representative have the right to report or file a complaint or grievance regarding the care or services they are receiving or have received at the facility and to have these reports reviewed through established complaint and grievance processes .All team members must immediately report any resident complaints to an area manager or facility Administrator, and grievances to the facility Administrator and/or designated Grievance Officer .On 8/19/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and discharged on 7/30/26. R1 had diagnoses including type 2 diabetes with neuropathy, alcohol-induced polyneuropathy, anxiety, mood disorder, weakness of bilateral lower extremities, and impaired mobility. R1 was responsible for their medical decisions.On 8/19/26 at 11:46 PM, Surveyor interviewed Physical Therapist (PT)-D who verified R1 had a restorative program that started on 11/26/25 when PT services ended. PT-D stated nursing staff are educated when a resident starts a restorative program and a binder for restorative activities is placed in the resident's room. The resident's care plan is updated and a purple muscle arm magnet is placed on the door frame of their room. The resident's mobility/ambulatory status is also listed on a white board in their room.On 8/19/26 at 3:32 PM, Surveyor interviewed Registered Nurse (RN)-C and PT-D along with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. RN-C oversaw the facility's restorative program and was aware that a resident reported they were not being walked by staff. RN-C could not recall the resident's name or the date they received the concern, but thought it was around 7/3/26. When asked if R1 informed RN-C that they weren't being walked, RN-C said yes. RN-C and PT-D could not figure out why R1's restorative care plan was discontinued. The assumption was that the projected end date approached and the facility's medical record system automatically discontinued the care plan. RN-C verified a grievance was not initiated related to the lack of restorative services.

Based on observation, staff interview, and record review, the facility did not ensure menus met the nutritional needs of residents in accordance with established national guidelines. This practice had the potential to affect more than 4 of the 58 residents residing in the facility.The facility did not implement a menu that delineated portion sizes for residents.Findings include:The facility's Long Term Care (LTC) Dining Services Policy, dated 8/12/25, indicates: The Dietary Coordinator will observe meal preparation and services to assess ordered diet, portion sizes, temperature, flavor, variety, and tray passing for accuracy, and will report any concerns to the Administrator, Director of Nursing (DON), Dietitian, or other necessary leader as needed.On 3/18/26 at 12:10 PM, Surveyor observed Dietary Aid (DA)-E prepare scoops/ladles for plating food. The meal consisted of a baked potato, broccoli and cheese served on top of the baked potato, minestrone soup with noodles, and peaches served on top of cottage cheese. Surveyor interviewed DA-E who stated there is no specific scoop or ladle size used for the food served and DA-E uses scoops and ladles that seem best suited for the food, including a larger ladle which works best for soup. DA-E wasn't sure how many ounces of protein or other food items should be on each resident's plate. DA-E stated some residents eat less and DA-E uses half of the scooped/ladeled amount. DA-E stated DA-E knows which residents eat small or large portions. DA-E verified meal tickets do not always indicate if a resident wants small or large portions.On 3/18/26 at 12:22 PM, Surveyor observed DA-I use a purple scoop to put 2 scoops of cottage cheese and 1-2 slotted spoonfuls of peaches in bowls for residents. Surveyor noted it was a different portion than DA-E had put in bowls earlier. DA-E used a large spoon for the cottage cheese and a large ladle for the peaches.On 3/18/26 at 1:05 PM, Surveyor interviewed Dietary Supervisor (DS)-F who was aware portion sizes were not consistent and staff were not educated to use specific portions for each type of food, including protein. DS-F indicated there was a plan to institute a new food program with consistent recipes and portion sizes. DS-F stated staff would be educated on using measured scoops/spoodles to ensure residents receivenconsistent portions to support a nutritious diet.On 3/18/26 at 3:35 PM, Surveyor interviewed Registered Dietician (RD)-G who indicated scoop and portion sizes are not on residents' meal tickets; however, residents' preferences for smaller or larger portions are on the meal tickets. RD-G indicated staff need additional education to correctly portion food onto plates. RD-G stated RD-G was working with DS-F to implement a new food program with consistent recipes and portion sizes.On 3/19/26 at 4:15 PM, Surveyor reviewed residents' meal tickets for the evening meal which contained residents' diets, allergies, food textures, and food requests. The meal tickets did not contain portion sizes with the exception of 1 meal ticket that had small portions manually written on the pre-printed ticket.

Based on staff interview and record review, the facility did not ensure the Office of the State Long-Term Care Ombudsman was updated regarding hospital transfers and/or discharges for 4 residents (R) (R6, R43, R55, and R62) of 4 sampled residents.R6 was transferred to hospital on 1/7/26. Long-Term Care Ombudsman (LTCO)-C was not updated regarding R6's hospital transfer. R43 was trasferred to the hospital on [DATE] and 11/9/25. LTCO-C was not updated regarding R43's hospital transfers.R55 was transferred to the hospital on 9/28/25. LTCO-C was not updated regarding R55's hospital transfer.R62 discharged from the facility on 1/31/26. LTCO-C was not updated regarding R62's discharge.Findings include: The facility's Long Term Care (LTC) Discharge and Transfer Policy, revised 4/24/25, indicates: .7. The facility will forward a copy of all discharge/transfer notices to the Office of the State LTC Ombudsman. 1. Between 3/17/26 and 3/19/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, diabetes, and left below-the-knee amputation (BKA). R6's Minimum Data Set (MDS) assessment, dated 1/13/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 had intact cognition. R6 made R6's own healthcare decisions. An emergency room (ER) admission note, dated 1/7/26, indicated R6 was sent to the ER for possible infection of the left BKA stump and to rule out possible sepsis. The facility did not provide documentation when asked to indicate LTCO-C was notified of R6's hospital transfer. (See interview under example 4.) 2. Between 3/17/26 and 3/19/26, Surveyor reviewed R43's medical record. R43 had a cardiac pacemaker and was admitted to the facility on [DATE]. R43 had diagnoses including asthma and paroxysmal atrial fibrillation (an irregular heartbeat). R43's MDS assessment, dated 10/29/25, contained a BIMS score of 11 out of 15 which indicated R43 had moderate cognitive impairment. R43 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. A Nurse Practitioner note, dated 11/7/25 at 6:44 AM, indicated R43 had left-sided chest pain at a level 9 out of 10, a rapid and irregular heart rate, and shortness of breath. R43 was sent to ER for evaluation. The facility did not provide documentation when asked to indicate LTCO-C was notified of R43's hospital transfer. A provider note, dated 11/9/25 at 5:45 PM, indicated R43 complained of chest pain at a level 8 out of 10. R43 was shaky, hypertensive, and had an oxygen saturation of 85% on room air. R43 was sent to the ER for evaluation. The facility did not provide documentation when asked to indicate LTCO-C was notified of R43's hospital transfer. (See interview under example 4.) 3. On 3/18/26, Surveyor reviewed R55's medical record. R55 was admitted to the facility on [DATE] and had diagnoses including cancer, indwelling catheter, and history of urinary tract infection. R55's MDS assessment, dated 2/11/26, had a BIMS score of 13 out of 15 which indicated R55 had intact cognition. R55's medical record indicated R55 was transferred to the hospital on 9/28/25 due to sepsis. On 3/18/26 at 2:29 PM, Surveyor requested Ombudsman notification for R55's hospital transfer. The informatin was not provided. (See interview under example 4.) 4. Between 3/17/26 and 3/19/26, Surveyor reviewed R62's medical record. R62 was admitted to the facility on [DATE] and had diagnoses including coronary artery disease, heart failure, and diabetes. R62's MDS assessment, dated 1/7/26, had a BIMS score of 13 out of 15 which indicated R62 had intact cognition. R62's medical record indicated R62 was discharged from the facility on 1/31/26. On 3/19/26 at 9:45 AM, Surveyor interviewed Social Worker (SW)-D who verified SW-D did not send transfer/discharge notices to LTCO-C. SW-D stated SW-D was told by a previous Social Worker that LTCO-C had asked the facility not to send transfer/discharge notices because the facility had too many residents. On 3/19/26 at 10:51 AM, Regional Field Operations Supervisor (RFOS)-M contacted LTCO-C via email to verify if LTCO-C asked the facility not to send transfer/discharges notices. On 3/19/26 at 1:11 PM, LTCO-C indicated via email it is a facility requirement to notify LTCO-C of transfers and discharges and LTCO-C would not advise a facility not to do so.

Based on observation and staff interview, the facility did not ensure food was stored, prepared, or served under sanitary conditions. This practice had the potential to affect more than 4 of the 58 residents residing in the facility.Multiple food items were undated, expired, and/or not sealed properly.Findings include:The facility's Food Procurement, Storage, Preparation, and Service Policy, revised 2/8/26, indicates: Date marking of food prepared and packaged in a food processing plant and served in a food establishment: These foods must be clearly marked with the date the original container is opened; and they must be consumed or discarded within seven days including the day the container is opened. Must be maintained at 41 degrees or less for the duration of the seven days .At no time will the food be sold or served beyond the expiration date placed on the original container by the food manufacturer.On 3/17/26 at 9:02 AM, Surveyor began an initial tour of the kitchen with Head [NAME] (HC)-H and observed the following: ~ Thawed bread and buns in the kitchen prep area without a pull-date~ An undated open bag of ziti pasta~ An undated open bag of egg noodles ~ A bowl of green grapes with a discard date of 3/11/26~ An open and undated plastic bin of powdered sugar that contained a measuring cup~ An open and undated plastic bin of all-purpose flour not in the original packaging~ An open and undated plastic bin of granulated sugar ~ An open and undated plastic bin that contained a bag of long grain white rice.On 3/17/26 at 9:02 AM, Surveyor interviewed HC-H who indicated the bread and buns should have been dated when they were removed from the freezer. HC-H indicated both bags of pasta should have open dates and the green grapes should have been discarded. HC-H removed the measuring cup from the bin of powdered sugar and verified the measuring cup should not have been in the bin. HC-H indicated the powdered sugar, all-purpose flour, granulated sugar, and long grain white rice should have been dated when opened. On 3/17/26 at approximately 9:30 AM, Surveyor interviewed Dietary Supervisor (DS)-F who joined the kitchen tour. DS-F agreed the bread and buns should have been dated when pulled from the freezer, the grapes should have been discarded, and the measuring cup should not have been in the bin of powdered sugar. DS-F also verified the powdered sugar, granulated sugar, all-purpose flour, and long grain white rice should have been dated when opened.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R63) of 2 sampled residents received care and treatment to prevent accidents. R63 was observed smoking outside the facility. R63's medical record did not contain a smoking assessment to ensure R63 was safe to smoke independently and/or without supervision. Findings include: The facility's Smoking Policy, dated 1/31/24, indicates: Team members will enforce a non-smoking campus by designating safe smoking areas, providing resident education, and completing resident assessments for smoking to ensure precautions are taken for the individual safety as well as the safety of others in the facility .a. Any resident choosing to smoke will be assessed by a licensed nurse utilizing the Smoking Evaluation Risk Flowsheet. This assessment will be completed prior to the resident smoking and will be repeated as needed and with a change of condition. Between 3/17/26 and 3/19/26, Surveyor reviewed R63's medical record. R63 was admitted to facility on 2/28/26 and had a diagnosis of necrotizing fasciitis. R63's Minimum Date Set (MDS) assessment, dated 3/2/26, indicated R63 was independent with hygiene, toileting, transfers, and dressing. R63 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R63 had intact cognition. A care plan, dated 3/1/26, indicated R63 should follow the smoking policy for safety considerations and was safe to smoke. R63's medical record did not contain a smoking assessment. Surveyor requested R63's smoking assessment from Nursing Home Administrator (NHA)-A. On 3/18/26 at 9:24 AM, Surveyor observed R63 smoking outside the facility with another resident. On 3/18/26 at 10:36 AM, Surveyor interviewed NHA-A who indicated the facility did not have a smoking assessment for R63. NHA-A verified a smoking assessment should have been completed.

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 2 residents (R) (R2 and R6) of 2 sampled residents.During wound care for R2, Registered Nurse (RN)-J did not appropriately change gloves and cleanse hands. In addition, RN-J applied Medi-honey to R2's wound bed with a soiled glove.Staff did not comply with enhanced barrier precautions (EBP) during wound care for R6.Findings include: The Wisconsin Department of Health Services webpage titled Healthcare-Associated Infections, last updated on 2/24/26 indicates: Hand hygiene refers to cleaning your hands, either by washing with soap and water, or using alcohol-based hand rub (ABHR). Hand hygiene should be performed before and after contact with a patient or resident, immediately after touching blood, body fluids, non-intact skin, mucous membranes, or contaminated items (even when gloves are worn during contact), immediately after removing gloves, when moving from contaminated body sites to clean body sites while providing care, and after touching objects and medical equipment in the immediate patient-care vicinity. The Centers for Disease Control and Prevention (CDC) (6/28/24) states enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). 1. Between 3/17/26 and 3/19/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including diabetes, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 2/11/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R2 had intact cognition. On 3/19/26 at 9:15 AM, Surveyor observed RN-J remove R2's left foot dressing. RN-J then removed gloves, completed hand hygiene, and donned clean gloves. RN-J put wound cleanser on a 4 x 4 gauze pad and cleansed R2's open wound. RN-J then opened an island dressing, put Medi-honey on the tip of RN-J's soiled glove, and put the Medi-honey on the wound bed. RN-J removed gloves, dated the dressing, and completed hand hygiene. RN-J donned clean gloves and put the dressing on R2's left foot wound. On 3/19/26 at approximately 9:30 AM, Surveyor interviewed RN-J who verified RN-J should have removed gloves and completed hand hygiene after cleansing the wound and before putting Medi-honey on the wound bed. On 3/19/26 at 10:20 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated RN-J should have completed hand hygiene and donned clean gloves between dirty and clean aspect of wound care. DON-B indicated staff should use a Q-tip or applicator to apply Medi-honey. 2. Between 3/17/26 and 3/19/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, diabetes, suprapubic catheter for neurogenic bladder, and pressure injuries to the right heel, right buttock, and perineum, right mid-foot diabetic ulcer, and left below-the-knee amputation (BKA). R6's MDS assessment, dated 1/13/26, had a BIMS score of 15 out of 15 which indicated R6 had intact cognition. R6 made own R6's own healthcare decisions. On 3/18/26 at 9:46 AM, Surveyor observed an EBP sign and a personal protective equipment (PPE) cart outside R6's room. The sign indicated staff must wear a gown and gloves during high-contact resident care such as wound care. Surveyor observed Licensed Practical Nurse (LPN)-L and RN-K complete hand hygiene and don gloves. LPN-L and RN-K did not don gowns prior to entering R6's room. RN-K touched R6 and R6's Prevalon heel boot (used to offload heels). When Surveyor asked if LPN-L and RN-K should wear gowns during wound care for a resident on EBP, RN-K stated yes.

Based on staff interview and record review, the facility did not ensure monitoring for adverse consequences of psychotropic medication was provided for 1 resident (R) (R7) of 5 sampled residents. R7 had orders for buspirone (an antipsychotic medication) and olanzapine (an antipsychotic medication). The facility did not complete quarterly Abnormal Involuntary Movement Scale (AIMS) assessments (used to monitor patients on long-term antipsychotic medications for involuntary muscle movements associated with tardive dyskinesia) for R7.Findings include:The facility's Psychotropic Monitoring policy, revised 8/12/25, indicates: .Long Term Care (LTC) will monitor residents who are receiving antipsychotic drug therapy for significant adverse effects of such therapy .will monitor residents on antipsychotic drug therapy through use of the Abnormal Involuntary Movement Scale (AIMS). 2. Team members will complete the AIMS for residents on antipsychotic drug therapy: a. Upon admission; b. At the start of a new antipsychotic medication; c. Upon each Quarterly MDS assessment .On 3/18/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, depression, and anxiety. R7's Minimum Data Set (MDS) assessment, dated 12/31/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R7 had severely impaired cognition. R7 had an activated Power of Attorney for Healthcare (POAHC).R7's medical record contained the following orders: ~ Buspirone 5 milligrams (mg) and buspirone 10 mg at bedtime~ Olanzapine 2.5 mg at bedtimeR7's medical record indicated R7's most recent AIMS assessment was completed on 7/12/25.On 3/19/26 at 10:53 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R7's last AIMS assessment was completed on 7/12/25. DON-B indicated AIMS assessments should be completed quarterly per the facility's policy.

Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During observations of medication administration, 2 errors occurred during 30 opportunities which resulted in a 6.67% medication error rate that affected 1 resident (R) (R32) of 4 residents observed during medication administration.R32 had an order for pantoprazole (used to treat acid reflux). The order stated to give the medication on an empty stomach. On 3/18/26, staff administered pantoprazole to R32 after R32 started eating breakfast. In addition, R32 had an order for isosorbide (used to prevent/treat chest pain). The order indicated not to crush the medication. Staff crushed the medication prior to administration.Findings include:The facility's Oral Medications That Should Not Be Crushed or Altered form, updated 3/9/26, indicates: The following table contains drugs .that have characteristics that may make it inappropriate to crush or alter the dosage form to help facilitate drug delivery .Medications which should not crushed fall into one of the following categories: extended release products .pantoprazole tablet is slow release .On 3/18/26, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including acid reflux, congestive heart failure, and coronary artery disorder. R32's Minimum Data Set (MDS) assessment, dated 2/25/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R32 had intact cognition.On 3/18/26 at 8:24 AM, Surveyor observed Registered Nurse (RN)-K prepare and administer R32's AM medication. R32 was eating breakfast in the dining room. Surveyor observed RN-K crush isosorbide with other medications, except pantoprazole. RN-K administered the crushed medications in applesauce.Surveyor reviewed R32's Medication Administration Record (MAR) which contained the following physician orders:~ Pantoprazole 20 milligram (mg) tablet, give daily before morning meal. Administration instructions: Take on an empty stomach. Do not crush or chew.~ Isosorbide dinitrate 10 mg tablet, give 2 times daily. Administration instructions: Do not crush. On 3/18/26 at 12:32 PM, Surveyor interviewed RN-K and Director of Nursing (DON)-B. RN-K confirmed RN-K crushed R32's isosorbide and administered R32's pantoprazole during breakfast. DON-B indicated RN-K had just started working at the facility and was not familiar with R32. DON-B confirmed RN-K should have followed the administration instructions for both medications.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R52) of 1 sampled resident received the necessary care and services to prevent or monitor weight loss.R52 had significant weight loss. R52's weight was not monitored as ordered. In addition, appropriate follow-up was not completed, including timely notification of the physician.Findings include:On 3/17/26, Surveyor reviewed R52's medical record. R52 was admitted to the facility on [DATE] and had a diagnosis of high blood pressure. R52's Minimum Data Set (MDS) assessment, dated 10/22/25, had a Brief Interview for Mental Status (BIMS) score of 3 out 15 which indicated R52 had severe cognitive impairment. R52 had an activated Power of Attorney for Healthcare (POAHC).R52's care plan indicated R52 should be weighed weekly (with a start date of 11/3/25).Surveyor reviewed R52's weights and noted the following:~ On 1/8/26, R52 weighed 198.2 pounds (lbs).~ On 2/19/26, R52 weighed 183.1 lbs (which was a significant weight loss of 7.62%).R52's medical record did not contain a re-weight or indicate the physician was notified of the weight loss.On 3/18/26 at 2:47 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the physician was not notified regarding R52's weight loss of more than 5% in one month. DON-B verified the physician should have been notified and staff should have attempted to re-weigh R52.On 3/18/26 at 3:40 PM, Surveyor interviewed Registered Dietitian (RD)-G who was aware of R52's weight loss. RD-G confirmed staff should have re-weighed R52 and notified the physician if R52 had a weight loss of more than 5% in one month.On 3/19/26 at 8:15 AM, Surveyor requested R52's order for weight monitoring.On 3/19/26 at 8:29 AM, Surveyor interviewed Registered Nurse (RN)-J who reviewed R52's medical record and indicated the start date for weekly weights was 1/9/25. RN-J indicated R52 is weighed weekly with showers. RN-J stated if R52 has significant weight loss or gain, RN-J updates the physician and RD-G.On 3/19/26 at 9:24 AM and 9:34 AM, Surveyor interviewed DON-B who indicated R52 refused to re-weighed. DON-B verified the refusal was not documented in R52's medical record. DON-B indicated R52 did not have a physician order for weights and the facility would do a minimum of monthly weights.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 47 residents residing in the facility.The facility did not monitor and document refrigerator and freezer temperatures in units that held food for resident consumption. Findings include:On 7/7/25, Nursing Home Administrator (NHA)-A indicated the facility follows the Wisconsin Food Code.The 2022 Wisconsin Food Code documents at 3-202.11 Temperature: Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. Refrigerators should be set below 41° Fahrenheit (F) (5° Celsius (C)) and freezers at or below 0° F (-18° C).The facility's Dining Services Temperature Monitoring Policy, revised 3/8/23, indicates: The purpose of this policy is to outline the standards and processes for required temperatures in refrigerators, freezers, and dishwashers to maintain safety and prevent foodborne illness in long term care (LTC) facilities .Each LTC facility will monitor the temperatures of dishwashers, refrigerators, and freezers on each shift to maintain safety and prevent future foodborne illnesses .Dining Services team members will follow the procedures in the Patient/Resident Food Refrigerator and Freezer Temperature Monitoring Policy .The facility's LTC Food and Beverage Brought in from Outside Resources Policy, revised 10//8/24, indicates: Refrigerators, including those in resident rooms, must be in good repair and keep foods at or below 41° F. Freezers must keep frozen foods frozen solid. Team members will use the following methods to determine the proper working order of the refrigerators and freezers: a. Document the temperature of the external and internal refrigerator gauges. Refrigerators must be 41° or less. Freezers must be 10° or less for reach-in, or 0° or less for walk-in. b. If temperatures are out of range, notify maintenance and supervisor, follow facility policy for food disposal. c. Check for situations where potential for cross-contamination is high (e.g., raw meat stored over ready-to-eat items) .On 7/7/25 at 9:31 AM, Surveyor entered the kitchen for an initial tour with Food Service Specialist (FSS)-C. Surveyor observed a walk-in cooler that contained food. Beyond the walk-in cooler was a walk-in freezer. Surveyor also observed a set of reach-in coolers in the preparation/cooking area. Surveyor also observed two semi-trucks in the parking lot that stored food for resident consumption. One truck contained refrigerated food and the other truck contained frozen food. Surveyor noted there was not a visible thermometer inside the freezer truck.During the initial tour on 7/7/25 at 9:31 AM, Surveyor interviewed FSS-C who indicated a few of the main coolers and freezers were removed approximately six weeks ago and the refrigerator and freezer trucks were implemented. FSS-C indicated staff obtain and document cooler and freezer temperatures daily, including temperatures in the refrigerator and freezer trucks. FSS-C indicated a few weeks ago one of the trucks stopped working and the food was spoiled and discarded. FSS-C did not know if there was a thermometer inside the freezer truck but indicated there should be one.Surveyor reviewed the facility's central kitchen cooler/freezer temperature log that indicated cooler and freezer temperatures should to be taken twice daily. The log contained a spot for one cooler/refrigerator temperature and one freezer temperature, however, the facility had more than one cooler/refrigerator and more than one freezer. In addition, there were no temperatures documented after 6/4/25.On 7/7/25 at 9:47 AM, Surveyor interviewed [NAME] (CK)-D who indicated CK-D did not obtain temperatures inside the semi-truck because CK-D had to climb inside the box to get them which was difficult. CK-D indicated all cooler, refrigerator, and freezer temperatures should be obtained and recorded twice daily. When asked why truck temperatures were not obtained, CK-D indicated staff were not told to obtain truck temperatures. When asked why indoor refrigerator and freezer temperatures were not documented since 6/4/25, CK-D stated, I guess we didn't do them since the other ones were taken out.On 7/7/25 at 9:49 AM, Surveyor interviewed FSS-C who indicated all cooler, refrigerator, and freezer temperatures should be obtained and documented twice daily. FSS-C was not sure why that was not being done.On 7/7/25 at 3:19 PM, Surveyor interviewed NHA-A who indicated staff should monitor, test, and record the temperatures of all coolers, refrigerators, and freezers daily. NHA-A also indicated kitchen staff should be aware of and follow the policy.

Based on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R1) of 2 sampled residents. The facility did not ensure R1's oxygen orders were consistently followed. R1's plan of care did not indicate R1 received oxygen therapy and did not include respiratory care, goals, or interventions related to respiratory disease. In addition, R1's primary diagnoses list did not include a chronic obstructive pulmonary disorder (COPD). Findings include: The facility's Long Term Care (LTC) Resident Plan of Care policy, revised 6/12/25, indicates: The resident plan of care policy outlines the standards and processes for resident care planning .and applies to all team members in long-term care facilities .LTC facilities must develop and implement a baseline and comprehensive plan of care (POC) for each resident which includes the instructions needed to provide effective person-centered care of the resident and meet professional standards of quality care .The Interdisciplinary Team (IDT) will continue to develop the baseline POC into a comprehensive POC for each resident .Documentation of all POCs will include the following: abilities and needs .goals or desired outcomes, individualized interventions. The IDT will update/document the POC following an incident or event that causes a change in the POC or the resident's condition. On 7/7/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including centrilobular emphysema, vascular dementia, and atrial fibrillation. R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R1 had moderately impaired cognition. R1 had an activated Power of Attorney for Healthcare (POAHC). A history and physical note, dated 10/2/24, indicated R1 had a past medical history diagnosis of COPD. A hospital Discharge summary, dated [DATE], indicated R1 had admitting diagnoses of shortness of breath and hypoxia. R1's hospital course included: 1. Acute hypoxic respiratory failure and rhinovirus COPD exacerbation. Surveyor noted R1's past medical records indicated R1 had a diagnosis of COPD (dated 9/15/17). R1's plan of care, initiated 9/13/24, did not include the use of oxygen or respiratory interventions related to chronic respiratory disease. An Emergency Department (ED) provider note, dated 1/7/25, indicated R1 had a past medical history diagnosis of COPD. R1's chief complaint for the visit was shortness of breath. A physician order, dated 1/7/25, stated: May titrate oxygen up to 6 liters by nasal cannula with a goal of oxygen saturation 90% or greater. A progress note, dated 1/8/25 at 6:58 AM, indicated R1's oxygen saturation was 67% on 10 liters of oxygen. A Hospice Medical Director note, dated 1/8/25, indicated R1 was likely transitioning and the suspected etiology was advanced COPD complicated by R1's advanced age. ~R1's Treatment Administration Record (TAR) contained the following documentation: ~ On 1/9/25 at 2:00 PM: Oxygen saturation: 83%; Oxygen flow rate: 8 liters/minute~ On 1/9/25 at 1:00 PM: Oxygen saturation: 88%; Oxygen flow rate: 8 liters/minute ~ On 1/9/25 at 8:00 AM: Oxygen saturation: 88%; Oxygen flow rate: 8 liters/minute~ On 1/9/25 at 4:00 AM: Oxygen saturation: 88%; Oxygen flow rate: 8 liters/minute~ On 1/9/25 at 12:00 AM: Oxygen saturation: 83%; Oxygen flow rate: 8 liters/minute On 7/7/25 at 2:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. DON-B confirmed R1's oxygen concentrator should be set at the level ordered by the physician and confirmed R1's order was not followed on 1/8/25 and 1/9/25 when R1's oxygen was documented at 8-10 liters/minute. DON-B also confirmed oxygen therapy and respiratory care were not included in R1's plan of care and verified COPD was not included in R1's active diagnoses list. DON-B verified documentation of R1's hospital visits on 1/7/25 and 9/30/25 indicated R1 had an exacerbation of COPD. DON-B indicated diagnoses should automatically transfer over in the system from the hospital to the facility. DON-B verified COPD should be on R1's active diagnoses list. On 7/7/25 at 4:55 PM, Surveyor interviewed DON-B who indicated the facility does not have policies related to the administration of oxygen or physician orders.

Based on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R9) of 1 sampled resident. R9 fell during an EZ Stand transfer on 7/8/24. Following the fall, R9's care plan was updated with an intervention to transfer R9 with the assistance of two staff for all EZ Stand transfers. On 12/8/24, Certified Nursing Assistant (CNA)-G transferred R9 via EZ Stand without a second staff present. R9 fell during the transfer and sustained a right tibial plateau fracture. R9 was assessed by therapy and a recommendation was made to transfer R9 with two staff and a Hoyer lift. R9's care plan was not properly updated. Findings include: The facility's Resident Plan of Care Policy, revised 7/15/24, indicates: The purpose of this policy is to outline the standards and processes for providing high quality, person-centered care to all residents through a plan of care to promote continuity of care, communication among team members, resident safety, and safeguard against an adverse event .The following elements of a resident's plan of care may be kept in the resident's medical record: a. Nursing care (i.e., self-care deficit, restorative, fall prevention, skin injury, elimination, pain, and other specific needs as identified) .Documentation will include the following: .individualized interventions. The Interdisciplinary Team (IDT) will update/document a plan of care following an incident or event that causes a change in the plan of care or resident's condition . The facility's Resident Fall and Injury Prevention Policy, revised 10/22/24, indicates: The purpose of this policy is to outline the standards and processes to monitor long-term care environments and resident safety to prevent resident falls and injuries .Interventions will be assessed and added to the resident plan of care as needed .E. Post Fall Care and Post Fall Huddle: 1. If a resident fall occurs, team members will .d. Review the plan of care and update with new fall interventions . On 12/17/24, Surveyor reviewed R9's medical record. R9 had diagnoses including tibial plateau fracture-right (12/8/24), restless leg syndrome, lymphedema, and primary osteoarthritis of both knees. R9's Minimum Data Set (MDS) assessment, dated 11/15/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 was not cognitively impaired. R9 was R9's own decision maker. R9's medical record indicated R9 fell on [DATE] during an EZ Stand transfer. Nursing staff indicated R9 coughed, appeared to lose consciousness, and slid out of the EZ Stand. R9's care plan was updated with an intervention for the assistance of two staff during all EZ Stand transfers. The facility's EZ Stand slings were replaced to ensure the slings secured properly. R9 did not sustain an injury during the fall. R9's medical record indicated R9 fell on [DATE] during an EZ Stand transfer and sustained a right knee tibial plateau fracture. The facility's investigation indicated CNA-G transferred R9 with an EZ Stand lift without a second staff present. R9 indicated R9's knee buckled and R9 began to fall which caused the EZ Stand to tip over. R9 fell to the floor on R9's left side and the EZ Stand was in contact with R9's right knee. R9 had pain and bruising and was sent to the emergency room (ER). An X-ray identified the fracture. The facility's investigation indicated an intervention was initiated on 12/8/24 to use a Hoyer lift when R9 felt weak. A progress note, dated 12/11/24, indicated R9 was assessed by physical therapy staff for use of a lift. Documentation indicated R9 required a Hoyer lift with the assistance of two staff for all transfers. A Hoyer lift was determined to be the most appropriate and safest transfer technique due to R9's history of falls in the EZ Stand. On 12/17/24, Surveyor reviewed R9's care plan which stated the following, Please don (put on) my air splint on my L (left) ankle when I get up in the morning before using EZ stand lift .I transfer with assist of 2 people and Hoyer lift. I must have air splint on my L ankle to stand with the lift. Bathroom needs met with urinal and bed pan. I must have air splint on my L ankle to stand with the lift. On 12/17/24 at 1:24 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. NHA-A and DON-B indicated a care plan intervention was added for two staff with all EZ Stand transfers following R9's fall on 7/8/24 because R9 had periods of unconsciousness during transfers. NHA-A indicated medical tests were completed to rule out ongoing medical issues and stated the intervention was initiated to ensure safety during transfers. DON-B indicated CNA-G did not follow R9's care plan on 12/8/24 and did not have a second staff present when CNA-G transferred R9 with the EZ Stand. During the investigation, CNA-G confirmed there was not a second staff present during the transfer. Following the fall, DON-B indicated R9's fall prevention care plan was updated on 12/11/24 with an intervention to use a Hoyer lift for all transfers following a physical therapy assessment of R9. DON-B confirmed R9's care plan should not include verbiage about donning a splint for EZ Stand lift use and indicated R9 should only be transferred with a Hoyer lift. DON-B indicated the EZ Stand portion of the care plan was forgotten and should have been removed. DON-B indicated R9's care plan would be revised to remove the verbiage that R9's left leg splint should be applied prior to EZ Stand transfers. On 12/17/24 at 3:00 PM, Surveyor interviewed NHA-A who indicated an investigation was completed following R9's fall on 12/8/24. NHA-A indicated staff were educated on transfers and following care plans and stated the lift manufacturer came to the facility to ensure all lifts were in proper working order. NHA-A indicated the facility provided staff training but possibly should have focused more time on the care plan to ensure R9's care plan was updated properly.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R22, R15, and R30) of 4 residents observed during the provision of cares. During an observation of wound, incontinence, and catheter care for R22 on 12/17/24, Registered Nurse (RN)-J, Certified Nursing Assistant (CNA)-K, and CNA-L did not wash or sanitize hands between glove changes. During an observation of peri-rectal care for R15 on 12/17/24, CNA-C did not wash or sanitize hands between glove changes. R30 was on enhanced barrier precautions (EBP). During an observation on 12/18/24, RN-I did not don a gown prior to administering R30's tube feeding. Findings include: The facility's Long Term Care Infection Prevention and Control Program Policy, revised 5/17/24, indicates: .to prevent, recognize and control the onset and spread of infection whenever possible .Hand Hygiene: the cleaning of hands by either handwashing (washing hands with soap and water) or antiseptic hand rub (i.e., alcohol-based hand sanitizer) .Team members will use an alcohol-based hand rub (ABHR): .Before and after resident contact .After contact with a resident's surroundings or equipment .Before donning sterile or non-sterile gloves or other personal protective equipment (PPE) .After removing gloves or other PPE .After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, as long as hands are not visibly soiled .If moving from a contaminated body site to a clean body site during resident care .Enhanced Barrier Precautions (EBP) will be used .for residents with an infection or colonization with a novel or targeted multidrug-resistant organism (MDRO when contact precautions with room isolation do not apply, and for residents with chronic wounds or indwelling medical devices. Team members will use a gown and gloves for close contact activities .EBP will also be used when a resident has an infection with an MDRO that is not included on the list of targeted MDROs and contact precautions with room isolation do not apply .Close contact activities include: .Bathing/showering .Assisting with toileting or changing briefs .Manipulation or care of indwelling devices including central lines, urinary catheters, feeding tubes . 1. From 12/16/24 to 12/18/24, Surveyor reviewed R22's medical record. R22 was admitted to facility on 8/10/23 and had diagnoses including paraplegia, neurogenic bladder, neuralgia, and fecal incontinence. R22's Minimum Data Set (MDS) assessment, dated 10/1/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R22 was not cognitively impaired. The MDS also indicated R22 required partial/moderate assistance with hygiene and to roll left and right. R22 was dependent with toileting. On 12/17/24 at 10:16 AM, Surveyor observed RN-J, CNA-K, and CNA-L provide wound, incontinence, and catheter care for R22. RN-J, CNA-K, and CNA-L sanitized hands and donned gloves. CNA-L pulled R22's blanket back and opened R22's soiled brief. CNA-K wiped R22's perineal area from front to back twice with a wash cloth and removed gloves. Without washing or sanitizing hands, CNA-K donned clean gloves and again wiped R22's from front to back with a wash cloth and removed gloves. Without washing or sanitizing hands, CNA-K donned clean gloves and CNA-K and CNA-L rolled R22 on the right side. CNA-K handed R22's catheter bag to CNA-L who hung the catheter bag on the other side of the bed. CNA-K wiped R22's rectal area (which contained visible feces) from front to back and removed gloves. Without washing or sanitizing hands, CNA-K donned clean gloves, cleansed R22's Foley tubing with a wash cloth, and removed gloves. Without washing or sanitizing hands, CNA-K donned clean gloves, again cleansed R22's rectal area with a wash cloth, and removed gloves. Without washing or sanitizing hands, CNA-K donned clean gloves. CNA-K and CNA-L removed R22's soiled brief and placed a clean brief under R22. CNA-K removed gloves, but did not wash or sanitize hands before donning clean gloves. CNA-K then assisted RN-J with wound care. With the same gloved hands, CNA-K opened a 2 x 2 gauze package. RN-J removed R22's soiled dressing and removed gloves. Without washing or sanitizing hands, RN-donned clean gloves. CNA-K opened a container of saline and poured saline on a 2 x 2 gauze pad held by RN-J. RN-J cleansed R22's wound with the saline-soaked gauze. CNA-K again poured saline on a 2 x 2 gauze pad and RN-J continued to cleanse R22's wound. CNA-K then removed gloves. Without washing or sanitizing hands, CNA-K donned clean gloves, opened a 4 x 4 gauze package, and gave the gauze to RN-J. RN-J dried R22's wound with the gauze and removed gloves. Without washing or sanitizing hands, RN-J donned clean gloves, applied barrier cream to R22's reddened wound, and removed gloves. Without washing or sanitizing hands, RN-J donned clean gloves. CNA-K opened an Optifoam dressing and RN-J applied the dressing to R22's wound. RN-J and CNA-K then removed gloves and washed hands. On 12/17/24 at 10:52 AM Surveyor interviewed RN-J and CNA-K who verified they were trained to wash or sanitize hands between glove changes during wound and pericare. RN-J and CNA-K verified they did not wash or sanitize hands between glove changes during wound and pericare for R22. RN-J indicated RN-J knew better and taught infection control to CNAs. 45943 2. From 12/16/24 to 12/18/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including diabetes, neurogenic bladder, multiple sclerosis, and blindness both eyes. R15's MDS assessment, dated 10/15/24, had a BIMS score of 15 out of 15 which indicated R15 was not cognitively impaired. R15 was R15's own decision maker. R15 was on EBP due to a suprapubic catheter. On 12/17/24 at 11:10 AM, Surveyor observed CNA-C complete peri-rectal care for R15. During the observation, CNA-C removed soiled gloves and donned clean gloves without completing hand hygiene. When Surveyor asked CNA-C if CNA-C had washed or sanitized hands between glove changes, CNA-C verified CNA-C did not do so but was aware CNA-C should complete hand hygiene between glove changes. 47248 3. On 12/18/24, Surveyor reviewed R30's medical record. R30 had diagnoses including dysphagia and oropharyngeal-increased difficulties with chewing and swallowing leading to percutaneous endoscopic gastrostomy (PEG) placement (a medical procedure that involves inserting a feeding tube into a patient's stomach through the abdominal wall). R30's MDS assessment, dated 8/22/24, had a BIMS score of 8 out of 15 which indicated R30 had severely impaired cognition. R30 had an activated healthcare decision maker. R30's medical record contained the following tube feeding order: Jevity 1.2 via peg and bolus/syringe goal of 480 (milliliters) (three times daily)-60 ml five times daily. Flush 60 ml before and after. On 12/18/24 at 9:58 AM, Surveyor observed RN-I administer R30's tube feeding. Surveyor noted an EBP sign and a PPE cart outside R30's room. RN-I completed hand hygiene and donned gloves. Surveyor noted RN-I did not don a gown prior to administering the tube feeding. Surveyor observed RN-I administer the tube feeding with gloves and no gown. After RN-I completed the tube feeding and cleansed hands, Surveyor interviewed RN-I who indicated RN-I was not required to wear a gown when administering a tube feeding because there were no bodily fluids involved. On 12/18/24 at 10:10 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the facility's policy and indicated DON-B expects staff to don PPE for residents on EBP prior to administering a tube feeding as well as during wound care and care for indwelling medical devices.

Based on staff and interview and record review, the facility did not ensure 1 resident (R) (R311) of 1 resident received appropriate dialysis care and services. R311 received dialysis services. R311 did not have a dialysis care plan and staff did not complete pre- and post-dialysis assessments. In addition, staff did not assess and monitor R311's fistula site. Findings include: The facility's Long-Term Care Dialysis Collaboration of Care Policy, revised 8/6/24, indicates: Nursing team members will assess residents pre-dialysis, as appropriate, and monitor them post-dialysis, including taking vital signs. From 12/16/24 to 12/18/24, Surveyor reviewed R311's medical record. R311 was admitted to the facility on [DATE] and had diagnoses including end stage renal disease (ESRD) with dependence on renal dialysis. R311's Admission Minimum Data Set (MDS) assessment, dated 12/10/24, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R311 was not cognitively impaired. R311 had an order for hemodialysis every Tuesday, Thursday, and Saturday. In addition, R311 received intravenous (IV) antibiotic therapy at dialysis (dated 12/10/24). Surveyor noted R311's medical record did not contain a care plan for dialysis. Surveyor also noted R311's medical record did not contain documentation that R311's fistula site was assessed by nursing staff. On 12/16/24 at 9:33 AM, Surveyor interviewed R311 who indicated R311 received dialysis three times weekly and IV antibiotic therapy at dialysis. R311 indicated there was good communication with the dialysis center. On 12/18/24 at 8:50 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated nursing staff should document daily on R311's fistula, but were not doing so at that time. DON-B indicated there was no paperwork sent with R311 to dialysis appointments. When Surveyor asked if R311 had a dialysis care plan, DON-B indicated R311 did not have a dialysis care plan. On 12/18/24 at 9:23 AM, Surveyor interviewed Registered Nurse (RN)-D who indicated staff did not do pre- or post-dialysis assessments for residents. RN-D indicated vital signs and a fistula assessment should be done after every dialysis procedure. On 12/18/24 at 9:29 AM, Surveyor reviewed the facility's dialysis policy with DON-B who indicated nursing staff were not following the policy and procedure for dialysis patients. DON-B indicated DON-B expects nursing staff to complete a pre- and post-dialysis assessment for all dialysis patients which includes a full set of vital signs and a fistula assessment on the days they receive dialysis.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R36) of 2 sampled residents reviewed for hospitalization received the required written information of the duration of the bed hold, the reserve bed hold payment rate, and the right of the resident to return to the facility. R36 was transferred to the hospital on 6/8/24. R36's Guardian was not provided a written bed hold notice. Findings include: The facility's Long-Term Care Transfer Notice and Bed Hold Policy, revised 1/15/24, indicates: 1.establishes the standards and processes for residents that transfer to the hospital .2. Prior to transfer to the hospital .team members will provide written information to the resident or their legal representative. b. For Medical Assistance Residents: The bed hold daily rate is automatically paid for by the State of Wisconsin for 15 days. After 15 days, the resident or resident's representative understands it is their responsibility to pay the daily rate to guarantee the bed will be held for their return. If the resident or their representative do not pay the daily rate to have a bed held, they understand that a bed may not be available. If a resident/representative chooses not to pay to have a bed held, the resident may be admitted to the facility to their original room if available or immediately to a semi-private bed as it becomes available if they are eligible for Medicaid nursing facility services or Medicare nursing services. From 12/16/24 to 12/18/24, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including cerebrovascular accident (CVA) (otherwise known as stroke), dysphagia, cognitive impairment, and gastrojejunostomy (GJ) tube (a tube that provides nutrition directly to the stomach and small intestine). R36 was unable to communicate verbally. R36's Minimum Data Set (MDS) assessment, dated 11/27/24, indicated R36 was rarely/never understood. R36 had a Guardian for healthcare decisions. R36's medical record indicated R36 was sent to the emergency room (ER) on 6/8/24 due to nausea, vomiting, and low blood pressure. R36 was diagnosed with hypotension secondary to nausea and vomiting related to hypovolemia (low blood plasma volume). Documentation on 6/8/24 at 9:41 AM indicated R36's Guardian was notified of R36's hospital transfer. R36's medical record did not indicate a written Bed Hold/Transfer notice was provided to R36's Guardian. On 12/18/24 at 11:22 AM, Surveyor interviewed Registered Nurse (RN)-E who indicated if a resident has a change in condition and is transferred to the hospital, nursing staff have the resident sign a Bed Hold/Transfer form that is sent to the hospital with the resident (resident gets a copy). If a resident is unable to sign the form, nursing staff call the resident's family, Power of Attorney for Healthcare (POAHC), or Guardian to obtain verbal consent. If the family, POAHC, or Guardian is nearby, they are asked to come to the facility and sign the form. RN-E was unsure what occurs if a resident's representative is unable to sign the form and indicated the facility's Social Worker may email or send a copy of the Bed Hold/Transfer form. On 12/18/24 at 12:41 PM, Surveyor interviewed Social Worker (SW)-F who confirmed the facility did not have a Bed Hold/Transfer form for R36's 6/8/24 hospital transfer. SW-F was unsure if a Bed Hold/Transfer form is sent with a resident to the hospital. SW-F indicated SW-F emailed nursing staff on 6/10/24 because SW-F was unable to locate a Bed Hold/Transfer form for R36 and did not receive one. SW-F indicated it is nursing staffs' responsibility to inform, obtain a signature, and provide a copy of the Bed Hold/Transfer form to a resident or their representative. SW-F was unsure of the process for ensuring a resident's family, POAHC, or Guardian receives a written copy of the Bed Hold/Transfer form and indicated it may be nursing staffs' responsibility.

Based on staff interview and record review, the facility did not ensure a written transfer notice was provided for 1 resident (R) (R36) of 2 residents reviewed for hospitalization . The facility did not provide R36's Guardian with a written transfer notice or notify the Ombudsman when R36 was transferred to the hospital on 6/8/24. Findings include: The facility's Long-Term Care Transfer Notice and Bed Hold Policy, last revised 1/15/24, indicates: 1.establishes the standards and processes for residents that transfer to the hospital .2. Prior to the hospital .team members will provide written information to the resident or their legal representative. From 12/16/24 to 12/18/24, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including cerebrovascular accident (CVA) (otherwise known as stroke), dysphagia, cognitive impairment, and gastrojejunostomy (GJ) tube (a tube that provides nutrition directly to the stomach and small intestine). R36 was unable to communicate verbally. R36's Minimum Data Set (MDS) assessment, dated 11/27/24, indicated R36 was rarely/never understood. R36 had a Guardian for healthcare decisions. R36's medical record indicated R36 was sent to the emergency room (ER) on 6/8/24 due to nausea, vomiting, and low blood pressure. R36 was diagnosed with hypotension secondary to nausea and vomiting related to hypovolemia (low blood plasma volume). Documentation on 6/8/24 at 9:41 AM indicated R36's Guardian was notified of R36's hospital transfer. On 12/18/24 at 11:22 AM, Surveyor interviewed Registered Nurse (RN)-E who indicated if a resident has a change in condition and is transferred to the hospital, nursing staff have the resident sign a Bed Hold/Transfer form that is sent to the hospital with the resident (resident gets a copy). If a resident is unable to sign the form, staff call the resident's family, Power of Attorney for Healthcare (POAHC), or Guardian and obtain verbal consent. If the family, POAHC, or Guardian are nearby, they are asked to come to the facility and sign the form. RN-E was uncertain what occurs if they are unable to sign and indicated the facility's Social Worker may email or send a copy of the Bed Hold/Transfer form. On 12/18/24 at 12:41 PM, Surveyor interviewed Social Worker (SW)-F who confirmed the facility did not have a Bed Hold/Transfer form for R36's 6/8/24 hospital transfer. In addition, SW-F indicated the facility did not have proof of Ombudsman notification. SW-F was unsure if a Bed Hold/Transfer form is sent with a resident to the hospital. SW-F indicated SW-F emailed nursing staff on 6/10/24 because SW-F was not able to locate a Bed Hold/Transfer form for R36. SW-F indicated the responsibility to inform, obtain a signature, and provide a copy of the form to a resident or their representative is the responsibility of nursing staff. SW-F was unsure of the process for ensuring a resident's representative receives a written copy of the form and indicated nursing may be the responsible party.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 2 residents (R) (R2 and R3) of 5 sampled residents. After a resident-to-resident altercation on 4/23/24, R2 expressed to staff that R2 was fearful of R3. The facility did not thoroughly investigate the incident. Findings include: The facility's Resident Abuse Prevention & Reporting Policy, last revised on 1/9/24, indicates: The purpose of this policy is to outline the standards and processes to ensure: (1) Residents live in a safe environment where they are free from abuse and neglect and are treated with respect and dignity; (2) To be in compliance with state and federal laws and regulations .ThedaCare will protect residents from all forms of abuse .All LTC (long-term care) team members will receive education about how to identify signs and symptoms of abuse and to immediately report any suspicions or allegations of abuse or any other defined misconduct to the Administrator .These signs could include: .h. Making comments that someone hurt them, is mean to them, that they are afraid of someone, or making a request that someone in particular not come in their room .When an incident or suspected incident of abuse or any other defined misconduct is reported, the Administrator, or their designee, will promptly and thoroughly investigate the incident. On 6/5/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and depression with anxiety. R2's Minimum Data Set (MDS) assessment, dated 5/7/24, stated R2's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R2 had little cognitive impairment. R2's medical record indicated R2 was responsible for R2's healthcare decisions. On 6/5/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (commonly known as stoke) which resulted in left-sided paralysis, major depressive disorder, and anxiety. R3's MDS assessment, dated 3/20/24, stated R3's BIMS score was 13 out of 15 which indicated R3 had little cognitive impairment. R3's medical record indicated R3 was responsible for R3's healthcare decisions. R3's medical record contained a nursing note, dated 4/23/24, that indicated: Writer was notified that while R3 visited R2 on a different unit, a Certified Nursing Assistant (CNA) noted R3 was verbally aggressive toward R2. The CNA also reported R3 pushed R2's bed while R2 sat on the side of the bed. R2 reported to the CNA that R3 threw a lighter at R2. Writer spoke to R2 who stated the lighter did not hit R2, but R2 was fearful of R3. The CNA asked R3 to return to R3's unit. R3 complied. R2's medical record did not contain documentation regarding the incident. On 6/5/24, Surveyor reviewed a typed document which indicated: R2 and R3 had an argument on 4/23/24. The nurse on the unit notified NHA-A via email: I need to inform you of an aggressive act that happened on R2's unit. R3 came down to R2's room and stated to R2 that R2 is a cheater. I witnessed R3 push on the bed. I told R3 we don't tolerate aggressive behavior and told R3 to go back to R3's unit. I asked R2 if R3 hit R2. R2 stated R3 threw a lighter in anger, but it did not hit R2. In addition, documents indicated NHA-A interviewed R2 and R3, instructed the Social Worker (SW) to follow up with R2, and updated staff to monitor the situation. The documents did not contain interviews of other residents or staff. On 6/5/24 at 2:16 PM, Surveyor interviewed Director of Nursing (DON)-B who verified a resident expressing fear of another resident constitutes an allegation of abuse which should be thoroughly investigated. DON-B verified a thorough investigation includes interviews of staff and other residents.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the Nursing Home Administrator (NHA) and State Agency (SA) for 2 residents (R) (R2 and R3) of 5 sampled residents. On 4/23/24, R3 and R2 had an altercation. Following the altercation, R2 stated to staff that R2 was fearful of R3. Staff did not report the incident to NHA-A or the SA in a timely manner. Findings include: The facility's Resident Abuse Prevention & Reporting Policy, last revised on 1/9/24, indicates: The purpose of this policy is to outline the standards and processes to ensure: (1) Residents live in a safe environment where they are free from abuse and neglect and are treated with respect and dignity, (2) To be in compliance with state and federal laws and regulations .ThedaCare will protect residents from all forms of abuse .All LTC (long-term care) team members will receive education about how to identify signs and symptoms of abuse and to immediately report any suspicions or allegations of abuse or any other defined misconduct to the Administrator .These signs could include: .h. Making comments that someone hurt them, is mean to them, that they are afraid of someone, or making a request that someone in particular not come in their room .The proper method of reporting is in-person or phone call to assure prompt notification is made .the facility must report the allegations to DQA (Division of Quality Assurance) (SA) no later than twenty-four hours in accordance with state law. On 6/5/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and depression with anxiety. R2's Minimum Data Set (MDS) assessment, dated 5/7/24, stated R2's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R2 had little cognitive impairment. R2's medical record indicated R2 was responsible for R2's healthcare decisions. On 6/5/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (stoke) which resulted in left-sided paralysis, major depressive disorder and anxiety. R3's MDS assessment, dated 3/20/24, stated R3's BIMS score was 13 out of 15 which indicated R3 had little cognitive impairment. R3's medical record indicated R3 was responsible for R3's healthcare decisions. R3's medical record contained a nursing note, dated 4/23/24, that indicated: Writer was notified that while R3 was visiting R2 on a different unit, a Certified Nursing Assistant (CNA) noted R3 was verbally aggressive toward R2. The CNA also reported R3 pushed R2's bed while R2 sat on the side of the bed. R2 reported to the CNA that R3 threw a lighter at R2. Writer spoke to R2 who stated the lighter did not hit R2, but R2 was fearful of R3. The CNA asked R3 to return to R3's unit. R3 complied. R2's medical record did not contain documentation regarding the incident. On 6/5/24, Surveyor reviewed a document provided by the facility that indicated: R2 and R3 had an argument on 4/23. A nurse on the unit notified NHA-A via email: I need to inform you of an aggressive act that happened on R2's unit. R3 came down to R2's room and stated to R2 that R2 was a cheater. I witnessed R3 push on the bed. I told R3 we don't tolerate aggressive behavior and told R3 to go back to R3's unit. I asked R2 if R3 hit R2. R2 stated R3 threw a lighter in anger, but it did not hit R2. On 6/5/24 at 2:16 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should have reported the above incident to NHA-A immediately and stated, Absolutely should have been a phone call. DON-B verified a resident expressing fear of another resident constitutes an allegation of abuse which should be reported to the SA. DON-B verified the email the nurse sent to NHA-A did not mention fear expressed by R2.

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 49 out of 50 residents residing in the facility (one resident received nutrition via tube feeding). The facility did not monitor and document food cooling temperatures. The facility did not have a practice to ensure opened time/temperature control foods were labeled with open and use-by dates. The facility did not store food in a manner that protected it from contamination. Findings include: On [DATE], Dietary Manager (DM)-D indicated the facility follows the Wisconsin Food Code as their standard of practice. 1. Food Cooling Temperature Requirement 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 section ,d+[DATE].15 documents 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. During an initial tour of the kitchen on [DATE] at 8:30 AM with Cook (CK)-E, Surveyor observed the walk-in cooler and freezer which contained several food items that were cooked and labeled with use or use-by dates. Surveyor interviewed CK-E who indicated the facility keeps leftovers. CK-E stated items are pre-made for future meals and stored in the freezer. CK-E indicated the steam table containers in the freezer labeled meatloaf [DATE] were made last week, labeled, and stored in the freezer until use on the date indicated on the container. During a continuous kitchen observation on [DATE] at 10:15 AM, Surveyor interviewed DM-D who indicated the facility cooks meals a couple of days in advance, cools the food and puts the food in the freezer. DM-D verified the facility also keeps leftovers from meal service in the cooler and freezer. DM-D indicated DM-D would look for a cooling log that documents food pre-made for future meals or food kept from meal service as leftovers. During a continuous kitchen observation on [DATE] at 2:21 PM, DM-D provided Surveyor with a document titled Temperature chart central kitchen, dated [DATE], that indicated on the bottom cooling to go to freezer product: meatloaf, date: ,d+[DATE], starting time 5:00, ending time 6:30, on ice in shotgun pans. DM-D indicated there were no other cooling logs for pre-cooked foods and leftovers and confirmed the start and end temperatures of the meatloaf were not documented to indicate the meatloaf was cooled safely within a 2-hour time frame. DM-D verified the facility does not have a log to monitor and document consistent time and temperatures of foods that are cooked, cooled, and stored for future use. 2. Open/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 5C (41F) 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. On [DATE] at 11:46 AM and on [DATE] at 9:00 AM, Surveyor observed the kitchenette on the Rosewood unit and noted 3 [NAME] brand ready care thickened honey consistency water containers. Directions on the containers indicated it was acceptable to use the product for up to seven days after opening. Surveyor observed the following containers: one container of lemonade with an open date of [DATE] and a use-by date of [DATE], one container of cranberry cocktail with an open date of [DATE] and no use-by date, and one open container of lemon-flavored water with a received date of [DATE] and no open or use-by dates. On [DATE] at 2:21 PM, Surveyor interviewed DM-D who confirmed the kitchenettes contained food and drinks not labeled with open or use-by dates. DM-D indicated the issue was discussed during morning meetings to ensure staff label food in the kitchenettes; however, DM-D acknowledged food and drinks are still not labeled and a system was not put in place to ensure food and drinks that are expired or without open and use-by dates are discarded and not served to residents. 3. Food Storage The Wisconsin Food Code 2022 documents at ,d+[DATE].11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (centimeters) (6 inches) above the floor. (B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under S ,d+[DATE].122. During an initial tour of the kitchen with CK-E on [DATE], Surveyor observed boxes of frozen foods stored on the floor of the freezer. Surveyor noted the first row of the freezer on the left-hand side contained one box labeled seafood that was opened and on its side. Surveyor observed two other boxes labeled seafood, two boxes labeled cheese pizza and two boxes labeled sliced strawberry on the floor of the freezer. Surveyor also observed fourteen stacked boxes of frozen vegetables and food products on the floor on the left-hand side of the freezer and six boxes of frozen vegetables stacked on top of each other on the floor on the right-hand side of the freezer. CK-E indicated food is delivered to the facility on Tuesdays and Fridays. During a continuous kitchen observation on [DATE] at 10:15 AM, Surveyor and DM-D verified the items mentioned above were still on the freezer floor. DM-D indicated the freezer contained more boxes stacked on the floor due to the food delivery on [DATE]. DM-D verified the boxes Surveyor observed on [DATE] were delivered on [DATE] and remained on the floor of the freezer since that date. DM-D indicated staff have been on vacation which makes scheduling difficult. DM-D acknowledged food should not be stored on the floor to prevent contamination.

Based on staff interview and record review, the facility did not ensure a legal representative was informed in advance or provided updated consents outlining the risks and benefits of prescribed psychotropic medications for 1 Resident (R) (R10) of 5 sampled residents. R10 was prescribed Seroquel (an antipsychotic medication), Effexor (an antidepressant medication), Wellbutrin (an antidepressant medication), Zyprexa (an antipsychotic medication) and lorazepam (a sedative/benzodiazapine medication). The facility did not obtain consent or updated consent forms for the medications. Findings include: The Food and Drug Administration (FDA) (fda.gov) documents, a boxed warning .is also commonly referred to as a black box warning. It appears on a prescription drug's label and is designed to call attention to serious or life-threatening risks. The Wisconsin Department of Health Services (DHS) (dhs.wisconsin.gov) documents, A boxed warning, also known as a black box warning, or a black label warning is named for the border surrounding the text of the warning that appears on the package insert, label, and other literature describing the medication (e.g., magazine advertising). It is the most serious medication warning required by the FDA. All antipsychotics and antidepressants along with many other psychotropic medications have a black box warning. On 9/12/23, Surveyor reviewed R10's medical record. R10 had diagnoses including late onset Alzheimer's disease with dementia, depression, and anxiety. R10 had an activated Power of Attorney (POA) for healthcare decision making. R10 was admitted to the facility on [DATE] and had physician orders for Wellbutrin (bupropion) XL 150 mg (milligrams) daily, Seroquel (quetiapine) 100 mg at bedtime and 25 mg BID (twice daily), and Effexor (venlafaxine) 100 mg BID and 50 mg at noon. On 5/26/23, R10 was prescribed lorazepam .5 mg twice daily PRN (as needed). On 7/28/23, R10 was prescribed Zyprexa (olanzapine) 5 mg daily. R10's medical record contained informed consent for medication forms for Wellbutrin, Seroquel and Effexor, dated 5/16/23, that documented verbal consent (R10's POA's name). R10's medical record did not contain informed consent for medication forms for lorazepam or Zyprexa. On 9/12/23 at 10:45 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R10's POA is pretty unresponsive regarding follow through with signing documents and returning calls related to R10's medical care. Surveyor requested informed consent for medication forms for R10's Wellbutrin, Seroquel, Effexor and Zyprexa as well as discontinued medication lorazepam. On 9/13/23, Surveyor reviewed R10's medical record and noted R10's monthly pharmacy reviews documented the following: A Pharmacy review, dated 5/15/23, indicated Informed consent (IC) for three medications. Medications listed on the pharmacy review were Seroquel 50 mg, Effexor 100 mg TID (three times daily), and bupropion XL 150 mg QID (four times daily). The Pharmacy review indicated informed consent was required for lorazepam PRN. A Pharmacy review, dated 7/11/23, indicated IC!! Medications listed on the pharmacy review were Seroquel 50 mg, Effexor 100 mg BID, bupropion XL 150 mg QID, olanzapine every AM, and lorazepam .5 mg BID. A Pharmacy review, dated 8/14/23, indicated IC third time. Medications listed on the pharmacy review were Seroquel 50 mg, Effexor 100 mg BID, bupropion XL 150 mg QID, and olanzapine every AM. A Pharmacy review, dated 9/12/23, indicated IC not complete or signed, Olanzapine missing. Medications listed on the pharmacy review were Seroquel 50 mg, Effexor 100 mg BID, bupropion XL 150 mg QD, and olanzapine every AM. A progress note, dated 6/19/23, indicated: Case review today with medication management team. (R10) has persistent and regular calling out and shouting and great difficulty redirecting this despite current medical regimen of bupropion XL 150 mg daily, venlafaxine three times daily, quetiapine 25 mg daily and scheduled lorazepam .5 mg three times daily .increase lorazepam to 1 mg daily at 2 PM, and .5 mg morning and night. Extend this order for 45 days .Continue current orders for bupropion, quetiapine, and venlafaxine .Next review 11/20/23. On 9/13/23 at 7:42 AM, Surveyor interviewed DON-B regarding informed consent for medication forms for R10. DON-B indicated verbal consents were obtained due to R10's POA being unresponsive at times. DON-B indicated R10's lorazepam and olanzapine were added after admission and DON-B would provide informed consents to Surveyor for all antidepressant and psychotropic medications prescribed to R10 from admission to the present. On 9/13/23 at 12:30 PM, Surveyor received informed consent for medications prescribed to R10 by Clinical Director (CD)-C. Surveyor reviewed the consents and noted informed consent for medication forms for Wellbutrin, Seroquel and Effexor, dated 5/16/23, documented verbal consent (R10's POA's name). Surveyor was not provided informed consent for medication forms for lorazepam or Zyprexa. Surveyor interviewed CD-C who indicated CD-C provided Surveyor with the only informed consents the facility had for R10. CD-C indicated lorazepam was given to R10 for a few months and was discontinued. CD-C verified the facility did not have an informed consent for medication form for lorazepam and did not have signed consent forms for Wellbutrin, Seroquel and Effexor. On 9/13/23 at 12:45 PM, Surveyor interviewed DON-B who verified the informed consents were not obtained for R10 because, despite several attempts, R10's POA was difficult to reach. Surveyor requested documentation of attempts to reach R10's POA regarding education provided on the risks and benefits of the prescribed medications and consent for the medications. On 9/13/23 at 1:15 PM, Surveyor reviewed documentation provided by DON-B regarding attempts to reach R10's POA and noted the following: A progress note, dated 5/11/23, indicated Social Worker (SW)-F called R10's POA regarding activation of R10's POA. The note indicated SW-F was unable to reach R10's POA. A voicemail was left for R10's POA and another relative. A progress note, dated 7/5/23, indicated SW-F spoke with R10's POA regarding clothing. R10's POA was unable to come to the facility due to transportation issues. The note did not indicate R10's POA was educated on the risks and benefits of R10's prescribed medications or asked to sign consent forms. A progress note dated, 7/11/23, indicated SW-F spoke with R10's POA regarding R10's continued behavioral struggles. R10's POA indicated they would visit R10 in the next few days. The note did not indicate R10's POA was educated on the risks and benefits of R10's prescribed medications or asked to sign consent forms. Progress notes, dated 7/4/23, 8/2/23, 8/16/23, 8/31/23, and 9/12/23, indicated voicemails were left for R10's POA regarding updates on behavioral concerns, a fall, discharge plans, and therapy options. The notes did not indicate R10's POA was educated on the risks and benefits of R10's prescribed medications or asked to sign consent forms.

Based on record review and staff interview, the services provided by the facility for 1 (resident #1) of 1 sampled residents that presented with foot wounds met professional standards of quality. Resident #1 presented with a right foot wound. When resident #1's foot wound condition deteriorated, staff did not assess/document the wound per the current standard of practice. Resident #1 developed gangrene and was diagnosed with [REDACTED].#1 underwent a partial amputation of the right foot. As a result of the facility's actions, this posed an Immediate Jeopardy situation that began on 02/21/13. The facility was formally notified on March 22, 2013. The facility removed the jeopardy on 3/25/13 and corrected the deficient practice on 3/26/13. Findings include: According to Chapter N6, "Standards of Practice for Registered Nurses and Licensed Practical Nurses", an RN (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: A) Assessment-- Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. B) Planning-- Planning is the developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. C) Intervention-- Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts as delegated to LPN's (Licensed Practical Nurse) or less skilled assistants. E) Evaluation-- Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to the "Wound Care Education Institute", copyright 2011, wound care documentation should include: ? Type of wound ? Staging or classification of wound ? Correct anatomical location ? Measurements in centimeters (include depth) ? Wound base tissue-slough, eschar, granulation, [MEDICATION NAME]; document percentage of tissue noted in wound bed ? Symptoms of infection ? Drainage ? Odor ? Tunneling/Undermining ? Wound edges- curled, calloused, macerated, detached ? Peri-wound- Intact, scaly, induration, [MEDICAL CONDITION], redness , warmth, color ? Pain ? Treatment ? Any procedures performed and responses ? Adverse reactions to care provided should include-record each phone call to or from a physician, including the exact time, message and response and any interventions implemented to change treatment and outcomes ? Any wound specific charting ? Worsening of any wound According to webmd.com, gangrene is a condition that occurs when body tissue dies. It is caused by a loss of blood supply due to an underlying illness, injury and/or infection. There are different types of gangrene and all require immediate medical attention. According to webmd.com, [DIAGNOSES REDACTED] (flesh-eating bacteria) is an infection caused by bacteria. It can destroy skin, fat, and the tissue covering the muscles within a very short time. The risk of getting this infection is higher if the patient uses steroids, which can lower the body's resistance to infection. A patient can get [DIAGNOSES REDACTED] when bacteria enters a wound. Early treatment of [REDACTED]. On 3/19/13, surveyor # reviewed resident #1's medical record. According to the hospital discharge summary dated 1/24/13, resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted with orders to receive a tapering dose of [MEDICATION NAME] (a corticosteroid medication which causes immunosuppresion) and on day 6 after admission, was stated on a daily dose of 2.5 mg (milligrams) of [MEDICATION NAME]. Nurses' notes dated 1/24/13 at 9:48 p.m. indicated resident #1 had small scratch like abrasions noted on the bilateral inner feet. [MEDICATION NAME] dressing present to the top of the right foot. Small area noted that is weeping fluid. A Weekly Wound Tracking Form was initiated for resident #1 on 1/29/13, for bilateral feet. The form indicated it was initiated due to weeping [MEDICAL CONDITION] and no pressure. The form documents the following: * 1/29/13- right foot dorsum: 1.6 X 5.9 with a depth of 0.4 (crater). Treatment indicated non-adhering gauze wrap with gauze. * 2/07/13-right foot dorsum: 1.0 X 5.4 (same treatment) * 2/12/13-right dorsum: 3.8 X 5.0 (decrease depth with less [MEDICAL CONDITION]) Treatment indicated the area was cleansed with normal saline, covered with gauze dressing and wrapped with gauze. * 2/19/13-right dorsum: 3.7 X 4.4 with 2 dark (no continuation of documentation). Treatment indicated the area was cleansed with normal saline covered with non-adherent gauze dressing and wrapped with gauze. Below all of the above documentation on the form, an undated written note indicated the MD (Medical Doctor) was updated and request for Santyl ([MEDICATION NAME] medication) on right dorsum. The Weekly Wound Tracking Form did not include documentation of a unit of measurement of the wounds, nor had the tracking form consistently assessed/documented depth. The Weekly Wound Tracking form did not include documented assessments of drainage, odor, wound base, tunneling/undermining, pain or periwound. Nurses' notes indicated the following Wound IDT (Interdisciplinary Team) notes: * 1/30/13 at 9:14 a.m. for 1/29/13: right foot dorsum open wound (crater) measuring 6.0 cm (centimeters) X 3.0 cm with a 0.4 depth. Cleansed with normal saline, covered with non-adherent dressing, then gauze dressing and wrapped with gauze. * 2/7/13 at 2:02 p.m.: resident has several open areas on both feet due to weeping [MEDICAL CONDITION] ....right foot- 1.0 cm X 5.4 cm with a crater of 0.3 cm. * 2/14/13 at 9:52 a.m.: right foot dorsum wound crater shaped and has less depth; measures 3.8 cm X 5.0 cm. Weekly skin check dated 2/13/13 at 11:36 p.m. in the nurses' notes that indicated the top of right foot wound draining moderate amount of greenish drainage. Sloughy area to right foot seafoam green in color...Message left for wound care team to assess the foot wound. The wound care team note had not addressed the slough. * 2/20/13 at 12:10 p.m. for 2/19/13: right foot dorsum wound measures 3.7 cm X 4.4 cm with <0.1 cm depth, now has slough and 2 discolored areas. MD updated with request for Santyl to wound, covered with gauze and wrapped with gauze changing dressing twice daily until healed. The Wound IDT documentation that was located in resident #1's nurses' notes had not contained an assessment regarding drainage, odor, wound base, tunneling/undermining, pain and periwound. The IDT notes did not document percentage of slough or location of slough and did not document specific assessments of the 2 discolored areas that were observed on the right dorsum on 2/19/13. On 3/19/13 at 3:00 p.m., surveyor # interviewed RN-K regarding documentation of resident #1's wounds. RN-K verified she had completed the Wound IDT documentation as reviewed. RN-K stated she wasn't a certified wound nurse. RN-K stated the assessment of resident #1's foot on 2/19/13 indicated that the resident's foot did not have redness and there was an open area in the center of the right dorsum of the foot. RN-K stated she recalled the two additional discolored areas that were discovered on 2/19/13 to the right dorsum, but could not recall any specifics regarding them. Nurses' notes dated 2/21/13 at 9:58 p.m., indicated moderate amount of drainage and slough noted to right foot. Area cleaned with normal saline, slough removed. Santyl applied to open area on the right foot....9:08 p.m.: right foot is reddened, especially the second, third, and fourth digits. Patient c/o (complained of) soreness in the foot. Will continue to monitor and update MD as necessary. On 3/19/13 at 1:40 p.m., surveyor # conducted a telephone interview with LPN (Licensed Practical Nurse)-A regarding the documentation of the right foot wound on 2/21/13. LPN-A verified she had completed the documentation and stated when she had first observed resident #1's right foot wound (could not recall when), the foot had some redness, was very [MEDICAL CONDITION] and was weeping clear fluid. LPN-A indicated when she observed resident #1's foot on 2/21/13, resident #1's foot was darker red in color and resident #1 had never complained of pain to the right foot before. LPN-A stated there was no drainage, [MEDICAL CONDITION] or foul odor when observed on 2/21/13. Nurses' notes dated 2/22/23 at 9:17 p.m., indicated there were open areas to the top of resident #1's feet. One is large and has a moderate amount of serosanguious drainage. Also has an open area on the medial side of his foot and it had bloody drainage. There is another small area of breakdown and a small amount of bloody drainage on the lateral aspect of the foot. There was a foul odor....did have dorsal pedal pulses assessed by the RN, however, pedal pulses were hard to feel due to patient's foot shaking. On 3/19/13 at 2:00 p.m., surveyor # conducted a telephone interview with LPN-B regarding the documentation on 2/22/13. LPN-B verified the documentation of resident #1's right foot. LPN-B stated she was a casual call employee of the facility and 2/22/13 was the first time she had ever worked with resident #1. LPN-B verified the documentation on 2/22/13 was as she had observed. LPN-B indicated there was a foul odor noted when she removed the old dressing. LPN-B stated she went and asked RN-C to assess resident #1's foot and indicated RN-C had assessed the foot and checked for pulses and indicated she would pass the assessment on to the day shift staff. Resident #1's medical record did not have documentation of an RN assessment of the resident's right foot on 2/22/13. On 3/19/13 at 2:30 p.m., surveyor # interviewed RN-C regarding the assessment which was completed on 2/22/13 of resident #1's right foot. RN-C verified she was the RN that LPN-B had requested an RN assessment of resident #1's right foot wound. RN-C stated she had never observed resident #1's foot prior to that evening and indicated resident #1's right foot had 3 open areas on the foot. RN-C stated there was an open area on the medial area of the foot that was black, and one open area each on the lateral foot and between the toes as LPN-B had documented. RN-C indicated resident #1's right foot had to have been swollen, but she could not recall specifically. RN-C stated there was no gross bleeding of the foot wounds, but recalled there was bloody drainage on the old dressing. RN-C verified she also had noted a foul odor when she was close to the right foot wound. RN-C stated she had checked for pulses but could not state for sure if pedal pulses were present, as resident #1's foot was shaking. RN-C indicated she had looked in resident #1's medical record for previous assessments of the right foot, but the documentation was not real good, so she was unaware if the condition was a change. RN-C stated she was aware that resident #1 had foot concerns, but wasn't sure if the condition of the right foot had deteriorated. RN-C indicated the night nurse was also present when the foot was assessed, and the decision was made to pass the assessment to the day shift, as they were more familiar with the condition of resident #1's foot. RN-C indicated she could not recall if resident #1 had complaints of right foot pain. RN-C verified she did not document an assessment of resident #1's right foot wound in the medical record. There was no assessment/documentation of resident #1's right foot in the resident's medical record for the night shift of 2/22/13 into 2/23/13. Nurses' notes dated 2/23/13 at 11:36 a.m., (written by a nursing school instructor) indicated: "Complaining of right foot pain, rates as 8 out of 10, throbbing, going on for the past two weeks, unable to palpate dorsalis pedis or post tibial pulse, used doppler with detection of dorsalis pedis pulse. Right foot warm to touch, redness to dorsal area extending from all toes to mid foot, purple discoloration to base of all toes, 3+ [MEDICAL CONDITION]. Right foot wound: 1.) Grade 1 ulcer to dorsal area from base of metatarsals with purulent yellow drainage measuring 4.5 X 5.0 cm, collected culture from top of right foot. 2.) Lesion to area between great toe and 2nd toe with foul odor drainage and Grade 3-4 ulceration extending down pedal side 5 cm and laterally to metatarsal of great toe, dark in color with skin laceration on the medial side, minimal sanguineous drainage, very painful to manipulation. 3.) Lateral wound grade 0 with redness measuring 2 X 1 cm. Patient wound not allow me to probe the area between his toes on the right foot due to the pain. Notified unit nurses LPN-D and RN-E". Nurses' notes dated 2/23/13 at 2:00 p.m., indicated writer went in to assess patient's feet this AM before breakfast. Right foot red, warm and painful rated a 6-7 this AM....2-3+ [MEDICAL CONDITION] to the right foot, foul smelling. See notes from 2/23 11:36 a.m. for details. Call placed to MD updated on foot and pain. Patient has not had this much pain in the foot. Foot is red from toes to below ankles. Dr. (Doctor) office called back at 12:30 p.m. and stated to send to ER (emergency room ) for proper evaluation and treatment....PCP (Primary Care Physician) happened to be in the building at 1345 (1:45 p.m.)and was updated that patient will be sent to the ER. On 3/19/13 at 5:00 p.m. and on 3/20/13 at 5:00 p.m., surveyor # conducted a telephone interview with LPN-D regarding the documentation contained in resident #1's medical record on 2/23/13. LPN-D stated she got report from the night shift regarding complaints of pain to the right foot, and to her knowledge, resident #1 had not complained of pain prior. LPN-D indicated she went and observed resident #1's right foot and the right foot was red, warm, painful and had foul odor when the dressing was removed. LPN-D indicated most of resident #1's top, medial and lateral foot was reddened and they were not red prior. LPN-D stated she had called the MD's office but could not recall what time, but indicated she had observed resident #1's foot sometime between 7:00 a.m. and 8:00 a.m. and stated the nursing school instructor had assessed the foot also. LPN-D stated she had told the physician's office that resident #1 had complained of severe pain and had no complaints prior, the foot was red, and there was a foul odor and this was a change in condition for resident #1. LPN-D indicated she thought resident #1 should be seen by a physician. LPN-D stated the office nurse indicated she would update the on call physician and return the call to the facility. LPN-D stated resident #1's right foot looked like there possibly could have been an infection. LPN-D indicated she could not recall when she had called the physician's office or when the physician's office had returned the call with orders to send resident #1 to the hospital for evaluation. LPN-D stated she also had updated RN-E regarding her observation of resident #1's foot, but was unaware if RN-E assessed resident #1's right foot. LPN-D stated when the nursing school instructor had informed her of her assessment, LPN-D indicated she had already called the physician's office. LPN-D stated after RN-E was informed of resident #1's right foot, she had not gotten involved or inquired about the status of resident #1. On 3/20/13 at 8:00 a.m., surveyor # interviewed RN-E regarding the condition of resident #1's right foot on 2/23/13. RN-E verified she was the RN which had become involved. RN-E indicated LPN-D had not updated her regarding the condition of resident #1's foot prior to the nursing school instructor requesting her also to assess the foot. RN-E stated the nursing school instructor had come to her between 9:00 a.m. and 10:00 a.m. requesting that she also assess resident #1's right foot. RN-E stated there were concerns about the foot and the physician needed to be contacted. RN-E verified she did not update the physician as she knew the nursing school instructor would follow up with the LPN and the physician. RN-E stated she could not specifically recall what the condition of resident #1's foot was at that time. RN-E verified she hadn't documented an assessment of resident #1's right foot because the nursing school instructor was there and she already was working with the LPN, and she was confident the nursing school instructor would take care of it as far as getting the physician notified. When asked if it was the nursing school instructor's responsibility to document the assessment and call the physician, RN-E replied she (RN-E) guessed she was ultimately responsible, as the nursing school instructor was not an employee of the facility. RN-E indicated she thought the situation was not grave, as when she entered resident #1's room, resident #1 was observed to have been sitting up and awake. RN-E verified she had not reviewed resident #1's medical record to assess if there had been a change in condition of resident #1's right foot. On 3/20/13, surveyor # reviewed the undated IRF ("Interagency Referral Form") that was completed by RN-F. The IRF indicated resident #1 was being transferred to the hospital because of increase pain, swelling and warmth of the right foot. There was redness from toes to below the ankle and foul smelling. On 3/20/13 at 12:00 p.m., surveyor # interviewed RN-F regarding the IRF document. RN-F stated she had not assessed resident #1's foot, and she completed the documentation to assist another nurse in the transfer to the hospital and was told what to write. RN-F stated she came to work on 2/23/13 at 2:00 p.m. and immediately assisted with the transfer. RN-F indicated resident #1 left the facility between 2:00 p.m. and 2:30 p.m. and a family member had transported. On 3/20/13, surveyor # reviewed the facility's 24 hour shift report from 2/19/13 through 2/23/13. The 24 hour shift report from 2/19/13 through 2/21/13 did not include documentation regarding the condition of resident #1's right foot. On 2/22/13, the 24 hour shift report indicated "Santyl right foot, looks red, update MD-G". The 24 hour shift report did not include documentation regarding the condition of resident 1's right foot for 2/23/13. On 3/20/13, surveyor # reviewed the ER report dated 2/23/13 which was documented by MD-I. The ER report indicated resident #1's right foot has a large necrotic ulcer on the medial aspect of the right foot near the MCP (metacarpophalangeal) joint and is weeping and malodorous with redness extending up into the foot. The redness does not extend proximal to the foot. The left foot shows a healing ulcer over the left lateral mid foot. Patient was given a dose of [MEDICATION NAME] (an antibiotic) intravenously. The patient will need to be admitted . On 3/20/13 at 12:10 p.m., surveyor # conducted a telephone interview with MD-I. MD-I verified he was the ER physician that had assessed resident #1 on 2/23/13. MD-I stated he reviewed the medical record and specifically recalled resident #1. MD-I indicated resident #1 presented to the ER with a large, draining, foul smelling ulcer to the right foot. MD-I indicated by the condition of the foot, the condition had to have been smoldering for days and staff at the facility should have recognized the concern earlier that 2/23/13. MD-I stated the drainage of the right foot was clear serous fluid, but indicated this type of fluid often associated with an infection. MD-I stated a physician should have been notified or minimally seen at the facility when resident #1 presented with pain, redness and change of color. MD-I stated resident #1 would have benefited from treatment if would have been seen earlier by a physician. On 3/20/13, surveyor # reviewed the "Teaching H & P" (history and physical) dated 2/23/13. The H&P indicated "Now comes in for left foot [MEDICAL CONDITION], fluctuant swelling and gangrene. Findings: Barely palpable dorsalis pedis. Fluctuant swelling with pus drainage from plantar aspect of left foot. Overlying gangrene and foul smelling discharge". (Question accuracy of "left" foot as operative report and ER report indicated right foot). The "Operative Report", dated 2/25/13 indicated preoperative [DIAGNOSES REDACTED]. The Postoperative [DIAGNOSES REDACTED]. The procedure indicated incision and drainage with removal of all nonviable tissue and bone. This included exploration and drainage of the deep plantar space of the right foot and removal of all five metatarsals on the right side. The History and Physical Podiatry Surgery Consultation, dated 2/26/13, indicated resident #1's WBC (white blood cell) count was 25.1, hemoglobin was 8.0 and hematocrit was 24.9 at the time of admission and was currently receiving blood. On 3/21/13 at 9:53 a.m., surveyor # conducted a telephone interview with CPS (Certified Podiatric MD and Surgeon)-L regarding resident #1's right foot. CPS-L stated the severity of resident #1's right foot infection was severe and the infection was a fast growing infection. Surveyor # updated CPS-L regarding resident #1's medical documentation and staff interviews of 2/21/13 & 2/22/13 when the right foot condition began to deteriorate. CPS-L stated the nurses should have notified a physician when the deterioration was first observed. CPS-L stated if resident #1 would have been seen by a physician 48 hours earlier, resident #1 probably would not had needed to have his foot amputated. The facility removed the immediate jeopardy on 3/25/13. The removal plan and subsequent actions of the facility was detailed and intertwined for F157, F281 and F309. This included revision of Notification for Physician practices with emphasis on change of condition, LPN role in identification of significant changes of condition, audits for wound care documentation and extensive Quality Assurance activities to serve as checks and balances as a result of a root cause analysis and developed plans. Education for all staff began on 3/25/13 and concluded on 3/26/13 with modifications to new staff orientation for any new staff coming to the facility after 3/26/13.

Based on record review and staff interview, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care 1 (resident #1) of 1 sampled residents that presented with foot wounds. Resident #1 presented with a right foot wound. When the condition of resident #1's foot wounds deteriorated, staff did not assess/document the wound per the standard of practice, and did not notify the physician regarding the deterioration of the right foot wound. Resident #1 did not receive the necessary care and services at the facility which resulted in resident #1 developing gangrene and being diagnosed with [REDACTED].#1 needed to undergo a partial amputation of the right foot. As a result of the facility's actions, this posed an Immediate Jeopardy situation that began on 02/21/13. The facility was formally notified on March 22, 2013 and a removal plan was received the night of March 22, 2013 that was accepted. The immediate jeopardy was removed on 3/25/13 and the deficient practice corrected on 3/26/13. Findings include: The facility's policy and procedure titled, "Notification of Physician (Change in Condition)", revised 1/5/2010, indicated the purpose of this procedure is to ensure that physicians and/or professional care providers are provided information in a timely manner regarding the patient's condition. When there is a sudden change of condition, the nursing home nurse is responsible to perform a complete assessment of vital signs and of the basic problem, and notify the physician. If the physician is not available, the medical director must be notified. If the medical director cannot be reached, then 911 must be called. Procedure: The following are examples of times when the physician must be immediately notified: a change in condition. According to the "Wound Care Education Institute", copyright 2011, wound care documentation should include: ? Type of wound ? Staging or classification of wound ? Correct anatomical location ? Measurements in centimeters (include depth) ? Wound base tissue-slough, eschar, granulation, [MEDICATION NAME]; document percentage of tissue noted in wound bed ? Symptoms of infection ? Drainage ? Odor ? Tunneling/Undermining ? Wound edges- curled, calloused, macerated, detached ? Peri-wound- Intact, scaly, induration, [MEDICAL CONDITION], redness , warmth, color ? Pain ? Treatment ? Any procedures performed and responses ? Adverse reactions to care provided should include-record each phone call to or from a physician, including the exact time, message and response and any interventions implemented to change treatment and outcomes ? Any wound specific charting ? Worsening of any wound According to webmd.com, gangrene is a condition that occurs when body tissue dies. It is caused by a loss of blood supply due to an underlying illness, injury and/or infection. There are different types of gangrene and all require immediate medical attention. According to webmd.com, [DIAGNOSES REDACTED] (flesh-eating bacteria) is an infection caused by bacteria. It can destroy skin, fat, and the tissue covering the muscles within a very short time. The risk of getting this infection is higher if the patient uses steroids, which can lower the body's resistance to infection. A patient can get [DIAGNOSES REDACTED] when bacteria enters a wound. Early treatment of [REDACTED]. On 3/19/13, surveyor # reviewed resident #1's medical record. According to the hospital discharge summary, dated 1/24/13, resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted with orders to have been administered a tapering dose of [MEDICATION NAME] (a corticosteroid medication which causes immunosuppresion) and on day 6, after admission, to have begun a daily dose of 2.5 mg (milligrams)of [MEDICATION NAME]. Nurses' notes dated 1/24/13 at 9:48 p.m. indicated small scratch like abrasions noted on the bilateral inner feet. [MEDICATION NAME] dressing present to the top of the right foot. Small area noted that is weeping fluid. A Weekly Wound Tracking Form was initiated for resident #1 on 1/29/13, for bilateral feet. The form indicated it was initiated due to weeping [MEDICAL CONDITION] and no pressure. The form documents the following: * 1/29/13- right foot dorsum: 1.6 X 5.9 with a depth of 0.4 (crater). Treatment indicated non-adhering gauze wrap with gauze. * 2/07/13-right foot dorsum: 1.0 X 5.4 (same treatment) * 2/12/13-right dorsum: 3.8 X 5.0 (decrease depth with less [MEDICAL CONDITION]) Treatment indicated the area was cleansed with normal saline, covered with gauze dressing and wrapped with gauze. * 2/19/13-right dorsum: 3.7 X 4.4 with 2 dark (no continuation of documentation). Treatment indicated the area was cleansed with normal saline covered with non-adherent gauze dressing and wrapped with gauze. Below all of the above documentation on the form, an undated written note indicated the MD (Medical Doctor) was updated and request for Santyl ([MEDICATION NAME] medication) on right dorsum. The Weekly Wound Tracking Form did not include documentation of a unit of measurement of the wounds, nor had the tracking form consistently assessed/documented depth. The Weekly Wound Tracking form did not include documented assessments of drainage, odor, wound base, tunneling/undermining, pain or periwound. Nurses' notes indicated the following Wound IDT (Interdisciplinary Team) notes: * 1/30/13 at 9:14 a.m. for 1/29/13: right foot dorsum open wound (crater) measuring 6.0 cm (centimeters) X 3.0 cm with a 0.4 depth. Cleansed with normal saline, covered with non-adherent dressing, then gauze dressing and wrapped with gauze. * 2/7/13 at 2:02 p.m.: resident has several open areas on both feet due to weeping [MEDICAL CONDITION] ....right foot- 1.0 cm X 5.4 cm with a crater of 0.3 cm. * 2/14/13 at 9:52 a.m.: right foot dorsum wound crater shaped and has less depth; measures 3.8 cm X 5.0 cm. Weekly skin check dated 2/13/13 at 11:36 p.m. in the nurses' notes that indicated the top of right foot wound draining moderate amount of greenish drainage. Sloughy area to right foot seafoam green in color...Message left for wound care team to assess the foot wound. The wound care team note had not addressed the slough. * 2/20/13 at 12:10 p.m. for 2/19/13: right foot dorsum wound measures 3.7 cm X 4.4 cm with <0.1 cm depth, now has slough and 2 discolored areas. MD updated with request for Santyl to wound, covered with gauze and wrapped with gauze changing dressing twice daily until healed. The Wound IDT documentation that was located in resident #1's nurses' notes had not contained an assessment regarding drainage, odor, wound base, tunneling/undermining, pain and periwound. The IDT notes did not document percentage of slough or location of slough and did not document specific assessments of the 2 discolored areas that were observed on the right dorsum on 2/19/13. On 3/19/13 at 3:00 p.m., surveyor # interviewed RN-K regarding documentation of resident #1's wounds. RN-K verified she had completed the Wound IDT documentation as reviewed. RN-K stated she wasn't a certified wound nurse. RN-K stated the assessment of resident #1's foot on 2/19/13 indicated that the resident's foot did not have redness and there was an open area in the center of the right dorsum of the foot. RN-K stated she recalled the two additional discolored areas that were discovered on 2/19/13 to the right dorsum, but could not recall any specifics regarding them. Nurses' notes dated 2/21/13 at 9:58 p.m., indicated moderate amount of drainage and slough noted to right foot. Area cleaned with normal saline, slough removed. Santyl applied to open area on the right foot....9:08 p.m.: right foot is reddened, especially the second, third, and fourth digits. Patient c/o (complained of) soreness in the foot. Will continue to monitor and update MD as necessary. On 3/19/13 at 1:40 p.m., surveyor # conducted a telephone interview with LPN (Licensed Practical Nurse)-A regarding the documentation of the right foot wound on 2/21/13. LPN-A verified she had completed the documentation and stated when she had first observed resident #1's right foot wound (could not recall when), the foot had some redness, was very [MEDICAL CONDITION] and was weeping clear fluid. LPN-A indicated when she observed resident #1's foot on 2/21/13, resident #1's foot was darker red in color and resident #1 had never complained of pain to the right foot before. LPN-A stated there was no drainage, [MEDICAL CONDITION] or foul odor when observed on 2/21/13. LPN-A indicated resident #1's condition had changed, but had not thought the change was significant to warrant notification to a physician. LPN-A did not have an RN assess the resident's wound. Nurses' notes dated 2/22/23 at 9:17 p.m., indicated there were open areas to the top of resident #1's feet. One is large and has a moderate amount of serosanguious drainage. Also has an open area on the medial side of his foot and it had bloody drainage. There is another small area of breakdown and a small amount of bloody drainage on the lateral aspect of the foot. There was a foul odor....did have dorsal pedal pulses assessed by the RN, however, pedal pulses were hard to feel due to patient's foot shaking. Resident #1's medical record did not include a documented RN assessment related to the 2/22/13 documentation by the LPN of the resident's right foot condition. On 3/19/13 at 2:00 p.m., surveyor # conducted a telephone interview with LPN-B regarding the documentation on 2/22/13. LPN-B verified the documentation of resident #1's right foot. LPN-B stated she was a casual call employee of the facility and 2/22/13 was the first time she had ever worked with resident #1. LPN-B verified the documentation on 2/22/13 was as she had observed. LPN-B indicated there was a foul odor noted when she removed the old dressing. LPN-B stated she went and asked RN-C to assess resident #1's foot and indicated RN-C had assessed the foot and checked for pulses and indicated she would pass the assessment on to the day shift staff. Resident #1's medical record did not have documentation of an RN assessment of the resident's right foot on 2/22/13. On 3/19/13 at 2:30 p.m., surveyor # interviewed RN-C regarding the assessment which was completed on 2/22/13 of resident #1's right foot. RN-C verified she was the RN that LPN-B had requested an RN assessment of resident #1's right foot wound. RN-C stated she had never observed resident #1's foot prior to that evening and indicated resident #1's right foot had 3 open areas on the foot. RN-C stated there was an open area on the medial area of the foot that was black, and one open area each on the lateral foot and between the toes as LPN-B had documented. RN-C indicated resident #1's right foot had to have been swollen, but she could not recall specifically. RN-C stated there was no gross bleeding of the foot wounds, but recalled there was bloody drainage on the old dressing. RN-C verified she also had noted a foul odor when she was close to the right foot wound. RN-C stated she had checked for pulses but could not state for sure if pedal pulses were present, as resident #1's foot was shaking. RN-C indicated she had looked in resident #1's medical record for previous assessments of the right foot, but the documentation was not real good, so she was unaware if the condition was a change. RN-C stated she was aware that resident #1 had foot concerns, but wasn't sure if the condition of the right foot had deteriorated. RN-C indicated the night nurse was also present when the foot was assessed, and the decision was made to pass the assessment to the day shift, as they were more familiar with the condition of resident #1's foot. RN-C indicated she could not recall if resident #1 had complaints of right foot pain. RN-C verified she did not document an assessment of resident #1's right foot wound in the medical record. There was no assessment/documentation of resident #1's right foot in the resident's medical record for the night shift of 2/22/13 into 2/23/13. The medical record indicated the night shift nurse had given resident #1 Tylenol 650 mg (milligrams) at 4:34 a.m. for complaints of right foot pain, a 5 rating of pain. Nurses' notes dated 2/23/13 at 11:36 a.m., (written by a nursing school instructor) indicated: "Complaining of right foot pain, rates as 8 out of 10, throbbing, going on for the past two weeks, unable to palpate dorsalis pedis or post tibial pulse, used doppler with detection of dorsalis pedis pulse. Right foot warm to touch, redness to dorsal area extending from all toes to mid foot, purple discoloration to base of all toes, 3+ [MEDICAL CONDITION]. Right foot wound: 1.) Grade 1 ulcer to dorsal area from base of metatarsals with purulent yellow drainage measuring 4.5 X 5.0 cm, collected culture from top of right foot. 2.) Lesion to area between great toe and 2nd toe with foul odor drainage and Grade 3-4 ulceration extending down pedal side 5 cm and laterally to metatarsal of great toe, dark in color with skin laceration on the medial side, minimal sanguineous drainage, very painful to manipulation. 3.) Lateral wound grade 0 with redness measuring 2 X 1 cm. Patient wound not allow me to probe the area between his toes on the right foot due to the pain. Notified unit nurses LPN-D and RN-E". Nurses' notes dated 2/23/13 at 2:00 p.m., indicated writer went in to assess patient's feet this AM before breakfast. Right foot red, warm and painful rated a 6-7 this AM....2-3+ [MEDICAL CONDITION] to the right foot, foul smelling. See notes from 2/23 11:36 a.m. for details. Call placed to MD updated on foot and pain. Patient has not had this much pain in the foot. Foot is red from toes to below ankles. Dr. (Doctor) office called back at 12:30 p.m. and stated to send to ER (emergency room ) for proper evaluation and treatment....PCP (Primary Care Physician) happened to be in the building at 1345 (1:45 p.m.)and was updated that patient will be sent to the ER. On 3/19/13 at 5:00 p.m. and on 3/20/13 at 5:00 p.m., surveyor # conducted a telephone interview with LPN-D regarding the documentation contained in resident #1's medical record on 2/23/13. LPN-D stated she got report from the night shift regarding complaints of pain to the right foot, and to her knowledge, resident #1 had not complained of pain prior. LPN-D indicated she went and observed resident #1's right foot and the right foot was red, warm, painful and had foul odor when the dressing was removed. LPN-D indicated most of resident #1's top, medial and lateral foot was reddened and they were not red prior. LPN-D stated she had called the MD's office but could not recall what time, but indicated she had observed resident #1's foot sometime between 7:00 a.m. and 8:00 a.m. and stated the nursing school instructor had assessed the foot also. LPN-D stated she had told the physician's office that resident #1 had complained of severe pain and had no complaints prior, the foot was red, and there was a foul odor and this was a change in condition for resident #1. LPN-D indicated she thought resident #1 should be seen by a physician. LPN-D stated the office nurse indicated she would update the on call physician and return the call to the facility. LPN-D stated resident #1's right foot looked like there possibly could have been an infection. LPN-D indicated she could not recall when she had called the physician's office or when the physician's office had returned the call with orders to send resident #1 to the hospital for evaluation. LPN-D stated she also had updated RN-E regarding her observation of resident #1's foot, but was unaware if RN-E assessed resident #1's right foot. LPN-D stated when the nursing school instructor had informed her of her assessment, LPN-D indicated she had already called the physician's office. LPN-D stated after RN-E was informed of resident #1's right foot, she had not gotten involved or inquired about the status of resident #1. On 3/20/13 at 8:00 a.m., surveyor # interviewed RN-E regarding the condition of resident #1's right foot on 2/23/13. RN-E verified she was the RN which had become involved. RN-E indicated LPN-D had not updated her regarding the condition of resident #1's foot prior to the nursing school instructor requesting her also to assess the foot. RN-E stated the nursing school instructor had come to her between 9:00 a.m. and 10:00 a.m. requesting that she also assess resident #1's right foot. RN-E stated there were concerns about the foot and the physician needed to be contacted. RN-E verified she did not update the physician as she knew the nursing school instructor would follow up with the LPN and the physician. RN-E stated she could not specifically recall what the condition of resident #1's foot was at that time. RN-E verified she hadn't documented an assessment of resident #1's right foot because the nursing school instructor was there and she already was working with the LPN, and she was confident the nursing school instructor would take care of it as far as getting the physician notified. When asked if it was the nursing school instructor's responsibility to document the assessment and call the physician, RN-E replied she (RN-E) guessed she was ultimately responsible, as the nursing school instructor was not an employee of the facility. RN-E indicated she thought the situation was not grave, as when she entered resident #1's room, resident #1 was observed to have been sitting up and awake. RN-E verified she had not reviewed resident #1's medical record to assess if there had been a change in condition of resident #1's right foot. On 3/20/13, surveyor # reviewed the communication documentation that was retrieved from the physician's clinic, regarding communication with the facility regarding resident #1 on 2/23/13. The clinic information indicated on 2/23/13 at: * 8:58 a.m.: LPN-D called the clinic to report to the on-call provider that resident #1, starting on Thurs 2/21 with having redness of the right great toe, but that the redness has now spread to his entire right foot. Also, the outer great toe has an area that looks necrotic, which has recently started to have a foul smell. * 10:38 a.m.: the facility called and indicated resident #1 only had Tylenol for pain and would also like orders for additional pain medication. * 10:46 a.m.: physician notified clinic nurse that he was sorry he did not cover for MD-G * 10:57 a.m.: clinic called facility and informed that MD-H was resident #1's physician. * 11:49 a.m.: patient needs to be seen in the ER (emergency room ) for appropriate evaluation and management. * 12:36 p.m.: call to LPN-D and informed- they will send patient to ER today and she will call his relatives now for transport- will be going to AMC (Appleton Medical Center) ER. On 3/20/13, surveyor # reviewed the undated IRF ("Interagency Referral Form") that was completed by RN-F. The IRF indicated resident #1 was being transferred to the hospital because of increased pain, swelling and warmth of the right foot. There was redness from toes to below the ankle and foul smelling. On 3/20/13 at 12:00 p.m., surveyor # interviewed RN-F regarding the IRF document. RN-F stated she had not assessed resident #1's foot, and she completed the documentation to assist another nurse in the transfer to the hospital and was told what to write. RN-F stated she came to work on 2/23/13 at 2:00 p.m. and immediately assisted with the transfer. RN-F indicated resident #1 left the facility between 2:00 p.m. and 2:30 p.m. and a family member had transported. On 3/20/13, surveyor # reviewed the facility's 24 hour shift report from 2/19/13 through 2/23/13. The 24 hour shift report from 2/19/13 through 2/21/13 did not include documentation regarding the condition of resident #1's right foot. On 2/22/13, the 24 hour shift report indicated "Santyl right foot, looks red, update MD-G". The 24 hour shift report did not include documentation regarding the condition of resident 1's right foot for 2/23/13. On 3/20/13, surveyor # reviewed the ER report dated 2/23/13 which was documented by MD-I. The ER report indicated resident #1's right foot has a large necrotic ulcer on the medial aspect of the right foot near the MCP (metacarpophalangeal) joint and is weeping and malodorous with redness extending up into the foot. The redness does not extend proximal to the foot. The left foot shows a healing ulcer over the left lateral mid foot. Patient was given a dose of [MEDICATION NAME] (an antibiotic) intravenously. The patient will need to be admitted . On 3/20/13 at 12:10 p.m., surveyor # conducted a telephone interview with MD-I. MD-I verified he was the ER physician that had assessed resident #1 on 2/23/13. MD-I stated he reviewed the medical record and specifically recalled resident #1. MD-I indicated resident #1 presented to the ER with a large, draining, foul smelling ulcer to the right foot. MD-I indicated by the condition of the foot, the condition had to have been smoldering for days and staff at the facility should have recognized the concern earlier that 2/23/13. MD-I stated the drainage of the right foot was clear serous fluid, but indicated this type of fluid often associated with an infection. MD-I stated a physician should have been notified or minimally seen at the facility when resident #1 presented with pain, redness and change of color. MD-I stated resident #1 would have benefited from treatment if would have been seen earlier by a physician. On 3/20/13 at 2:00 p.m., surveyor # updated DON (Director of Nursing)-J regarding the above findings. DON-J stated the physician should have been notified on 2/21/13 when resident #1 presented with increased redness and pain and definitely should have been notified on 2/22/13, when resident #1 had foul odor, increased pain and bloody drainage. DON-J stated 3 ? hours was too long to wait to hear from the physician after the concern was identified and the physician's office was notified. On 3/20/13, surveyor # reviewed the "Teaching H & P" (history and physical) dated 2/23/13. The H&P indicated "Now comes in for left foot [MEDICAL CONDITION], fluctuant swelling and gangrene. Findings: Barely palpable dorsalis pedis. Fluctuant swelling with pus drainage from plantar aspect of left foot. Overlying gangrene and foul smelling discharge". (Question accuracy of "left" foot as operative report and ER report indicated right foot). The "Operative Report", dated 2/25/13 indicated preoperative [DIAGNOSES REDACTED]. The Postoperative [DIAGNOSES REDACTED]. The procedure indicated incision and drainage with removal of all nonviable tissue and bone. This included exploration and drainage of the deep plantar space of the right foot and removal of all five metatarsals on the right side. The History and Physical Podiatry Surgery Consultation, dated 2/26/13, indicated resident #1's WBC (white blood cell) count was 25.1, hemoglobin was 8.0 and hematocrit was 24.9 at the time of admission and was currently receiving blood. On 3/21/13 at 9:53 a.m., surveyor # conducted a telephone interview with CPS (Certified Podiatric MD and Surgeon)-L regarding resident #1's right foot. CPS-L stated the severity of resident #1's right foot infection was severe and the infection was a fast growing infection. Surveyor # updated CPS-L regarding resident #1's medical documentation and staff interviews of 2/21/13 & 2/22/13 when the right foot condition began to deteriorate. CPS-L stated the nurses should have notified a physician when the deterioration was first observed. CPS-L stated if resident #1 would have been seen by a physician 48 hours earlier, resident #1 probably would not had needed to have his foot amputated. The facility removed the immediate jeopardy on 3/25/13. The removal plan and subsequent actions of the facility was detailed and intertwined for F157, F281 and F309. This included revision of Notification for Physician practices with emphasis on change of condition, LPN role in identification of significant changes of condition, audits for wound care documentation and extensive Quality Assurance activities to serve as checks and balances as a result of a root cause analysis and developed plans. Education for all staff began on 3/25/13 and concluded on 3/26/13 with modifications to new staff orientation for any new staff coming to the facility after 3/26/13.

Based on record review and staff interview, the facility did not immediately consult with the resident's physician when a significant change in the resident's physical condition had occurred and the need to alter treatment was significant for 1 (resident #1) of 1 sampled residents. Resident #1 presented with a right foot wound. When resident #1's foot wound had deteriorated in condition, the facility did not notify the physician regarding the deterioration of the right foot wound. Resident #1 developed gangrene and was diagnosed with [REDACTED].#1 underwent a partial amputation of the right foot. As a result of the facility's actions, this posed an Immediate Jeopardy situation that began on 02/21/13. The facility was formally notified on March 22, 2013. The facility removed the immediate jeopardy on 3/25 and corrected the deficient practice on 3/26/13. Findings include: The facility's policy and procedure titled, "Notification of Physician (Change in Condition)" revised 1/5/2010, indicated the purpose of this procedure is to ensure that physicians and/or professional care providers are provided information in a timely manner regarding the patient's condition. When there is a sudden change of condition, the nursing home nurse is responsible to perform a complete assessment of vital signs and of the basic problem, and notify the physician. If the physician is not available, the medical director must be notified. If the medical director cannot be reached, then 911 must be called. Procedure: The following are examples of times when the physician must be immediately notified: a change in condition. According to webmd.com, gangrene is a condition that occurs when body tissue dies. It is caused by a loss of blood supply due to an underlying illness, injury and/or infection. There are different types of gangrene and all require immediate medical attention. According to webmd.com, [DIAGNOSES REDACTED] (flesh-eating bacteria) is an infection caused by bacteria. It can destroy skin, fat, and the tissue covering the muscles within a very short time. The risk of getting this infection is higher if the patient uses steroids, which can lower the body's resistance to infection. A patient can get [DIAGNOSES REDACTED] when bacteria enters a wound. Early treatment of [REDACTED]. On 3/19/13, surveyor # reviewed resident #1's medical record. According to the hospital discharge summary dated 1/24/13, resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted with orders to receive a tapering dose of [MEDICATION NAME] (a corticosteroid medication which causes immunosuppresion) and on day 6 after admission, was started on a daily dose of [MEDICATION NAME] 2.5 mg (milligrams). Nurses' notes dated 1/24/13 at 9:48 p.m. indicated resident #1 had small scratch like abrasions noted on the bilateral inner feet. [MEDICATION NAME] dressing present to the top of the right foot. Small area noted that is weeping fluid. A Weekly Wound Tracking Form was initiated for resident #1 on 1/29/13, for bilateral feet. The form indicated it was initiated due to weeping [MEDICAL CONDITION] and no pressure. The form documents the following: * 1/29/13- right foot dorsum: 1.6 X 5.9 with a depth of 0.4 (crater). Treatment indicated non-adhering gauze wrap with gauze. * 2/07/13- right foot dorsum: 1.0 X 5.4 (same treatment) * 2/12/13- right dorsum: 3.8 X 5.0 (decrease depth with less [MEDICAL CONDITION]) Treatment indicated the area was cleansed with normal saline, covered with gauze dressing and wrapped with gauze. * 2/19/13- right dorsum: 3.7 X 4.4 with 2 dark (no continuation of documentation). Treatment indicated the area was cleansed with normal saline covered with non-adherent gauze dressing and wrapped with gauze. Nurses' notes included the following Wound IDT (Interdisciplinary Team) notes: * 1/30/13 at 9:14 a.m. for 1/29/13: right foot dorsum open wound (crater) measuring 6.0 cm (centimeters) X 3.0 cm with a 0.4 depth. Cleansed with normal saline, covered with non-adherent dressing, then gauze dressing and wrapped with gauze. * 2/7/13 at 2:02 p.m.: resident has several open areas on both feet due to weeping [MEDICAL CONDITION].right foot: 1.0 cm X 5.4 cm with a crater of 0.3 cm. * 2/14/13 at 9:52 a.m.: right foot dorsum wound crater shaped and has less depth; measures 3.8 cm X 5.0 cm . Weekly skin check documentation on 2/13/13 at 11:36 p.m. in the nurses' notes indicated the top of right foot wound draining moderate amount of greenish drainage. Sloughy area to right foot seafoam green in color .... Message left for wound care team to assess the foot wound. The wound care team note had not addressed the slough. * 2/20/13 at 12:10 p.m. for 2/19/13: right foot dorsum wound measures 3.7 cm X 4.4 cm with <0.1 cm depth, now has slough and 2 discolored areas. MD (Medical Doctor) updated with request for Santyl to wound, covered with gauze and wrapped with gauze changing dressing twice daily until healed. Nurses' notes dated 2/21/13 at 9:58 p.m. indicated moderate amount of drainage and slough noted to right foot. Area cleaned with normal saline, slough removed. Santyl applied to open area on the right foot....9:08 p.m.: right foot is reddened, especially the second, third, and fourth digits. Patient c/o (complained of) soreness in the foot. Will continue to monitor and update MD as necessary. On 3/19/13 at 1:40 p.m., surveyor # conducted a telephone interview with LPN (Licensed Practical Nurse)-A regarding the documentation of the right foot wound on 2/21/13. LPN-A verified she had completed the documentation and stated when she first observed resident #1's right foot wound (could not recall when), the foot had some redness, was very [MEDICAL CONDITION] and was weeping clear fluid. LPN-A indicated when she observed resident #1's foot on 2/21/13, resident #1's foot was darker red in color and resident #1 had never complained of pain to the right foot before. LPN-A stated there was no drainage, [MEDICAL CONDITION] or foul odor when observed on 2/21/13. LPN-A indicated resident #1's condition had changed, but had not thought the change was significant to warrant notification of the physician. Nurses' notes dated 2/22/23 at 9:17 p.m. indicated there were open areas to the top of resident #1's feet. One is large and has a moderate amount of serosanguious drainage. Also has an open area on the medial side of his foot and it had bloody drainage. There is another small area of breakdown and a small amount of bloody drainage on the lateral aspect of the foot. There was a foul odor....did have dorsal pedal pulses assessed by the RN (Registered Nurse), however, pedal pulses were hard to feel due to patient's foot shaking. On 3/19/13 at 2:00 p.m., surveyor # conducted a telephone interviewed with LPN-B regarding the documentation on 2/22/13. LPN-B stated she was a casual call employee of the facility and 2/22/13 was the first time she had ever worked with resident #1. LPN-B verified the documentation on 2/22/13 was as she had observed. LPN-B indicated there was a foul odor noted when she removed the old dressing. LPN-B stated she went and asked RN-C to assess the foot. LPN-B indicated RN-C had assessed the foot and checked for pulses and indicated she would pass the assessment on to the day shift staff. On 3/19/13 at 2:30 p.m., surveyor # interviewed RN-C regarding the assessment which was completed on 2/22/13 of resident #1's right foot. RN-C verified she was the RN that LPN-B had requested for an RN assessment of resident #1's right foot wound. RN-C stated she had never observed resident #1's foot prior to that evening. RN-C stated resident #1's right foot had 3 open areas on the foot and stated there was an open area on the medial area of the foot that was black, and one open area on the lateral foot and between the toes as LPN-B had documented. RN-C indicated resident #1's right foot had to have been swollen, but she could not recall specifically. RN-C stated there was no gross bleeding of the foot wounds, but had recalled there was bloody drainage on the old dressing. RN-C verified she also had noted a foul odor when she was close to the right foot wound. RN-C stated she checked for pulses but could not state for sure if pedal pulses were present, as resident #1's foot was shaking. RN-C indicated she had looked in resident #1's medical record for previous assessments of the right foot, but the documentation was not real good, so she was unaware if this condition was a change. RN-C stated she was aware that resident #1 had foot concerns, but wasn't sure if the resident's condition had deteriorated. RN-C indicated the night nurse, was also present when the foot was assessed, and the decision was made to pass the assessment to the day shift staff, as they were more familiar with the condition of resident #1's foot. RN-C indicated she could not recall if resident #1 had complaints of right foot pain. Nurses' notes dated 2/23/13 at 11:36 a.m. (written by a nursing school instructor) indicated: "Complaining of right foot pain, rates as 8 out of 10, throbbing, going on for the past two weeks, unable to palpate dorsalis pedis or post tibial pulse, used doppler with detection of dorsalis pedis pulse. Right foot warm to touch, redness to dorsal area extending from all toes to mid foot, purple discoloration to base of all toes, 3+ [MEDICAL CONDITION]. Right foot wound: 1.) Grade 1 ulcer to dorsal area from base of metatarsals with purulent yellow drainage measuring 4.5 X 5.0 cm, collected culture from top of right foot. 2.) Lesion to area between great toe and 2nd toe with foul odor drainage and Grade 3-4 ulceration extending down pedal side 5 cm and laterally to metatarsal of great toe, dark in color with skin laceration on the medial side, minimal sanguineous drainage, very painful to manipulation. 3.) Lateral wound grade 0 with redness measuring 2 X 1 cm. Patient wound not allow me to probe the area between his toes on the right foot due to the pain. Notified unit nurses LPN-D and RN-E". Nurses' notes dated 2/23/13 at 2:00 p.m., indicated writer went in to assess patient's feet this AM before breakfast. Right foot red, warm and painful rated a 6-7 this AM....2-3+ [MEDICAL CONDITION] to the right foot, foul smelling. See notes from 2/23 11:36 a.m. for details. Call placed to MD updated on foot and pain. Patient has not had this much pain in the foot. Foot is red from toes to below ankles. Dr. (Doctor) office called back at 12:30 and stated to send to ER (emergency room ) for proper evaluation and treatment....PCP (Primary Care Physician) happened to be in the building at 1345 (1:45 p.m.)and was updated that patient will be sent to the ER. On 3/19/13 at 5:00 p.m. and 3/20/13 at 5:00 p.m., surveyor # conducted a telephone interview with LPN-D regarding the documentation contained in resident #1's medical record on 2/23/13. LPN-D stated she got report from the night shift regarding resident #1's complaints of pain to the right foot, and to her knowledge, resident #1 had not complained of pain prior. LPN-D indicated she went and observed resident #1's right foot and the right foot was red, warm, painful and had foul odor when the dressing was removed. LPN-D indicated most of resident #1's top, medial and lateral foot was reddened and they were not red prior. LPN-D stated she had called the MD's office, but could not recall what time. LPN-D indicated she had observed resident #1's foot sometime between 7:00 a.m. and 8:00 a.m. and stated the nursing school instructor had assessed the foot also. LPN-D stated she told the physician's office that resident #1 had complained of severe pain and had no complaints prior, the foot was red, and there was a foul odor and this was a change in condition for resident #1. LPN-D indicated she thought resident #1 should be seen by a physician. LPN-D stated the office nurse indicated she would update the on call physician and return the call to the facility. LPN-D stated resident #1's right foot looked like there possibly could have been an infection. LPN-D indicated she could not recall when she had called the physician's office or when the office had returned the call with orders to send resident #1 to the hospital for evaluation. LPN-D stated she updated RN-E regarding her observation of resident #1's foot, but was unaware if RN-E assessed resident #1's right foot. LPN-D stated when the nursing school instructor had informed her of her assessment, she had already called the physician's office. LPN-D stated after RN-E was informed of resident #1's right foot, she had not gotten involved or inquired about the status of resident #1. On 3/20/13 at 8:00 a.m., surveyor # interviewed RN-E regarding the condition of resident #1's right foot on 2/23/13. RN-E verified she was the RN which had been involved. RN-E indicated LPN-D had not updated her regarding the condition of resident #1's foot prior to the nursing school instructor requesting her to assess the foot. RN-E stated the nursing school instructor had come to her between 9:00 a.m. to 10:00 a.m. requesting that she also assess resident #1's right foot. RN-E stated there were concerns about the foot and the physician needed to be contacted. RN-E verified she had not updated the physician as she knew the nursing school instructor would follow up with the LPN and the physician. RN-E stated she could not specifically recall what the condition of resident #1's foot was at that time. RN-E verified she hadn't documented an assessment of resident #1's right foot because the nursing school instructor was there and she already was working with the LPN, and she was confident the nursing school instructor would take care of it as far as getting the physician notified. When asked if it was the nursing school instructor's responsibility to document the assessment and call the physician, RN-E replied she guessed she (RN-E) was ultimately responsible, as the nursing school instructor was not an employee of the facility. RN-E indicated she thought the situation was not grave as when she entered resident #1's room, resident #1 was observed to have been sitting up and awake. On 3/20/13, surveyor # reviewed the communication documentation that was retrieved from the physician's clinic, regarding communication with the facility regarding resident #1 on 2/23/13. The clinic information indicated on 2/23/13 at: * 8:58 a.m.: LPN-D called the clinic to report to the on-call provider that resident #1, starting on Thurs 2/21 with having redness of the right great toe, but that the redness has now spread to his entire right foot. Also, the outer great toe has an area that looks necrotic, which has recently started to have a foul smell. * 10:38 a.m.: the facility called and indicated resident #1 only had Tylenol for pain and would also like orders for additional pain medication. * 10:46 a.m.: physician notified clinic nurse that he was sorry he did not cover for MD-G * 10:57 a.m.: clinic called facility and informed that MD-H was resident #1's physician. * 11:49 a.m.: patient needs to be seen in the ER (emergency room ) for appropriate evaluation and management. * 12:36 p.m.: call to LPN-D and informed- they will send patient to ER today and she will call his relatives now for transport- will be going to AMC (Appleton Medical Center) ER. On 3/20/13, surveyor # reviewed the undated IRF ("Interagency Referral Form") that was completed by RN-F. The IRF indicated resident #1 was being transferred to the hospital because of increase pain, swelling and warmth of the right foot. There was redness from toes to below the ankle and foul smelling. On 3/20/13 at 12:00 p.m., surveyor # interviewed RN-F regarding the IRF document. RN-F stated she had not assessed resident #1's foot, and she completed the documentation to assist another nurse in the transfer to the hospital and was told what to write. RN-F stated she came to work on 2/23/13 at 2:00 p.m. and immediately assisted with the transfer. RN-F indicated resident #1 left the facility between 2:00 p.m. and 2:30 p.m. and a family member had transported. On 3/20/13, surveyor # reviewed the ER report dated 2/23/13 which was documented by MD-I. The ER report indicated resident #1's right foot has a large necrotic ulcer on the medial aspect of the right foot near the MCP (metacarpophalangeal) joint and is weeping and malodorous with redness extending up into the foot. The redness does not extend proximal to the foot. The left foot shows a healing ulcer over the left lateral mid foot. Patient was given a dose of [MEDICATION NAME] (an antibiotic) intravenously. The patient will need to be admitted . On 3/20/13 at 12:10 p.m., surveyor # conducted a telephone interview with MD-I. MD-I verified he was the ER physician that had assessed resident #1 on 2/23/13. MD-I stated he reviewed the medical record and specifically recalled resident #1. MD-I indicated resident #1 presented to the ER with a large, draining, foul smelling ulcer to the right foot. MD-I indicated by the condition of the foot, the condition had to have been smoldering for days and staff at the facility should have recognized the concern earlier than 2/23/13. MD-I stated the drainage of the right foot was clear serous fluid, but indicated this type of fluid often associated with an infection. MD-I stated a physician should have been notified or minimally seen at the facility when resident #1 presented with pain, redness and change of color. MD-I stated resident #1 would have benefited from treatment if would have been seen earlier by a physician. On 3/20/13 at 2:00 p.m., surveyor # updated DON (Director of Nursing)-J regarding the above findings. DON-J stated the physician should have been notified on 2/21/13 when resident #1 presented with increased redness and pain and definitely should have been notified on 2/22/13, when resident #1 had foul odor, increased pain and bloody drainage. DON-J stated 3 ? hours was too long to wait to hear from the physician after the concern was identified and the physician's office was notified. On 3/20/13, surveyor # reviewed the "Teaching H & P" (history and physical) dated 2/23/13. The H&P indicated "Now comes in for left foot [MEDICAL CONDITION], fluctuant swelling and gangrene. Findings: Barely palpable dorsalis pedis. Fluctuant swelling with pus drainage from plantar aspect of left foot. Overlying gangrene and foul smelling discharge". (Question accuracy of "left" foot as operative report and ER report indicated right foot). The "Operative Report" dated 2/25/13 indicated preoperative [DIAGNOSES REDACTED]. The Postoperative [DIAGNOSES REDACTED]. The procedure indicated incision and drainage with removal of all nonviable tissue and bone. This included exploration and drainage of the deep plantar space of the right foot and removal of all five metatarsals on the right side. The History and Physical Podiatry Surgery Consultation dated 2/26/13 indicated resident #1's WBC (white blood cell) count was 25.1, hemoglobin was 8.0 and hematocrit was 24.9 at the time of admission and was currently receiving blood. On 3/21/13 at 9:53 a.m., surveyor # conducted a telephone interview with CPS (Certified Podiatric MD and Surgeon)-L regarding resident #1's right foot. CPS-L stated the severity of resident #1's right foot infection was severe and the infection was a fast growing infection. Surveyor # updated CPS-L regarding resident #1's medical documentation and staff interviews of 2/21/13 & 2/22/13 when the right foot condition began to deteriorate. CPS-L stated the nurses should have notified a physician when the deterioration was first observed. CPS-L stated if resident #1 would have been seen by a physician 48 hours earlier, resident #1 would probably have not had needed to have his foot amputated. The facility removed the immediate jeopardy on 3/25/13. The removal plan and subsequent actions of the facility was detailed and intertwined for F157, F281 and F309. This included revision of Notification for Physician practices with emphasis on change of condition, LPN role in identification of significant changes of condition, audits for wound care documentation and extensive Quality Assurance activities to serve as checks and balances as a result of a root cause analysis and developed plans. Education for all staff began on 3/25/13 and concluded on 3/26/13 with modifications to new staff orientation for any new staff coming to the facility after 3/26/13.

Based on observations, record review and staff interviews, the facility did not ensure that the resident environment remained as free of accident hazards as possible and that 2 (resident #2 and resident #3) of 14 sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #2 had a history of [REDACTED]. Staff did not provide adequate assistance while transferring resident #2, resulting in fracture of the humerus (upper arm). Resident #3 was assessed to be at high risk for falls. The resident's care plan intervention to keep walker within arm's reach when in room had not been consistently implemented. Findings include: 1. On 2/4/13, surveyor # reviewed the medical record of resident #2. The 6/20/12 facesheet contained within the medical record indicated resident #2 was originally admitted to the facility 1/4/08 with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment, dated 1/14/13, indicated resident #2 was dependent upon staff for extensive assistance with bed mobility, transfers, and ambulation. The DPOAHC (Durable Power of Attorney for Health Care) had been activated 12/27/07, naming resident #2's daughter as the decision maker for resident #2. A 10/28/12 written plan of care which identified the problem, "self care deficit" for resident #2 indicated, "1 or 2 assist with ambulation, needs padded gait belt (may refuse, encourage for safety), uses quad cane...when transferring, please go underneath resident's arm pit to prevent bruising due to fragile skin..." The 10/30/12 plan of care which identified the problem, "resists cares at times" directed staff to "leave and return in 5 minutes, re-approach to finish cares." During initial tour of the facility, 2/4/13 at 8:00 a.m., CNA (Certified Nursing Assistant)-I indicated to surveyor # , that resident #2 had experienced a fracture arm during staff transfer. The facility's investigation of the fracture, initiated 12/1/12 by DON (Director of Nursing)-A, indicated that CNA-E and CNA-D had been assisting resident #2 with bedtime cares on 11/30/12 and that resident #2 had been transferred into bed by CNA-E. CNA-E attempted to use the gait belt, however resident #2, often refused the gait belt. During the transfer, both CNAs heard a noise which sounded like a "muffled pop," after which resident #2 began to complain of arm pain. CNA-D reported the onset of pain to LPN (Licensed Practical Nurse)-F who then evaluated resident #2's pain. The investigation details further indicated that the night nurse administered pain medication to resident #2 at 11:00 p.m., but that resident #2 "did not want to go to the ER (emergency room )." The next morning, due to continued and increasing complaints of pain, the physician was called and an x-ray was ordered. At approximately 1:00 p.m., the results of "acute fracture of proximal humerus" were reported to the facility staff , who then notified the family, physician, DON and NHA (Nursing Home Administrator). A radiology report for resident #2, dated 12/1/12, indicated, "Acute fracture proximal humerus." Documentation from the radiologist did not reveal osteoporosis changes or pathological fracture. The investigation conclusion indicated, "(resident #2's) care plan for transfer was a 1 or 2 (assist). Padded gait belt was provided (noted that resident #2 often refused the gait belt anyway). Instruction on how to transfer included staff putting their arm under her right arm. The staff that transferred resident #2 did follow the resident's plan of care...It is this writer's belief that the resident's fracture was pathological in nature. The CNA's followed the resident's care card. Resident refused her gait belt for the transfer and did so frequently..." On 2/5/13 at 9:35 a.m., surveyor # interviewed CNA-J who verified resident #2 was not always compliant with gait belt use, however prior to the fracture, if resident #2 refused the gait belt, CNA-J would ask for assistance from a nurse who would re-educate or encourage. CNA-J indicated she may have transferred resident #2 without a gait belt once, but since the facility used the padded gait belt, resident #2 was more cooperative. On 2/5/13 at 10:30 a.m., surveyor # interviewed CNA-D who verified she and CNA-E were assisting with bedtime cares for resident #2 on 11/30/12. CNA-D revealed that CNA-E transferred resident 2 from the commode to the bed, and while CNA-D was bent down to assist with the resident's shoes, CNA-D heard a "pop." CNA-D stated she did not observe positioning during the transfer but saw "Resident #2 was laying down, CNA-E was standing over her, and the resident complained of pain in the shoulder." CNA-D also indicated that the gait belt was offered to resident #2 prior to the transfer, but resident #2 refused it. CNA-D further verified she did not assist with transferring resident #2, CNA-E performed the transfer alone. CNA-D revealed she immediately informed LPN-F of resident #2's complaint of pain, but not of the "popping" sound, because other staff and residents were in the immediate area and CNA-D was concerned about confidentiality. On 2/5/13 at 10:45 a.m., surveyor # interviewed CNA-E who confirmed the above and indicated application of the gait belt was attempted, but resident #2 refused. CNA-E stated she had performed bedtime cares in the bathroom while the resident sat on a wheeled commode. The commode was then pushed towards the bed, "I put one arm on (resident #2's) shoulder and neck and one arm under her knee and transferred her to bed. Usually, resident #2 rested her left arm in her lap during transfers, but she did not that day. Resident #2 yelled, 'Ow!' and I saw her left arm was stuck under her left leg." CNA-E indicated that the plan of care indicated resident #2 could be transferred with assistance of 1 staff, but she was not aware of a contingency plan for when resident #2 refused the gait belt. CNA-E stated when resident #2 refused the gait belt, "we just transferred without it and continued with the assistance of just one staff. CNA-E indicated she reported resident #2's "arm got stuck" to a nurse, but did not recall which nurse. On 2/5/13 at approximately 2:45 p.m., surveyor # interviewed DON-A. It was confirmed resident #2 had oftentimes refused the gait belt during transfers. DON-A verified she updated the plan of care for resident #2, after the fracture, to include, "resident #2 must wear gait belt related to upper extremity fracture." DON-A indicated recently, resident #2 had been cooperative with gait belt use, "even though she doesn't like it," due to encouragement and education. DON-A verified the plan of care for resident #2 had not been updated to direct staff how to transfer resident #2 when the gait belt was refused, instead the care plan indicated "to go under the resident's arm pit to prevent bruising." DON-A indicated only the staff involved with the transfer were re-educated. On 2/6/13 at 1:30 p.m., surveyor # interviewed FM (Family Member)-V, who was the DPOAHC for resident #2. It was verified that resident #2 had often refused the gait belt prior to the fracture, FM-V was aware the fracture occurred during a staff transfer, and FM-V now insists that staff transfer resident #2 with a gait belt for all transfers. Although DON-A's written conclusion indicated CNA-E "followed the care plan," interview with CNA-E by surveyor # indicated the plan of care was not followed as written, nor was it revised to include transfer techniques or adjustments to allow for safe transfers when resident #2 refused the gait belt. On 2/6/13, surveyor # reviewed the facility policy dated 1/11/11 entitled, "Gait Belts for Patient Transfer." The policy described the major steps involved in application of the gait belt, but no alternative methods of transfer were described for when a resident refused the gait belt. 2. Resident #3's admission face sheet dated 9/6/11 indicated the resident had [DIAGNOSES REDACTED]. The resident's most recent MDS (minimum data set) dated 11/20/12 indicated the resident had been assessed to score a 6 of a possible 15 on the cognitive screen (the higher the score, the more cognizant), had range of motion deficits in one lower extremity, and had a history of [REDACTED]. Review of the resident's medical record indicated the resident had sustained falls on 7/24/12; 8/29/12; and on 9/4/12. After each incident, the resident's fall plan of care was updated. The fall that had occurred on 8/29/12 included that the resident was seated in her recliner and had attempted to self transfer. Alarms were sounding but before staff could reach her, she fell backwards against the front of the recliner. The care plan intervention indicated to keep walker placed by resident so she could have support if she would try to stand without assistance again. The resident's current plan of care related to potential for falls and trauma, dated 11/16/12 indicated the resident had a history of [REDACTED]. Care plan interventions included to encourage resident to seek help, staff to look into room while passing, call light in reach, assist in ambulating, transferring, and toileting, TABS when in recliner, sensor pad at all times, floor sensor next to bed and in front of recliner when occupied, frequent checks, and keep walker within reach to use if getting up when not using call light. The resident's CNA (Certified Nursing Assistant) care card which was located on the back of her bathroom door mimicked the above fall interventions. A fall risk assessment scale was completed for the resident on 2/5/13 which indicated a score of 24. A score of greater than 20 indicated the resident was at high risk for falls. The assessment indicated that therapy had been notified of the findings. On 2/4/13 at 9:50 a.m., surveyor # observed resident #3 being assisted back from breakfast to her room. The resident was seated in her recliner with the foot of the recliner elevated, a sensor alarm was placed on the seat and on the floor in front of the recliner, and her walker was approximately 5 to 6 feet away from the recliner next to the foot of her bed. On 2/4/13 at 10:00 a.m., surveyor # interviewed CNA-I. CNA-I stated, "she (resident #3) doesn't know how to use the call light. On 2/5/13 at 3:10 p.m., surveyor # observed resident #3 seated in her recliner in her room with the foot of the recliner elevated, a sensor alarm was placed on the seat and on the floor in front of the recliner. The resident's walker was approximately 5-6 feet away from the recliner next to the foot of her bed. The resident's door was open but no staff were on that side of the resident unit at the time of the observation. On 2/5/13 at 3:15 p.m., surveyor # alerted RN (Registered Nurse)-Y to the above observation. RN-Y verified the resident had a care plan intervention to include placing the walker within arms reach for the resident and verified that the walker was presently placed out of the resident's reach.

Based on staff interview and record review, the facility did not ensure 1 (resident #1) of 8 sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #1 had a plan of care which indicated she was to have staff assistance for transfers and ambulation in an attempt to prevent falls. Resident #1 also had a plan of care that indicated she utilized a sensor pad alarm system to notify staff when the resident attempted to exit the chair independently. Staff interviews indicated resident #1 had a history of [REDACTED]. The facility did not revise resident #1's plan of care when staff were aware resident #1 disengaged the alarm. Resident #1 exited her chair, without the alarm sounding, and was discovered on the floor. Resident #1 sustained a hip fracture. Findings include: The face sheet, dated 7/18/11 and contained within the medical record, indicated resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The face sheet indicated resident #1 had an activated Power of Attorney for Healthcare. The facility completed an MDS (Minimum Data Set), dated 1/6/11, which indicated resident #1 had moderately impaired cognitive skills for decision making and required staff assistance for transfers and ambulation. The MDS indicated the facility completed a balance test for the resident for moving from seated to standing position, walking, turning around, moving on/off the toilet and surface-to-surface transfer. The results of the balance test indicated resident #1 was not steady and was only able to stabilize with human assistance with all tests conducted. The MDS indicated resident #1 sustained falls in the previous two to six months prior to admission to the facility. The facility completed a CAA (Care Area Assessment) for falls, no date when written, which indicated resident #1 had a history of [REDACTED]. The CAA indicated resident #1 was at risk for falls and developed a plan of care. Physical Therapy completed a therapy screen for resident #1 on 5/20/11. The screen indicated, "Nursing requested a screen to determine if pt. (patient) would have independent ambulation with two wheeled walker in room. Pt. has steady gait with 2 wheeled walker but at times tries to run or act out when other people are present. If no alarms on, pt. would walk out to unit and have unsafe mobility. Pt. does have dementia dx (diagnosis) and would not remember to call for help when amb. (ambulating) outside of room. Keep alarms on and have assist of one, even in room." The facility completed an MDS, dated [DATE], which indicated there had been no changes to the assessment of resident #1's cognitive, transfer, ambulation and balance status. Resident #1's medical record contained a current plan of care for "Potential for Trauma-Falls" related to decline in cognitive status, appliance or device used, syncope, incontinence and decline in functional status manifested by an unsteady gait with a history of falls. The plan of care was dated 5/27/11. The facility indicated the following interventions: * Observe, record and report all unsafe conditions and situations. Monitor for orthostatic hypotension if symptomatic, as needed. Encourage to ask for assistance. Anticipate fall times. Monitor closely. Assess for change in level of consciousness. * (added 7/15/11) Transfers with 1 assist with gait belt and wheeled walker. Bed in low position. Encourage to ask for assistance. Call light in reach. Assist in ambulating, transferring and toileting. Anticipate needs. Toilet every 2 hours and as needed. Mat by bed at night. Sensor pad in bed at night and when in chair during the day. 15 minute checks. On 7/26/11 at 11:00 a.m. surveyor # interviewed DON (Director of Nursing)-A regarding the interventions that were added on 7/15/11. DON-A stated the only change to the plan of care for resident #1 on 7/15/11 was 15 minute checks, all other interventions were implemented previously. The nurses' notes dated 7/15/11 indicated at 7:20 p.m. resident #1 had fallen in her room and was positioned on her hands and knees. Resident #1 stated, "I don't know what happened." The nurses' notes indicated the resident was sitting in the chair prior to the fall with the alarm on. The fall was unwitnessed, and the resident appeared to have crawled out of the bathroom holding her nightgown. No walker was near the resident. Resident #1 was placed on 15 minute checks. The nurses' notes dated 7/15/11 indicated at approximately 11:10 p.m. resident #1 complained of pain and had significant shortness of breath. The physician was notified and resident #1 was transferred to the emergency room . The hospital emergency room report, dated 7/16/11, indicated resident #1 was diagnosed with [REDACTED]. The facility initiated an investigation into the fall. The investigation contained a statement from CNA (Certified Nursing Assistant)-B, who discovered resident #1 on the floor. CNA-B indicated she went to check on resident #1, and the resident was on her hands and knees crawling. CNA-B indicated she had not heard the alarm going off. CNA-B stated the alarm was still in the resident's chair and functioning. CNA-B also indicated it was possible resident #1 had turned the alarm off independently. On 7/26/11 at 9:00 a.m. surveyor # interviewed CNA-B regarding resident #1's fall. CNA-B verified she had discovered resident #1 crawling on her hands and knees on the floor in her room on 7/15/11. CNA-B indicated it appeared resident #1 transferred independently from the chair, went into the bathroom and must have fallen on the way back from the bathroom; as the bathroom door was open, and previously it was closed. CNA-B stated the alarm on the chair was not sounding. CNA-B stated resident #1 had a history of [REDACTED]. CNA-B indicated she had never witnessed resident #1 ambulating independently without the alarm sounding, but was told by other staff that resident #1 disengaged her alarm independently. CNA-B indicated she did not know if licensed staff were aware of the resident's ability to disengage her alarm independently, but verified she had never updated a licensed staff person of resident #1 disengaging her alarm. CNA-B stated resident #1 was able to make her needs known but had intermittent confusion. CNA-B indicated resident #1 required one staff assist to transfer and ambulate and had intermittent unsteadiness when standing/ambulating. On 7/26/11 at 10:15 a.m. surveyor # interviewed LPN (Licensed Practical Nurse)-G regarding resident #1's fall on 7/15/11. LPN-G verified she arrived at the room after having been notified of resident #1's fall. LPN-G stated, upon her arrival, she observed resident #1 crawling on the floor; and the alarm was not sounding. LPN-G indicated the control box, which attached to the sensor pad on the chair, was attached to the arm of the chair and was in reach of resident #1 when she sat in the chair. LPN-G stated it was possible resident #1 pushed the button on the control box, which disengaged the alarm so it would not sound when she exited the chair. LPN-G indicated there was not a specific on/off switch; but if the button was pushed, it would disengage the alarm; and when pressure was applied to the sensor pad it would engage the alarm system. On 7/26/11 at 9:30 a.m. surveyor # interviewed CNA-C regarding resident #1's history of disengaging the alarm system. CNA-C verified resident #1 had a history of [REDACTED].#1 disengaged the alarm a "...few times a week." CNA-C indicated she had never witnessed resident #1 disengage the alarm, but had heard about it from other CNA staff through report. CNA-C indicated she did not know if licensed staff were aware that resident #1 disengaged the alarm independently. CNA-C stated in report staff were told "...to watch her close." CNA-C verified there were no changes to resident #1's plan of care regarding the resident's ability to independently disengage the alarm system. On 7/26/11 at 9:45 a.m. surveyor # interviewed RN (Registered Nurse)-D regarding resident #1 independently disengaging the alarm. RN-D stated she worked frequently with resident #1 and was not aware the resident disengaged the alarm. On 7/26/11 at 9:50 a.m. surveyor # interviewed MT (Medication Technician)-E regarding resident #1 disengaging the alarm. MT-E stated she had never heard that resident #1 independently disengaged the alarm, but had witnessed resident #1 ambulating independently. MT-E indicated resident #1 had placed a heavy object on the sensor pad, so the alarm would not sound. MT-E indicated she updated the licensed nurse regarding the incident, but could not recall which licensed nurse. On 7/26/11 at 10:00 a.m. surveyor # interviewed RN-F regarding resident #1 independently disengaging the alarm. RN-F verified resident #1 was able to make her needs known, but had intermittent confusion. RN-F stated resident #1 was at risk for falls because she moved so quickly. RN-F verified there were frequent times when resident #1 would independently exit her chair, and staff would respond to the alarm before the resident fell . RN-F stated he was not aware of any reports that resident #1 disengaged the alarm independently. RN-F indicated the control box to the sensor pad was always in direct reach of resident #1; and all the resident needed to do was to push the button, and the alarm would disengage. RN-F stated if he was aware resident #1 was independently disengaging the alarm, a change to the plan of care would need to have been implemented. On 7/26/11 at 11:55 a.m. surveyor # interviewed DON-A regarding devices used since resident #1's admission to the facility. DON-A stated resident #1 utilized a TABs unit (pull apart device) and the sensor pad system in the chair since admission. DON-A indicated the TABs unit was discontinued on 6/1/11, but the rationale as to why the TABs was discontinued was not documented. DON-A stated, to her knowledge, resident #1 utilized the same sensor pad system since admission. DON-A indicated she had spoken to direct care staff, and they indicated to her there had been no other sensor alarm system utilized. On 7/27/11 DON-A faxed notes from a Nursing Department meeting that was held on 7/20/11. Per the notes, the information provided to staff indicated alarms needed to be mounted in some way, either on a wall, with a safety pin, etc. Place work orders on my desk. Heard possibility that (resident #1) was turning her alarm off, if this is the case there needs to be a new intervention. The sign-in record for staff that had received the above information indicated thirty-one of eighty-three staff had not received the information.