Every finding on record at Plymouth Health Services

Based on interview, record review, and policy review, the facility did not ensure 1 of 3 residents (R1) reviewed for falls from a total sample sample of 14 residents was transferred with a mechanical device in a safe manner. R1's care plan indicated they should be transferred with a Sit-to-Stand lift and the assitance of two staff. R1 was transferred with one staff and slipped from the lift to the floor. Findings include: Review of the facility's Safe Handling and Transfers policy, dated 8/5/22 revealed: It is the policy of this facility to ensure residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines .All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be used dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used .Two staff members must be used when transferring residents with a mechanical lift . Review of R1's undated admission Record indicated R1 was admitted to the facility on [DATE] with diagnoses including anemia, difficulty in walking, and weakness. Review of an admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 6/14/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The assessment also revealed R1 required substantial/maximal assistance of staff for transfers. Review of R1's care plan, dated 6/8/26, revealed R1 had an activities of daily living (ADL) self-care deficit related to decreased mobility and weakness. The care plan contained an intervention to transfer with Sit-to-Stand lift with two assist, large sling (green). Review of a facility-reported investigation, dated 6/22/26, revealed R1 was being transferred in a Sit-to-Stand lift on 6/20/26 and slipped from the stand to the floor. During an interview on 7/6/26 at 12:10 PM, R1 was asked if they recalled the incident and stated, ''Yes. I was being transferred in that machine and it was taking too long. I was getting tired and weak in my legs. I just slid down.'' During an interview on 7/8/26 at 9:16 AM, Registered Nurse (RN)1 stated they were administering medications and training a new RN. RN1 stated Certified Nurse Aide (CNA)7 told the nurse in training who told RN1. RN1 went R1's room and observed them on the floor hanging by the arms. CNA8 was in the room. RN1 completed an assessment. R1 had no injuries or complaints. RN1 stated R1 told them that they slid out of the Sit-to-Stand lift. RN1 stated there should always be two staff during a transfer with a mechanical lift. During an interview on 7/8/26 at 10:30 AM, CNA7 stated they received a message from CNA8 to go to R1's room. When CNA7 got to the room, R1's leg was folded underneath them and their arms were hanging in the sling. CNA7 stated CNA8 wanted to lift R1 up with the Sit-to-Stand lift. CNA7 told CNA8 that the nurse needed to be notified and the Hoyer lift should be used instead. CNA7 informed the nurse in training and then asked RN1 to help get R1 off the floor. CNA7 stated two staff members should always be present for a transfer with a mechanical lift per the facility's policy and there were signs in the hall to remind staff. During an interview on 7/8/26 at 2:54 PM, CNA8 stated they no longer worked at the facility because of the incident. CNA8 stated they gave R1 a shower, brought them back to their room, and was going to transfer them from wheelchair to recliner with the Sit-to-Stand lift. CNA8 stated R1's legs gave out and they slid down. CNA8 verified that they knew two staff should be present for a mechanical lift transfer. During an interview on 7/8/26 at 4:03 PM, the Director of Nursing (DON) stated they received a text message about the incident. The DON obtained statements and made sure R1 was assessed. The DON stated, ''The CNA admitted to knowing that there should be two staff to do the transfer. I have a zero tolerance for putting a resident in a situation like that.'' During an interview on 7/8/26 at 5:58 PM, the Executive Director (ED) stated the facility's policy states two staff are required for mechanical lift transfers. The ED stated CNA8 stated they knew two staff were needed but thought the facility needed more staff.

Based on interview, record review, and policy review, the facility did not follow its abuse policy or thoroughly investigate an allegation of abuse for 1 of 5 residents (R3) reviewed for abuse in a total sample of 14 residents. R3 reported that they felt physically and emotionally scared when they went to the dining room and thought was what happening was abuse. The facility did not thoroughly investigate the allegation of abuse.Findings include: Review of the facility's Abuse, Neglect and Exploitation policy, dated of 7/15/22, revealed: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse .V. Investigation of Alleged Abuse, Neglect and Exploitation: .An immediate investigation is warranted when allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s). 6. Providing complete and thorough documentation of the investigation . Review of R3's undated admission Record revealed R3 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder and depressive disorder. Review of R3's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/25/26, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of R4's undated admission Record revealed an original admission date of 6/18/25. Review of R4's Quarterly MDS assessment, with an ARD of 6/8/26, revealed a BIMS score of 15 out of 15, indicating intact cognition. Review of a 2/18/26 investigation provided by the facility revealed R3 reported to the Licensed Clinical Social Worker (LCSW) on 2/17/26 that they felt physically and emotionally scared when they went to the dining room and felt what was happening by staff and residents was abuse and should be reported. The investigation did not contain staff statements or a conclusion/resolution. During an interview on 7/7/26 at 2:35 PM, Certified Nurse Aide (CNA)4 stated R3 and R4 called each other names a while ago. CNA4 stated staff monitor R3 and R4 who keep their distance from each other. During an interview on 7/8/26 at 10:02 AM, the LCSW was asked about the meeting they had with R3 and indicated the allegation was reported during a session in February (2026). When R3 mentioned they felt it was abuse, the LCSW informed the Social Services Director (SSD). During an interview on 7/8/26 at 10:30 AM, CNA7 stated R4 called R3 a fat pig under their breath but loud enough that it was heard. During an interview on 7/8/26 at 1:01 PM, the SSD stated they were told about R3's concerns by the LCSW. The SSD and the Executive Director (ED) spoke with R3 and R4. A safety plan was developed. The SSD stated staff monitor R3 and R4 if they are in the same area. When asked what the investigation should include, the SSD stated to make sure R3 was safe and witness statements. The SSD confirmed the investigation did not include witness statements from staff or a statement of conclusion and confirmed the investigation was not thoroughly completed. During an interview on 7/8/26 at 5:58 PM, the ED stated they and the SSD spoke to R3 and R4 who should be monitored when in the same area. When asked what should be included in a thorough abuse investigation, the ED stated interviews with witnesses, police contact, and a summary with a conclusion. The ED confirmed the investigation did not contain witness statements from staff and other residents and did not contain a conclusion.

Based on observation, interview, and record review, the facility did not ensure a resident area remained at a safe, comfortable, and home-like temperature for 4 residents (R) (R5, R1, R4, and R6) of 8 sampled residents. On 6/12/26, the rooftop air conditioner that cooled R5, R1, R4 and R6's wing stopped working which resulted in room temperatures that were above 81 degrees Fahrenheit (F).Findings include: The facility's Safe and Homelike Environment Policy, dated 6/16/22, indicates: .Comfortable and safe temperature levels mean the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia, and is comfortable for residents .7. The facility will maintain comfortable and safe temperature levels .The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees Fahrenheit. The facility's Emergency Operations Plan (EOP) related to Extreme Weather-Heat (page 23) indicates: Initial actions: Activate facility's EOP and appoint a facility Incident Commander (IC) if warranted. Assess residents for signs of distress and/or discomfort. Consider relocating residents to a cooler part of the facility. If the outdoor temperature is not cooler, keep the windows closed and shades drawn. (Note: It may be necessary to increase security to accommodate open windows, etc.) Provide cool washcloths and cooling fans for air circulation. Encourage residents to drink fluids to maintain hydration. On 6/25/26, the United States (US) National Weather Service [NAME] Bay, Wisconsin (WI) Facebook page indicated a warning related to .increasing heat and humidity expected early next week with a potential prolonged period of 90 degree plus temperatures and heat indices reaching 100 degrees F. On 6/26/26, a post indicated: Temperatures gradually increase into the weekend, becoming hot and humid much of next week. Heat indices may near or reach 100 degrees F. The National Weather Service Historical Temperature for the National Weather Service [NAME] Bay, WI indicates the high temperatures during this time period were: (Note: The temperatures below were actual temperatures, not feels-like temperatures which take in acount humidty. Feels-like temperatures were predicted to be over 100 degrees on the hottest days.) ~ 6/25/26 - 72 degrees F~ 6/26/26 - 75 degrees F~ 6/27/26 - 77 degrees F~ 6/28/26 - 79 degrees F~ 6/29/26 - 91 degrees F~ 6/30/26 - 91 degrees F~ 7/1/26 - 91 degrees F~ 7/2/26 - 89 degrees F~ 7/3/26 - 86 degrees F~ 7/4/26 - 77 degrees F R5 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF) and atrial fibrillation. A Comprehensive Minimum Data Set (MDS) assessment, dated 6/30/26, stated R5 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R1 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, anxiety, and obesity. A Comprehensive MDS asssessment, dated 5/6/26, stated R1 had a BIMS score of 15 out of 15, indicating intact cognition. A progress note, dated 6/30/26 at 2:14 AM, indicated R1 had panicked feelings due to the heat and was offered and refused cool washcloths and ice water. A progress note at 8:53 PM, indicated R1 was tearful about the heat and was offered a temporary room change to another hallway. R1 refused and stated it would take forever. Staff offered an ice bag. R1 declined and stated they would think about it. R1 was smiling and not tearful. R4 was admitted to the facility on [DATE] and had diagnoses including schizoaffective disorder and obstructive sleep apnea. A Quarterly MDS assessment, dated 6/8/26, stated R4 had a BIMS score of 15 out of 15, indicating intact cognition. R6 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD) and CHF. A Comprehensive MDS assessment, dated 7/2/26, stated R6 had a BIMS score of 15 out of 15, indicating intact cognition. On 7/1/26 at 9:25 AM, Surveyor used an infrared temperature gun to obtain temperatures in hallways and resident rooms on the second floor of the facility where all residents resided. Surveyor walked toward R5, R1, R4, and R6's unit and observed 2 portable air conditioning units in the hallway. Surveyor noted the temperature was warmer in their hallway. On 7/1/26 at 9:30 AM, Surveyor entered R5's room. R5 was sitting in front of a fan eating breakfast and indicated it was warm in their room. Surveyor obtained a temperature of 81.5 degrees F. R5 stated it was generally hot all of the time, but it was terrible in their room and horrible without the fan. R5 stated they got the fan from therapy staff the day before and were thankful to have it. R5 stated they usually woke up just drenched but actually slept the night before. R5 stated everyone knew the hot weather was coming, fans should have been offered to all residents, and the facility should have been more prepared. R5 stated staff put two portable air conditioners in the hallway yesterday which made a difference if R5 was in the hallway, however, R5 had to leave their door open which was not their usual practice. On 7/1/26 at 10:47 AM, Surveyor interviewed Physical Therapist (PT)-H who indicated it was hot and stifling during a care conference in R5's room on 6/30/26. PT-H stated they saw R5 for therapy prior to the care conference. It was hot at that time and PT-H told R5 they would try to find them a fan. PT-H indicated the fan came from the activities department. On 7/1/26 at 9:35 AM, Surveyor interviewed R1 in their room. The door was partially open and a portable air conditioner was outside the room. R1 was in bed facing the door. A bedside table in front of R1 contained a computer and multiple stacked boxes that formed a wall in front of R1. Surveyor could see the top of R1's head from the doorway. The temperature of R1's room was 84.4 degrees F. R1 had a cooling noodle around their neck and a fan that kitchen staff provided. R1 indicated the air conditioning had not been running for more than a week and it got progressively warmer in the facility over the weekend. R1 stated they spoke to Maintenance Director (MD)-D last week because R1 had multiple sclerosis (MS). R1's symptoms were exacerbated by heat because their body had a hard time regulating temperature. R1 stated they knew the heat wave was coming and the air conditioning was broken so they asked staff to ensure something was in place before the heat wave arrived. MD-D informed R1 that coils were out on the air conditioner and they were waiting for parts to arrive. MD-D stated the facility had portable units they could use if the air conditioning was not fixed before the weekend. R1 stated there were no portable units on Friday (6/26/26). Portable units in the hallway were not installed until Monday (6/29/26). R1 stated if they put ice on their face, it helped for 2 seconds, however, they had an overwhelming deep feeling of pain in their bones and their skin felt sunburned like there was a fire with embers burning that wouldn't go out. R1 stated they also experienced sensations of lightning bolts shooting down their legs, increased Charlie horses, cramping, and leg pains and felt dizzy and like they had to throw up. R1 also felt disoriented, couldn't find their words, and was terrified something would happen. R1 stated the heat made their anxiety worse and it felt like they were living in a crockpot. R1 opened their window over the weekend and monitored the outside temperature via thermometer and a computer. When it was 10 degrees cooler outside, R1 opened the window to get cool air. R1 stated a nurse entered their room on the morning of 6/28/26 and told them to close their window because they were causing the whole facility to heat up and there was a hot stream of air coming from their room. R1 stated the facility installed portable units on 6/29/26 and told residents they had to close their windows. R1 stated it was 84 degrees in their room for 8 hours and their roommate (R4) did not get out of bed much. R1 stated they did not have a privacy curtain and preferred to keep their door closed, however, they had to keep the door open due to the heat which affected R1's anxiety and made it difficult to have a bowel movement. R1 stated staff brought water and offered popsicles. R1 asked for a fan to be put in their doorway but had not received one. A progres note, dated 7/1/26 at 10:46 AM, indicated R1 and Nursing Home Administrator (NHA)-A discussed the heat in R1's room and the hallway. NHA-A explained to R1 and their family that the facility was doing all they could and had 2 units in the hallway. NHA-A indicated R1 could not keep their window open, however, R1 stated it was cooler outside which is why they opened it. NHA-A stated the air conditioning units were working overtime and iced up when windows were open. R1 and their family did not agree with NHA-A. A progress note at 12:19 PM, indicated maintenance staff and NHA-A discussed a window unit with R1 who stated they would wait for the new units to arrive. When asked if staff could position the unit and blow cool air into their room, R1 agreed. Ice water, ice bags, and popsicles were offered but R1 declined. R1 was offered a room that was cooler but declined. The note indicated R1 was a hoarder and there was little room for air exchange in their room. On 7/1/26 at 1:35 PM, Surveyor and MD-D entered R1's room. The temperature which was 80 degrees F according to MD-D's temperature gauge. R1 had a wet washcloth draped over their head. A portable air conditioner in the doorway was blowing cool air into the room. R1 asked MD-D for a fan pointing out of the room. R1 told MD-D that R1 felt abandoned and asked MD-D not to leave that day without doing something. MD-D exited the room. Surveyor interviewed R1 who indicated the air conditioner was put in the doorway approximately 45 minutes ago. When Surveyor asked if R1 was offered a room change, R1 stated a nurse offered to move R1 and R4 to a different room at 9:00 PM the night before. R1 stated with the amount of things they need and have, it would take hours to move. R1 also chose not to move because have anxiety which exacerbates MS symptoms and they were told the air would be fixed the next day. R1 stated if they knew if would take 3 weeks to fix the air conditioning, they might have changed rooms. R1 stated they had been asking MD-D about a fan for 1 or 2 days and was told NHA-A was going to buy fans. R1 did not feel staff treated the heat like an emergency since no one had taken R1's temperature. R1 stated some nurses offered ice and popsicles. On 7/1/26 at 3:55 PM, Surveyor returned to R1's room and noted the portable air conditioner was in the hallway and no longer in the room. The temperature in R1's room was 83.5 degrees F. R1 indicated they were told different air conditioning units were arriving that day and they would receive a fan. R1 still had not seen the fan and worried staff would leave again at the end of the day without doing anything. On 7/1/26 at 11:15 AM, Surveyor obtained temperatures on the unit with MD-D and noted the following: ~ At 11:21 AM, R6's room was 85.7 degrees F. R6 stated they wake up sweating every night. MD-D noted R6's heating unit was turned on and turned it off. ~ At 11:24 AM, R4's room was 86.8 degrees F. A fan was on in the room. In an earlier interview at 10:02 AM, R4 was resting in bed with an ice towel on their forehead and a fan was on. R4 indicated they had trouble sleeping the night before due to the heat and took melatonin to help. R4 stated portable air conditioning units in the hallway shut off when they are full and have to be emptied. R4 stated maintenance staff moved a fan to the other end of the hallway yesterday afternoon and R4 did not get any air. When R4 declined their shower because there was no air circulation in the shower room, staff offered a cold shower. R4 stated they heard on 6/26/26 that MD-D ordered parts to fix the air conditioner and the air conditioner would be fixed that today. R4 stated they previously opened their window at night which helped, however, it no longer helped due to the humidity. Staff told R4 to keep the window shut and blinds closed. R4 felt sick the day before due to the heat and had diarrhea. At 2:13 PM, Surveyor completed a follow-up interview with R4 who stated they were not offered a room change and would not have taken one if offered.On 7/1/26 at 10:49 AM, Surveyor interviewed MD-D who stated there were 5 air conditioning units on the roof. One of the larger units that cooled the 300 and 400 wings went out early last week and it took a while to get parts. MD-D stated the 100/200 wings, nursing area, and dining room felt cooler because the air conditioning units were working. MD-D stated the air conditioning usually just cools the hallways because there are no air conditioning vents in resident rooms. MD-D stated the facility bought portable air conditioning units that were installed (in the hallway) on 6/29/26, however, the units were not effective and the company was delivering 4 higher efficiency units that day. MD-D showed Surveyor that a local company was asked to evaluate the broken rooftop air conditioner on 6/12/26. MD-D stated the corporate policy is to obtain multiple bids prior to repair. The facility chose Company (CMP)-E. The parts to fix the air conditioner were on order and scheduled to arrive by 7/6/26. MD-D stated the initial company that evaluated the air conditioning unit on 6/12/26 was a small, local company that was not an approved vendor in the system and it would have taken time to get them approved. In addition, the company did not have the equipment to get parts on the roof. MD-D stated when the first company told them it was a coil, the facility contacted a second company who wanted to put a bandaid on it. MD-D contacted CMP-E on 6/22/26 and received a repair quote on 6/24/26. When asked what happened between 6/12/26 and 6/22/26, MD-D stated they had to obtain 3 bids and it took time to get contractors there. MD-D stated all quotes are sent to the coporate office and it takes time for delivery. The required part had a 7-day lead time. On 7/1/26 at 1:15 PM, Surveyor interviewed Service Representative (SR)-F who stated MD-D contacted them on 6/26/26 at 8:20 AM to purchase portable units which were delivered on 6/29/26. SR-F stated they were notified on 6/30/26 that the units were not doing the job and the facility needed something more. SR-F confirmed additional units were being delivered on 7/1/26. On 7/1/26 at 2:19 PM, Surveyor interviewed Account Representative (AR)-G who stated they were initially contacted by the facility on 6/22/26. AR-G looked at the facility's air conditioning unit on 6/24/26 and sent a quote the same day. AR-G received the signed quote on 6/29/26 and ordered the material the same day. AR-G received an email from the vendor on 6/30/26 that stated the part would arrive on 7/7/26 or 7/8/26. AR-G stated they would install the part within 24 hours of receiving it.On 7/1/26 at 3:03 PM, Surveyor interviewed NHA-A who had not purchased fans yet, but stated they would get one for R1. NHA-A stated they talked to MD-D the night before about getting/not getting more fans if they were purchasing larger portable air conditioning units. NHA-A stated the fans might make it worse and blow hot air around. When asked if room changes were offered to residents on the affected units, NHA-A stated R1 and R5 did not want to move but was not sure if R4 was offered a room change. NHA-A stated they purchased Gatorade, popsicles, and freezer pops and encouraged staff to offer the items. The facility provided documentation that a popsicle/water pass was completed on 6/30/26 at 2:00 PM and 7/1/26 at 11:00 AM. On 7/1/26 at 3:18 PM, Surveyor interviewed Director of Nursing (DON)-B and [NAME] President of Success (VPS)-C. DON-B indicated the facility did not increase dehydration monitoring for residents and stated additional vital signs were obtained if it looked like a resident was not doing well. DON-B stated staff were instructed to round frequently, offer water, and ensure doors were open and windows were closed. The facility purchased popsicles and had lemonade in the lower level lobby. VPS-C stated MD-D monitored the air temperature and talked with regional plant operations. VPS-C stated an air conditioning unit was moved into R1's room and no rooms were above 81 degrees F. Surveyor informed VPS-C of R1, R4, R5, and R6's room temperatures as well as observations and interviews from earlier that day. When asked about education, DON-B and VPS-C indicated verbal education was completed each shift regarding extra water passes and to let staff know where things were. Surveyor requested a more specific timeline between 6/12/26 and 6/22/26 when CMP-E was contacted as well as copies of phone records and quotes received.On 7/2/26 at 11:24 AM, Surveyor received a narrative email from MD-D which did not contain dates, times or vendors who were contacted. The narrative indicated: The delays experienced during this process have resulted from several factors outside the maintenance department's direct control, including: Corporate requirements for multiple competitive bids prior to approval; Vendor approval processes, including W-9 documentation and onboarding; Contractor response times and scheduling delays; Extended lead times for specialized replacement parts; The complexity of repairing a specialized rooftop unit requiring equipment capable of safely accessing the roof and replacing the condenser coil without causing additional damage; Contractors whose proposed repair methods did not provide a dependable long-term solution. The narrative also indicated: Throughout this entire process, the maintenance department has acted proactively and responsibly. Every reasonable effort has been made to identify qualified contractors, obtain competitive bids, secure corporate approvals, coordinate temporary cooling solutions, maintain operational HVAC equipment, and pursue the most reliable long-term repair available. (The narrative did not contain dates when various vendors were contacted or communication between 6/12/26 and 6/22/26. Surveyor requested the informaiton via email on 7/2/26.)On 7/6/26 at 9:51 AM, Surveyor received a timeline via email from VPS-C that indicated MD-D inspected the unit, discovered the leak, and noted the unit was not working on 6/12/26. A service technician inspected the unit and gathered information the same day and stated they would send a quote for repairs. A quote was not provided. MD-D spoke with a second service company about a quote on 6/22/26. MD-D did not agree with their approach. A quote was not provided. MD-D contacted CMP-E on 6/22/26. A technician was onsite and verified the information provided. (This was different than information provided in the interview with AR-G.) MD-D ordered temporary air conditioning units from CMP-E on 6/24/26. (This was different than information provided in the interview with SR-F which indicated they were contacted on 6/26/26.) MD-D received a quote from CMP-E on 6/25/26 who delivered 5 temporary air conditioners. (This was different than information from earlier interviews which indicated the units were installed on 6/29/26.) CMP-E's quote was approved by the facility's corporate office and sent back to CMP-E on 6/29/26. The repair should be completed on 7/8/26 contingent on receipt of the part.

Based on staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 17 residents residing in the facility.The facility did not track employee call ins due to illness and did not monitor signs and symptoms of illness or return to work dates. The facility's Infection Surveillance policy, dated 3/8/23, indicates: A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. Infection surveillance refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection related data .10. Employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza, or gastrointestinal infection outbreaks. From 8/18/25 to 8/20/25, Surveyor reviewed the facility's infection surveillance program which did not include tracking employee call ins due to illness or monitoring signs and symptoms of illness and return to work dates. Surveyor requested resident and staff line lists for January 2025 to the present. The facility provided resident line lists, including data related to infections as well as tracking and trending information. The facility did not provide documentation of employee illnesses or employee call ins due to illness for January 2025 to the present. Surveyor noted the facility had a COVID-19 positive staff in April of 2025 and a COVID-19 positive staff and resident on 8/20/25. On 8/18/25 at 11:40 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility does not keep track of employee call ins due to illness. DON-B indicated DON-B was told employees do not have to give a reason why they called in so the call in is documented on a slip without a reason. On 8/20/25 at 10:11 AM and 10:58 AM, Surveyor interviewed [NAME] President of Success (VPS)-C who indicated the facility does not have a policy or procedure for employee call ins due to illness and does not monitor employees' signs and symptoms of illness or return to work dates.

Based on observation, staff interview, and record review, the facility did not ensure kitchen equipment was monitored appropriately to ensure food safety. This practice had the potential to affect all 17 residents residing in the facility.The dishwasher did not meet the minimum wash and rinse temperatures to prevent the spread of foodborne illness. In addition, staff did not document internal surface temperatures.Staff did not consistently complete documentation logs for parts per million (PPM) of the sanitizing solution.Findings include:On 8/18/25 at 9:58 AM, Surveyor interviewed Dietary Manager (DM)-G and Regional Manager (RM)-H who indicated the facility follows the Federal and State Food Codes (whichever is stricter).Mechanical Warewashing:The 2022 Food and Drug Administration (FDA) Food Code documents at 8-103.12 (C) To maintain and provide to the regulatory authority or the department upon request records specified under section 1-106.12 that demonstrate that the following is routinely employed: (1) Procedures for monitoring the critical control points, (2) Monitoring of the critical control points.The 2022 FDA Food Code documents at Chapter 4-501.15 Warewashing Machines, Manufacturers, Operating Instructions: To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved.The 2022 FDA Food Code documents at Chapter 2-103.11 Person in Charge: The person in charge shall ensure that: (L) Employees are properly sanitizing multi-use equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, chemical concentration, pH, temperature, and exposure time for chemical sanitizing.The facility's Warewashing policy indicates all dish machine water temperatures will be maintained in accordance with manufacturer's recommendations for high temperature machines .Temperature and/or sanitizer concentration logs will be completed, as appropriate.On 8/20/25 at 9:09 AM, Surveyor completed a follow-up tour of the kitchen and noted staff were already in the process of washing dishes. Surveyor interviewed DM-G who stated the facility uses a hot water sanitizing machine. DM-G indicated the minimum wash temperature is between 150-160 degrees Fahrenheit (F) and the minimum rinse temperature is 180 degrees F. DM-G stated staff monitor and document temperatures prior to washing dishes 3 times per day. DM-G stated staff monitor the internal surface temperature with a fixed thermometer that is run through the machine prior to washing. DM-G stated the temperature should be above 160 degrees F. DM-G showed Surveyor the thermometer which was just run through the dish machine and read 164.3 degrees F. Surveyor observed the manufacturer's data plate attached to the underside of the dish machine. DM-G was not aware of the data plate. The data plate indicated a minimum wash temperature of 160 degrees F and a minimum rinse temperature of 180 degrees F. Surveyor observed Dietary Aide (DA)-I complete dishwashing. During the observation, Surveyor noted a rinse temperature of 176 degrees F on the machine's external thermometer. Surveyor noted DA-I did not monitor to ensure the minimum temperature was reached and did not rewash the dishware. On 8/20/25, Surveyor reviewed the facility's dish machine logs. The log template indicated temperatures are documented 3 times per day. Surveyor reviewed the logs for May 2025 through August 2025 and noted the following:~ In May 2025, the minimum rinse temperature was not reached in 35 of 93 occurrences. ~ In June 2025, the minimum rinse temperature was not reached in 16 of 90 occurrences.~ In July 2025, the minimum rinse temperature was not reached in 37 of 93 occurrences.~ In August 2025, the minimum wash temperature was not reached in 12 of 58 occurrences.Surveyor noted the facility's dish machine logs included documented PPM monitoring, but did not include internal surface temperature monitoring.On 8/20/25 at 11:34 AM, Surveyor interviewed DM-G who was not aware the dish machine log did not include an area to document internal surface temperatures. DM-G confirmed staff should be documenting internal surface temperatures for the dish machine. Sanitizing Solution PPM:The 2022 FDA Food Code documents at 8-103.12 (C) Maintain and provide to the regulatory authority or the department upon request records specified under section 1-106.12 that demonstrate that the following is routinely employed: (1) Procedures for monitoring the critical control points, (2) Monitoring of the critical control points.The 2022 FDA Food Code at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.On 8/20/25, Surveyor reviewed the facility's sanitizer bucket logs which indicated staff should test and document PPM of the sanitizing solution a minimum of every 4 hours or more often if necessary. Surveyor reviewed the May 2025 log and noted testing of the PPM of the sanitizing solution was not documented on 27 of 124 occasions.On 8/20/25 at 11:34 AM, Surveyor interviewed DM-G who confirmed staff should consistently test and document PPM of the sanitizing solution in the sanitizer buckets.

Based on observation, staff interview, and record review, the facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. This practice had the potential to affect all 17 residents residing in the facility.On 8/18/25, the lid on an outside refuse dumpster was open and the rear sliding door on another dumpster was ajar with exposed food pulled out. In addition, insects, including wasps and/or bees, were observed inside and outside the dumpster near the exposed food.Findings include:On 8/18/25 at 9:58 AM, Surveyor interviewed Dietary Manager (DM)-G and Regional Manager (RM)-H who indicated the facility follows the Federal and State Food Codes (whichever is stricter).The facility's Dispose of Garbage and Refuse policy, dated August 2017, indicates all garbage and refuse will be collected and disposed of in a safe and efficient manner .The Dining Services Director coordinates with the Director of Maintenance to ensure the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris .The Dining Services Director will ensure that appropriate lids are provided for all containers.The Wisconsin Food Code documents at Chapter 5-501.13, Receptacles: Except as specified in (B) of this section, receptacles and waste handling units for refuse, recyclables, and returnables and for use with materials containing food residue shall be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent.The Wisconsin Food Code documents at Chapter 5-501.15, Outside Receptacles: (A) Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for refuse and recyclables such as an on-site compactor shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and, if the unit is not installed flush with the base pad, under the unit.On 8/18/25 at 9:39 AM, Surveyor conducted an initial tour of the kitchen with Dietary Aide (DA)-I. During the tour, Surveyor and DA-I observed two outside dumpsters located by the receiving dock doors. One dumpster had an open lid with exposed refuse. The other dumpster had a rear sliding door that was ajar. Surveyor observed several garbage bags inside the dumpster that were open with exposed food. Surveyor also observed a bag that contained sliced bread outside the dumpster on the receiving dock ledge behind the open door. Surveyor and DA-I noted several slices of bread were removed from the bag and on the cement with bees and/or wasps hovering over the exposed food and inside the dumpster.On 8/18/25 at 9:58 AM, Surveyor interviewed DM-G who verified dumpster lids and doors should be securely shut.On 8/19/25 at 12:08 PM, Surveyor interviewed RM-H who stated DM-G cleaned the dumpsters and removed all exposed food.On 8/20/25 at 11:34 AM, Surveyor interviewed DM-G who stated DM-G thoroughly cleaned the dumpster area. DM-G stated the rear door to the dumpster was broken but DM-G and another staff got it closed and called the disposal company.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored and labeled appropriately in 1 of 1 medication cart and 1 of 1 medication storage room. This practice had the potential to affect more than 4 of the 17 residents residing in the facility.The medication cart contained resident medications with no use-by or open dates.R10's eye drops were not labeled with R10's name or instructions for use.On 8/19/25, a medication cart was left unlocked and unattended.Findings include:The facility's Medication Administration General Guidelines policy, dated1/25, indicates: .During administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the personnel administrating the medications when unlocked.During medication pass on 8/19/25 from 5:32 AM to 8:38 AM, Surveyor noted the medication cart contained the following medications with no open or use-by dates:~ A NovoLog flex pen injector 100 unit/milliliter (ml) for R10. ~ A bottle of dorzolamide hydrochloride/timolol maleate 2%/0.5% ophthalmic solution for R10. ~ A bottle of cyclosporine ophthalmic emulsion 0.05% for R10. ~ A bottle of brimonidine tartrate ophthalmic solution 0.15% for R10. ~ A bottle of prednisolone acetate ophthalmic suspension 1% for R10.On 8/19/25 at 8:45 AM, Surveyor interviewed Registered Nurse (RN)-M who verified R10's eye drops were not labeled with open dates.On 8/19/25 at 9:00 AM, Surveyor interviewed Director of Nursing (DON)-B who verified insulins and eye drops should be labeled with open dates.2. On 8/19/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including diabetes, methicillin sensitive Staphylococcus aureus (MSSA), glaucoma, and legal blindness.R10's medical record contained an order for Cosopt ophthalmic solution 2-0.5% (dorzolamide HCL-timolol maleate), instill 3 drops in right eye once daily for glaucoma.On 8/19/25 at 8:38 AM, Surveyor observed RN-M prepare to administer dorzolamide hydrochloride/timolol maleate 2%/0.5% ophthalmic solution to R10 when Surveyor noted there was not a label on the eye drop bottle or the storage bag that indicated R10's name, an open date, or instructions for use.On 8/19/25 at 8:45 AM, Surveyor interviewed RN-M who verified R10's eye drops and storage bag did not contain a label or resident identifier.3. On 8/19/25 at 5:18 AM, Surveyor noted a medication cart was unlocked and unattended in front of the nurses' station.On 8/19/25 at 5:20 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-O who verified the medication cart should not be unlocked when unattended.

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 medication administration observations, 2 errors occurred during 26 opportunities which resulted in an 7.69% medication error rate that affected 2 residents (R) (R7 and R16) of 4 residents observed during medication administration. On 8/19/25, R7 was administered the wrong cough medication.On 8/19/25, R16's scheduled 6:00 AM medication was administered at 7:36 AM.Findings include:The facility's Medication Administration General Guidelines policy, dated1/25, indicates: Prior to medication administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR); Medications are administered in accordance with written orders of the prescriber; Medications are administered within 60 minutes of scheduled time .1. On 8/19/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including diabetes, congestive heart failure, chronic kidney disease, and dysphagia.R7's medical record contained an order (dated 7/28/25) for guaifenesin-dextromethorphan (DM) liquid 100-10 mg/5ml, give 5 ml by mouth every 6 hours as needed for cough. On 8/19/25 at 6:43 AM, Surveyor observed Registered Nurse (RN)-M prepare and administer 5 milliliters (ml) of dextromethorphan hydrobromide 20 milligrams (mg)/guaifenesin 200 mg/phenylephrine hydrochloride 10 mg liquid (a combination medication used as a cough suppressant, an expectorant to help loosen mucous in the airways, and a nasal decongestant) from the facility's house stock. Surveyor noted the stock medication administered by RN-M was not in accordance with R7's order. On 8/19/25 at 3:28 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the wrong medication was administered to R7.2. On 8/19/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including multiplesclerosis (MS), anxiety, and depression.On 8/19/25 at 7:31 AM, Surveyor observed RN-M prepare and administer a 0.5 mg alprazolam extended release (ER) oral tablet to R16. The medication card label stated to give every 12 hours at 0600 (6:00 AM) and 1800 (6:00 PM). Surveyor reviewed R16's MAR which contained an order for alprazolam ER oral tablet extended release 24 hour 0.5 mg, give 1 tablet two times daily for anxiety 0600 and 1800.On 8/19/25 at 7:36 AM, Surveyor interviewed DON-B who verified R16's alprazolam 0.5 mg tablet that was scheduled for 6:00 AM was administered late.

Based on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 2 of 8 staff reviewed for caregiver background checks.The facility did not ensure a thorough caregiver background check was completed for Licensed Practical Nurse (LPN)-E and Certified Nursing Assistant (CNA)-F.Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/2022, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .I. Screening - A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff .Background checks, including re-checks, will be completed consistent with applicable state laws and regulations. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement. 2. Screenings may be conducted by the facility itself, a third-party agency .3. The facility will maintain documentation of proof that the screening occurred.On 8/19/25, Surveyor reviewed background check information for 8 facility staff, including LPN-E and CNA-F.LPN-E's hire date by corporate was listed as 10/30/24. LPN-E transferred to the facility on 6/22/25. LPN-E's Background Information Disclosure (BID) form was dated 6/23/25. LPN-E's Department of Justice (DOJ) criminal background check letter and Integrated Background Information System (IBIS) letters were both dated 8/18/25 (after the survey team entered the facility).CNA-F's hire date was listed as 1/2/2025. CNA-F's BID form was dated 8/23/23 which was prior to CNA-F's eighteenth birthday. The facility did not complete a new BID form after CNA-F turned eighteen on 7/5/25 and did not obtain DOJ or IBIS letters.On 8/19/25 at 10:44 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated background checks should be completed prior to staff starting at the facility. On 8/19/25 at 12:20 PM, Surveyor interviewed Business Office Manager (BOM)-D who indicated the facility's system changed approximately two weeks prior. BOM-D indicated recruiters from corporate used to complete the hiring process and background checks. BOM-D confirmed LPN-E did not have a DOJ or IBIS letter on file and a thorough background check was not completed prior to 8/18/25. BOM-D indicated CNA-F was under eighteen when hired and confirmed CNA-F worked in the facility between 7/5/25 and 8/18/25. BOM-D indicated CNA-F should have completed a new BID form after CNA-F turned eighteen.

Based on staff interview and record review, the facility did not ensure a Preadmission Screen and Resident Review (PASRR) was submitted for additional screening after a new antipsychotic medication was prescribed for 1 resident (R) (R12) of 5 sampled residents.On 8/27/24, R12 was prescribed Seroquel (an antipsychotic medication) for mood and behavior. The facility did not update R12's Level I PASRR Screen and did not submit for another Level II evaluation when R12 was prescribed a new medication.Findings include:From 8/18/25 to 8/20/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including malignant carcinoid tumor of the small intestine, anxiety disorder, depression, and labile mood. R12's Minimum Data Set (MDS) assessment, dated 8/7/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R12 had intact cognition. R12 had a Guardian who was responsible for R12's healthcare decisions. R12's PASRR Level I Screen was updated on 8/22/24 due to R12's change of condition and sent to the state designated authority for a PASRR Level II evaluation. The Level II Screen was completed on 8/23/24 and included R12's mental illness diagnoses of depression, anxiety, and labile mood and medications, including Zoloft (an antidepressant medication), Xanax (a sedative medication) and Depakote (an anticonvulsant medication).On 8/27/24, R12 was prescribed Seroquel for mood and behavior. R12's medical record did not include an updated PASRR Level I or Level II Screen.On 8/20/25 at 11:49 AM, Surveyor interviewed Social Worker (SW)-P who was responsible for completing PASRR Level I Screens and submitting them for Level II evaluation. SW-P stated SW-P completes resident reviews every 3 months to verify any changes. SW-P stated staff also notify SW-P if there is a change in condition or a new medication or diagnosis. SW-P confirmed R12's PASRR Level I Screen should have been updated to include the new order for Seroquel and submitted for a Level II evaluation.

Based on observation, staff interview, record review, and facility policy review, the facility did not provide mechanically altered diets as ordered by the physician for 2 residents (R) (R4 and R5) of 2 sampled residents. Failure to provide diets as ordered by the physician places residents at risk for malnutrition, choking, and aspiration. Findings include:The facility's undated Therapeutic Diets policy indicates: All residents have a diet order, including regular, therapeutic, and texture modification that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines .Mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physician's or delegated registered or licensed dietitian's order .An L3/Advanced diet consists of mechanical advanced, soft, chopped, soft and bite-sized .The food consists of foods of varying textures with the exception of very hard, sticky, or crunchy foods. Foods need to be served moist and ground, chopped, or in bite- sized pieces (less than 1 inch).1. A Face Sheet contained in R4's medical record revealed an admission date of 4/4/24 with medical diagnoses that included unspecified dementia, type 2 diabetes, and unspecified severe protein-calorie malnutrition. R4's current care plan, dated 10/23/24, indicated: I am at increased nutritional risk related to history of (type 2 diabetes mellitus), dementia/Alzheimer's disease, and low (Body Mass Index). Interventions included: Palliative care: Will accept food and fluids as desired and/or tolerated .Will exhibit no chewing or swallowing problems with current diet texture as evidenced by no (signs/symptoms) of aspiration, choking, or complaints of difficulty eating .R4's Physician's Order Report, dated 1/27/25, indicated: Diet: L3/Advanced texture, Regular/thin consistency, no room trays.R4's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/21/25, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R4 had severe cognitive impairment. The MDS assessment also indicated R4 experienced coughing or choking during meals during the assessment period.2. A Face Sheet contained in R5's medical record revealed an admission date of 10/06/14 with medical diagnoses that included dementia with severe agitation, Alzheimer's disease, and vascular dementia, severe with agitation. R5's care plan, dated 2/21/24, indicated: Potential for alteration in nutrition due to obesity .and (diagnosis) of dementia. Approaches included: The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date .will continue to feed self .R5's physician order, dated 1/27/25, indicated: Diet: L3/Advanced texture, Regular/thin consistency, liberalize diet (due to) advanced age and dementia (diagnosis).R5's Quarterly MDS assessment, with an ARD of 5/30/25, revealed R5 had a BIMS score of 3 out of 15 which indicated R5 had severely impaired cognition. The MDS assessment also indicated R5 experienced coughing or choking during meals during the assessment period.On 7/9/25 at 12:45 PM, Certified Nurse Aide (CNA)1 asked Surveyor to look at R4 and R5's meal trays. Both residents had cubed pork loin in a dish. The cubes were hard and greater than one inch in size. R4 and R5 also had broccoli spears that were firm to the touch with a fork. Tray cards revealed R4 and R5 were to have ground meat and broccoli soft and mashed.During an interview on 7/9/25 at 1:00 PM, Dietary Aide (DA)7 revealed the meat was supposed to be ground but the blender that was used to chop food was broken. DA7 indicated the Dietary Manager (DM) brought a blender from home and would not let staff use the Robot Coupe (professional food blender) in the kitchen. On 7/9/25 at 4:30 PM, the DM stated R4 and R5 had problems with swallowing and chewing and were to receive an L3/Advanced diet with soft, bite-sized foods at meals. The DM confirmed staff should not have served R4 and R5 the pork loin in chunks and indicated the pork loin should have been in smaller pieces and the broccoli should have been soft and mashed. The DM stated the Robot Coupe was available and the DM had not told staff not to use it.During a phone interview on 7/9/25 at 5:30 PM, the Registered Dietitian (RD) stated an L3/Advanced diet allows for bite sizes up to one inch, although the food should be soft.During an interview on 7/10/25 at 9:00 AM, the Director of Nursing (DON) stated a resident's menu card/diet card should be followed. The DON stated both R4 and R5 had severe dementia and had trouble with eating. The DON indicated R4 and R5 ate slowly, had to be encouraged to eat, and their food must be softened.

Based on staff interview and record review, the facility did not ensure care was provided in accordance with a physician order for 1 resident (R) (R2) of 4 sampled residents. Staff did not provide a prescribed treatment for R2's wound and administered a treatment that was not ordered by the physician without the physician's knowledge. Findings include: The facility's Medication Reconciliation policy, with a review date of 10/24/22, indicates: The facility reconciles medications frequently throughout a resident's stay to ensure the resident is free of significant medication errors .Daily Process: a. Address any clinically significant medication irregularities reported by the pharmacy consultant. b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given. c. Obtain and transcribe any new orders in accordance with facility procedures, obtain clarification as needed. New orders should have a second nurse to review the order for accuracy. d. Order medications from pharmacy in accordance with facility procedures for ordering medications. e. Verify medications received match the medication orders. On 10/9/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including diabetes, morbid obesity, anxiety, Fournier's disease of the vagina and vulva, and necrotizing fasciitis. R2's Minimum Data Set (MDS) assessment, dated 10/4/24, stated R2's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R2 had intact cognition. R2's medical record indicated R2 was responsible for R2's healthcare decisions. R2 had a physician order for Clotrimazole External Cream 1% apply twice daily to right inner thigh for 10 days for erythema (with a start date of 9/24/24). On 10/9/24, Surveyor reviewed R2's Medication Administration Record (MAR) from 9/24/24 through 9/30/24 and noted the following regarding R2's Clotrimazole cream: ~ 9/24/24 - Medication unavailable ~ 9/25/24 - No entry ~ 9/25/24 - On order ~ 9/26/24 - On order ~ 9/26/24 - N/A (not applicable) ~ 9/27/24 - No entry ~ 9/27/24 - Unavailable, on order ~ 9/28/24 - Medication administered ~ 9/28/24 - Medication administered ~ 9/29/24 - No entry ~ 9/29/24 - Unavailable ~ 9/30/24 - Unable to locate ~ 9/30/24 - Cream will be sent out today, resident updated ~ 9/30/24 - Medication on order from pharmacy, will be delivered on next run On 10/9/24 at 1:08 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the pharmacy did not have Clotrimazole cream in stock, so the facility used house stock antifungal cream until they were able to get Clotrimazole from the pharmacy. Surveyor noted R2 did not have a physician order for antifungal cream and R2's medical record did not indicate the physician was notified regarding the change in medication. On 10/9/24 at 1:37 PM, Surveyor interviewed DON-B who indicated the house stock antifungal cream was DermaFungal Antifungal Cream 2% Miconazole Nitrate. DON-B confirmed R2 did not have a physician order for the change in medication and staff did not update the physician. DON-B indicated DON-B expected staff to update R2's physician and MAR with the change in medication and initial the medication that was administered in place of Clotrimazole.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R5) of 2 sampled residents received appropriate care and services to prevent urinary tract infections (UTIs). Staff did not ensure R5 was provided catheter care in a manner that decreased the risk of infection. Findings include: The facility's Catheter Care policy, revised 3/15/23, indicates: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Privacy/dignity bags will be available and catheter drainage bags should be covered or shielded at all times while in use . On 8/26/24, Surveyor reviewed R5's medical record. R5 had diagnoses including type 2 diabetes with chronic kidney disease, retention of urine, and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. R5's Minimum Data Set (MDS) assessment, dated 6/11/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R5 had moderately impaired cognition. On 8/26/24 at 8:25 AM, Surveyor observed R5 in R5's room and noted R5's catheter drainage bag was uncovered and attached to the bottom of R5's wheelchair. R5's catheter tubing and drainage bag were in contact with the floor. A dignity bag was hung on the bottom of the other side of R5's wheelchair. On 8/26/24 at 10:21 AM, Surveyor observed R5 in R5's room and noted R5's catheter bag was uncovered and attached to the bottom of R5's wheelchair. R5's catheter tubing and drainage bag were in contact with the floor. A dignity bag was hung on the bottom of the other side of R5's wheelchair. Surveyor interviewed R5 who stated nursing staff assist with catheter care which was completed earlier that morning. R5 stated R5's catheter bag was hung underneath R5's wheelchair and R5 could not see the bag and tubing. R5 stated R5 relied on nursing staff to ensure catheter care was performed without complications. On 8/26/24 at 1:20 PM, Surveyor observed R5 in R5's room and noted R5's catheter bag was uncovered and attached to the bottoms of R5's wheelchair. R5's catheter tubing and drainage bag were in contact with the floor. A dignity bag was hung on the bottom of the other side of R5's wheelchair. On 8/26/24 at 1:22 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who was unsure of the facility's policy regarding covering catheter bags. ADON-C stated catheter bags should be hung below the level of the bladder and catheter bags and tubing should not be on the floor. During the interview, ADON-C and Surveyor went to R5's room. ADON-C confirmed R5's catheter bag was uncovered and the bag and tubing were in contact with the floor. ADON-C stated catheter bags and tubing should be kept off the floor for infection prevention and confirmed the facility's catheter care process was not followed.

Based on observation, staff and resident interview, and record review, the facility did not ensure 3 Residents (R) (R1, R2, and R5) of 5 sampled residents received the necessary care and services to prevent dehydration. The facility did not provide consistent hydration for R1, R2, and R5. Findings include: The facility's Hydration policy, dated 7/26/22, indicates: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health .4. b. Interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: .i. Offer the resident a variety of fluids during and between meals . 1. On 8/26/24, Surveyor reviewed R1's medical record. R1 had diagnoses including type 2 diabetes, severe constipation due to opioid use with current complications involving impaction, history of pressure and diabetic wounds with recent amputation of partial toe, and gout. R1's Minimum Data Set (MDS) assessment, dated 8/8/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. On 8/26/24 at 8:16 AM, Surveyor interviewed R1 who stated the water cup on R1's bedside table was from two days ago. R1 stated nursing staff do not provide water unless R1 asks. R1 stated R1 asks for water but it is not provided at times. R1 stated R1 had a care conference approximately one month ago and brought the concern to administration's attention. R1 stated R1 brought up the concern again at a follow-up care conference approximately one week prior. R1 stated it upset R1 that water was not provided and R1 frequently did not receive water when R1 asked. R1 stated R1 was concerned for residents who did not have the ability to ask and wondered how they were being hydrated. 2. On 8/26/24, Surveyor reviewed R2's medical record. R2 had diagnoses including fracture of the left tibia and hemiplegia (weakness on one side of the body). R2's MDS assessment, dated 7/23/24, had a BIMS score of 15 out of 15 which indicated R2 had intact cognition. On 8/26/24 at 10:17 AM, Surveyor interviewed R2 who stated the water cup on R2's bedside table was from last night. R2 stated R2 has to ask staff if R2 wants water. R2 stated R2 resided in other facilities were staff provided water throughout the day which staff did not do at this facility. 3. On 8/26/24, Surveyor reviewed R5's medical record. R5 had diagnoses including type 2 diabetes with chronic kidney disease, diabetic polyneuropathy, retention of urine, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, and gout. R5's MDS assessment, dated 6/11/24, had a BIMS score of 11 out of 15 which indicated R5 had moderately impaired cognition. On 8/26/24 at 10:21 AM, Surveyor interviewed R5 who stated the cup on R5's bedside table (which contained under 100 cc (cubic centimeters) of water) was from yesterday. R5 stated staff do not offer water or ensure water cups are filled and R5 has to staff if R5 wants water. R5 stated R5 asked staff for water that morning but had yet to receive it. R5 stated R5 was unsure what residents could who not ask received for hydration which bothered R5. On 8/26/24 at 11:43 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who stated CNA-F often did not have enough time to complete a water pass and provide hydration to residents. CNA-F stated water was provided per residents' request and confirmed staff were expected to complete a water pass each shift. On 8/26/24 at 11:38 AM, Surveyor interviewed CNA-D who stated staff were expected to complete a water pass once per shift and as needed. CNA-D stated water passes weren't completed at times due to staffing. CNA-D stated residents who asked for water were provided water and residents who were unable to ask received water at meals and during medication administration.

Based on staff and resident interview and record review, the facility did not ensure accurate administration of medication for 1 Resident (R) (R1) of 5 sampled residents. R1 did not consistently receive scheduled medications timely as ordered by R1's physician. Findings include: The facility's Medication Administration policy, dated 1/2024, indicates: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices .Medications are administered within 60 minutes of the scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . On 8/26/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, anxiety disorder, and history of urinary tract infections (UTIs). R1's Minimum Data Set (MDS) assessment, dated 5/29/24, stated R1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R1 had intact cognition. R1's medical record indicated R1 was responsible for R1's healthcare decisions. On 8/26/24 at 8:15 AM, Surveyor interviewed R1 who stated R1 often received R1's scheduled medications late. On 8/26/24, Surveyor reviewed R1's medical record which contained the following physician orders: ~ Cefadroxil (used to treat infection) oral capsule 500 mg (milligrams) give 1 capsule by mouth every morning and at bedtime (start date 8/8/24, end date 8/14/24). ~ Gabapentin (used to treat nerve pain) capsule 300 mg give 1 capsule by mouth three times a day. ~ Hydroxyzine HCl (hydrochloride) (used to treat anxiety) oral tablet 50 mg give 50 mg by mouth three times a day. ~ Insulin lispro (used to treat high blood sugar) (1 unit dial) subcutaneous solution pen injector 100 unit/ml (milliliter) Inject 10 units subcutaneously with meals .Give with sliding scale. ~ Insulin lispro (1 unit dial) subcutaneous solution pen injector 100 unit/ml inject as per sliding scale: if 0-100 = -2 (If less then 100 subtract 2 units); 150-199 = 2; 200-249 = 4; 250-299 = 6; 300-350 = 8, subcutaneously three times a day .hold if not eating. ~ Blood glucose monitoring before meals and at bedtime. Call Medical Doctor (MD) if blood glucose level is less than 100 or greater than 350. On 8/26/24 at 12:34 PM, Surveyor interviewed [NAME] President of Success (VPS)-E via phone. VPS-E stated the facility had liberalized medication pass times for most scheduled medications. VPS-E stated AM on the Medication Administration Record (MAR) meant a timeframe for medication pass of 6:00 AM to 10:00 AM; Noon meant a timeframe of 10:00 AM to 2:00 PM; PM meant a timeframe of 2:00 PM to 6:00 PM; and HS meant a timeframe of 6:00 PM to 10:00 PM. On 8/26/24, Surveyor reviewed R1's August 2024 MAR which indicated R1's cefadroxil was scheduled for AM and HS; R1's gabapentin was scheduled for AM, noon, and HS; R1's hydroxyzine was scheduled for AM, noon, and HS; R1's base dose of insulin lispro was scheduled for 8:00 AM, 12:00 PM and 5:00 PM; R1's sliding scale insulin was scheduled for AM, noon, and HS; and R1's blood sugar monitoring was scheduled for 7:30 AM, 11:30 AM, 5:00 PM, and 8:00 PM. On 8/26/24 at 1:05 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding meal times. NHA-A stated the facility's meal times were 8:30 AM for breakfast, 12:30 PM for lunch, and 5:30 PM for dinner. On 8/26/24, Surveyor reviewed a Medication Admin Audit Report which contained the medications R1 received from 8/9/24 through 8/26/24 and indicated the following: ~ On 8/9/24, R1's 8:00 AM dose of insulin lispro (to be given with meals as ordered) was administered at 9:56 AM; R1's AM dose of sliding scale insulin was administered at 9:57 AM; R1's blood sugar (to be obtained before meals as ordered) was obtained at 9:55 AM. ~ On 8/9/24, R1's 12:00 PM dose of insulin lispro was administered at 1:17 PM. ~ On 8/9/24, R1's noon dose of sliding scale insulin and blood sugar level was administered/obtained at 1:18 PM. ~ On 8/10/24, R1's 8:00 AM dose of insulin lispro was administered at 9:57 AM (to be given with sliding scale insulin as ordered); R1's AM dose of sliding scale insulin was administered at 10:44 AM from R1's 7:30 AM blood sugar level which was obtained at 8:57 AM. ~ On 8/10/24, R1's AM doses of cefadroxil, gabapentin, and hydroxyzine were administered at 10:47 AM. ~ On 8/10/24, R1's 12:00 PM dose of insulin lispro was administered at 1:28 PM; R1's noon dose of sliding scale insulin was administered at 3:04 PM from R1's 11:00 AM blood sugar level which was obtained at 1:28 PM. ~ On 8/10/24, R1's HS doses of gabapentin and hydroxyzine were administered at 10:17 PM. ~ On 8/11/24, R1's 12:00 PM dose of insulin lispro was administered at 2:00 PM; R1's noon dose of sliding scale insulin was administered at 2:01 PM from R1's 11:00 AM blood sugar level which was obtained at 2:00 PM. ~ On 8/12/24, R1's AM doses of gabapentin and hydroxyzine were administered at 10:42 AM. ~ On 8/12/24, R1's AM dose of sliding scale insulin was administered at 11:15 AM from R1's 7:30 AM blood sugar level which was obtained at 9:03 AM. ~ On 8/24/24, R1's 12:00 PM dose of insulin lispro was administered at 2:27 PM; R1's noon dose of sliding scale insulin was administered at 2:28 PM from R1's 11:00 AM blood sugar level which was obtained at 2:23 PM. ~ On 8/24/24, R1's noon doses of gabapentin and hydroxyzine were administered at 2:24 PM. On 8/26/24 at 1:47 PM, Surveyor interviewed VPS-E via phone. VPS-E verified R1's insulin should have been given with meals as ordered. VPS-E also verified the medications listed above were administered late based on the documentation.

Based on observation, staff and resident interview, and record review, the facility did not ensure adequate supervision was provided for 1 Resident (R) (R2) of 11 sampled residents. On 6/19/24, facility staff discontinued R2's increased supervision after an allegation of sexual assault. The facility did not ensure adequate supervision was provided to prevent R2 from wandering and/or disrobing in front of other residents. Findings include: On 7/31/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, hypertension, and congestive heart failure. R2's most recent Minimum Data Set (MDS) assessment, dated 7/6/24, stated R2's Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated R2 had moderate cognitive impairment. R2's wandering care plan, revised on 6/19/24, had a focus area of wandering related to cognitive impairment and a history of disrobing in public. The care plan contained interventions to continue to check frequently, encourage activities outside of room, and use a motion sensor to assist in monitoring R2's wandering. Nursing progress notes, dated 7/24/24 at 3:16 PM and 7/28/24 at 4:16 PM, indicated R2 came out of R2's room naked and was easily redirected. On 7/23/24 at 10:33 AM, Surveyor observed R2 asleep in a recliner in R2's room. Outside of R2's room, Surveyor observed a motion sensor that was switched to on. When Surveyor walked past the motion sensor, a green light flashed. Surveyor did not observe nursing or Certified Nursing Assistant (CNA) staff respond to the motion sensor. On 7/23/24 at 10:37 AM, Surveyor interviewed agency Licensed Practical Nurse (LPN)-C regarding R2's motion sensor. LPN-C stated LPN-C was not sure what the sensor was for. LPN-C checked with another staff and indicated the motion sensor was only for the night shift. LPN-C verified LPN-C did not keep track of the motion sensor. On 7/31/24 at 1:33 PM, Surveyor interviewed R8 regarding R2's wandering. R8 stated approximately one week ago, R8 saw R2 running around naked. R8 stated R8 had seen R2 naked approximately three times since R8's admission on 7/22/24. R8 stated R8 had not told anyone about the occurrences because nothing was being done. On 7/31/24 at 2:53 PM, Surveyor interviewed LPN-D regarding R2's motion sensor. LPN-D verified the motion sensor should be on at all times. On 7/31/24 at 2:59 PM, Surveyor interviewed CNA-F regarding R2's wandering and motion sensor. CNA-F stated last week, R2 started to come out of R2's room naked again. CNA-F stated R8 told CNA-F that R2 was in R8's bathroom during the night sometime last week. CNA-F also observed R2 come out of R2's room without pants. On 7/31/24 at 3:05 PM, Surveyor interviewed CNA-E regarding R2's wandering and motion sensor. CNA-E stated R2 came out of R2's room a couple of times during the last few weeks without clothes on. CNA-E stated within the last week and a half, R2 was found naked in R11's bathroom after supper. On 7/31/24 at 3:08 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R2's motion sensor and supervision. NHA-A verified the motion sensor should be on at all times. NHA-A was not aware of any instances where R2 was outside of R2's room naked. On 7/31/24 at 3:14 PM, Surveyor interviewed [NAME] President of Success (VPS)-G regarding R2's motion sensor and increased supervision. VPS-G verified R2's motion sensor should be monitored at all times. VPS-G stated 1:1 supervision education was provided after the incident on 6/7/24 but no formal education was provided related to R2's motion sensor. VPS-G stated regularly scheduled staff were aware of how to use the motion sensor but verified certain agency staff might not be.

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 26 residents residing in the facility. Staff did not perform proper hand hygiene prior to donning gloves, while passing silverware, prior to touching ready to eat food, and while doing dishes. Staff did not wear a beard net while plating food. The handwashing sink in the nourishment room on a resident unit was not in clean condition and appeared to be used for things other than handwashing. Kitchen equipment, refrigerators, an ice machine, and dishes were not stored clean, in a down facing position, covered appropriately, and/or stored 6 inches off the floor. Food items in unit refrigerators were not labeled or dated and/or were expired. Findings include: On [DATE] at 10:16 AM, Surveyor began an initial kitchen tour of the kitchen with Dietary Manager (DM)-D who stated the facility follows the Federal and State food codes (whichever is stricter). Hand Hygiene: The Wisconsin Food Code documents at Chapter 2 Personal Cleanliness at ,d+[DATE].14 titled When to Wash: Food employees shall clean their hands and exposed portions of their arms as specified under ,d+[DATE].12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (H) Before putting on gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. The Wisconsin Food Code documents at Chapter ,d+[DATE].11: (B) Knives, forks, and spoons that are not pre-wrapped shall be presented so that only the handles are touched by employees. The Wisconsin Food Code documents at Chapter ,d+[DATE].14 Wiping Cloths, Use Limitation: (A) Cloths in-use for wiping food spills from tableware and carry-out containers that occur as food is being served shall be: (1) Maintained dry; and (2) Used for no other purpose. (B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S ,d+[DATE].114; and (2) Laundered daily as specified under ,d+[DATE].11 (D). The facility's General Food Preparation and Handling policy, with a review date of [DATE], indicates: 5. Equipment: F. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food. The facility's Bare Hand Contact with Food and Use of Plastic Gloves policy, with a review date of [DATE], indicates: .1. Staff will use good hygienic practices and techniques with access to proper hand washing facilities (available soap, hot water, and disposable towels). Antimicrobial or antiseptic gel is not used in place of proper hand washing techniques. 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single-use gloves shall be used for only one task, used for one purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning work with food) and after removing single-use gloves. 6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hand must be watched. 7. Wash hands after removing gloves. The facility's Hand Washing-Food and Nutrition Services policy, with a review date of [DATE], indicates: Hands and exposed portions of arms should be washed immediately before engaging in food preparation: .f. After handling soiled equipment or utensils, Before donning disposable gloves for working with food and after gloves are removed. 4. Hand washing procedures will be posted by each hand-washing sink. 5. Food preparation and/or pot sinks will not be used for handwashing. During lunch service on [DATE] at 12:23 PM, Surveyor observed [NAME] (CK)-F don a pair of gloves prior to food service. CK-F did not wash hands prior to donning gloves. On [DATE] at 12:24 PM, Surveyor observed Dietary Aid (DA)-H approach the silverware tray. DA-H picked up a stack of forks, spoons, knives, and napkins. DA-H then passed out silverware in the dining room. DA-H walked from resident to resident, placed a napkin next to each resident and placed a knife, fork, and spoon in front of each resident. Surveyor observed DA-H touch the tips of the knives with DA-H's bare hands during the process. DA-H did not wash hands prior to touching clean silverware and napkins. On [DATE] at 12:25 PM, Surveyor observed CK-F take pre-service meal temperatures. Surveyor observed CK-F remove gloves, record the temperature, don gloves, and check the next temperatures. CK-F did not wash hands prior to donning gloves. On [DATE] at 12:31 PM, Surveyor observed CK-F don gloves to begin meal service. Surveyor observed CK-F touch scoops and food covers on the steam table while plating food for a resident. CK-F did not wash hands prior to donning gloves for meal service. On [DATE] at 10:22 AM, Surveyor observed Dietary Aid (DA)-G wash dishes. Surveyor observed DA-G spray and rinse dirty dishes with gloved hands, place the dishes in a rack, and push the rack through the dishmachine. DA-G then removed gloves and rinsed DA-G's hands with the wand used to rinse dirty dishes. DA-G then walked to the clean side of the dish area, pulled a clean rack out of the dishmachine, and touched clean bowls in a bin with DA-G's unwashed hands. When Surveyor stopped DA-G and informed DA-G that Surveyor did not observe DA-G wash hands prior to touching clean dishes, DA-G confirmed DA-G did not wash DA-G's hands. On [DATE] at 1:03 PM, Surveyor interviewed Regional Dietary Manager (RDM)-K and informed RDM-K of Surveyor's observations during meal service. RDM-K confirmed staff should perform hand hygiene prior to donning gloves, should touch silverware by the handles, and should use a tong for ready-to-eat food during meal service. On [DATE] at 10:25 PM, Surveyor interviewed DM-D who confirmed DA-G should have washed hands prior to touching clean dishes. Beard Net: The State of Wisconsin Food Code documents at ,d+[DATE].11: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. During lunch service on [DATE] at 12:23 PM, Surveyor observed CK-F put food in the steam table, obtain food temperatures, and plate two residents' meals behind the service area in the dining room. CK-F did not wear a beard net during the observation. On [DATE] at 2:42 PM, Surveyor interviewed DM-D who verified CK-F should have worn a beard net. Handwashing Sink: The Wisconsin State Food Code documents at ,d+[DATE].11 Using a Handwashing Sink: (A) A handwashing sink shall be maintained so that it is accessible at all times for employees use. (B) A handwashing sink may not be used for purposes other than handwashing. The Wisconsin State Food Code documents at ,d+[DATE].14 Handwashing Signage: A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees. The Wisconsin State Food Code documents at ,d+[DATE].11 (Equipment) Good Repair and Proper Adjustment: (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts ,d+[DATE] and ,d+[DATE]. On [DATE] at 2:05 PM, Surveyor inspected the nourishment room located across from the dining room on a resident unit. Surveyor noted the room contained a single sink with a bottle of dish soap and a bottle of cleanser between the wall and the sink. In addition, the upper right corner of the sink contained a sponge with brown edges, the top of the faucet contained a dry, crusted, brown-stained maroon rag, and one of drains contained chunks of food. Surveyor observed splatter around the sink and behind the wall. Surveyor opened the cabinet underneath the sink and noted the bottom of the cabinet had fallen out and contained crumbling fiberboard with dark/brown areas that appeared to be mold/mildew. On [DATE] 2:42 PM, Surveyor interviewed DM-D who stated the sink in the nourishment room was the sink kitchen staff needed to use for handwashing during meal service. DM-D stated the nourishment room sink was the only handwashing sink on the unit for kitchen staff. DM-D stated both housekeeping and kitchen staff cleaned the nourishment room. DM-D was unsure why there was dish soap, a dirty rag, and a sponge on/around the sink. DM-D confirmed the sink did not contain signage that indicated the sink was for handwashing. DM-D was also not aware of the condition of the cabinet underneath the sink. Cleanliness/Covering of Kitchen Equipment: The Wisconsin State Food Code documents at ,d+[DATE].11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (A) Except as specified in (D) of this section, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: (3) At least 15 cm (6 inches) above the floor and (2) Covered or inverted. The facility's General Food Preparation and Handling policy, with a review date of [DATE], indicates: 5. Equipment: A. All food service equipment should be cleaned, sanitized, air dried, and reassembled after each use. D. Flatware will be stored in such a manner to encourage contact with handles only. E. Staff will handle utensils, cups, glasses, and dishes in such a way as to avoid touching surfaces that food or drink will come in contact with. During the initial kitchen tour on [DATE], Surveyor observed an uncovered meat slicer on the counter that contained dried food. DM-D stated the meat slicer had not been used that day. DM-D stated DM-D would clean and cover the meat slicer. On [DATE] at 2:01 PM, Surveyor observed an uncovered three shelf utility cart in the dining room behind the kitchen service area that contained various dishes staff used to plate food during meal service. Surveyor observed a large plastic bag next to the cart that looked as if it was used to cover dishes on the cart. Surveyor noted the cart contained plates on the top shelf that faced up and bowls that were not inverted on two other shelves. On [DATE] at 1:57 PM, Surveyor observed a full size refrigerator in the dining room. The bottom of the refrigerator contained a dried pink and yellow substance. Surveyor also observed colored splatter behind juice containers on the second shelf. In addition, Surveyor observed dried pink splatter on the third shelf and cracks with what appeared to be a black substance at the bottom of the refrigerator. On [DATE] at 2:05 PM, Surveyor observed an ice machine in the nourishment room that contained drips on the inside and outside. Surveyor observed a coffee maker directly above the ice machine. Surveyor also observed a mini refrigerator/freezer in the nourishment room that contained dried brown splatter. In addition, a box of single-service decaf Folgers coffee packets was sitting on the floor. On [DATE] at 2:42 PM, Surveyor interviewed DM-D who confirmed food items should be stored 6 inches off the floor. DM-D also confirmed the refrigerators in the dining room and the nourishment room should be cleaned and stated the refrigerators are cleaned by housekeeping and kitchen staff. DM-D also verified the coffee splatter on the ice machine. Labeling, Dating, and Expired Food Items: The Wisconsin Food Code 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 paragraph ,d+[DATE].12, and except as specified in paragraph (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. Commercially processed food open and hold cold (B) Except as specified in paragraph (E)-(H) of this section, refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as day 1; and (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 On [DATE] at 2:01 PM, Surveyor observed the dining room refrigerator and noted three unlabeled and undated fruit plates covered in plastic wrap. The refrigerator also contained two covered and unlabeled resident meals. On [DATE] at 2:42 PM, Surveyor interviewed DM-D who confirmed the fruit plates should be labeled and stated one of the meal trays was left from lunch because the resident was at an appointment. DM-D confirmed the lunch trays were not labeled. On [DATE] at 2:23 PM, Surveyor reviewed the items in the nourishment room refrigerator with Certified Nursing Assistant (CNA)-I. Surveyor also observed the following: ~ One Ziploc bag labeled 209 which contained what appeared to be deli ham. The bag was not labeled with the contents, was not dated, and did not contain an expiration date. CNA-I confirmed the bag was not labeled and also stated the packaging looked puffy and full of air. CNA-I threw bag in the garbage. ~ One 24 ounce (oz) container of Great Value Lowfat Cottage Cheese with an expiration date of ,d+[DATE] and labeled M. D. CNA-I confirmed the cottage cheese was expired and stated when staff have time they check the refrigerator for expired and outdated items. ~ Three 4 oz containers of HC Plus 100% Prune Juice. Two containers did not contain written or manufacturer's expiration dates. The third container was dated [DATE]. CNA-I was not sure how long the prune juice was for and stated licensed staff handle prune juice. On [DATE] at 2:42 PM, Surveyor interviewed DM-D who verified the items in the refrigerator should be dated and disposed of when expired.

Based on staff interview and record review, the facility did not ensure 3 residents (R) (R7, R12 and R23) of 3 residents reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R7 was transferred to the hospital on 2/24/24. The facility did not provide R7 with a bed hold notification. R12 was transferred to the hospital on 11/13/23, 1/1/24 and 2/27/24. The facility did not provide R12 with a bed hold notifications. R23 was transferred to the hospital on 6/11/24. The facility did not provide R23 with a bed hold notification Findings include: The facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, with a revision date of 7/15/22, states it is the policy of the facility to permit each resident to remain in the facility, and not to transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of residents or other individuals are endangered, or as otherwise permitted by law. The facility will provide a notice of the facility's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours after the transfer. 1. From 6/24/24 through 6/26/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses including acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure and mild cognitive impairment. R7's Minimum Data Set (MDS) assessment, dated 6/11/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R7 had moderately impaired cognition. R7 was R7's healthcare decision maker. On 2/24/24, R7 was transferred to the hospital following a fall with injury and admitted with diagnoses including right frontal subdural hematoma and type II odontoid fracture. R7 returned to the facility on [DATE]. R7's medical record did not indicate R7 or R7's representative were provided with a bed hold notification. 2. From 6/24/24 through 6/26/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness on one side of the body) affecting the right dominant side and conversion disorder with motor symptom or deficit. R12's MDS assessment, dated 1/15/24, had a BIMS score of 15 out of 15 which indicate R12 had intact cognition. R12 was R12's healthcare decision maker. On 11/13/23, R12 was transferred to the hospital following a change in condition and admitted with a diagnosis of loss of sensation to bilateral lower extremities. R12 returned to the facility on [DATE]. R12's medical record did not indicate R12 or R12's representative were provided a bed hold notification. On 1/1/24, R12 was transferred to the hospital following a change in condition and admitted for a possible stroke. R12 returned to the facility on [DATE]. R12's medical record did not indicate R12 or R12's representative were provided a bed hold notification. On 2/27/24, R12 was transferred to the hospital for pre-planned medical testing. R12 returned to the facility on [DATE]. R12's medical record did not indicate R12 or R12's representative were provided a bed hold notification. 3. On 6/25/24, Surveyor reviewed R23's medical record. R23 was admitted to facility on 2/2/24 with diagnoses including neurogenic bledder, history of urinary tract infections (UTIs), diabetes, and anxiety disorder. R23's MDS assessment, dated 5/29/24, had a BIMS score of 15 of 15 which indicated R23 had intact cognition. R23 was R23's healthcare decision maker. R23 was transferred to the hospital on 6/11/24 with stroke-like symptoms. R23's medical record did not indicate R23 or R23's representative were provided a bed hold notification. On 6/25/24 at 2:44 PM, Surveyor interview Nursing Home Administrator (NHA)-A who confirmed bed hold notices were not provided. NHA-A stated for emergent transfers, the nurse should provide a behold notice, at least verbally, and if the resident is not capable, the nurse should call the resident's emergency contact or representative. NHA-A stated the Social Worker is responsible for following up with the resident or their representative on the next business day. On 6/26/24 at 11:02 AM, Surveyor interview Social Service Director (SSD)-C who acknowledged residents should be provided the option for a bed hold. SSD-C stated when SSD-C is not in the facility, it is the responsibility of the nurse to provide a bed hold notice. SSD-C stated if SSD-C is in the facility, SSD-C provides the bed hold notice. SSD-C acknowledged SSD-C has not been completing bed hold notices.

Based on staff interview and record review, the facility did not ensure 3 residents (R) (R7, R12 and R23) of 3 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. In addition, the facility did not inform the State Long-Term Care Ombudsman for 2 (R7 and R23) of 3 residents reviewed for transfer/discharge. R7 was transferred to the hospital on 2/24/24. R7 was not provided with a written transfer notice. In addition, the Ombudsman was not notified of R7's transfer. R12 was transferred to the hospital on 11/13/23, 1/1/24, and 2/27/24. R12 was not provided with written transfer notices. R23 was transferred to the hospital on 6/11/24. R23 was not provided with a written transfer notice. In addition, the Ombudsman was not notified of R23's transfer. Findings include: The facility's Transfer and Discharge (including Against Medical Advice (AMA)) policy, with a revision date of 7/15/22, states that it is the policy of the facility to permit each resident to remain in the facility, and not to transfer or discharge the resident from the facility except as initiated by the resident, necessary for the health and safety of residents or other individuals are endangered, or as otherwise permitted by law. In the event of emergency transfers/discharges, the facility will notify the resident and/or resident representative, and complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents the resident's status, diagnosis, allergies, reasons for transfer/discharge, contact information for practitioner, current medications, treatments, pertinent medical information, special risks, care plan goals, isolation precautions, and any other documentation, as applicable, to ensure a safe and effective transition of care. In addition, the Social Services Director (SSD) or designee shall provide notice of the transfer to a representative of the State Long-Term Care Ombudsman via a monthly list. 1. From 6/24/24 through 6/26/24 Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses including acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, generalized hypertension, and mild cognitive impairment. R7's Minimum Data Set (MDS) assessment, dated 6/11/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R7 had moderate cognitive impairment. R7 was R7's healthcare decision maker. On 2/24/24, R7 was transferred to the hospital following a fall with injury and admitted with diagnoses including right frontal subdural hematoma and type II odontoid fracture. R7 returned to the facility on [DATE]. R7's medical record did not indicate a written transfer notice was provided to R7 or R7's emergency contact. 2. From 6/24/24 through 6/26/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness on one side of the body) affecting the right dominant side, conversion disorder with motor symptom or deficit, and history of venous thrombosis and embolism. R12's MDS assessment, dated 1/15/24, had a BIMS score of 15 out of 15 which indicated R12 had intact cognition. R12 was R12's health care decision maker. On 11/13/23, R12 was sent to the hospital following a change in condition and admitted with a diagnosis of loss of sensation to bilateral lower extremities. R12 returned to the facility on [DATE]. R12's medical record did not indicate a written transfer notice was provided to R12 or R12's emergency contact. On 1/1/24, R12 was transferred to the hospital following a change in condition and admitted for a possible stroke. R12 returned to the facility on [DATE]. R12's medical record did not indicate a written transfer notice was provided to R12 or R12's emergency contact. On 2/27/24, R12 was transferred to the hospital for pre-planned medical testing. R12 returned to the facility on [DATE]. R12's medical record did not indicate a written transfer notice was provided to R12 or R12's emergency contact. 3. On 6/25/24, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] with diagnoses including neurogenic bladder, history of urinary tract infections (UTIs), diabetes, and anxiety disorder. R23's MDS assessment, dated 5/29/24, had a BIMS score of 15 of 15 which indicated R23 had intact cognition. R23 was R23's healthcare decision maker. R23 was transferred to the hospital on 6/11/24 with stroke-like symptoms. R23's medical record did not indicate a written transfer notice was provided to R23 or R23's emergency contact. In addition, the State Long-Term Care Ombudsman was not notified of R23's transfer. On 6/25/24 at 2:44 PM, Surveyor interview Nursing Home Administrator (NHA)-A who confirmed transfer notices were not completed. NHA-A stated for emergent transfers, the nurse is responsible for completing the notice of transfer/discharge, at least verbally, and if the resident is not capable, the nurse should call the resident's emergency contact or representative. NHA-A stated the Social Worker is responsible for following up with the resident and/or their representative on the next business day. On 6/26/24 at 11:02 AM, Surveyor interview Social Service Director (SSD)-C who acknowledged residents should be notified of transfers. SSD-C stated when SSD-C is not in the facility, it is the responsibility of the nurse to issue the transfer/discharge notice. SSD-C stated if SSD-C is in the facility, the notice is provided by SSD-C. SSD-C acknowledged SSD-C has not been completing transfer/discharge notices. SSD-C also confirmed SSD-C has not been submitting monthly transfer/discharge notification to the State Long-Term Care Ombudsman. On 6/26/24 at 10:00 AM, NHA-A confirmed the facility has not been notifying the State Long-Term Care Ombudsman of transfers and discharges.

Based on staff interview and record review, the facility did not ensure court-ordered documents for guardianship and protective placement were obtained and/or on file for 1 resident (R) (R14) of 14 sampled residents. R14 had a court-ordered guardian. The facility did not have court documents for determination of permanent guardianship on file. In addition, the facility did not ensure court-ordered protective placement was completed for R14. Findings include: WI State Statute Chapter 55.03(4). The law requires a court-ordered protective placement for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds ninety days. WI State Statue Chapter 54 indicates Standby guardian means an individual designated by the court under s. 54.52 (2) whose appointment as guardian becomes effective immediately upon the death, resignation, or court's removal of the initially appointed guardian, or if the initially appointed guardian is temporarily or permanently unable, unavailable, or unwilling to fulfill his or her duties .Chapter 54.52(2) states upon assuming office, the standby guardian shall so notify the court. Upon notification, the court shall issue new letters of guardianship that specify that the standby guardianship is permanent or that specify the time period for a limited standby guardianship. From 6/24/24 through 6/26/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] with diagnoses including cerebral palsy and mild cognitive impairment. R14's Minimum Data Set (MDS) assessment, dated 2/8/24, indicated R14 had severe cognitive impairment. R14 medical record indicated R14 had a court-appointed guardian. R14's medical record contained a court document indicating determination and order for standby guardian, termination of guardian of the estate, and protective placement with an unintelligible date. The document indicated the reason for guardianship with need for protective placement in a nursing home; however, the document did not specify the name of the facility or the date of protective placement or indicate when R14's protective placement was last reviewed. The name of R14's guardian was listed on the document with the words is new legal guardian as of Sept. 1997 handwritten on the document. The facility was not able to provide documents that indicated permanent guardianship was in place for R14 or an annual protective placement order. On 6/26/24 at 11:02 AM, Surveyor interviewed Social Services Director (SSD)-C and Nursing Home Administrator (NHA)-A. SSD-C confirmed the facility did not have documentation on annual review for protective placement or documentation on permanent guardianship. The facility was not able to provide additional documentation to show the facility filed for protective placement when R14 was admitted to the facility.

Based on observations, staff interviews, resident interviews, and family interviews, the facility did not provide safe and/or comfortable room temperature levels for 7 Residents (R) (R1, R2, R3, R4, R5, R8 and R9) of 9 sampled residents. In addition, 2 Residents (R1) and (R5) were hospitalized for [REDACTED]. R3, R4, R8 and R9 voiced concerns that the facility temperature was too hot. R1, R2 and R5's family members voiced concerns that the facility temperature was too hot. Additionally, during the time when room temperatures at the facility were above regulatory requirements, residents were not asked if they would like temporary placement at another facility. R3 and R4 were unsure if they would have accepted temporary placement had it been offered by the facility. In addition, temperature logs recorded by the facility indicated resident rooms and common areas were above 81 degrees Fahrenheit (F) for extended periods on multiple occasions and the facility did not undertake effective methods to adequately cool resident rooms. (*Note: The two examples below are being cited at scope/severity G; Actual Harm/Isolated) R1 experienced a change of condition while residing at the facility during a period when internal room temperatures exceeded 81 degrees F. R1 was sent to the ED (emergency department) and subsequently hospitalized related to heat exposure. R5 was hospitalized for [REDACTED]. The facility's temperature logs indicated temperatures in R5's room, the adjoining room of R5's spouse and the hallway in which both residents lived were in excess of 81 degrees F on multiple occasions prior to R5's hospitalization . In addition, R5 had a history of [REDACTED]. Findings include: 1. On 7/18/19 at 3:25 PM, the Surveyor interviewed CNA (Certified Nursing Assistant)-A and CNA-B regarding the air temperatures in the facility. CNA-A and CNA-B verified the temperature in the building was warm while working in the hall and in resident rooms. CNA-A was wiping sweat from the forehead area. CNA-A and CNA-B confirmed the portable AC (air conditioning) units were brought in today, but it still wasn't cool enough in the facility. On 7/18/19 at 3:40 PM, the Surveyor went in R2's room from the hall. The hall and R2's room were very warm even though R2 had a box fan in room and a portable AC unit was placed in the hall across from R2's room blowing air in the hall. The portable AC unit was set at 67 degrees F. There was a window AC unit in the middle of R2's room on the floor which was waiting for installation. On 7/18/19 at 3:45 PM, the Surveyor interviewed R3 regarding the air temperature of the facility. R3 stated, it could be a little cooler in the facility. R3 had not been offered to move to another facility where the AC was working. R3 was unsure if R3 would have accepted the offer to move. On 7/18/19 at 3:57 PM, the Surveyor interviewed R4 regarding the air temperature of the facility. R4 stated, room is hot. R4 had not been offered to move to another facility where the AC was working. R4 was unsure if R4 would have accepted the offer to move. On 7/18/19 at 5:07 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-C regarding the air temperature of the facility. NHA-C confirmed it was warm in the facility and stated a request had been placed for more portable AC units approximately one week ago, but the facility had not received the units. Another request was submitted today for additional portable AC units. On 7/18/19 at 5:30 PM, the Surveyor interviewed FM (Family Member)-D by telephone regarding the air temperature of the facility. FM-D stated R1 was admitted to the facility on [DATE] and the facility was hot on admission. The next day it was just as hot in the facility. Facility staff were sweating and when FM-D asked staff about the AC, staff advised FM-D the AC was not working. On 7/14/19, R1 was discharged to the hospital for a heat encounter/dehydration. FM-D verified R1 was not going to return to the facility because the facility was so hot. The facility did not offer R1 a transfer to another facility because the AC was not functioning. 2. On 7/18/19, the Surveyor reviewed a complaint filed with the State Agency. The complaint stated the facility had no air conditioning and resident room temperatures were as high as 92 degrees F. During an interview with the Surveyor on 7/18/19 at 3:26 PM, NHA (Nursing Home Administrator)-C stated three or four of the air conditioning units on the second floor were not working. NHA-C indicated the facility became aware of the issue during warmer weather at the end of May. NHA-C stated the Sheboygan Health Department and Police Department recently visited the facility due to concerns and complaints regarding temperatures in the facility. NHA-C stated the facility had an action plan, were in the process of getting pricing to repair the system and purchased fans and portable air conditioning units to help regulate temperatures. NHA-C also stated facility staff monitored temperatures at various points throughout their shifts and recorded them on a clipboard at the nursing station. NHA-C stated the facility received one resident complaint, one family complaint and no staff complaints regarding the facility's temperatures. Following the interview, the Surveyor and NHA-C took temperatures in resident rooms, hallways and common areas on the second floor and noted the following: Hallway 300 was 81.1 degrees F. Hallway 400 was 84 degrees F. room [ROOM NUMBER] was 88 degrees F. room [ROOM NUMBER] was temped at both 80.5 and 81.2 degrees F. As the Surveyor and NHA-C took temperatures in the facility, the Surveyor observed R8 sitting in a wheelchair wearing pants and a long-sleeved sweatshirt. The Surveyor noted the temperature of R8's room was 78.3 degrees F. R8 pulled on one of R8's sleeves stated, This is too hot. R8 stated the room was warm and R8 wanted to change clothes. The Surveyor also noted R9's room was 80.6 degrees F. R9 was sitting on the bed with the shades drawn, the lights off and a fan on a table next to the bed. R9 stated to the Surveyor and NHA-C, This is the hot room. The Surveyor reviewed the facility's action plan, implemented 6/24/19 and noted the following: 1. On 6/24/19, 6/25/19, 6/28/19, 6/29/19, 6/30/19, 7/01/19 and 7/02/19 the action plan indicated no after-hours calls were received from the facility relating to elevated temperatures on the units; however, included with the action plan were the following temperature logs: Temperatures on 6/24/19: Hallway 100 was 82 degrees F at 6:00 PM. Hallway 300 was 83 degrees F at 12:00 PM and 83.5 degrees F at 6:00 PM. Hallway 400 was 84 degrees F at 12:00 PM and 85 degrees F at 6:00 PM. room [ROOM NUMBER] was 82 degrees F at 6:00 AM and 12:00 PM and 86 degrees F at 6:00 PM. room [ROOM NUMBER] was 83 degrees F at 6:00 AM and 12:00 PM and 86 degrees F at 6:00 PM. room [ROOM NUMBER] was 84 degrees F at 12:00 PM and 83 degrees F at 6:00 PM. room [ROOM NUMBER] was 83 degrees F at 6:00 AM and 12:00 PM and 86 degrees F at 6:00 PM. Hallway 200 and room [ROOM NUMBER] had recorded temperatures of 81 degrees F at various points throughout the day. Temperatures on 6/25/19: Hallway 300 was 82 degrees F at 6:00 PM. Hallway 400 was 83 degrees F at 12:00 PM and 82 degrees F at 6:00 PM. room [ROOM NUMBER] was 87 degrees F at 12:00 PM and 89 degrees F at 6:00 PM. rooms [ROOM NUMBERS] were 84 degrees F at 6:00 AM, 85 degrees F at 12:00 PM and 87 degrees F at 6:00 PM. room [ROOM NUMBER] was 82 degrees F at 12:00 PM and 6:00 PM. room [ROOM NUMBER] was 84 degrees F at 12:00 PM and 6:00 PM. room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] had recorded temperatures of 81 degrees F at various points throughout the day. Temperatures on 6/28/19: room [ROOM NUMBER] was 84 degrees F at 12:00 AM, 3:00 AM and 6:00 AM, 84.5 degrees F at 9:00 AM, 86 degrees F at 12:00 PM and 3:00 PM and 85 degrees F at 6:00 PM and 9:00 PM. Temperatures on 6/29/19: Hallway 100 was 82 degrees F at 6:00 AM and 84 degrees F at 12:00 PM. Hallway 200 was 81.5 F degrees at 9:00 PM. Hallway 300 was 83.5 F degrees at 9:00 PM. Hallway 400 was 82 degrees F at 12:00 PM and 83 F degrees at 9:00 PM. room [ROOM NUMBER] was 82 degrees F at 6:00 AM, 85 degrees F at 12:00 PM and 83 degrees F at 9:00 PM. room [ROOM NUMBER] was 83 degrees F at 12:00 PM and 9:00 PM. room [ROOM NUMBER] was 82 degrees F at 6:00 AM and 12:00 PM and 83 degrees F at 9:00 PM. room [ROOM NUMBER] was 83 degrees F at 12:00 PM and 84 degrees F at 9:00 PM. room [ROOM NUMBER] was 81.5 degrees F at 9:00 PM. The Dining Room was 81 degrees F at 9:00 PM. Temperatures on 6/30/19: room [ROOM NUMBER] was 84 degrees F at 3:00 PM, 6:00 PM and 9:00 PM. Temperatures on 7/01/19: Hallway 100 was 81.5 degrees F at 6:00 PM. room [ROOM NUMBER] was 81.5 degrees F at 9:00 AM, 12:00 PM and 3:00 PM and 84.5 degrees F at 6:00 PM. room [ROOM NUMBER] was 86 degrees F at 9:00 AM, 84 degrees F at 12:00 PM, 83 degrees F at 3:00 PM and 88.5 degrees F at 6:00 PM. room [ROOM NUMBER] was 87.5 degrees F at 6:00 PM. room [ROOM NUMBER] was 83 degrees F at 6:00 PM. room [ROOM NUMBER] was 84 degrees F at 6:00 PM. rooms [ROOM NUMBERS] were 88.5 degrees F at 6:00 PM. Temperatures on 7/02/19: Hallway 400 was 86 degrees F at 12:00 AM and 3:00 AM, 86.5 degrees F at 6:00 AM, 88 degrees F at 9:00 AM and 12:00 PM and 90 degrees F at 6:00 PM. room [ROOM NUMBER] was 82 degrees F at 12:00 PM. room [ROOM NUMBER] was 84 degrees F at 9:00 AM and 83 degrees F at 12:00 PM. rooms [ROOM NUMBERS] were 84 degrees F at 6:00 PM. room [ROOM NUMBER] was 85 degrees F at 6:00 PM. Rooms 403 - 416 were 90 degrees F at 6:00 PM. Temperatures on 7/03/19: Hallway 100 was 84.5 degrees F at 12:00 PM. room [ROOM NUMBER] was 85 degrees F at 12:00 PM. room [ROOM NUMBER] was 83 degrees F at 12:00 AM and 3:00 AM and 88 degrees F at 12:00 PM. room [ROOM NUMBER] was 81.5 degrees F at 12:00 PM. room [ROOM NUMBER] was 85 degrees F at 12:00 AM and 3:00 AM and 81.5 degrees F at 12:00 PM. room [ROOM NUMBER] was 85 degrees F at 12:00 AM and 3:00 AM and 86.5 degrees F at 12:00 PM. Hallway 400 and Rooms 404 - 416 had recorded temperatures of 81 degrees F at 12:00 AM. Temperatures on 7/04/19: Hallway 100 was 86.5 degrees F at 12:00 PM. Hallway 300 was 84 degrees F at 9:00 PM. Hallway 400 was 82 degrees F at 9:00 PM. room [ROOM NUMBER] was 85 degrees F at 9:00 PM. room [ROOM NUMBER] was 90 degrees F at 12:00 AM 3:00 AM and 6:00 AM, 86.5 degrees F at 12:00 PM and 85 degrees F at 9:00 PM. Rooms 301, 302, 304, 308 and 313 were 86 degrees F at 9:00 PM. room [ROOM NUMBER] was 84.5 degrees at 12:00 PM and 86 degrees F at 9:00 PM. room [ROOM NUMBER] was 81.5 degrees at 12:00 PM and 92 degrees F at 9:00 PM. rooms [ROOM NUMBERS] were 86 degrees F at 9:00 PM. room [ROOM NUMBER] was 81 degrees F at 9:00 PM. Temperatures on 7/05/19: Hallway 400 was 82 degrees Fat 12:00 AM. room [ROOM NUMBER] was 82 degrees F at 12:00 AM and 3:00 AM. room [ROOM NUMBER] was 88.1 degrees F at 12:00 AM, 87 degrees F at 3:00 AM, 83 degrees F at 6:00 AM and 82 degrees F at 3:00 PM. room [ROOM NUMBER] was 83 degrees Fat 12:00 AM. room [ROOM NUMBER] was 90.2 degrees F at 12:00 AM, 90 degrees F at 3:00 AM, 85 degrees F at 6:00 AM and 82 degrees F at 3:00 PM. room [ROOM NUMBER] was 82.5 degrees F at 12:00 AM and 82 degrees F at 3:00 AM and 6:00 AM. Temperatures on 7/16/19: Hallway 100 was 82 degrees F during the PM shift. room [ROOM NUMBER] was 83.8 degrees F during the PM shift. room [ROOM NUMBER] was 82.3 degrees F during the PM shift. room [ROOM NUMBER] was 84.4 degrees F during the PM shift. room [ROOM NUMBER] was 82.1 degrees F during the PM shift. room [ROOM NUMBER] was 84 degrees F during the PM shift. Hallway 300, Hallway 400 and room [ROOM NUMBER] had recorded temperatures of 81 degrees F on the PM shift. A memo entitled Nursing, dated 7/04/19, stated It is nursing's responsibility to ensure that the temperature log is completed every half-hour and documentation is written on the sheets . The Surveyor noted the facility's temperature logs dated 7/04/19, 7/05/19 and 7/06/19 did not contain temperatures taken every half hour. In addition, the facility's action plan did not include temperatures from 7/07/19 - 7/15/19 and 7/17/19. Despite the Surveyor's request, temperature logs for the above mentioned dates were not provided by NHA-C. An email to NHA-C from OM (Ombudsman)-K, dated 7/16/19, indicated OM-K received a call regarding the temperature in the building. OM-K asked about the status of the facility's air conditioning system and wanted to know the steps being taken to ensure residents were kept safe and comfortable. NHA-C stated some air conditioning units weren't operable, but the facility had working air conditioning in the hallways. NHA-C stated the facility had an action plan in place and had not had rooms above 82 degrees to date. NHA-C stated the facility would continue to monitor the temperatures once per shift. 2. R1 was admitted to the facility during the time the facility air conditioning (AC) was not working. R1 was admitted with [DIAGNOSES REDACTED]. R1 was own decision maker with the assistance of family members. R1's TAR (Treatment Administration Record), dated 7/1/19 - 7/31/19, did not include monitoring for signs/symptoms of heat exposure/heat exhaustion/heat stroke when the AC was not working in the facility and temperatures exceeded 81 degrees F for multiple days in multiple areas of the building. R1's progress notes, dated 7/12/19 at 2:30 PM, indicated R1's family requested a room change and R1 was moved to another room in the facility. Family was concerned as R1 was lethargic and had an unresponsive episode in the morning. On call NP (Nurse Practitioner) called. The on call NP ordered lab work for the morning of 7/13/19, to check vital signs every shift twice daily, and to push fluids. R1's progress notes, dated 7/14/19 at 1:05 PM, indicated R1 was slightly lethargic this morning. Lungs with wheezes. Lower extremities with two (2) plus [MEDICAL CONDITION]. Was a no (urine) void this shift. Bladder scan was done and revealed 327 cc (cubic centimeters) of urine in the bladder. R1 stated R1 had no urge to urinate. Updated the NP on R1's condition and orders were received to send R1 to the ED (emergency department) as R1 had a very fine balance of dehydration versus [MEDICAL CONDITION] and AKI (acute kidney injury). R1 was transported to the ED by ambulance. R1's progress notes, dated 7/16/19 at 11:08 AM, indicated the facility followed up with R1's family regarding AC and high temperature concerns in the facility. R1's family indicated temperatures of R1's room were taken during R1's stay. The temperature in R1's room when taken by family on Friday, 7/12/19 was 85 degrees F and on Saturday, 7/13/19 the temperature was 88 degrees F. The family member believes own temperature gauge to be most accurate. The Surveyor requested a facility temperature log during the time when the AC was not working in the building. The facility did not provide the Surveyor with a temperature log of temperatures taken from 7/11/19 - 7/14/19 when R1 resided at the facility. The ED/hospital admission notes dated 7/14/19, indicated R1 was seen in the ED and family members indicated R1 was in a very hot environment at the the facility where R1 resided. The facility did not have AC that was working and the temperature was up to 87 degrees F yesterday (7/13/19) in R1's room. The family members stated portable AC units were brought in another room with a fan blowing toward R1's room, but R1's room remained hot. R1's creatinine was worse at 3.93 (2.6 on 7/13/19 and 0.88 on 7/11/19) and BUN (blood urea nitrogen) was abnormal at 47. R1's [DIAGNOSES REDACTED]. R1 was admitted to the hospital from the ED for further evaluation and treatment with [DIAGNOSES REDACTED]. R1 was maintaining blood pressure but might have been low at facility with antihypertensives and dehydration. On 7/18/19 at 4:55 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-C regarding the temperature in the facility. NHA-C verified the temperature in the facility was warm and stated more portable AC units were requested approximately one week ago and again today because NHA-C had not received a response back from the request a week ago. On 7/18/19 at 5:30 PM, the Surveyor interviewed R1's family member (FM)-D regarding temperatures in the facility. R1's FM-D verified R1's room was hot on R1's date of admission and continued to be hot because the AC was not working. R1 was not offered to go to another facility where the AC worked. Three portable AC units were placed in empty rooms. One of the three portable units was removed from an empty room and placed in R1's room on Saturday evening (7/13/19), but was not helping to cool room. R1 was discharged to the ED and then admitted to the hospital on [DATE]. (Reference citation at F684) 3. On 7/18/19, the Surveyor reviewed a complaint filed with the State Agency. The complaint indicated the facility did not have air conditioning and resident room temperatures were as high as 92 degrees F. During an environmental tour of the facility on 7/18/19, NHA-C indicated R5, who resided in a connecting room with R2 (R5's spouse) on the 400 unit, was currently hospitalized . As part of the facility's action plan to maintain safe temperatures in the building, staff were instructed to record temperatures on the units and notify administration if the temperatures rose above 82 degrees F. Upon review of the facility's temperature logs, the Surveyor noted facility recorded temperatures in R5's room on seven different days between 6/25/19 and 7/5/19 to be greater than 81 degrees F and as high as 90.2 degrees F (see F684 for details.) On 7/18/19, the Surveyor reviewed R5's medical record. R5 was admitted to the facility with [DIAGNOSES REDACTED]. R5's Admission MDS (Minimum Data Set), dated 6/14/19, indicated R5 had mild cognitive impairment, and required moderate to extensive assistance of staff for ADLs (activities of daily living). R5's Kardex (an abbreviated care plan used by nursing staff), dated 7/18/19, did not instruct staff to encourage fluids. R5's nutritional plan of care, dated 4/22/19, contained an intervention for a weekly hydration screen, but did not indicate R5 had a history of [REDACTED]. A progress note, dated 7/12/19 at 6:06 PM, stated, Resident states, 'I'm going to die.' Resident very weak and gray in color. (MD (Medical Doctor)-H) notified and ordered ER (emergency room ) evaluation . A progress note, dated 7/12/19 at 7:40 PM, stated (Hospital) called and stated resident was being admitted with pneumonia . On 7/18/19, the Surveyor reviewed R5's hospital admission history and physical, dated 7/12/19. R5 was admitted to the hospital with [REDACTED]. During an interview with the Surveyor on 7/18/19, DON (Director of Nursing)-I verified R5 did not have care plan to address R5's history of dehydration, but indicated encouraging fluids was a standard of practice during the heat. During an interview with the Surveyor on 7/18/19 at 7:45 PM, CC (Corporate Consultant)-J and NHA-C verified R5 should have had a care plan to address R5's history of dehydration. During an interview with the Surveyor on 7/19/19 at 12:55 PM, FM (Family Member)-E indicated R5 was sick for two weeks prior to R5's hospitalization and was unable to get up for lunch on one occasion during the previous week. FM-E visited R5 on the morning of 7/12/19 and stated R5 was shaking and R5's room was pretty hot. FM-E stated R5 asked to be taken to the hospital, but FM-E was unable to locate staff and had to return to work. FM-E asked a sibling to check on R5 later that day. FM-E indicated the temperature in the facility was hot for approximately 3 weeks and indicated R5 and R2 were frequently lying in bed when FM-E visited. FM-E expressed concern the facility didn't send R5 to the hospital sooner. FM-E stated, I went (to the hospital) last night. It was the first time (R5) was awake and able to talk they might be sending (R5) back (to the facility) today. I'm just concerned about the heat. (Reference citation at F684)

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 2 Residents (R) (R1 and R5) of 2 sampled residents who were hospitalized due to heat stress caused by excessive room temperatures. Per facility's own temperature logs, temperatures in multiple resident rooms exceeded 81 degrees Fahrenheit (F) and were as high as 92 degrees F for extended times over multiple days. R1 experienced a change of condition while residing at the facility during a period when internal room temperatures exceeded 81 degrees F. R1 was sent to the ED (emergency department) and subsequently hospitalized related to heat exposure. R5 was hospitalized for [REDACTED]. The facility's temperature logs indicated temperatures in R5's room, the adjoining room of R5's spouse and the hallway in which both residents lived were in excess of 81 degrees F on multiple occasions prior to R5's hospitalization . In addition, R5 had a history of [REDACTED]. This is evidenced by: The article entitled Heat Stress in Older Adults/Natural Disasters and Severe Weather found at https://www.cdc.gov with a last reviewed date of (MONTH) 19, (YEAR), indicated people aged [AGE] years or older are more prone to heat-related health problems. Older adults do not adjust as well as young people to sudden changes in temperature. Older adults are more likely to have chronic medical conditions which change normal body responses to heat. Older adults more than likely take prescription medications which affect the body's ability to control its temperature or sweat. Older adults need to stay cool and stay hydrated. Older adults should stay in air-conditioned buildings as much as possible. If the older adult does not have air conditioning, the older adult should locate an air-conditioned shelter in the area. The older adult should drink more water than usual and should not wait until thirsty to drink. If the older adult has a fluid restriction or is taking a diuretic (water pill), the physician should be contacted to determine how much fluids the older adult should be drinking during hot weather. 1. R1 was admitted to the facility during the time the facility air conditioning (AC) was not working. R1 was admitted with [DIAGNOSES REDACTED]. R1 was own decision maker with the assistance of family members. R1's physician orders [REDACTED]. Additionally, the physician orders [REDACTED]. R1's MAR (Medication Administration Record), dated 7/1/19 - 7/31/19, indicated R1 was administered 250 mg of [MEDICATION NAME] on the PM shift of 7/11/19, on the AM and PM shift of 7/12/19 and 7/13/19 and on the AM shift of 7/14/19. The MAR indicated [REDACTED]. R1's MAR indicated [REDACTED]. R1 was screened for hydration on 7/11/19 at 1:32 PM. The task entitled Hydration Screener, indicated R1's mucus membranes were moist, urine was not concentrated, pulse was not rapid, there had not been a rapid weight loss in the past seven (7) days, and R1 did not have an orthostatic drop in blood pressure when vitals were taken. R1 did not have any other hydration screens completed while residing at the facility when the AC was not working and resident room temperatures exceeded 81 degrees F in multiple rooms in the facility. R1's fluid intake was documented. On 7/11/19, R1 consumed a total of 600 ml (milliliters) of fluid. On 7/12/19, R1 consumed a total of 1260 ml of fluid. On 7/13/19, R1 consumed a total of 1755 ml of fluid. On 7/14/19, R1 consumed a total of 330 ml of fluid. It was unknown how many ml of fluid R1 needed to maintain hydration because a dietician had not reviewed R1 as of discharge to the ED on 7/14/19. Additionally, it was unknown what R1's output of urine was on 7/11/19, 7/12/19, 7/13/19, and 7/14/19 because R1's output was only documented as a check mark under continent, incontinent or did not void. R1 had a plan of care dated 7/12/19 and 7/13/19, but the plan of care did not include a focus area or interventions related to hydration needs or diuretic use. Additionally, the plan of care did not include a focus area or interventions related to monitoring for signs/symptoms of heat exposure because the AC was not working at the facility. R1's TAR (Treatment Administration Record), dated 7/1/19 - 7/31/19, did not include monitoring for signs/symptoms of heat exposure/heat exhaustion/heat stroke when the AC was not working in the facility and temperatures exceeded 81 degrees F for multiple days in multiple areas of the building. R1's progress notes, dated 7/12/19 at 2:30 PM, indicated R1's family requested a room change and R1 was moved to another room in the facility. Family was concerned as R1 was lethargic and had an unresponsive episode in the morning. On call NP (Nurse Practitioner) called. The on call NP ordered lab work for the morning of 7/13/19, to check vital signs every shift twice daily, and to push fluids. R1's progress notes, dated 7/12/19 at 6:00 PM, indicated staff will push fluids and get R1 up to bathroom soon. R1 was administered a diuretic earlier. R1's progress notes, dated 7/13/19 at 9:39 PM, indicated R1's creatinine and other labs were elevated. Orders included to push fluids and repeat lab work on Monday 7/15/19. If labs are still high on 7/15/19, R1 may need to be seen. AC placed in R1's room by maintenance. Trace [MEDICAL CONDITION] to legs at this time. R1's progress notes, dated 7/14/19 at 4:21 AM, indicated R1 had wheezes in lungs. Fluids encouraged, but R1 refused. Will repeat labs on 7/15/19. R1's progress notes, dated 7/14/19 at 1:05 PM, indicated R1 was slightly lethargic this morning. Lungs with wheezes. Lower extremities with two (2) plus [MEDICAL CONDITION]. Was a no (urine) void this shift. Bladder scan was done and revealed 327 cc (cubic centimeters) of urine in the bladder. R1 stated R1 had no urge to urinate. Updated the NP on R1's condition and orders were received to send R1 to the ED (emergency department) as R1 had a very fine balance of dehydration versus [MEDICAL CONDITION] and AKI (acute kidney injury). R1 was transported to the ED by ambulance. R1's progress notes, dated 7/16/19 at 11:08 AM, indicated the facility followed up with R1's family regarding AC and high temperature concerns in the facility. R1's family indicated temperatures of R1's room were taken during R1's stay. The temperature in R1's room when taken by family on Friday, 7/12/19 was 85 degrees F and on Saturday, 7/13/19 the temperature was 88 degrees F. The family member believes own temperature gauge to be most accurate. The Surveyor requested a facility temperature log during the time when the AC was not working in the building. The facility did not provide the Surveyor with a temperature log of temperatures taken from 7/11/19 - 7/14/19 when R1 resided at the facility. The ED/hospital admission notes dated 7/14/19, indicated R1 was seen in the ED and family members indicated R1 was in a very hot environment at the the facility where R1 resided. The facility did not have AC that was working and the temperature was up to 87 degrees F yesterday (7/13/19) in R1's room. The family members stated portable AC units were brought in another room with a fan blowing toward R1's room, but R1's room remained hot. R1's creatinine was worse at 3.93 (2.6 on 7/13/19 and 0.88 on 7/11/19) and BUN (blood urea nitrogen) was abnormal at 47. R1's [DIAGNOSES REDACTED]. R1 was admitted to the hospital from the ED for further evaluation and treatment with [DIAGNOSES REDACTED]. R1 was maintaining blood pressure but might have been low at facility with antihypertensives and dehydration. On 7/18/19 at 4:55 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-C regarding the temperature in the facility. NHA-C verified the temperature in the facility was warm and stated more portable AC units were requested approximately one week ago and again today because NHA-C had not received a response back from the request a week ago. On 7/18/19 at 5:30 PM, the Surveyor interviewed R1's family member (FM)-D regarding temperatures in the facility. R1's FM-D verified R1's room was hot on R1's date of admission and continued to be hot because the AC was not working. R1 was not offered to go to another facility where the AC worked. Three portable AC units were placed in empty rooms. One of the three portable units was removed from an empty room and placed in R1's room on Saturday evening (7/13/19), but was not helping to cool room. R1 was discharged to the ED and then admitted to the hospital on [DATE]. On 7/18/19 at 7:17 PM, the Surveyor interviewed DON (Director of Nursing)-I regarding monitoring of heat exposure/heat exhaustion/heat stroke on R1's MAR indicated [REDACTED]. DON-I confirmed R1 did not have anything on the plan of care related to hydration, diuretic use or heat exposure due to the AC not working because everyone upstairs (resident rooms are on the second floor of the facility) knows to push fluids during this. DON-I verified R1 was administered diuretics during R1's stay at the facility and output was only documented as continent, incontinent or did not void. DON-I then stated R1 was sent to the ED timely on 7/14/19 from the facility after DON-I completed an assessment and bladder scan. 2. On 7/18/19, the Surveyor reviewed a complaint filed with the State Agency. The complaint indicated the facility did not have air conditioning and resident room temperatures were as high as 92 degrees F. During an environmental tour of the facility on 7/18/19, NHA-C indicated R5, who resided in a connecting room with R2 (R5's spouse) on the 400 unit, was currently hospitalized . As part of the facility's action plan to maintain safe temperatures in the building, staff were instructed to record temperatures on the units and notify administration if the temperatures rose above 82 degrees F. Upon review of the facility's temperature logs, the Surveyor noted the following: 6/24/19: R2 and R5's rooms were 83 degrees F at 6:00 AM and 12:00 PM and 86 degrees at 6:00 PM. Hallway 400 was 84 degrees F at 12:00 PM and 85 degrees F at 6:00 PM. 6/25/19: R2 and R5's rooms were 84 degrees F at 6:00 AM, 85 degrees F at 12:00 PM and 87 degrees F at 6:00 PM. Hallway 400 was 83 degrees F at 12:00 PM and 82 degrees F at 6:00 PM. 6/29/19: R5's room was 83 degrees F at 12:00 PM and 84 degrees F at 9:00 PM. R2's room was 83 degrees F at 12:00 PM and 9:00 PM. Hallway 400 was 82 degrees F at 12:00 PM and 83 degrees F at 9:00 PM. 7/01/19: R5's room was 84 degrees F at 6:00 PM. R2's room was 87.5 degrees F at 6:00 PM. 7/02/19: R2 and R5's rooms were 84 degrees F at 6:00 PM Hallway 400 was 86 degrees F at 12:00 AM and 3:00 AM, 86.5 degrees F at 6:00 AM, 88 degrees F at 9:00 AM and 12:00 PM and 90 degrees F at 6:00 PM. 7/03/19: R2's room was 81.5 degrees F at 12:00 PM. R5's room was 80 degrees F at 12:00 AM and 3:00 AM, but not monitored at 12:00 PM. 7/04/19: R2's room was 81.5 degrees F at 12:00 PM and 92 degrees F at 9:00 PM. R5's room was not monitored. Hallway 400 was 82 degrees F at 9:00 PM. 7/05/19: R2's room was 90.2 degrees F at 12:00 AM, 90 degrees F at 3:00 AM, 85 degrees F at 6:00 AM and 82 degrees F at 3:00 PM. R5's room was not monitored. Hallway 400 was 82 degrees F at 12:00 AM. R5 and R2's room temperatures were not monitored from 7/06/19 through 7/12/19 when R5 was admitted to the hospital. On 7/18/19, the Surveyor reviewed R5's medical record. R5 was admitted to the facility with [DIAGNOSES REDACTED]. R5's Admission MDS (Minimum Data Set), dated 6/14/19, indicated R5 had mild cognitive impairment, and required moderate to extensive assistance of staff for ADLs (activities of daily living). R5's Kardex (an abbreviated care plan used by nursing staff), dated 7/18/19, did not instruct staff to encourage fluids. R5's nutritional plan of care, dated 4/22/19, contained an intervention for a weekly hydration screen, but did not indicate R5 had a history of [REDACTED]. A progress note, dated 7/12/19 at 6:06 PM, stated, Resident states, 'I'm going to die.' Resident very weak and gray in color. (MD (Medical Doctor)-H) notified and ordered ER (emergency room ) evaluation . A progress note, dated 7/12/19 at 7:40 PM, stated (Hospital) called and stated resident was being admitted with pneumonia . On 7/18/19, the Surveyor reviewed R5's hospital admission history and physical, dated 7/12/19. R5 was admitted to the hospital with [REDACTED]. During an interview with the Surveyor on 7/18/19, DON-I verified R5 did not have care plan to address R5's history of dehydration, but indicated encouraging fluids was a standard of practice during the heat. During an interview with the Surveyor on 7/18/19 at 7:45 PM, CC (Corporate Consultant)-J and NHA-C verified R5 should have had a care plan to address R5's history of dehydration. During an interview with the Surveyor on 7/19/19 at 12:55 PM, FM-E indicated R5 was sick for two weeks prior to R5's hospitalization and was unable to get up for lunch on one occasion during the previous week. FM-E visited R5 on the morning of 7/12/19 and stated R5 was shaking and R5's room was pretty hot. FM-E stated R5 asked to be taken to the hospital, but FM-E was unable to locate staff and had to return to work. FM-E asked a sibling to check on R5 later that day. FM-E indicated the temperature in the facility was hot for approximately 3 weeks and indicated R5 and R2 were frequently lying in bed when FM-E visited. FM-E expressed concern the facility didn't send R5 to the hospital sooner. FM-E stated, I went (to the hospital) last night. It was the first time (R5) was awake and able to talk they might be sending (R5) back (to the facility) today. I'm just concerned about the heat.

Based on record review and staff interview, the facility did not ensure 1 (R (Resident) 225) of 2 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R225 developed a left heel wound on 2/02/18. The facility did not revise R225's plan of care or add interventions for protection or pressure relief. When the wound opened on 3/02/18, the facility did not notify the MD (Medical Doctor) or revise R225's plan of care. When a second heel wound was discovered on 4/13/18, the facility received new treatment orders, an order for [REDACTED]. Approximately 2 weeks later, R225's wound worsened and was noted to be necrotic, malodorous and painful to the touch. R225 was admitted to a local hospital for possible osteo[DIAGNOSES REDACTED] (an infection of the bone) and did not return to the facility. The failure of the facility to follow professional standards of practice for the prevention, treatment and care of PIs created a situation of Immediate Jeopardy, which began on 4/13/2018. NHA (Nursing Home Administrator)-B was formally notified on 7/19/2018 that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 7/19/2018, however the deficient practice continued at a scope and severity of D (potential for more than minimal harm/isolated) as evidenced by the following examples: Findings include: The facility's Pressure Injuries/Skin Breakdown Protocol, dated 1/18/18, states: Assessment and Recognition 1. The License (sic) Nurses will assessed (sic) / observed (sic) and document an individual's significant risk factors for developing pressure injuries; for example, immobility, recent weight loss, and a history of pressure injuries(s) (sic). 2. In addition, the nurse shall assess and document/report the following: a. Vital signs b. Full assessment of pressure injuries including location, stage, length, width and depth, presence of exudates or necrotic tissue f. Current treatments, including support surfaces 4. Weekly skin observation. Report any abnormalities as indicated. 5. The physician will assist the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration. Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. Monitoring 2. License (sic) staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Example: On 7/18/18, the Surveyor reviewed R225's medical record. R225 was admitted to the facility with [DIAGNOSES REDACTED]. R225's most recent quarterly MDS (Minimum Data Set), dated 4/06/18, documented R225 was cognitively impaired, required extensive assistance for bed mobility, was at risk for pressure injuries and had 1 venous/arterial wound. The MDS also documented R225 had pressure reducing devices for bed and chair. An incident note, dated 2/02/18, stated, (R225) Had a (sic) Injury of Unknown Cause (Skin Tear, Bruise, Abrasion etc) incident on 2/02/18 at 10:00 AM. Incident details: left heel wound 3 cm (centimeters) (length) x 3 cm (width), no drainage noted. Immediate care plan intervention: none. Notifications: (MD (Medical Doctor)-F) and (POA (Power of Attorney)-K). A Non-Pressure Skin Condition assessment, dated 2/02/18, indicated R225 had a 3 cm x 3 cm left heel wound with no drainage or odor. The plan was to monitor the wound in the TAR (treatment administration record) until healed and assess for signs and symptoms of infection. MD-F was notified, but no interventions or protective devices were added by the facility. Non-Pressure Skin Condition assessments, dated 2/09/18 and 2/16/18, indicated R225 had a 3 cm x 3 cm left heel wound with no drainage or odor. The skin surrounding the wound was dry and calloused. The plan was to monitor the wound in the TAR and assess for signs and symptoms of infection. The assessments indicated there were no interventions in place and no protective devices were added. A Non-Pressure Skin Condition assessment, dated 2/23/18, indicated R225 had a 3 cm x 3 cm left heel wound with a scant amount of serosanguineous (thin and watery, pink fluid containing red blood cells) drainage. The area surrounding the wound was calloused and peeling. The plan was to assess for signs and symptoms of infection. The equipment/protection and intervention sections were not completed. A Podiatry note, dated 2/26/28, stated, Left medial heel presents with area where outer layer of skin is peeled off and with dry stable scab measuring approximately 1.0 cm x 0.8 cm with no odor, drainage, or SOI (signs of infection). No open ulcerations, acute blisters, drainage, bleeding, pain .I spoke to the patient's nurse who confirmed they are treating L (left) heel. Nurse confirmed that they are applying dressing/tx (treatment) to area. Informed nurse that dressing not intact today, but that dry scab was noted. R225's (MONTH) TAR contained the following intervention, initiated on 2/08, discontinued on 2/11 and reinitiated on 2/11: Foam border dressing; change every 3 days and PRN (as needed) until healed. Cleanse with wound cleanser each dressing change. A Non-Pressure Skin Condition assessment, dated 3/02/18, indicated R225 had a calloused open area on the left heel with a small amount of serosanguineous drainage. The plan was to assess for signs and symptoms of infection. The assessment indicated there were no interventions in place and no protective devices were added. According to the assessment, MD-F was not updated regarding the change in the wound. A Weekly Wound Log, dated 3/06/18, indicated R225 had a vascular left heel wound with no odor, a moderate amount of serous drainage and slough that measured 1.5 cm x 2.9 cm x 0.2 cm (depth). A Non-Pressure Skin Condition assessment, dated 3/09/18, indicated R225 had a 3 cm x 3 cm left heel wound with no drainage or odor. The skin surrounding the wound was dry and calloused. The plan was to monitor the wound in the TAR until healed. The equipment/protection and intervention sections were not completed. A Weekly Wound Log, dated 3/13/18, indicated R225 had a vascular left heel wound with no odor, a moderate amount of drainage and slough that measured 1.1 cm x 2.0 cm x 0.1 cm. A Non-Pressure Skin Condition assessment, dated 3/16/18, indicated R225 had a left heel wound with no drainage or odor. The skin was dry around the wound. The plan was to monitor the wound in the TAR until healed. The equipment/protection and intervention sections were not completed. A Weekly Wound log, dated 3/20/18, indicated R225 had a vascular left heel wound with no odor, a moderate amount of drainage and slough that measured 1.6 cm x 1.9 cm x 0.1 cm. A Non-Pressure Skin Condition assessment, dated 3/23/18, stated, No drainage noted to left heel continues with dry skin around the wound. The plan was to monitor the wound in the TAR until healed. An intervention was added to float heels off bed. A Weekly Wound Log, dated 3/27/18, indicated R225 had a vascular left heel wound with no odor, moderate drainage and slough that measured 1.6 x 1.8 x 0.1 cm. A Non-Pressure Skin Condition assessment, dated 3/30/18, stated Left heel. Dry wound bed; non-draining. The plan was to monitor the wound in the TAR until healed, assess for signs and symptoms of infection and monitor for 1 more week. R225's heels were to be floated off the bed. R225's (MONTH) and (MONTH) (YEAR) TARs contained the following intervention, initiated on 2/11 and discontinued on 4/10: Foam border dressing, change every 3 days and PRN until healed. Cleanse with wound cleanser each dressing change. The Surveyor noted dressing changes were not completed on 3/01, 3/16, 3/19, 3/25 and 4/03. A Weekly Wound Log, dated 4/03/18, indicated R225 had a vascular left heel wound with slough that measured 1.6 x 1.7 x 0.1 cm. A Weekly Wound Log, dated 4/10/18, indicated R225 had vascular left heel wounds that measured 2.4 x 2.0 x 0.2 cm and 3.2 x 1.4 x 0.1 cm. The log indicated the MD was updated. The Surveyor noted no new orders were initiated on 4/10/18. Skin Observation Tools, dated 4/04/18 and 4/11/18, indicated R225 had no new or existing skin impairments. A Non-Pressure Skin Condition assessment, dated 4/13/18, indicated R225 had left heel wounds that measured 2.4 x 2.0 and 3.2 x 1.4. The assessment stated, The center of the first wound has eschar and is encircled by bright red/pink open area. The second wound has eschar. Surrounding skin to both wounds is macerated. There is serosang drainage present .Fax sent to MD asking for an order for [REDACTED]. The plan was to monitor the wound in the TAR until healed, assess for signs and symptoms of infection, monitor for 1 more week and float R225's heels off the bed. A communication with physician note, dated 4/13/18, contained the following wound care orders initiated by APNP (Advanced Practice Nurse Prescriber)-G: Left heel wound #1, [MEDICATION NAME] paint every 3 days and PRN. Left heel wound #2, cleanse with soap and water, apply Iodosorb (a sterile antimicrobial dressing that absorbs fluid, removes exudate, slough and debris and forms a gel over the wound surface) to open wound followed by Allevyn life foam border dressing (a multi-layered foam and absorbent dressing) and wrap in Kerlix (gauze) to secure. Change every 3 days and PRN. APNP-G also ordered heel boots and asked the facility to order R225 a longer bed. An Aurora Extended Care Service note, dated 4/13/18, stated, [MEDICAL CONDITION]: We received a fax that the patient has 2 wounds on the left heel and the current order was to cleanse with soap and water and applying (sic) a foam dressing changing every 3 days and PRN. They report the wound is worsening. (The patient) has another area that is just a deep tissue injury. They're requesting an order for [REDACTED]. Wrap Kerlix around the foot to secure this in place. Dressing changes every 3 days and PRN. Deep tissue injury - [MEDICATION NAME] paint to (sic) 3 days; this area is very close to the other wound and will be covered by the same Allevyn life dressing. A Weekly Wound Log, dated 4/17/18, indicated R225 had a vascular left heel wound with no odor and a moderate amount of serosanguineous drainage that measured 2.4 x 2.0 x 0.1 cm and a second vascular left heel wound with no odor and no drainage that measured 3.2 x 1.4 x 0.1 cm. A Non-Pressure Skin Condition assessment, dated 4/20/18, indicated R225 had 2 left heal (sic) wounds that were painful to the touch with s/s drainage on dressings. Changed daily as ordered. The plan was to monitor the wound in the TAR until healed, assess for signs and symptoms of infection and monitor for 1 more week. In addition to floating R225's heals off the bed, heel lift boots were added. The Surveyor reviewed R225's (MONTH) TAR and noted R225's dressings were to be changed every 3 days and PRN instead of daily. A Weekly Wound Log, dated 4/24/18, indicated R225 had a vascular left heel wound with no odor and a moderate amount of drainage that measured 4.0 x 6.0 x 0.2 cm. A fax from APNP-G, dated 4/24/18, stated, Please get a new set of vitals today. Hold dressing change until I see (R225) tomorrow AM. A physician's orders [REDACTED]. Iodosorb to all wound beds. Cover with Allevyn Life. Change every 3 days. APNP-G also ordered a left heel X-ray to rule out osteo[DIAGNOSES REDACTED]. A nursing note, dated 4/25/18, stated, Per (MD-F), (R225) will be sent to (local) ER (emergency room ) non-emergent A nursing note, dated 4/26/18, stated, Resident admitted to (local hospital) for osteo[DIAGNOSES REDACTED], on IV (intravenous) antibiotics. A nursing note, dated 4/29/18, stated, Resident has been discharged to a different SNF (skilled nursing facility) from the hospital. Daughter was here yesterday and took all (R225's) personal belongings out of this facility. The Surveyor noted R225's (MONTH) TAR contained an intervention for diabetic foot checks every HS (at bedtime), initiated on 4/06/18, and an intervention to monitor dressing to left heel every shift to ensure it is intact, initiated on 4/20/18. In addition, the Surveyor noted R225's dressing change on 4/16 was not completed. The Surveyor reviewed R225's physician orders. R225 had an order, dated 10/05/17, that stated, Per (APNP-G), put resident on schedule for health drive podiatry and for dilated eye exam re (with regard to) diabetes and fax reports when done. The Surveyor reviewed R225's Diabetes Mellitus care plan, dated 12/06/16. Neither the diabetic foot checks or health drive podiatry interventions were added to the care plan. The Surveyor reviewed R225's Potential Impairment to Skin Integrity care plan, dated 12/06/16. The care plan contained interventions, dated 12/06/16, for heel lift boots and to float/elevate heels. The interventions were discontinued on 12/24/17. The Surveyor noted R225's Skin Integrity care plan was not revised when the the left heel wound was discovered or when the wound opened. The Surveyor noted R225's care plan was revised on 4/13/18, following the discovery of the second heel wound. The focus stated, The resident has a diabetic ulcer of the left heel related to diabetes, vascular insufficiency. A second focus, dated 4/13/18 and discontinued on 4/20/18, stated, The resident has 2 diabetic ulcers of the left heel related to diabetes, vascular insufficiency. The care plan contained the following interventions: Complete wound treatment as ordered (4/25/18); Ensure appropriate protective devices are applied to affected areas (4/13/18); Monitor/document wound: Size, Depth Margins: periwound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify MD as indicated (4/13/18); Refer to foot care nurse/podiatrist (4/13/18); Wound/Dressing: Observe dressing. Change dressing and record observations of site (4/20/18). The Surveyor reviewed R225's hospital notes and noted the following: An X-ray report, dated 4/25/18, stated, There appears to be a small cortical (the outer layer of a body structure)erosion posteriorly (behind) in the calcaneus (the large bone that forms the foundation of the rear part of the foot) .Cannot exclude osteo[DIAGNOSES REDACTED] at this time . R225 was started on IV [MEDICATION NAME] and [MEDICATION NAME] (both antibiotics used to treat infections). A note by a hospital MD, dated 4/26/18, stated, [DIAGNOSES REDACTED] of the left foot, heel with [MEDICAL CONDITION]. Seems like patient has a pressure ulcer of the left heel. X-ray of the foot shows erosion of the bone. Clinically it looks like osteo[DIAGNOSES REDACTED] .Patient has significant diabetic ulcer under left heel. It could be a pressure ulcer also. It is deep and painful upon touch. Patient also have (sic) surrounding swelling. It is red. An orthopedic consult note, dated 4/26/18, stated, Examination of the left heel reveals a heel ulcer which is covered with eschar. There is some redness and increased temperature of the skin surrounding the ulcer, but the remainder of (patient's) foot shows no wounds. (Patient) can flex and extend (patient's) toes and dorsal to plantar flex (patient's) ankle without difficulty. (Patient) has intact but decreased light touch sensation in the foot .I do not think (patient) needs formal surgical debridement (the removal of damaged tissue from a wound). A hospitalist note, dated 4/26/18, stated, .Wound care consulted as recommended .Recommend to discontinue IV antibiotics .Recommended MRI (magnetic resonance imaging), however patient unable to get MRI due to pacemaker. R225's hospital discharge summary, dated 4/27/18, stated, To follow up with ID (infectious disease) and bone biopsy as outpatient .Discussed with infectious disease. Okay to stop all antibiotics, no further imaging needed at this time. To continue wound care for possible pressure ulcer. Patient will get bone biopsy in 2 weeks for further workup. On 7/18/18 at 1:51 PM, the Surveyor interviewed APNP-G via telephone. APNP-G stated, (R225) had a history of [REDACTED]. I saw (R225) in (MONTH) of (YEAR) for a diabetic foot exam. There was no skin breakdown. The first time I was aware of the (recent) wound was 4/13. At some point before 4/13, they (the facility) received a wound order from us. When I saw the wound on 4/13, I added Iodosorb. There was another area that was a deep tissue injury. I went back (to the facility) on 4/25. The wound was worse .malodorous with one big necrotic area. They (nursing staff) said the [MEDICATION NAME] was applied, but the Iodosorb was unopened. I ordered the Iodosorb on 4/13 .they should've had it going by 4/14 or 4/15. The wound was really bad on 4/25 .one big necrotic area. I talked to (MD-F) who wanted (R225) sent to the ER. The biggest thing is that is that specific orders weren't followed, even though the TAR said they were. APNP-G indicated the facility employed mostly agency nurses and said, (R225) had a whole box of (Iodosorb) with several tubes. They weren't opened or punctured. APNP-G also stated, As far as I'm aware, we weren't notified when the wound opened. On 2/08, there was a foam border dressing changed every 3 days and PRN until healed ordered. The first time I see diabetic foot check put in as an order was 4/06 and Iodosorb was ordered on 4/13. The wound was not measured from 4/13 - 4/25. I told (FDON (Former Director of Nursing)-I) that the treatment wasn't done as it was supposed to be. On 7/18/18 at 3:45 PM, the Surveyor interviewed MD-F via telephone. MD-F indicated MD-F was not notified on 3/02/18 when the wound opened. MD-F stated, I would've wanted to know if there were any changes or worsening of the wound. MD-F indicated MD-F had concerns related to wound care in the facility due to the high volume of turnover and agency staff. On 7/19/18 at 8:25 AM, the Surveyor interviewed CC (Corporate Consultant)-J, DON (Director of Nursing)-C and NHA (Nursing Home Administrator)-D regarding R225's wound. CC-J provided the Surveyor with the Weekly Wound Logs referenced above that contained measurements and assessments of R225's wounds. The logs were completed by FDON-I and located in a binder in DON-C's office. CC-J, who doesn't regularly work in the facility and was not in the facility during the discovery or progression of R225's wound, was unable to answer why the information was not contained in R225's medical record. DON-C and NHA-D both started at the facility after R225 was discharged . Neither DON-C or NHA-D knew of any concerns related to R225's wounds. Aside from Agency LPN-H, there were no other nursing staff still working in the building who treated R225's wounds. DON-C indicated the facility identified problems with wound care during their quality assurance and performance improvement ad-hoc committee meetings. DON-C provided the Surveyor with minutes, dated 6/01/18, that indicated the facility determined that wound documentation was not consistently completed every 7 days with measurements and assessments. DON-C also provided the Surveyor with minutes, dated 6/25/18, that indicated the facility determined wound care plans do not have consistent and appropriate interventions. The follow up section stated DON-C completed 1:1 education with staff related to appropriate interventions on care plans related to wounds. DON-C stated DON-C conducted facility-wide education with nursing staff addressing both issues. DON-C was unable to provide documentation of the training provided and to whom it was provided. DON-C stated the training was done verbally and staff were not required to sign a form indicating they received the training. On 7/19/18 at 8:37 AM, the Surveyor interviewed Agency LPN-H who stated, I was here the first time (APNP-G) looked at the wound. I was here when (APNP-G) did the order (4/13). When (APNP-G) came back (4/25), the wound was way worse. It was shiny looking, gross, black and had a flap of skin coming off. I don't know that it was bigger, but it wasn't what it looked like when (APNP-G) originally assessed it. I did a dressing change the morning of 4/13 and PMs was supposed to do it again with the Iodosorb. When asked whether LPN-H knew if the Iodosorb order was followed, LPN-H stated, There was a box of approximately 4 small tubes that weren't opened. When asked about facility-wide wound care education, LPN-H stated LPN-H did not receive wound care education. The failure to provide care to prevent the development of pressure injuries created a finding of immediate jeopardy. The facility removed the jeopardy on 7/19/18 when it began implementing the following action plan: 1. A skin sweep was completed on all residents, any variances noted were updated to physician and family and orders were obtained and care plan updated. 2. Care plans for all residents reviewed with alterations for skin for appropriate interventions and updated as needed. 3. Hired wound certified consultant. 4. Residents with wounds: daily monitoring of wounds, completion of wound care as ordered, weekly assessments and measurements of wounds. Physician updated of new wounds, decline in woundsor changes in skin integrity, care plan updated to reflect the type of wound. 5. Wound- observe daily and assess weekly with measurements. Care plans to be updated with interventions to promote wound healing. 6. Education to be completed with all current staff on duty. All nursing staff to b educated prior to working on the floor. 7. Audits will be completed daily to validate wound and dressing changes times 4 weeks. 8. Audits will be completed weekly to validate wound documentation has been completed including measurements and physician notificationif warrented times 4 weeks.

Based on record review and staff interview, the facility did not notify a physician when 1 (Resident (R) 225) of 12 sampled residents experienced a significant change in wound status. The facility's failure to notify the physician in a timely manner resulted in actual harm to the resident. R225 developed a left heel wound on 2/02/18. The wound opened on 3/02/18. The facility did not notify R225's physician to consult with and/or receive new treatment orders until 4/13/18, when a second wound developed on the left heel. R225 was transferred to the hospital on [DATE] for possible osteo[DIAGNOSES REDACTED] (a bone infection) of the left heel. Findings include: The facility's Physician Notification by Nursing policy, dated 1/05/17, states: 1. Policy: 1.1 Physician notification must be completed immediately and with MD documented response with any significant change of condition, accident resulting in injury, if there is a need to alter treatment significantly and a transfer or discharge from the facility. A significant change of condition is a deviation from a resident's baseline in physical, cognitive, behavioral or functional status. 3. Procedure 3.1 Method of Procedure: A. Upon identification of a change of condition, the nurse is to complete the appropriate Assessment/Incident in the computerized medical record. 2. Incidents Pressure Ulcer - Acquired in house Injury of Unknown Cause 5. Other assessments/evaluations 7. A need to alter treatment significantly Note: This is a non-inclusive list. Professional judgement will dictate additional notification. B. Notify physician immediately and with MD documented response of assessment findings. D. Monitor per policy. E. If the resident's condition worsens during the subsequent 24 hours or is not resolving within a week, notify physician and review treatment. On 7/18/18, the Surveyor reviewed R225's medical record. R225 was admitted to the facility with [DIAGNOSES REDACTED]. R225's most recent quarterly MDS (Minimum Data Set), dated 4/06/18, documented R225 was cognitively impaired, required extensive assistance for bed mobility, was at risk for pressure injuries and had one venous/arterial wound. An incident note, dated 2/02/18, stated, (R225) Had a (sic) Injury of Unknown Cause (Skin Tear, Bruise, Abrasion etc) incident on 2/02/18 at 10:00 AM. Incident details: left heel wound 3 cm (centimeters) (length) x 3 cm (width), no drainage noted. Immediate care plan intervention: none. Notifications: (MD (Medical Doctor)-F) and (POA (Power of Attorney)-K). A Non-Pressure Skin Condition assessment, dated 2/02/18, indicated R225 had a 3 cm x 3 cm left heel wound with no drainage or odor. The plan was to monitor the wound in the TAR (treatment administration record) until healed and assess for signs and symptoms of infection. MD-F was notified, but no interventions or protective devices were added by the facility. A Non-Pressure Skin Condition assessment, dated 3/02/18, indicated R225 had a calloused open area on the left heel with a small amount of serosanguineous drainage. The plan was to assess for signs and symptoms of infection. The assessment indicated there were no interventions in place and no protective devices were added. According to the assessment, MD-F was not updated regarding the change in the wound condition. On 7/18/18 at 3:45 PM, the Surveyor interviewed MD-F via telephone. MD-F indicated MD-F was not notified on 3/02 when the wound opened. MD-F stated, I would've wanted to know if there were any changes or worsening of the wound. R225's (MONTH) and (MONTH) (YEAR) TARs contained the following intervention, initiated on 2/11 and discontinued on 4/10: Foam border dressing, change every 3 days and PRN (as needed) until healed. Cleanse with wound cleanser each dressing change. The Surveyor noted dressing changes were not completed on 3/01, 3/16, 3/19, 3/25 and 4/03. A Weekly Wound Log, dated 4/10/18, indicated R225 had vascular left heel wounds that measured 2.4 x 2.0 x 0.2 cm and 3.2 x 1.4 x 0.1 cm. The log indicated R225's physician was updated. The Surveyor noted no new orders were initiated on 4/10/18. A Non-Pressure Skin Condition assessment, dated 4/13/18, indicated R225 had left heel wounds that measured 2.4 x 2.0 and 3.2 x 1.4. The assessment stated, The center of the first wound has eschar and is encircled by bright red/pink open area. The second wound has eschar. Surrounding skin to both wounds is macerated. There is serosang drainage present .Fax sent to MD asking for an order for [REDACTED]. An Aurora Extended Care Service note, dated 4/13/18, stated, [MEDICAL CONDITION]: We received a fax that the patient has 2 wounds on the left heel and the current order was to cleanse with soap and water and applying (sic) a foam dressing changing every 3 days and PRN. They report the wound is worsening. (The patient) has another area that is just a deep tissue injury .Diabetic ulcer of the left heel .with fat layer exposed - cleanse with soap and water, apply Iodosorb, and cover with an Allevyn life dressing. Wrap Kerlix around the foot to secure this in place. Dressing changes every 3 days and PRN. Deep tissue injury - [MEDICATION NAME] paint to (sic) 3 days . A Weekly Wound Log, dated 4/24/18, indicated R225 had a vascular left heel wound that measured 4.0 x 6.0 x 0.2 cm. A nursing note, dated 4/25/18, stated, Per (MD-F), (R225) will be sent to (local) ER (emergency room ) non-emergent A nursing note, dated 4/26/18, stated, Resident admitted to (local hospital) for osteo[DIAGNOSES REDACTED], on IV (intravenous) antibiotics. The Surveyor reviewed R225's hospital notes and noted the following: An X-ray report, dated 4/25/18, stated, There appears to be a small cortical (the outer layer of a body structure)erosion posteriorly (behind) in the calcaneus (the large bone that forms the foundation of the rear part of the foot) .Cannot exclude osteo[DIAGNOSES REDACTED] at this time . R225 was started on IV [MEDICATION NAME] and [MEDICATION NAME] (both antibiotics used to treat infections). A note by a hospital MD, dated 4/26/18, stated, [DIAGNOSES REDACTED] of the left foot .Seems like patient has a pressure ulcer of the left heel. X-ray of the foot shows erosion of the bone. Clinically it looks like osteo[DIAGNOSES REDACTED] .Patient has significant diabetic ulcer under left heel. It could be a pressure ulcer also . A hospitalist note, dated 4/26/18, stated, Recommend to discontinue IV antibiotics . R225's hospital discharge summary, dated 4/27/18, stated, To follow up with ID (infectious disease) and bone biopsy as outpatient .To continue wound care for possible pressure ulcer. On 7/18/18 at 1:51 PM, the Surveyor interviewed APNP (Advanced Practice Nurse Prescriber)-G via telephone. APNP-G stated, (R225) had a history of [REDACTED]. I saw (R225) in (MONTH) of (YEAR) for a diabetic foot exam. There was no skin breakdown. The first time I was aware of the (recent) wound was 4/13. At some point before 4/13. When I saw the wound on 4/13, I added Iodosorb. I went back (to the facility) on 4/25. The wound was worse. They (nursing staff) said the [MEDICATION NAME] was applied, but the Iodosorb was unopened. I ordered the Iodosorb on 4/13 .they should've had it going by 4/14 or 4/15 .orders weren't followed, even though the TAR said they were. APNP-G indicated the facility employed mostly agency nurses and said, (R225) had a whole box of (Iodosorb) with several tubes. They weren't opened or punctured. I would've wanted to be notified of the change in the wound and I would've wanted to be notified if they didn't understand the treatment orders. On 7/19/18 at 8:25 AM, the Surveyor interviewed CC (Corporate Consultant)-J, DON (Director of Nursing)-C and NHA (Nursing Home Administrator)-D regarding R225's wound. CC-J, who doesn't regularly work in the facility, was not in the facility during the discovery or progression of R225's wound. DON-C and NHA-D both started at the facility after R225 was discharged . Neither DON-C or NHA-D knew of any concerns related to R225's wounds. Neither CC-J, DON-C nor NHA-D were aware R225's physician was not notified when the wound opened and that treatment orders were not followed. On 7/19/18 at 8:37 AM, the Surveyor interviewed Agency LPN-H who stated, I was here the first time (APNP-G) looked at the wound. I was here when (APNP-G) did the order (4/13). When (APNP-G) came back (4/25), the wound was way worse. When asked whether LPN-H knew if the Iodosorb order was followed from 4/13 until the time of discharge, LPN-H stated, There was a box of approximately 4 small tubes that weren't opened. For additional information, see citation text at F686.