Every finding on record at Rennes Health and Rehab Center-Appleton

Based on staff interview and record review, the facility did not ensure appropriate care and treatment related to weight monitoring was provided for 1 resident (R) (R86) of 2 sampled residents.The facility did not complete additional assessments and ensure the physician was notified when R86 had a weight gain of more than 2 pounds in 1 day.Findings include:The facility's Heart Failure-Clinical Protocol policy, revised April 2007, indicates: .2.The nurse will assess and document/report the following: a. Vital signs; b. General physical assessment .1. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example, what symptoms to expect, how often and what (weights .) to monitor, when to report findings to the physician, etc. 2. The physician will address related medical issues .whether to modify doses of diuretics .1. The physician will help monitor the progress of individuals with heart failure, including ongoing evaluation and documentation of signs, symptoms, and condition changes .From 8/4/25 to 8/6/25, Surveyor reviewed R86's medical record. R86 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, localized edema (swelling), and chronic diastolic (congestive) heart failure. R86's Minimum Data Set (MDS) assessment, dated 6/18/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R86 had moderate cognitive impairment. R86 had an activated Power of Attorney (POA).R86's medical record contained the following order: Standing - weights daily and notify provider if weight gain of more than 2 pounds in 1 day or 5 pounds in 1 week (ordered 6/30/25). R86's medical record contained the following information:~ On 7/8/25, R86 weighed133.4 pounds. On 7/9/25, R86 weighed 135.6 pounds. R86's medical record did not indicate the physician was notified of the 2.2 pound weight gain.~ On 7/11/25, R86 weighed 135.4 pounds. On 7/12/25, R86 weighed 137.6 pounds. R86's medical record did not indicate the physician was notified of the 2.2 pound weight gain.~ On 7/24/25, R86 weighed 140.2 pounds. On 7/25/25, R86 weighed 142.8 pounds. R86's medical record did not indicate the physician was notified of the 2.6 pound weight gain.On 8/4/25 at 9:38 AM, Surveyor interviewed R86 and noted R86's bilateral lower extremities were edematous. R86 indicated R86 did not like wearing compression stockings.On 8/6/25 at 11:25 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R86 had an order to update the physician with a weight gain of more than 2 pounds in 1 day or 5 pounds in 1 week. When Surveyor asked if the physician was notified when R86 gained more than 2 pounds between 7/8/25 and 7/9/25, 7/11/25 and 7/12/25, and 7/17/25 and 7/18/25, DON-B indicated DON-B would look for physician notification and follow up with Surveyor.On 8/6/25 at 11:27 AM, Surveyor interviewed Registered Nurse (RN)-C who verified R86 had an order to notify the physician for a weight gain of 2 pounds in 1 day or 5 pounds in 1 week. RN-C also indicated respiratory and edema assessments should have been completed for a gain of more than 2 pounds in 1 day and staff should have updated the physician in accordance with R86's order.On 8/6/25 at 12:22 PM and 12:54 PM, DON-B provided Surveyor with multiple physician upate notes. A note, dated 7/7/25, indicated the physician was notified of R86's weights from 6/24/25 to 7/7/25. A note, dated 7/30/25, indicated the physician was notified of R86's weights from 6/30/25 to 7/30/25. A note, dated 7/22/25, indicated the physician was notified of R86's weights from 7/10/25 to 7/22/25. The physician updates did not include next day updates for weight increases of more than 2 pounds in 1 day. DON-B verified the physician should have been notified of R86's weight gain in accordance with R86's order.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R2) of 5 sampled residents had a call light within reach. On 1/8/25, R2's call light was wedged between the mattress and side rail of R2's bed and not within R2's reach. Findings include: On 1/8/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including history of falling, diabetes, hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebrovascular accident (CVA) affecting the right dominant side, morbid obesity, and anxiety disorder. R2's Minimum Data Set (MDS) assessment, dated 11/21/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R2 was not cognitively impaired. R2's care plan, dated 9/21/23, contained an intervention to keep call light in reach. On 1/8/25 at 9:32 AM, Surveyor observed and interviewed R2 in bed. Surveyor noted R2's call light was wedged between the upper left-hand side of the mattress and a side rail on the bed. When Surveyor asked if R2 was able to reach the call light, R2 indicated R2 could not reach the call light and stated, Lots of times they put it (call light) on the back of the bed and I can't reach it. On 1/8/25 at 9:37 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated R2 should have a call light. CNA-D entered R2's room and asked R2, Did they not give it (call light) to you again? CNA-D located the call light at the top left-hand side of the bed and clipped the call light on R2's blanket per R2's request. On 1/8/25 at 11:25 AM, Surveyor again interviewed R2 who indicated it is rough when R2 doesn't have a call light and needs to use the restroom. R2 indicated R2 had incontinent episodes when the call light was not within reach and has had to holler to staff in the hallway to use the restroom. R2 indicated staff eventually show up to assist R2 to the restroom. On 1/8/25 at 12:50 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed call lights should be within reach of residents. On 1/8/25 at 1:05 PM, Surveyor interviewed Registered Nurse (RN)-E who indicated a call light should be on the resident or within reach.

Based on observation, staff and family interview, and record review, the facility did not ensure 1 resident (R) (R44) of 18 residents had a call light within reach or a means to call staff for assistance. During two observations, Surveyor noted R44's call light was not within reach. In addition, R44 did not have the correct call light to meet R44's needs according to R44's plan of care. Findings include: From 6/4/24 to 6/6/24, Surveyor reviewed R44's medical record. R44 was admitted to the facility on [DATE] and had diagnoses including senile degeneration of brain, vascular dementia, and encounter for palliative care. R44's Minimum Data Set (MDS) assessment, dated 3/21/24, contained a Brief Interview for Mental Status (BIMS) assessment that indicated R44 was rarely or never understood. R44 was admitted to Hospice services on 3/15/24. R44's spouse was R44's activated Power of Attorney (POA). R44's plan of care contained interventions for a soft-touch call light (dated 8/24/23) and to keep R44's call light within reach (dated 7/12/23). On 6/4/24 at 10:51 AM, Surveyor interviewed R44's spouse and noted R44's call light was clipped to a blanket on top of R44's right shoulder. Surveyor noted the call light contained a push button instead of a soft-touch pad. R44's spouse indicated R44 was not able to reach the call light in that position because R44 could not raise R44's arms that high and would probably not be able to push the button. On 6/5/24 at 1:01 PM, Surveyor observed R44 in R44's room in Broda chair with the back of the chair against R44's bed. Surveyor noted R44's push button call light was laying on R44's bed and not within R44's reach. On 6/5/24 at 1:19 PM, Surveyor and Director of Nursing (DON)-B entered R44's room and observed R44's call light. DON-B confirmed R44's care plan indicated R44 should have a soft-touch call light within reach.

Based on staff interview and record review, the facility did not develop a comprehensive care plan for 1 resident (R) (R44) of 3 sampled residents. The facility's Matrix and R44's Significant Change Minimum Data Set (MDS) assessment indicated R44 received Hospice services. R44 did not have a care plan for Hospice services. Findings include: The facility's Hospice Program policy, revised 11/2016, indicates: The care plan shall be revised and updated as necessary to reflect the resident's current status. On 6/5/24, Surveyor reviewed R44's medical record. R44's was admitted to the facility on [DATE] and was admitted to Hospice services on 3/15/24. R44 had diagnoses including senile degeneration of the brain, vascular dementia, and encounter for palliative care. R44's Significant Change Minimum Data Set (MDS) assessment, dated 3/12/24, contained a Brief Interview for Mental Status (BIMS) assessment that indicated R44 was rarely or never understood and received Hospice services. R44's spouse was R44's activated power of attorney (POA). On 6/4/24 at 11:50 AM, Surveyor interviewed R44's spouse who confirmed R44 received Hospice services. On 6/6/24 at 2:24 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R44 did not have a care plan for Hospice services. DON-B indicated a care plan should be completed the day a resident signs on to Hospice services and should be updated with a Significant Change MDS assessment.

Based on staff and resident interview, and record review, the facility did not review and revise the plan of care for 1 Resident (R) (R1) of 7 residents. R1 received a new order for a restorative ambulation program. The facility did not update R1's care plan to incorporate the ambulation program. Findings include: The facility's Review of Care Plans policy, dated 12/2016, indicates: The Interdisciplinary Team must review and update the care plan. On 4/8/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including myelodysplastic syndrome, hypertension, atrial fibrillation, and diabetes. R1's Minimum Data Set (MDS) assessment, dated 1/24/24, contained a Brief Interview for Mental Status Score (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. The MDS also indicated R1 was independent with ambulation. A care plan, initiated on 1/17/24, indicated R1 required assistance with ambulation. R1's medical record contained a therapy order for R1 to ambulate in the hallway with a 2 wheeled walker with assistance once daily as tolerated. Nursing documentation indicated R1 walked in R1's room and walked once in the hallway between 2/28/24 and R1's discharge on 3/4/24. Surveyor noted the ambulation program was not added to R1's care plan. On 4/8/24 at 12:16 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who stated R1 chose not to walk in the hallway but would often walk in R1's room. CNA-C stated CNA-C offered R1 the option to walk or use a wheelchair and R1 chose the wheelchair. CNA-C stated ambulation programs are listed on CNA care cards and showed Surveyor R1's care card. On 4/8/24 at 2:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R1's ambulation program was listed on R1's CNA care card but was not added to R1's care plan.

Based on resident representative and staff interview, and record review, the facility did not ensure written notice of a room change was provided for 1 Resident (R) (R1) of 2 residents reviewed. R1 was moved to a different room on 9/20/23. R1's medical record did not contain written notice to R1's representative notifying them of the room change. Findings include: The facility's Room Change/Roommate Assignment policy, revised May 2017, indicates: Prior to changing a room .all parties involved in the change/assignment (e.g., residents and their representatives) will be given notice of such change. R1 was admitted to the facility on [DATE] with diagnoses including urinary sepsis, chronic kidney disease, Alzheimer's disease, and depression. R1's most recent Minimum Data Set (MDS) assessment, dated 8/16/23, indicated R1's cognition was moderately impaired and R1 required extensive assistance of one to two staff for most activities of daily living (ADLs). R1 had an activated Power of Attorney for Healthcare (POAHC). On 11/21/23 at 10:34 AM, Surveyor interviewed R1's representative who stated when they went to visit R1 on 9/20/23, they were told R1 was moving to a different room. R1's representative indicated they were not provided written notice of the room change, including the reason for the room change. On 11/21/23 at 1:14 PM, Surveyor interviewed the Nursing Home Administrator (NHA)-A who stated a voicemail was left for R1's representative and secondary contact regarding the room change. NHA-A verified R1's representative was not given a written notice of the room change, including the reason for the room change.

Based on observation, Resident (R) interviews, and staff interviews, the facility did not ensure residents were provided a hand hygiene opportunity before lunch meal service for 13 residents. This practice had the potential to affect all the residents of the facility. Facility staff did not offer hand hygiene at the point of service for lunch meal to 11 residents in the main dining room and 2 residents provided room trays. Findings include: On 4/25/22 beginning at 11:44 AM, Surveyor began observations in the facility's main dining room. At 11:52 AM, Surveyor observed the first (unidentified) resident arrived in dining room for meal service. No hand hygiene was offered at that time. Eleven total residents independently walked with walker, wheeled own wheelchair, or were transported by staff to the main dining room for meal service. At 12:17 PM, Surveyor observed residents provided Philly cheesesteak sandwiches and french fries (both foods typically eaten with bare hands) without being offered hand hygiene before meal. Surveyor observed one resident was provided full assistance with dining. On 4/25/22 at 12:26 PM, Surveyor interviewed R41 and R48, who were seated and eating in the main dining room. R48 was eating an alternate meal with utensils and indicated the facility used to provide a packet with a wet wipe in it to clean hands before meals. R41 was eating food with hands and disclosed R41 most recently washed hands sometime in the morning. Surveyor observed R41 and R48 were actively working on projects with hands in adjacent activity room prior to lunch meal service. Surveyor attempted to interview two additional (unidentified) residents in main dining room but those residents were not able to be interviewed due to cognitive impairment or [CONDITION(S)] (communication disorder). On 4/25/22 at 12:28 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I, who was assisting with food delivery in the main dining room. CNA-I indicated residents were supposed to get hand hygiene before coming to the main dining room. On 4/25/22 at 12:37 PM, Surveyor followed meal tray cart to 300 unit of facility. Surveyor observed CNA-J serve trays to two (unidentified) resident rooms without offering residents hand hygiene at time of service. Surveyor interviewed CNA-J who explained the facility used to have individual sanitizer packets on room trays. CNA-J verified no sanitizer packets were on room trays at time of investigation and hand hygiene was not offered at time of service. On 4/25/22 at 12:41 PM, Registered Nurse (RN)-K overheard Surveyor interview CNA-J. RN-K revealed the food tray cart used to have a box of individual sanitizer packets on top of the cart. RN-K was not sure how long ago the individual sanitizer packets stopped being provided. On 4/25/22 at 12:45 PM, Registered Dietician (RD)-F confirmed to Surveyor that residents should be offered hand hygiene prior to meal service.

Based on staff interviews and record review, the facility did not ensure Resident (R) level 2 Pre-Admission Screening and Resident Review (PASRR) were completed when 30 day exemptions expired for 2 (R56 and R4) of 3 residents reviewed for PASRR. Facility did not submit a PASRR level 2 for R56 and R4, who were identified on PASRR level 1 as suspected of serious mental illness, when 30 exemption expired. Findings include: From [DATE] through [DATE], Surveyor reviewed R56's medical record which documented R56 was screened for mental illness, developmental disabilities, and intellectual disabilities on [DATE], and granted a 30 day hospital exemption for completing a PASRR level 2 screen, which was required because R56 was suspected of having a serious mental illness. R56 had a court ordered guardian at the time of investigation and was not responsible for decision making. Surveyor noted R56's 30 day exemption expired on [DATE] but R56's medical record did not contain a PASRR level 2. On [DATE] at 2:11 PM, Surveyor interviewed Social Worker (SW)-C and Admission Coordinator (AC)-D regarding R56's PASRR level 2. SW-C reviewed R56's medical record and verified R56's PASRR level 2 was not complete. SW-C and AC-D explained the facility had a multi-check process in place to ensure PASRR level 2 were completed at the end of 30 day exemptions. SW-C and AC-D indicated when a resident had an exemption, the exemption was documented on the resident's admission checklist and a note was placed in a master scheduling book for day 28 or 29 to follow-up. SW-C and AC-D could not articulate why R56's PASRR level 2 was not completed when R56's 30 day exemption expired. From [DATE] through [DATE], Surveyor reviewed R4's medical record which documented R4 was screened for mental illness, developmental disabilities, and intellectual disabilities on [DATE] and granted a 30 day hospital exemption for completing a PASRR level 2 screen, which was required because R4 was suspected of having a serious mental illness. Surveyor noted R4's 30 day exemption expired on [DATE] but R4's medical record did not contain a PASRR level 2. On [DATE] at 10:21 A.M., Surveyor interviewed the Nursing Home Administrator (NHA) - A, who verified that R4's PASRR level 2 was not completed and could not articulate why R4's PASRR level 2 was not completed when R4's 30 day exemption expired.

Based on Resident (R) interview, staff interviews, and record review, the facility did not ensure hospice communications were obtained and part of medical record for 1 (R20) of 2 residents reviewed for hospice services. Facility did not ensure hospice communication documentation was in R20's medical record in accordance with hospice agreement. Findings include: R20's hospice service provider agreement with facility, effective dated 6/11/21, documented, Coordination of Care . Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. And, Creation and Maintenance of Records . Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Hospice Patient, including evaluation, treatments, progress notes . Each record shall document that the specified services are furnished in accordance with this Agreement and shall be readily accessible and systemically organized to facility retrieval by either party. From 4/25/22 through 4/27/22, Surveyor reviewed R20's medical record which documented R20 did not have an activated Power of Attorney (POA) for healthcare and R20 was responsible for own decision making. R20's most recent Minimum Data Set (MDS), dated [DATE], Brief Interview for Mental Status (BIMS) assessment score was 12 out of 15 (moderately impaired cognition.) R20 began services with current hospice provider on 10/29/21. As of 3/14/22, R20's hospice visit schedule was as follows: Nurse once per week and as needed; Social Worker (SW)once per month; Nurse Aide three times per week; Chaplain once per month; Music therapy once per month. Surveyor noted R20's hospice binder documented one April 2022 nurse visit of 4/13/22 and no nurse visits in March 2022. The most recent Nurse Aide (NA) visit was 2/18/22. No documentation of SW visits or chaplain visits were in R20's hospice binder. On 4/26/22 at 11:50 AM, Surveyor interviewed R20 who expressed concerns with facility and hospice communications. R20 explained that sometimes facility staff weren't certain of which cares to provide or wait for hospice to provide. R20 said hospice is hot and cold. R20 elaborated that R20 thought hospice sometimes wasn't showing up as scheduled. On 4/26/22 at 12:11 PM, Surveyor interviewed Registered Nurse (RN)-H about R20's hospice services. RN-H confirmed hospice came to the facility to provide services for R20. RN-H was not certain which days of the week hospice NA visited R20 but thought Fridays were one of the days hospice NAs visited. RN-H indicated R20 fires some NA and explained R20 had at least three of four different hospice NA since beginning hospice. RN-H expressed being less familiar with R20's hospice provider compared to other hospice providers serving other residents at the facility. RN-H could not recall hospice NAs leaving progress notes. RN-H explained hospice nurses typically checked in verbally with the nurse on duty to determine supply needs and communicate changes. RN-H identified R20's hospice provider's nurses as inconsistent with checking in with the facility nurse on duty On 4/27/22 at 10:45 AM, RN-H explained to Surveyor that most hospice services require facility staff to sign-off that staff were in building and provided services. RN-H identified R20's hospice provider as not consistent with obtaining facility staff signatures. RN-H explained R20's hospice binder was kept at the 400 unit nurse station and if infection prevention protocols required doors to be closed between R20's unit and nurse station, it was rare for a person to come through the closed doors, especially with the signage that was posted to discourage people from moving one unit to another. On 4/26/22 at 12:48 PM, Surveyor interviewed SW-C regarding R20's hospice services. SW-C verified being the facility's hospice liaison jointly responsible with facility nurse for hospice service coordination. SW-C disclosed that the facility agreement with R20's hospice provider began in 2021. SW-C reviewed R20's hospice communications with Surveyor. SW-C indicated that if communications were missing, SW-C typically would reach out to hospice provider to discuss and get the situation corrected. On 4/26/22 at 3:18 PM, SW-C and Social Services Designee (SSD)-E met with Surveyor. SW-C explained some hospice progress notes were not in R20's hospice communication binder because the binder was through a closed door at times when infection prevention strategies were in place. SW-C presented hospice documentation of visits to Surveyor which SW-C confirmed were obtained after Surveyor investigation began. SSD-E explained that hospice was documenting visit information electronically and facility staff would sign off and communicate verbally at end of hospice visits. Surveyor reviewed hospice documentation with SW-C an SSD-E and observed signature spaces were consistently signed by hospice staff but not signed by facility staff in facility staff signature area. SW-C was not able to explain how communication was happening between hospice and facility when electronic documentation was not signed by facility staff or maintained in R20's medical record.

Based on staff and resident interview and record review, the facility did not ensure 1 (R) Resident (R26) of two sampled residents reviewed for restorative programs were provided with services to maintain physical abilities. The facility did not provide R26 with consistent assistance to ambulate three times daily per R26's current plan of care. Findings include: Facility policy titled, Restorative Nursing Services states, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. On 04/26/2021 at 11:34 AM, during an interview with the Surveyor, R26 reported staff were inconsistent in providing assistance with R26's ambulation (walking) three times daily. R26 explained that staff were supposed to walk R26 three times daily to help R26 get better or at least maintain R26's ability to walk. R26 explained that R26 received very few walks in comparison to the number of walks R26 should have been assisted with. On 04/27/2021 at 10:47 AM, Surveyor interviewed NM (Nurse Manager)-D. NM-D explained that R26 would get short of breath when walking and that walks to the bathroom were considered some of R26's walks. NM-D reported that R26 had not complained about not getting walks. On 04/27/21 at 11:05 AM, Surveyor interviewed CNA (Certified Nursing Assistant)-E. CNA-E explained that R26 would, Usually get walked once per shift. CNA-E reported that R26 would get walked two times on the AM (morning) shift if there was time. On 04/27/21 at 11:20 AM, Surveyor interviewed RN (Registered Nurse)-G. RN-G explained that R26 would usually get 1-2 walks per AM shift but if R26 would choose to sleep late, R26 would get one walk. On 04/27/21 at 11:30 AM, Surveyor interviewed ADON (Assistant Director of Nursing)-C. ADON-C explained that R26 should have been getting three walks per day between AM and PM shifts. On 04/27/21 at 1:05 PM, Surveyor interviewed DON (Director of Nursing)-B and reviewed R26's Point of Care Restorative Nursing Category Report. R26 had 38 documented walks with staff from 03/27/2021 through 04/26/2021. Per R26's plan of care, R26 should have had 90 walks from 03/27/2021 through 04/25/2021. DON-B explained that each missing entry on the Point of Care Restorative Nursing Category Report indicated R26 was not assisted with walking.

Based on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for one resident (R) (R1) of 3 residents reviewed for falls. R1 had three falls at the facility that were missing partial neurological checks and/or post-fall incident reports. Findings Include: The facility policy, titled Assessing Falls and Their Causes, dated 2007, states: Nursing staff will observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall, and will document findings in the medical record. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. It will note the presence or absence of significant findings. It further states: An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services no later than 24 hours after the fall occurs. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's most recent Minimum Data Set (MDS) assessment, 8/15/20, indicated R1 has mildly intact cognition, one-sided impairment on both upper and lower extremities, and had falls prior to admission as well as two falls without injury while at the facility. R1's care plan, initiated 8/10/20, stated that R1 had impaired physical mobility with risk for falls. Interventions included therapies for strength, call light in reach, proper lighting, orient to surroundings, fitted footwear, lay down after meals, call/don't fall sign, no Hoyer sling under resident in wheelchair (w/c), dunk w/c seat, and left arm trough to w/c for positioning. On 11/23/20, the Surveyor reviewed R1's medical record to include fall reports, vital signs, and progress notes. R1 had the following falls: ~ 8/11/20 - unwitnessed fall at 5:45 AM, no injury noted. Added lipped mattress and soft touch call light along with low bed and floor mats. Post fall incident report was completed and neuro checks conducted. The neurological (neuro) check flow sheet was missing assessments of level of consciousness (LOC), motor response, hand grasp, pupil react/size, and speech at 11:45 PM and 3:45 AM. ~ 8/13/20 - unwitnessed fall at 6:45 PM, no injury noted. Post fall incident report form was not completed and neurological checks were conducted. The flow sheet was missing assessments of breathing, LOC, motor response, hand grasp, pupil react/size, and speech at 4:45 AM and blood pressure, pulse, temperature, and respirations at 12:45 AM on 8/15. ~ 8/23/20 - unwitnessed fall at 11:30 AM, no injury noted. Post fall incident report was completed and neuro checks conducted. The neurological check flow sheet was missing blood pressures at 1:15 PM, 2:15 PM, and 3:15 PM and assessments of level of consciousness (LOC), motor response, hand grasp, pupil react/size, and speech at 3:15 PM. R1 was sent to ThedaCare Medical Center at 3:30 and passed away at home on 8/27/20. On 11/23/20, the Surveyor interviewed the Director of Nursing (DON) - B, who stated she was not sure why the vitals/assessments were not completed. On 11/25/20 at 12:09 PM, the Surveyor interviewed Physician (MD) - C (Dr.(NAME)Schreiber), who stated that the emergency room reported R1 was found unresponsive at 3 PM on 8/23 and sent to the ER. According to MD-C, the facility had conducted adequate assessment and the lack of partial assessments at 1:15, 2:15 and 3:15 PM would not have changed the outcome for R1.

Based on observation, record review and staff interviews, the facility did not ensure 2 (Resident (R) 2 and R1) of 7 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R2 had a non-removable hard cast to the left lower extremity. On 7/05/18, R2 complained of intense pain to the left heel and stated the heel felt like it was rubbed raw. R2's physician was notified via fax; however, the facility didn't follow up when the physician did not respond to the fax until 7/10/18, 5 days after the original fax was sent. In addition, the physician ordered a wound clinic consultation on 7/10/18; however, the facility didn't follow up with the consultation request. As a result, R2 did not see the wound clinic until 7/30/18, 20 days after the original wound clinic consultation was ordered. R2 was referred to a vascular surgeon for an unstageable left heel pressure injury at that time. R1 was admitted to the facility on [DATE] with a red and purple area to the left buttock/ischium with blanchable skin. The care plan indicated R1 was to have a ROHO cushion while seated in the wheelchair. R1 did not have a cushion on the seated surface of the electric wheelchair because of safety concerns and the facility was waiting for physical therapy to evaluate R1, for safety related to using a pressure redistribution cushion on the seated surface of the resident's electric wheelchair. On 6/13/18, R1's red area to the left buttock/ischium was assessed as a new open area. On 7/2/18, the facility received an order for [REDACTED]. There was not contact with the physician in the week it took to receive the fax back with an order to the wound clinic. On 7/16/18 when R1 went to the first scheduled appointment at the wound clinic, it was determined the pressure injury was unstageable and after debridement a Stage 3. Findings include: The facility's Change in a Resident's Condition or Status policy, dated (MONTH) 2007, states: Our facility shall promptly notify the resident, his or her Attending Physician and representative (sponsor) of changes in the the resident's medical/mental condition and/or status. 01. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: b. A discovery of injuries of an unknown source; d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly. 02. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; c. Requires interdisciplinary review and/or revision to the care plan. 1. On 8/01/18, the Surveyor reviewed R2's medical record. R2 was admitted to the facility with [DIAGNOSES REDACTED]. R2's most recent MDS (Minimum Data Set) assessment, dated 6/06/18, documented R2 was at risk for pressure injuries and required extensive assistance of staff for bed mobility. R2's Impaired Skin Integrity care plan, dated 5/07/18, contained the following interventions: ~ free float heels when in bed with heels up (5/07/18) ~ blue boot at all times to ensure no pressure to left foot (7/10/18) ~ wound clinic for treatment of [REDACTED]. A fax to MD (Medical Doctor)-D, dated 7/05/18, stated, Resident complains of intense pain to back of (resident's) left foot above the heel. Rates pain 9/10 and stated that it feels like it has been rubbed raw. Unable to address due to cast in place. The physician did not respond for five days and the facility did not follow up to get a response. MD-D's response, dated 7/10/18, stated, Will address at today's appointment. A second response by MD-D, dated 7/10/18, stated, Cast removed - wound care - eval and treat left heel pressure ulcer. A wound care referral form, dated 7/10/18, stated, Strict NWB (non-weight bearing). Put patient in a pressure relief boot on the left heel .Wound care to left heel - eval and treat pressure sore .follow-up 6 weeks with x-rays. The wound care referral did not occur until 20 days later. A nursing note, dated 7/11/18, stated, Minimal pain experienced with assessment and dressing. Cleansed with NS (normal saline), applied [MEDICATION NAME] (used to promote wound healing) and covered with [MEDICATION NAME] (an absorbent foam dressing). Requesting dressing order. Will continue to monitor on weekly wound rounds and PRN (as needed). Educated on use of moon boot, using heels up cushion in bed and using pillow while in wheelchair. Resident is agreeable with treat (sic) and has already started offloading weight to back of ankle. A fax to APNP (Advanced Practice Nurse Prescriber)-E, dated 7/11/18, stated, Wound located upper heel/lower tendon area. Wound measuring 4 cm (centimeters) x 3.5 cm, superficial bruising extending 1.5 cm beyond wound bed, appears to be a deep tissue injury. Pressure ulcer unstageable. Slough and eschar covering entire wound bed. Expresses pain upon assessment. (MONTH) we have an order to apply Santyl (a [MEDICATION NAME] ointment) to wound bed .Cover with [MEDICATION NAME]. To be changed daily. APNP-E's response, dated 7/11/18, stated, Agree with request. A nursing note, dated 7/20/18, stated, Per wound care team .would like antibiotic therapy and wound care consult. A wound note, dated 7/25/18, stated, Wound to left heel measuring 2.3 cm x 3 cm. Wound bed 100% slough, unable to remove with cleansing. Wound needs debridement (the removal of dead, damaged or infected tissue to improve the healing potential of the remaining healthy tissue), scheduled to be seen by outpatient wound clinic on 7/30. A nursing note, dated 7/30/18, stated, Resident returned from wound care. Progress note per (APNP-F): (Resident) needs to go to see a vascular surgeon with being diabetic with an unstable heel ulcer. The leg/foot is at risk. A wound consultation note, dated 7/30/18, stated, As far as I can tell without (MD-D's) notes, the cast was removed (MONTH) 10. (Resident) states (MD-D) told (resident) (resident) would have to go see a wound specialist, but has no idea why (resident) never got the referral or if (resident) did, why the nursing home did not send (resident). (Resident) states the nursing home has a wound specialist who was using cream on it .(Resident) states (resident) has never seen a vascular surgeon regarding (resident's) heel and has never had a DFU ([MEDICAL CONDITION]) before .Patient has a full thickness heel ulcer to (patient's) left heel as a result of a cast injury. (Patient) does complain of some pain if it is touched. The bed is 100% thick slough that is tightly adhered. Wound measurements: 3 x 2.2 .treatment plan: [REDACTED]. On 8/01/18 at 8:55 AM, the Surveyor observed RN (Registered Nurse)-G provide wound care for R2's left heel. The wound measured 2.3 cm x 3.1 cm. RN-G stated, (R2) saw the wound clinic yesterday and will be referred to a vein specialist. R2 stated, (APNP-F) was wondering why I wasn't there (wound clinic) sooner than yesterday. On 8/01/18 at 1:25 PM, the Surveyor interviewed TRN (Triage Registered Nurse)-H, who worked in MD-D's office. TRN-H stated the preferred communication regarding a change in condition would be via telephone or voicemail. TRN-H stated faxes were received in the business office which was on a different floor than the wound clinic. TRN-H stated business office staff delivered the faxes to the wound clinic; however, the delivery process wasn't as prompt or efficient as a phone call. TRN-H stated, The only communication I see is on 7/10. The next encounter was on 8/01 .(MD-D) has an NP (Nurse Practitioner) that could've assisted. We absolutely could've seen (R2) sooner. On 8/01/18 at 1:50 PM, the Surveyor interviewed DON (Director of Nursing)-A regarding R2's wound. DON-A stated, (RN-B) was educated about not calling the doctor and getting a response. Everyone was educated. There was a read and sign related to wound pain. We definitely wouldn't wait five days to hear from the MD if someone was complaining of pain and that their foot felt like it was rubbed raw. We monitored (R2's) pain. (R2) only complained of pain once between 7/05 and the 7/10 appointment. DON-A provided the Surveyor with the facility's education regarding wound pain. The Surveyor noted the education was dated 7/27/18 and multiple staff were trained on 7/30/18 and 8/01/18. The Surveyor noted RN-B's name was not on the signature sheet. DON-A stated RN-B was educated, but was unable to locate documentation of RN-B's education. During an interview with the Surveyor on 8/01/18 at 2:02 PM, RN-B stated (RN-B) did not recall receiving education regarding wound pain. RN-B stated (RN-B) had a conversation with DON-A regarding terminology in RN-B's charting, On 8/01/18 at 3:21 PM, the Surveyor observed R2 in bed with a boot on the left heel and the right heel in full contact with the mattress. R2 stated to the Surveyor, I don't wear a boot on the right heel. On 8/01/18 at 3:44 PM, the Surveyor interviewed RN-C regarding R2's positioning in bed. The Surveyor and RN-C were unable to locate a second heel boot or a HeelZup cushion in R2's room. R2 indicated there used to be a HeelZup cushion in the room. On 8/01/18 at 4:30 PM, the Surveyor interviewed DON-A regarding R2's positioning in bed and wound consultation. DON-A verified R2's heels should be free floated in bed and stated, (R2's) HeelZup device was on the floor in the room. A housekeeper saw it and thought it was an infection control issue. The housekeeper took it to laundry. Staff should have gotten a new one. DON-A was unsure why R2 didn't see the wound clinic prior to 7/30/18 when a consultation was ordered on [DATE]. The Clinical Guideline, published by the NPUAP (National Pressure Ulcer Advisory Panel) in 2009, entitled Pressure Ulcer Prevention encourages healthcare personnel to consider individuals who are bedfast and/or chair fast to be at risk of pressure ulcer development and to develop and implement a prevention plan when individuals have been identified at risk of developing pressure ulcers. The use of repositioning should be considered in all at-risk individuals. Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas. Pressure redistribution seat cushions should be used for individuals sitting in a chair when mobility is reduced and who are thus at risk of pressure ulcer development .Without pressure relief, a pressure ulcer may occur very quickly. The second edition published in 2014, entitled Prevention and treatment of [REDACTED]. Pressure redistributing support surfaces are designed to either increase the body surface area that comes in contact with the support surface (to reduce interface pressure) or to sequentially alter the parts of the body that bear load, thus reducing the duration of loading at any given anatomical site. Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced. Ensure that selection of a pressure redistributing seat cushion is appropriate to the individual. According to the NPUAP 2014 Quick Reference Guide, Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown is classified as full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage 3 or 4. 2. On 8/1/18, the Surveyor reviewed R1's electronic medical record. The medical record indicated R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The electronic medical record included an admission/5 day MDS assessment dated [DATE], that documented R1 scored 15 out of 15 on the cognitive screen (the higher the score, the more cognizant), required extensive assistance for bed mobility and transfer, did not ambulate, was at risk for the development of pressure injury, and had a pressure reducing device for bed and chair. R1's Braden skin risk score assessment (scale for predicting pressure injury risk), dated 5/29/18, documented R1 was at risk for the development of pressure injuries with a score of 15. R1's risk factors included [MEDICAL CONDITIONS] or quadraplegia, extensive assistance was required with transfer, sensory perception was completely limited with limited ability to feel pain over most of body surface, mobility was lightly limited with R1 making frequent, though slight, changes in body or extremity position independently, R1 was chairfast with the ability to walk severely limited or nonexistent, and friction/shear is a potential problem. R1's current plan of care, dated 5/30/18, indicated R1 was at risk for impaired skin integrity related to spinal cord infarction with [MEDICAL CONDITION]. Noted to have bilateral intramuscular hematomas to buttocks on admit. Open area to left buttock noted 6/13/18. Interventions with an approach start date of 5/30/18 included: ~ keep off left buttock as much as possible ~ educate to off load when in wheelchair ~ report any signs of skin breakdown to left buttocks, has red area ~ ROHO cushion in wheelchair ~ side to side repositioning in bed ~ An approach start date of 6/13/18 indicated R1 was to have a treatment to the left buttock per orders and R1 will use ROHO cushion in both wheelchair and electric wheelchair. R1's current plan of care, dated 5/30/18, indicated R1 had impaired physical mobility with risk for falls related to spinal cord infarction with [MEDICAL CONDITION]. Interventions with an approach start date of 5/31/18 included: ~ allow R1 to maneuver power wheelchair in room, facility and courtyard ~ must wear seatbelt, does not need assistance to put on ~ An approach start date of 6/13/18 indicated R1 had a trapeze to bed for mobility R1's Admission Nursing Assessment: Skin Check was completed on date of admission 5/29/18. Body marks are indicated on the diagram and include old scars, bruises or discolorations, skin tears/lacerations, pressure ulcers, other ulcerations, and any other questionable markings. The diagram indicated there was a red and purple area on the left buttock/ischium with blanchable skin. On 5/31/18 at 9:08 AM, the progress notes indicated R1 had staining present to the coccyx. Skin blanchable. Nurse to obtain barrier cream order. Continue with repositioning plan. On 5/31/18 at 2:00 PM, the progress notes indicated R1 had the power wheelchair assessment completed. R1 was safe to maneuver power wheelchair within room, facility, and outdoor courtyard. Wheelchair seatbelt required. R1 is able to fasten/unfasten seatbelt independently. An order was obtained to use seatbelt in electric chair for positioning. On 5/31/18 at 2:12 PM, the medication administration history indicated R1 was up in electric wheelchair and around facility. Will pass onto PM shift. On 5/31/18 the facility indicated R1 completed a Powered Personal Mobility Device Skills Test. R1 was tested on R1's owned device by physical therapy. R1 passed the test in all applicable areas. On 6/1/18 at 2:18 PM, the medication administration history indicated R1 was in therapy and in electric wheelchair. On 6/13/18 at 6:57 AM, the progress notes indicated there was a shear like area noted to left buttock (near upper leg) measuring 0.5 cm x 3 cm x 0.1 cm. No pain, no drainage, periwound intact, wound edges irregular, wound bed pink. Fax sent to physician to request order for [MEDICATION NAME] cream twice daily and as needed until healed. On 6/13/18 at 10:05 AM, the progress notes indicated the new open area was assessed. Shearing present. Given ROHO cushion for power chair. Barrier cream already in place. On 6/13/18, the medication administration history indicated there was an order with a start date of 6/13/18 to ensure wheelchair cushion is in place when using electric scooter and to check ROHO cushion every shift for proper inflation. On 6/13/18 at 1:51 PM, the physician agreed to the order to apply [MEDICATION NAME] cream twice daily and as needed until healed. At 2:21 PM, the physician agreed to the order to cleanse the wound with normal saline and apply [MEDICATION NAME] every three (3) days to shear area on left buttock. On 6/27/18 at 4:30 PM, the progress notes indicated R1 has a wound to left buttock measuring 2.5 cm x 4.8 cm. R1 has a ROHO cushion, repositioning every two (2) hours, will add air bed and review treatment with physician. At 5:21 PM, a fax was sent to the physician requesting an order for [REDACTED]. On 6/29/18 at 7:43 AM, the progress notes indicated R1 has special mattress on bed now, new order for [MEDICATION NAME] with [MEDICATION NAME] dressing daily to open area on the left buttock. On 7/1/18 at 11:40 AM, the progress notes indicated R1's buttock dressing fell off. A new dressing was applied per treatment orders. Noted center of wound was a 0.4 cm x 0.4 cm dark area appears to be eschar. Area is firm. Noted around eschar lining of slough. Remaining part of wound granulation tissue noted. Encouraged R1 to reposition self often and try to lean more on opposite buttock if able. R1 continues with ROHO cushion and air mattress. At 12:28 PM, the progress notes indicated WCN (Wound Care Nurse)/DON-A was notified. At 2:34 PM, the progress notes indicated per WCN recommendations request Santyl twice daily to area. Call out to physician on call. At 2:53 PM, the progress notes indicated a new order was received from the physician for Santyl twice daily to eschar on wound to left buttock and cover with [MEDICATION NAME]. On 7/2/18 a fax was sent to R1's physician requesting an order for [REDACTED]. On 7/2/18 at 2:44 PM, the progress notes indicated it was OK for wound consult with wound clinic. Fax placed in appointment folder. On 7/3/18 at 4:06 PM, the progress notes indicated the following regarding R1: ~ assessed by nursing for transfer with slide board related to open area to left ischium. R1 was noted to place slide board under upper thigh. R1 was questioned regarding placement of slide board. R1 stated this was how R1 wanted to place the board because in the hospital (R1) ended up with a large hematoma to both buttocks and it was thought to be related to the slide board. R1 does have a potential for injury to the area related to placement, but wants to place slide board there per R1's request. ~ has a ROHO cushion in electric wheelchair. When asked if R1 could lift self up to reposition some, R1 stated cannot with ROHO cushion but was able to with no cushion there. R1 does have a manual wheelchair that is used for appointments. R1 was asked if (R1) was able to reposition self with the ROHO cushion in the manual wheelchair and R1 had not tried it. R1 was asked if R1 was willing to try to get in the manual wheelchair to see if R1 is able to reposition self and was agreeable for dinner tonight. If able to do this, R1 is also willing to try it for one week and see how R1's open area looks. The ROHO cushion was assessed and inflation was appropriate. There was not any indication of education provided to R1 regarding placement of the slide board or the offer of staff repositioning R1 while seated in the electric wheelchair. On 7/5/18 at 11:41 AM, the progress notes indicated the area to left ischial tuberosity is showing improvement. Center slough is 2 cm x 1.6 cm. Total wound is 3.5 cm x 4 cm area has granulation in outer wound. No firmness or induration to outer tissue, wound edges are well approximated without any redness or warmth to surrounding skin. R1 has no feeling to area so has no pain. R1 did have a hematoma to bilateral buttocks at hospital prior to admit. Transfers on slide board to wheelchair. On 7/9/18 at 5:23 PM, the progress notes indicated R1's physician agreed to refer R1 to the wound clinic. On 7/10/18 at 10:16 AM, the progress notes indicated R1 was updated on wound clinic referral. On 7/11/18 at 1:36 PM, the progress notes indicated there was a hard mass located over the left ischial tuberosity which measured 2 cm x 2.4 cm. Mass is 100% eschar and slough. Pink ring encircling mass. No pain present at wound site. Skin warm to touch. Peri wound blanchable. Continue with current treatment of [REDACTED]. On 7/16/18 at 3:04 PM, the progress notes indicated the following regarding R1: ~ had been seen at the wound clinic by APNP-F and new orders were received for dressing changes and return to wound clinic in one week. Additional orders included R1 must use ROHO cushion any time R1 sits, only should be sitting for meals or physical therapy, not any other time. R1 needs to be laying, head of bed raised to 30 degrees, and turned every one to two hours. R1 needs to use Hoyer lift, not slide board to avoid shearing. R1 needs air alternating air fluidized type mattress as this is a Stage 3 or Stage 4 pressure injury. It was unknown if it was Stage 3 or Stage 4 at this time because APNP-F had not reached healthy tissue, bone may be exposed. ~ wound clinic notes written by APNP-F and dated 7/16/18, indicated R1 was seen at the wound clinic for a pressure ulcer to the left buttock. R1 stated to APNP-F had been admitted to the facility for approximately one week when R1 started to develop an ulcer to the left buttock. R1 stated the nurse looked at the wound and did not send R1 to the wound clinic because the wound was getting better. R1 indicated the way the facility had him transfer on the slide board contributed to the development of the pressure injury. R1 did have a ROHO cushion that was provided to R1 in the middle of (MONTH) (6/13/18). R1 does not have any pain with the injury as R1 indicated was paralyzed from the waist down. ~ APNP-F described R1's pressure injury as an unstable pressure injury to the left ischial tuberosity. Pre debridement the wound is 100% thick adherent white colored slough. The peri wound is red, nonblanching below. The edges are attached. A 15 blade was used to cut away some of the adherent slough and necrotic tissue. Post debridement there is still white adherent slough around the edges. Stage of pressure injury of ischium is unstageable and measures 2 cm x 3.1 cm x 1.6 cm. Cleanse wound with saline. Apply a barrier cream such as [MEDICATION NAME] cream to the peri wound. Fluff a 4 x 4 and soak in quarter percent Dakin's and loosely pack ulcer. Cover with a dry 4 x 4 and paper tape. Change this every morning and every evening. Return to clinic in 7 to 10 days. Continue to use ROHO cushion. Stop using the slide board and use a lift instead. Sit only three times a day to reduce pressure. Lay in bed with head of the bed below 30 degrees and be turned every two hours. ~ wound clinic notes written by APNP-F and dated 7/23/18, indicated R1 was seen at the wound clinic by APNP-F and R1 has a Stage 3 pressure injury to the left ischial tuberosity. Pre debridement the wound is 90% clean red healthy appearing tissue with 10% thick adherent white colored slough to the center of the wound. The peri wound is red, nonblanching below. Edges are attached. A 15 blade scalp was used to cut away the remaining slough tissue. No bone was probed. Total debrided was 4.5 square cm. Stage 3 pressure injury of ischium measuring 1.5 cm x 3.0 cm x 3.3 cm. Return to clinic in seven days and will switch plan of care to actually be able to treat the bed of the wound. The first 14 days of Dakin's soak was to clean the wound up, this will be discontinued at the next appointment. On 8/1/18 at 7:50 AM, the Surveyor interviewed DON-A regarding R1's dressing changes. DON-A verified R1's dressing to the left ischial tuberosity was completed earlier on wound rounds. On 8/1/18 at 9:00 AM, the Surveyor interviewed DON-A regarding R1. DON-A verified R1 had a [MEDICAL CONDITION] and had hematomas to the buttocks on admit. The area opened, DON-A questions shear. DON-A feels the open area is coming from the inside out, not healing. DON-A indicated the consultants are WCC (wound care certified) and can call them with questions, has not needed to call. DON-A indicated took the wound care course in (MONTH) (YEAR) with another nurse, but is not WCC nor are other nurses at the facility. On 8/1/18 at 12:20 PM, the Surveyor interviewed R1, who indicated a pressure redistribution cushion (ROHO) was not offered/placed on the seated surface of the electric wheelchair until R1 had been at the facility at least 10 or more days (6/13/18). R1 verified was able to slide forward and back in the electric wheelchair, but could not lift buttocks completely to reposition self prior to and after placement of ROHO cushion in the electric wheelchair. R1 questioned if the pressure injury came from the slide board being jammed under (R1) by staff. R1 confirmed the use of the slide board is only completed by therapy now. Additionally, R1 confirmed does not sit in the electric scooter as much now, as spends more time in bed per the wound clinic to heal the pressure injury. On 8/1/18 at 2:02 PM, the Surveyor interviewed RN-B via telephone. RN-B verified R1 had a skin assessment completed on admission to the facility and confirmed R1 had a red and purple area to the left buttock/ischium with blanchable skin when assessed on admission. RN-B indicated repositioning in bed was put in place and R1 was able to move around/forward in the chair to straight cath self. RN-B indicated a pressure redistribution cushion was not put in place for R1 because R1 had extra padding (not pressure redistribution) on the seat of the electric wheelchair and a ROHO cushion was provided for R1 on 6/13/18, after it was discussed that R1's weight needed to be redistributed, as R1 needed to sit on a flatter surface. On 8/1/18 at 2:40 PM, the Surveyor interviewed COTA (Certified Occupational Therapy Assistant)-I regarding R1. COTA-I indicated the facility is now using a Beasey slide board for R1. R1 sits on the Beasey slide board now and scoots rather than sliding. On 8/1/18 at 3:05 PM, the Surveyor interviewed DON-A regarding R1. DON-A verified R1's wound to the left buttock/ischium was not considered to be a pressure injury on 6/13/18 even when called shearing. DON-A still doesn't consider wound pressure even though APNP-F staged the pressure injury as unstageable and then a Stage 3 pressure injury after debridement. DON-A verified the left buttock/ischium was assessed to be red/purple with a blanchable area on admission by RN-B. DON-A then stated can't remember if there was an open area, this wound was not through the skin, not a pressure injury. DON-A confirmed the physician's orders [REDACTED]. After the order for the wound clinic was placed in Epic on 7/10/18, the facility was able to schedule an appointment for R1 to see APNP-F on the first available appointment of 7/16/18. DON-A confirmed the facility follows NPUAP for guidelines and treatment of [REDACTED]. On 8/1/18 at 4:40 PM, the Surveyor interviewed DON-A who verified R1 received a ROHO cushion on 6/13/18, for the electric wheelchair. DON-A confirmed a pressure redistribution cushion was not placed on the seated surface of the electric chair until 6/13/18, because R1 needed an evaluation from therapy for safety prior to placing a cushion on the seated surface of the motor and therapy had provided a safety assessment on 5/31/18. On 8/10/18 at 11:29 AM, the Surveyor interviewed APNP-F at the wound clinic via telephone regarding R1. APNP-F indicated there was a possibility (professional opinion) the pressure injury to the left buttock/ischial tuberosity could have been prevented if a pressure redistribution cushion had been placed on the seated surface of the electric wheelchair, and if observation of the slide board transfers with staff, other than therapy had occurred sooner. APNP-F wondered if the nurses were WCC at the facility and what type of training had been provided related to pressure injuries. APNP-F stated the wound is deep .could be bone and has not reached healthy skin yet. APNP-F commented R1 is generally healthy and wondered why the facility would wait so long to send R1 to the wound clinic for care, Took too long to get (R1) to the wound clinic for treatment of [REDACTED].

Based on observation, interview and record review, the facility did not ensure food was stored, prepared, distributed and served under sanitary conditions. The facility's practice had the potential to affect residents in 1 of 2 dining rooms. DA (Dietary Aide) used gloved hand to touch multiple surface areas and then touched ready to eat food. Findings include: On 5/14/18 at 8:42 AM, while completing the initial tour of the kitchen, the Surveyor interviewed DM (Dietary Manager)-A, who indicated the facility follows the Federal and State Food Codes. Per 3-304.15 (A) of the WI State Food Code, single-use gloves shall be used for only one task such as working with ready-to-eat-food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 5/14/18 at 12:07 PM, the Surveyor observed the resident's lunch service in the dining room located between the 100 wing and 400 wing. DA-B washed hands and placed gloves on both hands and started to plate food. DA-B grabbed a plate and bowl and with the right gloved hand, touched the chili handle and then with same right gloved hand, touched a grilled cheese sandwich and placed it on a plate. DA-B stepped away from the service area and touched multiple surface areas that included the refrigerator door handle, drawer handles, the spatula to flip the grilled cheese sandwiches and a container of crackers. While wearing the same soiled gloves, DA-B continued plating the resident's food. DA-B grabbed a plate, removed a bun from the bag and placed the bun on the plate removing the upper bun. With DA-B's right gloved hand, touched the handle of a spatula to place a fish patty on the bottom bun and then placed the top of bun over the fish patty. While wearing the smae soiled gloves, DA-B partially removed the wrapping from a tray with the right gloved hand and placed a small dish of cucumber salad on the resident's plate. DA-B then placed the plate of food on the counter for a CNA (Certified Nursing Assistant) to pick up for delivery to the resident. While wearing the same soiled gloves, DA-B continued plating food for the residents throughout the food service observation, touching ready to eat foods. On 05/14/18 at 02:22 PM, the Surveyor interviewed DM-A regarding hand hygiene and glove use. DM-A stated if dietary aides are staying with the same task and only touching handles of food items, then ok to use gloved hands for grabbing ready to eat foods. However, if staff go and do other tasks such as make grilled cheese sandwiches, touch drawer handles, touch refrigerator handles, then staff need to wash hands and put new gloves on. DM-A stated DA-B was very new to serving food and they will be working with DA-B to ensure she understands proper hand hygiene and glove use.

Based on observations, staff interviews and record review, the facility did not maintain an infection control program that staff did not ensure staff follow correct hand hygiene procedures during observations of direct care involving 6 (R (Resident) 377, R18, R233, R241, R235 and R382) of 10 sampled residents. During IV (Intravenous) medication administration for R377, staff did not appropriately remove gloves and cleanse hands. During [DEVICE] (Gastrostomy tube, a tube inserted into the stomach to deliver nutrition) medication administration for R18, staff did not appropriately remove gloves and cleanse hands. During wound care observation for R233, staff did not appropriately remove gloves and cleanse hands. R233's wound culture results tested positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus). During catheter care for R241, who was on contact precautions for history [MEDICAL CONDITION], staff did not appropriately remove gloves and cleanse hands. During the perineal care for R235, staff did not appropriately cleanse hands. Staff did not appropriately complete hand hygiene after completing perineal cares for R382. Staff did not appropriately remove gloves and cleanse hands after cleaning R382's bathroom. Findings Include: The Morbidity and Mortality Weekly Report dated 10/25/02 and published by the Centers for Disease Control and Prevention entitled Guideline for Hand Hygiene in Health Care Settings indicated recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The facility's Handwashing Hand Hygiene policy, revised dated 4/29/13: Policy Interpretation and Implementation 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); e. Before and after entering isolation precaution settings; i. Before and after handling peripheral vascular catheters and other invasive devices; k. Before and after changing a dressing; n. Before and after assisting a resident with toileting (hand washing with soap and water); o. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and [DIAGNOSES REDACTED]icile (hand washing with soap and water); q. After contact with a resident's mucous membranes and body fluids or excretions; r. After handling soiled or used linens, dressings, bedpans, catheters and urinals; u. After removing gloves or aprons; 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub .for all of the following situations; a. Before and after direct contact with resident; e. Before handling clean or soiled dressing, gauze pads, ; f. Before moving from a contaminated body site to a clean body site during resident care; h. After handling used dressings, contaminated equipment, etc.; j. After removing gloves. 7. Hand hygiene is always the final step after removing and disposal of personal protective equipment. Procedure: Washing Hands 2. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least fifteen (15) seconds under a moderate stream of running water, at a comfortable temperature. 3. Rinse hands thoroughly .inside of sink. 4. Dry hands thoroughly with paper towel and then turn off faucet with a clean, dry paper towel. Examples: 1. On 5/16/18 at 08:05 AM, the Surveyor observed RN (Registered Nurse)-E during the administration of IV medication for R377. With cleansed hands, RN-E hung the IV antibiotic bag on the IV pole, pierced the IV bag and attached the IV tubing, primed the IV tubing and entered the rate of the infusion into the IV pump. Without cleansing hands, RN-E applied gloves, cleansed R377's PICC (Peripherally Inserted Central Catheter, provides IV access directly into large vein) line port with an alcohol wipe and attached the IV tubing. RN-E was unable to get the IV pump started. RN-E removed gloves and without cleansing hands left R377's room to find another nurse to assist. RN-E re-entered R377's room without washing/cleansing hands and then left R377's room again without cleansing hands and retrieved a new IV pump and again re-entered R377's room without cleansing hands. RN-E removed the current IV pump from the IV pole, replaced it with a different IV pump, clamped the IV tubing and removed the IV tubing from the first IV pump. RN-E then disconnected the IV tubing from the resident's PICC line port, primed the IV tubing, reattached the IV tubing to the second IV pump, reset the IV pump rate, cleansed the PICC line port with alcohol, attached the IV tubing back into the PICC line port and started the IV pump infusion. RN-E left R377's room with the first IV pump and entered the 100/300 wing medication room and then sanitized hands after she exited the medication room. Immediately following the above observation, the Surveyor interviewed RN-E regarding the above IV administration observation with R377. RN-E verified the above observation and indicated was so frustrated and embarrassed when the first IV pump did not work, didn't cleanse hands. RN-E further indicated should have cleansed hands and worn gloves when attaching the IV tubing to R377's PICC line. RN indicated it is the facility's policy to cleanse hands before and after entering a resident's room and whenever going from a dirty to a clean task. 2. On 5/16/18 at 9:45 PM, the Surveyor observed RN-F during R18's [DEVICE] medication administration. With cleansed and gloved hands, RN-F set up R18's medication and supplies without concern. RN-F then touched R18's garbage container with gloved hand touching the inside and outside of the garbage container. While wearing the same soiled gloves, RN-F completed the [DEVICE] medication administration, threw out disposable items, removed gloves and sanitized hands. RN-F returned items to medication cart and sanitized hands. Immediately following the above observation, the Surveyor interviewed RN-F regarding the observation with R18. RN-F verified the above [DEVICE] medication administration observation and indicated should have changed gloves and sanitized hands after touching R18's garbage container. RN-F further indicated it is facility policy to change gloves and sanitized hands whenever going from a dirty to a clean site. On 05/16/18 at 01:04 PM, the Surveyor interviewed DON (Director of Nursing)-C regarding hand hygiene. DON-C indicated it is the facility's policy to sanitize/wash hands when entering and leaving a resident's room and to remove gloves and sanitize/cleanse hands whenever going from a dirty to clean task and/or area. 3. On 05/15/18 the Surveyor reviewed R233's medical record which included [DIAGNOSES REDACTED]. Documentation indicated the results of R233's left lower extremity wound culture was positive [MEDICAL CONDITION]. R233's impaired skin integrity plan of care included intervention of contact precautions r/t (related to)[MEDICAL CONDITION] in LLE (Left Lower Extremity). On 05/17/18 at 09:53 AM, the Surveyor observed RN-D complete R233's wound care. RN-D washed hands for four seconds, shut the faucet off, dried hands and applied PPEs (Personal Protective Equipment) to include; a facemask, gloves and gown. RN-D then set up supplies, removed the soiled dressing and cleansed the wounds on R233's LLE. RN-D removed gloves, washed hands for three seconds, shut off the faucet, dried hands and applied clean gloves. RN-D applied [MEDICATION NAME] (antibiotic) ointment topically to R233's LLE wounds and without removing soiled gloves, applied the dressing to the resident's wounds. RN-D gathered supplies, removed PPEs, washed hands for four seconds, dried hands, applied clean gloves, gathered garbage and supplies, left R233's room, disposed of the garbage, cleansed reusable supplies, removed gloves and sanitized hands. Immediately following the above observation, the Surveyor interviewed RN-D regarding the observation of R233's wound care. RN-D verified the above observation and indicated it was the facility's policy to wash hands for about a minute, cleanse hands when entering and leaving a resident's room, and to change gloves and cleanse hands whenever going from a dirty to a clean area. In addition, RN-D indicated after applying [MEDICATION NAME] ointment to R233's wounds, should have changed gloves and wash hands so I didn't contaminate the dressing. On 05/17/18 at 10:24 AM, the Surveyor interviewed DON-C regarding the observation of wound care with R233. DON-C indicated it was the facility policy to wash hands for at least 20 seconds and to turn off the faucet using a clean dry paper towel after drying hands. DON-C further indicated it was the facility's policy to change gloves and cleanse hands whenever going from a dirty to a clean area. 4. On 5/15/17, the Surveyor reviewed R241's medical record which included documentation the resident as admitted with an indwelling urinary catheter for the [DIAGNOSES REDACTED]. R241's record included documentation that the resident had a history of [REDACTED]. On 05/16/18 at 07:25 AM, the Surveyor observed CNA (Certified Nursing Assistant)-G provide catheter care for R241. With cleansed hands, CNA-G applied PPEs to include facemask, gloves and gown then emptied R241's catheter. CNA-G capped the graduated urinal, placed it on a barrier on the floor, removed gloves, and without cleansing hands, adjusted R241's sock, catheter leg bag and right pants leg. Without cleansing hands CNA-G applied clean gloves and emptied, rinsed and placed R241's urinal into a bag. CNA-G then removed PPEs and washed hands. Immediately following the above observation, the Surveyor interviewed CNA-G regarding the observation of care with R241. CNA-G verified the above observation and indicated it is the facility's policy to cleanse hands before entering and leaving a resident's room and change gloves and cleanse hands whenever going from a dirty to a clean area. 5. On 5/17/18 at 09:20 AM, the Surveyor observed CNA-G and CNA-J answer R235's call light after cleansing hands and applying gloves. CNA-G and CNA-J assisted the resident to a standing position after the resident had urinated and had a bowel movement. CNA-G cleansed R235's perineal area without concern and removed gloves. Without sanitizing/washing hands, CNA-G pulled up R235's brief and pants, removed the gait belt, touched the pivot lift, assisted R235 back into the wheel chair, cleansed R235's hands and then CNA-G washed her hands. Immediately following the above observation, the Surveyor interviewed CNA-G regarding the observation with R235. CNA-G verified the above observation and indicated it was the facility's policy to cleanse hands before and after cares and whenever going from dirty to clean area. 6. The facility's policy, [MEDICAL CONDITION] (revised (MONTH) 2010), states When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant hand washing with soap and water, rather than alcohol-based hand rubs, for the mechanical removal of [MEDICAL CONDITION] spores from hands. R382 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 05/15/18 at 12:57 PM, the Surveyor observed CNA-G assist R382 to the bathroom while wearing PPEs (Personal protective equipment). CNA-G stepped out of the bathroom, removed PPEs, used hand sanitizer and left R382'S room to dispose of the garbage. CNA-G returned to R382's room wearing PPEs and assisted R382 with perineal cares. CNA-G then removed PPEs and without washing hands, touched R382, R382's wheelchair and the bathroom door handle. On 05/16/18 at 9:57 AM, the Surveyor observed Housekeeper-H clean R382's bathroom while wearing gloves. When Housekeeper-H finished cleaning, removed gloves and without washing hands, Housekeeper-H entered another resident's room and began cleaning.

Based on observation and staff interviews, the facility did not prepare, serve and store food under sanitary conditions. This practice had the potential to affect all residents in the facility. Staff did not consistently label food with use-by dates per facility policy. Undated, expired and incorrectly labeled food and beverage items were observed in multiple areas of the facility. A container with turkey soup was observed in the left-over freezer with an open lid. Staff incorrectly tested the Multi-Quat sanitizing solution in the three-compartment sink. A wall in the dishwashing area contained food and beverage debris; A wall behind the stove/cooktop contained grease and food debris. Three hanging lights over the steamtable in the 400 dining room contained visible dust. Findings include: Upon entrance to the facility on [DATE], surveyor # conducted an initial tour of the kitchen with CD (Corporate Dietician)-I at 9:05 a.m. CD-I confirmed the facility followed the Federal Food Code. The 2013 Federal Food Code's preface I indicates most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort. For some, especially older adults in health care facilities and those with impaired immune systems, foodborne illness is more serious and may be life threatening. ~ UNDATED/EXPIRED/INCORRECTLY LABELED FOOD AND BEVERAGE ITEMS The 2013 Federal Food Code 3-501.17 (B) indicates refrigerated food 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 or discarded. The facility's Food Receiving and Storage policy, dated 7/2014, states: * Food items out of their original box will be labeled with the name of the items and the use-by date/expiration date. * If an item has a manufacturer use-by date, this must be followed, even if it is removed from the original box. FOOD ITEMS USE BY DATE - AFTER OPENING: Chocolate Syrup 6 months Salad Dressing (bottled) 3 months Milk 7 days Juice 5 days Bread (frozen) 3 months Soup (frozen) 3 months During an initial tour of the kitchen with CD-I on 1/20/16 at 9:05 a.m., surveyor # observed the following: Food Prep Cooler- * 1 undated square metal pan of cooked carrots * 1 undated square metal pan of cooked broccoli * 1 open and undated gallon of Vitamin D milk * 3 trays containing 9 bowls of fruit salad and 7 slices of cake dated 1/19 * 1 container of chicken noodle soup dated 12/1 The items were verified by CD-I who verified the carrots and broccoli should have been dated. CD-I was unaware if the items dated 12/1 and 1/19 indicated the use-by dates or were mislabeled. CD-I also verified the facility does not date milk when opened and uses the manufacturer's expiration date. On 1/20/16 at 1:25 p.m., surveyor # interviewed DS (Dietary Supervisor)-J who stated, The soup dated 12/1 was opened on Monday night (1/18). The broccoli and carrots were made yesterday (1/19). The trays dated 1/19 were made yesterday (1/19). They should have been labeled with the use-by dates. Dry Storage Area- * 1 plastic bag of hamburger buns with a use-by date of 1/17 * 1 plastic bag of hot dog buns with a use-by date of 1/5 * 1 plastic bag of hot dog buns with a use-by date of 1/19 These items located in the dry storage were verified by CD-I. On 1/20/16 at 2:10 p.m. and 1/21/16 at 12:00 p.m., surveyor # observed the following: Main dining room refrigerator- *1 open and undated 46 oz carton of prune juice On 1/20/16 at 11:30 a.m., surveyor # observed the following: 400 dining room refrigerator- *1 open and undated container of butter The item was verified by DA (Dietary Aide)-L who indicated DA-L opened the butter that morning, but forgot to label the container. On 1/26/16 at 1:55 p.m., surveyor # observed the following: 400 dining room- * 1 open and undated 64 oz pump dispenser of Simply Thick Instant Food Thickener. Instructions on the bottle state, Use within 90 days of opening. 400 dining room refrigerator- * 1 open and undated gallon of Skim milk * 1 open and undated gallon of Vitamin D milk These items were verified by CD-I, who indicated the thickener should have been labeled with a use-by date. On 1/26/16 at 2:05 p.m., surveyor # observed the following: Main dining room refrigerator- * 1 open and undated 46 oz carton of prune juice * 2 undated dessert cups with plastic lids labeled pudding. These items were verified by CD-I who indicated the prune juice and dessert cups should have been labeled with use-by dates. On 1/26/16 at 2:25 p.m., surveyor # observed the following in the kitchen: Left-over freezer- * 1 pan of lasagna dated 1/21/16 * 1 container of pork dated 1/24/16 * 1 container of pea soup dated 12/23/15 * 1 undated loaf of gluten-free white bread Counter- *2 open and undated 64 oz pump dispensers of Simply Thick Instant Food Thickener. Instructions on the bottles state, Use within 90 days of opening. Food prep cooler- * 1 open bottle of Hershey's chocolate syrup dated 6/25 * 1 plastic squeeze bottle labeled caramel dated 6/25 * 1 unlabeled and undated plastic squeeze bottle of what appeared to be ranch dressing * 1 unlabeled plastic squeeze bottle of what appeared to be ranch dressing dated 12/20 * 1 unlabeled and undated plastic squeeze bottle of what appeared to be french dressing * 2 unlabeled and undated plastic squeeze bottles of what appeared to be Italian dressing * 1 unlabeled plastic squeeze bottle of what appeared to be thousand island dressing dated 11/11/15 *1 unlabeled and undated plastic squeeze bottle of what appeared to be thousand island dressing * 1 open and undated gallon of Vitamin D milk * 2 open and undated gallons of Skim milk These items and dates were verified by CD-I, who was unsure if some of the items in the food prep cooler and left-over freezer were dated with use-by dates. CD-I indicated all items should have been dated and labeled, including the thickeners. ~ DATING SYSTEM The facility's Food Receiving and Storage policy states: Foods shall be received and stored in a manner that complies with safe food handling practices. 6. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use-by date). During surveyor # 's initial tour of the kitchen on 1/20/16 at 9:05 a.m., surveyor # interviewed DS-J regarding the facility's food dating practice. When surveyor # inquired about a container of chicken soup in the food prep cooler dated 12/1 and 3 trays of fruit salad cups and cake slices dated 1/19, DS-J indicated the dates represented when staff put the items in the cooler and not the use-by dates. Surveyor # also observed a jar of pickles in the cooler dated 2/1/16. DS-J indicated since today's date was 1/20/16, that date would be the use-by date. On 1/20/16 at 1:55 p.m., surveyor # observed food prep in the kitchen. Surveyor # noted a metal pan of hot dogs in the left-over freezer dated 1/20/16 and a metal container of baked beans dated 3/18/16. DS-J indicated the hot dogs were put in the cooler yesterday (1/19) and marked with today's date; however, the baked beans were marked with the use-by date. DS-J verified some of the items in the freezer contained use-by dates and some contained dates when they were put in the freezer. DS-J stated, We changed everything in the coolers to the use-by dates and I didn't tell staff to do the same in the left-over freezer. On 1/26/16 at 2:20 p.m., surveyor # again observed the contents of the food prep cooler and the left-over freezer. The left-over freezer contained the following: * 1 container of turkey soup dated 4/18/16 * 1 large pan of lasagna dated 1/21/16 * 1 container of pork dated 1/24 * 1 container of pea soup dated 12/23/15 * 1 container of beef stew dated 4/17/16 * 1 container of baked beans dated 3/18/16 * 1 pan of barbecue ribs dated 1/31/15 On 1/26/16 at 2:25 p.m., surveyor # verified the items and dates with CD-I who indicated was unsure if the items with dates prior to 1/26 were labeled with use-by dates or the dates they were put in the freezer. CD-I stated she would check the facility's cooling log. CD-I was also unable to verify if the containers of salad dressing, chocolate syrup and caramel in the food prep cooler were labeled with use-by dates or the dates the items were put in the cooler. On 1/27/16 at 9:58 a.m., CD-I informed surveyor # the pea soup dated 12/23/15 and barbecue ribs dated 1/31/15, were not on the facility cooling log. CD-I could not verify whether the dates were the use-by dates and discarded the items. In addition, surveyor # observed the following in the food prep cooler: * 1 container of pureed vegetables dated 2/26 * 1 metal pan containing 2 baked potatoes dated 2/26 * 1 container of pureed meat dated 2/26 * 1 container labeled Ground 400 dated 2/26 * 1 container labeled Ground Main dated 2/26 * 1 container labeled Potato Main dated 2/26 * 2 pans of coleslaw dated 2/26/16 * 2 pans of beef dated 2/26/16 * 1 pan of tater tots dated 2/26/16 * 1 tray containing individual bowls of apricots dated 2/26/16 CD-I verified the dates of the above items and indicated the items were to be served for supper on 1/26/16. CD-I verified the dates with DC (Dietary Cook)-W, who indicated DC-W mislabeled the items as 2/26 or 2/26/16 instead of 1/26 and/or 1/26/16. ~ STORAGE OF FROZEN FOOD The facility's Food Receiving and Storage policy states: 9. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. On 1/26/16 at 2:20 p.m., surveyor # observed a container of turkey soup, dated 4/18/16, in the left-over freezer with a partially open lid. CD-I was unaware how long the soup was open to air and verified the container should be covered. On 1/27/16 at 9:58 a.m., CD-I informed surveyor # the cover to the pea soup was replaced and the soup was still in the freezer. ~ MULTI-QUAT TESTING During the initial tour of the kitchen, surveyor # confirmed with CD-I the facility used a Multi-Quat solution for dishwashing in the three-compartment sink. Surveyor # asked DC-K to check the ppm (parts per million) of the sanitizing solution. DC-K retrieved a cup of water from the sink, placed a testing strip in the cup for approximately 7 seconds and indicated the solution tested above 400 ppm. When surveyor asked DC-K to take the temperature of the water, DC-K placed a thermometer in the cup and stated the temperature was 70 degrees. Surveyor # observed the thermometer with DC-K and verified a temperature of 92 degrees. DC-K indicated 92 degrees was an acceptable temperature for an accurate reading. DC-K then read the chart on the wall above the three-compartment sink and stated the water should be between 65 and 75 degrees for testing purposes. DC-K retrieved another cup of water from the sink and placed the cup in an ice bath. When the temperature reached 72 degrees, DC-K held a test strip in the water for approximately 6 seconds. Instructions on the test strip kit indicate a strip is to be held in the sanitizing solution for 10 seconds. ~ CLEANLINESS The 2013 Federal Food Code 6-201.11 addresses Floors, Walls, and Ceilings. Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. The 2013 Federal Food Code 4-601.11 (C) indicates nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 1/20/16 at 9:05 a.m. and 1:30 p.m., surveyor # observed the dishwashing room in the kitchen. Surveyor # observed food debris, including drips and red liquid spills on the wall across from the dishwashing machine. Surveyor # also observed a grease-like substance and food debris on the wall behind the stove/cooktop. On 1/26/16 at 2:22 p.m., surveyor # observed the wall across from the dishwashing machine and the wall behind the stove/cooktop to be in the same condition. Surveyor # verified the condition of the walls with CD-I, who was unsure when the walls were last cleaned. On 1/26/16 at 1:55 p.m., surveyor # observed the 400 dining room. Surveyor # observed 3 lights with visible dust hanging above the steam table/serving area. On 1/26/16 at 2:05 p.m., surveyor # verified the dusty lights with CD-I. ~ ACTIVITY ROOM FOOD On 1/22/16 at 10:01 a.m., surveyor # observed food in cabinets in the facility's activity room. Food items included: ~ 21 oz (ounce) can of Cherry Pie filling/topping with a substantial dent on the can's side which extended to both seams ~ 12 oz can of tomato paste best by dated 11/28/15 ~ 14.4 oz box of honey graham crackers best by dated 8/3/15 On 1/22/16 at 10:09 a.m., surveyor # interviewed AD (Activity Director)-V regarding the food items in the activity room. AD-V verified the food items were used for activities. AD-V stated the activity department's practice is to go through food monthly to check dates and organize. At that time, AD-V verified each item listed above was expired with the exception of the dented can of pie filling. AD-V verified the dent was extensive enough to impact seams on both can ends. AD-V discarded the expired and dented items at that time. On 1/22/16 at 10:32 a.m., surveyor # observed food in cabinets in the facility pub located between the 100's wing and the therapy department. Food items included: ~ 14.1 oz box of graham cracker crumbs best by dated 12/31/12 ~ unlabeled Ziploc bag of circle and rectangle crackers On 1/22/16 at 10:43 a.m., surveyor # interviewed AD-V regarding the food items in the facility pub. AD-V verified the activity department was responsible for contents of the pub cabinets. AD-V verified the graham cracker crumbs were expired and the Ziploc bag did not have a label. At that time, AD-V discarded both items.

Based on observations, staff and resident interviews, and record review, the facility did not ensure pressure ulcer prevention devices and services were consistently implemented according to the individual care plans for 4 (residents #2, #6, #7, and #10) of 14 sampled residents reviewed for pressure ulcers and at risk for developing pressure ulcers. Resident #10 had a stage 2 pressure ulcer on the resident's right heel with fragilely healed skin at the time of survey. Resident #10 was in bed 2 hours and 14 minutes without a HeelZup device in place as indicated by resident #10's care plan. Resident #6 was assessed to be at risk for developing pressure ulcers. The resident's care plan included the approach to have the resident's heels up when in bed. Observations were made of resident #6 with their heels in direct contact with the mattress, not elevated as directed in the resident's care plan. Resident #7 was assessed to be at risk for developing pressure ulcers. The resident's care plan included the approach to have the resident's heels elevated when in bed and in the broda chair. Observations were made of resident #7's heels in direct contact with pillow, not elevated as directed in the resident's care plan. Resident #2 had a stage 2 pressure ulcer to the resident's coccyx and was assessed to be at very high risk for the development of pressure ulcers. Resident #2 had a care plan approach for a moisture barrier cream (a cream to protect the skin against irritation/breakdown) after each toileting/incontinence episode. That approach was not consistently implemented. Findings include: On 1/27/16 at 1:36 p.m., surveyor # interviewed RNC (Registered Nurse Consultant)-U regarding pressure ulcers. RNC-U stated the facility utilized the NPUAP (National Pressure Ulcer Advisory Panel) as its standard of practice for pressure ulcer prevention and treatment. NPUAP Quick Reference Guide 2014 documents, The reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used . Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure- a state sometimes called 'floating heels.' 1.1 Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows. NPUAP Quick Reference Guide 2014 documents, Preventive Skin Care Recommendations: 5. Protect the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage. It is important to note that skin damage from moisture is not a pressure ulcer, but that presence of skin damage from moisture may increase the risk of pressure ulceration. EXAMPLES: 1. On 1/20/16, surveyor # reviewed resident #10's medical record. Resident #10's record documented the following: ~ [DIAGNOSES REDACTED]. ~ 1/8/16- admission skin assessment documented right heel dry, scaly, callous. ~1/8/16- nurse's note documented fragile healed R (right) heel with [MEDICATION NAME] dressing. Skin thick and dry. No drainage or odor. ~1/8/16- Braden Scale for Predicting Pressure score = 18 (indicating at risk) ~1/12/16- wound care consult ordered. ~1/12/16- right heel pressure ulcer measurement: 2.5 cm (centimeters) by 1.6 cm with defined edges and 100% pink fragile skin. ~1/12/16- skin care plan documented Use a heels up in bed for pressure redistribution devices. ~1/15/16- MDS (Minimum Data Set) assessment documented admitted with a stage 2 pressure ulcer and was at risk for skin breakdown. ~1/15/16- Braden Scale = 18 ~1/19/16- right heel pressure ulcer measurement: 2.2 cm by 2.0 cm with thin brown, dry eschar. On 1/21/16 at 3:56 p.m., surveyor # observed resident #10 sleeping in bed with the room door open. The resident's HeelZup device was visible in resident #10's recliner. Resident #10's feet were not visibly elevated. On 1/21/16 at 4:01 p.m., surveyor # interviewed CNA (Certified Nursing Assistant)-Q regarding resident #10. CNA-Q verified working resident #10's wing. CNA-Q indicated not knowing how long the resident had been in bed, but was in bed when I came on shift (at 2:00 p.m.). On 1/21/16 at 4:14 p.m., surveyor # interviewed RN-R regarding resident #10. RN-R indicated the resident was in bed her shift, but did not specifically observe the resident until approximately 3:10 p.m. When the surveyor asked if resident #10's feet were currently free floated, RN-R stated, They (resident #10's heels) should be free floated. After entering resident #10's room, RN-R asked resident #10 for permission to look at the resident's feet. RN-R removed the resident's blanket and observed the resident wearing a sneaker on the left foot and an adaptive footwear on the right foot, with both heels in full contact with the mattress. At that time, resident #10 stated, I told the girls (CNAs) they could leave them (footwear) on. RN-R then asked the resident regarding the HeelZup device and resident #10 replied, I forgot. RN-R commented, It's not your responsibility to remember and offered to remove the resident's footwear and apply the HeelZup device at that time. Resident #10's footwear was removed and the resident stated, That feels better. RN-R then assessed resident #10's right heel, and the surveyor observed a light brown circle approximately 2 cm by 2 cm on resident #10's right heel. The resident's skin was intact and the heel blanched during RN-R's assessment. RN-R then placed the HeelZup device on resident #10's bed and positioned resident #10 so both heels were free floating. 2. Resident #6 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to resident #6's current MDS (Minimum Data Set) assessment dated [DATE], resident requires extensive assist with bed mobility and total dependence with transfers. Resident #6's Braden scale assessment dated [DATE], documented the resident is at moderate risk for the development of pressure ulcers and has limited mobility. Resident #6's care plan dated 12/17/14, indicates to offload heels when in bed and broda chair. On 1/20/16 at 10:30 a.m., surveyor # observed resident #6 lying back in their broda chair with both heels in full contact with the pillow located on the broda chair. At that time, the surveyor felt under both heels and could feel pressure on heels from pillow. The resident was observed again approximately at 11:30 a.m., in the same position. On 1/27/16 at approximately 3:20 p.m., during the final exit of the survey with the facility staff, DON (Director of Nursing)-B indicated that blue boots were added to the resident's care plan on 1/22/16 due to reported issue with reddened area on resident's heel. 3. Resident #7's medical record included documentation that the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. According to the most recent MDS assessment dated [DATE], resident #7 requires extensive assist with bed mobility, transfers and has a history of falls. Resident #7's Braden scale assessment dated [DATE], documents the resident is a moderate risk for pressure ulcers and has very limited mobility and is chairfast. Resident #7's care plan dated 1/15/16, instructs staff to offload the resident's heels when in bed. On 1/26/16 at 2:20 p.m. and 3:32 p.m., surveyor # observed resident #7 lying in bed resting, both heels were in direct contact with the mattress. On 1/27/16 at 7:20 a.m., surveyor # observed resident #7 lying in bed with both heels in direct contact with the mattress. On 1/27/16 at 7:25 a.m., surveyor # interviewed CNA-P regarding resident #7. CNA-P verified that resident #7's heels should be free floated according to the resident's care plan. CNA-P commented staff must not have done this, when they laid resident #7 down last night. 4. Resident #2's face sheet, contained within the medical record dated 11/20/15, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's initial MDS assessment dated [DATE], documented the resident was severely cognitively impaired, required extensive assistance from staff for personal hygiene, and was always incontinent of bladder and frequently incontinent of bowel. Additionally, the MDS indicated resident #2 was at risk for pressure ulcer development. Resident #2 was assessed on 11/20/15, per a Braden scale for the prediction of pressure ulcer risk, to be at very high risk for the development of pressure related ulcers. Resident #2's bladder incontinence plan of care, dated 11/10/15, included a care plan approach for staff to apply a moisture barrier cream to the skin. According to resident #2's progress notes, dated 12/2/15, resident #2 was noted to have a stage 2 coccyx pressure ulcer that measured 1.2 cm (centimeter) in length, by 1 cm in width, by 0.1 cm in depth. The most recent progress notes for resident #2, dated 1/19/16 indicated, the stage 2 coccyx pressure ulcer measured 0.5 cm by 0.3 cm. On 1/26/16 at 7:55 a.m., surveyor # observed CNA-H and CNA-G provide cares for resident #2. CNA-H and CNA-G assisted resident #2 onto the bedpan, while in bed. CNA-H verified resident #2 urinated in the bedpan. CNA-H provided cares, placed the disposable brief on resident #2, pulled up the resident's pants, and assisted the resident into the wheelchair. CNA-H did not apply any moisture barrier cream to resident #2's skin. Following the completion of cares, surveyor # interviewed CNA-H regarding the above observation. CNA-H verified she did not offer or apply a moisture barrier cream to resident #2. On 1/27/16 at 1:10 p.m., surveyor # interviewed NM (Nurse Manager)-C regarding the above observation with resident #2. NM-C verified a moisture barrier cream was a part of resident #2's current plan of care, and should be applied to the resident's skin after each toileting/incontinence episode. NM-C stated, the moisture barrier cream is used to prevent skin breakdown.

Based on record review and staff interview, the facility did not implement their policies and procedures to minimize the risk of residents acquiring, transmitting, or experiencing complications from Pneumococcal Pneumonia. The facility did not implement its policies and procedures to ensure that 7 (resident #2, #17, #4, #5, #16, #7, and #8 ) of 17 sampled residents were offered an appropriate Pneumococcal immunization. Resident #2 received the Pneumococcal vaccine in 11/19/04. Resident #2 was eligible to receive the recommended PCV13 (13-Valent Pneumococcal Conjugate Vaccine) vaccine, which was not offered by the facility and/or documented that education had been provided regarding the benefits and potential side effects of the PCV13 vaccine in the resident's medical record. Resident #17 received the Pneumococcal vaccine in 09/25/08. Resident #17 was eligible to receive the recommended PCV13 vaccine, which was not offered by the facility and/or documented that education had been provided regarding the benefits and potential side effects of the PCV13 vaccine in the resident's medical record. Resident #4 had a history of [REDACTED]. Staff confirmed the vaccine wasn't administered within thirty days of admission. Resident #5's Immunization Information & Consent form indicated the resident had not received the PPSV23 or PCV13 vaccines. The form didn't indicate whether the resident was offered, wished to receive, declined or was provided education regarding the vaccines. Staff confirmed the resident wasn't offered or administered the vaccine within thirty days of admission. Resident 16's Immunization Information & Consent form indicated the resident received the PPSV23 vaccine on 1/1/07 and was due for the PCV13 vaccine. The form did not indicate whether the resident was offered, wished to receive or declined the vaccine. Staff confirmed the resident was not offered, did not receive and was not provided education regarding the PCV13 vaccine. Resident #7's Immunization Information and Consent form indicated resident received the PPSV23 vaccine on 2/8/2008 and was due for the PCV13 vaccine. Staff confirmed resident #7 was not offered or provided education regarding PCV13 vaccine. Resident #8's Immunization Information and Consent form indicated resident received the PPSV23 vaccine on 8/16/2002 and was due for the PCV13 vaccine. Staff confirmed resident #8 was not offered or provided education regarding PCV13 vaccine. Findings include: The facility's policy and procedure titled, Pneumococcal Vaccine revised 5/21/15 indicated the following, All residents will be offered the Pneumococcal vaccine, in accordance with the current CDC (Centers for Disease Control and Prevention)/ACIP (Advisory Committee on Immunization Practices) recommendations, to aid in preventing Pneumococcal infections (e.g., pneumonia). 1. Prior to or upon admission, residents will be assessed for eligibility to receive the Pneumococcal vaccine, and when indicated, will be offered the vaccinations within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of Pneumococcal vaccination status will be conducted upon admission if not conducted prior to admission 3. Before receiving the Pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the Pneumococcal vaccine. (See current vaccine information statements at www.cdc.gov/vaccines/pubs/vis/default.htm for educational materials.) Provision of such education shall be documented in the resident's medical record. 4. Pneumococcal vaccinations will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved Pneumococcal vaccination protocol. 5. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of refusal of the Pneumococcal vaccination. 6. For residents who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. 7. Administration of the Pneumococcal vaccination or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) and ACIP recommendations at the time of vaccination. (2015-guidelines below). 8. Inquiries concerning our facility's policies governing Pneumococcal vaccinations should be referred to the Infection Control Coordinator or Director of Nursing Services. Administration Guidelines: All persons over 65 should receive a one-time dose of the 13-Valent Pneumococcal Conjugate Vaccine (PCV13) as well as the one time dose of the 23-Valent Pneumococcal [MEDICATION NAME] (PPSV-23). Pneumococcal vaccine-naive persons aged greater than 65 should have the PCV13 administered at age greater than or equal to 65, then in 6-12 months after administration of the PCV13, the PPSV-23 should be administered. If the person has already received the PPSV-23, the PCV13 can be administered 1 year after the date of administration of the PPSV-23. If the person was 64 or younger when the PPSV23 was administered, then the current guidelines still apply regarding re-vaccination at age 65, but would need to be greater than or equal to 5 years after the first administration of the PPSV23. Once the person is aged 65, the PVC13 should be offered as well. Again it should be administered before the PPSV23 (if indicated), with 6-12 month wait between the next PPSV23 dose. If the dose of the PPSV23 was administered first, then the PVC13 cannot be administered for a year from the date of the PPSV23 dose. DHS (Department of Health Services) Memo, dated 11/21/14, indicated, .if an adult has previously received a dose of Pneumococcal vaccine prior to December 2011 but does not know what type it is, it is reasonable to assume that it was PPSV23 because PCV13 was licensed by FDA during December 2011 . 1. Resident #2's face sheet dated 11/20/2015, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's date of birth was 11/14/1918. The facility provided a WIR (Wisconsin Immunization Record) form for resident #2, dated 1/26/16 that noted, resident #2 received a dose of Pneumococcal vaccine on 11/19/04. On 1/26/16 at 10:25 a.m., surveyor # interviewed DON ( Director of Nursing)-B regarding resident #2's PCV13 vaccine. DON-B verified resident #2 had not been offered and did not receive the PCV13 vaccine. DON-B stated, I looked through resident #2's medical record and can not find any documentation resident #2 was offered or declined the PCV13 vaccine. I checked the WIR and left resident #2's daughter a message. 2. Resident #17's face sheet dated 11/16/2015, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's date of birth was 11/14/1918. Resident #17's Immunization Information and Consent form, located in the resident's medical record, indicated resident #17 received a dose of Pneumococcal vaccine on 09/25/08. The immunization form noted resident #17 needs the PCV13 vaccine. Additionally, the form signed and dated on 11/9/15, by resident #17 indicated, the resident gave the facility permission to administer the vaccine if the vaccine had not already been received. On 1/27/16 at 11:00 a.m., surveyor # interviewed DON-B regarding resident #17's PCV13 vaccine. DON-B verified resident #17 had not been offered and did not receive the PCV13 vaccine. DON-B stated, I looked through resident #17's medical record, and can not find any documentation resident #17 was offered or declined the PCV13 vaccine. 3. On 1/20/16, surveyor # reviewed the medical record of resident #4. The resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent MDS (Minimum Data Set) assessment, dated 12/23/15, documented the resident's Pneumococcal vaccination was up-to-date. Upon review of the medical record, surveyor # observed an Immunization Information & Consent form signed by the resident on 12/17/15. Resident #4 indicated on the form (resident #4) wished to receive both the PCV13 (Prevnar 13) and PPSV23 vaccinations. An undated and uninitialed hand-written side note stated, Does not think (resident #4) ever had this. The form also indicated the resident received the PPSV23 vaccine on 10/1/14 and wished to receive the TD (Tetanus-[MEDICATION NAME]) booster. Resident #4's nurse's note dated 9/30/15, documented, Chest x-ray received. Pneumonia present. Resident #4 was eligible for the PCV13 vaccination on 10/2/15. A fax to MD (Medical Doctor)-S dated 1/2/16, documented, Resident has no record of receiving the Prevnar 13 or the tetanus vaccine. Resident has consented to both vaccines. Can we have an order to administer the Prevnar 13 and the [MEDICATION NAME] (Tetanus-[MEDICATION NAME]-Pertusis)? The form appeared to be refaxed to MD-S on 1/19/16 with an added note, Please address. The form, signed and faxed to the facility by MD-S on 1/19/16, stated, Yes, can administer both vaccines. On 1/22/16 at 12:05 p.m., surveyor # interviewed DON-B regarding resident #4's vaccination status. DON-B stated, I'm not sure if (resident #4) was missed on admission. I'll have to check. Resident #4's nurse's noted dated 1/23/16, documented, Prevnar 13 provided to the L (left) deltoid. On 1/26/16 at 12:10 p.m., surveyor # interviewed NM (Nurse Manager)-O regarding resident #4's Prevnar 13 vaccination. NM-O indicated the vaccine wasn't given earlier because NM-O was waiting for MD-S's reply. NM-O verified resident #4 received 2 vaccines on 1/23/16, including the Prevnar 13. 4. On 1/20/16, surveyor # reviewed the medical record of resident #5. The resident was admitted to the facility on hospice with a [DIAGNOSES REDACTED]. vaccination was not up-to-date or received and was not offered by the facility. Upon review of the medical record, surveyor # observed an Immunization Information & Consent form which was signed by the resident's spouse on 11/9/15. The form had hand-written question marks next to the lines Date received Pneumococcal PCV 13 vaccine and Date received Pneumococcal PPSV23 vaccine. An undated and uninitialed hand-written side note stated, No record of receiving at (MD-T). Not in WIR (Wisconsin Immunization Registry). Resident #5's nurse's note dated 1/21/16, documented, Writer spoke with resident and spouse regarding whether (resident #5) wanted to receive the pneumonia vaccine or the tetanus vaccine and they declined. On 1/21/16 at 3:45 p.m., surveyor # interviewed NM-O regarding resident #5's vaccination status. NM-O indicated the process for assessing vaccination status had recently changed. NM-O stated facility social workers used to gather vaccine information upon admission and forward the information to the nursing staff. NM-O indicated the admitting nurse is now in charge of gathering vaccination information for new admissions. NM-O stated, This (resident #5's vaccination information) should have been checked. 5. On 1/26/16, surveyor # reviewed the closed medical record of resident #16. The resident had [DIAGNOSES REDACTED]. The resident's most recent MDS assessment, dated 10/30/15, documented the resident's Pneumococcal vaccination was up-to-date. Upon review of the medical record, surveyor # observed an Immunization Information & Consent form which was signed by the resident on 10/23/15. The form indicated the resident received the PPSV23 vaccine on 1/1/07 and was due for the PCV13 vaccine. The form contained the lines, I wish to have the Pneumococcal vaccinations (PCV13, PPSV23) and I DO NOT wish to have the Pneumococcal vaccinations. Both lines were left blank. Surveyor # was unable to determine if the resident was offered the PCV13 vaccine. On 1/27/16 at 11:00 a.m., surveyor # interviewed DON-B regarding resident #16's vaccination status. DON-B indicated resident #16 did not receive the PCV13 vaccination. DON-B was unable to confirm whether or not the resident was offered the vaccination. 6. Resident #7's face sheet dated 11/20/15, indicated the resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. The residents date of birth was 4/28/1927. Resident #7's Immunization Information & Consent form located in the resident's medical record and dated 11/16/15, documented the resident received the Pneumococcal PPSV23 vaccination on 2/25/2008. The form did not include documentation if the resident received or was offered the PCV13 vaccination. On 1/27/16 at 2:35 p.m., surveyor # interviewed NM-O regarding resident #7. NM-O indicated resident #7 was not offered the PCV13 and the resident was not provided education regarding the PCV13 vaccination. NM-O indicated the POA was called today and does want resident #7 to receive the PCV13 vaccination. 7. Resident #8's face sheet dated 11/25/16, indicated the resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. The resident's date of birth is 3/14/1930. Resident #8's Immunization Information & Consent form located in the resident's medical record documented the resident received the Pneumococcal PPSV23 vaccination on 8/16/2002. The Immunization form does not indicate if the resident received, was offered and/or given education regarding the PCV13 vaccination. On 1/27/16 at 2:40 p.m., surveyor # interviewed NM-O regarding resident #8. NM-O indicated the PCV13 vaccination was never offered to resident #8 and the resident did not receive education in regards to the vaccination. NM-O also indicated that resident #8 was offered the PCV13 vaccination today but declined the vaccination.

Based on observations, resident and staff interviews and record review, the facility did not protect confidential medical information for 1 (residents #20) of 20 sampled and supplemental sampled residents. Resident #20 had a 3-day voiding tracker sheet posted on a shared bathroom door in a shared bedroom, in full view, that contained confidential health information. Findings include: The facility's policy titled, Confidentiality of Information dated 12/2006 indicated, The facility shall treat all resident information confidentially . 1. The facility will safeguard all the residents records, weather medical, financial, or social in nature, to protect the confidentiality of the information. 2. Access to resident medical records will be limited to the staff and consultants providing services to the resident . 4. Release of resident information, including video, audio, or computer stored information, will be handled in a manner to protect resident rights. 5. Residents may initiate a request to release information contained in their records and charts to anyone they wish. Such requests will be honored only upon the receipt of a written, signed, and dated request from the resident or representative . On 1/20/16, during the initial tour, NM (Nurse Manager)-C indicated, resident #20 was cognitively intact. On 1/21/16, surveyor # completed a record review for resident #20. Resident #20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 1/20/16 and 1/21/16, during observations of resident #20's room, surveyor # observed a bright yellow informational sheet of paper, 8-1/2 inches by 11 inches, taped on the shared bathroom door in the resident's room. The sheet of paper was dated 1/19/16, and read, (Resident #20's) 3-Day Voiding Tracker. Information on the sheet of paper included: Did resident request toileting? Yes/No, Did the resident have an urge to void? Yes/No, When prompted was resident dry or wet, Did resident void on toilet? Yes/No, the sheet of paper included written documented results for resident #20. The bathroom door was open and the sheet of paper was visible to visitors and resident #20's room mate. On 1/21/16 at 10:15 a.m., surveyor # interviewed resident #20 in the resident's room. Resident #20 indicated (resident) was a person who likes to have privacy, and moved into a private room in the facility on 1/20/16. Resident #20 stated, I would not like any of my personal information to be public knowledge. On 1/21/16 at 12:05 p.m., surveyor # interviewed LPN (Licensed Practical Nurse)-D regarding the informational sheet of paper that was posted on resident #20's shared bathroom door in the resident's room. LPN-D verified the bright yellow informational sheet of paper was posted on the shared bathroom door and visible to the roommate and visitors. LPN-D stated, (Resident #20) moved to a private room yesterday (1/20/16). I will remove the sheet of paper. LPN-D indicated the practice of the facility is to tape the 3-Day Voiding Tracker sheets to resident's bathroom doors, because it's easier for staff to track. LPN-D stated, when the tracker sheets are filled out, they are placed in the medical record. On 1/26/16 at 7:30 a.m., surveyor # interviewed DON (Director of Nursing)-B regarding the 3-Day Voiding Tracker sheets. DON-B stated, The 3-Day Voiding Tracker sheets are taped to resident's bathroom doors if the resident is a new admit, or has a change in condition. The 3-Day Voiding Tracker sheets are colored yellow to catch the attention of staff when in the bathroom with a resident.

Based on record review and staff interview, the facility did not ensure that 2 (resident #4 and #6) of 17 sampled residents had assessments that accurately reflected the residents' status. Resident #4 was alert, oriented and cognitively intact. The resident's MDS (Minimum Data Set) assessment dated [DATE], documented staff assessments for cognition and pain instead of resident interviews. Staff indicated the look back period for this resident interview was missed for both sections and a staff assessment was completed instead. Resident #6's MDS assessment dated [DATE], indicated the resident was taking pain medication along with non-pharmacological interventions for pain. The assessment for pain was not completed and checked as not assessed. Findings include: On 1/20/16, surveyor #3057 reviewed resident #4's medical record and it indicated the resident had [DIAGNOSES REDACTED]. The resident's most recent MDS assessment dated [DATE], documented the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 (the maximum score possible). Resident interviews for cognition and pain were conducted as well. Upon review of resident #4's MDS assessment dated [DATE], surveyor # noted a staff assessment was completed for Section C - Cognitive Patterns, not a resident interview. In section CO600. Should the Staff Assessment for Mental Status be Conducted? MDSN (Minimum Data Set Nurse)-M checked, Yes (resident was unable to complete interview). According to CMS's (Centers for Medicare and Medicaid) RAI Version 3.0 Manual Section C coding instructions, Code 1, yes: if the resident chooses not to participate in the BIMS or if four or more items were coded 0 because the resident chose not to answer or gave a nonsensical response. The staff assessment indicated the resident's short and long-term memory were intact and the resident was able to recall the current season, location of room, staff names and faces and the fact that he/she was in a nursing home. The resident was assessed by staff in section C100. Cognitive Skills for Daily Decision Making as Independent - decisions consistent/reasonable. Upon further review of resident #4's MDS assessment dated [DATE], surveyor # noted a staff assessment was completed for pain, not a resident interview. In Section J - Health Conditions J0100. Pain Management, MDSN-M checked boxes indicating the resident was on a scheduled pain medication regimen, received PRN (as needed) pain medication and received non-medication intervention(s) for pain within the last 5 days. In section J0200. Should Pain Assessment Interview be Conducted?, MDSN-M checked Yes. The pain assessment interview had not been conducted and section J0600. Pain Intensity which asks for a numeric rating on a scale of 0-10, contained a -. In section J0700. Should the Staff Assessment for Pain be Conducted?, MDSN-M did not answer yes or no. The staff assessment for pain indicated the resident had vocal complaints, displayed facial expressions and exhibited daily indicators of pain. On 1/21/16 at 3:30 p.m., surveyor # interviewed MDSN-M regarding resident #4's cognition and pain assessments. MDSN-M indicated the facility missed the look back period for the resident's 10/15/15 MDS. MDSN-M also indicated the facility was instructed to use a staff assessment, instead of a resident interview, if the look back period was missed. MSDN-M stated, I try to tell the team to add a note to say why we missed it so we can fix the process. I'm under the impression our interviews have to be a couple days within the look back period or they aren't accurate. We have 7 days after the look back period to complete the MDS. There's a time frame where it has to be locked and we stick to it. On 1/26/16 at 1:20 p.m., surveyor # again interviewed MDSN-M regarding resident #4's 10/15/15 MDS. MDSN-M indicated even though the look back periods for the resident and staff assessments are the same, the facility will use a staff assessment completed up to 2 days past the look back period, but not a resident interview. MDSN-M verified if the resident look back period is missed, the staff look back period is missed also according to MDS protocol. MDSN-M indicated 8 people in the facility complete the required MDS assessments. MDSN-M believed resident #4 was assigned to another person. MDSN-M stated, When I went to do the MDS, I saw it was missed. MDSN-M also indicated she believed she was supposed to click yes if a staff assessment was to be done and was unaware that a yes answer indicated the resident was unwilling to complete the interview or was unable to do so due to nonsensical responses. On 1/27/16 at 8:30 a.m., surveyor # interviewed CRS (Clinical Reimbursement Specialist)-N, a corporate consultant who assists the facility with MDS education and training. CRS-N indicated staff are to mark an area as not assessed if the look back period is missed. CRS-N stated, The area is to be left as not assessed until the next MDS is done. A correction wouldn't be appropriate. Staff are to document the assessment in the resident's chart. CRS-N indicated education would be provided for staff in the facility regarding the MDS process. 2. On 1/21/16, surveyor # reviewed the medical record of resident #6. Resident #6 was admitted on [DATE], with chronic shoulder and lower back pain. The resident's [DIAGNOSES REDACTED]. Resident #6's annual MDS assessment dated [DATE], documented in Section J - Health Conditions under J0100. Pain, the resident was on a scheduled pain medication regimen and the facility conducted a pain assessment interview with the resident. Resident #6's quarterly MDS assessment dated [DATE], documented in Section J- Health conditions under J0100. Pain, the resident was on a scheduled pain medication regimen, received PRN (as needed) pain medications in the last 5 days, and received non-medication interventions for pain. The facility did not complete the sections that addressed conducting a pain assessment interview, asking the resident if pain was present, frequency of the pain, pain effect on functioning and pain intensity. On 1/27/16 at 2:42 p.m. surveyor # interviewed MDSN-M regarding resident #6. MDSN-M indicated resident #6's quarterly MDS assessment dated [DATE], pain section should have been assessed. MDSN-M verified the resident should have been interviewed regarding pain and should have been documented in the quarterly MDS assessment.

Based on observation, staff interview and record review, the facility did not ensure residents were free of a medication error rate of five percent or greater for 1 (resident #19) of 8 sampled and supplemental sampled residents observed during medication administration. Four of thirty-six opportunities observed during medication administration resulted in errors to equal an error rate of 11.11 percent. One error was related to the administration of an inhaler which was not administered as directed by the manufacturer. One error was related to the administration of one nasal spray administered in each nostril when the physician's orders [REDACTED]. Two errors were related to crushing of medications that should not be crushed. Findings include: 1. On 1/21/16 at 8:23 a.m., surveyor # observed RN (Registered Nurse)-E and RN-F hand resident #19 an [MEDICATION NAME] 250/50 inhaler. The resident took an inhalation of [MEDICATION NAME] and after the resident inhaled the medication, RN-E gave the resident a cup of water. RN-E did not offer the resident any direction regarding the water provided and the resident took a drink of the water and swallowed it. Following this observation, RN-E verified the above observation and verified instructions were not provided to the resident prior to, during, and/or after the administration of the [MEDICATION NAME] inhaler. According to the [MEDICATION NAME] inhaler manufacturers specifications, the resident should rinse mouth with water to prevent thrush after breathing in this medication. Spit out the water. Do not swallow it. 2. On 1/21/16 at 8:20 a.m., surveyor # observed RN-E administer one nasal spray of [MEDICATION NAME] spray in each of resident #19's nostrils. RN-E verified one spray of the [MEDICATION NAME] spray was administered in each nostril for resident #19. The current 1/2016 physician's orders [REDACTED]. On 1/21/16 at 8:45 a.m., surveyor # interviewed RN-E regarding the physician's orders [REDACTED]. RN-E verified resident #19 should receive two sprays of [MEDICATION NAME] spray in each nostril and only one spray was administered in each of the resident's nostrils. 3. On 1/21/16 at 8:15 a.m., surveyor # observed RN-E and RN-F prepare resident #19's morning medications. RN-E crushed and placed two 20 mEq (milliequivalents) potassium chloride extended release tablets into a medication cup. RN-E and RN-F verified the potassium chloride extended release tablets were crushed and administered the medication to resident #19. According to www.Drugs.com, dated 1/15/16 indicated, swallow potassium chloride extended-release tablets whole. Do not break, crush, chew, or suck on the tablets before swallowing. 4. On 1/21/16 at 8:15 a.m., surveyor # observed RN-E and RN-F prepare resident #19's morning medications. RN-E crushed and placed three 30 mg (milligram) [MEDICATION NAME] extended release tablets into a medication cup. RN-E and RN-F verified the isosobide [MEDICATION NAME] extended release tablets were crushed and administered the medication to resident #19. According to www.Drugs.com, dated 1/2015 indicated, [MEDICATION NAME] extended release tablets should not be chewed or crushed and should be swallowed together with a half-glassful of fluid. Do not break the 30 mg tablet. On 1/21/16 at 10:50 a.m., surveyor # interviewed PHD (Pharmacist from Health Direct)-A via the telephone regarding resident #19's medication regimen. PHD-A indicated, resident #19's [MEDICATION NAME] extended release 30 mg tablets should not be crushed. PHD-A stated, once the [MEDICATION NAME] extended release 30 mg tablets are crushed, the medication is released at a fast rate, and could cause a decrease in the resident's blood pressure. Surveyor # then questioned PHD-A regarding resident #19's potassium chloride extended release tablets. PHD-A stated, potassium chloride extended release tablets should not be crushed because the medication is released at a fast rate and may cause stomach irritation.

Based on record reviews, interviews with staff, and observations, the facility did not maintain an Infection Control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of and transmission of infections. This has the potential to affect all 81 residents. The facility had not implemented their procedures to ensure containment of GE (Gastroenteritis) during an outbreak in the facility of the disease which began on 11/26/11: -Staff did not use appropriate personal protective equipment when caring for ill residents; -Nursing, maintenance, housekeeping and laundry staff were allowed to work in all areas of the facility and were not confined to one unit to prevent the spread of infection; -The facility did not notify the hospital, outside healthcare providers, visitors, outpatient therapy participants, the medical director, or the local health department that an outbreak of GE was occurring in the facility; -The facility did not suspend admissions during the GE outbreak; -The facility did not suspend group activities such as meals, activities, and therapy; -Staff did not wash their hands at appropriate times and did not encourage residents to wash their hands after toileting; -The facility had not maintained an accurate employee illness line list to include the names of all staff that had called in sick with GE type symptoms; -Housekeeping staff did not implement appropriate cleaning protocols including ceasing vacuum use, enhanced cleaning of high touch surfaces and use of a bleach solution; -Dietary staff did not use appropriate sanitizing agents and/or temperatures to kill norovirus. Failure to take aggressive and appropriate actions during a GE outbreak created the potential that the illness could spread and created the potential for hospitalization s and death related to dehydration and other complications of vomiting and diarrhea. The immediate jeopardy began on 11/26/11 when an outbreak was evident as 5 residents and 1 staff person were ill with GE symptoms and the facility did not implement aggressive measures to prevent further spread of the illness to other residents and had not notified their medical director or their local public health department. The Nursing Home Administrator was notified of the immediate jeopardy on 11/28/11 at 3:45 p.m. The immediate jeopardy was removed in 11/28/11, but noncompliance remains at the lower scope and severity level of F (potential for more than minimal harm/widespread) as the facility must complete all training and monitor staff for adherence. Findings include: On 11/28/11 at 10:10 a.m., NHA (Nursing Home Administrator)-DD verified to surveyor # that the facility follows the Wisconsin Department of Health Recommendations for the Prevention and Control of GE Outbreaks in Long Term Care Facilities. Facility policies were consistent with these guidelines, but these were not consistently followed as evidenced below. During the above interview, NHA-DD also verified that pink signs on resident doors indicated that resident was having signs and symptoms of GE and enhanced precautions had been initiated for that resident. The facility's policy regarding GE Identification and Outbreak Management, dated 12/17/10 indicated the following procedures: *An outbreak of GE should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days. The local Health Department will be notified of any suspected or confirmed GE outbreaks. PERSONAL PROTECTIVE EQUIPMENT (PPE) The facility's policy and procedure for GE Identification and Outbreak Management, dated 12/17/10 indicates: *PPE will be donned before entering the rooms of residents with symptoms and when in contact with symptomatic residents. Remove goggles, gloves or face shield, gown and mask. Perform hand hygiene with soap and water before exiting room. Assist, cue and/or encourage residents to wash hands with soap and water before meals, after toileting. ~On 11/28/11 at 9:30 a.m., surveyor # observed XRT-S (X-Ray Technician) exit resident #4's room with a mobile X-Ray machine. XRT-S had not donned any PPE before entering the resident's room. The surveyor immediately interviewed XRT-S. XRT-S stated, "...I didn't know what the pink sign on his (resident #4's) room meant. I took the mobile X-Ray machine into his room to do a chest X-Ray... ~On 11/28/11 at 9:35 a.m., surveyor # observed RN (Registered Nurse)-A sitting on resident #25's bed. The resident was having active emesis into a pink basin. RN-A was not wearing any PPE. RN-A took the pink pan and rinsed it out for the resident, cleansed her hands and exited the room. The surveyor noted that resident #25 had a pink sticker on her door that indicated "see nurse before entering room." The surveyor immediately interviewed RN-A. RN-A stated, "...I don't know her (resident #25) diagnosis. She was having phlegm emesis." Resident #25's name was listed on the facility's resident GE symptom line list on 11/28/11 with symptoms of nausea and vomiting. On 11/30/11 at 8:05 a.m., surveyor # interviewed RN-AA. RN-AA stated, "...we are directed to gown, glove and wear a mask whenever we go into a room with a resident who has a pink sticker on their door, even if it's just to give medications." On 11/30/11 at 9:15 a.m., surveyor # interviewed DON (Director of Nursing)-V. DON-V stated, "...minimally, she (RN-A) should have worn gloves when entering her (resident #25) room when she had active emesis, and a mask. She (resident #25) was placed on the GE line list on 11/28/11. On residents with pink signs on the door, gowns are to be worn if staff anticipate contact with vomit or stool." ~On 11/28/11 at 9:00 a.m., surveyor # observed HK-EE (Housekeeper) in the hallway of the 400 unit. "...I haven't' been given any directive to do anything different with cleaning of the facility...The pink signs on the doors tells us what symptoms resident are having and we are to wear gloves when in their rooms. We don't have to wear any other PPE..." ~On 12/5/11 at 10:30 a.m. surveyor # observed M-X enter Room AAA, which had a pink sign on the door frame "see nurse before entering room." M-X did not don a gown, mask, or gloves before entering Room AAA. M-X fixed a leak in the bathroom of the room. Surveyor # asked him if he needed a mask when entering the room. M-X stated "no...she's not sick." CNA-K walked by and stated "yes, you need a mask and gloves when entering (Room AAA) and a gown if she is having emesis for contact." M-X then stated "I looked at my list this morning...not on list...thought it (list) was current from this morning." ~On 12/5/11 at 12:39 p.m. surveyor # observed CNA-TT leave Room BBB without having a mask, gloves, or a gown on while in the room. Room BBB had a pink sign on the door "see nurse before entering room." CNA-TT went into Room CCC after leaving Room BBB and washed her hands in the bathroom. CNA-TT stated to surveyor # "she (Room BBB) had some diarrhea, not GI over the weekend...don't need personal protective equipment...she is on liquids yet." On 12/5/11 at 12:45 p.m. surveyor # interviewed LPN-UU who stated when going into Room BBB "need gloves and a mask because she is in the 48 hour period...not active...CNA's know" they need to wear a mask and gloves when going into Room BBB. On 12/5/11 at 12:55 p.m. surveyor # interviewed RN-A regarding precautions for room [ROOM NUMBER]. RN-A stated "need to wear mask and gloves...gown too if touching anything in room, such as the faucets, toilet, resident, or anything the resident may have touched. Not actively vomiting, but still in 48 hour window." On 12/5/11 at 1:00 p.m. surveyor # interviewed DON-V who verified staff need to wear a mask and gloves when going into Room BBB. MANAGEMENT OF STAFF The facility's policy regarding GE Identification and Outbreak Management, dated 12/17/10 indicated the following procedures: *The facility will make every effort to keep consistent staff, that includes all departments, assignments as possible. The facility will discontinue floating staff, that includes all departments and includes food service as much as possible. Line list tracking will include all staff name, unit, observed and reported symptoms, onset date and time, resolved date and time for illness and return to work dates/times. *...Only essential staff should enter the affected resident's room. Only essential staff should enter any unit that has been closed/quarantined. ~On 11/28/11 at 9:30 a.m., surveyor # observed M (Maintenance)-Z walking from the 400 resident unit through the hallway leading to the therapy department. ~On 11/28/11 at 9:00 a.m., surveyor # observed HK-EE in the hallway of the 400 unit. "...I haven't' been given any directive to do anything different with cleaning of the facility. I float to all the wings..." ~On 11/28/11 at 10:00 a.m., surveyor # observed the Laundry and interviewed LA (Laundry Aide) -G who verified that she worked the weekend -- Saturday 11/26/11 and Sunday 11/27/11-- and was notified that there was "diarrhea going on" on wing 100 and wing 400 and nothing on wings 200 and 300. LA-G stated that she puts on gloves and a gown and goes from wing to wing (wings 200, 300, and 400) and picks up all the bagged laundry from each wing. LA-G stated that wing 100 brings their own laundry to the laundry room. LA-G stated she brings the bagged laundry all down to the laundry room where she unloads and separates the bagged laundry in the dirty laundry area. ~On 11/28/11 at 11:55 a.m., DON-V verified to surveyor # that during the facility's known outbreak of GE, one housekeeper had cleansed the odd numbered resident rooms and one housekeeper had cleansed the even numbered resident rooms on both 11/26/11 and 11/27/11. Additionally, one laundry aide had delivered clean laundry to all residents in the facility on 11/26/11 and on 11/27/11. The facility had not followed their policy relating to discontinuation of floating staff throughout the building during a known GE outbreak. ~On 11/28/11 at 12:20 p.m., surveyor # interviewed CNA-I who verified that she was orienting as a CNA and as a bath aide. CNA-I verified that on Saturday 11/26/11 she worked as a CNA on the 100 wing and on Sunday 11/27/11 she worked as a CNA on the 400 wing. On Monday 11/28/11, she verified that she was working as a bath aide between the 100, 200, and 300 wings giving residents baths along with CNA-E. ~On 11/29/11 at 8:05 a.m., surveyor # interviewed HK-U. HK-U stated, "...All the rooms with the pink tags on them are getting cleaned twice daily. We are still just doing all of the other surfaces in the building once a day like before. I worked the weekend (11/26/11-11/27/11). We had two housekeepers cleaning resident units. One of us did the odd numbered rooms, and one of use did the even numbered rooms on all of the units. No one has discussed how to progress from unit to unit yet as far as how the housekeepers should be doing things like with the carts if we can be taking them from unit to unit. I would imagine they will be letting us know soon." ~On 11/29/11 at 8:27 a.m., surveyor # observed CNA-C come out of the doors that led to the 100 wing (with a sign on the doors stating the unit/wing was closed to through traffic) and come into the 400 wing dining room kitchen area. CNA-C assisted in getting the resident food tray cart ready (putting juices and condiments in the cart) for the 100 wing, waited until the dietary staff prepared the resident breakfast trays for the 100 wing, and loaded the resident food trays into the food tray cart. At 8:40 a.m., surveyor # observed CNA-C and CNA-D take the resident food tray cart from the 400 wing dining room and push it back to the doors that were closed which led to the 100 wing. CNA's C and D then opened the doors to the 100 wing and pushed the food tray cart onto the 100 wing and began serving trays to the 100 wing residents. ~On 11/29/11 at approximately 1:00 p.m., surveyor # reviewed the facility's direct care staff assignments for the time frame of 11/26/11 through 11/28/11. The surveyor noted that CNA-I, who was a new employee orienting to the facility had been assigned to work the day shift on the 100 resident unit on 11/26/11, had been assigned to work the 400 resident unit, which had several residents with signs and symptoms of GE on 11/27/11 and had been assigned to be the bath CNA for the entire facility on 11/28/11. It was also noted that CNA-P had been assigned to the 300 resident unit on 11/27/11 and to the 400 resident unit on 11/28/11; CNA-N had been assigned to the 200 resident unit on 11/27/11 and to the 100 resident unit on 11/28/11 and CNA-O had been assigned to the 300 resident unit on 11/27/11 and to the 400 resident unit on 11/28/11. The facility had not ensured that staff were not floating and had not made an effort to keep consistent staff assigned during an outbreak of GE in the facility. ~On 11/28/11 at 11:20 a.m., surveyor # interviewed MS (Maintenance Supervisor)-W, M-S and M-Z. MS-W stated, "...I worked on 11/26/11 and was working on the entrance doors to the facility. There was no sign that the facility had an issue with GE. I came in today at 7:00 a.m. and have been all over the building." M-X stated, "...I came in at 8:30 a.m. today. I walked down the 400 unit hallway to check the mechanical room then I went all over the building to do some painting." M-Z stated, "...I came in at 7:00 a.m. today. I've been in the shop, the kitchen, the activity room and basically all over the building. My supervisor told me around 9:00 a.m. today that we have GE going around, but I didn't know that right when I came into the building. I come in through the therapy doors and there was no sign there indicating an issue." ~On 11/29/11 at 8:00 a.m., surveyor # observed MS-W walking through the 100 resident unit. The surveyor immediately interviewed the staff. MS-W stated, "...there is to be no through traffic in the affected resident units." ~On 11/28/11 at 10:30 a.m., DON-V gave a staff GE symptom line list to surveyor # . The list included that on 11/26/11, DA (Dietary Aide)-J had called in sick with fever, nausea, vomiting and diarrhea. On 11/28/11 at approximately 1:00 p.m., DON-V gave an updated staff GE symptom line list to surveyor # . The revised list included that CNA-K had called in sick on 11/27/11 with vomiting and diarrhea and RN-L had called in sick on 11/26/11 with nausea, vomiting and diarrhea. The facility had not been ensuring that employees line lists for GE symptoms were being updated and reviewed. On 11/29/11 at 3:15 p.m., surveyor # interviewed NHA-DD. NHA-DD stated, "...the weekend supervisor is to fill out the staff sick line list. That didn't get done for 3 employees who called in sick with GE over the weekend." NOTIFICATION According to the facility's policy and procedure for GE Identification and Outbreak Management, dated 12/17/10: *Any sister facilities that share staff and/or resources with the facility will be notified of suspected or confirmed GE outbreaks. A hospital, clinic or other facility will be notified of the transfer of a resident, regardless of symptoms, from a facility with an outbreak of GE. Visitors will be notified of an increase in GE illness from postings on facility entrance doors. Posting will instruct visitors to refrain from visiting if they have symptoms of acute GE through 48 hours after last symptoms. Referral sources will be notified of increase in GE surveillance for the communication to families, patients making considerations for facility placement. Referrals should be made to sister facilities without GE surveillance. *If visitation is necessary, facility staff will instruct visitors on use of PPE and hand hygiene. Visitors will be provided education on Norovirus and/or GE. ~On 11/26/11 at 8:00 a.m., the survey team entered the facility. It was noted by surveyor # that there was no signage on the facility's front entrance doors that the facility was experiencing an outbreak of GE. ~During the initial tour of the facility on 11/28/11 at approximately 8:15 a.m., surveyor # observed pink signs on the door jam of six resident rooms located on the 100 and 400 resident units. The surveyor interviewed LPN-BB (Licensed Practical Nurse). LPN-BB verified to the surveyor that the residents with the pink sign on their door were experiencing symptoms of GE. It was noted by the surveyor that neither the 100 or 400 resident units entrance doors had been closed and no signage had been posted that those two units were experiencing an outbreak of GE. ~On 11/28/11 at 10:05 a.m., surveyor # interviewed the front desk receptionist. Receptionist M stated, "...I have not been made aware to tell visitors anything. If we have outbreaks, they tell me and I alert guests." ~On 11/28/11 at 10:15 a.m., surveyor # interviewed DON-V. DON-V functioned as the facility's Infection Preventionist. DON-V gave the resident GE symptom line list to the surveyor. It was noted that resident #21, #20, #24, and #3 (all residing on the 100 unit) had been on the list beginning on 11/26/11 with symptoms of nausea and vomiting and/or diarrhea; resident #23 (who resided on the 200 unit) was on the list 11/26/11 for nausea, fever and diarrhea; and resident #4 (who resided on the 400 unit) was on the list on 11/26/11 for fever, nausea, vomiting and diarrhea. DON-V stated, "...our definition of a GE outbreak is two or more residents and/or staff within 24 hours that have nausea/ vomiting, and/or loose stools and fever. We will be alerting the Health Department today. The outbreak began on 11/26/11. " On 11/28/11 at approximately 1:00 p.m., a revised resident GE symptom line list was given to surveyor # . Resident #23 (who resided on the 100 unit) had been added to the list on 11/28/11 with symptoms of diarrhea and fever and resident #25 (who resided on the 400 unit) had been added to the list with symptoms of nausea and vomiting on 11/28/11. ~The line list provided by DON-V indicated that resident #33 had been sent to the hospital radiation department on 11/28/11. DON-V confirmed that the hospital radiation department had not been notified of the facility's GE outbreak prior to sending resident #33 to their facility. The line list indicated that there had been no other residents discharged from the facility during the GE outbreak in the facility. ~Surveyor # immediately reviewed the facility's resident discharge report. The report indicated that resident #41 and resident #42 had been discharged to two separate local hospitals on 11/26/11. On 11/28/11, surveyor # interviewed the RN who had assisted with resident #42's admission to the hospital via the telephone. RN-FF stated, "...we were not made aware that the facility had a GE outbreak when she (resident #42) was admitted to our hospital on [DATE]." On 11/28/11 at 1:40 p.m., surveyor # interviewed RN-PP from Appleton Medical Center Hospital via phone regarding resident #41's admission to the hospital on [DATE]. RN-PP stated that she worked all weekend and took the (resident/patient) admissions. RN-PP verified that resident #41 had been on two different units in the hospital and she reviewed the nurses notes and physician notes and did not see anything in the admission information about being notified of a GE outbreak when resident #41 was admitted . RN-PP stated to surveyor # that she was not told of anything about a GE outbreak from the facility regarding resident #41. On 11/28/11 at 11:30 a.m., surveyor # interviewed AA (Administrative Assistant)-CC via the telephone. AA-CC works at the radiology department in the hospital where resident #33 had been transported to on 11/28/11. AA-CC stated, "...I was the first person here today. There was no message on the answering machine and when she (resident #33) arrived to our department, no one notified us that the facility she came from was having a GE outbreak." ~On 11/28/11 at 10:50 a.m., LPN-BB verified to surveyor # that the facility's Medical Director had just been informed of the facility's outbreak of GE. LPN-BB stated, "...he (Medical Director) didn't know about it until just now." ~On 11/28/11 at 10:08 a.m. surveyor # and surveyor # interviewed DON-V who stated "I should have had one of the nurses put the sign up (on the doors) because we don't have a receptionist on the weekend." ~On 11/28/11 at 2:19 p.m. surveyor # interviewed R-M who stated "Would not tell a visitor or a family member they can't visit...it is their decision after we tell them what is going on. If it was a bigger problem, but with only this amount (of ill residents) we don't discourage visits...let them (visitors) make a decision." R-M verified she does advise visitors of the illness going around at the facility. A visitor entered the building and R-M advised the visitor of the gastrointestinal illness in the building. The visitor asked R-M how the resident was doing. The visitor stated "okay...I'll visit for a little bit." R-M did not discourage the visit, offer the visitor a mask, or educate the visitor related to the outbreak in the facility. ~On 11/29/11 at 9:47 a.m. surveyor # observed two visitors enter the facility. R-M stated to the visitors "we have the GI flu on the 100 wing...just so you know." R-M did not discourage the visit, offer the visitors a mask, or educate the visitors related to the outbreak in the facility. ~On 11/29/11 at 10:30 a.m. surveyor # observed R-M advise two visitors that the "GI flu is in the building...just so you are aware." R-M did not discourage the visit, off the visitors a mask, or educate the visitors related to the outbreak in the facility. SUSPENSION OF ADMISSIONS According to the facility's policy and procedure for GE Identification and Outbreak Management, dated 12/17/10: *Unaffected residents and/or new admission should not be transferred to units with acute GE surveillance...The Infection Preventionist and Quality Assurance Committee will consult with the Medical Director on the surveillance of acute GE symptoms and consider closing the facility to new admissions. On 11/28/11 at 10:15 a.m., surveyor # interviewed DON-V. DON-V functioned as the facility's Infection Preventionist. DON-V gave the resident GE symptom line list to the surveyor. The list also indicated that resident #5 was admitted to the 400 unit of the facility from the hospital on [DATE]. DON-V verified to the surveyor that resident #5 or her family had not been notified of the facility's GE outbreak prior to her admission to the facility SUSPENSION OF GROUP ACTIVITIES AND GROUP DINING According to the facility's policy and procedure for GE Identification and Outbreak Management, dated 12/17/10: *Cancel or postpone group activities for at least 48 hours after the last identified case. ~On 11/28/11 at 9:38 a.m., surveyor # interviewed RT-T (Rehabilitation Technician). RT-T stated, "...we are still having therapy for residents in the therapy room. Quarantined residents have colored stickers on their doors. We are alerted to what precautions to use with them. There is a GE issue with quite a few residents right now. Therapy for sick residents is done in their rooms, but we are still bringing well folks to the therapy gym for their sessions." ~On 11/28/11 at 10:00 a.m., surveyor # observed 16 residents gathered in a circle in the activity room located next to the dining room near the front of the building. The activity occurring included a parachute. ~On 11/28/11 at 11:00 a.m., surveyor # observed 11 residents gathered in a group in the activity room located next to the dining room near the front of the building. The activity occurring included a dog. At 11:35 a.m., surveyor # observed 12 residents in the same group activity in the activity room. ~On 11/28/11 at 2:15 p.m. surveyor # observed 12 residents in the activity room near the front entrance playing bingo. One staff member was calling bingo and another female was assisting a resident with her bingo card. ~On 11/28/11 at 2:17 p.m. surveyor # interviewed DON-V related to the activity. DON-V verified the residents were playing bingo and that there were two staff members assisting with the activity. ~On 11/28/11 at 4:10 p.m., surveyor # observed residents gathered in a circle in a group activity going on in the activity room located next to the dining room near the front of the building. ~On 11/29/11 at 8:15 a.m., surveyor # observed the breakfast meal in the 400 wing dining room. Surveyor # observed RN-A administering medications to residents in the dining room and interviewed RN-A regarding the residents who were dining together. RN-A identified the following residents by name and/or wing observed dining together at tables (and surveyor # verified where the residents lived via the Roster Matrix from the facility): -Residents #30, #31, and #32 from the 400 wing and an unnamed female from the 200 wing were observed eating together at a table. -Resident #33 from the 400 wing, resident #34 from the 200 wing, and resident #35 from the 300 wing were observed eating together at a table. -Resident #36 from the 400 wing and resident #7 from the 200 wing were observed eating together at a table. -Resident's #28 and #16 from the 400 wing, resident #37 from the 200 wing, and resident #38 from the 300 wing were observed eating together at a table. -Resident #4 from the 400 wing and observed receiving Speech therapy services from ST-H (Speech Therapist) at the table during the breakfast meal, along with resident #18 from the 400 wing who had a male visitor, resident #27 from the 300 wing, and resident #26 from the 200 wing. Resident #4 had not been asymptomatic for 48 hours and was allowed to dine with others. A nursing progress note dated 11/27/11 at 9:12 p.m., indicated resident #4 continued with loose stools. ~On 11/29/11 at 8:40 a.m., surveyor # observed that group dining was continuing in one of the main dining rooms near the front entrance of the facility. ~On 11/29/11 at 12:30 p.m., surveyor # again observed that group dining was continuing in one of the main dining rooms near the front entrance of the facility. The surveyor noted that their were 10 tables of residents eating in the dining room together. ~On 11/29/11 at 12:35 p.m., surveyor # observed the noon meal in the 400 wing dining room. Surveyor # observed RN-A administering medications to residents in the dining room and interviewed CNA-E and CNA-B regarding the residents in the dining room at the tables. CNA-E and CNA-B identified the following residents who were eating together at tables: -Residents #32 and #31 from the 400 wing, residents #7 and #39 from the 200 wing were observed eating together at a table. -Resident #35 from the 300 wing and residents #30 and #36 from the 400 wing were observed eating together at a table. -Residents #4 and #28 from the 400 wing and resident #29 from the 200 wing who had a female visitor were observed eating together at a table. -Residents #14 and #34 (who had a caregiver with her from the Home Instead agency) also eating breakfast and CNA-E verified that the caregiver comes in daily for resident #34) from the 200 wing were observed eating together at a table. -Resident #8 from the 200 wing, residents #18 and #40 both from the 400 wing, and resident #27 from the 300 wing were observed eating together at a table. HAND HYGIENE *On 12/5/11 surveyor # reviewed the facility's procedure, which was not dated, for handwashing. The procedure indicated to wet hands with water and apply one squirt of soap. Using friction, rub hands together, cleaning under the nails and between fingers thoroughly. Wash up to your wrist as well. Do this for at least 15 seconds. Rinse hands well without touching the inside of the sink or the faucet (these are always considered soiled). Leave water running. Dry hands well. When finished, turn off faucet with a clean paper towel. When to wash hands (at a minimum): Before and after each resident contact, after touching a resident or handling his or her belongings, whenever hands are obviously soiled, after contact with any body fluids, and after handling any contaminated items (linens, soiled diapers, garbage, etc.). ~On 11/29/11 at 9:40 a.m., surveyor # observed CNA-D as she prepared to check resident #1's brief. The CNA donned gloves. The resident had not been incontinent, but CNA-D cleansed his rectal area with a wet wipe and before removing gloves and cleansing hands, CNA-D picked up a tube of barrier cream, applied it to the resident's rectal and buttock areas, set the tube on the resident's bedside dresser, touched the resident's clean brief, and shirt, removed gloves and cleansed hands, picked up the container of wet wipes and placed it on the over the bed tray table. At the time of the observation, resident #1 ate all meals in his room utilizing the over the bed tray table. On 11/20/11 at 8:20 a.m., surveyor # interviewed CNA-D. CNA-D verified to the surveyor that staff were directed to remove gloves and cleanse hands after the provision of pericare for residents before touching clean items. ~A nursing progress note, dated 11/28/11, indicated, resident #5 is "C-diff positive, given [MEDICATION NAME] by mouth." On 11/29/11 at 9:10 a.m. surveyor # observed CNA-NN assist resident #5 with toileting. CNA-NN performed pericare, took off her gloves and washed her hands. CNA-NN assisted resident #5 to stand while the resident used the grab bars next to the toilet and pulled up her own brief. CNA-NN then assisted resident #5 back into her wheelchair, pushed her back to her bed, and assisted resident #5 into bed. Resident #5 began touching the bedside table, breakfast tray and began consuming her eggs and sausage. On 11/29/11 at 12:35 p.m. surveyor # interviewed DON-V, regarding the above observation. DON-V confirmed staff should offer or prompt residents to wash their hands after toileting. ~On 12/5/11 at 10:30 a.m. surveyor # observed M-X enter room [ROOM NUMBER], which had a pink sign on the door frame "see nurse before entering room." M-X did not don a gown, mask, or gloves before entering Room AAA. M-X fixed a leak in the bathroom of the room. At 10:38 a.m. M-X exited Room AAA without sanitizing or washing hands. M-X walked down the hall and then washed his hands in the restroom. ~On 12/5/11 at 12:39 p.m. surveyor # observed CNA-TT leave Room BBB without having a mask, gloves, or a gown on while in the room. Room BBB had a pink sign on the door "see nurse before entering room." CNA-TT did not wash her hands after leaving room BBB. CNA-TT went into room CCC and washed her hands in that bathroom. CNA-TT stated to surveyor # "she (room BBB) had some diarrhea, not GI over the weekend...don't need personal protective equipment...she is on liquids yet." ENVIRONMENTAL CLEANING The facility's policy and procedure for "GE Identification and Outbreak Management" dated 12/17/10 includes: *Disinfect equipment with chlorine bleach at a minimum of 1000 ppm (parts per million) and/or use of approved facility disinfectant wipes with effective chlorine bleach concentrations. *Additional daily cleaning routines will be implemented. Additional cleaning will be provided for bathrooms, areas surrounding resident living spaces, faucets, door handles, light switches, bed rails, computes, telephones and any frequently touched surfaces. Use of chlorine bleach will be used, at a minimum concentration of 1000 ppm to clean all hard, non porous environmental surfaces. The use of chlorine bleach, up to 5000 ppm may be used in areas with high levels of soiling and resistant surfaces. Steam cleaning will be used for all carpeting and soft furnishings. Vacuuming will not be used for up to 12 days after the last documented case and/

Based on observation, record review, and staff and resident interviews the facility did not ensure that 1 of 9 sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #1 was at risk for falls and used an alarm to alert staff to her unsafe movements. On 12/31/10, Resident #1 sustained a fall when left unattended on the toilet, resulting in a right fractured femur. Following Resident #1's return to the facility, the facility continued the use of a Tabs alarm when Resident #1 was in the wheel chair. Staff were also to apply a knee immobilizer to Resident #1's right leg during Hoyer transfers related to the femur fracture. On 1/18/11, resident #1 was observed sitting in a wheel chair from breakfast until 11:40 a.m. without the Tabs alarm attached to the wheel chair. Additionally, CNAs (Certified Nursing Assistant) did not apply the knee immobilizer to resident #1's right knee prior to transfers on 1/18/11, using a Hoyer lift transfer as directed in her plan of care. Findings include: 1) Surveyor # reviewed resident #1's medical record on 1/18/11. The face sheet dated 1/4/11 indicated that resident #1 had been admitted to the facility on [DATE] and readmitted on [DATE] following a hospitalized from [DATE] - 1/4/11 for treatment of [REDACTED]. Resident #1 also had [DIAGNOSES REDACTED]. Resident #1's MDS (minimum data set) dated 9/13/10 indicated she had severe cognitive impairment and required extensive assistance of 2 for transfers. Resident #1's nurses notes dated 12/31/10 indicated that resident #1 was found on her bathroom floor at 1:35 p.m. with hip deformity and pain and was transferred to the emergency room and admitted to the hospital with [REDACTED]. On 1/18/11 at 2:45 p.m. surveyor # interviewed ADON-G (Assistant Director of Nursing ) regarding resident #1. ADON-G stated that resident #1's fall risk assessment dated [DATE] indicated she had a score of 11 and that any resident with a score over 10 is considered high risk of falls. ADON-G indicated that resident #1's updated falls risk assessment dated [DATE], upon return from the hospital resulted in a score of 20. During an interview with surveyor # , ADON-G verified that resident #1's plan of care dated 10/26/10 indicated that staff were to utilize a Tabs alarm when resident #1 was in her wheel chair. Surveyor # reviewed the facility's investigation, dated 1/6/11 of resident #1's fall that occurred on 12/31/10. The conclusion documented that on 12/31/10, resident #1 had been left unattended on the toilet by CNA-E (Certified Nursing Assistant), fell , and sustained a right femur fracture. On 1/18/11 at 8:05 a.m. surveyor # interviewed NHA-D (Nursing Home Administrator) regarding resident #1's fall on 12/31/10. NHA-D confirmed that CNA-E had left resident #1 unattended while on the toilet. Additionally, NHA-D stated that the facility's policy states that any resident that has an alarm can never be left unattended on the toilet. Surveyor # conducted a phone interview with RN-F (Registered Nurse) regarding resident #1's fall on 12/31/10. RN-F verified that she was the nurse on duty at the time of the incident on 12/31/10 and that resident #1 had been left unattended on the toilet and was found on the floor. RN-F indicated that CNA-E felt very bad about the incident and knew she had not followed the care plan, which instructed her to stay with resident #1 when on the toilet, because resident #1 had an alarm. On 1/18/11 at 12:40 p.m. surveyor # conducted a phone interview with CNA-E regarding resident #1. CNA-E verified that she left resident #1 unattended on the toilet, when she briefly left to weigh her wheel chair. CNA-E verified that resident #1 fell and was aware that resident #1 sustained a fracture as a result of the fall. Additionally, CNA-E verified she had not followed resident #1's care plan and knew that residents with alarms must be supervised at all times when on the toilet. Resident #1 sustained harm of a fractured right femur when left unattended on the toilet on 12/31/10 by CNA-E who did not follow her care plan. 2) Resident #1's medical record contained a therapy note from Appleton Medical Center dated 1/3/11 indicating that resident #1 had severe dementia and became agitated and "..unable to move safely within orthopedic restrictions resulting in the immobilizer for safety during transfers". On 1/18/11, ADON-G stated to surveyor # that resident #1's plan of care was updated on 1/4/11 after the 12/31/10 fall, indicating that staff are to use a Tabs alarm when resident #1 is in the wheel chair, a sensor alarm when in bed, transfer with 2 assist and a Hoyer, and to apply a knee immobilizer to her right knee during Hoyer transfers. On 1/18/11 at approximately 11:00 a.m. surveyor # observed resident #1 in a group activity in the dining room seated in her wheel chair. Resident #1 did not have a Tabs alarm attached to her wheel chair as indicated in her care plan. On 1/18/11 at approximately 11:40 a.m. surveyor # observed resident #1 seated in her room in her wheel chair. Resident #1 did not have a Tabs alarm attached to her wheel chair as indicated in her care plan. Surveyor # interviewed resident #1 and asked if she ever fell . Resident #1 stated she did and pointed to her bathroom. Surveyor # then asked resident #1 if she got hurt during the fall. Resident #1 stated that she broke her leg and patted her right upper leg. On 1/18/11 at approximately 11:45 a.m. surveyor # observed CNA-A and CNA-B transfer resident #1 from her wheel chair to the bed using a Hoyer lift, provide personal cares and then transfer resident #1 back to her wheel chair using the Hoyer lift. During these Hoyer lift transfers, surveyor # did not observe CNA-A or CNA-B apply the immobilizer to resident #1's right knee as directed in her plan of care. CNA-A commented to surveyor # that resident #1 had a bad knee and needed the Hoyer lift to transfer. On 1/18/11 at approximately 11:55 a.m. surveyor # interviewed CNA-A and CNA-B regarding resident #1 not having a Tab clip alarm on her wheel chair when observed in group activity and in her room prior to the Hoyer lift transfers. CNA-A indicated she thought she had put the alarm on when she got resident #1 up that morning, stating that therapy must have removed it. CNA-A then went down to the therapy department and asked staff where resident #1's Tabs alarm was. OT (Occupational Therapist)-C verified that she brought resident #1 directly from the breakfast table to therapy and resident #1 "...did not have a Tabs alarm on her wheel chair", as required in her care plan. CNA-A then applied a Tabs alarm to resident #1's wheel chair. On 1/18/11 at 12:20 p.m. surveyor # observed resident #1's knee immobilizer lying on a chair in the corner of her room. Surveyor # interviewed CNA-A and CNA-B regarding the use of resident #1's knee immobilizer. CNA-A and CNA-B verified that the knee immobilizer had not been applied to resident #1's right knee during the Hoyer lift transfers observed by surveyor # , stating that they "...didn't think it was on her care card to do so". Surveyor # , CNA-A and CNA-B reviewed resident #1's care card at that time and noted that resident #1's care card indicated, "R (right) knee immobilizer on during Hoyer transfers." On 1/18/11 at approximately 3:30 p.m. surveyor # reviewed the observations of resident #1 with NHA-D during the exit meeting. NHA-D confirmed that facility staff did not follow resident #1's care plan as indicated.