Every finding on record at Rennes Health and Rehab Center-De Pere

Based on observation, staff interview and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 3 residents (R) (R145, R21, and R71) of 8 sampled residents.Certified Nursing Assistant (CNA)-G did not wear a gown while emptying R145's catheter bag. In addition, R145 did not have an enhanced barrier precautions (EBP) sign on or near R145's door or a personal protective equipment (PPE) cart outside or near R145's room.CNA-C did not wear a gown while providing Foley catheter care for R21. In addition, R21 did not have an EBP sign on or near R21's door or a PPE cart outside or near R21's room.R71 was on droplet precautions due to a respiratory illness. CNA-F applied an N95 respirator over a surgical mask to care for R71 which did not allow the N95 to properly seal to CNA-F's face.Findings include: The facility's undated Enhanced Barrier Precautions (EBP) policy indicates: EBP is used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. EBP targets gown and glove use during high-contact resident care activities when contact precautions don't otherwise apply .examples of high-contact resident care activities requiring the use of a gown and gloves for EBP include: .device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) . According the Food and Drug Administration's website (FDA.gov) as of 1/21/26: An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. Note that the edges of the respirator are designed to form a seal around the nose and mouth. 1.From 1/12/26 to 1/15/26, Surveyor reviewed R145's medical record. R145 was admitted to the facility on [DATE] and had a diagnosis of urinary retention in the pre-operative setting. A care plan, initiated 1/8/26, indicated R145 had a Foley catheter (initiated 1/2/26) for urinary retention in the pre-operative setting. The catheter was removed on 1/7/26 per an admission order but was placed again due to retention. A care plan, initiated 1/6/26, indicated R145 was on EBP. On 1/1/4/26 at 9:55 AM, Surveyor observed CNA-G enter R145's room and empty R145's catheter bag. CNA-G did not don a gown prior to entry. Surveyor also noted R145's uncovered catheter bag was on the floor. Surveyor interviewed CNA-G who did not think R145 was on EBP because there was not an EBP sign or a PPE cart outside or near R145's room. CNA-G stated CNA-G would have donned a gown if CNA-G had known R145 was on EBP. CNA-G verified an uncovered catheter bag should not be on the floor and stated catheter bags are usually hung on the side of residents' beds. On 1/14/26 at 9:59 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-E who confirmed a catheter bag should not be on the floor and verified there should be an EBP sign on or near R145's door and a PPE cart outside or near R145's room. 2. From 1/12/26 to 1/15/26, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including cerebral vascular accident, chronic kidney disease, retention of urine, anxiety, and myoneural disorder. R21's Minimum Data Set (MDS) assessment, dated 10/20/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R21 had intact cognition. A care plan, dated 8/6/25, indicated R21 was on EBP due to an indwelling Foley catheter. On 1/14/26 at 9:47 AM, Surveyor entered R21's room. Surveyor did not observe a sign that indicated R21 was on EBP or a PPE cart outside or near R21's room. CNA-C positioned R21 in bed and provided Foley catheter care. CNA-C did not wear a gown during the process. On 1/14/26 at 10:04 AM, Surveyor interviewed CNA-C who verified CNA-C should have worn a gown during catheter care. On 1/14/26 at 10:06 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who verified CNA-C should have worn a gown during catheter care. LPN-D was not certain if an EBP sign or a PPE cart were outside R21's room. On 1/14/26 at approximately 10:40 AM, Surveyor interviewed ADON-E who stated ADON-E would check why an EBP sign and a PPE cart were not in place for R21. ADON-E confirmed a gown should be worn when staff provide Foley catheter care. 3. From 1/12/26 to 1/15/26, Surveyor reviewed R71's medical record. R71 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD) and Alzheimer's disease. R71's MDS assessment, dated 12/23/25, had a BIMS score of 13 out of 15 which indicated R71 had intact cognition. R71's medical record indicated R71 was on droplet transmission-based precautions (TBP) due to a respiratory illness. A red droplet TBP sign outside R71's room directed staff to don a gown, gloves, and an N95 respirator prior to entering the room. There was also a PPE cart outside the room. On 1/13/26 at 11:58 AM, Surveyor interviewed R71 in R71's room. As Surveyor exited the room, Surveyor observed CNA-F place an N95 respirator over a surgical mask that covered CNA-F's mouth and nose and state CNA-F needed to empty R71's garbage. On 1/13/26 at 12:01 PM, Surveyor interviewed CNA-F who stated CNA-F put an N95 respirator over the surgical mask because R71 had a wet cough and CNA-F thought that would provide more protection. CNA-F stated the facility provided training on how to properly wear an N95 respirator. (Of note: The surgical mask did not allow the N95 respirator to properly seal on CNA-F's face.) On 1/14/26 at 10:07 AM, Surveyor interviewed ADON-E who stated CNA-F should not have worn an N95 respirator over a surgical mask. ADON-E stated CNA-F should have taken the surgical mask off prior to donning the N95 and stated staff are not trained wear N95 respirators over surgical masks. ADON-E verified R71 was on droplet TBP until 1/14/26 at 5:00 PM if symptoms did not worsen.

Based on observation, staff, resident, and resident representative interview, and record review, the facility did not ensure a hand splint, a compression sleeve, and passive range of motion (PROM) exercises were provided for 1 resident (R) (R83) of 1 sampled resident.R83's hand splint and compression sleeve were not applied as ordered. In addition, R83 did not receive PROM restorative therapy per therapy discharge recommendations, a physician's order, and R83's plan of care.Findings include:The facility's Rehabilitative Nursing Care policy, revised April 2007, indicates: Rehabilitative nursing care is provided for each resident admitted .3. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence. 4. Rehabilitative nursing care is performed daily for those residents who require such services. Such programs include, but are not limited to: .d. Assisting residents to adjust to their disabilities, to use their prosthetic device, and to redirect their interest, if necessary; .f. Assisting residents with their routine range of motion exercises; .h. Others as prescribed by the resident's attending physician. 5. Through the resident's care plan, the goals of rehabilitative nursing care are reinforced in the activities program, therapy services, etc.From 1/12/26 to 1/15/26, Surveyor reviewed R83's medical record. R83 was admitted to the facility on [DATE] and had diagnoses including age-related osteoporosis with current pathological fracture of the left humerus, subsequent encounter for fracture with non-union, unspecified dementia with mood disturbance and anxiety, and unspecified symptoms and signs involving cognitive functions following cerebral infarction. R14's Minimum Data Set (MDS) assessment, dated 10/28/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R83 had moderately impaired cognition. The MDS assessment also indicated R83 had a restorative therapy program.R83's medical record contained the following physician orders:~ Wash left upper extremity (LUE) 24-hour Tubigrip with soap/water (dated 7/7/25)~ Weight bearing status: Ok to bear weight to LUE, gentle range of motion (ROM), stretching, strengthening every shift (dated 7/10/25)~ Sling and wrist splint to LUE on at bedtime (HS), off in AM, once daily (dated 8/20/25)~ Compression sleeve to LUE during the day, wrist brace at night; skin checks with donning/doffing, encourage to wear for 12 hours/day, twice daily (dated 9/10/25)On 1/14/26, Surveyor reviewed R83's Treatment Administration Record (TAR) which indicated the above orders were documented as completed from 12/1/25 through 1/14/26. R83's care plan, revised 10/30/25, contained the following interventions:~ LUE wrist brace at night, compression sleeve during the day.~ Assist (R83) with seated or supine LUE PROM exercises daily including: finger, wrist, elbow, flexion/extension, shoulder abduction, shoulder flexion 10 times each.R83's care sheet (an abbreviated care plan used by nursing staff), dated 1/13/26, contained the following intervention:~ LUE PROM dailyA physician progress note, dated 7/10/25, contained a recommendation to work on passive and active ROM and strengthening with therapy. The note indicated R83 could bear weight through the LUE without restrictions. The physician indicated R83 should wear a night splint on the left wrist for nerve palsy. Restorative monthly notes, dated 10/31/25, 11/24/25, and 12/30/25, indicated: Restorative program for passive and active ROM and ambulation. (R83) completes seated bilateral lower extremity ([NAME]) active ROM and LUE passive ROM exercises daily, worksheets in wardrobe. (R83) ambulates in hall with a front-wheeled walker with the assistance of one, distance as tolerated with wheelchair to follow for fatigue and maintains strength with this. Ambulation ranges 50-100 feet. Continue with current plan of care, no decline noted per physical therapy assessment.On 1/12/26 at 8:30 PM, Surveyor observed R83 in bed. A left wrist splint was on the bedside table out of R83's reach. On 1/13/26 at 2:45 PM, Surveyor interviewed R83 who did not have a compression sleeve on the left arm and was not aware of R83's LUE exercises. R83 reached over to the left hand and moved R83's left fingers from a fist to an open palm with R83's right hand. R83 stated R83 has to move the left hand and arm with the right hand and has limited movement in the LUE due to a fracture and surgeries. R83 was left-handed and had to learn to use the right hand. R83 verified R83 was not wearing a compression sleeve and did not know where it was. R83 pointed to the splint on the bedside table and stated R83 wears the splint occasionally. When Surveyor asked when R83 wears the splint, R83 was not sure and stated staff do not tell R83 when to wear it. On 1/13/26 at 2:54 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-K who stated R83 wears a splint at bedtime. When Surveyor indicated R83's care sheet contained an intervention for daily LUE PROM, LPN-K stated Unit Manager (UM)-M updates residents' care sheets daily. LPN-K stated staff use care sheets and care plans to direct resident care. On 1/14/26 at 8:00 AM, Surveyor observed LPN-J administer medication to R83. When LPN-J and Surveyor entered R83's room, R83 was asleep in bed. R83's LUE splint was on the bedside table out of R83's reach.On 1/14/26 at 10:28 AM and 11:52 AM, Surveyor observed R83 in a wheelchair wearing the LUE splint. R83 stated R83 did not wear the splint often and no one told R83 why R83 needed the splint. R83 stated staff do not complete arm or hand exercises with R83. On 1/14/26 at 1:15 PM, Surveyor met with R83 and R83's Power of Attorney ((POA)-N) in the dining room. Surveyor noted R83 was not wearing a compression sleeve on the LUE. POA-N stated R83 fractured R83's humerus 3 times and had surgery. POA-N stated R83 had an appointment next week with an orthopedic surgeon and was advised by an orthopedic surgeon to wear a splint on the left wrist at night to keep the left hand from contracting. An orthopedic surgeon also advised R83 to wear a compression sleeve during the day to decrease swelling. POA-N visited R83 daily and had not seen R83 with a compression sleeve on for months. When POA-N asked why R83 was not wearing a compression sleeve, R83 stated staff did not tell R83 to wear it. POA-N stated R83 did not know when or why R83 should wear the compression sleeve or splint. R83 stated staff do not complete LUE exercises with R83. On 1/14/26 at 2:47 PM, Surveyor observed R83 in bed without a compression sleeve. On 1/15/26 at 8:12 AM, Surveyor observed R83 asleep in bed. A LUE wrist splint was on the bedside table and out of R83's reach. On 1/15/26 at 12:15 PM, Surveyor observed R83 in R83's room without a LUE compression sleeve. Certified Nursing Assistant (CNA)-I was in the room. When Surveyor asked about R83's compression sleeve, CNA-I found the sleeve in R83's bathroom and stated R83 did not like to wear the sleeve. R83 accused CNA-I of lying. R83 stated staff do not put the compression sleeve on or encourage R83 to wear the sleeve and R83 did not know what R83 should wear or when to wear it. CNA-I did not know which LUE exercises R83 should complete daily. Surveyor assessed R83's ability to apply and remove the wrist splint and noted R83 was unable to apply the splint independently but could remove it independently. On 1/15/26 at 12:40 PM, Surveyor interviewed Occupational Therapist (OT)-L who stated R83 was last seen by occupational therapy (OT) on 9/9/25. OT-L stated R83 had radial nerve palsy and OT was discontinued due to a lack of progress. OT-L verified R83 had a current restorative program. OT-L stated R83 should do LUE passive and active ROM exercises with staff each day and stated the exercises were posted on the inside of R83's closet. OT-L stated when a resident is discharged from therapy, therapy provides a sheet that contains restorative therapy exercises and instructions. OT-L stated therapists train staff and post exercises in residents' rooms. Surveyor observed restorative exercises posted in R83's closet. On 1/15/26 at 1:25 PM, Surveyor interviewed CNA-H who completed restorative ambulation with R83 on 1/15/26. CNA-H showed Surveyor that 15 minutes of restorative ambulation was documented as completed on the morning of 1/15/26. When Surveyor asked about other exercises in R83's restorative therapy plan, CNA-H stated R83's restorative plan included ambulating in the hall. CNA-H was not aware LUE PROM exercises were included in R83's restorative therapy.On 1/15/26 at 2:08 PM, Surveyor interviewed UM-M who reviewed and oversaw R83's restorative goals each month. UM-M indicated physical therapy assistants (PTAs) and CNAs complete restorative exercises with residents and it is the CNAs' responsibility to document restorative minutes completed or refused in the resident's chart. UM-M verified UM-M updates and prints R83's care sheet daily which indicates staff will complete LUE PROM with R83 daily. UM-M stated R83 should wear the left wrist splint at night and LUE compression sleeve during the day. UM-M stated staff should assist and encourage R83 to wear the LUE splint at night and compression sleeve during the day even though R83 does not like to wear the splint. UM-M reviewed physician progress notes with Surveyor which indicated the physician was notified on 8/26/25, 9/4/25, and 9/8/25 when R83 refused to wear the LUE splint. UM-M indicated the physician gave an order on 9/10/25 to continue to encourage R83 to wear the LUE splint at night. UM-M also reviewed R83's care sheet and TAR with Surveyor. UM-M verified staff documented on R83's TAR that PROM was completed 3 times daily and restorative therapy was completed once daily.

Based on staff interview and record review, the facility did not ensure a grievance was documented, thoroughly investigated, or resolved for 1 resident (R) (R1) of 5 sampled residents. R1 and R1's activated Power of Attorney for Healthcare ((POAHC)-C) reported a grievance involving staff. The facility did not document, investigate, resolve, or provide follow-up for the grievance. Findings include: The facility's Grievances/Complaints, Recording and Investigating policy, revised April 2017, indicates all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance .2. Upon receiving a grievance and complaint report, the Grievance Officer (Administrator) will begin an investigation into the allegations .5. The Resident Grievance/Complaint Investigation Report Form will be filed with the Administrator within 5 working days of the incident .6. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 5 working days of the filing of the grievance or complaint .8. A summary of all grievances must be signed and will be made available to the resident or person acting on behalf of the resident upon his/her request. On 1/22/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, dependence on renal dialysis, depression, anxiety disorder, and unspecified hearing loss. R1's Minimum Data Set (MDS) assessment, dated 8/16/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R1's cognition was moderately impaired. R1's medical record indicated R1 had an activated POAHC to assist with healthcare decision making. R1 discharged from the facility on 10/20/24. On 1/22/25 at 9:17 AM, Surveyor interviewed POAHC-C who indicated R1 told POAHC-C that Certified Nursing Assistant (CNA)-E was rude and physically rough with R1 and requested that CNA-E not provide care for R1. POAHC-C stated Director of Nursing (DON)-B was aware of the concern and indicated DON-B would take care of it, however, R1 told POAHC-C that CNA-E continued to enter R1's room. POAHC-C indicated POAHC-C was in R1's room on one occasion when CNA-E responded to R1's call light and asked, What do you want? POAHC-C asked nursing staff why CNA-E was caring for R1 and was told the facility was short-staffed. POAHC-C stated POAHC-C was not informed of the results of the grievance and did not know if a grievance form was completed on POAHC-C or R1's behalf. On 1/22/25 at 12:28 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B. NHA-A stated after POAHC-C's first few grievances, DON-B and POAHC-C agreed that DON-B would be the point person for POAHC-C to contact with questions and concerns. DON-B indicated DON-B was aware of a concern with a CNA who POAHC-C and R1 did not care for. DON-B indicated POAHC-C originally told Unit Manager (UM)-H that the concern was with CNA-E, however, POAHC-C's description of the CNA and the reported statements made by the CNA did not match CNA-E. Based on the information, DON-B and UN-H assumed the CNA was CNA-D. DON-B stated CNA-D was educated on appropriate and professional communication and was instructed only to enter R1's room if necessary and with another staff. DON-B denied that physical roughness was reported. DON-B stated DON-B and POAHC-C verbally discussed the concerns which were resolved immediately, therefore, a grievance form was not completed. NHA-A stated POAHC-C did not request to file a formal grievance. On 1/22/25 at 12:53 PM, Surveyor interviewed CNA-D who confirmed CNA-D received education regarding interactions with R1 and was instructed not to go into R1's room. CNA-D stated CNA-D did not provide care to R1 following the education. On 1/22/25 at 1:19 PM, Surveyor interviewed CNA-E who denied any knowledge regarding R1 and concerns with CNAs. On 1/22/25 at 2:18 PM, Surveyor interviewed UN-H who denied any knowledge regarding R1 having concerns with a specific CNA. On 1/22/25 at 2:52 PM, Surveyor again interviewed POAHC-C who provided an accurate description of CNA-E and provided Surveyor with CNA-E's name.

Based on observation, staff interview, and record review, the facility did not ensure medications for 11 residents (R) (R36, R55, R51, R69, R52, R20, R75, R22, R213, R57, and R88) of 16 residents in 2 of 3 medication carts were stored, labeled, or dated appropriately. The facility also did not ensure expired medications and medical supplies were discarded in 2 of 2 medication storage rooms. Medication carts and storage rooms contained open, undated, and expired medications and medical supplies. Findings include: The facility's Medication Labeling and Storage policy, revised February 2023, indicates: Medication Storage: .3) If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .Medication Labeling: 1) Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2) The medication label includes, at a minimum: .d) expiration date, when applicable; e) resident's name; .4) For over-the-counter (OTC) medications in bulk containers, the label contains: .f) expiration date. 5) Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 6) Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date .8) If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. The facility's Discarding and Destroying Medications policy, revised November 2023, indicates: Medications that cannot be returned to the dispensing pharmacy (e.g., non unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals. Insulin glargine manufacturer's ([NAME] Lilly) instructions at 16.2 Storage indicate: Store unused insulin glargine in a refrigerator between 36 F (Fahrenheit) and 46 F (2 C (Celsius) and 8 C). Do not freeze. Discard insulin glargine if it has been frozen. Protect insulin glargine from direct heat and light. The insert also indicates that an in-use vial or open SoloStar (insulin pen) is good for 28 days refrigerated or at room temperature. Ipratropium bromide and albuterol nebulizer packaging indicates: Storage Conditions: Protect from light. Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks. Discard if the solution is not colorless. During an observation of medication administration with Licensed Practical Nurse (LPN)-J on 9/16/24 at 11:20 AM, Surveyor observed an open bottle of floor stock acetaminophen 500 mg (milligram) tablets without a visible expiration date. LPN-J confirmed the bottle did not contain an expiration date. On 9/16/24 at 11:27 AM, LPN-J indicated if there is not a visible expiration date on the bottle, the medication should be disposed of and not used. LPN-J also indicated insulin, eye drops, and nebulizers should be labeled with open dates. On 9/17/24 at 10:41 AM, Surveyor observed the 200 unit medication cart and noted the following: ~ An open bottle of Geri Care multi-vitamin dietary supplement 100 tablets with an open date of 9/16/24. The bottle contained a best-by date of 8/2024. ~ An open and undated Breo Ellipta 200 mcg (microgram)/25 mcg inhaler, fluticasone propionate nasal spray, and a fluticasone furoate vilanterol 200 mcg/25 mcg inhaler for R36. ~ An open and undated Touejo Max Solostar insulin glargine 300 units/milliliter (ml) 3 ml prefilled pen for R55. The label indicated the pen expired 56 days after opening. ~ An open and undated vial of insulin lispro 100 unit/ml for R51. ~ An open and undated box of 48 Restasis vials. ~ Two open and undated bottles of 6.5% Murine ear drops for R69. ~ An open and undated 0.5 fluid ounce bottle of Refresh Tears for R52. The packaging indicated to discard 90 days after opening. ~ An open and undated fluticasone vilanterol 200 mcg/25 mcg inhaler for R20. The packaging indicated to discard 6 weeks after opening. ~ An open and undated ventolin HFA 90 mcg/1 actuation inhaler for R75. ~ An open and undated bottle of 50 mcg fluticasone spray for R22. On 9/17/24 at 11:50 AM, Surveyor confirmed with LPN-K that the above medications were open and undated. LPN-K indicated the medications should contain open dates. On 9/17/24 at 11:58 AM, Surveyor observed the 300 unit medication cart and noted the following: ~ An open and undated Basaglar KwikPen 100 units/ml 3 ml insulin pen for R213. ~ An open and undated bottle of 0.4-0.3% Systane gel drops for R57. The package indicated the medication expired 28 days after opening. ~ An open bottle of 0.03% 30 ml 21 mcg/spray ipratropium bromide nasal solution for R57 that was dated 3/7. ~ Three open and undated 3 mg vials of albuterol sulfate inhalation solution for R57. ~ An open and undated albuterol HFA 90 mcg per actuation inhaler for R88. On 9/17/24 at 12:12 PM, Surveyor confirmed with Registered Nurse (RN)-L that nasal sprays should be discarded 90 days after opening. RN-L also confirmed there were no open dates on the insulin and eye drops. At 12:32 PM, Surveyor confirmed with RN-L the albuterol sulfate inhalers were open and undated. On 9/17/24 at 12:48 PM, Surveyor observed the 500 unit medication storage room and noted the following: ~ An Inteliswab COVID-19 rapid test with an expiration date of 11/30/23. ~ An open, undated, and unlabeled bottle of Benefiber. ~ Three 2 ml Vacuette blue top test tubes with expiration dates of 5/4/24. ~ Two 6 ml Vacuette red top test tubes with expiration dates of 11/13/23. ~ Four 6 ml Vacuette red top test tubes with expiration dates of 8/30/24. ~ Two 6 ml BD Vacutainer red top test tubes with expiration dates of 2/29/24. ~ Five 1.8 ml BD Vacutainer blue top test tubes with expiration dates of 5/31/24 ~ One 1.8 ml BD Vacutainer blue top test tube with an expiration date of 4/30/24. On 9/17/24 at 12:52 PM, Surveyor confirmed with RN-L the medication storage room contained an open, undated, and unlabeled bottle of Benefiber. RN-L indicated bottle was not in use and disposed of the bottle. At 1:20 PM, Surveyor interviewed RN-L who confirmed the COVID-19 test and test tubes were expired. RN-L indicated expired items should be removed and discarded. On 9/17/24 at 1:26 PM, Surveyor observed the 600 unit medication storage room and noted the following: ~ Six 1.8 ml BD Vacutainer blue top test tubes with expiration dates of 5/31/24. ~ Nine 6 ml Vacuette red top test tubes with expiration dates of 8/30/24. ~ One 2 ml Vacuette blue top test tube with an expiration date of 5/4/24. ~ One 15 ml culture and sensitivity stool transport orange top test tube with an expiration date of 7/26/24. ~ Twenty one 10 mg bisacodyl suppositories with expiration dates of 7/31/24. On 9/17/24 at 1:51 PM, Surveyor confirmed with RN-M the medical supplies and suppositories were expired and should have been discarded. On 9/17/24 at 2:53 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated inhalers, insulins, eye drops, ear drops, and nebulizers should have open dates. DON-B also indicated the expired test tubes and suppositories should have been discarded.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect more than 4 of the 109 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled with open or use-by dates. Findings include: On 9/16/24, Registered Dietician (RD)-D indicated the facility followed the Wisconsin Food Code as their standard of practice. Open/Undated Foods: The Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S3-502.12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for safety food, prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees C (Celsius) (41 degrees F (Fahrenheit)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition: (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day. The facility's Food Receiving and Storage policy, revised July 2014, includes the following: .6. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use-by date). During an initial kitchen tour that began at 8:28 AM on 9/16/24, Surveyor observed food storage areas with Assistant Dietary Manager (ADM)-C and noted the following: Coolers: ~ A 2 quart plastic container of tuna salad dated 9/11/24 with no use-by date ~ An open container of whipped topping with a use-by date of 9/12/24 ~ A container of sliced Swiss cheese with a use-by date of 9/13/24 ~ Two trays of undated food items for lunch and dinner (per ADM-C) ~ An undated pan of sliced tomatoes ~ An undated pan of sliced onions Freezers: ~ Corn dogs dated 9/8/24 (open date per ADM-C) with no use-by date ~ An undated half of a chocolate roll cake Dry Storage: ~ Powdered sugar dated 9/18/24 (open date per ADM-C) with no use-by date During the initial kitchen tour that began at 8:28 AM on 9/16/24, Surveyor interviewed ADM-C regarding the food observed in storage. ADM-C disposed of the tuna salad and stated the tuna salad should have been used within 3 days. ADM-C stated ADM-C expects staff to label food items with use-by dates and dispose of food that is past the use-by date. ADM-C indicated the whipped topping and Swiss cheese were past their use-by dates and should have been disposed. ADM-C indicated the trays of food in the cooler should contain use-by dates. ADM-D indicated the pans of tomatoes and onions were from a recent celebration and should contain use-by dates. ADM-C disposed of the powdered sugar, corn dogs, and chocolate cake and indicated the items should have use-by dates. ADM-C stated ADM-C expects staff to label all open and prepared food with an open, made, and/or use-by date.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 2 residents (R) (R54 and R317) of 7 sampled residents observed during the provision of cares. During an observation on 9/18/24, Certified Nursing Assistant (CNA)-F and CNA-G did not don gowns prior to the provision of care for R54 who was on enhanced-barrier precautions (EBP). During an observation on 9/16/24, CNA-H and CNA-I did not ensure R317's catheter bag was not in contact with the floor and was below the level of R317's bladder. Findings include: The Centers for Disease Control and Prevention (CDC) states: Use EBP when performing high-contact resident care activities .Includes the use of gown and gloves. The CDC EBP sign states: Providers and staff .wear gloves and a gown for the following high-contact resident care activities: changing briefs or assisting with toileting .Wound Care: any skin opening requiring a dressing The facility's Catheter Care, Urinary policy, revised September 2005, indicates: .4. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .11. Be sure the catheter tubing and drainage bag are kept off the floor. 1. On 9/18/24, Surveyor reviewed R54's medical record. R54 was hospitalized on [DATE] for gallbladder perforation with intrahepatic abscess status post cholecystostomy tube (Jackson Pratt (JP) drain) placement on 5/29/24. The abscess culture grew Klebsiella oxytoca. R54 also had diagnoses including chronic ulcer to the left lower leg and a stage 3 sacral pressure injury. R54's care plan, dated 4/18/24, indicated R54 was on EBP due to wounds and an indwelling medical device. On 9/18/24 at 9:33 AM, Surveyor observed a personal protective equipment (PPE) bin and EBP sign outside R54's room. Surveyor observed CNA-F and CNA-G approach R54 in R54's room to check R54's incontinence pad. CNA-F and CNA-G were wearing gloves but no gowns. As CNA-F and CNA-G approached R54 in bed, Surveyor asked CNA-F and CNA-G if they should be wearing gowns. CNA-F and CNA-G then donned gowns before providing care. On 9/18/24 at 9:40 AM, Surveyor interviewed CNA-F who verified CNA-F and CNA-G should have donned gowns prior to approaching R54 to provide incontinence care. On 9/18/24 at 2:47 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects staff to don PPE prior to providing direct care for a resident on EBP. 2. On 9/16/24 at 11:15 AM, Surveyor observed CNA-H and CNA-I provide assistance to R317. Surveyor observed CNA-H assist R17 with putting on pants. R317 sat on the edge of the bed while CNA-H threaded R317's catheter tubing down R317's left pant leg. Surveyor noted R317's catheter bag was in contact with the floor. CNA-H and CNA-I then assisted R317 into R317's wheelchair via mechanical lift. During the transfer, Surveyor noted R317's catheter bag was hung on a bar of the mechanical lift that was above the level of R317's bladder. On 9/16/24 at 11:23 AM, Surveyor interviewed CNA-H who verified R317's catheter bag was on the floor when CNA-H put the catheter tubing through R317's pant leg. CNA-H also verified R317's catheter bag was hung on the bar when the bag should have been below the level of R317's bladder. On 9/18/24 at 2:47 PM, Surveyor interviewed DON-B who indicated DON-B expects staff to keep catheter bags off the floor.

Based on staff interview and record review, the facility did not ensure a vaccination was re-offered for 1 resident (R) (R18) of 5 sampled residents. R18 was not offered the 20-valent pneumococcal conjugate vaccine (PCV20) since R18 refused the vaccine upon admission on 10/20/21. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13(R)) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20(R)) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23(R)) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults [AGE] years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults [AGE] years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The facility's Pneumococcal Vaccine policy, revised 3/4/22, indicates: All residents will be offered the pneumococcal vaccine, in accordance with current CDC and Advisory Committee on Immunization Practices (ACIP) recommendations, to aid in preventing pneumococcal infections .Pneumococcal vaccinations will be administered to residents per our facility's physician-approved pneumococcal vaccination protocol. From 9/16/24 to 9/18/24, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, chronic kidney disease stage 3, and dementia. R18's Minimum Data Set (MDS) assessment, dated 8/31/24, indicated R18 had severely impaired cognition. R18 had an activated Power of Attorney (POA). R18's medical record indicated R18 received the PCV13 vaccine on 9/23/15 and the PPSV23 vaccine on 6/11/86 (at [AGE] years old). R18's medical record indicated R1's POA declined a pneumococcal immunization for R18 on 10/20/21. On 9/18/24 at 11:21 AM, Surveyor interviewed Infection Preventionist (IP)-E who indicated IP-E was unsure if the PCV20 vaccine was offered to R18 since admission. Per IP-E, the PCV20 vaccine should have been re-offered. On 9/18/24 at 1:14 PM, Surveyor interviewed IP-E regarding the time frame in which staff should re-offer a pneumococcal vaccine if a resident refuses. Per IP-E, the facility follows up with residents within a year if they refuse a vaccine. On 9/18/24 at 2:00 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility follows the CDC guidelines of when to re-offer immunizations. DON-B indicated the facility needs to develop a more clear-cut policy regarding vaccination re-offer guidelines. DON-B indicated R18 should have been re-offered the most appropriate pneumococcal vaccine since R18's declination upon admission.

Based on observation, staff and resident interview, and record review, the facility did not ensure fall prevention interventions were implemented for 1 Resident (R) (R5) of 1 resident. R5 had a history of falls with injury at home and in the facility. R5's plan of care contained interventions for a body pillow while in bed and to place R5's wheelchair in an angled position at the foot of the bed. Those interventions were not consistently followed. Finding include: R5 was admitted to the facility with diagnoses including fracture of unspecified carpal bone, right wrist, encounter for fracture with routine healing, fracture of nasal bones, hemiplegia (paralysis of one side of the body) following cerebral infarction, vascular dementia, and history of falling. R5's Minimum Data Set (MDS) assessment, dated 9/26/23, indicated R5 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R5 had intact cognition. R5's MDS also indicated R5 required the assistance of one staff with bed mobility, and transfers. R5 had a restorative walking program with the assistance of one staff with a gait belt following with R5's wheelchair. On 10/24/23, Surveyor reviewed a care plan that contained a problem area of falls and a goal that R5 would remain free from significant injury with falls. The care plan contained the following interventions: Room layout adjustment by Physical Therapy (PT) - wheelchair at the foot of the bed angled at 90 degrees facing the pillow to allow for greater success with self-transferring (dated, 6/26/23); Body pillow in bed (dated, 7/23/22). On 10/24/23 at 8:49 AM, Surveyor interviewed R5 who indicated R5 had falls at home and while at the facility. R5 stated R5 hurt R5's arm and wrist during a fall at home, and reinjured the wrist during a fall a few months ago. R5 stated R5 received therapy, had tape on the floor, and pointed to a body pillow and an alarm on R5's wheelchair. On 10/24/23 at 11:57 AM, Surveyor observed R5 in bed without a body pillow in bed or a wheelchair at the foot of the bed. Surveyor noted the body pillow was on a chair in the room and R5's wheelchair was on the other side of the room. On 10/24/23 at 12:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who indicated R5 had falls at the facility and was admitted to the facility following a fall at home. CNA-D indicated R5 had a fall a couple months ago and broke (R5's) wrist. CNA-D indicated R5's care plan included bed and chair alarms, grip tape on the floor next to the bed, a body pillow in bed while sleeping, and anti-roll back bars, anti-tip bars and auto lock brakes on R5's wheelchair. During the interview, CNA-D indicated CNA-D was not aware how R5's wheelchair should be positioned while R5 was in bed and showed Surveyor the Kardex (an abbreviated care plan) used by nursing staff. CNA-D reviewed R5's fall preventions and indicated R5's wheelchair should be placed at the foot of the bed, angled at 90 degrees, and facing the pillow to allow for greater success with self-transferring. CNA-D confirmed R5 fell out of the bed and fell while self-transferring. CNA-D indicated CNA-D would check to ensure R5 had the appropriate fall interventions in place. Surveyor observed CNA-D enter R5's room, place the body pillow in bed with R5, and move R5's wheelchair from across the room to a 90-degree angle next to R5's bed facing the pillow. CNA-D stated CNA-D did not position R5 in bed prior to Surveyor's observation, but verified the body pillow was not in bed, and the wheelchair was not positioned at the foot of R5's bed. CNA-D confirmed the fall preventions on R5's care plan were not followed. CNA-D indicated CNA-D received recent education on fall preventions and care plans. On 10/24/23 at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R5 had falls with injuries while in the facility, most recently on 6/23/23 when R5 refractured R5's wrist. DON-B indicated R5's care plan was updated by physical therapy to include a room layout adjustment with R5's wheelchair next to the bed because R5 self-transferred at times. DON-B also indicated R5 should have a body pillow while in bed. DON-B verified staff received training regarding fall preventions and following care plans and stated DON-B expected staff to follow residents' fall preventions.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 103 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The facility did not ensure time/temperature control foods were labeled with opened or use-by dates. Findings include: On [DATE], Registered Dietician (RD)-F indicated the facility follows the Wisconsin Food Code as their standard of practice. Food Cooling Temperatures: The Wisconsin Food Code 2022 documents at section ,d+[DATE].14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The Wisconsin Food Code 2022 section ,d+[DATE].15 documents Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S ,d+[DATE].14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial kitchen tour beginning at 8:11 AM on [DATE], Surveyor noted the reach-in cooler contained steam table containers; one container was labeled Pork Chop ,d+[DATE] and three containers were dated ,d+[DATE]. Cook (CK)-I indicated the unlabeled containers dated ,d+[DATE] contained pureed turkey, ground Philly cheesesteak meat (regular consistency) and ground Philly cheesesteak meat (pureed consistency). CK-I indicated the meats were for the [DATE] lunch meal and were made probably earlier in the morning. During a continuous kitchen observation beginning at 7:55 AM on [DATE], Surveyor interviewed Dietary Manager (DM)-G regarding leftovers kept in the reach-in cooler, and the food cooling process. DM-G indicated the facility does not keep leftovers and does not have a process for cooling foods. Surveyor interviewed DM-G about foods observed in the reach-in cooler on [DATE]. At that time, RD-F indicated to Surveyor instruction was provided to CK-I to throw away the container of turkey because it was not cooled correctly. Surveyor interviewed RD-F regarding the pre-made ground Philly cheesesteak meat that Surveyor observed on [DATE] pre-made for lunch and served to residents during the [DATE] lunch meal as well as the container of pork chops that Surveyor observed in the reach-in cooler. RD-F indicated, Oh you are right indicating all meat that was observed during the intial kitchen tour on [DATE] was not cooled properly and should have been discarded and was not. DM-G further confirmed the facility does not have a process for monitoring the temperature of foods made ahead of time for meal service, does not use an approved cooling method and does not have cooling temperature logs. Open, Undated Foods: The Wisconsin Food Code 2020 documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when packaging food using a reduced oxygen packaging method as specified under S,d+[DATE].12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for food safety, prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5C (41F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition. (A) A food specified under ,d+[DATE].17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in ,d+[DATE].17 (A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day. During an initial kitchen tour beginning at 8:11 AM on [DATE], Surveyor observed the dry storage area and noted the following undated items: -A bag of [NAME] walnuts with no opened date and a manufacturer use-by date of [DATE]. -Six [NAME] Buddy snack bar boxes with no received by, use-by, or opened dates. -Six oatmeal cream pie snack cake boxes with no received by, use-by or opened dates. During an initial kitchen tour beginning at 8:11 AM on [DATE], Surveyor interviewed Assistant Dietary Manager (ADM)-H regarding the process for rotating stock and ensuring foods received first are used first, and foods that are expired are removed from the rotation and not used. ADM-H indicated staff used the first in, first out process for foods, manufacturer use-by date indicated on the food box or item, as well as stickers on items that label the food Use First. ADM-H indicated the stock is rotated quickly due to the large resident census. Continouing with the initial kitchen tour beginning at 8:11 AM on [DATE], Surveyor toured the walk-in cooler. Surveyor observed and RD-F confirmed one large unlabeled and undated container of peaches, one previously opened bag that contained three stalks of celery, closed with a twist tie, one opened bag of shredded lettuce, one box that contained five bags of grapes, one opened bag of grapes, one large opened box of oranges, one large opened box of sweet potatoes, one large opened box of onions and one large open box of tomatoes without received, opened, or use-by dates. Surveyor observed and RD-F confirmed three Ziploc bags of bagels without opened or use-by dates and three boxes of cream pies without received, use-by, or manufacturer use-by dates in the walk-in freezer. During a continuous kitchen observation beginning at 7:55 AM on [DATE], Surveyor toured the walk-in cooler. Surveyor observed and RD-F confirmed one bag with three stalks of celery closed with a twist tie, one opened bag of shredded lettuce, one box that contained five bags of grapes, one opened bag of grapes, one large opened box of oranges, one large opened box of sweet potatoes, one large opened box of onions and one large opened box of tomatoes without received, opened, or use-by dates. DM-G indicated the peaches were used on [DATE] during the lunch meal. During a continuous kitchen observation beginning at 7:55 AM on [DATE], Surveyor toured the dry food storage area. Surveyor observed and RD-F confirmed six [NAME] Buddy snack bar boxes without received, use-by, or opened dates and six boxes of oatmeal cream pie snack cakes without received, use-by or opened dates. RD-F verified the [NAME] walnuts were discarded by staff on [DATE] after Surveyor noted they were expired. Surveyor and DM-G also observed three Ziploc bags of bagels without opened or use-by dates and three boxes of cream pies without received, use-by or manufacturer use-by dates in the walk-in freezer.

Based on observation, staff and resident interview, and record review, the facility did not ensure 5 Residents (R) (R84, R6, R18, R65, and R56) of 24 sampled residents were assessed to safely and accurately self-administer medication. R84 did not have a self-administration of medication assessment or physician order to self-administer Vitamin D 800 units which was observed at R84's bedside. R6 did not have a self-administration of medication assessment or physician order to self-administer Tucks pads and Preparation H ointment which were observed at R6's bedside. R18 did not have a self-administration of medication assessment or physician order to self-administer Vitamin B-12 1000 milligrams (mg) which was observed at R18's bedside. R65 did not have a self-administration of medication assessment or physician order to self-administer Systane eye drops which were observed at R65's bedside. R56 did not have a self-administration of medication assessment or physician order to self-administer Refresh eye drops or VapoCOOL severe cherry cough drops which were observed at R56's bedside. Findings include: The facility's Self-Administration of Drugs, Med-Pass, Inc. Revised August 2006 policy contained the following information: As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. 1. R84 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN) and heart disease. R84's Minimum Data Set (MDS) assessment, dated 6/20/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R84 did not have impaired cognition. On 8/14/23 at 10:21 AM, Surveyor observed a bottle of Vitamin D on R84's bedside table. R84 stated R84 took Vitamin D daily. From 8/14/23 through 8/16/23, Surveyor reviewed R84's medical record which did not contain a physician order for Vitamin D. R84's medical record also did not contain a physician order or self-administration of medication assessment that indicated R84 could self-administer medication or have medication at bedside. 2. R6 was admitted to the facility on [DATE] with diagnoses including HTN, type 2 diabetes mellitus with diabetic chronic kidney disease and hemorrhoids. R6's MDS assessment, dated 5/22/23, contained a BIMS score of 15 out of 15 which indicated R6 did not have impaired cognition. On 8/14/23 at 1:36 PM, Surveyor observed a container of Tucks pads and Preparation H ointment on R6's bedside table. R6 indicated R6 used both products on a regular basis for discomfort. From 8/14/23 through 8/16/23, Surveyor reviewed R6's medical record and noted physician orders to use Tucks pads every shift as needed and Preparation H four times daily as needed. R6's medical record did not contain a physician order or self-administration of medication assessment that indicated R6 could self-administer medication or have medication at bedside. 3. R18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), osteoporosis and anemia. R18's MDS assessment, dated 5/15/23, contained a BIMS score of 15 out of 15 which indicated R18 did not have impaired cognition. On 8/14/23 at 12:49 PM, Surveyor observed a bottle of Vitamin B-12 1000 mg and a bottle of Refresh eye drops on R18's bedside table. From 8/14/23 through 8/16/23, Surveyor reviewed R18's medical record and noted a physician order for Refresh eye drops twice daily that could be self-administered at bedside. R18's medical record did not contain a physician order or self-administration assessment that indicated R18 could self-administer Vitamin B-12. On 8/15/23 at 2:50 PM, Surveyor interviewed R18 who indicated R18's physician recommended R18 start taking Vitamin B-12 so R18 took Vitamin B-12 every morning. 40343 4. R65 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic cataract and dry eye syndrome of bilateral lacrimal glands. R65's most recent MDS assessment contained a BIMS score of 15 out of 15 which indicated R65 did not have impaired cognition. The MDS also indicated R65 required limited to extensive assistance of staff for activities of daily living (ADLs). On 8/14/23 at 10:57 AM, Surveyor observed a bottle of Systane eye drops and an albuterol inhaler on R65's bedside table. R65 indicated R65 self-administered both medications when I need them. On 8/15/23, Surveyor reviewed R65's medical record and noted a physician order for an albuterol inhaler every four hours as needed. Surveyor also noted a self-administration of medication assessment, dated 6/21/23, for use of the inhaler. R65's medical record also contained a physician order for Systane eye drops one drop in each eye three times daily as needed, dated 9/19/22. R65's medical record did not contain a physician order to self-administer the eye drops or a self-administration of medication assessment for the eye drops. On 8/15/23 at 9:17 AM, Surveyor interviewed R65 who was sitting in a recliner in R65's room. R65's Systane eye drops were at bedside. R65 indicated R65 self-administered the eye drops that morning and used the eye drops almost every day. 42248 5. R56 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF) and type 2 diabetes mellitus with diabetic chronic kidney disease. R56's Quarterly MDS assessment, dated 4/20/23, contained a BIMS score of 15 out of 15 which indicated R56 did not have impaired cognition. On 8/14/23 at 9:35 AM, Surveyor observed two boxes of Refresh eye drops, nasal spray, an albuterol inhaler, and VapoCOOL severe cherry cough drops on R56's nightstand. Surveyor interviewed R56 who stated R56 used the medications, had understanding of the medications, and knew how to use the medications properly. On 8/15/23, Surveyor reviewed R56's medical record which included medication orders for the two of the four medications observed in R56's room: ~Albuterol sulfate HFA aerosol inhaler; 90 mcg (micrograms)/actuation; amt: 2 puffs; inhalation; Special Instructions: Wait one minute between puffs. Rinse mouth after use. Okay to keep at bedside Every 6 hours PRN (as needed) ~Saline Nasal Mist (sodium chloride) OTC (over the counter) aerosol, spray; 0.65%; amt (amount): 1-2 sprays; Special Instructions: May keep at bedside. Surveyor also noted a self-medication administration assessment, dated 4/11/23, that indicated R56 could self-administer the albuterol inhaler and a self-administration of medication assessment, dated 5/31/23, that indicated R56 could self-administer the nasal spray. R56's medical record did not contain physician orders that indicated R56 could self-administer Refresh eye drops and VapoCOOL severe cherry cough drops. On 8/15/23 at 11:17 AM, Surveyor interviewed Registered Nurse (RN)-C who stated residents can self-administer medication if they are assessed as able to accurately do so. On 8/15/23 at 11:15 AM, Surveyor interviewed Director of Nursing (DON)-B who stated residents who indicate they would like to self-administer medication need an assessment to ensure they can safely and accurately administer the prescribed medication. DON-B stated staff will obtain a physician order and ensure the medication can be locked/secured in the resident's room. If the medication is not kept in the resident's room, the medication is locked in the medication cart and given to the resident to self-administer. DON-B toured the above residents' rooms with medication at bedside and verified the residents did not have self-administration of medication assessments or physician orders to self-administer the identified medications.

Based on observation, staff and resident interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with facility policy for 8 Residents (R) (R84, R6, R18, R14, R31, R60, R65, and R56) of 24 sampled residents. On 8/14/23, Surveyor observed unsecured oral medication at R84's bedside. On 8/14/23, Surveyor observed unsecured and unlabeled non-oral medication at R6's bedside. On 8/14/23, Surveyor observed unsecured and unlabeled oral and non-oral medication at R18's bedside. On 8/14/23, Surveyor observed unsecured non-oral medication with an illegible label at R14's bedside. On 8/14/23, Surveyor observed an unsecured non-oral medication labeled with another resident's name at R31's bedside. On 8/14/23, Surveyor observed unsecured and unlabeled non-oral medications at R60's at bedside. On 8/14/23, Surveyor observed unsecured and unlabeled oral and non-oral medications at R65's bedside. On 8/14/23, Surveyor observed unsecured and unlabeled oral and non-oral medications at R56's bedside. Findings include: The facility's Storage of Medications policy, revised August 2006, contained the following information: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use . 1. R84 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN) and heart disease. R84's Minimum Data Set (MDS) assessment, dated 6/20/23, contained a Brief interview for Mental Status (BIMS) score of 15 out of 15 which indicated R84 did not have impaired cognition. On 8/14/23 at 10:21 AM, Surveyor observed a bottle of Vitamin D on R84's bedside table. 2. R6 was admitted to the facility on [DATE] with diagnoses including HTN, type 2 diabetes mellitus with diabetic chronic kidney disease and hemorrhoids. R6's MDS assessment, dated 5/22/23, contained a BIMS score of 15 out of 15 which indicated R6 did not have impaired cognition. On 8/14/23 at 1:36 PM, Surveyor observed an unlabeled container of Tucks pads (medicated cooling pads used to treat hemorrhoid discomfort), a tube of Preparation H with an expiration date of 5/2021, a bottle of AmLactin cream (a medicated moisturizer), and triamcinolone acetonide cream (a combination antifungal/steroid used to treat skin infections) on R6's bedside table. The items were unlocked and unattended in R6's room. 3. R18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), osteoporosis and anemia. R18's MDS assessment, dated 5/15/23, contained a BIMS score of 15 out of 15 which indicated R18 did not have impaired cognition. On 8/14/23 at 12:49 PM, Surveyor observed a bottle of Vitamin B-12 1000 mg (milligrams) and a bottle of Refresh eye drops on R18's bedside table. The bottle of Vitamin B-12 did not contain a label. Both items were unlocked and unattended in R18's room. 4. R14 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, Parkinson's disease and chronic kidney disease. R14's MDS assessment, dated 8/3/23, contained a BIMS score of 1 out of 15 which indicated R14 had severely impaired cognition. On 8/14/23 at 10:37 AM, Surveyor observed an empty bottle of miconazole nitrate powder (an antifungal medication) with an illegible label in a basket on R14's bedside table. R14's medical record contained a physician order for miconazole powder twice daily. 5. R31 was admitted to the facility on [DATE] with diagnoses including COPD, osteoporosis and anemia. R31's MDS assessment, dated 6/15/23, contained a BIMS score of 15 out of 15 which indicated R31 did not have impaired cognition. On 8/15/23 at 12:57 PM, Surveyor observed a bottle of Hibiclens (an antimicrobial and antiseptic skin cleanser) labeled with R31's roommate's name in a bucket with other non-medicated wound care supplies on R31's bedside table. 6. R60 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, HTN, and psoriasis. R60's MDS assessment, dated 5/25/23, contained a BIMS score of 15 out of 15 which indicated R60 did not have impaired cognition. On 8/14/23 at 1:59 PM, Surveyor observed two buckets with wound care supplies on R60's bedside table. Medicated items included: diclofenac sodium (a nonsteroidal anti-inflammatory drug used to treat mild-to-moderate pain) with an illegible label, a bottle of nystatin powder (an antifungal medication) and a tube of hydrocortisone cream (a topical steroid commonly used to treat skin conditions). 40343 7. R65 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with diabetic cataract and dry eye syndrome of bilateral lacrimal glands. R65's most recent MDS assessment contained a BIMS score of 15 out of 15 which indicated R65 did not have impaired cognition. The MDS also indicated R65 required limited to extensive assistance of staff for activities of daily living (ADLs). On 8/14/23 at 10:57 AM, Surveyor observed a bottle of Systane eye drops and an albuterol inhaler on R65's bedside table. On 8/15/23, Surveyor reviewed R65's medical record and noted a physician order for an albuterol inhaler every four hours as needed and an order that R65 could keep the inhaler at bedside. A self-administration of medication assessment indicated R65's inhaler would be kept in the medication cart. R65's medical record also contained a physician order for Systane eye drops one drop in each eye three times daily as needed, dated 9/19/22. R65's medical record did not contain a physician order that indicated the Systane eye drops could be kept at bedside. On 8/15/23 at 9:17 AM, Surveyor interviewed R65 who was sitting in a recliner in R65's room. R65's Systane eye drops and inhaler were at bedside. R65 indicated R65 self-administered the eye drops and inhaler that morning. R65 also indicated the eye drops and inhaler were kept in R65's room. 42248 8. R56 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF) and type 2 diabetes mellitus with diabetic chronic kidney disease. R56's Quarterly MDS, dated [DATE], contained a BIMS score of 15 out of 15 which indicated R56 did not have impaired cognition. cognition. On 8/14/23 at 9:35 AM, Surveyor observed two boxes of Refresh eye drops, nasal spray, an albuterol inhaler, and VapoCOOL severe cherry cough drops on R56's nightstand. Surveyor interviewed R56 who stated R56 used the medications, had understanding of each medication, and knew to how self-administer the medications properly. On 8/15/23, Surveyor reviewed R56's medical record which included the following orders for two of the four unsecured medications observed in R56's room: ~Saline Nasal Mist (sodium chloride) OTC (over the counter) aerosol, spray; 0.65%; amt (amount): 1-2 sprays; nasal Special Instructions: may keep at bedside. ~Albuterol sulfate HFA aerosol inhaler (used to treat asthma); 90 mcg (micrograms)/actuation; amt: 2 puffs; inhalation Special Instructions: Wait one minute between puffs. Rinse mouth after use. Okay to keep at bedside Every 6 Hours PRN (as needed). R56's medical record did not contain orders for Refresh eye drops or VapoCOOL severe cherry cough drops and did not indicate the medications could be kept at bedside. On 8/15/23 at 11:15 AM, Surveyor interviewed Director of Nursing (DON)-B who stated staff obtain a physician order for residents who wish to self-administer medication and provide a safe area to lock/secure medication in the resident's room. If the medication is not kept in the resident's room, the medication is stored in the medication cart and given to the resident to self-administer. DON-B stated all medications should contain a legible label and can be sent back to pharmacy to replace worn labels. DON-B indicated pharmacy checks the medication carts for expired medications monthly and nurses check medications stored in resident rooms. DON-B again indicated all medications left in resident rooms should be locked and secured. DON-B toured the above residents' rooms with medications at bedside and verified the identified medications were not appropriately stored and/or labeled. On 8/15/23 at 11:17 AM, Surveyor interviewed Registered Nurse (RN)-C who stated medications must be stored in a locked drawer in the resident's room. RN-C verified pharmacy inspects the medication carts monthly and nurses are responsible for ensuring medications stored in resident rooms are not expired. On 8/15/23 at 4:10 PM, Surveyor interviewed RN-D who indicated nurses should date medications with the opened date to ensure they are not used past the use-by date. On 8/16/23 at 11:28 AM, Surveyor interviewed Infection Preventionist (IP)-E who stated nurses should date medications when they are opened.

Based on staff interview and record review, the facility did not ensure an as needed (PRN) psychotropic medication was not utilized more than 14 days unless an alternate duration with rationale was provided for 1 Resident (R) (R29) of 5 residents reviewed for unnecessary medications. The facility did not discontinue R29's PRN alprazolam (an anti-anxiety medication) order after 14 days or obtain an alternate duration with rationale. Findings include: The facility's Antipsychotic Medication Use policy, with a revised date of 2016, indicated: The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. From 8/14/23 through 8/16/23, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] with diagnoses including late-onset Alzheimer's disease, dementia with mood disturbance, and insomnia. R29's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R29 did not have impaired cognition. R29 required minimal to extensive assistance of staff with activities of daily living (ADLs). R29 had an order for alprazolam 0.25 mg (milligrams) at bedtime as needed, dated 6/9/23, with an Open Ended end date. The provider did not provide a rationale for extending the use of alprazolam or provide a specific duration. R29's alprazolam was administered five times from 8/1/23 through 8/15/23. On 8/16/23 at 12:33 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B received a report from the pharmacist in July 2023 that requested a provider rationale to continue the PRN alprazolam and an end date. DON-B indicated the pharmacist request was missed in July 2023; however, a request was sent to the provider on 8/16/23 requesting a rationale and end date. DON-B verified residents require both a rationale to continue a PRN psychotropic medication beyond fourteen days and a documented duration.

Based on observation, staff interviews, and record review, the facility did not ensure food was stored and served under sanitary conditions. The practices had the potential to affect all 99 residents. Dietary Aide (DA)-J did not wash hands after touching facemask before touching plate cover, trays, and food service cart. Staff did not ensure cooks' refrigerator, sandwich station, and oven handles were clean. Findings include: On 9/13/22 at 8:31 AM, Registered Dietician (RD)-K indicated the facility used the Wisconsin (WI) Food Code as its standard of practice. Hand Washing WI Food Code 2020 documents at 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE- USE ARTICLES, and: (A) After touching bare human body parts other than clean hands and . (I) After engaging in other activities that contaminate the hands On 9/13/22 at 11:55 AM, Surveyor observed DA-J assisting with meal tray service. DA-J adjusted mask and wiped face and without washing hands or changing gloves, DA-J continued receiving trays to place plate dome on before placing meals in the food service cart. Surveyor interrupted DA-J to inquire when hands should be washed. DA-J removed gloves and washed hands at that time. DA-J then returned to continue receiving lunch meal trays. DA-J paused receiving trays, removed a cloth from pocket, wiped face under mask, returned cloth to pocket, adjusted mask, removed one glove, continued loading the meal tray cart, then removed the other glove. No hand hygiene happened after glove removal. DA-J closed food service cart and pushed food to 500 unit. On 9/15/22 at 11:08 AM, Dietary Manager (DM)-L and RD-K confirmed DA-J should have removed gloves and washed hands after touching mask and face during meal service. Equipment Cleanliness WI Food Code 2020 documents at 4-601.11(C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 9/13/22, during initial kitchen tour beginning at 8:31 AM, Surveyor observed and RD-K verified the cooks' refrigerator had crumbs on the interior floor, food residue smears inside and out, and dried finger prints on the exterior of the door concentrated near the handles. Assistant Dietary Manager (ADM)-M indicated the cooks' refrigerator was supposed to be cleaned daily. ADM-M indicated cleaning documentation for the cooks refrigerator did not exist. Surveyor observed and RD-K verified the sandwich station (refrigerated unit with top access and workspace for sandwich assembly) had tomato soup splash at the top access point, cheese shreds and lettuce shreds on the interior bottom, and a visibly soiled door handle which was sticky to Surveyor's touch. RD-K touched tomato splash and indicated it was partly dried. ADM-M identified the tomato soup splash occurred the previous day (9/12/22). Surveyor observed and RD-K verified the conventional oven was soiled on the interior floor, the exterior handle was sticky and knobs for the stovetop were visibly soiled. DM-L indicated facility ovens were cleaned daily. On 9/13/22, facility provided Surveyor with daily cleaning list documentation. Surveyor observed most recent cleaning signed off was dated 9/10/22. Daily cleaning list did not include refrigeration equipment or sandwich station. On 9/14/22 at 2:44 PM, DM-L provided revised daily cleaning list to Surveyor and explained the list now included refrigerators and the sandwich station now. DM-L verified 9/10/22 was the most recent cleaning documentation available.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services to assure accurate and safe administration of medications for 5 Residents (R) (R2, R26, R59, R72 and R248) of 24 sampled residents. R2 had an [MEDICATION(S)] inhaler (a device with a medicated solution breathed in to open up air passages) on a bedside table in R2's room for which R2 indicated would self-administer. R2's medical record did not contain an order to self-administer medication(s) nor an assessment for self-administration of medication. R26 had a small plastic cup containing multiple pills on a bedside table in R26's room. R26 indicated nurses leave the pills for R26 to take on own. R26's medical record did not contain an order to self-administer medication(s) nor an assessment for self-administration of medication. Facility did not assess R59's ability to self-administer medications every quarter per policy. R59's cognition declined since previous assessment 12/2/21. Open container of antacid ([MEDICATION(S)]/Tums) was observed at R59's bedside. R72 had a small plastic cup of multiple pills on meal tray during breakfast and had a small plastic cup of three round white pills during lunch on a beside table in R72's room. R72 indicated nurses leave the pills for R72 to take on own. R72's medical record did not contain an order to self-administer medication(s) nor an assessment for self-administration of medication. R248 had Refresh eye drops at a bed-side table in R248's room. R248's medical record did not contain and order to self-administer medication(s) nor an assessment for self-administration of medication. Findings: Facility policy titled Self-Administration of Drugs, revision dated August 2006, read as follows: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment including (but not limited to) the resident's: a. Ability to read and understand medication labels, b. Comprehension of the purpose and proper dosage and administration time for his or her medications, c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them, and d. Ability to recognize risks and major adverse consequences of his or her medications 12. Nursing staff will review the bedside medication record on each nursing shift, and they will transfer pertinent information to the medication administration record (MAR) kept at the nursing station,appropriately noting that the doses were self-administered. 13. The staff and practitioner will periodically (for example, during quarterly MDS (minimum data set) reevaluate a resident's ability to continue to self-administer medications. 1. R2 was admitted to the facility on [DATE]. R2's cognitive screen dated 9/2/22 scored 12/15 indicating moderate cognitive impairment. On 9/13/22 at 12:00 PM, Surveyor observed R2 seated in R2's room with a portable bedside table placed in front of R2. On the bedside table was an [MEDICATION(S)] inhaler. Surveyor interviewed R2, who indicated they used the inhaler when feeling stuffy. On 9/13/22, Surveyor reviewed R2's medical record which contained a physician order with a start date of 4/4/22 for [MEDICATION(S)] Sulfate aerosol inhaler, 2 puffs inhalation, every 4 hours PRN (as needed). Special instructions: Wait one minute between puffs. Rinse mouth out after use. R2's medical record did not contain a physician order to self-administer medication(s) nor a self-administration of medication assessment. On 9/14/22 at 2:31 PM, Surveyor observed the [MEDICATION(S)] inhaler to be on R2's bedside table in R2's room. On 9/15/22 at 8:12 AM, Surveyor observed the [MEDICATION(S)] inhaler to be on R2's bedside table in R2's room. Surveyor interviewed R2 who indicated R2 used the inhaler once in the morning as it has been stuffy and dry in their room. R2 indicated having utilized the inhaler daily for at least the past week. On 9/15/22 at 9:00 AM. Surveyor reviewed R2's September MAR which had no entries for the month of September to reflect R2 used [MEDICATION(S)]. On 9/15/22 at 9:13 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R2 did not have an order to self-administered medication or a self-administration of medication assessment. On 9/15/22 at 9:34 AM, Surveyor interviewed Registered Nurse (RN)-C who confirmed being aware of R2's [MEDICATION(S)] inhaler in R2's room. RN-C indicated R2 tells us when they take the medication, which is once in a while. RN-C confirmed R2 had not informed RN-C that R2 used the inhaler that morning. 2. R26 was admitted to the facility on [DATE]. R26's cognitive screen dated 6/30/22 scored 10/15 indicating moderate cognitive impairment. On 0/13/22 at 11:09 AM, Surveyor observed R26 seated in their room with a portable bedside table placed in front of them. On the table was a small clear plastic cup containing multiple pills. R26 confirmed they were morning medications which were left by the nurse. R26 stated that it was typical for the nurses to leave the pills for R26 to take independently. On 9/13/22, Surveyor reviewed R26's medical record which contained physician orders for medications including (but not limited to), cholecalfiferol (treatment for vitamin D deficiency), [MEDICATION(S)] (normalizes blood pressures), [MEDICATION(S)] (used to improve heart's ability to pump blood to the body), [MEDICATION(S)] (for depression), [MEDICATION(S)] (treats fluid build-up), nortripyline (treatment for depression), [MEDICATION(S)] (a heart medication). R26's medical record did not contain a physician order to self-administer medication(s) nor a self-administration of medication assessment. On 9/15/22 at 9:13 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R26 did not have an order to self-administer medication or a self-administration of medication assessment. 3. On 9/13/22 at 9:52 AM, Surveyor observed an open container of antacid medication on R59's nightstand next to bed. R59 explained to Surveyor that R59's family brought the medication into the facility. R59 could not say where the lid for the container was but indicated the lid was missing for some time. From 9/13/22 through 9/15/22, Surveyor reviewed R59's medical record which documented R59's order for Tums (antacid) as ok at the bedside. R59's most recent self-administration of medication assessment, dated 12/2/21, indicated R59 was safe to self-administer antacid kept at bedside. R59's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) assessment score of 12 (cognitively intact). Surveyor noted this score was the most recent score prior to self-administration assessment dated [DATE]. R59's most recent MDS, dated [DATE], documented a BIMS score of 9 (moderately impaired). On 9/15/22 at 12:27 PM, Director of Nursing (DON)-B disclosed to Surveyor that the facility required self-administration of medication assessments to be completed at a frequency of every three months. On 9/15/22 at 12:51 PM, NHA-A verified to Surveyor that R59's was not assessed for self-administration of medication since 12/2/21. 4. R72 was admitted to the facility on [DATE]. R72's cognitive screen dated 8/15/22 scored 14/15 indicating cognitively intact. On 9/13/22 at 9:50 AM, Surveyor observed R72 sitting up in bed in R72's room with a breakfast meal tray set on top of a portable bedside table placed in front of R72. On the meal tray was a small clear plastic cup containing multiple pills. R72 confirmed they were morning medications left by the nurse. R72 indicated the nurses left the pills for R72 to take independently On 9/13/22 at 12:51 PM, Surveyor observed R72 sitting up in bed in R72's room and on top of a portable bedside table was a small clear plastic cup containing 3 round white pills. R72 confirmed they were noon medications which were left by the nurse. R72 indicated the nurses left the pills for R72 to take on R72's own. On 9/13/22 at 1:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who verified leaving R72's morning and noon medications at bedside due to R72 wanting to take medications with meals. LPN-F also confirmed R72 does not have an order to self-administer medications. On 9/13/22 at 1:30 PM, Surveyor reviewed R72's medical record which did not contain a physician order to self-administer medication(s) nor a self-administration of medication assessment. On 9/14/22 at 10:43 AM, Surveyor reviewed R72's medical record and noted a new order for self-administered medication and a self-administer medication assessment documented on 9/13/22 at 5:28 PM. These were documented after Surveyor discussed medications left at the bedside with LPN-F on 9/13/22 at 1:15 PM. 5. R248 was admitted on [DATE] for orthopedic aftercare with additional diagnoses of but not limited to unspecified injury of muscle in right arm, [CONDITION(S)] ([CONDITION(S)]), chronic kidney disease, chronic pain, and history of falling. R248 was R248's own decision maker. On 9/14/22 at 8:26 AM, Surveyor observed Registered Nurse (RN)-D enter R248's room to administer medications. R248's bedside table contained Refresh eye drops. R248 self administered the Refresh eye drops. On 9/14/22 at approximately 8:35 AM, Surveyor interviewed RN-D who verified Refresh eye drops were in R248's room and that RN-D did take the eye drops from R248's room. RN-D verified R248 did not have a self-administration of medication assessment for Refresh eye drops, only nebulizers. On 9/15/22 at 11:34 AM, Surveyor interviewed RN-E, who verified R248's medical record did not contain a self-administration of medication assessment for refresh eye drops until 9/14/22. On 9/15/22 at 12:28 PM, Surveyor interviewed DON-B who stated the expectation for a resident to be allowed to self-administer medications was to be assessed prior to the resident being allowed to do so to ensure the resident's safety.

Based on observation, interview and record review, the facility did not ensure one resident (R) (R90) of five residents reviewed for pressure injury prevention received care to prevent pressure injuries. R90 was assessed to be at risk for pressure injury. R90 did not have interventions in place as indicated on R90's care plan to prevent pressure injuries from developing. Findings: R90 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/13/22 at 11:38 AM, Surveyor interviewed R90 who was sitting up in a wheelchair in R90's room. R90 indicated having a sore heel and toes stating, I am going to have a nurse look at it (pointing to right heel). Surveyor observed two blue pressure injury relief boots in the seat of R90's recliner. On 9/13/22, Surveyor reviewed R90's medical record which included a skin risk assessment dated ,d+[DATE] which indicated R90's risk score to be 13-14; moderate risk for development of pressure injury. Subsequent skin risk assessments for R90 conducted on 8/29/22, 9/5/22 and 9/12/22 indicated R90's risk score to be 15-18; at risk for development of pressure injury. R90's skin careplan indicated at risk for impaired skin integrity. Care plan goal indicated, Resident will remain free from pressure injuries with adherence to plan of care. Care plan interventions included (but not limited to), heel boots in bed (initiated 9/9/22) and free float heels when in bed with use of heels off cushion (initiated 8/22/22). Progress note dated 9/9/22 2:03 PM read, Pt (patient) c/o (complaint of) R (right) heel pain. At assessment bilateral heels are in tact, red and blanching. Requesting to pad/protect with a foam bordered dressing change QOD (every other day). Heel boots in bed. The progress note was entered by facility's wound care certified (WCC) nurse, Registered Nurse (RN)-G. R90's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Bilateral heels: pad and protect with a foam bordered dressing change QOD - (Every Other Day,) (initiated 9/9/22). On 9/14/22 at 10:30 AM, Surveyor observed R90 lying in bed partially on back and partially on the left side of R90's body. Neither foot had a pressure relief boot on. Surveyor noted a bandage centered over R90's entire right heel. R90's feet were directly placed on the mattress (not floated). Surveyor observed the blue heel boots placed on R90's recliner. On 9/15/22 at 8:21 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who confirmed R90 could not get in and out of bed independently. On 9/15/22 at 11:43 AM, Surveyor observed R90 lying in bed on R90's left side with the right leg crossed over the left leg near the ankle area; both feet were touching the mattress (not floated). There was a rolled blanket below R90's feet which where exposed. Between the blanket and the foot board of the bed, were two blue heel boots standing upright, not placed on R90. Surveyor requested Registered Nurse (RN)-C to observe R90 who confirmed heels were not floated in bed and the heels up cushion was not present. RN-C indicated the heel boots took the place of the heels up cushion. RN-C stated they did not like the boots. Surveyor and RN-C observed the bandage to be present on R90's right heel, however now slipped off to the side of heel. Surveyor observed a reddish-purple area with circular border (approximately the size of a quarter) on the outer edge of R90's heel which was not covered by the bandage. RN-C removed the current bandage. RN-C pushed on R90's heel and when touching the round red/purple circular area, R90 flinched and said ouch. The Surveyor observed the circular area to not return to original color immediately after RN-C pushed on it like the areas outside the discoloration did. RN-C indicated that RN-C would go get the RN-G to look at the heel. On 9/15/22 at 11:45 AM, RN-G assessed R90's heel. RN-G indicated since admission, R90 complained of right heel pain, an x-ray showed a heel spur. RN-G, while pushing on R90's heel, indicated sometimes when pushing on the middle (of the red/purple circular area) it will blanch and return blood flow after a while. RN-G confirmed the area outside the discolored circular area returned to normal color immediately after release of pushing on the area. On 9/15/22 at 11:53 AM, RN-G, RN-H, and an RN Surveyor observed R90's right heel. Surveyors observed the discolored circular area to return to normal color slower than the area around the circular area (indicating color/blood flow is not returning promptly to the area). On 9/15/22 at 12:17 PM, Surveyor again reviewed R90's care plan, the heels up cushion was removed. A new intervention, 15 minute checks for heel boot use was initiated 9/15/22. On 9/15/22 at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the interventions of heel boots as well as heels up cushion were interventions on R90's care plan to prevent pressure injury. NHA-A provided Surveyor documentation by RN-G and RN-H following their 9/15 assessment of R90's right heel, which indicated R90's right heel ruddy and slowly blanches.

Based on interview and record review, the facility did not ensure adequate pain management was provided to 1 Resident (R) (R16) of 22 sampled residents. On 8/11/21 during wound care, R16 verbalized and expressed physical indications of extreme pain related to R16's wound care treatment. The facility did not consistently pre-medicate R16 prior to wound care to help alleviate anticipated pain. Findings include: Facility provided policy titled Pain Clinical Protocol with revision date of January 2012 stated, To ensure adequate and individualized pain management interventions are identified and implemented to meet the acceptable comfort range . The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or the potential for pain . The physician and interdisciplinary team will establish a medication treatment regimen based on consideration of the following: the resident's medical condition, current medication regimen, nature, severity and cause of the pain, course of illness, and treatment goals . If an acceptable comfort range is not met the interdisciplinary team, along with the physician shall reconsider approaches and make adjustments as indicated . On 8/10/21, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's Minimum Data Set (MDS) assessment dated [DATE] stated R16's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R16 had no cognitive impairment. On 8/11/21 at 7:45 AM, Surveyor was informed by Nursing Home Administrator (NHA)-A that staff would be ready to complete R16's wound care for Surveyor to observe at 8:15 AM. On 8/10/21, Surveyor had informed NHA-A that Surveyor would like to observe R16's wound care on 8/11/21 at a time convenient for R16 and staff; and that Surveyor would be available any time after Surveyor's arrival to facility at 7:30 AM. On 8/11/21 at 8:23 AM, Surveyor observed Registered Nurse (RN)-C provide wound care to R16's [CONDITION(S)] burn area/perineal area with the assistance of Certified Nursing Assistant (CNA)-D. RN-E was also in R16's room. RN-E indicated RN-E was Wound Care Certified (WCC). There was a religious program with soft music playing on R16's television set. After gathering supplies, RN-C asked R16 Are you ready? and R16 indicated, yes R16 was ready for wound care. CNA-D held CNA-D's hands out towards R16's hands and stated to R16, Remember you can squeeze as hard as you want. R16 grasped CNA-D's hands with R16's left hand. RN-C proceeded with wound care procedure. During the provision of wound care R16 called out several times, I want to die! Just let me die! I can't stand the pain! Staff offered to give R16 rest breaks but R16 declined. At one point, R16 was observed to place R16's right hand in R16's mouth and bite down. After the provision of wound care, RN-C offered R16 pain medication. RN-C left R16's room then returned and administered to R16 oral pain medication at 8:44 AM. When asked by RN-C to rate R16's pain on a scale of 0-10, R16 stated, 10. After assisting CNA-D with other personal cares for R16, RN-E left R16's room and came back with a facility Social Worker who spoke with R16 about R16's expressed wish to die while Surveyor observed CNA-D provide other cares for R16. On 8/11/21 at 8:47 AM, Surveyor interviewed RN-C regarding R16's pain. RN-C stated, [R16]'s good until dressing change. RN-C indicated R16's last dose of oral pain medication prior to dressing change was 2:10 AM on 8/11/21. RN-C indicated RN-C usually gave oral pain medication 30 minutes to one hour prior to wound care and that wound care was usually completed after the morning medication pass for the entire unit was completed. RN-C indicated RN-C had been told that 8:15 AM was when Surveyor would observe R16's wound care. On 8/11/21 at 10:28 AM, Surveyor reviewed R16's Care Plan which stated, Alteration in Comfort r/t (related to) [CONDITION(S)], suprapubic catheter placement, wounds, [CONDITION(S)] [CONDITION(S)], weakness . Goal . Resident will verbalize reduction of pain within 30 minutes of nursing/med (medication) interventions. Resident's pain will remain within established goal of ***___*** [goal was left blank in care plan] . Encourage resident to request pain medication before pain exceeds goal . Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse effects emerge . Monitor and record any complaints of pain, location, duration, quality, alleviating factors, aggravating factors . Offer non-pharmacological (not medications) interventions such as: repositioning, ice, quiet environment, dim lighting, massage, aromatherapy, music, spiritual support, deep breathing, etc . See MAR (medication administration record) for current med regimen. Monitor and record effectiveness and report need for alternative pain management approaches to MD (physician) as needed . Therapy modalities for pain control. R1's medical record contained the following physician orders: ~ [MEDICATION(S)] (medication used for moderate to severe pain) patch 72 hour; 50 mcg (micrograms)/hr (hour); amount to administer: 1 patch transdermal (via the skin) once every 3 days for Malignant Neoplasm of Vulva, which was ordered on 5/5/21. ~ Offer pain medication q6hr (every six hours) and before scheduled therapies, which was ordered on 5/7/21. ~ DermaPhor (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) ointment topical (on the skin) Twice a Day and PRN (as needed) for Neoplasm related pain, which was ordered on 5/3/21. ~ Dermoplast (medication used on the skin to stop itching and pain from certain skin conditions) aerosol (spray) 20-0.5% (percent) QID (four times a day) PRN for pain, which was ordered on 5/3/21. ~ [MEDICATION(S)]-Acetaminophen (medication used to treat moderate to severe pain) tablet 5-325mg (milligrams) Amount to administer 1 tablet oral every 6 hours PRN for Neoplasm related pain, which was ordered on 5/3/21. ~ Wound care: Vulva: Soak kerlix (type of rolled gauze dressing) with 2% liquid [MEDICATION(S)] (medication used to decrease discomfort or pain during certain medical procedures). Leave in place 5-10 minutes. Then remove old dressing. Insert saline (normal saline; used to supply water and salt normally found in the body) moist kerlix to the wound cavity and cover with ABD 3x/day (three times a day), which was ordered on 6/18/21. R16's Treatment Administration Record (TAR) for August 2021 indicated R16's wound care as ordered was completed three times a day as scheduled, one time per shift. Shift 1 (day shift) contained entries that indicated on 8/7/21 wound care was not completed with accompanying documentation which stated, unable to get to this shift. All other scheduled wound care treatments from 8/1/21 through Shift 1 on 8/11/21 were documented as completed as scheduled either by unit nurse or wound care nurse. R16's MAR for August 2021 indicated R16 received three doses of the oral pain medication [MEDICATION(S)]-Acetaminophen on the dates of 8/1/21, 8/2/21, 8/3/21, 8/5/21, 8/6/21 and 8/7/21. R16 received two doses of the oral pain medication [MEDICATION(S)]-Acetaminophen on the dates of 8/4/21 at 3:02 AM and 4:43 PM; 8/8/21 at 10:34 AM and 8:42 PM; 8/9/21 at 3:51 AM and 8:34 PM; and 8/11/21 at 2:09 AM and 8:44 AM. R16 received one dose of the oral pain medication [MEDICATION(S)]-Acetaminophen on the date of 8/10/21 at 4:40 PM. There were no documented PRN doses of DermaPhor or Dermoplast in August 2021. All scheduled doses of Fentynal and DermaPhor were documented as administered. R16's medical record contained a Pain Assessment Interview dated 8/8/21 in which R16 indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In section of Pain Assessment Interview titled Indicators of Pain or Possible Pain in the last 5 days Check all that apply the following were checked: 1) Non-verbal sound (crying, whining, gasping, moaning, or groaning) ; 2) Vocal complaints of pain (that hurts, ouch stop) ; 3) Facial expressions (grimaces, winces, wrinkle forehead, furrowed brow, clenched teeth or jaw) and 4) Protective body movements or postures (bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement). Further checked was Indicators (as listed above) of pain or possible pain observed Daily. There was no documentation in R16's nursing progress notes indicating R16's physician was updated regarding R16's report of continuous pain during Pain Assessment Interview dated 8/8/21. R16's medical record contained a Referral Form signed and dated by a physician on 7/29/21 which stated in hand-writing, Refer Palliative Care . Please use Walkman/headphones and have [R16] distracted with music. Continue dressing changes TID & (and) PRN . R16's progress notes contained the following entries: ~ 8/11/21 at 2:33 AM: Wound dressing change: Patient pre-medicated before dressing change. Old dressing moderately saturated with yellow/greenish drainage and malodorous. [R16] was then pre-medicated with [MEDICATION(S)] which is minimally effective per patient. Peri area is red macerated tissue. Non-viable tissue within the wound. Area packed with kerlix soaked in NS (normal saline). ABD (type of absorbent dressing pad) covered on top of kerlix. Patient skin tender and tape hurts [R16] so ABD was placed within thigh folds. ~ 8/11/21 at 9:04 AM: Writer called to room r/t resident stating during wound care that [R16] wants to die. RN and CNA also present during visit. [R16] denied suicidal ideation. [R16] stated [R16] is tired of treatment as it causes pain and discomfort, and [R16] feels ready to end treatment and wants to sign onto hospice. [R16] states [R16] has been thinking about this over the last couple of days. Reassurance provided to resident. Resident and writer spoke with [named family member] on the phone as well. [Named family member] and other [family member] will be in this morning to provide support and to speak with [R16] about final decisions for treatment versus hospice and upcoming appointments. Referral will be made to hospice today per [R16]'s request. Brief education provided to [R16] on end of life process. Resident calm and wanting to rest following visit. SS (Social Services) to check in with resident and family later this morning again. On 8/11/21 at 11:18 AM, Surveyor interviewed NHA-A. Surveyor discussed observations of wound care with NHA-A. NHA-A verified the pain goal for R16 was left blank in R16's care plan but did not comment as to why. When questioned, NHA-A stated, I agree we should try whatever we can to try to make someone comfortable.

Based on interview and record review, the facility did not ensure that 1 of 1 sampled residents (R1) received an RN (Registered Nurse) assessment and appropriate medical care when R1 had a significant change in his medical condition. On 6/9/20 CNA (Certified Nursing Assistant)-C reported to LPN (Licensed Practical Nurse)-D that R1 was exhibiting signs of a stroke with left sided weakness, left sided eye droop and left sided facial droop. LPN-D failed to properly evaluate R1 and failed to notify an RN to assess R1. R1 went a full day without a comprehensive assessment until 6/10/20 when assessed by LPN-E and RN-G. R1 was sent to the ED (Emergency Department) then returned later that afternoon on 6/10/20 with a [DIAGNOSES REDACTED]. R1 ultimately passed away at the facility on 6/15/20. As a result of the facility's failure to properly assess R1 on 6/9/20 R1 waited a full 24 hours later before being sent to the ED on 6/10/20 for treatment of [REDACTED]. This created a finding of Immediate Jeopardy that began on 6/9/20. NHA (Nursing Home Administrator)-A was notified of the immediate jeopardy on 8/26/20 at 3:00 PM. The jeopardy was verified to be removed later that day on 8/26/20; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: According to the Stroke Association, Quick Stroke Treatment Can Save Lives .If you're having a stroke, it's critical that you get medical attention right away. Immediate treatment may minimize the long-term effects of a stroke and even prevent death. Thanks to recent medical advances, stroke treatments and survival rates have improved greatly over the last decade. http://www.strokeassociation.org/STROKEORG/General/Why-Getting-Quick-Stroke-Treatment-Is-Important_UCM_ 0_Article.jsp. Timely intervention may reduce or minimize the most common types of disability after stroke, which include impaired speech, slowed ability to communicate, weakness or paralysis of limbs on one side of the body, restricted physical abilities, and difficulty gripping or holding things. According to the Wisconsin Nurse Practice Act, Chapter N6, a licensed practical nurse (LPN) can perform the following duties: N6.04(1) In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider: (a) Accept only patient care assignments which the L.P.N. is competent to perform. (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan . The Wisconsin Nurse Practice Act, N6.03(1), when describing the duties of a registered nurse (RN), notes, An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. By law and training, an LPN cannot assess an individual. R1 was admitted to facility on 11/14/18 with the [DIAGNOSES REDACTED]. On 6/9/20 during the AM shift CNA-C notified LPN-D that R1 was exhibiting signs of change of condition including left sided weakness, left sided eye droop and left sided facial droop. R1's medical record indicated a nursing note from LPN-D on 6/9/20 at 10:19 AM recorded as a late entry on 6/12/20 at 6:19 AM, Writer called to room due to resident very lethargic. Resident able to move extremities independently. Resident was afebrile (having no fever). Lung sounds clear. No shortness of breath. Oxygen levels and all other vitals at baseline. Resident chief concern is lethargy. Resident does have a history of this issue. Will continue to monitor. There was no evidence of an RN assessment. A nursing note from LPN-D on 6/9/20 at 1:21 PM recorded as a late entry on 6/12/20 at 6:21 AM indicated, Resident remains lethargic throughout shift with some episodes of more activity at times. Vitals all remain at baseline. Output for shift is somewhat decreased but will be receiving a flush catheter. There was no evidence of an RN assessment, A nursing note from LPN-F on 6/9/20 at 9:01 PM recorded as a late entry on 6/16/20 at 4:02 PM indicated, Resident noted to be sleeping all shift. Would wake for staff and took medications without incidence. Choosing not to eat dinner tonight. No neurological deficits noted. There was no evidence of an RN assessment. Surveyor interviewed CNA-C on 8/26/20 at 10:20 AM. CNA-C indicated she had reported to LPN-D on the AM shift that R1 was exhibiting left sided weakness, left sided eye droop and left sided facial droop. LPN-D and CNA-C went into R1's room. CNA-C indicated LPN-D sat R1 up on edge of bed and took his vitals. CNA-C indicated that's all LPN-D did, she kind of just brushed it off and did not document his current condition. CNA-C also indicated that LPN-D did not communicate R1's current condition to the next shift. CNA-C also indicated that R1 could not swallow or keep liquids in his mouth and did not eat that AM shift. Surveyor interviewed LPN-D on 8/26/20 at 11:53 AM. LPN-D indicated that she remembered CNA-C coming to her on 6/9/20 with concerns for R1 with left sided weakness and facial droop. LPN-D indicated she took R1's vitals and did not notice any facial droop and could move both arms and legs. LPN-D indicated that lethargy was the key symptom. LPN-D indicated she did not notify an RN to assess R1 but communicated to the next shift. LPN-D also indicated that she did not document R1's assessment that day because she had forgotten. When she returned on 6/12/20 her unit manager requested she make a late entry of her assessment. Surveyor interviewed CNA-C on 8/26/20 at 10:20 AM. CNA-C indicated that when she returned to her AM shift the next day, 6/10/20, R1 was exhibiting the same signs of left sided weakness, left sided eye droop and left sided facial droop. CNA-C at this time notified LPN-E to evaluate R1. LPN-E concluded he was exhibiting signs of a stroke with no hand strength and left sided facial droop with drooling. LPN-E then contacted the unit manager RN-G. RN-G assessed R1 and agreed with LPN-E. LPN-E then contacted R1's POA (Power of Attorney) and the Physician. R1 was then sent to the ED (Emergency Department). LPN-E indicated R1 returned that afternoon with a [DIAGNOSES REDACTED]. A nursing note from LPN-E on 6/10/20 at 8:52 AM indicated, With cares this AM (R1) left side flaccid. Responds to painful stimuli by grimacing. Pupils are equal and reactive however slow to react. Vital signs stable at this time. Left side of mouth is drooping. Mouth breathing. Call placed to POA and she stated if provider would like him sent to ED she would like (R1) sent. Call placed to provider. A nursing note from LPN-E on 6/10/20 at 9:10 AM indicates MD (Medical Doctor)-H stated to send R1 to the ED for evaluation and treatment. POA was called and updated on plan to send R1 to the ED. On 8/26/20 at 12:10 PM Surveyor interviewed MD-H. MD-H indicated that she was not at the facility on 6/10/20 as she was in the Hospital at the time due to having surgery. MD-H indicates she does not remember if she received a call for R1 on 6/10/20 and that she would have to review her notes and charting, but would not be returning to the facility until Monday the 31st of August. On 8/26/20 at 12:28 PM Surveyor interviewed DON (Director of Nursing)-B. DON-B indicated that an RN would not necessarily assess a resident if an LPN had already done an assessment with a resident who was at baseline. DON-B also indicated that CNA-C had come to her with concerns for R1 and the stroke he had. DON-B indicated that's when she directed the unit managers to see if there was an assessment done with R1. DON-B also indicated the unit managers then had the LPN's document their assessments as a late entry. Please note that an LPN can collect data but cannot assess a resident. Collected information needs to be given to an RN who can assess and develop a nursing plan of care and interventions. On 8/26/20 at 1:02 PM Surveyor interviewed DON-B. DON-B verified that R1 had passed away at the facility on 6/15/20 at 1:29 AM. DON-B also indicated that she can only assume R1 passed away from a stroke. The facility's failure to provide care consistent with current standards of practice for completing an RN assessment for a resident with a significant change in condition delayed treatment options and created a reasonable expectation that serious harm could occur, and thus created finding of IJ that began on 6/9/20. The immediate jeopardy was verified to be removed on 8/26/20 when the facility began implementing the following: ~educate all RN/LPN's prior to their next shift on RN assessments for changes of condition, including neurological changes, and timely documentation. ~educate all staff prior to their next shift on reporting changes in condition and discussing any situation they feel has not been resolved/addressed with the supervisor, DON, or NHA.

Based on observation, staff interviews and record review, the facility did not maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection related to hand hygiene practices for 3 (R (Resident)15, R1 and R24) of 8 sampled and supplemental sampled residents observed receiving care during 9 observations of hand hygiene. RN (Registered Nurse)-C managed R15's IV (Intravenous) access device, tubing, administered medication and discontinued IV medication with bare hands and did not perform hand hygiene before touching multiple items at nursing station and medication cart. CNA (Certified Nursing Assistant)-F did not cleanse hands after providing cares and direct contact with R1 and before retrieving supplies from the unit refrigerator and kitchenette. RN-B did not wear clean gloves during administration of eye drops to R24 and washed hands less than the required amount of time before and after medication administration for R24. 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. According to the facility's policy Handwashing/Hand Hygiene, revised April 2010: This facility considers hand hygiene the primary means to prevent the spread of infections. When to wash hands: 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 . d. Before and after performing any invasive procedure (e.g., fingerstick blood sampling) . h. Before and after assisting a resident with personal care . i. Before and after handling peripheral vascular catheters and other invasive devices . l. Upon and after coming in contact with a residents intact skin, (e.g., when taking a pulse or blood pressure and lifting a resident) . q. After contact with a resident's mucous membranes and body fluids or excretions . s. After handling soiled equipment or utensils u. After removing gloves . 1. On 8/23/17 at 11:29 a.m., during a routine medication pass observation, the Surveyor observed RN-C administer IV (Intravenous) medication and care via R15's PICC (peripherally inserted central catheter) line. RN-C entered R15's room with prefilled syringes of saline and [MEDICATION NAME] solutions and placed the syringes on the resident's bedside table. After washing hands and not applying gloves, RN-C disconnected R15's IV tubing from the PICC line site, touching the resident's skin. With bare hands, RN-C cleansed the PICC line site with an alcohol wipe, connected and infused the contents of the saline and then [MEDICATION NAME] syringes. After disconnecting the last syringe, RN-C tucked R15's PICC line tubing inside the resident's shirt and collected all discarded items used during the medication administration, touching the table, IV pump, resident and call light. Without performing hand hygiene, RN-C departed the resident's room carrying the discarded items and depositing them in the med cart garbage container. RN-C then removed the pharmacy label from the IV medication bag that had been in the garbage container, discarded it at the nursing station, after touching the gate and desk. Without performing hand hygiene, RN-C proceeded to the medication cart, touched the computer and multiple items that were located on the top of the medication cart. Immediately following the above observation, the Surveyor interviewed RN-C, who confirmed the observation and verified I should have washed my hands before leaving the resident's room, after touching contaminated items and before touching clean surfaces. On 8/28/17 at 1:25 p.m., the Surveyor interviewed DON (Director of Nursing)-A, who confirmed the facility's policy required staff to perform hand hygiene after direct contact with residents and medical equipment. After reviewing the above observation of RN-C and R15, DON-A agreed RN-C should have performed hand hygiene upon leaving the resident's room and prior to touching clean items. 2. On 8/23/17 at 1:48 p.m., the Surveyor observed CNA (Certified Nursing Assistant)-E and CNA-F reposition R1. Without performing hand hygiene, CNA-E and CNA-F touched the resident and R1's wheelchair, armrest, table, catheter tubing, clothing and other items in the resident's room. After repositioning R1, both CNAs departed the room without performing hand hygiene. CNA-E proceeded to the unit's kitchenette and removed a straw from a drawer and a can of soda from the refrigerator. CNA-E carried the items to R1's room, moved R1's table and placed the opened soda can and straw on the table, then performed hand hygiene. Immediately following the above observation, the Surveyor interviewed CNA-E, who verified the observation and confirmed staff are required to perform hand hygiene after every encounter which was defined by CNA-E as after providing peri (perineal) care, toileting (care). On 8/23/17 at 2:00 p.m., the Surveyor interviewed CNA-F, who indicated staff are not required to perform hand hygiene after adjusting or repositioning a resident, stating Would have needed to perform hand hygiene if peri care, etc. (was provided). On 8/28/17 at 1:25 p.m., the Surveyor interviewed DON-A, who confirmed the facility's policy required staff to perform hand hygiene after direct contact with residents and equipment. After reviewing the above observation of CNA-E and CNA-F with R1, DON-A agreed staff should have performed hand hygiene after repositioning R1 and prior to leaving the room. 3. On 8/23/17 at 8:30 a.m., the Surveyor observed RN-B administer eye drops to R24 during a routine medication pass. RN-B touched multiple items on the medication cart, locked the cart and entered R24's room with a bottle of Artificial Tears. After placing the eye drops bottle on the table, RN-B applied clean gloves, then removed the gloves, placing them on the table. RN-B opened the bathroom door, turned on the water faucet and for a duration of 4 seconds soaped and rinsed hands before reaching for toweling to dry hands and turn the water off. RN-B then applied the previously removed gloves, picked up the bottle of Artificial Tears, removed the cap and placed one drop of the liquid in each of R24's eyes. RN-B then replaced the cap, placing the bottle in own pocket, removed and discarded gloves. RN-B then washed hands for a duration of four seconds in the bathroom sink. Immediately after the above observation, the Surveyor interviewed RN-B, who confirmed the observation and verified being unsure how long the facility required staff to wash hands. On 8/28/17 at 1:25 p.m., the Surveyor interviewed DON-A, reviewing the above observation of RN-B and R24. DON-A indicated it was facility policy to wash hands at least 15 seconds and agreed RN-B should have applied clean gloves, not the ones removed prior to administering eye drops to R24.

Based on observation, staff interview and record review, the facility did not ensure 1 (R (Resident) 1) of 20 sampled residents reviewed had an environment as free from accident hazards as possible and was provided adequate supervision and/or devices to prevent injuries. R1 relied upon staff for repositioning while in wheelchair. Staff were observed, on two occasions, repositioning R1 by pulling on the resident's arms alone and did not use an assistive device. This practice had the potential to cause injury to R1. Findings include: The facility's policy Repositioning, revised April 2007, indicated: Purpose The purpose of this procedure is to provide guidelines for the assessment of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed-or chairbound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents . General Guidelines 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief . 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. 4. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. Repositioning the Resident in the chair . 2. Check the care plan, assignment sheet or the communication system to determine resident-specific positioning needs including special equipment; resident level of participation and the number of staff required to complete the procedure . R1's most recent MDS (Minimum Data Set) assessment dated [DATE], documented R1 had multiple diagnoses, including CVA (Cerebral Vascular Accident/Stroke), Diabetes and Dementia. The assessment documented R1 was at risk for pressure injury, had a Stage 3 pressure injury and relied upon staff for extensive assistance with transfers, bed mobility and had limited mobility of extremities. R1's undated CNA care assignment sheet included a symbol of a clock, with q2h (every two hours) typed next to it and instructed staff to Transfer: Hoyer with 2 assist; assist of 3 as needed .Other: Right side flaccid (hanging loosely) . 1. On 8/22/17 at 2:07 p.m., the Surveyor interviewed CNA (Certified Nursing Assistant)-G, who indicated the (above) assignment sheet symbol meant staff were expected to reposition R1 every two hours. CNA-G indicated that although staff offer the resident to lie down every two hours, R1 often refuses, but agrees to being repositioned in the wheelchair. On 8/23/17 at 1:48 p.m., the Surveyor observed CNA-E and CNA-F reposition R1, who was seated in wheelchair without the use of a mechanical lift sling or gait belt in place. CNA-F reached between R1's left side and the wheelchair and pulled a pillow from under R1's hip. Both CNAs then hooked their arms in R1's armpits and in unison pulled R1 toward the back of the chair. The Surveyor observed the resident's upper body move 1 to 2 inches, while the lower body moved very little. CNA-F then pulled the resident to the left with R1's left arm, as CNA-E pushed the pillow between the right side of the wheelchair and R1's hip. After placing R1's right arm in an armrest, both CNAs departed. On 8/23/17 at 2:00 p.m., the Surveyor interviewed CNA-F, who confirmed the above observation and verified gait belts and a Hoyer lift were available to assist with repositioning R1, but were not used. 2. On 8/28/17 at 7:06 a.m., the Surveyor observed CNA-G and RN (Registered Nurse)-D reposition R1. After transferring R1 from bed to wheelchair with a Hoyer (total) mechanical lift, the staff removed the lift sling. CNA-G indicated R1 needed to be re-positioned toward the back of the chair and CNA-G and RN-D hooked their arms under the resident's armpits and hoisted, in unison, toward the back of the chair, moving R1 1 to 2 inches closer to the back of the wheelchair. On 8/28/17 at 1:17 p.m., the Surveyor interviewed COTA (Certified Occupational Therapy Assistant)-H, who confirmed a resident who is unable to assist with repositioning in a wheelchair and requires a total body lift, staff should use a (mechanical lift) sling to reposition (the resident); lift resident with a gait belt or place resident back into bed then return properly to a wheelchair using the lift. COTA-H verified a resident should never be lifted under the arms to reposition, especially if no gait belt is used, as it could cause injury to the resident. On 8/28/17 at 1:25 p.m., the Surveyor interviewed DON-A regarding the two observations of staff repositioning R1. DON-A confirmed staff should use available equipment to assist with repositioning and avoid resident injury.

Based on record review and staff interview, the facility did not ensure 2 (Resident 2 and Resident 20) of 22 sampled residents had the required PASRR (Pre-Admission Screen and Resident Review) Level 1 completed to determine appropriate placement of the resident in the facility or if specialized services were needed. The facility did not complete a PASRR Level 1 Screen for Resident 2 and Resident 20 upon admission. Findings include: 1. On 7/5/16, Surveyor reviewed the medical record of Resident 2. The medical record contained a PASRR Level 1 Screen dated 12/31/15. Page 1 of the PASRR Screen states, NOTE: Under these sections, nursing facilities MUST NOT admit any new resident who is suspected of having a serious mental illness or a developmental disability unless the State mental health authority/State developmental disability authority or designee has evaluated the person and determined if the person needs nursing facility placement and if the person needs specialized services, except as provided in Section B of this form. If a nursing facility admits a resident without completion of the appropriate screen(s), then the facility is in violation of the statutory requirement, which may result in initiation of termination action against the facility. The form instructs the reviewer to determine whether or not the resident is suspected of having a serious mental illness or developmental disability based on the responses to the questions in Section A of the form. Resident 2's Level 1 Screen indicated the resident was not suspected of having a serious mental illness or developmental disability; however, Section A was not completed. Section A addresses: Current Diagnosis, Medications, Symptomatology and Developmental Disabilities. Section A states, If you have answered 'NO' to all the above questions in Section A, the person does not require further PASRR evaluation. Sign this form and place in the person's chart. If you have answered 'YES' to any of the questions, proceed to Section B. On 7/7/16 at 9:30 a.m., Surveyor interviewed SW (Social Worker)-F whose signature was on Resident 2's PASRR Level 1 Screen. SW-F indicated she did not fill out Section A of the PASRR which included an assessment of the resident's medications over a 6 month period and symptomatology that may suggest the presence of a major mental illness. 2. On 7/7/16, Surveyor reviewed the medical record of Resident 20. The medical record contained a PASRR Level 1 Screen that indicated the resident was not suspected of having a serious mental illness or developmental disability. Section A of the the Level 1 Screen was not completed and the form was not signed or dated. On 7/7/16 at 3:25 p.m., Surveyor interviewed SW-F regarding Resident 20's PASRR Level 1 Screen. SW-F verified the PASRR was not signed or dated. SW-F verified Section A of the PASRR was not completed. SW-F was unable to verify whether or not the PASRR Level 1 Screen was conducted prior to the resident's admission to the facility.

Based on observations, record review, staff, family and resident interviews, the facility did not ensure that 1 (resident #9) of 10 sampled residents reviewed for abuse remained free of sexual abuse. Resident #9's current plan of care included the intervention that the resident was not to have male caregivers. On the night shift of 9/15/15, the facility scheduled CNA (Certified Nursing Assistant)-A as the only CNA working the unit on which resident #9 resided. The only other person assigned to work on the unit that night was a male RN (Registered Nurse). On 9/15/15, CNA-A choose not to follow resident #9's plan of care and entered the resident's room to check for incontinence. On 9/16/15, resident #9 alleged CNA-A inserted his fingers into the resident's vagina during the night shift which began on 9/15/15. Based on the allegation of sexual abuse, CNA-A was suspended and subsequently terminated. Physical evidence noted in the SANE (Sexual Assault Nurse Examiner) report, dated 9/16/15, indicated the vaginal injuries were consistent with sexual assault. CNA-A was arrested on 10/2/15 with the potential charge of two felonies related to the sexual assault of resident #9. The result of this deficient practice created an immediate jeopardy situation that began on 9/15/15. The facility was notified of the immediate jeopardy on 9/22/15. The immediate jeopardy was removed on 9/16/15. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) pending re-education of 19 staff who had yet to work. Findings include: The facility's Abuse Prohibition Policies and Procedures, dated 5/10/10 and revised 9/26/12, documented Rennes Health Centers shall provide care and services that prohibit abuse, neglect, involuntary seclusion and misappropriation of property for all residents. Residents shall not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, staff or other agencies serving the individual, family members or legal guardians, friends, or other individuals. The policy defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. CNA-A, a male caregiver, began working at Rennes in August 2014. Prior to September 2015, CNA-A had had one allegation against him since beginning employment. The facility's investigation into that allegation, dated 1/31/15, indicated resident #10 reported she thought it was strange that CNA-A kissed her on the forehead the previous evening. Resident #10 requested to not have male caregivers after this incident occurred with CNA-A. CNA-A was suspended pending the investigation. CNA-A was interviewed and confirmed he kissed resident #10 to provide comfort to the resident. The report indicated staff were educated on professional boundaries. The facility did not self-report this incident. On 9/23/15 at 8:52 a.m., surveyor # interviewed resident #10 regarding the incident with CNA-A. Resident #10 stated she had broken her arm and was at the facility for rehab. Resident #10 stated one night she needed help to the bathroom so she placed the call light on and CNA-A entered. Resident #10 stated CNA-A kneeled in front of her and kissed her on the forehead without saying anything. Resident #10 requested to have a female CNA take her to the bathroom at that time. CNA-A left and a female caregiver came in to assist the resident. Resident #10 stated after that incident she requested to not have male caregivers because she was afraid that CNA-A would come back and try to go a little further and do something sexual with her. Resident #10 stated CNA-A did assist her to the bathroom at a later date, but she did not require as much assistance at that time and nothing happened, therefore she did not report CNA-A being in her room, even though she did not want male caregivers. On 9/23/15 at 7:48 a.m., surveyor # interviewed DON-E regarding the incident of CNA-A kissing resident #10 on the forehead. DON-E confirmed that CNA-A was placed on administrative leave because the facility was unsure of the nature of the kiss. DON-E confirmed the incident was not self reported to the State agency. On 9/15/15, the facility's nursing staffing schedule documented CNA-A as the only CNA assigned to the 300 unit for the night shift and the charge nurse responsible for the 300 unit for the night shift was RN-F, who is also a male. Therefore, the facility did not provide a female caregiver or a female supervisor to oversee resident #9's care. 1. The undated Resident Admission Record indicated resident #9, who lives on the 300 unit, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's MDS (Minimum Data Set) assessment signed as complete on 9/10/15, documented the resident's BIMS (Brief Interview of Mental Status) score as 13 out of 15, meaning she is cognitively intact. The MDS indicated the resident was occasionally incontinent of urine; less than 7 episodes of incontinence during the look-back period and did not demonstrate hallucinations, delusions or behaviors, other than rejection of care 1 to 3 times during the look-back period. Resident #9's electronic plan of care was reviewed and noted the resident had a number of problem areas listed, examples as follows: ~ problem dated 9/4/15- has functional bowel and bladder incontinence related to physical weakness, poor mobility, and [MEDICAL CONDITION]. Interventions included: prompted voiding every 2 to 3 hours, provide incontinence protection (brief, pull-up, pad), assure adequate peri care is given, and provide privacy and adequate time to void in the bathroom. ~ problem dated 8/31/15- ability to perform daily cares has declined related to hospitalization with subsequent admission to the facility related [MEDICAL CONDITIONS], DM (Diabetes Mellitus), HTN, [MEDICAL CONDITION], and muscle spasms. The goal stated resident #9 will gain skills and participation with daily cares with current interventions in place. Interventions included: no male caregivers, which was updated on 9/16/15 to specifically state No male caregivers in room: no peri care, no showers/baths, no dressing/undressing. ~ problem dated 9/1/15- is alert and oriented, is able to make own decisions, and is admitted for short term rehabilitation. On 9/16/15, RN-B signed a statement which stated CNA-C reported that resident #9 had a complaint about a staff member. CNA-C stated she entered resident #9's room to assist the resident with putting socks and pants on. The statement continued on to state resident #9 had reported to CNA-C that the night shift CNA should be fired. Resident #9 stated the male CNA from the night shift put his fingers in her brief and then into her vagina. As a result, RN-B and SW (Social Worker)-D questioned resident #9 and the resident reported that a tall male wearing khaki scrubs came into her room between 11:40 p.m. and 12:40 a.m. (9/15/15-9/16/15), to obtain vitals signs including blood pressure and temperature. Resident #9 reported being half asleep when the CNA checked her brief without stating what he was doing. Resident #9 had reported it felt like the CNA's fingers went into her vagina, that the CNA was not wearing gloves and had pulled her brief down prior to inserting his fingers into the her vagina. On 9/16/15, RN-B and DON (Director of Nursing)-E completed a second interview with resident #9. Resident #9's allegation of sexual abuse remained the same as the initial interview. Resident #9 stated she felt a fingernail down there and that is what woke her up completely and then she asked the CNA what he was doing. RN-B and DON-E completed a physical exam at that time and did not observe trauma, redness, or bruising. On 9/16/15, SW-D signed a statement that documented resident #9 reported to RN-B and SW-D that a male CNA wearing khaki scrubs entered the resident's room to take vital signs and after checking the resident's blood pressure and temperature, the CNA felt the outside of resident #9's brief and then pulled the brief down and felt between my legs with his fingers going inside my vagina. Resident #9 stated to the CNA What are you doing? You would know if I wet the bed, my sheets would be saturated. Resident #9 then told the CNA to leave the room and not to come back. The resident placed the call light on for assistance and the male CNA came back into the room to assist and resident #9 told the CNA again to get out and never come back. Resident #9 stated the CNA was not wearing gloves at the time of the encounter and the resident expressed having difficulty getting back to sleep that night following the incident. The facility's investigation dated 9/16/15, documented CNA-A was the tall, male CNA wearing khaki scrubs that resident #9 alleged sexually abused her. CNA-A was immediately placed on suspension pending the investigation. The investigation included the following immediate interventions: resident #9 was assessed on 9/16/15, DePere Police Department contacted, family involvement, SANE assessment completed in the ED (Emergency Department), and the care plan intervention modified to 2 caregivers to provide support. The outcome of the investigative findings documented the facility terminated the identified employee (CNA-A) for not following facility policy and resident #9's plan of care. RN-G completed the SANE documentation, dated 9/16/15 at 10:22 p.m., that stated resident #9 reported on the evening of 9/15/15, CNA-A entered the resident's room at approximately 10:00 p.m. to obtain the resident's vital signs after which the CNA pulled back the bed linens, pulled down the brief, felt around the mons pubis, and then stuck 1 or 2 fingers into the resident's vagina. Resident #9 reported the CNA was not wearing gloves when the fingers were inserted into the resident's vagina. A physical exam was completed and an area of deep redness was observed at 7 o'clock on the hymenal wall. The area measured 1 cm (centimeter) x 1.5 cm and the resident reported the area was painful with touch of a sterile Q-tip. Several wet to dry swabs were completed to this area, the surrounding area, and the mons pubis area. Resident #9 was concerned with sexually transmitted infections and it was determined to treat the resident as [MEDICATION NAME] for preventing [MEDICAL CONDITION]. Resident #9 was prescribed oral [MEDICATION NAME], oral [MEDICATION NAME], and an IM (Intramuscular) injection of [MEDICATION NAME]. RN-G's impression of the assessment documented Sexual assault consistent with history provided. Resident #9 presented to the ED with no eye droop, no mouth droop, talking coherently, and able to converse well, telling stories about the resident's past, present, as well as the resident's children. On 9/22/15 at 9:10 p.m., surveyor # interviewed the SANE, RN-G who reported she has been a SANE for 6 years. RN-G stated vaginal sexual assault trauma occurs in the area of the vagina between 5 o'clock and 7 o'clock, because the force of the fingers of the assaulter go downward. Resident #9 had an area of deep redness at 7 o'clock. The area appeared to be an abrasion from a finger nail. RN-G stated if a person would have been wearing a glove, the glove would have padded the fingernail and protected the skin from injury. RN-G stated there is no way resident #9 could have caused the injury to herself due to the physical anatomy of the resident's body and hand and how it would need to be positioned to insert one or two fingers into the vagina. RN-G stated due to the location of the injury, the trauma is consistent with sexual assault. RN-G stated resident #9 was alert and oriented and very coherent during the assessment. RN-G stated when a perpetrator works in the healthcare field, such as long term care, the person may change jobs as frequently as every year. (Review of CNA-A's employee file noted CNA-A became a CNA in 2012 and has worked at a different nursing home every year, working in a total of three nursing homes thus far.) On 9/21/15 at 3:35 p.m., surveyor # interviewed DT (Detective)-H from the DePere Police Department, handling the alleged sexual abuse case involving resident #9 and CNA-A. DT-H reported he specializes in sensitive crimes and has been in this field of work for over [AGE] years. DT-H stated he interviewed CNA-A regarding the incident and CNA-A informed DT-H that resident #9 had accused him of sexual assault. CNA-A stated he did not touch resident #9's vagina and stated Why would a young person want to finger an old lady? DT-H stated CNA-A was not informed by himself or the facility who the allegation was made by or the nature of the allegation, but simply, that there was an allegation made against CNA-A by a resident. DT-H stated, based on the knowledge (and other supporting information as stated above) that CNA-A has regarding the situation, it appears that CNA-A is guilty of the allegation made by resident #9. DT-H stated DNA samples were obtained from CNA-A and the trauma area to resident #9's vagina. DT-H reported the results of the DNA samples would return in approximately 6-12 weeks. DT-H stated CNA-A reported he went into resident #9's room to obtain vital signs and when completed, he grabbed the outside of the resident's brief to check for incontinence. CNA-A then stated he lifted the brief away from the body to look inside for urine. CNA-A explained to DT-H that if the resident had been incontinent an area on the outside of the brief would change color, indicating moisture. CNA-A told DT-H he made a mistake by going into resident #9's room. CNA- A also told DT-H that he prefers to work with the dementia residents. On 9/22/15 at 9:10 a.m., surveyor # interviewed CNA-A who confirmed he normally works 12 a.m. to 8 a.m. as a float CNA, floating between units in the facility and covering for other CNAs when they go on a break. CNA-A stated on 9/15/15, he was scheduled to work 10:00 p.m. to 6:00 a.m. on the 300 unit, which was not his regular unit or shift. CNA-A was asked to write a statement of what tasks he completed that evening, who he cared for, and what cares he provided for each person. CNA-A wrote a statement stating he was placed on the 300 unit and the night shift consists of checking and changing residents (for incontinence) or toileting the residents. CNA-A noted that the nights are busy and CNAs kinda go to their wings and tend to their wings. CNA-A indicated resident #9 turned on the call light, so he answered the light and asked the resident what she wanted and the resident did not respond, so he checked the resident's brief, at which time the resident told the CNA to get a woman. Surveyor # continued to interview CNA-A from 9:25 a.m. to 10:00 a.m. CNA-A stated he did not sexually assault resident #9. CNA-A stated the facility called him and told him he was being suspended due to a sexual assault allegation on 9/16/15, but did not tell him what type of sexual assault allegation had been made or which body part/parts were involved. CNA-A stated he did not know that resident #9's plan of care stated the resident was not to have any male caregivers and that he made a mistake. Surveyor # asked CNA-A what mistake he made, and CNA-A stated he should not have gone into resident #9's room. Surveyor # then asked CNA-A again if he knew prior to going into resident #9's room that the resident's plan of care stated to not have any male caregivers and CNA-A stated he was aware of the plan of care prior to entering the resident's room, but he was distracted and should not have answered the call light. CNA-A stated he pulled down the brief to check for incontinence after asking resident #9 if the resident had to use the bathroom or if the resident was wet (from urine). CNA-A stated resident #9 stared at him blankly and did not answer, so he checked the resident by pulling the brief up (which is not what CNA-A described in the previous sentence), away from the body and looked inside for urine. At 9:45 a.m., surveyor # entered the room and began taking notes, while surveyor # interviewed CNA-A. CNA-A reported he normally works the 200 unit and the scheduler had him on the wrong unit (the 300 unit). CNA-A stated I work the unit where it is safer for a male to work (the 200 unit). The residents on the 200 unit are long term, friendly, and less crazy. CNA-A stated he believes resident #9 wanted to get him in trouble, as after he checked her, she requested to have a woman nurse. CNA-A stated he thought he told a nurse that resident #9 wanted to see a nurse, but does not recall who he told. CNA-A reported there was a previous incident in which he kissed a resident on the forehead and was suspended, but he was allowed back to work after a few days. On 9/22/15 at 1:05 p.m., surveyor # interviewed DON-E regarding what the facility told CNA-A regarding the allegation against him. DON-E stated CNA-A was informed that an abuse allegation was made against him by a resident. DON-E confirmed she did not state the allegation was sexual in nature. DON-E questioned CNA-A, if he knew who would make an allegation against him and he stated he did not know. CNA-A then stated he entered (resident #9's room during the night shift of 9/15/15) and the resident has a plan of care for no male caregivers, but he was on a roll getting vital signs and just went in to do that for the resident. On 9/22/15 at 2:15 p.m., surveyor # interviewed RN-I, who worked the night shift on 9/15/15. RN-I stated CNA-A did not report to her that resident #9 wanted to see a female nurse. On 9/22/15 at 2:20 p.m., surveyor # interviewed RN-J, who worked the night shift on 9/15/15. RN-J stated CNA-A did not report to her that resident #9 wanted to see a female nurse. On 9/22/15, from 2:30 p.m. until 3:00 p.m., surveyor # interviewed resident #9 regarding the incident, with resident #9's daughter present during part of this interview. Resident #9 indicated she was upset by the incident and was observed crying twice during the interview. Resident #9 recalled the events consistent with the statements previously noted. Resident #9 stated she was asleep when the CNA entered her room that evening, confirming that the call light was not on when CNA-A entered the room. Resident #9 stated CNA-A did not say anything when he entered the room and began taking the resident's vital signs. Resident #9 stated it was not unusual for staff to take vital signs and therefore this action was not concerning. Resident #9 stated CNA-A then pulled back the covers, grabbed the outside of her brief, then pulled the brief down and inserted two fingers into her vagina. Resident #9 stated the CNA's fingernail pinched her vagina and the resident yelled What are you doing? Resident #9 stated CNA-A stated he was checking her to see if she was wet. Resident #9 stated she told CNA-A to leave and never come back. Resident #9 stated she cried all night long because she was afraid the CNA would come back into her room. Resident #9 stated since the assault, she was told by staff that CNA-A lost his job and she is fearful that he will come back to harm her, because CNA-A knows where she lives and she feels the CNA now has nothing left to lose. Resident #9 stated there was a heavy rain since the assault occurred and something hit the resident's window and the resident stated she felt so afraid because she thought it was CNA-A coming back to hurt her. Resident #9 stated she feels embarrassed and afraid since the assault occurred, stating Who knows what he (CNA-A) would've done if I was one of those confused residents and didn't know what was going on? He would have kept doing it (fingers in vagina) or done even more. Resident stated, I cried today when my son left because I feel safe when he's around and I don't feel safe here (in facility). Resident #9 stated her lifelong occupation consisted of working as a CNA and as a CNA, resident #9 did not care for males and did not feel comfortable with males caring for her, therefore upon admission, resident #9 requested not to have male caregivers. Resident #9 stated, I never thought I would be in this situation at this time in my life. Resident #9's daughter stated resident #9 has not been progressing in therapy since the IM injection, as it has caused her a lot of physical pain due to an acute muscle injury when the antibiotic was administered into the thigh area. Resident #9 began to cry at this time, stating prior to the assault, she had been walking more and doing better in therapy, but now due to the pain in the injection site from the IM [MEDICATION NAME], she has not been doing as well in therapy. On 9/23/15 at 8:20 a.m., surveyor # interviewed PT (Physical Therapist)-K regarding resident #9. PT-K stated resident #9 has not being doing as well in therapy after the incident, as she had been prior. PT-K stated resident #9 has missed three sessions of therapy since the incident and has been spending more time with family. On 10/2/15 at 1:52 p.m., DT-H reported to surveyor # that CNA-A was arrested on 10/2/15 with the potential charge of two felonies related to the sexual assault of resident #9. According to the criminal complaint, dated 10/5/15, resident #9 stated after the sexual assault occurred, she lay in bed awake and afraid that CNA-A would come back into the room. Resident #9 got out of bed and placed the walker under the door handle to alert the resident if the CNA was coming back into the room. Resident #9 wanted to talk to someone about the incident, but the resident knew CNA-A was assigned to her unit for the night. The criminal complaint also states that CNA-A did admit to wiping the resident's vagina with toilet paper because the resident was incontinent, but that the brief was not changed. DT-H questioned why the brief was not changed if the resident had been incontinent. CNA-A admitted that the resident was not incontinent, but was wiped anyway to keep the resident dry. Resident #9 was not free from sexual abuse by CNA-A. This created a finding of immediate jeopardy, which the facility removed on 9/16/15 when the facility completed the following: ~ Provided immediate education to all staff regarding the facility abuse policies and procedures. All staff were educated prior to working their next shift. ~The facility provided re-education to all nursing staff regarding the facility policies and procedures for following the plan of care and proper perineal care. ~ The facility interviewed other residents that potentially may have been affected regarding any inappropriate treatment, and no concerns were identified. Resident interviews addressed their feeling of safety, if anyone else had experienced any sexual misconduct, any felt uncomfortable with any visitors, staff or other resident. Residents were questioned if they felt uncomfortable would report those events to the facility staff. Residents expressed no concerns. ~ The facility assessed all residents for any signs or symptoms of mistreatment and no concerns were identified. ~The facility completed perineal care audits to ensure proper procedures are followed. ~The facility continues to complete random interviews with staff to verify knowledge of the education provided. The deficient practice continues at a lower scope/severity level pending completion of training for all staff. On 9/23/15, DON-E provided surveyor # a document that indicated 19 staff had not yet been educated related to abuse, the facility policy of perineal care and not following the resident's plan of care. The 19 staff who had not yet been educated, have not worked since the allegation of sexual abuse on 9/16/15.

Based on record review, resident and staff interview, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable well-being for 1 (resident #1) of 8 sampled residents. Resident #1 was administered in error 90 mg (milligrams) of immediate release [MEDICATION NAME] intended for another resident. The administering nurse identified a wrong medication had been given and called the on-call doctor; however,she incorrectly informed the physician that the dosage was 30 mg and, when given orders to "monitor," failed to clarify with the physician how frequently the resident should be monitored. The facility licensed staff, working the next shift, failed to monitor resident #1 from 10:30 p.m. on 10/4/13 to about 4:00 a.m. on 10/5/13. Resident #1 was found to be in respiratory distress at 4:05 a.m. necessitating treatment at the emergency room . As a result of the facility's actions, this posed an Immediate Jeopardy situation that began on 10/4/13. The facility was formally notified on 10/15/13 and a removal plan was received on 10/15/13 that was accepted. The immediate jeopardy was removed on 10/5/13 and the deficient practice corrected on 10/6/13. Findings include: According to www.drugs.com "An overdose of [MEDICATION NAME] can be fatal. Overdose symptoms may include extreme drowsiness, pinpoint pupils, confusion, cold and clammy skin, weak pulse, shallow breathing, [MEDICAL CONDITION], or breathing that stops." The facility's policy and procedure titled, "Acute Condition Changes - Clinical Protocol" revised April of 2009 states: ASSESSMENT AND RECOGNITION 1. As part of the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay.... 2. In addition, the Nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, etc.; j. All active diagnoses; k. All current medications. MONITORING AND FOLLOW-UP 1. The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. 2. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. On 10/11/13 surveyor # reviewed resident #1's medical record. According to the hospital discharge summary, dated 10/7/13, resident #1 was a [AGE] year old with [DIAGNOSES REDACTED]. Resident #1 had originally been admitted to the facility on [DATE]. Medications included [MEDICATION NAME], vitamins and nutritional supplements. The resident was not receiving any pain medication. The hospital discharge summary stated resident #1 "Was brought to this hospital at around 5:00 a.m. on the day of admission (10/5/13). She had apparently been given the wrong person's medications. She received 3 tablets of immediate release [MEDICATION NAME], 30 mg each..... A [MEDICATION NAME] infusion was started. She was admitted to the intensive care unit.... The patient was treated with a [MEDICATION NAME] infusion for around 24 hours. Later on the following morning, she was quite alert, coherent and able to eat. She was transferred to the medical floor and observed for another 24 hours," Resident #1 was discharged back to the facility on [DATE]. The discharge [DIAGNOSES REDACTED]. 2. Decreased level of consciousness secondary to #1. 3. Respiratory depression secondary to #1. On 10/11/13 at 1:45 p.m. surveyor # interviewed resident #1. Resident #1 stated she came to the facility because she had gotten weak at home and it was hard for her caretaker to rise her out of bed. She stated she was in the facility for a short time when a nurse mixed up her pills and she was given someone else's [MEDICATION NAME]. She stated she began feeling sick and was taken to the hospital to wash the medication from her system. She stated she was sick for a week with an upset stomach and didn't want to eat. Today she is feeling good and had a good breakfast and lunch. She stated she is feeling fine now and is working in therapy and getting stronger. The facility report titled "Event Report" with completion date of 10/10/13 documented that on 10/4/13 at 8:00 p.m. RN (Registered Nurse)-A gave resident #1 a medication not for the resident. The medication was 90 mg of immediate release [MEDICATION NAME] by mouth. Documentation stated that the resident, the family, and on call physician Dr (Doctor)-B were notified. Documentation in the report dated 10/4/13 at 8:00 p.m. stated "Call placed to (Dr-B) on call and gave orders to continue to monitor for respiratory depression and increased sedation. If either occur, send to ER (emergency room )." The facility "Event Report" in the "Interventions" section documented "Per T.O. (Telephone Order) from (Dr-B), we are to continue to monitor x (for) 72 hours for increased sedation and respiratory depression. If any of those occur, we are to send the resident to the ER." The facility "Event Report" further documented on 10/5/13 at 4:05 a.m. "F/U (follow up) Writer (RN-C) was called to room where Patient was noted to be cyanotic, diaphoretic, and nonresponsive. Patient was noted to be moaning periodically. VS (vital signs) 97, respirations were 26/min (per minute) and shallow, (blood pressure) 108/42 and O2 (oxygen) was 35% on room air, temp (temperature) would not register. Blood sugar 266. Oxygen was applied via nasal cannula. No change noted. Changed to oxygen via mask. Oxygen was 94% on 3.5 L (liters). Respirations were 30/min and shallow. Call placed to on call (Dr-B). Awaiting call back. VS: Pulse 88, B/P (blood pressure): 81/35, temp 98.1 axillary." The "Event Report" then documented that at 4:14 a.m. Dr-B gave a telephone order to send resident #1 to the emergency room via 911 ambulance. At 4:22 a.m. the ambulance arrived to transport resident #1 to the emergency room . At 5:15 a.m. resident #1's family was informed of the transfer. Review of the nursing notes by surveyor # verified the above entries. Additionally, the nurses notes and medical record were reviewed for documentation of assessments done of resident #1 following the medication error at 8:00 p.m. on 10/4/13. The facility computer vitals entries provided to surveyor # by DON (Director of Nursing)-D, on 10/14/13 at 1:55 p.m., documented vital signs recorded on the morning of 10/4/13 at 10:16 a.m. and then the next entry on 10/4/13 at 9:56 p.m. There were no documented vital signs over the next six hours; the next vitals entered were in the nurses notes as documented above on 10/5/13 at 4:05 a.m. The only other documentation of facility staff caring for/or assessing resident #1 was in the nurses notes at 12:30 a.m., when night nurse RN-C documented that F/U (follow up): Patient is alert at the time of this assessment. NOC (night) CNA (Certified Nursing Assistant) stated patient is talking and answering questions with no confusion or changes in LOC (Level of Consciousness) noted. No complaints of shortness of breath or respiratory distress observed or reported by patient. Patient states she felt fine and would call for staff is she needs anything. Call light within reach." No vital signs were recorded with this entry. Per interview of RN-C by surveyor # on 10/14/13 RN-C verified she did not directly observe resident #1 until approximately 4:05 a.m. on 10/5/13. On 10/11/13 at 9:30 a.m. surveyor # interviewed DON-D. DON-D verified that the 12:30 a.m. check of resident #1 was done by a CNA and not done by the nurse on duty, RN-C. DON-D stated the first time resident #1 was assessed by RN-C, in person, was around 3:45 a.m. on 10/5/13. There had been no RN assessment of this resident for approximately six hours after the medication error. Surveyor # interviewed DON-D on 10/14/13 at 2:18 p.m. regarding assessments done of resident #1 following the medication error. DON-D verified there was only two sets of vitals recorded in the record following the medication error at 8:00 p.m. One set of vitals were recorded on 10/4/13 at 9:56 p.m. and one on 10/5/13 at 4:05 a.m. At 2:45 p.m. DON-D stated she spoke to RN-A and was informed by RN-A that she took two sets of vitals during her shift, one was entered in the computer at 10:00 p.m. The other set of vitals was written on a napkin, not entered in the computer and lost. On 10/15/13 the facility provided documentation from RN-A stating "On 10/4/13 I (RN-A) took (resident #1's) vitals twice. Once, right after the incident occurred and the second time approximately an hour later. Both sets of vitals were stable and within normal range. Resident was not experiencing respiratory depression or increased sedation at either time of assessment." On 10/11/13 at 11:20 a.m. surveyor # interviewed RN-A. RN-A stated she worked on the afternoon shift of 10/4/13. RN-A stated she usually works on a different wing and was not familiar with the 400 wing. RN-A stated that she was on the second medication pass and popped out three tablets of [MEDICATION NAME] for resident #2. She was needed in another room so she flipped the MAR (medication administration record) and took the open pills with her. She returned and looked at the top page of the MAR and saw resident #1's picture on the top and gave the pills to her. She went back out of the room and flipped the MAR and immediately realized that she gave the pills to the wrong resident. RN-A stated she then verified the dosage and medication by looking at the medication card. The top of the card read 30 mg of immediate release [MEDICATION NAME]. She then called the on call physician and informed him that the resident had received 30 mg of immediate release [MEDICATION NAME] intended for another resident. She stated she informed the physician that the resident's condition was normal. She stated that the physician told her the first two hours were most important, to monitor for increased sedation and decreased respirations. RN-A stated she also called DON-D and was given the same instructions. RN-A stated she did vital signs right away on resident #1 and had the two wing CNAs checking on resident #1. RN-A stated she told them to keep resident #1 up and then did another set of vitals an hour later. RN-A stated she checked resident #1 before 10:30 p.m. and she was fine, responding as usual. The night shift started at 10:30 p.m. and she explained to the night shift to continue to monitor and continue to have the CNAs check the resident. On 10/14/13 at 12:55 p.m. surveyor # interviewed CNA-E by telephone. CNA-E verified she was working on the 400 unit on the evening of 10/4/13. CNA-E stated that RN-A gave resident #1 the wrong medicine. She stated that RN-A called the doctor and told the CNAs to keep checking on resident #1 and keep their eyes on her every 15 minutes. CNA-E stated she put resident #1 to bed around 9:00 p.m. or 9:30 p.m. At that time resident #1 was alert and talking. The shift ended at 11:00 p.m. CNA-E stated the last time she checked on resident #1 was at 10:15 p.m. CNA-E stated resident #1 was sound asleep with a normal sleep pattern. When the next shift came on CNA-E told them to keep checking on resident #1, probably every 15 minutes to a half-hour. CNA-E stated that resident #1 seemed fine during the shift. She stated that RN-A went in to check on resident #1 about 9:00 p.m. and then at the end of the shift. CNA-E stated that she reported to RN-A that resident #1 was doing well. On 10/14/13 at 1:12 p.m. surveyor # interviewed CNA-F by telephone. CNA-F stated that RN-A reported the medication error right away. CNA-F stated that she took vitals, at least twice. She stated the blood pressure was in normal range and the oxygen was fine. Resident #1 was alert and talking and said that she was fine. CNA-F stated she last took vitals at 10:30 p.m. and that they were normal and that she reported them to RN-A. CNA-F stated she gave report to the night staff and told them they had to watch resident #1 more often. She did not specify how often. On 10/14/13 at 6:35 p.m. surveyor # interviewed RN-G by telephone. RN-G stated he was the night supervisor on 10/4/13. RN-G stated he received report from RN-A about 10:30 p.m. RN-A reported that she had made a medication error, by giving resident #1 30 mg of [MEDICATION NAME] at 8:00 p.m. RN-G stated the order was to monitor for lethargy or respiratory distress every shift RN-G stated RN-A assessed resident #1 prior to shift change, shortly after 10:00 p.m. RN-G stated he was covering 3 wings until 12:30 a.m. RN-G stated that the 400 nurse, RN-C came in at 12:30 p.m. and was given report by RN-G. RN-G verified he did not assess resident #1 from 10:30 p.m. to 12:30 a.m. but that CNA- H saw the resident between 11:30 p.m. and 12:30 a.m., during first rounds. RN-G stated CNA-H reported on the condition of resident #1 next around 4:00 a.m., at second rounds. RN-G stated the rescue squad was summoned. Afterwards the nurses realized that resident #1 had received 90 mg of [MEDICATION NAME] rather than 30 mg after they looked at the medication card. On 10/14/13 at 5:06 p.m. surveyor # interviewed RN-C by telephone. RN-C stated she began work at 12:30 a.m., on 10/5/13, by receiving report from RN-G. RN-G told her resident #1 had received 30 mg of [MEDICATION NAME] at 8:00 p.m. RN-G told her they were to monitor q (every) shift for decreased respiration and increased lethargy. RN-C stated she instructed CNA-H to monitor with frequent checks during rounds every two hours. RN-C stated after the fact she found out CNA-H did not check on resident #1 during the 2:00 a.m. to 2:30 a.m. rounds due to going to another wing to cover a break. RN-C stated RN-G stated resident #1 was checked at 12:30 p.m. and was doing well. RN-C stated that after hearing resident #1 had not been checked at 2:00 a.m. she instructed CNA-H to obtain vitals on resident #1. RN-C stated she followed behind her. RN-C stated CNA-H came right out of the room and stated resident #1 was in distress. RN-C stated she went in immediately to get vitals. She then called the doctor. With the help of the other nurses the emergency squad was called. RN-C stated the emergency squad administered [MEDICATION NAME] in the facility. After resident #1 was sent out RN-C stated she and the other nurses examined the medication card and discovered that resident #1 was given 90 mg of [MEDICATION NAME] and not 30 mg as originally reported. RN-C stated she then called the hospital, DON, physician, family and Nursing Home Administrator to inform them of the correct dosage. Surveyor # attempted to interview CNA-H by telephone but a return call was not received. On 10/15/13 at 8:50 a.m. surveyor # interviewed Dr-B by telephone. Dr. B verified that he was the on call physician on the evening of 10/4/13 when resident #1 was given [MEDICATION NAME] intended for another resident. Dr-B verified he did instruct the nurse to continue to monitor for respiratory depression and increased sedation and if either occurred to end to the ER. He verified he did not specify how often to monitor. Dr-B stated he would have expected someone to be with resident #1 every 15 minutes. Dr-B verified that he was informed the dosage was 30 mg. When Dr-B was informed by surveyor # that the dosage was actually 90 mg he stated he would have ordered her to be sent to the ER for treatment with [MEDICATION NAME]. He stated he was informed later of her change in condition and ordered her to be sent to the ER. The facility removed the immediate jeopardy on 10/5/13 and corrected the deficient practice on 10/6/13 as follows: On 10/11/13 at 8:15 a.m. NHA (Nursing Home Administrator)-I provided surveyor # with the materials and education that began on 10/5/13 education that was provided to the licensed staff as a result of the medication error and subsequent lack of monitoring for the incident of 10/4/13. The education information included the policy and procedure titled "Administering Medications" last revised 12/20/12. The Policy in part stated "The licensed nurse shall follow the five 'Rights" for medication pass.: Right Resident, Right Medication, Right Time, Right Dose, Right Route." The inservice was attended by all licensed staff. The educational information dated 10/5/13, used at the inservice, also contained the point "When a medication error is suspected or identified, it is the identifying nurses' responsibility to complete an initial assessment of the resident (which includes, but is not limited to): ... 4. Determine if the omitted dose, excessive or low dose, or wrong medication has had any adverse effects.....6. Complete a thorough assessment of the resident routinely (based on the medication, resident condition and potential effects of the medication error), including but not limited to: vital sign monitoring, head to toe assessment of the resident's condition.....9. All nurses will complete routine monitoring for adverse effects, and if noted, consult with the physician and notify the resident/responsible party. 10. All assessments will be documented within matrix, and will be continued for a minimum of 24 hours (longer based on resident's need/reaction or clinical determination). " The educational information also included information titled "How does MS.IR ([MEDICATION NAME] immediate release work) I was dated as received by the facility on 10/5/13. It stated "Also when notifying MD (medical doctor) ensure that all information is accurate. When a med error occurs take the time to investigate the situation in detail. It is important that the MD know the correct circumstances of the situation. It is also important to monitor the resident frequently for any adverse reaction." Additional material was submitted by the facility to the survey agency that clarified the expectations for monitoring residents during a medication error on 10/19/13 that was accepted. Surveyor # interviewed DON-D on 10/11/13 at 9:30 a.m. DON-D stated she contacted RN-A prior to her shift on 10/5/13 and had a nurse give her education about the medication error before she began her work shift. DON-D stated all licensed staff were also given education prior to working. All licensed staff also had medication pass audits completed. DON-D stated RN-A and RN-C were given extra education and written discipline as a result of the incident and subsequent lack of monitoring for change of condition. On 10/11/13 at 2:15 p.m., surveyor # interviewed DON-D about the education provided for the monitoring of the side effects following the medication error. DON-D stated it was covered in the educational information dated 10/5/13, as noted above. The corporate consultant clarified on 10/19/13 that the education provided on 10/5 and 10/6/13 also included obtaining specific directions from the physician when orders were given "to monitor" and on expectations for what monitoring/assessment included, which would include taking and documenting vital signs.