Every finding on record at River's Bend Health Services

Based on interview, record review, and policy review, the facility did not report allegations of abuse in a timely manner for 5 residents (R) (R2, R3, R4, R5, and R6) of 10 sampled residents. On 1/27/26, staff witnessed (Certified Nursing Assistant)5 display rude, loud, and rough behavior toward R6. Interviews determined R2, R3, R4, and R5 experienced similar behavior by CNA5 that day. The allegations of abuse were not reported in a timely manner.Findings include: Review of the facility's All Staff Abuse, Neglect policy, dated 7/15/22, revealed: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 1. Review of the admission Record located under the Profile tab in the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses including muscle weakness, depression, and anxiety. Review of R2's Quarterly Minimum Data Set (MDS) assessment located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 5/4/26 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The assessment indicated R2 required partial/moderate assistance of staff for toileting, personal hygiene, and transfers. 2. Review of the admission Record located under the Profile tab in the EMR revealed R3 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, weakness, and difficulty walking. Review of R3's 5-day MDS assessment located under the MDS tab in the EMR with an ARD of 5/7/26 revealed a BIMS score of 12 out of 15, indicating moderately impaired cognition. The assessment indicated R3 was dependent on staff for toileting and transfers. 3. Review of the admission Record located under the Profile tab in the EMR revealed R4 was admitted to the facility on [DATE] with diagnoses including weakness. Review of R4's Quarterly MDS assessment located under the MDS tab in the EMR with an ARD of 4/14/26 revealed a BIMS score of 15 out of 15, indicating intact cognition. The assessment indicated R4 was dependent on staff for toileting and hygiene. 4. Review of the admission Record located under the Profile tab in the EMR revealed R5 was readmitted to the facility on [DATE] with diagnoses including muscle weakness and difficulty walking. Review of R5's admission MDS assessment located under the MDS tab in the EMR with an ARD of 6/17/26 revealed a BIMS score of 15 out of 15, indicating intact cognition. The assessment indicated R5 required substantial/maximal assistance of staff for toileting and personal hygiene. 5. Review of the admission Record located under the Profile tab in the EMR revealed R6 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes mellitus with neuropathy, and chronic kidney disease. Review of R6's admission MDS assessment located under the MDS tab in the EMR with an ARD of 2/1/26 revealed a BIMS score of 12 out of 15, indicating moderately impaired cognition. The assessment indicated R6 required substantial/maximal assistance of staff for toileting, personal hygiene, and transfers. Review of an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 1/28/26, revealed on 1/28/26, the Director of Nursing (DON) was notified by the Unit Manager (UM) that on the 1/27/26 PM shift, the UM and Certified Nursing Assistant (CNA)7 observed CNA5 display rude, loud, and rough behavior toward R6. During interviews it was discovered that R2, R3, R4, and R5 also had negative interactions with CNA5. The report revealed the DON was notifiied at approximately 10:21 PM on 1/27/26, however, the report was not submitted to the State Agency until 1/28/26 at 9:37 PM. During an interview on 7/1/26 at 2:49 PM, the Administrator stated they thought allegations of abuse needed to be reported within 24 hours of discovery. The Administrator indicated they did not know allegations of abuse needed to be reported to the State Agency within 2 hours of discovery.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Certified Nursing Assistant (CNA)-C) of 8 employees reviewed for caregiver background checks.The facility did not complete a thorough background check for CNA-C prior to hire.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulations. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement. 2. Screenings may be conducted by the facility itself, a third-party agency, or academic institution. 3. The facility will maintain documentation of proof that the screening occurred .On 1/28/26 Surveyor requested background check information for 8 staff, including Department of Justice (DOJ) and Governmental Findings reports, reference checks, and license information.Surveyor reviewed background check information for CNA-C and noted CNA-C was hired by the facility on 7/9/25. CNA-C's DOJ and Governmental Findings reports were dated 1/28/26 (the day they were requested by Surveyor).On 1/28/26 at 2:06 PM, Surveyor interviewed Business Office Manager (BOM)-D who indicated BOM-D could not find DOJ and Governmental Findings reports for CNA-C and requested the reports that day. BOM-D thought a thorough background check for CNA-C was completed by a previous human resources staff; however, BOM-D could not locate all of the required information. When Surveyor asked if BOM-D had a receipt that indicated the findings were requested prior to CNA-C's hire date, BOM-D stated BOM-D would check.On 1/28/26 at 2:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not employed by the facility when CNA-C's background check should have been completed in July. NHA-A was aware that BOM-D could not find the DOJ and Governmental Findings reports for CNA-C. NHA-A stated the facility requested new reports that day and was still looking for a receipt for the original request. NHA-A indicated it is the facility's practice to complete all background check and pre-employment screening prior to hire.On 1/28/26 at 4:25 PM, NHA-A indicated the facility did not have a receipt for DOJ and Governmental Findings reports requested for CNA-C prior to hire.

Based on staff interview and record review, the facility did not report an allegation of neglect to the State Agency (SA) for 1 resident (R) (R1) of 7 sampled residents.An allegation of neglect that occurred on 12/23/25 and involved R1 and Certified Nursing Assistant (CNA)-E was reported to Nursing Home Administrator (NHA)-A. NHA-A did not report the allegation of neglect to the SA.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state Survey Agency and other officials in accordance with state law .VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services (APS), and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .B. The Administrator will follow up with government agencies to report the results of the investigation when final within five working days of the incident, as required by state agencies.On 1/28/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including dementia, chronic kidney disease with heart failure, anxiety, and depression. R1's most recent Minimum Data Set (MDS) assessment, dated 12/18/25, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R1 had severely impaired cognition. R1 had an activated Power of Attorney (POA).On 1/28/26, Surveyor requested a copy of the facility's report to the State Agency regarding an allegation that R1 did not receive care from CNA-E on 12/23/25 between 2:00 PM and 9:00 PM. On 1/28/26, Surveyor was unable to interview R1 due to cognitive impairment.On 1/28/26 at 2:20 PM, Surveyor interviewed NHA-A who stated NHA-A did not report the allegation of neglect involving R1 and CNA-E to the SA. NHA-A stated NHA-A thought the allegation did not need to be reported because the facility had proven that the incident was a miscommunication issue.

Based on staff interview and record review, the facility did not thoroughly investigate an allegation of neglect for 1 resident (R) (R1) of 7 sampled residents.An allegation of neglect that occurred on 12/23/25 and involved R1 and Certified Nursing Assistant (CNA)-E was reported to Nursing Home Administrator (NHA)-A. The facility did not thoroughly investigate the allegation of negelct.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state Survey Agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written .V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur On 1/28/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including dementia, chronic kidney disease with heart failure, anxiety, and depression. R1's most recent Minimum Data Set (MDS) assessment, dated 12/18/25, had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 which indicated R1 had severely impaired cogniton. R1 had an activated Power of Attorney (POA).On 1/28/26, Surveyor requested and reviewed a copy of the facility's investigation regarding an allegation that R1 did not receive care from CNA-E on 12/23/25 between 2:00 PM and 9:00 PM. The investigation included an emailed allegation of neglect from Registered Nurse (RN)-F, four summarized interviews with staff, one summarized interview with R1's POA, and an investigative narrative written by NHA-A. The investigation did not contain additional resident interviews to determine if other residents had similar concerns and did not include staff education related to neglect. On 1/28/26, Surveyor was unable to interview R1 due to cognitive impairment.On 1/28/26 at 4:00 PM, Surveyor interviewed NHA-A who indicated NHA-A thought staff education was provided and additional residents were interviewed, but needed to check with Director of Nursing (DON)-B. Proof of additional resident interviews and staff education was not provided as of this writing. NHA-A stated CNA-E was not on the schedule during the investigation and indicated the facility had proven the incident was a miscommunication issue.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R48) of 19 sampled residents had the right to make healthcare decisions in accordance with applicable law.R48 was admitted to the facility without an activated Power of Attorney for Healthcare (POAHC) and was not provided the right to sign consent for admission or an advance directive that indicated R48 did not wish to be resuscitated (DNR). In addition, R48's Power of Attorney (POA) paperwork did not allow R48's designated health care agent to admit R48 to long-term care for longer than a short-term stay.Findings include:Wisconsin Chapter 155.05(2) indicates: Unless otherwise specified in the power of attorney for health care instrument, an individual's power of attorney for health care takes effect upon a finding of incapacity by 2 physicians, as defined in s. 448.01(5), or one physician and one licensed advanced practice clinician, who personally examine the principal and sign a statement specifying that the principal has incapacity. Mere old age, eccentricity, or physical disability, either singly or together, are insufficient to make a finding of incapacity; and (4) The desires of a principal who does not have incapacity supersedes the effect of his or her power of attorney for health care at all times.Wisconsin Chapter 155.20(2)(c)2 indicates: A health care agent may consent to the admission of a principal to the following facilities, under the following conditions: a. To a nursing home, for recuperative care for a period not to exceed 3 months, if the principal is admitted directly from a hospital inpatient unit, unless the hospital admission was for psychiatric care. b. If the principal lives with his or her health care agent, to a nursing home or a community-based residential facility, as a temporary placement not to exceed 30 days, in order to provide the health care agent with a vacation or to release temporarily the health care agent for a family emergency.From [DATE] to [DATE], Surveyor reviewed R48's medical record. R48 was admitted to the facility on [DATE] for rehabilitation, was admitted to Hospice services on [DATE], and had diagnoses including chronic obstructive pulmonary disease (COPD), anxiety, vascular dementia, depression, and osteoarthritis. R48's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 0 of 15 which indicated R48 had severely impaired cognition. R48 had an activated POAHC as of [DATE] who assisted with medical decision making. R48's medical record contained POA paperwork signed on [DATE] that indicated R48 designated Health Care Agent (HCA)-E as the primary health care agent and HCA-F as an alternative health agent in the event R48 was deemed incapacitated. The paperwork indicated R48 did not want the health care agent to admit R48 to a nursing home for a purpose other than recuperative care or respite care.R48's medical record contained an admission agreement signed on [DATE] by HCA-F who indicated HCA-F was R48's POAHC.R48's medical record also contained a Cardiopulmonary (CPR)/Resuscitation Consent form, dated [DATE], that indicated no CPR and no resuscitation in writing per verbal from HCA-E. There were no signatures on the bottom of the form.A progress note, dated [DATE], indicated staff informed Advanced Practice Nurse Prescriber (APNP)-D that R48 was mostly nonverbal, followed approximately 50% of commands, and responded with head shakes to approximately 75% of yes/no questions. APNP-D indicated in a progress note on [DATE] that R48 was more responsive to yes/no questions.A progress note, dated [DATE] and written by Social Worker (SW)-C, indicated a care conference was held on [DATE] with R48, HCA-E, and HCA-F. HCA-E and HCA-F wanted R48 to stay at the facility long-term due to care needs. A copy of activation of POA paperwork was requested to be provided to HCA-E and HCA-F.R48's medical record contained an incapacitation form signed on [DATE]. On [DATE] at 9:46 AM, Surveyor interviewed SW-C who indicated R48 did not have an activated POAHC upon arrival at the facility from the hospital. SW-C indicated R48 could respond to yes/no questions with head shakes and could express R48's wants and needs but did not speak fluidly during conversation. SW-C was not aware of any documentation that indicated R48 wanted HCA-E or HCA-F to sign or give consent for admission or a resuscitation determination. SW-C was not aware that R48's POA paperwork indicated R48 declined to be admitted to the facility for long-term care. SW-C reviewed R48's no resuscitation form and indicated HCA-E should not have provided consent on [DATE]. On [DATE] at 11:26 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility does not have a policy regarding POA paperwork that indicates a resident does not want to remain in the facility long-term or what to do if a resident is unable to sign consents, including consent for admission.

Based on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R3 and R41) of 19 sampled residents received staff assistance as needed to complete activities of daily living (ADLs).R3 did not receive weekly showers as scheduled.R41 did not receive weekly showers as scheduled.Findings include:The facility's Activities of Daily Living (ADLs) policy, dated 7/26/22, indicates: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. The care and services will be provided for the following ADLs: 1. Bathing, dressing, grooming and oral care .3. A resident who is unable to carry out ADLs will receive the necessary treatment to maintain good nutrition, grooming, and personal and oral hygiene .1.From 12/16/25 to 12/18/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE], received Hospice care, and had diagnoses including congestive heart failure (CHF), diabetes, fibromyalgia, chronic pain, weakness, and difficulty walking. R3's Minimum Data Set (MDS) assessment, dated 11/16/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 had intact cognition. The MDS also indicated R3 had impairment on both sides of the upper and lower body, required partial/moderate assistance with toileting, and was fully dependent for upper/lower body dressing and putting on/taking off footwear. R3 made R3's own healthcare decisions. On 12/16/25 at 10:47 AM, Surveyor interviewed R3 who indicated R3 did not receive regularly scheduled showers because the facility was understaffed. R3 indicated R3 should receive a shower at 7:00 PM on Sunday but doesn't because staff are busy putting others to bed. R3 indicated R3 asked staff for a shower on another day of the week, but hasn't received one. R3 stated R3 had not had a shower for 3 weeks and had a fungal rash under both breasts.A care plan, initiated 1/7/25, indicated R3 had an ADL self care deficit related to physical limitations. The care plan contained a goal (initiated 2/4/25) that R3 would be clean, dressed, and well-groomed daily to promote dignity and psychosocial well-being. The care plan contained an intervention for bathing/showering - assist of 1 (initiated 1/7/2025). A care plan, initiated 10/30/25, indicated R3 had a fungal rash under both breasts. R3's Kardex (an abbreviated care plan used by nursing staff), dated 12/17/25, indicated R3 required the assistance of one staff for bathing/showering and should receive a shower/bath on Sunday PM. The Kardex also indicated R3 had a fungal rash under both breasts.On 12/17/25 at 10:45 AM, Surveyor interviewed R3 who indicated R3 was not offered a shower and still had not received a shower. On 12/18/25 at 11:21 AM, Surveyor interviewed Hospice Registered Nurse (HRN)-H who indicated Hospice does not provide showers or bathing assistance to R3 per R3's request. HRN-H showed Surveyor a Hospice order, dated 8/27/25, that indicated R3 requested not to be bathed by Hospice staff and would be bathed by facility staff.On 12/18/25 at 11:30 AM, Surveyor interviewed R3 who indicated R3 had not yet received a shower.On 12/18/25, Surveyor reviewed task completion logs for R3 that indicated 7 of 20 scheduled showers were completed from August 2025 through 12/18/25. Surveyor noted the following documentation:~ August 2025: 1 of 5 scheduled showers were completed: 8/3/25 - no documentation on log or in progress note; 8/10/25 - shower completed; 8/17/25 and 8/31/25 - shower refused (no documentation in progress note); 8/24/25- shower refused.~ September 2025: 1 of 4 scheduled showers were completed: 9/7/25 - no documentation (a progress note indicated R3 refused a shower); 9/14/25 - shower completed; 9/21/25 - shower refused (no documentation in progress note); 9/28/25 - no documentation on log or in progress note.~ October 2025: 1 of 4 scheduled showers were completed: 10/5/25 and 10/12/25 - shower refused (no documentation in progress note); 10/19/25 - no documentation on log or in progress note; 10/26/25 - shower completed.~ November 2025: 3 of 5 scheduled showers were completed: 11/2/25 - shower refused (a progress note indicated R3 refused personal cares, a shower, and a skin assessment); 11/9/25, 11/16/25, and 11/30/25 - shower completed; 11/23/25 - shower refused (no documentation in progress note).~ December 2025: 1 of 2 scheduled showers were completed (at the time of survey): 12/7/25 - shower completed; 12/14/25 - shower refused (no documentation in progress note). 2. From 12/16/25 to 12/18/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including dementia, CHF, chronic kidney disease, type 2 diabetes, weakness, anxiety, and depression. R41's MDS assessment, dated 11/16/25, had a BIMS score of 15 out of 15 which indicated R41 had intact cognition. The MDS also indicated R41 required supervision/touch assistance with showering/bathing, partial/moderate assistance with upper body dressing, substantial/maximal assistance with lower body dressing, and was dependent on staff for putting on/taking off footwear.A care plan, initiated 12/29/23, indicated R41 had an ADL self care deficit related to impaired mobility secondary to extensive surgery to right lower extremity. The care plan contained a goal (initiated 12/29/23) that indicated R41 would improve R41's current level of ADL function through the review date. The care plan contained interventions for bathing/showering - assist of 1 and avoid rushing (initiated 12/29/23). R41's Kardex, dated 12/18/25, indicated R41 required the assistance of one staff for bathing/showering and should be showered/bathed on Monday.On 12/16//25 at 11:07 AM, Surveyor interviewed R41 who indicated R41 did not receive enough showers. R41 indicated R41 is supposed to receive a shower on Monday night but it had been at least two weeks since R41 had a shower. R41 stated R41 would like to be showered twice per week. On 12/17/25 at 10:50 AM, Surveyor observed Certified Nursing Assistant (CNA)-I and R41 talking through an open door in R41's room. Surveyor heard R41 tell CNA-I that R41 did not receive a shower on Monday and needed one. CNA-I told R41 that if no one gave R41 a shower before next Monday (12/22/25), CNA-I would stay late on 12/22/25 and shower R41. CNA-I then left the room.On 12/17/25 at 10:53 AM, Surveyor interviewed R41 who stated staff had not offered R41 a shower on Monday (12/16/25). R41 indicated staff offered to give R41 a shower next Monday if R41 hadn't had one by then. R41 appeared angry and stated, I don't want to wait another whole goddamn week. R41 stated R41 had an appointment on Friday (12/19/25) and wanted to be clean before it.On 12/17/25 at 11:02 AM, Surveyor interviewed CNA-I who verified R41 told CNA-I that R41 hadn't had a shower in two weeks. CNA-I told R41 that if R41 wasn't showered by 12/22/25, CNA-I would stay late and give R41 a shower. CNA-I indicated residents should be showered as scheduled and it should be documented in their medical record. CNA-I stated if a resident refuses a shower/bath, the refusal should be documented in a progress note and the nurse should be notified. CNA-I stated a resident who refuses a shower should not have to wait until the following week for one and staff should re-offer the shower on another shift or day. CNA-I was not aware of a protocol for re-offering a shower when a resident refuses.On 12/18/25, Surveyor reviewed task completion logs for R41 that indicated 6 of 20 scheduled showers were completed for R41 between August 2025 and 12/18/25. Surveyor observed the following documentation: ~ August 2025: 0 of 4 scheduled showers were completed: 8/4/25, 8/11/25, 8/18/25, and 8/25/25 - no documentation on log or in progress notes. Surveyor noted the task documentation for Monday (as scheduled) could not be filled in; however, the task documentation for Wednesday was available for staff to document. Surveyor noted the following:~ 8/6/25, 8/13/25, and 8/27/25 - no documentation; 8/20/25 - not applicable (NA)~ September 2025: 1 of 5 scheduled showers were completed: 9/1/25, 9/8/25, 9/15/25, and 9/22/25 - no documentation on log or in progress notes; 9/29/25 - shower completed.Surveyor noted the task documentation for Monday (as scheduled) could not be filled in except for 9/29/25; however, the task documentation for Wednesday was available for staff to document. Surveyor noted the following:~ 9/3/25, 9/10/25, 9/17/25, and 9/25/25 - NA~ October 2025: 3 of 4 scheduled showers were completed: 10/6/25, 10/13/25, and 10/27/25 - shower completed; 10/20/25 - shower refused (no documentation in progress note).~ November 2025: 2 of 4 scheduled showers were completed: 11/3/25 and 11/17/25 - shower completed; 11/10/25 and 11/24/25 - shower refused (no documentation in progress note).~ December 2025: 0 of 3 scheduled showers were completed (at the time of survey): 12/1/25 and 12/8/25 - shower refused (no documentation in progress note); 12/15/25 - NA (no documentation in progress note).On 12/18/25 at 9:00 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated showers should be completed as scheduled. NHA-A indicated if a resident refuses a shower, staff should re-offer the shower one to two times per shift until the shower is given. NHA-A indicated residents who often refuse showers should be provided shower education which should be documented in a progress notes and on their care plan. NHA-A indicated staff should be able to document showers completed, offered, or refused on days other than the resident's scheduled day(s). NHA-A stated a refused shower should be documented in a progress note in the resident's medical record.On 12/18/25 at 11:00 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated residents should receive at least one shower per week unless they refuse. DON-B indicated if a resident refuses, staff should document the refusal and re-offer the shower the same day and/or the next day. DON-B indicated the nurse should be notified of the refusal and the refusal should be documented in the resident's medical record. DON-B indicated if a resident refuses often, it should be noted on their care plan which should contain other interventions for bathing. DON-B indicated management, including Assistant Director of Nursing (ADON)-G, should be viewing and auditing shower sheets and addressing residents who do not receive weekly showers. On 12/18/25 at 11:45 AM, Surveyor interviewed ADON-G who indicated residents should receive their showers as scheduled, unless they refuse. ADON-G indicated if a resident refuses, the refusal should be documented in their medical record by the CNA and the nurse and the shower should be re-offered. ADON-G indicated if a resident often refuses, it should be noted on their care plan and a risk versus benefits assessment should be completed. ADON-G stated shower schedules are posted on each unit and noted on residents' care plans. ADON-G stated it is not acceptable for shower documentation to be missing or not completed and it is not acceptable for residents to go weeks without showers. ADON-G indicated ADON-G is supposed to audit shower documentation but had not done so in awhile due to other responsibilities. ADON-G indicated ADON-G should have received automatic alerts from the medical record system regarding missing documentation and showers for R3 and R41; however, ADON-G had not followed-up because ADON-G was busy with other responsibilities.

Based on staff interview and record review, the facility did not ensure a pneumococcal vaccine was offered for 1 resident (R) (R5) of 5 sampled residents.R5 was not offered the PCV20 vaccine per the facility's policy.Findings include:The facility's Pneumococcal Vaccine (Series) policy, revised 3/25/25, indicates: Each resident will be assessed for pneumococcal immunization upon admission .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized .6. The type of pneumococcal vaccine (PCV15, PCV20, PCV21, or PPSV23) offered will depend upon the recipient's age, certain risk conditions, and previously received pneumococcal vaccines, in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations. On 12/16/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including infection and inflammatory reaction due to internal right knee prosthesis and type 2 diabetes. R5's Minimum Data Set (MDS) assessment, dated 12/5/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker. R5's medical record indicated R5 received a PCV23 vaccine on 7/2/13 and a PCV13 vaccine on 12/30/16. R5 was older than 65 years. Per CDC guidelines and with shared decision making, R5 should have been offered the PCV20 vaccine. R5's medical record did not indicate R5 was offered a PCV20 vaccine. On 12/17/25 at 11:12 AM, Nursing Home Administrator (NHA)-A provided Surveyor a vaccination consent form signed by R5 on 12/16/25 that indicated R5 wanted to receive a PCV20 vaccine. NHA-A stated R5 was ill in October and staff had not followed-up with R5 to see if R5 wanted the vaccine. NHA-A confirmed the vaccine should have been offered to R5.

Based on staff interview and record review, the facility did not ensure a COVID-19 vaccine was offered for 1 resident (R) (R5) of 5 sampled residents.R5 was not offered a COVID-19 vaccine per the facility's policy.Findings include:The facility's COVID-19 Vaccination policy, dated 9/13/24, indicates: It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine.On 12/16/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including infection and inflammatory reaction due to internal right knee prosthesis and type 2 diabetes. R5's Minimum Data Set (MDS) assessment, dated 12/5/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker. R5's medical record indicated R5's last COVID-19 vaccination was on 10/11/24. R5's medical record did not indicate R5 was offered a COVID-19 vaccine. On 12/17/25 at 11:12 AM, Nursing Home Administrator (NHA)-A provided Surveyor a vaccination consent form signed by R5 on 12/16/25 that indicated R5 wanted to receive a COVID-19 vaccine. NHA-A stated R5 was ill in October and staff had not followed-up with R5 to see if R5 wanted the vaccine. NHA-A confirmed a COVID-19 vaccine should have been offered to R5.

Based on staff and resident interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 1 resident (R) (R1) of 1 sampled resident.R1 reported an allegation of staff-to-resident abuse. The facility did not report the allegation of abuse to the SA.Findings:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Reporting/Response: The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services (APS), and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .On 11/24/25, Surveyor reviewed R1's medical record. R1 had diagnosis including lymphedema, type 2 diabetes, chronic pain, ongoing psychiatric follow-up for diagnosis of depression, anxiety, prolonged grief disorder, borderline personality disorder, and multiple personality disorder. R1 had a recent hospitalization for surgery with an exacerbation of psychiatric symptoms post-operatively. R1's Minimum Data Set (MDS) assessment, dated 9/12/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. On 11/24/25 at 9:26 AM, Surveyor interviewed R1 who indicated Scheduler (SCH)-C and Driver (DRV)-D accompanied R1 to a physician appointment and argued amongst each other during the transport, including yelling at each other and using vulgar profanities. R1 indicated SCH-C and DRV-D also yelled at R1 in a threatening manner not to tell anyone about the argument which made R1 uncomfortable. R1 reported the incident to staff. R1 did not believe the facility investigated the incident because no one followed-up with R1. On 11/24/25, Surveyor reviewed the facility's grievance file which did not contain a grievance related to R1's allegation of abuse. On 11/24/25 at 12:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed former SCH-C and former DRV-D assisted R1 with transportation to medical appointments. DON-B indicated an argument occurred between SCH-C and DRV-D during a transport and was reported to former Nursing Home Administrator (NHA)-E. DON-B indicated NHA-E would have reported the incident to the SA. DON-B did not have any further information regarding the report.On 11/24/25 at 1:45 PM, Surveyor requested information from NHA-A regarding an argument between SCH-C and DRV-D during a medical transport for R1. On 11/24/25 at 2:37 PM, NHA-A approached Surveyor and indicated the allegation of abuse reported by R1 was not reported to the SA but should have been reported in accordance with the facility's policy and state and federal regulations.

Based on staff and resident interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R1) of 1 sampled resident. R1 reported an allegation of staff-to-resident abuse. The facility did not thoroughly investigate the allegation of abuse.Findings include:The facility's Abuse, Neglect, and Exploitation policy, dated 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .V. Investigation of Alleged Abuse, Neglect, and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigations include: Identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation .identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s), focusing the investigation on determining if abuse, neglect, exploitation, or mistreatment has occurred, the extent and cause, and providing complete and thorough documentation of the investigation .On 11/24/25, Surveyor reviewed R1's medical record. R1 had diagnoses including lymphedema, type 2 diabetes, chronic pain, ongoing psychiatric follow-up for diagnosis of depression, anxiety, prolonged grief disorder, borderline personality disorder, and multiple personality disorder. R1 had a recent hospitalization for surgery with an exacerbation of psychiatric symptoms post-operatively. R1's Minimum Data Set (MDS) assessment, dated 9/12/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. On 11/24/25 at 9:26 AM, Surveyor interviewed R1 who indicated Scheduler (SCH)-C and Driver (DRV)-D accompanied R1 to a physician appointment and argued amongst each other during the transport, including yelling at each other and using vulgar profanities. R1 also indicated SCH-C and DRV-D yelled at R1 in a threatening manner not to tell anyone about the argument which made R1 feel uncomfortable. R1 reported the incident to staff but did not think the facility investigated the incident because no one followed-up with R1. On 11/24/25, Surveyor reviewed the facility's grievance file which did not contain a grievance for R1's allegation of abuse. On 11/24/25 at 12:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed former SCH-C and former DRV-D assisted R1 with transportation to medical appointments. DON-B confirmed an argument occurred between SCH-C and DRV-D during a transport. DON-B indicated the incident was reported to former Nursing Home Administrator (NHA)-E who would have investigated the incident. DON-B did not have any further information regarding the investigation.On 11/24/25 at 1:45 PM, Surveyor requested the facility's investigation for R1's allegation of abuse.On 11/24/25 at 2:37 PM, NHA-A approached Surveyor and indicated the facility did not have an investigation for R1's allegation of abuse. NHA-A indicated an investigation should have been initiated after R1 reported that R1 was yelled at by SCH-C and DRV-D and felt uncomfortable due to vulgar language that was used. NHA-A also indicated SCH-C and DRV-D should have been suspended pending results of the investigation. NHA-A indicated NHA-A interviewed staff that day (11/24/25) after becoming aware of R1's allegation of abuse and discovering arguments between SCH-C and DRV-D occurred on multiple occasions.

Based on observation, staff interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R3) of 3 sampled residents.The facility did not ensure dirt, debris, food, and spills on R3's floor were cleaned in a timely manner.Findings include: The facility's Resident/Patient Room Cleaning policy, dated 2/1/25, indicates: (The facility's contracted company) is committed to providing a safe, clean, and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices. This policy applies to all environmental services staff under the direction of (the contracted company) and supplements facility policies only where (the contracted company) has assumed responsibility for environmental services operations Floors will be dust mopped, then damp mopped, and any carpet vacuumed in a manner consistent with accepted infection control practices . On 7/1/25, Surveyor reviewed R3's medical record. R3 had diagnoses including dementia, end-stage renal disease on hemodialysis, heart failure with pericardial effusion, chronic obstructive pulmonary disorder (COPD), and anxiety. R3's Minimum Data Set (MDS) assessment, dated 6/5/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R3 had intact cognition. R3 had an activated healthcare decision maker. R3's medical record indicated R3 had five falls since 3/28/25 with falls due to weakness during self-transfers. A care plan, dated 6/5/25, indicated R3 required the assistance of one staff for all transfers. On 7/1/25 at 9:40 AM, Surveyor interviewed Housekeeper (HSK)-E who indicated spills and sticky floors can be environmental hazards. HSK-E indicated if there is a spill or sticky floor in a resident's room, the floor should be mopped. HSK-E indicated the Supervisor should be notified of all concerns. HSK-E indicated HSK-E had been employed for a few months and received education during orientation. On 7/1/25 at 9:50 AM, Surveyor interviewed HSK-F who indicated environmental hazards include spills on the floor. HSK-F indicated HSK-F mops the floor if there is anything on it, moves clutter if there is clutter in the pathway of a resident, and reports all concerns to the Supervisor. HSK-F indicated HSK-F received education on environmental hazards and sticky floors in January of 2025 and participates in yearly in-services to complete environmental cleaning tasks. On 7/1/25, at 10:10 AM, Surveyor interviewed R3 who indicated housekeeping staff do not clean R3's room daily and indicated staff should mop every day but have not in the last week. R3 indicated R3's floor was sticky and stated R3 heard Surveyor's shoes stick to the floor. Surveyor noted R3's floor felt sticky and contained multiple brown colored stains, dirt and debris near R3's bed, and dark brown dirt debris in the corner of the room, near the door, and behind R3's recliner. R3 pointed to the floor near the bed and under the bedside table and stated, This food spill has been here for several days. On 7/1/25 at 10:56 AM, Surveyor observed HSK-D mop R3's floor. Surveyor interviewed HSK-D who indicated residents' rooms and bathrooms are mopped at least three times per week or more if there is visible dirt. HSK-D indicated sticky floors can be a hazard and that cannot happen. HSK-D indicated HSK-D receives a check off sheet every day that indicates which rooms need to be mopped or deep cleaned. KSK-D checks off the items when completed. On 7/1/25 at 12:37 PM, Surveyor interviewed R3 and noted R3's floor contained the same brown colored spills near the bed. Surveyor also noted the floor was still sticky and Surveyor's shoes stuck to the floor when Surveyor walked in the room. R3 indicated HSK-D mopped the floor but did not move any items or mop behind the recliner or under the bed. R3 then moved the bedside table to show Surveyor that the floors were still in the same condition. R3 indicated housekeeping staff do not do a thorough job and R3 would appreciate it if they moved items and fully cleaned the floor so it is not dirty, sticky, and unsanitary. On 7/1/25 at 1:30 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-G who indicated residents' floors should never be left unclean, sticky, or with spills. CNA-G indicated CNA-G received training on environmental hazards upon hire and had not observed any unclean floors. On 7/1/25 at 1:35 PM, Surveyor interviewed CNA-H who indicated residents' floors should be clean. CNA-H indicated if a resident's floor is dirty or sticky, nursing or housekeeping staff are made aware. CNA-H indicated if no one is available, CNAs clean the floors to ensure residents are safe from environmental hazards. CNA-H indicated CNA-H received training on environmental hazards upon hire. On 7/1/25 at 1:40 PM, Surveyor interviewed Housekeeping Manager (HSKM)-C in R3's room. HSKM-C observed R3's floor and indicated the floor was not cleaned per the company's policy or training. HSKM-C stated housekeepers are trained and expected to move furniture or items in the room, including bedside tables, as well as dry mop and wet mop the floor, including behind recliners and under beds. HSKM-C indicated R3's floor was sticky and verified the floor contained dirt, debris, and spills. HSKM-C indicated the floor needed to be redone because it was not cleaned to expectations.

Based on staff interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified of a fall for 1 resident (R) (R2) of 4 sampled residents. R2 had a witnessed fall on 12/4/24. R2's POAHC (POAHC-G) was not notified of the fall in a timely manner. Findings include: The facility' Fall Prevention and Management Guidelines policy, dated 7/18/24, indicates: When any resident experiences a fall, the facility will .Notify the physician and family/responsible party. Review the resident's care plan and update with any new interventions put in place to try to prevent additional falls . On 2/17/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, ischemic stroke, pulmonary hypertension, and chronic diastolic heart failure. R2's Minimum Data Set (MDS) assessment, dated 12/4/24, indicated R2 had intact cognition. R2 had a POAHC that was activated on 11/23/24. R2's care plan, dated 11/30/24, indicated R2 was at risk for falls. R2 had a witnessed fall on 12/4/24 when R2 was walking with a Certified Nursing Assistant (CNA) and R2's hips gave out. R2 was lowered to the floor and sustained an abrasion on the upper back. On 2/17/25 at 1:56 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who completed an incident report on the fall. LPN-D indicated LPN-D notified R2's Hospice agency of the fall but confirmed POAHC-G was not notified. On 2/17/25 at 1:52 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated nursing staff should report a fall to a resident's POAHC within several hours of the incident.

Based on staff interview and record review, the facility did not individualize and revise the comprehensive plan of care for 1 resident (R) (R2) of 4 sampled residents. R2's plan of care did not indicate R2's activities of daily living (ADL) needs. In addition, R2's plan of care was not updated after a fall on 12/4/24. Findings include: The facility's Fall Prevention and Management Guidelines policy, dated 7/18/24, indicates: .When any resident experiences a fall, the facility will .review the resident's care plan and update with any new interventions put in place to try to prevent additional falls . The facility's Change in Condition of the Resident policy, dated 12/2016, indicates: When a resident presents with a possible change of condition .update the plan of care as needed . On 2/17/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, ischemic stroke, pulmonary hypertension, and chronic diastolic heart failure. R2's Minimum Data Set (MDS) assessment, dated 12/4/24, indicated R2 had intact cognition. R2's Power of Attorney for Healthcare (POAHC) was activated on 11/23/24. On 2/17/25 at 10:29 AM, Surveyor interviewed R2's POAHC (POAHC-G) who indicated POAHC-G visited R2 every day in the late morning. POAHC-G indicated R2's breakfast tray was covered and untouched when POAHC-G arrived. POAHC-G alleged staff did not provide meal tray set up and dining assistance. R2's care plan, dated 11/30/24, indicated: ADL self-care deficit .related to: Inadequate oral intake related to history of poor oral intake as evidenced by self reported weight loss of 30-40 pounds and varied intake since admission. R2 is at nutrition risk related to Hospice care. Intervention: Eating (specify-independent, assist of 1, setup, supervision). The care plan did not indicate the level of assistance R2 required for dining and was not individualized for R2. R2's medical record indicated R2 had a witnessed fall on 12/4/24 when R2 was walking with a Certified Nursing Assistant (CNA) and R2's hips gave out. R2 was lowered to the floor and sustained an abrasion on the upper back. On 12/16/24, the facility's Interdisciplinary Team (IDT) reviewed R2's fall. The IDT recommended an intervention to have 2 staff assist R2 during ambulation. R2's care plan indicated: At risk for falls due to: (specify) .Interventions/tasks: Ambulation/locomotion: with device (specify-cane, walker, wheelchair, Broda chair) .Transfer: Assist of 1 with gait belt. R2's care plan indicated R2 required the assistance of 1 person with a gait belt for transfers but did not specify the type of assistive device R2 required for ambulation. Surveyor also noted R2's care plan was not updated with the IDT's recommendation to have 2 staff assist R2 with ambulation. On 2/17/25 at 1:52 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated a resident's care plan should specify the resident's level of assistance required for ADLs and fall prevention strategies.

Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with the facility's policy. One of 5 medication carts was unlocked and unattended. and 3 of 5 medication carts and 2 of 3 medication storage rooms contained expired medication and medical supplies. In addition, the facility did not ensure an inhaler was labeled in accordance with the manufacturer's recommendations for 1 Resident (R) (R45) of 6 sampled residents observed during medication administration. This practice had the potential to affect more than 4 of the 69 residents residing in the facility. On 8/26/24, a medication cart on the 100 wing was unlocked and unattended. On 8/26/24, medication carts and medication storage rooms contained expired medications and medical supplies. On 8/27/24, staff administered an undated inhaler to R45. Findings include: The facility's Medication Storage policy, dated 1/2024, indicates: Medications and biologicals are stored properly, following manufacturers' or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication .Procedures: .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access .12. Note the date on the label for insulin vials and pens when first used .14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock The facility's Medication Administration General Guidelines policy, dated 1/2024, indicates: Medication Administration: .8. Check expiration date on package/container. No expired medication will be administered to a resident .b. The nurse shall place a 'date opened' sticker on the mediation if one is not provided by the dispensing pharmacy and enter the date opened. c. Certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency .multi-use eye drops and ointments should be disposed of 28 days after initial use. Medication Cart: On 8/26/24 at 9:30 AM, Surveyor observed a medication cart unattended and unlocked in the 100 wing hallway. On 8/26/24 at 9:31 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-N who stated LPN-N did not normally leave the medication cart unlocked and verified the medication cart should be locked when unattended. On 8/27/24 at 10:44 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed medication carts should be locked when unattended. Expired Medication and Supplies: On 8/27/24 at 11:00 AM, Surveyor observed 3 of 5 medication carts and 2 of 3 medication storage rooms and noted the following: 100 Wing Medication Cart: ~ A bottle of One Daily supplement with an expiration date of 6/2024. ~ An open and undated bottle of Timolol .5% eye drops for R41. ~ An open and undated bottle of Systane .4% eye drops for R41. ~ An open and undated fluticasone inhaler for R45. ~ An open lispro pen injector dated 7/19/24 for R56. ~ An open and undated Trelegy inhaler for R1. ~ An open and undated fluticasone inhaler for R1. ~ An open and undated bottle of Humulin insulin. ~ An open and undated bottle of saline nasal spray. ~ An open and undated bottle of lactulose solution for R7. ~ An open and undated bottle of Chlorhexide .12% for R33. ~ Six insulin syringes with expiration dates of 1/31/24. On 8/27/24 at 11:20 AM, Surveyor interviewed Medication Tech (MT)-P who verified the above findings. 400 Wing Medication Cart: ~ An open and undated albuterol inhaler for R5. ~ An open and undated bottle of lactulose. On 8/27/24 at 12:02 PM, Surveyor interviewed LPN-Q who verified the above findings. 500 Wing Medication Cart: ~ Four finger lancets and one capped needle for an insulin pen on top of the medication cart. ~ Geri-ZDryl Diphenhydrain HCL 25 mg (milligrams) with an expiration date of 6/2024. ~ An open, unlabeled and undated bottle of glucose tablets. ~ A bottle of Nurses exceptional hand sanitizer with an expiration date of 11/2022. ~ An unlabeled and undated Byeyna inhaler. ~ Open bottles Neomycin, Polymyxin, and Dexameth eye drops for R16 dated 6/13/24. ~ An open and undated bottle of Timolol eye drops for R21. ~ An open bottle of Timolol eye drops for R21 dated 6/5/24. ~ An open, unlabeled, and undated bottle of Artificial Tears. ~ An open albuterol inhaler for R14 dated 1/1/24. ~ An open and unlabeled Ventolin HFA inhaler for R39. ~ A bottle of Saw Palmetto with an expiration date of 12/2020. ~ A Binax Now COVID-19 test with an expiration date of 1/23/24. ~ A bottle of iron supplement liquid with an expiration date of 2/2022. ~ An open and undated bottle of Pro Heal liquid protein that expired 60 days after opened per the label. ~ An open and undated DuoNeb for R22. On 8/27/24 at 11:25 AM, Surveyor interviewed LPN-O who verified the above findings. 1st Medication Storage Room: ~ A box of blood collection needles with an expiration date of 4/30/24. On 8/27/24 at 12:02 PM, Surveyor interviewed LPN-Q who verified the above finding. 2nd Medication Storage Room: ~ A Biofreeze single pack with an expiration date of 5/2024. ~ Four bottles of vitamin B6 100 mg with expiration dates of 5/2023 (1), 2/2024 (2), and 6/2024 (1) ~ A bottle of saline nasal spray with an expiration date of 7/2024. ~ A bottle of Nephro vitamin C and B with an expiration date of 1/2024. ~ Twenty five .5 cc (cubic centimeter) One Care insulin safety syringes with expiration dates of 1/31/24. ~ A wide band male external catheter with an expiration date of 2/28/23. ~ An Iprotege non-adherent oil emulsion dressing with an expiration date of 2/2024. ~ Two WIC silver 0.4 x 14 ropes with expiration dates of 4/2023. ~ Eleven Amsino straight catheters with expiration dates of 11/5/21. ~ A povidone iodine swab stick with an expiration date of 10/2023. ~ A self catheter 16 French with an expiration date of 9/1/23. ~ An open bottle of rubbing alcohol with an expiration date of 1/2020. ~ Three sterile field towel/drape kits with expiration dates of 8/2017. ~ Nine Natura stomahesive kits with expiration dates of 7/2020. On 8/27/24 at 12:45 PM, Surveyor interviewed LPN-O who verified the above findings. On 8/27/24 at 2:55 PM, Surveyor interviewed DON-B who verified the medication carts and medication storage rooms contained expired medications and supplies. DON-B stated DON-B expects staff to go through the carts and medication storage rooms every few months to check for expired medications and supplies. Medication Without an Open Date: From 8/26/24 to 8/28/24, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] with diagnoses including diabetes, atrial fibrillation, and coronary artery disease. R45's Minimum Data Set (MDS) assessment, dated 8/14/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R45 had intact cognition. R45 was responsible for R45's healthcare decisions. On 8/27/24 at 8:24 AM, Surveyor observed MT-P administer 2 puffs of a fluticasone 250 mg/50 mcg (microgram) inhaler that did not contain an open date to R45. The fluticasone manufacturer's instructions indicate: Store Flovent Diskus in the unopened foil pouch and only open when ready for use. Safely throw away Flovent Diskus 50 mcg in the trash 6 weeks after you open the foil pouch or when the counter reads 0, whichever comes first. Safely throw away Flovent Diskus 100 mcg and Flovent Diskus 250 mcg in the trash 2 months after you open the foil pouch or when the counter reads 0, whichever comes first. On 8/27/24 at 8:50 AM, Surveyor interviewed MT-P who verified R45's inhaler did not contain an open date. On 8/27/24 at 10:44 AM, Surveyor interviewed DON-B who stated DON-B expects staff to date insulin, eye drops, and inhalers when they open the medications.

Based on resident and staff interview, the facility did not consistently provide or offer a substantial evening snack to residents. The timeframe from the supper meal to the breakfast meal was greater than 14 hours. This had the potential to affect more than 4 of the 69 residents residing in the facility. A substantial snack was not regularly offered to residents which created a gap of more than 14 hours between the supper and breakfast meals. Findings include: The facility did not provide a snack policy. On 8/26/24 at 9:12 AM, Surveyor began an initial kitchen tour. During the tour, Dietary Manager (DM)-I stated the facility did not have a regular snack cart or snack pass. DM-I stared staff could enter the kitchen and make a sandwich or retrieve what was requested for a snack. DM-I stated the kitchen used to put more snacks in the nourishment room and on the drink carts, but there was an issue with the snacks disappearing. DM-I also stated some residents took snacks and didn't eat them which resulted in snacks piling up in residents' rooms. DM-I stated the approximate meal time for breakfast was 7:45 AM, the approximate meal time for lunch was 11:45 AM, and the approximate meal time for supper was 4:45 PM. DM-I stated the majority of residents chose to eat in their rooms. The facility's survey binder contained a Dining Meal Service Times schedule and location of all dining rooms. The sheet indicated meal service times were as follows: ~ 100 wing - breakfast 8:05 AM, lunch 12:05 PM, and dinner 4:30 PM ~ 200/300 wing - breakfast 7:55 AM, lunch 11:55 AM, and dinner 4:40 PM ~ 400 wing - breakfast 7:45 AM, lunch 11:45 AM, and dinner 4:40 PM ~ 500 wing - breakfast 7:45 AM, lunch 11:45 AM, and dinner 4:30 PM ~ 600 wing - not listed ~ Main dining room - breakfast 8:15 AM, lunch 12:15 PM, and dinner 4:50 PM From 8/26/24 to 8/28/24, Surveyor reviewed R43's medical record. R43 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. R43's Minimum Data Set (MDS) assessment, dated 7/24/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R43 had intact cognition. From 8/26/24 to 8/28/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. R50's MDS assessment, dated 8/15/24, had a BIMS score of 15 out of 15 which indicated R50 had intact cognition. From 8/26/24 to 8/28/24, Surveyor reviewed R58's medical record. R58 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease. R58's MDS assessment, dated 6/2/24, had a BIMS score of 14 out of 15 which indicated R58 had intact cognition. During a Resident Council interview on 8/26/24 at 1:31 PM, the following residents expressed concern regarding snacks: ~ R43 stated the facility did not have an evening snack cart or snack pass. R43 stated R43 had diabetes, received 10 units of insulin in the evening, and sometimes R43's blood sugar was low in the evening. R43 stated the Certified Nursing Assistants (CNAs) needed to run to the kitchen and make R43 a sandwich but staff were already busy running around. R43 stated there were refrigerators on the units where sandwiches and snacks could be kept for CNAs to grab. ~ R50 confirmed the facility did not have a snack pass. R50 stated the facility used to have sandwiches and boxes of cookies but R50 had not seen those for awhile. R50 stated if R50's blood sugar gets low, R50 wants a cookie or juice. R50 stated R50 goes to the vending machine to get snacks. R50 said R50 can ask for a snack, but staff have to go to the kitchen and find something for R50 to eat. R50 stated there is a refrigerator where snacks can be kept and where the facility used to keep sandwiches and snacks. ~ R58 stated R58 purchases snacks and keeps snacks in R58's room but it would be nice if snacks were offered. On 8/26/24 at 3:20 PM, Surveyor interviewed Anonymous Staff (AS)-L who stated the facility did not have a snack cart. AS-L stated AS-L has to go to the kitchen and get residents whatever AS-L can find. AS-L stated AS-L brings in snacks to keep in AS-L's bag and also knows of another staff that brings in snacks so they have something handy to provide residents. AS-L stated there used to be a snack pass but some residents hoarded the snacks. AS-L stated staff were told to offer a snack and if the resident did not want to eat the snack at that moment, staff were told to tell residents they could ask for a snack later. AS-L stated residents now have to ask if they want a snack. AS-L stated there used to be pre-made sandwiches, but not anymore. AS-L stated staff have to break into the kitchen and make sandwiches or find something for residents to eat. AS-L stated AS-L does not have the time to do that and has had to run through the facility to find a snack for a resident with low blood sugar. On 8/26/24 at 3:35 PM, Surveyor interviewed CNA-M who confirmed the facility did not have a snack pass and the kitchen did not supply snacks. CNA-M stated CNA-M had only seen saltine crackers and chocolate cookies available. CNA-M stated there were supposed to be sandwiches in the nourishment room, but often there were no sandwiches. CNA-M stated CNA-M has had to go to the kitchen to see what CNA-M could find. CNA-M stated it's difficult because CNA-M is busy trying to get residents to bed in the evening. On 8/26/24 at 11:30 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility does not have a policy on snack pass but is aware of the regulation that requires no more than 14 hours between meal times. Surveyor informed NHA-A of the resident and staff concern that snacks were not offered unless residents asked. Surveyor also informed NHA-A that because a substantial snack was not offered in the evening, there was a more than 14 hour gap between supper and breakfast. NHA-A acknowledged the gap and verified the facility should be completing a snack pass for residents.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 69 residents residing in the facility. The 300 unit refrigerator was not in a clean condition and contained items that were not labeled or dated and were expired. In addition, the refrigerator temperature log was not completed and items in the nourishment room were not labeled or dated. Milk and juice were not held at a cold temperature during lunch service. Findings include: On [DATE] at 9:00 AM, Surveyor began an initial tour of the kitchen with Dietary Manager (DM)-I who stated the facility followed the Wisconsin (WI) Food Code as its standard of practice. The WI Food Code documents at ,d+[DATE].17 Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food), Date Marking: (A) Refrigerated, ready-to-eat, potential hazardous food (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 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The Wisconsin Food Code documents at ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (C) Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The facility's undated Food: Safe Handling for Foods from Visitors policy indicates: Action Steps: .4. When food items are intended for later consumption, the responsible staff member will: Insure that foods are in a sealed container to prevent cross contamination; Label foods with resident name and the current date. 5. Refrigerator/freezers for storage of foods brought in by visitor will be properly maintained and: Have temperature monitored daily for refrigeration less than 41 degrees and freezer less than 10 degrees; Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for greater than 7 days. (Storage of frozen foods and shelf stable items may be retained for 30 days.); Cleaned weekly. On [DATE] at 9:52 AM, Surveyor observed the 300 wing refrigerator and noted the following: ~ The temperature log sheet for the refrigerator/freezer was on top of the refrigerator and was blank. ~ The top seal of the refrigerator door contained black grime. ~ An open and undated 18 ounce box of [NAME] bran flakes. ~ An open and undated package of commercially packaged bagels. ~ An open and undated 46 ounce container of Sysco Thick-it apple juice. ~ An open and undated 46 ounce container of Sysco lemon water. ~ An unlabeled and undated Styrofoam cup of chocolate pudding. ~ An undated bowl of watermelon covered with plastic wrap and labeled with a room number. ~ A bowl of watermelon labeled with a resident's first name and room number with an expiration date of [DATE]. ~ An unlabeled and undated sour cream container with yogurt and strawberries wrapped in a bread bag and secured with a clothes pin. ~ An unlabeled and undated plastic bag of summer sausage. ~ String cheese with expiration date of [DATE]. ~ A plastic wash basin that contained stale bread, an open water bottle, sliced summer sausage that was gray in color, an unopened wet box of [NAME] chicken crackers, and venison sausage that was gray in color There were no dates on the items. ~ Six 4 ounce containers of multi-flavor Activia yogurt labeled with a room number and expiration dates of [DATE]. ~ Ten 4 ounce containers of multi-flavor Activia yogurt labeled with a room number and expiration dates of [DATE]. The following items were observed in the 300 wing freezer: ~ An unlabeled and undated package of what appeared to be frozen meatballs. ~ An unlabeled and undated plastic covered bowl of what appeared to be frozen meat and vegetables. ~ An undated package of [NAME] Buddies chicken nuggets labeled 302 cm. The following items were observed in the nourishment room cupboard: ~ Six undated plastic covered bowls of cereal not in the original packaging. On [DATE] at 10:02 AM, Surveyor interviewed Director of Nursing (DON)-B who verified the unit refrigerator should be cleaned. DON-B also confirmed all items in the refrigerator should be labeled and dated and expired food should be thrown out. DON-B stated the facility did not have a process to clean the refrigerator or dispose of resident food. DON-B verified the refrigerator/freezer temperature log was blank and indicated a log with refrigerator and freezer temperatures should be attached to the side of the refrigerator and staff should document temperatures daily. 43361 The Wisconsin State Food Code documents at ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding: Time/temperature control for safety food shall be maintained: (2) At 41 degrees Fahrenheit (F) or less. On [DATE] at 11:30 AM, Surveyor observed the drink cart for lunch service in the 600 wing hallway. The drink cart contained half-gallon containers of milk and various juices in plastic pitchers. The milk and juices were in a bin of ice but were not submerged in ice. On [DATE] at 12:29 PM, Surveyor observed staff pass lunch trays on the 600 unit. As staff passed each tray, Surveyor observed staff pour milk and juice from the drink cart per resident preference. On [DATE] at 12:33 PM, Surveyor temped the milk after the last meal tray was delivered on the 600 unit. The temperature of the milk was 46.2 degrees F. The temperatures were verified by Certified Nursing Assistant (CNA)-J who passed meal trays. CNA-J verified the drink cart came to the unit before the meal cart and the 600 unit was the last unit to receive meal trays. On [DATE] at 12:35 PM, Surveyor poured a glass of apple juice and temped the juice which was 49.2 degrees F. On [DATE] at 12:39 PM, Surveyor observed staff pass the last resident tray on the 300 unit. Surveyor noted milk and juice were on a utility cart in a bin of ice, but the ice did not cover the milk. Surveyor temped the milk which was 42.7 degrees F and the apple juice which was 43.3. degrees F. On [DATE] at 11:40 AM, Surveyor informed DM-I of the drink temperatures post-service. DM-I stated cold drinks/food should remain under 41 degrees F.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. This had the potential to affect more than 4 of the 69 residents residing in the facility. R36 was on enhanced barrier precautions (EBP) due to a permacath. On 8/27/24, staff did not wear personal protective equipment (PPE) during high-contact resident care. In addition, there was not a sign posted near R36's room that indicated R36 was on EBP. On 8/27/24, staff transported unbagged soiled linens in a resident hallway. Findings include: The facility's Enhanced Barrier Precautions policy, with a revision date of 8/8/24, indicates: Implementation of Enhanced Barrier Precautions: .b. Personal protective equipment for enhanced barrier precautions is only necessary when performing high-contact care activities .High-contact resident care activities include: a. dressing .c. transferring . The facility's contracted service's Handling, Transporting and Storage of Laundry policy, with a revision date of 10/2023 indicates: Contaminated laundry is bagged at the point of collection (i.e., location where it was used). 1. On 8/27/24 at 9:07 AM, Surveyor observed Certified Nursing Assistant (CNA)-G assist R36 with getting dressed. Surveyor noted CNA-G was not wearing PPE. Surveyor observed a PPE cart outside R36's door, but did not observe a sign that indicated R36 was on precautions. On 8/27/24 at 9:07 AM, Surveyor interviewed CNA-G who confirmed CNA-G was not wearing PPE. When Surveyor asked why there was a PPE cart outside R36's door, CNA-G stated the cart was for mask storage which staff had to wear due to a recent COVID-19 outbreak. On 8/27/24 at 9:13 AM, Surveyor interviewed Infection Preventionist (IP)-H who confirmed R36 was on EBP due to a permacath and stated staff should wear PPE during high-contact resident cares. IP-H also confirmed there should be a sign posted that indicated R36 was on EBP. On 8/27/24 at 1:27 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed signage should be posted and staff should wear PPE when a resident is on EBP. 2. On 8/28/24 at 9:09 AM, Surveyor observed CNA-D transport unbagged soiled linens from a resident's room to the soiled linen room. CNA-D carried the soiled linens with gloved hands. On 8/28/24 at 9:12 AM, Surveyor interviewed CNA-D who confirmed soiled linens should be placed in a bag prior to transporting them through hallways and to the soiled linen room. On 8/28/24 at 12:32 PM, Surveyor interviewed DON-B who confirmed soiled linens should be bagged prior to transportation and stated the facility does not follow the contracted service's policy for transporting linens because it is not the facility's policy. When asked for the facility's policy, DON-B stated the facility did not have a policy.

Based on observation, staff and resident interview, and record review, the facility did not ensure a physician's order was obtained and a self-administration of medication assessment was completed for 1 Resident (R) (R68) of 7 sampled residents. On 8/26/24, Registered Nurse (RN)-K left medication at R68's bedside for R68 to self-administer. R68 did not have a physician's order or self-administration of medication assessment that indicated R68 could safely and accurately self-administer medication. Findings include: The facility's Resident Self-Administration by Resident policy, dated 1/2023, indicates: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's Interdisciplinary Team has determined the practice would be safe, and the medications are appropriate and safe for self-administration. From 8/26/24 to 8/28/24, Surveyor reviewed R68's medical record. R68 was admitted to the facility on [DATE] with diagnoses including non-infective gastroenteritis and colitis. R68's Minimum Data Set (MDS) assessment, dated 8/7/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R68 had intact cognition. R68 was responsible for R68's healthcare decisions. On 8/26/24 at 11:12 AM, Surveyor interviewed R68. During the interview, RN-K entered R68's room and stated RN-K had R68's noon medication. RN-K put the medications on R68's bedside table and instructed R68 to take the medication when R68's lunch tray was delivered. R68 agreed and RN-K exited the room. R68's Medication Administration Record (MAR) indicated R68 was prescribed the following medication: ~ Liquid Protein AWC three times a day for poor intake ~ Pancrelipase (Lip-Prot-Amyl) oral capsule delayed release particles 24000-76000 units (Pancrelipase (Lipase- Protease-Amylase)) give 7 capsules by mouth with meals for pancreatitis and give 2 capsules by mouth as needed for pancreatitis. Take when eating any snacks. ~ Creon dose should equal 168,000 TID (three times daily) (24,000 capsule x 7). May open capsules and sprinkle in small amount of yogurt or applesauce, pudding, etc. R68's care plan did not indicate R68 was able to self-administer medication and R68 did not have a physician's order to do so. On 8/26/24 at 11:36 AM, Surveyor interviewed RN-K regarding the medication that was left at R68's bedside. RN-K stated it was RN-K's first day working with R68. RN-K stated RN-K assumed R68 had an order to self-administer medication because R68 was cognitively intact. RN-K reviewed R68's physician orders and verified R68 did not have an order to self-administer medication. On 8/27/24 at 1:41 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R68 should have a physician's order to self-administer medication. DON-B stated nurses should observe residents take their medication unless a self-administration of medication assessment is completed.

Based on staff interview and record review, the facility did not ensure 2 Residents (R) (R223 and R173) of 4 sampled residents signed and received copies of the Notice of Medicare Non-Coverage (NOMNC) form and/or Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form which are used to inform residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility), and standard claim appeal rights and instructions. The facility did not provide an ABN form (a document that explains financial liability, including the facility's daily rate for services) to R223 when R223's Medicare benefits ended on 2/25/23 and R223 remained in the facility. The facility did not provide a NOMNC form (used to inform Medicare beneficiaries when their covered services are ending and their appeal rights) to R173 at least two calendar days before R173's Medicare services ended. Findings include: The Centers for Medicare and Medicaid Services (CMS) form CMS-10123 indicates a NOMNC form must be delivered at least two calendar days before Medicare-covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48 hour requirement .The provider must ensure the beneficiary or representative signs and dates the NOMNC form to demonstrate the beneficiary or representative received the notice and understands the termination decision can be disputed. CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) form indicates: The ABN provides information to the beneficiary so the beneficiary can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility .The ABN is only issued if the beneficiary intends to continue services and the Skilled Nursing Facility believes the services may not be covered under Medicare. 1. From 8/26/24 to 8/28/24, Surveyor reviewed R223's medical record. R223's Medicare Advantage plan ended services with a last covered day of 2/25/23. The facility issued a NOMNC form to R223 with a signature date of 2/23/23. R223 remained in the facility under private pay status. The facility did not provide R223 or R223's representative with an ABN form or provide evidence that R223 or R223's representative were aware of the facility's private pay cost. R223 passed away on 3/30/23. 2. From 8/26/24 to 8/28/24, Surveyor reviewed R173 medical record. R173's Medicare Part A coverage ended with a last covered day of 3/14/24. The facility issued a NOMNC form to R173 which R173 signed and dated on 3/13/24. R173 remained in the facility after 3/14/24. On 8/27/24 at 9:09 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility did not have a signed ABN form for R223 when R223's Medicare services ended and R223 remained in the facility. NHA-A also confirmed the facility did not have evidence to support R223 or R223's representative were updated on the facility's private pay rate.

Based on staff and resident interview and record review, the facility did not ensure 3 Residents (R) (R223, R20, and R70) of 3 residents reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R223 was transferred to the hospital on 1/26/23. Neither R223 or R223's emergency contact were provided with a written transfer notice for R223's hospital transfer. R20 was transferred to the hospital on 5/17/24. Neither R20 or R20's emergency contact were provided with a written transfer notice for R20's hospital transfer. R70 was transferred to the hospital on 5/23/24. Neither R70 or R70's emergency contact were provided with a written transfer notice for R70's hospital transfer. Findings include: The facility's Transfer and Discharge policy, with a revision date of 7/15/22, indicates: It is the policy of the facility to permit each resident to remain in the facility, and not transfer or discharge the resident form the facility except as .necessary for the health and safety of the resident .Emergency Transfer/Discharge is initiated by the facility for medical reasons, or for the immediate safety or welfare of the resident, the following is the responsibility of the nurse unless otherwise specified: .b. Notify resident and/or resident representative; .j. Provide transfer notice as soon as practicable to resident and representative. 1. From 8/26/24 to 8/28/24, Surveyor reviewed R223's medical record. R223 was admitted to the facility on [DATE] and had diagnoses including chronic diastolic congestive heart failure, unspecified dementia, with unspecified severity without behavioral disturbance, psychotic disturbance, anxiety, and personal history of traumatic brain injury. R223's Minimum Data Set (MDS) assessment, dated 1/18/23, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R223 had intact cognition. R223's medical record indicated R223 had a change in condition on 1/26/23 and was transferred to the hospital. R223 returned to the facility on [DATE]. F223's medical record did not indicate R223 or R223's representative were provided with a written transfer notice. On 8/28/24 at 11:57 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the facility did not provide a written transfer notice to R223 or R223's representative. 2. From 8/26/24 to 8/28/24, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), morbid obesity, type 2 diabetes, and acute kidney injury. R20's MDS assessment, dated 8/12/24, had a BIMS score of 15 out of 15 which indicated R20 had intact cognition. On 8/26/24 at 11:51 AM, Surveyor interviewed R20 who stated R20 was hospitalized twice since admission. R20 could not recall if the facility provided R20 or R20's representative with written transfer notices. R20's medical record indicated R20 was hospitalized on [DATE] and 7/31/24. R20's medical record indicated a written transfer notice was provided for R20's 7/31/24 hospital transfer, but did indicate R20 or R20's representative were provided with a written transfer notice for R20's 5/17/24 hospital transfer. On 8/27/24 at 12:30 PM, Surveyor interviewed NHA-A who confirmed the facility did not provide a written transfer notice for R20's 5/17/24 hospital transfer. NHA-A confirmed R20 should have received a written transfer notice. 3. From 8/26/24 to 8/28/24, Surveyor reviewed R70's medical record. R70 was admitted to the facility on [DATE] and had diagnoses including displaced intertrochanteric fracture of right femur, hepatic encephalopathy, type 2 diabetes, borderline personality disorder, and acquired absence of right and left leg above the knee. R70's MDS assessment, dated 7/1/24, had a BIMS score of 0 out of 15 which indicated R70 had severe cognitive impairment. R70 had a professional guardian to assist with healthcare decisions. R70's medical record indicated R70 had a change in condition on 5/23/24 and was transferred to the hospital. R70's medical record contained a transfer notice, dated 5/23/24, that was not signed by R70 or R70's guardian. On 8/27/24 at 11:05 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B expects staff to ensure transfer notices are signed and dated.

Based on observations, staff interviews and record review, the facility did not provide necessary treatment of [REDACTED]. R6 developed a Stage 3 pressure injury to the 4th toe on the left foot. The facility did not consistently follow APNP's (Advanced Practice Nurse Prescriber) orders for prevention and treatment of [REDACTED]. The facility failed to apply the larger slippers on R6 and, as a result, the resident's Stage 3 pressure injury deteriorated to a Stage 4 and the resident developed osteo[DIAGNOSES REDACTED] (an infection of the bone). The failure of the facility to follow the APNP's orders for R6 resulted in the resident's Stage 3 pressure injury deteriorating to a Stage 4 pressure injury and the development of osteo[DIAGNOSES REDACTED]. This created a situation of Immediate Jeopardy, which began on 12/12/17 when the APNP at the wound clinic ordered the larger slipper and the facility failed to apply the larger slippers. INHA (Interim Nursing Home Administrator)-B was formally notified on 1/24/18 that an Immediate Jeopardy situation existed and the Immediate Jeopardy was removed on 1/10/18. However the deficient practice continued at a scope and severity of D (potential for more than minimal harm/isolated) as evidenced by the following example: R5 had Stage 3 pressure injuries to the right and left buttocks. The APNP at the wound clinic ordered [MEDICATION NAME] or equivalent protective barrier ointment to be applied to the buttocks liberally, like cake frosting, to provide a barrier from urine and/or stool. Additionally, the APNP's orders indicated the facility was to ensure R5's heels were free from the bed. Neither of the APNP's orders were consistently followed by the facility. Findings include: 1. On 1/23/18, the Surveyor reviewed R6's medical record. The medical record included documentation that R6 was admitted to the facility with [DIAGNOSES REDACTED]. R6 had a wound tracker (Wound Evaluation Week 1) completed by the facility with a signed date of 12/3/17, for a wound that was identified on 10/17/17. The evaluation indicated the wound on the left toe was identified on 10/17/17, was a vascular (venous) wound and measured 1.5 cm (centimeter) length, 1.2 cm width and 0.0 depth. The wound was 90 percent granulation and 10 percent slough. Treatment ordered to the left 4th toe on 10/17/17 was calcium alginate, cover with Band-Aid. R6's medical record included facility progress notes. The facility progress notes dated 12/5/17, documented orders had been received to start R6 on Keflex (an antibiotic) 500 mg (milligram) 3 times a day for 7 days, wound to be cultured and referral to wound clinic for left foot 4th toe wound. On 12/8/17, R6's antibiotic order was changed. The Keflex was discontinued and Bactrim DS was ordered and started 2 times a day for 7 days. R6's Wound Evaluation Week 2 documented the wound measured 1.0 cm length, 1.6 cm width and 0.2 cm depth. The wound was currently a Stage 2 and treatment ordered on [DATE] included Bactrim DS twice daily for 7 days, calcium alginate to area and cover with Band-Aid to be changed daily. R6 was seen at the wound clinic on 12/12/17 by APNP-G, who is a CWON (Certified Wound Ostomy Nurse). Documented assessment by APNP-G indicated R6 had a pressure injury of toe of left foot, Stage 3. The plan and orders to the facility included to remove old dressing from the left 4th toe, wash leg and foot with Ph balanced soap and moisturize. Skin prep to periwound, [MEDICATION NAME] AG to wound bed ,cover with gauze and tape. Change Tuesday, Thursday and Saturday and as needed for soiling. R6 arrived at the wound clinic with slippers on that appear too small for R6. MUST GET NEW SLIPPERS. RECOMMEND A VELCRO TYPE AND ORDER 1/2 SIZE LARGER. Follow up in one week. This note will serve as orders for the facility. The left foot 4th toe reopened after healing 3/8/17. Size of the Stage 3 pressure injury on the left foot 4th toe was 0.5 cm length x (by) 1.2 cm width x 0.05 depth; 0.6 cm total sq (square) cm and the wound bed was 100 percent granulation. No bone or tendon exposed. Hammertoe deformity was noted. The facility's progress notes dated 12/12/17, documented R6 had a left 4th toe wound. Wound care instructions were provided by APNP-G as well as an order that stated R6 must get new slippers 1/2 size bigger. The facility spoke with R6's family member, who will order new slippers and send to facility for resident. R6's Wound Evaluation Week 3 was completed by the facility with a signed date of 12/17/17. The evaluation documented the wound measured 1.0 cm length, 1.5 cm width and 0.1 cm depth. The wound was a Stage 2 and was 100 percent granulation. R6 was seen at the wound clinic on 12/20/17 for a follow up appointment with APNP-G. The documented assessment indicated R6's wound is considerably worse today. (R6) arrived with same slippers on as at appointment despite us requesting (R6) not wear these and to get a new pair. Left 4th toe probes to bone today (Stage 4 pressure injury). X-ray obtained. Will call with results but likely has osteo (osteo[DIAGNOSES REDACTED]). CANNOT WEAR SLIPPERS THAT HE CAME TO APPOINTMENT WITH. THIS WAS AN ORDER AT HIS LAST VISIT. MAY USE GRIPPER S[NAME]KS OR GET A LARGER PAIR OF SLIPPERS - RECOMMEND AGAIN 1/2 SIZE LARGER. (MONTH) need surgical consult for amputation if this does not get better. This note will serve as orders for the facility. The left 4th toe pressure injury size was 5.0 cm length x 1.1 cm width x 0.4 cm depth with 5.5 total sq cm compared to 0.6 at last visit. 100 percent granulation, probes to bone. Follow up on 12/27/17. R6 was seen at the wound clinic on 12/27/17 for a follow up appointment with APNP-G. The documented assessment indicated left foot 4th toe measured 0.6 cm length x 0.9 cm width x 0.2 cm depth with 0.54 total sq cm compared to 5.5 total sq cm at last visit. Wound bed was 100 percent granulation and probes to bone (Stage 4 pressure injury). Appointment scheduled for 12/28/17 with the general/vascular surgeon. On 12/28/17, R6 was seen by the general/vascular surgeon for an evaluation of the left 4th toe Stage 4 pressure injury. The surgeon confirmed R6's left 4th toe had osteo[DIAGNOSES REDACTED] with X-ray evidence of the PIP (proximal interphalangeal) joint. Recommend amputation. R6 had a significant change MDS (Minimum Data Set) assessment completed on 1/12/18, which documented the resident's cognition was severely impaired and R6 had a Stage 4 pressure injury. R6's CAA (Care Area Assessment) dated 1/12/18, documented R6 had two pressure injuries to the toes of left foot. R6 had an unstageable pressure injury to the left great toe and a healing Stage 4 pressure injury to the left 4th toe. R6 was seen by the wound clinic. To avoid complications and minimize risks, R6 should wear looser fitting slippers or grippy socks. R6's plan of care with a last care plan review completed date of 1/18/18, indicated R6 has a pressure ulcer left great toe related to a history of ulcers. An intervention indicated staff were to ensure R6 wore Velcro strapped slippers that were 1/2 half size bigger. On 1/23/18 at 5:09 p.m., the Surveyor interviewed ADON (Assistant Director of Nursing)-C who functions as the facility's WCC (Wound Care Certified) nurse. ADON-C verified APNP-G had written an order for [REDACTED]. R6 continued to wear slippers that were too small until the follow up appointment at the wound clinic with APNP-G. Wearing the larger slippers as ordered was delayed and wearing the smaller slippers did contribute to the development of pressure injury to R6's toes. On 1/23/18 at 8:50 p.m., the Surveyor interviewed RN (Registered Nurse)-D regarding R6. RN-D verified R6 always wears slippers even in bed. RN-E joined the conversation and verified R6 wore slippers 24/7 and would get upset when needs to take the slippers off. On 1/23/18 at 8:57 p.m., the Surveyor interviewed CNA (Certified Nursing Assistant)-F regarding R6. CNA-F confirmed R6 wore slippers 24/7 and stated R6 pitches a fit if take off slippers. On 1/23/18 at 9:55 p.m., the Surveyor interviewed INHA-B regarding R6. INHA-B verified R6's larger slippers were not delivered to the resident timely as ADON-C indicated. The facility realized physician/APNP orders were not being followed and educated nurses on following orders. INHA-B verified not other staff were educated as a result of R6 not receiving slippers sent to the facility. On 1/24/18 at 9:10 a.m., the Surveyor interviewed APNP-G via telephone regarding R6. APNP-G verified R6's pressure injury progressed from a Stage 3 to a Stage 4, was able to probe bone. APNP-G then stated if R6's slippers were worn all day, it (Stage 4 pressure injury) was definitely from the slippers. The facility's failure to consistently complete the orders written by APNP-G regarding R6's pressure injury created a finding of immediate jeopardy. The facility removed the jeopardy on 1/10/18, when the following was completed: ~ On 1/10/18 and 1/11/18- Facility nurses were trained/educated regarding processing and following orders as well as trained/educated on skin policy/procedure. The education indicated if the facility receives any orders/recommendations from an NP (Nurse Practitioner) or MD, (Medical Doctor) the facility nurses need to process those orders and implement the orders. Any orders/recommendations need to be placed on the TAR (Treatment Administration Record) and it is our job to ensure there is follow up with our CNAs and that orders/recommendations get onto our CNA sheets. ~ The CNA sheets have been updated and they are all in the resident's rooms. ~ Whenever you find a new in house acquired pressure ulcer, you need to notify your DON (Director of Nursing) and/or ADON. 2. On 1/23/18, the Surveyor reviewed R5's medical record. The medical record indicated R5 was admitted to the facility with [DIAGNOSES REDACTED]. R5's quarterly MDS assessment completed on 10/26/17 documented R5's cognition was severely impaired, R5 required extensive assistance with bed mobility and transfers, and R5 did not have any unhealed pressure injuries. On 10/18/17, R5 was seen at the wound clinic by APNP-G. The documented assessment/plan indicated R5 had a Stage 2 pressure injury to the right and left buttocks. APNP-G ordered [MEDICATION NAME] or equivalent protective barrier ointment to be applied liberally, like cake frosting, to provide barrier from urine and/or stool. Reapply daily. Additionally, APNP-G wrote an order for [REDACTED]. On 10/25/17, R5 was seen by APNP-G at the wound clinic. APNP-G indicated R5 arrived to the clinic with stool under the dressing and a very thin layer of [MEDICATION NAME]. APNP-G again wrote an order for [REDACTED]. On 11/15/17, R5 was seen by APNP-G at the wound clinic. APNP-G indicated R5 arrived at the clinic with no [MEDICATION NAME] to buttock wound per provider orders. The facility was called and made aware to follow orders. Must apply the [MEDICATION NAME] protective barrier ointment liberally, like cake frosting, to provide barrier from urine and/or stool. Reapply daily. Additionally, the orders indicated staff were to ensure the heels are free from the bed. R5's CNA Kardex plan of care with a print date of 1/23/18 indicated R5's heels were to be free floated while in bed. This was not the plan of care posted in R5's room. The plan of care Kardex in R5's room, with a date of 1/4/18, did not indicate heels were to be free floated. Staff were following R5's plan of care Kardex dated 1/4/18. On 1/23/18 at 7:25 p.m. and 7:53 p.m., the Surveyor observed R5 in bed with both heels placed directly on a pillow. At 8:00 p.m., the Surveyor interviewed CNA-A regarding the placement of R5's heels. CNA-A verified both heels were placed directly on the pillow and should be free floating. CNA-A then free floated R5's heels. On 1/23/18 at 8:21 p.m., the Surveyor interviewed ADON-C regarding R5's orders from the wound clinic. ADON-C verified verbal education was provided to the nurses regarding applying the [MEDICATION NAME] after the orders received by the wound clinic. ADON-C indicated not having any documentation related to the education provided to the nurses. ADON-C indicated CNAs were not educated because the nurse apply the [MEDICATION NAME], not the CNAs. ADON-C indicated was not aware R5 went back to the wound clinic on 11/15/17 and did not have [MEDICATION NAME] on the wounds as ordered. ADON-C verified the education provided to the nurses did not work, as staff were not following R5's treatment plan, and R5's heels should be free floating while in bed.