Every finding on record at Sauk Co Health Care Center

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 2 sampled residents (R46). R46 had a history of Foley catheter obstruction resulting in UTI (Urinary Tract Infection) and sepsis. On [DATE] - [DATE], staff observed and documented that R46 had decreased urine output, including no output on the NOC (overnight) shift on [DATE]. There is no evidence of provider notification of the overall decreased output and no evidence of increased monitoring or assessments by facility staff. On [DATE], R46 was transferred to the hospital and admitted to the ICU with due to an occluded Foley catheter, UTI, and septic shock. R46 expired at the hospital on[DATE]. The facility's failure to increase monitoring and assessments when R46 presented with a change of condition (decreased urine output) and failure to consult with a medical provider resulted in actual decline in R46's condition leading to R46's death. These failures created a finding of immediate jeopardy (IJ) that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 11:35 AM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Evidenced by: According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. The facility's policy, Change of Condition, dated 3/2011, states, in part: Policy: the shift supervisor will immediately inform the resident, consult with the resident's physician, notify the resident's legal representative or interested family member when there is an acute change in condition (ACOC) defined as sudden, clinically important deviation from a resident's baseline. 'Clinically important' means a deviation that, without intervention, may result in complications or death. Procedure: 1. Identify residents at risk of ACOC and document assessment. An ACOC is reported immediately to the unit supervisor or shift supervisor by the interdisciplinary team member who first notices the change. The unit supervisor collects data on the resident and forwards it to the shift supervisor who completes and documents the nursing assessment. 2. Notification of Physician and resident or medical contact of ACOC. When an ACOC occurs, the shift supervisor will notify the attending physician. 3. Documentation in the resident's record. The shift supervisor will document the notification of the physician and resident/medical contact. Change in Elimination Patterns: The following may indicate an ACOC and should be assessed further:. 1. Abrupt change in frequency of urination. The facility's policy, Caring for Resident with Indwelling Catheter, dated 2/16, states, in part: . Policy: It is the policy of [Facility name] to promote comfort and safety of residents and prevent the spread of infection. 13. Measure and record the amount of urine and report increases or decreases in the amount of urine to the nurse. R46 was admitted to the facility on [DATE] with diagnoses that include, in part: Unspecified Dementia, moderate, with agitation, Acute pyelonephritis (kidney infection), Obstructive and reflux uropathy (blockage in urinary tract) unspecified, Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease unspecified, Neuromuscular dysfunction of bladder unspecified, Acute kidney failure unspecified, Chronic kidney disease, stage 3A, Frequency of micturition (urinating), and BPH (Benign Prostatic Hypertrophy) with lower urinary tract symptoms. R46's Comprehensive Care Plan states, in part: Problem: Potential for Altered Urine pattern. Start Date: [DATE]. Goal: Complications avoided, No UTIs (Urinary Tract Infections), skin integrity maintained. Target Date: 4/26. Nurse Aide Interventions: Encourage fluid intake. Use urinal. Record intake every shift. Record output every shift. Use protective pads. Cleanse peri-area and apply barrier cream to after incontinent episodes and PRN. Report changes in voiding pattern or appearance of urine to the nurse. Observe void pattern, provide privacy. Keep clean and dry. Nurse Interventions: Administer meds as ordered. Encourage fluid intake. Discuss possibility of other treatments with physician. Initiate toileting assessment. Catheterize every 8 hours. Start Date: [DATE]. R46's Physician Orders included, in part:--Change foley bag 1x (one time) per week Monday on shower day. Start Date: [DATE].--Size of catheter 16 FR (French) 30 mL (milliliter) balloon. Reason for Foley neurogenic bladder.--Provide foley catheter care q shift (each shift). Start Date: [DATE].--Intake q shift NOC (overnight) AM PM--Output q shift NOC AM PM On [DATE], R46's Physician Progress Note indicates, in part: Urinary retention with history of recurrent catheterization with history of bilateral hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine that cannot drain properly into the bladder) in 2016 due to urinary retention. Patient was receiving intermittent catheterization several times per day but due to his general physical status and difficulty with being cooperative to treatment. Order for indwelling Foley catheter was also placed. GFR (Glomerular Filtration Rate, measures how well your kidneys filter waste and excess fluid from your blood; It is the best overall indicator of kidney function) of 69. This is from [DATE]. On [DATE] at 6:29 AM, R46 was transferred to ER via ambulance for COC (change of condition) evaluation including symptoms of abdominal pain, bladder distension, oliguria (abnormally low urine output,) and UTI. R46's hospital documentation included the following, in part: Presented to the ER for evaluation of occluded Foley catheter and abdominal pain. Has a hx (history) of BPH and has been straight cathed on a regular basis but a Foley catheter was placed on [DATE] and was noted to not be draining as the patient was having abdominal pain. Urinalysis. showed evidence of urinary tract infection.Had over 1L (liter) in his bladder despite the Foley catheter being in and appears catheter is obstructed and was removed. New catheter placed which is now freely flowing. The patient was admitted to the hospital as inpatient for treatment of acute pyelonephritis with hx (history) of occluded Foley catheter, sepsis without shock and acute kidney injury superimposed on chronic kidney disease. On [DATE], R46 was discharged from the hospital and returned to the facility. A review of R46's EHR (Electronic Health Record) indicates the following documented I&O (Intake and Output) and progress notes:-On [DATE]: 24 hour intake of 670 mL (milliliter); 24 hour output of 1150 mL-On [DATE]: 24 hour intake of 990 mL; 24 hour output of 1250 mL-On [DATE]: 24 hour intake of 1270 mL; 24 hour output of 630 mL-On [DATE] a nursing progress note indicates: Foley was irrigated with 45 mL NS (Normal Saline). Amount returned 35 ml tolerated well.Fluids encouraged. Continue to observe.-On [DATE]: 24 hour intake of 1780 mL; 24 hour output of 300 mL(Of note for [DATE]: per shift recordings included outputs of 100 mL on AM shift, 200 mL on PM shift, and 0 mL on NOC (overnight) shift. There is no evidence that the provider was notified of decreased output overall and no output on the NOC shift.)-On [DATE]: 24-hour intake of 950 mL; 24 hour output of 550 mL(Of note for [DATE]: per shift recordings included outputs of 100 mL on AM shift, 200 mL on PM shift and 250 mL on NOC shift. There is no evidence that the provider was notified of decreased urine output, no evidence of increased monitoring or assessments for R46.)-On [DATE], R46's output was recorded as 100 mL on the day shift.-On [DATE] at 6:43 AM, a nursing progress notes indicates: Intake 150 Output 25 (milliliters).-On [DATE] at 12:53 PM, progress note: Refused to get out of bed this shift. Refused meals. Allowed staff to encourage fluids and accepted supplement. -On [DATE] at 5:41 PM, progress note: Transferred to [local] hospital for evaluation/COC (Change of Condition)/abnormal VS (Vital Signs). Temp(temperature) 98.4, Pulse 134, Resp(respirations) 25, BP (blood pressure) 143/66, O2 (oxygen) 88% started on oxygen 2L (liters) nasal canula and O2 came up to 94%; BGM (blood glucose monitor) 259. projectile liquid vomiting, pulse continues to be elevated, expiratory wheezes, cool, clammy and shaking, grey in color, decreased urine output. was transferred to ER via ambulance. On [DATE] at 2:35 PM, Surveyor interviewed LPN C (Licensed Practical Nurse), who stated he came into work on [DATE] at 2:30 PM. LPN C stated R46 had been having a steady decline, but on [DATE] he noticed he was really not doing well. LPN C stated he was notified by the CNAs that R46 was breathing real heavy and wasn't aware of anything when normally he would respond to staff. LPN C stated he took R46's vital signs and noticed that R46's pulse was increased, his blood pressure was low, and he was hyperventilating. LPN C stated he called the nurse supervisor, either ADON D (Assistant Director of Nursing) or RN E (Registered Nurse), and they decided to send R46 out right away. Surveyor asked LPN C about R46's history of UTIs. LPN C stated yes, R46 had frequent UTIs, he would be fine for awhile and then he would get another UTI. Surveyor asked what kind of interventions were in place for R46 with a history of catheter associated UTI. LPN C stated they would flush R46's catheter, check it for kinks, and keep strict I&O (intake & output) monitoring on R46.On [DATE] at 3:00 PM, Surveyor interviewed ADON D (Assistant Director of Nursing), who stated she was leaving for the day on [DATE], when LPN C asked her to come look at R46. LPN C noticed that R46 was diaphoretic (sweating heavily) and pale and didn't look good. ADON D stated they took R46's vital signs and his pulse was irregular, and they put oxygen on R46. RN E also came and looked at R46 and they decided to call 911 right away. ADON D stated R46 had been refusing to get out of bed earlier in the day, but that was not abnormal for him. ADON D stated R46 had dementia and could get nasty if staff tried to get him to eat or get up when he wanted to be left alone. ADON D stated R46 had a Foley catheter in place, but that if he had no urine output, she would expect that the nurse remove it out and put in a new one. ADON D also indicated the facility has a bladder scanner machine, so she would expect staff to use that to check to see if R46 had urine in his bladder that wasn't draining out, also check for kinks, and make sure the stat lock was in place on the catheter. Surveyor asked what kind of interventions were in place for R46 with a history of catheter associated UTIs. ADON D stated R46 had orders to flush and change his catheter if it got clogged.On [DATE] at 3:48 PM, Surveyor interviewed RN E who stated she came in for her shift on [DATE] at 3:00 PM, and was getting report from the day shift supervisor when LPN C said R46 was not looking good and asked her to come check him out. RN E stated both her and ADON D went to R46's room and she could tell right away that R46's color was way off, he was gray, cool, and clammy. RN E stated they took R46's vital signs and he was in a-fib (atrial fabulation) and his pulse was elevated, O2 (oxygen) was slightly low, and he was shaking. RN E indicated ADON D stayed with R46 while she ran and called 911. RN E stated while she was printing the paperwork to send with R46 in the ambulance, she noticed he had decreased urine output the night before. RN E indicated she had not received any report from day shift that he had decreased output. RN E stated when the ambulance arrived, R46 started vomiting, and then they got him out right away to the hospital. RN E stated she had talked to the day shift nurse after R46 was sent out, and the day shift nurse said R46 had not eaten anything that morning or at lunchtime. RN E stated decreased output was not necessarily unusual for R46, and it wasn't uncommon for him to not eat or drink throughout the day, and there were days he would just sleep and not want to be bothered by staff. RN E indicated if R46 had no urine output at all for a shift, she would consider that a change of condition that would warrant notifying the doctor. RN E stated in this case, R46 was definitely in a critical situation, and the second she walked into R46's room she could tell he didn't look good. Surveyor asked what kind of interventions were in place for R46 with a history of catheter associated UTIs. RN E stated they were watching his urine, making sure it wasn't cloudy, discolored, or smelly, and observing for decreased urine output. R46's hospital documentation, dated [DATE] includes, in part: Presented to the ER with acute onset SOB (Shortness of Breath), fever, and altered mental status. Patient noted to have tachycardia (fast heartbeat), fever, hypoxia (low oxygen) on room air, and hypotension (low blood pressure) prompting ER evaluation. He had an episode of emesis prior to arrival. Upon arrival, critically ill, dehydrated and unwell. Profoundly hypotensive despite fluids, though fever is resolving after IV (intravenous) Tylenol per EMS (Emergency Medical Service). Foley catheter was exchanged with significant urine output noted, suggesting prior obstruction as a contributing factor. Initial evaluation was notable for elevated lactic acid and evidence of end-organ dysfunction including acute kidney injury. Clinical picture was most consistent with urosepsis (a life-threatening medical emergency where a urinary tract or prostate infection spreads into the bloodstream, triggering systemic sepsis). Vital signs in the ER were BP 74/48; Pulse 92; Temp 98.1; Resp 25; SpO2 99% .admitted inpatient to the ICU (Intensive Care Unit) for severe sepsis with septic shock secondary to catheter associated urinary tract infection complicated by acute kidney injury, hypotension requiring vasopressor support and altered mental status. Following ICU admission, the patient remained critically ill. Prognosis was discussed and the patient is considered high risk for mortality given septic shock and underlying comorbidities. Labs indicate a GFR of 15 . Urinalysis from the indwelling catheter is grossly abnormal consistent with severe urinary tract infection. Labs are consistent with sepsis, including AKI (Acute Kidney Injury), elevated lactate, and leukopenia (low white blood cell count). [Resident Name] is at high risk of death and unlikely to survive his septic shock secondary to complicated urinary tract infection due to obstructive uropathy which has now been resolved with a new Foley catheter.-On [DATE] at 5:50 AM, R46 passed away in the hospital ICU. On [DATE] at 3:30 PM, Surveyor interviewed DON B who stated she would have to look into the situation and get back to Surveyor. DON B stated facility protocol is that the floor nurse should notify the RN supervisor of any change of condition. DON B stated she is not notified of every change of condition. DON B indicated if a resident had no urine output for a shift, she would expect the nurse to at least put a note in the chart that they checked for kinks, ensured the resident was not laying on catheter, and stuff like that. DON B stated staff should be following the policy for notifying the doctor of changes in condition. DON B stated it was pretty normal for R46 to refuse meals or to get out of bed, and that if R46 told you to leave him alone, you left him alone. Surveyor asked what kind of interventions were in place for R46 with a history of catheter associated UTIs. DON B stated they were flushing R46's catheter and monitoring his output. On [DATE] at 4:09 PM, Surveyor interviewed CNA F and asked her about R46's decreased urine output. CNA F stated she would consider that a change of condition, and she would report to the nurse right away anytime a resident had less than 250 mL of urine output for the shift. On [DATE] at 4:11 PM, Surveyor interviewed CNA G and asked about R46's decreased urine output. CNA G stated she records each resident's I&O on a sheet and gives it to the nurse, but if a resident had no output for a shift, she would report that to the nurse right away. On [DATE] at 8:52 AM, Surveyor interviewed RN H about R46. RN H indicated R46 was very strongly opinionated on his choices, so if he wanted to stay in bed, they would let him sleep and hold his breakfast tray for him to eat later. Surveyor asked what kind of interventions were in place for R46 with a history of catheter associated UTIs. RN H stated he would check the catheter for sediment, see if it needs flushing, and let the supervisor know right away of the decreased output. RN H stated R46 should have been at least putting out 30 mL per hour or 240 mL per shift. RN H indicated that having no output for a shift would be unacceptable. On [DATE] at 9:46 AM, Surveyor interviewed CNA I about R46's decreased urine output. CNA I indicated she just recently became a CNA, but she was taught to empty the resident's catheter each shift and document the amount. CNA I stated if a resident had no output for a shift, she would let the nurse know right away so they could push fluids. On [DATE] at 9:50 AM, Surveyor interviewed CNA J about R46. CNA J stated R46 did not like to get out of bed he would get mad if they tried to get him up when he wanted to stay in bed. CNA J stated she had worked the day before R46 was sent to the hospital, and he had maybe 100 mL for output on her shift, so she had let the nurse know right away because that was really unusual for R46. On [DATE] at 10:04 AM, Surveyor interviewed NHA A and asked if he would have expected staff to be monitoring and flushing R46's catheter given his history of catheter associated UTIs. NHA A stated yes, that was his expectation. Surveyor asked NHA A if he would have expected staff to notify the doctor if R46 had decreased urine output for several days, and no output for an entire shift. NHA A stated yes, that was his expectation. On [DATE] at 11:46 AM, Surveyor left a voicemail with MD K (Medical Doctor) to discuss R46's history and expectations of care for R46. Surveyor did not receive a call back. The facility's failure to provide necessary monitoring and assessments and provider notification of a resident's change of condition resulting in actual decline and R46's death created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy The facility removed the jeopardy on [DATE], however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan:*Resident (R46) was transferred to ER on [DATE] due to refusing meals, refusing to get out of bed, and being diaphoretic, clammy and wheezing. Also had abnormal vital signs and was vomiting. *All nursing staff will be educated on early warning signs for acute change of conditions for an indwelling catheter, including blocked or zero urine output. Education started [DATE] on pm shift and will get completed prior to staff starting their next shift or via phone call. This will be completed Tuesday [DATE]th2026. Power point presentation on change of condition to nursing staff will be completed Friday [DATE]th, 2026. Reviewed all residents with catheters for any change in conditions. All residents with catheters had a visual assessment completed and documentation viewed to assure compliance on [DATE].*On [DATE], facility reviewed and updated Change in Condition policy. Acknowledgement form gone over and signed by nurses. This will be completed Tuesday [DATE]th 2026. Updated Policy given and acknowledgement form signed by all staff by Friday [DATE]th 2026.*Audits will be completed by DON or designee on output from urinary catheters on all residents with indwelling catheters daily x 1 month, then weekly x4 weeks, then randomly monthly x3 months.*Audits will be completed by DON or designee for change of condition that notification of MD was completed and documented per policy after reviewing the daily 24 hour report. Daily x 1 month, weekly x 4 weeks then randomly monthly x 3 months.* A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months.

Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 43 residents (R) in the facility. The facility staff infection control line list did not contain information regarding start of symptoms, resolution of symptoms, and testing which made it unclear if staff were excluded from work for an appropriate amount of time. The facility's monthly infection control rates were not segregated for specific infection types. This is Evidenced by: The facility policy, Infection Prevention and Control Program, dated 5/26, indicates, in part: Purpose: The objective of this requirement is for the facility to develop a comprehensive Infection Prevention and Control Policy that establishes a facility-wide system for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff.Policy: .The Infection Prevention and Control Program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff.conducted according to regulatory requirements and following accepted national standards. The facility provided, as a policy, the State of Wisconsin, Department of Health Services, BCD (Bureau of Communicable Disease) memo 2025-4, Health Care Personnel Exclusion and Return to Work Following an Acute Respiratory Illness, dated 11/10/25, indicates, in part: Background - .Other essential practices include: .Prompt identification and exclusion of symptomatic HCP (Health Care Personnel).Exclusion criteria - HCP should be excluded from work if they: Test positive for a respiratory virus such as influenza, RSV, or SARS-CoV-2. or Develop symptoms suggestive of an acute respiratory viral illness, defined as having two or more of the following: cough, shortness of breath, sore throat, runny nose, headache, myalgia, chills, fatigue, or fever. The facility policy, Infection Surveillance Policy and Procedure, dated 5/26, indicates, in part: Policy: .Surveillance includes the routine, ongoing, and systematic collection, analysis, interpretation and dissemination of surveillance data to be able to identify infections, risks, communicable disease outbreaks and to maintain or prove resident health and care.Infection Data Collection and Analysis -- 1. Data is tabulated by type of infection.Reporting -- 1. Analysis and conclusions are reported to the Quality Assurance (QA) committee on a minimum of a quarterly basis. Example 1 On 6/2/26 and 6/3/26 Surveyors reviewed the infection control line lists provided by the facility. The staff infection control line list did not include return to work dates and Surveyors requested these from DON B (Director of Nursing). DON B returned the line lists with return to work dates hand-written on the side of the line lists. On 6/3/26 at 2:15 PM, Surveyors conducted the infection control interview with DON B and DON in training L. DON B indicated she is overseeing the Infection Prevention Program while DON in training L completes her training. During the interview Surveyors reviewed the staff line lists from March, April and May of 2026 with DON B and DON in training L. Surveyors noted no symptom start dates, no symptom resolution dates, and no information regarding testing for acute respiratory illness or symptoms potentially related to covid. During the interview, Surveyors reviewed the following staff, as examples of the missing information noted throughout the line lists, with DON B and DON in training L:April 2026: CNA M (Certified Nursing Assistant): Symptoms: sick feverLDW (Last Day Worked): blankCall in date: April 22Return to work date (of note, this is handwritten in after surveyors requested information) April 24th May 2026:CNA NSymptoms: sore throat coughLDW: May 11Call in date: 5/11/26Return to work date (of note, this is handwritten in after surveyors requested information) May 12th. During the review of these examples and the overall line list. DON B indicated there is not a current process for who is determining when staff can return to work and that staff return when they feel better. DON B also indicated that there should have been testing for the two examples reviewed and someone from the facility should have informed the staff members of when to come back versus them just coming back on their own. DON B indicated after discussions yesterday they are putting a process in place to change this. Of note: without an accurate staff line list or staff call-in process, it is unclear if staff were excluded from work appropriately to prevent the spread of potential communicable illnesses. Example 2On 6/2/26 at approximately 11:00AM Surveyors returned to the conference room to find a document titled, Rate of Infection, that listed monthly overall infection rates from May 2025 to May 2026. The list did not contain segregated rates by infection type. On 6/3/26 at 3:05PM Surveyors interviewed DON B and DON in training L. During the interview DON B indicated that she came to the facility in December, and she did not find any rates other than overall monthly rates and indicated they do not currently have segregated rates by infection type.

Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 sampled residents (R2).On 12/10/25 staff observed and documented an open area on R2's left 5th digit. The facility did not complete an initial comprehensive assessment of the wound including, measurements, size and characteristics. On 12/19/25, R2 was sent to emergency department due to deterioration in the wound. R2 was diagnosed with a displaced fracture and osteomyelitis requiring antibiotic therapy. Evidenced by:According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.Per the wound care education institute Best Practices for Wound Assessment and Documentation states, in part: . Foundational elements of wound assessment. A structured approach to wound assessment is key to capturing the clinical picture and determining the best course of action for care. Here are the essential components to document: .1. Precise anatomical location.2. Wound classification and etiology. Determine and document the wound's origin. Common types include: Pressure injuries: Classify by stage using the National Pressure Injury Advisory Panel's (NPIAP) guidelines. Arterial or venous ulcers: Note underlying circulatory insufficiencies. Diabetic foot ulcers: These are often neuropathic, so assess the patient's offloading status. The patient should be assigned a [NAME] grade and updated as needed. Surgical incisions or traumatic wounds: Include the mechanism of injury or surgical intent.Documenting wound etiology ensures targeted interventions and appropriate resource use .3. Accurate wound measurements.*Length.*Width.*Depth.4. Wound bed characteristics Quantify the percentage and type of tissue present: Granulation: Red, moist, and bumpy - This is a sign of healthy tissue growth. Slough: Yellow/white, stringy, or moist. May be adherent or loosely attached. This is non-viable and may require debridement. Eschar: Thick, dry, black, or brown. Document if stable or if debridement is needed. Hyper granulation: Assess for signs of infection and/or necessary treatment changes, such as stopping a collagen application.Descriptive wound bed assessments help monitor healing phases and guide appropriate debridement strategies.5. Wound edge and margin assessment Evaluate wound edges for signs of healing or chronicity: Defined vs. undefined: Defined edges are more acute, and undefined may suggest chronicity. Epibole (rolled edges): This is common in stalled wounds. Undermining or maceration: This may indicate moisture imbalance or shearing/friction forces.Marginal changes can be early indicators of delayed healing or infection.6. Exudate characteristics Drainage quality provides vital clues about wound status: Amount: None, scant, light, moderate, or heavy. Type: Serous (clear), serosanguineous, sanguineous, seropurulent, or purulent. Color and consistency: Thick yellow/green with odor may indicate infection. Odor: Describe only after cleansing to eliminate confounding factors.Always correlate exudate changes with wound progression and signs of infection.7. Peri wound skin statusDocument any abnormal findings in the tissue surrounding the wound: Color: Erythema may signal infection or inflammation. Texture: Watch for induration, bogginess, or dryness. Breakdown: Maceration, excoriation, or denuded skin may indicate excessive moisture or friction.Healthy peri wound skin supports optimal wound healing and should be protected as part of the overall care plan.8. Pain and symptom reportingPain is a critical, yet often under-documented, aspect of wound assessment. Capture: Intensity: Use a numeric or verbal pain scale. Descriptors: Burning, aching, stabbing, etc. Timing: Before, during, or after dressing changes. Management: Note what interventions alleviate or exacerbate pain The facility's policy entitled Wound Treatment Management, dated 4/2024, states, in part: . Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Policy Explanation and Compliance Guidelines: .8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound.R2 was admitted to the facility on [DATE] and has diagnoses that include cerebrovascular disease (a group of conditions that impair brain blow flow), unspecified dementia, severe with anxiety, and bilateral osteoarthritis of hip.R2's Minimum Data Set (MDS) Significant Change Assessment, dated 1/22/26, shows R2 has severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 00.R2's progress notes are as follows: R2's Progress Note, dated 12/10/25, at 12:34 PM, states: Left hand pinky has open area reported to supervisor.Important to note: There is no wound assessment with characteristics of wound or measurements indicated when found.R2's Progress Note dated 12/11/25, at 3:12 PM, states: Orders Received from [physician name] .Cleanse scab on pinky finger on left hand with soap and water-apply betadine and allow to dry then leave open to air. R2's Care Plan states, in part: . Problem: Potential for tissue integrity impairment. Related to: Immobility, HLD (hyperlipidemia), CAD (coronary artery disease), Dry, scaling areas, advanced age, fragile skin, incontinence. Manifested by: Reddened areas, itching, edema, moist areas, blisters, bruises easily.Goal: Skin will remain intact, Free of irritation, No breakdown of area. Goal Time: 2/26Approach: Nurses- Inspect skin especially bony prominences and dependent areas for redness/breakdown daily. Assess skin status.R2's Progress notes continued: 12/11/25, at 3:12 PM, Skin Problems: Wound care to left pinky as ordered .12/12/25, at 1:49 PM, Procedure Done: wound treatment done per order.12/13/25, at 12:24 AM, Procedure Done: Wound treatment done per order.12/13/25, at 12:35 PM, Procedure Done: wound treatment done per order.12/14/25, at 12:16 AM, Procedure Done: wound treatment done per order.12/15/25, at 2:49 PM, Weekly Skin Assessment: within normal limits, warm, dry, no open areas. Skin Problems: small wound to left pinky, being treated. Foot Problem/Care: Nails are clean and smooth; heels are firm and blanchable.Important to note this is not a thorough wound assessment. This does not indicate characteristics of the wound or measurements. There is no documentation of wound assessments from 12/10/25 to current to indicate staff are monitoring R2's wound for decline or improvement.12/15/25, 16:43 PM, Wound treatment done per order to left pinky finger, left pinky nail appears to be falling off, no s/s (signs or symptoms) of infection.Important to note: This is a change in the wound. There is no physician notification or a thorough assessment of the wound documented in R2's record.12/16/25 at 12:59 PM, Skin Problems: Wound care to left pinky as ordered.12/17/25 at 12:26 PM, Skin Problems: Wound care to left pinky as ordered.12/18/25 at 12:43 PM, Procedure Done: wound treatment done per order.12/19/25 at 2:55 PM, Skin Problems Left pinky cleaned as ordered, notified Charge nurse of change in wound appearance.12/19/25 5:35 PM, General Skin Condition: Resident left pinky finger noted to have a large hematoma- on lateral finger red and warm- . POA (power of attorney) and on call doctor phoned and he would like to have this hematoma looked [sic] in ER (emergency room) .Important to note: There are still no wound characteristics/assessments documented in R2's record.12/19/25 at 5:45 PM, Resident Transferred: 12/19/25 Time of Transfer: 6:00 PMTransferred to: [Hospital name] . by ambulance. R2's Rapid Assessment and Management, dated 12/19/25, at 6:32 PM, states, in part: . Brief HPI (history of present illness): .Patient presents with: Hand Pain. Sent from the [Nursing Home name] due to swollen left pinky, with pus drainage. Unclear if there was an associated injury. Patient nonverbal at baseline.Focused Physical Exam: Patient is holding her hand gripped aggressively. Left pinky is quite swollen on the ulnar aspect, purplish, with purulent drainage. (of note: R2's record does not have any documentation of purulent drainage being present prior.)R2's hospital Discharge summary, dated [DATE], states, in part: . Chief Complaint: Hand painHistory of Present Illness: R2 presents with hand pain. History provided by daughter in law at bedside. Per daughter in law, wound with blood blister to left pinky was noticed about 1 week ago. Yesterday, noticed worsening swelling and redness and drainage prompting sending the patient to the emergency department today. Patient is nonverbal and non-ambulatory at baseline. No known injuries. Mental status is at baseline. Goals of care primarily end-of-life and comfort oriented.Orders Placed at this Encounter:- Wound culture with gram stain.- XR (x-ray) Hand Min 3 Views .- Ambulatory Referral to Orthopedic Surgery.-Cephalexin 500 mg (milligrams) Oral Capsule.1 capsule by mouth 2 times daily for 7 days.- Sulfamethoxazole-Trimethoprim 800-160 mg oral tablet. Take 1 tablet by mouth 2 times daily for 7 days.Physical Exam: .Skin: General: Skin is warm and dry. Comments: Left hand 2+ radial pulse, approximately 4 cm (centimeters) hematoma with purulent drainage to ulnar aspect of fifth digit, finger contracted at baseline.Medical Decision Making:R2 here with hand pain.Concern for hematoma to the lateral aspect of her hand that is now infected with purulent drainage. I am concerned for underlying infection. I had an extensive discussion with family member at bedside. We discussed likelihood of infection and possibility of worsening without surgical intervention, osteomyelitis, abscess, fracture. Would require evaluation by hand surgeon and consideration for procedure. X-ray imaging with possible nondisplaced fracture involving the mid diaphysis of the pinky finger distal phalanx. Finger not amenable to buddy taping due to her significant contractures. Family relate that goals of care currently end-of-life and comfort. Would not want to pursue any surgical evaluation or intervention. They are amenable (open to) to drainage in the emergency department with oral antibiotics. I &D (incision & drain) was performed. Wound culture obtained. Provided with a dose of Bactrim and Keflex. They were provided a referral to hand clinic for wound re-evaluation if they so choose. Option to follow up with hand clinic or primary care doctor.XR Hand Min 3 Views L (left) (Final Result): Impression: 1. Possible nondisplaced fracture involving the med diaphysis (central shaft of a long bone) of the pinky finger distal phalanx (bone found at the tip of finger) .Indication: left pinky hematoma/abscess, eval for fracture.Findings: Bones appear osteopenic. Possible nondisplaced fracture involving the mid diaphysis of the pinky finger distal phalanx best seen on the oblique view.Diagnosis: ImpressionAbscessClosed Nondisplaced fracture of distal phalanx of left little finger. R2's After Visit Summary, dated 12/19/25, states, in part: . Reason for visit: hand pain.Diagnoses: Abscess. Closed nondisplaced fracture of distal phalanx of left little finger.Lab Tests in Progress: Wound Culture with gram stainImaging Tests: XR Hand Min 3 Views L.Orders: 1) Cephalexin 500 mg 1 capsule by mouth 2 times daily for 7 days. 2) Sulfamethoxazole-trimethoprim 800-160 mg 1 tablet by mouth 2 times daily for 7 days. 12/19/25 11:39 PM, Returned from: Emergency Room. Return Date: 12/19/25. Return Time: 10:33 PM.12/19/25, at 11:39 PM, Orders received from [Physician name] Result: . 1) Cephalexin (first generation antibiotic used to treat various bacterial infections) 500 mg (milligrams) by mouth 2 times daily for 7 days abscess to left little finger 2) Sulfamethoxazole-trimethoprim (antibiotic also used to treat various bacterial infections) 800-160 by mouth 2 ties daily for 7 days abscess to left little finger. Of note: facility did not assess R2's abscess upon returning from the hospital or document the size or characteristics for this area. 12/20/25 at 11:34 PM, Orders received from [Physician name} Result: . 1) Follow-up with hand clinic for wound re-evaluation. If you would prefer to not see a specialist given goals of care, please follow-up with PCP (Primary Care Physician) . R2's Wound Culture Results, dated 12/26/25, states, in part: . Specimen Description: Wound Special Requests: Hand, Left Gram Stain: No Epithelial Cells Seen. WBCS (white blood cells) few. Gram Positive COCCI rare. Culture Results: Moderate growth of Staphylococcus Aureus Susceptibility. R2's Nurse Practitioner (NP) Progress Note, dated 12/28/25, states, in part: . Routine Visit: 12/28/25. S (situation): . New concerns with patient are her left-hand wound. Noted for the month of December. December 11th patient was found to have a scab on her pinky finger for her left hand. She was taken to the ER on [DATE]. This was secondary to hematoma that was noted on the left 5th digit. New orders were received after wound culture grew staph infection.Patient is placed on Keflex and Bactrim at this time. Left fifth digit tip is blackened. At this time unable to assess fully as extension is not complete. Area had foul odor with moisture noted in the [NAME] surface of hand. Unable/difficult to assess secondary to the contractures and inability to open and extension complete. folded hand washcloth was placed wound was left open to air. Recommend follow-up with PCP (Primary Care Physician) and Hand Specialist.New orders will be to change dressing/washcloth to left hand as needed recommending frequent changes. Of note: there is no evidence of R2's abscess being monitored or assessed by facility staff from 12/19/25 to 12/29/25.NP D Progress Note, dated 12/29/25, states, in part: . Chief Complaint: Left little finger swelling. History of Present Illness: Writer was asked to consult and exam R2. Prior to evaluation, radiographs were reviewed with orthopedic surgeon [Physician name] and per the x-ray there is erosive bone loss at the 5th distal phalanx consistent with osteomyelitis. R2 was evaluated in the emergency room on [DATE].Physical Examination: .Hand/Upper Extremity Examination: Skin: Black eschar to the left little finger, distal phalanx. Fingernail is starting to fall off. Palpation/Tenderness: Tenderness to 5th distal phalanx with palpation. Upper extremity range of motion: Severe flexion contractures of all fingers of the left hand.Diagnostic Studies: Radiographs of the left hand were obtained 12/19/25 and per orthopedic team review of images demonstrate.Bone erosion of the 5th distal phalanx consistent with osteomyelitis.Plan: 1. Writer called and spoke to family member. and discussed treatment options including conservative measures such as monitoring, oral antibiotics, and repeat x-rays versus surgical removal of the finger, however, it would not be our recommendation to proceed with surgery due to R2's current health state and physical condition. The surgery would require general anesthesia and her to be intubated (we would need to use a paralytic to be able to access her hand for surgery given her contractures.) .3) Monitor hand and finger daily, applying betadine.4) Monitor for systemic signs of infection such as redness, swelling, increased pain, drainage, red streaking, and fever.5) Prescribed daily antibiotic therapy for 6 weeks (which may extend), to include Bactrim 800/160 mg twice daily) .6) Follow up x-rays in 4 weeks of the left hand, little finger. R2's Physician Orders, dated 1/19/25, states, in part: . Monitor left hand pinky for systemic infection- increase warmth, red streaking, fever/rapid heartbeat/increase in pain or discomfort every shift AM PM NOC First Date: 12/30/25.Important to note: there is no documentation of monitoring/assessment of R2's wound to left pinky finger until ordered by NP D on 12/30/25.On 2/3/26 at 10:54 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) regarding R2's left fifth digit. LPN E indicated it had been broken about a month ago. LPN E indicated R2's left pinky had been tested, and osteomyelitis was found at that time. LPN E indicated R2's left hand is pretty contracted, and staff have to pull R2's fingers up to get the palm protectors on. LPN E indicated she is not aware of how R2's left pinky finger had been broken. Surveyor asked LPN E what the facility's process is when a wound or a change of condition is observed with a resident. LPN E indicated the floor nurse would report it to the nurse supervisor. The nurse supervisor would do an incident report, report to the physician and receive an order.On 2/3/26 at 11:30 AM, Surveyor requested from DON B (Director of Nursing) an incident report for R2's wound from 12/10/25 and weekly wound assessment documentation. DON B informed Surveyor there was no incident report for R2 and there is no weekly wound assessment documentation.On 2/3/26 at 11:56 AM, Surveyor left a message for R2's POA. Surveyor did not receive a phone call back.On 2/3/26 at 12:31 PM, Surveyor interviewed LPN F. Surveyor asked LPN F if she was the nurse that discovered the wound to R2's left pinky finger on 12/10/25. LPN F indicated yes, a CNA (Certified Nursing Assistant) reported to LPN F R2's left pinky finger was bleeding. LPN F indicated she had called the nurse supervisor, and LPN F and the nurse supervisor assessed R2's left pinky. LPN F indicated they cleaned the area and found a tiny [NAME] at the tip of R2's left pinky finger bleeding. LPN F indicated it was close to R2's fingernail. LPN F indicated the nurse supervisor then called the doctor. Surveyor asked LPN F to explain the facility process when a wound is found or a resident has a change of condition. LPN F indicated the floor nurse reports it to the nurse supervisor and the nurse supervisor calls the physician and completes the documentation on the wound or change of condition. Surveyor asked LPN F if she was aware of what caused the wound to R2's left pinky finger LPN F indicated she did not know.Surveyor attempted to phone R2's PCP and left a message on 2/3/26 at 1:13PM, but did not receive a call back.Surveyor placed a call out to the nurse supervisor a message was left on 2/3/26 at 1:15 PM. Surveyor did not receive a call back.On 2/3/26 at 3:07 PM, Surveyor interviewed DON B and ADON C (Assistant Director of Nursing). Surveyor asked DON B and ADON C when they first became aware of R2's wound to her left pinky finger. DON B indicated it wasn't a wound it was a blood blister. DON B and ADON C indicated they became aware of the blood blister first part of December. Surveyor asked DON B and ADON C if they would expect wound assessments initially when a wound is found and then weekly thereafter. DON B and ADON C indicated not on a blood blister. Surveyor asked DON B and ADON C if they could describe R2's left pinky finger the day she was sent to the emergency department. ADON C indicated the pinky finger was swollen and red; it was warm. ADON C indicated there was a hematoma to the left pinky finger. Surveyor asked if the finger had any drainage and ADON C indicated when they removed the splint there was yellow drainage on the splint. Surveyor asked if the drainage came from the swollen area/hematoma. ADON C and DON B indicated no, that they did not know if there was another wound because they could not visibly see due to the contracture of the left hand and swelling. Surveyor asked if the facility determined a root cause for the wound. DON B indicated it was from the splint and the hand contracture, so the splint was discontinued, and a washcloth was ordered per physician. Surveyor asked if the facility has a wound nurse or who is responsible for wounds. ADON C indicated all the nurses are responsible, but the RN supervisor would do the measurements. Surveyor asked DON B if she would expect wound assessments/documentation of R2's wound to the left pinky finger. DON B indicated she would not on a hematoma. The Surveyor pointed out that the swollen left pinky finger per hospital discharge was referred to as an abscess. Surveyor asked if an abscess would be a wound. DON B indicated if the abscess is open and draining it would be. Surveyor asked DON B how one would monitor the abscess for improvement or worsening without wound assessments. DON B indicated they would be assessing it with the daily treatment and the weekly skin assessments. Staff would notify their supervisor of changes. Surveyor asked DON B if R2's left pinky finger was being monitored prior to the hematoma development. DON B indicated the facility does weekly skin assessments with baths and the CNAs monitor with the palm protector placement and removal. Surveyor asked DON B if she would expect wound assessments to be completed after R2 returned from the emergency department on antibiotic. DON B indicated yes.On 2/4/26 at 8:03 AM, Surveyor interviewed NP D. Surveyor went over the timeline from the date of R2's wound (open area) discovered on 12/10/25 to R2 being sent to emergency department on 12/19/25 with a change of a hematoma noted to R2's left pinky finger and discovering osteomyelitis along with a closed nondisplaced fracture of distal phalanx of left little finger. NP D indicated she does not think there is a fracture. NP D indicated her and the surgeon looked at the radiograph yesterday (2/3/26) and it looks like a shadow. NP D indicated radiographs are typically taken with the hand open, in R2's case the radiograph was taken with the hand clenched shut due to the contracture of the hand. The shadow could be due to the radiograph taken with a closed hand. The only way to know if there is a fracture is to do a repeat radiograph in 4 weeks; the body responds to a fracture by sending calcium to the fracture. On the x-ray you will see all the calcium surrounding the fracture as it lights up on the x-ray. Surveyor asked NP D if she would expect the facility to be monitoring and completing wound assessments on R2's left pinky finger. NP D indicated yes, at least daily. Surveyor asked NP D if she would expect wound assessments to be documented and NP D indicated yes. Surveyor asked NP D in her professional opinion what caused R2's osteomyelitis and NP D indicated the open area. NP D indicated bacteria more than likely entered into the open area. NP D indicated osteomyelitis will spread bone to bone and is very aggressive and hard to treat with oral antibiotics. In R2's case, she is very fragile and not the healthiest and on end-of-life cares. Osteomyelitis will continue to progress from bone to bone. Another concern with osteomyelitis, the bacteria causing osteomyelitis can cause one to become septic. I chose to treat with oral antibiotics to slow the progression of the osteomyelitis down. Surveyor asked if the osteomyelitis could have been prevented and NP D indicated no, with R2 she is nonverbal. Most people with osteomyelitis have a lot of pain and can tell you. (Of note: R2's hospital diagnosis list did not have osteomyelitis listed, however it was referenced.)Staff observed R2's wound on 12/10/25. Staff did not continuously assess, document, and monitor R2's wound. R2 had a change in the wound 9 days later on 12/19/25 where there is a hematoma. R2 was sent to the emergency department and diagnosed with an abscess and closed nondisplaced fracture of distal phalanx of left little finger.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 1 of 3 Residents reviewed (R2).Facility became aware of an injury of unknown origin on 12/19/25 when R2 was sent to the emergency department and was found to have a closed nondisplaced fracture of the left pinky finger. The facility failed to conduct and complete a thorough investigation.Evidenced by:The facility policy entitled Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 12/2025, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from Abuse. Sauk County Health Care Center will take all reasonable measures to ensure resident safety and security and will promptly investigate all reports/allegations of resident rights violations, abuse, neglect, mistreatment, injuries of unknown source or misappropriation of property, resident to resident incidents, reporting the investigative results to the appropriate agencies in accordance with state and federal laws.Definitions of Abuse and Neglect: .g. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met:i. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident;ii. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.PROCEDURE: RESPONDING/INVESTIGATING/PROTECTION:All allegations of misconduct will be thoroughly investigated.3. Any facility employee having either direct or indirect knowledge of potential misconduct involving a facility resident shall immediately follow the reporting procedures.4. The Supervisor receiving verbal or written information shall take prompt measures to assess and ensure the safety and welfare of the resident(s) involved, immediately notify the Administrator or Administrator designee of the allegation along with any other appropriate individuals. Following notification of the Administrator, the supervisor/administrator reporting will immediately complete the Alleged Nursing Home Resident Mistreatment Report via the online reporting system.5. The supervisor or designee will report suspected crimes to law enforcement. Serious injuries will be reported no later than 2 hours after discovery. Nonserious injuries will be reported no later than 24 hours after discovery.8. For the Nursing Home, the Administrator, Social Worker, DON (Director of Nursing) or designee will complete the investigation. THOROUGH INVESTIGATION:All nursing homes must immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident, and document the findings for each incident. A thorough investigation may include: .-Identifying and interviewing other staff or residents in the immediate area at the time of the incident who may have witnessed what occurred.-Interviewing other residents to determine if they have been abused or mistreated.-Interviewing staff who worked previous shifts to determine if they were aware of an injury or incident.13. The investigation will be conducted within 5 working days of the alleged incident.14. The Administrator. shall complete. Caregiver Misconduct Incident Report. The completed form, along with a copy of the Alleged form and the appropriate supporting documentation will be submitted via the MISCONDUCT INCIDENT REPORTING SYSTEM and/or forwarded to the Division of Quality Assurance, Office of Caregiver Quality. This will be completed within five working days of the alleged incident. R2 was admitted to the facility on [DATE] and has diagnoses that include cerebrovascular disease (a group of conditions that impair brain blow flow, including stroke, carotid stenosis (narrowing of the carotid arteries in the neck caused by plaque buildup), aneurysms (dangerous bulge in the artery wall caused by weakened vessels, which can cause severe bleeding or death if ruptures) and vascular malformations. These occur when blood vessels in the brain are damaged or blocked by atherosclerosis (condition where plaque builds up inside your arteries and overtime hardens and causes your arteries to narrow), blood clots, or rupture and unspecified dementia, severe with anxiety, and bilateral osteoarthritis of hip.R2's Minimum Data Set (MDS) Significant Change Assessment, dated 1/22/26, shows R2 has severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 00.R2's Progress Notes as follows:12/19/25, at 2:55 PM, Skin Problems: Left pinky cleaned as ordered, notified Charge nurse of change in wound appearance.12/19/25, 5:35 PM, General Skin Condition: Resident left pinky finger noted to have a large hematoma- on lateral finger red and warm- . POA (power of attorney) and on call doctor phoned and he would like to have this hematoma looked [sic] in ER (emergency room) .12/19/25, at 5:45 PM, Resident Transferred: 12/19/25 Time of Transfer: 6:00PMTransferred to: [Reedsburg Area Medical Center] . by ambulance.12/19/25, 11:39 PM, Returned from: Emergency Room. Return Date: 12/19/25. Return Time: 10:33 PM. R2's Hospital Rapid Assessment and Management, dated 12/19/25, at 6:32 PM, states, in part: . Brief HPI (history of present illness): .Patient presents with: Hand Pain. Sent from the Sauk County Care Center due to swollen left pinky, with pus drainage. Unclear if there was an associated injury. R2's hospital Discharge summary, dated [DATE], states, in part: . Chief Complaint: Hand pain.Medical Decision Making:R2 here with hand pain. X-ray imaging with possible nondisplaced fracture involving the mid diaphysis of the pinky finger distal phalanx.XR Hand Min 3 Views L (left) (Final Result): Impression: 1. Possible nondisplaced fracture involving the med diaphysis of the pinky finger distal phalanx.Indication: left pinky hematoma/abscess, eval for fracture.Findings: Bones appear osteopenic. Possible nondisplaced fracture involving the mid diaphysis of the pinky finger distal phalanx best seen on the oblique view.Diagnosis: ImpressionAbscessClosed Nondisplaced fracture of distal phalanx of left little finger.On 2/3/26 at 10:54 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) and asked if she could tell Surveyor about R2's left pinky finger. LPN E indicated it had been broken about a month ago. LPN E indicated R2's left pinky had been tested, and osteomyelitis was found at that time. LPN E indicated R2's left hand is pretty contracted, and staff have to pull R2's fingers up to get the palm protectors on. LPN E indicated she is not aware of how R2's left pinky finger had been broken. Surveyor asked LPN E what the facility's process is when a wound or a change of condition is observed with a resident. LPN E indicated the floor nurse would report it to the nurse supervisor. The nurse supervisor would do an incident report, report to the physician and receive an order.On 2/3/26 at 11:30 AM, Surveyor requested from DON B (Director of Nursing) an incident report for R2's wound from 12/10/25 and weekly wound assessment documentation. DON B came back and informed Surveyor there was no incident report for R2 and there is no weekly wound assessment documentation.On 2/3/26 at 4:34 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if an injury of unknown source should be reported to the state. NHA A indicated yes. Surveyor asked NHA A if R2's closed nondisplaced fracture to the left pinky finger should have been investigated to determine the cause of the fracture, NHA A indicated yes.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 residents (R2) reviewed for abuse.Facility became aware of an injury of unknown origin on 12/19/25 when R2 was sent to the emergency department and was found to have a closed nondisplaced fracture of the left pinky finger. The facility failed to report it to the state within the required timeframe.Evidenced by:The facility policy entitled Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 12/2025, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from Abuse. Sauk County Health Care Center will take all reasonable measures to ensure resident safety and security and will promptly investigate all reports/allegations of resident rights violations, abuse, neglect, mistreatment, injuries of unknown source or misappropriation of property, resident to resident incidents, reporting the investigative results to the appropriate agencies in accordance with state and federal laws.Definitions of Abuse and Neglect: .g. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met:i. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident;ii. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.PROCEDURE: RESPONDING/INVESTIGATING/PROTECTION:All allegations of misconduct will be thoroughly investigated.3. Any facility employee having either direct or indirect knowledge of potential misconduct involving a facility resident shall immediately follow the reporting procedures.4. The Supervisor receiving verbal or written information shall take prompt measures to assess and ensure the safety and welfare of the resident(s) involved, immediately notify the Administrator or Administrator designee of the allegation along with any other appropriate individuals. Following notification of the Administrator, the supervisor/administrator reporting will immediately complete the Alleged Nursing Home Resident Mistreatment Report via the online reporting system.5. The supervisor or designee will report suspected crimes to law enforcement. Serious injuries will be reported no later than 2 hours after discovery. Nonserious injuries will be reported no later than 24 hours after discovery.8. For the Nursing Home, the Administrator, Social Worker, DON (Director of Nursing) or designee will complete the investigation.R2 was admitted to the facility on [DATE] and has diagnoses that include cerebrovascular disease (a group of conditions that impair brain blow flow, including stroke, carotid stenosis (narrowing of the carotid arteries in the neck caused by plaque buildup), aneurysms (dangerous bulge in the artery wall caused by weakened vessels, which can cause severe bleeding or death if ruptures) and vascular malformations. These occur when blood vessels in the brain are damaged or blocked by atherosclerosis (condition where plaque builds up inside your arteries and overtime hardens and causes your arteries to narrow), blood clots, or rupture and unspecified dementia, severe with anxiety, and bilateral osteoarthritis of hip.R2's Minimum Data Set (MDS) Significant Change Assessment, dated 1/22/26, shows R2 has severe cognitive impairment with a BIMS (Brief Interview of Mental Status) score of 00.R2's Progress Notes as follows:12/19/25, at 2:55 PM, Skin Problems: Left pinky cleaned as ordered, notified Charge nurse of change in wound appearance.12/19/25, 5:35 PM, General Skin Condition: Resident left pinky finger noted to have a large hematoma- on lateral finger red and warm- . POA (power of attorney) and on call doctor phoned and he would like to have this hematoma looked [sic] in ER (emergency room) .12/19/25, at 5:45 PM, Resident Transferred: 12/19/25 Time of Transfer: 6:00 PMTransferred to: [Reedsburg Area Medical Center] . by ambulance.12/19/25, 11:39 PM, Returned from: Emergency Room. Return Date: 12/19/25. Return Time: 10:33 PM. R2's Hospital Rapid Assessment and Management, dated 12/19/25, at 6:32 PM, states, in part: . Brief HPI (history of present illness): .Patient presents with: Hand Pain. Sent from the Sauk County Care Center due to swollen left pinky, with pus drainage. Unclear if there was an associated injury. R2's hospital Discharge summary, dated [DATE], states, in part: . Chief Complaint: Hand pain.Medical Decision Making:R2 here with hand pain. X-ray imaging with possible nondisplaced fracture involving the mid diaphysis of the pinky finger distal phalanx.XR Hand Min 3 Views L (left) (Final Result): Impression: 1. Possible nondisplaced fracture involving the med diaphysis of the pinky finger distal phalanx.Indication: left pinky hematoma/abscess, eval for fracture.Findings: Bones appear osteopenic. Possible nondisplaced fracture involving the mid diaphysis of the pinky finger distal phalanx best seen on the oblique view.Diagnosis: ImpressionAbscessClosed Nondisplaced fracture of distal phalanx of left little finger.On 2/3/26 at 10:54 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) and asked if she could tell Surveyor about R2's left pinky finger. LPN E indicated it had been broken about a month ago. LPN E indicated R2's left pinky had been tested, and osteomyelitis was found at that time. LPN E indicated R2's left hand is pretty contracted, and staff have to pull R2's fingers up to get the palm protectors on. LPN E indicated she is not aware of how R2's left pinky finger had been broken. On 2/3/26 at 11:30 AM, Surveyor requested from DON B (Director of Nursing) an incident report for R2's wound from 12/10/25 and weekly wound assessment documentation. DON B came back and informed Surveyor there was no incident report for R2 and there is no weekly wound assessment documentation.On 2/3/26 at 4:34 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if an injury of unknown source should be reported to the state. NHA A indicated yes. Surveyor asked NHA A regarding R2. Surveyor asked NHA A if R2's fracture should have been reported to state with not knowing what the cause was, NHA A indicated yes. Surveyor asked NHA A if R2's closed nondisplaced fracture to the left pinky finger should have been investigated to determine the cause. NHA A indicated yes.

Based on interview and record review, the facility failed to thoroughly investigate an accusation of verbal abuse for 2 of 3 residents (R1 & R2) reviewed for abuse.Facility became aware of an abuse allegation on 10/4/25 regarding R1 and R2. The facility did not conduct a thorough investigation or put protections in place during the investigation. Evidenced by:The facility policy entitled, Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 10/2024, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, exploitation, corporal punishment or involuntary seclusion.Definitions: Definitions of Abuse and Neglect: .i. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident.Procedure: Responding/Investigating/Protection:All allegations of misconduct will be thoroughly investigated.1. Any person may report an allegation of potential resident mistreatment, neglect, abuse, misappropriation of resident property, injury of unknown source, resident rights violation, or resident to resident incident to any entity employee at any time. Upon receiving such a report, either verbal or written, the entity employee shall immediately intervene, if necessary, and assure resident safety. Resident safety is priority. Once resident safety is ascertained, reporting individual will immediately inform the unit nurse/supervisor or management staff, who will immediately notify the administrator or administrator designee in person or with direct telephone contact.Examples of ways to ensure resident safety include:A. Removing the alleged perpetrator from the facility.4. The supervisor receiving verbal or written information shall take prompt measures to assess and ensure the safety and welfare of the resident involved, immediately notify the Administrator. of the allegation along with any other appropriate individuals. Following notification of the Administrator, the supervisor/administrator reporting will immediately complete the Alleged Nursing Home Resident Mistreatment Report via the online reporting system @ https://dqa.wi.gov/DHSSurveys/takesurvey.aspx?surveyid=96mi3mi4 .6. Resident or resident legal representative will be immediately informed. of the initiation of the investigation.9. Staff to include contracted staff will be oriented to the Abuse Report Policy and Procedure to include their reporting requirements . Staff are required to report suspected misconduct and crimes to their immediate supervisor immediately.Thorough Investigation:All nursing homes must immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident, and document the findings for each incident. A thorough investigation may include: .*Identifying and interviewing other staff or residents in the immediate area at the time of the incident who may have witnessed what occurred.*Interview other residents to determine if they have been abused or mistreated.12. Based upon initial information received from the resident and/or employee(s), the entity Administrator. will take/direct appropriate action to protect the resident's health, safety and welfare from any real or perceived future misconduct while the investigation is in progress. Such action will include suspending the involved employee(s) from further work duties until the investigation is completed.14. The Administrator. shall complete Form F-62447, Caregiver Misconduct Incident Report if an investigation was initiated. The completed form, along with a copy of the Alleged Form and the appropriate supporting documentation will be submitted via the MISCONDUCT INCIDENT REPORTING SYSTEM and/or forwarded to the Division of Quality Assurance, Office of Caregiver Quality. This will be completed within five working days of the alleged incident. Example 1:R1 admitted to the facility on [DATE] and has diagnoses that include Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks) and metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic disorder).R1's Quarterly Minimum Data Set (MDS) Assessment, dated 8/10/25 shows that R1 has severe cognitive impairment by showing no Brief Interview of Mental Status (BIMS) score.R2 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain).R2's admission MDS Assessment, dated 9/15/25 shows that R2 has a BIMS score of 3 indicating R2 has severe cognitive impairment.On 10/14/25 at 10:52 AM, Surveyor interviewed R2. Surveyor asked R2 if the staff treat her well and R2 indicated no. Surveyor asked R2 to tell Surveyor about that and R2 shrugged her shoulders. Surveyor asked R2 if staff have ever hurt her or yelled at her. R2 answered yes to staff yell at her. Surveyor asked R2 when staff yell at her and R2 indicated quite often. R2 could not indicate what staff or when. R2 indicated when staff yell at her it does not make her feel good.On 10/14/25 at 11:45 AM, NHA A (Nursing Home Administrator) provided Surveyor with the investigation he conducted of the allegation.The NHA A's summary dated 10/04/25, states: I received the phone call from (DON B (Director of Nursing)) around 8:15 PM of a possible allegation. The accused employee (CNA E (Certified Nursing Assistant)) was immediately sent home. The accuser refused to leave a statement when asked to by DON B. I arrived at the facility about 9:15 PM. Upon entering the facility, I talked with the nurse on the (name) wing and discussed the incident with all staff members on the location. I asked all staff members to complete a statement if they hadn't written one already. Next, I went to room [number] to interview the resident. Upon entering the room the resident appeared to be happy and in a good mood. Resident did not appear to be frightened or upset. I asked her how she was and if her night was going ok. Resident said yes. I asked R1 if she felt safe, and she responded yes. Than [sic] we talked a little while about the tv show she was watching.The next morning a skin assessment was done on all residents on (unit name0, with no findings.Signed NHA A.The investigation completed by NHA A includes:4 staff statementsSkin check dated 10/5/25 for all residents on that unit onlyEducation on treating residents with dignity and respect. One staff signature sheet dated 10/4/25 with 20 signatures, and another signature sheet dated 10/6/25 with 17 signatures.Of note: there are no resident interviews.CNA E's Invoices showing the days CNA E worked at the facility show CNA E worked on 10/5/25, 10/6/25, and 10/7/25.Of note: The investigation was still being conducted on 10/6/25 with staff being educated on 10/6/25.On 10/14/25 at 11:06 AM, Surveyor interviewed NHA A who indicated an allegation was reported to him on 10/4/25 at 8:15 PM from DON B. NHA A indicated he was informed that CNA D refused to write a statement and walked out during her shift. NHA A indicated he arrived at the facility at 9:15 PM and was informed CNA E told R1 if she got up again CNA E was going to slap her. CNA E had got sent home around 8:00PM. NHA A indicated when he arrived at the facility at 9:15 PM he spoke with RN F who was getting statements from staff. NHA A indicated the 3 CNAs reported they were trying to redirect R2 back to the hall and CNA E said If R2 wanted out she is strong enough to run all of us over. NHA A indicated the staff said CNA E said it more in a joking way. NHA A indicated he received statements from all staff and education was started that night on1) If a resident is leaving the hall, we cannot block resident. Staff to try to redirect resident and if unable 1 staff is to stay with the resident, and 2) Staff to be professional and not demeaning communication in front of or with the residents. NHA A indicated he spoke with R1 and asked her if anything happened that evening; R1 indicated no. NHA A asked R1 if she felt safe and R1 indicated yes. Surveyor asked NHA A if R1 is alert and oriented, and NHA A indicated no. NHA A indicated a skin check was performed on all residents just on that unit the next morning. Surveyor asked NHA A if this incident was an allegation of abuse and NHA A indicated yes. Surveyor asked NHA A when an allegation of abuse be reported to the state agency, and NHA A indicated within 2 hours. Surveyor asked if the incident was reported to the state agency and NHA A indicated no because he investigated and found the other witnesses had different stories and CNA D would not give a statement. NHA A indicated the facility assured R1 was safe, and education was started and continued through the weekend. Surveyor asked if the investigation was considered completed before the education was completed. NHA A indicated no. Surveyor asked if CNA E worked the weekend, and NHA A said he would check. Surveyor asked NHA A for time punches for CNA E. Surveyor asked if an allegation of abuse should have been reported to the state within 2 hours and, NHA A indicated yes.Of note: CNA E worked the next day on 10/5/25 and on 10/6/25 while the investigation was still being conducted. Residents' safety was not ensured at time.On 10/14/25 at 11:35 AM, Surveyor interviewed DON B who indicated she received a call from RN F on 10/4/25 at 7:41 PM about CNA D reporting overhearing CNA E saying she was going to slap R1. CNA D was there with RN F during the phone conversation, and it was on speaker. CNA D indicated she feared for her life and wanted to leave the facility. CNA D wanted the police phoned. DON B asked CNA D if someone had threatened her and CNA D indicated no, but she heard CNA E yell at R1. CNA D indicated she doesn't feel safe. DON B indicated she told CNA D to fill out a statement and that CNA E would be sent home. CNA D would not complete a statement at that time but did write a statement a few days later and emailed it to her. CNA E was sent home after completing a statement of the incident. DON B indicated she called NHA A immediately at 7:50 PM and informed him of the abuse allegation and that CNA D left facility because she feared for her life. DON B indicated NHA A was going to the facility to interview staff. DON B indicated the morning of 10/5/25, a skin sweep on that unit was conducted by RN C. Surveyor asked DON B when an allegation of abuse should be reported to the state agency, and DON B indicated within 2 hours.On 10/14/25 at 3:35 PM, CNA D returned Surveyor's phone call. CNA D indicated on 10/4/25 she was working on the same unit as CNA E and observed CNA E being reckless with the residents all day by pulling the residents up by their hands instead of using a gait belt. CNA D indicated R1 and R2 had been wandering off the unit the whole shift. CNA D indicated one-time R2 had wandered off the unit and CNA E brought R2 back and stated to R2 You do that again I am going to beat your butt. Throughout the shift after that R2 was acting more confused by pushing her tray table from her room up the hallway instead of her walker. CNA D indicated she reported the incident to the nurse (CNA D could not recall the nurse's name). Surveyor asked CNA D what time she reported the incident, and CNA D could not recall. CNA D indicated CNA E had told her and another cna that she wanted to bop R1 on the head, and R1 was in close range when that was said. Surveyor asked CNA D when she overheard CNA E tell R1 she was going to beat her butt what CNA D did. CNA D indicated she was working with another resident at the time, but as CNA D walked past CNA E and R1 she said Stop to CNA E. CNA D indicated she estimates reporting it an hour to an hour and a half later to the nurse. CNA D indicated the nurse phoned DON B and had her on speaker phone. CNA D informed DON B she felt unsafe and wanted to leave the facility. CNA D wanted the police phoned due to CNA E threatening a resident and because of CNA E's actions. CNA D informed DON B she would fill out a statement later she just wanted to leave the facility. CNA D filled a statement out indicated she emailed it to the facility. CNA D indicated she left the facility right after talking to DON B (CNA D unsure of time). Facility became aware of an abuse allegation on 10/4/25 involving CNA E and the facility did not conduct a thorough investigation or put protections in place during the investigation.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 3 residents (R1 and R2) reviewed for abuse. Facility became aware of an abuse allegation on 10/4/25 at 7:41 PM involving R1 and R2 The facility did not report the allegation to the State Agency. Evidenced by: The facility policy entitled, Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 10/2024, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, exploitation, corporal punishment or involuntary seclusion.Definitions: Definitions of Abuse and Neglect: .i. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident.Procedure: Responding/Investigating/Protection:All allegations of misconduct will be thoroughly investigated.1. Any person may report an allegation of potential resident mistreatment, neglect, abuse, misappropriation of resident property, injury of unknown source, resident rights violation, or resident to resident incident to any entity employee at any time. Upon receiving such a report, either verbal or written, the entity employee shall immediately intervene, if necessary, and assure resident safety. Resident safety is priority. Once resident safety is ascertained, reporting individual will immediately inform the unit nurse/supervisor or management staff, who will immediately notify the administrator or administrator designee in person or with direct telephone contact.Examples of ways to ensure resident safety include:A. Removing the alleged perpetrator from the facility.4. The supervisor receiving verbal or written information shall take prompt measures to assess and ensure the safety and welfare of the resident involved, immediately notify the Administrator. of the allegation along with any other appropriate individuals. Following notification of the Administrator, the supervisor/administrator reporting will immediately complete the Alleged Nursing Home Resident Mistreatment Report via the online reporting system @ https://dqa.wi.gov/DHSSurveys/takesurvey.aspx?surveyid=96mi3mi4 .6. Resident or resident legal representative will be immediately informed. of the initiation of the investigation.9. Staff to include contracted staff will be oriented to the Abuse Report Policy and Procedure to include their reporting requirements . Staff are required to report suspected misconduct and crimes to their immediate supervisor immediately. Thorough Investigation:All nursing homes must immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident, and document the findings for each incident. A thorough investigation may include: .*Identifying and interviewing other staff or residents in the immediate area at the time of the incident who may have witnessed what occurred.*Interview other residents to determine if they have been abused or mistreated.12. Based upon initial information received from the resident and/or employee(s), the entity Administrator. will take/direct appropriate action to protect the resident's health, safety and welfare from any real or perceived future misconduct while the investigation is in progress. Such action will include suspending the involved employee(s) from further work duties until the investigation is completed.14. The Administrator. shall complete Form F-62447, Caregiver Misconduct Incident Report if an investigation was initiated. The completed form, along with a copy of the Alleged Form and the appropriate supporting documentation will be submitted via the MISCONDUCT INCIDENT REPORTING SYSTEM and/or forwarded to the Division of Quality Assurance, Office of Caregiver Quality. This will be completed within five working days of the alleged incident. Example 1:R2 was admitted to the facility on [DATE] and has diagnoses that include vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain).R2's admission Minimum Data Set (MDS) Assessment, dated 9/15/25 shows that R2 has a Brief Interview of Mental Status (BIMS) score of 3 indicating R2 has severe cognitive impairment.On 10/14/25 at 10:52 AM, Surveyor spoke with R2. Surveyor asked R2 if she receives the care she needs at the facility and R2 indicated yes. Surveyor asked R2 if the staff treat her well and R2 indicated no. Surveyor asked how the staff treat her and R2 did not answer. Surveyor asked if any staff have ever physically or verbally abused R2 by hurting her or yelling at her. R2 indicated yes. R2 could not indicate when or who. R2 indicated it happens quite often staff yell at her. Surveyor asked R2 if staff hurt her and R2 indicated no. Surveyor asked R2 how that makes her feel when staff yell at her and R2 shrugged her shoulders. Surveyor asked if it makes her feel good and R2 indicated not good.On 10/14/25 at 3:35 PM, CNA D (Certified Nursing Assistant) returned Surveyor's phone call. CNA D indicated on 10/4/25 she was working on the same unit as CNA E and observed CNA E being reckless with the residents all day by pulling the residents up by their hands instead of using a gait belt. CNA D indicated R1 and R2 had been wandering off the unit the whole shift. CNA D indicated one-time R2 had wandered off the unit and CNA E brought R2 back and stated to R2 You do that again I am going to beat your butt. Throughout the shift after that R2 was acting more confused by pushing her tray table from her room up the hallway instead of her walker. CNA D indicated she reported the incident to the nurse (CNA D could not recall the nurse's name). Surveyor asked CNA D what time she reported the incident, and CNA D could not recall. CNA D indicated CNA E had told her and another CNA that she wanted to bop R1 on the head. Surveyor asked CNA D when she overheard CNA E tell R1 she was going to beat her butt what CNA D did. CNA D indicated she was working with another resident at the time so nothing, but she reported it an hour to an hour and a half later. CNA D indicated the nurse phoned DON B (Director of Nursing) and had her on speaker phone. CNA D informed DON B she felt unsafe and wanted to leave the facility. CNA D wanted the police phoned due to CNA E threatening a resident and on CNA E's actions. CNA D informed DON B she would fill out a statement later she just wanted to leave. CNA D indicated she left the facility right after talking to DON B (CNA D unsure of time).Of Note: Surveyor unsuccessful in connecting with RN F (Registered Nurse) and CNA E for interview.Example 2:R1 admitted to the facility on [DATE] and has diagnoses that include Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior. Symptoms eventually grow severe enough to interfere with daily tasks) and metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic disorder). R1's Quarterly Minimum Data Set (MDS) Assessment, dated 8/10/25 shows that R1 has severe cognitive impairment by showing no Brief Interview of Mental Status (BIMS) score.On 10/14/25, at 10:56 AM, Surveyor interviewed RN C. RN C indicated when she came onto shift on 10/4/25 she had heard from the PM (evening) nurse a complaint that staff was trying to stop a resident from leaving the unit. RN C indicated NHA A came into the facility that evening due to the complaint. RN C indicated she had to sign something for abuse and care planning.On 10/14/25 at 11:06 AM, Surveyor interviewed NHA A (Nursing Home Administrator) who indicated an allegation was reported to him on 10/4/25 at 8:15 PM from DON B (Director of Nursing). NHA A was informed around 8:00 PM CNA E told R1 if she got up again CNA E was going to slap R1. CNA E had got sent home. NHA A indicated he arrived at the facility at 9:15 PM and spoke with RN F who was getting statements from staff. NHA A indicated he received statements from all staff and education was started that night on) If a resident is leaving the hall, we cannot block resident. Staff to try to redirect resident and if unable 1 staff is to stay with the resident, and 2) Staff to be professional and not demeaning communication in front of or with the residents. NHA A indicated he spoke with R1 and asked her if anything happened that evening; R1 indicated no. NHA A asked R1 if she felt safe and R1 indicated yes. Surveyor asked NHA A if R1 is alert and oriented, and NHA A indicated no. Surveyor asked NHA A if this incident was an allegation of abuse and NHA A indicated yes. Surveyor asked NHA A when an allegation of abuse be reported to the state agency, and NHA A indicated within 2 hours. Surveyor asked if the incident was reported to the state agency and NHA A indicated no because he investigated and found the other witnesses had different stories and CNA D would not give a statement. NHA A indicated the facility assured R1 was safe, and education was started and continued through the weekend. NHA A indicated it should have been reported to the state.On 10/14/25 at 11:35 AM, Surveyor interviewed DON B (Director of Nursing) who indicated she received a call from RN F on 10/4/25 at 7:41 PM about CNA D reporting overhearing CNA E saying she was going to slap R1. CNA D was there with RN F during phone conversation, and CNA D indicated she feared for her life. DON B asked CNA D if someone had threatened her and CNA D indicated no, but she heard CNA E yell at R1. CNA E was sent home after completing a statement of the incident. DON B indicated she called NHA A immediately at 7:50 PM and informed him of the abuse allegation and that CNA D left facility because she feared for her life. DON B indicated NHA A was going to the facility to interview staff. The next morning 10/5/25 NHA A informed DON B the allegation was unfounded. DON B indicated the morning of 10/5/25, a skin sweep on that unit was conducted by RN C. Surveyor asked DON B when an allegation of abuse should be reported to the state agency, and DON B indicated within 2 hours.Facility staff were aware of an allegation of abuse involving R1 and R2, this was not reported to the state survey agency within the required timeframes.

Based on interview and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 3 residents (R) reviewed for pressure injuries (R19). R19 was at risk for developing pressure injuries (PI) related to decreased mobility, bilateral above knee amputation, and radiation therapy. R19 developed a facility-acquired stage 3 PI. The facility did not identify or stage this as a PI but considered it a chronic wound, identifying the root cause was related to friction and shearing from the use of a slide board transfer. The facility continued to use the slide board transfer until after R19 had a EpiFix flap procedure to heal the PI. Additionally, R19 was known to use a rolled washcloth under his hip which the facility also identified as contributing to the PI. Despite these known risk factors, the facility continued to utilize the slide board and failed to provide documented risk vs. benefits to R19 regarding continued use of the slide board and use of the washcloths. R19 developed a facility acquired stage 3 PI, which deteriorated, became infected, and required an EpiFix graft in an attempt to heal the PI. The facility's failure to use an alternative transfer method to the slide board and failure to provide resident with risk vs. benefits of continued use of the slide board led to a finding of immediate jeopardy that began on 3/12/25. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 3/31/25 at 12:38pm. The immediate jeopardy was removed on 3/31/25 and continues at a scope/severity of D (Potential for harm/isolated). Findings include: The facility's policy titled Pressure Injury Prevention reviewed 4/2024 states in part: Clinical conditions that this facility identifies as risk factors for development of pressure injuries include, but are not limited to: Impaired or decreased mobility and functional ability, terminal illness, semi-comatose or comatose, COPD, peripheral vascular disease, diabetes, bowel incontinence, urinary incontinence or chronic voiding dysfunction, paraplegia, quadriplegia, sepsis, terminal cancer, chronic or end-stage renal, liver and/or heart disease, disease or drug-related immunosuppression, body cast, malnutrition, dehydration, moderate to severe cognitive impairment, use of psychotropic medication, steroid therapy, radiation therapy, chemotherapy, renal dialysis, history of pressure injuries, impaired diffuse or localized blood flow, increased friction or shear, resident refusal to some aspects of care and/or treatment, and head of bed elevated majority of day due to medical necessity . Assessment: C. If a resident is admitted or develops a pressure injury, pressure injuries will be staged following the National Pressure Injury Advisory Panel (NPIAP) pressure injury staging system. Per the NPIAP, a pressure injury is defined as .localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. NPIAP definitions include: Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. R19 was admitted to the facility on [DATE]. Diagnoses include: malignant neoplasm of prostate (prostate cancer), non ST elevation myocardial infarction (a serious heart attack that occurs when blood supply to the heart is reduced causing damage), hypertensive heart disease with heart failure, venous insufficiency, cerebral ischemic attacks and related syndromes (strokes, occurs when blood flow to the brain is interrupted causing brain cells to die), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and thrombocytopenia (low platelet level in blood). R19's most recent Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 15, indicating R19 is cognitively intact. Facility completed an additional BIMS on 3/28/25 and R19's score was also 15. Surveyor reviewed MDS assessments for R19 going back to facility's last recertification survey which was completed on 5/1/24. *On the Annual MDS completed 5/8/24, Section M indicates no unhealed pressure ulcers. *Quarterly MDS completed on 8/9/24, Section M indicates 1 unhealed pressure ulcer, stage 2. *Quarterly MDS completed on 11/12/24, Section M indicates no unhealed pressure ulcers. *Quarterly MDS completed on 2/12/25 indicates no unhealed pressure ulcers. Although the facility selected no unhealed pressure ulcers on 3 of the 4 MDS assessments, Surveyor noted observed R19 had weekly wound measurements during those months for a left buttock wound. R19's care plan dated 3/26/20 states in part: Problem: Self Care Deficit .3/19/25, Special Approaches: .enhanced barrier precautions .Transfer: 2 Assist Hoyer .Repositioning/Bed Mobility: Assist of 1 person, minimal, bilateral grab bars to aid in repositioning .Toileting: I use urinal, slide board A of 1 person .Skin: Roho Cushion, Encourage/Reposition q (every) 2 hours, keep skin clean and dry, apply moisturizer, report changes in skin to nurse .3/10/2020, Problem: Potential for incontinence, Pericare when incontinent .cleanse peri area and apply barrier cream after incontinent episodes and PRN (as needed), Incontinence check every hour .11/13/2022, Manifested by: potential for abraded/open skin, fragile skin .11/13/2023, Related to: mobility deficit, diuretic usage, bladder flow obstruction, slide board use, prostate CA (cancer) .11/12/2020, Problem: 5/28/2020, Potential for Tissue integrity impairment .2/12/2025, Roho cushion .Reposition every 2 hours; lift and move resident carefully and with adequate assistance to prevent shearing of the skin .Keep skin clean and dry .give incontinence care after each episode of incontinence; apply moisturizer and moisture barrier PRN. Utilize draw sheet for positioning/turning. Position pillows as needed, Room safeguards: Air mattress, Apex cushion to w/c .3/10/2020, Problem: Potential for Alteration in Bowel Elimination .assist resident with toileting every 2 hours and as needed, assist resident with cleansing perianal area after bowel movements, maintain resident dignity, praise continency .3/31/2023, **enhanced barrier precautions** open wound to buttock .3/12/25, Potential for infection: left buttock wound .Manifested by: drainage, redness . Of note: Physician progress note dated 10/28/24 states in part; he notes difficulty in obtaining a Roho cushion for offloading. We discussed the importance of offloading in regard to wound healing. Specifically, we discussed the benefits of obtaining a Roho cushion. It should be noted R19's care plan indicates R19 Roho was care planned beginning on 2/12/25. However, a progress note dated 1/9/25 states R19 was using a Roho on this visit. This is several months after a Roho was recommended by R19's physician. Additionally, R19's care plan states in part: .2/15/25, Care Plan Summary .R19 had a surgical procedure to close the chronic wound to his left buttock. The drain fell out and sutures were removed. The procedure was unsuccessful. He continues to have an open area, surgeon was notified. He sees wound care on a regular basis. He seen the surgeon again and R19 is to try to stay in bed as much as possible and stay off bottom. If the wound does not decrease in size surgeon wants to perform flap procedure . Progress notes in R19's Electronic Health Record include, in part: 1/21/24 - Wound on left buttock started 1/22/24 - Physician note - .He does have a history of Prostate Cancer, was started on radiation on November 29, 2023, again. A/P: 1. Hypertensive Heart Disease 2. Coronary Artery Disease 3. Diarrhea Secondary to Radiation . 2/9/24 - Care plan summary notes - .He is currently using a slide board for transfers. R19 states the slide board causes him pain and now he has shearing. He was seeing therapy for a different transfer method or slide board. Therapy states he did not like the other board and stopped going after 4 visits . Of note: there is no evidence that the facility completed risk vs benefits with R19 despite knowing that R19 did not want to try an alternative slide board or by declining participation in therapy. 2/17/24 - Physician note - .He is complaining of a lot of soreness on his bottom because of the diarrhea which has created a couple of wounds . 3/21/24 - Physician note - .We will need to find a solution to decrease friction from the sliding board as much as possible which appears to be contributing to slow healing of the wound . 5/16/24 - Physician note - .Completed radiation in January 2024 and as a consequence there was radiation proctitis with frequent diarrhea. He reports that the diarrhea has significantly improved since last week, however he is still dealing with a wound that seems to be consistent with an ulcer on the left buttock, likely from frequent friction on the sliding board . 6/4/2024 - Started wound clinic 8/13/24 - Wound clinic note - .nonhealing ulcer to left buttock, .5 x .5 x .3 - undermining from 10 o'clock to 11 o'clock approximately .3cm . 8/27/24 - Wound clinic note - .nonhealing ulcer to left buttock, .7 x .7 x .3 - undermining from 7 o'clock to 10 o'clock approximately .3cm . 9/10/24 - Wound clinic note - .nonhealing ulcer to left buttock, Thickness: full, .6 x .6 x .4 cm, undermining to circumference of wound . Patient Education: Continue using cushion in chair at all times. Reposition frequently. Lay on your side at night to relieve pressure. Patient states he has a pressure reducing mattress. 9/24/24 - Wound clinic note - .Wound is bigger .1 x .8 x .5, undermining to circumference of the wound .Mixture of granulation tissue and nongranular tissue .appearance of biofilm present . 10/7/24 - Wound clinic note - .chronic wound buttocks, 1 cm x .8 cm, undermining present . 10/28/24 - Wound clinic note - .History of Present Illness: .He developed multiple wounds of the buttocks approximately 6 months ago as a consequence of loose stools due to radiation for prostate cancer. All of the wounds have since resolved with the exception of a persistent wound of the left gluteal region .Procedure: Sharp debridement and partial delayed primary closure of wound, left buttock .Findings: 2x2x1cm ulceration of the left gluteal region with fibrous tissue about the base and undermining circumferentially. The fibrous tissue about the base was sharply debrided with partial primary closure of the wound over a Penrose drain . He notes difficulty obtaining a Roho cushion for offloading given he is currently in the process of obtaining a new chair. Also, noted today he is sitting on a folded towel underneath the wound of left buttock. States he has been doing this for some time as he feels that it alleviates some pressure and discomfort. Assessment and Plan .We discussed the importance of offloading in regard to wound healing. Specifically, we discussed the benefits of obtaining a Roho cushion and avoidance of placing a towel underneath the left buttock, as this may well be making the ulceration worse . Of note: there is no evidence that the facility completed risk vs. benefits with R19 despite knowing that R19 was using a rolled-up washcloth under his bottom while in his wheelchair. 11/1/24 - .has surgical wound left buttock, length .8cm, width 1cm, depth .5cm, drainage none, odor none, wound bed open, intact surrounding tissue .drain and sutures removed . 11/6/24 - Wound doctor note - .History of Present Illness: .chronic decubitus ulceration of the left buttock .The Penrose drain placed within the wound was noted to be dislodged by staff at his facility. This along with the suture for delayed primary closure was removed. He presents today at the request of facility staff due to concerns of worsening of the wound . Assessment and plan: The wound appears to be progressing well. We discussed the importance of continue to work on offloading specially I recommend a Roho cushion as he does spend 4 to 5 hours/day in his chair. We will attempt to arrange this for him. Of note: R19 is not currently using a Roho despite wound physician's recommendation for the use of a Roho cushion on 10/28/24. 12/4/24 - Wound doctor note - .Primary Diagnosis: Pressure Injury of left buttock, stage 3 .1 month status post debridement and partial delayed primary closure of a chronic decubitus ulceration of the left buttock .He occasionally places a towel under the left gluteal region during transport as this improves symptoms during transport . Assessment and plan: One month status post debridement and partial delayed closure of chronic decubitus ulceration of the left buttock, progressing well, significantly improved since debridement and delayed primary closure. 1/9/25 - Wound doctor note - .History of Present Illness: .chronic decubitus ulceration of the left buttock . he has been progressing well post procedurally. He occasionally places a towel under the left gluteal region during transport as this improves symptoms during transport. He is using a Roho cushion in his wheelchair. There is a 1 x 1 x 0.5 cm wound of the left gluteal region, increased in size from his previous visit. There is granulation tissue about the base of the wound. There is mild undermining of the wound circumferentially. Assessment and Plan: Wound is improved since partial delayed primary closure but has increased in size from his previous appointment. We discussed that we should continue to work on offloading, and avoidance of placing a towel underneath the wound during transport. He does have a Roho cushion which is excellent. Of note, although the physician discussed the avoidance of using the towel there is no evidence that the facility completed risk vs benefits with R19 despite knowing that R19 was using a rolled-up washcloth under his bottom while in his wheelchair. 1/22/25, Wound Clinic Assessment 1cm x 1cm x 0.4cm nonhealing ulcer to left buttock, full thickness. undermining entire circumference of wound, unable to measure due to pain. Granulation tissue 20% Slough 80%, distinct unattached wound border circumference of wound. Of note, R19's Medication Administration Record/Treatment Administration Record (MAR/TAR) for January shows the following entry added on 1/9/2025 and signed off through March 2025, Encourage repositioning and document refusals. *Ensure off-loading of left hip, avoid placing towel under left buttock when in w/c! Three times daily NOC AM PM 2/12/25 - .chronic wound to left buttock, 1cm x 1.2cm x .2cm, scant drainage, no odor, granulation tissue, intact, fragile - worsening, becoming larger . 2/12/25 - Wound doctor note - .Primary Diagnosis: Pressure Injury of left buttock, stage 3 . 2/19/25 - Chronic nonhealing ulceration overlying the left ischial tuberosity. He did undergo primary closure of this wound on 11/4/24 in clinic. He initially responded well to this, but the wound has since recurred. He has been undergoing cares in the wound clinic without significant improvement. He notes some pain at the site, although this is fairly minimal. He notes no drainage from the wound. Of note, he was recently transition {sic} to an inflatable cushion on his wheelchair as opposed to the Roho cushion. There is a 1.1cm x 1.1cm x .2cm wound of the left gluteal region, increased in size from his previous visit. There is granulation tissue about the base of the wound. There is mild undermining of the wound circumferentially. There is erythema and skin breakdown of the bilateral ischial tuberosities. He did undergo primary closure of the wound on 11/4/24, which initially resulted in resolution of this wound, with subsequent recurrence. We discussed that this is likely due to persistent trauma on the wound in his chair and potentially during patient transfer. We discussed that it be preferable for him to transition back to the Roho cushion as he was transitioned to an inflatable cushion approximately 2 weeks ago. Examination today is notable for PI and trauma to the skin overlying the bilateral ischial tuberosities. As this would be ongoing for some time, we discussed procedural options to address this. We discussed that we would likely proceed with advancement flap for definitive repair. However, we did discuss that this would require him to be out of the chair for at least 2 weeks, potentially longer. Alternatively, we discussed that we could avoid utilizing the chair for the next 2 to 3 weeks and assess his progress with this. We did discuss that the wound would likely demonstrate interval improvement with minimizing trauma to this area. He would like to try this option instead. Will plan on clinic follow-up in 3 weeks to assess his progress and need for advancement flap at this time. 2/26/25 - .per wound clinic, chronic denuded area (open area where the skin has been completely removed, exposing underlying tissue), left buttock, length 1.3cm x width 1cm, worsening, getting larger . 3/5/25 - .per wound clinic, chronic denuded area, left buttock, 1cm x 1cm x .2cm, improving, becoming larger . 3/5/25 - Wound clinic note Chronic nonhealing ulceration overlying the left ischial tuberosity. He did undergo primary closure of this wound on 11/4/24 in clinic. He initially responded well to this, but the wound has since recurred. He has been undergoing cares in the wound clinic without significant improvement. He notes persistent pain at the site. Previously we elected to transition back to the Roho cushion and minimizing time in his chair. He seems to have responded minimally to these interventions. And now is experiencing pain overlying the right ischial tuberosity. There is a 1 x 1 x .2cm wound of the left gluteal region, stable in size from his previous visit. There is granulation tissue about the base of the wound. There is mild undermining of the wound circumferentially. There is erythema (redness) and skin breakdown of the bilateral ischial tuberosities. There is now an additional superficial ulceration overlying the right ischial tuberosity . Assessment and Plan: Examination today is notable for trauma to the skin overlying the bilateral ischial tuberosities and now superficial ulceration overlying the right ischial tuberosity. The ulceration to the left ischial tuberosity is unchanged. With this, we discussed concerns in proceeding with the rotational flap closure, as despite interventions thus far, he continues to demonstrate trauma to this region. I am concerned that a rotational flap repair would fail for the same reasons. We discussed that it may be prudent to proceed with submission for Edify and/or Heliogen application to the wound, which may expedite wound healing. We discussed the continued importance of minimizing trauma to the skin of this region as well as minimizing time in his chair. Of note: Despite the MD noting the importance of minimizing trauma to the buttocks and PI areas there is no evidence the facility provided alternative transfer methods besides the slide board to R19. Additionally, there is no evidence the facility discussed the risks of the slide board transfer, continued shearing making wound healing difficult, deterioration of the wound, or potential for infection. R19 presents with deterioration of his PI and now an additional PI to the right ischial tuberosity. 3/6/25 - .open area, appears to be shearing from sliding in bed or using slide board or both, right inner thigh - .5cm x .5cm x <.1cm, no drainage, no odor, wound bed sheared, surrounding tissue intact, fragile, dry . 3/11/25 - .chronic wound left buttock, 1 x 1.3 x .1cm, drainage heavy >75%, no odor, non-granular tissue, surrounding tissue intact, reddened, redness noted 7cm around wound . 3/11/25 - .right ischium shearing, length 1cm x width .6cm x .1cm, no odor, no drainage, non-granular tissue, intact . 3/12/25 - Staff from Sauk County Health Care Center called this AM with concerns over patient having increased drainage and redness to the left wound, also reports new wound to right leg. Infection Indicators: erythema (redness), increased drainage. Wound culture collected 3.12.25. Left ischial tuberosity full thickness, 1cm x 1.3cm x 0.1 cm. 100% nongranular tissue, denuded erythema. Stage 2 right inner thigh, healed. Wound culture results: moderate growth of beta hemolytic streptococcus. R19 was started on Cephalexin 500mg capsule by mouth three times a day for 7 days, beginning 3/13/25. 3/19/25 - .left buttock, .8 x .8 x .1cm, drainage light <25%, no odor, wound bed nonviable tissue 100%, surrounding tissue denuded, erythema . 3/19/25 - .shearing/friction from slide board/bed, right inner thigh, .3cm x .4cm x <.1cm, scant drainage, no odor, non-granular 100% . 3/26/25 - nurse note - .right thigh wound healed, Dr. applied EpiFix graft to left buttock wound .8 x 1 x .1cm . 3/26/25 - Change of Condition notes - .Wound nurse, orders from Dr. - new orders received and noted .right thigh wound healed - no dressing needed .left buttock wound measures .8cm x 1cm, graft applied - do not remove dressing for at least 5 days. Please call wound clinic if dressing needs to be changed before - resident updated and agrees to plan of care . On 3/26/25 at 3:53 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) regarding R19's PI and if it has ever been staged. LPN D indicated it's not considered a pressure injury and has never been staged. On 3/26/25 at 4:14 PM, Surveyor interviewed LPN L at the wound clinic via phone and asked about R19's wound. She indicated it should be classified as a pressure injury, she thought when they started seeing him it was staged at stage 2. She stated, somewhere along the way, it got changed to non-healing chronic wound. LPN L stated R19 had an EpiFix graft done today, and dressing can't be removed for 5 days unless there is drainage. Surveyor asked LPN L about the infection and LPN L indicated they did a wound culture at the clinic on 3/12/25 due to increased redness around the wound. They swabbed it and culture came back showing an infection. On 3/27/25 at 8:29 AM, Surveyor interviewed RN E (Registered Nurse) about how wounds get classified in the facility. RN E stated the Wound Nurse classifies wounds. On 3/27/25 at 8:36 AM, Surveyor interviewed ADON I (Assistant Director of Nursing, also Wound Care Certified, facility wound nurse) regarding R19 and the staging of his wounds. ADON I stated if she felt a wound was related to pressure, it would be staged - only time wound is staged is if it's pressure. ADON I indicated she didn't feel R19's wound was pressure. She stated he first got the wound after radiation treatment when he had diarrhea. Surveyor asked why R19's PI wasn't on the matrix, ADON I indicated it's not on matrix because the facility does not consider R19's wound a pressure injury. ADON I stated the wound was caused by friction and shearing from R19's slide board and this continues and could be why it isn't healing. ADON I indicated R19 is getting therapy currently, they have tried 2 different slide boards - plastic and wood. ADON I stated R19 has not always been compliant with therapy in the past. ADON I stated she doesn't think R19's PI was ever staged. Surveyor asked if the facility completed a risk vs benefits with R19, regarding the use of the slide board, sitting up in the wheelchair and use of the Roho cushion. ADON I indicated she did, but she did not document this anywhere. Surveyor asked if it should be documented and ADON I stated yes. During a follow up interview with ADON I on 3/27/25 at 10:59 AM, Surveyor asked if ADON I was aware of R19 sitting on a towel or washcloth when in R19's w/c (wheelchair). ADON I indicated no, she wasn't aware of that. When asked if there should be anything between a Roho cushion and resident, she stated no. Surveyor asked ADON I if friction and shearing are components of pressure. ADON I stated yes, it can be. When asked about what standard of practice she is using to classify or stage wounds, ADON I stated she uses the book she received from wound care certification course WCEI (Wound Care Education Institute). Surveyor also asked what the facility does to prevent infection. ADON I stated, change dressing as ordered, cleaning wound, incontinence care, random audits - PPE (personal protection equipment) application/removal, hand hygiene - every other month, DON B (Director of Nursing) does the audits. On 3/27/25 at 10:41 AM, Surveyor interviewed R19 and asked if he is using a towel under his bottom when he is in his w/c. R19 stated no, he doesn't remember having a towel. He indicated he rolled up washcloths a couple times and put them on his bottom to relieve pressure in his wheelchair. He stated his doctor talked to him about not doing this, indicated the facility didn't. R19 stated his doctor wasn't happy about it. Of note, on 3/27/25 at 10:45 AM, Surveyor observed a rolled-up washcloth in R19's wheelchair while interviewing him. Surveyor also observed a stack of washcloths on his table. On 3/27/25 at 10:46 AM, Surveyor interviewed CNA J (Certified Nursing Assistant) who has worked at facility for 6 years. CNA J indicated she is aware R19 has a wound on his bottom, CNA J stated she cleans R19 up when R19 is incontinent. CNA J stated R19 likes to put washcloths in the peri area, and he might be propping them on his bottom. CNA J indicated she would advise him against it and stated she has talked to the nurse in the past about R19 sitting on washcloths. Surveyor asked CNA J how R19 transfers. CNA J stated R19 was using a slide board. Surveyor asked if they had tried other alternatives beside the slide board. CNA J stated not until now, now we are to use a Hoyer transfer. On 3/27/25 at 10:51 AM, Surveyor interviewed LPN G about R19 having a washcloth in his wheelchair. LPN G stated she knows R19 uses washcloths to wash hands after using his urinal. LPN G indicated she doesn't know about R19 putting a washcloth in his wheelchair. LPN G stated she has talked to R19 in the past about it but doesn't know about a risk vs benefits form. Surveyor asked if she ever discussed the concerns about using the slide board as a contributing factor to his PI. LPN G stated no, he has been using the slide board. On 3/27/25 at 3:31 PM, Surveyor Interviewed DON B (Director of Nursing), and ADON I and asked about the slide board being a contributing factor for R19's wounds. DON B and ADON I indicated the facility tried different slide boards, wood and plastic. They indicated maintenance sanded down a board to see if that would make one smoother, they thought maybe there was a rough spot on the slide board causing friction. Surveyor asked if any other interventions were attempted and they replied, he is working with therapy now, have tried supplements. DON B and ADON I stated R19 is now a Hoyer transfer, and he has refused Hoyer in the past. Surveyor asked if friction was a component to R19's pressure injuries. DON B and ADON I indicated no. Surveyor asked what they consider friction, they responded going against another surface, not pressure necessarily. Surveyor asked DON B and ADON I if friction could turn into pressure. DON B stated, Not for this resident. DON B stated R19 repositions himself all the time, they feel it is shearing and friction and don't consider the wound pressure. Surveyor asked DON B and ADON I if the wound physician note called the wound decubitus ulceration, why didn't facility call it that. They indicated the primary physician identified it as friction and shearing from diarrhea related to radiation. They stated he had so much diarrhea at first, impaired vascularity, radiation, was a smoker - feels that all components put together contributed. Surveyor asked about risk vs benefits being done regarding the use of the slide board, using a washcloth under his bottom in w/c, refusing therapy in the past, and continued use of the slide board. DON B stated she talked to R19 about these things. Surveyor asked if it was documented, and she stated she would have to check the documentation. DON B stated risk vs benefits should be documented. No documentation was provided by the facility for risk vs benefits. A risk and benefit was completed after surveyors exited the facility. On 3/31/25 at 10:40 AM, Surveyor interviewed WD K (Wound Doctor) via phone and asked about the staging and treatment of R19's PI. Surveyor asked WD K how he would classify R19's PI. WD K stated he would classify it as a pressure injury, stage 3. He stated it's a decubitus ulceration; there is subcutaneous tissue. He added it would still be a stage 3 pressure injury now. Surveyor asked WD K if the facility should have considered alternatives for the slide board. WD K stated it's not for him to say but it likely is a causative factor. WD K told Surveyor he's glad he uses a Hoyer now. Surveyor asked about the primary closure procedure completed on 10/28/24. WD K stated he felt it was needed because the wound was chronic, wasn't resolving, and was causing resident discomfort. Surveyor asked about the EpiFix graft done on 3/26/25. WD K indicated he wanted to do the graft as the wound had deteriorated and this was an effort to help the PI heal. The facility identified the use of a slide board transfer as a causative factor in contributing to R19's PI development. Despite this knowledge R19 continued to use the slide board. There is no evidence the facility provided R19 with the risks for continuing the use of slide board transfers or using rolled-up washcloths to relieve pressure on his bottom while in wheelchair. The facility did not identify R19's left gluteal pressure injury as a pressure injury (PI) or stage the PI despite the wound physician identifying it as a stage 3 pressure injury or decubitus ulceration on multiple progress notes. R19 developed two facility-acquired pressure injuries. R19's left ischial tuberosity deteriorated and became infected requiring a EpiFix graft to promote healing. The facility's failure to use an alternative transfer method to the slide board and failure to provide resident with risk vs. benefits of continued use of the slide board led to serious harm and created a finding of immediate jeopardy. The facility removed the jeopardy on 3/31/25 when it completed the following: R19 was educated Friday, March 28 on Risks vs Benefits regarding use of the slide board and placing barrier on top of pressure relieving device which decreases effectiveness. Resident was consistently refusing interventions including, but not limited to, nutritional supplements, attending scheduled appointments regularly, participating in therapy and following recommendations of using Hoyer Lift instead of the slide board. This was also included in his Risks vs Benefits education. Nursing staff was educated beginning 3/31/25 and/or prior to their next shift to be worked regarding: Prevention of Pressure Injury, including: A. Pressure Points, Shearing, Friction and Proper Positioning. B. What to look for regarding what interventions are working and what

Based on observation, interview, and record review, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable for 1 of 2 medication rooms and 2 of 5 medication carts reviewed for compliance. Surveyor observed the following: -R25's PRN (as needed) Loperamide (27 capsules) expired 12/24. -R19's PRN Loperamide (4 capsules) expired 12/24. -R6's escitalopram (1 tablet) card expired 9/24. -3 boxes of blood glucose control solutions expired (7/27/23 & 3/1/25). -R9's Naproxen (7 tablets) PRN card expired 11/24. -6 stock insulin pens were expired: -1 Semglee expired 6/24. -2 Tresiba expired 12/31/23 & 11/30/24. -3 Basaglar expired 8/17/24 and 2 on 4/04/24. -Stock supply of Promethazine suppositories (6 suppositories) expired 10/24. Evidenced by: The facility policy entitled, Medication Storage Policy, undated, states, in part: .Policy: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Procedure: . D. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All drugs shall be returned to the dispensing pharmacy or destroyed per state regulation . Example 1: On 3/25/25 at 1:58 PM, Surveyor observed cart #3 with LPN C (Licensed Practical Nurse). Surveyor found R25's PRN card of loperamide 2 mg (milligrams) 27 capsules with an expiration date of 12/24. Surveyor found R19's PRN card of loperamide 2 mg, 4 capsules with an expiration date of 12/24. Surveyor found R6's escitalopram 10 mg cycle card with 1 tablet expired on 9/24. Surveyor found 2 boxes of blood glucose control solutions expired on 7/27/23 & 3/1/25. On 3/25/25 at 2:17 PM, Surveyor interviewed LPN C and asked what the expiration dates were on the two boxes of blood glucose control solutions. LPN C indicated 7/27/23 and 3/1/25. LPN C indicated both boxes were expired and should not be in circulation and removed from the cart. Surveyor asked LPN C what the expiration dates were on R25 and R19's PRN loperamide cards and R6's escitalopram card. LPN C indicated by looking at it she was not sure, and LPN C indicated she needed to call the pharmacy. LPN C returned and indicated the date on the card was when the prescription expired not the medication. LPN C indicated there is no expiration dates on the cards. Surveyor asked how one would know when the medications expire then, and LPN C indicated you would not know as the medications come out of one big stock bottle that has an expiration date on, but the cards do not and should. LPN C indicated the three cards are being returned to the pharmacy. Example 2: On 3/25/25 at 2:33 PM, Surveyor observed medication cart #2 and medication storage room with RN E (Registered Nurse) and found R9's PRN card of Naproxen 500 mg with 7 tablets expired on 11/24. Surveyor found 6 stock insulin pens expired: one Semglee insulin glargine injection 100 units/mL (milliliter) expired on 6/24, two Tresiba insulin degludec injection pens 200 units/mL expired on 12/31/24 & 11/30/24, and three Basaglar insulin glargine injection pens 100 units/mL expired on 8/17/24, 4/4/24, and 4/4/24. Surveyor found a stock box of Promethazine 25 mg suppositories- 6 suppositories expired on 10/24 and a box of blood glucose control solution expired on 3/1/25. On 3/25/25 at 3:02 PM, Surveyor interviewed RN E and asked what the expiration date is on the medication card for R9. RN E called the pharmacy and found the date on the bottom right corner of the pharmacy label is the expiration date and the upper date is when the pharmacy filled the card. RN E confirmed R9's Naproxen expired on 11/24, and the box of Promethazine suppositories expired on 10/24. RN E indicated the box of blood glucose control solution expired on 3/1/25. Surveyor asked RN E if the 6 stock insulin pens were expired and RN E phoned pharmacy back. Surveyor spoke with PH F (pharmacist) who indicated the Semglee pen expired on 6/24 the manufacturer' date, Tresiba pens expired on 12/31/24 and 11/30/24, the manufacturer's date, and the three Basaglar pens expired on 8/17/24, 4/4/24, and 4/4/24, the manufacturer's date. RN E indicated the expired medications should not be in circulation and removed them. On 3/26/25 at 10:45 AM, Surveyor interviewed DON B (Director of Nursing) and informed DON B of the expired medications: R25's PRN (as needed) Loperamide (27 capsules) expired 12/24, R19's PRN Loperamide (4 capsules) expired 12/24, R6's escitalopram (1 tablet) card expired 9/24, 3 boxes of blood glucose control solutions expired (1-7/27/23 & 2-3/1/25), R9's Naproxen (7 tablets) PRN card expired 11/24, 6 stock insulin pens were expired (1 Semglee expired 6/24. 2 Tresiba expired 12/31/23 & 11/30/24. 3 Basaglar expired 8/17/24 and 2 on 4/4/24) and the stock supply of Promethazine suppositories (6 suppositories) expired 10/24. DON B indicated PH F had phoned her regarding the expired medications found and the expired medications should not be in circulation. DON B indicated her expectation is for the staff to check and know where the expiration dates are on medications administered and education is in progress to all nurses since this was brought to DON B's attention.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 residents (R30 & R9) included in the medication pass task, which resulted in an error rate of 6.9%. R30 did not receive her ordered senna at the ordered time. R9 did not receive her ordered aspirin at the ordered time. Evidenced by: The facility policy entitled, Medication Pass, dated 2/2016, states, in part: .Policy: It is the policy of the [Facility name] that medications prescribed by the Physician will be administered accurately and timely. Procedure: .2. Read and compare the label on the drug with the MAR (Medication Administration Record) at least three (3) times- before, during and after preparing the drug .16. Be sure that you have the- A. Right Drug B. Right Dose C. Right Route D. Right Time E. Right Resident . Example 1: R30 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia following nontraumatic intracerebral hemorrhage affecting left nondominant side (paralysis or weakness on one side of the body) and hypertensive heart disease without heart failure (heart issues that develop due to long-term high blood pressure). R30's Quarterly Minimum Data Set (MDS) Assessment, dated 9/24/24, shows that R30 has a Brief Interview of Mental Status (BIMS) score of 8 indicating R30 has moderate cognitive impairment. R30's Physician Orders, dated 3/25, states, in part: .3/26/25 Drug: Senna-Docusate Sodium 8.6mg (milligrams)-50mg Tablet by mouth Take 1 daily AM for constipation . R30's Medication Administration Record (MAR) for March 2025 shows: Drug: Senna-Docusate Sodium 8.6mg-50mg Tablet by mouth Take (1) daily AM For: Constipation . Drug: Anorco Ellipta 62.5 mcg (micrograms)/ACT-25 mcg/ACT Aerosol Powder Breath Activated Inhalation Take (1) puff daily AM For: Restrictive lung diagnosis. Drug: [Protonix] Pantoprazole Sodium 40 mg Tablet Delayed Release by mouth Take (1) daily AM For: Gastroesophageal Reflux Disease (GERD) Drug: [Keppra] levetiracetam 250 mg Tablet by mouth Take (1) BID (twice a day) AM at bedtime. For: Seizure first date: 7/24/24 Drug: Artificial Tears . 0.5%-0.6% Solution to eye(s) (both) Take (1) TID (three times a day) AM PM at bedtime. For: Dry eyes Drug: Cetirizine . 10 mg Tablet by mouth Take (1) daily AM For: Pruritis (itching) first date: 10/03/24 Drug: metformin . 500 mg Tablet by mouth bid AM PM First Date: 3/6/25 For: Type 2 Diabetes Mellitus Drug: Gabapentin 100 mg capsule by mouth Take (1) bid AM Midday For: Neuropathic Pain Drug: Vitamin D .1.25 MG (5000 UT) Capsule by mouth Take (1) 1 x week Tuesday AM For Vit D deficiency . On 3/25/25 at 8:05 AM, Surveyor observed LPN C (Licensed Practical Nurse) administer scheduled AM medications which did not include the scheduled senna docusate sodium as it is ordered. On 3/25/25 at 9:30 AM, Surveyor reconciled medications that were administered to R30 to R30's MAR to find the senna docusate sodium was signed out that it was given. Surveyor had observed the medication pass and senna docusate sodium was not administered. On 3/25/25 at 9:47 AM, Surveyor interviewed LPN C and asked about the senna docusate sodium being signed out as if it was given. LPN C indicated she thought she had given it. Surveyor informed LPN C showed Surveyor's documentation it had not been administered. Surveyor asked LPN C if that was a medication error and LPN C indicated she would just give R30 the senna at lunch time. Example 2: R9 was admitted to the facility on [DATE] and has diagnoses that include hypertensive heart and kidney disease with heart failure (occurs when high blood pressure damages the kidneys and heart, leading to complications like heart failure and kidney failure). R9's Quarterly MDS Assessment, dated 2/8/25, shows that R9 has a BIMS score of 11 indicating R9 is mildly impaired cognitively. R9's Physicians Orders, dated 3/2025, states, in part: . . Drug: Aspirin EC (enteric coated) 81 mg Tablet Delayed Release by mouth Take (1) daily at bedtime. For: Anticoagulant Therapy . R9's March MAR shows: Drug: [acetaminophen 8 hour] Acetaminophen ER (extended release) 650 mg Tablet Extended Release by mouth TID Early AM Midday at bedtime. Not to exceed 3GM(GRAMS)/24 hour. For: Pain. Drug: Carvedilol 6.25 mg Tablet by mouth BID with meals Breakfast Supper For: Hypertension. Drug: Glimepiride 4 mg Tablet by mouth Take (1) bid with meals Breakfast Supper. For: Type 2 Diabetes Mellitus. Drug: Docusate Sodium 100 mg Capsule by mouth Take (1) bid AM PM For: Bowel Aid. Drug: Sertraline . 50 mg Tablet by mouth Take (1) daily PM For: Depression/anxiety . On 3/25/25 at 4:03 PM, Surveyor observed LPN D administer medication to R9 which included docusate sodium, aspirin, sertraline, carvedilol and glimepiride. (of note: R9's aspirin is ordered at bedtime) On 3/25/25 at 4:21 PM, Surveyor interviewed LPN D and asked when the aspirin is to be administered. LPN D indicated it should have been given after supper as a bedtime medication as ordered. LPN D indicated she had noticed the aspirin was for bedtime but had already put it in the medication cup and just decided to give it. Surveyor asked if this is a medication error and LPN D indicated yes, the aspirin should have been administered at bedtime. Surveyor asked what the 5 rights are that are used for medication pass and LPN D indicated right med, right patient, right time, right route, and right dose. Surveyor asked LPN D when medications are ordered to administer at bedtime, what time does facility use for bedtime. LPN D indicated bedtime scheduled medications get administered after supper until 10:00 PM. On 3/26/25 at 10:45 AM, Surveyor interviewed DON B (Director of Nursing) and informed her of the medication observation errors. DON B indicated senna and aspirin being administered at the wrong times are medication errors. DON B indicated she would expect medications to be administered at ordered times.

Based on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (R25) reviewed for catheter care out of total sample of 17. Staff did not perform appropriate hand hygiene per Standards of Practice while providing catheter care. Evidenced by: The facility policy entitled. Hand Washing, dated 3/19/24, states, in part: . Purpose: -To cleanse hands to prevent the spread of potentially deadly infections -To provide a clean and healthy environment for residents, staff, and visitors -To reduce the risk to the healthcare provider of colonization or infections acquired from a resident Hand hygiene continues to be the primary means of preventing the transmission of infection. Policy: It is the policy of this facility that hand hygiene (HH) (e.g. hand washing and/or Alcohol-based hand rub (ABHR), also known as Alcohol-based hand sanitizer (ABHS), is to be performed consistent with accepted standards of practice in order to reduce the potential of the spread of pathogens. Procedures: Hands shall be washed . 2. Before and after any personal body function, such as eating, blowing or wiping nose, coughing, sneezing, smoking, using bathroom, combing hair. 3. Before and after direct contact with residents . 5. After handling waste materials, bedpans, feces, specimens, secretions, drainage, or blood . R25 was admitted to the facility on [DATE], and has diagnoses that include Extended spectrum beta lactamase (ESBL) resistance (an enzyme produced by some bacteria that makes them resistant to certain antibiotics, including penicillins and some cephalosporins, making them harder to treat), retention of urine (difficulty urinating and completely emptying the bladder), and obstructive and reflux uropathy (a condition where urine flow is blocked or backs up, potentially damaging the kidneys). R25's Quarterly Minimum Data Set Assessment, dated 1/8/25, shows R25 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R25 is cognitively intact. R25's Care Plan, dated 2/2/22, states, in part: . Problem: 2/02/22 Altered Urine Pattern R/T (related to) Diabetes, Chronic Foley Catheter .Nurse Aide: . Provide catheter care with cares and as needed .Special Approaches: **enhanced barrier precautions**(an infection control strategy that uses gloves and gowns during high-contact resident care to reduce the spread of multidrug-resistant organisms (MDROS)) . Problem: 2/02/22 Infection: Enhanced barrier precautions** Nurse Aide- Use good hand washing techniques before and after cares, Keep area clean and dry . R25's Medication Administration Record for March 2025 shows: -Entry Date- 2/02/22 Administer Foley catheter care BID (twice a day) AM at bedtime AM CNA (certified nursing assistant) PM CNA . R25's Physician Orders, dated 3/17/25, states, in part: . Administer Foley catheter care bid AM at bedtime AM CNA PM CNA . Change indwelling foley catheter as needed when encrusted or obstructed. Reason for Foley- Neurogenic bladder **extension tubing must be placed ** SIZE OF CATHETER Other: 18 FR (French) 10 mL (milliliter) balloon . On 3/26/25, at 11:08 AM, Surveyor observed CNA H perform catheter care on R25. CNA H did not change gloves or perform hand hygiene after providing catheter care or before retrieving R25's gait belt off R25's walker. CNA H then wrapped the gait belt around R25. CNA H then proceeded to assist R25 to a standing position from the toilet, CNA H pulled R25's clean brief and pants up. CNA H then untucked R25's shirt and walked R25 out of bathroom to his electric wheelchair, while wearing the same gloves used to perform peri care and catheter care. On 3/26/25, at 11:15 AM, Surveyor interviewed CNA H and asked when hand hygiene should be performed. CNA H indicated anytime gloves are removed, after going from peri cares to the back side of residents, when dirty, and from going from clean to dirty areas. Surveyor asked if hand hygiene and gloves should have been changed after catheter care was completed and touching R25's gait belt and clothing and CNA H indicated yes. Surveyor asked if CNA H performed hand hygiene at that time and CNA H indicated she did not and should have. On 3/26/25, at 11:15 AM, Surveyor interviewed DON B (Director of Nursing) and informed her of observation of catheter care. Surveyor asked DON B if she would expect hand hygiene to be performed in between catheter care and applying gait belt, pulling up brief and pants and walking R25 to his electric wheelchair. DON B indicated yes, hand hygiene and glove change should have been performed.

Based on interview and record review, the facility did not implement policies and procedures to prohibit and prevent abuse for 1 of 8 staff reviewed for caregiver background checks. LPN G (Licensed Practical Nurse) was hired on 12/3/24 and had lived in one other state within the last three years. LPN G's background check information did not contain an out-of-state criminal background check. This is evidenced by: The facility's Prevention/Reduction of Resident Abuse, Neglect, Exploitation or Misappropriation of Property policy, revised 05/19 and reviewed 10/24, indicates in part: Employee Screening and Training .d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. The facility's Care Giver Background Investigations policy, reviewed/revised on 03/21/14, indicates in part: As applicable, other documentation will be obtained by the entity when information is needed to complete the background check, such as out of state's conviction records when a 'caregiver' has lived out of the state in the last three years, military discharge papers, arrest and conviction disposition information from local clerks of courts or tribal courts, etc. On 3/24/25, Surveyor reviewed LPN G's background check information. LPN G's date of hire was 12/3/24. LPN G's Background Information Disclosure (BID) was completed on 11/19/24. The BID indicated LPN G had resided outside of Wisconsin within the last three years. Surveyor reviewed all background check information and noted an out-of-state criminal background check was not included for the state LPN G had resided in. On 3/25/25 at 10:00 AM, Surveyor requested LPN G's out-of-state background check from NHA A (Nursing Home Administrator). NHA A indicated the facility did not complete an out-of-state background check for LPN G and acknowledged that they should have.

Based on interview and record review, the facility did not ensure that each resident received, and the facility provided, care and services consistent with professional standards of practice (N6. Wisconsin Nurse Practice Act) for 1 of 5 residents (R4) reviewed for change of condition. R4 presented with a change of condition including decreased appetite (even her favorite foods), abdominal pain, fatigue, nausea, and vomiting. The facility failed to complete a GI (Gastrointestinal)/abdominal assessment and failed to notify R4's physician with R4's complaints of abdominal pain. R4 became lethargic and was transferred to the hospital and noted to have a perforated colon and pneumoperitoneum (the presence of air or gas in the abdominal cavity.) R4 was not a surgical candidate and returned to the facility on hospice services. The facility's failure to recognize a significant change of condition, complete a comprehensive nursing assessment, and notify the physician with a change of condition created a finding of Immediate Jeopardy beginning on 9/27/24. NHA A (Nursing Home Administrator) and the DON B (Director of Nursing) were informed of the finding of Immediate Jeopardy on 10/16/24 at 3:00 PM. The immediacy was removed on 10/16/24 and continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. The facility's policy titled Change of Condition dated 3/2011 states in part; Policy: The shift supervisor will immediately inform the resident, consult with the resident's physician, notify the resident's legal representative, or interested family member when there is an acute change of condition (ACOC) defined as a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that without intervention may result in complications or death. Procedure: 1. Identify resident at risk of ACOC and document assessment. An ACOC is reported immediately to the unit supervisor or shift supervisor by the interdisciplinary team member who first notices the change. The unit supervisor collects data on the resident and forwards it to the shift supervisor who completes and documents the nursing assessment. 2. When an ACOC occurs, the shift supervisor will notify the attending physician or designated alternate. If unable to contact either of the above, the Medical Director will be contacted. The resident or the resident's designated medical contact will also be notified. 3. Documentation in the resident's record: the shift supervisor will document the notification of the physician and resident/medical contact along with new orders in the resident's record. 4. For repeated and recurring deviations of vital signs, refusal to take meds, chest pain, or slowly declining condition, the physician may order that the physician only wants to be notified if the change in condition persists or if the deviation exceeds the physician's specific and stated limits. These guidelines must be noted in the physician order. 5. All ACOCs must be documented, and the individual care plan revised to reflect changes in care and treatment. ACOCs will be communicated from shift to shift via shift report, report book and individual unit daily shift reports. Physical symptoms: Level of Consciousness (LOC): 1. Levels of consciousness are alert, drowsy/lethargic, stuporous, and comatose. 2. The following may indicate an ACOC and should be assessed further: Frequent fluctuations in LOC. A reduction of one level or more of LOC (e.g., from alert to lethargic or from lethargic to stuporous. Hypersomnolence (more sleepy than usual or sleepy for most of the day.) Condition: Acute change in mental status. Report immediately: Sudden onset. Report next day: Gradual onset. Emesis: Report Immediately: greater than 1 episode in 24 hours. Accompanied by abdominal pain and changes in vital signs. Report next office day: single episode. Diarrhea: Report Immediately: acute onset of multiple episodes with change in vital signs and/or altered mental status. Report on next office day: Persistent loose stools for greater than 48 hours while diarrhea is being treated symptomatically. Chronic loose stools. According to https://www.webmd.com/digestive-disorders/what-is-bowel-obstruction: A bowel obstruction is a serious problem that happens when something fully or partly blocks either your large or small intestine. It's also known as an intestinal obstruction. When your digestive system is hindered this way, it can be difficult or impossible to have a bowel movement or pass gas. You might also have stomach pain and a swollen belly. A bowel obstruction is when a section of your intestine is fully or partially blocked. Types of Bowel Obstruction, Doctors divide bowel obstructions into two main types according to their location. Small bowel obstruction About 80% of all bowel obstructions affect the small intestine. A blockage here can keep digested food from reaching your large intestine. Large bowel obstruction, A blockage in your large intestine can slow or stop the passage of poop out of your body. In either intestine, a bowel obstruction can be: Partial. When your bowel is only partly blocked, some gas, food, and liquid can still pass through it. Signs of an intestinal blockage will depend on how serious the obstruction is. But a blockage almost always comes with belly pain, usually around your belly button, and cramps. Other bowel obstruction symptoms include Constipation, Inability to pass gas, Loss of appetite, Nausea or vomiting, A hard, swollen belly, Diarrhea (with a partial blockage), Dehydration. If you've been constipated and have any of these other symptoms, contact your doctor right away. Many people with bowel obstructions are older and may have other serious illnesses, so a bowel obstruction may be life-threatening. According to the National Library of Medicine https://pmc.ncbi.nlm.nih.gov/articles/PMC4535122/ Pneumoperitoneum is the presence of air or gas in the abdominal (peritoneal) cavity. It is usually detected on x-ray, but small amounts of free peritoneal air may be missed and are often detected on computerized tomography (CT).[1] The most common cause of a pneumoperitoneum is a perforation/disruption of the wall of a hollow viscus. The causes of pneumoperitoneum occurring in children are different from the adult population. A gastrointestinal perforation constitutes one of the commonest surgical emergencies. The causes of pneumoperitoneum in adults are perforation .Common signs and symptoms are abdominal pain, vomiting, abdominal distension, constipation, fever, diarrhea, tachycardia (pulse >110/min), hypotension (systolic blood pressure <100 mmHg), urine output (<30 mL/h), and tachypnea (respiratory rate >20/min). R4 was admitted to the facility on [DATE] with diagnoses that include dementia, falls, low back pain, chronic kidney disease stage 3b, and weakness. R4's care plan dated 7/10/24 states in part, dysuria, urine loss due to cognitive impairment. Nurses encourage fluid intake, assess for abdominal distension, assess for UTI (urinary tract infection), monitor I&O (Intake and Output). Potential for Comfort Alteration dated 7/10/24 states in part, showing pain behavior, G.I. (gastrointestinal) concerns/problem. (i.e., nonverbal signs of discomfort (crying, moaning, grimacing, guarding). Assess bowel function and provide prescription to promote defecation. Assess pain, quality, location on-set and effective measures. Monitor for lethargy, change in cognitive status, or loss of appetite. Assess physical symptoms. Notify MD as needed. Care Plan Summary dated 7/23/24 states in part, she rarely complains of pain, she is consuming 50-100% of meals. According to meal percentage documentation for September 2024. , R4 ate 25-100% of meals up until 9/21/24 where R4's meal percentages are as follows: 9/21/24 - Breakfast - bites, Lunch-0%, Dinner-25% 9/22/24 - Breakfast - 25%, Lunch-Bites, Dinner-0% 9/23/24 - Breakfast - 50 %, Lunch-0%, Dinner-25% 9/24/24 - Breakfast - 100%, Lunch-50%, Dinner-75% 9/25/24 - Breakfast - bites, Lunch-not charted, Dinner-25% 9/26/24 - Breakfast - bites, Lunch-bites, Dinner-25% 9/27/24 - Breakfast - 100%, Lunch-Bites, Dinner-0% 9/28/24 - Breakfast - 100%, Lunch-Bites, Dinner-75% 9/29/24 - Breakfast - bites, Lunch-not charted, Dinner-75% R4's BM (Bowel Movement) record is as follows: 9/21/24 - No BM 9/22/24 - Large Formed 9/23/24 - No BM 9/24/24 - Small loose 9/25/24 - Medium loose 9/26/24 - Large (does not specify consistency) 9/27/24 - Large loose x3 9/28/24 - Medium (does not specify consistency) 9/29/24 - Large (does not specify consistency) Of note, from 9/24/24 to 9/29/24, R4 had several loose BMs which can occur with a SBO (Small Bowel Obstruction). R4's weights were as follows: 7/12/24 - 172.8 (Admission weight) 7/25/24 - 176.8 8/17/24 - 175.0 8/30/24 - 175.4 9/2/24 - 177.0 9/26/4 - 171.0 (R4 lost 3.35% of her weight in 24 days) R4's nursing progress notes state the following: 9/9/24 at 15:43 (3:43 PM) usually amount eaten varies 50 to 75%. Has a fair appetite, resident reports feeling satisfied and full. 9/9/24 at 15:44 (3:44 PM) is incontinent of bowel more than 3 times per week. Bowel elimination pattern is regular (at least one movement every 3 days). 9/21/24 at 00:05 (12:05 AM) having nausea tonight no emesis. Refused 7-Up. Continue to observe. 9/23/24 at 16:12 (4:12 PM) Tums 500 mg (milligram) tablet given for GI upset. 9/26/24 at 00:31 (12:31 AM) resident coughing and had a small emesis of undigested food at 200 [sic]. Oral care given and sips of water. No further emesis. 9/26/24 at 13:41 (1:41 PM) Late Entry for 9/25/24 physician visit and examined. Physician Progress Note dated 9/25/24 states in part: nursing staff notes the following concerns or recommendations: none. The patient reports the following concerns: none. General appearance: not in acute distress. Appearance: Normal appearance. Not ill-appearing. The physician completed the following exam HENT (Head/Ear/Nose/Throat): Head normocephalic - Pulmonary: Pulmonary effort normal - Musculoskeletal: Cervical Back: Neck supple. Neurological: Mental Status: she is alert and Psychiatric: Mood and Affect: Mood Normal. Behavior: Behavior Normal. It should be noted according to the progress note dated 9/25/24 there is no evidence the physician completed an abdominal/GI assessment. R4's nursing progress notes state the following: 9/27/24 at 14:27 (2:27 PM) Blood Pressure: 112/74, resident complains of fatigue, lethargy (mild pain), abdominal. Resident's face was flushed most of the day. Resident had a large, incontinent BM after lunch today. Resident had flu shot 1-2 days ago and his [sic] may be side effects. Resident did lay down in the afternoon after lunch, warm blanket put over her abdominal area. No further complaints at this time lying down. The facility 24-hour board (nursing report between shifts) for R4 states in part: 9/27/24 AM shift - increased weakness, fed 100%. There are no entries for PM or NOC shift. It should be noted on 9/27/24, R4 was noted to have abdominal pain, fatigue, lethargy, a loose stool, and bites for lunch. Despite these signs and symptoms of a change of condition there is no evidence the facility completed an RN assessment. R4's nursing progress notes state the following: 9/28/24 at 12:45 PM Tums 500 mg tablet chewable. The facility 24-hour board for R4 states in part: 9/28/24 AM shift - not eating well, afebrile. PM shift - Refused meal did not get OOB (out of bed). 9/29/24 at 14:36 (2:36 PM) call placed to on-call (physician name) regarding COC (change of condition). New orders received obtain CBC (Complete Blood Count), CMP (Complete Metabolic Panel), UA (Urinalysis) culture if indicated. It should be noted there is no documentation or assessment in the nursing notes indicating what the COC was for R4. The last nursing note indicating symptoms was dated 9/27/24, two days earlier. 9/29/24 at 15:51 (3:51 PM) spoke with on-call (physician name) regarding lab results BUN (Blood Urea Nitrogen). (A laboratory test that test the amount of urea nitrogen in your blood, which can indicate how well your kidneys are functioning. A normal BUN is 6-21mg/dl (milligrams per deciliter)). Lab results: BUN 123 (An elevated BUN can be signs of kidney problems.) It should be noted R4 has a history of stage 3b chronic kidney disease meaning she has moderate to severe loss of kidney function. The 24-hour board for R4 dated 9/29/24 states in part; AM shift - emesis again today, afebrile, not eating or drinking. Received orders for UA, Comp panel. PM Shift - Sent out. R4's nursing progress notes state the following: 9/29/24 at 16:09 (4:09 PM) states in part; resident transferred 9/29/24. Time of Transfer: 16:30 (4:30 PM). Transferred to: (Hospital Name). Reason: for evaluation, COC. Primary sign/symptom leading to transfer: abnormal labs, or test, altered mental status, nausea/vomiting, nutrition (inadequate intake food/fluid). Primary diagnosis/presumed diagnosis leading to transfer: dehydration, failure to thrive, BUN 123. 9/29/24 at 22:43 (10:43 PM) spoke with ER (emergency room ) Regarding: admitted for AKI (Acute Kidney Injury). EMS (Emergency Medical Services) report dated 9/29/24 states in part; report response: emergency response. Unit notified dispatch: 9/29/24 16:36 (4:36 PM). Primary Symptom - Malaise. Other Associated Symptoms - Abdominal rigidity, Nausea, Vomiting. Primary Impression: GI/GU (Genitourinary) - Nausea (w/vomiting). Patient Care Report Narrative: Ambulance dispatched to (Facility Address) with COC. En route immediately and upon arrival at the scene, we were met in hallway by nurse and directed us to patient room. Upon entering room, EMS found a patient lying supine in bed with her eyes closed. Her daughter was in the room as well, talking to another nurse that was standing at the patient bedside. Daughter stated that the patient has been having nausea and vomiting over the last couple of days and today she is very lethargic. Patient has a history of dementia and the daughter states she is a DNR (Do Not Resuscitate). Appears to be in no obvious signs of distress but is very lethargic. Abdomen is distended and rigid with reports of nausea and vomiting over the past couple of days, unable to keep anything down. Once placed in ambulance patient was hooked to cardiac monitor showing an irregular rhythm with first degree heart block (slow conduction of heart) was obtained with a 12-lead ECG (Electrocardiogram). Patient was given 150 ml (milliliter) of LR (Lactated Ringers) for hypotension (low blood pressure). Vital Signs Recorded with EMS: 9/29/24 at 16:52 (4:52 PM) BP (blood pressure) 77/57 (low bp), Pulse: 88, Respirations: 16, Oxygen Saturation: 96%. Temperature: 97.4 9/29/25 at 17:03 (5:03 PM) 75/56, Pulse 65, Respirations: 16, Oxygen Saturation: 96%, Temperature: 97.4. Of note, the paramedics' assessment indicates R4 was lethargic with a distended abdomen and nausea and vomiting the past couple of days. However, there is no indication or documentation in R4's medical record of an abdominal assessment by the facility despite presenting with GI symptoms. Hospital History and Physical dated 9/29/24 states in part; Chief Complaint: presents with fatigue and vomiting. Presents with nausea, vomiting and poor p.o. (oral) intake. Her daughter states that for the past week, she has been having vomiting after she tries to eat or drink. In addition, the past several days she has been feeling fatigued, lethargic, and complaint of dull, intermittent lower abdominal pain. She has been sleeping most of the day. According to the EMR (electronic health record) notes, patient has been having decreased urine output for an unspecified period of time. Nursing home staff noted her BP (blood pressure) had been low and contacted EMS. There are no reports of fever, chills, constipation, diarrhea, hematuria (blood in urine), urgency, chest pain or URI (upper respiratory illness) symptoms or shortness of breath. ED (Emergency Department) Findings: In the ED, she was severely hypotensive (low blood pressure). She received 2 liters of normal saline bolus with minor improvement. Her lab work showed marked prerenal azotemia (a condition that occurs when there is a buildup of nitrogen waste products in the blood due to decreased blood flow to the kidneys) with a BUN of 123 and Creatinine of 2.4. Urinalysis was positive for nitrates, leukocyte esterase, and bacteria (sign of infection). She was given 2 grams of IV (Intravenous) Rocephin (antibiotic). An x-ray of the abdomen showed findings consistent with SBO (small bowel obstruction) and bowel perforation. ED provider called the on-call general surgeon. Given her advanced age and comorbidities, she would not be a candidate for surgical intervention. I discussed goals of care with her daughter. They wish for her to be DNR (Do Not Resuscitate) (No life saving measures). They do not wish to pursue any aggressive intervention, such as pressors (medication to increase blood pressure), intubation (tube inserted to assist with breathing) or surgery. She will be admitted for comfort care and hospice consult. Reason for Admission: SBO with perforation. Vital signs in ED: BP: 63/41 (Critically low), P (Pulse): 83, T (Temperature): 97.7, R (Respirations): 18, Oxygen Saturations; 95 % Constitutional: General: She is sleeping. In no acute distress. She is ill-appearing. Abdominal: General: Bowel sounds are increased. There is distension. Palpations: Abdomen is soft. Tenderness: There is guarding. There is no rebound. Results Review: Labs: CMP (Compete Metabolic Panel) shows azotemia with creatinine of 2.4 (elevated) (A creatinine level is a measurement of the amount of creatinine in your blood or urine and is used to evaluate your kidney function. Normal range 0.6 -1.1. elevated range can indicate decreased kidney function.) and BUN 123 (elevated). This is consistent with prerenal AKI (Acute Kidney Injury) (a sudden decline in kidney function). WBC (White Blood Cells) WBC: 10.4 (slightly elevated) (Indication of infection). UA (Urinalysis) was positive for nitrate and leukocyte esterase (indication of urinary tract infection). Imaging: x-ray of abdomen shows dilated bowels consistent with small bowel obstruction. Pneumoperitoneum is seen, suggesting bowel perforation. Plan: Given her assessment findings, it is likely that she is approaching end-of-life. We will implement comfort measures accordingly per family wishes. Prognosis: Death expected. R4's abdominal x-ray dated 9/29/24 at 1719 (5:19 PM) states in part; Indication: vomiting and hypoxia. Technologist Note: pain, vomiting and hypoxia. Findings: Dilated, gas-filled small bowel loops, measuring up 4.4. cm (centimeters), suspicious for a SBO (small bowel obstruction). Pneumoperitoneum, suggesting bowel perforation. Discharge Summary dated 10/2/24 states in part; discharge diagnosis and hospital problems: small bowel obstruction, nausea with vomiting, AKI (a sudden decline in kidney function), hypotension, acute cystitis without hematuria (inflammation of the bladder without bleeding) and early onset dementia. Summary of hospitalization presents last night with lethargic [sic], nausea, vomiting and poor p.o. (oral) intake. Patient was found to have evidence of SBO and bowel perforation. admitted for comfort care. Today being discharged back to nursing facility for transition to hospice. Nursing Home Progress notes dated 10/2/24 at 23:23 (11:11 PM) state in part; came back to facility to be taken care of Hospice [sic] due to diagnosis of SBO and perforation. On 10/16/24 at 7:12 AM, Surveyor interviewed CNA L (Certified Nursing Assistant) regarding R4. Surveyor asked CNA L how R4 appeared days prior to her hospitalization . CNA L stated R4 had a distended stomach, not acting herself, we all knew something was wrong with her. CNA L stated her appetite decreased and she was just not herself. Surveyor asked CNA L what she means that R4 was not herself. CNA L stated she wasn't eating well, she had the distended abdomen, was nauseated and vomiting, and just not her alert, cheerful self. Surveyor asked CNA L if she told anyone about how R4 was presenting. CNA L stated yes, I reported it to the nurses; CNA L was not able to recall what nurses she reported it to. On 10/16/24 at 7:25 AM, Surveyor interviewed CNA K regarding R4. Surveyor asked CNA K how R4 appeared days prior to her hospitalization . CNA K stated R4 would not eat, she was eating less, more withdrawn, would call out at times which was unusual for her, and she complained of some abdominal pain. Surveyor asked CNA K if she told anyone about R4's behavior, CNA K stated the nurses were aware she was not eating much and more withdrawn. On 10/16/24 at 7:00 AM, Surveyor interviewed Agency LPN F (Licensed Practical Nurse) regarding R4. Surveyor asked LPN F how R4 appeared days before she was hospitalized . LPN F stated R4 was slowly declining, she was yelling out, then that stopped. She was not eating for several days, not drinking, wouldn't even drink her coffee, she loved her coffee, she was like a shell in her chair. Surveyor asked if R4 complained of abdominal pain, LPN F stated not sure if she could. No real nausea/vomiting when I was working. LPN F stated, I just thought she was declining due to her advanced age. LPN F stated a few days or so ago, prior to her hospitalization , we noticed she was just not herself. Surveyor asked LPN F what she noticed was different. LPN F stated she was just out of it, very sleepy, not eating, not drinking. LPN F stated, I never thought she was sick. Surveyor asked LPN F if a resident is presenting with nausea/vomiting, abdominal pain, and lethargy what would she do. LPN F stated I would let the Dr. know. Surveyor asked if LPN F would have an RN assess a resident with these complaints, LPN F stated yes. On 10/16/24 at 7:20 AM, Surveyor interviewed LPN N regarding R4. Surveyor asked LPN N how R4 appeared days prior to her hospitalization . LPN N stated R4 was weaker, quieter, withdrawn. LPN N stated she was usually more cheerful. Surveyor asked LPN N if she noticed a COC with R4. LPN N stated not until 3-4 days prior to her hospitalization it was obvious something was not right, we were just not sure what was occurring. Surveyor asked when a resident is presenting with a COC or just not seeming right what would you do. LPN N stated let the charge nurse know of the concerns. Surveyor asked LPN N if she reported the concerns she was seeing to the charge nurse. LPN N stated the charge nurse was aware. On 10/16/24 at 7:30 AM, Surveyor interviewed RN I (Registered Nurse)/Nurse Supervisor regarding how R4 appeared days prior to her hospitalization . RN I stated R4's appetite was poor, she was more lethargic, more tired, just feeling punky. Surveyor asked RN I how long R4 presented this way prior to hospitalization . RN I stated probably 2-3 days. RN I stated R4 had constipation issues and we were monitoring her bowel sounds and abdomen. Surveyor asked RN I where Surveyor could find the assessments for R4, and RN I stated they would be in the medical record under nursing progress notes. On 10/16/24 at 10:45 AM, Surveyor interviewed Agency RN M regarding R4. Surveyor asked RN M how R4 appeared days prior to her hospitalization . RN M stated, the day I sent R4 out to the hospital she was not eating, was more lethargic, had an emesis and a large BM on my shift. I called the Dr. on-call as she was not feeling well for a few days. I received an order to complete labs and her BUN was elevated so we sent her out. RN M stated she had an altered mental status, did not have much intake so R4 was sent to the hospital, and they found she had a SBO and UTI. Surveyor asked RN M did you complete an assessment on R4 when she was presenting this way. RN M stated she did not recall completing an assessment. R4 just could not get fluids in, was lethargic, and not talking. On 10/16/24 at 1:50 PM, Surveyor interviewed RN O regarding R4. RN O stated she worked on Saturday 9/28/24, and R4 had an emesis 1 day prior to 9/29/24. RN O stated R4 had a good day on 9/28/24. RN O stated gradually R4 was not eating the way she had been. She complained some of GI upset and received Tums. RN O stated on 9/29/24, R4 did not want to get out of bed, we knew something was not right and we called Dr. and received orders for labs and UA. RN O stated, I did not have concerns; except she was not eating like normal and knew something was brewing just not obvious. Surveyor asked RN O if during the time R4 had a decreased appetite, not feeling well, did she complete a GI assessment. RN O stated no, I didn't recognize anything out of the ordinary. On 10/16/24 at 10:50 AM, Surveyor interviewed DON B (Director of Nursing) regarding R4. Surveyor asked DON B what the facility was aware of prior to R4 being sent to the hospital. DON B stated R4 had just recently received the flu shot and told staff to monitor residents for potential reactions to the flu vaccine, we thought it was the flu vaccine. Surveyor asked DON B to review R4's nursing progress notes. DON B stated, I see on 9/27/24 she was more lethargic, flushed, had a large BM, and we were monitoring her. On 9/28/24, there was nothing charted. On 9/29/24, she was not eating and decided to get labs to see how R4 was doing. Labs were abnormal, R4 had an emesis, and she was sent out. DON B stated, it seems to me like R4 was an erpy person, meaning having small emesis. DON B stated R4 was not a big eater, ate small amounts and always had. DON B stated I know she had a SBO, but she was still pooping and eating at baseline. Surveyor asked DON B what standard of practice the facility follows for COC and MD notification, DON B stated Interact. Surveyor asked DON B about the nursing note for 9/26/24 for R4. Surveyor discussed the progress notes, 24-hour board, staff interviews regarding R4 and asked DON B on 9/27/24 when the nurse documents R4 presented with abdominal pain, fatigue, and lethargy, what would your expectations be. DON B stated she would hope for a GI assessment and to call the MD. DON B stated it was a small emesis of undigested food and she was coughing; this was R4's baseline. Surveyor asked DON B if the facility has a morning stand-up (staffing meeting) and DON B stated yes. Surveyor asked DON B if R4 was brought up at the stand-up meeting. DON B stated, I think R4 was a long-term erpy resident and this was not abnormal. Surveyor asked DON B when looking over R4's symptoms for the 2-3 days prior to R4's hospitalization would you expect the nursing staff to complete an RN assessment? DON B stated 100 percent if having abdominal pain. DON B stated there was nothing out of baseline for R4, we had no idea she had a COC until the day the labs were drawn then we realized something was occurring. On 10/16/24 at 11:50 AM, Surveyor interviewed R4's physician MD P (Medical Doctor) regarding R4's COC. Surveyor asked MD P if she would expect to be notified if a resident presents with nausea, vomiting, abdominal pain, and lethargy. MD P stated she would expect the nursing staff to contact her with a full assessment. Surveyor asked MD P if this would include things such as listening to bowel sounds, palpating the abdomen, full set of vital signs, MD P stated yes. MD P stated if it were just nausea we could give an antiemetic (medication for nausea), continue to monitor and escalate care if exam shows other finding such as nausea, vomiting, abdominal pain, and lethargy. MD P stated if R4 was presenting with nausea, vomiting, abdominal pain, and lethargy, the facility should have notified the physician on-call. R4 presented with decreased appetite, nausea, vomiting, abdominal pain, and lethargy. The facility failed to recognize R4's change of condition, failed to complete a GI/abdominal assessment, and failed to notify R4's physician with R4's complaints of abdominal pain. R4 became lethargic and was transferred to the hospital and noted to have a perforated colon and pneumoperitoneum. The facility's failure to recognize a change of condition, complete a comprehensive nursing assessment, and notify the physician with a change of condition created a reasonable likelihood for serious harm, thus leading to an immediate jeopardy situation which began 9/27/24. The facility removed the immediate jeopardy on 10/16/24 by taking the following actions: DON and ADON (Assistant Director of Nursing) did a complete facility wide sweep to determine if any residents had a COC. Any residents identified with a COC had an immediate nursing assessment completed and MD/POA (Power of Attorney) updated. DON and ADON reviewed the 24-hour report to confirm accuracy and to identify any other residents with a potential COC. DON educated nursing staff and reiterated the importance of completing accurate nursing assessments and documentation in a timely manner. Including education on what to include in a thorough GI/digestive assessment and how to interpret the results. If assessment is abnormal, following with COC protocol including MD/POA notification. All staff received immediate education prior to their next working shift on the following: o Change of Condition o Nursing Documentation/Assessment o MD/POA Notification o 24-hour report should be brought to morning clinical meeting and afternoon stand down o 24-hour reports should include, but are not limited to: resident COC, follow up assessments, negative behaviors, pressure injuries, falls, resp/GI symptoms admissions, discharges, room changes, appointments, MD rounds, new orders, care plan changes, medication changes, therapy updates, refusals, change in functional and cognitive status Audits will be completed on all the above items. Findings will be presented at least quarterly at QAPI. o On October 17, 2024, nurses and CNAs were given Skills Assessment sheets to determine what area of focus is needed to perform job duties effectively. DON and/or ADON will review Assessment sheets, educate

Based on interview and record review, the facility failed to ensure each resident (R) received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for falls. On 9/2/24, R1 was in the shower room when CNA D (Certified Nursing Assistant) attempted to remove R1's incontinent product from under her while she was sitting in the shower chair. This caused R1 to begin to fall. CNA D and CNA E assisted R1 to the floor. When a nurse had not shown up for 15 minutes, CNA D & CNA E assisted R1 off of the floor prior to a nurse assessing R1 for any type of injury. From the fall incident on 9/2/24, R1 sustained a fracture to her right tib/fib. On 10/4/24, R1 had an x-ray completed that showed an angulated and displaced left femur fracture. R1 was sent to the hospital on 10/14/24 related to R1 now having an open fracture of the left femur. The facility's failure to prevent accidents from occurring due when CNA D and CNA E attempted to remove an incontinent product while R1 was in a shower chair and then transferring R1 without a nurse assessment resulted in a right tib/fib fracture and a left angulated and displaced femur fracture. These failures created a finding of immediate jeopardy that began on 9/2/2024. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 10/16/24 at 3:00 PM. The immediate jeopardy was removed on 10/16/24, however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement their removal plan. Evidenced by: Facility policy titled Fall/Accident Prevention, states in part: .Resident/client will receive adequate supervision and assistive devices, based on the comprehensive assessment to prevent accidents and falls. The facility will identify residents at risk for falls/accidents and adequately plan care and implement procedures to prevent falls . 1 .Appropriate interventions will be implemented for each resident to prevent falls/accidents based on individual resident need . All residents will be assessed on an individualized basis and will receive adequate supervision appropriate assistive devices will be provided to prevent accidents and falls .Assistive devices will be assessed for appropriateness, safety, and teaching of use provided In addition, CNA care cards and ICP will also reflect residents' extreme high risk for falls .2. After each fall, the nurse will implement a temporary fall CP (care plan) times 72 hours and complete a fall assessment in the nursing notes. Assessment should include date, time, location of fall, circumstances of the fall including circumstances are root cause leading to the fall/accident, (such as meds or wet floor) witnessed, unwitnessed, injuries, pain, interventions to prevent further falls and treatment provided .MD (Medical Doctor) will be updated on all falls with significant injury and incident will be reported to responsible party immediately if injury and within 24 hours if no injury .5. An accident report (for internal use only) will be completed by the neighborhood nurse or supervising nurse with each fall. The DON, Administrator, and medical director will receive a copy of the incident for follow-up and evaluation if needed. The resident is placed on 24-hour report for 72 hours for follow-up by nursing. Unwitnessed falls without a root cause identified will be investigated per facility Policy and Procedures . Per John Hopkins, The femur is the large bone in the upper part of your leg. Different kinds of trauma can damage this bone, causing it to fracture into 2 or more pieces. This might happen to the part of the femur near your knee, near the middle of the femur, or in the part of the femur that forms part of your hip joint. In certain types of femur fractures, your femur has broken, but its pieces still line up correctly. In other types of fractures (displaced fractures), the trauma moves the bone fragments out of alignment. (https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/femur-fracture-open-reduction-and-internal-fixation) R1 was admitted on [DATE], with diagnoses that include anemia, bilateral primary osteoarthritis of knee, chronic peripheral venous insufficiency, anxiety disorder, abnormal coagulation profile, and age-related osteoporosis without current pathological fracture (5/10/23). R1's significant change MDS (minimum data set) dated 9/10/24, indicates R1 is severely cognitively impaired and has impairment on one side of her lower extremities. R1 is dependent on staff for eating, toileting, showers, transfers, and dressing. Section J includes R1's staff pain assessment, which indicates R1 has shown nonverbal signs of pain including, facial expressions, and protective body movements which have been observed daily. R1 is indicated as not having any falls since prior assessment. CNA D's (Certified Nursing Assistant) witness statement dated 9/2/24 indicates: Name of victim (R1). Was the victim injured, yes is marked. What happened? While giving a shower to (R1), I (CNA D) tried to pull the brief (incontinent product) out from under her bottom so that I could wash her bottom. In doing so, (R1) started to slip from the shower chair, to prevent a fall the other CNA (CNA E's name) and I lowered (R1) to the floor. She did not hit her head and to my knowledge at this point, I thought we were careful to not hit any of her extremities. we pulled the emergency call button. While we were waiting for the nurse we covered her in bath blankets and waited. After 15 minutes I (CNA D) grabbed the Hoyer lift and used it to lift (R1) from the floor to her reclined Broda chair. I then wheeled her down to her room and the nurse and I hoyered her to her bed. While I was getting her dressed in a gown I noticed that her leg looked off. I immediately notified the nurse to check her leg for injury. When did it occur? (date and time) 9/2/2024 8:45 PM. On 10/15/25 at 11:30 AM, Surveyor interviewed CNA D regarding R1's fall in the shower room. CNA D indicated that when R1 is in the shower she gets cold, so CNA D swaddled/wrapped her up in blankets and did not see she still had her incontinent brief on. CNA D indicated R1 was transferred to the shower chair and CNA D noticed R1's brief was still on. CNA D indicated she tried to pull it down through the hole, I shouldn't of. CNA D indicated her and CNA E lowered R1 to the floor and got her into the wheelchair with the hoyer and the nurse came in, then we transferred her to the bed. CNA D indicated while getting R1 dressed she called the nurse back in and noticed her leg was broken. CNA D stated, I was in a rush, as they're always short staffed. CNA D indicated we pulled the emergency cord and it was cold in there, she (R1) was crying. CNA D indicated R1 had a brace after the incident to her right leg and rolling her was hard to do for cares. CNA D indicated they put a pillow between her legs when moving and rolling her back and forth. CNA D indicated R1's left leg was fine and did not notice anything wrong with her left leg. CNA E's witness statement dated 9/2/24 indicates: Name of victim (R1). Was the victim injured? Yes is marked injury to the leg. What happened? (CNA D) attempted to get brief off of her in the shower chair to try (and) wash her bottom. She slipped out of the shower chair. So we lowered her down to floor. We pulled the emergency cord. We waited for 15 minutes. She was very vocal while on the cold shower floor. She had blankets under her head and ankles. We hoyered her from the ground into her wheelchair. We were finally able to get a nurse, she came (and) we took her into her room. Where the nurse checked her out. When did it occur? Around 8:45 PM on September 2nd 2024. On 10/15/24 at 3:58 PM, Surveyor interviewed CNA E regarding the incident with R1. CNA E indicated they got R1 into the shower chair, and halfway through realized her brief/incontinent product was on. CNA D tried to get it out, when tried to rip it, it pulled her bottom off the chair and we couldn't get her back on the chair. CNA E indicated CNA E and CNA D lowered R1 to the floor, clicked on the emergency light. CNA E couldn't find the nurse, so CNA D said, Ok let's get her up. CNA E indicated they got R1 up into her shower bed or chair, got another nurse. CNA E indicated the nurse didn't get the page for the emergency light for the spa room. CNA E indicated CNA D helped get R1 up off the floor using the hoyer lift (full body) and then put more blankets on R1. CNA E indicated they waited approximately 15 minutes before getting her up off the floor. CNA E indicated R1 didn't look in pain after the nurse assessed her, she was asleep. CNA E indicated CNA E looked for their nurse but couldn't find the nurse, so CNA E went and got LPN F. CNA E indicated R1 went out to the hospital and came back with a pillow between her legs, not to lay on her right side, assist with meals and to keep a pillow between her legs when she was up. LPN F's (Licensed Practical Nurse) witness statement dated 9/2/24 indicates: Name of victim: (R1). Was the victim injured? Yes is marked. What happened? (CNA E's name), CNA came over to (unit name) stating they need a nurse and can't find (name of unit) nurse, that they have had the emergency light on in (unit name) spa for 15 min. When writer arrived at spa, resident was in her Broda chair. (CNA D), CNA stated that resident was lowered to the ground after discovering that they did not remove resident's brief and resident slipped out of chair. CNAs stated that they put resident back in chair because of resident being on the floor for 15 min already. Writer tried to get vitals but resident too contracted. (RN G) floor nurse came (and) took over. On 10/15/24 at 2:40 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) regarding R1's fall. LPN F indicated she was working on another unit when an aide came running over to get her. LPN F indicated she went into the spa room and assessed her and that R1 doesn't talk, she didn't know anything was broken, R1 was very rigid and anxious. LPN F indicated R1 was on the floor when she went to the spa room. (of note: CNA D and CNA E indicated they moved R1 before the nurse assessed and LPN F's witness statement indicates R1 was moved prior.) LPN F indicated R1's legs are always contracted. LPN F indicates she did not know she had to call a nursing supervisor with a fall, and RN G took over. RN G's (Registered Nurse) witness statement dated 9/2/24 indicates: Name of victim: (R1). Was the victim injured? Yes is marked left lower leg swelling & bruising. What happened? Aides reported after resident in bed that her left leg looked weird. (LPN E) nurse, wrote note on my wing sheet that resident had been lowered to floor in shower room. Per CNAs resident had slipped when attempting to remove brief. When did it occur? 2100 (9:00 PM) 9/2/24. On 10/15/24 at 2:57 PM, Surveyor interviewed RN G regarding R1. RN G indicated she was working that unit that night and when the fall occurred she was in doing a treatment on another resident. RN G indicated when she came out of that room she had a note R1 had fallen. RN G indicated when she got to R1 she was in bed and you could see bruising and swelling. RN G indicated she called the charge nurse and sent R1 out to the hospital. RN G indicated that when R1 came back from the hospital, she had a splint on her Right right leg and had to keep it locked at 60 degrees and provide support to the leg as much as possible. R1's Purposeful Post-fall Huddle, conducted on 9/2/24 indicates the following: Resident (R1), date of fall: 9/2/24, time of fall: 2045 (8:45 PM), day of week: Monday. Date of huddle: 9/2/24, time of huddle: 2230 (10:30 PM). Resident: what were you trying to do? CNA was attempting to remove brief from resident while resident was still in shower chair. Root Causes: 1. CNA attempting to remove brief from resident while resident was sitting in shower chair. Action plan: What can be done to avoid future falls (interventions)? Use shower bed chair. On 9/2/24, R1's Progress notes are as follows: At 22:20 (10:20 PM) R1's Nurses note states in part: .Transferred to: (Hospital name). Transportation: by ambulance.Reason: for evaluation.Primary sign/symptom leading to transfer: Fall(s) Pain (uncontrolled) Trauma (fall-related or other) . At 22:20 (10:20 PM) R1's Nurses note states in part: .Transfer: two assist with Hoyer needs 2 assist.Notification: ER notified and given report, administrator notified, DON (Director of nursing) notified, SW (social worker) notified, ambulance called, physician notified, family notified daughter (name). At 23:04 (11:04 PM) R1's Nurses note states in part: .Skin problems: Left lower leg, below the knee swelling and start of bruising noted, after being assisted to the floor during a shower. 4 1/2 x 5 3/8 swelling and bruised area. Per CNA, resident lowered to the floor in shower room by 2 after slipping while attempting to remove brief. Aat 23:12 (11:12 PM) R1's Nurses note states in part: Comments: Resident suffered left leg injury while showering. EMS called for transport to (Hospital Name). Left facility at 2305 (11:05 PM) with patient left leg stabilized with blue foam splint and towels. Assisted to EMS cot with 4 . {sic} At 23:32 (11:32 PM) R1's Nurses note states in part: Note: Resident was in the shower room with a staff member when she started to slip off of the shower chair and was lowered to the floor. Resident was lifted off the floor using a hoyer lift by two CNA's. Then the resident was placed in her w/c (wheelchair), transferred to her room and hoyer lifted into bed by CNA and LPN. Writer was called by assigned LPN to assess resident at this time. Resident's right leg is swollen from her foot to her knee and is becoming bruised. There is a large, raised area distal to the knee measuring 4 1/2 x 5 3/8 inches. Resident is moaning/crying in pain. (Physician Name) ordered transfer to hospital . At 23:55 (11:55 PM) R1's Nurses note indicates R1's Healthcare Power of Attorney (HCPOA) was called regarding a fall and injury. On 10/16/24 at 10:10 AM, Surveyor interviewed DON B and NHA A regarding the incident with R1. DON B indicated she started an investigation and CNA D and CNA E both said they made a mistake as they took R1 to the shower room in the chair, noted the brief was on and instead of taking R1 back to her room they tried to take it off of her in the chair, R1 began to slide out, they noted sliding and lowered her. DON B indicated they activated the emergency light in the shower room and R1 was cold on the floor, so they covered her up with blankets. LPN F assessed and R1 was in bed when noted leg wasn't right. RN G had a note of R1 falling, then RN G assessed and noted R1's leg. NHA A indicated the fall occurred around 2045 (8:45 PM). Surveyor asked DON B and NHA A both to read the witness statements from CNA D, CNA E, and LPN F regarding R1's fall. Surveyor asked if they were aware that R1 was moved off the floor without a Nurse assessing R1 first. DON B replied the staff get an RN to assess her to ensure no internal/external rotation and the RN gives the okay if the resident can get up or not. DON B indicated they do a fall investigation which looks at the root cause of what happened, what caused it, what was happening etc., and it's reviewed by the IDT (interdisciplinary team) to review interventions are appropriate to fix it and notifications were done to the MD and representative/family. DON B indicated she individually met with CNA D, CNA E, and LPN F. DON B indicated CNA D and CNA E said the call light was on and felt like 15 minutes had gone by. DON B indicated LPN F indicated she assessed R1 and DON B educated LPN F that LPNs cannot assess. DON B indicated that a nurse should have done an assessment before moving R1. DON B indicated she educated CNA D and CNA E on what to do if it occurs again before transferring resident to check brief is off or take back to the bed/room to take brief off. DON B indicated this was an isolated event and verbal education was done with CNA D. Surveyor asked DON B for documentation of verbal education, DON B indicated she does not have anything. On 9/2/24 at 11:24 PM, R1's Emergency Department (ED) note indicates: R1 received a CT of cervical spine, CT chest, abdomen, pelvis, CT angio of right lower extremity. Clinical impression: Fall, right tibial plateau fracture with some tibial posterior displacement, fibular neck fracture, elevated white count and hypoxia. On 9/3/24 at 6:53 AM, R1's Nurses note states in part: .resident has been admitted to the hospital with a tib-fib fracture . On 9/3/24 at 11:36 AM, R1's 'Physician Discharge Summary,' states in part: .Principal problem: Closed fracture of right tibial plateau.Presentation: (R1) is a resident at (Facility name). She is normally bed-bound and requires maximum assistance assistance [sic] with hoyer lift. Earlier this evening, the CNAs had placed her on a shower chair. They were attempting to take off her brief to get her in the shower and she ended up having a fall on the bathroom floor . ED findings: in the ED, she was in a lot of pain and was crying out. Her right leg appeared swollen and painful but pulses were present. Reason for admission: Inpatient status for closed fracture of right tibial plateau secondary to fall. Hospital course . Ortho evaluated the patient and recommended a brace placement. Patient will be sent back to SNF (skilled nursing facility) with increased pain medications. On 9/3/24 at 15:03 (3:03 PM,) R1's Nurses note indicates R1 was readmitted to the facility at 1:40 PM. On 10/4/24 at 3:06 PM, R1's Radiology report states in part: results: recent fracture involving left distal femur with moderate angulation and displacement. The joint shows no dislocation. There is diffuse osteopenia and moderate degenerative changes left knee. Conclusion: Recent fracture involving left distal femur with moderate angulation and displacement. On 10/4/24 R1's Orthopedic NP note written by NP C, states in part: .at approximately 1630 (4:30 PM) writer was notified of the radiography results.subsequently went to the (name of facility) in person to view the radiographs on (company name) website. After review of the imaging, writer evaluated (R1). (R1) is up in her Broda chair and is eating supper in the dining room. She does not appear to be in any distress . The left knee was intact, but had a large circular red/purple area that was covered with a mepilex foam dressing for protection. The overlaying skin was intact, but upon palpitation of the area, the end of the femur could be palpated. (R1) did not show signs of pain during the exam.Staff deny any falls, trauma or injury other than the fall on 9/2/24 for which (R1) was hospitalized for a right tibial plateau fracture. No injury to the left knee or leg was noted and no imaging was obtained during that hospitalization . On 10/1/24, Nursing staff (Name) notified (R1's) primary care provider of a concerning [sic] a nodule to the left knee, approximately the size of a grape. No warmth was noted and no signs of pain were reported. A foam dressing was applied for padding of this area and a pillow was placed between her knees for additional pressure relief . Assessment and plan: .Writer called and spoke to (R1's) healthcare power of attorney (HCPOA), her daughter (Name) to discuss radiographic findings . (daughters name) asked writer when the femur fracture may have occurred, unfortunately this is not something I am able to answer. It would take a high impact injury such as a fall to fracture a femur in this manner. (R1) did have a fall on 9/2/24 . (daughters name) decision to proceed with non-operative management [sic] .after discussion, there is limited splinting that is available for this, and positioning with pillows and limiting flexion would be appropriate. Wwriter spoke to (daughters name) as she was concerned about's [sic] splinting the femur.Orders: 1. Monitor knee for skin integrity. Keep knee stabilized with pillows. 2. may get up for meals . On 10/6/24 R1's 'Physician Monthly Progress,' states in part: routine visit .(R1) had already been diagnosed with closed fracture of the right tibia plateau but most recently after being evaluated by orthopedics and nurses staff [sic], had an x-ray on 10/4/24 that also shows left femur fracture. Non operative treatment decided by family and orthopedic team .she is lying in bed sleeping. no acute distress. she has her right knee in a brace. on her left knee, she has a bulge noted that has sticky cushioning material on it for protection .6. History of bilateral chronic knee pain. Continue morphine, recently increased to QID secondary to her right tibial plateau fracture and now left femur fracture . On 10/7/24, R1's Orthopedic NP note, written by NP C, states in part: .writer found 2 knee abduction pillows. The goal of splinting is to decrease the flexion that (R1) is able to do, however she has a permanent flexion contracture and her fracture is displaced, so standard splinting was not an option. I also had to take in consideration her potential for compromised skin integrity given her age and limited motion. The overall concern was that the displaced femur could break through the skin . Assessment and Plan: .report the application of the 2 soft abduction knee pillows to help reduce flexion of the knee. Writer discussed that the greatest concern is that the displaced femur fracture could break through the skin causing an open fracture which would prompt a hospital admission and IV (intravenous) antibiotics and possible surgical interventions. (daughters name) reported understanding .Foley catheter would be appropriate at this time to reduce rolling and movement for incontinence care.Orders: 1. Monitor knee for skin integrity. 2. Keep knee pillows (2) on at all times. May remove for skin checks or hygiene as needed. 3. monitor for signs of infection. 4. may get up for meals. 5. insert foley catheter. 6. call orthopedics department for any questions or concerns . On 10/11/24 at 19:36 (7:36 PM), R1's Nurses note states in part: Skin problems: writer changed mepilex to L knee d/t (due to) soaked w/serosanguineous drainage. There is no evidence of an assessment, measurement of area, R1's provider or HCPOA was being updated regarding this note or change in R1's Left knee condition. R1 was sent to the hospital on 10/14/24 around 1:52 PM. On 10/14/24 at 2:53 PM, R1's Emergency Department note states in part: Today the skin over the distal end of the femur broke down and she now has an open wound over the fracture and concerning for open fracture . Musculoskeletal: Comments: Hands elbows and hips contractured, patient is in bilateral leg splints, open wound to left medial knee area with moderate serous drainage .Neurological: .nonverbal, moaning occasionally unrelated to cares. On 10/14/24 at 3:50 PM, R1's Orthopedic note states in part: .Reason for admission: impending open left distal femur fracture. History of present illness: .She had a progressive concerning appearance of her distal femur fracture site with tenting of the skin and now with an ulceration overlying the bony prominence and concern for impending open fracture of the distal femur . Plan: 1 .Activated medical power of attorney elected to proceed with a closed reduction procedure with splinting +/- any incision and drainage or irrigation and debridement determined to be necessary intraoperatively. She had no interest in amputation and no interest in any type of internal fixation of the distal femur fracture . On 10/14/24 at 3:47 PM, R1's Hospital Documentation indicates in part: Chief complaint leg injury. Presentation: Is unsure how the patient fell . On my encounter, patient is moderate distress .patient was hospitalized in the beginning of September for a fall .Reason for admission: Left femur fracture management. On 10/15/24 at 2:00 PM, R1's Hospital Documentation states in part: .scheduled for closed reduction and possibly debridement of open wound by orthopedic surgery this afternoon.Problems: Type I or Type II open comminuted intra-articular fracture of distal end of left femur . On 10/15/24 at 6:06 PM, R1's Hospital Documentation states in part: .Preoperative diagnoses: open, comminuted, displaced, left distal femur fracture. Postoperative diagnosis: Open, comminuted, displaced, left distal femur fracture. Procedure: 1. Open reduction of comminuted, displaced, left distal femur fracture. Application of left knee brace.3. irrigation and debridement/incision and drainage of open left distal femur fracture, debridement of skin, soft tissue and bone/femur. skin incision measures 5cm (centimeters). Open skin wound measured 1cm.Findings: .grade 1, open left distal femur fracture. fracture was significantly displaced, shortened and with valgus angulation. The distal medial femoral metaphysis was protruding through the skin medial with overlying ulceration and breakdown of skin. Debridement of open wound and ulceration of skin debridement of soft tissue and bone. Improved alignment of left distal femur fracture.Indications: there was significant valgus deformity of her fracture, however, and there was tenting and protrusion of her skin along the distal and medial aspect of her thigh. Eventually there was skin breakdown due to overlying ulceration and an open distal femur fracture. This opened and began draining within the last several days . (Of note, an open fracture is a break where the bone protrudes through the skin or when there's a wound that reaches down to the broken bone. These types of fractures are more complicated and serious to treat because of the increased damage to the surrounding tissue such as muscles, tendons, and ligaments and there is an increased risk of infection.) On 10/15/24 at 4:30 PM, Surveyor interviewed MD J (Medical Doctor) who is R1's primary physician. MD J indicated after incident on 9/2/24, R1's left leg was not imaged at the hospital or worked up. Surveyor asked MD J regarding how R1's femur fracture became angulated and displaced., MD J indicated if it occurred on 9/2 and went undetected it could happen by rolling her or from pressure to the area. MD J indicated they couldn't have prevented the displacement if they didn't know about it. On 10/16/24 at 9:17 AM, Surveyor spoke with Ortho NP C regarding R1. NP C indicated she had her first encounter with R1 on 9/2 when she was brought to the ER. NP C indicated R1 was seen for a tibial plateau fracture and placed in a knee immobilizer due to permanent flexor contracture, her knees are always bent and R1 has severe knee arthritis. NP C indicated R1 had extensive imaging but no imaging of the left leg due to no injury visible to that leg. NP C indicated she didn't notice anything with R1's left leg. NP C indicated on 10/4 she was notified of a bump on R1's knee and R1 got x-rays which noted a 100% displaced femur fracture. NP C indicated R1's femur was completely separated. NP C indicated that DON B called her regarding R1's skin had broken open and possible open fracture. NP C indicated an open fracture is a life-threatening thing. NP C indicated upon R1's arrival the skin was broken and actively draining serous drainage, sharp fracture, R1 had the thinnest piece of tissue over the femur, a small piece of the distal femur was able to be reduced enough to get a flexion knee immobilizer on her, which she'll have for the rest of her life. NP C was unable to tell R1's daughter if the fracture did occur from 9/2 as no imaging was done and to break a femur and displace it, it takes a high energy impact to do that. The failure to prevent accidents from occurring due to CNA D and CNA E not safely transferring/ensuring R1 was in a safe position prior to trying to remove her incontinent brief resulted in a right tib/fib fracture and a left angulated and displaced femur fracture after a fall in the shower room as well as staff not following the fall procedure by lifting R1 off the floor without a nursing assessment created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on 10/16/24 when it had completed the following: DON and ADON did a complete facility wide audit on transfer status of all residents to confirm accuracy on the care card. Resident care plans were reviewed for transfer status and ensured accuracy. All staff received immediate education prior to their next working shift on the following: Transfers: * Reviewed transfer policy and procedure and will present to all staff. * Always follow care card on how to transfer resident * Always use a gait belt when transferring resident * Always use 2 people for Hoyer transfer * Do not bump arms/legs during transfer * Do not attempt to remove garments resident is sitting on or pull -on the garments a resident is sitting on. Take time to ensure resident is ready for transfer into shower chair, all articles of clothing are off. If not, use safe transfer method to stand up or lay resident down. * Always report to nurse if resident is not tolerating current transfer method. Falls: * Reviewed facility fall policy and procedure and will present to all staff. * If resident falls, activate emergency cord and if no response, call out. * DO NOT move resident until an RN assesses for injury * RN to complete fall assessment including neurological and body assessment with vitals * If injury, update MD and call 911 to send to hospital for evaluation if ordered * Update: POA, DON/ADON, Administrator Skin: * Reviewed COC policy and procedure and will discuss will all nursing staff on recognition of COC and MD Notification. * CNA's report any and all skin changes to your nurse immediately * Nurse assess skin and document with measurements * Update DON and Wound Nurse * Update MD and POA Audits will be completed on all of the above items. Findings will be presented at least quarterly at QAPI. * Beginning on 10/16/24 the facility will begin auditing resident transfers as follows: 5x weekly x 4 weeks; weekly x 4 weeks; monthly x 1 month. * All falls will be audited for the following: Root Cause identification MD Notification; POA/Family Notification, if applicable, Care Plan updated, RN Assessment done 5x weekly x 4 weeks; weekly x 4 weeks; monthly x 1 month.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was adequately monitored and that the drug regimen was free from adverse consequences for 1 of 1 resident (R2) reviewed for adequate monitoring. R2 has a diagnosis of Atrial Fibrillation (an irregular heartbeat, that occurs when the upper chambers of the heart beat rapidly and irregularly) and receives Coumadin (a blood thinner). R2 was prescribed Bactrim on 10/1/24. Antibiotics can potentiate the effect of Warfarin (Coumadin). The facility did not complete monitoring for symptoms of drug interactions. R2 was sent to the hospital after a fall and was found to have a supratherapeutic (high) INR (international normalized ratio, a lab that measures how long it takes the blood to clot) of 4.5. The therapeutic range for INR is 2-3. This is evidenced by: The facility's policy titled Warfarin (Coumadin) Monitoring states in part; Purpose: To assure resident safety with a goal to maintain INR and keeping within residents therapeutic range. No adverse side effects from Coumadin. Policy: All residents receiving Warfarin therapy will also receive monitoring of its efficacy via resident observation and PT/INR (Prothrombin Time/International Normalized Ratio), A lab the [sic] measures clotting time, monitoring per physician order monitoring throughout the course of co-treatment. 11. The nurse will add the resident to the 24-hour report and indicate that co-treatment is taking place. This will communicate the need for additional monitoring of symptoms of active bleeding. 13. The nurse supervisor will provide ongoing monitoring of the implementation of this policy, including appropriate observation action, and documentation. According to http://packageinserts.bms.com/pi/pi_coumadin.pdf, Concomitant use of drugs that increase bleeding risk, antibiotics, antifungals, botanical (herbal) products. More frequent INR monitoring should be performed when starting or stopping other drugs, including botanicals, or when changing dosages of other drugs, including drugs intended for short-term use (e.g., antibiotics, antifungals, corticosteroids.) R2 was admitted to the facility on [DATE]. R2 has diagnoses of atrial fibrillation, dementia, Chronic Kidney Disease, and Diabetes. R2's care plan dated 5/21/24 states in part: resident will remain within individualized target range for INR without side effect. No uncontrolled bleed, minimal bruising. R2's physician's orders for September state in part: Coumadin 6 mg (milligrams) add to 1 mg total dose 7 mg daily order date 10/16/23. R2's Injury/Incident/Accident Investigation Report dated 9/30/24 states in part; resident slid off the edge of his bed onto the floor on his buttocks. ROM (Range of Motion) per baseline. Denies hitting head. No bruising or redness noted. Fix it to prevent further recurrence: UA obtained. It should be noted R2 had no symptoms of a Urinary Tract Infection (UTI). R2's nursing notes state the following: On 9/30/24 at 15:27 (3:27 PM) late entry for 9/29/24, resident continues to wander during shift. Refused straight cath (a tube inserted into the bladder to drain urine) refused personal cares and toileting/changes. N.O. (New order) obtained for UA/C&S (Urinalysis with Culture and Sensitivity), a test to check for urinary tract infection, what bacteria is present and appropriate antibiotic to use. Specimen obtained after attempts to straight cath. UA positive for UTI, culture pending. On 9/30/24 at 3:58 AM states in part: new lab: UA with culture and sensitivity if indicated. Increased confusion, increased sediment and mucous as well as very dark urine when the nursing staff cathed (Catheterization-tube inserted into bladder.) Of note confusion, increased sediment, mucous and dark urine are not criteria to gather a UA. On 10/1/24 at 9:19 AM, new orders received and noted: Bactrim DS (double strength) take 1 tablet PO (by mouth) BID (twice a day) for potential UTI. MD educated on protocol per facility that normally we wait for the culture to return before obtaining antibiotics. On 10/1/24, physician order Bactrim DS take 1 tablet PO BID x 7 days for potential UTI. MD educated on protocol per facility that normally we wait for the culture to return before obtaining antibiotics. Of note, there is no indication that the facility made the physician aware R2 was receiving Coumadin. Bactrim is a medication known to potentiate Coumadin. On 10/3/24 at 19:52 (7:52 PM), Urinary findings continues to be treated with Bactrim DS. On 10/4/24 at 23:02 (11:02 PM), Urinary findings continues to be treated with Bactrim DS. Of note, there is no indication in R2's medical record indicating the facility notified the anticoagulation clinic R2 was started on Bactrim. On 10/6/24 22:02 (10:22 PM), A telephone order states send to (Hospital Name) for evaluation of possible fracture or displacement. A hospital laboratory report dated 10/6/24 states Protime (lab used to see how long it takes the blood to clot) 42.1 (high) normal range 11.5-14.5. INR 4.5 (high) normal range 2-3. INR supratherapeutic (critically high). Nursing note on 10/7/24 at 9:05 AM states returned from emergency room . Nursing note on 10/7/24 at 10:57 AM states in part: new orders received and noted. Discontinue Bactrim Start Keflex 500 mg TID (Three Times a Day) Hold amlodipine and Dyazide times 3 days. (Blood Pressure Medications) Hold Coumadin today. Start Coumadin 4mg on 10/8/24 and 10/9/24. INR lab on 10/10/24. On 10/16/24 at 5:00 PM, Surveyor interviewed DON B (Director of Nursing) regarding R2's medication monitoring. DON B stated when R2 was placed on the Bactrim the facility should have contacted the anticoagulant clinic and typically we check the INR in 1-3 days after antibiotic is started. Surveyor asked DON B if that occurred for R2, and DON B stated, I cannot see we followed through with this process and 100 percent we should have. R2 was receiving Coumadin 7 mg daily. R2 was started on Bactrim DS which potentiates Coumadin. The facility did not monitor R2's INR while R2 was receiving Bactrim. R2's INR was critically high at 4.5 placing R2 at increased risk for bleeding.

Based on observation, interview, and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 1 sampled residents (R12) out of a total sample of 17 residents reviewed. R12 developed a pressure injury in the facility. Over time, this pressure injury developed an odor, grew in size, and was noted to have an increase in drainage. The facility did not update R12's Medical Doctor (MD) with these changes. Surveyor observed R12 calling out, striking, and wincing in pain during wound care. Staff were unaware R12 had an order for as needed oxycodone to be given prior to wound care. Staff took a defensive approach by placing pillows between R12 and themselves prior to providing wound care and during wound care and staff did not stop when R12 began calling out and striking during wound care. Surveyor observed R12 to be in the same position for extended periods without being repositioned. Surveyor observed R12 to have three or four layers between him and his pressure relieving mattress. Surveyor observed poor hand hygiene during R12's wound care treatment. Staff inconsistently staged R12's wound and left out important details of the wound's drainage and characteristics of the wound bed in weekly assessments, including how much slough covered the wound bed and how much granulation tissue covered the wound bed. Surveyor observed R12 to have his heels directly in contact with the mattress and not offloaded/floated as ordered. The facility's failure to provide care for R12 consistent with current SOP to prevent and treat PIs led to the development of an infected stage 4 PI thus creating a finding of Immediate Jeopardy (IJ) that began on 1/20/24. NHA A (Nursing Home Administrator) was notified of the IJ on 4/18/24 at 5:07 PM. The Immediate Jeopardy was removed on 4/18/24; however, the deficient practice continues at a scope/severity of D (potential for minimal harm/isolated) as the facility implements its removal plan. Evidenced by: Facility policy, entitled Change in Condition, reviewed 4/2024, includes, in part: The shift supervisor will immediately inform the resident, consult with the resident's physician, notify the resident's legal representative or interested family member when there is an acute change in condition defined as sudden, clinically important deviation from the resident's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death . When an acute change in condition occurs, the shift supervisor will notify the attending MD or designated alternate . The shift supervisor will document the notification of the MD and the resident/medical contact along with new orders in the resident's record . Pain-The following may indicate an acute change in condition and should be assessed further: pain worsened in severity, intensity, or duration, and/or occurring in a new location, new onset of pain ., new onset of pain greater than 4 on a 10 point scale . please refer to the table of categories of symptoms that may help to define an acute change in condition . Facility policy, entitled Pressure Injury Prevention, reviewed 4/2024, includes: it is the policy of the facility that residents who enter the facility without pressure injuries will not develop pressure injuries unless the clinical condition demonstrates they were unavoidable . and that a resident having pressure injuries will receive necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing . clinical conditions that this facility identifies as risk factors for development of pressure injuries include but are not limited to: impaired or decreased mobility and functional ability, terminal illness, peripheral vascular disease, diabetes, bowel incontinence, urinary incontinence, history of previous pressure injuries, impaired diffuse or localized blood flow, increased friction or shear, and resident refusal to some aspects of care and treatment . If a resident is admitted or develops a pressure injury, pressure injuries will be staged following the national pressure injury advisory panel pressure injury staging system. Residents will be repositioned at least every two hours to prevent skin breakdown. If an injury is on the resident's buttocks/coccyx area, resident will be repositioned every hour . Lift sheets will be used in bed to decrease friction and shear . heels are free floated for those at high risk .Measurements are completed in terms of length x width. Describe stage of injury per the national pressure ulcer advisory panel. The documentation should include exudates-type, amount, odor . describe wound bed appearance and surrounding tissue . know any signs or symptoms of infection . assess for signs and symptoms of discomfort. If discomfort is present during dressing change: stop immediately and offer analgesic to decrease discomfort. Whenever possible premedicating should occur to prevent discomfort . dressing changes: wash hands, assemble dressing supplies, use barrier between dressings and table for infection control purposes, open dressing supplies and prepare for use, apply gloves, remove dressing and dispose in waste receptacle, note any drainage or odor, remove gloves, wash hands, apply gloves, cleanse wound from clean to dirty, pat dry, measure wound, apply treatment per MD order, cover with dressing, secure with tape, remove gloves, wash hands . Facility policy, entitled Wound Treatment Management, reviewed 4/2024, includes: to promote wound healing of various types of wounds it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . the effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include lack of progress towards healing, changes in the characteristics of the wound . characteristics of the wound: pressure injury stage or level of tissue destruction . size-including shape depth and the presence of tunneling or undermining, volume and characteristics of exudate, presence of pain, presence of infection or need to address bacterial bioburden, condition of the tissue in the wound bed, condition of [NAME] wound skin . Facility policy, entitled Hand Hygiene, reviewed 4/2024, includes: .hand hygiene . as the single most effective means of preventing the spread of infection . hand hygiene is the responsibility of all employees . when to wash your hands: . before and after each direct contact with residents . after handling waste materials with secretion, drainage, or blood . after glove removal, after handling soiled linen . AMDA Clinical Practice Guidelines/Interact Tool for Change In Condition, dated 2014, includes: When to report to the MD . Immediate Notification-any symptom, sign, or apparent discomfort that is: acute or sudden in onset, and a marked change in relation to usual symptoms or signs or unrelieved by measures already prescribed . Non-Immediate Notification-new or worsening symptoms that do not meet above criteria . The National Pressure Ulcer/Injury Advisory Panel's Standards of Practice for Pressure Ulcer Prevention Points and Pressure Injury Stages, dated 2016, includes: Reposition bed-bound persons at least every two hours and chair-bound persons every hour (emphasis intended.) consistent with overall goals of care . Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use. According to the NPUAC, Pressure Ulcer Assessments should be done initially and re-assessed at least weekly and to document the results of all wound assessments. A two-week period is recommended for evaluating progress toward healing. Signs of deterioration (e.g., increase in wound dimensions, change in tissue quality, increase in wound exudate or other signs of clinical infection) should be addressed immediately . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. According to the National Pressure Ulcer Advisory Panel (NPUAP), dated 6/13/12, recommends use of positioning devices and incontinence pads that are compatible with the support surface and to limit the amount of linen and pads placed on the bed. They also direct clinicians not to leave moving and handling equipment under the individual after use. American Medical Directors Association (AMDA) guideline for the cause, prevention, and treatment of pressure sores, undated, includes: Use adequate pain control measures including additional dosing at the time of debridement or dressing changes . R12 admitted to the facility on [DATE]. He has diagnoses including nonverbal vascular dementia, severe Peripheral Arterial Disease with ischemic necrosis of foot, large left popliteal aneurysm and embolization of a right popliteal aneurysm resulting in acute ischemia, Diabetes Mellitus Type 2, cerebral vascular accident, expressive aphasia, and prostate cancer. R12's Comprehensive Care Plan, initiated 9/9/17, includes: 4/10/19 inspect skin especially bony prominences and dependent areas for redness, breakdown . Provide pressure reduction/relief mattress on bed and pad/cushion in wheelchair, heel and elbow protectors if indicated. Assess skin status, assess nutrition, keep MD (Medical Doctor) informed, administer analgesics as ordered . 12/4/20 nail care by nurse . observe for non-verbal signs and symptoms of discomfort . 3/1/21 lift and move resident carefully and with adequate assistance to prevent shearing of skin. Keep skin clean and dry, encourage and assist to reposition, report changes in skin to nurse, give incontinence care after each episode of incontinence, apply moisturizer and barrier as needed, inspect skin daily, positioning pillows as needed, air mattress, rolling pin . assist resident toileting every 2 hours and as needed . 9/27/23 assess and monitor for changes in skin injury . weekly . Clean, apply medication and dress open area as ordered. Daily inspection of skin including bony prominences and dependent areas for redness or breakdown. Keep clean and dry, monitor for drainage, color, odor . Ensure proper positioning of absorbent products/cath strap. Encourage mobility of extremities and reposition every 2 hours, reposition hourly if up in chair and wound is on seating surface. If possible, avoid seating resident on wound area, limit seating time in chair as tolerated, give incontinence care after each episode . apply moisture, apply barrier . Keep skin clean and dry, change wet linen, use incontinence pads, barrier cream to peri area as needed. Report changes in skin to nurse. Float heels and use pillows to maintain lateral position and separation of bony prominences. 12/4/23 Problem: infection to right digit (toe), necrotic, poor circulation . Use good hand hygiene techniques before and after cares . 12/28/23 Diabetes Mellitus, immobility, Hoyer lift transfer . Assess and monitor for changes in skin injury on weekly flow sheet. bony prominences and dependent areas for redness or breakdown. Keep clean and dry, monitor for drainage, color, odor . Pressure relieving device in chair, pressure relieving device for bed, applications of dressings . 2/7/24 Problem: infected Decubitus Sacral Ulcer . related to poor skin condition, diabetes mellitus, poor vascular condition . Manifested by drainage, warmth, and redness . Goal: free of signs of infection . Interventions: Nurse-Use good hand washing technique before and after cares. Wear gloves with cares. Note characteristics of drainage. Monitor labs as ordered . CNA-Use good hand washing techniques before and after cares, keep area clean and dry, help resident to wash hands, assist resident with turning every 2 hours, encourage fluid intake . use enhanced barrier precautions. 3/29/24 nail care by nurse, transfer-2 assist with Hoyer . repositioning/bed mobility- 1 assist, head of bed at 30 degrees or less, reposition at least every 2 hours, broda chair . skin-keep skin clean and dry, report changes in skin to nurse . cognition-alert and oriented times 1 . R12's Nurse Notes, dated 10/4/23, indicate R12 has an open wound on buttock. R12's Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 10/6/23, indicates R12 requires substantial maximal assistance with rolling left to right and his helper does more than half the work. R12's MDS also indicated he is dependent on staff assistance to transfer from his bed to chair or chair to bed. R12's MDS indicates he receives scheduled pain medication for pain and the facility does not use non-pharmaceutical interventions for pain. R12's MDS states the facility should use facial expressions as indicators of pain and R12 was observed to have pain 1 or 2 days out of the 5 days observed. R12's Braden Scale Skin Assessment, dated 10/9/23, includes a score of 17, indicating high risk . Moisture-occasionally moist, skin is occasionally moist, requiring an extra linen change approximately once a day. Activity-chairfast . Mobility-slightly limited . can't bear weight or assisted to chair or wheelchair . Friction/shear-potential problem . some sliding with repositioning . occasionally slides down in chair/bed . R12's Nurse Notes, dated 10/11/23, indicate R12's open area to buttock is no longer open and they are treating with daily barrier cream as prevention. R12's Nurse Notes, dated 10/19/23, indicate R12 has a new area of shearing to right buttock and staff were educated on the proper use of a Hoyer sling. The area is measuring 1.4cm x 0.9cm x 0.1cm with drainage that is light, less than 25% serous. The wound bed consists of granulation tissue while the surrounding skin is intact. It also indicates R12 is on a turning/repositioning program, receives applications of ointment/medications, receives application of dressings. R12's Nurse Notes indicate the MD (Medical Doctor) order is as follows: the area is to be cleansed with normal saline solution, patted dry, apply Medihoney, and covered with Mepilex border every three days and as needed until healed. R12's Nurse Notes, dated 10/25/23, indicated the area measures 1.3cm x 0.5cm x 0.1cm. The drainage is light with less than 25% serosanguineous. There is no odor. The wound bed consists of granulation tissue. R12 has pressure relieving device for chair and pressure relieving device for bed, is on a turning/repositioning program, is receiving ulcer care and application of dressings, and incontinence care. R12's Nurse Notes, dated 11/3/23, includes in part: Mepilex border changed to coccyx, Medihoney applied per order. Scant amount of serous drainage noted on old Mepilex dressing . [NAME] slough noted to wound bed. (It is important to note this is the first mention of slough in the wound bed and it does not contain how much of the wound bed is covered in slough. The staff have reported granulation tissue in wound bed up until this point. Surveyor found no evidence of R12's MD being updated with this worsening status/change in the wound's wound bed.) R12's Nurse Notes, dated 11/7/23, include sheared area to buttocks . 1.8cm x 1.4cm x less than 0.1cm . light drainage less than 25% serosanguinous . odor-none . wound bed: granulation tissue, surrounding skin: intact . (It is important to note the wound is showing an increase in size from the last documented measurements.) R12's MD Progress Note, dated 11/8/23, includes Buttock lesion . Has had it for 2 weeks . Shear type injury as slid down in bed. Using Medihoney and Mepilex currently per wound team. Buttocks with two lesions, central one is over tailbone, with erythematous base, no significant discharge currently. Several layers deep, approximately 2cm x 1 cm. Lesion on left buttock, very superficial, with overlying light eschar, also approximately 1cm x 2cm. R12's Nurse Note, dated 11/15/23, includes partial thickness skin loss with exposed dermis stage 2 pressure right medial buttock . 1.5cm x 1.0cm x 0.1cm scant serous . no odor . wound bed-granulation tissue .surrounding tissue-intact, fragile . R12's Nurse Notes, dated 11/22/23, include sheared area to coccyx . 2cm x 1cm x 0.1cm . drainage-scant serous .Odor-no odor . wound bed-yellow slough, granulation tissue . surrounding skin-intact, fragile .the length was 1.5cm last week and this week it is 2.0 cm . R12's Nurse Notes, dated 11/29/23, include sheared area to coccyx . 2cm x 1cm x 0.1cm. Drainage: scant serous, Odor-no odor . Wound bed-yellow slough, granulation tissue . surrounding skin-intact, fragile . (It is important to note the description of the wound bed lacks how much slough and granulation tissue was observed to be present in the wound bed.) R12's Nurse Notes, dated 12/6/23, include sheared area to coccyx . 1.5cm x 0.5cm x less than 0.1 cm . Drainage-scant serous drainage . Wound bed-yellow slough, granulation tissue . Surrounding tissue is intact, fragile . (It is important to note the description of the wound bed lacks how much slough and granulation tissue was observed to be present in the wound bed.) R12's MD Progress Note, dated 12/13/23, includes: buttocks wound measuring 1.5cm x 0.5cm x 0.1cm . is currently being treated with Medi-honey and coverage every three days . No signs of infection and decreasing in size . Pressure ulcer-overall improving-staff applying Medihoney . R12's Podiatrist Note, dated 12/21/23, includes Resident remains on antibiotics . (It is important to note R12 is also being treated for foot ulcers/osteomyelitis in his left foot at this time and is receiving antibiotics for this.) R12's Nurse Notes, dated 12/25/23, include open area to sacrum 5cm x 1.5cm. Wound bed had yellow slough in it . Wound treatment completed per order. Open area to left buttocks 1cm x 0.5cm . Cleansed area with normal saline. Applied Mepilex. (It is important to note there are 2 areas being measured now. It is also important to note the size increase since the last measurement.) R12's MD Progress Note, dated 12/26/23, includes new order: Duoderm to wound on buttocks. Change every 3 days until healed . R12's MDS, with ARD 1/1/24 indicates R12 requires substantial/maximal assist when rolling left to right bed mobility and is dependent on staff assistance when transferring from bed to chair or chair to bed. R12's MDS indicates he is on scheduled pain medications. He did not take any as needed pain medications and the facility is not using non-pharmaceutical interventions related to R12's pain. R12's MDS also indicates his pain indicators are facial expressions, protective body postures/movement, rubbing area of pain, and clutching or holding of body part. The frequency of R12's pain is as follows: R12 was observed to have pain 1-2 days out of 5 observed. R12's Nurse Notes, dated 1/4/24, include sheared area to right buttocks, 2 areas: first area-4.5 cm x 2cm x 0.2 cm . Drainage-light drainage, less than 25% serosanguineous . Wound bed-yellow slough, granulation tissue. Surrounding skin-intact, blanchable . second area-located directly next to large area - 1.5cm x 0.3cm x less than 0.1 cm . Drainage- light, less than 25% serosanguinous . Wound bed-yellow slough, granulation tissue . Surrounding skin intact, blanchable . (It is important to note the description of the wound beds lacks how much slough and granulation tissue was observed to be present in the wound bed.) R12's Nurse Note, dated 1/10/24 includes 4.6cm x 1.5cm x 0.2cm . Drainage-moderate 25-75% serosanguinous . Odorous-foul . Wound bed-yellow slough yellow . Surrounding tissue-fragile . worsening, becoming larger, becoming deeper . (It is important to note only one area is measured this time, not two and there is a reported foul odor in the wound.) R12's MD Progress Note, dated 1/10/24, includes attending MD examined client: new orders for Santyl to coccyx wound daily . consult with Infectious Disease for coccyx wound and coordinate with podiatrist appointment . According to <https://santyl.com/hcp/dosing> Important Safety Information Indication: Collagenase SANTYL Ointment (SANTYL) is indicated for debriding chronic dermal ulcers and severely burned areas. Contraindications: Debilitated patients should be closely monitored for systemic bacterial infections because of the theoretical possibility that debriding enzymes may increase the risk of bacteremia. (Emphasis intended.) R12's Hospital Note, dated 1/10/24, includes pressure ulcer worsening currently unstageable due to slough present. Already on antibiotics which should cover typical staph/strep. Concern for possible fungal component. Will start enzymatic and place referral for wound consult. Ongoing pressure ulcer to buttocks. Began as a shear injury. Last one to two weeks has gotten significantly worse and deeper. Prior was placing Duoderm. Recently changed to Medi-honey with Mepilex. Wound care/dietary with recent request for additional supplements vitamin C and zinc. I did ok zinc but only for 10 days given high dose request . evidence additional can be detrimental. Resident is in bed. Has been in bed except for meals due to pressure. Groans when we do buttock exam but otherwise allows treatment. Buttock upper portion shallow. Erythematous. Lower portion significantly deeper with right pitting white base looks like slough . (It should be noted the antibiotics are for the foot infection. The PI was not cultured at this time to ensure sensitivity to current antibiotic.) R12's Nurse Note, dated 1/17/24, includes, Partial thickness skin loss with exposed dermis . pressure stage 2 . obscured full thickness and tissue loss . unstageable . location-coccyx . 2 cm x 1cm x changed depth . odorous none . Wound bed-black eschar . (It is important to note the two different stages named in this note for this one wound and the wound bed lacks the description of how much of the wound bed is covered by black eschar.) R12's Nurse Notes, dated 1/18/24, includes removed previous dressing to coccyx, rinsed with normal saline solution, applied Santyl cream, applied dressing and taped, no change to wound, slough still present on wound bed, no signs of infection, no odor noted . (It is important to note this note says slough to the wound bed while 1/17/24 note says black eschar to the wound bed.) R12's Nurse Note, dated 1/19/24, includes buttock treatment done per MD order. Wound is heavy with yellow slough. Surrounding tissue is intact. No signs of infection noted. (It is important to note the description of wound is heavy with yellow slough. There is no evidence of R12's MD being notified of this change in wound status.) R12's Nurse Note, dated 1/20/24, includes dressing to coccyx, rinsed with normal saline solution, applied Santyl cream, applied dry dressing and taped, no change in wound, slough still present on wound bed, no signs of infection, odor noted. (It is important to note an odor was noted and there is no evidence of R12's MD being notified of this change in wound status.) R12's Nurse Note, dated 1/21/24, includes removed previous dressing to coccyx, small amount of drainage noted to previous dressing, rinsed with normal saline solution, applied Santyl cream, applied dry dressing and taped, slough still present on wound bed, no signs of infection, odor is noted . refused change in position-called staff (explicit language) . (It is important to note there is an odor noted and R12's MD is not being notified of this wound status. It is also important to note R12 is refusing position changes and is calling staff explicit names while his documented indicators for pain, on his 1/1/24 MDS, are facial expressions, protective body postures/movement, rubbing area of pain, and clutching or holding of body part. There is no evidence of R12's MDS being updated on these nonverbal indicators of pain or his refusal of care.) R12's Nurse Notes, dated 1/22/24, indicate R12's MD was notified due to respiratory symptoms and positive results of his COVID 19 test. The following skin measurements were taken after the MD notification was documented . coccyx . 4cm x 2.5cm, depth undermining . Drainage-moderate drainage 25-75%, Odorous-strong . Wound bed-yellow slough, tunneling . Surrounding tissue-intact, reddened, fragile . worsening . becoming larger, becoming deeper, sloughing occurring tenderness present . (It is important to note the facility did not provide evidence of R12's MD being notified of the wound status changes including the larger size, the depth now undermining, and the strong odor.) R12's Nurse Note, dated 1/23/24, includes refused some cares . kicking, upset . buttocks dressing changed per order. Moderate amounts of serous drainage present. Slight foul odor noted . (It is important to note staff are still documenting the wound has an odor and there is still no MD notification.) R12's Podiatrist Progress Note, dated 1/24/24, includes remains on antibiotics until assessment during next appointment. (Of note R12 continues on the antibiotic for his foot yet staff document increased odor in R12's PI. Santyl has a contraindication for causing bacteremia in debilitated patients.) R12's Nurse Notes, dated 1/26/24, includes buttock treatment done per MD order. Wound is heavy with yellow slough. Surrounding tissue intact. No signs of infection noted. R12's Nurse Notes, dated 1/29/24, include removed previous dressing to coccyx, small amount of drainage noted to previous dressing, rinsed with normal saline solution, applied Santyl cream, applied dry dressing and taped, no signs of infection, odor is noted . R12's Hospital Notes, 1/30/24, include imaging: CT (imaging of soft tissue) pelvis with contrast: impression soft tissue defect dorsal to the distal sacrum and proximal coccyx. CT is not the most sensitive study for the detection of underlying osteomyelitis. Consider either an MRI (magnetic resonance imaging/imaging of bone) of the bony pelvis and/or a limited three phase bone scan to the pelvis and lower extremities. R12's Hospital Notes, dated 1/31/24, include the palliative care medicine service was asked by MD to provide consultation for R12 to elucidate goals of care in order to aid in assistance with code status, advanced directives, and or appropriate surrogate. Goals of care to get him back to baseline . to heal the wound up . guardian open to aggressive measures including Intensive Care Unit level care, blood transfusions, etc. would need to further discuss the idea of surgery and or vasopressors depending on indications for each. Palliative care will continue to follow for emotional, spiritual, psychosocial support and symptom management . R12's activated power of attorney does think he's in pain . of note he does have metastatic prostate cancer with bone lesions seen upon diagnosis . was on leuprolide. We did discuss concern for patient surgery and poor wound healing as well as concern for being more sedentary with increased pain post op and worsening sacral ulcer. R12's Hospital Notes, dated 2/1/23, include asked to be seen by MD regarding a sacral decubitus ulcer. He is a complex patient with non-verbal vascular dementia and multiple other medical issues. He is admitted for IV (intravenous) antibiotics to treat a sacral decubitus ulcer. On inspection, there is some necrotic tissue in the wound. It does not appear too deep, but it could be down to the sacrum as there is not much tissue depth in that area. This can be surgically debrided while he is in the hospital. He will need to be off Apixaban (blood thinner) for 2 days prior to having surgery . There is a 2cm x 3 cm sacral decubitus ulcer present . The patient can have debridement scheduled in the operating room but would need to be off apixaban (blood thinner) prior to surgery He was seen by NP (Nurse Practitioner/name) in clinic 2 days ago and due to the concern over osteomyelitis of the residual wound as well as a very deep and necrotic sacral decubitus ulcer, was recommended for admission. R12's Hospital Notes, dated 2/3/24, includes Surgery General: rolled on to the table in a left lateral decubitus position. The wound was about 3cm by 2cm in diameter and 2cm deep. There was a mixture of dead and viable tissue in the wound and there was a foul odor. The non-viable tissue was removed with sharp and cautery dissection. This included epidermis, dermis, subcutaneous tissue, and fascia. The wound was irrigated and then packed with gauze. Of note, the description of removal of fascia indicates R5 had a full-thickness tissue loss indicating a Stage IV PI. According to NPIAP a Stage 4 Pressure Injury is defined as a Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. R12's Hospital Discharge Orders, dated 2/6/24 include: Oxycodone HCI 5mg . Tablet by mouth . Take 1 twice a day as needed. Give prior to wound cares for pain . (Emphasis Intended.) (It is important to note the hospital note, dated 1/30/24, states there is a concern for R12 being more sedentary with increased pain post operation. It is also important to note the many different times in different places it is documented that R12 is noncommunicative. As of 2/6/24, R12 has an order for as needed pain medication to be administered prior to wound care. R12 will not be able to ask for this pain medication, staff will need to anticipate this care need for him. R12's MDS indicates his pain indicators.) R12's Hospital Notes, dated 2/6/24, include the following: admitted [DATE] . discharged [DATE] . Infected decubitus sacral ulcer, DM Type 2, Malignant Prostate Neoplasm, Osteomyelitis of 2nd toe . Augmentin ordered two times a day through 2/17/24 . Infectious Disease Wound Clinic follow up . physical therapy/occupational therapy consult . frequent position changes on/off loading wound . non healing infected sacral wound having failed outpatient management with local wound cares and 500mg cephalexin two times a day . admitted for treatment of infected decubitus sacral ulcer. Contributed to by chronic immobility, advanced dementia with expressive aphasia, and sev [TRUNCATED]

Based on observation and interviews, the facility failed to serve food at an appetizing temperature. This has the potential to affect 2 of 17 sampled Residents (R32 and R3) and 2 of 3 supplemental Residents (R36 and R20). R3, R32, R36, and R20 voiced concerns that hot food was not always served hot and cold food was not served cold. 1 of the 2 test trays temped failed to meet appropriate temperatures. Evidenced by: The facility policy, Food Temperatures, with a revised date of, 4/2024, states, in part; .All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F All cold food items must be maintained at served at a temperature of 41 F or below Example 1 On 4/18/24 at 8:01 AM, the kitchen delivered breakfast on B Hallway. Surveyor requested the last tray on the cart. Dietary Aide provided Surveyor the last tray. The tray had French toast sticks, bacon, yogurt, and crushed strawberries. French toast sticks temped at 102.3 F and were hard. No concerns with bacon and yogurt. Crushed strawberries temped at 60 F. Example 2 R32 was admitted to the facility on [DATE]. R32's most recent Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) of 15 indicating R32 is cognitively intact. On 4/18/24 at 8:40 AM, R32 indicated breakfast items that are supposed to be hot are often served warm or cold. R32 said the French toast sticks and pancakes are often cold. R32 indicated R32's breakfast was cold this morning. Example 3 R36 was admitted to the facility on [DATE]. R36's most recent MDS, dated [DATE], indicates a BIMS of 15 indicating R36 is cognitively intact. On 4/18/24 at 8:30 AM, R36 indicated breakfast was cold this morning. R36 indicated the French toast sticks and bacon were cold. R36 indicated crushed strawberries were not cold and are supposed to be cold. R36 indicated staff would heat items up for R36, but it gets so busy during mealtimes. Example 4 R20 was admitted to the facility on [DATE]. R20's most recent MDS, dated [DATE], indicates a BIMS of 13 indicating R20 is cognitively intact. On 4/18/24 at 8:35AM, R20 indicated R20's breakfast was cold this morning. R20 indicated R20 had French toast sticks and they were cold and hard. On 4/18/24 at 11:29AM, DM C (Dietary Manager) indicated DM C would expect hot foods served hot and cold foods served cold. DM C indicated understanding when discussing breakfast tray temps. DM C indicated the crushed strawberries should be served cold. DM C indicated the facility wants to get back to serving meals in the kitchenette areas to improve the temps of meals. DM C indicated DM C is aware of the concerns with the temperature of meals. The facility failed to ensure hot foods were served hot and cold foods were served cold. 39849 Example 5 R3 indicated hot foods are not served hot. R3 was admitted to the facility on [DATE]. R3's most recent Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 15. Indicating R3 is cognitively intact. On 4/15/24 at 2:59 PM, during the initial screening process, R3 informed Surveyor that at times the food is not warm enough. R3 indicated that it happens almost every day and there is no specific meal time related to this. R3 indicated staff will warm it; however, feels it shouldn't have to warmed so often.

Based on interview and record, the facility did not ensure that 4 of 4 sampled residents (R1, R12, R13, and R35) received treatment and care in accordance with professional standards of practice for foot care. The facility failed to provide diabetic foot checks daily in accordance with current standards of practice. The facility did not have a policy reflecting the current standards of practice related to diabetic foot checks. Evidenced by: Facility policy, entitled Skin Integrity-Foot Care, reviewed 4/2024, does not reflect current standards of practice related to daily diabetic foot checks completed by a nurse or someone with education to perform assessments. Per the American Medical Directors Association - The Society for Post-Acute and Long-Term Care Medicine. Pressure Ulcers. Clinical Practice Guideline, dated 12/9/14, includes, in part: http://www.amda.com/tools/guideline.cfm#pressureulcer .to the extent feasible, caregivers should educate patients about daily foot care .Treatment of foot problems in patients with diabetes is generally stratified into three broad risk categories: at-risk foot; current mild foot, ankle, or heel infection or ulcer; and limb-threatening foot, ankle, or heel infection or ulcer . Treatment of foot problems in patients with diabetes is generally stratified into three broad risk categories: at-risk foot . has neuropathy .vascular insufficiency .cannot see, feel, or reach their feet .Treatment Plan . Refer for podiatric care at least annually and as needed for specific foot problems .Train caregivers to perform daily foot care and inspection . Risk Category: At-risk foot (patients who smoke; have vascular insufficiency, neuropathy, retinopathy, nephropathy, history of ulcers or amputations, structural deformities, infections, skin/nail abnormality; are on anticoagulation therapy; cannot see, feel, or reach their feet.) Treatment Plan: Refer for podiatric care at least annually and as needed for specific foot problems . Train caregivers to perform daily foot care and inspection . To the extent feasible, train patients to perform daily foot care and inspection . Example 1 R1 admitted to the facility on [DATE] and has diagnoses, including Type 2 Diabetes Mellitus with diabetic neuropathy. R1's Medication/Treatment Administration Record (MAR/TAR) for [DATE], February 2024, March 2024, and April 2024 includes 5/7/19 Foot Exam 2 times monthly by nurses-Nurse to cut and file finger and toe nails on the PM shift every 2nd and 4th Tuesday., indicating the facility is not performing daily diabetic foot checks. R1's Physician Orders, January 2024, February 2024, March 2024, and April 2024, indicate there is no order for daily diabetic foot checks. R1's Comprehensive Care Plan, initiated 4/30/2019, indicates staff are not performing daily diabetic foot checks on R1. Example 2 R12 admitted to the facility on [DATE]. He has diagnoses, including nonverbal vascular dementia, severe Peripheral Arterial Disease with ischemic necrosis of foot, large left popliteal aneurysm and embolization of a right popliteal aneurysm resulting in acute ischemia, Diabetes Mellitus Type 2, cerebral vascular accident, expressive aphasia, and prostate cancer. R12's Physician Orders, January 2024, February 2024. March 2024, April 2024, indicate there is no order for daily diabetic foot checks. R12's MAR/TAR for January 2024, February 2024, March 2024, and April 2024 include: 9/9/17 Foot exam two times monthly by Nurse- nurse to cut and file finger and toe nails on PM shift every 2nd and 4th Friday, indicating the facility is not providing daily diabetic foot checks per current standards of practice. R12's Comprehensive Care Plan, initiated 9/9/17, does not have any goals or interventions related to daily diabetic foot checks. Example 3 R13 admitted to the facility on [DATE] and has the following diagnoses: Type 2 Diabetes Mellitus with diabetic chronic kidney disease, long term use of insulin, and a personal history of disease of the skin and subcutaneous tissue/stage 2 pressure ulcer to right buttock. R13's Physician Orders, January 2024, February 2024, March 2024, and April 2024 indicated there is no order for daily diabetic foot checks. R13's MAR/TAR, January 2024, February 2024, March 2024, and April 2024, include: 4/27/21 Foot exam two times monthly by Nurse- nurse to cut and file finger and toenails on PM shift every 2nd and 4th Tuesday, indicating the facility is not providing daily diabetic foot checks per current standards of practice. R13's Comprehensive Care Plan, initiated 4/27/21, does not include interventions or goals related to daily diabetic foot checks. Example 4 R35 admitted to the facility on [DATE] and has a diagnosis including Type 2 Diabetes Mellitus. R35's Physician Orders for January 2024, February 2024, March 2024, and April 2024 indicated there is no order for daily diabetic foot checks. R35's MAR/TAR, January 2024, February 2024, March 2024, and April 2024, include: 4/12/21 Foot exam two times monthly by Nurse- nurse to cut and file finger and toenails on PM shift every 1st and 3rd Fridays, indicating daily diabetic foot checks are not completed. R35's Comprehensive Care Plan, initiated 4/12/21, does not include interventions or goals related to daily diabetic foot checks. On 4/17/24 at 4:31 PM, RN F (Registered Nurse) indicated diabetic foot checks are done weekly on the resident's bath day. On 4/17/24 at 4:35 PM, RN G indicated diabetic foot checks are completed two times a month and are scheduled on the resident's MAR/TAR. On 4/17/24 at 4:39 PM, RN H indicated diabetic foot checks are not done daily, but they are done every two weeks and they pop up on the MAR/TAR when they are due. On 4/17/24 at 4:46 PM, DON B (Director of Nursing) indicated she was unaware of the current standard of practice for daily diabetic foot checks. DON B indicated the CNAs (Certified Nursing Assistants) check feet regularly, but the nurses check once a week with bath schedules and twice a month for performing nail care.

Based on observation, record review and interviews, the facility did not cool down foods to be served again using the correct process. This has the potential to affect all 58 residents. The facility did not cool foods using the correct process. This has the potential to cause a foodborne illness outbreak in the facility. This is evidenced by: The FDA Food Code requires that food be cooled from 135 degrees F to 70 degrees F within two hours and from 135 degrees F and 41 degrees F within a total of six hours. The FDA defines cooling as a critical point essential in preventing foodborne illness outbreaks. On 10/11/2021 at approximately 11:00AM, Surveyor did the initial tour of the kitchen. It was observed that there was no cool down log available for viewing when Surveyor requested nor was there a process posted where staff could view it. On 10/11/2021, Surveyor spoke with Dietary Manager (DM) C regarding the process they use to cool foods after serving as they do use leftovers frequently. DM C stated they do serve leftovers but they do not keep a log of cool down temps. They put the foods on ice at first but do not follow up with any temperatures. On 10/12/2021, Surveyor interviewed Cook-D regarding leftovers and the cooling process. Cook-D responded that the process for saving leftovers is to date and label them, put directly in the cooler and that they don't let them sit out. Surveyor asked if they had a cooling process, and Cook-D responded that usually they are just put in the cooler after serving. When asked if any temperatures were taken, Cook-D responded that they were not. Surveyor asked if many leftovers were served, and Cook-D responded that they did serve a lot of leftovers. On 10/12/2021, Surveyor interviewed Cook-E regarding the cooling process. Surveyor asked if they kept a cooling log. Cook-E responded that they did not. Surveyor asked what the cooling process was, and Cook-E stated that they get a bucket of ice to stick the food into, then place it in the cooler to make sure the temperature gets to 70 degrees. Surveyor enquired if they took a temperature to validate the food had reached 70 degrees. Cook-E stated no they did not as they would have left work by that time. Surveyor asked if the PM shift was told to take the temperature then, and Cook-E responded that the PM shift was not notified that a temperature needed to be taken. Surveyor asked if they thought then, that a temperature was ever taken and Cook-E responded that they did not think a temperature was ever taken. On 10/13/2021, Surveyor interviewed DM C again regarding cooling process. DM C stated they used to have a cool down process and use it, but since COVID-19 they had not been doing it. Surveyor asked if they were aware there was a cool down process. DM C stated they were. On 10/13/2021, Surveyor asked if they could review current cooling logs. DM C stated there were no cooling logs to review. The FDA Food Code requires that food be cooled from 135 degrees F to 70 degrees F within two hours and from 135 degrees F and 41 degrees F within a total of six hours. The FDA defines cooling as a critical point essential in preventing foodborne illness outbreaks.

Based on observation, interview, and record review, the facility did not ensure safe and secure storage, including limited access and mechanisms, to minimize loss or diversion for scheduled medications in 2 of 2 medication rooms. - R63's multi-dose bottle of liquid [MEDICATION NAME] and two back up bottles of multi-dose liquid [MEDICATION NAME], a Schedule IV medication, were stored in an unlocked refrigerator in the A/B Wing medication room. - R45's multi-dose bottle of liquid [MEDICATION NAME] (Schedule IV) was stored in an unlocked refrigerator in the C/D Wing medication room. This is evidenced by: On 8/14/19 at 1:13 PM, Surveyor and LPN H (Licensed Practical Nurse) conducted an observation of the A/B Wing medication room. Surveyor observed three multi-dose bottles of liquid [MEDICATION NAME] concentrate in an unlocked refrigerator. The refrigerator observed was inside of the medication room within the Team Station. R63's order indicates [MEDICATION NAME] 2mg (milligram) per mL (milliliter), 30mL bottle. Take 0.5mg (0.25mL) per [DEVICE] every two hours as needed for anxiety/air hunger. The two multi-dose bottles of back up liquid [MEDICATION NAME] oral concentrate, also located in the A/B medication room refrigerator, read 2mg per mL and were 30mL bottles. On 8/15/19 at 8:28 AM, Surveyor interviewed RN F (Registered Nurse) regarding the multi-dose bottles of liquid [MEDICATION NAME] stored in the A/B Wing medication room. RN F indicated she was not aware if liquid [MEDICATION NAME] should be double locked, since it was kept in the refrigerator. She indicated that [MEDICATION NAME] in pill form, stored on the medication carts, are kept in the locked box, under double lock. RN F indicated anyone who works at the facility has access to the Team Station. On 8/15/19 at 8:22 AM, Surveyor and LPN G observed the refrigerator in the C/D Wing medication room. Surveyor observed one multi-dose bottle of liquid [MEDICATION NAME] concentrate in an unlocked refrigerator. The refrigerator for the C/D Wing was also observed to be inside of a medication room within the C/D Wing Team Station. The C/D Team Station was also accessible to all staff members. LPN G indicated that all other narcotics are double locked. Oral narcotics are locked in the medication cart in a separate locked box. LPN G indicated that all staff and departments could access the Team Station but the general public could not. R45's order indicates [MEDICATION NAME] 2mg per mL, 30mL bottle. Take 0.5mg (0.25mL) under tongue every four hours as needed for agitation/anxiety. On 8/15/19 at 11:02 AM, Surveyor requested the facility's medication storage policy regarding storage of narcotics. DON B (Director of Nursing) indicated the facility did not have one. DON B indicated they follow the manufacturer's guidelines and she had just reviewed the State Operations Manual. Surveyor requested any information on manufacturers' recommended storage guidelines the facility used. On 8/15/19 at 12:40 PM, DON B provided manufacturer's recommendation information, pointing out storage temperature of liquid [MEDICATION NAME]. Surveyor and DON B reviewed facility set up and agreed the liquid [MEDICATION NAME] is only secured by one lock at this time. The Team Station is a locked door, accessible with an employee badge that all general staff members (certified nursing assistants, dietary, housekeeping, maintenance, etc.) can access. The medication room is located inside of the Team Station. DON B states, Only nurses can get into the med room. There was no lock or lock box on or in the refrigerator in the A/B Wing medication room refrigerator or the C/D Wing medication room refrigerator which each contained multi-dose bottles of liquid [MEDICATION NAME]. The facility did not ensure scheduled medications are stored with a double lock.