Every finding on record at Serenity Spring Senior Living at Green Bay

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 48 residents residing in the facility.The reach-in coolers and freezers contained expired and/or undated items.During an observation of food service, [NAME] (CK)-K touched serving dishes, trays, plates, and utensils with gloved hands. CK-K then left the steam table and opened a package of cups. CK-K then returned to the steam table and picked up a food item with the same gloved hands.Findings include:During an initial kitchen tour that began at 8:36 AM on 1/5/26, Dietary Manager (DM)-J stated the facility follows the Wisconsin Food Code.Undated/Expired Foods:The 2022 Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition: (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day.During an initial kitchen tour that began at 8:36 AM on 1/5/26, Surveyor and DM-J observed the following expired items in the reach-in cooler:~ Two bags of baby carrots with use-by dates of 1/4/26~ Two bags of baby carrots with use-by dates of 12/12/25~ One unlabeled bag of grapes that contained what appeared to be moldSurveyor and DM-J observed the following items in the reach-in cooler that did not contain a delivery date, open date, and/or use-by date:~ Three bags of carrots~ One bag of cabbage~ Two heads of lettuce~ Two bags of tomatoes~ Three cucumbers~ One bin of oranges~ One bin of apples~ Five bell peppers~ One bag of 6 lemons~ Eight egg trays with 30 eggs in each tray~ One bag of hot dogs removed from the original packaging~ Three 3 pound bags of chicken breastsSurveyor and DM-J observed the following items in the reach-in freezer that did not contain a delivery date, open date, and/or use-by date:~ Nine bags of green beans~ Nine bags of cauliflower~ Six bags of hot dog buns~ Eight loaves of bread ~ Seven bags of whipped topping ~ Sixteen cartons of whipped topping~ Six bags of broccoli~ One box of 48 strawberry sundaes~ One box of 48 vanilla ice cream cupsSurveyor and DM-J observed the following undated items in the dry storage area:~ One tub of sugar~ One bucket of flourDuring a tour of the unit refrigerators on 1/5/26 at 10:20 AM, Surveyor observed the following undated items in the Caring Drive refrigerator: ~ Nine containers of prune juice concentrate ~ One open bottle of ketchup~ Five Snack Pack pudding packs~ A half container of vanilla ice creamDuring a tour of the unit refrigerators on 1/5/26 at 11:30 AM, Surveyor observed the following undated items in the Grand Ave refrigerator:~ Fourteen 4 ounce canisters of prune juice concentrate ~ Thirty-six 4 ounce canisters of grape juice concentrate ~ One undated container of resident food Surveyor observed the following undated items in the refrigerator on the therapy unit:~ Six 4 ounce canisters of prune juice concentrate ~ Fourteen 4 ounce canisters of grape juice concentrateDuring the initial kitchen tour that began at 8:36 AM on 1/5/26, DM-J confirmed foods delivered, opened, and used to serve residents should include the delivery date or use-by date that the vendor stamps on products. DM-J verified the items observed in the reach-in cooler and freezer did not contain delivery dates and/or use-by dates.On 1/5/26 at 2:36 PM, Surveyor interviewed DM-J who verified food in the unit refrigerators is delivered to the unit from the kitchen, is subject to the same dating system used by the kitchen, and should include the delivery date or use-by date the vendor stamps on products.Hand Hygiene:The 2022 Wisconsin Food Code documents at 3-301.11 Preventing Contamination From Hands: (A) food employees shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S 3-302.15 or as specified in (D) of this section, food employees may not contact exposed, ready-to-eat foods with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.The 2022 Wisconsin Food Code documents at 3-304.15 Gloves, Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat foods or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.During a continuous observation of lunch service that began at 12:01 PM on 1/5/26, Surveyor observed CK-K apply gloves and begin lunch service at a unit steam table. CK-K obtained temperatures of the food, touched a thermometer, recorded the temperatures with a pen, and began meal service with the same gloved hands. CK-K picked up a bowl and used a ladle to put food in the bowl. CK-K then picked up a plate, crackers, and a small cup to scoop cheese from a bin. CK-K touched the inside of the bin with gloved hands. CK-K then picked up a piece of cornbread and put it on the plate. CK-K put plates on trays, touched counter tops and service areas, and picked up scoops and ladles with the same gloved hands. CK-K served eleven residents before CK-K ran out of small cups to scoop cheese and left the steam table. CK-K opened a package of cups on a supply cart and removed cups to take back to the steam table. CK-K then resumed lunch service with the same gloved hands. CK-K served six more residents and again used a ladle to put food in a bowls, picked up plates, crackers, and small cups to scoop cheese from a bin and again touched the inside of the bin with gloved hands. CK-K used the same gloved hands to put cornbread on plates. CK-K then put the plates on trays and again touched counter tops, service areas, scoops, and ladles with the same gloved hands.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 48 residents residing in the facility.The facility did not have an accurate flow diagram of the facility's water system that identified areas where Legionella could grow. In addition, the facility did not maintain drinking fountains on two units or post signs that residents and visitors should not use the fountains.Staff did not appropriately remove personal protective equipment (PPE) and cleanse hands during the provision of care for R4.Findings include:The facility's Legionella/Water Management policy, revised 4/15/25, indicates: Grancare Nursing Center, care partners, and neighbors will benefit from this policy by being prevented from an outbreak. Grancare will provide a sanitary environment to avoid sources and transmission of infection and communicable disease .Legionella can be found everywhere in natural, [NAME] environments, but generally in those environments, the bacteria are present in insufficient numbers to cause disease. In human-made water systems like the plumbing of large buildings, cooling towers, decorative fountains, and hot tubs, Legionella can amplify and be transmitted to susceptible hosts through aerosolization. Certain conditions allow for amplification of Legionella. Water systems that are not properly cleaned, maintained, or disinfected are at risk for Legionella amplification .Legionella can grow in parts of the building's water systems that are continually wet, and certain devices can spread contaminated water droplets via air. Examples of these system components and devices include: Hot and cold water storage tanks .Electronic and manual faucets .Showerheads .Ice machines .Decorative fountains.Internal factors in buildings that can lead to Legionella growth: Biofilm; Scale and sediment; Water temperature fluctuations; Water pressure changes; pH; Inadequate disinfectant; Water stagnation .The facility's Implementation of Enhanced Barrier Precautions to Prevent Spread of Multidrug-Resistant Organisms (MDROs) policy, revised 6/6/25, indicates: Grancare will decrease the spread of MDROs to all neighbors by using enhanced barrier precautions (EBP) .Neighbors are at risk of becoming colonized and developing infection with an MDRO. Grancare will implement EBP as directed by the Centers for Disease Prevention and Control (CDC) to balance the use of personal protective equipment (PPE) and room restriction to prevent MDRO transmission with neighbors' quality of life .EBP expands the use of PPE and refers to the use of gowns and gloves during high-contact care activities that provide opportunities for the transfer of MDROs to care partners' hands and clothing. MDROs may be indirectly transferred from neighbor to neighbor during high-contact care activities. Neighbors with wound and indwelling medical devices are at especially high risk of acquisition and colonization with MDROs. The use of gowns and gloves for high-contact care activities is indicated when contact precautions do not otherwise apply, for neighbors with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for neighbors with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for EBP include: Dressing; Bathing/ showering; Transferring; Providing hygiene; Changing dirty linens; Changing briefs or assisting with toileting; Device care or use: central line/intravenous (IV), urinary catheter, feeding tube, bodily drain; Wound care: any skin opening with drainage requiring a dressing .Gowns and gloves are required prior to high-contact care activities and during cares.1. On 1/6/26, Surveyor reviewed the facility's Water Safety and Management Plan. The plan indicated the facility did not have a water fountain which Surveyor observed on a wall in the facility. The plan also included diagrams of water flow that did not include the water fountain, rehabilitation ice machine, rehabilitation tub room, and 2 drinking fountains.On 1/6/26 and 1/7/26, Surveyor noted the water shut off valve was turned off on the Caring Hall drinking fountain. Surveyor attempted to push the button on the water fountain. Water came to the surface of the spout but did not come out. Surveyor also noted the Caring Hall and Grand Hall drinking fountains were unplugged from their outlets. On 1/7/26 at 10:22 AM, Surveyor interviewed Maintenance Director (MD)-G who reviewed the facility's water diagram with Surveyor. MD-G pointed out where the 2 drinking fountains, the rehabilitation ice machine, and the rehabilitation tub room should be indicated on the diagram. MD-G stated MD-G cleans and completes maintenance on the water fountain and facility's two ice machines quarterly but does not have documentation of maintenance or cleaning. (Nursing Home Administrator (NHA-A) provided documentation of monthly maintenance and cleaning on 1/14/26.) MD-G stated MD-G flushes the rehabilitation tub room weekly, however, it was not indicated on MD-G's weekly flush log. MD-G verified the water shut off valve on the Caring Hall drinking fountain was turned off and turned it back on. MD-G was not aware the valve was shut off. MD-G verified the 2 drinking fountains were not plugged into the outlets and stated the drinking fountain compressors were not functioning. MD-G stated the water in the drinking fountains was at room temperature because the compressors did not work to cool the water. MD-G indicated the drinking fountains were used daily by housekeeping to fill cat water dishes. MD-G verified there was not a sign instructing residents or visitors not to use the drinking fountains and verified there was nothing in place to prevent residents or visitors from using drinking fountains. 2. From 1/6/26 to 1/7/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including history of urinary tract infections, multiple sclerosis, paraplegia, resistance to multiple antibiotics, and candidiasis. R4's Minimum Data Set (MDS) assessment, dated 11/14/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R4 had intact cognition. R4's medical record indicated R4 was on EBP and had a Foley catheter.On 1/7/26, Surveyor observed an EBP sign on R4's door and a PPE cart outside R4's room. On 1/7/26 at 12:58 PM, Surveyor observed Certified Nursing Assistant (CNA)-H and CNA-I apply PPE and complete peri care for R4. CNA-H then removed gloves, repositioned R4, positioned a Hoyer sling in R4's bed, and removed CNA-H's mask. CNA-H attached the sling to the lift, hooked R4's catheter bag on the lift, and transferred R4 to a wheelchair. CNA-H then hooked R4's catheter bag to the wheelchair, covered R4 with a blanket, picked up a soiled wash cloth off the floor and put it in a soiled linen bag. CNA-H then washed hands, removed CNA-H's gown, and placed the gown in a bin outside R4's room. CNA-H did not complete hand hygiene after removing PPE and exiting R4's room. CNA-I removed gloves while transferring R4 to the wheelchair and held the left side of R4's face to protect R4 from the lift bar. CNA-I repositioned R4, removed the sling from the lift, and removed the lift from R4's room. CNA-I then removed CNA-I's gown and brought the lift to the shower room. Surveyor did not observe CNA-I complete hand hygiene. On 1/7/26 at 1:10 PM, Surveyor interviewed CNA-H who indicated CNA-H removed gloves after completing peri care because the gloves were soiled. CNA-H acknowledged R4 was on EBP and CNA-H should have worn gloves during contact with R4. CNA-H confirmed hand hygiene should be completed upon exit of a resident's room and after PPE is removed. On 1/7/26 at 1:15 PM, Surveyor interviewed CNA-I who verified R4 was on EBP and confirmed gloves should be worn during the provision of personal care. CNA-I also verified hand hygiene should be completed upon exiting a resident's room.On 1/7/26 at 2:03 PM, Surveyor interviewed Director of Nursing (DON)-B regarding EBP and hand hygiene. DON-B verified CNA-H and CNA-I removed gloves prematurely while providing care for R4. DON-B stated staff should wear gloves and a gown for the entirety of direct patient care and confirmed CNA-H and CNA-I should have completed hand hygiene upon exiting R4's room.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R8) of 5 sampled residents suspected of having a mental illness was screened through the Pre-admission Screen and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required.R8's PASRR Level I Screen did not indicate R8 was admitted to the facility with a mental illness and took antidepressant medication. Therefore, a PASRR Level II Screen was not completed to determine if nursing home placement was appropriate and if R8 required specialized services.Findings include:The facility's Preadmission Screening and Annual Resident Review policy, dated 12/28/21, indicates neighbors with mental illness will be evaluated to ensure proper care and treatment is provided in the most appropriate setting.From 1/5/26 to 1/7/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder, migraine with aura, and atrial fibrillation. R8 was responsible for R8's own medical decisions. R8's Minimum Data Set (MDS) assessment, dated 12/12/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R8 had intact cognition.R8's medical record contained a PASRR Level I Screen, dated 3/24/23, that did not indicate R8 had a diagnosis of major depressive disorder and did not identify that R8 was prescribed nortriptyline (an antidepressant medication). The PASRR Level I Screen listed mirtazapine (Remeron) as an other drug but not an antidepressant. Due to inaccurate documentation, R8 did not receive a PASRR Level II Screen to determine if nursing home placement was appropriate and if specialized services were required.A hospital record from an overnight stay, dated 8/10/23, indicated R8 had a diagnosis of major depressive disorder and orders for nortriptyline (for headaches) and Remeron (for depression).On 1/7/26 at 1:21 PM, Surveyor interviewed Neighbor Advocate (NA)-D who was not aware that R8 had a diagnosis of major depressive disorder and was prescribed antidepressant medication. NA-D verified a PASRR Level II Screen was not completed for R8. NA-D confirmed R8's PASRR Level I Screen should have indicated R8 had a serious mental illness and took antidepressant medication. NA-D stated NA-D would complete a correct PASRR Level I Screen for R8 on 1/7/26.On 1/7/26 at 1:57 PM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-C who coded R8's MDS assessment to indicate PASRR Level II conditions were met due to R8's diagnosis of a serious mental illness and orders for antidepressant medication. MDSC-C indicated R8 was admitted to the facility with major depressive disorder and was prescribed 2 antidepressant medications, nortriptyline and Remeron.On 1/7/26 at 2:04 PM, Surveyor interviewed NA-D who indicated NA-D filled out R8's admission PASRR Level I Screen incorrectly on 3/24/23. NA-D indicated the PASRR Level I Screen should have contained R8's diagnosis of major depressive disorder and that R8 was prescribed both antidepressant medications upon admission which would have required a PASRR Level II Screen.

Based on observation, staff interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R22) of 14 sampled residents.R22 did not have a call light within reach during observations on 1/5/26 and 1/6/26.Findings include:The facility's Room Service Lights/Call Lights policy, dated 10/19/15, indicates: Facility neighbors will have the ability to call for and receive assistance .each neighbor when in their room or in bed, must have the room service light placed within reach at all times, regardless of the care partner's assessment of neighbor's ability to use it.From 1/5/26 to 1/7/26, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, legal blindness, spinal stenosis, and segmental and somatic dysfunction of the sacral region. R22 had an activated Power of Attorney for HealthCare (POAHC) who assisted with medical decisions. R22's Minimum Data Set (MDS) assessment, dated 11/14/25, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R22 had severely impaired cognition.A care plan, dated 8/13/25, indicated R22 was unaware of safety risks due to poor vision and occasional confusion. R22 had a history of falls and had interventions to remind R22 to ask for help and to keep important items within reach. On 1/5/26 at 10:01 AM, Surveyor observed R22 in a wheelchair in R22's room. R22's call light was on the bed and not within reach.On 1/5/26 at 10:03 AM and 1/7/26 at 9:02 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who indicated R22 did not usually use the call light, however, the call light should be within reach. CNA-E stated CNA-E always clipped the call light to R22's wheelchair. CNA-E then entered R22's room and clipped the call light to R22's wheelchair. CNA-E stated staff complete a visual check any time they walk past R22's room and/or every 2 hours if not more. CNA-E stated R22 can respond to questions and staff offer R22 the recliner, the bathroom, or a drink. CNA-E stated staff need to know when R22 is in the room so they can check on R22. (Of note: R22's care plan did not address frequent checks except to assist with repositioning every 1-2 hours while in bed.)On 1/6/26 at 3:50 PM, Surveyor observed R22 in a wheelchair in R22's room. R22's call light was on the bed and not within reach.On 1/6/26 at 3:51 PM, Surveyor interviewed CNA-F who indicated R22 does not use the call light, however, CNA-F usually leaves the call light next to R22. CNA-F indicated the call light should be clipped to R22's wheelchair before staff leave the room. CNA-F then entered R22's room and clipped the call light to R22's wheelchair.R22's medical record indicated R22 had a fall on 11/29/25. The assessment indicated R22 used the remote control for an electric recliner to put the recliner in a position that caused R22 to slide down to the base of the recliner. The fall investigation indicated R22 did not call for assistance. The assessment did not indicate if R22's call light was within reach or if R22 was capable of using the call light.On 1/7/26 at 9:07 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R22's call light should have been within reach. DON-B stated R22 can not use the call light but the call light should still be within reach. DON-B indicated staff know R22 well and anticipate and provide for R22's needs.

Based on staff and resident interview and record review, the facility did not report allegations of abuse to the State Agency (SA) for 2 residents (R) (R1 and R4) of 4 sampled residents. On 11/11/24, R1 reported an allegation of potential sexual abuse that occurred on 11/10/24. The facility did not report the allegation to the SA in a timely manner. On 9/20/24, R4's family reported that a staff pushed R4 down and told R4 to stop it when R4 attempted to stand. The facility did not report the allegation of abuse to the SA. Findings include: The facility's Neighbor Abuse, Neglect, Exploitation, Misappropriation, Injuries of Unknown Source, Reporting of Incident, Neighbor-to-Neighbor policy, revised 7/25/24, indicates: It is the policy of the facility to ensure that all neighbors be free of all forms of abuse and that all alleged violations of federal or state laws which involve .abuse, neighbor-to-neighbor altercations .are verbally reported immediately to the community mentor/designee and verbally or written to other officials in accordance with state law. Federal requirements under 42 CFR state that if the events that cause the allegation involve abuse or result in serious bodily injury, nursing homes must report the violation to the administrator of the facility and the Division of Quality Assurance (DQA) no later than 2 hours after the allegation is made. All other allegations that do not involve abuse and do not result in serious bodily injury must be reported no later than 24 hours after the allegation is made. In addition, nursing homes must report to DQA and law enforcement any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility .Administrator or designee will complete the online form through the State of Wisconsin Misconduct Incident Reporting (MIR) system .the facility must immediately report all incidents of alleged .neighbor-to-neighbor altercations, abuse .to DQA. 1. On 11/27/24, Surveyor reviewed R1's medical record. R1 had diagnoses including Alzheimer's disease and Parkinson's disease. R1's Minimum Data Set (MDS) assessment, dated 10/18/24, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R1 had moderately impaired cognition. R1 had an activated decision maker. On 11/27/24, Surveyor reviewed a facility-reported incident that indicated R1 reported to staff on 11/11/24 that during personal cares on the evening of 11/10/24, Certified Nursing Assistant (CNA)-D asked R1 if it felt ok and indicated CNA-D wanted to make sure CNA-D was not hurting R1. CNA-D then stated, Women usually like it when I'm down there. R1 indicated CNA-D did not touch R1 inappropriately, however, R1 did not like the comments CNA-D made. The facility initiated an investigation and submitted an initial report to the SA on 11/13/24. The initial report was not submitted within the required timeframe. On 11/27/24 at 12:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the self-report regarding R1 was not submitted timely because NHA-A thought the incident was not reportable. NHA-A indicated R1 was not able to accurately recall events due to a diagnosis that caused confusion. NHA-A confirmed the allegation resulted in an investigation and CNA-D no longer worked at the facility. 2. On 11/27/24, Surveyor reviewed the facility's grievance file. A grievance submitted on 9/20/24 indicated R4's family reported to Social Worker (SW)-C that a staff pushed R4 down and told R4 to stop it when R4 attempted to stand without assistance. Surveyor reviewed the grievance and investigation and noted the allegation of abuse was not reported to the SA. On 11/27/24, Surveyor reviewed R4's medical record. R4 had diagnoses including chronic obstructive pulmonary disease (COPD) and multiple fractures. R4's MDS assessment, dated 9/6/24, had a BIMS score of 9 out of 15 which indicated R4 had moderately impaired cognition. R4 had an activated decision maker. On 11/27/24 at 9:45 AM, Surveyor interviewed R4 who indicated nursing staff ask R4 not to stand without assistance. R4 indicated R4 feels like R4 is being told what to do and feels a loss of independence. R4 indicated a staff grasped R4's arms to assist with a transfer and R4 felt that R4 was pushed. R4 indicated R4 now understood that the nurse attempted to assist R4 and did not have harmful intent. R4 reported the incident to R4's decision maker. Staff spoke to R4 and the staff about the incident. R4 confirmed R4 did not have abuse or neglect concerns and indicated R4 should request assistance from staff who were attempting to help prevent R4 from falling. On 11/27/24 at 10:15 AM, Surveyor interviewed SW-C who indicated R4's decision maker reported that R4 stated a staff grabbed R4's arms and prevented R4 from fully standing without assistance. SW-C interviewed R4 who indicated a staff grabbed R4's arms to steady R4 and that R4 cannot do anything on R4's own. SW-C indicated R4 did not like staff assistance with transfers and ambulation despite multiple falls prior to admission. SW-C confirmed an investigation was completed and there was no misconduct on the part of staff. SW-C indicated the grievance was not reported to the SA because the incident was not viewed as an allegation of abuse. SW-C indicated R4's decision maker did not indicate they believe abuse occurred, however, R4 had reported the incident to them. On 11/27/24 at 12:10 PM, Surveyor interviewed NHA-A who indicated the grievance regarding R4 was an allegation of abuse, however, due to discussions with SW-C, R4, and staff, it was determined the allegation was not reportable because the allegation was reported by R4's decision maker. During the investigation, NHA-A indicated R4 reported staff grabbed R4 to steady R4 when R4 attempted to stand and was told not to stand without assistance. NHA-A indicated customer service and resident approaches education was provided to nursing staff to prevent future incidents.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect more than 4 of the 50 residents residing in the facility. Food items for resident consumption were not labeled with open or expiration dates and/or were beyond the labeled discard date in 3 of 3 unit refrigerators. Staff did not follow safe food cooling protocol. Findings include: On [DATE] at 1:30 PM, Surveyor interviewed Dietary Manager (DM)-C who stated the facility followed the Food and Drug Administration (FDA) Food Code. Unlabeled/Undated/Expired Food: The 2022 FDS Food Code documents at ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food: Disposition .Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding .Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers .A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections. The facility's Food Handling Policy Strategy, revised [DATE], indicates: .5. The Danger Zone refers to food temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness .Time/Temperature Control for Safety (TCS) Food refers to food that requires time/temperature control for safety to limit the growth of pathogens or toxin formation .6. Opened containers for refrigerated foods need to be marked with the date opened and use-by date 18. Neighbor perishable food items in a refrigerator need to have a date opened written on them. On [DATE] at 8:35 AM, Surveyor observed the refrigerator/freezer on the Grand Avenue unit with Dietary Aide (DA)-D and noted the following items: ~ An open, unlabeled, and undated ,d+[DATE] full bottle of Pepsi ~ Two undated containers of milk ~ A container of barbecue sauce with an open date of [DATE] and no use-by date ~ A peanut butter and jelly sandwich made on ,d+[DATE] with no use-by date and 2 undated peanut butter and jelly sandwiches ~ An open bottle of pancake and waffle syrup with an open date of ,d+[DATE] and no use-by date ~ An open and undated bag that contained 5 waffles ~ An open and undated box that contained 3 lemon and lime Popsicles During the observation, DA-D indicated the above items did not belong in the refrigerator/freezer and should be discarded. DA-D also stated there were 3 unit kitchens in the facility. On [DATE] at 9:00 AM, Surveyor observed the refrigerator/freezer on the Caring Drive unit with DA-E and noted the following items: ~ An open and undated caramel macchiato creamer ~ An open and undated bottle of Wishbone raspberry walnut vinaigrette dressing ~ An open and undated bottle of Spicy Mike's sweet spicy spears ~ An open bottle of syrup with an expiration date of ,d+[DATE] ~ An open and undated bottle of relish ~ A open container of [NAME]-Dazs coffee ice cream with a use-by date of [DATE] ~ A closed bag of [NAME] steam fresh super sweet corn with a use-by date of [DATE] ~ An unopened and unlabeled Hot Pocket with no use-by date During an initial tour of the kitchen that began at 9:15 AM on [DATE], Surveyor and DM-C observed the dry storage area and noted the following items: ~ A dented can of solid pack pumpkin ~ An open and undated bag of enriched egg product ~ Nine unopened bottles of sugar free pancake and waffle syrup with no expiration dates DM-C verified the facility could not use the products and stated DM-C would dispose of the items. On [DATE] at 1:30 PM, Surveyor interviewed DM-C regarding the unlabeled, undated, and expired food items observed on the Grand Avenue and Caring Drive units. DM-C indicated DM-C was working on trying to remind staff to label and date food items. On [DATE] at 8:35 AM, Surveyor and DM-C observed the refrigerator/freezer on the Turn Around Circle (TAC) unit and noted an open and undated container of vanilla bean ice cream. Food Cooling: The 2022 FDA Food Code documents at ,d+[DATE].12 Microwave Cooking: The rapid increase in food temperature resulting from microwave heating does not provide the same cumulative time and temperature relationship necessary for the destruction of microorganisms as do conventional cooking methods. In order to achieve comparable lethality, the food must attain a temperature of 74 degrees Celsius (C) (165 degrees Fahrenheit (F)) in all parts of the food. Since cold spots may exist in food cooking in a microwave oven, it is critical to measure the food temperature at multiple sites when the food is removed from the oven and then allow the food to stand covered for two minutes post microwave heating to allow thermal equalization and exposure. Although some microwave ovens are designed and engineered to deliver energy more evenly to the food than others, the important factor is to measure and ensure that the final temperature reaches 74 degrees C (165 degrees F) throughout the food. The facility's Food Handling Policy Strategy, revised [DATE], indicates: The Danger Zone refers to food temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness .10. Reheated cooked foods present a risk because they have passed through the Danger Zone multiple times during cooking, cooling, and reheating. The Potentially Hazardous Foods (PHF)/Time/Temperature Control for Safety (TCS) food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees F at least 15 seconds. On [DATE] at 11:50 AM, Surveyor observed DA-E reheat a pureed patty melt in the microwave. DA-E did not stir the food and cool for 2 minutes before rechecking the temperature which was at 164 degrees F. DA-E stated DA-E did not know the patty melt should be stirred or allowed to cool before obtaining the temperature. On [DATE] at 12:16 PM, Surveyor observed DA-F reheat resident food brought in from outside the facility in the microwave. DA-F did not stir, cool, or obtain the temperature of the food prior to serving. DA-F stated the temperature of microwaved reheated food was typically not obtained.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R9 and R16) of 2 sampled residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R9 was transferred to the emergency room (ER) on 8/31/24 and was not provided a written transfer notice. R16 was transferred to the hospital on 8/7/24 and was not provided a written transfer notice. Findings include: The facility's Discharge or Transfer Policy, revised 9/19/23, indicates: Transfer of Discharge refers to the movement of a neighbor to a bed that is outside of the certified facility, not within the same facility. Transfer refers to moving a neighbor from one facility to another, with the expectation that the neighbor will be returning to the facility. Discharge refers to moving a neighbor from the facility to either another facility or to a different community location .Upon discharge, the charge nurse should document the discharge or transfer in the medical record .Documentation should include appeal rights. 1. From 9/3/24 to 9/5/24, Surveyor reviewed R9's medical record which indicated R9 had urinary tract infection (UTI) symptoms and was transferred to theER on [DATE]. R9's medical record did not indicate the facility provided R9 with a written transfer notice. On 9/5/24 at 12:35 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a transfer notice is given to a resident only if they return after midnight. Since R9 returned before midnight, DON-B indicated R9 did not need a transfer notice and was not given one by nursing staff. DOB-B indicated DOB-B would inform Social Worker Designee (SWD)-J of the requirement to provide a written transfer notice whether a resident returns to the facility before midnight or not. 2. From 9/3/24 to 9/5/24, Surveyor reviewed R16's medical record which indicated R16 was transferred and admitted to the hospital on 8/7/24 with diagnoses of hyperkalemia and diabetic ketoacidosis. R16's medical record included documentation that the facility provided R16 with a written transfer notice that was signed and dated on 8/8/24 by SWD-J. R19 returned to the facility on [DATE] and signed the written transfer notice on 8/15/24. The transfer notice did not include contact information for the State Agency (SA). On 9/5/24 at 1:17 PM, Surveyor interviewed DON-B who was not aware of the requirement to include State Agency contact information on transfer notices. DON-B indicated DON-B would notify NHA-A and have the form updated.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 2 sampled residents reviewed for hospitalization received the required written information of the duration of the bed-hold, the reserve bed-hold payment rate, and the right of the resident to return to the facility. R9 was transferred to the emergency room (ER) on 8/31/24 and was not provided a bed-hold notice. Findings include: The facility's Bedhold policy, effective 12/26/16, indicates: Temporary absences due to hospitalization or therapeutic leave may warrant a bedhold. A copy of the bedhold policy will accompany each neighbor upon discharge to the hospital .In the case of an unexpected hospitalization , Social Services will contact the neighbor's representative within twenty-four hours of dishcarge to confirm if the neighbor/representative wishes to hold the bed .Confirmation either verbally or written is required. A written Bedhold Confirmation Form will be provided by Social Services. From 9/3/24 to 9/5/24, Surveyor reviewed R9's medical record which indicated R9 had urinary tract infection (UTI) symptoms and was transferred to theER on [DATE]. R9's medical record did not indicate the facility provided R9 with a bed-hold notice. On 9/5/24 at 12:35 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a bed-hold notice is given to a resident only if the resident returns after midnight. DON-B indicated since R9 returned before midnight, R9 did not need a bed-hold notice and was not given one by nursing staff. DON-B indicated DON-B would inform Social Worker Designee (SWD)-J of the requirement to provide a bed-hold notice whether a resident returns before midnight or not.

Based on staff interview and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 45 of 46 residents (one resident was fed via tube) residing in the facility. Cooling logs were not completed for leftover foods. Refrigerator temperature logs were not completed for 1 of 2 unit refrigerators and not consistently completed for the coolers and freezers in the kitchen. Findings include: On 8/21/23 at 9:06 AM, Surveyor began an initial tour of the kitchen with Cook (CK)-D who indicated the facility followed the Federal Food Code. Cooling Logs: The FDA Food Code 2022 at 3-501.14 Cooling indicates: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 Fahrenheit (F) to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. The facility's Food Handling policy, with a revision date of 4/15/22, indicates: 11. Cooling .During the cooling process, monitor/measure the food temperatures every one to two hours in an attempt to assure food safety. During the initial kitchen tour on 8/21/23, Surveyor noted the facility's coolers contained labeled leftovers. Surveyor requested to review the facility's cooling log. CK-D indicated CK-D needed to ask Registered Dietician (RD)-C when RD-C returned to work the following day. CK-D indicated staff re-used the leftovers for alternate items for residents. On 8/23/23 at 11:18 AM, Surveyor interviewed RD-C who confirmed there should be a cooling log for leftovers. RD-C indicated the facility used to complete cooling logs, but that practice has fallen by the wayside. RD-C provided Surveyor with a copy of a cooling log and indicated if there are leftovers, the cooling log should be completed. Temperature Logs: The facility's Food Handling policy, with a revised date of 4/15/22, indicates: 3. Temperatures for refrigeration need to be regulated when storing food. The refrigerator must be in good repair and keep foods at or below 41 degrees F. Take temperatures on a daily basis . During the initial kitchen tour on 8/21/23, Surveyor reviewed the facility's Cooler and Freezer Temperatures log which indicated: Check cooler and freezer temperatures every day and mark down. The log contained four coolers and freezers in the kitchen. Surveyor noted the log began on 7/26/23. Between 7/26/23 and 8/20/23, the log contained missing entries for 10 days, including 7/27 through 7/31, 8/2, 8/13, 8/14, 8/16, and 8/18. On 8/22/23 at 12:39 PM, Surveyor observed both unit refrigerators which were located in the units' kitchenettes. Surveyor noted both refrigerators contained resident food and supplement food. Surveyor was unable to locate temperature logs for the refrigerators. On 8/23/23 at 11:18 AM, Surveyor interviewed RD-C and requested to see the facility's temperature logs. RD-C provided a complete log for one of the unit refrigerators; however, RD-C indicated there might be a gap in the other unit refrigerator's temperature log. RD-C indicated RD-C planned to educate staff and move the temperature logs for the unit refrigerators to the main kitchen so staff did not forget to take the temperatures. RD-C located a log for one of the unit refrigerators that was last completed on 1/27/23. No other temperature logs were located. RD-C confirmed temperatures should be taken daily.

Based on staff interview and record review, the facility did not ensure implementation of the abuse prevention policy which required out-of-state background check be completed for perspective employees who lived out-of-state for 1 (Certified Nursing Assistant (CNA)-C) of 8 sampled staff. The facility did not complete an out-of-state background check for CNA-C who disclosed living outside the state of Wisconsin in 2022. Findings include: Facility policy titled Neighbor Abuse, Neglect, Exploitation, Misappropriation, Injuries of Unknown Source, Reporting of Incidents, Neighbor - to - Neighbor, revision dated 5/2/22, documented will make a good faith effort to obtain any out-of-state conviction records for applicants who resided outside of Wisconsin at any time during the three years preceding the date of the search. On 10/20/22, Surveyor reviewed background check information for sample of employees. CNA-C's Background Information Disclosure (BID) documented CNA-C lived out of state in an undisclosed state from 2-25-22 through 6/10/22. No out-of-state background check information was provided with CNA-C's file. On 10/25/22 at 12:30 PM, Nursing Home Administrator (NHA)-A confirmed via email that CNA-C lived out-of-state in Tennessee. NHA-A verified the policy was to complete an out-of-state background check for people who lived out of state within the past three years. NHA-A indicated CNA-C's out-of-state check was not completed per policy prior to Surveyor investigation.

Based on staff interview and record review, the facility did not ensure a Legal Guardian (LG) of a Resident (R) exercised rights within the limits set by state statute for 1 (R45) of 1 sampled residents with a LG. The facility did not petition the court for R45's protective placement at the facility when R45's stay exceeded 60 days in 2015. Findings include: Wisconsin (WI) state statute chapter 55.055(1)(b) documents The guardian of an individual who has been adjudicated incompetent may consent to the individual's admission to a nursing home or other facility not specified in par. (a) for which protective placement is otherwise required for a period not to exceed 60 days. From 9/20/22 through 9/22/22, Surveyor reviewed R45's medical record which documented court orders for a LG in 2012. R45 was admitted to the facility in 2015. Surveyor noted no protective placement or annual review of protective placement was in R45's medical record. On 9/21/22 at 9:01 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C, who verified also acting as the social services designee. CNA-C confirmed being aware of protective placement requirements for residents with a LG. CNA-C indicated CNA-C would look for R45's protective placement and most recent annual review documents. On 9/21/22 at 2:20 PM, Director of Nursing (DON)-B verified to Surveyor that R45 was not protectively placed at facility.

Based on observation, staff interview, and record review, the facility did not ensure medications were dispensed and administered safely for 1 Resident (R) (R45) of 52 residents. Licensed Practical Nurse (LPN)-D dispensed medications into a medication cup for R45 then left medications in front of R45 before leaving medications and R45 unattended in dining area. Findings include: From 9/20/22 through 9/22/22, Surveyor reviewed R45's medical record which documented R45 was found incompetent by a court and ordered a legal guardian for decision making in 2012. Surveyor noted R45's record did not include an assessment for safety of self-administration of medications. On 9/20/22 at 11:58 AM, Surveyor entered dining area and observed four pills and/or tablets in a medication cup in front of R45, who was seated in a wheelchair. Surveyor noted no staff were present. On 9/20/22 at 12:00 PM, Surveyor located LPN-D, who confirmed dispensing R45's medications. LPN-D explained R45 prefers to take R45's medications with a meal. LPN-D needed to obtain the blood sugar level of another resident in that resident's room. LPN-D verified medications were left with R45 without staff present. LPN-D indicated that if LPN-D was going to be gone more than a few minutes, LPN-D would have secured R45's medications. Following interview, Surveyor observed LPN-D approach R45 and encourage R45 to take medications. On 9/21/22 at 12:31 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R45. DON-B verified R45 did not have a self-administration of medication assessment in R45's record. DON-B explained R45 had cognitive issues and dexterity problems which would prevent R45 from safely self-administering medications. DON-B voiced an expectation that the nurse who administers medications need to keep a resident in eyesight until medications are consumed. DON-B accessed R45's medical record which documented noontime medications and supplements included Lactobacillus (a probiotic supplement), two Tylenol (anti-pain medication), and [MEDICATION(S)] (anticonvulsant/nerve pain medication).

Based on staff interview and record review, the facility did not ensure monitoring of a Resident (R) who was prescribed a high risk medication for 1 (R36) of 5 residents reviewed for medications. The facility did not monitor R36 for possible negative side effects associated with [MEDICATION(S)] (narcotic opioid pain medication). Findings include: Drugs.com documents possible side effects of [MEDICATION(S)] use can include life-threatening respiratory depression. Other side effects can include but are not limited to: irregular heartbeat, blurred vision, dizziness, [CONDITION(S)] and seizures. From 9/20/22 through 9/22/22, Surveyor reviewed R36's medical record which documented R36's prescription for [MEDICATION(S)] twice per day and additional [MEDICATION(S)] every six hours as needed. On 9/22/22 at 1:52 PM, Director of Nursing (DON)-B informed Surveyor that DON-B searched R36's medical record and was not able to locate side effect monitoring. DON-B verified side effect monitoring should be in place for high risk medications.

Based on staff interview and record review, the facility did not ensure monitoring of a Resident (R) who was prescribed high-risk [CONDITION(S)] medications for 2 (R297 and R21) of 5 residents reviewed for medications. The facility did not monitor R297 for possible negative side effects associated with [MEDICATION(S)] (antianxiety medication) and [MEDICATION(S)] (antidepressant medication). The facility did not monitor R21 for possible negative side effects associated with [MEDICATION(S)] (antidepressant medication) and [MEDICATION(S)] (antipsychotic medication). Findings include: 1. From 9/20/22 through 9/22/22, Surveyor reviewed R297's medical record which documented R297's prescriptions for [MEDICATION(S)] and [MEDICATION(S)] both taken daily at bedtime. Surveyor was not able to locate side effect monitoring. On 9/22/22 at 1:43 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R297's high risk medications. DON-B explained R297 was a newer resident and verified side effect monitoring was important for high risk medications. 2. From 9/20/22 through 9/22/22, Surveyor reviewed R21's medical record which documented R21's prescriptions for [MEDICATION(S)] and [MEDICATION(S)] both taken daily. Surveyor was not able to locate side effect monitoring. On 9/22/22 at 2:19 PM, Surveyor interviewed LPN-D who stated high risk medication monitoring is normally in the medication administration record (MAR) or the treatment administration record (TAR.) LPN-D stated side effects for medications can also be found in the paper chart within the medication specific consent form.

Based on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported to the State Survey Agency (SA) for 2 residents (R) (R4 and R5) of 5 residents reviewed for abuse/neglect/mistreatment. A facility grievance report, dated 1/18/22, indicated R4 reported a potential abuse/neglect/mistreatment-related concern. The facility did not report the allegation to the SA. A facility grievance report, dated 2/27/22, indicated R5 reported a potential abuse/neglect/mistreatment-related concern. The facility did not report the allegation to the SA. Findings: The facility's policy titled Neighbor (Resident) Abuse, Neglect, Exploitation, Misappropriation, Injuries of Unknown Source, Reporting of Incidents, Neighbor-to-Neighbor stated the following: It is the policy of Grancare Nursing Center to ensure that all neighbors be free of all forms of abuse and that all alleged violation of Federal or State laws which involved mistreatment, neglect, exploitation, abuse, Neighbor-to-Neighbor altercations, injuries of unknown source or misappropriation of neighbor property are verbally reported immediately to the Community Mentor/designee and verbally or written to other officials in accordance with State Law. Federal requirements under 42 CFR state that if the events that cause the allegation involve abuse or result in serious bodily injury, nursing homes must report the violation to the administrator of the facility and the DQA (Division of Quality Assurance) no later than 2 hours after the allegation is made. All other allegations that do not involve abuse and do not result in serious bodily injury must be reported no later than 24 hours after the allegation is made. In addition, nursing homes must report to DQA and law enforcement any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. Grancare shall investigate each alleged violation and report the results of all investigations to the Administrator/designee. 1. On 4/7/22, Surveyor reviewed the facility's grievance file. A grievance related to R4, dated 1/18/22, read as follows: Concern: Not a friendly care partner. Would bark at me like a dog. Snaps at R4 and walks out. R4 told care partner that care partner did not need to talk to R4 that way. Care partner stormed out and said you can get yourself out. R4 heard care partner out in the hall talking about R4. 2. On 4/7/22, Surveyor reviewed the facility's grievance file. A grievance related to R5 dated, 2/27/22, read as follows: Concern: Night CNA (Certified Nursing Assistant) stating to R5, I (R5) don't have to go potty yet. R5 voiced that R5 is fearful of the care partner's attitude. On 4/7/22 at 2:29 PM, Surveyor interviewed DON (Director of Nursing)-B. DON-B indicated the facility conducted investigations into each of the allegations; however, the facility did not report the allegations to the SA.

Based on record review and interview, the facility did not maintain evidence that all allegations of abuse/neglect were thoroughly investigated for 2 residents (R) (R4 and R5) of 5 residents reviewed for abuse/neglect. Facility grievance report dated, 1/18/22, indicated R4 reported a potential abuse/neglect-related concern. The facility was not able to provide documentation of a thorough investigation into the allegation. Facility grievance report dated, 2/27/22, indicated R5 reported a potential abuse/neglect-related concern. The facility was not able to provide documentation of a thorough investigation into the allegation. Findings: The facility's policy titled Neighbor (Resident) Abuse, Neglect, Exploitation, Misappropriation, Injuries of Unknown Source, Reporting of Incidents, Neighbor-to-Neighbor stated the following: Investigation and Reporting: -When an incident or suspected incident of Neighbor abuse, neglect, Neighbor-to-Neighbor altercation or misappropriation of Neighbor property, or injury of unknown source is reported, the Administrator or Director of Nursing/designee will appoint a staff member(s) to immediately investigate the incident. The investigation will be reviewed, as appropriate, by the Administrator, Social Services, the Director of Nursing and/or other disciplines, if necessary. -The NHA (Nursing Home Administrator)/designee will ensure that the person in charge of the investigation has a copy of any necessary forms in order to complete the investigation, and any supporting documents relative to the incident. 1. On 4/7/22, Surveyor reviewed the facility's grievance file. A grievance related to R4 dated, 1/18/22, stated: - Concern: Not a friendly care partner. Would bark at me like a dog. Snaps at R4 and walks out. R4 told care partner that care partner did not need to talk to R4 that way. Care partner stormed out and said you can get yourself out. R4 heard care partner out in the hall talking about R4. - Involved Parties Aware of Resolution: DON (Director of Nursing)-B and SS (Social Services)-F. On the grievance form was a handwritten note, dated 1/19/22, which read: Discussed concern with care partner. Tone of voice discussed and how to empower elders. Gentle handling information covered verbally. Care partner stated the neighbor became upset because care partner had a dry cough and didn't want care partner to care for R4. Stated R4 was yelling at care partner. F/u (follow up) will happen with both parties 1/26/22. Signed by DON. A second handwritten note was dated 1/28/22 and read: Care partner stated their relationship is good. R4 has done exercise and (care partner) has done cares. R4 stated no further concerns with that care partner or any. Signed by DON. The grievance did not contain investigation information related to an interview with R4 on 1/18/22, interviews with potential witnesses, a written statement by the care partner or interviews with other staff and residents. On 4/7/22 at 2:29 PM, Surveyor interviewed DON-B. DON-B indicated than an investigation was conducted in which other residents were interviewed by SS-F. DON-B thought the interviews were written down, but DON-B was unable to locate the documents. DON-B indicated that the care partner had a dry cough and R4 mistook this as a bark (like a dog would make). DON-B did not provide information related to the allegation of R4 stating Care partner stormed out and said you can get yourself out. 2. On 4/7/22, Surveyor reviewed the facility's grievance file. A grievance related to R5, dated 2/27/22 and 2/28/22, read as follows: Concern: Night CNA (Certified Nursing Assistant) stating to R5, I (R5) don't have to go potty yet. R5 voiced that R5 is fearful of the care partner's attitude. 2/28/22: Further investigation. R5 stated R5's not afraid to call for assist and doesn't feel R5 was abused or neglected. R5 stated R5 didn't like the attitude of the night care partner. Resolution: January CNA education was on communication. I spoke to night CNA care partners that work Gran Ave and gave education on how the tone of your voices or statements may come off wrong. R5 calls for assistance every 20-30 minutes at times to use the bathroom on all shifts - R5's not interested in bladder training. R5 stated R5 doesn't need it. CNA will notify the nurse to help answer call light if they have other neighbors to assist. Night nurses educated on concern also. Daughter updated also. I followed up with R5 on 2/28-3/4. R5 had no further concerns about care partners. Daughter was updated on no further concerns. Dated and signed 3/4/22 by DON-B. The grievance did not contain investigation information such as an interview with R5 at the time the concern was noted nor were there any further documents with the grievance such as staff interviews/statements or interviews with other residents. On 4/7/22 at 2:29 PM, Surveyor interviewed DON-B. DON-B indicated that the a staff member contacted DON-B on Saturday 1/26/22 at night related to the grievance. The staff member indicated R5 had a concern about a care partner telling R5 that R5 could not go to the bathroom. DON-B stated that night DON-B probably called the night nurse or maybe called the next day to start an investigation of what was going on. DON-B believed statements were taken, but DON-B was unable to locate them. DON-B indicated R5 would not tell DON-B the name of the care partner or the date the incident occurred. DON-B indicated DON-B talked to care partners who were on the schedule on Gran Ave for night shift for one week prior to R5's allegation. DON-B indicated DON-B provided education to care partners regarding tone of voice and to take R5 to bathroom when R5 requested as DON-B was not able to determine how/what was said other than R5's statement. DON-B was unable to recall if DON-B interviewed other residents. DON-B was also unable to locate investigation documents.

Based on observation, record review and interviews, the facility did not ensure 1 resident (R) (R1) of 5 residents received care/treatment in accordance with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation did not reflect R1 received provider-ordered Gold Bond lotion (used to hydrate and nourish skin). Additionally, R1's care plan or kardex (a tool used by CNAs (Certified Nursing Assistants) to guide resident care) did not include information to prompt CNAs to initiate the application of Gold Bond lotion for s/s (signs/symptoms) of itching. In addition, the nurses caring for R1 did not assess or document skin changes on R1's arm. Findings: The facility's policy titled Skin Breakdown/Pressure Injury Prevention, with a revision date of 2/23/22, stated the following: Strategy: Provide a standard of care to enable the nurse to select appropriate nursing interventions for the prevention and care of skin breakdown and pressure injuries in accordance with medical orders. Body skin checks will be done on every neighbor (resident) during weekly bath or shower. If areas of concern are noted during the skin assessment, this should be verbalized by Spa Assistant or CNA assisting with the bath, spa or shower to the nurse. Nurse will complete follow up and route information to the DON (Director of Nursing). The DON is to notify the NHA (Nursing Home Administrator) as warranted. On 4/7/22, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had skin-related medication orders including: -[MEDICATION(S)] Solution (a topical medication used for skin conditions), one application at bedtime for Pruritus (itching), inflammation - apply to scalp. (Initiated 10/7/20) -[MEDICATION(S)] Shampoo for Seborrheic [CONDITION(S)], topical 2 times a week, Monday and Friday AM. Once healed change to BID (twice daily) PRN (as needed). (Initiated 10/7/20) -[MEDICATION(S)] Powder (an antifungal medication used to treat fungal or yeast infections) 1 application topical twice per day AM and HS (bedtime) for cutaneous candidiasis, to skin areas under abdominal folds, use until skin is clear. (Initiated 10/7/20) -Gold Bond lotion to be applied PRN per package directions for s/s of itching. Dose (1 application) topical as needed for Pruritus Hiemalis (dry skin [CONDITION(S)]). (Initiated 11/5/21) R1's MAR (Medication Administration Record) included each of the above noted orders; however, the Gold Bond lotion had no indication of being utilized (as would be indicated by a nurse signing off on the MAR) on MARs reviewed back to 2/1/22. All other medications were signed out when administered. On 4/7/22 at 9:10 AM, Surveyor interviewed R1. During the interview, Surveyor observed dry patchy areas of skin on R1's face and scalp. The areas on the face and scalp were not red, scabbed or bleeding. R1 was wearing a sweatshirt at the time; therefore, R1's arms were not observed. R1 indicated they put cream on my skin. On 4/7/22 at 9:15 AM, Surveyor interviewed Wound Care Nurse (WC)-D who indicated having checked R1's skin at times but stated the nurses working the floor were the ones who checked R1's skin routinely with cares and the ones who documented on R1's skin. Surveyor requested documentation related to skin assessments for R1. WC-D provided documentation from 1/1/22 to 3/19/22. Surveyor reviewed R1's skin documentation and noted there was no current documentation related to R1's upper body rash/[CONDITION(S)]. WC-D confirmed there was no documentation more current than 3/19/22 and no documentation related to the skin of R1's upper body (i.e. arms, head). Upon further record review, Surveyor noted a fax cover sheet, dated 11/5/21, which was sent to R1's NP (Nurse Practitioner). The fax read as follows: Could we have a PRN order for Gold Bond lotion PRN per package directions for s/s of itching? Received order 11/5/21. There was also a fax cover sheet, dated 3/3/22, regarding scratch marks on R1's upper thighs near the perineal area due to R1 scratching the area. It was noted that R1 had Gold Bond medicated lotion available. The NP's response was: Please continue to monitor, update me for worsening of symptoms, bleeding, discharge, redness/warmth. On 4/7/22 at 10:13 AM, Surveyor interviewed RN (Registered Nurse)-E who indicated that R1 had dry/scaly skin, received lotion to arms, had a scalp treatment which was done at night and on Mondays and Fridays got a special shampoo for the scalp. On 4/7/22 at 11:03 AM, Surveyor interviewed DON-B regarding R1's arms. DON-B indicated R1 had Gold Bond lotion at bedside which the CNAs put on R1 twice per day. DON-B stated, (R1) does scratch a lot. DON-B indicated CNA-J and CNA-L were R1's routine CNAs. On 4/7/22 at 11:10 AM, Surveyor interviewed CNA-L who stated, I put Gold Bond to arms/legs all over, because (R1) is rashy.'' CNA-L confirmed CNA-L applied the lotion for over two months. CNA-L stated, Yes, I always put lotion on (R1) when getting (R1) up. CNA-L confirmed CNA-L does not chart the application of the Gold Bond lotion in R1's medical record and stated, I let nurses know. CNA-L assisted R1 with taking off R1's sweatshirt so Surveyor could observe R1's arms. Surveyor observed R1's right arm between the elbow and wrist. Surveyor noted the underside of the arm was red, with darker red raised bumps which appeared to have some slight dried blood at the raised areas. The skin was scaly and there was a Band-Aid placed over the center of the reddened area. Surveyor observed a spot of blood on the center of the Band-Aid. Surveyor observed lotions and powder at R1's bedside. Surveyor noted there was no Gold Bond lotion at R1's bedside; however, there was a white bottle of lotion with Aloe which was noted to be at other residents' bedsides during prior observations. Surveyor asked CNA-L if the lotion CNA-L used was the lotion with Aloe at R1's bedside or a Gold Bond brand lotion. CNA-L confirmed it was the lotion with Aloe, not Gold Bond. Surveyor interviewed R1. R1 indicated R1's right arm itched and confirmed R1 had recently scratched the arm. R1 explained the itching was why LPN (Licensed Practical Nurse)-G put a Band-Aid on R1's arm last night. On 4/7/22 at 11:16 AM, Surveyor interviewed RN-E regarding the Band-Aid on R1's arm. RN-E stated, (LPN-G) must have put that on last night, I have not seen (R1) yet. RN-E was not aware of skin issues on R1's right arm. On 4/7/22 at 11:24 AM, Surveyor interviewed DON-B who confirmed the lotion with Aloe at R1's bedside was not the provider-ordered Gold Bond. DON-B stated, That is not an anti-itch cream. It is skin cream, not Gold Bond. DON-B contacted the pharmacy who indicated the facility ordered and received Gold Bond for R1 on 11/5/21 and again on 3/3/22 (consistent with the fax sheets noted above). An opened, but nearly full, bottle of Gold Bond was then located in R1's bathroom. On 4/7/22 at 12:25 PM, Surveyor interviewed CNA-K who was identified as R1's usual caregiver. CNA-K indicated CNA-K applied Gold Bond (from a green and gold bottle) and the lotion with Aloe to R1's elbows and arms daily. CNA-K stated, I gave (R1) Gold Bond this morning. CNA-K stated, I regularly use it because the area ([CONDITION(S)]) on arm comes and goes. CNA-K showed Surveyor the bottle of Gold Bond in R1's bathroom which was nearly full. CNA-K indicated the skin on R1's arm heals and then gets worse. Surveyor reviewed the directions on the Gold Bond bottle which read: Apply to affected area up to 3 or 4 times daily. On 4/7/22, Surveyor reviewed R1's care plan and kardex. R1's care plan stated to apply cream/ointments as ordered, but the intervention was not specific to [CONDITION(S)]. The care plan did not indicate nursing was to monitor skin for [CONDITION(S)], pruritus, itching, etc. R1's kardex did not include information regarding [CONDITION(S)] on R1's arms, head or scalp. The kardex did not include instructions to apply Gold Bond to areas of skin with s/s of itching. On 4/7/22 at 12:42 and 1:28 PM, Surveyor interviewed DON-B who confirmed the Gold Bond order was on R1's MAR, but was signed out as given for the MARs reviewed back to 2/1/22. DON-B confirmed CNAs do not have access to the MAR and nurses would need to tell CNAs to apply Gold Bond to R1's skin as those instructions were not on the CNA kardex. DON-B reviewed R1's medical record and confirmed there was no documentation by nursing related to monitoring the red area on R1's right arm. DON-B stated, It (application of Gold Bond) should be documented by a nurse when the CNA puts it (lotion) on; the CNA tells the nurse when gives it and nurse documents on the MAR. The CNA would not know to give, so nurse instructs the CNA to give it (Gold Bond). DON-B also confirmed that LPN-G did not communicate or document anything related to placing the Band-Aid on R1's arm. DON-B indicated it was DON-B's expectation that CNA staff notify the nurse if R1 had an area to skin and that nurses would monitor the area weekly. DON-B was not sure how recent R1's current right arm redness was. DON-B indicated if it was something that flared up, the facility could contact the physician, get a medication scheduled and address R1's skin on the Growth Plan (care plan). DON-B indicated it did not take much for R1 to itch. On 4/7/22 at 1:30 PM, Surveyor conducted a follow-up interview with RN-E. RN-E indicated RN-E asked CNAs on each shift if they put anything on R1 (i.e. creams) and documented their responses. Surveyor pointed out that barrier cream (which RN-E confirmed was applied by CNAs) was signed out on the MAR daily, but Gold Bond was not signed out at all. RN-E confirmed the Gold Bond was not signed out as given. RN-E stated, I first saw the arm area now. When I go to the room, I don't undress (R1). RN-E indicated the barrier cream was signed out daily because that is an automatic. I know they put it on each time R1 goes to the bathroom, so I sign it out. Surveyor questioned how nurses would know to monitor the skin on R1's right arm. RN-E stated, I just now added to monitor (R1's) right arm area to the Treatment Administration Record (TAR). RN-E showed Surveyor the newly-entered nursing order to monitor the skin areas each shift. RN-E also provided Surveyor with a copy of a fax notification sheet (which was sent out this date) to R1's provider requesting the provider look at areas (skin) next time you are in house. The fax also included skin documentation, dated 4/7/22 12:59 PM, which read: Has rash(es) present in past 7 days. Has rash to right forearm that has multiple scabs and an abraised/scratch area, skin is dry and irritated, states that it itches at times. Length (head to toe) 10.3 cm (centimeters); width (side to side) 5.2 cm. On 4/7/22 at 1:33 PM, Surveyor conducted a follow-up interview with CNA-L. When asked how CNA-L knew to put Gold Bond on R1's skin, CNA-L responded, If (R1) is itching or dry, I put just a little bit on. I know my people. I've been doing this for 20 some years. CNA-L confirmed that a nurse did not instruct CNA-L to apply Gold Bond to R1's arm. CNA-L added, If I notice it (skin) getting worse or (R1) is itching it, I tell the nurse that I put Gold Bond on. CNA-L confirmed CNA-L did not tell the nurse on R1's unit (RN-E) yet that Gold Bond was applied that morning. CNA-L confirmed CNA-L considered the arm to be worse than usual and stated, I think (R1) scratches it so much. I can tell it's freshly scratched. On 4/7/22 at 1:41 PM, Surveyor interviewed LPN-G who stated LPN-G typically worked night shifts. LPN-G confirmed LPN-G put a Band-Aid on R1 the evening of 4/6/22. LPN-G stated, (R1) had just scratched it. LPN-G indicated that information was not passed on to the next shift nurse nor did LPN-G document anything related to R1's right arm. LPN-G stated, It looked like psoriasis (a non-contagious [CONDITION(S)] disease characterized by raised areas of abnormal skin) or a dry area. I had not seen that area before. LPN-G confirmed that other than R1's scratches to legs, weekly assessments were not being done by nursing of the skin on R1's upper body (e.g arms, head).

Based on Resident (R) interview, staff interviews, observation, and record review, the facility did not ensure residents were free from significant medication errors when a diuretic medication was not administered as ordered for 1 (R20) of 6 residents reviewed for unnecessary medications. The facility did not administer R20's diuretic, [MEDICATION(S)] ([MEDICATION(S)]/water pill), daily since ordered on 6/16/21 (48 doses missed) which resulted in R20 experiencing increased [CONDITION(S)] and shortness of breath and requiring the use of oxygen therapy beginning on 7/31/21. Findings include: Surveyor reviewed R20's medical record which documented R20 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Advanced Practice Nurse Practitioner (APNP)-G note, dated 6/16/21, documented R20 had acute on chronic CHF at time of visit. Same APNP-G note explained R20 experienced increased [CONDITION(S)], documented at 1+, and weight gain. R20 denied shortness of breath at the time of APNP-G's visit but experienced chronic fatigue and weakness. APNP-G made note of improved laboratory results related to R20's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor noted R20's June and July 2021 physician orders did not include an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor was unable to locate a discontinuation order. Medical Doctor (MD) note, dated 6/23/21, documented R20's [CONDITION(S)] 1+ at time of visit. Nursing note dated 7/31/21, documented R20 began experiencing shortness of breath, slight crackles bilaterally in upper lobes (both lungs), and pale coloring. Oxygen at 2 liters per minute was applied to R20 for comfort. The on-call physician directed staff to continue to monitor. Telephone and fax summary records documented Registered Nurse (RN)-F communicated to R20's MD's office on 8/2/21 that R20 had [CONDITION(S)] of the lower extremities of 2+ to 3+ and clarified the [CONDITION(S)] was closer to 2+. The reply, dated 8/3/21, was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Epic (electronic health record) order summary from MD office was attached and reflected 6/16/21 order of [MEDICATION(S)]. On 8/2/21 at 10:13 AM, Surveyor observed R20 had [CONDITION(S)] to bilateral lower extremities and was receiving oxygen via nasal cannula. At the time of observation, Surveyor interviewed R20. R20 confirmed R20 was experiencing [CONDITION(S)] and explained R20 had a weight gain related to [CONDITION(S)]. R20 explained R20 wasn't sure if a diuretic was currently administered because the diuretic medication was sometimes put on hold because of R20's kidney problems. R20 indicated oxygen was a new treatment that started when R20 had a hard time breathing over the weekend. R20 reported oxygen helped noticeably with R20's shortness of breath. On 8/4/21 at 9:23 AM, Surveyor interviewed RN-F regarding R20's [MEDICATION(S)] orders. RN-F revealed RN-F was following up with R20's MDs office today (8/4/21) when MD office mentioned R20's daily [MEDICATION(S)] order. RN-F indicated R20's physician orders did not include a daily [MEDICATION(S)] order. At that time, Surveyor showed RN-F [MEDICATION(S)] order dated 6/16/21 on APNP-G's visit note. RN-F verified R20's [MEDICATION(S)] order was not on R20's current monthly physician orders. RN-F verified R20 began using oxygen therapy over the weekend. RN-F indicated the usage was to address difficulty breathing, not for low oxygen saturation. At 9:30 AM, RN-F approached Surveyor to communicate R20's MD office was notified that R20's daily [MEDICATION(S)] order had not been given since ordered on 6/16/21. RN-F indicated R20's MD office would further review the order and determine if 20 mg [MEDICATION(S)] daily was still appropriate. On 8/4/21 at 9:33 AM, Surveyor interviewed Director of Nursing (DON)-B regarding transcription of orders from visit notes. DON-B indicated a facility nurse is expected to read the orders, get clarifications as needed, and sign off when orders are entered into the system. DON-B reviewed R20's 6/16/20 orders from APNP-G with Surveyor. DON-B commented the primary signature was from a nurse who DON-B identified as in orientation/training at the time of signature and the secondary signature was of that nurse's training nurse. On 8/4/21 at 12:07 PM, DON-B approached Surveyor to communicate R20's MD office completed review and confirmed R20's [MEDICATION(S)] 20 mg daily order as appropriate.

Based on staff interviews and record review, the facility did not ensure a Resident (R) with an unwitnessed fall had neurological checks completed to screen for subdural hematoma (blood collection on surface of the brain) for 2 (R43 and R17) of 4 residents reviewed for falls. The facility did not implement their policy to perform neurological checks after R43 had an unwitnessed fall out of bed on 7/27/21. The facility did not implement their policy to perform neurological checks after R17 had an unwitnessed fall out of a chair on 4/20/21. Findings include: The facility's policy, titled Post Fall, revised 1/23/21, states: Neuro checks and vitals are done every 1 hour x 4, then every 2 hours x2, then every 4 hours x4, then every shift x72 hours. Modified neuro checks and vitals are done: unwitnessed fall - no known head hit - every 2 hours x4 then every shift x 72 hours. If fall was witnessed and no head hit occurred, neuro checks will not be needed. 1. From 8/2/21 through 8/4/21, Surveyor reviewed R43's medical record which documented R43 had an activated Power of Attorney (POA) and was not responsible for medical decision making. R43's most recent Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) assessment score was a 6 out of 15 (severe cognitive impairment). R43 fell five times in the 120 days reviewed, including one fall with major injury to the head. Physician note, dated 6/8/21, documented R43 was removed from antiplatelet therapy because of R43's recurrent falls. On 7/27/21, R43 fell by rolling or sliding out of bed when attempting to get out of bed to use the bathroom. Surveyor could not find evidence of whether or not the fall was witnessed or if neurological checks were completed. On 8/4/21 at 1:30 PM, Surveyor interviewed Registered Nurse (RN)-E, who verified being a member of the facility falls committee. RN-E indicated the fall committee did not meet to review and discuss R43's 7/27/21 fall prior to interview. RN-E accessed R43's medical record and verified R43 fell and documentation did not identify whether or not R43's fall was witnessed or unwitnessed. RN-E explained R43 slid to the floor on R43's buttocks and did not sustain an injury. RN-E indicated the nurse who responded would have asked R43 whether or not R43 hit R43's head and in RN-E experience, R43 would provide accurate information for short periods of time after an event. At 2:04 PM, RN-E approached Surveyor and confirmed R43 was not witnessed at the time of fall on 7/27/21. RN-E verified it was the facility's policy to complete neurological checks for any unwitnessed fall. 2. R17 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] Disorder, generalized anxiety disorder, depressive disorder, and [CONDITION(S)] (drop in blood pressure when changing positions). R17's Minimum Data Set (MDS) assessment, dated 3/8/21, indicates R17's cognition was intact. On 8/3/21, the Surveyor reviewed R17's medical record to include falls and vital signs. R17 had an unwitnessed fall on 4/20/21 and there was no evidence of neurological assessments. The document titled Incident Report dated 4/20/21, states no neuro-checks - no head hit .time last observed for safety: 0100. R17 was prescribed [MEDICATION(S)] (blood-thinning medication) at the time of the fall. On 8/4/21, Nursing Home Administrator (NHA) - A verified that neurological checks were not completed for R17's fall on 4/20/21.

Based on staff interview and record review, the facility did not ensure 1 Resident (R)(R27) of 20 sampled residents were provided services following State Statute Chapter 55.03(4). The law requires a court ordered protective placement for any resident admitted to a nursing home, who has a legal guardian and whose nursing home stay exceeds ninety days. R8 was admitted to the facility with the consent of a legal guardian; however, the facility did not pursue protective placement when the resident's stay exceeded ninety days. The facility extended the rights of the guardian, for nursing home admission, beyond those rights allowed in State law. Findings include: R27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's medical record included a petition for guardianship, from Brown County Court filed 6/28/2007. The Surveyor was unable to locate any protective placement order in R27's medical record. On 8/4/21 at 10:45 A.M., the Surveyor interviewed NHA (Nursing Home Administrator) - A regarding R27. NHA-A stated that the facility had not initiated the protective placement process for R27.

Based on observations, record review and staff interviews, the facility did not ensure 4 (residents #5, #3, #1 and #12) of 12 sampled residents reviewed for pressure ulcers received the necessary treatment and services to prevent pressure ulcers, to promote healing and prevent infections, or deterioration of existing pressure ulcers. Example 1 Resident #5 was assessed to be at risk for pressure ulcer development. The facility did not immediately develop a plan of care that met the needs of resident #5 and did not address a specific schedule for repositioning or offloading to prevent the development of pressure ulcers. Resident #5 developed a stage two pressure ulcer on the coccyx. Resident #5's plan of care was not revised to include a specific repositioning schedule after the development of the stage two pressure ulcer. When resident #5's pressure ulcer deteriorated to a stage 3, and further deteriorated to a stage 4 pressure ulcer, the written plan of care did not define a specific repositioning schedule. An alternating air pressure mattress was not initiated as a part of the resident #5's plan of care in attempt to reduce pressure. Although the facility indicated this type of device was offered to resident #5, and the resident initially refused the mattress, the facility did not re-approach the resident or involve the activated power of attorney to encourage its use. The facility utilized a pressure reducing Roho (brand name) cushion for resident #5's seated surfaces. The facility did not ensure staff were trained in the correct inflation procedures for the Roho cushion. Observations were conducted where resident #5 was seated in the wheelchair for several hours. The facility did not document weekly wound assessments of the coccyx pressure ulcer per current standards of practice and the facility's policy and procedure. The facility did not provide nutritional interventions that were measurable to ensure adequate protein intake to promote wound healing, except to "encourage high protein foods." Laboratory tests were not ordered, such as serum total protein, serum [MEDICATION NAME] and serum pre-[MEDICATION NAME], to determine resident #5's nutritional status. During an observation of wound care, staff did not follow resident #5's physician's orders [REDACTED]." The failure of the facility to implement appropriate preventative and treatment interventions for resident #5 resulted in an avoidable stage 4 pressure ulcer. This created a situation of Immediate Jeopardy, which began 4/15/14 when the pressure ulcer was unstageable, the wound bed was covered with slough, and the wound was approximately 3 to 4 cm (centimeters) deep..." NHA (Nursing Home Administrator)- D was formally notified on 5/15/14 that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 5/16/14, however the deficient practice continued at a scope and severity of G (actual harm/isolated) as evidenced by the following examples: Example 2 Resident #3 was admitted to the facility with an area of skin impairment on the left hip and was assessed by the facility to be at risk for further pressure ulcer development. The facility did not immediately develop a plan of care that met the needs of resident #3 to address a specific schedule for repositioning or offloading of the buttocks or heels to prevent the development of a pressure ulcer. Resident #3 developed an unstageable pressure ulcer presented on the right heel and a "reddened, sheared area on the right upper buttocks." Resident #3's medical record documentation indicated, "High risk for skin breakdown." The facility did not revise resident #3's written plan of care to include a specific repositioning schedule or offloading of the heels. Resident #3 developed an unstageable pressure ulcer on the left heel and documentation included, "observed rubbing heels on the bed." Resident #3 developed an additional open area on the left buttock. Resident #3's written plan of care was not revised to implement a specific repositioning schedule, or means to offload the heels prior to the development of wounds on both heels. The facility did not document wound assessments of hip, heels and coccyx pressure ulcers weekly as the facility policy and procedure indicated. The facility did not provide nutritional interventions in attempt to promote wound healing until approximately 6 months after admission. Observations were conducted of resident #3 seated in the wheel chair for several hours. The failure of the facility to implement appropriate preventative and treatment interventions for resident #3, resulted in an avoidable stage 3 and an unstageable pressure ulcer on each heel of resident #3. Example 3 Resident #1 was assessed to be at risk for the development of pressure ulcers. The plan of care for resident #1 included pressure redistribution modalities in place on bed and chair. The plan of care did not include interventions to free float or means to offload the resident's heels when in bed. During observations of resident #1 in bed, the resident's heels were in direct contact with the bed. Example 4 Resident #12 developed a stage II pressure ulcer to the right inner buttocks on 5/10/14 per a nursing documentation. The facility staff did not complete a full wound assessment or document that the wound bed had been monitored since the pressure ulcer had first presented on 5/10/14. The resident's plan of care had not been revised to include interventions related to the onset of the pressure ulcer. Additionally, a care plan intervention regarding pressure reducing devices on all seated surfaces for the resident, per facility policy, had not been consistently implemented. Not all staff were aware that resident #12 was to have a pressure reducing cushion while seated in the lounge chair, where resident #12 is seated a majority of the day. Findings include: Facility Policy and Procedure entitled,"Skin Breakdown/Pressure Sore Prevention" with a revision date of 3/8/14, indicated, "...guidelines will be followed to prevent, minimize and treat skin breakdown and pressure sores, based on guidelines set forth by AMDA (American Medical Director's Association)... The charge nurse should notify the dietary manager of the resident with the pressure sore so that dietary interventions can be implemented including the addition of high protein and Vitamin C food sources and so the dietician is aware. The policy and procedure indicated the following: ~ A weekly skin assessment must be added to the treatment sheet by the nurse... ~ The care plan should also be reviewed to ensure the steps being taken are still appropriated and meet the needs of the resident... ~ Measurements and documentation are to be completed by the charge nurse. ~ Skin documentation may include: status of the wound, measurements...pain issues, nutrition... Prevention: ~ Provide pressure relieving or reduction surfaces. EX: chair cushion, Roho cushion, pressure reduction mattress. ~ Elevate heels off bed with use of towel, pillows or wedge... ~ Reposition frequently while in bed or up in chair, as neighbor allows. Teach and encourage neighbors to do small positional changes every 15 minutes.... ~ For all neighbors with pressure sores and for those at high risk: consider high protein options at meals...double meat (or at least offer it), cheese, yogurt, eggs at meals or snacks." The AMDA "CPG (Clinical Practice Guideline) for Pressure Ulcers," dated 2007, indicated the following measures for prevention and treatment of [REDACTED]. ~ Create a turning and positioning schedule that is based on the patient's individual risk factors. ~ Maintain the lowest possible head elevation to reduce the impact of shear...Use appropriate offloading and pressure-redistributing devices..." ~ Monitoring considerations: Weekly or Dressing change monitoring; Location and staging, size, depth etc., presence of exudate...presence of pain...status of wound bed...description of wound edges..." ~ Many clinicians recommend caloric intake of 30 kcal/kg (kilocalorie/kilogram) and daily protein intake of 1.2 to 1.5 g/kg (grams/kg) of body weight for nutritionally compromised patients or are at risk for pressure ulcers. 1. On 5/13/14, surveyor # reviewed resident #5's medical record. The facesheet contained within the medical record indicated resident #5 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #5's admission nursing assessment indicated "sleeps in recliner and has for the past couple years, bed taken out of room." The Braden scale indicated resident #5 was at low risk for pressure ulcer development. Resident #5's admission MDS (Minimum Data Set) assessment dated [DATE], indicated the resident has moderate cognitive impairment, and was dependent on staff for extensive assistance with transfers and bed mobility. The MDS indicated resident #5 did not have pressure ulcers. Resident #5's CAA (Care Area Assessment) based on the 6/17/14 MDS assessment indicated resident #5 "requires staff assistance to move sufficiently to relieve pressure over any one site...confined to a bed or chair most of the time...at risk...will develop care plan." Nurse's note dated 6/26/13 indicated, Appearance of a stage 2 pressure ulcer, partial thickness loss of skin layers...2.0 cm (centimeters) by 0.5 cm. Interventions indicated that resident #5 sleeps only in recliner, is cooperative with having Roho (specialty pressure reducing cushion) in place in recliner and wheel chair, food intake encouraged, fluid intake encouraged, skin patted dry after cleanse...MD (Medical Doctor) order: fax sent to ask for Duoderm dressing... The physician's progress notes dated 7/5/13 documented resident #5 "Still refuses to sleep in bed, sleeps only in her recliner. She has now developed an early pressure sore in the coccyx area from prolonged sitting." CARE PLAN: A CNA (Certified Nursing Assistant) Care Card dated 6/6/13, indicated resident #5 required, "extensive assist of one for bed mobility....sleeps in recliner." No additional interventions relating to pressure ulcer prevention or repositioning were identified on the CNA Care Card. Resident #5's written plan of care relating to skin breakdown, dated 8/13/13 indicated "I prefer to sleep in my recliner versus a bed. You have explained the risks and benefits of my choices and I understand. I currently have a stage 2 pressure ulcer on my coccyx. Remind me to reposition frequently. I have a pressure redistribution cushion in my wheel chair and recliner." A repositioning schedule was not specified in this plan of care. The plan of care dated 8/13/13 relating to the resident's cognitive impairment indicated, "At times I may become confused." Nurse's notes dated 10/23/13, indicated "Appearance of stage 3 pressure ulcer, full thickness loss, exposing the subcutaneous tissues- presents as deep crater...0.9 cm x 0.7 cm x 0.2 cm...encouraged to lie down in bed...will only sleep and rest in recliner...Duoderm dressing applied...food intake encouraged, fluid intake encouraged...is on a protein supplement." Resident #5's plan of care dated 10/23/13, directed staff to use "[MEDICATION NAME]." This plan of care was not revised to include a repositioning schedule intervention, and continued to direct staff to "remind me to reposition frequently." No specialty mattress was added to the plan of care at this time. Resident #5's plan of care dated 12/5/13, indicated, "I refuse to sleep in bed. Encourage me to lay down for 30 minutes throughout the day....Remind me to reposition frequently." No additional changes were made to the resident's plan of care. Nurse's notes dated 4/14/14, documented the coccyx wound as "stage 3 pressure ulcer presents as a deep crater...having small amount of light green drainage...MD updated" This documentation did not include wound measurements and did not include a description of the wound bed and surrounding tissue. Nurse's notes dated 4/15/14, documented wound "Unstageable, wound bed was covered with slough, approximately 3 - 4 cm deep..." Nurse's notes dated 4/24/14, documented "appearance of a stage 4 pressure ulcer...measuring 6.2 cm by 4.5 cm by 2.0 cm deep, and 2.6 cm tunneling from 11 o'clock to 1 o'clock 1.8 cm." Resident #5's current plan of care, with an updated date of 2/17/14 was not revised to include the development of the stage 4 pressure ulcer. This plan of care did not address the need for a specialty air mattress and did not include a specific repositioning schedule. The CNA Care Card, with an updated date of 4/2/14 indicated the resident required extensive assistance for bed mobility and refuses to sleep in bed at times. This CNA care card did not include written interventions related to offloading pressure from resident #5's coccyx. On 5/14/14 at 1:00 p.m., surveyor # interviewed CNA-A regarding a repositioning schedule for resident #5. CNA-A stated, "We turn everybody every 2 hours." CNA-A indicated resident #5's plan of care did not include anything "special" related to the stage 4 pressure ulcer. CNA-A stated she had re-adjusted resident #5's pillows that day, but that sometimes the resident refused to go back to bed. On 5/14/14 at 1:05 p.m., surveyor # interviewed CNA-B regarding a repositioning schedule for resident #5. CNA-B indicated every 2 hour repositioning was standard for all residents at risk for pressure ulcers but no unique schedule was developed for resident #5. On 5/14/14 at 1:10 p.m., surveyor # interviewed CNA-O regarding a repositioning schedule for resident #5. CNA-O indicated resident #5 was toileted after meals, usually laid down in bed after meals and was repositioned every "couple of hours." On 5/15/14 at 9:15 a.m., surveyor # interviewed SSA (Social Services Assistant)-HH regarding resident #5. SSA-HH stated "everyone who is admitted "at risk," gets the same interventions, all staff are aware of what they are; repositioning every 2 hours and a pressure reducing cushion." On 5/15/14 at 2:30 p.m., surveyor # interviewed NHA-D and DON (Director of Nursing)-C regarding resident #5's bed. NHA-D and DON-C verified the resident's bed was removed from the room upon admission and was placed back in the resident's room "about a month and a half ago." At 2:45 p.m., DON-C approached surveyor # indicating the bed was replaced in resident #5's room in January 2014. The facility did not provide documentation to support the actual date the bed was returned to the resident's room, but it was verified there wasn't any bed in the room when the care plan directed staff to lay resident #5 down for 30 minutes each day. ROHO CUSHION: The NPUAP (National Pressure Ulcer Advisory Panel) Quick Reference Guide, published in 2009, indicated the following: * Examine the appropriateness and functionality of the support surfaces on every encounter with the individual. * Verify that the support surface is being used within its functional life span, as indicated by the specific manufacturer's recommended test method (or other industry-recognized test method) before use of the support surface." Resident #5's admission nurse's notes dated 6/6/13, documented the addition of a "pressure reducing cushion in the wheel chair." Resident #5's written plan of care dated 8/13/13, indicated "I have a pressure redistribution cushion in my wheelchair and recliner." Manufacturer's guidelines presented by the facility to surveyor # indicated the following procedure: * To obtain maximum therapeutic benefit and comfort from the Roho cushion. * Place hand pump hose over valve and inflate until the cushion arches slightly. * With cushion in this over-inflated condition, place the individual on the cushion in his/her normal sitting position... * Place your hand between cushion and the individual's deepest bony prominence. * With your hand in place, slowly turn the valve clockwise to release some air to immerse the individual in the cushion. When you can barely move your fingertips, (approximately 1/2 inch) between the individual's deepest prominence and the bottom, rotate the valve clockwise to close. Wiggle fingers to make sure there is approximately 1/2 inch of air between the person and the bottom." On 5/14/14 at 2:05 p.m., surveyor # interviewed DON-C regarding the use of Roho cushions. DON-C indicated the CNA's were responsible for maintaining the inflation of the Roho cushion and inflate them as needed. On 5/14/14 at 2:10 p.m., surveyor # interviewed CNA-H regarding the use of Roho cushions. CNA-H indicated the cushion is inflated with a hand pump located in the linen room and stated she feels the cushion to determine if it needed to be inflated, making sure it wasn't "too hard or too soft." On 5/14/14 at 2:11 p.m., surveyor # interviewed CNA-I regarding the use of Roho cushions. CNA-I indicated she was unaware how or when to inflate a Roho cushion. On 5/14/14 at 2:13 p.m., surveyor # interviewed CNA-J regarding the use of Roho cushions. CNA-J indicated the inflation of the Roho cushion was assessed everyday. CNA-J stated "You just feel the cushion bumps, make sure it's not too hard or too soft." CNA-J did not describe measuring the inflation of the Roho cushion as indicated in the Manufacturer's guidelines: checking the bony prominence and deflating the cushion while the resident was seated. On 5/14/14 at 2:15 p.m., surveyor # interviewed CNA-K regarding the use of the Roho cushion. CNA-K indicated she was unaware how or when to inflate a Roho cushion. On 5/14/14 at 2:16 p.m., surveyor # interviewed CNA-L regarding the use of the Roho cushion. CNA-L indicated she was unaware how or when to inflate a Roho cushion. On 5/14/14 at 2:25 p.m., surveyor # interviewed CNA-G regarding the use of the Roho cushion. CNA-G stated she knew how to inflate the Roho cushion. To determine its need for inflation she would feel the cushion, stating "You don't want it too hard or too soft." CNA-G did not describe measuring the inflation of the Roho cushion as indicated in the Manufacturer's guidelines: placing a hand under a resident and feeling for a half inch of air. On 5/15/14 at 7:37 a.m., surveyor # interviewed CNA-M regarding the use of the Roho cushion. CNA-M stated she placed her hand underneath the cushion, between the cushion and the seat surface (not between the resident and the cushion) to determine if inflation was required. Surveyor # observed CNA-M touching the Roho cushion in resident's wheel chair and stated "It could use more air." During this observation of CNA-M checking the inflation of the Roho cushion, resident #5 was not seated in the wheel chair. DOCUMENTING ASSESSMENTS Resident #5's nurse's notes documented the following: * 6/26/13- "appearance of a stage 2 pressure ulcer on the coccyx." Measurements and wound description were documented as 2.0 cm X 0.5 cm. Wound bed has fragile tissue present with new 40% of new skin growth buds present. Small amount of sero-sanguineous (the nature of serum and blood) drainage. The surrounding tissue is intact and blanchable (circulation test performed by applying and then quickly releasing pressure. The skin that was depressed, should lose color and return to normal within two seconds or less). * 7/15/13- Measurements and wound description were documented as 1.2 cm X 0.4 cm. Wound bed clean, scant amount of sero-sanguineous drainage. 70% of new skin growth present throughout the wound. Edges intact. Surrounding skin is intact and blanchable. (18 days between documented assessments). * Weekly documentation of pressure ulcer assessments continued thru 8/14/13. Documentation indicated the ulcer wound minimally fluctuate with decrease and increase size, but the pressure ulcer remained a stage 2. * 8/27/13- Measurements and wound description were documented as 1.0 cm X 0.5 cm. The wound bed was clean and pink in color. 80% of new skin buds present. A small amount of sero-sanguineous drainage. Wound edges were intact. The wound was without epibole (rolled wound edges). (12 days between documented assessments) * Weekly documentation of pressure ulcer assessments continued thru 9/25/13. Documentation indicated the ulcer wound minimally fluctuate with decrease and increase size, but the pressure ulcer remained a stage 2. * 10/10/13- Measurements and wound description were documented as 1.0 cm X 0.3 cm with a depth of 0.2 cm. The wound is oval shape and the surround skin is blanchable. * 10/14/13- Measurements and wound description were documented as 1.0 cm X 0.6 cm with a depth of 0.2 cm. The documentation indication the wound bed has 80% stringy slough present with small amount of sero-sanguineous drainage. The documentation indicated the pressure ulcer had deteriorated and was a stage 3. * Weekly documentation of pressure ulcer assessments continued thru 12/19/13. Documentation indicated the ulcer would minimally fluctuate with decrease and increase size, but the pressure ulcer remained a stage 3. * The nurses notes indicated the next assessment was completed on 12/31/13. Measurements and wound description documentation indicated on 12/31/13, the wound was 2.1 cm X 0.8 cm with a depth of 0.2 cm. The wound bed presented with 80% of stringy slough with a small amount of sero-sanguineous drainage. (12 days lapsed without documented wound assessment). * Measurements and wound description were noted on 1/10/14, and then not again until 1/20/14. The documentation from 1/20/14 indicated the pressure ulcer was 1.3 cm X 0.4 cm with a depth of 0.2 cm. The wound bed was observed to contain 60% slough, the edges were intact without epibole and a scant amount of sero-sanguineous drainage was present. (10 days lapsed without documented wound assessment). * Nurses notes continued to describe the ulcer weekly until 3/29/14. Documentation indicated the ulcer would minimally fluctuate with decrease and increase size, but the pressure ulcer remained a stage 3. * Measurements and wound description were noted on 3/29/14. The documentation indicated the pressure ulcer had a diameter of 1.2 cm with a depth of 0.5 cm. There wasn't any documentation noting the length of the ulcer. The wound description indicated the wound bed is clean and pink. The edges of the wound are fragile and without epibole. Small amount of sero-sanguineous drainage. (13 days without lapsed documented wound assessment). * The facility completed a wound assessment on 4/1/14. The assessment indicated the wound was 2.0 cm X 1.1 cm with a depth of 1.3 cm. The wound bed was clear. * The facility did not complete a comprehensive assessment of the coccyx pressure ulcer until 4/24/14. The documentation on 4/24/14 indicated resident #1's pressure ulcer had deteriorated to a stage 4 ulcer. The documentation indicated the coccyx ulcer was now 6.2 cm X 4.5 cm with the deepest depth of 2.0 cm. The documentation indicated the ulcer also contained tunneling at the 11 o'clock to 1 o'clock position of 1.8 cm. NUTRITION The NPUAP Quick Reference Guide, published in 2009, indicates to provide nutritional support to each individual with nutritional risk and pressure ulcer risk, following the nutritional cycle. This should includes the following: * Nutritional assessment. * Estimation of nutritional requirements. * Comparison of nutrient intake with estimated requirements. * Provide appropriate nutrition intervention... * Monitoring and evaluation of nutritional outcome, with reassessment of nutritional status at frequent intervals while an individual is at risk. * Offer each individual with nutritional risk and pressure ulcer risk a minimum of 30-35 kcal per kg body weight per day, with 1.25-1.5 g/kg/day protein and 1 ml of fluid intake per kcal per day." Admission dietary assessment notes for resident #5 dated, 6/15/13, indicated resident #5 had a "good appetite, and estimated fluid requirements were 1,950 cc (cubic centimeters) daily, 65 grams of protein and 1708 kcal." A dietary note on 7/16/13, indicated resident #5 received a "Healthy Shot" (supplement), one ounce, twice daily. After the stage 2 pressure ulcer deteriorated to a stage 3, the dietician documented, "Encourage meat and other high protein foods to help expedite healing." Dietician progress notes, dated 1/14/14, for resident #5 indicated, "is given 'Healthy Shot' twice daily for additional protein and low [MEDICATION NAME] level..." Dietician progress note dated 4/15/14 for resident #5 indicated, "current weight is 133 pounds which is down from previous quarter of 141 pounds. For height and weight is acceptable...staff are advised to encourage neighbor at meals and with snacks." Dietician progress note dated 4/29/14 for resident #5 indicated, "Recently stage 3 wound progressed to a stage 4. Spoke to RN about increasing 'Healthy Shot'...to 2 oz..." A follow up estimated fluid, protein and caloric need assessment was not conducted after resident #5's pressure ulcer deteriorated to a stage 3 and further deteriorated to a stage 4 pressure ulcer. On 5/15/14 at 11:50 a.m., surveyor # interviewed RD (Registered Dietician)-F who verified she was familiar with resident #5. RD-F confirmed a calorie count or intake assessment was not conducted to compare estimated requirements with nutrient intake. Additionally, serum [MEDICATION NAME], serum pre [MEDICATION NAME] or serum total protein laboratory tests were not recommenced or ordered for resident #5, to determine the resident's nutritional status or the effectiveness of the supplement. When asked how staff would track, monitor or determine how much added protein was consumed by resident #5, RD-F stated normally she would order double meat portions or put the resident on a "meal monitor." Double meat portions or a meal monitor were not implemented for resident #5. The written plan of care for resident #5, dated 2/17/14, indicated, "I prefer smaller portions." WOUND DRESSING Wound Clinic physician's orders [REDACTED]. A fax to the Wound Clinic physician from the facility, dated 5/11/14, described the current wound treatment for [REDACTED]...0.25% Dakin's moistened gauze, followed by [MEDICATION NAME] border, change daily." A physician's telephone order, dated 5/12/14, directed staff (regarding the dressing) to be "changed twice daily, clean wound, apply skin prep to surrounding tissue, gently pack with 0.25% Dakin's moistened gauze and cover, tilt seen by wound clinic 5/20/14." On 5/15/14 at 7:50 a.m., surveyor observed wound care provided to resident #5 by LPN (Licensed Practical Nurse)-N. LPN-N removed tape and the old dressing, which was saturated with amber, sero-sanguineous (a mixture of serum and blood) drainage. Similar colored drainage was noted on the resident's brief. The dressing that was removed by LPN-N was a [MEDICATION NAME] type dressing, which was confirmed verbally by LPN-N. LPN-N was observed to cleanse the pressure ulcer with normal saline, skin prep was applied and a gauze soaked with 0.25% Dakin's solution was packed into the wound. The wound was covered with a [MEDICATION NAME] pad and secured with "[MEDICATION NAME]" tape. On 5/15/14 at 11:00 a.m., surveyor # interviewed LPN-N regarding the [MEDICATION NAME] versus [MEDICATION NAME] dressing. LPN-N was not aware of the specific physician's orders [REDACTED]. "It has more cushion." LPN-N indicated there wasn't any [MEDICATION NAME] dressings in the medication/treatment cart or in resident #5's collection of dressing supplies. On 5/15/14 at 11:30 a.m., surveyor # spoke to the Wound Clinic staff, LPN-P who verified [MEDICATION NAME] and [MEDICATION NAME] were not interchangeable products. LPN-P indicated the [MEDICATION NAME] was gentle to the skin as it had an adhesive border that was easy to remove. LPN-P stated the Wound Clinic would not recommend the use of the [MEDICATION NAME] dressing in place of [MEDICATION NAME] without a physician's orders [REDACTED]. OBSERVATIONS The NPUAP Quick Reference Guide, published in 2009, indicated for stage III, IV, and unstageable pressure ulcers, "Position the individual off of the area(s) of stage III, IV, and unstageable pressure ulcers. If pressure over the area cannot be relieved by repositioning or if there are pressure ulcers on multiple turning surfaces, evaluate the individual and provide a support surface properly matched to his/her needs, considering pressure redistribution, shear reduction, and microclimate control. Keep the individual off of the area as much as possible...It is the responsibility of the professional to provide the most appropriate support surface to meet the individual's needs for pressure redistribution, microclimate control, and comfort. On 5/14/14 at 10:00 a.m., surveyor # observed resident #5 on the Roho cushion seated in the wheel chair in the lobby. On 5/14/14 at 10:05, activity staff were observed by surveyor # , assisting resident #5, by pushing her in the wheel chair, from the lobby to the activity area where the resident participated in exercises, Catholic mass and rosary service. At 12:00 p.m., still seated in the wheel chair, resident #5 was observed in the dining room waiting for lunch to be served. At 12:30 p.m., resident #5 was observed eating in the dining room. At 1:00 p.m., surveyor # observed resident #5, seated in the wheel chair, sitting in the resident's room. On 5/15/14 at 8:00 a.m., surveyor # observed resident #5 in the wheel chair, awaiting breakfast in the dining room. At 9:00 a.m., surveyor # observed resident #5 seated in the wheel chair in the lobby. At 10:00 a.m., surveyor # observed resident #5 still in the wheel chair in the lobby. At 11:00 a.m., resident #5 was observed participating in activities in the dining area, seated in the wheel chair. At 11:30 a.m., surveyor # observed resident #5 in the wheel chair participating in activities. At 12:00 p.m., surveyor # noted resident #5 in the dining area waiting to be served lunch, still seated in the wheel chair. The facility's failure to provide needed care to prevent resident #5's pressure ulcer from deteriorating to a stage 4 created a finding of immediate jeopardy. The facility removed the jeopardy on 5/16/14, by which time it had completed the following: 1. All residents with pressure ulcers were reassessed and weekly wound assessment has been added to their TAR's (treatment administration record). Care plans of residents with pressure ulcers and residents at high risk of developing pressure ulcers per the Braden assessment have been reviewed and revised as necessary. Residents with pressure ulcers have had resident specific repositioning interventions added to their care plans. Wound team will be responsible to review and revise care plans of residents with pressure ulcers, to include specific repositioning interventions during weekly rounds. 2. Verbal and written education provided to all on-duty nurses and CNA's provided on 5/15/14 to include the following: ~ Pressure ulcer prevention and treatment ~ Roho inflation, to include folders ~ "free floating" of heels when in bed This education continued to occur until all current Nursing Department staff members were educated at the start of their next shift worked. 3. Pressure ulcer prevention and treatment policies reviewed and updated. The intervention to offer "Specialty Mattress" has been added to the "New Pressure Ulcer (sore) Protocol" and "High Risk for Pressure Ulcer Protocol." Updated standards of practice for resource purposes have been obtained and available to include "Pressure ulcer prevention/treatment quick reference guides, located at nursing stations and DON's office. 4. Roho cushion audits were completed. Nursing order to check the proper inflation was added to physician's orders [REDACTED]. 5. MDS coordinator re-educated on proper completion of Braden Scale assessment, to include appropriate scoring of all sections. 6. Additional education provided to nurses included: ~ Guidelines for care plan initiation and upd

Based on observation, record review, staff and resident interviews, the facility did not ensure that each resident received and the facility provided the necessary care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (resident #3) of 15 sampled residents. Resident #3 has a history of chronic pain and has received scheduled [MEDICATION NAME]es, [MEDICATION NAME] and [MEDICATION NAME] and PRN (as needed) [MEDICATION NAME] and [MEDICATION NAME] for pain management. Resident #3 was observed to be in pain and was verbalizing pain and moaning with facial grimacing during wound cleansing and re-dressing of bilateral heel ulcers. Although, resident #3 receives scheduled pain medications and has physician's orders [REDACTED]. The facility did not provide appropriate pain management prior to the completion of a painful ulcer treatment, nor did the facility stop the procedure when resident #3 was verbalizing pain to provide pain medications before continuing the ulcer treatment. In addition, resident #3 did not receive scheduled medications until after the completion of the procedures. Findings include: Surveyor # reviewed resident #3's medical record and it indicated resident #3 was admitted with multiple [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment dated [DATE], indicated resident #3 had pain 3 - 4 days and was able to verbalize having pain, as well as exhibiting facial grimacing. Resident #3's most recent pain assessment dated [DATE], indicated the resident has pain from the heel wounds and lower back and can express pain by, "restlessness (and) may become agitated and yell out." Resident #3's current physician's orders [REDACTED].#3 receives a scheduled [MEDICATION NAME] Patch every 3 days, [MEDICATION NAME] twice a day and [MEDICATION NAME], extra strength 2 twice daily. Additionally, the resident was able to have regular strength [MEDICATION NAME] PRN and [MEDICATION NAME] every hour PRN for pain. On 5/15/14 at 7:50 a.m., surveyor # observed LPN-R cleanse and redress resident #3's right and left heel wounds while CNA (Certified Nursing Assistant)-S held the resident's leg up. During the procedure, resident #3 began moaning and complaining of pain. When resident #3 was asked what was hurting, resident #3 stated, "With the heel." When CNA-S asked if the pain was from her holding up his leg, resident #3 stated, "No. With the heel, with the heel." Surveyor # interviewed LPN-R at that time regarding resident #3 and if the resident was pre-medicated with pain medication prior to the procedure. LPN-R stated, "(resident #3) has scheduled pain meds (medications)." LPN-R continued to complete the treatment of [REDACTED]. moaning out with pain. On 5/15/14 at 8:18 a.m., surveyor # interviewed DON (Director of Nursing)-C regarding resident #3 and requested the resident's May 2014 MAR. Surveyor # and DON-C observed the May 2014 MAR and noted that resident #3's 8 a.m. scheduled medications had not yet been signed out as being administered. Surveyor # and DON-C then reviewed resident #3's May 2014 PRN MAR and noted that the May 2014 MAR did not include documentation that indicated resident #3 received any PRN pain medication prior to staff completing resident #3's ulcer treatments. On 5/15/14 at 9:30 a.m., surveyor # interviewed resident #3 regarding the wound cleaning and re-dressing that had been observed earlier. When asked if the resident had pain during the treatment of [REDACTED].#3 stated, "Oh, you bet!" Resident #3 commented "Oh yes!" when asked if he has pain when staff clean and change the dressing. Surveyor # then asked resident #3 to rate his pain, using the 1 - 10 pain. Resident #3 stated, "90%." Surveyor asked resident #3 to clarify if 90% meant "9", and resident #3 responded,"Yes." On 5/15/14 at 9:35 a.m., surveyor # interviewed LPN-R regarding resident #3's complaints of pain during the earlier treatment observation. LPN-R verified she did not administer resident #3's morning (8:00 a.m.)scheduled medications prior to the wound care. LPN-R stated she doesn't routinely assess the resident for pain before doing the wound treatment as the treatment is usually done a little later after the scheduled pain medications have been given to the resident.