Every finding on record at Sheboygan Progressive Health Services

Based on interview and record review, the facility failed to ensure 2 residents (R) (R1 and R2) of 7 sampled residents received care and treatment based upon comprehensive assessments and in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) after experiencing a change in condition.The day after an unwitnessed fall, R1 presented with a change of condition including increased pain, decreased appetite, reduced fluid intake, and decreased mobility. The facility did not ensure a nursing assessment was completed or notify R1's physician and Power of Attorney for Healthcare (POAHC) in a timely manner. R1's pain and decreased intake continued until they were transferred to the hospital 4 days after the fall. R1 was diagnosed with minimally displaced left lateral L2 and L3 transverse process fractures and a mild compression fracture of the T12 vertebral body. R1 was also diagnosed with sepsis secondary to urinary tract infection (UTI), toxic metabolic encephalopathy secondary to infection, concern for bilateral lobe infiltrates, acute kidney injury, cystitis, and severe protein-calorie malnutrition. R1 passed away at the hospital 13 days after the change of condition.R2 bumped their foot on a sit-to-stand lift and sustained a left great toe wound. Advance Practice Nurse Practitioner (APNP)-D ordered Betadine twice daily until healed and to monitor for signs and symptoms of infection. Staff did not consistently complete the Betadine treatment or monitor R2 for infection. The wound increased in size and R2's great toenail fell off. Betadine twice daily was ordered a second time but not consistentely completed by facility staff. Nineteen days later, R2 was admitted to the hospital with confusion, altered mental status, and an open wound on the left great toe. A magnetic resonance imaging (MRI) scan showed early osteomyelitis in the tip of the toe. R2 underwent a partial amputation of the left great toe. The facility's failure to address changes in condition by completing comprehensive nursing assessments, monitoring, providing treatment as ordered, and notifying the provider in a timely manner created a finding of immediate jeopardy that began on 5/2/26. Nursing Home Administrator (NHA)-A was informed of the immediate jeopardy on 6/16/26 at 5:20 PM. The immediate jeopardy was removed on 6/17/26, however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Change in Condition of the Resident policy, dated 9/20/22, indicates the facility should immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there is .a significant change in condition in the resident's physical, mental, or psychosocial status (that is, a deterioration in heath, mental, or psychosocial status in either life-threatening conditions or clinical complications) or a need to significantly alter treatment (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .Immediate notification of the physician for any symptom, sign, or apparent discomfort that is .acute or sudden in onset, and a marked change in relation to usual symptoms and signs, or unrelieved by measures already prescribed requires a phone call to the provider. According to the Wisconsin Nurse Practice Act, N6.03(1): An RN (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to LPNs (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. Example 1: R1 was admitted to the facility on [DATE] and had diagnoses including malignant lung cancer, dysphagia, anxiety, and difficulty walking. A Minimum Data Set (MDS) assessment, dated 2/16/26, stated R1's Brief Interview for Mental Status (BIMS) score was 11 out of 15, indicating moderate cognitive impairment. R1 had an activated POAHC (POAHC-C) to assist with healthcare decisions. A fall care plan, dated 2/11/26, indicated R1 was at risk for falls. A urinary incontinence care plan, dated 2/11/26, contained an intervention to report signs/symptoms of UTI such as flank pain and change in mental status. A risk for alteration in hydration care plan, dated 2/20/26, indicated R1 was at risk due to inadequate intake. The care plan contained an intervention to report changes related to signs of fluid deficit (dry skin and mucous membranes, cracked lips, poor skin turgor, thirst, fever, constipation, dizziness upon sitting/standing, confusion or change in mental status, decreased urinary output, abnormal labs, etc.) An MDS assessment, dated 5/5/26, indicated R1 was at risk for falls and had experienced 2 or more falls since admission. The assessment also indicted R1 was at risk for UTIs with frequent urinary incontinence. R1's medical record contained an order for oxycodone (an opioid medication) 5 milligrams (mg) every 6 hours as needed (PRN) for pain. On 6/15/26, Surveyor reviewed a grievance filed by POAHC-C on 5/5/26. The grievance stated the facility failed to recognize and notify the physician and POAHC-C of a change in condition for R1. The grievance indicated an investigation was initiated. On 6/15/26 at 10:36 AM, Surveyor interviewed POAHC-C who stated R1 fell on 5/1/26. POAHC-C stated they arrived at the facility on 5/5/26 after they were notified of R1's change in condition. POAHC-C stated R1 was in bed, was weak and lethargic, and POAHC-C had to wipe out R1's mouth which was full of junk. POAHC-C stated Director of Nursing (DON)-B acknowledged the facility failed to recognize the change in condition and update the physician and POAHC-C timely. DON-B indicated the facility woud do an investigation. POAHC-C indicated if the facility had updated them sooner, they would have asked that R1 be sent to the hospital since R1 had a history of mental status changes with UTIs. POAHC-C stated they did not receive information from the facility regarding the outcome of the investigation or corrective measures that were taken. POAHC-C stated R1 did not recover at the hospital and passed away on 5/15/26. A fall investigation, dated 5/5/26, indicated R1 had an unwitnessed fall in the bathroom at approximately 1:40 PM while attempting to self-transfer from the toilet. A nursing assessment identified a 6.0 centimeter (cm) x 0.5 cm abrasion on the right scapula. R1 complained of back pain immediately following the fall and was assisted to bed via 2 staff and a Hoyer lift. R1's physician was notified at 2:04 PM. POAHC-C was notified at 2:03 PM. R1's Medication Administration Record (MAR) indicated they had a pain level of 5 out of 10 (with 10 being the worst pain) on 5/1/26 at 3:58 PM. Oxycodone was administered. A progress note, dated 5/1/26 at 5:31 PM, stated R1 reported oxycodone was ineffective; however, R1 was more relaxed and less vocal. Staff applied ice per R1's request. A progress note, dated 5/2/26 at 5:21 AM, stated R1 rested comfortably in bed during the shift and had no complaints of pain or discomfort. R1's MAR indicated they had a pain level of 7 out of 10 on 5/2/26 at 9:49 AM. Oxycodone was administered. A progress note at 10:10 AM indicated R1 seemed more relaxed. A progress note at 8:59 PM indicated R1 was alert but not talking, not eating, and not taking medication. Staff were unsure if this was R1's choice. R1 remained in bed but did not call out in pain when turned from side-to-side or boosted. R1's MAR indicated they had a pain level of 3 out of 10 on 5/3/27 at 11:47 AM. Oxycodone was administered. A progress note at 1:01 PM indicated R1 seemed more relaxed. A progress note at 9:01 PM indicated R1 complained of minimal pain. R1 had not urinated during the shift and accepted medication only when placed in their mouth. The note indicated R1 did not eat supper and may need to be fed. When staff attempted to obtain vital signs, R1 turned over and said leave me alone. A progress note, dated 5/4/26 at 9:51 AM, indicated R1 was sleeping and declined breakfast. A progress note at 1:59 PM indicated R1 declined to get up for a meal during the AM shift and was incontinent of a large amount of urine. A progress note at 9:14 PM indicated R1 remained in bed, refused to eat even after staff attempted to feed them, and hardly drank any water with medication. There were no signs of increased pain or discomfort to R1's back. A progress note, dated 5/5/26 at 12:43 AM, indicated R1 was resting comfortably in bed and had no complaints of pain or discomfort. A progress note at 2:40 PM indicated APNP-D was updated and ordered R1 be sent to the Emergency Department (ED). A progress note at 2:55 PM indicated R1 remained in bed, was quiet, and did not eat. R1 drank a bit of water and did not complain of pain when asked but was slow to respond. R1's skin was warm, dry, and pale. A progress note at 3:02 PM indicated POAHC-C was updated. On 6/15/26 at 1:16 PM, Surveyor interviewed APNP-D who confirmed staff updated them about R1's fall on 5/1/26. APNP-D indicated R1 was at baseline at the time. APNP-D stated staff did not provide additional updates until the afternoon of 5/5/26. APNP-D stated if staff had contacted them sooner, APNP-D would have sent R1 to the hospital sooner due to a critical status change. Surveyor reviewed statements from nursing staff who worked with R1 from 5/1/26 through 5/5/26. Of the 13 staff who provided statements, 10 staff indicated they were aware of R1's decreased intake, increased pain, and/or overall change in routine, abilities, and condition. A written statement by Licensed Practical Nurse (LPN)-F, dated 5/6/26, indicated LPN-F worked with R1 on the 5/1/26, 5/2/26, 5/3/26, and 5/4/26 PM shifts. LPN-F was aware R1 was not getting out of bed or eating but questioned behavioral issues. LPN-F stated they told the Certified Nursing Assistants (CNAs) to assist R1 with eating, however, R1 refused. LPN-F also indicated R1 did not drink much water with medications. On 6/16/26 at 10:58 AM, Surveyor left a voicemail for LPN-F but did not receive a return call. A written statement by LPN-G, dated 5/6/26, indicated LPN-G worked with R1 at the time of the fall on 5/1/26 and again on 5/4/26. LPN-G stated the night nurse reported R1 had decreased output from 5/2/26 through 5/3/26, however, LPN-G noted R1 was incontinent of a large amount of urine on 5/3/26 into the morning of 5/4/26. LPN-G indicated during their shift on 5/4/26, R1 declined to get up for meals and had incontinent episodes. LPN-G indicated R1 did not complain of pain but was visibly agitated. On 6/16/26 at 9:36 AM, Surveyor left a voicemail for LPN-G but did not receive a return call. Surveyor reviewed R1's bowel and bladder elimination record for 5/1/26 through 5/5/26 and noted there was no urinary elimination recorded on all 5 days. On 6/16/26 at 9:40 AM, Surveyor interviewed NHA-A who stated R1's urinary output was not included in bowel and bladder elimination because R1 did not have a catheter and was incontinent of urine. Surveyor reviewed R1's fluid intake which indicated documentation is completed once per shift. R1's fluid intake for 2/11/26 through 4/30/26 indicated R1 refused fluids during 2 of 234 shifts and consumed less than 260 cubic centimeters (ccs) of fluid during 4 of 234 shifts. R1's fluid intake documentation for 5/1/26 through 5/5/26 (until R1 was transferred to the hospital) indicated: ~ 5/1/26: 360 ccs (AM shift); 360 ccs (PM shift); 240 ccs night (NOC) shift ~ 5/2/26: 0 ccs; R1 refused fluids on all three shifts. ~ 5/3/26: 200 ccs (AM shift); 240 ccs (PM shift); R1 refused fluids on the NOC shift. ~ 5/4/26: 300 ccs (AM shift); 320 CCs (PM shift); 200 ccs NOC shift ~ 5/5/26: 120 ccs (AM shift); R1 refused fluids on the PM shift. Surveyor reviewed R1's nutrition intake which indicated documentation is completed once per shift. R1's nutrition intake documentation for 2/11/26 through 4/30/26 indicated R1 refused meals on 14 of 234 shifts. R1's overall meal intake was greater than 25% for 226 of 234 shifts. R1's nutrition intake documentation for 5/1/26 through 5/5/26 (until R1 was transferred to the hospital) indicated: ~ 5/1/26: R1 consumed 76-100% for 2 of 3 meals. R1 refused dinner. ~ 5/2/26: R1 refused 2 of 3 meals. R1 consumed 0-25% of dinner. ~ 5/3/26: R1 consumed 0-25% of breakfast and 51-75% of lunch. R1 refused dinner. ~ 5/4/26: R1 consumed 0-25% of all three meals. ~ 5/5/26: R1 consumed 0-25% of breakfast. R1 refused lunch. R1's overal intake prior to 5/1/26 compared to after 5/1/26 revealed a decline in overall fluid and nutrition intake. A hospitalist note, dated 5/7/26, indicated R1 was diagnosed with sepsis secondary to UTI with known source, leukocytosis with white blood cell count 20,000, tachycardia with a heart rate of 114, UTI with hematuria and proteinuria, toxic metabolic encephalopathy secondary to infection, concern for bilateral lobe infiltrates, acute kidney injury, and severe protein-calorie malnutrition with low albumin. R1 was started on intravenous (IV) antibiotics. A hospitalist note, dated 5/12/26, indicated R1 was transitioned to Hospice care. R1 passed away on 5/15/26. R1's death certificate indicated the cause of death was urosepsis and acute cystitis. The facility's failure to identify a significant change in condition, complete ongoing assessments, and notify the provider and POAHC in a timely manner created a reasonable likelihood for serious harm thus leading to a finding of Immediate Jeopardy. On 6/16/26 at 9:40 AM, Surveyor interviewed NHA-A who provided documentation and indicated the facility completed a past non-compliance (PNC). NHA-A indicated the facility was aware of the non-compliance related to staff identifying R1's significant change in condition and timely notifying R1's physician and POAHC-C. On 6/16/26, Surveyor reviewed the facility's PNC documentation which included a Critical Event Analysis and Action Plan Worksheet, dated 5/7/26. The worksheet indicated the facility became aware of the non-compliance on 5/5/26. Systemic measures taken to prevent recurrence included re-education of nurses on proper notification of healthcare providers and resident representatives on changes in condition. The worksheet indicated audits would be completed weekly for 4 weeks on residents with changes in condition to ensure proper notification and assessments are completed. Training Log/In-Service sheets attached to the worksheet contained training dates of 4/30/26 which was 2 days prior to the onset of R1's change in condition. The list of trainings included 4 topics, including notification on change of condition. Surveyor noted 20 staff signatures were dated prior to 5/5/26 which indicated the training was provided prior to the facility identifying the non-compliance on 5/5/26. On 6/16/26 at 2:40 PM, Surveyor interviewed [NAME] President of Success (VPS)-H, NHA-A and DON-B about the education. NHA-A stated the facility educated staff on an unrelated topic and added the education about change of condition to the training. On 6/16/26 at 3:37 PM, Surveyor again interviewed NHA-A. Surveyor asked when the change of condition training was added and when staff received the education. NHA-A stated they were not certain. The facility removed the jeopardy on 6/17/26, however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility contiues to implement the following action plan as well as the action plan for Example 2: 1. Completed a review of residents who had a change of condition within the last 30 days to ensure notificiations were made in a timely manner. 2. Provided staff education on the facility's change in condition policy, including assessing/evaluating the resident and timely provider notification. Initiated re-education of the E-Interact change in condition tool of when to report to the MD/NP/PA. A print out of the tool was placed at each nursing station for staff reference. 3. Held an ad-hoc QAPI meeting to discuss survey findings and removal plan. Reviewed the facility's change in condition policy with the Medical Director to ensure the policy meets current standards of practice. 4. Initiated change in condition audits that include reviewing progress notes, validating completion of assessments, and notification of the MD. Audits will be completed daily for 7 days and then continue with weekday morning clinical meetings for 8 weeks. Example 2: The facility's Skin Integrity/Foot Care Policy, dated 12/15/23, indicates the facility will ensure residents receive proper treatment and care to maintain good foot health and maintain skin integrity of the foot .referrals to podiatrists or wound care physicians will be made when appropriate .RNs and LPNs will participate in the management of medical conditions by following physician orders, assessment/observation of residents, and reporting changes in condition to the resident's physician. R2 was admitted to the facility on [DATE] and had diagnoses including dementia, diabetes, chronic kidney disease, and congestive heart failure with lower extremity edema. An MDS assessment, dated 5/1/26, stated R2's BIMS score was 7 out of 15, indicating severe cognitive impairment. R2 had an activated POAHC (POAHC-M) and discharged from the facility on 5/25/26. A comprehensive care plan, revised 5/5/26, indicated R2 had an open area on the left great toe. The care plan contained interventions to administer treatment per MD orders and for podiatric care as needed. R2's care plan also had an endocrine focus area related to diabetes with interventions to inspect feet daily for open areas, sores, edema, or redness and to administer all medications/treatments per MD order. A progress note, dated 5/6/26 at 9:06 PM, indicated R2 had a bruise on the left great toe that measured 0.6 cm x 1.2 cm with a loosened toenail, erythema (redness) but blanchable, and scant blood. The injury was noted by an RN during bedtime cares. R2 indicated they bumped their toe on the sit-to-stand machine that morning. Betadine was applied to the site. The physician and POAHC-M were notified. R2's care plan was updated to ensure R2 wore proper footwear during transfers. A fax from APNP-D on 5/6/26 contained an order to apply Betadine twice daily until healed and monitor for signs/symptoms of infection. (Of note: The order was not transcribed in R2's medical record and was not on R2's Treatment Administration Record (TAR).) A progress note, dated 5/7/26 at 2:30 AM, indicated R2 had a bruise on the left great toe and the nail was slightly loose. A progress note at 9:30 AM indicated R2 had a bruise on the toe and a dressing was applied. The toenail was lifted up and a small amount of bloody drainage was noted. A progress note at 10:29 PM, indicated R2's dressing was clean and intact. Bloody drainage was noted. A weekly skin check, dated 5/11/26, indicated R2 had a bruise on the great toe and the nail was loose. A weekly skin check, dated 5/18/26, indicated there was a concern with the left toe. A physician visit note, dated 5/18/26 at 10:00 AM and written by Medical Doctor (MD)-I, indicated R2 had a contusion on the left great toe with damage to the nail that measured 1.5 cm x 0.2 cm x 0.2 cm with no signs of infection. The left great toenail came off with a dressing following a previous injury. The note stated to continue wound care. A fax, dated 5/18/26 and written by APNP-D, contained an order for Betadine to the left great toe twice daily and cover with dry dressing until healed. (Of note: R2's TAR indicated the order was transcribed for 5/18/26 to 5/19/26 (four treatments) and then stopped.) On 6/15/26 at 10:01 AM, Surveyor interviewed APNP-D who verified they were notified of R2's wound on 5/6/26 and ordered Betadine treatments twice daily until healed and to monitor for signs/symptoms of infection. APNP-D indicated the Betadine orders should have been transcribed on 5/6/26 and 5/18/26 and completed as ordered. APNP-D was not aware the treatments were not completed. APNP-D stated staff should have viewed the wound at least once daily to monitor for signs and symptoms of infection and/or healing and should have completed full assessments weekly. APNP-D stated they were not aware if/when R2's left great toenail fell off or if the wound worsened prior to hospitalization. APNP-D stated they rely on staff assessments and updates to direct treatment decisions. APNP-D indicated the facility should have referred R2 to a wound physician and/or podiatrist since R2 was diabetic and had significant lower extremity edema which significantly impacts wound healing. On 6/15/26 at 12:30 PM, Surveyor interviewed POAHC-M who was notified of R2's left toe wound by Registered Nurse (RN)-J. POAHC-M stated when R2 went to the hospital on 5/25/26, hospital staff were concerned about the toe. An MRI on 5/26/26 showed osteomyelitis in the left great toe. POAHC-M verified R2 had a partial amputation of the left great toe on 5/29/26. On 6/16/26 at 2:44 PM, Surveyor interviewed RN-J who verified they discovered the toe injury on 5/6/26 during cares. RN-J stated R2 indicated they bumped the toe on a sit-to-stand lift and was not wearing appropriate footwear to prevent the injury. RN-J stated they removed R2's socks and noted the left great toenail was loose and bloody. RN-J assessed the wound and updated DON-B, POAHC-M, and APNP-D of the injury. RN-J verified orders were requested from APNP-D but the fax was not returned until after the completion of RN-J's shift. RN-J stated they worked a few shifts after the injury was first observed and noted wound care was not being done correctly or not at all. RN-J stated the wound had an occlusive dressing in place at times which they reported to DON-B. RN-J stated the last time they saw R2's toe was approximately a week before R2 went to the hospital. RN-J stated the toenail was gone and the wound bed was moist and draining. An emergency room (ER) visit note, dated 5/25/26 at 1:56 AM, indicated R2 sustained a foot injury approximately two weeks prior that resulted in loss of the toenail and ongoing pain. At the time of the injury, R2's legs were significantly swollen. The ER summary indicated the left diabetic foot wound was likely infected. (Of note: Surveyor observed a photo of R2's left great toe wound from the ER. The wound appeared to cover the entire tip of the left great toe and contained cracked/peeling edges. The wound bed was 40% slough and 60% granulation. No measurements were available.) An X-ray report, dated 5/25/26 at 2:29 AM, revealed soft tissue swelling on the left distal first digit (toe). An MRI report, dated 5/26/26 at 1:13 PM, indicated a concern for early osteomyelitis on the distal tuft of the first distal phalanx (toe). A surgical report, dated 5/29/26 at 1:10 PM, indicated R2 was diagnosed with gangrene with osteomyelitis of the left hallux (big toe). The digit was disarticulated (amputated) at the interphalangeal joint without incident. A portion of necrotic soft tissue was sent to microbiology for culture and sensitivities. Wound culture results, dated 5/29/26 at 1:28 PM, indicated many staphylococcus lugdunensis, corynebacterium striatum, and rare staphylococcus coagulase negative. On 6/16/26 at 3:14 PM, Surveyor interviewed DON-B who stated they were not informed wound care for R2's left toe was done incorrectly or not at all. DON-B was not sure when R2's toenail fell off but thought it was between 5/7/26 and 5/18/26 based on the limited documentation and was not sure if the physician was notified of the change in wound status. The failure to provide treatment in accordance with physician orders and failure to update the physician of a change in condition of a wound led to serious harm for R2 which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 6/17/26, however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement the following following action plan as well as the action plan for Example 1: 1. Completed a skin sweep of all residents to identify any skin concerns. Assessments were completed for residents identified with skin impairments. Treatment orders and physician notification were reviewed. 2. Iniitiated re-education on the facility's pressure injuries and non-pressure injuries policy, including appropriately monitoring and assessing wounds and following treatment orders as indicated. Initiated re-education for nursing staff on accurately transcribing provider orders and using a double-check system requiring two nurses to validate transcribed orders. 3. Held an ad-hoc QAPI meeting to discuss survey findings and a removal plan. Reviewed the facility's pressure injuries and non-pressure injuries policy and change in condition policy with the Medical Director to ensure the policies meet current standards of practice. 4. Initiated weekly audits of newly identified and existing wounds to ensure assessments are completed thoroughly per policy and there is documentation of MD notification. Dressing change competencies will be initiated with licensed nurses at least 5 times per week for 3 weeks until completed. Weekly audits of no less than 5 new or changed orders will be completed to ensure the double check process is followed and orders are transcribed appropriately.

Based on interview and record review, the facility did not ensure assistive devices to prevent accidents were implemented for 1 resident (R) (R1) of 3 residents from a total sample of 9 residents. R1 had an unwitnessed fall while self-transferring from wheelchair to toilet. Staff did not ensure R1's chair alarm was in place prior to the fall. R1 was transferred to the hospital and diagnosed with minimally displaced left lateral L2 and L3 (lumbar spine/lower back) transverse process fractures and a mild compression fracture of the T12 vertebral body (junction between the mid and lower back).Findings include:The facility's Fall Prevention and Management Guidelines policy, dated 7/18/24, indicates each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury.R1 was admitted to the facility on [DATE] and had diagnoses including malignant lung and brain cancer and difficulty walking. R1's Comprehensive Minimum Data Set (MDS) assessment, dated 2/16/26, stated R1's Brief Interview for Mental Status (BIMS) score was 11 out of 15, indicating moderate cognitive impairment. An admission Evaluation, dated 2/11/26, indicated R1 was at risk for falls. A fall care plan was initiated. The care plan contained an intervention, dated 4/14/26, for a chair alarm in wheelchair to be changed between surfaces. A fall incident report, dated 5/1/26, indicated R1 had an unwitnessed fall in the bathroom at approximately 1:40 PM while attempting to self-transfer from toilet to wheelchair. A nursing assessment identified a 6.0 centimeter (cm) x 0.5 cm abrasion on the right scapula. R1 complained of back pain immediately following the fall and was assisted to bed via 2 staff and a Hoyer lift. R1's physician and Power of Attorney for Healthcare (POAHC) were notified. A post fall assessment, dated 5/1/26, indicated R1's chair alarm was not in place. An immediate intervention indicated staff would be educated to transfer R1's bed alarm to the wheelchair. The assessment indicated education was provided to the Certified Nursing Assistant (CNA) (CNA-K) on 5/1/26 at 1:50 PM. On 6/16/26, Surveyor reviewed the nursing schedule for 5/1/26 which indicated Licensed Practical Nurse (LPN)-G and CNA-K were assigned to R1's unit at the time of the fall. On 6/16/26 at 10:43 AM, Surveyor interviewed CNA-K who stated they heard yelling after lunch on 5/1/26 and and went to check on R1. CNA-K and LPN-G found R1 on the floor in the bathroom. CNA-K stated R1 had attempted to self-transfer to the toilet and fell. CNA-K and LPN-G assisted R1 from bed to wheelchair earlier in the day and assisted R1 with toileting prior to lunch. CNA-K acknowledged that when assisting R1 from bed to wheelchair earlier in the day, CNA-K noticed R1 had a bed alarm and wondered if they also had a chair alarm. CNA-K did not see a chair alarm listed on R1's care plan. CNA-K confirmed they did not transfer the alarm to R1's wheelchair and the alarm was not on the wheelchair when they fell. CNA-K confirmed they were educated about ensuring the alarm is transferred from bed to chair. CNA-K stated when they next worked with R1 on 5/4/26, they noticed R1 was moving slower and did not get out of bed. CNA-K stated R1 was transferred to the hospital the following day. On 6/16/26 at 9:36 AM, Surveyor left a message for LPN-G. A return call was not received.A change in condition summary, dated 5/5/26, indicated R1 had altered consciousness, decreased mobility following the fall, a resting pulse of greater than 100, and indicators of pain. The physician was updated and ordered R1 be sent to the hospital for evaluation. A computed tomography (CT) scan of R1's lumbar spine on 5/5/26 revealed minimally displaced left lateral L2 and L3 (lumbar spine/lower back) transverse process fractures and a mild compression fracture of the T12 vertebral body (junction between the mid and lower back) with minimal height loss and no retropulsion (an involuntary tendency to lean or walk backward).Nursing Home Administrator (NHA)-A added an Interdisciplinary Team (IDT) note to R1's fall report on 5/5/26 that indicated R1 had a sensor pad in bed which was not moved to the wheelchair. Reeducation for direct care staff to ensure alarms are properly placed was initiated. On 6/16/26 at 2:40 PM, Surveyor interviewed NHA-A, Director of Nursing (DON)-B, and [NAME] President of Success (VPS)-H. When asked about the chair alarm, DON-B and VPS-H indicated R1 most likely self-transferred from bed to chair which is why the alarm was not transferred. When Surveyor stated CNA-K said they transferred R1 from bed to chair but did not transfer the alarm, VPS-H stated even if the chair alarm was in place, it would not have changed the outcome and would only have notified staff that R1 was out of the chair. DON-B stated education was completed with all nursing staff to ensure alarms are transferred between surfaces. When Surveyor asked what prompted the education if management was not aware staff did not transfer the alarm, VPS-H, NHA-A, and DON-B could not recall. NHA-A stated they spoke with CNA-K via phone but did not record their statement or that NHA-A had done one-on-one education with them at that time. NHA-A and DON-B confirmed staff were not educated on following residents' care plans and other residents were not interviewed to ensure there were no other concerns with following care plans. On 6/16/26 at 3:14 PM, DON-B provided Surveyor with chair alarm education sign-in sheets and stated education was completed with all nursing staff. Surveyor reviewed the sign-in sheets which included CNA-K's signature dated 5/22/26.

Based on interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Registered Nurse (RN)-E) of 9 employees reviewed for caregiver background checks. The facility did not complete a thorough background check for RN-E. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property .Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state law and regulation. Responsibility for performance of compliance checks on contracted temporary staff will be established via contractual agreement .Screenings may be conducted by the facility itself, a third-party agency, or academic institution .The facility will maintain documentation of proof that the screening occurred . On 6/16/26, Surveyor requested background check information, including Department of Justice (DOJ) and Governmental Findings reports for a sample of 9 staff. Surveyor reviewed background check information for RN-E who was hired by the facility on 6/24/25. Surveyor noted part of RN-E's background check was completed on 6/6/25, however, RN-E's DOJ and Governmental Findings reports were dated 6/16/26. On 6/16/26 at 3:32 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated they contacted the agency from which RN-E was hired, but the agency did not have DOJ or Governmental Findings reports for RN-E and stated RN-E's file had been deleted. NHA-A indicated the facility should have completed all background check and pre-employment screening prior to RN-E's employment and should retain copies of background check and pre-employment screening information for all employees.

Based on observation, staff interview, and record review, the facility did not ensure pureed food was prepared in a method that conserved the nutritive value for 3 residents (R) (R22, R35, and R40) of 3 sampled residents who had orders for pureed diets.Staff did not follow recipes while pureeing food to ensure the nutritive value was conserved. In addition, staff did not offer residents on a pureed diet one of the items as listed on the menu and the residents' meal tickets.Findings include: The facility's contracted food service company's Food: Quality and Palatability policy, revised 9/2017, indicates: Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet residents' needs. 1. Menu items are prepared according to the menu, production guidelines, and standardized recipes .3. Food and liquids/beverages are prepared in a manner, form, and texture that meets residents' needs. 4. The cook(s) prepare food in accordance with the recipes .The facility's contracted food service company's Menus Policy Statement, dated October 2022, indicates: Menus will be planned in advance to meet nutritional needs of the residents in accordance with established national guidelines .3. Menus will include standardized recipes.According to the publication All About Recipes, Part II from the College of Agriculture, Biotechnology and Natural Resources [NAME], A., and [NAME], S. 2021, It is important to follow a recipe to ensure accurate nutrition content, which is important for schools, hospitals, and nursing homes. Modifying a recipe by adding water lowers the nutritional quality of the food.The facility's lunch menu on 8/12/25 included scalloped potatoes with ham, herbed green beans, a wheat dinner roll, and sliced peaches.From 8/11/25 to 8/13/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including dysphagia and chronic respiratory failure with hypoxia. R22's diet orders indicated R22 was at nutrition risk related to dysphagia (difficulty swallowing), history of percutaneous endoscopic gastrostomy (PEG) tube feedings, need for mechanically altered diet and thickened liquids, obesity, limited activity level, history of weight gain, and need for meal assistance. R22 had swallowing difficulty related to oropharyngeal dysphagia as evidenced by the need for a mechanically altered diet with thickened liquids.From 8/11/25 to 8/13/25, Surveyor reviewed R35's medical record. R35 was admitted to the facility on [DATE] and had diagnoses including dysphagia oropharyngeal phase, spastic hemiplegic cerebral palsy, and functional quadriplegia. R35 had an order for a dysphasia pureed level 1 diet with large portions. From 8/11/25 to 8/13/25, Surveyor reviewed R40's medical record. R40 was admitted to the facility on [DATE] and had diagnoses including history of transient ischemic attack and cerebral infarction. R40 had an order for a pureed diet with thin liquids.Surveyor observed lunch service on 8/12/25 beginning at 11:31 AM. At 11:57 AM, Surveyor observed [NAME] (CK)-O serve a meal that included pureed food. When Surveyor asked about the process for pureeing food, CK-O initially indicated CK-O followed recipes. CK-O then indicated CK-O did not follow a recipe and usually used hot water as a thinning agent but also used milk, gravy, juice, and broth. CK-O indicated CK-O does not measure the amount of liquid used to puree food and free pours an undetermined amount. CK-O indicated if the food is too thick, CK-O adds more water or another thinning liquid. If the food is too thin, CK-O adds a few tablespoons of a thickening agent or powder. CK-O confirmed CK-O should use recipes to conserve the nutritional value of the pureed food, but stated CK-O had pureed food for a long time. CK-O was unable to find recipes for the food that CK-O had pureed that day. CK-O initially indicated CK-O used dinner rolls and hot water for the pureed dinner roll on the menu but then indicated CK-O used unmeasured amounts of packaged breadcrumbs and hot water for the dinner roll. CK-O indicated using breadcrumbs was easier than pureeing actual dinner rolls and indicated it was easier to use hot water as a thinning agent. CK-O indicated CK-O used milk as a thinning agent to puree French toast for breakfast that morning and chose milk as a thinning agent because it had more nutrients. CK-O again indicated that CK-O guessed on the amount of food and liquid agents used and used CK-O's judgment to choose a thinning agent. CK-O, District Manager (DM)-J, and Account Manager (AM)-L looked through binders in the kitchen but were unable to find pureed food recipes for the meals prepared that day. AM-L and DM-J later provided Surveyor with a pureed dinner roll recipe. Surveyor continued to observe and interview CK-O who indicated CK-O added approximately 3 cups of food in the blender prior to pureeing scalloped potatoes and ham. CK-O verified CK-O used an unmeasured amount of water, seasoning, and butter to blend the potatoes and ham. CK-O indicated CK-O added too much liquid and the mixture was too thin so CK-O added 2 tablespoons of mashed potato flakes. CK-O then clarified the 2 tablespoons were not measured and CK-O had free poured an unmeasured amount of potato flakes into the potatoes and ham to thicken them. On 8/12/25 at 12:56 PM, Surveyor interviewed AM-L and DM-J who verified staff should follow a recipe to prepare pureed food to maintain the appropriate consistency and nutritive value. AM-L and DM-J indicated the facility follows the National Dysphagia Diet (NDD) standards for pureed food, but are in talks to switch to the International Dysphagia Diet Standardization Initiative (IDDSI).On 8/12/25 at 1:01 PM, Surveyor interviewed Registered Dietitian (RD)-K who indicated if cooks don't use a specified liquid, the value of the pureed food cannot be determined.On 8/12/25 at approximately 2:15 PM, Surveyor interviewed Speech Therapist (ST)-M who indicated ST-M used the IDDSI diet, however, the facility used the NDD which was easily translatable. ST-M indicated cooks should use the IDDSI fork test to check the consistency of food. ST-M indicated ST-M could see how the recipe for pureed dinner rolls that did not specify which liquid and how much should be used to puree the item could be misconstrued and may alter the value of the food. Surveyor requested pureed recipes for all meals served during the survey from 8/11/25 through 8/13/25.On 8/12/25 at 4:07 PM, Surveyor interviewed AM-L and DM-J who indicated the facility switched menu companies a few weeks prior and did not have all the recipes for pureed items on the menu from 8/11/25 through 8/13/25. AM-L and DM-J were unsure why the facility did not have specific recipes for pureed food. AM-L indicated the recipes were vague and should specify what type of liquid should be used to thin during the puree process. AM-L indicated staff should not use water as a thinning agent. AM-L and DM-J verified changing the liquid used during the puree process can alter the nutritional value and consistency of the food.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary care and services to maintain the highest practicable physical well-being related to wound management for 1 resident (R) (R6) of 2 sampled residents.The facility did not monitor and assess R6's left lower extremity venous stasis wound in accordance with R6's physician order and plan of care. In addition, the facility's wound nurse was not aware that the wound had re-opened.Findings include:The facility's Pressure Injuries and Non-Pressure Injuries policy, revised 7/20/22, indicates: .For those residents admitted with or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote integrity. The following protocols should guide prevention and treatment efforts, unless otherwise specified by a physician .2. Weekly: a. Complete a head-to-toe skin check and document findings on the skin review .If new areas are present: Notify Medical Doctor (MD) and resident's responsible party; Initiate treatment per order .Update plan of care; Discuss during shift-to-shift report process; Review with Interdisciplinary Team (IDT). Assess current wounds at least every seven days or more frequently as needed (e.g., decline in wound, presence of infection, wound healed). If a wound fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident's overall clinical condition should be re-assessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions. Results may vary depending on the resident's overall condition and interventions/treatments used. The complexity of the resident's condition may limit responsiveness to treatment or tolerance for certain treatment modalities. The clinicians, if deciding to retain the current regimen, should document the rationale for continuing the present treatment to explain why some, or all, of the planned interventions remain relevant despite little or no apparent healing .On 8/11/25, Surveyor reviewed R6's medical record. R6 had diagnoses including type 2 diabetes with neuropathy, venous stasis wound to lower left extremity (chronic and open), and chronic pain syndrome. R6's Minimum Data Set (MDS) assessment, dated 6/12/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 had intact cognition.A care plan, dated 6/12/25, indicated R6 had an alteration in skin integrity related to impaired mobility, left lower extremity venous ulcers, and an open area on the left posterior lower leg. The care plan indicated R6's skin would remain intact, free from erythema, breakdown, excoriation, or bruising until the next review.R6 had an order to wash the left posterior lower leg with normal saline or wound cleanser, apply Xeroform to the wound bed, cover with an ABD pad, and secure with Kerlix daily and as needed (PRN) every morning for wound care.A non-pressure weekly tracker, dated 2/22/25, indicated R6 had a new skin concern (venous stasis wound) on the left lower leg acquired in-house that measured 2 centimeters (cm) x 2 cm with superficial depth.A non-pressure weekly tracker, dated 2/26/25, indicated the wound was healing nicely.A non-pressure weekly tracker, dated 3/5/25, indicated the wound was healed and closed.No further non-pressure weekly trackers were completed after 3/5/25 for R6's left lower extremity wound.A weekly skin assessment, dated 3/17/25, indicated R6 had an open area on the left lower extremity. Weekly skin reviews from 3/17/25 to 4/7/25 indicated R6 had an open area on the left lower extremity.Weekly skin assessments, dated 4/14/25 and 4/21/25, indicated R6 had a skin tear. The assessments did not contain the location or measurements of the skin tear.A skin assessment, dated 4/21/25, indicated R6 had an open area on the left lower extremity.Weekly skin assessments from 4/21/25 to 8/5/25 indicated R6 had an open area on the left lower extremity but did not contain measurements, physician notification, treatment changes, or documentation of healing or signs/symptoms of infection.On 8/11/25 at 10:06 AM, Surveyor interviewed R6 who indicated R6 had open wounds on the left leg that staff cleaned and dressed daily. Surveyor noted enhanced barrier precautions (EBP) were not in place for R6. R6 indicated staff attempted to do R6's dressing change that morning, however, R6 requested staff complete the dressing change later in the day because when staff repositioned R6 for the dressing change, it caused pain in R6's hip.On 8/12/25 at 10:49 AM, Surveyor interviewed R6 who indicated staff had not completed R6's wound care yet but would be there shortly.On 8/12/25 at 11:26 AM, Surveyor interviewed Resident Care Management Director (RCMD)-D who was also the facility's wound nurse and completed wound rounds with the physician on Wednesdays for open wounds. RCMD-D indicated R6's left lower extremity venous stasis wound was healed and stated floor staff completed weekly wound care for R6 for a closed wound that required care.On 8/12/25 at 2:37 PM, RCMD-D approached Surveyor and indicated RCMD-D reviewed R6's medical record which contained unclear documentation as to whether R6's wound was open. RCMD-D stated RCMD-D removed R6's left lower extremity bandages and confirmed R6's left lower extremity venous stasis wound was open. RCMD-D and Surveyor went to R6's room where RCMD-D completed wound care and noted the wound measured 5.8 cm x 5.2 cm and contained 30% skin and 70% granulation. RCMD-D indicated R6 was placed on precautions for the open wound. RCMD-D confirmed RCMD-D was not aware the wound had reopened after it healed in March and was not aware EBP should have been initiated prior to 8/12/25. RCMD-D indicated RCMD-D would follow R6's wound care, complete weekly non-pressure wound trackers, and complete weekly wound rounds with the physician. At that time, R6 indicated staff had informed R6 that the wound had reopened, however, R6 was unable to remember the date.On 8/13/25 at 8:01 AM, Surveyor interviewed Infection Preventionist (IP)-E who confirmed the facility's policy indicates EBP should be initiated when a resident develops a chronic open wound. IP-E verified an open or re-opened venous stasis wound is considered a chronic wound and EBP should be initiated at the time the wound is discovered or re-opened. On 8/13/25 at 8:57 AM, Surveyor interviewed RCMD-D who confirmed R6 had a left lower extremity venous stasis wound that started on 2/22/25 and was monitored by RCMD-D and the wound physician. RCMD-D indicated prior to 8/12/25, RCMD-D was not informed that the wound had reopened. RCMD-D indicated nursing staff had a meeting approximately a month ago that included training on a new process to ensure RCMD-D was informed of new open areas or wounds that had re-opened. RCMD-D indicated the mailbox outside RCMD-D's office labeled Skin is where nursing staff put weekly skin assessments or information regarding new or re-opened wounds. RCMD-D indicated RCMD-D spoke to nursing staff while completing R6's MDS assesment who indicated R6's wound was healed. RCMD-D confirmed R6's medical record and skin assessments did not indicate when R6's wound re-opened. RCMD-D confirmed better communication regarding skin concerns was the reason for the staff meeting and training on the new process to better monitor and ensure appropriate wound care is provided.On 8/13/25 at 10:36 AM, Nursing Home Administrator (NHA)-A provided Surveyor with training materials for the new process to ensure efficient communication regarding skin concerns. The training materials included a calendar that indicated when weekly skin trackers should be completed for residents who required them. NHA-A indicated all nursing staff were trained and confirmed the training took place on 6/23/25 as indicated on the employee sign-in sheet. NHA-A verified staff did not follow the procedures put in place to ensure appropriate and timely treatment for R6.

Based on observation, staff interview, and record review, the facility did not ensure care and treatment was provided to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R7) of 3 sampled residents.R7 had multiple healed wounds, including a stage 1 pressure injury on the coccyx, and had an unhealed abrasion on the left scapula. During observations on 8/12/25 and 8/13/25, R7's air mattress was not set to the appropriate setting. Findings Include: The facility's Pressure Injuries and Non-Pressure Injuries policy, dated 7/20/22, indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive treatment, care, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The following protocols should guide prevention and treatment efforts, unless specified by a physician otherwise .2. Develop interventions based on individual risk factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, end of life/Hospice, resident choice/preference, or medications that may impact healing. From 8/11/25 to 8/13/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including moderate protein calorie malnutrition, congestive heart failure, spondylosis, and polyneuropathy. R7 had an activated Power of Attorney (POA) and received Hospice services. R7's Minimum Data Set (MDS) assessment, dated 7/21/25, indicated R7 was dependent on staff for transfers, eating, hygiene, and toileting and had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R7 had severely impaired cognition. R7's medical record indicated R7 acquired a stage 1 pressure injury to the coccyx on 6/22/25 (currently healed), an abrasion to the right scapula on 6/16/25 (currently healed), a skin tear to the right elbow (currently healed), and an abrasion to the left scapula on 8/10/25. A care plan, dated 6/26/25, indicated R7's air mattress should be set at 75-100 pounds. A physician order, dated 6/26/25, stated to check function and settings of the air mattress every shift and indicated the air mattress should be set at 75-100 pounds every shift for pressure reduction. On 8/12/25 at 10:57 AM and 11:50 AM, Surveyor observed R7 in bed and noted R7's air mattress was set at 300 pounds. On 8/13/25 at 7:53 AM, Surveyor observed R7 in bed and noted R7's air mattress was set at 300 pounds. On 8/13/25 at 10:41 AM and 3:14 PM, Surveyor interviewed Resident Care Management Director (RCMD)-D who verified R7's air mattress was set at 300 pounds but should be set at 75-100 pounds. RCMD-D indicated a Hospice Certified Nursing Assistant (CNA) increases the setting when they get R7 out of bed and forgets to put it back to the correct setting. RCMD-D indicated R7's air mattress was initiated on 5/12/23. RCMD-D was unsure of the setting when the air mattress was initiated and stated the setting may have changed when Hospice became involved on 1/25/25. RCMD-D verified R7's physician order indicated the air mattress should be set at 75-100 pounds.

Based on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R22) of 2 sampled residents.R22 had an order for continuous positive airway pressure (CPAP) for obstructive sleep apnea. The facility did not clean R22's CPAP machine per manufacturer's instructions.Findings include:The facility's undated Oxygen Administration policy indicates: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences .7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment .d. CPAP mask - The mask is part of a system that allows a resident to receive continuous positive airway pressure, with or without an artificial airway. The system is comprised of a mask, tubing, and a machine that generates a constant flow of air pressure .10. Equipment includes a selection from the following: .d. Humidity bottle and tubing .The facility's CPAP Therapy policy, dated 6/24/22, indicates Continuous positive airway pressure is used to treat obstructive sleep apnea. The goals of this therapy include: improve ventilation, improve quality of sleep, decrease hospitalization, improve cognitive function, improve oxygen saturation during sleep, decrease work of breathing and improve lung compliance .Follow these steps for cleaning your CPAP patient circuit: .3) With a soft cloth, gently wash mask or pillows with a solution of warm water and a mild clear liquid detergent; 4) Rinse thoroughly ; 5) Allow the mask or pillows to air dry; .8) Clean the CPAP unit as necessary; 13) Filter maintenance .; 15) Disposable filter should be replaced per manufacturer's recommendations .The Air Fit ResMed Mask User Guide indicates: Cleaning your mask: Mask and headgear should only be handwashed by gently rubbing in warm (approximately 86 Fahrenheit (F)/30 Celsius (C)) water using mild soap. All components should be rinsed well with drinking quality water and allowed to air dry out of direct sunlight .Daily/After each use: Disassemble the mask components according to the disassembly instructions. Handwash the separated mask components (excluding headgear and soft sleeves). To optimize the mask seal, facial oils should be removed from the cushion after use. Use a soft bristle brush to clean the vent. Inspect each component and, if required, repeat washing until visually clean. Rinse all components well with drinking quality water and allow to air dry out of direct sunlight. When all components are dry, reassemble according to the reassembly instructions. Disposable filter to be replaced monthly.Harvard Health Publishing of Harvard Medical school, dated 10/8/19, indicates: A CPAP machine is one of the best treatments for people with obstructive sleep apnea, a condition that causes you to stop breathing periodically during sleep. The pauses in sleep occur when muscles in the throat relax so much that they block the airway. CPAP keeps your airway open. The CPAP system consists of a small bedside pump that pushes a forceful stream of air through a tube and into a mask you wear while you sleep. Bacteria and mold can accumulate in different parts of the device .Given that the mask, tubing, and other components are breathed into and deliver air throughout the night, their cleanliness can be a serious health concern. Daily cleaning removes dangerous microbes, mold, dust, and debris .CPAP machines are humid and often warm, making them the perfect home for mold, bacteria, viruses, and other harmful microbes. Cleaning your CPAP components regularly washes these microbes away and prevents them from reaching dangerous levels, but neglecting your CPAP machine's hygiene can lead to both acute and chronic respiratory conditions.On 8/11/25, Surveyor reviewed R22's medical record. R22 had diagnoses including obstructive sleep apnea, diffuse traumatic brain injury with loss of consciousness of unspecified duration, acute and chronic respiratory failure with hypoxia, and acute and chronic respiratory failure with hypercapnia. In April of 2025, R22 was diagnosed with pneumonia. R22's Minimum Data Set (MDS) assessment, dated 5/13/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R22 had intact cognition. A care plan, dated 5/13/25, indicated R22 used a CPAP machine per MD order and had/was at risk for respiratory impairment related to history of aspiration and sleep apnea. R22 had the following orders: ~ Change oxygen tubing and humidifier bottles weekly. Date tubing one time a day every Sunday for infection control and as needed for visibly soiled or known contamination (start date 6/15/25).~ CPAP filters change one time a day every month starting on the 10th for 1 day (start date 12/10/23).~ Daily Cleaning .Wipe the portion of the mask that comes in contact with your skin with a damp cloth or alcohol free wipe. This removes most skin oil from the mask. Empty any remaining water from the humidifier chamber. Fill the chamber with soapy warm water and shake vigorously. Rinse the chamber with clean water. Air dry. Everyday shift. (Start date 5/22/23). On 8/11/25 at 9:28 AM, Surveyor interviewed R22 who indicated R22 used a CPAP machine with oxygen nightly. R22 was unsure when the CPAP mask and filter were last cleaned or changed and indicated the mask was dirty. Surveyor noted R22 used a ResMed 10 air sense machine. The mask appeared oily and contained white matter. The mask was next to the machine on R22's bedside table and the humidifier was connected to the machine. Surveyor also noted the CPAP filter was black and the filter's housing unit contained a ring of black particles. The machine was connected to an oxygen concentrator that contained tubing dated 8/4. Surveyor reviewed R22's August 2025 Treatment Administration (TAR) and noted the following: ~ On 8/3/25 and 8/11/25, change and date oxygen tubing was documented as completed.~ On 8/10/25, change CPAP filter was not documented as completed. There was no documentation that indicated the filter was changed in August of 2025.Surveyor reviewed R22's July 2025 TAR and noted the following: ~ On 7/10/25, change CPAP filter was documented as completed. On 8/11/25 at 2:55 PM, Surveyor observed R22's CPAP machine in the same position and in the same condition with tubing still dated 8/4.On 8/12/25 at 8:28 AM, Surveyor observed R22's CPAP in the same condition and noted the CPAP humidifier was empty, contained visible humidity in the chamber, and was connected to the machine. On 8/12/25 at 1:10 PM, Surveyor interviewed Registered Nurse (RN)-C who confirmed R22's oxygen tubing was dated 8/4 and had not been changed per R22's orders. RN-C indicated night (NOC) shift staff or whoever completes the AM medication pass usually cleans the CPAP machine and mask and removes the humidifier and allows the parts to air dry. RN-C confirmed R22' CPAP machine was not cleaned and the filter and tubing were not changed as ordered and was unsure when the filter was last changed or if R22 had supplies. RN-C indicated RN-C would locate supplies and ensure the daily cleaning and filter change were completed. On 8/12/25 at 1:20 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B would check when the last time supplies were ordered and would provide Surveyor with orders for monthly filter changes and daily cleaning in accordance with the facility's policy.

Based on observation, staff and resident 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 for 2 residents (R) (R27 and R28) of 8 sampled residentsR27 had an open chronic wound. Enhanced barrier precautions (EBP) were not implemented for R27.R28 had an indwelling urinary catheter. EBP was not initially implemented for R28. After EBP was implemented on 8/12/25, Surveyor observed staff provide care without donning the appropriate personal protective equipment (PPE). Findings include: The facility's Enhanced Barrier Precautions policy, revised 8/8/24, indicates: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs) .2. Initiation of EBP: .B. An order for EBP will be initiated for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, peripherally inserted central catheters (PICCs), hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes even if the resident is not known to be infected or colonized with an MDRO .Personal protective equipment (PPE) (i.e., gowns and gloves) for EBP is only necessary when performing high-contact care activities .4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, h. Wound care: any chronic skin opening requiring a dressing .1. From 8/11/25 to 8/13/25, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] and had diagnoses including pressure ulcer of right heel stage 3, pressure ulcer of sacral region stage 2, and type 2 diabetes. R27's Minimum Data Set (MDS) assessment, dated 7/31/25, had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated R27 had intact cognition.On 8/11/25 at 10:33 AM, Surveyor noted R27's room did not contain an EBP sign or a PPE cart near the entrance.On 8/11/25 at 10:33 AM, Surveyor interviewed R27 who indicated R27 had an open wound on the foot and staff provided daily wound care. Surveyor noted there was not an EBP sign or PPE cart near the entrance to R27's room. On 8/12/25, Surveyor reviewed R27's plan of care and Kardex (an abbreviated care plan used by nursing staff) which did not indicate R27 was on EBP.On 8/12/25 at 7:28 AM, Surveyor interviewed R27 who indicated R27 received a shower and wound care that morning. Surveyor noted there was not an EBP sign or PPE cart near the entrance to R27's room.R27's medical record contained an order that indicated: Iodosorb External Gel 0.9 % (Cadexomer Iodine) apply to right heel topically once daily. Cleanse with sodium chloride (NaCl), apply ointment to wound bed, methylene blue foam to cover, ABD then Kerlix, tubigrip (start date 8/7/25 at 7:00 AM). (Surveyor noted R27 did not have an order for EBP.)On 8/12/25 at 9:40 AM, Surveyor interviewed Infection Preventionist (IP)-E who indicated a resident with an open chronic wound should be on EBP.On 8/12/25 at 11:23 AM, Surveyor reviewed R27's orders and noted a new order for EBP that read: Enhanced barrier precautions (due to) heel wound (start date 8/12/25 at 2:00 PM). On 8/13/25 at 6:59 AM, Surveyor noted an EBP sign on the wall near the entrance to R27's room and a PPE cart outside the room. On 8/13/25 at 8:01 AM, Surveyor interviewed IP-E who indicated R27 was put on EBP. IP-E verified R27 had a wound and should have been put on EBP prior to 8/12/25. IP-E indicated IP-E was unaware of R27's wound prior to 8/12/25 and indicated any nurse, including the wound nurse, could have and should have put R27 on EBP for the open wound. IP-E indicated R27's wound care could have been completed without the use of EBP because EBP wasn't implemented when the wound was first observed. On 8/13/25 at 11:38 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated a resident with an open chronic wound should be on EBP.On 8/13/25 at 1:47 PM, Surveyor interviewed Resident Care Management Director (RCMD)-D who was also the facility's wound nurse. RCMD-D indicated R27 should have been on EBP for the wound. RCMD-D indicated RCMD-D used standard precautions during R27's wound care, however, EBP should have been in place.2. From 8/11/25 to 8/13/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] and was readmitted on [DATE] with an indwelling urinary catheter after a hospital stay. R28 had diagnoses including hydronephrosis, chronic kidney disease, urinary retention, and urinary device. R28's MDS assessment, dated 6/20/25, had a BIMS score of 4 out of 15 which indicated R28 was severely cognitively impaired.A progress note, dated 8/11/25 at 9:17 PM, indicated R28 returned to the facility with a Foley catheter and was on an antibiotic for a possible urinary tract infection.On 8/12/25 at 7:34 AM, Surveyor interviewed Unit Manager (UM)-G who indicated R28 returned from the hospital the previous evening, had a catheter, and should be on EBP. On 8/12/25 at 7:35 AM, Surveyor noted there was not an EBP sign or PPE cart near the entrance to R28's room.On 8/12/25 at 7:39 AM, Surveyor observed R28 in the main dining room and noted R28's uncovered catheter bag was hung from the lower part of R28's wheelchair.On 8/12/25 at 8:39 AM, Surveyor observed R28 in the dining room eating breakfast and noted R28's catheter bag was not covered with a dignity bag.On 8/12/25 at 9:19 AM, Surveyor observed an EBP sign and PPE cart near the entrance to R28's room.On 8/12/25 at 9:35 AM, Surveyor interviewed UM-G who was unsure when EBP was implemented for R28. On 8/12/25 at 9:40 AM, Surveyor interviewed IP-E who implemented EBP for R28 at 8:15 AM that morning. IP-E indicated EBP should have been implemented as soon as R28 returned from the hospital on 8/11/25. IP-E indicated staff would have completed catheter care, personal care, and a transfer before putting R28 to bed on8/11/25 and would have emptied R28's catheter bag and got R28 up and dressed at a minimum on 8/12/25 since R28 was readmitted . IP-E indicated it was difficult to know if staff used EBP during cares but indicated it was unlikely since there was not an EBP sign or PPE cart near R28's room. IP-E indicated nurses can and should implement EBP right away for a resident with a catheter. IP-E also indicated catheter bags should be covered for infection control and privacy.On 8/12/25 at 9:51 AM, Surveyor observed R28 in R28's room with an uncovered catheter bag under R28's wheelchair.On 8/12/25 at 9:55 AM, Surveyor observed R28 self-propel down the hallway with an uncovered catheter bag under R28's wheelchair.On 8/12/25 at 9:57 AM, Surveyor interviewed Registered Nurse (RN)-H who confirmed R28's catheter bag should contain a privacy cover.On 8/12/25 at 10:01 AM, Surveyor observed R28 in the dining room with an uncovered catheter bag under R28's wheelchair.On 8/12/25 at 11:33 AM, Surveyor observed Physical Therapy Assistant (PTA)-I in R28's room. R28 was in bed and PTA-I indicated PTA-I was going to get R28 up. Surveyor observed PTA-I remove R28's catheter bag from the side of the bed and hang the bag from R28's walker with a bare hand. Surveyor observed PTA-I help R28 move R28's feet toward the side of the bed. Another staff walked by at that time and verbally reminded PTA-I that PTA-I should use PPE because R28 was on EBP. Surveyor observed PTA-I exit the room and view the EBP sign and PPE cart near the entrance to R28's room. On 8/12/25 at 11:35 AM, Surveyor interviewed PTA-I who was not aware that R28 was on EBP prior to the observation and didn't see the EBP sign or PPE cart. PTA-I verified PTA-I should have donned PPE before touching R28's catheter bag or starting to transfer R28. On 8/12/25 at 11:38 AM, Surveyor interviewed DON-B who indicated a resident with a catheter should be on EBP. DON-B indicated if EBP was not implemented, it was an oversight. DON-B indicated staff should not handle a catheter bag and complete high-contact cares without wearing the appropriate PPE.

Based on staff interview and record review, the facility did not implement their written policy and procedure to prevent abuse, neglect, injuries of unknown origin, and misappropriation of resident property for 1 (Certified Nursing Assistant (CNA)-C) of 8 staff reviewed for caregiver background checks. CNA-C's background check information indicated CNA-C was convicted of disorderly conduct in 2022 and 2025. The facility did not request a copy of CNA-C's criminal complaint, judgement of conviction, or relevant court and police documents as instructed by the Background Information Disclosure (BID) form and Department of Health Services (DHS) memo P-00274 Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility. Findings include: DHS memo P-00274 Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility for Chapter 50 Programs, dated 4/2020, contains the following information: This document lists Wisconsin crimes and other offenses that the Wisconsin State Legislature, under the Caregiver Law, Wis. Stat. S 50.065, has determined require rehabilitation review approval before a person may receive regulatory approval, work as a caregiver, reside as a non-client resident at, or contract with an entity .Additional information must be obtained when: The BID or Department of Justice (DOJ) response indicates a conviction of any of the following, where the conviction occurred five years or less from the date on which the information was obtained .6. Disorderly conduct .These convictions do not prohibit employment, but do require the entity to obtain the criminal complaint and judgment of conviction from the Clerk of Courts office in the county where the person was convicted. The facility's Caregiver Background Checks policy, revised August 2017, contains the following information: A reported history of criminal activity will be reviewed by the Human Resources Department for further consideration of hiring decisions. On 2/27/25, Surveyor reviewed background check information for 8 sampled staff, including CNA-C who began employment at the facility on 7/25/23 and completed a BID form on 1/6/25. CNA-C's Department of Justice (DOJ) letter indicated CNA-C was convicted of disorderly conduct on 3/17/22 and 1/6/25. Surveyor noted CNA-C's background check information did not include a judgement of conviction or information related to the criminal complaints. On 2/27/25 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated the facility did not request additional information related to CNA-C's disorderly conduct convictions in 2022 and 2025. NHA-A verified all staff require a full background check prior to employment at the facility.

Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R4) of 18 sampled residents. On 2/27/25, R4 was observed self-administering medication. During the observation, R4 dropped pills in R4's bed and was unable to find them. R4 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R4 could self-administer medication. Findings include: The facility's Medication Administration Self-Administration by Resident policy, dated January 2023, indicates: Residents who desire to self-administer medication are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. Procedures: 1. If the resident desires to self-administer medication, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process . On 2/27/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including diabetes, weakness, chronic pain, and hypertension. R4's Minimum Data Set (MDS) assessment, dated 12/15/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 was not cognitively impaired. R4's medical record indicated R4 was responsible for R4's healthcare decisions. R4's medical record indicated R4 had a change in condition on 2/26/25 and was prescribed normal saline .9% 1 liter intravenously every shift for dehydration and was placed on 2 liters of oxygen via nasal cannula to maintain an oxygen saturation level above 90%. On 2/27/25 at 9:23 AM, Surveyor observed R4 attempt to self-administer medication from a cup placed on R4's table. Surveyor noted R4 had difficulty retrieving pills from the medication cup. R4 spilled three pills into R4's bed linens and was unable to find them. R4 indicated R4 always self-administers medication. R4's medical record did not contain a physician's order to self-administer medication or a self-administration of medication assessment that indicated R4 could safely and accurately self-administer medication. On 2/27/25 at 12:51 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a resident should have a physician's order and a self-administration of medication assessment completed prior to self-administering medication. DON-B verified R4 did not have an order to self-administer medication or a self-administration of medication assessment that indicated R4 could safely and accurately self-administer medication. On 2/27/25 at 12:56 PM, Surveyor interviewed Registered Nurse (RN)-D who verified RN-D left a cup of medication on the table for R4 to self-administer. RN-D indicated R4 can usually self-administer medication without difficulty. On 2/27/25 at 2:51 PM, Surveyor interviewed RN-D who indicated RN-D should not have left medication with R4 due to R4's change in condition. RN-D verified R4 did not have a physician's order to self-administer medication or a self-administration of medication assessment.

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 31 residents residing in the facility. Procedures for reheating food in a microwave were not followed. Cooling temperature logs were not completed for leftover and pre-made food. Cold food items were not maintained at a proper temperature during meal service. Staff did not complete appropriate hand hygiene during meal service. Findings include: On 6/17/24 at 9:47 AM, Surveyor conducted an initial tour of the kitchen. Surveyor interviewed Dietary Manager (DM)-N who stated the facility follows the Federal Food and Drug Administration (FDA) Food Code as its standard of practice and uses a contracted provider for dietary services. Reheating Procedures: The 2022 FDA Food Code documents at 3-403.11 Reheating for Hot Holding (B): .Time/Temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees Fahrenheit (F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. The facility's contracted service's Food: Preparation policy, dated February 2023, states all foods are prepared in accordance with the FDA Food Code. The policy also states when reheating, food will be rapidly heated to 165 degrees F for 15 seconds. On 6/18/24 at 11:53 AM, Surveyor observed lunch service. Surveyor observed [NAME] (CK)-O heat a bowl of tomato soup in the microwave for approximately 30 seconds. CK-O then asked a nursing staff to remove the bowl from the microwave and serve it to a resident. Surveyor observed the nursing staff remove the bowl from the microwave and serve it to a resident without stirring or checking the temperature. On 6/18/24 at 1:48 PM, Surveyor interviewed CK-O who confirmed the temperature of the tomato soup was not checked prior to serving. CK-O stated CK-O knows the soup is hot enough when CK-O can see steam. CK-O was not aware CK-O should check the temperature of microwave heated foods prior to serving. CK-O was also not aware what temperature the soup should be before serving and that CK-O should wait two minutes before serving. Food Cooling Log: The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 C (Celsius) (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The facility's contracted service's Food: Preparation policy, dated February 2023, states all foods are prepared in accordance with the FDA Food Code and cooks are responsible for food preparation techniques which minimize the amount of time food items are exposed to temperatures greater than 41 degrees F and/or less than 135 degrees F, or per state regulation. The policy also states prepared hot food items not intended for immediate service will be cooled using the following guidelines: Place in shallow pans or cut/slice to promote rapid cooling, Time/Temperature Control for Safety (TCS) foods will be cooled from 135 degrees F to 70 degrees F within 2 hours and from 70 degrees F to 41 degrees F within 4 hours. The total cooling time cannot exceed 6 hours with the clock starting at 135 degrees F. During an initial tour of the kitchen on 6/17/24 at 9:47 AM, Surveyor observed a container of ravioli. DM-N stated the ravioli was left over from a previous meal. Surveyor reviewed the kitchen's cooling log and noted the ravioli was not documented on the log. DM-N confirmed the ravioli should be documented on the cooling log. On 6/18/24 at 11:38 AM, Surveyor interviewed Regional Dietary Manager (RDM)-M who stated the facility does not usually keep leftovers and verified pre-made food items should be documented on the cooling log. RDM-M stated the facility has a new cook who was not aware of the documentation procedures for cooling logs. RDM-M stated education was completed with all staff on the importance of completing the cooling log. During an observation of lunch service on 6/18/24, at 11:53 AM, Surveyor observed a container of cold macaroni salad. CK-O stated CK-O made the salad the previous day and placed it in the cooler overnight. CK-O stated CK-O separated the salad into separate smaller containers and left the containers to cool, then placed them in an ice bath prior to placing the macaroni salad in the cooler. CK-O verified CK-O did not document the macaroni salad on the cooling log. RDM-M confirmed the macaroni salad should have been documented on the cooling log. Surveyor reviewed the ingredients for the macaroni salad which included elbow noodles, green onions, green peas, celery, canned red peppers, sweet pickled relish, mayo salad dressing, salt, and garlic salt. Holding Temperatures: The 2022 FDA Food Code documents at 3-501.16 Time/Temperature Control for Safety Food (TCS), for hot and cold holding: Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth (A) Except during preparation, cooking, or cooling, or when time is used as the public health control .(1) At 135 degrees F or above or (2) At 41 degrees F or less. On 6/18/24 at 11:53 AM, Surveyor observed lunch service. Surveyor observed cold macaroni salad that was removed from the cooler and placed on top of ice next to hot foods on the steam stable. CK-O took the initial temperature which was 42.3 degrees F for the regular texture macaroni salad and 48 degrees F for the pureed macaroni salad. CK-O then placed the salads in the freezer for 5 minutes. CK-O removed the salads from the freezer and temped the salads which were 39 degrees F for the regular texture macaroni salad and 41 degrees F for the pureed macaroni salad. CK-O stated the temperature should be 41 degrees F or less for cold foods. Lunch service began at 11:53 AM and ended at 1:03 PM. Following the last tray served, Surveyor asked CK-O to take the temperature of the macaroni salad which was 50.2 degrees F. CK-O confirmed the temperature was outside of the appropriate temperature for cold food holding. Hand Hygiene: The 2022 FDA Food Code documents at 2-301.14: Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. The 2022 FDA Food Code documents at 3-301.11 Preventing Contamination from Hands indicates: (A) Food employees shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. The facility's contracted service's Food: Preparation policy, dated February 2023, states staff will practive proper hand washing techniques and glove use, and dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. On 6/18/24, at 11:53 AM, Surveyor observed tray line lunch service. At the beginning of service, Surveyor observed CK-O don gloves without completing hand hygiene. With gloved hands, CK-O untied and opened a bag of hot dog buns, removed a steam table cover, picked up a plate, removed a hot dog bun, and used both gloved hands to open the bun. CK-O used tongs to put the hot dog in the bun. With the same gloved hands, CK-O touched a macaroni salad container, a bag of chips, and a meal ticket and placed items on a tray. Surveyor observed CK-O follow the same procedure for 9 resident meal trays until RDM-M intervened and educated CK-O on the proper procedure for handling ready-to-eat food. RDM-M instructed CK-O to complete hand hygiene and retrieve additional tongs. CK-O completed hand hygiene and returned to the steam table with tongs. RDM-M instructed CK-O to don a glove on the left hand and use tongs in the right hand to remove a bun from the bag. RDM-M instructed CK-O not to touch any surfaces, other than the bun, with CK-O's gloved left hand. During the remainder of tray line service, Surveyor observed CK-O touch three plates, serving utensils, and the bag of hot dog buns on four occasions without removing the left glove and completing hand hygiene. Following the observation, Surveyor interviewed RDM-M who confirmed Surveyor's observation and verified gloves should be changed after touching contaminated surfaces. RDM-M also confirmed hand hygiene should be completed before re-gloving.

Based on staff interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R24 and R10) of 5 sampled residents. R24 experienced a fall due to an improper sling size for a sit-to-stand (STS) lift when only one staff was present during the transfer. R10 experienced pain due to an improper sling size for a STS lift when only one staff was present during the transfer. Findings include: The facility's Safe Resident Handling and Transfers policy, dated 8/5/22, indicates: .8. The facility will ensure there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per the manufacturer's instructions on proper sling sizing .10. Two staff members must be utilized when transferring residents with a mechanical lift .14. Resident lifting and transferring will be performed according to the resident's individual plan of care . The manufacturer's Patient Sling Reference Guide recommendations, dated 2007, indicate: Available sling sizes are P, medium, large, extra-large, and XXL and states sling size and fit can vary significantly depending on patient weight and girth. 1. From 6/17/24 to 6/19/24, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including hemiparesis (paralysis on one side of the body) following cerebral infarction (otherwise known as stroke) affecting the left dominant side, weakness, and recurrent left hip dislocation. R24's Minimum Data Set (MDS) assessment, dated 5/18/24, documented R24's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R24 had intact cognition. R24's care plan indicated R24 had an activity of daily living (ADL) self-care deficit related to physical limitations and left hemiparesis. The care plan contained an intervention, initiated on 11/30/22 and discontinued on 1/2/24, that stated to transfer R24 with a STS lift with a standard size sling and the assistance of two staff. The care plan indicated after 1/2/24, staff should use a full mechanical lift to transfer R24. On 6/18/24, Surveyor reviewed a Witnessed Fall Report, dated 5/18/24. In the report, Certified Nursing Assistant (CNA)-G indicated R24 let go of the STS lift handles and R24's arm slipped through the sling when R24 was being toileted. The report indicated R24's fall was slow and controlled. R24 did not hit R24's head during the fall and did not complain of pain after the fall. On 6/18/24 at 1:46 PM, Surveyor interviewed CNA-G regarding R24's fall on 5/18/24. CNA-G stated at the time of the fall, CNA-G used the STS lift alone without the assistance of a second staff. CNA-G was aware of the facility's policy that two staff were needed for mechanical lift transfers but stated a second staff was not available at the time. CNA-G was aware the lift had different size slings and stated the sling used for R24 on was too loose. CNA-G stated R24 slid out of the sling and CNA-G assisted R24 to the floor in a slow and controlled manner. CNA-G stated CNA-G did not know how to determine the correct size sling to use and did not know how to choose an appropriate sling for a resident. On 6/18/24 at 1:55 PM, Surveyor interviewed CNA-F and CNA-H. CNA-F and CNA-H stated sling size is determined by a resident's weight. CNA-F and CNA-H were unsure if sling size is listed in residents' care plans. CNA-F showed Surveyor a standard size sling. Surveyor noted the sling contained an extra large manufacturer's label. CNA-F referred to the weight limit tag on the sling which stated the sling was safe up to 450 pounds. CNA-F stated there were no residents over 450 pounds and the sling was appropriate for all residents. CNA-F stated CNA-F adjusts the straps if the sling is too loose for a resident. On 6/19/24 at 11:43 AM, Surveyor interviewed R24 who described the incident on 5/18/24 when R24 fell from a STS lift. R24 stated R24 fell out of the lift because the sling was too large. On 6/19/24 at 11:46 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-K who stated CNAs decide which sling to use with each resident. LPN-K stated LPN-K did not know how to determine the correct sling size. On 6/19/24 at 11:48 AM, Surveyor interviewed Registered Nurse (RN)-L who stated RN-L refers to the manufacturer's guide to choose the sling size based on the resident's weight. RN-L stated Director of Nursing (DON)-B records the proper sling size in the residents' care plans. On 6/19/24 at 11:52 AM, Surveyor interviewed RN-J who stated RN-J refers to manufacturer's guidance, the sling size listed in the care plan, and weight sizes on slings to choose a sling size for a resident. RN-J did not know who was responsible for documenting sling sizes in residents' care plans. 2. From 6/17/24 to 6/19/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including hemiparesis following cerebral infarction affecting the right dominant side and morbid obesity. R10's MDS assessment, dated 5/14/24, indicated R10's BIMS score was 15 out of 15. R10's care plan, dated 5/29/24, stated R10 had an ADL self-care deficit with right sided weakness and physical limitations. The care plan contained interventions for maximum assistance with toileting with a STS lift and two staff during waking hours and transfer with STS lift with the assistance of two staff with an Invacare standard size sling. On 6/17/24 at 12:12 PM, Surveyor interviewed R10 who described an incident that occurred in the last month when CNA-I assisted R10 to the bathroom with a STS lift. R10 stated the sling was too small and caused pain in R10's arms. On 6/18/24 at 10:25 AM, Surveyor interviewed CNA-E who verified R10 transfers to the toilet with a STS lift. CNA-E stated if R10 is lifted with a standard size sling, the sling pinches R10's arms and causes pain. CNA-E stated R10 requires a size larger than the standard size sling. CNA-E stated each unit has a STS lift and a standard size sling is kept with the lift and used for most residents. During the interview, CNA-E took Surveyor to a closet in the central dining area where lift slings were stored. CNA-E could not locate the size sling CNA-E stated R10 needed. On 6/18/24 at 10:39 AM, Surveyor interviewed DON-B who stated DON-B expects two staff to be present for mechanical lift transfers and the appropriate sized sling to be used. On 6/18/24 at 11:08 AM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A who were unaware R10 experienced pain due to an incorrect size lift sling. On 6/18/24 at 3:34 PM, Surveyor interviewed NHA-A who investigated R10's report of pain with a mechanical lift transfer. NHA-A's investigation indicated CNA-I used a STS lift without a second staff present. NHA-A stated NHA-A expects staff to determine which sling to use based on the manufacturer's recommendations. NHA-A stated the sling size should be evaluated by a nurse or physical therapist and documented in the resident's care plan. On 6/19/24 at 11:38 AM, Surveyor interviewed R10 who used a STS lift for all out-of-bed activities. R10 stated R10 preferred to have larger size sling when transferred with the STS lift. R10 stated staff use a smaller size sling multiple times per week. R10 stated the smaller sling puts pressure on R10's arms and causes pain. On 6/19/24 at 12:55 PM, Surveyor interviewed NHA-A who stated there are no specific staff responsible for choosing sling sizes. NHA-A stated staff should check the resident's care plan or manufacturer's instructions posted at the nurses' station to determine the correct sling size for each resident.

Based on staff interview and record review, the facility did not ensure the required Minimum Data Set (MDS) assessment data was transmitted timely for 3 residents (R) (R45, R46 and R47) of 4 residents reviewed for MDS completion. Two of R45's MDS assessments, both dated 1/30/24, did not have completed transmissions as of 6/17/24. Two of R46's MDS assessments, dated 11/29/23 and 12/15/23, did not have completed transmissions as of 6/17/24. Two of R47's MDS assessments, both dated 7/2/23, did not have completed transmissions as of 6/17/24. Findings include: Chapter 5 of Centers for Medicare & Medicaid Services' (CMS') Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual dated October 2023 (for use Effective October 1, 2023) indicates: Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare or Medicaid-certified beds regardless of the payer source .When the transmission file is received by iQIES, the system performs a series of validation edits to evaluate whether or not the data submitted meet the required standards. MDS records are edited to verify that clinical responses are within valid ranges and are consistent, dates are reasonable, and records are in the proper order with regard to records that were previously accepted by iQIES for the same resident. The provider is notified of the results of this evaluation by error and warning messages on a Final Validation Report. All error and warning messages are detailed and explained in the Error Messages guide .Providers must transmit all sections of the MDS 3.0 required for their state-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements .Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date . 1. On 6/17/24, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. R45 had a planned discharge to the community on 1/30/24. R45's medical record contained a completed, but not accepted, Medicare 5 Day MDS assessment, dated 1/30/24. In addition, R45's medical record contained a completed, but not accepted, Discharge Return Not Anticipated MDS assessment, dated 1/30/24. 2. On 6/17/24, Surveyor reviewed R46's medical record. R46 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD). R46 had a planned discharge to the community on 12/15/23. R46's medical record contained a completed, but not accepted, Medicare 5 Day MDS assessment, dated 11/29/23. In addition, R46's medical record contained a completed, but not accepted, Discharge Return Not Anticipated MDS assessment, dated 12/15/23. 3. On 6/17/24, Surveyor reviewed R48's medical record. R48 was admitted to the facility on [DATE] with diagnoses including COPD. R48 passed away at the facility on 7/2/23. R48's medical record contained a completed, but not accepted, End of PPS Part A Stay MDS assessment, dated 7/2/24. In addition, R48's medical record contained a completed, but not accepted, Death in Facility MDS assessment, dated 7/2/24. On 6/18/24 at 10:32 AM, Surveyor interviewed Registered Nurse (RN)-C who stated RN-C started as the MDS nurse in December of 2023 and was still in training. RN-C stated regional staff were responsible for the transmission of MDS assessments. On 6/18/24 at 10:41 AM, Surveyor interviewed Director of Clinical Reimbursement (DCR)-D who verified regional staff were responsible for the transmission of MDS assessments. DCR-D stated the process was completed within the facility's electronic medical record (EMR) system and DCR-D had access to the iQIES system. Following a review of the above scenarios, DCR-D verified the above listed MDS assessments showed completed only and transmission was not complete/accepted. DCR-D stated, We should have caught it when it closed. DCR-D further stated, It was a coding error on our end. When asked if DCR-D checked iQIES for missing assessment reports, DCR-D indicated DCR-D had not.

Based on staff and resident interview and record review, the facility did not make a prompt effort to thoroughly investigate and resolve grievances for 1 Resident (R) (R1) of 5 sampled residents. On 2/15/24, R1 expressed grievances during a meeting with staff and Ombudsman (OMB)-C. The grievances were not investigated or resolved. Findings include: The facility's Grievance/Complaint Report, with a revised date of 1/2020, indicates: This form is utilized to provide written documentation of any grievance or complaint expressed or filed by a resident or resident representative as well as to record the follow-up action taken and results thereof . On 3/13/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), bipolar disorder (a serious mental illness characterized by extreme mood swings), schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and major depressive disorder. R1's Minimum Data Set (MDS) assessment, dated 12/7/24, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had no cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decisions. On 3/13/24 at 10:10 AM, Surveyor interviewed R1 who indicated R1 expressed care concerns during a meeting on 2/15/24 regarding staff not providing incontinence care timely or frequently enough and hurrying through cares. R1 indicated R1 saw no improvement and did not receive any resolution from the facility. R1 stated R1 expressed additional concerns on 3/9/24 which staff stated they were acting on. On 3/13/24, Surveyor reviewed R1's medical record which did not contain documentation of a meeting on 2/15/24. On 3/13/24, Surveyor reviewed the facility's grievances which did not contain documentation of the concerns R1 expressed on 2/15/24 and 3/9/24. On 3/13/24 at 1:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility had one grievance from R1 which the facility was still working on. On 3/13/24, Surveyor reviewed a Grievance/Complaint Report, dated 3/9/24, that indicated: .(R1) notes not being toileted/changed as often as (R1) would prefer. (R1) requested CNA (Certified Nursing Assistant) get items from vending machine and (R1) had to wait a long time to get requested items .(NHA-A) met with (R1) on 3/11/24 to learn of concerns. (R1) prefers to be changed every 2-3 hours and is comfortable being woken up to have care .(NHA-A) met with CNAs and nursing staff to update on requests and (change) of care plan. Education provided on POC (Point of Care) charting to ensure knowledge of charting cares provided more than once per shift .Investigation initiated and re-education initiated and is ongoing. Attached documents included a call light audit tool, proof of staff education, and R1's care plan updates. On 3/13/24 at 1:55 PM, Surveyor interviewed OMB-C via phone. OMB-C indicated OMB-C attended a meeting on 2/15/24 with R1, Director of Nursing (DON)-B, and the facility's Social Worker (SW). OMB-C indicated R1 expressed concerns that staff rushed through cares and did not change R1 frequently enough which R1 feared could lead to urinary tract infections (UTIs). OMB-C indicated OMB-C followed up with an email to DON-B and received a response. On 3/13/24, Surveyor reviewed emails between OMB-C and DON-B, dated 2/23/24, that indicated: (from OMB-C to DON-B) .I just wanted to follow up and see how things are going since our meeting last week for (R1). Has anything new come up? Are items (R1) discussed in the meeting being addressed as discussed? Just looking for some follow up information .and (from DON-B to OMB-C) .(R1) continues with the same complaint/concerns about (R1's) care and (R1's) roommate's care. I have provided education to the individuals (R1) named as well as all staff. I have not received any new concerns, just a repeat of the same conversation. We will continue to educate staff about meeting all of the residents' needs . On 3/13/24 at 2:10 PM, Surveyor interviewed DON-B who indicated DON-B participated in the meeting via phone on 2/15/24 with R1, OMB-C and the facility's SW. DON-B indicated discussions occurred regarding R1's concerns of not being toileted or changed and staff rushing and not doing cares the way R1 liked and regarding the facility educating staff on R1's care needs. DON-B indicated a discussion also occurred regarding R1's choice to purchase products that were usually provided by the facility, but R1 preferred specific brands. DON-B indicated R1 would praise specific staff one minute then complain of (same staff) the next. DON-B stated DON-B did not document the meeting and thought the SW would do so. DON-B indicated when DON-B hung up, the SW later told DON-B that R1, OMB-C and the SW continued to discuss the same concerns over and over. On 3/13/24 at 2:45 PM, Surveyor interviewed DON-B who indicated the facility did not have documentation of the meeting on 2/15/24. When asked what the facility did in response to the concerns expressed by R1, DON-B indicated the facility scheduled OMB-C to come at the end of March to provide resident rights training for staff. On 3/13/24 at 2:59 PM, Surveyor interviewed NHA-A who verified the facility did not have documentation that any of the concerns expressed by R1 on 2/15/24 were investigated or addressed by the facility.

Based on staff interview and record review, the facility did not ensure 1 Certified Nursing Assistant (CNA) (CNA-C) of 5 CNAs had a valid Certified Nursing Assistant Certification. CNA-C's Certified Nursing Assistant Certification was not active because CNA-C had a substantiated finding of neglect on 6/28/22. Despite the substantiated finding of neglect, CNA-C continued to work at the facility after 6/28/22. Findings include: On 7/12/23, Surveyor requested CNA-C's background check and CNA registry information. On 7/12/23, Surveyor reviewed CNA-C's Certified Nursing Assistant Certification from https://wi.tmuniverse.com which indicated CNA-C had a substantiated finding of neglect on 6/28/22. Due to the substantiated finding on file, CNA-C cannot work as a caregiver in Department of Health Services (DHS) regulated facilities in Wisconsin, except those specifically approved under the rehabilitation review process. When CNA-C was hired at the facility on 1/3/23, the facility accepted a CNA registry from a staffing agency, dated 3/10/22, and did not review the current registry before the facility allowed CNA-C to start work on 1/3/23. On 7/12/23, the facility provided CNA-C's schedule and/dates the facility paid CNA-C's staffing agency when CNA-C worked. The schedule/dates the facility paid the staffing agency included when CNA-C worked on the 100, 200, and 600 units. CNA-C worked at the facility with a substantiated finding of neglect on 3/2/23, 3/6/23, 3/11/23, 3/16/23, 3/20/23, 3/21/23, 3/22/23, and 3/28/23 even though CNA-C was not allowed to work as a caregiver in DHS regulated facilities. On 3/28/23, a resident reported an allegation of physical abuse that involved CNA-C. On 4/11/23, the facility was advised that CNA-C was not allowed to work in DHS regulated facilities due to a substantiated finding of neglect on 6/28/22. On 7/12/23 at 2:33 PM, Surveyor interviewed Scheduling Coordinator (SC)-E who verified CNA-C worked at the facility with a substantiated finding of neglect. SC-E stated going forward, SC-E reviews the staffing agency computerized background checks, including the CNA registry, for every new agency employee to ensure CNAs do not have substantiated findings. SC-E verified the facility does not complete their own check of the CNA registry to make sure a CNA is eligible to work in a federally certified nursing home prior to allowing a CNA to work at the facility. On 7/12/23 at 3:35 PM, Surveyor interviewed [NAME] President of Success (VPS)-F who stated the facility is expected to check the status of a CNA on the CNA registry prior to allowing the CNA to work in the facility as opposed to checking what the agency has documented online.

Based on staff interview and record review, the facility did not implement written policies and procedures to prohibit mistreatment, neglect and abuse of residents for 2 staff (Certified Nursing Assistant (CNA)-C and Registered Nurse (RN)-D) of 8 staff reviewed during the caregiver program compliance check. CNA-C was hired on 1/3/23. The facility did not have a completed Background Information Disclosure (BID) form for CNA-C. RN-D was hired on 2/27/23. The facility did not have a Department of Justice (DOJ) letter for RN-D. Findings include: The facility's Abuse Prohibition Policies and Procedures, revised 7/15/22, stated the facility will provide protections for the health, welfare and rights of each resident by developing and implementing written polices and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. One of the components of the policy included screening of potential employees. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulation. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement. Screenings may be conducted by the facility itself, third-party agency or academic institution. The facility will maintain documentation of proof that the screening occurred. 1. On 7/12/23, Surveyor reviewed background check information for CNA-C. The facility did not have a BID form for CNA-C and was unable to get CNA-C's BID form from CNA-C's staffing agency who also did not have a completed BID form for CNA-C. 2. On 7/12/23, Surveyor reviewed background check information for RN-D. The facility did not have a DOJ letter for RN-D until the facility printed the DOJ letter from the agency website on 7/12/23. On 7/12/23 at 2:33 PM, Surveyor interviewed Staffing Coordinator (SC)-E regarding a BID form for CNA-C and a DOJ letter for RN-D. SC-E stated the facility was unable to obtain a BID form from CNA-C's staffing agency and the facility did not attempt to have CNA-C fill out a BID form. On 5/6/23 after CNA-C no longer worked at the facility, SC-E was advised to look through background checks for agency staff to ensure all parts of the background check were completed as required. SC-E went through all background checks and missed RN-D's DOJ letter. SC-E stated, Printed it (DOJ letter) today (7/12/23). Hopefully, didn't miss another one. In addition, SC-E indicated SC-E was advised on 6/9/23 that background checks do not need to be printed, but need to be verified as reviewed. SC-E stated printing the information was how SC-E verified the background checks were reviewed.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R48) of 3 sampled residents reviewed for falls had adequate assistive devices and interventions in place to prevent accidents. R48 was at risk for falls. R48's care plan contained interventions for the assistance of one staff and a gait belt for transfers. R48 had a functional maintenance program (FMP) from therapy that was not given to nursing or incorporated in R48's plan of care. The FMP indicated R48 was to be transferred with a front wheeled walker in addition to a gait belt. R48 was transferred without a front wheeled walker and/or gait belt twice. R48 fell twice on R48's right leg below-the-knee post amputation surgical site and required two additional surgeries to close the site. Findings include: The facility's Fall Prevention and Management Guidelines policy, revised on 11/8/22, indicated each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. A diagnosis of a loss of limb may contribute to an increase in falls or increased risk of injury, should a fall occur. When a resident experiences a fall, the facility will review the resident's care plan and update with any new interventions put in place to try to prevent additional falls. Each fall will be reviewed with the interdisciplinary team (IDT). Actions of the IDT may include additional revisions to the plan of care including assistive devices and education of staff as to any care plan revisions. 1. On 4/4/23, Surveyor reviewed R48's medical record. R48 was admitted to the facility for short-term rehab with a diagnosis of below-the-knee amputation (BKA) of the right leg. R48's five day Minimum Data Set (MDS) assessment, dated 3/20/23, indicated R48's cognition was intact. R48 required extensive assistance of two plus staff for transfers, did not ambulate, and required limited assistance from two plus staff for toileting. R48's balance was not steady, and R48 required staff assistance to stabilize. R48 had one fall since admission. On 4/4/23, Surveyor reviewed R48's plan of care, last revised on 3/3/23. R48's plan of care indicated R48 had an activities of daily living (ADL) self-care deficit related to right BKA. An intervention initiated on 3/3/23, with a revision date of 3/28/23, indicated R48 was to transfer with the assistance of one staff and a gait belt. Another intervention, initiated on 3/27/23 and revised on 3/28/23, indicated R48 was to use a two wheeled walker (front wheeled walker) and one assist for transfers, and a gait belt. On 4/4/23, Surveyor reviewed R48's post fall assessment. The post fall assessment indicated on 3/19/23, Licensed Practical Nurse (LPN)-L was assisting R48 with transferring from the wheelchair to the toilet when R48's left leg gave out. LPN-L was able to get R48 to the toilet, but R48's right leg surgical wound hit the floor. R48 was sent to the Emergency Department (ED) for evaluation. R48's surgical wound was sutured, and R48 returned to the facility. The notes on the post fall assessment stated the IDT met on 3/20/23 and indicated physical therapy (PT) would reinforce the need for use of the two wheeled walker with all transfers and a gait belt. The post fall assessment indicated R48's plan of care was reviewed and updated. On 4/4/23, Surveyor reviewed R48's Critical Event Worksheet with a discovery date of 3/28/23. The summary stated R48 fell on [DATE] when LPN-L transferred R48 without a gait belt and R48's amputation site reopened during the incident. R48 was sent to the hospital, required sutures at the amputation site, and returned to the facility following the procedure. Systemic measures to prevent recurrence included staff education on following the care plan and Kardex (an abbreviated care plan often used by Certified Nursing staff) for the transfer status of residents and stated five staff members will be audited per week for four weeks. On 4/4/23, Surveyor reviewed R48's post fall assessment which stated on 3/27/23, Certified Nursing Assistant (CNA)-M was transferring R48 from the toilet to the wheelchair with a gait belt when R48 fell to the floor in the bathroom. R48's right leg amputation stump made contact with the floor when R48's leg gave out/slipped. R48 was sent to the ED for evaluation. On 4/4/23, Surveyor reviewed a statement written by CNA-M regarding R48's fall on 3/27/23. CNA-M documented CNA-M and a nurse assisted R48 onto the toilet on the morning of 3/27/23. When CNA-M assisted R48 off the toilet, CNA-M helped R48 stand by using a gait belt and bars in the bathroom. R48's foot lost grip on the floor and R48 went down on the toilet seat. On the way down, R48's amputation stump bumped the floor of the bathroom. R48's care plan stated R48 required the assistance of one staff with transfers and toileting. A progress note, dated 3/27/23 at 11:20 AM, stated when CNA-M assisted R48 off of toilet, R48's left foot lost footing and R48 fell backwards onto the toilet. R48 was holding the assistance bars in the bathroom on the left side and leaned to the right bumping R48's amputation stump on the floor. The notes on the post fall assessment indicated the IDT met on 3/28/23 and determined CNA-M followed R48's plan of care with one assist and use of a gait belt. R48's toilet transfer status changed to sit-to-stand lift and physical therapy was to continue working with R48 toward independence. R48's care plan was updated. On 4/4/23, Surveyor reviewed R48's hospital records. The records indicated R48 had a right BKA on 2/27/23 and fell on [DATE] when R48 was transferred at the facility without a gait belt. R48 had right leg pain and was diagnosed with traumatic wound dehiscence. A dressing was placed on the wound and Keflex (an antibiotic) was started until R48 could have surgery to close the wound. On 3/23/23, Orthopedic Surgeon (OS)-O completed irrigation, debridement, and re-closure of the right BKA traumatic wound dehiscence. In addition, the hospital records indicated R48 was admitted to the hospital on 3/27/23 for right leg suture site pain after falling at the facility a second time and was again diagnosed with traumatic wound dehiscence. OS-O again completed irrigation, debridement, and re-closure of the right BKA traumatic wound dehiscence. On 4/4/23 at 12:51 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R48's falls. With the first fall on 3/19/23, it was noted therapy notes indicated R48 should be transferred with a two wheeled walker and a gait belt. LPN-L did not use a two wheeled walker or gait belt when LPN-L transferred R48. LPN-L and other staff were educated starting on 4/3/23. The intervention to use a two wheeled walker and gait belt with transfers was not added to R48's care plan until 3/28/23 after R48's second fall. On 4/4/23 at 1:13 PM, Surveyor interviewed [NAME] President of Success (VPS)-C regarding R48's falls. VPS-C verified R48's care plan was not updated with a two wheeled walker until after the second fall on 3/27/23. VPS-C stated someone did not update the care plan. On 4/4/23 at 1:58 PM, Surveyor interviewed LPN-L who stated LPN-L was educated regarding R48's fall on 3/19/23 and verified LPN-L did not use a gait belt or front wheeled walker when transferring R48. The education provided was to follow therapy guidelines of using a two wheeled walker when transferring R48. On 4/4/23 at 2:03 PM, Surveyor interviewed Occupational Therapist (OT)-K who verified R48 progressed rapidly to use a two wheeled walker with the assistance of one staff. A FMP was documented in R48's medical record on 3/17/23 to use a front wheeled walker (two wheeled walker) with the assistance of one staff and a gait belt for all transfers. On 4/4/23 at 2:10 PM, Surveyor interviewed Director of Nursing (DON)-B regarding education provided to staff after R48's falls. DON-B verified education was only provided for LPN-L. DON-B stated the education for other staff began after the survey started on 4/3/23 and was ongoing. The education included where to locate the Kardex for proper knowledge of resident needs and requirements for safe transfer, and fall risk reduction. The objectives included how to identify where the Kardex is located and how to access the Kardex, identification of when a gait belt should be used, the protocol for observed changes in resident needs, and how to indicate and place interventions on a resident's care plan and Kardex. On 4/4/23 at 3:30 PM, Surveyor interviewed NHA-A who stated NHA-A was not able to provide the FMP from 3/17/23 for R48 which indicated R48 was to use a front wheeled walker for transfers as indicated by OT-K. The front wheeled walker was documented in R48's medical record, but Director of Rehab (DOR)-N stated to NHA-A staff must not have made a copy of it. Staff would not know a two wheeled walker was needed to transfer R48 unless they read it in the computer. On 4/4/23 at 3:57 PM, Surveyor interviewed OS-O via telephone. OS-O stated the need for irrigation, debridement and re-closure of R48's right BKA surgical site was caused by a direct blow to the area from the falls. OS-O verified the irrigation, debridement and re-closure occurred twice within four days because with the first fall, an on-call physician saw R48 but wanted OS-O to look at the wound since OS-O performed the amputation. The wound was bandaged and when OS-O returned from vacation, OS-O checked the wound and completed the surgery. The second surgery was completed by OS-O right away after R48 fell . Education was not completed timely for staff after R48 fell the first time on 3/19/23 and did not include therapy staff who did not provide nursing with R48's FMP. Education was not completed timely for R48's second fall on 3/27/23 and again did not include therapy staff who did not provide nursing with R48's FMP to use a wheeled walker with transfers.

Based on observation and resident and staff interview, the facility did not ensure call lights were within reach for 2 Residents (R3 and R25) of 17 residents reviewed. R3 was observed on multiple occasions in R3's room without a call light within reach. R25 was observed without a call light within reach in R25's room. Findings include: R3 was admitted to the facility on [DATE] and had diagnoses of cerebral palsy and anxiety disorder. R3's Minimum Data Set (MDS) assessment, dated 1/18/23, contained a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R3 had severe cognitive impairment. R3's MDS also indicated R3 did not have upper extremity (shoulder, elbow,wrist, and hand) impairment. R25 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. R25's Significant Change MDS assessment, dated 2/4/23, indicated R25 was rarely or never understood. R25's MDS also indicated R25 did not have upper extremity impairment. Between 4/3/23 and 4/5/23, Surveyor made the following observations: ~On 4/3/23 at 10:24 AM, Surveyor entered R3's room to interview R3 who stated R3 wanted a cup of coffee. Surveyor noted R3's call light was on the bed and not within R3's reach. Surveyor exited the room and informed Certified Nursing Assistant (CNA)-J that R3 wanted a cup of coffee and R3's call light was out of reach. CNA-J stated the call light should be near R3, moved the call light within R3's reach and obtained a cup of coffee for R3. ~On 4/3/23 at 2:13 PM, Surveyor observed R3 in R3's room in a wheelchair facing the door. Surveyor noted R3's call light was on the bed and not within R3's reach. ~On 4/3/23 at 4:08 PM, Surveyor observed R3 in the same location in R3's roomand noted R3's call light was not within reach. ~On 4/5/23 at 10:46 AM, Surveyor observed R25 in a wheelchair in R25's room with a bedside table in front of R25. Surveyor noted R25's call light was not within reach. On 4/5/23 at 11:06 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expected call lights to be within residents' reach when residents are in their rooms.

Based on observation, staff interview, and record review, the facility did not ensure care plan interventions were followed for 2 Residents (R) (R33 and R2) of 17 residents reviewed. R33 had care plan interventions for a splint on the left hand and a pillow under R33's right arm. The interventions were not consistently implemented. R2 had care plan interventions for padded side rails and bed in a low position. The interventions were not consistently implemented. Findings include: The facility's Comprehensive Care Plan policy, revised on 9/23/22, contained the following information: It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .8. Staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions initially and when changes are made. 1. R33 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy. R33's Minimum Data Set (MDS) assessment, dated 3/5/23, indicated R33 was rarely or never understood which indicated R33 had severe cognitive impairment. R33's MDS also indicated R33 had range of motion (ROM) impairments to both upper and lower extremities. R33 had an activities of daily living (ADL) self-care deficit care plan related to cerebral palsy and bilateral upper extremity contractures. The care plan contained an intervention for a pillow under R33's right arm when in Broda chair and a nursing/restorative intervention, initiated on 1/17/23, for: Splint/brace program left hand resting splint. On in AM. Off HS (evening). 1st strap; over knuckles and between thumb and index finger. 2nd strap; over wrist. 3rd strap; over forearm. Monitor skin prior to applying splint and with removal of splint. Keep splint dry and clean. Between 4/3/23 and 4/5/23, Surveyor made the following observations: ~On 4/3/23 at 1:16 PM, Surveyor observed R33 in a Broda chair in the solarium without a splint on the left hand or a pillow under the right arm. ~On 4/4/23 at 10:14 AM, Surveyor observed R33 in a Broda chair in R33's room without a splint on the left hand or a pillow under the right arm. ~On 4/4/23 at 4:20 PM, Surveyor observed R33 in a Broda chair in the solarium without a splint on the left hand or a pillow under the right arm. ~On 4/5/23 at 9:42 AM, Surveyor observed R33 in a Broda chair in the solarium without a splint on the left hand or a pillow under the right arm. On 4/4/23 at 2:16 PM, Surveyor interviewed Occupational Therapist (OT)-K who stated R33 was discharged from therapy on 1/12/23 with goals to tolerate resting splint without signs or symptoms of skin breakdown in order to maintain passive ROM and to demonstrate improvement in right upper extremity (RUE) (hand) and left upper extremity (LUE) (hand) medicarpal phalangeal (MP) joint (finger) extension. OT-K stated R33's right hand did not need a splint, but R33 should wear a splint on the left hand daily. R33 stated when R33 was in therapy, R33 tolerated the splint. 2. R2 was admitted to the facility on [DATE] with diagnoses of spastic hemiplegia cerebral palsy, functional quadriplegia, severe intellectual disability, and unspecified convulsions. R2's MDS assessment, dated 2/17/23, indicated R2 was rarely or never understood which indicated R2 had severe cognitive deficits. R2 had an ADL self-care deficit care plan related to decreased functional mobility, physical limitations due to contractures, and total assistance for all cares. R2's plan of care contained an intervention for a safety device of 2-1/2 assist rails for limited mobility due to cerebral palsy, hemiparesis, and contractures. Related interventions included: Padded assist rails while in bed; Ensure proper positioning with proper body alignment while using safety device; Observe for effectiveness of safety devices. In addition, R2 had a falls care plan related to impaired balance that contained interventions for bed in low position and attempt to keep call light within reach. Between 4/3/23 and 4/5/23, Surveyor made the following observations: ~On 4/3/23 at 12:48 PM, Surveyor observed R2 in bed. Surveyor noted R2's bed was not in the low position and R2's side rails were not padded. Immediately following the observation, Surveyor asked Certified Nursing Assistant (CNA)-G if R2's bed should be in the low position. CNA-G stated CNA-G was new and asked another CNA if R2's bed should be in the low position. CNA-G then stated CNA-G thought the bed should probably be in the low position and lowered the bed. ~ On 4/4/23 at 10:09 AM, Surveyor observed R2 in bed. Surveyor noted R2's bed was not in the low position and R2's side rails were not padded. On 4/3/23 at 9:55 AM, Surveyor interviewed CNA-G who stated CNA-G was an agency CNA and this was CNA-G's second time working in the facility. Surveyor asked CNA-G how CNA-G knew or was informed of residents' care needs. CNA-G pulled out a resident roster that contained residents' names and room numbers. CNA-G told Surveyor CNA-G wrote notes on the sheet for some of the main things. Surveyor reviewed the sheet with CNA-G and noted there were only 3 care items identified on the sheet. If a resident required a Hoyer lift, H was handwritten next to their name. If a resident needed a shower, Shower was written next to their name. If CNA-G needed to record urinary output for a resident, that was handwritten on the sheet also. CNA-G stated CNA-G took the basics and asked questions if needed. On 4/3/23 at 4:29 PM, Surveyor interviewed agency CNA-E who stated CNA-E worked in the facility a couple of times and doesn't see care plans or a Kardex (a brief summary of a resident's care needs that often includes fall interventions, diet information, restorative care, transfer status and activities of daily living (ADL) needs, etc.). When asked how CNA-E knows residents' care needs, CNA-E stated CNA-E asks what CNA-E needs to know for the residents and writes it down. When asked if Surveyor could see the sheet CNA-E follows, CNA-E told Surveyor the sheet was in CNA-E's bag, but since CNA-E worked a couple of shifts at the facility, CNA-E was pretty familiar with the residents. When Surveyor asked how CNA-E is notified of changes between shifts, CNA-E stated CNA-E gets the changes in shift report from the nurse. On 4/5/23 at 11:06 AM, Surveyor informed Nursing Home Administrator (NHA)-A of Surveyor's observations and that agency staff were not using a Kardex or printed care plans to care for residents. NHA-A stated NHA-A expected all staff to implement care plan approaches per residents' care plans.

Based on observation and staff interview, the facility did not ensure medications were dispensed and administered in accordance with the facility's self-administration policy for 1 Resident (R) (R22) of 17 residents. Surveyor observed a medication cup that contained 2 white oblong pills on R22's bedside table. R22 did not have an assessment for self-administration of medication or a physician's order to self-administer medication. Findings include: The facility's Self-Administration of Medications policy, revised in January 2018, contained the following information: If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. R22 was admitted to the facility on [DATE] and had diagnoses of spastic hemiplegic cerebral palsy, insomnia, chronic pain syndrome, and major depressive disorder. R22's Minimum Data Set (MDS) assessment, dated 1/11/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R22 had mild cognitive impairment. R22 had an activated Power of attorney for Healthcare (POAHC). On 4/3/23, Surveyor reviewed R22's medical record and noted the following order: ~ Acetaminophen (Tylenol) 500 mg (milligrams) Give 2 tablets QID (4 times a day) for general pain. On 4/3/23 at 12:29 PM, Surveyor interviewed R22 who was resting in bed. Surveyor observed a medication cup on R22's bedside table that contained 2 white oblong pills. R22 stated the medication was Tylenol and was provided by a nurse. On 4/3/23, Surveyor reviewed R22's medical record which did not contain a self-administration of medication assessment or a physician's order to self-administer medication. On 4/3/23 at 12:43 PM, Surveyor interviewed Registered Nurse (RN)-H who stated R22 did not have a self-administration of medication assessment. RN-H said RN-H left the Tylenol for R22 to take when R22 wanted because R22 was slow in taking medication that morning. RN-H stated R22 would not pass a self-administration of medication assessment due to R22's cognition. On 4/4/23 at 12:35 PM, Surveyor interviewed Director of Nursing (DON)-B who stated medication should not be left at the bedside unless a resident has a self-administration of medication assessment and a physician's order to do so.

Based on record review and staff interview, the facility did not ensure a physician was notified in a timely manner when 1 Resident (R2) of 1 resident experienced a significant change in condition. R2 was admitted to the facility following an episode of pancreatitis and was being monitored for an increased white blood cell count. On 9/11/21, CNA (Certified Nursing Assistant)-D reported stool came out of R2's vagina during peri-care. LPN (Licensed Practical Nurse)-C assessed R2 and stated stool came out of R2's vagina and rectum simultaneously. LPN-C faxed MD (Medical Doctor)-E; however, MD-E did not receive the fax and follow up was not completed. When FM (Family Member)-G asked MD-E on 9/15/21 why R2 was not sent to the hospital sooner, MD-E completed a pelvic exam, confirmed the presence of stool and instructed staff to send R2 to the ER (emergency room ). R2 spent five days in the hospital, received IV (intravenous) antibiotics and was discharged with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to consult with a physician in a thorough and timely manner related to a change in condition that resulted in a finding of Immediate Jeopardy that began on 9/11/21. NHA (Nursing Home Administrator)-A was notified of the Immediate Jeopardy on 10/06/21 at 10:30 AM. The jeopardy was removed on 10/06/21; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: According to the World Health Organization, [CONDITION(S)] is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. It is frequently a final common pathway to death for many infectious diseases worldwide. It involves organ dysfunction caused by a disarticulated host response to infection and if not recognized early and managed promptly, it can lead to septic shock, multiple organ failure and death [CONDITION(S)] is a medical emergency and can present with various signs and symptoms at different times. Warning signs and symptoms include: fever or low temperature, altered mental status, difficulty breathing and rapid breathing, increased heart rate, weak pulse/low blood pressure, low urine output, cyanotic or mottled skin, cold extremities and extreme body pain or discomfort. In 2017, the largest contributors to [CONDITION(S)] cases and [CONDITION(S)]-related mortality across all ages were diarrheal diseases On 10/05/21, the Surveyor reviewed R2's medical record. R2 was admitted to the facility for short-term rehab following hospitalization for acute pancreatitis (inflammation of the pancreas) with deconditioning. R2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Admission MDS (Minimum Data Set), dated 9/05/21, indicated R2 was cognitively impaired, incontinent of bowel and bladder and required extensive assistance for toileting and personal hygiene. R2's plan of care stated R2 had a self-care deficit due to pancreatitis and physical limitations and contained interventions to assist R2 with daily hygiene. R2's plan of care also stated R2 was incontinent of bowel and bladder and contained interventions to provide incontinence care, record bowel movements and report abnormalities including changes in frequency, consistency and control. An APNP (Advance Practice Nurse Practitioner) progress note, dated 9/07/21, stated R2 had bowel movements every other day. R2's medical record did not contain documentation of a change in consistency or frequency. A hematology report, dated 9/08/21, indicated R2's WBC (white blood cell) count was 12.1 (12,100 wbcs (white blood cells) per microliter of blood). (The normal range is between 4,000 and 11,000 white blood cells per microliter of blood). A hematology report, dated 9/13/21, indicated R2's WBC count was 12.7. A late entry progress note, dated 9/11/21 at 3:13 PM but written on 9/17/21 at 3:17 PM, stated LPN-C was called to R2's room after CNA-D observed bowel contents coming from R2's vagina. The note stated R2 was in a side-lying position and stool was puddling from her vagina and continued to puddle after she was cleaned. The note stated MD-E was notified via fax. FM-G was notified as well. R2 was afebrile (without fever) and reported no additional concerns. The note stated there was no response from MD-E during the shift. A progress note, dated 9/12/21, stated Stool from vagina monitored. A progress note, dated 9/13/21 at 11:44 AM, stated NP (Nurse Practitioner)-J noted lab results and ordered labs to be repeated on 9/15/21. A progress note on 9/13/21 at 12:52 PM, stated R2 was [CONDITION(S)] (a rapid heartbeat that may be regular or irregular) and assessed by NP-J with an order to continue to monitor. The notes on 9/13/21 did not indicate NP-J was notified of or assessed R2 for stool in the vagina. A progress note, dated 9/14/21, stated, UA (urinalysis) (a urine test) (noted by (MD-E). NNO (no new orders). The note did not indicate MD-E was notified of or assessed R2 for stool in the vagina. A progress note, dated 9/15/21 at 1:18 PM, stated, (MD-E) in to see (R2) regarding elevated WBC. (MD-E) informed of fecal mater coming from (R2's) vagina. Verbal order received to send (R2) to ER for evaluation. (FM-G) contacted by (MD-E) and is waiting for (R2) at the hospital. A progress note at 4:07 PM stated R2 was admitted to the hospital and was receiving IV fluids and antibiotics. A progress note written by MD-E on 9/15/21 stated, (R2's) WBC came back at 22 this morning. It was 12 two days ago. I came to assess her this morning. Nursing staff told me that she looked more pale today. CXR (chest X-ray) and UA were negative earlier this week. Nursing staff asked me if I received a fax from the weekend regarding feces coming out of (R2's) vagina. I did not receive any fax regarding this or hear about it. I also called NP who has been following (R2) very closely and checked if she had known about this but she did not. Over the weekend, two nursing staff witnessed feces coming out from vagina and from anus at the same time. MD-E performed a pelvic exam with a gloved finger and noted feces was easily identified on the glove. R2 stated she was cold, but denied abdominal pain, dysuria, increased frequency or urgency and fever. A hospital history and physical, written by MD-K on 9/15/21, stated R2 presented to the ER for evaluation of feculent (containing dirt, sediment or waste matter) discharge from the vagina. The note stated, (R2's) husband reports that approximately five days ago he was notified by nursing staff at (R2's) skilled nursing facility that (R2) was having feculent discharge from her vagina. (R2's) husband states that the supervising physician was not notified until today when (R2) was transferred to the emergency department. (R2's) physician at the skilled nursing facility, (MD-E), contacted the undersigned MD reporting that (R2) is having feculent discharge from the vagina and (R2) has an up trending WBC to 22,000 earlier today. (R2) is uncertain if she has been having loose or watery stools/diarrhea nor does (R2's) husband know. (R2's) husband states that (R2) appears more confused today . The note also stated an external vaginal exam showed crusted discharge and feces. A speculum exam showed 20 mls (milliliters) of soupy foul-smelling purulent (containing pus) gray/green discharge in the vaginal vault with suction required. The note indicated lab results showed significant leukocytosis (a blood condition in which the white cell count is above normal) at 23.3 and stated, Given (R2's) significant leukocytosis and [CONDITION(S)], (R2) does meet the criteria for [CONDITION(S)] .Given (R2's) markedly abnormal vaginal exam a plan was made to pursue a transvaginal (across or through the vagina) ultrasound. The note also indicated the possibility of an infection was likely due to retained liquid stool secondary to poor hygiene. The note stated R2 would be admitted to the hospital for further treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital discharge summary, dated 9/20/21, listed R2's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary stated R2 presented to the ER with increasing generalized weakness and low-grade fever. The summary also indicated R2 had stool-like material coming out of her vagina for multiple days and was sent to the ER for further evaluation due to suspected [CONDITION(S)] (urinary tract infection). A vaginal exam verified stool in R2's vagina. A CT (computed tomography) scan (a series of X-rays used to produce a three dimensional image of soft tissues and bones) of the abdomen/pelvis did not show evidence of an enterovaginal fistula (an abnormal opening that connects the vagina to another organ, such as the bladder, colon or rectum), but did show liquid stool throughout the colon which raised the possibility of [CONDITION(S)] (inflammation of the colon) or gastroenteritis (infectious diarrhea and/or an inflammation of the gastrointestinal tract). R2 was treated with IV [MEDICATION(S)] (an antibiotic used to treat a wide variety of bacterial infections) for five days prior to discharge. The note stated R2 remained weak and deconditioned and opted to go home with home care services. On 10/05/21 at 10:30 AM, the Surveyor interviewed DON (Director of Nursing)-B regarding R2. DON-B verified LPN-C faxed MD-E upon discovery of the stool on 9/11/21; however, LPN-C sent the fax to the wrong number. DON-B verified MD-E was not aware R2 had stool in her vagina until MD-E arrived at the facility on 9/15/21 to assess R2 due to an increased white blood cell count. On 10/05/21 at 12:00 PM, the Surveyor interviewed LPN-C regarding R2. LPN-C stated CNA-D notified LPN-C that stool came out of R2's vagina during incontinence care on the 9/11/21 AM shift. LPN-C stated, (CNA-D) got me and I watched stool pour out of (R2's) rectum and vagina. LPN-C described the stool as thick black liquid with a foul odor. LPN-C stated R2 was sick, had an increased white blood cell count and didn't feel well. LPN-C stated LPN-C put a gloved finger in R2's vagina and pulled out stool. LPN-C stated LPN-C retrieved MD-E's number from a spread sheet next to the fax machine and faxed MD-E; however, LPN-C later discovered the number was incorrect. LPN-C stated LPN-C put the fax in a folder for follow-up and included the information in twenty four hour report; however, the information got dropped somewhere during LPN-C's subsequent days off. LPN-C verified LPN-C did not write a timely progress note and stated, I didn't do the note like I should have .no excuse for that. I did a late note, though. On 10/05/21 at 1:20 PM, the Surveyor interviewed FM-G via telephone. FM-G stated, Once (R2) got out of the hospital (on 9/20/21), I basically lost my wife .it's not her. FM-G stated R2 was constantly confused and did not consistently recognize FM-G or their children. FM-G verified R2 was admitted to the facility to gain strength and motor skills following hospitalization for pancreatitis, dehydration and malnourishment. FM-G stated the events at the facility that led to R2's second hospitalization affected R2's brain. FM-G stated FM-G was unsure if R2's brain would clear from toxic metabolic [CONDITION(S)]. FM-G expressed concern that R2 sat for five days with poop and pus in her vagina. FM-G stated FM-G was R2's main caregiver for the past six years. FM-G verified FM-G was notified of R2's change of condition on 9/15/21 and was told MD-E was notified as well. FM-G stated, 'I put my trust in (the facility) and thought they were handling it .Nobody followed up with (MD-E). On 10/05/21 at 3:30 PM, the Surveyor interviewed DON-B regarding the facility's physician notification protocol. DON-B stated the facility did not have a protocol for physician notification. DON-B stated if a physician did not respond to a fax, DON-B expected staff to use their best nursing judgement, wait a couple days and call the physician back. DON-B also stated there were folders at the nursing stations for nurses to check and ensure follow-up was completed for faxes. On 10/06/21 at 8:10 AM, the Surveyor interviewed MD-E regarding R2. MD-E verified MD-E was not notified prior to 9/15/21 that R2 had stool in her vagina. MD-E stated MD-E ideally would've wanted to be notified sooner than five days. On 10/20/21 at 9:30 AM, the Surveyor interviewed MD-K regarding R2. MD-K stated MD-K had a difficult time completing R2's vaginal exam due to the amount of the foul-smelling stool in R2's vaginal vault. MD-K initially suspected R2 had a fistula; however, the physical exam showed no signs of an open wound and all scans and tests were negative. MD-K stated MD-K believed the stool acquired in R2's vagina was due to poor hygiene and poor perineal care. MD-K stated there were four criteria for [CONDITION(S)]: increased heart rate, increased respiratory rate, increased white blood cell count and a change in body temperature. MD-K stated in order to be diagnosed as septic, a person needed to meet at least two of the four criteria. MD-K confirmed R2 was [CONDITION(S)] and had an increased white blood cell count which warranted a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MD-K verified R2's [CONDITION(S)] was related to [CONDITION(S)] and indicated with [CONDITION(S)] and diarrhea, R2 was at risk for skin breakdown and increased infection. MD-K also stated R2 presented to the ER with altered mental status, which would previously have led MD-K to classify R2's [CONDITION(S)] as severe; however, guidelines related to the classification of severe [CONDITION(S)] recently changed. MD-K verified a resident with a change in condition that indicated an infection and included a change in mental status should have been evaluated by a physician as soon as possible. MD-K said MD-K could not classify R2's condition as life-threatening when R2 was not assessed by a physician for five days following her change in condition, but stated, You can't be sure if something is life-threatening or not when you don't know what you are dealing with. Regarding FM-G's concern that R2 remained confused, MD-K verified R2 had toxic metabolic [CONDITION(S)]. MD-K stated MD-K could not predict if and when R2's mental faculties would return to baseline. The failure to consult with a physician in a thorough and timely manner related to a change in condition created a finding of Immediate Jeopardy. The facility removed the jeopardy on 10/06/21, when it completed the following: 1. Initiated change of condition education for licensed staff. 2. Developed a shift-to-shift reporting process for any communication to an MD that had not yet received a response. 3. Ensured all phone and fax numbers for MDs and NPs were current.

Based on staff interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (resident #1) of 10 sampled residents. On 10/24/11 resident #1 experienced a change in his cognitive level, as evidenced by intermittent confusion. Furthermore, resident #1 exhibited unsteadiness with transfers. Following a treatment session, PT (Physical Therapist)-B reported a concern with the safety of resident #1's independent use of an electric wheel chair to LPN (Licensed Practical Nurse)-A. LPN-A did not take immediate action to revise resident #1's safety/supervision plan until the use of the scooter and intermittent confusion could be fully assessed to determine safety needs. As a result, resident #1 was assisted back into the electric wheel chair for the lunch meal. Resident #1 propelled the wheel chair back to his room after lunch without supervision and attempted to self-transfer from the scooter. Resident #1 subsequently fell and sustained a fracture of the cervical spine at C4. Findings include: The facility's Risk Reduction Falls and Injuries Program/Procedure, revised January 2009, indicated the facility, "...Communicate interventions during shift report and daily clinical rounds to the caregiving team...review and revise Plan of Care annually, quarterly and with change of condition...". The face sheet, dated 8/24/11 and contained within the medical record, indicated resident #1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The medical record documented resident #1 had been hospitalized from [DATE] to 10/21/11. Resident #1 was re-admitted to the facility on [DATE]. The hospital physician's orders [REDACTED]. The hospital Nursing Transfer/Discharge Summary, dated 10/21/11, documented resident #1 required assistance with transfers and ambulation. The Nursing Comprehensive Admission Data Collection and Assessment, dated 10/21/11, documented resident #1 was alert to person, place and time, and required one staff assistance for bed mobility, transfers, and ambulation in room. The assessment further documented resident #1 was not steady (able to stabilize with assist) for moving from seated to standing, walking, turning around and surface-to-surface transfers. The Resident Lifting, Transferring, and Repositioning Data Collection form, dated 10/21/11, indicated resident #1 transferred with a walker and stand by assistance of staff. Progress notes on 10/21/11, 10/22/11 and 10/23/11 documented resident #1 was alert and oriented (X3) (times three). Progress notes for resident #1, dated 10/24/11 at 4:00 a.m., documented, "Resident more confused this night. Concern about power scooter. Rang several times asking if he was laying on his scooter...asking CNA (Certified Nursing Assistant) does not like him or numerous other statements that are not making sense. Then states 'I am confused'. Now is very concerned that he is confused...". The PT daily note for resident #1, dated 10/24/11, documented, "...frequent instruction for safety (with) tasks-do not get out of bed alone, safety (with) electric w/c (wheel chair)-pt. (patient) running into objects-OT (Occupational Therapy) to assess safety...sit (to) stand (with) min/mod (minimum/moderate) (assist) (with) posterior lean when standing (without) UE (upper extremity) support...". On 10/27/11 at 9:20 a.m. surveyor # interviewed PT-B regarding resident #1 and the fall the resident sustained [REDACTED].#1 on 10/24/11 around 10:00 a.m. PT-B stated, when she entered resident #1's room, the resident was attempting to transfer himself out of bed. PT-B stated she instructed resident #1 he needed to wait for staff assistance, and he indicated he understood. PT-B stated during the treatment session, she became concerned with resident #1's safety with the use of the electric wheel chair. PT-B stated the resident was not negotiating the wheel chair well and rammed into a therapy mat. PT-B indicated that, during a transfer, resident #1 began leaning posteriorly (backwards). PT-B indicated resident #1 was weaker from the last time she worked with him, prior to his hospitalization . After the treatment session was completed, PT-B assisted resident #1 back into his recliner and informed LPN-A of her concerns regarding resident #1's safety maneuvering the wheel chair independently. PT-B stated she spoke with Occupational Therapy and informed staff an evaluation of the use of the electric wheel chair/scooter needed to be completed. The plan of care entitled, "Fall/Injury Assessment: Prevention and Management Plan of Care", dated 8/1/11, documented resident #1 was at risk for falls due to pain, unsteady, osteoarthritis, acute infection, exhaustion, weakness, cardiovascular diagnosis, Alzheimer's, and visual and hearing sensory impairments. The interventions indicated resident #1 required general supervision and assist of one to transfer and ambulate. The plan of care for ADL (Activities of Daily Living)/mobility, dated 8/1/11, documented resident #1 utilized an electric wheel chair and required one assist for ambulation and transfers. No changes were made to the plan of care in relation to the supervision plan for resident #1 following the intermittent confusion and safety concerns related to the electric wheel chair use on 10/24/11. On 10/24/11 at 12:35 p.m. the Accident/Incident Report documented, "Pt. (resident #1) found sitting on floor next to bed he states he was going to the bathroom and didn't want to wait and fell while amb. (ambulating) hit back of head on the floor...". Behaviors exhibited just before the incident were documented as "confused" and "unsteady". The document further indicated resident #1 was more confused and was trying to transfer from the wheel chair to the bathroom. The progress notes at 1:00 p.m. documented resident #1 was transported to the emergency room . The hospital History & Physical, dated 10/25/11, documented resident #1 was transferred for evaluation with Neurosurgery. The history and physical further documented resident #1 had been severely deconditioned from his recent sepsis bacteremia, making him at risk for falls. The hospital discharge summary dated 10/26/11 documented an acute c-spine fracture at C4 endplate fracture, and indicted resident #1 was to wear a brace and neck collar at all times except bathing. Resident #1 returned to the facility on [DATE] at 10:30 p.m. On 10/27/11 at 10:25 a.m. surveyor # interviewed LPN-A regarding resident #1 and the fall the resident sustained [REDACTED]. LPN-A verified she was aware resident #1 had intermittent confusion on 10/24/11. LPN-A verified after the PT treatment session, PT-B reported to her concerns regarding resident #1's use of the electric wheel chair. PT-B indicated resident #1 was not paying attention enough to where he was driving to be using the wheel chair. PT-B indicated OT would be evaluating the safe use of the electric wheel chair for resident #1. LPN-A stated she was not in the building at the time of the fall, but when she returned was informed of the incident. LPN-A verified resident #1 was sent out to the hospital shortly after the fall on 10/24/11. On 10/27/11 at 1:35 p.m. surveyor # interviewed CNA-C regarding resident #1 and the fall the resident sustained [REDACTED]. CNA-C indicated at one point resident #1 called for assistance and was concerned that it was snowing. CNA-C stated she reoriented resident #1, and then he stated he was having a dream. CNA-C stated resident #1 was more confused than normal and had been frequently calling for staff assistance and reassurance. CNA-C stated she reported that change to the nurse. On 10/27/11 at 1:10 p.m. surveyor # interviewed CNA-D regarding resident #1 and the fall the resident sustained [REDACTED].#1 on 10/24/11 during the day shift tour of duty. CNA-D stated she went into resident #1's room prior to lunch to get the resident ready for lunch. Resident #1 was seated in his recliner chair fully clothed. CNA-D offered to assist resident #1 to the bathroom, and he agreed. CNA-D stated resident #1 was confused at that time. CNA-D stated during the transfer resident #1 was "shaky" and seemed to be in a hurry to do things. CNA-D stated resident #1 required more assistance with the transfer than he had in the past, and she had to catch him to prevent him from falling twice during ambulation. CNA-D stated she assisted resident #1 to the toilet then into the electric wheel chair. CNA-D indicated resident #1's confusion did seem to dissipate after toileting. CNA-D stated resident #1 then took himself in the electric wheel chair down to the unit dining room. CNA-D stated she was not aware of any concern regarding resident #1's use of the electric wheel chair/scooter and had not been informed of any changes to his supervision plan. CNA-D stated the next time she saw resident #1 was after he fell , after lunch. CNA-D verified resident #1 was sent to the hospital shortly thereafter. During an interview with surveyor # on 11/1/11 at 8:10 a.m., CNA-D again verified she assisted resident #1 from his recliner to his electric wheel chair on 10/24/11 just before lunch. CNA-D verified she was not aware of any concerns regarding resident #1's electric wheel chair use or any changes to his supervision plan. CNA-D verified after she assisted resident #1 into the electric wheel chair, the resident propelled himself to the dining room without staff assistance. On 10/27/11 at 9:10 a.m. surveyor # interviewed CNA-E regarding resident #1 and the fall the resident sustained [REDACTED].#1 was more confused than he had been prior. CNA-E stated the resident was also more "staggery" with transfers, and needed more physical help. CNA-E stated resident #1 required two assist for transfers in the morning, as he was more confused and not transferring well. CNA-E stated she was not aware of any changes to resident #1's supervision plan or concerns with the use of the scooter or safety due to the increased confusion/unsteadiness. CNA-E stated she was in the unit dining room and saw resident #1 exit and return to his room after lunch. CNA-E verified resident #1 was in his electric scooter and independently went to his room after lunch. CNA-E stated within a matter of minutes she saw the resident's bathroom call light go on, then was summoned to the room by RN (Registered Nurse)-F. CNA-E stated when she entered the room, resident #1 was on the floor near his bed facing the doorway. CNA-E stated the electric wheel chair was in front of the resident, and his walker was off to the side. CNA-E was not aware of any changes to resident #1's supervision plan on 10/24/11. CNA-E verified shortly after the fall, resident #1 was sent to the hospital. On 10/27/11 at 12:55 p.m. surveyor # interviewed Concierge-I regarding resident #1 and the fall the resident sustained [REDACTED].#1 resided on 10/24/11. Concierge-I stated on 10/24/11 around 12:30 p.m. to 12:35 p.m. she noticed resident #1's bathroom light was on, then heard resident #1 yelling for help. Concierge-I stated when she entered resident #1's room, the resident was in the room by himself, and was on the floor. Concierge-I indicated she called for assistance, and RN-F entered the room. On 10/27/11 at 9:32 a.m. surveyor # interviewed RN-F regarding resident #1 and the fall the resident sustained [REDACTED].#1 had fallen. RN-F stated when she entered the room, resident #1 was observed on the floor; and resident #1 was "babbling" and not making sense regarding not wanting to wet. RN-F verified resident #1 reported he attempted to self-transfer from the electric wheel chair, when he sustained a fall. RN-F indicated a full assessment was completed; and when resident #1 complained of hip pain, the resident was subsequently sent to the emergency room for evaluation. On 11/1/11 at 8:55 a.m. surveyor # interviewed LPN-A regarding the safety plan for resident #1 after the concerns were raised by PT-B on 10/24/11. LPN-A stated the plan was that resident #1 was not going to use the electric wheel chair/scooter until after the OT evaluation. LPN-A stated she recalled resident #1 was left in the electric wheel chair after the PT treatment and was not transferred out of the electric wheel chair, so as not to upset the resident prior to lunch. LPN-A stated she thought CNA-D was with her at the time of the discussion with PT-B. LPN-A stated no formal changes were made to the supervision plan but indicated staff should be watching him more closely. LPN-A stated if resident #1 had been transferred out of the electric wheel chair, she would have told the CNAs to remove the scooter/electric wheel chair from the room until after the therapy evaluation for safe use. LPN-A did not recall PT-B informing her of the attempted self-transfer by resident #1 on 10/24/11. On 11/1/11 at 9:00 a.m. surveyor # clarified with CNA-D the events of 10/24/11. CNA-D stated she was not informed by anyone, including LPN-A, about a change in supervision plan for resident #1 and had not been informed of the safety concerns related to the scooter/electric wheel chair use. CNA-D verified just prior to lunch, she transferred resident #1 from the recliner into the scooter. CNA-D verified resident #1 was allowed to utilize the scooter/wheel chair independently to go to lunch. CNA-D verified she was not involved and did not hear the conversation with LPN-A and PT-B. At 9:05 a.m. on 11/1/11 LPN-A stated she needed to clarify her statement to surveyor # . LPN-A stated resident #1 had been taken out of the electric wheel chair and placed in the recliner after the therapy treatment on 10/24/11. LPN-A thought she had communicated to the CNA that the resident shouldn't be in the scooter until further evaluated, but perhaps the CNA did not hear. LPN-A verified she did not directly inform the CNAs of such, but she assumed CNA-D overheard the conversation while at the nurses' desk. LPN-A verified no changes were made to the plan of care for resident #1 on 10/24/11 regarding supervision despite the intermittent confusion and concerns of safety voiced by PT-B. On 11/1/11 at 9:10 a.m. surveyor # clarified with PT-B the events of 10/24/11. PT-B verified she informed LPN-A of resident #1's attempt to self-transfer and her concerns regarding the safe use of the scooter/electric wheel chair after her treatment session on the morning of 10/24/11. PT-B verified she transferred resident #1 out of the electric wheel chair into the recliner before exiting the room and having the discussion with LPN-A. On 11/1/11 at 9:20 a.m. surveyor # interviewed COTA (Certified Occupational Therapy Assistant)-G. COTA-G stated on 10/24/11 she was informed by PT-B that resident #1 needed to be evaluated for safe use of the electric wheel chair/scooter. COTA-G stated she went to resident #1's room prior to lunch, and resident #1's was seated in his recliner. COTA-G stated she told resident #1 that she needed to go over the safety checklist for the use of the scooter/electric wheel chair. COTA-G verified she did not see resident #1 in the wheel chair, but was going to do the assessment after lunch. COTA-G stated resident #1 was being visited by therapy dogs at the time; therefore, was distracted during the conversation. The COTA progress note on 10/24/11 indicated, "Pt. educated on wheelchair safety, pt. in recliner, pt. understood handout and purpose to perform checklist for safety. Pt. sent out to hospital." During the interview with surveyor # , COTA-G verified she informed resident #1 that they would be completing the checklist later when he was in is scooter, and he understood the need to do so. COTA-G verified the safety assessment had not been completed prior to the fall and subsequent transfer to the hospital. On 11/1/11 at 10:00 a.m. surveyor # interviewed RN-F regarding resident #1. RN-F stated she was not aware of any safety concerns related to resident #1 on 10/24/11. RN-F verified she had not been informed of any concerns related to increased confusion or safe use of the electric wheel chair prior to the resident's fall on 10/24/11. On 11/1/11 at 10:05 a.m. surveyor # interviewed RN-H regarding resident #1. RN-H stated she was not aware of any safety concerns related to resident #1 on 10/24/11. RN-H verified she had not been informed of any concerns related to increased confusion or safe use of the electric wheel chair prior to the resident's fall on 10/24/11. RN-H verified there had been no changes to the plan of care on 10/24/11 prior to the fall. RN-H stated if Therapy did not want resident #1 to use the scooter/electric wheel chair, it should have been removed from the room. On 11/1/11 the facility provided surveyor # an investigation regarding resident #1. A statement written by PT-B on 10/27/11 documented the events of 10/24/11. The statement included the following, "...Pt. came down to dept. and was using electric w/c when he demo'd (demonstrated) unsafe negotiation of w/c. PT notified both nurse + occupational therapy who planned on completing a full safety assessment of w/c later in day...Nurse educated that pt. should not be in electric w/c alone...". The investigation included a statement written by CNA-J regarding the events of the night of 10/23/11 going into 10/24/11. The statement documented CNA-J was with resident #1 "... many times during the night to reposition him and answer his call light...Resident was very confused on this night. He was making a lot of statements about his power scooter during the night. He asked multiple times if he was laying on his scooter...Also made statement asking if staff was mad at him and to please not turn against him...He kept saying he must be confused. I went in to his room with the lab tech early in the morning and hes (sic) thought he was in his apartment...I went in again about 30 minutes later around 5:15 (a.m.) and did his morning cares and he seemed less confused at that time...".