Every finding on record at Spring Valley Health and Rehab Center

Based on observation and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This has the potential to affect all 35 residents residing in the facility.Garbage dumpsters were open on 3 different observations.This is evidenced by:According to State Operations Manual, Appendix PP: Guidance to Surveyors for Long Term Care Facilities, revised last 4-25-25, garbage receptacles should be covered to prevent the harborage and feeding of pests.On 12/1/25 at 4:30 PM, Surveyor observed garbage dumpster and recyclable containers were uncovered. On 12/2/25 at 1:01 PM, Surveyor observed with Dietary Manager (DM) M that garbage dumpster and recyclable containers were uncovered. Surveyor interviewed DM M who stated, talk to Plant Operations Director (POD) I, he handles that. Surveyor asked if DM M's staff take garbage out to the dumpsters. DM M asked, So is that our problem? Surveyor replied yes, it is the responsibility of whoever takes garbage out to close them after using.On 12/2/25 at 1:01 PM, Surveyor interviewed POD I about garbage pickup service and dumpster management. POD I stated that GLF takes care of the garbage on Tuesday mornings and does not think there is a policy. POD I asked if the garbage cans were open. Surveyor told POD I yes.On 12/2/25 at 5:30 PM, Surveyor observed garbage dumpster still uncovered. Surveyor looked inside dumpster; 4-5 garbage bags were present. On 12/3/25 at 7:48 AM, Surveyor observed dumpsters; they remained open. On 12/3/25 at 7:56 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about the dumpsters. NHA A stated in a questioning tone when asked about the dumpsters, what are they supposed to be closed. When Surveyor said yes, NHA A stated well the garbage man came last night. Surveyor explained they were open when she looked on 12/2/25 at 1:01 PM with DM M and at 5:30 PM. At 5:30 PM on 12/2/25, there were 4-5 bags of garbage in the can. Surveyor asked Administrator if there was a policy. NHA A stated he did not think so, but he would look into it. On 12/4/25 at 10:32 AM, POD I stated there is no policy for garbage.

Based on observation, interview and record review, the facility did not maintain safe storage and sanitary environment in which food is prepared and distributed. This has the potential to affect all residents who reside in the facility.Facility staff did not monitor dishwasher temperatures consistently.Facility staff did not monitor refrigerator and freezer temperatures consistently. This is evidenced by:The facility policy titled, Policy and Procedure Manual [NAME] & Associates, Inc: Food Storage, dated 2021, states: 13. Refrigerator food storage: .b. Temperatures for refrigerators should be between 35 to 39F. Thermometers should be checked at least two times each day. 14. Frozen Foods: .b. Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day.The facility policy titled, Policy and Procedure Manual [NAME] & Associates, Inc: Dish Machine Temperature Log, dated 2021, states: The director of food and nutrition services will post a log near the dish machine for the staff to document temperatures. 1. Staff will monitor dish machine temperature throughout the dishwashing process.2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal.On 12/1/25 at 9:41 AM, Surveyor started the observation of the kitchen on entrance per survey protocols. Dietary Manager (DM) M was not available for initial tour. [NAME] N walked Surveyor through the initial tour. [NAME] N stated they take the temperatures of the fridges and freezers twice a day. It is the beginning of December, and logs were posted but not started for the month. Past logs were not on clipboards. [NAME] N stated the records and policies can be found with DM M. On 12/2/25 at 1:01 PM, Surveyor asked DM M for logs for all fridges, freezer and dishwasher. DM M provided Surveyor what she had. DM M stated that when the Regional Manager came for her orientation, DM M was told they only needed to keep 3 months' worth of logs, and she tossed all logs before September 2025. DM M stated she knows tracking temperatures is a problem and it is on her list to fix. DM M is new to the position and started around 11/13/25. DM M stated she has met with staff about job descriptions and expectations. Temperature taking is a task facility has required prior to DM M starting. Some logs for September and October were provided; no logs for November were provided. What was provided was the following:Kitchen cooler 1:September 28, 30 temperatures missed.October - completedNov - nothing receivedKitchen cooler 2:September 21, 22, 25, 27, 28 temperatures missed.October complete, no dates missedNov - nothing receivedChest Freezer 1: September 30 missed temperaturesOctober 7, 19, 23, 24 missed temperatures,Nov - nothing received Chest Freezer 2:September. 21, 22, 27, 28, 30 temperatures missed.October 6, 19, 23, 24 missed.Nov - nothing receivedChest Freezer 3:September 21, 22, 25, 27, 28, 30 temperatures missed.October 24 completedNovember nothing receivedKitchen Freezer 1:September 30 temperatures missed.October 2025 completedNovember nothing receivedKitchen freezer 2:September 28, 30 temperatures missed.October - completeNovember nothing receivedKitchen Freezer 3:September 28, 30 temperatures missed.October - completedNovember nothing receivedRiver Ridge [NAME] Fridge Freezer:Only one log available - 10/27 through Nov. 2nd - Temperatures missed on 10/27, 10/28, 10/29, 10/30, 10/31, 11/2River Ridge Black Fridge:Only one log available - 10/27 through Nov. 2nd - Temperatures missed on 10/28, 10/29, 10/30, 10/31, 11/1, 11/2River Ridge Stainless Freezer:Only one log available - 10/27 through Nov. 2nd - temperatures missed 10/27, 10/28, 10/31, 11/2 Stainless [NAME] Fridge:Only one log available - 10/27 through Nov. 2nd Temperatures missed on 10/27, 10/28, 10/29, 10/31White [NAME] Freezer:Only one log available - 10/27 through [DATE]nd Temperatures missed 10/27, 10/28, 10/29, 10/31Black [NAME] Freezer:Only one log available 10/27 through [DATE]nd Temperatures missed 10/27, 10/28, 10/29 ,10/30, 10/31Black [NAME] Fridge:Only one log available - 10/27 through-[DATE]nd Temperatures missed 10/27, 10/28, 10/29, 10/31On 12/2/25 at 1:01 PM, Surveyor asked for dishwasher hot water sanitizing temperature logs. There is a hot water sanitizing dishwasher in the main kitchen, Ridge River Kitchenette, and [NAME] Kitchenette. The following is what was received: 1. Kitchen [DATE] - Temperatures missed 9/6, 9/7, 9/8, 9/11, 9/17, 9/21, 9/22, 9/24, 9/25, 9/28 2. No location listed - November 2025 - Temperatures missed 11/13, 11/14, 11/19/25.3. No location, undated log - Temperatures missed on 4th, 5th, 17th, 18th, 19th, 23rd, and 31st On 12/3/25 at 8:55 AM, Surveyor walked through both small kitchenettes with DM M. At end of the tour Surveyor asked DM M again for kitchenette fridge/freezer logs, how long the sanitizer put in spray bottles from wall system is stable from manufacturer, and dishwasher logs again. DM M stated we do not have logs for kitchenette dishwashers. Surveyor asked DM M one last time for all logs she has for main kitchen and kitchenette for fridge, freezers and dishwashers.On 12/3/25 at 10:10 AM, DM M stated to Surveyor she has given Surveyor all the logs DM M has for dish washing temperatures, refrigerator and freezer logs.

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 35 residents residing in the facility.The facility's Dietary Manager (DM) M does not have required certifications for the Dietary Manager role, there is no full time Registered Dietician, and the facility does not have a waiver in place or on file. Findings include:On 12/2/25 at 1:01 PM, Surveyor interviewed Dietary Manager (DM) M and asked what qualifications they held that allowed them to assume the role of Dietary Manager. DM M stated she does not hold any certifications or degree. DM M stated she started this position approximately three weeks ago, around November 13. DM M stated she is qualified to be Dietary Manager because she has 3 years' experience at her last job. DM M stated she was not required to be certified or licensed at the last job but is enrolled in a class starting 12/17/25. DM M stated there is a Registered Dietician about 10 hours a week and available to contact when she needs her. DM M does not know if Nursing Home Administrator (NHA) A filed for a waiver.On 12/02/25 at 2:32 PM, Surveyor interviewed NHA A who stated the DM M just started her position at Spring Valley but is an experienced Dietary Manager. NHA A stated DM M is enrolled in a class starting 12/17/25. Surveyor went through the flow sheet on citing an F801 with NHA A. NHA A stated there is no full-time registered dietician and they do not have any waivers in place. On 12/3/25 at 3:38 PM, NHA A brought email evidence of Registered Dietician responding to facility request. Email was sent on 12/3/25 at 2:33 PM and Registered Dietician responded on 12/3/25 at 3:19 PM.

Based on observations, interviews, and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) to include outcome surveillance systems to prevent the transmission of disease and infection, which has the potential to affect all 33 residents in the facility and did not perform proper infection control practices for 2 out of 2 residents observed for tube feedings (R7, R19). Facility has no surveillance system to track and monitor staff illnesses/infections. Facility had incomplete and untimely illness/infection surveillance for residents. Registered Nurse (RN) O wore same gown while going in and out of R7's room and R19's room, who were on enhanced barrier precautions. RN O did not allow the syringe to dry after rinsing it following flushing R7's Peg tube. RN O placed the plunger back into the syringe and placed the wet syringe inside a wet graduate, which promoted bacterial growth. RN O did not allow the syringe to dry after rinsing it following flushing R19's's Peg tube. RN O placed the plunger back into the syringe and placed the wet syringe inside a wet graduate, which promoted bacterial growth. RN O did not allow the syringe to dry after rinsing it following administering medications via R19's's Peg tube. RN O placed the plunger back into the syringe and placed the wet syringe inside a wet graduate, which promoted bacterial growth. Facility policy titled, Infection Prevention and Control (General), dated [DATE] states, in part: . the Infection Preventionist responsibilities for infection prevention and control include, but are not limited to: Conducts surveillance for community-associated infections and/or other communicable diseases. Assures compliance with state/federal regulatory and accreditation standards as they pertain to infection and prevention/control matters within the community . Example 1 On [DATE], Surveyor interviewed Nursing Home Administrator (NHA) A and asked who the Infection Preventionist was. NHA A stated they have gone through many of them since he was hired 7 months ago, but currently it is Director of Nursing (DON) B. On [DATE] at 10:42 AM, Surveyor asked DON B for the infection control surveillance logs. DON B reported they are behind on entering the information. DON B stated he has only been employed for 3 weeks and is trying to catch up. On [DATE], Surveyor received the surveillance binder from DON B. DON B handed Surveyor the binder and a stack of papers that are to be placed in the binder that, We were behind on. I am trying to enter everything to give to you. Surveyor skimmed the binder and asked for the surveillance logs for employees. DON B stated they could not locate a binder for tracking employee illnesses. Surveyor asked what was in the resident surveillance binder from [DATE] to current. DON B stated nothing was in the binder after [DATE].Example 2 On [DATE], Surveyor reviewed the facility's Infection Prevention and Control manuals for surveillance tracking of resident infections/illness. Concerns identified were: 1. No facility map tracking by room was utilized since the last standard survey on [DATE]. 2. The facility does not have the specifics of a surveillance document, such as symptoms, tests performed with dates/results with dates, isolation, symptoms resolution date, whether resident hospitalized , or expired, unless it is specifically documented. 3. [DATE]: 7 infections identified: Tracking form not completely filled out. Dates of reviews were [DATE] and [DATE] (after Surveyors entered the facility). 4. [DATE]: 2 infections identified: Tracking form not completely filled out. Date of reviews was [DATE] (after Surveyors entered the facility). 5. [DATE]: 5 infections identified: One was not reviewed at all; 4 others were reviewed after 2 months. 6. [DATE]: 4 infections identified: Reviewed [DATE] (after Surveyors entered the facility). 7. [DATE]: 3 infections. Not reviewed for over 2 weeks. On [DATE], Surveyor interviewed NHA A to discuss infection control surveillance. NHA A stated they currently do not have a qualified IPIC nurse since the last one left on [DATE]. NHA A stated they hired a new IPIC nurse that will be starting later in [DATE]. Example 3 Surveyor requested policies which included Enhanced Barrier Precautions, on [DATE] at 11:59 AM, from Nursing Home Administrator (NHA) A, and [DATE] at 11:01 AM, from Assistant Director of Nursing (ADON) C. A policy related to Enhanced Barrier Precautions was not provided. The facility policy titled Transmission-based Precautions, dated [DATE], states, Follow nationally recognized standards and guidelines for transmission based (isolation) precautions. To include standard, Contact, Droplet, and airborne precautions to prevent spready of infectious pathogens in the community. Per the CDC operations memo titled, QSO24-08-NH, dated [DATE], states in 2019, CDC introduced Enhanced Barrier Precautions (EBP). They are a strategy for high contact care in nursing home, recommending gown, and gloves for specific activities such as catheter care, wound care, and feeding tube care. Per CDC guidelines from website titled, How to Clean, Sanitize and Store Feeding Items Frequently Asked Questions, dated [DATE], states: The CDC explicitly recommends that reusable items . should be allowed to air-dry thoroughly before storing to help prevent germs and mold from growing. Once completely dry, items should be stored in a clean, protected area. On [DATE] at 9:37 AM, Surveyor observed Registered Nurse (RN) O flush R7's peg tube, cleanse site and change peg tube dressing and wound dressings with assist of ADON C distracting R7. RN O started by cleaning the peg tube. RN O did not have all the dressings she needed, took off gloves, left room, came back into room, performed hand hygiene, and with same contaminated gown continued with peg tube dressing. Talking to herself, RN O stated, I better double check. RN O took off her gloves and left room again with gown on. Surveyor observed RN O's gown touching medication cart while RN O checked what was on the computer. RN O came back into the room, performed hand hygiene, donned new gloves, and stated R7 ate her meal so does not need a bolus feeding. With contaminated gown, RN O checked placement via auscultation, flushed the Peg tube, and started administering medications. After administering meds, RN O and ADON C changed dressings bilaterally to both knees and assessed shoulder and healed wound locations for R7. Before completing the dressing change, RN O left the room for supplies 3 more times.RN O went back to her computer to check dressing change orders/directions with gown on, did not change gown and gown was touching medication cart.RN O left for collagen dressing with gown on, came back into room and continued cares with same gown on. RN O left because a coworker knocked on door, and RN O stepped out to talk with them, again pulling her gown out of the way and getting her keys and going into medication cart. At 10:02 AM, RN O cleaned up her supplies, took the graduate cylinder and syringe back into bathroom. RN O rinsed the syringe and graduate, kept wet syringe together and put back in its wrapper, placed inside wet graduate upright cylinder and placed on towel on side of sink closest to the toilet. Wet syringe was put back together and placed in wet graduate, not allowing to air dry first, promoting bacterial growth. Example 4 On [DATE] at 11:45 AM, RN 0 started preparing to administer medications to R19 via her peg tube. RN O completed hand hygiene and put on a gown when she had all her medications ready to go at R19's side. RN O started by disconnecting the tube feeding and paused. RN O stepped back from R19 and left the room with gown and gloves on, came back in room with stethoscope, took gloves off, and completed hand hygiene. With same contaminated gown on, RN O checked placement of peg tube via auscultation. RN O proceeded to administer medication one at a time with flush in-between wearing same contaminated gown. When medications were administered, RN O reconnected the feeding tube, started the feeding, and cleaned up her work area. RN O took graduate cylinder to the bathroom, rinsed and put the wet syringe in the wet container, not allowing to air dry and promoting bacterial growth. Example 5 On [DATE] at 2:32 PM, Surveyor observed RN O administer medications to R19. Once set up, RN O disconnected the feeding and looked at Surveyor and said the order still says to check placement by listening so can I still do that. Surveyor told her to do what she thinks is right. RN O took off gloves and went out of room to medication cart with gown on. RN O pulled gown out of the way, pulled out her keys, opened cart, got a tape measure, and put keys back in her pocket. RN O let the gown fall back into place and came back into the room. RN O performed hand hygiene, put on new gloves, with same contaminated gown bent over R19, and measured placement of the peg tube. With same gloves and gown, RN O administered R19's medication. When task was completed, RN O cleaned up her supplies, took the graduate cylinder and syringe back into bathroom. RN O rinsed the syringe and graduate, kept wet syringe together, placed inside wet graduate upright cylinder and did not allow to air dry, promoting bacterial growth. On [DATE] at 12:11 PM, Surveyor interviewed RN O who stated enhanced barrier precautions (EBP) should be used any time there is a catheter, peg tube, wound care or nebulizer. Surveyor asked when do you wear a gown, gloves, or change them. RN O stated you should change gloves as needed, a lot of times. RN O stated PPE required for precautions is gloves, gown, mask if upper respiratory and goggles if splashes. Surveyor asked RN O if the gown needs changing. RN O stated it usually doesn't but would change it if I get it soiled. RN O stated the gown is worn to protect you and the resident, but mostly the resident. RN O stated she probably would not need to change her gown. Surveyor asked even if you leave the room. RN O stated, I should have changed it. RN O stated the med cart was just outside the door in the hall. I consider my med cart to be part of the room. On [DATE] at 3:36 PM, Surveyor interviewed ADON C who stated EBP should be followed with all residents with catheters, wounds, peg tubes, and things like that. A gown is like gloves and needs to be put on before you start, kept clean, changed if dirty, and taken off in the room before you leave. Hand hygiene should be performed before you enter the room, do anything with patients, if you are going from dirty to clean, or leaving the room. Surveyor asked what if you leave the room with your gown and gloves on. ADON C stated both should be changed.

Based on interviews and record reviews, the facility did not ensure their designated Infection Control Preventionist (ICP) completed training in infection control (IC) prior to assuming the role, without oversight by another IC trained individual. This has the potential to affect all 33 residents in the facility.An ICP is an essential component of an effective infection control program and is the person designated by the facility to be responsible for infection control.The Centers for Disease Control and Prevention (CDC), CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings updated October 2022, states in part, . Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . Assign one or more qualified individuals with training in infection prevention and control to manage the facility's infection prevention program . On 12/03/2025 at 2:00 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who identified Director of Nursing (DON) B as the facility's current ICP. Surveyor asked for DON B's professional credentials regarding infection control training. NHA A stated that no one in the facility has completed the infection control education since the last DON's employment terminated on 11/20/25 and confirmed there is no other staff in the building that is qualified. NHA A stated they hired an ICP that plans to start at the end of December.

Based on observation, interview and record review, the facility did not ensure all portions of the call light system were working properly. This had the potential to affect all 35 residents. The facility's call light system is not visible in the hallways unless the corner with computer screen is in direct line of sight. Staff need to be close to screen to read who has their call light on.The call light system does not have auditory alarms. Call lights are often not answered in timely manner, resulting in injuries and interference with resident choices.Surveyor requested facility policy, and none was provided. According to Ford, Dean and [NAME], PA white paper, titled What is Average Response Time in a Nursing Home, dated 3/4/25, states: It is important for staff workers at nursing homes and assisted living centers to respond quickly when residents signal that they need assistance. They may need assistance for a variety of reasons, as extreme as a fall or a poor reaction to medication and as simple as needing help getting food or taking a shower. In general, it's important for these response times to be under five minutes. Delays can be highly detrimental to elderly individuals. Example 1 R5 was admitted to the facility on [DATE] with pertinent diagnoses of idiopathic peripheral neuropathy, atrial fibrillation, overactive bladder, localized edema, and pressure ulcer stage 4 of back, buttock, and hip. R5's most recent significant change Minimum Data Set (MDS) assessment, dated 11/07/25, noted a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition is intact. R5 requires partial/moderate assist with lying to sitting; substantial/max assist with shower/bathing self, upper/lower dress, personal hygiene, rolling left to right, and sit to lying; dependent assist with toileting hygiene, chair/bed transfer, toilet transfer, and wheeling 50 feet in wheelchair. R5 is always incontinent of bowel and bladder. From November 1 through December 2nd, R5 had 33 call lights that took 20-30 minutes to be acknowledged. There were 33 call lights that took over 30 minutes to be cleared. Of the 33 call lights, 12 required a reset at 30 min and were on for a range of 33 min 18 sec to needing to reset twice and being answered at 70 min 16 sec. On 10/28/25, R5 had a fall after her air mattress started deflating. Charting of fall occurred at 6:50 PM after patient was assessed and deemed stable. R5 reported she put her call light on, and no one came. As the air mattress deflated, she rolled out of bed. According to call record log R5 put on her call light at 5:22:54. It went 30 min 3 sec without being answered so it reset and went another 10 min and 59 sec before it was answered. R5 waited for assistance for 40 min 62 sec and by that time she had an unwitnessed fall. On 12/01/25 at 2:02 PM, Surveyor interviewed R5 regarding call lights and staffing. R5 stated frequently having to wait 15-20 minutes or longer for assistance after using call light. R5 stated that on 10/28/25, R5's bed began to deflate and R5 turned on call light. For approximately 15-20 minutes, R5 waited for staff to assist, but no one answered call light. R5 stated the bed completely deflated and she began to slide down off the side of the bed and was unable to reposition self and ultimately fell out of the right side of the bed and landed on right side. R5 stated she believed she hit her head on both the bed frame and floor but did not lose consciousness. R5 stated she was still holding the call light after fall and believed she pushed the button again, but that the call light should have still been calling for assist as no one came into the room to turn it off yet. R5 stated she laid on the floor for an additional 15-20 minutes before staff entered the room to assist. Surveyor reviewed facility's call light log for 10/28/25 and noted the following: On 10/28/25 at 5:23 PM, R5's call light was turned on. R5's call light remains on until 6:04 PM. No other call light recordings were noted after this time. On 12/03/25 at 10:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F regarding call light system. CNA F stated the facility's call light system is very outdated, has no alarm or visible light attached to it. CNA F stated the only way to know if a resident has turned on their call light is to see it on the monitor at the nursing station. CNA F stated that staff are frequently unaware of call lights if they are assisting residents in rooms and the monitor is not visible from all the hallways. On 12/04/25 at 10:39 AM, Surveyor interviewed Director of Nursing (DON) B regarding call light system. Surveyor asked DON B's expectation for staff to answer call lights. DON B stated difficulty in providing a timeframe, but expressed that the desire would be for call lights to be answered within 10-15 minutes. Surveyor asked DON B if the current call light system had any audible alarm or visible light for notification that a call light is on. DON B stated no, the light being turned on is only visible from the computer monitor at the nurse's station. Surveyor asked DON B if this monitor was visible from all resident hallways. DON B stated no, it is not. Surveyor asked DON B if this could be a potential risk for safety and impaired resident care. DON B stated yes, that the inability to see or hear resident call lights is a concern and should be addressed. Example 2 On 12/01/25, Surveyor completed screening interviews with residents in the [NAME] Neighborhood of the facility. Surveyor noted no audible call light alarms and no visible lights outside of resident rooms indicating a call light was turned on. Surveyor observed a computer monitor located at the nursing station. The monitor had resident room numbers listed for the facility. Surveyor asked staff by the monitor how the call light system worked. Staff stated the monitor will display a resident room number in red when the call light is turned on. When staff turn off the call light, the resident room will return to white on the monitor. Staff stated that no audible alarm or sound is emitted from the monitor and staff do not have any portable devices to alert them when a resident turns on their call light. R12 was admitted to the facility on [DATE] with pertinent diagnoses of morbid obesity with diabetic neuropathy, Crohn's disease, diabetes mellitus type 2, chronic pain syndrome, and generalized anxiety disorder. R12's most recent annual Minimum Data Set (MDS) Assessment, dated 11/14/25, noted a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact. R12 requires substantial/max assist with shower/bathing self, upper dress, personal hygiene, and rolling left to right; Dependent assist with toileting hygiene, lower dress, sit to lying, lying to sitting, and chair/bed transfers. R12 is always incontinent with bowel and bladder. On 12/01/25 at 10:33 AM, Surveyor interviewed R12 regarding call lights and staff assistance. R12 stated frequently waiting for staff for upwards of 20 minutes on average. R12 stated she couldn't recall the exact date but recently waited for over 6 hours for staff to change soiled brief. R12 stated that at approximately 6:30 PM, she turned on her call light and after 20-30 minutes, a staff member entered her room and told her they didn't have time to change R12's brief and to call another staff member to assist, then turned off R12's call light. R12 stated she didn't have the ability to call for a specific staff member and turned the call light back on. R12 stated after approximately 20 minutes, the same staff member came back into R12's room and turned off the call light and told R12, I told you, I don't have time right now. You are going to have to wait. R12 stated feeling upset and uncomfortable having to sit in her soiled brief. R12 stated she had to wait until the next shift came on-duty to be cleaned up, but by this time R12 was experiencing some burning from skin irritation after sitting in the soiled brief from approximately 6:30 PM – 12 AM. R12 stated that no skin breakdown occurred, but the irritation lasted for 2-3 days after incident. Surveyor asked R12 if this concern was mentioned to a nurse or the administrator. R12 stated she couldn't remember for sure but thought she had told the administrator. Of note: Surveyor reviewed R12's medical record and there was no documentation of reddened or irritated skin. Surveyor reviewed facility's grievance/complaint log and did not note any documentation of R12 reporting having to wait for staff assistance for 6 hours during the past year. Example 3 R3 was admitted to the facility on [DATE], with diagnoses that include but are not limited to: Body Mass Index (BMI) 60-69.9, edema, peripheral vascular disease, kidney disease, immobility syndrome (paraplegic), atrial fibrillation, congestive heart failure, restress legs, sleep apnea, and muscle weakens. R3's most recent significant change Minimum Data Set (MDS) assessment, dated 11/24/25, documents a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact. R3 requires assist of 2 with mechanical lift to change positions, going from lying to sitting and sitting to lying. R3 needs assistance to shower/bathe, dress, with personal hygiene and cares, with at least 1 and often 2 assist. On 12/1/25 at 10:01 AM, Surveyor interviewed R3, who stated he had just put his call light on to get up. Surveyor continued with the screening interview while waiting for staff to respond to reported call light. Confirmed by the call light log report, R3 did put his call light on at 9:57:42 AM. At 10:27:42 AM, the call light reached the 30 minute mark and reset. At 10:35:33 AM (37 min 51 sec), Certified Nursing Assistant (CNA) R came in and acknowledged R3's call light, telling R3 that they would be back. By 11:01 AM, no one had come back to get R3 up for the morning. Surveyor suggested that R3 put his call light back on. At 11:23:51 AM, CNA R came in to get R3 up for the day. R3 waited for 116 minutes to get up for the morning. During the interview with Surveyor, R3 mentioned 3 times that he was supposed to go down to therapy before lunch. Surveyor heard R3 during cares tell CNAs that he had missed going to therapy. R3 was up and dressed just in time to go to lunch; therapy exercises were missed. From November 1 through December 2nd, R3 was out of the facility in the hospital. For the remainder of the period, R3 had 9 call lights that took between 20-30 minutes to be cleared by staff and 33 call lights that took over 30 minutes or more to be cleared by staff. Of the 33 call lights, 12 required a reset at 30 min and were on for a range of 34 min 23 sec to needing to reset twice and being answered at 104 min 30 sec.

Based on interview and record review, the facility did not ensure 1 (R1) of 1 resident reviewed for post-traumatic stress disorder (PTSD) received culturally competent, trauma informed care in accordance with professional standards of practice and accounting of resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of R1.R1 does not have a person-centered care plan for triggers and interventions for R1's PTSD diagnosis. Findings:The facility policy titled Trauma Informed Care dated 12/2025 documents: This community ensures that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident . Person-centered care plan will be developed with resident's and /or family involvement to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident and will account for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.R1 was admitted to the facility on [DATE] with diagnoses that include PTSD, depression, and insomnia. R1's Minimum Data Set (MDS), dated [DATE], indicated R1 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15. R1 eats independently and receives moderate assistance for bed mobility, toileting, and transfers. R1 did not have an activated power of attorney and makes own decisions. Surveyor reviewed R1's care plan and found no plan was created for R1 regarding PTSD. Care plan dated 9/25/25 documents noncompliance with plan of care and mood/behavior. Interventions are: Observe for percent of time in compliance. If alternatives are appropriate review for alterations or change if ineffective. Observe / Monitor / Document behaviors/mood and notify supervisor, SW, and / or MD as needed. Surveyor reviewed R1's CNA Kardex and noted no documentation for possible triggers for R1's PTSD and no interventions to prevent possible PTSD triggers for R1. Social worker was not available for interview at the time of this investigation. On 12/03/25 at 8:35 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C and asked to show the care plan that addresses R1's PTSD. ADON C stated there is not one, but R1 sees an in-house psych provider weekly. ADON C added that R1's PTSD is from childhood and states that R1 had recent suicide attempts and will get quiet. ADON C stated she will get a care plan in there right away. On 12/03/25 at 9:17 AM, Surveyor interviewed Certified Nursing Assistant (CNA) K who reported working at the facility for approximately a year. CNA K stated she is not aware of who has PTSD or what the interventions are for R1 when told R1 has PTSD.

Based on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed and was not documented in the Wisconsin Bed Hold and Notice of Transfer for 2 of 3 residents (R) (R5, R3) reviewed.R5 was transferred to the hospital on [DATE] and 11/04/25. A bed hold notice with daily rate to reserve bed and a written notice of transfer were not documented.R3 was transferred to the hospital on 3/11/25, 4/20/25, and 10/25/25. A bed hold notice with daily rate to reserve bed and a written notice transfer were not documented.R3 was transferred to the hospital on [DATE]. A notice of transfer discharge was given but did not specify reason for transfer or daily rate to reserve bed. This is evidenced by: Facility policy titled, Bed Hold and Re-Admission, with a review date of 12/2025, states in part: Before a resident is transferred to a hospital or placed on therapeutic leave, written notification is provided to the resident and/or resident representative that specifies: Bed hold: the duration of the bed hold period.Bed hold transfer: At the time of transfer for hospitalization or leave, written notice that specifies the duration of the facility bed hold period is provided to the the resident and/or resident representative. A copy and/or documentation of the notice is placed in the resident's medical record. Facility policy titled, Transferring a Resident to Another Facility or Hospital, with a review date of 12/2025, states in part: Procedure: 2. In an acute change of condition/emergency situations: d. Notify the resident's representative of the pending transfer to include appeal notification. F. Complete the transfer form and bed hold information to be sent with resident. Example 1 On 06/07/25, R5 had a change in mentation and began experiencing chest pain. R5 was transferred to the hospital via ambulance and admitted to the hospital. R5's family and provider were notified. No written notice of transfer indicating reason for transfer and destination was documented. A bed hold indicating the daily rate to reserve bed and appeal rights was not documented. On 11/04/25, R5 experienced increased weakness and dizziness and was transferred to the emergency room for evaluation. R5 returned to the facility on the same day. No written notice of transfer indicating reason for transfer and destination was documented. A bed hold indicating the daily rate to reserve bed and appeal rights was not documented. On 12/04/25 at 10:06 AM, Surveyor interviewed Health Information Clerk (HIC) D regarding bed holds and written notice of transfer. HIC D provided Surveyor with a nurse progress note, dated 06/07/25, stating family approved bed hold until resident is strong enough to return to facility. Surveyor asked HIC D if there was any documentation of the bed hold being completed by R5 when R5 returned to facility on 06/17/25. HIC D stated no. HIC D stated not having any documentation of a bed hold or written notice of transfer completed for R5 for the transfer that occurred on 06/07/25 and 11/04/25. Example 2 On 3/11/25, R3 had hypertension (high blood pressure) and tachycardia (fast heartbeat). R3 was feeling nervous, confused, and light-headed. R3's pulse was erratic ranging between 116 and 146 beats per minute (BPM). Facility called emergency medical services (EMS) and R3 was sent to the emergency room (ER). R3 was hospitalized . R3's physician was notified, and a voicemail was left with R3's family. No written notice of transfer indicating reason for transfer and destination was documented. A bed hold indicating the daily rate to reserve bed and appeal rights was not documented. On 11/04/25, R3 was very lethargic and off baseline per documentation. R3's face was flushed and pulse elevated at 116. Per the documentation R3 stated, something is wrong, and requested to go to the ER. R3 was hospitalized . No documentation that family or physician were notified. No written notice of transfer indicating reason for transfer and destination was documented. A bed hold indicating the daily rate to reserve bed and appeal rights was not documented. On 10/25/25, R3 appeared very pale and complained of feeling light-headed and dizzy. Per documentation, R3 stated, doesn't feel right, and wanted to go to the ER. R3 had 4+ pitting (significant) and taut edema in his lower extremities. Facility notified the on-call physician. It is documented that R3 did not want family notified and verbal bed hold obtained. No required written notice of transfer indicating reason for transfer and destination was documented. A bed hold indicating the daily rate to reserve bed and appeal rights not documented. On 11/7/25, 5 days post hospital discharge, R3 returned to hospital due to rectal bleeding. Document for Notice of Transfer/Discharge available but does not document specific reason for hospitalization or daily rate for bed hold. No documentation of physician or family notified, or R3 refusing family notification. On 12/3/25 at 11:34 AM, Assistant Director of Nursing (ADON) C provided Surveyor with one bed hold notice for the four hospitalizations. ADON C stated there are no other bed hold/transfer notices she can find. ADON C stated she usually fills them out but if they are not hospitalized , they are not kept. R3 was hospitalized for all of these, and bed hold and written transfer notice required.

Based on staff interview and record review, the facility did not provide appropriate notices for residents (R) whose Medicare Part A coverage was discontinued for 2 of 3 residents reviewed. (R5, R4) -Did not provide Advanced Beneficiary Notice (ABN) for 2 of 3 residents. (R4, R5) -Did not provide the required 2-day notice that Medicare coverage will end for 1 of 3 residents reviewed. (R5) Findings: R4 had a skilled Medicare A Service Episode with a start date of 07/15/25 and last covered date of 07/30/25. The facility/provider initiated the discharge from Medicare A Services when benefit days were not exhausted. The facility checked the box on the SNF Beneficiary Protection Notification Review form that asked the question Was a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), Form CMS-10055 provided to the resident? The facility checked the box Yes with a date of 12/02/25 after the survey was in process.R5 had a skilled Medicare A Service Episode with a start date of 06/17/25 and last covered date of 009/24/25. The facility/provider initiated the discharge from Medicare A Services when benefit days were not exhausted. The facility checked the box on the SNF Beneficiary Protection Notification Review form that asked the question Was a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), Form CMS-10055 provided to the resident? The facility checked the box Yes with a date of 12/02/25 after the survey was in process. On the box on the SNF Beneficiary Protection Notification Review form that asked the question Was a Notice of Medicare of Non-Coverage (NOMNC) provided to the resident? The box labeled YES. R5 received and dated the NOMNC on 09/23/25, which was only 1 day notice instead of the required 2-day notice. Surveyor reviewed R5's electronic health record (EHR) and did not find notes explaining reason only a one-day notice of benefits ending was given. Surveyor could not interview the social worker because s/he was unavailable. On 12/04/25 at 12:12 PM, Surveyor interviewed Assistant Executive Director (AED) L who stated she does not know why only a one-day notice was given to R5 but will check on it. On 12/04/25 at 12:56 PM, AED L returned and stated there was only a one-day notice given. They could not find any notes as to why. Surveyor asked AED L if she would expect that residents receive a two-day notice which she replied yes.

Based on observation, record review and interview, the facility did not ensure 2 of 2 residents (R) with an NG-Tube (Nasogastric) in the facility received the appropriate treatment and services to prevent complications of enteral feedings and medication administration. (R7 and R19)R19 had unlabeled/dated enteral solutions being administered.R19 and R7's Gastrostomy tube (G-tube/ feeding tube) placement was not appropriately assessed prior to medication administration. Example 1Per provided facility policy, titled Care and Treatment of Feeding Tubes, dated copyright 2024 The Compliance Store, LLC, states: Policy: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with intervention to prevent complications to the extent possible.The American Society for Parenteral and Enteral Nutrition, Enteral Nutrition Practice Recommendations (2017, Journal of Parenteral and Enteral Nutrition-Vol 41, Number 1, Jan/February 2017, 34-44) indicate that a label should be affixed to all enteral nutrition delivery systems. The label should reflect the patient's demographics (name/location), individuals responsible for hanging and preparing, and the date and time the formula is prepared and hung. The enteral nutrition label should be compared with the enteral nutrition order for accuracy and hang time or beyond-use date before administration.Per facility provided policy titled, Verifying Placement of Feeding Tube, dated copyright 2024 The Compliance Store, LLC, states: Policy: It is the practice of this facility to ensure proper placement of feeding tubes prior to beginning g a feeding, flushing the tube, or before administering medications via feeding tube.4. Procedure for verifying placement of feeding tubes:c. Verify tube placement:i. For gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the markings on the tube. ORii. Measure length of tube from insertion site to tip.R19 was admitted to the facility on [DATE] with the diagnoses that include but are not limited to cerebral palsy, generalized idiopathic epilepsy, dysphasia, (difficulty swallowing), aphasia (inability to speak, understand read and write), Rett's syndrome, severe intellectual disability, and gastrostomy (has a feeding tube/g-tube). R19's Minimum Data Set (MDS) assessment, dated 9/1/25, indicates that R19 is cognitively impaired, does not understand, cannot respond, and is wheelchair dependent and a full assist of 2 for all activities of daily living and cares.R19's care plan, dated 10/2/25, states. Feeding Tube: At Risk for Complications with tube feeding.Verify placement of feeding tube prior to administering any medication, flushing the tube or beginning a feeding. Tube length on admission: Black marking on tube at 6cm against skin and bumper. Measure 7 inches of length from tube insertion site to end of the tube (not entire connector piece). If measurements are incorrect, do not put anything in tube and notify MD. Date Initiated: 7/11/25.R19's Order Summary Report, dated 12/2/25, states: Verify placement of feeding tube prior to administering any medications, flushing the tube or beginning a feeding. Tube Length on admission: Black Marking on tube at cm against skin and bumper. Measure 7 inches of length from tube insertion site to end of tube (not entire connector piece.) if measure is incorrect, do not put anything in tube and notify MD. Order date 6/13/2025. Apply label to tube feeding bag. Include: Name, Room#, Date, time started, feed rate, formula and volume/day one time a day. Order started 12/2/25.On 12/2/25 at 7:40 AM, Surveyor observed R19's tube feeding bag running at 57ml/hr. per physician order. There was no label on tube feeding bag or tube identifying it was Jevity or the date and no time that the feeding was started. On 12/2/25 at 10:07 AM, Surveyor asked Registered Nurse (RN) O about tubing feeding and should it be labeled. RN O stated night shift sets up the new and they didn't label it. They should have. On 12/2/25 at 11:08 AM, Surveyor observed unlabeled feeding tube and bag with Assistant Director of Nursing (ADON) C who stated the expectation is that it should be labeled. Night shift usually does it. ADON C will get Surveyor the policies.On 12/2/25 at 12:02 PM, while Surveyor was in R19's room with ADON C and RN O, it was noted that the tube feeding bag remained unlabeled, no date at minimum. ADON C stated she did not label the tube feeding back earlier when we saw it because she would have had to dump and start over, and we already saw it that way, so she didn't want to waste it.On 12/2/25 at 12:13 PM, Director of Nursing (DON) B stated tube feeding bags/tubing are usually changed on night shift and labeled when they start the next day's feeding. Surveyor asked if it is not labeled what should the next shift do. DON B stated they should put a date on it, they aren't sure the time, but they can at least date it.On 12/2/25 at 11:45 AM, RN O started preparing to administer medications to R19 via her peg tube. RN O completed hand hygiene and put on a gown when she had all her medications ready to go at R 19's side. RN O started by disconnecting the tube feeding and paused. RN O stepped back from R19, left the room with gown and gloves on, came back in room with stethoscope, took gloves off and completed hand hygiene. With same contaminated gown on, RN O checked placement of peg tube via auscultation and proceeded to administer medication one at a time with flush in-between. On 12/2/25 at 12:12 PM, RN O stated you check placement of a g-tube by listening for air in the stomach when you push about 5cc in with the syringe. If you can hear the noise, you are in the right part of stomach. On 12/2/25 at 12:14 PM, ADON C stated proper placement is with a swoosh of air and you hear it, or you can measure if you know what the length of the tube is supposed to be.On 12/2/25 at 12:13 PM, Surveyor interviewed DON B who stated you test proper placement of a g-tube with the measurement thing. There is a doctor's order that is distinct on how long the tubing should be, its placement. There should be a measuring tape in the room and before they utilize the tube, they would measure it. Example 2R7 was admitted to the facility on [DATE], with the diagnoses that include but are not limited to protein-calorie malnutrition, adult failure to thrive, dysphagia (difficulty swallowing), and unstageable pressure ulcer.R7's Minimum Data Set (MDS) assessment, dated 10/1/25, indicates that R7 is moderately cognitively impaired, she understands and is understood with behaviors of yelling out due to anxiety and hallucinations. R7 uses a wheelchair for mobility with assist of one to go 50 feet or further, is assist of 2 with mechanical lift for position changes and requires set up assistance for eating, oral hygiene and brushing her teeth.R7's Order Summary Report, dated 12/2/25, states: Verify placement of feeding tube prior to administering any medications, flushing the tube, or beginning a feeding. Tube Length on admission: Black Marking on tube at cm against skin and bumper. Measure 7 inches of length from tube insertion site to end of tube (not entire connector piece.) if measure is incorrect, do not put anything in tube and notify MD. Order date 9/23/25.On 12/2/25 at 9:37 AM, Surveyor observed Registered Nurse (RN) O flush R7's peg tube, cleanse site and change peg tube dressing and wound dressings with assist of ADON C distracting R7. RN O started by cleaning the peg tube. RN O did not have all the dressings she needed, took off gloves, left room, came back, performed hand hygiene, and with same contaminated gown continued with peg tube dressing. With contaminated gown, RN O checked placement via auscultation of g-tube and flushed the g-tube and started administering medications. On 12/2/25 at 12:12 PM, RN O stated you check placement of a g-tube by listening for air in the stomach when you push about 5cc in with the syringe. If you can hear the noise, you are in the right part of stomach. On 12/2/25 at 12:14 PM, Assistant Director of Nursing (ADON) C stated proper placement is with a swoosh of air and you hear it when using a stethoscope and listen, or you can measure if you know what the length of the tube is supposed to be.On 12/2/25 at 12:13 PM, Surveyor interviewed DON B, who stated you test proper placement of a g-tube with the measurement thing. There is a doctor's order that is distinct on how long the tubing should be, its placement. There should be a measuring tape in the room and before they utilize the tube, they would measure it.

Based on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R)(R5) reviewed.R5 had a fall; the facility did not initiate immediate intervention to prevent future falls, complete staff education and review and revise care plan fall interventions.This is evidenced by:Facility policy titled, Accidents/Falls - HDGR, with a review date of 12/2024, states in part: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Procedure: 5. Resident care plans should be evaluated and updated with each fall with a new and applicable intervention based on root cause. The focus is to be on prevention and maintaining a safe environment.R5 was admitted to the facility on [DATE] with pertinent diagnoses of idiopathic peripheral neuropathy, age-related osteoporosis, sensorineural hearing loss bilateral, atrial fibrillation, overactive bladder, localized edema, and pressure ulcer stage 4 of back, buttock, and hip.R5's most recent significant change Minimum Data Set (MDS) assessment, dated 11/07/25, noted a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact. R5 requires partial/moderate assist with lying to sitting; substantial/max assist with shower/bathing self, upper/lower dress, personal hygiene, rolling left to right, and sit to lying; dependent assist with toileting hygiene, chair/bed transfer, toilet transfer, and wheeling 50 feet in wheelchair. R5 is incontinent of bowel and bladder. R5 has had one fall with injury (except major) since admission.R5's care plan, dated 10/17/24, with a target date of 01/28/25, states: At risk for falls.with interventions of call light positioned for easy access (10/24/24), check for unmet needs: pain, toileting, hunger, thirst, temperature (10/20/25), encourage/assist with non-skid shoes/socks (10/20/25), ensure environment is free of clutter (10/20/25), fall review per facility protocol (10/24/24), have commonly used articles within easy reach (10/20/25), reinforce need to use the call light to request assistance (10/24/24).Of note: R5's alternating air mattress is not noted to include settings and monitoring for functioning; no new safety interventions implemented after fall on 10/28/25.Surveyor reviewed R5's fall incidents and noted facility did not educate staff regarding air mattress settings or monitoring of the air mattress to ensure proper functioningOn 10/28/25 at 6:30 PM, R5 had an unwitnessed fall in room; R5 was found lying on floor on right side next to bed. R5 stated bed deflated and rolled out of bed. R5 reported hitting head, face and right shoulder bruised, and abrasion on left outer ankle. DON and provider were notified. Facility investigation determined root cause to be bed malfunction. Durable Medical Supply (DME) was contacted to inspect bed and air mattress was replaced. Facility implemented Performance Improvement Plan (PIP) on 11/04/25 that stated, [R5] had a fall on 10/28/25. Air mattress broke while resident was lying in bed. Interventions included complete education on provider notifications (11/05/25 and 11/11/25), obtain air mattress manufacturer's guidelines (11/05/25), audit other air mattresses to ensure we have manufacturer recommendations for all of them and ensure they are being followed and documented (11/05/25), and start maintenance air mattress tracking log of pressures in the air mattresses (no date noted).R5's fall with injury was on 10/28/25. Surveyor reviewed R5's nursing progress notes and noted:On 11/04/25, facility nurse noted R5 required more assist during transfer due to increased weakness and pain in lower extremities, dizziness, and lightheadedness. R5 stated having continued pain on right side of head where it was hit during fall on 10/28/25. Provider was notified and R5 was transferred to the hospital for further evaluation. Hospital discharge notes stated CT scan indicated no hemorrhage and no fractures; diagnoses of vertigo and hematoma of scalp. R5 returned to facility same day.On 12/01/25 at 2:02 PM, Surveyor observed R5 in bed. R5's bed was an alternating air mattress set at level 4 and functioning properly. Surveyor asked R5 about the fall that occurred on 10/28/25. R5 stated that she observed the bed starting to deflate and turned on call light. For approximately 15-20 minutes, R5 waited for staff to assist, but no one answered call light. R5 stated the bed completely deflated and she began to slide down off the side of the bed and was unable to reposition self and ultimately fell out of the right side of the bed and landed on right side. R5 stated she believed she hit her head on both the bed frame and floor but did not lose consciousness. R5 stated she was still holding the call light after fall and stated she pushed the button again, but the call light should have still been calling for assist as no one came into the room to turn it off yet. R5 stated she laid on the floor for an additional 15-20 minutes before staff entered the room to assist. Surveyor asked R5 if staff were monitoring the air mattress functioning appropriately. R5 stated she did not know.On 12/03/25 at 10:28 AM, Surveyor interviewed Certified Nursing Assistant (CNA) E regarding resident air mattresses. CNA E stated not receiving any education or training on monitoring air mattresses for safety or appropriate settings for use. CNA E stated the only thing she was aware of regarding air mattress operation was that if it is beeping to contact maintenance. Surveyor asked CNA E if she knew what settings a resident's air mattress should be set to. CNA E stated no.On 12/03/25 at 10:34 AM, Surveyor interviewed CNA F regarding air mattresses and R5's fall. CNA F stated being at the facility for over a year and a half and had never received training or education regarding monitoring air mattress functioning. Surveyor asked CNA F if she knew what settings R5's bed should be set at. CNA F stated no and never received any education or training regarding this.On 12/03/25 at 11:45 AM, Surveyor interviewed CNA G regarding air mattresses. CNA G stated not receiving any official education or training on resident air mattresses regarding functioning or settings. Surveyor asked CNA G if aides are expected to check if air mattresses are functioning. CNA G stated not being aware of having to check this as part of her job responsibility.On 12/03/25 at 11:46 AM, Surveyor interviewed Registered Nurse (RN) H regarding air mattresses. RN H stated no recollection of training or education regarding air mattress functioning or settings. Surveyor asked RN H how staff know if an air mattress is functioning appropriately. RN H stated using visual observation of bed being inflated and checking with touch for empty air areas, but most air mattresses are provided by hospice, and hospice usually checks for functioning. RN H stated the only inspection she makes is by checking that air mattress is on. RN H stated not knowing what other nurses do but was not aware of any responsibility to check or document air mattress functioning.On 12/03/25 at 12:07 PM, Surveyor interviewed Plant Operations Director (POD) I regarding air mattresses. POD I stated being contacted approximately 1-2 weeks ago by the Nursing Home Administrator (NHA) A via email to review air mattress manufacturer guidelines and inspect all residents with air mattresses for appropriate settings. POD I provided Surveyor with a sticky note and paper with handwritten room numbers and air mattress settings that had no date or signature. POD I stated that prior to this, no assessment of air mattress settings or functioning had been completed. Surveyor asked POD I if he was expected to check functioning on a schedule (i.e. weekly, monthly, etc.). POD I stated not being aware of a schedule and was only told to ensure all air mattresses were set according to manufacturer's settings.On 12/03/25 at 1:39 PM, Surveyor interviewed NHA A regarding R5's fall and investigation. Surveyor asked NHA A what the facility determined was the root cause of R5's fall. NHA A stated it was a bed malfunction. Surveyor asked NHA A if air mattress functioning was assessed for any resident prior to this incident. NHA A stated no. Surveyor asked NHA A why follow-up education did not include air mattress functioning and setting. NHA A did not provide an answer but stated that originally the plan was for POD I to ensure functioning and setting, but NHA A failed to follow-up to ensure weekly monitoring was being completed. NHA A stated recognition that nursing staff should have been educated on air mattress functioning and appropriate settings and would now include it on the nurse task list.Facility did not educate staff regarding air mattress settings or monitoring of the air mattress to ensure proper functioning. Facility did not have a routine maintenance/monitoring plan in place for the air mattress prior to R5's fall on 10/28/25 to ensure all resident's who have air mattresses, are functioing properly and are on the proper settings for each resident.

Based on interview, observation and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 3 residents (R)(R5) reviewed.R5 developed a stage 3 Pressure Injury (PI) on right buttock and a stage 3 PI on left buttock. The facility did not completely weekly assessments and update care plan with PI interventions.This is evidenced by:Facility policy titled, Pressure Injury/Skin Integrity, with a reviewed date of 12/2025, states in part: It is the policy of this facility to enable nursing staff to manage wounds and select appropriate interventions according to National Pressure Injury Advisory Panel (NPUAP). Based on the comprehensive assessment of a resident, Health Dimensions Group Communities will ensure: Routine ongoing documentation should be conducted related to the resident's skin condition and the resident's response to the care and treatment of the skin. Wound documentation is more detailed than routine skin documentation and shall include information related to the wound based on a clinical assessment. Documentation: 1) Routine ongoing documentation should be conducted related to the resident's skin condition and the resident's response to the care and treatment of the skin. The frequency of documentation shall be determined based on the resident's individual needs in accordance with accepted standards of practice, at least weekly. 3) Wound Documentation Guidelines (documentation may include): a. Document size. b. Document any undermining/tunneling/sinus tract.c. Describe any exudates - type, amount, and/or odor.d. Describe the various types/characteristics of tissue in wound bed.e. Wound edges may be described.f. Describe any indicators of infection.g. Document pain.Care Planning: 1) Upon admission, a baseline plan of care will be developed to identify areas of concern, risk factors, or existing wounds, measurable goals of care, and to specify interventions to preserve and/or treat skin integrity issues. A. Pressure Injury (Prevention) - Reduce pressure/shearing intervention examples but not limited to: i. Pressure reducing devices such as an air mattress or chair cushion.R5 was admitted to the facility on [DATE] with pertinent diagnoses of idiopathic peripheral neuropathy, atrial fibrillation, overactive bladder, localized edema, and pressure ulcer stage 4 of back, buttock, and hip.R5's most recent significant change Minimum Data Set (MDS) assessment, dated 11/07/25, noted a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition is intact. R5 requires partial/moderate assist with lying to sitting; substantial/max assist with shower/bathing self, upper/lower dress, personal hygiene, rolling left to right, and sit to lying; dependent assist with toileting hygiene, chair/bed transfer, toilet transfer, and wheeling 50 feet in wheelchair. R5 is always incontinent of bowel and bladder.R5's care plan, dated 07/31/25, with a target date of 01/28/26, states: At risk for complications related to pressure ulcers and skin integrity due to noncompliance and refusing repositioning and pressure relief interventions with interventions of educate/remind as needed about potential negative outcomes r/t choice (07/31/25), check for comfort levels - pain, thirst, hunger, temperature - offering comfort as able/accepted (07/31/25), involve family/friends as available/able (07/31/25), seek residents reasons for non-compliance (07/31/25), SS to intervene as needed/requested (07/31/25).R5's care plan, dated 10/17/24, with a target date of 01/28/26, states: Actual impaired skin integrity, stage 4 pressure ulcer to right and left buttocks with risk for further impaired skin integrity including skin tears, pressure ulcers r/t resident is non-compliant with interventions for skin breakdown prevention and pressure ulcer prevention strategies, decreased mobility, bowel and bladder incontinence, non-ambulatory status. Interventions include: Keep HOB less than 30 degrees (10/06/25), low air loss mattress (08/21/25), resident is to be in bed at all times other than toileting, daily weight and breakfast only (08/21/25), Roho Quadtrol Select Cushion in wheelchair (06/24/25), staff encourage and assist res to off-load pressure to buttocks (07/21/25), supplements as ordered for wound healing (06/25/25), wound care per MD orders, observe for healing, s/sx infection including increased redness, warmth, swelling, drainage, odor, pain, fever - consult with provider if concerns arise (06/25/25), Wound Clinic to Eval and Treat per WWH Providers (08/04/25), assist/encourage pressure relief as needed/accepted (10/02/25), follow community skin protocol (10/02/25), observe skin with AM/PM cares and with toileting.weekly skin check.(10/17/24), pressure reduction mattress on bed (10/02/25).-Of note: no specification for settings of air mattress or monitoring of function noted.R5's physician orders:08/21/25 Low Air Loss mattress-Of note: no setting parameters for air mattress noted.10/04/25 Ensure wound vac is ON, charged (or charging) & functioning at 125 mmHg every shift for wound care11/07/25 WOUND CARE: Left Buttocks - Ensure Santyl is being placed to wound bed in the afternoon every Tue, Fri for wound care.11/14/25 WOUND CARE: Right Buttocks Wound 1.) Cleanse with VASHE; soak for 5 mins. 2.) Apply skin prep to surround skin. 3.) Cover with Mepilex. In the morning every Fri for wound care. R5's BRADEN Score assessments:05/05/25 - 18 low risk05/26/25 - 19 no risk-Of note: This assessment was completed after initial assessment of PI on right buttock06/17/25 - 14 moderate risk08/06/25 - 16 mild/low risk10/15/25 - 13 moderate risk11/07/25 - 15 mild/low riskR5's facility wound assessments:05/14/25 - INITIAL ASSESSMENT - Right buttocks, stage 3 - 2.3 cm x 1.3 cm x 0.2 cm - provider notified and seen; documented assessments; interventions implemented.-Of note: prior skin assessments completed weekly noted no areas of redness or impairment.05/19/25 - initial Wound Care Clinic visit; stage 3 PU right upper buttocks; debridement completed. New wound care orders implemented.Weekly wound assessments completed by facility and wound care clinic. Treatments completed per order.On 06/07/25, R5 was hospitalized with Non-ST elevation myocardial infarction. R5 returned to facility on 06/17/25.06/23/25 - Wound assessment completed. Right buttock 2.6 cm x 2.5 cm x 1.9 cm with new undermining at 10 to 1 - 2.5 cm. Wound clinic assessed and implemented new orders.-Of note: Facility did not complete skin assessment on readmission to facility on 06/17/25. R5 did not have documented wound assessment noted for 6 days following readmission.Weekly wound assessments completed by facility. Treatments completed per order.07/21/25 - NEW Left Buttock stage 1 - 2.5 cm x 3.5 cm x 0 cm. Wound clinic assessed and implemented treatment.07/28/25 - Left buttock measured 3 cm x 4 cm x 0.1 cm and noted as stage 2. Provider notified. No new orders noted. No new interventions implemented.-Of note: no wound clinic visit or assessment noted.08/04/25 - Right buttock: 0.7 cm x 0.7 cm x 1.5 cm; Left buttock: 3.5 cm x 6.7 cm x 0.2 cm and noted as stage 3. Both wounds have worsened. Provider notified. New treatment orders received, and new wound clinic consult ordered. Administrator notified to order new low air loss mattress.08/06/25, R5 was seen by a new wound care clinic provider for more advanced care and to take over wound treatment. Right buttock: 1.0 cm x 0.5 cm x 8.5 cm; Left buttock: 3.2 cm x 4.6 cm x 0.1 cm. New treatment plan implemented. New orders include: measure and document wound condition per facility policy and to contact wound care clinic with any deterioration.Weekly wound assessments completed by facility. Treatments completed per order.09/11/25 - Wound clinic visit. New orders obtained: turn and reposition every 2 hours: right/left runs, avoid back.-Of note: no documentation of this intervention being implemented or resident refusal noted.09/18/25 - Right buttock: 0.7 cm x 0.5 cm x 8.5 cm; Left buttock: 2.5 cm x 3.5 cm x 3 cm.09/25/25 - Wound clinic documentation: no wound measurements noted. Surgical consult for debridement scheduled for 09/26/25.-Of note: no wound clinic or surgical consult documentation noted for 09/26/25 appointment.No wound clinic visits/assessments or facility assessments noted for R5's left buttock or right buttock PI noted between 09/26/25 - 10/16/25.10/16/25 - Wound clinic documentation: Left buttock: 8.8 cm x 3.5 cm with depth and undermining. No documentation of right buttock documented. Documentation noted black granufoam was not inside the left buttock wound very far. Order sent to facility to be sure to gently pack dead space with black granufoam and apply wound vac at continuous low suction 125 mmHg and change twice a week. Continuous order noted to reposition every 2 hours.-Of note: no order or care plan intervention to reposition every 2 hours noted. No documentation of resident refusal of repositioning every 2 hours was noted.No facility assessments noted for R5's left buttock or right buttock PI noted between 10/17/25 - 10/28/25.10/28/25 - Wound clinic documentation: Right buttock: 1 cm x 0.7 cm x 1.1 cm with undermining; Left buttock: 7.5 cm x 3 cm x 6 cm. Continuous order noted to reposition every 2 hours.-Of note: no order or care plan intervention to reposition every 2 hours noted. No documentation of resident refusal of repositioning every 2 hours was noted.No facility assessment of R5's left and right buttock PI was documented after 09/18/25.On 12/04/25 at 12:48 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C regarding R5's PIs. Surveyor asked ADON C if nurses are expected to document wound assessments weekly. ADON C stated yes. Surveyor asked for R5's facility wound assessments after 09/18/25. ADON C looked through R5's medical record and stated not being able to find any. ADON C stated that the prior DON was completing weekly wound assessments and thought that the floor nurse completing wound care was documenting this. ADON C stated that this is a concern and at minimum, should have been documented weekly to monitor for changes.

Based on interview and record review, the facility did not ensure a resident who entered the facility as an exception (an exempted hospital discharge) that was later found to require more than 30 days care, received a Level II resident review within 40 calendar days of admission, for one of one resident (R1). State of Wisconsin regulation 42 CFR 483.106(b)(2)(ii), If an individual who enters a nursing facility as an exception (an exempted hospital discharge) is later found to require more than 30 days of care, the State mental health or intellectual disability authority must conduct a Level II resident review within 40 calendar days of admission. R1 was admitted to the facility on [DATE] with diagnoses that include anxiety, depression, and PTSD. R1 has intact cognition and makes own decisions. On 12/02/25 at 3:43 PM, Surveyor requested a Level II PASARR screening from Social Worker (SW) J after Surveyor was unable to locate it in R1's electronic health record (EHR). On 12/02/25 at 4:11 PM, SW J provided R1's level 1 PASARR screen that identifies R1 had a major mental disorder and was discharged from a hospital with a 30-day exemption. SW J stated that she is late completing the level II PASARR screen. On this day, R1 has been in the facility 68 days; 28 of those days the facility has not been in compliance.

Based on interview and record review, the facility did not develop and implement an Abuse, Neglect, and Exploitation policy to prevent and identify potential abuse concerns. This had the potential to affect all residents in the facility that would need a self report made. -Facility had an abuse policy that referred to Nebraska reporting regulations instead of Wisconsin reporting regulations. Findings include:The facility's policy and procedure for Abuse Prevention, last reviewed November 2024, includes, in part.7. Reporting: a. Any employee who suspects an alleged violation immediately notifies the administrator. The administrator notifies the appropriate state agency immediately, following state law. b. The results of all investigations are reported to the administrator and the appropriate state agency, as required by state law and/or within 5 working days of the alleged violation. e. When reporting alleged abuse, neglect, or exploitation to the state of Nebraska, please email to: dhss.healthfacilityinvestigations@nebraska.gov .On 08/08/25 at 3:39 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A where did the facility policy titled, Abuse, Neglect, and Exploitation, and Suspected Crimes, come from. NHA A reported the facility uses Health Dimensions Group (HDG). Surveyor reported to NHA A that in #7 in the policy for reporting letter (e.) states when reporting to Nebraska and identifies an email located in Nebraska. Surveyor asked if NHA A knows why this policy is being utilized to train staff on proper reporting measures when allegations of abuse occur. NHA A reported the policy must have been for another facility building that is under the HDG company. Surveyor asked NHA A if there are any other policies that were reviewed with staff when educating about abuse and neglect concerns. NHA A reported other than Relias training the facility uses this policy that Surveyor is referring to. NHA A reported to Surveyor they do report all allegations to the State of Wisconsin, even though this error is in the abuse reporting policy. Surveyor verified that self reports have been being reported to the State of Wisconsin to the correct contact. NHA A stated the abuse policy will need to be updated with correct state regulations and contact information when training staff.

Based on observation, interview, and record review, the facility did not ensure the residents' environment remains as free of accident hazards as possible. Two of four residents (R) reviewed for falls with history of falls (R26 and R31) did not have post fall assessments, care plan interventions updated after falls, and had subsequent falls with major injuries. R26 and R31 are being cited at actual harm. R6 and R2 did not have post fall assessments and care plan updates after falls. One resident (R14) did not have a safety assessment or care plan for leaving facility campus and traveling on a busy highway with power wheelchair. R2, R6, and R14 are being cited at severity level 2 (potential for more than minimal harm). Observations of wet floors with no wet floor signs in place to prevent accidents occurred for R21, R13, R1, R187, and R186. Findings include: Facility policy and procedure entitled Accidents/Falls, last reviewed 11/2023, states in part: .5. Resident care plans should be evaluated and updated with each fall with a new and applicable intervention based on root cause. The focus is to be on prevention and maintaining a safe environment .Each incident/accident or fall must be investigated and/or assessed to determine the root cause of the episode to prevent any further injury .10. The resident's individualized care plan is to be updated with any changes or new interventions post fall/incident/accident, communicated to appropriate staff, and implemented . Example 1: R26 was admitted to the facility on [DATE] with the following diagnoses, in part, age-related osteoporosis without current pathological fracture, unspecified symptoms and signs involving cognitive functions following cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, history of falling, anxiety disorder, and difficulty in walking. On 07/30/24 at 9:08 AM, Surveyor interviewed R26 who stated they fell sometimes and had a fall that resulted in a right shoulder fracture. Review of R26's medical record identified a fall risk assessment dated [DATE] that indicated R26 had 1 to 3 falls in the past 3 months and was assessed at risk for falls. R26's medical record identified R26 had an unwitnessed fall in the bathroom on 03/22/24. R26 reported hitting the back of head on the toilet during the fall. The fall risk screening tool completed after R26's fall on 03/22/24 identified R26 at risk for falls. The Interdisciplinary Team (IDT) Post Fall Review, dated 03/28/24, states in part, .Describe new fall prevention interventions to be implemented as a result of the assessment: resident is not to be left in the bathroom unattended . Surveyor reviewed R26's Safety/Falls care plan and did not identify any updated interventions to include not leaving R26 unattended in the bathroom. Surveyor identified an incident note dated 04/25/24 that indicated R26 had an unwitnessed fall in the bathroom that resulted in a laceration on left eyelid, laceration on right side of chin, and moderate amount of bleeding from nose. R26 was transferred to the hospital for evaluation. Surveyor was unable to identify an Interdisciplinary Team (IDT) post fall review completed after the fall on 04/25/24. The hospital discharge summary dated 04/30/24, states in part, .suffered a mechanical fall resulting in a right shoulder fracture on 04/25/24. Patient underwent ORIF [Open Reduction Internal Fixation surgery] on 04/25/24 . On 08/01/24 at 12:30 PM, Surveyor interviewed Director of Nursing (DON) B and asked if R26's Safety/Falls care plan was updated after the fall on 03/22/24. DON B reviewed the documents and stated the IDT review recommended resident is not left alone in the bathroom to prevent future falls after the fall on 03/22/24. DON B reviewed R26's care plan and stated it did not look like it was updated with this new intervention after R26's fall on 03/22/24. DON B stated they could not locate a post fall IDT review of R26's fall on 04/25/24. DON B stated R26's Safety/Falls care plan should have been updated with the IDT recommendation after the fall on 03/22/24 to try to prevent future falls. 43352 Example 2: R31 was admitted to the facility on [DATE] and has diagnoses that include anxiety disorder, hypertension, depression, and congestive heart failure. On 05/08/24, a fall risk assessment was completed. R31 was marked as being a fall risk, reason general weakness related to recent hospitalization . On 05/30/2024 at 1:43 PM, a nurse progress note read, Resident has had two falls today. First fall was at 9am resident received a skin tear consistent with partial degloving of right forearm, area was cleansed and skin was reapproximated and steri stripped, covered with gauze and wrapped with kerlix. Resident assisted to go to exercise per her request. Resident vitals stable after fall. Did not hit head as fall was witnessed. Resident then fell at 1300, unwitnessed. Complained of right shoulder and hip pain, bleeding from right great toe skin tear to left hand and bleeding noted in her mouth. Resident was not moved from the floor. 911 was called. Unable to obtain BP due to complaints of pain 97.7-18-106 95%. Resident left facility at 1330 via ambulance in c-collar due to unwitnessed fall. Resident did receive ativan this am per request for anxiety. Hospital discharge summary, dated 05/30/24, read in part, Diagnoses: compression fracture of C7 vertebra and multiple skin tears. On 08/01/24 at 9:43 AM, Surveyor asked DON B for fall investigations. On 08/01/24 at 10:28 AM, DON B brought in what they had and indicated there is no fall investigation or interventions that were put into place after R31's fall on 5/30/24 at 9:00 a.m. R31 then fell again at 1:00 p.m. and sustained a compression fracture of C7. 47807 Example 3: R6 was admitted to the facility on [DATE] and has diagnoses that include hypertension, neurogenic bladder, dementia, depression, and cataracts. R6's most recent Minimum Data Set (MDS) indicated that R6 has had two or more falls since admission to the facility. R6's care plan related to falls states: At Risk for Complications with OR falls R/T current medical / physical status. Has meds/dx that can/may affect fall risk. On 06/11/24 at 9:00 AM, a nurse progress note related to R6's fall read that the writer was paged to resident's room for a fall. Writer was informed that a CNA was using the sit to stand with R6 when R6 tried to pull himself all the way up, which caused the sling to become unattached. The Certified Nursing Assistant (CNA) stayed and was able to lower R6 to the ground. Registered Nurse arrived to assess and help. R6 stated they did not know how that happened. On 08/01/24 at 2:20 PM, Surveyor asked DON B for fall investigations. On 08/01/24 at 2:38 PM, DON B brought in what they had and indicated there was no evidence of an IDT review and care plan update after the fall occurred, only the initial assessment found after the fall took place. 48793 Example 4: R2 was admitted on [DATE]. R2's diagnoses include pressure ulcer to the left heel, pyogenic arthritis, emphysema, anemia, and type 2 diabetes mellitus. R2's MDS assessment, completed on 05/30/24, confirmed R2 scored 15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R2 has impairment to lower extremities bilaterally. R2 needs partial to moderate assistance during transfers from bed to wheelchair. Surveyor reviewed R2's medical record and documentation indicated that R2 had falls on: -08/07/23 R2 had an unwitnessed fall in the bathroom. R2 had no injuries, physician was notified. -02/06/24 R2 had an unwitnessed fall in R2's room next to R2's bed. R2 had no injuries, physician was notified. -06/16/24 R2 had unwitnessed fall in the hallway. R2 suffered several skin tears to the scalp, face, and right knee. -06/30/24 R2 had unwitnessed fall in R2's room in front of wheelchair. R2 had no injuries, physician was notified. Review of R2's medical record identified a fall risk assessment dated : -11/29/23 R2 had 1 to 3 falls in the past 3 months and was assessed at risk for falls. -02/10/24 R2 had 1 to 3 falls in the past 3 months and was assessed at risk for falls. -03/01/24 R2 had 1 to 3 falls in the past 3 months and was assessed at risk for falls. -04/30/24 R2 had 1 to 3 falls in the past 3 months and was assessed at risk for falls. -06/17/24 R2 had 1 to 3 falls in the past 3 months and was assessed at risk for falls. Review of R2's medical record identified the Interdisciplinary Team (IDT) Post Fall Review, dated 07/02/24, stated in part, .Describe new fall prevention interventions to be implemented as a result of the assessment: Remind [R2] to use call light and wait for staff to assist with transfers to prevent falls/injuries . No other IDT reviews were found for previous falls. Surveyor reviewed R2's Safety/Falls care plan and did not identify any updated interventions after: -08/07/23 -02/06/24 -06/16/24. R2's care plan noted fall interventions placed on 04/05/24 for assistive device bilateral grab bars on bed to aid in bed mobility. R2's care plan noted fall interventions placed on 06/25/24 for call light positioned for easy access. Has visual reminders in room to use call light. Surveyor identified an incident note dated 04/25/24 that indicated R26 had an unwitnessed fall in the bathroom that resulted in a laceration on left eye lid, laceration on right side of chin, and moderate amount of bleeding from nose. Surveyor was unable to identify an IDT post fall review completed after the fall on 04/25/24. On 08/01/24 at 8:47 AM, Surveyor asked DON B for fall investigations. On 08/01/24 at 10:28 AM, DON B brought in what they had and indicated there is not much documentation on R2's falls and only one IDT review was found. DON B indicated that staff will be educated on fall preventions and to correctly document falls and interventions put into place. Example 5: On 07/31/24 at 8:12 AM, Surveyor observed Housekeeper P cleaning R21's room. Surveyor observed Housekeeper P mopping R21's floor. Housekeeper P did not place wet floor sign outside R21's room to show the floor was still wet. Housekeeper P walked down hallway to the next room. On 07/31/24 at 8:16 AM, Surveyor observed Housekeeper P cleaning R13's craft room. Surveyor observed Housekeeper P mopping the floor. Housekeeper P did not place wet floor sign outside of the craft room to show the floor was still wet. Housekeeper P walked down hallway to the next room. Surveyor observed R13 wheel into R13's craft room in wheelchair. On 07/31/24 at 8:42 AM, Surveyor observed Housekeeper P cleaning R1's room. Surveyor observed Housekeeper P mopping R1's floor. Housekeeper P did not place wet floor sign outside R1's room to show the floor was still wet. Housekeeper P walked down hallway to the next room. On 07/31/24 at 9:31 AM, Surveyor observed Housekeeper P cleaning R187's room. Surveyor observed Housekeeper P mopping R187's floor. Housekeeper P did not place wet floor sign outside R187's room to show the floor was still wet. Housekeeper P walked down hallway to the next room. On 07/31/24 at 9:40 AM, Surveyor observed R187 wheel electric wheelchair in room. Surveyor observed floor still to be wet. On 07/31/24 at 9:45 AM, Surveyor observed Housekeeper P cleaning R186's room. Surveyor observed Housekeeper P mopping R186's floor. Housekeeper P did not place wet floor sign outside R186's room to show the floor was still wet. Housekeeper P walked down hallway to the next room. On 07/31/24 at 9:46 AM, Surveyor interviewed Housekeeper P and asked what expectation is for placing yellow wet signs out after mopping resident rooms and common areas. Housekeeper P indicated that Housekeeper P never was really told if wet signs should be placed or not. Surveyor asked Housekeeper P how Housekeeper P would prevent residents or staff from slipping or injuring themselves if there was not a yellow wet sign out to warn them that the floor is potentially wet. Housekeeper P indicated that Housekeeper P would start placing wet floor signs out after mopping rooms and common areas. On 07/31/24 at 2:10 PM, Surveyor interviewed DON B and asked what expectation was for Housekeeper P utilizing wet floor signs after mopping. DON B indicated that after mopping anywhere in the facility, a yellow wet floor sign should be placed in visible view to all traffic to prevent residents, family members, and staff from slipping and falling on wet floors. DON B indicated that Housekeeper P should have been using yellow wet floor signs after mopping all areas. Example 6: Facility policy and procedure entitled Resident Leave of Absence, last revised 11/22, stated: When a resident leaves the facility, it will be documented as to the intent of the resident's absence, when the resident left, with whom, and the expected time of return. R14 was admitted to the facility on [DATE] with the following diagnoses, in part, stage 4 pressure injury to the sacral region, type 2 diabetes mellitus, morbid obesity, and paraplegia as a result of traumatic spinal cord injury. On 07/31/24 at 11:21 AM, Surveyor asked CNA E where R14 was, so Surveyor could observe R14's safety with smoking. CNA E stated R14 had checked out smoking materials a while ago. CNA E stated that R14 was going to Subway for lunch and was probably still gone from the facility. Surveyor asked CNA E how R14 gets to Subway. CNA E stated R14 travels down there in the power wheelchair. Surveyor noted Subway was slightly over one mile from the facility, and R14 must travel on a busy state highway with a hill and curve in the road to get to Subway. Surveyor was unable to find any safety assessments or safety care plan or any documentation on R14's medical record that addressed R14 leaving the facility campus and traveling down the highway in a power wheelchair to Subway. On 08/01/24 at 8:06 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about R14 leaving facility campus and traveling to Subway in a power wheelchair. NHA A was not aware that this was occurring. NHA A did not know if any safety assessments had been completed related to R14 leaving the campus and traveling down the highway in the power wheelchair. NHA A did not think this was a safe practice and would look into it. On 08/01/24 at 8:15 AM, Surveyor interviewed CNA E who reported R14 signed out on a clipboard kept at the medication cart when going out to smoke or to Subway, and then signed back in upon return. Surveyor asked CNA E if there was any kind of safety assessment completed or a safety care plan related to R14 leaving the facility campus to go to Subway. CNA E did not know if a safety assessment was done or if there was a safety care plan related to R14 traveling down the highway in the power wheelchair. On 08/01/24 at 9:30 AM, Surveyor interviewed DON B and asked if a safety assessment was completed and safety care plan in place related to R14's leaving the campus to go down the highway in a power wheelchair to Subway. DON B was not sure due to being new to the facility but did not think there was a care plan or safety plan or agreement in place for this situation. DON B would look to see what was completed related to this situation. Surveyor asked if the facility had a policy and procedure related to Leave of Absence (LOA) for residents that would apply to this situation. DON B stated they probably have a policy but did not think it was implemented in R14's situation. On 08/01/24 at 10:11 AM, Surveyor interviewed Registered Nurse (RN) D who stated there was no formal safety assessment completed related to R14's safety to leave the campus and travel down the highway to Subway. RN D stated they did get a flag for the wheelchair but did not know if the flag was on the wheelchair. RN D stated someone viewed R14 traveling down the road in the wheelchair and R14 did travel on the correct side of the road and was viewed as safe to do this, but no formal assessment had been done. Surveyor asked RN D if they had developed a safety agreement or plan related to R14 leaving the facility campus and traveling down the busy state highway in a power wheelchair. RN D stated nothing like that had been done. RN D stated, I suppose it should be care planned, but [R14] does sign out when leaving the building. On 08/01/24 at 11:25 AM, Surveyor observed R14 exit the building to smoke. R14 did not have a flag on the power wheelchair.

Based on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 33 residents in the facility. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to effect 33 of 33 residents reviewed. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 and Norovirus during an outbreak. -Observations were made of the facility not implementing Enhanced Barrier Precautions (EBP) for 2 of 3 sampled residents (R187, R186) on EBP. -Certified Nurse Assistants (CNA) were observed not wiping down Hoyer lifts after leaving an EBP room. -Registered Nurse (RN) did not follow appropriate infection control practices during wound care for 2 of 4 (R2, R7) sampled residents. This is evidenced by: Example 1 The facility policy entitled, Water Management Program, dated 11/2022, states in part: Infection Control - . #2. Develop a description of the facilities water system, including narrative description and a process flow diagram . #3. Risk Assessment - will be conducted by water management team annually to identify where legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. #4. Establish control measures, control limits, and control measures monitoring plan . #6. The measures shall be specified in the water management program action plan. The Center for Disease Control and Prevention (CDC) guidelines entitled, Controlling Legionella in potable water systems, last reviewed March 15, 2024, states in part: Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. On 08/01/24 at 8:04 AM, Surveyor reviewed the facility's Water Management Plan (WMP) and did not find a record of maintenance, inspections, or flushing of areas of concerns that required flushing. Surveyor did not observe the updated version of water management plan being utilized. Surveyor did not observe the flow diagram or WMP updated with locations of hot spots/stagnation areas deemed high risk areas of Legionella growth. Surveyor did not observe an annual risk assessment completed at all. Surveyor observed that the water management plan was copied and printed from CDC recommendations but was not individualized specific to the facility water systems. On 08/01/24 at 10:03 AM, Surveyor interviewed RN D, the Infection Control Nurse, who indicated that RN D and maintenance are responsible for the water management plan in the facility. Surveyor interviewed RN D and asked to walk Surveyor through the WMP. RN D indicated the current WMP that the facility is using does not show distinct quality measures on the flow diagram or where stagnation/hot spots are located throughout the facility. RN D indicated that nothing has specified locations, and the flow diagram shows just description such as water heater, fountain, etc. but not where these items are located through the building and what is being assessed. RN D indicated the WMP was printed directly from the CDC and not individualized. RN D indicated there were no audit logs being completed by the facility. Example 2 Surveyor reviewed Infection Control (IC) surveillance logs and found the facility identified the facility had an outbreak of Norovirus in April 2024. Line lists did not consist of any other information. Surveyor could not distinguish when outbreak began and when outbreak ended and how many residents and staff were affected by the outbreak. Surveyor observed data logs to be inconsistent and missing residents' identifiers and room numbers. Surveillance logs were observed missing information identifying onset of symptoms, when precautions were implemented, any testing, last well date, when symptoms ended, when precautions ended, and if provider was notified. Surveyor reviewed IC 2023-June 2024 data line lists for residents and staff. Surveyor noted that all line lists from January 2023-June 2024 were inconsistent and missing data. Surveyor reviewed and noted line lists were missing the infection site, pathogen, signs and symptoms, residents' or staff's location, last well date, any summary and analysis of the number of residents and staff who developed infections. Line lists had incomplete data. On 08/01/24 at 10:03 AM, Surveyor interviewed RN D who confirmed there was another outbreak of COVID-19 but that no documentation was found. RN D indicated that RN D could not find any information or line lists pertaining to the COVID-19 outbreak. RN D could not confirm who all was affected by the outbreak and what measures the facility did to mitigate the spread of COVID-19. Surveyor asked RN D if there was any other information that RN D could provide Surveyor pertaining to the documentation of the COVID-19 outbreak. RN D indicated that RN D had no other information as the COVID-19 outbreak was not surveilled as it should have been. Surveyor asked RN D about the process for tracking surveillance of resident infections and sicknesses. RN D indicated that line lists were incomplete throughout the whole year last year in 2023 and into June of 2024. Example 3 The facility policy entitled, Enhanced Barrier Precautions, dated 04/1/24, states in part: . EBP precautions will be applied for any resident high contact care activities involving residents who have wounds, indwelling medical devices, and infections. Precautions include use of gown, gloves and will be used with any high contact activities including dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting care . On 07/30/24 on 9:37 AM, Surveyor observed CNA H and CNA Q enter R187's room. R187 is on EBP due to chronic open wounds on the buttocks. CNA H and CNA Q entered the room without applying Personal Protective Equipment (PPE). CNA H and CNA Q performed peri cares on R187 and then transferred R187 with Hoyer to R187's wheelchair. CNA H and CNA Q pushed Hoyer lift out of R187's room without wiping down the Hoyer lift and exited R187's room. CNA H and CNA Q sanitized hands after walking to soiled room to dispose of soiled trash. Example 4 On 07/30/24 at 2:56 PM, Surveyor observed CNA J, CNA L, and CNA M don PPE before entering R186's room to provide cares. R186 is on EBP due to having a catheter. On 07/30/24 at 2:59 PM, Surveyor observed CNA M walk out of R186's room and down the hall wearing full PPE from R186's room. CNA M was observed walking down hall in full PPE and entering clean linen closet to obtain clean linens. Surveyor observed CNA M walk back down the hallway with full PPE and back into R186's room. On 07/30/24 at 3:07 PM, Surveyor observed CNA J, CNA L, and CNA M walk out of R186's room with PPE on and park the Hoyer lift outside in hallway. CNA J, CNA L, and CNA M doffed their PPE in the hallway where R186's PPE trash can is located. CNA J, CNA L, and CNA M walked down the hallway and into a storage break room. Surveyor did not observe hand sanitizing performed. Example 5 On 07/30/24 on 9:37 AM, Surveyor observed CNA H and CNA Q enter R187's room, who is on EBP. CNA H and CNA Q performed peri cares on R187 and then transferred R187 with Hoyer to R187's wheelchair. CNA H and CNA Q pushed Hoyer lift out of R187's room without wiping down the Hoyer lift and exited R187's room. CNA H and CNA Q sanitized hands after walking to soiled room to dispose of soiled trash. CNA H and CNA Q did not return to sanitize the lift. Example 6 On 07/31/24 at 10:58 AM, Surveyor observed RN C enter R2's room. RN C washed hands for 5 seconds and dried hands with paper towels. RN C applied gloves and placed new paper towels on floor next to R2 to create a barrier on the floor. RN C took R2's shoes and socks off and placed to the side. RN C opened a blue gown with contaminated gloves and placed blue gown on. RN C gathered supplies out of closet drawer where wound supplies were stored with contaminated gloved hands. RN C laid them on the paper towels on the floor. RN C changed gloves and reapplied a pair of gloves without performing hand hygiene in between glove use. RN C proceeded to grab the wound care solution bottle and spray gauze and then wash the surface of the right great toe wound. RN C then grabbed mepilex dressing and applied the dressing to the right great toe wound. RN C took gloves off and reapplied another pair of gloves without performing hand hygiene in between glove use. RN C proceeded to grab the wound care solution bottle, spray gauze and then wash the surface of the left great toe wound. RN C stated, I forgot the scissors. RN C walked over to the dresser drawer and grabbed the scissors out with the contaminated gloves, then grabbed the sterile pack of Aquacel, opened the package and grabbed the whole sheet of Aquacel out of the package. RN C cut the length needed for dressing change and then laid supplies on the paper towel surface on floor. RN C then opened Mepilex package and grabbed the piece of Aquacel and applied the Aquacel to R12's left great toe. Surveyor observed RN C place the plastic film side of the Aquacel directly on R2's wound. RN C then took Mepilex dressing and applied to R2's left great toe wound. RN C then grabbed the Aquacel pad and readjusted the big piece of supplies and placed it back in the packaging and rolled the top down. RN C picked up all the supplies with the right contaminated gloved hand. While RN C held the supplies in the right hand, RN C picked up the trash on the dirty paper towels on floor and threw in the trash. RN C then grabbed the supplies with the contaminated left hand and placed the supplies back into the wound supply drawer. RN C took gloves off and exited R2's room. Surveyor did not observe RN C perform hand hygiene after exiting R2's room. On 07/31/24 at 11:08 AM, Surveyor interviewed RN C and asked about hand hygiene practices during wound care. RN C indicated that RN C used gloves often and sanitized as needed. RN C admitted to not washing hands or using hand sanitizer between glove changes. Interviews On 08/01/24 at 10:03 AM, Surveyor interviewed DON B and asked about Infection Control (IC) management through the building. DON B indicated that IC is lacking in many ways as there has been huge turn over with staff and going forward DON B will be implementing new measures and will be involved with managing IC. On 08/01/24 at 11:10 AM, Surveyor interviewed RN D and asked about hand hygiene practices. RN D indicated that expectation is that hands are to be sanitized between glove changes and before or after leaving a resident's room. Surveyor indicated to RN D that Surveyor had observations of staff not utilizing PPE in EBP rooms and exiting EBP rooms with PPE still on. Surveyor also indicated that equipment being used in EBP rooms was not being wiped down appropriately. RN D indicated that it is expectation that all staff follow the EBP policy through the whole facility and don and doff PPE according to EBP policy. RN D indicated that any equipment that is utilized in EBP rooms is to be wiped down thoroughly with sanitizing wipes if equipment is used for other residents. 40181 Example 6 Facility policy and procedure entitled Handwashing, last revised 11/22, stated in part: .Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Alcohol based hand sanitizer should be used: Immediately before touching a patient .before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or the patient's immediate environment. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal . Resident (R) 7 was admitted to the facility on [DATE] with diagnoses including, in part, malignant neoplasm of endometrium, unspecified wounds left lower leg, local infection of the skin and subcutaneous tissue, and cellulitis of left lower limb. On 07/30/24 at 10:07 AM, Surveyor interviewed R7 who stated they had wounds on lower legs and the nurse changed bandages daily. Surveyor asked if R7's wounds were infected. R7 stated they had recently been on antibiotics for infection in the leg wounds, but they were better now. Surveyor reviewed R7's medical record and identified the following physician orders: 07/10/24 Apply hydrofera blue to Left Ankle wound, cover with 4x4 Mepilex dressing. Change daily. (& prn to keep ulcer covered) may wrap to reinforce dressing(s). one time a day Left Ankle ulcer. 07/10/24 Right & left medial ankle - open areas. cleanse, dry, Aquacel overtop & beyond open areas, followed by mepilex dressing. Change daily & prn. may wrap legs to reinforce dressings. one time a day for open areas right lower leg/ ankle & left medial ankle. 01/23/24 Cover left ankle ulcer &/or right medial thigh PRN excessive drainage. per hospice. Use mepilex or ABD pad & tape, use nurse judgement as needed for excess drainage. On 07/31/24 at 9:49 AM, Surveyor observed RN C provide wound care for R7's lower leg wounds in R7's room. RN C used Alcohol Based Hand Rub (ABHR) at the doorway of R7's room and donned gown and gloves upon entering the room. With gloved hands RN C pushed R7 in the wheelchair directly in front of a dresser in the room. With gloved hands RN C opened the bottom drawer of the dresser which was filled with dressing supplies. RN C removed the old dressing from the left outer ankle and threw it in the waste basket beside the dresser. With the same gloves on, RN C reached in the drawer and took several gauze pads out of a package, picked up a bottle of wound wash, wet the gauze pads, and washed the wound on R7's left outer ankle. RN C disposed of the gauze pads used to wipe the wound. With the same gloves on, RN C reached in the drawer and took a piece of hydrofera blue dressing out of an opened package in the drawer. RN C cut the blue dressing with a scissors from the drawer. RN C placed the remaining blue dressing back in the opened package in the drawer and placed the scissors on the bottom of the drawer. RN C did not sanitize the scissors before or after use. With the same gloves on and while holding the cut blue dressing in one hand, RN C opened the second drawer on the dresser and took out a package with an ABD pad, opened the package and placed the blue dressing on the ABD pad. RN C placed the ABD pad and blue dressing in their lap while squatted down in front of R7's wheelchair. With the same gloves on, RN C took a piece of Aquacel dressing out of an opened package in the drawer and cut it with the scissors. RN C did not sanitize the scissors before or after use. RN C placed the remaining Aquacel dressing back in the opened package in the drawer. While holding the Aquacel dressing in one hand, RN C reached in the second drawer and took out a second ABD pad, took it out of the package, and placed the Aquacel dressing on top of the ABD pad. RN C then placed the ABD on top of the other ABD pad in their lap. With the same gloves on, RN C removed the old dressing from R7's left inner ankle and threw it in the trash. With the same gloves on, RN C took some gauze pads out of the opened package in the drawer, picked up the wound wash bottle, and wet the gauze pads. RN C wiped the wound on R7's left inner ankle and threw the gauze pads in the trash. With the same gloves on, RN C took a package of roll gauze out of the drawer and opened it. RN C placed the ABD pad with the hydrofera blue dressing on the left outer ankle and the ABD pad with the Aquacel dressing on the left inner ankle and then wrapped the roll gauze around the dressings to hold them in place. RN C cut the roll gauze with the scissors from the drawer and placed the remaining roll and scissors back in the drawer. RN C took tape out of the drawer and taped the roll gauze in place. With the same gloves on, RN C removed the old dressing from R7's right ankle and threw it in the trash. With the same gloves on, took several gauze pads out of the opened package in the drawer, picked up the bottle of wound wash and wet the gauze pads. RN C wiped R7's wound on the right ankle with the wet gauze pads. RN C threw the gauze pads in the trash. With the same gloves on, RN C took a mepilex dressing out of the drawer and opened the package. While holding the mepilex dressing in one hand, RN C took the Aquacel dressing out of the opened package in the drawer and cut a piece with the scissors from the drawer. RN C placed the remaining Aquacel dressing back in the open package in the drawer and placed the scissors back in the drawer. RN C placed the cut piece of Aquacel dressing over the wound on R7's right ankle and covered it with the mepilex dressing. RN C removed gloves and gown and threw away. RN C did not use ABHR or wash hands after removing gown and gloves. RN C took a pen out of uniform pocket and wrote on the dressings. RN C placed supplies back in the drawers and closed the drawers. RN C put on clean gloves without using ABHR or washing hands and took the plastic bag liner out of the trash can, tied it, and set it on the floor. RN C placed a new plastic bag in the trash can. RN C picked up the tied bag with gloved hands and left resident room. R7 asked Surveyor a question as RN C was leaving the room, so Surveyor did not observe RN C after they left the room with the trash bag and gloves on. Surveyor noted RN C did not change gloves or sanitize hands or scissors at any time during the wound care procedure. RN C touched multiple dressing supplies and surfaces with contaminated gloves during the wound care procedure. RN C did not sanitize or wash hands after removing gown and gloves and before putting clean gloves on. On 07/31/24 at 11:52 AM, Surveyor interviewed RN C about the above observation and asked what the facility procedure was for glove use, glove change, and hand hygiene during wound care. RN C stated they should wash hands or use ABHR before putting on gloves and when they change gloves. Surveyor asked if RN C changed gloves or used ABHR at any time during the wound care procedure. RN C said they used ABHR before putting on the gown and gloves prior to providing wound care. Surveyor asked RN C if they should change gloves and use ABHR after removing old dressings and cleaning wounds, and before touching or cutting new dressings. RN stated they probably should do that but did not do that today during R7's wound care. On 07/31/24 at 12:12 PM, Surveyor interviewed Director of Nursing (DON) B and reviewed the above wound care observation performed by RN C. Surveyor asked DON B what the expectation would be for hand hygiene, and glove changes during wound care procedures. DON B stated RN C should use ABHR or wash hands before starting, and every time they change gloves. DON B stated RN C should remove gloves, use ABHR, and put on clean gloves after removing old dressings, cleaning wounds, and before touching clean dressings. DON B stated the scissors used to cut dressings should be sanitized with an alcohol wipe before use. DON B stated RN C should wash hands with soap and water after removing gown and gloves when wound care procedure is completed. DON B stated RN C did not perform appropriate infection control procedures during this wound care observation and education would be provided.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility did not ensure that food that was opened was thrown out according to policy. The facility did not cover food as it was being distributed in the hallways. The facility did not ensure staff used proper hand hygiene when distributing food and that hair nets were in place. This has the ability to affect all 33 of 33 residents residing in the facility. Findings include: Example 1 Expired/undated food The facility policy entitled, Food Storage, dated year 2021 states, 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days of discarded as per the 2017 Federal Food Code. On [DATE] at 8:30 AM, Surveyor performed initial tour of kitchen where they noted items in the refrigerator that were leftovers having open dates of: Diced pineapple dated [DATE] Diced potatoes dated [DATE] Pudding [DATE] Poke cake [DATE] Ham [DATE] Lobster meat was not dated On [DATE] at 8:59 AM, Surveyor interviewed Culinary Director (CD) G regarding policy for food that was opened and the storage of that food. CD G said they would expect that all foods that have been opened should be dated with the open date and throw out at a maximum of five days later. Surveyor then showed CD G the items in the fridge to which they said they would have expected those foods to be thrown out. Example 2 Uncovered food On [DATE] at 12:17 PM, Surveyor observed orange sherbert being distributed to residents eating in their own rooms that were not covered when being walked down the hallway of the facility on trays. The food items were open to the air around them. R28, R5, R13, R20, and R21 were all served the uncovered sherbert after it was walked down the hallways in the facility past the rooms of other residents. This had the potential to contaminate the sherbert. On [DATE] at 11:47 AM, Surveyor interviewed CD G regarding their expectations of food being covered when distributing to residents' rooms. CD G would expect that all foods that will be traveling outside of the dining area would be covered, and we have been working on that. There was no policy received regarding the covering of foods while being distributed to residents who choose to eat in their rooms. 43352 Example 3 The facility policy, entitled Employee Sanitary Practices states in part, All employees wear hair restraints to prevent to prevent hair from contacting exposed food. On [DATE] at 8:26 AM, Surveyor observed Dietary Aide (DA) F serving breakfast on [NAME] household. DA F had a hair net on that did not completely cover all DA F's hair. DA F's bangs and hair around frame of face was not covered with the hair net. On [DATE] at 8:57 AM, Surveyor observed Certified Nursing Assistant (CNA) H in kitchenette preparing a breakfast tray. CNA H had their hair pulled back but not in a hair net. On [DATE] at 9:22 AM, Surveyor interviewed Culinary Director (CD) G and asked if they require all hair to be covered by a hair net. CD G indicated yes. Example 4 The facility policy, entitled Bare Hand Contact with Food and Use of Plastic Gloves, reads in part Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. On [DATE] at 8:30 AM, Surveyor observed DA F put on gloves; no hand washing was observed prior to donning gloves. DA F grabbed bread from bag, put in toaster, pressed the lever down with same gloved hands, then opened up milk, poured a glass of milk, grabbed meal ticket, grabbed toast from toaster, buttered toast, cut toast in half on the cutting board, then removed gloves, washed hands and with bare hands picked up buttered toast and put it on a plate. CNA H said to DA F, You forgot to put gloves on. DA F said, Yeah I know I just washed my hands. On [DATE] at 8:41 AM, Surveyor observed DA F put on gloves; no hand washing was observed prior to donning of gloves. DA F grabbed bread out of bag with same gloved hands, put bread in the toaster, pushed the lever down, touched plastic covered menu, then went to the toaster, grabbed the toast with same contaminated gloved hands. DA F put butter and jelly on the toast holding on to it with the same gloved hands. On [DATE] at 9:22 AM, Surveyor told CD G about the above observations. CD G said, I see where that is going. Surveyor asked CD G if DA F did the above properly. CD G indicated no.

Based on observation, interview and record review, the facility did not ensure that 2 of 4 residents (R) reviewed for pressure injuries (PI) (R2 and R187) received care consistent with professional standards of practice to promote healing of existing PIs. R2 developed an unspecified injury stage PI to the left heel on 05/30/23 and an ulcer to the great right toe. On 07/09/24, the PI reoccurred to the left heel and the right great toe. On 07/09/24, a new PI occurred to the left great toe. The care plan for PI interventions was not updated since 08/14/23. R2 was not repositioned or encouraged as needed for pressure relief as instructed on the PI care plan. R187 was admitted to the facility with a stage 3 PI to the left posterior thigh. The facility did not ensure R187's buttocks/thighs were protected, did not reposition R187, and inconsistent assessments of the wounds were noted. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 07, March 2024, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side-lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free from the bed, use heel offloading devices for high-risk pressure injuries. The facility policy entitled, Pressure Ulcer/Skin Integrity, stated in part, .1. Upon admission, and thereafter, residents will be assessed for the potential risk for skin breakdown resulting from bony prominences. -2. Skin inspection upon admission, and thereafter, a skin inspection will be completed to identify pre-existing, or potential areas of skin breakdown over bony prominences. It is recommended that assessments be completed as soon as reasonably but not to exceed 24 hours after admission. -4. Wound identification: i. Differentiate the type of wound. ii. Determine wound stage. iii. Describe and monitor the wounds characteristics. iv. Monitor for progress toward healing. vii. Monitor dressings and treatments. -5. Treatment/ Management: residents will receive services treatment/services include: ii. Pressure relieving equipment. iii. Repositioning or off-loading. -6. Documentation: b. Wound documentation is more detailed than routine skin documentation and shall include information related to the wound based on a clinical assessment. -7. Care Planning: b. Comprehensive resident-centered care pans will be developed per the RAI/Care plan timelines and reviewed/revised thereafter . Example 1 R2 was admitted on [DATE]. R2's diagnoses include pressure ulcer to the left heel, pyogenic arthritis, emphysema, anemia, and type 2 diabetes mellitus. R2's Minimum Data Set (MDS) assessment, completed on 05/30/24, confirmed R2 scored 15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R2 requires partial to moderate assistance with rolling from side to side and transferring from bed to wheelchair. R2's care plan was initiated on 05/10/23 and revised on 11/06/23, and included the following interventions: Activities of Daily Living: -Transfers: Assist of one. Skin Integrity: -Assist/encourage pressure relief as needed/accepted. R2's physician orders on include: -Left great toe-aqualcel and mepilex, right great toe mepilex, monitor heels, float heels as much as possible, every 48 hours for wound care. -Encourage to elevate feet frequently throughout the day, wear Podus boots or float heels on pillow while in bed, encourage to remove shoes when in recliner four times a day for pressure reduction measures. -Offload plan: Frequent position changes independently or with assistance. Custom orthotics and/or insoles per orthotist evaluation. Removing shoes when at rest and not ambulating, floating the heel off the bed by applying pillow under calves and custom booties to be worn while in bed to off-load heels every shift. - Assess skin and complete skin assessment form, and document, one time a day every Wed for ongoing monitoring. The care plan has no new PI interventions since 11/06/23. Surveyor reviewed documentation and found no Braden Score identifying R2 as a risk for pressure injuries. Review of nursing documentation on 07/09/24 showed left great toe 1st lateral toe had measurements L 0.7 cm W 0.5 cm, D 0.2 cm. No documentation about the PI care or comprehensive assessment of the PI on R2's left great toe. Review of nursing documentation on 07/16/24 showed left posterior heel had circular reddened area measures L1 cm W 1 cm, and D 0. Right toe No skin problems of right foot, and left great toe 1st lateral toe had serous drainage measuring L 0.6 cm W 0.5 cm, D 0.1 cm. Review of nursing documentation on 07/30/24 showed left posterior heel had circular reddened area measures L1 cm W 1 cm, and D 0. Right toe No skin problems of right foot, and left great toe 1st lateral toe had serous drainage measuring L 0.5 cm W 0.4 cm, D 0.1/0.1 cm. No further documentation about PI care or the comprehensive assessment of the PI on R2's left heel, left great toe, and right great toe was found on the medical record until 07/09/24. No documentation of updates about the PI to R2's physician was found on the medical record during that time frame. No documentation of dressing changes to wounds were found nor any other measurements and condition of the wound bed of the left and right great toe wounds. The orders for wound care during that time frame were for wound care every two days. On 07/30/24 at 1:27 PM, Surveyor observed R2's shoes on while in recliner with feet lying flat against recliner footrest, no pillow underneath to float heels. Surveyor did not observe Podus boots applied to R2 while in recliner and the Podus boots were observed located across the room stored on spare chair. On 07/30/24 at 2:58 PM, Surveyor observed R2's shoes on while in recliner with feet lying flat against recliner footrest, no pillow underneath to float heels. Surveyor did not observe Podus boots applied to R2 while in recliner and the Podus boots were observed located across the room stored on spare chair. On 07/31/24 at 1:51 PM, Surveyor observed R2's shoes on while in recliner with feet lying flat against recliner footrest, no pillow underneath to float heels. Surveyor did not observe Podus boots applied to R2 while in recliner and the Podus boots were observed located across the room stored on spare chair. On 07/31/24 at 10:58 AM, Surveyor observed Registered Nurse (RN) C enter R2's room. RN C indicated that wound dressing changes were performed yesterday on 07/30/24 but RN C would remove dressings and redress R2's wounds so Surveyor could see wounds on R2's feet bilaterally. RN C took R2's shoes and socks off and placed to the side. Surveyor assessed no dressings on R2's left foot or right foot. Surveyor assessed a dime size reddened opened circle area on R2's left great toe on top side of foot and a small reddened area with a small pen dot size scab to the right great toe area. On 07/31/24 at 11:08 AM, Surveyor interviewed RN C and asked why there was not a dressing in place if wound care was completed yesterday on 07/30/24. RN C indicated that RN C was unsure why dressing was not in place. RN C indicated that R2 is supposed to have aquacel applied with a mepilex in place on the left great toe and just a meplix applied to the right great toe. Surveyor asked RN C if R2's wounds were pressure related. RN C indicated that R2 has had bad edema a lot but that R2 wears R2's loafers all the time and it appears to look like pressure is causing the redness on the outer sides of the great toes bilaterally causing R2's great toes to break open. Surveyor asked RN C if R2 takes breaks from wearing loafers to prevent the pressure from occurring. RN C indicated that staff is supposed to encourage R2 to elevate legs and take loafers off when in recliner or in bed. On 07/31/24 at 2:10 PM, Surveyor interviewed Director of Nursing (DON) B and asked what expectation was for wound management and assessing R2's wounds on bilateral feet. Surveyor indicated that R2 did not have proper assessment completed for the new and old wounds that have opened back up on R2's feet. Surveyor stated to DON B that Surveyor could not find any documentation on when R2's left heel wound was healed and reoccurred. DON B indicated that DON B understands the facility is not completing weekly assessments adequately on R2. Example 2 R187 was admitted on [DATE]. R187's diagnoses include atrial fibrillation, edema, chronic obstructive pulmonary, morbid obesity, and peripheral vascular disease. Review of R187's baseline care plan initiated on 07/18/24 indicated: -Weekly skin check. -Review skin concerns with MD. -Pressure reduction cushion in wheelchair. -Pressure reduction mattress on bed. R187's physician orders on include: .-Apply triad paste over open slits to posterior thighs twice a day for skin breakdown, open slits. -May receive barrier cream of choice applying to the skin as indicated for preventative wound care as well as for the treatment of open areas every shift to peri area. -Pressure redistribution mattress low air loss every shift. -Skin management: Braden Scale-Admission. Weekly x4, Monthly one time a day every 4 weeks on Thursday. -Skin management: Braden Scale-Admission. Weekly x4, Monthly one time a day every Thursday. -Skin management: Weekly Body Observation and form to be completed 1x week every day shift every Saturday for prevention -weekly skin check tool . Surveyor reviewed documentation from an outside wound clinic R187 was attending before being admitted to the facility that noted stage 3 wound to the left posterior thigh full thickness measuring Length 4.6 cm, Width 2 cm, and Depth 0.1 cm. Recommendations suggest off-loading wound, low air mattress, reposition per facility protocol, turn side to side in bed every 1-2 hours. Review of nursing documentation on 07/18/24 showed left buttock open area no specification of type of injury with measurements containing length 1 cm and width 1 cm. Surveyor reviewed documentation on 07/20/24 Braden Scare completed with score of 15 high risk of skin breakdown. Summary findings indicate R187 requires assist with bed mobility admitted with open area to buttock. No further documentation about PI care or a comprehensive assessment of the PI on R187's buttocks was found on the medical record since admission on 07/18/24. No documentation of updates about the wound to R187's physician was found on the medical record during that time frame. On 07/31/24 at 6:43 AM-8:07 AM, Surveyor observed R187 lying in bed with head of bed positioned sitting upright at a 90-degree angle directly applying pressure to the buttocks. On 07/31/24 at 8:07 AM, Surveyor observed R187 being turned from side to side by staff for peri cares. Surveyor observed scattered open areas to the posterior sides of thighs and buttocks bilaterally. Surveyor also observed a dime size open sore that was pink/red in color located on R187's right posterior thigh/buttock area. R187 indicated to staff that R187's bottom hurts and itches. R187 asked CNA H to itch the area when CNA H applied Triad cream. Surveyor asked CNA H when these wounds were opened. CNA H indicated that CNA H is unsure, but they apply barrier cream as much as they can. On 07/31/24 at 2:10 PM, Surveyor interviewed DON B and asked what expectation was for wound management and assessing R187's posterior thigh/buttocks PIs. Surveyor indicated that R187 did not have proper assessment completed for the new wounds that have opened on R187's posterior right thigh and buttock. Surveyor indicated to DON B that Surveyor cannot find proper assessments completed weekly for measurements, and condition of the wounds to the buttocks. DON B indicated the staff are not completing weekly assessments adequately on R187. DON B indicated the documentation of skin issues has not been completed to its entirety. DON B confessed this is a facility wide issue and the facility will be incorporating new measures and interventions in place to fix the issue. DON B indicated the expectation is that a head-to-toe skin assessment is completed upon admission and documented. Thereafter weekly skin assessments and Braden score assessments are to be completed by a registered nurse.

Based on observations, interviews and record reviews, the facility did not provide spinal precautions and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 18 residents (R21) reviewed. Staff did not follow spinal precautions to manage R21's T11 fracture by not providing log rolling during repositioning while R21 was in bed. Staff did not follow physician orders to keep back brace on R21 when head of bed is over 30 degrees. Findings include: R21 was admitted on [DATE]. R21's diagnoses include fracture of T9-T10 vertebra, fracture of first lumbar vertebrae, fracture of second lumbar vertebrae, fracture of third lumbar vertebrae, fracture of fourth lumbar vertebrae, concussion without loss of consciousness, and traumatic brain injury. R21's Minimum Data Set (MDS) assessment, completed on 07/17/24, confirmed R21 scored 12 during a Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R21 requires total substantial maximal assistance with rolling from side to side. R21 does not get out of bed. R21's care plan was initiated on 01/05/24, and included the following interventions: Activities of Daily Living: -Bed Mobility: Assist of 2 log roll as much as able, remind resident to keep straight as possible. -Head of Bed below 30 at all times if resident does not have thoracic-lumbar-sacral orthosis (TLSO) brace on. May go above 30 degrees if she has TLSO brace on or is out of bed. Resident is on bed rest. R21's physician orders on 01/04/24 include: -Bed rest at all times every shift for lumbar fractures. -Do not elevate head of bed over 30 degrees every shift for lumbar fractures. R21's physician orders on 05/29/24 include: -Specialist has to decide discontinuation of back brace. Continue back brace as ordered. R21's physician orders on 07/08/24 include: -Adjust current TLSO brace. -Continue with restrictions. -Follow up with brace and CT scan. On 07/30/24 at 2:34 PM, Surveyor interviewed R21. Surveyor asked R21 why R21 was admitted to the facility. R21 indicated that R21 was in a motor vehicle collision and is on spinal precautions. Surveyor asked what spinal precautions indicated for R21. R21 indicated that R21 is to be log rolled while in bed, on bedrest and R21 should be wearing R21's back brace. R21 indicated that R21 has been losing weight and the brace is uncomfortable so R21 has not been wearing the brace for a while now. Surveyor observed back brace lying on a box on the floor across the room with papers and bags stored on top. On 07/31/24 at 6:39 AM, Surveyor observed R21 lying in bed supine with head of bed at a 45-degree angle sleeping. Surveyor did not observe R21's back brace (TLSO) on R21. Surveyor observed back brace lying on a box on the floor across the room with papers and bags stored on top. On 07/31/24 at 8:20 AM, Surveyor observed R21 lying in bed supine with head of bed at a 45-degree angle sleeping. Surveyor did not observe R21's back brace on R21. Surveyor observed back brace lying on a box on the floor across the room with papers and bags stored on top. On 07/31/24 at 8:51 AM, Surveyor observed Certified Nurse Assistant (CNA) K and CNA N provide cares. CNA N grabbed behind R21's back of shoulders and R21's hip area and rolled R21 to the left towards CNA K. Surveyor observed R21's right leg cross over R21's left leg and R21's left leg bent backwards. Then after CNA N completed peri cares on R21, CNA K placed hands underneath R21's waist and upper shoulders and rolled to the right towards CNA N. Surveyor observed R21's left leg cross over R21's right leg and R21's right leg bent backwards slightly. Surveyor did not observe CNA K and CNA N log roll R21 as ordered, and care planned during R21's cares. Surveyor did not observe any spinal precautions in place for rolling R21. On 07/31/24 at 12:45 PM, Surveyor observed R21 lying in bed with head of bed at almost 90-degree angle with lunch tray in front on bedside table. Surveyor did not observe R21's back brace on R21. Surveyor observed back brace lying on a box on the floor across the room with papers and bags stored on top. On 07/31/24 at 3:40 PM, Surveyor interviewed CNA I and CNA O and asked CNA I and CNA O how R21 is moved while in bed. CNA I and CNA O indicated that R21 is a log roll since on spinal precautions while in bed. CNA O indicated that R21 does not get out of bed as R21 is on bed rest per provider orders. Surveyor asked CNA I and CNA O where staff find the transfer status and mobility in bed for R21. CNA I indicated that CNAs follow the Kardex for R21. Surveyor asked CNA I and CNA O to show Surveyor the documentation of the Kardex. CNA I pulled the Kardex up for R21 and showed Surveyor that the Kardex did not have specifications on bed mobility. On 07/31/24 at 3:49 PM, Surveyor interviewed Director of Nursing (DON) B and asked about expectation for bed mobility with R21. DON B indicated that bed mobility for R21 is log rolling due to R21 being on spinal precautions. DON B indicated that all staff are to follow the spinal precautions for R21. Surveyor asked how staff were to know that R21 is on spinal precautions and has staff been educated on how to properly perform log rolling. DON B indicated that it should be in R21's Kardex that staff follow and going forward DON B would be educating staff immediately on performing only log rolls with R21. Surveyor asked DON B if DON B was aware that R21's head of the bed has been up as high as 90 degrees during observations. DON B was unaware that R21's head of bed has been up this far and stated that it shouldn't be that high. Surveyor reviewed physician orders that indicate the head of bed shouldn't be any higher than 30 degrees. DON B indicated that DON B would educate R21 on the head of the bed being elevated and the restrictions that R21 has in place for spinal protection. On 07/31/24 at 4:08 PM, DON B provided documentation to Surveyor showing that R21's Kardex indicated under Activities of Daily Living (ADL) that Bed Mobility stated, Assist of 2 log rolls as much as able, remind resident to keep as straight as possible. DON B indicated that through review of the specialist orders R21's head of bed is not supposed to exceed 20 degrees without applying the TLSO brace. DON B indicated that DON B would be fixing the order right away, educating staff, and R21. DON B also indicated that back in May a nurse requested that the TLSO brace be discontinued, and the provider wrote orders back to continue TLSO brace and that it was the specialist decision to discontinue or not. DON B confirmed the nurse had discontinued the TLSO brace without proper orders from a physician.

Based on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff. Surveyor observed Certified Nursing Assistant (CNA) apply prescribed Nystatin powder to a resident's (R) skin for 1 of 1 observation. (R187) Findings include: On 07/30/24 at 8:56 AM, Surveyor observed Nystatin powder sitting on bedside table in R187's room. Surveyor asked R187 what the powder was on the bedside table and if it was stored in R187's room regularly. R187 indicated that it is antifungal powder for R187's abdominal folds. R187 indicated that the CNAs usually apply this when CNAs get R187 out of bed. On 07/30/24 at 10:01 AM, Surveyor observed morning cares being performed for R187 by CNA H and CNA Q. Surveyor observed a cup of Nystatin powder located on R187's bedside table. CNA Q picked up the Nystatin powder and handed the powder to CNA H. CNA H applied Nystatin powder to R187's abdominal folds bilaterally and placed Nystatin powder in R187's groin area. On 07/31/24 at 11:16 AM, Surveyor interviewed CNA H and asked what the expectation is for Nystatin powder to be administered by CNAs. CNA H indicated that CNA H has always applied Nystatin powder for the nurses. Surveyor asked if CNA H had any training or experience with applying Nystatin powder. CNA H indicated that no, CNA H has not had any formal training. Surveyor reviewed R187's medical record and identified the following physician's order, dated 07/18/24: Nystatin powder; 100,000 unit/gram; amt: to abdominal folds; topical Two Times A Day. On 07/31/24 at 3:49 PM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation is of CNAs applying nystatin powder to R187. DON B indicated that expectation would be that only nurses administer Nystatin powder to R187. DON B indicated that CNA H should not have administered Nystatin powder to R187.

Based on interviews and record reviews, the facility failed to protect a resident's right to be free from sexual abuse. The facility did not implement interventions to protect residents (R) from sexual abuse by a resident. Not implementing interventions affected 1 of 2 residents (R1) reviewed for sexual abuse. *On 03/28/24, a Certified Nursing Assistant (CNA) found R2 in R1's room. R2 was shirtless and zipping and buttoning R2's pants while in R1's bed. R1, who is cognitively impaired, stood in the middle of the room with a T-shirt and no pants. The facility did not implement appropriate interventions to prevent a second occurrence of sexual abuse from occurring. *On 04/01/24, a CNA found R2 in R1's room. R1 was in bed on R1's back. R2 was lying with R2's head next to R1's feet. R2's feet were on the floor with R2's legs off the bed and his pants and brief pulled all the way down to R2's feet with his bare buttocks on the bed next to R1's waist, and R2's penis was exposed. The failure implement immediate safety measures to prevent further sexual abuse from occurring created a finding of immediate jeopardy which began on 03/28/24. The State Agency (SA) notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 04/17/24 at 2:15 p.m. The facility took steps to correct the deficient practice on 04/02/24, after the incident to ensure compliance. Based on this determination, the immediate jeopardy was removed and corrected on 04/02/24. The citation is issued as past non-compliance. Findings include: The facility's Abuse, Neglect, and Exploitation policy dated April 2008, with recent revision date of January 2023, states: It is the policy of this community to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of property. It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws that involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) are reported immediately to the administrator of the community. Prevention: d. The residents have a right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. Resident's cognition will be assessed on admission and with change in condition to determine capacity to consent to a sexual contact. Assessments will be maintained in the medical record and their care plan will be updated to reflect these preferences as a preventative measure against sexual abuse. R1 is a female resident who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, disorientation, and depression. R1's Minimum Data Set (MDS) assessment dated [DATE] identifies a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicates severe cognitive impairment. R1's MDS documents R1 requires set-up with eating, substantial/maximum assistance with showering/bathing, partial/moderate assistance with dressing, supervision/touch assistance with personal hygiene, is independent with bed mobility, sitting to stand positions, chair to bed/bed to chair transfers, toilet transfers, and supervision with walking. R1's medical record documents R1 has an activated Power of Attorney for Health Care (POAHC). R1 has a determination of incapacitation which is signed on 02/23/22 stating R1 is incapacitated, that is Unable to receive and evaluate information effectively or to communicate decisions to such an extent that she/he lacks the capacity to manger her/his health care decisions. R1 has a care plan stating the focus is abuse prevention due to vulnerability. It was initiated on 02/02/24. R1's goals state R1 will have minimized the risk of abuse through the next review date. It was initiated on 02/02/24. The target date is 05/13/24. R1's interventions are to observe, suspect abuse, remove the resident from the aggressor, and relocate to a safe location. Observe and provide a safe environment. Notify the supervisor, DON, NHA, and SW (Social Worker). Date initiated 02/02/24. R2 is a male resident who was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, Alzheimer's disease, and hallucinations. R2's BIMS score is 15 out of 15, indicating intact cognition. R2's MDS dated [DATE] documents that R2 is independent with eating, requires substantial/moderate assistance with showering/bathing, dressing, personal hygiene, tub/shower transfers, partial/moderate assistance with toileting hygiene, bed mobility, walking 50 feet with two turns, is independent with toilet transfers, and wheelchair mobility. R2's care plan states inappropriate comments toward others/staff and residents. R2's goal is to have zero episodes of inappropriate comments per month. Date initiated 05/17/23. Revision date of 11/07/23. Target date of 06/25/24. R2's mood behavior will not interfere with other residents' rights through the next review. The review was initiated on 05/08/23. The revision date was 11/07/23. The target date was 06/25/24. R2's interventions are to allow resident to choose when they want things done, within reason. Date initiated 05/08/23. Check for comfort levels, thirst, hunger, and temperature-offering comfort as able/accepted. Date initiated 05/08/23. R2's abuse risk care plan for actual and/or potential abuse vulnerability. Date initiated 05/08/23. Revision date of 08/10/23. R2's goal is to minimize the risk of abuse through the next review date. The review was initiated on 05/08/23. The revision date was 11/07/23. The target date is 06/25/24. R2's interventions are to observe/suspect abuse, move the resident from the aggressor, and relocate. Date initiated 05/08/23. On 04/16/24, Surveyor reviewed a facility-reported incident, which stated on 03/28/24, a CNA found R2 in R1's room. R2 was shirtless and zipping/buttoning his pants while in R1's bed. R1 was standing in the middle of the room in a t-shirt and no pants. The facility separated R1 and R2 but did not implement any additional interventions. On 04/01/24, R2 was again found in R1's room by a CNA. R1 was in bed on her back. R2 was lying with his head next to R1's feet. R2's feet were on the floor with his legs off the bed, and his pants and brief pulled all the way down to his feet with his bare buttocks on the bed next to R1's waist. R2's penis was exposed. Facility investigation indicates that R1 and R2 were separated. R1 was monitored for distress. Nursing staff conducted assessments on R1 and R2, and no injuries were noted. The facility contacted the ombudsman and provided education to staff on abuse, identification, prevention, and reporting abuse. Staff signatures indicate the facility provided education on 04/02/24. The facility notified R1's and R2's family members and physicians of the incidents. The facility notified the police, and nursing conducted head-to-toe assessments on R1 and R2. The facility initiated 1:1 supervision 24/7 of R2, with the facility working on a discharge plan for R2. The facility interviewed staff and other residents. Facility documentation, dated 03/28/24, states CNA D informed Registered Nurse (RN) G that CNA D had walked into R1's room and R2 was shirtless in R1's bed while R1 was standing in the middle of the room with no pants on. RN G and CNA D spoke with both residents (R1 and R2) and asked each of them about the situation, and both denied anything sexual occurring. Both residents (R1 and R2) were informed their families would be contacted. RN G contacted R1's family, who expressed no interest in further action other than keeping the residents separated to prevent a repeat situation. The facility contacted R2's family, and R2's family were skeptical and upset about the problem. Still, they did not express any interest in taking further action other than keeping the residents apart to prevent a repeat situation. A progress note in R2's medical record states that on 03/28/24 at 10:20 p.m., CNA D informed RN G that R2 referred to R1 by saying, She's the confused one. Social Worker (SW) C's documentation on 04/01/24 at 6:38 p.m., states that the note is a follow-up on the incident on 03/29/24 (the date should be 03/28/24). The facility will continue to investigate to ensure that both parties consent. An ombudsman notification was sent to determine the proper protocol for this situation. On 04/16/24 at 11:55 a.m., Surveyor interviewed CNA D and asked CNA D to walk Surveyor through the incident that occurred on 03/28/24 between R1 and R2. CNA D stated she checked on R2 for evening care, and R2 was not in R2's room. R1 and R2 were seen together in the evening, walking around the facility. CNA D went to R1's room, knocked, and entered; R2 was zipping and buttoning his pants when CNA D walked in and R2 was shirtless in R1's bed. CNA D returned R2 to his room, R2 stated, If I were a little younger and a little faster, it would have happened. R2 said, I suppose you will give her (R1) the third degree. CNA D stated the facility would talk with R1 to see what happened. CNA D stated that R2 said, She is the forgetful one. R2 also told CNA D that R1 and R2 used to be neighbors. On 04/16/24 at 3:15 p.m., Surveyor interviewed RN G and asked RN G to walk Surveyor through the incident that occurred on 03/28/24 between R1 and R2. RN G was paged regarding the incident. RN G stated CNA D checked on R2 for evening care, but R2 was not in R2's room. RN G stated when RN G got to R1's room, R2 was standing in the middle of the room in a T-shirt and briefs, and R2 was putting on a shirt. RN G stated RN G assisted R2 to the wheelchair and assisted R2 to R2's room. When questioned about the incident, RN G stated R2 kept saying, I can't get an erection; all I can do is try. RN G stated the Medication Technician (MT) H and CNA D stated R1 said a man had crawled into the bed. R1 did not know it was R2 at that moment. RN G stated R1's and R2's families were notified about the incident and told the residents were separated and would be monitored. Families are not concerned, per RN G. On 04/16/24 at 10:38 a.m., Surveyor interviewed DON B and asked about the incident between R1 and R2 on 03/28/24 and why the police were not called and why the facility did not initiate an investigation. DON B stated the facility was looking at the encounter as consensual. DON B stated R1 and R2 are routinely going about the facility together. DON B stated R1 and R2 have a right to a relationship. Surveyor asked if the facility had assessed the residents' ability to consent. DON B said, No. Of note, R1's BIMS is 3, meaning R1 does not have the capacity to consent to a sexual relationship. The facility did not implement interventions to prevent further abuse. The facility did not notify police, did not conduct an investigation, did not notify R1's or R2's physicians timely, and did not conduct an intimacy & sexual history on R1 and R2 relating to the 03/28/24 sexual abuse incident. The facility was aware that R1 has a determination for incapacity. The facility was aware in May of 2023 of R2's inappropriate comments toward others/staff and residents. Surveyor reviewed R1's and R2's medical records for the second incident on 04/01/24. R2's progress note states on 04/01/24 at 9:19 p.m., R2 was found in R1's room for the second time. R1 was in R1's bed on R1's back. R2 was lying with R2's head next to R1's feet. R2 had R2's feet off the floor with R2's legs off the bed with, R2's pants and brief pulled all the way down to the feet and R2's bare buttocks on the bed next to R1's waist, and R2's penis exposed. R1 and R2 stated they needed a few minutes. RN G and CNA F assisted R2 with pulling up R2's pants and assisting R2 to the wheelchair. R1's underwear was found in the bed at R1's feet. Staff assisted R2 back to R2's room and questioned R2 about the situation. R2 stated R2 hadn't been able to get an erection for a long time, and all R2 could do was try. RN G asked what happened in the room and R2 stated they (R1 and R2) were lying there. RN G asked R2 if R2 knew R1 was confused, making the situation complicated, to which R2 replied, I know, she's confused. She keeps asking me how many kids I have and asks me other questions repeatedly. The facility implemented 15-minute checks throughout the night. A behavior progress note, dated 4/1/2024 at 9:35 p.m., states R1 was questioned about the situation, to which R1 replied, I don't know what happened. He (R2) just crawled into bed with me and started kissing me. R1 was observed earlier in the night as going to bed after R2 had already gone to bed, suggesting that R2 had gotten himself out of bed and entered the resident's room. On 04/10/24 at 1:22 p.m., Surveyor interviewed CNA F and asked to walk Surveyor through the incident between R1 and R2 on 04/01/24. CNA F stated when CNA F walked into R1's room, R2 yelled, Get out. R2 was sitting on R1's bed, but R1's legs were off the bed, and R2 was lying partially down by R1's waist with no pants on. CNA F stated that R1 had a nightgown on. CNA F stated CNA F and MT H returned to R1's room after RN G took R2 back to R2's room and asked R1 what happened. R1 stated R1 was sleeping, and R2 came in, got into bed with R1, and started kissing R1. CNA F stated MT H and CNA F were assisting R1 in settling in bed again, but R1's bedding had to be changed because the sheet had a quarter-size blood spot. Surveyor asked if R1 was injured. CNA F stated that CNA F did not know. On 04/16/24 at 3:15 p.m., Surveyor interviewed RN G and asked RN G to walk Surveyor through the incident between R1 and R2 on 04/01/24. RN G stated RN G was in the room next to R1's. CNA F notified RN G R2 was in R1's room. RN G stated when RN G got to R1's room, R1 had no underwear on. R2 was sitting on the side of R1's bed, upper body lying on the bed, R2's pants were around R2's ankles, and R2 was all exposed. RN G stated RN G assisted R2 in getting dressed and helped him get in the wheelchair and back to R2's room. In R2's room, R2 said nothing had happened. RN G stated RN G had asked R2 if R2 knew R1 was confused. RN G stated RN G told R2 due to R1's confusion, R1 couldn't consent. R2 stated R2 knows that. RN G stated that RN G had told R2 that this could not happen again. RN G stated CNA F told RN G when R1 was asked about the incident, R1 said R1 didn't know and He just came in and started kissing her. R1 didn't know who he was. On 04/16/24 at 3:35 p.m., Surveyor interviewed MT H and asked MT H to walk through the incident between R1 and R2 on 04/01/24. MT H stated CNA F came to get MT H to go into R1's room to find out what happened. R1 was dressed in pajamas. When R1 was asked what happened, R1 said he came into the room and started kissing me. MT H stated R1 was asked multiple times about the incident and R1 replied with the same answer. A social service progress note dated on 4/2/2024 at 4:23 p.m. states SW C was notified on 04/02/24 of the 04/01/24 incident between R1 and R2. SW C documents that both residents (R1 and R2) were questioned, and R2 stated that R1 wanted R2 to come to R1's room and wanted sex. SW C's documentation states when R1 was questioned, R1 didn't remember a man in R1's room or know who R2 is. SW C's documentation states when asked if R1 wanted R2 in R1's bed, R1 said, No. SW C's documentation states this incident was reported to the state, and a call was placed to the police department to report the incident. Police came to the facility and agreed that R1 could not give explicit consent on this advance from R2. Police spoke with R2 and told R2 clearly that R2 is not to go in R1's room again or touch R1 due to R1's inability to make a clear consensual decision regarding sex. SW C's documentation states R2 stated R2 felt bad because R1 wanted more, and R2 hasn't been able to have sex due to prostate issues and is unable to have an erection. (R2's medical record does not state any diagnoses related to the prostate.) SW C's documentation states the facility called the ombudsman earlier to ensure it was proceeding correctly and did not infringe on resident rights. The skin and progress note in R1's medical record dated 4/2/2024 at 6:06 p.m states a head-to-toe skin assessment was performed on R1. R1's right forearm had an approximately 1-inch long-healed scratch from the previous injury when R1 scratched self with R1's nails. No other skin issues were noted. The progress note contains no detailed information on assessing the genital area of R1 to assess for indicators of sexual abuse. R1's medical record progess note dated 04/02/24 at 8:21 p.m. states the primary physician was notified of the 04/01/24 incident between R1 and a male resident. The physician wants to be notified if any issues arise, such as agitation, distress, or unusual behavior. The facility did not notify the physician timely. R2's skin and wound progress note dated 04/02/24 at 6:10 p.m. states R2 underwent a head-to-toe skin assessment. R2 has a small open area on the inner left buttock with a small amount of blood drainage. The abscess on the testicles appears to be gone. Multiple bruised areas on the right hand and right forearm from R2 hitting hand/arm on banister when wheeling down the hallways in a wheelchair. No other skin issues were noted. The facility did not conduct intimacy & sexual history assessments on R1 and R2 until 04/02/24. The results differ between R1 and R2. Results read as follows: Comfortable giving or receiving affection such as a touch, a hug, or a kiss? R1 Yes R2 Yes Are you accustomed to sleeping alone in bed? R1 Yes R2 Yes Are you currently involved in a relationship? R1 No R2 I thought maybe. Before living here, how did you show your companion that you cared? R1 He has been gone a long time. R2 I haven't had one since my wife. Before living here, what was your comfort level with sexual contact? R1 Why are you asking me this. R2 No problems Are you seeking a relationship with someone in the facility? R1 No R2 Not anymore Do you have any concerns regarding your interactions with this person R1 No R2 I didn't realize she has a bad memory Any history of abuse? R1 No R2 No Any history of sexually transmitted infections? R1 No R2 No On 04/02/24 at 8:21 p.m., R1's medical record progress note states the primary physician was notified of the 04/01/24 incident between R1 and a male resident. The physician wants to be notified if any issues arise, such as agitation, distress, or unusual behavior. The facility did not notify the physician timely. The facility contacted R2's physician assistant (PA) on 04/02/24 at 8:32 p.m. regarding the incident between R2 and a female resident on 04/01/24. The note states R2 will be seen by the primary physician on 04/03/24. The facility did not notify the physician timely. The primary physician saw R2 on 04/03/24 and ordered Sertraline 50mg by mouth tablet to be started at HS (hour of sleep) on 04/05/24. On 04/04/24 at 8:07 a.m., the facility notified R1's primary provider to discuss an action plan to have R1 evaluated for trauma impact. The physician was informed R1 has not had any physical or emotional signs of trauma. The physician agrees with the current plan and will monitor for trauma and update as needed. On 04/16/24, Surveyor observed R2 in R2's room watching TV, conversing with staff, and eating meals. Surveyor observed R1 during the survey eating meals in the dining room and attending activities in the dining room. On 04/16/24 at 11:28 a.m., Surveyor interviewed Ombudsman (OM) E via telephone and asked if the facility contacted OM E regarding two incidents between R1 and R2. OM E stated the facility did contact OM E. OM E stated OM E told the facility R1 and R2 have a right to a relationship. OM E stated SW C was informed about assessing residents for ability to consent and no ability to consent. OM E stated the form for the assessment was emailed to SW C. OM E stated OM E would be at the facility on 04/23/24 for a meeting to inform everyone about resident rights, having a relationship, consent, and safety. On 04/16/24 at 4:05 p.m., Surveyor interviewed SW C about the incidents between R1 and R2. SW C stated SW C was notified, and OM E was contacted to ensure the facility handled the situation appropriately. Surveyor asked if R1 and R2 were assessed for the ability to consent. SW C stated no assessment was completed until 04/02/24. SW C stated SW C received the form from OM E. Surveyor asked if the family of R1 was asked about a physical exam/rape kit following the incident. SW C stated R1's family didn't want anything done. SW C stated both families stated R1 and R2 have known each other for [AGE] years. SW C stated R2 had not pursued anyone until R1 was admitted to the facility. On 04/16/24 at 10:38 a.m., Surveyor interviewed DON B about the incident between R1 and R2 on 04/01/24. DON B stated R2 was in R1's room fully exposed on the bed and R1 did not have any underwear on. DON B stated R1 and R2 were separated. R2 was placed on every 15-minute checks at first, then supervision was changed to 1:1 24 hours a day, seven days a week. DON B stated the facility is looking into alternative placement for R2. On 04/16/24 at 1:15 p.m., Surveyor interviewed R1 and asked about the incident between R1 and R2. R1 did not know what Surveyor was talking about. R1 could not recall anything. Surveyor asked if R1 knew R2. Surveyor stated R2's name and R1 said R1 knew R2 and they were friends. Surveyor asked if R1 feels safe in the facility and R1 stated R1 felt safe. Surveyor asked about abuse. R1 denied any abuse. On 04/16/24 at 1:37 p.m., Surveyor interviewed R2 and asked about the incident between R2 and R1. R2 stated he was sitting with R1 and other residents in the dining room after activities and R1 got up and started wandering around. R2 stated he figured R1 was looking for R1's room. R2 stated he had taken R1 to R1's room. R2 stated R1 invited R2 into the room. R2 stated he has known R1 for many years. R1 and R2 have been friends, and their kids went to school together per R2. R2 stated R1 kept asking him where R2's wife was. R2 stated R1 wanted R2. R1 started undressing and trying to undress R2. R2 stated he and R1 were in bed together when staff came to the room. R2 stated he didn't want to hurt R1. R2 stated he lost his head. R2 stated he is not proud of self. R2 stated R2's kids are not proud of R2 either. On 04/17/24 at 12:16 p.m., Surveyor spoke with R1's family member (FM) J. Surveyor asked if the facility notified the family about R1's two incidents with a male resident. FM J stated the facility notified the family immediately. Surveyor asked if the facility offered to have R1 examined after the incidents. FM J stated the family didn't want anything done. FM J stated R1 doesn't remember from one minute to the next. FM J stated that R1 was happy-go-lucky and that the family believes R1 had not been injured. Surveyor asked if the facility was doing what the family expected. FM J stated the facility is fine. The facility is doing what it needs to do to keep the two residents apart. On 04/16/24 at 12:42 p.m., Surveyor interviewed R2's FM I and asked if the facility notified the family about R2's two incidents with a female resident. FM I stated the facility notified the family. Surveyor asked if the facility was doing what the family expected. FM I stated the facility is doing its best to prevent further incidents. FM I stated these two residents have known each other for many years. FM I states no further concerns at this time. There is no evidence that R1 had the ability to consent to a sexual relationship due to her cognitive impairment. Sexual contact with a person who has not consented to such contact or who is unable to consent is considered sexual assault in Wisconsin. According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, Emotional signs and symptoms [of sexual assault in a nursing home] include denial, humiliation, flashbacks, intense fear, guilt, anxiety, depression, feelings of hopelessness and helplessness, phobias, and rage. These conditions are symptomatic of post-traumatic stress disorder or rape trauma syndrome. Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often, cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. Providing these victims with necessary services makes it more challenging because they cannot express their needs. In addition, victims suffering from dementia, including Alzheimer's disease, often display post-rape emotional distress, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff members. Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders The facility's failure to keep residents free from sexual abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 03/28/24. On 04/02/24, the facility identified the deficient practice that occurred when R2 sexually abused R1. The facility took steps to correct the deficient practice and ensure compliance on 04/02/24. Based on this determination, the immediate jeopardy was removed on 04/02/24 and corrected on 04/02/24 when the facility implemented the following: 1. Placed R2 on 1:1 supervision 24 hours a day, seven days a week. 2. Moved R2 to another room across from the nurse's station, further from R1. 3. Educated staff on abuse, identification, prevention, and reporting abuse. 4. Physician review of medications for R2. 5. Obtained Neuro psych referral for R2. 6. R1's care plan updated follows: R1's care plan states that the focus is trauma-informed care. R1 has the potential for complications related to experienced trauma due to diagnosis of dementia and to possible non-consensual sexual encounter with a male resident on 04/01/24. Date initiated 04/02/24. R1's goals state R1 will be free of serious negative outcomes related to personal trauma. Date initiated 04/02/24. Target date of 05/13/24. R1's interventions are to encourage residents to talk about the past and to make goals and decisions about care. By listening, R1 establishes a trusting relationship with the resident. R1 maintains a calm, non-threatening manner while working with the resident. 7. R2's care plan update as follows: Has a history of sexual behavior toward a female resident on 04/01/24. The plan of care is to be one-on-one with the resident 24/7, with staff taking turns, and start a plan of discharge. Date initiated 04/02/24. Intervention: Allow resident to wander within the unit, along with one-on-one with staff. Date initiated 04/02/24.

Based on record review and interview, the facility did not immediately consult with the physician for 1 of 2 residents reviewed for a significant change in condition (R1). The facility did not immediately consult with R1's physician after R1 sustained a fall causing a change in condition to his right foot. This fall resulted in the resident's foot hanging on by one (or possibly two) tendon(s). There is no evidence that staff, who were expecting the foot to fall off at any time, consulted with the physician about this or sought medical direction for continued care. The facility did not consult with the physician after the tendon was cut to inform the physician what had been done. The physician did not learn this until after the resident's death. Facility failure to promptly consult with the physician of the resident's change in status of his foot created a finding of immediate jeopardy that began on 05/25/22. Surveyor notified Nursing Home Administrator (NHA) A of the immediate jeopardy on 06/10/22 at 10:30 a.m. The immediate jeopardy was removed on 06/13/22, however the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement their action plan. This is evidenced by: R1 was admitted to the facility from the hospital on 03/11/22 on hospice care and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) assessment indicated that R1 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact). R1 was his own decision maker. R1's skin status on admission: both feet were black from the ankle down to the toes from frost bite, back of lower legs, back of ankles/Achilles, and back of both heels. R1 had 4th degree frostbite, the appearance was dry and mummified - cold to the touch. Drainage was moderate, sero purulent with a foul odor. R1's Nurse's notes, dated 05/25/22, read in part, .R1 rolled out of bed and was found lying on floor, right foot was saturated with blood. Wound care provided to right foot which is no longer attached to ankle is attached by one tendon, resident made no indications of pain during repositioning of foot to line up with ankle, foot was wrapped in kerelex and taped. Hospice was made aware of findings and change of condition. There is no indication the facility consulted with the physician about the fact that the ankle was attached by one tendon and sought medical direction for continued care. Surveyor reviewed Hospice note dated 05/25/22 at 9:30 am that read in part, .facility staff did report that patient's right foot appears to be close to detaching from patient's body. At 8:45 PM on 05/25/22, the resident continued to be delirious. The dressing was changed because it was drenched with bloody drainage. The resident's eyes were open but staring past writer. The resident appeared comfortable with no signs of moaning. The facility did not consult with the physician regarding the resident's [CONDITION(S)], bloody drainage, or about the earlier fall, and did not explain that the foot was attached by only one tendon. On 06/08/22 at 3:00 pm, Surveyor interviewed RN D and asked what she did on 05/27/22 when she did R1's wound care. RN D indicated that she removed the bandage and R1's right foot was hanging by a tendon. RN D indicated she used a bandage scissors and in 3-4 snips she cut the tendon and the foot was detached. She indicated she watched R1's facial expressions during the time and there were no grimaces or signs of pain. After the foot was detached she wrapped the open wound with Vaseline and gauze to make him comfortable. She put the foot in a zip lock baggie and then a red biohazard bag. The physician was not consulted prior to cutting the tendon or after the foot was removed. Surveyor asked RN D if she notified anyone. She indicated she did not. Surveyor asked if RN D documented it and she indicated she did not, she spaced it out. RN D indicated that someone else notified the DON (Director of Nursing). On 06/08/22 at about 1:15 pm, Surveyor interviewed CNA (Certified Nursing Assistant) G and asked about what she remembered about R1 and what she witnessed during R1's wound care on 05/27/22. CNA G stated that the resident was acting weird on 5/27/22 and was not in his right mind. R1 would ring his call light but then not remember what he needed. Both CNA G and CNA H assisted RN D with wound care. CNA G indicated that after RN D cut off the bandage, RN D stated she didn't know why anyone hadn't cut the tendon. Without obtaining consent from R1 and without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked CNA G if she felt R1 was in pain during this. CNA G did not think R1 was in pain during the procedure but indicated the tendon was jumping. On 06/08/22 at about 2:50 pm, Surveyor interviewed CNA H and asked about what she witnessed during wound care on 05/27/22 with R1. CNA H indicated she was holding the resident's hand and stated the resident had a death grip during the time RN D cut the tendon, and that she had never had R1 squeeze her hand like that before. CNA H told Surveyor that the foot was being held on by two tendons, not one as others reported. On 06/08/22 at 1:27 pm, Surveyor interviewed CNA I and asked about R1 and losing his foot. CNA I indicated that R1 went downhill mentally after his fall and began bleeding more. She indicated the resident really declined after his foot was gone. She said his color was worse and his condition overall was worse. On 06/08/22 at 2:07 pm, Surveyor interviewed DON by phone. DON indicated she was not made aware of the incident until Sunday. She indicated that the NHA thought it fell off and was also not aware of how the foot became detached. DON B indicated the only thing that was keeping the foot attached was the tendon, the bone had already been gone. She indicated she thought R1 was septic and getting delusional. Surveyor asked DON B at any time did the physician or hospice tell you to snip the tendon, DON B indicated no. Surveyor asked DON B if she felt R1 was in any more pain after the tendon was cut, DON B indicated no. Surveyor asked DON B if hospice or the physician were notified as to what happened with the foot, DON B indicated she did not know. She indicated the foot was coming off and hanging by a little white thread. Surveyor asked her if she would want her staff to cut the tendon, DON B indicated, No, it's something I would not do either. Surveyor asked DON B what should have been done, she indicated 1st call hospice and then keep primary physician in the loop. On 06/09/22 at about 2:09 pm, Surveyor interviewed Dr. C and asked if she was made aware of the condition of R1's foot after his fall on 05/25/22. Dr. C indicated she was not. Surveyor asked Dr. C if she was made aware of R1's tendon being cut, Dr. C indicated she was not made aware of how the tendon was cut and the foot removed until after R1 passed on 6/2/2022. Dr. C indicated what happened was not within the nurse's scope of practice. Dr. C indicated an autopsy was ordered because of conflicting information as to how much tissue was still attached. The facility's failure to consult with the physician about R1's deteriorating foot condition and about a nurse severing the foot created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 6/13/22 when the facility completed the following: The facility provided Professional Nursing Staff (RNs and LPNs) with continuing education and refresher training/updates on the identification of change(s) in condition, if they occur. Education was provided to consult with resident's physician to implement changes in the residents' plan of care if a change in condition does occur. Director of Nursing and Clinical Services and the Registered Nurse Educator with the assistance of other Nurse Leadership Team Members reviewed and updated as indicated the policy and procedures that covers the identification change in conditions. Director of Nursing and Clinical Services and the Registered Nurse Educator with the assistance of other Nurse Leadership Team Members reviewed and updated as indicated the policy and procedures that covers the notification and consultation with the Resident's physician to implement changes in the Resident's change in conditions.

Based on interview and record review, the facility did not provide care consistent with professional standards of practice and with the resident's wishes for care and treatment for 1 of 2 Residents reviewed (R1) who experienced a significant change in condition. R1 was admitted with frostbitten feet that were in need of treatment. R1 did not have weekly assessments to include measurements and the condition of the affected feet. When R1 fell on [DATE], R1's foot became mostly detached. Nursing did not consult with the physician about this change. On 05/27/22, a Registered Nurse (RN) worked outside her scope of practice and cut the remaining tendons to amputate the foot. The RN did not have an order to do this and did not get the resident's consent and did not know what his wishes were. Facility failure to provide ongoing assessments and monitoring of the wound and failure to act within a nurse's scope of practice created a finding of immediate jeopardy that began on 03/26/22. NHA A was notified of the immediate jeopardy on 06/10/22 at 10:30 am. The immediate jeopardy was removed on 06/13/22, however the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility implements their action plan. Findings include: According to N6.03, Standards of practice for a registered nurse in Wisconsin: An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R1 was admitted to the facility from the hospital on 03/11/22 on hospice care, and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) assessment indicated that R1 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) and that R1 was his own decision maker. R1's initial skin assessment indicated R1 had sustained severe frostbite, and both his feet were black from his ankle down to his toes. His feet and lower legs had sustained 4th degree frostbite and were dry, mummified, and cold to touch. They had moderate sero-purulent drainage and a foul odor. Review of R1's electronic medical record, the only other documented nurse assessment of the wounds was on 03/19/22. Included in this assessment was the statement that it did not appear as if the foot and tendon were firmly attached to the foot. There were no documented assessments after this date and no communication with the physician or with hospice regarding any changes to the resident's feet in the medical record. Next expected assessment, if done weekly, would have been 03/26/22. On 06/08/22 at about 12:05 pm, Surveyor asked NHA A for weekly skin assessments for R1. RN E brought Surveyor a print out of the nurse assessment for 03/19/22. On 06/09/22 at about 12:54 pm, Surveyor asked DON B if there were any other assessments for R1 other than the 03/19/22 document already received. DON B and RN E looked in the computer while Surveyor was in the room and DON B indicated that's all there is, there are no other nursing notes or skin assessments. Lack of ongoing assessments of R1's feet, ankles, and lower legs would have prevented staff from identifying changes in the condition of R1's lower extremities and prevented earlier medical intervention. On 5/25/22 this resident had an unwitnessed fall out of bed. The right foot was saturated with blood. The resident was showing signs of [CONDITION(S)]. Note indicated that wound care was provided to the right foot, which is no longer attached to the ankle, attached by one tendon only. Facility staff repositioned the foot to line up with the ankle, then wrapped it with kerlix and taped to secure. Facility staff did not consult with the physician for continued direction for medical care of the resident's foot and ankle. (Cross reference F580.) On 05/27/22, RN D provided wound care to R1, accompanied by CNA H and CNA G. On 06/08/22 at about 1:15 pm, Surveyor interviewed Certified Nursing Assistant (CNA) G and asked about what she remembered about R1 and what she witnessed during R1's wound care on 05/27/22. CNA G stated that the resident was acting weird on 5/27/22 and was not in his right mind. R1 would ring his call light but then not remember what he needed. Both CNA G and CNA H assisted RN D with wound care. CNA G indicated that when RN D cut off the bandage, RN D stated she didn't know why anyone hadn't cut the tendon. Without obtaining consent from R1 and without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked CNA G if she felt R1 was in pain during this. CNA G did not think R1 was in pain during the procedure but indicated the tendon was jumping. On 06/08/22 at about 2:50 pm, Surveyor interviewed CNA H and asked about what she witnessed during wound care on 05/27/22 with R1. CNA H indicated she was holding the resident's hand and stated the resident had a death grip during the time the RN D cut the tendon and that she had never had R1 squeeze her hand like that before. CNA H told Surveyor that the foot was being held on by two tendons, not one as others reported. On 06/08/22 at 3:00 pm, Surveyor interviewed RN D and asked her to describe the steps she took for wound care on 05/27/22 on R1. RN D indicated after she cut the bandage off she saw R1's right foot was hanging by a tendon. RN D indicated she used a bandage scissors, cut the tendon in 3-4 snips, and detached the foot. RN D indicated that she observed R1 the whole time and she observed no signs of pain. RN D asked R1 afterwards if he was in pain. R1 said his arm hurt, so RN D gave a prn pain medication. Surveyor asked RN D what she did with the foot; RN D indicated it was placed in a baggie and then a biohazard bag then put in the freezer by NHA A. Surveyor asked RN D if she documented the procedure, RN D indicated she did not, I just spaced it. Surveyor asked RN D if she told the next shift what happened. RN D indicated she did and that's when she realized she should not have done it. RN D acted outside the scope of practice of an RN when she cut the tendon without medical orders to do so. On 06/08/22 at 1:27 pm, Surveyor interviewed CNA I and asked about R1 and losing his foot. CNA I indicated that R1 went downhill mentally after his fall and began bleeding more. She indicated the resident really declined after his foot was gone. She said his color was worse and his condition overall was worse. On 06/09/22 at about 2:09 pm, Surveyor interviewed Dr. C and asked if she was made aware of the condition of R1's foot after his fall on 05/25/22. Dr. C indicated she was not. Surveyor asked Dr. C if she was made aware of R1's tendon being cut; Dr. C indicated she was not made aware of how the tendon was cut and the foot removed until after R1 passed on 06/02/2022. Dr. C indicated what happened was not within the nurse's scope of practice. Dr. C indicated an autopsy was ordered because of conflicting information as to how much tissue was still attached. The facility's failure to assess the condition of R1's feet on at least a weekly basis, to seek treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in a finding of immediate jeopardy. The immediate jeopardy was removed on 06/13/22 when the facility completed the following: Professional Registered Nurses Staff provided with continuing education and refresher training/updates on ensuring ongoing assessments are completed based on current standards of practice. Professional Nurse Staff (RNs and LPNs) provided with continuing education and refresher training/update on ensuring ongoing wound care is being completed based on current standards of practice. Reviewed and updated the policy and procedures that cover ongoing assessments by Registered Nurses based on current standards of practice. Reviewed and updated policy and procedures for ongoing wound care based on current standards of practice.

Based on interview and record review, the facility failed to ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 2 hospice residents (R1). R1's plan of care was not coordinated and communicated adequately between the facility and hospice regarding R1's ongoing foot condition or when R1's foot was removed by an RN. The facility did not develop a communication plan that included how communication would be provided and documented between the facility and hospice to ensure the needs of the resident were addressed and met. Failure to notify hospice of continued change in condition and clinical complications which suggested a need to alter R1's plan of care did not allow for hospice to provide medical direction and management for R1. Facility failure to coordinate care with hospice regarding the care and treatment needed for R1's foot created a finding of immediate jeopardy that began on 05/25/22. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 06/10/22 at 10:30 am. The immediate jeopardy was removed on 06/13/22, however the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The facility service agreement entered on October 3, 2013 between Hospice and Spring Valley Health and Rehabilitation Center reads in part, .Facility shall immediately inform Hospice of any change in the condition of a Hospice Patient. Based on record review, R1 had an unwitnessed fall on 05/25/22. Resident rolled out of bed and was found on floor, right foot saturated w/blood. Resident was showing signs of [CONDITION(S)], was talking in word salad. Wound care was provided to right foot which is no longer attached to ankle, is attached by one tendon, resident made no indications of pain during repositioning of foot to line up with ankle, and was then wrapped with [MEDICATION(S)] and taped to secure. Hospice made aware of new findings. Safety measure put in place to prevent fall, bed in lowest position, floor mat, bed against wall. There was no collaboration with hospice or the physician about continued care for R1's foot, which was attached by 1 or 2 tendons. The medical record indicated on 05/25/22 at 8:45 pm, dressing change to right foot due to being drenched with bloody drainage. R1 assessed, continues to be delirious, unable to take scheduled [MEDICATION(S)] tablets, given liquid comfort meds. Eyes open but no eye contact, staring past writer, nonverbal, appears comfortable, no physical signs of discomfort, no moaning. Review of hospice client coordination notes, there is no mention that this assessment was shared with hospice. There is no documentation hospice was made aware of the update of R1's condition and the assessment completed by the facility. On 06/08/2022 at 1:13 pm, Surveyor interviewed CNA G who indicated that R1 was weird on 05/27/22, not in his right state of mind, ringing call light and not remembering what he needed. There is no indication hospice was made aware of this. CNA G indicated she and CNA H were asked to assist RN D with holding R1's leg while RN did wound care on 05/27/22. CNA G said that the nurse cut off the bandage then said she didn't know why anyone hasn't cut off the tendon and that it would relieve pain. RN D then cut the tendon and CNA G indicated you could see R1 was not in any pain, but the ligament was spasming. CNA G did not know what to do with the foot that was detached so she went to the NHA and asked what to do. He told her to put it in a baggie and then a red biohazard bag. On 06/08/22 at 3:00 pm, Surveyor interviewed RN D and asked what she did on 05/27/22 when she did R1's wound care. RN D indicated that she removed the bandage and R1's right foot was hanging by a tendon. RN D indicated she used a bandage scissors and in 3-4 snips she cut the tendon and the foot was detached. She indicated she watched R1's facial expressions during the time and there were no grimaces or signs of pain. After the foot was detached, she wrapped the open wound with Vaseline and gauze to make him comfortable. She put the foot in a zip lock baggie and then a red biohazard bag. Surveyor asked RN D if she notified Hospice or the doctor of the condition of R1's foot. RN D indicated she did not. Surveyor asked if RN D had updated Hospice or the doctor after cutting the tendon holding the foot, RN D indicated she did not. Surveyor asked RN D if it was documented anywhere about what she had done, and she indicated she did not, she spaced it out. RN D indicated that someone else notified the DON, it was done and nothing she could undo. On 06/09/22, Surveyor interviewed RN F who is the Hospice Nurse and asked if hospice was made aware of R1's foot being amputated. RN F indicated that she was off the weekend and first saw R1 on 05/30/22. She indicated that is when she noticed the foot was missing and associated it with the fall. RN F indicated she was not aware of the amputation until another facility staff told her about it on 06/01/22. Surveyor asked RN F if she had done wound care on R1's foot. RN F indicated when she arrives, the facility usually has already done the wound care and if the bandage is clean and dry she didn't want to move R1 any more than necessary because of his high amount of pain and wants to keep him comfortable. RN F did not provide the wound care, or inspect the wound if the bandage was clean and dry when she was in the facility. On 06/08/22 at 2:07 pm, Surveyor interviewed Director of Nursing (DON) B by phone. DON B indicated the only thing that was keeping the foot attached was the tendon, the bone had already been gone. She indicated she thought R1 was septic and getting delusional. Surveyor asked DON B at any time did the doctor or hospice tell you to snip the tendon, DON B indicated no. Surveyor asked DON B if she felt R1 was in any more pain after the tendon was cut, DON B indicated no. Surveyor asked DON B if hospice or the doctor were notified as to what happened with the foot, DON B indicated she did not know. She indicated the foot was coming off and hanging by a little white thread. Surveyor asked her if she would want her staff to cut the tendon, DON B indicated, No, it's something I would not do either. Surveyor asked DON B what should have been done; she indicated 1st call hospice and then keep primary physician in the loop. The facility's failure to collaborate and communicate with R1's hospice provider about the deteriorating condition of R1's foot and the nurse's decision to cut and detach foot without first contacting hospice, the lack of notifying hospice of the clinical complications of the foot attached with just a tendon, and the lack of coordinating an appropriate course of care for R1's foot resulted in immediate jeopardy starting 05/25/22. The immediate jeopardy was removed on 6/13/22 when the facility completed the following: Professional Registered Nurse Staff (RNs and LPNs) were provided with continuing education and refresher training/updates on ensuring communication with hospice(s) regarding patient care. Professional Nurse Staff (RNs and LPNs) were provided with continuing education and refresher training/updates on ensuring communication with hospice(s) regarding ongoing care of Resident(s). Administrator, Director of Nursing and Clinical Services, the Registered Nurse Educator, and/or other Nurse Leaders conferenced with Resident DNM's hospice provider nurse manager and operations managers/supervisor on June 13, 2022 to discuss, review, and identify opportunities to improve communication between Spring Valley Health and Rehabilitation Center's health care personnel and the hospice's health care personnel. Director of Nursing and Clinical Services and the Registered Nurse Educator with the assistance of other Nurse Leadership Team Members reviewed and updated as indicated the policy and procedures that covers communication with hospice(s) regarding Resident care. Director of Nursing and Clinical Services and the Registered Nurse Educator, with the assistance of other Nurse Leadership Team Members reviewed and updated as indicated the policy and procedures that covers communication with hospice(s) regarding Residents' ongoing care.

Based on observation, interview, and record review, the facility did not ensure each resident is free from sexual abuse from other residents or the likelihood of future abuse occurring. This occurred for 1 of 2 residents (Resident (R) 16) reviewed for abuse. *R9 sexually abused R16 in the dining room. R9's care plan states R9 is not to be allowed to be with female residents unattended. Facility failed to prevent future sexual abuse of R16 from occurring. R16's care plan was not updated with abuse interventions to protect R16 and other residents from further abuse. This is evidenced by: Facility policy for Preventing Violations of Resident's Rights and Resident Abuse. Policy states, in part: .The Spring Valley Health and Rehabilitation Center strictly enforces the Resident Rights of all Residents. All forms of abuse, neglect, mistreatment, and misappropriation of Resident property are strictly prohibited. Violations of Resident Rights will be fully investigated taking appropriate remedial action and reporting as indicated to the regulatory agencies and/or law enforcement agencies . The policy states, in part: .Immediately upon learning of an allegation and throughout the reporting and administrative investigation, the Spring Valley Health and Rehabilitation Center will take every necessary precaution to protect the resident(s) from any potential harm, any possible subsequent incidents of misconduct or retaliation including those person(s) reporting an allegation or witnesses providing information on the allegation . The policy states, in part: .So as to eliminate future occurrences of resident rights and resident abuse, responses can include, but are not limited to: 1. Review and resolution by the Spring Valley Health and Rehabilitation Center, Inc., Board of Commissioners to commit resources and/or establish policy (ies) determined to be appropriate to address an occurrence or potential occurrence. 2. Study and analysis by the Quarterly Quality Assessment and Assurance Committee or a Sub-committee so as to develop and implement studies and subsequent action plans that could eliminate occurrences or potential occurrences. 3. Development or revision of Departmental Procedures providing clearer guidance to staff so as to eliminate occurrences or potential occurrences. 4. Administrative directives or initiatives that address occurrences and potential occurrences, especially those needing immediate intervention and action . On 03/22/21, Surveyor reviewed R9's medical record. R9 was admitted to the facility 07/24/19. R9 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9 has a Brief Interview for Mental Status Score (BIMS) of 5 of 15 possible points. According to the BIMS assessment, a score of 5 indicates severe cognitive impairment. On 03/22/21, Surveyor reviewed a document, dated 06/24/20, which stated facility knew of R9's history of inappropriate sexual behaviors with other residents. The document stated an appropriate care plan was put into place with the appropriate interventions for the safety of the residents. Surveyor reviewed R9's 06/24/20 care plan. The care plan states, in part: .Problem (BEHAVIOR) related to history of sexual misconduct; dementia related to dementia environmental triggers manifested by inappropriate touching. Potential for disruptive behavior (sexual) primarily directed at young staff, potential for others. Interventions: Nurses-Identify patterns of behavior, if [R9] is making sexually inappropriate comments during cares, staff may redirect with statements such as that is inappropriate, that makes me uncomfortable do not allow resident to be with female residents unattended with other female residents, staff may choose to do cares with 2 staff if resident is making any sexually inappropriate comments or gestures. Nurse Aide-Report to nurse any inappropriate comments or gestures, staff may choose to do care with 2 staff if resident is making any sexually inappropriate comments or gestures. Do not allow resident to be left unattended with other female residents. Record behaviors. Maintain safety of resident and others. Report pain indicators. 01/13/21 Social Services-1:1 visits. Review quarterly behavior document with behavioral consultant and prn. Identify unique characteristics that may be used to reduce agitation (eg: work history, hobbies, sense of identity) . Care plan states, in part: .R9 is transferred using a sit to stand. Eating is independent after tray set-up. Interventions state, in part: .03/11/21 Nurse Aide---Other Special Directions: Certified Nursing Assistant (CNA) may use assist of 2 at any time. Resident has a history of sexually inappropriate behaviors, please notify nurse of any episodes. If resident exhibits behaviors, please ensure he is safe and attempt to re-approach at a later time. Resident must be a 1:1 when in dining room. The intervention on 3/11/21, does not identify why R9 needs to be 1:1 in the dining room. This intervention does not protect female residents that are in the hallway or in their rooms. R9 is mobile and can get into other rooms and down the hallways of the facility by propelling his wheelchair. Surveyor reviewed R9's nurse's notes. On 01/04/21, emergency room visit. On 01/30/21, sexually inappropriate behavior toward others, such as grabbing, touching times 3, intervention: 1:1 outcome: unchanged. On 03/03/21, no behaviors. On 03/10/21, tried to hit CNA, going in other's rooms three times during shift, unable to redirect him. Charged at staff while in wheelchair. On 03/11/21, no behaviors noted. On 03/17/21, Sexually inappropriate with another female resident. No other information documented on this incident. No documentation in medical record of physician notification of abuse incident or family notification of abuse incident. On 03/22/21 at 3:50 P.M., Surveyor interviewed CNA G. Surveyor asked if R9 has had inappropriate interactions with staff or residents. CNA G stated, No, not that I know of. Surveyor asked if CNA heard about any inappropriate behaviors of R9 toward residents or staff. CNA stated, No. Surveyor asked what type of behaviors R9 exhibits are monitored. CNA G stated there was nothing really, except staff has to make sure he is alone and supervised due to history of behaviors. Surveyor asked if these behaviors occurred in the facility or elsewhere. CNA G stated, I'm not sure, Surveyor asked if R9 is allowed to be in same room with other residents. CNA G stated he can be with other residents, but he has to be supervised. Surveyor asked if R9 has displayed any odd behaviors. CNA G stated, No. On 03/23/21 at 2:38 P.M., CNA G returned to facility to speak with Surveyor and clarify information given in interview on 03/22/21. CNA G stated, I was told to lie about R9 by DON B. I wasn't here that day, but heard that he touched another resident. On 03/22/21 at 4:03 P.M., Surveyor interviewed Registered Nurse (RN) D. Surveyor asked if R9 has inappropriate behaviors. RN D stated he has had inappropriate behaviors. RN D stated R9 has touched staff, does not know if he has touched residents inappropriately. Surveyor asked what type of touch with the staff does R9 exhibit. RN D stated R9 will grab female breasts. Surveyor asked if staff ever reported him touching other residents. RN D stated, No. Surveyor asked when staff gets touched and staff tells him to stop, is he aggressive. RN D stated he will just stop. He is redirected easily. Surveyor asked if behaviors are documented. RN D stated the aides used to document, but that is changing. The nurse will be documenting a summary note weekly on behaviors. On 03/22/21 at 4:48 P.M., RN D returned to the conference room and handed Surveyor a note. Note stated I'm sorry I withheld information. My DON asked me to as I did not witness the incident. [R9] exposed and touched another resident. The resident was [R16]. On 03/23/21 at 11:48 AM, Surveyor received a phone call from RN D. RN D told Surveyor that she wasn't truthful in her interview on 03/22/21. RN D stated her boss, DON B, prior to meeting Surveyor yesterday, had her change her documentation in the chart on R9. RN D stated R16 never has such behavior. RN D stated that the wording she changed in the chart had said, Resident was sexually inappropriate behaviors towards another resident in the dining room. RN D stated the wording was changed to, Resident was sexually inappropriate in the dining room. On 03/22/21 at 4:56 P.M., Surveyor interviewed CNA H. Surveyor asked CNA H if R9 exhibited any inappropriate behaviors toward other residents or staff. CNA H stated, No. Surveyor asked if CNA H heard of any inappropriate behaviors through other staff. CNA H stated, No. Surveyor asked when resident is in the dining room, can he go sit with another resident if he wants to. CNA H stated that he has to be 6 feet apart for social distancing. Surveyor asked if R9 had any behaviors that are monitored and have to be documented. CNA H stated, No. On 03/23/21 at 12:16 P.M., CNA H stated when she started working at the nursing home, the women training her told her that R9 had sexual behaviors. CNA H has never seen anything but wanted to correct her statement. On 03/23/21 at 10:25 AM, Surveyor interviewed RN E. Surveyor asked RN E if any inappropriate behaviors by R9 were ever witnessed by her. RN E stated she never witnessed any inappropriate behaviors, but she would see him move towards other residents and would redirect him. Surveyor asked if R9 is monitored for any behaviors. RN E stated resident is monitored for inappropriate touching of staff or comments and also with residents. Surveyor asked RN E if she is aware of any incidents involving R9's inappropriate behaviors. RN E stated there was a dining room incident and she heard about it after she had gotten to work. R9 was witnessed by Occupational Therapy Assistant (OTA) F, where he had his hand on a female resident's breast and her shirt was lifted up. RN E stated she was informed the OTA F separated the residents and the office was monitoring the resident for the rest of the day because there was not enough staff do 1:1 supervision. RN E stated she also has heard R9 say inappropriate things to residents and staff. On 03/23/21 at 10:45 A.M., Surveyor interviewed OTA F. Surveyor asked if OTA F ever witnessed any inappropriate behaviors of R9. OTA F stated, Yes, I have. OTA F stated she witnessed R9 lifting up R16's shirt and touching her breast. The OTA F stated R16 was making uncomfortable sounds, such as Ah, Ah. OTA F stated she separated the residents and reported to RN C. OTA F stated she took R9 to his room and the RN C assessed R16. On 03/23/21 at 2:58 PM, Surveyor interviewed RN C. Surveyor asked if RN C knew of any incident of inappropriate behavior of R9. RN C stated resident has a history of inappropriate touch. Surveyor asked if there have been any incidents with R9. RN C stated there have been incidents with younger staff who lack experience working with residents. RN C stated 2 CNAs should enter R9's room when assisting resident. Surveyor asked RN C if R9 has had any incidents of inappropriate behavior with other residents. RN C stated he had touched a CNA's breasts. RN C stated she believed he had also with other residents. RN C stated she didn't see the incident, but a report came through on another resident and an investigation was done. RN C stated who the other resident was in the incident, R16. R9 had his chair behind R16's chair and was touching her breast and R16's shirt was lifted up. RN C stated R16 has inappropriate behaviors and will lift her shirt up inappropriately. RN C stated therapy reported the incident to her. RN C stated therapy took R9 to his room and she assessed R16 and R16 showed no signs of distress. RN C stated DON B contacted the family of R16. Surveyor asked what interventions were put into place after the incident. RN C stated 1:1 supervision was put into place. On 03/24/21 at 10:00 A.M., Surveyor interviewed DON B. Surveyor asked DON B if she was aware of any behavioral incidents of R9 with other residents or staff. DON B stated she was aware of both. Surveyor asked what behaviors were you aware of. DON B stated sexual inappropriate behaviors like touching. DON B stated if a CNA was with a resident, he would touch their butt or reach across and touch their breasts. Surveyor asked about any behaviors with other residents. DON B stated there was an incident where R9 touched another female resident's breast. R9 went around by R16 and was seen by therapy with his hand on her breast and her shirt was lifted up. The DON B stated the staff moved R9 and made sure R16 was safe. DON B stated the care plan was updated for 1:1 supervision of R9 after the incident. Surveyor asked DON B if both residents' physicians and families were notified of the incident. DON B stated they were notified. Surveyor asked why didn't the medical records have any documentation of the incident or notifications of physicians or families. DON B stated it isn't in the record, and it was probably written elsewhere. Surveyor asked if DON B knew of resident's history of sexual behaviors. DON B stated yes. Surveyor stated such documentation should be part of the medical record of the resident. Surveyor stated to DON B that during staff interviews it was brought forth by the staff that DON B told staff to lie and to state general behaviors of residents when they met with the surveyors. DON B denied this. DON B stated, If I were to lie, I wasn't trying to hide it . Surveyor asked DON B about having an RN change documentation on R9 to remove the words another resident from the sentence sexually inappropriate with another resident. DON B stated she was trying to get the RN to document only what she saw or heard and that she did not ask her to change the documentation. DON B stated, If I wanted documentation changed, I could have changed it myself. Surveyor asked why incident was not reported by the facility. DON B stated that according to the flowsheet it states that those who don't know what they are doing, you don't have to report it. Staff identified R16 as being the victim of R9's sexual advances. Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE]. R16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's BIMS score is 1 of 15 possible points which indicates severe cognitive impairment. Surveyor reviewed R16's care plan. Care plan states, in part: .12/09/20 Problem (ADLS/FUNCTIONAL)-Self-care deficit needs total assist with bed mobility, transfers, toilet use, needs limited assist with eating related to acute illness (hx of frequent falls), chronic illness (osteoarthritis) decreased mobility, muscle weakness, dementia manifested by decreased (Activity of Daily Living) ADL participation . Care plan states, in part: .11/27/20 Problem (COGNITIVE LOSS) Cognitive loss Potential for 02/17/21 Problem (COGNITIVE LOSS) Cognitive loss related to depression related to Alzheimer's/dementia depression manifested by impairment noted with ability to make safe decisions. Decline in performance of activities of daily living, or instrumental ADLS. Interventions: Social Services-1:1 visits. Assess cognitive status. Encourage resident to express feelings regarding current situation and anticipated changes. Assess/monitor for behavior changes, including agitation, anxiety, aggression, delusions, hallucinations, and/or decreased inhibitions. Assess for signs/symptoms of depression. Establish baseline for cognitive abilities with BIMS. Reorient as needed. Encourage socialization. Monitor for changes in cognitive abilities. Provide support to family/significant other (s) . The care plan does not identify abuse or how staff will maintain the safety of R16 from R9. Surveyor reviewed R16's nurse's notes. No documentation in record regarding abuse incident, physician notification, or family notification. On 03/22/21 at 9:00 a.m., Surveyor observed R9 in his room lying in bed sitting up at a 30 degree angle. R9 is observed to be able to move his hands up above his head. Surveyor tried to interview R9; he would not respond to questions. On 03/22/21, Surveyor observed R16 eating in dining room for breakfast, lunch and dinner. R16 ate alone at the dining table. On 03/23/21 at 11:39 A.M., Surveyor observed R9 wheeling out of his room door and wheeling himself down hallway. R9 wheeled self approximately 1/3 of the way down hall. CNA J walked down hallway and redirected resident to his room for his lunch meal. Resident in his room eating the lunch meal. On 03/23/21 at 11:59 A.M., R9 finished lunch meal and propelled self in wheelchair out of his room down hallway. R9 was sitting in lounge area and CNA J turned TV on for R9. On 03/23/21 at 12:55 P.M., Surveyor observed R9 propelling self in wheelchair toward exit door. Dietary Director (DD) N stopped R9, and then RN I who was working on the floor assisted R9. R9 had no difficulty propelling self in his wheelchair.

Based on interview and record review, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 10 sampled residents (Resident #6 and 2). 1. Resident #6 was described to be shouting, begging staff to stop during the showers. Resident #6 received showers weekly, causing distress and psychosocial harm to her. 2. Resident #2 has a venous stasis ulcer. The facility did not complete and document weekly skin assessments of the resident's ulcer and did not develop a care plan related to the resident's ulcer. This is evidenced by: The facility policy entitled, Dementia Care Policy, states in part: .1. Person-Centered Care: Provide a supportive environment that promotes comfort and recognizes individual needs and preferences. 2. Quality and Quantity of Staff: Provide staff, both in terms of quantity (direct care as well as supervisory staff) and quality to meet the needs of the residents as determined by resident assessments and individual plans of care. 3. Thorough Evaluation of New or Worsening Behaviors: Identify and address treatable medical, physical, emotional, psychiatric, psychological, functional, social, and environmental factors that may be contributing to behaviors. 4. Individualized Approaches to Care: Utilizing a consistent process that focuses on a resident's individual needs and tries to understand behavior as a form of communication may help to reduce behavioral expressions of distress in some residents . Resident #6 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Resident #6's Minimum Data set (MDS) assessment, dated 02/23/16, indicates that Resident #6 has severe cognitive impairments. Resident #6's self care deficit care plan includes an approach, dated 06/23/15, which states: Nurse Aide ---BATHING: Extensive assist, 2 assist. Resident #6's Certified Nursing Assistant (CNA) Kardex states in part: My bathing routine: Friday evening shift Assistance Needed: Two Assist. Surveyor reviewed the CNA charting on showers, and for the past six months Resident #6 has consistently received a shower once per week. On 03/22/16 at approximately 2:30 p.m., Surveyor conducted an interview with Resident #6's Family Member (FM) R. FM R stated that Resident #6 is scared to death of water and showers. Surveyor asked what happens during Resident #6's showers. FM R stated that staff sing to her in the shower and that has helped. FM R told Surveyor that Resident #6 did not know how to swim and has always been fearful of water, but she always liked to be kept clean. On 03/23/16 at approximately 8:10 a.m., Surveyor asked CNA D about Resident #6's showers. CNA D stated that Resident #6 doesn't like it, she hollers, and they tell her that they will do it as fast as they can. CNA D stated, Yes when asked if it is every time Resident #6 showers. CNA D stated, We use two people and get it done as fast as we can. On 03/24/16 at 8:25 a.m., Surveyor asked LPN B about Resident #6's showers. Licensed Practical Nurse (LPN) B stated, She screams and hollers, it's just awful, she's telling us its against what she wanted, it's so traumatic to her, we could hear her hollering out here. LPN B is standing in the hallway outside of Resident #6's room. On 03/24/16 at 9:00 a.m., Surveyor asked CNA F about Resident #6's showers. CNA F is identified in the charting as one of the CNAs who has assisted Resident #6 with showers. CNA F stated, She really doesn't like it, she screams, yells and fights you. CNA F described Resident #6 rocking in her shower chair trying to get out. Surveyor asked if this happens every time Resident #6 gets a shower. CNA F replied, Every time, all the time. CNA F stated, She usually yells mama and begs you to stop. Surveyor asked what CNA F does when this happens. CNA F replied, I always make sure I have another CNA. I go through the routine. I try to get done as fast as I can. Surveyor asked what the other CNA does. CNA F replied that they help to be sure Resident #6 is stable in the chair. Surveyor asked if CNA F ever reported this to the nurse. CNA F stated that the nurse already knows. CNA F told Surveyor that Resident #6 gets a shower every week. On 03/24/16 at 9:05 a.m., Surveyor informed the Director of Nursing (DON) and Director of Resident Services (DRS) H about the above conversations regarding Resident #6's shower. Both indicated they were not aware of this. At 9:20 a.m., DRS H stated they will be giving Resident #6 bed baths. Surveyor asked DRS H if Resident #6 has the right to refuse a shower. DRS H stated, Of course. On 03/24/16 at 10:15 a.m., DRS H brought in a complaint/grievance regarding Resident #6's showers and stated they have begun an investigation. On 03/24/16 at 12:50 p.m., Surveyor asked CNA D how long Resident #6 had been getting upset with her showers. CNA D replied, I don't know how long she's been like that, as her dementia worsened. On 03/24/16 at 12:55 p.m., Surveyor asked CNA F how long Resident #6 had been getting upset with her showers. CNA F stated that Resident #6 has been like that since she got hired. CNA F's hire date is listed as 11/11/15. 2. The facility's policy entitled, Prevention and treatment of [REDACTED].II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented .I. Update care plan for skin integrity and nursing assistant Kardex. J. Initiate weekly wound documentation . Resident #2 has a [DIAGNOSES REDACTED]. Per record review by Surveyor on 03/22/16, Resident #3 currently has a venous stasis ulcer on the right ankle which developed on 03/07/16 measuring 2 centimeters (cm). Per a nurse's note, dated 03/08/16 at 10:20 p.m., the venous stasis ulcer on the right ankle measured 1 cm by 1 cm. Per a nurse's note, dated 03/11/16 at 2:12 a.m., Skin Problems: DC (Director of Nursing initials) RN (Registered Nurse) wound nurse assessed right ankle ulcer, New treatment plan added to tx (treatment). Wound looks smaller than the last time writer observed on 3/8/16. No measurements were documented of the ulcer on this date. Surveyor reviewed the medical record and could find no further documentation of weekly assessments and measurements of the ulcer. On 03/24/16 at 12:30 p.m., Surveyor requested the weekly skin assessments and measurements of Resident #2's venous stasis ulcer on the right ankle from the DON. The DON stated on 03/19/16, LPN I assessed and measured the resident's right ankle ulcer but did not document it. Surveyor reviewed the resident's current interdisciplinary care plan and CNA care plan with the DON. The care plans did not include a care plan related to the resident's venous stasis ulcer on the right ankle. The DON stated Registered Nurse (RN) A, RN P and herself are responsible for developing and revising resident care plans.

Based on record review and interviews, the facility did not complete a thorough assessment to determine the root cause of decline in bowel function or offer appropriate interventions which would allow the residents to maintain or restore their bowel function for 2 of 13 residents (Resident #12 and #1). The facility did not provide appropriate care and treatment for 1 of 1 sampled resident (Resident #9) with a skin tear and blisters. 1. Resident #12 had a decline in bowel function. No bowel assessments completed and no toileting program implemented. 2. Resident #1 had a decline in bowel function. No bowel assessments were completed and no toileting program was implemented. 3. Resident #9 was discovered with a skin tear on her left inner thigh and a blister on her right abdomen. Treatment Administration Records (TAR) were not updated accurately and timely. As evidenced by: On [DATE], Surveyor # requested a copy of the Facility's Bowel and Bladder Policy and Procedure. No Policy and Procedure provided. 1. Resident #12 On [DATE] at 1:30 p.m., Surveyor # reviewed the medical record for Resident #12 and noted the following information: - Minimum Data Set (MDS), dated [DATE], stated Resident #12 was occasionally incontinent of bowel, which consists of one episode of bowel incontinence. The MDS states Resident #12 was not on a bowel toileting program. The MDS documents Resident #12's mental status as a score of 3, which indicates Resident #12 is cognitively impaired. - MDS, dated [DATE], stated Resident #12 was frequently incontinent of bowel, which consists of two or more episodes of bowel incontinence but at least one continent bowel movement. The MDS coded Resident #12 as having a bowel toileting program. The MDS documents Resident #12's mental status as a score of 2, which indicates Resident #12 is cognitively impaired. - MDS, dated [DATE], stated Resident #12 was always incontinent of bowel. The MDS also coded Resident #12 as having a bowel toileting program. The MDS documents Resident #12's mental status as a score of 2, which indicates Resident #12 is cognitively impaired. - MDS, dated [DATE], stated Resident #12 was always incontinent of bowel. The MDS also coded Resident #12 as having a bowel toileting program. The MDS documents Resident #12's mental status as a score of 3, which indicates Resident #12 is cognitively impaired. - Comprehensive Care plan, dated [DATE], titled, "PROBLEM: ADL/Functional" states, "Nurse Aide--TOILETING: I am Dependent, 1 assist, use incontinence brief. Provide perineal care." No toileting schedule or program noted on the care plan. The care plan had no changes following a decline in bowel continence. - Certified Nursing Assistant (CNA) care plan, dated [DATE], states, "TOILETING: I am Dependent, 1 assist, Use incontinence brief. Provide perineal care." No toileting schedule or program noted on the care plan. The care plan had no changes following a decline in bowel continence. On [DATE] at 2:50 p.m., Surveyor # interviewed the Director of Nursing (DON) and Registered Nurse (RN) E. This surveyor reviewed the decline in bowel function for Resident #12 according to the MDS with both the DON and RN E. This surveyor asked both the DON and RN E if a bowel assessment had been completed when Resident #12 had a decline. Both the DON and RN E stated they would have to look into the medical record to verify if a bowel assessment had been put into place. This Surveyor asked the DON and RN E if Resident #12 was on a toileting program and the DON stated, "No. He has no toileting program and is not on a toileting schedule." On [DATE] at 8:50 a.m., Surveyor # interviewed RN E. RN E stated there were no bowel assessments for Resident #12 in the medical chart nor was Resident #12 on any type of toileting program. RN E stated a full assessment should be completed at least quarterly and with any decline according to the MDS. This surveyor asked RN E if this had been done for Resident #12 and RN E stated, "No." RN E stated he did not know why the nursing staff did not assess Resident #12 when there was a decline in bowel function. RN E stated he did not know why Resident #12 was not on a toileting schedule. RN E stated he would be putting a plan into place to ensure an assessment and toileting schedule be implemented immediately. No further information provided. 2. On [DATE], Surveyor # reviewed the medical record for Resident #1 and noted the following information: - MDS, dated [DATE], showed Resident #1 was frequently incontinent of bowel (which consists of two or more episodes of bowel incontinence but at least one continent bowel movement). - MDS, dated [DATE], showed Resident #1 was frequently incontinent of bowel. - MDS, dated [DATE], showed Resident #1 was always incontinent of bowel. - MDS, dated [DATE], showed Resident #1 was always incontinent of bowel. All above MDSs showed the following: Resident #1 was not on a bowel toileting program and cognitive skills were documented as moderately impaired. -Care Plan read in part: "[DATE] PROBLEM: ADLs/Functional: Nurse Aide--TOILETING: Dependent, 2 or more assist, use incontinence brief. Provide perineal care." No toileting schedule or program were noted on the care plan. The care plan had no changes following a decline in bowel continence. - CNA Guidelines for Daily Care read in part: "TOILETING: Nurse Aide-- Encourage fluid intake. Toilet per scheduled toileting plan. Report changes in voiding pattern or appearance of urine. Provide privacy." No toileting schedule or program were noted on the care plan. The care plan had no changes following a decline in bowel continence. On [DATE] at 9:55 a.m., Surveyor asked the DON what "toilet per schedule toileting plan" meant. DON stated she did not know and would have to look that up. DON was informed that CNA S told Surveyor Resident #1 is not toileted because she gets upset. On [DATE] at 8:20 a.m., Surveyor followed up with the DON and RN E regarding the definition of "toilet per scheduled toileting plan." The DON stated, "Didn't find anything for that." Surveyor informed the DON and RN E about Resident #1's decline in bowel continence per the MDSs and asked if there were any bowel assessments, tracking or toileting program. RN E stated, "No." 3. Resident #9's care plan identified the need of extensive assistance of two with positioning and bed mobility. Resident #9 transferred with a mechanical lift and assistance of two staff. Resident #9 is to be repositioned every two hours in bed and every hour when up in her chair. Surveyor reviewed Resident #9's facility standing orders. The order included: 14. Steri-strip to miner skin tears after wound cleansing. 15. [MEDICATION NAME] ointment PRN (as needed) to skin tears. 16. Opsite, Duoderm or [MEDICATION NAME] or equivalent to minor abrasions change q (every) ,[DATE] days. 17. Routine wound/skin care per facility policy. The facility's "Standing Orders for Wound Care" stated, "These are facility standing orders: Physicians may order alternative treatments as appropriate. MD must be notified for all new wounds, significant changes and non-healing wounds." Skin Tears: Cleanse wound with normal saline or Dermal Wound Cleanser. A. With skin flap: Skin Prep PRN (as needed), approximate edges with steri-strips. Change prn. B. For light to moderate drainage: "Apply transparent dressing or composite dressing or foam composite dressing. Change every 5 days and PRN C. For light to moderate drainage, fragile skin. Apply hydrogel sheet dressing. Secure with conforming bandage. Change every 5 days and PRN. Pressure Ulcers: Initiate Wound Flow Sheet. Document size and wound status weekly and PRN. Notify Registered Dietician. Cleanse with normal saline or Dermal Wound Cleanser. Skin-Prep PRN. Stage 2: Partial Thickness: A. Blister: Apply several coats of Skin-Prep daily or Skin-Prep and cover with transparent dressing. Change prn. B Abrasion or shallow crater with minimal to moderate amount of drainage: Apply hydrogel wound gel. Apply composite dressing or foam composite dressing. Change ever 5 days and pen *The above orders are initiated according to AHCPR Guidelines and that of the nurses judgement. Prior MD authorization has been documented on House Standing Orders or Physician order [REDACTED]. A. Blister on Abdomen: [DATE] 11:53 p.m. Resident #9's nurses' notes stated, "Skin Problems: blister Location: (50) right lower abdomen Area: length (cm) 4.0 width (cm): 2.0 depth: 0 Currently open area to blister; measurements are: length (cm): 1.1 width (cm): 0.6 depth: 0 Drainage: scant amount (one droplet) of clear drainage noted. Procedure Done: Cleansed area with DWC (Dermal Wound Cleanser). Applied skin prep to area surrounding open part of blister. Comments: Resident has no idea what happened to cause this skin problem." Resident #9's medical record contains no documentation the physician was notified of the blister or physician orders [REDACTED].#9's care plan. Resident #9's Treatment Administration Record (TAR) did not identify a treatment was initiated.) [DATE] at 2:16 p.m.. "Skin Problems: open area Location: abdomen, right of belly button Drainage: Light green in color Skin Treatment: cleansed with DWC, pat dry, [MEDICATION NAME] applied, covered with dry gauze Action: continue to observe if no improvement update md." Resident #9's TAR contained a nursing order dated [DATE]: Cleanse abdomen open area with DWC, pat dry, apply [MEDICATION NAME], and cover with dry gauze for 3 days. If does not improve or worsens notify MD daily. [DATE] at 2:36 p.m. "Skin Problems: RLQ (right lower quadrant) of abdomen. Location: (50) right lower abdomen Description: tenderness present red surrounding site. Wound bed is green-ish. Area: length (cm) 1.9 width (cm) 2.6 depth: 0 Drainage: None Skin Treatment: Cleansed area with DWC, applied [MEDICATION NAME], applied non-adherent dressing, then secured with paper tape. Procedure Done: Skin tx (treatment) done per order. Action: Physician notified Via INEXX (Fax)." The INEXX sent to the physician stated, "Abd. wound discovered ,[DATE] appears to be a burn, noted to be worsening. Length 1.3, Width 0.9. all edges of wound have redness extending for approximately 0.5 cm. No drainage, however wound bed is greenish-grey in color. We have been cleansing with DWC, applying [MEDICATION NAME], and covering with gauze BID (twice daily). Will continue to monitor thru weekend. Any new orders." Resident #9's TAR identified the nursing order treatment was discontinued on [DATE]. No new treatment was added to the TAR. [DATE] at 12:19 a.m. "Physician Contact: Per INEXX attending physician Regarding: injury (abd (abdominal) wound) noted. No new orders at this time. Notify (MD's name) if not improving as expected." [DATE] at 2:18 p.m. "Assessment Type: Follow-up assessment Area 1: (50) right lower abdomen. Wound Type: Stage 2 Wound Tissue: greenish-yellow pink - around borders of wound. Surrounding Tissue: pink Healing Progress: worsened wound bed appears worse. MD did assess area today, awaiting new orders. Comments: Dressing changed this AM per order. (DWC, [MEDICATION NAME], gauze tape)." The physician progress notes [REDACTED].#9 had the wound for approximately one week. It had been covered with bandages and just recently had developed increasing surrounding [DIAGNOSES REDACTED]. The wound was approximately 3 cm long and 1 ,[DATE] cm wide. It is covered by eschar. There is no induration or discharge. "Skin wound with some mild surrounding [MEDICAL CONDITION]. The physician ordered [MEDICATION NAME] 500 mg TID (3 times daily) for 7 days. The nursing staff will continue to dress it daily, Follow up if not significantly healed in the next 7 days." [DATE] at 10:34 p.m. "Skin Problems: Open area remains to right lower quadrant of abdomen, no drainage noted, area cleansed with DWC and [MEDICATION NAME] and gauze applied, area appears to have slough in center and is slightly pink around edges." [DATE] at 10:16 a.m. Skin Problems: open area Location: (50) right lower abdomen Description: appears more clean tenderness present greenish-yellow hardened drainage to center of wound. Edges have 0.4 cm redness to all sides. Area: Length (cm): 2 width (cm): 3.3 depth: 0 Drainage: light Skin Treatment: no pressure relief devices for bed or chair, no turning/repositioning program, no nutrition/hydration program interventions to manage skin problems, no ulcer or surgical wound care, no nonsurgical dressings applied, no ointments or medications applied. Procedure Done: Skin tx done per order. Procedure Result: unchanged. Action: continue to observe." 3:18 p.m. Family/Guardian Contact: family/guardian, (name of guardian), Regarding: change in condition infection of abdominal wound - started on antibiotics." On [DATE] at 9:45 a.m., Surveyor interviewed the DON and RN E related to the blister. The DON and RN E stated they did not know the cause of the blister. The DON stated the facility would use their standing orders for treatment of [REDACTED]. The DON and RN E stated treatments used for Resident #9 should be on the TAR. B. Skin Tear to Left Inner Thigh: On [DATE] at 6:56 p.m., Resident #9's nurses' notes stated, "Note: Has skin tear to her left inner thigh (59). Length: 3 cm Width: 2 cm Open area measures 1.5 cm by 2 cm Depth: 0." The next entry in Resident #9's medical record or nurses' notes related to the skin tear was on [DATE] at 1:36 p.m. The note stated, "Weekly Skin Assessment: Skin Problems: Had tear/cut(s) in past 7 days. Location: (59) left anterior thigh Description: becoming smaller becoming more shallow appears more clean. Area: length (cm) 0.8 width (cm) 1.2 depth 0 Drainage: None Skin Treatment: cleanse area, applied skin prep. Procedure Result: improved." On [DATE] at 10:53 a.m., Surveyor observed RN L perform Resident #9's dressing change to her abdomen and suprapubic catheter site. At 11:20 a.m., RN L had completed the dressing changes and exited the room without assessing Resident #9's left inner thigh. At 11:25 a.m., CNA O and Surveyor entered Resident #9's room. CNA O stated Resident #9 had a skin tear on her left inner thigh for several days now. CNA O stated she thought it was from the incontinence pad not being positioned correctly and rubbing on the inside of her thighs. CNA O positioned Resident #9 to view the area on the left inner thigh. Surveyor observed an area with a shiny appearance. CNA O verified the area was open and thought the shiny appearance was something the nurse put on. Review of Resident #9's [DATE] TAR revealed no nursing order or treatment order for the area on Resident #9's left inner thigh. Resident #9 was seen by her physician on [DATE]. The progress notes does not identify the physician assessed the skin tear. Resident #9's nurses' notes and medical record contain no documentation the physician was notified of the skin tear. On [DATE] at 9:45 a.m., Surveyor discussed [DATE] abservation with the DON and RN E where RN L did not assess Resident #9's left inner thigh. The DON and RN E stated RN L should have assessed the skin tear. The DON stated the facility would use their standing orders for treatment of [REDACTED].#9 should be on the TAR.

Based on observations, record review and staff interviews, 6 of 8 residents (Resident #2, #9, #5, #7, #3 and #12) reviewed for pressure ulcers and pressure ulcer risk had not received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The first two examples are at a scope and severity level G, the remaining examples are identified at a lower level severity. 1. Resident #2 was admitted to the facility with no skin breakdown. On 04/13/14, Resident #2 developed redness on her buttocks/coccyx. No preventative measures were implemented. Resident #2 developed a Stage 2 pressure ulcer on her coccyx/buttocks on 04/17/14. 2. Resident #9 developed multiple, reoccurant pressure sores on the toes. The physician was not updated, new interventions were not developed and current interventions were not consistantly followed. 3. Resident #5 is assessed to be at risk for development of pressure ulcers. Interventions were not implemented to prevent pressure ulcers. 4. Resident #7 has a history of skin issues on the buttocks. Resident #7's pressure relieving cushion was not in place on three days of survey. No protective barrier cream was applied as directed. 5. Resident #3 was not repositioned every two hours, checked and changed for incontinence and developed a stage II pressure ulcer. 6. Resident #12 developed two stage II pressure ulcers to his toes. No interventions put into place to prevent ulcers from occurring. This is evidenced by: The facility's policy and procedure for the Prevention and treatment of [REDACTED]. 1. Prevention of Pressure Ulcers: A. Braden Scale and Comprehensive Risk Data Collection form (which includes skin audit) will be done: upon admission, weekly for the first 4 weeks, quarterly and with a change in status (i.e. pressure ulcer development, change in mobility, continence status, change in condition, nutrition, etc.) A. Turning and Repositioning Observation (tissue tolerance) - Optimal depending on state requirements and/or MDS (Minimum Data Set) (capturing turning and repositioning). Pressure is the leading cause of pressure sores. An effective turning and repositioning schedule can help reduce the risk of developing a pressure ulcer. Everyone's tissue tolerance (the ability of the skin and its supporting structures to endure the effects of pressure without breakdown) is different. Therefore, it is important to individualize each resident's turning and repositioning schedule. For those residents that are immobile, or need assistance with mobility, complete a Turning and Repositioning (Tissue Tolerance) Observation form. Upon admission, re-admission, with a change in condition (including the development of a pressure ulcer or change in mobility status), annually and in both the lying and sitting positions. B. Monitoring of Skin Integrity: -Skin will be observed daily with cares by the nursing assistant. If any skin concerns are notes, they are to be reported immediately to the designated nurse. -Weekly skin audits on bath/shower day will be performed by the Licensed Nurse -The care plan for Skin Integrity is to be evaluated and revised based on response, outcomes and the needs of the resident. C. Nutrition: The Dietician will be notified: -If a resident is considered a nutritional risk -Upon discovery of a wound -When a wound declines unexpectedly -If a wound is not showing progress in 2-4 weeks D. Therapy: A Therapy evaluation will be requested for wheelchair seating evaluation as appropriate. II. treatment of [REDACTED]. If a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer the following procedure is to be implemented: 1. Initiate Wound Care Protocol (they must be a part of the signed standing orders). The back of the Wound Care Protocols has space for the facility to write in the specific name brand products that are used. 2. Notify Physician/NP (Nurse Practitioner) and Family/Designee. 3. Notify Supervisor/Designee. 4. Notify Dietary for nutritional interventions. 5. Notify Therapy Department for seating surface evaluation and possible treatment interventions and other interdisciplinary team members as appropriate. 6. Re-evaluate turning and repositioning intervals; initiate a new Turning and Repositioning Observation form (only if utilizing per state regulations). 7. Initiate Braden Scale and Comprehensive Risk Data Collection form. 8. Re-evaluate interventions per risk factors identified. For intervention tips, see Pressure Ulcer Prevention & Treatment Intervention Guidelines or Skin Risk Assessment Interventions Suggestions in Protocols and Intervention section. 9. Update the Care Plan for Skin Integrity and nursing assistant care cards with skin concern, appropriate risk factors, turning intervals and interventions as appropriate. 10. Initiate Weekly Wound Documentation Progress Sheet which will include: type of wound, location, date, stated (pressure ulcers only) or indicate partial or full thickness (arterial, venous, [MEDICAL CONDITION]/diabetic ulcers), length, width and depth; wound base description and if present: drainage, odor, undermining, tunneling, and/or pain. 11. When a pressure ulcer is present, daily wound monitoring should include: -An evaluation of the ulcer, if no dressing is present -An evaluation of the status of the dressing, if present -The status of the area surrounding the ulcer (that can be observed without removing the dressing). -The presence of possible complications, such as signs of infections -Whether pain, if present, is being adequately controlled Document on any changes or concerns in the nurses notes and re-evaluate prior steps 1-9 as appropriate. 12. Notify the Physician/NP/Family and Supervisor/Designee if the ulcer(s) has not shown progress in 2-4 weeks and/or is deteriorating unexpectedly. Re-evaluate plan of care as appropriate. 1. Resident #2 was admitted to the facility on [DATE] following a fall with a traumatic subdural hematoma. The Braden Scale completed on 04/09/14 identified Resident #2's mobility was very limited. Resident #2 made occasional slight changes in body/extremity position, couldn't make frequent or significant changes alone. Friction/Shearing was a potential problem as Resident #2 had some sliding with repositioning and occasionally slid down in bed and chair. Resident #2 was chair fast and requires assistance to chair or wheelchair. Resident #2's skin was rarely moist, her sensory perception was very limited. Resident #2 only responded to painful stimuli and couldn't communicate pain except by moaning or restlessness. The total score was 14 which indicated Resident #2 was at moderate risk for skin breakdown. Resident #2 transferred with a mechanical lift and assistance of two staff. Resident #2's admission assessment for bowels identified she was incontinent of bowels at least once daily. Resident #2's care plan did not identify a turning/repositioning program, preventative skin care or the use of a cushion in her wheelchair when up. Resident #2's nurses' notes on 04/13/14 identified she was having frequent loose stools throughout the p.m. shift and was medicated with Tylenol for complaints of pain of the coccyx. The note at 6:13 p.m. stated, "Coccyx reported to be red from AM nurse, coccyx remains red, protective barrier cream applied and resident repositioned side to side frequently this evening, having incontinent loose stools, having discomfort to area, resident continued to be repositioned frequently." The nurses' notes on 04/14/14 identified Resident #2's coccyx remained pink, the area was cleansed and barrier cream was applied. Resident #2 complained of discomfort to area and was repositioned side to side frequently. Resident #2 received Tylenol for the pain in her coccyx. The nurses' notes on 04/16/14 at 3:05 p.m. identified Resident #2's "bottom has reddened areas but no oa (open areas), epc (barrier cream) applied, continue to reposition and move pressure relieving cushion into w/c (wheelchair) and recliner when sitting up - resident not able to off-load on her own." The nurses' notes on 04/17/14 at 3:11 p.m. identified Resident #2 had open areas on the upper right and left buttocks - Stage 2 shearing ulcers on mid buttocks. Granulation was occurring. Skin treatment was done as ordered. No measurements of the open areas were documented. Resident #2's admission MDS, dated [DATE], identified the need of extensive assistance of two with bed mobility, transfers, dressing and toilet use. Resident #2 had functional limitations in range of motion on one side involving the upper and lower extremities. Resident #2 had an indwelling catheter, was frequently incontinent of bowels and was not on a bowel toileting program. Resident #2 was at risk of developing pressure ulcers, had no unhealed pressure ulcers and had no other ulcers, wounds or skin problems. The Skin and Ulcer treatment intervention was identified as a pressure relieving device for bed. The CAAs (Care Area Assessment) identified Resident #2 had no pressure ulcers and required staff assistance to move sufficiently to relieve pressure over any one site. Requires pressure reducing mattress or seat cushion. Resident #2 slides down in bed and has limited mobility. The description of the problem identified Resident #2 had no issues with skin breakdown/pressure ulcers and was at moderate risk for skin breakdown according to the Braden Scale assessment. Resident #2 had a pressure relieving mattress in place. The CAA identified a care plan would be developed for "moderate risk for skin breakdown" related to limited mobility manifested by: "Stage 2 pressure ulcer on upper coccyx. The interventions were: -Nurses: "Daily skin assessment while areas of breakdown present. Educate resident/family/staff regarding treatment and preventative measures. Administer medications/treatment as ordered and evaluate effectiveness. Reduce pressure and friction as able. Monitor lab values. Pressure relieving devices for bed." -Nurse Aide: "Assist with hygiene and general skin care. Avoid using hot water for cleansing, reposition frequently in bed, Minimize pressure on bony prominence's, Report changes to nurse, Use pillows for support, Use moisturizer with cares, Keep skin clean and dry and Barrier cream to peri area as needed." Review of Resident #2's current care plan identified the same approaches as in the CAA. The problem (Pressure Ulcer) Moderate risk for skin breakdown manifested by was updated on 04/29/14 to "Moisture Associated [MEDICAL CONDITION]." The next entry in the nurses' notes related to the open areas on her buttocks was 04/21/14 at 11:58 p.m. The entry identified the left buttocks open area was 4 cm long and 2 cm wide. The right buttocks open area was 2.5 cm long and 1.7 cm wide. The crease of Resident #2's buttocks has an open area 2 cm long and 1.5 cm wide. The skin treatment was identified as, "Receives turning/repositioning program. Side to side." The skin treatment was done as ordered. The nurses' notes on 04/22/14 identified the open area on the right upper side of the buttocks was 2.2 cm long by 3 cm wide. The left upper side of the buttocks: entire red area (open area within red area) was 7.0 cm long by 3 cm wide. The open area within the red area was 1.5 cm long by 0.7 cm wide. The upper outer aspect of the left buttocks was red but not open. The area was 3 cm wide by 0.8 cm wide. The left upper-most area of the buttocks was red but not open. The red area was 1.2 cm long and 0.4 cm wide. The physician was notified by fax. The family was notified. The Director of Nurses (DON) - Wound care nurse assessed the area and advised writer to apply Alleyn Non-adhesive dressing and secure with tape. A fax was sent to Resident #2's physician on 04/22/14. "Resident has stage 2 pressure ulcer to buttocks. Alleyn-gently (foam style), dressing applied today after DON assessed area. Length of red area on left buttocks is Length 7 cm width, 3 cm open area within this is length 1.5 cm, width 0.7 cm. Right side of buttocks has two red areas. Length 3 cm width 0.8 cm 3rd red area id length 1.1 cm width 0.4 cm. Any new orders? DON has ordered special dressings for this resident." The physician did not respond to the fax. On 04/23/14, a Braden Scale was completed. The information was the same as the Braden Scale completed on 04/09/14. The assessment did not identify the open or reddened areas on Resident #2's buttocks. On 04/26/14, the nurses' notes identified a transparent dressing was in place on Resident #2's buttocks. On 04/27/14, the nurses' notes identified Resident #2's "coccyx and medial buttocks remain reddened with open area, old dressing covered with stool, small amount of dried blood noted on old dressing, area cleansed and [MEDICATION NAME] dressing applied. Repositioned onto sides frequently." Observations/Interviews: Resident #2's Certified Nursing Assistant (CNA) care plan does not identify the use of a cushion in her wheelchair or recliner, the frequency of repositioning or checking for incontinence, that she is not to be positioned on her back in bed, that staff were to apply barrier cream or that she has a pressure ulcer. On 04/29/14 at 10:35 a.m., Surveyor observed Resident #2 lying on her back in bed. CNA I was preparing for Resident #2's morning cares. CNA I stated Resident #2 did not have any skin breakdown or reddened area present on admission. CNA I stated currently Resident #2 had open areas on her "bottom" and reddened areas. CNA I stated when Resident #2 was in bed she was only to be positioned on her sides and that Resident #2 was now using an "air cushion" in her wheelchair due to her open areas. CNA I stated Resident #2 had not used any cushion in her wheelchair or recliner until just recently and that Resident #2 would sit in her recliner in the afternoon. CNA I stated Resident #2 was frequently incontinent of bowels. When asked if more frequent incontinence checks were completed related to the incontinent bowels CNA I stated, "No, she was just checked every two hours for incontinence." When asked if Resident #2 was repositioned more frequently since she developed the pressure/open areas, CNA I stated, "No. Staff reposition Resident #2 every two hours in bed from side to side. Resident #2 is not to be on her back in bed except during cares." On 04/29/14 at 10:51 a.m., Surveyor observed Registered Nurse (RN) J enter the room with Resident #2's dressing supplies and placed a barrier on the over bed tray table directly next to the wash basin. RN J applied a pair of gloves from her pocket, without washing her hands. RN J removed the soiled dressing and discarded it. RN J verified Resident #2 had a pressure ulcer. RN J stated the [MEDICATION NAME] dressing on Resident #2's pressure ulcer was not the dressing that was supposed to be applied. RN J stated the [MEDICATION NAME] dressing did not provide any cushioning. RN J stated an Allevyn Gentle dressing was suppose to be used on the pressure ulcer. RN J removed her gloves, reached into her uniform pocket, removed a pair of gloves and applied them without washing her hands. RN J cleansed the pressure ulcer with the Dermal Wound Cleanser, set the bottle on the bedside stand, dabbed the pressure ulcer with gauze dressings and removed her gloves. Without washing her hands, RN J reached into her uniform pocket, removed one glove, reached across Resident #2 and the bed, reached into CNA I's uniform pocket, removed one glove and applied the gloves to her hands. RN J opened and applied the Allevyn Gentle dressing to the pressure ulcer, applied pressure to secure the dressing to the skin, disposed of the wrapper and barrier in the garbage, removed her gloves, picked up the Dermal Wound cleanser bottle and un-opened [MEDICATION NAME] package, opened the room door and exited without washing her hands. On 04/29/13 at 2:25 p.m., Surveyor interviewed CNA I who stated Resident #2's open area developed at the facility after admission. CNA I stated she had reported the redness and open area about one and a half weeks ago. The nurses started applying a dressing about one week ago. CNA I stated it was then they started the side to side positioning only when Resident #2 was in bed. CNA I stated no cushion had been used in the wheelchair or recliner until the open area developed. CNA I stated staff applied PC (Protective Cream) following incontinent episodes. CNA I stated they only began applying EPC (Extra Protective Cream) after Resident #2 developed the red areas. CNA I stated Resident #2 is not able to reposition herself. CNA I stated Resident #2 used to be in the wheelchair for meals and then was placed in her recliner between meals with her feet elevated. On 04/29/14 and 04/30/14, during Resident #2's record review, Surveyor noted there were no physician orders for the treatment to Resident #2's pressure ulcer. On 04/30/14 at 8:25 a.m., Surveyor observed Resident #2 lying in bed on her back. On 04/30/14 at 10:40 a.m., Surveyor interviewed RN L related to Resident #2's treatment orders. RN L stated she would have to "look to see what treatment" Resident #2 had ordered. At 11:15 a.m., RN L checked Resident #2's Medication Administration Record [REDACTED]. RN L found no treatment orders for the pressure ulcer on the MAR indicated [REDACTED]. On 04/30/14 at 1:52 p.m., Surveyor observed RN L check the dressing on Resident #2's buttocks/coccyx. The dressing was not changed as it was intact. RN L stated she understood Resident #2's skin was already compromised when she was admitted . The pressure relieving cushion on the wheelchair and recliner had recently been implemented. RN L stated Resident #2 had not used any type of cushion in her wheelchair or recliner prior to the skin breakdown. RN L stated Resident #2 was admitted on antibiotics and struggled with incontinent loose stools which have resolved since Resident #2 is no longer on the antibiotic. At the time Resident #2 was having the loose stools she was "pretty disoriented" and staff had to anticipate when she needed to have a bowel movement. RN L stated she did not think the frequency of staff checking Resident #2 for incontinent stools had been changed from every two hours to more frequent monitoring. RN L stated Resident #2 was currently being repositioned every two hours even with the development of the pressure ulcer. RN L stated the open areas Resident #2 developed since admission are pressure ulcers. RN L stated she did not know if preventative skin care (barrier creams) were applied prior to staff noticing the redness on Resident #2 buttocks/coccyx. On 04/30/14 at 3:04 p.m., Surveyor interviewed CNA N who stated Resident #2 used to be incontinent of stool all the time. CNA N stated the incontinence was much better now. CNA N stated Resident #2 did not always have a cushion in her wheelchair or recliner. CNA N stated this was something new in the last week or so. CNA N stated Resident #2 needs assistance with repositioning. CNA N stated sometimes Resident #2 had scooted or slid down in her wheelchair. CNA N stated initially they did not apply barrier cream to Resident #2's buttocks. When Resident #2 developed the red areas that is when staff started applying the barrier cream. CNA N stated they only apply the EPS if the area is really red otherwise they just apply the other barrier cream if needed. On 05/01/14 at 3:20 p.m., Surveyor interviewed the DON related to no treatment being ordered for Resident #2's pressure ulcer. The DON stated the facility did have physician orders but they had not been transcribed onto the physician orders sheet or TAR. The DON stated RN L had spoken with her on 04/30/14 about Resident #2 not having any treatment orders for the pressure ulcer. The DON stated she had assessed the pressure area and determined an Allevyn dressing was the most appropriate treatment. Surveyor requested a copy of the physician progress notes [REDACTED]. On 05/06/14, the DON presented Surveyor with additional nurses' notes for Resident #2. -On 04/29/14, the nurses' notes identified Resident #2 was examined by her physician. No other information related to the exam was documented. -On 04/30/14, a Braden Scale was completed. The total score was 19, which indicated Resident #2 was at low risk for pressure ulcers. A late entry was made regarding the physician's exam on 04/29/14. The note stated the physician wanted to discuss with a colleague the dressings and prognosis, etc. The DON presented Surveyor with an updated care plan problem: "Pressure Ulcer: Kennedy Terminal Ulcer on Coccyx." No changes were made to the approaches. On 05/05/14 at 9:30 a.m., Surveyor interviewed the DON and RN E who stated Resident #2 had not been placed on a bowel training program or more frequent incontinence checks during the time she was frequently incontinent of bowel. The DON and RN E stated Resident #2's condition had improved since admission; however, the physician has scheduled a meeting with the family to discuss enrolling Resident #2 in hospice care. The DON stated Resident #2 has developed a Kennedy pressure ulcer and the physician feels hospice is appropriate at this time even with Resident #2's improvements in cognition and strength. The DON stated every bed in the facility has a Panacea mattress which is for pressure reduction. The DON and RN E stated they did not know why a cushion was not placed in Resident #2's wheelchair and recliner on admission. The DON stated her expectation was that during the therapy evaluations the type of wheelchair cushion needed would be assessed. The DON and RN E stated they believed Resident #2 was now using a gel cushion in her wheelchair. The DON and RN E stated Resident #2's care plan should have been updated to reflect the pressure ulcer and new interventions. Surveyor requested a copy of the physician progress notes [REDACTED]. On 05/06/14 at 1:25 p.m., the DON informed Surveyor Resident #2 was using a Roho cushion in her wheelchair. No assessment was provided related to the Roho cushion being the appropriate cushion to be used by Resident #2 or when it was implemented. Surveyor requested a copy of the physician progress notes [REDACTED]. On 05/07/14, at the time of the final exit at 5:15 p.m., the facility had not provided the physician progress notes [REDACTED]. 2. Resident #9's [DIAGNOSES REDACTED]. Resident #9's quarterly Minimum Data Set completed on 09/20/13, identified she required extensive assistance with bed mobiliy, transfers, dressing and grooming. Resident #9 had functional limitations impairemonts of both her upper and lower extremities and used a wheelchair for mobility. Resident #9 was at risk of developing pressure ulcers. Resident #9 had no healed or unhealed pressure ulcers. Resident #9's care plan identified she required extensive assistance of two with positioning and bed mobility. "I have a grab side rail on each side of my bed that I utilize when rolling and repositioning me. Please encourage me to utilize these when working with me." Resident #9 requires extensive assistance of one with dressing. Resident #9 transfered with a mechanical lift and assistance of two staff. Resident #9's physician orders contained an order on 12/29/12: Coordinate all cares to coincide with repositioning (turn every 3 hours during the night). Resident #9's nurses' notes on 11/15/13 identified she was having more difficulty pulling herself over on her side in bed so staff could place the bedpan, provide peri care, place the depends, etc. On 11/30/13, Resident #9's nurses' notes stated, "Pressure Ulcer Risk: great toe, at first knuckle, left foot. General Skin Condition: various scabs, scrapes, to mid-section; toes have various stages of abrasions, bruising, marks, etc., 2nd area : 3rd toe l (left) foot, dorsal open area. Location: dorsal aspect mid 1st-2nd toes L foot, second area: dorsal aspect base of 3rd-4th toes and tip of 5th toe. Skin/Wound Infection: Placed on shift report. Description: tenderness present. Area: gr (great) toe: .7 x .6 cm, 3rd toe .5 x 0.4 cm. Drainage: None. Skin Treatment: Receives turning/repositioning program. Application of nonsurgical dressintgs (with or withut topical medications) other than to feet. Receives other preventative or protective skin care (other than to feet). DWC (wound cleanser), allevyn gentle (for padding) to gr (great toe), DWC, allevyn thin to 3rd toe. Procedure Done: as decribed above, wounds believed to be caused by res (resident) shoes. discussed with res cessation of shoe wearing for a time, res agree. Action: continue to observe Repositioned." Resident #9's care plan was not updated related to the developement of the pressure ulcers on her left great and third toe of her left foot. The care plan was not updated to not wear shoes for a time. The physician was not notified of the pressure ulcer. 0n 12/02/13 at 10:47 p.m., Resident #9's nurses' notes identified she continued to abstain from shoe wearing and utilizing foot cradle. There is no documentation when the foot cradle was placed on the bed. The foot cradle was not added to Resident #9's care plan. On 12/02/13 at 2:16 p.m., the nurses' notes stated, "Assessment type: Initial asasessment 12/02/13 Pressure Ulcer: Has partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stage 2). Area 1: Onset/Discovery Date: Noted after admission Presure Ulcer: Has partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg (stage) 2. dorsal aspect base of 3rd-4th toes and tip of 5th toe left foot, 4th toe. Wound Type: Stage 2. Wound Tissue: pink Surrounding Tissue: white Healing Progress: N/A (not applicable) (new area) Pressure Ulcer: Has full thickness of skin lost, exposing SubQ (subcutaneous) tissues-presents as a deep crater "Area 2: dorsal aspect mid 1st-2nd toes left foot, great toe. Onset/Discovery Date: 12/02/13 Noted after admission. Wound Type: Stage 3 Wound Tissue: pink Surrounding Tissue: white, Healing Progress: N/A (new area) Assessment Type: Initial Assessment 12/02/13 dorsal aspect mid 1st-2nd toes dorsal aspect base of 4th toe and 5th toe great toe on right and left foot, 5th toe on right foot. Onset/Discovery Date: 12/02/13 Noted after admission. Wound Type: toe nails are loose and beginning to fall off. Surrounding Tissue: normal for ethnicity. Healing Progress: N/A (new area)." No changes were made to Resident #9's care plan. The physician was not notified of the pressure ulcer. On 12/02/13 at 10:47 p.m. stated, "Note: dressing noted to left toes, continue to abstain from shoe wearing, and utilizing foot cradle." On 12/03/13 at 10:53 a.m., the nurses' notes stated, "Assessment Type: Follow-up assessment. Healing Progress: improving. Description: becoming smaller granulation occurring. Comments: continue plan of care, Wear slippers rather than shoes that are causing the pressure. Assessment Type: Follow-up assessment: Pressure Ulcer: Has full thickness of skin lost, exposing the SubQ tissues - presents as a deep crater. "Area 1: Left great toe Onset/Discovery Date: 12/02/13 Wound Type: Stage 3 Wound Tissue: reddened Surrounding Tissue: reddened. Healing Progress: N/A (new area) Description: granulation occurring Area: length (cm) .5 width (cm); .5 depth: .3 length x width (sq (square) cm) = 0.25 Area 1 L X W Score: (symbal for less than) 0.3 (1) Area 1 Exudate Amount: Light (1) Area 1 Tissue Type Score: Granulation tissue (2) Area 1 PUSH SCORE: 7 Comments: (Resident #9's first name) reports that the sores are from pressure from her shoes. Yesterday 4 digits revealed pressure areas. With immediate interventions vast improvements are observed today." The immediate interventions were not documented and Resident #9's care plan was not updated. The physician was not notified of the pressure ulcer. On 12/05/13, Resident #9's care plan was updated to include a problem, "High Risk for heel ulcer, At risk for skin breakdown Potential for heel breakdown related to fecal incontinence, disease process, [MEDICAL CONDITION], wheelchair bound and [MEDICAL CONDITION] related to [MEDICATION NAME] factors, limited mobility and fecal incontinence manifested by open [MEDICAL CONDITION] on the foot." The interventions were: Evaluate healing process and revise care plan as needed. Weekly skin assessment. Plan: allevyn thin to cover and protect. Wear slippers rather than the shoes causing the pressure. Skin assessment per policy. Identify and minimize exposure to mechanical and chemical skin irritants. Evaluate healing process and revise care plan as needed. Administer medications/treatments as ordered and evaluate for effectivenss. Elevate heels in bed. Use lifting devices; draw sheet (in bed). Monitor lab values. Monitor turning/repositioning program. Monitor nutrition or hydration interventions to manage skin problems. Monitor feet, update the nurse of changes. Utilize slippers instead of the shoes that caused the pressure ulcers on toes. Reposition every 2 hours in bed. Reposition every hour when up. Minimize pressure on bony prominences. Offer fluids with position changes. Use pillows for support. Do not position diorectly on pressure ulcer or areas of redness. Keep heels elevated in bed. Monitor weight. Keep linen clean, dry and wrinkle free. On 12/08/13 at 12:17 p.m., the nurses' notes stated, "Pressure Ulcer Risk: Has Stage 1 or greater ulcer. Skin Problems: open area Location: dorsal aspect base of 4th toe and 5th toe left foot, 5th digit Description: new area Area: length (cm) 0.5 width (cm): 0.3 depth 0 Stage 2 pressure ulcer Drainange: None Procedure Done: cleanse, dry, applied skin prep Procedure Result: unchanged. Action: continue to observe." The physician was not notified of the pressure ulcer. On 12/17/13 at 1:32 p.m., the nurses' notes stated, "Assessment Type: Follow-up assessment left foot; toes. Area 1: dorsal aspect tips of 1st-2nd toes tip of great toe. Area: length (cm) .5 width (cm) .5 pinpoint dark circle notes. depth 0. Area 2: dorsal aspect mid 1st-2nd toes great toe Area: length (cm) .6 width (cm) .9 depth 0. Area 3: dorsal aspect base of 4th toe and 5th toe outer aspect of 5th toe. Area: lenght (cm): .3 width (cm): .4 Comments: Cleansed with DWC, skin prep applied. Resident is wearing slippers, as new shoes may have caused these areas. Continue to monitor. Areas are improving." Resident #9's quarterly MDS, dated [DATE], identified Resident #9 had an unhealed pressure ulcer. (The date of the oldest Stage 2 pressure ulcer was 12/03/13.) The dimension of the pressure ulcer was 0.5 by 0.5 by 0.3 cm. Granulation tissue was present. The MDS identified the pressure ulcer was not present on the previous MDS. Other ulcers, wounds and skin problems included: other open [MEDICAL CONDITION] on the foot,[MEDICAL CONDITION](second or third degree) and application of nonsurgical dressings other than to feet. The skin and ulcer treatments included: pressure relieving devices for chair and bed, a turning/repositioning program, ulcer care, application of nonsurgical dressings other than to feet, applications of medications/ointments other than to feet and applications of dressings to feet. No updates were made to Resident #9's IPOC. On 12/25/13 at 2:47 p.m., the nurses' notes stated, "Weekly Skin Assessment: General Skin Condition: small scraps on several toes of left foot. Foot Problems/Care: abrasions on 1st, 3rd, 4th and 5th toes. Description: becoming smaller Procedure Done: Skin tx (treatment) done per order." No measurements of the abrasions/scrapes were documented. On 01/15/14 at 2:49 p.m., the nurses' notes stated, Weekly Skin Assessment: Skin Problems: Has no skin problems or lesion present Foot Problem/Care: Has had no foot problems or care in past 7 days and wears only socks when in wheelchair twice a day." On 01/23/14 at 2:27 p.m., the nurses' notes stated, "Pressure Ulcer Risk: Has Stage 1 or greater ulcer Skin Problems: open area Foot Problem/Care: pressure ulcer Location: dorsal aspect mid 1st-2nd toes left foot, great toe Description: ne

Based on observation, record review and interviews, the facility did not ensure that the resident environment remained as free of accident hazards as is possible and did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 12 sampled residents. (Residents #9, #5, and #4) Resident #9 was at risk for falls. She fell on [DATE], resulting in an olecranon fracture of the left arm that needed surgery and pinning. The care-planned alarm was not sounding and the person who responded could not remember if the alarm had even been applied. The facility did not analyze Resident #9's fall and implement new interventions or investigate the cause of her fall to prevent further falls and injury. Resident #5 received a cigarette burn on 05/16/12. The facility did not complete an investigation as to how this injury occurred, did not reassess the resident's ability to smoke safely, did no notify the physician and did not implement new interventions to prevent further incidents. Resident #4's care plan states to ensure resident is not placing objects in his mouth. During 1 of 3 meal observations when Resident #4 was unsupervised, the resident was observed stuffing a paper napkin in his mouth and chewing it with out staff awareness. This is evidenced by: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 fell on [DATE] that resulted in a fracture of the left olecranon, that had surgical repair on 03/30/12. Surveyor reviewed the medical record of Resident #9 on 07/12/12. The MDS (Minimum Data Set) dated 02/27/12 shows a BIMS (Brief Interview for Mental Status) score of 6 showing some difficulty with date orientation and recall ability. Assistance with transfers is coded extensive assistance with assist of one person physical assist. The falls risk assessment dated [DATE] scores the resident at 16 with a score of 14 or more indicating high risk for falls. The initial care plan dated 02/20/12 indicates: 1 person assist for pivot transfer with gait belt. The safety Notes reveal: I do have compression fractures in my mid to lower back that causes me pain so be careful when assisting me to transfer or for any bed mobility. The initial care plan has no other falls interventions listed. On 03/12/12 the nurse notes state, "Has been found especially on PM's to be self transferring herself onto her bed or into BR (bathroom). Discussed with staff and will apply clip alarm for her safety." The care plan dated 03/2012 (no specific day) has safety notes that state, "I should have a clip alarm in place for my safety. I have attempted to self transfer in the past. This will alarm staff of when I am trying to self transfer and will assist in keeping me safe." The CNA (Certified Nursing Assistant) care plan that is not dated has SAFETY: clip alarm Review of the nurses notes reveal on 03/16/12, "This writer summoned by Licensed Practical Nurse (LPN) F to examine this resident as she was found on floor getting up on her own. Resident sitting on chair stated "I'm fine, just my elbow"...Raised arm in attempt to above her chest flinched and grimaced "ouch, ouch, that hurts." Instructed LPN (Licensed Practical Nurse) to call on call to up condition for possible fracture. Ice applied to L(left) elbow...contacted Mobilex and they are able to provide X-ray of elbow..." No other information about the incident or investigation could be found in the nurses notes or medical record. Surveyor requested the incident/investigation report for this fall. On 07/12/12 the report was reviewed. It is titled "Resident Safety Report". Under Follow-Up review it states, "Resident was on her bed and proceeded to transfer herself was found on floor. Dietary Assistant (DA) I assisted resident up and into chair and went to get LPN F to report incident.... Clip alarm is used for her safety plan will be to continue as resident is feeling stronger and believes she can self transfer and ambulate. The CNA safety report was reviewed. It was completed by DA I. It asks if the fall was result of a transfer? The answer is NO. Transfer bed to chair? The answer is a question mark and a check mark. Does resident have safety plan? The answer is a question mark. Was safety device i.e. sensor pad, clip on alarms, restraints on? Is answered with a yes and N/A. Was the safety devices working properly ? The answer is a question mark. Was the safety device or alarm going off prior to fall? The answer is no. Did the resident remove safety devices or avoid alarm? The answer is no. The statement areas says to describe why it happened, possible causes , and resident response. This area states, "The resident was headed to her room and I walked with her to her room got her set up on the bed. I went back to doing dishes... heard yelling for help. I went in, picked her up set her on the chair told a CNA. They got the nurse." No information of why it happened or possible causes were included. The information in the report does not address how the facility assessed and analyzed the fall to implement fall interventions that are comprehensive and address the root cause of the fall in order to prevent future falls. There are no new interventions added to the care plan after the fall and fracture on 03/16/12. Surveyor reviewed the facility's Fall Assessment and Prevention Policy, under documentation it states: F. Licensed Nursing Staff must provide in the nurses notes of resident's chart an accurate and functional description of the incident. Document these findings in detail by describing the event including but not limited to: time, place and what actions were taken or interventions performed to prevent repeat incidence or any follow up care needed. On 07/12/12 Surveyor interviewed LPN F at 1:30 p.m. LPN F states he remembers that the dietary assistant helped her up off the floor and that he instructed DA I that a nurse should have been called first. When asked if the alarm sounded prior to the fall he stated, "I don't remember." Do you know if the alarm was used? "I don't recall." When asked if DA I would know to use the safety alarm for Resident #9, he stated, "I am not sure." On 07/12/12 at 1:45 p.m. Surveyor interviewed the Director of Nursing (DON) who filled out the safety report. When asked if Resident had a safety alarm or if it sounded at the time, she stated, "I don't recall." DON did recall reprimanding DA I for assisting resident off of the floor without getting a nurse. Surveyor interviewed the ADON on 07/12//12 at 1:50 p.m. The ADON was not aware of the incident. When asked where to find more information on the investigation and reporting of the incident she said this was what they had. When asked if all staff was educated on the incident she said "no." On 07/12/12 at 3:00 p.m. the Nursing Home Administrator (NHA) was notified of the concerns stated above. Surveyor asked if he had any more information to give, none was provided. 2. Resident #5 was admitted to facility on 08/08/11 with [DIAGNOSES REDACTED]. On 07/11/12 Surveyor reviewed Resident #5's medical record. Nurse's notes dated 05/16/12 read in part, "Cigarette burn to L (left) inner thigh continues to heal no s/s (signs or symptoms) of infection." On 07/11/12 at 10:30 a.m. Surveyor interviewed ADON and asked for any information related to the above documentation regarding Resident #5's burn. ADON reported she would look for any more documentation and would provide Surveyor with copies as soon as she found anything. Surveyor requested an investigation related to the burn, a documented assessment, MD notification, a smoking assessment, and follow up. On 07/11/12 at 12:00 p.m. ADON gave Surveyor a copy of a document titled, "Wound Assessment Progress Report" with documentation on the fourth line which read in part, "Date 5/2/12 L .5 x W .5 x D 1.0 with the word surface under the 1.0 crossed out Site # L (left) inner thigh, Stage/type burn, Initials MM, color pink." Surveyor # asked ADON about the "depth of the burn measuring at 1.0?" ADON responded, "I was the one that measured the burn and I distinctly remember the depth only being surface so I am unsure who crossed it out and wrote 1.0 over it." On 7/11/12 at Surveyor requested a smoking policy from ADON. SSD O was present at the time of request stated, "I will look for a policy and get back to you." On 07/11/12 at 5:00 pm Surveyor met with ADON and SSD O regarding Resident #5's burn and any additional documentation available. Surveyor was given a document by the SSD O which was titled, "RESIDENT GUIDELINES" and read in part: " A. SMOKING 3. Residents choosing to smoke may do so independently outside unless the Resident creates an unsafe situation or fire risk. If upon assessment by Spring Valley Health Care Center professional staff, it is determined that a Resident can not smoke independently, smoking parameters will be established for the Resident for the times and Staff assistance, when available, that will be necessary so as to minimize the risks and provide as safe as reasonable possible smoking for the Resident." Reviewed/updated: 10-13-2011." SSD O was asked if this was the most up to date policy for smoking in which she replied, "This is the only thing we have for a smoking and it is given to each resident upon admission." No smoking assessment was provided for Resident #5. Surveyor was also given a copy of a fax at this time from the ADON titled: Progress Notes signed by (Melby, Michael J) Author Type: HP PHYSICIAN with Resident #5's name in the top right corner. DATE OF SERVICE: 05/02/2012 which read in part: "He has a small ulcer along the inner thigh consistent with a cigarette burn which is not going to be debrided today." Surveyor then asked ADON for any further documentation or investigation regarding Resident #5's burn, in which ADON replied, "There is no other documentation related to Resident #5's burn." 3. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the record review by Surveyor on 07/10/12 - 07/11/12, the Minimum (MDS) data set [DATE] stated Resident #4 required extensive assistance of one staff with eating, has functional impairment in range of motion in both upper and lower extremities and is edentulous. The Certified Nursing Care plan states," Diet: mech (mechanical) soft, ensure resident is not placing objects in mouth." On 07/10/12 at 5:35 p.m. a Certified Nursing Assistant (CNA) was assisting the resident with his supper meal. At 6:05 p.m. the resident had finished his meal and the CNA removed his plate and returned it to the kitchen area. When the CNA walked away from the resident, the resident reached over and picked up a paper napkin that was laying next to Resident #7. Resident #7 was seated adjacent to Resident #4. Resident #4 stuffed the paper napkin in his mouth and was chewing on it. CNA D was assisting a resident at another table and did not observe this. Surveyor informed CNA D of the observation. CNA D removed the paper napkin from the resident's mouth which was balled up and was two inches in diameter. On 07/11/12 at 7:50 a.m. CNA P told Surveyor that Resident #4 has a tendency to grab things at the dinner table like a Kleenex or napkins. CNA P stated she had removed a Kleenex or something from the resident's mouth about two years ago but was not aware of any other incidents since then. On 07/12/12 at 8:15 a.m. Surveyor discussed the incident with Dietary Manager A who stated all residents receive cloth napkins and paper napkins are available but are used for wiping up only. On 07/12/12 at 9:10 a.m. Surveyor discussed the incident with the Assistant Director of Nursing (ADON) who stated Resident #4 has a history of putting objects in his mouth. The resident has had no choking episodes for a long time. The ADON stated the resident doesn't understand safety versus a soft banana versus a napkin. The ADON stated residents are not provided with paper napkins but receive cloth napkins. At times Resident #7 is messy so CNA's have paper napkins laying by Resident #7's plate for wiping up spills.