Every finding on record at St Francis Home

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 74 of 74 residents residing in the facility. The facility did not ensure time/temperature control foods were labeled appropriately with open and/or use-by dates. Findings include: On 3/30/26 at 9:22 AM, Food and Nutrition Services Director (FNSD)-C indicated the facility follows the Wisconsin Food Code as their standard of practice. The 2022 Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under S 3-502.12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition: (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) Except time that the product is frozen; (2) Is in a container or package that does not bear a date or day. The facility's undated Date Marking for Food Safety policy indicates: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .1. Refrigerated, ready-to-eat, time/temperature control for safety food/perishable food shall be held at a temperature of 41 degrees Fahrenheit or less for a maximum of seven days. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded .6. The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The dietary manager or designee shall spot check refrigerators weekly for compliance . During an initial tour of the kitchen with FNSD-C that began at 9:22 AM on 3/30/26, Surveyor observed the following food storage concerns: Dry Storage:~ Two plastic bins labeled salt 3/3 without use-by dates~ One plastic bin labeled baking cocoa 3/11 without a use-by date~ One bulk container labeled sugar 3/10 without a use-by date~ One bulk container labeled flood 3/10 without a use-by date~ One container labeled cracker crumbs 3/15/24 without a use-by date~ One package labeled instant cheese queso mix 11/5 without a use-by date Coolers:~ One container labeled breaded chicken 3/2 without a use-by date~ One rack of numerous pans of baked cookies and cinnamon rolls without use-by dates~ One pan with two packages labeled chicken thighs 2/20 without use-by dates~ One unlabeled package (waffles per FNSD-C) dated 3/30 without a use-by date~ One package labeled Braunschweiger opened 3/24 without a use-by date~ One container labeled breaded chicken patty 3/2 without a use-by or pulled-from-freezer date ~ One container labeled sloppy joe 3/11 pull 3/28 without a use-by date~ One unlabeled container of yellow material labeled open 3/26 without a use-by date~ One pan labeled cherry cheesecake 3/29 dinner without a use-by date~ One container labeled pork chops 3/18, leave out AM Tues without a use-by date~ One container labeled pork 3/5, pulled 3/28 for 3/31 without a use-by date Freezers:~ One container labeled hot dogs 2/19 without a use-by date~ One container labeled beef 3/12 without a use-by date~ One container labeled smoth steak 3/14 without a use-by date~ One container labeled beef tips 3/28 without a use-by date~ One container labeled sl. beef 3/25 without a use-by date~ One container labeled beef stroganoff 3/25 without a use-by date~ One container labeled beef casserole 3/11 without a use-by date~ One container labeled salisbury steak 3/9 without a use-by date~ One container labeled lasagna sauce 3/5 without a use-by date~ One container labeled riblettes 3/29 without a use-by date~ One container labeled brat patties 3/16 without a use-by date~ One container labeled BBQ pork 3/8 without a use-by date~ One container labeled sausage patty 3/28 without a use-by date~ One container labeled pulled pork 3/23 without a use-by date~ One container labeled kielbasa 3/17 without a use-by date~ One container labeled hamloaf 3/19 without a use-by date~ One container labeled ham 3/24 without a use-by date~ One container labeled pork in peach sauce 1/12 without a use-by date~ One container labeled cod 2/3 from 1/27 without a use-by date~ One package labeled pork 2/26 without a use-by date~ One package labeled beef 2/15 without a use-by date~ One package labeled turkey 2/14 without a use-by date~ One package labeled quiche 3/6 without a use-by date~ One package labeled squash 3/28 without a use-by date~ One container labeled fish 3/24 3/28 without a use-by date~ One package labeled soft pot 3/19 without a use-by date~ One package labeled sweet pot 3/12 without a use-by date~ One package labeled tavern fish 3/22 without a use-by date~ One container labeled salmon 3/27 without a use-by date~ One container labeled fish 3/27 without a use-by date~ One container labeled turkey 3/29 without a use-by date~ One container labeled chx 3/23 without a use-by date Following the observations, Surveyor interviewed FNSD-C who indicated bulk food items such as flour and sugar don't have use-by dates because they are used up quickly. FNSD-C verified the items should contain use-by dates. FNSD-C was unsure of the use-by dates for the dry storage items. When asked about missing use-by dates for the salt and baking cocoa, FNSD-C indicated the items should have use-by dates. FNSD-C did not know the use-by date of the cracker crumbs and indicated they should be thrown out. FNSD-C also did not know the use-by dates for the cheese mix and various items in the cooler and freezer. When asked the use-by dates for several of the frozen items, FNSD-C was unsure and confirmed the items should have been labeled with use-by dates.

Based on staff interview and record review, the facility did not ensure their abuse policy was implemented for 2 of 8 employees reviewed for employee reference checks. This practice had the potential to affect more than 4 of the 74 residents residing in the facility.The facility did not complete reference checks for Certified Nursing Assistant (CNA)-F and CNA-G.Findings include:The facility's Abuse, Neglect and Exploitation policy, revised 2025, indicates: .I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulation. Responsibility for performance of compliance checks on contracted temporary staff will be established via contractual agreement. 2. Screenings may be conducted by the facility itself, a third-party agency, or an academic institution. 3. The facility will maintain documentation of proof that the screening occurred .On 4/1/26, Surveyor reviewed background check information, including Background Information Disclosure (BID) forms, Department of Justice (DOJ) letters, Governmental Findings letters, reference checks, and license information for 8 staff including, CNA-F and CNA-G.CNA-F's hiring information indicated CNA-F was hired by the facility on 1/26/26. CNA-F's background check information did not include any reference checks.CNA-G's hiring information indicated CNA-G was hired by the facility on 2/23/26. CNA-F's background check information did not include any reference checks.On 4/1/26 at 10:49 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding reference checks for CNA-F and CNA-G. NHA-A indicated NHA-A requested everything on the list Surveyor requested from the facility's onboarding department. NHA-A indicted if reference checks were not included, the facility didn't have them. NHA-A confirmed reference checks should have been completed for CNA-F and CNA-G.

Based on staff interview and record review, the facility did not ensure the necessary care and services to monitor weight gain was provided 1 resident (R) (R5) of 2 sampled residents.R5's weight was not monitored as ordered. In addition, R5's physician was not notified as ordered when R5 gained 3 pounds or more in one day.Findings include:The facility's Weight Monitoring policy, revised 2025, indicates: .Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain).may indicate a nutritional problem.A weight monitoring schedule will be developed upon admission for all residents.If clinically indicated, monitor weight daily .The physician should be informed of a significant change in weight.Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate.The facility's undated Assisted Nutrition and Hydration policy indicates: .Recognize, evaluate, and address the needs of.the resident at risk or already experiencing impaired nutrition and hydration.Maintain acceptable parameters of nutritional status and electrolyte balance.Offer sufficient fluid intake to maintain proper hydration and health.The facility's Notification of Changes policy, revised 2025, indicates: The purpose of this policy is to ensure the facility promptly .consults the resident's physician.The facility must consult with the resident's physician when there is a change requiring such notification.Circumstances that require a need to alter treatment may include: a. New treatment; b. Discontinuation of current treatment due to: .acute conditions, exacerbation of a chronic condition.From 3/30/26 to 4/1/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including end stage renal failure, dependence on renal dialysis, and congestive heart failure. R5's Minimum Data Set (MDS) assessment, dated 2/19/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 made R5's own healthcare decisions.Surveyor reviewed R5's Treatment Administration Record (TAR) and noted the following physician orders: ~ Weights daily, update provider if weight increases by 3 pounds (lbs) in one day or 5 lbs in one week (start date: 8/26/26; discontinue date: 2/23/26) ~ Weights after dialysis only one time a day every Monday, Wednesday, and Friday, update provider if weight increases by 3 lbs in one day or 5 lbs in one week (start date: 2/25/26; discontinue date: 4/1/26) (Of note: The order was discontinued after Surveyor asked about R5's weights.)R5's TAR contained missing documentation on the following dates:~ On 11/15/25, 11/20/25, and 11/28/25 (for daily weights, update physician if weight increases by 3 lbs in one day or 5 lbs in one week; start date: 8/28/25; discontinue date: 2/23/26).~ On 12/29/25 (nights), 1/13/26 (nights), 1/18/26 (nights), 3/22/26 (nights), 3/28/26 (nights), and 3/31/26 (nights) for fluid restriction of 1800 milliliters (ml) - 720 ml (AMs), 460 ml (PMs), 160 ml (nights) every shift for fluid restriction (start date: 8/26/25)On 3/31/26 at 1:29 PM, Surveyor interviewed Registered Dietician (RD)-H regarding physician updates and documented weights. RD-H indicated R5 is weighed at dialysis and the facility uses that weight which is documented in R5's medical record as dialysis. RD-H stated if R5 is weighed at the facility, the weight is documented as wheelchair. RD-H indicated nurses are responsible for documenting weights and updating the physician with any changes.On 3/31/26 at 1:48 PM, Surveyor interviewed Registered Nurse (RN)-I who indicated R5's weights are obtained from the dialysis binder and entered in R5's medical record. RN-I indicated nurses are responsible for updating the physician if R5 has a weight increase of 3 lbs in one day or 5 lbs in one week. RN-I indicated R5 had an order for daily weights until the end of February (2026). RN-I indicated R5's weight order was changed due to dialysis. Surveyor and RN-I reviewed R5's weights and noted the following:~ On 2/4/26, R5 weighed 201.9 lbs (dialysis)~ On 2/5/26, R5 weighed 208.4 lbs (dialysis; increase of 6.5 lbs in one day) ~ On 2/14/26, R5 weighed 206.8 lbs (wheelchair) ~ On 2/15/26, R5 weighed 212.2 lbs (wheelchair; increase of 5.4 lbs in one day)~ On 2/21/26, R5 weighed 205.0 lbs (wheelchair) ~ On 2/22/26, R5 weighed 208.8 lbs (wheelchair; increase of 3.8 lbs in one day)On 3/31/26 at 1:56 PM after reviewing R5's weights, RN-I confirmed the physician should have been updated regarding R5's weight increases of 3 lbs in one day.On 4/1/26 at 11:28 AM, Surveyor interviewed Director of Nursing (DON)-B and Registered Nurse Supervisor (RNS)-E who confirmed the physician should have been updated of R5's weight gains of 3 lbs in one day per the physician's order.

Based on staff interview and record review, the facility did not ensure fistula monitoring and pre-treatment dialysis forms were completed for 1 resident (R) (R5) of 1 sampled resident.R5's Treatment Administration Record (TAR) indicated R5's fistula wasn't consistently monitored. In addition, R5's pre-treatment dialysis forms were not consistently completed.Findings include:The facility's Dialysis policy, revised 2025, indicates: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan.to meet the special medical needs of the resident receiving hemodialysis .The facility will assure each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include the ongoing assessment of the resident's condition and monitoring for complications before.dialysis treatments.ongoing assessment and oversight of the resident before, during, and after dialysis treatments .The licensed nurse will communicate to the dialysis facility via.written format, such as a dialysis communication form .The nurse will ensure the dialysis access site is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill. If absent, the nurse will immediately notify the attending physician, dialysis facility, and/or nephrologist.From 3/30/26 to 4/1/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including end stage renal failure, dependence on renal dialysis, and congestive heart failure. R5's Minimum Data Set (MDS) assessment, dated 2/19/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 made R5's own healthcare decisions. R5 received dialysis on Monday, Wednesday, and Friday.R5's TAR contained missing documentation for the following orders and dates:~ Dialysis evaluation form pre-treatment one time a day every Monday, Wednesday, and Friday. (R5's TAR indicated the order was not completed on 1/14/26 and 3/9/26.)~ Arteriovenous (AV) fistula - check bruit every shift. If bruit not auscultated, notify provider. (R5's TAR indicated the order was not completed on 11/16/25, 2/13/26, and 3/9/26.)~ AV fistula - check thrill every shift. If thrill not palpated, notify provider. (R5's TAR indicated the order was not completed on 11/16/25, 2/13/26, and 3/9/26.)~ Monitor AV site every shift for warmth, redness, tenderness, and edema, notify provider if present. (R5's TAR indicated the order was not completed on 11/16/25.)On 4/1/26 at 9:26 AM, Surveyor and Director of Nursing (DON)-B reviewed R5's TAR. DON-B was not aware of the missing documentation and stated DON-B would follow-up with Surveyor.On 4/1/26 at 11:19 AM, Surveyor interviewed DON-B and Registered Nurse Supervisor (RNS)-E. RNS-E indicated RNS-E could not find documentation in R5's progress notes that correlated to the missing entries on R5's TAR. RNS-E and DON-B confirmed the orders should have been completed and documented.

Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 3 residents (R) (R1, R6, and R39) of 3 sampled residents. R1 was on enhanced barrier precautions (EBP) for an indwelling catheter and wounds. During care observations and medication administration, staff did not adhere to EBP. R6 was on EBP for an indwelling catheter. During care and therapy observations, staff did not adhere to EBP. R39 had an order for EBP due to an indwelling catheter; however, there was not an EBP sign outside R39's room. During a care observation, staff did not adhere to EBP. In addition, R39's care plan did not indicate R39 was on EBP. Findings include: The facility's Enhanced Barrier Precautions policy, dated January 2025, indicates: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDROs). EBP refers to an infection control intervention designed to reduce the transmission of MDROs that employs targeted gown and gloves use during high-contact resident care activities .a. All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions. b. All staff receive training on high-risk activities and common organisms that require EBP. c. The facility will have discretion on how to communicate to staff which residents require the use of EBP prior to providing high-contact care activities .An order for EBP will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic [NAME] stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters .) .4. High-contact resident care activities include: a. Dressing; b. Bathing; c. Transferring; d. Providing hygiene; e. Changing linens; f. Changing briefs or assisting with toileting; g. Device care or use: central lines, urinary catheters .; h. Wound care; any skin opening requiring a dressing . 1. Between 3/30/26 and 3/31/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including pneumonia, obstructive and reflux uropathy, and presence of other specified devices. R1 had an indwelling catheter and a colostomy. R1's Minimum Data Set (MDS) assessment, dated 3/11/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1's medical record contained a physician order for EBP related to R1's indwelling catheter and wounds. A care plan, dated 3/24/26, indicated staff needed to wear a gown and gloves for all cares due to R1's indwelling catheter and wounds. On 3/30/26 at 12:23 PM, Surveyor observed a Centers for Disease Control and Prevention (CDC) EBP sign on the wall near the entrance to R1's room. The sign read: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean hands, including before entering the room and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following high-contact resident care activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. Surveyor also observed a personal protective equipment (PPE) cart near R1's door that contained gowns and gloves. On 3/30/26 at 12:24 PM, Surveyor observed Certified Nursing Assistant (CNA)-J enter R1's room with paper towels and a urinal to empty R1's colostomy bag. CNA-J was not wearing a gown. At 12:31 PM, Surveyor observed CNA-J exit R1's room with the urinal. CNA-J emptied the urinal into the toilet and rinsed the urinal with water. On 3/30/26 at 12:35 PM, Surveyor interviewed CNA-J who verified R1 had a colostomy and an indwelling catheter. When asked if staff should wear PPE for high-contact cares and R1's EBP order, CNA-J indicated CNA-J did not need to wear PPE. On 3/30/26 at 1:18 PM, Surveyor observed CNA-J enter R1's room with a urinal to empty R1's catheter bag. CNA-J was wearing gloves but not a gown. At 1:23 PM, Surveyor observed CNA-J exit R1's room and empty the urinal into the toilet. CNA-J rinsed the urinal with water and put it back in R1's room. Surveyor interviewed CNA-J who confirmed CNA-J did not wear a gown. 2. During the AM medication pass on 3/30/26 at 10:20 AM, Surveyor observed Registered Nurse (RN)-D administer Lantus insulin to R1's abdomen per subdermal injection without wearing a gown. An EBP sign outside R1's room indicated all staff completing direct resident care must wear gloves and a gown. On 3/30/36 at 10:25 AM, Surveyor interviewed RN-D who verified R1 was on EBP and RN-D did not wear a gown when administering R1's insulin. RN-D verified administering insulin to a resident is direct resident care and confirmed RN-D should have worn a gown per the facility's EBP policy. On 4/1/26 at 9:28 AM, Surveyor interviewed Director of Nursing (DON)-B who verified RN-D should have worn a gown when administering an insulin injection per the facility's EBP policy. 3. Between 3/30/26 and 3/31/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including sepsis due to methicillin-resistant Staphylococcus aureus (MRSA), calculus in the bladder, and obstructive and reflux uropathy. R6 had an indwelling catheter. R6's MDS assessment, dated 3/12/26, had a BIMS score of 15 of out 15 which indicated R6 had intact cognition. R6's medical record contained a physician order for EBP related to R6's indwelling catheter. The order indicated an EBP sign should be posted outside R6's room. A care plan, dated 3/26/26, indicated staff should use EBP related to R6's indwelling catheter. On 3/30/26 at 12:23 PM, Surveyor observed a CDC EBP sign on the wall near the entrance to R6's room. The sign read: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean hands, including before entering the room and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following high-contact resident care activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. Surveyor also observed a PPE cart near R6's door that contained gowns and gloves. On 3/30/26 at 12:39 PM, Surveyor interviewed R6 who stated R6 had an indwelling catheter and had approximately ten urinary tract infections (UTIs). R6 stated R6 had to take over part of R6's catheter care, including cleaning the tubing and penis with alcohol wipes, because staff didn't do it right. R6 stated R6 was familiar with sterile protocol for catheter care and asked staff to use proper catheter and penis cleaning protocol to protect R6 from infection. R6 indicated staff didn't follow the appropriate technique and didn't wear gowns during cares. R6 stated staff used to wear gowns but stopped wearing them months ago. R6 stated DON-B removed the receptacle near R6's door where staff discarded used gowns and gloves. R6 stated even when staff wore gowns for catheter care, they did not wear them for transfers, bed changes, or other cares. On 3/30/26 at 1:05 PM, Occupational Therapist (OT)-K entered R6's room with a mechanical lift as Surveyor was leaving. OT-K was not wearing a gown or gloves. Surveyor observed OT-K exit R6's room at 1:37 PM. On 3/30/26 at 1:39 PM, Surveyor interviewed OT-K who indicated OT-K provided occupational therapy for R6 which included repetitive transfers with the mechanical lift to maintain R6's ability to stand. OT-K indicated OT-K did not wear any PPE, including a gown or gloves, because OT-K didn't touch R6's catheter. When Surveyor asked if OT-K was familiar with the facility's EBP policy, OT-K stated OT-K was and again stated OT-K didn't need to wear PPE if OT-K wasn't completing catheter care. 4. Between 3/30/26 and 3/31/26, Surveyor reviewed R39's medical record. R39 was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease and diverticulum of bladder. R39 had an indwelling catheter. R39's MDS assessment, dated 11/20/25, had a BIMS score of 4 out of 15 which indicated R39 had severely impaired cognition. R39's medical record contained a physician order for EBP related to R39's indwelling catheter and wound care. R39's care plan indicated R39 was at risk for infection and complications of an indwelling catheter. The care plan did not indicate R39 was on EBP. On 3/30/26 at 1:57 PM, Surveyor observed R39 in the four seasons room. R39's catheter bag was inside a dignity bag that hung under R39's wheelchair. On 3/30/26 at 2:13 PM and 3/31/26 at 12:51 PM, Surveyor noted there was not an EBP sign outside R39's room. On 4/1/26 at 8:35 AM, Surveyor observed CNA-J complete catheter care for R39 without wearing a gown. CNA-J emptied R39's catheter bag into a urinal. Surveyor notified DON-B who accompanied Surveyor back to R39's room to observe CNA-J complete catheter care. DON-B informed CNA-J that a gown is required during direct care for residents with catheters who are on EBP. Surveyor noted an EBP sign was not posted outside or inside R39's room. On 4/1/26 at 9:19 AM, Surveyor interviewed DON-B who indicated a resident on EBP should have a sign near the entrance to their room indicating they are on EBP. On 4/1/26 at 9:55 AM, Surveyor interviewed Registered Nurse Supervisor (RNS)-E who indicated EBP should be indicated on the care plan of a resident who is on EBP. On 4/1/26 at 11:52 AM, Surveyor noted there was not an EBP sign posted outside R39's room. On 4/1/26 at 11:55 AM, Surveyor interviewed DON-B regarding an EBP sign for R39. DON-B confirmed there was not an EBP sign posted outside R39's room. When Surveyor asked how staff know R39 is on EBP without a sign and or indication on R39's care plan, DON-B indicated staff should know because R39 has a catheter.

Based on staff interview and record review, the facility did not report an allegation of misappropriation of contingency medication to the State Agency (SA). This had the potential to affect residents in the facility who may have needed contingency medications that were potentially diverted. On 1/11/25, the facility discovered missing doses of narcotic medication which raised the concern of potential drug diversion. The facility did not report the allegation of misappropriation to the SA. Findings include: The facility's Reporting Suspected Crimes Under the Federal Elder Justice Act, dated May 2020, indicates: It is the policy of this facility to a comply with the Elder Justice Act about reporting a reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act .Facilities are not required to report to either the State Survey Agency or local law enforcement under this act; only individuals are required to report. However, facilities may be required to report certain incidents under other federal, state, or local laws and regulations such as reporting to the SA abuse, neglect or misappropriation . On 4/21/25 at 10:09 AM, Surveyor interviewed Registered Nurse (RN)-D who was an agency nurse and worked at the facility part-time. RN-D indicated the nurse who worked on (a named hall) is the only nurse with a key to the facility's narcotic contingency medication. RN-D indicated if a narcotic medication is needed from the contingency box, two nurses call the pharmacy for permission. RN-D indicated this process changed after a big diversion which occurred around December 2024 in which almost the entire box of narcotics was missing. RN-D indicated contingency medications were moved to first floor during the process change. On 4/21/25 at 10:14 AM, Surveyor interviewed RN-E who indicated the new process started in December (2024) or January (2025) and includes checking the tag numbers and ensuring medication is in each compartment of the contingency box. RN-E indicated two nurses, one one each shift at shift change, complete the task. Surveyor observed RN-E open a cabinet in a locked medication room with a key from RN-E's pocket. RN-E indicated two nurses ensure the tag numbers on the box match the tag numbers written on the form and sign the form to verify it was checked and correct at shift change. Surveyor noted the contingency box was secured with two tags, one on each side. The box had an opaque see-through cover through which unit dose medications could be observed in individual compartments of the box. RN-E indicated the two nurses conduct a visual inspection of each compartment to ensure there are medications in each compartment but don't count the individual doses each shift. RN-E indicated if a medication is needed and the box is opened, the two nurses count the inventory of the box. On 4/21/25, Surveyor reviewed the facility's investigation which included a document titled Estimated Time form Discovery of Missing Controlled Substance II and Scheduled 2-5 Medications. The document indicated on 1/11/25 at 6:02 AM, staff called Director of Nursing (DON)-B and reported several medications were missing from the contingency box. The document indicated the contingency box was missing one 12 microgram (mcg) fentanyl (a narcotic medication used to treat severe pain) patch, five 15 mg morphine (a narcotic medication used to treat moderate to severe pain) IR (immediate release) tablets, five 15 mg morphine SR (sustained release) tablets, nine 5 mg oxycodone (a narcotic medication used to treat moderate to severe pain) tablets, ten 10 mg Oxycontin (a narcotic medication used to treat moderate to severe pain) ER (extended release) tablets, ten 5/325 mg hydrocodone/APAP (an opioid analgesic medication used to treat pain) tablets, and ten 10/325 mg hydrocodone/APAP tablets. The document indicated the facility contacted local law enforcement on 1/11/25 at approximately 8:30 AM. The document did not indicate the facility reported the potential allegation of misappropriation to the SA. On 4/21/25 at 2:37 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the SA was not notified of the potential allegation of misappropriation that was discovered on 1/11/25.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 8 residents (R) (R57, R28, R54, R186, R73, R30, R44, and R38) of 8 sampled residents. This practice had the potential to affect all 74 residents residing in the facility. The facility's line list for a current gastrointestinal outbreak (GI) of Norovirus was inaccurate for R57, R28, R54, R186, and R73. R30 was on enhanced barrier precautions (EBP) and had an EBP sign posted on R30's door. On 12/16/24, Certified Nursing Assistant (CNA)-P repositioned R30 without wearing the appropriate personal protective equipment (PPE). R44 was on EBP related to wounds and had an EBP sign posted on R44's door. On 12/17/24, CNA-L and Medication Technician (MT)-M repositioned R44 without wearing the appropriate PPE. R38 was on EBP and had an EBP sign posted on R38's door. On 12/16/24, CNA-K exited R38's room with a lift used to transfer R38. CNA-K did not sanitize the lift after use. In addition, PPE was not available in or near R38's room. Findings include: The Centers for Disease Control and Prevention (CDC) defines Norovirus as a very contagious virus that causes vomiting and diarrhea. The CDC document titled Guidelines for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, dated 2/2017, indicates: During outbreaks, place patients with Norovirus gastroenteritis on contact precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients .Wait at least 2 days (48 hours) after symptoms resolve .Begin active case-finding when a cluster of acute gastroenteritis cases is detected in the healthcare facility. Use a specified case definition, and implement line lists to track both exposed and symptomatic patients and staff . The facility's Infection Prevention and Control Program Policy, revised 2/2024, indicates: The Infection Preventionist (IP) .conducts surveillance for community-associated infections .to identify opportunities to prevent and/or reduce the rate of infection in our residents .surveillance includes use of a data collection tool .Collected by concurrent and/or retrospective chart review, review of microbiological reports, reports from resident care providers and review of other documents . The facility's Infection Prevention binder includes the Wisconsin Department of Health Services' Recommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities, dated 12/2017, which recommends: .Develop and implement routine surveillance for gastrointestinal infection in residents and staff to more rapidly identify illnesses and outbreaks .A line list is a log of ill staff and residents with similar signs and symptoms. It should be used as a tool to track illnesses within a facility when an outbreak is suspected and while an outbreak is occurring in real time . The facility's Enhanced Barrier Precautions (EBP) policy, revised 4/1/24, indicates: .For EBP, signage should clearly indicate the high-contact resident care activities that require the use of a gown and gloves (dressing, showering, transferring, providing hygiene, changing linens, changing briefs, device care, or wound care) .3. Make PPE, including gowns and gloves, available immediately outside of the resident's room, including a mask for cares that might generate splash or spray. Per facility signage posted on residents' doors, contact precautions indicates the use of patient-dedicated, single-use disposable or shared equipment that should be cleaned and disinfected between patients. 1. When Surveyor entered the facility on the morning of 12/16/24, Surveyor noted signage at the entrance and throughout the building that indicated the facility had an outbreak of Norovirus. At the entrance, Nursing Home Administrator (NHA)-A confirmed the facility was in an active Norovirus outbreak. On 12/17/24 at 1:45 PM, the facility provided Surveyor with infection prevention line lists, including a line list for the Norovirus outbreak. Surveyor reviewed the Norovirus line list and noted the first resident had a symptom onset date of 12/6/24. There were 25 residents on the line list some of which still had active infections. Surveyor also reviewed resident charting, including CNA bowel charting, and noted the following: ~ R57 was added to the line list due to GI symptom onset (diarrhea) on 12/12/24. The line list indicated R57's last symptom of diarrhea was on 12/13/24. R57's well date was listed as 12/16/24. R57's CNA bowel charting indicated R57 last had diarrhea on 12/15/24 at 7:26 PM which indicated R57's well date was incorrect and R57 should have still been on precautions. ~ R28 was added to the line list due to GI symptom onset (diarrhea) on 12/7/24. The line list indicated R28's last symptom of diarrhea was on 12/15/24. R28's CNA bowel charting indicated R28 last had diarrhea on 12/16/24 at 4:37 PM. ~ R54 was added to the line list due to GI symptom onset (diarrhea) on 12/11/24. The line list indicated R54's last symptom of diarrhea was on 12/15/24. R54's CNA bowel charting indicated R54 last had diarrhea on 12/16/24 at 1:55 PM. ~ R186 was admitted to the facility on [DATE]. R186 had a contact precautions sign on R186's door and a PPE cart outside R186's room. A progress note, dated 12/17/24 at 2:02 AM, indicated R186 had loose stools on 12/16/24 and was placed on contact isolation precautions. Surveyor noted R186 was not on the line list for GI symptoms. ~ R73 was added to the line list due to GI symptom onset (diarrhea and abdominal cramping) on 12/6/24. The line list indicated R73's last symptom of diarrhea was on 12/8/24. R73's well date was listed as 12/11/24. R73's CNA bowel charting indicated R73 last had diarrhea on 12/16/24. On 12/17/24 at 3:51 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B maintained the line list since Infection Preventionist (IP)-E had been out ill. DON-B indicated DON-B reviewed the 24-hour report daily which included progress notes, medication changes, and physician communication. DON-B indicated staff and shift huddles occurred daily and staff contacted DON-B if a resident had symptoms. When Surveyor reviewed the above discrepancies between the line list and CNA bowel charting, DON-B indicated the 24-hour report did not pull bowel documentation. DON-B confirmed R186 started symptoms yesterday and should be on the line list. DON-B also confirmed R57 should still be on precautions if R57's last documented bout of diarrhea was on 12/15/24. DON-B and NHA-A acknowledged that by not accurately tracking residents' last episodes of diarrhea on the line list, staff could be removing symptomatic residents from precautions too early which could cause continued spread of the illness. DON-B also confirmed the line lists should be accurate. On 12/18/24 at 8:51 AM, Surveyor observed a contact isolation precaution sign (which indicated anyone entering the room needed to wear a gown and gloves) on R73's door and a PPE cart outside R73's room. Surveyor interviewed MT-F who indicated R73 was on contact precautions. On 12/18/24 at 1:04 PM, Surveyor interviewed IP-E who indicated on 12/17/24, Social Worker (SW)-G called the staff who documented R73 had diarrhea on 12/16/24 and was told R73's bowel movement was a loose stool, not diarrhea. IP-E indicated the loose stool was not watery which indicated it was not Norovirus. IP-E indicated there should not have been a contact precautions sign on R73's door. IP-E stated staff were updated about precaution changes on the 24-hour board at the nurses' station, via daily communication, and during staff huddles. IP-E indicated either DON-B or IP-E calls the nurse on the floor to update them on precaution changes and the nurse either posts or removes precaution signs and PPE carts from outside residents' rooms. On 12/18/24 at 1:41 PM, Surveyor interviewed Registered Nurse (RN)-H who stated R73 was not on contact precautions at that time. When Surveyor asked how RN-H knew if a resident was on contact precautions, RN-H stated it was in the resident's care plan. RN-H and Surveyor looked at R73's care plan which did not indicate R73 was on contact precautions. RN-H and Surveyor looked at the 24-hour board in the facility's electronic medical record which did not indicate R73 was on contact precautions. RN-H did not know why R73's door had a contact precautions sign or why a PPE cart was located outside R73's room. At that time, MT-F stated R73 was supposed to be on contact precautions because R73 had a loose stool on 12/16/24. 45942 2. On 12/16/24, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including right femur fracture, gout, and rheumatoid arthritis. R30's Minimum Data Set (MDS) assessment, dated 10/8/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R30 was not cognitively impaired. On 12/16/24 at 11:00 AM, Surveyor observed an EBP sign on R30's door. Surveyor did not observe a PPE cart outside or inside R30's room. Surveyor observed CNA-P enter R30's room to reposition R30 prior to morning cares. On 12/16/24 at 11:38 AM, Surveyor interviewed CNA-P who indicated CNA-P was not sure why R30 was on EBP. CNA-P indicated R30 did not have wounds or an infection, therefore, CNA-P did not don PPE. CNA-P also indicated RN-I was unsure why there was an EBP sign on R30's door. On 12/16/24 at 1:15 PM, Surveyor noted the EBP sign was removed from R30's door. Surveyor interviewed R30 who indicated staff told R30 that since R30 was positive for methicillin-resistant Staphylococcus aureus (MRSA) a few years ago and was now colonized, the EBP sign was removed. R30 confirmed staff did not wear the appropriate PPE during cares. On 12/17/24 at 1:37 PM, Surveyor interviewed RN-I who indicated RN-I removed the EBP sign from R30's room because R30's wounds were healed. RN-I indicated R30 informed RN-I that R30's MRSA was colonized. RN-I indicated an EBP sign should have been in place per the facility's policy. On 12/17/25 at 1:45 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-J who indicated an EBP sign should be posted on or near R30's door and staff should wear the appropriate PPE during cares. On 12/17/24 at 2:00 PM, Surveyor observed an EBP sign on R30's door. Surveyor did not observe a PPE cart outside or near R30's room. 50467 3. On 12/17/24 at 9:30 AM, Surveyor observed CNA-L and MT-M enter R44's room to reposition R44. CNA-L and MT-M did not wear PPE during repositioning. Surveyor noted there was not a PPE cart inside or outside R44's room. When Surveyor asked if R44 was on EBP due to the EBP sign posted on R44's door, MT-M indicated gowns and gloves only had to be worn during wound care. When Surveyor inquired about PPE, MT-M stated PPE could be at the CNA desk or in storage. CNA-L then assisted R44 with dining and MT-M resumed medication pass. No PPE was brought to R44's room at that time. 4. On 12/16/24 at 10:28 AM, Surveyor observed CNA-K exit R38's room with a lift. CNA-K rolled the lift to a storage area and walked away. Surveyor interviewed CNA-K and asked if the lift should be sanitized after use. CNA-K indicated lifts only needed to be sanitized when the facility was on precautions which had been lifted. Surveyor noted R38 was on EBP due to a sign posted on R38's door Surveyor noted there was not a PPE cart inside or outside R38's room. CNA-K confirmed PPE should be available and went to a storage closet at the end of the hall. CNA-K returned with gowns and put them on a dresser next to the entrance to R38's room. On 12/17/24 at 10:25 AM, NHA-A and DON-B confirmed staff should wear PPE during high-contact cares for residents on EBP. DON-B indicated PPE carts should be outside the rooms of residents on precautions. DON-B also confirmed lifts should be wiped with cleaner and air dried for 1 minute before use on the next resident.

Based on staff interview and record review, the facility did not ensure a written transfer notice was provided for 1 resident (R) (R11) of 6 residents reviewed for hospitalization . In addition, the facility did not ensure the Ombudsman was notified of hospital transfers for 6 (R11, R33, R21, R30, R59, and R82) of 6 residents. R11 was transferred to the hospital on 2/22/24 and 5/1/24. Neither R11 or R11's Power of Attorney (POA) were provided with a written transfer notice for R11's 5/1/24 hospital transfer. In addition, the facility did not notify the Ombudsman of R11's hospital transfers. R33 was transferred to the hospital on 8/7/24. The facility did not notify the Ombudsman of R33's hospital transfer. R21 was transferred to the hospital on 12/11/24. The facility did not notify the Ombudsman of R21's hospital transfer. R30 was transferred to the hospital on 6/30/24. The facility did not notify the Ombudsman of R30's hospital transfer. R59 was transferred to the hospital on 11/2/24 and 11/13/24. The facility did not notify the Ombudsman of R59's hospital transfers. R82 was transferred to the hospital on 9/22/24 and 10/21/24. The facility did not notify the Ombudsman of R82's hospital transfers. Findings include: The facility's Admission, Transfer and Discharge policy, dated 10/2022, indicates: It is the policy to follow all state and federal regulations regarding admission, transfer, and discharge to and from the skilled nursing facility, and the transfer or discharge includes appropriate information that is communicated to the receiving health care provider or institution .7. Residents are notified in writing of their right to appeal this action. Written notification includes the name, email, and telephone number of the state long-term care Ombudsman, as well as information on how to obtain an appeal form. 1. From 12/16/24 to 12/18/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure and type 2 diabetes. R11 had an activated POA. R11's medical record indicated R11 had a change in condition on 2/22/24 and was transferred to the hospital. R11 returned to the facility on [DATE]. R11 had another change in condition on 5/1/24 and was transferred to the hospital. R11 returned to the facility on [DATE]. R11's medical record did not indicate R11 or R11's POA were provided with a written transfer notice for R11's 5/1/24 hospital transfer. On 12/17/24, Surveyor reviewed the facility's Ombudsman Notification for transfers/discharges and noted R11's 2/22/24 and 5/1/24 hospital transfers were not listed on the report provided to the Ombudsman. 2. From 12/16/24 to 12/18/24, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including cardiomyopathy, cardiomegaly, and type 2 diabetes. R33's medical record indicated R33 had a change in condition on 8/7/24 and was transferred to the hospital. R33 returned to the facility on [DATE]. On 12/17/24, Surveyor reviewed the facility's Ombudsman Notification for transfers/discharges and noted R33's 8/7/24 hospital transfer was not listed on the report provided to the Ombudsman. 45942 3. From 12/16/24 to 12/18/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following nontraumatic intracranial hemorrhage affecting the left non-dominant side and Parkinson's disease. R21's Minimum Data Set (MDS) assessment, dated 10/29/24, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R21 had severely impaired cognition. R21 had an activated Power of Attorney for Healthcare (POAHC). R21's medical record indicated R21 was transferred to the hospital on 12/11/24. On 12/17/24, Surveyor reviewed the facility's Ombudsman Notification for transfers/discharges and noted R21's 12/11/24 hospital transfer was not listed on the report provided to the Ombudsman. 4. From 12/16/24 to 12/18/24, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including arthritis and malnutrition. R30's MDS assessment, dated 10/8/24, had a BIMS score of 15 out of 15 which indicated R30 was not cognitively impaired. R30's medical record indicated R30 was transferred to the hospital on 6/30/24. On 12/17/24, Surveyor reviewed the facility's Ombudsman Notification for transfers/discharges and noted R30's 6/30/24 hospital transfer was not listed on the report provided to the Ombudsman. 5. From 12/16/24 to 12/18/24, Surveyor reviewed R59's medical record. R59 was admitted to the facility on [DATE] and had diagnoses including acute embolism (obstruction in blood vessel) and thrombosis (formation of blood clot) of right femoral (thigh) vein, Parkinson's disease, and obesity. R59's MDS assessment, dated 11/8/24, had a BIMS score of 12 out of 15 which indicated R59 had moderately impaired cognition. R59 did not have an activated healthcare decision maker. R59's medical record indicated R59 was transferred to the hospital on 11/2/24 and 11/13/24. On 12/17/24, Surveyor reviewed the facility's Ombudsman Notification for transfers/discharges and noted the Ombudsman was not notified of R59's 11/2/24 and 11/13/24 hospital transfers. 43361 6. From 12/16/24 to 12/28/24, Surveyor reviewed R82's medical record. R82 was admitted to the facility on [DATE] and had diagnoses including L1 compression fracture and acute cystitis. R82's medical record indicated R82 was hospitalized on [DATE]. R82 returned to the facility on [DATE] with diagnoses including aspiration pneumonia, acute hypoxic respiratory failure, and acute on chronic congestive heart failure (CHF). R82 was hospitalized again on 10/21/24 due to weakness and did not return to the facility. On 12/17/24, Surveyor reviewed the facility's Ombudsman Notification for transfers/discharges and noted the Ombudsman was not notified of R82's hospital transfers. On 12/17/24 at 2:13 PM, Surveyor interviewed Health Information Manager (HIM)-C who indicated HIM-C sent a monthly report to the Ombudsman. HIM-C indicated HIM-C used to include hospitalization s on the report, however, the Ombudsman only wanted to be notified of residents that had been discharged and not residents who had gone back and forth to the hospital. On 12/18/24 at 11:05 AM, Surveyor interviewed Ombudsman (OM)-D who indicated when OM-D speaks with facilities, OM-B encourages facilities to speak with the State Agency and consult the regulations regarding what information should be sent to the Ombudsman regarding transfers and discharges. OM-D did not recall telling the facility not to send hospital transfer information.

Based on observation, staff and resident interview, and record review, the facility did not ensure call lights were in reach for 5 residents (R) (R44, R10, R60, R38, and R285) of 21 sampled residents. R44, R10, R60, R38, and R285 were dependent on staff for mobility and cares. During observations on 12/16/24 and 12/17/24, R44, R10, R60, R38, and R285's call lights were not within reach. Findings include: On 12/17/24, Surveyor requested the facility's call light policy. The policy was not provided to Surveyor. 1. From 12/16/24 to 12/18/24, Surveyor reviewed R44's medical record. R44 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, palliative care, right and left hand contractures, and visual disturbance. R44's most recent Minimum Data Set (MDS) assessment, dated 11/22/24, indicated R44 was rarely/never understood. The MDS also indicated R44 had highly impaired vision. R44's care plan indicated R44 had right and left hand contractures with splints to both hands and was completely dependent on staff for cares. On 12/16/24 at 10:22 AM, Surveyor observed R44 in bed. Surveyor noted R44's call light was wrapped around R44's nightstand handle and R44 could not reach the call light from R44's position in bed. On 12/16/24 at 10:28 AM, Surveyor asked Certified Nursing Assistant (CNA)-K if R44's call light should be within reach. CNA-K indicated yes and attached the call light to R44's blanket. On 12/16/24 at 2:03 PM, Surveyor observed R44's call light hanging over the drawer of R44's nightstand. Surveyor asked CNA-K if R44's call light should be within reach. CNA-K confirmed R44's call light should be within reach and attached the call light to R44's blanket. 2. From 12/16/24 to 12/18/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, palliative care, and spinal stenosis. R10's most recent MDS assessment, dated 11/7/24, indicated R10 was rarely/never understood. On 12/16/24 at 2:10 PM, Surveyor observed R10 in bed. Surveyor noted R10's call light was hanging on the drawer of R10's nightstand and not within R10's reach. When Surveyor asked CNA-K if R10's call light should be within reach, CNA-K indicated yes and gave the call light to R10. 3. From 12/16/24 to 12/18/24, Surveyor reviewed R60's medical record. R60 was admitted to the facility on [DATE] and had diagnoses including fracture to olecranon process (portion of the elbow), Meniere's disease (condition that occurs when fluid builds up in the inner ear), hallucinations, irritable bowel syndrome (IBS), and radiculopathy of the cervical region of the spine (neuropathy that causes radiating pain when nerve/nerves are not working properly). R60's most recent MDS assessment, dated 9/27/24, had a BIMS score of 9 out of 15 which indicated R60 had moderate cognitive impairment. R60's care plan, with a revision date of 10/2/24, indicated R60 required the assistance of one staff to transfer and ambulate and should have a call light within reach. On 2/17/24 at 9:15 AM, Surveyor observed R60 in bed and noted R60's call light was across the room in a chair. Surveyor asked CNA-L if R60's call light should be within reach. CNA-L indicated yes and moved the call light within R60's reach. 4. From 12/16/24 to 12/18/24, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, palliative care, IBS, and stage 3 pressure injury to the sacral region. R38's most recent MDS assessment, dated 11/26/24, indicated R38 was rarely/never understood. On 12/17/24 at 9:20 AM, Surveyor observed R38 sitting in a Broda chair. Surveyor noted R38's call light was hanging on R38's nightstand drawer approximately 3 feet away. When Surveyor asked CNA-L if R38's call light should be within reach, CNA-L indicated yes. CNA-L moved R38 closer to the nightstand and put the call light in R38's lap. 5. From 12/16/24 to 12/18/24, Surveyor reviewed R285's medical record. R285 was admitted to the facility on [DATE]. R285's BIMS score had not been determined yet because R285 was a new admission and an MDS assessment had not been completed yet. R285's care plan indicated (under Safety/Falls) that R285's call light should be positioned for easy access. On 12/17/24 at 9:23 AM, Surveyor observed R285 sitting in a recliner. Surveyor noted R285's call light was on the bed and not within reach. When Surveyor asked if R285 was able to reach the call light, R285 indicated no. R285 indicated R285 was not able to get up independently and get the call light. On 12/17/24 at 9:29 AM, Surveyor interviewed CNA-N who indicated R285 should have a call light within reach and provided the call light to R285. On 12/17/24 at 10:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who confirmed residents should have call lights on their person or within reach.

Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 2 residents (R) (R11 and R19) of 21 sampled residents. R11 was prescribed lorazepam (an anti-anxiety medication) and oxycodone (an opioid medication). R11's MDS assessments, dated 5/21/24, 6/24/24 and 9/20/24, did not indicate R11 received anti-anxiety or opioid medication. R19 had a diagnosis of mental illness (MI). R19's MDS assessment, dated 8/6/24, indicated R19 did not have a serious mental illness. Findings include: 1. From 12/16/24 to 12/18/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including major depression disorder, altered mental status, and psychophysiologic insomnia. R11's MDS assessment, dated 9/20/24, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R11 had severely impaired cognition. R11 had an activated Power of Attorney (POA) to assist with healthcare decisions. R11 had physician's orders for lorazepam (with a start date of 5/15/24) and oxycodone (with a start date of 5/15/24). R11's MDS assessments, dated 5/21/24, 6/24/24, and 9/20/24 did not indicate R11 received anti-anxiety or opioid medication. 2. From 12/16/24 to 12/18/24, Surveyor reviewed R19's medical record. R19 admitted to the facility on [DATE] from another skilled nursing facility (SNF) and had diagnoses including schizoaffective disorder and anxiety disorder. R19's MDS assessment, dated 11/1/24, had a BIMS score of 15 out of 15 which indicated R19 was not cognitively impaired. R19's Preadmission Screening and Resident Review (PASRR) Level I, dated 9/12/17, indicated R19 was at another SNF at the time of completion and had an MI with corresponding medication. R19's PASRR Level II, dated 10/12/17, confirmed R19's MI diagnosis. R19 transferred to the facility on [DATE]. R19's MDS assessment, dated 8/6/24, indicated R19 was not evaluated by PASRR Level II and determined to have a serious MI (section A1500). On 12/18/24 at 1:21 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility had been in transition with an MDS coordinator and had an outside company completing MDS assessments in the interim, therefore, DON-B was unable to confirm the MDS coding errors. On 12/18/24 at 2:32 PM, Surveyor interviewed Social Worker (SW)-G who stated SW-G was responsible for completion of section A1500 of the MDS. SW-G indicated R19's MDS should have been coded to indicate R19 had a serious MI.

Based on staff and resident interview and record review, the facility did not ensure 2 residents (R) (R11 and R33) of 6 residents reviewed for hospitalization received written notification of the facility's bedhold policy when they were transferred to the hospital. R11 was transferred to the hospital on 2/22/24. The facility did not obtain written bedhold confirmation from R11 or R11's Power of Attorney (POA). In addition, R11 was transferred to the hospital on 5/1/24. Neither R11 or R11's POA were provided with a written bedhold notification for R11's 5/1/24 hospital transfer. R33 was transferred to the hospital on 8/7/24. The facility did not obtain written bedhold confirmation from R33 or R33's emergency contact. Findings include: The facility's undated Bedhold Policy and Notification/Acknowledgement policy indicates prior to a resident being transferred to a hospital .a notice is given concerning the facility's bedhold policy. 1. From 12/16/24 to 12/18/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, type 2 diabetes, and major depression. R11 had an activated POA. R11's medical record indicated R11 had a change in condition on 2/22/24 and was transferred to the hospital. R11 returned to the facility on [DATE]. R11 had another change in condition on 5/1/24 and was transferred to the hospital. R11 returned to the facility on [DATE]. On 12/17/24, Surveyor reviewed the Bedhold Notification/Acknowledgment for R11's 2/22/24 hospital transfer which did not include a signature of acknowledgement from R11 or R11's POA. In addition, the facility did not provide R11 or R11's POA with a written bedhold notice for R11's 5/1/24 hospital transfer. 2. From 12/16/24 to 12/138/24, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including cardiomyopathy, cardiomegaly, type 2 diabetes. R33 did not have an activated POA. R33's medical record indicated R33 had a change in condition on 8/7/24 and was transferred to the hospital. R33 returned to the facility on [DATE]. On 12/17/24, Surveyor reviewed the Bedhold Notification/Acknowledgment for R33's 2/22/24 hospital transfer which did not include a signature of acknowledgement from R33 or R33's emergency contact. On 12/18/24 at 1:44 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated it is the nurse's responsibility to ask the resident or their representative if they want a bedhold and the Social Worker's responsibility to follow-up and obtain responses and signatures. NHA-A confirmed signatures should have been obtained for R11 and R33's hospitalization s. NHA-A stated the facility did not complete a bedhold for R11's 5/1/24 hospital transfer because R11 did not want a bedhold and the facility discharged R11 from the record.

Based on staff interview and record review, the facility did not ensure a physician was notified when 1 resident (R) (R186) of 1 sampled resident had a blood sugar outside the parameters of a physician's order. R186 had an order to notify the physician if R186's blood sugar was higher than 400 mg/dL (milligrams per deciliter) or less than 60 mg/dL. On 12/15/24, R186's blood sugar was 409 mg/dL. R186's physician was not notified. Findings include: The facility's Notification of Change policy, revised 11/2022, indicates: The community will consult the resident's Physician, Nurse Practitioner, or Physician Assistant and notify the resident representative or an interested family member when there is: .acute illness or a significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) .A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences .or commence a new form of treatment to deal with a problem. Notification: Depending on the nursing assessment, appropriate notification may be immediate to 48 hours. From 12/16/24 to 12/18/24, Surveyor reviewed R186's medical record. R186 was admitted to the facility on [DATE] with diagnoses including diabetes and cellulitis of left limb. R186's Minimum Data Set (MDS) assessment, dated 12/16/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R186 was not cognitively impaired. R186 did not have an activated healthcare decision maker. R186 had a physician's order that indicated to notify the physician if R186's blood sugar reading was higher than 400 mg/dL or less than 60 mg/dL. On 12/17/24, Surveyor reviewed R186's blood sugar results and noted on 12/15/24, R186 had a blood sugar level of 409. R186's medical record did not indicate R186's physician was notified of the result. On 12/17/24 at 1:05 PM, Surveyor interviewed Registered Nurse (RN)-I who verified R186's blood sugar level on was 409 on 12/15/24. RN-I indicated if R186's blood sugar level was greater than 400, R186's physician should be notified. RN-I confirmed R186's medical record did not contain documentation of physician notification. On 12/17/24 at 3:55 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the physician should have been notified when R186's blood sugar level was over 400 per R186's order.

Based on staff interview and record review, the facility did not ensure the appropriate care and treatment were provided for 1 resident (R) (R54) of 1 resident reviewed for weight monitoring. The facility did not ensure R54's physician was notified when R54 had a significant weight gain. In addition, the facility did not consistently monitor R54's weight per the physician's order. Findings include: The facility's Nutrition Policy, dated 2/2023, indicates the facility maintains acceptable parameters of nutritional status such as body weight or desirable body weight range .unless the resident's clinical condition demonstrates that this is not possible, or the resident's preferences indicates otherwise. From 12/16/24 to 12/18/24, Surveyor reviewed R54's medical record. R54 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, personal history of other venous thrombosis and embolism, and chronic kidney disease, stage 3 unspecified. R54's Minimum Data Set (MDS) assessment, dated 10/17/24, had a Brief interview for Mental Status (BIMS) score of 14 out of 15 which indicated R54 was not cognitively impaired. R54's medical record contained the following information: ~ R54 had a physician's order for weights to be completed daily for 3 days and then weekly and to update the physician if R54's weight increased or decreased by 3 lbs in 1 day or 5 lbs in 1 week. ~ R54 was first weighed on 10/13/24 and was 151.2 lbs. ~ R54 weighed 152 lbs on 10/23/24. ~ On 11/5/24, R54 had a weight gain of 8.4 lbs in 23 days. R54's medical record did not indicate the physician was notified. ~ On 11/26/24, R54 had an additional weight gain of 7.2 lbs. R54's medical record did not indicate the physician was notified. ~ On 12/9/24, R54 had an additional weight gain of 9.7 lbs. R54's medical record did not indicate physician was notified. ~ On 12/11/24, R54 weighed 176.5 lbs (which was a 16.73% weight gain). The Dietitian documented R54 was up 20 lbs since admission. R54's medical record did not indicate the physician was notified. ~ On 12/11/24, R54's physician order was changed to daily weights due to edema and changes in medication and to update the physician if R54's weight increased or decreased by 3 lbs in 1 day or 5 lbs in 1 week. ~ R54's medical record did not contain weights after 12/11/24. On 12/18/24 at 1:01 PM, Surveyor interviewed Infection Preventionist (IP)-E who confirmed R54 was not weighed for the first 3 days following admission but should have been weighed per the physician's order. IP-E stated IP-E changed R54's order on 12/11/24 to daily weights because R54's weights had been off and R54 was started on a diuretic. IP-E confirmed R54's weights were not consistently obtained and should have been completed per the physician's order. IP-E confirmed R54's physician was not updated per the order or of R54's significant weight gain. IP-E indicated R54 was placed on isolation precautions on 12/11/24 due to illness. IP-E stated staff do not complete weights on residents who are on isolation precautions. IP-E confirmed staff should have updated R54's physician on the facility's inability to obtain R54's weight.

Based on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the safe administration of drugs and biologicals for 2 residents (R) (R27 and R78) of 21 sampled residents. On 12/16/24, Surveyor observed two inhalers on R27's bedside table. R27 indicated R27 self-administered the inhalers as needed. A self-administration of medication assessment, dated 9/24/24, determined R27 was unable to self-administer medication. On 12/17/24, R78's 500 milligram (mg) ranolazine (used to treat chest pain) tablet was administered late. Findings include: The facility's Medication Administration policy, revised 11/2024, indicates: This community supervises or administers all medications a resident receives as ordered by their physician. The community provides appropriate methods and procedures for obtaining, dispensing, and administering drugs approved by the resident's physician and consulting pharmacist .Staff members responsible for administering medications review the physician's order prior to administering medications .Medication Administration Record (MAR) is reviewed to obtain correct medication, time, dosage, and route of administration as ordered by the physician for each individual resident .Resident Medication Agreement: .3) When a resident's drugs are obtained from another pharmacy, it is the resident/responsible party's responsibility to see that all drugs brought in are in compliance with policy and state regulations. 4) To meet policy and state regulations, all medications must have a doctor's order and a proper label .If drugs are purchased from another pharmacy, it becomes the responsibility of the person obtaining the drugs to see that they are properly labeled. 5) Labels should include the name of the pharmacy, pharmacy's address and telephone number, name of the resident, name of the prescribing physician or dentist, date and prescription number, directions for use of the drug, dosage unit of the medication, quantity of the drug, expiration date, and other auxiliary statements as required by the drug and as determined by the pharmacist .7) When a resident moves in, the community requires a doctor's order in writing. Only those drugs listed on the order will be administered to the resident .9) No drugs are allowed in resident rooms unless specifically ordered by the physician. If a resident does self-administer medications, they must have a locked box or cabinet in their room. The resident will have a key to the box or cabinet and one key is kept in the medication room. 1. On 12/16/24, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] and had diagnoses including spinal stenosis, wheezing, and congestive heart failure. R27's Minimum Data Set (MDS) assessment, dated 10/8/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R27 had moderate cognitive impairment. R27 did not have an activated healthcare decision maker. On 12/16/24 at 11:27 AM, Surveyor observed two inhalers on R27's bedside table. The first inhaler was Spiriva 2.5 micrograms (mcg) with no open date. The second inhaler was albuterol sulfate 200 metered inhalation with no open date. R27 indicated both inhalers were brought from home. R27's medical record contained a physician's order for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 base) mcg/act (micrograms/actuation), 2 puffs inhale orally every 4 hours as needed for wheezing. R27 did not have a physician's order for Spiriva. R27's medical record contained a self-administration of medication assessment, dated 9/24/24, that indicated R27 was unable to self-administer medication. On 12/17/24 at 1:29 PM, Surveyor interviewed Registered Nurse (RN)-I who confirmed both inhalers were on R27's bedside table but should not be in R27's room. RN-I verified R27 had a physician's order for albuterol sulfate but did not have an order for Spiriva. RN-I also verified R27 did not have an order to self-administer medication or an assessment that indicated R27 could safely and accurately do so. Surveyor also interviewed Assistant Director of Nursing (ADON)-J who indicated R27 was unable to use a locked drawer and was, therefore, not able to self-administer medication. On 12/17/24 at 2:23 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R27's self-administration of medication assessment indicated R27 was unable to self-administer medication. DON-B indicated R27 should not have inhalers in R27's room. 2. On 12/17/24, Surveyor reviewed R78's medical record. R78 was admitted to the facility on [DATE] and had diagnoses including pulmonary embolism (obstruction in blood vessel), pressure ulcer stage 3 to left heel, and after care following surgical amputation to right leg. R78's MDS assessment, dated 10/4/24, had a BIMS score of 9 out of 15 which indicated R78 had moderately impaired cognition. R78 did not have an activated healthcare decision maker. On 12/17/24 at 9:07 AM, Surveyor observed Licensed Practical Nurse (LPN)-O prepare and administer R78's AM medication, including a 500 mg tablet of ranolazine. Surveyor reviewed R78's physician orders and noted R78 had an order for ranolazine 500 mg to be given by mouth every 12 hours at 8:00 AM and 8:00 PM. On 12/17/24 at 10:47 AM, Surveyor interviewed LPN-O who verified R78's ranolazine was scheduled for 8:00 AM and there was an hour window to administer. On 12/17/24 at 11:08 AM, Surveyor interviewed DON-B who indicated if a medication is ordered to be administered at 8:00 AM, there is a one hour window for administration. DON-B indicated if an 8:00 AM medication is administered at 9:07 AM, the medication is considered late.

Based on staff interview and record review, the facility did not ensure monitoring for high risk medications was in place for 3 residents (R) (R30, R69, and R11) reviewed for unnecessary medications. R30 was prescribed hydrocodone-acetaminophen (an opioid medication) for pain. R30 was not monitored for adverse reactions or side effects of the high-risk medication. R69 was prescribed oxycodone (an opioid medication) for pain. R69 was not monitored for adverse reactions or side effects of the high-risk medication. R11 was prescribed oxycodone and torsemide (a diuretic medication) for congestive heart failure (CHF). R11 was not monitored for adverse reactions or side effects of the high-risk medications. Findings include Per the Federal Food and Drug Administration (FDA), opioid medications have a black box warning. A black box warning is the FDA's strongest safety warning given to medications. These medications have the potential for severe side effects. The facility's Pain Management policy, dated 4/1/08, indicates: There is a system in place to identify, monitor and evaluate residents' pain .12. Potential side effects related to pain medications will be identified in the person-centered care plan. 1. On 12/17/24, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including right femur fracture, gout, muscle spasms, rheumatoid arthritis, and generalized discomfort. R30's Minimum Data Set (MDS) assessment, dated 10/8/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R30 was not cognitively impaired. R30's medical record indicated R30 was prescribed one 5-325 milligram (mg) tablet of hydrocodone-acetaminophen two times daily and as needed (PRN) every 6 hours for pain. Surveyor noted R30's pain care plan (initiated on 8/9/23) and medical record did not contain monitoring interventions for opioid use. On 12/18/24, Surveyor reviewed R30's plan of care and noted R30's pain care plan was updated on 12/17/24 to indicate R30 received opioid medication. The care plan indicated staff should monitor/notify for side effects of opioid use such as: sedation, dizziness, nausea, vomiting, constipation, and respiratory depression. 2. On 12/17/24, Surveyor reviewed R69's medical record. R69 was admitted to the facility on [DATE] and had diagnoses including spondylosis without myelopathy or radiculopathy, cervical region and osteoarthritis of the hip. R69's MDS assessment, dated 11/15/24, had a BIMS score of 1 out of 15 which indicated R69 had severely impaired cognition. R69 received Hospice services. R69's medical record indicated R69 was prescribed 5 mg of oxycodone every 2 hours as needed for pain 4-10/10 or terminal and 2 tablets by mouth 3 times daily. R69 had a pain care plan. Surveyor neither R69's pain care plan or medical record contained monitoring interventions for opioid use. On 12/18/24, Surveyor reviewed R69's plan of care and noted the facility had revised R69's pain care plan on 12/17/24 to indicate R69 received opioid medication and to monitor/notify for side effects of opioid use such as: sedation, dizziness, nausea, vomiting, constipation, and respiratory depression. On 12/18/24 at 12:47 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R30 and R69 did not have opioid side effect monitoring in their care plans prior to 12/17/24 but should have. 48794 3. From 12/17/24 to 12/18/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including CHF, chronic kidney disease, stage 3, and type 2 diabetes. R11's MDS assessment, dated 9/20/24, had a BIMS score of 6 out of 15 which indicated R11 had severely impaired cognition. R11 had an activated Power of Attorney for Healthcare (POAHC) to assist with healthcare decisions. R11's medical record contained physician orders for one 5 mg oxycodone tablet every 2 hours as needed for pain and one 10 mg torsemide tablet once daily for CHF. R11 had a pain care plan. Surveyor noted R11's pain care plan and medical record did not contain monitoring interventions for opioid or diuretic use. On 12/18/24, Surveyor reviewed R11's plan of care and noted R11's pain care plan was updated on 12/17/24 to indicate R11 received opioid medication and to monitor/notify for side effects of opioid use such as: sedation, dizziness, nausea, vomiting, constipation, and respiratory depression. R11's plan of care still did not contain monitoring interventions for diuretic use. On 12/18/24 at 10:18 AM, Surveyor interviewed DON-B who confirmed R11 did not have side effect monitoring in place for opioid medication (prior to 12/17/24) or diuretic medication but should have.

Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 32 opportunities which resulted in a 9.37% medication error rate that affected 1 resident (R) (R21) of 3 residents observed during medication administration. On 12/17/24, R21 was administered two medications in the wrong form and one incorrect medication. Findings include: The facility's Medication-Crushing policy, revised 4/1/08, indicates: Only appropriate medications will be crushed with physician orders .1) Only medications approved to be crushed by the manufacturer are crushed. 2) All crushed medications are documented with a physician's order. According to Carbidopa and Levodopa Extended-Release Tablets-Drugs.com: .How is this medicine best taken? .Swallow whole. Do not chew or crush. According to Potassium Chloride: Uses, Dosage & Side Effects-Drugs.com: .How Should I take Potassium Chloride? .Do not crush, chew, or suck on a tablet or capsule. The facility's Medication Administration policy, revised 11/2024, indicates: The community provides appropriate methods and procedures for obtaining, dispensing, and administering drugs approved by the resident's physician and consulting pharmacist .Staff members responsible for administering medications review the physician's order prior to administering medications .Procedure: .5) Medication Administration Record (MAR) is reviewed to obtain correct medication, time, dosage, and route of administration as ordered by the physician for each individual resident . 1. On 12/17/24, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) following nontraumatic intracranial hemorrhage (brain bleed) affecting the left non-dominant side and Parkinson's disease. R21's Minimum Data Set (MDS) assessment, dated 10/29/24, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R21 had severely impaired cognition. R21 had an activated Power of Attorney for Healthcare (POAHC). On 12/17/24 at 8:44 AM, Surveyor observed Licensed Practical Nurse (LPN)-O prepare and administer R21's AM medication. Surveyor observed LPN-O crush R21's medications, including carbidopa/levodopa (used to treat Parkinson's disease) 25-100 milligrams (mg) extended release and potassium chloride (supplement) 20 milliequivalents (mEq) extended release. Surveyor also observed LPN-O administer an 8.6 mg tablet of senna (used to treat constipation). Surveyor reviewed R21's physician orders and noted R21 did not have an order for senna 8.6 mg. R21 had an order for senna plus oral tablet 8.6-50 mg (which contained docusate, another laxative). On 12/17/24 at 9:05 AM, Surveyor interviewed LPN-O who indicated extended release medications should not be crushed. LPN-O indicated LPN-O crushed R21's extended release medications due to R21's swallowing issues. LPN-O indicated LPN-O should call a resident's physician prior to crushing extended release medications. On 12/17/24 at 9:18 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-J who indicated extended release medications should not be crushed. On 12/17/24 at 10:47 AM, Surveyor interviewed LPN-O who verified LPN-O administered senna 8.6 mg to R21 instead of senna plus 8.6-50 mg.

Based on staff and resident interview and record review, the facility did not ensure an injury of unknown source involving potential abuse/neglect was reported to the State Agency (SA) in a timely manner for 1 Resident (R) (R1) of 4 sampled residents. On 6/30/24, R1 had a fall with major injury. The facility did not submit a 5-day investigation to the SA in a timely manner. In addition, the report submitted to the SA had incorrect information. Findings include: The facility's Abuse, Neglect, and Exploitation policy, with a revision date of January 2023, states it is the policy of the facility to take appropriate steps to prevent the occurrence of abuse and neglect .b. The Administrator, Director of Nursing (DON), or designee will notify the appropriate regulatory, investigative, or law enforcement agencies immediately, in accordance with state regulations .b. The results of all investigations are reported to the Administrator and to the appropriate state agency, as required by state law and/or within 5 working days of the alleged violation. 1. On 7/29/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility) and osteoarthritis (a painful joint disease that results from breakdown of joint cartilage and underlying bone). R1's Minimum Data Set (MDS) assessment, dated 7/11/24, stated R1's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R1 had little to no cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decision. According to R1's medical record and a fall investigation, on 6/30/24 at approximately 8:35 AM, R1's right knee buckled behind R1's left leg when R1 pivot transferred from the toilet to a wheelchair. A Certified Nursing Assistant (CNA) assisted R1 to the floor. R1 complained of pain and was transferred to the emergency room (ER) and diagnosed with a mildly displaced fracture of the lateral aspect of the right distal femoral diaphysis (outside portion of the upper leg long bone at the lower end). The facility's 5-day investigation indicated R1's fall occurred on 6/30/24 at 12:00 PM. In addition, the 5-day investigation was due to the SA on 7/8/24. The facility did not submit the 5-day investigation until 7/9/24 at 1:00 PM. On 7/29/24 at 10:52 AM, Surveyor interviewed R1 who stated R1's fall occurred during morning cares in the bathroom when R1 got up on the morning of 6/30/24 with the assistance of a CNA. R1 reiterated the events of the fall which were consistent with the facility's investigation. On 7/29/24 at 2:09 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the time of R1's fall was listed incorrectly on the facility's 5-day investigation. NHA-A also verified the facility submitted the 5-day investigation late.

Based on staff interview and record review, the facility did not ensure an environment free of accident hazards for 2 Residents (R) (R1 and R3) of 4 sampled residents. On 4/8/24 and 6/21/24, R1 experienced falls. The facility did not revise R1's care plan to help prevent future falls. On 4/5/24, R3 slapped R2 on the arm and told R2 to shut up. The facility did not revise R3's care plan to include measures to prevent R3 from further inappropriate interactions toward residents. Findings include: 1. On 7/29/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility) and osteoarthritis. R1's Minimum Data Set (MDS) assessment, dated 7/11/24, stated R1's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R1 had little to no cognitive impairment. R1's medical record indicated R1 was responsible for R1's healthcare decision. R1's medical record, care plan, and fall investigations indicated the following: ~ On 4/8/24: R1 experienced a fall while staff transferred R1 with a sit-to-stand mechanical lift and R1's feet slipped off the lift platform. An assessment indicated R1 had no injuries from the fall. R1's care plan was not revised to prevent future falls. ~ On 6/21/24: R1 slid off a recliner and onto the floor after staff transferred R1 into the recliner and R1's feet got tangled up in the wheelchair pedals. An assessment indicated R1 had no injuries from the fall. R1's care plan did not contain a revision to prevent future falls. On 7/29/24 at 3:26 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the facility did not revise R1's care plan following R1's falls on 4/8/24 and 6/21/24. DON-B stated DON-B expects staff to care plan revisions post-fall to help prevent future falls and injury. 49563 2. On 7/29/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (CKD), congestive heart failure (CHF), diabetes, and urinary tract infection (UTI). R3's MDS assessment, dated 6/24/24, stated R3's BIMS score was 2 out of 15 which indicated R3 had severe cognitive impairment. R3's Power of Attorney for Healthcare (POAHC) was activated on 11/28/22. R3's medical record, care plan, and altercation investigation indicated the following: ~ On 4/5/24, R3 was sitting next to R2 when R3 slapped R2's arm and told R2 to shut up. Staff separated the residents. Following the resident-to-resident altercation, the facility did not revise R3's care plan or implement interventions to prevent future inappropriate interactions with other residents. On 7/29/24 at 2:22 PM, Surveyor interviewed DON-B who verified the facility did not revise R3's care plan after the resident-to-resident altercation on 4/5/24. DON-B stated DON-B expects staff to revise residents' care plans post-altercation to keep residents safe.

Based on observation, staff interview, and record review, the facility did not ensure interventions were implemented to reduce accidents and hazards and ensure a safe environment for 4 Residents (R) (R1, R8, R2, and R3) of 6 residents reviewed for fall prevention and supervision. R1's care plan contained an intervention that instructed staff not to leave R1 alone in the bathroom. The intervention was not consistently implemented. R8's care plan contained an intervention to transfer R8 with a sit-to-stand lift and the assistance of 2 staff. The intervention was not consistently implemented. A facility-reported incident (FRI), dated 12/19/23, indicated an intervention was added to R2's care plan for a stop sign banner across R2's doorway at night. The intervention was not consistently implemented or added to R2's care plan prior to 1/11/24. A FRI, dated 12/19/23, indicated an intervention was added to R3's care plan for a motion sensor alarm in R3's room. The intervention was not consistently implemented or added to R3's care plan prior to 1/11/24. Findings include: The facility's Mechanical Lifts (Total Body and Sit-to-Stand) policy, with a revision date of November 2023, indicated: All mechanical lifts will be operated per the manufacturer's instructions. Staff must be trained in lift use and safety precautions. A minimum of two staff members will be used for all total body lifts. Sit-to-Stand: Assistance with sit-to-stand lift is determined by therapy and assistance level is documented in the care plan and Certified Nursing Assistant (CNA) Kardex. 1. R1 was admitted to the facility on [DATE] with diagnosis including macular degeneration and cataracts of the eyes, hearing loss, morbid obesity, ulcer of the right lower leg, pain in right knee, edema, osteoarthritis (knee, ankle, foot), muscle weakness, and cellulitis of the lower extremities. R1's Minimum Data Set (MDS) assessment, dated 11/7/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. On 1/11/24, Surveyor reviewed R1's care plan which indicated R1 required a sit-to-stand lift for transfers with the assistance of 1-2 staff. R1's care plan for toilet use indicated: Assist of 1-2 staff, do not leave resident alone in the bathroom. R1's medical record contained a progress note, dated 11/20/23 at 2:52 PM, that indicated: R1 returned from the Emergency Department. R1 had a fall at the facility which R1 stated occurred when R1 was in the bathroom with the mechanical lift hooked up in front of R1 and staff left the bathroom. R1 indicated R1 removed R1's self from the lift sling, reached for the call light, and fell off the toilet and onto the floor. On 1/11/24 at 4:15 PM, Surveyor interviewed R1 who indicated staff continue to leave R1 alone in the bathroom with the lift, especially on the PM shift. R1 indicated when the lift battery dies, staff leave or shut the bathroom door, say they will be back, and then go help someone else. R1 stated the most recent occurrence was last evening (1/10/24). On 1/11/24 at 4:30 PM, Surveyor interviewed PM shift CNA-C who confirmed CNA-C provided care for R1. CNA-C indicated R1 is assisted to the bathroom via mechanical lift and 2 staff. CNA-C indicated it is okay to leave R1 alone in the bathroom and stated that is what everyone does on this shift. CNA-C indicated CNA-C has left R1 alone in the bathroom with the door closed and the lift attached, but locked. CNA-C stated CNA-C stands outside the door or in the room door threshold area which CNA-C believed that was allowed per R1's care plan. On 1/11/24 at 4:55 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R1's care plan instructed staff not to leave R1 alone in the bathroom. DON-B indicated staff need to have R1 within eyesight and should not shut the door when R1 is in the bathroom alone. 2. R8 was admitted to the facility on [DATE] with diagnosis including malnutrition, muscle weakness, generalized weakness, bilateral macular degeneration of eyes, and hearing loss. R1's MDS assessment, dated 11/27/23, contained a BIMS score of 9 out of 15 which indicated R8 was moderately cognitively impaired. On 1/11/24, Surveyor reviewed R8's care plan which indicated R8 required a sit-to-stand lift with the assistance of 2 staff for transfers. On 1/11/24 at 2:11 PM, Surveyor observed CNA-D enter R8's room with a sit-to-stand lift. CNA-D transferred R8 without the assistance of a second staff. On 1/11/24 at 3:11 PM, Surveyor interviewed CNA-D who indicated R8 only required 1 staff for transfers. Surveyor reviewed R8's care plan with CNA-D who indicated CNA-D was not aware that R8 required 2 staff for transfers. On 1/11/24 at 4:55 PM, Surveyor interviewed DON-B who confirmed R8's care plan indicated R8 required the assistance of 2 staff for transfers. DON-B indicated staff likely are not checking care plans. 38793 3. R2 was admitted to the facility on [DATE] with diagnosis including Lewy body dementia, anxiety, and history of stroke with right-sided hemiplegia (paralysis). R2's MDS assessment, dated 11/9/23, contained a BIMS score of 12 out of 15 which indicated R2 had mildly impaired cognition. On 1/11/24, Surveyor reviewed a FRI that occurred between R2 and R3. On 12/19/23, R3 was observed in R2's room touching R2 without R2's consent. CNA-E intervened, separated R2 and R3, and an investigation was completed. The investigation indicated an intervention was added to R2's care plan to place a stop sign banner across R2's doorway at night. Surveyor noted the intervention was not on R2's care plan. On 1/11/24 at 5:06 PM, Surveyor interviewed CNA-E regarding increased supervision/monitoring for R2. CNA-E verified CNA-E worked with R2 on 12/19/23 and 12/20/23. CNA-E indicated there were no interventions added for R2. On 1/11/24 at 2:10 PM, Surveyor interviewed CNA-F who worked with R2 on 12/20/23. CNA-F verified there was not a stop banner across R2's doorway and stated CNA-F chose to stay within eyesight of R2's doorway for most of the shift. On 1/11/24 at 10:34 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G via telephone who verified there was not a stop sign banner in place across R2's doorway at the time of the interview. On 1/11/24 at 3:13 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the intervention was not added to R2's care plan as of 1/11/24. 4. R3 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease, congestive heart failure, chronic kidney disease, and chronic obstructive pulmonary disorder (COPD). R3's MDS assessment, dated 12/27/23, contained a BIMS score of 5 out of 15 which indicated R3 had severely impaired cognition. On 1/11/24, Surveyor reviewed a FRI that occurred between R2 and R3. On 12/19/23, R3 was observed in R2's room touching R2 without R2's consent. Staff separated R2 and R3 and an investigation was completed. The investigation indicated an intervention was added to R3's care plan to use a motion sensor alarm in R3's room due to R3's tendency to wander on the unit. Surveyor noted the intervention was not on R3's care plan. On 1/11/24 at 11:14 AM, Surveyor observed a motion sensor alarm present in R3's room, but the device was not turned on. Surveyor observed staff enter and exit R3's room at 1:23 PM and 3:05 PM and the motion sensor did not alarm. On 1/11/24 at 5:06 PM, Surveyor interviewed CNA-E regarding increased supervision/monitoring for R3. CNA-E verified CNA-E worked with R3 on 12/19/23 and 12/20/23 and indicated there were no interventions added for R3. On 1/11/24 at 2:10 PM, Surveyor interviewed CNA-F who worked with R3 on 12/20/23. CNA-F verified a motion sensor was not in place in R3's room and CNA-F chose to stay within eyesight of R3's doorway for most of the shift. On 1/11/24 at 3:13 PM, Surveyor interviewed NHA-A who verified the intervention was not added to R3's care plan as of 1/11/24.

Based on resident and staff interview, and record review, the facility did not ensure timely reporting of an injury of unknown origin for 1 Resident (R) (R2) of 4 residents reviewed. R2 was diagnosed with a hip fracture of unknown origin. The injury was not reported to the State Agency (SA) within two hours of discovery. Findings include: The facility's Freedom from Abuse, Neglect, and Exploitation policy, dated May 2020, indicated: It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) are reported immediately to the administrator of the community. If the events that caused the allegation involve abuse or serious bodily injury, it must be reported to the State Agency immediately, but no later two hours after forming the suspicion per state and federal regulation. On 11/9/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility with diagnoses including a right hip fracture, and unilateral primary osteoarthritis. R2's Minimum Data Set (MDS) assessment, dated 11/3/23, contained a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R2 had moderately impaired cognition. The MDS also indicated R2 required staff assistance with activities of daily living (ADLs). A progress note, dated 10/28/23 at 10:00 PM, indicated R2 had respiratory difficulties and was sent to the emergency room (ER) for evaluation. A progress note, dated 10/29/23 at 12:50 AM, stated facility staff spoke with hospital staff who reported R2 complained of hip pain. An X-ray of the right hip indicated R2 had a mildly displaced and angulated right femoral neck fracture. On an initial report form submitted to the SA, the facility indicated the injury of unknown origin was discovered on 10/30/23. A hospital note dated 10/29/23, indicated R2 was admitted with pneumonia and a urinary tract infection (UTI), and complained of right lower extremity discomfort. An X-ray was obtained and showed an acute displaced hip fracture. R2 reported to hospital staff that R2 did not fall, but sustained an injury, bruise, and skin tear without pain during a past transfer. R2 opted not to have corrective surgery. On 11/9/23 at 11:53 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should have alerted the on-call nurse manager of the fracture report from the hospital during the AM shift on 10/29/23. DON-B indicated DON-B was not notified of R2's hip fracture on 10/29/23 and verified an initial report was submitted to the SA on 10/30/23. On 11/9/23 at 12:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B who verified a serious injury of unknown origin is reportable to the SA within two hours of discovery. NHA-A stated NHA-A was not notified of R2's hip fracture on 10/29/23