Every finding on record at St Paul Elder Services, Inc

Based on staff interview and record review, the facility did not ensure a provider was notified of a change in condition for 1 resident (R) (R1) of 3 sampled residents.The facility did not notify a provider and obtain an order when staff increased R1's oxygen (O2) to 4 liters per minute (LPM).Findings include:The facility's Condition or Status Change policy, revised 7/2023, indicates: 1. The nurse notifies the resident's physician or on-call physician when there has been: .c. A significant change in the resident's physical, emotional, or mental condition, including diagnostic testing results that are abnormal.Between 3/25/26 and 3/26/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including pneumonia and dependence on supplemental oxygen (both initiated 10/12/26). R1's Minimum Data Set (MDS) assessment, dated 9/13/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. A progress note, dated 10/12/25 at 10:50 AM, indicated R1's oxygen saturation level was in the 80s at room air and increased to 90% with an incentive spirometer and cough and deep breathing. R1's oxygen saturation was 85% with oxygen at 1LPM via nasal cannula and 90-93% on 2 LPM via nasal cannula. R1 had shortness of breath with exertion and lying flat and relief with sitting up and at rest. R1 complained of intermittent dizziness. R1's provider was notified. A progress note, dated 10/12/25 at 11:50 AM, indicated a Nurse Practitioner (NP) gave orders for a blood draw, fecal occult stool test x 3, duonebs as needed for shortness of breath and wheezing, and to hold R1's evening Eliquis (an anticoagulant medication used to prevent blood clots). R1 also had orders for a stat (without delay) 2 view chest X-ray done in the facility related to abnormal lung sounds and decreased oxygen saturation. All of the above orders were processed.A progress note, dated 10/12/25 at 4:23 PM, indicated R1's vital signs on the PM shift revealed a decreased oxygen saturation level of 85% on 2 LPM of oxygen via nasal canula. When R1's oxygen was increased to 2.5 LPM, R1's oxygen saturation level increased to 88%. A nursing assessment revealed wheezing/rales throughout the upper and lower lung bases. Rales/rhonchi were unrelieved with coughing. When R1's oxygen was increased to 3 LPM, R1's oxygen saturation level increased to 90-91%. R1 was encouraged to continue the incentive spirometer and cough and deep breathing. R1's physician was notified. Orders were received to keep R1's oxygen level above 90% and keep R1 on 3 LPM of oxygen via nasal cannula. R1 was adamant R1 did not want to go to the hospital and did not want R1's family or children updated. A stat X-ray was ordered and completed. The facility was awaiting the results.On 10/12/25, an order was initiated for oxygen at 3 LPM to keep oxygen saturation level greater than 90%. An order was also received to document on the Treatment Administration Record (TAR) 3 times per day (AM, PM, and Night) the LPM used and R1's oxygen saturation level. Surveyor reviewed R1's TAR and noted on 10/12/25 and 10/13/25, R1 was on 3 LPM of oxygen each shift. On 10/14/25, staff documented R1 used 4 LPM of oxygen. On the 10/14/25 AM shift, R1 used 4 LPM and R1's oxygen saturation level was 92%. On the 10/14/25 PM shift, R1 used 4 LPM and R1's oxygen saturation level was 92%. On the 10/14/25 into 10/15/25 night shift, R1 used 4 LPM and R1's oxygen saturation level was 92%. On the 10/15/25 AM shift, R1 used 4 LPM and R1's oxygen saturation level was 94%. R1's medical record did not include physician notification, a progress note, or an order updating R1's oxygen use to 4 LPM.A progress note, dated 10/14/25 at 2:39 PM, indicated R1 remained on 4 LPM of oxygen via nasal cannula to keep R1's oxygen saturation level greater than 90%. On 3/26/26 at 10:00 AM, Surveyor interviewed Physician Assistant (PA)-C via phone who worked for the facility's contracted medical provider. PA-C indicated if a resident has pneumonia and is already using oxygen, PA-C would want to know if oxygen was increased and why. PA-C indicated PA-C would have instructed staff to continue to monitor as long as R1 remained alert and did not use accessory muscles to breathe. PA-C indicated PA-C would not have sent R1 to the hospital at that time.On 3/26/26 at 11:10 AM, Surveyor interviewed PA-D who was called when R1 was sent to the hospital on [DATE]. PA-D indicated PA-D would want to know if oxygen was increased and why. PA-D indicated unless R1 was using accessory muscles to breathe, PA-D would have instructed staff to continue to monitor and would not have sent R1 to the hospital at that time.On 3/26/26 at 9:00 AM, Surveyor interviewed Director of Nursing (DON-B) who verified staff should have contacted R1's provider and obtained an order when they increased R1's oxygen to 4 LPM.

Based on staff and resident interview and record review, the facility did not ensure the environment was free from abuse for 7 residents (R) (R2, R4, R10, R11, R3, R1, and R9) of 11 sampled residents. R2 was involved in 8 resident-to-resident altercations between 1/25/25 and 5/29/25. The facility added interventions to R2's care plan and moved residents who might trigger R2 off the unit in an attempt to prevent future incidents, however, the interventions implemented failed to prevent further resident-to-resident altercations and instances of abuse. Findings include: The facility's Resident Protection and Prevention and Investigation of Abuse, Neglect, Misappropriation, Exploitation, Caregiver Misconduct, and Injuries of Unknown Source policy, revised 10/2022, indicates: .4. Corrective Action: .b. When the individual implicated in the alleged conduct is a resident, family member, or visitor, the facility documents that it has taken appropriate steps to respond to the incident and to address the conduct or behavior to prevent harm or injury to other residents. Attachment A titled Code of Federal Regulations Under Abuse indicates: For a definition for willful refer to the interpretive guidelines at F689 where under Resident-to-Resident Altercations it notes: A resident-to-resident altercation should be reviewed as a potential situation of abuse .Willful means the individual intended the action itself, regardless of whether or not the individual intended to inflict injury or harm. Even though a resident may have a cognitive impairment, he/she could still commit a willful act. On 6/16/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease with early onset, dementia with psychotic disturbance, major depressive disorder, anxiety disorder, and primary insomnia. R2's Minimum Data Set (MDS) assessment, dated 4/22/25, indicated R2 was rarely/never understood. The MDS also indicated R2 had physical and verbal behavioral symptoms directed toward others on 4-6 days of the week but less than daily during the lookback period. R2's admission MDS, dated [DATE], indicated R2 had physical and verbal behavioral symptoms directed toward others on 1-3 days of the week during the lookback period. The MDS also indicated R2's behaviors impacted others by putting others at significant risk for physical injury, intruding on the privacy or activity of others, and significantly disrupted the care or living environment. A care plan, initiated 1/25/25, indicated R2 was involved in a resident-to-resident altercation and was triggered by loud social environments, loud voices and direct tones, when peers corrected or attempted to tell R2 what to do, and by witnessing physical contact between others. When triggered, R2 might attempt to physically correct others' actions. The care plan contained an intervention to reassure R2 when providing care to peers in R2's vicinity. The care plan also indicated R2 attempted to help others at times which was not always liked by peers. Surveyor noted the care plan had been updated over time and was last updated on 6/3/25. On 6/16/25, Surveyor reviewed incidents that occurred between R2 and other residents since R2's admission. Incident #1: On 6/16/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and dementia. R4's MDS assessment, dated 5/1/25, indicated R4 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R4 had severe cognitive impairment. R4 had an activated Power of Attorney for Healthcare (POAHC). R4 passed away at the facility on 6/5/25. A facility-reported incident (FRI) submitted to the State Agency (SA) indicated on 1/25/25 at approximately 12:00 PM, R2 was walking down the hallway past R4's room. R4 was in the doorway of the room and R4 yelled at R2 with an escalated voice to go away. R2 reacted and tapped R4 on the top of the head. R4 yelled for staff who were in a room assisting another resident. When staff responded, R4 was in a wheelchair in the doorway and R2 was standing next to R4. R4 informed staff that R2 hit R4 on the top of the head after R4 told R2 to go away. The Interdisciplinary Team (IDT) and Expressive Action Team reviewed the incident. The facility implemented interventions to redirect R2 away from R4's room and use 1:1 support if R2 was in a negative mood. Staff education was completed. On 6/16/25, Surveyor reviewed R2's care plan and noted the following intervention was added on 1/28/25: If I am entering my peers' rooms, please redirect me in order to keep myself and others safe. On 1/25/25, an intervention was added that indicated: It is important for my peers to greet me with respect and kindness. I may become upset with a direct tone. Please help respond to my needs or guide my peers if I become upset. Incident #2: On 6/16/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and anxiety disorder. R10's MDS assessment, dated 5/7/25, indicated R10 was rarely/never understood. R10 passed away in the facility on 5/15/25. A FRI submitted to the SA indicated on 2/12/25 at approximately 2:30 PM, R10 stood up from a wheelchair in the dayroom and stated R10 needed to use the bathroom. Staff approached R10 so R10 would not self-ambulate. R2 was assisting the nurse on duty and followed the nurse when the nurse approached R10. When R10 threw R10's arms out to the side as if R10 was losing balance, R10's arms made contact with staff and possibly R2. The report indicated R2 reacted to situations quickly and when R2 thought R10 hit staff, R2 wrapped R2's arms and hands around R10. R2 let go when asked by staff. R10 and R2 were provided 1:1 support. An intervention was added to provide reassurance to R2 regarding the safety of peers and staff when providing care to others in R2's vicinity. R2's care plan was updated with additional resident-to-resident triggers and interventions. Staff were educated to ensure interventions were in place. A progress note, dated 2/12/25 at 1:07 PM, indicated the writer interviewed R2 after the altercation and R2's spouse walked around the neighborhood with R2. R2 approached R10 with the writer and shook R10's hand. R10 had no recollection of the incident and did not show any signs of distress. On 6/16/25, Surveyor reviewed R2's care plan and noted the following intervention was added on 2/12/25: When my peers are receiving cares within my vicinity, please reassure me that everything is okay and that everyone is safe. Incident #3: A FRI submitted to the SA indicated a second altercation with R4 occurred on 2/15/25 at approximately 4:30 PM in the day room during dinner. R4 swore at staff because R4 wanted salt with dinner. Staff turned around to retrieve the salt from a cabinet. When staff turned back around, they noted R2 had quickly stood up and hit R4 who hit R2 back. R4 attempted to kick R2 but no contact was made. R2 was redirectable, however, R4 continued to attempt to hit R2 while staff separated the residents. The FRI further indicated R2 was usually friendly and pleasant, enjoyed socializing with others, and had positive interactions with staff and peers. Since R2 moved to the unit, R2 was interested in walking around the neighborhood, offering handshakes, engaging with peers, and initiating interactions with residents and staff. R2's expressive actions came on quickly, especially when R2 was overwhelmed with excessive stimuli. The FRI indicated R2 had altercations in the past, may respond to situations that R2 perceives as disrespectful, and could often be redirected with a calm, gentle voice and active engagement. R2 responded positively to calming activities in a structured and peaceful environment when agitated. The exercise bike, walks, and conversations about football were effective. A progress noted, dated 2/16/25 at 3:05 PM indicated R4 was upset about the resident-to-resident altercation and was hard to redirect that day. A progress note. dated 2/17/25 at 7:07 AM, indicated R4 mentioned the altercation several times that morning. R4 indicated R4 yelled at R2 and told R2 to never do that again. Staff reminded R4 that R4 was safe. R4 slept for the first half of the shift but had difficulty sleeping later on. A Social Service progress note, dated 2/17/25 at 3:03 PM, indicated the writer met with R4 after the altercation. R4 was tired and did not sleep well. R4 indicated R4 had an altercation with R2. R4 indicated R4 felt safe and denied that anyone harmed R4. A progress note, dated 2/19/25 at 12:29 PM, indicated R4 did not recall the incident at that time but had moments of recollection throughout the week. On 6/16/25, Surveyor reviewed R2's care plan and noted the following intervention was added on 2/15/25: Offer me music headphones with spa music during my meals if the environment is loud or I am triggered by noise around me. Staff education included to attempt to keep R2 and R4 away from each other, anticipate their needs, and provide salt on R4's meal tray. Incident #4: On 6/16/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and anxiety disorder. R11's MDS assessment, dated 5/30/25, had a BIMS score of 4 out of 15 which indicated R11 had severe cognitive impairment. R11 had an activated POAHC. A FRI submitted to the SA indicated on 2/23/25 at approximately 12:50 PM, R11 walked to the doorway of R11's room and R2 walked past. R2 swung R2's arm out and hit R11 in the face/chin. R11 fell backwards onto R11's bottom and had a cut on the chin. R11 was provided 1:1 support. Staff took R2 for a walk and provided incontinence care for R2. The FRI indicated Nursing [NAME] Administrator (NHA)-A followed up with R11 and R2 throughout the week. R2 did not recall the incident and showed no signs of distress. R11 recalled the incident but felt safe and was not afraid of R2. All other residents on the neighborhood were interviewed with no concerns. Staff determined incontinence could have been the root cause of R2's expressive actions. The investigation indicated R2 was incontinent around lunch time. Staff assisted R2 with cares and provided lunch, however, R2 was agitated and stood during lunch. When staff offered R2's scheduled Tylenol, R2 threw it across the room. Staff were in the common area with R2 when another resident called for assistance. Staff approached the resident but still had R2 in view. R2 walked toward the hallway past the first and second resident rooms near the day room. When R2 approached the second room, R11 entered the doorway and R2 hit R11. R2 was incontinent at the time of the altercation and was assisted with cares. An intervention was added to see if R2 was incontinent if R2's mood began to change and indicated cares could be a trigger for R2. If R2 was not in a good mood, staff should take R2 for a walk and reapproach. A resident-to-resident incident report submitted to the SA as part of the facility's investigation indicated while R11 ambulated into the hallway by R11's room, R2 was walking toward but was behind R11. When R11 turned around, R11 and R2 were face-to-face. R2 made a fist and punched R11 in the chin which caused R11 to fall back onto R11's bottom. The report indicated R2 was agitated during lunch, didn't want to sit down, and paced the halls. An intervention was added to check R2 for incontinence when R2 seemed agitated and offer a walk. A witness statement from a nurse indicated R11 was walking out of R11's room by the side rail when another resident (R2) was walking toward R11 but was behind R11. The statement indicated when the nurse turned around, the nurse saw (R2) make a fist and hit R11 with a closed fist in the chin. R11 fell back onto R11's bottom. The following interventions were added: Ensure R2 is not incontinent, even if R2 was just assisted to the bathroom. If R2 is not accepting cares and is beginning to become upset, the nurse will designate someone to walk with R2 off the neighborhood and approach R2 again when R2 returns to the neighborhood. Walks usually help R2's mood which may allow cares to be accepted. If an associate is not available on the neighborhood, the nurse will call other neighborhoods to see if someone is available to assist. On 6/16/25, Surveyor reviewed R2's care plan and noted the following intervention was added on 2/23/25: If I appear uncomfortable or upset, please assess for incontinence. If my mood is impairing my ability to accept cares, please walk with me off of the neighborhood. Walking helps my mood. Once I return home, please reapproach me and provide cares. Incident #5: On 6/16/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, anxiety disorder, and major depressive disorder. R3's MDS assessment, dated 4/17/25, had a BIMS score of 2 out of 15 which indicated R3 had severe cognitive impairment. A FRI submitted to the SA indicated on 3/28/25 at approximately 9:30 AM, R2 and R3 were in the day room eating breakfast. R2 was standing next to R3 when R3 started yelling. R2 reacted by hitting R3 on the cheek. No injuries were noted. An immediate intervention was to offer R2 active engagement, including walking around the neighborhood. A Resident-to-Resident Behavior Incident Report indicated R3 was in a wheelchair in the day room near the table. R2 stood near R3 who yelled out. R2 hit R3 in the face and knocked R3's glasses off. On 6/16/25, Surveyor reviewed R2's care plan and noted the following intervention was added on 3/31/25: Please offer me an activity or engagement opportunity if we are on the neighborhood with downtime or if my peers are experiencing expressive actions of their own. Incident #6: A FRI submitted to the SA indicated on 3/30/25 at approximately 5:45 PM, R4 was in R4's room when R2 walked by. (The FRI indicated R2 and R4 had altercations in the past and R4 did not like when R2 was in R4's room.) When R4 saw R2 in R4's room, R4 yelled at R2 to get out of the room and wheeled toward R2. R2 pushed and struck R4's head. R4 punched and kicked at R2. Staff interviews indicated R4 recalled the event and stated R4 disliked R2. An intervention was added to ensure R2 did not enter R4's room. R4 was moved to a different unit on 4/2/25. On 6/16/25, Surveyor reviewed R2's care plan and noted the following intervention was added on 3/31/25: Please offer me an activity or engagement opportunity if we are on the neighborhood with downtime or if my peers are experiencing expressive actions of their own. Incident #7: On 6/16/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and diabetes. R9's MDS assessment, dated 1/14/25, had a BIMS score of 4 out of 15 which indicated R9 had severe cognitive impairment. An MDS assessment, dated 4/16/25, indicated R11 had short-term memory impairment. A FRI submitted to the SA indicated on 4/29/25 at approximately 12:45 PM, Certified Nursing Assistant (CNA) staff were assisting another resident and the nurse needed to step off the unit. R2 walked up to R9 in the day room and attempted to pull R9's wheelchair away from the table. R9 yelled at R2 and R2 hit R9 on the arm. In response, R9 scratched R2's arm. Staff provided 1:1 support. An intervention was added to have R2 with staff if the day room could not be monitored. R9 was moved to a room closer to the nurses' station. R2 was provided 1:1 support throughout the night and into the morning of 4/30/25. The FRI indicated staff were educated not to leave the day room unattended. R2's care plan was updated with the resident-to-resident altercation. The FRI also indicated the Social Worker (SW) met with R9 in R9's room and the day room following the altercation to assess for signs and symptoms of psychosocial distress. The SW and R9 were in the day room when R2 walked in. R9 tensed and watched R2 as R2 entered. Some distress and worry were noted during the SW's interview with R9. An incident note, dated 4/29/25 at 2:16 PM, indicated R9's provider was updated on the altercation and that R9 had pain and swelling to the right hand/wrist area. An order was obtained for a portable X-ray of the right hand/wrist. A progress note, dated 4/30/25 at 10:28 AM, indicated the base of R9's right thumb was swollen and tender. The X-ray was negative. The note also indicated R9 was fearful of R2 and yelled at R2 to get away from me. R9 swore at R2 when R2 approached R9 in the day room. Staff separated the residents. A Social Services note, dated 4/30/25 at 1:13 PM, indicated the writer met with R9 following the altercation to assess for psychosocial distress. R9 indicated a peer (R2) caused physical harm and entered R9's room uninvited. When the peer was visible to R9, R9 appeared tense. Reassurance was provided and effective. On 4/30/25, NHA-A met with R9 following the SW's interview. R9 indicated R9 was okay and agreeable to a room change on 5/1/25. R9 was moved closer to the nurses' station and main entry of the neighborhood and was happy with the move. A progress note, dated 5/1/25 at 5:02 PM, indicated R9 was interested in moving rooms, however, later on R9 was upset and fixated on where the keys were to lock the door. R9 asked what good the move was if R9 could not lock the door. R9 was provided 1:1 support and expressed worry about another resident (R2) from the incident. R9's anxiety improved following reassurance and redirection. On 6/16/25, Surveyor reviewed R2's care plan and noted the following intervention was added on 4/29/25: I like to push other residents' wheelchairs around the neighborhood. Please help redirect me by having me help you with something else and please make sure I am within your sight when I am walking around the neighborhood or in the dayroom. I enjoy taking a walk off the neighborhood and spending time with other departments. On 6/16/25 at 12:45 PM, Surveyor interviewed R9 who had moved to another unit on 6/12/25. R9 indicated R9 moved to get away from a (resident) (R2) who grabbed R9's wrist and dumped garbage in R9's room. R9 indicated R9 moved closer to the nurses' station after the incident but didn't like that (resident) and moved to another room which was better. R9 indicated R9 felt safe now that R9 was in the new room. On 6/16/25 at 10:56 AM, Surveyor interviewed Med Tech (MT)-C who indicated R9 moved off the unit last week because of R2. MT-C indicated R9 was not entirely innocent, though, because R9 had started to provoke R2 intentionally. Incident #8: On 6/16/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and dementia. R1's MDS assessment, dated 4/18/25, indicated R1 had short-term and long-term memory impairment. A FRI submitted to the SA indicated on 5/29/25 at approximately 5:30 PM, R2 had a resident-to-resident altercation with R1 when R2 trialed a potential move to a new neighborhood. R2 finished supper, walked around the neighborhood, and looked out the window next to the table where R1 was sitting. R1 began to talk loudly which was normal for R1. R2 slapped R1 on the cheek. Staff escorted R2 out of the dining room and back to R2's unit. R2 was calm before and after the incident. Staff provided 1:1 support for R1 who calmed down. The intervention was not to move R2 to the new unit. A statement by CNA-H (which was part of a Resident-to-Resident Behavior/Incident Report) indicated CNA-H was sitting next to R1 and another resident and assisting them with supper. R2 was standing next to the other resident. R1 was yelling/talking and R2 moved around the table to look out the window. R2 then quickly moved toward and slapped R1. R2 showed no sign of frustration or anger. R2 moved too quickly for CNA-H to know R2 was going to slap R1. The incident report indicated R1 initially had a red cheek. A progress note, dated 6/3/25 at 8:16 AM, indicated R2 experienced agitation with physical aggression at times. Triggers included assistance with personal hygiene/cares, bathroom needs, loud noises, fast movements, loud or yelling voices, and a negative environment. At times R2's agitation/aggression appeared to be untriggered. During periods of agitation, staff continued to offer redirection and engagement opportunities. R2 was involved in several resident-to-resident altercations and the IDT recommended R2 move off the neighborhood. During a trial visit on another neighborhood, R2 was involved in a resident-to-resident altercation. The provider was notified and asked to provide treatment recommendations and complete a medication review. On 6/16/25, Surveyor reviewed R2's medical record and did not note any care plan interventions or documentation that indicated R2 was provided 1:1 support for extended periods of time other than walks, activities, and other engagement, redirection, etc. Surveyor requested 24-hour reports for the incidents on 3/28/25, 3/30/25, and 5/29/25. On 6/16/25, the facility provided schedules, dated 4/29/25, that indicated staff were assigned to 1:1 supervision with R2 from 4:00 PM to 7:00 AM on 4/30/25. In addition, the facility provided the following 24-hour report documentation: ~ On 3/29/25, R2 and R3 were on the 24-hour report related to the 3/28/25 incident. The report indicated resident-to-resident prevention was a top priority on R2's unit and CNAs must ensure engagement was active prior to leaving the day room for cares. The nurse should intervene if R2 became expressive near another resident. The report contained an instruction to call coordinators for assistance after lunch if needed and call another unit at 8:00 PM for CNA assistance with restlessness. ~ On 4/1/25, R2 was on the 24-hour report for incidents on 3/28/25 with R3 and on 3/30/25 with R4. The report indicated to monitor each resident for signs/symptoms of psychological distress. The report also indicated resident-to-resident prevention was a top priority on R2's unit and CNAs must ensure engagement was active prior to leaving the day room for cares. The nurse should intervene if R2 became expressive near another resident. The report contained an instruction to call coordinators for assistance after lunch if needed and call another unit at 8:00 PM for CNA assistance with restlessness. ~ On 5/30/25, the 24-hour report indicated R2 had a resident-to-resident altercation while on another unit on 5/29/25. In an email to the SA on 6/17/25 at 4:31 PM, the facility provided information that indicated R2's family visited 5-7 days per week for approximately 3 hours at a time, however, 1:1 support was not consistently documented. The email indicated the facility used support staff for R2, including staff who were already scheduled and from other departments. The facility indicated they used a collaborative approach which allowed them to meet R2's needs more effectively while being mindful of staffing demands. The facility provided dates and times when family visited, activities engagement support, examples of 1:1 support, restorative care, and other IDT support. On 6/16/25 at 10:03 AM, Surveyor interviewed CNA-F who indicated CNA-F was educated on interventions for R2. CNA-F indicated CNA-F had been 1:1 with R2 for a shift which involved mostly redirecting R2. CNA-F stated if R2 had a conflict with another resident, R2 would be 1:1 for usually a day or two. On 6/16/25 at 10:56 AM, Surveyor interviewed MT-C who indicated staff kept an eye on R2 and confirmed R2 had altercations with other residents. MT-C indicated R2 was not on 1:1 supervision but if R2 was agitated, staff provided 1:1 support. MT-C thought R2 was on 1:1 supervision for a period of time after altercations, but was not sure if staff documented when R2 was 1:1. MT-C indicated if R2 needed a 1:1 staff, the facility needed to bring a staff person in so unit staff could care for other residents. On 6/16/25 at 11:20 AM, Surveyor interviewed CNA-E who worked regularly on R2's unit. CNA-E stated R2 was not consistently provided 1:1 supervision, however, if R2 was anxious and had an altercation, a 1:1 staff was provided for a few days. CNA-E indicated staff are to keep an eye on R2. CNA-E indicated R2 had recently declined a bit and could not get up ad lib the last two days. CNA-E indicated if R2 needed a 1:1 staff on the AM shift, the facility would pull someone. If a 1:1 staff was needed on the night shift, it was tougher because there was no one extra to pull. CNA-E indicated the nurse would sit with R2 if R2 was restless. CNA-E confirmed education related to R2 and incidents and updates were on the CNAs' pocket notes. On 6/16/25 at 1:03 PM and 2:50 PM, Surveyor interviewed Clinical Coordinator (CC)-G who indicated the facility worked to find a root cause for the altercations with R2 and updated R2's care plan appropriately after each incident. CC-G indicated overstimulation could trigger R2 and meals were a busy time so staff provided additional support during those times. CC-G indicated the facility implemented appropriate interventions and worked hard to understand R2 who was impulsive. CC-G indicated the facility contacted the Aging and Disability Resource Center (ADRC) and used family and volunteers for support. CC-G indicated there should always be staff in the day room and indicated the facility talked to staff about ensuring the day room was monitored. When asked about 1:1 support for R2, CC-G indicated the facility offers 1:1 support in general and indicated there are more eyes and ears available for R2 when needed. CC-G indicated staff from various departments take R2 for walks and there are extra staff from 2:30 PM-6:00 PM and a float staff on the night shift. CC-G indicated staff are usually scheduled for 2 hours on one neighborhood and 2 hours on another, but can be pulled if needed. When asked why 1:1 support was not added to R2's care plan, CC-G indicated the facility probably could have added 1:1 support officially when it was implemented on 4/29/25 and 4/30/25 and stated 1:1 support is offered intermittently and as needed. CC-G indicated R9 was moved off the unit last week because R9 started becoming aggressive toward R2 by being loud and slamming doors. CC-G indicated if R2 was in R9's vicinity, R9 hollered and got loud which was a trigger for R2. CC-G indicated when an altercation occurred, R2 was on the 24-hour report for a period of time and the Expressive Action Team met to ensure appropriate interventions and follow-up were completed. On 6/16/25 at 2:28 PM, Surveyor interviewed CNA-D and CNA-E who were charting at a table in the day room while R2 was seated in a recliner. CNA-D and CNA-E indicated R2's interventions were helpful but did not prevent altercations between R2 and other residents. When asked about staffing the day room at all times and keeping an eye on R2, CNA-E indicated there were usually 2.5 CNAs on each shift, however, if another unit was short, staff were often pulled from their unit to assist elsewhere. When asked about calling staff for assistance when R2 was agitated, CNA-D and CNA-E indicated they can and do call for assistance which is sometimes provided and sometimes not. CNA-D and CNA-E indicated the unit can be very busy and if there is a lot going on, it is difficult to keep an eye on R2. On 6/16/25 at 2:44 PM, Surveyor interviewed NHA-A who indicated the facility discusses R2 at weekly meetings where staff submit concerns and ideas and the team reviews incidents, looks at root causes, and evaluates if interventions are effective. NH-A indicated residents are added to the 24-hour report board and staff are updated via CNA pocket notes. NHA-A indicated each altercation was different for R2 who did not like what R2 perceived as disrespectful behavior, including yelling, loud noises, and not acknowledging R2 when someone walked by. NHA-A indicated the facility did a week long trial with R2 with staff or family on a new unit, however, an altercation with R1 occurred at the end of the trial and R2 did not move. NHA-A confirmed R9 started expressive actions toward R2 and was moved off the unit. NHA-A indicated all staff were aware of R2 and the facility had staff with R2 when altercations occurred who were not expecting R2 to respond that way. NHA-A indicated while 1:1 supervision was not officially assigned, R2 was often a nurse's assistant and staff often brought R2 to NHA-A, the SW, or Director of Nursing (DON)-B. For official 1:1s, NHA-A indicated the facility provided a 1:1 staff initially until R2 adjusted to the unit and then provided a 1:1 staff through the evening and into the next day following the incident with R9 because R9 was upset. NHA-A indicated the 1:1 staff was in place until staff were able to fully assess R9. When Surveyor indicated Surveyor observed R2 in a recliner and staff indicated R2 could not get up on R2's own and needed more assistance for dressing, NHA-A indicated R2 had a similar change a couple of weeks ago and then bounced back. When asked about a consistent 1:1 staff, NHA-A did not feel a 1:1 staff would help or would have helped and indicated staff were next to R2 during the 5/29/25 incident. NHA-A also indicated R2 had a significant altercation with a staff member during a 1:1 time period and indicated a 1:1 staff could trigger R2. NHA-A indicated the facility provided reasonable interventions after each of R2's resident-to-resident altercations despite the fact R2 continued to be involved in resident-to-resident altercations that included physical aggression toward others.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect more than 4 of the 98 residents residing in the facility. Food items were not labeled with received, opened, or use-by dates. Staff did not the ensure the temperature of the activity freezer was monitored to ensure resident food was stored safely. Cook (CK)-F and CK-E did not wait two minutes to temp microwave reheated food to ensure the food was heated evenly. Findings include: During a continuous kitchen observation that began at 11:30 AM on 4/1/25, Director of Dining (DD)-D indicated the facility follows the Wisconsin Food Code. Undated Items in Refrigerators/Freezers: The Wisconsin Food Code indicates at 3-501.17 Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food), Date Marking: .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 Celsius (C) (41 Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1 .ready to eat time and temperature controlled food shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded based on the temperature and time combinations . During an initial kitchen tour with Executive [NAME] (EC)-C that began at 8:18 AM on 3/31/25, Surveyor observed the dry storage area and noted multiple bottles of Simply Thick brand Thick & Easy clear drinks. The bottles contained a labeling sticker that indicated the date the drink was obtained by the facility, a line for staff to write the opened date, a line below the opened date for the expiration date, and line below the expiration date/use-by date that indicated the product should be thrown away seven days after opening. EC-C indicated stickers are affixed to the bottles when they arrive and are used to ensure staff label the bottles with the opened and use-by dates to ensure all clear drinks are discarded after seven days. On 3/31/25 beginning at 9:15 AM, Surveyor toured the facility's neighborhoods and noted the following: ~ The Poppy Place dining room refrigerator contained an undated Celsius drink and an undated container of queso cheese dip for resident consumption. The Poppy Place dining room freezer contained undated containers of chicken soup and beef vegetable soup. ~ The Birch Place dining room refrigerator contained an open container of Simply Thick brand Thick & Easy lemon-flavored juice with no open or use-by dates, an open bottle of Mountain Dew with no open or use-by dates, and a can of Bubbler with no use-by date. On 4/1/25 at 8:20 AM, Surveyor observed the Primrose Place dining room refrigerator and noted an open and undated container of Simply Thick brand Thick & Easy with an affixed label. Surveyor observed Certified Nursing Assistant (CNA)-G serve the open and undated Thick & Easy drink to a resident during meal service. During a continuous kitchen observation that began at 11:31 AM on 4/1/25, Surveyor interviewed EC-C who indicated the dining room refrigerators and freezers contain food items for resident use. EC-C verified the food and drink items observed by Surveyor were not labeled or dated in accordance with the facility's policy. Freezer Temperatures: The Wisconsin Food Code indicates: .1. Temperature control: Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. Refrigerators should be set below 41 F (5 C) and freezers at or below 0 F (-18 C). During a continuous kitchen observation that began at 11:31 AM on 4/1/25, Surveyor interviewed EC-C who indicated Activity Director (AD)-H was responsible for the refrigerator and freezer in the activity room and the temperature monitoring logs. On 4/1/25 at 1:18 PM, Surveyor toured the activity room and observed the refrigerator and freezer with AD-H. Surveyor observed containers of soup and ice cream in the freezer that AD-H confirmed were for resident consumption. Surveyor noted the refrigerator/freezer temperature log indicated the freezer temperature was above 0 degrees F on multiple dates. Surveyor interviewed AD-H who indicated AD-H did not know who was responsible for monitoring refrigerator/freezer temperatures. AD-H indicated AD-H collects and files the temperature logs and was unsure what the freezer temperature should be. Surveyor requested the facility's January, February, and March 2025 temperature logs. On 4/1/25 at 1:30 PM, Surveyor reviewed the activity room refrigerator/freezer temperature logs and noted the following: ~ In January of 2025, the freezer had a temperature above 0 degrees (with a highest recorded temperature of 20 degrees F) on 30 of 31 documented days. ~ In February of 2025, the freezer had a temperature above 0 degrees (with a highest recorded temperature of 28 degrees F) on 24 of 28 documented days. ~ In March of 2025, the freezer had a temperature above 0 degrees (with a highest recorded temperature of 24 degrees F) on 30 of 31 documented days. Microwave: The Wisconsin Food Code indicates at 3-403.11 Reheating for Hot Holding: .(B) Except as specified under (C) of this section, potentially hazardous food (time/temperature control for safety food) reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 C (165 F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating . During a continuous kitchen observation that began at 11:31 AM on 4/1/25, Surveyor observed CK-F heat an uncovered container of spaghetti in the microwave for one minute. CK-F stirred and temped the spaghetti (which did not reach 165 degrees F) and heated the spaghetti for another minute. CK-F temped the spaghetti again (which did not reach 165 degrees F) and heated the spaghetti for another minute. CK-E then stirred and temped the spaghetti which was 165 degrees F. CK-E indicated the food was up to temperature and put the spaghetti on a tray for service. CK-E did not wait two minutes to ensure the covered spaghetti maintained a temperature of 165 degrees F. Surveyor then observed CK-E heat a bowl of green beans in the microwave for one minute and temp the beans which did not reach 165 degrees F. CK-E heated the beans in the microwave for another minute and temped the beans without stirring them. Surveyor noted the temperature was 167 degrees F. CK-E then put the beans on a tray for service. Surveyor also observed CK-E heat a container of covered soup in the microwave for one minute and temp the soup which reached 170 degrees F. CK-E then handed the soup to staff to serve to a resident. CK-E did not wait two minutes to ensure the covered soup maintained a temperature of 165 degrees F. On 4/1/25 at 2:10 PM, Surveyor interviewed EC-C and DD-D who confirmed staff did not microwave food during lunch service in accordance the Wisconsin Food Code. EC-C and DD-D indicated it was an unusual process for the cooks because the food is usually cooked in the microwave and held for service and a temperature is obtained when the food is served. EC-C and DD-D indicated due to new admissions that day and one resident ordering soup for a meal, staff did not follow the usual process for having all food cooked prior to service.

Based on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 2 residents (R) (R59 and R214) of 27 sampled residents. R59's MDS assessment, dated 3/14/25, inaccurately indicated R59 had an unhealed stage 3 pressure injury. R214 had a physician order for tramadol (an opioid medication used to treat moderate to severe pain). R214's MDS assessments, dated 3/9/25 and 3/25/25, did not indicate R214 received opioid medication. Findings include: 1. From 3/31/25 to 4/2/25, Surveyor reviewed R59's medical record. R59 was admitted to the facility on [DATE] and had a diagnosis of pulmonary embolism. R59's Admission MDS assessment, dated 3/14/25, indicated R59 had an unhealed stage 3 pressure injury. On 4/2/25 at 11:55 AM, Surveyor interviewed Clinical Nurse Coordinator (CNC)-O who confirmed CNC-O completed R59's Admission MDS assessment. CNC-O stated R59's hospital discharge paperwork indicated R59 had a pressure injury. CNC-O stated upon assessment of the pressure injury, staff determined the pressure injury was resolved. CNC-O acknowledged R59's Admission MDS assessment was coded inaccurately. 2. From 3/31/25 to 4/2/25, Surveyor reviewed R214's medical record. R214 was admitted to the facility on [DATE] and had a diagnosis of fracture of the left humerus. R214 had the following physician orders for opioid medication: ~ Hydrocodone-acetaminophen (Vicodin) 5-325 milligrams (mg). Give 1 tablet by mouth every 6 hours as needed. (Start date: 2/28/25; End date: 3/4/25) ~ Tramadol 50 mg. Give 1 tablet by mouth every 6 hours as needed. (Start date: 3/4/25; End date: 3/5/25) ~ Tramadol 50 mg. Give 1 tablet by mouth every 4 hours as needed. (Start date: 3/5/25; No end date) R214's Discharge-Return Anticipated MDS assessment, dated 3/9/25 and R214's Admission MDS assessment, dated 3/25/25, did not indicate R214 received opioid medication. On 4/2/25 at 12:00 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R214 was prescribed opioid medication and had taken the medication during the MDS assessment period. DON-B confirmed R214's MDS assessments should have been coded to indicate R214 received opioid medication.

Based on observation, staff and resident interview, and record review, the facility did not ensure the appropriate care and treatment was provided for 1 resident (R) (R11) of 27 sampled residents. R11 had a wound on the left great toe. Staff did not complete a wound assessment or provide appropriate care for the wound. In addition, R11 was not provided compression stockings as ordered and was not placed on enhanced barrier precautions (EBP) when the wound was discovered. Findings include: The facility's Pressure Injury Prevention and Management policy, revised 10/2024, indicates: .The goal is that all residents receive prompt assessment and treatment for all skin conditions .C. Ongoing Assessment for Risk of Wound Development: 1. Certified Nursing Assistants (CNAs) observe skin with all cares and report any concerns to the charge nurse. 2. Any patient/resident living with diabetes will have foot checks every evening by the CNAs or designee. 3. Charge nurses are to conduct thorough skin observations on a weekly basis . The facility's Use of Personal Protective Equipment (PPE) and Standard and Transmission-Based Precautions and Enhanced Barrier Precautions policy, revised 8/30/22, indicates: .7. Enhanced Barrier Precautions (EBP) are designed to prevent the spread of novel and targeted multidrug-resistant organisms (MDROs) to those who are at risk or susceptible .A susceptible and at-risk resident is anyone who: 1. Has a wound or skin opening that requires a dressing regardless of any known MDRO colonization status of that resident .B. High-contact activities that require EBP to be used to protect susceptible or at risk residents: 1. dressing. 2. bathing/showering .8. wound care .Gloves and gown are worn during high-contact activities with those residents who are susceptible or at risk of infection . From 3/31/25 to 4/2/25, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease and polyneuropathy, age-related bilateral nuclear cataracts, hemiplegia and hemiparesis following cerebrovascular disease, and abnormalities of gait and mobility. R11's Minimum Data Set (MDS) assessment, dated 3/19/25, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R11 had severely impaired cognition. On 3/31/25 at 1:25 PM, Surveyor interviewed R11 who indicated R11 had an open sore on the left great toe. R11 stated R11 reported the wound to an unidentified female staff earlier that day and a staff applied ointment and a bandage. R11 indicated R11 was worried about the wound because R11 had toe ulcers in the past and almost lost two toes. Surveyor noted there was not an EBP sign on or near R11's door. R11's care plan contained an intervention to check R11's body for breaks in skin and treat promptly as ordered by the physician (initiated 9/20/24). R11's care plan did not include interventions for the toe wound or EBP. R11's medical record did not contain progress notes regarding the wound, wound assessments, or orders for wound care or EBP. In addition, there was no documentation that staff applied ointment and a bandage to R11's left great toe on 3/31/25. R11's Medication Administration Record (MAR) and Treatment Administration Record (TAR) contained orders for compression stockings 15-20 millimeters of mercury (mmHg) on in AM and off in PM. On 4/1/25 at 8:00 AM and 11:19 AM, Surveyor noted there was not an EBP sign on or near R11's room. On 4/1/25 at 11:31 AM, Surveyor interviewed Clinical Services Coordinator (CSC)-R and Infection Preventionist (IP)-K who indicated EBP should be initiated for any resident with an indwelling medical device or wound. IP-K indicated EBP should be implemented as soon as the reason for EBP is discovered. IP-K indicated EBP should be added to the resident's care plan and CNA pocket notes and an EBP sign should be posted at the resident's room entrance. IP-K indicated IP-K had walked the hall at approximately 10:00 or 10:30 AM and posted any missing signs for residents who should be on EBP. On 4/1/25 at 1:20 PM, Surveyor interviewed Wound Care Nurse (WCN)-Q who indicated WCN-Q had not seen R11 because R11 was not on WCN-Q's list of residents with wounds. WCN-Q indicated if staff discover a wound on a resident, they should complete a new wound note by completing a skin incident report. WCN-Q indicated the incident report is sent to the supervisor and the Director of Nursing (DON) who email the wound team. WCN-Q indicated WCN-Q assesses residents noted to have wounds or skin concern. WCN-Q reiterated WCN-Q did not have any new wounds to see other than a resident who was not R11. WNC-Q confirmed residents with wounds should be placed on EBP. On 4/1/25 at 2:05 PM, Surveyor interviewed R11 who indicated no one looked at R11's toe that day which still contained a bandage from the day before. On 4/2/25 at 7:38 AM, Surveyor noted there was not an EBP sign on or near R11's door. On 4/2/25 at 7:43 AM, Surveyor interviewed R11 who indicated R11 received a shower that morning. R11 indicated no one checked on R11's toe wound since the bandage and ointment were applied on 3/31/25. R11 indicated the staff who gave R11 a shower did not remove the bandage. R11 indicated R11 still had a wet bandage on the toe and no one had assessed the wound. R11 indicated R11 did not have much feeling in R11's toes so the wound did not hurt. R11 was concerned due to previous injuries from R11's shoes. R11 indicated R11's wounds did not heal well. R11 indicated R11 had not seen the wound since the bandage was applied. On 4/2/25 at 7:49 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-P who was not aware of R11's toe wound. LPN-P reviewed R11's medical record and indicated R11 did not have any wounds. Surveyor informed LPN-P that R11 had a toe wound with ointment and a bandage applied on 3/31/25 that was not assessed during R11's shower that morning. R11 walked down the hall at that time and confirmed what Surveyor had stated. When LPN-P asked R11 if a family member applied the bandage, R11 stated twice that a staff applied the bandage. LPN-P asked to see the wound and removed R11's shoe, sock, and bandage. Surveyor noted R11 was not wearing compression stockings. LPN-P and Surveyor observed an open wound on the front underside of R11's great toe. The skin surrounding the wound was moist and white. LPN-P cleaned the wound and applied a new dressing. LPN-P indicated LPN-P would notify the wound care team to assess the wound and determine treatment. On 4/2/25, Surveyor reviewed R11's TAR and noted LPN-P initialed at 7:29 AM that LPN-P put compression stockings on R11. Surveyor reviewed CNA task charting and noted CNA staff initialed nightly that they completed daily diabetic foot checks, including 3/31/25 and 4/1/25. No new skin issues were noted on the CNA task foot checks. On 4/2/25 at 10:02 AM, Surveyor noted an EBP sign at the entrance to R11's room. On 4/2/25 Surveyor noted R11's care plan had been updated with new orders initiated on 4/2/25 that indicated R11 had an open wound on the toe and staff should use EBP during cares. On 4/2/25 at 10:04 AM, Surveyor interviewed LPN-P who reviewed R11's MAR and TAR and confirmed LPN-P initialed that R11's compression stockings were applied. LPN-P indicated LPN-P should not have initialed the task without applying compression stockings. LPN-P indicated a supervisor posted the EBP sign due to R11's toe wound. On 4/2/25 at 12:52 PM, Surveyor interviewed Infection Preventionist (IP)-K who indicated R11's wound should have been assessed and documented on 3/31/25 when R11 reported the wound to staff. IP-K indicated R11 should have been on EBP since the day the wound was discovered. IP-K indicated it was not acceptable for staff to leave the bandage on in the shower and not inform the nurse that wound care needed to be completed. IP-K indicated there was a concern that R11's daily diabetic foot checks were not being done or accurately documented. IP-K indicated it is not acceptable for staff to document that R11's compression stocking were applied if they were not. IP-K agreed if staff followed the facility's protocol, addressed R11's wound, accurately completed diabetic foot checks, showers, and wound care, and ensured compression stockings were applied, R11 would have received appropriate care days before Surveyor alerted staff of R11's toe wound. On 4/2/25 at 1:15 PM, Surveyor interviewed DON-B who indicated a resident with a wound should be on EBP that is enacted immediately. DON-B indicated R11's wound should have been addressed on 3/31/25 when R11 reported the wound to staff. DON-B indicated R11 should have been placed on EBP and staff should have notified the wound care nurse to initiate a wound care plan. DON-B indicated R11's wound could be precarious because R11 was diabetic. DON-B indicated it is not acceptable for staff to document that tasks are completed when they have not been completed.

Based on staff interview and record review, the facility did not provide the necessary respiratory care and services for 3 residents (R) (R25, R29, and R13) of 3 sampled residents. R25 and R29's plans of care did not indicate R25 and R29 received oxygen therapy and did not contain orders to change R25 and R29's oxygen tubing. R13's plan of care did not indicate R13 received oxygen therapy. Findings include: The facility's Oxygen Storage, Transportation, and Administration policy, dated 2/21/24, indicates: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . The National Library of Medicine, Nursing Fundamentals (2021) indicates: .Goals, expected outcomes, and nursing interventions are documented in the patient's nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care . Found at https://www.ncbi.nlm.nih.gov/books/NBK591807/ 1. From 4/1/25 to 4/2/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including COVID-19, pulmonary fibrosis, sleep apnea with use of continuous positive airway pressure (CPAP) machine at night, and insomnia. R25's Minimum Data Set (MDS) assessment, dated 3/13/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R25 was not cognitively impaired. R25's plan of care did not indicate R25 received oxygen therapy. R25 did not have an order to change R25's oxygen tubing. Neither R25's Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicated R25's oxygen tubing was changed or scheduled to be changed. On 4/2/25 at 11:23 AM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A who indicated oxygen therapy should be identified on R25's care plan. DON-B indicated R25 should have an order to change R25's oxygen tubing. 50988 2. From 3/31/25 to 4/2/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including Lewy body dementia, acute respiratory failure, and dependence on supplemental oxygen. R29's MDS assessment, dated 3/3/25, had a BIMS assessment completed by staff and indicated R29 was unable to answer questions. R29's medical record did not contain a care plan for oxygen therapy. In addition, R29's medical record did not contain an order to change R29's oxygen tubing. On 4/1/25 at 1:00 PM, Surveyor interviewed DON-B who indicated an order to change oxygen tubing should be in place for all residents who use oxygen. DON-B verified R29 did not have an order to change R29's oxygen tubing. DON-B also indicated residents who receive supplemental oxygen should have a care plan for oxygen therapy. DON-B verified R29 did not have a care plan for oxygen use. On 4/2/25, Surveyor noted R29's medical record contained an order to change oxygen tubing every Friday with a start date of 4/1/25. R29's medical record also contained a care plan for oxygen therapy with an initiation date of 4/1/25. On 4/2/25 at 8:43 AM, Surveyor interviewed Registered Nurse (RN)-N who indicated residents on oxygen should have their oxygen tubing changed when soiled or every 30 days which should be documented on the resident's MAR. RN-N verified the order to change R29's oxygen tubing was not initiated until 4/1/25. 48794 3. From 3/31/25 to 4/2/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including cerebral infarction, palliative care, congestive heart failure and supplemental oxygen. R13's MDS assessment, dated 3/18/25, had a BIMS score of 7 out of 15 which indicated R13 had severely impaired cognition. R13's care plan did not indicate R13 received oxygen therapy. On 4/2/25 at 11:23 AM, Surveyor interviewed DON-B and NHA-A who indicated oxygen therapy should be identified on R13's care plan.

Based on observation, staff 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 2 residents (R) (R25 and R16) of 27 sampled residents. R25 was on airborne precautions (used to prevent the spread of germs through the air). Following the provision of care on 4/1/25, Certified Nursing Assistant (CNA)-L and CNA-M removed their N95 masks (used to filter out viruses in the air) prior to leaving R25's room. R16 had a catheter and was on enhanced barrier precautions (EBP). On 4/1/25, CNA-I and CNA-J did not wear gowns during high-contact resident cares. Findings include: The facility's Use of Personal Protective Equipment and Standard and Transmission Based Precautions and Enhanced Barrier Precautions policy, revised 8/30/22, indicates: .Airborne precautions are used for patients known or suspected to be infected with microorganisms that spread over long distances while suspended in the air .Personal protective equipment (PPE) use - a surgical mask and face shield or N95 .7. Enhanced Barrier Precautions (EBP) are designed to prevent the spread of novel and targeted multidrug-resistant organisms (MDROs) to those who are at risk or susceptible .A susceptible and at-risk resident is anyone who: 1. Has a wound or skin opening that requires a dressing regardless of any known MDRO colonization status of that resident .B. High-contact activities that require EBP to be used to protect susceptible or at risk residents: 1. dressing. 2. bathing/showering .8. wound care .Gloves and gown are worn during high-contact activities with those residents who are susceptible or at risk of infection . 1. On 4/1/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including COVID-19, bilateral hip osteoarthritis, pulmonary fibrosis, insomnia, and muscle weakness. R25's Minimum Data Set (MDS) assessment, dated 3/13/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R25 was not cognitively impaired. On 4/1/25 at 12:17 PM, Surveyor observed an airborne precautions sign on R25's door and a PPE cart that contained N95 masks, gowns, goggles and gloves outside R25's room. The airborne precautions sign indicated an N95 mask should be applied prior to entering R25's room and should be removed after exiting the room. Surveyor observed recommendations on top of the PPE cart that indicated staff should wear a gown, gloves, goggles, and an N95 mask when entering R25's room. Surveyor observed CNA-L and CNA-M complete hand hygiene and don gowns, goggles, and gloves prior to entering R25's room. On 4/1/25 at 12:33 PM, Surveyor observed CNA-L and CNA-M exit R25's room without any PPE, including N95 masks. On 4/1/25 at 12:33 PM, Surveyor interviewed CNA-L who indicated the N95 mask was the last thing CNA-L removed before leaving R25's room. CNA-L verified the airborne precautions sign on R25's door indicated CNA-L should not remove the mask prior to exiting R25's room. On 4/1/25 at 12:35 PM, Surveyor interviewed CNA-M who indicated the N95 mask was the last thing CNA-M removed prior to exiting R25's room. CNA-M verified the airborne precautions sign on R25's door indicated CNA-M should not remove the mask prior to exiting R25's room. On 4/1/25 at 12:53 PM, Surveyor interviewed Infection Preventionist (IP)-K who indicated CNA-L and CNA-M should have removed their N95 masks after exiting R25's room. On 4/2/25 at 10:04 AM, Surveyor interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A who both indicated staff should remove N95 masks after exiting the room of a resident who is on airborne precautions. 50988 2. From 3/31/25 to 4/2/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including supranuclear palsy, Parkinson's disease, and obstructive uropathy. R16's MDS assessment, dated 4/25/23, had a BIMS score of 15 out of 15 which indicated R16 was not cognitively impaired. On 4/1/25 at 9:10 AM, Surveyor observed an EBP sign posted outside R16's room and observed CNA-I and CNA-J transfer R16 to bed via sit-to-stand lift. Surveyor noted CNA-I and CNA-J did not wear gowns during the transfer as required for high-contact resident care. CNA-I then emptied urine from R16's catheter drainage bag into a urinal. CNA-I and CNA-J then completed peri-care for R16 who was incontinent of stool, changed R16's brief, and repositioned R16 without wearing gowns. On 4/1/25 at 9:27 AM, Surveyor interviewed CNA-I and CNA-J who acknowledged CNA-I and CNA-J should have worn gowns when completing peri-care, emptying R16's catheter bag, and transferring R16 to bed. CNA-I and CNA-J verified R16 was on EBP and had an EBP sign outside R16's room. On 4/1/25 at 2:57 PM, Surveyor interviewed DON-B who confirmed staff should wear gowns and gloves during high-contact cares for a resident on EBP. DON-B confirmed peri-care, emptying a catheter bag, and transferring a resident were considered high-contact resident cares.

Based on staff interview and record review, the facility did not ensure an allegation of misappropriation was reported to the State Agency (SA) for 1 resident (R) (R3) of 2 sampled residents. On 8/8/24, R3 alleged Certified Nursing Assistant (CNA)-C took R3's Fentanyl patch. The allegation of misappropriation was not reported to the SA. Findings include: The facility's Resident Protection and Prevention and Investigation of Abuse, Neglect, Misappropriation, Exploitation, Caregiver Misconduct, and Injuries of Unknown Source policy, revised 10/2022, states all associates are to immediately report any incident of misconduct, which includes abuse, neglect .misappropriation of a client's property. Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. The Nursing Home Administrator (NHA) should submit the initial report to the Division of Quality Assurance (DQA) Office of Caregiver Quality (OCQ) within 24 hours, as well as the local police in the event that a potential crime occurred. On 9/26/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including prostate cancer, anxiety, depression, and hypertension. R3's most recent Minimum Data Set (MDS) assessment, dated 8/2/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R3 had moderate cognitive impairment. R3 passed away at the facility with Hospice services on 9/9/24. On 9/26/24 at 10:01 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E regarding an allegation that R3 had a missing Fentanyl patch. LPN-E verified there was a time in August when R3's Fentanyl patch was missing. LPN-E stated LPN-E reported the missing patch to LPN-E's supervisor immediately. On 9/26/24, Surveyor reviewed the facility's investigation for the allegation of misappropriation. The investigation indicated NHA-A was notified by Nurse Manager (NM)-F around midnight on 8/9/24 that R3's Fentanyl patch was missing. The patch was verified to be in place by two staff between the PM and night (NOC) shifts. Around midnight, Registered Nurse (RN)-G went to verify R3's patch placement and noticed the patch was missing. RN-G immediately reported the missing patch to NM-F. NM-F and RN-G went to R3's room to verify the patch was missing. When asked about the patch, R3 stated, She took it off. The one I've never seen before. NM-F then notified NHA-A. NM-F gathered all staff on the unit and brought them into R3's room to see if R3 recognized any of them as the staff who took R3's Fentanyl patch. RN-G recalled that CNA-C had been on the unit for a period of time despite being assigned to a different wing. NM-F brought CNA-C into R3's room to see if R3 recognized CNA-C. R3 stated, I am sorry, I don't recall. NM-F left the room to find RN-G and CNA-C returned to CNA-C's unit. NM-F and RN-G returned to R3's room and noticed the Fentanyl patch was back on R3's chest and was sticking out of R3's gown. R3 stated CNA-C was the one who took the patch off and then put it back on. NM-F verified with R3 that CNA-C was the staff who took R3's Fentanyl patch off and then put it back on and R3 agreed. NM-F updated NHA-A about the suspicion that CNA-C took R3's Fentanyl patch and then returned it. NHA-A and NM-F asked CNA-C about the allegation and CNA-C denied it. CNA-C confirmed CNA-C had gone to R3's unit to help with linens. CNA-C was suspended pending further investigation and told CNA-C needed to submit to a drug test. CNA-C left the facility and resigned on 8/9/24. The local police department was notified of the allegation and a case number was assigned. NHA-A facilitated interviews with staff and residents, reviewed all residents for narcotic medications/patches, and provided education to staff on misappropriation and verifying patch placement. On 9/26/24 at 10:45 AM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B regarding R3's missing Fentanyl patch. NHA-A verified the allegation was not reported to the SA (DQA) because the patch was returned the same evening.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food was prepared, stored, and distributed which had the potential to affect 95 of 96 residents at the facility. One resident received nutrition via tube feeding. Food Storage -Surveyor observed multiple expired and unlabeled food and drink items, in the dry storage and cooler areas, available for service in the main floor kitchen. -Surveyor observed multiple expired and unlabeled food and drink items, in the dry storage and cooler areas, available for service in the prep kitchen. Dish Storage -Plastic drink pitchers were stored in a clean dish area below food items and contained food residue Findings include: On [DATE] at 8:51 AM, Surveyor met with Executive Chef (EC)-C to begin initial tour and review of the main level kitchen and preparatory kitchens. EC-C indicated that the facility followed ServSafe as the facility's standard of practice. According to Servsafe Essentials: Fifth Edition (2008), under the section titled Labeling: Label all TCS (temperature control for safety), ready-to-eat food prepped in-house that you have held for longer than 24 hours. The label .must include the name of the food and the date by which it should be sold, eaten, or thrown out. The facility policy titled Food Storage, with a revised date of [DATE], states: 4. All items are stored with a discard date indicated on the storage container. 5. When an item is removed from the original container each individual item needs to be labeled with the discard date .d. Remove and discard food that is spoiled or has been stored past the recommended storage time 1. On [DATE] at 8:51 AM, Surveyor conducted initial tour of the main level kitchen and main level kitchen food storage areas. Surveyor observed and EC-C verified the following: Upright cooler unit contained an opened bottle of nectar thick cranberry juice with an opened date of [DATE] and an opened bottle of thickened water that did not contain an open date or use-by date. Additionally, the cooler contained an opened, one gallon container of two percent milk with a best by date of [DATE] and an opened, one gallon container of fat free milk with a best by date of [DATE]. Neither milk gallon was labeled with an opened date. Walk-in cooler contained twenty-one orange, Mighty-brand shakes which did not contain pull or use-by dates. The Mighty shakes contained direction to keep frozen or use within fourteen days after thawing. The walk-in contained three honey consistency Mighty Shakes with use-by dates of [DATE]. Surveyor also observed four gallons of fat-free milk with best-by dates of [DATE]. Dry storage area contained nine boxes of Quaker-brand Cream of Wheat with use-by dates of [DATE]. Additionally, twelve boxes of Uncle Ben-brand Cream of Rice with use-by dates of [DATE] were located on the shelf available for use. On [DATE] at 9:23 AM, Surveyor conducted initial tour of the prep kitchen and prep kitchen food storage areas. Surveyor observed and EC-C verified the following: Bulk storage bin in the prep kitchen contained an opened bag of devil's food cake mix with no open date. Surveyor noted brown crumbs of cake mix residue outside of the opened bag, inside the bulk storage bin. Walk-in cooler area contained one, Log Cabin-brand syrup bottle without an open date. Additionally, Surveyor observed two opened bottles of barbecue sauce in the cooler area. Neither bottle of barbecue sauce contained an open date. Freezer area contained four styrofoam cups of icecream that were not marked with a date. On [DATE] at 9:25 AM, Surveyor interviewed Director of Nutrition Services (NS)-D related to observations from [DATE]. NS-D indicated that the expectation for dietary staff was to date items with an expiration date once they are opened. Additionally, NS-D explained that staff are expected to check product dates before use. 2. On [DATE] at 8:49 AM, Surveyor observed a storage shelf in the main level kitchen that contained both food products and clean dish storage. Surveyor noted containers of dry cereal were stored on shelving about drinkware. Surveyor observed three of the large, plastic drink pitchers stored on the shelf contained white and tan food particles. One of the three pitchers was stored upright on the shelf and Surveyor observed food particles on the interior surface of the drink pitcher. At 8:51 AM, when EC-C entered the main level kitchen for the initial tour. Surveyor interviewed EC-C related to the pitchers containing food residue. EC-C indicated that the pitchers had been previously cleaned and were stored for use. EC-C verified with Surveyor that the food stored above the clean dishes was a potential contamination source and that the pitchers needed to be cleaned again.

Based on record review and staff interview, the facility did not ensure that each resident (R) Minimum Data Set (MDS) assessment was coded and submitted accurately for 2 (R2 and R252) of 3 resident records reviewed for MDS errors. R2's MDS assessment record was over 120 days old and a Medicare 5-day assessment was completed but a Medicare Part A PPS (prospective payment system) Discharge Assessment was not completed. R252's MDS assessments contained errors that did not allow for successful transmission of MDS assessment since 1/2/21 (greater than 180 days prior to survey entrance). Findings include: 1. Page A-11 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (Version 1.17.1 dated October 2019) for A0310H indicated: Coding Instructions for A0310H, Is this a Part A PPS Discharge Assessment? Code 0, no: if this is not a Part A PPS Discharge assessment. Code 1, yes: if this is a Part A PPS Discharge assessment. A Part A PPS Discharge assessment (NPE Item Set) is required under the Skilled Nursing Facility Quality Reporting Program (SNF QRP) when the resident's Medicare Part A stay ends (as documented in A2400C, End Date of Most Recent Medicare Stay) but the resident remains in the facility. If the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or one day before the discharge date (A2000), the OBRA (Omnibus Budget and Reconciliation Act) Discharge assessment and Part A PPS Discharge assessment are both required and may be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to the discharge date (A2000). Coding instructions for A2400 on page A-36 of manual indicated: The End Date of the Most Recent Medicare Stay (A2400C) may be earlier than the actual discharge date (A2000) from the facility. If this occurs, the Part A PPS Discharge assessment is required. If the resident subsequently physically leaves the facility, the OBRA Discharge assessment would be required. If the End Date of Most Recent Medicare Stay (A2400C) occurs on the day of or one day before the discharge date (A2000), the OBRA Discharge assessment and Part A PPS Discharge assessment are both required and may be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to the discharge date (A2000). On 2/7/22, R2's MDS triggered the Resident Assessment task as part of the Long Term Care Survey Process (LTCSP). R2's MDS assessment record was noted to be over 120 days old. On 2/8/22, Surveyor reviewed the closed health record for R2. R2 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/8/22 at 9:33 AM, Surveyor interviewed MDS Registered Nurse (RN)-G related to R2's MDS assessment. RN-G explained that RN-G was typically responsible for MDS coordination and planning on the COR (Center of Rehabilitation) unit but that R2's 5-day Medicare and Discharge Assessments were completed while RN-G was on vacation. RN-G verified that R2 entered the facility on 8/17/21, had a 5-day assessment completed 8/23/21, and discharged [DATE] having a Discharge-Return Not Anticipated assessment completed the same day. Surveyor asked RN-G if the box on R2's Discharge Assessment, at A0310H, should have been marked to indicate a PPS Discharge Assessment had also been completed. RN-G explained that R2's MDS assessments had transmitted and been accepted on 9/1/21. RN-G explained that the MDS assessment would not lock or complete if there was a validation error. Surveyor reviewed R2's information in the electronic medical record which indicated R2's payor source as Network Health PDPM with an active billing date of 8/17/21 and a stop date of 8/23/21. Notice of Medicare Non-Coverage documentation in R2's record indicated that services for R2 would end 8/22/21. On 2/8/22 at 11:38 AM, Surveyor contacted the State of Wisconsin MDS Education Coordinator via email. To verify R2's MDS was incomplete/over 120 days old. The Wisconsin MDS Education Coordinator confirmed and also provided Surveyor with a copy of the facility's missing OBRA assessment report (including assessment missing for greater than180 days). Surveyor noted that four additional closed record residents were included on the report. On 2/8/22 at 3:58 PM, Surveyor met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B related to the facility MDS submission and accuracy process. DON-B indicated that the MDS process at the facility had recently changed. Whereas the Director of Rehab was previously responsible for scheduling MDS assessment, now, different MDS coordinators set the schedules for the different, respective resident units. Surveyor asked how the DON-B ensures the accuracy or timeliness of assessments, DON-B explained that DON-B follows the resident assessment critical element pathway but does not pull any additional MDS reports. At this time, Surveyor made NHA-A and DON-B aware of the four additional closed record OBRA MDS assessments that had not submitted in 180 days as per the report run by the Wisconsin State MDS Coordinator. On 2/9/22 at 8:30 AM, Surveyor followed-up with NHA-A and DON-B related to MDS assessments. NHA-A indicated that the error with R2's MDS assessment had been identified and RN-G would update the MDS as applicable. DON-B indicated that the facility was now implementing a process to identify missing assessments or potential software issues related to the MDS. 2. On 2/8/22, Surveyor reviewed the health record for R252 as part of the LTCSP Resident Assessment task. Surveyor noted R252 was missing submitted OBRA assessments for greater than 180 days yet still resided in the facility. R252 admitted to the facility 6/25/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/8/22 at 3:58 PM, Surveyor met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B related to the facility MDS submission and accuracy process. DON-B indicated that the MDS process at the facility had recently changed. Whereas the Director of Rehab was previously responsible for scheduling MDS assessment, now, different MDS coordinators set the schedules for the different, respective resident units. Surveyor asked how the DON-B ensures the accuracy or timeliness of assessments, DON-B explained that DON-B follows the resident assessment critical element pathway but does not pull any additional MDS reports. At this time, Surveyor made NHA-A and DON-B were made aware that the last accepted MDS OBRA assessment record in the state system for R252 was from 1/2/21. On 2/9/22 at 8:30 AM, Surveyor followed-up with NHA-A and DON-B related to MDS assessments. NHA-A indicated that the error with R252's MDS assessment had been identified and RN-G would update the MDS as applicable. DON-B indicated that the facility was now implementing a process to identify missing assessments or potential software issues related to the MDS. DON-B also provided Surveyor with an MDS 3.0 Assessment History Report which showed R252's MDS assessments from 4/4/21, 6/8/21, 9/8/21, and 12/9/21 had been completed but never accepted into the system. DON-B indicated that the facility was now aware of their ability to view the Accepted Date column of the report. Under the section, Monitoring the Quality of Care, the RAI manual states: MDS assessment data are also used to monitor the quality of care in the nation's nursing homes. MDS-based quality measures (QMs) were developed by researchers to assist: (1) State Survey and Certification staff in identifying potential care problems in a nursing home; (2) nursing home providers with quality improvement activities/efforts; (3) nursing home consumers in understanding the quality of care provided by a nursing home; and (4) CMS with long-term quality monitoring and The State Operations Manual, devised by CMS, further explains that MDS information serves as the clinical basis for care planning and care delivery and provides information for Medicare and Medicaid payment systems, quality monitoring and public reporting. MDS information as it is reported impacts a nursing home's payment rate and standing in termsof the quality monitoring process.

Based on observation, record review, and staff interview, the facility did not ensure the provision of pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident (R) for one (R21) of one sampled residents. R21 did not receive morning insulin of 5 units and received 7 units as ordered by the physician. Findings include: R21 was diagnosed with type II diabetes mellitus (DM) and was insulin dependent to manage blood sugar (BS) levels. On 2/8/22, Surveyor review the facility policy which indicated 10. Insert the insulin pen needle, 11. Prime pen with 2 units of insulin, 12. Re-check that the amount of insulin drawn into the syringe matches the amount of insulin ordered . On 2/8/22, Surveyor reviewed physician orders that indicated (Insulin [MEDICATION(S)]) inject 5 units subcutaneously in the morning for DM may hold insulin before meals if BS is less than 100, or eats less than 50%. On 2/8/22 at 9:10 AM, Surveyor inspected [MEDICATION(S)] insulin pen after Licensed practical nurse (LPN)-H applied needle and drew up insulin, the insulin pen read 7 units. Surveyor asked what the LPN-H did to prime the pen and LPN-H told the surveyor that 2 of the 7 units were used to prime the needle. Surveyor asked the LPN-H if that was the facility policy to draw up two extra unit to use for priming and LPN-H responded that is was the way LPN-H has always completed the task and 2 units will stay in the needle. On 2/8/22, Surveyor observed LPN-H give 7 units of [MEDICATION(S)] insulin into the left leg of R21. On 2/8/22 at 9:22 AM, Surveyor interviewed Director of Nursing (DON)-B regarding policy how to use an insulin pen. It was determined drawing up 2 units then wasting the 2 units happens before drawing up the physician ordered amount. Surveyor reproted observation to DON-B. On 2/8/22, Surveyor reviewed R21's nursing progress notes that documented notification to the Nurse Practitioner and the Power of Attorney for Health Care of insulin incident. No new orders were received. On 2/9/22, Surveyor reviewed R21's blood sugar monitoring records that listed blood sugars as the following: 2/9/2022 11:33 AM 379.0 2/9/2022 7:32 AM 138.0 2/8/2022 6:50 PM 226.0 2/8/2022 4:11 PM 133.0 2/8/2022 11:50 AM 421.0 2/8/2022 8:10 AM 172.0

Based on observation, record review and staff interview, the facility did not establish and maintain an Infection Control Program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 2 Residents (R) (R72 and R21) of 9 sampled residents during the observation of cares and catheter care. During the provision of cares for R72 the CNA (Certified Nursing Assistant) did not properly sanitize hands. The facility did not provide proper infection control techniques for R21's catheter bag that was not kept off the floor. Findings include: R72 was admitted to facility on 3/30/21 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R72's MDS (Minimum Data Set) dated 12/31/21 indicates that R72 requires total dependence for transfers, hygiene, bed mobility, bathing and dressing. On 2/8/22 at 10:16 AM Surveyor observed cares with R72. CNA-E donned new gloves but did not sanitize hands, CNA-F sanitized hands then donned new gloves. CNA-E and CNA-F pulled back R72's covers, removed heel lift and side pillows. CNA-E removed front of R72's brief and pushed brief down in between R72's legs. CNA-E wiped peri area front to back with a clean wipe, then wiped again with a clean wipe. CNA-E and CNA-F assisted R72 to her right side. CNA-E then with the same gloved hands removed soiled brief from underneath R72. CNA-E then wiped buttocks area front to back with a clean wipe, then again front to back with a clean wipe. CNA-E then touched new brief and put underneath R72. CNA-E at this time removed gloves but did not wash or sanitize hands. CNA-E then touched the side of resident and assisted R72 onto her back. CNA-E then with the same unsanitized hands assisted R72 with putting on a new brief, then put on new socks and pants. CNA-E then with the same unsanitized hands touched R72's pillows and heel lift. CNA-E then went to get lift for R72 and at this time sanitized hands before leaving the room. On 2/8/22 at 10:30 AM Surveyor interviewed CNA-E. CNA-E verified that she did not sanitize hands before donning gloves and after removing gloves. CNA-E also verified continuing with cares and not sanitizing hands. CNA-E did indicate that the facility does train and teach to sanitize hands before and after removing gloves after peri care. Finding included: Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's Minimum Data Set (MDS) assessment dated [DATE] stated R21's Brief Interview for Mental Status (BIMS) score was 5 out of 15 which indicated R21 had severe cognitive impairments. Surveyor reviewed R21 medical records which showed no evidence of intervention to prevent R21 from pulling or stepping on catheter tubing and bag. On 2/7/22 at 9:12 AM, Surveyor observed R21 catheter bag and tubing on the floor under the wheel chair. The catheter bag did not have a dignity cover over it. On 2/7/22 at 11:09 AM, Surveyor observed catheter bag and tubing on the floor under R21 wheel chair and R21 was standing on the tubing. On 2/8/22 at 7:48 AM, Surveyor observed catheter bag on the floor under R21 wheel chair and R21 was stepping on top of the catheter bag. On 2/8/22 at 7:56 AM, Surveyor observed R21 holding catheter tubing and lifting catheter bag off the floor while R21 was sitting in the wheel chair On 2/8/22 at 8:36 AM, Surveyor observed catheter bag on the floor under R21 wheel chair and R21 was stepping on top of the catheter bag. On 2/08/22 at 9:34 AM, Surveyor interviewed LPN-H who confirmed there were no active intervention to prevent R21 from pulling on catheter or stepping on catheter. On 2/08/22 at 12:26 PM, Surveyor interviewed NHA-A and DON-B who confirmed that interventions were not listed in R21 plan of care.

Based on observation, interview, and record review, the facility did not ensure that 1 Resident (R) (R1) of 3 residents reviewed had adequate supervision to prevent accidents during mechanical lift transfers. On [DATE], a Certified Nursing Assistant (CNA) attempted to transfer R1 from a shower chair to R1's bed with a Hoyer, full-body mechanical lift without a second staff member to assist as directed in R1's care plan. R1 fell to the floor from the lift sling and sustained subarachnoid and subdural hemorrhages (bleeding in the space between the brain and the surrounding brain membranes) from the fall. R1 was transferred to the hospital and expired three days later on [DATE] due to the brain bleed sustained in the fall. The facility's failure to ensure R1 received adequate staff supervision to prevent accidents created a finding of Immediate Jeopardy (IJ), which began on [DATE] when R1 fell to the floor from a lift sling during transfer and sustained injury. Nursing Home Administrator (NHA)-A was formally notified on [DATE] at 4:00 PM that an IJ situation existed. The IJ was removed on [DATE] and corrected on [DATE]. The deficient practice is being cited as past noncompliance. Findings include: According to the Center for Disease Control (CDC), Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas. According to the CDC, falls are the most common cause of traumatic brain injuries; traumatic brain injury accounts for 46% of fatal falls among older adults (those 65 or older). Among older adults, falls are the leading cause of injury death and are the most common cause of nonfatal injuries and hospital admissions for trauma. The CDC notes that in 2008, over 19,700 older adults died from unintentional fall injuries. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html. On [DATE], Surveyor reviewed R1's medical record. R1 was 88-years-old and admitted to the facility on [DATE] from an assisted-living facility due to increased falls. R1 had diagnoses to include spondylolysis (crack or stress fracture in one of the vertebrae), generalized muscle weakness, cognitive communication deficit, history of falls, and difficulty walking. R1's Minimum Data Set (MDS) assessment, dated [DATE], documented R1's Brief Interview for Mental Status (BIMS) score was 13 out of 15, indicating R1 was cognitively intact. R1 did have a legal decision-maker in place as outlined in R1's cognition care plan, because R1 was alert and cognitively intact with periods of confusion. MDS assessment also documented, in Section G: Functional Status, that R1 required extensive, physical assistance of two staff for transfers. The Physical Therapy Plan of Care, dated [DATE], documented that R1 was non-ambulatory and R1's safest transfer method was with an EZ stand (mechanical lift). The plan of care further noted that R1 had difficulty holding onto the EZ stand handle. Surveyor reviewed a nursing progress note from [DATE] at 9:00 AM which stated, Current status: Pt (patient) unsafe in EZ stand transfer. Pt needed to be lifted up in EZ stand physically by staff d/t (due to) being unable to hold onto handles or keep arms above strap. Pt changed to Hoyer lift. Therapy aware. Changed in pocket notes and in careplan. Review of a physical therapy note from [DATE] also documented the change to R1's transfer status and the use of a Hoyer lift transfer with assistance of two staff. R1's care plan, revised [DATE], indicated Help me transfer by 2A (two assist) hoyer transfer. The CNA pocket card (guide that staff reference which tells them how to care for residents) from [DATE], was reviewed and documented in the areas of transfer, toilet transfer, and clothing management and hygiene that R1 required assistance of two staff members with a Hoyer lift. The Facility-Reported Incident (FRI) submitted to the State office was reviewed, and the FRI documented that on [DATE] at approximately 5:00 PM, R1 had a witnessed fall to the floor from a sling during a full-body mechanical lift transfer in R1's room. Prior to the fall, CNA-C and CNA-D assisted R1 with transferring to a shower chair with a Hoyer mechanical lift. The care transfer sling was removed from underneath R1 prior to transport to the shower room. After R1's shower was completed, CNA-C brought R1 back to R1's room and turned on R1's call light to get help from another CNA to transfer R1 per care plan. However, when a second CNA did not arrive after a period of approximately five minutes, CNA-C placed a MedCare commode sling beneath R1 before commencing the lift transfer without assistance from a second staff member. CNA-C started to raise R1 with the Hoyer lift and slanted the lift towards the bed. R1's buttocks began to slip through bottom of the sling and R1 slid onto the floor, hitting the back of R1's head onto the floor. CNA-C activated the staff emergency light and Registered Nurse (RN)-E responded. RN-E assessed R1 for injuries. No pain or lacerations were noted. Vital signs and blood pressure were noted to be within normal range. Per a nursing note from [DATE] at 5:14 PM, R1 became nauseated and vomited. R1 was subsequently sent out to the hospital emergency room for further evaluation with R1's physician and Power of Attorney in agreement. On [DATE] at 12:57 PM, NHA-A confirmed with Surveyor that R1 had passed away at the hospital on [DATE]. The hospital discharge summary indicated that R1 had a fall while using a Hoyer lift. R1 was taken to an outside hospital emergency room (ER) where imaging revealed subarachnoid hemorrhage/subdural hemorrhage. R1 was transferred and admitted to another local hospital due to neurosurgical needs. R1's condition was noted to have continued to worsen. R1 was placed on inpatient hospice and passed away on [DATE] at 10:28 PM. The cause of death indicated on the hospital discharge summary was documented as intracranial hemorrhage. On [DATE] at 1:10 PM, Surveyor interviewed CNA-C related to the incident. CNA-C reiterated the incident as per the written statement in the FRI. CNA-C indicated that CNA-C waited about five minutes after placing R1's call light on for staff assistance. CNA-C expressed concern that R1 was becoming cold and indicated that CNA-C attempted to transfer R1 via the Hoyer lift independently without help from a second staff member. CNA-C explained that CNA-C knew R1 needed two staff members for transfers. CNA-C confirmed with Surveyor that the pocket note instructions for R1 documented that R1 was to be transferred with a Hoyer lift and two staff member's assistance. When asked about training CNA-C had received in regard to pocket note instruction and full-body lifts prior to the incident, CNA-C indicated that CNA-C had attended a CNA meeting on [DATE]. Surveyor reviewed facility-provided documentation related to the [DATE] CNA meeting. Surveyor noted CNA-C had attended and signed on the meeting sign-in sheets. The meeting agenda contained the agenda item 8. Following care plans and pocket notes-Must be followed. Surveyor also reviewed CNA-C's Relias (online training module) training. CNA-C had completed module trainings on weightbearing and non-weightbearing transfer, stand pivot transfers, slideboard, and pivot disk transfers on [DATE]. The facility's failure to ensure R1 received the appropriate staff supervision during mechanical lift transfer created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. On [DATE], the facility recognized the deficient practice and took steps to correct the deficient practice and ensure compliance at the time of the FRI investigation survey. Based upon this determination, the IJ was removed on [DATE] and corrected on [DATE] as evidenced below: -On [DATE] at 2:39 PM, NHA-A indicated to Surveyor that immediately following the [DATE] incident, CNA-C had been provided education concerning care plans and pocket notes. NHA-A also indicated that CNA-C had been suspended from work pending the investigation before receiving formal termination on [DATE]. Surveyor reviewed signed statement from CNA-C related to the education on [DATE]. The statement also noted that CNA-C completed a return demonstration of the incident and received additional education related to slings, sling placement, and best practices such as two-person assistance with transfers. -Surveyor reviewed submitted documentation that all staff working on [DATE] were provided education that included following care plans, pocket notes, and requiring the use of two staff members for all lifts. -Facility performed a root cause analysis and developed a Plan for Continued Compliance, dated [DATE], that identified areas of concern. Facility documentation also made note of continuous and ongoing audits. - Formal education including following pocket notes and care plans as well as education on full body lifts was provided on [DATE] and [DATE]. -Surveyor reviewed competency sign-offs on mechanical lift and sling use that occurred on [DATE]. -On [DATE] Surveyor observed two mechanical lift transfers with no concerns. At 10:46 AM, Surveyor observed R2 transferred via Hoyer lift. Surveyor noted two staff assisted R2 with the transfer, and the appropriate sling size was used per the pocket note and care plan. At 10:57 AM, Surveyor observed R3 transferred via EZ stand lift. Surveyor noted two staff assisted R3 with the transfer, and the appropriate sling size was used per the pocket note and care plan. -On [DATE] at 12:22 PM, Surveyor interviewed R3 regarding mechanical lift use. R3 indicated that R3 always feels safe with transfers and reported that there are always two staff present for transfers. -On [DATE], Surveyor made continuous observations of staff utilizing pocket notes. -Sampled residents care plans were reviewed and found to be updated with transfer status and sling size per facility action plan.

Based on observation, interview, and record review, the facility failed to maintain an accurate inventory of N95 masks and ensure staff wore N95 masks per the CDC guidance during the care of two residents (R1 and R2) to prevent the spread of COVID-19. This had the potential to affect 20 residents residing in the facility's Poppy Path corridor and nine residents residing in the facility's center of rehabilitation unit at the time of the survey. Findings include: Review of the COVID-19 Nursing Home Dataset, dated 9/6/20, revealed the facility had self-reported a total of: 31 residents with confirmed COVID-19, three resident deaths from COVID-19, and 30 staff with confirmed COVID-19, retrieved from data.cms.gov on 9/22/20. According to the Centers for Disease Control's (CDC) Preparing for COVID-19 in Nursing Homes, updated 6/25/20, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on 9/18/20: .Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission .oResidents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown . 1. Observation on 9/17/20 at 12:50 pm, in the facility's COR (center of rehabilitation) unit, revealed Nurse Assistant (NA1) walking with R1 from R1's restroom to R1's recliner in her room. NA1 was wearing a gown, gloves, a surgical mask, and protective googles. NA1 was not wearing a N95 mask. During an interview on 9/17/20 at 12:50 pm, with the Assistant Director of Nursing (ADON), the ADON confirmed that R1 was readmitted to the facility from the hospital two days prior. When asked what personal protective equipment (PPE) the staff were wearing when caring for residents during the 14 days after readmission to the facility, the ADON stated the staff were wearing a gown, gloves, eye protection, and a surgical mask. The ADON then confirmed that staff does not wear a N95 mask when caring for residents unless the resident has a confirmed COVID-19 test result. Review of R1's Admission Summary, dated 9/15/20 at 9:20 pm, confirmed that R1 was readmitted to the facility on [DATE] after being hospitalized . 2. Observation on 9/17/20 at 10:33 am, in the facility's Poppy Path corridor, revealed R2's resident room door had signage indicating that R2 was on contact and droplet transmission based precautions. During an interview on 9/17/20 at 10:42 am, with the Registered Nurse (RN1), when asked about R2's transmission based precautions, RN1 stated, She (R2) is on droplet and contact precautions right now. She had one loose, watery stool (a potential symptom of COVID-19). A COVID swab (a test to determine if a resident is infected with COVID-19) was done today at 7 (am). When asked what PPE was being used by staff when caring for R2 while awaiting the results of COVID-19 testing, RN1 stated staff was using a gown, face shield, gloves, and surgical mask. RN1 then confirmed the staff did not use an N95 mask for the care of a resident until the resident has confirmed COVID-19. Review of R2's Nursing Note, dated 9/17/20 at 10:13 am, revealed Staff noted resident has had a loose stool on 9/16. Resident placed on droplet and contact precautions .COVID swab obtained and sent to lab . During an interview on 9/17/20 at 11:11 am, with RN2, when asked when staff would wear a N95 mask during the care of a resident, RN2 stated, Any time I was working the COVID unit. When I'm doing the COVID testing I would wear one then. If they (a resident) came up positive. If they (residents) are here (on a non-COVID-19 corridor of the facility) and they (residents) get a symptom we (staff) would have the surgical mask until they test positive and go to the COVID unit. RN2 then confirmed that staff would wear a surgical mask, not a N95 mask, when caring for residents with symptoms of COVID-19 while awaiting testing results. When asked how long it takes the facility to receive test results for COVID-19, RN2 stated test results were being received 24 to 48 hours after the test is collected. During an interview on 9/17/20 at 8:35 am, with the Administrator and the Director of Nursing (DON), when asked about the facility's PPE supply, the Administrator stated, It's good now. For a little while we had to use some cloth gowns. When asked about the facility's use of N95 masks, the Administrator and DON, stated that the facility staff was using N95 masks only when caring for residents with confirmed COVID-19. When asked if staff were wearing N95 masks when caring for residents that had been readmitted to the facility with in the last 14 days, the Administrator and DON stated that staff were using surgical masks when caring for these residents. 3. Review of the COVID-19 Nursing Home Dataset, dated 5/31/20 to 9/6/20, retrieved at data.cms.gov, revealed the facility self-reported that the facility had at least one week's supply of N95 masks each week during the reporting time period. Review of the facility's PPE Monitoring, dated 9/17/20, revealed the facility's Count Today of N95 masks was 780. Further review of the facility's PPE Monitoring revealed the facility had used none of the 780 N95 masks since 8/11/20. During an interview on 9/18/20 at 10 am, with the President/Chief Executive Officer (President/CEO), Administrator, DON, and Senior Director of Support Services, the President/CEO, via telephone, stated, Under normal circumstances I would be at the facility when a federal survey was there. When asked why the facility staff was not wearing N95 masks, per CDC guidance, when caring for readmitted residents during the 14 days after readmission and when caring for residents with symptoms while awaiting COVID-19 testing results, the President/CEO stated The DQA (Department of Quality Assurance), DHS (Department of Health Services), and DPH (Department of Public Health) have said we only need N95's with COVID positive residents during aerosolized procedures. So we (the facility staff) are going above and beyond by using the N95s with all COVID positive residents .If someone admits to us with a negative COVID test from the hospital their status is not unknown .We are still trying to understand our burn rate .We don't just slap an N95 on staff when someone has symptoms. The President/CEO then stated the facility cannot get any N95 masks. When asked if the facility's PPE Monitoring, dated 9/17/20, which stated the facility had 780 N95 masks, was accurate, the Director of Support Services, stated the facility's PPE monitoring was not correct. During an interview on 9/18/20 at 7:30 pm, with the President/CEO, Administrator, and DON, the Administrator stated that after reviewing the facility's supply of N95 masks 580 of the 780 N95 masks were not usable. When asked why the 580 N95 masks were not usable, the Administrator stated that some of the masks had valves and some were a duck mask that the facility had not been able to fit test the facility's staff for. When asked how long the facility had not been using N95 masks for readmitted residents on 14 day quarantine and residents with symptoms awaiting COVID-19 testing results, the Administrator stated Since June 12th following the memo from DQA (Department of Quality Assurance). When asked for evidence of the facility's attempts to procure additional N95 masks, the facility provided e-mails dated: 4/24/20, 8/19/20, 9/4/20, 9/10/20, 9/11/20, 9/14/20, and 9/18/20 (the day of the survey). Review of the e-mails, dated 9/18/20, revealed the facility was successful in finding a vendor to procure N95 masks from. During the same interview on 9/18/20 at 7:30 pm, with the President/CEO, Administrator, and DON, when asked why the facility did not make more attempts to procure N95 masks prior to September, the President/CEO stated, I'm not sure that there would be e-mails every time she (Purchasing Agent) shops with them. She (Purchasing Agent) has a relationship with the vendors. They (vendors) would let her know if they (vendors) have them (N95 masks). According to the CDC's Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/20, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html on 9/18/20, .Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE . According to the CDC's Preparing for COVID-19 in Nursing Homes, updated 6/25/20, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on 9/18/20: .Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices . Personal Protective Equipment (PPE): Perform and maintain an inventory of PPE in the facility. Identify health department or healthcare coalition contacts for getting assistance during PPE shortages. The Supplies and Personal Protective Equipment pathway in the NHSN LTCF COVID-19 Module can be used to indicate critical PPE shortages (i.e., less than one week supply remaining despite use of PPE conservation strategies). Monitor daily PPE use to identify when supplies will run low; use the PPE burn rate calculator or other tools. Make necessary PPE available in areas where resident care is provided. Consider designating staff responsible for stewarding those supplies and monitoring and providing just-in-time feedback promoting appropriate use by staff. Facilities should have supplies of facemasks, respirators (if available and the facility has a respiratory protection program with trained, medically cleared, and fit-tested HCP), gowns, gloves, and eye protection (i.e., face shield or goggles) . Review of the facility's Infection Control - COVID19 policy, revision date 8/22/20, revealed: .For a resident/patient with suspected, probable or confirmed COVID 19, immediate infection prevention and control measures will be put into place. Symptoms may vary in severity. For any suspected, probable or confirmed COVID19, the incident command team and Medical Director or backup Medical Director will complete an individual assessment based off of supply management and prevalence of COVID 19 in the community to ensure the resident/patient are placed in proper precautions, have proper PPE, and have proper placement within the facility . Supply Management 1. St. Paul Elder Services will monitor necessary supplies and equipment and will report to incident command on an as needed basis. 2. St. Paul Elder Services will document efforts to obtain necessary PPE and supplies needed. St. Paul Elder Services will take actions to mitigate any resource shortage and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible. 3. If we cannot obtain needed supplies and equipment from vendor: a. Contact the local and state public health agency. b. We would refer to CDC for guidance to optimize the current supply or identify the next best option . Review of the facility's Use of Personal Protective Equipment and Standard and Transmission Based Precautions and Enhanced Barrier Precautions policy, revision date, 5/2020, revealed: Purpose: It is best practice at St. Paul Elder Services (SPES) to utilize Standard and Transmission Based precautions based upon the circumstances, risk of exposure to body fluids and type of illness present. Body Fluids that are considered infectious at all times are blood and blood products, all body fluids, secretions and excretions except sweat, non-intact skin and mucous membranes. All Personal Protective Equipment (PPE) is available at all times for associates to use as indicated . Conservation of PPE - When there is a disruption of supply chain of PPE, as in the case of a pandemic illness, measures will be taken to conserve use of PPE. Guidance will be taken from the CDC, Wisconsin DPH, OSHA and manufacturers regarding appropriate actions at that time .

Based on observation, staff interview and record review, the facility did not ensure an Infection Control Program was maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for 2 of 3 residents (R); 1 of 1 resident (R24) observed during [MEDICAL CONDITION] care and 1 of 2 residents (R280) observed during contact precautions. LPN (Licensed Practical Nurse)-B did use appropriate hand washing technique and maintain sterile environment while providing [MEDICAL CONDITION] care for R24. R280 was admitted to the facility with[DIAGNOSES REDACTED] ([MEDICAL CONDITION], a bacteria that infects the colon) and was on contact precautions. PT (Physical Therapist)-C did not follow the posted contact precautions during a therapy session. Findings include: Facility policy; [MEDICAL CONDITION] Care for disposable cannulas, review date 12/2017, states; Procedure: 3. Wash your hands, put gloves on and organize all necessary equipment and supplies at the bedside, creating a sterile environment. 4. Maintaining sterility, place bowls and tray with supplies in separate locations on the bedside table. 5. Open sterile water . bowl. 6. Place cotton-tip .care tray. 7. Pick up a gauze pad with fingers of clean hand. 8. Stabilize the neck flange with dirty hand. 9. When removing the inner cannula, be sure and discard tube a. (Standard remove) 10. Discharge gauze. 11. Remove [MEDICAL CONDITION] dressing. 12. Hand hygiene and put on sterile gloves 13. Use the cotton swab or gauze 4x4 between [MEDICAL CONDITION] and the skin to clean the area around the stoma. Clean from stoma outward. This will .mucus. Do NOT insert cotton swab [MEDICAL CONDITION] or stoma. 14. Repeat using a clean cotton swab each time, until the area around the stoma and under [MEDICAL CONDITION] flange is clean. 15. Rinse the area using a fresh cotton swab dipped in clean sterile water or saline. 16. Use a dry gauze 4x4 to dry around stoma using gentle patting. 17. Slide inner cannula back [MEDICAL CONDITION] (keeping inner cannula sterile), using motion. 18. To reinsert in place. 19. Replace [MEDICAL CONDITION] dressing. 20. [MEDICAL CONDITION] if .clean technique. 21. Position resident so that they are comfortable. 22. Reassess respiratory .oximetry. 23. Discard all materials. 24. Perform hand hygiene. 25. Document procedure. Facility Hand Hygiene Policy, revised date 01/2017, states; Purpose: The purpose of this procedure is to provide guidelines to employee for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap arid water. If hands are not visibly soiled, use an alcohol-based rub for routinely decontaminating hands. General Guidelines: 1. A minimum of twenty (20) second hand washing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: a. When hands are visibly body fluids. b. After contact with blood, body fluids, secretions, mucous membrane, or non-intact skin. c. After handling items potentially contaminated with blood, body fluids, or secretions. f. If exposure to [MEDICAL CONDITION] is suspected or proven. 3. The use of gloves does not replace hand washing. 4. If hands are not visibly soiled, use an alcohol-based hand rub for all the following situations: b. Before direct contact with residents. c. Before donning gloves. d. Before performing any non-invasive procedures. e. Before medications. f. Before handling clean or soiled dressing, gauze pads, etc. g. Before moving from contaminated body site to a clean body site during resident care. h. After contact with resident's intact skin. i. After handling used dressings, contaminated equipment, etc. j. After contact with inanimate objects (e.g., medical equipment) in the immediate vicinity of the resident. k. After removing a glove. Steps in the Procedure: 1. Washing Hands a. Wet hands under running water. b. Dispense soap. c. Vigorously lather hands with .twenty (20) seconds. d. Rinse hands thoroughly . (20) seconds. e. Dry hands thoroughly with paper towels and the turn off faucets with a clean, dry paper towel. Facility [MEDICAL CONDITION] policy, revised date 11/16, states; Purpose: To provide guidelines for the care of persons with diarrhea associated with [MEDICAL CONDITION] (verified by culture or by evidence of positive cytotoxin assay) and to prevent transmission of [MEDICAL CONDITIONS] to others. A. General Measures 1. Prevention and control of [MEDICAL CONDITION] within St. Paul Elder Services should be identified as a resident safety measure. 2. St. Paul Elder Services follows Standard Precautions for all resident's blood, body fluids, excretions and secretions that are considered potentially infectious. Gloves are to be worn when handling feces or focally-contaminated articles or surfaces. 3. Residents with diarrhea associate with [MEDICAL CONDITION] will be placed on contact precautions. Contact precautions are to be kept in place until drug therapy is completed and diarrhea has ceased for an additional 48 hours. If resident admitted for 48 hours. 4. Residents who are considered .Contact precautions should be put into place while awaiting the results of the evaluation. 6. When residents have diarrhea or fecal incontinence, maintain hygiene and hydration. All focally-contaminated surfaces (including equipment, commodes, toilet, etc.) must be considered potentially infectious. Equipment should not be shared unless it is properly sanitized in between resident use. Toilet and commodes .resident use. 8. Soap and water are the preferred means of hand sanitation; the friction of the hand washing is necessary to remove the spores from hands. Alcohol based hand sanitizing products are not sporicidal. 1. On 4/5/18, the Surveyor reviewed R24's medical record, which included documentation that the resident was admitted to the facility with [DIAGNOSES REDACTED]. On 04/10/18 at 09:59 AM, the Surveyor observed LPN-B provide [MEDICAL CONDITION] care for R24. LPN-B washed hands then turned off water by touching the faucet handle directly with hand and dried hands with paper towel. Without wearing gloves, LPN-B set up a sterile field with supplies, replaced suction tubing on the suction machine, placed new suction tubing on a clean reusable washcloth. Without washing hands, LPN-B applied gloves and removed R24's trachea O2 mask, inner [MEDICAL CONDITION] cannula and cleansed the O2 mask of mucus. LPN-B then removed gloves and without cleansing/sanitizing hands, applied sterile gloves, removed R24's soiled [MEDICAL CONDITION] dressing and wiped the mucus of the [MEDICAL CONDITION] area and tip of trachea flange with a reusable washcloth. LPN-B removed gloves and washed hands. LPN-B then turned off the water by touching the faucet handle directly with hand and dried hands with paper towel. LPN-B applied sterile gloves and suctioned R24's tracheal secretions twice, placing the suction tubing on a clean wash cloth when done. Without changing gloves, LPN-B cleansed R24's trachea area and flange. While wearing the same soiled gloves, LPN-B applied a clean dressing under R24's trachea site and placed a clean washcloth under R24's trachea. LPN-B then disposed the soiled supplies from bedside table and straightened area, removed gloves and washed hands. At this time R24 then began coughing up mucus. Without wearing gloves, LPN-B gathered supplies and set up a new sterile field. Without cleansing/sanitizing hands, LPN-B applied sterile gloves, removed R24's trachea O2 mask, cleansed mucus from the washcloth that had been placed under R24's trachea with clean washcloth, wiped mucus from R24's chest, suctioned the trachea two more times, cleaned up the supplies, removed gloves and washed hands. Immediately following the above observation, the Surveyor interviewed LPN-B regarding R24's [MEDICAL CONDITION] care. LPN verified touching the faucet handle after washing hands and cross contaminating hands, before setting up the sterile field without applying gloves. LPN-B verified did not complete hand hygiene prior to applying sterile gloves and performing [MEDICAL CONDITION] care which is to be a sterile technique. LPN-B verified wearing soiled gloves when inserting the sterile inner cannula and applying the clean dressing. LPN-B indicated sterile gloves should be changed, per facility policy, whenever going from dirty to a clean task and verified not following the facility's policy while providing [MEDICAL CONDITION] care for R24. On 04/11/18 at 07:53 AM, the Surveyor interviewed DON (Director of Nursing)-A regarding the observation of [MEDICAL CONDITION] care for R24. DON-A indicated facility policy to use a clean paper towel to turn off faucet after a staff member washes their hands and hands should be washed/sanitized prior to applying sterile and clean gloves. In addition, DON-A indicated staff should washed/sanitized hands whenever going from dirty to clean. 2. On 4/5/18, the Surveyor reviewed R280's medical record. R280 was admitted to the facility with [DIAGNOSES REDACTED]. R280's Nursing progress note dated 4/8/2018 at 4:13 PM documented R280 continues on contact precautions for [MEDICAL CONDITION] DX (diagnosis). On 04/09/18 at 08:00 AM, the Surveyor observed R280 walking with PT-C to the therapy room. No PPE (Personal Protective Equipment) was being used by either PT-C or R280. R280 was observed seated on an exercise bike in the therapy room. On 04/09/18 at 08:45 AM, the Surveyor observed PT-C holding onto R280's gait belt walking in the direction of R280's room. PT-C and R280 entered the resident's room, PT-C removed the gait belt from R280's waist and at doorway of R280's room, PT-C used hand sanitizer to cleanse hands. PT-C did not wear any PPE while in R280's room. Immediately following the above observation, the Surveyor interviewed PT-C who verified no PPE was used during the therapy session. PT-C indicated would only use PPE if PT-C had taken R280 to the bathroom. PT-C verified only hand sanitizer was used to cleanse hands upon leaving R280's room. PT-C stated would use the gait belt (used on R280) with other residents. PT-C further stated, I guess I should wash it because he is on precautions. In the therapy room PT-C indicated would use wipes that contained bleach to wipe off the equipment (exercise bike) R280 used in therapy. PT-C showed the Surveyor a red container of disposable wipes that did not have bleach as a listed ingredient. PT-C then stated would use wipes with bleach. PT-C indicated the exercise bike had not been sanitized yet and verified leaving the therapy area before cleansing the exercise bike that R280 used. On 04/11/18 at 12:09 PM, PT-C approached the Surveyor and indicated would like to talk to the Surveyor about the above observation and interview. PT-C said, I think what I was trying to say I know that if I'm not toileting the resident (on precautions for [MEDICAL CONDITION]) I don't have to use all PPE and wasn't toileting R280. PT-C also said, I know R280 is cognitively aware, independently toilets self and (R280) washes (R280) hands appropriately. PT-C verified not having observations of R280 washing hands. PT-C verified seeing R280 for other therapy sessions and no PPE was worn during any of the sessions. PT-C indicated washes hands when returns to the therapy room when seeing a resident. PT-C also indicated typically would not leave the therapy area without cleaning the machines. On 04/11/18 at 08:05 AM, the Surveyor interviewed DON-A regarding R280. DON-A indicated would expect gloves to be worn, dedicated gait belt be used for only the resident on contact precaution, hands should be washed verses hand sanitizer and the exercise bike used with R280 should have been cleaned with disposable bleach wipe before the therapist left the therapy room. On 04/11/18 at 12:57 PM, the Surveyor interviewed COTA (Certified Occupational Therapist)-D regarding hand hygiene and sanitization of therapy equipment. COTA-D indicated sanitizes hands before and after therapy. COTA-D further indicated typically uses hand sanitizer to cleanse hands when entering and leaving a resident room, unless precaution indicate to wash hands. COTA-D indicated will clean machines used by residents prior to leaving the therapy room. On 04/11/18 at 01:00 PM, the Surveyor interviewed COTA-E regarding hand hygiene and sanitization of therapy equipment. COTA-E indicated sanitizes hands upon entering and leaving a room. COTA-E indicated usually does not bring residents who are on precautions to the therapy room. On 04/11/18 at 01:02 PM, the Surveyor interviewed OT (Occupational Therapist)-F regarding hand hygiene and sanitization of therapy equipment. OT-F indicated usually does not bring residents on precautions to the therapy room. OT-F further indicated typically uses soap and water to cleanse hands after contact with a resident. OT-F indicated would sanitize equipment before leaving the therapy room.

Based on observation, staff interview and record review, the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. The facility's practice had the potential to affect 124 out of 126 residents residing at the facility. ~ Wash temperatures in the mechanical dishmachine were below the Manufacturer's recommended 120 degrees F (Fahrenheit) in the kitchen located on the same level of the nursing home adjacent to the dining room. ~ The facility had not been using the appropriate chemical test strips since 2/1/17, as the facility was using a test strip to measure the parts per million of quaternary instead of chlorine in the low temperature dishmachine in the kitchen located on the same level of the nursing home adjacent to the dining room. ~ Two black carts located in the main kitchen in lower level used after cooking soup and during food preparation were observed with an accumulation of food debris in the crevices of the handles, dried food spills along the sides and an accumulation of food debris, dirt and other contaminates in the crevices of each shelf. ~ The knobs and handles on the stove, braiser/tilt skillet, steamer, fryers, pressure fryers and convection oven located in the main kitchen in lower level had an accumulation of food residue, grease, dirt and other contaminates. ~ The plastic affixed wall dispensers for tin foil and plastic wrap located in the main kitchen in lower level had food residue, grease, dust, dirt and other contaminates. ~ Cooking equipment used to cool the majority of the food located in the main kitchen in lower level had an accumulation of grease, food residue, dirt, dust and other contaminates. Findings include: The 2013 Federal Food Code's Preface I indicates most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims foodborne illness results only in discomfort or lost time from the job. For some, especially preschool age children, older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. In addition, the 2013 Federal Food Code's Preface 1 indicates epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments: 1. Improper holding temperatures, 2. Inadequate cooking, such as undercooking raw shell eggs, 3. Contaminated equipment, 4. Food from unsafe sources, and 5. Poor personal hygiene. The Food Code also addresses controls for risk factors and further establishes 5 key public health interventions to protect consumer health. Specifically, these interventions are: demonstration of knowledge, employee health controls, controlling hands as a vehicle of contamination, time and temperature parameters for controlling pathogens, and the consumer advisory. On 2/14/17 at 8:43 a.m., Surveyor interviewed DNS (Director of Nutrition Services)-A, who indicated the facility referenced the Federal Food Code and ServSafe as their standards of practice. Kitchen on the main level: ~ Wash temperatures below the minimum 120 degrees F According to the Federal Food Code 4-501.110(B) for mechanical dishwashing equipment the temperature of the wash solution in a spray type dishwasher that use chemicals to sanitize may not be less than 120 degrees F. The Federal Food Code 4-501.15(A) indicates a warewashing machine and it's auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions. On 2/15/17 at 8:20 a.m., Surveyor interviewed DA (Dietary Aide)-C, who indicated the mechanical low temperature dishmachine's minimum wash and rinse temperatures were 120 degrees F. On 2/15/17 at 8:32 a.m., Surveyor observed the data plate on the mechanical low temperature dishmachine that used chemicals to sanitize the dishes. The data plate read; wash temperature 120 degrees F, rinse temperature 120 degrees F and 50 ppm (parts per million). On 2/15/17 from 8:27 a.m. to 9:14 a.m., Surveyor observed dishwashing with the facility's mechanical low temperature dishmachine. Five out of eight racks of plates, cups, trays and other dishes were washed below the required 120 degrees F. The wash temperatures were as follows: ~ 8:33 a.m., 116 degrees F ~ 8:45 a.m., 106 degrees F. ~ 8:56 a.m., 113 degrees F. ~ 9:10 a.m., 113 degrees F. ~ 9:13 a.m., Surveyor and DNS-A observed the wash temperature of 116 degrees F. DNS-A verified the wash temperature was too low and directed staff to stop washing dishes in the dishmachine. DNS-A indicated she would call the Eco Lab Representative. When asked if staff have a procedure to run the dishmachine until the temperatures are up to 120 degrees before washing the dirty dishes, DNS-A indicated they did not. On 2/15/17 at 12:20 p.m., Surveyor interviewed SDSS (Senior Director of Support Services)-B regarding the wash temperatures below 120 degrees F in the low temperature dishmachine in the Nursing Home Kitchen. SDSS-B verified the rinse solution is used for was cycle and the reason the wash temperature is too low. On 2/16/17 at 1:45 p.m., Surveyor and Surveyor met with DNS-A, SDSS-B, NHA-W (Nursing Home Administrator) and ANHA (Assistant Nursing Home Administrator)-X and reviewed the temperature of dish washing issues. DNS-A verified staff did not have a system or procedure to run the low temperature dishmachine until the temperatures reached 120 degrees F before washing dirty dishes. DNS-A and SDSS-B verified ELR (Eco Lab Representative)-Y recommended staff run the dishmachine until the temperature reaches 120 degrees F before washing dirty dishes. DNS-A indicated staff were being trained to run the dishmachine until the temperature was up to 120 degrees before washing dirty dishes. ~ Testing chlorine in dishmachine: The Federal Food Code for determining the chemical sanitizer concentration in the dishmachine 4-501.116 states the concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. On 2/15/17 at 8:27 a.m., Surveyor interviewed DNS-A regarding test strips used for the low temperature dishmachine. DNS-A showed the surveyor the roll of QT-10 Hydrion test strips. When asked, DNS-A indicated they use what was provided by Eco Lab and verified using the QT-10 Hydrion test strips to test the sanitizer in the dishmachine, DNS-A indicated long as she had worked at the facility, about a year. Surveyor then interviewed TLC (Team Lead/Cook)-H regarding the QT-10 Hydrion test strips and he indicated they have been using them for as long as he worked there, which was 4 to 5 months. Note: QT-10 Hydrion is used to measure the concentration of quat sanitizer, not chlorine. On 2/15/17 at 8:37 a.m., Surveyor interviewed DA-C and asked DA-C to test the concentration of the sanitizer in the low temperature dishmachine. Using the QT-10 Hydrion test strips, DA-C followed the directions for the QT-10 Hydrion test strips and the test strip turned yellow. Note the color Yellow is not one of the colors on the color key on the container. When asked, DA-C indicated the concentration of the sanitizer was 150 to 200 ppm. The color on the key for 200 ppm is orange. In addition, DA-C indicated they use the same test strips for test the sanitizer in the three compartment sink. Surveyor observed a dispenser with Oasis 146 quat sanitizer by the three compartment sink. At 8:45 a.m., when asked, DNS-A read the name of the sanitizer used in the low temperature dishmachine, DNS-A read Sodium Hypochlorite Ultra Sanitizer (Chlorine). On 2/15/17 at 9:04 a.m., Surveyor interviewed DA-D regarding the QT-10 Hydrion test strips, and she verified they used them for testing the sanitizer in the low temperature dishmachine. When asked if they used the same test strips for the quat sanitizer, DA-D was not sure and thought they used a different test strip that turned purple and were in a tube. Note: DA-D described the test strips observed by Surveyor used to test the chlorine sanitizer in low temperature dishmachines. On 2/15/17 at 9:06 a.m., Surveyor interviewed DA-E regarding the test strips used to the test the chlorine in the low temperature dishmachine. DA-E indicated staff use the QT-10 Hydrion test strips to test both the dishmachine and three compartment sink sanitizers. DA-E indicated they used to use a different test strip in a tube for the dishmachine. When asked when, DA-E answered October 2016 and commented the dishmachine readings used to be at 50 ppm not 200 ppm. DA-E then indicated they ran out of the test strips in the tube a few weeks ago. On 2/15/17 at 9:16 a.m., Surveyor and DNS-A reviewed the sanitizer logs for the dishmachine and noted 12/2016 and 1/2017 staff documented 50 ppm and 2/2017 staff began documenting 200 ppm. It was noted the test strips QT-10 Hydrion were used to test the concentration in the Oasis 146 quat sanitizer used in the three compartment sink and red buckets, not the chlorine sanitizer used in the low temperature dishmachine. During interviews, staff recalled using other test strips and was unable to determine when the facility ran out of the chlorine test strips. DNS-A indicated she would request new test strips from Eco Lab immediately. On 2/15/17, Surveyor and DNS-A reviewed the last report from Eco Lab, dated 2/1/17. The chlorine for the low temperature dishmachine tested at 50 ppm. On 2/16/17 at 1:45 p.m., Surveyor and Surveyor met with DNS-A, SDSS-B, NHA-W, and ANHA-X regarding the test strips. DNS-A verified staff had been using the incorrect test strips and now had the correct test trips from Eco Lab to test the concentration of the sanitizer in the low temperature dishmachine and staff were educated to inform management when they run out of test strips. Main kitchen in lower level- ~ Equipment in need of cleaning: The Federal Food Code addresses cleaning of equipment and utensils at 4-601.11(C) (Objective) Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils indicates nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The Federal Food Code regarding cleaning of cooking and baking Equipment under 4-602.13 indicates nonfood-contact surfaces of equipment shall be cleaned at a frequency to preclude accumulation of soil residues. On 2/15/17 at 12:35 p.m., Surveyor and DNS-A observed DC (Dietary Cook)-F place soup in clean pans on a black cart. The black cart was observed to be soiled with crevices, handles, sides, and bottom two shelves soiled with an accumulation of food residue, dried spills and splashes, food debris and crumbs, dirt and other contaminates. At that time, DC-G commented she only washed the top of the cart and did not sanitize the top before giving the cart to DC-F to use for the pans of soup to be served. On 2/15/17 at 12:40 p.m., Surveyor and DNS-A observed the following equipment: ~ The Braiser or Tilt Skillet's control knobs, front sides, crevices had an accumulation of food residue, grease, food debris, crumbs, dried spills and spatter, dirt and other contaminates. ~ The Cleveland Steamer's control knobs and handles had an accumulation of food residue, grease, dirt and other contaminates. ~ Two Vulcan Fryers were observed with handles, doors, front sides, crevices and ledges had various degrees of food residue, grease, dirt and other contaminates. DNS-A declined to touch the handle or door, stating she could see that it was very dirty. ~ Two Pressure Fryer 600's control knobs, front and front sides, crevices were soiled with food residue, grease, food debris and crumbs. ~ A Vulcan Convection Oven had four handles had a thick accumulation of food residue, grease, dirt and other contaminates that easily was removed with a fingernail. The bottom handles were soiled with food residue, grease and dirt. On 2/15/17 at 12:55 p.m., Surveyor , DNS-A and SDSS-B reviewed the equipment concerns and verified the cooking equipment had an accumulation of food residue, grease, spills, spatters, dirt and other contaminates. On 2/15/17 at 1:00 p.m., Surveyor , DNS-A and SDSS-B observed a second black cart with two large cartons of mashed potatoes and two packages of brown gravy on top. The cart had an accumulation of food residue, dried spills and spatter, crumbs, dirt and other contaminates. DNS-A and SDSS-B verified the cart should be cleaned and sanitized before use. On 2/15/17 at 1:02 p.m., Surveyor , DC-F, DNS-A and SDSS-B observed plastic dispensers affixed to the wall used to dispense tin foil and plastic wrap. Both dispensers had an accumulation of food residue, dirt, dust, and other contaminates. On 2/16/17 at 1:45 p.m., Surveyor and Surveyor met with DNS-A, SDSS-B, NHA-W, and ANHA-X to review the equipment in need of cleaning.

Based on observation, record review and staff interview, services provided or arranged by the facility were not provided in accordance with the written plan of care for 1 (R (Resident) 13) of 11 sampled residents observed receiving cares. R13's plan of care included interventions for barrier cream and oral care. Those interventions were not consistently implemented. Findings include: On 2/14/17, Surveyor reviewed the medical record of R13. The resident was admitted to the facility with [DIAGNOSES REDACTED]. R13's most recent MDS (Minimum Data Set) assessment, dated 12/23/16, documented R13 needed extensive assistance of staff for ADLs (activities of daily living) and personal cares. R13's functional incontinence plan of care, dated 2/12/16, included the following intervention: Check me on routine rounds and PRN (as needed). Wash, rinse and dry my perineum. Apply barrier cream (7/25/13). R13's ADL plan of care, dated 4/23/13, included the following intervention: I prefer to have my teeth brushed twice daily - use Prevident tooth paste (sic) (4/24/13). On 2/15/17 at 7:45 a.m., Surveyor observed CNA (Certified Nursing Assistant)-O and CNA-P provide morning cares for R13. During cares, CNA-O provided anterior and posterior peri-care. Following peri-care, RN-M entered the room and completed coccyx wound care. Following wound care, CNA-O and CNA-P continued with morning cares. CNA-O and CNA-P attached R13's brief without applying barrier cream, dressed and transferred R13 from the bed to the Broda chair. CNA-O combed R13's hair and without providing oral care, transferred R13 to the dining room. Immediately following the observation, Surveyor interviewed CNA-O, who indicated R13 was not offered or provided oral care because R13 does not like oral care. When asked by Surveyor if R13 should be offered oral care and/or educated on the benefits of oral care despite past refusals, CNA-O stated she will offer oral care after breakfast.

Based on record review and staff interview, the facility did not ensure 1 (R (Resident) 8) of 14 sampled residents reviewed met the PASRR (Pre-Admission Screen and Resident Review) requirements. R8's medical record did not include a Level II PASRR screen following a 30 day maximum hospital discharge exemption. Findings include: 1. R8 was admitted to the facility in October 2016 with a [DIAGNOSES REDACTED]. R8's Level 1 PASRR screen completed on 10/18/16, documented R8 had a serious mental illness which was being treated with medications. The PASRR documented that a short-term exemption was requested following a hospital discharge - 30 day maximum. R8 was admitted to the facility under the hospital discharge exemption to convalesce for 30 days or less. With the hospital discharge exemption box checked yes, R8 entered the facility with county approval, as evidenced by receipt of a signed F- form from the county on 10/19/16. R8's medical record did not include documentation that a Level 2 PASRR had been completed once the hospital discharge exemption with a 30 day maximum had been reached and R8 remained living in the facility. On 2/20/17 at 1:27 p.m., Surveyor interviewed RNCC (Registered Nurse/Clinical Coordinator)-K regarding R8. RNCC-K verified the facility should have completed a Level 2 PASRR for R8 on or before the last day of the permitted time period and will be sending it (Level 2 PASRR screen) out today.

Based on observation, record review and staff interview, the facility did not ensure 1 (R (Resident 13) of 20 residents reviewed for pressure injury and pressure injury risk received the necessary treatment and services to promote healing and/or prevent pressure injuries from developing. R13 had a stage 3 pressure injury to the coccyx. R13's plan of care included interventions of a foot cradle, an alternating air mattress, a coccyx dressing and blue heel boots, or heels free floated. Those interventions were not consistently implemented. Findings include: The facility's Pressure Injury Prevention and Management policy, dated January 2017, states: Purpose: Any resident with a pressure injury receives treatment and services consistent with the goal of promoting healing and preventing infection and preventing new pressure injuries from developing. D. Wound Management Principles 3. Wound management principles include, and are not limited to: a. Control or elimination of causative factors such as: i. Pressure-maximizing pressure redistribution and off-loading of pressure ii. Shear vii. Foot care and treatment c. Maintenance of a physiological local wound environment including, and not limited to: vii. Protecting the wound Sensory Perception Impairments: ~ Position body with pillows/support devices: heel boots, heel protectors . ~ Protect bony prominences ~ Ensure pressure reducing mattress/cushion ~ Float heels Activity/Mobility/Friction/Shear Deficits: ~ Float heels ~ Foot care and treatment ~ Draw sheet for lifting 1. On 2/14/17, Surveyor reviewed the medical record of R13. The resident was admitted to the facility with [DIAGNOSES REDACTED]. R13 developed a facility-acquired coccyx pressure injury on 3/26/16. R13's most recent MDS (Minimum Data Set) assessment, dated 12/23/16, documented R13 was dependent on staff for bed mobility and had impaired ROM (range of motion) to both upper and lower extremities. R13 was at risk for the development of pressure injuries and had a stage 3 pressure injury measuring 1.2 by 1.0 by 1.1 cm (centimeters). R13's Weekly Wound Care Documentation for Pressure Injury assessment, dated 2/14/17, indicated R13 had a stage 3 pressure injury that measured 1.0 by 0.5 by 1.0 cm. The wound assessment indicated the measurements were the same as the previous assessment on 2/07/17. The 2/07/17 wound assessment indicated the wound improved from the assessment on 1/31/17 which documented measurements of 1.2 by 1.0 by 1.4 cm. R13's undated pocket note (a modified care plan carried by nursing staff), provided to Surveyor on 2/15/17, included the following interventions: Specialty air mattress 160 pounds; Bilateral blue boots in bed or float feet; Coccyx dressing and foot cradle in bed. R13's skin integrity plan of care, dated 3/29/16, included the following interventions: I have a foot cradle on my bed (2/07/17); I have a specialty alternating air mattress on my bed (12/30/16); I have blue boots that I wear when in bed. I don't always like to wear them. Please float my feet during those times (4/24/13); Monitor dressing daily to ensure it is intact and adhering. Report loose dressing to treatment nurse (3/29/16). R13's February 2017 TAR (treatment administration record) included the following instructions for staff: Bilateral blue boots on while in bed; Check that coccyx dressing is clean, dry, intact every shift; Coccyx: cleanse area with wound cleanser, apply skin prep to peri-wound. Gently pack area with polymem rope followed by 2 by 2 gauze. Cover with bordered gauze and change daily and PRN (as needed); Monitor air mattress settings every shift (should be on Alternate, not Static) (initiated 2/16/17). On 2/15/17 at 7:45 a.m., Surveyor observed CNA (Certified Nursing Assistant)-O and CNA-P provide morning cares for R13. Upon entering the room, Surveyor noted R13's alternating air mattress was unplugged from the wall. When Surveyor inquired about the mattress, CNA-O plugged in the mattress. CNA-O was unaware of why the mattress was unplugged or when it became unplugged. Surveyor observed the air mattress was set to Static and R13's heels were in direct contact with the mattress. CNA-O and CNA-P used a draw sheet to pull, not lift R13 across the bed. During peri-care, Surveyor noted R13 did not have a dressing on the coccyx area. CNA-O and CNA-P verified the observation and verified R13 should have a dressing in place, indicating R13's dressing may have fallen off during a shower on the previous (2/14) PM (evening) shift. CNA-O and CNA-P confirmed they did not provide cares or enter R13's room earlier that morning (2/15), prior to Surveyor 's observing morning cares. When Surveyor inquired about blue heel boots, CNA-O stated, (R13) hasn't had blue boots in a long time. We just float (R13's) heels. In addition, Surveyor did not observe a foot cradle in the room. Following cares, RN (Registered Nurse)-M entered the room to provide wound care. CNA-O and CNA-P did not inform RN-M that R13's coccyx wound area did not have a dressing in place when they provided morning cares for R13. R13's 2/2017 TAR included documentation that instructed staff to check that coccyx dressing is clean, dry, intact every shift. The TAR did not include initials from the PM shift nurse on the 2/14/17, but included initials as completed on the 2/15/17 NOC (night) shift. On 2/15/17 at 11:40 a.m., Surveyor observed R13 in bed positioned on their right side with a pillow between the knees. R13's right lateral (outer) foot, ankle and heel and left medial (inner) foot, ankle and heel were in direct contact with the mattress. Surveyor did not observe a foot cradle in the room. On 2/15/17 at 11:53 a.m., Surveyor observed CNA-Q answer R13's call light. After CNA-Q assisted R13, a pillow was placed between R13's knees and positioned R13 on their right side. Surveyor noted R13's right lateral foot, ankle and heel and left medial foot, ankle and heel were again in direct contact with the mattress. Surveyor interviewed CNA-Q immediately following the observation. CNA-Q indicated R13 wore blue heel boots at night and stated R13's heels were to be floated when in the Broda chair, but could be in contact with the mattress at that time. Surveyor observed 1 blue heel boot on the bottom shelf of a book case, but did not observe a foot cradle in the room. On 2/16/17 at 8:21 a.m., Surveyor observed R13 in bed with both heels in direct contact with the mattress. Surveyor did not observe a foot cradle in the room. On 2/16/17 at 10:15 a.m., Surveyor interviewed CC (Clinical Coordinator)-N regarding R13's foot cradle. CC-N stated R13 did not have a foot cradle and was not aware the intervention was added to R13's care plan on 2/07/17. On 2/20/17 at 10:10 a.m., Surveyor observed R13 in bed wearing knit booties. R13 was positioned with a pillow between the lower legs with the right lateral foot, ankle and heel and left medial foot, ankle and heel in direct contact with the mattress. Surveyor did not observe a foot cradle in the room. On 2/20/17 at 10:30 a.m., Surveyor interviewed CC-N while in R13's room. CC-N indicated R13's air mattress was to be set on Alternate at 160 pounds and indicated RN-T, the facility's wound care nurse, suggested a foot cradle for R13. When RA (Restorative Aide)-U brought the foot cradle to R13's room, R13 refused. CC-N indicated the intervention was removed from R13's plan of care; however, R13 might reconsider the intervention in the future. Surveyor and CC-N observed R13's heels. CC-N verified R13's heels weren't free floating and stated, I'm not sure if (R13) is refusing to have heels floated. Staff should chart refusals if blue boots aren't worn. CC-N also indicated nursing staff should document on any resident with skin issues who refuses interventions. Approximately five minutes after exiting R13's room, CC-N approached Surveyor and indicated R13 allowed CC-N to float (R13's) heels. Upon review of R13's skin integrity and progress notes, Surveyor was unable to locate documentation in the medical record regarding R13's refusal of heel boots. Surveyor observed a late entry restorative note, composed on 2/16/17 at 10:38 a.m. and dated 2/07/17 at 10:37 a.m., that stated, Restorative offered and explained use of foot cradle to resident. Resident refused to use foot cradle due to feet being cold often. Wound nurse updated.

Based on observation, staff interview and record review, the facility did not ensure 1 (R (Resident) 2) of 6 sampled residents reviewed for catheter cares, received the appropriate treatment and services to prevent urinary tract infections. During an observation of catheter care, CNA (Certified Nursing Assistant)s elevated R2's urinary catheter drainage bag above the level of the resident's bladder. Findings include: HICPAC (Healthcare Infection Control Practices Advisory Committee) 2009 Guideline For Prevention Of Catheter Associated Urinary Tract indicates: III. B (1) Keep the collecting bag below the level of the bladder at all times . The facility's document CNA STANDARDS OF CARE, last revised 2/2015, instructed: It is important to ensure that catheter bags remain below level of bladder. Surveyor reviewed R2's medical record from 2/14/17 to 2/20/17. The plan of care included R2's diagnoses, which included weakness and neuromuscular dysfunction of bladder. R2's MDS (Minimum Data Set) assessment, dated 1/13/17, documented the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) of 15, is dependent upon staff for extensive assistance with hygiene, bathing and required use of a urinary catheter. On 2/15/17 at 8:27 a.m., Surveyor observed CNA-I and CNA-J transfer R2 from the bed to a wheelchair, with the use of a total body mechanical lift. Once R2 was positioned on the lift sling, CNA-I and CNA-J attached the sling straps to the lift. CNA-I then picked up the resident's urinary catheter drainage bag and attached it to the lift sling above R2's abdomen and then used the electric control to raise R2 off the bed, while CNA-J monitored the transfer. R2's catheter drainage bag was also lifted to approximately 12 inches above the level of R2's bladder. The bag's tubing contained yellow liquid (urine), some of which flowed toward the resident as the bag was raised. CNA-I operated the lift, placing R2 just above the resident's wheelchair, then lowered R2 onto the chair. As the resident was lowered, the level of the catheter drainage bag was returned to the level of the bladder. On 2/15/17, at 8:45 a.m., Surveyor interviewed CNA-J regarding R2's transfer observation. CNA-J confirmed and verified urinary catheter bags should be at the level of the resident's bladder or lower. CNA-J verified the catheter bag should not be attached to the part of the mechanical lift that rises and lifts the catheter bag higher than the resident's bladder. On 2/20/17, at 12:35 p.m., Surveyor interviewed RN/CC (Registered Nurse/Clinical Coordinator)-K, who verified catheter bags should not be raised above the level of the resident's bladder.

Based on record review, and staff and resident interviews, the facility did not ensure that 1 resident (resident #3) out of 22 sample residents was free of a significant medication error. Resident #3 was admitted with orders for [MEDICATION NAME] 0.25 mg (milligrams) tid (three times a day) scheduled. According to documentation, resident #3 did not receive a total of 7 doses as a result of nursing staff not calling resident #3's physician or the on-call physician to obtain a script. Therefore, the medication was stopped abruptly and resident #3 had a reoccurrence or relapse of her symptoms of anxiety. Findings include: [MEDICATION NAME] ([MEDICATION NAME]) Prescribing Information as provided by the FDA (Food and Drug Administration) and Manufacturer's instructions on the package insert at <http://labeling.pfizer.com/ShowLabeling.aspx?id=547> indicates the following; [MEDICATION NAME] is used for the treatment of [REDACTED]. At least 6 of the following 18 symptoms are often present in these patients: Motor Tension (trembling, twitching, or feeling shaky; muscle tension, aches, or soreness; restlessness; easy fatigability); Autonomic [MEDICAL CONDITION] (shortness of breath or smothering sensations; palpitations or accelerated heart rate; sweating, or cold clammy hands; dry mouth; dizziness or light-headedness; nausea, diarrhea, or other abdominal distress; flushes or chills; frequent urination; trouble swallowing or 'lump in throat ' ); Vigilance and Scanning (feeling keyed up or on edge; exaggerated startle response; difficulty concentrating or 'mind going blank' because of anxiety; trouble falling or staying asleep; irritability. * Risk of Dose Reduction Withdrawal reactions may occur when dosage reduction occurs for any reason. This includes purposeful tapering, but also inadvertent reduction of dose (eg, the patient forgets, the patient is admitted to a hospital). Therefore, the dosage of [MEDICATION NAME] or [MEDICATION NAME] should be reduced or discontinued gradually. * To discontinue treatment in patients taking [MEDICATION NAME], the dosage should be reduced slowly in keeping with good medical practice. * Information for Patients states do not stop taking this medication abruptly or decrease the dose without consulting your physician, since withdrawal symptoms can occur. * Warnings, Dependence and Withdrawal Reactions, Including [MEDICAL CONDITION]: Certain adverse clinical events, some life-threatening, are a direct consequence of physical dependence to [MEDICATION NAME]. These include a spectrum of withdrawal symptoms; the most important is [MEDICAL CONDITION]. Even after relatively short-term use at the doses recommended for the treatment of [REDACTED]. * Drug Abuse and Dependence, Physical and Psychological Dependence: 1. Withdrawal symptoms similar in character to those noted with sedative/hypnotics and alcohol have occurred following discontinuance of benzodiazepines, including [MEDICATION NAME]. The symptoms can range from mild dysphoria and [MEDICAL CONDITION] to a major syndrome that may include abdominal and muscle cramps, vomiting, sweating, tremors and convulsions... 2. While it is difficult to distinguish withdrawal and recurrence for certain patients, the time course and the nature of the symptoms may be helpful. A withdrawal syndrome typically includes the occurrence of new symptoms, tends to appear toward the end of taper or shortly after discontinuation, and will decrease with time. 3. While the severity and incidence of withdrawal phenomena appear to be related to dose and duration of treatment, withdrawal symptoms, including [MEDICAL CONDITION], have been reported after only brief therapy with [MEDICATION NAME] at doses within the recommended range of treatment of [REDACTED]. Signs and symptoms of withdrawal are often more prominent after rapid decrease of dosage or abrupt discontinuance. 4. Psychological dependence is a risk with all benzodiazepines, including [MEDICATION NAME]. According to the 7/6/12 face sheet contained in resident #3 medical record, she was admitted on [DATE] with [DIAGNOSES REDACTED]. This is resident #3's second admission to the facility. Resident #3 had been previously admitted to the facility on [DATE] following a hospitalization , and was discharged back to the community on 5/31/12. According to the Discharge Summary from St Elizabeth's dated 5/22/12, resident #3 had been prescribed [MEDICATION NAME] 0.25 mg three times a day as needed. On 7/9/12 during the initial tour at 9:30 a.m. resident #3 told surveyor # that she was concerned because she did not receive her [MEDICATION NAME] all weekend when she was admitted to the facility on [DATE], because the facility could not get the [MEDICATION NAME]. A Concern/Complaint/Grievance Management Form indicated resident #3 complained to SW (Social Worker)-AA on 7/2/12 at 11:00 a.m. that she was admitted to the facility on Friday 6/29/12 and normally takes "Lorazapam" (should be [MEDICATION NAME]) three times daily for anxiety. Resident #3 indicated she was told there wasn't a script for the medication, and that she kept telling nursing staff about it, but no one looked into it. Resident #3 said that she was very nervous over the weekend and it was finally addressed on the morning of 7/2/12. According to the form, DON (Director of Nursing)-Y and AC (Admissions Coordinator)-EE contacted the Discharge Coordinator at St. Elizabeth's Hospital regarding necessary scripts. The Discharge Coordinator spoke with resident #3's physician and two scripts were faxed to the facility's pharmacy, but not the script for the resident #3's [MEDICATION NAME]. The facility investigation indicated that RN (Registered Nurse)-X sent a fax to the physician to request a script for resident #3's [MEDICATION NAME] but did not follow up with a phone call to the physician until Saturday 6/30/12, by which time the office had closed. On 7/10/12 at approximately 3:30 p.m. surveyor # and # met with NHA(Nursing Home Administrator)-V and DON-Y for the daily exit meeting. Surveyor # reviewed resident #3's 7/2/12 concern and the facility's investigation. When DON-Y was asked about staff training. DON-Y said that she spoke with RN-X and he was provided education related to the error. DON-Y, when asked if additional nurses were provided education, indicated they felt it was an isolated incident. Upon further questioning, DON-Y stated she interviewed 4 or 6 other nurses who work on (resident #3's unit) and they all indicated that they would have called the physician or the on call physician. DON-Y verified that nursing staff on other units were not interviewed or provided education. According to the 6/29/12 discharge summary from (resident#3's Hospital), resident #3 was discharged with orders for [MEDICATION NAME] 0.25 mg tid scheduled. A nurse's note dated 6/29/12 1535 (3:35 p.m.) indicated resident #3 arrived at the facility via transport of her son. Her weight and vitals were obtained and she was oriented to her room. The next nurse's note on 6/29/12 at 2040 (8:40 p.m.) indicated resident #3 was alert and orientated to person, place and time, and that her short term memory was intact. The note did not include documentation that there was a discussion regarding the daily dosage and/or how long resident #3 had been taking [MEDICATION NAME]. The 6/29/12 fax marked urgent was faxed to (resident # 3's Clinic) on 6/30/12 at 12:34 a.m. requesting valid scripts for resident #3's [MEDICATION NAME], and [MEDICATION NAME] 0.25 mg take 1 tablet, PO (by mouth), TID. The fax also requested that the physician respond to the pharmacy's concerns 1-3. On the fax are the instructions for "Nurses: all urgent information faxed or sent to the prescriber needing a response today must be accompanied by a phone call to the office." The following nurse's notes documented observations, complaints and concerns expressed by resident #3: ~ 6/30/12 1555 (3:55 p.m.) "slight nausea" and "excessive exhaustive behavior" ~ 7/1/12 0730 (7:30 a.m.) "c/o (complaint of) nausea," "c/o chronic back pain, pt (patient) anxious, states "I feel like I am going to die today," concerned about bruising on R (right) hand" ~ 7/1/12 2230 (10:30 p.m.) "A&Ox3 (alert and oriented times person, place and time). Able to make needs known to staff. Has hx (history) of anxious/nervous affect. Waiting for [MEDICATION NAME] and scheduled [MEDICATION NAME] from PCP (primary care physician). Needing reassurance/calming. States she is throwing up, but is actually spitting phlegm." ~ 7/2/12 0130 (1:30 a.m.) "I've had a headache ever since I've been here." ~ 7/2/12 0800 (8:00 a.m.) "Pt has tremor to B (bilateral) hands, writer assisted pt in taking medications. Pt c/o feelings of anxiety all weekend. MD office called, writer spoke with triage nurse regarding script for [MEDICATION NAME] which is scheduled. Awaiting a return call at this time." The following nurse's notes document resident #3's condition after she received the scheduled [MEDICATION NAME]: ~ 7/2/12 1315 (1:15 p.m.) "Pt reports anxiety is much improved. Tremors no longer present. Pt appears much more calm." ~ 7/2/12 1455 (2:55 p.m.) "Appetite improving now greater than 75%" (eating more than 75% of her food). Surveyor # reviewed resident #3's MAR (Medication Administration Record) and they indicated that resident #3 did not receive the evening dose of [MEDICATION NAME] 0.25 mg on 6/29/12 as well as the three doses of [MEDICATION NAME] on 6/30/12 and 7/1/12. Resident #3 received her first dose of [MEDICATION NAME] on the morning of 7/2/12, as documented on the MAR. On 7/11/12 at 11:50 a.m. DON-Y provided surveyor # with a copy of the 6/30/12 24 hour report sheet for resident #3. The report indicated that they still needed multiple scripts, including the script for resident #3's [MEDICATION NAME], and that the clinic was called but it was too late because it was closed. The report documented on the PM (second shift) that resident #3 was anxious and had a small emesis, and was given 650 mg of Tylenol at 1500 (3:00 p.m.) and [MEDICATION NAME] at 2100 (9:00 p.m.). On 7/11/12 at 11:21 a.m. surveyor # interviewed RN-X via telephone regarding resident #3. RN-X verified that he was the admitting nurse for resident #3 on 6/29/12 and was aware resident #3's [MEDICATION NAME] did not arrive at 8:00 p.m. when the medications were delivered by the pharmacy. RN-X verified that he did not call resident #3's physician nor the on-call physician to request a script for the [MEDICATION NAME], but should have per the facility's expectations. In addition, RN-X indicated he was aware that if staff cannot reach the resident's physician or the on-call physician they should call the facility's Medical Director, but did not. RN-X indicated he told resident #3 that they did not have her [MEDICATION NAME] and she was okay with it. RN-X Verified that he sent the fax requesting a script for resident #3's [MEDICATION NAME] on 6/30/12 at 12:35 a.m. When asked if he was aware that [MEDICATION NAME] should not be stopped abruptly, RN-X said that he was. RN-X did say that he passed on report to the third shift nurse to have the day nurse call resident #3's physician in the morning for the [MEDICATION NAME] script. During the interview with RN-X on 7/11/12 at 11:21 a.m. he indicated that he worked again on 6/30/12 from 10:00 a.m. to 3:00 p.m. RN-X told surveyor # that he tried to call resident #3's physician, but said it was too late and the clinic had closed for the day. On 7/11/12 at 2:05 p.m. surveyor # interviewed RN-Z via telephone regarding resident #3. RN-Z verified that she worked the day shift on 6/30/12. RN-Z indicated that she thought the physician had already been made aware of the missing script for resident #3's [MEDICATION NAME], and had not been told that she needed to contact the physician by the night nurse in report on the morning of 6/30/12. When asked, RN-Z verified that she noted that resident #3 did not have her morning dose of [MEDICATION NAME] 0.25 mg when she gave the resident her medications. RN-Z indicated that she did not follow up nor did she call MD (medical doctor)-CC nor the on-call doctor to request a script for resident #3's [MEDICATION NAME]. When asked, RN-Z verified that she was aware that [MEDICATION NAME] should not be stopped abruptly and that there was a risk for [MEDICAL CONDITION] if stopped abruptly. RN-Z stated that resident #3 did not show any sign of [MEDICAL CONDITION] or convulsions. Additionally, RN-Z stated that she worked the day shift on 6/30/12, scheduled from 6:00 a.m. until 2:30 p.m.. RN-Z verified that resident #3 did not receive [MEDICATION NAME] when she gave medications to resident #3 and stated that resident #3 complained of nausea and feeling anxious. RN-Z stated that she did not inform resident #3's physician on 6/30/12 that resident #3 had not received the [MEDICATION NAME] or that resident #3 had complained of nausea and feeling anxious. On 7/11/12 at 2:30 p.m. surveyor # interviewed resident #3 about the concern she shared with surveyor # regarding not receiving her [MEDICATION NAME] the weekend after she was admitted to the facility. Resident #3 shared that she had been "very anxious all weekend" and had a terrible headache. Resident #3 indicated that in addition she had been "very shaky" and that even the nurse had noticed it and had to help her take her medications in the morning. The nurse called her doctor that morning and got her [MEDICATION NAME] right away, and the shakiness stopped once she took her medication, and she started feeling better and less anxious. At 2:30 p.m. surveyor # asked resident #3 about her [MEDICATION NAME], and she indicated that she had been consistently taking it three times a day for at least the past year or more. On 7/11/12 at 3:10 p.m. surveyor # interviewed MD (Medical Doctor)-CC's nurse, RN-DD. RN-DD verified that she would not have wanted resident #3 to stop taking her [MEDICATION NAME] abruptly. RN-DD reviewed resident #3's medical history and indicated when asked that resident #3 had been taking [MEDICATION NAME] 0.25 mg tid since 2/2009, and that resident #3 routinely refilled her prescription for [MEDICATION NAME] 0.25 mg 90 tablets monthly. RN-DD verified that the facility could have had either MD-CC or the on-call doctor be paged. RN-DD indicated instructions were left on how to get in contact with MD-CC if there were any problems, since this had been her (resident #3)second hospitalization . On 7/12/12 at 11:50 a.m. surveyor # interviewed resident #3 and she indicated that without her [MEDICATION NAME] she felt really anxious, antsy, sick and would go between feelings of hot and cold. Resident #3 also shared that she didn't know that not taking her [MEDICATION NAME] would make her feel so rotten, and that she would worry so much more than usual without it. Resident #3 verified that she had told the nurses about how anxious she felt. She stated that she did receive some pain medications which helped her sleep at night. Resident #3 shared that she felt better once she received her [MEDICATION NAME] and felt even better after a few days. Resident #3 said that MD-CC told her she was sorry for how bad she felt 6/29/12 until 7/2/12, and that no one got a hold of her because she had left instructions on how to get a hold of her. Resident #3 said that the nurses' should have tried harder to get her medication. On 7/12/12 at 12:00 p.m. surveyor # interviewed MD-CC's nurse RN-DD, via telephone regarding resident #3. RN-DD stated that resident #3 was seen in her office 7/11/12 morning, and surveyor # asked if MD-CC believed resident #3 had experienced any withdrawal symptoms. The information documented in resident #3's nurse's notes contained in her medical record had been reviewed with RN-DD by surveyor # . RN-DD indicated that MD-CC stated that since she had not seen resident #3 6/30/12 through the morning of 7/2/12, she could not be sure if the resident experienced any withdrawal symptoms. On 7/12/12 at approximately 12:15 p.m. surveyor # interviewed PD (Pharmacist Director)-BB regarding the process that the pharmacy follows when a resident is admitted . PD-BB indicated that the facility will fax a copy of the Discharge Summary including the discharge medications, a technician will input the information in the computer, and then the Pharmacist will reconcile the orders and return a fax to the facility related to any discrepancies once he is finished. PD-BB when asked, indicated it was the facility's responsibility to contact the physician and obtain any missing scripts. Surveyor # interviewed PD-BB on 7/24/12 at 1:10 p.m. and she indicated that the pharmacy received resident #3's discharge orders including her medications from the facility at 4:28 p.m. and the pharmacist reconciled the medications and sent a fax back to the facility that a script was needed for resident #3's [MEDICATION NAME] at 5:21 p.m. PD-BB indicated that nursing should have called resident #3's physician or the on-call physician to request a script for the [MEDICATION NAME] and that the medication would have been delivered at 8:00 p.m. that evening, but no one did. On 7/12/12 at 12:24 p.m. during an interview, DON-Y verified to surveyors # and # that all of the nurses, not just RN-X and RN-A, who worked from 6/29/12 through the weekend would have been responsible to contact resident #3's physician or the on-call physician to request a script for her [MEDICATION NAME]. Information provided by NHA-V on 7/13/12 indicated the weekend resident #3 was admitted to the facility 6/29/12 through 7/2/12 was excessively hot and seemed to increase her anxiety. In addition, NHA-V provided documentation from the Villa which indicated resident #3 would become anxious related to feelings of frustration, loss of control, poor health, family relationships, changes or up coming appointments, when not feeling well, and would get easily upset and worry excessively at times. According to the information resident #3 had made negative comments in the past of wishing she would die or wanting to go the the hospital. Last, resident #3 admitted that she has been a worrier all her life. Information provided by NHA-V on 7/18/12 indicated they met with MD-CC and she did not feel resident #3 experienced any withdrawal symptoms, and she had symptoms similar to her baseline. According to surveyor # 's interviews with resident #3 during the survey, resident #3 stated she felt her anxiety had worsened when she was not taking the [MEDICATION NAME] and she noted improvements once she resumed her medication. On 7/25/12 at 1:26 p.m. surveyor # interviewed KCR-FF (Clinic Receptionist) regarding after hours phone coverage. KCR-FF verified that they have an answering service, Telsec, that takes over as soon as the clinic closes for the day including Saturdays and Sundays.