Every finding on record at Sturgeon Bay Health Services

Based on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 1 resident (R) (R8) of 7 sampled residents.The facility did not contact the state mental health authority to pursue further PASRR screening for R8 when R8's 30-day exemption expired.Findings include:The facility's Resident Assessment: Coordination with Pre-admission Screening and Resident Review Program policy, dated [DATE], indicates: The facility coordinates assessments with the Pre-admission Screening and Resident Review (PASRR) program under Medicaid to ensure individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs .ii. A positive Level I Screen necessitates a PASRR Level II evaluation prior to admission .2. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or intellectual disability authority has determined appropriate for admission .4. Exceptions to the PASRR program include those individuals who are .admitted directly from a hospital, require nursing facility services for the condition for which the individual received care in the hospital, and have been certified by the attending physician before admission as likely to require less than 30 days of nursing facility services .5. If a resident who was not screened due to an exception above (section 4) remains in the facility longer than 30 days: a. The facility must screen the individual using the Level I screening process or refer any resident who has or may have a mental health diagnosis or intellectual disability or related condition to the appropriate state designated authority for Level II PASRR evaluation and determination. B. The Level II resident review must be completed within 40 calendar days of admission .6. Social Services shall be responsible for keeping track of each resident's PASRR screening status and refer to the appropriate authority.On [DATE], Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder, generalized anxiety disorder, and attention deficit disorder. R8's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R8 had moderately impaired cognition. R8 was R8's own decision maker.R8's medical record contained a PASRR Level I Screen, dated [DATE], that indicated R8 had a 30-day exemption. Surveyor noted a PASRR Level I Screen was not submitted when R8's 30-day exemption expired on [DATE] and a PASRR Level II Screen was not completed despite the fact R8 had a mental health disorder with medication management. On [DATE] at 8:13 AM, Surveyor interviewed Social Services Director (SSD)-D who indicated a PASRR Level I Screen was not completed because R8 was expected to be at the facility for 30 days for rehabilitation and then discharge to an assisted living facility. SSD-D indicated SSD-D would check R8's medical record to see if the required PASRR Level I and Level II Screens were completed.On [DATE] at 9:50 AM, Nursing Home Administrator (NHA)-A approached Surveyor and indicated PASRR Level I and Level II Screens following the expiration of R8's 30-day exemption were not completed as required.On [DATE] at 1:00 PM, Surveyor interviewed SSD-D who confirmed a PASRR Level I Screen following the expiration of R8's 30-day exemption and subsequent Level II Screen were not completed as required.

Based on resident and staff interview and record review, the facility did not ensure the accurate acquisition and administration of medication for 1 resident (R) (R38) of 6 sampled residents. R38 had orders for 50 milligrams of scheduled and as needed (PRN) tramadol. R38 did not receive eight doses of the medication when the medication ran out and/or was not removed from contingency stock.Findings include:According to the United Stated Drug Enforcement Agency (DEA), controlled medications are medications classified as Schedule I, II, III, IV, or V based on the potential of abuse or dependency. Schedule I has the highest potential and Schedule V has the least potential of abuse or dependency.The facility's Medication Ordering and Receiving From Pharmacy; Provider Ordering and Receiving Controlled Medications policy indicates: Ordering and Receiving Controlled Medications .5. Refill requests for CIII-CV (C = Schedule) and partial fill requests for CII: a. If one or more refills (CIII-Vs) or a partial fill quantity (CIIs) remains: Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand. If only one refill remains (CIII-Vs) or only a partial fill quantity remains (CIIs), the pharmacy will simultaneously dispense the remaining fill and, if necessary, proactively seek out a new, complete prescription from the prescriber for future use. The facility may be asked to contact the prescriber for a new prescription upon request for a medication with no remaining fills available. The policy includes a list of medications available through the facility's contingency stock dispensing machine and includes ten tramadol (an opioid medication used to treat moderate to moderately severe pain and classified as a Schedule IV medication) 50 milligram (mg) tablets.From 3/2/26 to 3/4/26, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] and had a diagnosis of rheumatoid arthritis. R38's most recent Minimum Data Set (MDS) assessment, dated 12/5/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R38 had intact cognition. The MDS assessment indicated R38 had a pain regimen, as needed pain medication that was offered and both taken and declined, a pain level of 6 on a scale of 0 to 10 (0 = no pain; 10 = highest pain), and had pain that occasionally interfered with activities. R38 was R38's own decision maker.A care plan indicated R38 had the potential for pain related to rheumatoid arthritis. The care plan contained a goal that R38 will indicate pain management is within acceptable limits and pain or analgesia will not affect participation in activities of choice or daily care. The care plan contained interventions to administer pain medication per Medical Doctor (MD) orders, implement non-drug therapies to assist with pain and monitor for effectiveness as needed, notify MD if pain frequency/intensity is worsening or if current analgesia regimen has become ineffective, and report non-verbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. R38 had the following physician orders: ~ Tramadol oral tablet 50 mg. Give 1 tablet by mouth every 6 hours as needed (PRN) for pain. ~ Tramadol oral tablet 50 mg. Give 1 tablet by mouth every night shift for pain between 3:00 AM and 4:00 AM.On 3/2/26 at 10:33 AM, Surveyor interviewed R38 who stated R38's pain medication for rheumatoid arthritis (a chronic, systemic autoimmune disease where the immune system attacks the joint lining causing painful inflammation, stiffness, and potential deformity) was not refilled timely and R38 had missed some doses. R38 stated the facility informed R38 that the physician was contacted for a refill. R38 stated R38 was diagnosed with rheumatoid arthritis as a child and had pain and decreased range of motion since childhood. On 3/3/26 at 10:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated if a resident's medication runs low or runs out, staff reorder from the pharmacy through the resident's electronic medical record. LPN-E stated staff need to reorder a medication when the resident has two to three days of medication remaining. When staff reorder a medication, they write an X or an R on the medication card which means the medication was reordered. LPN-E stated the pharmacy delivers medication every morning between 3:00 AM and 4:00 AM. LPN-E indicated the facility had issues with receiving medication because some staff ordered medication too early and the pharmacy did not fill the medication. LPN-E indicated when a resident's medication is not in the medication cart, staff remove medication from contingency (extra medication provided by the pharmacy in a secure location). If the medication is not in stock or in contingency, the nurse faxes the provider and requests an order for the medication. LPN-E verified R38's tramadol had run out. LPN-E stated tramadol was supposed to be delivered in the early morning of 3/3/26 but did not arrive. LPN-E stated LPN-E will report to the PM shift to pass the information onto the night shift that R38's tramadol will be delivered during the 3:00 AM to 4:00 AM delivery on 3/4/26. LPN-E stated LPN-E would contact the pharmacy to ensure the medication was ordered.LPN-E and Surveyor reviewed R38's Medication Administration Record (MAR) which indicated tramadol was last administered on 2/27/26 at 3:20 AM. LPN-E stated tramadol should be in contingency. LPN-E stated when LPN-E was working and R38's tramadol was due, R38 did not appear to be in pain and was the same as LPN-E and Surveyor observed during medication administration that morning. LPN-E assessed R38's pain during medication administration. R38 stated the pain was the same as usual. LPN-E stated if R38 is sleeping during the 3:00 AM to 4:00 AM tramadol administration time, R38 will wake up, take the medication, and fall back to sleep within five minutes. LPN-E stated R38 had not requested other interventions or pain medication when R38's tramadol was out during shifts that LPN-E worked since 2/27/26 and had not indicated that R38's pain was worse than normal. LPN-E stated the only time R38 appeared to be in pain was during a recent rectal prolapse. On 3/3/26 at 12:28 PM, Surveyor interviewed R38. When asked about R38's pain on a scale of 0 to 10 when tramadol was not administered, R38 stated R38's pain was a 6 out of 10 but worsened when R38 moved around. R38 stated R38's pain was a 4 out of 10 when tramadol was administered. R38 stated staff offered acetaminophen which was ineffective and R38 refused. R38 stated R38 does not know why R38 is not receiving tramadol. On 3/4/26 at 10:43 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated a refill request for R38 was submitted to the provider who had twice sent the refill to the wrong pharmacy. NHA-A stated a pain assessment was completed, R38 was monitored, and other pain medications were offered and declined. NHA-A stated staff education regarding the availabiity of contigency stock will begin prior to nurses working their next shift. NHA-A stated R38 received tramadol from contingency for the HS dose on 3/3/26 and the 3:00 to 4:00 AM dose on 3/4/26.Surveyor requested the contingency stock dispensing machine report for tramadol 50 mg tablets for February 2026 through 3/4/26. On 3/4/26 at 12:26 PM, Director of Nursing (DON)-B provided a usage report for tramadol 50 mg tablets from the contingency machine. The report indicated R38's tramadol dose was taken from contingency stock on the following dates and times: ~ Removed on 2/26/26 at 11:26 PM by DON-B and administered on 2/27/26 at 3:00 AM - 4:00 AM. (Of note: The dose was not documented as administered according to R38's MAR.)~ Removed on 3/3/26 at 4:56 PM for an as needed (PRN) bedtime dose.~ Removed on 3/4/26 at 4:14 AM for the 3:00 AM - 4:00 AM dose~ On 3/4/26 at 4:19 AM, staff re-counted due to entering the wrong number during the prior transaction. One tramadol 50 mg tablet was removed during two documented transactions on 3/4/26.According to R38's MAR, tramadol 50 mg was not administered at the scheduled time of 3:00 AM - 4:00 AM and the PRN bedtime dose per R38's request to be given every evening before bed on the following dates and times:~ On 2/27/26 at 3:00 AM - 4:00 AM: Documented as code 9 (other/see progress note). (Of note: The dose was taken out of contingency but was not documented as administered.) ~ On 2/27/26 at bedtime: No documentation~ On 2/28/26 at 3:00 AM - 4:00 AM: Documented as code 9~ On 2/28/26 at bedtime: No documentation~ On 3/1/26 at 3:00 AM - 4:00 AM: Documented as code 9~ On 3/1/26 at bedtime: No documentation~ On 3/2/26 at 3:00 AM - 4:00 AM: Documented as code 9~ On 3/2/26 at bedtime: No documentation~ On 3/3/26 at 3:00 AM - 4:00 AM: No documentationSurveyor noted tramadol 50 mg tablets were available in contingency stock during the above missed administration times.On 3/4/26 at 1:28 PM, Surveyor interviewed DON-B who worked the night shift on 2/26/26 and was informed by the PM nurse that R38 did not have any tramadol 50 mg tablets. DON-B retrieved one tramadol 50 mg tablet from contingency on the evening of 2/26/26 in anticipation of administering the medication to R38 on 2/27/26 for the 3:00 AM - 4:00 AM dose. DON-B was aware that R38's tramadol was out but did not recall the date. DON-B checked the 24-hour board for documentation but no documentation was found. NHA-A was present during interview and stated NHA-A would check to see if a request for tramadol was made prior to R38's last dose. Evidence of a request to refill was not provided during the survey.On 3/4/26 at 1:40 PM, Surveyor and DON-B reviewed the facility's narcotic log which indicated R38's tramadol ran out on 2/27/26. DON-B stated when there are 5 doses of a medication remaining, staff should reorder the medication through the resident's electronic medical record. The pharmacy fills the request and delivers the medication. DON-B stated the pharmacy contacts the facility if the medication does not have any refills. The nurse then contacts the provider for a refill and writes a progress note. R38's progress notes indicated the following: ~ On 3/1/26 at 12:45 PM, the facility contacted the provider and requested to refill R38's tramadol.~ On 3/2/26 at 2:07 AM, R38's tramadol was on hold until available from the pharmacy.~ On 3/3/26 at 1:30 PM, the pharmacy indicated they did not receive a prescription. The writer stated a tramadol refill was requested from the provider on 3/1/26.~ On 3/3/26 at 6:00 PM, the provider stated previous prescriptions were sent to wrong pharmacy. The provided indicated a presciption would be sent to the correct pharmacy.~ On 3/3/26 at 9:33 PM, the provider indicate a tramadol prescription was sent to the pharmacy.~ On 3/4/26 at 4:38 AM and 5:00 AM, clinical follow-up indicated R38 was resting comfortably in bed. R38's reported pain was chronic and the nurse administered tramadol 50 mg. A one-time pharmacy code was obtained to retrieve the medication from contingency. The pharmacist stated the pharmacy still did not have a tramadol prescription from the provider.~ On 3/4/26 at 11:39 AM and 2:13 PM, there was communication with the provider and pharmacy regarding the tramadol prescription. The prescription was received and the pharmacy indicated they would send it STAT (urgent; without delay).On 3/4/26 at 3:23 PM, Surveyor interviewed DON-B who stated the pharmacy sent DON-B a message that a nurse requested a code to retrieve one tramadol tablet from contingency on 3/4/26, however, the code did not work. A second code was given at 4:19 AM for the 3:00 AM - 4:00 AM dose and one tramadol tablet was removed from contingency. DON-B stated staff are educated on contingency stock and how to obtain medication by requesting a one-time code from pharmacy to access the dispensing machine. DON-B stated nurses are aware tramadol is in contingency but did not use the contingency dispensing machine to obtain tramadol for R38's missed doses.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R3, R4, and R5) of 3 residents observed during the provision of care. R3 was on enhanced barrier precautions (EBP). On 7/8/25, staff repositioned R3, adjusted R3's pillows and bedding, and provided incontinence care without wearing a gown and/or gloves. In addition, staff administered medication to R3, exited the room without completing hand hygiene, and retrieved supplies from the medication cart for another resident.R4 was on EBP. On 7/8/24, staff dressed and groomed R4 without wearing a gown or gloves.R5 was on EBP. On 7/8/25, staff assisted R5 with peri-care and a transfer from toilet to wheelchair without wearing a gown.Findings include:The facility's Enhanced Barrier Precautions Policy, revised 8/8/24, indicates: .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high-contact resident care activities .4. High-contact resident care activities include: a. dressing; .c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting .The facility's Medication Administration General Guidelines Policy, revised 1/2025, indicates: .Medication Administration: .11 .Hands are washed with soap and water again after administration and with any resident contact. Antimicrobial sanitizer may be used in place of soap and water as allowed per state nursing regulations and facility policy .1. On 7/8/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including dementia, history of multiple sclerosis, acute cystitis without hematuria, and neuromuscular dysfunction of bladder. R3's Minimum Data Set (MDS) assessment, dated 5/4/25, contained a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R3 had severe cognitive impairment. R3 had a Guardian for healthcare decisions. R3's medical record indicated R3 was on EBP for a pressure Injury.On 7/8/25 at 8:47 AM, Surveyor observed Certified Nursing Assistant (CNA)-C reposition R3, place pillows behind R3's back, and adjust R3's bedding and gown without wearing a gown or gloves. Surveyor observed an EBP sign and a personal protective equipment (PPE) cart that contained gowns and gloves outside R3's room. At 8:54 AM, Surveyor observed CNA-C provide incontinence care for R3 and noted CNA-C wore gloves but did not wear a gown.On 7/8/25 at 10:09 AM, Surveyor interviewed CNA-C who did not know why R3 was on EBP. CNA-C verified an EBP sign was posted outside R3's room and indicated a gown and gloves should be worn when personal cares are provided.On 7/8/25 at 11:22 AM, Surveyor interviewed Infection Control (IC)-F who indicated R3 was on EBP for a now healed pressure injury, however, the facility's policy indicates EBP is maintained for two weeks post wound healing. IC-F indicated staff should follow EBP when repositioning, adjusting bed linens, and providing incontinence care for R3.On 7/8/25 at 11:54 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should wear a gown and gloves during repositioning, adjusting pillows/linens, and during incontinence care for residents on EBP. 2. On 7/8/25 at 9:11 AM, Surveyor observed Licensed Practical Nurse (LPN)-E administer medication and adjust R3's linens without wearing a gown or gloves. LPN-E then exited R3's room without completing hand hygiene and retrieved a blood glucose monitor and supplies for another resident from the medication cart. On 7/8/25 at 10:16 AM, Surveyor interviewed LPN-E who confirmed R3 was on EBP and an EBP sign was posted outside R3's room. LPN-E verified LPN-E did not complete hand hygiene after administering medication to R3 and before retrieving items from the medication cart. On 7/8/25 at 11:54 AM, Surveyor interviewed DON-B who indicated staff should complete hand hygiene after administering medication and prior to entering the medication cart.3. On 7/8/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including history of quadriplegia, urinary tract infection (UTI), and neuromuscular dysfunction of bladder. R4's MDS assessment, dated 6/2/25, contained a BIMS score of 15 out of 15 which indicated R4 had intact cognition. R4 was responsible for R4's healthcare decisions. On 7/8/25 at 10:07 AM, Surveyor observed CNA-C and CNA-D dress R4, put on R4's socks, and fix R4's hair without wearing a gown or gloves. Surveyor observed an EBP sign and a PPE cart that contained gowns and gloves outside R4's room. On 7/8/25 at 10:09 AM, Surveyor interviewed CNA-C who verified CNA-C did not wear a gown or gloves while dressing/grooming R4. CNA-C verified an EBP sign was posted outside R4's room and indicated a gown and gloves should be worn when dressing residents on EBP.On 7/8/25 at 10:12 AM, Surveyor interviewed CNA-D who verified CNA-D did not wear a gown or gloves while dressing/grooming R4. CNA-D verified an EBP sign was posted outside R4's room and indicated a gown and gloves should be worn when dressing residents on EBP.On 7/8/25 at 11:22 AM, Surveyor interviewed IC-F who indicated R4 was on EBP for a suprapubic catheter. IC-F indicated staff should follow EBP when dressing R4. On 7/8/25 at 11:54 AM, Surveyor interviewed DON-B who indicated staff should wear a gown and gloves and during dressing/grooming cares for a resident on EBP. 4. On 7/8/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including history of joint (knee) replacement surgery, chronic obstructive pulmonary disorder (COPD), and atrial fibrillation. R5's MDS assessment, dated 7/6/25, contained a BIMS score of 15 out of 15 which indicated R5 had intact cognition. R5 was responsible for R5's healthcare decisions. On 7/8/25 at 9:17 AM, Surveyor observed Occupational Therapist (OT)-G assist R5 with peri-care and transfer R5 from the toilet to a wheelchair without wearing a gown. Surveyor observed an EBP sign and a PPE cart that contained gowns and gloves outside R5's room. On 7/8/25 at 11:22 AM, Surveyor interviewed IC-F who indicated R5 was on EBP for a right knee surgical site. IC-F indicated staff should follow EBP during toileting and transfers for R5.On 7/8/25 at 11:29 AM, Surveyor interviewed OT-G who stated upon entering R5's room, OT-G observed R5 stand up from the toilet. OT-G donned gloves quickly to assist R5 for safety. OT-G indicated OT-G usually donned a gown and gloves, however, OT-G was concerned for R5's safety and acted quickly.On 7/8/25 at 11:54 AM, Surveyor interviewed DON-B who indicated staff should assist R5 to a sitting position and then don a gown and gloves prior to assisting R5 with peri-care and a wheelchair transfer.

Based on staff and resident interview and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 3 residents (R) (R2, R1, and R6) of 4 sampled residents. R2 used a ROHO cushion (a type of cushion designed to prevent pressure injuries by using interconnected air cells to distribute weight and reduce pressure points) that was noted to be deflated. R2's plan of care did not indicate R2 used a ROHO cushion, did not contain an order to ensure the cushion was inflated, and was not updated with timely interventions after R2 developed what was initially thought to be a pressure injury but was later determined to be a sebaceous or pilonidal cyst. R2 was also provided a foam cushion with a cut-out but did not have an assessment for the cushion and did not use the cushion in R2's recliner.R1 and R6 had ROHO cushions. R1 and R6 did not have orders to ensure the ROHO cushions were properly inflated.Findings include:The facility's Pressure Injuries and Non Pressure Injuries policy, revised 7/20/22, indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries .Residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The staging of pressure injuries is consistent with the recommendations of the National Pressure Injury Advisory Panel (NPIAP) and the Resident Assessment Instrument (RAI) Manual, Section M .2. Weekly .Complete a head to toe skin check and document findings on the skin review. If new areas are present: .v. Update plan of care .The care plan should be updated to reflect the resident's choice and what interventions will be in place to minimize risk to the resident. The facility's Use of Support Services policy, dated 6/16/22, indicates: Support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. 1. From 6/5/25 to 6/6/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had a diagnosis of stage 4 pressure injury to coccyx. (On 6/27/25 (after the survey), the area on R2's coccyx was determined to be a sebaceous or pilonidal cyst.) R2's Minimum Data Set (MDS) assessment, dated 4/23/25, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R2 had moderate cognitive impairment. R2 was R2's own decision maker. The MDS assessment also indicated R2 rolled left to right independently and required supervision or touching assistance for transfers from chair to bed and toilet. A care plan, dated 3/24/24, indicated R2 was at risk for alteration in skin integrity related to frail skin, falls, decreased mobility, gradual decline in weight, protein malnutrition, and use of glasses. The care plan contained interventions for a pressure redistributing device on bed (dated 3/28/25) and to provide preventative skin care routinely and as needed (PRN) (dated 3/24/24). The care plan did not contain an intervention for a ROHO cushion.On 6/5/25 at 9:32 AM, Surveyor interviewed R2 who indicated R2 had a wound that was getting better but didn't know a wound could be that painful. In a subsequent interview on 6/6/25 at 3:50 PM, R2 indicated the facility gave R2 a cushion with a cut-out that was hard to use. R2 stated R2 had to sit on the cushion a certain way or it didn't work and the wound doctor said it was the wrong type of cushion. R2 was currently using a ROHO cushion which staff checked for inflation most of the time. R2 indicated R2 could reposition independently in a chair. Surveyor noted the cushion was properly inflated during both interviews.A progress note, dated 11/5/24 at 5:32 PM, indicated R2 had pneumonia, was placed on precautions, and was started on an antibiotic.A progress note, dated 11/6/24 at 8:40 PM, indicated R2 had an open area on the coccyx (tailbone) that measured 1.2 centimeters (cm) x 0.2 cm x 0.1 cm. The site was cleansed with soap and water and a border foam dressing was applied. The physician and the Director of Nursing (DON) were informed. A wound note, dated 11/6/24, indicated R2 had a moisture-related, stage 1 wound that measured 1.2 cm x 0.2 cm x 0.1 cm. A risk management note, dated 11/8/24, indicated R2 had occasional urinary incontinence and a moisture-related wound. A root cause analysis indicated a ROHO cushion used in R2's wheelchair was deflated. The ROHO cushion was removed and replaced with a pressure-relieving cushion. A sweep of the building was completed with no other ROHO cushions found. R2 was followed by wound care weekly and had weekly skin assessments. R2 was encouraged to lay down and offload pressure. An Interdisciplinary Team (IDT) clinical review note, dated 11/8/24, indicated R2 was independent in R2's room and spent most days in a wheelchair or recliner. R2 complained of pain to the coccyx. R2's wound measured 1.2 cm x 0.2 cm x 0.1 cm. A root cause analysis indicated R2's wheelchair cushion was not effective and needed adjustment. Immediate interventions included to educate R2 on the need to reposition periodically throughout the day. Long term interventions included to assess R2's wheelchair cushion for functionality and possible replacement. A clinical follow-up note, dated 11/8/24, indicated R2 had an open area on the coccyx. R2's cushion was exchanged for a new one. The note indicated staff should monitor the wound and apply more interventions if needed.A progress note, dated 11/13/24, indicated R2 was alert and oriented, used the call light for assistance, required minimal assistance with dressing and grooming after set up, and was continent of bowel and bladder. R2 ambulated with the assistance of 1 staff and a 2-wheeled walker and self-propelled in a wheelchair to and from all destinations. A facility wound assessment, dated 11/15/24, indicated R2 had an unstageable pressure injury that measured 2.1 cm x 1.1 cm. A treatment note, dated 11/18/24, indicated R2 agreed to trial a position change every 3 hours during the night. The note indicated a repositioning schedule would be implemented through the following evening and encouraged through the rest of the week. A facility wound assessment, dated 11/25/24, indicated R2 had an unstageable pressure injury that measured 3 cm x 1.2 cm. The note indicated to continue the same treatment to promote an antilytic debriding environment. The wound grew in size, however, the wound bed tissue improved from 95% to 70% slough.A facility wound assessment, dated 11/30/24, indicated R2 stated the wound felt better and R2 was able to sit on R2's buttocks without pain. A facility wound assessment, dated 12/2/24, indicated R2 had a stage 3 pressure injury that measured 3.4 cm x 1.5 cm. A care plan, dated 12/2/24, contained interventions (dated 12/2/24) for repositioning and a specialty offloading cushion. The specialty offloading cushion was removed from the care plan on 12/20/24. A facility wound assessment, dated 12/9/24, indicated R2 had a stage 3 pressure injury that measured 3.8 cm x 1.3 cm. A pressure-reducing cushion was to be used at all times. The assessment indicated R2 used a cushion in R2's wheelchair but spent time in a recliner sitting directly on the wound. R2 indicated the wound hurt when R2 sat in the recliner. The assessment indicated the cushion should be transferred to all chairs and a pillow should be placed behind R2's back in the recliner since R2 transferred independently. Staff were educated to check on R2 in the recliner for self-transfers and cushion use. R2 stated R2 liked the cushion and pillow.A facility wound assessment, dated 12/16/24, indicated R2 had a stage 3 pressure injury that measured 3.6 cm x 1.6 cm. R2 experienced pain during wound cleansing. A wound care consult was requested due to no improvement of the wound in 2 weeks. A facility wound assessment, dated 12/23/24, indicated R2 had a stage 3 pressure injury that measured 3.6 cm x 1.6 cm. A wound clinic appointment was scheduled.A wound clinic note, dated 12/27/24, indicated R2 had a stage 4 sacral deep tissue injury that measured 3.5 cm x 1.4 cm x 0.8 cm that contained granulation at the periphery with deep subcutaneous necrosis prior to debridement. The wound extended to exposed fascia, but not the bone. The note indicated R2 previously had a ROHO cushion in the wheelchair, however, it was not adequately inflated and resulted in the current deep sacral decubitus ulcer. R2 stated the facility replaced R2's cushion with 2 new cushions approximately one month ago, including a foam cushion as the base and a second foam cushion with a coccygeal cut-out. R2 stated R2 spent most of the day in the recliner which DON-B confirmed. R2 arrived at the appointment in a wheelchair with 2 foam cushions as described above. R2 confirmed R2 used to have a ROHO cushion that was underinflated. The note indicated offloading was of the utmost importance and indicated R2's pressure injury was most likely caused by sitting for prolonged periods in a recliner. It was the opinion of the writer and their colleagues that a ROHO cushion was superior to all other foam and gel cushions if properly inflated. The note contained a recommendation that R2 use an adequately inflated ROHO cushion for all seated surfaces that was checked weekly and replaced if it leaked air at too rapid of a rate. On 12/30/24, the facility updated R2's care plan with an intervention for a ROHO cushion on chair surfaces. An order was added to check R2's cushion for air every shift. A facility wound assessment, dated 12/30/24, indicated R2 had a stage 3 pressure injury (not a stage 4 as the wound clinic note indicated). The pressure injury was mechanically debrided during a wound care appointment.Surveyor reviewed the rest of R2's wound assessments and noted the wound clinic continued to stage R2's pressure injury as a stage 4, however, the facility continued to stage the pressure injury as a stage 3 on assessments dated 1/6/25, 1/13/25, 1/20/25, 1/27/25, 2/3/25, and 2/10/25. In February 2025, the facility hired Wound Registered Nurse (WRN)-E who staged R2's pressure injury as a stage 4 on 2/17/25. R2's wound remained stable or improved on further assessments.On 6/5/25 at 1:59 PM, Surveyor interviewed WRN-E who indicated WRN-E was not employed by the facility when R2 developed the (suspected) pressure injury but confirmed R2 should have been evaluated for an appropriate cushion and the cushion should have been added to R2's care plan. WRN-E stated residents with a ROHO cushion should have an order to check the cushion for proper inflation. WRN-E also confirmed the cushion should be on all surfaces. WRN-E indicated if WRN-E had staged a wound differently than the wound clinic, WRN-E would default to the wound clinic's staging.On 6/5/25 at 2:53 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility could not locate therapy notes, assessments, or orders related to R2 having a ROHO cushion prior to the discovery of the (suspected) pressure injury on 11/6/24. NHA-A indicated it was possible R2's family brought the ROHO cushion to the facility. NHA-A also indicated the facility could not locate therapy assessments for R2's cushions, including an initial evaluation for a ROHO cushion or any other cushion. NHA-A confirmed that between 11/8/24 and 12/27/24, it appeared R2 had 1 or 2 different cushions, however, NHA-A could not provide a timeline because there was no documentation or an updated care plan. NHA-A indicated the facility's previous wound nurse (who no longer worked at the facility) must have decided to use the foam cut-out cushion.On 6/5/25 at 3:53 PM, Surveyor interviewed NHA-A and [NAME] President of Success (VPS)-C. VPS-C confirmed R2's original ROHO cushion and an order to check the cushion for inflation should have been on R2's care plan. VPS-C indicated the facility's previous wound nurse was working on certification and was supervised by a wound nurse from the program. VPS-C indicated the previous wound nurse likely initiated the foam cushions and should have completed an evaluation and care plan update. NHA-A and VPS-C provided return demonstration ROHO cushion staff education on 12/6/24 and in January 2025. Surveyor noted the education was not signed by all staff and requested to see orders for R1 and R6 who also had ROHO cushions. On 6/6/25 at 8:33 AM, VPS-C provided a timeline of R2's (suspected) pressure injury and indicated the initial risk management report that identified the ROHO cushion as the cause of the pressure injury was wrong. VPS-C indicated R2 was just diagnosed with pneumonia and spent more time in R2's recliner. VPS-C indicated the initial wound was due to incontinence at a stage 1. VPS-C confirmed the progress note on 11/15/24 regarding repositioning should have been added to R2's care plan and acknowledged R2's wound development care plan should have been completed more timely. NHA-A confirmed a cushion should be added to a resident's care plan when it is implemented. On 6/6/25 at 9:24 AM, Surveyor interviewed DON-B who confirmed R2 had a ROHO cushion prior to developing the (suspected) pressure injury. DON-B confirmed a resident with a ROHO cushion should have an order to check the cushion for air every shift and confirmed an improperly inflated ROHO cushion could lead to harm. DON-B indicated when DON-B entered R2's room on 11/8/24, R2 was in the recliner and the deflated ROHO cushion was in R2's wheelchair. DON-B tried to unsuccessfully inflate the cushion and then put a regular pressure-relieving cushion in R2's wheelchair. DON-B was not sure when the foam cushions were implemented. DON-B confirmed R2's medical record should have contained a note or assessment and the cushions should have been added to R2's care plan. DON-B indicated a wound nurse can initiate a cushion, however, a resident should be referred to therapy if there is a question. DON-B indicated DON-B completed a sweep of the building for ROHO cushions and provided staff education at a huddle and a meeting. Surveyor noted only 17 of 43 staff signed the education regarding a return demonstration on ensuring a ROHO cushion is inflated properly. (Note: A wound note from Medical Doctor (MD)-F, dated 6/27/25 and provided to the State Agency on 6/27/25, indicated MD-F assessed R2's wound on 6/27/25 and determined the wound had a capsule-like lining to the wound bed and an odor reminiscent of a sebaceous cyst. Based on the current findings and the wound's failure to heal with previous treatment, MD-F indicated the wound was more likely to be a sebaceous or pilonidal cyst instead of a pressure injury.)2. From 6/5/25 to 6/6/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had a diagnosis of pressure injury to coccyx stage 4. R1's MDS assessment, dated 5/27/25, had a BIMS score of 13 out of 15 which indicated R1 had intact cognition. A pressure injury to coccyx stage 4-in house care plan, initiated on 4/24/25, indicated R1 often refused to be repositioned and pushed against pillow placement so R1 was no longer laying on R1's side. The care plan contained an intervention, dated 4/24/25, for a ROHO cushion at all times when in wheelchair. R1 discharged from the facility on 5/23/25.R1's medical record indicated R1 went to the hospital on 4/28/25 and returned on 5/6/25. R1 did not have an order to check the ROHO cushion for inflation after R1 returned from the hospital.On 6/6/25 at 8:33 AM, Surveyor interviewed VPS-C who confirmed R1 did not have an order to check the ROHO cushion for inflation after R1 returned from the hospital. 3. From 6/5/25 to 6/6/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including spondylosis without myelopathy and pressure ulcer of sacral region stage 3. R6's MDS assessment, dated 4/28/25, had a BIMS score of 14 out of 15 which indicated R6 had intact cognition.On 6/5/25 at 3:45 PM, Surveyor interviewed R6 who confirmed R6 had a ROHO cushion which was not consistently checked for inflation. R6 indicated sometimes R6 needed to remind staff to check the cushion or be sure it was underneath R6. R6 stated R6's pressure injury was improving.R6's medical record contained a nursing order, initiated on 5/8/25, to check the ROHO cushion every shift for functionality and add air when needed. The order was discontinued on 5/14/25. R6 was transferred to the hospital on 5/13/25 and returned to the facility on 5/19/25. On 6/6/25 at 8:33 AM, Surveyor interviewed VPS-C who confirmed the order to check air in R6's ROHO cushion was not reinstituted after R6 returned from the hospital.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R1) of 4 sampled residents was transferred safely with a mechanical lift. On several instances between 12/10/24 and 12/20/24, therapy and nursing staff documented R1 was unable to safely transfer with a sit-to-stand lift. On 12/18/24, therapy staff determined R1 should be transferred with a full body (Hoyer) lift for safety. R1's care plan and Certified Nursing Assistant (CNA) Kardex (an abbreviated care plan used by nursing staff) were not updated with the changes and staff continued to transfer R1 with a sit-to-stand lift. On 12/18/24, staff observed significant bruising on R1's left upper arm, shoulder, and torso. On 12/20/24, lab results indicated R1 was experiencing severe acute anemia. R1 was hospitalized from 12/20/24 to 12/23/24 and required a blood transfusion. Findings include: The facility's High Risk Medications Anticoagulant Policy, dated 8/30/23, indicates anticoagulant medications are associated with greater risks of adverse consequences than other medications. The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include, but are not limited to: bleeding, unusual bruising, blood in urine/stool, lower blood pressure, and fall in hematocrit or hemoglobin. On 1/22/25, Surveyor requested the facility's mechanical lift policy. Nursing Home Administrator (NHA)-A provided Surveyor with a staff lift competency evaluation form that indicated staff should be able to locate a resident's care plan to validate transfer status and sling size/type. On 1/22/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including spondylosis (spinal arthritis), weakness, spinal stenosis (narrowing of the spinal column causing compression on the nerves and vessels), rheumatoid arthritis, and long-term use of an anticoagulant (blood thinning) medication. R1's most recent Minimum Data Set (MDS) assessment, dated 12/30/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 was not cognitively impaired. R1 was R1's own decision maker. R1's admission care plan (initiated 12/4/24) stated R1 was a pivot transfer with the assistance of two staff and a gait belt. The care plan contained an intervention to monitor and report adverse effects such as bruising due to anticoagulation therapy. R1's CNA Kardex indicated R1 required two staff to pivot assist with a gait belt as of 12/20/24. R1's care plan was revised on 12/24/24 and stated R1 transferred with the assist of two staff and a Hoyer lift with a large sling An admission assessment, dated 12/4/24, indicated R1's skin was intact. A progress note, dated 12/5/24, indicated R1 was a pivot transfer with the assistance of two staff and a gait belt. A therapy evaluation, dated 12/9/24, indicated R1 should be transferred with a sit-to-stand lift. A skin assessment, dated 12/10/24, indicated R1 had a bruise on the chest. (There was no additional documentation and the physician was not notified.) A therapy note, dated 12/10/24, indicated R1 had exponential difficulty with sit-to-stand transfers and therapy recommended further strengthening. A therapy note, dated 12/12/24, indicated staff attempted to transfer R1 with a sit-to-stand lift but R1 had poor quad activation leading to safety hazard with sling slide and poor ascend capabilities. A therapy note, dated 12/13/24, indicated staff attempted a sit-to-stand transfer, however, R1 was not able to get R1's hips off the wheelchair seat with maximum assistance of pulling up on bars/pushing up on wheelchair arm rests. A therapy note, dated 12/16/24, indicated R1 continued to use a sit-to-stand lift but the lift was hard on R1's shoulders due to weakness and both hands for gripping. A progress note, date 12/17/24, indicated R1 was transferred from a recliner to the toilet. A CNA statement indicated R1 did not transfer well, did not hold onto the sit-to-stand well, and did not bear weight well. The note indicated R1's elbows floated up like chicken arms and R1 obtained a skin tear on the left elbow. The physician was notified and a treatment was ordered. A therapy communication form, dated 12/17/24 and completed by Licensed Practical Nurse (LPN)-D, indicated R1 had an unsafe sit-to-stand transfer on the PM shift. A progress note, dated 12/18/24, indicated R1 transferred with a sit-to-stand lift with two staff which left bruising on R1's skin. A therapy note, dated 12/18/24, indicated staff used a sit-to-stand lift to raise R1 from a recliner but R1 was not able to get R1's hips off the surface and hung in the lift in a chair position. In response to caregivers' concerns about lift safety, weakness, and left shoulder pain, a functional maintenance plan (FMP) was written for the use of a Hoyer lift until R1 got stronger and R1's shoulder pain subsided. The FMP, dated 12/18/24, indicated R1 was safer with a Hoyer lift due to shoulder discomfort. A skin assessment, dated 12/19/24, indicated R1 had bruising on the left upper arm, chest, side, and back. (There was no additional documentation and the physician was not notified.) A therapy note, dated 12/20/24, indicated R1 reported that staff transfer R1 with a sit-to-stand lift and don't listen when R1 is raised in the lift and states R1's shoulder is sore. A progress note, dated 12/20/24, indicated R1's lab results showed a low hemoglobin and R1 was sent to the Emergency Department (ED) for evaluation. Nursing staff agreed to change R1 to a Hoyer lift for safety precautions. ED staff notified the facility that R1 was admitted and had extensive bruising on the upper torso. An ED note, dated 12/20/24 at 6:08 PM, indicated R1 was seen for evaluation due to anemia, hyphenate (low blood sodium level), and low carbon dioxide (CO2) levels. R1 had a significant hematoma on the bilateral chest that was worse on the left torso/chest and left upper arm. There were concerns regarding the hematoma and R1's decreased blood pressure. R1 reported discomfort to the chest and abdomen, denied any falls, and indicated R1 received Eliquis (anticoagulant medication) daily. Lab results indicated R1's hemoglobin was 9.6 (down from 15.4 one month prior). A computed tomography (CT) scan of R1's chest, abdomen, and pelvis indicated a significant hematoma of the left pectoral muscle that measured 11 centimeters (cm) at the widest point. R1's blood pressure was 90/58 millimeters of mercury (mmHg) (normal blood pressure is 120/80 mmHg) with dizziness noted. A Hospitalist visit note, dated 12/20/24, indicated R1 was admitted with acute blood loss anemia due to traumatic hematoma of the chest wall. R1 had severe pain while lifted in a sit-to-stand lift at the nursing home. R1 had diffuse ecchymosis (skin discoloration/bruising) throughout the chest wall and back. R1 reported dizziness and lightheadedness and was hypotensive. R1 responded to intravenous (IV) fluids and transfusion with 1 unit of packed red blood cells. A progress note, dated 12/21/24, indicated R1 was admitted for acute anemia and a hematoma on the left armpit into the left chest and down to the ribs and left lower back. R1's Eliquis was being held and R1 would remain at the hospital until at least 12/23/24. A Discharge Summary, dated 12/23/24, indicated R1 had acute blood loss anemia due to traumatic hematomas of the thorax likely related to a lifting device. On 1/22/25 at 10:11 AM, Surveyor interviewed Physical Therapist (PT)-C who verified R1 was initially a pivot transfer but was changed to a sit-to-stand lift on 12/9/24. PT-C stated R1 had some issues with the sit-to-stand lift (including increased pain when the sling slid up into R1's shoulders) and indicated R1 could only handle approximately 20-30 seconds of weight bearing. PT-C indicated R1 stated on multiple occasions that it would be nice to have staff who were trained to use the lift. PT-C verified nursing staff were able to go from pivot transfer to sit-to-stand lift or sit-to-stand lift to Hoyer lift if they felt it was safer for a resident, however, nursing staff were not allowed to go the opposite way for safety reasons. PT-C stated if there are changes in a resident's transfer status, therapy staff complete an FMP that is given to nursing staff to update the resident's care plan and CNA Kardex. PT-C verified R1 was compliant with therapy exercises. On 1/22/25 at 12:14 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who verified there was an incident on 12/17/24 when a CNA told LPN-D that R1 did not safely transfer with the sit-to-stand lift. LPN-D filled out a therapy communication form on 12/17/24 and indicated R1 had difficulty transferring with the lift which resulted in a skin tear on the elbow. LPN-D assessed R1's bruising on 12/19/24 and verified R1's physician was not updated. LPN-D verified staff used a sit-to-stand lift with R1 until after R1 returned from the hospital on 12/23/24. On 1/22/25 at 1:04 PM, Surveyor interviewed R1 who verified R1 told multiple staff the sit-to-stand lift was too difficult to use and R1 experienced pain during most transfers. R1 stated R1 did not notice the bruising until staff noticed it on 12/18/24. R1 stated R1's left shoulder was painful and rated the pain at level 7 out of 10 before R1 went to the hospital. R1 verified staff used the sit-to-stand lift for transfers until R1's hospitalization on [DATE]. R1 stated staff currently use a Hoyer lift to transfer R1. On 1/22/25 at 1:34 PM, Surveyor interviewed CNA-E who verified R1 transferred with a sit-to-stand lift until R1's hospitalization on [DATE]. CNA-E verified therapy staff write an FMP when a resident's transfer status changes and stated CNA-E follows interventions on a resident's Kardex or care plan. CNA-E verified R1 had difficulty using the sit-to-stand lift at times due to not being able to bear weight. On 1/22/25 at 1:38 PM, Surveyor interviewed LPN-H who indicated therapy staff put FMPs in a communication binder. LPN-H indicated nursing staff are responsible for updating residents' care plans and Kardexes as well as Director of Nursing (DON)-B and floor staff. On 1/22/25 at 2:01 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified R1 changed from a pivot transfer to a sit-to-stand lift on 12/9/24 and to a Hoyer lift on 12/18/24 per therapy instructions. NHA-A verified R1's care plan and Kardex were not updated to reflect the changes until 12/24/24. On 1/22/25 at 2:13 PM, Surveyor interviewed CNA-F who verified R1 transferred with a sit-to-stand lift until R1's hospitalization on [DATE]. CNA-F stated R1's extensive bruising was not present prior to 12/16/24. CNA-F stated R1 sometimes had difficulty supporting R1's body weight during transfers with a sit-to-stand lift and complained of shoulder pain at times. On 1/22/25 at 2:37 PM, Surveyor interviewed CNA-G who stated R1 was initially a pivot transfer and was changed to a sit-to-stand transfer until R1's hospitalization on [DATE]. CNA-G observed R1's torso bruising when CNA-G changed R1's shirt on the 12/18/24 PM shift. When CNA-G asked R1 where the bruising came from, R1 stated the bruising was probably from the lift sling. CNA-G informed LPN-I. CNA-G worked the following day and noted the bruising had spread which CNA-G communicated to nursing staff. CNA-G stated R1 struggled with the sit-to-stand lift at times and CNA-G stopped raising R1 when R1 asked. CNA-G indicated therapy staff are responsible for determining a resident's transfer status and changes are communicated through FMPs. CNA-G thought DON-B or the Assistant Director of Nursing (ADON) was responsible for updating residents' care plans and Kardexes. On 1/22/25, NHA-A provided Surveyor with an improvement plan, dated 12/23/24 to 12/26/24, related to skin assessments, nurse/physician notification of skin concerns, skin monitoring for residents on anticoagulant medication, and abuse/neglect. NHA-A verified staff were not educated on updating care plans or Kardexes or on safe transfers since the incident with R1 was identified. Per the facility's investigation, CNA-G reported to LPN-I that R1 had bruising on R1's chest, back, and under arm on the 12/18/24 PM shift. LPN-I did not assess R1's new bruising and passed the information to night (NOC) shift Registered Nurse (RN)-J. RN-J did not assess R1's bruising and passed the information to AM shift LPN-D.

Based on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R15) of 1 resident with a legal guardian was obtained when the resident's nursing home stay exceeded 90 days. R15 had a legal guardian. The facility did not obtain court-ordered protective placement for R15 to ensure R15 resided in the least restrictive environment at the facility. Findings include: State Statute Chapter 55.03(4) indicates court-ordered protective placement should be obtained for any resident admitted to a nursing home who has a legal guardian and whose nursing home stay exceeds 90 days. On 10/28/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including Down syndrome. R15's Minimum Data Set (MDS) assessment, dated 9/12/24, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R15 had severely impaired cognition. R15 a had a guardianship in place at the time of admission. R15's medical record contained a guardianship that was dated 4/6/09. R15's medical record did not contain annual protective placement paperwork. On 10/29/24, the facility provided Surveyor with paperwork for R15's original guardianship in April of 2009. On 10/29/24 at 9:57 AM, Surveyor interviewed Social Worker (SW)-I who indicated R15 was not protectively placed and had resided at the facility for a long time. On 10/29/24 at 10:19 AM, Surveyor again interviewed SW-I who indicated SW-I contacted Adult Protective Services (APS) who indicated R15's guardianship was sought by family in lieu of a Power of Attorney for Healthcare (POAHC) due to R15's developmental disability, not a safety issue. APS indicated the county wasn't involved with R15's guardianship. SW-I indicated SW-I was not aware that no matter how a guardianship was sought, when a resident enters a nursing home for long-term care, the resident needs protective placement in the facility. SW-I indicated APS told SW-I that residents who are admitted to a facility with more than 16 beds and have a guardianship need protective placement. SW-I indicated SW-I would work with APS to get R15's protective placement completed.

Based on staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 1 resident (R) (R5) of 13 sampled residents. On 10/18/24, R5 was hospitalized due to not eating or drinking. R5 did not have a care plan that addressed nutrition or hydration. Findings include: The facility's Comprehensive Care Plan policy and procedure, dated 9/23/22, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 10/28/24, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (stroke), hemiplegia and hemiparesis, weakness, and diabetes. R5's Minimum Data Set (MDS) assessment, dated 8/19/24, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R5 had severe cognitive impairment. R5's medical record indicated R5 had a guardian. R5's medical record did not contain a care plan to address R5's nutrition/hydration needs. R5's medical record indicated R5 was not eating or drinking and was sent to the hospital on 10/17/24. R5 returned to the facility on [DATE] with diagnoses of thyrotoxicosis, urinary tract infection (UTI), candiduria, hypernatremia, and hypercalcemia. On 10/21/24, hospital staff notified facility staff of R5's lab results and R5 was hospitalized to optimize hydration and stabilize electrolytes. R5 returned to the facility on [DATE]. Surveyor noted R5 had a 12.4 pound (15%) weight loss since admission (including a 3.58% weight loss in the last 30 days). A Nutritional Assessment, dated 10/28/24, indicated R5 was on a regular diet, puree texture, regular thin consistency and contained indications to monitor R5's weight, oral intake, and labs. On 10/28/24 at 11:04 AM, Surveyor interviewed R5's guardian who indicated R5 had not been eating much and staff asked the guardian to bring R5's favorite foods from home to improve R5's nutrition/hydration. On 10/30/24 at 11:19 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated staff tried nutritional shakes with no success and asked R5's guardian to bring R5's favorite foods. LPN-E indicated R5 should have a care plan to address nutrition/hydration. On 10/30/24 at 11:21 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R5 did not have a nutrition care plan. DON-B indicated DON-B expected a care plan to be in place to address R5's weight loss and nutritional needs.

Based on observation, staff interview, and record review, the facility did not ensure nail care was provided for 1 resident (R) (R28) of 14 residents reviewed for activities of daily living (ADL) assistance. Staff did not provide routine nail care for R28. Findings include: The facility's Nail Care Policy, dated 4/20/23, indicates: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .2. Identify conditions that increase the risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. On 10/28/24, Surveyor reviewed R28's medical record. R28 had diagnoses including renal failure, arthritis, and hypertension. R28's 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 R28 had moderate cognitive impairment. R28's medical record indicated R28 was responsible for R28's healthcare decisions. R28's plan of care indicated R28 required assistance of staff for all cares. On 10/28/24 at 10:40 AM, Surveyor interviewed R28 who indicated R28 had concerns with R28's fingernails and toenails. R28 indicated R28's nails were too long and R28's toenails caused pain/pressure in R28's feet. R28 indicated weekly showers were provided, but nail care was not provided. Surveyor noted R28's fingernails were a 1/2 inch above R28's fingertips. Five of the nails were split/cracked in the middle and many of the nails contained sharp and jagged edges. Surveyor noted R28's toenails were 1/4-1/2 inch above the toe and were thick, yellow, and crusted. In addition, 3 toenails were starting to curl over the toe. On 10/29/24 at 1:51 PM, Surveyor interviewed Certified Nurse Assistant (CNA)-G who indicated residents were provided weekly showers and nail care was provided the CNAs unless the resident was diabetic. CNA-G indicated during the 4 months CNA-G worked at the facility, CNA-G had never provided nail care. On 10/29/24 at 1:53 PM, Surveyor interviewed CNA-H who indicated nail care was provided on shower days once per week. On 10/29/24 at 1:56 PM, Surveyor interviewed Registered Nurse (RN)-D who observed R28's nails with Surveyor and verified there was significant growth and it appeared R28 had not had proper nail care for awhile. RN-D provided nail care for R28. On 10/29/24 at 1:59 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated nail care should be provided on shower days. DON-B indicated CNAs provided nail care unless the resident was diabetic which required a nurse to provide nail care.

Based on observation, staff interview, and record review, the facility did not provide appropriate care and services for 1 resident (R) (R4) of 2 sampled residents with an indwelling catheter. On 10/28/24 and 10/30/24, R4's catheter drainage bag and tubing were observed in contact with the floor. Findings include: The facility's Catheter Care policy and procedure, dated 3/15/23, does not address the positioning/placement of catheter tubing or drainage bags. On 10/28/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including history of diabetes, chronic kidney disease (CKD), heart failure, and urinary tract infection (UTI). R4's Minimum Data Set (MDS) assessment, dated 9/22/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R4 had moderate cognitive impairment. R4 had an activated Power of Attorney (POA) for healthcare decisions. R4's medical record indicated R4 was sent to the Emergency Department (ED) on 10/9/24 for not drinking and lethargic behavior. R4 was treated and returned to the facility. On 10/11/24, ED staff notified the facility that R4 had a UTI and was prescribed antibiotics. R4 had a Foley catheter placed on 10/14/24 for comfort. On 10/28/24 at 12:58 PM and 10/30/24 at 9:01 AM, Surveyor observed R4 and noted R4's catheter bag was covered by a dignity bag and attached to the bottom of R4's wheelchair. Surveyor noted the dignity bag and catheter tubing were dragging on the floor. On 10/30/24 at 9:13 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated Foley care was provided daily in the morning and evening. CNA-F verified catheter bags and tubing should not touch the floor and repositioned R4's catheter bag and tubing to prevent them from touching the floor. On 10/30/24 at 9:16 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who verified catheter bags and tubing should not touch the floor. On 10/30/24 at 9:24 AM, Surveyor interviewed Director of Nursing (DON)-B who verified catheter bags and tubing should not touch/drag on the floor.

Based on observation, staff interview, and record review, the facility did not ensure necessary treatment and services related to nutrition were provided for 1 resident (R) (R33) of 4 sampled residents. R33 was prescribed large portions for meals. During lunch service on 10/29/24, kitchen staff did not ensure R33 received large portions. In addition, R33 was prescribed a nutritional supplement 3 times per day for weight management. When R33 returned from the hospital on 10/18/24, the nutritional supplement was not provided for 11 days. Findings include: On 10/30/24 at 1:51 PM, [NAME] President of Success (VPS)-C indicated the facility did not have policies for nutrition or re-admission orders. Between 10/28/24 and 10/30/24, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including T11-T12 vertebra subsequent encounter for fracture with routine healing and displaced intertrochanteric fracture of the right femur. R33's Minimum Data Set (MDS) assessment, dated 10/24/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R33 did not have cognitive impairment. R33 was R33's own decision maker. A nutrition care plan, initiated on 9/23/24, indicated R33 was at risk for nutritional status change related to low body weight upon admission and weight decline. A goal, dated 9/23/24, indicated R33 would maintain R33's weight with no significant weight changes and weight gain was desirable. An intervention, dated 9/30/24, indicated to provide diet as ordered .large portions. On 10/30/24 at 11:51 AM, Surveyor interviewed R33 who confirmed R33 had lost a significant amount of weight in the last year. R33 was not sure why R33 lost weight and indicated R33 wanted to gain weight. R33's medical record indicated the following: ~ On 9/24/24, R33 weighed 130.6 pounds (lbs). ~ On 9/27/24, R33 weighed 123.7 lbs. ~ An admission nutrition progress note, dated 9/30/24, indicated R33 should receive large portions. R33 had a low body weight upon admission and weighed 165 lbs approximately 1 year ago. At home, R33 consumed 2-3 meals per day. R33's appetite was pretty good but there could be more. R33 was offered and accepted large portions. ~ On 10/11/24, R33 weighed 122.2 lbs (which was a 6.4% weight loss in less than 30 days). ~ On 10/14/24, staff notified the physician of R33's significant weight loss and initiated Sysco shakes three times daily (TID) with meals. R33 was admitted to the hospital. ~ On 10/18/24, R33 returned to the facility. Sysco shakes were not re-initiated. ~ A nutrition assessment, dated 10/28/24, indicated R33 weighed 122.0 lbs on 10/25/24. A gradual weight change was present (a 6.58 % decline over 30 days). Nursing staff updated R33's physician when R33 weighed 122.2 lbs on 10/14/24. R33's weight had stabilized since that time. R33 had a low body weight upon admission and weighed 165 lbs approximately 1 year ago. At home, R33 consumed 2-3 meals daily. R33 was offered large portions upon admission which R33 wanted to continue. R33 also wanted to resume Sysco shakes. A request was sent to R33's physician. The assessment indicated staff should continue to monitor R33's weight and oral intake. R33's care plan was reviewed and revised. ~ On 10/28/24, an intervention was added to R33's care plan to provide supplements as ordered. ~ A progress note, dated 10/29/24, indicated R33's physician ordered Sysco shakes TID due to weight loss and low body weight. During lunch service on 10/29/24 at 12:01 PM, Surveyor noted R33's meal ticket indicated R33 should receive regular large portions, 1 cup of carrots, 1 cup of scooped noodles, and 4.5 ounces of meat. Surveyor observed [NAME] (CK)-J plate a 1/2 cup of carrots (1 scoop), a 1/2 cup of noodles (1 scoop), and 1 scoop of meat for R33 and then cover R33's plate. Dietary Aid (DA)-K placed R33's tray on a meal cart. Surveyor stopped DA-K and asked if R33 received large portions. DA-K sent the tray back to CK-J who put another scoop of each item on R33's plate. On 10/30/24 at 8:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA-G) and CNA-M who were familiar with R33. CNA-G and CNA-M indicated they did not notice if R33 received double portions for meals or more food than others, however, CNA-M indicated R33 received 2 servings of oatmeal for breakfast that day but ate only 1 serving. CNA-G indicated R33 was a decent eater and staff documented R33's intake. Surveyor reviewed R33's meal intakes and noted they were mostly 75-100%. On 10/30/24 at 9:17 AM, Surveyor interviewed Registered Dietician (RD)-L who indicated R33 lost weight R33's first week in the facility which wasn't unusual and R33's weight had been stable since then. When asked about the supplement that was initiated on 10/14/24 prior to R33's hospital stay, RD-L confirmed the supplement did not get re-initiated when R33 returned from the hospital. RD-L confirmed when a resident returned from a hospital stay, RD-L hoped what the facility did dietary-wise prior to the hospital stay was re-initiated or that staff asked if they were unsure. RD-L indicated R33's weight remained stable without the supplement. When Surveyor indicated R33 wanted to gain weight and informed RD-L that CK-J did not initially provide R33 with large portions during the lunch meal on 10/29/24, RD-L indicated CNAs should double check residents' meal tickets when meals were served to help ensure nothing was missing. On 10/30/24 at 12:47 PM, Surveyor interviewed VPS-C who indicated if a resident was out of the facility for more than 3 days, the facility treated the resident as a new admission when they returned. VPS-C indicated the Nurse Manager, Director of Nursing (DON), or Assistant Director of Nursing (ADON) should review and compare orders to what the resident had previously. VPS-C confirmed R33's supplement should have been initiated upon R33's return from the hospital.

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 all 38 residents residing in the facility. The facility did not monitor and document food cooked temperatures and food cooling temperatures. Findings include: On 10/3/23, Executive Director (ED)-C verified the facility follows the Food and Drug Administration (FDA) Food Code as their standard of practice. Cooked temperatures: The FDA Food Code 2022 indicates at section 3-401.11 Raw Animal Foods. (A) Except as specified under (B) and in (C) and (D) of this section, raw animal foods such as eggs, fish, meat, poultry, and food containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked .Internal Cooking Temperature Specifications for Raw Animal Foods .Raw eggs cooked for immediate service, fish, intact meat, except whole meat roasts and whole muscle intact beef steak at 145 F (Fahrenheit) for 15 seconds .Commercially raised game animals, rabbits at 155 F for 17 seconds .Non-intact meats and raw eggs not for immediate service, wild game animals, poultry, stuffed fish, meat, pork, pasta, ratites, stuffing containing fish, meat, ratites & poultry at 165 F for greater than 1 second . The FDA Food Code 2022 indicates at section 3-403.11 .(C) and (D) Food that is taken from a commercially processed, hermetically sealed container or intact package cooked to a temperature of 135 F. During a continuous kitchen observation on 10/3/23 beginning at 8:24 AM, Surveyor observed Dietary Manager (DM)-D serve breakfast at the steam table. Surveyor interviewed DM-D regarding food cooked temperatures and holding temperatures. DM-D indicated temperatures are obtained and documented when food is removed from the oven and placed in the steam table for holding and serving at meal times. DM-D indicated the only food temperature obtained is the holding temperature at the steam table. Surveyor reviewed the facility's food holding temperatures for each meal. Surveyor noted appropriate holding temperatures for hot foods above 135 degrees, and cold foods below 41 degrees. Surveyor noted an entry in which the food temperature for chicken was documented at 145 degrees, which is an appropriate food holding temperature, but not an appropriate cooked temperature. Surveyor noted the bottom of the form used to document food temperatures indicated Hot foods to be held above 135 and cold foods to be held below 41. DM-D stated DM-D was only trained to obtain and document holding temperatures, not food cooked temperatures. During a continuous kitchen observation on 10/3/23 beginning at 11:20 AM, Surveyor observed green beans on the stove. Surveyor also observed scalloped potatoes and scalloped potatoes with ham in the oven. Surveyor observed DM-D remove the green beans from the stove, remove both types of scalloped potatoes from the oven, and place the items in the steam table. DM-D did not obtain and document food cooked temperatures at that time. At 11:50 AM, Surveyor observed DM-D obtain and document the following temperatures: ~Scalloped potatoes with ham - 199 degrees F ~Scalloped potatoes without ham - 178 degrees F ~Green beans - 184 degrees F ~Pureed green beans - 143 degrees F ~Pork chop - 153 degrees F Surveyor interviewed DM-D regarding the minimum cooked temperatures for green beans and pork chops. DM-D indicated DM-D was unsure of the minimum cooked temperature for vegetables and stated pork chops should be cooked to 165 degrees F. Cooling Temperatures: The FDA Food Code 2022 documents at 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit) (F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The FDA Food Code 2022 documents at section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial kitchen tour conducted with DM-D on 10/2/23 beginning at 8:30 AM, Surveyor noted the freezer contained pre-made frozen pureed food in three containers labeled meatball 9-6-23, two containers labeled chicken 9-28-23, three containers labeled pork 9-12-23, two containers labeled waffle 9-9-23, three containers labeled Sausage 9-19-23, and one container labeled Puree Fish without dates. Surveyor also observed a tray of small containers labeled Soup 10-4-23 in the walk-in cooler. DM-D indicated the soup was pre-made and frozen for ala carte items. During a continuous kitchen observation on 10/3/23 beginning at 8:24 AM, Surveyor interviewed DM-D regarding leftovers and pre-made frozen foods. DM-D indicated the facility keeps leftovers and pre-made foods, including soup, which are cooled on the prep counter. DM-D stated some items are pureed and placed in the freezer or walk-in cooler for future use. DM-D indicated the food is cooled and temperatures are obtained. When the temperature is under 100 degrees, DM-D stated the food is placed in the freezer and kept for use within a couple of days. DM-D was unable to verify the time and temperature control for food safety time frames for cooling foods and confirmed the facility does not document the temperatures of the food.

Based on staff interview and record review, the facility did not ensure residents were free from unnecessary psychotropic medications by monitoring for adverse reactions for 2 Residents (R) (R8 and R33) of 5 residents reviewed. R8 was prescribed lorazepam (a psychotropic medication used to treat anxiety). The facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment (used to assess tardive dyskinesia (involuntary repetitive movements) in those who are prescribed psychotropic medications) to monitor for adverse side effects of the medication. R33 was prescribed quetiapine fumarate (Seroquel) for agitation related to unspecified dementia with anxiety. The facility did not complete an AIMS assessment. (Persons taking antipsychotic medication need to be monitored for movement disorders. The AIMS aids in the early detection of tardive dyskinesia as well as provides a method for ongoing surveillance.) Findings include: The National Institutes of Health (NIH) National Library of Medicine, last updated on 4/24/23, describes the Abnormal Involuntary Movement Scale (AIMS) as a method to measure involuntary movements known as tardive dyskinesia (TD) and indicates: It is recommended to administer the AIMS at baseline before initiating antipsychotic medications, with a follow-up screening .close monitoring is essential because with early diagnosis, the drug may be discontinued, or the dose lowered to prevent full-blown tardive dyskinesia. The facility's Psychotropic Medications policy, last reviewed on 10/24/22, indicated residents should not receive psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) .8. Residents who receive an antipsychotic medication will have an AIMS test performed on admission, at least every six months, when the antipsychotic is changed, and as needed (PRN). 1. Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] with diagnoses including unspecified anxiety disorder and was prescribed lorazepam .5 mg (milligrams) twice daily and PRN for anxiety. R8 had a care plan, initiated 8/3/22, that indicated R8 was at risk for adverse effects related to the use of antianxiety medication. The care plan contained interventions for AIMS testing and evaluation of the effectiveness and side effects of the medication for possible decrease in psychotropic drug use. Surveyor noted R8's medical record did not contain an AIMS assessment. 45943 2. Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, and depression. R33 was prescribed quetiapine fumarate 12.5 mg by mouth at bedtime for agitation related to unspecified dementia, unspecified severity, with anxiety. R33 had a care plan that indicated R33 was at risk for behavior symptoms related to dementia with agitation and at risk for adverse effects related to the use of antipsychotic medication. The care plan contained an intervention for AIMS testing per facility guidelines (upon admission, initiation of, change of, every 6 months, and PRN). Surveyor noted R33's medical record did not contain an AIMS assessment. On 10/4/23 at 11:05 AM, Surveyor interviewed Director of Nursing (DON)-B who reviewed R8's and R33's medical records and confirmed AIMS assessments were not completed. DON-B indicated Nursing Home Administrator (NHA)-A or Social Services Coordinator (SSC)-E are responsible for ensuring AIMS assessments are completed and stated nursing staff complete AIMS assessments as well. On 10/4/23 at 11:21 AM, Surveyor interviewed NHA-A who indicated nursing staff is responsible for completing AIMS assessments and stated NHA-A and SSC-E are not responsible for completing the assessments.

Based on staff interview and record review, the facility did not ensure the mandatory staffing data submitted from 4/1/22 through 6/30/23 was complete, accurate, and auditable. This had the ability to affect all 37 residents residing in the facility. Payroll Based Journal (PBJ) data submitted by the facility from 4/1/22 through 6/30/23 was not complete, accurate, or auditable. Findings include: PBJ Staffing Data Reports generated quarterly indicated the facility triggered for Failed to Have Licensed Nursing Coverage 24 Hours/[NAME] the following dates from 4/1/23 through 6/30/23: Fiscal Year Quarter 3 2023 (April 1 - June 30): 4/7, 4/8, 4/9, 4/22, 4/23, 4/30, 5/7, 5/14, 6/17, and 6/18 Fiscal Year Quarter 4 2022 (July 1 - September 30): 7/1, 7/10, 8/29, 9/3, 9/11, 9/18, and 9/25 Fiscal Year Quarter 3 2022 (April 1 - June 30): 6/20, 6/21, 6/23, 6/25, 6/26, 6/28, and 6/30 Surveyor reviewed the facility's Daily Schedule sheets for each date specified in the report and noted all dates had licensed staff on duty for each shift. On 10/4/23 at 2:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Executive Director (ED)-C regarding the PBJ Staffing Data Reports. NHA-A and ED-C were unsure why the data failed to reflect the facility had licensed nursing coverage 24 hours/day and stated the facility must enter the agency staff in manually each week. On 10/4/23 at 2:35 PM, NHA-A asked to speak with Surveyor and verified the data submitted was inaccurate. NHA-A indicated the facility switched to a new reporting system and NHA-A believed there was an error in reporting the data for agency staff.

Based on observation, staff interview and record review, the facility failed to ensure each resident was accurately assessed for risk, monitored post-fall or maintain an environment that was free from accident hazards for 3 of 3 residents (R) (R27, R34 and R19) reviewed for falls. -The facility did not implement their policy to consistently complete neurological checks, fall risk assessments, post fall assessments and care plan updates after R27's falls. -The facility did not implement their policy to consistently complete neurological checks, fall risk assessments, post fall assessments and care plan updates after R34's falls. -The facility did not implement their policy to consistently complete neurological checks, fall risk assessments, post fall assessments and care plan updates after R19 had 14 documented falls from 6/4/22 through 8/3/22. Findings include: Facility policy titled Fall Prevention and Management Guidelines with a revised date of March 10, 2021, directs staff to complete a post fall investigation and a fall risk assessment after every fall. Same policy stated, Upon initial review, investigation, and assessment, nurse to update the care plan as to (i) any new interventions put in place to try to prevent additional falls, and (ii) removal of any interventions determined to be no longer appropriate. Same policy indicated neurological checks post fall were to be completed initially at time of fall then every 15 minutes x 3, then every 30 minutes x 2 then hourly x 4 and then every 8 hours x 9 for a total of 19 neurological checks post fall. 1. During this recertification survey, Surveyor reviewed R27's medical record. R27 was admitted to facility on 7/8/22 with diagnosis including but not limited to acute [CONDITION(S)], muscle weakness, difficulty in walking, [CONDITION(S)], hypertension and dementia. R27 was severely cognitively impaired. R27's progress notes dated 7/27/22 at 1:56 AM and 7/28/22 at 7:30 AM, indicated R27 had fallen in the bathroom on each date. A Post Fall Assessment was completed and dated 7/27/2022 at 2:24 AM. New interventions were added on 7/27/22 including Shown how to use her call light appropriately. Call don't fall sign placed on bedside table. R27's medical record contained no Post Fall Assessment and R27's plan of care contained no new fall prevention interventions following R27's fall of 7/28/22. R27's Post Fall Assessment of 7/27/22 did not identify R27's high-risk medications or physical status impairments, identifying R27 as Low Risk for falls with a score of 7. R27 had 11 neurological checks completed after having 2 falls., 7/27/22 and 7/28/22. A progress note dated 7/29/22 at 5:03 AM, stated Resident is on follow up for: Unwitnessed fall. The current status is Small lump to the back of her head. Denies headache or dizziness. R27's medical record contained no notification of R27's provider of the newly discovered lump to the head. On 8/17/22 at 11:55 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated a provider should be updated with any change in a resident's condition, calling the DON first, and then updating the provider. R27's provider was not updated when a lump was noted on 7/29/22, on the back of R27's head. 2. On 8/15/22 at 11:58 AM, Surveyor observed R34 with a cast on the left arm. R34 and R34's nephew who was visiting R34, indicated R34 had fallen at facility and broke R34's left arm. A review of R34's medical record revealed R34 was admitted to facility on 1/9/20 with diagnosis including but not limited to [CONDITION(S)], heart failure and chronic kidney disease. R34's most recent diagnosis included but were not limited to displaced comminuted fracture of the left ulna (arm) and muscle weakness. R34 was severely cognitively impaired per most recent assessment. R34 had documented falls on 2/11/22, 2/23/22, 3/14/22 and 7/10/22. R34 sustained a fracture of the left arm from the fall on 7/10/22. A review of R34's care plan revealed all of R34's fall interventions were dated 1/14/22 and 1/19/22. R34's plan of care was not revised to include new fall prevention interventions after R34's falls. R34's Post Fall assessment dated [DATE], did not identify all of R34's physical status impairments, previous falls or high-risk medications and indicated R34 was Low Risk for falls with a score of 9. Neuro checks were not completed on R34 per policy. R34 had no neurological checks completed post fall for fall dated 2/11/22. R34's other fall dates had some neuro checks completed but not as policy directed. On 8/16/22 at 2:00 PM, Surveyors interviewed NHA-A who stated, The care plan should be updated with every fall with an intervention. 3. From 8/15/22 through 8/17/22, Surveyor reviewed R19's medical record. R19 was admitted to facility on 10/14/21 with diagnoses including but not limit to [CONDITION(S)] and [CONDITION(S)] following cerebral infarction (muscle weakness of [CONDITION(S)] on one side of the body), diabetes mellitus type two, recurrent depressive disorder, anxiety disorder, [CONDITION(S)], chronic kidney disease and muscle weakness. R19 was cognitively intact per most recent assessment. R19's medical record which documented R19 had an extensive history of falls, including unwitnessed falls on 6/4/22, 6/17/22, 6/22/22, 7/4/22, 7/8/22, 7/18/22, 7/20/22, 7/21/22, 7/29/22, 7/31/22, 8/1/22, 8/3/22 and witnessed falls on 7/17/22 and 7/23/22. R19's fall risk assessment indicate R19 had a score of 14 and was at moderate risk for falls. ~On 6/4/22 at 9:30 AM, R19 had a progress note stating, Resident is on follow up for: unwitnessed fall overnight. Surveyor noted neuro checks were initiated but the documentation showed gaps where neuro checks were not consistently completed. Surveyor did not observe a fall risk assessment completed on 6/4/22 or a care plan update on 6/4/22 for R19. ~On 6/17/22 at 7:02 AM, R19 had a progress note stating, Resident was transferring self out of bed without shoes. States that R19 slipped out of bed. Was found laying on stomach . Surveyor did not observe a fall risk assessment completed on 6/17/22 or a care plan updated on 6/17/22 for R19. ~On 6/22/22 at 21:12 PM, R19 had a progress note stating, .found resident sitting on floor beside bed . Surveyor did not observe a fall risk assessment completed on 6/22/22 or a care plan updated on 6/22/22 for R19. ~On 6/23/22 at 9:42 AM, R19 had a progress note stating, R19 has experienced change in place to floor three times since evening of 6/22/2022. Surveyor observed one post fall assessment completed on 6/22/22 at 9:40 PM. Surveyor did not observe a fall risk assessment completed on 6/22/22 or 6/23/22 or a care plan updated on 6/22/22 and 6/23/22 for R19. ~7/4/22 at 9:35 AM, R19 had a progress note stating, .Resident found sitting on floor in front of wheelchair between bed and wheelchair . Surveyor noted neuro checks were initiated but the documentation showed gaps where neuro checks were not consistently completed. Surveyor did not observe a fall risk assessment completed on 7/4/22 or a care plan update on 7/4/22 for R19. ~7/8/22 at 4:39 AM, R19 had a progress note stating, .observed resident using the bathroom, while administering medications to roommate, resident then later called out for help, stating R19 lost the left side shoe and slipped on the floor . Surveyor noted neuro checks were initiated but the documentation showed gaps where neuro checks were not consistently completed. Surveyor did not observe a fall risk assessment completed on 7/8/22 or a care plan update on 7/8/22 for R19. ~7/17/22 at 1:55 PM, R19 had a progress note stating, .Fall was witnessed by named staff member, stated that resident slipped off the bed onto R19's bottom, resident did not hit R19's head . Surveyor did not observe a fall risk assessment completed on 7/17/22 or a care plan updated on 7/17/22 for R19. ~7/18/22 at 4:45 PM, R19 had a progress note stating, .Noted resident laying in prone position on floor . Resident states R19 hit R19's head on the left side . Surveyor noted neuro checks were initiated but the documentation showed gaps where neuro checks were not consistently completed. Surveyor did not observe a fall risk assessment completed on 7/18/22 or a care plan updated on 7/18/22 for R19. ~7/20/22 at 8:20 PM, R19 had a progress note stating, Patient's roommate rang call light and stated patient was on the floor. Writer entered room and found patient sitting upright on floor mat in front of bed, leaning back against the bed . Surveyor noted neuro checks were initiated but the documentation showed gaps where neuro checks were not consistently completed. Surveyor did not observe a fall risk assessment completed on 7/20/22 or a care plan update on 7/20/22 for R19. ~7/21/22 at 1:00 PM, R19's post fall assessment stated R19 slipped. Surveyor did not observe any neuro checks completed for R19. Surveyor did not observe a fall risk assessment completed on 7/21/22 or a care plan update on 7/21/22 for R19. ~7/23/22 at 9:39 AM, R19 had a progress note stating, Witness patient attempted to get out of bed without assist and slid to the floor mat . Surveyor did not observe a post fall assessment or a care plan update on 7/23/22 for R19. ~7/29/22 at 3:40 AM, R19 had a progress note stating, This writer heard resident calling for help .Resident was sitting on the floor with R19's hands holding onto the sink . Surveyor noted neuro checks were initiated but the documentation showed gaps where neuro checks were not consistently completed. Surveyor did not observe a fall risk assessment completed on 7/29/22 or a care plan update on 7/29/22 for R19. ~7/31/22 at 11:11 PM, R19 had a progress note stating, Patient was getting out of bed, lost R19's balance and fell to the floor . Surveyor noted neuro checks were initiated but the documentation showed gaps where neuro checks were not consistently completed. Surveyor did not observe a fall risk assessment completed on 7/31/22 or a care plan updated on 7/31/22 for R19. ~8/1/22 at 10:45 AM, R19 had a fall risk assessment stating, Patient observed sitting on the floor in the bathroom . Surveyor did not observe any neuro checks completed for R19. Surveyor did not observe a post fall assessment completed on 8/1/22 or a care plan update on 8/1/22 for R19. ~8/3/22 at 5:38 PM, R19 had a progress note stating, Patient had a fall at 1440 (2:40 PM) .Patient was found sitting in front of R19's bed on R19's coccyx . Surveyor noted neuro checks were initiated but the documentation showed gaps where neuro checks were not consistently completed. Surveyor did not observe a post fall assessment on 8/3/22 for R19. On 8/16/22 at 2:00 PM, Surveyors interviewed NHA-A who stated, The care plan should be updated with every fall with an intervention. On 8/17/22 at 10:45 AM, Surveyor interviewed NHA-A regarding R19's neuro checks, fall risk assessment, and post fall assessment. NHA-A verified R19's neuro checks, post fall assessments and fall risk assessments had gaps. NHA-A indicated they expect staff to follow the policy in regards to neuro checks, fall risk assessments and post fall assessments.

Based on record review and staff interview, the facility did not ensure 1 Resident (R) (R9) of 5 residents reviewed for care plans for high risk medications had care plans in place to monitor for effectiveness and side effects. R9 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility did not develop a comprehensive care plan to monitor for the effectiveness and side effects of this medication. Findings include: 1. On 8/17/22, the Surveyor reviewed R9's medical record. R9 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . and embolism (occurs when a piece of a blood clot, foreign object, or other bodily substance becomes stuck in a blood vessel and largely obstructs the flow of blood.) R9 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's medical record did not contain a care plan to address the use of the [MEDICATION(S)] and monitor for effectiveness or side effects. On 8/17/22 at 11:46 AM, the Surveyor interviewed the interim DON (Director of Nursing)-B regarding R9's use of an anticoagulant. Interim DON-B verified R9 did not have a care plan to address the use and side effects of the anticoagulant and stated the expectation would be for R9 to have a care plan for this high risk medication.

Based on observation and interview, the facility did not provide a sanitary environment to help prevent the transmission of communicable diseases for 2 (R13 and R10) of 6 sample residents observed during medication administration. Licensed Practical Nurse (LPN)-C administered a medication to R13 after medication fell on to the top of the medication cart. LPN-E did not offer R10 hand hygiene before handing eye dropper for medication self-administration training. Findings Include: 1. On 7/13/21 at 8:35 A.M., the Surveyor observed LPN-C administering medications to R13. LPN-C touched the computer, two medication drawer handles, and three different medication stock bottles. LPN-C dropped a Senna tablet (laxative) onto the medication cart. LPN-C picked up the pill with a bare hand and, without completing hand hand hygiene, placed pill into R13's medication cup. LPN-C then administered all of R13's medications. On 7/13/21 at 8:45 A.M., the Surveyor interviewed LPN-C, who verified that LPN-C picked up the pill with LPN-C's bare hand from the medication cart without completing hand hygiene. LPN-C also stated that the top of the medication cart was not sanitized prior to preparing R13's medications. 2. On 7/12/21 at 9:33 AM, Surveyor waited to interview R10 while R10 independently ambulated to R10's bathroom. Surveyor observed that R10 did not perform hand hygiene after utilizing the toilet. After interview, R10 laid in bed for a short time then exited room and ambulated up and down the hallway with R10's walker. On 7/12/21 at 9:59 AM, LPN-E directed R10 to sit in chair near medication cart at end of hallway. Without offering hand hygiene to R10, LPN-E handed R10 an eye dropper and directed R10 to drop one drop into left eye. R10 was not successful and LPN-E then assisted R10 with administration. R10 immediately left the area after administration and Surveyor interviewed LPN-E who explained R10 was in the process of learning to apply own eye drop in preparation for discharge to a lesser care setting. LPN-E verified no hand hygiene was offered to R10 prior to handing R10 eye dropper and said, That would be a good idea.

Based on Power of Attorney (POA) interview, staff interview, and record review, the facility did not ensure a Resident (R) and resident's representative were involved in care planning on a quarterly basis for 1 (R29) of 1 residents reviewed for care plan frequency. The facility did not invite R29 and R29's activated POA-I and alternate POA-J to quarterly care conferences; the facility practice was not to invite residents and resident representatives to quarterly care conferences. Findings include: From 7/12/21 through 7/14/21, Surveyor reviewed R29's medical record which documented R29 had an activated POA with POA-I listed as decision maker and POA-J listed as alternate. R29's record documented the facility InterDisciplinary Team (IDT) held a quarterly care conference for R29 on 6/2/21. Surveyor noted the quarterly care conference note documented R29 had activated POA-I as decision maker but did not document POA-I was invited or present at care conference. On 7/12/21 at 10:22 AM, Surveyor interviewed R29's POA-I together with R29's alternate POA-J. POA-I and POA-J explained they worked together to make decisions on R29's behalf. POA-I and POA-J could not recall being invited to participate in a care conference in person or telephonically to discuss R29's goals and interventions to meet goals in the past three to six months. On 7/14/21 at 9:15 AM, Surveyor interviewed Social Worker (SW)-D regarding care conferences. SW-D verified R29's POA-I and POA-J were not invited to R29's quarterly care conferences. SW-D explained the facility identified some care conference issues that developed over the time of the COVID-19 pandemic and adopted a process to invite residents and families to admission, annual, significant change, and as needed care conferences and meet as an IDT without resident and family for quarterly care conferences.

Based on staff interview and record review, the facility did not ensure a Resident (R) Pre-Admission Screening and Resident Review (PASRR) level 2 was completed when 30 day exemption ended for 1 (R10) of 2 sampled residents reviewed for PASRR requirements. The facility did not ensure R10's PASRR level 2 was completed when R10's 30 day hospital exemption expired and R10 remained in the facility. Findings include: From [DATE] through [DATE], Surveyor reviewed R10's medical record which documented R10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The county review granted a 30 day hospital exemption for PASRR level 2 requirements on [DATE]. Surveyor noted no PASRR level 2 was in R10's medical record and the 30 day exemption expired more than 60 days prior to investigation. On [DATE] at 12:02 PM, Nursing Home Administrator (NHA)-A approached Surveyor to communicate R10's PASRR level 2 was not located. NHA-A verified the 30 day exemption expired and R10 should have a PASRR level 2 completed.

Based on staff interviews and record review, the facility did not ensure code status was consistent across electronic and physical records and Do Not Resuscitate (DNR) form was not completed for 1 (R10) of 1 residents reviewed for advanced directives. The facility did not obtain signatures from R10's activated Power of Attorney (POA)-F or alternate POA-G and R10's Medical Doctor (MD) on DNR form utilized by staff to determine whether or not to perform Cardiopulmonary Resuscitation (CPR). Findings include: From [DATE] through [DATE], Surveyor reviewed R10's medical record. Surveyor noted R10's Electronic Health Record (EHR) documented R10 with DNR status on the profile banner. R10's attached EHR documents did not include a DNR form. Surveyor located a DNR form in R10's paper medical record that was partially filled out but did not include the signatures of R10's decision maker, POA-F, and R10's MD. R10's EHR documented POA-F provided verbal consent for DNR orders upon R10's admission and directed staff to obtain a signature from alternate POA-G for DNR and all admission documents because POA-F was not able to visit building to sign and did not have means to electronically sign documents. POA-G was available as a resident at the building until [DATE]. On [DATE] at 1:41 PM, Assistant Director of Nursing (ADON)-E reviewed R10's medical record with Surveyor and confirmed R10's DNR paperwork did not have the required signatures. ADON-E was not able to explain how R10's DNR status would be conveyed if R10 needed to transfer to another health care setting. On [DATE] at 10:44 AM, Surveyor interviewed Registered Nurse (RN)-K regarding code status. RN-K indicated that if there was a code event, RN-K's practice is to look for the Wisconsin (WI) DNR form which was filed at the front of resident paper medical records. At the time of interview, RN-K looked at R10's medical record and indicated R10 would be given CPR because there was no signed DNR form. On [DATE] at 10:48 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-C regarding code status. LPN-C indicated LPN-C would look for the WI DNR form which was filed at the front of resident paper medical records. At the time of interview, LPN-C reviewed R10's medical record and indicated R10 would be treated as full code and given CPR because there was no signed DNR form.

Based on staff interviews and record review, the facility did not ensure informed consent was obtained initially and at the expiration of consent for a Resident (R) with [CONDITION(S)] brain disorder who was prescribed a [CONDITION(S)] medication for 2 (R10 and R33) of 5 residents reviewed for unnecessary medications. The facility did not obtain informed consent from R10's activated Power of Attorney (POA)-F prior to administering [MEDICATION(S)] (an antipsychotic medication); R10 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility did not obtain informed consent at the expiration of consent from R33's activated POA-H but continued administering [MEDICATION(S)] (an antipsychotic medication) and [MEDICATION(S)] (an antidepressant medication); R33 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Food and Drug Administration (FDA) (fda.gov) documents, a boxed warning . is also commonly referred to as a black box warning. It appears on a prescription drug's label and is designed to call attention to serious or life-threatening risks. Wisconsin (WI) Department of Health Services (DHS) (dhs.wisconsin.gov) documents, A boxed warning, also known as a black box warning, or a black label warning is named for the border surrounding the text of the warning that appears on the package insert, label, and other literature describing the medication (e.g., magazine advertising). It is the most serious medication warning required by the FDA. All antipsychotics and antidepressants along with many other [CONDITION(S)] medications have a black box warning. 1. From 7/12/21 through 7/14/21, Surveyor reviewed R10's medical record which documented R10's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor was not able to locate informed consent for R10's [MEDICATION(S)]. On 7/13/21 at 1:47 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-E regarding R10's informed consent for [CONDITION(S)] medication use. ADON-E verified R10's medical record did not contain informed consent documents. ADON-E accessed R10's Electronic Health Record (EHR) at the time of interview and indicated there was no note indicating education was provided and consent obtained from POA-F for R10's [MEDICATION(S)] use. ADON-E verified R10 should have had an informed consent in the medical record. 2. From 7/12/21 through 7/14/21, Surveyor reviewed R33's medical record which documented R33's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R33's medical record contained informed consent for [MEDICATION(S)] and [MEDICATION(S)] dated 3/27/20 under the statement This medication consent is for a period effective immediately and not to exceed fifteen (15) months from the date of my signature. On 7/13/21 at 1:56 PM, Surveyor interviewed ADON-E regarding R33's informed consents. ADON-E verified R33's [MEDICATION(S)] and [MEDICATION(S)] consents were past beyond 15 months old. ADON-E indicated the InterDisciplinary Team (IDT) had a process to review informed consents but ADON-E was not able to state why R33's informed consents were more than 15 months old.

Based on record review and staff and resident interview, the facility did not provide the necessary care and services to maintain the highest practical well being for 1 Resident (R) (R1) of 3 sampled residents. R1 decided during the night to go to the emergency room in the morning to be evaluated for abnormal bleeding. R1 had an increase in pain and felt that the staff was not helping R1. R1 called emergency services (911) to be transported to the hospital. When the 911 dispatch called the nursing facility to confirm R1's pain and need for emergent transfer, the RN (registered nurse) on duty caring for R1 informed the dispatch service it was not an emergency and emergency transport was not needed, even though the RN had not assessed R1. RN stated R1 would be sent to the ER (emergency room ) by a non-emergent cab van service. When R1 arrived at the ER by cab van, R1 was found to have a [DIAGNOSES REDACTED] (collapsed lung). R1 experienced severe pain and agitation during the wait for non-emergent transport. Findings include: The Surveyor reviewed R1's medical record on 12/20/19 in response to an anonymous complaint submitted to the State Agency. R1 was admitted to the facility on [DATE]. R1's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/28/19, documented R1's BIMS (Brief Interview of Mental Status) to be a 15/15 which indicated R1 was cognitively intact. R1 was noted to have bleeding due to an unknown cause which started on 12/12/19. R1 takes scheduled daily [MEDICATION NAME] (an anticoagulant which helps keep blood flowing and decreases chance of clots) medication. The facility contacted the physician and obtained laboratory orders to draw on 12/13/19. R1's nurses notes in R1's medical record documented the following: On 12/13/19 at 9:50 PM, Writer contacted DCMH (Door County Medical Hospital) lab and had recent lab faxed over. Writer entered (R1's) room and reviewed all labs with (R1). Writer encouraged (R1) to go to ED (emergency department) for further evaluation as (R1) continued to have episodes of blood in urine. At the time, (R1) refused to go to ED, stated, My family won't know that I'm there. Writer assured she would contact (R1's) family. (R1) continued to refuse stating, (R1) was going to bed. On 12/14/19 at 4:30 AM, (R1) continues with moderate amount of blood in (R1's) brief from front to back of absorbent padding. Blood med (medium) dark red in color, no clots noted. (R1) continues to deny pain, SOB (shortness of breath), change in dizziness, or lightheadedness. (R1) did state, however, that if (R1) is still bleeding when brief changed, that (R1) wanted to go to the ED in the AM. On 12/14/19 at 5:43 AM, Give APAP (Tylenol) 1000 mg (milligram) by mouth two times a day for pain arm and shoulder pain. On 12/14/19 at 5:47 AM, Phone call received from (R1's physician) at 5:30 asking how (R1) is doing and if bleeding continues. MD (Medical Doctor) updated and informed that (R1) states (R1) wanted to go to the ED if bleeding continued during the noc (night), which it has been. MD in agreement and also stated to HOLD [MEDICATION NAME] ([MEDICATION NAME]) until bleeding is figured out. On 12/14/19 at 8:51 AM, (R1) had no blood in brief upon waking at 6:00 AM, and a small amount of bright red blood in toilet. (R1) denies SOB, weakness. (R1) wanted to go to ER and transportation was arranged via D2D (Door to Door a van transport company.) (R1) then called 911 and stated that writer was not moving fast enough. (R1) did complain of right shoulder pain while grabbing left shoulder then switched to right shoulder after writer clarified which shoulder was painful. (R1) was independent with care this AM and transfers. (R1) did call writer names and states writer was stupid and did not know anything. MD was updated on prior shift and agreed with sending patient if more blood in brief. (Named RN) was given report at ER at approximately 7:30 AM. Patient left approximately 7:45 AM. On 12/14/19 at 12:26 PM, Per RN in ER (R1) admitted for right pneumothorax (collapsed lung) and will place foley (catheter) for hematuria (blood in urine). R1's was in the hospital from 12/14/19-12/16/19. R1's hospital History and Physical which was dictated by the physician on 12/14/19, and signed by physician on 12/15/19 at 2:11 PM, stated: Patient complained of gross hematuria yesterday and right-sided chest pain. (R1) was brought to the emergency room and found to have an INR (International Normalized Ratio used to determine how well the anticoagulant medication is working) of 3.4 for which (R1) is on for chronic anticoagulation for [DIAGNOSES REDACTED] (can cause blood clots to form.) (R1's) therapeutic range is between approximately 2.5-3. However, (R1) was complaining of right-sided chest pain and found to have asymmetrical breath sounds. A chest x-ray demonstrated approximately 70% pneumothorax on (R1's) right side. 12/16/19 at 10:39 AM, writer (a hospital case manager) met with (R1) to discuss discharge plans. (R1) stated would prefer not to go back to Sturgeon Bay Health Services because (R1) had asked nurse to call 911, but the nurse told (R1) did not need to go to the hospital. (R1) stated (R1) then called 911 and the ambulance called the nurse who told them not to come. (R1) informed the case manager (R1) did not want to leave the Sturgeon Bay area where (R1) has lived and worked (R1's) entire life. On 12/20/19 at 9:25 AM, the Surveyor interviewed R1 regarding R1's recent transfer to the hospital. R1 informed the Surveyor R1 called 911 and staff canceled the ambulance call. R1 stated, The nurse wouldn't do anything and I could not breathe and was having so much pain, so I called 911. R1 stated the pain started at approximately 6:00 AM, and did not stop. R1 stated, I called 911, and when they called the facility back the nurse told them I did not need an ambulance. R1 stated, I could hardly talk I was having so much pain. My chest hurt so bad. R1 stated R1 informed RN (Registered Nurse)-B of the pain she was experiencing and RN-B did not take any vitals or complete any kind of assessment to determine what was causing the pain. On 12/20/19 at 1:00 PM, the Surveyor interviewed RN-B who started her shift at 6:00 AM on 12/14/19. RN-B stated she received report which stated R1 was going to the hospital to be evaluated in the ER and the physician had been updated regarding the transfer. RN-B stated the plan told to her in report was that R1 would be going to the ER by D2D transport company. RN-B informed the Surveyor D2D did not open up until 7:00 AM on 12/14/19. RN-B informed the Surveyor she had not completed any kind of assessments including a pain assessment, lung assessment, or vital signs on R1 before R1 left the facility for the ER. RN-B informed the Surveyor that R1 had called RN-B into the room at approximately 6:30 AM to observe blood R1 had passed in the toilet. R1 told RN-B R1 was internally bleeding and RN-B informed R1 that R1 had blood in her urine. R1 informed RN-B at this time R1 had called 911 and an ambulance was on the way to the facility. RN-B informed R1 911 dispatch had called the facility and they were not on their way because RN-B informed the dispatch service that it wasn't appropriate for R1 to go in ambulance because R1 was not internally bleeding. R1 was then upset with RN-B for canceling the ambulance call. On 12/20/19 at 1:11 PM, the Surveyor interviewed RN-C who worked until 6:00 AM on 12/14/19. RN-C stated R1 had two incontinence brief changes during her shift with a moderate amount of blood in R1's brief. RN-C stated she obtained vital signs on R1 once on her shift around 1:00 AM and RN-C did not chart the vital signs in the computer until 4:00 AM. RN-C informed the Surveyor that R1 decided to go to the hospital and R1's physician had called the facility to check on R1 at approximately 5:45 AM, and approved the transfer to the emergency room to have R1 evaluated. RN-C stated there was no change in R1 the last time she saw R1 on 12/14/19 which was approximately 5:40 AM. RN-C stated R1 informed RN-C since R1's return that R1 experienced severe pain at approximately 6:00 AM, which is when RN-C had already left the facility. On 12/20/19 at 1:25 PM., the Surveyor interview CNA (Certified Nursing Assistant)-D who started her shift at 3:00 AM on 12/14/19. CNA-D stated she overheard R1 and RN-B talking about blood in the toilet and knew that R1 was upset with RN-B but didn't know any more information about the situation. CNA-D stated she helped R1 get her coat on when D2D picked R1 up for transport. CNA-D stated R1 could not move her shoulder to put her coat on at that time because R1 was in so much pain. On 12/20/19 at 1:40 PM., the Surveyor talked to FM (Family Member)-A regarding R1's transport to the hospital. FM-A stated R1 called FM-A the morning of 12/14/19 because R1 did not know what to do and felt the facility was not helping R1. FM-A stated FM-A could tell R1 was in pain. FM-A stated R1 was concerned the facility was not helping R1 so FM-A directed R1 to call 911 because FM-A did not know what to do. FM-A stated R1 called back a couple minutes later and stated the facility canceled R1's 911 call and arranged for D2D services to pick up resident later in the morning. FM-A stated R1 was concerned because R1 did not have any cash to pay for the D2D transport. FM-1 stated R1 was distraught for approximately an hour because R1 felt nobody at the facility was helping R1 with her pain. On 12/20/19 at 1:45 PM, the Surveyor interviewed R1 regarding the transfer. R1 stated R1 thought R1'[MEDICAL CONDITION] was back because of the bleeding and chest pain R1 was experiencing, and that is why R1 was so afraid and desperate for help on 12/14/19. R1 stated when D2D picked resident up the driver asked R1 if R1 had any money for the ride and informed R1 sometimes residents have coupons to give the driver. R1 told the driver R1 needed to get to the ER right away and was not worried about the money. R1 was so angry that RN-B did not take her seriously and canceled her 911 call that R1 does not recall a lot of the ride because she was so upset. R1 informed the Surveyor R1 must have been grimacing on the ride because the driver asked if R1 was ok multiple times on the ride. The Surveyor placed a call to the D2D driver, and the driver did not return the call. The Surveyor contacted the Door County Sheriff's Department regarding the 911 and 911 dispatch calls. The exact times of the calls were not able to be obtained but audio messages of the calls were obtained and provided to the Surveyor. In the audio, R1 can be heard informing the dispatcher, They won't do anything for me and I have such pain I need help but no one will help me. R1 also informed the dispatcher that R1 had internal bleeding for the past two days. The dispatcher then calls the facility back and speaks with RN-B. The dispatcher informs RN-B, R1 called 911 and stated R1 is not getting any help and has internal bleeding. RN-B can be heard telling dispatch, No. (R1) is having some blood with urination we were going to send (R1) with D2D per the doctor's order so (R1) can be seen in the ER per R1 request. We told (R1) a 911 call wasn't appropriate and (R1) didn't care and (R1) was going to call until someone came. We are sending (R1) D2D. The dispatch can then be heard informing RN-B that they will not be sending an ambulance. On 12/23/19 at 10:20 AM, the Surveyor interviewed MD (Medical Doctor)-F who confirmed the facility spoke with him on 12/14/19 at approximately 5:45 AM. MD-F stated the facility reported R1 had an INR that was slightly elevated and MD-F ordered R1's [MEDICATION NAME] to be placed on hold. MD-F also ordered R1 to be sent to the ER for evaluation. MD-F stated the logistic of the transport to the ER was not discussed and MD-F stated usually someone who goes to the ER would go in an ambulance. MD-F stated D2D would be used for transports to and from the clinic, for example, when R1 goes to the clinic for wound care. On 12/20/19 at 2:10 PM, the Surveyor interviewed DON (Director of Nursing)-E who stated the facility started an investigation regarding the incident. DON-E stated the facility was under the impression that nothing had changed with R1 and R1's only concern was related to the blood R1 was experiencing in her brief. DON-E confirmed an assessment was not completed to include vital signs, pain, or lung assessment on R1 to assess the pain she was experiencing. DON-E stated it was her understanding that RN-B had spoken with the ambulance services and the ambulance services determined the situation to not be an emergency. DON-E was not aware that RN-B only talked to the dispatch service and that RN-B canceled the emergency services on her own.

Based on record review and staff interview, the facility did not ensure 2 (R (Resident)1 and R3) of 4 sampled residents received adequate supervision and assistance devices to prevent accidents. R1 was admitted to the facility with a history of falls at home and weakness. R1 was incontinent of bladder and was confused at times. The facility initiated a baseline care plan that indicated R1 had a history of [REDACTED]. Staff indicated R1's initial care plan from the resident's day of admit did not include interventions in an attempt to prevent falls. Four hours after admission, R1 fell in the bathroom, was transferred to the hospital and diagnosed with [REDACTED]. As a result of the [MEDICAL CONDITION], R experienced increased pain and was administered an increase in narcotic administration for pain control. R3 was observed in a Hoyer lift with only one staff member present, instead of the required two staff present. Findings include: 1. R1's initial Progress Note (PN) after admission, which was dated 11/02/18 at 21:26 (9:26 PM), documented: Resident was admitted to the facility from the hospital at 1515 (3:15 PM) via wheelchair with door to door transport. Was oriented to room. Per report from the hospital, Patient had a fall at home and fractured right ribs. Has chronic pain all over. Does not ambulate. Uses sit to stand to transfer and is very hard of hearing. Is oriented to self. Is incontinent of bowel and bladder. Is not factual at times. Has some paranoia. Was hallucinating last night and saw spiders and bats on the walls, Tries to get up without assistance. Resident appears very confused while writer was completing assessment in room. Unable to answer many questions when asked. At 1930 (7:30 PM), writer was called to resident's room for a fall. Resident was found sitting on the floor in the bathroom. States she hit her head. Resident did indeed have a bump and redness to the left side of the head. Writer tried to assess bilateral lower extremities, resident screamed out in pain, stating her left leg/hip hurt. Ambulance called to transport resident to Emergency Department (ED) for evaluation and treatment. R1's medical record included a baseline care plan dated 11/02/18. The initial care plan indicated R1 was confused and had a history of [REDACTED]. This care plan did not include any fall interventions listed in attempt to prevent further falls. This plan of care indicated R1 required 2 assist for pivot transfers and was dependent on staff for toileting. The baseline plan of care indicated R1 utilized a Foley catheter. R1's medical record did not include documentation of R1's use of a Foley catheter, as documentation indicated R1 was incontinent of bladder. A Comprehensive plan of care dated 11/02/18, included the following interventions upon admission to the facility: ~ Encourage to transfer and change positions slowly ~ Fall Risk ~ Medications as ordered ~ Provide assist to transfer and ambulate as needed ~ Reinforce w/c (wheel chair) safety as needed such as locking brakes ~ Report development of pain, bruises, change in mental status, Activities of Daily Living function, appetite or neurological status [REDACTED]. ~ Therapy eval and treat as ordered R1's Admission Evaluation dated 11/02/18 documented R1 required extensive assistance of 1 staff for toileting and transfer needs, alert to person and place, was incontinent of bladder daily and did not utilize a catheter, had severe pain daily, did not ambulate, had a history of [REDACTED]. The evaluation indicated R1 was at risk for falls, but did not document or summarize what made R1 a falls risk and did not include interventions in an attempt to prevent falls. The evaluation did not include documentation indicating R1 had a recent fracture related to a fall at home. In addition, R1's plan of care did not include R1's toileting needs. An untitled report related to R1's fall on 11/02/18, indicated Certified Nursing Assistant (CNA) found resident in bathroom on floor. When writer went to assess resident, resident was sitting on floor facing the toilet with pants around the knees, no shoes on and pants were wet with urine. Resident states she hit her head on something, unsure of what and fell on to left hip. Writer palpated left hip and resident cried out in pain. Resident unable to extend left leg without crying out in pain. I slipped and fell on the floor. I hit my head. ~ the report indicated Immediate Action taken was R1 was sent to the ED for eval and treat. Outcome: unknown. When resident returns, move bed against the wall, provide touch call pad, ensure resident is wearing gripper socks at all times and ensure w/c is next to the bed with brakes on. ~ the report indicated R1 had occasional labored breathing and short periods of hyperventilation, repeated troubled calling out. Loud moaning or groaning, crying, facial grimacing, rigid, fists clenched, knees pulled up, pushing or pulling away and striking out. Also indicated unable to console, distract, or reassure. ~ the untitled fall report indicated the bathroom floor was wet and R1 was confused, impaired memory and had weakness. Predisposing situations factors were listed as call light improperly used, was transferring self and fall occurred during a transfer. The facility completed a Post Fall assessment dated [DATE]. The assessment indicated the call light was within reach, the w/c was next to the bed and lights were on in the room. The assessment indicated R1 indicated she needed to use the bathroom and was wearing socks. R1 was last seen in bed and R1's physical status was hard of hearing, unsteady gait, had weakness and pain. The assessment stated R1 was confused and disoriented most of the time, and was receiving an antihypertensive, narcotic and antidepressant medications. The hospital History and Physical dated 11/03/19, indicated R1 was sent to the ED from the facility on 11/02/18 after falling off the toilet at the nursing home. R1 had been admitted to the facility on [DATE] from the hospital, after being admitted on [DATE] for a fall with left leg weakness. R1 was diagnosed with [REDACTED]. R1's hospital Discharge Summary dated 11/06/18, documented R1 was diagnosed with [REDACTED]. R1 was re-admitted to the facility on [DATE]. On 02/20/19 at 11:35 AM, the Surveyor conducted a telephone interview with CNA-A, who verified she was the CNA that was working with R1 when admitted to the facility on [DATE]. CNA-A indicated she was aware R1 had memory deficits and had a history of [REDACTED]. CNA-A indicated she did not recall being given any information regarding R1's incontinence status or toileting needs. CNA-A stated she did not assist R1 to the bathroom prior to the fall on 11/02/18 and indicated R1 was very hard of hearing, so did not think R1 could understand anything that was said to her (R1). CNA-A stated another CNA actually discovered R1 on the floor when R1 fell in the bathroom on 11/02/18. CNA-A indicated she could not be certain where R1 was located prior to the fall, either in bed or in the w/c. CNA-A stated about an hour before R1's fall in the bathroom, CNA-A had assisted R1 into bed as she had observed R1 attempting to self transfer. CNA-A indicated she was not aware if R1 remained in bed or self transferred and was sitting in the w/c prior to taking herself to the bathroom. On 02/20/18 at 2:00 PM, the Surveyor conducted a telephone interview with Licensed Practical Nurse (LPN)-B, who verified she was the nurse in charge of R1's care on the day of admission to the facility. LPN-B stated R1 was oriented to self, was very hard of hearing and was incontinent of bladder. LPN-B indicated she was aware R1 was to be transferred using a sit to stand lift, as reported by the hospital staff. LPN-B stated she reported this information to CNA-A and CNA-C, who were caring for R1 on the day of her admit. LPN-B stated she was notified that R1 was lying on the floor and when she (LPN-B) arrived to R1's room, R1 was observed lying on the bathroom floor with her head underneath the sink and the floor was wet with urine. LPN-B indicated R1 had been in the resident's room watching television prior to the fall, highly confused, was wearing shoes and her call light was in reach. LPN-B indicated staff were unaware that R1 did not know how to use the call light at that time and R1 had been admitted to the facility because of recent falls. LPN-B stated she had given report to the CNAs regarding R1's care needs, but had not addressed R1's toileting/incontinence needs as LPN-B trusted the CNAs knew what to do when residents are incontinent. LPN-B indicated there were no interventions in place to prevent falls as R1 had just been admitted to the facility earlier that day. LPN-B stated after R1 fell in the bathroom, it was decided when R1 returned from the hospital, R1's care plan would have interventions to include a touch call light system be used, R1's bed would be placed against the wall and the w/c would have locked brakes and placed next to the bed. 2. R3's most recent admit to the facility on [DATE]. According to R3's most recent quarterly MDS assessment dated [DATE], R3 was dependent on staff for ADLs (Activities of Daily Living). The ADLs section of R3's quarterly clinical review assessment completed on 02/01/19, documented R3 to be total assistance of two with bed mobility, transfer, and toileting. On 02/21/19 at 10:19 AM, R3 was brought to room by CNA-E. The Surveyor observed CNA-E hook R3's Hoyer sling up to Hoyer lift and raised R3 in the air. CNA-E then lowered R3 back into chair. CNA-E stated that R3 needed to be repositioned and the other staff members were on break. CNA-E informed the Surveyor there is always 2 people when transferring residents in Hoyer lifts, but not when the resident just needs to be repositioned. On 02/21/19 at 1:45 PM., DON (Director of Nursing)-G informed the Surveyor that 2 staff need to be present anytime a resident is hooked up and lifted with a Hoyer, even if it is just for repositioning. DON-G stated education will need to be done with staff to be sure this is understood.

Based on staff and resident interviews and record review, the facility did not ensure 1 (R1) of 5 sampled residents was free from abuse and intimidation. R1 stated she suffered emotional abuse when the facility's previous NHA (Nursing Home Administrator)-A used intimidation to make R1 provide a written statement stating R1's interview/statements regarding a previous investigation that had resulted in citations at the facility were not true. The facility had received two Federal citations during a previous investigation for deficient practices directly involving NHA-A. Following the investigation, NHA-A sought out R1 in an isolated environment and personally coerced R1 to write a statement retracting the statements that were used to support previous citations. This incident caused psychosocial harm to the resident. Findings include: According to the facility's abuse policy and procedure dated 12/2016, each resident has the right to be free from abuse including intimidation and psychological harm. Residents are not to be subjected to abuse from anyone including facility staff. All staff are to have received training on abuse including preventing, identification, and reporting without fear of reprisal. According to R1's face sheet dated 1/9/17, R1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) assessment dated [DATE] documented R1 was cognitively intact, was assessed to have no mood disturbances, and had no behaviors. R1's care plan, last revised 12/13/16, documented R1 was at risk for falls, but was independent with cares and ambulation. R1 also had a care plan for obsessive compulsive behaviors dated 12/13/16, which included repetitive hand washing and wearing gloves during meals. No documentation of recent increased sleep disturbances, appetite changes, or mood changes were noted. On 4/28/17, a complaint investigation was completed at this facility and as a result, two citations were issued, both of which involved deficient practices related to actions by the facility administrator at that time (NHA-A). R1 had provided a statement supporting the determination of deficient practices and that statement was included in the citations. On 6/14/17 at 9:30 a.m., Surveyor interviewed R1. R1 stated approximately one to one and a half weeks after the previous State investigation at the facility, NHA-A entered R1's room and closed the door behind him. R1 stated it was supper time, which R1 commonly does not eat, and residents and staff were not around because they were in the dining rooms. R1 was seated on the side of the bed and NHA-A sat down in a chair right next to the bed. R1 stated the NHA leaned forward and was so close to R1 that she could have touched his nose. R1's stated her personal space was being invaded and she felt very uncomfortable; R1 stated it was too close. R1 demonstrated to the Surveyor how close the NHA was, and it was about 12 inches from the resident's face. R1 then stated NHA-A began to whisper to the resident: The lady from State came to see you I hear. R1 replied, yes and asked the NHA why he was whispering. The NHA replied, So no one can hear me. The NHA then told R1 that he (NHA) did not say the things R1 reported him saying during the State investigation and that it was a misunderstanding. R1 argued that NHA-A did and reminded the NHA of what he had said. The NHA asked R1, Are you afraid of me? Are you afraid of what I will do? NHA-A then asked R1 to write a letter saying the information R1 had provided to the State surveyor was not true. The NHA told R1 the citations he was receiving from the State bothered him because he had received the same ones in the past. R1 wrote a letter and brought it to the NHA. NHA-A read the letter and said, This is no good, it's the same thing you told the State lady. NHA-A then asked R1 to soften it because he could lose his job. R1 felt bad and changed the letter to reflect what the NHA had directed her to do. After R1 presented the revised letter, NHA-A instructed R1 to add more to the end of the letter and asked R1 not to tell anyone about their conversation. R1 requested a copy of the letter and was provided with one. NHA-A indicated he would be sending the letter to the State. R1 stated the NHA's face was expressionless during her encounters with him. R1 verified NHA-A did not threaten her, but described his actions that coerced her to write and edit the letter as secretive and creepy. R1 indicated the incident caused her to be fearful of NHA-A. R1 stated after the encounter regarding the letter she believed NHA-A watched her when she was out of her room. R1 stated that NHA-A approached her again on a subsequent day and told her to tell him if anyone gave her any trouble. R1 stated she did not sleep for three days after the initial encounter with NHA-A because she was afraid he would come back. R1 stated the NHA no longer works in the building, but works for the company and still comes back to the facility three days per week. R1 remains fearful of NHA-A. R1 denied changing any routines, increases in medications, or decreases in appetite. R1 stated she is not as happy as she used to be, but is trying to stay busy to be able to get over it. On 6/14/17 at 10:00 a.m., AS (Anonymous Staff)-B verified to the Surveyor that R1 reported the incident involving NHA-A. AS-B could not recall the exact date, but stated it was about a week after the last investigation ended (4/28/17). AS-B was informed by R1 that NHA-A had told R1 to write a letter and what to write in it. AS-B verified R1 was upset and bothered by the encounter with NHA-A. On 6/14/17 at 10:10 a.m., AS (Anonymous Staff)-C verified to the Surveyor that R1 reported NHA-A had entered her room during a meal when no one else was around and told R1 to write a letter changing the statements previously given to the State surveyor. AS-C could not recall the exact date, but believed this to have occurred about four weeks ago. R1 reported to AS-C that NHA-A was very close to R1 during the encounter. AS-C reported R1 felt very uncomfortable and scared. AS-C believed NHA-A to be harassing R1 and believed NHA-A wanted to clear his name before taking a different position with the company. On 6/14/17 at 10:47 a.m., NHA-A was interviewed by Surveyor via telephone. NHA-A did not recall the date or time of day the encounter with R1 occurred or if the door was closed. NHA-A stated he went to R1's room to follow up with the resident based on the concerns that were brought to his attention from the previous State investigation. NHA-A sat relatively close to R1. NHA-A stated R1 denied telling Surveyor the statements about the NHA from the previous investigation. NHA-A denied asking R1 to write a letter and stated R1 wanted to write a letter, even though he verified he wanted a letter to use to dispute the citations that were issued. NHA-A also denied telling R1 what to write in the letter; however NHA-A stated provided R1 with suggestions and told her it looks fine. NHA-A denied asking R1 if she was afraid of him or placing R1 in an intimidating situation. Instead, NHA-A stated he asked R1 if she was uncomfortable, though he denied R1 looked uncomfortable.