Every finding on record at Sun Prairie Senior Living

Based on observations, interviews, record reviews, and facility policy review, the facility failed to protect the residents' (R3 and R4's) right to be free from physical abuse by a resident (R2). The facility failed to ensure interventions were implemented after R2 slapped R3 across the face and when R2 slapped R4's head after an unprovoked interaction. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation Procedural Guidelines, dated 12/26/24 revealed, .The purpose of this policy is to.ensure the prevention and reporting of suspected or alleged resident use and neglect.ABUSE is the willful infliction of injury.means the individual must have acted deliberately.PHYSICAL ABUSE.includes, but is not limited to hitting, slapping, punching, biting and kicking.Resident to resident abuse with our without cause. Review of R2's Face Sheet in the electronic medical record (EMR) revealed R2 was admitted to the facility 04/09/25 with diagnoses to include a seizure disorder and vascular dementia. Review of R2's Comprehensive Care Plan revealed, Resident demonstrates inappropriate behaviors including slapping, calling the police. Resident's [NAME] name is [NAME] and (R2) will get upset if she feels someone is referencing her [NAME] name in a derogatory way. Refusing to ambulate at times. Resident is at risk for verbal altercations with residents and staff. Approaches include: 1. Target behavior monitoring q [every] shift Dated 06/15/26 2. Determine cause for inappropriate behavior and refer to physician as needed for intervention. Dated 07/14/25 3. Encourage participation in structured activities as appropriate. Dated 07/14/25 4. Observe for triggers of inappropriate behaviors and alter environment as needed. Dated 07/14/25 5. Assess for unmet needs such as need for toileting, rest, food, companionship, etc. Dated 07/14/25 6. Assist resident to [sic] away from other residents as needed. Dated 07/14/25 Review of R2's 01/04/26 Comprehensive Care Plan revealed, Resident has a history of period of antagonistic interactions with fellow peers. Resident engages in periodic teasing, antagonistic remarks, and banter that has the potential to escalate into verbal interactions. Approaches include, but are not limited to: Monitor interactions when residents are together, especially during known trigger times i.e. mealtimes/activities. Review of R2's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/04/26 revealed R2 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15 indicating moderately impaired cognition and had no behaviors. Review of R2's Psychiatry Follow-up Visit Note dated 05/07/26 revealed, .[R2] was seen by psychiatry for anxiety and depression.Judgement and insight is good.Nursing reports no behavior concerns at this visit. Notably she continues to deny mood, depression or anxiety at today's visit. Review of the Facility Investigation provided by the Executive Director (ED) dated 05/15/26 at 3:05 PM revealed, R2 made contact with R3 in R3's room. There were no witnesses. R3 reported the incident to the nurse on duty. Review of a 05/15/26 Interview with R3 by the Assistant Director of Health Services (ADHS) revealed, R2 wheeled in my room asking me to go find (ADHS). I asked her what do you want with the (ADHS). R2 said I want to go home. I replied, 'how is (ADHS) going to help you with that.' I guess she didn't like my answer, so she slapped me across the face. The (ADHS) asked R3 what happened next. R3 replied, She just rolled out. The ADHS asked if R3 felt safe in this facility. R3 responded, Yes, she does not hit hard. Review of a 05/15/26 at 4:57 PM Progress Note by Licensed Practical Nurse [LPN] 1 revealed, .Resident refused to get dressed today and stayed in room in hospital gown again today. Up in wheelchair talking to roommate and using the toilet then returning to bed.Resident remains very sarcastic with staff.Very resistant to redirection.The NP [Nurse Practitioner] was here to see other residents and spoke to R2 when she saw her in the hall and convinced resident to get dressed and to go outside. NP updated on behaviors.Before staff able to get resident dressed, resident wheeling self outside in hospital gown attempting to follow NP. Activity staff stopped resident when resident wheeling down driveway. Resident swinging arms attempting to hit staff.At about 3 pm another resident's call-lite was going off and this writer answered it. R3 asked 'Where is R2?' Told resident R2 was with staff and resident stated, 'Good because she keeps wandering in here and she slapped me across the face.' R2 had come [into R3's room] to ask if R3 had seen the ADHS and when R2 was told no, R2 slapped her.[R2] initially stated she didn't know if she hit R3 but then looked sheepish and told this writer 'Just take me to my room.' Resident remains in room on 15-minute checks. Review of the 05/15/26 Staff Schedule revealed from 2:00 PM to 4:30 PM, there was only one Resident Care Associate [RCA] on duty at the time of the incident; in addition, there were two nurses and other ancillary staff. An updated Care Plan dated 05/18/26, revealed an revised approach of: Offer redirection or alternative activities when early signs of irritation appear such as offering ice cream, listening to country music, doing hands on crafts, having a newspaper to read and quite [sic] one on one interactions. Review of the Facility Investigation provided by the ED revealed: On 05/23/26 at approximately 1705 [5:05 PM] ED was notified of a resident-to-resident interaction that occurred while residents were outside with activity staff member. R2 was observed making contact with the back of R4's head. The interaction was witnessed and both residents were separated by activity staff member to prevent further contact. R2 was transferred to the hospital emergency department for evaluation. Review of a Progress Note written by the ADHS dated 05/23/26 at 7:05 PM, indicated: .Writer spoke with R4 about the recent incident and what had happened. R4 stated, I was sitting outside and we were watering plants. We were sitting in a group when R2 came up from behind me and started hitting me in the head with my hat on. She then took my hat off and continued to slap my head. I think she thought it was funny, but she would not stop. Then the LEA (Life Enrichment Associate) yelled at her and she finally stopped. The ADHS asked why do you think she thought she was being funny. [R4] stated, Because she was calling me a dummy and other little kid names like that. Review of the 05/25/26 Hospitalist follow-up Progress Note revealed, .[R2] knew location this morning, but couldn't recall why she was here. Did have insight that she is living at [facility name], no longer working there. She admits that she gets confused and can't recall if she works there or lives there at times.Alert, pleasant and cooperative. Oriented to person and location.She also tells me that she gets confused and thinks that people are calling her Miss Crap. She states that whenever anyone calls her Miss Crap, she reaches out and gives them 'a little slap.' And as she was saying this, she reached out to try to demonstrate it on me. I had to dodge her slapping me.has had numerous outbursts of aggression to several patients. most likely this is related to a progression of MCI/Dementia [mild cognitive impairment]. Review of a 05/26/26 Written Statement by the Life Enrichment Associate revealed, At approximately 3:30 PM, I was out watering the plants with some residents. There were some gentlemen sitting at a table together outside conversing. At approximately 4:00 PM, [R2] came outside and went to the table the guys were sitting at. She took the hat off one of the residents at the table [R4] and hung it up on the trellis. After the hat was taken off, [R2] made contact to the back of [R4's] head. I told [R2] to stop and got the residents separated and redirected [R4] to the dining room as it was almost dinner time. Review of the quarterly MDS with an ARD of 06/04/26 revealed R2 had a BIMS score of 14 out of 15 which indicated R2 was cognitively intact, had signs and symptoms of depression, and had no behaviors. Review of a 06/18/26 Safety Care Plan revealed, Resident [R2] has impaired cognition with associated short term memory impairment and risk for confusion, disorientation, altered mood, impaired or reduced safety awareness r/t [related to]: Vascular dementia, mild, with other behavioral disturbance. Approaches included but were not limited to.Determine if decisions made by the resident endanger the resident or others. Intervene if necessary. During an interview on 08/12/26 at 8:36 AM, the ED and the Director of Health Services [DHS] were asked what interventions were in place to prevent R2 from hitting or slapping other residents. The ED stated, It was mostly redirection. The ED further stated, R2 and R3 used to be roommates and had gotten along really well. Then R2 was getting into R3's business so R2's family had agreed to move her to a different room. R3 did not want to be around R2 any longer. The ED was asked based on the times of both the incidents, it appears that they occur more after 2:00 PM than any other time of day; did you consider this when planning interventions to keep other residents safe. She stated, We try to look for patterns with the behavior, but we were not able to find consistency with this.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 34 residents who reside in the facility.Surveyor observed cereal spilled on the floor and an open container for storing dry pasta in the kitchen pantry.Surveyor observed milk temperatures to be out of range on room trays being delivered to residents for lunch.Surveyor observed sanitizing solution to test outside of the recommended range for parts per million (ppm) concentration.Surveyor observed male staff to have facial hair and to be working with resident food without hair restraints in place.Surveyor observed a refrigerator for resident snacks to be broken with melted, warm food inside of the refrigerator and freezer. This is evidenced by: Example - Pantry foodSurveyor requested a food safety policy, but the facility was unable to provide one.The Food and Drug Administration (FDA) Food Code 2022, includes in part: Food Storage . Food shall be protected from contamination by storing the Food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .On 03/29/26 at 8:29 AM, Surveyor did an initial tour of the kitchen and observed cereal spilled all over the floor in the panty. Surveyor also observed a clear bin of dry pasta with the lid uncovered. On 3/29/26 at 10:03 AM, Surveyor went through the kitchen again with DFS S (Director of Food Services). Surveyor informed DFS S about the cereal on the floor in the pantry and the uncovered lid on the dry pasta. Surveyor and DFS S walked into the pantry. Most of the cereal had been cleaned up, but there were still some on the floor. DFS S acknowledged this. DFS S also closed the lid on the storage bin of pasta. On 3/31/26 at 4:33 PM, Surveyor shared concerns with NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CSRN O (Clinical Support Registered Nurse). Example - Milk temperaturesSurveyor requested a food safety policy, but the facility was unable to provide one.The Food and Drug Administration (FDA) Food Code 2022, includes in part: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. Time/Temperature control for safety - food shall be maintained:.(2) At 5 C (41 F) or less.On 3/29/26 at 11:47 AM, Surveyor observed room trays stacked in two carts for residents who want to eat lunch in their rooms. Drinks were on the trays covered with plastic wrap.On 3/29/26 at 12:25 PM, staff members placed food on room trays on one cart and were preparing to take them to resident rooms. [NAME] T took the temperature of food on one of the trays but did not take the temperature of any beverages. Surveyor asked [NAME] T if she could take the temperature of a glass of milk that had been sitting on one of the room trays in the cart. [NAME] T took the temperature of the milk. It was 69 degrees F. [NAME] T indicated that was high and had new milk poured for the tray.On 3/29/26 at 12:27 PM, Surveyor told DFS S (Director of Food Services) about the temperature of the milk being 69 degrees. DFS S said the temperature should be lower. Surveyor asked DFS S to take the temperature of a glass of milk sitting on a tray on the second cart. DFS S took the temperature of the milk. It was 71 degrees. DFS S indicated the temperature was warmer than usual because it didn't come straight from the refrigerator. DFS S discarded the milk and replaced it on two trays on the cart.On 3/30/26 at 1:17 PM, Surveyor interviewed DFS S about the process for preparing room trays for meals. DFS S indicated staff had poured the drinks for the room trays too far in advance and he will revisit the policy with staff. Staff should be cold holding drinks until they go out. DFS S indicated they often take the temperature of the milk before it goes out. DFS S indicated staff should be taking the temperature of beverages along with trays before they are sent out.On 3/31/26 at 4:33 PM, Surveyor shared concerns with NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CSRN O (Clinical Support Registered Nurse). Example - Sanitizing solutionFacility policy, titled Manual Sanitation, revised 01/2023, states in part: .*First sanitizer bucket will be made at am (morning) shift and then checked every four hours thereafter to ensure it meets the appropriate disinfectant level. Test strips should be used to test that the final concentration of the solution is 150-400 PPM (parts per million). A sanitizer is recommended for sanitizing utensils of surfaces which have direct contact with food, and which cannot be sanitized by immersion in 180 degree F. *75 degrees F 200-300p ppm room temperature (Ultimate Sanitizer). On 3/30/26 at 1:15 PM, Surveyor asked DFS S (Director of Food Services) to demonstrate how to test the sanitizing solution used by the facility. DFS S poured sanitizing solution into a bucket and used a test strip to determine the ppm (parts per million) concentration of the testing solution. DFS S indicated it tested at 500 ppm. Surveyor asked how DFS S knew this was the proper range for the sanitizing solution to be at and he said it is what he was told by the company that oversees the food service staff. Surveyor and DFS S looked at the sanitizing solution bottle (Ultimate Sanitizer) and could not identify if this was the correct ppm concentration. Surveyor asked for the facility's policy.On 3/30/26 at 4:40 PM, Surveyor reviewed the facility policy with DFS S and asked if 500 ppm is in the correct range for the sanitizing solution. DFS S indicated 500 ppm is a little high and said he would be contacting food service management to follow up on this and make adjustments. Surveyor also reviewed a printed electronic log kept by kitchen staff members with DFS S. The log recorded the sanitizing solution ppm as 175 ppm each day. Surveyor asked DFS S who is testing the solution and recording it each day. DFS S indicated the solution is being tested each day, but they do not keep a log of the test results each day. DFS S indicated that number recorded on the log is actually the water temperature. On 4/1/26 at 3:00 PM, Surveyor shared concern with NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CSRN O (Clinical Support Registered Nurse).Example - [NAME] restraintsThe Food and Drug Administration (FDA) Food Code 2022, includes in part: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed or worn to effectively keep their hair from contacting exposed food .Facility policy, titled [NAME] and Hairnet, revised 7/9/25, states in part: Purpose: The purpose of this policy is to: Beards and mustache hair must be covered while in kitchen food product area. Facial hair restraints are required in any food production area. Facial hair is not exempt from the hair restraining standard. It is up to each campus to define which type of facial hair requires a beard net. Procedure: Some common approaches include: -Cover all beard or mustache hair that is more than 1/8 of an inch growth. -Like hair restraints, facial hair restraints must be worn. -A clean or new guard must be used at the start of each shift.On 3/29/26 at 11:47 AM, Surveyor observed DFS S (Director of Food Services) to be working on the lunch meal preparation without donning a beard restraint to cover his facial hair. On 3/30/26 at 1:11 PM, Surveyor observed [NAME] U preparing food in the kitchen with a beard and no beard restraint in place. [NAME] U applied a beard restraint a few minutes later.On 3/30/26 at 1:17 PM, Surveyor interviewed DFS S and asked what the policy is for covering facial hair with a beard restraint. DFS S indicated the policy is anything over 1/8 of an inch should be covered. Surveyor asked for the facility policy on this. On 3/30/26 at 4:40 PM, Surveyor asked DFS S how 1/8 of an inch is measured for facial hair on employees when determining if they should wear a beard restraint. DFS S said 1/8 of an inch is the first level on a trimming device and said typically staff members are good at being clean shaven and not having facial hair. Surveyor informed DFS S that the general guideline is that all facial hair requires a beard restraint. On 4/1/26 at 1:00 PM, NHA A (Nursing Home Administrator) indicated the facility's policy on beard restraints is what was provided. The facility does not have a more specific policy that it provides to kitchen staff regarding facial hair needing to be covered if it is over 1/8 of an inch.On 4/1/26 at 3:00 PM, Surveyor shared concern with NHA A, DON B (Director of Nursing), and CSRN O (Clinical Support Registered Nurse). Example - RefrigeratorSurveyor requested a food safety policy, but the facility was unable to provide one.The Food and Drug Administration (FDA) Food Code 2022, includes in part: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. Time/temperature control for safety - food shall be maintained:.(2) At 5 C (41 F) or less. The freezer equipment should be designed and maintained to keep foods in the frozen state.On 4/1/26 at 1:00 PM, Surveyor inspected a refrigerator in the conference room with a sign indicating it is for resident snacks. Surveyor opened the refrigerator door and observed several packs of melted Jell-O. The refrigerator was running and the temperature inside was warm. The refrigerator emitted a foul odor into the conference room. Surveyor also opened the freezer door and observed individual ice cream cups that appeared unfrozen because the temperature in the freezer was so warm. On 4/1/26 at 1:35 PM, Surveyor interviewed DFS S (Director of Food Services) and ADFS Z (Assistant Director of Food Services) and asked who is responsible for monitoring that refrigerator temperature. DSF S and ADFS Z indicated the resident snack refrigerator had been broken for weeks and they were surprised to hear it was still running with food inside. DFS S and ADFS Z indicated maintenance had been told about this issue and they were supposed to take care of it a long time ago.On 4/1/26 at 2:18 PM, Surveyor spoke with PSA R (Plant Services Assistant). PSA R indicated that kitchen staff had never submitted a work order for the broken refrigerator and that they had just notified him about this issue a few minutes ago.On 4/1/26 at 3:00 PM, Surveyor shared concern with NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CSRN O (Clinical Support Registered Nurse).

Based on observation, interview, and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 2 of 16 sampled residents (R4 & R44). R4 reported to Surveyor that their divider curtain was soiled and that their carpet had not been vacuumed. R44 reported that their toilet overflows and no one will fix it. Evidenced by: Facility did not provide a policy on housekeeping. Example 1: R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, and type 2 diabetes mellitus. R4's most recent Minimum Data Set (MDS) dated [DATE] states that R4 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R4 is cognitively intact. On 3/29/26 at 9:29 AM, Surveyor interviewed R4. R4 reported to Surveyor that their room divider curtain was soiled, and it grosses out their visitors. Surveyor observed the curtain to have several brownish-black spots on it. Surveyor also noted that R4's carpet had debris and smashed popcorn on it. R4 stated that the popcorn was from a couple of days ago. Surveyor asked R4 if their carpet gets vacuumed daily, R4 stated that it didn't get vacuumed yesterday and that they didn't vacuum it yesterday. On 3/30/26 at 12:10 PM, Surveyor observed R4's room. Surveyor noted that the debris and smashed popcorn remained on the floor, and the divider curtain remains stained. On 3/31/26 at 8:41 AM, Surveyor observed R4's room and noted that the area appears to have been vacuumed. On 3/31/26 at 8:48 AM, Surveyor interviewed Hskpr J (Housekeeper). Surveyor asked Hskpr J how often the resident rooms are vacuumed, Hskpr J stated that they are vacuumed everyday and that they had to unclog the vacuum this morning. Surveyor asked Hskpr J what steps they take if a room divider curtain is soiled, Hskpr J stated that maintenance would have to take it down so that it can get washed. Surveyor asked Hskpr J to observe R4's curtain. Surveyor asked Hskpr J if the curtain appeared soiled, Hskpr J stated that it has something on it, but it might be stained. Surveyor asked Hskpr J if the curtain should be replaced, Hskpr J stated yes. On 3/31/26 at 9:28 AM, Surveyor interviewed NHA A (Nursing Home Administrator) in R4's room. Surveyor asked NHA A how often the resident rooms should be vacuumed, NHA A stated daily. Surveyor reported to NHA A that observations were made for 2 days that R4's carpet had not been vacuumed. R4 reported to Surveyor and NHA A that they were trying to pick up the debris with their grabber. Surveyor asked NHA A if the room divider curtain appears soiled, NHA A stated yes and that it should be replaced. Surveyor asked if these concerns were promoting a homelike environment, NHA A stated no. Example 2: R44 voiced concerns about the toilet in her bathroom leaking. R44 was admitted to the facility on [DATE] with diagnoses that include spondylosis with myelopathy (compression of the spinal cord that can result in walking instability and weakness), dizziness and giddiness, and rheumatoid arthritis (pain, swelling, and inflammation in the joints). R44's admission Minimum Data Set (MDS) dated [DATE] states that R44 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R44 is cognitively intact. On 3/29/26 at 9:10 AM, Surveyor interviewed R44. R44 indicated the toilet in her bathroom had been leaking since 3/19/26 and said there is a puddle on the floor near the front of her toilet every night. R44 indicated she had complained about it eight times to the aides and they have written notes for maintenance and told them about it. R44 indicated maintenance came in to look at her toilet on 3/25/26 but did not fix the issue. On 3/30/26 at 7:25 AM, Surveyor interviewed DPO Q (Director of Plant Operations) and asked him about R44's leaking toilet. DPO Q indicated the hose in the back of the toilet had been pulled out, so it sprayed water when the toilet was flushed. This was adjusted. DPO Q indicated residents can mess with the toilet sometimes and this happens. DPO Q indicated PSA R (Plant Services Associate) went into R44's room last week but didn't find anything else wrong. Surveyor told DPO Q that R44 indicated that nobody had followed up with her on this and it was still an issue. DPO Q indicated PSA R can be quiet around residents, so he would go and talk to her about the issue. On 3/30/26 at 3:14 PM, Surveyor interviewed R44. R44 indicated DPO Q had stopped in her room earlier that day, but the toilet was not leaking at that time and he didn't say anything to her. Surveyor looked at R44's toilet. There was a large puddle of water on the floor surrounding the front of the toilet. On 3/30/26 at 3:30 PM, Surveyor went to get DPO Q so he could look at R44's toilet. DPO Q observed the puddle on the floor, examined the toilet, and told R44 that he would get it fixed as soon as possible. R44 thanked DPO Q for letting her know and told him this has been an issue for nine days. On 3/31/26 at 9:41 AM, Surveyor interviewed CNA V (Certified Nursing Assistant) about R44's toilet. CNA V indicated she has worked with R44 twice and was aware that her toilet was leaking. The first time she worked with her, R44 asked CNA V to check if there was water on her bathroom floor because she was afraid of slipping. CNA V said this happened approximately a week ago and knew maintenance had been notified about the issue. On 3/31/26 at 2:47 PM, Surveyor interviewed LPN M (Licensed Practical Nurse) about R44's toilet. LPN M indicated she submitted a work order on 3/26/26 when she first found out about R44's toilet leaking. LPN M indicated she was unsure if it had been leaking prior to 3/26. On 3/31/26 at 9:49 AM, DPO Q let Surveyor know that he changed the ring on R44's toilet last night and checked it again this morning and it wasn't leaking. Surveyor asked when he had been notified that the toilet was leaking. DPO Q indicated staff submitted a maintenance request last week and staff notified the maintenance staff about it when they passed them in the hallway. DPO Q said he would check to see when the maintenance request was submitted, as PSA R had initially done a hose adjustment and tightened the base of R44's toilet. On 3/31/26 at 12:25 PM, DPO Q brought Surveyor a work order for R44's toilet with a due date of 3/26/26. The work order was created that day (on 3/31/26). The work order indicated PSA R had fixed a loose hose tank and tightened R44's toilet base. Surveyor asked if 3/26 was when they were notified about the toilet leaking and DPO Q said yes. On 4/1/26 at 11:50 AM, Surveyor interviewed R44. R44 indicated her toilet was fixed and no longer leaking.

Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 2 residents reviewed for grievances (R26). R26's Activated Power of Attorney (APOA) expressed concerns regarding R26 not getting out of bed for activities and that R26 had a broken wheelchair. The facility failed to provide a written resolution to R26's APOA. Evidenced by:The facility policy titled Resident Concern Process last reviewed 12/16/24 states in part .4. The facility staff will follow these basic steps in response to a complaint: *Listen to the concern without interruption *Thank the person who brought the concern to staff * Apologize to the person bringing the concern and acknowledge that what happened is not our standard * Not make excuses for why or how this has happened * Take steps to correct the problem *Make the problem their own by following up to make sure it is resolved and stays resolved *Any concern that is suspected to be abuse, neglect or misappropriation of funds must be reported immediately to the Executive Director and the Director of Health Services. 5. Enter the concern using the desktop icon labeled Resident Concern Form. All concerns should be entered electronically.7. Follow-up from the department leader will occur within 24-48 with resolution entered in [Facility Program] .9. The department leader will investigate and discuss the concerns with the team and will implement or educate to prevent further concerns. 10. The department leader will document the resolution on the concern form using an addendum when needed and will follow up with the person reporting the concern to explain the solution.14. Resident rights for filing a grievance.* At the conclusion of the investigation for a concern or grievance, the resolution will be documented and shared with the resident or his/her representative. This may be verbal or in writing. R26 was admitted to the facility on [DATE] with diagnoses that include dementia, progressive supranuclear ophthalmoplegia (a rare neurodegenerative disorder characterized by progressive loss of eye movement control, balance issues, and cognitive decline), type 2 diabetes mellitus, and dysphasia, oropharyngeal phase (the inability to swallow food or drink. The condition can also cause breathing difficulties, choking, and drooling). R26's most recent Minimum Data Set (MDS) dated [DATE] states that R26 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R26 is cognitively intact. On 3/31/26 at 8:12 AM, Surveyor interviewed APOA K. APOA K reported to Surveyor that they had brought concerns regarding R26 to NHA A (Nursing Home Administrator) and that NHA A does not always return their calls or follow up on concerns. APOA K reported that they expressed concerns about R26 not getting out of bed on 2 Sundays in December (the 21st and the 28th) to attend activities and they left messages for NHA A that weren't returned. On 3/31/26 at 9:21 AM, Surveyor requested any grievances related to R26 and APOA K's concerns. NHA A reported that they believe the concerns were written up as grievances and would provide the investigations to Surveyor. NHA A provided Surveyor with a spreadsheet of grievances for the month of December. The document contained: R26 name, Concern date: 12/28/25, Nature of concern: Daughter upset that resident was not up for activities. Wheelchair was noted by staff that a part was broken. [Hospice Agency] was called to come out and evaluate chair. Dissatisfaction level: Concerned, Date entered: 12/28/25, Resolution: Satisfactorily- Hospice came in and replaced wheelchair that was broken. Resolution date: 12/28/25, resolution date entered: 12/29/25, Social Services Review: yes, Comments: working on establishing date for care conference with daughter, Date resolution entered: 12/29/25. It is important to note, there was no grievance filed regarding APOA K's concerns on 12/21/25. On 4/1/26 at 10:01 AM, Surveyor interviewed NHA A. Surveyor asked NHA A what the facility's process was for grievances, NHA A stated that the facility has an online forum and a paper forum for submitting concerns and that if staff receives a concern, they will enter it there right away. Surveyor asked NHA A if there was an investigation into why R26 was not gotten up for activities, could staff have provided R26 with an alternate wheelchair, was R26 interviewed, was staff interviewed, and did they contact the daughter regarding their concerns, NHA A stated that they were usure about the investigation. Surveyor asked NHA A if they provided R26's APOA with a written resolution, NHA A stated no.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 16 Residents (R43) reviewed for abuse.R43 and FM G (Family Member) reported an allegation of abuse and the facility did not submit a report to the State Agency (SA).Evidenced by:The facility's Abuse and Neglect Procedural Guidelines policy, dated 8/29/19, states, in part: Facility has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. 1. The facility has implemented processes in an effort to provide a comfortable and safe environment. 2. The Executive Director and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures. 3.a. Verbal Abuse-verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. i. Staff to resident-any episode;.c. Mental/Emotional Abuse-mental abuse if the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. d. Identification.ii. Any person with knowledge or suspicion of suspected violations shall report immediately, without fear of reprisal.iv. IMMEDIATELY notify the Executive Director.ii. The Executive Director is responsible for: 1. Notification to the State Department of Health (per State guidelines) and other agencies, which include the Ombudsman, Adult Protective Services and/or local law enforcement agencies, as indicated.g. Reporting/response i. Any staff member, resident, visitor or resident representative may report known or suspected abuse, exploitation, neglect, or misappropriation to local or state agencies. ii. Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.R43 admitted to the facility 2/20/26. R43's Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact.On 3/31/26 at 2:10 PM, Surveyor interviewed R43 and FM G (Family Member). R43 stated that two nights ago, around 3:00 AM, a CNA (Certified Nursing Assistant) was in the room and stated, You're trouble. When I speak, you don't speak. FM G stated the CNA's comments were reported to DSS E (Director of Social Services) earlier today.On 4/1/26 at 9:50 AM, Surveyor interviewed R43 who stated, it didn't feel too good. I didn't understand why I would be called trouble and her saying 'you don't speak when I'm speaking'; I just shut up, but I didn't know how I'd explain what I needed. I am at their mercy.On 4/1/26 at 8:25 AM, Surveyor interviewed DSS E who stated she was aware of the concern yesterday (3/31/26) and investigation had been started by LPN D (Licensed Practical Nurse), as LPN D knew who was working.On 4/1/26 at 8:45 AM, Surveyor interviewed LPN D and NHA A (Nursing Home Administrator). LPN D stated I heard 3rd hand that the son had made a comment about a staff member concern. LPN D stated she did not recall the exact comment but had reached out to the two staff members who were scheduled to see if they had conversation with the resident. NHA A stated I was told that R43 didn't like the staff member's approach. NHA A indicated being unaware of the comment that was reported by R43 / FM G. Surveyor asked NHA A if this comment could be considered abuse. NHA A stated it depends on the context. Surveyor asked how that would be determined. NHA A stated through interview of the resident. Surveyor asked if the resident was interviewed. NHA A stated no, I was unaware that this comment was made. I wasn't fully aware of the concern. Surveyor asked if NHA A would expect to be made aware. NHA A stated yes, I heard from AC F (Admissions Coordinator) that there was a concern with approach. Surveyor asked if the concern was reported to State Agency. NHA A stated no.On 4/1/26 at 9:04 AM, Surveyor interviewed AC F who stated I was with DSS E when FM G reported. I felt like it should be escalated. I went to LPN D. Anytime there is a concern with a resident it should be taken to management for resident comfort and safety. Surveyor asked if the comment was potentially abuse. AC F stated, I would say that is not any way that I would want someone speaking to my mother. I gave the statement information to LPN D. I believe that NHA A was aware.

Based on interview and record review, the facility did not ensure it had evidence that an alleged violation was thoroughly investigated for 2 of 16 Residents (R27 and R34) reviewed for abuse. Facility did not thoroughly investigate an allegation of abuse (resident-to-resident) for R27 and R34. Evidenced by: Facility Policy entitled 'Abuse, Neglect and Exploitation Procedural Guidelines, states in part: .The facility has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. Procedures: The facility has implemented processes in an effort to provide a comfortable and safe environment. The Executive Director (also known as NHA A, Nursing Home Administrator) and Director of Health Services are responsible for the implementation and ongoing monitoring of abuse standards and procedures. Physical Abuse - includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Resident to resident abuse with or without cause. Investigation: The Executive Director is accountable for investigating and reporting; iii. Investigating different types of alleged violations; iv. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. V. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. No documentation was provided to show that other residents or responsible parties were interviewed to see if others may have been affected. R27 was admitted to the facility on [DATE] with diagnoses including stroke (blood flow to the brain is blocked or a vessel bursts), hemiparesis (one sided body weakness). R34 was admitted to the facility 4/9/25 with diagnoses including stroke, chronic encephalopathy (brain damage that causes confusion, altered mental status and personality changes, seizures), cerebral ischemia (reduced blood flow reduces oxygen to the brain), unspecified convulsions (symptom of seizure), and major depressive disorder (persistent sadness) Self-Report Date Occurred: 12/31/25Date Discovered: 12/31/25Describe the Incident: R34 made contact with the top of R27's head. Residents (R34 and R27) were immediately separated. R27's skin assessment completed with no new findings noted. R27 denies any pain or injury from incident. Investigation initiated and interventions put in place to keep residents apart. Describe the Effect: R27 denied any pain or injury - immediately separated Explain what steps the entity took upon learning of the incident: Residents separated immediately Summary of Investigation: On the above date and approximate time, an incident occurred in the dining room prior to the evening meal involving Resident 34 (R34) and Resident 27 (R27). The residents were observed engaging in their usual bantering and playful teasing, which staff report has historically been harmless and reciprocal. During this interaction, R34 tapped R27 on the back of his head. Staff were present in the dining room at the time of the incident and immediately intervened, separating both residents and redirecting them to ensure physical and psychosocial safety. No further physical contact occurred. Due to the nature of event an investigation was immediately initiated, and initial report was made to DQA (Division of Quality Assurance) per CMS (The Centers for Medicare and Medicaid Services) guidelines Head-to-toe assessment was completed on R27 with no injuries, bruising, swelling or neurological changes noted. R27 denied any physical or emotional pain or discomfort following the incident. NHA A (Nursing Home Administrator), attending medical providers, and emergency contacts were notified promptly. New orders obtained for neurological monitoring every shift for three days for R27 with no abnormal findings noted. Psychosocial monitoring was initiated and remains ongoing. R27 indicates he feels safe in the facility and expresses no concerns or fear regarding R34. He denied pain or distress related to the incident. R34 did not express intent to harm and was redirected appropriately at the time of the incident. A review of R34's medical and psychiatric history was completed as part of the investigation. R34 has a documented history of chronic encephalopathy (brain damage that causes confusion, altered mental state and personality changes, seizures), cerebral ischemia (reduced blood flow reduces oxygen to the brain), unspecified convulsions (symptom of seizure), and major depressive disorder (persistent sadness). Psychiatric provider documentation indicates poor judgement, poor limited insight, poor impulse control, flight of ideas, and tangential thought process. R34 remains under the care of Behavioral Care Solutions (psychiatric provider). Psychiatric provider updated on the incident and request was made for further psychiatric assessment with further recommendations if indicated. The incident was isolated and brief, with immediate staff intervention. Upon investigation it is noted that R34 and R27 reported feeling safe. Staff supervision was present and appropriate at the time of the incident. R34's cognitive and psychiatric impairments may have contributed to impaired impulse control. Care plans for both residents were reviewed and updated to reflect the incident along with individualized interventions. Increased monitoring and redirection strategies were reinforced for Resident A, particularly during social interactions. Education initiated regarding de-escalation techniques, early identification of escalating, and redirection strategies. Based on thorough investigation, this incident was promptly identified and addressed, with appropriate interventions implemented to ensure resident safety. No injuries occurred, and the affected resident reports feeling safe in the facility. The facility took immediate and appropriate action consistent with CMS (The Centers for Medicare and Medicaid Services) regulations to prevent recurrence, address contributing factors, and protect the physical and psychosocial well-being of all residents. Two staff members, RN H (Registered Nurse) and LEA I (Life Enrichment Associate) witnessed the resident-to-resident incident.RN H signed the following typed statement: On Wednesday 12/31/25 R27 was sitting in his electric wheelchair at the dinner table. R34 stood up from her wheelchair and popped him on his head. As I (RN H) looked up while watching another resident taking her pills-R34 was standing up over R27. I (RN H) stated, (R34's name), don't do that. R27 told her, What the hell, do not touch me. I (RN H) immediately checked R27 head to toe-there were no related bruises or scratches noticed. I (RN H) notified the NP (Nurse Practitioner) right away as well as his family member. On 3/29/26 at 9:50 AM, Surveyor spoke with R27. R27 stated he does not recall this incident and feels safe at the facility. On 3/29/26 at approximately 10:00 AM, Surveyor spoke with R34. R34 does not recall this incident and feels safe at the facility. On 3/31/26 at 3:05 PM, Surveyor called RN H. Surveyor requested RN H return the phone call. RN H did not return Surveyor's phone call. LEA I (Life Enrichment Associate) signed the following typed statement: On Wednesday 12/31/25 at dinner, R34 went up behind R27 and tapped him on the back of his head multiple times. RN H and LEA I told R34 to stop what she was doing and redirected her back to her table. LEA I later provided education to R34 regarding her actions and told her that is was [sic] not appropriate and she cannot continue to do those things. On 3/31/2026 3:10 PM, Surveyor spoke with LEA I. Surveyor asked LEA I to describe the resident-to-resident incident she witnessed in the dining room. LEA I stated, R34 came up behind R27 and started hitting him on top of the head with her open hand. LEA I stated she and RN H witnessed it and right away separated R34 from R27. LEA I stated we (LEA I and RN H) advised R34 that this was not the right thing to do. Surveyor asked LEA I to demonstrate how R34 hit 27. LEA I stated it wasn't a tap it was a smack. LEA I demonstrated that R34 hit R27 hard on the head with her open palm. LEA I stated, R27 was wearing a baseball hat at the time. LEA I stated, R34 and R27 do not attend activities together and staff keep them separated. LEA I stated, she has not seen R34 become escalated or make physical contact with any other residents. It is important to note, the facility interviewed R34 and R27 however, the facility did not interview other residents to determine to scope of the issue. On 4/01/26 at 7:55 AM, Surveyor spoke with NHA A (Nursing Home Administrator). NHA A has worked at the facility for three (3) months. NHA A stated, this incident occurred right after she started working at the facility. NHA A stated, she was notified that R34 approached R27 from behind and tapped R27 on the back of the head. LEA I intervened immediately and RN H assessed. NHA A stated, no concerns were noted with R27 and he feels safe at the facility. Surveyor asked NHA A, if the facility interviewed other residents to determine the scope of the concern. NHA A stated, no. Surveyor asked NHA A if she should have interviewed other residents to determine the scope of the concern with R34. NHA A stated, no, because the incident was a resident-to-resident incident, so she only interviewed R27. NHA A stated, she was not aware she should have interviewed other residents to determine the scope of this concern. This is not a thorough investigation.

Based on interview and record review, the facility failed to ensure that the assessments must accurately reflect the resident's status for 1 of 16 residents' (R5) Minimum Data Sets (MDS) reviewed for accuracy. R5's MDS dated [DATE] does not have her pressure injury (PI; localized damage to skin and underlying tissue caused by prolonged pressure) coded correctly. This is evidenced by: The Facility does not have a Policy and Procedure for MDS accuracy. The Facility follows the Resident Assessment Instrument (RAI) manual. Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/23, documents the following, in part: .The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status . On 7/16/25 Hospice identified, assessed and measured R5's PI's as follows: Pt (patient) now has a 9.0 x 17.3 cm (centimeter) open area that at the coccyx has undermining at 7-9 o'clock with a depth of 2.1 cm with the left buttock having 2 (two) necrotic areas, and the right buttock as 2 necrotic , slough present to coccyx area. On 7/16/25 R5's Nurse Practitioner assessed and documented the following PIs (pressure injuries):Decubitus ulcer of coccyx, unstageableDecubitus ulcer of left buttock, unstageableDecubitus ulcer of right buttock, stage 3 R5's current Physician Orders includes, in part, as follows: 2/11/26 Bilateral buttocks/coccyx: Cleanse with wound cleanser, pat dry, loosely pack .25% Dakins moistened gauze into wound leave a tail exposed, cover tail with one sheet of collagen. Apply Optilock. Apply sure prep (skin prep) to surrounding peri wound. Secure with zinc oxide tape. Change daily and PRN (as needed). Special Instructions: May overlap dressings to cover coccyx area. R5's MDS dated [DATE] documents the following, in part: .Section M . M0210 Unhealed Pressure Ulcer/Injury marked .NO . On 4/1/26 at 3:05 PM, Surveyor spoke with Clinical Support RN O (Registered Nurse). Surveyor asked Clinical Support RN O, would you expect MDS's to be completed accurately, Clinical Support RN O stated, yes. Surveyor asked Clinical Support RN O, should R5's MDS document her PI's. Clinical Support RN O stated, yes.

Based on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASRR) process for 1 of 5 residents (R43) reviewed for PASRR screening. R43 did not have a PASRR Level I (1) completed. This is evidenced by: The facility provided the Wisconsin Department of Health Services Forward Health Update, volume 2023-37, dated 11/2023, for their PASRR policy. The Forward Health Update states, in part: Federal regulations.require that all individuals seeking admission to a Medicaid-enrolled nursing facility be screened to determine the presence of a major mental illness and/or developmental disability. Nursing facilities fulfill this requirement by conducting a preadmission Level I screen for anyone who meets the definition of a 'new admission.'. R43 was admitted to the facility on [DATE], was on hospital leave from 2/21/26-3/20/26, and readmitted to the facility on [DATE], with diagnoses that include Parkinson's disease (neurological disorder affecting movement), depression, and insomnia due to other mental disorder. Surveyor requested PASRR documentation for R43. On 4/1/26 at 1:00 PM, NHA A (Nursing Home Administrator) indicated they were unable to locate a PASRR on file for R43. On 4/1/26 at 1:30 PM, Surveyor asked DON B (Director of Nursing) if a PASRR should have been completed for R43. DON B indicated if it is in the facility's policy, it should have been completed.

Based on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 2 of 5 sampled Residents (R4 & R41).R4 reported that they have only had 1 shower since their admission to the facility.R41 reported that they have only had 1 shower since their admission to the facility. R41 has facial hair that is approximately 1/4- 1/2 long and facility staff has not shaved R41.Evidenced by:The facility does not have a policy for ADLs (Activities of Daily Living).Example 1R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, and type 2 diabetes mellitus.R4's most recent MDS (Minimum Data Set) dated 2/25/26 states that R4 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R4 is cognitively intact. R4's MDS also states that R4 requires substantial/maximal assistance for showering/bathing.R4's care plan dated 2/17/26 states in part .Problem: Profile Care Guide Goal: To communicate resident care needs Approach: .Showers: TWICE WEEKLY PER SCHEDULE AND PRN (as needed) .Transfers: One Assist.The facility's Shower Schedule states that R4 is scheduled to have a shower on Friday AM shift.R4's Point of Care History states that R4 only received a shower on 2/28/26.On 3/29/26 at 9:26 AM, Surveyor interviewed R4. Surveyor asked R4 if they were getting their showers as scheduled, R4 stated no, and that they have only had 1 shower since admission.Example 2R41 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of prostate (prostate cancer), dementia, and anxiety.It is also important to note that R41 is missing 3 fingers on their left hand, only has partial thumb and partial 5th digit.R41's care plan dated 3/20/26 states in part .Problem: Profile Care Guide Goal: To communicate resident care needs. Approach: .Showers: TWICE WEEKLY PER SCHEDULE AND PRN (as needed) Transfers: One Assist.The facility's Shower Schedule states that R41 is scheduled to have a shower on Saturday PM shift.R41's Point of Care History states that R41 has not had a shower since their admission to the facility.On 3/29/26 at 9:14 AM, Surveyor interviewed R41. Surveyor observed that R41 had 1/4-1/2 facial hair. Surveyor asked R41 if they were getting their showers as scheduled, R41 stated that they believe that they have had one shower but was not sure. Surveyor asked R41 if they liked the whiskers on their face, R41 stated no but no one is shaving them, and they can't do it themselves.On 3/30/26 at 1:51 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how many showers R4 and R41 have had, DON B stated that from reviewing the documentation, R4 has had 1 shower since admission, and there is no documentation of R41 receiving a shower. Surveyor asked DON B if residents should have showers as scheduled, DON B stated yes. Surveyor asked DON B how often residents should be shaved, DON B stated that they were unsure.On 3/30/26 at 2:00 PM, Surveyor interviewed CNA P. Surveyor asked CNA P how often residents get shaved, CNA P stated anytime they ask or everyday as part of their ADLs. Surveyor asked CNA P if they knew the last time R41 was shaved, CNA P stated that they did not know. Surveyor asked CNA P who got R41 up this morning, CNA P stated that they did. Surveyor asked if R41 was shaved today, CNA P stated no. Surveyor and CNA P went to observe R41, who still had long whiskers. Surveyor asked CNA P if they noticed R41's whiskers when they got them up, CNA P stated no.

Based on observation, interview and record review, the facility did not ensure that the resident environment remains as free of accident and hazards as possible for 2 of 4 sampled residents (R27 & R26). Surveyor observed R27's motorized wheelchair (Motorized Assistive Devices) being charged in the conference room. NHA A (Nursing Home Administrator) states the wheelchair should be charged in the Conference Room. Surveyor observed the Conference Room to not have a fire safe door. R26 has an order to be supervised at meals. The facility was not providing supervision with breakfast. Evidenced by The facility did not have a policy for charging electric wheelchair batteries. The facility also did not have a policy for Motorized Assistive Devices. On 3/31/26 at 8:30 AM, Surveyor observed R27's wheelchair battery charging in the conference room while Surveyors were in the conference room. On 3/31/26 at 8:37 AM, Surveyor asked NHA A (Nursing Home Administrator) to walk to conference room with Surveyor. Surveyor showed NHA A the battery charging. NHA A stated, this is R27's battery for his wheelchair. Surveyor asked NHA A if the battery should be charged behind a fire-proof door. NHA A stated that batteries should not be charged in resident areas but she is unsure if they need to be charged behind a fire-proof door. NHA A stated, residents do not utilize the conference room. NHA A stated, she will check the facility policy and get back to Surveyor. Surveyor reviewed the facility's March Activity Calendar. The facility's Activity Calendar further demonstrates the conference room is utilized by residents for the following: (3/1, 3/8, 3/15, 3/22, 3/29/26) Book Club each Sunday 3/16/26 Absentee Voting: Spring Election (3/3, 3/10, 3/17, 3/24, 3/31/26) Bible Sharing each Tuesday On 3/31/26 at 8:55 AM, R27 entered the conference room and stated his family member is bringing him dinner tonight and will have her dog. R27 stated they are going to use the conference room. R27 inquired what time Surveyors would be done today. Of note: This further demonstrates that residents utilize the conference room. On 3/31/26 at 9:25 AM, NHA A (Nursing Home Administrator) stated the facility does not have a policy regarding charging batteries. Surveyor asked NHA A, why it is important to charge batteries behind a fire proof door. NHA A stated, in case it was to explode it is isolated and fumes can be harmful to residents and personnel. Surveyor asked NHA A what the room is called where the battery is located. NHA A stated the conference room. Example 2 R26 was admitted to the facility on [DATE] with diagnoses that include dementia, progressive supranuclear ophthalmoplegia (a rare neurodegenerative disorder characterized by progressive loss of eye movement control, balance issues, and cognitive decline), type 2 diabetes mellitus, and dysphasia, oropharyngeal phase (the inability to swallow food or drink. The condition can also cause breathing difficulties, choking, and drooling). R26's most recent MDS (Minimum Data Set) dated 2/6/26 states that R26 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R26 is cognitively intact. R26's physician's order dated 7/28/25 states OT (Occupational Therapy) evaluated: use built up handle utensils (spoon and fork) during mealtimes supervision required for spilling. Three times a day. R26's care plan dated 3/27/23 states in part .Problem: Profile Care Guide Goal: To communicate resident care needs. Approach: .Approach start date: 6/6/25 Eating: Use built up handle utensils (spoon and fork) during mealtimes. Supervision with all meals for safety. On a regular mechanical soft diet with no straws. R26's Dining/Eating Assistance Needed assessment dated [DATE] states in part: .Eating assistance – Indicate resident's current ability to eat meals: Needs frequent cueing with meal. Current fluid consistency: Nectar. Complicated eating problems- Check all that apply: Difficulty swallowing, Recent episode of coughing or choking while eating. Surveyor's observations: 3/30/26: 8:53 AM: meal tray brought into R26's room. 8:55 AM: CNA (Certified Nursing Assistant) left resident's room to get a clothing protector and returned to resident's room 8:56 AM: CNA left resident's room. 3/31/26: 8:31 AM: LPN took meal tray to resident's room. 8:34 AM: LPN left resident's room. 8:35 AM: Surveyor went into R26's room, no staff supervision while R26 eats breakfast. On 3/31/26 at 8:12 AM, Surveyor interviewed APOA K (Activated Power of Attorney). APOA K reported to Surveyor that R26 needs thickened liquids and no straws, but when they were visiting, R26 had thin liquids and straws. APOA K also reported that R26 eats lunch and dinner in the dining room, so R26 is supervised, but always eats breakfast in their room unsupervised and R26 is at risk for choking and pocketing food due to their diagnosis. Surveyor asked APOA K if R26 has had any choking incidents, APOA K stated no. On 3/31/26 at 8:54 AM, Surveyor interviewed CNA V. Surveyor asked CNA V how often they supervise R26 while eating breakfast, CNA V stated that they were unaware that R26 required supervision until today. On 3/31/26 at 8:57 AM, Surveyor interviewed CNA W. Surveyor asked CNA W if they were familiar with R26, CNA W stated yes. Surveyor asked CNA W how often R26 eats breakfast in their room, CNA W stated every day. Surveyor asked CNA W how they are supervising or watching them eat, CNA W stated that they do frequent checks on them. Surveyor asked CNA W if they are in the room supervising, CNA W stated that they are in the room for a few minutes to make sure R26 is eating. On 3/31/26 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if a resident is supposed to have supervision with meals, would they expect staff to remain with the resident until they are done eating, DON B stated yes. Surveyor asked DON B if staff should be dropping off the resident's tray and leave the room, DON B stated no.

Based on observation, interview, and record review, the facility did not ensure a resident who requires BiPAP respiratory support was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (R4) reviewed with BiPAP.R4 was admitted to the facility with an order for BiPAP; the order was never transcribed and R4 has not received the BiPAP since admission.Evidenced by:The facility does not have a policy for respiratory care.R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, OSA (Obstructive Sleep Apnea), and type 2 diabetes mellitus.R4's most recent MDS (Minimum Data Set) dated 2/25/26 states that R4 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R4 is cognitively intact.R4's hospital discharge orders dated 2/2/26 state in part .BiPAP/NPPV (Bilevel positive airway pressure/Non-invasive positive pressure ventilation) Order Comments: Full mask- Use all night and when napping. Order specific questions: Equipment: Home. Bleed in oxygen (LPM (Liters per Minute): 2. IPAP (cm H2O (Inspiratory Positive Airway Pressure) is a critical component of non-invasive ventilation, measured in centimeters of water, used to assist patients with respiratory issues): 16. EPAP (cm H2O (Expiratory Positive Airway Pressure measured in centimeters of water): 12.It is important to note that R4's BiPAP orders were not transcribed at the facility, therefore, R4 has not been using BiPAP at the facility.R4's care plan dated 2/2/26 states in part .Problem: [R4] requires use of: BiPAP d/t (due to): OSA. Goal: Resident will tolerate use of (BiPAP/CPAP/Trilogy Vent) without complications.It is important to note that all Approaches (interventions) were added to R4's care plan on 3/31/26.On 3/29/26 at 9:29 AM, Surveyor interviewed R4. Surveyor noted that R4's BiPAP machine was sitting on the floor. Surveyor asked R4 if their BiPAP machine is always on the floor, R4 stated yes, because they haven't set it up yet. Surveyor asked R4 if they are supposed to wear it every night, R4 stated yes, and it's supposed to be connected to oxygen.On 3/30/26 at 1:19 PM, Surveyor interviewed LPN X (Licensed Practical Nurse). Surveyor asked LPN X if R4 uses their BiPAP, LPN X stated that when R4 first admitted to the facility, they refused it, but they would have to check with the night shift nurse to see if they're using it. Surveyor asked LPN X if R4 refused the BiPAP, would that be documented, LPN X stated that it should be.On 3/30/26 at 1:21 PM, Surveyor interviewed DON B (Director of Nursing), CSRN O (Clinical Support Registered Nurse), and IP/WN C (Infection Preventionist/Wound Nurse). Surveyor asked DON B what they can tell about R4's BiPAP, DON B stated that they know that R4 wears a BiPAP at night. IP/WN C stated that R4 refuses BiPAP. Surveyor asked if R4's physician had been updated on their refusals, DON B stated they would have to look. Surveyor asked why R4's BiPAP machine is on the floor, IP/WN C stated that R4 puts the machine on the floor. Surveyor asked if R4 had an order for BiPAP, CSRN O stated that they did not see an order. Surveyor reviewed R4's hospital discharge orders with staff. Surveyor asked if R4 should have an order for BiPAP, CSRN O stated yes.

Based on interview and record review the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 sampled resident (R4) reviewed for dialysis. R4 receives dialysis and the facility staff were not fluent in the emergency plan for a resident bleeding from their dialysis access site. This is evidenced by: The facility's policies titled Pre-Dialysis Patient Assessment and Post-Dialysis Assessment dated 12/1/2022 does not include an emergency plan. According to Clinical Journal of the American Society of Nephrology article titled Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies dated February 2017, .Vascular Access Hemorrhage: Hemorrhage from an AV access is an uncommon but potentially fatal complication if it is not recognized promptly and acted on with an appropriate intervention. Most fatal vascular access hemorrhages occur outside of the dialysis facility, but occasionally, they rupture at the dialysis unit (120). Patients and their families should be educated about the recognition and emergent management of a bleeding AV access. In the event of bleeding from vascular access site, direct continuous pressure with a finger for 15-20 minutes is the most effective method of controlling the bleeding. In the event of rupture of a PSA or aneurysm away from dialysis unit or hospital, direct pressure with a finger at the site of bleeding is the best method of controlling bleeding. Patients should be advised to continue holding direct pressure until emergency medical help arrives and avoid applying a tourniquet, towel, or BP cuff to the extremity. https://journals.lww.com/cjasn/fulltext/2017/02000/diagnosis,_treatment,_and_prevention_of.20.aspx R4 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease, congestive heart failure, OSA (Obstructive Sleep Apnea), and type 2 diabetes mellitus. R4 attends dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) on Mondays, Wednesdays, and Fridays.R4 has a CVC (central venous catheter, a flexible tube inserted into a large vein to provide immediate vascular access for hemodialysis) access site to their right upper chest.R4's care plan dated 2/17/26 states in part: .Problem: Resident has an IV (Intravenous) access site for dialysis. Goal: Resident will not exhibit signs of complications from IV. Approach: Assess for complication from IV (localized infection, systemic infection, electrolyte imbalance, air embolus, dislodgement, infiltration, phlebitis, fluid overload, dehydration) Q (every) shift and PRN (as needed). IV access care as ordered. Notify physician of any complications. Observe IV site for swelling, redness, tenderness, and warmth.It is important to note that R4's care plan does not include an emergency plan for a resident bleeding from their dialysis access site. Additionally, R4's physician orders do not include monitoring of dialysis site, nor instructions for staff regarding an emergency plan. On 3/30/26 at 2:53 PM, Surveyor interviewed CNA Y (Certified Nursing Assistant). Surveyor asked CNA Y what steps they would take if they noticed that R4 was bleeding from their dialysis site, CNA Y stated that they would go get the nurse, put on PPE (Personal Protective Equipment), and assist the nurse. On 3/30/26 at 2:53 PM, Surveyor interviewed LPN M (Licensed Practical Nurse). Surveyor asked LPN M what steps they would take if they noticed that R4 was bleeding from their dialysis site, LPN M stated they would make sure the resident is stable, call the provider to see what to do next, and if a RN (Registered Nurse) was available, they would go get them, and then they would do their best to stop it. On 3/30/26 at 2:58 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what steps they would expect staff to take if they noticed that R4 was bleeding from their dialysis site, DON B stated that they would expect staff to apply pressure and don't let go, call for help, dial 911 and send them to the hospital. Surveyor asked DON B if monitoring of R4's dialysis site should be on the MAR/TAR (Medications Administration Record/ Treatment Administration Record), DON B stated yes.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (R33) resident based on the review of medication storage in 2 of 3 medication carts.R33 was given oxycodone after the printed expiration date on the medication card.This is evidenced by:The facility's policy, titled General Guidelines for Administration of Medication, effective 12/1/22, states in part: Purpose: To maintain the safety and comfort of the patient regarding the administration of medication. Procedure:.20. Expiration dates for all medication in inventory are recorded and the inventory must be monitored on a monthly basis. This ensures that medication is replaced prior to the expiration date.R33 was admitted to the facility on [DATE] with diagnoses that include encephalopathy (group of conditions that cause brain dysfunction), pain in left hip, and generalized anxiety disorder.R33's physician orders include the following: 1/16/26: Oxycodone - schedule II (2) tablet; 5 mg; amt: 2.5 mg; oral. Every 12 hours - PRN (as needed). On 3/30/26 at 4:00 PM, Surveyor observed the medication cart for rooms 18-46 with RN L (Registered Nurse). Surveyor noted that R33's oxycodone (5 mg tablets) had an expiration date of 3/16/26. There were three oxycodone tablets remaining in the package.RN L confirmed that the oxycodone tablets had expired and should not be in circulation and asked LPN M (Licensed Practical Nurse) to dispose of them with her.R33's Medication Administration Record (MAR) for March 2026 indicates the oxycodone was administered to R33 on 3/19/26 at 3:05 AM and on 3/20/26 at 11:03 PM. On 3/31/26 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) and CSRN O (Clinical Support Registered Nurse). CSRN O indicated that the pharmacy comes into the facility, audits medications, and disposes of expired medications. Random checks for expired medications are also done by nursing staff. CSRN O indicated nursing staff informed them about the two expired medications that were found in the cart. CSRN O indicated pharmacy staff had been in the facility the week before to go through medication cards, but they must have missed the two expired medications that were found. CSRN O and DON B indicated they would expect both expired medications to have been disposed of.

Based on observation and interview, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 2 residents (R5 and R33) based on the review of medication storage in 2 of 3 medication carts.R5's lorazepam tablets were expired.R33's oxycodone tablets were expired.This is evidenced by:The facility's policy, titled Medication Storage, revised on 11/1/22, states in part: .6. SOP (Standard Operating Procedure) Details. E. Inspection of Storage Areas i. The pharmacy must inspect every medication in the pharmacy on a monthly basis for expiration dating, package integrity and storage area cleanliness. ii. Outdated or otherwise unusable medications must be immediately pulled from active inventory and segregated to an area to prevent unintentional use.Example 1On 3/30/26 at 4:00 PM, Surveyor observed the medication cart for rooms 18-46 with RN L (Registered Nurse). Surveyor noted that R5's lorazepam (0.5 mg tablets) had an expiration date of 1/17/26. There were 14 lorazepam tablets remaining in the package.RN L confirmed that the lorazepam tablets had expired and should not be in circulation and asked LPN M (Licensed Practical Nurse) to dispose of them with her.Example 2On 3/30/26 at 4:00 PM, Surveyor observed the medication cart for rooms 18-46 with RN L (Registered Nurse). Surveyor noted that R33's oxycodone (5 mg tablets) had an expiration date of 3/16/26. There were three oxycodone tablets remaining in the package.RN L confirmed that the oxycodone tablets had expired and should not be in circulation and asked LPN M (Licensed Practical Nurse) to dispose of them with her.On 3/31/26 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) and CSRN O (Clinical Support Registered Nurse). CSRN O indicated that the pharmacy comes into the facility, audits medications, and disposes of expired medications. Random checks for expired medications are also by nursing staff. CSRN O indicated nursing staff informed them about the two expired medications that were found in the cart. CSRN O indicated pharmacy staff had been in the facility the week before to go through medication cards, but they must have missed the two expired medications that were found. CSRN O and DON B indicated they would expect both expired medications to have been disposed of.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 1 Resident (R24) observed for wound care and 1 of 1 Resident (R35) on transmission based precautions. IP/WN C (Infection Preventionist / Wound Nurse) had breaches in infection control when IP/WN C did not perform hand hygiene after cleansing R24's wound prior to touching clean dressings. R35's is on contact precautions; staff removed a used cup from R35's room. Evidenced by: The facility's Guideline for Handwashing/Hand Hygiene policy, dated 11/18/25, states, in part: The purpose of this policy is to: Handwashing is the single most important factor in preventing transmission of infections. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 1. All health care workers shall utilize hand hygiene frequently and appropriately.3. Health Care Workers shall use hand hygiene at times such as: .d. after removing gloves, worn per Standard Precautions for direct contact with excretions or secretions, mucous membranes, specimens, resident equipment, grossly soiled linen, etc. The facility's Guidelines for General Wound and Skin Care policy, dated 5/10/17, states, in part: 1. Wash hands before and after resident contact. Observe standard precautions. Important to note: this policy does not include specific directive for when glove change and hand hygiene is needed during a dressing change. Example 1 On 3/30/26 at 10:34 AM, Surveyor observed IP/WN C perform wound care for R24. IP/WN C cleansed, rinsed, and dried the wound, applied skin prep to the periwound (intact skin around the wound) and inserted Collagen into the wound bed. IP/WN C removed gloves, applied a new set of gloves, and applied a bordered dressing. *Important to note: there was no glove change and hand hygiene between cleansing the wound and applying the skin prep / inserting the collage and there was no hand hygiene with the glove change prior to applying the bordered dressing. On 3/30/26 at 10:44 AM, Surveyor interviewed IP/WN C and asked about infection control with wound care. IP/WN C stated need to follow Enhanced Barrier Precautions, do frequent handwashing and glove changes. Hand hygiene/glove change is needed before you begin, after removing dressing, after cleaning, after measurement; anytime going from dirty to clean. Surveyor asked if IP/WN C had changed gloves/performed hand hygiene after cleansing R24's wound. IP/WN C stated no, I should've before the collagen was inserted. Surveyor asked if IP/WN C had performed hand hygiene when gloves were changed prior to applying the bordered dressing. IP/WN C stated no, I should've had sanitizer. On 3/31/26 at 1:49 PM, Surveyor interviewed DON B (Director of Nursing) and asked about infection control with wound care. DON B stated gloves are considered contaminated after cleansing a wound and glove change with hand hygiene is needed after cleansing, prior to applying the treatment. DON B stated hand hygiene is needed after removal of gloves prior to applying new gloves. Example 2: The facility's policy, titled Guidelines for Contact Precaution, revised on 2/28/24, states in part: Procedure 1. Contact Precautions is a method designed to reduce the risk of transmission of microorganisms by direct or indirect methods. b. Indirect contact transmission involves contact of a susceptible host with a contaminated intermediate object, usually inanimate, in the resident's environment. 5. Personal Protective Equipment: a. Wear gloves before contact with the resident or environmental objects. Change gloves and wash hands after having direct contact with the resident, possible infective material, or potentially contaminated environmental objects and between each resident care intervention. R35 was admitted to the facility on [DATE] with diagnoses that include sepsis due to Escherichia coli (systemic inflammatory response due to an E. coli bacterial infection), extended spectrum beta lactamase (ESBL) resistance (bacteria that produce enzymes that are resistant to common antibiotics), and acute pyelonephritis (bacterial infection causing inflammation of the kidneys). R35 was placed on contact precautions at the facility due to her ESBL infection and had a sign on her door indicating contact precautions were in place. On 3/29/26 at 3:10 PM, Surveyor observed LPN N (Licensed Practical Nurse) standing in the doorway of R35's room wearing PPE (personal protective equipment), which included a gown and gloves. LPN N asked a CNA (certified nursing assistant) walking down the hallway to get R35 some soda and handed her R35's drinking cup. The CNA took the cup down the hallway to refill it. The cup still had a small amount of soda in it. On 3/29/26 at 3:18 PM, Surveyor observed the CNA bring R35's cup back down the hallway and set it on top of the medication cart that LPN N was using in the hallway. The cup had the same amount of soda in it as when it was taken out of the room. Surveyor asked LPN N if she should have taken the cup out of R35's room if she is on contact precautions. LPN N indicated that she should have asked the CNA to bring soda to R35's room instead of taking her drinking cup out of the room. On 3/31/26 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) and CSRN O (Clinical Support Registered Nurse) and asked if drinking cups should be removed from a resident's room, refilled, and brought back into the room if he or she is on contact precautions. CSRN O said no, it should not be.

Based on interview, and record review, the facility failed to develop a person-centered comprehensive care plan to meet personal preferences and goals, or address the resident's medical, physical, mental, and psychosocial needs for 1 of 3 residents (R1). R1's comprehensive care plan does not include approaches for staff to follow for R1's care This is evidenced by: The facility's policy titled Comprehensive Care Plan Guideline, dated 5/22/18, includes the following: Purpose To ensure appropriateness of services and communication that will meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident. A comprehensive care plan will be developed within 7 days of completion with the admission comprehensive assessment. Problem areas should identify the relative concerns. Goals should be measurable and attainable. Interventions should be reflective of the individual's needs and risk influence as well as the resident's strength. The comprehensive care plan should be reviewed no less than quarterly with the completion of the OBRA (Omnibus Budget Reconciliation Act) assessment, and revised to reflect changes in the resident's condition as they occur. Pertinent care plan approaches are communicated to the nursing staff per the 24-hour CRCA assignment or the care tracker profile dependent on campus preference. Comprehensive care plans need to remain accurate and current. R1 admitted to the facility on [DATE] with diagnoses including dementia, need for assistance with personal care, chronic pain, anxiety, and type 2 diabetes. R1's OBRA (Omnibus Budget Reconciliation Act) quarterly assessment, dated 4/22/25, includes the following activities of daily living (ADLs) and the assistance required by staff: Eating: Partial/moderate assistance Oral hygiene: Dependent Toileting hygiene: Dependent Upper body dressing: Substantial/maximal assistance Lower body dressing: Dependent Putting on/taking off footwear: Dependent Personal hygiene: Dependent Roll left and right: Dependent Sit to lying: Dependent Lying to sitting on the side of bed: Dependent Sit to stand: Dependent Chair/bed-to-chair transfer: Dependent Toilet transfer: Dependent R1's OBRA quarterly assessment, dated 4/22/25, includes the following: Frequently incontinent of urine, frequently incontinent of bowel. R1's comprehensive care plan, printed 6/6/25, includes the following: Problem: Experiences episodes of incontinence Approaches: Blank Problem Category: ADL's (activities of daily living) Approaches: Blank Problem: At risk for hypo/hyperglycemia (low/high blood sugar) Approaches: Blank Problem Category: Pain Approaches: Blank Problem: has a diagnosis of anxiety Approaches: Blank R1's resident profile, printed on 6/6/25, includes the following approaches, in full: Assist of one with bathing and showering. It is important to resident to pick out their own clothes in the morning. Transfer: EZ stand (mechanical lift) transfer with 1 Eating: feeds self On 6/6/25 at 10:13 AM, Surveyor interviewed CNA C (Certified Nursing Assistant) regarding resident's care plans and approaches. CNA C indicated staff are aware of how to care for residents by using the care planned approaches for residents in the resident profile. CNA C indicated the resident profiles are in the computer. Surveyor asked CNA C to open R1's resident profile to answer questions about R1's care. CNA C indicated she could not find any approaches to care for R1 in R1's resident profile. Surveyor asked CNA C how she would know what to do for R1 and CNA C indicated she would not know. On 6/6/25 at 2:40 PM, Surveyor interviewed CNA D regarding resident's care plans and approaches. CNA D indicated she would review the resident's profile for approaches to care for a resident. On 6/6/25 at 1:45 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) regarding care plans. Both NHA A and DON B acknowledged there were no approaches in R1's care plan or on her resident profile and there should be. R1's comprehensive care plan does not include approaches for staff to follow for R1's care

Based on interview and record review, the facility did not ensure that the resident environment remained as free of accident hazards as possible for 2 of 6 residents (R6 and R5) reviewed. CNA C reported performing solo transfers for residents requiring assist of two staff members. Evidenced by The facility's Resident Transfers policy, dated 12/16/24, states, in part: Overview To ensure the safety of residents and staff when performing mobility/transfer tasks.3. Campuses determine the amount of assistance required for transfers and record this on the Nursing Admission Observation, the Care Assist profile, and the Resident Care Plan to provide communication to all staff regarding safe transfers. The facility's Guidelines for Resident Utilizing a Lift policy, dated 12/17/24, states, in part: Purpose To ensure the safety of residents and staff when performing lift transfer tasks.3.Staff should seek the assistance of a second person for those residents' care planned for assistance of two with the lifting device or as needed for safe handling. Example 1 R6 admitted to the facility on [DATE] with diagnoses that include, in part: chronic diastolic heart failure (a condition where part of the heart muscle becomes stiff, preventing it from filling properly with blood, leading to symptoms of shortness of breath, fatigue, and leg swelling); anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear and nervousness that can significantly interfere with daily life); artificial knee joint, bilateral (knee replacements to both right and left knee) R6's MDS (minimum data set) with a reference date of 2/3/25, Section B indicates R6 has clear speech, is able to understand others and is able to make herself understood. R6's Therapy Update form, dated 2/26/25, indicates that R6 is a pivot transfer with assist of 2. R6's Care Plan states, in part: Problem: ADL's (activities of daily living) Profile Care Guide. Transfers: 2 assist pivot transfers with gait belt/walker. On 3/3/24 at 2:25 PM, Surveyor interviewed R6 and asked about transfers. R6 stated that sometimes one staff member assists and sometimes two staff members assist. Surveyor asked R6 how many staff members are supposed to assist. R6 stated R6 was unsure and took it for granted that the staff would know how many needed to help. Example 2 R5 admitted to the facility on [DATE] and has diagnoses that include, in part: atherosclerotic heart disease of native coronary artery (a condition that causes reduced blood flow to the heart muscle); vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). R5's MDS (minimum data set) dated 2/6/25, section C indicates R5 is severely cognitively impaired. R5's Care Plan states, in part: Problem-Profile Care Guide. Transfers: I need assist of 2 and hoyer lift for all transfers. Important to note that R5 was unable to answer Surveyors questions. On 3/3/24 at 2:00 PM, Surveyor interviewed CNA C and asked about resident transfers. CNA C stated that there are times when a resident has a need and there is not staff around to assist. If the resident has a need, CNA C stated that CNA C will transfer the resident solo, even if the resident is care planned as a two assist. CNA C stated that R6 is to pivot transfer with a gait belt (transferring device) and two staff assist, but CNA C has transferred R6 alone. CNA C stated that R5 is to transfer with a mechanical lift and two staff assist, but CNA C has transferred R5 alone. On 3/3/24 at 3:48 PM, Surveyor interviewed DON B and asked how many staff are expected to assist when a resident transfers with a mechanical lift. DON B stated two. Surveyor asked how many staff are expected to assist a resident with a transfer when the care plan states pivot transfer with 2 assist. DON B stated two. Surveyor asked if the facility would expect staff to transfer R6 and R5 with two assist. DON B stated yes. CNA C indicated at times CNA C does not transfer R5 and R6 with an assist of 2.

Based on record review and interview, the facility did not ensure a Registered Nurse (RN) worked for 8 consecutive hours in a day, 7 days a week. This has the potential to affect all 33 residents (R) residing within the facility. On Wednesday, January 1, 2025, the facility did not have an RN in the building 8 consecutive hours on any of the three shifts. Evidenced by: On 1/8/25 at 9:43 AM, Surveyor reviewed nursing staff schedules and postings from 12/23/24 to 1/6/25. Surveyor observed no RN on the schedule for 1/1/25 and the posting which shows hours worked for nursing staff was filled with zeros for all three shifts under RN column for 1/1/25. On 1/9/25 at 2:40 PM, Surveyor interviewed DON B (Director of Nursing) regarding RN coverage. Surveyor asked DON B if he would expect an RN to be in the building every day for at least 8 consecutive hours; DON B stated yes. Surveyor asked DON B if he was in the building on 1/1/25; DON B indicated he was not in the building that day. Surveyor asked DON B why there wasn't an RN in the building on 1/1/25. DON B indicated there was supposed to be an RN on the schedule that day but they called in.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 33 residents who reside in the facility. Surveyor observed male staff to have facial hair and to be working with resident food without hair restraints in place. The facility did not keep a record of when staff manually monitored the internal temperature of the facility's dishwasher. Surveyor observed food to be in circulation passed the use by date. Surveyor observed dented cans to be in circulation. Surveyor observed food that had been removed from the original packaging to be unlabeled and undated. Evidenced by Example 1 The Food and Drug Administration (FDA) Food Code 2022, includes in part: Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair; that are designed or worn to effectively keep their hair from contacting exposed food . On 1/7/25 at 11:10 AM, Surveyor observed Director of Food Services C and Assistant Director of Food Service D to be working on the lunch meal preparation without donning hair restraints to cover their facial hair. Director of Food Service C indicated the facility policy is that hair over 1/8 of an inch must be covered. On 1/9/25 at 11:51 AM, Surveyor observed Dietary Aide H preparing resident lunch meal with a full beard and without hair restraint. During an interview Dietary Aide H and Assistant Director of Food Service D indicated beard nets are available and should be being used to cover facial hair. On 1/9/24 at 1:48 PM, during a phone interview, Director of Food Service C indicated hair should be covered when working with food. Example 2 Facility policy entitled Dish Machine, with review date of 11/30/2021, includes: . High Temperature Dishwasher recommended guidelines: wash 150-165 degrees Fahrenheit; final rinse 180 degrees Fahrenheit . 160 degrees Fahrenheit at the rack level/dish surface reflects 180 degrees Fahrenheit at the manifold . On 1/9/25 at 9:08 AM, Surveyor observed the facility's dishwashing routine and reviewed dishwashing temperature log. When asked if staff have a system for monitoring the internal temperature of the dishwasher manually, Dietary Aide H indicated Director of Food Services C does this each morning by running a test strip through the machine. On 1/9/25 at 11:51 AM, Assistant Director of Food Services D indicated the Director of Food Service C does run a test strip through the dishwasher daily, but he does not keep them or record the results. On 1/9/24 at 1:48 PM, during a phone interview Director of Food Service C indicated he does send a test strip through the dishwasher daily but does not record the results or save the strips. Example 3 On 1/6/25 at 9:00 AM, Surveyor observed 2 dented cans (tuna and creamed corn) in circulation. Assistant Director of Food Service D indicated dented cans should be disposed of. On 1/9/25 at 1:48 PM, Director of Food Services C indicated dented cans should be discarded. Example 4 On 1/6/25 at 9:00 AM, during initial tour of the facility's kitchen, Surveyor observed a resealed container of cottage cheese with a use by date of 1/3/25 and a resealed container of V8 juice with use by date of 1/1/25. Assistant Director of Food Service D indicated these items should have been pulled and disregarded. On 1/9/25 at 1:48 PM, Director of Food Services C indicated food pass the use by date should be removed from circulation. Example 5 On 1/6/25 at 9:00 AM, Surveyor observed a container of brown pudding like substance with no label and no date on it. Assistant Director of Food Services D indicated this item should have a label and a date on it. On 1/9/25 at 1:48 PM, during a phone interview, Director of Food Services C indicated food removed from the original packaging should be labeled and dated.

Based on observation, interview, and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect the entire census of 33 residents. The facility was in a COVID-19 outbreak and the facility failed to do contact tracing and complete appropriate testing of residents and staff. The facility is not placing all staff that call in sick on the employee line list. The line list does not include last day worked, or area worked in. Staff was observed not wearing appropriate personal protective equipment (PPE) when administering eye drops to resident (R) R16. Surveyor observed staff providing care for a resident who was in enhanced barrier precautions without proper PPE. Surveyor observed staff administer eye drops to resident without donning gloves. Surveyor observed resident catheter to be in direct contact with he wheel of his wheelchair while the wheel was in motion and in contact with the floor. Surveyor observed CNA M (Certified Nursing Assistant) to be on her phone texting and then assisting R16 with his meal without performing hand hygiene in between. Evidenced by: The facility's policy titled Infection Prevention and Control Program (IPCP) last reviewed on 12/17/24 states in part .g. Monitors health status of residents (i.e., identifies those at risk for infection; reviews immunization status, etc.). h. Monitors health status of employees for results of testing .6. Report and track all staff illnesses and restrictions. To include but not limited to a. Prohibiting contact with residents or their food when staff have potentially communicable diseases or infected skin lesions .c. Monitoring for clusters or outbreaks of illness among staff .e. Education and competency assessment to ensure staff follow the IPCP's standards, policies, and procedures. Therefore, staff must be informed and competent. Knowledge and skills pertaining to the IPCP's standards, policies and procedures are needed by all staff to follow proper infection control practices (e.g., hand hygiene and appropriate use of personal protective equipment) while other needs are specific to roles, responsibilities, and situations (e.g., injection safety and point of care testing) . The facility's policy titled COVID-19 Identification and Management last reviewed on 6/5/23 states in part .Contact tracing should be performed for any new, single onset of COVID-19 to identify employee(s) who had a higher risk exposure or resident(s) who may have had a close contact with the individual(s) with confirmed COVID-19. Contact tracing steps include Case investigation: Is the identification of employees with confirmed COVID-19. Infection Preventionist (IP) will conduct an interview of employee and gather information to help determine with whom they have had close contact during the time they may have been infectious. For COVID- 19, a close contact is defined as any individual who was within 6 feet of an infected person for at least 15 minutes for a cumulative total of 15 minutes over 24 hours starting from 48 hours before the person began feeling sick for from the date of the positive test result if asymptomatic. Contact tracing is the subsequent identification, monitoring, and support of their contacts who have been exposed and possible infected with the virus, not all employees within the campus .Testing for COVID-19: Residents and staff, even with mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test (POC) for COVID-19 as soon as possible. When unable to identify close contacts: Staff: Test all staff, regardless of vaccination status, facility- wide or at a group level is staff are assigned to a specific location where the new case occurred (ex. hall or unit). Residents: test all residents, regardless of vaccination status, facility- wide or group (ex. hall or unit) . Facility policy, titled Enhanced Barrier Precautions Standard Operating Procedure, dated 4/1/24, includes Enhanced Barrier Precautions (EBP) will be in place during high contact care activities for residents with he following conditions: all residents with chronic wounds . all residents with indwelling catheters, . High contact activities include but are not limited to morning and evening ADL care, toileting, showers, . transfers when bundled together with other high contact activity . Example 1 On 1/8/25, Surveyor reviewed the facility's infection control program policies, line lists for residents and staff, and the facility's most recent COVID-19 outbreak summary. Surveyor noted that the staff line list for October does not include any illnesses other than COVID-19. Surveyor requested the staff call-ins for October, November, and December. Staff call-ins and illnesses not on the line list include: October: SM V (Staff Member) called in sick on 10/5/24-10/7/24 with not feeling well, stomach ache, no GI (Gastrointestinal) symptoms. The facility's Time and Attendance Form indicates that SM V works in the health Center. SM W is listed in the facility's COVID October 2024 outbreak summary. The document indicates that SM W had .c/o (complained of) sore throat/cough since 10/18/24. tested positive for COVID and went home . December: ES Q (Environmental Services) called in sick on 12/8/24 with a headache. It is important to note that the facility's staff line list does not include the staff member's last date worked or where in the building the staff member worked. Therefore, the facility was not able to track and trend staff illnesses. Example 2 The facility had a COVID-19 outbreak in October 2024. The document COVID October 2024 states in part: 10/22/24: R184 was diagnosed with COVID. Resident was sent to the hospital for fever 101.3 and with uncontrollable shaking and significant decline in mobility/ ADL (Activities of Daily Living). Returned to facility on 10/22/24. SM X called with c/o GI s/s (signs/symptoms). Stating vomited in the PM (afternoon) of 10/21/24 .on 10/24/24 SM X called stating she was positive for COVID. Signs and symptoms (s/s) began on 10/21/24 and tested positive for COVID on 10/22/24 . 10/23/24: R185 had been having c/o (complaints of) not feeling the best, with fatigue and occasional dizziness and feeling lightheaded .resident tested positive. R186 has been having a decline with PT (Physical Therapy) and with c/o SOB (Shortness of Breath) past few days .Resident was due to d/c (discharge) on 10/24/24 and d/t (due to) continued s/s and retested and was positive for COVID. SM W, stating with c/o sore throat/cough since 10/18/24. tested positive for COVID and went home . 10/25/24: R187 with large emesis. COVID test negative. 10/28/24: R5 with c/o sore throat . COVID test done and negative . It is important to note that R187 and R5 were never placed on the line list. Additionally, Surveyor requested documentation regarding contact tracing and testing; the facility provided documentation of 2 additional nursing home residents that were tested as a result of the outbreak. There was no documentation provided of staff or house wide resident testing. On 1/8/25 at 2:13 PM, Surveyor interviewed CRN I (Clinical Registered Nurse) and DON B (Director of Nursing). Surveyor asked what the facility's outbreak policy is. CRN I stated that if staff have symptoms, they would be tested , if they are positive, they would be away from the facility, test on day 8, and follow the CDC (Centers for Disease Control) guidelines. Surveyor asked if the facility did contact tracing after the first positive resident or staff. CRN I and DON B stated they were unsure. Surveyor asked if they would expect that SM W would have been on the line list. CRN I stated that she would not necessarily put it on the line list. Surveyor asked if R185 and R5 should have been added to the line list due to having symptoms. CRN I stated that if they were in an outbreak, then yes. Surveyor asked what the facility's definition of an outbreak was; DON B stated 3 or more cases. 38882 Example 3 R16 admitted to the facility on [DATE] with the following diagnoses: unspecified dementia, anxiety disorder, acquired absence of the left leg below the knee, and encephalopathy. R16's hospital discharge, dated 12/21/24, includes: .history of recurrent UTI (urinary tract infections) . Urinary catheter management: insertion date 12/4/24 . Reason for foley-end of life care . internal . dressing and wound care to sacral and right medial great toe pressure injuries . On 1/7/25 at 9:21 AM, Surveyor observed CNA E (Certified Nursing Assistant) and CNA F transfer R16 using a Hoyer lift from his chair to the bed. CNA E and CNA F did not don any personal protective equipment (PPE). (It is important to note R16 is on enhanced barrier precautions (EBP) due to having wounds and a catheter.) On 1/7/25 at 10:45 AM, Surveyor observed CNA E, CNA F, and LPN K (Licensed Practical Nurse) assisting R16 with AM cares and transferring him from bed to chair without the use of PPE. CNA F, CNA E, and LPN K indicated they should have had on a gown, gloves, and mask while assisting R16 since he is in EBP. On 1/8/25 at 12:41 PM, RN I (Registered Nurse) indicated staff should have on PPE while assisting R16 with hands on care and while transferring him. Example 4 Facility policy, titled Eye Drop Administration, dated 11/18, includes, in part: equipment requirement eye drop medication, gauze pad, examination gloves, barrier, . With a gloved finger, gently pull-down lower eyelid to form pouch while instructing the resident to look up . On 1/8/25 at 7:33 AM, Surveyors observed LPN L (Licensed Practicing Nurse) administering R16's eye drops without donning gloves. LPN L indicated she should have had gloves on. On 1/8/25 at 12:41 PM, RN I indicated LPN L should don gloves while administering anyone's eye drops. Example 5 R16's hospital discharge, dated 12/21/24, includes: . history of recurrent UTI (urinary tract infections) . Urinary catheter management: insertion date 12/4/24 . Reason for foley-end of life care . On 1/7/25 at 9:20 AM, Surveyor observed a sign on R16's door indicating staff were to use enhanced barrier precautions (EBP) while providing R16 cares. R16's sign on door, included: Everyone must clean their hands, including before entering and when leaving the room . providers and staff must also wear gloves and a gown for the following high contact resident care activities: dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care including central line/urinary catheter/ . wound care . On 1/7/25 at 9:21 AM, during an interview, RR G (Resident Representative) indicated he was concerned about R16 having reoccurring urinary tract infections. RR G and Surveyor observed R16's catheter to be hanging from the side of his wheelchair in contact with the front wheel. Surveyor observed CNA E and CNA F turn R16 around in his wheelchair and R16's catheter was pulled in the wheel track of the wheelchair. CNA E and CNA F indicated R16's catheter should not be in direct contact with the floor or the wheels of his wheelchair. On 1/8/25 at 12:41 PM, RN I indicated R16 has a history of urinary tract infections and catheters should not be in direct contact with the floor or the wheels of the wheelchair. Example 6 On 1/8/25 at 8:55 AM, Surveyor observed CNA M in R16's bedroom texting on her personal cell phone as she sat next to R16. R16's half eaten meal was in front of him on a table. CNA M set her phone down on her lap and gave R16 a bite. CNA M picked up her phone a second time and began to touch the screen as if she was typing something. She again set her phone on her lap and assisted R16 with his meal. On 1/8/25 at 8:57 AM, LPN L indicated CNA M should wash her hands after handling her personal phone and before assisting R16 with his meal. On 1/8/25 at 12:41 PM, RN I indicated CNA M should wash her hands after handling her cell phone and before assisting R16 with his meal.

Based on interview and record review, the facility did not ensure that 1 (R19) of 12 residents out of a total sample of 14 residents received assessment and appropriate and timely medical care with a change in medical condition. R19 had an unwitnessed fall on 10/21/23 at 6:15 PM. R19 experienced change of condition and the facility failed to properly assess range of motion (ROM)/change in ambulation ability on 10/21/23. The facility failed to identify change in resident when resident experienced the inability to move right leg and increased weakness on 10/21/23 and the morning of 10/22/23. R19 went to emergency roiagnom on [DATE] at 11:00 AM and was diagnosed with a right hip fracture. Evidenced by The facility policy titled, Notification of Change in Condition, with a revision date of 12/31/22, states, in part; .PURPOSE to ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when: 1. An accident involving the resident which result in an injury and has the potential for requiring physician intervention. 2. A significant change in the resident's physical, mental or psychosocial status. 3. A need to alter treatment significantly. Sample reasons to notify the physician immediately but not limited to: .2. Need to alter treatment significantly .5. A fall with significant injury .PROCEDURES 1. Resident assessments for change in condition, suspected injury, event of unknown origin or ordered lab and/or other diagnostic tests should be completed in a timely manner .4. Documentation of notification or notification attempts should be recorded in the resident electronic health record . The facility policy titled, Falls Management Program Guidelines, with a revision date of 3/16/22, states, in part; .PROCEDURE .2. Should the resident experience a fall the attending nurse shall complete the Fall Event This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions 5. The resident care plan should be updated to reflect any new or change in interventions. 6. Nursing staff will monitor, and document continued resident response and effectiveness of interventions for 72 hours. 7. Discuss risks and interventions with resident and/or responsible party and communicate interventions during shift report . R19 was admitted to the facility on [DATE] with diagnoses including: unspecified dementia without behavioral disturbance, unspecified osteoarthritis, muscle weakness, repeated falls, other symbolic dysfunctions, weakness, mixed hyperlipidemia, and sick sinus syndrome. R19's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/1/23, indicates R19 has a Brief Interview for Mental Status (BIMS) score of 4 out of 15 indicating R19 is severely cognitively impaired. R19 has an activated power of attorney. R19's Comprehensive Care Plan, states, in part; Problem Start Date: 10/20/23 Resident demonstrates signs and symptoms of OCD (obsessive compulsive disorder). Goal: Resident's OCD symptoms will be lessened with assist of anti-depressant. Approach: Encourage resident and representative to participate in Resident First Meetings and plan of care. Encourage resident to voice concerns, feelings, and problems as they occur rather than internalizing. Give meds as ordered and monitor for side effects and monitor behaviors. Observe mood, affect, and behaviors with all hands-on care and treatment Provide 1:1 supportive contact as needed. Res may need redirection due to non-compliance and resistance with ADLs/interventions for falls. Problem Start Date: 7/24/23 Demonstrates non-compliance with plan of care as evidenced by choosing to get up and move around his room on his own without assistance. Has reminders in his room that he should ask for assistance with standing and moving around his room. States he has gotten up on his own for many years and he does not feel that there is a need to ask for help. Has had falls in the past. Goal: Preferences will be honored to the extent that non-compliance with his plan of care will not result in injury to himself. Approach: Educate regarding his plan of care and risk and benefits of compliance . Problem Start Date: 4/6/23 ADL's Resident requires staff assistance to complete ADL tasks completely and safely. Goal: Resident will have ADL needs met safely by staff. Approach: .Allow Resident sufficient time to complete all or parts of task. Do not rush resident .Observe for deterioration in ADL abilities and report if occurs Problem Start Date: 4/3/23 Falls has a potential for falls related to cognitive issues. Goal: Will not sustain serious injury through the review date. Approach: 10/3/23 Provide resident with safety devices/appliance: wedge cushion in w/c when up. 9/11/23 Anti-lock brakes to prevent w/c for moving when res is non-compliant with transferring self. 8/6/23 Have staff offer frequent toileting when res is awake. 7/19/23 Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c. Grippy socks on at night. 5/16/23 Leave night light on in room. Notes remain in room reminding resident to ring for assist. 4/3/23 Be sure my call light is within reach and encourage me to use it for assistance as needed. 4/3/23 PT (Physical Therapy) evaluate and treat as ordered or PRN (as needed) . Problem Start Date: 10/27/23 Pain At risk for pain R/T (related to): arthritis and fracture. Goal: Resident's pain will be at a tolerable level with interventions. Approach: 10/27/23 Administer medications as ordered and notify MD for any side effects observed or lack of effectiveness. 10/27/23 Attempt non-pharmacological interventions. 10/27/23 Notify MD of increased pain. 10/27/23 Observe for and record verbal and non-verbal signs of pain. 10/27/23 Reposition as needed . It is important to note R19's care plan for pain is started when readmitted after fall with fracture. R19's care plan does not include what an acceptable pain level is for R19, nor does it include how R19 expresses pain if he is not able to verbally communicate that he is in pain. R19's Medication Administration Record/Treatment Administration Record (MAR/TAR) October 2023, states, in part; Order Set Target Behavior- OCD tendencies, restlessness, refusal of cares. At the end of each shift mark frequency- how often behavior occurred & intensity- how resident responded to redirection. Intensity code: 0=did not occur; 1=easily altered; 2=difficult to redirect. Frequency Three times a day. Special Instructions If you mark anything but zero, please make a progress note. R19's documentation shows from October 1st-18th that the behavior did not occur or that R19 was easily able to redirect. On 10/18 2 difficult to redirect. On 10/21 (day of fall) it shows 0 documented on AM shift (7a-3p), 0 documented on PM shift (3p-11p) and 1- easily altered. On 10/22 the documentation is blank. R19's MAR/TAR October 2023, states, in part; Order Acetaminophen (OTC - over the counter) tablet; 325mg; PO every six hours-PRN .take 2 tablets orally every six hours as needed for pain or fever .10/21 (day of fall) Time 11:27PM PRN Reason: Pain. Temperature Before 97.5F. Pain Before: 0 numeric (0-10). PRN result follow up: E. PRN result 1:16AM PRN Result-Follow up: Effective. It is important to note R19's Neurological Checklist from 10/21/23-10/22/23 indicates 10/10 pain at 8:15PM-10:15PM. Surveyor reviewed R19's October 2023 Progress Notes. R19's resistive to cares, will decline assistance from staff. R19's documentation shows R19 will state he can do tasks on own, does not need assistance. R19's documentation shows R19 will stand up on own, attempt to self-transfer, impulsive, and noted confusion. R19 had one documented physical aggression prior to fall with fracture on 10/21/23. On 10/14/23 .CNA reported cursing, grabbing, hitting, kicking, screaming, and threatening comments during cares. In bed sleeping soundly at this time. No other documented physical aggression until 10/21/23. On 10/20/23 7:40am resident slept well throughout the night with no attempts to get out of bed on own. Checked on frequently throughout the night. 10/20/23 4:26pm citalopram given as ordered. Resident calm and cooperative with cares today. Sitting in room with wife this pm holding hands. On 10/21/23 2:08am Resident checked frequently during the night no attempt to get out of bed. Slept well during the night. (It is important to note Nurses Progress note does not have any documentation of R19's fall on 10/21/23.) On 10/22/23 1:16pm (RN N documented), Resident lying in bed on his back without changing position early in shift. Resident uncooperative at 8am with assessment of limbs. Refused to get out of bed. Refused to eat breakfast or take medications. Refused to get out of bed. Refused to eat breakfast or take medications. Refused to allow staff to clean him or assist with dressing. Multiple attempts to accomplish the above-mentioned tasks. Staff checked on resident multiple times. Resident finally agreed that he needed assistance and allowed limb assessment at 11am. Stated that R knee is painful. Resident would not straighten RLE (right lower extremity). R (right) knee larger than L (left). VSS wnl (vital signs within normal limits) at 8am. Blood pressure 164/62, HR 74, R 20, T 97.1, O2 94% at 11am. L lip drooping, resident oriented to self only, red face. Spoke with POA (power or attorney) .On call MD. Both stated to send resident to the hospital. Called ambulance to transport. Ambulance arrived within 30 minutes of call. ADON (assistant director of nursing) notified of transport to hospital. Resident cleaned up by staff. Paperwork sent including POA document, face sheet, orders. Received call from RN at ER (emergency room ) who asked questions regarding resident baseline and POA phone number. RN stating that resident was running temp of 100.3 at time of admission to ER. ER staff will contact POA (power of attorney), and facility as needed .10/22/23 5:56pm Message received from ER. Resident admitted .Message did not state diagnosis. 10/23/23 7:21pm Late entry: (RN M late entry from noc (night) 10/21 .) Resident sleeping quietly during Neuro Checks during the night. Resident was asked if he was in any pain. Resident responded with (what do you want?) Resident check every hour during the night. LPN (licensed practical nurse) and CNA (certified nursing assistant) went to get Pt (patient) up for breakfast and Pt was very combative grabbing and pulling at staff. Refusing care. Yelling get out of here. LPN asked resident if he was in any pain. LPN noticed when moving Pt (patient) he would yell (Get away leave me alone). Holding on to his covers not allowing to be changed. Pushing and grabbing CNA arms. Report was given during change of shift to RN. Vitals were taken and each neuro check during the night. Resident uncooperative with care . R19's Fall Event from 10/21/23, states, in part; event date: 10/21/23 6:16pm, completed date 10/23/23 7:55pm. Description: Resident fell out of his wheelchair while in his room- unwitnessed event at 18:15 (6:15 PM). Resident scraped his right elbow open wound noted. Site cleansed with alcohol, ABD (bandage) and tape applied. No injury to his head reported. A&O at time of event. Resident denied pain at that time. Resident later complained of inability to move his right leg/hip given Tylenol and ice packs applied to right hip. VSS .Location of Fall Resident Room. What was resident doing just prior to fall? Transferring self Was Fall witnessed? No-initiate neuro check order set. Did Resident hit head? No .Other contributing factors Resident refused to comply with safety measures such as call light use, alarms, appliances, etc.new interventions- other, describe- frequent rounding q (every) 15 mins (minutes). R19 Neurological Checklist from 10/21/23-10/22/23 states, in part; .6:15PM R Leg/hip weak until 10:15PM .Pain 10/10 at 8:15PM-10:15PM .vital signs within normal range. 11:15PM-4:15AM states resident is asleep and that neurological checks were completed, and vitals completed. 8:15AM documented that resident refused ROM/assessment of legs . The facility internal investigation timeline states, in part; .On 10/21/23, at 1815 resident had an unwitnessed fall from his w/c. Stated that he didn't hit his head. Resident A&O (alert and oriented). Does have episodes of confusion and forgetfulness. C/O (complained of) pain to right elbow. Nurse inspected right elbow and noted an abrasion present. Temp 97.5 spo2 97% on RA (room air). Scraped his right elbow Right elbow minor abrasion noted. Wound cleansed and ABD pad applied. Resident denied c/o pain to any other body part. On call physician informed. Per CNA statement, resident was last seen after supper, when she assisted him back to his room, which would have been approximately 1700-1715 (5:00 - 5:15 PM). Per Nurse's statement, resident did not c/o any pain initially after the fall. He was assisted up with 2 assists back to his w/c (wheelchair). There was no evidence of right leg shortening, internal or external rotation. The nurse and CNA checked on resident frequently after the fall. No c/o's were expressed. No verbal or nonverbal expressions of pain were reported by resident. At approximately 2130 (9:30 PM), resident c/o pain in his right hip. The nurse assessed him and applied an ice pack to right hip and administered Tylenol as ordered. PM nurse reported off to NOC nurse for further monitoring. NOC nurse and CNA checked on resident several times during the night. Resident was sleeping soundly. No c/o pain was expressed. Between 0530 AM and 0600 AM, the nurse and CNA were in resident's room to get him checked and changed and ready for breakfast. The resident did not want to be touched, told staff to leave him alone. He also c/o right hip pain. Staff made sure resident was safe and reported off to oncoming shift. NOC nurse informed Day shift nurse of resident's c/o right hip pain and asked that she call the MD and update him/her. Day shift nurse reported that resident was checked on frequently and he repeatedly refused to allow staff to change him, reposition him or get him dressed. At 11am, resident agreed to allow the nurse to complete an assessment on him. Resident stated that his right knee was painful. The nurse stated resident's right knee was larger than his left. POA and on call MD were updated on resident's condition and was advised by both to send resident to the hospital. Resident was transported by ambulance to hospital. History: Resident has a history of being very independent and non-compliant, refusing cares, staff assistance for most things and following/allowing fall interventions to be initiated and used. He believes he can do more independent tasks than what he really is capable of doing. Resident has a hx of falls . Surveyor reviewed witness statement forms from internal investigation. Witness statement forms state, in part. RN L (Registered Nurse) .I last saw resident when he was in his w/c (wheel chair) eating dinner. After he was discovered, he did not c/o any pain in legs or hips. Only c/o pain in right elbow/forearm where he sustained an abrasion. 2 staff assisted him off the floor to his w/c. There was no evidence that he had any problems with his right leg/hip. No c/o pain. No shortening or rotation. I informed the oncoming nurse of resident's fall and c/o of inability to move his right leg. RN M .I worked the night shift on 10/21. Resident slept the entire night. He did not have any c/o's. He doesn't always tell us when he is in pain. We checked on him often during the night and he was sleeping each time. At 0530 (5:30 AM), we went to check and change him and get him up and dressed for breakfast. We made him possibly send him out. {sic} RN N .written statement not provided to Surveyor. CNA H (Certified Nursing Assistant) .I am not sure of what resident was doing prior to the fall. I was at the other end of the building when the fall happened. I last saw resident after supper when I helped him to his room, about 1700-1715 (5:00 PM - 5:15 PM), because he didn't know which way his room was. He was sitting up in his w/c. I didn't see him after the fall. I only knew of his fall after it had happened. I didn't have any interaction with him after the fall. CNA P I looked frequently into resident's room when walking. He was in his room in his w/c. he was messing around with stuff on his dresser before he was found on the floor. Around 6pm, I'm not sure of the time, the nurse came and asked me if I could come help transfer resident off the floor. He stood well and we assisted him back into his w/c. I assisted him with cares. The nurse put ice on his hip later. CNA Q .I worked the night shift and took care of resident. He slept most of the night. I checked on him during each round. He didn't have any c/o pain during the night. He didn't want me to touch him for turning or check and change. At approximately 6am, the nurse and I were helping to position him in bed. On 11/28/23 at 11:07AM, Surveyor observed R19. R19 indicated he did not think that he had any falls while at the facility, but that he can't remember. R19 indicated he felt comfortable and voiced no concerns. On 11/29/23 at 4:08PM, RN O (Corporate Registered Nurse) indicated she was notified of R19's fall with fracture and the need to complete an investigation. RN O indicated she conducted the investigation and collected statements from the staff who worked on 10/21/23 and 10/22/23. RN O indicated she asked the staff who worked questions about R19's pain and if he experienced any pain. RN O indicated initially R19 did complain of some knee and hip pain. RN O indicated it was reported to her that R19 slept all night and didn't complain of any pain. RN O indicated it was reported to her that R19 woke up around 5:30-6:00 AM and that he didn't want to be bothered, and that was not unusual for him. RN O indicated the NOC staff got him cleaned up and got him ready for breakfast. RN O indicated it is not unusual for R19 to refuse cares. Surveyor asked RN O about the internal investigation timeline that RN O provided Surveyor. Surveyor asked specifically about the following statement from NOC RN, Between 0530 and 0600, the nurse and CNA were in resident's room to get him checked and changed and ready for breakfast. Resident did not want to be touched, told staff to leave him alone. He also c/o right hip pain. Staff made sure Resident was safe and reported off to oncoming shift. NOC nurse informed Day shift nurse of resident's c/o right hip pain and asked that she call the MD and update him/her. Surveyor asked if at that time was MD contacted? RN O indicated I don't know. Surveyor asked RN O to please provide any other additional documentation or information that the facility may have regarding R19's fall investigation. On 11/29/23 at 4:30 PM, RN N indicated she was the AM nurse on 10/22/23. RN N indicated the NOC nurse reported to her that R19 had a fall. RN N indicated that R19 will refuse staff assistance and that is normal. RN N indicated she completed vitals but tried not to bug him and let him rest. RN N indicated pain monitoring is completed on the resident's MAR/TAR and in the progress notes. On 11/29/23 at 5:21 PM, RN M indicated she was the NOC RN on 10/21/23. RN M indicated that R19 slept all night and that R19 was in bed all night. RN M indicated that she completed vitals, and they were within normal range. RN M indicated she feels that he doesn't want to cause a ruckus and that he's a man! Surveyor asked RN M about the documented witness statement form she had completed indicating R19 was in pain at 5:30 AM. RN M indicated I might have written that, but that's not exactly what I meant. RN M indicated it was normal for R19 to decline cares and that you need to reapproach. RN M indicated she passed all of this on to the oncoming AM nurse. RN M indicated she did not notify MD at 5:30-6:00 AM when R19 refused to get out of bed. On 11/30/23 at 10:10 AM, Surveyor asked RN O if the facility completed any education with the nurses after the 10/21/23 incident. RN O indicated, We did. Surveyor asked RN O to provide any education the facility completed with nurses regarding areas of concerns they identified from the 10/21/23 incident. On 11/30/23 at 10:20 AM, DON B (Director of Nursing) indicated they had a DON B indicated she was making a copy of what was reviewed from the 10/30/23 meeting and putting it at the nurse station today as well. On 11/30/23 at 10:30 AM, LPN J (Licensed Practical Nurse) indicated she knows R19 very well. LPN J indicated R19 can be a very stubborn man and has past trauma from childhood. LPN J indicated if R19 feels like he is being hurried or rushed he will refuse cares and assistance. LPN J indicated if R19 feels something should be done a certain way, there is no changing his mind. LPN J indicated R19 does take a little bit more time assisting him with cares. LPN J indicated for example, prior to the 10/21/23 fall when it was R19's shower day, they will talk about it earlier in the day and write a note for him because if R19 starts to change his clothes in the evening, he will refuse the shower. LPN J indicated if he has that reminder, he most likely will wait and take his shower. Surveyor asked LPN J how does staff know if R19 is in pain? LPN J indicated if he is calling out, moaning, restless, and he will tell you if he is in pain, but you have to ask. LPN J indicated she did not think R19 would just come out and tell someone he is in pain. LPN J indicated R19 can be combative so if he was to be more combative than usual, I would question that. LPN J indicated if R19 would refuse bingo that would be an indicator. LPN J indicated she had more of a 1:1 informal conversation with DON B after the 10/21/23 incident. LPN J indicated she heard the staff really fought R19 while he was in bed after the fall because they wanted to complete an assessment on him. LPN J indicated she would have sent him out, but she understands the nurses were following procedure and going through the proper channels. LPN J indicated prior to the 10/21/23 fall R19 would self-transfer and LPN J indicated R19 did not experience inability to move right leg. LPN J indicated after an unwitnessed fall vitals should be taken, check ROM, neuro checks, see if the resident can stand and transfer, and get them comfortable/safe. LPN J indicated notifications then need to be made to resident's doctor and POA if necessary. At 11:04 AM, LPN J indicated to Surveyor there was a nurse meeting on 10/30/23, and at that time they went over change of condition and what the process is. LPN J indicated I don't know if it was necessarily for R19's incident. LPN J indicated that usually any time they have a nurse meeting/education there is a staff sign in sheet. On 11/30/23 at 11:29AM, RN M indicated the morning of 10/22/23 R19 was wide awake in bed and was really fighting us! RN M stated, He did not want us touching him at all. Did not! I made sure when RN N came in that morning to report that something wasn't right and that she should see him now before I leave. RN N said she had to pass medications. Surveyor asked RN M if she received education regarding RN M stated the meeting was some kind of discussion about something. RN M indicated it would have been good to go over all of these things that we should do because anything could have happened while he was in that bed. On 11/30/23 at 12:30 PM, DON B indicated she did not have a staff sign off sheet because they had so much to cover at the meeting. On 11/30/23 at 1:57 PM, Surveyor asked DON B what opportunities for improvement did the facility identify after the investigation for the 10/21/23 incident? DON B indicated the communication between shifts and nurses, the need to reassess and notify again after an incident if there is a change with resident, and the fall policy in general. DON B indicated if R19 refuses assistance then the staff need to reapproach him. Surveyor shared with DON B there is a concern regarding the incident. Surveyor indicated the concern is with assessment and timely/appropriate medical care. Surveyor indicated through reviewing facility investigation and nurse interviews it appears there is a concern with communication between nurses as well. On 11/30/23 at 2:10 PM, Surveyor shared with NHA A (Nursing Home Administrator) there is a concern with the 10/21/23 incident and the investigation. Surveyor indicated there is a concern with the lack of assessment, appropriate/timely medical care, and communication break down between shifts. Surveyor discussed education that was completed on 10/30/23 at the nurse meeting. Surveyor indicated there was no staff signature sheet, RN L did not attend/DON indicated she called RN L but no documentation showing this, and through interview staff are not remembering topics that were discussed pertinent to R19's incident. NHA A indicated DON B typically does have a staff signature sheet verifying education was received, NHA A indicated he is not sure why this was not done on the 10/30/23 nurse meeting. On 11/30/23 at 2:40PM, MD R (Medical Director) and RN O indicated they reviewed R19's documentation neurological checklist from 10/21/23-10/22/23. MD R indicated from a clinical standpoint they do not feel the incident rises to a harm level. MD R indicated vital signs were within R19's baseline. RN O indicated when pain was documented, a PRN was given. Surveyor asked MD R and RN O if weakness/inability to move right leg was a change for R19. RN O indicated RN O was not sure and that R19 has a diagnosis of arthritis. Surveyor asked MD R if she had reviewed the nursing witness statement forms and the timeline from the investigation. MD R indicated she had not. Surveyor discussed documentation showing missed opportunities of when the RN should have notified primary doctor and failed to provide timely/appropriate medical treatment. RN O indicated R19 will refuse cares and that is not new. Surveyor questioned the intensity level of physical aggression, and RN O indicated she does not know the resident. Surveyor asked RN O if facility had any other documentation to share with Surveyor. RN O stated, Just what came out of our mouths right now . On 11/30/23 at 3:47 PM, RN L indicated she was the nurse that worked on 10/21/23 when R19 had unwitnessed fall which resulted in fracture. RN L indicated RN L heard a sound and ran to R19's bedroom. RN L indicated R19 reported he didn't hit his head and she noted that his elbow was scratched. RN L indicated R19 was denying that he was in pain after the fall. RN L indicated at the time of the fall she asked him questions about his pain and general assessment questions. RN L indicated, I didn't complete ROM or attempt to move legs because I didn't want to make the situation worse. RN L indicated she notified the on-call MD and talked with RN N and ADON/IP C (Assistant Director of Nursing/Infection Preventionist) after fall. RN L indicated she reported to the NOC RN about the fall, notification that was made, and the treatment she completed to R19's elbow. RN L indicated she reported that NOC RN needs to keep an eye on him. RN L indicated R19 didn't want to go to the hospital and that they need to continue to monitor. RN L stated, Like I said, I tried to document, I'm new to that facility .I did document he refused medical attention. RN L indicated she remembers a conversation she had not with DON B but with ADON/IP C after the incident. RN L stated, I don't remember what we discussed or what was covered. I suggested we need to do more frequent rounding/monitoring . It is important to note it is not documented in Progress Notes, Fall Report, and Witness Statement Report that R19 refused to go to the hospital on 10/21/23. The facility failed to re-assess R19 once he complained of pain and inability to move right leg on 10/21/23. The facility failed to ensure timely and appropriate medical attention was provided when R19 expressed a change on the morning of 10/22/23.