Every finding on record at The Pines Post Acute and Memory Care

Based on interview and record review, the facility did not ensure care plans were followed for 2 residents (R) (R2 and R1) of 5 sampled residents.R2 was allowed to exit a secure memory care unit and move throughout the non-secure part of the building. The intervention was not reflected on R2's care plan. In addition, R2 had a care plan intervention for behavior charting every shift. The intervention was not consistently completed.R1 had a care plan intervention for behavior charting every shift. The intervention was not consistently completed.Findings include:The facility's Comprehensive Person-Centered Care Planning policy, dated 8/2026, indicates: It is the policy of this facility that the Interdisciplinary Team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs indentified in the comprehensive assessment .6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each Minimum Data Set (MDS) assessment and with any changes in care needs. 1. R2 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease with late onset, dementia, anxiety disorder, cognitive communication deficit, bilateral macular degeneration, and restlessness and agitation. A Minimum Data Set (MDS) assessment, dated 5/5/26, stated R2 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. R2 discharged from the facility on 6/29/26 and passed away on Hospice care.On 8/6/26, Surveyor reviewed R2's medical record and noted the following: ~ A potential for psychosocial well-being problem related to an altercation with another resident care plan was initiated on 6/7/26.~ A potential for behavior problem related to agitation/anger with others care plan was initiated on 3/27/26. The care plan contained interventions to approach in a calm manner (3/27/26); Document behaviors and R2's response to interventions (3/27/26); Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner; Divert attention. Remove from situation and take to alternate location as needed. Offer to take for coffee (3/27/26); and Redirect from others when upset/agitated (5/1/26).A care plan for psychotropic medication use was initiated on 9/26/22 and contained interventions to monitor/record occurrence of target behavior symptoms; Verbal aggression/easily agitated and indicating need to make sure room door is shut due to cats/dogs in there. A care plan for anti-anxiety medication use was initiated on 4/14/24 and contained an intervention to monitor/record occurrence of target behavior symptoms (increased anxiety, increased pacing). A care plan for antidepressant medication use was initiated on 6/26/25 and contained an intervention to document episodes of behavior: Increased anxiety, including agitation, looking for (family), stating they are leaving. R2's Treatment Administration Record (TAR) contained the following orders for behavior monitor charting: ~ Monitor episodes of increased anxiety, increased pacing behaviors every shift.~ Monitor episodes of behavior noted every shift: Verbal aggression/easily agitated and indicating R2 needs to make sure room door is shut due to cats/dogs in there (initiated 2/23/25).~ Antidepressant monitoring: Document episodes of behavior; increased anxiety .every shift (initiated 2/17/26).Surveyor reviewed R2's behavior charting and noted the following: ~ In April 2026, staff did not document behaviors for 16 shifts.~ In May 2026, staff did not document behaviors for 6 shifts.~ In June 2026, staff did not document behaviors for 13 shifts. On 6/7/26 at approximately 6:00 PM, R2 was struck by R1 in the main part of the building.On 8/6/26 at 11:44 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D regarding R2 being struck in the main part of the building when they resided on the secured memory care unit. LPN-D stated R2 became agitated and banged on the door at times and was allowed to leave the unit. LPN-D stated staff on the memory care unit call when R2 leaves the unit so other staff know to keep an eye on them. LPN-D confirmed staff let them know R2 left the unit on 6/7/26. As LPN-D walked toward R2, they saw R1 approach and strike R2. LPN-D could not get there in time to prevent the altercation. On 8/6/26 at 2:04 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-C who indicated staff can tell when R2 needs to move more than the memory care unit will allow and they let them roam the main part of the building. CNA-C stated staff on the memory care unit let staff in the main part of the building know when R2 is off the unit so they can keep an eye on R2. CNA-C stated on the evening that R1 struck R2, they could tell R2 needed to burn energy as they were wheeling around. CNA-C said R2 was not behavioral at the time but was moving more so they notified staff that R2 was leaving the unit. CNA-C opened the door and did not see R1. CNA-C stated LPN-D came to the unit a short time later and said R1 had struck R2. Surveyor noted the intervention staff used to let R2 off the memory care unit was not on their care plan. On 8/6/26 at 12:00 PM and 3:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed staff should document R2's behaviors every shift and verified the intervention to leave the memory care unit should have been added to their care plan. 2. R1 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following non-traumatic intracerebral hemmorrhage affecting the right dominant side, aphasia, vascular dementia with anxiety and mood disturbance, major depressive disorder, cognitive communication deficit, anxiety disorder, and apraxia. An MDS assessment, dated 7/20/26, stated R1 had a BIMS score of 3 out of 15, indicating severely impaired cognition. On 8/6/26, Surveyor reviewed R1's medical record and noted the following: ~ A care plan for antidepressant medication use related to depression and anxiety was initiated on 9/8/19 and contained the following intervention: Behavior symptoms: Document episodes of behavior, depressed statements, withdrawn, isolation (initiated 4/26/23). ~ A care plan for antipsychotic medication use related to major depression was initiated on 5/27/20 and contained the following intervention: Monitor episodes: upset with placement, irritability, anger, anxiety, and frustration. ~R1's TAR contained an order for behavior monitoring that indicated: Document episodes of behavior: Anxiousness, irritability .every shift for sertraline (started 1/21/26).~ R1's TAR contained an an order for behavior monitoring that indicated: Document episodes of behavior: Depressed statements, withdrawn, isolation .every shift for sertraline.~ R1's TAR contained an order for behavior monitoring that indicated: Upset with placement, irritability, anger, anxiety, frustration .every shift for apriprazole.Surveyor reviewed R1's behavior charting and noted the following: ~ In April 2026, staff did not document behaviors for 18 shifts.~ In May 2026, staff did not document behaviors for 8 shifts.~ In June 2026, staff did not document behaviors for 8 shifts.~ In July 2026, staff did not document behaviors for 10 shifts.A psych provider note on 5/29/26 indicated staff reported R1 exhibited anger at times and inappropriately touched staff. Sertraline was increased from 150 milligrams (mg) to 175 mg daily to treat mood. A progress note written by LPN-D on 6/7/26 at 6:14 PM described a resident-to-resident physical altercation in which R1 struck R2. Surveyor noted R1's care plan did not contain an intervention to monitor for physical aggression toward others or sexual behavior toward staff although staff documented the behaviors in progress notes.On 8/6/26 at 2:01 PM and 3:15 PM, Surveyor interviewed NHA-A who stated staff were not monitoring R1 for physical or sexual behavior because they monitor the precursor behaviors of agitation and anxiousness which can lead them to be physical and/or sexual toward staff. NHA-A confirmed staff should document R1's behaviors every shift.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 44 residents residing in the facility.Staff did not test the parts per million (PPM) of the Quaternary sanitizing solution per the manufacturer's instructions.The reach-in cooler did not maintain a consistent and safe temperature for items that required storage at 41 degrees Fahrenheit (F) or below.The reach-in cooler contained unlabeled, undated, and/or expired items.Findings include:On 7/15/25, Lead [NAME] (LC)-D indicated the facility follows the Wisconsin Food Code. Sanitizing Solution Testing:The Hydrion Quaternary test strip package insert indicates the test solution should be between 65 and 75 degrees F at the time of testing.During an initial kitchen tour on 7/15/25 at 8:21 AM, Surveyor observed the three-compartment sink which contained a bucket of sanitizing solution. Surveyor also observed a sanitizer bucket log which contained PPM documentation. Surveyor noted the log did not indicate the temperature of the sanitizing solution. Surveyor also noted a poster above the three-compartment sink that indicated the recommended water temperature for the Oasis 146 QUAT sanitizer was 65 to 73 degrees F.During a continuous kitchen observation that began at 10:25 AM on 7/16/25, Surveyor interviewed LC-D and Director of Food and Nutrition (DFN)-E. DFN-E indicated kitchen staff use the three-compartment sink to prepare sanitizer buckets used to clean dining and food prep areas. DFN-E confirmed staff do not test or document the temperature of the water added to the the sanitizer buckets. LC-D then temped the water from the faucet that is used to prepare sanitizer buckets and showed Surveyor the thermometer which read 98.4 degrees F. LC-D indicated the temperature was above the recommended range. DFN-E filled another container with water from the faucet and indicated the temperature was 79.5 degrees F. DFN-E again indicated the water temperature was above the manufacture's recommended temperature range of 65 to 75 degrees F. Reach-In Cooler:The 2022 Wisconsin Food Code documents at 3-202.11 Temperature: .Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. Refrigerators should be set below 41 F (5 Celsius (C)) and freezers at or below 0 F (-18 C) .The 2022 Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees C (41 degrees F) (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day.During an initial kitchen tour that began at 8:21 AM on 7/15/25, Surveyor noted the reach-in cooler thermometer read 49 degrees F and observed the following items in the reach-in cooler:~ Two unopened gallons of milk~ One open and half-full gallon of milk~ One case of string cheese~ One three-quarters full case of yogurt ~ Three containers of Magic Cups~ One half-full case of whipped margarine spread~ One unlabeled container (dated 7/14) of thickened pre-mixed honey consistency red juice~ One container of honey consistency thickened water (dated 7/11)~ One container of nectar consistency apple juice (dated 7/8)~ Two open containers of Med Pass 2.0 (one dated 4/20 and the other dated 6/2)~ Three containers of Prairie brand lactose-free milk During a continuous kitchen observation that began at 10:25 AM on 7/16/25, Surveyor noted the reach-in cooler thermometer read 51 degrees F. Surveyor interviewed DFN-E who indicated a 50 degree temperature in the reach-in cooler was concerning and the food in the cooler needed to be brought to the correct temperature or it would not be served. Surveyor noted the following items in the reach-in cooler:~ One unopened gallon of milk~ One open gallon of milk~ One case of string cheese~ One three-quarters full case of yogurt~ Three containers of Magic Cups~ One half-full case of whipped margarine spread~ One container of thickened juice (dated 7/14)~ One unlabeled container of thickened pre-mixed honey consistency red juice (dated 7/14)~ One container of honey consistency thickened water (dated 7/11)~ One container of nectar consistency apple juice (dated 7/8)~ Two open containers of Med Pass 2.0 (one dated 4/20 and the other dated 6/2)~ One covered tray of individual bowls of fruit cocktail Surveyor observed LC-D remove the fruit cocktail during lunch service and obtain a temperature of 49.6 degrees F. The fruit cocktail was served to residents during lunch. Surveyor noted thickened liquids and juice from the reach-in cooler were also served to residents during lunch and milk from the cooler was thickened with Simply Thick and served to residents. Expired Items in Reach-In Cooler:The 2022 Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under 3-502.12, and except as specified in (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees C (41 degrees F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition: (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day.According to Simply Thick (a food and beverage thickener designed to improve the lives of people living with swallowing disorders, otherwise known as dysphagia) documents at https://www.simplythick.com: You can keep beverages thickened with Simply Thick Easy Mix in the refrigerator for up to 72 hours after mixing. After this period, it is recommended to discard the beverage to ensure safety and effectiveness .After this period, the beverage should not be consumed for safety reasons.According to [NAME] Health makers of Med Pass 2.0 (a supplement that provides additional calories and protein) documents at [NAME].Health.com .Once opened, Med Pass 2.0 can stay in the refrigerator for up to 4 days if properly refrigerated .During an initial kitchen tour that began at 8:21 AM on 7/15/25, Surveyor observed the following items in the reach-in cooler:~ Three containers of Prairie Farms lactose-free milk with best-by dates of 7/10/25~ One container of thickened juice (dated 7/14)~ One container of thickened pre-mixed honey consistency juice~ One container of thickened pre-mixed nectar consistency water~ Thickened apple juice (dated 7/8)~ Two open containers of Med Pass 2.0 (one dated 4/20 and one dated 6/2)During a continuous kitchen observation that began at 10:25 AM on 7/16/25, Surveyor interviewed LC-D who confirmed the facility uses Simply Thick to thicken drinks for residents who require thickened liquids. During a continuous kitchen observation that began at 10:25 AM on 7/16/25, Surveyor interviewed DFN-E who indicated thickened apple juice should not be in the cooler and stated thickened juices and Med Pass 2.0 can be kept pre-mixed in the cooler for seven days. DFN-E also verified the Prairie Farms lactose-free milk was expired and disposed of on 7/15/25.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. One of three medication carts was observed unlocked and unattended during medication administration. This practice had the potential to affect more than 4 of the 44 residents residing in the facility.The Memory Lane medication cart was unlocked and unattended during medication administration on 7/17/25. Findings include:The facility's Medication Storage policy indicates: .b.Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.On 7/17/25 at 9:35 AM, Surveyor noted the medication cart on Memory Lane was unlocked and unattended. During the observation, Registered Nurse (RN)-C returned to the medication cart. The medication cart was left unlocked and unattended for 10 minutes. On 7/17/25 at 9:45 AM, Surveyor interviewed RN-C who verified RN-C left the medication cart unlocked and unattended. RN-C indicated it was an accident and RN-C's practice was to lock the medication cart.On 7/17/25 at 9:59 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated medication carts should be locked when unattended.

Based on staff interview and record review, the facility did not ensure a written transfer and/or bed hold notice or Ombudsman notification was provided when 2 residents (R) (R45 and R47) of 2 sampled residents transferred to the hospital and/or discharged from the facility.R45 was transferred to the hospital on 4/14/25 and 5/13/25. Neither R45 or R45's Guardian were provided a written transfer notice. R45 was also transferred to the hospital on 4/29/25. Neither R45 or R45's Guardian were provided a written transfer or bed hold notice. In addition, the Ombudsman was not notified of the transfers or R45's discharge from the facility following the 5/13/25 hospital transfer.R47 was discharged to an assisted living facility on 5/12/25. The Ombudsman was not notified of the discharge. Findings include:The facility's Admission/Discharge/Transfer: Subject: Bed Hold - Transfer/Discharge - Ombudsman notification policy, revised 7/17/25, indicates: It is the policy of this facility to inform the resident or the resident's representative in writing of the right to exercise the bed hold provision of 15 days upon admission and before transfer to a general acute care hospital .A written transfer/discharge notice must be completed at the time of transfer or discharge and the Ombudsman is to be notified of all transfers and discharges. A copy of the bed hold notification along with the transfer/discharge notice shall become a part of the resident's health record at the time of transfer .each transfer/discharge notice shall include: The reason for the transfer or discharge, the right to appeal the transfer or discharge, and the contact information of the state Ombudsman and the Disability Rights Commission.1. From 7/15/25 to 7/17/25, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE] and had diagnoses including stroke affecting the left non-dominant side, seizures, and depression. R45's Minimum Data Set (MDS) assessment, dated 4/22/25, had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R45 had severely impaired cognition. R45 had a Guardian for healthcare decisions.On 4/14/25, R45 was transferred to the hospital following a fall. R45 was diagnosed with an intraventricular hemorrhage in the posterior right ventricle (brain bleed). R45's medical record did not not indicate a written transfer notice was provided to R45 or R45's Guardian or that the Ombudsman was notified of the transfer.On 4/29/25, R45 was transferred to the hospital and diagnosed with a complicated urinary tract infection (UTI). R45 returned to the facility the same day. R45's medical record did not indicate a written transfer or bed hold notice was provided to R45 or R45's Guardian or that the Ombudsman was notified of the transfer.On 5/13/25, R45 was transferred to the hospital and diagnosed with pneumonia. R45 did not return to the facility. R45's medical record did not indicate a transfer notice was provided to R45 or R45's Guardian or that the Ombudsman was notified of the transfer and discharge.On 7/17/25 at 11:16 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware that a transfer notice should be completed for residents who are transferred to the hospital. NHA-A verified R45 and R45's Guardian were not provided with a written transfer and/or bed hold notice and the Ombudsman was not notified. On 7/17/25 at 12:36 PM, Surveyor interviewed Director of Nursing (DON)-B who verified neither R45 or R45's Guardian were provided a bed hold notice for R45's 4/29/25 hospital transfer. DON-B indicated the Ombudsman notifications for May were missed.2. From 7/15/25 to 7/17/25, Surveyor reviewed R47's medical record. R47 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, cognitive communication deficit, epilepsy, and history of repeated falls. R47's MDS assessment, dated 3/31/25, had a BIMS score of 4 out of 15 which indicated R47 had severely impaired cognition. R47 had a Guardian for healthcare decisions.On 5/12/25, R47 was discharged to an assisted living facility. R47's medical record did not indicate the Ombudsman was notified of the discharge. On 7/17/25 at 1:20 PM, Surveyor interviewed NHA-A who verified Ombudsman transfer and discharge notifications were missed in May and were sent on 7/17/25.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 1 resident (R) (R10) of 4 sampled residents.R10 had a fall with injury on 6/6/25. Following the fall, the facility did not implement or add physical therapy recommendations to R10's plan of care to prevent future falls or injury.Findings include:The facility's Nursing Clinical Safety Assessment-Falls policy, revised 1/2025, indicates: It is the policy of this facility to evaluate extent of injury after a fall and prevent complications .16. If there is an existing plan of care in the resident's medical record pertaining to falls, it must be updated to reflect newly identified risk factors and approaches .On 7/15/25, Surveyor reviewed R10's medical record. R10 had diagnoses including dementia, diabetes mellitus type 2, unsteadiness on feet, long term use of anticoagulants, and general weakness. R10's Minimum Data Set (MDS) assessment, dated 5/20/25, had a Brief Interview for Mental Status(BIMS) score of 3 out of 15 which indicated R10 had severely impaired cognition. R10 had an activated Power of Attorney for Healthcare (POAHC). A progress note, dated 6/6/25, indicated the writer was outside R10's room and heard R10 say R10 needed to use the restroom badly. The writer saw R10 sit up on R10's bed, lock the walker, and stand. R10 was wearing gripper socks. R10 started to walk toward the bathroom and left the writer's view. R10 yelled that R10 had fallen and hit R10's head. The walker was observed on top of R10's chest. When the writer asked if R10 had moved too fast and lost R10's footing, R10 indicated that must have been what happened. R10 reported pain and the writer observed redness on the left side of R10's forehead. R10's vital signs were within normal limits. Staff assisted R10 up and R10 walked to bed with the walker. R10 then used the restroom with the assistance of staff. An Interdisciplinary Team (IDT) note, dated 6/9/25, indicated the fall occurred on 6/6/25 and R10 was referred for physical therapy (PT) and occupational therapy (OT) with an authorization date of 6/17/25.A care plan, dated 6/11/25, indicated R10 was independent or needed limited assistance with ambulation with a walker in R10's room. R10 was independent with wheelchair mobility and used an assistive device-walker, wheelchair. R10 was independent or needed limited assistance with transfers. The care plan contained interventions to provide supportive care and assistance with mobility as needed and document assistance as needed. A therapy referral was ordered. A Fall Risk Evaluation, dated 6/12/25, indicated R10 was at moderate risk for falls. Surveyor noted R10's transfer and ambulation statuses were not updated following the therapy referral on 6/17/25. On 7/17/2025 at 8:15 AM, Surveyor interviewed Director of Rehabilitation (DOR)-G who indicated R10 currently worked with OT and was discharged from PT on 7/14/25. DOR-G confirmed PT/OT was ordered due to a fall on 6/6/25 and indicated the goal was to get R10 back to independent with transfers and ambulation. DOR-G confirmed R10 required the assistance of one staff with a gait belt for all transfers and ambulation which was recommended by PT/OT on 6/19/25 and discussed with nursing staff in a morning meeting. DOR-G indicated transfer and ambulation status is conveyed to nursing staff during morning meetings and it is the responsibility of nursing staff to update residents' care plans. DOR-G also indicated things get lost in the system at times and care plans do not always get updated. DOR-G indicated DOR-G had documentation of the discussion during the 6/19/25 morning meeting and would provide the documentation to Surveyor. On 7/17/25 at 8:35 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated R10 was independent with transfers and ambulation unless R10 requested assistance and used the call light. CNA-F confirmed R10 did not use the call light for transfers or ambulation. On 7/17/25, Surveyor received the 6/19/25 morning meeting documentation from DOR-G. Surveyor noted R10's PT/OT evaluation was completed and indicated R10 transferred with the assistance of 1staff, a four-wheeled walker, and a gait belt. On 7/17/25 at 11:56 AM, Surveyor interviewed Registered Nurse (RN)-H who indicated R10 was referred to PT/OT so R10 could maintain independence. RN-H indicated therapy staff give nursing staff a recommendation sheet with a resident's transfer/ambulation status following an evaluation which is how nursing staff know the resident's care plan should be updated. RN-H indicated therapy staff should provide a recommendation sheet and not just update staff in morning meeting. RN-H indicated a new Director of Rehabilitation had just started and the team should discuss how to ensure care plans get updated. RN-H confirmed R10's care plan did not accurately reflect R10's current transfer and ambulation status.

Based on staff interview and record review, the facility did not ensure appropriate weight monitoring was provided for 1 resident (R) (R14) of 3 sampled residents.The facility did not update the physician regarding R14's weight loss of 6.15% from 6/6/25 to 7/4/25. In addition, the facility did not use the same device to obtain R14's weight on each weigh date. Findings include:The facility's Nursing Administration - Nutrition policy, revised 1/2025, indicates: It is the policy of this facility to ensure all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible .Significant weight loss - 5% in one month, 7.5% in three months, or 10% in six months, as well as unplanned weight loss that occurs over time that does not meet the guidelines for significant weight loss and does not trigger review of the nutritional status .should be addressed in the care plan .Weights should be obtained via the same device on each weigh date .The Interdisciplinary Team (IDT) will further assess nutritional needs and goals of the resident in the context of his/her overall condition. Nutritional assessment may include: Weighing and weight changes .2. Any resident weight that varies from the previous reporting by 5% in 30 days, 7.5% in 90 days, and 10% in 180 days will be evaluated by the IDT to determine the cause of the weight loss/gain and interventions required. Family member/responsible party and attending physician will be notified by the unit manager .4. The nurse will notify the physician, family, and/or resident of the weight loss/gain with interventions. 5. Any resident meeting the criteria for weight loss and any resident at risk will be weighed weekly with the weight entered in the weekly weight progress notes. Weekly weights will be reviewed each week by the dietary manager. Any obscure weights will be re-weighed the next day .From 7/15/25 to 7/17/25, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including nontraumatic intracerebral hemorrhage, vascular dementia with mood disturbance, cognitive communication deficit, and hemiplegia affecting the right dominant side. R14's Minimum Data Set (MDS) assessment, dated 4/15/25, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R14 had severely impaired cognition. R14 had an activated Power of Attorney for Healthcare (POAHC). A care plan, revised 1/8/25, indicated R14 was at high nutritional risk secondary to cerebrovascular accident, diabetes, dementia, hypertension, anxiety, and dysphagia, needed a therapeutic diet, and had significant weight loss. The care plan contained the following interventions: Will maintain adequate nutritional status as evidenced by maintaining weight, however, incremental weight loss (1 kilogram/week) beneficial related to high body mass index (BMI) - goal <30; No concentrated sweet, regular texture diet (no corn, no peas), thin liquids; dependent for eating; Sit on R1's right side to help encourage R1 to keep head upright; Usually able to complete liquids independently; Encourage healthy snacks between meals low in refined carbs; Offer cottage cheese; Meals in Blue Spruce dining area; Monitor intake and record every meal; Monitor/assess per primary care physician recommendations with any reported coughing concerns with meals; No preference for mealtimes; Offer and encourage fluids throughout day to help maintain hydration status. Provide 240 milliliters (ml) of fluids between meals. Monitor for signs and symptoms of dehydration. Report significant changes to provider; Weekly weights times four weeks and then monthly if stable.Surveyor reviewed R14's weights and noted the following:~ On 7/4/25 at 11:39 AM, R14 weighed 190.7 pounds (sitting) ~ On 6/27/25 at 11:43 AM, R14 weighed 192.0 pounds (sitting) ~ On 6/20/25 at 12:32 PM, R14 weighed 188.4 pounds (sitting) ~ On 6/14/25 at 11:21 AM, R14 weighed 189.4 pounds (Hoyer scale) ~ On 6/13/25 at 1:02 PM, R14 weighed 199.7 pounds (Hoyer scale) ~ On 6/6/25 at 12:32 PM, R14 weighed 203.2 pounds (sitting) ~ On 5/30/25 at 1:01 PM, R14 weighed 201.4 pounds (Hoyer scale) ~ On 5/23/25 at 11:27 AM, R14 weighed 198.6 pounds (Hoyer scale) ~ On 5/16/25 at 11:05 AM, R14 weighed 200.4 pounds (Hoyer scale) ~ On 5/9/25 at 12:13 PM, R14 weighed 198.3 pounds (sitting) ~ On 5/2/25 at 11:17 AM, R14 weighed 199.2 pounds (sitting) ~ On 4/25/25 at 11:10 AM, R14 weighed 199.4 pounds (sitting)A weight/skin assessment, completed by Registered Dietitian (RD)-K and dated 6/26/25 at 9:21 PM, indicated R10 had a current weight (as of 6/20/25) of 188.4 pounds and a BMI of 29.1 (which was considered overweight). R10 flagged for weight loss. R10's weight loss history included a loss of -5.1% (significant) in 1 month. R10 was prescribed a diuretic medication and mild weight fluctuations were expected. There was no edema noted. The assessment indicated gradual weight loss (1-2 kilograms/week) was beneficial due to R10's high BMI. R10 was prescribed a no concentrated sweets, regular, thin liquids (no corn, no peas) diet and had an order for 240 ml of fluids three times daily between meals. R10's meal intake was between 76-100% with 9 of 10 snacks accepted. The assessment indicated to continue to offer snacks and fluids between meals and continue to monitor R10's weight.A weight/skin assessment, completed by RD-K and dated 7/9/25 at 7:25 PM, indicated R10 currently weighed (as of 7/4/25) 190.7 pounds and had a BMI of 29.4 (which was considered overweight). R10 flagged for weight loss. R10's weight loss history included a loss of -6.2% (significant) in 1month. R10 was prescribed a diuretic medication and mild weight fluctuations were expected. No recent edema was noted. The assessment indicated gradual weight loss (1-2 kilograms/week) was beneficial due to R10's high BMI. R10 was prescribed a no concentrated sweets, regular, thin liquids (no corn, no peas) diet and had an order for 240 ml of fluids three times daily between meals. R10's meal intake was between 76-100% with 11 of 11 snacks accepted. The assessment indicated to continue to offer snacks and fluids between meals. On 7/16/25 at 11:52 AM, Surveyor interviewed Registered Nurse (RN)-J who confirmed R14's weight loss of 12.5 pounds from 6/6/25 to 7/4/25. RN-J did not know why R14 was losing weigh and was not sure if the physician was notified of the weight loss.On 7/16/25 at 2:03 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R14 had a significant weight loss of 6.2% from 6/3/25 to 7/11/25. DON-B indicated the physician was not updated regarding the weight loss. DON-B met with RD-K during a monthly weight review meeting on 7/9/25 and indicated R14's weight loss was reviewed during the meeting. DON-B also acknowledged R14's weights were obtained via Hoyer scale and sitting and stated R14's weights should have been obtained in the same manner.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R21) of 16 sampled residents had a call light within reach and was provided hearing aids. On 7/16/25, R21 was in R21's room without access to a call light or a means to notify staff if assistance was needed. In addition, R21 did not have hearing aids in either ear on 7/15/25. Findings include:From 7/15/25 to 7/17/25, Surveyor reviewed R21's medical record. R21 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (paralysis on one side of body) and hemiparesis (weakness on one side of the body) following a stroke affecting the left non-dominant side, anxiety, chronic pain, asthma, and neuromuscular dysfunction of bladder with urinary incontinence. R21's Minimum Data Set (MDS) assessment, dated 4/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R21 had intact cognition. The MDS assessment also indicated R21 had hearing aids. R21 had a Guardian who assisted with healthcare decisions.R21's plan of care indicated R21 was at risk for falls related to left hemiparesis and contained interventions to be sure the call light was within reach and encourage R21 to use the call light to call for assistance. R21's plan of care also indicated R21 was at risk for impaired visual function but did not indicate R21 had impaired hearing. On 7/15/25 at 11:00 AM and 11:18 AM, Surveyor interviewed R21 who stated, Sometimes they (staff) put my call light on my left side where I can't reach it. They do it on purpose. I have a reacher and I have to be creative to reach the things I need. R21 also indicated R21 had two hearing aids that were not very good ones. Surveyor noted R21 did not have hearing aids in either ear. R21 indicated R21 was not wearing hearing aids because staff did not put them in. R21 stated R21 had to ask staff to put them in.On 7/16/25 at 11:49 AM, Surveyor observed Certified Nursing Assistant (CNA)-I provide cares for R21. CNA-I left the room and was halfway down the hallway when Surveyor informed CNA-I that R21's call light was hung on the left bedrail and out of R21's reach.On 7/16/25 at 11:57 AM, Surveyor interviewed CNA-I who verified the call light was not within R21's reach. CNA-I then placed the call light on R21's abdomen.On 7/16/25 at 1:25 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R21's plan of care did not address hearing/hearing aids. DON-B also verified R21's MDS assessment indicated R21 had hearing aids and agreed R21 should have had a care plan for hearing/hearing aids. On 7/17/25 at 10:45 AM, Surveyor interviewed DON-B who verified R21's call light should have been within reach due to R21's limited mobility from a stroke that affected the left upper extremity. DON-B indicated the facility did not have a call light policy and stated it was a standard of care that call lights need to be within residents' reach.

2. On 6/19/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had a diagnosis of Parkinson's disease. R2's MDS assessment, dated 5/2/25, had a BIMS score of 9 out of 15 which indicated R2 had moderate cognitive impairment. R2 had a POAHC. R2's care plan indicated the following: ~ Sensor alarm to bed and chair to alert staff of self-ambulating so staff can assure R2 is using R2's walker ~ Do not put feet up in recliner, unable to put down independently Surveyor reviewed a fall investigation that indicated R2 was found on the floor of R2's room on 4/27/25 at 6:15 PM. CNA staff had assisted R2 to bed less than five minutes prior. A Licensed Practical Nurse (LPN) entered R2's room to administer medication at 6:15 PM and observed R2 ambulating independently in the room and bleeding above the right eye. The bed alarm was not sounding when the LPN entered the room. R2 was unable to state what occurred but reported that R2 fell. R2 was transferred to the emergency room (ER) for evaluation. It was determined that staff did not turn on the bed alarm when they assisted R2 to bed. The Interdisciplinary Team (IDT) reviewed the incident and verified that failure to follow R2's care plan resulted in the lack of immediate notification of R2's fall although R2 was discovered shortly afterward. The fall resulted in the reopening of a prior cut that needed to be resutured (stitches were removed from R2's right eye on 4/26/25). Immediate education was provided to the staff who did not follow R2's care plan and education was provided to all staff in the following days. The investigation included an interview with CNA-F who indicated R2 was toileted prior to being assisted to bed. CNA-F was aware that R2 needed a chair alarm but not a bed alarm. The investigation also included an interview with CNA-G who indicated R2 was toileted prior to being assisted to bed. CNA-G was not aware that R2 needed a bed alarm. On 6/19/25 at 9:35 AM, Surveyor observed a staff assist R2 into R2's recliner. Surveyor heard the alarm pad beep twice as R2 sat in the recliner. The staff ensured R2's call light was within reach and exited the room. On 6/19/25 at 9:37 AM, Surveyor observed R2 stand up from the recliner and heard the alarm sound. RN-H and LPN-I immediately responded and assisted R2 back into the recliner. Surveyor observed RN-H raise the footrest of the recliner and ensure R2's call light was within reach. RN-H and LPN-I then exited the room. On 6/19/25 at 9:58 AM, Surveyor interviewed DON-B who showed Surveyor the Kardex behind R2's door. DON-B verified the Kardex indicated the footrest of the recliner should not be raised. DON-B verified R2's footrest was in a raised position and lowered R2's footrest for safety. On 6/19/25 at 10:08 AM, Surveyor interviewed RN-H who verified RN-H responded to R2's alarm and raised the footrest on R2's recliner. RN-H did not realize R2's care plan indicated the footrest should not be raised. RN-H was aware care plan interventions were listed in the computer and on the back of room doors. RN-H verified staff had received education a couple months ago regarding falls and the importance of following care plan interventions. Based on observation, staff interview, and record review, the facility did not ensure fall prevention interventions were in place for 2 residents (R) (R1 and R2) of 5 sampled residents. R1's care plan contained interventions for bed and chair alarms for fall prevention. On 5/16/25, staff did not ensure R1 had a wheelchair alarm and R1 fell. On 5/26/25, staff did not ensure R1 had a bed alarm. R1 fell while attempting to get out of bed. On 6/7/25, staff did not ensure R1 had a wheelchair alarm. R1 self-transferred, fell, and sustained a hip fracture that required hospitalization. (This example is being cited at a level G.) R2's care plan contained interventions for bed and chair alarms for fall prevention. On 4/27/25, staff did not ensure R2 had a bed alarm. R2 fell and reopened a suture line on R2's forehead sustained in a previous fall. In addition, R2's care plan indicated R2 was not to have the footrest raised while in R2's recliner. On 6/19/25, staff raised the footrest while R2 was in the recliner. Findings include: The facility's Falls Program policy, dated 4/2025, indicates: It is the policy of this facility to reduce the number and severity of falls and to identify high risk residents and take precautionary measures .3. Staff to check at beginning of every shift for correct application of care planned interventions (i.e., alarms, floor mats, call light within reach, restraints, wheelchairs, bed rails, etc.) . 1. On 6/19/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including dementia, chronic multifocal osteomyelitis in right ankle and foot, and diabetes. R1's Minimum Data Set (MDS) assessment, dated 5/20/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had intact cognition. R1 had an activated Power of Attorney for Healthcare (POAHC). A care plan (initiated 5/15/25) indicated R1 was at risk for falls related to weakness and multiple sclerosis and contained the following intervention: Fall prevention devices per orders and/or per Kardex (an abbreviated care plan used by nursing staff) - chair alarm and bed alarm due to impulsiveness, does not always ask for assistance (initiated 5/19/25). A care plan (initiated 5/15/25) indicated R1 had an activities of daily living (ADL) self-care performance deficit related to multiple sclerosis and contained the following intervention: Transfer: Two assist pivot transfer with gait belt and walker (initiated 5/15/25). A care plan (initiated 6/1/25) indicated R1 was on diuretic therapy related to hypertension (high blood pressure) and contained the following interventions: May cause dizziness, postural hypotension (low blood pressure), fatigue, and an increased risk for falls. Observe for possible side effects (every) shift (initiated 6/1/25); Monitor for increased falls with position changes (initiated 6/1/25). A progress noted, dated 6/7/25 at 12:45 PM, indicated the writer was called to R1's room by an activity staff who was in the hallway and heard noise from the room. R1 was observed on the floor on R1's left side with R1's legs in the bathroom and upper body in the bedroom. R1's walker was between the bed and the doorway and R1's wheelchair was next to the recliner. R1 had a hematoma and was bleeding from the left side of the head at the hairline. R1 reported head pain but denied arm and leg pain. R1 later complained of upper left thigh pain when sitting in the wheelchair. The on-call provider was notified and R1 was sent to the Emergency Department (ED). On 6/19/25, Surveyor reviewed a facility-reported incident (FRI) that indicated on 6/7/25 at 11:25 AM, Activities Aide (AA)-J witnessed R1 fall. AA-J called for assistance and told Assistant Director of Nursing (ADON)-K what had occurred. ADON-K assisted R1 and notified the on-call doctor at approximately 11:40 AM. Emergency Medical Services (EMS) arrived and transported R1 to the hospital. ADON-K interviewed staff on the unit and discovered R1's care plan was not followed regarding the use of a chair alarm. As a result of the fall, R1 was hospitalized with a hip fracture. Surgical repair was scheduled, however, R1 passed away on 6/11/25 with the cause as death listed as acute encephalopathy (a sudden disturbance in brain function often caused by systemic issues rather than direct brain injury). The fall investigation contained an interview with ADON-K, dated 6/7/25, that indicated ADON-K was notified by activity staff at approximately 11:25 AM that R1 was on the floor in R1's bedroom. ADON-K observed R1 on the floor and noted R1 was bleeding from the head. ADON-K applied pressure to the area and completed a neuro assessment. The bleeding was not controlled and the physician was notified at approximately 11:40 AM. R1 was sent to the ED for evaluation and treatment due to a head injury, anticoagulant use, and upper left thigh pain. ADON-K noted R1's chair alarm/sensor pad was not in the wheelchair and observed a sensor pad on the floor next to R1's recliner with the alarm in the side pocket of the recliner. R1 was last seen in the sun room in a wheelchair. An undated interview with AA-J indicated AA-J was in the hallway on 6/7/25 at approximately 11:30 AM and heard the clinking sounds of a walker bumping into something. AA-J looked in R1's room and saw R1 fall backwards and hit R1's head on the floor. AA-J saw ADON-K at the end of the hallway and notified ADON-K that R1 fell. An interview with Certified Nursing Assistant (CNA)-L, dated 6/11/25, indicated CNA-L had gotten R1 up before breakfast on 6/7/25 and was unaware that R1 should have a chair alarm, but knew R1 had bed an recliner alarms. CNA-L indicated R1 went to the sun room for breakfast and worked on a puzzle in the sun room after breakfast. Prior to lunch, CNA-L went to another wing that needed assistance and was not on the unit when R1 fell. An undated handwritten statement from CNA-L indicated CNA-L thought R1 self-transferred to a rocking chair from R1's wheelchair and then walked to the bathroom. The chair alarm was on the floor and CNA-L saw R1 laying on the floor by R1's bathroom door. On 6/19/25 at 1:50 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B who verified staff did not follow R1's care plan and did not ensure R1 had a chair alarm on 6/7/25. Education was provided to all staff regarding following care plan interventions, however, current noncompliance was observed during the survey. (See example 2)

Based on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 1 (Certified Nursing Assistant (CNA)-C) of 8 staff reviewed for caregiver background checks. The facility did not ensure a thorough caregiver background check was completed for CNA-C. Findings include: The facility's Abuse Prevention Program, dated 5/2025, indicates: It is the policy of this facility that each resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation .Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident .2. All employees will be properly screened for criminal background at a minimum of on hire and every four years . Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility For Chapter 50 Programs, dated 4/2020, indicates: This document lists Wisconsin crimes and other offenses that the Wisconsin State Legislature, under the Caregiver Law, Wis. Stat. § 50.065, has determined require rehabilitation review approval before a person may receive regulatory approval, work as a caregiver, reside as a non-client resident at, or contract with an entity .Additional information must be obtained when: .The Background Information Disclosure (BID) or Department of Justice (DOJ) response indicates a conviction of any of the following, where the conviction occurred five years or less from the date on which the information was obtained .6. Disorderly conduct Wis. Stat. § 947.01 .Note: These seven convictions do not prohibit employment, but do require the entity to obtain the criminal complaint and judgment of conviction from the Clerk of Courts office in the county where the person was convicted . On 6/19/25, Surveyor reviewed background check information for 8 facility staff, including CNA-C, and noted CNA-C was a contracted CNA whose hire date was listed as 10/1/24. CNA-C's BID form was dated 1/13/25. The facility did not provide CNA-C's Wisconsin DOJ criminal background check letter or Integrated Background Information System (IBIS) letter. An Attestation Notification indicated CNA-C's agency no longer provided copies of background check results due to an increased focus on privacy laws, federal and/or state regulations, the Fair Credit Reporting Act, restrictions set forth by contracts, and increased focus on joint employer liability. On 6/19/25 at 2:57 PM, Surveyor interviewed Human Resource Manager (HRM)-D who indicated staffing agencies provide the facility's scheduler with agency staff members' criminal background check information and the scheduler sends the information to HRM-D who keeps files on all agency staff. When asked about the DOJ and IBIS letters for CNA-C, HRM-D indicated the agency that CNA-C worked for no longer provides criminal background check documents to the facility due to a data breach. On 6/19/25 at 3:18 PM, Surveyor interviewed Agency Manager (AM)-E via phone who verified AM-E was the manager of the agency that employed CNA-C. AM-E indicated the agency does not provide criminal background check information to facilities in order to protect the privacy of agency employees. During the interview, AM-E emailed CNA-C's DOJ and IBIS letters to Surveyor. With AM-E on the phone, Surveyor reviewed CNA-C's DOJ letter, dated 1/16/25, and IBIS letter, dated 1/16/24. The DOJ letter indicated CNA-C was charged with Disorderly Conduct Wis. Stat. § 947.01(1) in 2021. The charge was dismissed and CNA-C was instead convicted of Disorderly Conduct Wis. Stat. § 31.02(1). AM-E was unaware of the Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility For Chapter 50 Programs document and indicated the agency has its own hiring standards which do not include a detailed review of Disorderly Conduct Wis. Stat. § 947.01 if an agency staff is convicted of such.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents was free from being physically restrained. R1 had Alzheimer's disease and had a history of tearing apart R1's incontinence brief. On the 4/1/25 PM shift at approximately 9:30 PM, Certified Nursing Assistant (CNA)-C tied the sleeves of R1's nightgown closed with R1's arms inside and tucked a blanket across R1's lap and under both sides of the mattress after R1 repeatedly tried to rip off R1's brief. R1 was restrained in bed until approximately 12:10 AM when staff on the next shift did a routine check on R1. R1 was restrained in such a way that R1 could not access R1's hands or call light and could not move freely in bed. The facility's failure to ensure R1 was not physically restrained and its failure to ensure R1 could move freely in bed and had access to R1's hands and call light created a finding of immediate jeopardy that began on 4/1/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 4/24/25 at 5:00 PM. The immediate jeopardy was removed and corrected on 4/2/25. This is being cited as past noncompliance. Findings include: The facility's Restraint Assessment, Physical policy, revised 8/2007, indicates: It is the policy of this facility to ensure that no resident is placed in physical restraints for the purpose of discipline or convenience and that restraints are only applied to treat the resident's medical symptoms .A physical restraint is defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body, that the resident cannot remove easily, and restricts freedom of movement or normal access to one's body . On 4/24/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) following cerebral infarction (stroke) affecting the right dominant side, major depressive disorder, and aphasia (an inability to comprehend or formulate language due to damage to the brain). R1's Minimum Data Set (MDS) assessment, dated 2/4/25, documented a Brief Interview for Mental Status (BIMS) score of 2 out of 15 which indicated R1 had severe cognitive impairment. R1 had a court appointed Guardian who was responsible for R1's healthcare decisions. R1's medical record indicated R1 required total assistance of one staff for lower torso cares including incontinence brief changes. R1 could wash R1's face if instructed to do so. R1's plan of care indicated R1 had been tearing R1's incontinence brief apart since 3/2/20 and contained an intervention for staff to check and change R1 frequently. R1's plan of care plan also indicated R1 would sit on R1's bed with R1's legs crossed at times. On 4/24/25, Surveyor reviewed a facility investigation that indicated Licensed Practical Nurse (LPN)-D entered R1's room to provide care on 4/2/25 at 12:10 AM. LPN-D pulled back R1's bedding and noted the sleeves of R1's nightgown were tied tightly shut with R1's arms inside and prevented R1 from being able to access R1's hands. LPN-D also observed a folded blanket placed across R1's waist and tucked under the mattress on both sides of the bed. LPN-D immediately untied the sleeves of R1's nightgown and untucked the blanket from the mattress. When LPN-D asked Certified Nursing Assistant (CNA)-E what was mentioned during shift change report for R1, CNA-E stated the PM shift agency CNA (CNA-C) said R1 was ripping off R1's brief and throwing things around but CNA-C got R1 to stop. Physical and pain assessments were completed with no sign of injury. Bruising was noted on the tops of R1's hands, however, a nurse determined they were not new bruises. The facility's Social Worker (SW) interviewed R1 and determined R1 felt safe did and did not recall an altercation. NHA-A, local law enforcement, R1's Guardian, R1's physician, and the State Agency (SA) were notified timely. CNA-C was removed from all future shifts. Ongoing physical and psychosocial monitoring was initiated for R1. On 4/24/25 at 12:10 PM, Surveyor interviewed LPN-G via phone. LPN-G verified LPN-G worked the 4/1/25 PM shift. LPN-G indicated the last time LPN-G saw R1 was at approximately 6:30 PM when LPN-G observed R1 in a chair in R1's room watching TV. LPN-G was unsure what time R1 was assisted to bed and indicated last rounds by PM CNAs were usually done between 9:30 PM and 10:00 PM. LPN-G did not know when CNA-C restrained R1 and indicated LPN-G was upset when LPN-G heard what had happened. On 4/24/25 at 1:41 PM, Surveyor interviewed NHA-A who indicated the facility determined CNA-C restrained R1 during last rounds on the 4/1/25 PM shift at approximately 9:30 PM. On 4/24/25 at 2:06 PM, Surveyor interviewed LPN-D via phone. LPN-D indicated R1 was restless at the beginning of the overnight shift from 4/1/25 into 4/2/25. LPN-D indicated R1 appeared in no distress but was not sleeping like R1 usually did. LPN-D discovered R1 at approximately 12:00 AM with R1's arms inside R1's night gown lying loosely on R1's abdominal area. LPN-D indicated the sleeves of R1's night gown were turned inside out on the inside of the night gown and indicated R1 may have done that by R1's self. LPN-D indicated R1 was wearing an incontinence brief which R1 had a habit of shredding. LPN-D indicated LPN-D immediately untied the sleeve ends and provided care to R1. On 4/24/25, Surveyor reviewed an email from CNA-C's agency, dated 4/2/25, that stated, .Here is the statement received from (CNA-C) .Yeah. That was a dumb idea. The resident was ripping stuff apart and trying to smear stuff on the walls so I tied the end of the sleeves so (R1) couldn't rip at anything anymore. I don't recall putting the blanket under the mattress. I remember tucking it under (R1) like I usually do . On 4/24/25 at 9:31 AM, Surveyor interviewed R1 who was only able to provide yes/no and one word answers. R1 indicated R1 felt fine and staff were nice to R1. R1 indicated no one had hurt R1 at the facility. R1 was observed in a wheelchair in the day room with no visible restraints. The failure to ensure R1 was not physically restrained and the failure to ensure R1 access to R1's hands and call light and could move freely in bed created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The facility removed the jeopardy and corrected the deficient practice on 4/2/25 when it completed the following: 1. Initiated ongoing physical and psychosocial monitoring for R1. 2. Completed skin assessment for other cognitively impaired residents. 3. Notified CNA-C's staffing agency and did not allow CNA-C to return to the facility. 4. Educated facility and agency staff on the facility's abuse and restraint policies.

Based on staff interview and record review, the facility did not implement policies and procedures to prevent abuse and complete a thorough and timely background check for 1 (Certified Nursing Assistant (CNA)-H) of 8 sampled staff. The facility did not ensure a background check was completed every four years for CNA-H, including a Background Information Disclosure (BID) form, Department of Justice (DOJ) report, and an Integrated Background Information System (IBIS) letter. Findings include: The facility's Pre-Employment Investigations policy, dated January 2022, indicates: Post Employment Offer Procedures: Wisconsin Department of Health Caregiver and Department of Justice Criminal Background Checks Required Every Four Years: These checks shall be performed every four years or at any time within that period that the company has reason to believe new checks should be obtained. On 4/24/25, Surveyor reviewed a sample of employees for caregiver background check compliance, including CNA-H. Surveyor noted CNA-H was an agency CNA who started working at the facility on 7/1/23. The background check information provided to Surveyor by the facility on 4/24/25 indicated CNA-H's BID form, DOJ report, and IBIS letter were last completed and reviewed by the agency on 8/14/19. On 4/24/25 at 1:50 PM, Surveyor interviewed NHA (Nursing Home Administrator)-A who indicated CNA-H was an agency staff who began working at the facility on 7/1/23. NHA-A verified CNA-H had worked in the facility in the last three months and the only background check information the facility had for CNA-H was dated 8/14/19. NHA-A stated it is the facility's policy to ensure background checks are completed every four years for all staff, including agency staff.

Based on observation, staff interview, and record review, the facility did not ensure 1 of 2 refrigerators in the medication storage room that contained vaccines and insulin maintained a temperature between 36 and 46 degrees. In addition, the facility did not ensure medications for 11 residents (R) (R23, R41, R11, R9, R12, R13, R32, R39, R7, R35, and R30) of 49 residents in 3 out of 3 medications carts were labeled and/or dated appropriately. Refrigerator temperature log sheets indicated temperatures were more than 46 degrees for a refrigerator in the medication storage room. During observations on [DATE], the thermometer in the refrigerator indicated the temperature was 52 degrees and 54 degrees. The refrigerator contained vaccines and insulin which should be stored between 36 and 46 degrees Fahrenheit (F) to preserve their integrity. Medication carts contained an insulin pen, inhalers, and eye drops which were not labeled or dated appropriately. Findings include: The facility's Medication Storage/Storage of Medications policy (Nursing Care Center Pharmacy Policy and Procedure Manual 2007) indicates: .11. Medications requiring refrigeration or temperature between 36 degrees and 46 degrees are kept in a refrigerator with a thermometer to allow temperature monitoring .the temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily .12. Insulin products should be stored in refrigerator until opened. Note the date on the label for insulin vials and pens when first used. Storage information for Purified Protein Derivative (PPD) (for tuberculosis tests) indicates the storage temperature should be between 35 and 46 degrees F. In-use vials should be discarded after 30 days. Packaging information for insulin aspart, insulin lispro (Humalog), and insulin glargine indicates unopened vials are good until the expiration date when stored between 36 and 46 degrees F. Opened vials should be discarded after 28 days. Packaging information for Levemir indicates unopened vials are good until the expiration date when stored between 36 and 46 degrees F. Opened vials should be discarded after 42 days Packing information for Humulin R indicates unopened vials are good until the expiration date when stored between 36 and 46 degrees F. Opened vials should be discarded after 31 days. Packaging information for Spiriva Respimat indicates: .Three months after insertion of cartridge, throw away the Spiriva Respimat even if has not been used, or when the inhaler is locked, or when it expires, whichever comes first. Packaging information for Breo Ellipta indicates: .Write the tray opened and discard dates on the inhaler label. The discard date is 6 weeks from the date you open the tray. Packaging information for fluticasone salmeterol (Advair HFA) indicates: .Do not use the inhaler after the expiration date, which is on the packaging it comes in. 1. On [DATE] at 12:55 PM, Surveyor reviewed medication refrigerator temperature logs. The [DATE] log contained 3 temperatures of 48 degrees which were not in the acceptable range of 36 to 46 degrees. On [DATE] at 1:02 PM, Surveyor observed the medication refrigerator in the medication storage room which contained PPD skin test vials, influenza vaccines, insulin, and contingency medications. Surveyor observed a temperature log on the front of the refrigerator for [DATE] which documented 6 out of 13 temperatures in excess of 46 degrees (48 degrees). Surveyor checked the medication refrigerator thermometer located inside the door which read 52 degrees. Following the observation, the thermometer was moved to the inside shelf. In addition, Surveyor noted the medication refrigerator temperature log contained only one temperature entry per day. Licensed Practical Nurse (LPN)-G (who was present during the observation) confirmed the temperature log should be filled out twice daily (day and night). On [DATE] at 1:12 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B was not sure of the temperature range requirements for the medication refrigerator and stated the temperature should be checked once daily. On [DATE] at 2:44 PM, Surveyor rechecked the medication refrigerator thermometer which read 54 degrees. 2. On [DATE] at 10:37 AM, Surveyor observed 3 medication carts and noted 12 of 49 residents' medications were improperly labeled or expired. Medication Tech (MT)-F confirmed the items below were improperly labeled, not dated, or expired: ~ An open and undated Humalog KwikPen for R23 ~ An open and undated bottle of prednisolone one AC eye drops for R41 ~ An open bottle of Artificial Tears for R11 (dated [DATE]) ~ Open and undated albuterol inhalers for R9, R11, R12, R13, and R32 ~ An open bottle of Artificial Tears for R39 (dated [DATE]) ~ An open and undated Spiriva Respimat inhaler for R7 ~ An open and undated albuterol inhaler for R7 ~ An open and undated Breo Ellipta inhaler for R12 ~ An open albuterol inhaler for R35 (dated ,d+[DATE]) ~ Open and undated fluticasone salmeterol inhalers for R35 and R13 ~ An open and undated fluticasone salmeterol inhaler without a name (for R30) On [DATE] at 2:40 PM, Surveyor interviewed DON-B who confirmed the above medications should contain open/expiration dates and resident names and should be disposed of when beyond the open date timeframe guidelines. On [DATE] at 9:37 AM, Surveyor interviewed Pharmacist (PH)-I who indicated eye drops are considered expired 30 days after opening. PH-I indicated the facility should document their expectations for eye drop expiration in their policy. A policy regarding storage and labeling for eye drops was not provided upon Surveyor's request.

Based on staff interview and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect multiple residents residing in the facility. Food cooling logs indicated food was cooled incorrectly on 6 occasions from December 2023 to April 2024. Findings include: On 5/13/24, Surveyor conducted an initial tour of the kitchen. Dietary Manager (DM)-J indicated the facility follows the Wisconsin Food Code. The Wisconsin Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 degrees Fahrenheit (F) to 70 degrees F; and (2) Within a total of 6 hours from 135 degrees F to 41 degrees F or less. A facility-provided [NAME] Cooling Food document contained the following directions: Cool food from 135 degrees to 70 degrees F in 2 hours or less. Corrective Action: If the food is more than 70 degrees F at 2 hours, reheat to 165 degrees F and start over or discard. Reheating can only be done one time. If it has been more than 2 hours, the food must be discarded. If 70 degrees F or less in 2 hours, continue to cool to 41 degrees F in a total of 6 hours. Corrective Action: If total cooling time exceeds 6 hours the food must be discarded. The document contained date, food, start time, start temp, 2 hours (less than 70), 4 hours, 8 hours (less than 41), corrective action and initial columns. The document did not contain a column for 6 hours. On 5/13/24, Surveyor reviewed the facility's food cooling logs which contained the following information: ~ 12/24/23 - An entry for roast contained a start time of 12:00 PM with a start temperature of 191 degrees F. The 2 hour cooling temperature was 201 degrees. The 4 hour cooling temperature was 78 degrees. The 8 hour cooling temperature was 38 degrees. The corrective action column contained the word No. ~ 1/4/24 - An entry for meat sauce contained a start time of 7:50 AM with a start temperature of 191 degrees. The 2 hour cooling temperature was 71 degrees. The corrective action column contained the word No. ~ 2/7/24 - An entry for lasagna contained a start time of 10:00 AM with a start temperature of 199 degrees. The 2 hour cooling temperature was 78 degrees. The corrective action column contained the word No. ~ 2/13/24 - An entry for chicken noodle contained a start time of 6:45 AM with a start temperature of 181 degrees. The 2 hour cooling temperature was 79 degrees. The corrective action column contained the word No. ~ 2/22/24 - An entry for lasagna contained a start time of 12:20 PM with a start temperature of 150 degrees. No further entries were completed. ~ 4/4/24 - An entry for [NAME] contained a start time of 10:00 AM with a start temperature of 201 degrees. The two hour cooling temperature was 71 degrees. No corrective action was documented. On 5/14/24 at 9:45 AM, Surveyor interviewed DM-J who confirmed cooked food should be cooled to a temperature of 70 degrees within 2 hours and cooled to 41 degrees over a period of 6 hours. Surveyor reviewed the above cooling log entries with DM-J who indicated kitchen staff should be re-educated on the food cooling process. On 5/14/24 at 12:33 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility uses the [NAME] Cooling Food document as their policy/procedure for cooling food and follows the Wisconsin Food Code. Surveyor reviewed the above food cooling entries with NHA-A who indicated education was initiated for kitchen staff on proper cooling methods.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 resident (R) (R16) of 1 resident during the provision of wound care. R16 was on Enhanced Barrier Precautions (EBP). During an observation of wound care on 5/13/24, Licensed Practical Nurse (LPN)-C did not don the appropriate personal protective equipment (PPE) and did not perform appropriate hand hygiene. Findings include: The facility's IPCP (Infection Prevention Control Program) Standards and Transmission-Based Precautions policy, last revised 3/2024, indicates: Transmission-based precautions are the second tier of basic infection control and used in addition to standard precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission .1. Standard precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard precautions include: .b. Hand hygiene .3. EBP are used in conjunction with standard precautions and expand the use of PPE to gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of multi-drug resistant organisms (MDROs) to staffs' hands and clothing which can then be transferred to residents or from resident-to-resident (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs) .PPE: The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with .I. Wounds and/or indwelling medical devices regardless of known MDRO infection or colonization. Wounds include but are not limited to: chronic wounds, pressure injuries, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers .C. Examples of high-contact resident care activities requiring gown and glove use for EBP include .wound care: any skin opening requiring a dressing. On 5/13/24, Surveyor reviewed R16's medical record. R16 had diagnoses including methicillin susceptible Staphylococcus aureus (MSSA) infection as the cause of diseases classified elsewhere, non-pressure chronic ulcer of left calf with fat layer exposed, local infection of the skin and subcutaneous tissue, and seborrheic dermatitis. R16's Minimum Data Set (MDS) assessment, dated 3/19/24, stated R16 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R16 had intact cognition. R16's medical record contained the following: ~EBP: MDRO: MSSA/Pseudomonas/Aeruginosa/Chronic Wound ~Wound care to bilateral lower extremities: Cover superficial open area to back of left lower extremity with ABD pad (a highly absorbent dressing that provides padding and protection for large wounds) and wrap with Kerlix (woven gauze) until healed. ~Cleanse bilateral lower extremities with mild soap and water daily. ~Apply ammonium lactate to dry areas of legs. ~Apply ABD pads to weeping areas and secure with Kerlix. On 5/13/24 at 9:11 AM, Surveyor interviewed R16 in R16's room. A sign next to R16's door indicated R16 was on EBP. R16 stated R16 had eczema and open areas on R16's bilateral lower extremities. R16 stated nursing staff provide daily wound care for R16's bilateral lower extremities. During the interview, LPN-C entered the room to perform wound care and placed a barrier and supplies on R16's bedside table. LPN-C filled a bucket with warm water and soap, cleansed hands, and donned 2 sets of gloves. LPN-C did not don a gown or any other PPE. LPN-C removed Kerlix from R16's right leg and washed the leg. LPN-C stated R16's right heel had an open area that wept and placed cream on the area. With the same gloved hands, LPN-C applied ammonium lactate on R16's right leg. LPN-C then removed the first set of gloves, placed an ABD pad on R16's right heel, and rolled R16's right leg in Kerlix. LPN-C then removed the second set gloves and dated/initialed a piece of tape to secure the Kerlix. LPN-C removed another roll of Kerlix from a drawer and put the Kerlix on R16's bedside table. LPN-C then cleansed hands and again donned two sets of gloves. LPN-C filled a bucket with warm water and soap, removed Kerlix from R16's left leg, and washed the leg. With the same gloved hands, LPN-C applied ammonium lactate to R16's left leg. LPN-C removed the first set of gloves and wrapped R16's left leg with Kerlix. LPN-C then removed the second set of gloves and exited R16's room to get more Kerlix. Without performing hand hygiene or donning gloves and a gown, LPN-C re-entered R16's room, donned gloves, and continued to wrap R16's left leg. LPN-C then removed gloves and dated/initialed a piece of tape to secure the Kerlix. On 5/13/24 at 9:49 AM, Surveyor interviewed LPN-C who verified R16 was on EBP and verified LPN-C should have worn a gown during wound care. LPN-C indicated LPN-C prefers to wear two sets of gloves during wound care so LPN-C can remove bandages and clean wounds, remove the first set of gloves, and then apply creams and not have to perform hand hygiene. LPN-C confirmed when LPN-C left R16's room to get more Kerlix, LPN-C did not perform hand hygiene before donning gloves and resuming wound care. On 5/14/24 at 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed LPN-C spoke with DON-B regarding wound care and was educated that donning two sets of gloves during wound care is not in accordance with the facility's infection control policy and procedure. DON-B indicated staff are expected to wear the appropriate PPE during high-contact cares for residents who are on EBP.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R49) of 1 resident observed during catheter care received appropriate care and services to prevent urinary tract infections (UTIs). Staff did not ensure R49 received catheter care in a manner that decreased the risk for infection. Findings include: The facility's Catheter Care, Foley policy, last revised 3/2016, indicates: Purpose: To promote hygiene, comfort and decrease risk of infection for catheterized residents Procedure: .9. Using soap and water on a washcloth, clean the catheter insertion site in a downward motion (front to back). Clean the length of the Foley catheter (from resident toward bag). Changing sides of washcloth with each swipe. On 5/14/24, Surveyor reviewed R49's medical record. R49 had an activated healthcare decision maker and admission diagnoses of sepsis due to urinary tract infection and benign prostatic hyperplasia with lower urinary tract symptoms of retention of urine and indwelling catheter. R49's Minimum Data Set (MDS) assessment, dated 4/25/24, stated R49 had a Brief Interview for Mental Status (BIMS) score of 9 out 15 which indicated R49 had moderately impaired cognition. R49 was recently prescribed cefdinir (an antibiotic medication) 300 mg (milligrams) twice daily for 6 days for sepsis due to UTI with an end date of 4/24/24. On 5/14/24 at 10:15 AM, Surveyor observed Certified Nursing Assistant (CNA)-D perform catheter care for R49. Surveyor observed CNA-D use a washcloth to clean the length of the Foley catheter tubing starting at the drainage bag and going toward R49. When Surveyor stopped CNA-D from improperly cleaning R49's Foley catheter in a method that could prevent the spread of infection, CNA-D indicated CNA-D did not know the proper procedure to prevent the spread of infection was to clean the length of the Foley catheter from R49 toward the drainage bag. On 5/14/24 at 2:15 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should start at the resident and clean in a downward motion toward the catheter drainage bag during catheter care. DON-B indicated nursing staff recently completed skills training and assessments for catheter care.

Based on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 2 residents (R) (R35 and R12) of 5 residents observed during medication pass. On 5/14/24 at 8:45 AM, Surveyor observed Licensed Practical Nurse (LPN)-H administer an Advair Diskus inhaler (corticosteroid inhaler used for emphysema) to R35. An order for the inhaler indicated R35 should rinse R35's mouth with water and spit the water in a cup. LPN-H did not offer R35 water after administration of the inhaler or encourage R35 to rinse and spit. In addition, LPN-H crushed R35's enteric-coated ferrous (iron) sulfate tablet. On 5/14/24 at 8:55 AM, Surveyor observed LPN-H administer a Breo Ellipta (a corticosteroid inhaler used for asthma) inhaler to R12. An order for the inhaler indicated R12 should rinse and spit after use. LPN-H did not offer R12 water after administration of the inhaler or encourage R12 to rinse and spit. In addition, LPN-H provided R12 with 120 cc (cubic centimeters) of Med Pass 2.0 (a supplement to help promote weight gain). R12 did not have an order for Med Pass 2.0. Findings include: Patient information for Advair Diskus indicates: .Rinse your mouth with water after breathing the medication. Spit out the water. Do not swallow it. Ferrous sulfate (Feosol, Feratab) Copyright (C)2011-2024 GoodRx, Inc. states via its website: An enteric coating is a specific coating that not only protects the stomach but prevents medications from dissolving too early. This ensures they reach the small intestine for better absorption. Crushing, splitting, or chewing enteric-coated pills could result in irritation or a less effective treatment. Patient information for Breo Ellipta indicates: .Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water. 1. On 5/14/24, Surveyor reviewed R35's medical record. R35 was admitted to the facility on [DATE] with diagnoses including stroke, anemia, dementia, aphasia, and asthma. R35's Minimum Data Set (MDS) assessment, dated 4/23/24, stated R35 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R35 had severely impaired cognition. R35's medical record contained the following orders: ~ Advair Diskus Aerosol powder breath activated 250-50 mcg (micrograms)/dose 1 inhalation orally every 12 hours for mild persistent asthma, rinse mouth with water and spit back into cup after administration ~ Ferrous sulfate 325 (65 FE) mg give 1 tab by mouth once daily for supplement On 5/14/24 at 8:55 AM, Surveyor observed LPN-H administer an Advair Diskus inhaler to R35. LPN-H did not offer R35 water to rinse R35's mouth as ordered. LPN-H also administered a crushed (per R35's request) enteric-coated ferrous sulfate tablet. On 5/15/24 at 10:03 AM, Surveyor interviewed LPN-H who verified the facility's stock supply of ferrous sulfate is enteric-coated. LPN-H also verified the medication should not be crushed. On 5/15/24 at 10:13 AM, Surveyor interviewed Assisted Director of Nursing (ADON)-E who confirmed enteric-coated ferrous sulfate should not be crushed and stated the facility will get a different form of the medication (liquid or chewable) if R35 cannot swallow the medication. 2. On 5/14/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction, dementia, and asthma. R12's MDS assessment, dated 3/19/24, stated R12 had a BIMS score of 4 out of 15 which indicated R12 had severely impaired cognition. R12's medical record contained the following orders: ~ Breo Ellipta powder breath activated 100-25 mcg/dose 1 puff inhale orally once daily for emphysema. Rinse mouth with water and spit back into cup after use ~ House Supplement two times daily for a history of weight loss and low body mass index (BMI) (The order did not contain a dose or amount) On 5/14/24 at 8:45 AM, Surveyor observed LPN-H administer 120 cc of Med Pass 2.0 to R12. On 5/14/24 at 8:48 AM, Surveyor observed LPN-H administer R12's Breo Ellipta inhaler. LPN-H did not offer R12 water to rinse R12's mouth as ordered. On 5/15/24 at 11:03 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the House Supplement is made by dietary services and should be served between meals. DON-B verified Med Pass 2.0 is not the House Supplement.

Based on staff interview and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 2 Residents (R) (R22 and R39) of 2 sampled residents. Staff witnessed R22 grab R39's breast. The facility did not complete a thorough investigation for the allegation of sexual abuse. Findings include: The facility's Abuse Prevention Policy and Procedure contained the following information: The investigation shall consist of: interviews with any witnesses to the incident and .an interview with staff members (on all shifts) having contact with the resident(s) during the period of the alleged incident. Surveyor reviewed a facility-reported incident (FRI) that involved an allegation of abuse involving R22 and R39. The FRI indicated on 4/21/23, R22 grabbed R39's breast. Licensed Practical Nurse (LPN)-G was the only witness. R22 and R39 were immediately separated. R39 was assessed and had no injury. R22 and R39 were interviewed by Director of Nursing (DON)-B as indicated in nursing documentation. At the time of investigation, both R22 and R39 did not recall the incident. Surveyor reviewed R22's medical record. R22 had diagnoses to include paranoid schizophrenia and moderate intellectual disabilities. R22's most recent Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R22 had moderate cognitive impairment. R22 had an activated Power of Attorney for Healthcare (POAHC) who was responsible for R22's health care decisions. R22's medical record indicated R22 had escalating inappropriate behaviors which were monitored. R22's care plan was revised and contained interventions to protect other residents and R22's medications were adjusted. Surveyor reviewed R39's medical record. R39 had diagnoses to include dementia and depression. R39's most recent MDS assessment contained a BIMS score of 5 out of 15 which indicated R39 had severe cognitive impairment. R39 was on Hospice and had a Guardian who was responsible for R39's health care decisions. On 5/10/23 at 9:48 AM, Surveyor interviewed Social Worker (SW)-H who stated Nursing Home Administrator (NHA)-A and DON-B interviewed R22 and R39 after the incident. On 5/10/23 at 10:51 AM, Surveyor interviewed NHA-A who stated there was no need to interview LPN-G following the incident because LPN-G was the only witness and what LPN-G witnessed was written in the progress note. NHA-A stated interviews with other staff were not completed, including interviews regarding R22's recent behaviors and other incidents that may have occurred. Surveyor reviewed the investigatory process with NHA-A who verified a thorough investigation was not completed in accordance with the the facility's Abuse Prevention Policy and Procedure.

Based on observation, staff interview, and record review, the facility did not ensure supervision in accordance with the resident's plan of care was provided for 1 Resident (R) (R22) of 15 residents reviewed. R22's plan of care contained an intervention for a motion detector on R22's door to alert staff when R22 exited the room. R22's plan of care also contained an intervention for R22 to be within eye sight while out of R22's room. The interventions were not consistently implemented. Findings include: 1. R22 was admitted to the facility on [DATE] with diagnoses that included intellectual disabilities, paranoid schizophrenia, and cognitive communication deficit. R22's Minimum Data Set (MDS) assessment, dated 3/15/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R22 had mild cognitive impairment. During the survey, R22 was observed self-propelling a wheelchair with R22's feet. On 4/21/23, a care plan was initiated for R22 related to the potential to demonstrate physical behaviors (sexual) due to poor impulse control and verbal behaviors (sexual). The care plan was initiated following an incident when R22 grabbed R39's breast. The allegation of abuse was reported to the State Agency. The care plan included the following approaches, dated 4/21/23: ~Motion detector on my door to alert when I leave my room ~Staff to have me within eye sight while out of room. On 5/9/23 at 9:54 AM, Surveyor observed R22 in R22's room. Surveyor observed a white box attached to the door frame at approximately waist level. On 5/9/23 at 10:15 AM, Surveyor noted R22's call light was activated. Surveyor observed Certified Nursing Assistant (CNA)-C enter and exit R22's room. Surveyor did not hear the motion alarm sound. On 5/9/23 at 10:18 AM, Surveyor noted R22's call light was activated. At 10:23 AM, Surveyor observed CNA-C enter and exit R22's room. Surveyor did not hear the motion alarm sound. On 5/9/23 at 10:25 AM, Surveyor noted R22's call light was activated. At 10:27 AM, Surveyor observed Nursing Home Administrator (NHA)-A enter R22's room. At 10:29 AM, Surveyor observed NHA-A exit R22's room. Surveyor did not hear the motion alarm sound. On 5/9/23 at 10:31 AM, Surveyor noted R22's call light was activated. At 10:34 AM, Surveyor observed CNA-C enter and exit R22's room. Surveyor did not hear the motion alarm sound. On 5/9/23 at 10:43 AM, Surveyor interviewed CNA-C who stated CNA-C was a contracted staff and worked at the facility for approximately one month. When asked about an alarm on R22's door, CNA-C stated CNA-C thought the alarm should be activated around meal times. Surveyor asked CNA-C how the alarm worked. CNA-C stated the alarm was a motion alarm and should sound when passed by. CNA-C stated sometimes if staff walk quickly through the plane of the alarm, the alarm doesn't sound. CNA-C stated R22 is slower and the alarm would definitely go off if R22 entered or exited the room. CNA-C confirmed the alarm was not activated. CNA-C activated the alarm, waved a hand in front of the alarm multiple times and noted the alarm sounded. Surveyor showed CNA-C R22's care plan which indicated the alarm should be activated when R22 is in R22's room due to an incident that occurred with another resident. When asked how CNA-C receives care plan updates and is made aware of residents' care plan interventions, CNA-C stated CNA-C looks in the computer for changes since the last time CNA-C worked. CNA-C also stated R22 displayed a lot of sexual behaviors toward staff lately. On 5/9/23 at 1:39 PM, Surveyor observed R22 sitting in the hallway. Surveyor noted there were no staff within eye-sight of R22. Surveyor then observed R22 self-propel R22's wheelchair up the hallway toward the main corridor. Surveyor also observed R20 sitting in a wheelchair in the hallway. Surveyor observed R22 self-propel past R20. Surveyor walked to R22's room and noted R22's motion alarm was turned off. At 1:46 PM, Surveyor observed staff exit a resident's room and ask R22 where R22 was going. Surveyor noted R22 was not within eyesight for 7 minutes while out of R22's room. On 5/10/23 at 8:56 AM, Surveyor observed R22 sitting in R22's doorway directly in line of the door alarm. Surveyor noted the motion alarm did not sound. Surveyor also noted the alarm was turned off. On 5/10/23 at 9:08 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who confirmed R22 had an alarm and stated the alarm worked sporadically. Surveyor noted R22 was still sitting in the doorway at that time. LPN-D stated R22 may have turned the alarm off. LPN-D flipped the switch to the on position; however, the alarm did not sound. R22 said to LPN-D, I want to punch you. LPN-D took the alarm off the bracket, adjusted the alarm and noted the alarm then sounded. LPN-D took the alarm off the door and stated LPN-D would try to find different batteries. On 5/10/23 at 10:02 AM, Surveyor interviewed Director of Nursing (DON)-B who stated LPN-D brought the alarm to DON-B and thought the batteries needed to be replaced. DON-B stated staff were monitoring R22 on a 1:1 basis until staff figured out if they could continue to use the alarm or needed to implement another intervention. DON-B verified the alarm should have been turned on and in working order when R22 was in R22's room.

Based on observation, staff interview, and record review, the facility did not ensure pureed food in accordance with a diet trial was provided for 1 Resident (R22) of 15 residents reviewed. R22 did not receive a pureed diet as indicated for the lunch meal on 5/8/23. Findings include: R22 was admitted to the facility on [DATE] with diagnoses that included intellectual disabilities, paranoid schizophrenia, cognitive communication deficit, and dysphagia (difficulty swallowing). R22's Minimum Data Set (MDS) assessment, dated 3/15/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R22 had mild cognitive impairment. On 5/8/23, Surveyor noted R22 had a physician's order for a NCS (No Concentrated Sweets) diet, mechanical soft texture, honey-thick consistency. R22 was to be supervised in the dining area while eating. On 5/8/23, Surveyor noted the following progress notes in R22's medical record: ~A progress note, dated 5/5/23 at 2:11 PM, stated R22 was observed choking while eating baked fish and fried rice with beans and salsa during the lunch meal. The note stated the Heimlich maneuver was performed and R22 started coughing up rice and beans. After the incident, Speech Therapy entered the dining room and was updated. Speech Therapy wrote a trial for pureed food and honey-thickened liquids. R22's Power of Attorney (POA), Director of Nursing (DON)-B, and R22's physician were updated. ~A progress note, dated 5/6/23 at 2:56 PM, stated R22 refused breakfast and was eating fast during lunch. Staff reminded R22 to slow down; however, R22 did not slow down. R22 was coughing and choking despite the fact R22's food was pureed and drink was honey-thickened liquid. After staff talked to R22 about the importance of eating slowly, R22 got upset and refused to continue eating. R22 was offered a snack later, but refused. ~A progress note, dated 5/7/23 at 1:40 PM, stated R22 asked for cheese and berries that R22's family brought the day before. Staff explained R22 couldn't eat cheese or berries due to the choking risk. R22 was upset and continued to eat fast and cough at times while eating pureed food. ~A progress note, dated 5/7/23 at 5:59 PM, stated R22's POA visited and brought cheese cubes and fresh berries. Staff reminded R22's POA about R22's diet trial of pureed food and honey-thickened liquids. The note stated all staff were aware of R22's diet. On 5/8/23 at 11:50 AM, Surveyor entered the dining area on R22's wing. Surveyor observed R22 eating lunch while sitting at a table facing the window. Surveyor noted R22 had mechanical soft broccoli, mechanical soft meat, and buttered noodles. R22 was eating independently and coughing. NHA-A, who was assisting another resident at a nearby table, reminded R22 to eat slowly. Surveyor left R22's table to reference R22's diet. Surveyor observed Speech Therapist (ST)-E enter the room and ask NHA-A how R22 was doing. ST-E looked at R22's plate and said R22 was supposed to have a pureed diet. NHA-A took R22's plate and staff went to the kitchen to retrieve a plate with pureed food. On 5/8/23 at 12:00 PM, Surveyor interviewed ST-E who stated ST-E was contacted last Friday (5/5/23) after R22's choking incident and downgraded R22's diet to a pureed trial. ST-E stated ST-E wrote a slip and gave the slip to Dietary Manager (DM)-F and the nurse manager. On 5/8/23 at 12:09 PM, Surveyor interviewed DM-F who confirmed ST-E notified DM-F of R22's downgraded diet on 5/5/23. Surveyor reviewed R22's meal ticket for the 5/8/23 lunch meal which indicated a mechanical soft diet. DM-F stated DM-F did not change R22's diet in the meal ticket system. DM-F stated DM-F thought R22 received the pureed diet over the weekend because DM-F put a note in the kitchen. On 5/10/23 at 10:02 AM, Surveyor interviewed DON-B who confirmed R22 was on a pureed trial diet through 5/10/23. DON-B verified R22 should have received a pureed diet on 5/8/23.

Based on observations and interview, the facility did not ensure two Residents (R1) of three Residents reviewed for activities of daily living received necessary services to maintain cleanliness and services to assist with vision and hearing deficits. R1 was observed to have food crumbs and stains on R1's clothing and food crumbs and debris in R1's wheelchair. R1 was observed to be without R1's hearing aides and glasses. Staff interviews indicated staff inconsistencies with knowledge of these devices for R1. Findings: R1 was admitted to the facility on [DATE]. R1's diagnoses included dementia with psychosis (a mental condition in which thought and emotions are lost with external reality), insomnia and low back pain. R1's care plan indicated: Encourage to participate to the fullest extent possible with each interaction. Wears eyeglasses - ensure that they are accessible to (R1) and assist with cleaning as needed. The care plan did not note hearing aides. On 12/6/22 at 1:15 PM, Surveyor observed R1 seated in a Broda chair (a type of wheelchair). Surveyor observed R1 to have food crumbs on R1's lap. R1's clothing was noted to have food stains on which appeared to be from that day as they were not yet set-in. R1's Broda chair had food crumbs and debris in the crevices and on the seat. The arm rests of R1's Broda chair had food debris and/or stains as well as a sticky material noted on them. R1 was noted to not have R1's glasses on nor hearing aides in. On 12/6/22 at 1:33 PM, Surveyor interviewed day shift Certified Nursing Assistant (CNA)-E who indicated not being aware R1 had glasses or hearing aides. CNA-E confirmed the unit in which R1 resides is the unit CNA-E is regularly assigned to. With regards to R1's Broda chair, CNA-E indicated that R1's spouse (Power of Attorney for Health Care (POAHC-C)) has complained more than once of R1's wheelchair being dirty. With regards to crumbs on resident's lap and clothing, CNA-E indicated with only one CNA on the unit, it can be hard to get to wiping up residents after meals. On 12/6/22 at 2:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A indicated R1 did have glasses but NHA-A was not aware of hearing aides. On 12/6/22 at 2:10 PM, Surveyor interviewed Hospice Registered Nurse (RN)-F. RN-F indicated that R1 does need glasses. RN-F indicated R1 did have glasses on yesterday when seen by RN-F. RN-F indicated R1 did not have hearing aides, indicating that R1 may not leave hearing aides in. On 12/6/22 at 3:28 PM, Surveyor interviewed evening shift CNA-G. CNA-G indicated R1 had not worn hearing aides since admission, due to R1 throwing them out when left in ears. CNA-G indicated R1 had glasses and wore them almost every day, they were located in R1's top drawer in R1's room. CNA-G indicated R1 would typically allow glasses to stay on. CNA-G indicated that resident wheelchairs were cleaned once a week on the resident's shower/bath day; CNAs bring the wheelchair to the shower room for cleaning and a nurse watched the unit during that time. CNA-G indicated if there were too many active residents on the unit, the wheelchairs may not get done (cleaned). On 12/6/22 at 3:45 PM, Surveyor interviewed Social Worker (SW)-D who indicated that during a care conference in mid-November, R1's Power of Attorney for Healthcare (POAHC)-C complained of R1's wheelchair being dirty. SW-D stated, and it (wheelchair) was (dirty). SW-D indicating having the wheelchair cleaned and that SW-D notified Director of Nursing (DON)-B and the unit nurse of this (dirty wheelchair concern) right away. On 12/6/22 at 5:30 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-K who indicated never seeing R1 with glasses on or hearing aides in. LPN-K indicated, R1 probably would not leave them on/in as R1 doesn't always leave R1's socks on. On 11/7/22 at 7:45 AM, Surveyor interviewed Hospice CNA-L who indicated R1 has hearing aides and glasses. CNA-L indicated when CNA-L is the one getting R1 ready in the morning, CNA-L will put R's glasses on and R1 allows them to stay on. CNA-L said R1's hearing aides are kept in the nurse's cart and that the nurse puts R1's hearing aides in. On 11/7/22 at 8:25 AM, Surveyor interviewed day shift CNA-N who indicated having heard R1 has a hearing aide, but CNA-N has never seen one. CNA-N confirmed R1 has glasses and the CNA-N puts them on the days CNA-N works and R1 keeps them on. Regarding wheelchair, CNA-N confirmed R1's wheelchair has been dirty. CNA-N indicated the wheelchair is to be cleaned on R1's shower day. On 11/7/22 at 8:36 AM, Surveyor interviewed LPN-J regarding R1's hearing aids. LPN-J looked in the nurse's medication cart which LPN-J was utilizing on R1's unit for R1's hearing aids and then indicated, they (hearing aids) are not in here (the cart). On 11/7/22 at 8:57 AM, Surveyor interviewed Regional Nurse Manager (RN)-O who indicated RN-O thought R1's hearing aids were once housed in the nurse station desk because R1 did not use them. Surveyor requested an admission inventory for R1, RN-O reviewed the inventory for R1 and indicated R1's hearing aids were not noted on the admission inventory. RN-O indicated that LPN-J had now contacted R1's POAHC-C to see if POAHC took them home and POAHC-C confirmed they had not taken hearing aids home. On 11/7/22 at 9:08 AM, Surveyor interviewed LPN-M. LPN-M indicating not being aware R1 had hearing aides. LPN-M confirmed R1 wore glasses. On 11/7/22 at 10:01 AM, Surveyor interviewed NHA-A who indicated having worked night shift the previous evening and NHA-A washed R1's wheelchair. NHA-A informed Surveyor, the facility had now located R1's hearing aids in the nurse station. On 10/7/22 at 10:56 AM, Surveyor interviewed POAHC-C who indicated upon admission, POAHC-C was assured that R1's hearing aid would be put in every day. POAHC-C indicated that when visiting, R1 did not consistently have glasses on and never had hearing aides in. POAHC-C further indicated that R1 was not kept clean, noting that food has been seen on R1's face on visits and that R1's wheelchair was observed to be dirty during family visits.

Based on observation, record review, resident and staff interviews, the facility did not ensure pressure injury (PI) prevention and treatment was provided according to standards of practice for 1 (R (Resident) 4) of 5 sampled residents reviewed for PI risk. R4 developed a PI to the heel on 3/14/18 that was still present at the time of survey. The facility failed to adequately assess R4 for PI risk and modify the resident's plan of care to prevent development of the stage 3 PI to R4's left heel. In addition, the facility chose to hold the collagen treatment for [REDACTED]. Findings include: On 5/17/18 at 1:21 PM, during an interview with the Surveyor, Director of Nursing (DON)-A indicated the facility utilized the National Pressure Ulcer Advisory Panel (NPUAP) guidelines as the facility's standard of practice for PI (older terminology = pressure ulcer or bed sore) prevention and treatment. The updated staging system includes the following definition: ~ Stage 3 PI: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable PI. ~ Risk factors include: chair-bound, decreased mental status, exposure to moisture, incontinence, immobility, inactivity. Note: Identify all individual risk factors to guide specific preventive treatments and modify care according to the individual factors. ~ PI treatment: NPUAP 2014 Quick Reference Guide documents Consider using collagen matrix dressings for non-healing Category/Stage 3 and 4 pressure ulcers. Strength of Evidence = supported by indirect evidence and/or expert opinion; Strength of Recommendation = no specific recommendation Example: On 5/15/18, the Surveyor noted the facility identified R4 as having a facility acquired PI. On 5/16/18 at 9:11 AM, the Surveyor observed R4 wearing a shoe on the right foot and a blue boot on the left foot while seated in a wheelchair. At 9:26 AM, R4 told the Surveyor, I injured my foot. R4 could not recall the cause of the foot injury or how long it had been injured. On 5/16/18 at 1:59 PM, the Surveyor interviewed DON-A regarding R4's PI. DON-A indicated one day a blister was found, the treatment was started the same day the PI was discovered and the blister blew a couple days later. On 5/16/18, the Surveyor began reviewing R4's medical record, which included documentation that the resident's [DIAGNOSES REDACTED]. R4's medical record included the following documentation: ~ Activated Power of Attorney for Health Care dated 5/6/15 ~ Hospital discharge summary dated 3/2/18, indicated discharge [DIAGNOSES REDACTED]. ~ Minimum Data Set assessment dated [DATE] included BIMS (brief interview mental status) score of 14, indicating alert and oriented; bed mobility indicated required extensive assist of one; frequently incontinent of urine and always incontinent of bowel and the resident was at risk for the developing pressure injuries. ~ At risk for skin impairment r/t (related to) impaired mobility care plan included the following interventions: 3/3/18- keep skin clean and dry. Use lotion on dry skin. Pressure reducing cushion to wheelchair. Pressure reducing mattress. Weekly skin assessment by licensed nurse. 3/9/18- assess resident skin with each ADL (activity of daily living), toileting and reposition encounter and report to nurse with findings. Note: R4's hospital discharge informed staff the resident experienced [MEDICAL CONDITION] and foot drop. Despite R4's [DIAGNOSES REDACTED]. ~ Braden Scale (for predicting PI risk) score of 17 (low risk) dated 3/9/18 ~ weekly skin evaluation dated 3/12/18, no open areas ~ progress note dated 3/14/18, Note Text: Called to resident room by aid this am. Resident has a fluid filled blister to left heel with a black colored circle in center. Resident stated I told aid that my heel hurt this am. Writer measured wound, cleaned area gently, applied skin prep and then applied a [MEDICATION NAME] island dressing to area for protection. Wound measures 5.0 cm (centimeters) (1.97 inches) for fluid filled area and 1.0 cm (0.39 inches) for black area. Resident then had a gripper sock applied to left foot, no shoe at this time. Heel boot on when up in chair and heels up when in bed. The physician was notified and responded. ~ Braden Scale dated 3/16/18, score of 17 ~ 3/18/18, Blister opened and drained clear fluid, with measurement: 4.5 x (by) 7 x 0.2 cm (1.77 x 2.76 x 0.07 inches). ~ 3/19/18, physician's verbal order: cleanse daily, apply triple antibiotic ointment and adhesive dressing. ~ 3/18/18, physician's faxed order: Juven supplement BID (twice a day), multivitamin with minerals daily. Dressing treatment: cleanse area, hydrogel to wound bed, cover with non-adherent and wrap with kerlix daily. ~ 3/18/18- Care plan updated to include Heel booty on left foot when up in chair. Heelz up when in bed and in recliner. ~ 3/25/18, physician's treatment order: Skin prep BID and Duoderm change every 3 days and as needed. ~ 3/26/18, measurements - 4.2 cm x 6.4 cm x 0.2 cm ~ 4/02/18, measurements - 4.1 cm x 6.2 cm x 0.2 cm ~ 4/04/18, Physician notified new eschar area: wound has 50% eschar area to middle of wound bed. wound measures 4.5 cm x 5.5 cm, small amount of serous drainage. Wound previously was healing nice and decreased in size, (R4) has heelz up in bed and blue bootie when up for Therapy/meals. Wound edges are attached (No) tunneling. Physician ordered debridement with Santyl BID ~ 4/06/18,- Braden Scale score 14 (moderate risk) ~ 4/11/18, measurements - 4.3 cm x 5.3 cm x 0.1 cm ~ 4/13/18, Braden Scale score 12 (high risk) ~ 4/18/18, measurements - 4.2 cm x 5.5 cm x 0.1 cm ~ 4/25/18, measurements - 4.3 cm x 5.0 cm x 0.0 cm ~ 4/26/18, Physician notified of Wound Care Certified (WCC) nurse recommendations to change treatment to clean left heel, apply Santyl to eschar area, cover with hydrogel dressing then from dressing, wrap with kerlix daily. Also recommending you could cross hatch eschar area. Physician responded with agreement to treatment change. ~ 5/02/18, measurements - 4.0 cm x 4.7 cm R4's Treatment Administration Record (TAR) dated 4/4/18 to 5/7/18 included documentation that the Santyl BID applications had been completed. ~ 5/07/18 - Physician's phone order for treatment change to clean wound apply collagen to wound bed, cover with Hydrogel dressing, then foam dressing wrap with kerlix daily ~ 5/09/18, measurements - 4.0 cm x 4.7 cm comments on weekly PI form documented current treatment: left heel cleanse with wound cleaner. Cover with 2x 2 hydrogel dressing, covered with 4x 4 foam dressing and wrap with Kerlix. Change daily and PRN (as needed). Eschar area is gone. ~ 5/07/18, new physician's phone order for Left heel wound care. Clean wound apply collagen to wound bed, cover with Hydrogel dressing, then foam dressing wrap with kerlix daily R4's TAR dated 5/8/18 to 5/13/18 included documentation that both Collagen and Santyl daily treatments had been completed. ~ 5/16/18, skin assessment - beefy red base with 50% slough; stage 3; 3.7 x 4 cm ~ 5/16/18, staff contacted the physician to inform and request Wound bed dry. Can we continue with hydrogel pad, foam cover, then wrap with kerlix. Can we DC (discontinue) collagen? The physician did not respond prior to the end of the survey on 5/17/18. On 5/17/18 at 9:52 AM, during an interview with the Surveyor, R4 indicated no one changed the dressing yet today and complained of the heel hurting. On 5/17/18 at 9:56 AM, Licensed Practical Nurse (LPN)-C informed the Surveyor that R4's dressing change had already taken place today. LPN-C indicated R4's mentation had declined during the duration of stay. R4 used to recognize people's faces and know names. On 5/17/18 at 10:44 AM, the Surveyor interviewed DON-A, who verified the facility did not have a Wound Care Certified (WCC) nurse on staff and an outside WCC nurse visited once per month. On 5/17/18 at 11:32 AM, R4 indicated the left heel (PI location) hurt and agreed to a dressing change so surveyors could observe the PI. R4 indicated the heel pain level was a 5 on a scale of 10. LPN-C began to remove the dressing, but stopped to apply additional liquid via a spray bottle because the hydrogel dressing was adhered to the area, commenting the hydrogel was drying onto the wound bed. LPN-C then proceeded to apply hydrogel foam dressing and wrapped with kerlix. LPN-C then applied a pressure reduction boot with heel cutout. At 11:47 AM, the Surveyor obtained R4's permission and checked the resident's foot position in the reduction boot and it was noted and LPN-C and DON-A verified, R4's heel was not placed in the free float cutout of the boot as intended for use. On 5/17/18 at 12:19 PM, the Surveyor interviewed DON-A regarding the Collagen not applied to R4's heel as ordered during the dressing change observation. DON-A responded the facility had requested the Collagen application to be discontinued. The facility did not provide the survey team with the physician's orders [REDACTED]. On 5/17/18 at 5:43 PM, the facility emailed the Surveyor a document signed by DON-A and Nursing Home Administrator (NHA)-B stating The root cause of injury is underdetermined(sic) as no outside causes of pressure occurred. The same email verified the Collagen treatment had been held during the Surveyor's observation of R4's treatment on 5/16/18, while the facility awaited the physician's response to discontinue the Collagen.

Based on observation, record review, staff and resident interviews, the facility did not provide adequate pain relief for 1 of 9 sampled residents (R3) reviewed for pain. R3 was readmitted to the facility with a hospital acquired stage 3 pressure injury. R3 did not have a pain management care plan in place. Surveyor observed R3 grimacing, and complaining of pain related to pressure injury during a transfer. Staff indicated R3 has been complaining of pain related to the pressure injury since return to facility on 3/16/17. R3's complaints of pain related to pressure injury were not reported to the nurse. Findings include: The facility policy titled: Pain Management dated 7/2015 states: Policy: If is the policy of this facility to provide an environment and program that assist each resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. Purpose: The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by ~ Screening to determine if the resident has been or is experiencing pain ~ Identifying circumstances when pain can be anticipated ~ Developing and implementing a plan, using pharmacological and/or non-pharmacological interventions to manage the pain an/or try to prevent the pain consistent with the resident's goal. Procedures: Assessments: 1. The resident will be assessed for pain. A. On admission with a pain-related diagnosis, or if pain is indicated through the Nursing Admission Evaluation. B. Upon development of new symptoms of acute of chronic pain that has not been previously assessed, and C. Quarterly as indicated. NOTE: Residents who are cognitively impaired may exhibit pain through new or changed behaviors 2. Complete the LN -Pain Evaluation (found in PCC) Management: 1. Document on the Care Plan any preventative or care interventions (pharmacological and non-pharmacological) for any resident admitted with pain. 2. Medication(s) received, refused and response to medication will be documented on the Medication Administration Record (MAR). Monitoring: 1. Monitor pain status and treatment effects every shift. 2. Consult physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. 3. Update care plan as needed. Example: R3 was readmitted to the facility on [DATE] following a hospital stay. R3's most recent quarterly MDS (Minimum Data Set) assessment dated [DATE] documented R3 to be dependent on staff for bed mobility, transfer, dressing, toileting, hygiene. R3's 1/9/17 BIMS (Brief Interview of Mental Status) documented a score of 9 out of 15, which indicates moderate cognitive impairment. R3 was readmitted to the facility with a Stage 3 Pressure injury to coccyx acquired at the hospital. Some facility documents indicated a stage 2 pressure injury, and after facility wound nurse assessed area, determined it was a stage 3 because adipose (body fat) tissue was exposed and not slough as previously charted. On 3/16/17 a Pain Risk Evaluation was completed for R3 which documented the following: 1. Level of Consciousness/Mental Status 3. Comatose, Depressed, Constant Wanderer - Disoriented x 3 2. Current Pain Problem 0. None 3. Indication of Pain Problem 0. None 4. Any Pain Medications Resident Receiving 0. None 5. Predisposing Diagnosis & Conditions Respond below based on the following conditions:Headache, Wound, Pressure ulcers, UTI/Infections, Debility, Post-surgical, amputation, Ortho/[MEDICAL CONDITION], Cancer, [MEDICAL CONDITION], Pancreatitis, and Other Terminal Conditions. 2. 1-2 Conditions present Predisposing diagnosis & Condition 0. No change in medication and/or terminal condition in the past 7 days 6. Associated symptoms contributing to Pain 0. None R3's medical record did not include a care plan in place related to pain management or a pressure injury care plan in place which would direct staff how to manage R3's pain related to the pressure injury. R3's physician orders [REDACTED]. R3's physician orders [REDACTED]. R3 received as needed [MEDICATION NAME] 650 mg on the following dates: ~ 3/17/17 at 0936 - given for pain in neck -stiffness ~ 3/29/17 at 125 - given for joint discomfort during therapy. ~ 3/30/17 at 0952 - was given for hip pain during morning cares. R3's OT (Occupational Therapy) notes documented: On 3/25/17 - Pain- General Was pain treated during this encounter = No (has Roho cushion c/o (complained of) pain in her bottom) R3's PT (Physical Therapy) noted documented: On 3/30/17 - Pain - General Was pain treated during this encounter = No (Pt c/o buttocks pain, repositioned pt (patient) in broda chair for relief. Readjusted Roho cushion in Broda chair for better fitting & comfort for pain relief. PTA (Physical Therapy Assistant)-K documented the note on 3/30/17. A 3/16/17 Skin Evaluation documented Residents coccyx has pressure wound . Area is tender to touch. New dressing applied. On 3/29/17 at 8:00 a.m., the Surveyor observed R3 sitting in a broda w/c (wheelchair) in the unit lobby waiting for the breakfast meal. R3 informed Surveyor I have bed sores, and that is why I like to lay down, so that it feels better. Can you see to it that I can lay down? Tell them I want to eat sooner so I can lay down sooner. On 3/29/17 at 8:10 a.m., Surveyor informed CNA (Certified Nursing Assistant)-E of R3's request. CNA-E stated, We are on our way down there right now. On 3/29/17 at 8:15 a.m., R3 was removed from the unit lobby and taken to the dining room for breakfast. On 3/29/17 at 9:15 a.m., R3 was taken to room. CNA-E and CNA-F were in R3's room and informed Surveyor they would be transferring R3 from w/c to bed. R3 complained of pain related to the bed sores to staff and stated, I have to lay down. CNA-F reassured R3 that they were going to lay R3 down and it would feel better after R3 was in bed. During the transfer, R3's facial expression was noted to be grimacing in pain. R3 loudly stated, It hurts! three times during transfer. On 3/29/17 at 1:35 p.m., Surveyor interviewed CNA-E who confirmed R3's pain at 9:15 a.m. and stated R3 has been complaining of pain related to sores on her butt since she came back from the hospital. CNA-E stated she thinks the nurse is aware of the pain. On 3/29/17 at 1:40 p.m., Surveyor interviewed CNA-F who confirmed R3's pain at 9:15 a.m. and stated R3 usually says my bottom hurts. Today was the worst R3 has been and I probably forgot to tell the nurse about it. On 3/30/17 at 11:00 a.m., CNA-I informed Surveyor that CNA-I works on the unit 2-3 times per week where R3 resides and stated R3 has complained about pain to her bottom related to pressure injury previously while working the unit. On 3/30/17 at 5:30 p.m., Surveyor interviewed CNA-J who indicated R3 has been complaining about pain related to pressure injury on her bottom since R3 returned from the hospital. On 3/29/17 at 1:30 p.m., Surveyor interviewed LPN (Licensed Practical Nurse)-D who was the nurse for R3. LPN-D was not aware of R3 having any pain related to current pressure injuries. LPN-D stated CNA-E and CNA-F did not inform LPN-D about R3's complaints of pain. On 3/30/17 at 1:55 p.m., Surveyor interviewed PTA-K who stated R3 was complaining about pain related to her pressure injury on her bottom, and this was the first day PTA-K recalls R3 complaining of pain to the area. PTA-K did not tell the nurse because R3 just had her bandage changed. On 3/31/17 at 8:30 a.m., DON (Director of Nursing)-B informed Surveyor that if a resident is complaining of pain CNA's should be reporting the pain to the nurse. DON-B also stated CNA's have an alert button in their electronic charting that could alert the nurse if a resident is having pain. On 3/31/17 at 11:10 a.m., DON-B confirmed to Surveyor that R3 did not have a care plan in place to notify staff how to manage R3's pain. DON-stated because R3 was a readmitted to facility from the hospital, R3's care plans that were previously in place just remained.

Based on staff interview and record review, the facility did not have procedures in place to assure that those residents who needed a pneumococcal vaccination were offered the opportunity in a timely manner. The facility did not have an effective program to identify who was eligible for a vaccination, did not offer the vaccine to residents who were known to be eligible and had not vaccinated any residents in-house. The facility did not implement its policies and procedures and current standards of practice identified by the ACIP (Advisory Committee on Immunization Practices). The facility did not identify residents who were not vaccinated for pneumonia and offer residents the opportunity to be vaccinated. The facility failed to offer or administer the pneumococcal vaccine to 24 of 50 residents residing in the facility who were eligible to receive the pneumococcal vaccine. The facility did not know the vaccination history of 12 additional residents and did not know if they should be offered and administered a pneumococcal vaccine. The facility did not re-offer the pneumococcal vaccine to 2 residents, who had previously refused the pneumococcal vaccine. The facility has not vaccinated anyone for pneumonia. The facility's practice has the potential to affect all current and future residents. Residents #8, #18, #22 and #34's medical records indicated the residents were previously vaccinated with [MEDICATION NAME] 23 (PPSV23). The facility did not offer or administer the Prevnar 13 (PCV13) as recommended. Residents #5, #40, #44, #4, #6, #33, #35, #27, #11, #32, #37, #25, #42, #38, #13, #39, #23, #31, #43, and #12 medical records indicated the residents received a pneumococcal vaccination prior to the introduction of Prevnar 13. (Presumably, these residents had received PPSV23.) Per standards of practice, thee residents were eligible to be immunized with Prevnar 13. The facility did not offer or administer these residents the PCV13 as recommended. Residents #41, #24, #17, #3, #28, #20, #29, and #36 were previously vaccinated for pneumonia. The facility did not know if these residents had received PPSV23 or PCV13 and did not know if they should be offered PCV13. Residents #10, #19, #21 and #30's medical records did not include documentation regarding their pneumococcal vaccination status. Consequently, the facility did not know if these residents should be offered and vaccinated with Prevnar 13. Residents #16 and #14's medical records indicated both residents refused the pneumococcal vaccination. The resident's medical records did not include documentation that the pneumococcal vaccine was re-offered, declined, or administered. The facility's failure to have a system that identified the pneumococcal vaccination history of each resident, that identified which residents were eligible for a pneumococcal vacine, and that educated and offered residents the pneumococcal vaccine per current standards of practice regarding identifying residents who were not vaccinated for pneumonia and offering residents and new admissions the opportunity to be vaccinated created a finding of immediate jeopardy that began on 1/13/16. The facility was notified of the immediate jeopardy on 2/25/16 and removed the jeopardy on 2/26/16. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as the facility continues to implement its removal plan. Findings include: According to the American Family Physician publication dated 10/15/04 entitled, Pneumonia in Older Residents of Long-Term Care Facilities, Residents in long-term care facilities have more functional disabilities and underlying medical illnesses and are at increased risk of acquiring infectious disease. Pneumonia is the leading cause of morbidity and mortality in this group. It is also the leading reason for transfer to acute-care facilities. Residents of long-term care facilities develop pneumonia approximately 10 times more frequently than older adults in the community. Their hospitalization rate is reported to be nearly 30 times higher. Prevention of pneumonia in long-term care facilities focuses on recognizing and modifying risk factors. These include the immunization rates. On 2/23/16 during the entrance conference with the facility, DON (Director of Nursing)-H verified to surveyor # that she was responsible for the facility's immunization and infection control program. On 2/24/16 at 4:30 p.m., surveyor # interviewed DON-H regarding the facility's procedure for determining the vaccination status of residents upon admission. DON-H indicated the admitting nurse assesses a resident's vaccination status through interviews with either the resident, family members, POAs, guardians, outside medical personnel and/or the WIR (Wisconsin Immunization Registry). DON-H stated, If a resident hasn't had a pneumococcal vaccine, we offer it, get an order and obtain consent. It (pneumococcal vaccination) is added to the resident's MAR (Medication Administration Record). Any nurse can give the vaccine. (LPN (Licensed Practical Nurse)-P) is in charge of the program. On 2/25/16 at 9:40 a.m., surveyor # interviewed LPN-P regarding the facility's immunization program. LPN-P indicated she was responsible for the influenza vaccinations and TB ([MEDICAL CONDITION]) screening. LPN-P indicated she is not responsible for the pneumococcal vaccination program. LPN-P indicated pneumococcal vaccinations are not done in the facility and stated, Everyone on the vaccination list who received a pneumococcal vaccine received it outside of the facility. LPN-P also indicated pneumococcal VIS (Vaccination Information Sheets) are not given to residents and stated, If someone doesn't have one (pneumococcal vaccine), we don't give it. It makes sense to say that it isn't offered because we don't have the vaccine to give. On 2/25/16 at 11:00 a.m., surveyor # interviewed DON-H regarding the facility's pneumococcal vaccination process. DON-H indicated she started employment with the facility in the past year and confirmed the facility did not give pneumococcal vaccines. DON-H indicated there was confusion with the program and the process. The above indicates the facility did not have any program for vaccinating residents for pneumonia, even prior to the guideline changes introduced by the Advisory Committee on Immunization Practices (ACIP) in September 2014. The ACIP published an article on 9/19/14 in the Morbidity and Mortality Weekly Report entitled, Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal [MEDICATION NAME] Vaccine Among Adults Aged at or Above [AGE] years: Recommendations of the ACIP which indicated, Use of PCV13 since 2010 among children in the United States has reduced pneumococcal infection indirectly among adults. By 2013, the incidence of IPD (Invasive Pneumococcal Disease) caused by serotypes unique to PCV13 among adults aged at or above [AGE] years had declined by approximately 50% compared with 2010, when PCV13 replaced PVC7 in the pediatric immunization schedule. However, in 2013, an estimated 13,500 cases of IPD occurred among adults aged at or greater than 65. Approximately 20%-25% of IPD cases and 10% of community-acquired pneumonia cases in adults aged at or greater than 65 are caused by PCV13 serotypes and are potentially preventable with the use of PCV13 in this population. On December 30, 2011, PCV13 was approved for use among adults age 50 or greater to prevent pneumonia and invasive disease serotypes contained in the vaccine. The guidelines for pneumonia vaccination for residents age 65 or greater included the following: * Pneumococcal vaccine-naive person age 65 or greater: PCV13 then 6-12 months later, PPSV23. * Persons who previously received PPSV23 at age 65 or greater: PCV13 at or after 1 year of PPSV23. * Persons who previously received PPSV23 before age 65: PCV13 at age 65 or greater at or after 1 year of PPSV23, then PPSV23 6-12 months after PCV13. On 9/4/15, the ACIP revised the above recommendations which included a dose of PCV13 be followed by a dose of PPSV23 in all adults age 65 or older who have previously received pneumococcal vaccine. When both PCV13 and PPSV23 are to be administered, PCV13 is recommended before PPSV23, based on studies demonstrating a better response to serotypes common to both vaccines when PCV13 is given first. Studies evaluating the immune response to a conjugate vaccine (PCV13) followed by a [MEDICATION NAME] vaccine (PPSV23) demonstrated that following the PPSV23 dose, antibody levels against serotypes common to both vaccines were higher than the pre-PCV baseline. The guideline for pneumonia vaccination for residents age 65 or greater included the following: * Pneumococcal vaccine-naive person age 65 or greater: PCV13 at or after 1 year, PPSV23. * Persons who previously received PPSV23 at age 65 or greater: PCV13 at or after 1 year of PPSV23. * Persons who previously received PPSV23 before age 65: PCV13 at age 65 or greater at or after 1 year of PPSV23, then PPSV23 at or after 1 year after PCV13. The CDC (Centers for Disease Control and Prevention) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, indicated, .for those who have already received 1 or more doses of PPSV23, or those with unclear documentation of the type of pneumococcal vaccine received: administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose . The WI (Wisconsin) DHS (Department of Health Services) Memo, dated 11/21/14, indicated, .if an adult has previously received a dose of pneumococcal vaccine prior to December 2011 but does not know what type it is, it is reasonable to assume that it was PPSV23 because PCV13 was licensed by the FDA during December 2011 . The DQA (Division of Quality Assurance) sent an email message via listserv on 2/12/16 to all nursing home providers. The email indicated, Prevnar 13 (PCV-13) immunization for preventing pneumococcal infections is part of the standard of practice for immunizing adults in nursing homes . On September 19, 2014, the CDC published new ACIP recommendations pertaining to pneumococcal vaccination. The recommendations were updated on September 2015 and incorporated into the 2016 ACIP Adult Immunization Schedule. ACIP now recommends that adults aged [AGE] years and older receive the pneumococcal conjugate vaccine (PCV13, Prevnar-13®) followed by the pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME]®23) .Nursing homes that have not incorporated PCV-13 into their pneumococcal immunization program must immediately work with their Medical Director and Infection Preventionist to do so. Failure to do so may put a facility at risk of being out of compliance with F334 Pneumococcal Immunizations, F501 Medical Director, and F441 Infection Control. Noncompliance may result in a serious deficiency(s) . On 2/24/16 beginning at 9:30 a.m., surveyor # interviewed DON-H regarding the facility's immunization policies, which DON-H provided. Pneumococcal and Influenza vaccination policies DON-H indicated she and MD-AA discussed the PCV13 guidelines at the January QA (Quality Assurance) committee meeting and the committee developed a PIP (Performance Improvement Plan), dated January 2016. The goal of the plan was to educate residents over age 65 on the importance of PCV13 and allow residents the choice whether or not to receive the vaccination. The PIP indicated PCV13 was discussed with MD (Medical Director)-AA who was supportive of the plan. The plan was to during the months of February and March, educate nursing staff at the March meeting and have residents begin receiving PCV13 in April of 2016. At the time of survey, no evidence was provided that the facility had begun implementing this plan. DON-H indicated she didn't see an urgency to vaccinate residents sooner than April 2016. DON-H confirmed the facility currently had 2 residents with pneumonia and 1 resident who was treated earlier in the month for pneumonia. At the time of survey, the facility had not offered the pneumococcal vaccine PCV13 to 24 residents who were eligible and had not identified if 12 additional residents were eligible to receive it, as follows: Residents Vaccinated With PPSV23 and Who Were Eligible for PCV13. * Resident #8, age 82. admitted [DATE]. Last PPSV23 administered on 5/9/11. The resident was not offered or administered PCV13, per standards of practice. * Resident #18, age 70. admitted [DATE]. Last PPSV23 administered on 6/4/08. The resident was not offered or administered PCV13, per standards of practice. * Resident #22, age 76. admitted [DATE]. Last PPSV23 administered on 12/17/12. The resident was not offered or administered PCV13, per standards of practice. * Resident #34, age 87. admitted [DATE]. Last PPSV23 administered on 4/24/07. The resident was not offered or administered PCV13, per standards of practice. Residents Vaccinated Prior to December 2011 and Who Presumably Had Received PPSV23 and Who Were Eligible for PCV13. The following residents were vaccinated prior to December 2011. Their records did not indicate which pneumonia vaccine they had received; however, it is presumed they had received PPSV23 since they were vaccinated prior to the introduction of PCV13. *,Resident #11, age 98. admitted [DATE]. diagnosed with [REDACTED]. Last pneumococcal vaccine administered on 10/15/07. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #4, age 97. admitted [DATE]. diagnosed with [REDACTED]. Last pneumococcal vaccine administered on 10/28/02. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #32, age 85. admitted [DATE]. Last pneumococcal vaccine administered on 5/15/06. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #37, age 91. admitted [DATE]. Last pneumococcal vaccine administered on 9/17/10. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #25, age 81. admitted [DATE]. Last pneumococcal vaccine administered on 9/25/08. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #6, age 85. admitted [DATE]. Last pneumococcal vaccine administered on 9/9/11. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #33, age 86. admitted [DATE]. diagnosed with [REDACTED]. Last pneumococcal vaccine administered on 7/1/08. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #42, age 96. admitted [DATE]. diagnosed with [REDACTED]. Last pneumococcal vaccine administered on 10/27/05. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #35, age 89. admitted [DATE]. Last pneumococcal vaccine administered on 11/14/04. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #27, age 83. admitted [DATE]. Last pneumococcal vaccine administered on 11/24/11. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #5, age 90. admitted [DATE]. Last pneumococcal vaccine administered on 4/20/06. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #40, age 94. admitted [DATE]. Last pneumococcal vaccine administered on 11/2/06. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #44, age 101. admitted [DATE]. Last pneumococcal administered vaccine on 1/1/04. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #38, age 91. admitted [DATE]. Last pneumococcal vaccine administered on 3/14/08. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #13, age 89. admitted [DATE]. diagnosed with [REDACTED]. Last pneumococcal vaccine administered on 7/13/00. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #39, age 92. admitted [DATE]. diagnosed with [REDACTED]. Last pneumococcal vaccine administered on 10/29/09. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #23, age 77. admitted [DATE]. Last pneumococcal vaccine administered on 10/26/04. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #31, age 85. admitted [DATE]. Last pneumococcal vaccine administered on 10/4/06. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #43, age 100. admitted [DATE]. Last pneumococcal vaccine administered on 11/22/06. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. * Resident #12, age 84. admitted [DATE]. Last pneumococcal vaccine administered on 5/8/09. The resident was eligible to receive the PCV13 and was not offered or administered the PCV13 vaccine, per standards of practice. Residents With Unclear Documentation of the Type of Pneumococcal Vaccine Received The following residents received a pneumonia vaccine after December 2011. Their records did not identify which vaccine they had received. As a result, the facility was not aware if these residents should be offered Prevnar 13. * Resident #41, age 94. admitted [DATE]. diagnosed with [REDACTED]. Last pneumococcal vaccine administered on 9/9/13. It is not known what type of vaccine this resident had received (PPSV23 or PCV13); consequently, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #24, age 80. admitted [DATE]. Last pneumococcal vaccine administered on 11/7/12. It is not known what type of vaccine this resident had received (PPSV23 or PCV13); consequently, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #17, age 65. admitted [DATE]. Last pneumococcal vaccine administered on 9/18/12. It is not known what type of vaccine this resident had received (PPSV23 or PCV13); consequently, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #3, age 71. admitted [DATE]. Last pneumococcal vaccine administered on 2/14/14. It is not known what type of vaccine this resident had received (PPSV23 or PCV13); consequently, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #28, age 83. admitted ,[DATE]. Last pneumococcal vaccine administered on 10/8/12. It is not known what type of vaccine this resident had received (PPSV23 or PCV13); consequently, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #20, age 71. admitted [DATE]. Last pneumococcal vaccine administered on 8/27/14. It is not known what type of vaccine this resident had received (PPSV23 or PCV13); consequently, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #29, age 83. Unknown admitted . Last pneumococcal vaccine administered on 6/22/14. It is not known what type of vaccine this resident had received (PPSV23 or PCV13); consequently, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #36 age 90. admitted [DATE]. Last pneumococcal vaccine administered on 1/19/12. It is not known what type of vaccine this resident had received (PPSV23 or PCV13); consequently, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. Residents With Unknown Pneumococcal Vaccine Status * Resident #10, age 65. admitted [DATE]. The facility had no record of the resident's pneumococcal vaccination status. Because it is not known if this resident had been vaccinated, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #19, age 70. admitted [DATE]. The facility had no record of the resident's pneumococcal vaccination status. Because it is not known if this resident had been vaccinated, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #21, age 75. admitted [DATE]. The facility had no record of the resident's pneumococcal vaccination status. Because it is not known if this resident had been vaccinated, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. * Resident #30, age 84. admitted [DATE]. The facility had no record of the resident's pneumococcal vaccination status. Because it is not known if this resident had been vaccinated, the facility did not know if this resident should be offered or administered PCV13 per standards of practice. Residents Listed as Pneumococcal Vaccination Refusals * Resident #14, age 43. admitted [DATE]. The facility indicated the resident refused the pneumococcal vaccine; however, the facility was unable to provide documentation of the refusal and education provided to the resident, POA (Power of Attorney) or guardian. * Resident #16, age 61. admitted [DATE]. The facility indicated the resident refused the pneumococcal vaccine; however, the facility was unable to provide documentation of the refusal and education provided to the resident, POA or guardian. Surveyors # and # reviewed the facility's infection line list and resident's pneumococcal vaccine history and noted the following: * 7 residents were diagnosed with [REDACTED]. Two of the residents were diagnosed with [REDACTED]. On 2/24/16 at 3:10 p.m., during the daily exit meeting with the facility, DON-H indicated a QA meeting was held on 1/13/16. The QA committee discussed PCV13 and developed a PIP, by which it would begin to offer and administer PCV13 in April of 2016. At the time of survey, the facility did not implement anything relating to their plan (e.g., updating existing policy and procedures, identifying which residents were eligible, developing educational material, and seeking resident/guardian consent). The failure to develop and implement current standards of practice regarding administration of PCV13 vaccinations to all current eligible residents and potential new admissions and ensuring that residents were offered the opportunity to be vaccinated against pneumonia according to current standards of practice created a finding of immediate jeopardy, given the morbidity rates for the elderly who develop pneumonia. This was removed when the facility completed the following: 1. Resident #11: RN conducted an assessment of the resident on 02/25/2016. MD was notified of the resident's current condition. Prevnar 13 will be administered when Pneumonia is completely resolved and if the resident or responsible party consents to the administration of the vaccine. Care was reviewed and modified to reflect new 2. Resident #13: discharged to the acute hospital on [DATE]. 3. Resident #41: RN conducted a comprehensive assessment of the resident on 02/25/2016. MD was notified of the resident's current condition. Prevnar 13 will be administered when Pneumonia is completely resolved and if the resident or responsible party consents to the administration of the vaccine. 4. Policy and Procedure for Pneumonia vaccine has been reviewed to ensure policy is consistent with the current WI DHS memorandum on New Recommendation for Pneumococcal Vaccination of Adults dated November 21, 2014. Policies for Pneumonia Vaccination, surveillance of health care associated infections, guidelines for pneumonia management in Long Term Care Facilities will be reviewed by the QA&A Committee. 5. The facility reviewed the facility's Performance Improvement Plan on Pneumonia vaccination on 02/25/2016 with the Medical Director to revise the date on provision of the vaccines. 6. The facility conducted an audit on 02/25/2016, to identify individual resident's Pneumonia vaccination status, including but not limited to the type of Pneumonia vaccine received and residents that meet the criteria for Prevnar 13 vaccine as stated in the WI DHS recommendations for Pneumococcal Vaccination of Adults. Residents were identified from the facility Immunization Audit completed on 02/25/2016. Identified resident s that meet the requirements for the Prevnar 13 vaccine guidelines will be provided with the Pneumonia VIS. Vaccine will be administered once consent and physician order [REDACTED]. 7. Director of Nursing in coordination with the facility staff met with individual residents and/or contacted responsible party to provide information on the vaccine and obtain consent for it. 8. As part of Pneumonia Vaccination Program education for staff and residents, Vaccine Information Statement (VIS) for Pneumonia have been distributed to alert residents and will be mailed to the resident's responsible party. 9. Prevnar 13 vaccines have been ordered through the pharmacy for immediate delivery today. 10. The immunization log will be updated to reflect the administration of Prevnar 13 to residents consented to the administration of the vaccine. 11. Facility started an audit to determine residents with infection requiring isolation based on McGeer's Criteria. 12. Medical Director Resource will provide an in-service to Medical Director on 02/25/2016. 13. DON will in-service nursing staff on the facility's Infection Control Program specifically on the Pneumonia Vaccination Program and precautions on residents with Pneumonia. In-service was started on 02/22/2016. 14. NHA and DON are responsible for monitoring the implementation of the above plan. 15. DON, NHA, Infection Control Preventionist, Clinical RN Resource and Medical Director to review said policies, summary of surveillance activities. Infection Control Preventionist, RN will provide summary of pneumonia vaccination status and activities to QA and A committee for review and recommendations. 16. Infection Preventionist will continue to review new admit residents for Pneumonia Vaccine qualification. 17. Residents with positive symptoms will be placed on necessary infection precaution with notification of MD and will continue to follow MD orders. On 2/25/16 at 9:20 a.m., NHA-N told surveyor # , Staff contacted the pharmacy to deliver fifty doses of the pneumococcal vaccine to the facility. Staff are reaching out to residents and their families for consent, and will begin to administer the vaccine today.

Based on observations, interviews with staff, and record review, the facility did not maintain an Infection Control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of and transmission of infections. This has the potential to affect all 50 current residents and any new residents that would be admitted to the facility. The facility did not implement its policies and procedures and current standards of practice identified by the ACIP (Advisory Committee on Immunization Practices). The facility did not identify residents who were not vaccinated for pneumonia and offer residents the opportunity to be vaccinated. The facility failed to identify, offer or administer the pneumococcal vaccine to 39 of its 50 residents residing in the facility who were eligible to receive the Pneumococcal vaccine (Residents #10, 15, 19, 21, 30, 16, 14, 8, 18, 22, 34, 5, 40, 41, 4, 44, 6, 33, 35, 27, 24, 11, 32, 37, 25, 42, 17, 38, 13, 3, 39, 28, 20, 29, 23, 31, 43, 36, and 12). Residents #4, #11 and #13 were diagnosed with [REDACTED]. Staff did not utilize appropriate precautions and PPE (Personal Protective Equipment) while caring for the residents. Additionally, residents #11 and #13 had active respiratory signs and symptoms, and both residents were allowed to co-mingle with non-infected residents during meals and activities. Staff were allowed to float between the SCU and non-affected units, and non-affected residents were allowed to participate in off unit activities. The failure to isolate residents who were ill and to use appropriate precautions when caring for these residents created an immediate jeopardy situation because it allowed for the spread of infection to other residents. The jeopardy began on 2/23/16. The facility was notified of the immediate jeopardy on 2/25/16 and removed the jeopardy on 2/26/16. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as the facility continues to implement its removal plan and as evidenced by the following: During an observation of cares for resident #6, who was on contact precautions with a known skin infection, staff used a pink basin for bathing the resident, and without santiizing the basin, put the basin away for additional use. CNA (Certified Nursing Assistant)-B did not wash/sanitize hands after re-entering resident #3's room to finish a.m. cares touch resident, oxygen tubing, and resident personal and shared items. CNA-Q did not remove gloves and/or wash/sanitize hands after providing personal cares for resident #2 prior to touching personal and shared items. Findings include: Pneumococcal Vaccines/Precautions/Observations The facility did not offer or administer the pneumococcal vacine to 39 of its 50 residents currently residing in the facility at the time of survey who were eligible for the vaccine (Residents #10, 15, 19, 21, 30, 16, 14, 8, 18, 22, 34, 5, 40, 41, 4, 44, 6, 33, 35, 27, 24, 11, 32, 37, 25, 42, 17, 38, 13, 3, 39, 28, 20, 29, 23, 31, 43, 36, and 12). From September 2015 through February 2016, seven residents were identified on the facility's infection line list as having been diagnosed with [REDACTED]. As a result, two of these residents (Residents #4 and #13) required hospitalization for treatment of [REDACTED]. Additionally, the facility had no pneumococcal vaccine history for 5 (resident #10, #15, #19, #21, #30) of the 39 residents. Residents (#16 and #14) medical records indicated a refusal of the Pneumococcal vaccination with no documentation to include if the vaccine was re-offered, declined, or given. Refer to the citation text at F334 for additional information. Resident #4 was admitted to the facility on [DATE] and resided on the SCU. Review of the facility's infection line list indicated, resident #4 was diagnosed with [REDACTED]. Resident #13 was admitted to the facility on [DATE] and resided on the SCU. Review of the facility's infection line list indicated, resident #13 was diagnosed with [REDACTED]. Resident #11 was admitted to the facility on [DATE] and resided on the SCU unit. Review of the facility's infection line list indicated, resident #11 was diagnosed with [REDACTED]. Progress Notes for resident #11 indicated the following: *2/20/16- increased coughing with green sputum, lung sounds diminished. ATB (antibiotic) ordered for ten days related to pneumonia . *2/21/16- wet and course productive cough, lung sounds diminished . *2/22/16- productive cough with clear and light green sputum .Cough continues productive of green sputum . *2/23/16- occasional productive cough continues with greenish/white sputum . *2/24/16- Congested cough noted throughout shift . On 2/24/16 at 10:50 a.m., surveyor # interviewed DON (Director of Nursing)-H regarding residents #4, #11 and #13. DON-H confirmed all three residents resided on the SCU unit and were recently diagnosed with [REDACTED].#4, #11 and #13 had not been tested for influenza. On 2/23/16 during initial tour of the Memory Lane unit, surveyor # interviewed LPN (Licensed Practical Nurse)-A who verified resident #4, resident #13 and resident #11 were diagnosed with [REDACTED]. It was further confirmed resident #4 was completing antibiotics that day, but residents #13 and #11 were newly diagnosed and actively symptomatic. All three residents were pointed out to the surveyor as they were seated in the common dining area with other residents of the unit. LPN-A indicated none of the residents had been placed on droplet precautions or isolation. On 2/23/16 at 11:00 a.m., surveyor # observed residents dining on the Memory Lane unit. The dining area had 12 residents seated at 4 tables. Resident #11 was continuously observed from 11:00 a.m. to 11:30 a.m., with a persistant, loose, productive cough, unable to exhibit any cough ettiquitte. At 11:30 a.m., resident #11 told staff, I don't feel good, I want to go to my room. During the same observation, resident #13 was also noted to have a persistant, productive cough. Resident #13 was seated with other residents in the same dining room. On 2/23/16 at 2:40 p.m., surveyor # interviewed LPN-J who also verified resident #13 and resident #11 had pneumonia, were symptomatic and were not on droplet precautions or isolation. It was further verifed resident #4's pneumonia was recently resolved, but the resident was never on droplet precautions or isolation. LPN-J verified to surveyor # resident #11, resident #6 and resident #26, from the Memory Lane unit, were currently off the unit in the main dininig room at a group BINGO activity. On 2/24/16 at 8:02 a.m., surveyor # observed LPN-A administer medications to resident #6 on the Memory Lane unit. On 2/24/16 at 8:25 a.m., surveyor # followed LPN-A off the unit to B wing and observed the LPN administer medications to resident #9. LPN-A verified to surveyor at that time that she is responsible for both wings and floated between the two units providing cares all during the shift. On 2/24/16 at 1:15 p.m., surveyor # observed residents in the dining/activity area of the Memory Lane unit. Resident #6, resident #10, resident #5, resident #4, resident #40, resident #24 and resident #38 were all seated at one long table listening to a religioius audio tape as they waited to leave the unit for community church services. Also among them was resident #11, diagnosed with [REDACTED]. On 2/24/16 at 1:30 p.m., surveyor # observed resident #11 leave the Memory Lane unit to attend community church services in the main dining room with other residents from throughout the facility. On 2/25/16 at 12:40 p.m., surveyor # interviewed CNA (Certified Nursing Assistant)-B who verified she worked the Memory Lane unit on 2/24/16 and worked on another wing 2/25/16. CNA-B indicated many of the staff are not dedicated to a particular unit but float throughout the facility. On 2/25/16 at 12:50 p.m., surveyor # interviewed CNA-DD who verifed she scheduled the staff and worked as a CNA. It was confirmed that CNA-DD floated throughout the facility on 2/24/16 and 2/25/16 to assist residents and staff. CNA-DD also added many of the CNAs are not assigned consistantly to one unit but work any unit from day to day. CNA-DD verified any nurse assigned to the Memory Lane unit would also be in charge of the B wing during the same shift. The facility's Surveillance of Infections policy, dated 11/2007, states: It is the policy of this facility that there will be a system in place whereby the tracking and trending of potential/actual infections will be monitored to ensure that measures are taken to prevent any potential outbreak. All residents with the following criteria have a potential for infection: 1. Temperature elevation over 101 degrees Fahrenheit 4. Receiving antibiotics 5. If culture obtained for any reason 6. Has an abnormal chest x-ray indicative of an infiltrate or infectious lesion 9. Coryza, cough-producing yellowish or green sputum 12. Persistent eye irritation with exudate Procedures: 2. Any questions about the nature of the infection, treatment, isolation procedures, cultures and sensitivities, etc. are brought to the attention of the DNS (Director of Nursing Services). 3. An Infection Control Log is maintained at the nurses' station either in a notebook or in front of the MAR (Medication Administration Record). Charge nurses will be responsible to record the requested information of all residents displaying any of the above symptoms on the log. 4. DNS/Designee will review the log during the morning routine to ensure all potential/actual infections/outbreaks are being identified. This will be accomplished through observation of the twenty-four (24) hour report, telephone orders and/or change of condition documentation. The facility's Infection Control Policy, dated 5/2007, states: The goals of the Infection Control Program are to: A. Decrease the risk of infection to patients and personnel. B. Monitor for occurrence of infection and implement appropriate control measures. A. Surveillance of Infections There is on-going monitoring for infections among patients and personnel and subsequent documentation of infections that occur. B. Implementation of Control Measures: Prevention of spread of infections is accomplished by use of Universal Precautions and other barriers, appropriate treatment and follow-up and employee work restrictions for illness. C. Prevention of Infection: Staff and patient education is done to focus on risk of infection and practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment. Infection Control data is collected and monitored monthly and reported at QA (Quality Assurance) meetings which provides input and direction for the Infection Control Program. Policies and procedures relating to Infection Control are approved by the committee. Reports of infections are presented to committee which recommends actions and control measures as needed. Compliance with Infection Control practices is monitored and documented by: 1. Staff evaluation 2. Observation of practices 3. The ICP (Infection Control Preventionist), Director of Nursing and Department Managers review the compliance monitoring and initiate appropriate actions. HAND HYGIENE: The facility's A Guide to the Usage of Gloves policy, dated 7/2007, states: The Centers for Disease Control and Prevention's new standard precautions recommend using gloves when handling any body fluids or items contaminated with body fluids. ~ Wear clean non-sterile gloves when handling body fluids and contaminated items. Gloves are to be worn when cleaning an incontinent resident, handling or touching any resident's body fluids or mucous membranes, handling items or surfaces soiled with body fluids and when washing residents' genitalia. Note: The facility's policy did not address hand hygiene before, during and after glove usage while providing incontinence care for residents. 1. On 2/23/16 at 3:05 p.m., surveyor # observed CNA (Certified Nursing Assistants)-W and CNA-Y provide incontinence care for resident #1. CNA-W applied gloves and retrieved a clean brief while CNA-Y raised the resident's bed. CNA-W unfastened the resident's brief, confirmed the resident was incontinent of urine and used wipes to provide anterior pericare. Without removing gloves and cleansing hands, CNA-W adjusted the resident's soaker pad and assisted CNA-Y with repositioning the resident to the right side. CNA-W then provided posterior pericare and removed the resident's brief. Without removing gloves and cleansing hands, CNA-W applied a clean brief and touched the resident's knees and hands in the process. CNA-W removed gloves, and without washing or cleansing hands, touched the resident's pants, opened the bathroom door, applied clean gloves and retrieved a lift sling. CNA-W and CNA-Y repositioned resident #1 onto the right and then the left side while placing the lift sling underneath the resident. CNA-W removed gloves and without washing or sanitizing hands, retrieved a Hoyer lift. After attaching the resident's sling to the lift, CNA-W retrieved the remote control, touched the resident's hand and began to lift the resident. During the transfer, the lift stopped working. CNA-W lowered the resident to the bed and without washing or sanitizing hands, left the room to retrieve a new battery. CNA-W returned to the room, changed the battery and proceeded to transfer the resident from bed to wheelchair. CNA-W then bagged the resident's garbage and washed hands. Immediately following the observation, surveyor # interviewed CNA-W regarding hand hygiene. CNA-W confirmed staff are trained to remove gloves and cleanse hands following pericare. CNA-W stated it was difficult to remember to do so at times. 2. On 2/24/16 at 9:10 a.m., surveyor # observed CNA-T and CNA-U provide incontinence care for resident #2. After using a Hoyer lift to transfer the resident from wheelchair to bed, CNA-T and CNA-U positioned the resident in bed on top of the Hoyer sling. CNA-U applied gloves while CNA-T left the room to retrieve a clean brief. CNA-T returned to the room and without washing or sanitizing hands, applied gloves. CNA-T unfastened the resident's brief and confirmed the resident was incontinent of urine and a small amount of stool. CNA-T used wipes to provide anterior pericare, removed gloves and washed hands. CNA-T then applied clean gloves and assisted CNA-U with rolling the resident to the right side. When CNA-T and CNA-U rolled the resident, surveyor # observed wipes visibly soiled with urine and stool on top of the resident's sling. CNA-U picked up and disposed of the soiled wipes with a gloved hand while CNA-T provided posterior pericare. Without removing gloves and cleansing hands, CNA-U picked up a clean brief. Without removing gloves and cleansing hands, CNA-T, along with CNA-U, rolled the resident from right to left and positioned the resident's brief. CNA-U removed gloves and, without cleansing hands, attached the brief. CNA-T then removed gloves and washed hands. CNA-U pulled up the resident's pants and adjusted the lift sling. CNA-T and CNA-U then transferred the resident from bed to wheelchair. During the observation, surveyor # interviewed CNA-T and CNA-U regarding the soiled lift sling. CNA-T and CNA-U verified the soiled wipes were in contact with the sling and stated they would only change the sling if the sling was soiled with a larger amount of stool. Immediately following the observation, surveyor # interviewed CNA-T and CNA-U regarding hand hygiene. CNA-T verified not removing gloves and cleansing hands following posterior pericare. CNA-T indicated she should have removed gloves and cleansed hands before applying a clean brief. CNA-U verified not removing gloves and cleansing hands after handling soiled wipes. Contaminated Wash Basin On 2/23/16, surveyor # reviewed the medical record of resident #6. The 10/1/15, facesheet contained within the medical record indicated resident #6 was admitted with [DIAGNOSES REDACTED]. The most recent quarterly MDS (Minimum Data Set) assessment dated [DATE], documented resident #6 scored 4 of 15 on the BIMS (Brief Interview for Mental Status) which indicated severe cognitive impairment. The same MDS further documented resident #6 was dependent upon staff for extensive assistance with toileting, hygiene and bathing. MD progress notes for resident #6, dated 2/1/16, documented, the resident had, cellulitis of buttocks. On 2/23/16 at 9:00 a.m., surveyor # interviewed LPN-A who verified resident #6 was on contact precautions for a Staph and Strep infection of the buttocks. A cart with personal protective equipment was noted outside the room of resident #6. Staff were observed wearing gowns and gloves when providing cares for resident #6. Wound culture results dated 2/4/16, documented resident #6 had Staphylococcus Aureus and Beta [DIAGNOSES REDACTED] Strep C from the open skin on the buttocks. The written plan of care for resident #6, dated 2/4/16, indicated Has infection of staph/strep to buttocks, Maintain Universal Precautions when providing resident cares. On 2/14/16 at 7:35 a.m., surveyor # observed the provision of cares for resident #6 by CNA-B and CNA-C. The CNAs were wearing gowns and gloves as the cleansed the residents body using a wash basin for the water to rinse the soapy, contaminated cloths. The buttocks, sacrum, groin and perineum of resident #6 were noted with extensive (75 to 80%) excoriation and bright, beefy red color. The CNAs verified resident #6 had a skin infection which was the reason for the PPE (Personal Protective Equipment). Resident #6 was observed scratching the reddened area. After cleansing the resident, CNA-B emptied the wash basin, rinsed and dried the basin placing it in resident #6's night stand. CNA-B verified to surveyor # , that the basin was not sanitized, just rinsed and dried and that was the usual practice. On 2/25/16 at 9:55 a.m., surveyor # interviewed DON-H who verified resident #6 had a skin infection that was not improving and that the resident was on contact, not universal precautions. DON-H confirmed the wash basin should have been sanitized after use as it could contaminate other skin areas or re-infect the resident. A nurse's note dated 2/25/16, indicated resident #6 experienced a new onset of Left eye swollen, deep red at base with redness throughout. Doctor ordered [MEDICATION NAME] (antibiotic) drops in the left eye for 4 days. Precautions in place. 3. Resident #3's most recent MDS (Minimum Data Set) assessment documented the resident cognition was intact. The resident required extensive assistance for bed mobility, transfer, and ADL's (Activities of Daily Living). On 2/25/16 at 7:30 a.m., surveyor # observed CNA-B and CNA-GG gather additional supplies and then enter resident #3's room to complete morning cares for resident #3. CNA-GG washed hands and applied gloves. CNA-B without washing or sanitizing hands applied gloves. CNA-B and CNA-GG assisted resident #3 with applying a clean brief, dressing, shoes and sat resident up on side of bed. CNA-B then removed gloves and without washing/sanitizing applied gloves and assisted CNA-GG with transferring resident #3 into wheelchair. CNA-B removed gloves and washed hands. CNA-B left room to fill resident #3's portable O2 (oxygen) tank. CNA- went through three doors and outside, brought O2 tank back to resident's room, and went to get new oxygen tubing and nasal cannula in storage cabinet in hallway. CNA-B entered resident #3's room without washing/sanitizing hands donned gloves unwrapped new oxygen tubing/nasal cannula, attached tubing to the portable O2 tank and placed nasal cannula on resident #3. CNA-B removed gloves and washed hands. Immediately following the observation surveyor # interviewed CNA-B regarding resident #3. CNA-B verified not washing/sanitizing hands after re-entering resident #3's and before donning gloves and verified touching resident, multiple personal/shared items. CNA-B further verified not washing/sanitizing hands after obtaining supplies and applying resident #3's oxygen tubing and nasal cannula. 4. On 2/23/16, surveyor # reviewed resident #7's medical record. Review of resident #7's face sheet dated 10/26/15, indicated resident was admitted to the facility multiple [DIAGNOSES REDACTED]. Resident #7's medical record indicated resident has history of MRSA (Methicillin Resistant Staphylococcus Aureus) in urine and remains on contact precaution with cares. Resident #7 also has a foley catheter. Resident #7's most recent MDS (Minimum Data Set) assessment, dated 1/27/16, documented the resident's cognition was intact. The resident required extensive total assistance with bed mobility, transfer, and ADL's (Activities of Daily Living). On 2/24/26 at 9:00 a.m., surveyor observed CNA-Q and CNA-L provided a.m. cares and perineal care for resident #7. CNA-Q,CNA-L and surveyor # sanitized hands, and applied PPE (Personal Protective Equipment) to included, gown, mask and gloves, as resident #7 was on contact precautions for all cares. CNA-Q knocked and entered the resident's room. CNA-L assisted resident #7 with repositioning and removal of clothing. CNA-Q performed a.m. cares starting with resident #7's face and ending with perineal/catheter. CNA-Q then without removing gloves, washing or sanitizing hands assisted CNA-L dressing resident. CNA-Q and CNA-L then removed gloves, washed hands and donned gloves. CNA-Q and CNA-L transferred resident #7 into electric scooter and CNA-Q assisted resident #7 in completed a.m. routines (shaving). CNA-L gathered linens, garbage removed PPE inside doorway of resident #7, washed hands donned gloves to dispose of linens and garbage. On 2/24/16 at 9:30 a.m., surveyor # interviewed CNA-Q regarding resident #7. CNA-Q verifed not removing gloves, washing or sanitizing hands after providing perineal/catheter care for resident #7. On 2/25/16 at 8:00 a.m., surveyor # interviewed DON (Director of Nursing)-H regarding hand hygiene policy and procedure. DON-H indicated it is the facility's expectation that gloves should have removed and hands washing/sanitized after providing perineal care resident. DON-H also indicated whenever a staff member leaves residents room hand washing should be completed upon return before touching the resident. DON-H further indicated the facility regularly provides education on hand hygiene, but will review and re-educate staff. The Facility's failure to isolate residents who were ill and to use appropriate precautions when providing care for these residents The immediate jeopardy situation was removed with the facility implemented the following: 1. Facility audit completed to determine resident's with infection requiring isolation based on McGeer's Criteria. 2. Director of Nursing provided in-service to nursing staff on the facility's Infection Control Program specifically on isolation precautions per CDC guidlelines on residents with Pneumonia. 3. Review of the infection control surveillance log was completed and residents identified to have active infections were reviewed for proper isolation precautions per policy and as recommended by CDC.

Based on observation, record review and staff interview the facility did not ensure that 10 (residents #46, #4, #5, #10, #13, #22, #24, #28, #40 and #11) of 18 sampled and supplemental sampled residents received adequate supervision and assistance devices to prevent accidents. Resident #46 was assessed to be at high risk for falls. The facility implemented interventions for fall prevention and injury protection, but the facility did not follow the interventions that were put into place. Resident #46 sustained a fall. The facility completed an initial assessment, but did not complete a comprehensive assessment with each neurological assessment. In addition, resident #46 ambulated all the time according to staff. After resident #46's fall, resident #46 was observed sitting and no longer ambulating. The facility did not recognize resident #46's change in condition. Approximately 3 hours after the resident's fall, family came to the facility and with the assistance of the nurse, resident #46 was assisted to the bathroom. Family observed the resident's leg to be turned outward and instructed the staff to transfer the resident to the hospital. Resident #46 was diagnosed with [REDACTED]. Resident #4 was assessed to be at risk for falls and had interventions in wear hipsters (a padded device worn in attempt to prevent injury if a resident falls). Resident #4 was observed without wearing the hipsters. In addition, the facility's standard of practice is for staff to use a gait belt for transfers. On 2/25/16, CNA (Certified Nursing Assistant)-CC was observed transferring resident #4 without the use of a gait belt. Resident #10 had 10 incidents of resident to resident altercations involving 7 residents who reside on the dementia unit Memory Lane, were not thoroughly investigated or reported. Additionally, sufficient interventions were not implemented to protect residents #4, #5, #13, #22, #24, #28 and #40 from resident #10's repeated aggression when behaviors were escalating. Example 1 is determined to be cited at a severity level of G (actual harm). Examples 2 and 3 are cited at a severity level of D (potential for harm). Findings include: 1. On 02/10/16, surveyor # reviewed resident #46's medical record. The facility completed a fall risk assessment, dated 11/28/15, which indicated resident #46 is at high risk for falls. The facility developed a plan of care dated 11/28/15, At risk for falls related to confusion, poor communication/comprehension. The following interventions were put into place: ~ Occupational, Physical and Speech Therapy evaluation and treatment per physician orders. ~ Anticipate and meet needs. ~ Be sure the call light is within reach and encourage to use it to call for assistance as needed. ~ Tab alarm (a pull apart device that alarms when a person attempts to stand) on bed. ~ Tab alarm to w/c (wheelchair). The facility expanded the At risk for falls plan of care on 11/30/15. The care plan read At risk for falls related to recent stroke, dementia, unaware of safety needs, confusion, deconditioning, gait/balance problems and incontinence. The PT (Physical Therapy) Discharge Summary, dated 12/09/15, documented resident #1 was in therapy from 11/30/15 to 12/09/15 and indicated the goal for resident #46 was for the resident to be ambulatory to and from the dining room/activity room with appropriate assisted device versus hand held assistance with one assist. The goal was not met and at time of discharge from the PT services, resident #46 had variable ability with ambulation with staff into the bathroom and in the hallway to/from meals with contact guard assist and cues with the sue of a 2 wheeled walker. The therapy notes indicated the resident is unable to progress due to increased confusion and medication changes since admitted . The Progress Notes dated 12/10/15, documented at 7:51 a.m., resident #46 is alert, oriented times one. The resident is lethargic, forgetful and confused. Pleasant and cooperative with cares. Extra encouragement given by staff throughout the day. Reminders to wait for staff before walking with walker continuously related to unsteadiness on feet. The resident's balance/gait is unsteady. The resident was unsteady on feet with walker when ambulating in the hallway and was caught falling backwards by staff and then assisted in the w/c this AM. The Progress Notes dated 12/14/15 documented at 7:08 a.m., resident #46 had an unwitnessed fall at 6:00 a.m., the aide was walking by the room and heard the walker hit the floor and the resident was found on her right side. The resident had garbled speech. Resident #46 sustained multiple skin tears to the left and right forearms. The skin tear to the right bottom forearm measured 4.0 cm (centimeters) by 1.0 cm and another skin tear measured 2.0 cm by 1.0 cm. The resident's right wrist skin tear measured 2.0 cm by 1.2 cm. Fall interventions were updated to use gripper socks, hipsters, geri sleeves, toileting schedule and to set up with activities. The resident resides on the memory care unit and has a [DIAGNOSES REDACTED]. The facility developed an additional plan of care Potential for injury related to fall on 12/14/15. The interventions included to set up with activities to keep occupied and to toilet every 2 hours while awake. In addition, the facility added to the At risk for falls plan of care that the resident should wear hipsters at all times. The Progress Notes dated 12/27/15 documented at 11:47 a.m., the nurse was standing at the medication cart with CNA (Certified Nursing Assistant) -C when a loud crash was heard. The nurse and CNA ran to the room to find the resident lying on right hip on top of the Christmas tree. Assessed and no bruising or skin alterations were noted. The resident's speech is garbled and unable to communicate what she was doing prior to the fall. The resident has been pacing the neighborhood and in/out of rooms all shift. Unable to redirect at times .POA (power of attorney) was notified of all and asked to come take the Christmas tree down as the skirt is a fall hazard. The Progress Notes dated 12/27/15 documented at 9:04 p.m., the nurse was called onto the secured unit by staff stating that the resident was up walking with the walker during supper. Staff stated the resident stopped by the drink cart and proceeded to grab onto the cart and tried to walk around with the walker. The resident then fell down landing on the right side. Injury to head is unknown. Staff were assisting with other residents when the resident went by the cart and unable to get to the resident before the fall. Assessment indicated no injuries. The resident assisted to a sitting position and placed in a chair. The Progress Notes dated 12/27/15 documented at 9:17 p.m., resident #46's family came to the facility to visit. About that time the resident started indicating pain. When asked where the pain was from, resident reached down toward the periarea. Both daughter and nurse assumed that perhaps the resident needed to use the bathroom. Nurse and daughter assisted the resident to stand and the resident was unwilling to stand or walk. At this time the daughter wanted the resident assessed again. The nurse assessed the right hip/leg where the resident was rubbing. No bruising noted. Daughter was very concerned that the hip or pelvis could be fractured. Hydrocodone (a narcotic for pain) was administered per family request to help with pain. Physician updated and the resident was sent to the hospital for evaluation. The hospital ED (Emergency Department) notes dated 12/27/15, indicated resident #46 appears to be in mild to moderate pain. The right leg appears slightly shortened. Temperature flex to the right hip caused pain at the hip. Obvious deformity. The resident will not move the right leg secondary to pain. An X-ray was completed at the hospital. The X-ray report, dated 12/27/15 had findings of completed transverse fracture through the right femoral neck with moderate varus angulation noted. On 02/10/16 at 10:50 a.m., surveyor # interviewed CNA-C regarding resident #46. CNA-C stated resident #46 wandered all the time except when family is present. CNA-C indicated at times the resident would sit long enough to consume meals but other times would not. CNA-C stated if the resident would sit for extended periods of time (without family present) she would question what was going on with the resident as that would be a change. CNA-C indicated staff try to stay with resident #46 when up ambulating, but there are only 2 CNAs on the unit and that is not always possible. CNA-C verified she responded to resident #46's fall in the AM on 12/27/15, but could not recall if the resident was wearing hipsters as directed by the plan of care. On 02/10/16 at 9:05 a.m., surveyor # conducted a telephone interview with LPN (Licensed Practical Nurse)-D regarding resident #46. LPN-D verified she was the nurse in charge of resident #46 at the time of the fall on 12/27/15 on the PM shift. LPN-D stated she was notified by a CNA that resident #46 had fallen. LPN-D indicated resident #46 was ambulating with the walker and the walker got stuck and the resident fell on to resident's right side. LPN-D stated it was the same side the resident fell on earlier in the day. LPN-D indicated she assessed the resident the best she could as the resident kept trying to get up. LPN-D verified she had not completed any further motor function assessments after the initial assessment. LPN-D stated it appeared the resident did not sustain any injuries. LPN-D indicated the fall occurred around 5:30 p.m., and after resident #46 had fallen, the resident was placed in a chair to be monitored. LPN-D stated she had been on/off the unit the remainder of the evening. LPN-D indicated that usually resident #46 is wandering all the time, but after the resident had fallen the resident remained seated in the chair. LPN-D stated she thought it was strange that the resident was not ambulating. LPN-D stated the resident was moaning, but that was not unusual as the resident always moaned when she ambulated. LPN-D indicated shortly before the daughter came to the facility LPN-D did notify RN (Registered Nurse)-E that she had thought it was unusual for the resident to be sitting and not ambulating. LPN-D indicated she did not know if RN-E went and assessed resident #46. LPN-D stated when family came to the facility (approximately 8:30 p.m.) the resident was rubbing her periarea and we (nurse and family) thought the resident needed to use the bathroom. LPN-D indicated she assisted the resident to the bathroom and that is when the daughter noticed the resident's right leg was turned outward. LPN-D stated the daughter asked if there could be a fracture and the LPN indicated yes. LPN-D stated the daughter was very upset that the facility did not notice the abnormality of the leg earlier. LPN-D indicated the daughter requested the resident be sent to the hospital. LPN-D indicated the daughter asked her why the resident was not wearing hipsters and she replied she didn't even know the resident was suppose to wear hipsters. LPN-D stated she told the daughter she would place the hipsters on resident #46, but she couldn't locate any hipsters. LPN-D verified the Tabs alarm was not in place prior to the fall as there was not an alarm sounding. LPN-D indicated that alarms are to notify staff when the resident stands and staff are to try and keep an eye on the resident, but that was not always possible as the staff are busy. On 02/11/16 at 9:40 a.m., surveyor # interviewed RN-E regarding resident #46. RN-E stated she did hear over the walkie talkie that resident #46 had fallen (12/27/15 at 5:30 p.m.). RN-E stated she was busy and heard the resident was assessed so she didn't assess the resident. RN-E stated it was around 8:30 p.m., when RN-E and LPN-D were sitting at the nurses station (outside the memory care unit) when the daughter came and told LPN-E that she wanted resident #46 sent to the hospital. RN-E stated that is when LPN-D asked RN-E to assess resident #46. RN-E indicated she did then assess resident #46 and when the RN arrived to the room, resident #46 was in bed and it appeared the resident's hip was turned outward and the resident was saying she was comfortable. RN-E stated she also indicated the resident needed to be sent to the hospital. RN-E indicated when LPN-D asked RN-E to assess resident #46, LPN-D stated it appeared the resident was having more pain. RN-E stated LPN-E did not tell RN-E that resident #46 had been sitting after the fall as that would have been unusual, as the resident only sat for short periods of time. On 02/11/16 at 11:45 a.m., surveyor # conducted a telephone interview with CNA-F regarding resident #46. CNA-F stated she is familiar with resident #46 and was working with another resident at the time resident #46 fell (12/27/15 on PM shift). CNA-F indicated when she entered the hall from the other resident's room she observed LPN-D and CNA-G assist resident #46 into the resident's room. CNA-F stated about 45 minutes after resident #46 had fallen, the resident was antsy and that was an indicator the resident needed to use the bathroom. CNA-F stated she asked LPN-D if the resident was cleared to use the bathroom, and LPN-D responded yes. CNA-F stated the resident appeared as usual when she assisted resident #46 to the bathroom. CNA-F indicated the resident was seated prior to being taken to the bathroom. CNA-F stated any time a resident falls, staff complete 15 minute checks and the resident was always sitting down when she completed the checks. CNA-F stated at the time, she did not think anything about resident #46 sitting all the time after the fall, as she assumed the resident was just scared. CNA-F indicated now that questions are being asked, she did think it was odd that the resident remained seated. On 02/11/16 at 1:25 p.m., surveyor # interviewed CNA-G regarding resident #46. CNA-G verified he witnessed the fall on 12/27/15 on the PM shift. CNA-G stated he thought the resident tripped on the walker the resident was using in the hall and then fell to the floor. CNA-G indicated after the resident fell , he responded. CNA-G indicated he immediately notified LPN-D and the nurse came and completed an assessment. CNA-G stated he was assisting another resident to eat when he witnessed resident #46 fall and he didn't know where the other CNA on the unit was at the time of the fall. CNA-G stated resident #46 always tried to ambulate and did not sit very much. CNA-G indicated staff try to be with the resident when ambulating, but can not always. CNA-G stated resident #46 did not utilize alarms so there wasn't any alarm sounding when the resident stood from a chair. On 02/11/16 at 2:20 p.m., surveyor # interviewed DON (Director of Nursing)-H regarding resident #46. DON-H stated the facility does complete fall investigations and staff do look at interventions in place, but only document if the interventions are not in place. DON-H stated after each resident fall, the staff complete a Fall Huddle/Investigation form and a Fall Check List. The surveyor requested to view the investigation forms. DON-H was observed to look through a pile of papers on a table in her office and only provided both forms for the 12/27/156 AM fall. DON-H was unable to locate the investigations for resident #46's remaining falls. On 02/11/16 at 2:25 p.m., surveyor # interviewed ADON (Assistant Director of Nursing)-I regarding resident #46. ADON-I verified she was the nurse who was working on the unit on 12/27/15 on the day shift at the time of resident #46's fall. ADON-I reviewed the following investigation forms with the surveyor: The Falls Huddle form included the following: ~ What time was the resident last seen before fall- ? Wandering ~ Who last saw the resident before the fall- Wandering ~ Describe needed level of assist- No assist ~ Fall alarm sounding at time of fall- N/A (not applicable) The Falls Checklist (for AM fall on 12/27/15) includes an area that directs staff to list fall interventions that are in place, suggested and added. This area was left blank and not completed. ADON-I verified she completed the investigation forms and did not complete them as directed. ADON-I stated alarms were not sounding at the time of the fall and verified resident #46's plan of care directed staff to place alarms in the w/c and bed. ADON-I stated she thought the resident was sitting in the glider chair in the resident's room and the alarm was not needed in the glider. ADON-I stated alarms are used to notify staff as the resident is very unsteady and staff are to be with the resident when ambulating. ADON-I stated she didn't ask staff where resident #46 was prior to the fall. On 02/11/16 at 3:05 p.m., surveyor # interviewed LPN-J regarding resident #46. LPN-J stated alarms are placed wherever the resident is seated. LPN-J indicated the alarms are utilized to notify staff when the resident would stand and staff were to ensure resident #46 used the walker. LPN-J stated if resident #46 used the walker, then staff did not have to stay with the resident. LPN-J indicated if resident #46 would not use the walker, then staff were to stay with the resident as resident #46 was unsteady. On 02/11/16 at 3:10 p.m., surveyor # interviewed CNA-K regarding resident #46. CNA-K stated when resident #46 was admitted to the facility, staff were not directed to stay with the resident when ambulating and as resident #46 became more unsteady, the alarms were utilized where ever the resident was seated. CNA-K stated the alarms were used to notify staff when the resident stood, as resident #46 was a high risk for falls. CNA-K indicated resident #1 ambulated all the time and if resident #46 was in the hall, staff were required to stay with the resident. CNA-K stated if resident #46 was in other areas on the unit, then staff were to supervise the resident so if the resident was going to fall, then staff could get to resident #46 prior to falling. On 02/16/16 at 9:25 a.m., surveyor # interviewed CNA-L regarding resident #46. CNA-L stated if a resident uses an alarm and would attempt ambulation, staff are required to remain with the resident as the alarm indicates the resident is a high risk for falls. On 02/16/16 at 10:05 a.m., surveyor # interviewed CNA-B regarding resident #46. CNA-B stated resident #1 was confused and would not recall conversations. CNA-B indicated alarms were placed after resident #46's first fall. CNA-B stated alarms were used to notify staff when the resident gets up and alarms were to be placed in whatever chair resident #46 sat. CNA-B indicated if resident #46 activated an alarm after waking up in the morning, then staff were to remain with the resident as resident #46 was very unsteady. CNA-B stated a short time after the resident is up, then staff did not have to remain with the resident. CNA-B indicated resident #46 had intermittent unsteadiness and would ambulate up/down the hall on the unit most of the day. Surveyor # reviewed resident #46's Neurological Assessment Flow Sheet which was completed by staff after each fall. Every flow sheet had an area where motor functions were to be documented. The motor function documentation had not been completed on any of the Neurological Assessment Flow Sheets. On 02/16/16 at 10:15 a.m., surveyor # interviewed ADON-I and DON-H regarding the motor function area that was not completed on the forms as noted above. ADON-I verified she did not complete the motor function area for the assessments she completed for the fall that occurred on 12/27/15 on the AM shift. DON-H stated there must be documentation for motor function in the progress notes. On 02/16/16 at 12:30 p.m., surveyor # interviewed DON-H relating to resident falls. DON-H stated if a resident has an alarm, the resident was assessed to be at high risk for falls. DON-H indicated staff are expected to respond to the alarms and stay with the resident if ambulating, in an attempt to prevent falls. On 02/16/16 at 2:30 p.m., surveyor # updated NHA (Nursing Home Administrator)-N and DON-H of the above findings related to resident #46. NHA-N stated the facility had a complete a mock survey in January 2016 and identified staffing was a problem on the secured unit. NHA-N stated the nurse is not assigned to the secured unit only. DON-H indicated the facility increase staffing related to the findings of the mock survey and the facility had not identified any concerns regarding resident #46's falls prior to this investigation. 2. Surveyor # reviewed the medical record of resident #4. The Admission Record, dated 2/16/16, indicated resident #4 was admitted to the facility on [DATE] with a history of multiple fractures to the pelvis, [DIAGNOSES REDACTED] following a cerebral vascular accident, difficulty walking, falling, and anxiety. The Fall Risk Evaluation completed on 2/16/16 determined resident #4 is at high risk of sustaining a fall. The fall plan of care, dated 8/8/15, indicated resident #4 was at risk for falls due to actual falls, dementia, medications, and behaviors. An intervention to include wearing hipsters (padding wore around the hips for protection in the case of a fall) as tolerated was added to the plan of care on 12/30/15. Additional interventions included a floor mat next to the bed, cradle mattress, tab alarm, and Sentury (sensor) mat while in bed and chair. Resident #4's CNA care card, dated 2/23/16, and utilized by direct care staff indicated, transfers: stand pivot with one assist. According to the Progress Notes, resident #4 has had approximately 6 falls since November of 2015. On 11/30/15, resident #4 fell on the left side resulting in a large hematoma to the left hip. In addition, on 12/30/15, hipsters were added to the plan of care after the resident had a fall. The following interviews were conducted on 2/16/16 by surveyor # regarding resident #4's hipsters: ~ 10:45 a.m., LPN-A confirmed she did not know if resident #4 was wearing hipsters. ~ 10:50 a.m., CNA-B confirmed she assisted resident #4 with morning cares and dressing. CNA-B stated she did not apply resident #4's hipsters as there were none available in the residents room or on the linen cart. CNA-B stated she did not report the missing hipsters to the nurse on duty or the laundry department in an attempt to obtain a new/clean pair of hipsters for resident #4 to wear. On 2/25/16 at 9:00 a.m., surveyor # observed resident #4 sitting in a wheelchair in the resident's room. CNA-CC and CNA-V entered resident #4's bedroom and assisted the resident with toileting. Resident #4 was seated calmly in the wheelchair. CNA-CC pushed the wheelchair into the bathroom and in front of the toilet. Without using a gait belt, CNA-CC assisted the resident to a standing position and guided the resident to pivot and sit on the toilet. When resident #4 had finished toileting, without using a gait belt, CNA-CC assisted the resident to a standing position. CNA-CC provided perineal care for resident #4. When care was completed, CNA-CC assisted the resident to sit in the wheelchair, without the use of a gait belt. On 2/25/16 at 9:15 a.m., surveyor # interviewed CNA-CC regarding the use of a gait belt when transferring residents. CNA-CC indicated a gait belt was to be used any time a resident was a one staff transfer. CNA-CC stated, there wasn't a gait belt in the bedroom .I should of put a gait belt on resident #4, but I didn't. On 2/25/16 at 9:30 a.m., surveyor # interviewed DON-H regarding the use of a gait belt when transferring residents. DON-H indicated it was the facility's standard to use a gait belt with all resident transfers. When DON-H was informed of the observation of CNA-CC not utilizing a gait belt during a transfer with resident #4, DON-H stated, I would of expected a gait belt to be used. 3. On 2/24/16, surveyor # reviewed the medical record of resident #10. The 11/12/15 facesheet contained within the medical record, indicated the resident was admitted to the facility with [DIAGNOSES REDACTED]. The initial MDS (Minimum Data Set) assessment, dated 11/19/15, documented resident #10 was moderately cognitively impaired and exhibited verbal behaviors towards others. The quarterly MDS dated [DATE], documented resident #10 exhibited wandering behaviors. The written plan of care for resident #10, initiated 11/12/15, documented the following interventions related to Cognition: ~ Cueing, reorienting as needed, dated 11/13/15 ~ Give medications as ordered, dated 11/13/15 ~ If resident upset and agitated, attempt to redirect with folding, enjoys Johnny Cash music, dated 1/28/16 ~ Keep routine consistent and try to provide consistent caregivers as much as possible, dated 11/13/15 ~ Resident behaviors are triggered by loud noises, yelling by other residents. Redirect to a quiet area, i.e. room with music, offer bathroom, dated 1/28/16 Wandering: ~ Apply wanderguard, dated 11/23/15 ~ Distract from wondering by offering pleasant diversion, dated 11/23/15 ~ Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs . Behaviors related to: easily upset with others: ~ Administer medications as ordered, dated 12/14/15 ~ Anticipate and meet needs, 12/14/15 ~ Minimize potential for resident's disruptive behaviors by offering talks which divert attention (specify) - this was left blank, dated 12/14/15 ~ Monitor behavior episodes and attempt to determine underlying cause. ~ Consider location, time of day, persons involved and situations. ~ Document behavior and potential causes, dated 12/14/15 ~ Staff member to be in view of hallway at all times to monitor resident, dated 12/14/15 ~ During group activities, gently remind (resident #10) to not to continue with attempting yelling, attempting to hit or kick. If continues to do so is disturbing other residents assist to a quieter location, dated 11/2/15 Resident #10's Nurse's Notes included the following documentation: ~ 12/2/15- wandering behaviors at 3:49 a.m. Later that same day, Resident very difficult to redirect .attempting to enter other resident's rooms. With staff direction from multiple different staff persons resident became very agitated. Resident attempted to hit staff, .stating I will do what I want . resident refused activities .resident would go into other residents rooms and take their blankets off them .very difficult to redirect . ~ 12/9/15- .saw (resident #10) approach an aide and resident #5 .resident #10 tried to take the towels that resident #5 was folding .resident #10 let go of the towels and struck resident #5 on the back of right hand .the residents began to verbally argue .fax out to update both MDs, DON aware .writer and aide within feet of incident and witnessed the entire altercation . ~ 12/10/15- resident #10 aggressor in altercation concerning another resident (resident #5). Staff reported was walking with resident #5 when resident #10 walked over and grabbed ahold of the walker. Staff tried to redirect resident #10 so that she would let go of the walker. Resident #10 refused and became more agitated .after trying some more redirection, resident #10 finally let go of walker then reached up and hit resident #5 on the right shoulder before walking away. ~ 12/12/15- saw resident #22 walking down the hall with daughter on one side and son in law on the other. Resident #10 was approaching/walking down the hallway behind them. Activity aide reported that resident #10 struck resident #22 in the middle of the back with an open palm. ~ 12/17/15- Voiding in inappropriate places - had a bowel movement in peers bed. Hard to redirect at times, .later the same day, Difficult to redirect from peers rooms. Continues to resist cares and redirection. ~ 12/18/15- Resident #10 was standing in dining room and walked up to table that had peers sitting at it. Picked up cups that were in front of peer and another resident began yelling at them for picking those cups up. Resident #10 became upset and hit resident #5 .on the back of the head with an open hand . ~ 12/19/15- Resident #10 wanders up and down the hallway .entering other resident rooms and had a bowel movement in resident #11's bed this a.m. ~ 12/24/15- Resident #10 wandering in and out of peers room and upsetting them. Voiding in inappropriate places .Did void and defecate in peers bed several times. ~ 12/31/15- Resident #10 was trying to hug and kiss resident #24 .previously resident was going in and out of peer's room and the was observed pulling up pants in the hallway .continues to go in male peers room and will hit staff when being redirected . ~ 1/20/16- Resident #10 involved in two resident to resident altercations this shift. First incident occurred late morning when resident became anxious when peer began yelling .while trying to separate the two residents, resident #5 kicked at resident #10 striking in the left shin . Second incident occurred after lunch when resident #10 was arguing with fell ow peers about a blanket .became frustrated with resident #13, grabbed resident #13's forearm .resident #10 did let go when asked . ~ 1/21/16- Resident #10 was standing in hallway when another female peer (resident #4) ran into the back of resident #10's feet and resident turned and yelled .then striking resident #4 in the head .'She hit me so I hit her back' . ~ 1/25/16- Encouraged staff to keep residents away from resident #10 at most times to avoid conflict and touch from the resident .closely monitor the spaces between resident #10 and all other residents. ~ 1/27/16- Resident was involved in a resident to resident altercation .resident #10 tried to move resident #13's wheelchair. Resident #13 then stated to leave them alone, that's when resident #10 hit resident #13 open handed on the right shoulder . Documentation presented by the facility showed 15 minute checks for resident #10 was initiated after this incident and continued until 1/29/16. ~ 2/4/16- Resident #10 and peers were eating lunch when resident #10 went over by resident #28 .yelling and pulling at her sweater .then used a blanket to hit resident #40 on the head. On 2/25/16 at 8:45 a.m., surveyor # interviewed NHA (Nursing Home Administrator)-N regarding preventing and identifying resident to resident altercations. NHA-N verified there were no interviews of other staff or residents, no further investigation, no additional records. When asked about interventions to protect the other residents on the unit, NHA-N indicated there was no formal 1:1 imitated to protect residents from the aggression of resident #10, but sometimes additional staff were added to the unit. We tried to keep resident #10 in our line of sight. NHA-N also verified medication changes were instituted. When asked about dementia training, NHA-N states that some staff that were consistent caregivers on Memory Lane, were involved in dementia training, but NHA-N had no formal, written content to share. NHA-N indicated the facility was searching alternative dementia intervention programs, but had not instituted one yet. NHA-N agreed, there did not appear residents on the dementia unit were kept safe from repeated aggression by resident #10. See F225 and F226 for additional documentation.

Based on observation, staff interview and record review, the facility did not ensure that a resident who entered the facility without a limited range of motion did not experience reduction in range of motion for 3 (residents #6, #12 and #14) of 10 residents reviewed for range of motion in a total sample of 15 residents. Resident #6 did not have deficits with ROM (Range of Motion). The facility did not identify resident #6's need for ROM to her upper extremities nor did the facility develop and implement a plan of care to prevent decline in ROM. Resident #6 was observed to have her arms/wrists in a bent position. Resident #14 did not have deficits with ROM. The facility did not identify resident #14's need for ROM to her fingers nor did the facility develop and implement a plan of care to prevent decline in ROM. Resident #14 was observed to have her fingers bent towards the palm of her hands. Resident #12 did not have deficits with ROM. The resident required total assistance with ADLs (Activities of Daily Living). The facility did not identify risk factors for a decline in ROM for resident #12 nor did the facility develop and implement a ROM program for resident #12. Findings include: Surveyor # reviewed the facility policy and procedure for ROM, dated 1/1/10. The policy and procedure indicated the purpose of ROM activities was to prevent deformities, increase mobility, lessen pain with regular exercise and joint movement, and to improve strength, endurance, balance and coordination. The policy indicated residents who would benefit from ROM were residents who demonstrated decreased ability or total inability to move one or more joints and for residents who experienced generalized weakness and inactivity resulting from alteration in cognitive function. On 10/7/10 at 10:25 a.m. surveyor # interviewed PTA (Physical Therapy Assistant)-N regarding facility practices for development of ROM. PTA-N stated nursing would notify the Therapy Department to evaluate a resident when they noticed a problem. PTA-N indicated any resident who was dependent on staff for ADLs should have a basic ROM program to prevent decline in ROM. PTA-N indicated nursing could develop a basic ROM program. 1. Surveyor # reviewed resident #6's medical record on 10/5/10. According to the face sheet, dated 8/30/10, resident #6 was admitted to the facility on [DATE]. Resident #6's [DIAGNOSES REDACTED]. The physician's progress note, dated 9/9/10, indicated resident #6 had [DIAGNOSES REDACTED], a disorder where parts of the body develop weakness/stiffness. The facility completed a data collection tool, dated 1/7/10. The data collection tool indicated resident #6's ROM was within normal limits. Surveyor # reviewed resident #6's comprehensive plan of care, dated 1/7/10, for activities, nutrition, impaired communication, pain, assist with oral care, fall risk, seat belt use, at risk for [MEDICAL CONDITION], assist with ADLs, potential for impaired skin integrity and cognitive loss. There was no direction for staff to complete ROM exercises for resident #6 to prevent a decline in ROM. The facility completed an annual MDS (Minimum Data Set), dated 1/12/10. The MDS indicated resident #6 had long and short-term memory deficits and severe cognitive impairment. The MDS indicated resident #6 had no functional limitations in ROM, but was totally dependent on staff for ADLs. Surveyor # reviewed the ADL RAP (Resident Assessment Protocol), dated 1/12/10. The review indicated resident #6 required extensive to total staff assist with all her ADLs. The RAP review did not address any risk factors for potential for decline in ROM for resident #6. The facility completed an annual MDS, dated [DATE]. The MDS indicated resident #6 continued with long and short-term memory deficits and severe cognitive impairment. The MDS indicated resident #6 had no functional limitations in ROM, but was totally dependent on staff for ADLs. Surveyor # reviewed resident #6's CNA (Certified Nursing Assistant) care card (no date when developed). The care card included directions for staff to complete ROM exercises for resident #6 five times weekly but did not indicate which joints required ROM. On 10/6/10 at 8:35 a.m. surveyor # interviewed COTA (Certified Occupational Therapy Assistant)-I regarding resident #6's ROM needs. COTA-I stated resident #6 should have been on a ROM program. COTA-I verified she could not locate a ROM program for resident #6. On 10/6/10 at 8:45 a.m. surveyor # interviewed CNA-E about ROM exercises for resident #6. CNA-E verified resident #6 was not on a ROM program. CNA-E stated she had completed AM (morning) cares that morning for resident #6 and had not completed any ROM exercises for resident #6, except with dressing. On 10/6/10 at 9:45 a.m. surveyor # interviewed COTA-I. COTA-I stated by looking at resident #6, a person would think she required ROM; but resident #6 was actually very flexible as indicated in past therapy records. COTA-I indicated ROM would have been needed for the resident's arm related to [DIAGNOSES REDACTED]. COTA-I reviewed resident #6's CNA care card and verified the care card directed staff to provide ROM five times weekly but was not specific as to which joints should receive ROM. COTA-I stated she would have resident #6 re-evaluated and a specific plan of care would be developed. On 10/6/10 at 10:55 a.m. surveyor # and CNA-E reviewed resident #6's CNA care card, which was located inside resident #6's closet in her room. CNA-E verified she was unaware resident #6 was on a ROM program, nor was she aware ROM was written on resident #6's care card. CNA-E stated resident #6's right arm was contracted, and she could barely move the resident's arm when she dressed resident #6. On 10/6/10 at 1:00 p.m. surveyor # interviewed RN (Registered Nurse)-B regarding resident #6's ROM. RN-B verified she had completed the data collection tool dated 1/7/10 and had assessed resident #6 for ROM deficits. RN-B stated she completed ROM on resident #6 herself, and resident #6 had no deficits in ROM at that time. On 10/7/10 at 8:45 a.m. surveyor # observed OTR (Registered Occupational Therapist)-J evaluate ROM for resident #6. The resident was observed to have ROM deficits in her right wrist and elbow. On 10/7/10 at 8:55 a.m. surveyor # interviewed OTR-J regarding deficits of ROM for resident #6. OTR-J verified the resident had functional ROM deficits of her right wrist and elbow. OTR-J indicated resident #6 would benefit from ROM. OTR-J stated she could not determine how long resident #6 had deficits, but by looking at a previous picture she could assume it had been for awhile. OTR-J indicated she had never evaluated resident #6 for ROM prior to 10/7/10. OTR-J indicated she would be indicating therapies work with resident #6 for ROM exercise development. 2. On 10/6/10 surveyor # reviewed resident #14's medical record. According to the face sheet, resident #14 was admitted to the facility on [DATE]. The MDS, dated [DATE], indicated resident #14 had a [DIAGNOSES REDACTED]. The facility completed a data collection tool, dated 11/15/09. The data collection tool indicated resident #14's ROM was within normal limits. The 11/24/09 MDS indicated resident #14 had long and short-term memory deficits and moderately impaired cognitive skills for daily decision making. The MDS indicated resident #14 required extensive to total assist with ADLs. The MDS indicated resident #14 had no functional limitations in ROM. Surveyor # reviewed the ADL RAP dated 11/24/09. The review indicated resident #14 required extensive to total staff assist with all her ADLs. The RAP review did not address any risk factors for potential decline in ROM for resident #14. On 10/6/10 at 3:50 p.m. surveyor # observed resident #14 sitting in her wheel chair in her room. Resident #14 was observed clenching her fingers towards the palms of her hands. On 10/6/10 surveyor # reviewed resident #14's CNA care card (no date when developed). There was no direction for ROM located on the care card. Surveyor # reviewed resident #14's comprehensive plan of care, dated 9/29/09, for ADL assistance, activities and nutrition. There was no direction for staff to complete ROM exercises for resident #14 to prevent a decline in ROM. On 10/6/10 at 3:50 p.m. surveyor # interviewed CNA-L regarding resident #14's ROM. CNA-L stated resident #14 was not on a specific ROM program, and ROM was only completed with dressing. CNA-L reviewed the CNA book where documentation of residents who required ROM was located. CNA-L verified resident #14 was not on a ROM program or there would have been a documentation record located in the CNA book. There was no documentation record for resident #14. On 10/7/10 at 7:30 a.m. surveyor # interviewed CNA-G regarding resident #14. CNA-G verified she completed morning cares for resident #14 on some mornings. CNA-G stated she did not complete any specific ROM exercises for resident #14, as the resident was not on a ROM program. On 10/7/10 at 10:00 a.m. surveyor # interviewed COTA-I regarding ROM for resident #14. COTA-I stated resident #14 was to be on a ROM program for upper extremities, which would have included exercises for bilateral shoulders. COTA-I verified resident #14 had the ROM program developed on 10/15/08. (The ROM program was located in the therapy office and not in resident #14's active medical record). On 10/7/10 at 10:10 a.m. surveyor # and COTA-I entered resident #14's room. Resident #14 was observed lying in bed with her fingers clenched towards the palms of her hands. Surveyor # observed COTA-I attempt to extend resident #14's fingers. COTA-I was able to extend the fingers on resident #14's left hand without difficulty. COTA-I began to extend resident #14's fingers on her right hand. Resident #14 displayed non-verbal signs/symptoms of pain, i.e., eyes opened wide, mouth opened wide, eyebrows furrowed. COTA-I verified resident #14 displayed non-verbal signs/symptoms of pain. COTA-I indicated she was not going to proceed further with extending resident #14's right fingers related to pain. COTA-I stated resident #14 had declined in ROM to her fingers and required heat treatments and development of ROM programs. COTA-I indicated resident #14 would probably need splint placement for her right hand. On 10/7/10 at 10:40 a.m. surveyor # interviewed LPN (Licensed Practical Nurse)-C regarding facility protocol for identification of risk factors for ROM. LPN-C stated she was not aware of any nurses who developed ROM programs for residents. LPN-C indicated therapies would get involved when a problem was identified. On 10/7/10 at 10:50 a.m. surveyor # interviewed DON (Director of Nursing)-M regarding identification of potential concerns for ROM. DON-M stated she was not aware of any nurse in the facility who developed basic ROM programs for residents who were cognitively impaired, dependent on staff for ADLs and had functional ROM. DON-M indicated when staff noted a problem in ROM for residents, therapies were notified to evaluate the resident. 3. On 10/6/10 surveyor # reviewed resident #12's medical record. According to the data collection tool, dated 2/9/10, resident #12 was admitted to the facility on [DATE]. The MDS, dated [DATE], indicated resident #12 had a [DIAGNOSES REDACTED]. The facility completed an MDS, dated [DATE], which indicated resident #12 had long and short-term memory deficits with severe cognitive impairment. The MDS indicated resident #12 required total assistance from staff for ADLs. The MDS indicated resident #12 had no functional limitations for ROM. Surveyor # reviewed the ADL RAP, dated 2/9/10. The review indicated resident #12 required extensive to total staff assist with all her ADLs. The RAP review did not address any risk factors for potential for a decline in ROM for resident #12. On 10/6/10 surveyor # reviewed resident #12's CNA care card (no date when developed). There was no direction for ROM located on the care card. Surveyor # reviewed resident #12's comprehensive plan of care, dated 2/9/10, for cognitive impairment, assistance with ADLs, and activities. There was no direction for staff to complete ROM exercises for resident #6 to prevent a decline in ROM. On 10/7/10 at 2:40 p.m. surveyor # interviewed CNA-H regarding resident #12. CNA-H verified resident #12 was dependent on staff for ADLs and only made very minimal movements of the extremities independently. On 10/6/10 at 3:50 p.m. surveyor # interviewed CNA-L regarding ROM for resident #12. CNA-L stated resident #12 was not on a specific ROM program, and ROM was completed only with dressing. CNA-L reviewed the CNA book where documentation of residents who required ROM was located. CNA-L verified resident #12 was not on a ROM program or there would have been a documentation record located in the CNA book. There was no documentation record for resident #12. On 10/7/10 at 10:05 a.m. surveyor # interviewed COTA-I regarding ROM for resident #12. COTA-I stated resident #12 continued to have functional ROM but should have a ROM program, as resident #12 was dependent on staff; and ROM should prevent future contractures.