Every finding on record at Waters Edge Health and Rehabilitation Center

Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R2) of 4 sampled residents. On 5/21/2026, R2 was involved in a resident-to-resident altercation. The facility did not provide adequate supervision to prevent the resident-to-resident altercation. Findings include: R2 was admitted to the facility on [DATE] with diagnosis that includes Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life) and adult maltreatment (encompasses the physical, emotional, or sexual abuse, neglect, financial exploitation, or self-neglect of a vulnerable adult (18 or older)). R2's admission Minimum Data Set (MDS) assessment dated [DATE] documents that R2 has a Brief Interview for Mental Status score of 00 indicating severe cognitive impairment, hallucinates, has delusions, wanders and is independent with ambulation. R2's Care Plan indicates R2 is/has potential to be physically aggressive, by touching other residents/staff related to anger, dementia and poor impulse control, initiated on 11/20/2025 with the following interventions:-administer medications as ordered. Monitor/document side effects and effectiveness.-Assess and anticipate needs-Assess coping skills and support system-Assess understanding of the situation-Monitor verbally aggressive behaviors. Document observed behavior and attempted interventions-Psychiatric/Psychogeriatric consult as indicated-Staff approach calmly, use soft tone of voice, and clearly explain care.-Staff will prioritize active engagement and routine presence in common areas.- When agitated, intervene before escalation, guide away from source of stress, engage calmly in conversation; if response is aggressive, staff to walk away and approach later.-triggers for physical aggression when peers pace by R2's room or enter R2's room. Behaviors are de-escalated by redirection.-provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of agitation, assist to set goals for more pleasant behavior and encourage seeking out staff when agitated.-monitor stop signs across door. R2's progress note dated 5/21/2026 at 9:21 AM, by Social Services-D, documents in part: R2 exhibiting abusive language. R2 appears to be experiencing an increase in this expression, this expression is care planned and R2 is receiving psych services.R2's progress note dated 5/21/2026 at 9:43 AM, by Social Services-D, documents in part: R2 exhibiting wandering. This expression is care planned and R2 is receiving psych services.Per the Facility's Misconduct Report, R2 was involved in a resident-to-resident altercation on 5/21/2026 at 11:45 AM. R2 was observed bringing personal items into the dining room to pack to go see R2's friend who recently moved to another unit. R1 walked past R2's items that were brought into the dining room and R2 responded by pushing R1 with an open hand because R1 was too close to R2's belongings. R1 and R2 were immediately separated, police were notified, Physician and R2's power of attorney were notified and increased supervision for R2 was initiated. Skin assessments and pain evaluations were completed for R1 and R2 with no injuries noted.On 6/10/2026, at 10:00 AM, Surveyor observed R2 wandering the hallway on the unit until eventually sat in the common area breifly for coffee. On 6/10/2026, at 11:22 AM, Surveyor interviewed Social Services-D who indicated she did not observe the incident but went to the unit after it occurred. Social Services-D informed Surveyor that R2 is very protective of their belongings. Social Services-D spoke with R2 following the incident and R2 indicated being very upset that R1 was by R2's belongings. Social Services-D encouraged R2 to bring their belongings back to their room with no further incident. In collaboration with the intradisciplinary team (IDT), R2's care plan interventions were reviewed and revised. Surveyor asked Social Services-D about Social Services-D's progress note indicating an increase in behavior R2 was exhibiting just prior to the incident occurring. Social Services-D indicated that when a behavior is triggered in the electronic health record, usually by a Certified Nursing Assistant in the tasks section, Social Services-D receives an alert and follows up on the triggered behavior. Social Services-D indicated that the behavior may have been from the previous day and was unable to clarify when R2 was experiencing the behaviors Social Services-D was following up on. Social Services-D notified psych services after the incident occurred and indicated she would expect an increase in monitoring and supervision to occur for R2 when they have an increase in behaviors.On 6/10/2026, at 1:20 PM, Surveyor interviewed Unit Manager-C who indicated R2 is known to be territorial over their belongings and care plan interventions have been in place to keep other residents out of R2's room for this reason. Unit Manager-C indicated that she was called to the floor after the incident between R1 and R2. Unit Manager-C observed R2 in the dining room with 2 plastic bags filled with R2's belongings and R2 stating fucking cunt taking my things. R2 was placed on 15-minute checks following the incident and the care plan was updated to include encouraging R2 to keep belongings in their room. Unit Manager-C informed Surveyor that when R2 exhibits an increase in behaviors, Unit Manager-C expects to be notified and increase supervision to be implemented.On 6/10/2026, at 3:02 PM, Surveyor informed the Facility of the concerns regarding R2.On 6/11/2026, at 10:35 AM, Surveyor interviewed DON-B who indicated that she would expect R2 to have an increase in supervision when experiencing and increase in behaviors to prevent altercations between R2 and other residents from occurring. No further information was provided.

Based on interviews and record review, the facility did not ensure a resident-to-resident altercation was thoroughly investigated for 1 (R2) of 1 resident-to-resident altercation reviewed.On 5/21/2026, R2 was involved in a resident-to-resident altercation. The Facility did not interview all staff that were present on the unit at the time of the incident.Findings include:The facility policy with a last reviewed date of 11/8/2023, titled Abuse, Neglect and Exploitation documents, in part: It is the policy of the facility that each individual will be free from Abuse . It is the policy of this facility that reports of abuse are promptly and thoroughly investigated . The investigation is the process used to try to determine what happened . Investigation of abuse includes identifying and interviewing others who might have knowledge of the allegations .R2 was admitted to the facility on [DATE] with diagnosis that includes Dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life) and adult maltreatment (encompasses the physical, emotional, or sexual abuse, neglect, financial exploitation, or self-neglect of a vulnerable adult (18 or older)). R2's admission Minimum Data Set (MDS) assessment dated [DATE] documents that R2 has a Brief Interview for Mental Status score of 00 indicating severe cognitive impairment, hallucinates, has delusions, wanders and is independent with ambulation. Surveyor reviewed the Facility provided file for R2's resident-to-resident altercation investigation and noted the following:Per the Facility's Misconduct Report, R2 was involved in a resident-to-resident altercation on 5/21/2026, at 11:45 AM. R2 was observed bringing personal items into the dining room to pack to go see R2's friend who recently moved to another unit. R1 walked past R2's items that were brought into the dining room and R2 responded by pushing R1 with an open hand because R1 was too close to R2's belongings. R1 and R2 were immediately separated, police were notified, Physician and R2's power of attorney were notified. Skin assessments and pain evaluations were completed for R1 and R2 with no injuries noted.Surveyor reviewed the Facility provided file for R2's resident-to-resident altercation investigation and noted the following:A statement by Certified Nursing Assistant (CNA)-E, indicating CNA-E was passing lunch trays on the unit when she heard someone yelling from the dining room. CNA-E ran to the dining room and saw R1 getting up from the floor and R2 was standing over R1. CNA-E asked R1 what happened and R1 indicated R2 pushed them down. CNA-E then went to get management.There were no other staff statements provided by the Facility.

Based on interview and record review, the facility did not timely report and thoroughly investigate allegations of abuse (sexual, physical, and verbal) and did not take proactive steps to prevent further potential abuse. This has the potential to affect all 30 residents on the dementia unit. The facility did not ensure that residents on the unit were protected while the investigation should have been in progress. R89 has a history at the facility of resident-to-resident incidents including punching residents and yelling and swearing at other residents. In addition, R89 has grabbed arms, kicking and punched and hit staff in the face during cares. Supervision for R89 was only increased at time of incidents but then was not continued to prevent further incidents. *On 4/19/25, an allegation of resident-to-resident altercation involving R89 and R122 was reported immediately to Nursing Home Administrator (NHA)-A. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. *On 6/4/25, R89 was observed in R110's room, a female resident with a history of sexual assault was inappropriately sexually touched by R89. R89 was on R89's knees at R110's bedside. R110's brief was off, was not covered with a sheet or blanket, and R89 was observed with R89's hand on R110's vaginal area. The allegation of sexual assault was not reported to the State Survey Agency within 2 hours, was not reported to law enforcement, and was not thoroughly investigated. *On 8/10/25, R89 was observed to have R89's hand under R110's shirt. The allegation of abuse was not reported to the State Survey Agency within 2 hours and was not thoroughly investigated. *On 4/19/25, R89 was observed punching R122 in the face in which R122 sustained a skin tear to the left cheek. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. *On 6/28/25, R89 was observed verbally abusing and physically threatening R39. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. Staff reported R106 is known to have physical aggression towards R121 and staff reported observed escalating behaviors of R106 towards R121. The facility did not ensure R121 was free from verbal and physical abuse by R106 residing in the facility. *On 3/17/25, R106 was observed repeatedly hitting R121 with a pillow. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. *On 4/30/25, R106 was heard to physically threaten R121 by stating R106 wanted to cause bodily harm and cause bleeding. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. On 8/30/25, R64 and R46 were involved in an unwitnessed physical altercation which resulted in R64 receiving a red mark and 2 small cuts to the right side of her face. On 9/5/25, R64 and R46 were in the dining room without staff providing one-to-one monitoring and again got into a physical altercation. R64 was struck by R46 leaving her with a small scratch to the right side of her face, her left cheek was red, and left eye was slightly swollen. Both resident-to-resident altercations were not thoroughly investigated. R64 alleged that R37 said R37 would hurt R64. The investigation was not thoroughly investigated as no staff were interviewed to see if they had any knowledge of this or any previous concerns regarding R37. The failure of the facility to immediately report allegations of abuse to the State Survey Agency, its failure to complete a thorough investigation of the allegations of abuse, and its failure to put measures in place to prevent further potential abuse led to the finding of Immediate Jeopardy (IJ), which started on 3/17/25. On 9/2/25, at 4:28 PM, Nursing Home Administrator (NHA)-A, and Director of Nursing (DON)-B were informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 9/30/25. The deficient practice continues at a scope and severity (S/S) of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings Include: The facility's Abuse, Neglect and Exploitation policy and procedure last reviewed/revised 7/12/25 documents: “Guideline: It is the guideline of this facility to provide protections for the health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has zero tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property.”… …2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3.The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written… …”V. Investigation of Alleged Abuse, Neglect, and Exploitation A. An immediate investigation is warranted when suspicion of abuse. neglect, or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigation include: 1.Identifying staff responsible for investigation 2.Exercising caution in handling evidence that could be used in a criminal investigation 3. Investigating different types of alleged violations 4.Identifying and interviewing all involved persons, including alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations 5.Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause 6.Providing complete and thorough documentation of the investigation”… …”VI Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. C. Increased supervision of the alleged victim and residents D. Room or staffing changes if necessary, to protect resident(s) from the alleged perpetrator E. Protection from retaliation F. Providing emotional support and counseling to the Resident during and after the investigation, as needed G. Revision of the resident's care plan if the resident's medical, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse”… …”VII Reporting/Response A. The facility will have written procedures that include: 1.Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. b. Not later than 24 hours if the vents that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. It is important staff feel comfortable to report all concerns by assuring that reporters are free from retaliation or reprisal. 3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint.”… …”VIII Coordination with QAPI A. The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program. 1. Cases of physical or sexual abuse, for example by facility staff or other residents, will be reviewed for and receive corrective action and tracking by the QAA Committee. This coordinated effort results in the QAA Committee determining: a. If a thorough investigation is conducted b. Whether the resident is protected c. Whether an analysis was conducted as to why the situation occurred d. Risk factors that contributed to the abuse e. Whether there is further need for systemic action such as: i. Insight on needed revisions to the policies and procedures that prohibit and prevent abuse/neglect/misappropriation/exploitation ii. Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about iii. Efforts to educate residents and their families about how to report any alleged violations without fear of repercussions. iv. Measures to verify the implementation of corrective actions and timeframes. v. Tracking patterns of similar occurrences. 1.) R89 was admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia, Unspecified Severity with Agitation (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Depression(mood disorder that causes persistent feelings of sadness and loss of interest), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Visual Hallucinations (sensory experiences where a person sees objects, people, or scenes that are not actually present. R89 currently has a legal guardian. R89's Quarterly Minimum Data Set (MDS) completed 5/19/25 documents R89's Brief Interview for Mental Status (BIMS) score to be 0 indicating R89 demonstrates severely impaired skills for daily decision making. R89's MDS documents R89's Patient Health Questionnaire (PHQ-9) score to be 0 R89's MDS also documents R89 has no range of motion (ROM) impairment. R89's care card instructing nursing staff in the care of R89 as of 8/25/25 documents: --Correct R89 when using incorrect words to promote word finding Initiated 7/22/25 R89 has sleep deprivation due to dementia. Initiated 4/9/25 --Assess for underlying physiological illnesses causing sleep loss, assess for level of agitation. Initiated 4/9/25 --Keep environment quiet for sleeping. Initiated 4/9/25 --Obtain a sleep wake history Initiated 4/9/25 R89 has experienced trauma due to (this is blank) Triggers that have potential to re-traumatize me (Provide Examples) Sound, smell, touch, taste, sight, other. (this is blank) Once I experience a trigger, I may display these signs/symptoms: anxiety/edginess, overwhelming, anger/irritability, changes in mood state, nightmares, change in sleep pattern, confusion/disorientation, pain/achiness, muscle tension, extreme alertness/hypervigilance, withdrawal/avoidance of activities, other Initiated 2/24/25 Revised 5/14/25 R89 is at risk for mood impairment due to depression and anxiety Initiated 2/13/25 --Monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Initiated 2/13/25 --Monitor/record/report to MD as needed mood patterns signs of symptoms depression, anxiety, sad mood as per facility behavior monitoring protocols. Initiated 2/13/25 R89 has behavior problems refusing cares, combative, yelling, grabbing, and displaying loving affection towards females. R89 has hallucinations. Surveyor noted this is not specified. Initiated 2/13/25 Revised 7/11/25 --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. Initiated 2/13/25 --If reasonable, discuss R89's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to R89. Initiated 2/13/25 --Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated 2/24/25 --Praise any indication of R89's progress/improvement in behavior. Initiated 2/24/25 --Remind R89 that R89's niece wants R89 to work with staff. Initiated 2/24/25 --Explain all procedures to R89 before starting and allow R89 extra time to adjust to changes. Initiated 4/15/25 --Offer a quiet setting. Initiated 4/15/25 --Caregivers to provided opportunity for positive interaction, attention. Stop and talk with R89 as passing by. Initiated 4/15/25 --Provide support to room. Initiated 4/15/25 --Re-approach R89 when initially unapproachable. Initiated 4/15/25 --Allow R89 time to be more independent with cares. Initiated 5/7/25 --Offer coffee per R89's preference to help assist with cares. Initiated 5/14/25 --Offer R89 a shower once a day. R89 is calmer after receiving shower. Initiated 7/11/25 --Monitor for hallucinations. Initiated 7/11/25 --R89 enjoys watching funny animal videos. Initiated 7/17/25 --When becoming agitated offer to take R89 outside. Initiated 7/21/25 --R89 to be 1:1 when out of room. Initiated 8/3/25 R89's Trauma Informed Care completed 6/4/25 documents R89 has experienced physical assault. On 6/24/25 an allegation of abuse was reported between R89 and R110. R110 was admitted to the facility on [DATE] with diagnoses that include Bipolar (episodes of mood swings ranging from depressive lows to manic highs) and Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities),. R110 currently has a legal guardian. R110's Quarterly Minimum Data Set (MDS) completed 7/25/25 documents R110 demonstrates severely impaired skills for daily decision making with recent and remote memory loss. R110's MDS documents R110's Patient Health Questionnaire (PHQ-9) score to be 0. R110's MDS also documents R110 has no range of motion (ROM) impairment. R110's care card instructing nursing staff in the care of R110 as of 8/25/25 documents: -9/10/24 Keep door open at night as R89 allows to anticipate needs R110 is high risk based upon sex offender and behavior evaluation. R110 shows sexual urges through masturbation. R110 has not made any sexual behaviors towards staff or peers. R110 has poor understanding of safety for self. Initiated 2/27/24 --Report sexual behaviors to charge nurse or social worker. Initiated 2/27/24 R110 has a behavior problem R110 will sit on the floor, sleeping without R110's clothes on and crawl around, sexual behaviors, and exit seeking. Created 2/6/24 Initiated 5/22/25 --If reasonable, discuss R110's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to R110. Initiated 2/6/24 --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. Initiated 2/6/24 *On 6/4/25, an allegation of sexual abuse involving R89 and R110 was immediately reported by Anonymous (Anon)-Q to Unit Manager (UM)-F. Anon-Q reported that R89 was observed in R110's room. R110 was in a low bed to the ground, without a brief on, and no sheet or blanket covering R110. R89 was observed kneeling on R89's knees next to R110's bed with R89's hand on R110's vaginal area. Anon-Q wrote out a written statement. Human Resources (HR)-L also provided a written statement as HR-L had been walking with Anon-Q at the time. On 8/25/25, at 2:30 PM, Surveyor interviewed Anon-Q. Anon-Q informed Surveyor that Anon-Q observed R89 touching R110 on R110's vaginal area. Anon-Q described that R89 was out of R89's wheelchair on R89's knees next to R110's bed which was in the lowest position. R89's hand was on R110's vaginal area. R110's brief was off and R110 was uncovered with no sheet or blanket. Anon-Q stated Anon-Q had to physically lift R89 up and position R89 back in R89's wheelchair and removed R89 from R110's room. Anon-Q immediately informed Unit Manager (UM)-F. Anon-Q stated that R89 and R110 would often be together and R89 would go into R110's room. Anon-Q stated that R89 has always been “touchy feely” with R110. Anon-Q stated staff were always trying to separate R89 and R110. Anon-Q wrote a statement of what Anon-Q observed and was told by administration to “keep an eye on him”. Anon-Q was informed NHA-A had to look at “tapes.” Staff was informed that R89 was only in R110's room for 30 seconds so nothing could have happened. On 8/25/25, at 3:44 PM, NHA-A informed Surveyor that the camera tapes from 6/10/25 have been taped over. NHA-A stated that the camera footage only goes back to 7/18/25. NHA-A informed Surveyor that R89 was not in R110's room long enough for anything to happen. On 8/26/25, at 8:07 AM, Human Resources (HR)-L informed that HR-L submitted a written statement. HR-L did observe R89 in R110's room, but HR-L stated that HR-L did not see R89 touching R110. HR-L did observe that R110 was not wearing a brief and heard Anon-Q ask R110 if R110 was ok. On 8/26/25, at 2:01 PM, Surveyor interviewed Unit Manager (UM)-F. UM-F is aware of R89 going into R110's room. UM-F stated that UM-F helped interview R89 and R110 as instructed. UM-F denies instructing anyone to complete vaginal checks of all females on the unit after the incident between R89 and R110. UM-F is aware of R89 going into R110's room. UM-F stated that when R110 is unclothed, R110's door should be shut and the stop sign put across the doorway. On 8/26/25, at 9:00 AM, NHA-A informed Surveyor that both the “CNA and HR” had said R89 never touched R110. NHA-A stated that NHA-A watched cameras and that it “was less than 10 seconds” that R89 was in R110's room. NHA-A stated that both R110 and R89 were interviewed about the incident and both R110 and R89 denied. Surveyor questioned how R110 and R89 with severely impaired skills could understand the questions being asked. NHA-A stated it was okay because they were interviewed right after and would have given valid answers despite their severely impaired cognitive skills, memory impairment documented in both R110 and R89's electronic medical record (EMR). On 8/26/25, Surveyor was provided a “soft file” by NHA-A. Statements obtained by NHA-A via phone indicates staff did not observe anything and camera footage indicated R89 was not in the room for more than 28 seconds. The typed staff statements are not signed by the employee and only signed by NHA-A. UM-F and DC-M provided statements that R89 and R110 denied any interaction dated 6/4/25. All other typed staff statements are dated 6/5/25. On 8/26/25, at 10:06 AM, Anon-Q again provided the exact same details of the sexual assault between R89 and R1as in previous interview. Anon-Q confirmed that R89 was touching R110's vaginal area. Anon-Q confirmed putting a statement in writing. The allegation of sexual assault was not reported to the State Survey Agency within 2 hours, was not reported to law enforcement, and was not thoroughly investigated. The care plan was not updated to protect other residents from further potential abuse. On 8/25/25, at 10:54 AM, Surveyor asked Anonymous (Anon)-N about the allegation of R89 between R89 and R110 on 6/4/25. Anon-N stated, “that's an interesting question because it was not on the 24-hour board”. The 24-hour board is the nurse's communication between nurses. Anon-N is aware that a ‘sexual assessment' was completed on every female resident on the unit. Anon-N also informed Surveyor that R89 had an incident of being sexually inappropriate the day before 6/4/25. Anon-N stated that R89 was known to get into other resident rooms. Anon-N describes R89 as confused, agitated, and not easy to redirect. Anon-N states that R89 gets triggered very easily. On 8/25/25, at 1:01 PM Anonymous (Anon)-P informed Surveyor that Anon-P was aware of the allegation of sexual abuse between R89 and R110. Anon-P stated that NHA-A stated it never happened. Anon-P informed Surveyor that R110 frequently takes off R110's brief and prefers to have R110's brief off and pull legs up into chest almost like in the ‘fetal position'. Anon-P also stated it was common for R89 to wander in and out or rooms and was attracted to R110. Anon-P stated that R110 would frequently take off R110's brief and be in bed naked from the waist down. Anon-P stated administration knew that R89 was obsessed and attracted to R110. Anon-P informed Surveyor that it was a common thing for R110 to take R110's briefs off and go up into the fetal position, with R110's legs open so it could have easily happened with R89 touching R110 in the amount of time administration is stating R89 was in the room. On 8/26/25, at 7:35 AM, Social Worker (SW)-D cannot remember anything that happened in June between R89 and R110 but was informed of the incident between R89 and R110. SW-D stated that R110 likes to sleep naked and R89 went into R110's room. SW-D was informed that R89 was not in R110's long enough for anything to happen. SW-D described R89 to be agitated and will yell. SW-D stated that R89 will wander into other rooms. SW-D stated that R89 likes R110 and has been in R110's room, and staff are supposed to keep a close on R89. On 8/26/25, at 8:10 AM, Anonymous (Anon)-R informed Surveyor that R89 can be very much sexually inappropriate and is sexually aggressive with words. Anon-R was informed to keep an eye on R89. Anon-R stated that R89 has had multiple resident-to-resident altercations. Anon-R stated that Anon-R stays clear of R89 because R89 punched Anon-R in the mouth causing injury. On 8/26/25, at 2:38 PM, Director of Nursing (DON)-B informed Surveyor that there was “not enough time for anything to happen”. DON-B then stated that NHA-A “was a big part of the investigation.” DON-B informed Surveyor that R89 was only in the room for 9 seconds so there was not enough time to do anything. Surveyor asked DON-B about who instructed nursing staff to complete vaginal checks on the female residents on the unit. DON-B does not know and was not aware this was done. On 8/26/25, Surveyor on the team conducted an EMR review of all female residents on the unit. Currently there are 19 females. On 6/4/25, a nurse documented a ‘vaginal assessment' was completed on two female residents and a third female resident refused the vaginal assessment. On 8/26/25, at 3:31 PM, Dementia Coordinator (DC)-M informed Surveyor that DM-M was instructed to perform an inspection of all the females on the unit by NHA-A. DC-M described an inspection as providing incontinence cares and DM-M was checking for drainage and redness. Surveyor asked DC-M why DC-M was completing this task. DC-M stated, “that was the day R89 was in R110's room”. DC-M stated it was completed in an “abundance of care”. DC-M stated that DC-M completed on 3 residents including R110 but then was told to stop by NHA-A. DC-M did not document this task. DC-M stated that DC-M was looking for redness in the vagina area, discharge in the brief of the female residents. DC-M then stated that vaginal check was really “an inspection.” DC-M stated that not all residents were inspected because R89 was not in the room long enough because it was a ‘brief short moment in time” and there was no contact. *On 8/10/25 a second allegation of abuse involving R89 and R110 was reported. Anonymous (Anon)-W documented in R89's electronic medical record (EMR): …”Writer was notified by CNA that R89 tried to put his hand under R110's shirt. When R89 was redirected, R89 became very agitated. Writer notified DON and supervisor. Per DON to start 1:1 with R89 and monitor behaviors.”… On 8/27/25, at 3:51 PM, NHA-A informed Surveyor that there was camera footage, and it never happened, but there is a soft file that NHA-A will provide. Surveyor shared the concern that an allegation of R89 putting R89's hand under R110's shirt was not reported to the State Agency and a thorough investigation was not completed. On 8/28/25, at 8:25 AM, Surveyor observed the camera footage. At 1.04.24, Surveyor observed R110 in R110's wheelchair with R110's legs up in the air, in the hallway next to the handrail. At 1.04.31, R89 comes up from behind, and 1.04.43, pulls R110's wheelchair closer to R89. At 1.04.54, R89 grabs R110's hands with left hand and right hand goes to bottom of R110's shirt. An unknown resident approaches both R110 and R89 and stands in front of both R110 and R89 and a clear view is obstructed. At 1.05.28, R110 pulls arms and hands away from R89. At 1.05.36, R89 grabs R110's hands again and places R89's hands with R110's hands close or on R110's chest. At 1.05.53, Anonymous (Anon)-HH is observed coming behind R110 and pulled R110 backward towards the dining room. R89 is observed following R110. On 8/28/25, at 9:18 AM, Surveyor left message for Anon-HH and did not receive a call back during the survey process. On 8/28/25, at 9:27 AM, Surveyor spoke with Anon-W. Anon-W stated it was Anon-W's first time working the unit. Anon-W stated a CNA reported to Anon-W that R89 was attempting to put R89's hand under R110's shirt. Anon-W reported to administration right away and was instructed to place R89 on 1:1 supervision right away and keep R89 and R110 separated. Surveyor reviewed the facility's provided soft file statements. Anon-W's statement states that Anon-HH reported R89 touching R110 inappropriately. The statement obtained by the facility does not specify what the inappropriate touching was. Anon-HH's facility statement also does not refer to what the inappropriate touching was. The typed facility staff statements are not signed by the employee or administration. On 9/2/25, at 12:16 PM, Surveyor interviewed NHA-A in regard to R89 and R110's allegation of sexual abuse. NHA-A stated that R89 was in R110's room for “seconds”. NHA-A stated, because R89 was only in the room for seconds, nothing could have happened. NHA-A states “CNA saw R89 still in R89's chair”, and then stated “R89 was observed trying to climb out of the chair”. NHA-A stated that NHA-A would have reported if there were witnesses who reported that R89 “actually” touched R110. Surveyor provided information from interviews to NHA-A. “If I had statements, I would have reported it.” NHA-A stated, “If people would just tell us the truth. I don't get why they would not be honest. I can't help staff lie. What can I do when they lie?” NHA-A confirmed a facility reported incident was not submitted to the State Survey Agency. Surveyor spoke with NHA-A about the 8/10/25 incident between R89 and R110 and the allegation of inappropriate touching. NHA-A stated that the call went to DON-B and that R89 and R110 were only holding hands which the families are okay with. NHA-A stated that staff “thought something could happen but never saw anything.” Surveyor shared the allegation was documented and R89's care plan with interventions was not updated and put in place to prevent further abuse from occurring. Surveyor share the allegation should have been reported to the State Agency. NHA-A confirmed that the incidents had not been reported to the State Agency. Surveyor notes that a thorough investigation was not completed in regard to the allegation of R89 inappropriately sexually touching R110 two times. NHA-A confirmed that NHA-A did not believe the incidents happened between R89 and R110, despite staff expressing it did based on observations. Surveyor notes there is no Misconduct Incident Report submitted by the facility to the State Survey Agency. 2.) R122 was admitted to the facility on [DATE] with diagnoses of Alzheimer's(progressive disease that destroys memory and other important mental functions), Unspecified Dementia, Severe, with Agitation(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Essential Hypertension(most common type of high blood pressure), and Anemia(lack of blood). R122 had an activated Health Care Power of Attorney (HCPOA) while at the facility. R122's admission MDS documents R122 has recent/remote memory loss and demonstrates severely impaired skills for daily decision making. R122's MDS documents R122 has continuous inattention. R122's Patient Health Questionnaire (PHQ-9) scored a 2 indicating minimal depression. R122's MDS also documents physical and verbal behaviors and rejection of care 1-3 days and wandering 4-6 days. R122 has no range of motion (ROM) impairment. R122 requires partial/moderate assistance for eating and upper dressing. R122 requires substantial/maximum assistance for showers and lower dressing. R122 is independent for mobility and transfers. *On 4/19/25, an allegation of resident-to-resident altercation between R89 and R122 was reported immediately to NHA-A. It was reported that R89 had punched R122 in the face causing a skin tear to the left cheek. On 8/25/25, at 1:01 PM, Surveyor interviewed Anonymous (Anon)-P in regard to the incident between R89 and R122. Anon-P stated that R89 thought R122 had called R89 a clown. R89 swung out and Anon-P heard R122 say “ouch.” Anon-P observed a small cut on the outside of R122's left cheek. It was reported that NHA-A stated that NHA-A watched cameras, and it never happened and that R122 bit the inside of R122's lip. Anon-P stated R122 had a fresh injury on the outside of R122's left cheek. Surveyor reviewed R122's EMR and notes that R122 has a completed initial wound assessment dated [DATE] that documents R122 has a new skin tear to the face, however, no other details are documented. On 8/26/25, at 10:42 AM, Surveyor interviewed Anonymous (Anon)-S in regard to the incident between R89 and R122. Anon-S stated that Anon-S was present the night R89 punched R122. Anon-S heard the punch. Anon-S was at the nurse's station and R89 and R122 were in front of the nurse's station. Anon-S back was turned at the time, but Anon-S heard the punch. Anon-S observed R89 have a stance like R89 had just hit R122 and R122 was holding R122's lip. Anon-S reported it immediately to NHA-A. Anon-S was then informed by NHA-A that NHA-A had watched the cameras and R122 had hit R122's self. Anon-S stated that R122's cheek had to be cleaned and treated. Anon-S stated that R89 is physically aggressive with other residents. On 8/27/25, at 3:51 PM, Surveyor interviewed NHA-A about the incident between R89 and R122. NHA-A stated that R122 bit the inside of R122's cheek and nothing happened because the CNA stated R89 and R122 never connected. NHA-A confirmed there is no facility soft file with s

Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administration was not promoting the highest practicable mental and psychosocial well-being of residents by failing to implement procedures based on the facility Abuse, Neglect, and Exploitation policy and procedure last revised 7/12/25. Multiple staff were aware R89 and R106 were unpredictable. R89 had multiple resident-to-resident altercations, as well as punching staff in the face and was sexually inappropriate to staff and residents. Staff informed administration of R89's physical aggression and sexual behaviors to administration. Staff warned administration that R106 was escalating in behaviors towards R121. Furthermore, as Surveyor attempted to investigate the abuse allegations, the facility attempted to intimidate staff to limit the information shared with State Agency staff as well as not maintain accurate documentation of staff statements in regard to allegations of abuse. Staff who have reported abuse on the dementia unit have been terminated by the facility and suspended during the survey process. This deficient practice has the potential to affect all 30 residents residing on the dementia unit within the facility at the time of the survey.During a complaint survey conducted on 8/25/2025-9/2/2025, it was determined 11 deficiencies existed including the deficient practice at F835 (Administration). Each of the deficiencies identified systemic issues within the facility that were not addressed by facility administration through established processes. Three of the deficiencies have been identified to be deficient at a severity level of immediate jeopardy at a scope of pattern. Additionally, systemic concerns were identified with the environment, including pest control, reporting of abuse allegations, treatment/services for dementia, specialized services, quality of care, and treatment/services for pressure injuries.*On 4/19/25, an allegation of resident-to-resident altercation involving R89 and R122 was reported immediately to Nursing Home Administrator (NHA)-A. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F600, F607 F609, F610)*On 6/4/25, R89 was observed in R110's room, a female resident with a history of sexual assault was inappropriately sexually touched by R89. R89 was on R89's knees at R110's bedside. R110's brief was off, was not covered with a sheet or blanket, and R89 was observed with R89's hand on R110's vaginal area. The allegation of inappropriate sexual contact was not reported to the State Survey Agency within 2 hours and was not thoroughly investigated. (Cross reference F600, F607 F609, F610)*On 8/10/25, R89 was observed to have R89's hand under R110's shirt. The allegation of inappropriate sexual contact was not reported to the State Survey Agency within 2 hours and was not thoroughly investigated. (Cross reference F600, F607 F609, F610)*On 4/19/25, R89 was observed punching R122 in the face in which R122 sustained a skin tear to the left cheek. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F600, F607 F609, F610)*On 6/28/25, R89 was observed verbally abusing and physically threatening R39. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F600, F607 F609, F610)*On 3/17/25, R106 was observed repeatedly hitting R121 with a pillow. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F600, F607 F609, F610)*On 4/30/25, R106 was heard to physically threaten R121 by stating R106 wanted to cause bodily harm and cause bleeding. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours and was not thoroughly investigated. (Cross reference F600, F607 F609, F610)*Staff are in fear of retaliation and do not know what to report to administration.The administration's failure to review what happened with R110,R26, R121, R57, R122, and R39, its failure to implement procedures to ensure that vulnerable residents were protected from abuse or further potential abuse, its failure to follow the policy and procedure to ensure staff was free from retaliation, its failure to develop a plan for monitoring R89 and R106 and ensuring the safety of all residents on the dementia unit, and its failure to ensure all staff were not intimidated by administration, not feeling able to freely speak to Surveyor staff or there would be negative consequences up to losing their jobs, created a finding of Immediate Jeopardy (IJ) beginning on 3/17/25.On 9/2/25, at 4:28 PM, Nursing Home Administrator (NHA)-A, and Director of Nursing (DON)-B were informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 10/30/25. The deficient practice continues at a scope and severity (S/S) of an F (potential for harm/widespread) as the facility continues to implement their action plan.Findings Include:The Facility Assessment Tool dated 8/1/24 was provided to Surveyor. The Facility Assessment Tool was reviewed with QAPI on 8/6/24. Surveyor notes the Facility Assessment Tool has not been reviewed on an annual basis. Surveyor notes the facility documented an average of 45 residents have behavioral health needs. The facility also documents the facility can manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma,/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities, substance use disorder. As part of providing person-centered/directed care the facility documents specific care related to preventing abuse and neglect.Surveyor's investigation includes information to demonstrate the facility was aware of R89's history of touching R110 in the past that was not addressed based on staff interviews.Facility records indicate R89 has a history of inappropriate sexual behavior. Additionally, a care plan indicated R89 has behavior problems of yelling, grabbing, displaying loving affection towards females, refusing cares, and combative. R89 has active orders for psychotropic medication(s) and use behavior management related to visual hallucinations. The facility had an awareness of R89's likelihood to engage in sexually inappropriate behavior and did not take steps to prevent it from occurring.The facility did not ensure R110, a vulnerable adult who is unable to verbalize due to severely impaired cognitive skills and who is unable to protect herself due to R110's limited physical mobility was free from sexual abuse and did not protect other residents from possible abuse. R110 triggered on R110's trauma assessment as having experienced sexual and physical assault.The facility was aware R89's behaviors of hitting, punching, grabbing, yelling, and swearing at other residents and staff. R89 triggered on R89's trauma assessment as having experienced physical assault. The facility did not increase and maintain supervision resulting in R89 verbally and physically abusing R26, R57, R122, and R39. R89 continues to wander in/out of resident rooms.*On 6/4/25, an allegation of sexual abuse involving R89 and R110 was immediately reported by Anonymous 5 (Anon)-Q to Unit Manager (UM)-F. Anon-Q reported that R89 was observed in R110's room. R110 was in a low bed to the ground, without a brief on, and no sheet or blanket covering R110. R89 was observed kneeling on R89's knees next to R110's bed with R89's hand on R110's vagina area. Anon-Q wrote out a written statement. Human Resources (HR)-L also provided a written statement as HR-L had been walking with Anon-Q at the time.The allegation was reported immediately by staff to administration; however, the allegation was not reported to the State Survey Agency, law enforcement, and was not thoroughly investigation. Administration informed Surveyor that the allegation never happened due to R89 not being in R110's room for a long enough time.The facility provided a 'soft file' containing typed employee statements with only administration signature and the statements do not match the statements provided to Surveyor of the employees.*On 8/10/25, Anonymous 11 (Anon)-W documented in R89's electronic medical record(EMR):.Writer was notified by CNA that R89 tried to put his hand under R110's shirt. When R89 was redirected, R89 became very agitated. Writer notified DON and supervisor. Per DON to start 1:1 with R89 and monitor behaviors.On 8/27/25, at 3:51 PM, NHA-A informed Surveyor that there was camera footage, and it never happened, but there is a soft file that NHA-A will provide. Surveyor shared the concern that an allegation of R89 putting R89's hand under R110's shirt was not reported to the State Agency and a thorough investigation was not completed. The allegation was reported immediately by staff to administration, however, the allegation was not reported to the State Survey Agency and was not thoroughly investigation. Administration informed Surveyor that the allegation never happened due to camera footage.The facility provided a 'soft file' containing typed employee statements with only administration signature and the statements do not match the statements provided to Surveyor of the employees and documentation located in R89's EMR.*On 4/19/25, an allegation of resident-to-resident altercation between R89 and R122 was reported immediately to NHA-A. It was reported that R89 had punched R122 in the face causing a skin tear to the left cheek.The allegation was reported immediately by staff to administration; however, the allegation was not reported to the State Survey Agency and was not thoroughly investigated. Administration informed Surveyor that the allegation never happened due to camera footage of what looks like R122 hitting R122's self.The facility did not provide a soft file of statements.*On 6/28/25, an allegation of verbal abuse and physical threatening involving R89 and R39 was not reported immediately to NHA-A and was not reported to the State Survey Agency within 24 hours.The allegation was not reported immediately by staff to administration. The facility did not report the allegation to the State Survey Agency and was not thoroughly investigated. Administration informed Surveyor that the allegation never happened because it was the perception of the staff member at the time.The facility provided a 'soft file' containing typed employee statements with only administration signature and the statements do not match the statements provided to Surveyor of the employees.*The facility did report to the State Survey Agency a resident-to-resident altercation involving R89 who punched R57, a female resident in the face on 7/6/25.*The facility did report to the State Survey Agency a resident-to-resident altercation involving R89 who punched R26 in the face on 8/3/25.R89 had 2 separate incidents of inappropriate sexual contact with R110. R89 had 4 separate incidents of physical and/or verbal abuse towards 4 residents.The facility did not complete a thorough investigation of the incidents resulting in R89's continued abuse of residents on the unit. Administration was notified by staff of continued concerns and allegations and is aware of R89's physical aggression towards residents and staff. Despite administration's knowledge regarding the abuse allegations, R89 has continued to abuse residents.Staff reported R106 is known to have physical aggression towards R121 and staff reported observed escalating behaviors of R106 towards R121. The facility did not ensure R121 was free from verbal and physical abuse by R106 residing in the facility.*On 3/17/25 an allegation of resident-to-resident altercation of R106 hitting R121 with a pillow was immediately reported to NHA-A.R121's EMR documents that nursing staff were monitoring R121 for a resident-to-resident altercation.The allegation was reported immediately by staff to administration. The facility did not report the allegation to the State Survey Agency and was not thoroughly investigated. Administration informed Surveyor that the allegation did not happen.The facility provided a 'soft file' containing typed employee statements with only administration signature and the statements do not match the statements provided to Surveyor of the employees.*On 4/30/25, an allegation of verbal abuse and physical threatening involving R106 and R121 was reported immediately to NHA-A and was not reported to the State Survey Agency within 24 hours. The allegation was not thoroughly investigated. Administration informed Surveyor that the staff member should not have written:Anonymous - (Anon)-X documented on 4/30/25 that a . CNA reported to Anon-X that she witnessed R106 threatening R121. Writer informed Unit Manager and who returned with instructions to monitor R106 and R121 this evening closely. NOC nurse updated. R106 placed on 24 hour board.The facility provided a 'soft file' containing typed employee statements with only administration signature and the statements do not match the statements provided to Surveyor of the employees.Facility staff informed Surveyor that administration was aware R106, who was roommates with R121, was having a difficult time with R121 in the room and had repeatedly asked to be moved out of the room. R106 had behaviors like throwing juice at R121 leading up to the resident-to-resident altercation on 3/17/25.Surveyor also notes that R106 is barricading R106's self in R106's room at night. When asked by Surveyor as to why, R106 reports R106 has feelings of wanting to kill R89 because R89 continues to wander in R106's room. R106 reports R106 will hear the chair move, and this is R106's solution. Staff confirmed R106 is barricading R106's self at night.On 8/25/25, at 10:54 AM, Surveyor interviewed Anonymous (Anon)-N who describes the dementia unit where the residents reside as very chaotic and make for very long days. Anon-N does not feel supported by administration. Anon-N reports staff do not have a say in the care of residents or consulted for person-centered interventions.On 8/25/25, at 1:01 PM, Anonymous (Anon)-P informed Surveyor that there are 4-5 residents who require a lot of supervision on the dementia unit, so it is impossible to keep 1:1 supervision at times on R89. Anon-P stated the staff are overloaded with cares on the unit. Administration has never given just one person to maintain 1:1 supervision on R89 and have been told it is the responsibility of the staff working on the dementia unit. Anon-P stated that when an incident happens there is never an investigation. Administration blames the staff. Anon-P stated, When you tell administration, they don't do anything or reply.On 8/25/25, at 2:30 PM, Surveyor interviewed Anonymous (Anon)-Q. Anon-Q states it is not safe on the dementia unit. R89 is punching residents. We are told to keep an eye on R89 but there is not enough staff to supervise R89 and care for all the other residents. Typically, there is 3 certified nursing assistants and 1 nurse on days and PMs.On 8/26/25, at 8:10 AM, Surveyor interviewed Anonymous (Anon)-R. Anon-R stated that Anon-R was punched in the mouth by R89. Anon-R stated that administration hides everything, and staff are told that 1:1 supervision for R89 is not in the budget and that it is on the staff who are working the unit which at time of survey process had a census of 30 residents. Anon-R has a fear of retaliation if Anon-R reports or speaks up about anything. Anon-R especially fears retaliation from Unit Manager (UM)-F and feels the position of UM is a conflict of interest. Anon-R states Anon-R cries everyday but can't leave because Anon-R is afraid who will care for the residents on the dementia unit.On 8/26/25, at 10:06 AM, Anon-Q informed Surveyor that Anon-Q had written out a statement in regard to R89 going into R110's room and touching R110 on the vagina area so a picture was taken of the statement because staff felt something might happen to the written statement and the incident would get covered.On 8/26/25, at 1:42 PM, Psychologist (Psych)-C has not been involved with any staff training on the dementia unit.On 8/26/25, at 2:01 PM, UM-F informed Surveyor that staff have not come to UM-F and stated they are afraid working on the unit.On 8/27/25, at 7:05 AM, Anonymous (Anon)-N stated to Surveyor that Anon-2 has not received any trainings specific to the dementia unit, Anon-N stated there is only a couple of staff left from over a year ago so not everyone has had the training. There has been a high turnover of staff lately on the dementia unit.On 8/27/25, at 10:04 AM, Surveyor was informed by Anon-X that Anonymous (Anon)-U was drilled by administration after speaking with Surveyor on 8/26/25. Administration wanted to know what Anon-U had said to Surveyor. Anon-X stated that Anon-U was very uncomfortable, nervous, and having severe anxiety and Anon-X tried to help Anon-U through the shift. Anon-X stated the fear of retaliation is evident. People speaking up are now fired for no reason. Anon-X has a fear of retaliation.On 8/27/25, at 10:12 AM, Anon-U confirmed to Surveyor that Anon-U was approached by administration before speaking with Surveyor on 8/26/25. Administration told Anon-U to tell Surveyor that R89 is not violent. Anon-U was approached by UM-F after speaking with Surveyor and wanted to know what Anon-U had said to Surveyor. Anon-U stated Anon-U chose not to disclose to UM-F and then was also approached by Director of Nursing (DON)-B and wanted to know what Anon-U said and what did the Surveyor ask. Anon-U chose not to disclose to DON-B. Anon-U stated it was very distressing to have UM-F and DON-B do that. Anon-U has a fear of retaliation, especially now that administration knows Anon-U has spoken with Surveyor.On 8/28/25, at 8:48 AM, Anon-Q confirmed that Anon-Q did not receive any training or training materials to assist with interventions for residents on the dementia unit. Anon-Q stated there have been so many altercations on the dementia unit. Anon-Q stated staff stopped reporting and charting because nothing gets done and staff are afraid of getting fired if they do report. Anon-Q stated, We don't know what to report anymore.On 8/28/25, at 10:37 AM, Anonymous (Anon)-II stated Anon-II never received trainings for the dementia unit. They put so many trainings in front of our faces.On 8/28/25, at 2:51 PM, Surveyor interviewed Anonymous (Anon)-X. Anon-X stated that Anon-X was terminated for not reporting abuse of R106 verbally abusing and physically threatening R121. Anon-X documented that management had been informed of the incident. Surveyor reviewed Anon-X's disciplinary action form dated 5/9/25. It is documented that Anon-X did not report an allegation of abuse and was terminated over the phone. However, Surveyor notes the facility did not report the allegation of abuse to the State Survey Agency. Anon-X expressed that the dementia unit has been stable for years until recently and other staff have been terminated that worked the unit.On 9/2/25, at 12:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regards the allegations of abuse that were not reported to the State Survey Agency and thoroughly investigated as well as R89's continued abuse towards residents and staff as evident by an additional 2 facility reported incidents of R89 punching 2 residents in the face. NHA-A stated the criteria for the dementia unit is for a resident to have a dementia diagnosis and to be able to benefit from activities. The goal is for residents who experience 'mid' dementia would appropriate for the unit. Staff should have the ability, thought processes, and interventions to take care of the residents on the dementia unit. Surveyor discussed the concern that staff have provided statements in regard to the 6 allegations of abuse not reported to the State Survey Agency or thoroughly investigated indicating there was validity of the incident that staff reported to administration. NHA-A stated that NHA-A is in charge of working an allegation of abuse from beginning to end including reporting and conducting a thorough investigation. Criteria is based on what NHA-A is informed of. If there is a true witness, will take their statement and then go to the cameras. NHA-A stated NHA-A would error on the side of caution and report. NHA-A stated NHA-A does not know why staff would document something not accurate in the EMR or tell NHA-A something different in an interview. Surveyor asked NHA-A what the process is of collecting statements from staff when an allegation of abuse is reported. NHA-A stated the interviews are conducted over the phone and NHA-A will type what the staff member is stating. NHA-A will check with the staff member verbally what was stated. NHA-A does not have the staff member review and acknowledge the statement is accurate or gather written statements. If there are no eyewitnesses, then the allegation of abuse did not happen. If a nurse puts a note in an EMR that is inaccurate and the investigation is already completed, nor further action is taken. No one is telling the staff to document and staff should not be charting something they did not see. NHA-A stated that staff have gotten terminated because they did not line up with the plan. NHA-A stated that had NHA-A had the statements from staff, NHA-A would have reported. Surveyor shared the serious concern that once an allegation of abuse is reported, there is an obligation for the facility to report the allegation of abuse and complete a thorough investigation. NHA-A stated, if people would just tell me the truth. I don't get why people would not be honest. I can't help that staff lie, what can I do when they lie?On 9/2/25, at 3:06 PM, Anon-Q informed Surveyor that Anon-Q had been suspended upon arriving for shift today. Anon-Q asked Social Worker (SW)-E, why, for telling the truth? Anon-Q stated, I did nothing wrong. They always fire people. I feel defeated. You can't report anything. I know I am going to get fired. Surveyor notes that Anon-Q was crying during the interview.Surveyor notes that six allegations of abuse reported by staff on the dementia unit were not reported and thoroughly investigated. Staff no longer are confident in reporting allegations of abuse and fear retaliation by administration. Staff do not feel trained to adequately provide care and services to the residents on the dementia unit and do not feel supported by administration to provide person-centered interventions.The failure of administration to ensure the building was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident created a situation of Immediate Jeopardy. The facility removed the jeopardy on 10/30/25 when had completed the following:* Residents reviewed for proper placement on Dementia Unit. 2 Residents identified as needing placement with active efforts for discharge to proper community placement.* admission team aware of additional review to be conducted, when possible placement on Dementia Unit, to ensure resident aligns with unit's goals and bed availability is appropriate.* Employee Feedback form initiated to solicit feedback and solutions when staff see an opportunity and desire to remain anonymous or not.* Facility initiated new tool from the Center of Excellence Post-Behavior Root Cause Analysis (RCA) form, providing additional insight to residents when behaviors occur - this tool utilizes a team approach (huddle) to gain knowledge of behaviors/events. Facility Staff completed this tool for those residents with known behaviors on the dementia unit to further care plan any additional interventions that may reduce resident to resident interactions and behaviors.* Regional Human Resources Director onsite and initiated interviews with current staff* Administrator of Sister Facility, Social Services background, provided remote review of focused Dementia Unit residents to provide additional suggestions and feedback for interventions, and providing on-site support to assist efforts on 9/30/25.* Current Nursing Home Administrator was placed on administrative leave by Director of Operations* Re-Education by Director of Operations, to Interdisciplinary Team (Dementia Unit focused) immediately to include the following. Use of Post-Behavior Root Cause Analysis (RCA) Form. Re-Education by IDT, to Facility Staff immediately include the following. Use of Employee Feedback Form. Facility Staff that have not yet received the re-education, and required to complete, will have these items completed prior to their next scheduled shift.* Monitor: Review of Post-Behavior Root Cause (RCA) completion for behaviors completed 5 days a week for 1 week, then 3 days a week for 2 weeks and 1 x week for 3 weeks.* Use of Employee Feedback Form reviewed upon receipt 5 days per week for 1 week, then 3 days a week for 2 weeks then 1 day a week for 3 weeks.* Ad Hoc QAPI Held on 9/29/25 to discuss the above actions taken.

Based on observation, interview, and record review the facility failed to ensure residents were free from verbal, physical, and sexual abuse between residents residing on the facility's dementia unit. This deficient practice had the potential to affect all 30 residents residing on the facility's dementia unit.12 different allegations/incident of resident to resident abuse were identified during the survey. Facility records indicate R89 has a history of inappropriate sexual behavior. Additionally, a care plan indicated R89 has behavior problems of yelling, grabbing, displaying loving affection towards females, refusing cares, and combative. The facility had an awareness of R89's likelihood to engage in sexually inappropriate behavior and did not take steps to prevent it from occurring. Despite this known history, supervision for R89 was only increased at time of incidents but then was not continued to prevent further incidents: *On 4/19/25, an allegation of resident-to-resident altercation involving R89 and R122 was reported immediately to Nursing Home Administrator (NHA)-A. *On 6/4/25, R89 was observed in R110's room (a female resident with a history of sexual assault) touching her inappropriately. R89 was on R89's knees at R110's bedside. R110's brief was off and was not covered with a sheet or blanket. R89 was observed with R89's hand on R110's vaginal area *On 8/10/25, R89 was observed to have R89's hand under R110's shirt. *On 4/19/25, R89 was observed punching R122 in the face in which R122 sustained a skin tear to the left cheek. *On 6/28/25, R89 was observed verbally abusing and physically threatening R39. *On 9/8/25 R89 was found sitting on R110's bed at 3:43 PM. R89 was on 1:1 supervision on day and PM shifts and should not have had access to R110's room. This is the third encounter between R89 and R110. Surveyor's investigation demonstrates the facility was aware of R89's history of touching R110 in the past that was not addressed based on staff interviews. Staff reported R106 is known to have physical aggression towards R121 and staff reported escalating behaviors of R106 towards R121. The facility did not ensure R121 was free from verbal and physical abuse by R106 residing in the facility. *On 3/17/25, R106 was observed repeatedly hitting R121 with a pillow. *On 4/30/25, R106 was heard to physically threaten R121 by stating R106 wanted to cause bodily harm and cause bleeding. *On 9/22/25 R105 grabbed R46's arm and slapped R46's arm in the dining room. *On 9/23/25 R11 grabbed R77's arm, R77 moved and R11 grabbed R77's arm harder. *On 9/24/25 R89 threw an object that hit R11 in the forehead. *On 9/25/25 R11 grabbed R46's arm and attempted to bite R46. *On 8/30/25, R64 and R46 were involved in an unwitnessed physical altercation which resulted in R64 receiving a red mark and 2 small cuts to the right side of her face. The facility's immediate intervention was to separate both R64 and R46 and place R64 on one-to one-monitoring. The facility failed to keep R64 safe by providing dedicated staff to perform the one-to-one monitoring. The facility did not update R64's plan of care or instruct the staff how to maintain one- to one supervision. On 9/5/25, R64 and R46 were in the dining room without staff providing one-to-one monitoring and again got into a physical altercation. R64 was struck by R46 leaving her with a small scratch to the right side of her face, her left cheek was red, and left eye was slightly swollen. The facility's failure prevent abuse created a finding of immediate jeopardy that began on 3/17/25. On 9/2/25, at 4:28 PM, Nursing Home Administrator (NHA)-A, and Director of Nursing (DON)-B were informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on 9/30/25. The deficient practice continues at a scope and severity (S/S) of a E (potential for harm/pattern) as the facility continues to implement their action plan. Findings Include: The facility's Abuse, Neglect and Exploitation policy and procedure last reviewed/revised 7/12/25 documents: …”Guideline: It is the guideline of this facility to provide protections for the health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has zero tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property.”… …”Definitions: “Abuse” means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. “Alleged Violation” is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. “Physical Abuse” includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. “Sexual Abuse” is non-consensual sexual contact of any type with a resident. “Verbal Abuse” means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.”… ** R89 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity with Agitation (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Depression (mood disorder that causes persistent feelings of sadness and loss of interest), Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Visual Hallucinations(sensory experiences where a person sees objects, people, or scenes that are not actually present. R89 currently has a legal guardian. R89's Quarterly Minimum Data Set (MDS) completed 5/19/25 documents R89's Brief Interview for Mental Status (BIMS) score to be 0 indicating R89 demonstrates severely impaired skills for daily decision making. R89's MDS documents R89's Patient Health Questionnaire (PHQ-9) score to be 0. R89's R89's MDS also documents R89 has no range of motion (ROM) impairment. R89 has experienced trauma due to (this is blank) Triggers that have potential to re-traumatize me (Provide Examples) Sound, smell, touch, taste, sight, other. (this is blank) Once I experience a trigger, I may display these signs/symptoms: anxiety/edginess, overwhelming, anger/irritability, changes in mood state, nightmares, change in sleep pattern, confusion/disorientation, pain/achiness, muscle tension, extreme alertness/hypervigilance, withdrawal/avoidance of activities, other Initiated 2/24/25 Revised 5/14/25 R89 is at risk for mood impairment due to depression and anxiety Initiated 2/13/25 --Monitor/document/report as needed any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Initiated 2/13/25 --Monitor/record/report to MD as needed mood patterns signs of symptoms depression, anxiety, sad mood as per facility behavior monitoring protocols. Initiated 2/13/25 R89 has behavior problems refusing cares, combative, yelling, grabbing, and displaying loving affection towards females. R89 hallucinates. Initiated 2/13/25 Revised 7/11/25 --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. Initiated 2/13/25 --If reasonable, discuss R89's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to R89. Initiated 2/13/25 --Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated 2/24/25 --Praise any indication of R89's progress/improvement in behavior. Initiated 2/24/25 --Remind R89 that R89's niece wants R89 to work with staff. Initiated 2/24/25 --Explain all procedures to R89 before starting and allow R89 extra time to adjust to changes. Initiated 4/15/25 --Offer a quiet setting. Initiated 4/15/25 --Caregivers to provided opportunity for positive interaction, attention. Stop and talk with R89 as passing by. Initiated 4/15/25 --Provide support to room. Initiated 4/15/25 --Re-approach R89 when initially unapproachable. Initiated 4/15/25 --Allow R89 time to be more independent with cares. Initiated 5/7/25 --Offer coffee per R89's preference to help assist with cares. Initiated 5/14/25 --Offer R89 a shower once a day. R89 is calmer after receiving shower. Initiated 7/11/25 --Monitor for hallucinations. Initiated 7/11/25 --R89 enjoys watching funny animal videos. Initiated 7/17/25 --When becoming agitated offer to take R89 outside. Initiated 7/21/25 --R89 to be 1:1 when out of room. Initiated 8/3/25 R89's Trauma Informed Care completed 6/4/25 documents R89 has experienced physical assault. 1.) On 6/24/25 there was an allegation of abuse between R89 and R110. R110 has diagnoses that include Metabolic Encephalopathy (brain dysfunction resulting from underlying condition that disrupts the metabolic processes), Bipolar(episodes of mood swings ranging from depressive lows to manic highs), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities),. R110's Quarterly Minimum Data Set (MDS) completed 7/25/25 documents R110 demonstrates severely impaired skills for daily decision making with recent and remote memory loss *On 6/4/25, Anon-Q reported that R89 was observed in R110's room. R110 was in a low bed to the ground, without a brief on, and no sheet or blanket covering R110. R89 was observed kneeling on R89's knees next to R110's bed with R89's hand on R110's vaginal area. Anon-Q wrote out a written statement. Human Resources (HR)-L also provided a written statement as HR-L had been walking with Anon-Q at the time. On 8/25/25, at 2:30 PM, Surveyor interviewed Anon-Q. Anon-Q informed Surveyor that Anon-Q observed R89 touching R110 on R110's vagina area. Anon-Q described that R89 was out of R89's wheelchair on R89's knees next to R110's bed which was in the lowest position. R89's hand was on R110's vaginal area. R110's brief was off and R110 was uncovered with no sheet or blanket. Anon-Q stated Anon-Q had to physically lift R89 up and position R89 back in R89's wheelchair and removed R89 from R110's room. Anon-Q immediately informed Unit Manager (UM)-F. Anon-Q stated that R89 and R110 would often be together and R89 would go into R110's room. Anon-Q stated that R89 has always been “touchy feely” with R110. Anon-Q stated staff were always trying to separate R89 and R110. Anon-Q wrote a statement of what Anon-Q observed and was told by administration to “keep an eye on him”. Anon-Q was informed NHA-A had to look at “tapes”. Staff was informed that R89 was only in R110's room for 30 seconds so nothing could have happened. On 8/26/25, at 8:07 AM, Human Resources (HR)-L informed that HR-L submitted a written statement. HR-L did observe R89 in R110's room, but HR-L stated that HR-L did not see R89 touching R110. HR-L did observe that R110 was not wearing a brief and heard Anon-Q ask R110 if R110 was ok. On 8/26/25, at 9:00 AM, NHA-A informed Surveyor that both the “CNA and HR” had said R89 never touched R110. NHA-A stated that NHA-A watched cameras and that it “was less than 10 seconds” that R89 was in R110's room. NHA-A stated that both R110 and R89 were interviewed about the incident and both R110 and R89 denied. Surveyor questioned how R110 and R89 with severely impaired skills could understand the questions being asked. NHA-A stated it was okay because they were interviewed right after and would have given valid answers despite their severely impaired cognitive skills, memory impairment documented in both R110 and R89's electronic medical record (EMR). On 8/26/25, at 10:06 AM, Anon-Q again provided the exact same details of the sexual assault between R89 and R110 as in previous interview. Anon-Q confirmed that R89 was touching R110's vaginal area. Anon-Q confirmed putting a statement in writing. On 8/26/25, at 10:19 AM, Surveyor was provided a copy of Anon-Q's written statement by Anon-P via email. On 8/25/25, at 3:44 PM, NHA-A informed Surveyor that the camera tapes from 6/10/25 have been taped over. NHA-A stated that the camera footage only goes back to 7/18/25. NHA-A informed Surveyor that R89 was not in R110's room long enough for anything to happen. On 8/25/25, at 10:54 AM, Surveyor asked Anonymous (Anon)-N about the allegation of R89 between R89 and R110 on 6/4/25. Anon-N stated, “that's an interesting question because it was not on the 24-hour board”. The 24-hour board is the nurse's communication between nurses. Anon-N is aware that a ‘sexual assessment' was completed on every female resident on the unit. Anon-N also informed Surveyor that R89 had an incident of being sexually inappropriate the day before 6/4/25. Anon-N stated that R89 was known to wander in other resident rooms. Anon-N describes R89 as confused, agitated, and not easy to redirect. Anon-N states that R89 gets triggered very easily. On 8/25/25, at 1:01 PM Anonymous 4 (Anon)-P informed Surveyor that Anon-P was aware of the allegation of sexual abuse between R89 and R110. Anon-P stated that NHA-A stated it never happened. Anon-P informed Surveyor that R110 frequently takes off R110's brief and prefers to have R110's brief off and pull legs up into chest almost like in the ‘fetal position'. Anon-P also stated it was common for R89 to wander in and out of rooms and was attracted to R110.Anon-P stated that R110 would frequently take off R110's brief and be in bed naked from the waist down. Anon-P stated administration knew that R89 was obsessed and attracted to R110. Anon-P informed Surveyor that it was a common thing for R110 to take R110's briefs off and go up into the fetal position, with R110's legs open so it could have easily happened with R89 touching R110 in the amount of time administration is stating R89 was in the room. On 8/26/25, at 8:10 AM, Anonymous 6 (Anon)-R informed Surveyor that R89 can be very much sexually inappropriate and is sexually aggressive with words. Anon-R was informed to keep an eye on R89. Anon-R stated that R89 has had multiple resident-to-resident altercations. Anon-R stated that Anon-R stays clear of R89 because R89 punched Anon-R in the mouth causing injury. On 8/26/25, at 12:37 PM, Surveyor interviewed Anonymous (Anon)-G. Anon-G stated that R89 is “touchy feely” with R110. R89 will grab R110's shoulders and rub R110's shoulders. Anon-G has seen R89 kiss R110. R89 would initiate the kissing and R110 would kiss back. Anon-G observed R89 hugging and kissing R110. A couple of months ago Anon-G observed R89 kissing R110 in R110's room. After the 6/10/25 incident between R89 and R110, staff were informed to keep R89 and R110 separated. Anon-G stated that R89 can be disruptive and is supposed to have supervision but does not always have the supervision. On 8/26/25, at 2:01 PM, Surveyor interviewed Unit Manager (UM)-F. UM-F is aware of an incident at the end of June where R89 and R110 were kissing each other. UM-F is aware of R89 going into R110's room. UM-F is aware of R89 going into R110's room. UM-F stated that when R110 is unclothed, R110's door should be shut and the stop sign put across the doorway. On 8/26/25, at 2:38 PM, Director of Nursing (DON)-B informed Surveyor that there was “not enough time for anything to happen”. DON-B then stated that NHA-A “was a big part of the investigation”. DON-B informed Surveyor that R89 was only in the room for 9 seconds so there was not enough time to do anything. On 8/27/25, at 7:10 AM, Anonymous (Anon)-V described R89 has unpredictable and will switch very quickly. Anon-V stated that R89 can be aggressive a lot. 2.) On 8/10/25, Anonymous 11 (Anon)-W documented in R89's electronic medical record (EMR): …”Writer was notified by CNA that R89 tried to put his hand under R110's shirt. When R89 was redirected, R89 became very agitated. Writer notified DON and supervisor. Per DON to start 1:1 with R89 and monitor behaviors.”… On 8/27/25, at 3:51 PM, NHA-A informed Surveyor that there was camera footage, and it never happened, but there is a soft file that NHA-A will provide On 8/28/25, at 8:25 AM, Surveyor observed the camera footage. At 1.04.24, Surveyor observed R110 in R110's wheelchair with R110's legs up in the air, in the hallway next to the handrail. At 1.04.31, R89 comes up from behind, and at 1.04.43, pulls R110's wheelchair closer to R89. At 1.04.54, R89 grabs R110's hands with left hand and right hand goes to bottom of R110's shirt. An unknown resident approaches both R110 and R89 and stands in front of both R110 and R89 and a clear view is obstructed. At 1.05.28, R110 pulls arms and hands away from R89. At 1.05.36, R89 grabs R110's hands again and places R89's hands with R110's hands close to or on R110's chest. At 1.05.53, Anonymous (Anon)-HH is observed coming behind R110 and pulled R110 backward towards the dining room. R89 is observed following R110. On 8/28/25, at 9:18 AM, Surveyor left message for Anon-HH and did not receive a call back during the survey process. On 8/28/25, at 9:27 AM, Surveyor spoke with Anon-W. Anon-W stated it was Anon-W's first time working the unit. Anon-W stated a CNA reported to Anon-W that R89 was attempting to put R89's hand under R110's shirt. Anon-W reported to administration right away and was instructed to place R89 on 1:1 supervision right away and keep R89 and R110 separated. Surveyor reviewed the facility's provided soft file statements. Anon-W's statement states that Anon-HH reported R89 touching R110 inappropriately. The statement obtained by the facility does not specify what the inappropriate touching was. Anon-HH's facility statement also does not refer to what the inappropriate touching was. The typed facility staff statements are not signed by the employee or administration. On 9/2/25, at 12:16 PM, Surveyor interviewed NHA-A in regard to R89 and R110's allegation of sexual abuse. NHA-A stated that R89 was in R110's room for “seconds.” NHA-A stated, because R89 was only in the room for seconds, nothing could have happened. NHA-A states “CNA saw R89 still in R89's chair”, and then stated “R89 was observed trying to climb out of the chair”. Surveyor spoke with NHA-A about the 8/10/25 incident between R89 and R110 and the allegation of inappropriate touching. NHA-A stated that the call went to DON-B and that R89 and R110 were only holding hands which the families are okay with. NHA-A stated that staff “thought something could happen but never saw anything.” 3.) R122 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's (progressive disease that destroys memory and other important mental functions), and Unspecified Dementia, Severe, with Agitation (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life),. R122 had an activated Health Care Power of Attorney (HCPOA) while at the facility. R122's admission MDS documents R122 has recent/remote memory loss and demonstrates severely impaired skills for daily decision making. R122's MDS documents R122 has continuous inattention. *On 4/19/25, an allegation of resident-to-resident altercation between R89 and R122 was reported immediately to NHA-A. It was reported that R89 had punched R122 in the face causing a skin tear to the left cheek. On 8/25/25, at 1:01 PM, Surveyor interviewed Anonymous (Anon)-P in regard to the incident between R89 and R122. Anon-P stated that R89 thought R122 had called R89 a clown. R89 swung out and Anon-P heard R122 say “ouch”. Anon-P observed a small cut on the outside of R122's left cheek. It was reported that NHA-A stated that NHA-A watched cameras, and it never happened and that R122 bit the inside of R122's lip. Anon-P stated R122 had a fresh injury on the outside of R122's left cheek. Surveyor reviewed R122's EMR and notes that R122 has a completed initial wound assessment dated [DATE] that documents R122 has a new skin tear to the face, however, no other details are documented. On 8/26/25, at 10:42 AM, Surveyor interviewed Anonymous (Anon)-S in regard to the incident between R89 and R122. Anon-S stated that Anon-S was present the night R89 punched R122. Anon-S heard the punch. Anon-S was at the nurse's station and R89 and R122 were in front of the nurse's station. Anon-S back was turned at the time, but Anon-S heard the punch. Anon-S observed R89 have a stance like R89 had just hit R122 and R122 was holding R122's lip. Anon-S reported it immediately to NHA-A. Anon-S was then informed by NHA-A that NHA-A had watched the cameras and R122 had hit R122's self. Anon-S stated that R122's cheek had to be cleaned and treated. Anon-S stated that R89 is physically aggressive with other residents. On 8/27/25, at 4:17 PM, Surveyor interviewed Anonymous (Anon)-T. Anon-T stated that Anon-T was at the nurse's station at the time of the incident between R89 and R122. Anon-T observed R89 punch R122 around the lip area. Anon-T stated that there was definite contact between R89 and R122. Anon-T saw R89 hit R122, and Anon-T stated that Anon-T had to get between R89 and R122 and separate R89 and R122. Anon-T stated R89 is combative and wanders up and down the hallway. Anon-T stated that R89 has punched multiple staff in the face. Anon-T described R89 as having violent tendencies, very unpredictable, would get very angry and quickly switch moods. On 8/27/25, at 3:51 PM, Surveyor interviewed NHA-A about the incident between R89 and R122. NHA-A stated that R122 bit the inside of R122's cheek and nothing happened because the CNA stated R89 and R122 never connected. NHA-A confirmed there is no facility soft file with staff statements of the incident between R89 and R122. NHA-A shared that R89 is quick to temper and impulsive. NHA-A stated R89's Seroquel has been increased and R89 is more stable now. 4.) R39 was admitted to the facility on [DATE] with diagnoses that include Unspecified Dementia, Unspecified Severity, with Anxiety (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R39's admission MDS documents R39 has a Brief Interview for Mental Status (BIMS) score of 4 indicating R39 demonstrates severely impaired skills for daily decision making. R39 has no mood issues. R39's MDS also documents physical behaviors and other behaviors 1-3 days. *On 6/28/25, an allegation of verbal abuse and physical threatening involving R89 and R39 was reported. On 6/28/25, Anonymous (Anon)-T documented in R89's EMR: …”so R89 began verbally harassing R39 as well, calling R39 expletives and threatening to physically assault R39. “… On 8/26/25, at 2:51 PM, Surveyor interviewed Anon-T regarding R89 threatening R39. Anon-T stated, “it was textbook definition. Harm without injury”. Anon-T stated that R89 became enraged. Anon-T stated R89 was yelling and swearing at R39 and threatened to physically assault R39. Anon-T stated the AM Certified Nursing Assistants (CNAs) had to calm R89 down. Anon-T confirmed to Surveyor that R89 was verbally abusive towards R39 and confirmed R89 threatened to physically assault R39. On 7/1/25, Director of Nursing (DON)-B documented: …”Summary of investigation provides enough information to show nurse charted what she perceived not what actually happened and no threatening remarks were actually made.”… On 9/2/25, at 1:26 PM, Surveyor interviewed DON-B in regard to the incident between R89 and R39. DON-B stated that Anon-T just assumed what was said or done. DON-B stated that DON-B quickly read the documentation and spoke with Anon-T. On 8/28/25, at 2:51 PM, Anonymous 12 (Anon-X) stated that R89 almost came to blows with another resident back in March. Anon-X notified DON-B who informed Anon-X, “if something happens, call the police.” Anon-X described R89 as “straight up violent.” Anon-X stated R89 hit a CNA so hard, the CNA had to go to the hospital. Anon-X also stated that R89 would be sexually inappropriate with staff. Surveyor reviewed the facility's soft file of typed staff statements provided about the incident between R89 and R39. The typed facility staff statements are not signed by the employees. Anon-T's statement does not match what Anon-T confirmed in an interview with Surveyor. 5.) R106 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia and Hemiparesis Following Cerebral Infarction(complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Metabolic Encephalopathy (brain dysfunction resulting from underlying condition that disrupts the metabolic processes), Depression(mood disorder that causes persistent feelings of sadness and loss of interest), Delusional Disorder (delusions are a specific symptom of psychosis related to thought disorder or mood disorder), and Visual Hallucinations(sensory experiences where a person sees objects, people, or scenes that are not actually present). R106 has a legal guardian. R106's Quarterly MDS completed 7/23/25 documents R106's BIMS score is 12, indicating R106 demonstrates moderately impaired skills for daily decision making. R106's PHQ-9 score is 10, indicating R106 has moderate depressive symptoms. R106's MDS documents hallucinations and delusions. R106's MDS document verbal and physical behaviors, and rejection of care 1-3 days. *On 3/17/25 an allegation of resident-to-resident altercation of R106 hitting R121 with a pillow was immediately reported to NHA-A. R121's EMR documents that nursing staff were monitoring R121 for a resident-to-resident altercation. R121 has diagnoses that include Hemiplegia and Hemiparesis Following Cerebral Infarction (complete paralysis on one side of body and partial/incomplete weakness on one side following stroke) and Vascular Dementia (brain damage caused by multiple strokes). R121 has a legal guardian. R121‘s Quarterly MDS documents R121 has short and long term memory impairment and demonstrates moderately impaired skills for daily decision making. R106's EMR documents that R106 had a room change and being monitored post resident to resident altercation. …”R106 did not make contact with R121 that the altercation took place with.”… On 8/25/25, at 1:01 PM, Surveyor interviewed Anon-P in regard to the resident-to-resident altercation between R106 and R121. Anon-P stated R106 attacked R121 with a pillow and staff had to physically get between R106 and R121. Anon-P stated staff couldn't leave the room so Anon-P texted NHA-A. NHA-A sent 3 staff up to help. Staff knew something was going to happen. R106 had been unhappy and wanted to move out of the room for a long time. R121 would cough a lot and not cover R121's mouth. R106 had been threatening R121. R106 had thrown juice at R121 prior to the altercation and Anon-P stated NHA-A had been told to get R106 out of R121's room. On 8/26/25, at 9:52 AM, Surveyor interviewed Anon-P again. Anon-P stated that Anon-P and another staff member heard yelling so both went running. Anonymous (Anon)-U made it to the room first and witnessed R106 hitting R121 with the pillow. R121 had indicated R106 had hit R121 over and over with pillow by moving hand back and forth and stating “Bam Bam.” R121's hair was everywhere, and face was red. DON-B came up then and asked questions. On 8/26/25, at 10:22 AM, Surveyor interviewed R106 in regard to the incident. R106 stated that R121 wouldn't cover R121's mouth and was coughing all the time and spreading germs. R106 was afraid of getting sick. R106 stated R106 asked the social worker several times to move out of the room but it never happened. R106 stated R106 was so frustrated. “It got to the point where I couldn't handle it anymore. It had been building up. It was all me, not him. I was hitting him with the pillow. It just reached a point where I couldn't take it anymore. I was so frustrated.” On 8/26/25, at 3:21 PM, Surveyor interviewed Anonymous (Anon)-U. Anon-U stated that Anon-U responded to R106 and R121's room after hearing yelling. Anon-U got into the room and observed R106 repeatedly hitting R121 with a pillow. Anon-U stated that R121's glasses were crooked on R121's face and R121's was red. Anon-U stated R121 was facing the window and R106 was hitting R121 over the head with the pillow. R121 has one arm that is contracted so R121 could not stop R106. Anon-U and Anon-P could not get R121 out of the room to safety because R106 wouldn't let them out of the room. Anon-P texted for help. The rehabilitation director who is no longer employed with the facility was able to get R121 out of the room to safety. Anon-U stated that R106 was accusing R121 of taking things and informed Anon-U and Anon-P that R106 kept telling the facility R106 wanted out and was fed up. On 8/28/25, at 10:25 AM, Surveyor was walking down the hallway, and R106 asked to speak to Surveyor. R106 stated R106 wanted to explain what happened with R121. R106 stated that “they wouldn't listen to me and move me out of the room. I feel like they tricked me into moving onto the unit. Got to the point with too much frustration. I thought about the pillow and started hitting him with it. I lost it. I didn't want to beat up an old man, but I had enough.” Surveyor asked R106 why R106 barricades R106's door. R106 stated it is to stop R89 from wandering in R106's room and taking R106's belongings. R106 stated if R106 catches R89 in R106's room R106 “feels like killing R89” so barricading the door R106 can hear the chair move when sleeping and then knows when someone is coming into R106's room. On 9/2/25, at 9:11 AM, Unit Manager (UM)-F is unaware of any roommate problems between R106 and R121. On 8/26/25, at 9:00 AM, NHA-A informed Surveyor that R

Based upon observation, interview and record review, the facility did not ensure 1 (R106) of 1 residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being.*R106 was not provided medically related social services to address the emotional distress R106 was expressing that affected R106's mental and psychosocial well-being, resulting in R106 left the facility Against Medical Advice(AMA) without medically needed medications.Findings Include:The facility's Facility assessment dated [DATE] documents that the facility can provide person-centered/directed care: psycho/social/spiritual support including mental health and behavior.R106 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction(complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Hyperlipidemia(high levels of fat particles in the blood), Metabolic Encephalopathy(brain dysfunction resulting from underlying condition that disrupts the metabolic processes), Depression(mood disorder that causes persistent feelings of sadness and loss of interest), Delusional Disorder(delusions are a specific symptom of psychosis related to thought disorder or mood disorder), and Visual Hallucinations(sensory experiences where a person sees objects, people, or scenes that are not actually present). R106 discharged from the facility on 9/17/25.R106's Quarterly MDS completed 7/23/25 documents R106's BIMS score is 12, indicating R106 demonstrates moderately impaired skills for daily decision making. R106's PHQ-9 score is 10, indicating R106 has moderate depressive symptoms. R106's MDS documents hallucinations and delusions. R106's MDS document verbal and physical behaviors, and rejection of care 1-3 days. R106 has upper extremity ROM impairment on one side. R106 is set-up for eating and upper body dressing and supervision for showers. R106 requires partial/moderate assistance for lower body dressing. R106 is independent for mobility and transfers.R106's care card instructing nursing staff in the care of R106 as of 8/25/25 documents:-R106's triggers for wandering/eloping are over stimulation. R106's behaviors are de-escalated by walking with R106.-If reasonable discuss R106's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to R106.-Distract R106 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (this is blank)-Locomotion: R106 can walk independentlyR106's applicable comprehensive care plan focused problems document:.R106 is an elopement risk/wanderer due to history of attempts to leave facility unattended.Initiated 1/22/25 .R106 has expressions due to hallucinations and paranoia.Triggers unknown at this time.R106 blocks door.Initiated 5/1/25 Revised 5/20/25R106 was last evaluated by Psychiatric Nurse Practitioner (Psych NP)-JJ on 7/28/25. Psych NP-JJ documented that R106 was suspicious during the visit and R106 has been paranoid about police officers being in the facility.Surveyor notes that R106 was involved in two separate resident-to resident altercations while at the facility. Multiple staff reported that R106 would barricade R106's door so no residents would wander in.On 8/26/25, at 10:22 AM, Surveyor interviewed R106 who stated that R106 does not want to be at the facility.On 8/28/25, at 10:25 AM, Surveyor spoke with R106 again. R106 stated that everyone keeps stealing. The facility will not allow R106 off the unit and feels trapped. R106 does not want to be at the facility.On 9/17/2025, at 12:45, Social Worker Assistant (SWA)-D documented:.This writer was notified by staff the police were in R106's room to deliver R106 court papers for his upcoming guardianship hearing. While this writer and the police was in the room. R106 became somewhat agitated regarding the guardianship reporting R106 does not need a guardian. Then R106 began reporting to the officer there are people in the facility stealing from him. This writer asked R106 what was stolen from him, and R106 reported it was R106's backpack. This writer opened the resident's linen closet, moved a blanket and there was R106's backpack. R106 then began reporting it was not R106's backpack. This writer has seen R106 with that backpack for months. This writer explained to R106 the police now have his statement that someone is stealing from him, and it will be addressed immediately with the administrator. R106 appeared to understand the police's knowledge, and it was being handled by management.This writer and the officer proceeded to the administrator's office to report the incident.While this writer was speaking with Nursing Home Administrator (NHA)-A, another staff member came and reported the nurse on 2 North needed assistance immediately. This writer and multiple other staff members went to the unit.It was reported that R106 became physically and verbally aggressive. Staff intervened and was able to redirect R106. This writer immediately called the police. Multiple staff members remained on the unit to ensure everyone was safe until the police arrived. The police arrived and worked with the facility in attempts to ensure the safety of the staff and the other residents. The crisis center was notified to assess R106, Adult Protective Services(APS) was contacted to assess R106. The crisis center, and APS reported that R106 can make decisions for R106 and if wants to leave the facility he may leave. This writer asked R106 if R106 would like to leave the facility and R106 reported yes. This writer explained Against Medical Advice(AMA) to R106, and R106 signed the AMA documents. This writer and other staff remained with R106 while R106 gathered R106's belongings and exited the building to ensure the safety of others.On 9/17/25, at 4:59 PM, Licensed Practical Nurse (LPN)-ZZ documented:. Acute hallucinations, delusions, confusion, agitation and aggression. Nurses observation of R106: R106 became agitated and aggressive after being served court documents by the sheriff. R106 was observed shouting, swearing, and attempting to physically approach another patient. R106 was not easily redirected and became increasingly agitated as staff intervened. R106 was noted yelling, That man is in my room. Despite staff efforts, R106's agitation continued to escalate. Call placed to NP, DON and administration to advise. New order place to send to emergency room for eval and treatment. R106 is R106's own person and refused. Social service and crisis intervention called.On 9/17/2025, at 5:55 PM, Nursing Home Administrator (NHA)-A documented:.At approximately 1:10 PM, writer was called up to the unit due to change of condition and agitation following services of guardianship paperwork. Sheriff immediately returned to room and facility called police for assistance. Police and staff members remained with resident until APS arrival who interviewed R106. R106 decided to discharge from facility AMA. Risks and benefits up to and including possible injury and death of AMA discharge discussed with R106. R106 signed AMA form in presence of APS worker and police officers. APS provided card to R106 to call later when R106 arrived at his destination. R106's ride arranged for pick up and was taken to motel per R106's preference. R106 packed up belongings and left facility.On 9/17/2025, at 6:52 PM, NHA-A documented:.R106's brother and provider are aware of R106's choice to sign out AMA this afternoon.Surveyor was provided R106's guardianship document and SWA-D email documents.On 6/12/25, the petition for permanent guardianship and protective placement was filed in the circuit court.On 6/12/25, the examining physician's or psychologist's report for adult guardianship was submitted to the circuit court. The actual report was completed by Medical Director (MD)-J and not a psychologist.On 6/17/25, an order appointing guardian ad Litem or Attorney was entered into circuit court. Court documents document the guardianship hearing was to be 7/24/25.On 7/25/25, an email sent by APS to SWA-D documents R106 contesting the guardianship and protective placement and another hearing is scheduled for 9/3/25.On 9/3/25, APS sent SWA-D an email that the guardianship and protective placement was dismissed by the court and a new petition was re-filed and waiting for new court date.On 8/8/25, Business Office Manager (BOM)-TTT sent SWA-D an email stating that the pending guardianship was only of person and not estate.On 9/11/25, a new petition was filed in court for permanent guardianship and protective placement was filed in the circuit court along with a guardian ad Litem or Attorney was appointed. The new court hearing is scheduled for 10/14/25.Surveyor notes there is no documentation by social services in regard to R106's pending guardianship. There is no documentation that SWA-D as R106's primary social worker provided psychosocial support and advocated for R106 during the guardianship process. SWA-D did not assist R106 in exercising R106's rights.On 9/23/2025, at 10:22 AM, NHA-A informed Surveyor that the facility did what they could. NHA-A stated R106's brother wanted nothing to do with R106. NHA-A stated that if R106 stepped off the property, R106 would be in imminent danger and could be declared as at risk, however, NHA-A stated that Nurse Practitioner (NP)-K called a ride for R106. NHA-A stated R106 ended up in an emergency room in Milwaukee and the facility lost track of R106.On 9/24/2025, at 9:25 AM, NP-K was not in the facility at the time of R106's incident. NP-K was outside and saw R106 at the bus stop. NP-K stated NP-K ethically had to do something. NP-K stated R106 had no place to go, no bus pass, no money, no medications. Shelters were not able to take. NP-K was told R106 was not allowed back in the building. NP-K stated NP-K's husband came and got R106 and transported R106 to the motel. NP-K stated NP-K was informed R106 grabbed a nurse which made R106 a danger to other residents. NP-K did not know the whole situation. NP stated had everything been explained to R106, NP-K believed it all could have been avoided. NP-K believed that R106 would have been able to understand everything and was rational about things. NP-K stated, It would not have happened if it had been explained to R106, the process of everything.On 9/24/2025, at 10:31 AM, Surveyor interviewed SWA-D in regard to R106. Surveyor asked SWA-D what SWA-D did to assist R106 with the guardianship process. SWA-D stated SWA-D did not have any part of it. SWA-D stated the guardianship was applied for before SWA-D started there. SWA-D stated it is all new to SWA-D about SWA-D's role with guardianship about how it works. SWA-D confirmed SWA-D did not contact R106's guardian ad Litem to help advocate for R106. SWA-D shared the concern that R106 had expressed to Surveyor that R106 did not want to be at the facility and was feeling trapped. Surveyor shared the concern that with R106's diagnosis of paranoid delusions and hallucinations, that emotional support was not provided to R106 during the guardianship process.On 9/25/2025, at 11:45 AM, Surveyor interviewed adult protective services (APS)-WWW in regard to R106. APS-WWW stated that APS received the referral on 5/8/25 for guardianship for R108. APS-WWW stated that APS had to find a guardian which took a long time. A brother from out of state agreed and file in June the petition for guardianship. The Guardian ad Litem appeared for R106 in July and stated R106 wanted to contest. Time limits ran out on 9/3/25 as advised by corporate counsel. APS-WWW refiled on 9/3/25 and got a new court hearing date of 10/14/25. On 9/17/25 when APS-WWW visited R106, APS-WWW informed Surveyor APS-WWW stated that after talking to R106 APS-WWW felt that R106 had regained capacity and was not as confused. APS-WWW stated APS-WW would have expected SWA-D to educate and keep R106 informed of the process of guardianship and communicate with Guardian ad Litem and APS-WWW in regard to any updates with behavior and cognition. APS-WWW believes that R106 may have regained R106's capacity. APS-WWW stated R106 felt like the facility was keeping R106 and was not working on discharge plans. APS-WWW stated APS-WWW felt bombarded by two staff in particular at the time the papers were served. To add to all the confusion that day. SWA-D and SWE was telling APS-WWW on that day that the facility did not want R106 and why couldn't APS just move R106 to another facility. APS-WWW tried to explain the process of guardianship and the law and was told the law is wrong. APS-WWW stated a few days later, received a phone call from SWA-D requesting the guardianship paperwork again. SWA-D was questioning this as the facility had already been provided the documents and R106 was no longer there. APS-WWW stated that felt was suspicious. APS-WWW stated that R106 had a duffel and two garbage bags full of belongings and walked to the bus stop. APS-WWW watched from the car for a few minutes and R106 appeared to be appropriate at the bus stop, so APS-WWW left. APS-WWW confirmed that the SWA-D could have done more to advocate and assist with the process for R106. APS-WWW confirmed that R106 was extremely agitated that day and felt bad for R106. APS-WWW described the situation as very chaotic. And R106 was clearly in distress per APS-WWW.On 9/29/2025, at 11:56 AM, SWA-D stated APS-WWW stressed to R106 the importance of staying at the facility but could not force R106 to stay. SWA-D informed Surveyor that SWA-D was unaware of any medication issues. SWA-D was sad the way R106 left the facility and didn't sleep that night. On 9/30/2025, at 8:20 AM, Surveyor interviewed NP-K. NP-K stated R106 was a very smart man, R106 had a plan. R106 wanted to get on the bus, go to department of motor vehicles, get an identification card and go to the bank.NP-K stated it was about 6:00 PM, after hours when R106 was at the bus stop. NP-K stated R106 tripped over R106's big bag of belongings. NP-K stated that 911 assessed R106 at the bus stop. NP-K stated that the facility can see the bus stop from the cameras. R106 had been out there for quite a bit. NP-K was told by the facility NP-K could not talk with R106. NP-K felt NP-K needed to get help for R106. Surveyor and NP-K reviewed R106's medications together. NP-K reviewed R106's blood sugars and stated that R106's blood sugars were creeping up. NP-K stated that a diagnosis of diabetes can go either way. R106 was receiving Insulin inject 26 units one time a day. R106 was receiving Januvia 50mg one time a day for diabetes. R106 was also receiving 75 mg of Seroquel one time a day. NP-K confirmed that it is very significant that R106 did not have insulin, nothing to monitor R106's blood sugars, and stopping Seroquel instead of tapering is extremely dangerous. NP-K stated any reasonable person without these medications and others would be at risk.On 9/30/2025, at 10:05 AM, SW-E is unaware that R106 received any medication information or access to a pharmacy to get medications.On 9/30/2025, at 10:28AM, SWA-D informed Surveyor that SWA-D did not provide R106 with any copies of physician orders to take with R106 when R106 left AMA. On 9/30/2025, at 11:40 AM, Surveyor shared with Director of Nursing (DON)-B the serious concern that R106 was not provided medically related social services concerning R106 not receiving assistance with the guardianship process resulting in R106 leaving AMA with no medications or access to list of medications. Surveyor explained with R106' diagnoses of depression, delusional disorder, and visual hallucinations, R106's expressions or indications of distress that affected R106's mental and psycho-social well-being, like R106's resident-to-resident altercations, or barricading R106's self in room were not identified. R106's need for emotional support and not providing services to help R106 achieve the highest practicable psychosocial well-being resulted in R106 being impulsive and leaving the facility AMA without access to important medications. No further information was provided at this time.

Based on interview and record review the Facility did not provide appropriate treatment and services for 1 (R89) of 1 resident with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.R89 has a diagnosis of Unspecified Dementia, Unspecified Severity with Agitation, Depression, Anxiety Disorder and Visual Hallucinations. On 6/4/25, R89 triggered on the trauma assessment as having experienced physical assault, however, there is no care plan with person centered interventions for staff to work with R89. There was no comprehensive assessment with individualized interventions of R89's behaviors, the facility did not assess the behavior change to identify the root/cause of R89's behavior. The facility did not complete a dementia assessment. The Treatment Administration Records (TARS) do not document any behavior accurately for R89. There is no comprehensive assessment with individualized interventions of R89's behaviors, the facility did not assess the behaviors to identify the cause of R1s's behavior, and the care plan was not revised as person centered. On 8/3/25, the facility updated R89's care plan to reflect that R89 was to receive 1:1 supervision, however, the 1:1 supervision was to be expected from staff on shift and not an actual single staff supervising only R89. R89 did not have a comprehensive assessment identifying specific behaviors along with non-pharmalogical interventions, an individualized plan of care to address behaviors effecting others including physical, sexual, and verbal abuse including verbally threatening to other residents on the dementia unit.Findings include:R89 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity with agitation, depression, anxiety disorder, visual hallucinations and essential hypertension. R89 currently has a legal guardian.R89's Quarterly Minimum Data Set(MDS) completed 5/19/25 documents R89's Brief Interview for Mental Status(BIMS) score to be 0 indicating R89 demonstrates severely impaired skills for daily decision making. R89's MDS documents R89's Patient Health Questionnaire(PHQ-9) score to be 0. R89's MDS documents R89 demonstrated rejection of care 1-3 days. R89's MDS also documents R89 has no range of motion(ROM) impairment. R89 requires substantial/maximum assistance for eating, upper and lower dressing, mobility, and transfers. R89 is dependent assistance for showers.R89's care card instructing nursing staff in the care of R89 as of 8/25/25 documents:-R89 requires stand by 1 staff to move between surfaces as necessary-R89 is independent by 1 staff to turn and reminders to reposition in bed-R89 requires minimum assistance by 1 staff to dress-R89 requires minimum assistance by 1 staff with bathing/showering each shift and as necessaryR89's applicable comprehensive care plan includes the following:Problem: R89 has impaired cognitive function/dementia or impaired though processed due to dementia Initiated 2/24/25 Revised 5/14/25Intervention: Correct R89 when using incorrect words to promote word finding Initiated 7/22/25Problem: R89 has sleep deprivation due to dementia. Initiated 4/9/25Interventions:--Assess for underlying physiological illnesses causing sleep loss, assess for level of agitation. Initiated 4/9/25--Keep environment quiet for sleeping. Initiated 4/9/25--Obtain a sleep wake history Initiated 4/9/25Problem: R89 is an elopement risk/wanderer due to disoriented to place, impaired safety awareness, R89 wanders aimlessly, significantly intrudes on the privacy or activities Initiated 6/5/25Problem: R89 has experience trauma due to (not complete/left blank) Triggers that have potential to re-traumatize me (not complete/left blank). Once I experience a trigger, I may display these signs/symptoms: anxiety/edginess, overwhelming, anger/irritability, changes in mood state, nightmares, change in sleep pattern, confusion/disorientation, pain/achiness, muscle tension, extreme alertness/hypervigilance, withdrawal/avoidance of activites, other Initiated 2/24/25 Revised 5/14/25Problem: R89 is at risk for substance abuse related to historical use of alcohol and recreational drugs Initiated 7/28/25Problem: R89 is at risk for mood impairment due to depression and anxiety Initiated 2/13/25Interventions:--Monitor/document/report as needed any risk for harm to self:suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Initiated 2/13/25--Monitor/record/report to MD as needed mood patterns signs of symptoms depression, anxiety, sad mood as per facility behavior monitoring protocols. Initiated 2/13/25Problem: R89 has behavior problems refusing cares, combative, yelling, grabbing, and displaying loving affection towards females. R89 has hallucinations. Initiated 2/13/25 Revised 7/11/25Interventions:--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. Initiated 2/13/25--If reasonable, discuss R89's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to R89. Initiated 2/13/25--Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated 2/24/25--Praise any indication of R89's progress/improvement in behavior. Initiated 2/24/25--Remind R89 that R89's niece wants R89 to work with staff. Initiated 2/24/25--Explain all procedures to R89 before starting and allow R89 extra time to adjust to changes. Initiated 4/15/25--Offer a quiet setting. Initiated 4/15/25--Caregivers to provided opportunity for positive interaction, attention. Stop and talk with R89 as passing by. Initiated 4/15/25--Provide support to room. Initiated 4/15/25--Re-approach R89 when initially unapproachable. Initiated 4/15/25--Allow R89 time to be more independent with cares. Initiated 5/7/25--Offer coffee per R89's preference to help assist with cares. Initiated 5/14/25--Offer R89 a shower once a day. R89 is calmer after receiving shower. Initiated 7/11/25--Monitor for hallucinations. Initiated 7/11/25--R89 enjoys watching funny animal videos. Initiated 7/17/25--When becoming agitated offer to take R89 outside. Initiated 7/21/25--R89 to be 1:1 when out of room. Initiated 8/3/25R89's Trauma Informed Care completed 6/4/25 documents R89 has experienced physical assault.R89's current physician orders document R89 is currently prescribed:-Benadryl-I tablet every 24 hours as needed for hives Start 8/25/25-no end-Buspirone HCI Oral Tablet 10 mg was changed from two times a day for anxiety to three times 25 mg two times a day for ana day as of 8/25/25-Cymbalta was discontinued on 8/30/25-Depakote ER Oral Tablet Extended Release 24 hour 500 mg for seizures, start date of 2/11/25-Donepezil HCI Oral Tablet 10 mg at bedtime-start date of 2/11/25-Gabepentin Oral Tablet 100 mg 1 tablet two times a day for anxiety disorder- start date of 7/11/25-Hydroxyzine HCI Oral Tablet 25 mg 1 tablet two times a day for anxiety-start date of 4/26/25-Seroquel Oral Tablet 12.5 mg two times a day related to unspecified 100 mg start date of 8/18/25-Trazadone HCI Oral Tablet for depression-start date of 2/11/25Surveyor reviewed R89's Treatment Administration Records (TAR) for March, April, June, July and August. Staff were to monitor and document behaviors every shift related to aggressive and impulsive behavior. Documentation reflects no and multiple blanks where behaviors were not being assessed. The documentation in the TAR does not reflect documentation in R89's progress notes.Staff were to monitor for hallucinations, however, Surveyor learned during interviews with staff that they did not know what R89's hallucinations were. Surveyor noted the documentation in the TAR had some check marks with multiple blanks throughout the months. The instructions were for staff to check yes or no.Staff were to be documenting and monitoring R89 being resistive to cares. R89's TAR reflect mostly no with blanks.Surveyor notes that staff were not monitoring R89s behaviors. The facility did not complete a root/cause analysis of R89's behaviors in order to implement a person-centered care plan with interventions.Surveyor reviewed R89's psychiatric consults:-3/7/25 the following is documented by Psychiatric Nurse Practitioner (Psych NP)-JJ, .Would recommend to taper Aricept due to advanced dementia and medication could be contributing to R89's behaviors .-4/11/25 Psych NP-JJ documented, .Staff report that dementia is advanced with aggressive and inappropriate behaviors that have improved since the Aricept tapered off. Would recommend starting to taper the Seroquel .-5/2/25 Psych NP recommended no medication changes.-7/11/25, Psych NP recommended to increase Buspar to address anxiety and added Seroquel due to aggressive behaviors.-8/8/25 Psych NP increased Seroquel due to increased aggressive behaviors.Surveyor reviewed R89's progress notes located in R89's EMR and noted the following:-2/18/25 6:18 AM .R89 uncooperative and aggressive behaviors during cares throughout night shift. R89 yelling explicit language, punching, kicking, and elbowing staff. Redirection did not work .-2/18/25 6:11 PM, .Resistive with cares, taking multiple staff members to perform cares .-2/21/25 6:01 AM, .R89 observed to be resistive to care and refused to let anyone touch R89. Education and redirection ineffective .-2/21/25 11:11 AM, .R89 is resistive with cares .-2/22/25 06:20 AM, .Combative and aggressive towards staff .-2/22/25 6:58 AM, .Multiple attempts made by all staff, R89 would become combative and swat and kick at staff .-2/23/25 7:10 PM, .Staff reported to writer that during HS cares on 2/22 it took 4 staff members to provide cares for R89. During this time, R89 kicked a CNA in the chest, knocking her into the TV and punched a second CNA in the chest, DON and Admin made aware .-2/28/25 8:24 AM .R89 combative with cares, striking out and yelling at staff .-3/2/25 6:05 AM .While the aides were getting the residents up for the day, R89 made inappropriate comments . -3/7/25 11:27 AM .Continues to be verbally aggressive with staff during cares .-3/17/25 6:38 PM .CNA reported to writer that during cares last evening, R89 punched her in the right eye. Writer noted a dark area surrounding her right eye. DON made aware of incident. R89 placed on 24 hour board for monitoring .-3/20/25 7:45 PM .Noted kicking and punching staff .-4/17/25 3:33 PM .R89 wandered into another room .-4/19/25 6:44 AM he will slap the shit out of a staff member .-4/19/25 9:45 PM .R89 in hallway when R89 heard another resident say 'he is a clown.' R89 became aggressive, stood up and swung on the resident .-5/6/25 4:05 AM .Writer was approached by both CNAs on the unit, stating that R89 had punched one of them in the face. R89 turned and swung at her with closed fist, hitting her in the face, and shortly afterwards causing swelling to her lip. DON and Admin and unit manager notified .-5/6/25 4:14 AM .R89 approaching residents doors and pushing/pulling/jiggling door handles to different rooms .-5/7/25 11:28 AM .R89 resistant to care and yelling/scream during cares .-6/28/25 6:37 AM .R89 began verbally harassing the resident, calling him expletives and threatening to physically assault him .-6/30/25 3:51 PM .R89 being monitored for acute behavior change .-7/7/25 7:56 AM .R89 was involved in an altercation with another resident that was physical. R89 was put on 1:1 supervision .-7/20/25 10:48 PM .R89 agitated opening other resident doors. R89 exit seeking majority of shift, requesting to go outside, approaching exit doors .-8/3/25 8:10 PM .Called to unit for resident-to-resident altercation. Administrator, DON notified .-8/8/25 7:00 PM .R89 found on 2 south, resting in another resident bed .-8/10/25 3:45 PM .Writer was notified that R89 tried to put R89's hand under another resident shirt. When R89 redirected, R89 became very agitated. Writer notified DON and supervisor. Per DON to start 1:1 with R89 and monitor behaviors .-8/12/25 10:52 PM .R89 wandering in and out of rooms .On 8/25/25, at 10:54 AM, Surveyor asked Anon-N about R89. Anon-N stated that R89 was known to get into other resident rooms. Anon-N described R89 as confused, agitated, and not easy to redirect. Anon-N stated R89 gets triggered very easily.On 8/25/25, at 11:38 AM, Nurse Practitioner (NP)-K informed Surveyor that NP-K was not aware of any allegations of sexual abuse between R89 and R110. NP-K stated that R89 gets agitated and gets triggered easily. NP-K stated that R89 is on a lot of psychiatric medications. NP-K stated, It's not about adding a million meds, but the approach is the best thing.On 8/25/25, at 2:30 PM, Surveyor interviewed Anon-Q. Anon-Q was told by administration to keep an eye on him.On 8/26/25, at 7:35 AM, Social Worker (SW)-D described R89 to be agitated and will yell. SW-D stated that R89 will wander into other rooms. SW-D stated that R89 likes R110 and has been in R110's room, and staff are supposed to keep a close eye on R89.On 8/26/25, at 8:10 AM, Anon-R informed Surveyor that R89 can be sexually inappropriate and is sexually aggressive with words. Anon-R was informed to keep an eye on R89. Anon-R stated that R89 has had multiple resident-to-resident altercations. On 8/26/25, at 12:37 PM, Surveyor interviewed Anon-G. Anon-G stated that R89 can be disruptive and is supposed to have supervision but does not always have the supervision.On 8/27/25, at 7:10 AM, Anon-V described R89 has unpredictable and will switch very quickly. Anon-V stated that R89 can be aggressive a lot and can be very disruptive and refuses cares. Anon-V is unaware of any delusions or hallucinations. Anon-V states R89 has been in bed more frequently in the past of couple of weeks, sleeping a lot. Anon-V stated Anon-V has not received any specific training on how to care for the residents on the dementia unit.Documentation in R89's EMR on 8/10/25, states, .Writer was notified by CNA that R89 tried to put his hand under R110's shirt. When R89 was redirected, R89 became very agitated. Writer notified DON and supervisor. Per DON to start 1:1 with R89 and monitor behaviors .On 8/27/25, at 3:51 PM, Surveyor interviewed NHA-A. NHA-A shared that R89 is quick to temper and impulsive. NHA-A stated R89's Seroquel has been increased and R89 is more stable now.On 8/27/25, at 4:17 PM, Surveyor interviewed Anon-T. Anon-T stated that R89 has punched multiple staff in the face. Anon-T described R89 as having violent tendencies, very unpredictable, would get very angry and quickly switch moods.On 8/28/25, at 2:51 PM, Anon-X stated that R89 would be sexually inappropriate with staff. Anon-X stated R89 does not meet the profile of someone with dementia.On 8/25/25, at 10:54 AM, Surveyor interviewed Anon-N who describes the dementia unit where R89 resides as very chaotic and make for very long days. Anon-N does not feel supported. Anon-N reports staff do not have a say in the care of residents or consulted for person-centered interventions.On 8/25/25, at 1:01 PM, Anon-P informed Surveyor that there are 4-5 residents who require a lot of supervision on the dementia unit, so it is impossible to keep 1:1 supervision at times on R89. Anon-P stated the staff are overloaded with cares on the unit. Administration has never given just one person to maintain 1:1 supervision on R89 and have been told it is the responsibility of the staff working on the dementia unit. Anon-P stated that when an incident happens there is never an investigation. On 8/25/25, at 2:30 PM, Surveyor interviewed Anon-Q. Anon-Q states it is not safe on the dementia unit. We are told to keep an eye on R89 but there is not enough staff to supervise R89 and care for all the other residents. Typically, there is 3 certified nursing assistants and 1 nurse on days and PMs.On 8/26/25, at 8:10 AM, Surveyor interviewed Anon-R. Anon-R stated that staff are told that 1:1 supervision for R89 is not in the budget and that it is on the staff who are working the unit which at time of survey process had a census of 30 residents.On 8/26/25, at 1:42 PM, Psychologist (Psych)-C has not been involved with any staff training on the dementia unit. Psych-C has not personally evaluated R89, but R89 is more dementia than depression. Most effective has been the increase in Seroquel. Ideally, it would be appropriate for the facility to implement non-pharmalogical interventions like de-escalation, slow the situation down. Finding out triggers for R89 and redirection. Recommending not doing anything to cause more conflict and decrease stimulation. Surveyor noted on the care plan that triggers were not identified even though the care plan prompted the writer to document those. On 8/27/25, at 7:05 AM, Anon-N stated to Surveyor that Anon-2 has not received any trainings specific to the dementia unit, Anon-N stated there is only a couple of staff left from over a year ago so not everyone has had the training. There has been a high turnover of staff lately on the dementia unit. Anon-N stated that Anon-N has not seen any visual hallucinations with R89 and wouldn't know what to look for.On 8/27/25, at 12:37 PM, Surveyor interviewed Medical Director (MD)-J. MD-J has been made aware of R89's behaviors and it is hard to determine with dementia. MD-J stated the facility needs to rule out brain injury, complete blood work, MRI, and/or mental health treatment. MD-J stated R89 should have 1:1 supervision 24 hours 7 days a week. On 8/27/25, at 1:34 PM, Surveyor interviewed Dementia Coordinator (DC)-M. DC-M stated that DC-M is a certified nursing assistant. DC-M has not seen any delusions/hallucinations in a long time with R89, about 4 months ago. DC-M stated R89 has 'word salad'. DC-M confirmed that psychological services have not done any trainings specific to the dementia unit. DC-M stated that R89 does a lot of wandering on the unit.On 8/27/25, at 3:51 PM, NHA-A stated that a training had been done at the end of April on abuse and neglect and how it applies to dementia. NHA-A stated staff have to look at the root/cause of a behavior. NHA-A stated the goal is for staff to be trained on 2 different dementia trainings every 2 years alternately.On 8/28/25, at 8:48 AM, Anon-Q confirmed that Anon-Q did not receive any training or training materials to assist with interventions for residents on the dementia unit. Anon-Q stated there have been so many altercations on the dementia unit.On 8/28/25, at 10:37 AM, Anon-II stated Anon-II never received trainings for the dementia unit. On 9/2/25, at 12:16 PM, Surveyor interviewed NHA-A in regards to R89 and all the allegations of abuse. NHA-A stated the criteria for the dementia unit is for a resident to have a dementia diagnosis and would benefit from activities. NHA-A stated that residents with 'mid' dementia would be appropriate for the unit. NHA-A stated staff should have the ability, thought processes, and interventions to take care of the residents on the dementia unit. Surveyor shared the serious concern with NHA-A that R89 has a diagnosis of dementia and staff have not been trained or have demonstrated the skills to support R89 that are directed towards understanding, preventing, relieving, and/or accommodating R89's distress or loss of abilities. Surveyor shared that R89's comprehensive care plan has not been assessed, developed, and implemented to meet R89's needs. Surveyor shared that R89's behavioral expressions may have been exacerbated by environmental triggers in an attempt to communicate an unmet need, discomfort, or thoughts that R89 can no longer verbally communicate. Surveyor shared the serious concern that the facility based on all of R89's verbal, physical, and sexual incidents did not process a root/cause analysis of R89's expressions in order to provide R89 with the needed specialized services and supports to work with R89's diagnosis of dementia. Further, the facility has not provided the specialized dementia training to all staff working the dementia unit. Staff have been unable to assess and provide appropriate dementia care to R89.

Based on observation, interview, and record review, the facility did not maintain an effective pest control program to address the flies in the facility.*) R13 informed Surveyor that the facility has a problem with flies and has a fly swatter by the bed to keep flies away. Surveyor observed flies by R13's bedroom window.*) R26 had flies in R26's room during an interview with Surveyor and were landing on R26's hat.*) R75 informed that the flies in the facility are bad, especially when food is out.*) R107 informed Surveyor that flies are around in the room and hallways especially when food is not picked up right away or garbage's are not emptied.*) Surveyors observed flies in resident rooms, resident unit hallways, and hallway by the facility kitchen.This deficient practice has the potential to affect all 103 of 103 resident residing in the facility at the time of the survey.Findings include:The facility policy titled Pest Control Program implemented on 4/2/2025 documents: It is the guideline of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations.5. Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures, i.e. dumpster area, etc.*) R13 was admitted to the facility on [DATE]. R13's admission Minimum Data Set (MDS) assessment dated [DATE] documents R13 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R13 has intact cognition.On 9/2/2025, at 9:30AM, Surveyor interviewed R13 who stated that flies are bad in the facility, has been good couple days and not swarming but usually one or two flies daily. Surveyor observed a fly swatter on R13 bedside table. R13 stated that R13 will swat flies away with it. R13 stated that when food trays come is usually when flies are around or when R13 is having a wound change or getting cleaned up. Surveyor observed 2 flies on R13's bedroom window.*) R26 admitted to the facility on [DATE]. R26's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R26 has a Brief Interview for Mental Status (BIMS) score of 14 indicating R26 has intact cognition.On 8/28/25 at 9:47 AM, A Surveyor was interviewing R26. Surveyor observed a fly flying around R11 and landing on R26's hat. Surveyor observed R26 attempt to swat the fly away and stated, These darn flies.*) R75 was admitted to the facility on [DATE]. R75's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R75 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R75 has intact cognition.On 9/2/2025, at 9:40AM, Surveyor interviewed R75 who stated the flies have been really bad in the facility. Last couple weeks when it was really warm outside was the worst. R75 stated it is better but still get flies in the room daily. R75 stated R75 has reported the flies to staff.Surveyor observed 2 flies on R75's bedroom window. *) On 9/2/2025, at 10:12 AM, Surveyor observed flies on the ceiling right outside of the kitchen door in the basement level hallway. Surveyor observed that the kitchen door was open.*) R14 was admitted to the facility on [DATE]. R107's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R07 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R107 has intact cognition.On 9/2/2025, at 11:18AM, Surveyor interviewed R107 who stated that the flies can get pretty bad especially when food is out, or garbage's are not emptied. R107 stated R107 has reported the fly issue multiple times to staff and management but they say nothing can be done about the flies. On 9/2/2025 at 11:23 AM, Surveyor interviewed licensed practical nurse (LPN, agency)-Y and certified nursing assistant (CNA)-Z who stated the flies can get really bad at times and can get very annoying. CNA-Z stated that staff report the flies to management but not sure if anything gets done about it because it seems like there are always flies around. LPN-Y stated that LPN-Y is agency staff so not in the facility often, but whenever LPN-Y does come to the facility there are always flies around. Surveyor observed flies flying around the 1-north nursing station.On 9/2/2025, at 12:23PM, Surveyor interviewed regional maintenance director (RMD)-CC and maintenance director-DD who stated that they were notified about flies couple weeks ago. Maintenance director-DD stated maintenance director-DD walked around the hallway with a fly swatter and killed flies. Maintenance director-DD stated that the 1-North hallway seems to get it the worst with flies because there is a back door at the end of the unit and when you exit out that door the dumpsters are located right outside that doorway. Maintenance director-DD stated that there are 2 bug zappers by the main exits, 1 located at the main entrance, and 1 located at that back door by the dumpsters. Maintenance director-DD stated that the pest control company was not contacted because the flies were no more than what there usually are in the facility. RMD-CC stated that there really is not anything that can be done about the flies.On 9/2/2025, at 4:28PM, Surveyor shared concerns with nursing home administrator (NHA)-A and director of nursing (DON)-B of surveyor's observations of flies in the building and resident concerns regarding flies in the facility.

Based on observation, 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 6 (R80, R71, R45, R129, R11, & R90) of 6 Residents. *Appropriate hand hygiene was not observed during medication administration for R80 & R71. *Staff did not wear appropriate Personal Protective Equipment (PPE) when administering medication via a G (gastrostomy) tube to R80 & R45 who are on Enhanced Barrier Precautions (EBP). *The glucometer was not disinfected after R129's blood sugar was obtained. *Staff did not wear appropriate PPE during personal cares and tube feeding procedures for R11 who is on enhanced barrier precautions. *R90's Foley catheter drainage bag was observed on the floor and without any barrier to prevent contamination. Findings include: The facility's policy titled, Hand Hygiene and revised 03/27/2025 Under Guidelines documents All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under Explanation and Compliance Guidelines documents 1. Taff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under conditions listed in, but not limited to, the attached hand hygiene table. The Hand Hygiene Table includes Before preparing or handling medications The facility's policy titled, Enhanced Barrier Precautions and date reviewed/revised 01/05/2025 under Definitions documents Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities. Under Explanation and Compliance Guidelines documents 4. High-contact resident care activities include a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) lines, midline catheters. h. Wound care: any skin opening requiring a dressing. The facility's policy titled, Glucometer Disinfection and date reviewed/revised 11/11/2024 under guideline documents The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Under Policy Explanation and Compliance Guidelines documents 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's infections for multi-resident use. 3. The glucometers will be disinfected with a wipe pre-saturated with an EPA (environmental protection agency) registered healthcare disinfectant that is effective against HIV (human immunodeficiency virus), Hepatitis C and Hepatitis B virus. 4. Glucometers will be cleansed and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 1.) On 9/23/25, at 8:49 a.m., Surveyor observed Licensed Practical Nurse (LPN)-KK inform R80 she was going to give him his medication. Surveyor observed there is an Enhanced Barrier Precaution sign on R80's door. At 8:51 a.m. Surveyor observed LPN-KK start to prepare R80's medication which consisted of Famotidine 20 mg (milligrams), Amantadine HCL 100 mg, Vitamin C 500 mg, Gabapentin 100 mg, Levetiracetam 1500 mg, Vitamin D3 400 IU (international unit), and Doxazosin Mesylate 2 mg. Surveyor observed LPN-KK did not perform any hand hygiene prior to preparing these medications. LPN-KK crushed Levetiracetam, placed gloves on, opened the Gabapentin capsules & poured the medication into a med cup. LPN-KK crushed the remainder of R80's medication individually pouring the medication in med cups. At 9:03 a.m. LPN-KK removed her gloves and placed another pair of gloves on. LPN-KK did not perform any hand hygiene. LPN-KK entered R80's room with the medication in individual medication cups and added water to each medication cup. Surveyor observed LPN-KK is only wearing gloves and is not wearing a gown. At 9:06 a.m. LPN-KK informed R80 she needs to check his blood pressure, placed R80's tube feeding on hold and obtained R80's blood pressure of 125/85. LPN-KK stirred each medication with a straw and at 9:09 a.m. LPN-KK checked placement of R80's G (gastrostomy) tube. At 9:11 a.m. LPN-KK flushed R80's G tube and then administered R80's medication individually flushing with water in between each medication. After administering R80's medication, LPN-KK placed a washcloth under R80's tube, pulled down R80's gown, covered R80 with bedding and stated to R80 ok [first name of R80] you have all your medication. At 9:24 a.m. LPN-KK rinsed out the syringe container, removed her gloves, wiped off the over bed table with a paper towel and then went to the medication cart. Surveyor observed LPN-KK did not perform hand hygiene after removing her gloves and was not wearing the appropriate PPE (personal protective equipment) for R80 who is on enhanced barrier precautions. 2.) On 9/23/25 at 9:37 a.m. Surveyor observed Licensed Practical Nurse-MM start to prepare R71's medication which consisted of Metoprolol Tartrate 12.5 mg (milligrams), Gabapentin 100 mg, Eliquis 5 mg, Furosemide 40 mg, Isosorbide Mononitrate 30 mg, Aspirin, 81 mg, Vitamin D3 5000 units, Hydrocodone Acetaminophen5-325 mg and Advair 250 mcg/50 mcg inhaler. Surveyor observed LPN-MM did not perform any hand hygiene prior to preparing R71's medication. 3.) On 9/23/25 at 11:57 a.m. Surveyor observed Registered Nurse (RN)-LL cleanse her hands and place gloves on. RN-LL placed a strip in the glucometers, cleansed R129's right ring finger with an alcohol pad, waved her hand over R129's finger to help dry the finger, poked R129's right ring finger, squeezed, and placed a drop of blood on the strip. RN-LL stated the blood sugar is 165. RN-LL removed her gloves and cleansed her hands. At 11:59 a.m. RN-LL disposed of the lancet in the sharps container and placed the glucometer on top of the medication cart. At 12:06 p.m. RN-LL administered R129's Novolin R insulin according to physician orders. At 12:07 p.m. Surveyor asked RN-LL if she has any other blood sugars. RN-LL explained to Surveyor she has two on the unit, R129 and R25. RN-LL gathered supplies to check R25's blood sugar. Surveyor asked RN-LL if she was going to check R25's blood sugar. RN-LL replied yes. Surveyor asked RN-LL if there is only one glucometer on each medication cart. RN-LL replied yes. Surveyor asked RN-LL when she disinfects the glucometer. RN-LL informed Surveyor she should probably have cleaned it before each patient. At 12:11p.m. RN-LL removed a wipe from the Micro-Kill two container and wrapped the glucometer with the wipe. At 12:12 p.m. RN-LL unwrapped the glucometer and placed a strip in the glucometer. Surveyor noted the disinfectant wipe was wrapped around the glucometer for only one minute. Surveyor noted the label on the wipe container documents disinfects hard nonporous surfaces in 2 minutes. RN-LL with gloves on cleansed R25's right index finger with an alcohol pad, waved to help dry R25's finger, poked R25's finger, squeezed the right index finger and placed a drop of blood on the strip. R25's blood sugar is 198. On 9/24/25 at 1:15 p.m. Surveyor observed the Micro-Kill two germicidal wipes container which documents disinfects hard nonporous surface(s) in 2 minutes. Under directions for use documents To clean and disinfect hard, nonporous surfaces: If present use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow surface to remain visibly wet for contact time(s) listed on the label. Repeated use of wipe may be needed to ensure that the surface remains visibly wet for contact time(s) listed on the label. Let air dry. Front label documents Bacteria (2-minute contact time). Multi drug resistant bacteria (2-minute contact time) Pathogenic Fungi (2-minute contact time), Mycobacterium (TB) (1 minute contact time) Viruses (2-minute contact time) Virus (1 minute contact time) list SARS CoV2. Bloodborne pathogens 2-minute contact time HIV-1, Hepatitis B virus, Duck HB, Hepatitis C. Under special instructions for cleaning and decontaminating against HIV 1 on surfaces/objects soiled with blood/body fluids for contact time documents Use wipe to thoroughly wet surface. Allow surface to remain visibly wet for two (2) minutes. Let air dry. Surveyor reviewed R129 and R25's diagnoses and noted neither resident have any blood borne diseases. On 9/23/25, at 12:16 p.m., Surveyor asked RN-LL if a resident is on enhanced barrier precaution does she have to wear PPE when administering their medication. RN-LL informed Surveyor the DON just told her if a resident receives medication via a feeding tube, then they have to wear PPE. If by mouth they do not. 4.) On 9/23/25, at 1:30 p.m., Surveyor observed Licensed Practical Nurse (LPN)-KK with R45 who was in bed. Surveyor observed LPN-KK move R45's gown up, check R45's enteral feeding tube's placement stating 10 of air, checking your tummy. After checking R45's feeding tube placement, LPN-K administered R45's medication individually and flushed in between each medication. After LPN-KK finished administering R45 her medication, LPN-KK connected and started R45's tube feeding. LPN-KK removed her gloves and washed her hands Surveyor observed LPN-KK is only wearing gloves and does not have a gown on. Surveyor observed on R45's door is an enhanced barrier precaution sign. On 9/23/25, at 1:37 p.m., Surveyor asked LPN-KK when administering medication via a G (gastrostomy) tube to a resident who is on enhanced barrier precautions are you required to wear PPE. LPN-KK informed Surveyor they must wash their hands and wear gloves. LPN-KK then stated some people (referring to residents) you do but everyone doesn't have the same thing. On 9/24/25, at 9:04 a.m., Surveyor Unit Manager (UM)-F, who is currently the facility's infection preventionist if a resident is on enhanced barrier precautions during medication administration what PPE should the nurse wear. UM-F asked Surveyor GT or orally then informed Surveyor if orally since it is not a high contact activity they wouldn't have to wear a gown. Surveyor asked if the medication was administered via a tube. UM-F informed Surveyor they would be gowning up. Surveyor asked UM-F for medication via a feeding tube the nurse should wear gloves & a gown. UM-F replied yes. On 9/24/25, at 9:09 a.m., Surveyor asked UM-F what the expectation for hand hygiene during medication pass is. UM-F informed Surveyor either sanitize or wash their hands in between residents. Surveyor asked prior to preparing a resident's medication should the nurse perform hand hygiene. UM-F replied yes. Surveyor asked when staff removes their gloves should they perform hand hygiene prior to placing on another pair of gloves. UM-F replied yes. On 9/24/25, at 9:12 a.m., Surveyor asked UM-F after a nurse checks a resident's blood sugar what should the nurse do with the glucometer. UM-F replied to use a wipe to clean them. Surveyor asked if the glucometer should be disinfected prior to checking the next blood sugar. UM-F replied yes. Surveyor asked UM-F if the nurse should follow the manufacturers recommendations on the wipe container. UM-F replied yes. Surveyor informed UM-F Surveyor as observed Micro Kill one and Micro Kill two on medication carts. Surveyor asked which wipe staff should be using to disinfect the glucometer. UM-F informed Surveyor they can use either wipe just as long as they are following the recommendations. On 9/24/25, at 9:18 a.m., Surveyor informed UM-F of the infection control concerns observed by Surveyor. 5.) The facility's policy and procedure titled Catheter Care dated 12/2/2024. The procedure explanation includes:2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. R90 was admitted to the facility on [DATE] for wound care and has a suprapubic bladder catheter. R90 is in Enhanced Barrier Precautions due to having wounds, colostomy and a suprapubic catheter. On 9/23/2025, at 8:13 AM, R90 bladder drainage bag was uncovered laying on the floor. On 9/24/2025, at 8:58 AM bladder drainage bag hanging on bed frame uncovered. On 09/24/2025, at 1:07 PM, Surveyor interviewed the Director of Nurses (DON) – B. The DON-B stated the Foley drainage bag should not be on the floor and should also be in a cover. On 9/24/2025, at 2:47 PM. At the facility exit meeting with the Nursing Home Administrator (NHA) -A and DON-B, Surveyor shared the drainage bag concerns. 6.) R11 was admitted to the facility on [DATE] with diagnoses of Autistic Disorder (affects how people interact with others, communicate, learn, and behave.), Repeated Falls, Unspecified Intellectual Disabilities (individual exhibits significant limitations in both intellectual functioning and adaptive behavior), Epilepsy (chronic neurological condition characterized by recurrent seizures, which are episodes of shaking and convulsions), Mood [Affective] Disorder (persistent and significant changes in mood, emotions, and behavior), Anxiety Disorder (excessive worry, fear, and nervousness that can interfere with daily life) and Gastrostomy(surgical procedure that creates an opening in the stomach through the abdominal wall to allow for feeding and medication administration directly into stomach). R11 currently has a legal guardian. R11's admission Minimum Data Set (MDS) completed 7/9/25 documents R11 demonstrates severely impaired cognitive skills for daily decision making and has short and long term memory deficits. R11's Patient Health Questionnaire (PHQ)-9 score is documented as 14 indicating R11 demonstrates moderate depressive symptoms. R11 demonstrates physical behaviors that significantly interferes with resident care, participation in activities, intrudes on privacy or activity of others, disrupts care of living environment. R11's MDS also documents that R11 demonstrates rejection of care and wandering daily. R11's has no range of motion impairment. R11 requires supervision for eating (at time of MDS, R11 was nothing by mouth (NPO), dependent for showers. R11's MDS requires partial/moderate assistance for upper dressing and substantial/maximum for lower body dressing. R11 is independent for mobility and transfers. R11 currently receives bolus tube feedings four times a day for nutrition. R11's electronic medical record (EMR) contains a progress note written by Licensed Practical Nurse (LPN)-HHH on 9/21/25.R11 continues to have frequent loose stools. Nurse Practitioner updated, orders received to obtain stool specimen for possible C-diff, once specimen obtained can start Loperamide 2 mg every 8 hours PRN(as needed). Stool Specimen obtained. On 9/22/25, LPN-ZZ documented.Continues on contact precautions as stool sample for c-diff is pending. On 9/23/2025, at 11:39 AM, Surveyor observed R11 receiving bolus tube feeding. LPN-MM retrieved a bottle of tube feeding from R11's room, showed R11 the bottle, took gloves out of LPN-MM's pocket and put the gloves on. LPN-MM had Certified Nursing Assistant (CNA)-UUU assisting with the tube feeding. LPN-MM donned a gown from the cart located outside the room and with same gloves on, proceeded to start the process of R11 receiving tube feeding. CNA-UUU was also in the room with LPN-MM and was assisting to keep R11 calm and stable in the wheelchair. CNA-UUU placed hand on R11's arm and wheelchair. Surveyor observed R11 holding the tube for LPN-MM to inject the tube feeding by way of syringe. Surveyor observed when the procedure was complete, LPN-MM took off gown and gloves. CNA-UUU took off gloves. Neither LPN-MM nor CNA-UUU performed hand hygiene. Surveyor also observed that neither LPN-MM or CNA-UUU performed hand hygiene on R11 who was holding the tube the entire time, is pending for C-Diff and it is common for R11 to use the handrail and carts to pull self along the hallway while propelling the wheelchair. Surveyor notes the sign on the door states Enhanced Barrier Precautions (EBH) and other signs taped over that states to see nurse before entering room. Surveyor notes there is a cart outside R11's room containing personal protective equipment (PPE). On 9/23/2025, at 1:28 PM, Surveyor observed LPN-MMM in R11's room not wearing a gown, only wearing gloves. LPN-MM stated LPN-MM was changing R11's brief. Surveyor notes LPN-MM did perform hand hygiene after. On 9/24/2025, at 6:34 AM, Surveyor notes the contents of the cart outside of R11's room. The cart has hand sanitizer and two boxes of gloves on top, one box of gloves is empty. The first drawer has about twenty surgical masks. The middle drawer has two gowns in plastic and the bottom drawer has one gown in plastic. The sign on the door for is for EBP. The sign to stop and ask a nurse has been removed since yesterday. On 9/24/2025, at 6:51 AM, Surveyor observed R11 open up R11's door and came out to doorway. R11 is wearing a black shirt, shoes and brief which the is to be saturated with urine. Dementia Coordinator (DC)-M went into room and put gloves on. DC-M asked Unit Manager (UM)-F to bring towels and washcloths. DC-M did not put a gown on. DC-M then came out and got gloves and gown and provided cares for R11. Surveyor did not observe DC-M perform hand hygiene at any time. On 9/24/25, at at 10:01 AM, A Surveyor on the team interviewed UM-F who is also in the role of Infection Preventionist. The Surveyor asked UM-F about R11 being in isolation. UM-F stated, we have come to the nurse sign right now but R11 is in contact isolation. The nurse put the wrong one up there, but I have to fix it. Staff were going to try and get a sample but not sure they got one yet. Sometimes residents will pull signs off the door. I just have to grab from downstairs. Surveyor has not observed any residents on the unit attempting to pull signs off the doors. Surveyor also notes a stool specimen was collected back on 9/21/25. On 9/24/2025, at 2:57 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Director of Operations (RDO)-XX, and Director of Operations (DO)-YY the infection control concerns involving R11 and staff not wearing the appropriate PPE during cares and the tube feeding procedure. No further information has been provided by the facility at this time. On 9/25/2025, at 11:10 AM, Surveyor observed that the sign on R11's door now states contact precautions. On 9/25/2025, at 1:15 PM, Surveyor asked UM-F why there is a different sign on R11's door. UM-F stated there was a green sign on the door (for contact precautions), but it must have been taken down. Sometimes they pull the signs.

Based on observation, interview, and record review, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 4 of 4 medication carts observed effecting a pattern of residents residing in the facility. *On [DATE] at 12:01 p.m. during the medication administration task Surveyor observed R129's Novolin R insulin pen was not dated when opened. *On [DATE], at 11:33 a.m., Surveyor observed in the front 2 South medication cart in the top drawer a bottle of artificial tears lubricant eye drops for R2 not dated when opened. *On [DATE], at 11:49 a.m., in the top drawer left section of the 1 North back medication cart Surveyor observed approximately 33 small pink pills laying in the drawer. *On [DATE], at 11:53 a.m., Surveyor observed in the 1 North back medication cart a purple plastic basket containing 6 insulin pens not separated, not labeled with a resident's name and/or not dated when open for R125, R130, R53, & R81. *On [DATE], at 12:36 PM, Surveyor observed 1 bottle of blood glucose test strips that was not labeled when opened in the 2 North medication cart. *On [DATE], at 1:25 PM, Surveyor observed loose blood glucose test strips sitting in a medication cup with no expiration date or labeled when opened date, and all Over the Counter (OTC) medications were not labeled with opened dates in the 1 South medication cart. Findings include: The facility's policy titled, Insulin Pen and last reviewed/revised [DATE] under Explanation and Compliance Guidelines documents 2. Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. 3. If the label is missing, the pen will not be used; a new pen must be ordered from the pharmacy. 9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation. The facility's policy titled, Medication Storage and last reviewed/revised [DATE] under Policy documents It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light ventilation, moisture control, segregation, and security. 1.) On [DATE], at12:01 p.m., Surveyor observed Registered Nurse (RN)-LL place gloves on, cleansed the top of R129's Novolin R insulin pen, attached a needle and prime the pen with 2 units. RN-LL then dialed 2 units of Novolin R. Surveyor noted insulin pen is not dated when opened. At 12:03 p.m. Surveyor asked RN-LL if she was going to administer R129 her insulin. RN-LL replied yes. Surveyor asked RN-LL how she knew R129's insulin is not expired as the insulin pen is not dated. RN-LL informed Surveyor R129 was recently admitted . Surveyor asked if insulin pens should be dated when opened. RN-LL replied we are suppose to 2.) On [DATE], at 11:33 a.m., Surveyor observed in the front 2 South medication cart, in the top drawer, a bottle of artificial tears lubricant eye drops marked with only a resident's first name and not dated when opened. On [DATE], at 11:40 a.m., Surveyor asked Licensed Practical Nurse (LPN)-MM when eye drops are open should the bottle be dated with the date opened. LPN-MM replied I don't know for sure then stated should be dated. Surveyor showed LPN-MM the artificial tears bottle marked with only a residents first name & not dated. Surveyor asked about the first name. LPN-MM informed Surveyor it is probably R2. 3.) On [DATE], at 11:49 a.m., in the top drawer left section of the 1 North back medication cart Surveyor observed approximately 33 small pink pills laying in the drawer towards the back of the drawer. On [DATE], at 12:06 p.m. Surveyor showed Licensed Practical Nurse (LPN)-Y the 33 small pink pills laying in the back of the drawer of the 1 North back medication cart. Surveyor asked if these pills should just be laying in the drawer. LPN-Y replied no and informed Surveyor he just cleaned the medication cart last week. 4.) On [DATE] at 11:53 a.m. Surveyor observed in the 1 North back medication cart in the top drawer a purple plastic basket. Inside this plastic basket were the following: *A used Lyumjev (insulin lispro-aabc) kwik insulin pen for R125 not dated when opened. *A used Novolog flex insulin pen that is not labeled with a resident's name and not dated when opened. *A used Ozempic pen with the pharmacy label partially removed with the only portion of the label on the pen is the number [PHONE NUMBER]-12. The Ozempic pen is dated when opened. *A used Lantus Solostar insulin pen for R130 not dated when opened. *A Lantus Solostar insulin pen for R53. *A Humalog insulin kwikpen for R81 not dated when opened. Surveyor observed these 6 insulin pens were not separated in bags or other means and were just placed all together in the purple plastic basket. On [DATE], at 12:05 p.m., Surveyor asked LPN-Y if resident's insulin pens should be dated when open, labeled with a resident's name and separated. LPN-Y replied yes. Surveyor showed LPN-Y the insulin pens in the purple basket. On [DATE], at 12:54 p.m., Surveyor asked Director of Nursing (DON)-B if insulin pens should be dated when opened. DON-B replied yes. Surveyor then asked if the insulin pens should be separated. DON-B replied yes and explained each pen in an individual bag with the resident's name on it. Surveyor asked DON-B if a pharmacy label should be removed. DON-B replied no that's how you know who's pen it is. On [DATE], at 12:55 p.m., Surveyor asked DON-B if eye drops should be dated when opened. DON-B replied they are supposed to be, yes. Surveyor informed DON-B of Surveyors observation in the front 2 South medication cart & 1 North back medication cart. On [DATE], at 12:36 PM, Surveyor observed medication cart on 2 North, and notes, 1 bottle of blood glucose test strips that was not labeled when opened. On [DATE], at 1:25 PM, Surveyor observed medication cart on 1 South and observed loose blood glucose test strips sitting in a medication cup with no expiration date or labeled when opened date. Surveyor also notes all Over the Counter (OTC) medications in the 1 South medication cart were not labeled with opened dates in the 1 South medication cart. Surveyor asked Registered Nurse (RN)-UU what was in the medication cup and RN-UU stated she ran out of blood glucose test strips earlier that day and had to borrow some from another cart because she ran out. Surveyor asked RN-UU how she knows when the test strips expire and RN-UU states there is an expiration date on the bottle. Surveyor then asked RN-UU if she will write anything on a bottle of blood glucose test strips when she gets a new bottle. RN-UU states, no she does not write on the bottle. Surveyor asked RN-UU how she knows when the blood glucose test strips expire, and RN-UU states there is a manufacturer expiration date on the blood glucose test strip bottle. RN-UU states her unit goes through test strips so quickly that they don't expire. RN-UU then stated sometimes we have 10 or more residents on the unit who are diabetics but right now we don't have that many diabetics. Surveyor notes, facility staff are unable to identify when test strips are opened or expired after open date. According to National Diabetic Supply, while sealed and unopened products [glucose test strips] are typically good until their expiration date, once opened, they have a limited usage period. Most brands recommend using them within 3 to 6 months after opening to ensure accurate results. https://nationaldiabeticsupply.com/best-practices-when-storing-glucose-test-strips/?srsltid=AfmBOoov0ttjAHsVCr5znH6vRgQym-fVv7R4s9RcCD898w3JrnsTCEvP On [DATE], at 1:47 PM, Surveyor interviewed Registered Nurse (RN)-NN and RN-LLL and asked if glucose test strips are labeled. RN-NN and RN-LLL stated, yes, staff are to label the glucose test strip bottle with an open date to determine expiration dates. On [DATE], at 8:39 AM, Surveyor requested a facility policy for glucose test strip storage. Director of Nursing (DON)-B states the facility does not have a policy regarding storage of glucose test strips. On [DATE], at 9:23 AM, Surveyor notified DON-B of concerns with the above findings. DON-B acknowledge these concerns. On [DATE], at 2:44 PM, the above findings were shared with Regional Director of Operations (RDO)-XX and Director of Operations (Director of Ops)-YY, and DON-B.

Based on observation, interview and record review the facility did not ensure that residents environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 12 (R60, R11, R41 and R90) residents reviewed for falls. R60 had a fall from bed while staff was providing cares which resulted in a laceration requiring sutures. The care plan was not revised with recommended interventions and staff were not educated following the fall. R11 had multiple falls. Observations found fall precaution interventions were not implemented and the facility did not complete thorough investigations of his falls. Following the falls, there was no evidence of an RN assessment. R41 had 6 falls while residing in the facility. The facility did not thoroughly investigate each fall to determine a root cause analysis to implement appropriate interventions to prevent further falls. R90 had a fall from bed. The facility did not thoroughly investigate the fall to determine a root cause analysis to implement appropriate interventions to prevent further falls. Findings include: The facility policy titled “Fall Prevention Program” dated 10/8/24 documents (in part) … .Each resident will be assessed for fall risk minimally upon admission, quarterly, annually and with change of condition and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 3. The nurse will acknowledge the resident's fall risk and initiate interventions on the resident's baseline care plan, with consideration of the resident's level of risk and individual needs. 4. The nurse will refer to the facility's Fall Care Plan template as a guide in determining potential initial interventions . 8. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored and reevaluated post fall as needed for effectiveness. b. The plan of care an Kardex will be revised as needed. 9. When any resident experiences a fall, the facility will: f. Review the resident's care plan and update as indicated. g. Document all evaluations/assessments and actions taken. h. Obtain witness statements to aide in root cause determination and injury review. i. Monitor residents' condition and response to interventions as per standard of practice. 1) R60 admitted to the facility on [DATE] and has diagnoses that include chronic kidney disease stage 3, chronic obstructive pulmonary disease, morbid obesity, asthma, dysphagia, anxiety disorder, major depressive disorder, hypertension, gout, gastroesophageal reflux disease and hereditary and idiopathic neuropathy. R60's admission MDS (Minimum Data Set) dated 8/3/25 documents: functional limitation in range of motion lower extremity (hip, knee, ankle, foot) - impairment on both sides. Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed-partial/moderate assistance. R60's Admission/readmission/routine Head to Toe Evaluation dated 7/28/25 documents: Fall Risk evaluation-High risk. R60's BIMS (Brief Interview for Mental Status Score) dated 7/28/25 documents a score of 15, indicating no cognitive impairment. On 9/22/25 at 12:04 PM, Surveyor observed R60 lying in bed on her back, with the bed positioned against the wall on the left side. During initial interview, R60 reported she had a fall a few weeks ago. “The aid was rolling me over on my left side. I guess she forgot to lock the wheels on the bed because when she rolled me over and I put my hand on the wall to support myself, the bed moved and I rolled right out of bed onto the floor, landing on my face.” R60 pointed to her left eye, stating “I had 9 stitches.” Surveyor observed a scar above her left eyebrow. Surveyor reviewed R60's care plan on 9/22/25 which documented: The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) (blank) - date initiated 7/28/25. Intervention: Bed Mobility - the resident requires moderate assistance by 1 staff to turn and reposition in bed every 2-3 hours and as necessary - date initiated 7/28/25, revision on 8/19/25. The resident is at risk for falls, accidents and incidents r/t (blank) - date initiated 7/28/25. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance –date initiated 7/28/25. Facility progress notes documented: On 9/1/25 at 6:28 PM, resident fell with CNA (Certified Nursing Assistant) in room while check and changing resident and she (CNA) unlocked bed to move bed with resident on side and she fell between bed and wall and gashed her head open above left eyebrow and sent out via hospital, family and NP (Nurse Practitioner) notified of occurrence. On 9/1/25 at 6:28 PM, called to room. Resident noted to be on the floor face down.stated CNA was in the room doing her (R60's) cares and when she was on her side (left side), she (R60) started moving away from the wall and the patient fell between the bed and the wall. Patient noted to have blood coming from the face. Face wiped clean and it was noted to be a laceration to the upper left brow 2 cm (centimeters) x 4 cm. Notably in pain and anxious. 911 called and writer stayed on the floor with patient until EMS (Emergency Medical Services) arrived. While waiting for EMS, ROM (Range of Motion) applied to all extremities with no new issues noted. Neuros initiated. DON (Director of Nursing), POA (Power of Attorney) and on call NP were notified of incident. Further intervention is to change patient from 1 assist with cares to a 2 assist with cares for safety and decrease risk for falls. EMS took her to ER (Emergency Room). On 9/1/25 at 10:26 PM hospital called and reported the CT (Computerized Tomography) negative. Stitches in place to left upper brow will be returning when transport becomes available. The hospital ED (Emergency Department) notes dated 9/1/25 document (in part) XXX[AGE] year-old female who presents to the ED with a fall. The patient was being cleaned up in her bed at her living facility, the bed started to roll, and she tried to turn and rolled out of bed. Hit her left forehead and left arm. Complains of pain in these areas. There is a large 4.5 cm laceration on the left forehead. X-rays negative for fractures. CT head negative for acute intracranial abnormality. Surveyor was provided R60's fall investigation which documented: Witnessed Fall with head injury 9/1/25 1850 (6:50 PM). Incident description: Nurse was called due to resident falling out of bed during a check and change. Resident stated she was getting changed by the CNA when the bed fell away from the wall, and she landed on the ground and hit her head. Resident was taken to hospital via ambulance due to hitting her head and getting a face laceration to forehead above the left eyebrow. Injuries observed at time of incident: No injuries observed at time of incident. Level of pain numerical: 10 LOC (Level of Consciousness): Alert, oriented to person, place. Notes: Resident fell out of bed during check and change and hit her head. Injuries report post incident: No injuries observed post incident. Predisposing environmental factors: Check mark other Predisposing situation factors: Check mark other Other info: During check and change fell out of bed. 9/2/25 IDT (Interdisciplinary Team) met to discuss recent fall. Resident was receiving incontinence cares when she rolled out of bed. CNA was in providing cares per CP (Care Plan) of 1 assist. Resident was rolled in bed and kept rolling and rolled off the bed. CP reviewed and updated for assist of 2 when cares are provided. Fall investigation form signed by CNA-WW 9/1/25: Factors observed at the time of the fall: Circle all that apply: (circled) Environmental factors/other - (handwritten) “unlocked bed.” What could have been done differently to prevent this fall? Leave the bed locked. CNA-WW statement: I grabbed what I needed for cares. I was almost done with the resident. I helped her turn towards me, wheels locked on bed. (R60) then I needed to turn towards wall. The blankets were stuck between bed and wall when I turned the bed into the unlock position at that time (R60) slightly pushed against the wall the whole bed moved and (R60) fell slowly to the floor, smacking her head causing lac (laceration). Immediately went for help. On 9/10/25 at 7:00 AM, NP note/assessment: Currently in bed lying supine. Nine sutures present just above the left eyebrow that are clean, dry and intact. Some scabbing present. Skin pink. No swelling present. Sutures present for one week and are ok to remove per ER MD (Medical Doctor). Nine sutures successfully removed, and the patient tolerated well. No bleeding present. Area cleansed followed by TAO (triple antibiotic ointment). Surveyor noted on 9/22/25, there were no new interventions added to R60's care plan following the 9/1/25 fall. On 9/24/25 while reviewing R60's care plan, Surveyor noted the following revisions that were not present upon Surveyor's initial review of the care plan on 9/22/25: Bed Mobility: The resident requires moderate assistance by 2 staff to turn and reposition in bed every 2-3 hours and as necessary - date initiated 9/1/25, created on 7/28/25, revision on 9/22/25. Ensure Bed locks are engaged – date initiated 9/23/25. Surveyor noted these care plan revisions were added to R60's care plan after the start of survey on 9/22/25. On 9/23/25 at 10:25 AM, Surveyor asked CNA-FF where she would look to see how to care for a patient, for example how they transfer, continence, etcetera. CNA-FF reported they use the Kardex. Surveyor asked if staff has a paper copy to carry with them or is it in the residents' room. CNA-FF reported the Kardex is in the binder at the nurses' station and proceeded to show Surveyor a white binder containing residents' Kardex. Surveyor noted the resident Kardex in the binder were last updated on 5/13/25 and R60 did not have a Kardex in the binder. Surveyor asked CNA-FF if a resident does not have a Kardex what would you do and how would you know what is necessary to care for the resident? CNA-FF stated, “If they are a new admit, I'm old school - I would ask the nurse in report.” On 9/23/25 at 12:59 PM, Surveyor spoke with DON-B with Nursing Home Administrator (NHA)-A present. Surveyor reviewed R60's fall investigation and asked what was done following R60's fall. DON-B stated, “We updated her care plan to be a 2 person with bed mobility and we did informal education with the CNAs on the unit to let them know she is now a 2 person.” Surveyor asked if any fall education was provided to any other staff after R60's fall. NHA-A stated, “Only the CNAs on the unit, and we updated her care plan.” Surveyor advised DON-B and NHA-A that R60's care plan was not revised to indicate 2-person bed mobility or the intervention to keep bed brakes locked until after the start of survey (interventions were added to care plan on 9/22/25 and 9/23/25). Surveyor asked and confirmed the fall investigation provided is the complete investigation. Surveyor advised the Kardex binder on the unit does not include a Kardex for R60 and in fact all other residents' Kardex had not been updated/were dated effective 5/13/25. 2) R11 was admitted to the facility on [DATE] with diagnoses of autistic disorder, repeated falls, unspecified intellectual disabilities, epilepsy, mood disorder, dementia, and anxiety. R11's admission Minimum Data Set (MDS) completed 7/9/25 documents R11 demonstrates severely impaired skills for daily decision making and both short and long term memory impairment. The MDS documents R11 does not have range of motion impairment. R11 requires substantial/maximum assistance for dressing and hygiene, supervision for transferring, eating and mobility. R11's Fall Care Area Assessment (CAA) completed 7/3/25 documents a fall CAA was triggered due to behaviors of wandering occurring daily, taking antianxiety, and antidepressant medications. The CAA documents R11 has ongoing use of psychotropic medications, weakness present that relies on staff for assist, rarely to never understood or understands. R11's Fall Risk Evaluation Document: - 7/3/25 score of 18 – in progress (not complete) - 7/31/25 score of 29 - 9/17/25 score of 27 A score of 10 or higher indicates the Resident is at high risk of falling. R11's Kardex dated 9/24/25 documents: - Allow resident to remain standing if R11 chooses - Antiroll back on wheelchair - Dycem in wheelchair to prevent slipping out - Encourage resident to keep hands free when up ambulating - Gripper socks or slippers with non skid bottoms at night. - Lock wheelchair after standing to prepare for sitting back down - Offer soothing music to assist resident with sleep hygiene - Resident to have a wedge cushion so R11 will not slip out while self propelling - Staff to ambulate resident to allow R11 to stretch R11 legs when R11 attempts to stand. - Staff to engage resident while propelling R11 in wheelchair either by holding hand or walking along side R11 R11's comprehensive care plan for Falls documents, The resident is at risk for falls, accidents, and incidents r/t (related to) SHUFFLING ON FEET OCCASIONALLY initiated on 7/5/25, revised 7/7/25. Interventions - Allow resident to remain standing if R11 chooses. Initiated 8/11/25. - Anticipate and meet the resident's needs. Initiated 7/22/25. - Antiroll back on wheelchair. Initiated 7/25/25 - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated 7/5//25 - Dycem in wheelchair to prevent slipping out. Initiated 7/11/25. - Educated nurses on locking med (medication) cart wheels when med cart not in use. Initiated 8/11/25. - Encourage resident to keep hands free when up ambulating. Initiated 9/22/25. - Gripper socks or slippers with non-skid bottoms at night. Initiated 7/22/25. - Guardian updated to bring in sodas for resident to curb expressing self by putting self on the floor. Initiated 7/28/25. - Lock wheels after standing to prepare for sitting back down. Initiated 7/21/25. - Offer soothing music to assist resident with sleep hygiene. Initiated 7/31/25. - Resident to have a wedge cushion so R11 will not slip out while self-propelling. Initiated 7/12/25. - Staff to attempt to ambulate resident to allow R11 to stretch legs when R11 attempts to stand. Initiated 7/10/25. - Staff to engage resident while propelling R11 in wheelchair either by holding hand or walking along side R11. Initiated on 7/30/25. The resident has a behavior problem r/t (related to) intellectual disabilities (BITES, HITS, KICKS, THROWS ITEMS, PUTTING SELF ON FLOOR, AND PACES). Initiated 7/5/25, revision on 9/11/25. - I like to be approached forward, does not like people behind R11. Initiated 9/12/25. - I like to touch hair. Is very soothing to me. Please offer me the manikin head so that I can play with their hair instead of accidently pulling at staffs hair. Initiated 8/25/25. - If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Initiated 7/5/25. Revision on 9/11/25. 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. Initiated 7/5/25. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated 7/9/25 - Offer to hold residents hand for comfort. Initiated 7/22/25. - Praise any indication of the residents progress/improvement in behavior. Initiated 7/9/25. - Resident does not like fitted sheet on bed, only flat sheet and pillows. Initiated 8/7/25 - Resident enjoys to sit in dining room by window with blinds up to look out towards the water and have radio with R11. Initiated 7/22/25. - Resident likes to fidget with the cord to the radio and extension cord. Initiated 9/12/25 - Resident starts to tap fingers or feet when overstimulated. Allow resident time and offer a hand to hold. Initiated 7/9/25. - The resident enjoys calling and talking to sister (POA) [power of attorney]. Initiated 7/21/25 - The resident likes to touch their forehead to staff forehead for stimulation and calming (the resident initiates this only when reaching for your hand to touch their neck or when they reach their hand to staff's neck). Initiated 7/9/25 On 9/23/25, at 1:00 PM, Surveyor reviewed R11's 17 falls along with the facility's fall packets (investigations) of each fall from July 2025 to present (2025). 1 On 7/10/25, at 10:00 AM, R11 had a witnessed fall in the dining room while attempting to self ambulate. No injuries reported. All notifications completed. No Registered Nurse (RN) assessment completed. All staff statements collected and included in the packet. The root cause determined to be R11's poor safety awareness and attempts to self-ambulate. The care plan was updated and the intervention was initiated to have staff offer R11 to ambulate when R11 is attempting to stand up. 2 On 7/11/25, at 2:00 PM, R11 had a witnessed fall by the nurses' station while self-propelling in the wheelchair R11 scooted out of the wheelchair and onto the floor. No injuries reported. All notifications completed. No RN assessment completed. All staff statements included in the packet. The root cause determined to be R11 slid out of the wheelchair. The care plan was updated and the intervention of adding a dycem to the wheelchair. 3 On 7/12/25, at 1:34 PM LPN (Licensed Practical Nurse)-FFF documents a progress note that R11 had 2 witnessed falls. The first in R11's room at 11:00 AM and the second in the dining room at approximately 12:00 PM and it was witnessed by activity staff. No injuries noted and POA (power of attorney) made aware. There is not an investigation for this fall. The care plan was not reviewed and no updates to R11's care plan were made. 4 On 7/12/25, at 12:00 PM, R11 had a witnessed fall in the doorway of R11 room. R11 attempting to propel forward in R11 wheelchair and fell forward from R11 momentum. No injuries reported. All notifications completed. No RN assessment completed. 1 missing staff interview about the fall from CNA-DDD. The root cause determined to be R11 momentum carried R11 out of the wheelchair and on to the floor while self-propelling. The care plan was reviewed, and the intervention was added of placing a wedge cushion on the wheelchair Surveyor notes that of the two falls above for 7/12/25, the fall in the dining room was not investigated. 5 On 7/18/25, at 8:20 PM, R11 had a witnessed fall in the dining room. R11 was in the wheelchair reaching for R11's stereo and the wheelchair rolled back and R11 fell. No injuries reported. All notifications completed. No RN assessment completed. All staff statements included in the packet. The root cause determined to be the wheelchair rolled back as the resident attempted to stand and reach for the stereo. The care plan was reviewed and the intervention of anti-roll backs added to the wheelchair. 6 On 7/19/25, at 12:15 PM, R11 had a witnessed fall in the dining room. R11 was stood from the wheelchair, R11 fell before staff could reach R11. No Interdisciplinary note was made and there was no review of the care plan and no interventions implemented. 7 On 7/21/25, at 08:23 AM, R11 had a witnessed fall in R11's room. The fall was witnessed by R11's peer, but no interview of name of the peer was included in the fall investigation. All notifications completed. No RN assessment completed. The root cause was determined to be R11 fell when he attempted to sit in the chair in R11's room. The care plan was updated and the intervention of locking R11's wheelchair at bedside was placed. 8 On 7/22/25, at 10:15 AM, R11 had a witnessed fall in the dining room. All notifications completed. No RN assessment completed. The root cause was determined to be R11 was not an active participant in the activity and attempted to ambulate away. The care plan was reviewed and the intervention of keeping R11's radio near R11 at all times if he does not want to be an active participant in an activity was placed. 9 On 7/22/25, at 4:00 PM, R11 had an unwitnessed fall in R11's room. All notifications completed. A neurological assessment was completed. No RN assessment completed. The root cause was determined to be R11 may express R11's needs and wants by placing R11 on the floor. The care plan was reviewed and the intervention of providing sodas to R11 to make R11 happy was placed. 1 On 7/30/25, at 11:30 AM, R11 has a witnessed fall in the hallway. All notifications completed. No RN assessment completed. The root cause was determined to be R11 placed R11's feet down while being pushed in the wheelchair. The care plan was reviewed and updated with the intervention of having a second staff member walk along side of R11 or hold R11's hand while being pushed in the wheelchair. 1 On 7/31/25, at 3:05 AM, R11 had a witnessed fall in the hallway. All notifications completed. No RN assessment completed. The root cause was determined to be R11 was attempting to self-ambulate and fell. The care plan was reviewed and updated the intervention of offering soothing music at night to help with sleep was placed. On 8/10/25, at 2:25 AM, R11 had a witnessed fall by the nurses station on the unit. All notifications completed. No RN assessment completed. The root cause was determined to be R11 fell when trying to move past the med cart and the cart moved causing the fall. The care plan reviewed and updated, the intervention implemented was the staff was educated to keep nurses cart wheels locked. On 8/10/25, at 01:05 AM, R11 had a witnessed fall in the dining room. All notifications completed. RN assessment completed. The root cause was determined to be R11 fell when trying to stand when being asked to sit. The care plan was reviewed and updated and the intervention implemented was to allow R11 to stand if he chooses to do so 1 On 8/23/25, an emergency department note documents R11 had an unwitnessed fall and low oxygen status. It documents the facility staff are not sure what happened. There is no documentation that the facility completed a thorough investigation of this fall. On 9/12/25, at 10:50 PM, a progress note by LPN-GGG documents R11 had a fall at the doctor's office and received 2 sutures. A fall investigation was not completed. 1 On 9/17/25, at 6:45 AM, R11 had a witnessed fall in R11's room. All notifications completed. No RN assessment completed. The root cause was determined to be R11 fell when ambulating with both hands full. The care plan was reviewed and updated and the intervention implemented was to encourage R11 to have less items in hands so that R11 can stabilize or reach for assistance. 1 On 09/25/2025, at 12:54 PM, Surveyor observed R11 sitting in the hallway in a wheelchair. R11 has a table with R11's stereo in front. R11 was holding on to an extension cord and grabbing out at CNA-CCC. R11 then stood up, and CNA-CCC told R11 to sit down. R11 did not sit down and stepped toward CNA-CCC, Then R11 fell. R11 did not hit head. R11's wheelchair was not locked. LPN-ZZ told Unit manager (UM)-F to go and get an RN. LPN ZZ trying to get vitals signs. The RN-QQ responded and assessed. On 9/25/24, at approximately 1:00 PM, LPN-ZZ documented in a progress note R11 had a witnessed fall in the hallway. R11 attempted to stand and walk without assistance, when reaching for R11's designated CNA-CCC, R11 fell. All notifications completed. RN QQ documented “Staff came to report R11 on [Unit R11 resides] had a fall and they needed writer to come assess R11. R11 had put self back in w/c (wheelchair) MAEW (Moves All Extremities Well) no apparent injury” as the assessment for R11's fall. All notifications completed. R11 was on direct (1:1) supervision by CNA-CCC and will continue to be directly supervised. Surveyor noted CNA-CCC did not attempt to ambulate R11 and did not lock R11's wheelchair per care plan. Surveyor made the following observations of R11's care plan not being implemented: 1.Dycem and wedge cushion not in wheelchair 9/22/25 at 1:02 PM 9/23/25, at 7:24 AM 9/23/25 at 10:38 AM 9/24/25 at 7:06 AM On 9/24/25, at 9:50 AM, Surveyor observed the Kardex for R11 at the nurses station. The last update to the Kardex is documented as 7/30/25. The dycem and wedge cushion is included in the current Kardex. On 9/24/25, at 9:52 AM, Surveyor interviewed CNA-DDD about R11's dycem and wedge cushion in the wheelchair. CNA-DDD stated R11 must have removed it and it is usually left in the chair. LPN-ZZ states LPN-ZZ will call laundry to see if it was sent there to be cleaned. On 9/24/25, at 9:53 AM, Surveyor conducted observed R11's room and did not see a wedge cushion or dycem. 2. Medication cart wheels unlocked 9/22/25 at 1:04 PM 9/23/25 7:21 AM and 10:38 AM 9/25/25, at 7:45 AM and at 10:22 AM On 9/24/25, at 1:21 PM, Surveyor Interviewed DON-B . DON-B states DON-B and NHA-A are responsible for making sure the fall packets are completed. DON-B stated its expected that facility and agency staff follow the Kardex for the residents. DON-B states DON-B is unsure why the dycem was sent to laundry when it can be wiped down. DON-B stated there should be a second cushion in case one gets soiled and is sent to be cleaned. DON-B states DON-B will look into the cushion and dycem that was to be observed missing from R11's chair. DON-B stated the fall from the doctor's office should have been investigated and was not. Surveyor asked DON-B about the unwitnessed fall on 8/23/25. DON-B states DON-B is not sure and will have to look into it. No further information was provided from DON-B or the facility regarding incomplete investigations and/or no investigations of R11's falls, and as to why R11 did not have R11's wedge cushion and dycem in R11's wheelchair per R11's care plan. On 9/25/25, at 7:36 AM, Surveyor observed CNA-EEE trying to pull R11 backwards multiple times to get R11 to go into R11's room to eat breakfast. R11 ‘s care plan documents an intervention to not approach R11 from behind. On 9/25/25, at 7:40 AM, Surveyor interviewed CNA-EEE. CNA-EEE states CNA-EEE is unsure if the dycem is in the wheelchair as R11 was already in the wheelchair when CNA-EEE arrived to work today. Surveyor noted there is a normal cushion in the chair and not a wedge cushion. On , Surveyor observed the medication cart wheels to be in the unlocked position and the cart moves when pushed. On 9/25/25, at 1:34 PM, Surveyor interviewed DON-B. DON-B states the RN assessment should be included in the fall packets but a progress note is also acceptable. DON-B stated if an LPN writes a post fall evaluation, an RN must sign off on it or write another progress note after stating they agree with the assessment. 3) On 9/23/25, at 1:30 PM, Surveyor noted there were 10 occurrences where R11 had put self on the floor. These occurrences do not have any fall investigations. 1 On 7/12/25, at 2:45 PM, A note written by LPN-FFF documents “…Difficult to redirect, pushing through staff in an attempt to get past. When R11 unable to get through, R11 sat down on the floor between staff and attempt to scoot past…” On 8/2/25, at 11:19 AM, A note written by RN-NN documents “…the patient [R11] would sit on the floor and proceed to drink the soda that R11 had taken… When R11 did stand up with staff help R11 would only take a few short steps before pulling self down again. This time patient [R11] sat in the other patients doorway . When R11 is unsuccessful, patient will place self on the floor in hopes to sneak past staff and get into the room…” 3 On 8/3/25, at 7:54 PM, A note written by Agency Nurse-MMM documents “…R11 placed self on the floor during this shift.” On 8/4/25, at 8:10 PM, A note written by LPN-HHH documents “R11 entering other resident's rooms, when attempting to redirect, R11 puts self on floor…” 5 On 8/12/25, at 5:39 AM, A note written by RN-III documents “…R11 is currently sitting on the floor near the exit after setting self purposefully on the floor.” 6 On 8/12/25, at 6:35 PM, A note written by LPN-HHH documents “…R11 did not want the items, R11 put self on floor, assisted R11 off of the floor and was able to bring back to R11's room…” 7 On 8/15/25, at 6:16 AM, A note [NAME]

Based on interview and record review, the facility did not ensure 7 (R11, R1, R3, R9, R120, R41, and R90) of 7 residents reviewed were notified of the reason for transfer/discharge and bed hold policy in writing to the resident and/or their representative. Residents were not notified of the rate to reserve the resident's bed because it was not documented in the transfer and bed hold notice. The transfer and bed hold notice did not document the email address for the The State Survey Agency and for the Long Term Care Ombudsman. The transfer and bed hold notice also did not contain documentation of the name , address(mail and email) and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities and mental disorders. The ombudsman was not notified of the transfer/discharge. *R11's transfer and bed hold notice dated 8/25/25 was not provided to R11's representative in writing and R11's transfer and bed hold notice did not contain the bed-hold reserve rate and the name, address(mail and email) and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities. The ombudsman was not notified of the transfer/discharge. *R1 was sent to the hospital on 2/4/25, 3/12/25, and 6/22/25. R1 was not provided a proper transfer/discharge and bed hold notice in writing and the ombudsman was not notified of the transfer/discharge. *R3 was not provided a proper transfer/discharge and bed hold notice in writing and the ombudsman was not notified of the transfer/discharge. *R9 was sent to the hospital on 8/6/25 and 9/8/25. R9 was not provided a proper transfer/discharge and bed hold notice in writing and the ombudsman was not notified of the transfer/discharge. *R120's against medical advice(AMA) discharge on [DATE] was not communicated to the ombudsman. *R41 was transferred to the hospital on 3/11/25 and their Power of Attorney for Healthcare (POA-HC) was not provided a proper written transfer notice and bed-hold information. The Ombudsman was not notified of this transfer to the hospital. *R90 was transferred to the hospital on 6/30/25. R90 was not provided a proper written transfer notice and bed-hold information. The Ombudsman was not notified of this transfer to the hospital. Findings Include: The facility's Bed Hold Notice Upon Transfer policy and procedure revised 10/29/24 documents: .Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or the resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed. Policy Explanation and Compliance Guidelines: Bed Hold Notice Upon Transfer 1.Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility b. The reserve bed payment policy in the state plan policy c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility. 5.The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or representative in the resident's medical record. 1) R11 was admitted to the facility on [DATE]. R11 currently has a legal guardian. R11 was transferred to the hospital on 8/23/25. R11's Transfer and Bed Hold Information dated 8/25/25 does not contain the room reserve rate, or the name, address (mail and email) and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities. The form states that a verbal consent to hold a bed was obtained. On 9/24/2025, at 9:58 AM, Surveyor interviewed Social Worker Assistant (SWA)-D and asked what role SWA-D has in the bed hold policy. SWA-D stated the process is all new to SWA-D but SWA-D calls families to get a bed hold. SWA-D will call them to ask if the resident is returning after the resident has been discharged . If the resident is responsible for themselves, will attempt to reach resident by cell phone or the social worker at the hospital. SWA-D does not notify the ombudsman when discharged to the hospital, to the community and AMA. SWA-D only obtains verbal consents for the transfer/bed hold notice and does not mail it to the representative. On 9/24/2025, at 11:59 AM, Social Worker (SW)- E told Surveyor that SW-E does not send any discharge information to the ombudsman on discharges. SW-E stated Business Office Manager (BOM)-TTT will send out the transfer/bed hold notice either by mail or email to the representative. On 9/24/2025, at 1:02 PM, Surveyor interviewed BOM-TTT in regard to the transfer/bed hold notices. BOM-TTT stated BOM-TTT will mail to the Health Care Power of Attorney (HCPOA) or guardian the transfer/bed hold notice in an envelope and include a stamped envelope for the HCPOA or guardian to mail back. When BOM-TTT receives the transfer/bed hold notice back, it is scanned in. If the transfer/bed hold notice is scanned in, the original is kept in medical records. *) R1 admitted to the facility on [DATE] and has diagnoses that include diffuse Traumatic Brain Injury, Acute and Chronic Respiratory Failure with Hypoxia, Protein-Calorie Malnutrition, Tracheostomy status, Neuromuscular Dysfunction of Bladder, Anxiety Disorder, Chronic Pain Syndrome, Colostomy status, contractures of muscle, unspecified convulsions, Hypotension, Stage 4 pressure injuries, history of pulmonary embolism, gastrostomy status, Anemia, Encephalopathy, history of venous thrombosis and embolism and Extended Spectrum Beta Lactamase (ESBL) resistance. R1 was hospitalized for change in condition on 2/4/25, 3/12/25 and 6/22/25. There was no evidence R1's Mother/Guardian was provided the hospital transfer and bed hold notice information and no evidence the Ombudsman was notified. The facility forms titled Transfer and Bed Hold Information has a section to elect Yes I would like a bed hold or No I would not like a bed hold. Surveyor noted for the effective date of discharge/transfer on 2/4/25, 3/12/25 and 6/22/25 – there was no evidence the form was provided to R1's Mother/Guardian, neither form had an election indicated and neither of the forms were signed by R1's Mother/Guardian. On 9/24/25 at 2:45 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern there is no evidence R1's Mother/Guardian receive the bed hold and transfer notice information from the above hospitalizations. In addition, there is no evidence the Ombudsman was notified. 3) R3 was admitted to the facility on [DATE] and is their own person. On 5/20/25, R3 experienced a change of condition. R3 was admitted to the hospital on [DATE] and returned to the facility on 5/26/25. Surveyor reviewed R3's Electronic Medical Record (EMR) for documentation that R3 was given a bed hold and transfer notice. Surveyor noted a bed hold and transfer notice was not scanned into the EMR. On 9/24/25, facility provided Surveyor with R3's Transfer and Bed Hold Information form dated 5/21/25 which documented, in part: . [Facility] is transferring/discharging: [R3] to [Hospital] . Surveyor noted the section documenting, Yes I would like a bed hold is checked yes. Surveyor noted the section requiring a resident's signature documents: Verbal Consent. Surveyor noted R3 did not sign the transfer and bed hold form per the facility policy. Surveyor noted that R3 was not provided a copy in writing of the bed hold and transfer notice per the facility policy. Surveyor noted that R3's transfer and bed hold form was not scanned into R3's EMR per facility policy. Surveyor noted the facility did not provide documentation that the Ombudsman was notified of R3's hospitalization. On 9/24/25 at 2:52 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that R3 did not sign and receive in writing the bed hold and transfer notice from R3's hospital transfer on 5/20/25. In addition, the facility did not provide documentation that the Ombudsman was not notified of R3's hospitalization. 4) R9 was admitted to the facility on [DATE] and has a Guardian of Person and Estate in place. R9 was hospitalized on [DATE] due to increased restlessness, confusion and low oxygen saturation. There was no evidence R9's Guardian was provided the hospital transfer and bed hold notice information and no evidence the Ombudsman was notified. R9 was re-admitted to the facility on [DATE] and then sent back out to the hospital on 9/6/25 for hypoxemia. There was no evidence R9's Guardian was provided the hospital transfer and bed hold notice information and no evidence the Ombudsman was notified. 5) R120 was admitted to the facility on [DATE] and discharged on 6/14/25. R120 is their own person. R120's nurses note dated 6/14/25, at 11:00 a.m. and written by Licensed Practical Nurse (LPN)-JJJ documents Resident signed AMA form and left facility his care giver came and got him with his electric scooter, and he drove the electric scooter across the street to his apartment. On 9/25/25, at 7:32 a.m., Surveyor informed Social Worker (SW)-E Surveyor had reviewed R120's discharge and noted R120 left AMA on 6/14/25. Surveyor asked SW-E if the Ombudsman was notified of R120's discharge. SW-E informed Surveyor when a resident signs out AMA they should notify the Ombudsman and APS (Adult Protective Services). Surveyor asked how this notification is done. SW-E replied either by phone or email. SW-E informed Surveyor she knows she notified APS. Surveyor inquired about the Ombudsman. SW-E informed Surveyor the system at the facility is the social worker for what ever floor the resident resided on notifies the Ombudsman. Surveyor noted R120 did not reside on SW-E's floor. On 9/25/25, at 7:44 a.m., Surveyor asked SWA-D when a resident is discharged who is notified. SWA-D replied the family, if AMA contact APS and let people in the company know. Surveyor asked SWA-D who notifies the Ombudsman. SWA-D informed Surveyor when she was in training in May she asked SW-E who notifies the Ombudsman, and SW-E said she did. Surveyor asked SWA-D if SW-E notifies the Ombudsman when a resident is discharged for the entire facility. SWA-D nodded to indicate yes. Surveyor asked SWA-D if she notified the Ombudsman when R120 was discharged on 6/14/25. SWA-D replied no. Surveyor informed SWA-D Surveyor had spoke with SW-E about Ombudsman notification when a resident is discharged and SW-E told Surveyor she does the first floor, and you (SWA-D) do the second floor. SWA-D replied guess I will start doing it. 6) R41 was admitted to the facility on [DATE] for rehab services and has an activated POAHC. Surveyor reviewed the medical record. There was not a bed-hold or transfer notice for the 3/11/25 transfer to the hospital. On 9/23/25, at 3:05 PM, Surveyor requested R41's bed hold and transfer notice. On 9/24/2025, at 8:25 AM, Surveyor received a Transfer and Bed -Hold Information form dated 3/12/25. It does not include the required transfer notice information or the right to appeal, the name and contact information of the State Ombudsman. There is no evidence that the notice was provided in writing. The information provided was a verbal consent for a bed-hold by a staff member. The form does not document who was verbally notified. There was no evidence the State Ombudsman was notified of the transfer to the hospital on 3/11/25. 7) R90 was admitted to the facility on [DATE] for wound care. R90 is their own person. R90 Minimum Data Set (MDS) assessment documents a hospital stay from 6/30/25 – 7/8/25. On 9/22/2025, at 10:36 AM, Surveyor interviewed R90. R90 could not recall details of their hospitalization. Surveyor reviewed the medical record. There was not a bed-hold or transfer notice for the 6/30/25 transfer to the hospital. On 9/23/25, at 3:05 Surveyor requested R90 bed-hold and transfer notice. On 9/24/2025, at 8:25 AM, Surveyor received a Transfer and Bed -Hold Information form dated 7/12/25, It does not include the required transfer notice information of the right to appeal, the name and contact information for the State Ombudsman, or that it was provided in writing at the time of transfer. The information provided was a verbal consent for a bed-hold by a staff member. The form does not document who was verbally notified. There was no evidence the State Ombudsman was notified of the transfer to the hospital on 6/30/25.

Based on record review and staff interviews, the facility did not report allegations of abuse to the State Survey Agency. Residents (R110, R89, R26, R106, R121, R122, R39, R69, and R116) were identified in 8 allegations of abuse and/or resident-to-resident altercations. Although reported to NHA-A (Nursing Home Administrator), the incidents were not reported immediately to the State Survey Agency. Findings Include: The facility's Abuse, Neglect and Exploitation policy and procedure last reviewed/revised 7/12/25 documents: .Definitions: 'Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 'Alleged Violation' is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. 'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. 'Verbal Abuse' means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.”… .Reporting/Response 1.Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies(e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. b. Not later than 24 hours if the vents that cause the allegation do not involve abuse and do not result in serious bodily injury. 1) On 3/17/25, an allegation of resident-to-resident altercation involving R106 and R121 was reported immediately to NHA-A. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours. Staff reported they went running to R106 and R121's room because they heard yelling. Staff reported to NHA-A immediately that they had witnessed R106 repeatedly hitting R121 on the head with a pillow. Staff observed R121's glasses on crooked, hair messed up, and redness to the face. Staff separated R106 and R121, but needed assistance to remove R121 from the room as R106 would not allow them to leave. Staff texted NHA-A the circumstances and staff responded to assist. NHA-A informed Surveyor there was no resident-to-resident altercation so no report was made. The facility had a soft file (informal notes). Surveyor's review of the file found typed up staff statements. There were no signatures on the statements. 2) On 4/30/25, an allegation of verbal abuse and physical threatening involving R106 and R121 was reported immediately to NHA-A and was not reported to the State Survey Agency within 24 hours. R106 was overheard by staff saying R106 would “wet someone,” which is slang for causing enough injury to make someone bleed. R121 was in the vicinity when R106 stated this. The nurse on the unit was informed by staff who charted the incident and was informed by the supervisor to keep R106 and R121 separated and continue to monitor R106 and R121 and place R106 and R121 on the 24-hour board. NHA-A informed Surveyor there was no resident-to-resident altercation involving verbal abuse or physically threatening so no report was made. The facility had a soft file of typed unsigned statements from staff. 3) On 4/19/25, an allegation of resident-to-resident altercation involving R89 and R122 was reported immediately to NHA-A. The allegation of resident-to-resident altercation was not reported to the State Survey Agency within 24 hours. R89 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity with Agitation(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Depression(mood disorder that causes persistent feelings of sadness and loss of interest), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities), Visual Hallucinations(sensory experiences where a person sees objects, people, or scenes that are not actually present), and Essential Hypertension(chronic condition of persistently high blood pressure). R89 currently has a legal guardian. R89 was observed by staff to punch R122 in the face causing a skin tear to the left cheek. The staff member had to get between R89 and R122 to separate R89 and R122. Another staff member heard the physical contact R89 made to R122 with R122 stating “ouch.” NHA-A was immediately notified. NHA-A informed staff that NHA-A watched the cameras and determined there was no resident-to-resident altercation and stated R122 had hit R122's self and bit the inside of R122's cheek. NHA-A stated the resident-to-resident altercation did not happen as staff reported to surveyor. NHA-A told surveyor there was no soft file on this incident. 4) On 6/4/25, an allegation of sexual abuse involving R89 and R110 was reported immediately to NHA-A. The allegation of sexual abuse was not reported to the State Survey Agency within 2 hours and law enforcement was not notified. Staff reported immediately to NHA-A that R89 had been found in R110's room on R89's knees at R110's bedside. R110's bed was in the lowest position. R110's brief was off and was not covered with a sheet or blanket. R89's hand was on R110's vagina area. NHA-A stated the inappropriate sexual behavior could not have happened as NHA-A watched cameras and R89 was not in the room long enough for anything to happen. The facility had a soft file of typed unsigned statements from staff. 5) On 6/28/25, an allegation of verbal abuse and physical threatening involving R89 and R39 was not reported immediately to NHA-A and was not reported to the State Survey Agency within 24 hours. Staff documented in R89's electronic medical record(EMR) that R89 was verbally assaultive towards R39 and was physically threatening R39. Staff did not report it to NHA-A. Director of Nursing (DON)-B documented in R89's record that staff had documented what was perceived rather than what actually happened. The facility had a soft file of typed unsigned statements from staff. 6) On 8/10/25, an allegation of sexual abuse involving R89 and R110 was reported immediately to NHA-A. The allegation of sexual abuse was not reported to the State Survey Agency within 2 hours. Staff reported that R89 was inappropriately touching R110 under R110's shirt. NHA-A was immediately informed. Staff were instructed to place R89 on 1:1 supervision. NHA-A stated that the inappropriate touching did not happen. The facility had a soft file of typed unsigned statements from staff. On 9/2/25, at 12:16 PM, Surveyor interviewed NHA-A as to why NHA-A did not report the allegations of abuse and resident to resident altercations. NHA-A confirmed that NHA-A is responsible for coordinating and submitting facility reported incidents (FRI) to the State Survey Agency. NHA-A stated that with all 6 allegations that witnesses indicated that the allegations did not happen as initially reported so there was no need to submit to the State Survey Agency. NHA-A indicated NHA-A has “erred on the side of caution” and reported other incidents. Surveyor shared the concern with NHA-A that once the allegation of abuse is reported, the facility has an obligation to report immediately to the State Survey Agency, including notifying law enforcement if required. The facility has provided no further information at this time. 7) On 8/15/25, R116 and R69 had a resident to resident altercation. The facility conducted an investigation into the incident, but the completed investigation was submitted late to the State Agency on 8/25/25. On 9/29/25 at 1:23 p.m. Surveyor interviewed NHA-A. Surveyor asked NHA-A why the completed self report investigation was submitted late to the State Agency. NHA-A stated she forgot because she had a family emergency, and it was submitted late.

Based on observation, record review and interview, the facility did not ensure privacy and confidentiality for 12 of 20 residents. On 9/24/25, at 12:46 PM, R112's person health information was observed unprotected on an unattended medication cart computer screen, in the hall in view of anyone walking in the hallway. On 9/23/25, at 1:30 PM, Surveyor observed, from the hallway, Licensed Practical Nurse (LPN)-KK move R45's gown up, check R45's enteral feeding tube's placement, flush the tube and administer medication via the enteral tube. R45's room door was not closed. On 9/25/25, at 11:19 AM, Surveyor observed on top of the 2 South medication cart is a 2 South sheet with approximately eleven resident's names with personal information such as their blood pressure, vital signs, types of liquids received, seizure monitoring, fall risk, no male care givers, etc. This sheet was in view of anyone passing the 2 South medication cart. Findings include: The facility's policy titled Maintenance of Electronic Clinical Records, dated 11/11/24, states, A complete and accurate electronic clinical record .maintaining the confidentiality of the residents' information. The facility's policy titled Health Insurance Portability and Accountability Act (HIPAA) Sanctions, dated 5/12/25, last reviewed 7/9/25, states, All employees will be educated on relevant policies and procedures for which they are expected to comply, including this sanctions policy. 1) On 9/24/25, at 12:46 PM, R112's health information was observed on a computer screen on top of an unattended unlocked medication cart in the hallway on the second floor, south wing of the facility. No staff were observed around the medication cart. The information visible included R112's medications and reasons for the medication to be used. The medication cart was observed to be facing the elevators to the facility, approximately 25 feet from the elevators. Surveyor observed a resident sitting in a Broda chair approximately 6 feet from the medication cart during the time it was unattended. Surveyor overheard Certified Nursing Assistant (CNA)-SS tell Registered Nurse (RN)-QQ that RN-LL was out on break. Surveyor notes R112 to be severely impaired for cognitive skills and is unable to be interviewed. 2) On 9/23/25, at 1:30 p.m., Surveyor observed Licensed Practical Nurse (LPN)-KK with R45 who was in bed. Surveyor observed the room door open and the privacy curtain was not pulled. Surveyor observed LPN-KK move R45's gown up, check the placement of R45's enteral feeding tube stating 10 of air, checking your tummy. After checking R45's feeding tube placement, LPN-K administered R45's medication individually and flushed in between each medication. After LPN-KK finished administering R45 her medication, LPN-KK connected and started R45's tube feeding. Throughout the observation, LPN-KK did not provide R45 with privacy during treatment. On 9/29/25, at 12:47 p.m., Surveyor asked R45 when the nurse is checking her feeding tube and administering medication through the tube does she want her room door open or closed. R45 replied closed, I prefer it closed because have to pull my dress up, referring to her gown. On 9/30/25, at 8:40 a.m., Surveyor asked DON-B when a nurse is checking placement of a resident's feeding tube and administering medication what is her expectation regarding the resident's room door. DON-B replied I would suggest the room door to be closed or the curtain drawn. Surveyor informed DON-B of Surveyor standing in the hallway and being able to observe R45's tube feeding placement being checked and medications being administered. 3) On 9/25/25, at 11:19 a.m. Surveyor observed Licensed Practical Nurse-MM take the vital sign machine, which was next to the 2 south medication cart, and wheel the vital sign machine down the hallway. Surveyor observed on top of the medication cart was a 2 South Sheet with approximately 11 residents names with personal information such as their blood pressure, vital signs, types of liquids received, seizure monitoring, fall risk, no male care givers, etc. This sheet was in view of anyone passing the medication cart. On 9/25/25, at 12:56 p.m., Surveyor asked DON-B about personal information being left on top of a medication cart unattended. DON-B informed Surveyor it should not be laying out. Surveyor informed DON-B of the observation of the 2 South sheet on top of the 2 South medication cart with approximately eleven residents name and personal information unattended.

Based on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment. This had the potential to affect all 103 Residents residing in the facility at the time of the survey.*) R13 informed Surveyor that R13's room does not get cleaned daily and that the garbage is not always emptied causing odors in the bedroom.*) R107 informed Surveyor that R107's room does not get cleaned every day per policy and that the garbage do not get emptied. R107 had a dry yellow spot on the top sheet of R107's bed and a urine odor was noted and R107's garbage was full.*) Surveyor reviewed grievances from May 2025 - August 2025 and noted 11 total grievances regarding bedrooms not being cleaned.Findings include:The facility housekeeping and laundry services are outsourced and provided by [laundry/housekeeping service company]. The facility provided Surveyor a Housekeeping and Laundry Program sheet that documents: . Areas of responsibility- Cleaning of all resident areas, common areas, administrative and ancillary offices, nursing areas, employee occupied areas, entrances.*) R13 was admitted to the facility on [DATE]. R13's admission Minimum Data Set (MDS) assessment dated [DATE] documents R13 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R13 has intact cognition.On 9/2/2025, at 9:30AM, Surveyor interviewed R13 who stated R13's bedroom does not get cleaned daily. Surveyor asked when the last time R13's bedroom was cleaned. R13 stated that could not remember, maybe Saturday. R13 stated there was only 1 cleaning person that actually used sprays to clean R13's bedroom but R13 has not seen them for a while. Surveyor asked how housekeeping cleans R13's room now. R13 stated that they just empty the garbage's when they are full and will wipe up room and mop about 1 time a week. Surveyor noted a slight urine odor in R13's room. R13 stated the aide was going to come and change R13's sheets and get R13 ready for the day. Surveyor asked of R13 has reported that R13's room is not being cleaned. R13 stated R13 usually notifies someone, and they send someone in to clean R13's room.*) R107 was admitted to the facility on [DATE]. R107's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R107 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R107 has intact cognition.On 9/2/2025, at 11:18AM, Surveyor interviewed R107 who stated R107's room does not get cleaned daily. Surveyor asked when the last time R107's room got cleaned. R107 replied it was cleaned on Friday or Saturday. R107 has filled out grievances and the facility will send someone in to clean R107's room. R107 stated housekeeping used to have to fill out a sheet when the room clean was completed, but R107 has not seen that happen for a while.Surveyor noted a dried yellow area on the top sheet of R107's bed and R107's garbage was full.On 9/2/2025, at 11:23AM, Surveyor interviewed licensed practical nurse (LPN, agency)-Y and certified nursing assistant (CNA)-Z who stated housekeeping does not always clean resident rooms daily and nursing staff has to clean up messes at times. LPN-Y stated that housekeeping has not been on the unit yet today that LPN-Y could tell. CNA-Z stated that the cleanliness of the facility could be better and that some days residents' rooms do not get cleaned. CNA-Z stated that it has been reported but not sure what has happened.*) On 9/2/2025, Surveyor reviewed the grievances from May 2025 - August 2025 and noted 11 grievances filed regarding cleanliness during that time. The grievances referenced resident room not being cleaned. The investigation concluded that the resident's rooms were not cleaned and the resolution notes on the grievances documented sending housekeeping in to clean the resident's rooms. Surveyor noted that an investigation documented no resident rooms were cleaned on the 2-south unit on 5/24/2025 - 5/26/2025. On 9/26/2025, at 11:30AM, Surveyor interviewed housekeeper-AA who stated that there should be 1 housekeeper on each unit and residents' room should get cleaned daily, but that does not always happen. Housekeeper-AA was not sure why some resident's rooms do not get cleaned, just that at times housekeeper-AA is asked to clean a resident's room on a different unit than the one assigned. Surveyor asked what gets cleaned daily. Housekeeper-AA replied that the resident's garbage is emptied, sweep the room, wipe down surfaces, and get bedrooms ready for new admissions. Housekeeper-AA stated that resident rooms get a deep clean monthly. Housekeeper stated that if there is anything on the ground such as a body fluid that is more than a quarter cup in size, housekeeping will not clean it up and that it is the facility staff responsibility to clean which facility staff can not always get to it right away if they are busy.On 9/2/2025 at 11:49AM, Surveyor interviewed district manager-BB who stated housekeeping should clean rooms daily that includes disinfecting surfaces, sweeping, mopping, and cleaning bathrooms. District manager-BB stated that resident get basic cleaning daily and will get a deep clean monthly that includes wiping the bed frame, inside the windows in addition to the basic cleaning. Surveyor asked if there have been concerns with rooms not being cleaned. District manager-BB was aware of some concerns so there have been walk throughs and following up to make sure rooms are being cleaned appropriately daily. Surveyor asked to review the room walk throughs or audits. District manager-BB stated that the walkthroughs were more observation and there were no sheets filled out or documentation regarding what rooms were looked at. Surveyor shared concerns residents had regarding bedrooms not being cleaned daily and that garbage were observed being full. On 9/2/2025, at 4:28PM, Surveyor shared concerns with nursing home administrator (NHA)-A and director of nursing (DON)-B of resident concerns that there bedrooms were not being cleaned daily and Surveyor's observation of full garbage's, odors in bedrooms, and stains on resident sheets.

Based on interview and record review the facility failed to ensure staff did not engage in misappropriation of 1 (R9) of 1 resident's reviewed for misappropriation of property.*R9's cell phone was reported to be missing on 9/15/2025. Through investigation it was determined there was a misappropriation of property when housekeeper-PP took R9's personal cell phone on 8/21/2025 while R9 was hospitalized without R9's consent.Findings include:R9 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. R9 has diagnoses that include Chronic Respiratory Failure, Type 2 Diabetes Mellitus, Tracheostomy, and Encephalopathy. R9's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R9 has moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. R9 was confused and forgetful at times and had a guardian to assist in making healthcare decisions. On 9/15/2025, at 3:23 PM, the facility submitted an initial facility self-report to the State Agency acknowledging that R9's personal cell phone was missing. Surveyor reviewed the facility self-report and noted the facility concluded R9's phone was taken by housekeeper-PP around 8/21/2025 while R9 was admitted to the hospital.On 9/15/2025 R9's family member filed a grievance with social worker (SW)-D R9's personal cell phone was missing. SW-D looked in the laundry and residents' room with R9 and R9's family member permission. R9's family member was able access R9's phone records and noted R9's phone has been in use. Police were notified and an investigation was initiated.Police and R9's family member were able to determine R9's cell phone account was logged out and the [NAME] card removed on 8/21/2025. Review of phone records indicated the facility was called the morning of 9/15/2025. Nursing home administrator (NHA)-A was able to determine the phone call was made to the housekeeping director and the call came from housekeeper-PP. NHA-A reviewed facility surveillance and noted housekeeper-PP accessed R9's room on 8/21/2025, the same day R9's phone account was logged out of and [NAME] card taken out. NHA-A and police were unable to locate housekeeper-PP for interview.Findings of the facility self-report conclude R9's personal cell phone went missing while R9 was hospitalized between 8/6/2025 - 9/9/2025. R9's family reported R9's cell phone missing on 9/15/2025 and through investigation was determine housekeeper-PP went into R9's room on 8/21/2025. Through review of R9's phone records, R9's cell phone account was logged out and the [NAME] card taken out on 8/21/2025, and housekeeper-PP made a phone call on 9/15/2025 that came from the same phone number as R9's cell phone concluding that housekeeper-PP took R9's personal cell phone.On 9/29/2025, at 9:24 AM, Surveyor interviewed SW-D who stated R9's family would call R9 on the cell phone. When R9's family reported the cell phone missing on 9/15/2025 staff searched the laundry room and R9's room, then it was noted that R9's phone was still being used, and police were called, and an investigation began. SW-D stated R9's family filed a police report with the officer that came to the facility. Currently SW-D assists R9 with making phone calls to R9's family and arranging with R9's family for R9 to receive their phone calls. SW-D stated R9's family is working with police and the phone company to get R9 a new phone but is not sure of what the status is of that.On 9/29/2025, at 9:45 AM, Surveyor observed R9 lying in bed watching TV. R9 stated SW-D helps R9 call family and R9's family is working to get another cell phone for R9. R9 is happy to get the help from the facility to communicate with R9's family and getting a new cell phone.

Based on interview and record review the facility did not ensure its procedures for indicating a residents' code status was followed for 1 (R11) of 20 residents sampled.R11 did not have a current physician order for R11's code status.Findings Include:The facility's policy and procedure Communication of Code Status revised 4/1/25 documents: .Explanation and Compliance Guidelines:2. When an order is written pertaining to a resident's presence or absence of an Advanced Directive, the directions will be clearly documented in designated sections of the medical record. 3. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record.4. The designated sections of the medical record are: physician orders obtained per election form and uploaded signed election form.R11 was admitted to the facility on [DATE] and has a legal guardian. On 9/22/2025, at 12:55 PM Surveyor completed a record review and notes that on 7/7/25, R11's guardian signed for R11 to be full code status. Surveyor noted on R11's current physician orders, there is no order for full code status.On 9/23/2025, at 1:53 PM, Surveyor received a copy of R11's current physician orders and confirmed R11's full code status is not documented in R11's current physician orders On 9/23/2025, at 1:55 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-MM. LPN-MM stated that the nurses have basic information for each resident on the unit which includes the code status of each resident. R11's code status documents full code. LPN-MM stated that LPN-MM would also double check in the resident's electronic medical record (EMR). Both Surveyor and LPN-MM pulled up R11's EMR and LPN-MM confirmed that R11 does not have a current code status listed.On 9/23/2025, at 10:14 AM, Surveyor interviewed Social Worker Assistant (SWA)-D in regard to code status. SWA-D stated that SWA-D had nothing to do with obtaining code status or maintaining the code status in a resident's EMR. SWA-D will verify in the care conference of what the code status is. Surveyor notes that R11 has not had a care conference.On 9/24/2025, at 2:57 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Director of Operations (RDO)-XX, and Director of Operations (DO)-YY the concern that R11's current physician orders to not have an order for R11's full code status. NHA-A stated the expectation is that there should be a physician order for code status for each Resident.On 9/25/2025, at 8:12 AM, NHA-A informed Surveyor that the facility conducted an audit of every Resident to verify there was a physician order for code status.

Based on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R11) of 1 Resident reviewed with PASARR level 2 recommendations. *R11's PASARR dated 7/28/25 determination states R11 requires intensive, continuous treatment program called specialized services to address R11's intellectual/developmental disability or mental illness.Findings Include:The facility's Specialized Rehabilitative Services revised 11/11/24 documents:.The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan. These services will assist them in attaining, maintaining, or restoring their highest practicable level of physical mental functional and psycho-social well-being. It will also ensure that residents with Mental Disorder(MD), Intellectual Disability(ID) or related conditions receive services as determined by their Preadmission Screening and Resident Review (PASARR) .1.Specialized rehabilitative services include but are not limited to the following:a. Physical therapyb. Speech-language pathologyc. Occupational therapyd. Respiratory therapye. Specialized services for mental illness or intellectual disability (those services to be provided by the State in accordance with the PASARR report)f. Mental health rehabilitative services for mental illness and intellectual disability or services of a lesser intensity(those services to be implemented by facility staff regardless of whether or not they are required to be subject to the PASARR process)2.Specialized rehabilitative services will be provided under the written order of a physician by qualified personnel.3.The services will be provided or coordinated by qualified personnel. In-house providers and outside resource providers shall not be excluded from participating in any federal or state health care program.4.The care plan for individuals receiving specialized rehabilitative services will be monitored and revised as indicated by a licensed professional.R11 was admitted to the facility on [DATE] with diagnoses of autistic disorder, repeated falls, unspecified intellectual disabilities, epilepsy, Mood [Affective] Disorder, anxiety disorder and gastrostomy (surgical procedure that creates an opening in the stomach through the abdominal wall to allow for feeding and medication administration directly into stomach). R11 currently has a legal guardian.R11's Level I screen summary indicates R11 has a major mental disorder, has displayed symptoms that suggest the presence of a major mental illness and receives psychotropic medications to treat the symptoms or behaviors of a major mental disorder. The Level I also documents that R11 has a diagnosis of cerebral palsy, epilepsy, autism, brain injury or intellectual/developmental condition other than mental illness, that results in impairment of general intellectual function or adaptive behavior similar to that of the intellectual disabled persons, and requires treatment or services similar to those required for these persons and was manifested before the person was age [AGE].R2's Level II completed 7/28/25 documents R11 requires intensive, continuous treatment program called specialized services to address R11's intellectual/developmental disability or mental illness. It further documents, .R11 is in need of specialized services at this time. R11 has a diagnosis of autism, intellectual disability and behavior disturbance. The focus of specialized services is to maintain or improve R11's current level of functioning. Specialized services should include a thorough assessment of R11's unique capabilities and functional limitations by a QIDP (qualified intellectual disabilities professional) .R11 would benefit from physical/occupational therapy to improve self-cares, mobility, and strength. Staff should monitor for signs of nonverbal communication. R11 should be approached in a positive manner. Opportunities for socialization, sensory stimulation and leisure should be provided. R11 should be involved in daily decision making as able. Needs appropriate interventions and redirection for maladaptive behavior. Caregivers and staff whom are familiar with R11 should be involved in R11's plan of care as they are familiar with R11 .The assessment completed on 7/28/24 for persons with intellectual/developmental disabilities documents the following for R11:-R11 currently requires increased assistance for activities of daily living. Therapies should focus on strengthening and increasing independence with self-help skills.-R11 currently requires increased assist with sensory motor development-R11 does not make R11's needs known to staff. Staff should observe for nonverbal communication and allow opportunities for R11 to express R11's preferences and desires.-R11 should be given simple one step directions and given extra time and repetition for processing as needed.-R11 should be encouraged to participate in independent living skills as able. R11's caregiver notes that R11 was more independent and participatory with independent living skills in the past.-R11 will become agitated and disruptive when upset or frustrated. Efforts to discover the cause of the agitation should be made. R11 should be approached with a positive demeanor and body language.R11's facility generated comprehensive care plan documents the following:1.R11 requires specialized services per PASARR level II to address his/her developmental disability needs. Initiated 8/25/25 Interventions Include:-Interdisciplinary(IDT) will work collaborate with family and staff to identify R11's likes/dislikes and daily preferences 8/25/25-R11's dignity and autonomy will remain through review date 8/25/25-R11's sister has provided list of common words/phrases R11 uses and what need/want R11 is trying to communicate with their use 8/25/252. R11 has a behavior problem r/t (related to) intellectual disabilities (BITES, HITS, KICKS, THROWS ITEMS, PUTTING SELF ON FLOOR, AND PACES). Initiated 7/5/25, revision on 9/11/25. Interventions Include:-I like to be approached forward, does not like people behind R11. Initiated 9/12/25.-I like to touch hair. Is very soothing to me. Please offer me the manikin head so that I can play with their hair instead of accidently pulling at staffs' hair. Initiated 8/25/25.-If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Initiated 7/5/25. Revision on 9/11/25.-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. Initiated 7/5/25.-Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Initiated 7/9/25-Offer to hold R11's hand for comfort. Initiated 7/22/25.-Praise any indication of the residents progress/improvement in behavior. Initiated 7/9/25.-R11 does not like fitted sheet on bed, only flat sheet and pillows. Initiated 8/7/25-R11 enjoys to sit in dining room by window with blinds up to look out towards the water and have radio with R1. Initiated 7/22/25.-R11 likes to fidget with the cord to the radio and extension cord. Initiated 9/12/25-R11 starts to tap fingers or feet when overstimulated. Allow resident time and offer a hand to hold. Initiated 7/9/25.-R11 enjoys calling and talking to sister (POA) [power of attorney]. Initiated 7/21/25-R11 likes to touch their forehead to staff forehead for stimulation and calming (the resident initiates this only when reaching for your hand to touch their neck or when they reach their hand to staff's neck). Initiated 7/9/253. R11 is resistive to care grabbing/scratching related to adjustment to nursing home, anxiety, dementia Initiated 9/12/25 Interventions Include:-Educate R11/family/caregivers of the possible outcome(s) of not complying with treatment or care 9/12/25-Encourage as much participation/interaction by R11 as possible during care activities 9/12/25-Give clear explanation of all care activities prior to an as they occur during each contact 9/12/25-If R11 resists with activities of daily living, reassure R11, leave and return 5-10 minutes later and try again 9/12/25-Praise R11 when behavior is appropriate 9/12/254. R11 is at risk for mood impairment related to Autism Initiated 7/5/25 Interventions Include:-Educate R11/family/caregivers regarding expectations of treatment, concerns with side effects and potential adverse effects, evaluation, maintenance, provide cna/nurses with guidelines of interventions to assist in expression management 9/13/25-Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness 7/5/25-Monitor/record mood to determine if problems seem to be related to external causes 9/13/25-Monitor/record/report to MD PRN mood patterns signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols 7/5/255. R11 has experienced trauma related to triggers that have potential to re-traumatize R11(provide examples) sound, smell, touch, taste, sight, other. Once R11 experience a trigger, R11 may display these signs/symptoms: anxiety/edginess, overwhelming, anger/irritability, changes in mood state, nightmares, change in sleep pattern, confusion/disorientation, pain/achiness, muscle tension, extreme alertness/hypervigilance, withdrawal/avoidance of activities Initiated 7/9/25 Interventions Include:-Build trust with R11 by using a calm voice and following up on what is being said 7/9/25-Empower by using positive statements 7/9/25-Encourage R11 that this is a safe place 7/9/25Surveyor originally reviewed R11's care plans from 8/25/25-9/2/25. Surveyor reviewed R11's care plan from 9/22/25-9/29/25 and notes that the above care plans have not been updated to include person-centered interventions related to R11's PASARR documented recommendations.Surveyor reviewed R11's medications used to treat R11's behaviors and Unspecified Mood (Affective) Disorder and Anxiety Disorder. Surveyor reviewed R11's admission medications on 8/27/25. Surveyor notes the following:-Amitriptyline HCI -Buspirone HCI-Lorazepam -Olanzapine-Quetiapine Fumarate-TemazepamSurveyor reviewed R11's Treatment admission Record (TARS) for July and August and notes that the facility was not monitoring any of R11's behaviors related to the usage of the above medications. On 9/23/25, Surveyor reviewed R11's re-admission physician orders. Surveyor notes R11 is on the same medications as admission.-Amitriptyline HCI -Buspirone HCI-Lorazepam -Olanzapine-Quetiapine Fumarate-TemazepamOn 9/12/25, Oxcarbazepine was prescribed to R11 for moods. Surveyor reviewed R11's current TARS and notes that the facility did not start monitoring for R11's behaviors and signs/symptoms of mood until 9/13/25, despite being on the medications since re-admission on [DATE] The TARS do not record R11's behaviors(expressions) as documented in R11's progress notes of R11's electronic medical record(EMR).On 7/28/25, Psychologist (Psych)-C evaluated R11. Psych-C documented: .R11 can be intrusive and difficult to redirect. R11 was seen in the day room attempting to grab items off the wall and become physically intrusive with staff. It appears that R11 can easily become agitated and ramped up. It is difficult to redirect R11 or ask R11 to follow instructions. It appeared that Psych-C was present and watching that R11 became more ramped up and determined to act out with staff. Discussed history as it relates problem. Discussed triggers. Discussed issues with staff .R11 is most likely going to be best served with behavioral approaches, environmental considerations and proper psychiatric medication management .Consider the following:-Continue to attempt to reduce impact of R11's behavior by removing staff, other residents and R11 is agitated or intrusive.-Continue to attempt to avoid physical interaction when R11 is agitated or intrusive. R11 appears to ramp up further when physically engaged.-Continue to use dementia de-escalating approaches by calming, re-assuring and reducing stimulation.-Consider placement in a smaller environment that reduces the potential of activating and stimulating events and environment.Surveyor notes that Psych-C's recommendations have not been incorporated into R11's person-centered care plan as targeted interventions.Surveyor has reviewed R11's progress notes from day of admission to present. R11's progress notes contains consistent regular documentation of R11's disruptive behaviors. Examples of behaviors: yelling, turning tables over, disrobing, refusing cares, biting, hitting staff, pulling hair, pinching, impulsive, wandering into other rooms. It is documented that R11 is very hard to redirect. R11 is currently on 1:1 supervision at all times.Surveyor notes that R106 has been the victim of resident-to-resident altercation three different times, and has been the aggressor in three resident-to-resident altercations.On 8/25/25, at 10:54 AM, Surveyor interviewed Anonymous (Anon)-N. Anon-N stated R11 throws things, pulls hair, flips tables, and is very erratic. Anon-N states have to keep other residents safe, have to move residents quickly to safety when R11 melts down. Anon-N describes the unit as very chaotic and R11 can be very loud and disruptive. Anon-N stated the staff have no say in the care or interventions of R11.On 8/25/25, at 11:32 AM, Nurse Practitioner (NP)-K informed Surveyor that R11 is hard to figure out and believes it is all in the approach. NP-K has not been involved with R11's need for specialized services.On 8/25/25, at 12:17 PM, Anon-O does not know anything about specialized services and has not received any training related to specialized services.On 8/25/25, at 1:01 PM, Anon-P stated that R11 is not appropriate for the unit and is very difficult and has not been given any specific interventions to implement for R11.On 8/26/25, at 7:35 AM, Surveyor interviewed Social Worker Assistant (SWA)-D in regard to R11. SWA-D stated that SWA-D is not a QIDP. SWA-D stated R11 needs a smaller environment. On 8/26/25, at 8:10 AM, Anon-R stated that it is currently calmer on the unit with R11 in the hospital. Anon-R stated staff have not received training on how to best work with R11.On 8/26/25, at 12:37 PM, Anon-G informed Surveyor that the facility is not fully equipped to handle R11. Anon-G stated that the residents on the unit are more agitated with R11 on the unit. R11 constantly grabs at other residents.On 8/26/25, at 1:42 PM, Surveyor interviewed Psych-C. Psych-C stated that Psych-C was unaware that R11 required specialized services until this morning. Psych-C confirmed that Psych-C has not helped with any development of a specialized care plan for R11 and has not been involved in any staff training. Psych-C stated that R11 almost should have 1:1 supervision. On 8/27/25, at 11:36 AM, Surveyor interviewed Occupational Therapist (COTA)-H in regard to R11. COTA-H stated that COTA-H was not asked to be a part of developing a specialized care plan for R11. On 8/27/25, at 12:27 PM, Medical Director (MD)-J informed Surveyor that MD-J knew R11 at another facility where R11 ripped a television off the wall. On 9/2/25, at 8:10 AM, Social Worker (SW)-E stated that SWA-D would be responsible for developing a specialized service care plan for R11. On 9/2/25, at 8:32 AM, SWA-D confirmed that SWA-D was unaware that R11 requires specialized services. On 9/2/25, at 9:24 AM, Dementia Coordinator (DC)-M is not aware that R11 requires specialized services and does not know what specialized services is.On 9/2/25, at 12:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to specialized services for R11. NHA-A realized that R11 requires specialized services after Surveyor brought it to the attention of Psych-C. SWA-D, per NHA-A should have told Psych-C that R11 requires specialized services. NHA-A stated that SW-E is reviewing specialized services with SWA-D. NHA-A stated that R11 needs a smaller environment. Surveyor shared the concern that there is no documentation of the facility tracking and trending R11's behaviors.Surveyor notes that R11's EMR contains no documentation that R11 has been evaluated and reviewed by psychiatric services since 7/28/25.On 9/29/2025, at 12:00 PM, SWA-D informed Surveyor that SWA-D has not had anything to do with specialized services for R11 since 9/2/25. SWA-D informed Surveyor that psychiatric services have not evaluated or treated R11 since re-admission to the facility. SWA-D confirmed R11 has only been seen on 7/28/25.

Based on observation, record review and interviews, the facility did not ensure 2 of 20 sampled residents' plan of care contained accurate information to implement interventions. * R90 was observed with an air mattress on their bed and a blue mat on their floor. R90 plan of car for a pressure injury did not include an air mattress. R90 plan of care for falls did not indicate when, and where, to use a blue mat. *R11 Guardian directed them to have pleasure feedings. This intervention was not documented on R11 comprehensive plan of cares. The facility's policy and procedure titled Care Plan Revisions Upon Status Change dated 5/12/2025. The purpose of this policy is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Findings include: 1.) R90 was admitted to the facility on [DATE] for wound care. On 9/22/2025, at 10:37 AM, Surveyor interviewed R90 in their bed. R90 was laying on their right side in bed. There was a mat on the left side of the bed. R90 stated they did not have any falls. R90 had an air mattress on their bed. R90 currently has a pressure injury on their right heel and sacrum. Surveyor reviewed the medical record. R90 had a fall from their bed on 7/25/25 with no injury. The fall documentation on 7/25/25 does not include a blue mat for an intervention. R90 has a stage 4 pressure injury on their sacrum. The wound assessment from Advanced Wound Care, dated 7/9/2025, documents the use of an air mattress to promote healing. On 9/23/2025, at 8:13 AM, Surveyor observed R90 in their bed. There was no blue mat on the floor. There was a folded blue mat leaning against the wall. There was an air mattress on the bed. On 09/24/2025, at 8:54 AM, Surveyor observed R90 in their bed eating breakfast. There was a blue mat on the left side of the bed. R90 body was facing the right side of the bed.R90 plan of care documents:*The resident is at risk for falls, accidents and incidents related to DeconditioningDate Initiated: 07/08/2025Created on: 06/14/2025An intervention dated on 6/14/25 includes a Floor Mat. There is not a direction on where, and when, to place the blue mat. There is not an assessment for the blue floor mat. *The resident has potential/actual impairment to skin integrity related to needs assist with cares. Pressure wounds to sacrum and heel.Date initiated: 6/12/25Created on: 6/12/25Intervention dated on 6/12/25 for a pressure reduction mattress. There is not a documented intervention for an air mattress to address R90 pressure injuries. On 9/25/2025, at 9:28 AM, Surveyor interviewed the Director of Nurses (DON) – B. The DON-B did not have information related to the air mattress. R90 does have an air mattress and did not know why it was not on the plan of care for pressure injury. On 9/24/2025, at 9:32 AM, Surveyor interviewed the DON-B. The DON-B will review for additional information. On 9/24/2025, at 1:10 PM the DON-B spoke with Surveyor. The DON-B stated the blue mat is used for the side R90 leans to in bed. This is not documented on the plan of care, nor observed during observations. 2) R11 was admitted to the facility on [DATE] and has a legal guardian. R11 receives nutrition through a feeding tube, however the guardian has requested that R11 receive pleasure feedings of scrambled eggs two times a day. R11's Nutritional Evaluation completed 9/15/25 by Registered Dietitian (RD)-RRR documents R11 remains NPO due to ongoing aspiration risk and diagnosis Dysphagia, Oropharyngeal Phase. Tube feeding was increased (from 330cc 3 times a day to 360 cc three times a day) on 9/15/25 due to staff report that he has expressions around mealtime and appears as though R11 is hungry after R11's tube feedings. R11's Risk/Benefit Record Tool completed 9/17/25 by Social Worker Assistant (SWA)-D. The Risk/Benefit Record Tool documents that R11 will be receiving pleasure/small amounts of food two times daily. R11's current physician orders document regular diet mechanical soft-ground meat texture, thin consistency, can only have scrambled eggs for pleasure feeding with a start date 9/18/25. R11's comprehensive care plan has not been revised to include R11's pleasure feedings of scrambled eggs two times a day. Surveyor notes these targeted problems were not updated with the pleasure feedings of scrambled eggs two times a day. There is no documentation in R11's care plan that risks/benefits were reviewed with R11's representative and R11's representative requested the two pleasure feedings of scrambled eggs per day. R11's Kardex which instructs Certified Nursing Assistants (CNA) in the care of R11 as of 9/25/25 documents R11 is still NPO. On 9/25/2025, at 9:13 AM, Surveyor interviewed RD-RRR in regard to R11's comprehensive care plan. RD-RRR explained RD-RRR is at the facility two days a week, remote one day a week and always available. RD-RRR confirmed that R11's comprehensive care plan was not updated at the time pleasure feedings were added. RD-RRR informed Surveyor that RD-RRR updated R11's care plan indicating R11 can receive two pleasure feedings of scrambled eggs per day.

Based on observation, interview and record review the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and assistance with repositioning for 1 of 2 (R60) residents reviewed for ADL's (Activity of Daily Living).R60 was not provided assistance to reposition as she requested until Surveyor intervened and asked staff to assist the resident.Findings include:R60 was admitted to the facility on [DATE] and has diagnoses that include chronic kidney disease stage 3, chronic obstructive pulmonary disease, morbid obesity, asthma, dysphagia, anxiety disorder, major depressive disorder, hypertension, gout, gastroesophageal reflux disease and hereditary and idiopathic neuropathy.R60's BIMS (Brief Interview for Mental Status Score) dated 7/28/25 documents a score of 15, indicating no cognitive impairment.R60's admission MDS (Minimum Data Set) dated 8/3/25 documents: Functional Limitation in Range of Motion lower extremity (hip, knee, ankle, foot) - impairment on both sides.Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed - partial/moderate assistance. R60's Admission/readmission/routine Head to Toe Evaluation dated 7/28/25 documents: Fall Risk evaluation - High risk.R60's Physical Therapy Discharge summary dated [DATE] documents: Bed mobility roll left and right = Substantial/maximal assistance.On 9/22/25 at 11:55 AM, Surveyor observed R60 lying in bed on her back, wearing a gown. R60 told Surveyor she wanted to get boosted up in bed, But the aid said she can't help me because she don't want to hurt her back. Surveyor offered to find someone to assist R60. R60 stated, Yes, but she won't because she don't want to hurt her back. Surveyor put R60's call light on and within a minute Certified Nursing Assistant (CNA)-FF entered the room and turned off the call light. Surveyor told CNA-FF that R60 would like to be repositioned and boosted up in bed. R60 stated to CNA-FF Tell her what you tell me, you can't because you don't want to hurt your back. CNA-FF stated, I can't by myself, I have to get someone to help me and left the room. On 9/22/25 at 12:15 PM, Surveyor noted R60 remained in the same position on her back and noted R60 had slid down more near the middle of the bed. Surveyor asked if anyone had been in to reposition her yet. R60 stated, No. I told you, she won't because she don't want to hurt her back. Surveyor observed a different CNA in the dining area where 3 residents were seated eating lunch. Surveyor observed CNA-FF enter another resident's room.On 9/22/25 at 12:25 PM, Surveyor observed no staff had been in R60's room to reposition/boost her up in bed as requested. Surveyor observed CNA-FF passing lunch trays to resident rooms. Surveyor reminded CNA-FF that R60 had asked to be boosted in bed and asked if she has been in her room to reposition her. CNA-FF stated, No, the other aid had to stay in the dining room, so I was alone out here. Surveyor asked CNA-FF if she asked anyone else for assistance, such as the nurse, to help her reposition R60. CNA-FF stated, No, now I'm passing trays. It had been 30 minutes since Surveyor and R60 requested assistance.On 9/22/25 at 12:33 PM, Surveyor entered R60's room, noting she had not been repositioned or boosted in bed. R60 had received her meal tray. Surveyor asked R60 if she was having lunch. R60 was tearful and replied (with voice cracking), My back hurts, I need to be boosted. I can't eat now, I'm not hungry, my back hurts. On 9/22/25 at 12:35 PM, Surveyor approached Licensed Practical Nurse (LPN)-Y who was standing at the medication cart at the nurse's station. Surveyor advised LPN-Y that R60 is uncomfortable, tearful and asked to be repositioned 40 minutes ago. Surveyor asked LPN-Y if he would help the CNA reposition the resident. LPN-Y stated, Absolutely, I'll go down there right now. Surveyor observed LPN-Y and another staff member enter R60's room. On 9/22/25 at 1:10 PM, Surveyor observed R60 positioned more upright in bed, with pillows on each side. When asked how she was feeling, R60 stated, Better, thank you. Surveyor asked her if now that she was boosted in bed, is she going to have lunch. R60 stated, No, I'm not hungry now, just forget it. Surveyor noted the CNA Point of Care documentation enter on 9/22/25 at 1:00 p.m. indicated R60 consumed 75% of her meal, when in fact the resident did not eat lunch.

Based on facility policy, record review and interviews, the facility failed to ensure a safe environment for one of nine residents (Resident (R) 1) reviewed for accidents. R1 fell from his bed and onto the floor while a staff member (Certified Nursing Assistant (CNA1) was providing his routine care. This failure caused R1 to experience significant injuries related to the fall, including a broken hip and a large laceration to his forehead requiring nine staples. The findings include: The facility's Accidents and Supervision Policy dated 12/29/22 read, in pertinent part, The resident environment will remain as free of accident hazards as possible; and Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency, b. Based on the individual resident's assessed needs and identified hazards in the resident environment. Review of the facility's incident logs revealed an entry, dated 09/09/24, which indicated R1 had experienced a fall, on that date, that resulted in a head injury to the resident. Review of R1's Admission Record, dated 10/30/24 and found in the Electronic Medical Record (EMR) under the Profile Tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included history of motor vehicle accident (MVA) with traumatic brain injury (TBI). Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/22, revealed a Brief Interview for Mental Status (BIMS) assessment could not be completed related to the resident's poor cognition and inability to communicate. The resident was significantly cognitively impaired and minimally responsive. The assessment revealed R1 was totally dependent upon staff to complete all his Activities of Daily Living (ADLs) and required assistance from at least two staff members for bed mobility/to move about in his bed. Review of R1's Impaired Mobility Care Plan, dated 07/18/24 and found in the EMR under the Care Plan Tab, revealed the resident had impaired mobility related to his history of TBI. The care plan indicated the resident was completely dependent upon staff for all transfers and bed mobility with assist of two staff members. Review of R1's Fall Risk Evaluation, dated 07/04/24 and found in the EMR under the Evaluations Tab, revealed a fall risk score of 12, which indicated the resident was at moderate risk for falls. The evaluation indicated R1 was always totally incontinent, was disoriented, was confined to a chair, and was unable to independently able to come to a standing position. Review of R1's Functional Ability Evaluation, dated 08/07/24 and found in the EMR under the Evaluations Tab, revealed the resident had range of motion (ROM) impairments to his upper and lower extremities on both side of his body, was dependent upon a wheelchair for mobility, was completely dependent upon staff to complete all of his ADLs, including rolling in bed, bathing, personal hygiene, and transfers in and out of bed. Review of R1's Progress Notes, dated 09/09/24 at 3:41 PM and found in the EMR under the Notes Tab, read, in pertinent part, Called to Room by CNA. Resident laying on floor on back on left side of bed blood on left side of head noted. Had laceration (cut) to left scalp and left ear. Pressure applied to area .no s/sx (signs or symptoms) of pain noted. Family called and wants (R1) sent to ER (emergency room ) right away via 911 (emergency). Sent to (local Emergency Department). Transported via rescue. Review of R1's Progress Notes, dated 09/09/24 at 4:00 PM and found in the EMR under the Notes Tab, read, in pertinent part, Situation: Resident had fall from bed while getting cares has laceration to Left head and Left ear. Review of R1's Progress Notes, dated 09/09/24 at 8:25 PM and found in the EMR under the Notes Tab, read, in pertinent part, Returned from ER, all scans normal, 9 staples to left scalp, family aware no questions at this time. Review of R1's IDT (interdisciplinary team) Progress Notes, dated 09/09/24 at 8:25 PM and found in the EMR under the Notes Tab, read, in pertinent part, Late Entry: Note Text: Team met to discuss recent fall. CNA was in room changing resident when resident rolled out of bed on the left side of the bed. Laceration to head and resident was sent out to the hospital for evaluation. Further investigation showed that resident's plan of care was not followed. Care plan reviewed all other appropriate interventions were in place. Updated for resident to have a bari (large) bed. Education also provided to Staff regarding following plan of care. Review of R1's Progress Notes, dated 09/09/24 at 11:15 PM and found in the EMR under the Notes Tab, read, in pertinent part, resident was sent back to ER because family was concerned about high heart rate and O2 (oxygen) at 1730 (5:30 PM). This writer called ER for update and resident was admitted for UTI (urinary tract infection). Review of R1's Progress Notes, dated 09/16/24 at 10:49 PM and found in the EMR under the Notes Tab, read, in pertinent part, Clinical Summary: Resident awake eyes open, non-verbal, does not follow commands, skin warm and dry no s/sx (signs or symptoms) of pain, has 2 surgical incisions to Right hip with bruising noted, Dressing CDI (clean, dry and intact), blister to left foot both feet on pillows, left scalp has 9 staples to laceration, no drainage noted, .Total care, Hoyer (transfer) lift assist of 2 with bed mobility, Right leg swollen from hip to lower extremity, . Review of R1's History and Physical, dated 09/17/24, completed by the resident's physician, and found in the EMR under the Notes Tab, revealed, in pertinent part, Chief Complaint: [AGE] year-old male resident at (Facility) was seen for complete history and physical. The Medical problems that were addressed today: *Recent hospital admission: The resident was admitted on [DATE], decreased level of responsiveness/altered mental status post falling (sic) of his bed while getting care, has laceration to Left head and Left ear. in the ED he was found to have cystitis/UTI and was a treated with IV (intravenous) Rocephin (an antibiotic medication) and IV fluids And also was found to have displaced intertrochanteric fracture of the right femur, orthopedic surgery was consulted, he underwent surgery (to repair his broken femur) on September 12, 2024 . *Right femur fracture: S/P (status post) surgery on September 12, 2024. The facility's investigation related to R1's fall from bed, dated 09/16/24 and provided directly to the surveyor, revealed CNA1 did not follow the resident's established plan of care while changing the resident on 09/09/24. The investigation revealed R1 was to be moved about in bed by two staff members and CNA1 provided care to R1, and moved him about in his bed, without assistance of any additional staff. The investigation revealed R1 experienced a laceration to his head and a fractured right hip related to the fall. During an interview with the Administrator and Director of Nursing (DON) on 10/29/24 at 3:00 PM, both confirmed their expectation was staff were to follow each resident's plan of care related to the provision of care. The Administrator confirmed CNA1 did not follow R1's plan of care when providing care on 09/09/24 and this contributed to the resident's fall.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R3, R9, & R4) of 5 residents reviewed for pressure injuries. R3 was admitted to the facility on [DATE] with non-pressure areas. A Braden assessment was completed on date of admission which indicated R3 was at moderate risk for pressure injury development. The facility did not develop a skin integrity care plan until R3 developed an unstageable pressure injury on the sacrum. The skin integrity care plan interventions were not person centered. Licensed nursing staff were initialing two different treatments for the sacrum pressure injury at the same time. Weekly skin sheets were not being completed for R3. The facility was not monitoring R3's food, fluid, or repositioning. R3 was hospitalized on [DATE] and returned to the facility on [DATE]. When R3 returned to the facility, R3's sacrum pressure injury wasn't comprehensively assessed as there were no measurements, stage, or wound bed assessment. Data collection upon readmission was completed by an LPN. A comprehensive assessment was not completed until [DATE], one week later, when R3 was seen during wound rounds with Wound RN-X & Wound MD-F. On [DATE], Wound MD-F debrided R3's sacrum pressure injury, ordered a second antibiotic for wound infection, an appetite stimulant, and bed rest. On [DATE], R3 was admitted to the hospital with a necrotizing tissue infection. The facility's failure to provide care to prevent the development of pressure injuries and promote the healing of R3's pressure injuries, the failure to comprehensively assess, to develop and/or update resident's pressure injury care plans and monitor R3's fluid, food, and repositioning created a finding of Immediate Jeopardy (IJ) which began on [DATE]. NHA (Nursing Home Administrator)-A & DON (Director of Nursing)-B were notified of the immediate jeopardy on [DATE] at 4:14 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of G (harm/isolated) related to the example involving R9 and as the facility continues to implement its action plan. *R9's left buttock pressure injury was not comprehensively assessed until five days after admission when the wound MD assessed this pressure injury as unstageable with slough. Upon admission the facility identified R9 as having a stage 2 pressure injury to the left buttock. The care plan initiated after admission did not include comprehensive, individualized interventions to prevent decline of R9's pressure injury. *R4's air mattress was not set according to R4's weight. R4's pressure injury declined from a Stage 2 to Stage 3. This was identified as actual harm. Findings include: The facility's Pressure Injury Prevention and Management policy implemented [DATE] documents under Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevention infection and the development of additional pressure ulcers/injuries. Policy Explanation and Compliance Guidelines documents: 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 4. Interventions for Prevention and to Promote healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Provide non-irritating surfaces; and v. Maintain or improve nutrition and hydration status, where feasible. 5. Monitoring a. The RN (Registered Nurse) Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. 1.) R3 was originally admitted to the facility on [DATE]. R3's POA (Power of Attorney) for healthcare was activated on [DATE]. R3's diagnoses include hypertension, atrial flutter, cirrhosis of liver, left below knee amputation, diabetes mellitus, peripheral vascular disease, congestive heart failure, and depression. The nurses note dated [DATE] at 23:36 (11:36 p.m.) documents: Patient arrived via stretcher from [Name] hospital [City] by [Ambulance Company] EMS (emergency medical services). Patient was very nice and pleasant, alert and oriented x (times) 3. Patient arrived with a condom catheter and boot to right foot. Patient is a left amputee and he had a boot on it. Patient's vitals were stable. Blood sugar was 489 @ (at) 2240 (10:40 p.m.) Patient skin check was clear with no wounds. Patient signed to be a full code. Patient has a consistent carb (carbohydrate) diet of ,d+[DATE] gm (grams)/meal with cardiac diet modifier. This nurses note was written by DON (Director of Nursing)-B. The admission/readmission/routine head-to-toe evaluation dated [DATE] under the skin integrity section is checked for risk for skin alterations. For the question does the resident have any skin alterations? No is checked. This admission/readmission/routine head-to-toe evaluation was completed by DON-B. The Braden assessment dated [DATE] has a score of 15 which indicates moderate risk for pressure injury development. The facility did not develop a baseline skin integrity care plan. The late entry nurses note dated [DATE] at 08:53 (8:53 a.m.) and created on [DATE] at 0956 (9:56 a.m.) documents: Amendment to admission note. Resident is a recent amputee to the left leg with stitches still intact. Has a diabetic ulcer noted on the right foot and has MASD (moisture associated skin damage). This nurses note was written by DON-B. The nurses note dated [DATE] at 23:09 (11:09 p.m.) documents: Resident alert orientated times three complained of pain at hs (hour sleep) gave prn (as needed) dose of pain pill. Resident requires assist with ADLs (activity daily living) tolerates meds (medication) whole. Ate 100% of dinner with no issues noted. Adjusting well watching tv in room. Will monitor. This nurses note was written by Nursing-CC. The admission MDS (minimum data set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 9 which indicates moderate cognitive impairment. R3 is assessed as requiring set up for eating, partial/moderate assistance to roll left and right, substantial/maximal assistance for chair/bed to chair and toilet transfer. R3 is assessed as always incontinent of urine and bowel. R3 is assessed as being at risk for pressure injuries and is assessed as having a pressure injury, one unstageable slough and/or eschar present upon admission. The pressure injury CAA (care area assessment) dated [DATE] under analysis of findings documents: Res (Resident) has unstageable to sacral area. Res is at risk for further skin alterations d/t (due to) impaired mobility and diabetes. On [DATE] at 9:46 a.m., Surveyor informed MDS/LPN-L Surveyor was unable to locate in R3's medical record the development of the unstageable sacral pressure injury until [DATE] which was after the assessment reference date and asked MDS/LPN-L how she determined R3 came into the facility with the pressure injury. MDS/LPN-L informed Surveyor someone would have given her the information and that someone would have had to tell her and it would have been on the wound log. Surveyor asked if Surveyor could see the wound log MDS/LPN-L was referring to. MDS/LPN-L informed Surveyor she doesn't have the wound log and would have gotten the wound log from Wound RN-X. Surveyor asked MDS/LPN-L to look into this and get back to Surveyor. On [DATE] at 10:08 a.m., MDS/LPN-L informed Surveyor it was her mistake with coding R3 as being admitted with an unstageable pressure injury. MDS/LPN-L informed Surveyor she will go back and modify the MDS. MD (Medical Doctor)-N's progress note dated [DATE], under review of systems for skin/breast documents: Positive: Open lesions. Negative: Changes in hair or nails, Changes in skin color, Swelling, Itching, Bruises, Rash, Mass. Notes: The resident has left below-knee amputation surgical wound is clear 16 cm (centimeters) x (times) 0.1 cm and also has a non pressure ulcer on the right plantar 2.5 x 2.5 x 0 unstageable 100% eschar with no abnormalities and no exude. The nutritional note dated [DATE] at 15:22 (3:22 p.m.) by Dietitian-DD documents: Nutritional Assessment: EMR (electronic medical record) reviewed. Code status CPR (cardiopulmonary resuscitation). PMH (present medical history) above. Resident able to make needs known. Renal diet appropriate d/t (due to) AKI (acute kidney injury) with hyperkalemia and elevated renal labs. He has had good appetite since admission and intakes. Noted L (left) BKA. No issues reported with NVDC (nausea, vomiting, diarrhea, constipation) nor indigestion documented. No additional swallowing problems noted on current diet. He is on pureed, renal, cho (carbohydrate), diet consuming ,d+[DATE]% at meals, eats with setup/independence. FLD (fluid) intakes of ,d+[DATE] ml (milliliter)/meal. Diet is adequate to meet EEN (exclusive enteral nutrition diet). Will recommend addition to 30 mL ProSource BID (twice daily) to aid in healing No pressure injuries noted. LBM (last bowel movement) ,d+[DATE] (+) UOP (urinary output). On diuretic therapy, anticipate weight fluctuations from fluid shifts and h/o (history of) edema. Hospital weight used d/t lack of weight in PCC (pointclickcare). DON/Administrator aware of weight discrepancies. The weekly wound assessment dated [DATE] for date of wound measurement date documents [DATE]. Under type of wound pressure is checked. Under the wound description section for site documents 53) sacrum, Type is Pressure, length in centimeters is 8.0, Width 7.0, Depth 0.1 and Stage Unstageable. Percentage of granulation is 50 and Percentage of slough is 50. Under the Other section for other comments/recommendations documents Wound noted to Sacrum Treatment ordered. Resident currently on air mattress. Will continue with repositioning every ,d+[DATE] hours. On [DATE], the facility completed an unavoidable pressure injury form dated [DATE]. This was completed by Wound RN-X and signed on [DATE]. Wound MD-F's signature is also on the form but not dated. Surveyor noted there is a handwritten notation of Wound MD in agreement, wound possible Kennedy ulcer. This is the only documentation of a Kennedy ulcer in R3's medical record. The nurses note dated [DATE] at 16:15 (4:15 p.m.) documents: MD called and updated on Sacral wound-Santyl ordered. Resident and wife aware. This nurses note was written by Wound RN-X. The resident has an ADL (activities daily living) self-care performance deficit r/t (related to) care plan initiated [DATE] includes interventions of: *Bed Mobility: The resident requires (SPECIFY what assistance) by (X) staff to turn and reposition in bed (SPECIFY FREQ (frequency)) and as necessary. Initiated [DATE]. *Eating: The resident requires (SPECIFY what assistance) by (X) staff to eat. Initiated [DATE]. *Toilet Use: The resident requires (SPECIFY assistance) by (X) staff for toileting. Initiated [DATE]. *Transfer: The resident requires (SPECIFY what assistance) by (X) staff to move between surfaces (SPECIFY FREQ) and as necessary. Initiated [DATE]. Surveyor noted in the spaces on the care plan where information should be specified for R3, it was blank and did not include the specific assistance or frequency of an intervention for R3. The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t (related to) Initiated [DATE] which documents the following interventions: *Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Initiated [DATE]. *Encourage good nutrition and hydration in order to promote healthier skin. Initiated [DATE]. These care plans are not individualized and were not revised after implementation on [DATE]. Additionally, Surveyor noted areas of the care plan to specify locations of wounds were not completed for R3. The treatment order with a start date of [DATE] documents: Sacral area, clean with NSS (normal saline solution) and apply a foam dressing to area daily. One time a day for treatment. This treatment was discontinued on [DATE]. Review of R3's February 2024 treatment administration record reveals this treatment was completed daily from ,d+[DATE] to ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], blank on ,d+[DATE], ,d+[DATE], and blank on ,d+[DATE] & ,d+[DATE]. The treatment order with a start date of [DATE] documents: Santyl External Ointment 250 unit/gm (gram) (Collagenase) Apply to Sacral topically every day shift for wound care. Wash ,d+[DATE] strength Dakin's solution and pat dry. Skin prep peri wound. Apply Santyl to wound bed followed by Bordered gauze. This treatment was discontinued on [DATE]. Review of R3's February 2024 treatment administration record reveals this treatment was completed daily from ,d+[DATE] to ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], blank on ,d+[DATE], ,d+[DATE] and blank on ,d+[DATE] & ,d+[DATE]. Surveyor noted licensed nurses were initialing two different treatments as being completed for R3's sacral pressure injury. The weekly wound assessment dated [DATE] for date of wound measurement documents [DATE]. Under type of wound pressure is checked. Under the wound description section for site documents 53) sacrum, Type is Pressure, length in centimeters is 7.1, Width 6.5, Depth 0.1 and Stage Unstageable. Percentage of granulation is 25 and Percentage of slough is 75. The Other section for other comments/recommendations is blank. R3 was hospitalized on [DATE] and readmitted back to the facility on [DATE]. The nurses note dated [DATE] at 00:30 (12:30 a.m.) documents: Patient was lethargic and unresponsive to questions and commands. Patient had a time where he appeared to have apnea and I had to shake him. Vital signs were b/p (blood pressure) ,d+[DATE], temp 97.7, O2 (oxygen) 95%, RR (respiration rate) 17, pulse 78. I called the doctor and asked to have him sent to the ER (emergency room ), approval was granted. I called for follow up @ (at) 0015 (12:15 a.m.) and he was admitted with a UTI (urinary tract infection) and AKI (acute kidney injury). This nurses note was written by Nursing-EE. The admission/readmission/routine head-to-toe evaluation dated [DATE] under the skin integrity section is checked for risk for skin alterations. For the question does the resident have any skin alterations? Yes is checked. For the generic body diagram for site documents 53) sacrum and under description documents open area. Under diagnoses for d. Skin risk care plan: is checked for Focus: The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t Focus: The resident has potential/actual skin impairment to skin integrity of the (SPECIFY location r/t Goal: The resident will maintain or develop clean and intact skin by the review date. Intervention: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Intervention: Encourage good nutrition and hydration in order to promote healthier skin. Surveyor noted areas of the care plan to specify locations of wounds were not completed for R3. R3's sacrum open area was not comprehensively assessed as there are no measurements, stage, or description of the wound bed & peri wound. This assessment was completed by LPN (Licensed Practical Nurse)-BB. The Braden assessment dated [DATE] has score of 14 which indicates moderate risk for pressure injury development. The nurses note dated [DATE] at 23:17 (11:17 p.m.) documents: Patient appears lethargic, took couple bites of supper took little fluids. Took medication and was able to answer some questions. VSS (vital signs stable) area to sacral area remains. This nurses note was written by LPN-BB. On [DATE], R3 started receiving Bactrim DS oral Tablet ,d+[DATE] mg with directions to give 1 tablet by mouth two times a day for UTI (urinary tract infection) for 7 days with a discontinue date of [DATE]. The nurses note dated [DATE] at 22:22 (10:22 p.m.) documents: Alert and oriented. No c/o (complaint of) pain or discomfort. ABT/UTI (antibiotic/urinary tract infection). Fluids encouraged. No adverse reaction noted. This nurses note was written by RN-FF. The weekly wound assessment dated [DATE] for date of wound measurement documents [DATE]. Under type of wound, pressure is checked. Under the wound description section for site documents 53) sacrum, Type is Pressure, length in centimeters is 7.2, Width 7.0, Depth 3.0 and Stage Unstageable. Percentage of granulation is 25 and Percentage of slough is 75. For risk factors undermining is checked. Undermining (describe in reference to clock location in cm) documents ,d+[DATE] at 6.3 cm. The Other section for other comments/recommendations is blank. Surveyor noted this comprehensive pressure injury assessment is 7 days after R3 was readmitted back to the facility. Wound MD-F's assessment of R3's sacral pressure injury on [DATE], prior to debridement, was length 9.55 cm, width 7.95 cm, and depth 0.10 cm. Etiology is Pressure Ulcer Unstageable. Wound bed assessment is slough ,d+[DATE]%. Odor is normal odor. Wound MD-F's assessment of R3's sacral pressure injury on [DATE] post debridement documents: length 8.77 cm, width 7.22 cm, and depth 3.00 cm. Etiology is pressure ulcer Unstageable. Wound bed assessment is Slough ,d+[DATE]%, drainage amount is documented as small, drain description is serous, odor is normal odor, and periwound is indurated. Under notes documents Undermining ,d+[DATE] o'clock: 6.3 cm, CBC (complete blood count), CMP (comprehensive metabolic panel) [DATE], Prealbumin level now and in three weeks (may draw on [DATE]), bed rest please, and Keflex 500 mg (milligram) PO (by mouth) TID (three times a day) x 2 weeks. The nurses note dated [DATE] at 15:06 (3:06 p.m.) documents: Seen by in house wound MD Sacral wound debrided. Labs ordered, ATB to be started, bed rest, and supplement ordered. Wife at bedside and aware of orders. Primary MD aware. This nurses note was written by Wound RN-X. On [DATE], R3's sacral pressure injury treatment changed to: Cleanse sacral wound with ,d+[DATE] strength Dakin's solution and pat dry. Skin prep peri wound. Pack wound with ,d+[DATE] strength Dakin's moistened kerlix. Pack kerlix to undermining ,d+[DATE] at 6.3 cm Followed by Bordered gauze. Every day and evening shift for wound care. Surveyor reviewed R3's February treatment administration record and noted the treatment for R3's sacral pressure injury is initialed as being completed except on ,d+[DATE] when the day treatment is blank and on ,d+[DATE] when the day & evening treatments are blank. On [DATE], R3's order for Bactrim DS oral tablet ,d+[DATE] mg with directions to give 1 tablet by mouth two times a day for UTI was extended until [DATE]. Surveyor noted a second antibiotic was ordered on [DATE] for Keflex oral capsule 500 mg with directions to give 500 mg by mouth three times a day for wound infection until [DATE]. NP (nurse practitioner)-O's progress note dated [DATE] under assessment and plans includes documentation of Diabetes mellitus due to underlying condition with hyperglycemia. BG (blood glucose) is elevated may be due to wound debridement by wound care. He had a sacral abscess. He is currently on oral antibiotics and tolerating them well. [Wound MD-F] with W/C (wound care) is following. Labs are pending per W/C RN. Will continue to mx (monitor) for now. He was placed on supplements to help with healing. Bactrim DS is ordered BID (twice daily). The nurses note dated [DATE] at 15:02 (3:02 p.m.) documents: Spoke with wife regarding wound MD orders again from yesterday. Explained awaiting culture results and lab results to see if another ATB will be needed. Spoke about resident's poor appetite-wound MD updated and will start on Remeron for appetite stimulate. Wife would not give consent for Foley Catheter to be inserted. Wife aware of Remeron order. This nurses note was written by Wound RN-X. The nurses note dated [DATE] at 15:34 (3:34 p.m.) documents: Resident remains on Keflex for infection, no adverse effects noted. Will continue to monitor. This nurses note was written by Nursing-GG. The nurses note dated [DATE] at 16:35 (4:35 p.m.) documents: Resident currently receiving Bactrim and Keflex, no a/r (adverse reactions) to ABT, VSS, afebrile, no c/o pain or discomfort, no a/r to N.O (new order) for Remeron, tolerating well, currently resting in his bed, will continue to monitor. This nurses note was written by Nursing-HH. The nurses note dated [DATE] at 14:51 (2:51 p.m.) documents: Resident continues on antibiotics for sacral wound infection, no adverse reaction noted. V/S WNL (vital signs within normal limits,) no c/o pain noted Dressing clean, dry, and intact. Continue to monitor. This nurses note was written by LPN-II. The nurses note dated [DATE] at 19:45 (7:45 p.m.) documents: Resident was lethargic with altered mental status. VS: BP ,d+[DATE] HR (heart rate) 101 T (temperature) 97.9, RR 16 O2 Sats 88%. Writer administered 2L (liters) of O2 via nasal cannula O2 sats increased to 94%, Writer called Dr. no response. Writer called DON and discussed residents condition. Writer asked to send resident to hospital to be evaluated, writer got the ok, resident was transported to [hospital name] medical center by ambulance at approximately 1930 (7:30 p.m.). This nurses note was written by Nursing-GG. The nurses note dated [DATE] at 00:54 (12:54 a.m.) documents: Patient admitted to [hospital name] r/t necrotizing tissue infection. This nurses note was written by RN-U. The e-mar (electronic medication administration record) dated [DATE] at 07:29 (7:29 a.m.) documents wound infection. This was written by LPN-II. On [DATE], Surveyor requested and received CNA documentation for fluid intake, meal consumption, and turning & repositioning for the time period when R3 resided at the facility as Surveyor is unable to review this information in R3's medical record. The fluid intake is documented as follows: [DATE] at 8:23 p.m. 120 ml. [DATE] at 9:10 p.m. 120 ml. [DATE] at 8:39 p.m. 240 ml. [DATE] at 8:53 p.m. 280 ml. [DATE] at 6:29 a.m. 420 ml. [DATE] at 8:19 p.m. 300 ml. [DATE] at 10:29 p.m. 240 ml R3 was hospitalized on [DATE] & returned on [DATE]. [DATE] at 9:57 p.m. 60 ml. [DATE] at 9:42 p.m. 60 ml [DATE] at 4:35 p.m. 60 ml. Percentage of meal consumed is documented as follows: [DATE] at 9:11 p.m. 100%. [DATE] at 8:39 p.m. 100%. [DATE] at 8:52 p.m. 50%. [DATE] at 10:57 a.m. 100%. [DATE] at 9:48 a.m. 100%. [DATE] at 9:56 a.m. & 8:12 p.m. 100%. [DATE] at 6:00 p.m. 100% R3 was hospitalized on [DATE] and returned on [DATE]. [DATE] at 10:00 p.m. 25%. [DATE] at 6:00 p.m. 20%. Turned & Repositioned for the question did you turn & reposition is documented as follows: [DATE] at 8:23 p.m. yes. [DATE] at 5:00 p.m. yes. [DATE] at 5:07 p.m. yes. [DATE] at 6:29 a.m. yes. [DATE] at 9:48 a.m. yes. [DATE] at 9:58 a.m. & 8:16 p.m. yes. [DATE] at 4:57 p.m. yes. R3 was hospitalized on [DATE] and returned on [DATE]. [DATE] at 9:57 p.m. yes. [DATE] at 2:29 p.m. & 9:42 p.m. yes. [DATE] at 4:34 p.m. yes. On [DATE] at 9:30 a.m., Surveyor met with Wound RN (Registered Nurse)-X. Surveyor asked Wound RN-X about the process for when a resident is admitted regarding their skin integrity. Wound RN-X informed Surveyor the admitting nurse does the body check, any wounds that are identified are documented and they will follow the discharge orders until they are seen by herself and Wound MD-F. Surveyor asked Wound RN-X how she became aware of R3's pressure injury on [DATE]. Wound RN-X informed Surveyor the nurse or the CNA came to get her. Wound RN-X explained ,d+[DATE] was a Thursday. This is the day she goes to [name of sister facility] but came back here to chart. Surveyor asked Wound RN-X why R3's sacral pressure injury wasn't discovered until it was unstageable. Wound RN-X replied, I have no answer for you and stated this was the first time she saw it. Wound RN-X informed Surveyor R3 was not eating good and Wound MD-F did sign a form, referring to the unavoidable pressure injury form. Surveyor asked Wound RN-X why there wasn't a comprehensive pressure injury assessment on [DATE] when R3 returned to the facility. Wound RN-X informed Surveyor she didn't see R3 until ,d+[DATE]. Wound RN-X informed Surveyor R3 may have been admitted after they completed wound rounds. Surveyor asked Wound RN-X who would have been responsible for completing a comprehensive assessment when R3 returned. Wound RN-X informed Surveyor it would be the admission nurse to follow up on the measurements and orders, stating she should have put measurements in. Surveyor asked Wound RN-X if the wound bed should have been described. Wound RN-X replied yes. Wound RN-X informed Surveyor when they saw R3's pressure injury on [DATE] Wound MD-F debrided the pressure injury, cultured the area and the wife didn't want a Foley stating, I know we asked about that, referring to the use of a Foley catheter. Wound RN-X informed Surveyor R3 had an air mattress and was being seen by therapy. Wound RN-X informed Surveyor R3 may not have been getting enough protein and that R3 liked to lay on his back but they did reposition him. Surveyor asked Wound RN-X who is responsible for a resident's skin integrity care plan. Wound RN-X informed Surveyor they are all responsible as they all work together. Surveyor informed Wound RN-X R3's skin integrity care plan was not implemented until he had the unstageable Pressure injury on [DATE]. Wound RN-X replied I'm sure that's not correct, looked at R3's electronic medical record and then stated yes, that's when she started it. On [DATE] at 1:00 p.m., Wound MD-F spoke to Surveyor about R3's pressure injury. Wound MD-F informed Surveyor he only saw R3 on [DATE]. Wound MD-F informed Surveyor the pressure injury had 100% slough, the touch was boggy, liquid breaking down tissue, & was possibly infected. Wound MD-F informed Surveyor he debrided the wound and culture it and ordered labs. Surveyor inquired if the labs were done. Wound MD-F informed Surveyor he didn't see the labs and the culture came back after R3 was in the hospital. Wound MD-F informed Surveyor he ordered stat CBC, Prealbumin now & three weeks but doesn't think that was done. Wound MD-F informed Surveyor R3 was on prostat BID, R3 was not eating well, and right before R3 went to the hospital he had a UTI. Wound MD-F informed Surveyor R3's pressure injury may have been a Kennedy ulcer. Surveyor informed Wound MD-F Surveyor has concerns that a skin integrity care plan wasn't developed until after R3 developed the unstageable pressure injury, when R3 returned from the hospital there was not an assessment until a week later when R3 was seen on wound rounds, and the nurses were signing for two treatments for the sacrum. Wound MD-F informed Surveyor he couldn't address this. On [DATE] at 7:44 a.m., Surveyor asked LPN-AA about R3. LPN-AA informed Surveyor she didn't see him too much as she works third shift and R3 was in & out of the hospital. Surveyor asked LPN-AA if R3 ever refused anything from her. LPN-AA replied no, he never refused, pretty much slept. On [DATE] at 7:47 a.m., Surveyor spoke to CNA (Certified Nursing Assistant)-K regarding R3. CNA-K informed Surveyor she went in to change him, got R3 cleaned up and found the bed sore. CNA-K informed Surveyor she notified the nurse he had a big old bed sore. CNA-K informed Surveyor she had been off for a couple of days and when she came back that's when she found the bed sore. Surveyor asked if R3 got out of bed. CNA-K informed Surveyor he would get out of bed but would scream because of his butt, he never stayed up long and wanted to go back to bed. CNA-K informed Surveyor she had to reposition him off his wound and he would let them reposition him as long as he was off his wound. Surveyor asked if R3 would eat & drink. CNA-K informed Surveyor R3 wasn't a big eater or drinker. Surveyor inquired if R3 had to be fed. CNA-K informed Surveyor sometimes he would eat himself and other times they had to feed him. On [DATE] at 7:53 a.m., Surveyor spoke with CNA-JJ regarding R3. CNA-JJ informed Surveyor R3 was a pleasant man, always in pain, and was in & out of the hospital. CNA-JJ informed Surveyor every once in a while R3 had to be fed and as far as his cares he pretty much let them do him. Surveyor asked CNA-JJ if R3 would allow them to reposition him. CNA-JJ replied yes and explained a lot of times he wanted the pillow out, it was back & forth as he was uncomfortable. Surveyor asked CNA-JJ if she remembered when R3 developed the pressure injury on his sacrum. CNA-JJ replied, I don't remember. On [DATE] at 8:23 a.m., Surveyor met with DON-B to discuss R3. Surveyor asked DON-B who is involved in the care plan process. DON-B informed Surveyor social worker, activities, and nursing management are part of the care plan process. Surveyor asked about R3's ADL care plan. DON-B informed Surveyor it's generated from the head-to-toe admission once it's completed and locked. DON-B informed Surveyor it's her job, her unit managers, or nursing staff to put in the exact information. Surveyor informed DON-B the care plan was not updated as it doesn't indicate how R3 is transferred, his bed mobility, etc. DON-B replied, I understand. Surveyor asked about R3's skin integrity care plan explaining the interventions are not person centered and are the interventions from the admission/readmission head to toe assessment. DON-B informed Surveyor she hadn't gotten to the care plan yet and doesn't have a better answer. Surveyor asked why the nurses were initialing that two different treatments were being completed for the sacrum. DON-B informed Surveyor she will have to follow up with Wound RN-X about this. Surveyor asked DON-B why there wasn't a comprehensive assessment of R3's pressure injury when he was readmitted on [DATE]. DON-B informed Surveyor this was addressed in a facility performance improvement plan (PIP.) Surveyor informed DON-B Surveyor has serious concerns regarding the facility's assessment and treatment of R3's sacrum pressure injury. On [DATE] at 9:17 am., Surveyor asked NHA (Nursing Home Administrator)-A and DON-B where Surveyor would be able to locate weekly skin checks. NHA-A informed Surveyor they are in PCC (PointClickCare) under the evaluation tab. Surveyor asked NHA-A if they aren't under this tab where would Surveyor be able to find them. NHA-A informed they may be on paper. Surveyor informed NHA-A and DON-B Survey

Based on record review and interview, the facility did not ensure 1 (R9) of 3 residents reviewed received appropriate services related to catheter care and/or fecal incontinence with constipation to prevent urinary tract infections and to restore normal bowel function as possible. R9 had a Foley catheter placed and did not have a comprehensive care plan or orders for care or monitoring of the Foley catheter. R9 developed 2 urinary tract infections. R9 was assessed as being incontinent of bowel on admission and had concerns with constipation and loose stools. R9 did not have a comprehensive care plan for bowels and did not have monitoring or a toileting program to maintain continence and R9 became incontinent of bowel. Findings include: The facility policy entitled, Indwelling Catheter Use and Removal implemented on 10/20/2023 states: It is policy of this facility to ensure that indwelling catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice. Compliance Guidelines: . 3. The facility will conduct ongoing assessments for residents at risk for urinary catheterization or on residents with indwelling catheters to determine if the catheter needs to be continued or removed if the catheter is no longer necessary. 4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: . b. Timely and appropriate assessments related to the indication for use of an indwelling catheter. c. Identification and documentation of clinical indications for the use if the catheter as well as criteria for discontinuation of the catheter when the indication for use is no longer present. d. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. e. Response of the resident during the use of the catheter. f. Ongoing monitoring for changes in condition related to potential catheter associated urinary tract infections, recognizing, reporting, and addressing such changes. 8. Catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised . The facility policy entitled Incontinence, implemented on 10/20/2023 states: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Policy Explanation and Compliance Guidelines: 1. The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, service, and assistance to maintain continence unless his or her clinical condition is or becomes that continence is not possible to maintain. 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. R9 was admitted to the facility on [DATE] with a diagnoses that include open wound of lower back and pelvis, Type 2 diabetes mellitus, chronic obstructive pulmonary disease, neuropathy, anemia, chronic kidney disease stage 3, major depressive disorder, muscle weakness, and squamous cell carcinoma of the skin. R9's Admission Minimum Data Set (MDS) dated [DATE] documents that R9 has intact cognition with a brief interview for mental status (BIMS) score of 15 and the facility assessed R9 as needing moderate assist with 1 staff member for toileting and personal hygiene. The facility did not assess bowel continence for R9 and indicated R9 had an indwelling catheter. Surveyor reviewed R9's discharge paperwork from the hospital. Per a therapy assessment of R9 dated 11/24/2023, R9 was assessed as using a toilet with assistance at baseline, R9 was able to pull clothes down and up, and R9 stated R9's wife assisted with pericare. R9's head to toe assessment completed on 12/14/2023 documented that R9 was continent of bladder and bowel. On 12/15/2023 at 8:16 AM, nursing documented: .uses urinal during NOC (night/3rd) shift with staff assistance. On 12/15/2023 at 16:14 (4:14 PM) nursing documented: new order for Foley for wound protection. On 12/15/2023 at 16:35 (4:35 PM)nursing documented: foley inserted with no issues. Foley intact and patent, flowing clear yellow urine. Continue to monitor. On 12/16/2023 at 13:13 (1:13 PM) Director of Nursing (DON)-B documented: bladder evaluation summary: Resident currently has a catheter. Bowel Evaluation Summary: Continent of bowel . R9's medical record did not have physician orders for catheter care and no orders/treatment details to indicate what size of catheter or when to change R9's catheter/catheter bags and there were no orders for monitoring/caring for the catheter insertion site. Surveyor reviewed R9's care plan and noted there was no comprehensive care plan for R9's catheter use. On 12/18/2023 at 10:32 AM, nursing documented: noted scant amount hematuria (blood in the urine) in Foley. NP (nurse practitioner) gave new order for UA (urinalysis). On 12/21/2023 the NP (nurse practitioner) documents: UA results positive for candida . urinary tract infection . patient will complete Augmentin 875/125 twice a day (antibiotic for wound infection) on 12/22/2023. Resident currently has UTI with Candida. Plan to treat on 12/26/2023 after discussing with wound doctor course of antibiotic. Surveyor noted that there were still no orders for catheter care/monitoring, or a care plan initiated for R9's Foley catheter. On 12/26/2023, another UA was ordered to rule out contamination. On 12/29/2023 in the progress notes, NP documents: .seen today for follow up with UA. Discussed to start Fluconazole 200 mg qd (every day) for confirmed UTI with Candida until 1/17/2024. Resident denies problems with Foley. Urine is amber and some white sediment in line . Surveyor noted that R9's Fluconazole medication was not started until 1/3/2024 with the following order: Fluconazole Oral Tablet 200 MG (Fluconazole) - Give one tablet by mouth in the morning for UTI with Candida for 14 days (start: 1/3/2024, discontinue (D/C): 1/14/2024). Surveyor noted that there were still no orders for catheter care/monitoring, or a care plan initiated for R9's Foley catheter. On 1/12/2024 at 10:55 AM in the progress notes, nursing charted: Resident noted to be confused this am. Medical doctor (MD) here with NP and assessed resident. STAT (right away) lab orders in place but lab will not be leaving due to weather. Order to send to ER (emergency room ). Ambulnz (sic) called . and picked up at 11:22 AM to [Hospital name]. On 1/12/2024 at 21:53 (9:53 PM) in the progress notes, nursing charted: returned to the facility approx. 1700 (5:00 PM). To start BACTRIM twice daily for 14 days for UTI. First dose given today. On 1/22/2024 in the progress notes, NP documents: .For UTI resident is taking Bactrim DS with end date 1/26/2024. Foley has amber colored urine with white sloff (sic) coated on tubing, was placed for wounds and incontinence. Surveyor noted R9 was noted to be continent upon admission to the facility and there were still no orders for catheter care/monitoring, or a care plan initiated for R9's Foley catheter. On 2/10/2024 at 13:40 (1:40 PM) in the progress notes, nursing charted resident was complaining of bladder pain and no urine output, Writer changed catheter, output was 950 cc. Resident stated felt relief. MD was notified and aware of foley change and output. Surveyor noted that MD was notified after nurse changed out R9's foley and there still are no orders regarding monitoring or care for R9's foley catheter or indication what size of catheter to use. On 5/14/2023 at 1:21 PM, Surveyor interviewed Wound MD-F who was seeing R9 due to a sacral and left buttock wound. Wound MD-F recalled R9 having frequent stools that were at times liquid and not good for the healing of R9's wounds. Wound-MD stated sometimes facility staff had a hard time keeping up with R9's stools. Wound MD-F stated R9 was incontinent but was unsure if R9 used the toilet at times. Surveyor reviewed Certified Nursing Assistant (CNA) documentation for R9's bowels. CNA documentation was not consistent in documenting R9's bowel habits/patterns and did not indicate if R9 was continent or incontinent. R9's activities of daily living (ADL) care plan initiated on 12/14/2023 had the following interventions: TOILET USE: The resident requires extensive assistance by 2 staff for toileting. PERSONAL HYGIENE: I require extensive assistance of 1 for personal hygiene. Surveyor noted that there was not a care plan to specifically address R9's bowel continence/incontinence or issues related to R9's bowels. R9 was noted to be continent of bowels upon admission. Surveyor reviewed R9's progress notes and noted there was no charting documenting if R9 was having liquid stools or how staff were managing R9's bowels in addition to keeping R9's sacral wounds clean and free of stool. Surveyor noted that physician notes indicated R9 had bouts of constipation and was scheduled: Docusate Sodium oral tablet 100 MG-Give 1 tablet by mouth in the morning for constipation (start 1/28/2024.) Surveyor noted Prior to R9's Docusate medication being scheduled every day it was scheduled as PRN (as needed) and Surveyor noted that staff did not sign out as being given when R9 had constipation. Surveyor reviewed R9's medication administration records (MARs) during admission and noted that nursing staff was signing out R9's Docusate sodium as being given every day. On 2/12/2024 in the progress notes, NP documents . (R9) complained pain a little worse. Registered Nurse (RN) said RN just cleaned it, patient said they cleaned out the wound again and BM (bowel movement) gets in there sometimes and it is uncomfortable . On 5/15/2024 at 8:35 AM, Surveyor interviewed Physical Therapy Assistant (PTA)-Z who stated R9 was working on a goal to be able to be independent with self-cares. PTA-Z stated that when R9 was admitted R9 could use the toilet but then started to become incontinent and was not always able to tell when R9 had to have a bowel movement. On 5/15/2024 at 8:43 AM, Surveyor interviewed CNA-K who stated CNA-K took care of R9 a lot during R9's admission to the facility. CNA-K recalled R9 being incontinent of bowel majority of the time and had a lot of stools. Surveyor asked if R9 having a lot of stools was communicated to nursing. CNA-K does not recall if CNA-K ever told nursing about R9 having a lot of stools. Surveyor asked how CNAs document bowel movements/toileting habits of residents. CNA-K stated they give report and will sign out in the CNA tasks. Surveyor asked if CNA-K ever took R9 to the bathroom to use the toilet. CNA-K stated that sometimes when R9 put the call light on CNA-K would take R9 to the toilet if CNA-K got to R9 on time, otherwise CNA-K had to change R9's brief and wash R9 up. Surveyor asked CNA-K what kind of foley catheter cares were done for R9. CNA-K stated that CNA-K emptied the catheter bag for R9. Surveyor asked where CNA-K would find information regarding care for a catheter. CNA-K stated that it would be on the CNA Kardex for the resident and in the CNA task check off. Surveyor reviewed R9's CNA Kardex. Surveyor noted there is no mention of R9 having a catheter or any catheter care for R9. Surveyor also noted there is no toileting program for R9. The CNA Kardex has the following interventions: TOILET USE: the resident requires extensive assistance by 2 staff for toileting. PERSONAL HYGIENE: I do require extensive assistance of 1 for personal hygiene. On 5/15/2024 at 9:29 AM, Surveyor interviewed DON-B who stated DON-B could not recall doing a bladder evaluation summary for R9. DON-B stated DON-B recalled R9 having a catheter. Surveyor asked DON-B if R9 should have had a care plan and orders for catheter care/monitoring if R9 had a catheter. DON-B stated yes R9 should have had those in place if R9 had a catheter. Surveyor asked DON-B what kind of bowel monitoring or toileting program is done for residents to asses bowel habits for R9. DON-B stated DON-B was not aware of what R9's bowel habits were. Surveyor requested policies for bowel monitoring/assessment. On 5/15/2024 at 12:46 PM, DON-B stated the facility did not have a bowel monitoring policy. DON-B also stated that R9 was admitted to the facility with the Foley catheter in place already. Surveyor showed DON-B documentation that does not match up with R9 having been admitted with a Foley catheter in place. Surveyor shared concerns regarding R9's catheter and not having a care plan, or orders for catheter care/monitoring and R9 ended up with UTIs. Surveyor also shared concern that R9 was assessed as being continent of bowel and bladder on admission but then got a foley catheter placed and became incontinent of bowel and did not have a toileting program or monitoring in place. DON-B stated that DON-B and Nursing Home Administrator (NHA)-A are aware of the lack of monitoring. DON-B stated there was some documentation in the CNA charting, but not enough. No further information was provided as to why R9 did not receive appropriate services related to catheter care and/or fecal incontinence with constipation to prevent urinary tract infections and to restore normal bowel function as possible.

Based upon observation, interview, and record review, the facility was not administered in a manner to ensure residents attained or maintained their highest level of practicable well-being. This deficient practice had the potential to affect all 106 residents residing in the facility at the time of the survey. During a complaint survey conducted on 1/26/23 - 2/1/23, it was determined 8 deficiencies existed including the deficient practice at F835 (Administration.) Each of the deficiencies identified systemic issues within the facility that were not addressed by facility administration through established processes. Three of the deficiencies have been identified to be deficient at a severity level of immediate jeopardy and at a scope of either pattern or widespread. Additionally, systemic concerns were identified regarding the facility assessment, the role of the Infection Preventionist, oversight of medical records, and management of Covid vaccinations. CMS (Centers for Medicare and Medicaid Services) made providers aware of the requirements for each facility to develop and implement a water management plan with memos in 2017 and 2018. Despite these requirements, the facility did not take action to develop a water management plan until after a resident became ill with Legionella. In relation to the water management plan, the facility also did not ensure there was a designated infection preventionist (IP,) did not ensure there was a system to monitor proper sanitization of dining equipment, and did not have a QAA (Quality Assurance Assessment)/QAPI (Quality Assurance Performance Improvement Plan) process to review identified issues and establish plans for improvement within the facility. Additional failures of not developing a facility assessment that takes into consideration the overall dynamics, needs, and structures within the facility, ensuring documentation in the medical record based upon standards of practice, and ensuring residents received Covid vaccinations in accordance with standards of practice were identified. The failure of administration to ensure the building was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being of each resident created a situation of immediate jeopardy that began on 1/23/23 and was determined to be not removed at the time of exit from the survey on 2/1/23. Surveyor notified Nursing Home Administrator (NHA)-A of the finding of Immediate Jeopardy on 2/1/23 at 1:14 PM. Findings include: Example 1: The Centers for Medicare and Medicaid Services (CMS) issued memo QSO-17-30 on 6/2/17 and issued revised QSO-17-30 on 7/6/18 titled, Requirements to Reduce Legionella Risk in Healthcare Facility Waters Systems to Prevent Cases and Outbreaks of Legionnaires Disease (LD). On Page 3, under Expectations for Healthcare Facilities it states, CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems. Facilities must have water management plans and documentation that, at a minimum ensure each facility: ~Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. ~Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC (Centers for Disease Control) toolkit. ~Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions taken when control limits are not maintained. ~Maintains compliance with other applicable Federal, State, and local requirements . Health care facilities are expected to comply with CMS requirements and conditions of participation to protect the health and safety of patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance. In addition, CMS issued revisions to the regulations for nursing homes in Appendix PP dated 10/21/22. The same information that was communicated in Memo QSO-17-30 is found in the guidance at F880. On 2/1/23, at 1:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A asking who is responsible for the oversight of the facility including the QAPI/QAA committee, and water management plan? NHA A stated he was responsible for the oversight of the QAPI/QAA committee, and the facility's water management plan. On 1/30/23, at 9:57 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated the position of the IP is not listed because she currently holds that position along with her DON responsibilities and the positions are rolled together. DON-B stated it is the facility's plan to have the IP position to be created from the Assistant Director of Nursing Position (ADON) and the ADON position will be taken from a Unit Manager position. Surveyor reviewed the Facility Assessment Tool, dated 12/30/22 and reviewed by QAA/QAPI committee on 12/30/22. Surveyor noted this has not been completed by administration. The facility infection control policy provided by the facility administration during the survey was dated 10/30/22 indicating the date the policy was established by administration within the facility. The facility's Infection Control Program policy dated 10/30/22 documented a water management program had been established, control measures and testing protocols were in place to address potential hazards associated with the facility's water system, and identified the Administrator (NHA) A as the leader of the water management program. Review of the facility water management program during the survey indicated as of 1/31/23, the facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. This failure contributed to R1 being hospitalized from 1/18/23 through 1/25/23 and diagnosed with Legionella. While hospitalized , R1 was treated with azrithromycin (antibiotic.) The Wisconsin Department of Public Health identified this case met the requirements for a presumptive healthcare associated case of Legionella. Review of the overall water management plan (WMP) indicated it was not based upon current standards of practice by not including: water management team members who were knowledgeable about Legionella and the facility's water system, a description of the buildings water system using text and an accurate flow diagram of the system, an assessment of the facility's water system to identify all locations where Legionella could grow and spread, identification of where control measures should be applied based on where Legionella could grow and spread, identification of acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met, inclusion of a process to confirm the WMP is being implemented and is effective, implementation of hand hygiene, and prevention of cross contamination mitigation actions. Example 2: During the survey, Surveyor reviewed the facility's policy, entitled, Dishwasher Temperature, dated 1/16/2023, which documents: Policy: It is the policy of this facility to ensure dishes are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: 1 All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacturer's instructions shall be followed for machine washing and sanitization. 4. For low temperature dishwashers (chemical sanitization): a. The wash temperature shall be 120 F (Fahrenheit). b. The sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface at final rinse. 5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. 6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or refilled for cleaning purposes. On 1/19/23, the County Health Department in which the facility is located was notified of a Legionella positive urine antigen test (collected on 1/18/23) from R1, who resides at the facility. R1 was noted to have not left the facility since August of 2022. Given that R1 has not left the facility since August 2022, the case met the criteria for a presumptive healthcare-associated case of Legionella. On 1/23/23, the facility implemented water restrictions. The facility continued to use the dish machine located in the kitchen during this time as it was explained that the water going to the machine was a different system. On 1/26/23, at 3:02 PM, Surveyor toured the kitchen area with Dietary Supervisor (DS)-E. DS-E informed Surveyor they were given approval to use the dishwashing machine because it uses a separate water tank than the rest of the facility. DS-E stated they were not sure who provided the permission. DS-E stated the only water being used in the kitchen was being run through the dishwashing machine. During this time, Surveyor observed the process for testing how the dishwasher is effectively sanitizing items placed within it. It was observed the facility did not have an effective system to ensure the low temperature dishwasher that utilizes chemicals for sanitization was effectively sanitizing items to prevent food borne illness. Although Legionella is not known to be transmitted via objects such as dishware, the facility failure to monitor wash and rinse temperatures and chemical sanitization and not properly sanitizing the dishes and utensils creates a likelihood an infection could spread. Example 3: Additionally, within the 10/30/22 infection control policy and procedure there should be clear processes based upon standards of practice regarding how the facility will complete process surveillance (how the facility tracks the extent to which staff follow the facility's infection prevention and control policies and procedures.) During the survey from 1/26/23 through 2/1/23, facility Staff did not follow facility infection prevention and control policies and guidance related to the use of eye protection and source control to prevent the transmission of COVID-19, the use of PPE (personal protective equipment) during aerosol generating procedures, or the use of PPE for residents on Enhanced Barrier Precautions. Example 4: On 1/26/23 through 2/1/23, the facility assessment was reviewed by Surveyors who noted the Facility Assessment Tool, dated 12/30/22, did not identify the facility's need for the Infection Preventionist role or the designated hours per week necessary to perform their duties. An Infection Preventionist is responsible for managing the facility's Infection Prevention and Control Program (IPCP.) Additionally, the Facility Assessment Tool, dated 12/30/22, did not include a completed facility-based and community-based risk assessment, utilizing an all-hazards approach to create an emergency preparedness plan, including a water management plan, that met current standards of practice. 483.70 (e) clearly indicates the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Example 5: During the survey (1/26/23-2/1/23,) Surveyors reviewed the facility process related to QAA and QAPI. Surveyors noted the facility did not ensure their QAPI plan created by the QAA committee, headed by NHA A, developed and implemented appropriate plans of action for identified deficiencies related to the need to create a comprehensive Facility Assessment. The QAA committee did not identify the facility's approved Water Management Plan, dated December 2022, was created not using a risk-based assessment utilizing an all-hazards approach, to identify risks related to the building and physical structure of the building and met the current standards of practice. The QAA committee did not ensure the Facility Assessment identified the need for a facility designated Infection Preventionist and the amount of time the facility would allow for them to perform their role. Surveyors noted upon review of the facility survey history, the facility was not in compliance during this survey with regulations at F578 (formulation of advanced directives) and F689 (services/supervision to prevent accidents.) These citations were cited at the severity of an immediate jeopardy (Event ID: OMN811.) Example 6: The Wisconsin Administrative Code, Department of Health Services (DHS) documents; DHS 132.62 (2) (a) 3 a- Duties. The director of Nursing shall be responsible for Supervising the functions, activities, and training of the nursing personnel. DHS 132.45 (4) Medical Records (g) Record documentation. 1. All entries in medical records shall be accurate, legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry. During the survey, Surveyors noted additional concerns with how the facility administration ensures staff are documenting in a resident's medical record based upon current standards of practice. Noted was on: 1/23/2023 23:04 (11:04pm), TYPE: Nurses Note, Note Text: CNA (certified nurse aide) came and got me due to his feeding tub(e) leaking dark red liquid. when I observed tub(e) was out around 8 inches from the plastic piece of tubing. I pushed back in and it wouldn't stay. Had the RN (registered nurse) observe, and I called his doctor. was told to send in the morning due to after hours. The doctor is aware. The note is electronically signed by Licensed Practical Nurse (LPN) L but does not include LPN L's nursing credential, the identity of the RN who observed R3, and whether the leaking dark red liquid was blood. On 1/23/2023 at 23:10 (11:10 pm,) TYPE: Nurses Note, Note Text: I taped it up so it wouldn't come out. The note is electronically signed by LPN L but does not include LPN L's nursing credential. The next Progress Note that follows the 1/23/2023 at 23:10 (11:10pm) Nurses Note is dated 1/25/2023 at 00:00, TYPE: eMar - Medication Administration Note written by LPN J that does include LPN J's nursing credential. Subsequent Progress Notes after 1/25/2023 at 00:00 do not contain any note by the RN who observed R3 on 1/23/2023 at 23:10, do not contain an assessment of R3's feeding tube leaking dark red liquid and there is no Progress Note on the morning of 1/24/23 indicating the facility followed the doctor's order to send R3 to the hospital. On 1/30/23 at 2:41 pm, Surveyor spoke with DON B and requested additional information about evaluation of the feeding tube leaking dark red liquid and doctor being called and directing the nurse to send R3 to the hospital in the morning. When the additional information was provided to Surveyor, Surveyor asked DON B how she figured all of this out as this information is not included in R3's Progress Notes. DON B reported she had to call people to figure it out. Example 7: Additional systemic concerns were identified during the survey regarding administration of Covid vaccinations/boosters. On 1/27/23 at 8:25 am, DON-B provided Surveyor with the facility policy titled Infection Prevention and Control Program that includes a section titled COVID-19 Immunization. This section notes the following: Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility. Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions and contraindications to determine candidacy for the vaccination. Education about the risks, benefits and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine. Residents or resident representatives will have the opportunity to accept or refuse a COVID-19 vaccination, and change their decision based on current guidance. Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine. On 1/30/23, DON B provided Surveyor with a copy of R2's Personal Immunization History from the State of Wisconsin Immunization Registry that notes R2 completed a series of 3 Pfizer COVID-19 vaccines with the last dose received on 11/17/2021 so R2 would be eligible to receive the COVID-19 bivalent vaccine since September 2, 2022 according to the CDC Stay Up to Date with COVID-19 Vaccines including Boosters website located at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html?s_cid=11747:new%20vaccine%20for%20covid:sem.ga:p:RG:GM:gen:PTN:FY22 On 1/30/23 at 2:41 p.m., Surveyor asked DON-B if R2 was offered the COVID-19 bivalent booster. On 1/31/23 at 8:21 am, DON-B provided the following information: COVID Bivalent boosters are offered to our residents upon admission and on an ongoing basis for anyone who is due or has refused in the past. Per our pharmacy we must order in quantities of 1 vial which contains 6 shots. We are to not waste any of the vaccine and have a window of 12 to 24 hours to give the shots once the vaccine has arrived. We ask and have a list of residents/staff who would like this vaccine. Once we get to 6 residents a vial is ordered from the pharmacy. Cut off is Monday 5pm, for delivery the following Thursday night and dosing on Friday. On 1/31/23 at 10:28 am, Surveyor asked DON-B when staff approached R2 about getting a COVID-19 bivalent booster. Surveyor also informed DON-B the guidance for not wasting doses changed some time ago and current guidance is to not waste opportunities to vaccinate even if doses are wasted. Also, Pfizer offers the COVID-19 bivalent vaccine in single dose vials. DON-B responded to Surveyor via email on 1/31/23 at 12:04 pm and noted, Managers follow up the day after admission regarding vaccines. No information or documentation was provided to demonstrate R2 was offered a COVID-19 bivalent booster. The facility's failure to ensure the facility was administered in a manner to ensure residents attain or maintain their highest practicable level of well-being led to not having systems in place and established by administration that are to be in place based upon current regulations and standards of practices. This created a situation of immediate jeopardy that started on 1/23/23 and was not removed at the time of exit from the survey. (Cross-reference F812, F838, F867, F842, F880, F882, F887).

Based on interview and record review, the facility's Quality Assessment and Assurance Committee did not develop and implement appropriate plans of action to correct identify quality deficiencies. This has the potential to affect all 106 residents residing at the facility. The Quality Assessment and Assurance (QAA) Committee did not develop and implement appropriate plans of action for identified deficiencies related to the need to create a comprehensive Facility Assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. (Cross Reference F838) The facility did not complete a risk-based assessment, utilizing an all-hazards approach, to identify risks related to the building and physical structure of the building including a Water Management Plan that meets current standards of practice or identify the need for a facility Infection Preventionist. (Cross Reference F880 and F882) The Quality Assessment and Assurance (QAA) Committee created and approved of a Water Management Plan that did not meet current standards of practice and was not based on a facility risk-based assessment that would identify the facility's potential for Legionella bacteria in the water or mitigation strategies. The Quality Assessment and Assurance Committee (QAA) did not develop and implement appropriate plans of action for identified deficiencies regarding the need to establish and maintain an Infection Prevention and Control Program (IPCP) (Cross Reference F880,) including a designated Infection Preventionist, that works at least part-time in the facility that is not the Director of Nursing. (Cross Reference F882) Failure to develop an effective QAA (Quality Assessment and Assurance) committee to identify and review issues in the facility and to ensure proper policies and procedures are in place that meet the standards of practice created a finding of Immediate Jeopardy that began on 12/23/22. On 1/31/23, at 4:48 PM, the Director of Nursing-B, Regional Nurse Consultant-G, Corporate Educator-R, and Corporate Maintenance Supervisor-D were informed of the Immediate Jeopardy. The immediate jeopardy was not removed at the time of the facility exit on 2/1/23. Findings include: The facility's policy and procedure entitled, Quality Assurance and Performance Improvement (QAPI), date implemented 1/2023, documents: Policy: It is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcome of care and quality of life and addresses all the care and unique services the facility provides. Quality Assurance (QA) is the specification of standards for quality of services and outcomes, and systems throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards. Quality Assurance and Performance Improvement (QAPI) is the coordinated application of two mutually reinforcing aspects of quality management system: (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes, while involving residents and families in practical and creative problem solving . 2. The QAA (Quality Assessment and Assurance) Committee shall be interdisciplinary and shall: . a. Consist at a minimum of: i. The Director of Nursing; ii. The Medical Director or his/her designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other Individual in a leadership role; and iv. The Infection Preventionist. 3. The QAPI plan will address the following elements: . b. Policies and procedures for feedback, data collection systems, and monitoring. c. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: i. Tracking and measuring performance. ii. Establishing goals and thresholds for performance improvements. iii. Identifying and prioritizing quality deficiencies. iv. Systematically analyzing underlying causes of systemic quality deficiencies. v. Developing and implementing corrective action or performance improvement activities. vi. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revisiting as needed. 4. The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include but is not limited to: a. The written QAPI plan. b. Systems and reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events. c. Data collection and analysis at regular intervals. d. Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. 5. The plan and supporting documentation will be presented to the State Survey Agency or Federal surveyor at each annual recertification survey and upon request. Program Development Guidelines: . 3. Program Feedback, Data Systems, and Monitoring: . b. The facility draws data from multiple sources, including input from staff, residents, families, and other as appropriate. Data sources may include, but are not limited to: i. The facility assessment. 5. Program Systematic Analysis and Systematic Action- a. The facility takes action aimed at performance improvement as documented in QAA Committee meeting minutes and action plans. Performance/success of the actions will be monitored and documented in subsequent QAA committee or sub-committee meetings. On 2/1/23, at 1:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, who stated he was responsible for the oversight of the QAPI/QAA committee and the facility's water management plan. Water Management Plan: On 1/23/23, the facility was notified by the Wisconsin Department of Health Services, Division of Public Health of a positive Legionella urine antigen test having been collected from R1 while R1 was in the hospital. It is documented in the Initial Notification of Investigation, Wisconsin Department of Health Services, Division of Public Health investigation form that Director of Nursing (DON)-B completed a hypothesis-generating questionnaire with Public Health staff on 1/23/23. It is documented R1 had resided in the facility and had not left the facility since August 2022. Given that R1 had not left the facility since August 2022, this case met the criteria for a presumptive healthcare-associated case of Legionella. On 1/26/23 at 9:10 AM, Surveyor asked Director of Nursing (DON)-B for a copy of the facility's Facility Assessment and Water Management Plan. Nursing Home Administrator (NHA)-A was out of the country and unavailable for the survey. On 1/26/23 at 12:15 PM, Surveyor informed DON-B the facility Water Management Plan (WMP) that was provided, Untitled and dated December of 2022, had an illegible Roadmap for Responding to Legionella Environment test water flow diagram. DON-B stated she would try to make a more legible copy from their computer copy of the WMP. On 1/26/23 at 12:25 PM, Dietary Supervisor (DS)-E, who stated they were the acting NHA, informed Surveyor their copy of the facility WMP was no different and they would be contacting the person that created the WMP to obtain an easier to read copy. Surveyor notes the WMP untitled and dated December 2022, is generic and was not developed using a facility risk assessment identifying the facility's potential risk for Legionella and corrective actions that need to be taken nor does it describe the facility's water system in text and include a water flow diagram specific to the facility. The WMP does not identify measures (control measures) to prevent the growth of Legionella therefore the facility could not monitor these control measures as the WMP did not identify them. On 1/27/23 at 8:25 AM, Surveyor interviewed DON-B, Maintenance Supervisor (MS)-C, Corporate Maintenance Supervisor (CMS)-D, and facility contracted Plumber-H, who informed Surveyor the facility contracted with a 3rd party vendor to create a WMP for the facility. DON-B stated the facility received the WMP from the 3rd party vendor on 12/1/22 and that it was presented, reviewed, and approved at the facility QAPI (Quality Assurance and Performance Improvement) committee meeting on 12/23/22. DON-B stated last evening they contacted the 3rd party vendor, and the facility was provided with an updated WMP dated 1/26/23. DON-B stated the WMP dated 1/26/23 would still need to be reviewed and approved by the QAPI committee. DON-B stated prior to R1 testing positive for Legionella, the facility had a generic WMP and yesterday (1/26/23) a more in depth WMP was developed by a 3rd party vendor and it was specific to the building and developed related to the facility risk assessment. On 1/27/23, at 9:47 AM, Surveyor asked DON-B for QAPI sign in sheets and agendas for the last few meetings for review. DON-B stated the QAPI team uses a generic agenda form and minutes are not documented related to topics discussed at the QAPI meeting. DON-B stated the agenda does not change from meeting to meeting and the WMP was reviewed during the Safety Committee report at the December 23, 2022, meeting. Surveyor asked DON-B how the facility could identify what each QAPI meeting agenda consisted of if the facility did not tailor the agenda to the meeting and no minutes were taken. DON-B stated a folder is kept of each meeting and forms or papers that were reviewed are placed in the folder. Surveyor identified a concern related to the QAPI committee presenting, reviewing, and approving a WMP on 12/23/22 that did not meet the current standards of practice, and this was not identified by any member of the QAPI committee. Infection Preventionist: On 1/30/23, at 9:57 AM, Surveyor interviewed DON-B who stated the facility staffing plan (the facility's approach to staffing to ensure they have sufficient staff to meet residents' needs) can be found in the Facility Assessment provided to the Surveyor. Surveyor reviewed the Facility Assessment Tool, dated 12/30/22 and reviewed by QAA/QAPI committee on 12/30/22. Surveyor confirmed with DON-B the staffing plan 3.2 section of the Facility Assessment does not identify a facility need for the position of Infection Preventionist (IP). DON-B confirmed the position of an IP is not identified in the list of positions in Example 2 of the Staffing Plan section. Surveyor asked DON-B if the documented staffing plan under Example 2 is a representation of the facility's current staffing plan or an example of how to complete a staffing plan. DON-B stated the staffing plan 3.2, Example 2 is a representation of the positions and staff the facility identified were needed to care for the residents at the facility. DON-B stated the position of the IP is not listed because she currently holds that position along with her DON responsibilities and the positions are rolled together. DON-B stated it is the facility's plan to have the IP position to be created from the Assistant Director of Nursing Position (ADON) and the ADON position will be taken from a Unit Manager position. On 1/30/21, at 2:45 PM, DON-B, Corporate Nurse Consultant-G, Corporate Educator-R were informed of the concern the facility assessment does not identify the need for an IP (Cross Reference F882) and the survey team has identified deficient practice related to infection control during the onsite survey. (Cross Reference F880). The facility assessment did not include the completion of a facility risk assessment to create an effective Water Management Plan specific to the facility's identified risks and needs and for the concern the QAPI Committee reviewed and approved a WMP that does not meet current standards of practice. (Cross Reference F838) The deficient practice was identified at F835 (Administration,) F838 (Facility Assessment,) F880 (Infection Prevention and Control,) F882 (Infection Preventionist Qualification/Role.) Failure to develop and effective QAA (Quality Assessment and Assurance) committee to identify and review issues in the facility and to ensure proper policies and procedures are in place that meet the standards of practice created a finding of Immediate Jeopardy that began on 12/23/22 and has not yet been removed.

Based on observations, interviews, and record reviews, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 106 residents residing in the facility. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include water management team members who were knowledgeable about Legionella and the facility's water system - Describe the building's water system using text and an accurate flow diagram of the system - Include an assessment of the facility's water system to identify all locations where Legionella could grow and spread - Identify where control measures should be applied based on where Legionella could grow and spread - Identify acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met - Include a process to confirm the WMP is being implemented and is effective - Implement hand hygiene and prevention of cross contamination mitigation actions that were consistent with current standards of practice when the facility water supply was turned off in response to learning a facility resident was diagnosed with healthcare associated Legionnaires disease. The facility infection prevention and control program does not include process surveillance (how the facility tracks the extent to which staff follow the facility's infection prevention and control policies and procedures) based on national standards of practice. Facility Staff did not follow facility infection prevention and control policies and guidance related to: - Use of eye protection and source control to prevent the transmission of COVID-19 - Use of PPE (personal protective equipment) during aerosol generating procedures - Use of PPE for residents on Enhanced Barrier Precautions As of 1/31/23, the facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. R1 was hospitalized from 1/18/23 through 1/25/23. While in the hospital, R1 was diagnosed with Legionella and was treated with azrithromycin (antibiotic.) The Wisconsin Division of Public Health identified this case to meet the definition of a presumptive health-care associated case of Legionella. The failure of the facility to develop and implement a water management plan to prevent the growth of Legionella in the facility water system created a finding of immediate jeopardy which began on 10/30/2022. Surveyor notified Administrator A of the immediate jeopardy on 1/31/23 at 4:48 PM The immediate jeopardy was not removed at the time of the facility exit on 2/1/23. Findings include: The 7/6/18 revised CMS (Centers for Medicaid and Medicare Services) Quality, Safety and Oversight Letter 17-30 titled, Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) states: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. - Develops and implements a water management program that considers the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) industry standard and the CDC (Centers for Disease Control) toolkit - Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. - Maintains compliance with other applicable Federal, State and local requirements The 6/24/21 CDC Toolkit titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings identifies the key elements of a water management program for healthcare facilities to include: 1. Establish a water management program team 2. Describe the building water systems using text and flow diagrams 3. Identify areas where Legionella could grow and spread 4. Describe where control measures should be applied and how to monitor them 5. Establish ways to intervene when control limits are not met 6. Make sure the program is running as designed and is effective 7. Document and communicate all the activities Water Management Plan (WMP) not consistent with current standards of practice: On 1/27/23 at 8:25 am., DON B provided Surveyor with a copy of the facility Infection Prevention and Control Program (IPCP) policy dated 10/30/22. Surveyor reviewed the IPCP policy that noted the following under item 16. Water Management: a. A water management program has been established as part of the overall infection prevention and control program b. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems c. The Administrator serves as the leader of the water management program On 1/26/23, Surveyor received an untitled eight-page document identified by the DON-B as the facility's Water Management Plan (WMP) dated December 2022 that identified illegible diagrams on page 4 and 6. At 1:13pm, Surveyor spoke with DON-B who reported she has to retype the diagrams as they are very difficult to read. At 1:39 pm, DON-B provided Surveyor with a copy of the page 6 diagram which was annotated with numbers to identify the individual steps for each box of the diagram. A typed two-page document was attached to the page 6 diagram with the text for each box of the diagram. This document identified the following water management strategies: 1. Identify and describe the building water systems: Conduct a water systems survey, list salient information about each system, and show the systems in flow diagrams. (See the water system tables and flow diagrams.) There are no water system tables and flow diagrams in the WMP document that describe the facility's water system. 2. Conduct a hazard analysis of the water systems: Among the water systems identified in Step 1, determine which ones present a significant risk of Legionella growth and transmission. (See the Hazard Analysis of Water Systems.) There is no hazard analysis of the facility water system to identify where Legionella could grow and spread as well as identify the fact that the facility was built before 2003 therefore the facility is not required to meet Wisconsin Administrative Code, Chapter SPS 382.50(3)(b)6. requirement for nursing homes to have a hot water distribution systems installed and maintained to provide bacterial control by one of the following methods: a) Water stored and circulation initiated at a minimum of 140 degrees F (Fahrenheit) and with a return of a minimum of 124 degrees F b) Water chlorinated at 2mg/L residual c) Another disinfection system approved by the department 3. Establish control locations: For the water systems that present a significant Legionella risk (Identified in Step 2), determine points or steps at which Legionella control measures can be applied. (See Hazard Analysis of Water Systems.) The WMP does not describe where control measures should be applied as there was no assessment of where Legionella could grow and spread. 4. Establish and implement control measures with performance limits, monitoring, and corrective action: . The WMP did not establish and implement control measures with performance limits as the facility did not assess where Legionella could grow and spread so appropriate control locations could be applied. 5. Establish and implement verification procedures . 6. Establish and implement validation procedures 7. Establish and implement documentation. On 1/26/23 at approximately 9:56 am, Surveyor observed the hot water return in the mechanical room did not have a temperature gauge to determine if the return temperature was 124 degrees F. It should be noted the facility was not required to have a gauge because the facility was built before 2003, however the facility Legionella Surveillance policy implemented on 1/23/23 which is the same day the facility learned that R1 tested positive for Legionella, includes but is not limited to the following: - Temperature controls: - Hot water shall be stored above 140 degrees F (Fahrenheit) and circulated at a minimum return temperature of 124 degrees F. On 1/26/23 at 1:47 pm., Surveyor interviewed Maintenance Supervisor C and Corporate Maintenance Supervisor D. Maintenance Supervisor C reported he oversees the facility's maintenance program to include its water system. Corporate Maintenance Supervisor D reported he oversees many buildings owned by the corporation. Maintenance Supervisor C reported he received no training about Legionella and never heard the word Legionella until 1/23/23. Corporate Maintenance Supervisor D reported he received training about Legionella when he was with another company but not related to health care. On 1/26/23 at 2:14 pm, Surveyor interviewed DON (Director of Nursing) B and Regional Nurse Consultant G. Surveyor requested to review any other documents the facility has related to their WMP as well as the facility's previous WMP. Surveyor asked who developed the policy, when it was developed, and when it was discussed at the facility QAPI (Quality Assurance and Performance Improvement) meeting. On 1/27/23 at 8:25 am, Surveyor met with DON B, Maintenance Supervisor C, Corporate Maintenance Supervisor D, and Contracted Plumber H. DON B reported the facility corporation contracted with U.S. Water who provided the facility with a WMP on 12/1/22 that was approved by the QAPI Committee on 12/23/22. It should be noted the QAPI Committee approved a WMP that is not consistent with current standards of practice as the WMP did not include a facility assessment to identify where Legionella could grow and spread in the facility, did not describe the building water systems using text and flow diagrams, and did not identify measures (control measures) to prevent the growth of Legionella, therefore the facility could not monitor these control measures as the WMP did not identify them. DON B provided Surveyor with a new WMP that DON B reported she received last night (1/26/23) from U.S. Water. Surveyor asked Maintenance Supervisor C and Corporate Maintenance Supervisor D if they did any other monitoring or testing of water. Corporate Maintenance Supervisor C reported they check water temperatures in resident rooms on a weekly basis. He reported they check 2 rooms from the back wing and 2 rooms from the front per wing for each floor. Corporate Maintenance Supervisor C reported there are no logs or documentation of the temperatures. On 1/31/23, Surveyor reviewed the facility's new WMP dated 1/26/23. The new plan identifies the facility as having 3 floors but doesn't identify the year the facility was built which is essential information as any facility built before 2003 is not required to meet the Wisconsin Administrative Code 382.50(3)(b)6 requirement for nursing homes to have a hot water distribution system installed and maintained to provide bacterial control. On 1/31/23 at 10:38 am, Surveyor notified DON B that the facility WMP is not specific to the facility and includes control measures that are not applicable to the facility (whirlpool bathtubs, fish tanks, misters, piped eye wash stations, and disinfection levels.) As of 1/31/23, the facility did not have a system for preventing the growth and spread of Legionella in the facility's water system. On 1/27/23 at 9:34 am, Surveyor met with DON B who reported she received a telephone call from Kenosha Public Health on 1/23/23 at 11 am notifying her R1 who had been transferred to the hospital on 01/18/23 had a positive urine antigen test for Legionella. Surveyor notes the facility medical record documents R1 presented with shortness of breath on 12/15/22, shortly after one of R1's diuretic medications was discontinued. R1 was treated with Levaquin (antibiotic) from 12/15/22 through 12/21/22 for presumptive pneumonia. A chest X-ray taken at the facility on 1/4/23 demonstrated R1 continued to experience congestion. On 1/18/23, R1 was transferred to the hospital due to increased edema to the face, abdomen, arms, and legs as well as labored breathing. R1's hospital discharge summary dated 1/25/23 noted R1 was found to have Right Lower Lobe (RLL) pneumonia as well as a UTI (Urinary Tract Infection.) The hospital discharge summary dated 1/25/23 states (R1) was positive for Legionella and was treated with azithromicin (antibiotic.) R1 completed the course of antibiotic treatment while in the hospital. On 1/27/23 at 9:34 am, DON B provided Surveyor with the facility's PIP (process improvement plan) which documented the actions taken by the facility once they were notified R1 tested positive for Legionella. R1 returned to the facility on [DATE]. Actions with a completion date of 1/23/23 included but were not limited to: - Emergency QAPI (Quality Assessment Performance Improvement) meeting held to review Legionella outbreak and the steps taken so far to remediate the immediacy of the concern. A RCA (root cause analysis) is being completed to determine systemic gaps in monitoring the Water Management System to prevent legionella outbreaks. The QAPI Team will meet to discuss the RCA and implement corrective actions. During facility audits any discrepancies to the Water Management Plan will be immediately taken to the QAPI team so immediate corrective actions can be implemented. - All sinks within the facility have been covered or had the water shut off until such time that they are safe for resident use - Facility Water Management is being reviewed and mapped by US Water - A review of the previous water management plan was conducted and the following is being evaluated by US Water. - Created a flow diagram to reflect the current water system in the facility - Deadlegs (Dead legs), incoming water, disinfection system, water temperatures were added as potential hazards - Surveyor noted these hazards were not included in the 12/1/22 WMP. - A control monitor plan was developed to include the flushing of deadlegs (dead legs) per the CDC guidelines - A review of the CMS QSO -17-30 and the CDC Legionella Toolkit was conducted to highlight areas of improvement for our updated water management plan was conducted to highlight areas of improvement for our updated water management plan - Ice machines shut off - Shower rooms closed - 10 five-gallon [NAME] water tanks brought in to supply hot and cold water - hospitalized residents with respiratory symptoms had the hospital contacted and updated on current facility dx (diagnosis) of resident with legionella pneumonia - All residents were evaluated for s/sx (signs / symptoms) of Legionnaires by the Director of Nursing - All staff have been educated prior to next scheduled shift on facility Legionnaires Guidelines and specifically on the following: - No use of facility faucets, bedpan washers, ice machines, kitchen faucets/sprayers and any other water sources - Nebulizers, CPAP, Bi-PAP, and respiratory equipment to be rinsed with sterile water - DON B, LPN F and LPN I told Surveyor previously used distilled water As of 1/31/23, the facility's water management program was not specific to the facility in preventing the the growth and spread of Legionella in the facility's water system. Improper Hand Hygiene and Cross Contamination: On 1/26/23 at 8:26 am, Surveyor observed Certified Nursing Assistant (CNA) L leave the 2 North shower room and walk to the 2 North nurses' station to wash her hands. CNA L reported staff fill the communal water pitcher from the communal [NAME] water station located to the left of the sink behind the nurses' station to rinse their hands. CNA L dispensed soap onto her hands from the soap dispenser and then picked up the water pitcher with her left hand to rinse her right hand and then used her right hand to pick up the water pitcher and rinse her left hand and then used paper towel to dry her hands. After soaping up CNA L's hands, CNA L recontaminated her hands when reusing the contaminated water picture to rinse her clean hands. On 1/26/23 at 9:16 am, Surveyor observed the 2 South Staff Restroom near room [ROOM NUMBER]. The water faucet was wrapped in plastic and taped. A plastic container of PDI brand Sani-Hands wipes was sitting on the sink. CDC and facility guidance for Hand Hygiene recommend handwashing with soap and water after using the toilet. On 1/27/23, DON B provided Surveyor with a packet of information used for staff training that included but was not limited to the facility Legionella Surveillance policy dated 1/23/23, an attendance sheet signed by nine staff members to include Maintenance Supervisor C, copies of CDC information about Legionella, copies of CDC information that included a 2 page document titled Hand Sanitizer Use Out and About with sections titled When Should I Use and How Should I Use and a typed document titled Education on completion of cares for resident. The Hand Sanitizer Use Out and About copy includes 10 indications for when soap and water should be used for handwashing to include but is not limited to after using the toilet. The document Education on completion of cares for residents document includes but is not limited to: 3. Use ABHR (alcohol-based hand rub) for hand hygiene for staff and residents, utilize bottled water for hand hygiene if hands are visibly soiled. 1 bottle per person per use. 4. Bottled water for drinking, hand washing, brushing teeth, and rinsing items (bed pans, basins, and denture cups). The directions provided, to only use bottled water for hand hygiene if hands are visibly soiled is not consistent with CDC guidance and has the potential for residents and staff to transmit infections. On 1/26/23 at 9:27 am, Housekeeper O stated to Surveyor, the water situation is difficult. Housekeeper O showed Surveyor a large size plastic container she takes back and forth to the 2 South nurses' station communal [NAME] water station to fill with water for cleaning. This practice has the potential for cross contamination. Stagnant Water: On 1/26/23 at 8:26 am, Surveyor spoke with CNA L about the 2 North Shower Room which is not being used as the facility water is turned off and the water faucets are covered with plastic and taped up to prevent use. CNA L reported prior to the water being shut off, staff used the shower to the back of the shower room and didn't use the shower to the left of the entry door. It should be noted that sections of water pipe that contain water that has no flow or does not circulate is considered a dead leg and recognized risk factor for the growth of Legionella. Control measure options include routine flushing or removal of the piping. On 1/26/23 at 11:16 am, Surveyor toured room [ROOM NUMBER] - Patient Lift Room with Contracted Plumber H that housed a large ice machine. Contracted Plumber H stated when the ice machine stops running water is trapped in the hose and could siphon back. The ice machine was turned off. On 1/26/23 at 11:34 am, Surveyor toured the 1 South and 1 North Shower Rooms with Contracted Plumber H who reported because the bathtubs have not been used, he was contracted this week to remove the water pipes connecting the tubs to the main water line. It should be noted that sections of water pipe that contain water that has no flow or does not circulate is considered a dead leg and recognized risk factor for the growth of Legionella. On 1/26/23 at 11:47 am, Surveyor, Regional Nurse Consultant G, and Contracted Plumber H toured the locked facility Beauty Shop located in the facility basement. Regional Nurse Consultant G reported it hasn't been in use since COVID-19 started as it's difficult to get beauticians. Surveyor observed a hose attached to the faucet and was able to turn on both the hot and cold water. It should be noted that water pipes and hoses that contain water that has no flow or does not circulate is considered a dead leg and recognized risk factor for the growth of Legionella. Facility infection prevention and control program does not include surveillance consistent with national standards of practice: The CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings located at https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html#anchor_72633 notes This document concisely describes a core set of infection prevention and control practices that are required in all healthcare settings, regardless of the type of healthcare provided. The practices were selected from among existing CDC recommendations and are the subset that represent fundamental standards of care that are not expected to change based on emerging evidence or to be regularly altered by changes in technology or practices and are applicable across the continuum of healthcare settings . Core Practice Category 4. Performance Monitoring and Feedback notes: 1. Identify and monitor adherence to infection prevention practices and infection control requirements 2. Provide prompt, regular feedback on adherence and related outcomes to healthcare personnel and facility leadership. 3. Train performance monitoring personnel and use standardized tools and definitions 4. Monitor the incidence of infections that may be related to care provided at the facility and act on the data and use information collected through surveillance to detect transmission of infectious agents in the facility. On 1/27/23 at 8:25 am, DON B provided Surveyor a copy of the facility's Infection Prevention and Control Program (IPCP) policy implemented on 10/20/22 that includes a section titled Surveillance that doesn't include surveillance for tracking the extent to which staff follow the facility's infection prevention and control policies and procedures. The IPCP policy includes a section titled Staff Education that notes, All staff shall receive training relevant to their specific roles and responsibilities, regarding the facility's IPCP, including policies and procedures related to their job function. All staff shall demonstrate competence in relevant infection control practices. Direct care staff shall demonstrate competence in resident care procedures established by our facility. On 1/30/23, at 11:30 AM, Surveyor interviewed Director of Nursing (DON)-B related to the facility's procedure for surveillance of staff adherence to infection prevention and control practices. DON-B stated currently the facility only completes hand washing audits of the staff but there is no tracking or trending of these audits or information (percentage or rate of staff adherence to these policies.) On 1/30/23, at 12:04 PM, DON-B informed Surveyor she has contracted staff in the building today to complete competency checks on staff related to changing or replacing a dislodged trach. DON-B stated prior to this the facility did not have staff competencies documented for reinserting or replacing trachs (tracheostomy tubes) in an emergency situation, but that will begin today. Facility staff did not follow facility infection prevention and control policies: Prevention of COVID-19 and improper use of PPE; On 1/26/23, the CDC COVID-19 Data Tracker noted Kenosha County had high community transmission. The CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic also known as CDC COVID-19 Healthcare Guidance notes, When SARS-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. On 1/26/23, 1/27/23 and 1/30/23, Surveyor observed signage on the left wall in the front lobby stating, Masks and eye protection must be worn. On 1/26/23 at 9:27 am, Surveyor observed Housekeeper O in the hallway near room [ROOM NUMBER] wearing a face mask that was below her nose. On 1/26/23 at 9:55 am, Surveyor observed LPN F in R2's room standing at the foot of the bed speaking with R2. LPN F pulled the mask down below her nose On 1/26/22 at 9:38 am, Surveyor observed Housekeeper P in the 2 South hallway wearing a face mask that was below her nose. On 1/27/23 at 2:38 pm, Surveyor observed LPN F while suctioning R1. LPN F's mask kept sliding down below her nose and LPN F had to keep pushing it up with her gloved hand. On 1/30/23, at 2:45 PM, Surveyor asked DON B about signage in the front lobby of the building stating masks and eye protection must be worn. DON-B stated the sign is for the staff. DON-B stated staff should be wearing masks and eye protection at all times. DON-B confirmed the sign was not meant for visitors. Aerosol-generating Procedures (AGP) and Enhanced Barrier Precautions: On 1/26/23 at 9:06 am, Surveyor observed LPN I who was wearing eye protection and a facemask suction R4's tracheostomy. LPN I was not wearing a gown or gloves. On 1/26/23 at 2:14 pm, Surveyor met with DON B and Regional Nurse Consultant G and requested facility policy for AGP. On 1/27/23 at 8:25 am, Surveyor reviewed the facility policy titled Aerosol Generating Procedures effective 9/26/22. The policy notes, Procedures that are believed to generate aerosols and droplets as a source of respiratory pathogens include .airway suction .HCWs (healthcare workers) caring for patients undergoing the aerosol generating procedures are at higher risk of contracting the diseases compared to HCWs caring for patients not undergoing these procedures . In a single room, when possible, with a minimum of personnel present; using the most qualified personnel to perform the aerosol generating procedures Requiring the use of personal protective equipment, specifically facial mask, full waterproof gown, face shield or goggles, and gloves. On 1/27/23 at 2:38 pm, Surveyor observed LPN F suction R1 who has a tracheostomy (trach) with copious secretions and is also on Enhanced Barrier Precautions. LPN F did not wear a gown and was wearing safety glasses with side protection instead of goggles or a face shield. While preparing to suction R1, LPN F donned clean gloves and proceeded to open a package of dressings, suction kit, and sterile gloves. LPN H donned a sterile glove over the dirty glove on her right hand. During this time, LPN F's facemask kept falling down below her nose and LPN F kept pushing it up with her left hand. LPN F removed her gloves after suctioning and wanted to sanitize her hands but was unable to do so as the container of hand wipes was empty. LPN F made no attempt to secure additional hand sanitizer wipes. LPN F donned clean gloves without performing hand hygiene and changed the trach dressing and towel around R1's trach as LPN F reported both were wet from secretions. Resident 2 - Enhanced Barrier Precautions (EBP) - On 1/27/23 and 1/30/23, Surveyor reviewed R2's record. R2's care plan noted R2 has a tracheostomy and feeding tube. Nurses Notes dated 1/22/23 noted R2 was admitted to the hospital with aspiration pneumonia. R2 returned to the facility on [DATE] and Nurses Notes noted .positive MRSA (Methicillin-resistant Staphylococcus aureus which is a multi-drug resistant organism (MDRO) in sputum. There is no indication in the record that R2 is on Enhanced Barrier Precautions despite the fact R2 has 2 indwelling medical devices, has MRSA in her sputum and lives on a unit with other residents who are infected with multi-drug resistant organisms. On 1/30/23 at 9:30 am, Surveyor spoke with LPN S about the number of residents with indwelling devices on the unit. LPN S pointed to a 4-column two-sided document that included Front Hall on one side and Back Hall on the other side as well as the room numbers, resident names, code status, and additional information for each resident. LPN S gave Surveyor a copy. The document identified eight other residents to be on Enhanced iso(isolation) on R2's hall but didn't include R2. On 1/30/23 at 2:41 pm, Surveyor spoke with DON and requested the rationale for why R2 was not on Enhanced Barrier Precautions. On 1/31/23 at 10:28 am, DON B provided Surveyor with the following information: Nurse lineup (document provided by LPN S) question regarding why R2 was not on there - the staff keep long term infections on that list that will never clear, chronic MDROs, not infections being actively treated. 24-hour report board with MRSA referenced. The 1/30/23 Report noted that R2 was being treated with the antibiotic Linezolid for MRSA in R2's sputum. Surveyor asked DON B for the rationale to require a physician order to place residents on Enhanced Barrier Precautions (EBP) as the facility's Enhanced Barrier Precautions (EBP) Policy implemented 12/23/22 states nursing staff may place residents with certain conditions or devices on EBP empirically while awaiting physician orders and an order will be obtained for EBP for residents with any of the following; - wounds, indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO - Infection or colonization with any resistant organisms . On 1/31/23 at 12:04 pm, DON B provided Surveyor with the following information. Corporate is back today and the policy she has does not state that we need an order. Our corporate is in the middle of building our policy and procedures and has a more updated one .

Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards of food service safety. This had the potential to affect 81 of 106 residents who receive food prepared by the facility kitchen. -Kitchen staff were not consistently checking dishwashing machine temperatures or parts per million of the sanitizing solution in the low temperature chemical sanitizing dishwashing machine. Therefore, staff were not ensuring the kitchenware was properly sanitized. On 1/26/23, the sanitizing test strips did not change colors to indicate the level of sanitizing solution present in the dishwashing machine because the sanitizer injector line was clogged. Failure to have systems in place to ensure wash and rinse temperatures and chemical sanitization levels were being monitored for proper sanitization of dishes and utensils for a population vulnerable to foodborne illness, and with a likelihood that at some point an infection could spread, created a finding of Immediate Jeopardy. The Immediate Jeopardy began on 1/23/23 and was removed on 1/27/23 when the sanitizing solution pump was replaced. On 2/1/23, at 1:14 PM Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed of the Immediate Jeopardy. This deficient practice continues at a scope and severity level of F (potential for harm/widespread) as the facility continues to monitor the effectiveness of their removal of the immediate jeopardy. Findings include: The Wisconsin State Food Code defines a highly susceptible population as: persons who are more likely than other people in the general population to experience food borne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care as .hospital or nursing home. (Agriculture, Trade and Consumer Protection, (ATCP) 75 Appendix, Register July 2020 No. 775. Published under s 35.93) According to the 2013 Food and Drug Administration (FDA) Food Code, Most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort or lost time from the job. For some, especially preschool age children, older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. Complications typically occur because of the effects of dehydration. According to Why a Dish Needs to Hit 160 Degrees to Really be Clean, Because most bacteria are killed at temperatures between 140 -150 , 160 is considered a safe industry standard to assure a dish or utensil has been properly sanitized. Common bacteria that may be spread include: Norovirus is a common bacteria which is easy to contract and quite contagious . Salmonella is perhaps the best known of bacterial infections and is present on many raw foods. Although cooking removes the bacteria assuming the inner portion of the food reaches a temperature of 150 , any utensils or surfaces used to prep the food remains infected. Listeria can be a particularly dangerous bacteria as it is able to grow even in refrigeration. Poisoning via Listeria typically resembles a mild flu condition but can be lethal for small children or the elderly. Staphylococcus aureus (S. aureus) is the typical bacterial variant in foods which are prepared after cooking, such as salads, especially the mayonnaise varieties such as potato or chicken salad. Preventing an outbreak requires diligent hand washing before and after handling each component of the recipe along with proper refrigeration of the food and of course, cleaning the dishes used during storage and serving. Clostridium botulinim, commonly known as botulism, is one of the rarer bacteria but is more likely to be a fatal infection rather than causing simple stomach problems for a few days. It's important to properly sanitize everything used for [NAME] foods and boil the food well before serving after the seal is broken. https://paperthermometer.com/blogs/posts/why-a-dish-needs-to-hit-160-degrees-to-really-be-clean. Surveyor reviewed the facility's policy entitled, Dishwasher Temperature, dated 1/16/2023, which documents: Policy: It is the policy of this facility to ensure dishes are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Compliance Guidelines: 1 All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacturer's instructions shall be followed for machine washing and sanitization. 4. For low temperature dishwashers (chemical sanitization): a. The wash temperature shall be 120 F (Fahrenheit). b. The sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface at final rinse. 5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded. 6. Water temperatures shall be measured and recorded prior to each meal and/or after the dishwasher has been emptied or refilled for cleaning purposes. On 1/19/23, the County Health Department in which the facility is located was notified of a Legionella positive urine antigen test (collected on 1/18/23) from R1, who resides at the facility. A lower respiratory specimen was collected from R1 and the hospital laboratory agreed to send the specimen to the Wisconsin State Laboratory of Hygiene for Legionella culture. R1 was noted to have not left the facility since August of 2022. Given that R1 has not left the facility since August 2022, the case meets the criteria for a presumptive healthcare-associated case of Legionella. On 1/23/23, the facility implemented water restrictions. Although Legionella is not known to be transmitted via objects such as dishware, the facility failure to monitor wash and rinse temperatures and chemical sanitization and not properly sanitizing the dishes and utensils creates a likelihood an infection could spread. On 1/26/23, at 3:02 PM, Surveyor toured the kitchen area with Dietary Supervisor (DS)-E. DS-E informed Surveyor they were given approval to use the dishwashing machine because it uses a separate water tank than the rest of the facility. DS-E stated they were not sure who provided the permission. DS-E stated the only water being used in the kitchen was being run through the dishwashing machine. Surveyor asked DS-E to show Surveyor how the dishwashing machine works. DS-E told Surveyor the dishwashing machine was a low temperature machine. DS-E confirmed with Surveyor the sanitization was proved by chemical. Surveyor asked DS-E to test the chemical sanitization that would typically be tested . DS-E took a test strip and put it into the water circulating at the side of the dishwashing machine. DS-E showed Surveyor the test strip and there was no color indicating the chemical sanitization level at PPM. DS-E confirmed the test strip should read at 50 ppm when properly sanitized and it is possible DS-E kinked the hose leading from the sanitizing solution bucket to the dishwashing machine when they showed Surveyor how the system works. DS-E stated they would shut the machine down and restart it to see if it resets the system. DS-E and Surveyor toured the rest of the kitchen area to observe the other water sources were off. DS-E then took Surveyor back to the dishwashing machine, ran the machine through another wash and rinse cycle testing the chemical sanitization level with a test strip. The test strip again did not change color indicating no chemical sanitization had taken place. DS-E informed the dietary staff to stop using the dishwashing machine and they would call to have it repaired. On 1/26/23, at 3:17 PM, Surveyor reviewed the facility's Low Temperature Dish Machine Temperature Log. The instructions on the log are documented as: Record the wash temp (temperature) (*F) (Fahrenheit), rinse temp. (*F) and the sanitization level (ppm) (Parts Per Million) of the dish machine before washing dishes for each meal. If the levels are out of acceptable range, do not wash dishes and notify supervisor. Manufacturer Guidelines: Wash Temperature (*F) 120-140 Rinse Temperature (*F) 120-140 Sanitizer Level (ppm): 50ppm Chlorine. Surveyor noted no temperatures were documented for the wash and rinse and no sanitization levels were documented for: 1/16/23: breakfast and lunch 1/17/23: breakfast, lunch, and dinner 1/18/23: breakfast, lunch, and dinner 1/19/23: breakfast, lunch, and dinner 1/20/23: breakfast, lunch, and dinner 1/23/23: lunch 1/24/23: lunch 1/25/23: breakfast, lunch, and dinner 1/26/23: breakfast and lunch On 1/27/23, at 9:24 AM, Surveyor observed Cook-R running the dishwashing machine. Cook-R informed Surveyor the dishwashing machine was a low temperature rinse with chemical sanitization machine. Cook-R demonstrated for Surveyor how the dishwashing machine worked. Surveyor asked if Cook-R had taken the temperature of the wash and rinse cycle and tested the level of the chemical sanitization yet today. Cook-R stated they had and showed Surveyor the temperature log sheet which documented a wash temperature of 120 F, rinse temperature of 140 F, and 50 mmp of sanitizing solution. Cook-R agreed to take the temperature of the dishwashing machine and chemical saturation level to allow Surveyor to observe. Surveyor observed Cook-R push a rack of dirty dishes into the dish machine, run the wash and rinse cycle, and test the sanitizing solution concentration. The wash temperature was 120 F, the rinse temperature was 140 F, and the sanitizing solution was at 50 mmp. Cook-R stated if the dishwashing machine was not testing to the requirements, she would seek out the Dietary Manager. On 1/27/23, at 4:00 PM, Surveyor met with Director of Nursing (DON)-B and Corporate Educator-R to inform them of the concern of staff not recording temperatures for the wash and rinse cycle and the chemical sanitization level of the dishwashing machine as well as Surveyor's observation of the chemical sanitization level not being evident when tested on [DATE] with Dietary Supervisor-E. DON-B informed Surveyor the chemical sanitization line had a clog in it and it was replaced last night and the dishwashing machine is working correctly today. On 1/30/23, at 3:16 PM, Surveyor interviewed Dietary Supervisor (DS)-E, who stated she expects staff to test the dishwashing machine temperatures and sanitization level at the beginning of each shift. DS-E states they believe the staff are following this requirement but forgetting to write down the observed temperatures and sanitization levels. DS-E stated they will be completing training with all staff to remind them to write down temperatures when they take them. DS-E stated there was a clog in the line taking the chemicals for sanitization to the dishwashing machine. DS-E stated this was identified the evening of 1/26/23 and has since been corrected. On 1/30/21, at 2:45 PM, DON-B, Corporate Nurse Consultant-G, and Corporate Educator-R were informed of the above concern. The facility removed the Immediate Jeopardy on 1/27/23 when: on 1/27/23, at 9:24 AM, Surveyor observed the dishwashing machine test at the correct temperature and PPM. DON-B had stated the line that brings chemical sanitizing liquid to dishwashing machine had been clogged and not allowing sanitizer to enter the dishwasher and the pump was replaced the evening of 1/26/23.

Based on interview and record review, the facility did not ensure all residents residing at the facility had appropriate advanced directive forms included in the residents' medical record according to the residents' and/or representatives' wishes for 4 of 6 (R1, R2, R3, R5) residents reviewed for advanced directives. *On [DATE] at approximately 9:00 AM, R1 was experiencing a change in condition. Facility staff contacted 911 as R1 continued to decline. A code blue was paged overhead and facility staff responded. R1 was assessed by facility staff to have slow, apneic breaths and eventually R1 stopped breathing and was absent of vital signs. Licensed Practical Nurse (LPN) I confirmed R1 was a Do Not Resuscitate (DNR) by checking the facility charting system and R1's hard chart. When EMS (Emergency Medical Services) arrived, staff informed EMS R1 was a DNR. EMS requested appropriate DNR paperwork to verify code status. Facility staff provided EMS with R1's Resident Code Status form, signed by R1's Power of Attorney (POA) on [DATE]; this documented that R1 is a DNR. EMS noted this form was not signed by R1's Physician. EMS then started Cardiopulmonary Resuscitation (CPR) due to R1's Resident Code Status form not being signed by R1's Physician. While attempting to intubate R1, EMS located an obstruction in R1's mouth/throat and quickly removed it. CPR continued on R1. Facility staff provided EMS with a second form, Emergency Care Do Not Resuscitate Order (DNR) signed by R1's Physician, dated [DATE], however this form was not signed by R1's activated Health Care Power of Attorney (POA.) EMS continued CPR due to the incomplete forms. EMS contacted their Medical Control and described the incomplete forms and was informed that CPR could be discontinued. Surveyors' record review and interview revealed that R1's DNR forms provided to EMS upon request were incomplete and did not include the appropriate signatures required. As a result of the incomplete DNR forms, EMS performed CPR on R1 against R1 and R1's POA's wishes. Additionally, the facility does not have a complete and comprehensive system in place to ensure advance directives are accurately executed with all appropriate signatures, that they are correctly maintained in the residents' medical record, and readily retrievable. *R2's advanced directive form included in the medical record did not include R2's physician signature. *R3's advanced directive form included in the medical record did not include R3's physician signature and did not include R3's legal representative signature. *R5's advanced directive form included in the paper medical record did not match R5's code status documented in R5's computer based medical record. The facility's failure to ensure R1's advanced directive was accurately completed, to include all of the necessary signatures, the facility's failure to honor R1's advanced directive to refuse CPR, and the failure of the facility to have a system in place to execute advanced directives and to honor residents' wishes for residents including R2, R3, and R5 in addition to R1 created a finding on immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A of the finding of immediate jeopardy on [DATE] at 10:34 am. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement and monitor the effectiveness of their action plan. Findings include: The facility policy, entitled CPR-Cardiopulmonary Resuscitation Guideline, without an effective and revised date states (in part .): .It is the practice this facility will provide basic life support, including CPR-Cardiopulmonary Resuscitation, when a resident requires such emergency care during a witness or unwitnessed event, prior to the arrival of emergency medical services, subject to physician order and resident choice. To provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), prior to the arrival of emergency medical personnel in accordance with related physician's orders, and the advance directives. .Facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services: in accordance with the resident's advanced directives and any related physician's order, such as code status, or in the absence of advanced directives or DNR order. 1. Surveyors investigated a facility self-reported incident dated [DATE] involving R1. The facility's self-report investigation indicated on [DATE] at 9:15 am, a Certified Nursing Assistant (CNA) (O) was assisting R1 with breakfast while R1 was in bed. R1 was noted to be having a change in condition and the CNA stopped feeding R1 while the other CNA went to get a nurse. The nurse came back and assessed R1, a suction machine and oxygen were obtained. R1 was noted to have gurgling and respirations and mottling of legs and arms. 911 was called and R1 continued to decline and stopped breathing before Emergency Medical Services (EMS) arrived. EMS began to intubate R1 while waiting for DNR (Do Not Resuscitate) paperwork. The EMS report referencing [DATE] documented, in part, that the call was for a man who was choking and unknown if breathing Upon entry to the second-floor staff met us in hallway and explained that the pt. (patient) was believed to be choking and was not breathing. We were advised the pt. was a DNR (Do Not Resuscitate) by staff. Staff was asked to produce the paperwork as we assessed the pt. situation. Pt found supine in bed and not breathing. Food could be seen in the mouth; we positioned the airway for assessment and pads were placed on the pt. CMAC was used to visualize airway for possible obstruction and to clear the airway. Obstruction was found and quickly removed. No pulse was present and a valid DNR was not presented .CPR was initiated, airway was patent .DNR paperwork provided had no DR signature, CPR was continued .Crews were told by staff that the manager (sic) office might have a valid copy .staff then produced a DNR form with a Dr signature, new form had pt. name but the pt. signature line was blank .Medical control was advised and MD P advised that the DNR should be upheld and resuscitation efforts discontinued .M1 and E3 crews advised the staff of the importance of keeping records available, up to date, and complete to respect pt's last wishes. The EMS report documents EMS responders were dispatched on [DATE] at 9:12 AM, arrived at the facility at 9:15 AM, and were at R1 at 9:19 AM. The EMS report documents CPR was started at 9:23 AM and continued to at least 9:24 AM. Surveyor reviewed a Notice of Removal of a Human Corpse from a Hospital/Nursing Home/Hospice form signed by LPN D and the Funeral Home dated [DATE] located in R1's medical record. The date and time of death was [DATE] 09:15 am. On [DATE] at 2:19 pm, Surveyor interviewed Certified Nursing Assistant (CNA) O via telephone who stated she was feeding R1 breakfast on [DATE] and noticed R1 had mottling. CNA O indicated R1 was assessed by the RN. When the paramedics arrived, CNA O moved out of the room due to not enough space. CNA O stated the paramedics were looking for paperwork, so they started CPR. They (the facility) had paperwork but that was after CPR was started. They did not have when the paramedics arrived to the room. On [DATE] at 8:00 AM, Surveyor interviewed LPN I. LPN I reported they were taking care of R1 on [DATE]. LPN I reported that R1 was recovering from COVID. LPN I reported that CNA H came to get LPN I to assess R1. LPN I reported that upon assessment R1 had mottling on R1's legs. LPN I reported that RN G assessed R1 and agreed with LPN I's assessment. LPN I reported that as RN G and LPN I were developing a plan on what to do next, R1 started coughing. LPN I reported that suction and oxygen were obtained, and RN G and LPN I suctioned R1. LPN I reported that a quick discussion into whether 911 should be called took place and 911 was called. LPN I reported that they did not believe R1 was choking because R1 was still breathing during this time. LPN I reported that R1 did have gaps between breaths and then took one last breath. LPN I reported they verified that R1 was a DNR by checking in the facility charting system and looking in R1's hard chart. LPN I reported they checked the Resident Code Status form in R1's hard chart that documented R1 was a No code or DNR. LPN I reported they did not look at whether the form was signed at the bottom or was completed, just that No Code was circled at the top of the form. LPN I reported once EMS arrived, they started CPR because EMS reported to the facility staff that R1's Code Status form was missing needed signatures. LPN I reported they believed Director of Nursing (DON) B provided EMS with R1's DNR forms. DON B was not in the facility during survey resulting in Surveyor being unable to interview DON B. On [DATE] at 1:35 PM, Surveyor interviewed Registered Nurse (RN) G. RN G reported that they are not that familiar with R1. RN G reported that on [DATE], Licensed Practical Nurse (LPN) I came to her and requested RN G assess R1. RN G reported they assessed R1 to have mottling on R1's legs and hands. RN G reported that while discussing with LPN I on next steps, R1 started to have some congestion. RN G reported that the suction machine and oxygen were obtained for R1. RN G reported RN G and LPN I were suctioning R1 and there was no food in R1's mouth. RN G reported that R1 was starting to get pale. RN G reported that a code blue was called over head to get more help in the room. RN G reported that they believed RN Manager J and Director of Nursing (DON) B were in the room when Emergency Medical Services (EMS) arrived. RN G reported that they did not observe the material that was removed from R1's mouth/throat. RN G reported that LPN I was responsible for getting the DNR forms for R1. On [DATE] at 8:00 AM, Surveyor interviewed RN Manager J who reported they are familiar with R1. RN Manager J reported during the morning on [DATE], they heard an overhead page for a code blue. RN Manager J reported when they arrived in R1's room, RN G and LPN I had finished suctioning R1. RN Manager J reported they noticed mottling on R1's legs from R1's toes to R1's knees. RN Manager J described mottling as purple blotchy discoloration in the skin. RN Manager J reported upon assessment R1 was absent of vital signs when RN Manager J got to R1's room. RN Manager J reported that from there, it was confirmed R1 was a DNR. RN Manager J reported that R1's code status was checked in the computer charting system ribbon at the top of R1's chart and the physician's orders. RN Manager J reported that CPR was not started by the facility due to R1 being a DNR. RN Manager J reported they are not aware when EMS was called and who called EMS. RN Manager J reported that that they did observe the obstruction that was found in R1's throat but did not recognize the item. RN Manager J reported that the current facility policy regarding what forms to complete for residents' code status is that both Resident Code Status and Emergency Care Do Not Resuscitate Order (DNR) forms need to be completed when a resident is a DNR. RN Manager J reported that there was staff training on code status and that code status forms need to be completed and that it needs to be completed by nursing staff. On [DATE] at 12:21 PM, Surveyor interviewed Physician K. Physician K reported that they reviewed the situation with R1 through feedback provided to him by the facility and informed Surveyor that he believed a large cardiac event was the cause of death. Physician K stated EMS finding the obstruction in R1's throat was more of an incidental finding. Physician K reported to Surveyor that the odds it (the obstruction) being related (to R1's cause of death) are slim. Physician K reported that they believe EMS enforces the DNR forms based on location and it is not the same across different locations. Surveyor asked if the facility discussed R1's DNR forms missing the appropriate signatures with Physician K who reported that the facility did go over the DNR forms with Physician K but is unable to remember the specifics of the forms. Physician K reported they believed the facility started CPR training but is not aware of specific details of the training. Physician K asked Surveyor if there is a requirement that the facility use 2 separate code status forms. Surveyor reviewed R1's medical record and noted the following: R1 was admitted to the facility on [DATE] with diagnoses that include dysphagia, anxiety disorder, and dementia with behavioral disturbance. R1's Quarterly MDS (Minimum Data Set) assessment, dated [DATE], documents a BIMS (Brief Interview for Mental Status) score of 0, indicating R1 is severely cognitively impaired for daily decision making. Section B (Hearing, Speech, and Vision) documents R1 is sometimes able to make themselves understood and is sometimes able to understand others. Section G (Functional Status) documents R1 requires extensive assistance of two plus person physical assist with bed mobility and limited assistance of one personal physical assist for eating. R1 had an activated Power of Attorney for Health Care (POA) as of [DATE]. R1's care plan, initiated [DATE], documented R1 and their responsible party have elected Do Not Resuscitate (DNR) Status. The care planned interventions section documents to review code status at quarterly care conferences and as needed, maintain R1's chart to include order and notation of code status, hospitalize R1 for acute status changes and send for tests and treatment, ensure R1's comfort, and update physician if responsible party elects a code status change as indicated by change in condition/treatment of R1's preference. R1's Physician's Order, with an order date of [DATE], documented R1 was a DNR. On [DATE] at 1:35 PM, Surveyor was provided with copies of R1's DNR forms Resident Code Status and Emergency Care Do Not Resuscitate Order (DNR) forms from Corporate Educator C. Corporate Educator C reported that the Emergency Care Do Not Resuscitate Order form was not signed by the POA and reported that it is possible that the POA didn't know that both forms needed to be signed. R1's Resident Code Status form that was provided to Surveyor by the facility documented R1 was a No Code or DNR. Surveyor noted R1's POA signed R1's code status form on [DATE], Surveyor noted this is 6 days after the date of the physician order in the record indicating DNR status. Surveyor also noted that the provided form was not complete as it did not include a Physician signature. R1's Emergency Care Do Not Resuscitate Order form that was provided to Surveyor by the facility documented R1 was a DNR. Surveyor noted R1's physician signed R1's DNR form on [DATE] and that R1's DNR form was not complete as it did not include R1's POA signature. Surveyor noted on the bottom of R1's DNR form, The above signatures and dates are required on this order to be valid and its intent carried out. On [DATE] at 1:06 PM, Surveyor shared concerns regarding R1 with Nursing Home Administrator (NHA) A and Corporate Educator C. Surveyor shared that the facility was unable to provide EMS with completed DNR forms for R1 including appropriate signatures on [DATE], resulting in R1 receiving CPR against R1 and R1's POA's wishes. 03357 On [DATE], the facility provided surveyors with an Orders Listing Report which documented the code status of each of the residents in the facility. The facility also provided Surveyor with a copy of the facility's CPR-Cardiopulmonary Resuscitation Guideline. On this guideline, there is no listed effective date, nor revised date. On [DATE], Physician K reviewed the policy. The CPR guideline's purpose includes: to provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), prior to the arrival of emergency medical personnel in accordance with related physicians' orders, and the advance directives. The guideline also defines a Code Status as the level of medical interventions a person wishes to have started if their heart or breathing stops. A Do Not Resuscitate (DNR) Order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence of an advance directive does not imply that a resident has a DNR order. The medical record should show evidence of documented discussions leading to a DNR order. Surveyor noted the CPR-Cardiopulmonary Resuscitation Guideline does not reference the two Advance Directives forms utilized by the facility to identify resident code status. The CPR guideline does not provide a procedure as to how the two types of Advanced Directive forms the facility uses are to be processed. On [DATE] at 11:00 am, Surveyor interviewed LPN Unit Manager D who works on the dementia unit. LPN D reported in regard to advanced directives, she would look in the electronic medical record in the header area. LPN D stated once there is a physician's order in the system, the header area will automatically reflect the physician's order for code status. If a Resident is DNR she would then look in the hard chart to confirm that the state form (Emergency Care Do Not Resuscitate Order form) was there. LPN D also stated we also have a more basic form used on admission (Resident Code Status) and then the State form (Emergency Care Do Not Resuscitate Order form) which is on blue paper. Those who are full code do not get the State form (Emergency Care Do Not Resuscitate Order form), they just get the standard (Resident Code Status) form which the nurse on the unit is responsible for signature. Surveyor reviewed both forms. The first form the facility utilizes is a Resident Code Status form, which verifies code status protocol (CPR/Full code or No Code/DNR) for each resident. This form has a Resident/Legal Representative and a witness dated signature line for both the full code and the no code sections. This form also has an area for Physician Certification with a physician signature line. This form is placed under the Advance Directives tab in resident hard charts. The second form the facility has begun to implement since [DATE] is the Emergency Care Do Not Resuscitate Order (DNR). This form is the Department of Health Services (DHS), Division of Public Health (DPH) form: F-44763. The Emergency Care Do Not Resuscitate Order (DNR) form states it cannot be used to communicate wishes to Responders. The form further states it is a legal document and is used to request a DNR bracelet by the attending health care professional on behalf of the patient/resident. According to LPN D, once signed by a resident/their legal representative and the physician, this form is copied blue and placed in the front of each hard chart. Only residents with No Code status are to receive this form in their hard chart. In addition, on each resident electronic record, the code status is designated in the ribbon/heading of each resident chart. This status is derived from physician's orders, also recorded in the Orders section of the electronic record. According to the Wisconsin (Wis.) Statutes (Stat.) Chapter 154 Advance Directives denotes the following: 154.19 Do-not-resuscitate order. (1) No person except an attending health care professional may issue a do-not-resuscitate order. An attending health care professional may issue a do-not-resuscitate order to a patient only if all of the following apply: (a) The patient is a qualified patient. (b) Except as provided in s. 154.225 (2), the patient requests the order. (bm) Except as provided in s. 154.225 (2), the patient consents to the order after being provided the information specified in sub. (2) (a). (c) The order is in writing. (d) Except as provided in s. 154.225 (2), the patient signs the order. (e) The health care professional does not know the patient to be pregnant. (2) (a) The attending health care professional, or a person directed by the attending health care professional, shall provide the patient with written information about the resuscitation procedures that the patient has chosen to forego and the methods by which the patient may revoke the do-not-resuscitate order. (b) After providing the information under par. (a), the attending health care professional, or the person directed by the attending health care professional, shall document in the patient's medical record the medical condition that qualifies the patient for the do-not-resuscitate order, shall make the order in writing and shall do one of the following, as requested by the qualified patient: 1. Affix to the wrist of the patient a do-not-resuscitate bracelet that meets the specifications established under s. 154.27 (1). 2. Provide an order form from a commercial vendor approved by the department under s. 154.27 (2) to permit the patient to order a do-not-resuscitate bracelet from the commercial vendor. (3) (a) Except as provided in par. (b), emergency medical services practitioners, as defined in s. 256.01 (5), emergency medical responders, as defined in s. 256.01 (4p), and emergency health care facilities personnel shall follow do-not-resuscitate orders. The procedures used in following a do-not-resuscitate order shall be in accordance with any procedures established by the department by rule. (b) Paragraph (a) does not apply under any of the following conditions: 1. The order is revoked under s. 154.21 or 154.225 (2). 2. The do-not-resuscitate bracelet appears to have been tampered with or removed Surveyor reviewed the following residents who were identified on the facility's Orders Listing Report provided to Surveyors on [DATE] as having a No Code advanced directive status. 2. R2 was initially admitted to facility on [DATE]. On [DATE], Surveyor reviewed R2's hard paper medical chart and found the most recent Resident Code Status form, dated [DATE]; this form did not have the physician's signature. There was also no Emergency Care Do Not Resuscitate Order (DNR) form in the hard chart. On [DATE], Surveyor was provided a Resident Code Status form dated [DATE], which denoted R2's code status as a DNR, with accompanying guardian and physician signatures. Physician's signature was not dated. On [DATE] at 2:20pm, Surveyor reviewed R2's hard chart and was not able to locate the Resident Code Status form dated [DATE]. In the hard chart remained Resident Code Status form dated [DATE] with no physician signature. 3. R3 was admitted to facility on [DATE]. On [DATE] at 10:51am, Surveyor interviewed Licensed Practical Nurse (LPN) D, who reported the process of checking a resident's code status. LPN D pulled up R3's electronic record, and the ribbon/header stated R3 was a CPR (Full) code. Surveyor previously reviewed the Order Listing Report provided to Surveyor earlier on [DATE] and noted R3 was listed as having No Code (DNR) status. LPN D reported the facility is waiting for R3's legal representative to come to the facility to sign the Resident Code Status form. Surveyor checked R3's hard paper medical chart and no Resident Code Status form was found. On [DATE], the facility provided surveyor with R3's Resident Code Status form, written by LPN D, reporting the confirmation of R3's code status was now back to DNR. There were no signatures of R3, R3's legal representative, nor physician on this form. On [DATE], at 2:15pm, Surveyor observed R3's electronic record and found the header/ribbon stated R3 had a DNR code status. 4. R5 was admitted to facility on [DATE]. On [DATE] at 10:53am, Surveyor found no Resident Code Status form in R5's hard paper medical chart. Surveyor spoke with LPN D, who verbalized R5 is now a CPR (Full) code due to R5's previous guardian passing away, and the facility does not have an updated Resident Code Status form signed by R5's new guardian. LPN D entered R5's electronic record; the ribbon/header denoted R5 is now a CPR (Full) code. LPN D reported a chart audit for Resident Code Status forms was performed by Medical Records E around the end of November or beginning of [DATE], and they are trying to work on getting forms for all residents with legal representative and physician signatures. On [DATE] at 1:01pm, Surveyor interviewed Medical Records E. Medical Records E reported they began performing chart audits for DNR status the beginning of December or late November, 2022. Medical Records E stated they were told to just do it and was not sure what prompted the audits. Medical Records E was stated she was working on the State Emergency Care Do Not Resuscitate Order forms and would need to double check when the facility started using this form. Medical Records E stated she had a few more audits to do as she was working on the DNR audits first and then the full code audits. Medical Records E could not provide Surveyor with specific information as to how many more DNR forms she still needed to have completed. Medical Records E reported attempting to get signatures where only verbal authorization is noted on Resident Code Status forms. Medical Records E stated she did not know when she sent forms out for signature. Medical Records E reports understanding the Emergency Care Do Not Resuscitate Order (DNR) trumps the Resident Code Status form. On [DATE] at 8:00am, Surveyor interviewed Registered Nurse (RN) J. RN J reported believing the current procedure for documenting resident code status is using both the blue (Emergency Care Do Not Resuscitate Order DNR) and white (Resident Code Status) forms. RN J reported it is the responsibility of licensed nursing department to determine the Resident Code Status forms are completed. On [DATE] at 12:05pm, Surveyor interviewed Social Worker (SW) F. SW F reported not being responsible for completing Advance Directives Emergency Care Do Not Resuscitate Order DNR, and Resident Code Status forms. SW F reported Medical Records-E has been assisting with completing the necessary Advance Directive forms. On [DATE] at 2:40 pm, Surveyor met with Administrator A and Corporate Educator C regarding the facility use of the Emergency Care Do Not Resuscitate Order DNR state form. Corporate Educator C stated the facility started using this form for all residents who wanted a DNR. Code status audits were completed on [DATE] confirming everyone's preferences. Then the facility got the phone number and addresses to send out the forms for signature after [DATE]. Surveyor indicated the Emergency Care Do Not Resuscitate Order DNR state form is to be used to request a DNR bracelet. Surveyor asked what the procedure is for the use of the bracelet that is to go along with this form. Administrator A and Corporate Educator C indicated the facility was not quite there yet with the bracelets. On [DATE], Administrator A provided Surveyor with the following facility actions after R1's incident on [DATE]. On [DATE] an AD Hoc QAPI meeting was held. The agenda for this meeting included: 1. Review of incident 2. Review of food consistency order and food provided 3. Review of code status policy and procedure 4. Chart review 5. Review of choking policy, s/sx of choking, Heimlich maneuver 6. Possible causes of incident 7. Review of educations conducted. Additional information included: Steps taken after incident: 1. Reviewed all diets for matching between PCC and kitchen (not an identified issue in incident). 2. Reviewed recipes for meals served that am (not identified as an issue. 3. Looked at food that resident was eating prior to incident by DON and Therapy director (not an issue.) 4. Education on food and fluid textures (not identified as an issue.) 5. Examined wipe for descriptive features and compared to ones in facility. 6. Foreign body policy and procedure reviewed with ad hoc 7. Education on choking s/sx and Heimlich maneuver initiated 8. Mock choking code completed [DATE] 9. Review of CPR policy with ad hoc 10. Validated all code status orders were in system (initiated state form). 11. Audit of breakfast on [DATE] for correct altered consistency (no issue noted.) 12. Audit of facility for removal of environmental items completed ,d+[DATE] and ,d+[DATE] 13. Education on storage of non-food items safely. 14. Maintenance to get locked cabinets for shower rooms and personal resident non-food items. 15. Review of chart and incident with medical director/primary MD. Along with this information were lists of employee signatures on the above education received pertaining to Storing of personal resident items and items not meant for consumption, food and fluid texture, choking, staff choking quiz, staff competency of Heimlich Maneuver, all dated [DATE]. The information provided included a picture of the wipe type material removed from R1's airway, a code blue drill dated [DATE], the CPR policy not dated however was signed by the Medical Director/MD K on [DATE], the Foreign Body Airway Obstruction and Management (Choking) guideline not dated but was signed by the Medical Director/MD K on [DATE]. Although this information was provided, the facility's failure to ensure R1's advanced directive was accurately completed, to include all of the necessary signatures, the failure of the facility to honor R1's advanced directive to refuse CPR, and the failure of the facility to have a system in place to execute advanced directives and to honor residents' wishes created a finding on immediate jeopardy that began on [DATE]. The IJ was removed on [DATE] when the facility implemented the following: * Resident records were reviewed to determine code status was elected by the resident and/or resident representative and an order received by the physician. * The review confirmed documentation is secure inside the medical record. * On [DATE] the facility reviewed the policy and procedure for Communication of Code Status Policy. Together with the QAPI team, modifications were made and approved. * Staff education was conducted prior to next schedule shift regarding the F578 regulation, Facility policies on Communication of Code Status and Proper completion of CPR election form. * The Director of Nursing/Designee will conduct audits weekly X 30 days. Results of the audits will be reviewed at the QAPI meeting for further recommendations. Audits will include: Presence of Code Status election forms Signatures by residents and/or resident representatives Signatures of physician on the form Code Status election forms with signatures are filed under the Advanced Directive tab in the Medical Record. * The Facility Assessment will be updated to the policy on Communication of Code Status.

Based on observation, interview, and record review, the facility did not ensure 1 (R1) of 1 resident's reviewed received adequate supervision and assistive devices to prevent accidents. R1 had a known history of ingesting foreign objects such as napkins, dietary slips, and feces. R1 was known to like doing things with his hands and in the past has been known to break his brief or would try to take his brief off. Although R1 was known to ingest foreign objects and to try to remove his brief, the facility did not assess this behavior to identify a root cause analysis for this behavior. The facility did not care plan for this behavior to ensure all staff were aware of R1's tendency to put items in his mouth and did not identify or provide the supervision necessary to ensure R1 did not have access to such items as to not ingest them. On [DATE] at 9:15 am, during breakfast, R1 started gurgling with respirations and had mottling of the arms and legs. 911 was called and R1 continued to decline. Suctioning and oxygen was provided however R1 stopped breathing before Emergency Medical Service (EMS) arrived. EMS was having difficulty intubating R1 and removed what appeared to be a wipe from R1's airway. EMS started Cardiac Pulmonary Resuscitation (CPR) however, CPR was discontinued and R1 was pronounced deceased on [DATE] at 9:15 am. The facility's failure to assess R1's behavior of putting foreign objects in his mouth, not conducting a root cause analysis of this behavior, and the failure to care plan to ensure all staff were aware of R1's tendency to put items in his mouth including not identifying the supervision and services necessary to ensure R1 did not have access to such items as to not ingest them, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A of the finding of immediate jeopardy on [DATE] at 10:34 am. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor the effectiveness of their action plan. Findings include: The facility policy entitled Foreign Body Airway Obstruction and Management (Choking) Guideline, without an effective and revised date states (in part .): Purpose: To provide guidance on both the identification of airway obstruction and intervention to remove obstruction. The application of emergency first aide in response to airway obstruction is applied and followed regardless of code status. This emergency response applies to both full code and do not resuscitate election status. Definitions: Airway obstruction: Can occur anywhere from the pharynx to the bronchi .Also, the degree of obstruction is important as a partial obstruction will still allow passage of air and may provide additional time before the patient becomes hypoxic. Spasm and edema result from airway obstruction and becomes more severe as time passes. Simultaneously the patient's efforts to expel the object decrease over time . .Guideline . If the obstruction is mild and the resident is coughing forcefully, there is no reason to intervene: spontaneous coughing and breathing typically relieve the obstruction. If severe obstruction develops, an immediate intervention is required to relieve the obstruction .Intervention required include administration of abdominal thrusts; also referred to as the Heimlich Maneuver. .A complete airway obstruction will result in respiratory failure if not recognized and treated early. Sudden onset of respiratory distress accompanied by coughing, stridor, wheezing, or gagging warrants emergent action and such illicia high suspicion for foreign body airway obstruction . Surveyors investigated a facility self-report investigation dated [DATE] involving R1. The facility's self-report investigation indicated on [DATE] at 9:15 am, a Certified Nursing Assistant (CNA) was assisting R1 with breakfast while R1 was in bed. The CNA questioned another CNA about what was going on with R1. The CNA stopped feeding R1 while the other CNA went to get a nurse. The nurse came back and assessed R1, a suction machine and oxygen were obtained. R1 was noted to have gurgling and respirations and mottling of legs and arms. 911 was called and R1 continued to decline and stopped breathing before Emergency Medical Service (EMS) arrived. EMS began to intubate R1 while waiting for DNR (Do Not Resuscitate) paperwork. EMS was having difficulty intubating and pulled what appeared to be a cloth wipe from R1's throat. The facility's investigation included staff interviews and a verification of investigation. This included a summary documenting in part, review of the circumstances and clinical presentation was discussed with the resident's physician who felt that a large cardiac event was more likely to be the cause of death based on the presentation. Resident physician felt that the discovery of a wipe (found by EMS in R1's airway) was more of an incidental finding instead of the cause of death as it would be impossible for audible breathing and full exchange of air to be heard if the wipe were in his throat or mouth. In addition to the facility's self-report, Surveyor had a copy of the Kenosha EMS report for [DATE]. The Kenosha EMS report documented: Call Type (referring to what was called in): Choking Primary impression (upon EMS impression upon arrival to R1): Choking. Cardiac Arrest: No. Cardiac Arrest Etiology: Not applicable. The EMS report documented, in part, that the call was for a man who was choking and unknown if breathing Upon entry to the second-floor staff met us in hallway and explained that the pt. (patient) was believed to be choking and was not breathing. We were advised the pt. was a DNR (Do Not Resuscitate) by staff. Staff was asked to produce the paperwork as we assessed the pt. situation. Pt found supine in bed and not breathing. Food could be seen in the mouth; we positioned the airway for assessment and pads were placed on the pt. CMAC was used to visualize airway for possible obstruction and to clear the airway. Obstruction was found and quickly removed. No pulse was present and a valid DNR was not presented .CPR was initiated, airway was patent .DNR paperwork provided had no DR signature, CPR was continued .Crews were told by staff that the manager (sic) office might have a valid copy .staff then produced a DNR form with a Dr signature, new form had pt. name but the pt. signature line was blank .Medical control was advised and MD P advised that the DNR should be upheld and resuscitation efforts discontinued . The EMS report also indicates: PSAP (public safety answering point): [DATE] 9:09:54 Disp (dispatch) Notified: [DATE] 9:12:00 Unit Disp: [DATE] 9:12:00 Enroute: [DATE] 9:12:13 At Scene: [DATE] 9:15:52 At Patient: [DATE] 9:19:16 In Service: [DATE]: 9:42:06 Surveyor reviewed a Notice of Removal of a Human Corpse from a Hospital/Nursing Home/Hospice form signed by LPN D and the Funeral Home dated [DATE] located in R1's medical record. The date and time of death was [DATE] 09:15 am On [DATE] at 8:55 am, Surveyor interviewed CNA T who worked second shift on [DATE] and who took care of R1. CNA T stated R1 liked to stay in bed. CNA T reported when he did get up, he liked to play with puzzles. CNA T stated R1 liked to do things with his hands. CNA T stated R1 did not put things in his mouth. CNA T stated last time she saw R1 was around 8pm ([DATE]). CNA T stated the next day she heard the news he passed away saying, when I took care of him, he said thank you. CNA T stated, I changed his brief, he was wet using washcloths to clean him up, changed linens at that time. CNA T stated his brief was not torn when she changed him however sometimes he would break his brief but not that evening. CNA T stated he always wanted something in his hands. I remember sometimes he would try to take it off (referring to his brief.) CNA T stated she did not assist him with eating the evening prior, never saw anything in his mouth. When I fed him, I would always take the napkin and the dietary slip off and put in the garbage. There was no specific reason for CNA T stated they just do this for everyone she assists with feeding. On [DATE] at 2:19 pm, Surveyor interviewed CNA O who reported while serving R1 breakfast, she noticed R1's legs appeared to be mottling. CNA O stated R1 had eaten about ,d+[DATE] cups of food and that's it. CNA O stated she stopped feeding R1 when she noticed the mottling, called for her coworker (CNA H) and in turn the LPN and then RN came to assess R1. Paramedics came and there was not enough space, so she moved out of the room. CNA O stated the paramedics started CPR as the facility looked for the CPR paperwork. On [DATE] at 2:49 PM, Surveyor interviewed CNA H who stated she was familiar with R1. CNA H reported she remembered that R1 ate feces in the past and that when staff were to serve R1 their tray, all items like napkins had to be taken off the tray. CNA H reported that CNA O asked CNA H to come look at R1. CNA H reported they looked at R1's legs and saw mottling. CNA H stated she left to go get LPN I. CNA H reported that while LPN I and RN G were assessing R1, R1 starting coughing. LPN I and RN G used a suction machine to try to get whatever they thought R1 had in R1's mouth. CNA H reported that when EMS arrived, CNA H went to the hallway because there were too many people in R1's room. On [DATE] at 8:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN) I who reported they were taking care of R1 on [DATE]. LPN I reported R1 was recovering from COVID. LPN I reported that CNA H came to get LPN I to assess R1. LPN I reported upon assessment R1 had mottling on R1's legs. LPN I reported that RN G assessed R1 also and agreed with LPN I's assessment. LPN I reported that as RN G and LPN I were developing a plan on what to do next, R1 started coughing. LPN I reported that suction and oxygen were obtained, and RN G and LPN I suctioned R1. LPN I reported that a quick discussion into whether 911 should be called took place and 911 was called. LPN I reported that they did not believe R1 was choking because R1 was still breathing during this time. LPN I reported that R1 did have gaps between breaths and then took one last breath. LPN I reported they verified R1 was a DNR by checking in the facility charting system and looking in R1's hard chart. LPN I reported that they checked the Resident Code Status form in R1's hard chart that documented R1 was a No code or DNR but did not look at signatures. LPN I reported that once EMS arrived, they started CPR because EMS reported to the facility staff that R1's Code Status form was missing needed signatures. (Cross-reference F578). Surveyor asked LPN I if they were aware of any instance of R1 putting nonfood items in R1's mouth. LPN I reported to Surveyor that R1 would put napkins in their mouth once or twice that they were aware of. LPN I reported that napkins were supposed to be taken off R1's tray to try to prevent R1 from putting nonfood items in R1's mouth. On [DATE] at 1:35 PM, Surveyor interviewed Registered Nurse (RN) G who reported she is not that familiar with R1. RN G reported that Licensed Practical Nurse (LPN) I came to her and requested RN G assess R1. RN G reported they assessed R1 to have mottling on R1's legs and hands. RN G reported while discussing with LPN I on next steps, R1 started to have some congestion. RN G reported the suction machine and oxygen were obtained for R1. RN G reported she (RN G) and LPN I were suctioning R1 and there was no food in R1's mouth. RN G reported R1 was starting to get pale. RN G reported that a code blue was called over head to get more help in the room. RN G reported they believed RN Manager J and Director of Nursing (DON) B were in the room when Emergency Medical Services (EMS) arrived. RN G reported that they did not observe the material that was removed from R1's mouth/throat. On [DATE] at 8:00 AM, Surveyor interviewed RN Manager J who reported being familiar with R1. RN Manager J stated that during the morning on [DATE], they heard an overhead page for a code blue. RN Manager J reported when they arrived in R1's room, RN G and LPN I had finished suctioning R1. RN Manager J reported she noticed mottling on R1's legs from R1's toes to R1's knees. RN Manager J described the mottling as purple blotchy discoloration in the skin. RN Manager J reported upon assessment R1 was absent of vital signs when RN Manager J got to R1's room. RN Manager J reported from there, it was confirmed R1 was a Do Not Resuscitate (DNR). RN Manager J reported R1's code status was checked in the computer charting system and the physician's orders. RN Manager J reported they are not aware when Emergency Medical Services (EMS) was called or who called EMS. RN Manager J reported she observed the obstruction that was found in R1's throat but did not recognize the item. On [DATE] at 12:21 PM, Surveyor interviewed Physician K. Physician K reported that they reviewed the situation with R1 through feedback provided to him by the facility. Physician K reported to Surveyor that he believed a large cardiac event was the cause of death and EMS finding the obstruction in R1's throat was more of an incidental finding. Physician K reported to Surveyor that the odds it (the obstruction) being related (to R1's cause of death) are slim. Surveyor asked Physician K if they were aware of R1's behavior of eating nonfood items such as napkins and feces. Physician K reported they were aware of the incidents of R1 eating nonfood items. On [DATE] at 8:44 am, Surveyor interviewed LPN U who works the 2 North (dementia) unit working 3 days a week. This is the unit R1 resided on. LPN U stated she has been here since March and heard the facility is a no wipe facility meaning the facility uses wash clothes versus wipes. LPN U stated she was familiar with R1 stating, he did put things in his mouth. LPN U stated any time I worked I would move napkins, dietary's paper slip because he would put them in his mouth and chew it. A few times he's ripped his brief apart. LPN U stated she did not see the material that had been removed from R1's throat, when she returned back to work, she heard what happened. LPN U stated, I believe it was care planned to get the napkins off his tray. On [DATE] at 12:00 pm, CNA V informed Surveyors that Social Worker F spoke to her while she was on 2 South, asking if any residents put things in their mouth. CNA V stated, I don't know what it was however she heard it could have been him ripping his brief and ate it or a wipe. On [DATE] at 10:43am, Surveyor interviewed Certified Nursing Assistant (CNA) M who reported most of the residents on the unit (2 North dementia care) require set-up to consume meals. CNA M reported there are some residents who require staff assistance for eating. CNA M reported the unit does not use (incontinence) wipes now and that when wipes were used, they were gone after a couple days. CNA M reported wipes were small in shape, flushable, and stored in supply room on the unit. CNA M reported using washcloths for resident cares. CNA M reports never providing cares for R1. On [DATE] at 10:30am, surveyor interviewed Housekeeper L. Housekeeper L reported housekeeping does not usually use sanitizing wipes in the facility. Housekeeper L reported housekeeping sprays multi-surface cleaning agent on rags for cleanup and sanitizing purposes. Housekeeper L reports housekeeping does not use wipes of any kind for cleansing/sanitizing. On [DATE] at 10:50am, Surveyor found a concave shaped fibrous piece of cloth on the floor in R3's room. On [DATE] at 10:51am, surveyor interviewed Housekeeper N. Housekeeper N reported the cloth came off a brief. On [DATE] at 3:15 PM, Surveyor interviewed Administrator A and Corporate Educator C. Corporate Educator C reported there was an instance that R1 ate feces in the past, but they were not aware of R1 eating other nonfood items. Corporate Educator C reported that the object found in R1's mouth/throat looked like a wipe which was disposed of by the facility due to it becoming moldy. Corporate Educator C stated the facility took a picture of the wipe and compared it to the other wipes used in the facility and determined the wipe was not a wipe the facility uses. Corporate Educator C stated they also reviewed the food to see if it was the appropriate diet and consistency. On [DATE] at 2:40 pm, Administrator A stated he did not have a dietary ticket for [DATE] however provided Surveyors with a dietary ticket for R1 dated [DATE] which documented Floor staff remove any type of paper (Napkin, meal ticket) from tray before serving. On [DATE] at 12:00 pm, Surveyor reviewed the EMS video showing on [DATE] CPR was being administered to R1. The video also showed an almost fluffy, white material in R1's airway that was removed by EMS. Surveyor reviewed R1's medical record which indicated in part: R1 was admitted to the facility on [DATE] with diagnoses that include dysphagia, anxiety disorder, and dementia with behavioral disturbance. R1's hospital discharge summary prior to being admitted to the facility documented R1 required wrist restraints and required staff to be with R1 at all times due to aggression towards staff. R1's Quarterly MDS (Minimum Data Set) assessment, dated [DATE], documents a BIMS (Brief Interview for Mental Status) score of 0, indicating R1 is severely cognitively impaired for daily decision making. Section B (Hearing, Speech, and Vision) documents R1 is sometimes able to make themselves understood and is sometimes able to understand others. Section G (Functional Status) documents R1 requires extensive assistance of two plus person physical assist with bed mobility and limited assistance of one personal physical assist for eating. Section H (Bowel and Bladder) documents R1 is always incontinent of bowel and bladder. R1's care plan, initiated [DATE], documents that R1 has an activities of daily living (ADL) self-care deficit. The intervention section, dated [DATE], documents R1 requires total assistance with meals. R1s progress notes reflect in part: R1's Nurse's Note, dated [DATE], documented (R1) was noted eating own feces, writer and CNA assisted with cleaning up resident as he was soiled with urine and feces. Resident began to swing on staff and was redirected. R1's Nurse's Note, dated [DATE], documented, MD updated on recent events. Call out to psych, awaiting response. [DATE] 11:21 AM Nurses note: Writer approached by CNA with request to assess resident's lower extremities. Upon assessment, resident presented with mottling to both lower extremities .Writer requested RN from 2S assess resident. RN agreed with writer's findings. While in the room, resident began coughing. Writer sat him up in bed and staff encouraged him to continue coughing. While staff continued to encourage him to cough, writer retrieved a suction machine and RN retrieved tubes to device. Then returned to room where resident continued to cough. Staff hooked up suction device and began to suction resident. 911 contacted as situation progressed. At this point, it appeared that there was no food left in his mouth. Writer now able to hear gurgling from resident and continued to suction resident for possible secretions. No squeaking or [NAME] noted with respirations. Resident did not appear to be choking. Resident's respirations and heart rate began to decrease, and resident began having apnic episodes every several seconds, so RN retrieved oxygen machine to bring to room, but respirations and heart rate ceased before she returned. MD pronounced time of death and POA notified. LPN I. [DATE] 11:58 Social Services Note Text: Writer spoke with family regarding funeral home preference. They did not have any prearrangements but preferred (name) funeral home in Union Grove, WI. Writer along with family spoke with (name) funeral home, they were provided information requested. Wife and family were satisfied. Funeral home will be picking Resident up today. Wife/family had no other questions or concerns. Thanked facility for taking care of Resident. SW F Surveyor was provided with R1's speech therapy notes and psychiatric services notes. Surveyor noted there was no documentation regarding R1 putting nonfood items such as feces or napkins in R1's mouth. Surveyor reviewed R1's care plan and noted the care plan did not address R1's behaviors of placing feces and napkins in his mouth nor did it address any behavior of picking at/tearing or playing with their brief. Surveyor noted there is no monitoring of R1 for such behaviors. Surveyor noted there is no monitoring to include how often R1 was displaying behaviors of putting items into his mouth or identifying what the items were. Surveyor noted there were no interventions in R1's care plan to prevent R1 from putting nonfood items in his mouth to ensure R1's safety and wellbeing. There are no interventions identified in R1's care plan as to the supervision needed to ensure R1 would not place nonfood items in his mouth. Surveyor reviewed R1's Certified Nursing Assistant (CNA) Kardex dated [DATE]. The CNA Kardex tells CNAs working in the facility how to take care of R1. The CNA Kardex did not address that R1 displays behaviors of placing feces, napkins, and paper in his mouth or picking at/tearing or playing with his brief. The CNA Kardex does not document any supervision and monitoring for such behaviors to ensure the safety of R1. The CNA Kardex does not document the frequency of how often R1 is displaying placing nonfood items in R1's mouth and what they may be. Surveyor reviewed R1's physician's orders which did not address R1 placing nonfood items in R1's mouth. R1's physician's orders did not address that R1 displays behaviors of placing feces, napkins, and paper in mouth and does not document any supervision and/or monitoring for R1 regarding such behaviors. On [DATE] at 2:40 PM, Nursing Home Administrator (NHA) A provided Surveyor with a copy of R1's meal ticket, with a date of [DATE], that documented Floor staff remove any type of paper (Napkin, meal ticket) from tray before serving. On [DATE] at 12:00, Surveyors observed the process of the noon meal tray delivery on the 2 North unit. Surveyors observed the CNAs take the trays from the cart and deliver the trays to the resident rooms. The trays are set on the over bed table in front of residents. The CNAs then return to the tray cart and continue delivering trays. When the trays have been delivered, Surveyors observed the CNAs return to the resident rooms to assist with the meal. Surveyors noted the placing of the tray in front of the resident prior to assisting the resident with their meals allows time for a resident to touch items on their tray. Surveyor noted this practice of leaving a tray in front of a resident could pose to be a safety risk for a resident who may be prone to placing items in their mouth if left unsupervised. Administrator A provided Surveyor with the following facility actions after R1's incident on [DATE]. On [DATE] an AD Hoc QAPI meeting was held. The agenda for this meeting included: 1. Review of incident 2. Review of food consistency order and food provided 3. Review of code status policy and procedure 4. Chart review 5. Review of choking policy, s/sx of choking, Heimlich maneuver 6. Possible causes of incident 7. Review of educations conducted. Additional information included: Steps taken after incident: 1. Reviewed all diets for matching between PCC and kitchen (not an identified issue in incident). 2. Reviewed recipes for meals served that am (not identified as an issue.) 3. Looked at food that resident was eating prior to incident by DON and Therapy director (not an issue.) 4. Education on food and fluid textures (not identified as an issue.) 5. Examined wipe for descriptive features and compared to ones in facility. 6. Foreign body policy and procedure reviewed with ad hoc 7. Education on choking s/sx and Heimlich maneuver initiated 8. Mock choking code completed [DATE] 9. Review of CPR policy with ad hoc 10. Validated all code status orders were in system (initiated state form.) 11. Audit of breakfast on [DATE] for correct altered consistency (no issue noted.) 12. Audit of facility for removal of environmental items completed ,d+[DATE] and ,d+[DATE] 13. Education on storage of non-food items safely. 14. Maintenance to get locked cabinets for shower rooms and personal resident non-food items. 15. Review of chart and incident with medical director/primary MD. Along with this information were lists of employee signatures on the above education received pertaining to Storing of personal resident items and items not meant for consumption, food and fluid texture, choking, staff choking quiz, and staff competency of Heimlich Maneuver, all dated [DATE]. The information provided included a picture of the wipe type material removed from R1's airway, a code blue drill dated [DATE], the CPR policy not dated however was signed by the Medical Director/MD K on [DATE], the Foreign Body Airway Obstruction and Management (Choking) guideline not dated but was signed by the Medical Director/MD K on [DATE]. Although this information was provided, on [DATE] at 1:06 PM, Surveyor shared concerns regarding R1 with Nursing Home Administrator (NHA) A and Corporate Educator C. Surveyor shared interviews with facility staff revealed R1 was known to place nonfood items like napkins and feces in their mouth and play with their brief. R1 did not have a care plan or interventions for these behaviors. R1's medical record does not include a root cause analysis as to why R1 was placing nonfood items in his mouth. R1's medical record/care plan does not include any monitoring for this behavior. There is no indication as to the frequency for this behavior, no ongoing identification as to what types of items R1 was placing in his mouth, and no indication of the supervision necessary to prevent R1 from placing nonfood items in his mouth There are no interventions as to what staff should do to prevent R1 from placing nonfood items in his mouth to provide for a safe environment, other than the meal ticket provided to surveyors with a date of [DATE] for floor staff to remove any type of paper (Napkin, meal ticket) from tray before serving. R1 had a known history of ingesting foreign objects such as napkins, dietary slip, and feces however the facility did not assess this behavior to identify a root cause analysis for this behavior. The facility did not care plan for this behavior to ensure all staff were aware of R1's tendency to put items in his mouth and did not identify or provide the supervision necessary to ensure R1 did not have access to such items as to not ingest them, which lead to a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility implemented the following: * Records of all residents on every unit were reviewed to determine if there is a known history of ingesting foreign objects. * Residents with a known history of ingesting foreign objects will have an assessment of this behavior with documentation of the assessment including an individualized plan of care for the behavior that will include determined supervision. * On [DATE], the Facility policy on Accidents and Supervision was reviewed and was modified to include identifying residents with known history or observation of consuming foreign objects * Licensed Nursing Staff were educated on the facility policy regarding, Accidents and Supervision and identifying residents with known history or observation of consuming foreign objects. * Licensed Nursing Staff were educated on conducting and documenting an assessment of the behavior, including a root cause analysis, to determine individualized causal factors to make changes to prevent future accidents. Developing an individualized plan of care including a plan for supervision. * Unlicensed Nursing Staff to be educated on facility policy, Accidents and Supervision and identifying residents with known history or observation of consuming foreign objects: Education included reporting to the nurse immediately any known or unknown history, attempts or consumptions of foreign objects. * The Director of Nursing / designee will conduct daily audits to ensure all required components are in place. Results of these audits will be reviewed at the Quality Assurance Performance Improvement (QAPI) meeting for further recommendations. * The Facility assessment will be reviewed and updated to reflect behaviors of ingesting foreign objects and revised process.

Based on observation, record review, and interview, the facility did not ensure interventions were implemented to prevent the development of pressure injuries and the physician and resident representative were not notified in a timely manner of a new pressure injury for 5 (R39, R67, R130, R46, and R61) of 6 residents reviewed for pressure injuries. * R39 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R39 developed two Stage 2 pressure injuries to the right and left inner buttocks on 2/27/2022. Wound Physician-N determined on 3/2/2022 that the two Stage 2 pressure injuries identified on 2/27/2022 had merged to become one Stage 3 pressure injury to the perineum and advised the nursing staff to obtain a pressure reducing cushion for the Broda chair. Surveyor noted 3/2/2022 was the first comprehensive assessment of R39's wound, three days after the development of the pressure injury on 2/27/22. R39 did not have a Care Plan that addressed the type of chair R39 was to use when gotten out of bed. R39 did not have a Care Plan that indicated how often or how long R39 should be up in the Broda chair. R39 did not have documentation of an assessment that a Broda chair would provide appropriate offloading with R39's history of pressure injuries. The Registered Dietician was not notified of the impaired skin integrity. * On 12/30/21 R67 was found to have an abrasion on her left hip. The area was cleaned and border dressings were applied to protect the skin. No assessment and documentation about the wounds were made until 1/4/22 at which time, the wound was assessed as Pressure, unstageable 7 cm by 19 cm. 80 percent slough 20 percent granulation (Stage 3) and R67's physician was contacted. R67's physician guardian were not contacted timely. No treatment was on the Treatment Administration Record (TAR) until 1/5/22 when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] * R130, R46, and R61 were observed to not have their heels floated. Findings: The facility policy and procedure entitled, Prevention of Pressure Ulcers/Injuries dated 7/2017 states: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Conduct a comprehensive skin assessment upon admission, including: a. Skin integrity . b. Tissue tolerance . c. Areas of impaired circulation due to pressure from positioning or medical devices. 3. Use a screening tool to determine if resident is at risk for under-nutrition or malnutrition. 4. Inspect the skin on a daily basis when performing or assisting with personal care of ADLs (Activities of Daily Living). a. Identify any signs of developing pressure injuries (i.e., nonblanchable [CONDITION(S)]),. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Prevention: . Mobility/Repositioning: 1. Choose a frequency for repositioning based on the resident's mobility, the support surface in use, skin condition and tolerance, and the resident's stated preferences. 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. 5. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based the resident's mobility, continence, skin moisture and prefusion, body size, weight, and overall risk factors. Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. 1. R39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's Comprehensive Admission Minimum Data Set (MDS) assessment dated [DATE] coded R39 as being completely dependent for all activities of daily living, including bed mobility, and received all nutrition through a gastrostomy tube and supplemental oxygen through a [CONDITION(S)]. R39 has a Guardian. R39 had a Stage 4 pressure injury to the coccyx/sacrum that healed on 10/27/2021. R39's Impaired Skin Integrity Care Plan was initiated on 10/22/2021 and had the following interventions in place on 2/27/2022: -Treatments as ordered -Wound Physician-N to assess and treat -Assist to reposition approximately every 2-3 hours and as needed -Barrier cream after each incontinent episode and as needed -Free float heels in bed using pillows -Lotion skin with cares -Weekly skin assessment -Specialty Air Mattress: pressure alternating; monitor for inflation every shift -Monitor skin with all cares; report any changes to nurse -Update physician as needed -OK for Hoyer pad to be left under R39 when up in wheelchair -Keep nails short to reduce risk of scratching or injury from picking at skin -Refer to therapy as needed On 2/27/2022 at 10:01 PM in the progress notes, nursing charted R39 had an open area to the right and left buttock. Zinc and [MEDICATION(S)] was applied to the area. On 2/27/2022 on the Initial Wound Assessment form, nursing documented R39 had a Stage 2 pressure injury to the left inner buttock that measured 2.0 cm x 3.0 cm x 0.2 cm. No description of the wound bed was charted. The wound had moderate serosanguineous drainage. The form indicated the bed had a pressure reduction/redistribution mattress, turning and repositioning was being done, and the wound had a treatment or application of a dressing. The form did not indicate the chair had a pressure reduction/redistribution cushion. The Nurse Practitioner was notified. The form did not document the responsible party had been notified. On 2/27/2022 on the Initial Wound Assessment form, nursing documented R39 had a Stage 2 pressure injury to the right inner buttock that measured 2.0 cm x 3.0 cm x 0.2 cm. No description of the wound bed was charted. The wound did not have any drainage. The form indicated the bed had a pressure reduction/redistribution mattress, the chair had a pressure reduction/redistribution cushion, turning and repositioning was being done, positioning/splinting devices were used, and the wound had a treatment or application of a dressing. The Nurse Practitioner was notified. The form did not document the responsible party had been notified. On 2/27/2022 a treatment order was obtained to cleanse the open areas to the left and right inner buttocks with normal saline, pat dry, apply zinc followed by and adhesive foam dressing to both areas daily and as needed. The treatment order was not signed out as completed on the Treatment Administration Record on 2/28/2022. The Impaired Skin Integrity Care Plan was not revised to address the two new pressure injuries. R39 received all nutrition through a gastrostomy tube and no documentation was found that Registered Dietician-P was notified of the new pressure injuries. On 3/2/2022 at 9:54 AM, Surveyor observed R39's wound assessment and treatment completed by Wound Physician-N with the assistance of Registered Nurse (RN)-C and Certified Nursing Assistant (CNA)-O. R39 was observed to be in bed with the head of the bed elevated at approximately 30 degrees. An alternating pressure air mattress was in place and heel boots were on both feet. Wound Physician-N stated R39 had been followed by Wound Physician-N for other pressure injuries that have healed, and this was the first time seeing R39 in a long time. Wound Physician-N stated this was the first time observing the new pressure injuries. Surveyor observed CNA-O roll R39 onto the left side. R39 was very stiff and clenched the buttocks making it difficult for RN-C to access the pressure injuries. Surveyor observed an open area to the inner right buttock that measured approximately 2 cm x 2 cm with bright red tissue in the wound bed and an open area to the inner left buttock that measured approximately 2 cm x 2 cm with bright red tissue in the wound bed. Wound Physician-N assessed the wound and changed the treatment to silver alginate twice daily to the wounds with no adhesive dressing. Wound Physician-N stated the dressing would stay in place on its own due to R39's stiffness and clenching of the buttocks. Wound Physician-N looked at the Broda chair in R39's room and touched the seat of the chair. Wound Physician-N asked if R39 sat in the Broda chair at all or if R39 stayed in bed. RN-C stated R39 did not get up out of bed. CNA-O corrected RN-C by stating R39 just recently started on a schedule that R39 sits in the chair for a couple hours a day. No cushion was observed in the Broda chair. Wound Physician-N stated a cushion needed to be put in the chair to reduce pressure. Surveyor asked CNA-O how often R39 was up in the chair. CNA-O stated R39 gets up on a schedule posted at the nurses' station. CNA-O stated R39 gets up two to three times a week for two hours at a time. Surveyor asked CNA-O if R39 had a cushion in the chair previously. CNA-O stated R39 did not have a cushion, but stated Wound Physician-N said to get a cushion as Wound Physician-N was leaving so it will be in the chair next time R39 gets up. On 3/2/2022 on the Weekly Wound Assessment form, RN-C documented R39 had a Stage 3 pressure injury to the perineum that measured 1.4 cm x 2.8 cm x 0.1 cm with 80% granulation, 5% eschar, and 10% epithelial tissue. The comment section stated R39 was seen by the wound physician and per the wound physician the wound is a Stage 3 wound and the site is at the perineum. The wound measured as one wound and not two separate wounds as noted on the initial wound assessments. Surveyor noted 3/2/2022 was the first comprehensive assessment of R39's wound, three days after the development of the pressure injury on 2/27/22. On 3/2/2022 on Wound Physician-N's wound documentation in the notes section, it states a cushion is to be anchored to the Broda chair. R39's Impaired Skin Integrity Care Plan was revised on 3/2/2022 with the following interventions: -Gel cushion in Broda chair. (may use foam cushion until Gel cushion arrives.) -OK to see in house wound physician Surveyor reviewed R39's comprehensive care plan. R39 did not have a Care Plan that addressed the type of chair R39 was to use when gotten out of bed. R39 did not have a Care Plan that indicated how often or how long R39 should be up in the Broda chair. R39 did not have documentation of an assessment that a Broda chair would provide appropriate offloading with R39's history of pressure injuries. In an interview on 3/3/2022 at 9:46 AM, Surveyor asked Registered Dietician (RD)-P how the nutritional needs for R39 were calculated. RD-P stated weights, labs, and the medical status are reviewed to know if the protein is sufficient to meet the needs to maintain good nutritional health. RD-P stated R39 gets all the nutrition through a gastrostomy tube. RD-P stated R39 had an ulcer in January, 2022 so protein was increased at that time. Surveyor asked RD-P if RD-P was notified of new pressure injuries on 2/27/2022. RD-P stated this was the first RD-P was hearing about the new pressure injuries. RD-P stated normally the facility staff would call to let RD-P know of any changes in condition. On 3/3/2022 at 10:07 AM, Surveyor observed R39 in bed. A cushion had been placed in R39's chair. In an interview on 3/3/2022 at 10:12 AM, RN-Q stated R39 is on a schedule to get up that is found at the nurses' station. Surveyor reviewed the schedule; R39 was scheduled to get up for two hours on Monday afternoon, Wednesday afternoon, and Saturday afternoon. In an interview on 3/3/2022 at 3:04 PM, Surveyor shared with Nursing Home Administrator-A, Director of Nursing-B, Corporate RN-G, and Corporate RN-H the concern R39 developed two Stage 2 pressure injuries to the right and left inner buttocks on 2/27/2022 with no documentation of the wound base and was then determined to be a Stage 3 pressure injury to the perineum by Wound Physician-N on 3/2/2020. R39 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Impaired Skin Integrity Care Plan was not revised until 3/2/2022 to put a cushion in the chair. The Registered Dietician was not notified of the new pressure injuries until Surveyor told RD-P about the pressure injuries. On 3/7/2022 at 10:50 AM, RN-C brought three statements from nursing staff indicating R39 had not been observed up in a Broda chair in the last month. Surveyor reviewed the statements. The three staff members that wrote the statements worked first shift only. R39 was scheduled to be up in the Broda chair on second shift and the first shift staff would not have observed activities on second shift. No further information was provided at that time. On 3/11/2022 at 4:32 PM, Corporate RN-H sent an email with the following statement from Wound Physician-N: I was made aware that there was an issue identified regarding offloading for (R39) while in his Broda chair. Manufacturer recommendations do not advise a cushion over a Broda as the design is touted not to 'bottom out'. In my experience this works on a case by case basis and in rare instances requires an additional cushion appropriately anchored to the chair to prevent falls. I believe that since this is one of those rare instances, that the facility adhered to standards of care with regards to no cushion on the Broda. Surveyor reviewed the statement and Wound Physician-N's statement indicated R39 using a Broda chair with a cushion was one of those rare instances. Wound Physician-N had recommended the use of a cushion in the Broda chair when R39 was assessed on 3/2/2022. Wound Physician-N comprehensively assessed R39. This was the first comprehensive assessment of R39's wound, three days after the development of the pressure injury. No assessment had been completed prior to the development of the pressure injury to determine if the Broda chair was appropriate for an individual with a history of Stage 4 pressure injuries. On 3/16/2022 at 9:27 AM, Corporate RN-H sent an email with the manufacturer's information regarding Comfort Tension Seating - Broda. The manufacturer states: Broda's proprietary Comfort Tension Seating conforms to the body, providing enhanced pressure redistribution and long-term seating comfort. Each strap conforms individually to the patients' body, thus suspending the weight of the patient across multiple points. Comfort Tension Seating works in conjunction with the tilt-in-space . seating system to provide therapeutic pressure relief, enhance postural support and maintain skin integrity. The seating base used in this system is a heavy gauge [MEDICATION(S)] chloride strapping installed under tension and riveted to the seating frame of the chair. With memory retention, the straps return to their original shape within seconds providing consistent seating comfort and pressure redistribution. Broda's special seat strapping allows air circulation to help reduce heat and moisture build-up. The straps adjust to the size and weight of the individual, providing an individualized fit and superior comfort. The system evenly distributes patent weight across multiple points, improving oxygenation and blood flow, aiding in the maintenance of skin integrity. Surveyor reviewed the information provided. The manufacturer's information did not address an individual with skin integrity concerns or wound management; it talked about pressure redistribution but not pressure offloading. From the Broda website (https://brodaseating.com/education/seating-positioning/comfort-tension-seating/), it states: For those who may require additional cushions for the purposes of wound care management, we recommend an assessment from a licensed clinician to choose the appropriate cushion and ensure that the user is properly positioned in their current wheelchair with the addition of the cushion. The Broda company reiterates an additional cushion may be required for wound care management and an assessment should be completed to determine the appropriate cushion is used. 2. R67 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/2/22 R67's progress notes dated 12/30/21 at 1:34 AM was reviewed and read: R67 was found to have an abrasion on her left hip. The two areas where top layer of skin was gone measured 9 centimeters (cm) by 2 cm and 3 cm by 1.5 cm. The area was cleaned and border dressings were applied to protect the skin. No documentation about the wounds were made until 1/4/22. On 3/2/22 R67's Weekly wound assessment written by Registered Nurse (RN)- C, who is the facility's wound nurse, was reviewed and read: Pressure, unstageable 7 cm by 19 cm. 80 percent slough 20 percent granulation. 2 areas noted on 12/30/21 as abrasions have merged into 1 wound. Area reclassified as a pressure wound. Will see house wound doctor. On 3/2/22 at 1:30 PM RN-C was interviewed and indicated she was first notified of R67's pressure injury on 1/4/22 and that is the first time she was aware the physician was contacted. On 3/1/22 R67's court appointed guardian was interviewed and indicated she was not notified of R67's pressure injury until the end of February 2022. On 3/1/22 R67's treatment administration record (TAR) was reviewed and no treatment was on the TAR until 1/5/22 when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/02/22 at 11:00 AM R 67's pressure injury to her left hip was observed with Wound Physician- N and measured 3.8 cm by 6.3 cm. Pressure injury stage 3. Wound Physician-N was interviewed and indicated the pressure injury looked like it was a result of shearing. On 3/02/22 at 3:01 PM Corporate RN -H was interviewed and indicated R67's physician was not notified of her pressure injury until 1/4/22 and should have been notified the same day it was discovered. The above findings were shared with the Administrator and Director of Nursing on 3/3/22 at 3:00 PM. Additional information was requested if available. None was provided. 3. R130 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & [CONDITION(S)], hypertension, and [CONDITION(S)]. The Braden assessment dated [DATE] has a score of 16 which indicates moderate risk. The Facility did not develop a baseline care plan for R130. On 2/28/22 at 10:48 a.m. Surveyor observed R130 in bed on his back wearing only an incontinence product. Surveyor observed R130's heels are not being offloaded. On 2/28/22 at 1:19 p.m. Surveyor observed R130 dressed for the day laying on his back in bed. Surveyor noted R130's heels are not being offloaded. On 2/28/22 at 2:27 p.m. Surveyor observed R130 continues to be in bed on his back. Surveyor observed R130's heels are resting directly on the mattress. On 3/1/22 at 8:13 a.m. Surveyor observed R130 in bed on his back with the head of the bed elevated. Surveyor observed R130's heels are not being offloaded. On 3/1/22 at 9:28 a.m. Surveyor observed R130 in bed on his back with CNA (Certified Nursing Assistant)-E in R130's room. Surveyor asked CNA-E if R130 has anything on his feet. CNA-E removed the sheet from R130's feet. Surveyor observed R130's feet are bare with his heels resting directly on the mattress. On 3/1/22 at 10:16 a.m. Surveyor observed CNA-E check R130's incontinence product and change the abdominal binder. After changing the abdominal binder, CNA-E asked R130 if he was comfortable and if he wanted to go on his side which R130 declined. CNA-E covered R130 with a sheet, raised the head of the bed and lowered the bed down. Surveyor observed CNA-E did not offload R130's heels and R130's heels are resting directly on the mattress. On 3/1/22 at 11:10 a.m. Surveyor observed R130 continues to be in bed on his back with R130's heels resting directly on the mattress. On 3/1/22 at 1:22 p.m. Surveyor observed R130 continues to be in bed on his back with R130's heels resting directly on the mattress. On 3/2/22 at 8:27 a.m. Surveyor observed R130 in bed on his back. R130's heels are resting directly on the mattress and the soles of his feet are pressing against the footboard. On 3/2/22 at 10:20 a.m. Surveyor observed R130 continues to be in bed on his back. R130's heels continue to be resting directly on the mattress and the soles of R130's feet are pressing against the footboard. On 3/2/22 at 1:02 p.m. Surveyor asked LPN (Licensed Practical Nurse)-D what staff are doing to prevent R130 from developing pressure injuries. LPN-D informed Surveyor staff reposition R130 when up in the wheelchair and when R130 is in bed he is repositioned every two hours. LPN-D informed Surveyor R130 has no restriction so he can go from back to either side. Surveyor inquired what is being done to prevent pressure injuries from developing on R130's heels. LPN-D informed Surveyor R130's heels could be floated and a pillow placed underneath to float the heels. Surveyor informed LPN-D of Surveyor's observations of R130's heels not being offloaded and the soles of R130's feet pressed against the footboard. LPN-D informed Surveyor she is going to get R130 boots. On 3/2/22 at 3:35 p.m. Administrator-A, DON (Director of Nursing)-B, Corporate RN (Registered Nurse)-G and Corporate RN-H were informed of the above. On 3/3/22 at 8:43 a.m. Surveyor observed R130 in bed on his back with the head of the bed slightly elevated. Surveyor asked R130 if he has anything on his feet. R130 informed Surveyor he believes so. Surveyor observed R130 is wearing bilateral pressure relieving boots. The nurses note dated 3/3/22 documents Heal boots in place. The Visual/Bedside Kardex report printed on 3/4/22 under the resident care section documents encourage to T & R (turn and reposition) every 2-3 hours and to float his heels when in bed. and encourage to wear heel boots to bilateral feet when in bed. 4. R46 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's Quarterly MDS (Minimum Data Set) dated 1/16/22 documents that R46 suffers from short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R46 has severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that R46 requires extensive assistance and a two person physical assist for his bed mobility needs. Section G also documents that R46 has total dependence on staff and requires a two person physical assist for his transfer needs. Section G0400 (Functional Limitation of Range of Motion) documents that R46 has no impairment to either side of her upper or lower extremities. Section M (Skin Conditions) documents that R46 has no unhealed pressure ulcers/injuries and that she is not at risk for the development of pressure injuries/ulcers. R46's Pressure Injury/Ulcer CAA (Care Area Assessment) dated 10/16/21, documents that R46 triggered for further assessment for the development of pressure injuries/ulcers, however the Analysis of Findings and Care Plan Considerations sections were left blank and provided no additional information. R46's Braden Scale for Predicting Pressure Ulcers assessment dated [DATE] documents a score of 14, indicating that R46 is at moderate risk for the development of pressure ulcers/injuries. R46's Skin Integrity care plan dated as initiated on 2/25/21 documents under the Interventions section, Float heels off bed with pillow when in bed as patient allows. On 2/28/22 at 9:48 a.m., Surveyor observed R46 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R46's heels were not floated to relieve pressure per R46's plan of care. On 2/28/22 at 3:03 p.m., Surveyor observed R46 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R46's heels were not floated to relieve pressure per R46's plan of care. On 3/1/22 at 8:14 a.m., Surveyor observed R46 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R46's heels were not floated to relieve pressure per R46's plan of care. On 3/1/22 at 10:49 a.m., Surveyor observed R46 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R46's heels were not floated to relieve pressure per R46's plan of care. On 3/1/22 at 2:01 p.m., Surveyor observed R46 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R46's heels were not floated to relieve pressure per R46's plan of care. On 3/2/22 at 8:11 a.m., Surveyor observed R46 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R46's heels were not floated to relieve pressure per R46's plan of care. On 3/2/22 at 11:58 a.m., Surveyor observed R46 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R46's heels were not floated to relieve pressure per R46's plan of care. On 3/2/22 at 1:27 p.m., Surveyor observed R46 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R46's heels were not floated to relieve pressure per R46's plan of care. On 3/2/22 at 3:46 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. On 3/3/22 at 12:54 p.m., Surveyor informed MDS RN (Registered Nurse)-L of the above findings. Surveyor asked MDS RN-L if R46 was at risk for the development of pressure injuries, as Section M of R46's Quarterly MDS dated [DATE] documented R46 was not at risk for the development of pressure injuries. MDS RN-L informed Surveyor that Section M was incorrect and that R46 was indeed at risk for the development of pressure injuries. No additional information was provided as to why the facility did not ensure that R46 had interventions in place to prevent the development of pressure injuries. 5. R61 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] & [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] Disease and Dependence on Wheelchair. R61's Annual MDS (Minimum Data Set) dated 2/6/22 documents that R61 suffers from short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R61 has severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that R61 requires extensive assistance and two person physical assist for his bed mobility needs. Section G also documents that R61 has total dependence on staff and requires a two person physical assist for his transfer needs. Section G0400 (Functional Limitation of Range of Motion) documents that R61 has impairment to one side of both his upper and lower extremities. Section M (Skin Conditions) documents that R61 is at risk for the development of pressure injuries and at the time of the assessment had no unhealed pressure injuries/ulcers. R61's Pressure Injury/Ulcer CAA (Care Area Assessment) dated 2/6/21, documents that R61 triggered for further assessment for the development of pressure injuries/ulcers, however the Analysis of Findings and Care Plan Considerations sections were left blank and provided no additional information. R61's Braden Scale for Predicting Pressure Ulcers assessment dated [DATE] documents a score of 14, indicating that R61 is at moderate risk for the development of pressure ulcers/injuries. R61's Skin Integrity care plan dated as initiated on 2/10/21 documents under the Interventions section, Heel boots on when in bed. On 2/28/22 at 9:40 a.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 2/28/22 at 12:34 p.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 2/28/22 at 3:09 p.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 3/1/22 at 8:13 a.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 3/1/22 at 9:24 a.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 3/1/22 at 10:49 a.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 3/1/22 at 2:01 p.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 3/1/22 at 2:01 p.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. Surveyor asked R61 if he had any issues wearing heel boots. R61 shook his head up and down and stated it was okay for him to have heel boots. On 3/2/22 at 8:12 a.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 3/2/22 at 11:58 a.m., Surveyor observed R61 laying supine in bed with both heels resting directly on the mattress. Surveyor noted that R61 was not wearing heel boots to offload pressure as documented in R61's plan of care. On 3/2/22 at 3:46 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. No additional information was provided as to why the facility did not ensure that R61 had interventions in place to prevent the development of pressure injuries.

Based on observation, interview and record review, the facility did not ensure that 3 (R63, R66, R130) of 7 residents reviewed received adequate supervision and assistance devices to prevent accidents. *R63 had 6 falls from 11/5/21 through 2/27/22. The facility's fall investigations for R63 were not thorough, fall prevention interventions were not implemented and care plan updated with fall prevention interventions timely to prevent R63's next fall. On 11/24/21, R63's fall resulted in a laceration requiring sutures. *R66 was observed to not have his call light within reach and reminders to ask for assistance signage in his room per plan of care fall interventions. *R130 is assessed to be at high risk for falls. R130's fall care plan includes an intervention to encourage resident to ask for assistance. R130 was observed to not have a call light in reach to ask for assistance if needed. R130 was also observed to not have a mat on the floor. Staff interviewed indicated R130 should have a mat on the floor on the right side of the bed and that R130's call light should be in reach. Findings include: The Facility's Falls and Fall Risk, Managing Policy, with a review date of March 2018, documents . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk. 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 1.) R63 was admitted to the facility on [DATE] with diagnoses that include acute embolism and [CONDITION(S)] of deep veins of lower bilateral extremities, mild protein-calorie malnutrition, anxiety disorder, attention and concentration deficit, depression, generalized muscle weakness, and [CONDITION(S)]. R63's Admission MDS (Minimum Data Set), with an assessment reference date of 10/29/21, documents: a BIMS (Brief Interview Mental Status) score of 15, which indicates R63 is cognitively intact for daily decision making. R63 is independent with bed mobility, transfers and toilet use. R63 ambulates in a wheelchair. No is coded as related to R63 having falls in the month prior to admission and within 2 to 6 months prior to admission. R63's fall CAA (Care Area Assessment), dated 10/29/21, is triggered for falls, but there is no analysis of findings documented in the admission MDS CAA section. On 10/22/21, R63's Facility Elopement Risk Review was completed with a score of 14, indicating R63 is at risk for elopement. R63's Fall care plan, created on 10/27/21, documents the following interventions: - Anticipate and meet the Resident's needs; -Encourage resident to ask for assistance; -Encourage the resident to wear appropriate footwear - gripper socks or non-slip shoes; -Fall assessment to be completed upon admission, after falls, quarterly, and PRN (As Needed); -Follow therapy recommendations for transfers and mobility; -Place call light within reach; -Review information on past falls and attempt to determine cause of falls; -Update MD (Medical Doctor) PRN. R63's Fall comprehensive care plan had the following interventions added: -11/5/21 Fall- Resident educated to report falls asap and to use call light to ask for assistance with transfers. Date created 11/18/21. -11/14/21 Fall - Resident was educated on the risk vs benefits of consuming alcohol and the potential for injury. Social services to follow up and offer AA. Date created 11/18/21. -11/24/21 Fall - Assist to bed when intoxicated and make sure bed in low position and remove all clutter in resident's room. Date created 12/9/21. -12/10/21 Fall - AA offer accepted, offered self lock brakes for wheelchair, resident decline. Aware of risks and benefits. Date created 12/23/21. -12/11/21 Fall - Staff educated to encourage indoor activities in the common room, maintenance checked sidewalks for hazards. Date created 1/3/22. -12/31/21 Fall - Redirect and encourage R63 to lay down in room while under consumption. Education provided to not self transfer without staff assist. Date created 1/21/22. -1/5/22 Incident - Resident was educated to not stick her hand into closing doors instead to push the elevator button again or ask for assistance. Date created 1/27/22. -2/27/22 Fall - Resident offered assistance with alcohol cessation which was declined. Educated on risks vs benefits she verbalizes understanding. Therapy to screen/eval for wheelchair mobility outdoors. Date created 3/2/22. R63's comprehensive care plan was updated on 11/26/21, to include a new focus on history of alcohol dependency related to depression and poor impulses with a goal of resident will refrain from using non-prescribed substances and/or alcohol through the next review date. The interventions are as follows: -Hold meds if appears to be drinking alcohol; -If you suspect resident has been using non-prescribed substances, notify supervisor immediately; -Offer AODA supportive services; -Offer psychiatric services; -Offer substance abuse resources; -Resident agreed to leave alcohol with nurse when she purchases it so that nursing can control. Date initiated 2/3/22; created on 2/8/22. Fall 1 On 11/5/21, R63's Medical Record documents: nurses note dated 11/5/21 at 1:11 PM: Resident reported to staff that she had fallen earlier today around 0600 (6:00 AM) and got herself back up without alerting staff. R63 decided to report this fall that occurred in her room now due to an increased pain to left hip/buttock. Writer assessed her and she is able to move leg, off-loading from left side in her wheelchair. Area to trochanter is swollen and some bruising is starting to area. Declined ice stated she is going outside and to activities. Back of head assessed since resident stated that she also bumped her head on the garbage can. No bump felt. Resident stated it is okay. Blood pressure 98/82, Pulse 104, R (respirations)18, SPO2 96% on room air. R63 stated the reason she fell is she lost her balance when getting out of bed. Neurochecks are negative. Doctor was updated on the fall. DON (Director of Nursing) aware of fall. X-ray ordered to left hip. The incident report dated 11/5/21, at 6:00 AM, under incident description for Nursing description documents Resident stated that she fell in room about 0600 on 11/5/21 and got herself back up without telling anyone. Resident decline writer to update any family. Under resident description documents She stated that she had got up from bed and was attempting to transfer to her wheelchair and lost her balance and fell on the floor, landing on her left hip/buttock and hit the back of her head on the garbage can. She stated she got herself back up by using the side of the bed and didn't want to tell anyone. Later she decided to report this to staff when hip started to hurt more. Notes were added on 11/8/21 indicating IDT (Interdisciplinary Team) met and discussed resident self reported fall from 11/5/21. The root cause of this fall was determined to be from resident not asking for assistance to transfer. Intervention: resident was educated that she needs to use her call light and ask for assistance to transfer. She voiced understanding. Resident was also educated that falls need to be reported right away and that she shouldn't get up before being assessed. The facility did not conduct a thorough investigation as there are no staff statements as to who or when R63 was seen, if prior fall prevention interventions were in place at the time of the fall and a new fall risk evaluation was not completed. R63's care plan was updated on 11/18/21 to include a new fall prevention intervention of: Resident educated to report falls asap (as soon as possible) and to use call light to ask for assistance with transfers. Fall 2 On 11/14/21, R63's Medical Record documents: nurses note dated 11/14/21, at 7:30 PM, Resident was found on Left side of body on elbow in another residents room. Resident denies hitting head. Resident is intoxicated, bottle of amersterdam 1/4 still left. Resident assisted back into wheelchair. Called and updated DON and also Dr. (doctor). Received orders to hold medications. RN (Registered Nurse) on that assigned floor aware that the resident had unwitnessed fall and neurocheck s and body check to be initiated. The incident report dated 11/14/21, at 7:00 PM, under incident description for nursing description documents Resident was found intoxicated, laying on her left side, on her left elbow. Resident was alone in room [xxx] which is not her room. Under resident description documents Resident reported she did not hit her head when she fell . Notes were added to the form stating IDT met and discussed resident unwitnessed fall while intoxicated. No injuries were noted. The root cause of this fall was determined to be from resident being intoxicated. Resident was educated on the risks and benefits of consuming alcohol and the potential for injury. Social services to follow up and offer AA (Alcoholics Anonymous). MD (Medical Doctor)was contacted and medications were held secondary to her intoxication. The facility did not conduct a thorough investigation as there are no staff statements as when R63 was last seen, where R63 obtained the alcohol from, what additional safety precautions were in place once staff identified R63 was intoxicated, whether prior interventions were in place at the time of the fall. There is no social services documentation regarding follow up to this fall and offering of AA services. R63's care plan was updated with a new fall prevention intervention of: Resident was educated on the risk vs benefits of consuming alcohol and the potential for injury; Social Services to follow up and offer AA on 11/18/21. R63's care plan was updated related to alcohol dependency and poor impulses on 11/26/21. No fall risk evaluation was provided post fall. This was 12 days after R63's fall related to alcohol use. Fall 3 On 11/24/21, R63's Medical Record documents: 11/24/21, at 2:30 AM, The night CNA (Certified Nursing Assistant) called this nurse to the resident's room. The resident was on the floor of her room and her feet were 1 foot from the side of her bed. Her head was on the foot of her tray table, in the middle of the floor. The resident was reported to be intoxicated at 5:30 (p.m.) earlier in the shift. The resident reported to this nurse that she hit her head when she fell . The resident first said she hit her head and it was painful. But changed her story and said she did not want to go to the hospital and nothing was painful. EMS (Emergency Medical Services) was called. When she stood up some blood was at her right upper ocular orbit. At that point she agreed to go to the ER (emergency room ) with the EMS. The nurses note dated 11/24/21, at 2:04 PM, documents, Resident returned from ER sutures in laceration right elbow area, resident immediately got up into wheelchair and went out to smoke, neuro (neurological) check within limits throughout day, sutures to be removed in 5 days, resident to follow up with primary within 4 days, call placed to Dr office informed. No signs of ETOH ([MEDICATION(S)] alcohol) to this hour today. The incident report dated 11/24/21, at 12:20 PM, under incident description for nursing description documents The night CNA's called me to resident's room. The resident was on the floor of her room and her feet were 1 foot from the side of her bed. Her head was on the foot of her tray table in the middle of the floor. The resident was reported to be intoxicated at 5:30 PM. The resident reported to this nurse that she hit her head. For resident description documents The resident first said she hit her head and it was painful. She did not want to go to the hospital and nothing was painful. Notes were added on 11/30/21 stating IDT: resident has a history of [CONDITION(S)] intake. Resident was offered AA (Alcoholics Anonymous), Resident continues to decline treatment. Intervention: ETOH (alcohol) intake will be to assist to bed when intoxicated and make sure bed in low position and remove all clutter in resident's room. The facility did not conduct a thorough investigation as there are no staff statements as to who or when R63 was last seen, where R63 obtained the alcohol, what additional safety precautions were in place once staff were aware of R63's intoxication, whether prior fall prevention interventions were in place at the time of the fall. There is no social services documentation regarding follow up to this fall or if/when AA was offered. The alcohol dependency and poor impulse care plan was put into place on 11/26/21 after this fall with injury, but not after the fall on 11/14/21 when R63 was observed to be intoxicated. No fall risk evaluation was completed post fall. R63's care plan was updated on 12/9/21 to included the fall prevention intervention of staff to assist R63 to bed when intoxicated and make sure bed in low position and remove all clutter in resident's room. This was 15 days after R63's fall. Fall 4 On 12/10/21, R63's Medical Record documents: progress note dated 12/10/21, at 7:00 AM, states Resident was spotted sitting on the floor in her room yelling. Resident noted to be sitting in front of the bed. Gripper socks noted to bilateral feet. Wheelchair wasn't locked sitting next to the bed. Resident stated that she was trying to get into bed. Nursing assessment performed. Vitals stable. Resident denies pain and discomfort at this time. No change in LOC (Loss of Consciousness) noted. Nurse assisted CNA staff to transfer resident via Hoyer lift back into bed. Resident was self transferring and did not ask for assistance and was noted intoxicated. DON notified. MD notified. Meds (medications) held per MD order. The Social Services note, dated 12/10/21, at 11:18 AM, indicates Contacted clinical psychologist in regards to seeing resident as soon as possible. Surveyor noted this was the first progress note by social services related to R63's need for services. The incident report dated 12/10/21, at 7:00 AM, under incident description for nursing description documents Resident was spotted in sitting in floor in her room yelling. Resident noted to be sitting in front of the bed. Gripper socks noted to bilateral feel. Wheelchair wasn't locked sitting next to the bed. The resident description documents Resident stated she was trying to get into bed. Notes added on 12/10/21, documents IDT: met and discussed resident's unwitnessed fall in her room. ETOH consumption noted. The root cause of this fall was determined to be from resident's brakes not being locked during transfer under consumption of alcohol. Intervention: resident was offered to have self locking brakes applied to her wheelchair which she declined. Risks vs benefits discussed she continued to decline. Resident is noted to be under the influence consecutively while at the facility. Falls have occurred due to ETOH intake. AA services have been offered and accepted. Social Services will schedule an appointment. The facility did not conduct a thorough investigation as there are no staff statements as to who or when R63 was last seen, where R63 obtained the alcohol, what additional safety precautions were in place once staff identified R63 was intoxicated, whether prior fall prevention interventions were in place at the time of the fall. There is no social services documentation regarding follow up to this fall or if/when AA was offered, but a clinical psychologist was now contacted for services. R63's care plan was updated on 12/23/21 with new fall prevention interventions that include: AA offer accepted, offered self lock brakes for wheelchair, resident decline. Aware of risks and benefits. This is 13 days after R63's fall and R63 had a 5th fall on 12/11/21. Facility's fall risk evaluation form was completed on 12/10/22 with a score of 6 or moderate risk of falls. Fall 5 On 12/11/21, R63's Medical Record documents: progress note: 12/11/2, at 10:30 PM, Writer heard a loud noise and commotion coming from the patient patio area, upon further investigation patient was found on the ground lying on her right side. Patient refused vitals and neuro checks. Refused to stay on the ground until help came and was assisted back to chair. Writer noted bleeding laceration above right eye and bruising to right cheek. Patient denied pain. Due to bleeding and the fact that the patient is on anticoagulant and was noted to be intoxicated writer called 911. Patient originally refused to go to the emergency room , however after discussing the risk of possible hemorrhaging, patient complied and was sent to the emergency room for further observation. MD notified, DON updated. Patient is her own person and does not wish to notify anyone else at this moment. The incident report dated 12/11/21, at 11:00 PM, under incident description for nursing description documents: Writer was standing by the nurses station and heard a sound as if someone had fallen outside, upon further investigation Nurse witnessed R63 on the ground on the patio ramp. For resident description documents Resident stated she stood up and tripped into the crack on the sidewalk of the outside ramp causing her to fall. Notes added on 12/11/21, document IDT: met and discussed residents unwitnessed fall on the patio. Resident noted to have ETOH consumption. The root cause of this fall was determined to be from isolated incident, crack noted on ground. Intervention: Educate staff to redirect residents to common area for social activities. Maintenance checked sidewalk for any hazards. None noted that needed repair. The facility did not conduct a thorough investigation as there are no staff statements as to who or when R63 was last seen, where R63 obtained the alcohol, what additional safety precautions were in place once staff identified R63 was intoxicated, was the fall due to the intoxication, whether prior interventions were in place at the time of the fall and the care plan was not updated until 1/3/22 with the new interventions. Fall risk assessment was completed on 12/11/22 with a score of 13 indicated moderate risk for falls. Fall 6 On 2/27/22, at 10:25 PM, R63's medical record states Resident went out to store without signing out was found on street laying on ground, resident smells like alcohol and medications. The unwitnessed fall incident report dated 2/27/22, at 10:45 PM, under incident description for nursing description documents Resident left the building in her wheelchair on 2/27/22 at 1800 (7:00 PM) with another resident stating they were going to get cigarettes. At 2045 (8:45 PM) the other resident came back and stated R63 had fallen out of her wheelchair in the street and he did not know where R63 was because he was lost. Writer and another RN went out to look for the resident and located her with EMT about 4 blocks south of the facility. Resident had her head wrapped by EMT and visible blood on her face below the right eye. Resident was belligerent stating she refused to go in the ambulance and was not going to the ER. EMT had her sign AMA (Against Medical Advice) and left RN's to walk her back to the building. For resident description documents She hit a bump and it flew her out of the wheelchair. There were notes added to the incident report on 2/28/22 documenting: IDT met and discussed residents fall that occurred while outside the facility. Residents sustained a head injury and was notable intoxicated and belligerent.The root cause of this fall was determined to be related to the resident's alcohol intoxication.Intervention: the resident was again offered assistance with alcohol cessation which was declined. Therapy will screen/eval for wheelchair mobility outdoors. No post fall risk assessment was part of the fall information. The facility did not conduct a thorough investigation as there are no staff statements as to who or when R63 was last seen, where R63 obtained the alcohol, what additional safety precautions were in place once staff identified R63 was intoxicated, whether prior interventions were in place at the time of the fall. There is no social services documentation regarding follow up to this fall or if/when any alcohol cessation program was offered. There was no assessment completed for R63's regarding safety or need for increased supervision related to leaving the building unsupervised. R63's care plan was updated on 3/2/22 with new fall prevention interventions that include: Resident offered assistance with alcohol cessation which was declined. Educated on risks vs benefits she verbalizes understanding. Therapy to screen/eval (evaluate) for wheelchair mobility outdoors. On 3/3/22, at 10:00 AM, Surveyor requested any other fall documentation for R63 from Director of Nursing (DON)-B including staff statements, social services documentation and IDT notes. On 03/07/22, at 8:28 AM, Surveyor interviewed Social Services (SS)-I. SS-I stated she meets with R63 weekly as R63 was having a hard time with the death of R63's husband. R63 also meets with a Clinical Psychologist and the Psychologist sends email updates to SS-I. SS-I stated she has not had time to review the emails or suggestions from the Psychologist and does not know what has happened in their meetings. SS-I said the past DON tried to get R63 to turn in the alcohol to the nurses to monitor, but the staff were not trained properly so it never really happened. SS-I stated that more needs to be done with R63's issues, but just hasn't had time to focus on them and is behind in any documentation. SS-I said there was a contact made in November to try to get some AA (Alcoholics Anonymous) into the facility, but never heard back from them. SS-I had new alcohol cessation resources to provide to R6 and will review that soon. On 03/07/22, at 8:55 AM, Surveyor interviewed Registered Nurse (RN)-F. RN-F stated R63 hides the alcohol, has been intoxicated often and does not turn any alcohol to be locked up. RN-F stated they have not been monitoring R63's alcohol and was not sure how that was to be done. On 03/07/22, at 10:09 AM, Surveyor interviewed Corporate Registered Nurse (CRN)-H. CRN-H stated there were no further investigation materials, staff interviews, for any of the falls for R63. CRN-H did not believe R63 was an elopement risk and that R63 was safe to leave the facility. On 03/07/22, at 11:38 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor informed NHA-A and DON-B of the concerns of lack of assessments/documentation to ensure safety and concerns related to R63's alcohol dependency, incomplete fall investigations, and care plan interventions not being implemented timely after each of R63's fall resulting in injury to R63. NHA-A said she met with R63 in early February as that was the first NHA-A knew about the alcohol concern. NHA-A stated they talked to the Ombudsman for recommendations on what to do with R63 and just got the recommendations today so will look at those. NHA-A indicated the past DON was working on some of these issues with R63, but cannot find any other documentation to provide Surveyor. No further information was provided. 2.) R66 was admitted to the facility on [DATE] with diagnoses that include subarachnoid hemorrhage, repeated falls, dysphagia, altered mental status, and fracture of medial orbital wall. R66's Admission MDS (Minimum Data Set) assessment, dated 11/2/21, indicated in Section J (Health Conditions) that R66 did not have any falls prior to admission. The Falls CAA (Care Area Assessment) was triggered for falls for R66, but was not completed with any analysis of findings. R66's Quarterly MDS (Minimum Data Set) assessment, dated 2/22/22 documents: a BIMS (Brief Interview for Mental Status) score of 15, indicating R66 is cognitively intact to make daily decisions. Section G (Functional Status) documents: R66 is independent with bed mobility and transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents no impairment to either side of both of R66's upper and lower extremities. R66's care plan, dated as initiated on 10/27/21, has a focus area of The Resident is at risk/has potential for falls, accidents and incidents related to generalized weakness, history of falls. and Alteration in musculoskeletal status related to fracture of right medial orbital wall. Interventions include: -Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance; -Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness; -I need to change position frequently. Alternate periods of rest with activity out of bed in order to prevent respiratory complications, dependent [CONDITION(S)], flexion deformity and skin pressure areas; -Monitor for fatigue; -Monitor/document for risk of falls. Educate resident, family/caregivers on safety measures that need to be taken in order to reduce risks of falls (If resident has a care plan for falls, refer to this). R66's fall care plan was revised to include an intervention, initiated on 12/16/21, that states Reminder signs to be placed in residents room to call for assistance. Surveyor noted on the Facility's Visual/Bedside Kardex Report for R66 documents the following (in part): Safety: 11/19/21 - Reminder signs to be placed in the residents room to call for assistance. Resident Care: Place call light or other communication devices within reach at all times. R66's Falls Risk Assessment, dated 11/24/21, documents a score of 17, indicating R66 is at high risk for falls. On 2/28/22, at 1:21 PM, Surveyor observed R66 laying in bed resting with call light clipped to the wall by the wall outlet. The call light was out of reach from the resident. It was behind the privacy curtain and above the bed of the roommate clipped to the outlet. This Surveyor did not observed reminder signs in the room to encourage R66 to ask for assistance as identified in R66's care plan. On 3/1/22, at 9:26 AM and 10:14 AM, Surveyor observed R66 laying in bed watching television with call light clipped to the wall by the wall outlet. The call light was out of reach from the resident behind the privacy curtain and above the bed of the roommate clipped to the outlet. This Surveyor did not observed reminder signs in the room to encourage R66 to ask for assistance as identified in R66's care plan. On 3/2/22, at 1:11 PM, Surveyor observed R66 finishing his lunch sitting on bed with call light clipped to the wall by the wall outlet. The call light was out of reach from the resident behind the privacy curtain and above the bed of the roommate clipped to the outlet. This Surveyor did not observed reminder signs in the room to encourage R66 to ask for assistance as identified in R66's care plan. On 3/2/22, at 1:38 PM, Surveyor interviewed CNA (Certified Nursing Assistant)-R. CNA-R said that R66 does ask for assistance and is not sure why the call light has been clipped to the wall and not in reach. CNA-R stated she did not notice the call light on the wall, but it should be next to the resident always. CNA-R does not recall any signage in R66's room to remind R66 to call for assistance. On 3/2/22, at 1:49 PM, Surveyor interviewed RN (Registered Nurse)-C. RN-C said the call light should not be clipped to the wall. RN-C went into R66's room and took the call light down and put it next to R66. RN-C said R66 was upset with the education of the call light, but R66 did allow the call light to be placed on the dresser next to the bed. RN-C was not aware of any reminder signs posted in R66's room to encourage R66 to ask for assistance to prevent falls. On 3/3/22, at 10:50 AM, Surveyor informed NHA (Administrator)-A and DON (Director of Nursing)-B of the observations of the call light not being accessible to R66 and no signage posted in R66's room to remind R66 to ask for assistance to prevent falls per R66's care plan. No additional information was provided as to why R66 did not have his fall interventions in place per R66's plan of care. 3. R130 was admitted to the facility on [DATE] with diagnoses which includes cerebral infarction, [CONDITION(S)] & [CONDITION(S)] following cerebral infarction, [CONDITION(S)], hypertension, [CONDITION(S)] and gastrostomy status. The fall assessment dated [DATE] has a score of 13 which is moderate risk. Surveyor noted in R130's paper record there is an interim plan of care which is blank. R130's name is not on this form, there is no date, and none of sections have been completed. The nurses note dated 2/27/22 documents Resident friend coming to visit found resident on floor in room, came to desk reported, staff came to room accessed sic (assessed) resident, stated he was trying to get into bed, CNA (Certified Nursing Assistant) had been in room 5 minutes prior and resident stated he was going to stay up. Writer accessed on floor no apparent injury, hoyer lifted to bed and neuro checks initiated. The fall investigation not dated under other pertinent information documents matt to floor and bed in low position. On 2/27/22 an at risk/has potential for fall, accidents and incidents care plan was developed. Interventions all dated 2/27/22 are as follows: * Root cause: PT/OT (physical therapy/occupational therapy) to screen, and offer resident to be assist to bed, after lunch. * Anticipate and meet the Residents needs. * Encourage resident to ask for assistance. * Follow therapy recommendations for transfers and mobility. The fall risk assessment dated [DATE] has score of 20 & 18 both which indicates high risk for falls. On 3/1/22 at 8:13 a.m. Surveyor observed R130 in bed on his back with the head of the bed elevated high. The call light is hanging down off the bed and is not within R130's reach. The floor mat is folded up next to the chair in the room. On 3/1/22 at 9:22 a.m. Surveyor observed R130 continues to be in be [TRUNCATED]

Based on interview, observation and record review, the facility did not ensure treatment and services were in place in order to provide appropriate incontinence/indwelling catheter services according to professional standards of practice to prevent urinary tract infections ([CONDITION(S)]) for 1 (R9) of 2 residents reviewed for indwelling catheters. * R9 was admitted to the facility with an indwelling Foley catheter. An order was put in place at admission to change R9 Foley catheter once a month. R9 Foley catheter was not changed until admission to the hospital 63 days after his admission. R developed [CONDITION(S)] related to a [CONDITION(S)]. Findings include: R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/23/21, R9's physicians orders were reviewed and read: 18 French/ 10 milliliter bulb Foley catheter to straight drain. Change every month and as needed. The order was made by Physician-H. On 11/22/21 R9's care plan titled: Catheter use: indwelling catheter related to neuromuscular disfunction of bladder dated 9/7/21 was reviewed and read: Change catheter per order. On 11/23/21, R9's treatment administration record was reviewed from admission (9/3/21) to 11/8/21. The order for an 18 French/ 10 milliliter bulb Foley catheter to straight drain, Change every month and as needed was not signed out as completed for the entire duration. The transcribed order did not have a date specified to change R9's Foley catheter so it would not have shown up as a task to be done so the nurse would not have been alerted to do this task. On 11/23/21 at 3:05 PM Vice President of Clinical Operations-C was interviewed and indicated that R9's catheter was not changed in the facility since admission and the order was incorrectly put into the computer so it did not show up for the nurse to change it. On 11/22/21 at 9:00 AM R9 was interviewed and indicated his Foley catheter was not changed at all while he was in the facility. R9's hospital record for the 11/8/21 admission was reviewed and read: R9 presents with a fever of 100.6 degrees fahrenheit sore throat and 2 loose stools. Amber urine with a large amount of bacteria present. There is enlargement in the prostate gland. The Foley catheter balloon appears to be expanded within the prostate gland. The tip of the Foley catheter is within the urinary bladder and the bladder is decompressed. The Foley will be exchanged by nursing. [CONDITION(S)] due to [CONDITION(S)]. discharged on [DATE] in stable condition with orders for intravenous antibiotics via a PICC line insert. On 11/23/21 at 1:05 PM, R9 Physician-H was interviewed and indicated that he ordered R9's Foley catheter to be changed once a month. Physician-H also indicated that the fact that R9's Foley catheter was not changed according to his orders could have definitely contributed to the reason R9 developed a [CONDITION(S)] and related [CONDITION(S)]. On 11/24/21 at 10:00AM R9's Foley catheter was observed to be draining clear yellow urine. The above findings were shared with the Administrator and Director of Nurses on 11/23/21 at 3:30 PM. Additional information was requested if available. None was provided.

Based on interview and record review the facility did not provide adequate supervision to prevent choking for 1 resident (R19) of 1 supplemental residents identified as being at risk for choking. The recommendation from the speech therapy assessment was for R19 to receive bite size pieces and close and constant supervision during meals because of R19's high risk for choking. On [DATE] R19 choked on a bratwurst. He he was not served bite-size pieces and was not being constantly observed by the Certified Medication Assistant who was seated at the table with him. As a result of his choking episode R19 suffered cardiac arrest and an anoxic brain injury as a result of the lack of oxygen to his brain and eventually expired on [DATE]. The failure to provide R19 with constant supervision while eating, especially in light of the fact that he had not received bite-size pieces of bratwurst, created a situation of immediate jeopardy beginning on [DATE]. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 11:00 a.m. This immediate jeopardy was removed on [DATE]. The deficient practice continues as a scope and severity of an E (potential for harm /pattern) as the facility continues to implement its action plan. Findings include: R19 was a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R19 had a full code status and his wife was his activated power of attorney for healthcare. R19's Minimum Data Set ((MDS) dated [DATE] indicates he had short and long term memory impairment and was unable to complete a Brief Interview for Mental Status due to his impaired cognitive function. The MDS also assessed R19 to have moderately impaired decision making skills. On [DATE] Surveyor reviewed R19's nurse's note dated [DATE] which states: Called to the dining room (R19) choking. (R19) brought to his room, mouth swipe done, teeth removed. No noted food, Heimlich performed. (R19) unresponsive, (R19) full code. 6:05 p.m. code called and 911. Supervisor also performed Heimlich, cardiopulmonary resuscitation (CPR) started. 6:14 p.m. 911 here and took over. On [DATE] Surveyor reviewed R19's emergency medical transportation report which states: arrived at 6:14 pm vital signs absent. Inserted an airway and were able to get heart started with CPR. No spontaneous breathing. On [DATE] Surveyor reviewed Resident 19's [DATE] Physicians orders which indicates: regular diet, regular texture meats cut into bite size pieces started [DATE]. On [DATE] R19 was assessed by speech therapy regarding swallowing/diet. Review of R19's Speech pathology report dated [DATE] indicates: Mechanical soft diet, swallow therapy, eat slowly, constant supervision, small bites/sips. Patient presents with a mild-moderate oropharyngeal dysphagia characterized by reduced labial closure, slower oral transit time, reduced bolus control, slower mastication, premature spillage, piecemeal swallows. Additional speech therapy recommendations dated [DATE] by Speech Therapist (ST)-N state: The patient eats very fast and does not consistently chew what he has in his mouth before attempting to swallow. He consistently will try to put more food in his mouth before he has swallowed what is already there. He also displays tendency to drink with a mouthful of food and tries to talk while he still has food in his mouth. The behaviors described put the patient at high risk of choking and possible aspiration. The patient has been seen by a speech pathologist for 3 previous episodes of evaluation/treatment since February 2016 for the same condition. The patient is not able to recall instructions or monitor his eating behavior. He continues to need the supervision and cueing to eat safely. Recommendations: mechanical soft texture, thin liquids with extra sauce or gravy to keep food moist. Supervision: Close and Constant (bolded) whenever he eats. Cueing for the following a. eat slowly b. small bites, small sips c. chew food before swallowing d. swallow what he has in his mouth before taking more food. On [DATE] at 7:30 a.m. Surveyor interviewed ST-N who indicated close and constant supervision of R19 meant eyes on him at all times ST-N indicated that was needed even if he was receiving a mechanical soft diet. Staff would need to be even more careful with R19 with a regular diet. ST- N indicated R19's healthcare power of attorney refused a mechanical soft diet for R19 several times. ST-N indicated R19 had 2 concerns related to eating: what he was eating and the rate at which he ate. ST-N indicated R19 ate very fast. ST-N also indicated bite size pieces are bite size pieces and gave no specific measurement to what a bite size would be. On [DATE] at 3:30 p.m. Corporate Nurse Consultant -I indicated speech therapy was consulted and a bite size piece would be ¼ inch by ¼ inch. This is equivalent to pieces that are 0.635 centimeters x 0.635 centimeters. On [DATE] Surveyor observed a sample of the bratwurst that R19 ate on [DATE] given to Surveyor by Dietary Manager (DM)-E. The sample of the bratwurst measured 3 centimeters (cm) by 14.5 cm. DM-E indicated the bratwurst is precooked and there would be approximately 15% shrinkage upon reheating. DM-E indicated the CNA who cut food stated it was cut length wise and width wise into 8 pieces (with shrinkage each piece would be approximately 3 cm x 1.3 cm). On [DATE] at 12:55 p.m. Surveyor interviewed Certified Nursing Assistant (CNA)-G who cut R19's bratwurst on [DATE]. CNA-G drew a picture of how he cut R19's bratwurst. CNA-G's picture indicated the bratwurst was cut lengthwise and widthwise to make 8 pieces. CNA-G indicated he was not at the table to assist the resident with the meal but watched him for a short time to see what he was going to do before going to pass trays on the floor. CNA-G indicated R19 started to eat and before he finished the first piece R19 put another piece in his mouth and CNA-G told R19 to slow down and then went to pass trays on the floor. CNA-G indicated the only staff in the dining room after CNA-G left was Medication Technician (MT)-H who was seated at R19's table between him and another resident on the other side of the table. On [DATE] at 10:15 a.m. Surveyor interviewed MT-H who was in the dining room sitting at the table with R19. MT-H indicated that Resident 19 was eating sausage in bite size pieces and afterward R19 took a drink and she heard him gasp. MT-H then asked R19 if he was ok and he shook his head yes and started eating again. R19 then gasped again and MT-H paged the nurse to come to the dining room. MT-H indicated she then pushed R19 to his room to meet the nurse there. MT-H indicated the nurse grabbed a glove and did a finger sweep. MT-H then indicated R19's eyes rolled in the back of his head and the nurse did the Heimlich but nothing came out. MT-H indicated she then called the code and ran to the nurse's station to look at Resident 19's code status and relayed it to the nurse. MT-H indicated she then called 911 and waited for rescue. MT-H indicated R19's sausage was cut the full circumference and about 3 centimeters long. MT-H indicated she understood she had to be at the table with him cueing him but not keeping him under constant supervision. MT-H told Surveyor at the time the resident gasped she had her head turned assisting another resident. MT-H stated if she had known R19 was supposed to receive constant supervision she would have kept her eyes on him the entire time and gotten someone else to assist the other resident. On [DATE] at 3:30pm Corporate Nurse Consultant -I confirmed to Surveyor that Medication Technician-H was not CPR (cardiopulmonary resuscitation) certified or trained by the facility to do the Heimlich at the time of R19's choking. On [DATE] at 3:23 p.m. Surveyor interviewed Licensed Practical Nurse (LPN)-J who responded to R19's code on [DATE]. LPN-J indicated she was having trouble getting the suction machine started and thought it might have been broken. LPN-J indicated she didn't think it was ever started while R19 was there. LPN-J indicated that it is her understanding that a nurse is supposed to be in the dining room supervising at meals. On [DATE] at 3:01 p.m. Surveyor interviewed Registered Nurse Manager (RN) - K who indicated she talked to R19's power of attorney for healthcare. RN-K indicated R19 and the power of attorney for healthcare both refused mechanical soft diet recommendations. RN-K stated she did not have a risk agreement signed by R19's power of attorney for health care. RN-K also indicated she instructed LPN-J and the other nurses on how to use the suction machine as LPN -J did not know how to hook it up on [DATE]. RN-K indicated that the suction machine was never broken like LPN-J said. Surveyor noted there was no risk agreement for choking found in R19's medical record. On [DATE] at 2:21 p.m. Surveyor interviewed RN-L who responded to the code for R19 on [DATE]. RN-L indicated she got R19 on his bed, R19 was unresponsive and she started CPR. RN-L indicated that she did not notice breaths going into R19 during CPR. RN-L stated she continued CPR until 911 arrived. On [DATE] at 1:49 p.m. Surveyor # interviewed Medical Doctor (MD)-M (R19's primary physician) who indicated both resident and wife were noncompliant with diet recommendations. MD-M indicated he got the results of R19's video swallow but not R19's speech pathologists recommendations. MD-M indicated he never spoke to facility about speech pathology recommendations but after he reviewed R19's video swallow he said he continued with the family wishes. On [DATE] Surveyor reviewed R19's emergency room report written by MD-O on [DATE] which indicates: (R19) evaluated in the emergency room found to have pulses but to be in atrial fibrillation. The patient had a king airway that was removed. I examined the patient's airway and identified a large piece of sausage that was stuck in the back of his oropharynx. With forceps I was able to carefully remove the piece of sausage and intubate the patient. The patient remains in [DIAGNOSES REDACTED]but has been ventilated easily. There has been no other neurologic reaction since intubation. On [DATE] at 7:15 a.m. Surveyor interviewed MD-O who indicated a piece of sausage was pulled out of R19's oropharynx that was approximately 2 centimeters long by 1.5 centimeters wide. MD-O also indicated no casing was left on the sausage and it was somewhat masticated. MD-O stated the piece of sausage was disposed of and not preserved as MD-O didn't realize it may have been necessary to save it. On [DATE] Surveyor reviewed R19's neurological consult dated [DATE] which states: The patient was in PEA arrest (cardiac arrest) on the arrival of EMS (Emergency Medical Services) at the nursing facility where he choked. He underwent a cooling procedure. He has been sedated and paralyzed due to continuous myoclonic jerking of the body. I am asked to give a neurological prognosis. The patient has not had any spontaneous purposeful movement or eye movement, when he is not sedated the myoclonic jerks become quite severe to the point where it is difficult for him to tolerate the ventilator. Physical exam: No withdrawal to deep pain in any extremity. Triple reflex to deep pain in both legs. Severe anoxic injury to the brain. Prognosis looks very poor based on the clinical exam. On [DATE] Surveyor reviewed R19's hospital discharge summary dated [DATE] which states: Death secondary to anoxic brain injury due to airway occlusion by a foreign body. Subsequent anoxic brain injury from prolonged hypoxia. Cardiac arrest. The facility's failure to ensure R19 received the proper supervision during meals as recommended by Speech Therapy created a situation of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it implemented the following action plan: *Audit was conducted comparing orders to diet prepared and fed. * Audit was completed on speech therapy notes in the past 3 months versus orders in the charts. * Audit of dietary tray cards and CNA care cards vs MD orders. * Education was provided to the nursing staff upon arrival for their next shift including proper set up and use of the suction machine 50% to licensed staff completed [DATE]. Bite size piece definition per speech therapist ,[DATE] by ,[DATE] inch 50% completed by [DATE] all nursing staff. How and when to use Heimlich 50% completed by [DATE] all licensed staff, Presence of nurse in the dining room 50% completed by [DATE]. Appropriate use of risk benefit form frequency and how to complete 50% completed to all licensed staff [DATE]. * Audit of all residents receiving assistance with meals to ensure supervision is maintained. Nurse to conduct audit in dining room 2 times daily for 2 weeks, 2 meals biweekly for a month, and monthly or as indicated by Quality Assurance beginning [DATE]. * Safety audit tool will be completed by management team to ensure nurse in the dining room, nurse aware where to find suction machine and how to use, use of Heimlich maneuver and how to complete and use the risk/benefit form. Monitored 1 meal daily times 4 weeks, 2 meals weekly for 2 weeks, 2 meals biweekly for a month, and monthly or as indicated by Quality Assurance beginning [DATE]. * Dietary safety audit tool used by nursing management to ensure compliance with risk benefit forms for random audits. Risk benefit education will be provided annually to staff, reviewed quarterly with families at care conferences, and with change of conditions beginning on [DATE]. * Ad Hoc Quarterly Assurance.

Based on a complaint investigation, review of a facility self-report allegation, medical record review, resident interview and staff interview, the facility did not provide medically related social services to attain or maintain the highest practicable mental and psychosocial well-being for 1 (Resident #3) of 6 residents reviewed. Resident #3, who displays hoarding behaviors, did not have a plan of care in place to address these behaviors and the facility did not involve Resident #3 in the process of de-[DIAGNOSES REDACTED] her room in anticipation of a new roommate on 01/19/16, resulting in facility staff forcibly taking some of Resident #3's possessions to be placed in storage. On 01/22/16, Resident #3 was noted with abnormal behaviors including tremors and jumpiness and she was sent to the Emergency Department (ED) and was diagnosed with [REDACTED]. The facility had removed possessions from Resident #3's room without her prior knowledge or permission on at least 1 previous occasion leading to increased anxiety as Resident #3 was afraid to leave her room for fear staff would take her possessions. When speaking to Surveyor # on 05/10/16 at 11:35a.m., Resident #3 became tearful as she recounted staff removing her possessions on 01/19/16. She informed Surveyor # that her possessions including drawings and poetry she had written, were treated like it was trash, it's all gone and it was more disturbing to me than any roommate. Despite the facility being aware of Resident #3's behavior of hoarding and her on-going mental and psychosocial distress, as of 05/12/16, a plan of care addressing these issues had not been initiated. Findings include: Surveyor # reviewed Resident #3's medical record on 05/10-05/12/16, as part of a complaint investigation alleging Former Nursing Home Administrator (FNHA)-I and Former Director of Nursing (FDON)-J came into Resident #3's room unannounced on 01/19/16, and started removing Resident #3's possessions from the A side of the room without her permission. Resident #3 lived by herself on the B side of the room and also had possessions on the A side of the room due to hoarding behavior. The possessions were removed from the A side of the room due to Resident #3 receiving a roommate. Resident #3's quarterly Minimum Data Set assessment completed on 04/01/16 shows her to be cognitively intact. A Behavioral Health Consult dated 09/01/15 indicates, She reported her depressed mood rating to be 1-2/10 and her anxiety rating to be 9/10. She reports herself doing poorly one month ago with her hoarding when she had her room partially cleaned out while she was at the MD's office. Her anxiety however is so high because she is afraid to leave her room because she's afraid they will clean out her clutter again . A Behavioral Health Consult dated 09/09/15, indicates, Worked with Resident #3 on the helplessness she feels with this most recent affront on her hoarding. Resident #3's current plan of care does not include a problem of hoarding, or interventions to minimize the behavior/clutter. Progress Note documentation on 11/06/15 indicates, Facility Administrator (FNHA-I) and Director of Nursing (FDON)-J spoke with Resident #3 today regarding the need to organize her room in anticipation of a roommate being admitted . Resident #3's belongings have extended past the B side of the room and Resident #3 has boxes and clutter over the entire room. Resident #3 was asked to please decide what she needs and what can be placed in storage. Resident #3 was angry and stated she needs everything and refused to clean, organize or store any of her belongings. There is no evidence Former Social Worker (FSW)-M was working with Resident #3 to involve her in the process of de-[DIAGNOSES REDACTED] her room. Progress Note documentation on 12/18/15 indicates, Administrator (FNHA-I) and Director of Nursing (FDON)-J approached Resident #3 in her room again today regarding organizing and de-[DIAGNOSES REDACTED] her room. Again Resident #3 refused and asked us to leave the room. Again, there is no evidence Former Social Worker (FSW)-M was working with Resident #3 to involve her in the process of de-[DIAGNOSES REDACTED] her room. Progress Note documentation on 01/15/16 indicates, Resident #3 informed by Administrator (FNHA-I) that we had numerous admissions and she could anticipate a roommate within the next few days or week. Again Resident #3 refused to make room on the A side. Administrator (FNHA-I) informed Resident #3 we would need to work with her to give her roommate appropriate space . There is no evidence a plan was developed to work with Resident #3 to de-clutter her room. Progress Note documentation on 01/19/16 indicates, Facility Administrator (FNHA-I), DON (FDON-J) and Maintenance Director approached Resident #3 to assist in re-organizing room and making room ready for a roommate. Resident #3 was very angry and refused to allow anything to be taken out of her room. Boxes were placed on a cart for storage .Resident #3 began running her electric wheelchair into Maintenance Directors legs. In the hallway Resident #3 had the Maintenance Director pinned to wall with her electric wheelchair .Facility Administrator (FNHA-I) had to pull wheelchair off Maintenance Directors legs . Progress Note documentation on 01/22/16, indicates Resident #3 was noted with abnormal behaviors including tremors and jumpiness and she was sent to the Emergency Department (ED) and was diagnosed with [REDACTED]. When speaking to Surveyor # on 05/10/16 at 11:35a.m., Resident #3 became tearful as she recounted staff removing her possessions on 01/19/16. She informed Surveyor # that her possessions including drawings and poetry she had written, were treated like it was trash, it's all gone and it was more disturbing to me than any roommate. When asked on 05/11/16 at 11:12a.m., about an issue with her television, Resident #3 informed Surveyor # that, that other thing was heart breaking. When asked whether she was referring to the taking of her possessions, Resident # 3 indicated, Yes. Surveyor # spoke with FSW-M on 05/11/16, at 8:08a.m. FSW-M indicated that facility staff had informed Resident #3 that they would need to remove items from her room, but had not received her permission to do so or told her when items would be removed. FSW-M indicated there had been no formal plan to work with Resident #3 to organize her room prior to 01/19/16. Surveyor # spoke with Anonymous Staff (AS)-N. AS-N indicated that on 01/19/16, they observed FNHA-I, FDON-J and the Maintenance Director enter Resident #3's room with a cart, and then heard a lot of noise coming from Resident #3's room. AS-N stated the situation wasn't good. AS-N also indicated Resident #3 was struggling with them to keep her possessions. AS-N indicated Resident #3 had not been informed prior to FNHA-I, FDON-J and the Maintenance Director entering her room that they would be taking Resident #3's possessions. AS-N indicated there was complete disregard for Resident #3's clothing and other possessions, they just kept grabbing stuff. AS-N described Resident #3 as scared and clearly violated and described the incident as traumatic. AS-N indicated that they had successfully worked with Resident #3 previously in de-[DIAGNOSES REDACTED] her room in anticipation of receiving a roommate which did not come about. Despite the facility being aware of Resident #3's behavior of hoarding and her on-going mental and psychosocial distress, and despite previous success in helping Resident #3 de-clutter her room, as of 05/12/16, a plan of care addressing these issues had not been initiated.

Based on interviews and record review, facility staff did not provide pain management according to accepted standards of practice for 1 of 1 Resident (Resident #16) experiencing pain; nor did they provide services to prevent 1 of 1 Resident (Resident #11) from becoming incontinent of bowel. Resident #11 was continent of bowel on admission. Findings include: 1.) Surveyor # reviewed Resident #16's medical record on 5/28/14- 6/3/14. Resident #16 was admitted to the facility on [DATE] following abdominal surgeries including repair of gastric and colon lacerations from a previously-placed gastric-pancreatic stent, [MEDICAL CONDITION] placement and jejunostomy (feeding tube) placement. Resident #16 has [DIAGNOSES REDACTED]. Surveyor # reviewed a Patient Nursing Evaluation form completed for Resident #16 on 5/1/14. Under the "Pain" section, it indicates Resident #16 has daily, constant pain, rated a "6" on a scale of zero being no pain and 10 being the worst pain imaginable. Acceptable level of pain is 2-6. Surveyor # reviewed a Pain assessment dated [DATE] for Resident #16 which states Resident #16's pain is located in his abdomen; duration of pain- constant; frequency of pain-constant "it's always there"; Feeling of pain- Internal and External, incisional. Resident #16 verbally rated his pain as "6" on 0-10 scale, and described it as "ache" and "dull." A section of the Assessment is titled "Quality of Life/Activities of Daily Living"; staff did not check any of the choices given nor did they add comments in the space labeled "other." This section does ask if "Pain affects the Resident's ability to rest/sleep, but it is not checked. (Cross reference F329 regarding use of the hypnotic Ambien-staff report pain wakes Resident #16 and he then takes a pain pill and sleeping pill and goes back to sleep.) The "Cause of Pain" is noted to be recent abdominal surgery, [MEDICAL CONDITION], J-tube placement and incisional pain. The Assessment indicates Resident #16's acceptable level of pain is 2-6, he does not receive scheduled pain medications, PRN (as needed) medications are Tylenol, and [MEDICATION NAME] 5/325mg. (5 milligrams [MEDICATION NAME] with 325 milligrams [MEDICATION NAME]) every 4 hours, 1 or two tablets, as needed. The pain medication is noted to be effective. The pain is relieved by medication and diversional activity. "Time elapsed until pain relief: 1-2 hours." The Assessment "Conclusion" is left blank. Preprinted options are: -No pain, intervention not necessary. Reassess quarterly or with onset of pain. -Pain management intervention is necessary, refer to resident plan of care. -Change in intervention, refer to resident plan of care. "Interdisciplinary Team (IDT) Progress Note" is also left blank. Surveyor # reviewed Resident #16's Initial MDS (Minimum Data Set) completed 5/8/14 indicating in the previous five days, Resident #16: had no scheduled pain medication, did receive PRN pain medication, and did not receive any non-medication interventions for pain management. The MDS indicates Resident #16 has almost constant pain (the highest frequency available to be selected), rated 7 on scale of 0-10, and noted pain makes it hard to sleep at night. Surveyor # reviewed "Sleep Monitor" forms filled out for Resident #16 for three nights following his admission. (Cross reference F329 Re:[MEDICATION NAME].) The Sleep Monitor for 5/2/14- 5/3/14 states Resident #16 went to bed at 2300 (11:00 p.m.); it took him 30 minutes to fall asleep, and Resident #16 remained asleep all shift. Total hours in bed: 7 1/2; Total hours of sleep: 7; Total time awake: 30 minutes. The Sleep Monitor for 5/3/14- 5/4/14 indicates Resident #16 went to bed at 2300; it took 30 minutes for Resident #16 to fall asleep; Resident #16 remained asleep from 2330-0230 (11:30 p.m. until 2:30 a.m.). What caused Resident to waken?- "PRN [MEDICATION NAME]" (pain pill). After the Resident's needs were met, did s/he return to sleep?- "Yes." Is there a physical condition that may impact his/her willingness to return to bed (such as shortness of breath or restless leg syndrome, arthritis, or other discomfort?-"Discomfort." Total hours in bed: 8 hours. Total hours of sleep: 7 hours. Total time awake: 1 hour. The Sleep Monitor for 5/4/14-5/5/14 indicates Resident #16 went to bed at 11:00 p.m., it took 30 minutes to fall asleep, and remained asleep from 11:30 p.m. until 1:30 a.m. What caused Resident to waken?- "[MEDICAL CONDITION] care, pain medication." After the Resident's needs were met, did s/he return to sleep" -"Yes." Physical condition that may impact..."Discomfort." Total hours in bed: 8 hours; Total hours of sleep: (left blank), Total time awake (left blank). On 6/2/14 at 1:30 p.m. Surveyor # interviewed LPN (Licensed Practical Nurse)-Q regarding Resident #16's use of [MEDICATION NAME], a hypnotic/sleeping pill. LPN-Q stated Resident #16 often wakes up because he is in pain and needs a pain pill. Surveyor # reviewed a Monthly Behavior Summary/Psychoactive Gradual Dose Reduction (GDR) Review form for Resident #16 which states [MEDICATION NAME]([MEDICATION NAME]) use was reviewed 5/6/14 (before he ever took his first dose on 5/7/14 and five days after admission.) The "Comments" were" [MEDICATION NAME] be given before midnight." Surveyor # reviewed Resident #16's Care Plan for pain, dated 5/1/14 and updated 5/7/14 and 5/9/14. It states Resident #16 has chronic pain, rated "7" on scale of 0-10 in his abdomen, intermittent, does not interfere with activities. The pain is related [MEDICAL CONDITION](gastro-[MEDICAL CONDITION] reflux disease), recent abdominal surgery, pancreatitis, peritonitis, and history of GI (gastro-intestinal) bleed. On 5/7/14 staff added "pain always there per resident." The Care Plan Goal is: Resident will state/demonstrate relief or reduction in pain intensity after receiving interventions through next review date of 8/1/14. Care Plan Approaches include: Monitor and report pain to nurse; Report changes in pain location/type/frequency/intensity to physician; Provide/encourage non-medication related interventions as applicable: (nothing is checked or added after "Other", but the following interventions are left blank- relaxation techniques, repositioning, rest, massage, diversion activity, social interaction, therapy/exercise, other); Administer [MEDICATION NAME] as ordered, monitor for effectiveness and for possible side effects; Invite, encourage,remind, escort to preferred activities consistent with the resident's interests as a diversion from pain; Educate resident/family about comfort measures, [MEDICATION NAME] medications, and discuss fears/concerns regarding pain, comfort and disease process; Notify the resident's physician if pain not adequately relieved with current regimen and interventions; Monitor for signs and symptoms of constipation and administer bowel protocol prn; Schedule pain medication administration prior to treatment/activities known to contribute to pain as applicable. Additional approaches: 5/1/14 Monitor pain Q (each) shift. Resident #16's Admission Physician order [REDACTED]. PO (by mouth) 1 tablet Q (every) 4 hours PRN for pain and 2 tablets every 4 hours for pain scale 7-10 /10 moderate to severe pain. On 6/3/14 at approximately 9:45 a.m., Surveyor # reviewed Resident #16's MAR (Medication Administration Record) and Controlled Drug Use Record with LPN (Licensed Practical Nurse)-Q and RN (Registered Nurse) Supervisor-P. The MAR is where nurses sign out each and every medication when given, and the Controlled Drug Use Record is where the nurses sign out any controlled medication, which would include Resident #16's pain medication. Nurses count the controlled medications and match them to the Controlled Drug Use Records at the start and end of each shift, so the Controlled Drug Use Records are more accurate. Resident #16's June 2014 MAR showed Resident #16 did not receive any pain medication on 6/1/14; received two tablets of PRN [MEDICATION NAME]/APAP ([MEDICATION NAME])- (generic [MEDICATION NAME])-on 6/2/14 at what looks to be 5:45 a.m., though it is hard to read, and none thus far on 6/3/14. RN-P also thought it said 0545 (or 5:45 a.m.) on 6/2/14, but also was unsure and suggested we check to see what time it was signed out on the Controlled Drug Use Record. The Controlled Drug Use Record shows staff signed out the pain medication for Resident #16 at 5:45 a.m. on 6/3/14, not 6/2/14. In addition, whereas the June MAR shows Resident #16 only received two [MEDICATION NAME]/APAP pain pills from 6/1 until 9:30 a.m. on 6/3, the Controlled Drug Use Record shows staff signed out 18 pain pills for Resident #16 during that time. Nurses signed out the [MEDICATION NAME]/APAP for Resident #16 at the following times: 6/1/14 0530 (5:30 a.m.) two tablets 6/1/14 12:30 p.m. two tablets (the Record shows 6/2/14 at 12:30 p.m., but RN-P stated it must have been 6/1/14 or the end of shift counts would have been off, and the next entry is 6/1/14 at 1700 (5:00 p.m.), and there is a different entry later on for 6/2/14 at 12:30 p.m., so the nurse must have signed them out on 6/1/14, not 6/2/14.) 6/1/14 1700 (5:00 p.m.) two tablets 6/1/14 2100 (9:00 p.m.) two tablets 6/2/14 0330 (3:30 a.m.) two tablets 6/2/14 0830 (8:30 a.m.) two tablets 6/2/14 12:30 p.m. two tablets 6/2/14 2000 (8:00 p.m.) two tablets 6/3/14 0545 (5:45 a.m.) two tablets. The Controlled Drug Use Record shows 30 pain pills were dispensed and delivered to the facility on [DATE] for Resident #16. The record shows Resident #16 received 29 [MEDICATION NAME]/APAP 5/325mg. tablets between 5/30/14 at 8:45 p.m. and 6/3/14 at 5:45 a.m., a period of three and one-half days. Nurses' signed out the first two tablets on 5/30/14 at 8:45 p.m., and two more tablets on 5/31/14 at 3:00 a.m. and 5/31/14 at 7:30 a.m., one tablet on 5/31/14 at 2:00 p.m., two tablets on 5/31/14 at 6:00 p.m., and two tablets on 5/31/14 at 10:00 p.m. Each time staff administer two tablets it is for moderate to severe pain. The May 2014 MAR does not indicate Resident #16 received any [MEDICATION NAME]/APAP (generic [MEDICATION NAME]) on 5/30/14 through 5/31/14; the last dose documented on the May MAR is at 8:00 a.m. on 5/29/14. This Controlled Drug Use Record shows Resident #16 received 11 tablets on 5/30/14 and 5/31/14. The previous Controlled Drug Use Record, obtained a little later from Medical Records, shows staff signed out two tablets on 5/30/14 at 4:00 a.m. and one tablet at 8:30 a.m., totaling 14 tablets signed out for Resident #16 on 5/30 and 5/31, while the MAR shows no [MEDICATION NAME]/APAP were given those two days. Surveyor # asked RN-P if staff have reassessed Resident #16's pain since admission on 5/1/14, considering the large number of PRN pain pills he takes, looking over the past few days. RN-P stated nurses assess his pain every shift, and pointed to the MAR. A hand-written entry on the June 2014 states "Mon (monitor) pain Q shift", and there are spaces for night, day and PM shifts to record a number. Surveyor # and RN-P reviewed the entries for June 1 which appear to have all been entered as "0", then a "7" was written over the "0"'s. RN-P did not know why the "0"'s were changed to "7"'s, or if the rating was before or after a PRN pain medication was given. The only entry for monitoring pain on 6/2/14 was a "7" on PM shift; day shift and night shift were blank even though they administered four pain pills. Night shift entered a "7" for 6/3/14. Per the MD orders, a rating of 7-10 is moderate to severe pain. Surveyor # asked RN-P if they assessed Resident #16's pain including if the pain medication is effective, how long it takes for the medication to provide relief and how long the relief lasts, would scheduling pain medication provided better pain relief, possibly preventing Resident #16's pain from getting to the "moderate to severe" range requiring use of two PRN pain pills, or any other interventions to manage pain besides the PRN pain pill. Surveyor # noted in a Pain assessment dated [DATE], it is noted "diversional activity" helps relieve the pain, and asked if staff investigated what diversional activities or non-pharmacologic interventions may help relieve Resident #16's pain. RN-P stated there should have been a "Pain Monitoring Flowsheet" in Resident #16's MAR, but there was not one in the MAR. RN-P then added a Pain Monitoring Flowsheet to the MAR (on 6/3/14) which directs staff to document the date and time a pain management intervention was initiated, the Resident's pain scale rating (verbal or non-verbal scale), additional signs of pain, medication and dose administered, alternative treatments (heat, cold, relaxation, etc.), Resident's pain rating after treatment or medication, comments and staff initials. Surveyor # asked LPN-Q and RN-P if they had considered or discussed scheduling Resident #16's pain medication per professional pain management standards that recommend around-the-clock dosing, or scheduled pain medication, to keep Resident #16's pain at a more manageable level, less than 7-10, less than moderate to severe, so Resident #16's pain does not get to the moderate to severe level so often. Neither LPN-Q nor RN-P were aware of discussions with the Resident and physician weighing the risks and benefits of around-the-clock dosing. LPN-Q noted Resident #16 has abused alcohol in the past, and perhaps that is why the medication is not scheduled. RN-P stated Resident #16 has been going to therapy, and with more activity, that may increase his pain, even though the therapy is very beneficial. Surveyor # asked if they discussed offering or scheduling pain medication before therapy if they believe part of the pain is caused from participating in therapy. RN-P was not aware of any such discussions. RN-P stated Resident #16 said "I don't want to be in pain, so I'm going to take the pain pills." Surveyor # then obtained Resident #16's previous Controlled Drug Use Record sheets from Medical Records because only the one Record starting 5/30/14 was in the binder on the medication cart. Seven additional Controlled Drug Use Records were reviewed. The first [MEDICATION NAME]/APAP was delivered for Resident #16 on 5/2/14; a card of 24 pills was delivered. A nurse signed out the first tablet on 5/2/14 at 9:45 p.m., and the last of the 24 tablets was signed out on 5/6/14 at 5:45 a.m.; the 24 tablets [MEDICATION NAME] just over three days. The six additional Controlled Drug Use Records were reviewed. These six records were each for deliveries of 30 [MEDICATION NAME]/APAP tablets; each card of 30 [MEDICATION NAME] a few days. In total, Resident #16 received 233 [MEDICATION NAME]/APAP "as needed" tablets in one month, from the evening of 5/2/14 to early morning on 6/3/14. Almost always, (107 times), Resident #16 received two tablets at the same time indicating he complained of moderate to severe pain (7-10/10). Surveyor # reviewed Resident #16's May 2014 MAR which documents single tablets of [MEDICATION NAME]/APAP were given to Resident #16 on 5/4, 5/7 and 5/21, though on 5/21, the Controlled Drug Use Record shows two tablets were signed out on 5/21/14 at 3:00 a.m., 7:30 a.m., 1:10 p.m., 6:00 p.m. and 11:00 p.m.- no single tablets were signed out. The May MAR shows 21 two-tablet administrations of [MEDICATION NAME]/APAP for moderate to severe pain, which totals 42 tablets. Adding the three single-tablet administrations with the 42 tablets given in two-tablet administrations, the May MAR shows a total of 43 tablets administered PRN to Resident #16. However the Controlled Drug Use Records reveal Resident #16 received 215 tablets of [MEDICATION NAME]/APAP in the month of May, 2014, not 43 as documented on the MAR. Also on the May MAR, nurses did not start monitoring Resident #16's pain each shift until 5/24/14, when it was added to the MAR more than three weeks after his admission and start of receiving pain medication. (Resident #16's Care Plan directed staff to monitor pain Q shift as of 5/1/14). Starting on 5/24/14, day shift and PM shift consistently documented "7"'s for Resident #16's pain (severe), while night shift consistently entered "0" for no pain, except on 5/28/14 which was left blank. However the Control Drug Use Record shows a night shift nurse gave Resident #16 a minimum of two pain pills each night 5/24/14 through 5/31/14. At approximately 11:00 a.m. on 6/3/14 Surveyor # shared this information with DON (Director of Nursing)-B, asking if there was additional information regarding Resident #16's pain management regimen. As it appears, a pain assessment was conducted 5/1/14 indicating constant severe abdominal pain (7/10). Resident #16's May MAR documents 43 tablets of [MEDICATION NAME]/APAP administered, while the Controlled Drug Use Record indicates 215 tablets were signed out for Resident #16 during May. For June 1-3, the MAR shows two tablets signed out, while the Controlled Drug Use Record reveals 18 tablets were signed out for Resident #16 during that time. Surveyor # asked if they had considered scheduling pain medication or around-the-clock administration of pain pills to prevent Resident #16's pain from reaching moderate to severe levels as often, and possibly prior to therapy if that increases Resident #16's pain. Surveyor # noted no evidence was observed indicating nurses evaluated the effectiveness of Resident #16's pain management regimen after initiation, assessing if it was providing Resident #16 with the pain relief he needed or if improvements could be made. DON-B was not aware of the particular circumstances of Resident #16's pain management program. No further information was provided. 2.) Surveyor # 's review of the initial MDS dated [DATE] indicates Resident #11 is cognitively intact, able to communicate her needs and is continent of both bowel and bladder. The facility conducted a significant change in condition MDS assessment on 4-23-14 for Resident #11, in which one area that triggered the new assessment was a decline in the resident's bowel status; the MDS now indicates the resident is totally incontinent of bowel. The 4-23-14 significant change MDS indicates the resident has no bowel program, requires total assistance from two staff members in order to use the toilet facilities. The facility conducted additional assessment of Resident #11's bowel function on 5-9-14 that takes into consideration various factors such as laxative use, length of incontinence, history of constipation, and perception of the need to defecate. The evaluation does not note the resident's usual bowel elimination pattern, nor does it consider if there are reversible causes for the resident's incontinence. The evaluation of the resident's incontinence is the resident's decreased perception to defecate. On 5-30-14 at 9:40 AM, Surveyor # interviewed Resident #11 and asked the resident if she received needed help to toilet and conduct her ADLs (activities of daily living). Resident #11 indicated she is "diapered now, because I cannot walk." Resident #11 also stated she is "trained to be incontinent" and was "told I have to hoyered (transferred from surface to surface with a mechanical lift), and they don't have enough people (staff)." On 5-30-14 at 11:35 AM, Surveyor # interviewed RN-L and asked how the facility is managing Resident #11's bowel status. RN-L indicated the staff should be checking with the resident and offering a bedpan while in bed, or to toilet while in wheelchair. On 5-30-14 at approximately 11:50 AM. Surveyor # interviewed CNA-I and asked her what she should be doing to assist the resident with her elimination needs. CNA-I indicated Resident #11 is put back in bed and checked for incontinence and changed every two hours for both her bowel and bladder needs. CNA-I also stated the resident does not indicates when she has to use the toilet, nor does use the call light to indicate the need to toilet. On 5-30-14 at 1:00 PM, Surveyor # related the above interviews of staff and the resident, to the administrative staff, the administrator and director of nurses, and asked for additional information that would address the resident's bowel decline and for a comprehensive plan of care to assist Resident #11 to improve her bowel incontinence. On 6-2-14 at 1:15 PM, RN-L presented information from a diagnostic MRI (magnetic resonance imaging) report of the resident's spine dated 2-20-14, that notes Resident #11 has disc herniation at the C3 - C4 (cervical) level, that according to RN-L, the interdisciplinary team thinks could be contributing to the resident new onset incontinence. RN-L also stated the nursing staff would offer Resident #11 opportunities to toilet and/or a bedpan when in bed.

Based on interview and record review, the facility did not ensure each resident who is incontinent of bladder receive appropriate services and treatment and services to restore as much normal bladder function as possible. The facility did not ensure 1 of 4 residents who are incontinent, Resident #11, did not receive appropriate evaluation of her incontinence and care planning in order to assist her to achieve her highest level of continence. Findings include: 1) Resident #11 was admitted to the facility on [DATE]; the initial MDS dated [DATE] indicates the resident is cognitively intact, is able to make her needs known and requires the total assistance from two staff members to complete her toilet needs. The initial MDS also indicates the resident is frequently incontinent of bladder. Surveyor # interviewed RN-L on 6-2-14 at 1:15 PM; RN-L indicated Resident #11's incontinence pattern was a constant "dribbling". RN-L's statement however, does not coincide with the documentation in the nurses' notes during the MDS "look back" period of 1-29-14 to 2-5-14, wherein the documentation notes the resident is able to use the call light appropriately to ask for assistance to toilet, and remained continent. The facility conducted a significant change in condition MDS on 4-23-14, one of the areas that triggered the updated assessment is a decline in the resident's urinary status, going from continent or mostly continent to totally incontinent. As part of the significant change in condition evaluation, the facility conducted a three day bladder voiding pattern record between 5-7-14 to 5-9-14 that notes Resident #11 had 20 episodes of being wet versus 48 times when she was dry. The bladder record notes Resident #11 was not offered the opportunity to use the toilet; the evaluation of the voiding pattern record states the resident is totally incontinent. On 5-30-14 at 9:40 AM, Surveyor # interviewed Resident #11 and asked if she received necessary assistance to complete her ADLs, including to get to the toilet. Resident #11 stated in the interview she is "diapered now, because I cannot walk." Resident #11 also stated she is "trained to be incontinent" and was "told I have to hoyered (transferred from surface to surface with a mechanical lift), and they don't have enough people (staff)." On 5-30-14 at approximately 11:50 AM, Surveyor # interviewed Certified Nursing Assistant (CNA)-I, and asked what she does to assist the resident with her elimination needs. CNA-I stated Resident #11 is assisted back to bed to check and change her incontinence brief every two hours. On 5-30-14 at 1:00 PM, Surveyor # related the above interviews and information from the resident's clinical record with respect to the resident's decline in her urinary status. On 6-2-14 at 1:15 PM, RN-L presented an updated assessment dated [DATE], that included a new three day voiding pattern record initiated on 5-30-14 to 6-1-14, wherein Resident #11 was offered the bedpan. The new evaluation also reviews possible causes for the resident's decline in her urinary status, information from a 2-20-14 diagnostic MRI report, that diagnosed spinal herniation/stenosis at the C3 - C4 level. RN-L also stated the resident will going forward be offered opportunities to use the toilet/commode or bedpan on at least every two hour intervals.