Every finding on record at Whispering Pines Nursing and Rehab, LLC

Based on observation, interview, and record review, the facility did not ensure care and treatment were provided to prevent the development of pressure injuries and/or promote healing for 2 residents (R) (R3 and R7) of 2 sampled residents in a total sample of 18 residents. R3 is being cited at severity level 3 (actual harm/isolated). R2 is being cited at severity level 2 (potential for more than minimal harm).R3 was determined to be at risk for pressure injury development. Interventions were not implemented upon this determination. R3 developed multiple pressure injuries within 12 days of admission. Treatment orders in R3's medical record were not consistent with written orders and were not correctly followed or consistently completed. In addition, care plan interventions were not consistently implemented and infection control standards were breached during wound care. R7 had a stage 3 pressure injury on the coccyx. A treatment order was changed on 8/18/26 but was not implemented until 8/25/26. Findings include: The facility's Pressure Injury Prevention and Wound Care Management policy, revised 8/25/25, indicates: A resident who has a pressure injury will receive care and services to promote healing and prevent additional ulcers. The facility's Care of the Diabetic Resident, revised 6/30/25, indicates: .6. Diabetic foot care: a. Provide foot care or inspection as needed based on resident needs, per provider orders, and per state and federal regulations for foot health. Report abnormalities or concerns to the licensed nurse and/or practitioner as applicable; b. Provide treatments to feet as ordered . The facility's Infection Control Program, revised 5/8/24, indicates: The infection control program exists to ensure a safe, sanitary, and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of disease and infection. R3 was admitted to the facility on [DATE] due to falls, syncope, and a left wrist fracture and had a diagnosis of diabetes mellitus type 2 with diabetic neuropathy. An admission Minimum Data Set (MDS) assessment, dated 7/20/26, stated R3 had a Brief Interview for Mental Score (BIMS) of 15 out of 15, indicating intact cognition. Between 8/26/26 and 8/27/26, Surveyor reviewed R3's medical record. Braden Scale (a clinical tool to predict the risk of developing pressure injuries with scores ranging from 6 to 23; lower scores mean a higher risk for skin breakdown) assessments indicated the following: ~ 7/16/26 - Score: 19; Low risk~ 7/23/26 - Score: 16; At risk (No new interventions were added to R3's care plan.)~ 7/24/26 - Score: 13; Moderate risk (Interventions were added to R3's care plan on 7/27/26.) ~ 7/31/26 - Score: 14; Moderate risk~ 8/7/26 - Score: 15; At risk~ 8/18/26 - Score: 16; At risk A care plan, initiated 7/17/26, indicated R3 had diabetes mellitus. The care plan contained interventions to check body for skin alterations and treat promptly as ordered by doctor (dated 7/17/26) and inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness (dated 7/17/26). A care plan, initiated 7/16/26, indicated R3 had limited physical mobility related to left wrist fracture and left foot. The care plan contained an intervention to wear a heel boot to the left foot while up (initiated 7/27/26). A care plan, initiated 7/27/26, indicated R3 was at risk for alteration in skin integrity related to decreased mobility and had pressure injuries on the left heel (7/26/26); left plantar foot (7/26/26); coccyx (7/28/26); and a deep tissue injury (DTI) on the bottom of the left foot (8/18/26). The care plan contained the following interventions: Heel boots to bilateral feet at all times (initiated 7/27/26; revised 8/21/26); Air mattress to relieve pressure, set to 300 pounds, alternating pressure every 10 minutes (initiated 7/28/26; revised 7/29/26); Keep skin clean and dry (initiated 7/27/26); Take off foot pedals when just sitting in chair, not transferring (initiated 8/18/26); Turn and reposition at least every 2 hours per tolerance and schedule (initiated 7/27/26); Use a draw sheet and 2 people when pulling resident up in bed (to prevent shear) (initiated 7/27/26; revised 7/29/26); Use a pressure relieving cushion in wheelchair (initiated 7/27/26; revised 7/29/26); Use A&D ointment, BAZA (skin protectant/moisture barrier ointment), or other skin barrier cream as needed (initiated 7/27/26) (R3's care plan did not include risk for alteration in skin integrity related to decreased mobility until 7/27/26.) On 8/26/26, Surveyor reviewed R3's Kardex (an abbreviated care plan used by nursing staff) which indicated: Mobility/transfer: Will wear heel boot to left foot while up; Skin: Heel boot to left foot at all times; Can wear footwear of choice on right foot; Take off foot pedals when just sitting in chair, not transferring; Turn and reposition at least every 2 hours per tolerance and schedule. A progress note on 7/25/26 at 5:38 AM by Registered Nurse (RN)-L indicated at approximately 10:00 PM on 7/24/26, RN-D (who worked the PM shift) reported to RN-L that Certified Nursing Assistant (CNA)-P informed them that a blister on R3's left heel had burst and was draining. RN-D asked RN-L to assess R3's left heel. RN-L assessed R3's heel at 10:20 PM and documented the following wounds on the left foot: ~ Left 5th toe - Laceration approximately 0.5 centimeters (cm) (length) x 0.2 cm (width). No exudate. Redness (outlined and not included in the measurement) was noted from the 5th toe to the lateral side of the foot. RN-L cleansed the area with wound cleanser and applied Betadine. ~ Plantar, ball of left foot - Intact circular bluish ulcer approximately 3.7 cm x 7.2 cm. RN-L cleansed the area with wound cleanser and applied Betadine. ~ Left heel - Moderate amount of exudate from a burst left heel blister approximately 6.5 cm x 8 cm. RN-L cleansed the area with wound cleanser, applied Betadine, an ABD pad, and wrapped the area in Kerlix. The progress noted indicated R3 denied pain or discomfort but stated they were working with physical therapy on a pedal bike. R3's lower legs were offloaded off the bed with pillows and heel boots were applied. RN-L instructed R3 not to apply pressure to the left foot, to wear heel boots in bed, and to wear the left heel boot at all times. RN-L assessed R3's right foot with no concerns. RN-L notified Former Director of Nursing (FDON)-Q (who no longer worked at the facility) and the physician. The note indicated the wound RN would assess and staff should continue to monitor via the 24-hour board to ensure the redness did not pass the outline. R3 was non-weight bearing on the left foot. Progress notes on 7/26/26 at 1:33 PM and 2:07 PM indicated R3 had an open area on the coccyx that appeared to be caused by shear. The area was cleansed and Mepilex was applied. The wound was 11.22 cm squared. (Treatment orders for the wound were not entered in R3's Treatment Administration Record (TAR) until 7/28/26 when the wound was identified as a pressure injury.) R3's TAR contained the following orders: 7/16/26–8/2/26: Diabetic foot check: Notify provider if any concerns noted at bedtime for diabetic protocol (PM shift) 7/27/26-present: Diabetic foot check: Notify provider if any concerns every night (NOC) shift related to type 2 diabetes mellitus with diabetic neuropathy (The TAR indicated the order wasn't completed on 8/20/26.) 7/25/26-7/28/26: Left heel: Cleanse with wound cleanser, pat dry, apply Betadine, ABD, then Kerlix; Left plantar/ball of foot: Apply Betadine and leave open to air; Left 5th toe: Cleanse with wound cleanser, pat dry, apply Betadine, and leave open to air every PM shift for wound care until assessed by wound RN. 7/28/26–8/4/26: Left heel: Cleanse with wound cleanser, pat dry, apply Betadine, ABD, then Kerlix two times daily for wound care; Left plantar forefoot: Cleanse with wound cleanser, pat dry, apply Betadine two times daily for wound care. 8/4/26–8/18/26: Left heel: Cleanse with wound cleanser, pat dry, apply Betadine moistened gauze, cover with ABD, and secure with Kerlix every AM shift for wound care. (The TAR indicated the treatment wasn't completed on 8/5/26, 8/6/26, 8/12/26, and 8/13/26); Left plantar forefoot: Cleanse with wound cleanser, pat dry, apply Betadine moistened gauze, cover with ABD, and secure with Kerlix every AM shift for wound care. (The TAR indicated the treatment wasn't completed on 8/5/26, 8/6/26, 8/12/26, 8/13/26, and 8/14/26.) 8/18/26–8/25/26: Left plantar forefoot, medial lateral plantar, heel: Cleanse with wound cleanser, pat dry, apply Betadine moistened gauze, cover with ABD, and secure with Kerlix every AM shift for wound care. (The TAR indicated the treatment wasn't completed on 8/21/26.) 8/25/26–present: Left heel: Apply Betadine moistened gauze, cover with ABD, and secure with Kerlix every AM shift for wound care; Left plantar forefoot: Cleanse with wound cleanser, pat dry, apply honey fiber sheet. 7/28/26-8/4/26: Coccyx: Cleanse with wound cleanser, pat dry, apply skin prep to peri wound, Medihoney to wound bed, and cover in silicone foam dressing every AM shift for wound care. (The TAR indicated the treatment wasn't completed on 7/29/26.) 8/4/26–8/14/26: Coccyx: Cleanse with wound cleanser, pat dry, apply skin prep to peri wound, Medihoney followed by calcium alginate to wound bed, and cover in silicone foam dressing every AM shift for wound care. (The TAR indicated the treatment wasn't completed on 8/6/26.) 8/14/26–8/18/26: Coccyx: Cleanse with wound cleanser, pat dry, apply skin prep to peri wound, apply Iodosorb to wound bed, apply calcium alginate to wound bed, and cover with silicone foam dressing every AM shift for wound care. 8/18/26–8/25/26: Coccyx: Cleanse with wound cleanser, pat dry, apply skin prep to peri wound, apply Medihoney to wound bed, apply calcium alginate to wound bed, and cover with silicone foam dressing every AM shift for wound care. (The TAR indicated the treatment wasn't completed on 8/19/26 and 8/21/21.) 8/25/26-present: Coccyx: Cleanse with wound cleanser, pat dry, apply skin prep to peri wound, apply honey fiber sheet to wound bed, and cover with silicone foam dressing every AM shift for wound care. On 8/13/26, an as needed (PRN) treatment was completed for the order: Coccyx: Cleanse with wound cleanser, pat dry, apply skin prep to peri wound, Medihoney followed by calcium alginate to wound bed, and cover in silicone foam dressing as needed if soiled. Surveyor reviewed Wound Clinic (WC)-G notes written by Medical Doctor (MD)-O and scanned into R3's medical record that indicated the following: 7/28/26: Site 1: Unstageable deep tissue injury (DTI) of the left heel undetermined thickness; Pressure; 56 square cm; Moderate serous exudate with dried fibrinous exudate (scab); Primary dressing: Leptospermum honey apply once daily and as needed if saturated, soiled, or dislodged. For 30 days; Secondary Dressing: Superabsorbent gelling fiber with silicone border and faced apply once daily and as needed if saturated, soiled, or dislodged. For 30 days. Site 2: Unstageable DTI of the left, lateral foot undetermined thickness; Pressure; 30 square cm; No exudate; Skin intact with purple/maroon discoloration; Primary Dressing: Betadine apply once daily and as needed if saturated, soiled, or dislodged. For 30 days; Secondary dressing: Gauze island with border 4-inch x 10-inch apply once daily and as needed if saturated, soiled, or dislodged. For 30 days. (The order was entered in R3's TAR as twice daily, not daily as written.) Site 3: Unstageable DTI coccyx undetermined thickness; Pressure; 40.5 square cm; Moderate serous exudate with dried fibrinous exudate; Primary Dressing: Leptospermum honey apply once daily and as needed if saturated, soiled, or dislodged. For 30 days; Alginate calcium apply once daily and as needed if saturated, soiled, or dislodged. For 30 days. 8/4/26: Site 1: Unstageable DTI of the left heel undetermined thickness; Pressure; 44.2 square cm; No exudate; Skin intact with purple/maroon discoloration; Primary Dressing: ABD pad apply twice daily and as needed if saturated, soiled, or dislodged. For 30 days; Betadine apply twice daily and as needed if saturated, soiled, or dislodged. For 30 days; Secondary Dressing: Gauze roll 4.5 inches apply twice daily and as needed if saturated, soiled, or dislodged. For 30 days. (This order was entered in R3's TAR as once daily in the AM, not twice daily as ordered.) Site 2: Unstageable DTI of the left, lateral foot undetermined thickness; Pressure; 18 square cm; No exudate; Skin intact with purple/maroon discoloration; Primary Dressing: Betadine apply once daily and as needed if saturated, soiled, or dislodged. For 30 days; Secondary dressing: Gauze island with border 4-inch x 10-inch apply once daily and as needed if saturated, soiled, or dislodged. For 30 days. (This order was entered in R3's TAR as once daily in the AM, not twice daily as ordered.) Site 3: Unstageable DTI coccyx undetermined thickness; Pressure; 3.5 square cm; Moderate serous exudate and dried fibrinous exudate; Primary Dressing: Leptospermum honey apply once daily and as needed if saturated, soiled, or dislodged. For 24 days; Alginate calcium apply once daily and as needed if saturated, soiled, or dislodged. For 24 days. 8/18/26: Site 1: Unstageable DTI of the left heel undetermined thickness; Pressure; 36 square cm; No exudate; Skin intact with purple/maroon discoloration; Primary Dressing: ABD pad apply twice daily and as needed if saturated, soiled, or dislodged. For 17 days; Betadine apply twice daily and as needed if saturated, soiled, or dislodged. For 17 days; Secondary Dressing: Gauze roll 4.5 inches apply twice daily and as needed if saturated, soiled, or dislodged. For 17 days. Site 2: Unstageable DTI of the left lateral foot undetermined thickness; Pressure; 22 square cm; No exudate; Skin intact with purple/maroon discoloration; Primary Dressing: Betadine apply twice daily and as needed if saturated, soiled, or dislodged. For 10 days; ABD pad apply twice daily and as needed if saturated, soiled, or dislodged. For 17 days; Secondary dressing:Gauze roll 4.5 inches apply twice daily and as needed if saturated, soiled, or dislodged. For 17 days. Site 3: Stage 3 pressure wound coccyx full thickness; Pressure; 8.9 square cm; Moderate serous exudate; Thick adherent devitalized necrotic tissue: 20%; Granulation tissue: 80%; Primary Dressing: Leptospermum honey apply once daily and as needed if saturated, soiled, or dislodged. For 10 days; Alginate calcium apply once daily and as needed if saturated, soiled, or dislodged. For 10 days; Secondary Dressing: Superabsorbent gelling fiber with silicone border and faced apply once daily and as needed if saturated, soiled, or dislodged. For 1 day. Site 3: Surgical excisional debridement procedure: Remove necrotic tissue and establish the margins of viable tissue. Site 5: Diabetic wound of the left, distal, plantar foot full thickness; Duration: > 6 days; 8 square cm; Depth is unmeasurable due to nonviable tissue and necrosis; No exudate; Thick adherent devitalized necrotic tissue: Primary Dressing:Betadine apply once daily and as needed if saturated, soiled, or dislodged. For 30 days. 8/25/26: Site 1: Unstageable DTI of the left heel undetermined thickness; Pressure; 39 square cm; No exudate; Skin intact with purple/maroon discoloration; Primary Dressing: ABD pad apply once daily and as needed if saturated, soiled, or dislodged. For 10 days; Betadine apply once daily and as needed if saturated, soiled, or dislodged. For 10 days; Secondary Dressing: Gauze roll 4.5 inches apply once daily and as needed if saturated soiled, or dislodged. For 10 days. Site 2: Unstageable DTI of the left distal, lateral foot undetermined thickness (resolved 8/25/26); Follow up only as needed. Site 3: Stage 3 pressure wound coccyx full thickness; 7.2 square cm; Moderate serous exudate; Slough: 20%; Granulation tissue: 80%; Primary Dressing: Alginate honey-impregnated apply once daily and as needed if saturated, soiled, or dislodged. For 30 days; Secondary Dressing: Superabsorbent gelling fiber with silicone border and faced apply once daily and as needed if saturated, soiled, or dislodged. For 30 days. Site 3: Sharp selective debridement procedure: Remove dried exudate or debris Site 5: Unstageable (due to necrosis) of the left, distal, plantar foot full thickness; Pressure; Duration: > 12 days; 19.25 square cm; Depth is unmeasurable due to nonviable tissue and necrosis; Moderate serous exudate; Thick adherent devitalized necrotic tissue: 100%; Primary Dressing: Betadine apply once daily and as needed if saturated, soiled, or dislodged. For 30 days; Alginate honey-impregnated apply once daily and as needed if saturated, soiled, or dislodged. For 30 days; Secondary Dressing: Superabsorbent gelling fiber with silicone border and faced apply once daily and as needed if saturated, soiled, or dislodged. For 30 days. (The order was entered in R3's TAR for ABD secondary dressing, not superabsorbent gelling fiber with silicone border and faced secondary dressing as ordered.) During an observation of wound care, Surveyor noted the ABD was removed. (See wound care observation below.) Site 5: Surgical excisional debridement procedure: Remove necrotic tissue and establish margins of viable tissue. Risk Management documentation for R3's wounds indicated: New pressure ulcer dated 7/24/26 at 10:20 PM and included documentation as described in RN-L's nursing note on 7/25/26 as noted above. The document included a notes section dated 7/28/26 by FDON-Q that indicated: New (injuries) are noted to R3's left heel and left lateral forefoot. Root Cause: R3 was noted to have left foot pressed against the footboard intermittently. Interventions: R3 is to offload the area, heel boot to left foot at all times while not transferring or walking with therapies. On 8/26/26 at 8:45 AM, Surveyor interviewed R3 who stated staff noticed a blister on the back of their heel two days after admission and initially thought it was from the exercise bike in physical therapy. R3 skipped the exercise bike in their next therapy session, however, two more blisters appeared on the left foot. R3 stated they also had a sore at the top of their buttocks. R3 thought the wounds were healing and stated their dressings were changed that morning. During the interview, R3 was sitting in their wheelchair. R3's left foot was wrapped with gauze from the toes to above the ankle. R3 had a sock on the right foot. Both feet were resting on top of the metal bar of a bedside table in front of R3. On 8/26/26 at 9:54 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who had just assisted R3 from the bathroom into their wheelchair. R3's feet were on the foot pedals of the wheelchair. CNA-I stated R3 puts their feet on the foot pedals and wears heel boots when they are in bed. CNA-I stated R2 was fairly mobile and could reposition themself. CNA-I stated if R3 does not reposition themself, CNA-I reminds them to every two hours. CNA-I stated R3 uses the bathroom approximately four times per shift and is repositioned then also. On 8/26/26 at 10:03 AM, Surveyor interviewed R3 and Family Member (FM)-S who indicated R3 is 6 feet 2 inches tall. FM_S stated R3's bed upon admission was too short and their feet touched the footboard. R3 stated they did not have heel boots at that time but were elevating their legs on pillows at night. R3 and FM-S did not recall when staff removed the footboard or provided R3 with a different mattress and a longer bed. FM-S stated R3 did not have any pressure injuries prior to admission. R3 stated their wounds were still black but gradually diminishing. R3 stated staff did not tell them to reposition, however, one of their family members was a nurse and encouraged them to reposition to offload pressure on their coccyx. On 8/26/26 at 11:44 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-J who stated it was R3's choice to wear a heel boot on the left foot, leave the foot pedals on their wheelchair, and wear a shoe on the right foot. When Surveyor informed ADON-J that R3's position at 9:45 AM did not match their care plan or Kardex and that CNA-I positioned R3 and stated it was in accordance with R3's care plan, ADON-J verified CNAs access care plans via the computer. On 8/26/26, ADON-J provided Surveyor a Risks versus Benefits document, dated 8/26/26 at 12:30 PM, that indicated: 1. Recommendations: Do not use foot pedals while sitting up in wheelchair in room and not transferring from area to area. 2. Discipline making recommendation: Nursing, Administration, therapy, wound care MD, and team3. Benefits associated with choosing not to follow recommendations: Resident comfort4. Risks associated with choosing not to follow recommendations: With the way R3 sets their foot on the pedal, there is an increase in worsening of current wounds and a possibility of new wounds. 5. Conclusion: R3 has been educated on reasons to not use foot pedals all the time and let their foot rest on the floor versus the end of the pedal. R3 will try to do that more often. 6. Date discussed with resident/representative party: 8/26/26 at 12:00 PM On 8/26/26 at 2:05 PM, Surveyor interviewed R3 who was sitting in their wheelchair without foot pedals. R3 was wearing a gripper sock on the left foot which was resting on the metal bar of their bedside table and in contact with the floor. R3 was not wearing a left heel boot. R3 stated they did not mind heel boots and followed staffs' suggestions. R3 could not recall who removed the heel boot or when it was removed. R3 stated their feet did not hurt because of neuropathy and the pain would have to be severe for them to feel it. On 8/26/26 at approximately 2:15 PM, Surveyor and CNA-K observed R3 in a wheelchair in their room. The wheelchair did not have foot pedals and R3 did not have a boot on the left foot. R3 had a shoe on the right foot. When Surveyor asked CNA-K how R3 should be positioned, CNA-K stated the wheelchair pedals should be off unless staff are transferring R3 or unless they want them on. CNA-K stated R3 should wear a heel boot on the left foot at all times and indicated they wear a heel boot on the right foot at times which was recently implemented. When Surveyor asked if R3's care plan interventions were currently implemented as Surveyor and CNA-K were observing R3 from the hallway, CNA-K stated that was usually how R3 sat and they did not have concerns with R3's position or interventions. (CNA-K did not acknowledge that R3 was not wearing a left heel boot and did not offer to apply the boot.) On 8/27/26 at approximately 8:45 AM, Surveyor asked Director of Nursing (DON)-B if they could observe wound care for R3's left foot. At 10:00 AM, DON-B informed Surveyor they were changing the wound care orders for R3's left foot because two treatments for two wounds were entered as one order and the order did not indicate how to apply Medihoney. On 8/27/26 at 10:42 AM, Surveyor observed Licensed Practical Nurse (LPN)-M complete wound care for R3's left foot. At 10:50 AM, ADON-J entered the room to assist. Treatment items were on the bedside table. LPN-M used bandage scissors to remove Kerlix secured with tape which was dated 8/26. LPN-M removed one ABD pad from R3's heel and one from the distal plantar of the foot. LPN-M used wound cleanser to loosen two layers of dressings from each of the wounds; honey fiber and Betadine-soaked gauze. After LPN-M cleansed the wounds, they cut honey fiber to size for both wounds with the same bandage scissors used to cut the soiled Kerlix. LPN-M then placed Betadine-soaked gauze and honey fiber on the heel wound. When ADON-J asked if honey fiber went on both wounds, LPN-M stated yes and indicated that is what R3 had on each wound. ADON-J showed LPN-M a handwritten note and instructed them to remove the honey fiber and place only Betadine-soaked gauze on the heel followed by an ABD pad. ADON-J stated the heel should be cleansed, patted dry, covered with Betadine-soaked gauze, and covered with an ABD pad and indicated the same ABD pad also covered the mid-plantar area that was not open and was just for protection. LPN-M continued to place Betadine-soaked gauze on the distal plantar portion of R3's left foot when ADON-J stopped LPN-M and instructed them to put honey fiber on the wound, cover with an ABD pad, and wrap with Kerlix. LPN-M left the room to retrieve another piece of honey fiber. Upon return, LPN-M completed the treatment, applied Kerlix, and dated and initialed the tape. LPN-M put a gripper sock on R3's right foot and applied a heel boot on the left foot. After the treatment was completed at 11:15 AM, LPN-M gathered supplies and took them back to the treatment cart in a plastic bin that contained the bandage scissors, an unopened dressing, wound cleanser, and a Sharpie. LPN-M put an unopened package of honey hydrogel and a bottle of Dermal wound cleanser in the treatment cart. The bin was previously observed on R3's bedside table without a barrier. The wound cleanser touched the bedside table, the floor, and soiled gloves, and the scissors were not cleaned following wound care. LPN-M wiped a spot off the top of the cart with an alcohol wipe and cleansed hands. On 8/27/26 at 11:21 AM, Surveyor interviewed LPN-M who stated they check current treatment orders in a resident's medical record and gather supplies from the treatment cart. When Surveyor asked LPN-M about treatment items that were in R5's room and put back in the treatment cart, LPN-M stated that was not their usual practice. LPN-M stated they planned to cleanse the items when they got back to the cart but there were no wipes on the cart. On 8/27/26 at 12:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated staff should follow a resident's care plan and Kardex. When Surveyor requested information regarding R3's footboard and air mattress, NHA-A stated a bed extender was placed on 7/24/26 and an air mattress was installed on 7/28/26. On 8/27/26 at approximately 2:00 PM, Surveyor informed Regional Director of Operations (RDO)-C that the orders on R3's TAR did not match MD-O's orders. The facility was not aware of the discrepancies. At approximately 3:00 PM, RDO-C informed Surveyor that RN-H received verbal orders from MD-O and the verbal orders that were entered did not match the written orders. On 8/27/26 at 3:36 PM, Surveyor interviewed RN-H who verified they were wound certified and rounded with MD-O on Tuesdays. RN-H stated they began rounds sometime in early August 2026 and did not round with MD-O on 7/28/26. RN-H stated R3's heel was stable and the left forefoot was stable with eschar. RN-H stated DTIs evolve as they start with non-blanchable purple or stable eschar. RN-H stated if the DTI becomes unstable, they try to debride with honey first to remove slough from the wound. RN-H stated even though a wound measures smaller, the wound can be considered deteriorating if there is enough slough. RN-H stated DTIs like R3's can happen quickly in residents with diabetes and neuropathy, can occur in 20 minutes, and be caused by something as simple as a shoe rubbing. RN-H stated they write down all verbal orders when they round with MD-O. After rounds, RN-H enters the verbal orders in residents' medical records which are then active treatment orders. After rounds, MD-O leaves the facility, writes notes, and provides them to the facility. RN-H stated when the orders are received, they are not in the facility and do not have the ability to view the written orders provided by MD-O. RN-H stated the facility needs to return to how they used to do orders during wound rounds which included writing verbal orders and having MD-O verify the orders prior to leaving the facility. On 8/27/26 at 4:12 PM, Surveyor interviewed MD-O who stated R3's wounds are sometimes unavoidable due to diabetes and small vessel disease. MD-O stated R3's heel wound was getting smaller and they were only using Betadine. MD-O stated R3's coccyx wound was improving, but the lateral plantar wound by the toes had increased in size. MD-O stated that wound was pressure, however, diabetes and small vessel disease can compound the size of the wound due to poor healing. MD-O stated sometimes R3 can be non-compliant which increases wound deterioration. MD-O stated they are in the facility twice a week and do not have concerns with communication with staff. MD-O stated they call with clarification as needed. Surveyor was unable to verify through interviews and record review the presence of R3's left foot pressure injuries prior to the initial documentation dated 7/25/26 at 5:38 AM by RN-L. 2. R7 was admitted to the facility on [DATE] and had diagnoses including relapsing multiple sclerosis, type 2 diabetes, and peripheral vascular disease. An MDS assessment, dated 7/13/26, stated R7 had a BIMS score of 3 out of 15, indicating severely impaired cognition. On 8/26/26, Surveyor reviewed R7's medical record. R7 saw Wound Clinic (WC)-G weekly for a stage 3 pressure injury on the coccyx. R7's medical record contained the following order: ~ Coccyx: Clean with wound cleanser and dry well. Apply collagen to wound bed (dated 7/21/26; discontinued 8/24/26) A wound note from WC-G on 8/18/26 indicated there was a change in R7's wound care orders and stated Primary Dressing: Leptospermum honey apply once daily and as needed. Alginate calcium apply once daily and as needed. Wound notes from WC-G on 8/21/26 and 8/25/26 contained the following order: Primary Dressing: Leptospermum honey apply once daily and as needed. Alginate calcium apply once daily and as needed. On 8/25/26, Registered Nurse (RN)-H entered the following order in R7's medical record: Coccyx: Clean with wound cleanser and dry well. Apply honey fiber to wound bed. (Of note: Honey fiber is a product that includes both Leptospermum honey and alginate calcium.) On 8/26/26 at 11:51 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the order from WC-G on 8/18/26 was not entered into R7's medical record until 8/25/26. DON-B indicated RN-H is in the facility on Tuesday evenings to round with the wound physician and enters orders after they are finished. On 8/26/26 at 2:35 PM, Surveyor interviewed RN-H who indicated they had been in the facillity for a couple of weeks on Tuesdays to round with the wound doctor from WC-G. RN-H indicated they switched R7's treatment to honey fiber on 8/25/26. When Surveyor informed RN-H that WC-G's notes indicated the order was implemented on 8/18/26 but was not entered in R7's medical record until 8/25/26, RN-H indicated they and the wound doctor stand outside residents' rooms and record orders. RN-H enters the orders from their handwritten notes after they are finished with rounds. RN-H stated after the wound doctor writes paper notes after they leave and sends them to the facility. RN-H stated they do not see the paper notes so if something changes after rounds, they would not know.

Based on interview and record review, the facility did not ensure grievances were thoroughly completed, investigated, or resolved for 11 residents (R) (R1, R2, R5, R9, R10, R11, R12, R13, R14, R15, and R16) of 15 sampled residents in a total sample of 18 residents. Ten grievances involving care concerns that affected R1, R2, R5, R9, R10, R11, R12, R13, R14, R15, and R16 were not thoroughly completed, investigated, or resolved.Findings include:The facility's Grievance/Concern policy, revised 10/29/24, indicates: .The facility will make prompt efforts to resolve all grievances .The Administrator or designee is the Grievance Official who is responsible for .leading necessary investigations by the facility .Staff will immediately report all alleged violations involving neglect, abuse .by anyone furnishing services on behalf of the facility to the Administrator .The grievance form includes .the steps being taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, whether the grievance was confirmed or not confirmed, corrective action taken or to be taken, and the date the written decision was issued .The facility will take appropriate corrective action in accordance with state and federal regulations if the alleged violation of a resident's rights is confirmed by the facility or if an outside entity having jurisdiction confirms a violation for any resident's rights within it's area of responsibility.1. On 1/30/26, R1 filed a grievance related to call light response time and care needs not being met. The Resolution section of the grievance form was not fully completed and the Administrator's signature was left blank. (A Minimum Data Set (MDS) assessment, dated 1/30/26, stated R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition.)2. On 6/12/26, a Certified Nursing Assistant (CNA) reported that R2 and R15 were soaked through when laid down. CNA-R was working in their hallway. The investigation section of the grievance was filled out on 6/15/26 and indicated CNA-R was reminded of care needs and basics, to ask for help, and to seek the nurse or the Director of Nursing (DON)/Assistant Director of Nursing (ADON) if they need transfer and mobility assistance. CNA-R indicated they understood. The Resolution section of the grievance was not fully completed and the Administrator's signature was left blank. (An MDS assessment, dated 7/28/26, stated R2 had a BIMS score of 6 out of 15, indicating severely impaired cognition. An MDS assessment, dated 7/22/26, indicated R15 was rarely/never understood.)3. On 8/10/26, R5 filed a grievance related to difficulty with staff when asking to be put in their chair. The grievance form was not fully completely and the Administrator's signature was left blank. (An MDS assessment, dated 6/10/26, stated R5 had a BIMS score of 11 out of 15, indicating moderately impaired cognition.)4. On 6/26/26, R9 reported to staff they felt like they were treated like an animal due to lack of communication/introduction by staff. Former Director of Nursing (FDON)-Q wrote in the investigation section on 6/29/26: (R9) appears to have settled into new surroundings and stated this is very different from home .Staff are stating names and has a better understanding of new routine. The investigation did not identify the staff, shift, or date(s) R9 may have referred to. The Resolution section of the grievance was partially blank and did not contain the Administrator's signature. (An MDS assessment, dated 7/7/26, stated R9 had a BIMS score of 14 out of 15, indicating intact cognition.)5. On 6/7/26, R10 reported to staff that the girls working that day were not very nice and were crabby and walked away when R10 asked for things. An investigation was completed on 6/11/26 FDON-Q. The Findings and Disposition section indicated: Writer met with (R10) who couldn't state who they were speaking about specifically. Customer service education added to all staff Relias education. The Administrator's signature and date were left blank. Surveyor noted R10 reported a specific date in the grievance. The investigation did not include which staff were working in R10's hall on 6/7/26 and the investigation was not completed until 4 days after the grievance was filed. (An MDS assessment, dated 6/23/26, stated R10 had a BIMS score of 15 out of 15, indicating intact cognition.)6. On 7/8/26, R11 expressed frustration with an AM CNA on 7/7/26 (related to not getting a shower) and 7/8/26 (R11 did not want to provide details). The investigation was not completed by Social Workers (SW)-E until 8/10/26. (An MDS assessment, dated 7/22/26, stated R11 had a BIMS score of 15 out of 15, indicating intact cognition.)7. On 8/10/26, R12's family member filed a grievance that indicated R12 had to wait too long for a call light and sat in a soiled brief for too long due to the wait. SW-E completed the investigation portion of the grievance on 8/13/26. The Findings and Disposition section indicated: SW-E and another staff discussed incontinence with R12 and their family member and reminded them to use their call light if their brief is wet. The investigation did not include interviews with other residents or staff who worked during that timeframe or a review of call light response times. (An MDS assessment, dated 8/25/26, stated R12 had a BIMS score of 7 out of 15, indicating severely impaired cognition.)8. On 6/11/26, R13 informed staff that CNA staff keep shutting off their call light off without getting them up. FDON-Q completed the investigation section of the form on 6/15/26 which indicated: Spoke with R13 who stated this day was not normal. The investigation did not identify or include a statement from the CNAs who worked that day. The Resolution section of the grievance was not fully completed and the Administrator's signature was left blank. (An MDS assessment, dated 6/18/26, stated R13 had a BIMS score of 15 out of 15, indicating intact cognition.)9. On 6/24/26, R14 filed a grievance that indicated they were not washed up or changed since 6/23/26. The investigation was not completed until 8/10/26 by SW-E. (An MDS assessment, dated 8/3/26, stated R14 had a BIMS score of 14 out of 15, indicating intact cognition. R14 passed away on 7/29/26.) 10. On 6/29/26, CNA-R reported during shift change rounds that they did not have time to change R14, R15, and R16. The reporting CNA noted R15 was soaked through their brief and pants. FDON-Q wrote on 6/29/26 that CNA-R was spoken to regarding continued care concerns with incontinence care. The grievance did not indicate follow-up was completed and the Administrator's signature was left blank. In addition, FDON-Q did not interview R14 who was able to be interviewed. (An MDS assessment, dated 8/3/26, stated R14 had a BIMS score of 14 out of 15, indicating intact cognition. An MDS assessment, dated 7/22/26, indicated R15 was rarely/never understood. An MDS assessment, dated 6/26/26, stated R16 had a BIMS score of 14 out of 15, indicating intact cognition.) On 8/26/26 at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A, Regional Director of Operations (RDO)-C, and SW-E. When Surveyor noted some of the grievances were reported in June but were not completed until 8/10/26, SW-E stated they were cleaning an office and found grievances that had not been addressed. NHA-A and RDO-C confirmed the grievances were not fully addressed or completed timely.

Based on interview and record review, the facility did not ensure allegations of abuse/neglect were thoroughly investigated for 5 residents (R) (R8, R10, R11, R17, and R18) of 15 sampled residents in a total sample of 18 residents. The facility did not thoroughly investigate allegations of abuse/neglect for R8, R10, R11, R17, and R18.Findings include:The facility's Vulnerable Adult Abuse and Neglect Prevention policy, revised 7/9/26, indicates: .4. Investigation: a. Upon receiving a complaint of alleged mistreatment, the Administrator must be notified immediately, and they, the Director of Nursing (DON), or assigned designee will coordinate an investigation, which will include completion of witness statements. b. All parties involved including two of the following - staff, residents, or visitors who were potentially involved .c. When a specific staff member is implicated in the alleged event, the person will be removed from the resident's care area immediately, interviewed by the supervisor assigned, asked to provide a written statement, and suspended until the investigation is completed. d. Investigations shall include witness interviews, resident interviews when possible, review of clinical records .and determination of root cause and corrective actions. Investigations shall begin immediately upon receipt of an allegation and continue until sufficient facts are obtained to determine findings and corrective actions. Follow-up in the form of additional medical and psychological examination and treatment will be documented and implemented, as well as continuing communication with the resident's responsible party. The investigation and written findings are completed and reviewed with the Administrator, DON, and Director of Social Services. On 8/26/26, Surveyor reviewed the facility's grievance file and noted the following allegations of abuse/neglect were not reported to State Agency (SA) or thoroughly investigated:~ On 6/29/26, A Certified Nursing Assistant (CNA) reported that weekend staff do not get R8 up for lunch or change them during the day and they do not get lunch or changed a lot of weekends. The investigation section of the grievance was completed by Former Director of Nursing (FDON)-Q on 6/29/26 and indicated R8 had only eaten 0-25% three times in the last 21 days. R8 weighed 153.4 pounds (lbs) on 6/1/26 and 157.8 lbs on 6/21/26 and their weight was stable. The facility could not provide a thorough investigation for the allegation of neglect, including resident and staff interviews. (A Minimum Data Set (MDS) assessment, dated 7/13/26, stated R8 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition.~ On 6/8/26, R10 reported to therapy staff that they wanted to transfer facilities because staff either do not respond to their call light or enter their room and turn their call light off without providing assistance. R10 stated it happens every night. R10 also reported concerns of not being able to breathe, needing to toilet, and needing repositioning which were not addressed. The investigation section was completed by FDON-Q on 6/8/26 and indicated they spoke with R10 and their spouse in depth. R10 was upset regarding a staff member and the issues were addressed. R10 was pleased with the outcome and stated they had not had a night like that again. The facility could not provide a thorough investigation for the allegation of neglect, including interviews with staff and residents. (An MDS assessment, dated 6/23/26, stated R10 had a BIMS score of 15 out of 15, indicating intact cognition.)~ On 6/9/26, R11's family member reported that R11 told them they want to die. R11 stated a (named) CNA is very rude and always complains when they use their call light. R11 stated the CNA enters their room huffing and puffing and says Jesus Christ and is always angry. The investigation indicated Social Worker (SW)-E spoke with R11 and their family member. R11 stated the (named) CNA and CNA-R are bossy and rude when their call light is on. R11 stated the staff are not physical with them, however, they are concerned with their attitude and how they talk to them. The follow-up section indicated customer service education was assigned to both CNAs. The facility could not provide a thorough investigation for R11's allegation of abuse, including resident and staff interviews or assigned/completed education for the CNAs. (An MDS assessment, dated 7/22/26, stated R11 had a BIMS score of 15 out of 15, indicating intact cognition.)~ On 6/7/26, staff filled out a grievance form after R17 reported to housekeeping staff that some staff are mean and they are afraid to ask them for help. The grievance indicated FDON-Q completed an investigation on 6/15/26 and spoke with R17 who stated they had no concerns since the incident. R17 denied any needs during the conversation and stated they are pleased with care at the facility. The facility could not provide a thorough investigation for R17's allegations of abuse/intimidation, including resident and staff interviews. (An MDS assessment, dated 6/30/26, stated R17 had a BIMS score of 15 out of 15, indicating intact cognition.)~ On 7/30/26, R18 reported that a CNA and nurse refused to give them medication for itching and hives. R18 requested to file a formal complaint against the CNA and nurse. FDON-Q filled out the investigation section of the grievance on 8/6/26 and indicated they met with R18 regarding medication administration. R18 was informed of their medication, dose, use, etc. R18 denied they had any itching episodes since the incident and was encouraged to use topical medication as well. No other concerns were reported. The facility could not provide a thorough investigation for the allegation of neglect, including interviews with the CNA and nurse as well as other staff and residents. (An MDS assessment, dated 7/13/26, stated R18 had a BIMS score of 12 out of 15, indicating moderately impaired cognition.)On 8/26/26 at 1:45 PM, Surveyor reviewed the above grievances with Nursing Home Administrator (NHA)-A, Regional Director of Operations (RDO)-C, and SW-E. RDO-C was not aware of the allegations and agreed the allegations of abuse and neglect should have been more thoroughly investigated. SW-E indicated it is a team effort when grievances are completed to determine whether they are reviewed. RDO-C indicated FDON-Q and CNA-R are no longer are employed by the facility.

Based on interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 5 residents (R) (R17, R10, R11, R8, and R18) of 15 sampled residents in a total sample of 18 residents. Allegations of abuse involving R17, R10, R11, R8, and R18 were not reported to the SA.Findings include:The facility's Vulnerable Adult Abuse and Neglect Prevention policy, revised 7/9/26, indicates: Alleged abuse is a situation or occurrence that is observed or reported by staff, residents, relatives, visitors, another healthcare provider, or others but has not yet been investigated and, if verified, could be non-compliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse .11. Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness .The failure or omission by a caregiver to supply a vulnerable adult with care or services including, but not limited to .health care .which is reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety .Reporting of incidents: a. All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's designee .The facility must report to the State Agency immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the alleged violation involves neglect .or exploitation and does not involve serious bodily injury. All allegations of abuse, neglect .shall be reported immediately, regardless of the perceived credibility of the allegation or the status of the investigation .Within 5 business days, an investigation report will be completed and turned into the Department of Health Services (DHS) and to the Administrator or designee. On 8/26/26, Surveyor reviewed the facility's grievance file and noted the following grievances contained allegations of abuse/neglect that were not reported to the SA:~ On 6/7/26, R17 reported to housekeeping staff that some staff are just mean and they are afraid to ask them for help. (A Minimum Data Set (MDS) assessment, dated 6/30/26, stated R17 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition.) ~ On 6/8/26, R10 reported to therapy staff that they wanted to transfer facilities because staff either do not respond to their call light or enter their room and turn their call light off without providing assistance. R10 stated it happens every night. R10 also reported concerns of not being able to breathe, needing to toilet, and needing to reposition which were not addressed. (An MDS assessment, dated 6/23/26, stated R10 had a BIMS score of 15 out of 15, indicating intact cognition.)~ On 6/9/26, R11's family member stated R11 told them they want to die. R11 stated a (named) Certified Nursing Assistant (CNA) is very rude and always complains when they use their call light. R11 stated the CNA enters their room huffing and puffing and says Jesus Christ and is always angry. The investigation indicated Social Worker (SW)-E spoke with R11 and their family member. R11 stated the (named) CNA and CNA-R are bossy and rude when their call light is on. R11 stated the staff were not physical with them, however, they were concerned with their attitude and how they talk to them. (An MDS assessment, dated 7/22/26, stated R11 had a BIMS score of 15 out of 15, indicating intact cognition.)~ On 6/29/26, a CNA reported that weekend staff do not get R8 up for lunch or change them during the day and they do not get changed or have lunch a lot of weekends. (An MDS assessment, dated 7/13/26, stated R8 had a BIMS score of 12 out of 15, indicating intact cognition.)~ On 7/30/26, R18 reported that a CNA and nurse refused to administer medication for their itching and hives. R18 requested to file a formal complaint against the CNA and nurse. (An MDS assessment, dated 7/13/26, stated R18 had a BIMS score of 12 out of 15, indicating moderately impaired cognition.)On 8/26/26 at 1:45 PM, Surveyor reviewed the above grievances with Nursing Home Administrator (NHA)-A, Regional Director of Operations (RDO)-C, and SW-E. RDO-C was not aware of the grievances and agreed some the grievances contained potential allegations of abuse/neglect and should have been reported to the SA. SW-E indicated it is a team effort with grievances to determine whether they are reviewed or not.

Based on interview and record review, the facility did not ensure activities of daily living (ADL) assistance was provided for 2 residents (R) (R3 and R4) of 4 sampled residents in a total sample of 18 residents.R4 was not offered or provided a shower since admission on [DATE].R3 did not receive showers as scheduled. In addition, multiple call lights for R3 were not answered timely. Findings include: The facility's Activities of Daily Living (ADL) policy, revised 2/25/25, indicates: .2. The facility will provide care and services for the following ADLs: Bathing and Hygiene: Assistance with bathing or showering and maintaining personal hygiene. The facility's Call Light Use and Response policy, revised 7/18/23, indicates: Purpose: 1. To respond promptly to a resident's call for assistance .1. Facility personnel will be aware of call lights; 2. Answer call lights promptly whether or not the staff person is assigned to the resident or not; 3. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room and attend to the resident's needs . 1. R4 was admitted to the facility on [DATE] and had diagnoses including acute and chronic respiratory failure with hypoxia and weakness. A Minimum Data Set (MDS) assessment, dated 8/18/26, stated R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. On 8/26/26 at 11:16 AM, Surveyor interviewed R4 who indicated they had not had a shower or been offered a shower since admission. R4 stated they recently started Hospice care and Hospice staff were coming the next day to give them a shower. R4 stated it will feel good to have their hair washed since their hair hasn't been washed and they haven't received a shower since prior to admission. R4 indicated staff wash them up in bed every day but they are looking forward to a shower. R4 was not sure of their shower day. On 8/26/26, Surveyor interviewed Certified Nursing Assistant (CNA)-T who showed Surveyor a laminated shower schedule kept at the nurses' station. Surveyor noted the schedule was assigned by room and R4's shower day was Wednesday AM. Per the schedule, R4 should have had a shower on 8/19/26. On 8/26/26 at 1:20 PM, Surveyor interviewed CNA-F who documented on 8/19/26 at 1:57 PM that R4 required partial/moderate assistance to shower/bathe self. CNA-F indicated they did not shower R4 on 8/19/26 but washed them during daily cares. CNA-F indicated if residents are given a bath, staff should document in the bathing section and answer the questions in that section. On 8/26/26, Surveyor reviewed R4's bathing documentation in CNA charting in their medical record which indicated: Bathing (Prefers: (blank)). Surveyor noted there was not a shower/bath day added. After Surveyor brought this to the facility's attention, Wednesday AM was added. On 8/26/26 at 3:34 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R4 had not received a shower since admission. 2. R3 was admitted to the facility on [DATE] for falls, syncope, and a left wrist fracture and had a diagnosis of diabetes mellitus type 2 with diabetic neuropathy. An MDS assessment, dated 7/20/26, stated R3 had a BIMS score of 15 out of 15, indicating intact cognition. A Comprehensive MDS assessment, dated 8/3/26, indicated it was very important to R3 to be able to choose between a tub bath, shower, bed bath, or sponge bath. A mobility assessment indicated R3 required partial/moderate assistance for toilet transfers which meant the helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort. On 8/26/26 at 8:45 AM, Surveyor interviewed R3 who stated they had one shower since admission which occurred that morning. R3 stated Wednesday is their shower day, but it comes and goes and staff forget. R3 did not feel it was due to neglect. R3 stated staff use wash cloths to wash their face and head. R3 stated one of their biggest complaints is that call lights can take 1 to 1-1/2 hours to answer and at times result in incontinence. R3 stated it is rare when it happens and it typically occurs during mealtimes because staff are passing meal trays. On 8/26/26 at 10:03 AM, Surveyor interviewed R3 and Family Member (FM)-S. R3 stated staff sometimes remind them on Monday that their shower day is Wednesday. FM-S stated a staff said R3 refused showers. FM-S stated R3 had 3 showers (of 6 potential showers) since admission on [DATE]. R3's Kardex (an abbreviated care plan used by nursing staff) indicated they were to be bathed on Wednesday AM with the assistance of 1 staff. R3's Treatment Administration Record (TAR) indicated they should be bathed on Wednesday AM. In July, R3's shower was scheduled on the PM shift from 2:00 PM–10:00 PM. In August, R3's shower was scheduled for the AM shift from 6:00 AM–2:00 PM. Documentation included what type of bathing was provided and indicated the following: ~ 7/22/26: Code 2 - bed bath ~ 7/29/26: Code RR - resident refused ~ 8/5/26: Code RR - resident refused ~ 8/12/26: Code 2 - bed bath ~ 8/19/26: Code RR - resident refused ~ 8/26/26: Code 1 - shower On 8/26/26, Surveyor reviewed a grievance filed by FM-S on 8/2/26 at 10:20 AM that indicated R3 did not receive a shower on Wednesday (7/29/26). Former Director of Nursing (FDON)-Q stated R3 would receive a shower on Monday (7/27/26) and Wednesday (7/29/26), however, they have not had one since admission. The grievance indicated Assistant Director of Nursing (ADON)-J completed the investigation on 8/2/26. ADON-J spoke with R3 and FM-S in a care conference on 7/30/26 and indicated R3 would receive a shower that day at 1:30 PM. R3 was sleeping and did not want to get up at that time. After further discussion, R3's bath day was changed to Wednesday AM. R3 agreed and FM-S was present. The grievance indicated follow-up was completed on 8/3/26. R8 received a shower in the AM with therapy and was told their showers will be given on Wednesday AM in the future. Surveyor reviewed call light audit reports for R3 for 7/30/26, 8/1/26, 8/22/26, and 8/26/26 for a 24-hour period and noted the following: 7/30/26:~ 6:00 AM - 40 minutes~ 5:00 PM - 44 minutes 8/1/26:~ 4:00 PM - 31 minutes 8/22/26:~ 11:00 AM - 31 minutes~ 5:00 PM - 27 minutes~ 7:00 PM - 23 minutes On 8/26/26 at 9:54 AM, Surveyor interviewed CNA-I who stated call lights can take longer to answer during mealtimes because CNAs are passing trays and drinks from the beverage cart and helping feed residents in the dining room. CNA-I stated the facility currently staffs 1 CNA on each of 3 wings. CNA-I stated the 3 CNAs work together to pass trays and drinks and assist in the dining room which can result in call lights not being answered as quickly. CNA-I stated a call light was on for 38 minutes last weekend which they observed at the nurses' station. CNA-I stated all staff should answer call lights, not just CNAs. Regarding R3's shower, CNA-I stated R3's shower day is Wednesday AM and they give them a shower in the morning. CNA-I stated in the beginning of R3's stay, showers were hit or miss and R3 refused them at times. CNA-I stated they try to reapproach a couple hours later and let the nurse know if a resident refuses. On 7/26/26 at 1:07 PM, Surveyor interviewed ADON-J who stated CNAs document showers in residents' medical records.

Based on interview and record review, the facility did not ensure timely physician notification of a change in condition for 1 resident (R) (R1) of 4 sampled residents in a total sample of 18 residents.Staff administered an as needed (PRN) pain medication for R1. The medication which was documented as ineffective with a follow-up pain assessment of 10 out 10 (with 10 being the highest pain level). The physician was not notified. Findings include: The facility's Change in Condition policy, revised 11/13/24, indicates: 1. The physician .will be notified when .signs/symptoms are unrelieved by measures already prescribed. 2 .Uncontrolled pain .R1 was admitted to the facility on [DATE] for aftercare following joint replacement surgery and had diagnoses including osteoarthritis and personal history of thrombosis and embolism. A Minimum Data Set (MDS) assessment, dated 1/30/26, stated R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. R1 did not have an activated Power of Attorney (POA). R1 was transferred to the hospital on 2/1/26 following a change in condition and did not return to the facility. A medication administration progress note written by Registered Nurse (RN)-D on 1/31/26 at 10:22 AM indicated R1 was given 5 milligrams (mg) of PRN oxycodone for right knee pain. A follow-up pain assessment documented by RN-D on 1/31/26 at 11:43 AM indicated the oxycodone was ineffective and R1's pain was a level 10 out of 10. R1's medical record did not indicate the physician was notified.On 8/26/26 at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Regional Director of Operations (RDO)-C who confirmed the physician should have been notified.

Based on observation, staff and resident interview, and record review, the facility did not provide adaptive eating equipment for 1 resident (R) (R2) of 3 sampled residents. R2 was not provided with a lipped plate (a plate with raised edges to assist in guiding food onto utensils and prevent spills), a rocker knife (a curved blade designed to cut through food using a back-and-forth rocking motion) or built-up utensils (adaptive eating aids with enlarged handles) as indicated in their plan of care. Findings include: R2 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, rhabdomyolysis (muscle breakdown causing their contents to enter blood stream), type 2 diabetes, epilepsy, mood disorder, and insomnia. R2's Minimum Data Set (MDS) assessment, dated 3/25/26, stated R2 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS assessment indicated R2 had impairment of the upper extremities and required supervision or touching assistance with eating.A care plan indicated R2 had the potential for altered nutritional status related to Parkinson's disease, diabetes, left-side weakness, and the need for an altered consistency diet. A Mini Nutritional Assessment (MNA) indicated R2 was at risk for malnutrition, had weight loss on 1/6/26, and started oral nutritional supplements. On 3/17/26, R2 was upgraded to a level 7 regular consistency diet per the Speech Therapy (initiated 12/10/25; revised 4/13/26).R2's Kardex (an abbreviated care plan used by nursing staff) indicated: Eating/Nutrition: Eats in dining room: rocker knife, lipped plate, built-up utensils, provide set-up with supervision, monitor/document/report any signs/symptoms of dysphagia (difficulty or discomfort in swallowing food, liquids, or saliva) .Provide adaptive utensils: rocker knife, lipped plate .A nutrition progress note/dietitian summary, dated 5/11/26, indicated R2 had Parkinson's disease, diabetes, seizures, and left-side weakness and ate in the main dining room with set-up assistance and supervision for meals. The summary contained the following interventions: .rocker knife, lipped plate, built-up utensils (initiated 12/10/25; revised 12/12/25) .On 6/8/26 at 12:08 PM, Surveyor observed R2 in a recliner in their room with their legs elevated. Certified Nursing Assistant (CNA)-C delivered R2's lunch tray and placed the tray on R2's lap per their request. There were two cups of chocolate milk on the bedside table. CNA-C asked if R2 needed help cutting food. R2 declined. CNA-C told R2 to holler if they needed anything. After CNA-C exited the room, Surveyor asked if staff offer to help R2 during meals. R2 stated staff do not offer very often. R2 opened a napkin which contained a regular fork, knife, and spoon. R2's lipped plate contained half of a baked sweet potato, green beans, and a slice of meat with gravy. R2 was also given a piece of cake with whipped topping in a bowl. R2 attempted unsuccessfully to cut the meat and poked the fork into the meat to take bites. R2 had tremors while eating. A meal ticket on R2's tray included the following instructions: .adaptive equipment: lipped plate. R2 stated they were having trouble eating due to tremors from Parkinson's disease and showed Surveyor their hands which were shaking. R2 stated they needed assistance with eating at times. On 6/8/26 at 12:46 PM, Surveyor interviewed R2 and observed their lunch plate. R2 ate all of the meat and sweet potato. When Surveyor asked about utensils, R2 stated staff used to provide funny looking utensils that R2 used for a while but had stopped providing them.On 6/8/26 at 12:48 PM, CNA-C entered R2's room to remove the meal tray. Surveyor interviewed CNA-C after exiting R2's room. CNA-C verified R2 consumed approximately half of the meal and stated R2 liked to eat in their recliner with a meal tray on their lap. CNA-C stated R2 had became shakier and lethargic over the last few months. CNA-C stated they ask R2 if needs assistance cutting food and R2 says yes at times. On 6/8/26 at 2:57 PM, Surveyor interviewed Director of Nursing (DON)-B who stated R2 still required built-up silverware. On 6/9/26 at 8:28 AM, Surveyor observed R2 in a recliner in their room with their feet down and a breakfast tray on a table in front of them. CNA-D was in the room working on a laptop. R2 stated it was hard to eat as R2 attempted to cut bacon, eggs, and toast but had difficulty. R2 did not have a lipped plate or built-up utensils. CNA-D did not get up to assist R2. When asked if staff offered to set up their meal, R2 stated no. When asked if CNA-D offered to cut R2's meal, CNA-D stated no and that R2 did not usually ask to have their food cut. CNA-D stated CNA-D just set R2's meal on the table. When CNA-D asked if they could cut up R2's breakfast, R2 asked if CNA-D could make them a breakfast sandwich. Surveyor reviewed R2's meal ticket which indicated R2 should have a lipped plate. CNA-D stated it did not look like R2 had a lipped plate. CNA-D made R2 a breakfast sandwich and cut it in half. R2 was able to pick up the sandwich and eat it. On 6/9/26 at 8:50 AM, Surveyor observed CNA-D with R2's breakfast tray. R2 consumed 100% of the breakfast sandwich and 75% of the chocolate milk. Surveyor and CNA-D went to the kitchen to review adaptive equipment. CNA-D informed Assistant Dietary Manager (ADM)-E that R2 did not receive a lipped plate at breakfast. ADM-E stated they get interrupted and likely missed providing a lipped plate. Dietary Manager (DM)-F joined the interview and stated when therapy sends an order for adaptive equipment, DM-F enters the order on the meal ticket and verbally informs staff. DM-F stated dietary staff see the adaptive equipment on the meal ticket and serve the meal appropriately. DM-F stated orders should be added to a resident's meal ticket when they are written and provided to the resident at meals. A nutritional/dietary note, dated 6/9/26 at 11:29 AM, indicated: .R2 should have built-up utensils and a lipped plate at meals to ease the ability to self feed. R2 typically eats 50-75% of meals. On 6/9/26 at 1:28 PM, Surveyor interviewed DM-F who stated RD-G informed them of a discrepancy between R2's care plan and meal ticket. DM-F added adaptive equipment of built-up utensils and a rocker knife and provided Surveyor with R2's updated meal ticket which included a lipped plate, rocker knife, and built-up utensils.

Based on observation, staff interview, and record review, the facility did not provide care and treatment to promote healing and/or prevent new pressure injuries from developing for 1 resident (R) (R3) of 3 sampled residents. R3 was at risk for the development of pressure injuries and had a care plan intervention for a left heel boot to be worn at all times. On 6/8/26, R3 was observed without a left heel boot for over four hours. Findings include: The facility's Pressure Injury Prevention and Wound Care Management policy and procedure, dated 8/26/18, indicates: The facility will ensure residents receive care and services to prevent additional pressure ulcers from forming .residents at risk for the development of pressure injuries will have their individualized care plan interventions and approaches documented in the residents' care plans .pressure reduction surfaces should be provided for prevention of pressure injuries . R3 was admitted to the facility on [DATE] and had diagnoses including metabolic encephalopathy, diabetes, multiple sclerosis, and peripheral vascular disease. R3's Minimum Data Set (MDS) assessment, dated 5/20/26, stated R3 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severely impaired cognition. The MDS assessment indicated R3 was at risk for pressure injuries, had an unhealed stage 4 pressure injury, and had pressure reducing devices for bed and chair. R3's comprehensive care plan, revised 5/14/26, indicated R3 were at risk for alteration in skin integrity related to reduced mobility, peripheral vascular disease, multiple sclerosis, and diabetes. The care plan contained interventions (added 2/11/26) for a heel boot to left foot at all times and to float heels in bed. R3's medical record indicated R3 had a healing stage 4 pressure injury on the coccyx and a recently healed (as of 6/2/26) vascular injury on the left heel. On 6/8/26 at 9:36 AM, Surveyor observed heel boots on a chair in R3's room. From 9:36 AM to 1:12 PM (3 hours and 36 minutes), R3 was in a Broda chair without heel boots. From 1:12 PM to 2:05 PM, Surveyor observed R3 in bed without a left heel boots or floated heels. On 6/9/26 at 9:56 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R3's heels should be floated while in bed and R3 should have a heel boot on the left heel at all times due to R3's risk for pressure injury development.

Based on observation, staff and resident interview, and record review, the facility did not provide adequate supervision to prevent accidents for 1 resident (R) (R2) of 3 sampled residents. R2's care plan indicated they required supervision while eating. On 6/8/26, R2 was observed eating in their room without supervision. Findings include: R2 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, rhabdomyolysis (muscle breakdown causing their contents to enter the blood stream), type 2 diabetes, and epilepsy. R2's Minimum Data Set (MDS) assessment, dated 3/25/26, stated R2 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. The MDS assessment indicated R2 had impairment of the upper extremities and required supervision or touching assistance with eating. R2's care plan indicated R2 had the potential for altered nutritional status related to Parkinson's disease, diabetes, left-sided weakness, and the need for an altered consistency diet. R2's Kardex (an abbreviated care plan used by nursing staff) indicated: Eating/Nutrition: Eats in dining room: rocker knife (curved blade designed to cut through food using a back-and-forth rocking motion), lipped plate, built-up utensils (adaptive eating aids with enlarged handles), provide set-up with supervision, monitor/document/report any signs/symptoms of dysphagia (difficulty or discomfort in swallowing food, liquids, and saliva): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Provide adaptive utensils, rocker knife, lipped plate . A Mini Nutritional Assessment (MNA) indicated R2 was at risk for malnutrition, had weight loss on 1/6/26, and started oral nutritional supplements. On 3/17/26, R2 was upgraded to a level 7 regular consistency diet per Speech Therapy (initiated 12/10/25; revised 4/13/26). A nutrition progress note/dietitian summary, dated 5/11/26, indicated R2 had Parkinson's disease, diabetes, seizures, and left-sided weakness and ate in the main dining room with set-up assistance and supervision for meals. The note contained the following interventions: Eats in dining room .Provide set-up with supervision (initiated 1/27/26; revised 1/27/26); Monitor/document/report any signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals (initiated 12/13/25). On 6/8/26 at 12:08 PM, Surveyor observed R2 in their room in a recliner. Certified Nursing Assistant (CNA)-C delivered a lunch tray and put the tray on R2's lap per R2's request. There were two cups of chocolate milk on the table. CNA-C told R2 to holler if they needed anything and exited the room. A meal ticket on the tray indicated R2 should eat in the dining room. Surveyor noted R2 had mild tremors while eating. R2 stated they were having trouble feeding themself due to tremors from Parkinson's disease and needed assistance at times. On 6/8/26 at 12:48 PM, CNA-C entered R2's room to remove the meal tray. Surveyor interviewed CNA-C after they exited the room. CNA-C verified R2 ate approximately half of the meal and indicated R2 likes to eat in the recliner with a meal tray on their lap. CNA-C indicated R2 had been shakier and more lethargic over the last few months but did not need supervision during meals. On 6/8/26 at 2:57 PM, Surveyor interviewed Director of Nursing (DON)-B who did not think R2 needed supervision during meals. On 6/9/26 at 8:28 AM, Surveyor observed R2 in a recliner in their room with a breakfast tray on a table in front of them. CNA-D was in the room working on a laptop. On 6/9/26 at 1:30 PM, Surveyor interviewed Registered Dietitian (RD)-G who stated R2 is encouraged to eat in the dining room, however, R2 is private due to Parkinson's tremors and prefers to eat in their room where supervision isn't provided. RD-G stated the facility had R2 sign a risk versus benefit statement. On 6/9/26, Surveyor reviewed a risks versus benefits statement (dated 6/9/26 at 11:45 AM) that indicated: Recommendations: Eating in dining room, supervision with meals; Discipline making recommendation: Registered Nurse (RN), Medical Doctor (MD), Dietary; Benefits associated with choosing not to follow recommendations: Resident choosing to eat in room; Risks associated with choosing not to follow recommendations: At risk for aspiration, medical diagnosis of Parkinson's that may affect swallowing and will worsen as the disease progresses leading to choking, pneumonia, and early death; Resident/responsible party's response to risk versus benefit: Resident wishes not to eat in dining room and wants to continue eating in room. Date and time discussed with resident/responsible party: 6/9/26 at 11:45 AM; Care plan updated; Signed by: Verbal from resident, dated 6/9/26. A nutriton/dietary note, dated 6/9/26 at 11:29 AM, indicated: Met with R2 regarding oral intake, tolerance .and refusal to eat in dining room for meals. R2 has been encouraged to eat in the main dining room for meals but prefers to eat meals in their room. R2 stated they are a private person and is concerned their tremors will be noticeable to others. R2 has been advised to have supervision at meals due to safety concerns and the ability to offer more assistance as needed with the potential progression of Parkinson's disease and seizure activity. R2 is their own decision maker and agrees to sign a risks versus benefits statement to continue to eat in their room .R2 has no complaints regarding chewing, swallowing, nausea, or vomiting. Has snacks in room (crackers, sodas, etc.) and is aware of snacks available from nursing staff. Does not wish to have additional foods added to meals .likes regular consistency food .Will update nutrition plan of care as needed. On 6/9/26 at 2:38 PM, Surveyor interviewed R2 regarding their understanding of the risks versus benefits statement. R2 stated the only part R2 understood is that there is a risk for choking. R2 stated supervision was mentioned, but staff did not say for sure if it would be provided. R2 stated shaking in public makes them uncomfortable which is why they haven't been in the dining room in months. R2 stated staff do not provide supervision in their room during meals except during breakfast that morning. On 6/9/26 at 2:50 PM, Surveyor interviewed RD-G and Unit Manager Registered Nurse (RN)-H regarding R2's risks versus benefits statement. RD-G and RN-H stated the facility typically does not have staff provide supervision in a resident's room during meals. RD-G and RN-H stated staff offered R2 different or less busy spots in the dining room and stated R2 would receive more supervision in the dining room versus staff walking up and down the hall monitoring R2. On 6/9/26 at 2:55 PM, Surveyor interviewed Regional Director of Clinical Services (RDCS)-I who stated supervision is supervision, whether in the dining room or not, and the issue would be corrected.

Based on observation, staff interview, and record review, the facility did not ensure appropriate respiratory care was provided for 2 residents (R) (R5 and R6) of 2 sampled residents. R5 received oxygen therapy with humidification. A bottle of distilled water used for oxygen therapy was left uncovered. In addition, the bottle was dated 6/2 which was 3 days beyond the expiration date per the facility's policy. R6 received oxygen therapy with humidification. A bottle of distilled water used for oxygen therapy was not dated when opened in accordance with the facility's policy. Findings include: The facility's Policy and Procedure Respiratory Infection Control Practices, revised 6/15/23, indicates: Purpose: To provide infection control guidelines to help prevent infections associated with respiratory therapy equipment, including ventilators, and to prevent transmission of infections to residents and staff. Oxygen Administration .b. Use distilled water for humidification as needed. c. [NAME] bottle of distilled water with date and initials upon opening and discard after 72 hours . 1. R5 was admitted to the facility on [DATE] for short-term rehab and had a diagnosis of heart failure. R5's admission Minimum Data Set (MDS) assessment, dated 6/8/26, indicated R5 received oxygen therapy. R5's medical record included an order for oxygen at 4 liters per minute (lpm) via nasal cannula with a start date of 6/4/26. On 6/9/26 at 10:33 AM, Surveyor and Director of Nursing (DON)-B observed R5's oxygen concentrator and a gallon of distilled water (highly purified water) on R5's bedside table that was used to fill a humidification bottle. The bottle of distilled water was uncovered and contained a hand-written date of 6/2. The cover was on the table next to the bottle. DON-B put the cover on the bottle and verified the bottle was dated 6/2 (which was past the 72 hour expiration date noted in the facility's policy). 2. R6 was admitted to the facility on [DATE] and had a diagnosis of pneumonia. R6's Minimum Data Set (MDS) assessment, dated 6/3/26, included a pulmonary diagnosis of asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease. The MDS assessment indicated R6 used oxygen therapy. R6's care plan contained an intervention to provide oxygen per Medical Doctor (MD) orders (dated 5/4/26). On 6/9/26 at approximately 10:40 AM, Surveyor and DON-B observed R6's oxygen concentrator and an open, undated gallon of distilled water on R6's bedside table that was used to fill a humidification bottle. DON-B verified the bottle did not contain an open date.

Based on staff interview and record review, the facility did not provide pharmacy services to ensure the accurate administration of medication for 1 resident (R) (R2) of 4 sampled residents.R2 had an order for a carbidopa-levodopa (orally disintegrating) 25-250 milligrams (mg) tablet every 8 hours (used to treat motor symptoms of Parkinson's disease, including stiffness, tremors, and slowness). The order was entered for 8:00 AM, 12:00 PM, and 4:00 PM. Findings include: The facility's Policy and Procedure Physician Orders, revised 11/13/24, indicates: Purpose: To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards .3. Physician orders must be documented clearly in the medical record including the required components of a complete order .e. dose and frequency of administration .6. Clear and complete orders will be transcribed to the appropriate administration record (Medication Administration Record (MAR)/Treatment Administration Record (TAR)) . R2 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, rhabdomyolysis (muscle breakdown causing muscle contents to enter the blood stream), type 2 diabetes, epilepsy, mood disorder, and insomnia. R2's Minimum Data Set (MDS) assessment, dated 3/25/26, stated R2 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. On 6/8/26 and 6/9/26, Surveyor reviewed R2's medical record. R2's MAR included an order for carbidopa-levodopa (oral tablet disintegrating) 25-250 mg, give 1 tablet by mouth three times daily related to Parkinson's disease without dyskinesia (involuntary, erratic, and uncontrollable muscle movements) without mention of fluctuations. The order was dated 12/28/25 at 9:30 AM and scheduled for 0800 (8:00 AM), 1200 (12:00 PM), and 1600 (4:00 PM). A provider visit note, dated 5/15/26, contained an order for carbidopa-levodopa, orally disintegrating, 25-250 mg oral tablet, take 1 tablet by mouth every 8 hours. (Of note: R2's MAR was not updated with the new order to administer the medication every 8 hours.) A Discharge summary, dated [DATE], included an order for carbidopa-levodopa oral tablet disintegrating 25-250 mg (every 8 hours). R2's MAR was not updated with the newly ordered medication administration time of every 8 hours. On 6/8/26 at 2:57 PM, Surveyor interviewed Director of Nursing (DON)-B who reviewed R2's MAR and noted carbidopa-levodopa was scheduled for 8:00 AM, 12:00 PM, and 4:00 PM. DON-B verified the carbidopa-levodopa order for every 8 hours on R2's 5/18/26 discharge summary. DON-B stated R2 at times requests medication times be changed due to anxiety. DON-B stated they would talk to R2 and check with the pharmacy. On 6/9/26 at 12:15 PM, Surveyor interviewed Medical Doctor (MD)-J who stated R2's carbidopa-levodopa administration time would not have increased seizures, however, there may have been an increase in Parkinson's symptoms. MD-J stated they try to time the administration of the medication with nursing administration times and the resident's sleep schedule.

Based on staff interview and record review, the facility did not ensure the safety of 1 resident (R) (R17) of 2 sampled residents.R17 was at high risk for wandering and had a Wanderguard (WG) bracelet. R17 exited the facility on 4/1/26 between 4:00 AM and 4:30 AM through an unalarmed door. R17 was found approximately 1.1 miles away at 6:40 AM at R17's apartment. R17 sustained a broken finger during the elopement. (This is being cited at past non-compliance.)Findings include: The facility's Elopement Risk and Prevention policy, dated 8/1/2015, indicates: The facility shall ensure all residents receive adequate supervision and assistive devices to prevent accidents, including elopement, wandering, and unsafe exits.Between 4/13/26 and 4/14/26, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including rhabdomyolysis, acidosis, presence of automatic cardiac defibrillator, and alcoholic liver disease. R17's Minimum Data Set (MDS) assessment, dated 4/1/26, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R17 had moderately impaired cognition. R17 had an activated Power of Attorney for Healthcare (POAHC.) On 3/17/26, staff placed a Wanderguard (WG) bracelet on R17 related to wandering throughout the facility and having difficulty finding R17's room. On 4/1/26, R17 exited the facility through an unalarmed employees only door and was found approximately 1.1 miles away at R17's apartment in bed. It was later determined R17 sustained a broken finger during the elopement. The facility's investigation indicated on 4/1/26 at approximately 6:18 AM, Therapy Director (TD)-G went to R17's room and R17 was not there. TD-G informed staff who began to search for R17. Staff notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and the police. TD-G began searching the neighborhood in TD-G's vehicle. NHA-A instructed TD-G to go to R17's previous address. When TD-G arrived at R17's previous address, the police were there. R17's wheelchair was underneath a stairwell and one of the foot pedals was at the top of the stairs. The police entered R17's residence and discovered R17 asleep in bed. The facility was aware of R17's location at approximately 6:40 AM. The facility notified R17's physician and POAHC about the elopement.R17 was transported to the emergency room (ER). R17's bloodwork was normal. The ER did not complete imaging because R17 did not report concerns with pain or movement. R17 returned to the facility at approximately 10:00 AM. R17's WG was checked and was in working order. R17 was placed on a 1:1 supervision for 72 hours and then 15 minute checks. R17 was still on 15 minute checks at the time of the survey. When NHA-A asked why R17 left the facility, R17 stated R17 wanted to sleep in R17's bed. When NHA-A asked the route R17 used to exit the facility, R17 took NHA-A down R17's hallway and turned left down another resident hallway. R17 stated R17 exited the facility through an employees only door that required a code to open. R17 did not recall entering a code. R17 indicated R17 went out the unalarmed exit door and through a courtyard to the front of the building. On 4/1/26, the facility tested all doors to ensure alarms and the WG system were working. The facility noted there was not a Tabs alarm (a magnetic monitoring device) on the employees only door or on other employees only exit doors. The facility added a Tabs alarm to the coded employees only door where R17 exited and contacted the vendor to add a WG alarm to the door. In addition, Tabs alarms were added to 2 other exit doors in the employees only area. The facility implemented hourly door checks.On 4/1/26, the facility interviewed night shift staff regarding R17's last known whereabouts. Certified Nursing Assistant (CNA)-H last saw R17 on rounds between 4:00 and 4:30 AM in a wheelchair in R17's room facing the window. CNA-I last saw R17 between 3:00 and 3:30 AM and stated R17 was by the nurses' station most of the night. CNA-I told R17 to go back to R17's room which R17 did. Surveyor verified the statements during phone interviews with CNA-H and CNA-I.On 4/2/26, therapy staff were working with R17 in the morning when R17 reported numbness in R17's fingers that moved into the hand. R17's physician ordered an X-ray which revealed a fracture of the left ring finger. R17 was offered a splint but refused. Ice and elevation orders were obtained. Pain assessments were completed each shift with no concerns. During an interview, R17 indicated R17 slipped up the stairs when going to R17's apartment and fractured R17's finger. Other residents were interviewed regarding abuse and injury of unknown origin with no concerns. The facility reviewed other residents with WGs and completed new wander risk assessments.The facility initiated elopement education and care plan updates for R17, including 1:1 supervision. The facility also initiated education for the employees only door code which included not sharing the code with residents. The education indicated the code would be changed quarterly and instructed staff to ensure the code is covered when entered if residents are nearby.Between 4/13/26 and 4/14/26, Surveyor reviewed the facility's 1:1 and 15 minute check sheets, R17's care plan, elopement drills, and door checks. R17's medical record indicated R17's WG function was checked daily and placement was checked every shift. Surveyor interviewed staff who indicated they received education on the elopement policy, doors, and updates to R17's care plan which included increased supervision. Surveyor reviewed the police report which indicated at approximately 4:30 AM, the police department received a call regarding a man wearing flannel pajama pants and pushing a wheelchair near 2 cross streets and a local business. The police responded but did not find anyone. On 4/14/26, Surveyor drove the route to the cross streets indicated in the police report where an elderly gentleman was observed at approximately 4:30 AM. Surveyor noted it was 0.7 miles from the facility. R17's apartment was approximately 1.1 miles from the facility. There were sidewalks along the possible routes R17 could have taken. Between 4/14/26 and 4/15/26, Surveyor observed R17 multiple times. R17 interacted with Surveyor, other residents, and staff. During the survey, Surveyor observed the front door (which had a WG alarm) alarm on multiple occasions. If a resident with a WG wheeled past the door, the alarm activated. Surveyor observed staff respond immediately.On 4/14/26 at 11:00 AM, Surveyor interviewed NHA-A who confirmed the door R17 exited through was not alarmed. NHA-A thought R17 saw staff enter the code and most likely used the code. NHA-A indicated and Surveyor confirmed (via education review and staff interview) staff should not share the code with residents and should cover the panel when entering the code. NHA-A also indicated a WG alarm would be added to the employees only door.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 34 residents residing in the facility.Staff did not consistently monitor food holding temperatures.Toasters in the main kitchen contained dried food debris.Staff did not follow sanitation practices when using a thermometer to check cooking temperatures.Findings include:On 4/12/26 at 9:24 AM, Surveyor completed an initial tour of the kitchen with Dietary Manager (DM)-C who stated the facility follows the Federal Food Code.Food Cooking/Holding Temperatures:The facility's Food Temperature Record policy, dated 6/28/22, indicates: It is the policy of the facility to ensure foods and beverages are held and served at temperatures which comply with state and federal regulations .Preparation of food is to be completed as close to serving time as possible and transferred to holding equipment no more than 30 minutes prior to meal service .4. Hot foods must be held at a minimum temperature of 135 degrees Fahrenheit (F).The 2022 Food and Drug Administration (FDA) Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that: (I) Employees are properly maintaining the temperatures of time/temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures.The 2022 FDA Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, for Hot and Cold Holding: Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone of 41 degrees F to 135 degrees F too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth (A) Except during preparation, cooking, or cooling, or when time is used as the public health control .(1) At 135 degrees F or above or (2) At 41 degrees F or less.During an initial tour of the kitchen on 4/12/26 at 9:24 AM, DM-C stated the facility monitors cooking and holding temperatures. DM-C stated cooking temperatures are obtained when food comes out of the oven, and holding temperature are obtained prior to meal service.On 4/12/26 from 12:16 PM to 12:41 PM, Surveyor observed lunch service. Surveyor noted holding temperatures were not obtained prior to, during, or after serving was completed.On 4/12/26, Surveyor reviewed the facility's Food Temperature Logs for the past 30 days. Surveyor noted the following inconsistences with the completion of cooking and holding temperatures:~ For the week of 3/15/26 to 3/21/26, cooking temperatures were incomplete for 4 of 21 meals; holding temperatures were incomplete for 2 of 21 meals.~ For the week of 3/22/26 to 3/28/26, cooking temperatures were incomplete for 1 of 21 meals; holding temperatures were incomplete for 6 of 21 meals.~ For the week of 3/29/26 to 4/4/26, cooking temperatures were incomplete for 5 of 21 meals; holding temperatures were incomplete for 3 of 21 meals.On 4/12/26 at 2:55 PM, Surveyor interviewed DM-C who stated cooking and holding temperatures should be completed for all meals. DM-C stated DM-C did not check holding temperatures for lunch on 4/12/26 because the food was removed from the oven close to serving time. DM-C acknowledged cooking and holding temperatures should be obtained for all meals. DM-C acknowledged there were inconsistencies in the log entries for cooking and holding temperatures.Kitchen Equipment:The 2022 FDA Food Code documents at 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.The 2022 FDA Food Code documents at 4-602.12 Cooking and Baking Equipment: (A) The food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours.During an initial tour of the kitchen with DM-C on 4/12/26 at 9:24 AM, Surveyor observed two toasters that contained a significant amount of dried food debris and crumbs on the interior and exterior.On 4/12/26 at 2:58 PM, Surveyor interviewed DM-C who stated the toasters should be cleaned after each use or at least every day. DM-C acknowledged the dried food debris and verified the toasters should have been cleaned.Food Temperature Measuring Device:The facility's Calibration of Thermometer policy, dated 6/1/23, indicates: The purpose of the policy is to ensure thermometers are calibrated on a regular basis, documented food temperatures are accurate, and proper procedures are used to clean and sanitize probe thermometers .4. Procedure - Cleaning and Sanitizing: 4.1. Prior to each use, probe thermometer must be cleaned (if visibly soiled) and/or sanitized with an alcohol wipe or Quat sanitizer. Stem must air dry completely for at least 10-15 seconds before inserting into food. Thermometer must also be sanitized with an alcohol wipe or Quat sanitizer between each use, allowing thermometer to air-dry completely as listed above each time it is sanitized.The 2022 FDA Food Code documents at 4-602.11 Equipment Food-Contact Surfaces and Utensils: (A) Equipment food-contact surfaces and utensils shall be cleaned: (4) Before using or storing a food temperature measuring device; and (5) At any time during the operation when contamination may have occurred.On 4/12/26 at 11:35 AM, Surveyor observed DM-C obtain cooking temperatures. DM-C used a probe thermometer to check the internal cooking temperature of bone-in chicken. DM-C did not sanitize the probe prior to inserting it into the chicken. After removing the thermometer, DM-C placed the thermometer on the prep counter. Surveyor noted the prep counter contained dried food debris. DM-C temped the chicken again with the same thermometer. DM-C did not sanitize the thermometer after setting it on the prep counter or before inserting the thermometer into the chicken. Surveyor observed DM-C repeat the process an additional 3 times. During the observation, Surveyor did not observe DM-C sanitize the thermometer.On 4/12/26 at 11:41 AM, Surveyor observed DM-C obtain cooking temperatures. DM-C used a probe thermometer to check the internal cooking temperature of mashed potatoes. DM-C did not sanitize the probe prior to inserting it into the potatoes or after removing the thermometer. DM-C placed the thermometer on the prep counter where it rested against a cloth that contained food debris. DM-C temped the mashed potatoes again with the same thermometer. DM-C did not sanitize the thermometer before inserting it into the mashed potatoes.On 4/12/26 at 2:58 PM, Surveyor interviewed DM-C who confirmed DM-C did not sanitize the thermometer prior to use, after setting it on the prep counter, or after it came in contact with a used cloth. DM-C verified thermometers should be sanitized between uses.

Based on observation, staff and resident interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R34) of 12 sampled residents.On 4/12/26, R34 was observed in R34's room without a call light within reach.The facility's Call Light Use and Response policy, dated 1/14/19, indicates: .4. When providing care to the residents, position the call light conveniently for the resident and within easy access for use .9. Be sure call lights are placed within reach at all times.On 4/12/26, Surveyor reviewed R34's medical record. R34 was admitted to the facility on [DATE] and had diagnoses including osteoporosis with current pathological fractures and right humerus fracture related to fall. R34's Minimum Data Set (MDS) assessment, dated 3/29/23, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R34 had intact cognition. The MDS also indicated R34 was dependent on staff for transfers, toileting, and locomotion of wheelchair.R34's medical record indicated R34 fell while self-transferring from a wheelchair to a recliner in R34's room on 3/23/26 which resulted in a right humerus fracture. On 4/12/26 at 9:42 AM, Surveyor heard R34 call out for help. Surveyor entered R34's room and asked if R34 needed help. R34 was in a wheelchair with a sling on R34's right arm. R34 indicated R34 was in pain, could not call staff, and needed a pain pill. Surveyor noted R34's call light was on the floor approximately 10 feet from the wheelchair. R34 stated staff brought R34 back to the room and left. R34 did not remember who brought R34 back to the room. Surveyor informed Registered Nurse (RN)-F that R34 requested a pain pill. On 4/12/26 at 9:49 AM, Surveyor interviewed RN-F who verified R34's call light was on the floor and R34 could not reach it. RN-F attached R34's call light to the wheelchair and indicated the call light should always be within reach.On 4/13/26 at 9:30 AM, Surveyor interviewed Director of Nursing (DON)-B who verified the facility's policy indicates a resident's call light should be within reach and accessible at all times.

Based on staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when allegations of abuse were not reported to local police department and/or State Agency (SA) for 3 residents (R) (R13, R20, and R51) of 4 sampled residents.R13 touched R20 inappropriately on 3/29/26. The allegation of abuse was not reported to the SA or local police department.R13 kissed R51 in the dining room on 1/12/26. The potential allegation of abuse was not reported to the SA.Findings include:The facility's Vulnerable Adult Abuse and Neglect Prevention policy, dated 11/2017, indicates: .9. Resident-to-Resident Abuse: The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, exploitation and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents .6. Reporting of Incidents: .b. The facility must report to the State Agency immediately.no later than 24 hours if the alleged violation involves neglect, misappropriation of resident property, or exploitation and does not involve serious bodily injury. IV. Call law enforcement officials if suspected concern is criminal in nature (murder, manslaughter, rape, assault and battery, sexual abuse, theft/robbery). V. For allegations or incidents of sexual abuse, aside from the immediate preliminary report to the state health department, the policy of the facility is to make a police report with the local police department. 1. From 4/13/26 to 4/14/26, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including early onset Alzheimer's disease and dementia with behavioral disturbance. R13's Minimum Data Set (MDS) assessment, dated 4/12/26, had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R13 had severely impaired cognition. From 4/13/26 to 4/14/26, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had a diagnosis of multiple sclerosis. R20's MDS assessment, dated 3/19/26, had a BIMS score of 15 out of 15 which indicated R15 had intact cognition. A progres note, dated 3/29/26 at 10:51 PM, indicated R20 was approached by R13 at approximately 6:30 PM outside the dining room. An agency nurse noticed R20 looked uncomfortable, approached the residents, and observed R13 quickly move R13's hand away from R20. The nurse did not see where R13 touched R20. The nurse approached another nurse who asked R20 what happened. When asked if R13 touched R20, R20 stated yes and pointed to R20's vaginal area. When asked if R13 touched R20's vaginal area, R20 nodded yes. When asked if R13 said anything while touching R20, R20 stated R13 said, I love you. R20 was reassured that R13's behavior was inappropriate. R20 nodded in agreement and stated, I was just like, why? R13 was removed from the area after the incident and placed on 1:1 supervision. R20 requested to go outside to smoke/vape.The facility provided Surveyor with an investigation for the incident. Surveyor noted the police were not contacted and the incident was not reported to the SA.(See interview under example 2.)2. From 4/13/26 to 4/14/26, Surveyor reviewed R51's medical record. R51 was admitted to the facility on [DATE] and had diagnoses including acute cystitis, psychophysical visual disturbances, and major depressive disorder. R51's MDS assessment, dated 1/21/26, had a BIMS score of 15 out of 15 which indicated R51 had intact cognition. R51 discharged from the facility on 1/21/26.A progress note, dated 1/13/26 at 4:10 AM, indicated (R13) grabbed R51 by the shoulders and kissed R51 on the mouth during supper on 1/12/26. R51 stated it didn't feel good but R51 was not upset at the time. A progress note, dated 1/13/26 at 10:15 PM, indicated the writer spoke with R51 via phone with a Licensed Practical Nurse (LPN) in the room to follow-up about the incident. R51 stated it was a joke. R13 put R13's arm around R51's shoulder. R51 and R13 had been kidding with each other since day one. R51 stated R13 was a sweetheart and R51 had no problem with R13. R51 stated if R13 said something raunchy, R51 told R13 to calm it and R13 said okay.On 4/14/26 at 12:02 PM, Surveyor interviewed R51 via phone about the incident on 1/12/26. R51 stated R13 reached up and kissed R51 and R51 was not expecting it. R51 stated the kiss occurred in the dining room during supper and everyone around them laughed and thought it was a joke. R51 laughed also. R51 stated R51 did not want to be kissed and did not ask to be kissed. R51 stated R13 was fine at first but then started talking smutty. R51 felt like R13 was stalking R51 at times, however, staff were with R13 all the time after that. R51 stated R51 was moved to a table in the dining room on the other side of the wall. R13 sat at R51's old table so they would be separated. R51 stated R51 felt secluded from friends in the dining room and felt R51 was being punished for something R13 did. R51 decided to eat in R51's room. R51 stated R51 discharged from the facility on 1/26/26 because R51 did not go to the facility to be stuck in a corner. R51 informed R51's physician why R51 wanted to discharge.A physician note, dated 1/21/26, indicated R51 appeared depressed and made comments that R51 did not have a say in R51's life. R51 thought people did not like R51 because of issues with another resident (R13) who tried to kiss R51. R51 had to change seating positions in the cafeteria and refused to go to the dining room for meals. R51 wanted to discharge home and was not interested in an assisted living facility.On 4/13/26, the facility provided Surveyor with an investigation for the incident. Surveyor noted the potential allegation of abuse was not reported to the SA; however, the incident was reported to the police. (Of note: The investigation revealed another resident was upset over unwanted remarks in the dining room from R51. That incident was reported to the SA and the police. When the police were at the facility for that incident, they were informed of the incident between R51 and R13 on 1/12/26.)On 4/14/26 at 2:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Regional Director of Operations (RDO)-J who indicated the facility used the Department of Health Services (DHS) resident-to-resident altercation flowchart (dated 6/2018). Because R20 and R51 indicated in interviews that neither were affected by the incidents and were both their own decision makers, the facility did not report the incidents. RDO-J acknowledged incident reporting criteria needed to be reviewed with staff.

Based on staff interview and record review, the facility did not provide the necessary edema care and treatment for 1 resident (R) (R16) of 1 sampled resident.R16 had an order for Tubigrips for diagnoses of lymphedema and congestive heart failure (CHF). The Tubigrips were not consistently applied. In addition, R16's care plan did not contain interventions to address lymphedema.Findings include: From 4/12/26 to 4/14/26, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including chronic wound with lower extremity lymphedema, congestive heart failure (CHF), and chronic pain. R16's Minimum Data Set (MDS) assessment, dated 4/1/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R16 had intact cognition. R16 made R16's own healthcare decisions.A Hospital Discharge summary, dated [DATE], indicated R16 had chronic wounds with bilateral lower extremity (BLE) lymphedema. The summary stated to continue compression wraps.A Health Status Note, dated 3/26/26, indicated R16 had BLE 2+ edema.A Daily Skilled Charting Note, dated 4/11/26, indicated R16 had BLE 2+ pitting edema. Pedal pulses were present.A care plan, dated 4/12/26, indicated R16 had chronic pain related to cervicalgia, urinary disorder, and lymphedema. The care plan contained an intervention, dated 3/26/26, to administer treatments as ordered. (Of note: The care plan did not contain interventions that addressed lymphedema such as elevating legs or Tubigrips.)R16's April 2026 Medication Administration Record (MAR) contained the following orders:~ Oxycodone HCL 5 milligrams (mg) 1 tablet every 6 hours as needed (PRN) for severe pain. (R16 did not receive oxycodone on 4/12/26. On 4/13/26 at 9:10 PM, R16 received oxycodone which was effective.) ~ Gabapentin 300 mg three times daily (TID) for neuropathic pain. (The medication was administered as ordered on 4/12/26, 4/13/26, and 4/14/26.)On 4/12/26 at 12:40 PM, Surveyor observed R16 in a wheelchair with R16's legs in a dependent position and feet on the floor. R16's feet were swollen. R16 was wearing Tubigrips. R16 indicated the Tubigrips were for compression to decrease swelling.On 4/14/26 at 8:30 AM, Surveyor interviewed R16 who was frustrated and upset that R16's Tubigrips had not been applied since they were removed on the evening of 4/12/26. R16 stated R16 had pain and increased swelling in both legs. R16 was in a wheelchair with R16's legs in a dependent position. R16 was not wearing Tubigrips. R16's feet were swollen and painful to touch.On 4/14/26 at 8:41 AM, Surveyor interviewed Director of Nursing (DON)-B who stated R16 did not indicate to DON-B during AM medication pass that R16's Tubigrips were not applied or that R16 was in pain. DON-B was made aware by a Certified Nursing Assistant (CNA) that R16's Tubigrips were not applied and could not be found. DON-B stated castor oil was applied to R16's legs so the Tubigrips may have been soiled and sent to laundry. DON-B asked therapy staff to get new Tubigrips for R16. On 4/14/26 at 10:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R16's Tubigrips. A short time later, Surveyor observed NHA-A enter R16's room with Tubigrips.On 4/14/26 at 11:45 AM, Surveyor again interviewed DON-B who verified R16's Hospital Discharge Summary indicated R16 should have compression wraps (Tubigrips). DON-B was not aware who completed R16's admission and verified R16's care plan did not contain interventions to address lymphedema until 4/14/26.

Based on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 30 opportunities which resulted in a 6.67% medication error rate that affected 1 resident (R) (R27) of 3 residents observed during medication administration.During the AM medication pass on 4/13/26, R27's insulin aspart (for diabetes) was administered late. In addition, the wrong dose of Slow Magnesium (a supplement containing magnesium chloride with calcium) was administered.Findings include:The facility's Administering Medications policy, revised 1/22/24, indicates: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations .4. Medications shall be administered per provider's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified .the medication is labeled according to accepted standards .On 4/14/26, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] and had diagnoses including diabetes and nutritional anemia. R27's Minimum Data Set (MDS) assessment, dated 1/22/26, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R27 had moderate cognitive impairment.On 4/13/26 at 9:23 AM, Surveyor observed Registered Nurse (RN)-D prepare and administer R27's AM medications. RN-D was aware RN-D was administering R27's insulin aspart late, but indicated RN-D did not like to administer insulin in the dining room. During preparation of R27's medications, Surveyor noted the bottle of Slow Magnesium used for R27 contained magnesium 128 milligrams (mg), chloride 373 mg, and calcium 212 mg.On 4/13/26 at 10:00 AM, Surveyor reviewed R27's Medication Administration Record (MAR) and noted the following orders:~ Slow Mag tablet delayed release 71.5-119 mg (magnesium chloride-calcium carbonate), give 1 tablet by mouth once daily for supplement.~ Insulin aspart 100 unit/milliter, inject per sliding scale .Inject subcutaneously in the morning at 7:30 AM.On 4/13/26 at 10:56 AM, Surveyor interviewed RN-D who compared the facility's Geri Care Slow Magnesium Chloride with Calcium bottle to R27's MAR and acknowledged the doses were different. RN-D verified Slow Magnesium at the higher dose of magnesium 128 mg, calcium 212 mg, and chloride 373 mg was administered and was incorrect. On 4/13/26 at 11:05 AM and 11:48 AM, Surveyor inteviewed Director of Nursing (DON)-B and informed DON-B of Surveyor's medication administration observations. DON- B indicated the administration of Slow Magnesium was a medication error due to the different doses. DON-B reviewed R27's MAR and confirmed insulin aspart was ordered for 7:30 AM. DON-B verified insulin aspart was administered late if given after 9:00 AM.

Based on staff interview and record review, the facility did not ensure Pre-admission Screening and Resident Review (PASRR) requirements were met for 1 resident (R) (R20) of 5 sampled residents.R20 had a mental illness diagnosis as indicated on R20's PASRR Level I Screen. A PASRR Level II Screen was not completed. Findings include:According to the State of Wisconsin Department of Health Services (DHS), Pre-admission Screening and Resident Review (PASRR) is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual disability (ID)/developmental disability (DD) and/or mental illness (MI). This is called a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require they receive additional services for their ID/DD and/or MI. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an ID/DD and/or MI for PASRR purposes. This is a Level II Screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. Nursing facilities may seek county exemption for applicants with ID/DD and/or MI whose stay in the facility is expected to be recuperative care or short-term, as evidenced by receipt of County Review of Nursing Home, IMD or ICF/IID Referrals.From 4/12/26 to 4/14/26, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, depression, and anxiety. R20's Minimum Data Set (MDS) assessment, dated 3/19/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R20 was not cognitively impaired. R20 was responsible for R20's healthcare decisions. R20's medical record contained a PASRR Level I Screen, dated 7/10/25, that indicated R20 had a current MI diagnosis. Surveyor noted R20's medical diagnoses included depression and anxiety. R20's MDS assessment, dated 7/10/25, indicated R20 had depression and anxiety. R20's medical record did not contain a PASRR Level II Screen.On 4/14/26 at 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated Business Office Manager (BOM)-E was responsible for completing PASRRs.On 4/14/26 at 11:53 AM, Surveyor interviewed BOM-E who verified R20 did not have a PASRR Level II Screen. BOM-E stated BOM-E should have completed one and must have missed the Level II Screen.

Based on staff interview and record review, the facility did not ensure the Ombudsman was notified of transfers and discharges for 5 residents (R) (R29, R26, R2, R16, and R13) of 5 sampled residents. R29 was discharged home on 11/22/24. The facility did not notify the Ombudsman of R29's discharge. R26 was discharged home on 12/23/24. The facility did not notify the Ombudsman of R26's discharge. R2 was transferred to the hospital on 7/11/24. The facility did not notify the Ombudsman of R2's transfer. R16 was transferred to the hospital on 5/28/24. The facility did not notify the Ombudsman of R16's transfer. R13 was transferred to the hospital on 10/14/24 and 12/28/24. The facility did not notify the Ombudsman of R13's transfers. Findings include: The facility did not provide a policy related to notifying the Ombudsman of transfers and discharges. 1. From 1/13/25 to 1/15/25, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE] following an exacerbation of congestive heart failure (CHF). R29 discharged home on 11/22/24. 2. From 1/13/25 to 1/15/25, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] following a hospitalization for sepsis. R26 was discharged home on 12/23/24. 3. From 1/13/25 to 1/15/25, Surveyor reviewed R2's medical record. R2 was admitted to facility on 3/1/24 and had diagnoses including diabetes, anemia, and depression. R2 was transferred to the hospital on 7/11/24 for a positive blood culture. 4. From 1/13/25 to 1/15/25, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE] and had diagnoses including peripheral vascular disease (PVD) and diabetes. R16 was transferred to the hospital for evaluation of a foot wound on 5/28/24. 5. From 1/13/25 to 1/15/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including dementia, diabetes type 2, and hypertensive heart disease. R13 was transferred to the hospital on 10/14/24 and 12/28/24. Surveyor reviewed the facility's November and December 2024 Ombudsman notifications for transfers and discharges and noted the transfers and discharges were faxed to the Ombudsman on 1/13/25. On 1/14/25, Nursing Home Administrator (NHA)-A provided Surveyor with copies of 4 months of Ombudsman notifications. Surveyor noted the fax cover sheet was sent on 1/13/25. NHA-A indicated staff were attempting to locate proof the notifications were sent monthly. On 1/15/25 at 10:56 AM, Surveyor interviewed Social Worker (SW)-H and showed SW-H the fax cover sheet and copies of the last 4 months of Ombudsman notifications that indicated they were sent on 1/13/25. SW-H indicated SW-H sends the notifications monthly via fax but does not save copies of the faxes so SW-H resent them. SW-H indicated SW-H was on leave for a period of time in the fall and NHA-A was going to send the notifications in SW-H's absence. On 1/16/25 at 12:10 PM, Surveyor interviewed Ombudsman (OMB)-I who confirmed OMB-I received faxes of the facility's last 4 months of transfers and discharges on 1/13/25. OMB-I indicated OMB-I tells facilities they need to keep the documents to prove they were sent. OMB-I indicated OMB-I covers 8 counties and could not recall if OMB-I received the monthly notifications from the facility.

Based on staff and resident interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 resident (R) (R22) of 15 sampled residents. R22 reported to staff that a staff member stole R22's soda. The facility did not report the allegation of misappropriation to the State Agency (SA) or local law enforcement. Findings include: The facility's Policy and Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 10/29/24, indicates: Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, or misappropriation shall intervene to safeguard the resident and then immediately report to the Administrator or designee. The Administrator or designee will report .to the State Agency per state and federal requirements .13. Misappropriation of Property: (a) The intentional taking, misplacement, carrying away, using, transferring, concealing, or retaining possession of a resident's movable property without the vulnerable adult's consent .6. Reporting of Incidents: a. All allegations and or suspicions .must be reported to the Administrator immediately .b. The facility must report to the State Agency immediately, but .not later than 24 hours if the alleged violation involves .misappropriation of resident property .10. Reporting Reasonable Suspicion of a Crime (under the Elder Justice Act): 1. All employees of this facility have the following responsibilities and rights under federal law: If you reasonably suspect that a crime has occurred against a resident or person receiving care, you must report that suspicion to the police and State Survey Agency . From 1/13/25 to 1/15/25, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including depression and surgical wound complications. R22's most recent Minimum Data Set (MDS)assessment, dated 11/27/24, indicated R22 had moderate cognitive impairment. On 1/13/25 at 10:43 AM, Surveyor interviewed R22 who indicated R22 suspected a staff stole soda from R22's personal supply which was kept in R22's room. R22 indicated approximately two week prior, R22 returned to R22's room from an activity and noticed R22's soda was gone. R22 had two bottles of soda left and suspected a staff member had stolen the soda. R22 reported the theft concern to Assistant Director of Nursing (ADON)-D who informed R22 that the allegation of theft was addressed with the accused staff member. On 1/14/25 at 9:41 AM, Surveyor interviewed ADON-D who confirmed R22 had accused a staff of stealing R22's soda. ADON-D confirmed R22 made the allegation in the preceding week, however, ADON-D was unsure of the exact date the concern was reported. ADON-D indicated R22's daughter typically brought R22 a 24-case of soda, however, R22 had reported soda missing from a six-pack and ADON-D did not think R22's report was credible. ADON-D indicated ADON-D informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B about the allegation of misappropriation on the same day the allegation was made. ADON-D indicated ADON-D, NHA-A, and DON-B discussed the allegation. ADON-D was unable to provide Surveyor with documentation related to the allegation of misappropriation and confirmed ADON-D did not report the allegation of misappropriation to the SA. On 1/14/25 at 10:15 AM, Surveyor interviewed DON-B who confirmed R22 alleged that a staff took R22's soda. DON-B was unsure of the exact date R22 reported the theft but confirmed it was reported in the week preceding the interview. DON-B confirmed DON-B, NHA-A, and ADON-D discussed the allegation. DON-B was unable to provide Surveyor with documentation related to the allegation of misappropriation and confirmed the allegation of misappropriation was not reported to the SA. On 1/14/25 at 10:40 AM, Surveyor interviewed NHA-A who confirmed NHA-A, DON-B, and ADON-D discussed R22's allegation that a staff member took R22's soda. NHA-A confirmed NHA-A was made aware of the allegation in the week preceding the interview. On 1/15/25 at 2:28 PM, Surveyor again interviewed NHA-A who confirmed R22's report of missing soda was an allegation of misappropriation. NHA-A confirmed NHA-A did not report the allegation of misappropriation to the SA or local law enforcement.

Based on staff interview and record review, the facility did not ensure food was prepared in a form designed to meet individual needs for 1 Resident (R) (R1) of 7 residents on mechanically altered diets. R1 had a mechanically altered diet. R1's diet was not followed on 11/7/23, which resulted in a choking episode that required intervention by nursing staff and emergency medical services (EMS) to clear R1's airway. R1 passed away on 11/7/23 as a result of the choking episode. Failure to ensure foods were served to residents in the appropriate texture created a finding of Immediate Jeopardy (IJ), which began on 11/7/23. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 11/9/23 at 3:45 PM. The immediate jeopardy was removed on 11/9/23; however, the deficient practice continues at a severity/scope level of D as the facility continues to implement its removal plan. Findings include: According to data from the National Safety Council, choking is the 4th most common cause of death. https://injuryfacts.nsc.org/all-injuries/deaths-by-demographics/deaths-by-age/data-details/ As of October 2021, the Academy of Nutrition and Dietetics announced International Dysphagia Diet Standardization Initiative (IDDSI) is the only professionally recognized standard of care for texture modified diets in the Nutrition Care Manual of the Academy of Nutrition & Dietetics for the United States. The facility's Diet and Diet Orders policy, with a revision date of 5/14/21, indicated: All diets will be prescribed by the Attending Physician. The Dietitian will review diets for accuracy and therapeutic goals and recommend changes to the Physician as deemed appropriate .When necessary, the Attending Physician will order therapeutic or mechanically altered diets to address certain diseases .8. The regular menu will be modified and reviewed by the Dietitian and for both therapeutic and consistency modifications, with input from the Food Service Manager or Dietary Manager. Spreadsheets will be available and used by the dietary staff in the service of all meals to ensure food provided is consistent with diet order. 9. The Center will utilize a tray identification system to ensure diet accuracy in the service of the meals .11. Residents on therapeutic or mechanically altered diets will not receive foods or fluids outside the diet order unless approved by the Attending Physician in conjunction with the Dietitian, nursing and/or therapy .Responsibilities: Dietitian - Monitor compliance with policy by ensuring accuracy of diets and communicating changes or recommendations. Ensures that care plan is updated with diet changes. Food Service Director/Dietary Manager - Ensures that food provided is consistent with diet order and that tray card accurately reflects resident/patient diet order and food preferences. Therapy Department - Screens, evaluates and treats residents/patients as applicable to provide least restrictive diet consistency. Provides written documentation of changes to diet or liquid consistency. Nursing Department - Enters diet orders in EMR (electronic medical record) per Physician's order and in compliance with approved diet type and texture. In cooperation with the other departments, ensures appropriate diet and liquids are provided and reports any discrepancies .Instructions: All diet orders must be consistent with diets offered .Diets offered will be as follows: .Diet texture: .Level 7 Easy to Chew . The facility's undated IDDSI education indicated: The International Dysphagia Diet Standardisation Initiative (IDDSI) is a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with dysphagia of all ages, in all care settings, and for all cultures .7. Easy To Chew Description/Characteristics: Normal, everyday foods of soft/tender textures .Does not include: hard, tough, chewy, fibrous, stringy, crunchy, or crumbly foods .This level could present a choking risk for people with clinically identified increased risk of choking, because food pieces can be of any size. Restricting food piece sizes aims to minimize choking risk .(the next statement was added by the facility and not part of the original IDDSI verbiage) MOST SIMILAR TO DIET CALLED MECHANICAL SOFT - our policy calls for this level to have chopped meats .(original IDDSI verbiage resumes here) Food Specific Examples: Meat - Cooked until tender .(the next statement was added by the facility and not part of the original IDDSI verbiage) Per our policy, meat will be chopped unless tender enough to be flaked (fish) .(original IDDSI verbiage resumes here) Bread, sandwiches and toast that can be cut or broken apart into smaller pieces with the side of a fork or spoon can be provided at clinician discretion . On 11/9/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease, cognitive communication deficit, and dysphagia (difficulty swallowing). R1's Minimum Data Set (MDS) assessment, dated 9/11/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was not cognitively impaired. R1's Power of Attorney for Healthcare (POAHC) document, dated 11/13/14 and activated on 3/12/19, indicated R1's POAHC was responsible for R1's healthcare decisions. On 11/9/23, Surveyor reviewed R1's physician diet order which stated, Heart Healthy (Cardiac) diet, Level 7 Easy to chew texture, Level 0 Thin (Regular) consistency. On 11/9/23, Surveyor reviewed R1's care plan which stated, I have potential for altered nutritional/hydration status . with interventions to include DIET TEXTURE - Level 7 - Easy to chew. On 11/9/23, Surveyor reviewed a nursing progress note which indicated: 11/7/2023 .Writer alerted to choking episode in dining room. Heimlich maneuver initiated by (Registered Nurse (RN)-E) was unsuccessful. (R1) assisted to floor by (Director of Nursing (DON)-B), therapy and CNA (Certified Nursing Assistant). Crash cart obtained and suction started. (R1) was side lying while attempts to clear the obstruction continued. EMS were notified. (RN-G) attempted side lying Heimlich without success. (R1) noted to have weak pulse - not breathing, cyanotic. EMS arrived on scene and assumed care. At time of EMS arrival, (R1) was pulseless and non-breathing. Code status confirmed DNR (Do Not Resuscitate). EMS was able to clear obstruction with forceps and suction. Leads attached with no viable heart rhythm noted. Police present at time . On 11/9/23, Surveyor reviewed R1's physician code status order of DNR/No Code and R1's Wisconsin form titled Emergency Care, signed and dated by R1's POAHC and physician on 6/30/23, that indicated Emergency providers as appropriate will provide .Clear airway and Emergency providers will not .perform chest compressions . On 11/9/23, Surveyor reviewed the facility's report document, with date occurred 11/7/23, that indicated: (R1) unexpectedly passed away as a result of a choking incident in the dining room. (R1) was observed choking at approximately 12:54 PM and staff responded immediately and appropriately to the incident .Facility has suspended pending investigation staff that were involved in the event from dietary service to table service. Staff education initiated immediately on diet consistencies. Audits initiated immediately for cook to sign off on any resident on an altered diet consistency. On 11/9/23, Surveyor reviewed the facility's investigation which included the following staff interviews: Dietary Aide (DA)-C's handwritten statement, dated 11/7/23, indicated: I was rinsing dishes at the window by the dishwasher. I glanced up when I was putting a dish on a rack and saw (R1) was choking on (R1's) lunch. I immediately stopped what I was doing and ran into the dining room, which only took a couple seconds. I told the CNAs in the dining room (R1) was choking and they immediately called out for a nurse. CNA-D's handwritten statement dated, 11/7/23, indicated: I was sitting in the dining room feeding another resident when I heard a kitchen aide say 'I think (R1's) choking'. I looked around, noticing it was (R1). I went over to (R1) and confirmed (R1) was choking. I began to pat (R1's) back, when (R1) spit milk out of (R1's) mouth. I then screamed for help stating 'I need a nurse for help'. The nurse (RN-G) came running in for help. (RN-G) then stated to me to grab the crash cart and I did so. I continued to assist the nurse, until the hot dog was out of (R1's) throat. RN-E's handwritten statement, dated 11/7/23, indicated: Writer alerted to choking episode in dining room. Writer initiated Heimlich maneuver unsuccessfully. (R1) was assisted to floor by (DON-B), CNA and therapist. Crash cart obtained. Suction started. EMS activated. Continued attempts to clear obstruction. (RN-G) attempted side lying Heimlich without success. Weak pulse noted. Attempts to suction and clear continued. EMS arrived - noted no pulse, not breathing. EMS confirmed code status and continued to attempt to clear obstruction. EMS was successful in removing the obstruction with forceps and suction. No viable heart rhythm noted on leads. Police present. Medication Technician (MT)-F's handwritten statement, dated 11/7/23, indicated: (CNA-D), (DON-B), (RN-E) and I lifted (R1) out of (R1's) chair and put (R1) on the floor. (RN-E) used suction on (R1). We rolled (R1) to (R1's) side, patted (R1) on (R1's) back, suctioned and encouraged (R1) until EMT (emergency medical technicians) arrived. RN-G's handwritten statement, dated 11/7/23, indicated: When writer entered dining room, (R1) was on (R1's) left side with (DON-B) holding (R1's) head and nurse manager suctioning. (R1's) lips were purple, agonal breathing (short, labored, gasping breaths), sending faint pulse. Writer attempted abdominal thrusts for 15 seconds until ambulance arrived. We turned (R1) onto (R1's) back, opened the airway and attempted to remove sausage from blocking airway. Once small piece removed, (R1) went pulseless and eyes became fixed. Second larger piece was removed and leads showed (R1) was in PEA (pulseless electrical activity) and is a DNR. On 11/9/23 at 11:18 AM, Surveyor interviewed NHA-A who indicated NHA-A learned from interviews with staff that R1 was given the wrong food. NHA-A indicated the report from the staff interviews was not yet written and NHA-A had handwritten notes only. NHA-A indicated after the incident on 11/7/23, NHA-A spoke to Dietary Manager (DM)-H who told NHA-A that DM-H let Cook (CK)-I know R1 requested a hot dog on a bun and DM-H told CK-I to cut it up. NHA-A indicated CK-I assumed DA-C heard the directive from DM-H. NHA-A indicated DA-C told NHA-A that DA-C did not hear the directive from DM-H. NHA-A indicated the cooks were to have altered diets ready to serve. On 11/9/23, Surveyor reviewed undated handwritten notes by NHA-A who stated the notes were written on 11/7/23 during event and with start of investigation. The notes indicated: .(DM-H) told (CK-I) to cut the hot dog. (CK-I) did not cut hot dog. Hot dogs left whole for person serving. Assumed server heard. (DA-C) said (DA-C) did not hear that . On 11/9/23 at 11:50 PM, Surveyor interviewed Speech Language Pathologist (SLP)-J who verified SLP-J was involved in the assessment of R1's dietary needs. SLP-J stated, We tried pureed, but (R1) didn't like it. (R1) did fine on easy to chew (diet). When asked how small a cut up hot dog should be on a Level 7 Easy to Chew diet, SLP-J stated, Have to be able to cut with tongs of a fork on the side. Has to soften with a fork. Really not a size thing. Could serve someone a whole piece of salmon. Salmon is soft. Ground up hot dog would be easy to chew. Cut up hot dog would not be easy to chew .That would be what I'm comfortable with. When it says 'meat to be chopped', I would say into very small pieces. Like two-centimeter pieces probably. Small enough that it would soften with fork. On 11/9/23 at 12:47 PM, Surveyor observed a food item in a zip-lock bag in NHA-A's office. NHA-A verified the item was a piece of Kielbasa sausage which EMS pulled from R1's throat. The piece of Kielbasa was approximately two inches long and a little over one inch wide. The bag also contained a full Kielbasa sausage that was six and a half inches long and a little over one inch wide. NHA-A verified the full Kielbasa sausage was an example of what was served to R1 on 11/7/23. On 11/9/23 at 12:49 PM, Surveyor interviewed NHA-A who indicated the lunch meal on 11/7/23 was French onion pork loin, scalloped potatoes, and green beans. NHA-A indicated alternate meal items always available were soup of the day, sandwich of the day, salad with protein, and hot dog with bun. On 11/9/23 at 1:05 PM, Surveyor interviewed DM-H who indicated a Level 7 Easy to Chew diet required meats to be cut up into smaller pieces. When asked how small, DM-H stated, Level 6 is 1.6 centimeters, but bigger than that for Level 7 .We do chopped (meat) here for Level 7. Level 6 should be ground (meat). When asked about DM-H's instructions to CK-I for R1's lunch meal on 11/7/23, DM-H stated, The cook was not in the kitchen when I first heard (R1) wanted a hot dog for lunch. I left a note telling the cook (R1) wanted a hot dog for lunch. DM-H indicated the note did not instruct CK-I to cut up the hot dog. DM-H stated, So I talked to the cook to tell (CK-I) to cut up the hot dog in case (CK-I) didn't think of it. When asked if R1 was served a hot dog or a Kielbasa sausage, DM-H stated, It was a Kielbasa. (R1) was okay with getting that since we didn't have hot dogs, but it (Kielbasa) should have been cut up. When asked what size DM-H expected CK-I to cut the Kielbasa, DM-H stated, The way I cut it up, and the way I would expect them (cooks) to do it, is down the long way, then those strips cut the long way again so four long strips then cut the strips in one-half inch pieces. (1.2 centimeters equals one-half inch.) On 11/9/23 at 3:15 PM, Surveyor interviewed SLP-J via phone. When asked if SLP-J authorized any adjustments to R1's Level 7 Easy to Chew diet, SLP-J stated, I don't think so .I know I didn't adjust for Kielbasa. When asked if bread was allowed on a Level 7 Easy to Chew diet, SLP-J stated, Anyone can have bread on that diet .anything fork tender. Bread on Level 7 should be fine. A piece of bread. When asked if a bun was appropriate for a Level 7 Easy to Chew diet, SLP-J stated, Bun is fine. I would say that qualifies as easy to chew. Meat only if sliceable on side of fork. When Surveyor asked SLP-J's thoughts on the Kielbasa alternative, SLP-J stated, (R1) was not given correct texture. Not the right item. (R1) maybe could have been given Kielbasa in another form. Cut up into a size that loses its form with a fork. Or ground up. SLP-J indicated adjustments to IDDSI diet levels should be specifically added to a resident's diet order and care plan. SLP-J further stated, I didn't even know we (facility) served Kielbasa. The failure to ensure a resident received food in the correct form led to serious harm which created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy. The facility removed the jeopardy on 11/9/23 when it completed the following: 1. Reviewed all residents' diet orders and tray cards for accuracy. 2. Reviewed the IDDSI Level 7 Easy to Chew Framework with staff and updated the facility's policies and procedures accordingly. 3. Educated staff on the requirements of F805 and serving food in accordance with residents' diet orders. 4. Initiated meal and snack audits.

Based on record review, staff and family interviews, the facility did not ensure 1 (resident #1) of 8 residents reviewed were provided the necessary care and services to maintain the highest physical well-being related to oxygenation. Resident #1 was noted to have a low oxygen saturation level of 73%. The facility staff attempted to trouble shoot the oxygen concentrator without applying supplemental oxygen, at which time the resident's oxygen saturation level had dropped into the 60's with skin, nail beds, and oral mucosa becoming dusky. Family applied supplemental oxygen and resident #1's oxygen saturation returned to an acceptable level. Findings Include: Early symptoms of [MEDICAL CONDITION] (low oxygen levels) include anxiety, dyspnea (difficulty breathing), and tachypenia (increased respiratory rate). Late symptoms of [MEDICAL CONDITION] include cyanosis (a bluish discoloration of the skin resulting from inadequate oxygenation) and lethargy. 1. According to the Admission Record, resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/29/15 at 7:00 a.m., LPN (Licensed Practical Nurse)-A documented the following in resident #1's medical record: Rechecked complained of not being able to Breath at the present time is on oxygen 8 L (liters/minute) per rebreather mask. Residents head elevated in high position oxygen Sats checked residents sating at 73% oxygen mask check placed in water to see if bubbling occurred mask functioning properly at the present time LPN went to get RN (Registered Nurse) for assessment hospice contacted by phone informed of resident complaint and the resident's oxygen per hospice increase oxygen to 10 L per rebreather mask. The nurse's note continued with the documentation that hospice would call family and send a nurse to facility. Resident #1's oxygen was rechecked and was at 99%. On 6/29/15 at 7:00 a.m., resident #1's oxygen saturation was documented by LPN-A that stated 60%, in the electronic vital section of the online medical record. On 6/29/15 at 8:00 a.m., LPN-A documented a subsequent note stating she was called back to resident #1's room due to the resident complaining of not being able to breath and the resident had an oxygen saturation of 70%. Resident #1's skin appeared pale. The rebreather mask was not functioning properly according to concerns from the family and the mask was exchanged out with a new mask. Hospice was informed by phone that the resident was placed on portable oxygen awaiting for arrival of new concentrator. Family was present at the time the hospice nurse arrived and hospice nurse was informed of assessment performed by RN. Resident #1's brother was present and upset stating he felt the facility could have done more for the resident during this incident. According to the notes from Agnesian Hospice, LPN-A called hospice on 6/29/15 at 8:40 a.m., (not at 7:00 a.m.) and reported the low oxygen saturation level of 73% and was informed to increase the oxygen level to 10 L/min, up from 8 L/min. At 8:45 a.m., the hospice RN contacted resident #1's physician and informed the physician of the low oxygen saturation and obtained the order to increase the oxygen. A subsequent call from LPN-A between 8:45 a.m. and 8:52 a.m., occurred informing hospice that resident #1's oxygen saturation was now in the 60's and LPN-A would be getting a portable oxygen tank. The hospice chaplain documentation included that the chaplain arrived at the facility at 9:00 a.m. and family was with the resident at that time. On 7/22/15 at 9:40 a.m., surveyor # interviewed LPN-A regarding the events that occurred on 6/29/15 with resident #1. LPN-A stated she went into the resident's room on the morning of 6/29/15, during the morning medication pass due to complaints from the resident of the oxygen not working. LPN-A with the assistance of DON (Director of Nursing)-B, began to trouble shoot the oxygen tubing. The mask was placed in water and no bubbles were present. A new mask was obtained and applied to resident #1. The resident #1's oxygen saturation levels returned to normal with the new mask. Later, family reported that the resident still was not getting oxygen. LPN-A stated the resident appeared to be anxious, but not in distress because the resident was able to talk to LPN-A, to report that he was short of breath and that there was no oxygen coming from the concentrator. A new mask was applied without relief. LPN-A stated she then placed the resident on portable oxygen and the hospice nurse arrived and took over. LPN-A stated she applied the portable oxygen, not FM (Family Member)-C. LPN-A denied resident #1 having cyanosis during the low oxygenation encounter. On 7/22/15 at 10:46 a.m., surveyor # interviewed FM-C regarding resident #1's the low oxygen saturation level on 6/29/15. FM-C stated he received a call from hospice relating to resident #1 having low oxygen saturation levels in the 60's and 70's. FM-C stated he clocked out of work at 8:52 a.m. that day and arrived at the facility within 10 minutes. FM-C stated no one was present with the resident, however the Chaplain arrived within minutes. FM-C indicated resident #1 was anxious and confused, looked really tired and complained of not being able to breath, talking but not making sense. FM-C stated no oxygen was felt coming out of the mask and he then went to get LPN-A, who did not come to the room immediately. FM-C stated LPN-A came to the resident's room after an unknown amount of time passed. LPN-A informed FM-C that the resident's mask wasn't working earlier, but the mask was changed and it was working now. FM-C stated the oxygen was not working and LPN-A checked the resident's oxygen saturation and it was 65% and a second finger read 75%. LPN-A then submerged the mask under water and no bubbles were coming out. FM-C stated he then hooked resident #1 up to one of the portable oxygen tanks that was in the resident's room and applied oxygen to the resident because the nurse was not doing anything for the resident's low oxygen level. FM-C stated he believed, but could not be certain, that it had been approximately 30 minutes since the time he received the call related to low oxygen levels before he applied the portable oxygen on resident #1. FM-C indicated the room had 2 empty oxygen tanks and a third oxygen tank had 100%, so I turned it on and (resident) perked up and the O2 level went back up to 98 -99%. On 7/22/15 at 1:00 p.m., surveyor # conducted a subsequent interview with LPN-A regarding resident #1. LPN-A stated she does not recall if the portable oxygen tank was in the resident's room, however adamantly states that she applied the portable oxygen tank. LPN-A also stated DON-B was present during the second encounter of low oxygenation. A hospice note, dated 6/29/15, documented that the nurse arrived to the facility at 9:45 a.m., and received report from the facility staff that it was noted that resident #1's oxygen saturation was 60% and the resident's face was pale/gray and lips were cyanotic. After the oxygen was applied, oxygen saturation increased to 99% and lips were starting to turn back to pink/red. On 7/22/15 at 1:25 p.m., surveyor # interviewed DON-B regarding resident #1's low oxygen saturation. DON-B confirmed she would have expected LPN-A to apply the portable oxygen before trouble shooting the oxygen concentrator if a resident's oxygen saturation level was in the 60's, as resident #1 had. DON-B also confirmed she was not present during the second encounter with resident #1 having low oxygen levels. On 7/27/15 at 1:40 p.m., surveyor # interviewed CH (Chaplain)-D regarding resident #1. CH-D confirmed she arrived at the facility on 6/29/15 at 9:00 a.m., due to resident #1 having low oxygen saturation levels. CH-D stated the resident was saying no air and after a few minutes of being in the room, she left the room to get LPN-A. When notified of the concerns, LPN-A stated she had already checked the oxygen concentrator and it was functioning normally and the resident's oxygen level was back up over 90%. CH-D indicated she was firm with LPN-A and informed her the oxygen was no longer working. LPN-A then went into the room and resident #1's oxygen level was in the low 60's. LPN-A then began to trouble shoot the concentrator after the family member reported it was not functioning. CH-D stated FM-C then began to apply the portable oxygen while LPN-A was still trying to trouble shoot the concentrator. CH-D stated FM-C was upset that LPN-A did not act quickly. CH-D stated she did not believe LPN-A thought the issue was urgent and did not appear to be in a hurry. CH-D indicated it was probably about 9:20 a.m. or 9:25 a.m. before the resident was hooked up to the portable oxygen tank. On 6/29/15 between 8:45 a.m. and 8:52 a.m., resident #1's oxygen saturation level of 60's was reported to LPN-A. Resident #1 did not receive oxygen until approximately 9:20 a.m. to 9:25 a.m., when a family member applied oxygen on resident #1, while LPN-A continued to trouble shoot the oxygen concentrator. LPN-A did not treat resident #1's low oxygen saturation level immediately, even though the resident's skin appeared dusky, lips were blue tinged, the resident complained of not being able to breath, and there was no oxygen coming from the oxygen concentrator for approximately 40 minutes.

Based on record review and staff interview, the facility did not immediately consult with the resident's physician when the resident experienced a significant change in physical status for 1 (Resident #1) of 11 sampled residents resulting in the resident's death. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #1 was assessed by the facility to not have any [MEDICAL CONDITION] of the lower extremities upon admission, nor did the resident require oxygen supplementation. The resident developed lower extremity [MEDICAL CONDITION], shortness of breath that required oxygen supplementation and complaints of transient chest pain and epigastric (the frontal surface of the body overlying the heart and lower part of the rib cage) pain. The facility did not complete a comprehensive assessment to include all symptoms the resident was experiencing in light of the recent history of a tibial fracture. The facility did not consult with the physician regarding the resident's symptoms until 3 days after Resident #1 displayed a significant change in condition. Resident #1 was sent to the hospital and diagnosed with [REDACTED]. Resident #1 expired in the emergency room . The failure to immediately consult with the physician when Resident #1 experienced a significant change in condition created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. The NHA (Nursing Home Administer) was informed of the immediate jeopardy on [DATE] at 11:15 a.m. The jeopardy was removed on [DATE], however the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) while the facility continues to fully implement it's action plan. Findings include: According to the National Institute of Health, "Pulmonary embolism (PE) occurs equally in men and women. The risk increases with age. For every [AGE] years after age 60, the risk of having PE doubles...Other factors also can increase the risk for PE, such as: *Being bedridden or unable to move around much *Having surgery or breaking a bone (the risk goes up in the weeks following the surgery or injury) http://www.nhlbi.nih.gov/health/health-topics/topics/pe/atrisk The Mayo Clinic website indicated [MEDICAL CONDITION] embolism can be life threatening, but prompt treatment can greatly reduce the risk of death. Seek immediate medical attention if you experience unexplained shortness of breath (SOB) or chest pain. Symptoms: * SOB typically appears suddenly and always gets worse with exertion. * Chest pain, The pain may become worse when you breathe deeply, cough, eat, bend or stoop. The pain will get worse with exertion but won't go away when you rest. * Leg pain or swelling, or both, usually in the calf. The facility's policy and procedure for "Acute Condition Changes-Clinical Protocol," with a revision date of [DATE] indicated the following: * The nurse shall assess and document/report the following baseline information: (This list includes, but is not limited to:) - Vital signs - Onset, duration, severity - All active diagnoses * Before contacting the physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician. * Nursing staff will contact the physician based on the urgency of the situation. * The nursing staff and physician will discuss possible causes based on resident history, current symptoms... On [DATE], surveyor # reviewed Resident #1's medical record. According to the face sheet, dated [DATE], Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #1 was [AGE] years-old and was not on any anticoagulant medications. The facility initiated a plan of care on [DATE], which indicated an "Alteration in musculoskeletal status related to [MEDICAL CONDITION] tibia." The goal is written that the resident will remain free of complications, such as an embolism...through the review date. The approaches were as follows: * Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. * Follow Medical Doctor (MD) orders for weight bearing status. See MD orders and or Physical Therapy treatment plan. * Give [MEDICATION NAME] as ordered ([MEDICATION NAME]-a pain medication) by the physician. Monitor and document for side effects and effectiveness. The plan of care did not address signs/symptoms of an embolism. The medical record documented the following: * Progress Notes (PN)- [DATE]-- No SOB, no [MEDICAL CONDITION]. * PN- [DATE]-- No SOB, no [MEDICAL CONDITION]. * Skin Observation Tool- [DATE]-- Left lower extremity slightly swollen, tender to touch. * PN- [DATE]-- No SOB, no [MEDICAL CONDITION]. * "Skilled Charting" note- [DATE]-- 2 plus [MEDICAL CONDITION], indentation subsides rapidly. Respiration within normal limits (WNL), pain 5 on a ,[DATE] scale, using as needed (PRN) [MEDICATION NAME]. (Resident is using [MEDICATION NAME] for pain, and there isn't a physician's orders [REDACTED]. * PN- [DATE] documented 2245 (10:45 PM)-- complained of (c/o) upper gastric (stomach) pain just beneath right breast. States hurts when she breathes. Oxygen (O2) saturation (sats) 84% on room air (RA). Temperature 100.4, pulse 98, respirations 28. O2 placed at 2 liters via nasal cannula (NC) and sats came up to 91%. Tums given for gastrointestinal (GI) upset and Tylenol given for temperature. Resident states there is an area of swelling beneath the right breast, but could not determine that. Appeared to be equal to left side. O2 increased to 3 liters. Will continue to monitor to see if pain goes away. * PN- [DATE] documented at 2250 (10:50 PM)-- Re checked resident O2 sats. Now 96% on 3 liters of O2 per nasal cannula. Resident still c/o discomfort to area beneath right breast when she breathes. Resident stated something that was done on previous night started her discomfort. Said it began when they lowered her position in bed. Will continue to monitor. Resident doesn't appear to be in any distress at this time. * PN- [DATE] documented at 2257 (10:57 PM)-- c/o upper gastric pain. [DATE] documented at 0335 (3:35 AM)-- PRN effective/sleeping. The medical record did not contain any documentation on [DATE] in regards to Resident #1's increase in [MEDICAL CONDITION] status, shortness of breath with the need for oxygen therapy and correlated these symptoms with the resident's recent tibial fracture and a possible development of an embolism. The facility did not identify the change of condition based upon Resident #1's entire clinical condition, nor did the facility complete a comprehensive assessment regarding Resident #1's clinical condition. The facility did not consult with Resident #1's physician after experiencing a significant change in condition. * PN- [DATE] documented at 0238 (2:38 AM)-- Resident is on oxygen via nasal cannula. Sats 90% on 1 liter. Have been attempting to wean resident off. The medical record contained a fax to the physician dated [DATE] which stated, Resident O2 sats have been between 84% - 87% on room air. Oxygen started and O2 sats increased to 90% - 97%. May we have an order for [REDACTED]." * [DATE]-- Occupational Therapy notes- Upon arrival, patient sitting in recliner and reported she was not feeling well. Per Physical Therapy Assistant (PTA), who treated her earlier, the O2 level was at 88% and per Registered Nurse (RN) was increased 2 to 2 ? liters this morning. Arm bike at low resistance level tolerated 2 minutes, then 1 minute, then rested. O2 sat at 92% and pulse at 102. Patient rested and discussed pain in location of rib cage area on the left. RN assessed previously per patient report with assessment on Thursday ([DATE] was a Sunday, previous Thursday was [DATE].) She reported RN looked at pulse, checked lungs and did not find anything conclusive. Patient reported when reaching forward that she noticed it slightly and discussed it maybe muscular or skeletal related. * [DATE]-- Physical Therapy notes--...Patient notes that she had difficulty breathing earlier today and has supplemental O2. O2 sats with exercise dropped to 86% on 2 liters, within 1 minute O2 sats increased to 92%. * [DATE]-- Occupational Therapy notes- split session: Patient in wheelchair (w/c) with SOB with O2 at 82% - 89% with 4 liters .....Informed nursing about the SOB. Changed O2 tank, instructed pt with breathing exercise. Patient then increased to 92% - 93%. * [DATE]- Physical Therapy notes--...Patient c/o increase in shortness of breath and O2 sats 85% on 4 liters oxygen, with cues for deep breathing O2 sats increased to 90%. Patient c/o increase in right abdominal pain of ,[DATE] (1 - 10 pain scale.) RN notified of patient's decrease in O2 sats and pain... * PN-[DATE] documented at 1339 (1:39 PM)-- Care Conference Summary. Interdisciplinary team (IDT) met to review plan of care (POC.) Therapy relayed progress. O2 initiated over the weekend due to sats being lower than normal. Continues with right upper gastric pain. * PN- [DATE] documented at 1503 (3:03 PM)-- At 1315 (1:15 PM) resident c/o SOB. O2 sat was 85% - 90%. Noted portable O2 was empty. Placed on another machine and O2 came up to 92%. At 1345 (1:45 PM) called into room by Certified Nursing Assistant (CNA.) Resident wants to be transferred to the hospital now. O2 sats 85% - 92% with O2 on. Temp 99.5, skin warm and dry. Resident is unable to slow breathing down, unable to breathe in thru nose and out of mouth. Complaining of pain while breathing in. MD called and orders given to send to emergency room (ER.) Resident left at 1415 (2:15 PM.) The "Weights and Vitals Summary," which was printed from the computer by the facility, indicated the resident did not utilize oxygen therapy upon admission. The summary indicated oxygen was initiated on [DATE] and the resident utilized oxygen continuously until Resident #1 was sent to the emergency roiagnom on [DATE]. The record does not indicate how many liters were being administered, nor an assessment as to why the oxygen liter flow was changed. The progress notes and Physical Therapy/Occupational Therapy notes show multiple different liter flows of oxygen that were administered to the resident, but there is no assessment as to why the liter flow of oxygen was changed. The ER documentation indicated the following: Arrived 1448 (2:48 PM.) Chief complaint: SOB with abdominal pain and chest pressure. Started Thursday ([DATE]), increasing in pain. Computed Tomography (CT) scan completed- Extensive severe bilateral [MEDICAL CONDITIONS] essentially completely occluding the right [MEDICAL CONDITION] (lung) circulation to the distal right main [MEDICAL CONDITION] artery level and beginning at the distal (farthest from the center) left main [MEDICAL CONDITION] artery and extending into multiple branch vessels although with less severe occlusion (state of being closed.) There is evidence of increased right heart pressure. [DIAGNOSES REDACTED]. Resident expired at 1722 (5:22 PM.) MD notes- Patient critically ill, elderly female with acute abdomen and chest pain. Clinical suspicion was for acute [MEDICAL CONDITIONS] (PE) given left leg swelling due to recent tibial fracture as well as swelling of leg and immobility...Electrocardiogram (EKG) was also done showing some ischemic (restriction in blood supply to the tissue) changes, probably due to right heart strain... On [DATE] at 10:35 AM, surveyor # interviewed DON-A (Director of Nursing) regarding updating the physician in regards to Resident #1's change in condition. DON-A verified that she could not find any documentation that the physician was called. On [DATE] at 2:20 PM, surveyor # interviewed MD-G (Medical Doctor) regarding Resident #1's assessment conducted by RN-B on [DATE]. The surveyor read the assessment notes to MD-G and asked if he had been made away of these assessment findings would he have done something more than oxygen. MD-G stated, "Oh, absolutely. I am looking at her chart right now and it is blank." On [DATE] at 2:40 PM, surveyor # interviewed RN-F regarding the O2 request she faxed to the physician on [DATE]. RN-F stated the CNA (Certified Nursing Assistant) caring for Resident #1 that night, approached RN-F and stated something just didn't seem right with the resident. RN-F stated she assessed Resident #1 and at the time of the assessment, the resident only complained of leg pain. RN-F noted there was no order for the oxygen that Resident #1 was using. RN-F indicated she was aware that Resident #1 had been using oxygen therapy and there had been some problems with her O2 saturations, so she faxed the physician requesting an order for [REDACTED]. On [DATE] at 2:50 PM, surveyor # interviewed DON-A regarding MD notification of changes in condition. DON-A stated the staff know when to update the physicians. DON-A was asked what she knew of Resident #1's change of condition. DON-A stated she was aware of an increased temperature one time, but it had come down with medication. On [DATE] at 3:30 PM, surveyor # interviewed LPN-C (Licensed Practical Nurse) in regards to when staff should consult with a physician. LPN-C verified any time there is a change in the respiratory status or any condition that is not normal for the resident. LPN-C indicated staff should look at the whole picture of the resident. On [DATE] at 4:25 PM, surveyor # interviewed MD-G in regards to what changes he would have made to Resident #1's plan of care if he would have been aware of Resident #1's condition on [DATE]. MD-G stated he would have sent the resident to the ER for evaluation. MD-G indicated if the resident was assessed on [DATE] instead of [DATE], her chance of survival would have definitely increased. The failure to immediately consult with the physician when Resident #1 experienced a significant change in condition created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], by which time it had completed or begun implementing the following: 1. All licensed nurses were reeducated on timely consultation with physicians when a change in resident condition is identified; 2. Reviewed residents to ensure physicians were consulted on changes in resident conditions; and, 3. Director of Nursing began to monitor the 24 hour report log to ensure changes in condition were reported and monitored.

Based on record review and staff interview, the facility did not provide the necessary care and services when a change of condition occurred for 1 (Resident #1) of 11 sampled residents resulting in the resident's death. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #1 was assessed by the facility not to have any [MEDICAL CONDITION] of the lower extremities upon admission, nor did the resident require oxygen supplementation. The facility developed a plan of care regarding Resident #1's tibial fracture, which included a goal that indicated the resident would be free from complications related to the tibial fracture such as an embolism. The facility did not identify on the plan of care what the signs/symptoms of an embolism are. The resident developed lower extremity [MEDICAL CONDITION], shortness of breath that required oxygen supplementation and complaints of transient chest pain and epigastric (the frontal surface of the body overlying the heart and lower part of the rib cage) pain. The facility did not complete a comprehensive assessment to include all symptoms the resident was experiencing in light of the recent history of a tibial fracture, nor did the facility consult with the physician regarding the resident's symptoms until 3 days after Resident #1 displayed a significant change in condition. Resident #1 was sent to the hospital and diagnosed with [REDACTED]. Resident #1 expired in the emergency room . The failure to provide appropriate care to ensure the physical well being of Resident #1 based on professional standards of practice created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. The NHA (Nursing Home Administer) was informed of the immediate jeopardy on [DATE] at 11:15 a.m. The facility removed the jeopardy on [DATE], however the deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) while the facility continues to fully implement its action plan. Findings include: According to the National Institute of Health, "Pulmonary embolism (PE) occurs equally in men and women. The risk increases with age. For every [AGE] years after age 60, the risk of having PE doubles...Other factors also can increase the risk for PE, such as: *Being bedridden or unable to move around much *Having surgery or breaking a bone (the risk goes up in the weeks following the surgery or injury) http://www.nhlbi.nih.gov/health/health-topics/topics/pe/atrisk The Mayo Clinic website indicates [MEDICAL CONDITION] embolism can be life threatening, but prompt treatment can greatly reduce the risk of death. Seek immediate medical attention if you experience unexplained shortness of breath (SOB) or chest pain. Symptoms: * SOB typically appears suddenly and always gets worse with exertion. * Chest pain, The pain may become worse when you breathe deeply, cough, eat, bend or stoop. The pain will get worse with exertion but won't go away when you rest. * Leg pain or swelling, or both, usually in the calf. The facility's policy and procedure for "Acute Condition Changes-Clinical Protocol," with a revision date of [DATE] indicates the following: * The nurse shall assess and document/report the following baseline information: (This list includes, but is not limited to:) - Vital signs - Onset, duration, severity - All active diagnoses On [DATE], surveyor # reviewed Resident #1's medical record. According to the face sheet, dated [DATE], Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. She was [AGE] years old and was not on any anticoagulant medications. The facility initiated a plan of care on [DATE] indicating an "Alteration in musculoskeletal status related to [MEDICAL CONDITION] tibia." The goal is written that the resident will remain free of complications, such as an embolism.....through the review date. The approaches were as follows: * Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. * Follow Medical Doctor (MD) orders for weight bearing status. See MD orders and or Physical Therapy treatment plan. * Give [MEDICATION NAME] as ordered ([MEDICATION NAME]-a pain medication) by the physician. Monitor and document for side effects and effectiveness. The plan of care did not address signs/symptoms of an embolism. The medical record documented the following: * Progress Notes (PN)- [DATE]-- No SOB, no [MEDICAL CONDITION]. * PN- [DATE]-- No SOB, no [MEDICAL CONDITION]. * Skin Observation Tool- [DATE]-- Left lower extremity slightly swollen, tender to touch. * PN- [DATE]-- No SOB, no [MEDICAL CONDITION]. * "Skilled Charting" note- [DATE]-- 2 plus [MEDICAL CONDITION], indentation subsides rapidly. Respiration within normal limits (WNL), pain 5 on a ,[DATE] scale, using as needed (PRN) [MEDICATION NAME]. (Resident is using [MEDICATION NAME] for pain, and there isn't a physician's orders [REDACTED]. * PN- [DATE] documented 2245 (10:45 PM)-- complained of (c/o) upper gastric (stomach) pain just beneath right breast. States hurts when she breathes. Oxygen (O2) saturation (sats) 84% on room air (RA). Temperature 100.4, pulse 98, respirations 28. O2 placed at 2 liters via nasal cannula (NC) and sats came up to 91%. Tums given for gastrointestinal (GI) upset and Tylenol given for temperature. Resident states there is an area of swelling beneath the right breast, but could not determine that. Appeared to be equal to left side. O2 increased to 3 liters. Will continue to monitor to see if pain goes away. * PN- [DATE] documented at 2250 (10:50 PM)-- Re checked resident O2 sats. Now 96% on 3 liters of O2 per nasal cannula. Resident still c/o discomfort to area beneath right breast when she breathes. Resident stated something that was done on previous night started her discomfort. Said it began when they lowered her position in bed. Will continue to monitor. Resident doesn't appear to be in any distress at this time. * PN- [DATE] documented at 2257 (10:57 PM)-- c/o upper gastric pain. [DATE] documented at 0335 (3:35 AM)-- PRN effective/sleeping. The medical record did not contain any documentation on [DATE] in regards to Resident #1's increase in [MEDICAL CONDITION] status, shortness of breath with the need for oxygen therapy and correlated these symptoms with the resident's recent tibial fracture and a possible development of an embolism. The facility did not identify the change of condition based upon Resident #1's entire clinical condition, nor did the facility complete a comprehensive assessment regarding Resident #1's clinical condition. The facility did not consult with Resident #1's physician after experiencing a significant change in condition. * PN- [DATE] documented at 0238 (2:38 AM)-- Resident is on oxygen via nasal cannula. Sats 90% on 1 liter. Have been attempting to wean resident off. The medical record contained a fax to the physician dated [DATE] that stated, Resident O2 sats have been between 84% - 87% on room air. Oxygen started and O2 sats increased to 90% - 97%. May we have an order for [REDACTED]." * [DATE]-- Occupational Therapy notes- Upon arrival, patient sitting in recliner and reported she was not feeling well. Per Physical Therapy Assistant (PTA), who treated her earlier, the O2 level was at 88% and per Registered Nurse (RN) was increased 2 to 2 ? liters this morning. Arm bike at low resistance level tolerated 2 minutes, then 1 minute, then rested. O2 sat at 92% and pulse at 102. Patient rested and discussed pain in location of rib cage area on the left. RN assessed previously per patient report with assessment on Thursday ([DATE] was a Sunday, previous Thursday was [DATE]). She reported RN looked at pulse, checked lungs and did not find anything conclusive. Patient reported when reaching forward that she noticed it slightly and discussed it maybe muscular or skeletal related. * [DATE]-- Physical Therapy notes--...Patient notes that she had difficulty breathing earlier today and has supplemental O2. O2 sats with exercise dropped to 86% on 2 liters, within 1 minute O2 sats increased to 92%. * [DATE]-- Occupational Therapy notes- split session: Patient in wheelchair (w/c) with SOB with O2 at 82% - 89% with 4 liters...Informed nursing about the SOB. Changed O2 tank, instructed pt with breathing exercise. Patient then increased to 92% - 93%. * [DATE]- Physical Therapy notes-- ...Patient c/o increase in shortness of breath and O2 sats 85% on 4 liters oxygen, with cues for deep breathing O2 sats increased to 90%. Patient c/o increase in right abdominal pain of ,[DATE] (1 - 10 pain scale). RN notified of patient's decrease in O2 sats and pain... * PN-[DATE] documented at 1339 (1:39 PM)-- Care Conference Summary. Interdisciplinary team (IDT) met to review plan of care (POC). Therapy relayed progress. O2 initiated over the weekend due to sats being lower than normal. Continues with right upper gastric pain. * PN- [DATE] documented at 1503 (3:03 PM)-- At 1315 (1:15 PM) resident c/o SOB. O2 sat was 85% - 90%. Noted portable O2 was empty. Placed on another machine and O2 came up to 92%. At 1345 (1:45 PM) called into room by Certified Nursing Assistant (CNA). Resident wants to be transferred to the hospital now. O2 sats 85% - 92% with O2 on. Temp 99.5, skin warm and dry. Resident is unable to slow breathing down, unable to breathe in thru nose and out of mouth. Complaining of pain while breathing in. MD called and orders given to send to emergency room (ER). Resident left at 1415 (2:15 PM). The "Weights and Vitals Summary," which was printed from the computer by the facility, indicated the resident did not utilize oxygen therapy upon admission. The summary indicated oxygen was initiated on [DATE] and the resident utilized oxygen continuously until Resident #1 was sent to the emergency roiagnom on [DATE]. The record does not indicate how many liters were being administered, nor an assessment as to why the oxygen liter flow was changed. The progress notes and Physical Therapy/Occupational Therapy notes show multiple different liter flows of oxygen that were administered to the resident, but there is no assessment as to why the liter flow of oxygen was changed. The ER documentation indicated the following: Arrived 1448 (2:48 PM). Chief complaint: SOB with abdominal pain and chest pressure. Started Thursday ([DATE]), increasing in pain. Computed Tomography (CT) scan completed- Extensive severe bilateral [MEDICAL CONDITIONS] essentially completely occluding the right [MEDICAL CONDITION] (lung) circulation to the distal right main [MEDICAL CONDITION] artery level and beginning at the distal (farthest from the center) left main [MEDICAL CONDITION] artery and extending into multiple branch vessels although with less severe occlusion (state of being closed). There is evidence of increased right heart pressure. [DIAGNOSES REDACTED]. Resident expired at 1722 (5:22 PM). MD notes- Patient critically ill, elderly female with acute abdomen and chest pain. Clinical suspicion was for acute [MEDICAL CONDITIONS] (PE) given left leg swelling due to recent tibial fracture as well as swelling of leg and immobility ... ....Electrocardiogram (EKG) was also done showing some ischemic (restriction in blood supply to the tissue) changes, probably due to right heart strain ... ... On [DATE] at 10:35 AM, surveyor # interviewed DON-A (Director of Nursing) regarding updating the physician in regards to Resident #1's change in condition. DON-A verified that she could not find any documentation that the physician was called. On [DATE] at 1:30 PM, surveyor # interviewed PTA-H (Physical Therapy Assistant) regarding Resident #1's breathing and complaints of pain during therapy. PTA-H verified Resident #1 complained of SOB on [DATE], and then right abdominal pain on [DATE]. PTA-H stated she informed LPN-D (Licensed Practical Nurse) of the resident's complaints of pain on [DATE]. On [DATE] at 1:40 PM, surveyor # interviewed OT-E (Occupational Therapist) regarding Resident #1's breathing and complaints of pain during therapy. OT-E stated therapy staff always check the O2, (tank) and replaces it when it is low. OT-E stated Resident #1 consistently complained of pain, but the pain was not in a consistent location. On [DATE] at 2:15 PM, surveyor # conducted a telephone interview with RN-B regarding his assessment of Resident #1 on [DATE]. RN-B did recall the first time Resident #1 complained of chest pain. RN-B stated he didn't think Resident #1's condition was at a level to call the physician at that time. RN-B felt staff had the option to place a resident on O2 if needed, without an order. RN-B stated Resident #1 originally complained of chest pain to the CNA. When RN-B spoke to Resident #1, the resident said she may have strained something the night before. On [DATE] at 2:20 PM, surveyor # interviewed MD-G regarding Resident #1's assessment conducted by RN-B on [DATE]. The surveyor read the assessment notes to MD-G and asked if he had been made away of these assessment findings would he have done something more than oxygen. MD-G stated, "Oh, absolutely. I am looking at her chart right now and it is blank." On [DATE] at 2:40 PM, surveyor # interviewed RN-F regarding the O2 request she faxed to the physician on [DATE]. RN-F stated the CNA caring for Resident #1 that night, approached RN-F and stated something just didn't seem right with the resident. RN-F stated she assessed Resident #1 and at the time of the assessment, the resident only complained of leg pain. RN-F noted there was no order for the oxygen that Resident #1 was utilizing. RN-F indicated she was aware that Resident #1 had been utilizing oxygen therapy and there had been some problems with her O2 saturations, so she faxed the physician requesting an order for [REDACTED]. On [DATE] at 2:50 PM, surveyor # interviewed DON-A regarding MD notification of changes in condition. DON-A stated the staff know when to update the physicians. DON-A was asked what she knew of Resident #1's change of condition. DON-A stated she was aware of an increased temperature one time, but it had come down with medication. On [DATE] at 4:25 PM, surveyor # interviewed MD-G in regards to what changes he would have made to Resident #1's plan of care if he would have been aware of Resident #1's condition on [DATE]. MD-G stated he would have sent the resident to the ER for evaluation. MD-G indicated if the resident was assessed on [DATE] instead of [DATE], her chance of survival would have definitely increased. The failure to comprehensively assess Resident #1's symptoms in light of her [DIAGNOSES REDACTED].g., immediate consultation with the physician) placed Resident #1 at risk for serious harm and created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], when it had completed or begun implementing the following: *Staff were educated on what constitutes a change in condition including clinical protocols, and physician consultation; *Staff were educated on oxygen use and the need for physician orders [REDACTED]. *All residents have been reviewed to ensure any change of condition has been reported to RN on duty and the physician; and *Changes in condition are documented on the 24 hour report log which is monitored by the Director of Nursing for appropriate follow-up.

Based on observation, staff interview, record review and policy review, the facility did not maintain and implement an infection control program designed to prevent the development and transmission of infection for of 17 of 51 residents who resided at the facility. The facility practices had the potential to affect all 51 residents in the facility. The facility did not recognize an outbreak of GE (Gastroenteritis) when the GE line list indicated 4 residents (#18, #19, #10, #26) developed GE symptoms between 4/23/11 and 4/25/11. The facility did not promptly inform the Public Health Department when an outbreak was apparent. The facility did not minimize movement of residents when asymptomatic, exposed residents were allowed to consume meals in a common dining area with other residents and in group activities. Facility staff did not wear proper personal protective equipment when caring for residents who had active signs/symptoms of GE. The facility did not disinfect equipment that was shared by residents with appropriate disinfectants that were effective against Norovirus. The facility did not properly disinfect walls, curtains, carpeting, handrails, door knobs with disinfectant that was effective against Norovirus. The facility did not consult with the Medical Director for appropriate procedures to limit the admission of residents to the facility when there was an outbreak of GE. The facility did not have policies and procedures readily accessible for staff to know how to manage infectious disease. The failure of the facility to immediately implement appropriate procedures to limit the transmission of disease created a situation of Immediate Jeopardy, which began on 4/25/11, when the resident line list revealed four residents demonstrated signs/symptoms of GE within the previous forty-eight hours. On 5/4/11 at 9:50 a.m. NHA (Nursing Home Administrator)-H was formally notified that an Immediate Jeopardy situation existed. Immediate Jeopardy was determined to have been removed but not corrected on 5/4/11; the deficiency continues at a scope/severity level of F (potential for harm/widespread) because all portions of the facility's action plan, including staff training, had not been fully implemented or tested . Findings include: 1. The WDPH (Wisconsin Division of Public Health's) "Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities" revised 10/20/09 indicated an outbreak of viral gastroenteritis should be suspected when two or more residents and/or staff develop new onset of vomiting and/or diarrhea within one to two days. Each resident unit should immediately report any resident with a sudden onset of symptoms suggestive of viral GE to infection control practitioner or person in charge. The recommendations also direct the facility to notify the local Health Department of any suspected or confirmed outbreak. On 5/3/11 at approximately 8:30 a.m., during initial tour of the facility, surveyor # became aware that approximately 3 residents residing on the north wing had developed symptoms of GE. No isolation carts were observed in the hallways, staff were noted to be entering and exiting resident rooms without personal protective apparel. On 5/3/11 at approximately 8:30a.m., during initial tour of the facility, surveyor # became aware that approximately 6 residents residing on the west wing had developed symptoms of GE. Staff were observed to be entering and exiting resident rooms without personal protective apparel. On 5/3/11 at 9:10 a.m. surveyor # interviewed ADON (Assistant Director of Nursing)-C regarding Infection Control. ADON-C revealed that DON (Director of Nursing)-M was responsible for Infection Control, however DON-M was out of the facility for an extended medical leave which started 4/20/11. ADON-C indicated RN-L was managing infections in DON-M's absence. During an interview on 5/3/11 at 9:20 a.m., surveyor # verified the infection control process with RN (Registered Nurse)-L who confirmed it was her responsibility to record all infections, including GE, on a line list clipboard. RN-L also indicated that after recording the data, she had no further responsibility. RN-L indicated DON-M handled infection management from that point. On 5/3/11 surveyor # reviewed the resident and staff GI line lists. The resident line list from 4/1/11, indicated 12 residents (#18, #19, #10, #26, #9, who was listed on two dates during the outbreak, #13, #20, #21, #22, #23, #24, #25) exhibited any combinations of nausea, vomiting and/or diarrhea. The resident line list indicated residents from all three units had been affected with symptoms of GE. During the 5/3/11, 9:10 a.m. interview with surveyor # , ADON-C indicated that she was unaware that on 4/25/11, four residents within forty-eight hours presented with symptoms of GE and that was the definition of an outbreak. ADON-C revealed she had reviewed the line list with senior leadership during daily morning meeting on 4/30/11 and 5/2/11 without concern. ADON-C further verified the local public health department was not notified of any potential outbreak. ADON-C indicated the facility did not have a specific policy for gastroenteritis, but RN-L presented the WDPH recommendations as their standard of practice. The facility policy entitled "Infection Control Surveillance Log" dated 10/9 indicated: "all residents with an actual infection will have a Resident Infection Record completed and will be logged on Infection Control Surveillance log..." Surveyor # reviewed the closed record of resident #13 on 5/4/11 and resident #13's nurses notes dated 1/1/11 document that resident #13 was experiencing nausea and having liquid stools. Nurses notes dated 1/3/11 state resident #13 had "diarrhea, liquid, brown in colostomy" and resident #13's family was called regarding a change in condition. Diarrhea and loose stools continued on 1/4/11 and 1/5/11 and resolved on 1/7/11 according to the nurses notes. Resident #13 did not appear on the resident line lists reviewed by surveyor # on 5/3/11 and 5/4/11. On 5/4/11 at 4:00 p.m., surveyor # interviewed the LPHD, (Local Public Health Department) RN-V, who confirmed the facility had not notified them of a potential outbreak of GE on 4/25/11, but did notify them on 5/3/11. RN-V indicated she was not aware the outbreak included fourteen affected residents, just that "several" residents were reported ill. By not promptly reporting to the LPHD, the facility had not obtained stool cultures, therefore did not know what microorganism had caused GE. 2. The WDPH recommendations indicated a facility should cancel or postpone group activities for at least forty-eight hours after the last identified case. Facilities are directed to minimize movement of residents. Asymptomatic, exposed residents should not be moved from an affected to an unaffected resident unit. Additionally, the recommendations indicate a facility should consider discontinuing use of common dining areas and instituting in-room dining. On 5/3/11 at 9:50 a.m., surveyor # interviewed ADON-C and RN-L who verified group activities continued from 4/25/11 through 5/3/11, even when fourteen residents presented with GE symptoms 5/3/11. ADON-C verified residents who were not ill, but were exposed on the unit, were allowed to move to areas in the facility that had not been affected by the illness. ADON-C indicated unaffected residents who resided on the north, south and west wings continued to take their meals in a common dining area. RN-L confirmed that residents who had presented with symptoms of GE were immediately isolated to their rooms, but only until their symptoms resolved, not for the recommended 48 hours. On 5/3/11 at 10:00 a.m., surveyor # expressed to ADON-C and RN-L that policies and procedures regarding the prevention and control of GE were not observed in the facility and that immediate action was required. On 5/3/11 at 1:00 p.m., ADON-C confirmed that communal dining and activities had been suspended by 11:00 that morning. On 5/5/11 at 10:00 a.m., surveyor # confirmed with AD (Activities Director)-W, that she was unaware of an outbreak of GE until 5/3/11 and that residents had been involved in group activities until 5/3/11, when resident units were closed. 3. The WDPH recommendations indicated facility staff should wear PPE (Personal Protective Equipment) to include gloves and gowns upon entry to the room and when in contact with the symptomatic resident, and masks/goggles if vomitus is present. During the 5/3/11, 9:50 p.m. interview with surveyor # , RN-L indicated gloves were required to be worn when caring for ill residents, but gowns and masks were not. Regarding isolation carts or availability of PPE, RN-L indicated each wing had its own cart to be used for the entire wing. At the time of the interview, 2 isolation carts were being used on the south wing outside each room of residents diagnosed with [REDACTED]. A third isolation cart was designated outside the room of resident #9, who was diagnosed on [DATE] with[DIAGNOSES REDACTED]icile (a GE illness). During the 5/3/11, 10:00 a.m. interview with surveyor # , ADON-C indicated nursing staff used gloves when providing care for ill residents; and gowns were available but staff were not required to use them and would have to obtain the gowns down the hall in a storage closet. On 5/3/11 at 10:30 a.m., surveyor # interviewed HSK (Housekeeper)-J. HSK-J indicated when she cleaned resident rooms, she utilized gloves, but not gowns, for personal protective equipment. Additionally, HSK-J indicated she would know if a resident was ill by the presence of an isolation cart outside the resident room. At the time of the interview, HSK-J indicated she was aware of only 2 residents in the building affected with GE. 4. The WDPH recommendations indicated facility staff should use only chlorine bleach or a U.S. Environmental Protection Agency approved disinfectant in controlling GE outbreaks. The recommendations directed staff to clean and disinfect all equipment including, but not limited to blood pressure cuffs, stethoscopes, electronic thermometers and transfer lifts before using for another resident. The recommendations indicated Norovirus may remain viable for up to twelve days in carpeting or other environmental surfaces. Therefore, a through cleaning of carpets, curtains, walls, and all equipment is essential. Steam cleaning should be used for all carpeting and soft furnishings. Dry vacuuming had the potential to re-circulate the viruses and is not recommended. The recommendations also indicated enhanced cleaning and disinfection should continue for at least seventy-two hours after the last documented case. Additionally the WDPH indicated in Appendix I, "Ineffective disinfectants: Quaternary compounds..." On 5/3/11 at 12:30 p.m. DM (Dietary Manager)-Q verified to surveyor # the meal carts that are sent out to the units and hold resident meals and meal trays are always cleaned with Quat sanitizer, even during outbreaks. On 5/3/11 at 9:30 a.m., RN-L presented Product Specification Documents for "Heavy Duty Acid Bathroom Cleaner", "NDC (Neutral Disinfectant Cleaner)" and "Lemon Lift." The NDC Produce Specification Document dated 4/08, listed micro-organisms NDC was effective against. Norovirus was not on the list. The MSDS (Material Data Safety Sheet) for NDC dated 6/13/02, indicated the product was a quaternary ammonium compound and did not contain bleach. During the 5/3/11, 10:30 a.m. interview with surveyor # , HSK-J indicated the product used on hard surfaces such as tables, doorknobs, and handrails, was "Neutral Disinfectant Cleaner." This product was used routinely, even in times of known outbreak. For toilets and bathroom sinks, the facility utilized, "Heavy Duty Acid Bathroom Cleaner." HSK-J further revealed the frequency of cleanings was not increased during an outbreak. Additionally, HSK-J stated "Lemon Lift" was a product also used on bathrooms walls. The undated Product Specification Document for Lemon Lift indicated it was a cleaner which contained bleach but was "NOT TO BE USED AS A HARD SURFACE SANITIZER OR DISINFECTANT." The Product Specification Document dated 5/09 for Heavy Duty Acid Bathroom Cleaner indicated it was effective against Norovirus. On 5/3/11 at 10:45 a.m., surveyor # interviewed HSK/LS-(Housekeeping/Laundry Supervisor)-K who verified the above products were used routinely and she was unaware which of the above were ineffective. HSK/LS-K indicated she would contact the product supplier to obtain a disinfectant effective against Norovirus. On 5/4/11 at 9:00 a.m., surveyor # interviewed HSK/LS-K and HSK-J. It was revealed that a new disinfectant which was effective against Norovirus, had been ordered but not received. In the interim, the facility was using Clorox bleach wipes for hard surfaces, but not on floors. On floors, the facility used "A-125-Dry." The Product Specification Document for A-125 Dry, indicated it was a heavy duty detergent with no sanitizing or disinfecting agents within. On 5/5/11 at 8:00 a.m., surveyor # interviewed HSK/LS-K who indicated the new disinfectant had arrived and its use, initiated. The Product Specification Document, presented at that time, dated 6/09, indicated "Antibacterial All Purpose Cleaner" was effective against Norovirus. HSK/LS-K stated this product was now used for all hard surfaces and floors. On 5/3/11 at approximately 11:00a.m., surveyor # observed HSK-J vacuuming the carpet floor in the main lobby area by the resident's large tv outside the main resident dining room with a regular dry vacuum. During the 5/4/11 interview with surveyor # at 9:00 a.m., HSK-J stated carpeting had been dry vacuumed daily as per usual practice and that she was unaware of WDPH recommendations regarding dry vacuuming. 5. The WDPH recommendations indicated the facility should limit new admissions until the incident of new cases has reached zero for at least 48 hours. If new admissions are being considered, consult with the IC (Infection Control Nurse) and MD (Medical Director) first. The recommendations indicate facility staff, in consultation with their MD, should consider closing the unit or facility to new admissions. On 5/3/11, surveyor # reviewed the admission and discharge resident list presented upon entrance by the facility. Resident #29 was admitted to the facility 4/26/11, after the outbreak of 4/25/11. According to interview with CNC (Corporate Nurse Consultant)-N on 5/5/11 at 9:30 a.m., resident #29 developed symptoms of GE on 5/4/11. On 5/4/11 at 11:00 a.m., surveyor # interviewed MD (Medical Director)-R. MD-R stated that he was first made aware of the outbreak of GE on 5/3/11 by the NHA and had not been consulted regarding limiting admissions or discharges. MD-R also revealed that he was not familiar with the WDPH recommendations of the prevention and control of acute viral GE, including the definition of an outbreak. MD-R indicated he thought the facility should notify him when 7-8 residents became ill with symptoms of GE and was unaware the number had reached 14 residents on 5/3/11 and up to 18 residents on 5/4/11. On 5/4/11 at 3:00 p.m., during daily exit with the facility, surveyor # confirmed with ADON-C, that admissions to the facility had continued through the outbreak but admissions were placed on hold beginning 5/3/11, after surveyors identified the outbreak. 6. The WDPH recommendations for the management of staff indicated to limit staff from moving between affected and unaffected units. The staff illness policy should be developed and implemented whereby ill staff must be excluded from work until 48 hours after symptoms subside. On 5/4/11 at 8:20 a.m. HSK-J verified to surveyor # the units were first put on lockdown on 5/3/11. HSK-J also verified to surveyor # on 5/3/11 she was the only housekeeper on duty for all the wings and on 5/4/11 there were two housekeepers on duty and both were going in between wings. On 5/3/11 at 12:40 p.m. LPN (Licensed Practical Nurse)-B verified to surveyor # she was currently passing medications to residents on two different wings. On 5/3/11 at 9:00 a.m., surveyor # interviewed AA (Administrative Assistant)-O and obtained the staff line list of GE illness. AA-O indicated that she maintained the list which did not include staff well dates and only sporadically listed return to work dates. AA-O indicated staff should stay home until 48 hours symptom free. On 5/3/11, surveyor # reviewed the staff line list for GE illness and noted CNA (Certified Nursing Assistant)-S was ill with GE symptoms 4/16/11 and returned to duty 4/17/11. On 5/5/11 at 2:15 p.m., surveyor # interviewed CNA-S who confirmed she was ill with GE symptoms and returned to work the next day. CNA-S indicated she thought the policy was for ill staff to return to work 24 hours after symptoms resolve. On 5/5/11 at 2:00 p.m., surveyor # interviewed LPN-T who confirmed the facility policy indicated staff ill with GE symptoms could return to work 24 hours after symptoms resolve. LPN-T provided to surveyor # 7, a facility "Employee Return to Work After Illness Form." It was revealed that staff who returned to work after illness were required to sign the form indicating they were asymptomatic of any infectious disease. The form did not indicate the number of hours after symptom resolution. On 5/5/11 at 2:10 p.m., surveyor # interviewed OT (Occupational Therapist)-U who confirmed if she was ill with symptoms of GE, she could return to work 24 hours after symptoms resolved. 7. The WDPH recommendations indicated Norovirus outbreaks can be detected early by recognizing the typical symptoms of illness, and can be controlled by promptly implementing aggressive infection control measures to prevent the virus from being transmitted from person to person. When appropriate prevention and control measures are not implemented immediately, outbreaks can continue for weeks causing many illnesses, some hospitalization s and the occasional death from dehydration and other complications of vomiting and diarrhea. The recommendations indicate it is the responsibility of the Long Term Care Facility to implement aggressive infection control measures quickly... During the 5/3/11, 10:25 a.m. interview with surveyor # , ADON-C indicated she had not believed residents had Norovirus because many residents had symptoms [MEDICATION NAME] less than 24 hours. ADON-C and RN-L verified there were no facility practice changes when residents and staff presented with signs/symptoms of GE, except that residents were placed in isolation. RN-L presented an infection control manual that contained: * "Infection Control Surveillance Log Policy and Procedure" dated 10/9, * "Infection Control Program Overview" dated 2/09, * "WDPH Recommendations for the Prevention and Control of Viral Gastroenteritis Outbreaks in Wisconsin Long Term Care Facilities," dated 10/20/09. On 5/3/11 at 3:00 p.m., surveyor # asked for policies and procedures that identified and defined infectious diseases and necessary precautions and preventative interventions. CNC-N indicated the corporation had developed a multiple binder IC (Infection Control) program that was not available in the facility. CNC-N stated it was never delivered. ADON-C and CNC-N stated that any additional infection control information was kept in DON-M's office. During off shifts, weekends and times when DON-M was not in house, such manuals and policies were unavailable to staff. ADON-C and CNC-N agreed staff were not given access to the policies and procedures in managing infections in the facility. On 5/5/11 at 11:30 a.m., CNC-N indicated through interview with surveyor # , the comprehensive corporate infection control policy was brought to the facility 5/4/11 and not available to staff until then. 8. WDPH recommended that signage should be posted which indicated the facility was experiencing an increase in GE illness. Visits to symptomatic residents should be discouraged and appropriate PPE, provided. Upon entrance to the facility 5/3/11 at 8:00 a.m., surveyor # observed no signage posted to indicate the facility was experiencing an outbreak of GE. On initial tour of the facility at 8:15 a.m., no signage was posted on or outside any individual resident room doors that would indicate a need for attention to isolation precautions. On 5/3/11 at 11:00 a.m., surveyor # observed a sign at the front door warning visitors of an outbreak of GE in the facility. Additionally, the doors of affected resident's rooms were posted with signs indicating the need for contact precautions. On 5/3/11 at 3:30 p.m., surveyor # confirmed through interview with ADON-C that signs had been posted throughout the facility that day. The failure of the facility to appropriately implement procedures to limit the transmission of infection created a situation of Immediate Jeopardy. The Immediate Jeopardy was removed on 5/4/11, after the facility had implemented many of the precautions recommended by the Wisconsin Division of Public Health. By this date the facility had initiated training to all staff related to recognition of potential infectious outbreaks, limited contact between residents, visitors and non-essential staff during periods of outbreak, begun using personal protective equipment; begun environmental cleaning using appropriate, effective cleaning products; and managed new admissions and discharges to/from the facility.