Every finding on record at Wi Veterans Home-Boland Hall

Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 67 members (M) residing in the facility. The facility's infection surveillance program did not include a system to monitor employee illness symptoms, resolution of symptoms, or return to work dates.M5 was on enhanced barrier precautions (EBP). Certified Nursing Assistant (CNA)-J transferred M5 without donning the appropriate personal protective equipment (PPE). Staff did not offer members hand hygiene before meals, including M51, M60, M20, and M28.Staff did not ensure M45's catheter bag was covered and not in contact with the floor. Findings include; The facility's Infection Tracking and Surveillance policy, dated 4/17/25, indicates: The facility's Infection Preventionist designee shall be responsible for conducting surveillance using line lists, monitoring for clusters and outbreaks, conducting staff observations of infection control practices based on facility risk assessment (e.g., hand washing, catheter management), generating and disseminating surveillance data that includes infection rates, outbreaks, and trends, developing process improvement initiatives and staff education based on surveillance data and tracking. Employee Absence: 1. Employee Health or the Infection Preventionist or their designee(s) contact employees absent with respiratory or gastrointestinal symptoms to gather additional information and inform the employee when they can return to their work unit according to the illness policy. 2. The employee's name and symptom information is recorded on the facility tracking log for monitoring clusters and outbreaks. The facility's undated Wisconsin Veterans Homes Transmission-Based Precautions Policy No. WVH IC 01-06 indicates: Enhanced Barrier Precautions (EBP): 1. Implemented for members with novel or targeted multidrug-resistant organism (MDRO) infections, indwelling medical devices, and wounds, including as part of a public health containment response. This type of precaution falls between standard and contact and requires gown and glove use during specific high-contact member care activities for those identified as being at increased risk for MDROs. 1. When a member is colonized or has completed treatment for infection with a novel or targeted MDRO, direct care staff don a gown and gloves prior to high-contact activities including: dressing .bathing/showering .transferring .providing hygiene .changing linens .changing briefs or assisting with toileting .device care or use: central line, urinary catheter .Wound care: any skin opening requiring a dressing (excluding skin breaks or tears covered with an adhesive bandage or similar dressing) .Members with wounds and/or indwelling medical devices (i.e., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator) are placed on EBP regardless of their MDRO colonization status. The facility's Member Meals and Snacks policy, dated 3/13/26, indicates: Meals shall be served in a defined dining area. Dining areas may be within the member living unit or a shared communal area within the facility. Areas shall be determined by facility leadership .Hand hygiene shall be offered to all members prior to and following a meal. Staff shall assist members who cannot complete hand hygiene independently and wish to do so . The facility's External Urinary Drainage Management policy, dated 9/2025, indicates: .Bedside collection bags shall never touch the floor. They shall be hung from the beside free from touching the floor surface. If clearance is not achievable, a disposable incontinence pad shall be placed on the floor under the drainage bag . 1. On 4/22/26, Surveyor reviewed the facility's infection surveillance program and noted the facility did not maintain documentation of employee illness, including onset of symptoms, symptom resolution, or return to work dates. On 4/22/26 at 9:45 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-N who stated employees are given instructions when they call in sick. ADON-N stated the faciilty uses call-in slips but does not maintain a staff illness line list to aid with identifying outbreaks. ADON-N stated ADON-N took over the process in mid-February which seemed a little loose. On 4/22/26 at 9:45 AM Surveyor interviewed Director of Nursing (DON)-B who indicated the facility had a contracted Infection Preventionist who started keeping track of employee call-ins due to illness. DON-B stated DON-B would check with Human Resources and Scheduling to see if the process was maintained. On 4/22/26 at 11:32 AM, Surveyor interviewed DON-B who indicated Human Resources staff do not document or keep track of illness symptoms when employees call in sick. 2. Between 4/20/26 and 4/22//26, Surveyor reviewed M5's medical record. M5 was admitted to the facility on [DATE] and had diagnoses including history of urinary tract infections and obstructive/reflux uropathy. M5's Minimum Data Set (MDS) assessment, dated 3/30/26, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated M5 had severely impaired cognition. On 4/20/26 at 11:32 AM, Surveyor observed a sign on M5's door that indicated: Enhanced Barrier Precautions: All staff must wear gowns and gloves when providing high-contact care. Surveyor observed CNA-J enter M5's room and transfer M5 from wheelchair to recliner with a gait belt. CNA-J did not don gloves or a gown prior to the transfer. On 4/20/26 at 11:40 AM, Surveyor interviewed CNA-J who verified CNA-J should have worn gloves and a gown when transferring M5. On 4/22/26 at 9:30 AM, Surveyor interviewed DON-B who indicated staff should wear gloves and a gown when transferring members on EBP. 3. On 4/21/26 at 12:08 PM, Surveyor observed CNA-D serve lunch and assist nine residents in the second floor west dining room. CNA-D did not offer hand hygiene to members prior to the meal. On 4/21/26 at 12:50 PM, Surveyor interviewed CNA-D who verified CNA-D did not offer hand hygiene to members and stated CNA-D forgot while trying to ensure members were fed. On 4/21/26 at 12:36 PM, Surveyor observed Therapy Assistant (TA)-E deliver room trays. Surveyor noted the meal cart and meal trays did not contain hand wipes. Surveyor observed TA-E deliver a meal tray to M51 and M60. TA-E did not offer hand hygiene to M51 or M60. On 4/21/26 at 4:38 PM, Surveyor interviewed TA-E who indicated TA-E routinely delivered meals to members and had worked at the facility for several years. TA-E stated TA-E sanitized hands when entering and exiting members' rooms but did not offer members hand hygiene and was not aware TA-E should do so. On 4/21/26 at 12:42 PM, Surveyor interviewed M60 who stated staff did not offer hand hygiene prior to lunch that day, but M60 would like staff to do so. On 4/21/26 at 12:48 PM, Surveyor interviewed M51 who stated staff did not offer hand hygiene prior to lunch that day. M51 stated M51 has to wash M51's hands because staff don't ask and there are a lot of sick people in the facility. On 4/22/26 beginning at 8:27 AM, Surveyor observed CNA-F deliver room trays. Surveyor noted the meal cart and meal trays did not contain hand wipes. Surveyor observed CNA-F deliver trays to M20, M28, and M60. Staff did not offer hand hygiene to M20, M28, or M60. On 4/22/26 at 8:33 AM, Surveyor interviewed CNA-F who verified CNA-F did not offer hand hygiene to members when CNA-F delivered meal trays. CNA-F was not aware hand hygiene should be offered. On 4/22/26 at 8:36 AM, Surveyor interviewed M28 who stated staff did not offer hand hygiene prior to breakfast. M28 stated M28 would like staff to offer hand hygiene even though M28 doesn't eat with M28's hands. On 4/22/26 at 8:41 AM, Surveyor interviewed M60 who stated staff do not usually offer hand hygiene prior to meals and did not do so that day. M60 wished staff would offer hand hygiene, especially prior to breakfast, since M60 wore hand cream at night and would like it cleaned off before eating. On 4/22/26 at 8:42 AM, Surveyor interviewed M20 who stated staff did not offer hand hygiene with meal service. M20 stated M20 would like a hand wipe before eating so M20 could eat with clean hands. On 4/21/26 at 2:03 PM, Surveyor interviewed Dietary Services Director (DSD)-C who stated nursing staff should offer hand hygiene to members prior to meals. On 4/21/26 at 2:32 PM, Surveyor interviewed DON-B who verified staff should offer hand hygiene to members before meals. 4. On 4/20/26, Surveyor reviewed M45's medical record. M45 was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease stage 2, retention of urine, and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. M45's MDS assessment, dated 3/26/26, had a BIMS score of 15 out of 15 which indicated M45 had intact cognition. On 4/20/26 at 11:58 AM, Surveyor observed M45's Foley catheter bag attached to the bed without a dignity cover. The bottom of the catheter bag and drainage device connector were in contact with the floor. On 4/20/26 at 12:08 AM, Surveyor interviewed CNA-G who stated M45's uncovered catheter bag was touching the floor because M45's bed was in a low position. CNA-G verified the catheter bag should not be in contact with the floor. On 4/22/26 at 10:24 AM, Surveyor interviewed DON-B who stated staff should cover members' catheter bags with a dignity cover and keep catheter bags off the floor.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 67 of 67 residents residing in the facility. The facility did not accurately test parts per million (PPM) of the sanitizing solution or complete testing logs. Findings include: On 4/20/26 at 10:16 AM, Surveyor and Dietary Services Director (DSD)-C began an initial tour of the kitchen. DSD-C stated the facility follows the Federal Food and Drug Administration (FDA) Food Code. The 2022 FDA Food Code documents at 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization-Temperature, pH, Concentration, and Hardness: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under 7-204.11 Sanitizers, Criteria, shall be used in accordance with the Environmental Protection Agency (EPA)-registered label use instructions. The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. The Ecolab Oasis 146 Multi-Quat Sanitizer Data Sheet indicates the sanitizing solution needs to be tested for effectiveness by measuring the parts per million (PPM) dilution range. Hydrion Quat test strips are the appropriate testing strips. The sanitizing solution temperature should be within 65 to 75 degrees Fahrenheit (F). Staff should tear off a 2-inch strip and dip the strip in the sanitizing solution for 10 seconds then immediately compare the test strip color against the package scale. The effective PPM range is 150-400. Surveyor requested the facility's sanitizing solution testing policy and was provided a copy of the Ecolab Oasis 146 Multi-Quat Sanitizer Data Sheet. During the initial tour that began at 10:16 AM on 4/20/26, Surveyor noted there was not a log to monitor and document sanitizing solution in the dishwashing area. Surveyor observed the three-compartment sink and noted an Ecolab Oasis 146 Multi-Quat Sanitizer Data Sheet posted above the sink. Surveyor also observed a container of Ecolab Oasis 146 Multi-Quat Sanitizer in the kitchen. Surveyor interviewed DSD-C who stated staff did not test the sanitizing solution in the three-compartment sink. DSD-C stated there were testing logs in the cooking area of the main kitchen and the individual kitchenettes. Surveyor observed a testing log that did not contain temperatures in the cooking area of the main kitchen. The log contained PPM and staff initials. Several dates were not completed. DSD-C indicated food was not cooked on those dates but was warmed and served in the kitchen. Surveyor observed Hydrion sanitizer test strips on the sink. The test strip packaging indicated the sanitizing solution should be between 65 and 75 degrees F. Surveyor also observed QAC QRG sanitizer test strips which indicated best results are obtained between 65 and 75 degrees F and Noble Dip test strips which indicated the solution should be at 75 degrees F. On 4/20/26 at 12:23 PM, Surveyor observed the second floor east kitchenette and noted the sanitizer log did not contain a spot to document the temperature when testing the PPM. On 4/20/26 at 12:37 PM, Surveyor observed the second floor west kitchenette and noted the sanitizer log did not contain a spot to document the temperature when testing the PPM. On 4/21/26 at 8:05 AM, Surveyor observed the first floor west kitchenette and noted the sanitizer log did not contain a spot to document the temperature when testing the PPM. On 4/21/26 at 8:31 AM, Surveyor observed the first floor east kitchenette and noted the sanitizer log did not contain a spot to document the temperature when testing the PPM. On 4/21/26 at 1:49 PM, Surveyor observed Food Service Lead (FSL)-K test the sanitizing solution in the dishwashing area of the main kitchen with a Noble Dip test strip. FSL-K checked the temperature of the solution, dipped a strip in the solution, and compared to color to the package. FSL-K stated FSL-K did not know FSL-K needed to test the temperature of the solution prior to testing the PPM and had not done so before. Surveyor observed FSL-K ask Food Service Aide (FSA)-L and FSA-M if they temped the sanitizing solution prior to testing the PPM. FSA-L and FSA-M indicated they did not temp the santizing solution prior to testing the PPM and did not know they were supposed to. FSA-M asked what to do and stated the water that mixes with the sanitizing solution is very hot. On 4/21/26 at 2:01 PM, Surveyor interviewed FSA-M who stated FSA-M had not previously temped the sanitizing solution and the logs did not contain an area to document it. FSA-M indicated the solution mix comes out hot and could burn someone. On 4/21/26 at 2:03 PM, Surveyor interviewed DSD-C who was not aware staff should test the temperature of the sanitizing solution prior to testing the PPM. On 4/21/26 at 2:32 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated kitchen staff should read and follow the sanitizer test strips and solution testing process, which includes testing the solution temperature to ensure effectiveness. On 4/21/26 at 4:31 PM, Surveyor interviewed DSD-C who indicated DSD-C contacted their sanitizer provider and the facility will be switching to sanitizer and testing strips that do not require temperature testing. DSD-C stated DSD-C will ensure the appropriate test strips and log are available to staff for the cooking and dishwashing areas in the main kitchen and the four kitchenettes.

Based on staff interview and record review, the facility did not ensure the Office of the State Long-Term Care Ombudsman was notified of transfers/discharges for 6 members (M) (M9, M7, M31, M11, M68, and M5) of 6 sampled members. M9 was transferred to the hospital on [DATE], 11/29/25, 12/25/25, and 2/26/26. Ombudsman (OMB)-H was not notified of the transfers.M7 was transferred to the hospital on 2/7/26, 2/26/26, and 3/11/26. OMB-H was not notified of the transfers. M31 was transferred to the hospital on 1/23/26 and 2/3/26. OMB-H was not notified of the transfers. M11 was transferred to the hospital on 1/6/26 and 1/30/26. OMB-H was not notified of the transfers.M68 was transferred to the hospital on 3/9/26 and did not return to the facility. OMB-H was not notified of the transfer/discharge.M5 was transferred to the hospital on 3/6/26. OMB-H was not notified of the transfer.Findings include: The facility's Notice of Transfer policy, dated January 2023, indicates: A designated employee sends a list of members transferred to acute care facilities during the prior month to the Long-Term Care Ombudsman within the first 10 days of the following month. 1. From 4/20/26 to 4/22/26, Surveyor reviewed M9's medical record. M9 was admitted to the facility on [DATE] and had a diagnosis of small cell lymphoma. M9's Minimum Data Set (MDS) assessment, dated 3/26/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated M9 had intact cognition. The MDS assessment also indicated M9 received chemotherapy. M9's medical record indicated M9 was transferred to the hospital on [DATE] and 11/29/25 for a neutropenic fever. M9 was transferred to the hospital on [DATE] for a neutropenic fever and a fall. M9 was transferred to the hospital on 2/26/26 for marginal cell lymphoma related to Obinutuzumab infusion. M9's medical record did not indicate OMB-H was notified of the transfers. (See interview under example 6.) 2. From 4/20/26 to 4/22/26, Surveyor reviewed M7's medical record. M7 was admitted to the facility on [DATE] and had diagnoses including dementia, repeated falls, syncope, and weakness. M7's MDS assessment, dated 3/5/26, had a BIMS score of 13 out of 15 which indicated M7 had intact cognition. M7 had an activated Power of Attorney for Healthcare (POAHC). M7's medical record indicated M7 was transferred to the hospital on 2/7/26 for a fall, on 2/26/26 for left shoulder pain, and on 3/11/26 for evaluation of repeated falls. M7's medical record did not indicate OMB-H was notified of the transfers. (See interview under example 6.) 3. From 4/20/26 to 4/22/26, Surveyor reviewed M31's medical record. M31 was admitted to the facility on [DATE] and had diagnoses including heart failure, occipital neuralgia, and cognitive impairment. M31's MDS assessment, dated 3/19/26, had a BIMS score of 15 out of 15 which indicated M31 had intact cognition. M31 had an activated POAHC. M31's medical record indicated M31 was transferred to the hospital on 1/23/26 for elevated hemoglobin and on 2/3/26 for mesa cystitis. M31's medical record did not indicate OMB-H was notified of the transfers. (See interview under example 6.) 4. From 4/20/26 to 4/22/26, Surveyor reviewed M11's medical record. M11 was admitted to the facility on [DATE] and had diagnoses including pneumonia, chronic obstructive pulmonary disease (COPD), and metabolic encephalopathy. M11's MDS assessment, dated 4/2/26, had a BIMS score of 15 out of 15 which indicated M11 had intact cognition. M11 had a Guardian for healthcare decisions. M11's medical record indicated M11 was transferred to the hospital on 1/6/26 for acute respiratory failure and bilateral pneumonia. M11 was also transferred to the hospital on 1/30/26 for acute on chronic respiratory failure, COPD exacerbation, and acute metabolic encephalopathy. M11's medical record did not indicate OMB-H was notified of the transfers. (See interview under example 6.) 5. From 4/20/26 to 4/22/26, Surveyor reviewed M68's medical record. M68 was admitted to the facility on [DATE] and had diagnoses including lung cancer and heart failure. M68's MDS assessment, dated 3/5/26, indicated M68 was cognitively impaired. M68's medical record indicated M68 was transferred to the hospital on 3/9/26 for an acute episode of shortness of breath related to lung cancer. M68 did not return to the facility. M68's medical record did not indicate OMB-H was notified of the transfer/discharge. (See interview under example 6.) 6. Between 4/20/26 and 4/22//26, Surveyor reviewed M5's medical record. M5 was admitted to the facility on [DATE] and had diagnoses including history of urinary tract infection and obstructive/reflux uropathy. M5's MDS assessment, dated 3/30/26, had a BIMS score of 4 out of 15 which indicated M5 had severely impaired cognition. M5's medical record indicated M5 was transferred to the hospital on 3/6/26 and diagnosed with pneumonia. M5 returned to the facility on 3/15/26. M5's medical record did not indicate OMB-H was notified of the transfer. On 4/21/26 at 3:36 PM, Nursing Home Administrator (NHA)-A indicated via Email that NHA-A thought a former medical records staff sent OMB-H a transfer/discharge list. NHA-A accessed the email of the former staff and noted transfer/discharge lists were not sent to OMB-H for the past 12 months. NHA-A indicated the process moving forward is for Social Services to notify OMB-H.

Based on staff interview and record review, the facility did not offer Prevnar 20 vaccines for 3 members (M) (M6, M7, and M31) of 5 sampled members.M6, M7, and M31 were eligible to receive the Prevnar 20 vaccine. M6, M7, and M31 were not offered the vaccine. The facility's Immunization Program, dated 4/17/25, indicates: All immunizations shall be offered and administered according to the most current guidance. Specific vaccines: Pneumococcal: 1. Licensed nursing reviews pneumococcal vaccine status on admission and at least annually and references the most current recommendations. 2. It is recommended that staff utilize the Centers for Disease Control and Prevention (CDC) PneumoRecs Vax Advisor to assist in determining the member's pneumococcal status and needs. 1. On 4/22/26, Surveyor reviewed M6's medical record. M6 was admitted to the facility on [DATE] and had diagnosis including diabetes, atrial fibrillation, and pneumonia. M6's Minimum Data Set (MDS) assessment, dated 3/4/26, had a Brief Interview for Mental Status (BIMS) score 14 out of 15 which indicated M6 had intact cognition. M6 had an activated Power of Attorney for Healthcare (POAHC). M6's medical record indicated M6 received a Pneumovax 23 vaccine on 11/30/18 and a pneumococcal conjugate 13 vaccine on 2/16/17. M6's medical record did not indicate M6 received or was offered a Prevnar 20 vaccine in accordance with CDC recommendations. On 4/22/26 at 11:32 AM, Surveyor interviewed Director of Nursing (DON)-B who verified M6 should have been offered a Prevnar 20 vaccine. 2. On 4/22/26, Surveyor reviewed M7's medical record. M7 was admitted to the facility on [DATE] and had diagnoses including dementia and heart failure. M7's MDS assessment, dated 3/5/26, had a BIMS score of 13 out of 15 which indicated M7 had intact cognition. M7 had an activated POAHC. M7's medical record indicated M7 received a Pneumovax 23 vaccine on 7/29/11 and a pneumococcal conjugate 13 vaccine on 3/2/15. M7's medical record did not indicate M7 received or was offered a Prevnar 20 vaccine in accordance with CDC recommendations. On 4/22/26 at 11:32 AM, Surveyor interviewed DON-B who verified M7 should have been offered a Prevnar 20 vaccine. 3. On 4/22/26, Surveyor reviewed M31's medical record. M31 was admitted to the facility on [DATE] and had diagnoses including heart failure and occipital neuralgia. M31's MDS assessment, dated 3/19/26, had a BIMS score of 15 out of 15 which indicated M31 had intact cognition. M31 has an activated POAHC. M31's medical record indicated M31 received a Pneumovax 23 vaccine on 5/15/16 and a pneumococcal conjugate 13 vaccine on 1/14/15. M31's medical record did not indicate M31 received or was offered a Prevnar 20 vaccine in accordance with CDC recommendations. On 4/22/26 at 11:32 AM, Surveyor interviewed DON-B who verified M31 should have been offered a Prevnar 20 vaccine.

Based on interview and record review the facility did not identify resident concerns as grievances for 1 (R1) of 1 Residents reviewed for grievances.Social Worker-Q did not initiate grievances when R1's power of attorney voiced a concern R1 was being put to be too early and R1 did not receive an eye drop medication according to physician orders.Findings include:The facility's policy titled, Grievances and Complaints and last reviewed January 31, 2023, under Purpose documents To provide members and their representatives with a process to assist in writing concerns or complaints regarding the environment, missing items, or care and treatment provided by WVH (Wisconsin Veterans Homes). Under policy documents *A grievance shall be considered any circumstance thought to be unjust and grounds for a complaint and meets at least one of the following criteria: Pertains to the environment or care and treatment provided by the Homes, including missing property. Has reference to state or federal regulations, facility policies, or Member Rights and Responsibilities. Requires facility management to perform fact finding and intervention. *Any person acting on behalf, or in interest of the member, shall be considered a representative and reserve the right to file a written grievance or complaint. *All grievances and concerns shall be documented at the time of report and investigated within five business days. *Each facility shall maintain an electronic log of grievances/concerns. *The grievance process shall be posted throughout the facilities and shall include: The right to file grievances orally or in writing. The right to file grievances anonymously. The right to obtain a written decision regarding the grievance. A reasonably anticipated timeframe for completing the review of the grievance.R1's diagnoses include Alzheimer's Disease (progressive brain disorder that causes gradual cognitive decline) and dementia (loss of cognitive function that interferes with a person's daily life and activities).R1 has an activated power of attorney for healthcare.On 12/2/25, at 8:33 a.m., Surveyor reviewed the facility's grievance log from August 2025 to November 2025. Surveyor noted R1 is listed on the grievance log on 9/10/25 regarding R1's eyeglasses chipped & needs a new lens. On 12/2/25, at 9:36 a.m., Surveyor spoke with R1's POA (power of attorney) on the telephone. During this conversation R1's POA informed Surveyor she had gone to name of SW (Social Worker)-Q regarding complaints of R1 going to bed too early at 7:00 p.m. and then R1 gets up in the middle of the night. Surveyor asked R1's POA when she informed SW-Q of this. R1's POA informed Surveyor she spoke to SW-Q a couple of times. R1's POA informed Surveyor she complained R1 didn't receive eye drops as the doctor ordered. R1's POA indicated they took R1 to the eye doctor and the eye doctor said to keep R1 on the same eye medication and start new eye drops. Surveyor asked R1's POA if SW-Q filed a grievance for her regarding these concerns. R1's POA replied that's what I thought [name of SW-Q] was doing.On 12/3/25, at 8:00 a.m., Surveyor asked SW-Q if there have been any concerns brought to her attention from R1's family regarding R1. SW-Q replied ya sure, there has been lots in the last two years. Surveyor asked SW-Q if there have been any concerns in the last couple of months. SW-Q informed Surveyor she would have to look back at the grievance log there may have been a grievance for missing two hats. Surveyor asked SW-Q how the family communicates concerns to her. SW-Q informed Surveyor she talks to them in person, they call, or email. Surveyor asked if there were any concerns about R1 being put to bed too early. SW-Q replied yup they have brought that up. Surveyor asked if a grievance was initiated for this. SW-Q replied she believes so. Surveyor asked SW-Q if there were any other concerns voiced to her. SW-Q replied not really. Surveyor asked SW-Q if there were any concerns voiced to her regarding R1 missing medication. SW-Q replied ya. Surveyor asked what the missing medication was regarding. SW-Q replied eye drops he didn't receive. Surveyor asked SW-Q if she did a grievance for R1 not receiving his eye drops. SW-Q informed Surveyor she would have to look at the log as this was several months ago. Surveyor informed SW-Q Surveyor would like to see R1's grievances for going to bed to early and R1 not receiving eye drops.On 12/3/25, at 8:10 a.m., Surveyor re-reviewed the grievance log and noted on 11/8/25 R1 was on the log for two marine hats missing.On 12/3/25, at 8:41 a.m. SW-Q informed Surveyor regarding R1's missing medication they did a risk, so she didn't do a grievance. Surveyor asked SW-Q why she didn't do a grievance. SW-Q replied they did a risk. Surveyor inquired about R1's grievance for going to be early. SW-Q replied this was discussed at a care conference and the care plan was updated. Surveyor asked SW-Q if she did a grievance. SW-Q replied no.On 12/3/25, at 10:02 a.m. SW-Q and Interim Director of Nursing (IDON)-B spoke with Surveyor. IDON-B informed Surveyor they did a medication error report for R1's missing eye. Surveyor explained to IDON-B Surveyor had spoke to SW-Q regarding R1's POA voicing a complaint R1 didn't receive his eye drops & SW-Q had informed Surveyor a risk was done. Surveyor wanted to know if a grievance was completed. SW-Q stated my mistake did not do a grieve and explained R1's daughter did come to her. IDON-B indicated it's still a grievance, its was still bothering R1's daughter and a grievance should have been done. Surveyor asked if there was a grievance for R1 going to bed too early. SW-Q informed Surveyor that was in the care conference and they changed the care plan. IDON-B stated this is a grievance and should have been written up. SW-Q stated this is my mistake. IDON-B stated that's how we learn.

Based on record review and interview, the facility did not ensure a resident's unaccounted for narcotic medication was reported to the local police. This was observed with 1 of 3 Facility Reported Incidents (FRI) reviewed.R2's narcotic medication was discovered unaccounted for and was not reported to the local police.The facility's policy and procedure titled Prohibition and Prevention of Member Abuse, Neglect, and Exploitation date 7/2/2024. The Policy documents: The Facility shall comply with Section 1150B [42 U.S.C. 1320b-25} Reporting to Law Enforcement of Crimes Occurring in Federally Funding Long-term Care Facilities. All incidents shall be investigated and reported to the appropriate agency as required by the agency.Findings include:Surveyor reviewed a Facility Reported Incident (FRI) regarding R2's missing narcotic medication. The FRI investigation documents there was a missing tablet of Hydrocodone 5/325 milligrams. This was discovered missing on 9/5/2025 through an audit. The medication was missing on 8/16/2025. The FRI investigation does not indicate the local police were notified. The FRI investigation documents the facility was unable to determine what happened to the missing narcotic. The local police were not contacted regarding the missing narcotic medication.On 12/2/25, at 10:34 AM, Surveyor interviewed Interim Director of Nurses (IDON) -B. The IDON-B did not have any additional information the local police were contacted.On 12/2/25, at 3:09 PM, at the facility exit meeting with Nursing Home Administrator (NHA)-A, Assistant Nursing Home Administrator (ANHA)-C and IDON-B. Surveyor shared the concerns with the local police were not contacted for the missing narcotic. No further information was provided.

Based on interview and record review the Facility did not ensure quality of care was provided for 1 (R1) of 6 Residents.R1's ophthalmology consult on 9/8/25 includes documentation under Blepharoconjunctivitis OS (left eye) to continue polymyxin- trimethoprim one drop four times a day to left eye. The facility did not continue this order and discontinued the eye drops on 9/8/25. R1 did not receive polymyxin- trimethoprim one drop four times a day to left eye according to physician orders.Findings include:R1's diagnoses include Alzheimer's Disease (progressive brain disorder that causes gradual cognitive decline), dementia (loss of cognitive function that interferes with a person's daily life and activities), central corneal ulcer (open sore on the cornea caused by an infection or other condition), left eye and conjunctivitis (inflammation of the eye's conjunctiva most caused by viruses, bacteria or allergies).R1's nurses note dated 9/4/25, at 8:30 a.m., and written by Licensed Practical Nurse (LPN)-J documents Left eye, sclera remains pink, left eye swollen. Eye drop instilled as ordered. Small amount of dry drainage noted around eye. Left eye cleansed. Writer informed ADON (Assistant Director of Nursing) that eye drop order is complete on Friday [tomorrow] and eye still is not clear. ADON states he will follow up.R1's nurses note dated 9/5/25, at 11:40 a.m., and written by Registered Nurse (RN)-I documents POA (Power of Attorney) called regarding the need for transportation for member to get to and from a 3:15 Ophthalmology appointment in [NAME] on Monday, 9/8. Writer reached out to leader of transportation staff to see if we could accommodate.R1's order note dated 9/5/25, at 12:55 p.m., and written by RN-I documents Polymyxin B-Trimethoprim Ophthalmic Solution 10000-0.1 Unit/ML (milliliter)-% (Polymyxin B-Trimethoprim) Instill 1 drop in left eye every 4 hours for conjunctivitis for 7 days. Start Date: 9/5/2025 End Date: 9/12/2025 POA notified and expressed agreement.Surveyor reviewed R1's September MAR (medication administration record) and noted an order date of 9/5/25 Polymyxin B-Trimethoprim Ophthalmic Solution 10000-0.1 Unit/ML-% (Polymyxin B-Trimethoprim) Instill 1 drop in left eye every 4 hours for conjunctivitis for 7 days. The D/C (discontinue) date is 9/8/25. Surveyor noted although the order was for 7 days R1's Polymyxin B-Trimethoprim Ophthalmic Solution 10000-0.1 Unit/ML-% was discontinued 4 days later. R1 received this eye drop medication on 9/5/25 at 1600 (4:00 p.m.) & 2000 (8:00 p.m.), 9/6/25 & 9/7/25 at 0000 (12:00 a.m.), 0400 (4:00 a.m.), 0800 (8:00 a.m.), 1200 (12:00 p.m.), 1600, & 2000, and 9/8/25 at 0000, 0400, 0800, 1200, & 1600.R1's nurses note dated 9/8/25, at 8:01 a.m., and written by LPN-J documents Atb (antibiotic) eye drop instilled into left eye. Sclera remains pink, dry drainage present around eye. Writer gently cleansed eye. Writer also cleansed left cheek biopsy site. Sutures remain intact, skin pink, no bleeding or drainage. Vaseline applied f/b (followed by) band aides. Remains on ATB post-surgical procedure of removal of cancer. Is afebrile.Medical Doctor (MD)-L's consultation note dated September 8, 2025, includes documentation of Blepharoconjunctivitis OS (left eye) Treatment Regimen Comprehensive: Start erythromycin ointment every 12 hours to eyelids apply twice daily to LEFT EYE. Continue polymyxin-trimethoprim one drop four times a day to LEFT EYE.R1's nurses note dated 9/8/25, at 14:37 (2:37 p.m.), written by RN-K documents Appointment on: 09/08/2025 with out to [Name] hosp (hospital) for eye appointment with wife and daughter [Name]. Facility transporting member. All current orders sent with member. Order changes: valacyclovir 500 mg (milligrams) tablet, one pill twice daily for 10 days. Erythromycin 5mg/gram (0.5%) eye ointment, apply 1/4 inch to L (left) eye twice daily. Follow up appt (appointment) 09/16/2025 at 2:15 PM. Follow-up appointment: Follow up with [MD-L] on 09/16/2025 at 2:15 PM. Provider notified at 09/08/2025 4:38 PM Member notified. NOK (next of kin)/Legal Rep (representative) notified 09/08/2025 4:30 PM.Surveyor reviewed R1's September MAR and noted R1 did not receive Polymyxin B-Trimethoprim Ophthalmic Solution 10000-0.1 Unit/ML-% after 9/8/25 at 1600 (4:00 p.m.).MD-L consultation note dated 9/16/25 under HPI (history present illness) for Interval History documents Per the daughter nursing home didn't give the pt (patient) polymyxin-trimethoprim drop. She stated they gave him the erythromycin and Valacyclovir. Tearing and some pain. Under Impression/Plan documents 2. Blepharoconjunctivitis OS angular (H10.522) Status: Resolved. Plan: F/U (follow up) for Next Visit. The patient should be scheduled for the following in prn (as needed): Plan: Treatment Regimen Comprehensive: Continue erythromycin ointment for 1 week then stop. Apply twice daily to LEFT EYE. Discontinue polymyxin-trimethoprim one drop four times a day to LEFT EYE.R1's incident note created on 9/16/25 with an effective date 9/8/25 at 1600 (4:00 p.m.) and written by RN-K documents DETAILS: Medication incident. Given/Ordered 09/08/2025 4:00 PM Initial shift after incident. 09/08/2025 4:00 PM polymyxin-trimethoprim eye drops 4x (times)/day/none. Medication error: discontinued medication that was supposed to be continued-polymyxin-trimethoprim eye drops, one drop 4x/day. [MD-L's name] from [Name] Eye notified-voicemail left at 0710 (7:10 a.m.) on 09/16/2025. [Name], Daughter/POA notified of med error-09/16/2025 at 0720. VITALS: BP (blood pressure) 130/96- 9/8/2025 08:04 (8:04 a.m.) Position: Sitting r (right)/arm, P (pulse) 96-9/8/2025 08:04 Pulse Type: Regular, T (temperature) 98.1 -9/8/2025 08:04 Route: Forehead (non-contact), R (respirations) 12.0 -9/8/2025 08:04, O2 (oxygen) 96.0% -9/6/2025 20:21 (8:21 p.m.) Method: Room Air, Pnl (pain level) 0 -9/8/2025 14:20 (2:20 p.m.) Pain scale: PAINAD. FOLLOW-UP: New intervention implemented and added to TPOC (temporary plan of care). notify family, physician, and DON (Director of Nursing) of med error. No adverse effects noted. NOTIFICATIONS: Provided notified this shift: 09/16/2025 7:10 AM [MD-L's name] NOK/Responsible party notified this shift: 09/16/25 7:20 AM [Name] POA Supervisor notified via phone: 09/16/2025 7:26 AM [Prior DON's name] DON.On 12/3/25, at 9:05 a.m., Surveyor asked RN-G the process when a resident returns from a consultation appointment with orders. RN-G informed Surveyor it depends on the orders whether its for an appointment or medication. RN-G indicated if the order is for medication they call [physician group] to clarify orders to let them know the resident came back with orders and ask if it's okay. If the resident has a power of attorney, they contact the power of attorney. RN-G explained the orders are put in their system, faxed to the pharmacy and write a progress note.On 12/3/25, at 11:31 a.m., Surveyor asked RN-D the process when a resident returns from a consultation appointment with orders. RN-D informed Surveyor the orders are usually transcribed by the nurse on the unit. A lot of times the POA attends the appointment so they may be aware. RN-D informed Surveyor the orders are scanned to pharmacy. Surveyor informed RN-D on 9/8/25 R1 went to an ophthalmology appointment with orders to continue the eye drop medication but the medication was discontinued. Surveyor asked RN-D if he knew why R1's eye drops not continued but discontinued. RN-D informed Surveyor he's not sure.On 12/3/25, at 12:10 p.m., Surveyor informed Interim Director of Nursing (IDON)-B R1 did not receive polymyxin-trimethoprim eye drops four times a day per MD orders as these eye drops were discontinued on 9/8/25.

Based on interview and record review the facility did not ensure each resident received adequate supervision to ensure each resident's environment remains free of accidents and hazards for 1 (R10) of 3 residents.On 10/18/25 during a body check R1 was identified with a skin tear over purple senile purpura to the right side of R1's clavicle. There is no evidence staff were interviewed to inquire how R1 may have received this skin tear and did any staff observe R1 picking his clavicle. On 10/21/25 R1 sustained a skin tear due to the arm of a shower chair having a sharp area. The facility removed the chair but there is no preventative measures documented to prevent this from occurring in the future. On 12/2/25 & 12/3/25 there are multiple observations of R1's plan of care not being followed for non-slip material (Dycem) on the wheelchair and padding of the lower portion of the front bars on R1's wheelchair.Findings include: The facility's policy titled, Member Incidents and with an effective date of November 1, 2025, under Policy includes documentation of Interventions shall be implemented for any incident that causes or potentially causes injury; the intervention shall be appropriate and applicable to the cause of the incident to prevent recurrence.R1's diagnoses include Alzheimer's Disease (progressive brain disorder that causes gradual cognitive decline), dementia (loss of cognitive function that interferes with a person's daily life and activities), hypertension (high blood pressure), anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), and hemiplegia (paralysis on one side of body) & hemiparesis (weakness on one side) following cerebral infarction (type of stroke) affecting right dominate side.R1 is not interview able and is dependent on staff for his ADL's (activities daily living).R1's at risk for falls care plan initiated 6/29/23 and revised on 10/19/23 includes an intervention of *Non-slip material to wheelchair to prevent member from sliding. Initiated 3/22/25 & revised 10/19/25.R1's potential for impairment to skin integrity care plan initiated 8/9/25 & revised 11/7/25 includes an intervention of *Padded side of w/c (wheelchair) seat and both front bars on lower part of w/c with black pool noodle for protection. Initiated 8/30/25 & revised 10/19/25.R1's Certified Nursing Assistant (CNA) care plan as of 12/2/25 under safety section includes *Non-slip material to wheelchair to prevent member from sliding. *Padded sides of w/c seat and both front bars on lower part of w/c with black pool noodle for protection.R1's nurses note dated 10/18/25, at 22:10 (10:10 p.m.), and written by Registered Nurse (RN)-M documents During members body check for shower, skin tear noted over purple senile purpura to right side of clavicle. Skin tear measuring 1.3cm (centimeters) x (times) 0.3cm x 0.1 cm. No drainage or s/s (signs/symptoms) of infection. No indication of pain or discomfort noted. Area cleansed and mepilex applied per NP (Nurse Practitioner) order [Name]. Charge nurse & POA (Power of Attorney) made aware.R1's nurses note dated 10/20/25, at 05:15 (5:15 a.m.) and written by RN-M documents Member rested well during the night. Dressing to right clavicle clean, dry and intact. No drainage noted to dressing. Surrounding skin intact. No pain indicated to the area. Jacket in place for skin protection.R1's IDT (interdisciplinary team) note dated 10/20/25, 16:18 (4:18 p.m.) written by RN-I documents Reason for discussion: Met to discuss root cause and intervention for wound. Summary of discussion: Proper people notified. RCA (root cause analysis): Member has a history of picking at skin. Likely self-inflicted. Intervention: Treatment as directed by provider.On 12/3/25 Surveyor reviewed the facility's investigation for R1's skin tear. Surveyor was provided with impaired skin integrity/wound checklist dated 10/18/25, incident audit report with dates of 10/18/25, 10/20/25 & 10/24/25, incident note dated 10/18/25, nurses note dated 10/18/25 at 22:10 & IDT note dated 10/20/25 at 16:18, incident report dated 10/18/25 at 21:30 (9:30 p.m.) and R1's potential for pain & potential for impairment to skin integrity. Surveyor noted this information did not include any staff statements or indications that staff was spoken to regarding if this area was observed by any staff prior to skin check, how R1 may have sustained this injury, whether any staff observed R1 picking his clavicle area etc.On 12/3/25, at 12:10 p.m., Surveyor met with Interim Director of Nursing (IDON)-B to discuss R1. Surveyor informed DON-B R1 sustained a skin tear with purple purpura which was noted during a skin check on 10/18/25. Surveyor inquired if there are any staff statements or had any staff been interviewed regarding this area. DON-B informed Surveyor RN-I is no longer employed at the facility but will investigate this and get back to Surveyor.On 12/3/25, at approximately 1:30 p.m., IDON-B informed Surveyor R1's has a history of scratching himself and has no further information to provide Surveyor.*R1's nurses note dated 10/21/25 at 21:02 (9:02 p.m.) and written by RN-N documents Member had just got done receiving a shower, transferred to bath scale to weigh member, member raised his L (left) arm while sitting in the chair and writer noticed some blood coming down the LFA (left forearm), member noted to receive a 1cm (centimeter) x (times) 1cm skin tear to the LFA as there was some hard plastic on the chair that was slightly jagged and his arm grazed this area of the scale when he was lifting up his arm. Writer assessed cause of injury, assessed the rest of his skin, contacted CRN (Charge Registered Nurse), POA (Power of Attorney) [Name], and on-call [Medical Group Name]. Writer cleansed dried and applied skin prep, Sorbact followed by 2x2 foam border dressing per order from [Name], PA (Physician Assistant).R1's nurses note dated 10/21/25, at 21:25 (9:25 p.m.), and written by RN-P documents Writer called and updated Interim DON on member left arm skin tear from [Name] shower chair arm, removed shower chair from unit per DON direction and TELS entered for maintenance.R1's nurses note dated 10/21/25, at 21:49 (9:49 p.m.) and written by RN-N documents Writer called and received order for skin prep, Sorbact, bordered foam and change every 3 days and PRN (as needed) from [Name], PA.R1's IDT (interdisciplinary team) note dated 10/22/25 at 09:51 (9:51 a.m.) and written by RN-I documents Reason for discussion: Met to discuss root cause and interventions for skin tear. Summary of discussion: Proper people notified. Root cause: Member has UTI (urinary tract infection), awaiting C & S (culture and sensitivity) to begin treatment. Member fell during self-transfer to toilet due to toileting need. Intervention: Staff to offer to assist him to the bathroom before 0500 (5:00 a.m.) and will add him to the NOC (night) get up list. Surveyor was unable to interview RN-I regarding this note as RN-I is no longer employed at the facility.On 12/3/25 Surveyor reviewed the facility's investigation which consisted of impaired skin integrity/wound checklist, Certified Nursing Assistant (CNA)-O's witness statement dated 10/21/25 and RN-D's witness statement dated 10/21/25. CNA-O's statement dated 10/21/25 documents The nurse and I showered member. After it was completed then we were drying him off before getting him off shower chair. As we were done, we noticed a small amount of blood on his arm. Nurse looked him over and found the source. Took care of it. It was on left arm.RN-D's statement dated 10/21/25 documents Writer notified by staff RN that member sustained a skin tear from the shower chair as there was one sharp piece of plastic on S/C (shower chair) arm. Writer took an emery board into tub room and filed area down smooth as well as several other areas of concern. Staff RN addressed skin tear through procedure.On 12/3/25, at 10:56 a.m. Surveyor asked Maintenance-F what equipment they check. Maintenance-F explained monthly they check sit to stand, bath chairs, some other kind of lifts. Surveyor asked if they check shower chairs. Maintenance-F replied no explaining there are no mechanics on it. Maintenance-F informed Surveyor [Name of Company] comes in but there is only one guy for two and a half states, so they try to take care of issues in house. Surveyor informed Maintenance-F on 10/21/25 a member (resident) sustained a skin tear from the shower chair. Maintenance-F replied yes, I remember that because we replaced it. Surveyor asked if they replaced the chair. Maintenance-F replied no, the arm where he got scratched. Surveyor asked if they checked other shower chairs. Maintenance-F replied yes, we did. On 12/3/25, at 11:28 a.m., Surveyor interviewed RN-D regarding the skin tear R1 sustained on 10/21/25. Surveyor asked RN-D what type of chair RN-D was referring to in his statement. RN-D replied [name of company]. RN-D informed Surveyor R1 was injured on the plastic arm there was a couple of different areas with sharp shards. RN-D informed Surveyor he tried to take an emery board to smooth them down but that was not good enough. RN-D informed Surveyor there is a new chair in there now.On 12/3/25, at 12:10 p.m., Surveyor informed Interim Director of Nursing (IDON)-B R1 sustained a skin tear on his arm from sharp pieces of plastic on the shower chair on 10/21/25. Surveyor asked IDON-B if any education was provided to staff or what did the facility do to prevent this from occurring in the future. IDON-B informed Surveyor she communicated to the charge nurse the chair must be removed. IDON-B informed Surveyor she will look into this and get back to Surveyor.On 12/3/25, at 12:53 p.m., Surveyor asked Maintenance-F when they are inspecting the [Name] chairs what are they inspecting. Maintenance-F informed Surveyor the mechanics to ensure the chair goes all the way up & down, wheels & brakes works, and the battery is charged. Surveyor asked if there is anything else. Maintenance-F informed Surveyor that the chair is operating properly. Surveyor asked Maintenance-F if they check for any jagged edges or anything else unsafe. Maintenance-F replied yes but at that time, referring to when R1 sustained the injury, they just lost their boss, another guy wasn't a team player, and it was a rough time. Maintenance-F explained he did what was supposed to do and might have scanned over it.On 12/3/25, at approximately 1:30 p.m., IDON-B informed Surveyor she does not have anything further to provide to Surveyor.*On 12/2/25, at 8:48 a.m., Surveyor observed R1 sitting in a high back wheelchair at a dining room table. Surveyor did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care. On 12/2/25, at 9:13 a.m., Surveyor observed R1 sitting in a personal type of recliner chair in the TV area with R1's legs extended and R1 is covered with a light bath blanket. Surveyor observed there is a black [NAME] Easy cushion in R1's wheelchair. Surveyor did not observe either on top or under R1's cushion nonslip material (Dycem). Surveyor did not observe any padding on the sides of R1's wheelchair and did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care. On 12/2/25, at 10:12 a.m., Surveyor observed R1 continues to be sitting in the personal type of recliner chair in the TV area with R1's legs extended. Surveyor did not observe padding on the sides of R1's wheelchair and did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care. R1's cushion still does not have nonslip material.On 12/2/25, at 11:11 a.m., Surveyor observed R1 continues to be sitting in the personal type of recliner chair in the TV area with R1's legs extended. Surveyor did not observe padding on the sides of R1's wheelchair and did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care. R1's cushion still does not have nonslip material.On 12/2/25, at 11:41 a.m., Surveyor observed Certified Nursing Assistant (CNA)-R & CNA-S transfer R1 from the recliner into R1's wheelchair using a gait belt. R1 was then placed at a table in the dining area. Surveyor did not observe padding on the sides of R1's wheelchair and did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care.On 12/2/25, at 1:18 p.m., Surveyor observed R1 sitting in the high back wheelchair in the TV area. Surveyor did not observe padding on the sides of R1's wheelchair and did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care.On 12/2/25, at 2:57 p.m., Surveyor observed R1 sitting in the high back wheelchair in the dining area. Surveyor did not observe padding on the sides of R1's wheelchair and did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care.On 12/3/25, at 7:50 a.m., Surveyor observed R1 sitting in a high back wheelchair at a table in the dining room. Surveyor did not observe padding on the sides of R1's wheelchair and did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care.On 12/3/25, at 9:02 a.m., Surveyor observed R1 sitting in the high back wheelchair at a table in the dining room. Surveyor did not observe padding on the sides of R1's wheelchair and did not observe the lower portion of the front bars on R1's wheelchair padded with black pool noodle per R1's plan of care.On 12/3/25, at 9:10 a.m., Surveyor observed CNA-E unlock R1's wheelchair, wheel R1 away from the table, wheel R1 down the hall and into R1's room.On 12/3/25, at 9:13 a.m., Surveyor observed CNA-E & CNA-H placed PPE (protective personal equipment) on and enter R1's room. CNA-E placed R1's wheelchair in front of the EZ stand. R1's feet were placed on the foot platform and R1's legs were buckled in. CNA-H placed a sling around R1, and the sling was attached to the lift. R1 was raised off the wheelchair, wheeled into the bathroom, CNA-H lowered R1's incontinence product & pants, and R1 was lowered onto the toilet.On 12/3/25, at 9:21 a.m., Surveyor asked CNA-E before R1 is placed back in the wheelchair Surveyor would like to speak with CNA-E. Surveyor informed CNA-E Surveyor thought R1 is supposed to have nonslip material (Dycem) in R1's wheelchair. CNA-E lifted up R1's cushion. Surveyor observed there is not any nonslip material either under or on top of R1's cushion. CNA-E informed Surveyor she didn't know and will have to check the care plan. CNA-E then removed R1's care plan from inside the bathroom cabinet. Surveyor asked about padding R1's wheelchair with a black pool noodle. CNA-E informed Surveyor she did see the black pool noodle in the past, but they were struggling with R1's foot pedals. CNA-E informed Surveyor the Dycem is green, looked in R1's room stating I don't see it. Surveyor informed CNA-E R1's wheelchair did not have Dycem and was not padded yesterday either. CNA-E replied that's two days in a row. On 12/3/25, at 12:10 p.m., Surveyor informed Interim Director of Nursing (IDON)-B of the observations on 12/2/25 & 12/3/25 of R1 not having nonslip material (Dycem) in R1's wheelchair and the sides of R1's wheelchair & the lower portion of the front bars on R1's wheelchair was not padded with black pool noodle per R1's plan of care.

Based on record review and interview, the facility did not ensure pharmacy procedures were followed to identify an unaccounted for narcotic medication. This was observed with 1 (R2) of 4 resident medication reviews. R2 was missing a narcotic medication on 8/16/25 that was not discovered until 9/5/25.Findings include:The facility's policy and procedure titled Controlled Substances dated 7/1/2004. This documents under Procedures: 4.) At time of administration, the licensed nurse compares the last recorded remaining medication count in the Electronic Health Record (HER) with the bubble pack/ medication package and enters the new remaining count value after the ordered dose(s) is prepared for administration/application. The number being administered is also recorded in the appropriate column of the Controlled Substance Perpetual Inventory sheet.Surveyor reviewed a Facility Reported Incident (FRI) involving R2's medication. The FRI document on 9/5/25, during an audit, 1 tablet of Hydrocodone 5/325 milligrams was missing. The FRI investigation determined the 1 tablet was missing from 8/16/25. The root cause was not able to be determined. The facility's policy and procedures were not consistently followed to identify this missing medication with shift-to-shift narcotic counts. The FRI resolution was to follow through the Quality Assurance Program Improvement (QAPI) to monitor this process through audits. The Administration that conducted the FRI investigation is unavailable for interview. This pharmacy process was not included in QAPI for monitoring.On 12/2/25, at 10:34 AM, Surveyor interviewed Interim Director of Nurses (IDON) -B. The IDON-B is in the process of developing an audit for narcotic counts. The IDON-B did not have any additional information related to this FRI investigation.On 12/2/2025, at 3:09 PM, at the facility exit meeting with the Nursing Home Administrator (NHA)-A, Assistant Nursing Home Administrator(ANHA) -C and IDON-B. Surveyor shared the concern with the narcotic count process, No further information was provided.

Based on observations, interviews and record reviews, the facility did not provide 5 residents (R4, R7, R11, R12 and R15) of 11 residents reviewed with the necessary cares and services to promote quality of life and assist residents to maintain their highest practicable level of physical, mental, and psychosocial well-being. *The facility did not provide R7 with the sense of safety within the Facility from R6. R7 indicated being in fear of R6, a resident who displayed escalating aggressive behaviors. R7 was assaulted by R6 and was assessed as experiencing Post-Traumatic Stress Syndrome (PTSD) as a result. R6 went on to assault R5 a few weeks later. The facility did not have a plan to effectively monitor R6. * The facility failed to provide R4 a sense of satisfaction with oneself, the environment, and the care received. R4 has continually expressed dissatisfaction with the living at the facility. R4's dissatisfaction with the facility has caused R4's behavior of planning unsafe ways of leaving the facility. R4's loss of a friend was not addressed in R4's plan of care potentially triggering unsafe behaviors by R4. *The facility was aware of R11's previous attempts and continued expressions of wanting to leave the facility and did not implement interventions to keep R11 safe while residing at the facility as evidenced by R11's [DATE] elopement from the facility. The facility did not identify R11's signs of distress exhibited by R11's expressions of wanting to leave the facility and attempting to elope. R11's care plan does not document person-centered interventions. Medically related social services has not been provided to R11 resulting in a deterioration in R11's psychosocial well-being. *R12 documents during a statement following a resident-to-resident altercation, that R12 did not feel safe at the Facility with R6 wandering “in here.” *R15 expressed being fearful of closing R15's eyes at night due to R14 wandering into R15's room. R15 expressed not being able to defend R15's self from R14 and wanting to purchase a water gun to deter R14 from entering R15's room. This pervasive disregard for residents' quality of life created a finding of immediate jeopardy that began on [DATE]. The Facility was notified of the immediate jeopardy on [DATE] at 11:37 AM. The immediate jeopardy was removed on [DATE] when the facility implemented an immediate jeopardy removal plan. Findings include: 1.) On [DATE], R6 was the aggressor in a resident-to-resident altercation with R7. On [DATE], R6 had another resident -to-resident altercation where R6 is the aggressor. A statement from R7, dated [DATE], documents R7 does not feel safe at the Facility with R6 around. R12's statement, dated [DATE], documents the resident feels unsafe when R6 wanders in “here.” On [DATE], at 6:46 PM, a progress note, by Registered Nurse (RN)-BB, documents R6 exhibiting severe anxiety/restlessness, ignoring redirection, staff shut all doors on unit, R6 would just open the doors to enter resident rooms, another resident in the hallway due to not wanting to be alone in the room with R6. R6 requiring 1:1 interaction with staff but management continues to deem R6 only needing 15-minute checks. Staff finding it difficult to tend to other residents and prevent resident to resident altercations Surveyor noted a progress note by PhD (Doctor of Psychiatry)-DD, dated [DATE], documents R7 is experiencing acute PTSD symptoms following recent assault by R6. R7 reports being “frightened and surprised” by the assault with fears R6 will return and hurt R7 again. PhD-DD documents R7's anxiety symptoms are currently heightened due to the recent assault and expressing fear in R6's return. 2.) R4 was admitted to the facility on [DATE] with diagnoses that include COPD, Dementia with Mood Disturbance, Dementia with Moderate Anxiety, PTSD, Multiple Sclerosis- and MVI (motor vehicle incident) with quadriplegia. R4 was placed under protective placement via a court order on [DATE]. R4's Determination and Order on Petition for Guardianship Due to Incompetency document dated [DATE] documents, This individual is found to be incompetent because other like incapacities .The court transfers to the guardian of the person the power to exercise in full the ability to receive medical or treatment records of the individual; make decisions related to mobility and transfer- Partial Transfer. The individual retains the power with Guardian consent. Protectively placed: indicating the ward is totally incapable of providing the wards own care or custody as to create a substantial risk of serious harm to the ward or others. Serious acts may be acts of overt acts or acts of omission.” R4 has an elopement history with multiple planned elopements from appointments. The most recent prior to [DATE] was dated [DATE] when R4 eloped from the hospital and was found at a hotel approximately seven hours later. A later investigation found R4 planned the elopement and had saved money to go to a different location and to live independently R4's Last Brief Interview for Mental Status (BIMS) was completed in June of 2024 with R4 scoring 15 indicating intact memory. R4 refuses to participate in the BIMS process. R4's minimum data set (MDS) with an assessment reference date of [DATE] documents under section GG that R4 uses a manual wheelchair and once seated can wheel independently at least 150 feet. R4's Discharge Care Plan initiated on [DATE] documents, DISCHARGE PLANS: Long-term stay anticipated at this SNF r/t (related to) I'm no longer able to reside at home d/t (due to) eviction from apartment, my history of falling at home. I voice wanting to leave the facility to go and live independently but I am unrealistic about my abilities. I refuse to have [NAME] County come out and do discharge options counseling. The VA (Veterans Affairs) spinal cord unit has encouraged me to talk to the county as the VA does not have a discharge option. R4's medications include Sertraline 50 mg daily started [DATE]. R4's Psychiatry progress note dated [DATE], at 2:42 PM, documents: “Pt is [AGE] year-old male seen today for follow up psychiatric evaluation. Pt seen for yelling, restiveness with cares and medications, anxiety and agitation. Pt will refuse cares/meds at times from certain staff, then report that he was not offered/given the cares/meds. Pt dismissive of exam today. Pt will discuss with staff and practitioners when he wants per staff report. Overall behaviors improved since rx (medication) sertraline….” R4's nursing note dated [DATE], at 12:54 PM, documents: “Writer attempted to recheck members blood pressure due to reading this morning. Member stated Get the fuck out! Get the fuck out! writer will notify physician. Supervisor aware. Member is on blood pressure medications as well. Plan of care continues.” R4's Incident Report dated [DATE], at 2:30 PM documents: “Incident description” Member was seen returning from the gazebo outside onto the unit. Member had 4 fluid filled blisters on his face. Immediate action taken, Description: member was monitored. Member did not report pain or discomfort from the Sunburn. The physician was called. Nurse notified physician and received orders Aloe. Aloe received. Member offered aloe. Member agreed and was applied. Mental Status oriented to Person. Oriented to situation. Oriented to place. Oriented to time. Predisposing factors: other. Predisposing Physiological factors: none. Predisposing Situation factors: Active exit seeker. Other info: Member prefers to be non-compliant. Member enjoys being outside in the sun. member does not like to wear sunscreen. (Historical Temperature was 84 degrees). R4's nursing note dated [DATE], at 1:00 PM, documents: “Register Nurse (RN) and Assistant Director of Nursing (ADON) went outside to assess member's forehead. Member refused. Was using abusive language and left the area where he was outside. RN and ADON notified member we were going back inside. Member's face is normal color, and he has a hat down over his forehead”. R4's elopement nursing note dated [DATE], at 2:48 PM, documents: Member left out the unit at 12:30 with water in hand. Declined sunscreen, had hat on. At approximately 1:30 member was not seen at the gazebo. Staff immediately went to look at {….Hall} and outside. Staff coming in for second shift alerted writer member was rolling towards Highway C. Writer and aid jumped in personal vehicle and drove towards member to check on safety. Member seen close to Wisconsin Southern Center State sign, Writer and aid got out and spoke with member. Member stated, “I don't want to be here, I want to go to [NAME]”. Writer called 911 when member appeared not to stop. Member agreed to come back to facility. Staff rolled member to safe location and called transport to pick him up to drive back to {….Hall}. New intervention implemented and added to TPOC (care plan). Provider notified this shift: [DATE] 2:45 PM. Family/Guardian notified [DATE] 2:45 PM. Supervisor notified via phone [DATE] 2:00 PM. (Historical Temperature was 86 degrees). R4's Psychiatric note dated [DATE], at 9:53 PM, documents: Reason: Adjustment disorder with Depression and Anxiety. R4, [AGE] years old male seen today for follow up psyche visit. Start time 10 AM end time 10:30 AM record review/consultation with staff 10 minutes, face- to -face with patient 20 minutes. This clinician was asked to see R4 by his Family Member. Attempts have been made over the past several months; however, he has refused services. Records indicate that last weekend he eloped twice, when found, he stated that he wanted to go to [NAME] as they have in his opinion, better physical therapy. He cooperated with staff and got in their car and returned to the facility. If R4 does not have a wander guard at this time, that should be considered. R4 was angry and frustrated. He did not wish to engage in individual therapy despite wanting to leave the facility and knowing that talking to the staff and cooperation could assist him in being accepted in another facility. He was verbally aggressive during the session and stated that no one could help him. He is oriented x 3. Due to his self-isolation and verbal aggressiveness, therapy will be attempted within the coming 2 weeks…. On [DATE], at 12:00 PM, Surveyor interviewed R4 about R4's elopement and [DATE] sunburn incident. Surveyor asked if R4 membered leaving the building in July. R4 informed Surveyor that R4 remembered leaving. R4 informed Surveyor “I was going to [NAME]”. Surveyor asked R4 why R4 wanted to leave. R4 informed Surveyor that “I don't like it here, I keep escaping” and that R4 has always planned on leaving. R4 informed Surveyor that R4 didn't believe the facility was trying to help him. R4 informed Surveyor that R4 was finally going to an assisted living next week Tuesday and that they won't treat him like a baby like they do here. Surveyor asked R4 why R4 had been out so long on [DATE] causing R4 to get a bad sunburn. R4 informed Surveyor the R4 was sad that day. R4 didn't seem like R4 wanted to continue. Surveyor asked if the Surveyor could come back later. R4 agreed. On [DATE], at 9:58 AM, Surveyor continued the interview with R4. Surveyor asked R4 if R4 could tell Surveyor about why R4 felt he needed to leave the facility. R4 informed Surveyor that R4 was going to [NAME] to the hospital because the Social Workers here won't help him. R4 informed Surveyor that R4 could have been in [NAME] but they didn't evaluate him because the Social Worker didn't help set it up. R4 informed Surveyor the Social Worker at [NAME] Hospital would help him. Surveyor asked R4 what route R4 took. R4 informed Surveyor that R4 wheel himself down the road from the Gazebo then down the main road towards the highway. R4 informed Surveyor they must have finally noticed I wasn't there, and they came after me. R4 informed Surveyor “I escaped in Milwaukee before; I had to do something”. R4 informed Surveyor that the family member was stealing from him and that they were not helping him get out here. R4 informed Surveyor They treat me like a baby here Surveyor asked R4 if R4 was being monitored by staff. R4 informed Surveyor the staff was not monitoring him but that after he left, they sure are now. Surveyor asked R4 if R4 had any provisions like water for the trip. R4 informed Surveyor that R4 was in Vietnam and knew how to pack a [NAME] sack. R4 informed Surveyor he had cloths and water with him. Surveyor asked R4 if he was planning to leave now. R4 informed Surveyor he was being transferred to an assisted living next week Tuesday and was happy about that. Surveyor asked R4 how long R4 was out on [DATE] when R4 received the Sunburn of R4's forehead. R4 informed Surveyor that R4 like to be in the Sun and often is outside tanning. R4 informed Surveyor the R4 was outside from about noon to after 3:00 PM maybe 3:20 PM. Surveyor asked why R4 was outside long enough to get burned. R4 informed Surveyor the R4 was thinking about R4's friend who died and R4 was very sad and didn't want to come inside. R4 informed Surveyor that R4 wanted to sit by himself outside for as long as possible. R4 informed Surveyor that R4 has a new friend now like R4 who wants to escape from here. R4 informed Surveyor my friend has escaped 3 times already. Surveyor asked R4 if the facility or social services had spoken to R4 about why he was sad and why he was outside for so long. R4 informed Surveyor that no one has spoken to me about anything about that day. R4 informed Surveyor that the social worker wouldn't help him anyway. On [DATE], at 2:12 PM Surveyor interviewed RN-V, Surveyor asked RN-V about R4's behaviors when R4 goes outside. RN-V informed Surveyor R4 refuses to sign out and refuses Sunscreen and other measures to protect R4 from injury. Surveyor asked RN-V about R4's friend that passed away and that R4 told the Surveyor that R4 stayed outside to long because R4 was sad on [DATE] over the death of R4's friend. RN-V informed Surveyor that R4 and the resident who passed away last February 2025 were close and went outside together. They often took their shirts off and had tanning contests despite warnings of Sun exposure by staff. RN-V informed Surveyor that R4 was impacted by the other member's death and that RN-V had informed Administration this was one of the concerns RN-V had for R4's behaviors. On [DATE], at 12:42 PM, Surveyor interviewed Director of Social Service (DSS)-D about R4. Surveyor asked DSS-D about R4's statement to Surveyor about a friend who passed away this year. DSS-D informed Surveyor that R4's friend at the facility passed away in February or 2025. Surveyor informed DSS-D that R4 informed the Surveyor that is why R4 had sat outside so long on [DATE] and that it still seems to trouble R4, and no one has spoken to R4 about it. DSS-D informed Surveyor they have spoken. Surveyor asked if DSS-D documented that conversation as Surveyor could not locate it and there is nothing in the care plan addressing it. DSS-D informed Surveyor it would be in the social service progress notes. Surveyor asked DSS-D how interventions and member care plans were assessed for the most meaningful and effective actions, especially triggers for behaviors that are implemented for each member. DSS-D informed Surveyor that the Interdisciplinary Team (IDT) reviewed the members care plan and implemented the interventions needed. Surveyor asked DSS-D if DSS-D could explain how that process works in the IDT meetings. DSS-D informed Surveyor the members charts were reviewed and the departments had input from their staff. Surveyor informed DSS-D that during an interview with R4 informed Surveyor the R4 has never stopped wanting to leave. Surveyor asked if DSS-D was aware R4 has never stopped wanting to leave. DSS-D acknowledged that R4 wanted to leave. Surveyor acknowledged to DSS-D that now the R4 is leaving R4 seems to be satisfied with the move to an assisted living. Surveyor asked DSS-D back before R4's elopement R4 had an elevation in behaviors of being resistive to cares and medications as noted by the psychiatry note on [DATE], and with R4's elopement history, was it safe or a good idea for R4 to have no meaningful psychosocial or proactive elopement/safety interventions in place except a 2-hour safety check placed on [DATE]. DSS-D informed Surveyor “no, probably not.” Surveyor asked NHA-A and DON-B for the process the IDT team used to develop, evaluate and implement safety and elopement interventions. Surveyor informed NHA-A that most of what the Surveyor noticed were safety checks, and motion lights. Surveyor requested any system the IDT team used to implement interventions and evaluate triggers for behaviors and the success of the interventions. DON-B informed Surveyor that ADON-S charted under the IDT notes in the point click care system. Surveyor informed DON-B these notes were sparse and basic and did not show the thought process behind the reason for the interventions or any analysis of the interventions being discontinued. NHA-A informed Surveyor she would look to see what the process involved and get back to the Surveyor. (Note: Surveyor noted there was no IDT meeting on R4 from [DATE] until after R4's [DATE] Sunburn incident.) Surveyor did not note any interventions documented in R4's safety plan of care for potential behavior triggers related to R4's sadness over R4's friend or the possibility R4 was not leaving on the anticipated day of Tuesday [DATE]. On [DATE], at 8:52 AM, Surveyor interviewed DON-B about members who are elopement risks. Surveyor asked DON-B if there was any more information about the processes for implementing interventions for members especially with risk factors such as dealing with psychosocial issues, elopement concerns or behaviors that might lead to injury like R4 staying outside too long and developing blistering sunburns. Surveyor informed DON-B that R4 was seen for behavior increases on [DATE] by psychiatric services and Surveyor did not note any care plan changes. DON-B informed Surveyor that DON-B did not find a policy or procedure for IDT care plan intervention implementation and evaluation. On [DATE]. At 3:24 PM, Surveyor gave serious concerns to NHA-A and DON-B from Surveyor's investigation as of [DATE]. Surveyor informed NHA-A that the facility did not evaluate the root causes of R4's [DATE] elopement and [DATE] blistering sunburn injury. The facility failed to implement meaningful and effective care interventions for R4 to keep R4 safe. R4's incident on [DATE] had no investigation on when or why R4 left the building and never asked R4 why R4 was outside for so long. R4 informed Surveyor that R4 was sad, and R4 went outside around 12:00 PM and did not come back into the building until around 3:20 PM. R4 informed Surveyor that he was sad thinking about his friend who had passed away. R4 informed Surveyor that no one has asked R4 anything about the [DATE] sunburn incident. R4 had a psychiatric consult on [DATE] asked for by R4's family because of increasing behaviors of refusing cares. Staff informed Surveyor that R4 had a history of refusing sunscreen and protective measures when in the sun before the [DATE] incident where R4 received a blistering sunburn. No psychosocial or proactive interventions were documented or discussed by the IDT team responsible for care plan interventions, and no proactive interventions to keep R4 safe from these behaviors were placed in R4's care plan until after R4 ended up with a blistering sunburn on R4's forehead. No root cause analysis except comments: “member prefers to be non-compliant” “Member enjoys being in the sun” and “Member refuses sunscreen” Nothing about R4's sadness over the loss of R4's friend or interventions related to R4's feelings of loss that may have triggered the behavior. Surveyor asked NHA-A if NHA-A would agree that R4 had nothing proactive in R4's plan of care for elopement and safety until after R4 almost made it almost a mile away to a highway in a wheelchair. NHA-A and DON-B agreed that the Surveyor was correct there was nothing proactive in place for R4's elopement concerns prior to R4's [DATE] elopement. NHA-A informed surveyor that a WanderGuard and closer monitoring of R4 are in place now. NHA-A informed Surveyor that the NHA-A had initiated training of the staff and NHA-A found that the staff believed R4 was R4's own person and could make all his own decisions. NHA-A informed surveyor the staff were not aware of R4's cognitive impairment. R4's Physicians order dated [DATE], at 06:30 AM documents, “Member cannot sign himself out (even to the grounds of the facility). He has recently left the property after signing himself out to the gazebo. Member must be always accompanied outside (by a staff member of a volunteer). All behaviors, including attempted elopements need to be documented and interventions immediately put into place. Member may use the courtyard for 1W (Memory Care) if he prefers. If member is in courtyard, must be placed on 15-minute checks.” No new psychosocial interventions in R4's safety care plans implemented to address R4's feelings of loss or potential disappointment with R4's transfer timeline. 3.) R11 was admitted to the facility on [DATE] with diagnoses that inclide Dementia Unspecified Severity (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), With Mood Disturbance, and Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R11 has an activated Health Care Power of Attorney (HCPOA) as of [DATE], however, there is a guardianship hearing on [DATE] because family no longer wants to be the HCPOA. R11's Quarterly Minimum Data Set (MDS) completed [DATE] documents R11's Brief Interview for Mental Status (BIMS) score is 12, indicating R11 demonstrates moderately impaired skills for daily decision making. R11's MDS documents no mood or behavior issues, including wandering. R11's main locomotion is by standard wheelchair. R11's Kardex, instructions to nursing staff was updated [DATE]. The Kardex documents: Safety -[DATE] Encourage member to ask for help with computer -Alert on call nurse or DON or ADON for all incidents (escalated behaviors, attempts at elopement) -R11 has a wander guard on R11's wheelchair because R11 tries to tear it off R11's arm/leg -R11 now lives in memory care R11 refused wander guard [DATE] -Redirect R11m when voicing need to leave facility to go to the bank. -Roam Alert wander band to R11's wheelchair R11's comprehensive includes the following applicable problems: 1.Safety Elopement: R11 at risk of elopement due to cognitive losses, Dementia high risk for elopement [DATE] R11 was waiting outside “for a ride to his bank”. 15-minute safety checks initiated for R11 whereabouts. R11 declines wearing roam alert device bracelet [DATE] 15-minute checks discontinued [DATE] Roam alert device on R11's wheelchair Initiated [DATE] Interventions: -Monitor my behaviors to determine: duration, frequency, intensity, and patterns. Consider any changes that may have occurred such as: a room change, change in cognitive status, medication changes, new staff, or termination of treatment program. Initiated [DATE] -Alert on call nurse or DON or ADON for all incidents (escalated behaviors, attempts at elopement) Initiated [DATE] -R11 has a wander guard on R11's wheelchair because R11 tries to tear it off R11's arm/leg Initiated [DATE] -R11 now lives in memory care Initiated [DATE] 2.Coping/Trauma Informed Care Plan: I am at risk for ineffective individual coping due to R11's diagnosis of Major Depressive Disorder, Recurrent Unspecified. Adjustment to nursing home. R11 referred to in-house psychologist on [DATE] Triggers: R11 breathing issues forced R11 to stop R11's construction in R11's 40s. When R11's breathing bothers R11, R11 can feel triggered. Initiated [DATE] Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated [DATE] -Arrange for psych consult, follow up as indicated. R11 referred to in-house psychologist [NAME] [DATE]. Initiated [DATE] -Assess/screen for post traumatic events and history of trauma, using nursing home appropriate screening tools, such as the LEC-5. Initiated [DATE] -R11 has deep breathing techniques to use when R11's breathing is bothering R11. R11 also enjoys socializing and being around family and friends. Initiated [DATE] -Discuss feelings around change and loss, facilitate R11's expression of these feelings. Initiated [DATE] -Encourage R11 to talk about how R11 is feeling to family, friends, or staff; remind R11 to utilize R11's support system if R11 is feeling down. Initiated [DATE] -Please watch R11 for the signs and symptoms which may indicate R11 feeling sad or depressed such somnolence, social isolation, increased sadness, frequent weeping, anger, refusal of cares, decreased appetite, weight loss/gain. Initiated [DATE] Starting [DATE], the facility completed an elopement assessment every day, sometimes multiple times a day until [DATE] triggering multiple times of a score of 10 or more indicating R11 must have a safety plan put into place. Surveyor notes a safety plan was not put into place at this time for R11. R11's current physician orders document R11 is on Duloxetine 20 mg 1 capsule at bedtime for pain in left foot. Surveyor notes that Duloxetine can be used to treat Major Depressive Disorder, Generalized Anxiety, and chronic pain. Surveyor notes there is no documentation how R11's Duloxetine has impacted R11's diagnosis of Major Depressive Disorder. The facility has not been monitoring for signs of symptoms of depression and/or behaviors related to the Duloxetine because the facility is stating the facility is treating R11 with Duloxetine for pain. The facility has no current accurate documentation of signs and symptoms related to R11's diagnosis of Major Depressive Disorder because the facility has not monitored R11's behaviors. Surveyor reviewed R11's electronic medical record (EMR) and notes the following progress notes: On [DATE], Director of Social Services (DSS)-D documented R11 had coat on stating R11 wanted to leave the building, order a cab, go to their bank and get a debit card. R11 stated that R11 wanted to complete an online purchase from a store of potato chips and other snacks. Placed on 15 checks. On [DATE], Registered Nurse (RN)-BB documented R11 voicing R11 wanted to leave and was hard to redirect. Making multiple statements about leaving on Monday and will have to be shot to be stopped. Stating is waiting for debit card so R11 can work R11's way to California and cross the border to Mexico for some new lungs. Stated the lungs would be from drug dealers that the Mexicans kill. R11 stated that R11 is too old to get new lungs in the US and that is why R11 has to go to Mexico for them. Surveyor notes there is root cause analysis by DSS-D or any interventions put in place for R11. On [DATE], Registered Nurse (RN)-CC documented R11 voicing the want to leave. R11 stating “you can't keep me here. I'm not a prisoner.” R11 wanting to go outside. R11 attempting to go to 2nd floor elevators and not easy to redirect. Surveyor notes there is no follow-up by DSS-D on how R11 is feeling and what psychosocial concerns R11 has. On [DATE], Registered Nurse (RN)-G documented R11 making multiple statements about leaving on Monday and R11 will have to be shot to be stopped. Surveyor notes there is no documentation DSS-D met with and provided support to R11 in regard to the intense feelings R11 was expressing. On [DATE], it is documented that 30-minute checks were discontinued for R11. On [DATE], it is documented that a referral to psychology was initiated. On [DATE], R11 was evaluated by Psychology (PhD)-DD with the goal for psychotherapy to address cognitive distortions, improve reality orientation, and enhance coping skills. R11 was to be seen for six individual psychotherapy sessions, each 30 minutes in duration, over the coming three months. R11 has not been seen since [DATE] by PhD-DD. On [DATE], Registered Nurse (RN)-EE documented R11 voiced to a staff member he had intentions of escaping during the planned facility shopping trip tomorrow [DATE]. R11 stated “I am going to escape and go to the bank, get a debit card, buy a plane ticket and I am going to buy a house in Hawaii and a plane ticket.” …”Called and reported to Interim commandant, DON, and ADON were notified.”… No documentation after this was voiced by R11 of any interventions put into place. Surveyor notes there is no documentation that DSS-D completed a root/cause analysis of R11's expressions. On [DATE], Activity Aide (AA)-FF documented R11 was waiting outside “for a ride to his bank”. Nursing aware. 15-minute checks initiated. On [DATE], another elopement assessment was completed with a score of 16, indicating R11 is high risk for eloping. Surveyor notes that an elopement care plan with a safety plan was not implemented until [DATE]. R11 had multiple previous verbalizations of wanting to leave the facility. On [DATE], 15-minute checks were implemented. The only intervention on R11's care plan added on [DATE] was to monitor behaviors to determine: duration, frequency, intensity, and patterns. Consider any changes that may have occurred such as: a room change, change in cognitive status, medication changes, new staff, or treatment of treatment program. On [DATE], Nursing Supervisor (NS)-HH documentation states 15-minute checks discontinued, however, Surveyor notes that staff continued to document 15 minute checks were in place. On [DATE], 15-minute checks were discontinued as documented by NS-HH. On [DATE], RN-BB documents R11 is expressing that R11's kids are taking R11 to court and trying to take all R11's money and that R11's children were handing over their HCPOA to a guardian. R11 is upset and unreceptive to redirection. Surveyor notes on [DATE] the coping trauma informed care plan was initiated. On [DATE], at 7:45 AM, R11 initiated conversation with Surveyor who was observing two other Residents on the unit. Surveyor notes R11 was very focused on leaving, the upcoming court hearing, and wanting to get to the bank so R11 can pay a lawyer for the upcoming court hearing. On [DATE], at about 9:55 AM. R11 was found out of the facility, down at the 3 way stop sign. Staff were alerted by a family membe

Based on observation, interview, and record review the facility did not ensure 6 (R2, R11, R4, R3, R8, and R10) of 7 residents received adequate supervision to prevent accidents from falls and elopements * R2 has had 15 falls since 1/9/25. On 1/17/25 R2 fell. A fall risk assessment on 1/17/25 indicates R2 is at low risk for falls. On 3/5/25 the facility completed another fall risk assessment and was assessed to be high risk for falls. R2 fell on 4/1/25, 4/3/25, & 4/7/25. R2's fall risk assessment dated [DATE] assesses R2 as low risk for falls. R2's fall risk assessment dated [DATE] and subsequent fall risk assessments assess R2 as high risk for falls. On 4/3/25 R2 was transferred to the hospital and diagnosed with a traumatic hematoma of the forehead. The facility did not thoroughly investigate R2's falls on 4/1/25, 4/3/25, & 4/7/25, did not determine if prior interventions were in place and did not determine a root cause of these falls to prevent further falls. On 4/9/25 R2 fell. R2 was transferred to the hospital on 4/9/25 and admitted on this date with diagnoses of Subdural Hematoma, Hematoma, Subarachnoid hemorrhage, T12 fracture and UTI. R2's hospital Discharge summary dated [DATE] documents She will need Keppra for 4 weeks for seizure prophylaxis. Following hospitalization R2 sustained falls on 4/16/25, twice on 4/29/25, 5/8/25, 5/10/25, 5/26/25, 6/24/25, 7/19/25, 7/25/25, & 8/18/25. With the exception of R2's fall on 7/19/25 the facility did not thoroughly investigate R2's falls, did not consistently obtain staff statements, and did not determine the root cause of R2's falls to help prevent further falls. *R11 was assessed as being high risk for elopement. On 3/26/25 R11 had a coat on stating wanted to leave the building, order a cab, and go to the bank for a debit card. On 4/12/25 R11 voiced he wanted to leave. On 7/8/25 R11 voiced to a staff member he had intentions of escaping during a planned facility shopping trip. R11 stated he was going to escape, go to the bank, get a debit card, buy a plane ticket and was going to buy a house in Hawaii. On 9/11/25 R11 was found out of the facility, down the road at the three way stop sign. Facility staff was unaware R11 had left the facility and was made aware by another resident's family member. The facility was aware of R11's previous attempts and continued expression of wanting to leave but did not implement interventions to keep R11 safe. *The facility failed to put a system in place to monitor R4's safety when R4 left the building unattended. On 6/28/25 R4 came in from the outdoors with 4 blisters from sunburn on R4's forehead. R4 was found outside by staff arriving to the facility for their assigned second shift. On 7/27/25 R4 had traveled in R4's wheelchair .9 miles on the road almost making it to a highway C a well-traveled local class A highway. The facility's failure to provide adequate supervision, to thoroughly investigate R2's falls and determine a root cause and its failure to prevent R11 and R4 from eloping from the facility led to a finding of immediate jeopardy (IJ) that began on 4/9/25. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed of the immediate jeopardy on 9/16/25 at 3:31 p.m. The immediate jeopardy was removed on 10/7/25 when the facility implemented and IJ removal plan. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) based on the following examples of additional noncompliance not at the level of immediate jeopardy: *On 5/25/25 R3 had an unwitnessed fall from R3's bed. The facility did not thoroughly investigate R3's fall and did not determine a root cause to help prevent further falls. On 8/18/25 R3 had an unwitnessed fall and was discovered on the floor next to R3's bed. R3 was transferred to the emergency room and on 8/19/25 R3 underwent surgery for a closed right hip fracture. The facility did not conduct a thorough investigation of R3's fall on 8/18/25. *R8 rolled out of bed on 2/28/25 and 4/11/25 both related to trying to reposition in bed as documented. The intervention to have a body pillow in place was to be implemented after the 2/28/25 incident. There is no documentation this was implemented. R8 rolled out of bed on 4/11/25 and the fall checklist documents that R8 has expressed a refusal of the body pillow. The facility did not implement an alternative intervention after refusing the body pillow in relation to the 2/28/25 incident resulting in R8 rolling out of bed again on 4/11/25. *R10 fell on 1/17/25 on the way to the bathroom. No intervention was put into place. R10 fell on 1/28/25 trying to get into wheelchair. No root/cause analysis as to why R10 was trying to get into the wheelchair. R10 fell on 2/16/25 attempting to get to the bathroom again. No interventions was put into place. On 8/10/25, R10 fell out of the recliner. There is no root/cause analysis and no intervention was put into place. Findings include: The facility's policy, titled “Member Falls” and last revised January 2025 under Policy documents: All members shall have a care plan addressing their fall risk and predisposing factors… Interventions implemented to prevent falls shall be individualized for the member and relevant to the root cause of a recent fall. Interventions that are generalized and are not relevant to the reason the member fell are not appropriate…. Under Procedure for Fall Care and Follow Up documents ….5. The Registered Nurse (RN) initiates fall documentation in the electronic record through risk management. 5.1 If the member has multiple falls, each fall is a new entry. A repeat unwitnessed fall or fall with head injury, restarts the neurological assessment schedule. 6. Additional information related to the member's fall is required to be documented as an incident assessment note in the member's chart. 7. The RN attempts to determine root cause of fall through member and staff interview, all known information is documented in the electronic record. 7.1 Review the members care plan, Kardex, and orders to determine if the plan was provided as written and if total plan of care addresses the root cause. 8. Implement a relevant intervention to prevent recurrence, considering the root cause of the incident…. 1.) R2 is [AGE] years old with diagnoses which includes Alzheimer's Disease (progressive brain disorder that causes gradual cognitive decline), dementia, anxiety disorder (group of mental health conditions characterized by excessive & persistent worry, fear, and nervousness that can interfere with daily life) depressive disorders, delusional disorders (a belief or altered reality that is persistently held despite evidence or agreement to the contrary), hypertension (high blood pressure), and diabetes mellitus (high blood sugar). R2 has had 15 falls since 1/9/25. R2's at risk for falls care plan initiated 4/14/25 & revised 9/10/25 documents the current following interventions: *High Risk: I am at an increased risk for falls based on my screening evaluation; this means that I have several predisposing factors which increase my risk for falls. Remind me to be safe and to call for assistance. Initiated 2/15/23. *Be Aware: I take medications that may cause e to have low blood pressures, remind me to change positions slowly. Initiated 2/15/23. *Arrange my environment to minimize my risk for falls; ensure my space is free of clutter and my furniture is securely against the walls. Initiated 2/15/23. *Orient me to the facility and my surroundings often as I can become confused, and this increases my risk for falls. Initiated 2/15/23. *Make sure I have everything I need and the call light close by. Initiated 2/16/23. *Member not to open brake away doors to assist with helping members to the unit. Initiated 11/5/24. *Keep door open when in room. Initiated 4/4/25. *Provide additional assistance with cares. Initiated 4/6/25. *Staff to assist member with AM cares. Initiated 4/16/25 & revised 6/25/25. *Utilizing a body pillow while member is in bed for safety and fall prevention. Initiated 4/20/25 and revised 5/5/25. *Utilize scoop mattress. Initiated 4/29/25 & revised 5/2/25. *Monitor and redirect member when in peers' personal space. Make sure non-slip material is placed in w/c or recliner before I sit down to prevent me from sliding. Initiated 4/29/25 & revised 6/25/25. *Encourage member to stay in common area. Include member in activities taking place on unit. Initiated & revised 5/8/25. *When member appears agitated or restless, toilet member. Initiated 5/9/25. * NOC (night) get up prior to leaving shift & bring to day room for supervision. Initiated 5/10/25 & revised 8/12/25. *Body pillow in place while member is in bed. Initiated 5/19/25 & revised 5/20/25. *PT (physical therapy) Eval (evaluation) and treat. Follow up with Ortho 6 weeks. Initiated 6/15/25 & revised 7/28/25. *Staff to monitor and supervise member when she is awake and sitting reclined in the recliner in dayroom. Initiated 5/26/25 & revised 6/25/25. *Member has individualized wheelchair set up by therapy. Chair to be in slight reclined position when not eating meals. Upright for meals. Initiated 6/25/25. *Member to have shoes on properly, heels to be in shoes correctly, not waking on back of shoes Initiated & revised on 6/25/25. *Motion sensor in room on at all times. Initiated & revised 6/25/25. *Leave sensor alarm on at all times. Initiated 6/25/25. *Member to wear shoes or grippy socks when standing up or transferring with staff. Initiated & revised 6/25/25. *Member to wear gripper socks while in bed every shift. Initiated 6/25/25. *Member to wear hip protectors during day on in AM with cares upon rising and off at HS (hour sleep) for prevention, size medium. Initiated 6/25/25. *To make sure member has items within reach when sitting in dining room table to avoid injury. Initiated 7/8/25. *Another motion sensor in members room near the door in front of bathroom entrance. Her current motion sensor is positioned above her bed and does not activate until there is motion just past the foot board of her bed, need detection for door and bathroom entrance. Initiated 7/21/25 and revised 9/10/25. *Maintenance to install another motion sensor in members room near door in front of bathroom entrance. Initiated 7/21/25. *Second motion sensor placed in room to cover bathroom entrance. Sensor to be on at all times and verified every shift for functionality. Initiated & revised 7/23/25. *Tels in for anti-roll backs for W/C. Initiated 7/28/25. *Member is not to be left alone when in the restroom. Initiated 8/12/25. *Member wants blinds to be closed when she goes to bed for sleeping. Initiated 8/19/25. The following are fall Interventions initiated and resolved/cancelled: *PT/OT (physical therapy/occupational therapy) eval and treat. Initiated 2/15/23 and revised & cancelled 4/11/25. *NP (Nurse Practitioner) ordered CBC (complete blood count), BMP (basic metabolic panel), UA (urinalysis). Initiated 12/4/23 and revised & cancelled 8/23/24. *Member to be 15-minute checks. If member sustains fall while on 15 min checks member will become 1:1. Initiated 4/9/25 & revised and cancelled 4/13/25. *Encourage me to take rest periods often as I may tire when I am ambulating with staff. Initiated 4/14/25 and revised & cancelled 6/25/25. *Member on 15 min (minute) check staff monitoring for safety due to high fall risk. Initiated & resolved on 4/16/25. *Motion sensor placed in member's room to alert staff when Member is attempting to transfer, toilet or ambulate independently. Initiated 4/16/25 & resolved on 6/25/25. *Member on 1:1 for safety and fall prevention. Initiated 4/17/25 & resolved 4/28/25. *Member to have untucked body pillow on the outer edge of the bed for protection against falls. Initiated 4/16/25 & revised and resolved 5/5/25. *Toileting program; at risking around mealtimes, and before bed. Staff to assist Member to toilet before 5AM if awake. Initiated 4/28/25 & resolved 6/25/25. *Member is 1:1. Initiated 4/29/25 & resolved 5/9/25. *Place Dycem in my w/c or recliner to prevent me from sliding out of chair. Initiated 4/29/25 and revised & cancelled 6/25/25. *Member to wear hip protector for safety. Initiated 4/30/25 & resolved 6/17/25. *Order pommel cushion for wheelchair to allow proper alignment for member when sitting in wheelchair. Initiated 5/2/25 and revised & cancelled 6/25/25 *Ordering small W/C (wheelchair) for Member. Initiated & resolved on 5/21/25. *Member is on 15 minute checks on night shit for fall prevention. Initiated 5/21/25 and revised & resolved 6/13/25. *Walking: 2ww (wheeled walker), gait belt, 2nd person to follow with wheelchair, ambulate 100-300 ft (feet) to and from meals and as needed when member has extra energy to prevent falls Initiated 5/25/25 & revised and cancelled 7/28/25. *When member is awake sitting in the recliner, don't put recliner in the reclined position. Initiated 5/25/25 and revised & cancelled 6/25/25. *Fall Prevention: 30-minute checks. Initiated 6/13/25 & revised and resolved 8/21/25. *Encourage member to wear gripper socks while in bed every shift. Initiated 6/18/25 and revised & resolved on 6/25/25. *Staff to make sure that member has gripper socks on at bedtime. Initiated 6/25/25 and revised & cancelled 6/25/25. *The resident requires limited assist of two staff members and gait belt for transfers. Initiated 6/25/25 & resolved 7/28/25. *Tels request for maintenance to install another motion sensor in members room near the door in front of bathroom entrance. Initiated 7/19/25 & revised and resolved 7/23/25. *Pt (patient) will receive frequent cues/reminders to ask for help if needing assistance. Initiated 7/25/25 and revised & cancelled 7/28/25. *Pt will receive frequent cues/reminders to ask staff for assistance before trying to self-ambulate. Initiated 7/25/25 and revised & cancelled 7/28/25. R2's fall CAA (care area assessment) dated 12/30/24 under analysis of findings for nature of problem/condition documents Member has a dx (diagnosis) of Alzheimer's Disease, dementia, anxiety, wandering, cognition is severely impaired. Receives scheduled antidepressant medication. Has had 5 falls in last year. Hx (history of) falls d/t (due to) UTI (urinary tract infection) is up ad lip/ambulatory. Should have proper footwear on, currently being treated by psych due to behaviors/increase in packing while looking for labor and delivery. R2's fall risk assessment dated [DATE] has a score of 8 which indicates low risk for falls. FALL R2's nurses note dated 1/17/25 at 07:15 (7:15 a.m.) written by Registered Nurse (RN)Supervisor-W documents Member was found sitting with legs out on the floor. Member was towards the foot of the bed. Member was fully dressed with nothing on the feet. Lamp was on in the room. Member stated they had a fall and bumped their head. Denied any other pains. Assessed member. Minimal help back into bed after placing shoes on feet. Member states bump to back of head. Assessment no abrasion, no bump, no indication of pain when touching, denied PRN (as need) pain relief medication. Neuro check was negative. BP (blood pressure) was elevated at 188/84. Check and hour and half later 170/82. All other vitals WNL (within normal limits). Lungs clear, BS (bowel sounds) all quads. (quadrants). Mentation at baseline. Updated supervisor and provider. Vitals BP 170/82, 1/17/25 05:17 (5:17 a.m.), Position: sitting l (left) arm, P (pulse) 68 – 1/17/25 0325 (3:25 a.m.), pulse type regular. T (temperature) 97.7 1/17/25 0325 Route: forehead (non-contact), R (respirations), O2 (oxygen) 95% -1/17/25 0325 Method: room air. Pnl (pain level) 1- 1/17/25 0235. Pain scale Pain ad. Follow up new intervention implemented and added to TPOC (temporary plan of care) wear shoes or gripper socks while ambulating/walking. Surveyor reviewed R2's fall investigation which includes an incident audit report for date of incident 1/17/25 03:10 (3:10 a.m.) and two fall/incident witness statements. Surveyor noted the facility's fall investigation was not thoroughly investigated as the investigation does not include when R2 was last toileted, how was R2 positioned in bed etc, if previous interventions were in place at the time of the fall and does not include a root cause. R2 ‘s care plan was not revised with the new intervention to wear shoes or gripper socks while ambulating. R2's fall risk assessment dated [DATE] has a score of 18 which indicates high risk for falls. R2's quarterly MDS (minimum data set) with an assessment reference date of 3/11/25 has a BIMS (brief interview mental status) score of 4 which indicates severe cognitive impairment. R2 is assessed as requiring set up or clean up assistance for eating, toileting hygiene, rolling left & right, and chair/bed to chair transfer. R2 is assessed as being independent for toilet transfer. R2 is occasionally incontinent of urine and frequently incontinent of bowel. R2 has fallen since prior assessment, one fall with no injury. FALL R2's nurses note dated 4/1/25 at 10:15 a.m. and written by Licensed Practical Nurse (LPN)-N documents CNA was giving member a shower. Member was standing in the shower, went to step out of the shower on a towel on the floor, fell and struck her head. CNA assisted member onto the shower chair and placed the call light on. See progress note for entire fall assessment. R2's nurses note dated 4/1/25 at 10:49 a.m. and written by LPN-N documents Certified Nursing Assistant (CNA) placed call light to shower room on to report that member fell on the floor. Writer entered tub room at 1015 member was sitting on the shower chair. CNA states member was stepping out on the shower, a towel was on the floor for member to step onto. Member fell and struck the back of her head on the shower wall. CNA informed writer that CNA assisted member back onto the shower chair. No redness or bruising noted to buttock or back. Writer did assess members head, no redness or injury at this time. Member unable to state what happened, was asking for under ware (sic)/clothing. Writer sent e mail to Assistant Director of Nursing (ADON) and charge nurses per fall check off sheet. ADON not in office. Writer obtained V.S. (vital signs) and did neuro check. Neuro check is negative bilateral pupils are large, round and reactive to light. Hand grasps are strong and equal. Call placed to [Name of medical group]. Writer spoke to [Name] NP and informed of fall wand that member struck her head, no visible injury. Informed that member has an order for prn (as needed) Voltaren gel no other blood thinners. New order received to send member to ER (emergency room) for eval due to her age. Call placed to members son [Name] and let a voice message requesting a return call. R2's nurses late entry nurses note dated 4/1/25 at 1700 (5:00 p.m.) documents Member returned from ER. ER called to get [Name] Pharmacy information to send antibiotic prescription for Member. Information was given to [Name] ER and prescription was sent to [Name] Pharmacy from [Name] ER. R2's fall risk assessment dated [DATE] has a score of 8 which indicates low risk for falls. R2's IDT (interdisciplinary team) note dated 4/2/25 at 9:53 a.m. & created on 4/3/25 at 17:56 (5:56 p.m.) written by ADON-S documents Met to discuss fall in shower. Intervention to provide shower stool/chair of appropriate size for member. Surveyor reviewed the facility's fall investigation for R2's fall on 4/1/25 which included an incident report, neuro assessments on 4/1/25 at 10:15 a.m. & 17:15 (5:15 p.m.) and 4/2/25 at 9:43 a.m., an incident audit report for incident date 4/1/25 10:15 a.m. and CNA-VV's fall/incident witness statement. Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate why CNA-VV placed a bath blanket on the floor, why did CNA-VV get R2 off the floor without being assessed by a Registered Nurse (RN) and did not determine the root cause. R2's care plan was not revised with an appropriate size shower stool/chair. FALL R2's nurses note dated 4/3/25 at 10:30 a.m. and written by LPN-N documents Writer was called to members room at 1030 per CNA. CNA states “Member is on the floor.” Writer went to room, member sitting a few feet away from door to her room. Member dressed with shoes on sitting on buttocks. Member noted with a large, raised bruise to the middle to her forehead. Member stated to writer “It happened so quick.” Member stated she fell in the bathroom. Member did have a BM (bowel movement) in the bathroom in her room. Writer informed ADON [initials] that member was on the floor. ADON did see member in her room. [Name] NP was on the unit NP did see member, noted bump to forehead and gave order to send to ER for an evaluation. Members ROM (range of motion) per usual. Member continuing to deny pain and discomfort. Body check was done, no other apparent injuries. Member was assisted to toilet to change clothing that was soiled. Writer placed call to members son [Name] who is members HC POA (healthcare power of attorney). Son is aware of fall, head injury and order to send to ER for an evaluation per NP who was in building and assessed member. [Name] Ambulance was called and cannot transport. [Name] Ambulance will transport member to [Hospital Name] for an evaluation due to head injury. R2's nurses note dated 4/3/25 at 18:49 (6:49 p.m.) written by RN Supervisor-W documents Member returned from [Name] ED (emergency department) at 1700 (5:00 p.m.). Member was diagnosed with acute cystitis without hematuria, traumatic hematoma of forehead, and fall. Member was started on ciprofloxacin 500mg (milligrams) tab (tablet) for acute cystitis. Member baseline mentation. R2's fall risk assessment dated [DATE] has a score of 12 which indicates high risk. R2's IDT note dated 4/4/25 at 10:41 a.m., created on 4/6/25 at 1447 (2:47 p.m.) and written by ADON-S, documents: Met to discuss fall. Intervention: Encourage member to stay in common area. Provide additional assistance with cares. Keep door open when in room. POA and physician notified of fall. Surveyor reviewed the facility's fall investigation for R2's fall on 4/3/25 which consisted of an incident report dated 4/3/25, neuro assessments dated 4/3/25 at 9:51 a.m., 10:35 a.m., 21:44 (9:44 p.m.), 4/4/25 at 05:15 (5:15 a.m.), 17:37 (5:37 p.m.), and 4/6/25 at 04:06 (4:06 a.m.) & 17:12 (5:12 p.m.). An incident audit report dated 4/3/25 10:30 a.m. and CNA-VV's fall/incident witness statement. Surveyor noted the facility did not thoroughly investigate R2's fall as there is no evidence the facility investigated whether prior interventions were in place. The facility did not clarify CNA-VV's statement regarding the last time staff interacted with R2 which was 10:22 a.m. when walking R2 to her bed & the last time R2 was toileted is documented as 10:25. The facility did not determine a root cause to help prevent further falls. Surveyor noted R2's fall care plan was revised on 4/4/25 & 4/6/25. R2's nurses note dated 4/4/25 at 14:44 (2:44 p.m.) written by RN-O documents Bruise to forehead remains, purple/red in color. Writer noted 2 new bruises developing to members right eye moving up into eyebrow and bridge of nose. Nose bruise 1.5 x .3 and eye bruise measures 2.5 x 1 cm (centimeter). Member had fall with head injury on 4/3. Bruises purple/red in color. Member denies pain/discomfort to area. FALL R2's nurses note dated 4/7/25 at 22:35 (10:35 p.m.) written by RN-QQ documents Staff found member sitting on the floor near her bed. Member said that she hit her head. Noted a small bump and redness on the occipital area, measures 2.5 x 1.5cm. No c/o (complaint of) pain. Neuro check and ROM per baseline. VSS (vital signs stable). No loss of consciousness. R2's fall risk assessment dated [DATE] has a score of 12 which indicates high risk. R2's nurses note dated 4/8/25 at 01:40 (1:40 a.m.) written by RN-QQ documents [Name] ambulance brought the member back to floor from [Hospital Name] ER. No new orders received. R2'S IDT note dated 4/8/25 at 10:05 a.m. documents Met to discuss 4/7/25 fall. Floor was reported to be dry when the member fell despite commenting she slipped. Med review completed by pharmacy – members fall do not appear to be associated with orthostatic hypotension as BP (blood pressure) is not abnormally low upon incident. BS (blood sugar) do not appear to be low. Possible transient torsades with cipro and quetiapine but unlikely. Unsteadiness could be attributed to active UTI (urinary tract infection). Culture from hospital shows susceptible to current antibiotic. Also discussed possible Vitamin D deficient or related to GDR (gradual dose reduction). Surveyor reviewed the facility's fall investigation for R2's fall on 4/7/25 which consists of an incident report dated 4/7/25, neuro assessment dated [DATE] at 22:35 (10:35 p.m.), 4/8/25 at 11:00 a.m., & 20:28 (8:28 p.m.), an incident audit report dated 4/7/25 at 22:35 (10:35 p.m.) and five fall/incident witness statements. Surveyor noted the facility did not thoroughly investigate R2's fall as there is no evidence the facility investigated whether prior interventions were in place, how R2 was in bed prior to the fall, and did not address R2's footwear when R2 indicated the floor was slippery. The facility did not determine a root cause to help prevent further falls. R2's falls care plan was not revised until after R2 sustained another fall on 4/9/25. FALL R2's nurses note dated 4/9/25 at 07:45 (7:45 a.m.) written by RN/Education-KK documents Member had transferred herself to the bathroom to toilet. It appears she had a bowel movement and possible stood up to pull her brief and pants up and lost her balance. Neuro check seems to be baseline, and no new injuries found on body check. Member was cleaned up transferred to toilet and clean close sic (clothes) put on. No signs or expression of pain. Member to be 15 min (minute) checks per IDT team. R2's fall risk assessment dated [DATE] has a score of 15 which indicates high risk. R2's IDT note dated 4/9/25 at 09:57 (9:57 a.m.) written by ADON-S documents IDT met to discuss 4/9 fall. Interventions: 15 minute checks and motion sensor put in room. POA, DON and NP notified. Concerns about multiple falls discussed. Call placed to physician for orders included concerns of possible sepsis given multiple recent diagnosis of infection and BP reported below baseline. New orders received from NP. Results will be reviewed and member will be seen tomorrow by NP. Surveyor noted the new orders are for Stat CBC (complete blood count) and BMP (basic metabolic panel). R2's nurses note dated 4/9/25 at 16:13 (4:13 p.m.) written by RN-BBB documents Writer spoke with [Name of Medical Group] and spoke with [Name] NP about member's STAT CBC and received no new orders with instructions to continue pushing fluids. R2's nurses note dated 4/9/25 at 18:04 (6:04 p.m.) written by RN-BBB Writer spoke with on-call [Name] NP to report STAT BMP results, writer received order to send member to emergency room for treatment of acute kidney injury based on elevated BUN (blood, urea, nitrogen) (39), elevated creatinine (1.46) and reduced eGFR (estimated glomerular filtration rate) (33). R2's nurses note dated 4/9/25 at 23:30 (11:30 p.m.) written by RN-QQ documents Member is admitted to [Hospital Name] with diagnoses of Subdural Hematoma, Hematoma, Subarachnoid hemorrhage, T12 fracture and UTI. Surveyor reviewed the facility's fall investigation for R2's fall on 4/9/25 which consists of an incident report dated 4/9/25. Under other info (information) documents Member lives on memory care unit and is (sic) severe dementia. She has recently had and tx (treatment) for Pneumonia and now UTI. Due to her age and deconditioning, confusion and lack of safety awareness she is high risk for falls. Neuro assessments dated 4/9/25 at, 05:45 (5:45 a.m.), 08:13 (8:13 a.m.) and 17:37 (5:37 p.m.), an incident audit report dated 4/9/25 at 07:45 (7:45 a.m.) and one staff statement by CNA-VV which documents As I went to do morning cares on [R2's initials] I walked in to her sitting on her bathroom floor with her brief and pants down to her knees. She had toilet paper in her hand and turned to her left side almost in a seated fetal position trying to wipe her bottom. Surveyor noted the facility did not conduct a thorough investigation as there is no evidence as to who last saw R2, when was she toileted, were prior interventions in place and did not determine a root cause to help prevent further falls. Surveyor noted the facility did not conduct a thorough investigation and did not determine the root cause of R2's four falls prior to R2's fall on 4/9/25. R2 transfer to the hospital and R2 was diagnosed with a Subdural Hematoma, Hematoma, Subarachnoid hemorrhage, & T12 fracture. R2's hospital Discharge summary dated [DATE] under diagnosis documents Traumatic subdural with intracranial bleed. Dementia with behavioral disturbance with some delirium. Essential hypertension. Urinary tract infection present on admission. Frequent falls. Under Hospital Course documents Patient is a [AGE] year-old female with dementia with power of attorney activation with frequent falls who comes in with a fall consequence of subdural hematoma and intracranial bleed. patient was monitored CT did not show worsening bleeding.

Based on interview and record review, the facility did not ensure residents were free from abuse affecting 2 of 11 residents (R7 and R5) reviewed for abuse concerns.On 7/17/25, R6 punched R7 in the head and mouth, resulting in R7 having a bloody lip. R6 was placed on 1 on 1 supervision for a short period of time. The facility indicated they did not have the staffing to keep a person on 1 on 1 supervision long term. R6 was then put on 15-minute checks. R6 continued to demonstrate aggressive behaviors where staff needed to intervene before the behaviors escalated. On 8/27/25, R6 hit R5 multiple times over the head with a cane. R5 was sent to the hospital where R5 was diagnosed with a Traumatic Brain Injury (TBI) - subdural hematoma (a collection of blood between the brain's outer covering and the surface of the brain,) small traumatic subarachnoid hemorrhage (a bleeding that occurs in the space between the brain and the arachnoid mater, one of the membranes covering of the brain,) and acute (sudden onset of symptoms and injury) left frontal ischemia (Occurs when blood flow to brain tissue is blocked or reduced. This deprives the cells of oxygen and nutrients, causing them to begin dying within minutes,) likely traumatic (Points to a head injury as the probable cause, rather than a typical stroke from a pre-existing condition like a blood clot from atherosclerosis), per hospital documentation. R5 was returned to the facility on 8/28/25 and required follow up with neurosurgery.The facility's failure to keep R7 and R5 free from abuse created a finding of immediate jeopardy that began on 7/17/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m. The immediate jeopardy was removed on 9/18/25 when the facility completed an IJ removal plan.Findings include:The facility's policy titled Prohibition and Prevention of member Abuse, Neglect, and Exploitation with a last revision date of 07/2024, documents in part, .Facility shall attempt to identify members exhibiting abusive behavior toward staff and/or other members and shall make referrals to appropriate agencies as needed.R6's most recent MDS, dated [DATE], documents R6 has a BIMS score of 4 indicating severe cognitive impairment, had wandering behaviors 1 to 3 days, no impairment in upper or lower extremities, uses a cane for mobility, and receives antipsychotic medications.R6 was admitted to the facility on [DATE] with diagnoses including Dementia with mood disturbances and psychotic disturbances. R6 is on the memory care unit following an altercation with another resident and has been receiving Behavior Psychiatric services since 09/03/2024. Surveyor noted R6 has 8 documented incidents of aggressive behaviors since receiving Behavior Psychiatric Services. On 9/15/2025, 10:33 AM, Surveyor interviewed RN-BB (Registered Nurse). RN-BB explained to Surveyor, RN-BB has worked at the facility since 2017 and worked with R6 since admission. RN-BB indicated R6 has had numerous resident to resident altercations. When R6 is on a 1:1 supervision, R6 does great but a couple days will go by after R6 comes of the 1:1 and R6 will be back in other resident rooms. RN-BB believes R6 has exhibited this repeated pattern of behavior.1. Surveyor reviewed the Facility Reported Incident involving a resident-to-resident altercation that occurred on 7/17/2025 with R7. R7 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).R7's most recent MDS, dated [DATE], documents R7 has a BIMS score of 14 indicating R7 is cognitively intact, has no behaviors, has no impairment in upper or lower extremities, and uses a walker as a mobility device.The facility's incident report documents R6 walked into R7's room and hit R7 in the mouth and head. Certified Nursing Assistant (CNA)-II was checking on residents in the dining room and noticed R6 was not in the recliner where R6 had previously been sitting. CNA-II walked toward R6's room to locate R6 and heard R7 yelling out for help. CNA-II observed R6 standing over R7. R7 was sitting in R7's recliner while R6 had ahold of R7's wrists. R7 was attempting to get R6 away from R7, using R7's legs. CNA-II was able to separate R6 and R7. CNA-II then walked R6 down the hall and informed the Nurse immediately, who then went and assessed R7. R6 was immediately placed on a 1:1 supervision. On 7/18/25, the Intradisciplinary Team (IDT) met to discuss R6 and R7's altercation and documented a stop sign will be placed across R7's door, R6 and R7 will not sit together during activities or during meals and will be kept separated in the hallways and elevators and R6 will remain on 1:1 supervision.Surveyor noted R6's Care Plan documents the follow for interventions following the 7/17/25 altercation: -A stop sign banner will be placed across the other Member's doorway.-Members will not sit together during activities, during mealtime and will be kept separated in hallways and/or elevators. All parties aware of interventions and in agreement with treatment plan. -Members will not sit together during activities, during mealtime and will be kept separated in hallways and/or elevators. Date Initiated: 07/17/2025 Revision on: 07/23/2025On 9/15/25, at 1:06 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated that after R6 punched R7 in the mouth, family members and other residents expressed being fearful of R6 and uneasy around R6. At that point, the facility began to realize R6 required more services than the facility could provide to keep other residents safe. DON-B explained the facility cannot provide staffing for residents to be 1:1 supervision indefinitely and believed R6 required that level of supervision. DON-B informed Surveyor that the facility has sent R6 to the hospital for evaluations in the past, but nothing comes from it. DON-B indicates the facility has been attempting to find alternative placement for R6 but would need to clarify with Director of Social Services-D. DON-B indicated the facility kept other residents safe by initiating temporary 1:1 supervision for R6 and monitoring R6's behaviors.On 7/22/25, Director of Social Services-D created a progress note and documented the following: Director of Social Services-D met with R6 to talk about a recent incident where R6 hit R7 in the face multiple times after entering R7's room. R6 did not recall the situation, does not recall hitting anyone or entering anyone else's room. Director of Social Services-D asked what makes R6 upset, R6 stated kids. R6 talked about kids making R6 upset. R6 went on to indicate that R6 does not like being instigated or being told what to do. R6 shared R6 becomes agitated by this. R6 then started to discuss with Director of Social Services-D about a doll indicating, she is not real. R6 mentioned that She can't understand what we are talking about because she is just a doll.Survey noted R6 was taken off 1:1 supervision on 7/23/25 and was placed on 15-minute checks for R6's whereabouts, per the IDT progress note dated 7/23/25.A progress note dated 7/24/25 documents R6 glared at residents, causing a staff member to be concerned enough to stop what the staff member was doing and to briskly walk toward R6 and intervene.A progress note dated 8/1/25 documents R6 had multiple attempts to wander down the hall with R7. R6 became visibly irritated/agitated and began pushing staff when redirection was attempted. The progress note documents staff were making great attempts to keep other residents safe by keeping R6 from going into other resident rooms.On 8/4/25, R6 was evaluated by Psych Nurse Practitioner (NP)-JJ, who documented R6 has a significant history of physical and verbal aggression, sexual inappropriateness, generalized anxiety disorder, dementia with anxiety, mood disorder, and insomnia. Plan: continue vpa (valproic acid/Depakote) risperidone, Duloxetine, emotional support no change, recent increase in vpa, taper to DC (discontinue) namenda, continue emotional support and behavior interventions; follow up 1 month, sooner prn.A progress note dated 8/8/25, documented R6 entered another resident's room and was escorted out.A progress note dated 8/14/25 documented R6 wandered into another resident's room and the other resident expressed frustration with R6 going into resident's room.On 8/21/25, at 3:51 PM, Director of Social Services-D met with R6 to conduct an annual MDS assessment, which documents in part: R6 has a BIMS score of 5, which was previously a 4, remained on 15-minute checks for safety, continues to wander the unit, usually successful staff redirection and documents R6 continues to be satisfied with their living arrangements.On 8/25/2025, Director of Social Services-D completed an assessment/screen for post traumatic events and a trauma informed care plan for R6 was initiated. The Interventions are as follows: Assess/screen for post traumatic events and history of trauma, using nursing home appropriate screening tools, such as the LEC-5 (The Life Events Checklist for DSM-5 (LEC-5) is a self-report measure designed to screen for potentially traumatic events in a respondent's lifetime). Display warmth when answering questions, offer unconditional acceptance, being available and respecting the member's use of personal space. Maintain a calm, non-threatening manner, while working with the member. Member enjoys [NAME] wow or tribal-type music. This came [sic] help member feel grounded and calm, while connecting with their cultural background. Member used to enjoy hunting, fishing, being outside in nature, making things/fixing things with their hands. Per member's guardian, this was member's stress relief and a way to feel calm. Member should be offered a supervised walk inside or outside or something to do with their hands if s/s (signs/symptoms) of anxiety start to arise. Move the member to a quiet area with minimal stimuli and to maintain calmness in one's approach to the member. Provide reassurance and comfort if applicable. Provide activities and invite the member to participate. Praise member for their engagement and participation in social interactions. Visit the member to provide activity schedule and to encourage social interactions.On 8/25/25, at 6:46 PM, a progress note by RN-BB documented R6 exhibiting severe anxiety/restlessness, ignoring redirection, staff shut all doors on unit, R6 would just open the doors to enter resident rooms, another resident in the hallway due to not wanting to be alone in the room with R6. R6 requiring 1:1 interaction with staff but management continues to deem R6 only needing 15-minute checks. Staff finding it difficult to tend to other residents and prevent resident to resident altercations.On 8/25/25, at 8:07 PM, a progress note by RN-BB documented R6 continuing to open other resident's doors. Two other residents complained that R6 was either standing over them while they were in bed or opened their door. Residents expressing feeling unsafe.On 9/15/2025, 10:33 AM, Surveyor interviewed RN-BB. RN-BB explained to Surveyor, RN-BB has worked at the facility since 2017 and worked with R6 since admission Surveyor asked RN-BB about RN-BB's progress note on 8/25/25. RN-BB indicated R6 was exhibiting wandering behaviors that were disruptive to other residents and informed the charge nurse RN-EE. RN-BB explained that any charge nurse can initiate 1:1 supervision for a resident but usually only implement 1:1 supervision if an actual altercation occurs.2. R5 was admitted to the facility on [DATE] with diagnoses to include Post Traumatic Stress Disorder (PTSD) (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as a natural disaster, war, physical or sexual assault, or a serious accident), Dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life,) and need for assistance with personal care.R5's Annual Minimum Data Set (MDS), dated [DATE], documents R5 has a Brief Interview for Mental Status (BIMS) score of 09 indicating R5 has moderate cognitive impairment and R5 has no limitations in upper or lower extremities.Surveyor reviewed the facility provided investigation regarding the altercation between R6 and R5 on 8/27/25. Surveyor noted the description of event documents the following: R6 entered R5's room. R5 was sitting in R5's room when R6 approached R5, R5 was startled and asked R6 what R6 wanted. R6 then began hitting R5 in the head and left eye with R6's cane. Staff witnessed R5 on R5's knees attempting to defend R5's self from R6. R5 and R6 were pulled apart and situation was diffused. R5 was cleaned up and assessed to have injuries to R5's head and left eye. R5 was sent to the hospital for further evaluation.Surveyor reviewed the facility provided document titled After Visit Summary for R5, dated 8/28/25. Surveyor noted R5 was discharged from the hospital with diagnoses that include Traumatic Brain Injury (TBI)-subdural hematoma measuring 5mm, Small Traumatic Subarachnoid hemorrhage, and Acute left frontal ischemia, likely traumatic.On 9/10/25, at 10:14 AM, Surveyor interviewed R5. Surveyor observed R5 to have a healing bruise under R5's left eye. R5 explained to Surveyor that R5 was working on bird houses in R5's room. R6 came into R5's room, catching R5 off guard and began hitting R5 over the head with R6's cane. R5 indicated that R5 has never experienced issues with R6 in the past, but explained other people have. During our discussion, R5 received a call for follow up regarding R5's injuries sustained during the assault. R5 indicated being ok with Surveyor listening to R5's phone call with Neurosurgery. Surveyor noted the Neurosurgery Nurse Practitioner explained to R5 the results of R5's most recent diagnostic imaging, indicating R5's brain bleed was getting smaller and no further follow up with neurosurgery was needed. R5 denied any pain or side effects of his injuries. R5 expressed feeling grateful and safe knowing R6 would not be returning to the facility. Surveyor noted that R6 remained at the hospital as of the time of the survey.On 9/15/25, at 1:06 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated DON-B expects staff on evenings and nights to call the on-call nurse, who will then call DON-B, regarding any new/worsening behaviors or in the event of a member-to-member altercation. During daytime hours, the Intradisciplinary team (IDT) will meet to discuss resident triggers, behaviors and incident. DON-B indicated DON-B or NHA-A can initiate 1:1 supervision for residents. DON-B indicated DON-B should have been made aware of R6's escalating behaviors and found interventions to keep other residents safe. The facility's failure to keep R7 and R5 free from abuse created a finding of immediate jeopardy that began on 7/17/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m. The immediate jeopardy was removed on 9/18/25 when the facility completed the following: - Staff development / Designee will educate licensed nurses and direct care staff on: Member to member altercation, abuse education, and educating on managing behaviors.- The social worker will review members for appropriate placement. All staff was educated member to member altercation policy, member behavior policy, care planning policy, mood assessment, and root cause analysis.- Social worker and clinical staff will review progress notes for resident's exhibiting aggressive behaviors or patterns of escalating behaviors and update care plans accordingly. IDT (interdisciplinary team) will review policy for member behaviors. Staff to review care plan for member's exhibiting behaviors for appropriate interventions. - SDC/Designee provided education to all staff regarding elopement on their very first shift in their work unit.- SDC/Designee provided education on managing aggressive behaviors and providing intervention before there is member to member contact. (early detection of escalating behavior) on their first shift in their work unit.- Administrator/Designee will provide education to social services on responding to resident's psychosocial needs, behaviors and wishes to be discharged , developing a plan and updating the care plans.- Administrator/Designee will provide education to mangers on completing a RCA (root cause analysis) for falls, elopements, and escalated behaviors. - SW (social worker) to audit 5 x per week x 6 weeks progress notes for any residents increase behaviors. Care plan & interventions to be updated based on Audit findings. Findings to be presented to QAPI (quality assurance and performance improvement) committee for review and suggestions. Findings discussed at IDT clinical daily stand-up meeting.No additional information was provided.

Based on interview and record review, the facility did not ensure that 5 of 15 residents reviewed (R6, R14, R15, R12 and R11) received medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. * R6 has had 13 episodes of aggressive behaviors toward staff and other residents since 7/26/24, On 7/17/25, R6 punched another resident in the mouth. On 8/25/25, R6 hit R5 on the head with R6's cane, resulting in a traumatic brain injury for R5. The facility did not identify and seek ways to support R6's psychosocial and behavioral needs by reevaluating and assessing R6's behaviors. The facility did not identify and promote non-pharmacological approaches to care that met the mental and psychosocial needs of R6 and did not assess and identify possible transition of care services for R6 The facility's failure to provide R6 with necessary medically related social services, created a finding of immediate jeopardy that began on 7/17/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m. The immediate jeopardy was removed on 10/7/25 when the facility implemented an immediate jeopardy removal plan. The deficient practice continues at a scope and severity of a E (pattern/potential for harm) for the following examples: *The facility did not reevaluate R14's behaviors in order to implement proper, person-centered interventions related to R14's psychosocial and behavioral needs. *The facility did not ensure R15's stop sign banner was in place to keep R14 from entering the room while R15 is in R15's room and did not follow up with R15's psychosocial needs following incident on 9/23/25. *Facility Social Worker did not follow up with R12 following R12's statement on 8/27/25 of feeling unsafe at the facility while R6 was at the facility. * Facility staff did not keep R11 from eloping from the facility. Facility staff did not update psychotherapy with R11's increased frustration or verbalizations of wanting to leave and feeling like a prisoner and did not address alternative placement or a less restrictive environment with R11 based on R11's continued verbalizations of wanting to leave the facility. Findings include: The facility's document titled “WISCONSIN VETERANS HOME Union Grove- Facility Assessment,” with a certification expiration date of November 25, 2025, documents in part, based on the resident assessment, the Facility accepts and provides for residents with Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder and behavior that need interventions. The decision to admit a resident is based on the following: does the Facility have sufficient staff to provide care for the resident, staff with the skill set to provide quality care, equipment and supplies need, additional staff training required and number of bed available. “Services and Care We Offer Based on our Resident's Needs.Mental Health and Behavior Manage the medical conditions and medication- related issues causing psychiatric symptoms and behavior identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities”. Under “Provide person-centered/directed care: Psycho/social/spiritual support ,“ the facility documents “Find out what resident's preferences are and routines are. what upsets him/her and incorporate this information into the care planning process. Record and discuss treatment and care preferences.” The facility documents “Caring for residents with mental and psychosocial disorders, and implementing nonpharmacological interventions is part of the Facility's competencies. 1.) R6 was admitted to the facility on [DATE] with diagnoses including Dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life) with mood disturbances and psychotic disturbances, Anxiety, Delirium, and Major Depressive Disorder Adjustment Disorder. R6's most recent MDS, dated [DATE], documents R6 has a BIMS score of 4 indicating severe cognitive impairment, had wandering behaviors 1 to 3 days, no impairment in upper or lower extremities, uses a cane for mobility and receives antipsychotic medications. Surveyor noted R6 has had 13 incidents of escalating aggressive behaviors since 7/26/24. a. On 6/9/25, R6 had a resident-to-resident altercation where R6 was the aggressor. No root cause analysis was completed. Surveyor noted a progress note dated 6/10/25, by Director of Social Services-D, which documents Director of Social Services-D met with R6 to discuss the incident, indicated R6 did not recall the incident, is in a good mood, does not have any concerns and remains on 1:1 supervision at that time. Surveyor noted Director of Social Services-D did not assess if current behavior interventions are effective for R6 or if any new interventions needed to be implemented. On 09/16/2025, at 12:24 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated that upon DON-B's arrival to the facility, DON-B noted root cause analyses were not being done and DON-B began implementing them. DON-B indicated R6 was put on temporary 1:1 supervision as an immediate intervention and expects Director of Social Services-D to be completing the root cause analysis and following up, as well as the intradisciplinary team (IDT). b. A progress note, dated 6/14/25, documents R6 started swinging R6's cane at staff. A progress note, dated 6/16/25, documents, R6 was seen by Psych Nurse Practitioner-JJ who documents “patient has a history of physical altercations and is involved in numerous aggressive acts, indicating a high potential for aggressive behavior. Inappropriate behavior toward staff suggests poor impulse control and potential risk. The patient's difficulty with redirection further increases the risk of problematic behaviors. Close monitoring and intervention strategies are necessary to manage these risks.” Surveyor noted no documentation indicating clarification on what Psych Nurse Practitioner-JJ meant by “Close monitoring and intervention strategies are necessary to manage these risks” or what the facility is doing to manage R6's risks or mention of R6 swinging cane at staff on 6/14/25. A progress note, dated 6/17/25, documents the IDT met on 6/16/25 for “Mind over meds behavior management meeting” and discussed R6's medications and behaviors. c. Surveyor reviewed R6's progress notes from the facility's Electronic Health Record, and noted on 7/1/25, R6 used R6's cane to hit a staff member in the stomach when redirection of wandering was attempted. The facility's document titled “Care Plan Report” for R6 documents R6 has a potential for behaviors with an initiation date of 7/1/25 and documents the following interventions: - A stop sign banner will be placed across the other Member's doorway. Members will not sit together during activities, during mealtime and will be kept separated in hallways and/or elevators. All parties aware of interventions and in agreement with treatment plan. Surveyor noted that the above intervention was related to member-to-member interactions despite the 7/1/25 incident involved R6 striking a staff member with his cane and not a member. - PT to evaluate if Member is safe ambulating without cane - Members will not sit together during activities, during mealtime and will be kept separated in hallways and/or elevators. - Administer medications as ordered. Monitor/document for side effects and effectiveness. - Anticipate and meet the resident's needs. - Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. - Close supervision for increased behavior and safety - Explain all procedures to the resident before starting and allow the resident time to adjust to changes. - If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. - Member to be toileted Q2 hours - Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. - Pharmacy medication review - Provide a program of activities that is of interest and accommodates residents status. - Safety: 15-minute checks for Member whereabouts on unit. Surveyor noted no documented root cause analysis was completed. A progress note, dated 7/2/25, documents, Director of Social Services-D met with R6 for follow up regarding incident with staff member. Director of Social Services-D documented R6 did not recall the incident and expressed R6 does not feel R6 used R6's cane inappropriately. Director of Social Services-D documented R6 stated feeling calm and neutral in R6's mood and denied concerns. A progress note, dated 7/2/25, documents, the IDT met to discuss the incident, R6 on 30-minute safety checks, and implemented a new intervention of Physical Therapy assessing R6 for the need of a cane as a mobility device. On 9/11/25, at 9:13 AM, Surveyor interviewed Physical Therapy (PT) Director-J who indicated R6 was evaluated on 7/3/25 for the need of R6's cane. PT Director-J indicated it was determined R6 required R6's cane for mobility but was given a smaller, lighter cane on 8/27/25. On 7/7/25, R6 was evaluated by Psych Nurse Practitioner-JJ who documents “Risk Assessment Patient has a history of physical altercations and is involved in numerous aggressive acts, indicating a high potential for aggressive behavior. Inappropriate behavior towards staff suggests poor impulse control and potential risk. The patient's difficulty with redirection further increases the risk of problematic behaviors. Close monitoring and intervention strategies are necessary to manage these risks.” Surveyor noted no behavior interventions implemented or evaluated for effectiveness. d. A progress note, dated 7/13/25, documents, R6 attempted to take a box of tissues from a table where other residents were sitting. The residents became upset, telling R6 not to take their tissues. R6 became agitated and appeared to want to strike peers. Staff intervened and gave R6 a box of tissues. On 7/15/25, PhD (Doctor of Psychology)-DD documented “Staff reports that there have been no aggressive behaviors noted for the past few weeks.” R6 continues to minimize aggressive behaviors and is not able to identify triggers for actions. Positive reinforcement should be given for appropriate behaviors. Identifying triggers has been difficult at this time; however, attempts should be made to identify aggressive moods, comments, or physical changes that might signify potential acting out behaviors. Surveyor noted at least 2 incidents of aggressive behaviors documented for R6 from 7/1/25 to 7/15/25 which PhD-DD seems unaware of. e. A progress note, dated 7/17/25, documents R6 punched another resident in the head and mouth. A root cause analysis documents R6 is confused and went down the wrong hallway and went into the room in the same area as R6's room, R6 thought someone was in R6's room and punched them. Surveyor reviewed the Facility Reported Incident involving the resident-to-resident altercation that occurred on 7/17/2025. The facility's incident report documents R6 walked into R7's room and hit R7 in the mouth and head. Certified Nursing Assistant (CNA)-II was checking on residents in the dining room and noticed R6 was not in the recliner where R6 had previously been sitting. CNA-II walked toward R6's room to locate R6 and heard R7 yelling out for help. CNA-II observed R6 standing over R7. R7 was sitting in R7's recliner while R6 had ahold of R7's wrists. R7 was attempting to get R6 away from R7, using R7's legs. CNA-II was able to separate R6 and R7. CNA-II then walked R6 down the hall and informed the Nurse immediately, who then went and assessed R7. R6 was immediately placed on a 1:1 supervision. A progress note, dated 7/18/25, documents, The IDT met to discuss the incident. The IDT documents, R6 is confused, entered another resident's room and became aggressive when asked to leave. R6 became agitated and hit the other resident in the face. Interventions documents, R6 was placed on a temporary 1:1 supervision, R6 was not to sit with the other resident during meals, activities and will be kept separate in hallways/elevators and a stop sign would be placed across the other resident's doorway. On 9/15/25, at 1:06 PM, Surveyor interviewed DON-B. DON-B indicated that after R6 punched the other resident in the mouth family members and other residents expressed being fearful of R6 and uneasy around R6. DON-B indicated that this is when the facility began to realize R6 required more services then the facility could provide to keep other residents safe. DON-B informed Surveyor that the facility has sent R6 to the hospital for evaluations, but nothing is founded. DON-B believes the facility has been attempting to find alternative placement for R6 but would need to clarify with Director of Social Services-D. DON-B indicated they kept other residents safe by initiating a temporary 1:1 supervision for R6 and were monitoring R6's behaviors. On 9/15/2025, at 1:51 PM, Surveyor interviewed Director of Social Services-D regarding finding placement for R6. Director of Social Services-D indicated that R6's family member has expressed in the past about R6 going home to the reservation, but no other attempts to find alternative placement were looked into. Surveyor noted on 7/21/25, R6 was evaluated by Psych Nurse Practitioner-JJ. Psych Nurse Practitioner-JJ evaluation documents: R6 had recent physical altercation with peer. R6 entered peers' room, possibly mistaking it for R6's, and struck peer. R6 last seen 7/7/25 where it was noted R6 was improving since re-increase risperidone after failed gradual dose reduction. R6 with significant history of physical and verbal aggression, sexual inappropriateness, generalized anxiety disorder, dementia with anxiety, mood disorder, and insomnia. Staff reports R6 has had a history of both physical and verbal aggression towards staff and peers. Surveyor noted the assessment and plan documented the following:-recent physical aggression-Plan: increase vpa (valproic acid), continue duloxetine, emotional support -Insomnia-well controlled-Plan: continue emotional support - Recent physical aggression-Plan: increased vpa, consider change to SSRI in future; continue emotional support-increase vpa ER 500; taper and DC namenda; continue emotional support; follow up next rounds” A progress note, dated 7/21/25, documents: Director of Social Services-D attempted to meet with R6 to follow up regarding the incident on 7/17/25 but R6 was sleeping. A progress note, dated 7/22/25, documents: Director of Social Services-D met with R6 to discuss the resident-to-resident incident on 7/17/25 and documents the following: “This writer met with member to talk about a recent member to member where this member hit member (R7) in the face multiple times after entering their room. This member did not recall the situation. This member does not recall hitting anyone or entering anyone else's room. When asked what makes this member upset, they stated “kids.” This member talked about kids making him upset as they are not aware of who they are, and they are dummies and have no respect. This member went on to state that he does not like being instigated or being told what to do. This member shared he becomes agitated by this. This member then started to discuss a doll and stated, “She is not real.” This member shared that those kids are toys, and they like to argue a lot. This member mentioned that “She can't understand what we are talking about because she is just a doll.” Surveyor noted Director of Social Services-D did not evaluate R6's current interventions or assess effectiveness of current interventions. A progress note, dated 7/24/25, documents R6 was glaring at particular residents, writer became concerned enough to “briskly” walk toward R6 to intervene. f. A progress note dated 8/1/25, by RN-BB, documents R6 had multiple attempts to interact with a resident R6 had an altercation with, redirection was causing R6 to become “agitated/irritated” and began pushing staff. A progress note, dated 8/21/25, documents Director of Social Services-D met with R6 to conduct an Annual Minimum Data Set assessment. Director of Social Services-D indicated R6 is currently on 15-minute checks for safety, wanders off unit usually redirectable by staff, no traumatic events in the assessment period, an updated LEC-5 (The Life Events Checklist is a self-report measure designed to screen for potentially traumatic events in a respondent's lifetime). would be completed and R6 is satisfied with living arrangements. A Trauma informed Care plan was initiated on 8/25/25 for R6. g. A progress note dated 8/25/25, at 6:46 PM, by RN-BB, documents: R6 exhibiting severe anxiety/restlessness, ignoring staff redirection, all doors were shut on hallway but R6 kept opening other resident's doors, another resident stayed in the hallway due to not wanting to be alone in the room with R6, R6 requiring nearly 1:1 supervision but management deems R6 as 15 minute checks. A progress note dated 8/25/25, at 8:07 PM, by RN-BB documents: R6 continuing to display severe anxiety/restlessness, going into other resident rooms, unsuccessful redirection and making other residents feel unsafe. On 9/15/2025, at 1:51 PM, Surveyor interviewed Director of Social Services-D regarding R6's escalating behaviors and what was done for R6 to prevent further incidents. Director of Social Services-D indicated that Director of Social Services-D has met with R6's family member and went over trauma informed care interventions on 8/25/25 but indicated that was done due to needing a facility wide audit on trauma informed care, which every resident received. Director of Social Services-D indicated it was not a direct response to R6's behaviors. On 9/16/25, at 12:24 PM, Surveyor interviewed DON-B. DON-B indicated R6's behaviors were discussed in IDT meetings, DON-B began initiating root cause analyses and indicated Director of Social Services-D was not following up on the Social Services side. Surveyor expressed the concern regarding lack of Social Services involvement in R6's care. The facility's failure to provide R6 with necessary medically related social services, created a finding of immediate jeopardy that began on 7/17/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 9/17/25 at 11:37 a.m. The immediate jeopardy was removed on 10/7/25 when the facility implemented the following: NHA educated Social Worker on the following policies: - Definition of F745 Medically related social services from CMS - Members Behavior Policy - Member to Member altercation policy - Care planning policy - Trauma informed Care Policy - Root Cause Analysis process - Member mood assessment policy - Member discharge policy - Member at risk for elopement or unsafe wandering policy SDC/Designee educated Staff on - Member Behavior policy, Member to member altercation policy, care planning policy and member at risk for elopement or unsafe wandering policy. Education was started 9-18-2025 and completed on 10/7/25 - Social worker attended the Wisconsin Nursing Home Social Workers Association fall conference 10/2-10/3/2025. - Social Worker/Designee to follow up with members or POA-HC or Guardian in discharge planning per member discharge policy for members wishing to discharge from facility. - Nurse Managers/Designee to complete elopement assessment for members due for quarterly assessment or with current change of condition warranting updated elopement assessment. - Social worker will establish a mentorship relationship with a licensed clinical social worker at the Wisconsin Veterans Home at King with weekly mentorship meetings. Facility will also pursue professional services for social services consulting. - The facility implemented a system/procedure to review every behavior event, resident -to resident altercations, and elopements during morning clinical which included reviewing assessment and care plan interventions for appropriateness. - Social Worker/Designee will review progress notes 5 x per week in clinical meeting auditing for members with increased behaviors, exit seeking, wishes to discharge and trauma. Those members identified will be adequately assessed and interventions put in place. Findings will be reported to QA for further recommendations. - Social Service Director and Administrator to conduct weekly meeting to review Medically Related Social Services concerns and establish process for addressing concerns. The deficient practice continues at a scope and severity of a E (pattern/potential for harm) for the following examples: 2.) R14 was admitted to the facility on [DATE] with diagnoses that include Adjustment Disorder (a mental health condition characterized by emotional and behavioral symptoms that develop in response to a significant life stressor), Presbyopia (a common age-related condition that affects the eye's ability to focus on near objects), Dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life) and Post-Traumatic Stress Disorder (PTSD) (A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event.) R14's Quarterly Minimum Data Set (MDS), dated [DATE], documents in part, R6 has a Brief Interview for Mental Status (BIMS) score of 12 indicating R14 has moderate cognitive impairment, no behaviors, has no impairment in upper or lower extremities, uses a walker and wheelchair for mobility and receives antidepressant medication. R15 was admitted to the facility on [DATE], with diagnoses including depression. R15's admission MDS, dated [DATE], documents BIMS score of 15 indicating R15 is cognitively intact, has impairment in lower extremities on one side and uses a wheelchair for mobility. Surveyor noted R15 is care planned for Trauma Informed Care, initiated 9/9/25 and documents “. Depressive disorder, recurrent severe without psychotic features. Member was referred to in-house psychiatrist on 3/11/25 and inhouse psychologist on 4/14/25” On 9/30/25, during the extended survey at the facility, Surveyor reviewed the facility's grievance log and noted a grievance from R15 regarding R14 entering into R15's room on multiple occasions, with the most recent time resulting in R14 removing R14's clothing while in R15's room. Surveyor reviewed the facility provided document titled, “Member Grievance/Concern,” dated 9/23/25, by Social Worker (SW)-C, which documents R14 keeps going into R15's room and this has occurred 6 times in 12 days. This has been occurring after dinner and before bed, and on occasion R14 wanders into R15's room with pants and underwear down. R14 was placed on a temporary 1:1 overnight. Resolution of the complaint documents, R15 has a stop sign banner in front of R15's door to stop R14 from going into R15's room and indicated SW-C followed up with R15 with no concerns. On 9/30/25, at 9:54 AM, Surveyor observed R15's door open, the stop sign banner hanging next to the door and was not across the doorway. Surveyor interviewed R15. R15 informed Surveyor of the concerns regarding R14 coming into R15's room and R15 expressed those concerns to Director of Social Services-D. R14 has come into R15's room [ROOM NUMBER] times in 12 days. R15 indicated a stop sign banner is supposed to stop R14 from entering R15's room but it does not do any good when it's not put up and seems to only go up when R15 is not in R15's room. R15 explained being afraid to shut R15's eyes at night due to R14 coming into R15's room. R15 indicated wanting to buy a squirt gun to defend R15's self against R14 but does not want to get in trouble or hurt R14. R15 explained that R15 cannot defend R15's self, due to having a bum leg. R15 explained R14's behavior as strange and uncomfortable. R15 began to get choked up talking about the incident; R15 explained that R15 informed Director of Social Services-D, who came and spoke with R15, but has not spoken to R15 since. Surveyor noted no new interventions were implemented for R14 or R15 following this incident. On 9/30/25, at 11:10 AM, Surveyor interviewed Director of Social Services-D. Director of Social Services-D indicated Director of Social Services-D did not complete LEC-5s following the incident with R14 and R15 and care plans were not assessed or updated, interventions were not assessed for effectiveness and indicated that should have been done when the situation occurred and at follow up. Director of Social Services-D indicated that R14 was placed on a temporary overnight 1:1 supervision following the incident. No other interventions were implemented, and current interventions were not assessed. On 9/30/25, at 3:02 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A indicated that NHA-A was going to make a change to the plan of correction that LEC-5s were going to be done annually instead of quarterly, but should still be completed in between with any traumatic events, indicating R14 and R15 should have been reassessed following the incident. NHA-A indicated that R14 and R15 should have interventions evaluated. NHA-A indicated that the stop sign banner should be up while residents are in their rooms to prevent other residents from going into other resident rooms. 3.) On 8/27/25, R6 was involved in a resident-to-resident altercation resulting in R5 sustaining a traumatic brain injury after being hit over the head with R6's cane. During the resident-to-resident investigation, Surveyor noted a statement by R12 indicating R12 did not feel safe in the facility with R6. On 9/30/25, at 2:36 PM, Surveyor interviewed Director of Social Services-D regarding follow up with R12's statement following the resident-to-resident altercation. Director of Social Services-D informed Surveyor that Director of Social Services-D has not followed up with R12 regarding R12's statement of feeling unsafe with R6 around. Surveyor noted there were no immediate interventions implemented and no social services assessment following R6's increased behaviors on 8/25/25 prior to the assault on 8/27/25. 4.) R11 was admitted to the facility on [DATE] with diagnoses of Dementia Unspecified Severity (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), With Mood Disturbance, Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow and make it difficult to breathe), Essential (Primary) Hypertension (most common type of high blood pressure), Chronic Respiratory Failure With Hypoxia (long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Insomnia (sleep disorder characterized by difficulty falling asleep), Unspecified, and Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Unspecified. R11's Quarterly Minimum Data Set (MDS) completed 6/26/25 documents R11's Brief Interview for Mental Status (BIMS) score is 12, indicating R11 demonstrates moderately impaired skills for daily decision making. R11's MDS documents no mood or behavior issues, including wandering. R11's main locomotion is by standard wheelchair. R11 is independent with dressing, mobility, and transfers. R11's Kardex (instructions to nursing staff) was updated 9/15/25. The Kardex documents: Safety -1/25/25 Encourage member to ask for help with computer -Alert on call nurse or DON or ADON for all incidents (escalated behaviors, attempts at elopement) -R11 has a wander guard on R11's wheelchair because R11 tries to tear it off R11's arm/leg -R11 now lives in memory care -R11 refused wander guard 4/25/25 -Redirect R11 when voicing need to leave facility to go to the bank. -Roam Alert wander band to R11's wheelchair R11's comprehensive care plan includes the following applicable problems: Safety Elopement: R11 at risk of elopement due to cognitive losses, Dementia high risk for elopement 7/10/25 R11 was waiting outside “for a ride to his bank”. 15-minute safety checks initiated for R11 whereabouts. R11 declines wearing roam alert device bracelet 8/4/25 15-minute checks discontinued 9/11/25 Roam alert device on R11's wheelchair Initiated 7/10/24 Interventions: -Monitor my behaviors to determine: duration, frequency, intensity, and patterns. Consider any changes that may have occurred such as: a room change, change in cognitive status, medication changes, new staff, or termination of treatment program. Initiated 7/10/25 -Alert on call nurse or DON or ADON for all incidents (escalated behaviors, attempts at elopement) Initiated 9/11/25 -R11 has a wander guard on R11's wheelchair because R11 tries to tear it off R11's arm/leg Initiated 9/11/25 -R11 now lives in memory care Initiated 9/11/25 2.Coping/Trauma Informed Care Plan: I am at risk for ineffective individual coping due to R11's diagnosis of Major Depressive Disorder, Recurrent Unspecified. Adjustment to nursing home. R11 referred to in-house psychologist on 6/10/25 Triggers: R11 breathing issues forced R11 to stop R11's construction in R11's 40s. When R11's breathing bothers R11, R11 can feel triggered. Initiated 9/9/25 Interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 9/9/25 -Arrange for psych consult, follow up as indicated. R11 referred to in-house psychologist 6/10/25. Initiated 9/9/25 -Assess/screen for post traumatic events and history of trauma, using nursing home appropriate screening tools, such as the LEC-5. Initiated 9/9/25 -R11 has deep breathing techniques to use when R11's breathing is bothering R11. R11 also enjoys socializing and being around family and friends. Initiated 9/9/25 -Discuss feelings around change and loss, facilitate R11's expression of these feelings. Initiated 9/9/25 -Encourage R11 to talk about how R11 is feeling to family, friends, or staff; remind R11 to utilize R11's support system if R11 is feeling down. Initiated 9/9/25 -Please watch R11 for the signs and symptoms which may indicate R11 feeling sad or depressed such as somnolence, social isolation, increased sadness, frequent weeping, anger, refusal of cares, decreased appetite, weight loss/gain. Initiated 9/9/25 Starting 3/26/25, the facility completed an [NAME]

Based on interview and record review, the facility did not ensure that all facility staff received required Effective Communication program training for 7 of 8 facility staff that was reviewed. This has the potential to affect the 71 Residents who reside at the facility and have the potential to receive care from Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN) and Food Service Assistants (FSA). Findings Include:On 09/30/24, at 12:35 AM, Surveyor reviewed CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ completed trainings for the past year and noted there was no documentation that CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ received training on the facility's effective communication program which outlined and informed staff of the elements and goals of the facility's Effective Communication program. On 9/30/24, at 1:09 PM, Surveyor requested missing training of the facility's Effective Communication program which outlined and informed staff of the elements and goals of the facility's Effective Communication program from NHA (Nursing Home Administrator)-A for CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZSurveyor was informed by NHA-A and Director of Nursing (DON)-R they had to call human resources and the education company to try to locate these missing education documentation for CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ. On 09/30/25, at 01:54 PM, DON-R informed Surveyor that the facility is still attempting to locate the missing documentation for the above employees by 10/1/25 in the morning for Surveyor.On 09/30/25, at 03:02 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ with the mandatory Effective Communication training. NHA-A informed Surveyor the facility was working on providing Effective Communication training to all staff because the Effective Communication training had never been included in the facility's training process.No additional information was provided as to why the facility did not ensure that CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ received the required Effective Communication program training.

Based on interview and record review, the facility did not ensure that all facility staff received required Quality Assessment and Performance Improvement (QAPI) program training for 7 of 8 facility staff that were reviewed. This has the potential to affect the 71 Residents who reside at the facility and have the potential to receive care from Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN) and Food Service Assistants (FSA).Findings Include:On 09/30/24, at 12:35 AM, Surveyor reviewed CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ completed trainings for the past year and noted there was no documentation that CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ received training on the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program. On 9/30/24, at 1:09 PM, Surveyor requested training of the facility's QAPI program which outlined and informed staff of the elements and goals of the facility's QAPI program from NHA (Nursing Home Administrator)-A for CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZSurveyor was informed by NHA-A and Director of Nursing (DON)-R they had to call human resources and the education company to try to locate missing education documentation for CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ. On 09/30/25, at 01:54 PM, DON-R informed Surveyor that the facility is still trying to have the missing documentation by 10/1/25 in the morning for Surveyor.On 09/30/25, at 03:02 PM, Nursing Home Administrator (NHA)-A confirmed the facility has not provided CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ with the mandatory QAPI training. NHA-A informed Surveyor the facility was working on providing QAPI training to all staff because the QAPI training was never included in the facility's training process.No additional information was provided as to why the facility did not ensure that CNA-TT, CNA-VV, CNA-WW, CNA-XX, LPN-I, LPN-N, and FSA-ZZ received the required Quality Assessment and Performance Improvement program training.

Based on record review and staff interviews, the facility did not ensure all allegations involving potential abuse and/or neglect, and injury of unknown origin were thoroughly investigated for 4 (R10, R8, R14, R3 and R2) of 10 facility reported incidents reviewed involving residents. *On 7/14/25, R14 and R10 were involved in a member-to-member altercation that was not thoroughly investigated, and the facility did not conduct interviews of other members. *On 8/27/25, R8 and R14 were involved in a member-to-member altercation that was not thoroughly investigated. *On 7/10/25, allegation of abuse was submitted to the State Survey Agency involving R3. The facility did not conduct interviews of other members. *A thorough investigation was not completed for R2's injury of unknown injury. Findings Include: The facility's Prohibition and Prevention Member Abuse, Neglect, and Exploitation effective 7/2/24 documents: .All incidents shall be investigated and reported to the appropriate agency as required by the agency. .The facility shall maintain records of incidents and accompanying information to meet legal and regulatory agency requirements. 4.The nursing supervisor or facility administrator immediately initiates initial reporting and conducts a thorough investigation. 8.A list of possible witnesses is given to the nursing supervisor as soon as possible. Copies of daily schedules and staff statement forms are placed on 24-hour report board, names of staff needing to provide statements are highlighted. Cross off the highlighted names after statements are obtained. The RNs follow-up with all staff who were on duty and may have provided any care for the affected member at time of the discovery and during the two previous shifts. 9.Interviewing the alleged victim, witnesses, accused individuals, and other members and staff. 10.The Social Worker will be involved in taking statements from the members involved in the situation and those who also could have been affected by this or a similar incident. 14.A file containing the supervisor summary, initial incident report, staff statements, any supporting documentation, and items submitted to DQA is routed to Administration for keeping; a copy goes to the facility administrator. 1.) R10 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease(long term conditions developed from chronic high blood pressure), Cerebral Ischemia(insufficient blood flow to meet metabolic demand), Cerebral Infarction(stroke resulting in blood flow being interrupted to brain leading to brain cell damage), Dysphagia(difficulty swallowing foods), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R10's Quarterly Minimum Data Set(MDS) completed 8/8/25 documents R10's Brief Interview for Mental Status(BIMS) score to be 11 indicating R10 demonstrates moderately impaired cognition. R10's MDS documents no mood or behavior concerns. R10 has no range of motion impairment. R10 is set-up for eating, dependent for showers, for upper/lower dressing, mobility and transfers. R14 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Essential Hypertension(chronic condition of persistently high blood pressure), Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Parkinson's Disease(disorder of the central nervous system that affects movement, often including tremors), Adjustment Disorder with Depressed Mood(depressed mood, tearfulness, and feelings of hopelessness in response to a stressful life event), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R14's Quarterly Minimum Data Set(MDS) completed 6/5/25 documents R14's Brief Interview for Mental Status(BIMS) score to be 12, indicating R14 demonstrates moderately impaired skills for daily decision making. R14's MDS documents no mood or behavior concerns. R14 has no range of motion impairment. R14 is independent with eating. R14 requires partial/ moderate assistance for upper body dressing and substantial/maximum assistance for lower dressing. R14 requires partial/moderate assistance for transfers and mobility. On 9/10/25, at 9:16 AM, Surveyor reviewed the facility reported incident(FRI) member-to-member altercation involving R14 and R10.It is documented that R14 is hard of hearing and did not hear R10 yelling at R14 to move R14's wheelchair resulting in R14 and R10 pulling at each other's arms and wrists. The summary documents a root cause is indicated, however, there is no documentation of what the root cause actually was and specific interventions for both R14 and R10. The facility did not obtain any other member statements to complete a thorough investigation. 2.) R8 was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease(long term conditions developed from chronic high blood pressure), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Osteoarthritis(degenerative joint disease), Alzheimer's(progressive disease that destroys memory and other important mental functions), and Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R8 currently has an un-activated Health Care Power of Attorney(HCPOA). R8's Quarterly Minimum Data Set(MDS) completed 7/17/25 documents R8's Brief Interview for Mental Status(BIMS) score to be 14 indicating R8 is cognitively intact for daily decision making. R8's MDS documents no mood or behavior concerns. R8 has no range of motion impairment. R8 is set-up for eating, dependent for showers, and substantial/maximum assistance for upper/lower dressing, mobility and transfers. R14 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Essential Hypertension(chronic condition of persistently high blood pressure), Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Parkinson's Disease(disorder of the central nervous system that affects movement, often including tremors), Adjustment Disorder with Depressed Mood(depressed mood, tearfulness, and feelings of hopelessness in response to a stressful life event), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R14's Quarterly Minimum Data Set(MDS) completed 6/5/25 documents R14's Brief Interview for Mental Status(BIMS) score to be 12, indicating R14 demonstrates moderately impaired skills for daily decision making. R14's MDS documents no mood or behavior concerns. R14 has no range of motion impairment. R14 is independent with eating. R14 requires partial/ moderate assistance for upper body dressing and substantial/maximum assistance for lower dressing. R14 requires partial/moderate assistance for transfers and mobility. On 9/10/25, at 9:59 AM, Surveyor reviewed the facility reported incident(FRI) member-to-member altercation involving R14 and R8. It is documented that R8 yelled for R14 to sit down in the wheelchair and R14 swung at R8. The facility documents in the summary of the incident that no contact was made between R8 and R14. A CNA's statement indicates that R8 had informed the CNA that R8 had been punched in the arm. The facility did not conduct an investigation of the statement by R8 that there may have been actual physical contact between R8 and R14. On 9/10/25, at 3:08 PM, Director of Nursing (DON)-B stated that a thorough investigation of a member-to-member altercation would consist of review of medication, who the member is, any history of behaviors, evaluate any injuries and the expectation is that a root cause analysis is conducted of the incident and implement new interventions. On 9/11/25, at 11:08 AM, Surveyor interviewed Social Worker (SW)-D in regard to the FRI process. SW-D stated that SW-D is responsible for interviewing other members when there is an allegation of abuse or neglect or member-to-member altercation. SW-D does not know why there would be no documented member interviews for the FRI involving R14 and R10. On 9/15/25, at 3:44 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that both R8 and R14 and R14 and R10 member-to-member altercations were not thoroughly investigated. No further information has been provided by the facility at this time. 3.) R3's diagnoses includes hypertension (high blood pressure), chronic kidney disease (kidneys are damaged and cannot filter blood and waste effectively), dementia (loss of cognitive function that interferes with a persons daily life and activities), depressive disorder, and Alzheimer's Disease (progressive brain disorder that causes gradual cognitive decline). On 7/10/25 the facility reported to the State agency an allegation of abuse involving R3. Surveyor reviewed the facility's reported incident and noted although multiple staff were interviewed regarding the allegation Surveyor was unable to locate evidence the facility interviewed other residents residing on R3's unit. On 9/15/25, at 8:49 a.m., Surveyor asked Director of Social Services (DSS)-D what is the process if a resident or family has an allegation of abuse. DSS-D informed Surveyor the allegation would be reported directly to the Administrator and Director of Nursing, an investigation would ensue, witness statements would be obtained, they would interview the member (resident) and the allegation would be reported to the State. Surveyor asked DSS-D if she is involved in the investigations. DSS-D replied typically not, depends on the day and time, may interview the member. Surveyor asked if other residents are interviewed. DSS-D replied ya, usually I would do a handful of interview able residents. Surveyor asked DSS-D if she was involved with R3's abuse investigation. DSS-D informed Surveyor she thinks she did member interviews. Surveyor showed DSS-D R3's facility reported incident and informed DSS-D Surveyor was unable to locate any resident interviews. DSS-D replied truthfully if not here can't say that it was done. DSS-D explained the Administrator usually asks her to interview members. They (Administrator & Director of Nursing) start the investigation and delegate. DSS-D stated that Administrator is not here any more. DSS-D stated I don't know why we wouldn't of done those. Surveyor asked DSS-D to check to see if there are any resident statements and get back to Surveyor. On 9/15/25, at 1:05 p.m., DSS-D informed Surveyor they don't have any member (resident) interviews. The facility did not conduct a thorough investigation for the abuse allegation involving R3 as the facility did not interview any residents to determine if there were any additional concerns regarding abuse. 4.) R2 was admitted to the facility on [DATE] with diagnoses that include Dementia with Psychotic Disturbance and Age related Osteoporosis. R2's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/22/25 documents under section C R2's Brief Interview Mental Status (BIMS) score was 4 indicating severe cognitive impairment for R2. R2's Nursing notes dated 6/14/25, at 7:30 AM, documents: “Writer assessed member's right shoulder, after unit nurse reported a very faint bruise, and c/o pain. Writer noticed, very faint yellow color bruise on member's right shoulder. Writer. Member appears to have pain with movement. Mild swelling present as well. Order for STAT x rays in place. ADON notified.” R2's Nursing note dated 6/14/25, at 7:10 AM, documents: “Call placed to {provider's office}. Spoke with NP (nurse practitioner) and informed that member has increased right shoulder pain with swelling, old bruising [yellowing] and limited ROM. New order received for a two view shoulder X Ray.” R2's Physician's order dated 4/11/25, at 6:03 PM, documents: “Diclofenac Sodium External Gel 1% (diclofenac sodium topical) Apply to left arm topically every 12 hours as needed for discomfort to left arm 2 grams every 12 hours.” R2's June 2025 Medication Administration Record (MAR) documents R2 receiving Diclofenac Sodium External Gel 1% as needed on 6/11/25 to the right shoulder for a pain score of 3 out of 10. (the order indicates left shoulder discomfort.) The June 2025 MAR documents R2's pain at 6:30 AM on 6/11/25 as a 2 out of 10, on 6/13/25 as 2 out of 10, and 6/14/25 as 2 out of 10. No other pain above 0 documented in June of 2025 prior to 6/11/25. No other as needed pain medications given to R2 prior to 6/11/25. R2's witness statement dated 6/15/25, at 10:45 AM, given by Licensed Practical Nurse (LPN)-N, documents: On 6/11/25 at 0750 writer applied Diclofenac Gel to members Right shoulder for complaints of discomfort. Member was sitting in a recliner in the TV room. Writer and ADON (BN) repositioned member in the chair and member stated she had pain in right shoulder. No swelling or bruising was present. R2's witness statement dated 6/15/25, at 4:37 AM, given by Certified Nursing Assistant (CNA)-MM, documents “On Thursday June 12th I toileted R2 and she complained of shoulder pain, and I reported it to nurse on PM shift.” R2's witness statement dated 6/16/25, at 07:14 AM, given by CNA-L, documents: “Yes on 6/13 PM shift. Toileting and changed clothes for bedtime. She was complaining of right shoulder pain at the time, and it was difficult for her to stand for transfers.” R2's witness statement dated 6/17/25, at 08:23 AM, given by Senior Therapist (STH)-AA, documents: “I was off on Thursday. I did a craft with her (R2) on Friday morning (6/13/25) and after she was done. She was complaining that her right upper arm was sore. Then she said she was tired and fell asleep in her wheel chair. I mentioned to a CNA (can't remember who) who was sitting there about her (R2) arm.” On 9/16/25, at 11:39 AM, Surveyor interviewed LPN-N about R2's shoulder pain on 6/11/25. LPN-N informed Surveyor that R2 had a history of arthritis and that R2 was complaining of right shoulder pain. Surveyor asked LPN-N if LPN-N reported the pain to the Supervisor. LPN-N informed Surveyor that LPN-N applied R2's as needed Voltaren gel to R2's right shoulder and did not think R2's pain needed to be reported. Surveyor asked LPN-N to verify it was the right shoulder and not the left shoulder in the order. LPN-N verified it was the right shoulder. On 6/16/25, at 12:31 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-S about R2's 6/14/25 investigation into the fractured Right clavicle. ADON-S informed Surveyor that the former Commandant had overseen the investigation and ADON-S felt it was done thoroughly. Surveyor asked ADON-S if ADON-S had any knowledge of the investigation and specifically of the witness statements documenting pain starting in R2's right shoulder on 6/11/25. ADON-S informed Surveyor he could not recall. Surveyor asked ADON-S if there were any investigation into the multiple witness statements indicating R2 had right shoulder pain on 6/11/25, 6/12/25, 6/13/25 and the right clavicle fracture was found on 6/14/25. ADON-S informed Surveyor that ADON-S did not have any knowledge of further investigation into the witness statements. On 9/16/25, at 12:30 PM a message was left with the Nurse Practitioners (NP) office, On 9/16/25, at 12:58 PM, Surveyor interviewed Nursing Home Assistant (NHA)-A about R2's right shoulder fracture discovered on 6/14/25. Surveyor asked NHA-A if NHA-A had anymore documentation from this investigation done by the previous NHA. NHA-A informed Surveyor that the Surveyor had everything that was on file for R2's 6/14/25 self-report. Surveyor showed NHA-A and Director of Nursing (DON)-B the witness statements indicating R2 had right shoulder pain starting on 6/11/25 and had received the only as needed pain medication on 6/11/25 by LPN-N. Surveyor informed NHA-A that a concern was the only charted pain for R2 in June 2025 prior to 6/14/25 was on 6/11/25, 6/13/25 and 6/14/25 the day the fracture was discovered. Surveyor asked NHA-A if there was any documentation to show any follow up by the former NHA on the witness statements documenting R2's pain started on 6/11/25. Surveyor informed NHA-A the concern that a follow up on those witness statements was not done especially when a right shoulder fracture was discovered is concerning. R2 had a significant injury discovered on 6/14/25 and evidence the injury may have started on 6/11/25 in the witness statements. Surveyor informed NHA-A these statements needed to be followed up to rule out abuse, neglect or another cause of R2's right shoulder pain. Surveyor informed NHA-A the only documented pain for R2 during the Month of June 2025 prior to 6/14/25 was on 6/11/25, 6/13/25 and 6/14/25. NHA-A informed Surveyor NHA-A would look for more information but informed Surveyor she understood the Surveyor's concern, but felt there was unlikely any more documentation. On 9/16/25, at 1:07 PM Surveyor interviewed STH-AA about R2's pain in the right upper arm on Friday 6/13/25. STH-AA informed Surveyor that R2 told STH-AA that R2's right arm hurts. STH-AA informed Surveyor that STH-AA informed the staff of the R2's pain complaint. Surveyor asked STH-AA if anyone brought R2 any pain medication or came back to assess R2. STH-AA informed Surveyor not while STH-AA was there. Surveyor asked STH-AA if anyone followed up with STH-AA on the witness statement STH-AA gave indicating R2 had right arm pain on 6/13/25 during R2's fracture investigation. STH-AA informed Surveyor no one followed up with STH-AA about STH-AA's statement indicating R2 had pain in the upper right arm on 6/13/25. No additional information was provided on why R2's 6/14/25 right clavicle fracture of unknown origin investigation was not thoroughly investigated.

Based on interview and record review the facility did not ensure a resident's physician was notified for 2 (R1 & R11) of 11 residents reviewed. R1's physician was not notified when R1 was screaming out in pain with minimal movement on 8/22/25. The incident report dated 8/22/25 documents the provider notification to be done the next day. R11's physician was not notified when R11 eloped on 9/11/25. Findings include: 1.) R1's diagnoses includes chronic embolism and thrombosis of right popliteal vein (vein of the lower limb), atrial fibrillation (irregular and rapid heart beat), hypertension (high blood pressure), left above knee amputation, obsessive compulsive disorder (excessive thoughts that lead to repetitive behaviors), dementia (loss of cognitive function that interferes with a persons daily life & activities) and history of traumatic brain injury (brain dysfunction caused by outside force usually a violet blow to the head). R1's nurses note dated 8/22/25 at 13:58 (1:58 p.m.) written by Registered Nurse (RN)-V documents: No new bleeding or bruising noted. Member returned from appointment with POA (Power of Attorney) at approximately 1150. The next nurses note is dated 8/22/25 at 16:18 (4:18 p.m.) written by RN-OO documents: Hall Certified Nursing Assistant (CNA) informed writer that member is screaming out in pain with minimal movement while trying to roll to L (left) side. Member refused and ordered the CNA to get out of the room and leave him be. Member had a Chiropractor appointment this AM (morning). There was no new orders from the appointment and no info (information) in report regarding new pain. R1's incident note dated 8/22/25 at 17:00 (5:00 p.m.) written by RN-OO documents: Hall CNA informed writer that member is screaming out in pain with minimal movement while trying to roll to L side. Member refused and ordered the CNA to get out of the room and leave him be. Member had a Chiropractor appointment this AM. There were no new orders from the appointment and no info in report regarding new pain. Member's POA [Name] informed writer of the reason for the member's knee pain. POA stated that when she is transferring the member in and out of the van, I sometimes bump his knee or it gets stuck when I take him to his appointments. POA stated the pain is not in the member's back, it's in their knee. VITALS: FOLLOW-UP: New intervention implemented and added to TPOC (temporary plan of care). extra caution when transferring/cares. NOTIFICATIONS: Provider notification to be done next day. NOK (next of kin)/Responsible party notified this shift: 08/22/25 5:00 PM [Name] done in person. Supervisor notified in person: 08/22/2025 4:18 PM (evening) [Name] Charge RN. R1's nurses note dated 8/22/25 at 17:30 (5:30 p.m.) written by RN-OO documents: Member's POA present at this time attempting to feed member themselves as they refused dinner. POA stated that member's pain is not in their back from the chiropractor appointment today but is in the knee. POA gave permission to not move forward with attempting to bathe member. R1's nurses note dated 8/23/25 at 02:55 (2:55 a.m.) written by RN-PP documents Unit CNA reported that member is screaming and hollering in pain. Writer and other charge nurse went to member's room, assessed member 'leg. Member is complaining of right hip/knee pain. Member screaming with movement. No visible redness, swelling, bruise or any injury noted. Pedal pulse palpable. Member had Chiropractor appointment during the day. Member has been complaining of right hip/knee pain since evening per charting. Member yelled out loud when staff tried to reposition member. Member refused to be repositioned. R1's nurses note dated 8/23/25 at 04:01 (4:01 a.m.) written by RN-QQ documents: Member was restless during night. C/o (complained of) pain on rt (right) hip and rt leg 5/10. Tramadol and Tylenol given at 0400 (4:00 a.m.). R1's nurses note dated 8/23/25 at 09:40 (9:40 a.m.) written by RN Supervisor-U documents: POA [Name] on unit due to member being sent out for eval (evaluation) & tx (treatment) due to new onset of uncontrolled pain to R hip/knee. [Name] agreed it was best to have it looked at to be safe. Voiced concern that member had surgery to site years ago. R1's nurses note dated 8/23/25 at 11:18 (11:18 a.m.) written by RN Supervisor-U documents: Member picked up by [Ambulance Name] via stretcher at 1055 (10:55 a.m.) for transport to [Hospital Name] for eval & tx for uncontrolled pain to R hip/knee. Management & Admissions updated via email of hospital transfer. R1's nurses note dated 8/23/25 at 22:34 (10:34 p.m.) written by RN Supervisor-W documents: Spoke with [Name] RN for Member at [Hospital Name]. Member was admitted for Femur facture of the right leg. Member will have surgery 08/24/25. [Name] stated Member will likely spend the next week as an inpatient of the unit [Name]. On 9/11/25, at 4:25 p.m., Surveyor interviewed RN-OO. Surveyor inquired about R1's pain on the day R1 had the Chiropractor appointment. RN-OO explain she and the Certified Nursing Assistant (CNA) went in the room, the CNA was barely touching R1 and R1 was screaming out in pain. RN-OO informed Surveyor she contacted R1's POA who informed her they were at the chiropractor. RN-OO informed Surveyor she asked R1's POA when R1's POA came to the facility about R1's right knee. RN-OO informed Surveyor R1's PO told her sometimes she bumps him. RN-OO informed Surveyor this day was R1's bath day and the POA told her not to worry about bathing R1. RN-OO informed Surveyor she didn't get anything from the other nurse about R1 being in pain so when the CNA told her R1 was yelling in pain it was a shock to her. Surveyor asked RN-OO when R1 was screaming out in pain why didn't she notify R1's physician regarding the pain and for recommendations such as an increase in pain medication or having an x-ray taken at the facility. RN-OO informed Surveyor she didn't know it was an option when R1's POA told her not to notify the doctor. RN-OO informed Surveyor name of R1's POA gave her permission not to notify the doctor because she was aware of the pain. On 9/115/25, at 8:28 a.m., Surveyor asked Assistant Director of Nursing (ADON)-S when ADON-S would expect a resident's nurse to notify the doctor. ADON-S replied that's a really involved question and explained change of condition, parameters provided by physician, falls. Surveyor asked what about if a resident has signs of pain. ADON-S informed Surveyor if the resident has pain more than usual, if the treatment is not successful or there is a change of condition. Surveyor asked ADON-S what if a POA tells the nurse not to notify the MD what should the nurse do? ADON-S replied I would hope the nurse would notify the physician if there were any of these things. Surveyor informed ADON-S of R1 was yelling out in pain with minimal movement during the evening shift on 8/22/25 after R1 had been out of the facility for a chiropractors appointment and RN-OO informing Surveyor she did not notify the doctor because R1's POA told her she didn't have to. No additional information was provided as to why R1's physician was not notified of R1's pain on 8/22/25. 2.) R11 was admitted to the facility on [DATE] with diagnoses of Dementia Unspecified Severity(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), With Mood Disturbance, Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Essential (Primary) Hypertension(most common type of high blood pressure), Chronic Respiratory Failure With Hypoxia(long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Insomnia(sleep disorder characterized by difficulty falling asleep), Unspecified, and Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Unspecified. R11 has an activated Health Care Power of Attorney(HCPOA) as of 1/10/24, however, there is a guardianship hearing on 10/6/25 because family no longer wants to be the HCPOA. R11's Quarterly Minimum Data Set(MDS) completed 6/26/25 documents R11's Brief Interview for Mental Status(BIMS) score is 12, indicating R11 is moderately cognitively impaired. R11's MDS documents no mood or behavior issues, including wandering. R11 requires set-up for eating. R11 is independent with hygiene, dressing, mobility, and transfers. R11 is occasionally incontinent of urine and always continent of bowel. On 9/11/25, at approximately 9:55 AM, a family member of another resident informed staff in the facility, that R11 was seen at the intersection of the 3 way stop sign. Staff went to R11. R11 stated R11 was trying to hitch hike a ride to the bank. R11 was then going to get a cab to Chicago and fly to Hawaii. Per the incomplete incident report the facility provided, R11 has been frustrated with notification of pending guardianship and wishes to move to Hawaii. R11 was moved to the memory care unit and a wander guard was placed on the metal bar under R11's chair. On 9/12/25, at 10:00 AM, Medical Doctor (MD)-L completed a monthly compliance visit. MD-L documents “no acute complaints or concerns are reported during this visit”. MD-L's documentation does not indicate that at anytime MD-L was notified of R11's elopement from the facility along with R11's continuous psychosocial verbalizations. On 9/15/25 at 3:44 PM, Nursing Home Administrator (NHA)-A stated that “no one is taking responsibility” for the incident report. Surveyor asked NHA-A what NHA-A meant by that. NHA-A stated that the expectation is that the nurse should complete the incident report at the time of the incident. This was not completed and notifications to R11's physician has not been completed. There is no documentation that R11's vitals were taken after the elopement. The incident is blank for sections mental status, predisposing environmental factors, predisposing situation factors. Surveyor notes there is no documented registered nurse (RN) assessment. The facility has not provided any statements in regard to R11's elopement from the facility. NHA-A stated the facility is still gathering statements. Surveyor shared the concern with NHA-A and Director of Nursing (DON-B) that R11's physician has not been updated in regard to R11's elopement from the facility. Surveyor shared based on documentation that MD-L completed a monthly compliance visit and does not document that MD-L was made aware of R11's elopement from the facility. NHA-A acknowledged the concern and provided no further information at this time. On 9/16/25, at 1:47 PM, Surveyor was provided documentation by the facility that the medical director was notified at 11:15 AM on 9/16/25 of R11's elopement from the facility. A body check was completed on 9/16/25. Surveyor noted that these actions were completed six days after R11's elopement. No additional information was provided as to why R11's physician was not notified of R11's elopement, when R11 eloped on 9/11/25.

The facility did not provide adequate evidence of a proper discharge for 1 of 3 residents (R6) reviewed for discharge and transfers.*The facility's physician did not document the specific needs for R6 that cannot be met at the facility, the facility's attempts to meet R6's needs, and the services available at the receiving facility to meet R6's needs for R6 to have an appropriate discharge.Findings:On 8/27/25, R6 was sent out to the hospital for a mental health evaluation from an appointment with R6's neurologist.At the time of R6's discharge, R6 was on the following medications per R6's Medication Administration Record:Risperidone 0.5mg two times per day and Duloxetine 60mg once per day.In a progress note dated 8/27/25 at 12:30 PM, Director of Social Services-D documented: This writer called member's guardian to inform them of the member to member that occurred today. This guardian presented as upset as evidenced by guardian raising their voice stating that this facility cannot discharge him as he is a veteran and has nowhere else to go. This writer informed guardian that they are not looking to discharge this member at this time, this writer is only calling to update this guardian of the incident that occurred. This guardian stated that this member is violent and will kill her if he comes home. This guardian repeatedly told this writer that this member cannot come home. This writer stated that the IDT needs to talk and discus next steps such as getting this member evaluated. This POA apologized for being upset with this writer and noted that they understand this facility has done everything they can to help this member and she feels badly that this incident occurred.A progress note dated 8/27/25 at 2:58 PM documents Nursing Supervisor-HH spoke with the nurse at the Milwaukee VA to discuss and give report and why R6 was sent to emergency room (ER). Nursing Supervisor-HH indicated R6 has had violent behaviors/aggression and assaults to peers and needs to be admitted for medication management. Nursing Supervisor-HH indicated the nurse unavailable at time for report to and information was left to give Nursing Supervisor-HH a call when available.Surveyor reviewed the Facility provided document, titled Notice of Transfer, dated 8/27/25 which included representative notification, reason and bed hold policy.On 8/29/25, at 11:11 AM, the Facility mailed R6's family member a Discharge Notice via certified mail.Surveyor reviewed the Facility provided document, titled Discharge Notice dated 8/29/25 and documents the R6 is being discharged from the Facility due to the Facility being unable to fully meet the care needs due to unpredictable and uncontrollable behaviors related to unspecified diagnoses. Documenting OMB will work with the facility and guardian, towards an alternative placement. The anticipated date of discharge of R6 is on or before 09/29/25.On 9/11/25, at 9:32 AM, Surveyor interviewed R6's family member. R6's family member explained that on 7/30/25 R6's family member spoke with Director of Social Services-D regarding R6 being in the hospital and indicated there was not a plan to discharge R6 from the Facility. R6's family member reached out to the facility on 9/3/25, via email, asking about updates on R6 and if R6 has returned to the Facility. Director of Social Services-D replied via email and informed R6's family member R6 was still at the hospital. On 9/4/25, R6's family member received the 30-day notice via mail, indicating the Facility could not take R6 back due to aggression and after 10 days, R6 would have to pay $723.00 per day to hold a bed at the Facility. R6's family member became tearful speaking with Surveyor about R6's aggressive behaviors at home and toward family members, expressing frustration of being unable to care for R6 at home and being afraid of R6. R6's family member explained R6 being 100% service connected, the financial concerns/struggles when considering paying for R6's bed hold, and it was unknown how long R6 would remain in the hospital. Once receiving the 30-day notice, R6's family member reached out to the Facility, expressing safety concerns if R6 had to return home and being unable to care for R6 safely.On 9/7/25, at 7:07 PM, NHA-A emailed the State Agency to provide additional information regarding the Facility Reported Incident regarding R6, which documents, on 9/4/25, R6's family member left a message with Director of Social Services-D being upset to receive the 30-day notice and requesting to speak to Director of Social Services-D. NHA-A documents, DON-B visited R6 at the hospital on 9/3/25 and found R6 to be heavily sedated, on a alternate diet, with a urinary catheter and receiving several new psychiatric medications for behaviors which explained R6 appearing sedated. NHA-A, DON-B and Director of Social Services-D met with the Medical Director-RR. Medical Director-RR recommended reassessing R6's necessary psychiatric medications if R6 was to return to the Facility, removing most new medication causing sedation and placed on a 1:1 supervision for a minimum of 48 hours to stabilize R6 at baseline. It was recommended R6 remain in the hospital over the weekend and return to the Facility early next week. The Facility then met with R6's family member to discuss the 30-day notice, bed hold and discharge plans. The Facility informed R6's family member R6 would remain in the hospital until a safe place is located for R6, then indicate R6's family member wanted R6 discharged from the Facility and proceeded to tell the team R6 would be tied to a chair, handcuffed, mouth duct taped, tortured and killed if R6 had to be released to R6's family member's care. Director of Social Services-D then called Adult Protective Services (APS) to report the comments made by R6's family member but was informed [NAME] County APS the case is out of their jurisdiction and would need to be referred to the Ashland County and/or Bad River [NAME].A progress note dated 8/27/25 at 4:45 PM documents DON-B called the ER and spoke to the physician who stated R6 is medically cleared to come back to the facility. DON-B indicated the facility cannot take R6 back due to being a danger to the other veterans in the facility's care.A progress note dated 8/27/25 at 6:10 PM, documents Neurology notes from appointment are as follows: Findings: R6 at baseline per Certified Nursing Assistant (CNA), no agitation today, 3-4 episodes of agitation/aggression in the last 2 months. Risperidone dose unchanged, started Depakote by the facility. Recommendations: Increase risperidone dose to 1 mg twice a day, Depakote not helpful consider discontinuing, will send to ER to rule out other etiology of agitation, attempt to identify agitation risk factors within facility and notify and follow up in 6 weeks.A progress note dated 8/28/25 at 5:20 PM, documents Nursing Supervisor-HH and DON-B called the hospital for an update on R6. R6 did not exhibit any behaviors and has someone watching R6 in the room due to R6 being unsteady.Surveyor reviewed the facility's document titled FAX TRANSMITTAL dated 9/3/25. Surveyor noted, the fax indicates Hospital Social Worker-QQ inquiring if R6 can return to the facility today (9/3/25).Surveyor reviewed the facility provided document with no title dated 9/3/25 which documents: Provider Summary and Outcome of Investigative Findings, R6 behaviors escalated due to possible toileting needs as R6 was seen attempting to use other resident's bathroom. Care plan interventions for R6 and education for staff members on escalating behaviors has been implemented. 30-day notice issued to Power of Attorney (POA) for placement in appropriate setting. Care conference to discuss relocation will be initiated upon guardian's receipt of 30-day notice. Staff to assist guardian with relocation placement.A progress note dated 9/4/25, documents POA left message for Director of Social Services-D around 8:30 AM, being upset to receive a 30-day notice and wanted to speak to the Director of Social Services-D. R6 remains at VA hospital in Milwaukee. DON-B visited member at hospital on 9/3/25 and found member heavily sedated, changed to a pureed diet and with a foley (catheter.)A progress note dated 9/5/25 at 8:51 AM by DON-B documents: Director of Social Services-D, DON-B, and NHA-A called R6's POA regarding R6's status, POA received the 30-day notice and was upset. Discussion regarding the bed hold ending on 9/5/25, the POA stated she wants R6 discharged today from Union Grove since the facility cannot care for R6 and POA cannot pay the private rate.On 9/11/25, at 11:36 AM, Surveyor interviewed Financial Specialist- FFF, Financial Management Supervisor- GGG and Reimbursement Specialist- HHH. Financial Management Supervisor- GGG indicated R6 is service connected, and the Veteran Association (VA) pays for 100% of R6's stay. R6 would need to pay a bed hold rate of $723.00 per day after the 10th day of being in the hospital. Reimbursement Specialist- HHH explained, typically the VA would pay bed hold if at 90% occupancy, but the Facility is not currently at 90% occupancy.On 9/11/25, at 4:30 PM, Surveyor interviewed Home Division Administrator-SS. Home Division Administrator-SS indicated R6 has aggressive behaviors, and the facility cannot provide 1:1 supervision for R6 and R6 requires mental health services that the facility cannot provide. Home Division Administrator-SS indicated on 9/3/25, R6 was medically cleared to return to the facility, but the facility could not accept R6 back.On 9/11/25, at 1:04 PM, Surveyor spoke with Hospital Social Worker-QQ. Hospital Social Worker-QQ indicated Hospital Social Worker-QQ was never made aware of R6's 30-day notice from the facility while R6 was admitted in the hospital. Hospital Social Worker-QQ informed Surveyor that on 9/2/25, Hospital Social Worker-QQ attempted to speak with the facility about R6 returning but got no response. Hospital Social Worker-QQ explained a note on 9/4/25 indicated the facility notified them of R6's discharge from the facility per POA's request.Surveyor reviewed the facility provided document titled Order Details for R6. Surveyor noted Medical Director-RR's verbal order, dated 9/4/25, documents: Member may be discharged from Union Grove Veteran's Home-[NAME] Hall per Guardian's request. No other documentation was provided.On 9/15/25, at 8:14 AM, Surveyor attempted to speak with Medical Director-RR. Medical Director-RR did not return Surveyor's call.On 9/15/25, at 1:06 PM, Surveyor interviewed DON-B. DON-B informed Surveyor that the facility does not admit residents who require 1:1 supervision, which is included in the admission Agreement. 1:1 supervision will be provided for residents for short term situations when needed following an incident, but there is no specified timeframe on length of 1:1 supervision, just cannot be indefinite. DON-B indicated this is due to staffing and cannot accommodate 1:1 supervision for residents' long term. DON-B informed Surveyor that R6 was requiring 1:1 monitoring while in the hospital and the facility cannot care for R6 in the facility. Surveyor expressed concern regarding R6's discharge and requested the physician's documentation of assessment, reason, and services the facility cannot provide for R6. DON-B indicated Medical Director-RR informed DON-B the facility could not take R6 back over the weekend due to staffing and were going to reassess R6 on Monday.On 9/16/25, at 1:31 PM, Surveyor informed the facility of the concerns. On 10/1/25, NHA-A informed Surveyor the facility does not plan to readmit R6.On 10/7/25, Interim NHA-A sent Surveyor an email containing the following documentation:A statement from RN Education-KK regarding R6 that documents: Writer called VAMC 10/03/25 and spoke to unit nurse caring for member. Unit nurse reported member very confused, still requiring being fed, most ADLs (activities of daily living) provided, and limited ability to communicate needs. Unit nurse also said member still becomes aggressive at times. Medications being adjusted. Member no longer in secure unit as 1:1 but requires a wander alert. Unit nurse feels R6 could be a safety risk for vulnerable patients due to being unpredictable.A statement from Interim NHA-A regarding R6 documents: Member continues to reside at VA medical Center in Milwaukee, WI.9/12/25: Program Manager [Name] MSW (Master Social Work) at VA medical center inquired on status of member with hospital. Member is still an inpatient on our PCU stepdown unit. R6 still has a CPO/1-1. He'll need to be off the 1-1 and behaviorally stable before a facility will take him.10/3/25: RN Contacted VA Medical Center to obtain update on R6. See RN notes attached.R6's Hospital Medical Record Progress notes dated 8/28/25 documents:Spoke to daughter and Pt has long history of violent behaviors including beatings, threats, and assaults/threats with weapons. He is able to be stabilized on medication regimens, but quickly becomes agitated with any changes to his regimen. At this time there is substantial medical reasoning based on patterns of behavior, not to mention safety concerns, that I can recommend that no medication weans should be attempted on this Pt, except as determined by his primary geriatrician.#Dementia, c/b behavioral issuesPer family, Pt is known to be violent at times but is generally cooperative when on a stable regimen. Followed geriatric outpatient for medical management. See above for details.PLAN:PTA risperidonePTA memantinePTA duloxetinePRN olanzapine 5mg POPRN olanzapine 5mg IMPRN trazadone 50mg [NAME] 9/16/25, at 12:24 PM, Surveyor interviewed DON-B. DON-B indicated DON-B went to visit R6 at the hospital on 9/3/25 and R6 was so heavily medicated, started on trazodone, indicating R6 could not eat and was changed to a pureed diet. DON-B indicated R6 needed to be off the new medications before allowing R6 back to the facility. DON-B included the Medical Director informed DON-B the facility could not take R6 back over the weekend due to R6 needing to be a 1:1, which the facility did not have the staff to accommodate that need. DON-B indicated the plan was to call back to the hospital on Monday and reassess R6. DON-B indicated, DON-B informed R6's family member, R6 would not be discharged from the facility following the 30 day notice until placement was found, POA then informed DON-B to just discharge R6 from the facility. The facility provided Surveyor with a document titled Order Summary Report for R6. Surveyor noted that on 8/27/25, R6 was sent to the hospital prescribed the following relevant medications: Risperidone 0.5mg two times per day and Duloxetine 60mg once per day.Surveyor reviewed the Hospital paperwork, dated 9/2/25, which documents R6's current active relevant medications are as follows: Duloxetine 60mg daily, Olanzapine Injection 5mg/0.5 vial as needed, risperidone 0.5mg twice per day as needed, risperidone 1mg every 12 hours, and Trazodone 50mg as needed twice per day.On 9/17/25, at 10:30 AM, Surveyor spoke with Hospital RN-EEE, who informed Surveyor that based on Hospital documentation, R6 was calm and cooperative on 9/3/25, has a history of being difficult to arouse, did not have a 1:1 in place, was not restrained, and did not receive any of R6's prescribed as needed medications (risperidone, olanzapine and trazodone) in the hospital until 9/10/25. RN-EEE explained that R6 was on a pureed diet due to a failed swallow study. Surveyor noted that a change in R6's medications would not prevent R6 from returning to the facility. As of the time of the exit of the survey, R6 remained at the hospital and had been discharged from the facility. No additional information was provided as to why the facility's physician did not document the specific needs for R6 that cannot be met at the facility, the facility's attempts to meet R6's needs, and the services available at the receiving facility to meet R6's needs for R6 to have an appropriate discharge.

Based on observations, interviews, and record review, the facility did not ensure a resident (R14) with hearing impairment received proper treatment and assistive devices for 1 (R14) of 1 residents reviewed for assistive devices.Findings include:Surveyor requested a policy or procedure from the facility for residents requiring assistive devices for hearing, vision, and/or dental. Surveyor was notified that the facility had no policy or procedure for assistive devices.R14 was admitted the facility on 2/12/2020 with diagnoses of Dementia (progressive decline in thinking, communication, speech, and memory that interfere with daily life), Cognitive Communication Deficit (communication deficit from decline in memory, problem-solving, or attention), Post-Traumatic Stress Disorder (PTSD) (difficulty living day to day life due to experiencing a traumatic event), Adjustment Disorder with Depressed Mood (loss of interest in activities that were once enjoyable).R14's Quarterly Minimum Data Set (MDS) completed 6/5/25 documents a Brief Interview for Mental Status (BIMS) score to be a 12, indicating that R14 is moderately cognitively impaired. R14's MDS also documents that R14 does not wear hearing aids and hears with minimal difficulty.Surveyor reviewed annual MDS completed 9/24/2024 - section B, that documents R14 has minimal hearing deficit and does not wear hearing aids. In this section, a CAA is triggered and RN-P documents .member has minimal difficulty hearing, no hearing aids.R14's care plan initiated 9/18/21 documents that R14 has a communication problem r/t (related to) cognitive impairment, Hard of hearing. Under the interventions section it documents:- Ensure hearing aid(s) left and right is in place. collect at HS (hour of sleep)R14's Kardex as of 9/10/25, instructs nursing staff on dressing/Splint care, documents:- Ensure hearing aid(s) left and right is in place. Collect at HS (night) to be stored in the medication room.R14 physician order dated 2/29/2020 to 2/3/2025 documents an order for R14 to wear hearing aids.Surveyor noted that R14 did not have a current physician order to be wearing hearing aids. However, Surveyor noted that in R14's TAR (Treatment Administration Record) there was an order for nursing staff is to document the application and/or removal of hearing aids. Facility staff had been documenting that R14 had his hearing aids put in the morning and removed at bedtime from 2/29/2020 to 2/3/2025.On 7/14/2025, R14 had an altercation with another resident, the facility completed an investigation and identified the root cause is R14 being hard of hearing.On 9/10/2025, at 8:59 AM, Surveyor observed R14 sitting in the common area watching television (TV) away from R8 and R10. Surveyor noted that R14 appeared well groomed, had glasses on but Surveyor did not observe R14 to be wearing any hearing aids. On 9/10/2025, at 10:53 AM, Surveyor observed R14 in common area watching TV. R14 is separated from R8 and R10. Surveyor observed R14 to not have any hearing aids in R14's ears.On 9/10/2025, at 11:04 AM, Surveyor interviewed certified nursing assistant (CNA)- H about R14's hearing aids and ability. CNA- H stated R14 hears from the right ear better but is unsure if R14 has hearing aids. CNA-H looked around R14's room and did not locate any hearing aids and stated the members will have a pouch or a container for the hearing aids.On 9/11/2025, at 8:44 AM, Surveyor observed R14 sitting in the main common area separated from R8 and R10. Surveyor observed R14 to not have any hearing aids in R14's ears.On 9/11/2025, at 9:29 AM, Surveyor interviewed Family Member (FM) -K regarding R14's hearing aids. FM -K stated the hearing aids were lost about a year ago and that is the last time Family-K is aware that R14 had hearing aids. FM -K stated that a grievance was not filed to their knowledge. FM -K stated that R14 would sometimes take the hearing aids out and the staff would keep them so they would not get lost. FM -K stated that R14 would benefit from having the hearing aids.On 9/11/2025, at 11:30 AM, Surveyor observed R14 sleeping in the common area in a recliner with a blanket on R14. Surveyor observed R14 to not have any hearing aids in R14's ears.On 9/11/2025, at 12:44 PM, Surveyor observed R14 separated from R8 and R10. Surveyor observed R14 to not have any hearing aids in R14's ears.On 9/11/2025, at 1:21 PM, Surveyor interviewed Director of Social Services (DSS)-D regarding the grievance process. DSS-D states DSS-D is the grievance officer for this facility, a list of grievance officials can be found on each floor, and this grievance process is reviewed upon admission. DSS-D states if a family member reports an issue to the nurse or other staff, then the staff member is responsible for filing the grievance and processing it to DSS-D.On 9/11/2025, at 1:43 PM, Surveyor observed R14 in R14's room watching TV. Surveyor noted that the TV was extremely loud and can be heard from several rooms away. Surveyor asked R14 if the TV could be turned down for interview. R14 agreed and Surveyor observed the TV volume setting had been set to 100, which is the. volume setting the maximum the TV can be set to.Surveyor asked R14 if R14 has hearing aids, R14 stated yes and that the hearing aids were put at the front desk a long time ago. R14 stated R14 would wear the hearing aids if another pair was provided. R14 states R14 would be very happy to have hearing aids again and feels it would help R14 talk to others and hear R14's TV.Surveyor reviewed the facility's grievance log noted that on 9/6/2022, FM -K had reported the hearing aids missing for quite some time. It was found that a staff member had placed them in the medication room due to the hearing aids being broken. The hearing aids went out for repair.Surveyor reviewed R14's Electronic medical record (EMR) and a progress note from 9/7/2022 at 11:32 AM written by Former Social Services-C documents the hearing aids were left at the front desk and the driver was notified.R14's progress note dated 9/23/2022 at 10:45 AM documents the return of the hearing aids and they are in place by Registered Nurse (RN)-G.R14's Audiologist ([NAME])-G note dated 1/24/25 documents R14's responsive capacity as confused and a limited evaluation from R14's lack of compliance with the test but suggests moderate hearing loss. [NAME]-G documents R14's clinical findings for degree of hearing loss as could not establish hearing loss. [NAME]-G recommends: Slow clear speech with Visual cues, No further testing required.R14's progress note dated 2/3/25 at 8:14 AM written by LPN-N documents: No hearing aids available.Surveyor noted that R14's physician order for hearing aids was discontinued on this date with no explanation.On 9/15/2025, at 10:48 AM Surveyor interviewed Director of nursing (DON)-B regarding the process for replacing or repairing assistive devices. DON-B informed Surveyor that the that the unit clerk that handled repair and/or replacement and scheduling appointments for audiology is no longer working at the facility and there is a new employee being trained currently.On 9/15/2025, at 10:55 AM, Surveyor interviewed Director of Activities (DA)-F. DA-F informed Surveyor that R14 participates in activities two to three times a week. DA-F stated DA-F can't recall R14 ever having hearing aids. DA-F states it would be helpful for R14 to have hearing aids as R14 does have difficulty hearing. DA-F states R14 will let others know if R14 cannot hear them or has trouble understanding.On 9/15/2025, at 11:08 AM, Surveyor interviewed Activity Aid (AA)-E. AA-E stated that AA-E has never seen any hearing aids or assistive devices for R14's hearing while employed at the facility. AA-E stated R14 is quiet and likes independent activities and is not sure if giving new hearing aids would improve quality of life but feels it should be attempted as it potentially could increase quality of life and improvement in socializing.On 9/15/2025, at 3:22 PM, Surveyor shared a concern with DON-B and Administrator-A that R14 is missing hearing aids. The facility had no additional information to provide at this time.On 9/16/2025, at 9:42 AM, Surveyor interviewed Registered Nurse (RN)-O about R14's hearings aids to verify that R14's hearing aids are not in the building. RN-O stated RN-O has never seen R14 with hearings aids. RN-O showed surveyor where hearing aids and other individual devices are stored. RN-O stated each resident has their own bin with their name on it. RN-O showed surveyor where the hearing aids are kept. Surveyor observed multiple charging cases for hearing aids that are plugged into the power. Surveyor observed that each hearing aid box has resident names, medical record number, and room number on them. R14's name was not amongst the hearing aid charging cases.On 9/16/2025, at 9:53 AM, DSS-D shared additional information regarding R14's hearing aids. DSS-D stated that DSS-D sent a message to the in-house audiology group to schedule an appointment for R14 and is awaiting response back from audiology.No additional information was provided.

Based on observation, record review, and staff interviews, the facility did not ensure that 1 out of 4 residents (R2) reviewed remained free from sexual abuse. R2, a female resident with a significant history of PTSD (post-traumatic stress disorder) and a history of sexual assault was inappropriately sexually touched by R1. The facility's failure to keep R2 safe from and free from sexual abuse created a finding of immediate jeopardy that began on 5/6/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 5/29/25 at 3:50 p.m. The immediate jeopardy was removed on 5/30/25, however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy last revised on July 2, 2024 and titled, Prohibition and Prevention of Member (Resident) Abuse, Neglect, and Exploitation documents: *All staff shall be expected to immediately report any, and all, observed or alleged abuse and other reportable incidents. *Immediate intervention shall be initiated to maintain member safety with all observed or suspected allegations. Reporting: (includes) 1.) On observation of actual or suspected abuse, or other reportable incident, staff immediately reports the event to the RN (Registered Nurse), nursing supervisor, or facility NHA. 2.) The RN and unit staff immediately develop a plan to maintain member safety, removing any potentially harmful agents/situations and conducts an initial evaluation of the circumstances. 5.1) If the incident resulted in serious bodily injury, notification to local law enforcement is required within 2 hours of forming suspicion. Incidents not resulting in serious bodily injury must be reported to law enforcement no later than 24 hours after forming the suspicion. 8.) A list of possible witnesses is given to the nursing supervisor as soon as possible. 10.) The Social Worker will be involved in taking statements from the members involved in the situation and those who also could have been affected by this or similar incident. 1.) R1 was originally admitted to the facility on [DATE] with diagnoses that include PTSD (Post-Traumatic Stress Disorder) (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), dementia, and Cognitive Communication Deficit. R1's Minimum Data Set (MDS) dated [DATE] documents that R1 has a BIMS (Brief Interview for Mental Status) score of 8, indicating that R1 has moderate cognitive impairment. The MDS documents that R1 is ambulatory and can walk at least 150 feet and turn twice with supervision of staff. The MDS documents that R1 uses a 4 wheeled walker and exhibits no behaviors. Surveyor conducted a review of R1's individual plan of care and noted: R1 has a potential for wandering with walker, R1 attempted to visit his old room, found outside in parking lot looking for a ride. This care plan was initiated 9/29/21 and last revised 6/8/24. The resident has impaired cognitive function due to dementia. R1's behavior care plan was written on 2/14/23 and documents that R1 has potential for aggressive or threatening behavior due to dementia. Interventions include that R1 likes personal space and encourage staff and other residents to respect R1's space. Targeted behavior is striking out at staff or peers. R2 was admitted to the facility on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD), Personal History of Physical and Sexual Abuse, Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), Recurrent, Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), Personal History of Other Mental and Behavioral Disorders, dementia, Severe, with Mood Disturbance (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), and Early Onset Alzheimer's Disease (progressive disease that destroys memory and other important mental functions.) R2's care plan includes an intervention initiated on 2/11/25 that documents R2 is to have only female caregivers due to history of trauma. R2's Quarterly MDS dated [DATE] documents that R2's short- and long-term memory is impaired and R2 demonstrates severely impaired skills for daily decision making. The MDS documents that R2 has no depressive or behavioral symptoms. The MDS also documents: R2 has clear speech, is understood, and understands; R2 requires set-up for eating, supervision for mobility, and substantial/maximum assist for transfers; R2 is dependent for showers; R2 has no range of motion impairment and R2 is independent with ambulation. On 5/6/25, the facility submitted the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report (F-62617) to the state survey agency. The form indicated that on 5/6/25, Resident (R1) reached out and grabbed another resident (R2). The date and time this occurred is documented as 5/6/25 at 11:00 a.m. The report documents that the time the facility discovered the alleged abuse/mistreatment was at 3:00 p.m. on 5/6/25. This form was submitted by NHA-A. On 5/12/25, the facility submitted the Misconduct Incident Report (F-62447) which documented the facility became aware of a resident to resident altercation. The report documents that the date/time the incident occurred is 5/6/25 at 1:30 p.m. The report asks the facility to explain the steps taken, upon learning of the incident, to protect the affected person(s) and others from further potential misconduct. The facility report documents: residents placed in safe location and investigation ensued. The affected person is listed as R2, and the accused is listed as R1. The facility documented that law enforcement was not contacted or involved. Persons with knowledge of the incident are listed as Laundry Aide-C, CNA (Certified Nursing Assistant)-D and RN (Registered Nurse)-F. The report also contained a typed summary from NHA-A about the incident. Surveyor noted the following: On Tuesday, May 6, 2025, this writer (NHA-A) was informed by laundry staff member of a resident-to-resident altercation whereby a male resident (R1) placed his hand on female resident (R2) crotch as she was walking near him. At the time of the incident, the nurse on the unit was made aware and both residents were immediately separated and maintained in a safe situation. This writer (NHA-A), DON-B and ADON (Assistant Director of Nursing)-E were also informed of the situation. Both residents (R1 and R2) live in the Memory Care area of our community, and both have activated Power of Attorneys (POA). R1 has a BIMS score of 9 (moderate cognitive impairment) on 3/12/25 and R2 has a BIMS score of 1 (severely impaired cognition) as of 2/24/25. Due to the cognition deficit and dementia diagnosis, it was determined that we were not able to immediately determine the psychological or emotional harm on the female resident (R2), so a self-report was submitted to Department of Health Services of Caregiver Quality. Activated POAs for both residents were communicated with as to what the situation was and how we are going to move forward to keep our residents safe. Male resident (R1) was moved to a different unit where no female residents reside and continues on 30-minute checks to assure safe distance from female residents. We will continue to monitor his adjustment to the new room/wing for any adverse effects. Female resident's (R2) mood and behavior indicated no immediate adverse effect from this altercation. We will continue to monitor. Care plans were reviewed by nursing and updated and consent for psych services for male resident (R1) was received from POA. Female resident (R2) involved in the altercation will be monitored for psycho-social/mood and/or behavior changes because of this situation and care plan updated as needed to assure safety and well-being. No other residents were identified as being at risk because of this altercation, but again, we will continue to monitor and provide a safe and secure environment for all. Surveyor conducted a review of the written statements that were included with the misconduct report. On 5/6/25, a member grievance/concern form was filled out by Laundry Aide-C. The form documented that R1 and R2 were involved and that Laundry Aide-C was delivering linens, R1 had grabbed R2 in the crotch. And then R2 walked back over and R1 grabbed her in the butt. The aide stated that it has been going on for a while. On 5/28/25 at 11:20 a.m., Surveyor interviewed Laundry Aide (LA)-C regarding what she witnessed between R1 and R2 on 5/6/25. LA-C stated that it was early in the afternoon on 5/6/25 and she was delivering resident laundry on the unit. R2 had come over to LA-C and gave her a hug, something she would do often, and continued to walk about the hallway. R1 was seated in a chair at the table near the nursing desk. LA-C stated that when R2 walked past R1, he scooted in the chair towards R2 and grabbed her in the crotch. LA-C said to R1 you can't do that, that is not nice. R2 appeared shocked and walked away. R2 continued to walk up and down the hallway and again past LA-C. LA-C stated that when she walked past R1 again, approximately 5 minutes later, R1 grabbed R2 in the butt. LA-C said she told R1 again, that is not nice. LA-C stated that R2 was then guided over by the dining room table and R1 stayed where he was originally seated. LA-C stated she is not sure what they (unit staff) did after that. LA-C stated that she then reported what she witnessed to her boss. LA-C stated that the nurse was aware what happened as she was in the area. LA-C stated that her boss brought her down to report what she saw to DON-B and ADON-E, who then alerted NHA-A. LA-C said she gave her statement, and someone had typed it out and she signed it that day. Surveyor asked LA-C how did R2 respond to the incidents. LA-C stated that R2 appeared shocked that it happened. LA-C stated she had never seen this happen between R1 and R2 before. A written witness statement from CNA-D was reviewed by Surveyor. The statement, dated 5/6/25 at 4:25 p.m., documented that the incident involved R1 and R2 on 5/6/25 at approximately 7:30 a.m. CNA-D documents that on 5/6/25 at approximately 1:30 p.m., not too long after lunch, R2 was walking the hallway per usual as she does. R1 was sitting in his chair. As R2 walked by R1, R1 reached out and grabbed R2 touching her butt area. R2 exchanged words with R1. Nurse instructed R1 to not touch R2 again. To my knowledge, R1 heard her and nodded. Shortly after, then R2 continued to pace the floor and R1 touched R2 front area which caused R2 to be upset. Floor nurse then intervened and instructed R1 to move from his original sitting area to a new table out of the way of R2. Also, the behavior from R1 is not new. He has tried this before. On 5/28/25 at 12:07 p.m., Surveyor interviewed CNA-D regarding the incident on 5/6/25 with R1 and R2. CNA-D stated that R2 paces the hallways all day long, this is her usual thing that she does. CNA-D recalls that it was in the afternoon, after lunch, on 5/6/25 when R1 was seated in his specific spot at a table near the nurse's desk and hallway. CNA-D stated she was seated in the dining area and watched R2 walk past R1, and he tried to grab her. R2 tried to say the f-word several times and kept walking. The 2nd pass through the common area, R1 grabbed R2 in the butt. I yelled for R1 to stop and let her go. CNA-D reported to the nurse right away. The nurse got up from the desk and intervened. R2 continued to walk the hallway and a little bit later (unknown how long) R2 walked by R1 again and this time he grabbed her front area (crotch). CNA-D stated that R2 said stop aggressively. She asked R2 if she was alright and R2 just kept walking away from the area. The nurse heard the commotion and intervened again by having R1 move to the dining room table so R2 could walk freely in the common areas. CNA-D stated that the staff were told to keep R1 and R2 separated by having R1 move tables. CNA-D stated that she has seen R1 try to grab for R2 previously and R2 will yell out stop. CNA-D stated that she does not know why R1 wasn't moved after the first time he was able to grab and touch R2. CNA-D stated that the nurse was aware of the situation because she heard all of the yelling and commotion. On 5/12/25, a written statement was submitted from RN-F regarding the incident between R1 and R2. The statement indicates that RN-F, on May 6, 2025, was notified by Laundry Aide that R1 was attempting to touch another member (resident) inappropriately. Writer did not see incident however got up and approached both members and Laundry Aide. Writer made sure both members were separate and safe. R1 remained in his seat and the other member (R2) was on the other side of the Laundry Aide. Writer was not aware of any physical contact so writer spoke to R1 and reminded him we cannot touch others. A little while later, R2 was walking down the halls on the unit and R1 attempted to touch R2 again. Writer removed R1 to another table out of the hallway view. Again, R1 did not make contact from writers acknowledgement however due to members dementia writer was unsure if member (R1) would continue to attempt to touch other members. Member (R1) was ok with moving to a different table. On 5/29/25 at 10:45 a.m., Surveyor interviewed RN-F regarding the incident that happened between R1 and R2. RN-F confirmed that she was working on day shift 5/6/25. RN-F stated that she did not observe anything happen between R1 and R2. RN-F stated that she also was not told that R1 touched R2, only that he had attempted to touch her. RN-F stated that when she first heard that R1 had tried to touch R2 she stated that the two residents need to be separated, and staff should be on high alert. RN-F stated that she had been busy doing charting and passing medications at the time. RN-F stated that the first report came from the laundry aide that R1 was trying to touch R2. RN-F stated that she then asked where was R2. R2 was walking in the hallway as she always does. RN-F stated that she told staff to just monitor the 2 residents. RN-F stated that awhile later, she heard the aide say to R1 NO so she got up from the nurse's desk and R1 was sitting in the same spot he was previously and R2 had already walked away down the hallway. RN-F stated that she was again told that R1 tried to touch R2, so she said we must move R1. RN-F said that they moved R1 to a table near the window facing the TV and out of the walkway. RN-F stated that nothing happened after that. RN-F stated that she emailed her statement to the NHA, as she works part time and was not back at the facility for a few days. RN-F stated that she had never witnessed R1 try to touch R2 like that before. On 5/29/25 at 1:50 p.m., Surveyor interviewed RN-H regarding the incident between R1 and R2 on 5/6/25. RN-H stated that the incident happened on his shift as he worked 2nd shift on 5/6/25. RN-H stated that when he was getting report at the beginning of his shift from the 1st shift nurse, he received a rough description of what happened between R1 and R2. Then ADON-E came up to the unit and stated that he was not happy about the whole situation. Surveyor asked what that meant. RN-H stated it was maybe because it took too long to report it. RN-H stated he was instructed to document the incident in the electronic record. RN-H stated that he felt this incident was kind of building up between R1 and R2. He has witnessed R1, on a number of occasions, try to reach out and grab R2's hands. R1 would want to look at R2's tattoos closer. RN-H stated that R1 has Parkinson's and R2 walks very quickly so he was surprised that R1 was able to make contact with R2. RN-H stated that R2 would walk by R1 500 times a day because that is all she did was pace the unit. RN-H stated R1 would watch R2 walk by and sometimes would yell out Hey to get her attention. It didn't seem to bother R2 at all. R1 does not talk much and R2 has a lot of difficulty making her needs verbally known. RN-H stated he was instructed to put R1 in 1 to 1 supervision until he could get the incident documented in the medical chart. DON called the families and notified them of the situation. RN-H stated that after the reports were written, he believed R1 was then on 30-minute checks. Surveyor noted discrepancies within the facility's investigation regarding the incident that occurred on 5/6/25 between R1 and R2. The written summary provided by NHA-A documents that there was only 1 time where R1 touched R2 inappropriately on 5/6/25. Both witness statements from Laundry Aide-C and CNA-D state that R2 was touched 2 different times, 1 time in the crotch area and 1 time in the butt by R1. Both witness statements state different times that these incidents occurred. The summary indicates that nurse was aware of the incident and separated R1 and R2 to maintain a safe situation, although R1 was able to grab and touch R2 a second time. The time between these 2 incidents is not reflected in any of the witness statements, only that R2 had walked away after the 1st incident and sometime later walked by R1 again and he grabbed her. NHA-A first identified the incident as happening at 11:00 a.m. on 5/6/25 and not discovered by the facility staff until 3:00 p.m. on 5/6/25. The 2nd submitted report to the state agency indicates the incident occurred at 1:30 p.m. on 5/6/25. The written statement from Laundry Aide-C does not indicate a time of occurrence, although the statement from CNA-D states the time of the occurrence was 7:30 a.m. on 5/6/25. The written statement from RN-F does not indicate what time she was notified or what time she took corrective action to keep the residents safe. Surveyor also noted that the facility did not thoroughly investigate this incident by interviewing all staff who may have had knowledge of this incident. A review of the schedule for 5/6/25 shows that 5 staff members were working on the unit for the morning shift (6:30 am-3:00 PM) in addition to Laundry Aide-C being on the unit returning resident clothing. Surveyor conducted further review of R1's medical record for further clarification of the incidents between R1 and R2. The following was noted: R1's nursing note dated 5/6/25 at 4:27 p.m. documents: Writer called POA to give update on member behavior of reaching out to touch female members. Left message to call back. This note was written by DON-B. R1's nursing note dated 5/6/25 at 5:15 p.m. documents: Member (R1) noted to reach out and grab fellow member R2 in a purposeful and inappropriate physical contact with member's genital/buttock area. Member (R1) has attempted to reach out and grab R2 in the past but has not targeted such areas and been successful. This note was written by RN-H who worked the 2nd shift on 5/6/25. R1's Incident note dated 5/6/25 at 5:19 p.m. documents: Follow-up: new intervention implemented and added to Treatment Plan of Care. Seating situation permanently changed. This note was written by RN-H. Surveyor reviewed R1's plan of care and noted it was updated with the following: On 5/6/25, the care plan was updated stating that R1 has actual problem of reaching out for inappropriate touching of other members. Interventions added on this date included: During non-meal hours R1 should be encouraged to be in the area over by the other male residents due to repeated reaching out in inappropriate manners to other residents. Encourage R1 to sit in the common area and not in hallway to prevent reaching out to females. 5/7/25 30-minute checks to ensure that when member is seated in common area that he is with other male members and not in common walkway areas utilized by pacing members. 5/8/25 targeted behavior is inappropriate touching of female staff or members. R1's IDT (interdisciplinary team) note dated 5/7/25 documents: Summary of discussion (late entry): met to discuss incident. All proper parties notified. Interventions: 30-minute checks to ensure that when member (R1) is seated in common area that he is with other male members and not in common walkway areas utilized by pacing members. During non-meal hours, R1 should be encouraged to be in area over by the other male members. Encourage member (R1) to sit in the common area and not in hallway to prevent reaching out to females. Monitor member (R1) behavior around female members. This note was written by ADON- E. R1's nursing note dated 5/7/25 at 1:38 p.m. documents: Per ADON-E, Member (R1) is on 30-minute checks. ADON-E updated members (R1) care plan. Member (R1) currently off the unit and out of the building with activity staff. Surveyor did request to see evidence that the 30-minute checks were being completed. The facility provided documentation with 30-minute checks starting at 1:40 p.m. on 5/7/25 until R1 moved to a different unit on the afternoon of 5/8/25. R1's communication note dated 5/7/25 at 4:30 p.m. documents: This writer met with member's (R1) POA and discussed a psychiatry referral for member. This POA was agreeable to transition R1 to see the in-house psychiatrist for a more integrated care approach instead of R1 going out to see a psychiatrist outside of this facility. This POA signed off on this consent. This writer and POA discussed R1's recent behavior towards female on the unit and inappropriately touching the female. This writer and POA discussed moving this member to a new unit, without females, as an intervention. This POA was agreeable to this idea, should the facility feel that it was in everyone's best interest. This note was written by SW (Social Worker)-G. Surveyor noted that although SW-G obtained consent for R1 to see the in-house psychiatrist for a more integrated approach, R1 did not actually have the initial Psychiatry evaluation until 5/19/25. R1's behavior note dated 5/7/25 at 10:29 p.m. documents: Member (R1) did not make contact; member emerged from his room with his walker and attempted to grab R2's arm however R2 walked away too quickly for R1 to make contact with her. Member noted to have 1 attempt to reach to and grab member (R2). This member (R1) did express great remorse to the writer and volunteered a promise to never do it again. Note written by RN-H. On 5/29/25 at 1:50 p.m., Surveyor interviewed RN-H. RN-H confirmed that on 5/7/25, he observed R1 come out of his room with his walker and try to grab R2 as she was walking by. R1 didn't really make contact, just grazed R2's arm. There is a speed difference in R1 and R2, she is fast to move. RN- H stated that he believed R1 was definitely interested in R2, although he doesn't show much interest in anything else. R1's communication note dated 5/8/25 at 12:00 p.m. documents: This writer called members (R1) POA and left a voice mail message. This writer informed POA of members (R1) room move to a new unit as an intervention to member's inappropriate touching towards a female peer on current unit. Note written by SW-G. On 5/29/25 at 11:46 a.m., Surveyor interviewed SW (Social Worker)-G regarding the incident between R1 and R2. SW-G stated that she does not recall how she found out about the inappropriate touching between R1 and R2. SW-G stated that she did not conduct any interviews with R1 or R2 immediately following the incident. SW-G sated that she did speak with R1's POA regarding having a psych evaluation and this was over the phone on 5/7/25. R1's POA did give consent to the evaluation and a room change. Surveyor asked SW-G why R1 did not have his initial psych evaluation until 5/19/25. SW-G stated she wasn't exactly sure but believes the in-house Psychiatrist was out on vacation and only comes to the facility every Monday. Surveyor asked SW-G when R1 moved rooms to a different unit on a different floor. SW-G stated that R1 moved in the afternoon of 5/8/25. Surveyor asked SW-G why R1 wasn't moved on 5/7/25 after the POA gave permission. SW-G stated she doesn't know why there was a delay in moving R1, maybe they didn't have a room ready or the manpower to move his belongings. Surveyor asked SW-G if she was aware that R1 attempted to grab R2 again after coming out of his room on 5/7/25. SW-G stated she was not aware of this. SW-G stated that interventions were put in place for 30-minute checks for R1 but not for R2. Staff were to be looking for any reactions to the incident from R2 and chart them in the electronic medical record. The delay in moving R1 created a very vulnerable situation and did not protect R2 from further sexually inappropriate touching. Given R2's extensive history of multiple trauma, especially sexual assault, this left R2 to be very vulnerable and any reasonable person would have the potential to respond to the actions of R1 in a negative way. On 5/28/25 at 10:49 a.m., Surveyor interviewed NHA-A in regard to the incident between R1 and R2 on 5/6/25. Surveyor stated to NHA-A that upon reviewing the written summary, it only identifies that R1 touched R2 inappropriately one time. The written witness statements document that R1 touched R2 twice. NHA-A stated that she thought it all happened at the same time. Surveyor asked NHA-A if she was aware what time the incidents happened because the facility's report documents 11:00 a.m., 1:30 p.m., witness statement says 7:30 am, and another states after lunch. NHA-A stated she does not recall what time she was notified and did not know the times of the incidents. NHA-A confirmed that the police were not called per the policy within 24 hours. NHA-A was asked what was done to protect the residents. NHA-A stated that R1 and R2 were separated. Surveyor asked if R1 and R2 were separated for safety, why was R1 able to touch R2 inappropriately a second time. NHA-A stated that NHA-A thought it all happened at the same time. On 5/28/25 at 2:28 p.m., Surveyor interviewed DON-B regarding the incident between R1 and R2 on 5/6/25. DON-B stated that she was made aware initially by ADON-E that the laundry aide had witnessed R1 touch R2 inappropriately. DON-B stated that she instructed ADON-E to gather interviews with any witnesses and find out where the incident happened. DON-B stated that she was not involved in the investigation because she was out of the facility for the next week immediately following the incident. DON-B stated that she was very concerned about R2 given her traumatic history with abuse and having flashbacks. DON-B stated that immediately following the incident, R1 was put on 15-minute checks and staff were to keep an eye on both R1 and R2 for any changes in behaviors. When R1 is out of his room, he is to sit in a more supervised area. DON-B is not aware of any other times where R1 inappropriately touched R2 or the other female residents on the unit. On 5/28/25 at 2:52 p.m., Surveyor interviewed ADON-E regarding the incident that occurred with R1 and R2 on 5/6/25. ADON-E stated he could not give a time of when he was notified but remembers the girl from laundry came into the conference room and told us she witnessed R1 touch R2 inappropriately. ADON-E stated that R1 had grabbed R2 in the crotch and then also grabbed her in the butt. ADON-E stated he immediately notified NHA-A because the issue needed to be addressed right away. ADON-E stated that an investigation began immediately and put R1 and R2 on 15-minute checks, if he remembers correctly. ADON-E stated that there were no behavioral changes to R2, and staff was keeping the 2 residents separated. Surveyor asked ADON-E what type of behaviors that the staff was monitoring for R2 to determine if she had been affected by this situation. ADON-E said they are watching all behaviors but could not give specifics for either resident. Surveyor noted that facility staff were aware that R1 had made several attempts to touch R2 as she would walk past him, although many thought it was harmless in intent. On 5/6/25, R1 was seated in a stationary chair at a table near the nurse's desk when R2 walked by. R1 grabbed R2 in the crotch, making R2 yell out stop and quickly walking away from the area. Staff told R1 that this was not nice of him and not to do it again. R1 remained seated in the same chair at the same table when R2 walked by again sometime later. R1 then grabbed R2 in the butt. R2 tried to swear at R1 and quickly walked away again. Staff determined that an immediate intervention was to move R1 to an area away from the walking path of R2. After NHA-A, DON-B, and ADON-E became aware of the situation, an investigation began and R1 was placed on 30 minute checks. DON-B thought it was 15 minute checks, but there was no evidence of this. R1's plan of care was updated with the interventions of having his seat moved when in the common area and staff are to observe him every 30 minutes. In the meantime, the afternoon of 5/7/25, R1 was able to walk out of his room and attempt to grab at R2 as she walked by in the hallway. R1 was moved to another unit on a different floor 2 days after the incident. The facility's failure to keep a resident free from sexual abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on 5/30/25, however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan: - Identified RN was suspended pending completion of investigation. - All staff have been in-serviced by their next scheduled shift on prohibition and prevention of member abuse, neglect, and exploitation with reporting expectations. - IDT team was educated on the process of trauma assessments, identification of the need for a trauma care plan and the necessitation of ongoing monitoring and auditing of interventions success. - All staff will be in-serviced by next scheduled shift assigned training regarding identifying trauma triggers and mitigation strategies. - Abuse screening was completed by a sampling of members. - All new admissions will be assessed and anyone who triggers for trauma needs will have those needs care planned by the IDT team, interventions will be evaluated and adjusted if needed monthly for 3 months and then quarterly results of assessments and interventions of new admissions will be reviewed in QAPI. No additional information was provided.

Based on interview and record review, the facility did not ensure that a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), received appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being for one (R2) of 4 residents reviewed. *R2's social history documents R2 experiencing trauma as an adult including sexual assault and having war related trauma resulting in a diagnosis of Post Traumatic Stress Disorder(PTSD). R2's Life Events Checklist for DSM-5(LEC-5) indicates R2 has a history of trauma and R2's comprehensive care plan was not individualized with known triggers, person-centered interventions, and/or goals related to R2's past history of trauma. Based on R2's history of trauma, R2 is vulnerable and on 5/6/25, the facility did not protect R2 from unwanted sexual contact from R1. Findings Include: Surveyor noted that the facility was not able to provide a policy and procedure for trauma informed care. The facility's Facility Assessment Tool dated May 2024 documents: .Psychiatric/Mood Disorders-psychosis, impaired cognition, mental disorder, depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, behavior that needs interventions . as a category of Residents that the facility is able to provide the care and meet the needs of Residents in that category. Currently the facility has an average of 23 requiring behavioral health needs. The facility documents mental health and behavior services are provided by: .manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities . Competencies Include: .Caring for Residents with mental and psychosocial disorders, as well as Residents with a history of trauma and/or PTSD, and implementing non-pharmacological interventions. 1.) R2 was admitted to the facility on [DATE] with diagnoses of Post-Traumatic Stress Disorder(PTSD)(a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), Personal History of Physical and Sexual Abuse, Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), Recurrent, Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities), Personal History of Other Mental and Behavioral Disorders, Dementia, Severe, With Mood Disturbance(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), and Early Onset Alzheimer's Disease(progressive disease that destroys memory and other important mental functions). R2's Quarterly Minimum Data Set(MDS) completed 5/13/25 documents R2's short and long term memory is impaired and demonstrates severely impaired skills for daily decision making. R2's MDS documents R2 has no depressive or behavioral symptoms. R2's MDS documents R2 has clear speech, is understood, and understands. R2 requires set-up for eating, supervision for mobility, and substantial/maximum assist for transfers. R2 is dependent for showers. R2 has no range of motion impairment and R2 is independent with ambulation. R2's current physician orders document R2 is receiving: -Aripiprazole 5 mg 1 tablet in morning for dementia with mood disturbances -Busipirone HCI 10 mg every morning and at bedtime for anxiety -Duloxetine HCI 60mg 2 capsules in morning for PTSD, Depression, Mental Health to PTSD, Chronic and Major Depressive Disorder R2's current Treatment Administration Record(TAR) documents R2's targeted behaviors are: -Behavioral Disturbances -Crying -Restless -Anxiety The facility is monitoring R2's targeted behaviors each shift. Surveyor reviewed R2's TAR for month of May and noted that from May 1-May 28, R2's targeted behaviors on 2nd shift occurred 12-18 times compared to 1st and 3rd shift where the targeted behaviors were 0-3 occurring. Surveyor also noted that R2's TAR does not document non-pharmalogical interventions put into place for staff to implement when R2 is demonstrating behavioral disturbance, crying, restless, and/or anxiety. R2's Social Service Interview completed 2/25/25 by Social Worker (SW)-G documents R2 served in the Iraq War and was in Afghanistan as part of the United States Army. R2's Social History completed 3/5/25 by SW-G documents R2 was living at an assisted living facility prior to admission to the facility. R2 was a supply specialist for the Army for 32 years. 15 years of active duty and 17 years in the reserves. R2 divorced from R2's husband in 2015 and they have 2 children, who the youngest is being raised by R2's husband. R2 has 3 other children, 1 of whom R2 gave up for adoption. R2 struggled with alcohol use in the past and has PTSD since 2002 after a long deployment in Afghanistan. R2 was raped and has anxiety. Information was provided by R2's daughter to SW-G. R2's LEC-5 completed by SW-G documents the following trauma: -2. Fire or explosion-happened to R2, R2 witnessed it, part of R2's job -3. Transportation accident-happened to R2 -5. Exposure to toxic substance-happened to R2, part of R2's job -6. Physical Assault-happened to R2 -7. Sexual Assault-happened to R2 -9. Other unwanted or uncomfortable sexual experience-happened to R2 -10. Combat or exposure to war-zone-R2 witnessed, part of R2's job -13. Severe human suffering-R2 witnessed, part of R2's job -14. Sudden violent death-R2 learned about it -17. Any other very stressful event or experience-R2 gave a child up for adoption SW-G also documented that R2 saw a little child get killed in Afghanistan. The child was strapped with a bomb. R2 experienced multiple times witnessing violent deaths as part of R2's military deployments. SW-G also documented that R2 struggled with R2's PTSD symptoms more so in the past. R2 can have sun downing around 6 PM. Surveyor reviewed R2's comprehensive care plan. Surveyor noted that there is no care plan in place for R2's past history of multiple trauma that is individualized with known triggers and person-centered interventions. Any information related to R2's multiple traumas related to R2's PTSD that SW-G obtained as documented in R2's social history and LEC-5 was not addressed further with a person-centered approach to include R2's triggers and person-specific interventions. Surveyor noted that R2's care plan includes an intervention initiated on 2/11/25 that states R2 is to have female caregivers due to history of trauma. On 5/12/25, the facility submitted the Misconduct Incident Report ( F-62447) which documented the facility became aware of a resident to resident altercation. The report documents that the date/ time the incident occurred is 5/6/25 at 1:30 PM. The report asks the facility to explain the steps taken, upon learning of the incident, to protect the affected person(s) and others from further potential misconduct. The facility documented residents placed in safe location and investigation ensued. The affected person is listed as R2, and the accused is listed as R1. The facility documented that law enforcement was not contacted or involved. Persons with knowledge of the incident are listed as Laundry Aide (LA)-C, CNA (certified nursing assistant)- D and RN ( registered nurse) (RN)- F. The report also contained a typed summary from Nursing Home Administrator (NHA)-A about the incident. Surveyor noted the following: On Tuesday, May 6, 2025. This writer ( NHA)- A) was informed by laundry staff member (LA)-C of a resident-to-resident altercation whereby a male resident ( R1) placed R1's hand on female resident ( R2) crotch as R2 was walking near R1. Surveyor conducted a review of the written statements that were included with the misconduct report. On 5/6/25, a grievance/concern form was filled out by Laundry Aide (LA)-C. The form documented that R1 and R2 were involved and that while LA-C was delivering linens, LA-C witnessed R1 grab R2 in the crotch. And then R2 walked back over and R1 grabbed R2 in the butt. LA-C stated that it has been going on for a while. On 5/6/25, R2's comprehensive care plan was updated that R2 had actual incident of being targeted with inappropriate physical contact from other member as well as a target of previous attempts to make inappropriate contact. 2 interventions were implemented on 5/6/25: -Ensure that R1 is seated on the far side of the day room and not in the pathway of R2's frequent pacing pathway. -Ensure R2 is redirected away from R1 who may continue to take opportunities to reach out to touch R2. On 5/7/25, R1 was able to walk out of R1's room and attempt to grab at R2 as R2 walked by in the hallway as documented by the facility. On 5/29/25, at 11:46 AM, SW-G informed Surveyors, SW-G does not know why there was a delay to transfer R1 to another room to another unit of the facility. R1 was not transferred until 5/8/25. The delay in moving R1 created a very vulnerable situation and did not protect R2 from further sexual inappropriate touching. Given R2's extensive history of multiple trauma, especially sexual assault, left R2 to be very vulnerable and any reasonable person would have the potential to respond to the actions of R1 in a negative way. Surveyor notes the facility's investigation of the incident between R1 and R2 indicate staff were aware that R1 was actively seeking R2 out and obsessed with R2. Based on R2's past trauma of sexual assault, the facility had not developed any person-centered interventions for R2 or were aware of any person specific triggers to be aware of that may indicate R2 was responding in a negative way to R1's unwanted attention or physical advances. R2 was first evaluated for an initial psychiatric evaluation by Psych NP (NP)-I on 4/21/25. NP-I documents that R2 is tearful and has anxious pacing on the unit and R2 reports dreams of service resulting in tearfulness. R2 was evaluated on 5/5/25 for follow-up by NP-I. NP-I documents R2 has delusions defined by flashbacks related to service due to PTSD. Surveyor noted that R2 was not evaluated by NP-I after the incident of R1 sexually inappropriately touching R2. Further, NP-I has not been asked by the facility to participate in developing a person-centered care plan to identify R2's triggers and implement person-specific interventions. On 5/29/25, at 10:52 AM, Surveyor interviewed Registered Nurse (RN)-F in regards to R2. RN-F stated R2 has trauma. RN-F informed Surveyor that R2 had been raped multiple times by peers in the Army while overseas. R2 did not deal with it upon return home and now has a diagnosis of Alcohol Induced Dementia. RN-F stated that R2 is able to answer yes and no questions appropriately. On 5/29/25, at 11:41 AM, Surveyor interviewed SW-G. SW-G stated that SW-G did not make any attempt to obtain previous mental health hospital records from veteran hospitals. Surveyor notes R2's admission signed consent included for the facility to obtain mental health records as it is indicated R2 had previous stays at 2 different military hospitals for mental health issues. Surveyor asked SW-G what is SW-G's understanding of R2's trauma/PTSD. SW-G stated all SW-G knows is that R2 was in Afghanistan and has different sexual abuse but that is the extent. SW-G stated SW-G does not know anything specific in regards to R2's past. SW-G informed Surveyor that SW-G is not the best person to ask about R2's usual behavior pattern as SW-G is not on the unit frequently. SW-G confirmed SW-G did not update NP-I about the incident between R1 and R2 and did not follow-up with R2 or R2's Health Care Power of Attorney about the incident. On 5/29/25, at 12:32 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J. CNA-J stated that R2 mumbles a lot and paces all day. CNA-J indicated R2 can answer yes/no questions appropriately. CNA-J stated that CNA-J was not surprised that the incident occurred between R1 and R2. CNA-J was told when CNA-J started employment at the facility that R1 likes to touch women and can be sexually inappropriate. He is touchy. On 5/29/25, at 1:45 PM, Assisted Living RN (RN)-K confirmed that R2 had lived at the assisted living from September of 2024 until February of 2025. RN-K stated the assisted living is predominantly female. RN-K informed Surveyor that R2 was very fearful of men during R2's stay at the assisted living. RN-K stated the assisted living sent over a lot of information on R2 including a care plan. On 5/29/25, at 2:07 PM, Surveyor interviewed RN-H. RN-H confirmed RN-H works the unit that R2 resides on, on a regular basis. RN-H does not know what R2's triggers are. RN-H stated R2 cries a lot but RN-H wishes he knew why. RN-H is aware that R2 has a past history of sexual trauma. RN-H will complete assessments of R2 including taking vitals, listening to stomach, and completing skin checks. On 5/29/25, at 3:50 PM, Surveyor shared the following concerns with NHA-A and Director of Nursing (DON)-B. Surveyor shared that R2's most documented behaviors occurred on the second shift when a regular male nurse worked on a consistent basis. Surveyor informed that the facility that it had not investigated if the behaviors could be correlated to the fact that R2 was being treated by a male nurse and this may be a trigger for R2. The facility not completing a thorough assessment of R2's multiple past trauma and related PTSD and no implementation of a person-centered care plan to address R2's PTSD, past trauma in order to reduce R2's triggers and initiate specific interventions was shared. Surveyor shared that R2 did not receive services to assist R2 in attaining the highest practicable mental and psychosocial well-being. Surveyor shared R2 did not receive appropriate person-centered and individualized treatment and services to meet R2's assessed needs. Surveyor shared that trauma informed care includes investigating the coping skills of R2 who has a history of trauma and PTSD, so assessment of R2's symptoms and implementation of care strategies should be highly individualized for R2. No additional information was provided by the facility as to why the facility did not ensure that R2, who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), received appropriate treatment and services to correct the assessed problem or attain the highest practical mental and psychosocial well-being.

Based on interview and record review, the facility did not ensure that 2 (R2 & R1) of 2 residents reviewed received adequate supervision to prevent accidents. * R2 had expressed his desire to live independently and not stay at the facility. R2 also has a history of elopements as well as leaving medical appointments early. R2 was sent to a hospital appointment with a transportation company and not accompanied by staff or provided with supervision. R2 eloped from the hospital and was found at a hotel approximately seven hours later. A later investigation found R2 planned the elopement and had saved money to go to a different location and to live independently. The failure to provide adequate supervision to prevent R2 from eloping created a finding of Immediate Jeopardy that began on 03/06/2025. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on 3/13/2025 at 1:22 PM. The immediate jeopardy was removed and corrected on 3/14/2025. The deficient practice continues at a scope and severity of a G (Actual Harm/Isolated) due to the following example: The facility failed to put a system in place to monitor R1's safety when R1 left the building unattended. R1 was found outside by staff arriving to the facility for their assigned second shift. R1 was transferred to the hospital for evaluation and was diagnosed with dehydration, heat exposure, and renal insufficiency. Findings include: 1.) R2 was admitted to the facility on [DATE] with diagnoses that include COPD, Dementia with Mood Disturbance, Dementia with Moderate Anxiety, PTSD, and mild cognitive impairment. R2 was placed under protective placement via a court order on 11/17/23. R2's Discharge Care Plan initiated on 5/6/22 documents, DISCHARGE PLANS: Long-term stay anticipated at this SNF r/t (related to) I'm no longer able to reside at home d/t (due to) eviction from apartment, my history of falling at home. I voice wanting to leave the facility to go and live independently but I am unrealistic about my abilities. I refuse to have [NAME] County come out and do discharge options counseling. The VA (Veterans Affairs) spinal cord unit has encouraged me to talk to the county as the VA does not have a discharge option. R2's Safety Care Plan initiated on 2/17/23 documents, SAFETY: I am at risk for becoming a danger to myself by trying to leave the facility unsafely. Under the Interventions is documented: If resident leaves the facility and cannot be redirected to stay, and he has no safe plan for returning home: 1. Contact the Supervisor to update what is happening. 2. Call 911, report we need assistance with resident who is trying to leave the facility without a plan and his safety is a concern. 3. A staff person should follow resident and reapproach him to return to the facility. The safety care plan does not address proactive measure to prevent R2 from eloping even though the 5/6/22 discharge plan indicates R2 speaks about wanting to leave the facility. There was no evidence that an elopement care plan was put into place prior to 3/6/25. Surveyor reviewed nursing/progress notes for R2 and noted the following: R2's psychiatric progress notes dated 4/5/23 document, We also discussed the recommendation for activation of his DPOAHC (Durable Power of Attorney for Health Care) and continued placement in a supervised living environment that can assist with medication administration, meal preparation and transportation. The veteran again disagreed with these recommendations, stating, This is bullshit! He discontinued the appointment and left the examiner's office . R2's nursing note dated 6/13/23 documents, Social Services Progress Note Text: Member was scheduled for an appointment at [name of hospital] Urology around 824am with Transtar transport. Hospital called at 2pm that member did not make it to the appointment. Member has not returned to the facility. Writer attempted to call member-phone disconnected. Writer and HUC called Transtar- confirmed patient was dropped off at [name of hospital] around 930am and they have not picked him up. Facility conducted campus and building search for member. Facility notified Zablock campus security. Writer called local law enforcement and APS per member safety plan. Surveyor noted that after the above event in June 2023, R2 was referred for protective placement. R2's evaluation for protective placement dated 10/24/23 documents, On June 13, 2023, the [NAME] County Human Services Department received a referral on behalf of R2 requesting Emergency Chapter 54/55 Guardianship and Protective Placement .The referral also stated that on June 13, 2023, R2 had a urology and spinal cord injury appointment at [hospital] name in Milwaukee, Wisconsin. While at the [hospital name], R2 reportedly eloped from the hospital. It was reported that R2 was picked up at the facility by Transtar. R2 was then dropped off around 9:30 AM at [hospital name]. It was reported that R2 had an appointment at 10:00 AM but did not attend the appointment. At 2:00 PM that afternoon, [hospital name] alerted the facility that R2 had missed his appointment. R2 was eventually located at the hospital hiding from staff. R2's Determination and Order on Petition for Guardianship Due to Incompetency document dated 11/17/23 documents, This individual is found to be incompetent because other like incapacities .The court transfers to the guardian of the person the power to exercise in full the ability to receive medical or treatment records of the individual; make decisions related to mobility and transfer- Partial Transfer. The individual retains the power with Guardian consent. On 3/7/24, R2 has an appointment at the VA. R2's appointment visit notes dated 3/7/24 that documents: Pick up at 930 AM. Resident returned from VA lab, Va x-ray .well after 6:00 PM. On 3/13/25 at 8:50 AM, Health Unit Coordinator (HUC) -W informed Surveyor that when she spoke to the hospital via telephone, she was informed that R2 did not attend the 3/7/24 appointment. Surveyor asked HUC-W if there was any information as to where R2 went on 3/7/24 as R2 did not attend the appointment. HUC-W informed Surveyor that there was no information as to where R2 went on 3/7/24 when R2 did not attend the appointment. R2's psychiatric note dated 4/16/24 documents, Resident has been isolating in his room. He frequently refuses cares. Resident repeatedly stated, I hate it here, I don't care anymore. His sister is attempting to relocate him closer to where she lives in La Crosse; however, that has been problematic. R2's Annual MDS dated [DATE] documents that R2 has short and long term memory problems. The MDS documents a PHQ-9 mood assessment score of 6, indicating that R2 has mild depression. Section GG documents that R2 has no impairment to R2's upper or lower extremities, uses a wheelchair for mobility purposes, is able to self-propel, and is independent wheeling himself at least 150 feet. R2's Psychosocial Well-being CAA (Care Area Assessment) dated 2/4/25 documents under the care plan considerations section, Member self-isolates in their room. Member does not often participate in activities. Member often refuses to participate in assessments with staff and daily cares. Staff assessments were completed, which rated member to be a 06 on the PHQ9 scaled, indicating mild depression. Despite R2's care planned interventions and R2's failure to show for appointments on 6/13/23 and 3/7/24, R2 was assessed for elopement risk on 2/4/25 and deemed to not be at risk for elopement with a score of 6. The elopement risk assessment documents that a score over 10 requires an elopement care plan. R2's nursing note dated 3/6/25 documents, Member was transported out of facility at [Name of hospital] Milwaukee for his ultrasound appointment by TranStar around 1300 (1:00 p.m.). Facility received call from Transtar Driver that when driver went back to pick member up from [name of hospital] Hospital after appointment, he was unable to locate member. Call placed to [name of hospital] hospital; staff confirmed that member never attended his appointment. Police was alerted by Hospital staff. [NAME] County Sheriff's office was informed by DON. Guardian [name] informed @ 1810 (6:10 p.m.). Police informed that silver alert was issued for member. Member was safely located by Milwaukee police approximately around 2130 (9:30 p.m.). Member was brought back to facility by unknown transportation service around 2330 (11:30 p.m.). Member wheeled his wheelchair to his unit with smiling face. Member refused body check and vitals and helped to go to bed by staff. The facility's self-report and investigation dated 3/6/25 documents, Trans star transportation picked up resident at 1:30 PM for a 2:30 PM ultrasound appointment at [hospital]. At 5:30 PM ADON (assistant director of nursing) was informed that resident was not at the designated spot at [hospital] for post appointment pickup. Call was placed to doctor's office, and it was made known that resident did not check in for his 2:30 PM ultrasound appointment. Timeline as follows: 5:30 PM- 9:52 PM 1. ADON informed DON. 2. DON called hospital and doctors office to inquire about resident. 3. Guardian, Regional Administrator and Administrator were notified. 4. DON called resident's cell phone (no answer). 5. DON called County Sheriffs office, County informed local sheriff. 6. Silver Alert issued. R1 was dropped off at hospital in Milwaukee at approximately 2:00 PM for appointment. Resident however did not go to said appointment. Resident left hospital on his own and was found at 9:13 PM at [NAME] Milwaukee Fairfield (hotel) Inn. On 3/7/25R2 was interviewed by Charge nurse. Resident stated that he planned the events yesterday. He stated that he had slowly been saving cash. He also stated that he was hoping to pay cash for a cab to the [NAME] VA because he likes that hospital better than the one in Milwaukee. When asked about why he tried what he did he stated that he was unhappy and feels like he lives in a prison. He also stated that he doesn't like the PT department here because they tell him that he can't walk and that they treat him like a kid. R2 was asked about how he felt while he was out last night and he stated that he wasn't cold nor scared. Charge nurse stated that he was in good spirits and laughing about the events of last night. R2's statement documented that the elopement was planned, R2 saved $900 prior to the elopement, and that R2 wanted to pay for a cab with cash and wanted to go to [NAME] as R2 likes that hospital. R2's nursing note dated 3/7/25 and completed by RN (Registered Nurse)-V documents, Resident frequently non-compliant with care plan for safety, has history of leaving scheduled medical appointments. R2's elopement care plan documents, I am at risk of elopement r/t Dementia with mood disturbance. 3/06 Member eloped from [Name of Hospital] Hospital from his appointment, silver alert was issued, member was located safe by Police. Interventions: Member is to have a companion ride along for all appointments to the VA. Q (every) checks 30 minutes. On 3/12/25 at 1:51 PM, Surveyor interviewed RN-V regarding R2's nursing note dated 3/7/25. Surveyor asked RN-V if R2 had eloped previously. RN-V informed Surveyor that R2 had eloped previously and/or had left appointments early, and that Surveyor should review R2's nursing notes. Surveyor asked RN-V why R2 was allowed to go appointments alone if he had eloped previously. RN-V informed Surveyor that RN-V did not know why R2 went to appointments alone as he had previously eloped. On 3/12/25 at 1:53 PM, Surveyor spoke with R2 about R2's elopement attempt. Surveyor asked R2 why R2 eloped from the facility. R2 informed Surveyor that R2 planned to go to the hospital in [NAME] as R2 hated living at the facility and that SW (Social Worker)-K did not help him get placement to live near [NAME]. R2 informed Surveyor that R2 planned to elope during his appointment as R2 had done it previously and R2 was aware that the facility did not send him with an escort. R2 informed Surveyor that R2 still wanted to leave the facility and had saved money to leave at R2's last appointment. R2 informed Surveyor that R2 felt extremely frustrated as SW-K did not speak with R2 and did not help R2 in any way to obtain another place to live. Resident believes that his sister gets his hopes up and it doesn't happen. Resident spends his days alone, playing chess on his computer. On 3/13/25 at 9:07 AM, Surveyor interviewed SW -K regarding R2's elopement and placement services. SW-K informed Surveyor that R2 had been offered placement services approximately 6 months prior to R2's elopement attempt but that the placement did not go through. SW-K informed Surveyor that she had not spoken to R2 since and stated that SW-K has attempted to speak with R2 but that R2 has refused to speak with SW-K. Surveyor asked SW-K if SW-K was aware that R2 was unhappy living at the facility and asked why no other placement services had been attempted for the last 6 months. SW-K informed Surveyor that SW-K was aware that R2 was unhappy living at the facility and stated that SW-K could not provide a reason as to why placement services had not been offered to R2 for the last 6 months. SW-K informed Surveyor that R2 refuses to speak with SW-K. Surveyor asked SW-K if SW-K had reached out and spoken with R2's guardian to again attempt to provide placement services for R2. SW-K informed Surveyor that SW-K had not reached out or spoken to R2's guardian for approximately 6 months. On 3/13/25 at 9:30 AM, Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if DON-B was aware that R2 had previously eloped during an appointment at the hospital. DON-B informed Surveyor that DON-B was not aware that R2 had previously eloped from appointments. Surveyor asked DON-B if DON-B was aware that R2 did not make an appointment on 3/7/24. DON-B informed Surveyor that DON-B was not aware that R2 did not make an appointment on 3/7/24. Surveyor asked DON-B why R2 was allowed to go to appointments without an escort or supervision as R2 had previously attempted to elope while at appointments. DON-B informed Surveyor that DON-B was not aware of previous elopement attempts and stated that DON-B could not provide any information as to why R2 was allowed to go to appointments without an escort or supervision. The failure to provide adequate supervision to prevent R2 from elopement created a reasonable likelihood for serious harm, thus resulting in a finding of Immediate Jeopardy that began on 03/06/2025. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on 3/13/2025 at 1:22 PM. The immediate jeopardy was removed on 3/14/2025 when the facility completed the following: - Affected resident continues to have periodic onsite checks (q (every) 2 hrs) in alignment with resident rounding policy. - All Staff will be educated regarding elopement on their very first shift in their work unit after 3.13.2025. - R2's care plan has been updated to require attendant at each external appointment/outing. Facility has made contact with the Guardian who is agreeable to a care plan meeting on March 17, 2025 @ 4:00 PM to discuss possible placement in the community, as this is what the member expressed a desire to do. - Facility has reviewed court determined member rights restrictions and has updated R2's care plan to reflect any/all court order rights and/or removals. - Member's care plan has been updated to include 2 hour checks whether member is in the building or anywhere on the premises. - Facility reviewed Member rounds policy and member elopement policy. The policies remain appropriate. - DON, ADONs and or designated licensed staff will audit weekly, for one month, member rounding and safety checks on all residents. If no concerns noted, will perform audit every two weeks for one month. If no concerns, will perform audits monthly for three months. If no concerns, random audits will be done. - All Audits will be reviewed during the facility's QAPI meetings. Facility will ensure attendant goes to every off-site appointment the member has, attendant will be identified in the appointment note in the EHR (Electronic Health Record). The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by: 51016 The facility's policy and procedure titled, Member Rounds, with a last revision date of January 7, 2025, documents: Rounding shall be defined as nursing staff accounting for all members assigned to their unit frequently using the 4 Ps of rounding and purpose. It should be understood rounding is not every 2 hours as that is merely an absolute minimum: rounding is a continual event. One round should flow into the next round, this is how rounding reduces fall, skin breakdown, and other accidents and injuries. - Walking rounds shall occur at AM (morning) into PM (afternoon) and PM into NOC (night) shift change with CNA (Certified Nursing Assistant) staff from oncoming and outgoing shifts. - A walking round shall be considered when staff physically walk the unit to observe each member and their status, any noted change of the member shall be promptly reported to the on-duty nurse. 2.) R1 was admitted on [DATE] with diagnoses that include repeated falls, dependence on other enabling machines and devices, unspecified Cranial Injury, Cognitive Communication Deficit, Post Traumatic Stress Disorder, and Encephalopathy. R1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 04/26/2024, documents a BIMS (Brief Interview for Mental Status) score of 10, indicating moderately impaired cognition for R1. Section GG (Functional Abilities and Goals) documents R1's self-care as needing maximal assist with toileting, dressing, bathing, indicating that facility staff provides more than half the effort for R1's self-care. Section GG also documents R1's mobility as dependent on staff for transfers, requires substantial/maximal assist using a manual wheelchair, indicating that facility staff provides more than half the effort for R1's wheelchair mobility. R1's Care Area Assessment (CAA) dated 05/10/24 documents under the analysis of findings section: R1 requires assistance with toilet use, has had a decline in condition and now requires use of a full body lift for transfers. Surveyor noted R1's care plan titled Potential Wandering was implemented for R1 on 7/12/24 after R1's 7/12/24's incident resulting in R1 being hospitalized for dehydration, heat exposure, and heat exhaustion. Under the interventions section it documents: Roam Alert. Under the goals section it documents: R1 will use the sign in/out form when leaving the unit. R1's nursing noted dated 7/12/24, at 03:30 PM, documents: Writer Licensed Practical Nurse (LPN)-D was called from receptionist that member (R1) was found stuck outside in the parking lot by staff coming into work. Writer LPN-D went to reception area and member (R1) was sitting in his w/c not responding, body very warm, very red in the face. Charge nurse went and gotten cold water for member (R1) to drink cool cloths to applied on member. Member brought up to 2nd floor 2 west and vital signs taken. Charge nurse continue to cool member (R1) down with cold water to drink and changing clothes for new cool cloths. Members (R1) not opening eyes, member (R1) is shaking his head yes and no. C/O nausea. Member (R1) continues to be non-verbal. Member (R1) was outside for about 1 hour and 15min. R1's nursing note dated 07/12/24, at 10:00 PM, documents: At 1530 (3:30 PM), writer Registered Nurse (RN)-C was walking into the building and noticed R1 sitting in his wheelchair near the outer corner of the car circle in front of [facility]. Writer RN-C called out R1's name a few times with no response, writer RN-C then walked up to member (R1) and noted that his face, neck, and arms were red, skin very warm to touch and member (R1) did not reply. Writer RN-C brought member (R1) inside the front entrance and receptionist called the unit LPN (Licensed Practical Nurse) to come down to also assess member (R1). Writer then went to grab member ice water and cold wet cloths. Member (R1) brought up to the unit and ADON (Assistant Director of Nursing) also present, placed fan facing member (R1) and ice-cold wet cloths to his forehead, back of neck, arms and armpits to help cool him down. Unit LPN took member vitals and continued to try to arouse him, facial grimacing noted with sternal rub, after a few minutes member then nodding his head when asked if he felt nauseated, not opening his eyes and no verbal response, member able to drink 2 cups of ice water with encouragement, member did say soda, skin slowly less red but still warm, unit LPN called NP (Nurse Practitioner) at 1545 (3:45 PM) and NP stated to continue to monitor him and if no improvement in mentation in 30 minutes send to ER (emergency room ) for Evaluation. At 1605 (4:05 PM) Power of Attorney called and then 911 to send R1 to hospital. 911 paramedics here and IV (Intravenous) inserted and normal saline IV started, blood sugar 120, R1 transferred to stretcher with Hoyer lift and R1 out to Hospital at 1630 (4:30 PM). R1 returned to the facility on 2010 (8:10 PM) with Dx (diagnosis) of dehydration, heat exposure/exhaustion and renal insufficiency and was given IV fluids, labs and imaging done- ECG (Electrocardiogram) and CXR (chest x-ray)- no new orders received. Member in bed watching TV and ate noodles and drank the broth, requested orange soda. Roam Alert bracelet and device applied to members rt wrist (#F0341C) per ADON instruction for safety, POA (Power of Attorney) is aware and agreeable. Writer questioned R1 and asked what he was doing outside on the opposite side of the drive circle, and R1 stated I went out there to find a good spot to get some sun and a tan, but I got stuck and then I fell asleep. Next thing I know I was at the hospital with the paramedics shaking me up, I won't be doing that anymore .Roam Alert Device with bracelet applied to R1's right wrist for safety precautions due to R1 being found outside in sun and heat. Tag #F0341C exp 8/2027. R1 must have escort when going outside. Surveyor noted that the outside temparature according to the National Weather Service on 7/12/24 was 82 degrees Farenheit. R1's hospital after visit summary documents: Today's visit you were seen by (Doctor) Diagnoses: Dehydration; Heat exposure; Renal insufficiency. On 3/12/25, at 02:05 PM, Surveyor interviewed Receptionist-H regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. Surveyor asked if Receptionist-H was working 7/12/24 the day when R1 was found outside by RN-C. Receptionist-H informed Surveyor that Receptionist-H was working on 7/12/24. Surveyor asked Receptionist-H if Receptionist-H remembered when R1 went outside. Receptionist-H informed Surveyor that Receptionist-H had no recollection of when and how R1 got outside. Surveyor asked Receptionist-H if R1 typically received help getting off the unit. Receptionist-H informed Surveyor R1 typically went off the unit and out of the building and came back independently. Surveyor asked Receptionist-H how the facility monitored the safety of R1 and other unsupervised residents after they exit the building to head outdoors. Receptionist-H informed Surveyor a sign in and out book that was started after R1's elopement incident on 7/12/24. Receptionist-H informed Surveyor that all residents must now sign in and out of the building. Surveyor asked Receptionist-H if Receptionist-H knew of any staff checking on R1 after R1 went outside on 7/12/24. Receptionist-H informed Surveyor that Receptionist-H did not remember seeing anyone check on R1. Surveyor asked Receptionist-H what the current protocol for resident's leaving the building unsupervised. Receptionist-H informed Surveyor the facility uses a sign in and out book. Surveyor asked Receptionist-H what the protocol prior to R1's 7/12/24 incident was. Receptionist-H informed Surveyor the facility always kept track of appointments and outings, and that after R1's 7/12/24 incident all unsupervised and supervised resident's leaving the building for any reason must sign in and out On 3/13/25, at 8:21 AM, Surveyor interviewed Receptionist-H regarding the facility monitoring protocol of unsupervised residents exiting the building to head outdoors. Surveyor asked Receptionist-H to explain the protocol put in to monitor unsupervised residents exiting the building to head outdoors. Receptionist-H informed Surveyor the residents sign into and out of the book. Any receptionist working will track all the times a resident exits the building and when a resident returns. The receptionist will write it in the book if the resident does not write it in themselves. Surveyor asked Receptionist-H who keeps an eye on the unsupervised residents outside on the facility grounds. Receptionist-H informed Surveyor the people working the reception desk will visualize where the residents are outside. Receptionist-H informed Surveyor the front desk will check on a resident frequently to make sure while the resident is outside is okay. Receptionist-H informed Surveyor all the receptionists keep a close eye out throughout the day to make sure the receptionist can see the resident through the windows. Receptionist-H informed Surveyor if a resident starts to move out of view, they will call the unit or go out and redirect the resident back into a visible location. Surveyor asked Receptionist-H if the facility had any safety monitoring protocols for unsupervised residents exiting the building to head outdoors prior to 7/12/24. Receptionist-H informed Surveyor the facility did not have a protocol to monitor unsupervised residents exiting the building to head outdoors prior to 7/12/24. Receptionist-H informed Surveyor the facility did keep track of resident's leaving and coming back from all appointments and family outings prior to 7/12/24. On 3/12/25, at 01:10 PM, Surveyor conducted a phone interview with CNA-E regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. Surveyor asked CNA-E if CNA-E remembered the incident with R1 on 7/12/24. CNA-E informed Surveyor that CNA-E did not remember R1 or the incident. CNA-E informed Surveyor that CNA-E was working the other second floor unit most of the time. Surveyor asked CNA-E what the facility's expectation was for staff to monitor the safety of residents leaving the unit or building unsupervised. CNA-E informed Surveyor that staff is supposed to round every 2 hours, but most residents do not stay out that long. Surveyor asked CNA-E how CNA-E would know what length of time a resident was gone. CNA-E informed Surveyor that if a resident hadn't come back for some time staff would notice and go look for them. CNA-E informed Surveyor that CNA-E was not familiar with R1 and had no further information for the Surveyor. On 3/12/25 at 01:12 PM Surveyor conducted a phone interview with CNA-F regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. CNA-F informed Surveyor CNA-F's shift started at 2:30 PM. CNA-F informed Surveyor CNA-F didn't see R1 in the parking lot when coming in for the shift. CNA-F informed Surveyor CNA-F remembered R1 coming back into the facility. CNA-F remembered R1 was lethargic and redden in the face. Surveyor asked CNA-F if R1 routinely went outside without supervision. CNA-F informed Surveyor that R1 went outside without supervision. Surveyor asked CNA-F what the facility's expectation of staff was to monitor the safety of residents like R1 going outside unsupervised. CNA-F informed Surveyor the expectation is to do rounds on all residents, there is no expectation to check on the independent residents like R1 who go off the unit, as those residents will come back to the unit on their own. CNA-F informed Surveyor that staff will check on residents that are fall risks or a wander risks. CNA-F informed Surveyor that staff wouldn't let a resident go out independently if that resident was at risk for injury. CNA-F informed Surveyor the staff will go with a resident if the resident is a fall risk or wander concern. CNA-F informed Surveyor R1 wasn't a fall risk or a wander risk and could be independent going outside. CNA-F informed Surveyor R1 was not the type of resident that needed to be supervised. CNA-F informed Surveyor that R1 would normally sit in the front lobby or go downstairs to the vending machines to get a soda. CNA-F informed Surveyor that R1wasn't at risk and R1 went outside frequently. CNA-F informed Surveyor R1 always came back in the facility on R1's own, so staff would not have checked on R1. Surveyor asked CNA-F if there is no policy or procedure for unit staff to check on unsupervised residents considered independent, then who would be responsible to check to make sure there are no medical or safety concerns when a resident is off the unit or outside CNA-F informed Surveyor the front desk will check on the residents and often the activities staff will check on the residents outside. Surveyor asked CNA-F if CNA-F was informing the Surveyor that R1 didn't need to be monitored off the unit or outside. CNA-F informed Surveyor that R1 went outside frequently and safely and didn't need to be monitored by the unit staff. On 3/12/25, at 02:49 PM, Surveyor interviewed LPN-D regarding R1's 7/12/24 incident resulting in R1's hospitalization for dehydration, heat exposure, and renal insufficiency. Surveyor asked LPN-D to provide details on the 7/12/24 incident with R1. LPN-D informed Surveyor that the day R1 was found in in the parking lot, LPN-D arrived that day to work a scheduled PM shift. Surveyor asked LPN-D what time LPN-D started work on 7/12/24. LPN-D informed Surveyor that LPN-D came in a little before the 2:30 PM shift start time. Surveyor asked LPN-D when the last time LPN-D saw R1 prior to R1 being found in the parking lot on 7/12/24. LPN-D informed Surveyor LPN-D saw R1 when coming in for LPN-D's shift just before 2:30 PM. Surveyor asked LPN-D what R1 was doing at the time LPN-D observed R1. LPN-D informed Surveyor R1 was in the front lobby talking about wheeling outside. Surveyor asked LPN-D how they determined the time frame of 1 hour and 15 minutes R1 was outside. LPN-D informed Surveyor the time 2:15 PM when LPN-D saw R1 in the lobby and the time 3:30 PM when RN-C found R1 was a 1 hour and 15 minutes. Surveyor asked LPN-D if R1 could wheel himself outside. LPN-D informed Surveyor that R1 does wheel down to lobby and outside for short distances. Surveyor asked LPN-D how often staff are expected to check on unattended residents that leave the unit or go outside of the building. LPN-D informed Surveyor that the Certified Nursing Assistants (CNAs) are good at letting LPN-D know when a resident has left the unit. Surveyor asked LPN-D if the protocol was the CNAs just know when a resident has left the unit and been gone too long. LPN-D informed Surveyor the staff will notice if a resident has been gone too long. Surveyor asked LPN-D how staff knew what time a resident left the unit. LPN-D informed Surveyor the staff will notice if a resident is leaving the unit. LPN-D informed Surveyor if a resident doesn't come back for some time, staff would let LPN-D know or go and look for them. Surveyor asked LPN-D how would staff know what time an unsupervised resident left the building once the resident was downstairs. LPN-D informed Surveyor the staff know the residents and when the residents are gone for too long a period, and the front desk staff would inform the units if a resident went outside to long. Surveyor asked LPN-D if there were any protocols for resident safety checks in the facility. LPN-D informed Surveyor the facility staff will do rounding every [TRUNCATED]

Based on interview and record review, the facility did not ensure that 1 (R2) of 6 residents reviewed received medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. * R2 eloped from the facility during a hospital appointment. R2 eloped from the hospital and was found at a hotel room approximately seven hours later. R2 had voiced and made it known to facility staff that R2 wanted to leave the facility and R2 was not provided with discharge/placement services. Findings include: 1.) R2 was admitted to the facility on [DATE] with diagnoses that includes COPD, Dementia with Mood Disturbance, Dementia with Moderate Anxiety, PTSD and mild cognitive impairment. R2's Annual MDS dated [DATE] does not documents that R2 has short and long term memory problems. The MDS documents a PHQ-9 mood assessment score of 6, indicating that R2 has mild depression. Section GG documents that R2 has no impairment to R2's upper or lower extremities and documents that the resident uses a wheelchair for mobility purposes as is able to self-propel and is independent wheeling himself at least 150 feet. R2's Psychosocial Well-being CAA dated 2/4/25 documents under the care plan considerations section, Member self-isolates in their room. Member does not often participate in activities. Member often refused to participate in assessments with staff and daily cares. Staff assessments were completed, which rated member to be a 06 on the PHQ9 scaled, indicating mild depression. R2's Discharge Care Plan initiated on 5/6/22 documents, DISCHARGE PLANS: Long-term stay anticipated at this SNF r/t I'm no longer able to reside at home d/t eviction from apartment, my history of falling at home. I voice wanting to leave the facility to go and live independently but I am unrealistic about my abilities. I refuse to have [NAME] County come out and do discharge options counseling. The VA (Veterans Affairs) spinal cord unit has encouraged me to talk to the county as the VA does not have a discharge options. R2's Safety Care Plan initiated on 2/17/23 documents, SAFETY: I am at risk for becoming a danger to myself by trying to leave the facility unsafely. Under the Interventions it documents: If resident leaves the facility and cannot be redirected to stay, and he has no safe plan for returning home:1. Contact the Supervisor to update what is happening. 2. Call 911, report we need assistance with resident who is trying to leave the facility without a plan and his safety is a concern. 3. A staff person should follow resident and reapproach him to return to the facility. Despite this R2's care plan interventions, R2 was assessed for elopement risk on 2/4/25 and deemed to not be at risk for elopement with a score of 6. The elopement risk assessment documents that anything over 10 requires an elopement care plan. Surveyor noted that R2 did not have a care plan for elopement developed until 3/8/25. R2's elopement care plan documents, I am at risk of elopement r/t Dementia with mood disturbance.3/06 Member eloped from [Name of Hospital] Hospital from his appointment, silver alert was issued, member was located safe by Police. Interventions: Member is to have a companion ride along for all appointments to the VA. Q (every) checks 30 minutes. R2's nursing note dated 3/6/25 documents, Member was transported out of facility at VA Hospital Milwaukee for his ultrasound appointment by TranStar around 1300. Facility received call from Transtar Driver that when driver went back to pick member up from VAMC Hospital after appointment, he was unable to locate member. Call placed to [NAME] hospital; staff confirmed that member never attended his appointment. VA Police was alerted by Hospital staff. [NAME] County Sheriff's office was informed by DON. Guardian [name] informed @ 1810. VA Police informed that silver alert was issued for member. Member was safely located by Milwaukee police approximately around 2130. Member was brought back to facility by unknown transportation service around 2330. Member wheeled his wheelchair to his unit with smiling face. Member refused body check and vitals and helped to go to bed by staff. The facility's self-report and investigation dated 3/6/25 documents, Trans star transportation picked up resident at 1:30 PM for a 2:30 PM ultrasound appointment at [hospital]. At 5:30 PM ADON (assistant director of nursing) was informed that resident was not at the designated spot at [hospital] for post appointment pickup. Call was placed to doctor's office, and it was made known that resident did not check in for his 2:30 PM ultrasound appointment. Timeline as follows: 5:30 PM- 9:52 PM 1. ADON informed DON. 2. DON called hospital and doctors office to inquire about resident. 3. Guardian, Regional Administrator and Administrator were notified. 4. DON called resident's cell phone (no answer). 5. DON called County Sheriffs office, County informed local sheriff. 6. Silver Alert issued. R1 was dropped off at hospital in Milwaukee at approximately 2:00 PM for appointment. Resident however did not go to said appointment. Resident left hospital on his own and was found at 9:13 PM at [NAME] Milwaukee Fairfield (hotel) Inn. Summary of events and Interview: On March 6th, 2025 Trans star transportation picked up resident at 1:30p for a 2:30 p ultrasound appt at VAMC. At 5:30 p ADON was informed that resident was not at the designated spot at VAMC for post appointment pickup. Call was placed to Dr. office, and it was made known that resident did not check in for his 2:30p ultrasound appointment. Upon learning this, Guardian, Administrator, Regional Director of Operations, [NAME] County Sheriffs, and Milwaukee County Sheriffs were all notified. Shortly after this (at approximately 7:08p) the DVA Informed us that the resident was last seen on camera arriving for his appointment at approximately 2:06p. At approximately 7:18 p a Silver Alert was issued for missing resident. At 9:13 a call was received that the resident was found safe and sound in a [NAME] Milwaukee Fairfield Inn. At 9:45 DON called DVA for update and was informed that the resident did not want to leave the hotel. After a call was placed to the resident by his sister/guardian, resident agreed to come back to the facility. Resident was returned to Union Grove VA safely and in good spirits. On March 7th, 2025, Resident was interviewed by Charge nurse. Resident stated that he planned the events yesterday. He stated that he had slowly been saving cash. He also stated that he was hoping to pay cash for a cab to the [NAME] VA because he likes that hospital better than the one in Milwaukee. When asked about why he tried what he did he stated that he was unhappy and feels like he lives in a prison. He also stated that he doesn't like the PT department here because they tell him that he can't walk and that they treat him like a kid. Resident was asked about how he felt while he was out last night and he stated that he wasn't cold nor scared. Charge nurse stated that he was in good spirits and laughing about the events of last night. R1's statement documented that the elopement was planned, R1 saved $900 prior to the elopement and that R1 wanted to pay for a cab with cash and wanted to go to [NAME] as R1 likes that hospital. R2's nursing note dated 3/7/25 and completed by RN (Registered Nurse)-V documents, Resident frequently non-compliant with care plan for safety, has history of leaving scheduled medical appointments. On 3/12/25 at 1:51 PM, Surveyor interviewed RN-V regarding R2's nursing note dated 3/7/25. Surveyor asked RN-V if R2 had eloped previously. RN-V informed Surveyor that R2 had eloped previously and or had left appointments early, and that Surveyor should review R2's nursing notes. Surveyor asked RN-V why R2 was allowed to go appointments alone if he had eloped previously. RN-V informed Surveyor that RN-V did not know why R2 went to appointments alone as he had previously eloped. On 3/12/25 at 1:53 PM, Surveyor spoke with R2 about R2's elopement attempt. Surveyor asked R2 why R2 eloped from the facility. R2 informed Surveyor that R2 planned to go to the hospital in [NAME] as R2 hated living at the facility and that SW-K did not help him get placement to live near [NAME]. R2 informed Surveyor that R2 planned to elope during his appointment as R2 had done it previously and R2 was aware that the facility did not send him with an escort. R2 informed Surveyor that R2 still wanted to leave the facility and had saved money to leave at R2's last appointment. R2 informed Surveyor that R2 felt extremely frustrated as SW-K did not speak with R2 and did not help R2 in anyway obtain another place to live. R2's nursing note dated 6/13/23 documents, Social Services Progress Note Text: Member was scheduled for an appointment at VAMC Urology around 824am with Transtar transport. Hospital called at 2pm that member did not make it to the appointment. member has not returned to the facility. Writer attempted to call member- phone disconnected. Writer and HUC called Transtar- confirmed patient was dropped off at VAMC around 930am and they have not picked up up. Facility conducted campus and building search for member. Facility notified Zablock campus security. Writer called local law enforcement and APS per member safety plan. Surveyor noted that after the above event, R2 was referred for protective placement. R2's evaluation for protective placement dated 10/24/23 documents, On June 13, 2023, the [NAME] County Human Services Department received a referral on behalf of R1 requesting Emergency Chapter 54/55 Guardianship and Protective Placement .The referral also stated that on June 13, 2023, R2 had a urology and spinal cord injury appointment at [hospital] name in Milwaukee, Wisconsin. While at the [hospital name], R2 reportedly eloped from the hospital. It was reported that R2 was picked up at the facility by Transtar. R2 was the dropped off around 9:30 AM at [hospital name]. It was reported that R2 had an appointment at 10:00 AM but did not attend the appointment. At 2:00 PM that afternoon, [hospital name] alerted the facility that R2 had missed his appointment. R2 was eventually located at the hospital hiding from staff. R2's Determination and Order on Petition for Guardianship Due to Incompetency document dated 11/17/23 documents, This individual is found to be incompetent because other like incapacities .The court transfers to the guardian of the person the power to exercise in full the ability to receive medical or treatment records of the individual; make decisions related to mobility and transfer- Partial Transfer. The individual retains the power with Guardian consent. R2's psychiatric progress notes dated 4/5/23 documents, We also discussed the recommendation for activation of his DPOAHC (Durable Power of Attorney for Health Care) and continued placement in a supervised living environment that can assist with medication administration, meal preparation and transportation. The veteran again disagreed with these recommendations, stating, This is bullshit! He discontinued the appointment and left the examiner's office. He stated that he did not have paperwork with him for the examiner to complete this visit. Surveyor continued to search for possible elopement episodes that were documented in R2's medical record. R2's visit notes dated 3/7/24 that documents: Pick up at 930 AM. Resident returned from VA lab, Va x-ray .well after 6:00 PM. When writer asked for the blue folder, the resident stated Member stated loudly I don't have that folder. They don't use that; they use one of those as Member pointed to his laptop. Writer looked around the room as Member talked and could not see the folder. Member stated, I never had one03-08-24: Huc (health unit coordinator) retrieving progress notes from appointment. Surveyor was unable to locate any visit notes for R2's visit to the hospital on 3/7/24. On 3/12/25 at 2:48 PM, Surveyor interviewed HUC-W regarding R2's hospital visit on 3/7/24. HUC-W informed Surveyor that HUC-W was not at the facility when this even occurred but stated that HUC-W would reach out to the hospital in Milwaukee and find out if R2 attended the 3/7/24 appointment. HUC-W informed Surveyor that HUC-W was not aware of the possibility that R2 did not attend his appointment on 3/7/24 for his appointment. On 3/13/25 at 8:50 AM, HUC-W provided Surveyor with a print of the hospital that documented no information available for R2's 3/7/24 appointment. HUC-W informed Surveyor that when she spoke to the hospital via telephone, she was informed that R2 did not attend the 3/7/24 appointment. Surveyor asked HUC-W if there was any information as to where R2 went on 3/7/24 as R2 did not attend the appointment. HUC-W informed Surveyor that there was not information as to where R2 went on 3/7/24 when R2 did not attend the appointment. R2's social services communication note dated 12/28/23 and completed by SW (Social Worker)-K, documents, This guardian inquired what next steps needed to be taken to transition this member to a facility that is closer to La [NAME], which is near the guardian. This writer shared that they will see what next steps are and get back to guardian. This writer explained that they will be out of the office 12/29/23 to 1/2/24 and will connect with this guarding again in the new year. This writer understood and this phone call came to an end. R2's social services communication note dated 4/2/24 and completed by SW-K, documents, This writer spoke with member guardian, [name]. This member guardian updated this writer that they have been working to figure out a new living arrangement for this member. This guardian shared that they were [NAME] to get this member an apartment with a private caretaker, however, that fell through. This guarding stated that they are starting over with looking at facilities and other living arrangements. R2's social services communication note dated 4/12/24 and completed by SW-K, documents, This writer called members guarding to discuss Healthdrive and R2's placement. This guarding expressed that they are pausing the look for a new placement for this member while they work to apply for Medicaid. R2's psychiatric note dated 4/16/24 documents, Resident has been isolating in his room. He frequently refuses cares. Resident repeatedly stated, I hate it here, I don't care anymore His sister is attempting to relocate him closer to where she lives in La [NAME]; however, that has been problematic. Resident believes that his sister gets his hopes up and it doesn't happen. Resident spends his days alone, playing chess on his computer. R2's social services communication note dated 5/2/24 and completed by SW-K, documents, This writer spoke with member regarding member's discharge to a new facility. This member has expressed that R2 would like to move closer to his sister in the [NAME] area. This writer spoke with member recently regarding an CBRF (Community Based Residential Facility) that was found in the Warren's area. This writer informed the member that there is a double room available and this member would need to share with a roommate. This member was unsure if he would like to have a roommate or not. After further discussion, this member felt that a roommate would not be a bad idea and that he could possibly move to a single room should one open up. This writer discussed the cost of the new living arrangement, which this member understood. This writer will get in touch with members guardian/POA to initiate next steps in this process. R2's social services communication note dated 6/12/24 and completed by SW-K documents, This writer met with member to discuss this members desire to discharge from the facility. Member has expressed wanting to be closer to R2's sister in [NAME], WI. A CBRF placement was located for this member in [NAME], WI .This member denied wanting a single room at this CBRF. R2's psychiatric note dated 11/19/24 documents, Resident presented as agitated with limited interaction with others. Staff reports that he has been refusing medications and been verbally abusive to staff. During this session, a housekeeper attempted to come in his room to clean; he became angry, ordering and demanding him to leave. He insists that his door be closed at all times. It was difficult eliciting more than a few words in response to questioning. There was no eye contact present. He denied suicidal ideation or intent. Goal: Monitor resident's comfort level with his living arrangement and address any concerns that may arise. Patient continues to isolate, spending most time in his room. Does not participate in resident activities or interact often with other residents. No longer requests to leave the facility or move closer to family. R2's social services communication note dated 7/22/24 and completed by SW-K, documents, This member and guarding were working with the ADRC in finding placement closer to this members guardian near [NAME]. One option was found, however, this member declined wanting to move at the time. Currently, this member is expressing that they are not interested in moving closer to their guardian any longer and would like to remain at the facility. On 3/13/25 at 9:07 AM, Surveyor interviewed SW-K regarding R2's elopement and placement services. SW-K informed Surveyor that R2 had been offered placement services approximately 6 months prior to R2's elopement attempt but that the placement did not go through. SW-K informed Surveyor that she had not spoken to R2 since and stated that SW-K has attempted to speak with R2 but that R2 had refused to speak with SW-K. Surveyor asked SW-K is SW-K was aware that R2 was unhappy living at the facility and asked why no other placement services had been attempted for the last 6 months. SW-K informed Surveyor that SW-K was aware that R2 was unhappy living at the facility and stated that SW-K could not provide a reason as to why placement services had not been offered to R2 for the last 6 months. SW-K informed Surveyor that R2 refuses to speak with SW-K. Surveyor asked SW-K if SW-K had reached out and spoken with R2's POA to again attempt to provide placement services for R2. SW-K informed Surveyor that SW-K had not reached out or spoken to R2's POA for approximately 6 months. Surveyor asked SW-K why SW-K had not followed up or provided discharge/placement services for R2 in the last six months. SW-K informed Surveyor that SW-K was not aware that R2 was an elopement risk and could not provide an answer as to why SW-K had not worked with or followed up with R2 regarding discharge/placement services in the last six months. On 3/13/25 at 9:30 AM, Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if DON-B was aware that R2 had previously eloped during an appointment at the hospital. DON-B informed Surveyor that DON-B was not aware that R2 had previously eloped from appointments. Surveyor asked DON-B if DON-B was aware that R2 did not make an appointment on 3/7/24. DON-B informed Surveyor that DON-B was not aware that R2 did not make an appointment on 3/7/24. Surveyor asked DON-B why R2 was allowed to go to appointments without an escort or supervision as R2 had previously attempted to elope while at appointments. DON-B informed Surveyor that DON-B was not aware of previous elopement attempts and stated that DON-B could not provide any information as to why R2 was allowed to go to appointments without an escort or supervision. Surveyor asked DON-B why SW-K had not provided discharge/placement services for R2 in the last six months. DON-B informed Surveyor that DON-B could not provide an answer as to why SW-K had not worked with or followed up with R2 regarding discharge/placement services in the last six months. No additional information was provided as to why R2 was not provided with medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of R2.

Based on observation, interview, and record review, the facility did not ensure that residents with pressure injuries or at risk for pressure injuries received appropriate care and treatment to prevent the development of pressure injuries and to promote healing for 1 of 5 residents (R18) reviewed for pressure injuries. *R18 was noted to have multiple facility acquired open areas to their bilateral buttocks on 8/30/23 that were not assessed upon discovery. At this time, the physician was not consulted with, the care plan was not revised with interventions, and a treatment was not initiated based upon an assessment of the wounds. The pressure injuries were not assessed until 9/13/23. At that time the resident was noted to have 2 stage 3 pressure injuries. The assessment on 9/13/23 states the wound bed is 100% subcutaneous tissue (this is bottom layer of skin in your body that consists of loose connective tissue, larger blood vessels and is the major fat storage layer) without additional description of necrotic tissue. Findings include: The facility policy entitled Wound Prevention and Treatment Program, last revised June 2021, documented, .A member with pressure injuries receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new injuries from developing . The wound prevention and treatment program shall include: Prompt assessment and treatment . d) When a skin change is identified, the licensed nurse: . vi) Assure comprehensively skin assessment .are documented in the EHR (Electronic Health Record) . Licensed Staff: Initial Evaluation: 2) Initial evaluation of Member's wound shall be documented in EHR. a) Documentation includes a complete description of findings including measurements, condition of per-wound, condition of wound bed, percentage, and type of tissue . Licensed Staff: Ongoing Wound Documentation: .2) Pressure wound measurements are documented weekly in the EHR by the RN (Registered Nurse) Wound Nurse . R18 was admitted to the facility on [DATE] and had diagnoses including Congestive Heart Failure and Chronic Kidney Disease stage 4. R18's Quarterly Minimum Data Set (MDS) assessment, dated 6/15/23, documented R18 had a Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment for daily decision making; requires partial/moderate assistance with toileting, independent with bed mobility and transfers; is at risk for the development of pressure injuries but currently does not have any pressure injuries. R18's Significant Change Minimum Data Set (MDS) assessment, dated 09/07/2023, documented R18 had a Brief Interview for Mental Status (BIMS) score of 13 indicating R18 is cognitively intact; R18 required extensive assistance of one staff for transfers; R18 was at risk for pressure injury development, and R18 had 2 stage 3 pressure injuries. R18's Care Area Assessments (CAAs) from 09/07/2023 significant change MDS documented, Member has had a decline in condition, requires more assistance and has declined hospice services. Member has impaired mobility, received assistance with bed mobility, was incontinent of bladder/bowel, uses a wheel chair, has pressure reducing device for chair/bed, better foot pad, protective treatment to heel, Prevalon boots, and application of ointment. Member has current pressure areas to buttocks. Member has diagnosis of diabetes, has lower extremity edema, has order for tubigrip, has diabetic shoes and has hx (history) of skin impairment to feet. See nutritional assessment and dietary care plan. R18's care plan, revised on 09/19/23, documented, The resident has hx (history) of open area to buttock stage II and DTI (Deep Tissue Injury) to right heel both obtained while hospitalized and hx of blisters and abrasions to the toes from trauma . o/a (open area) bilateral buttocks, and had interventions including: Apply lantiseptic ointment to members buttocks every shift and PRN (as needed) for protection. Date Initiated: 06/26/2023 Better foot pad to be in place at the foot of the bed, Encourage floating heels on pillows, Member will often refuse or kick pillows off the bed. Date Initiated: 05/11/2022 Encourage good nutrition and hydration in order to promote healthier skin. Date Initiated: 02/17/2021 Encourage member to wear pressure relief boots when in bed. Member has been known to refuse at times. Date Initiated: 05/05/2022 If skin tear occurs, treat per facility protocol and notify MD (Medical Doctor), family. Date Initiated: 02/17/2021 Keep skin clean and dry. Use lotion on dry scaly skin. Date Initiated: 02/17/2021 Member to use pressure relief cushion when in wheelchair. Date Initiated: 05/05/2022 The resident needs air mattress to protect the skin while in bed. Date Initiated: 08/05/2022 The resident needs cushion while in power chair and in recliner. Revision on: 09/19/2023 On 10/10/23, at 9:35 AM, Surveyor observed R18 sitting upright in their power wheelchair. R18 was steering the chair into their room. R18 informed Surveyor they have chronic toe wounds and maybe something on their bottom. Surveyor observed two Roho type cushions on R18's bed. Surveyor noted R18 was not sitting on a cushion on the power chair. Surveyor asked R18 if they used the cushions. R18 stated they were not certain. R18 informed Surveyor they sleep in the recliner and not in the bed. Surveyor reviewed R18's EHR and noted the following: On 8/30/2023, at 10:17 AM, a nurse documented in progress notes, Member informed writer [their] buttocks was ''sore'' and requested that writer see it. Member has three skin alterations, two o/a's (open areas) to right inner buttocks and one superficial area to left inner buttocks with fragile skin noted. Cleansed and applied Lantiseptic. Sent E mail [sic] to RN supervisor . and NP (Nurse Practitioner) requesting a treatment. On 8/31/2023, at 4:53 AM, a nurse documented in progress notes, Follow up two open areas to right butt. Site no longer two open area now is one large open area no change in left buttock treatment per orders. No c/o (complaints of) pain or discomfort. Surveyor notes the open areas are facility acquired open areas when R18 was assessed to be at risk for the development of pressure injuries, there is no comprehensive assessment of the areas, and there is no documentation of consultation with the physician or NP when the right inner buttock areas progressed from 2 areas to one larger area. Surveyor noted the following assessment documented in R18's Weekly Wound Observation Tool, dated 09/13/23, Right Buttock: date acquired 08/30/23; first observation (09/13/23); stage 3, 100% sub Q (subcutaneous) tissue; no drainage, no odor; 0.3 cm (centimeters) x 0.8 cm x 0.1 cm; no tunneling; Treatment Plan: Roho added to members reclining chair, member refuses to offload or use a Roho in power chair, TX (treatment) Medihoney and Mepilex daily .Left Buttock: date acquired 08/30/23; first observation (09/13/23); stage 3 100% Sub Q; no drainage; 0.3 cm x 1.0 cm x 0.1 cm; Treatment Plan: Medihoney to wound bed f/b (followed by) Mepilex daily and PRN (as needed) . Surveyor noted the following weekly wound assessments in R18's EHR: On 09/20/23: Right Buttock: improving, 100% granulation, 0.3 cm x 0.7 cm x 0.1 cm Left buttock: improving, 100% granulation, 0.5 cm x 1 cm x 0.1 cm On 09/27/23: Right Buttock: improving, 50% epithelial/50% granulation, 1.5 cm x 1.5 cm x 0.1 cm Left Buttock: unchanged, 50% epithelial/50% granulation, 0.7 cm x 0.4 cm x 0.1 cm On 10/04/23: Right Buttock: improving 100% granulation, 1 cm x 1 cm x 0.1 cm Left Buttock: improving, 70% epithelial/30% granulation, 1.5 cm x 1 cm x 0.1 cm Surveyor could not locate comprehensive assessments of the wounds between 08/30/23 (acquired date) and 09/13/23. Surveyor reviewed R18's Body Check Tool forms from 8/22/23 and 09/05/23. Neither form documented open areas to R18's bottom. Surveyor noted R18 had the following physician's orders: Apply lantiseptic ointment to members buttocks every shift and PRN for protection . Ordered on 07/06/23 and discontinued on 9/11/2023 On 09/11/23 the above order was changed to Zinc ointment per hard chart. On 09/13/23 the following order was activated, Wound care bilateral buttocks: Cleanse wounds with NS or wound cleanser. Apply medihoney and cover with bordered foam. Change daily & PRN. Every evening shift for wounds bilateral buttocks AND as needed for wounds bilateral buttocks. This order remained active through the Survey. On 10/11/23, at 9:42 AM, Surveyor observed R18's room and noted two Roho type cushions on the bed. Surveyor noted R18 was not in their room. On 10/11/23, at 9:45 AM, Surveyor observed R18 sitting in their power wheelchair in the dining area. R18 was not sitting on a cushion. On 10/11/23, at 10:29 AM, Surveyor observed wound Physician's Assistant (PA)-I and Registered Nurse (RN)-G perform wound care on R18. RN-G asked R18 if the Roho cushion was on the power chair. R18 replied no, I am not sitting on the cushion. RN-G informed Surveyor R18 was supposed to be sitting on a Roho cushion in the power chair and the recliner. RN-G educated R18 on the importance of using the Roho cushion and R18 verified understanding but stated the cushion sometimes upset R18. (R18 did not elaborate further.) On 10/11/23, at 10:34 AM, Surveyor observed two dressings on R18's bilateral buttocks. The dressings were dated 10/10/23, they were clean, dry, and intact. Per PA-I the right wound started as pressure, but the left started as MASD (Moisture Associated Skin Damage) and then because R18 is on R18's bottom a lot it turned into pressure. Per PA-I and RN-G the wounds were healing and looking better. On 10/11/23, at 3:08 PM, during the end of the day meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B Surveyor asked for all of R18's bilateral pressure injury assessments from date of onset to present. Surveyor explained Surveyor was having a difficult time determining when the pressure injuries developed, but relayed the information documented in the progress note on 08/30/23. On 10/12/23, DON-B provided Surveyor with R18's pressure injury assessments from 09/13/23 forward. There were no assessments provided prior to 09/13/23. On 10/12/23, at 10:54 AM, Surveyor interviewed Registered Nurse (RN)-H. RN-H informed Surveyor he filled in for wound rounds when RN-G was not working. Surveyor asked about R18's pressure injuries and asked if there were any assessments prior to 09/13/23. RN-H looked through R18's EHR and stated he did not see anything prior to 09/13/23. RN-H stated RN-G may be behind in wound rounds and RN-H went to get RN-G's paper wound binder. RN-H returned and reviewed RN-G's wound binder and stated he did not see any assessments prior to 9/13/23. RN-H informed Surveyor he just did an inservice on documentation because the facility's documentation is lacking. RN-H informed Surveyor the nurse who found the wound should have done measurements, described the wound, and requested a treatment order. Surveyor asked about R18's lantiseptic orders from July to September. Per RN-H the majority of the members use the lantiseptic ointment, it is more of a preventive treatment. RN-H had a meeting to attend and Surveyor asked RN-H to follow up if there was any additional information. On 10/12/23, at 12:32 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor relayed the concern of a lack of documentation for R18's wounds upon discovery on 08/30/23. Surveyor stated there was no comprehensive assessment until 09/13/23. DON-B informed Surveyor she noticed the same thing. DON-B stated she did not find any assessments prior to 09/13/23 nor a new treatment order prior to 09/13/23. DON-B informed Surveyor there should have been measurements/assessment when the wound was discovered. On 10/16/23 10:15 AM, Surveyor spoke with RN-G and Nursing Home Administrator (NHA)-A. Surveyor relayed the concern of a lack of a comprehensive assessment of R18's pressure injuries from date of discovery, 08/30/23 until 09/13/23. Per RN-G, wound rounds were completed on 08/30/23, but R18 was not seen because the wounds were not discovered yet. Per RN-G, she thought RN-J would have gotten the measurements. RN-G stated R18 had the Lantiseptic ointment in place at the time the wounds were discovered which was an appropriate treatment, RN-G stated wound rounds were done again on 09/06/23 but R18 was not seen. Neither RN-G nor NHA-A were certain as to why R18 was not seen during wound rounds on 09/06/23. Per RN-G, the staff were looking at R18's bottom daily and there was not a delay in care. Surveyor relayed the concern of a lack of a comprehensive assessment from 08/30/23 to 09/13/23 and upon assessment on 09/13/23 the wounds are categorized as stage 3 pressure injuries. RN-G informed Surveyor she would continue to look for additional information. On 10/16/23 at 10:33 AM, Surveyor interviewed RN-G. At this time RN-G reviewed R18's EHR and stated she did not locate any measurements of R18's pressure injuries prior to 09/13/23. RN-G informed Surveyor she thought maybe it would have been under assessments, but it was not. RN-G stated no one measured the pressure injuries until 09/13/23. Per RN-G the nurses on the floor are supposed to do the measurements if they discover a wound. No additional information was provided.

Based on observation, record review, and interview, the facility did not thoroughly assess, document, and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 6 (R40, R62, R57, R75, R12, and R68) of 9 residents reviewed for pressure injuries. *R40 developed Unstageable pressure injuries to the right first, second, and third toes while at the facility on 3/5/2021. The right second toe was not comprehensively assessed until 4/15/2021. The right first toe was not comprehensively assessed until 4/30/2021. The right third toe was not comprehensively assessed. A pressure area was identified to the right lateral foot on 4/18/2021 which was referred to as a Deep Tissue Injury on 4/25/2021. No comprehensive assessment was completed of the right lateral foot. *R62 developed pressure injuries to the right and left heels on 3/14/2021. The right heel was not comprehensively assessed until 3/26/2021. The right heel progressed from a deep tissue injury to Unstageable due to 100% necrotic tissue. The left heel was not comprehensively assessed when first discovered or at any time following discovery. The left heel progressed from a blister to a deep tissue injury to healed when observed by Surveyor on 5/5/2021. *R57 developed a pressure injury to the right lateral heel on 3/7/2021. The right heel was not comprehensively assessed until 3/19/201. The right heel progressed from a blood blister to Unstageable due to slough and necrotic tissue. *R75 developed a pressure injury to the left lateral foot on 3/27/2021. The area wasn't comprehensively assessed until 3/31/2021 and a treatment was obtained on 4/1/2021 but was not entered onto the Treatment Administration Record or Medication Administration Record. R75 developed a pressure injury to the left buttock on 4/19/2021 that was not comprehensively assessed, and a treatment wasn't initiated until 4/23/2021. *R12 developed a pressure injury to the left heel on 3/24/2021 which progressed from a deep tissue injury to Unstageable with no comprehensive assessment completed. Examples involving Residents R40, R62, R57, R75, R12 are being cited at a scope and severity of H (actual harm/pattern). *R68 was readmitted to the facility on [DATE] and was noted to have a deep tissue injury to the left buttock. This area was not comprehensively assessed. On 5/2/2021 R68 was noted to have an open area to the right buttock. This area was not comprehensively assessed. A treatment was not initiated until 5/3/2021. Findings include: The facility policy and procedure entitled Wound Prevention and Treatment Program (WPTP) dated 3/2020 states: The wound prevention and treatment program shall include: Prompt assessment and treatment. If any abnormality is identified on the body check, a RN (Registered Nurse) shall proceed with Root Cause Analysis, MD (physician) and family notification, and care planning to include active treatment plan as well as preventative measures to promote healing and prevent further skin breakdown. Any Member with wound treatment(s) shall have the wound area(s) monitored with each treatment and assessed at a minimum of weekly by an RN. The wound monitoring and assessment shall be documented in the EHR (Electronic Health Record). Signing off in the TAR (Treatment record) shall indicate that the wound/skin was monitored, and treatment was completed. Whenever a non-blanching area or any skin change is identified: It must be reported immediately to Licensed Staff. RN shall proceed with Root Cause Analysis, MD and family notification, and care planning to include active treatment plan as well as preventative measures to promote healing and prevent further skin breakdown. There must be documentation of an assessment, including measurements and recommended treatments. When a pressure injury is identified, Licensed Staff shall immediately notify physician, initiate treatment per MD order, notify wound coordinator, document in EHR, revise care plan, and notify POA if appropriate. All pressure injuries shall be identified and staged according to the National Pressure Ulcer Advisory Panel (NPUAP) criteria. Wound Care treatments shall be used for at least 2 weeks once initiated unless the wound deteriorates rapidly and is detrimental to Member's health such as in the case of active infection. If after 2 weeks there is no improvement, MD should be contacted, and treatment should be altered unless documented that other issues are present. 1.) R40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R40 needed total assistance with activities of daily living. R40's Skin Integrity Care Plan was initiated on 9/11/ for a history of pressure ulcers. The following interventions were in place on 3/5/2021: -Administer treatments as ordered and monitor of effectiveness. -Assure pads are in place on nose pieces of eye glasses. -Member will utilize bedder foot pad at the lower end of bed to prevent pressure areas to feet while lying down. -Monitor, document, and report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. -Remind and monitor resident to turn or reposition every two hours or more often as needed or requested. -Apply [MEDICATION(S)] to buttock bilaterally after toileting, do not massage over bony prominences and use mild cleansers for peri-care/washing. -Low air loss mattress, Roho cushion and heel boots when in bed; encourage to lay down after meals. On 1/24/2021, R40 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/5/2021 at 1:40 PM in the progress notes, nursing charted R40 had multiple old scabs to the right foot: right great toe measuring 0.4 cm x 0.3 cm, right great toe under the nail measuring 0.5 cm x 0.5 cm, the right second toe measuring 0.4 cm x 0.5 cm. The Wound Care Registered Nurse (RN) was notified and was instructed to monitor every shift until the scabs resolved and to wash the feet with soap and water twice daily followed by lotion until resolved. This treatment and monitoring of the scabbing to the right great toe and right second toe order was entered into the TAR on 3/5/2021. A comprehensive assessment of the right great and second toes were not completed or documented. From 3/5/2021 through 3/8/2021 in the progress notes, nursing charted scabs remain to toes on both feet, not differentiating which toes had scabs. On 3/9/2021 at 1:25 PM in the progress notes, nursing charted R40 had a bath that day and the scabbed areas on the toes fell off during the bath and are open to air. On 3/10/2021 at 4:52 PM in the progress notes, nursing charted R40's toes appeared to be dry with very small scabs. The charting did not clarify which toes had scabs or what part of the toes had scabs. No documentation was found from 3/10/2021 through 4/3/2021 regarding R40's toes. R40's Skin Integrity Care Plan was revised on 3/17/2021 with the following interventions: -Update the physician or nurse practitioner with changes. -Follow facility policies and protocols for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/4/2021 at 10:58 AM in the progress notes, nursing charted a scab from the right foot second toe fell off exposing a tendon. The wound care RN assessed the wound and a new order was put in place. A comprehensive assessment was not completed; no measurements, wound description, or etiology of the wound was documented. On 4/4/2021, a new order to apply [MEDICATION(S)] to the scabbed area on toes daily was initiated. The order did not denote which toes to apply the treatment. On 4/5/2021 on the Body Check Tool form, nursing documented no new or worsening skin issues or concerns since the last body check. The right toes had a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The form did not indicate which toes on the right foot were being treated and the wound or wounds were not comprehensively assessed: no measurements, staging, or wound base description. On 4/13/2021 on the Body Check Tool form, nursing documented no new or worsening skin issues or concerns since the last body check. The right first toe was scabbed over. No measurements were documented. On 4/15/2021 on the Weekly Wound Observation Tool form, nursing documented the third right toe had a wound that measured 0.5 cm in diameter with granular tissue (no etiology of the wound was provided), and the second right toe had an Unstageable pressure injury that measured 1.2 cm x 1.2 cm x 0.1 cm with 100% granulation. This was the first comprehensive assessment of the right second toe wound since it was first discovered on 3/5/2021. The right third toe was not comprehensively assessed. The right first toe was not documented on. On 4/18/2021 at 10:18 AM in the progress notes, nursing charted a red blanchable area was noted to the right lateral foot by the toes. The physician was notified and skin prep was ordered twice daily to the area. On 4/19/2021 on the Weekly Wound Observation Tool, the right first toe had an area that measured 5.0 cm x 5.0 cm with 100% eschar. The right second toe had an area that measured 0.7 cm diameter with 100% eschar. The third right toe had an area that measured 0.3 cm in diameter with 100% eschar. The descriptive line indicated the pressure injury was Unstageable, improving, 100% necrotic and had a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation did not indicate which area or toe was improving as the three areas were documented on the same form. On 4/25/2021 at 5:15 PM in the progress notes, nursing charted scabs remained to the toes on the right foot and the deep tissue injury remains to the right lateral foot. (The right lateral foot had not been comprehensively assessed and not documented on since 4/18/2021 when it was a red blanchable area.) On 4/30/2021 on the Weekly Wound Observation Tool form, nursing documented the right second toe was an Unstageable pressure injury measuring 0.7 cm x 1.0 cm x 0 cm with 100% necrotic tissue. The right second to had not been comprehensively assessed for 15 days, since 4/15/2021. On 4/30/2021 on the Weekly Wound Observation Tool form, nursing documented the right great toe was an Unstageable pressure injury measuring 0.7 cm x 0.5 cm x 0 cm with 100% necrotic tissue. This was the first comprehensive assessment after 4/19/2021. The right third toe was not comprehensively assessed after 4/19/2021. On 5/2/2021 at 10:10 AM in the progress notes, nursing charted an email was sent to the wound care team regarding the current treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R40 preferred the toes not be wrapped, but left open to air. The nurse requested the wound care team assess R40's right toes and change the treatment to [MEDICATION(S)] twice daily and leave open to air. No documentation was found showing this email was followed up on by the wound care team. The treatment orders in place as of 5/5/2021 were as follows: -Skin prep to heels/toes twice daily for protection (Put in place on 1/24/2021.) -Wash feet with soap and water followed by lotion until healed twice daily (Put in place on 3/05/2021.) -Monitor scabbing to right foot (first toe and second toe) until resolved every shift (Put in place on 3/05/2021.) -Apply [MEDICATION(S)] Wound/Burn Dressing Pad (Wound Dressings) to scabbed area to toes topically every day and wrap toes in gauze until healed (Put in place on 4/04/2021.) -Skin prep to lateral right foot twice daily for protection (Put in place on 4/18/2021.) On 5/5/2021 at 10:38 AM, Surveyor observed R40's wound care to the right first, second, and third toes by Registered Nurse Unit Manager (RN UM)-D. R40 had heel boots in place and an air loss mattress on the bed. Surveyor asked RN UM-D how R40 obtained the pressure injuries to the right first, second, and third toes. RN UM-D stated possibly from shoes, but didn't really know. RN UM-C came into R40's room during the dressing change and stated R40 didn't wear shoes so the facility didn't know what caused the wounds. R40's right first toe had a black area on the distal knuckle that measured approximately 0.7 cm x 0.5 cm with what appeared to be blistering around the wound. R40's right second toe was an open wound on the distal knuckle with pink granulation tissue that measured approximately 0.7 cm x 1.2 cm. R40's right third toe was almost healed with an area on the distal knuckle that measured 0.4 cm x 0.3 cm with pink epithelial tissue. [MEDICATION(S)] was applied to the three toes and covered with gauze and Kerlix. In an interview on 5/5/2021 at 10:56 AM, RN UM-D stated a new skin area that is found on a resident goes onto the 24-hour board on the unit and every morning in the interdisciplinary morning meeting, the new skin areas area reviewed. RN UM-D stated the wounds stay on the 24-hour board until they are healed and are discussed every morning. RN UM-D stated the floor nurses do not fill out the observation tool, but are expected to write a thorough progress note describing the wound. RN UM-D stated the floor nurses do not stage pressure injuries because they might stage it wrong or call the wound pressure when it is caused by something else. RN UM-D stated wound rounds are attempted to be done weekly on Monday, but sometimes things come up and they are unable to do wound rounds on that day. RN UM-D stated the Assistant Director of Nursing (ADON) and the wound nurses do the wound rounds. RN UM-D stated there are four wound nurses and each of the four units has a wound nurse assigned to them, however, two of the wound nurses have been out of the facility for many months so the two wound nurses that are still working try to cover all the units, but they get pulled in different directions to cover other open positions, so the wounds don't always get assessed every week. On 5/6/2021 at 11:33 AM, Surveyor reviewed R40's wound documentation and findings with Director of Nursing (DON)-B. Surveyor shared R40's right first and second toe had scabs on 3/5/2021 that weren't documented on or assessed comprehensively. On 4/4/2021, nursing documented a tendon on the right second toe was exposed and a treatment was obtained, but no comprehensive assessment was completed at that time. The first comprehensive assessment for the right second toe was on 4/15/2021, 40 days after first being discovered. The first comprehensive assessments for the right first toe and right third toe were on 4/19/2021, but the documentation on that date was unclear as to which of the three areas on the right toes were being assessed and staged. The right lateral foot was not comprehensively assessed at all. DON-B stated the wound nurses do rounds on all residents with wounds, but the nurse assigned to the unit R40 resides on has not been working in the facility since 3/2020, over a year ago. No further information was provided at that time. 2.) R62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R62 required extensive assistance with bed mobility and all other activities of daily living. R62 had a fall on 2/24/2021 and sustained a right [CONDITION(S)]. R62 was admitted to the hospital for surgical repair of the hip and returned to the facility on [DATE]. R62's Skin Integrity Care Plan was initiated on 10/25/2020 and the following interventions were in place on 3/14/2021: -Encourage good nutrition and hydration in order to promote healthier skin. -Ensure leg bag straps are not too tight when applied. -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Identify and document potential causative factors and eliminate and resolve where possible. -Keep skin clean and dry; use lotion on dry skin; do not apply on open areas. -Low air loss mattress to protect the skin while in bed; check inflation every shift. -Roho cushion to protect the skin while up in chair; check inflation every shift. On 3/14/2021 at 1:32 PM in the progress notes, nursing charted R62 had two pressure areas to the bilateral heels. The left heel had a blister that had a diameter of 1.0 cm. The right heel had a blanchable area with a purple center that had a diameter of 1.0 cm. Skin prep was applied to bilateral heels. Heel boots were in place. The physician was notified. On 3/14/2021 on the Comprehensive Skin Assessment form, nursing indicated a pressure injury was present and this was an admission/re-admission assessment. The form was completed by a Registered Nurse. No staging, measuring, or description of the wound was documented. The following orders were entered onto the Treatment Administration Record: -Heel boots in place at all times until resolved every shift for Pressure areas. -Skin prep to bilateral heels twice daily until resolved for Pressure areas. If areas open, reevaluate treatment. R62's Skin Integrity Care Plan was revised on 3/14/2021 with the following intervention: -Heel boots in place at all times until pressure areas to bilateral heels are resolved. On 3/14/2021 at 4:54 PM in the progress notes, nursing charted the blister to the left heel is intact and skin prep was applied to bilateral heels while R62 was in bed. On 3/15/2021 at 12:09 AM in the progress notes, nursing charted heel boots were on, the blister remains intact to the left heel, and the purple deep tissue injury to the right heel had no change. On 3/16/2021 at 10:58 AM in the progress notes, the dietitian charted R62 had blisters to bilateral heels. The physician was updated and wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The dietitian charted R62 will continue to be monitored for skin integrity. On 3/19/2021 at 12:02 PM in the progress notes, nursing charted R62's bilateral heels were looked at with the wound nurse. The note stated both heels have red areas 2.0 cm x 2.0 cm in diameter. R62 has heel boots, but frequently kicks them off. A heel pad for the bed was ordered and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R62's Skin Integrity Care Plan was revised on 3/19/2021 with the following intervention: -Encourage R62 to keep bilateral heel boots on as member frequently kicks them off. On 3/20/2021, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin prep to the left heel was continued. On 3/24/2021 at 4:55 PM in the progress notes, nursing charted open areas to bilateral heels remain. R62's Skin Integrity Care Plan was revised on 3/25/2021 with the following intervention: -Bedderfett heel protector pad on bed. On 3/26/2021 at 5:07 PM in the progress notes, nursing charted areas to bilateral heels remain intact. On 3/26/2021 on the Weekly Wound Observation Tool form, nursing documented this was the first observation of the right heel wound which was a ruptured blister with dry black eschar acquired on 3/14/2021. It was an Unstageable pressure injury measuring 1.0 cm x 1.0 cm x 0 cm with 100% dry black eschar cap. R62 had a low air loss mattress and needed to wear heel boots when in bed. Derma saver was added to the foot of the bed as R62 kicks off heel boots at times. This was the first comprehensive assessment of the right heel, 12 days after first discovered. The left heel did not have a comprehensive assessment after discovery of the blister on 3/14/2021. On 3/31/2021 at 5:10 PM in the progress notes, nursing charted pressure wounds on bilateral heels remain. The right heel was comprehensively assessed on 3/31/2021, 4/9/2021, and 4/15/2021. On 4/16/2021 at 2:09 PM in the progress notes, nursing charted deep tissue injury to bilateral heels remain. On 4/19/2021 on the Weekly Wound Observation Tool form, the right heel was comprehensively assessed. No comprehensive assessment of the right heel was documented for eleven days. On 4/30/2021 on the Weekly Wound Observation Tool form, the right heel was comprehensively assessed. On 5/1/2021, skin prep to the left heel was discontinued. No comprehensive assessment was documented for the left heel since the blister was discovered on 3/14/2021. On 5/5/2021 at 10:21 AM, Surveyor observed R62's wound treatment completed by Registered Nurse Unit Manager (RN UM)-D. RN UM-D stated R62's heel injuries were caused by R62 self-propelling the wheelchair using the heels to push forward. R62 was observed in bed with a heel boot on the right foot and the left foot heel boot had been pushed up the leg by R62 while in bed by moving the foot around. R62 was continuously moving the left leg, possibly due to [CONDITION(S)]. An air loss mattress was in place and a body pillow was to the right side. R62 had gripper socks on. R62 stated there was pain to the right heel, but the pain was not constant. The right heel had a dark scab measuring approximately 1.5 cm x 1.5 cm and was tender to the touch. RN UM-D cleansed the wound with wound cleanser and applied [MEDICATION(S)] to the right heel. Surveyor asked if R62 had a wound to the left heel. RN UM-D wasn't sure and stated there was no treatment ordered for the left heel. RN UM-D removed R62's left gripper sock and the area had intact skin that looked recently healed. RN UM-D stated this was not the unit RN UM-D was assigned to as the wound nurse; each of the four units had a wound nurse assigned and two of the four wound nurses had been out of work status for a few months so the two remaining wound nurses tried to cover as best they could, but they get pulled to cover open shifts and positions. RN UM-D stated the other wound nurse was covering passing medication on one floor and RN UM-D was covering scheduling because the scheduler called in that day. On 5/6/2021 at 11:33 AM, Surveyor reviewed R62's wound documentation and findings with Director of Nursing (DON)-B. Surveyor shared R62 had a blister to the left heel and a dark area to the right heel that was discovered on 3/14/2021. The right heel progressed to an Unstageable pressure injury. The right heel wasn't comprehensively assessed until 3/26/2021, twelve days after discovery, and wasn't documented on weekly. The left heel was never comprehensively assessed and wasn't documented on weekly. DON-B stated the wound nurses do rounds on all residents with wounds, but the wound nurse assigned to the unit R62 resides on had not been working in the facility since 3/2020, over a year ago. DON-B stated the wound nurses are being pulled to the floor to cover shifts if there is a call in by a nurse. DON-B stated wound rounds are done by the Assistant DON and the wound nurses. DON-B stated DON-B sends an email to the wound team to coordinate when wound rounds would be that week; they try to do wound rounds on Mondays, but they would switch wound rounds to another day of the week to accommodate schedules. No further information was provided at that time. 3.) R57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change Minimum Data Set (MDS) assessment dated [DATE] was completed due to R57's increased need for assistance with activities of daily living. R57 required extensive assistance with bed mobility, transfers, dressing, and toilet use. R57's Skin Impairment Care Plan was initiated on 9/27/2019. The following interventions were in place on 3/7/2021: -Avoid scratching and keep hands and body parts from excessive moisture; keep fingernail short. -Encourage good nutrition and hydration in order to promote healthier skin. -Keep skin clean and dry; use lotion on dry skin. -A gel cushion to protect the skin while up in a chair. On 3/7/2021 at 10:45 AM in the progress notes, nursing charted a blood blister measuring 1.0 cm x 0.6 cm was discovered on the right lateral heel. The blister had a small open area in the center. The wound was cleansed and [MEDICATION(S)] was applied. The physician was notified and an order was put in place for [MEDICATION(S)] to be applied twice daily to the right lateral foot until resolved. Monitor blood blister to right lateral heel until resolved and derma saver BedderFeet pad under R57's feet when in bed were added to the Treatment Administration Record to be signed off on every shift. On 3/7/2021 a Comprehensive Skin Assessment form was completed that indicated R57 had no skin issues. R57's Skin Integrity Care Plan was revised on 3/7/2021 with the following intervention: -Heel boot to the right foot at all times until the blood blister is resolved. On 3/9/2021 at 3:12 AM in the progress notes, nursing charted the dressing remains intact to the ruptured blood blister to the right heel. On 3/9/2021, R57 was transferred to the hospital and returned to the facility on [DATE]. On 3/12/2021 on the Comprehensive Skin Assessment form, nursing indicated a vascular ulcer was present. No location or description of the wound was documented. On 3/12/2021 on the Body Check Tool form, nursing indicated there were no new or worsening skin issues or concerns since the last body check. Nursing documented: Still has open area to right heel. No comprehensive assessment was documented on 3/12/2021 when R57 was readmitted to the facility with a wound to the right heel. On 3/13/2021 at 11:41 AM in the progress notes, nursing charted R57 had a pressure ulcer to the right lateral foot and the heel was macerated. R57 was educated on the importance of keeping the heel boot in place. On 3/15/2021 at 1:50 PM in the progress notes, the dietitian charted R57 was sent out on 3/9/2021 due to lethargy and altered mental status due to a urinary tract infection and returned to the facility on [DATE]. R57 had a blister to the right heel and orders were approved by the physician to start [MEDICATION(S)] twice daily to promote healing to the wound and discontinue when the wound heals. On 3/19/2021 on the Weekly Wound Observation Tool form, nursing documented the right heel has a deep tissue pressure injury acquired on 3/7/2021 that measured 3.0 cm x 3.0 cm x 0 cm with a 2.0 cm x 2.0 cm necrotic area equaling 75% necrotic area. The remaining 25% of the wound base did not have a description. This was the first comprehensive assessment of the right heel, twelve days after the wound was discovered on 3/7/2021, and three days after readmission from the hospital on 3/12/2021. R57's Skin Integrity Care Plan was revised on 3/19/2021 with the following intervention: -Heel boot to the right foot at all times until area is resolved; R57 frequently refuses to wear. -Heel pad on the bed. On 3/26/2021 on the Weekly Wound Observation Tool form, nursing documented the pressure injury to the right heel was now Unstageable due to 100% necrotic black eschar cap. The right heel was comprehensively assessed on 3/31/2021. On 4/7/2021 on the Weekly Wound Observation Tool form, nursing documented the pressure injury was located on the right elbow. All other information documented correlated with the right heel. On 4/8/2021 at 12:55 PM in the progress notes, nursing charted R57 had gone to the wound clinic and returned with the following orders: -Offloading; keep pressure off of heels; turn side to side every two hours; try to avoid laying on the right side. -Wound care to the right lateral heel to be done daily; switch to Dakins 0.25% (half strength) moistened 2x2 gauze covered with Kerlix wrap. -No smoking. -Follow up in 3-4 weeks. -No compression to area. R57 was transferred to the hospital on 4/11/2021 and was readmitted to the facility on [DATE]. On 4/16/2021 on the Body Check Tool form, nursing documented a new or worsening skin issue or concern was present since the last body check. The coccyx had a Stage 2 pressure injury that measured 0.5 cm x 0.5 cm x 0.1 cm. No description of the wound base was documented. Nursing charted: Continues with unstageable area to right heel 3cm x 2 cm. No description of the wound base was documented. On 4/17/2021, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/2021 on the Weekly Wound Observation Tool form, nursing documented the right heel pressure injury was Unstageable measuring 1.5 cm x 2.5 cm x 0 cm with 50% slough and 50% necrotic tissue. The treatment was changed to Santyl. The order for Santyl was obtained on 4/21/2021. On 4/27/2021, R57 was seen at the wound clinic and returned with the following orders: -Cleanse right heel with wound cleanser, apply Santyl with saline damp [MEDICATION(S)] blue; Cover with gauze & ABD pad & wrap with Kerlix; change every other day. -R57 is high risk for amputation; monitor right heel for signs/symptoms of infection every shift On 4/30/2021, the right heel Unstageable pressure injury was comprehensively assessed. On 4/30/21 on the Body Check Tool form, nursing documented no new or worsening skin issues. The right heel ulcer remained and redness to the coccyx continued. On 5/6/2021 at 9:48 AM, Surveyor observed Registered Nurse Unit Manager (RN UM)-C do wound care to R57's right heel. R57 had a boot on the right foot and the foot was wrapped in Kerlix. RN UM-C removed the old dressing from the right heel. The dressing had moderate serosanguinous drainage. The wound was on the lateral portion of the right heel and measured approximately 2.0 cm x 2.0 cm with a shallow depth. The wound base was 75% slough and 25% granulation tissue. RN UM-C applied Santyl to the wound base and covered the wound with saline-soaked [MEDICATION(S)] blue, covered it with gauze and wrapped the foot with Kerlix. Surveyor asked if R57 had a pressure area with a [MEDICATION(S)] dressing to the coccyx. RN UM-C stated wasn't sure and turned R57 over to view the coccyx. No open or reddened area was noted to the coccyx and no [MEDICATION(S)] dressing was in place as ordered. RN UM-C stated she would have a to see why there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/6/2021 at 11:50 AM, Surveyor reviewed R57's wound documentation and findings with Director of Nursing (DON)-B. A blood blister was discovered on 3/7/2021 on R57's right lateral heel. The wound was not comprehensively assessed until 3/19/2021, twelve days later. R57 was not comprehensively assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The pressure area to the coccyx discovered on 4/16/2021 was never comprehensively assessed or documented on weekly. DON-B stated the unit R57 resides on does not currently have a wound nurse that covers that area and have two other wound nurses that try to assess the wounds weekly. Surveyor asked DON-B if a resident should be comprehensively assessed when readmitted . DON-B stated yes, the resident should be assessed. DON-B stated R57 goes out to the wound clinic every three or four weeks so is being followed by a wound physician. No further information was provided at that time. 4.) R12 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Quarterly MDS (Minimum Data Set) documents a score of 10, indicating that R12 is moderately cognitively impaired. Section G (Functional Status) documents that R12 requires extensive assistance a one person physical assist for his bed mobility needs. Section G a

Based on observation, interview and record review the facility did not ensure that 8 (R20, R62, R12, R95, R15, R108, R47, R18) of 11 residents reviewed had an environment that was free of accident hazards and received adequate supervision and assistitive devices to prevent accidents. *R20 had multiple falls, one resulted in serious injuries of several rib fractures. R20's falls were not thoroughly investigated, the root cause of the falls were not identified, the interventions put into place do not address the reason for the falls and R20's care plan was not updated with fall prevention interventions. *R62 had multiple falls, one resulting in serious injury of right [CONDITION(S)]. R62's falls were not thoroughly investigated, care plan was not updated with fall prevention interventions. *R12 had falls that were not thoroughly investigated and fall prevention interventions were not identified. *R95 had falls that were not thoroughly investigated and fall prevention interventions were not identified. *R15 had falls that were not thoroughly investigated and fall prevention interventions were not identified. *R108 had falls that were not thoroughly investigated and fall prevention interventions were not updated on the care plan. *R47 had falls that were not thoroughly investigated and fall prevention interventions were not identified. *R18 had falls that were not thoroughly investigated and fall prevention interventions were not identified. Examples involving R20 and R62 are being cited at a scope and severity of G (actual harm/isolated). Findings include: The facility policy, entitled Member Falls, dated November 2009, last revision: April 2021, documents: Purpose/Overview: To ensure that each Member is provided a safe environment; To establish standard examination and documentation to be be completed on any Member after a fall. After a fall: . 4. Licensed staff on duty at the time of the fall: a) document each fall in the specified electronic health record folder; b) initiate the investigation process; c) Obtain witness statements from staff, Member, visitors as appropriate; d) Determine the root cause of the fall if possible. the fall documentation process is set up to help identify root causes and/or contributing factors to the fall; . j) Review the current Care Plan (POC)/CNA (Certified Nursing Assistant) Care Card related to falls. Fall Care Plan interventions may be found in other than a Fall Care Plan. i) Determine if the current plan has been fully implemented. If not, either revise the Care Plan or follow through with full implementation. enter any nursing orders (N.O.) needed for implementation and monitoring and perform any necessary assessments related to those orders; ii) determine if the current interventions address the root cause/contributing factors of the current fall. If not, revise the Care Plan. enter any nursing orders needed for implementation and monitoring and perform any necessary assessments related to those orders; k) The person documenting the initial fall writes a Care Plan Evaluation Note in the appropriate Care Plan to indicate that the Care Plan has been reviewed,noting changes made, assessments or N.O.; . 6) Fall Investigations, supporting documentation and witness statements are reviewed by the Interdisciplinary Team (IDT) following AM (morning) Clinical Report. Discussion focuses on the circumstances surrounding the fall, Member status at the time of the fall, care plan interventions in place, and effectiveness of these interventions. 1.) R20 was admitted to the facility on [DATE] with diagnoses that include: Repeated falls, chronic pain, low back pain, anxiety disorder, major depressive disorder, cognitive communication deficit, degeneration of nervous system due to alcohol and [CONDITION(S)] without behavioral disturbance. R20's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/21/21 documents: A Brief Interview of Mental Status (BIMS) score of 9, indicating moderate impairment for daily decision making; Patient Health Questionnaire (PHQ-9) score of 4, indicating minimal depressive symptoms; requires extensive assist of two staff for bed mobility, transfers and toilet use, extensive assist of one staff for dressing, personal hygiene and locomotion on the unit, supervision and one person assist for eating; not steady and only able to stabilize with staff assistance when moving from seated to standing, moving on and off the toilet, surface to surface, uses a wheelchair for mobility; has a catheter and is always continent of bowel; experience almost constant pain. R20's Care Area Assessment (CAA), related to falls, dated 5/4/21, documents: Member has impaired mobility, requires assistance with transfers, ambulation and toileting. Member should have walker but refuses to. Member transfers, ambulates and self without assistance, Member is unaware of safety concerns. Member experiences decline in mobility during UTI (Urinary Tract Infections). BIMs score of 9, has chronic pain to lower back. Member has history of falls. Member receives scheduled antianxiety and antidepressant medication. Member has had multiple falls since admission. Member should use call light and proper foot wear. R20's Care Plan, dated 1/19/21, documents: The resident is high risk for falls r/t (related to) confusion, gait/balance problems, [CONDITION(S)], unaware of safety needs. Interventions include: Anticipate and meet the resident's needs, date initiated: 5/13/2020; Attach call light to member, and remind member frequently to use it when he needs to transfer, date initiated: 5/3/21; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. the resident needs prompt response to all requests for assistance, dated initiated: 5/13/20; Ensure the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair), date initiated 2/3/21, revision on 2/3/21; Member is encouraged by staff to use w/c and walker on unit but due to confusion and lack of safety needs he refuses/forgets to use his wc and walker on the unit, date initiated: 2/3/21, revision on 2/3/21; PT (physical therapy) evaluation and treat as ordered or PRN (as needed). Assess for need to premedicate with [MEDICATION(S)] prior to participating in therapy, date initiated: 5/13/20, revision on: 5/18/20; Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove and potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team) as to causes, dated initiated: 5/13/20; The resident needs to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate and as needed for continued appropriateness and to ensure least restrictive device or restraint, date initiated: 5/13/20, revision on: 5/27/20; The resident needs a safe environment with even floors free from spills and/or clutter, adequate,glare free light, a working and reachable call light, the bed in low position at night, slide fails as ordered, handrails on walls, personal items within reach, date initiated: 5/13/20, revision on 5/27/20. R20's Care Plan dated, 10/7/20, documents: The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t Activity intolerance, confusion, disease process. Interventions include: . Nursing Rehab (rehabilitation)/Restorative: transfer program #1 member is supervision/limited assist of 1 with gait belt. Can be impulsive at times and will transfer self without waiting for assistance. Date initiated: 11/7/20, revision on 11/7/20. On 4/13/21, R20's Medical Record documents: A Fall Risk Assessment Score of 12, indicating a high risk for continued falls. On 12/17/20, at 04:45 (4:45 AM), R20's Medical Record documents: CNA went to check on [R20] because he as had frequent falls and found [R20] laying on his left side near the TV. [R20]'s walker was not within reach. No injuries observed at the time of incident. [R20] has been unsteady, SOB (Short of Breath) with exertion and was also incontinent of urine. Noted Member to have temp. (temperature) of 99.3. Predisposing Physiological Factors: Incontinent, Impaired Memory, Other - not described. Predisposing Situation Factors: Wanderer, ambulating without assistance. Fall Witness Statement, dated 12/17/20, documents: the time of the incident 0445 (4:45 AM). Activity at time of incident- what was member trying to do?- go back to bed. What does the member state happened?- [R20] wasn't able to tell me what he was trying do. Very confused. Had gripper socks on, was confused. Last contact with the member: 4:30 AM. Member found: laying on left side in room. Suggestions to prevent future falls/injuries: body pillow. Surveyor noted interventions of having items within reach including wheeled walker & call light attached were not implemented from the care plan. The facility's fall investigation does not document root cause of the fall, when R20 was last assisted to the bathroom. Intervention of a body pillow does not address the cause of the fall. The intervention of a body pillow was not added to the care plan. On 12/19/20, at 1435 (2:35 PM), R20's Medical Record documents: [R20] remains on 24 hour board for UWF (Unwitnessed Fall) on 12/17/20 and on [MEDICATION(S)]. [R20] is alert x (times) 3, pain to lower back 8/10, skin warm and dry. Lung sounds clear, abdomen soft, non tender with active bowel sounds in all four quadrants. No [CONDITION(S)], in bed during the am, refused breakfast, [R20] encouraged to get up for lunch and [R20] had increased pain to right side with difficult time raising up from bed and sitting in wheel chair. [R20] states pain is on his right side/rib cage area and that pain is from the last few days. Writer called Supervisor to inform that writer was going to call MD (Medical Doctor) for x-ray /possible rib fractures from previous falls. Supervisor stated ok and later assessment [R20]. Call placed to on call Doctor with update, new order for right rib x-ray. Call placed to POA (Power of Attorney) regarding new order for x-ray. On 12/20/20, at 11:09 AM, R20's Medical Record documents: X-ray results received. [R20] has right sided acute rib fractures. Call placed to on call MD. Awaiting call back with orders. Supervisor notified, states DON will be updated. On 1/19/21, at 18:30 (6:30 PM), R20's Medical Record documents: [R20] located on floor. [R20] was self-ambulating from bathroom and became weak so he lowered himself to the ground. No injury noted, neuro (neurological) checks negative, [R20] got self off floor to standing w/o (without) assistance. Predisposing situation factors: ambulating without assist. No witness statements were provided with the fall investigation. The facility's fall investigation does not document the root cause of the fall, when R20 was last seen, last assisted to the bathroom, what type of footwear R20 was wearing, if the call light was on or what interventions were put into place to prevent further falls. On 1/26/21, at 17:32 (5:32 PM), R20's Medical Record documents: Staff walked into members's room to administer 1700 (5:00 PM) medications and observed member sitting on floor in front of bed leaning with back against bed. Bed side table was in front of the bed and a dinner size plate of water was on the floor to the right of the bed side table. Member was sitting to the left of the bed side table. Member stated he didn't fall and that he put himself on the floor. Member refused to have ortho (orthostatic) blood pressure taken. Member got up off the floor by himself and hopped into his recliner. Member had socks on. Predisposing environmental factors: wet floor. Predisposing situational factors: Active exit seeking, ambulating without assistance. Prefers to have door to room closed at all times. CP (Care Plan) states he is LA (limited Assistance) 1 for transfers and ambulation , but lacks safety awareness and self transfers and ambulates by self. Fall Witness Statement, dated 1/26/21, documents: the incident occurred at 1732 (5:32 PM). What was member doing at time of incident? Did not know he fell till nurse told me. What does member state happened? I didn't see or hear [R20] fall. Nurse told me she found [R20] sitting on the floor of his room,body against bed. N/A (not applicable) documented for footwear at time of fall and behavior at time of fall and just prior to fall. Suggestions to prevent future falls/injuries: move closer to nursing station. The facility's fall investigation does not document the last time R20 was last seen, last assisted to the toilet, what R20 was attempting to do at the time of the fall or if the call light was on. Surveyor unable to locate documentation R20 was moved to a room closer to the nursing station. R20's care plan was not updated with fall prevention interventions. On 5/6/21, at 11:05 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated she believed the facility did not have a bed available to allow for the room change. Surveyor informed DON-B there is no documentation of the facility's inability to move R20 closer to the nursing station as recommended as a fall prevention intervention and no new intervention was put into place when the room change could not occur. DON-B stated she would need to look into this. On 4/8/21, at 2128 (9:28 PM), R20's Medical Record documents: At 2032 (8:32 PM) staff entered [R20]'s room to give him his medications and spotted him sitting on the floor. The nursing aides took [R20] in for a shower as [R20] was covered in stool. [R20] stated that, I hit my butt, the important part. When asked about pain, [R20] stated, I don't have any pain. Predisposing Physiological factors: confused, gait impairment. Predisposing situation Factors: ambulating without assistance. Fall Witness Statement, dated 4/8/21, documents: Saw [R20] sitting on his buttocks on his bathroom floor. Second Fall Witness Statement, dated 4/8/21, documents: Activity at time of incident-what was the member trying to do?- [R20] was walking to the bathroom and staff saw [R20] laying on the floor into his bathroom on is buttock. Intervention to prevent future falls: use call light. The facility's fall investigation does not document the root cause of the fall, if the resident had the call light on at the time of the fall, when R20 was last seen and last assisted to the toilet, if R20 had a walker or wheelchair with him and if R20 had appropriate footwear on. On 5/3/21, at 1400 (2:00 PM) R20's Medical Record documents: Writer was notified by Activity that [R20] was laying on the floor. When writer entered the room [R20] was lying on his right side on the floor, parallel to his bed. [R20] was fully dressed, bare feet, call light was not in reach. [R20] has an indwelling Foley catheter and was not soiled. [R20] stated he wanted to transfer from his bed to his recliner when he tried, his knees gave out. [R20] stated, I didn't fall. I didn't hit my head, I have no pain. Bruise to the left iliac crest, rear. Predisposing physiological factors: confused, impaired memory, weakness/fainted. Predisposing situation factors: ambulating without assist. Fall Witness Statement, dated 5/3/21, documents: time of incident: 1400 (2:00 PM). activity at time of incident- left blank. What does member state happened: N/A (not applicable). Footwear: socks. When was your last contact with member? : 1:45 PM, [R20] was in bed prior to staff going on [NAME]. Suggestion to prevent future falls: Check on [R20] more frequently. Second Fall Witness Statement, dated 5/3/21, documents: member states: he was going to his recliner. Position member found in: [R20] was in his room on his butt sitting beside his bed on the floor and I helped nurse to transfer [R20] up. Suggestions to prevent future falls/injuries: use the call light for help. The facility's fall investigation does not document the root cause of the fall, how long R20 had been in bed or if the call light was on. R20's care plan does not document and intervention of checking on R20 more frequently. On 5/06/21, at 10:46 AM, Surveyor interviewed DON-B, who stated, the facility procedure for completing and reviewing fall investigations is the nurse on duty at the time of the fall completes the incident report in the electronic medical record (EMR) and will obtain staff statements. The day after the fall or on Monday if the fall occurred on the weekend, the interdisciplinary team (IDT) will meet and have a clinical review of all concerns in the building and then the IDT will meet to review all fall investigations. The IDT is comprised of a physical therapist, activity staff, social worker, quality assurance (QA) nurse, all nursing supervisors and the administrator. DON-B stated the IDT will then review the fall investigation packet, the QA nurse will then look in the computer to see what the residents care plan documents as fall interventions, the IDT will then discuss new interventions that should be put into place and the QI nurse will add new interventions to the care plan. DON-B states a progress note is then added to the residents medical record to document this meeting and can be found under IDT notes in the residents EMR. On 5/6/21, at 11:05 AM, Surveyor informed DON-B, R20's Medical Record does not document an IDT note for all of R20's falls and when Surveyor was able to locate an IDT note related to a fall it did not document when R20 was last seen, what interventions were put into place and were in place at the time of the falls and what new interventions were added to prevent further falls. DON-B stated the facility created new fall witness forms that will answer all of the Surveyor's questions and requested to see R20's fall investigation packets the facility provided to this Surveyor. DON-B reviewed fall investigation packets provided to Surveyor and stated, the Fall Witness Statements were the newly created forms that should answer the questions related to the events surrounding R20's falls. DON-B stated the forms are not completed fully and are left blank in many spots. DON-B stated she would need to look into this further. On 5/6/21, at 4:00 PM, Nursing Home Administrator (NHA)- A and DON-B were informed of the concern R20 had multiple falls, one resulting in a serious injuries of rib fractures. R20's falls were not thoroughly investigated, the root cause of the fall was not identified, the interventions put into place do not address the reason for the falls and R20's care plan was not updated with fall prevention interventions. 2.) R62 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] disease, [CONDITION(S)], anxiety, post-traumatic stress disorder, schizophreniform disorder, hallucinations, depression, and [CONDITION(S)]. R62 required extensive assistance with transfers and all other activities of daily living. R62's Fall Care Plan was initiated on 12/12/2018. The following interventions were in place on 10/18/2020: -Be sure R62's call light is within reach and encourage R62 to use it for assistance; R62 needs prompt response to all requests for assistance. -Constantly remind R62 to have assistance with activities of daily living like showering and toileting. -Encourage R62 to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as frequent ambulation and exercise group. -Ensure R62 is wearing appropriate footwear when ambulating or mobilizing in a wheelchair; Gripper socks at night when not wearing shoes; door to bedroom to remain open as R62 allows for observation; if R62 is restless while in bed in early AM hours, offer to get up and out of bed and change catheter from overnight bag to leg bag. -Keep blankets off the floor; remind R62 to request assist to straighten blankets. -Motion sensor night light above bed; keep door open if R62 allows. -Physical Therapy to evaluate and treat as ordered or as needed. -Review information on past falls and attempt to determine cause of falls; record possible root causes; after remove any potential causes if possible; educate R62 of causes. -R62 need a safe environment with room free of clutter, assure personal items are within reach when in bed; Safety Awareness: Remind R62 to not use wheelchair as a walker. On 10/18/2020 at 12:20 PM, R62 had an unwitnessed fall in R62's room. R62 stated he was moving the wheelchair to the table and fell sideways. R62 was using the wheelchair as a walker. No injuries were sustained. The physician and family were notified. On 10/30/2020 at 3:27 PM in the progress notes, nursing documented a late entry for the Interdisciplinary Team (IDT) review on 10/19/2020 for the fall on 10/18/2020. The intervention was to remind R62 not to use the wheelchair as a walker. The summary of discussion was blank. No new interventions were put into R62's Fall Care Plan after the IDT reviewed the fall on 10/18/2020. R62's Fall Care Plan was revised on 10/30/2020 with the following intervention: -RESOLVED: Physical Therapy to evaluate and treat as ordered or as needed (removed from the care plan) No new interventions were added to the Fall Care Plan to prevent future falls. On 12/2/2020 at 2:45 AM, R62 had an unwitnessed fall out of bed. R62 stated he was dreaming. The bed was in a low position and the call light was in reach yet not activated. R62 was not wearing gripper socks as care planned. No injuries were sustained. The physician and family were notified. On 1/25/2021 at 3:46 PM in the progress notes, nursing charted a late entry for IDT review on 12/3/2020 for the fall on 12/2/2020. The fall and Fall Care Plan were reviewed. A floor mat was suggested by a staff member on a Fall/Incident Witness Statement form and was followed up with notation that a floor mat was not a safe intervention because R62 self-transfers from bed. No new interventions were put into R62's Fall Care Plan after the IDT reviewed the fall on 12/2/2020. On 12/18/2020 at 4:15 AM, R62 had an unwitnessed fall out of bed. R62 stated he was dreaming. The bed was in a low position and the call light was within reach yet not activated. R62 was not wearing shoes or socks. No injuries were sustained. The physician and family were notified. On 2/11/2021 at 4:51 PM in the progress notes, nursing charted a late entry for IDT review on 12/21/2020 for the fall on 12/18/2020. The IDT charted safety measures were in place. Fall/Incident Witness Statements suggested to leave the door open to R62's room if R62 allows. A fall mat was discussed. No new interventions were put into R62's Fall Care Plan after the IDT reviewed the fall on 12/18/2020. On 12/19/2020 at 4:10 AM, R62 had an unwitnessed fall out of bed. R62 stated he was dreaming. The bed was in a low position and the call light was within reach yet not activated. R62 was wearing a shoe on the left foot and the right foot was bare. No injuries were sustained. The physician and family were notified. No IDT fall review was documented in R62's medical record. No new interventions were put into R62's Fall Care Plan after the fall on 12/19/2020. On 12/23/2020 at 12:25 AM, R62 had an unwitnessed fall out of bed. R62 stated he got hit by a car. The bed was in a low position and the call light was within reach yet not activated. R62 did not have any footwear on. No injuries were sustained. The physician and family were notified. No IDT fall review was documented in R62's medical record. No new interventions were put into R62's Fall Care Plan after the fall on 12/23/2020. On 2/24/2021 at 8:30 AM, R62 had an unwitnessed fall in the bathroom. R62 stated he was getting off of the toilet. The call light was within reach yet not activated. R62 had shoes on. R62 was transported to the emergency room for a right [CONDITION(S)]. On 2/28/2021, R62 was readmitted to the facility following surgical repair for the right [CONDITION(S)]. On 3/12/2021 at 12:21 PM in the progress notes, nursing charted a late entry for IDT review on 2/25/2021 for the fall on 2/24/2021. R62 was unaware of safety issues and self-transferred to the toilet despite needing assist of one from staff. The summary of discussion was left blank. R62's Right [CONDITION(S)] Related to a Fall Care Plan was initiated on 2/28/2021 with the following interventions: -Anticipate and meet needs; be sure call light is within reach and respond promptly to all requests for assistance. -Follow physician orders for weight bearing status; see physician orders and/or Physical Therapy treatment plan. -Modify environment as needed to meet current needs; non-slip surface for bath/shower, bed in lowest position with wheels locked, floors that are even and free from spills, clutter, adequate glare-free light. -Monitor limb for swelling and skin changes; take pedal pulses as needed. -Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. -Monitor/document/report as needed signs/symptoms of [CONDITION(S)] complications. -Physical Therapy, Occupational Therapy evaluation and treatment per orders. R62's Fall Care Plan was revised on 3/2/2021 with the following intervention: -REMOVED: Safety Awareness: Remind R62 to not use wheelchair as a walker. (removed from the care plan) -Fall mat next to the bed. -Hip protectors on at all times. R62's Fall Care Plan was revised on 3/21/2021 with the following intervention: -Body pillow when in bed. On 4/11/2021 at 10:00 AM, R62 had an unwitnessed fall in the bathroom by the sink. R62 stated he was trying to go from point A to point B. R62 had shoes on and was using a wheeled walker. No injuries were sustained. The Fall/Incident Witness Statement had a suggestion for having R62 out of the room in activities or the dayroom to prevent future falls. On 4/26/2021 at 8:58 PM in the progress notes, nursing charted a late entry for IDT review on 4/12/2021 for fall on 4/11/2021. The summary of discussion stated the team met and discussed the fall. R62 lacks safety awareness and transfers by himself. Medication were reviewed. The Care Plan was reviewed. No new interventions were put into R62's Fall Care Plan after the IDT reviewed the fall on 4/11/2021. On 4/17/2021 at 10:30 AM, R62 had an unwitnessed fall in the bathroom trying to self-transfer on or off the toilet. R62 was wearing shoes and socks. The call light was in reach yet not activated. R62 was brought out into the day room for direct supervision. R62's Fall Care Plan was revised on 4/17/2021 with the following intervention: -Encourage R62 to be in the day room for direct supervision. On 4/19/2021 at 10:51 AM in the progress notes, nursing charted the IDT met to review the fall on 4/17/2021. The IDT determined the staff need to review R62's bowel program as the self-transfer appears to correlate with needing to use the toilet. In an interview on 5/6/2021 at 10:48 AM, Surveyor requested from Director of Nursing (DON)-B the paperwork that showed R62's bowel program had been reviewed following R62's fall on 4/17/2021. DON-B did not provide any documentation showing the review of R62's bowel program. On 5/4/2021 at 7:39 AM, Surveyor observed R62 in the day room. R62's room had a stop sign banner across the doorway. In an interview on 5/4/2021 at 7:52 AM, Registered Nurse (RN)-H stated R62 is a frequent [NAME] and we need to keep R62 out of R62's room. RN-H stated that is why there is a STOP sign over the doorway. On 5/5/2021 at 10:21 AM, Surveyor observed R62 in bed to have wound care completed. The bed was in a low position, a fall mat was on the floor, and a body pillow was to the right side of R62. R62 had gripper socks on and heel boots. On 5/6/2021 at 10:48 AM, Surveyor met with DON-B to discuss concerns and findings with R62's falls. R62 had eight falls in six months. Interventions were not implemented after each fall to prevent future falls. Documentation of IDT reviews of falls range from one day to several months or no IDT meeting was documented. On 2/24/2021, R62 sustained a right [CONDITION(S)] due to a fall in the bathroom. R62 had five falls prior to that with no investigation as to the cause of the fall or implementation of interventions to prevent future falls. Four falls in 12/2020 occurred falling from bed. Three falls in 2/2021-4/2021 occurred in the bathroom. R62 had a pattern with falls that could have potentially been prevented if interventions had been put in place addressing the causes of the falls. DON-B stated all falls are reviewed at morning meetings during the work week by an IDT consisting of therapy, activities, social services, the administrator, the QA (Quality Assurance) nurse, unit supervisors, and DON-B. DON-B stated they review the falls and read the packets that are submitted by the staff that are on duty when the fall occurred. DON-B stated the QA nurse puts in an IDT note in the progress notes which says the team discussed the fall, the Care Plan was reviewed, and then states what the new intervention is. The new intervention then gets put into the care plan. DON-B stated the facility implemented a new fall worksheet in 7/2020 that has all the questions Surveyor was asking about regarding the interventions in place for falls and the new interventions decided by the IDT. DON-B looked at the forms Surveyor had been provided by DON-B and DON-B stated staff weren't using the correct forms. In an interview on 5/6/2021 at 2:38 PM, Quality Assurance Registered Nurse (QA RN)-I stated falls were reviewed every weekday. QA RN-I stated the fall packet is completed by staff with a checklist to make sure all the wickets that need to be looked at are covered. QA RN-I stated last June, 2020 staff statements were added to the fall packet to find out why the fall occurred. QA RN-I stated the statements are only as good as the people filling out the forms. QA RN-I stated the IDT reviews the falls and makes a note about if the care plan was reviewed. QA RN-I stated a fall risk assessment is completed on admission. QA RN-I stated if a resident has a fall, then the goal changes from no fall to no major injury with a fall. QA RN-I stated residents with multiple falls goes through different interventions to make them safe, like a new mattress, a room change, anti-tippers to a wheelchair, or Dycem; all residents have a low bed. QA RN-I stated you might get to a point where there aren't any more interventions that you can do. On 5/6/2021 at 4:22 PM, Surveyor met with Nursing Home Administrator-A and DON-B. Surveyor shared the concerns with R62's multiple falls, no interventions implemented to prevent future falls, and the fall on 2/24/2021 resulting in a fracture of the right hip. No further information was provided at that time. 3.) R12 was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's Disease, Heart Failure, Chronic Kidney Disease and Dementia without Behavioral Disturbance. R12's Quarterly MDS (Minimum Data Set) documents a score of 10, indicating that R12 is moderately cognitively impaired. Section G (Functional Status) documents that R12 requires extensive assistance a one person physical assist for his bed mobility needs. Section G also documents that R12 has total dependence on staff and requires a two person physical assist for his transfer needs. Section G0400 (Functional Limitation of Range of Motion) documents that R12 has no impairment to either side of his upper or lower extremities. R12's Falls CAA (Care Area Assessment) dated 6/9/20 documents under the Analysis of Findings section, Requires total assist with transfer 2 staff/full body lift. Extensive to total assist with bed mobility needs. Incontinent of bowel and bladder. Cognitive impairment. Manual w/c (wheel chair) is used. Sensory impairment vision/hearing. Hx (history) of fall, see notes. R12's Falls care plan dated as initi [TRUNCATED]

Based on record review, interview and observation, the facility did not maintain an infection prevention and control program that helped prevent the development and transmission of COVID-19, potentially affecting 113 residents who resided on mixed living units where both COVID-19 positive and COVID-19 negative residents received assistance from facility staff. * Facility staff were observed not wearing full PPE (personal protective equipment) per CDC (Centers for Disease Control) and public health guidelines when working with both negative and positive COVID-19 (Coronavirus Disease 2019) residents. * Facility staff was observed not wearing appropriate PPE when entering a COVID-19 positive unit and or when working with a COVID-19 positive resident. * Facility staff was observed to not implement appropriate infection control measures, including handwashing and glove wearing, when providing assistance between COVID-19 positive and COVID-19 negative residents. The facility's failure to implement an infection prevention and control measures to prevent the spread of COVID-19 created a finding of immediate jeopardy that began on 8/3/20. The Nursing Home Administrator (Administrator-A) and DON (Director of Nursing)-B were notified of the immediate jeopardy on 8/13/20 at approximately 11:00 a.m. The immediate jeopardy was removed by the facility on 8/14/20. The deficient practice continues at a scope and severity of an F (potential for harm/widespread) as the facility continues to implement its action plan. Findings include: The facility's policy dated as revised on 8/6/20 and titled Wisconsin Veterans Home 2019 Novel Coronavirus (COVID-19) documents under the Policy section, Healthcare personnel caring for Member with confirmed or suspected 2019 Novel Coronavirus (COVID-19) shall adhere to recommendations for infection prevention and control from the Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, and state or local public health notifications. The CDC (Centers for Disease Control)'s recommendation dated as updated on June 25, 2020 and titled, Preparing for COVID-19 (Coronavirus Disease 2019) in Nursing Homes documents, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens .As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). Findings include: 1.) Facility Background On 8/12/20, an FICS (Focused Infection Control Survey) was conducted at the facility. As part of this survey, staffing levels, and PPE (personal protective equipment) supply levels and observations of infection control practices were reviewed. On 8/12/20 at 10:56 a.m., Surveyor conducted and FICS entrance conference interview with Administrator-A and DON-B. During this interview, Surveyor was informed by Administrator-A and DON-B of the following: As of 8/12/20, the facility currently had 19 residents confirmed as COVID-19 positive and had an active outbreak of COVID-19 on the 1 West Unit. Since 8/12/20, the facility had four residents diagnosed as COVID-19 positive expire. As of 8/12/20, the facility had 21 employees whom were confirmed as COVID-19 positive. Due to the amount of employees whom were not working due to a positive COVID-19 test, the facility had activated their emergency staffing plan and has supplemented their staffing levels with 20 federal VA (Veteran's Administration) employees. As of 8/12/20, the facility had tested all employees and residents for COVID-19 from 8/2/20 to 8/4/20. The facility had no designated COVID-19 unit; however over half the residents who were COVID-19 positive were located on the 1 West Unit. The remaining COVID-19 positive residents resided on floors 1 through 3, with COVID-19 positive residents having private rooms and bathrooms. As of 8/12/20, the 1 West Unit, which as of the time of the survey had an active outbreak, had 14 residents residing on the unit with 11 residents confirmed COVID-19 positive, 2 residents confirmed to be COVID-19 negative and 1 resident pending COVID-19 test results. Administrator-A informed Surveyor that the facility had been in contact with the Racine County Public Health Department and had reported the COVID-19 outbreak to the Racine County Public Health Department. Administrator-A, informed Surveyor that Racine County Public Health was aware of the outbreak and was in constant communication with the facility regarding measures that could prevent the further spread of COVID-19. Surveyor was informed by Administrator-A and DON-B that the facility did not have any PPE (personal protective equipment) shortages and that the facility was currently under a conventional capacity strategy with their PPE supplies. An inventory of PPE supplies provided to Surveyor by DON-B revealed that as of 8/12/20 the facility had: 1,265 N95 Masks (all sizes and brands), 538 face shields, 665 goggles and 1,280 gowns available for staff. 2.) PPE Use On 8/12/20 at 10:56 a.m., Surveyor interviewed Administrator-A and DON-B regarding the facility's PPE use. DON-B informed Surveyor that facility staff are expected to wear a face mask (N95 mask not required), a face shield and gloves when working with confirmed COVID-19 negative residents. DON-B informed Surveyor that facility staff were expected to wear a gown, an N95 mask, a face shield and gloves when working on the 1 West Unit (which was experiencing an active outbreak at the time of the survey) or when working with confirmed COVID-19 residents. Surveyor noted that the above recommendations were not in accordance to the most updated CDC (Centers for Disease Control) recommendations for the use of PPE during the COVID-19 Pandemic. The CDC's recommendations dated as updated on June 25, 2020 and titled Preparing for COVID-19 in Nursing Homes documents under the Core Practices section, Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The health department can assist with decisions about testing of asymptomatic residents. The CDC's recommendations dated as updated on July 15, 2020 and titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic documents under the Recommended infection prevention and control practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-COV-2 (Coronavirus Disease 2019) infection section documents, HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. On 8/12/20 at 1:06 p.m., Surveyor performed a walk-through of the 2 East unit, where R6, who was confirmed COVID-19 positive on 8/6/20, and R7, who was confirmed as COVID-19 positive on 8/9/20, resided. Surveyor observed facility staff providing assistance to COVID-19 negative residents on the 2 East unit without wearing full PPE per CDC recommendations. Surveyor observed facility staff on the 2 East Unit, wearing only face shields, masks (not N95 masks) and gloves when working with COVID-19 negative residents. Surveyor noted that while staff wore a gown, face shields and N95 masks when entering the R6 and R7's rooms, staff on the 2 East unit were not wearing full PPE per CDC recommendations when working with COVID-19 negative residents on the 2 East unit. On 8/12/20 at 1:15 p.m., Surveyor performed a walk-through of the 3 West unit, where R10, whom was confirmed as COVID-19 positive on 8/9/20, resided. Surveyor observed facility staff providing assistance to COVID-19 negative residents on the 3 West unit without wearing full PPE per CDC recommendations. Surveyor observed facility staff on the 3 West unit, wearing only face shields, masks (not N95 masks) and gloves when working with COVID-19 negative residents. Surveyor noted that while staff wore a gown, face shields and N95 masks when entering the R10's room, staff on the 3 West unit were not wearing full PPE per CDC recommendations. On 8/12/20 at 1:21 p.m., Surveyor performed a walk-through of the 3 East unit, where R8 and R9, both whom were confirmed as COVID-19 positive on 8/9/20, resided. Surveyor observed facility staff providing assistance to COVID-19 negative residents on the 3 East unit without wearing full PPE per CDC recommendations. Surveyor observed facility staff on the 3 East unit, wearing only face shields, masks (not N95 masks) and gloves when working with COVID-19 negative residents. Surveyor noted that while staff wore a gown, face shields and N95 masks when entering the R8 and R9's rooms, staff on the 3 East unit where not wearing full PPE, per CDC recommendations, when working with COVID-19 negative residents on the 3 East unit. On 8/12/20 at 1:47 p.m., Surveyor performed a walk-through of the 1 East Unit, where R4 and R5, both whom were confirmed as COVID-19 positive on 8/7/20, resided. Surveyor observed facility staff providing assistance to COVID-19 negative residents on the 1 East unit without wearing full PPE per CDC recommendations. Surveyor observed facility staff on the 1 East Unit, wearing only face shields, masks (not N95 masks) and gloves when working with COVID-19 negative residents. Surveyor noted that while staff wore a gown, face shields and N95 masks when entering the R4 and R5's rooms, staff on the 1 East unit where not wearing full PPE when working with COVID-19 negative residents per CDC recommendations. On 8/12/20 at 2:30 p.m., Surveyor made observations of the 1 West unit, which at the time of the survey, was having an active COVID-19 outbreak. Prior to entering the unit, Surveyor observed a sign outside of the 1 West Unit which stated, Droplet Precautions and called for the use of an N95 mask, a gown and a face shield to be donned by facility staff prior to entering the 1 West unit. On 8/12/20 at 2:36 p.m., Surveyor observed CNA (Certified Nursing Assistant)-C enter the 1 West unit without wearing a gown or an N95 mask. Surveyor observed CNA-C to enter the unit while only wearing a blue surgical mask and a face shield while holding a clear plastic bag containing an N95 mask. As CNA-C entered the unit, other CNAs working on the 1 West unit told CNA-C to put a gown on. CNA-E was then observed handing CNA-C a gown, which CNA-C put on, and then Surveyor observed CNA-C walk off the 1 West unit while still wearing the gown. Surveyor noted that per CDC recommendations and the facility's policy, CNA-C should have been wearing full PPE including a gown, N95 mask and a face shield before entering the 1 West unit. On 8/12/20 at 4:08 p.m., Surveyor informed Administrator-A and DON-B of the above findings. Surveyor asked Administrator-A if facility staff should be wearing full PPE (N95, gown, gloves and face shield) while on the units where COVID-19 positive residents reside. Administrator-A and Doctor-F informed Surveyor that due to the immediate care required by some COVID-19 residents, facility staff should be wearing full PPE while on units where COVID-19 positive residents reside. Administrator-A informed Surveyor that CNA-C should have been wearing an N95 mask, gown and face shield prior to entering the 1 West unit. On 8/17/20 at 3:29 p.m., Surveyor interviewed Public Health RN (Registered Nurse)-G regarding any recommendations made to the facility regarding the use of PPE for COVID-19 residents. Public Health RN-G informed Surveyor that Racine Public Health had recommended the use of full PPE (faceshield, N95 mask, gown and gloves) by facility staff working on units where any COVID-19 positive residents resided, regardless of the presence of any COVID-19 symptoms. Public Health RN-G informed Surveyor that the they had recommended to the facility that facility staff working on units where any COVID-19 positive residents resided should be wearing full PPE per CDC and DHS (Department of Health Services) guidelines. The Wisconsin Department of Health Services webpage documents under the COVID-19: Long- Term Care Facilities and Services section, If COVID-19 is identified in the facility, restrict all residents to their room and have HCP wear all recommended PPE for all resident care, regardless of the presence of symptoms. Refer to strategies for optimizing PPE when shortages exist. This approach is recommended to account for residents who are infected but not manifesting symptoms. Recent experience suggests that a substantial proportion of long-term care residents with COVID-19 do not demonstrate symptoms. When a case is identified, public health can help inform decisions about testing asymptomatic residents on the unit and in the facility. No additional information was provided. 3.) Hand Hygiene The CDC's recommendation documented as updated on May 17, 2020 and titled, Hand Hygiene Recommendations: Guidance for Healthcare Providers about Handy Hygiene and COVID-19 documents under the Background section, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. [MEDICATION NAME] hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The CDC's recommendations dated as updated on June 25, 2020 and titled Preparing for COVID-19 in Nursing Homes documents under the Core Practices section, Care must be taken to avoid touching the respirator, facemask, or eye protection. If this must occur (e.g., to adjust or reposition PPE), HCP should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others. On 8/12/20 at 2:31 p.m., Surveyor observed CNA-E go into R2's room while wearing an N95 mask, gown and faceshield, to place a shirt on R2. Surveyor noted that R2 was confirmed to be COVID-19 positive on 8/5/20 and that CNA-E was not wearing gloves when entering R2's room. On 8/12/20 at 2:33 p.m., Surveyor observed CNA-E exit R2's room and sanitize both his ungloved hands. Surveyor then observed CNA-E pick up a soiled shirt belonging to R2 with his ungloved left hand as he (CNA-E) exited R2's room. Surveyor then observed CNA-E stop R1, who was exiting his room located next to R2's room, and tell R1 he needed a facemask. Surveyor then observed CNA-E enter R1's room with R2's soiled shirt in his hand. Upon exiting R1's room, Surveyor observed CNA-E use both his ungloved hands, including utilizing his left hand holding R2's soiled shirt, to open a blue surgical mask and give it to R1. Surveyor then observed R1 place the mask on his face. Surveyor then observed CNA-E walk to the soiled linen bin and place R2's shirt in the soiled linen bin and then sanitize both his hands. Surveyor noted that R1 was confirmed to be COVID-19 negative and that CNA-E did not wash or use hand sanitizer on his ungloved hands after handling R2's soiled shirt with his bare hands and prior to entering R1's room and or prior to providing R1 with a mask that R1 placed on his face. On 8/12/20 at 2:36 p.m., Surveyor observed CNA-D physically place a blue surgical mask on R2's face using her bare hands. Surveyor then observed CNA-D then tell R2 to keep his mask on like her while CNA-D touched her face and the outside of her N95 mask without washing her hands. Surveyor observed CNA-D then walk to the nurse's station, in the process touching the hand rail and a desk at the nurse's station, before sanitizing her hands. During this observation, Surveyor heard facility staff tell CNA-D to make sure she washed her hands after placing a mask on R2. Surveyor noted that R2 was confirmed to be COVID-19 positive on 8/5/20 and that per facility and CDC guidelines, CNA-D should have been wearing gloves and should have washed or sanitized her hands after working with R2 and prior to touching the outside of her N95 mask and her face. On 8/12/20 at 2:36 p.m., Surveyor observed CNA (Certified Nursing Assistant)-C enter the 1 West unit without wearing a gown or an N95 mask. Surveyor observed CNA-C to enter the unit while only wearing a blue surgical mask and a face shield while holding a clear plastic bag containing an N95 mask. As CNA-C entered the unit, other CNAs working on the 1 West unit told CNA-C to put a gown on. CNA-E was then observed handing CNA-C a gown, which CNA-C put on, and then Surveyor observed CNA-C walk off the 1 West unit while still wearing the gown. Once outside the 1 West unit, Surveyor observed CNA-C speak with 2 other facility employees while still wearing her gown. Surveyor did not observe CNA-C wash or sanitizer her hands nor remove her gown immediately upon exiting the 1 West unit. Surveyor then observed CNA-C, after speaking with other facility staff, touch the outside of the PPE cart stationed outside of the 1 West unit and remove her gown. Surveyor noted that CNA-C did not sanitize her hands or remove her gown immediately after exiting the 1 West unit or before touching the PPE cart stationed outside the 1 West unit. On 8/12/20 at 4:08 p.m., Surveyor informed Administrator-A and DON-B of the above findings. Surveyor asked Administrator-A if CNA-E should be wearing gloves when handling soiled linen and if CNA-E should be washing and or sanitizing his hands prior to assisting a COVID-19 negative resident after handling the soiled linen of a COVID-19 positive resident. Administrator-A informed Surveyor that facility staff is expected to use gloves and wash their hands when moving from one patient's room to the other. Administrator-A informed Surveyor that CNA-E should have washed or sanitized his hands prior to assisting a COVID-19 negative resident after handling the soiled linen of a COVID-19 positive resident. Surveyor asked Administrator-A if CNA-C should have removed her gown and washed or sanitized her hands immediately after exiting the 1 West unit. Administrator-A informed Surveyor that CNA-C should immediately have removed her gown and sanitized her hands when she exited the 1 West unit. Surveyor asked Administrator-A if CNA-D should be wearing gloves and washing her hands before touching her N-95 mask and face after working with a COVID-19 positive resident. Administrator-A informed Surveyor that facility staff should be wearing gloves and full PPE (gown, N95 mask and faceshield) when working COVID-19 positive residents. The facility's failure to implement infection prevention and control measures to prevent the spread of COVID-19 created a finding of immediate jeopardy because of the ease with which [MEDICAL CONDITION] can spread and because of the serious effects it can have on the elderly and those with compromised systems. The immediate jeopardy was removed when the facility took the following action: 1. Nursing staff to be educated on Proper use of Personal Protective Equipment on training record 2. Observations Audits started on Nursing staff to use Proper Personal Protective Equipment during Direct Patient Care 3. Observations Audits started on Nursing staff to use Proper Personal Protective Equipment on entering the COVID Unit 4. COVID Dementia care plans for 1 West 5. Consultation with Doctor-F 6. Complete Nursing Assessment on all Members of 1 East Negative Members 7. Moved COVID negative member from double room [ROOM NUMBER] to single room [ROOM NUMBER] 8. Reviewed isolation outside of COVID Unit- one member met criteria to remove isolation 9. Complete COVID tests on three negative COVID members on 1 West, 1 East and 3 West. Rationale Identify Outbreak -Negative test and-negative-signs/symptoms then member will come out of isolation 10. Observe current status of COVID positive members to splint unit 11. Nursing staff were educated on specific infection control individualized COVID care plans for members with dementia on the Memory Unit on a training record. 12. QAPI process is ongoing to continually monitor the Nursing staff usage of Proper use of Personal Protective Equipment during Direct Patient Care and proper Hand Hygiene for quality assurance and performance improvement on an ongoing basis

Based on observation, interview, and record review the Facility did not ensure 5 (R128, R126, R150, R129 & R125) of 7 Residents reviewed for pressure injuries received the necessary treatment and services to promote healing and prevent new pressure injuries from developing. * R128 developed a pressure injury on 12/30/18 on the right heel. This pressure injury wasn't assessed or measured until 1/9/19, 8 days later. Treatment order's weren't obtained until 12/31/18. Interventions to offload R128's heels were not implemented until after the pressure injury developed. On 1/7/19 R128 developed a DTI (deep tissue injury) to left heel Achilles area. R128's care plan was not revised after the development of the 2nd pressure injury. On 1/26/19 R128 developed a pressure injury on her coccyx this area was not assessed or measured until the next day and there was no revision in the care plan. * R126 is at risk for pressure injury development. There were no interventions in place to prevent pressure injuries while R126 was at [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. * R150 is at risk for pressure injury development and was observed without his heels being offloaded. * R129 is at risk for pressure injury development and developed an unstageable pressure injury to the right great toe on 2/8/19. This pressure injury wasn't assessed until 2/13/19, 5 days later, by the wound team and a treatment was ordered on this date. There is no documentation R129's physician was consulted regarding the unstageable pressure injury. R129 was observed without pressure relieving boots or any offloading. * R125 is at risk for pressure injury development and developed a Stage 2 pressure injury on the right ischial tuberosity on 12/20/18. This pressure injury wasn't assessed until 12/26/18, 6 days later, the care plan did not include interventions to prevent the pressure injury from developing and was not updated once the pressure injury developed. R128 & R129 are being cited at a scope and severity of G (actual harm/isolated). Findings include: 1.) R128 has [DIAGNOSES REDACTED]. The Diabetes Mellitus care plan initiated 9/1/16 and revised 9/14/16 documents an intervention initiated 12/30/18 & revised 1/1/19 of Member needs to wear blue heel boots at all times, to prevent pressure areas. The quarterly MDS (minimum data set) with an assessment reference date of 10/17/18 documents R128 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R128 requires extensive assistance with one person physical assist for bed mobility, transfer & toilet use, requires limited assistance with one person to ambulate in her room and extensive assistance with one person physical assist to ambulate in the corridor. R128 is frequently incontinent of urine and always incontinent of bowel. R128 is at risk of developing pressure injuries and is coded as not having any pressure injuries. The Braden assessment dated [DATE] has a score of 18 which indicates at risk. The nurses note dated 12/30/18 documents Member has a small pressure area to the outer side of her right heel. Care plan was revised, and POA (power of attorney) notified. Member has to wear blue heel boots while in bed. The nurses note dated 12/31/18 documents purple area remains to the right lateral side of the heel. heel boots are on. Continue to monitor. The nurses note dated 12/31/18 documents outer right heel DTI (deep tissue injury) noted no complaint of pain, will continue to monitor. The nurses note dated 12/31/18 documents Fax received from Physician-BB to apple (sic) skin prep bid to outside of right heel. The nurses note dated 12/31/18 documents Member has a closed bruised DTI to right heel with no drainage. Skin prep applied. The pressure ulcer care plan initiated & revised on 1/23/19 documents interventions of Administer treatments as ordered and monitor for effectiveness. Member not to use shoes. Member to go back to bed after lunch, then up for dinner. initiated & revised 1/23/19, Assess/record/monitor wound healing weekly Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD (medical doctor). initiated & revised 1/1/19, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. initiated 1/23/19, The resident requires blue heel boots to both heels at all times bed/chair. initiated 1/1/9 & revised 1/7/19, The resident should not be longer than 2 hours in the broda chair. Up for meals. Member needs to be turned/repositioned at least every 2 hours, more often as needed or requested. initiated & revised 1/27/19. The nurses note dated 1/1/19 documents Called POA to discuss the plan of care in regards RT (right) heel DTI. POA will bring puffy socks. Member will be using heel protectors at all times, and no shoes on. This writer assessed area this AM (morning). DTI remains deep purple, and soft to the touch, However treatment is in place. The nurses note dated 1/2/19 documents DTI remains, treatment applied, skin is intact, heel boots on at all times. The nurses note dated 1/3/19 documents Closed deep tissue pressure wound to the right heel. Heel boots are in place. The nurses note dated 1/4/19 documents member does not complain of pain or discomfort on foot, no shoes worn this shift. heel boots on member whole shift. DTI remains unchanged. The nurses note dated 1/5/19 documents DTI remains to right outer heel, heel boots on. no c/o's (complaints) pain or discomfort. The nurses note dated 1/6/19 documents DTI remains to right outer heel, heel boots on. no c/o's pain or discomfort. The nurses note dated 1/7/19 documents DTI to right heel remains, skin is intact, treatment applied. DTI noted to left heel Achilles area. Area is dark red in colors, skin intact and about 1 cm x 1 cm in diameter. Surveyor noted this pressure injury is the 2nd deep tissue injury R128 developed. The nurses note dated 1/7/19 documents Writer gave POA update regarding DTI. POA expressed concern about new found area. Asking if a broda chair would be available. Writer stated to POA to ask the social worker about a broda chair. The nurses note dated 1/8/19 documents member wearing heel boots at all times DTI on left foot remain, no improvement noted. will continue to monitor member does not complain of pain. The weekly wound observation tool dated 1/9/19 for location documents right heel, date acquired is blank, and tissue type is necrotic tissue. Under the section wound measurements length is documented as 3 cm (centimeters), width 2, and depth 0. Under comments documents will either absorb due to initially a blister. Or will open. The right heel has a deeper area in the center L (length) .8 x (times) .5. Surveyor noted this is the first assessment and measurements for R128's right heel pressure injury since it was identified on 12/30/18. Interventions to offload R128's heels were not implemented until after the pressure injury developed. The weekly wound observation tool dated 1/9/19 for location documents left heel, date acquired is blank, and tissue type is necrotic tissue. Under the section wound measurements length is documented as 1.5, width 1.5, and depth 0. The comment section is blank. Surveyor noted the Facility completed the weekly wound observation tool for R128's right and left heel after the development of these pressure injuries. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. The significant change MDS with an assessment reference date of 1/16/19 documents R128 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R128 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use, does not ambulate and is frequently incontinent of urine and bowel. R128 is at risk for developing pressure injuries and is coded as having two unstageable deep tissue injury pressure injuries. The nurses note dated 1/26/19 documents DTI remains on buttock bilateral and lateral site of left thigh. Skin intact, no bleeding noted. Treatment applied as ordered. Surveyor noted this is the first note regarding DTI on R128's buttocks. The nurses note dated 1/27/19 documents DTI to the left thigh and heel bilateral remain intact. Treatment applied to the area. Heel boots in place. A 0.3 cm x 0.3 cm noted by the coccyx noted. Area is white in color, no bleeding or drainage noted. Surveyor noted there is no staging of the coccyx pressure injury. The nurses note dated 1/28/19 documents DTI to the left thigh and heel bilateral remain intact. Treatment applied to the area. Heel boots in place. Up for meals and in bed reposition. Coccyx area is white/yellow base with red edge, not open appears like a blister. Cushion applied to Broda chair. The nurses note dated 1/29/19 documents Areas remain repositioned Q (every) 2 hours, heel boots on. [MEDICATION NAME] to deteriorating area to coccyx. The pressure ulcer CAA (care area assessment) dated 1/29/19 under analysis of findings documents Member has impaired mobility, has had a decline in condition, is no longer ambulatory, has had weight loss, requires assistance with bed mobility, is incontinent of bladder/bowel, member currently has pressure injuries, receives arginade to promote wound healing, receives might (sic) shakes, tx (treatment) orders are in place for heels, heel protectors on at all times, repositioning program and [MEDICATION NAME] orders. See nutritional assessment and dietary care plan. The individual care service plan, which is utilized by the CNA's (Certified Nursing Assistants) located inside the bathroom cabinet dated 1/29/19 documents requires blue heel boots to both heels at all times bed/chair. The weekly wound observation tool dated 1/30/19 location documents coccyx, date acquired is 1/26/19, stage is II (2), and tissue type is granulation tissue. Under the section wound measurements length is documented as 1.2, width 1.2, and depth less than .1 cm (centimeters). The comment section is blank. On 2/19/19 at 7:59 a.m. Surveyor observed R128 in broda chair at head of table with her eyes closed. Surveyor spoke to R128 but R128 did not respond. Surveyor observed R128 is wearing pressure relieving boots. On 2/19/19 at 3:51 p.m. Surveyor observed R128 being wheeled down the hallway in a broda chair. Surveyor observed R128 is not wearing pressure relieving boots. On 2/20/19 at 9:38 a.m. Surveyor entered R128's room with RN (Registered Nurse) Supervisor-E and LPN (Licensed Practical Nurse)-D to observe R128's pressure injury treatment. (Cross reference F880). On 2/20/19 at 10:36 a.m. Surveyor met with RN (Registered Nurse) Supervisor-E who is the wound nurse for R128's unit to discuss R128's pressure injuries. Surveyor asked RN Supervisor-E why R128's right heel, which was identified on 12/30/18, wasn't assessed or measured until 1/9/19 eight days later. RN Supervisor-E informed Surveyor he has no clue. Surveyor informed RN Supervisor-E interventions to offload R128's heels were not implemented until after the pressure injury developed. RN Supervisor-E informed Surveyor R128 had a decline, they thought about hospice and prior R128 was ambulatory. Surveyor informed RN Supervisor-E there weren't any interventions for offloading. On 1/7/19 R128 developed a DTI (deep tissue injury) to left heel Achilles area and R128's care plan was not revised after the development of the 2nd pressure injury. Surveyor informed RN Supervisor-E R128 developed a pressure injury on her coccyx on 1/26/19 and this area was not assessed or measured until the next day and there was no revision in the care plan. 2.) R126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The potential impairment to skin care plan initiated & revised on 1/12/19 documents interventions also dated 1/12/19 of Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short., Educate resident/family/caregivers of causative factors and measures to prevent skin injury., Follow facility protocols for treatment of [REDACTED]. Use lotion on dry skin., Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. The [MEDICAL TREATMENT] care plan initiated & revised on 1/12/19 documents interventions also dated 1/12/19 of Check and change dressing daily at access site. Document., Encourage resident to go for the scheduled [MEDICAL TREATMENT] appointments Resident receives [MEDICAL TREATMENT] every MON (Monday)-WED (Wednesday)-FRI (Friday). Pick up time is 1330 (1:30 p.m.). Monitor labs and report to doctor as needed., Monitor vital signs daily. Notify MD (medical doctor) of significant abnormalities. Monitor/document/report PRN (as needed) for s/sx (signs/symptoms) of [MEDICAL CONDITION]: changes in skin tutor, oral mucosa, changes in heart and lung sounds., and Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. The admission MDS (minimum data set) with an assessment reference date of 1/17/19 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R126 requires extensive assistance with one person physical assist for bed mobility, transfer, & toilet and requires limited assistance with one person physical assist for ambulating. R126 is continent of urine and is frequently incontinent of bowel. R126 is at risk for pressure injury development and is coded as not having any pressure injuries. On 2/18/19 at 9:48 a.m. R126 informed Surveyor she goes out for [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. R126 indicated she leaves around 1:15 p.m. and comes back around 6:00 or 7:00 p.m On 2/18/19 at 11:28 a.m. Surveyor asked R126 if she has a cushion in her wheelchair. R126 replied yes. Surveyor asked R126 when she is sitting in the [MEDICAL TREATMENT] chair does she sit on anything. R126 informed Surveyor sometimes she sits on a pillow because her rear end gets sore. Surveyor asked if at the [MEDICAL TREATMENT] center do they transfer the cushion from her wheelchair into the [MEDICAL TREATMENT] chair. R126 replied no. On 2/20/19 at 10:22 a.m. Surveyor asked RN (Registered Nurse) Supervisor-E what interventions are in place to prevent R126 from developing a pressure injury while she is at [MEDICAL TREATMENT]. RN Supervisor-E informed Surveyor he didn't know and wasn't sure if [MEDICAL TREATMENT] staff transfer the wheelchair cushion into the [MEDICAL TREATMENT] chair. Surveyor asked RN Supervisor-E if he has contacted the [MEDICAL TREATMENT] center regarding the cushion. RN Supervisor-E replied no and explained just initially when setting up the days and transportation. Surveyor informed RN Supervisor-E Surveyor did not note any interventions. R126 had informed Surveyor her cushion is not transferred onto the [MEDICAL TREATMENT] chair and her buttocks get sore. On 2/20/19 12:05 p.m. RN Supervisor-E provided Surveyor with a piece of paper titled Area of review for State Survey. Surveyor noted for R126 the response documents Called Facility and instructed them to transfer her Roho to [MEDICAL TREATMENT] chair when there. On 2/21/19 RN Supervisor-E showed Surveyor on R126's [MEDICAL TREATMENT] communication form Please move wheelchair cushion to [MEDICAL TREATMENT] chair pressure relief was written on the top left of this form. 3.) R150's [DIAGNOSES REDACTED]. The history of self inflicted scratches initiated 6/2/18 and revised on 9/6/18 documents an intervention initiated 6/2/18 and revised 8/12/18 of The Member needs air loss mattress to protect the skin while IN BED. Float heels on pillow when in bed. The individual care service plan, which is utilized by the CNA's (Certified Nursing Assistants) located inside the bathroom cabinet dated 12/17/18 under the Resident Care section documents The member needs air loss mattress to protect the skin while IN BED. Float heels on pillow when in bed. The Braden assessment dated [DATE] has a score of 11 which indicates high risk. The quarterly MDS (minimum data set) with an assessment reference date of 1/20/19 documents R150 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R150 is dependent with one person physical assist for bed mobility, is dependent with two plus person physical assist for transfer & toilet use, does not ambulate and is frequently incontinent of bowel & bladder. R150 is at risk for developing pressure injuries and is coded as not having any pressure injuries. On 2/18/19 at 3:26 p.m. Surveyor observed R150 in bed on his left side. There is a body pillow along the right side and a mattress on the floor. Surveyor observed a green pressure relieving boot on the floor and the other boot in the garbage can at the foot of the bed. Surveyor observed R150 is wearing socks with his heels resting directly on the mattress. There was not a pillow under R150's legs to offload his heels. On 2/20/19 at 8:11 a.m. Surveyor observed R150 in bed on his left side with a body pillow along his right side. Surveyor observed a green pressure relieving boot on the mattress at the foot of the bed and the other pressure relieving boot is on top of the mattress in the corner. R150 is wearing socks with his heels resting directly on the mattress. R150's heels were not being offloaded. On 2/20/19 at 10:29 a.m. Surveyor asked RN (Registered Nurse) Supervisor-E if R150's heels should be offloaded when he is in bed. RN Supervisor-E replied absolutely. Surveyor informed RN Supervisor-E of the observations of R150's heels not being offloaded according to his plan of care. 4.) R129 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R129's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/22/19, documents: Brief Interview of Mental Status (BIMS) score of 7, indicating R129 has severe cognitive impairment; dependent on two staff for bed mobility, transfers and toilet use; dependent on one staff person for personal hygiene and mobility; extensive assist of two staff for dressing and extensive assist of one staff for eating. The MDS indicates R129 is at risk for pressure injuries and does not have any areas at this time. R129's Care Plan dated 11/18/17 with revisions on 10/19/18, documents: The resident has potential for impairment to skin integrity r/t (related to) fragile skin. Actual impairment bilateral Achilles, boil to left chest, and skin tear to right elbow. Interventions include: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernail short. (11/18/17); Encourage good nutrition and hydration in order to promote healthier skin (11/18/17); Follow facility protocols for treatment of [REDACTED]. Use lotion on dry skin. (11/18/17); The resident needs pressure relieving/reducing ROHO cushion to protect the skin while up in chair (11/18/17 revised 6/21/18); The resident needs pressure relieving/reducing mattress to protect the skin while in bed (11/18/17); Use caution during transfers and bed mobility to prevent striking arms, legs and hands against and sharp or hard surfaces (11/18/17). R129's Certified Nursing Assistant (CNA) Care Card, dated 2/20/19, documents: No tennis shoes, heel boots on at all times r/t (related to) bilateral Achilles tendon area. R129's Care Plan does not document interventions to prevent or treat the pressure injury to the right great toe acquired on 2/8/19. (Cross reference F657) On 2/8/2019, at 4:16 PM, R129's Medical Record documents: Member monitored due to an area measuring 0.8 cm (centimeters) x 0.8 cm on the tip of the right great toe. This area is best described as deep purple/red colored firm-dry tissue, flaky with no complaints of pain and no drainage. PT (Physical Therapy) contacted; writer requested modifying the present Broda chair with a foot-rest extension. Wound care also contacted via email. Will continue to monitor. On 2/13/18, R129's Weekly Wound Observation Tool, documents: Tip of right great toe has 100% hard black eschar, measuring 0.8 cm (centimeters) by 1 cm. treatment of [REDACTED]. This was documented as the first observation and assessment of this pressure injury with no prior reference for the wound. Surveyor noted this is despite documentation in the record indicating the wound was acquired on 2/8/19. On 2/13/2019, at 10:10 PM, R129's Medical Record documents: Right Great Toe has small area on tip consisting of eschar. No complaints of pain, No swelling. Treatment with [MEDICATION NAME] is bid (two times per day). This is a pressure related skin concern. Will monitor. On 2/13/19, R129's Medical Record documents: Doctor ordered Tip R (right) great toe [MEDICATION NAME] BID and stage and measure tip R toe Q (every) week with rounds on Wed AM. On 2/19/19, 8:34 AM, Surveyor observed R129 in bed with no heel boots on and heels not floated. On 2/21/19, at 12:03 PM, Surveyor interviewed Registered Nurse (RN)-I, who stated: R129 was documented to have an unstageable pressure injury to the right great toe on 2/8/19. It was believed the area occurred due to rubbing on the Broda chair foot rest. Physical Therapy was contacted to modify the Broda chair foot rest with a longer one. The facility wound team was then contacted via email and first assessed the area on 2/13/19. A treatment of [REDACTED]. RN-I stated she would look for documentation that R129's physician was notified of the new pressure injury on 2/8/19. RN-I stated R129 received the first treatment to the right great toe on 2/13/19 and is uncertain if that was related to the wound team's first assessment of of the wound occurring on that date or if no treatment was necessary until 2/13/19. On 2/21/19, at 1:36 PM, RN-I shared with Surveyor there is no documentation that R129's physician was notified of the new pressure injury to the right great toe when discovered on 2/8/19. RN-I stated she would expect R129's physician to be updated when the staff discovered the new pressure injury and stated it must have been over looked. RN-I stated the treatment of [REDACTED]. RN-I stated she isn't sure why the first assessment of the pressure injury occurred several days after it was discovered but the wound team provided the first assessment. RN-I stated R129's care plan was not updated to include interventions to prevent the pressure injury nor was the care plan updated once the pressure injury was discovered and she would have expected this to be done. RN-I stated that R129 is to have heel boots on at all times and is not sure why they were observed off on 2/19/19. On 2/21/19, Director of Nursing (DON)-B, was informed of the above concern. 5.) R125 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R125's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/27/18, documents a Brief Interview of Mental Status Score (BIMS) of 10, indicating R125 has moderately impaired cognition, required extensive assist of two staff for bed mobility, transfers, and toilet use, required extensive assist of one staff for dressing and personal hygiene needs. R125 is documented to be always incontinent of bladder and bowel and at risk for development of pressure injuries. R125's Care Plan, dated 1/27/17 and revised on 12/20/18, documents: The resident has actual impairment to the Right Lateral Heel and Right Buttock. Interventions include: Assess skin condition every week on bath day; Encourage good nutrition and hydration in order to promote healthier skin; Follow facility protocols for treatment of [REDACTED]. (etcetera) to MD (Medical Doctor). R125's care plan did not include interventions to prevent the right ischial tuberosity pressure injury and the care plan was not updated with interventions when the right ischial tuberosity pressure injury was identified in 12/20/18. (Cross Reference F657) R125's Weekly Wound Observation Tool, dated 12/26/18, documents: on 12/20/18 R125 acquired a Right Ischial Tuberosity pressure injury measuring 4 cm (centimeters) x (by) 2.5 cm x 0 cm. This was the first assessment of the Right Ischial Tuberosity, which occurred 6 days after it was first identified. Interventions of [MEDICATION NAME] (treatment) Q (every) shift, change wheelchair cushion to ROHO, air mattress, up for meals only and reposition Q 2 hrs (hours) were documented on the Wound Observation Tool. R125's care plan and Certified Nursing Assistance (CNA) care card only document the recommendation of repositioning Q 2 hrs. On 12/20/18, R125's medical record documents: CNA called writer related to her noting some blood in members brief. Writer assessed peri-area and noted member has open area to right buttock that measures 2.5 cm around. Area washed, patted dry and [MEDICATION NAME] applied. Area is superficial, pink/red in color. No s/s (signs/symptoms) of infection noted. Member denies pain to area. Writer will put in nursing orders to off-load member between meals to relieve pressure from buttock. There is no documentation that R125's Physician was notified and if the interventions of [MEDICATION NAME] ointment and off-loading between meals was appropriate and approved by R125's physician in the treatment of [REDACTED]. (Cross Reference F580) On 2/21/19, at 10:04 AM, Surveyor interviewed Registered Nurse (RN)-I, who stated: R125 was assessed to have a pressure injury to the right ischial tuberosity on 12/20/18. R125 was assessed by the wound team on 12/26/18. R125 had a prior standing order for [MEDICATION NAME] ointment. R125 was placed on 24 hour board for monitoring. The interventions of [MEDICATION NAME] ointment, low air loss mattress, off load after meals, up for meals only and side to side positioning in bed were documented on the 24 hour board. RN-I is unable to determine when the low air loss mattress was applied and if the interventions of off loading after meals and side to side positioning were initiated. A review of the 24 hour board for 12/20/18, documents: R124 has a new O/A (open area), right buttock, 2.5 cm around, washed [MEDICATION NAME] applied, low air loss mattress on, off load after meals, up for meal only, side to side position in bed. The facility was unable to locate the 24 hour board report for 12/26/18, the date R125 was seen by the wound team. There is no documentation that R125's physician was notified of the new open area to the right ischial tuberosity. Revisions to R125's care plan were not made to include the new interventions of: [MEDICATION NAME] ointment, off loading between meals, Roho cushion in wheelchair, low air loss mattress, off load after meals, up for meals only and side to side positioning in bed. On 2/21/19, 1:21 PM, RN-I informed Surveyor, that she is unable to locate documentation that R125's physician was notified of the pressure injury to the right ischial tuberosity identified on 12/20/18. RN-I stated she would expect to see R125's physician notified of the new pressure injury and the recommendations of [MEDICATION NAME] ointment, off loading between meals, Roho cushion in wheelchair, low air loss mattress, off loading after meals, up for meals only and side to side positioning in bed reviewed with the physician and placed on the care plan. RN-I is uncertain why the physician wasn't notified and the care plan not updated. RN-I was unable to explain why R125's new open area on the right ischial tuberosity was not assessed for 6 days after it was identified. On 2/21/19, Director of Nursing (DON)-B, was informed of the above concern.

Based on interview and record review, the facility failed to keep 1 (R2) of 6 residents reviewed free from sexual abuse. R1, who had been exhibiting escalating sexual behaviors and has a history of sexually abusing another resident, was to be on 1:1 staff supervision at all times with R1 to be in reach and sight of staff at all times. On 10/21/18, a CNA (certified nursing assistant) who was providing 1 to 1 supervision of R1, left R1 alone and unsupervised. While left unsupervised R1 entered a cognitively impaired, hospice resident's room (R2). R1 pulled off R2's blanket, attempted to remove his brief, and offered oral sex. R2 was noted to have severe anxiety following the incident, requiring anti-anxiety medications for severe anxiety and reported on 10/23/18 a guy tried to rape him. The facility's failure to protect R2 from sexual abuse resulted in a finding of immediate jeopardy, which began on 10/21/18. Administrator-A was notified of this finding on 11/7/18 at 2:00 pm. The immediate jeopardy was removed on 10/24/18 when the facility became aware that CNA-C left R1 unattended and implemented an action plan. The deficient practice continues at a scope/severity level of an E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's Abuse Prohibition and Investigation policy and procedure, with a last review date of (MONTH) (YEAR), defines sexual abuse as non-consensual sexual contact of any type with a Member. R1 was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. In (MONTH) (YEAR) R1 was hospitalized due to [MEDICAL CONDITION]. Following R2's hospitalization he began exhibiting increasing sexual behaviors including frequent masturbation in public places, inserting objects into his rectum and inappropriate sexual comments to staff and peers. Following an incident on 8/10/18 R1 was placed on 1:1 staff supervision. On 9/17/18 R1 was observed touching a severely cognitively impaired peers genitals. (Please see the Statement of Deficiency for Event ID XC6L11 for details regarding this incident.) R1's plan of care includes a focus area of The resident is/has potential for sexually inappropriate behavior r/t (related to) Dementia AEB (as evidenced by) propositioning staff (asking for a 'blow job'), putting call light in his rectum, trying to force staff to touch his groin, masturbating in public, disrobing in public, inappropriate sexual contact with peer, member also had been writing sexually inappropriate statements on his room walls, in magazines and attempted sexually inappropriate contact with peer (Oct (YEAR)) with an initiated date of 7/30/18. Interventions include 1:1 staff supervision at all times. Member to be in reach and sight at all times. All meals served at nurses station with an initiated date of 9/18/18. R2 has [DIAGNOSES REDACTED]. R2 is on hospice. A Minimum Data Set assessment, with an assessment reference date of 10/17/18 documents R2 as having a Brief Interview for Mental Status Score of 4, indicating that R2 is severely cognitively impaired. R1's progress notes document on 10/3/18 Member was inappropriate this evening. Member outside his doorway naked and asking 1:1 CNA to give him a blow job. Member masturbating several times this evening. Member asked 1:1 while outside in court yard if she could go inside so he could masturbate outside. Member asked 1:1 several times to give him a blow job. Writer saw member had written vulgar language on the wall by his bed, and member in bed naked. R1's progress notes on 10/5/18 document .After dinner member was sitting in day area to watch baseball game. 1:1 was sitting next to member member then stuck hand in pants and attempted to try and masturbate. 1:1 redirected members behavior. Few minutes later member got up and was walking and started to reach in pants while going towards another member, 1:1 stepped between members and redirected member to his own room. R1's progress notes on 10/7/18 document 1:1 maintained. Member went to approach another member, writer intervened and member then proceeded to walk to room . R1's progress notes on 10/19/18 document Member asked 1:1 staff if he could perform a blow job on another member. He was escorted back to his room. He remained there for remainder of shift. Progress notes on 10/21/18 at 9:36 am document remains with 1:1, 1:1 reported that when member and her went outside he took out his penis and started making inappropriate comments towards her. A facility self-report to the State Agency, documented as completed on 10/21/18, documents an incident occurred on 10/21/18 at 8:10 pm. A brief summary of the incident is documented as Member (R2) stated Member (R1) Entered his room and grabbed at his blanket before (R1) was redirected by staff and removed from the room. Member (R2) stated he was not exposed and his body or private area was not touched. As part of the facility investigation Nursing Supervisor-D interviewed R2 at 8:30 pm. The documentation of the interview indicates R2 stated At first when he walked into my room I thought it was my brother-in-law and wondering why he would be here tonight to see me, he looks like him. He put his cane next to my table by my bed and the next thing I know he grabs the covers, pulls the covers off of me and then grabbed my underwear (brief) and started with the tape, and then I realized that this guy is completely nuts. He then offered me oral sex and then I started yelling for him to get out of here. He did not touch my penis or my scrotum but he was near my groin. He didn't touch me. He was in here for about 3 minutes before the girl came in to grab him, and she had apparently been eating something because her mouth was smacking on some food or something. Nursing Supervisor-D documents in the investigation Writer was called by LPN (licensed practical nurse) (LPN-E) shortly after 8pm stating that Member (R1) had walked into Member (R2)'s room and now (R2) saying 'He tried to take my clothes off. Writer asked (LPN-E) to give his 1:1 CNA (CNA-C) the phone so I could ask her what happened. (CNA-C) stated that (R1) was in front of her and then all of a sudden he darted into Member (R2)'s room and pulled at the bed covers but did not touch Member (R2). Writer instructed (CNA-C) she must stay within arm's reach of (R1) and not let him out of her sight, and stay in front of him in the hall near Members rooms to help prevent him from going into others rooms. R2's progress notes document on 10/21/18 at 8:15 pm Member upset stating another Member entered his room and pulled on his blankets. Writer spoke to Member and reassurance given and he stated he was okay. R2's progress notes on 10/22/18 at 3:16 pm document member voiced concern about other members entering his room, reassured member that staff is always on duty and he is safe. On 10/23/18 at 1:07 am R2 required 2mg of [MEDICATION NAME] for severe anxiety/restlessness. The surveyor noted this was the first time that R2 required 2mg of [MEDICATION NAME] for severe anxiety. Progress notes document Member very restless this noc. Using call light very frequently. ETC Will monitor closely. Progress notes at 1:22 am Writer was giving member his pills and having a generalized conversation, member stated he was glad writer was here for safety. Prior to the incident R2 had taken 0.5 mg of [MEDICATION NAME] for mild anxiety 5 times. On 10/23/18 at 7:49 am R2 required 2 mg of [MEDICATION NAME] for severe anxiety/restlessness for the second time that day. Progress notes document .member restless and increased anxiety. A progress notes on 10/23/18 at 4:12 pm documents Attempted to meet with Member this morning, but said he was tired and to come back later. I returned later afternoon and Member was still feeling tired. I noted from reviewing the nurse charting that he has been feeling anxious. When I asked what he was anxious about, he said his stomach is bothering him; he feels nauseas (sic). I asked if he was feeling anxious about anything else and he said 'Yes, the other night, a guy tried to rape me.' I assured him that we will not allow anyone in his room and will keep him safe. He said he feels better knowing that . On 10/24/18 at 3:52 pm progress notes document Visited with (R2) today and noted that he now has a 1:1 to help reduce his anxiety. On 10/25/18 at 2:12 am R2 required 1mg of [MEDICATION NAME] for moderate anxiety/restlessness. Progress notes document member noted to have some anxiety and was unable to sleep. The facility's description of the incident concerning the incident on 10/21/18, signed as completed 10/26/18, documents A CNA assigned to Member (R1), removed him from Member (R2)'s room and after (R1) attempted physical contact with (R2). The CNA reported the incident immediately to the unit nurse. The Unit Nurse then informed her Supervisor. The Supervisor contacted the DON and investigation began. DON then reported the incident to the Administrator. The matter was reported to DQA (Division of Quality Assurance), law enforcement, and the POA's for both Members .(R1) does have Dementia and said he doesn't recall the incident, however, his psychiatrist was notified. Both Members have been monitored on a daily basis for any behavior or mood changes. (R2) did indicate sadness and lost of interest in things, but said it was related to his health issues, not the incident. (R2) initially denied being fearful, but staff noticed an increase in his anxiety. (R2) was given constant reassurance of safety and was given medication to reduce his anxiety. He was then assigned a 1:1 for additional support. The initial interview with (R1)'s assigned CNA said that she was with (R1) when the incident occurred, but that (R1) resisted her attempts to redirect him. However, during her investigatory hearing, she admitted to leaving his side for a moment to throw something away. When she returned, she found (R1) in (R2)'s room. (R1) had pulled off (R2)'s blanket and was attempting to undo his brief. The CNA removed (R1) immediately. No physical contact occurred . A police report on 10/24/18 documents (R2) and (R1) are housed on the same wing with their doors directly across from each other. (R2) is in hospice and is confined to his bed due to his declining medical health. (R1) is mobile but is supposed to be directly supervised by a staff member at all times. Staff member (CNA-C) was assigned to (R1) that night. (CNA-C) initially stated she was with (R1) the entire time. She later stated that she had left (R1)'s room to throw something away believing she was gone 2-3 minutes. When she returned (R1) was not in his room. A short time later she heard (R2) yell out. She went into this room and found (R1) standing over (R2). (R1) was then removed from the room .(R2) stated at the time of the incident he was laying in his bed facing his TV. (R1) then appeared at the entrance of his room. He was visible by the light of the TV. (R1) then uttered something about oral sex and then moved to the edge of his bed. He then pulled the blankets off of (R2)'s bed. He then tugged at (R2)'s underwear (diaper) tearing then and pulling on tape that was adhered to his thigh/hip. (R2) then yelled causing staff to come into the room .(R2) stated that his genital area was never touched and no sexual act took place. (R2) was emotionally shaken by the experience and has expressed concern that (R1) would come back into his room. A staff member has been placed with him to ensure his safety and reassure that (R1) will not have unwanted contact with him again. (R2)'s underwear were slightly torn and the tape on his upper thigh was affected but not removed. The blanket was found near his legs and not over him as it was normally I spoke to (R1) .I then asked him about his sexual urges and why the happen. (R1) only acknowledges that he does have them .I then spoke to (R2) .(R2) stated on the night of the incident he was laying in his bed facing the TV that was across the room. (R1) appeared at the entrance of his room. (R1) then uttered 'Cock sucker. Blow job.' (R1) then moved to the side of his bed and pulled his blanket off his body. Then then (sic) reached down and pulled at this waist line causing his paper underwear to tear and a part of the tape on his hip to come dislodged. He then yelled at (R1), 'Get out of here.' Multiple times .I then asked if (R1) ever exposed himself to him. (R2) stated the (R1) unzipped his zipper but that he never exposed himself On 11/7/18 at 2:36 pm the surveyor interviewed RN Supervisor-D. RN Supervisor-D informed the surveyor she had received a telephone call from LPN-E related to R1 getting into R2's room. RN Supervisor-D informed the surveyor she talked to R2 who had stated R1 had come into his (R2's) room, pulled at blankets, and tried to pull of his (R2's) underwear. The surveyor asked if R2 had said if a CNA was in the room. RN Supervisor-D stated R2 had stated it was a man in his room and the CNA came in later. The surveyor asked RN Supervisor-D if R2 had ever made any allegations like this before. RN Supervisor-D stated no, not like that while she was on duty. On 11/6/19 at 11:37 am DON-B informed the surveyor CNA-C switched her past story of being with the resident the whole time to admitting she had left her post (of being 1 to 1 with R1) to throw something away on 10/24/18. The surveyor reviewed education and noted CNA-C had received education related to providing 1 to 1 supervision on 10/9/18. The facility's failure to protect R2 from sexual abuse resulted in a finding of immediate jeopardy, which began on 10/21/18. The immediate jeopardy was removed on 10/24/18 when the facility completed the following: *Reassurance and support provided for both residents by nursing and social service and is ongoing. *Event was reported to the State Agency and law enforcement was contacted. *R1 continued on 1:1 monitoring within arm's reach at all times. *R2 was placed on 1:1 to provide reassurance and emotional support that he was safe in his environment until R2 determined he no longer wanted someone with him all the time on a 1:1 basis. *Both residents were placed on 24 hour report to monitor for any adverse effects that could be a result of the event. R1 was on report for behavior monitoring and R2 for psychosocial well-being. *Interviewable residents who reside on the unit were asked if they felt safe and all said yes. *Both residents' plan of care were reviewed and revised as appropriate following the event. Changes to plans of care were communicated to staff via shift reports. *The CNA admitted she failed to follow 1:1 policy and procedure she had been previously trained on. *Education for nursing staff who either provide 1:1, have the ability to provide 1:1, oversee 1:1 monitoring or who supervise nursing staff received in depth education that included 1:1 monitoring policy and procedure and behavior intervention techniques. *R1's psychiatrist was contacted regarding the member's behaviors. He reviewed R1's treatment plan. *The facility continues to pursue inpatient placement for R1's evaluation and treatment and/or medication adjustment for hypersexuality.

Based on a complaint investigation, medical record reviews, review of a facility self-report investigation and staff interviews, the facility did not keep 1 (R1) of 5 residents reviewed free from sexual abuse. R2, who had been exhibiting escalating sexual behaviors and was to be on 1:1 staff supervision and 30 minute visual checks, was left unsupervised for approximately 30 minutes on the pm shift on 9/17/18. During the time R2 was left unsupervised he left his bedroom where staff assumed he had been, went to the living unit lounge and was discovered by staff holding/examining R1's genitalia. The facility's failure to protect R1 from sexual abuse resulted in a finding of immediate jeopardy, which began on 9/17/18. Administrator A was notified of this finding on 10/15/18 at approximately 11:40 am. The immediate jeopardy was removed and corrected on 10/9/18. This is evidenced by: The surveyor reviewed R1's medical record as part of a complaint investigation alleging R1 was sexually assaulted by a peer on the p.m. shift of 9/17/18. Review of a significant change of condition Minimum (MDS) data set [DATE] revealed R1 is severely cognitively impaired. R1's Certified Nursing Assistant (CNA) Care Card printed 9/20/18 revealed R1 is independent with transfers and ambulation. R1's plan of care revised 5/24/17 indicates R1 has wandering behaviors including wandering into other residents' rooms, attempts to exit locked unit and pulls on blinds to attempt to get out windows and doors. Review of a self-report investigation into an allegation of resident to resident sexual assault, revealed that R2 assaulted R1 on 9/17/18 at approximately 8:00p.m. R2's medical record revealed R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R2's Progress Notes documentation revealed R2 had no episodes of inappropriate behavior from 2/20-6/27/18. On 6/28/18, R2 made inappropriate sexual remarks to staff. On 7/3/18, R2 had a [MEDICAL CONDITION] and was hospitalized from 7/3-7/9/18 due to [MEDICAL CONDITION]. Following R2's hospitalization he began exhibiting increasing sexual behaviors including frequent masturbation in public places, inserting objects into his rectum and inappropriate sexual comments to staff. These behaviors continued as of 10/15/18. On 8/10/18, R2's hyper-sexual behavior began to be directed toward peers. On 8/10/18, while R2 and a peer were sitting at the dining room table for lunch, R2 asked that peer to perform oral sex on R2. Following this incident the facility placed R2 on 1:1 staff supervision. R2 remained on 1:1 supervision through the morning of 9/17/18. When R2 was in his room, his 1:1 supervision consisted of staff sitting outside of his closed door to afford him privacy due to his frequent masturbation. On 8/28, 9/7 and 9/12/18, R2 again asked peers to perform oral sex on him. On 9/15/18, R2 exposed himself to a peer at dinner time. A Progress Note dated 9/16/18 at 9:10p.m., indicated, Writer went to members room just after 7:00p.m. and noted that member had written on several walls with a pen. Writing was sexually explicit in nature .Writer informed 1:1 to leave members door open and sit outside room looking in to help prevent future vandalism from member . On the morning of 9/17/18 the Interdisciplinary Team (IDT) met to discuss R2's behavior of writing on his bedroom walls. The IDT decided to continue R2 on 1:1 supervision with staff sitting outside his bedroom door when he was in his room and updated R2's plan of care adding 30 minute visual checks to ensure R2 was not defacing his bedroom walls. Review of the self-report investigation regarding this allegation revealed that at 8:00p.m. on 9/17/18, CNA-D was coming onto R1 & R2's living unit from another unit and noted R1 standing in the lounge with his pants and brief down to his knees. CNA-D's statement dated 9/17/18 indicates when she approached R1 to redirect him to pull up his pants, she noted R2 sitting on the floor in front of R1 holding R1's genitals. A statement obtained from Licensed Practical Nurse (LPN)-E indicates she was returning from a break and also came back to the unit at 8:00p.m. LPN-E witnessed R1 standing with his pants down and R2 was on the floor facing R1. LPN-E's statement indicates she did not see any physical contact between the 2 residents. On 10/11/18 at 1:55p.m., the surveyor spoke to CNA-B who was assigned to R2 on 9/17/18, on the p.m. shift. CNA-B stated it was her understanding that on the pm shift of 9/17/18, R2 was to be on 1:1 supervision when out of his room and 30 minute checks (not 1:1 outside his door) when R2 was in his room. CNA-B stated at approximately 7:30p.m. on 9/17/18, she left the area outside R2's bedroom door to relieve LPN-E who was providing 1:1 supervision for R4. CNA-B stated she was inside R4's bedroom and could not see R2's bedroom from where she was while supervising R4. The surveyor spoke to RN-C on 10/11/18 at 2:22p.m. RN-C, who had been the unit nurse on 9/17/18, pm shift, stated she had been in a resident's room assisting another CNA with a 2 person mechanical lift. RN-C indicated when she came out of that resident's room she was informed by CNA-D what had happened between R1 & R2. RN-C indicated she had not been informed by either the off going day nurse or the pm supervisor that R2's 30 minute visual checks were in addition to the 1:1 sitting outside his door when R2 was in his room. RN-D indicated she had reviewed the 24 hour report and assumed that R2 only needed to be checked every 30 minutes if he was in his room. RN-C indicated she had informed CNA-B of the every 30 minute checks based on her interpretation of the 24 hour report. Review of the 24 hour report for 9/17/18, revealed an entry for the 6:30a.m.-3:00p.m. shift indicating, 1:1 with 30 minute checks when in room. The surveyor spoke to Director of Nursing (DON)-A on 10/15/18, at 8:30a.m. DON-A, who is part of the IDT, indicated the IDT team decided to increase R2's supervision from 1:1 supervision to 1:1 supervision and 30 minute visual checks on the morning of 9/17/18, due to R2 defacing the walls in his bedroom on 9/16/18. DON-A was surprised that the pm staff on 9/17/18 had assumed that R2's level of supervision had been decreased based upon his escalation of behaviors (defacing the walls in his bedroom) on 9/16/18. Although R1 showed minimal response to the incidents that occurred on 9/17/18, using the reasonable person concept it is likely that a vulnerable person who is unable to defend himself could experience chronic or recurrent fear or anxiety when the facility fails to protect him from unsolicited sexual advances. The facility's failure to protect R1 from sexual abuse resulted in a finding of immediate jeopardy. The immediate jeopardy was removed on 10/9/18, after the facility revised its policy and procedure on 1:1 monitoring and in-serviced all staff on the policy and procedure on how to implement 1:1 member/resident supervision. During this complaint survey both R1 & R2 remained on 1:1 supervision. Sampled resident R4 was also on 1:1 supervision. At all observations of R1, R2 & R4, during this complaint survey, facility staff were providing the appropriate level of supervision for these residents.

Based on observations, record reviews, and interviews, the facility did not ensure that 2 (Resident #13 and #14) of 6 sampled residents with pressure ulcers received appropriate care and treatment to promote the healing of their pressure ulcers. * Resident #14 was admitted to the facility with an unstageable pressure ulcer to the right heel on 7/13/12. The admission assessment did not indicate that any impairment of skin integrity was observed on Resident #14's right heel. A skin check was completed by the nurse on Resident #14's bath day 7/18/12 and no indication of impairment of skin integrity was observed on Resident #14's right heel. It was not until 7/25/12 when Resident #14's right heel ulcer was discovered during a shower and at the point the pressure ulcer was assessed as a stage 3 ( a deterioration from stable eschar). Resident #14's heel did not receive any treatment for 13 days. * Resident #13 was observed to be lying on an air mattress that was not plugged in for a period of 3 hours and the head of the bed elevated at approximately 70 degrees for at least 1 hour. Resident #13 was observed to have a stage 2 facility acquired pressure ulcer to the coccyx. Findings include: 1.) Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/27/13 Surveyor #2692 reviewed Resident #14's Admission Minimum (MDS) data set [DATE]. The MDS is coded 0 (no) under pressure ulcers but is coded that Resident #14 is at risk for pressure ulcers and has a pressure reduction device for the bed and chair. On 2/27/13 at 12:05 p.m. Surveyor # interviewed Registered Nurse Manager (RN)-C who stated that Resident #14's right heel pressure ulcer was not discovered until 7/25/12 (13 days after admission), but was present on admission per conversations with the facility from which Resident #13 had been admitted . RN-C stated when he was discharged from the previous facility it was a deep tissue injury per their assessment. RN-C stated on 7/25/12 Resident #14 was assessed as having a stage 3 pressure ulcer when it was observed to be open and bleeding during his bath. On 2/28/13 at 7:10 a.m. Surveyor # interviewed RN-Q who stated on 7/13/12 she was the RN on the floor with Resident #14. RN-Q stated she was very busy that day and that RN-P agreed to help Licensed Practical Nurse (LPN)-O complete the admission assessment on Resident #14. RN-Q stated she signed off on the admission assessment and knows she shouldn't have but never actually assessed Resident #14. On 3/1/13 at 3:13 p.m. Surveyor # interviewed RN-P who stated she never assessed Resident #14 on 7/13/12 because RN-Q told her she had everything under control. RN-P stated if she would have completed an assessment on Resident #14 she would have signed off on it. On 2/27/13 Surveyor # reviewed Resident #14's Admission assessment dated [DATE] signed by RN-Q. The skin/wound section is checked no impairment of the right heel. On 2/27/13 Surveyor # reviewed the nurse's note dated 7/25/13 which read: Pressure stage 3 right heel, found today, length 1 centimeter by width 2 centimeters by depth 0.3 centimeters, white slough present. On 2/27/13 Surveyor # reviewed Resident #14's admission note at 7:16 p.m. which read: No pressure ulcer on admit. On 2/28/13 Surveyor # reviewed the nursing notes from the facility Resident #14 was previously admitted on [DATE] the note read: right heel wound improving it is dry and intact. On 2/28/13 Surveyor # reviewed Resident #14's wound doctors notes who assessed Resident #14 after the pressure ulcer first on 8/2/12 and reviewed the documentation of the pressure ulcer before admission to the facility. Resident #14's notes read: Lateral right heel 2 centimeters by 1.8 centimeters by 0.2 centimeters deep, 50% slough, debrided, unstageable pressure ulcer, probably will be stage 3, not acquired by facility. On 2/28/13 Surveyor # reviewed the investigation completed by the facility after Resident #14's pressure ulcer was found to be unattended for 13 days. The investigation revealed that LPN-F signed out a body check on Resident #14's shower day and did not indicate any impairment to Resident #14's right heel. On 2/28/13 at 7:40 a.m. Surveyor # observed Resident #14 receive a dressing change to the right heel. RN-R with assistance from RN-C removed Resident #14's current treatment and then measured the area which was observed by Surveyor # to be a small intact dry area of eschar with no signs of infection. RN-R measured Resident #14's right heel pressure ulcer which was: 1.3 centimeters by 0.4 centimeters and unstageable with no depth. On 2/28/13 Surveyor # reviewed the facility policy titled New Admissions-Licensed Staff dated 7/12 section 13.6 read: Assessment must be completed within 1 hour of admission. Assessment will include: skin condition. On 2/28/13 Surveyor # reviewed the pressure ulcer risk care plan dated 7/13/12 which read: inspect skin weekly, float heels, and reposition a minimum of every 2 hours. The above findings were shared with the Administrator and Director of Nurses on 2/28/13 at 3:00 p.m. Additional information was requested if available, none was provided. 2.) Resident #13 was admitted [DATE] with [DIAGNOSES REDACTED]. On 2/27/13 Surveyor # reviewed Resident #13's wound notes for a facility acquired pressure ulcer to the coccyx. The first measurements in the notes were 1/19/13 0.3 centimeters in length by 0.2 centimeters wide with no depth. On 2/28/13 at 7:30 a.m. Surveyor # observed Resident #13 lying in bed on an air mattress. The mattress was not plugged in and the mattress was flat. On 2/28/13 at 10:30 a.m. Surveyor # observed Resident #13 lying in bed on an air mattress. The mattress was not plugged in and the mattress was flat. Resident #13's head of the bed was rolled up at approximately a 70 degree angle. Resident #13 was moaning and asking to get out of bed. At 10:40 a.m. Surveyor # asked RN-C to come to Resident #13's room. Surveyor # asked RN-C to check Resident #13's bed to see if the air mattress was plugged in. RN-C stated it was not. Surveyor # asked RN-C why Resident # had the his head elevated so high (this causes increased pressure on the pressure areas). RN-C stated Resident #13 had not gotten up from bed yet today and had his head elevated for breakfast. On 2/28/13 at 10:50 a.m. Surveyor # interviewed Certified Nursing Assistant (CNA)-E who stated she finished assisting Resident #13 to eat breakfast at approximately 9:30a.m. and left the head of his bed up. CNA-E stated she normally would leave the bed up 30 minutes. Surveyor # asked what happened as it was now almost an hour and a half. CNA-E stated she really didn ' t forget she had charting to do and went on break and was going to attend to Resident #13 when she got back. CNA-E stated she did not notice Resident #13's bed to be unplugged. On 2/28/13 at 2:05 p.m. Surveyor # observed Registered Nurse (RN) - R assisted by RN-C complete a dressing change to Resident #13's coccyx. RN-R removed the treatment then measured the pressure ulcer on Resident #13's coccyx to be 1 centimeter in length by 0.5 centimeter ' s wide and 0.1 centimeters deep. RN-R staged the pressure ulcer as a stage 2. RN-C stated the area did have slough in it earlier in the week and now did not so she was going to call for a change in treatment. RN-R then completed the treatment as ordered. On 2/28/13 Surveyor # reviewed the manufacturer's information for the air mattress Resident #13 was observed to be lying on 2/28/13. The mattress product description for the Panacea Air Advance mattress includes a description of a safety air base of 2 inches to prevent bottoming out in the event of a power failure. The normal inflation description of the mattress is 8 inches which provide low air loss. The above findings were shared with the Administrator and Director of Nurses at the daily exit meeting on 2/28/13 at 3:00 p.m. Additional information was requested if available. None was provided.