Every finding on record at Willowdale Health Services

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmision of communicable disease and infection when 6 nursing staff (Licensed Practical Nurse (LPN)-G, LPN-L, Registered Nurse (RN)-I, Certified Nursing Assistant (CNA)-H, CNA-J, and CNA-K) did not complete required COVID-19 testing during a COVID-19 outbreak. This practice had the potential to affect all 25 residents residing in the facility.The facility had a COVID-19 outbreak that started on 1/14/26 and was still active on 2/11/26. LPN-G, LPN-L, RN-I, CNA-H, CNA-J, and CNA-K did not test for COVID-19 every other day and document the results in accordance with the facility's policy prior to working their scheduled shifts.Findings include:The facility's COVID-19 Prevention, Response and Reporting policy, revised 12/8/25, indicates: It is the policy of this facility to ensure appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections .The facility will perform viral testing for COVID-19 per national standards such as the Centers for Disease Prevention and Control (CDC) recommendations .Infection Control Guidance located at https://www.cdc.gov indicates the CDC recommendations for employee COVID-19 testing during a facility outbreak include: 1) Routine testing: Facilities should implement routine testing for healthcare personnel who have had a higher risk of exposure, regardless of vaccination status, to ensure safety and prevent transmission.On 2/10/26 at 10:45 AM, Director of Nursing (DON)-B provided Surveyor with a Critical Event Analysis and Action Plan Worksheet. DON-B indicated the facility discovered areas of improvement needed on 1/30/26 and was working toward correcting them. DON-B indicated part of the action plan included staff not following the facility's policy for COVID-19 testing. The Critical Event Analysis and Action Plan indicated the DON/designee was re-educating staff on the facility's COVID-19 prevention, response, and reporting policy and testing requirements. Surveyor noted the training log/sign in sheet for Response and Reporting and COVID-19 testing, dated 2/4/26, did not include CNA-H's signature.On 2/10/26 at 1:55 PM, Surveyor interviewed DON-B who indicated the faciltiy's procedure is for staff to enter the building by the timeclock, complete a COVID-19 test, and document their name, date, time, and test result prior to clocking in for their scheduled shift. Surveyor requested staff COVID-19 tests for 1/30/26 through 2/10/26. On 2/11/26 at 11:33 AM, DON-B provided documentation of staff COVID-19 tests. DON-B stated the facility's policy during a COVID-19 outbreak requires staff to complete a COVID-19 test every other day prior to clocking in for their shift and to document the results on a log.On 2/11/26, Surveyor reviewed nursing staff timecard punches for 1/30/26 through 2/11/26 and cross-referenced COVID-19 testing provided by DON-B. Surveyor noted the following nursing staff did not complete COVID-19 testing during the following timeframes in which they worked:~ LPN-G did not complete COVID-19 tests from 2/4/26 through 2/8/26. ~ CNA-H did not complete COVID-19 tests from 2/4/26 through 2/10/26.~ RN-I did not complete a COVID-19 test on 2/4/26. (RN-I last tested on [DATE]).~ CNA-J did not complete COVID-19 tests from 2/4/26 through 2/10/26.~ CNA-K did not complete a COVID-19 test on 2/6/26.~ LPN-L did not complete COVID-19 tests on 2/7/26 or 2/8/26.On 2/11/26 at 1:10 PM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A who were not aware that staff did not complete COVID-19 testing per policy during the facility's COVID-19 outbreak. DON-B indicated administration was working on a program to complete testing audits since the facility did not have a system to ensure staff completed the testing. DON-B and NHA-A were also not aware that CNA-H did not complete COVID-19 testing training on 2/4/26.

Based on staff, resident, and resident representative interview and record review, the facility did not notify a Power of Attorney (POA) or family representative of a change in condition for 3 residents (R) (R33, R20, and R6) of 6 sampled residents.R33 passed away on 1/27/26. R33's family was not notified of R33's passing in a timely manner.R20 was diagnosed with COVID-19 on 2/2/26 and was moved to a private room for isolation protocol. R20's POA was not notified of the diagnosis or room change until 2/4/26.R6 was diagnosed with COVID-19 on 1/29/26. R6's POA was not notified of the diagnosis until 2/5/26. Findings include: The facility's Change in Condition of the Resident policy, revised 9/20/22, indicates: The facility should immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident's representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention, a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications), or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .When a resident presents with a possible change of condition after a fall or other possible trauma or noted changes in mental or physical functioning .Notify the resident's family/responsible party as applicable and in accordance with the resident's wishes. 1.On 2/10/26, Surveyor reviewed R33's medical record. R33 had diagnoses including Parkinson's disease, prostate cancer, chronic kidney disease stage 3, and COVID-19 (dated 1/19/26). R33's Minimum Data Set (MDS) assessment, dated 1/21/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R33 had intact cognition. R33 was R33's own decision maker. R33 passed away on 1/27/26. R33's medical record did not indicate R33's family was notified when R33 passed away. R33's medical record contained two family emergency contacts to be notified of a change in condition. On 2/10/26, Surveyor reviewed the facility's grievance file and noted a grievance submitted by R33's family representative on 1/27/26 that indicated R33's family was not notified when R33 passed away. The corrective action taken indicated education was provided to Licensed Practical Nurse (LPN)-N and R33's family received an apology. The grievance indicated LPN-N received education on 1/29/26 regarding calling families, physicians, and managed care organizations to update on residents' conditions. 2. On 2/10/26, Surveyor reviewed R20's medical record. R20 had a diagnosis of COVID-19 (dated 2/2/26). R20's MDS assessment, dated 2/3/26, had a BIMS score of 3 out of 15 which indicated R20 had severely impaired cognition. R20 had an activated POA. A progress note, dated 2/4/26, indicated R20's POA was not notified on 2/2/26 of R20's room change or COVID-19 diagnosis. A grievance form was completed for the concerns. On 2/10/26, Surveyor reviewed the facility's grievance file and noted a grievance submitted by R20's POA on 2/4/26 that indicated R20's POA was not notified of R20's COVID-19 diagnosis. The grievance indicated nurses were educated on notification of a change in condition and R20's POA received an apology. 3. From 2/9/26 to 2/11/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including diabetes and stroke. R6's MDS assessment, dated 12/2/25, had a BIMS score of 15 out of 15 which indicated R6 had intact cognition. R6 did not have an activated POA but requested R6's designated POA be notified of any changes. A nursing note, dated 1/29/26, indicated R6's physician was notified of R6's positive COVID-19 test. R6's medical record did not indicate R6's representative (Power of Attorney (POA)-R) was notified of the positive test. On 2/9/26 at 11:01 AM, Surveyor interviewed POA-R who expressed concern about delayed notification of R6's COVID-19 diagnosis. POA-R stated POA-R was notified immediately by R6 but was not notified by the facility until 5-7 days later. On 2/10/26 at 12:54 PM, Surveyor interviewed R6 who was not sure if R6 notified POA-R and was not sure when the facility notified POA-R. On 2/10/26 at 10:45 AM and on 2/11/26 at 9:11 AM, Surveyor interviewed Director of Nursing (DON)-B who provided a Critical Event Analysis and Action Plan Worksheet and stated the facility discovered areas that needed improvement on 1/30/26 and were working to correct them. DON-B stated the action plan included notification of a resident's representative/POA regarding a change in condition. The action plan indicated the interim DON noted on 1/30/26 that families were not updated during the facility's COVID-19 outbreak. All families had since been called and COVID-19 positive residents were reviewed to ensure the correct precautions, notifications, care plans, orders, and documentation were in place. The action plan indicated the DON/designee would re-educate nurses on the facility's Change in Condition policy and audit any new residents diagnosed with COVID-19 until the outbreak was over. A training log/sign in sheet for change in condition/notification education, dated 2/5/26, contained the signatures of six nurses. Surveyor noted LPN-N, LPN-L, and Registered Nurse (RN)-M were not on the sheet. Surveyor reviewed the facility's COVID-19 outbreak timeline which indicated the outbreak started on 1/14/26. The timeline indicated the following: ~ On 1/19/26, R33 tested positive for COVID-19. On 1/27/26 R33 passed away. ~ On 2/2/26, R20 tested positive for COVID-19. ~ On 1/29/26, R6 tested positive for COVID-19. On 2/11/26, Surveyor requested and reviewed nursing staff timecard punches for 1/30/26 through 2/9/26 and noting the following: ~ LPN-N worked on 2/6/26, 2/7/26, and 2/8/26 but did not receive notification education. ~ LPN-L worked on 2/4/26, 2/5/26, 2/6/26, 2/7/26, and 2/8/26 but did not receive notification education. ~ RN-M worked on 2/5/26 but did not receive notification education. DON-B indicated notification documentation was located in the facility's infection control binder. DON-B stated the facility's notification process depends on if the resident is their own decision maker and wants the facility to notify their famiy. DON-B stated if a resident has a Guardian or an activated POA, the facility notifies the resident's representative within 24 hours. DON-B noticed nurses were not completing notifications timely and started an improvement plan. DON-B stated at the time R6 tested positive for COVID-19, the facility was operating as if R6's POA was activated and should have notified R6's representative within 24 hours. On 2/11/26 at 1:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B. NHA-A indicated the grievance filed by R20's POA started the review of residents' records to ensure notifications were made to all family members. NHA-A and DON-B indicated they were not aware of notification concerns prior to that date and stated the action plan to correct the issue was initiated due to the grievance. NHA-A stated when notification for R33's death occurred on 1/27/26, NHA-A did not see notification as a widespread issue and all nurses were not trained at that time. NHA-A verified notification for R6's COVID-19 positive test on 1/29/26 was not relayed timely to R6's POA. NHA-A and DON-B were not aware that all nurses were not trained on 2/5/26 and confirmed the facility's action plan had not been fully completed.

Based on staff interview and record review, the facility did not ensure a Minimum Data Set (MDS) assessment was completed accurately for 2 residents (R) (R8 and R4) of 5 sampled residents.R8's MDS assessment, dated 1/27/26, did not indicate R8 had a serious mental illness.R4's MDS assessment, dated 11/13/25, did not indicate R4 had a serious mental illness. Findings include: The facility's Resident Assessment-Coordination with Pre-admission Screening and Resident Review (PASRR) Program, revised 11/10/25, indicates: All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the state's Medicaid rules for screening .a. PASRR Level I - intial pre-screening that is completed prior to admission: 1. Negative Level I Screen - permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later .12. Positive Level I Screen - necessitates a PASSR Level II evaluation prior to admission. 1.From 2/9/26 to 2/11/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including bipolar mood disorder and anxiety. R8's Minimum Data Set (MDS) assessment, dated 1/27/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8 made R8's own medical decisions. R8's medical record indicated R8 had a diagnosis of bipolar mood disorder. R8's MDS assessment at Section A1500, dated 1/27/26, indicated R8 did not have a serious mental illness. On 2/11/26 at 11:37 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B and reviewed R8's MDS assessment. NHA-A and DON-B verified R8 had a mental illness that should have been reflected in Section A1500 on the MDS assessment. 2. From 2/9/26 to 2/11/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder, anxiety, and major depression. R4's MDS assessment, dated 11/13/25, had a BIMS score of 15 out of 15 which indicated R4 had intact cognition. R4 made R4's own healthcare decisions. R4's medical record indicated R4 had diagnoses including bipolar disorder, anxiety, and major depression. R4's MDS assessment, dated 11/13/25, indicated R4 did not have a serious mental illness. On 2/10/26 at 12:13 PM, Surveyor observed [NAME] President of Success (VPS)-C and Social Worker (SW)-E review Section A1500 of R4's 11/13/25 MDS assessment. VPS-C and SW-E confirmed the MDS assessment was incorrect. SW-E confirmed SW-E completed Section A1500 and should have documented Section A1500 as not assessed.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R8 and R4) of 5 sampled residents suspected of having a mental illness and/or intellectual/developmental disability were screened through the Pre-admission Screening and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required.The facility did not ensure completion of PASRR Level II Screens for R8 and R4.Findings include: The facility's Resident Assessment-Coordination and PASRR Program, revised 11/10/25, indicates: This facility coordinates assessments with the PASRR program under Medicaid to ensure individuals with a mental disorder .receive care and services in the most integrated setting appropriate to their needs .a. ii. Positive Level I Screen - necessitates a PASRR Level II evaluation prior to admission. b. PASRR Level II Screen - a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual who has a mental disorder .determines the appropriate setting for the individual and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder .who the state mental health .authority has determined as appropriate for admission. 3. A record of the pre-screening shall be maintained in the resident's medical record. 1. From 2/9/26 to 2/11/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including bipolar mood disorder and anxiety. R8's Minimum Data Set (MDS) assessment, dated 1/27/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8's MDS assessment at Section A1500 indicated R8 did not have a serious mental illlness. R8 made R8's own medical decisions. On 2/10/26, Surveyor reviewed R8's PASRR Level I Screen which indicated R8 did not have a mental illness despite the fact R8 had a diagnosis of bipolar mood disorder. On 2/11/26 at 11:37 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B and reviewed R8's PASSR Level I Screen. NHA-A and DON-B verified R8 had a mental illness that should have been documented on R8's PASRR Level I Screen. NHA-A and DON-B verified R8 should have had a PASRR Level II Screen completed and submitted for review. 2. From 2/9/26 to 2/11/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including bipolar disorder, anxiety, and major depression. R4's MDS assessment, dated 11/13/25, had a BIMS score of 15 out of 15 which indicated R4 had intact cogniton. R4's MDS assessment indicated at Section A1500 that R4 did not have a serious mental illness. R4 made R4's own healthcare decisions. R4's medical record did not contain a PASRR Level II Screen or county exemption paperwork. On 2/9/26 and on 2/10/26 at 8:39 AM, Surveyor requested R4's PASRR Level II Screen from NHA-A. On 2/10/26 at 12:13 PM, Surveyor interviewed SW-E who confirmed R4's PASRR Level II Screen was completed on 2/9/26 after Surveyor requested the form. SW-E indicated R4's PASRR Level I Screen should have indicated R4 had a serious mental illness. SW-E verified the facility did not have a copy of R4's county exemption paperwork.

Based on staff interview and record review, the facility did not ensure a comprehensive resident-centered dementia care plan was implemented for 1 resident (R) (R17) of 3 sampled residents.R17 had diagnoses of dementia and Alzheimer's disease. R17's comprehensive care plan did not contain dementia disease-related goals or interventions for care.Findings include:The facility's Comprehensive Care Plan policy, revised 9/23/22, indicates: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .On 2/11/26, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including dementia and Alzheimer's disease. R17's Minimum Data Set (MDS) assessment, dated 12/2/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R17 had moderate cognitive impairment. The MDS assessment indicated R17's active diagnoses included dementia and Alzheimer's disease. R17 was responsible for R17's healthcare decisions.A hospital Discharge summary, dated [DATE], indicated R17 had baseline cognitive impairment which contributed to difficulty following cues during therapy and impaired safety awareness during transfers and activities of daily living (ADLs).On 2/11/26, Surveyor reviewed R17's plan of care which did not contain dementia goals or interventions for care. R17's Kardex (an abbreviated care plan used by nursing staff) also did not contain interventions related to dementia.On 2/11/26 at 1:02 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who stated R17 had behaviors when R17 was admitted to the facility; however, CNA-F had not observed any recent behaviors. CNA-F reviewed R17's care plan and Kardex and confirmed R17's care plan did not address dementia.On 2/11/26 at 1:24 PM, Surveyor interviewed Registered Nurse (RN)-D who confirmed R17's care plan did not address dementia. RN-D stated if R17 had dementia-related concerns, interventions would be added to R17's care plan. RN-D indicated R17 was able to communicate R17's needs at that time and stated a baseline care plan is developed upon admission.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R5) of 1 sampled received the necessary care and services to prevent the development of pressure injuries and/or promote healing.R5 was admitted with stage 3 pressure injury on the left buttock and had an order for a pressure reducing mattress to be set at 150 pounds. During observations on 2/9/26, 2/10/26, and 2/11/26, R5's pressure reducing mattress was set at 200 pounds.Findings include:Based on guidelines followed by major medical organizations and the Centers for Medicare & Medicaid Services (CMS) criteria, which inform clinical practice, pressure-reducing mattresses - Avoid Excessive Firmness: While preventing bottoming out is critical, setting the pressure too high makes the mattress too firm, reducing its ability to conform to the body and increasing rather than reducing interface pressure on bony prominences (e.g., tailbone, heels).From 2/9/26 to 2/11/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including left buttock ulcer, diabetes with chronic kidney disease, protein-calorie malnutrition, and metabolic encephalopathy. R5's Minimum Data Set (MDS) assessment, dated 1/26/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. The MDS assessment indicated R5 had a stage 3 pressure ulcer upon admission. R5 made R5's own medical decisions.R5's medical record indicated R5's left buttock pressure injury measured 3 centimeters (cm) (length) x 2.5 cm (width) x.1 cm (depth) on 12/23/25. On 2/9/26, R5's left buttock pressure injury measured 3 cm x 4 cm x 0.1 cm.R5's medical record contained an order for a pressure reducing mattress set at 150 pounds. R5's Medication Administration Record (MAR) indicated R5's pressure reducing mattress should be set at 150 pounds and documented every shift.On 2/9/26 at 11:19 AM and 2/10/26 at 1:53 PM, Surveyor observed R5 in a wheelchair with a pressure reducing cushion in R5's room. Surveyor noted R5's pressure reducing mattress was set at 200 pounds.On 2/11/26 at 7:45 AM, Surveyor observed R5 in a bed in R5's room that did not have a pressure reducing mattress. Surveyor verified with Director of Nursing (DON)-B that R5 was not in the correct bed. DON-B indicated night shift staff reported that R5 self-transferred into the wrong bed and refused to get out. Surveyor attempted to interview R5 who indicated R5 sleeps wherever its available. Surveyor noted R5's pressure reducing mattress was on and set at 200 pounds. A progress note, dated 2/11/26 at 3:30 AM, indicated R5 refused to be in bed with the pressure reducing mattress because the mattress was deflated last week but was fixed by maintenance staff.On 2/11/26 at 12:17 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-O who stated R5 often self-transfers into a bed of choice. CNA-O stated only nurses check and adjust air mattress settings.On 2/11/26 at 12:32 PM, Surveyor interviewed Registered Nurse (RN)-P who verified R5's air mattress was set at 200 pounds. RN-P reviewed R5's MAR and verified the mattress should be set at 150 pounds per R5's order. RN-P stated the mattress is locked when it is set and must be unlocked to change the setting. Surveyor observed RN-P unlock the air mattress and change the setting to 150 pounds.On 2/11/26 at 12:38 PM, Surveyor interviewed DON-B who verified R5's air mattress was set at 200 pounds and should have been set at 150 pounds.

Based on staff interview and record review, the facility did not review and revise a care plan intervention for 1 resident (R) (R2) of 2 sampled residents. On 10/27/24, R3 alleged R2 hit R1 on the forearm in the doorway of the dining room. The facility implemented an intervention to serve R2 meals in R2's room or anywhere R2 preferred other than the dining room. There were no monitoring interventions to ensure R2 wasn't being secluded from other residents. In addition, the intervention was meant to be short term but was not removed from R2's care plan. Findings include: The facility's Abuse, Neglect and Exploitation Policy, revised 7/15/22, indicates: .Involuntary seclusion refers to the separation of a resident from other residents or .confinement to his/her room against the resident's will or the will of the resident's legal representative. Emergency or short-term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs as long as the least restrictive approach is used for the minimum amount of time . On 1/22/25, Surveyor reviewed R2's medical record. R2 had diagnoses including dementia with behavioral disturbance, anxiety, bipolar disease, and delusional disorder. R2's Minimum Data Set (MDS) assessment, dated 11/17/24, indicated R2 was rarely/never understood. R2 had a Guardian for healthcare decisions. R2 was monitored for behaviors including refusal of care, aggression toward staff, and yelling. R2's care plan indicated R2 was at risk for behavior related to a history of bipolar disorder and delusional disorders. The care plan contained interventions (initiated 10/27/24) to serve R2 meals in R2's room or anywhere R2 preferred other than the dining room and to intervene/redirect if R2 was near R1. On 1/22/25, Surveyor reviewed a facility-reported incident (FRI) that indicated on 10/27/24 at 8:40 AM, R2 hit R1 on the left forearm when R2 and R1 passed each other in the doorway of the dining room. R3 reported the interaction to a nurse. R1 was assessed and had no visible injuries. R1 initially indicated R1 was hit by R2. In a later interview, R1 indicated R1 was not hit by R2 but R2 pushed R1's wheelchair. R3 witnessed the incident and indicated there was an interaction but R3 was not certain what happened. R4 was interviewed and indicated R2 hit R1 but could not provide further details. In a later interview, R4 indicated R2 pushed R1's wheelchair. Because the information obtained during the investigation was variable, the incident was determined to be inconclusive for abuse. An intervention was added to R2's care to serve R2 meals in R2's room or anywhere R2 preferred other than the dining room. Surveyor noted the intervention did not contain a time frame, did not include monitoring to ensure R2 was not involuntarily secluded from other residents, and was still listed on R2's care plan. On 1/22/25 at 1:43 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the intervention to have R2 eat meals in R2's room or somewhere other than the dining room did not contain a stop or review date but was meant to be short term. NHA-A indicated if R2 refused the intervention and redirection did not work, staff were directed to stay with R2 in the dining room. NHA-A verified that was not included in R2's care plan. NHA-A indicated R2 currently ate in the small dining room (adjacent to the main dining room) or R2's room per R2's preference. NHA-A agreed R2's care plan should have indicated the intervention was short term and should have included monitoring to ensure R2 was not involuntarily secluded from other residents. NHA-A indicated R2's behaviors had improved since the incident on 10/27/24 and the intervention should have been removed from R2's care plan.

Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One medication cart was observed unlocked and unattended. In addition, 1 of 2 medication carts and 1 of 1 medication storage room contained expired medications and medical supplies. This practice had the potential to affect more than 4 of the 30 residents residing in the facility. The Chestnut hall medication cart (medication cart 1) and the medication storage room contained expired medications and medical supplies. In addition, the Chestnut hall medication cart was unlocked and unattended on 10/1/24. Findings include: The facility's Medication Storage policy, dated 1/2024, indicates: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication cares. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Expired Medications and Supplies: On 10/1/24 at 10:24 AM, Surveyor observed 1 of 2 medication carts and 1 of 1 medication storage room and noted the following: The Chestnut hall medication cart contained the following: ~ An open 16 ounce container of Geri Care brand Milk of Mag with an expiration date of 8/24 ~ An open bottle of Geri Care Fiber Laxative (90 capsules) with an expiration date of 9/2024 ~ A Dynarex brand povidone-iodine single use swab stick with an expiration date of 10/2023 ~ A 23 gauge x 1 inch 3 ml (milliliter) syringe with hypodermic needle safety with an expiration date of 9/30/24 The medication storage room contained the following: ~ Twenty 4.5 mg (milligram) packages of Nestle arginaid-arginine powder with expiration dates of 8/2024 On 10/1/24 at 11:05 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who verified the medications and supplies were expired and should have been disposed of. On 10/2/24 at 12:07 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who verified the expired medications and supplies should have been disposed of on or by the date they expired. 49563 Medication Cart: On 10/1/24 at 2:10 PM, Surveyor observed a medication cart that was unlocked and unattended in the Chestnut hallway. On 10/1/24 at 2:21 PM, Surveyor interviewed Registered Nurse (RN)-H who verified the medication cart was left unlocked. RN-H indicated medication carts should be locked when unattended. RN-H locked the medication after the interview. On 10/1/24 at 2:33 PM, Surveyor interviewed ADON-C who verified medication carts should be locked when unattended. ADON-C indicated ADON-C expects staff to follow the facility's policy. On 10/1/24 at 2:36 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified medication carts should be locked when unattended.

Based on staff interview and record review, the facility did not ensure written policies and procedures that prohibit mistreatment, neglect, and abuse of residents were consistently implemented for 1 of 8 staff reviewed during the caregiver program compliance check. Certified Nursing Assistant (CNA)-K indicated on CNA-K's Background Information Disclosure (BID) form that CNA-K lived out of state prior to moving to Wisconsin in June of 2024. The facility did not complete an out-of-state background check prior to CNA-K's hire on 7/9/24. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 7/15/22, indicates: Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of residential property .1. Background, reference, and credentials checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including rechecks, will be completed consistent with applicable state laws and regulation . On 10/1/24, Surveyor reviewed a BID form completed by CNA-K on 6/25/24. CNA-K indicated on the form that CNA-K lived out of state prior to moving to Wisconsin in June of 2024. Surveyor noted the facility completed a background check through the Wisconsin Department of Justice which did not include an out-of-state background check. On 10/1/24 at 11:39 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility had not done a federal or out-of-state background check for CNA-K. NHA-A indicated a federal background check should be completed prior to hiring a candidate who lived outside of Wisconsin.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R23) of 3 sampled residents. The facility did not report an allegation of mistreatment involving R23 to the SA. Findings include: The facility's Abuse, Neglect and Exploitation Policy, dated 7/15/22, indicates: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Mistreatment means inappropriate treatment or exploitation of a resident .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law .IV. Identification of Abuse, Neglect and Exploitation .2. Possible indications of abuse include, but are not limited to: a. Resident, staff or family report of abuse .VII. Reporting/Response .1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe .a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. From 9/30/24 to 10/2/24, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] with diagnoses including displaced fracture of left acetabulum, weakness, dementia, congestive heart failure (CHF), and transient ischemic attack (stroke). R23's Minimum Data Set (MDS) assessment, dated 7/19/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R23 had moderate cognitive impairment. The MDS assessment indicated R23 was dependent on staff for toileting and hygiene and required substantial/maximal assistance with dressing and eating. Surveyor reviewed an allegation of mistreatment involving R23 and Certified Nursing Assistant (CNA)-J that occurred on 6/24/24. On 10/1/24 at 9:32 AM, Surveyor interviewed R23 who did not report any concerns with staff or care at the facility. On 10/1/24 at 12:21 PM, Surveyor interviewed CNA-I who indicated CNA-I and CNA-J completed perineal care for R23 on 6/24/24. CNA-I indicated CNA-J washed around R23's testicles and made noises such as ding, ding, [NAME]. CNA-I indicated CNA-I didn't feel what CNA-J did was appropriate and reported it to the charge nurse after cares were completed. CNA-I indicated CNA-I went back into the room and apologized to R23 because CNA-I felt bad that had occurred. CNA-I also indicated Nursing Home Administrator (NHA)-A called CNA-I following the incident but only asked why CNA-I didn't stop CNA-J. On 10/2/24 at 10:14 AM, Surveyor interviewed NHA-A regarding the allegation and asked if the allegation of mistreatment was reported to the SA. NHA-A indicated the allegation was not reported to the SA, but the facility completed a competency skill check with CNA-J. NHA-A indicated NHA-A was on vacation at the time, but remembered there was a discrepancy of the timeframe when the incident occurred. NHA-A verified the incident should have been reported to the SA.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R23) of 3 sampled residents. The facility did not thoroughly investigate an allegation of mistreatment involving R23 and Certified Nursing Assistant (CNA)-J. Findings include: The facility's Abuse, Neglect and Exploitation Policy, dated 7/15/22, indicates: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Mistreatment means inappropriate treatment or exploitation of a resident .1. The facility will develop and implement written policies and procedures that: .b. Establish policies and procedures to investigate any such allegations .V. Investigation of Alleged Abuse, Neglect and Exploitation .A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. From 9/30/24 to 10/2/24, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] with diagnoses including displaced fracture of left acetabulum, weakness, dementia, congestive heart failure (CHF), and transient ischemic attack (stroke). R23's Minimum Data Set (MDS) assessment, dated 7/19/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R23 had moderate cognitive impairment. The MDS also indicated R23 was dependent on staff for toileting and hygiene and required substantial/maximal assistance with dressing and eating. On 10/1/24, Surveyor requested to review an investigation regarding an allegation of mistreatment involving R23 and CNA-J on 6/24/24. Nursing Home Administrator (NHA)-A provided Surveyor with a sheet of paper that contained 8 bullet points that were completed during the investigation. The investigation did not include resident interviews or additional staff interviews, including an interview with CNA-I who reported the incident. The investigation also did not include education with other staff members and only contained a perineal care competency checklist completed with CNA-J. On 10/1/24 at 9:32 AM, Surveyor interviewed R23 who did not report any concerns with staff or care at the facility. On 10/1/24 at 12:21 PM, Surveyor interviewed CNA-I who indicated CNA-I and CNA-J completed perineal care for R23 on 6/24/24. CNA-I indicated CNA-J washed around R23's testicles and made noises like ding, ding, [NAME]. CNA-I indicated CNA-I didn't feel what CNA-J did was appropriate and reported the incident to the charge nurse after cares were completed. CNA-I indicated CNA-I went back into the room and apologized to R23 because CNA-I felt bad that had occurred. CNA-I indicated NHA-A called CNA-I following the incident but only asked why CNA-I didn't stop CNA-J. On 10/2//24 at 10:14 AM, Surveyor interviewed NHA-A regarding the investigation. NHA-A indicated a competency skill check was completed with CNA-J. NHA-A indicated NHA-A was on vacation at the time of the incident, but remembered there was a discrepancy regarding the timeframe when the incident occurred. NHA-A verified the incident should have been more thoroughly investigated.

Based on staff interview and record review, the facility did not ensure a Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 resident (R) (R15) of 16 sampled residents. R15 had a history of bipolar disorder and dementia with psychotic features. R15's Quarterly MDS assessment, dated 8/17/24, indicated R15 did not have delusion or hallucinations. Findings include: From 9/30/24 to 10/2/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] with a medical history that included bipolar disorder and dementia with psychotic features. R15's Quarterly MDS assessment, dated 8/17/24, indicated in section E0100 that R15 did not have delusions or hallucinations. A nursing note, dated 8/17/24, stated, Resident does have visual and auditory hallucinations and is frequently seen reacting to internal stimuli. On 10/2/24 at 12:53 PM, Surveyor interviewed MDS Coordinator (MDSC)-L who indicated R15's Quarterly MDS assessment, dated 8/17/24, was based on R15's medical record between 8/11/24 and 8/17/24. MDSC-L reviewed the nursing note, dated 8/17/24, that indicated R15 had hallucinations and delusions. MDSC-L stated Social Worker (SW)-M completed section E0100 of the MDS assessment. MDSC-L indicated the 8/17/24 nursing note was not reviewed for section E because the MDS assessment was coded based on point-of-care documentation. Based on review of the 8/17/24 nursing note, MDSC-L indicated MDSC-L would have documented that R15 experienced hallucinations and delusions in section E0100. On 10/2/24 at 1:09 PM, Surveyor interviewed SW-M who indicated R15 had a history of hallucinations and delusions, but SW-M was unaware that R15 experienced those symptoms during the MDS seven day look back period. SW-M indicated SW-M had not witnessed R15 respond to internal stimuli and no other staff members had reported hallucinations to SW-M. SW-M indicated if SW-M had seen the 8/17/24 nursing note that mentioned R15's hallucinations and delusions, SW-M would have coded section E0100 differently.

Based on observation, staff interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 1 resident (R) (R182) of 2 residents with indwelling catheters. During an observation on 9/30/24, R182's uncovered catheter drainage bag was attached to R182's wheelchair and in contact with the floor. Findings include: On 10/1/24, Surveyor reviewed the facility's policy and procedure for catheter care and Relias training provided annually to nursing staff. The facility's Catheter Policy, dated 3/15/23, indicates: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .2. Privacy bags will be available and catheter drainage bags will always be covered while in use. The policy did not address positioning/placement of catheter tubing or drainage bags. The facility's Relias training for Care of a Urinary Catheter indicates: Many of the people you provide care for will have a urinary catheter. Unfortunately, urinary catheters often lead to infections and complications. According to the Agency for Healthcare Regency and Quality (2017), as many as 50-70% of urinary catheter-related infections can be prevented. You are in a position to prevent infections and complications caused by urinary catheters. By providing proper catheter care and understanding how infections and complications can develop, you can take steps to prevent them .Regular catheter care is important to prevent infection and other complications. Microbes, which cause infection, can enter the body through: .Portions of the equipment that touch a non-sterile surface, such as the floor .Follow your organization's policy on catheter care. Here are the steps to follow to provide basic catheter care: .11. Position and secure the drainage bag. The bed frame is a good place to hang the bag while the person is in bed. The drainage bag should be kept below the level of the person's bladder at all times. Do not place it on the floor. Once a bag touches the floor, it is contaminated. Place a bag cover over the bag to preserve the person's privacy. From 9/30/24 to 10/1/24, Surveyor reviewed R182's medical record. R182 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of rectum, diabetes, and malignant neoplasm of bone. R182's Minimum Data Set (MDS) assessment, dated 10/3/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R182 had intact cognition. R182's medical record indicated R182 had an activated Power of Attorney for Healthcare (POAHC). On 9/30/24 at 11:37 AM, Surveyor observed R182 in a wheelchair in R182's room. R182's uncovered catheter drainage bag was attached to R182's wheelchair and in contact with the floor. On 9/30/24 at 11:44 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who verified R182's catheter bag was uncovered and dragging on the floor. CNA-E indicated catheter bags should be covered and not in contact with the floor. On 10/1/24 at 1:42 PM, Surveyor interviewed Registered Nurse (RN)-F who verified the above findings for R182 and indicated catheter bags should not touch the floor and should be covered with a dignity bag. On 10/1/24 at 1:45 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who verified catheter bags should not touch the floor and should be covered with a dignity bag. ADON-C stated ADON-C expects staff to follow the facility's policy. On 10/1/24 at 2:25 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified catheter bags should not touch the floor and should be covered with a dignity bag.

Based on staff interview and record review, the facility did not ensure the provision of treatment and services to prevent weight loss for 1 resident (R) (R17) of 1 sampled resident. R17 was admitted to the facility on [DATE] and had a significant weight loss of 7.38% between 8/30/24 and 9/17/24. The facility's Registered Dietitian (RD) and physician were not notified following R17's weight loss and interventions were not put in place. Findings include: The facility's Weight Monitoring policy, with a review date of 12/21/22, indicates: The Interdisciplinary Team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. 1. Nursing staff will measure residents' weight on admission, the next 2 days, and weekly for 3 additional weeks thereafter. 2. If no weight concerns are noted after the initial 3 days and 3 weeks after, routine weights will be measured monthly thereafter, unless ordered more frequently by the physician .8. The threshold for significant weight change will be based on the following criteria: a. 1 month - 5% of weight change is significant; greater than 5% is severe. 10. The nursing staff will notify the individual or responsible party, physician and RDN (Registered Dietary Nutritionist) or designee of any individual with an unintended significant weight change. Between 9/30/24 and 10/2/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the rectum and secondary malignant neoplasm of liver and intrahepatic bile duct. R17's Minimum Data Set (MDS) assessment, dated 9/5/24, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R17 had intact cognition. R17 was R17's own decision maker. R17 previously resided at another facility and received Hospice services. R17's medical record indicated R17's family wanted to wait until R17 was settled to explore Hospice services. R17 had an order that indicated: Weight on admit, daily x 2, weekly x 3, then monthly. Obtain re-weight if change of 5 pounds since last weight. R17's weights between 8/30/24 and the last weight taken on 9/17/24 (which equaled a 7.38% weight loss) were as follows: ~ 8/30/24 - 151.8 pounds (lbs) ~ 9/1/24 - 147.2 lbs ~ 9/2/24 - 144.6 lbs ~ 9/9/24 - 138.2 lbs ~ 9/16/24 - 140.8 lbs ~ 9/17/24 - 140.6 lbs A nutrition assessment note, dated 9/6/24, indicated: R17 was a [AGE] year old short-term Hospice patient with colorectal cancer who had a nutrition problem of inadequate oral intake. R17's oral intake was likely adequate to meet R17's nutritional needs, though R17's intake was variable. The note indicated R17 might benefit from a nutritional supplement to help meet nutritional needs and indicated R17 would be seen within the next 7 days. The note also indicated R17 was independent with meals, had no skin issues/wounds, and had anticipated weight fluctuations related to fluid shifts due to diuretic therapy. R17's oral intakes and weights would be monitored and the RD was available as needed. R17's nutrition care plan, initiated 8/30/24, indicated R17 was at risk for nutritional status change related to potential for inadequate oral intake related to chronic disease state. The care plan contained interventions to review weight per facility protocol/MD orders (dated 8/30/24) and review weights and notify RD, Medical Doctor (MD), and responsible party of significant weight change (dated 9/6/24). R17's medical record did not contain any dietitian notes after the initial note and no progress notes or notification to the dietitian or MD related to R17's significant weight loss of 7.38%. Surveyor did not note any further weights after 9/17/24 or offers/orders for supplements to help increase or maintain R17's weight. On 10/2/24 at 11:00 AM, Surveyor requested any notifications and interventions implemented related to R17's significant weight loss. On 10/2/24 at 11:43 AM, R17 was weighed by staff. R17 weighed 131.8 lbs and had a 13.18% weight loss in just over 30 days. In addition, a 4 ounce med pass supplement was added on 10/2/24. On 10/2/24 at 12:52 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the RD and nurse should look at weights and alerts in the system. NHA-A indicated R17's physician should also have been notified. NHA-A stated the system should alert nursing staff when a significant weight is entered. NHA-A acknowledged R17 received Hospice services at a prior facility, but was not currently on Hospice services. Regardless of Hospice services, NHA-A indicated R17 should be offered something such as a supplement, brownie, etc. NHA-A indicated a Registered Nurse (RN) recalled having a conversation with R17 and R17's family that R17 didn't like Boost (a nutritional supplement) which R17 had at a previous facility. NHA-A indicated there were other things the facility could offer. NHA-A indicated the facility had a contracted RD who was new to the facility, came to the facility every other week, and had access to residents' medical records when not at the facility. On 10/2/24 at 1:08 PM, Surveyor interviewed RD-G via phone. RD-G indicated RD-G was at the facility every other week and reviewed weight warnings for residents once per week. RD-G indicated RD-G did not review weights for each resident but looked at weight warnings triggered in the system. RD-G saw the weight warning for the beginning of the month when R17 triggered for a 3% weight loss. RD-G indicated RD-G was not sure why the system did not trigger for R17's 9/17/24 weight. RD-G confirmed R17 should have been reviewed for significant weight loss after the 9/17/24 weight. RD-G indicated RD-G would review R17 and follow-up with the facility.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Multiple food items were expired, not dated, and/or not sealed properly. The dessert served for lunch on [DATE] was not maintained at the proper temperature during meal service and was not covered prior to service. A microwave and stove top were not kept in a clean condition. Multiple items were not stored 6 inches off the floor. The facility did not have testing logs for sanitizer buckets or the internal temperature of the dishwasher. The facility did not maintain a temperature log for the residents' refrigerator. Findings include: On [DATE] at 8:30 AM, Surveyor conducted a tour of the kitchen Cook (CK)-G and CK-I. On [DATE] at 1:32 PM, Surveyor interviewed Dietary Manager (DM)-H who indicated the facility uses the Wisconsin State Food Code as its standard of practice. 1. The Wisconsin State Food Code at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food indicates: Date Marking: (A) Except when packaging food using a reduced oxygen packaging method .refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Commercially processed food open and hold cold (B) .refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. The Wisconsin State Food Code at ,d+[DATE].11 Packaged and Unpackaged Food Separation, Packaging, and Segregation indicates: (A) Food shall be protected from cross contamination by (4) .storing the food in packages, covered containers, or wrappings. The facility's Food Preparation policy, revised ,d+[DATE], indicated: 17. All TCS (Time/Temperature Control for Safety) foods that are to be held for more than 24 hours at a temperature of 41 degrees F or less will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7). The facility's Cold Foods policy, with a revised date of ,d+[DATE], indicated: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. During the initial kitchen tour on [DATE], Surveyor noted the following items were out of compliance with the Wisconsin State Food Code: Items located in the dry storage area: ~Four open and undated 160 ounce (oz) bags of [NAME] pasta. Items located in the walk-in cooler: ~One open, unsealed, and stained 5.2 oz packet of Traditional stuffing mix seasoning. ~An open and undated 1 gallon container of gluten free soy sauce that was ,d+[DATE] full. ~One open, unsealed, and undated package of 6 peeled hard cooked eggs. ~One open and undated bag of lettuce. ~Twenty three 8 oz containers of Sysco 1% vitamin D milk with a manufacturer's use by date of [DATE]. Items located in the prep cooler in the kitchen: ~One undated metal pan marked Pineapple mdw. ~One covered, unlabeled, and undated metal pan that contained what appeared to be chili. ~One covered, unlabeled, and undated metal pan that contained a green pureed item. ~Nine undated containers of peaches covered with plastic wrap. ~One undated gallon of Sysco Golden Italian Dressing. On [DATE] at 2:30 PM, Surveyor interviewed RDM-F who confirmed the above items should be sealed, dated, and labeled appropriately. 2. The Wisconsin State Food Code at ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding indicates: (A) .Time/temperature control for safety food shall be maintained (2) At 41 degrees Fahrenheit (F) or less. The facility's Food: Preparation policy, with a revised date of ,d+[DATE], indicated: 13. All foods will be held at appropriate temperatures .less than 41 degrees F for cold food holding. On [DATE] at 11:24 AM, Surveyor entered the kitchen to watch meal service and noted an uncovered tray of orange Jell-O on the counter. Surveyor noted the dessert was for the lunch service. Surveyor observed CK-G obtain hot food temperatures prior to lunch service, however, CK-G did not obtain the temperature of the Jell-O. At the end of meal service on [DATE] at 12:13 PM, Surveyor asked CK-G to temp the Jell-O which was 54.9 degrees F. CK-G indicated CK-G didn't normally obtain cold food temperatures. During the initial kitchen tour on [DATE], Surveyor reviewed food holding temperature logs and noted cold food items and dessert temperatures were documented inconsistently. On [DATE] at 12:28 PM, Surveyor informed DM-H of the temperature of the Jell-O and that it was uncovered when Surveyor entered the kitchen. DM-H verified the Jell-O should have been covered and should be held at a temperature under 41 degrees F. 3. The Wisconsin State Food Code at ,d+[DATE].11 Equipment, Food Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicates: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The Wisconsin State Food Code at ,d+[DATE].12 Cooking and Baking Equipment indicates: (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. The facility's Food: Preparation policy, with a revised date of ,d+[DATE], indicated: All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. During the initial kitchen tour on [DATE], Surveyor observed the following: ~The kitchen microwave wave contained food crumbs. CK-G indicated CK-G did not use the microwave during breakfast service and did not know when the microwave was last cleaned. ~The stove top contained a white powder residue and crusted food on the sides of the stove. CK-G indicated CK-G boiled water on the stove for breakfast, but did not know when the stove top was last cleaned. On [DATE] at 2:30 PM, Surveyor interviewed Regional Dietary Manager (RDM)-F who confirmed the microwave and stove top should be cleaned regularly. 4. The Wisconsin State Food Code at ,d+[DATE].11 ,d+[DATE].11 Food Storage indicates: Food shall be protected from contamination by storing the food: (3) At least 15 cm (centimeters) (6 inches) above the floor. The facility's Food Storage: Cold Foods policy, with a revision date of ,d+[DATE], indicated: 1. All food will be stored 6 inches above the floor and 18 inches below the sprinkler unit. During the initial kitchen tour on [DATE], Surveyor observed the following: ~One box on the floor in the walk-in cooler that contained 4 bananas. ~One empty box on the floor in the walk-in cooler. ~One empty box on the floor in the kitchen. On [DATE] at 2:30 PM, Surveyor interviewed RDM-F who confirmed boxes should not be on the floor and empty boxes should be placed in refuse. 5. The Wisconsin Food Code Internal Temperature Monitoring of Dishwasher at ,d+[DATE].13 Temperature Measuring Devices, Manual and Mechanical Warewashing indicates: (B) In hot water mechanical warewashing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the utensil surface temperature. The Wisconsin Food Code at ,d+[DATE].14 indicates: (B) Cloths in-use for wiping counters and other equipment surfaces shall be (1) held between uses in a chemical sanitizer solution at a concentration specified under ,d+[DATE].114. The Wisconsin Food Code at ,d+[DATE].114 indicates: A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times .shall be used in accordance with the EPA (Environmental Protection Agency)-registered label use instructions. During the initial kitchen tour on [DATE], CK-G was not aware of an internal temperature monitoring device for the dishwasher. CK-G asked CK-I who indicated there were stickers to obtain the internal temperature, however, CK-I did not know where the stickers were and could not locate the log used to document internal dishwasher temperatures. During the initial kitchen tour on [DATE], Surveyor requested to see the log for ensuring the sanitizing buckets were maintained at the proper sanitization level. CK-I indicated CK-I did not know where the log was and stated the log was usually hung on the bulletin board. CK-I searched for the log and the test strips, but could not locate either one. On [DATE] at 2:30 PM, RDM-F confirmed the facility should maintain a log for internal dishwasher temperature monitoring and for proper sanitization levels in the sanitizer buckets. 6. The facility's Food Storage: Cold foods policy, with a revised date of ,d+[DATE], indicated: 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. On [DATE] at 10:23 AM, Surveyor noted the refrigerator for resident items was temporarily located in the therapy room because the prior resident refrigerator was not working. Surveyor could not locate a temperature log for the resident refrigerator in the therapy room. On [DATE] at 9:15 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated there was not a temperature log for the refrigerator in the therapy room. NHA-A indicated kitchen staff usually take care of the temperature; however, when the resident refrigerator in the dining room stopped working, resident items were moved to the therapy room and a temperature log was not completed.

Based on staff interview and record review, the facility did not ensure 4 Residents (R) (R10, R16, R25, and R5) of 13 sampled residents met the PASRR (Pre-Admission Screen and Resident Review) requirements. R10's medical record indicated R10 had mental illness diagnoses upon admission and was prescribed psychotropic medication. The facility completed a PASRR Level I Screen upon admission, but did not complete a Level II Screen when R10 remained in the facility long term. R16's medical record indicated R16 had a mental illness diagnosis upon admission and was prescribed psychotropic medication. The facility completed a PASRR Level I Screen upon admission, but did not complete a Level II Screen when R16 remained in the facility long term. R25's medical record indicated R25 had a mental illness diagnosis upon admission and was prescribed psychotropic medication. The facility completed a PASRR Level I Screen upon admission, but did not complete a Level II Screen following the expiration of R25's 30 day short-term hospital discharge exemption. R5's medical record indicated R5 had a mental illness diagnosis upon admission and was prescribed psychotropic medication. The facility completed a PASRR Level I Screen upon admission, but did not complete a Level II Screen. Findings include: 1. From 11/6/23 to 11/7/23, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] with diagnoses including anxiety disorder and major depressive disorder, recurrent. R10 had a physician's order for paroxetine (an antidepressant medication) which was eventually discontinued. A PASRR Level I Screen was completed for R10 upon admission, however, a Level II Screen was not completed when R10 remained in the facility. 2. From 11/6/23 to 11/7/23, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE]. R16 had a diagnosis of depression and a physician's order for Lexapro (an antidepressant medication) which was eventually discontinued. A PASRR Level I Screen was completed upon admission, however, a Level II Screen was not completed when R16 remained in the facility. 3. From 11/6/23 to 11/7/23, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had a diagnosis of anxiety disorder. R25 had a physician's order for Prozac (an antidepressant medication) which was eventually discontinued. A PASRR Level I Screen was completed upon admission, however, a Level II Screen was not completed when R25 remained in the facility past the 30 day short-term hospital discharge exemption. 4. On 11/8/23, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had a diagnosis of schizophrenia. R5 had physician's orders for risperiodone (an antipsychotic medication) and venlafaxine (an antidepressant medication). A PASRR Level I Screen was completed upon admission, however, a Level II Screen was not completed. On 11/7/23 at 11:07 AM, Surveyor interviewed Social Worker (SW)-E who indicated SW-E was not aware there were problems with residents' PASRRs until Surveyor brought forth the concerns. SW-E stated SW-E started SW-E's position a few months ago and came into a mess.

Based on observation, staff and resident interview, and record review, the facility did not provide a safe, clean, comfortable, home-like environment for 2 Residents (R) (R1 and R17) of 13 sampled residents. During an observation of R1's room, Surveyor noted a large hole in the wall behind R1's recliner. During an observation of R17's room, Surveyor noted a section of molding approximately 4 inches wide and 1.5 feet long hanging off the lower portion of R17's bathroom wall. Findings include: The facility's undated Admission Agreement indicated: Housekeeping and Maintenance: Our housekeeping and maintenance staff work to keep our center safe, comfortable, and clean. We consider a pleasant environment important to your well-being during your stay with us. 1. On 11/6/23 at 8:48 AM, Surveyor interviewed R1 in R1's room and noted a hole in the wall behind R1's recliner (next to R1's bed) that measured approximately 6 inches x 8 inches x 2 inches. The paint was scraped off the wall in several areas, the hole was partially filled with crumbled drywall, and there was a pile of chunked drywall and dust on the floor. Immediately following the observation, Surveyor interviewed R1 about the hole in the wall. R1 was aware of the hole and stated it was from R1 laying back in R1's recliner. When asked if R1 told anyone about the hole, R1 stated, They know about it. It's been there too long, at least two months. R1 then rolled over in bed and declined to answer any further questions regarding the hole in the wall. On 11/8/23 at 8:02 AM, Surveyor interviewed Registered Nurse (RN)-C who was aware of the hole in R1's wall, but did not know how long the hole had been there. RN-C stated, It's (the hole) been there for awhile. On 11/7/23 at 7:53 AM, Surveyor interviewed Director of Maintenance (DM)-D regarding the hole in R1's wall. When initially asked about the hole, DM-D indicated DM-D was unaware of the hole in R1's wall, but stated DM-D was told about the hole this morning. Surveyor asked to review the facility's maintenance work orders for the last 3 months. DM-D verified there was a work order for the hole in R1's wall from approximately 3 weeks prior, and DM-D was aware of the hole in R1's wall; however, DM-D did not complete the work order. On 11/8/23 at 8:28 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was aware of the hole in R1's wall and stated NHA-A's expectation is that maintenance concerns are completed in a timely manner so the environment at the facility is home-like. NHA-A further stated there needs to also be a solution so the hole in the wall does not happen again. 2. On 11/6/23 at 1:13 PM, Surveyor interviewed R17 in R17's room. Surveyor noted a section of brown molding approximately 4 inches wide by 1.5 feet long hanging off the lower portion of R17's bathroom wall under the right side of the sink. On 11/7/23 at 9:12 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-J who was unsure how long the molding was hanging off the wall in R17's bathroom, but indicated the molding was in that condition for a long time. On 11/8/23 at 9:43 AM, Surveyor interviewed R17 who stated R17 did not use the bathroom and had not seen the molding peeling away from the wall. On 11/8/23 at 9:47 AM, Surveyor noted the molding was fixed in R17's bathroom On 11/8/23 at 11:14 AM, Surveyor interviewed DM-D regarding the molding in R17's bathroom. DM-D stated a work order was entered recently. DM-D stated DM-D thought the molding was previously repaired with sticky tape, but was now fixed appropriately. DM-D was unsure how long the molding was in that condition prior to fixing the molding that morning. On 11/8/23 at 11:28 AM, Surveyor observed work order #379 for R17's room. The work order was created on 11/2/23 at 7:56 PM and assigned to DM-D by DM-D on 11/8/23 at 7:13 AM.

Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R24, R21, R7) of 13 sampled residents met the PASRR (Pre-Admission Screening and Resident Review) requirements. R24 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R24 received a qualifying diagnosis and was prescribed medication. R21's PASRR Level I Screen indicated R21 did not have mental illness. A Level II Screen was not completed when R21 received a qualifying diagnosis and was prescribed medication. R7 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R7 received a qualifying diagnosis and was prescribed medication. Findings include: 1. R24 was admitted to the facility on [DATE]. A PASRR Level I Screen was completed and indicated R24 did not have a mental illness diagnosis and was not prescribed medication for mental illness. R24's medical record indicated R24 was prescribed sertraline (an antidepressant medication) on 6/23/23, buspirone (an anxiolytic medication) on 7/11/23, and lorazepam (a sedative medication) for anxiety on 7/13/23. A PASRR Level II Screen was not initiated following the additional diagnosis and medication. 2. R21 was admitted to the facility on [DATE]. A PASRR Level I Screen was completed and indicated R21 did not have a mental illness, but was prescribed Seroquel (an antipsychotic medication). A physician order indicated R21 was prescribed Seroquel on 12/26/22. On 1/6/23, a medication consent for lorazepam was initiated. On 2/15/23, a diagnosis of anxiety disorder was added to R21's diagnoses list. A PASRR Level II Screen was not initiated following the additional diagnosis and medication. 3. R7 was admitted to the facility on [DATE] with a diagnosis of depression. R7's medical record contained a negative PASRR Level I Screen. Between 2/26/23 and 8/18/23, R7 was prescribed buspirone for anxiety. Between 2/26/23 and 5/30/23, R7 was prescribed PRN (as needed) lorazepam. On 5/5/23, a diagnosis of anxiety was added to R7's diagnoses list. A PASRR Level II Screen was not completed following the additional diagnosis and medication. On 11/7/23, Social Worker (SW)-E confirmed when new diagnoses or medications are added, the PASRR Level I Screen should be updated and submitted for a PASRR Level II Screen to be completed.

Based on observation, and staff and resident interview, the facility did not ensure menu items were served according to the extended menu for 2 Residents (R) (R7 and R3) of 2 residents with Level 1 puree texture diets. R7 and R3 did not receive dessert with lunch on 11/6/23. R7 and R3 did not receive a dinner roll with lunch on 11/7/23. During lunch service on 11/7/23, staff used an incorrect scoop size to serve pureed corn. Findings include: R7 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing). R7's prescribed diet was Level 1 puree texture. In addition, R7 received a tube feeding overnight. R3 was admitted to the facility on [DATE] with diagnoses including dysphagia. R3's prescribed diet was Level 1 puree texture. 1. On 11/6/23 at 12:26 PM, Surveyor observed lunch service in the dining room. The dessert was strawberry shortcake. Surveyor noted residents with regular texture diets received strawberry shortcake, however, Surveyor did not observe R7 or R3 receive dessert. On 11/6/23 at 12:56 PM, Surveyor observed staff take R7 back to R7's room. On 11/6/23 at 12:57 PM, Surveyor interviewed R7 who indicated R7 usually received dessert and would like dessert. On 11/6/23 at 1:06 PM, Surveyor interviewed Regional Dietary Manager (RDM)-F who verified R7 and R3 should have received dessert. RDM-F stated the staff who was supposed to puree the dessert had to leave and the staff who were left did not realize the dessert was not pureed. 2. On 11/7/23 at 11:53 AM, Surveyor observed lunch service from the kitchen. The menu contained a wheat dinner roll. Surveyor noted pureed dinner rolls were not on the steam table to be served. On 11/7/23 during lunch service, Surveyor noted R7 and R3's trays did not contain a pureed dinner roll as depicted on the menu. On 11/7/23 at 12:20 PM, Cook (CK)-G indicated CK-G did not puree dinner rolls and verified R7 and R3 did not receive a pureed dinner roll. On 11/7/23 at 12:28 PM, Surveyor interviewed Dietary Manager (DM)-H who verified R7 and R3 should have received a pureed dinner roll with lunch. 3. On 11/7/23 at 11:53 AM, Surveyor observed lunch service from the kitchen. Per the extended menu, residents on a Level 1 puree diet were supposed receive a #8 scoop of pureed corn. Surveyor noted a #12 scoop was used to serve the corn. On 11/7/23 at 12:28 PM, Surveyor reviewed scoop sizes with CK-G and DM-H. CK-G indicated CK-G was not aware of a menu to follow for scoop sizes and chose scoop sizes based on what CK-G was told. CK-G indicated CK-G worked at the facility for approximately 1 month. DM-H confirmed the wrong scoop size was used for pureed corn during lunch service.

Based on record review and staff interview, the facility did not implement written policies and procedures to screen potential employees that prohibited mistreatment, neglect and abuse of residents for 1 of 8 staff reviewed during the caregiver program compliance check. The facility did not complete Life Enrichment Coordinator (LEC)-E's New Jersey (NJ) background check prior to LEC-E working in the facility. Findings include: The facility's policy and procedure titled Abuse Prevention Program dated March 2018 stated: Policy: The objective of the Abuse policy is to comply with the seven-step approach to abuse, neglect and exploitation detection and prevention. 1) Screening: Abuse Policy Requirement: It is the policy of this facility to screen employees . prior to working with our residents. Screening components include verification of references, licenses, certifications and background checks . Procedures: Employee screening - Before new employees are permitted to work with residents, references will be verified as well as certifications, licenses, credentials, and a criminal background check. On 10/11/22 at 11:08 AM, Surveyor completed a caregiver program compliance check for eight sampled staff employed by the facility. LEC-E was hired on 8/1/22. LEC-E's Background Information Disclosure (BID) dated 7/1/22 indicated LEC-E resided in NJ within the past three years and the facility did not perform a NJ background check prior to LEC-E working in the facility. On 10/12/22 at 9:47 AM, DON-B provided LEC-E's NJ background check with a date of submission of 10/11/2022. On 10/12/22 at 12:18 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated LEC-E's NJ background check was not ran prior to LEC-E's hire date and was an oversight. NHA-A stated NHA-A ran LEC-E's NJ background check immediately upon notification of oversight. No criminal record was revealed. NHA-A stated the facility practice is to run complete background checks for all staff prior to their hire.

Based on record review, observations and staff interviews, the facility failed to ensure that 1 Resident (R) (R18) of 3 sampled residents reviewed for pressure injuries received necessary services to prevent pressure injuries from developing. R18 was not properly assessed for pressure injury risk prior to riding in the facility rickshaw (trishaw) bicycle. In addition, R18 was not provided a pressure redistributing cushion under R18's buttocks during a facility rickshaw (trishaw) ride. R18 developed an avoidable pressure injury as a result of the trishaw ride that was not properly assessed by the facility. R18's wound eventually deteriorated to a stage 4 pressure injury that required surgical debridement, use of a [DEVICE] (vac) and the introduction of antibiotics into the resident's medication regime relating to an infection. Failure of the facility to properly assess, monitor, and provide interventions to prevent the development of an avoidable stage 4 pressure injury for R18 created a finding of Immediate Jeopardy (IJ), which began on 7/9/19. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the IJ on 11/13/19 at 1:45 PM. The IJ was removed on 11/13/19. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: Advancing Excellence notes that Pressure ulcers can be dangerous and painful for a resident, in part because broken skin can allow infection into the body. If untreated, pressure ulcers can deepen and even expose the bone. Deeper ulcers may be hard to heal or may not heal at all. Sometimes, pressure ulcers can lead to death. The presence of pressure ulcers limits the quality of life for a resident as evidenced by: o Decrease in bowel and bladder function o More incontinence o Decrease in ability to move without help o Decrease in mental capacity o Increase in pain o Increased risk for infection o Less participation in activities http://www.nhqualitycampaign.org/files/factsheets/Staff%20Fact%20Sheet%20-%20Reducing%20Pressure%20Ulcers.pdf Mayo Clinic's website describes the complications of pressure injuries, including: Sepsis:[MEDICAL CONDITION] occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure. [MEDICAL CONDITION]: [MEDICAL CONDITION] is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. [MEDICAL CONDITION] can lead to life-threatening complications. Bone and joint infections: An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteo[DIAGNOSES REDACTED]) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications. http://www.mayoclinic.org/diseases-conditions/bedsores/basics/risk-factors/con- 848 The undated facility policy, titled Skin Management Policy-CAWs Policy Interpretation and Implementation, states: The facility will provide care based on each resident's comprehensive assessment to ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless pressure ulcers are unavoidable due to the predictable patterns of the resident's clinical condition or the resident or his/her representative's refusal of care and treatment to prevent pressure ulcers Based on each resident's comprehensive assessment, appropriate treatment and services are provided to prevent the formation of pressure ulcers. Residents having pressure ulcers receive necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing . The undated facility policy, titled Cycling Without Age Policy, states: .The Participants a. Participants include residents, volunteers, family members and staff who ride as passengers b. Participants or their Responsible Party must complete the Consent Form for Rickshaw Outing: Participants Consent may also be obtained via telephone from responsible parties c. Participants must wear seatbelt during operation of the rickshaw . On 11/12/19, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R18's Minimum Data Set (MDS) assessment, dated 6/28/19 indicated staff completed the BIMS (Brief Interview for Mental Status) and indicated R18 was severely impaired. Additionally, the assessment indicated R18 was at risk for pressure injury and had no pressure injuries. The assessment indicated R18 had skin/ulcer treatments in place, including a pressure reducing device for chair. The assessment also stated R18 required extensive assistance for bed mobility, with the help of 2 plus staff members to physically assist R18. Additionally, R18 was totally dependent on staff to assist with transfers, requiring 2 plus staff members. R18's care plan with an initiated date of 11/14/2018, a revision date of 10/9/19, and a target date of 1/6/20, stated: Resident is at risk for skin integrity condition, or pressure sores r/t (related to): Impaired mobility, Incontinence Interventions included add padding to sling as necessary when using trishaw with an initiated date of 7/27/19. Additional interventions include, Roho cushion (a pressure relieving cushion) to w/c (wheelchair) with an initiated date of 7/31/19. The care plan did not address a pressure reducing cushion was in place prior to 7/31/19. The care plan also did not address the Hoyer sling to remain under R18 when up in wheelchair. R18's Braden Scale Assessment completed 7/1/19 scored 13, which indicated moderate risk for pressure injury development. R18's Weekly Skin Review completed on 7/3/19, showed R18's skin was dry and an open area was located on the back of R18's head. No pressure injuries were noted on this assessment. R18's most recent Braden Scale Assessment completed 10/28/19, scored 13, which indicated moderate risk for pressure ulcer development. On 11/11/19 at 9:00 AM and approximately 1:00 PM the Surveyor observed R18 in wheelchair with mesh Hoyer sling over the Roho cushion which was underneath R18. Additionally, R18 was observed to have a wound vac in place on buttocks. On 11/12/19 at approximately 9:00 AM and at 1:06 PM, the Surveyor observed R18 in wheelchair with mesh Hoyer sling over Roho cushion underneath R18. Additionally, R18 was observed to have a wound vac in place. On 11/12/19 at 10:52 AM, the Surveyor interviewed CNA(Certified Nursing Assistant)-R. CNA-R verified R18 currently uses a mesh Hoyer sling over a Roho cushion while up in R18's wheelchair. On 11/12/19 at 10:58 AM, the Surveyor interviewed CNA-S. CNA-S verified R18 currently uses a mesh Hoyer sling over a Roho cushion while up in R18's wheelchair. CNA-S verified the mesh Hoyer sling is a full body mesh sling. On 11/12/19 at 11:03 AM, the Surveyor interviewed Life Enrichment Director (LED)-F. LED-F stated that the facility was giving residents rides twice a week in the rickshaws during the summer months. LED-F indicated that on 7/9/19 some of the Certified Nursing Assistants (CNAs) approached her to see if R18 could go on a rickshaw ride. LED-F stated she talked with the nurse who was working and the nurse said, I don't see why not. LED-F indicated she went on the ride with R18. LED-F showed a picture to Surveyor of R18 in the rickshaw with a pillow behind R18's head and the mesh Hoyer sling under R18. LED-F stated that the staff used the Hoyer lift to get R18 into the rickshaw and used the pillow behind R18's head to help keep R18 straight up while in the rickshaw. LED-F also thought the staff put something on R18's right side to keep R18 from tilting but she wasn't sure. LED-F was unsure if there was something under R18's buttocks. LED-F mentioned that R18 stayed up straight the whole ride. LED-F stated they found something on R18 that day and heard that R18 had a sore on R18's buttocks and facility staff thought it was from the rickshaw ride. LED-F stated R18 did not ride on the rickshaw after this event. On 11/13/19 at 7:55 AM, the Surveyor completed a follow-up interview with LED-F. LED-F has been at the facility since (MONTH) 2019. LED-F stated she was not trained on the rickshaw policy until recently. LED-F stated she has a binder with training for volunteers and consents for residents to ride in the rickshaw. LED-F indicated rickshaw rides usually last 40 minutes to 1 1/2 hours. LED-F indicated R18's ride was a maximum of 40-45 minutes. LED-F verified R18 did not have a consent from R18's responsible party to ride in the rickshaw. On 7/9/19 at 1:00 PM a Clinical Follow Up note completed by Registered Nurse (RN)-G stated, (R18) is on follow up for: Sheering to left gluteal fold. The current status is open area found by aides on resident's left gluteal fold when laying resident in bed with Hoyer lift. Sero/sang (serosanguineous) drainage noted on bed linens. Area 1 cm (centimeter) x 4 cm. Area cleansed and allevyn applied. (Advanced Practice Nurse Prescriber (APNP)-J) updated and orders received to cleanse area and apply allevyn q (every) 3 days and PRN (as needed) until healed. Area cleansed and allevyn applied. On 7/9/19, a Wound Evaluation Tracker was completed by RN-[NAME] RN-G assessed the wound to be a, skin tear to left gluteal fold measuring 1 centimeter (cm) x 4 cm RN-G stated the wound had,sero/sang drainage from wound that was thin, watery. Wound margins were defined surrounding tissue described as skin intact, skin surrounding wound darker pigmented. The assessment indicated current preventative interventions were a, W/C cushion and heel protectors. Additionally, the assessment indicated no change to care plan reviewed. On 7/9/19, APNP-J ordered staff to cleanse left gluteal fold skin tear with NS (saline) cover with Allevyn dressing every 3 days and PRN until healed. On 11/13/19 at 10:09 AM, the Surveyor interviewed CNA-T. CNA-T verified that if a resident has a pressure relieving cushion, the cushion should follow the resident from surface to surface. On 11/13/19 at 10:11 AM, the Surveyor interviewed CNA-U. CNA-U verified that if a resident has a pressure relieving cushion, the cushion should follow the resident from surface to surface. On 11/13/19 at 11:40 AM, the Surveyor interviewed LPN (Licensed Practical Nurse)-H. LPN-H stated R18 must have had some type of cushion in wheelchair prior to the Roho, otherwise R18 would have sat right on the chair. LPN-H stated after R18's pressure injury came up, then they put Roho cushion under him. LPN-H thought the Roho cushion started around the end of July. On 11/12/19 at 11:34 AM, the Surveyor interviewed RN (Registered Nurse)-[NAME] RN-G verified she was the RN working the day R18 went out for a ride on the rickshaw. RN-G stated the staff talked about the concerns for R18 going on the ride but she sat on the rickshaw seat and felt there was enough cushion. RN-G stated they thought about putting a cushion under R18 while in the rickshaw but didn't because they were worried about it slipping out of seat and the potential for R18 to fall out of the rickshaw. RN-G verified R18 had a pressure relieving cushion in place in July. RN-G verified the mesh Hoyer sling was under R18 during the ride as they used the Hoyer sling to transfer R18 into rickshaw. RN-G stated the Hoyer sling remains under R18 while up in wheelchair as R18 is very contracted and it would be too difficult to get the sling out from underneath R18. RN-G stated when R18 came back from the rickshaw ride, staff noticed a change in R18's skin integrity when toileting R18. Staff immediately told RN-G about the skin concern. RN-G stated upon assessing R18, she thought it was a skin tear from sheering from the mesh Hoyer sling and immediately contacted physician to get orders for treatment. RN-G stated, After awhile when the skin tear wasn't getting better, I realized it was probably a DTI (Deep Tissue Injury) from the ride. On 7/19/19, a Wound Evaluation Tracker was completed by LPN-K. LPN-K staged the left gluteal wound as a Stage I (1) with measurements to be 4.5 cm x 2.5 cm x 0.1 cm. LPN-K describe the exudate as sanguineous, thin watery, scant amount. Additionally, LPN-K indicated,wound bed is pink and surrounding skin area is grey/brown. LPN-K indicated the care plan was reviewed. On 7/26/19, a Wound Evaluation Tracker was completed by LPN-K. LPN-K staged the left gluteal wound as a Stage II (2) with measurements to be 7.0 cm x 3.0 cm x 1.0 cm. LPN-K described the exudate as sanguineous, thin, watery, moderate amount with a pungent odor. LPN-K indicated current preventative interventions included, W/C Cushion and Nutritional supplements. Additionally, LPN-K indicated the wound remained pink to the wound bed. Edges of the wound remain brown/grey. On 8/3/19 at 3:17 PM, a Communication with Physician note completed by DON-B stated, Wound to L (left) buttocks increasing in size with current tx (treatment). Does have some sloughy areas present. APNP updated for wound tx change. Orders noted: Cleanse wound with wound cleanser, skin prep peri wound, apply santyl oint (ointment) and cover with allevyn drsg (dressing). Change daily and prn until healed . On 8/3/19 at 9:44 PM, a Health Status Note completed by RN-L stated, Wound to left buttock has increased in size. edges pink and will bleed when cleaned. 25% of wound has slough with 50% eschar. reported to DON who was here and observed wound. order received for santyl which will be applied daily. will continue to monitor. On 8/4/19 at 10:25 PM, a Health Status Note completed by RN-L stated, wound to left buttock has improved slightly no odor noted no signs of infection. has increased area of granulation tissue, small amt (amount) bleeding around the circumference. On 8/5/19, a Wound Evaluation Tracker was completed by RN-M. RN-M did not mark any level for staging of the left gluteal wound. Measurements were 2 cm x 5 cm x 1 cm. RN-M noted the exudate to be serosanguineous, thin, watery and small/minimal amount with a foul odor. RN-M noted 50% necrotic wound bed. RN-M indicated current preventative interventions include, pressure redistribution mattress, W/C cushion, specific turn/reposition program. Current orders are in place as of 8/3/19. No further information was provided about the wound. On 8/9/19, a Wound Evaluation Tracker was completed by DON-B. DON-B indicated the left gluteal fold wound was a Stage II (2) with measurements to be 3.5 cm x 4.5 cm x 0.5 cm. DON-B described the exudate to be serosanguineous, thin, watery, moderate amount with a foul odor. DON-B indicated the wound margins were defined and stated, area is pink/red wound bed with brown defined skin around the wound bed. Brown circle to the middle of the wound is shrinking in size. Wound does appear to be getting better. Foul smell remains. DON-B indicated current treatment in place as of 8/3/19. DON-B stated, wound appears to be improving. On 8/9/19, the facility therapy department faxed the primary physician requesting, Can PT (physical therapy) eval (evaluate) & treat wound with sharp debridement as necessary? On 8/12/19, APNP-J responded yes. On 8/11/19 at 6:27 PM, a Health Status Note completed by LPN-N stated, .Foul odor noted. Size of wound is larger than when writer last viewed it. DON and Assistant Director of Nursing (ADON) stated they will evaluate and make decision in am (morning). On 8/12/19, a fax was sent to physician with a message from DON-B stating, need tx change. wound not healing APNP-J responded with the following orders for the pressure injury to left gluteal fold. cleanse with wound cleanser skin prep peri wound. Calcium Alginate to wound bed. cover with allevyn dressing change daily and PRN until healed. discontinue previous treatment. An 8/13/19 APNP-J visit summary stated, R18 is seen at the nursing home for an acute visit of an open wound on the left buttock. The summary continued to state, Last week R18 rode in the facility's bicycle rickshaw for 30 minutes. Seating area may not have been properly padded .as R18 is at significant risk for skin breakdown. R18 subsequently developed what appeared to be an abrasion on the left buttock area. Over the ensuing days, the area continued to break down. Currently it is open .Will refer to Wound Care for evaluation and recommendations. On 8/14/19, an Order Note states, Order received from APNP-J for, wound care referral for left buttock ulcer. Wound care appointment set up with Ascension at Chilton for 8/19/19 at 1pm . On 8/16/19, a Wound Evaluation Tracker was completed by DON-B. DON-B indicated the left gluteal wound was a Stage III (3) with measurements of 5.0 cm x 4.0 cm x 2.0 cm. DON-B indicated this was a pressure ulcer acquired in-house with an identification date of 6/6/19 (this should have read 7/9/19.) DON-B described the wound as peri area is natural skin color. Open area is beefy red but in the center of the wound it does have circular yellow sloughy area. DON-B described the exudate as sanguineous, thin, watery with a moderate amount but no odor present. DON-B indicated current treatment was in place as of 8/12/19 and R18 had a wound clinic appointment on 8/19/19. On 8/19/19 at 8:12 PM, a Communication with Physician note stated, (R18) out to wound clinic today .received orders for new wound orders. Keep pressure off the area. Recommend x-ray left hip to r/o (rule out) osteo[DIAGNOSES REDACTED] (bone infection.) f/u (follow up) with Dr (doctor) .for possible surgical debridement and wound vac. Wound instructions: 3 times/weekly 1)clean area with normal saline or wound cleanser. 2)Pat dry, pack with aqualcel Ag. 3) Cover with Allevyn dressing. Change 3/weekly and as needed. On 8/21/19, R18 received an x-ray to left hip to r/o osteo[DIAGNOSES REDACTED]. The results indicated, .there is no acute fracture or dislocation .no soft tissue swelling is present .no acute osseous abnormality. On 8/23/19, a Wound Evaluation Tracker was completed by LPN-K. LPN-K indicated the wound was a Stage IV (4) with measurements of 5.0 cm x 4.5 cm x 2.0 cm. LPN-K described the exudate as serosanguineous, thin, watery, moderate amount with a foul odor. LPN-K indicated treatment was in place ordered on [DATE]. LPN-K described the wound status as, skin around the wound bed intact, and normal color. Wound bed is beefy red. On 8/26/19, R18 went out to Wound Clinic. Wound Clinic findings state left buttock decubitus ulcer, stage III (3) good granulation with periphery some exposure muscular fascia but no bone and no infection. Wound clinic measurements were 4 cm x 4 cm x 3 cm. Wound Clinic's [DIAGNOSES REDACTED]. Follow up PRN. On 8/30/19, a Wound Evaluation Tracker was completed by LPN-K. LPN-K indicated the wound was a Stage IV (4) with measurements of 5.0 cm x 4.0 cm x 3.0 cm. LPN-K described the exudate as, [MEDICAL CONDITION], thin, watery with a moderate amount and foul odor. LPN-K indicated treatment was in place ordered on [DATE]. LPN-K described the wound status as area is deeper and drainage/wound bed is brown . On 8/30/19 at 3:36 PM, a Communication with Physician note stated, Wound to left gluteal fold assessed, noted with increased tan/brown drainage, increased slough/eschar to area, depth increased since previous measurement. Call was placed to Wound Clinic. Wound Clinic nurse stated they could see R18 next week or are in agreement if NP would order wound vac in facility. Call placed to APNP. Facility received order from APNP for wound vac 125 mmHg (millimeters of mercury) continuous, change dressing every Monday, Wednesday, Friday and PRN. On 9/4/19, a Wound Evaluation Tracker was completed by RN-[NAME] RN-G assessed the wound as a Stage II (2) with measurements of 3.5 cm x 4 cm x 4 cm with tunneling from 11-2. RN-G described the exudate as sanguineous, thin, watery, moderate amount with foul odor. RN-G described the wound bed as [DIAGNOSES REDACTED], Odor, 25% (percent) granulation, 65% slough and 10% necrotic. Periwound described as defined, tunneling with surrounding tissue color changes Brown staining. RN-G indicated current treatment as Wound vac ordered 8/30/19. RN-G described the wound status as, Wound bed burgandy in color with some slough. Edges of wound darkened. Tunneling present from 11-2. Foul odor present. Drainage burgandy in color. On 9/7/19 at 6:22 PM, a Change in Condition form was completed by RN-[NAME] RN-G assessed R18 as having a DTI (deep tissue injury) to left gluteal fold. Foul odor present from wound. R18's temperature was 100.4 (F). R18 was noted to be restless in chair Physician updated and recommended Keflex (an antibiotic) 500 mg (milligrams) PO (by mouth) TID (three times a day) for 7 days . On 9/8/19 at 5:40 PM, a Change in Condition form was completed by RN-[NAME] RN-G assessed R18's condition to be worse. Temp(temperature) increased to 101.1 (F), temp rechecked after scheduled tylenol and 101.6 (F). R18 noted to be, more restless after transferring to w/c (wheelchair) R18 remains [MEDICAL CONDITION] BP (blood pressure) elevated. Physician updated and recommended to send R18 to emergency room (ER) for evaluation. On 9/8/19, R18 was transferred to the emergency room at Calumet Medical Center in Chilton. An Ascension NE (Northeastern) WI (Wisconsin) St. Elizabeth Hospital History and Physical Report with an admitted [DATE] stated, the patient is transferred from Calumet Medical Center for management [MEDICAL CONDITION]ly due to infected decubitus ulcer in left buttocks. An Ascension NE WI St. Elizabeth Hospital Discharge Summary with a date of discharge 9/14/19 stated, hospital course: 1.[MEDICAL CONDITION]. The patient met criteria for systemic [MEDICAL CONDITION] response syndrome with T-max of 103.1 on 09/09/2019, heart rate of 106-118 and WBCs(white blood cells) of 14.1. Source of infection is left ischial infected decubitus ulcer with suspicion of osteo[DIAGNOSES REDACTED]. 09/09 blood cultures have been no growth. (named doctor 1) of infectious disease has been following. The patient has been treated with IV [MEDICATION NAME] (antibiotic). 2. Left ischial infected decubitus ulcers/suspicion for osteo[DIAGNOSES REDACTED]. The patient is status [REDACTED]. We continued Dakin's dressing changes twice daily by wound care nursing. The patient was initially on [MEDICATION NAME]/[MEDICATION NAME] IV. [MEDICATION NAME] was discontinued by (named doctor 1) of infectious disease and the patient completed [MEDICATION NAME] IV today on 09/14/2019 . On 9/14/19, R18 returned to the nursing facility. On 9/16/19, R18 went out to wound clinic. Wound clinic orders to continue changing wound vac 3 times a week. schedule appointments until improvement noted. On 9/17/19 at 11:18 AM, a General Note completed by ADON-E indicated facility received a call from Wound Clinic, they will no longer follow R18 due to transferring with a Hoyer lift. Wound Clinic recommend primary physician follows patient at facility for wound care. On 9/19/19 at 11:16 AM, a Behavior Note completed by LED-F stated IDT members met to discuss R18. Returned 9/14 hospitalization for wound infection. Completed IV (intravenous) antibiotics in hospital. ADL (activities of daily living) status no changes since prior to admit . Note indicates wound clinic no longer following R18 due to Hoyer lift status, recommend primary physician to follow at the facility. Appointment will be set up to see plastic surgeon. On 9/20/19, a Wound Evaluation Tracker was completed by ADON-E. ADON-E assessed the left gluteal fold wound to be a Stage IV (4) with measurements of 2.3 cm x 2.7 cm x 4.5 cm ADON-E described the position of the tunneling and undermining via clock method of tunneling at 12, 6.2 cm and undermining from 11-3. ADON-E described the exudate to be serosanguineous, thin, watery, moderate amount with no odor present. Current treatment in place is the wound vac. ADON-E indicated the wound status as, unable to visualize wound base due to depth and tunneling, but visible wound is beefy red, 100% clean, non-granular tissue. Wound margins well-defined, no redness or s/s infection. Some discomfort observed with measuring and packing of wound, otherwise resident tolerated dressing change well. On 9/27/19, a Wound Evaluation Tracker was completed by LPN-K. LPN-K assessed the left gluteal fold wound to be a Stage IV (4) with measurements of 2.5 cm x 2.5 cm x 4.5 cm LPN-K described the position of the tunneling and undermining via clock method of 1100 3.5 cm tunneling and 1500 3.5 cm tunneling. LPN-K indicated the exudate was sanguineous, thin, watery, moderate amount but no odor. LPN-K indicated the wound status as wound bed is beefy red. No odor with wound vac change. Wound appears smaller but there is tunneling present. On 10/3/19 at 10:23 AM, a General Note indicated the IDT met to discuss R18's stage 4 to left buttock with tunneling noted. Wound vac and is on protein supplement and prostat. Has air mattress, roho cushion and lies down after meals with turn and reposition. F/u (follow up) with plastic surgeon . On 10/4/19, a Wound Evaluation Tracker was completed by ADON-E. ADON-E assessed the left gluteal fold wound to be a Stage IV (4) with measurements of 2.2 cm x 2.2 cm x 2.5 cm with tunneling and undermining. ADON-E described the position of the tunneling and undermining via clock method of 9-5.7 cm 12-6.6 cm . On 10/7/19, R18 saw the plastic surgeon. The plastic surgeon stated, (R18) was initially seen at the hospital for evaluation of (R18's) ischial ulcer. At that time the cavity was quite large and had a significant amount of easily debrided ball necrotic tissue which was removed by the nursing staff and by dressing changes. (R18) is seen today in the emergency department for evaluation of ulcer and follow-up .The opening is approximately 3 cm in size. This extends approximately 2 cm interiorly 3 to 3.5 cm laterally and 3 1/2 to 4 cm superiorly. There is direct extension from the opening down to the ischium. The bone is palpable but is covered. There are no areas of soft or speculated bone noted on his examination today. There is no foul drainage .Overall the wound has improved significantly since (R18's) last visit .I would recommend continued dressing changes with a small [MEDICATION NAME] with a minimal amount of material to prevent transfer of pressure onto the wound .Due to the patient's contracted position any type of surgical intervention would be a significant undertaking and is likely to be ineffective in long term control of the patient's problems .As the wound is currently improving I would recommend that we continue with the current dressing care regime . On 10/11/19, a Wound Evaluation Tracker was completed by ADON-E. ADON-E assessed the left gluteal fold wound to be a Stage IV (4) with measurements of 2.3 cm x 2.1 cm x 2.9 cm with tunneling and undermining. ADON-E described the position of the tunneling and undermining via clock method 12' - 5.8 cm; 9' -5.6 cm undermining 9-1 . On 10/15/19, a Wound Evaluation Tracker was completed by ADON-E. ADON-E assessed the left gluteal fold wound to be a Stage IV (4) with measurements of 1.9 cm x 2.0 cm x 2.5 cm with tunneling and undermining. ADON-E described the position of the tunneling and undermining via clock method of undermining 10-12 tunnel at 10-6 cm tunnel at 12-6.9 cm. ADON-E described the current wound status as, Wound base beefy red, small amount of active bleeding with dressing change, 100% granulation, no slough visualized. Continues with undermining/tunneling. Peri-wound skin intact, no redness or s/s infection. Resident tolerated dressing change with minimal s/s discomfort. On 10/23/19, a Wound Evaluation Tracker was completed by ADON-E. ADON-E assessed the left gluteal fold wound to be a Stage IV (4) with measurements of 1.6 cm x 2.4 cm x 2.8 cm with tunneling and undermining. ADON-E described the position of the tunneling and undermining via clock method of undermining 10-12 tunnel 10-6.4 cm tunnel 12-6.5. ADON-E described the current wound status as, Wound base beefy red with a few small scattered areas of white/gray slough. Area continues to drain moderate amount thin, serosang drainage. Moderate amount active bleeding noted with dressing change. Peri-wound skin intact, no redness or s/s infection noted. Resident tolerated wound care with minimal s/s pain. On 10/25/19, an APNP-J visit note stated, Pressure ulcer left buttock. Ulcer developed in early (MONTH) 2019 and rapidly progressed in width and depth .was referred and followed by Wound Care at the Chilton Clinic. Willowdale's therapy department debrided the wound periodically as necessary .spiked a fever and wound developed a foul odor with increased drainage. On 9/9/19 .was transferred to the Ascension Calumet Hospital and then transferred to St. Elizabeth Hospital and admitted from 9/9/19 to 9/14/19 .treated for [REDACTED].continues with a Stage 4 left ischial pressure ulcer. This is managed with a wound vac. Will continue with nursing dressing vac changes M (Monday), W (Wednesday), F(Friday). Will continue with repositioning every 2 hours and use extra pillows as needed. On 10/30/19 and 11/6/19, a Wound Evaluation Tracker was completed by ADON-E. On 11/6/19 ADON-E assessed the left gluteal fold wound to be a Stage IV (4) with measurements of 2.4 cm x 2.4 cm x 3.7 cm with tunneling and undermining. ADON-E described the position of the tunneling and undermining via clock method of undermining/tunneling 10-12 10 - 6.3 cm 12 - 6.0 cm. ADON-E described the current wound status as, Wound base beefy red with about 30% yellow/gray slough scattered throughout wound base. Wound margins well-defined, no redness or s/s infection to area. Resident tolerated dressing change with minimal s/s discomfort. On 11/8/19, an APNP-J visit note indicated, Pressure Ulcer - Stable and slowly improving. No signs of infection, although tubing became kinked overnight, causing some pooling of fluid and odor in the wound bed. Continue present management. APNP-J notes R18 to have a Pressure ulcer of left buttock, stage 4. On 11/13/19 at 8:16 AM, the Surveyor and NHA-A observed the rickshaw in the facility garage. NHA-A verified it was a Triobike taxi. NHA-A stated the rickshaw is made for elderly and disabled people and they received the funding for the rickshaw through a grant with Calumet County. NHA-A indicated the facility had no policy regarding the facility providing rides in the rickshaw, nor does the resident or resident representative need to sign a release/consent to go on the rickshaw. NHA-A stated she was unsure if the cushion on the rickshaw was a pressure redistributing cushion. On 11/13/19 at 8:31 AM, the Surveyor interviewed with HEH (Human Electric Hybrids)-P located inYpsilanti, Michigan. HEH-P indicated being dealer of Triobike taxi (rickshaw) that is closest to the facility. HEH-P indicated the rickshaw is designed for people who are more dependent on mobility. HEH-P indicated the rickshaw only has a seatbelt. HEH-P indicated that based on his experience with the rickshaw, a facility/person could put an additional cushion on top of the seat for pressure reduction. On 11/13/19 at 8:39 AM, the Surveyor interviewed CWA(Cycling Without Age)-Q. CWA-Q indicated she is the CWA Chilton Chapter Director. CWA-Q indicated the CWA program is targete (TRUNCATED)