**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from mental abuse by staff. This affected 1 of 3 residents (R1) reviewed for mental abuse. Staff held R1 down and forced R1 to be catherized against her wishes. As a result, R1 experienced severe trauma and fear, stating she did not feel safe in the facility and requested to be removed from the facility. The facility's failure to ensure R1 was free from abuse created a finding of immediate jeopardy that began on 2/01/25. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and [NAME] President of Success (VPS) G were notified of the immediate jeopardy on 2/12/25 at 3:32 PM. The immediate jeopardy was removed 02/01/25 and corrected on 02/03/25. Based on this determination, this citation is being cited as past noncompliance. This is evidenced by: Surveyor requested and received the facility policy titled Abuse, Neglect and Exploitation dated 7/15/2022. The facility policy states in part, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Abuse means the willful infliction of injury, unreasonable confinement. Resulting in .pain or mental anguish .Instances of abuse for all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict harm. Mistreatment means inappropriate treatment .of a resident. Policy Explanation and Compliance Guidelines: The facility will develop and implement policies and procedures that: ~Prohibit and prevent abuse . Identification of abuse . ~The facility will have written procedures to assist staff in identifying abuse . ~Possible indictors of abuse include .physical abuse of a resident observed .psychological abuse of a resident observed .sudden unexplained changes in behavior and/or activities such as a fear of a person or place . R1 was admitted to the facility on [DATE] with primary diagnosis of Parkinson's disease. R1 was her own decision maker. R1's most recent significant change in status Minimum Data Set (MDS) conducted 1/21/25, noted resident understands, is understood and has unclear speech. R1 is cognitively intact with indicators of depressed mood. R1 had no behavioral symptoms, no hallucinations and no delusions. R1 required substantial assistance for bed mobility, transfers and hygiene. R1's care plan noted focus areas as follows: ~Resistive/non-compliant with treatments/care (refusing to reposition self while in recliner) r/t (related to) belief treatment is not needed. Interventions: Provide education about risks of not complying with therapeutic regimen. Initiated: 9/23/24. ~Difficulty communicating r/t Parkinson's disease. Goal: Needs will be met with comfort and dignity. Initiated: 8/09/24 Interventions: Provide reassurance and patience communicating with resident, repeat information as needed. ~At risk for changes in mood r/t situational depression. Goal: Will maintain involvement with adl (activities of daily living) performance and social activities. Initiated: 8/09/24 Interventions: Mood assessment is indicating 5/mild depression. Resident does not have a diagnosis of mental health condition . Assess for physical/environmental changes that may precipitate change in mood. Offer choices to enhance sense of control. ~Added on 2/03/25: At risk for re-traumatization of past event or experience where reminders/triggers of event may cause behavioral changes or emotional distress. Other: having a medical procedure done to her that she did not want done. Initiated 2/03/2025. Goal: Reminders/triggering events will be avoided with minimal impact during her stay within the facility. Approaches: Provide a safe environment. Remove/avoid situations that may trigger re-traumatization. R1's Psychosocial/Trauma Informed Care Assessments/Observations since R1's admission note the following in part, 8/09/24: Prior Trauma or hx/dx (history/diagnosis) pstd (post-traumatic stress disease)? None of the above. Other concerns: none. 10/28/24: Prior Trauma or hx/dx (history/diagnosis) pstd (post-traumatic stress disease)? None of the above. Other concerns: none. R1's trauma screen, dated 1/20/25, states in part, (check all those that apply) Does resident have any of the following that may affect her approach to care? Dx or Hx (diagnosis or history) of PTSD: unchecked Prior trauma: unchecked Newly identified trauma: unchecked None of the above: checked. Surveyor reviewed the Facility Reported Incident (FRI) with the following noted: Date occurred: 2/01/2025 Time occurred: 2:00 PM Briefly Describe the Incident: On 2/01/2025 it was reported [RN C] allegedly performed a straight catheterization on resident [R1], who was not in agreement. [RN C] directed two CNA's to assist her in the procedure [CNA D and CNA E]. An investigation was immediately begun. The accused employees have been suspended pending investigation. [R1] has a BIMS (brief interview of mental status) of 15 (cognitively intact) and is her own healthcare decision maker. [R1] is currently safe in the center and free from injury. Police department was contacted at 3:21 PM. Re-education of staff regarding abuse began on 2/01/2025. R1's trauma screen, dated 2/03/25, states in part, (check all that apply) Description: [R1] had a medical procedure done to her Saturday February 1, that she did not want done. [R1] reported that the nurse did that to me and those 2 girls held me down. [R1] reported she does not feel safe. Writer suggested a move to another hall and [R1] stated, That would probably help. Experience: Did any of these events bother you? Yes Comment on events resident was bothered by: [R1] is currently feeling unsafe due to the recent event that happened to her. Treatment: [R1] was happy with the idea of a room move. She feels that will help her feel safer. Additional comments: This is a new event for [R1], she will have her mood monitored for any significant changes . R1's nurse's notes from 1/29/25 at 12:42 PM state in part, Resident questioning if meds (medications) were given after given, repeatedly asking for duloxetine (antidepressant) and calling staff liars when 1:1 provided and reassured medications were given. Asking for pain meds for right arm pain. Offered Tylenol-refused. Voltaren gel applied, resident wiped off volteran gel with Kleenex. Weepy at times. Repositioned for comfort. Added to MD list of residents to be seen at next visit regarding right arm pain. Trying to use communication board. Several nurses offering meds-making suspicious comments 'no you didn't you are lying.' Nurse's note from 1/30/25 at 5:37 AM state in part, Resident assisted to the bathroom and after toileting said something inaudible, so writer asked resident to use communication board and she pin pointed HURTPEE, asked how she rates her pain and pin pointed. Tylenol given Voided a good amount and has not been frequenting the bathroom this shift .Encouraged to drink cranberry juice did not show any behavior such as crying or anger .AM nurse will be made aware . Nurse's note from 1/30/25 at 8:43 AM states in part, Provider contact: Reporting dysuria (discomfort when urinating), weepy with bathroom use/transfer this am, VSS (vital signs stable). Incontinent of urine. Provider response: Call back to request order to check for UTI. Physician Order dated 1/30/25: U/A (urinalysis), UC (urine culture) if positive due to dysuria for possible UTI (urinary tract infection) (may cath (catheter) if unable to do a clean catch) Situation/Change in condition: BP (blood pressure): 116/58, Pulse: 81, RR: 16.0, Temp: 98.8, increased confusion, other behavioral symptoms, painful urination Nurse's note from 1/30/25 at 7:00 PM states in part, On follow up for resident complaint of burning with urination. Status: VSS afebrile (vital signs stable without fever) has been pleasant and cooperative with staff this shift, no frequency, urgency or foul odor with urination. Attempt at urine catch was contaminated. No noted discomfort with void. Nurse's note form 1/31/25 at 6:54 PM states in part, Awaiting UA cultures, WBC (white blood cells) present, negative for bacteria and nitrates .refused dinner .trying to stand by self .witnessed fall . Nurse's note from 1/31/25 at 10:57 PM states in part, UA results received .nitrates negative, no bacteria, WBC's 21-50 awaiting culture Nurse's note from 2/01/25 at 7:20 AM states in part, UA sent and positive for WBC, no bacteria or nitrates, awaiting culture results. No urinary complaints noted on noc (night) shift. Nurse's note from 2/01/25 at 1:55 PM states in part, Tele-Health Visit (physician visit): RN reporting urine culture grew 10-15,000 mixed genital flora likely contamination and this was culture result report. Patient was having some dysuria on Thursday not on antibiotics. Spoke with patient on the phone today having some dysuria but no urgency/frequency, no fever, chills or abdominal pain. Discussed with RN to get another UA with urine culture, no need antibiotics in the meantime. Surveyor reviewed the facility Criteria for Infection Form-Urinary Tract Infections which notes: Residents without an indwelling Catheter: Resident Exhibits: Fever greater than 100.0 of 2.4 degrees over baseline for 2 instances in past 12 hours And 1 or more: Dysuria, urgency, frequency, suprapubic pain, gross hematuria, flank pain, urinary incontinence, shaking/chills Resident meets criteria to order urine culture or does not meet Criteria. Of note, nurse's notes show no evidence R1 had a fever thus she did not meet criteria to order a urine culture and have the need for a straight catheterization procedure. Surveyor noted no nurse's note for the event that occurred on 2/01/24 at 2:00 p.m., that was described in the facility self report. Nurse's note from 2/01/24 at 8:59 PM states in part, Behavior as usual, no increased pain levels noted. Nurse's note from 2/02/25 at 1:08 AM states in part, Vital signs stable, rates pain at a 4 per communication board but did not want Tylenol, resting in recliner. Nurse's note from 2/02/25 at 6:06 PM states in part, Toilet without complaints of burning .no increased pain. UA returned from lab-final report says negative . Nurse's note from 2/03/25 at 11:18 PM states in part, Follow up to room change, VSS moved to a new room today with a new roommate, adjusting well to change. Nurse's note from 2/04/25 at 4:44 AM states in part, Has been sleeping well so far tonight in her new room . no complaints of pain or discomfort noted . Nurse's note from 2/04/25 at 9:53 PM states in part, Resident crying that she doesn't like room and does not want to be in it. Late entry nurse's note written by Director of Nursing (DON) B: Effective 2/05/25 at 5:26 PM states in part, Writer informed by [VPS (Vice President of Success) G]: resident stated she desired to go to the hospital to be in a place she felt safe. Resident told writer and MSW (Social Worker) earlier in the day that she feels safe in the facility, however this evening she wishes to be removed and be sent to the hospital. I did speak with resident before call to EMS (emergency medical services), I asked her again if she wished to go, to which she said yes. I asked if ok to accompany her to ED (emergency department) for continuity of care .resident clearly indicated it was ok with her transferred via a stretcher and EMS . Surveyor received and reviewed R1's skin assessments post incident which noted no new skin impairments. Surveyor reviewed R1's Hospital Internal Medicine admission Note which states in part, On 2/05/25 at 7:34 PM: Chief Complaint: Generalized pain all over, patient has dementia that has worsened over past few months. History of present illness: patient having dementia with progressive delirium, starting to have intermittent hallucinations, but is still technically her own person. Patient accompanied by nurse at the nursing home, she is extremely familiar with the patient, they have a very good relationship, however, there has been increasing behaviors and increasing paranoia recently. Because of this they did a UA the mid-stream was unfortunately contaminated, so the doctor ordered a clean cath (catheter) sample, this was performed, and patient is alleging that she tried to refuse this, and it was forced on her anyway. Because of this APS (Adult Protective Services) was involved, they have completed in this investigation, they state patient states she feels uncomfortable and needs to be removed from the nursing home as soon as possible. Patient states that she feels comfortable in the nursing home as long as the nurse is there, however when the nurse goes home for the day she makes multiple statements about feeling uncomfortable, which triggered APS to advise removal from the nursing home today, which prompted her visit here .Nurse states that they did attempt to modify the patients living situation including moving contact with staff members she has poorly interacted with, changing to different room, however patient continues to make statements about feeling unsafe .Patient does have slurred speech but is intermittently able to be understood .she is refusing repeat urine. Nurse states patient with intermittently had hallucinations over last week, including children tickling her feet underneath her wheelchair and hearing giggling . Assessment/Plan: Patient presents for further evaluation of concerns about her safety at her home, patient having increased hallucinations and delusions over past week but not currently. Head CT (computed tomography) and basic labs .No explanation for symptoms identified, patient admitted for placement . On 2/05/25 at 7:53 PM: Hospital Internal Medicine admission Note states in part, Chief Complaint: Feels unsafe at the [facility] History of present illness: .presented to hospital today with complaints she was being mistreated, apparently patient has had worsening progressive dementia thought to be secondary to her Parkinson's and there were concerns that patient may have a UTI. A midstream clean catch urine was tested and was abnormal. A cathed urinalysis was ordered and patient had reported that when this was obtained, she refused but staff obtained it despite her refusal. Patient had complained to the director and reported this to Adult Protective Services. Adult Protective Services documented that the patient felt uncomfortable and unsafe at the nursing home. General Physical exam: no acute distress. Plan: admit for observation. Surveyor reviewed the police report for R1 which states the following in part, Incident Nature: Assault Date: 2/01/2025 at 3:22 PM Disposition: Arrest Brief Summary of Activity: Officer responded to an information case from a local assisting [sic] living. DHS (Department of Health) was contacted and informed of a possible elder abuse case. Details: On Saturday February 1, 2025, at approximately 3:30 PM officer was requested by dispatch to make contact with director from [facility name] . [NHA A] told me a nurse was ordered to collect a urine sample from a resident. She stated that the resident did not want to be subjected to a catheter. The nurse requested help from CNA's who held the residents' legs down and used the catheter. [NHA A] stated the resident [R1] was crying and asking them to stop. I arrived at [facility name] to speak with [R1] about what had occurred. I was greeted by another director at the building [DON B] .[DON B] stated that multiple other staff members could hear yelling and crying from [R1's] room when the incident took place .[DON B] told me she received the report and returned to work, she found [R1] in her room with her pants still around her lower legs. I met with [R1] in her room to speak with her about what happened. [R1] said that she was in bed when a nurse came in to take a urine sample. [R1] said that during the urine sample she asked them to stop several times and never consented for the sample to be taken. [R1] stated she tried to fight but her hands and legs were held down and out of the way of the procedure. [R1] stated she was in pain during the procedure and was still in pain. I called and spoke with [CNA E] to speak with her about what happened. [CNA E] stated .around 1:55 PM she was asked by [RN C] to assist with getting a urine sample. When she entered the room, [RN C] was going over the procedure with [R1]. [RN C] began cleaning [R1's] vaginal area and [R1] was saying no several times .was instructed to assist holding one of [R1's] legs to open the vaginal area. [R1] began resisting and crying. [RN C] then told [CNA E] to get help to hold [R1]. [CNA E] went into the hallway .and asked [CNA D] to come into the room. [CNA E] said her and [CNA D] each took a side of [R1] and held her down while [RN C] inserted the catheter. When both [CNA D] and [CNA E] held her down [R1] began to cry and yell louder. [CNA E] said she felt bad and quickly realized it was wrong. However, she felt she was in a tough spot because she was instructed to do so from the nurse. I then called [CNA D] to speak about what happened. [CNA D] said she was just starting her shift when [CNA E] came and asked her to help with [R1]. When [CNA D] entered the room, she stated [R1] was very worked up and crying. [CNA D] did what she was told by [RN C] and held one of [R1's] legs down .[R1] was yelling leave me alone, let me go . I called [RN C] asked her to provide accounts of what happened. [RN C] stated she received an order from a doctor to collect a urine sample. The previous sample was contaminated therefore the doctor ordered a new sample. The new sample was to be straight catheter. [RN C] went into [R1's] room and explained the procedure to her. I asked if [R1] said anything about the procedure and [RN C] said no. I asked if she appeared upset at all and [RN C] stated she did not think so. [RN C] told me [R1] is often upset and paranoid. [RN C] stated she only requested help to hold [R1's] legs down so she could administer the catheter. [RN C] said she never heard [R1] say anything and did not notice her face being upset. I asked [RN C] why she never heard [R1], and she said she was only focused on what she was doing and did not realize anything was wrong until she was notified of the report. Findings: Through my investigation, I learned two individuals held a resident down while a nurse used a catheter to get a urine sample. The resident appeared to be resisting and telling the nurse to stop according to the CNAs in the room. On 2/11/25 at 12:39 PM, Surveyor spoke with CNA D via phone about the facility reported incident. CNA D reported being on staff since 7/27/23 and familiar with R1. CNA D reported being a certified nursing assistant for almost 10 years. CNA D reported she had been asked by CNA E to come to R1's room. R1 was in bed when she entered the room with her pants and brief pulled down. In the room was RN C with catheter supplies prepared at bedside. Upon entering R1's room, R1 appeared distressed. CNA D reported R1 was physically upset with red face and starting to cry. RN C instructed CNA D and CNA E to hold R1's legs open with the CNAs on both sides of R1's bed. With CNA D and CNA E holding R1's legs open, R1 started to vocalize louder, yelling and trying to prevent nurse from doing procedure. CNA D used one hand to stop R1 from hitting RN C and grabbing catheter supplies as she held her leg with her other hand. CNA D reported R1 was in obvious distress as CNA D tried to console her. R1 started saying, Leave me alone, Don't touch me. R1 continued yelling until RN C finished procedure. R1 was yelling, crying, pushing at staff and the supplies. After the procedure the CNAs tried pulling R1's pants up and she did not want anyone to touch her. Surveyor asked CNA D why she did not stop RN C from doing the procedure when R1 was objecting and crying. CNA D responded she had just come on shift; she was told what to do and she thought the nurse would stop/quit the procedure and she did not. CNA D stated, I should have stopped the nurse, resident did not want the procedure, resident was refusing. It did not feel right and needed to report the incident to the director of nursing. On 2/11/25 at 12:59 PM, Surveyor spoke with CNA E about the facility reported incident. CNA E indicated she has been on staff since 10/04/24 and is familiar with R1. CNA E reported being a certified nursing assistant about 3 years. CNA E reported just before 2:00 PM she was asked by RN C to assist her in getting a urine sample from R1. R1 was in bed as she had laid her down 20-30 minutes before. RN C was already in the room at bedside with catheter supplies prepared when CNA E entered the room. CNA E assisted RN C with pulling R1's pants and brief down. RN C was explaining the procedure to R1 and R1 said no, consistently no. CNA E said she was thinking RN C would stop. CNA E stated she even offered to come back another time, but RN C either didn't hear or ignored the comment. RN C directed CNA E to place her hands on R1's inner thighs. R1 was not resisting until RN C started swabbing, then R1 started to squeeze her legs shut, using her muscles against CNA E's hands and stating No. RN C directed CNA E to get help. CNA E stepped out of the room and asked CNA D to come help. Both CNA E and CNA D went to each side of R1's bed to hold R1's legs open with RN C at end of the bed. R1 was resisting RN C at bottom of the bed, grabbing at the nurse and supplies and stating No. RN C pushed R1's arms up and the CNAs blocked her arms and held her arms up to keep her from grabbing at the nurse and catheter supplies. R1 stated, Let go, let go of my hands, get off me, as nurse was inserting the catheter. Surveyor asked CNA E why she did not stop the nurse and the procedure. CNA E responded, Honestly, I walked off. I was emotional and told my co-workers I needed to self-report myself as resident was refusing and we continued anyways. It was emotional. It felt wrong. CNA E indicated CNA D was also very uncomfortable with the incident. CNA E expressed looking back she didn't expect it; she felt stuck after the comment to try again another day was ignored by RN C. CNA E expressed she recognized R1 did not want it. The incident was reported to DON immediately and an investigation was started within a few minutes. On 2/11/25 at 3:39 PM, Surveyor spoke with Family Member (FM) H via the phone. FM H reported she had been in to visit R1 earlier the day of the incident. Later that day, R1 called. R1 was hard to understand, more so than usual, she was upset. R1 reported to FM H she was held down by staff for a catheter. The DON called FM H after talking with R1. DON B told her R1 had been straight cathed (catheterized) by a nurse and 2 CNAs. R1 said no and it hurts, and R1 could be heard from people down the hall. R1 had told DON B what had happened. DON B reported that the police were called, and staff were suspended. FM H explained R1 had been slowly declining since her admission to the nursing home. R1 had some pain issues, was more paranoid with behavioral concerns and a progressive cognitive decline. All thought to be related to her Parkinson's. FM H stated after the incident, she could see changes in R1. The facility tried room changes in the facility a few times but R1 still reported she felt unsafe and wanted to go to the hospital. Once at the hospital, a total decline began and R1 spiraled down. FM H indicated she was not sure if the decline was from all the quality-of-life changes in the past year, but the incident was part of it. FM H stated the incident was traumatic, and R1 can't communicate. FM H stated the plan was for R1 to return to the facility; however, R1 has not eaten for 5 days and family has made the decision for comfort cares. FM H reports it is not realistic for R1 to return, and she expects she will soon expire. On 2/11/25 at 3:58 PM, Surveyor spoke with CNA F. CNA F indicated she had worked for the nursing home many years and works the PM shift. CNA F expressed she works R1's hall and is familiar with R1. CNA F indicated on the day of the incident she entered the facility by the back door by the timeclock for her PM shift. Upon entering she could hear R1 screaming from her room (108) which is up the hall from timeclock, around the nurse's station and halfway up hall A. CNA F indicated R1 was very loud but the words could not be understood. CNA F asked CNA D and CNA E what was going on as they exited R1's room. CNA F expressed the CNAs said R1 was upset with catheter procedure she did not want. CNA F told CNA E and CNA D to report the situation. It was obvious R1 was very upset and continued to be upset until about 3:30-4:00 PM, when she settled down. CNA F reported the next day R1 transferred to another hall. CNA F expressed she did not hear R1 say she felt unsafe after the incident. On 2/12/25 at 8:15 AM, Surveyor spoke with RN C via the phone. RN C reported working at the facility 28 years. RN C reported working the AM shift and the wing where R1 resided. RN C reported R1 had an overall decline in the past few months. R1 was not as active, lowering herself to the floor, had increased complaints of discomfort and behavioral changes. RN C reported R1 had urinary incontinence at end of January which was unusual and R1 reported it hurt with urination. R1's physician was contacted and gave an order for a urine sample. Surveyor asked RN C if R1 had any fever with her complaints. RN C indicated R1 did not have a fever. Surveyor discussed the facility's criteria for obtaining a urine culture included reports of a fever. RN C indicated she was not aware the criteria specified a fever as part of the criteria. RN C indicated a clean catch urine was obtained for R1 by another staff nurse. On Saturday 2/01/25 the culture results showed contamination with WBCs and the on-call MD (physician) was called and discussed resident symptoms. MD spoke with resident who said burns. MD explained the 1st clean catch specimen was contaminated and the need to collect another one. RN C gathered supplies for a straight catheter to obtain the specimen, entered R1's room and assisted with lowering R1's blankets and pants. RN C explained she assisted R1 with peri care with wipes and saw no issues. R1 was calm. With swabbing, R1 became kind of rigid and RN C instructed CNA E to spread her legs. RN C said she knew it was not going to be easy due to R1's rigidness and asked CNA D to get help. CNA D got CNA E. The two CNAs were on each side of R1's bed with RN C at the foot of bed. RN C instructed the CNAs to spread R1's legs. RN C said it was quiet in the room and she had an issue with the first catheter and had another kit there to try. RN C said she has cathed many people and the second one filled, was removed and the CNAs were trying to re-dress R1 when she noticed she was weepy. RN C expressed she did not notice any objection from R1, did not see resident moving away and did not see any non-verbal cues resident was upset. RN C expressed, The CNAs are there to watch the patient and their comfort. The CNAs did not alert her to any issues. RN C expressed she did not know there was an issue until contacted later that day by DON B. RN C stated she would have stopped had she known R1 was objecting. On 2/12/25 at 11:37 AM, Surveyor spoke with Adult Protective Services (APS) I who indicated she received a report of incident on 2/03/25 by law enforcement. APS I reported to the facility on 2/05/25 and spoke with R1. R1 indicated she told staff she did not want straight catheter procedure when the nurse was explaining the procedure, as in the past it hurt. The nurse (RN C) had 2 CNA staff (CNA D and CNA E) hold her down by her arms and legs to do the catheter even though she said no several times. R1 said it hurt very bad and she did not consent to the procedure. R1 said she wanted to press charges as she doesn't want it to happen to another resident. R1 requested to move, as she did not feel safe. The facility moved her to another room but R1 requested a move as she continued to not to feel safe at the facility regardless of the change in room and the fact that the alleged staff had been suspended. APS I expressed she informed R1's managed care organization coach about the request to move; as well as facility administrator for R1's safety and wellbeing. R1 was transferred to the hospital that day. On 2/12/2025 at 1:13 PM, Surveyor spoke with DON B about the incident on 2/01/25 with R1. DON B indicated she was called by CNA E just after 2:00 PM stating she was uncomfortable with R1's straight catheter procedure. CNA E reported R1 did not want the procedure, and the procedure was done anyway. DON B said she came into the facility immediately and called NHA A when in route. Once at the facility she asked RN C about the straight catheter procedure and if R1 consented to the procedure. RN C said she did not decipher R1 did not want it done and she did not hear no but R1 was tearful. RN C was asked to leave the building and informed an investigation would be conducted. RN C did not note the incident in the nurse's notes. DON B stated she talked to CNA D next. CNA D explained she was asked to assist with the procedure. R1 was tearful and did not want the procedure done. CNA D said she was told to hold R1 in a position to obtain catheter urine. R1 was tearful. CNA D was asked to leave the facility was and informed of investigation. DON B said she then went to speak with R1. R1 said she wanted a clean catch and questioned why a straight catheter was done. DON B explained the specimen was contaminated and the provider gave an order for straight catheter. R1 did not want it done and did not give consent. R1 said no and no means no. Resident rights were violated by not being allowed to refuse treatment. Based on facility policies abuse occurred. DON B stated the facility immediately began training staff on resident rights and provided training to all staff before they reported to work. On 2/12/25 at 1:59 PM, Surveyor spoke with NHA A about the incident with R1 on 2/01/2025. NHA A indicated she was called by DON B around 2:15 PM on 2/01/2025 reporting CNA E said she was part of getting a urine sample from R1 when R1 said no and that R1 was upset. NHA A indicated she called law enforcement right away and started reporting to the state of Wisconsin Department of Health Services. NHA A reported DON B talked with RN C. NHA A indicated APS came in on 2/05/25 and reported to her R1 did not feel safe in the building, R1 wanted to press charges and APS I was going to contact the MCO regarding placement. VPS G spoke with R1 who stated she did not feel safe because staff were putting toys in pillowcases and on her bed making her lay on them. R1 was saying a little girl was under her wheelchair which was new for her. R1 was transferred to the hospital 2/05/25 around 5:30 PM and has not returned to the facility. On Monday 2/03/25 the facility continued staff education related to abuse, definitions, who to contact, allegations, reporting and resident rights. Specifically, what to do when someone says no. Surveyor asked NHA A if R1's rights were violated. NHA A responded R1's right to refuse treatment was violated as the CNAs held her legs down to obtain [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure each resident receives cares consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 4 sampled residents (R)1 and R3. On admission 5/20/24, staff identified R1 had a suspected deep tissue injury (DTI) from the coccyx to the peri area. Physician, Director of Nursing, or wound nurse were not notified of this suspected DTI. No care plan or interventions were put in place for the pressure injury. Pressure injury assessments were not completed after the identification of the DTI on 5/20/24. As a result, R1 developed an unstageable pressure injury and sepsis. R1 required hospitalization and surgical debridement of the PI. The PI was staged as a stage 4 pressure injury. The facility's failure to implement pressure injury interventions and assess R1's pressure injury, created a finding of immediate jeopardy that began on 05/27/24. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and [NAME] President of Success (VPS) J were notified of the immediate jeopardy on 08/21/24 at 12:16 PM. The immediate jeopardy was removed on 8/21/24; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan and as evidenced by the following example: R3 was admitted to the facility 08/09/24 with a PI on the left heel. R3's care plan included float heels as able; use pillows and/or positioning devices as needed. R3's heels were not being floated during numerous observations by survey team. Example 1: Based on the National Pressure Injury Advisory Panel (NPIAP), Pressure Injury Prevention Points dated April 2016, stated in part, RISK ASSESSMENT .5 Develop a plan of care based on the areas of risk, rather than on the total risk assessment score .SKIN CARE 1 Inspect all of the skin upon admission as soon as possible 2 Inspect the skin at least daily for signs of pressure injury, especially nonblanchable erythema. 3 Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows, and beneath medical devices. 4 When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent skin . 8 Avoid positioning an individual on an area of erythema or pressure injury .REPOSITIONING AND MOBILIZATION . 5 Avoid positioning the individual on body areas with pressure injury. R1 was admitted to the facility on [DATE] from an acute care hospital. R1 had a documented Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R1 has diagnoses of malnutrition, multiple myeloma (also known as Kahler's disease, an uncommon blood cancer that affects the bone marrow, the body's blood-forming system), left hip fracture of iliac wing (to heal with conservative measures), pain control, and therapy for non-weight bearing to the left lower extremity (NWBLLE). R1's Minimum Data Sets (MDS) assessment, dated 05/27/24, included the following: Mobility: Partial/moderate assistance with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, tub/shower transfer. Substantial/maximal assistance with toilet transfer. Skin: Does resident have a pressure injury: No Is resident at risk of a pressure injury: Yes Pressure reducing device for chair and bed: Yes Turning/Repositioning: No Pressure ulcer care: No Application of nonsurgical dressing: No On 8/20/24 at 11:00 AM, Surveyor reviewed R1's CNA [NAME] (patient care summary). The [NAME] indicated R1 was assist of 1 with bed mobility, personal hygiene, toileting bathing and showering. Transfer assist of one with gait belt. Record review identified a Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a client's risk for developing pressure injuries) was completed on 05/20/24 at 4:53 PM, with a score of 21, which meant R1 was not at risk for skin breakdown. Of note, R1 needs assistance to roll left and right, and partial to moderate assistance for all transfers. A weekly skin assessment completed on 05/20/24, at 9:09 PM, indicated R1 had a pressure injury to coccyx, From coccyx to peri area is dark purple and appears to be a DTI. No open area noted. Surveyor was unable to find any documentation in R1's medical record showing a physician, the wound care nurse or the DON was notified of this suspected DTI. Further review of R1's medical record identified there was no care plan for actual skin breakdown. R1 had a care plan focus, stating, At risk for alteration in skin integrity related to: impaired mobility. Interventions for this care plan included: Barrier cream to peri area/buttocks as needed, diet and supplements per Medical Doctor (MD) orders, observe skin condition with Activities of Daily Living (ADL) care daily and report abnormalities. The skin integrity care plan did not include any individualized pressure interventions for R1's coccyx DTI. There was no turning schedule despite R1 needing partial/moderate assistance with turning. Doctor's orders: NWB LLE started 05/20/24. Complete initial skin assessment and document in point click care every shift. Weekly skin review every Wednesday start 05/22/24 revision date 05/20/24. On 5/26/24, there was a weekly skin review in the medical chart, with a box checked for bruises under the skin conditions section. Nothing is documented under the site or description sections of the document. This weekly skin review has no documentation on the coccyx DTI. On 5/27/24 at 5:29 PM, the next progress note states in part: .Daughter came up to desk at shift change and stated that [R1] was admitted to the hospital for surgical procedure on her buttock. Surveyor was unable to identify information about how or why R1 was sent to the hospital in the medical record. Surveyor requested documentation. Director of Nursing (DON) B provided Surveyor with the Situation, Background, Assessment, and Recommendation (SBAR) and transfer to hospital form. The SBAR communication form reads in part on 05/27/24 at 7:32 AM: .BP 122/65, Pulse 148, RR 18, temp, 98.1, Skin evaluation: Pressure ulcer Does the patient have pain: Yes the pain is new Description of pain/location: New wound measuring at 3.7 x 2.2 x 0.7 with foul smelling purulent drainage noted coccyx. Intensity: 6 Called on call physician for acute care hospital and spoke with Medical Doctor (MD) G who gave orders to send to ER for evaluation and treatment. R1's Daughter notified 05/27/24 at 7:32 AM. Surveyor reviewed the ambulance report. On 05/27/24 at 8:15 AM, the ambulance record states the staff report that R1 had been feeling unwell, complaining of fatigue, lower back pain and fevers for the past two days. Staff checked a pressure ulcer located on the patient's coccyx and stated that it was black and oozing. Staff report the patient had a low-grade fever yesterday of 100 degrees Fahrenheit. Ambulance record indicates temperature of 99.5, HR of 136, 120, BP stable. On 08/20/24 at 9:48 AM, Surveyor phone interviewed R1's family member for any new or pertinent information. R1's daughter informed Surveyor that R1 required surgery for the wound on the butt, and the acute care facility that did the surgery staged the wound as a stage 4 pressure injury. R1 was still in another nursing home. R1 has not been home for 3 months now and her cancer treatments were put on hold until the wound could heal. On 08/20/24 at 12:45 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding cares for R1. CNA D did recall caring for R1. CNA D did not recall being informed that R1 had any skin issue or wounds at the time of admission to the facility. CNA D did not recall that R1 had any special turning or repositioning plan. CNA D did recall that R1 had a standard bed mattress and a cushion in the wheelchair. CNA D remembered one day, but was unsure of which day, when caring for R1 there was drainage from R1's bottom and on R1's depends. CNA D noted redness on R1's bottom and called Registered Nurse (RN) E to assess R1's skin. CNA D does not remember what or if any new interventions were started after this observation of redness and drainage. On 08/20/24 at 2:27 PM, Surveyor asked Assistant Director of Nursing (ADON) C (the facility's wound nurse), about the process of being notified if a resident has a PI. ADON C indicated on admission to the facility, if a resident has a PI, staff open up a wound tracker and that triggers ADON C to look at it on wound rounds on Wednesdays. On 08/20/24 at 2:40 PM, Surveyor interviewed Registered Nurse (RN) E. Surveyor asked RN E about being called in to assess an open wound on R1. RN E indicated the original wound was red and wasn't open, so barrier cream was applied and no dressings were in place at that time. RN E did not think that it needed any further treatment because it was red and not open. RN E indicates she would have notified the wound nurse if the area was open. Surveyor could not find any documentation in R1's medical record identifying RN E's assessment of the redness and drainage that was reported by CNA D. On 08/20/24 at 3:59 PM, Surveyor interviewed RN F regarding pressure relieving devices for R1. RN F indicated that R1 had a pressure relieving chair cushion in the wheelchair, and the facility provides those for all residents' wheelchairs. R1's mattress was a standard mattress. RN F also indicated that R1 was not started on a turning or repositioning schedule. RN F informed Surveyor that every time R1 went to the bathroom skin barrier cream was applied to the purple area and this area remained intact until R1 went to the hospital. RN F was asked about assessments that were performed on this area. RN F informed Surveyor that CNAs saw R1's bottom every time they took R1 to the bathroom and they never reported any open areas. On 08/21/24 at 8:50 AM, Surveyor interviewed via phone Medical Doctor (MD) G regarding care for R1's pressure injury. MD G informed Surveyor there was a hospital follow up visit completed on May 23, 2024, and there was no mention of or complaints of any skin issues. MD G informed Surveyor R1 did not complain of skin issues at the time of admission. Surveyor asked MD G if MD G was informed of the DTI to R1's bottom. MD G indicated, the first time I was notified was when the facility was sending R1 to the emergency room on [DATE]. On 08/21/24 at 10:21 AM, Surveyor interviewed ADON C about the suspected DTI to R1's bottom on admission. ADON C denied knowing anything about it. ADON C informed Surveyor that ADON C was never notified of the DTI. On 08/21/24 at 10:32 AM, Surveyor asked DON B about the suspected DTI to R1's bottom on admission. DON B informed Surveyor that DON B was never made aware of the DTI on 5/20/24. The failure to ensure each resident receives cares consistent with professional standards of practice to prevent pressure injuries created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 05/27/24. On 08/21/24, the facility took steps to correct the deficient practice and ensure compliance. The immediate jeopardy was removed on 08/21/24 when the facility implemented the following: 1. Facility in-house residents had their skin inspected by RN on 08/21/24 and no unidentified pressure injuries were discovered, current interventions were reviewed and verified in place as per care plan, and treatment orders are in place, accurate, and completed as ordered as of 08/21/24. 2. Re-education to licensed nursing staff (RNs and LPNs) was initiated on 08/21/24 for aggressive pressure injury prevention including visually inspecting resident's skin upon admission or readmission to identify skin impairments, notifying physician to obtain orders for treatment, notifying responsible party of resident, and interdisciplinary team (IDT) re-educated on pressure injury and non-pressure injury, need to review new or worsening skin impairments to ensure interventions are reviewed and care plan updated. 3. Re-education to nursing staff on 08/21/24 to monitor skin for injuries or changes with cares to ensure current he nurse if noted. 4. DON or designee to review facility charting for 2 weeks to ensure new admissions, readmissions, and current residents have skin impairments properly documented, orders implemented, and notifications completed and documented. This review will then be completed 5 days per week for 6 weeks or until substantial compliance maintained. 5. Audits will be completed for 8 weeks by DON or IDT to ensure in house residents with pressure injuries have established wound process in place including care plan review and evaluation. 6. Quality Assurance Performance Improvement (QAPI) meeting held on 08/21/24 to review pressure injury incident, discuss implementation of actions items as stated above.Example 2: R3 was admitted to the facility on [DATE] after an acute care hospital stay with the following diagnoses, in part, Parkinson's disease, polyosteoarthritis, and long term use of antibiotics. R3's admission assessment, dated 08/09/24, identified R3 had a Braden risk assessment score of 18, which indicated R3 was at risk for the development of a pressure injury. The admission assessment also identified R3 had a pressure injury on the left heel. The assessment did not identify the stage of the pressure injury or any measurements or description of the wound condition. R3's Minimum Data Set (MDS) assessment, dated 08/16/24, identified R3 was at risk for development of a pressure injury and had one unhealed stage 1 pressure injury. All of the subsequent Weekly Skin Review documents identified R3 had no skin impairments. Surveyor was unable to identify any other documentation of assessment of the left heel pressure injury, or documentation stating the left heel pressure injury was resolved. R3's care plan included the following focus areas, in part: The resident has a pressure ulcer (left heel) r/t [related to] recent hospitalization. Date initiated: 08/09/2024. Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date initiated: 08/09/2024. Interventions/Tasks: Administer treatments as ordered and monitor for effectiveness. Date initiated: 08/09/2024. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date initiated: 08/09/2024 .Actual pressure wound at left heel r/t recent hospitalization/immobility. Date initiated: 08/09/2024. Goal: Show no signs of infection. Interventions/Tasks: Encourage and assist as needed to turn and reposition; use assistive devices as needed. Float heels as able. Follow up care with MD as ordered. Use pillows and/or positioning devices as needed. R3's order summary did not contain any treatment orders for care or treatment of the left heel pressure injury. On 08/20/24 at 11:40 AM, Surveyor observed R3 seated in a wheelchair in R3's room. R3 was dressed and had gripper socks on both feet. R3's heels were resting directly on the floor. R3 stated they thought they had a sore on their heel. On 08/20/24 at 12:38 PM, Surveyor observed R3 seated in a recliner in R3's room. The footrest on the recliner was elevated and R3's heels were resting directly on the foot rest. R3 had gripper socks on both feet and her heels were not floated. On 08/20/24 at 12:45 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D and asked if R3 had any wounds or skin issues. CNA D was not aware of any wounds or skin issues for R3. Surveyor asked CNA D if they had any interventions for positioning or pressure relief for R3. CNA D stated they tried to encourage R3 to reposition every 2 hours. Surveyor asked if they were supposed to float R3's heels. CNA D was not aware of any interventions to float R3's heels. On 08/20/24 at 12:56 PM, Surveyor interviewed Registered Nurse (RN) H, who was caring for the residents on R3's hall, and asked if R3 had any wounds or pressure injuries. RN H stated they were not aware of any skin issues for R3. On 08/20/24 at 2:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C, who stated they were the facility's wound nurse. Surveyor asked if there was additional documentation of assessments of R3's left heel pressure injury that was identified on admission to the facility. ADON C stated they were not aware of R3's pressure injury. ADON C stated when a staff member identifies a new wound on a resident, they are supposed to inform ADON C. ADON C will then assess the wound and open a weekly wound tracker and do weekly wound assessments and documentation until the wound is healed. On 08/20/24 at 2:40 PM, Surveyor interviewed RN I, who stated R3 did have a previous pressure injury to the left heel when admitted from the hospital, but it had subsequently healed. RN I stated R3 did not have a current pressure injury to the left heel, but they neglected to update the care plan to reflect this. Surveyor asked RN I if there was documentation of an assessment of the left heel that showed the pressure injury had resolved. RN I stated they did not document an assessment of R3's heel showing the pressure injury had resolved. Surveyor asked if R3 was still at risk for development of pressure injuries. RN I stated R3 was still at risk for pressure injuries and staff should still follow the care plan and float R3's heels to prevent the recurrence of pressure injuries to R3's heels. Surveyor informed RN I of two observations of R3 seated without heels floated. RN I stated staff would be reeducated.