**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure all allegations of abuse and neglect were reported to the Nursing Home Administrator (NHA) or the State Agency (SA) for 3 residents (R) (R8, R9, and R10) of 11 sampled residents. In addition, the facility's Abuse/Mistreatment policy contained conflicting information related to reporting allegations of abuse/mistreatment. R8 reported to staff that a Certified Nursing Assistant (CNA) was short with R8 and would not allow R8 to have R8's face cream. The allegation of abuse was not reported to NHA-A or the SA. R9 reported to staff that it took 45 minutes for a CNA to respond to R9's toileting request and the CNA was rude, abrupt and unwilling to do (the CNA's) job. R9 also indicated the CNA would not give R9 a bath. The allegations of abuse and neglect were not reported to NHA-A or the SA. R10's daughter reported to staff that R10 was crying in R10's room and stated staff were mean and hurt R10. The allegation of abuse was not reported to NHA-A or the SA. The facility's Abuse/Mistreatment policy indicates the facility shall report all violations and substantiated incidents to the proper state agency, registry/licensing authorities, and local law enforcement as required; however, regulatory requirements indicate all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property be reported. Findings include: The facility's Grievance policy, dated July 2023, indicates: The Grievance Official or designee will: *Immediately report and take action pertaining to alleged violations involving neglect, abuse, mistreatment, exploitation, injuries of unknown source, and/or misappropriation of resident property in accordance with the facility's abuse policy. The Facility's Abuse/Mistreatment policy, dated April 2021, indicates: Each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat residents' symptoms. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. 5. The Administrator/designee will report to the DQA (Division of Quality Assurance) all alleged violations involving mistreatment, neglect, exploitation, or abuse .Reporting/Response: Facility shall report all violations and substantiated incidents to the proper state agency, registry/licensing authorities and local law enforcement as required .In the event of an alleged incident of abuse, neglect .1. All employees, contracted individuals, or volunteers are responsible for knowing about the facility's reporting procedures and requirements .All employees, contracted individuals and/or volunteers are required to report observations of abuse or mistreatment, resident complaints, concerns, allegations, injuries, incidents, and grievances immediately to their supervisor. Immediately means reporting should occur as soon as the safety of all residents are secured and all necessary emergency measures are taken, including removing the accused from services immediately. 1. On 4/8/24, Surveyor reviewed R8's medial record. R8 was admitted to the facility on [DATE] with diagnoses including pain, history of right hip arthroplasty, abnormalities of gait and mobility, muscle weakness, and history of falling. R8's Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8's care plan indicated R8 had impaired mobility and loss of independence and required a full body mechanical lift with the assistance of two staff for transfers. The care plan also indicated R8 required set up assistance for grooming. On 4/7/24, Surveyor reviewed a grievance report for R8, dated 1/15/24, that indicated an aide was short with R8 the previous night. R8 stated R8 asked for R8's face cream and the aide said, No. You're in bed and that's where you're going to stay. R8 indicated the staff with the aide was nice and got R8's cream, but the aide said, No. The grievance was signed by Director of Nursing (DON)-B on 1/16/24. 2. On 4/8/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including brain cancer, polyneuropathy, syncope, and weakness. R9's MDS assessment contained a BIMS score of 10 out of 15 which indicated R9 had moderate cognitive impairment. R9's care plan indicated R9 had impaired mobility and required a full body lift and the assistance of two staff for transfers. R9's care plan also indicated R9 required assistance with bathing. R9's thought process care plan contained interventions to acknowledge R9's perspective, encourage R9 to express feelings regarding R9's current situation and anticipated changes, provide a structured environment, and provide reassurance. On 4/7/24, Surveyor reviewed a grievance report for R9, dated 12/21/23, that indicated R9 was upset with cares provided that AM by a CNA. R9 stated it took 45 minutes for the CNA to respond to R9's toileting request. R9 had loose stools due to recent antibiotic treatment, requested to use the bathroom, and was told, I said I can't help you right now. After waiting long enough, R9 stated R9 would take R9's self to the bathroom and the CNA stated, Fine, take yourself. R9 stated the CNA was rude, abrupt, and unwilling to do the CNA's job. The grievance also indicated the CNA would not give R9 a bath per R9's choice. The CNA said staff would give R9 a shower but only if R9 stopped acting like that (meaning weak). The grievance was signed by DON-B on 12/21/23. 3. On 4/8/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dementia, multiple sclerosis, chronic pain, and anxiety disorder. R10's MDS assessment contained a BIMS score of 3 out of 15 which indicated R10 had severe cognitive impairment. R10's care plan indicated R10 required extensive assistance of staff for mobility and was able to verbalize pain and its location and intensity. R10's care plan contained interventions to anticipate and treat pain prior to transfer and movement, provide an explanation prior to moving, and to go slow and gentle because fast repositioning was alarming (dated 3/12/24). On 4/7/24, Surveyor reviewed a grievance initiated by R10's daughter, dated 2/20/24, that indicated R10 was crying in R10's room. Staff had just gotten R10 up via Hoyer lift for an appointment at 1:00 PM. R10 reported to R10's daughter that staff were mean to (R10) and hurt (R10). The grievance indicated Nurse Manager (NM)-C interviewed R10 for further clarification and R10 did not use the word mean. NM-C obtained witness statements from staff, dated 2/19/24. The grievance was signed by DON-B on 2/20/24 On 4/8/24 at 9:55 AM, Surveyor interviewed NM-C who confirmed NM-C received the initial allegation from R10's daughter, investigated the allegation, and reported the allegation to DON-B. NM-C stated the date on the grievance was incorrect and should be 2/19/24. NM-C confirmed the statements initially relayed to NM-C by R10's daughter would be considered abuse. On 4/8/24 at 9:58 AM, Surveyor interviewed DON-B who indicated allegations surface when R10's daughter visits. DON-B indicated DON-B believes this is attention-seeking and that R10 is trying to get a response from R10's daughter. DON-B stated the allegations were investigated. On 4/7/24 at 4:04 PM, Surveyor interviewed DON-B who confirmed the above allegations were not reported to the SA. On 4/8/24 at 9:45 AM, Surveyor interviewed NHA-A who confirmed the above allegations were not reported to NHA-A or the SA. NHA-A indicated DON-B is the first line of defense in terms of investigating situations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 3 residents (R) (R8, R9, and R10) of 11 residents. R8 reported to staff that a Certified Nursing Assistant (CNA) was short with R8 and would not allow R8 to have R8's face cream. The allegation of abuse was not thoroughly investigated. R9 reported to staff that it took 45 minutes for a CNA to respond to R9's toileting request and that the CNA was rude, abrupt and unwilling to do (the CNA's) job. R9 also stated the CNA would not give R9 a bath. The allegations of abuse and neglect were not thoroughly investigated. R10's daughter reported to staff that R10 was crying in R10's room and stated staff were mean and hurt R10. The allegation of abuse was not thoroughly investigated. Findings include: The Facility's Abuse/Mistreatment policy, dated April 2021, indicates: Investigation: Whenever there is an incident, allegation or grievance reported to an employee, they shall immediately protect the resident and notify their supervisor who shall immediately notify the Administrator, or designee. The facility shall start an investigation of all incidents, allegations, concerns, complaints, and grievances immediately. Violations will be thoroughly investigated. Investigations will be thorough and conducted after any reported incident. Investigations must collect information that corroborates or disproves the incident and document the findings of each incident. A thorough investigation may include the following: ~Conduct observations of alleged victim, including identification of any injuries, the location where the alleged incident occurred, interactions and relationships between the staff and the alleged victim and/or other residents, and interactions/relationships between the resident and other residents, as appropriate. ~Interview alleged victims(s) and witness(es). ~Interview the accused individual(s) allegedly responsible for the mistreatment . ~Interview other residents to determine if they have been abused or mistreated. ~Interview staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused. ~Interview staff who worked previous shifts to determine if they were aware of an injury or incident. ~Involve other regulatory authorities who may assist . In the event of an alleged incident of Abuse, Neglect, Exploitation, Mistreatment or Misappropriation of resident property: 1.After protecting the resident and all other residents from further incidents of misconduct or injury, the accused is removed from services immediately (if applicable) . 1. On 4/8/24, Surveyor reviewed R8's medial record. R8 was admitted to the facility on [DATE] with diagnoses including pain, history of right hip arthroplasty, abnormalities of gait and mobility, muscle weakness, and history of falling. R8's Minimum Data Set (MDS) assessment contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R8 had intact cognition. R8's care plan indicated R8 had impaired mobility and loss of independence and required a full body mechanical lift and the assistance of two staff for transfers. The care plan also indicated R8 required set up assistance for grooming. On 4/7/24, Surveyor reviewed a grievance report for R8, dated 1/15/24, that indicated a CNA was short with R8 the previous night. R8 asked for R8's face cream and the CNA said, No. You're in bed and that's where you're going to stay. The staff with the CNA got R8's face cream, but the CNA said, No. The grievance was signed by Director of Nursing (DON)-B on 1/16/24. The Action and Response Taken section of the grievance indicated: Include how resident was protected, how grievance was investigated, who was contacted, and how further potential violations will be prevented while the allegation is being investigated Provide and attach witness statements if appropriate. The grievance contained information that indicated DON-B contacted staff who worked that shift and what two of the staff stated. A wing assignment sheet was attached to the grievance. The Follow Up/Resolution/Conclusion section contained a note that indicated the grievance was unsubstantiated and staff would be re-educated and receive a discipline for not following the care plan. The grievance did not contain resident interviews, witness statements, written staff statements, or further information including how R8 was protected during the investigation. 2. On 4/8/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including brain cancer, polyneuropathy, syncope, osteoarthritis, and weakness. R9's MDS assessment contained a BIMS score of 10 out of 15 which indicated R9 had moderate cognitive impairment. R9's care plan indicated R9 had impaired mobility and required a full body lift and the assistance of two staff for transfers. The care plan also indicated R9 needed staff assistance for bathing. R9's thought process care plan contained interventions to acknowledge R9's perspective, encourage R9 to express feelings regarding the current situation and anticipated changes, give structured environment, and provide reassurance. On 4/7/24, Surveyor reviewed a grievance for R9, dated 12/21/23, that indicated R9 upset with care provided that morning by a CNA. R9 stated it took 45 minutes for the CNA to respond to R9's toileting request. R9 had loose stools due to recent antibiotic treatment. R9 requested to use the bathroom and the CNA stated, I said I can't help you right now. After waiting long enough, R9 stated R9 would take R9's self to the bathroom and the CNA stated, Fine. Take yourself. R9 stated the CNA was rude, abrupt, and unwilling to do the CNA's job. The grievance also indicated the CNA would not give R9 a bath per R9's choice. The CNA said staff would give R9 a shower but only if R9 stopped acting like that (meaning weak). The grievance was signed by DON-B on 12/21/23. The Action and Response Taken section contained a note that indicated the CNA was escorted out of the building and sent home pending the investigation. DON-B and R9's representative were updated regarding the care concerns and start of the investigation. The Follow Up/Resolution/Conclusion section contained a note that indicated the CNA was immediately escorted from the building. DON-B and the Registered Nurse (RN) Manager met with R9. The investigation indicated the CNA was new to the facility and had a poor approach. R9's concern was substantiated and the CNA was terminated. The grievance did not contain resident interviews, witness interviews, written staff statements, or further investigation information. 3. On 4/8/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility with diagnoses including dementia, multiple sclerosis, chronic pain, anxiety disorder, and palliative care. R10's MDS assessment contained a BIMS score of 3 out of 15 which indicated R10 had severe cognitive impairment. R10's care plan indicated R10 could verbalize the location and intensity of pain and required extensive assistance of staff for mobility. The care plan contained interventions to anticipate and treat pain prior to transfer/movement, explain what staff are doing prior to movement, and go slow and gentle because fast repositioning was alarming (dated 3/12/24). On 4/7/24, Surveyor reviewed a grievance initiated by R10's daughter, dated 2/20/24, that indicated R10 was crying in R10's room. Staff had just gotten R10 up via Hoyer lift for an appointment at 1:00 PM. R10 reported to R10's daughter that staff were mean to (R10) and hurt (R10). The Action and Response Taken section contained a note that indicated statements were collected from the CNAs who assisted with cares and the transfer. The statements were attached to the grievance form. The grievance form also indicated R10's care plan was reviewed and updated and an order was obtained for ibuprofen 400 mg (milligrams) for pain. A note indicated unit interviews were completed with no care or transfer concerns. The grievance did not contain resident interviews, witness interviews, or indicate how R10's safety was ensured pending the results of the investigation. On 4/8/24 at 9:58 AM, Surveyor interviewed DON-B who indicated allegations surface when R10's daughter visits. DON-B indicated DON-B believes this is attention-seeking and that R10 is trying to get a response from R10's daughter. DON-B stated, We investigated it. On 4/8/24 at 4:04 PM, Surveyor interviewed DON-B who indicated the above allegations were customer service situations and were not investigated as allegations of abuse or neglect. On 4/8/24 at 9:45 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the allegations were not reported to NHA-A. NHA-A indicated DON-B is the first line of defense in terms of investigating situations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 1 resident reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. R1 was transferred to the hospital on 3/27/24. R1 and/or R1's representative were not provided with a written transfer notice. Findings include: The facility's Transfer of Resident to the Hospital policy, with a review date of 5/2021, indicates: A written notification of transfer will be provided to the resident at the time of discharge with the date of discharge and where the resident is going. The nurse is to mark that the resident is being discharged because of a medical emergency. A copy of the discharge notification will be copied and placed in the medical record. The nurse will chart that the written notification of discharge was given. Note: The resident does not need to sign the form. On 4/7/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), pressure injury on the left lower back, coronary artery disease (CAD), and memory impairment. On 3/27/24, R1 sustained a skin laceration during a transfer and was transported to the hospital for evaluation and treatment. R1's medical record did not contain a transfer notice. Surveyor requested a copy of the transfer notice from Director of Nursing (DON)-B which was not provided to Surveyor. On 4/8/24 at 10:30 AM, Surveyor interviewed Social Services (SS)-D who confirmed the facility did not provide a transfer notice other than a bed hold notice. On 4/8/24 at 10:35 AM, Surveyor interviewed DON-B who confirmed DON-B was not aware of the need to provide a written transfer notice to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure allegations of abuse and misappropriation were reported to the State Agency (SA) for 2 residents (R) (R17 and R10) of 2 sampled residents. R17 reported an allegation of physical abuse. The facility did not report the allegation of abuse to the SA. The facility did not submit a 24-hour report to the SA regarding an allegation of misappropriation involving R10. Findings include: The facility's Abuse policy, dated 3/23, contained the following information: All alleged violations of abuse, neglect, exploitation of residents, misappropriation of resident property .must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency and Adult Protective Services where State law provides for jurisdiction in long-term care facilities .Not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property and does not result in serious bodily injury. Results of all investigations of alleged violations must be reported within 5 working days of the incident. 1. On 6/20/23, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses to include chronic heart failure, major depressive disorder, age-related cognitive decline, and unspecified dementia. R17's Minimum Data Set (MDS) assessment, dated 4/8/23, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R17 had moderate cognitive impairment. On 6/20/23, Surveyor reviewed the facility's grievance log. The log contained a grievance submitted via email by Family Friend (FF)-G that indicated R17 told FF-G on 4/5/23 that the staff member who gave R17 a bath was rough, caused R17 pain, and made R17 cry. FF-G reported FF-G observed bruising on R17's left forearm. On 6/20/23 at 1:48 PM, Surveyor interviewed Director of Nursing (DON)-B who stated any suspected abuse is reported to the SA. DON-B verified DON-B did not report R17's allegation of abuse to the SA. On 6/20/23 at 2:41 PM, Surveyor interviewed Social Services Director (SSD)-C regarding R17's allegation of abuse. SSD-C read FF-G's email and verified the email contained an allegation of abuse. 2. On 6/20/23, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder, depressive disorder, and arthritis. R10's MDS assessment, dated 5/8/23, contained a BIMS score of 15 out of 15 which indicated R10 was not cognitively impaired. From 6/19/23 through 6/21/23, Surveyor reviewed a facility-reported incident (FRI) regarding an allegation of misappropriation of medication involving R10. Surveyor noted the FRI did not contain a 24-hour report that was submitted to the SA. On 6/20/23 at 10:59 AM, DON-B provided Surveyor the facility's 5 day report. DON-B stated the previous Nursing Home Administrator (NHA) told DON-B the 24-hour report was submitted to the SA. DON-B stated DON-B believed the previous NHA filled out an incorrect form and the 24-hour report was not submitted. On 6/20/23 at 2:56 PM, Surveyor interviewed Registered Nurse Supervisor (RNS)-E regarding allegations of abuse and misappropriation. RNS-E verified allegations of abuse and misappropriation should be reported right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure allegations of abuse and misappropriation were thoroughly investigated for 2 Residents (R) (R17 and R10) of 2 sampled residents. R17 reported an allegation of abuse on 4/5/23. The facility did not thoroughly investigate the allegation of abuse or remove the accused staff member from resident care during the investigation. Staff reported a potential allegation of misappropriation involving R10 on 2/28/23. The facility did not thoroughly investigate the allegation of misappropriation. Findings include: The facility's Abuse policy, dated 3/23, contained the following information: It is the policy of this facility that reports of abuse, neglect, exploitation of residents, misappropriation of resident property .are promptly and thoroughly investigated. E. Investigation: a.When an incident of abuse, neglect, exploitation of residents, misappropriation of resident property .is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel .The investigation will include statements from all individuals involved to include: i. Statement from individual reporting the alleged abuse ii. Residents' statements iv. Visitor statements for anyone who may have witnessed the alleged abuse (if applicable) v. All involved staff who have or may have witnessed the abuse viii. A full assessment of the resident to identify any injuries present xi. A complete and thorough documentation of the entire investigation. c.Examples of reportable allegations of misappropriation of resident property that will be investigated include, but are not limited to: 7. Missing medications or diversion F. Protection Procedures must be in place to provide the resident with a safe, protected environment during the investigation: ii. The alleged perpetrator will immediately be removed and the resident protected. Employees accused of alleged abuse .be immediately removed from the facility and will remain removed pending the results of a thorough investigation. 1. On 6/20/23, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses to include chronic heart failure, major depressive disorder, age related cognitive decline and unspecified dementia. R17's Minimum Data Set (MDS) assessment, dated 4/8/23, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R17 had moderate cognitive impairment. On 6/20/23, Surveyor reviewed the facility's grievance log. The log contained a grievance submitted via email by Family Friend (FF)-G that indicated R17 told FF-G on 4/5/23 that the staff member who gave R17 a bath was rough, caused R17 pain, and made R17 cry. FF-G reported FF-G observed bruising on R17's left forearm. On 6/20/23, Surveyor reviewed the facility's investigation regarding R17's allegation of abuse. Surveyor noted the investigation did not contain thorough interviews of staff who cared for or observed R17 on the date of the alleged abuse. The investigation also did not contain interviews with residents who potentially witnessed or experienced similar treatment. Surveyor also noted the accused staff member was not removed from resident care during the investigation. The investigation indicated R17 denied the allegation of abuse and the facility believed the bruising occurred when R17 was combative during cares On 6/20/23 at 1:48 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility investigated the allegation right away. DON-B verified the accused staff member was not removed from resident care pending the results of the investigation. 2. On 6/20/23, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder, depressive disorder, and arthritis. R10's MDS assessment, dated 5/8/23, contained a BIMS score of 15 out of 15 which indicated R10 did not have cognitive impairment. From 6/19/23 through 6/21/23, Surveyor reviewed a facility-reported incident (FRI) regarding a potential allegation of misappropriation of R10's narcotic medication. The FRI indicated staff attempted to reorder narcotic medication for R10 on 2/28/23; however, the pharmacy stated the medication couldn't be reordered because the pharmacy sent a full card of the medication a few days earlier. The FRI did not contain resident or potential witness interviews regarding the allegation of misappropriation. On 6/20/23 at 2:56 PM, Surveyor interviewed Registered Nurse Supervisor (RNS)-E regarding allegations of abuse and misappropriation. RNS-E verified allegations of abuse and misappropriation should be investigated right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide care consistent with professional standards of practice to prevent pressure injuries from developing for 1 Resident (R) (R41) of 4 sampled residents. R41's plan of care contained an intervention to offload R41's heels while in bed. R41 was observed in bed on multiple occasions with R41's heels in direct contact with the mattress. Findings include: Surveyor requested the facility's pressure injury policy and was provided Pathway Health skin integrity/pressure ulcer care general information which listed general information quoted from the State Operations Manual (SOM) 483.25 for skin integrity. Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] with diagnoses to include dementia, thoracic compression fracture, contractures (left leg), peripheral vascular disease, pressure injury to buttocks (healed), and vascular injury to left great toe. R41's Minimum Data Set (MDS) assessment, dated 5/14/23, contained a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R41 had severe cognitive impairment. A Braden assessment, dated 6/12/23, indicated R41 was at moderate risk for skin breakdown with an additional risk factor can't raise leg in straight position. R41's impaired skin integrity plan of care contained interventions to continue offloading heels and pressure on toes. R41's Certified Nursing Assistant (CNA) care card instructed staff to offload R41's heels. On 6/19/23 at 10:55 AM, Surveyor observed R41 in bed on an air mattress. R41's right leg was crossed over the left leg and the lateral aspect of R41's left heel was in direct contact with the mattress. R41's right leg was straight and the back of the right heel was in direct contact with the mattress. R41 was asleep at the time of the observation. On 6/20/23 at 8:54 AM, Surveyor observed R41 asleep in the same position with the right leg crossed over the left leg and both heels in direct contact with the mattress. On 6/20/23 at 3:13 PM, Surveyor observed R41 with a pillow under the right side of R41's upper back. R41's body faced the left wall and R41's legs were in the same position as the previous observations. On 6/20/23 at 3:14 PM, Surveyor interviewed CNA-J who stated staff repositioned R41 side-to-side with pillows every two hours and placed a pillow between R41's legs because R41 liked to cross R41's legs. CNA-J stated R41 did not like to get out of bed and spent all of R41's time in bed, including meals. CNA-J was unsure if R41 had interventions to protect R41's heels and did not recall using a pillow to elevate R41's heels. Surveyor reviewed R41's medical record which contained a Braden assessment, dated 6/12/23, that indicated R41 was at moderate risk for skin breakdown with additional risk factors documented: can't raise leg in straight position. R41's care plan for impaired skin integrity included interventions of continued off loading of heels and pressure of toes. R41's CNA care card instructed staff to offload R41's heels. On 6/21/23 at 8:09 AM, Surveyor observed R41 in bed on R41's back with the right leg crossed over the left leg and both heels in direct contact with the mattress. At 8:12 AM, CNA-K raised the head of R41's bed and placed a pillow under R41's right side to position R41 for breakfast. On 6/21/23 at 9:19 AM, Surveyor and Licensed Practical Nurse (LPN)-L entered R41's room to observe R41's skin and noted R41's heels were in direct contact with the mattress. Surveyor noted both of R41's heels were red and blanchable when LPN-L felt for bogginess and asked about pain and tenderness. Surveyor also noted R41's left foot was against the foot board of the bed which created a reddened indented area to the lateral aspect of R41's foot. When LPN-L pushed on the area, Surveyor noted skin color changes and R41 denied discomfort. R41 was agreeable when LPN-L offered to offload R41's heels with a pillow. LPN-L positioned R41's right foot and left the room to retrieve a pillow for R41's left foot. On 6/21/23 at 9:48 AM, Surveyor interviewed Wound Care Registered Nurse (WCRN)-M who verified R41 spent most of R41's time in bed and R41's heels should be offloaded when R41 is in bed. On 6/21/23 at 11:00 AM, Surveyor interviewed Director of Nursing (DON)-B who verified R41's heels should be offloaded per R41's plan of care.

Based on observation, record review and staff interview, the facility did not ensure 1 (R) (R65) of 8 residents reviewed for pressure injuries received appropriate care and services to promote healing and/or prevent pressure injuries from developing. Observations of R65 sitting on sling in wheel chair throughout all 3 days of survey. Findings include: Facility's Skin Care Policy dated 6/21 indicates: To prevent the resident from developing pressure injuries unless clinically unavoidable and to provide care and services consistent with professional standards of practice to : Promote the prevention of pressure injury development Promote the healing of existing pressure injuries and prevent development of additional pressure injury. Prevention Practice: A. Reduce pressure/shearing/friction: 1. Use appropriate pressure reducing or relieving devices-mattress or wheel chair cushion. 6. Avoid wrinkles in clothing, linens, briefs R65 was admitted to facility on 2/13/18 with the diagnosis of impaired circulation, fragile skin, diabetes, chronic kidney disease and anemia. R65's most recent MDS (Minimum Data Set) dated 2/16/22 indicates that resident requires extensive assist with bed mobility, transfers, dressing, hygiene and bathing. R65 has a history of pressure injury on inner buttocks area that has currently healed, but a dressing is still in place for protection according to RN (Registered Nurse)-I. A Nursing note from 2/23/22 indicated, new area on bilateral buttocks, purple area, interventions in place and updated. A Nursing note from 3/8/22, indicated bilateral buttock reddened/purplish tender to touch. New order for Desitin per Nurse Practitioner. Surveyor had multiple observations throughout survey of R65 sitting directly on sling that was over cushion in wheelchair in the dining room. 3/7/22 at 11:45 AM 3/8/22 at 11:26 AM 3/9/22 at 12:33 PM On 3/9/22 at 1:25 PM Surveyor observed the buttocks area of R65. Surveyor observed reddened purple area from bilateral buttocks down to mid lateral thigh area. Purple area was blanchable to touch. Surveyor also noted a wound dressing on inner buttocks area. Purple area noted would be consistent with sitting down in a wheelchair. On 3/9/22 at 12:48 PM Surveyor interviewed RN-C. RN-C indicated that the facility did not have assessments of slings in chairs for residents. RN-C indicated that therapy may do an assessment for a lift but not for a sling in a chair. RN-C also indicated that a sling in a chair would not be care planned nor did they obtain a risk benefits statement for use of a sling in a chair which would reduce the effectiveness of the pressure relieving cushion.

Based on observation, Resident (R) interview, staff interviews and record review, the facility did not ensure oxygen tubing was changed for 1 (R68) of 1 residents reviewed for respiratory care. Facility staff did not change oxygen tubing and did not have documentation of hospice staff changing R68's oxygen tubing since oxygen was ordered 10/26/21. Findings include: Facility policy titled Nursing Oxygen, revision dated 1/2020, documented All tubing and nasal cannulas/face masks should be changed out every 5 days. From 3/7/22 through 3/9/22, Surveyor reviewed R68's medical record which documented R68 enrolled in hospice services on 11/17/21. R68's orders included a 10/26/21 oxygen order for shortness of breath and comfort. Surveyor noted R68's orders, Treatment Administration Record (TAR), and care plans did not address how often to change R68's oxygen tubing. On 3/7/22 at 12:38 PM, Surveyor observed R68 utilizing oxygen via nasal cannula. R68 revealed to Surveyor that R68 utilized oxygen for some time but was not able verbalize the timeframe when R68 began utilizing oxygen or how often tubing was changed out. Surveyor noted R68's oxygen tubing did not have an affixed dating indicator for when tubing was most recently changed. Surveyor sporadically observed R68 throughout survey from 3/7/22 through 3/9/22. R68 was using oxygen during all observations. On 3/9/22 at 9:30 AM, Surveyor interviewed Registered Nurse (RN)-C, who was unit manager for unit R68 resided on. RN-C explained that facility Supply Aide (SA)-F generally took care of oxygen tubing changes but because R68's tubing was supplied by hospice, RN-C was not certain if tubing change responsibility was handled by hospice or SA-F. At time of interview, RN-C reviewed R68's hospice care plan but was unable to determine responsibility or locate an oxygen tubing change order. At that time, RN-C called SA-F via telephone then conveyed to Surveyor that SA-F doesn't handle tubing for R68. On 3/9/22 at 11:59 AM, Nursing Home Administrator (NHA)-A confirmed R68's hospice documentation available at facility did not include information on oxygen tubing changes. NHA-A expressed an expectation that hospice follow the facility policy to change oxygen tubing every 5 days.

Based on staff interviews and record review, the facility did not ensure agreed upon hospice communication documentation was in a Resident (R) medical record for 1 (R68) of 1 sampled residents reviewed for hospice services. The facility did not ensure R68's hospice visit progress notes and oxygen tubing changes were included in R68's medical record. Findings include: Facility agreement with R68's hospice provider, signed 5/10/17, documented Part V: Medical Records. A. Facility shall prepare and maintain medical records for each Hospice patient receiving services pursuant to this Agreement . The medical records shall consist of at least progress notes and clinical notes describing all inpatient services and events. From 3/7/22 through 3/9/22, Surveyor reviewed R68's medical record which documented R68 enrolled in hospice services on 11/17/21. Surveyor noted R68's most recent hospice generated communication was an updated care plan dated 2/1/22. 2/1/22 updated care plan indicated a hospice nurse was to visit weekly, a hospice nursing aide was to visit weekly and a hospice social worker should visit monthly. Surveyor was not able to locate hospice visit progress notes by hospice nurses, aides, or social workers. Surveyor noted hospice orders did not address oxygen tubing changes. (Refer to F695 for respiratory care concern details related to R68.) On 3/8/22 at 1:34 PM, Surveyor interviewed Registered Nurse (RN)-D regarding R68's hospice service provider communications. RN-D explained R68's hospice provider requests staff to sign confirmation of presence in building on an electronic device. RN-D elaborated that RN-D did not have to sign the hospice device. Certified Nursing Assistance (CNAs) may also sign. RN-D indicated hospice will sometimes verbally debrief RN-D on services provided during hospice visit but if RN-D was unavailable, no verbal report occurred prior to hospice staff exiting the facility. RN-D denied ever receiving written progress note communications from R68's hospice provider. On 3/8/22 at 1:39 PM, Surveyor interviewed RN-C who was RN Manager for R68's unit. RN-C was not aware of who in facility was assigned as hospice coordinator/designee. At the time of interview, RN-C reviewed R68's hospice binder and verified no hospice visit communications were in the binder. RN-C then reviewed the remainder of R68's hard copy portion of medical record and confirmed R68's medical record did not contain hospice visit documentation. RN-C indicated RN-C communicated to R68's hospice provider in the past that hospice staff should let RN-C know when hospice staff are in the building but RN-C indicated R68's hospice staff did not consistently notify RN-C of presence in the facility. On 3/9/22 at 11:59 AM, Nursing Home Administrator (NHA)-A alerted Surveyor that NHA-A contacted R68's hospice provider to follow up on missing hospice visit progress notes. NHA-A was informed R68's hospice provider keeps progress notes in an online portal. Hospice provider indicated to NHA-A that facility had access to online portal. At 12:24, NHA-A disclosed to Surveyor that NHA-A followed-up with facility hospice designees (Social Services (SS)-E and RN-C) and learned facility staff did not have access to hospice online portal. NHA-A expressed an expectation that each hospice resident have up to date hospice information in their medical record.

Based on observations, staff interviews, and record review, the facility did not ensure food was stored, prepared, and served under sanitary conditions. The practices had the potential to affect all 75 residents. The facility stored expired and damaged products in the dry storage area. The facility did not clean equipment between uses. The facility did not follow disinfectant manufacturer contact time instructions. Findings include: On 3/7/22, during initial kitchen tour beginning at 10:17 AM, Dietary Manager (DM)-G indicted to Surveyor that the facility utilized the Wisconsin (WI) Food Code as its standard of practice. Expired and Damaged Products On 3/7/22, during initial kitchen tour beginning at 10:17 AM, Surveyor entered dry storage with DM-G and observed a cardboard box with wrinkled texture and dried lines from probable previous moisture exposure. The box was delivery dated 9/22/20 and contained 20 ounce (oz) containers of iodized salt. Surveyor removed a container from box and found salt inside container to be solid instead of granular. Salt container label was visibly wrinkled and water damage lines were visible on container. DM-G removed additional salt containers from damaged box and determined 12 containers of salt were damaged. Surveyor observed visible debris on top of 6 pound (lb) containers of dessert sprinkle style decorative toppings. DM-G verified debris was on top of dessert sprinkle containers and explained the overhead pipes in the room were recently cleaned. Dry storage products were largely covered but not all products were able to be covered during pipe cleaning process. Dessert decoration containers were further examined and determined to be expired. Five containers of rainbow sprinkles, one of orange sprinkles, one of white sprinkles, and three of lavender decorettes all were beyond best by dates. DM-G was not able to verbalize what system the facility had in place to ensure expired food was removed from dry storage and discarded. Surveyor observed and DM-G verified a clear bag containing 12 black bean burgers, delivery dated 1/28/22, had an accumulation of frost inside the bag with frost also clinging to the black bean burgers. DM-G was not able to indicated why the product had frost damage in less than 2 months time at the facility. DM-G discarded the black bean burgers at the time of observation. Soiled Equipment WI Food Code 2020 documents at 4-601.11 (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. On 3/7/22, during initial kitchen tour beginning at 10:17 AM, Surveyor observed and DM-G verified the facility meat slicer was covered by had dried meat residue on the underside of the cutting edge and white crumbs on the meat tray. DM-G was not able to identify what the while crumbles were but guess they may be salt. DM-G estimated the meat slicer was used approximately once per week. Surveyor touched convection oven handle to open oven and felt the handle was tacky. DM-G also touched handle and described area as tacky. DM-G identified the handles may have been tacky from grease accumulation. Surveyor observed a reach in refrigerator in the main kitchen had visible residue in finger print shapes on the exterior doors. The facility can open had dried food residue in red and brown colors died onto the cutting edge and the base. The microwave handle felt greasy and was visually soiled on the handle and around the handle on the door. On 3/7/22 beginning at 11:15 AM, Surveyor entered 1 [NAME] kitchenette with DM-G. Surveyor observed 1 [NAME] kitchenette oven was soiled externally and internally. Crumbs and dried yellow splatter were present on the handle and various shades of brown were baked onto the interior floor of the oven. DM-G explained the oven was generally used to hold hot foods and not on a cleaning schedule. Disinfectant Use Disinfectant spray directions indicated surface should be sprayed, debris wiped off then surface sprayed again and kept wet for one minute to sanitize. On 3/8/22 at 12:54 PM, Surveyor observed Dietary Aide (DA)-H clear 1 [NAME] dining tables. DA-H sprayed tables and wiped away debris. DA-H was not able to verbalize contact time of product to Surveyor. Surveyor reviewed instructions on label with DA-H which indicated one minute contact time requirement. On 3/9/22 at 9:11 AM, DM-G indicated DA-H reported issues with disinfectant spray use to DM-G on 3/8/22 after interaction with Surveyor. DM-G verified one minute contact time was required and explained in-service education was started with staff following DA-H reporting issue. DM-G explained the facility disinfecting product was changed with supply vendor change in October 2021.