**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of abuse was not reported to local law enforcement for 1 resident (R) (R2) of 6 sampled residents. R2 reported to staff that Certified Nursing Assistant (CNA)-C got in R2's face and would not wash R2 when R2 requested it. R2 reported to staff that R2 felt that was abuse. The facility did not report the allegation of abuse to local law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 7/15/22, indicate: It is the policy of the 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, neglect, exploitation, and misappropriation of resident property .VII Reporting/Response: A. The facility will have written procedures that include: 1) Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies such as law enforcement when applicable, within specific time frames. a) Immediately, but not later than two hours after the allegation is made, if the event that caused the allegation involves abuse or results in serious bodily injury, or b) Not later than 24 hours if the event that caused the allegation does not involve abuse and does not result in serious bodily injury. 2) Assuring that reporters are free from retaliation or reprisal. From 6/24/25 to 6/25/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including flaccid neuropathic bladder, congestive heart failure (CHF), and neuromuscular dysfunction of bladder. R2's Minimum Data Set (MDS) assessment, dated 5/23/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R2 had intact cognition. R2 was responsible for R2's healthcare decisions. From 6/24/25 to 6/25/25, Surveyor reviewed a facility-reported incident that indicated on 4/27/25 at 10:16 PM, Nursing Home Administrator (NHA)-A emailed an initial report to the State Agency (SA). The email stated on 4/27/25 at 8:10 PM, R2 reported to staff that CNA-C entered R2's room to put R2 to bed and did not wash R2 even though R2 requested it. R2 stated CNA-C got in R2's face and told R2 that R2 did not need to be washed up and that R2 was clean and dry already. R2 told another staff that R2 felt that was abuse. The report indicated CNA-C was suspended and removed from the facility pending the outcome of the investigation. On 4/27/25 at 10:00 PM, NHA-A interviewed Licensed Practical Nurse (LPN)-F who stated CNA-E informed LPN-F that R2 was put to bed in a Pull-Up and was not washed up. LPN-F asked CNA-E to wash and put a brief on R2. LPN-F spoke with R2 who was upset and indicated CNA-C told R2 that R2 was clean and dry and CNA-C did not have to wash R2. R2 indicated to LPN-F that R2 deserved to be yelled at because earlier in the evening R2 told CNA-C to get another staff to help R2 use the bathroom because CNA-C, the lift, and R2 would not all fit in the bathroom. LPN-F indicated LPN-F consoled R2. On 4/28/25 at 11:00 AM, Director of Nursing (DON)-B interviewed CNA-C who indicated R2 was not ready when CNA-C entered the room to assist R2 to bed. CNA-C told R2 to use R2's call light when R2 was ready. When R2 rang, CNA-C went back to the room to assist R2 who told CNA-C that CNA-C was too big to help R2 in the bathroom. CNA-C stated R2 was yelling and swearing when CNA-C went to get CNA-E to assist. CNA-C stated R2 then told CNA-E that CNA-C would not wash R2. CNA-C stated CNA-C planned on washing R2 in bed but needed to get a brief and was then unable to complete the cares because R2 was yelling. On 4/28/25 at 3:00 PM, NHA-A interviewed CNA-E who stated when CNA-E noticed R2's call light was on, CNA-C stated that R2 had already been toileted and assisted to bed and CNA-C was not going back into the room. CNA-E answered the call light and noted R2 was crying in bed. R2 told CNA-E that the big fat black aide who came to toilet R2 got in R2's face and said R2 was clean. R2 indicated CNA-C stated CNA-C was not going to wash R2 or change R2's underwear until R2 wet them and then someone else would change R2. CNA-E informed the charge nurse, LPN-F. On 6/25/25 at 11:24 AM, Surveyor interviewed NHA-A who verified local law enforcement was not notified of the allegation of abuse. NHA-A indicated NHA-A did not feel the incident was abuse after NHA-A interviewed R2 the following day and stated R2 did not feel it was abuse and R2 was rude to CNA-C. NHA-A understood the time frame for reporting and indicated NHA-A had two hours to report the allegation. NHA-A did not state if the incident should have been reported to local law enforcement. NHA-A stated when NHA-A spoke to R2, R2 did not feel the incident was abuse, however, NHA-A was unsure if R2 felt the incident was abuse when it was first reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure preventative action was taken following an allegation of misappropriation for 1 resident (R1) of 6 sampled residents. R1's family reported that two $50 bills were missing from R1's wallet. The facility was not able to determine what happened to R1's money and did not provide staff education on misappropriation to prevent recurrence. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 7/15/22, indicates: It is the policy of the 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, neglect, exploitation, and misappropriation of resident property .III. Prevention: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation .VII. Reporting: A. The facility will have written procedures that include: .4) Taking all necessary actions as a result of the investigation, which may include, but are not limited to the following: A. Analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property, or exploitation occurred, and what changes may be needed to prevent further occurrence. B. Defining whether care provisions should be changed and or improved to protect residents receiving services. C. Training of staff on changes made and demonstration of staff competency after training is implemented. D. Identification of staff responsible for implementation of corrective actions. E. The expected date for implementation. F. Identification of staff responsible for monitoring the implementation of the plan . From 6/24/25 to 6/25/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including infection and inflammatory reaction due to indwelling catheter, vascular dementia, metabolic encephalopathy, and Parkinsonism. R1's Minimum Data Set (MDS) assessment, dated 5/26/25, had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R1 had severe cognitive impairment. R1 had an activated Power of Attorney for Healthcare (POAHC). From 6/24/25 to 6/25/25, Surveyor reviewed a facility-reported incident (FRI), dated 6/2/25, that indicated R1's Family Member ((FM)-G) reported to Nursing Home Administrator (NHA)-A on 5/27/25 that R1 had four $50 bills in R1's wallet and two of them were missing. FM-G stated FM-G counted the money every morning when FM-G arrived at the facility and indicated the money went missing in the previous two days. FM-G counted the money on 5/23/25 and 5/24/25 and felt the money went missing on 5/25/25 or 5/26/25 because the money was missing when FM-G counted it on 5/27/25 between 6:30 AM and 7:00 AM. The FRI indicated on 5/27/25 at 3:30 PM, Director of Nursing (DON)-B interviewed another family member ((FM)-H) who stated R1 had $100 three weeks prior and had only $13 on 5/19/25. FM-H stated FM-H gave R1 five $50 bills on 5/19/25. FM-H stated FM-H put one in a graduation card for R1 and R1 should have had four $50 bills plus $13 from previous funds in R1's wallet. When DON-B asked if FM-H knew what happened to the $100 from three weeks ago, FM-H stated FM-H thought R1 hid money somewhere but denied R1 had hidden money prior. FM-H stated family would search R1's room. On 5/27/25 at 3:00 PM, DON-B interviewed R1 who indicated family informed R1 of the missing money. R1 confirmed R1 usually kept $100 in R1's wallet and was unable to state how much money was missing. When asked if R1 had seen anyone in R1's wallet, R1 stated sometimes R1 saw a medium-height bushy haired person exit R1's room in the middle of the night. R1 indicated R1 does not trust anyone. On 5/29/25 at 3:15 PM, FM-H stated family searched R1's room but did not find the missing money. FM-H stated FM-H would look into getting fake money to replace the real money in R1's wallet. On 6/25/25 at 11:33 AM, Surveyor interviewed NHA-A who stated staff searched R1's room but did not find the money. NHA-A stated the facility spoke with R1's family and offered to keep R1's money in the office safe, however, R1's family refused. NHA-A stated R1's family disagreed about what happened to the money. FM-H felt R1 hid the money but FM-G did not think that was something R1 would do. NHA-A stated the family was upset and believed they knew who took the money but would not tell the facility. NHA-A was unsure if staff education was completed and stated NHA-A would have to ask DON-B. On 6/25/25 at 11:47 PM, Surveyor interviewed DON-B who stated staff education related to misappropriation was not completed following the incident.

Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy when 1 of 2 medication carts was left unlocked and unattended during medication pass. This practice had the potential to affect more than 4 of the 50 residents residing in the facility. On 6/25/25, staff left a medication cart unlocked and unattended on multiple occasions during medication administration. Findings include: The facility's Storage of Medication policy, dated 1/2023, indicates: .In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as Medication Aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access . On 6/25/25 at 8:25 AM, Surveyor observed Licensed Practical Nurse (LPN)-I leave a medication cart unlocked and unattended on the 200 wing. The medication cart drawers faced the hallway and exposed the drawers during medication pass. On 6/25/25 at 11:25 AM, Surveyor observed LPN-I leave a medication cart unlocked and unattended outside the dining room. Surveyor observed multiple residents walk or wheel past the unlocked medication cart. The medication cart drawers faced the hallway and exposed the drawers during medication pass. On 6/25/25 at 9:03 AM and 11:25 AM, Surveyor interviewed LPN-I who verified the medication cart should not have been unlocked when unattended. LPN-I stated LPN-I usually locked the cart but forgot. On 6/25/25 at 11:29 AM, Surveyor interviewed Director of Nursing (DON)-B who verified medications carts should be locked when unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure injuries of unknown origin were reported to Nursing Home Administrator (NHA)-A or the State Agency (SA) for 1 resident (R) (R15) of 6 sampled residents. R15 was transferred to the hospital with a head injury following a fall from A Hoyer lift on 8/6/24. R15 was also hospitalized from [DATE] to 9/10/24 due to aspiration pneumonia. The facility did not report an injury of unknown origin to NHA-A or the SA after hospital staff notified the facility that R15 had a vaginal mucosa tear with dried blood. In addition, the facility did not report bruises on R15's legs and compression fractures to R15's mid and lower back that were documented on R15's hospital discharge summary to the SA. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: .1. The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect, and exploitation of residents .2. The facility will designate a leadership position who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law .B. Possible indicators of abuse include, but are not limited to: .2. Physical marks such as bruises or patterned appearances .on a resident's body. 3. Physical injury of a resident, of unknown source .VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes) immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b) Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .B. The Administrator will follow up with government agencies to report the results of the investigation when final within 5 working days of the incident as required by state agencies. From 11/11/24 to 11/13/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including stroke, hemiplegia (paralysis) and hemiparesis (weakness) affecting the left side, dysphagia (difficult swallowing) following stroke, aphasia (inability to speak) following stroke, gastrostomy (creation of an artificial opening in the stomach for feeding tube placement) status, and osteoarthritis. R15's Minimum Data Set (MDS) assessment, dated 8/23/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R15 had moderately impaired cognition. R15's medical record indicated R15 was sent to the hospital with a head injury after a fall from a Hoyer lift on 8/6/24 and was hospitalized from [DATE] to 9/10/24 due to aspiration pneumonia. A hospital admission history and physical note, dated 9/5/24, indicated R15 was admitted to the hospital on [DATE] at 10:52 PM for hypoxia (low oxygen). R15 had mild episodes of epistaxis (nosebleed) and a vaginal bleed. A bedside evaluation showed mild vaginal mucosa tears with dried blood. The note indicated R15 had multiple patches of ecchymosis (bruises) on the lower extremities and a computed tomography (CT) scan revealed age-indeterminate multilevel fractures in the thoracic (middle) and lumbar (lower) spine. On 11/13/24 at 8:07 AM, Surveyor interviewed Director of Nursing (DON)-B and asked if R15's injuries of unknown origin were reported to the SA. DON-B indicated the compression fractures were not reported because the discharge summary did not contain a discharge order specific to the compression fractures. DON-B reviewed R15's history and physical note and indicated the facility should have started an investigation to determine why R15 had compression fractures. DON-B indicated DON-B was not sure how to answer if DON-B suspected abuse regarding the fractures. DON-B indicated NHA-A and Administrator in Training (AIT)-C had no suspicion of abuse. DON-B indicated the facility should have gotten more details on how the fractures occurred. On 11/13/24 at 8:21 AM, DON-B indicated hospital staff notified Social Worker (SW)-D that R15 had a vaginal mucosa tear and dried blood. DON-B indicated staff should have read R15's history and physical/discharge summary thoroughly and the injuries should have been reported to the Interdisciplinary Team (IDT). DON-B indicated NHA-A should have been notified to determine if the injuries were reportable or not. On 11/13/24 at 10:42 AM, Surveyor interviewed NHA-A, DON-B, AIT-C and the facility's regional consultant. NHA-A stated R15's 8/6/24 fall was investigated and indicated R15 was sent to the hospital with no fractures. NHA-A also indicated the facility was not aware of R15's vaginal tear. When Surveyor asked NHA-A if the injuries of unknown origin should have been reported to the SA, NHA-A did not answer. When Surveyor asked if staff interviewed R15 regarding the injuries, DON-B indicated R15 could let staff know if there were any issues. On 11/13/24 at 10:53 AM, Surveyor interviewed SW-D who verified SW-D received a call from a hospital nurse who stated when R15 was examined, R15 had a vaginal tear or scratch. When the nurse asked if the facility was aware of the injury, SW-D stated SW-D was not aware. The nurse indicated the injury was in a suspicious area and the hospital was looking into it. SW-D indicated the nurse spoke to R15's Power of Attorney (POA) regarding abuse issues or questions that may have occurred during the fall. After becoming aware of R15's vaginal tear, SW-D informed AIT-C and DON-B and stated hospital staff did not have any follow-up with the facility after the concern was reported. SW-D confirmed SW-D did not document the phone conversation with the nurse but should have documented the call and reported the injury to nursing staff. On 11/13/24 at 11:00 AM, Surveyor interviewed DON-B, AIT-C, and the facility's regional consultant. DON-B indicated DON-B and AIT-C talked about R15's injury. DON-B asked if the facility was responsible if something happened at the hospital and indicated DON-B was still learning and was not familiar with nursing home processes and regulations. AIT-C indicated the facility did not have a record of any skin injuries for R15 and completed a skin assessment on 9/4/24. AIT-C said the injury could have happened at the hospital and indicated sometimes vaginal tears occur when pubic hairs are pulled. The facility's regional consultant indicated R15 had an enema in the hospital which may have caused the tear. The regional consultant indicated when hospital staff called SW-D, the facility thought the hospital was already investigating. When Surveyor asked if any of the possible causes for the vaginal mucosa tear that were mentioned were investigated, Surveyor did not receive an answer. NHA-A indicated if the hospital suspected abuse, they would have notified the SA and the facility would have been investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure injuries of unknown origin were thoroughly investigated for 1 resident (R) (R15) of 6 sampled residents. R15 was transferred to the hospital on 8/6/24 with a head injury following a fall from a Hoyer lift. R15 was also hospitalized from [DATE] to 9/10/24 due to aspiration pneumonia. The facility did not investigate an injury of unknown origin after hospital staff notified the facility that R15 had a vaginal mucosa tear with dried blood. In addition, the facility did not investigate bruises on R15's legs and compression fractures to R15's mid and lower back that were documented on R15's hospital discharge summary. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 7/15/22, indicates: 1. The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect, and exploitation of residents .b) Establish policies and procedures to investigate any such allegations .B. Possible indicators of abuse include, but are not limited to: .2. Physical marks such as bruises or patterned appearances .on a resident's body, 3. Physical injury of a resident, of unknown source .An immediate investigation is warranted when allegation or suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1) Identifying staff responsible for the investigation .3) Investigating different types of alleged violations; 4) Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5) Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6) Providing complete and thorough documentation of the investigation. From 11/11/24 to 11/13/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including stroke, hemiplegia (paralysis) and hemiparesis (weakness) affecting the left side, dysphagia (difficult swallowing) following stroke, aphasia (inability to speak) following stroke, gastrostomy (creation of an artificial opening in the stomach for feeding tube placement) status, and osteoarthritis. R15's Minimum Data Set (MDS) assessment, dated 8/23/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R15 had moderately impaired cognition. R15's medical record indicated R15 was sent to the hospital on 8/6/24 with a head injury following a fall from a Hoyer lift. R15 was also hospitalized from [DATE] to 9/10/24 due to aspiration pneumonia. A hospital admission history and physical note, dated 9/5/24, indicated R15 was admitted to the hospital on [DATE] at 10:52 PM for hypoxia (low oxygen). R15 was noted to have mild episodes of epistaxis (nosebleed) and a vaginal bleed. A bedside evaluation showed mild vaginal mucosa tears with dried blood. R15's skin had multiple patches of ecchymosis (bruises) on the lower extremities. A computed tomography (CT) scan indicated R15 had age-indeterminate multilevel fractures in the thoracic (middle) and lumbar (lower) spine. On 11/13/24 at 8:07 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility did not investigate the compression fractures after R15 returned from the hospital on 9/10/24 because the discharge summary did not have a discharge order specific to compression fractures. DON-B reviewed R15's hospital note and indicated the facility should have started an investigation to determine why R15 had multilevel compression fractures. On 11/13/24 at 8:21 AM, Surveyor interviewed DON-B who indicated the hospital notified Social Worker (SW)-D of R15's vaginal mucosa tear and dried blood. When Surveyor asked if the vaginal mucosa tear and dried blood warranted an investigation, DON-B indicated there should have been an investigation. DON-B indicated staff should have read R15's hospital discharge summary thoroughly and brought the concerns to the Interdisciplinary Team (IDT). On 11/13/24 at 10:42 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A, DON-B, Administrator in Training (AIT)-C, and the facility's regional consultant. NHA-A stated R15 had a fell from a Hoyer lift on 8/6/24 and the fall was investigated. NHA-A indicated R1 was sent to the hospital with no fractures and facility was not aware of R15's vaginal tear. When Surveyor asked NHA-A if the new injuries discovered after R15's 8/6/24 fall should be investigated, NHA-A did not answer. When Surveyor asked if staff interviewed R15 about the injuries, DON-B indicated R15 could let staff know if there were any issues. On 11/13/24 at 10:53 AM, Surveyor interviewed SW-D who verified SW-D received a call from a hospital nurse who stated R15 when R15 was examined, R15 had a vaginal tear or scratch. The nurse asked if the facility was aware of the injury. The nurse informed SW-D that the injury was in a suspicious area and the hospital was looking into it. SW-D indicated the nurse spoke with R15's POA regarding any abuse or questions that may have occurred during R15's fall. SW-D informed AIT-C and DON-B about R15's vaginal tear and stated the hospital did not provide any further follow-up with the facility. SW-D confirmed SW-D did not document the conversation with the hospital nurse but indicated SW-D should have documented the call and reported the injury to nursing staff. On 11/13/24 at 11:00 AM, Surveyor interviewed DON-B who indicated DON-B and AIT-C talked about the injury. DON-B asked if the facility was responsible if something happened at the hospital and indicated DON-B was still learning nursing home processes and regulations. AIT-C indicated the facility had no record of any skin injuries and completed a skin assessment on 9/4/24. AIT-C stated the injury could have happened at the hospital and indicated when pubic hairs are pulled they sometimes cause vaginal tears. The regional consultant indicated R15 had an enema in the hospital which may have caused the tear and indicated when the hospital called SW-D, the facility thought the hospital was already investigating. When Surveyor asked if any of the possible causes of a vaginal mucosa tear that were mentioned were investigated, Surveyor did not receive an answer. NHA-A indicated if the hospital suspected abuse, they would have notified the State Agency and the facility would have been investigated.

**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) (R15) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the Ombudsman of one of R15's transfers. R15 was transferred to the hospital on 8/6/24 and 9/4/24. Neither R15 or R15's Power of Attorney (POA) were provided with a written transfer notice for either transfer. In addition, the Ombudsman was not notified of R15's 8/6/24 transfer. Findings include: The facility's Transfers and Discharges document, revised 7/12/22, indicates: .Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility .Transfer and discharge include movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not .7. Emergency Transfers/Discharges-initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident .j) Provide transfer notice as soon as practicable to resident and representative, k) Social Services Director, or designee shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via a monthly list. From 11/11/24 to 11/13/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including stroke, hemiplegia (paralysis) and hemiparesis (weakness) affecting the left side, dysphagia (difficult swallowing) following stroke, aphasia (inability to speak) following stroke, gastrostomy (creation of an artificial opening in the stomach for feeding tube placement) status, and osteoarthritis. R15's Minimum Data Set (MDS) assessment, dated 8/23/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R15 had moderately impaired cognition. R15 had an activated Power of Attorney (POA). R15's medical record indicated R15 was sent to the Emergency Department (ED) with a head injury after a fall from a Hoyer lift on 8/6/24 and was hospitalized on [DATE] due to aspiration pneumonia. R15's medical record did not contain a written transfer notice that was provided to R15, R15's POA, or the Ombudsman. On 11/12/24 at 1:01 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who indicated LPN-F was not familiar with the facility's transfer process. On 11/12/24 at 2:06 PM, Surveyor received R15's written transfer notices from Director of Nursing (DON)-B and noted DON-B signed the signature line designated for R15/R15's POA. The transfer notices indicated R15/R15's POA were notified via phone for both transfers. DON-B indicated the forms were not signed by R15's POA. DON-B indicated the 9/4/24 transfer notice was mailed, but R15's POA did not fill out the form or return the form to the facility. DON-B confirmed there was no documentation that the transfer notices were mailed to R15's POA. In the bottom corner of the transfer notice, dated 9/4/24, was a hand-written note that indicated mailed, 9/4/24 to POA. A sticky note that stated Not signed but mailed out, never returned was also attached to the form. Surveyor noted the date of the transfer was written as 8/7/24, however, R15's medical record indicated R15 was transferred to the ED on 8/6/24 and returned to the facility on 8/6/24. On 11/13/24 at 4:58 PM, Surveyor interviewed Business office Manager (BOM)-E who indicated residents who are sent to the ED but not admitted to the hospital do not need to be provided with a written transfer notice. On 11/13/24 at 5:02 PM, Surveyor interviewed Social Worker (SW)-D who confirmed the Ombudsman was not notified of R15's transfer on 8/6/24. SW-D indicated SW-D did not know SW-D needed to inform the Ombudsman when residents were transferred to the ED and returned to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R15) of 2 residents reviewed for hospitalization received written information of the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R15 was transferred to the hospital on 8/6/24 and 9/4/24. Neither R15 or R15's Power of Attorney (POA) were provided with a written notice of the bed hold policy. In addition, the bed hold policy form was not filled out by the facility. Findings include: The facility's Transfer and Discharge policy, revised 7/15/22, indicates: .7. Emergency Transfers/Discharges initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident .i) Provide a notice of the bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours after the transfer. From 11/11/24 to 11/13/24, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including stroke, hemiplegia (paralysis) and hemiparesis (weakness) affecting the left side, dysphagia (difficult swallowing) following stroke, aphasia (inability to speak) following stroke, gastrostomy (creation of an artificial opening in the stomach for feeding tube placement) status, and osteoarthritis. R15's Minimum Data Set (MDS) assessment, dated 8/23/24, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R15 had moderately impaired cognition. R15's medical record indicated R15 was sent to the Emergency Department (ED) with a head injury after a fall from a Hoyer lift on 8/6/24 and was hospitalized on [DATE] due to aspiration pneumonia. R15's medical record did not indicated a written bed hold notice was provided to R15 or R15's POA. On 11/12/24 at 1:01 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who indicated LPN-F was not familiar with the facility's bed hold policy or bed hold notice form. On 11/12/24 at 2:06 PM, Surveyor received R15's written bed hold notices from Director of Nursing (DON)-B who indicated the forms were not signed by R15's POA. DON-B indicated the 9/4/24 form was mailed, but R15's POA did not fill out or return the form to the facility. DON-B confirmed there was no documentation that the bed hold notices were mailed to R15's POA. Surveyor noted the bed hold form was dated 8/7/24, however, R15's medical record indicated R15 was transferred to the ED on 8/6/24 and returned to the facility on 8/6/24. Surveyor also noted the bed hold forms did not contain the effective dates or daily rates. On 11/13/24 at 4:58 PM, Surveyor interviewed Business Office Manager (BOM)-E who stated the bed hold policy is filled out and BOM-E later sends the forms which are not provided at the time of transfer. BOM-E indicated residents who were sent to the ED but not admitted to the hospital did not need a bed hold notice.

Based on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 1 resident (R) (R31) of 17 sampled residents. The facility did not honor R31's meal preferences during the lunch meal on 11/12/24. Findings include: The facility's Meal Distribution document, revised February 2023, indicates: 1. All meals will be assembled in accordance with the individualized diet order, plan of care and preferences .4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients . The facility's Dining and Food Preferences document, revised October 2022, indicates: .7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies, intolerances, and preferences. 8. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. 9. The alternate meal and/or beverage will be provided in a timely manner. On 11/12/24 at 11:27 AM, Surveyor observed lunch service. Surveyor observed Dietary Manager (DM)-G serve meatloaf, potatoes, and green beans from the steam table while Registered Dietician (RD)-H made four hamburgers on the stove top. DM-G asked RD-H to make two pieces of French toast for two residents. DM-G then asked RD-H to make a third piece of French toast for R31. During the meal service, Surveyor observed [NAME] (CK)-I ask RD-H four separate times to make a piece of French toast for R31. The French toast was not made. At 12:16 PM, Surveyor observed RD-H ask DM-G who the leftover hamburger was for. DM-G indicated it must be an extra. RD-H indicated RD-H would offer the hamburger to R31 instead of the French toast. On 11/12/24 at 12:19 PM, Surveyor interviewed RD-H who indicated RD-H offered R31 a hamburger, but R31 didn't want it. RD-H indicated R31 wasn't feeling well, left the dining area without eating, and returned to R31's room. On 11/12/24 at 12:21 PM, Surveyor interviewed CK-I who indicated CK-I was upset that R31 did not get the French toast R31 asked for. CK-I indicated RD-H did not know what RD-H was doing and usually didn't cook. On 11/12/24 at 12:29 PM, Surveyor interviewed DM-G who indicated RD-H didn't cook at the facility and did not know R31 preferred French toast for every meal. DM-G indicated DM-G and CK-I usually ensure R31 gets French toast at every meal. On 11/12/24 at 12:48 PM, Surveyor and Administrator in Training (AIT)-C interviewed R31 who was awake in bed. R31 indicated R31 felt okay. When Surveyor asked if R31 received lunch, R31 indicated R31 did not receive lunch that day. R31 stated R31 asked for and waited for French toast, but staff did not give R31 any food. R31 stated R31 talked to kitchen staff in the past so R31 could have French toast at every meal because that is what R31 could eat without feeling ill. R31 stated R31 did not know why R31 didn't receive a meal that day. R31 indicated R31 left the dining room without eating because lunch was over and no one had brought R31's meal. When Surveyor asked if R31 was hungry, R31 indicated R31 was hungry and would eat French toast. At 12:54 PM, AIT-C stated AIT-C would go to the kitchen and have staff make R31 French toast. On 11/12/24 at 2:52 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and AIT-C. NHA-A stated NHA-A expects resident's preferences to be honored and indicated staff usually give residents what they want. NHA-A stated residents are encouraged to share their likes and preferences and it is common at every meal to accommodate them. NHA-A also indicated NHA-A expects that residents who want to eat are fed. AIT-C indicated R31 eventually received French toast and ate it all. On 11/13/24 at 11:02 AM, Surveyor interviewed DM-G who indicated DM-G was aware that R31 ate French toast for every meal and had done so for a month or two. DM-G indicated DM-G should have fixed R31's meal ticket to reflect R31's preferences rather than changing it at each meal. DM-G indicated DM-G and CK-I usually anticipated R31's request and made French toast for R31 at each meal along with two other residents who typically ate French toast at each meal. DM-G confirmed it was not okay that R31 left the dining room receiving lunch. On 11/13/24 at 11:06 AM, Surveyor interviewed RD-H who stated there was no more egg mixture and RD-H did not make French toast for R31 because RD-H did not know how to make the egg batter recipe. RD-H indicated RD-H discussed preferences, nutrition, and health risks/benefits with R31 earlier that day. RD-H indicated R31 stated R31 still wanted to have French toast for every meal. RD-H indicated RD-H discussed adding protein to each meal as well as French toast and R31 was agreeable. RD-H indicated RD-H updated R31's meal preferences, meal ticket, and care plan accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not ensure meals were prepared by a method that conserved nutritive value for 2 residents (R) (R10 and R38) of 2 residents who received pureed diets. Kitchen staff did not follow a recipe when preparing pureed food items to ensure and conserve the nutritive value of the food. Kitchen staff did not provide R38 all of the items listed on R38's meal ticket. Findings include: The facility's contracted food service's document, dated February 2018, indicates: The federal requirements for the provision of therapeutic diets stipulates that food must be in a form to meet individual needs and that a mechanically-altered diet is part of the physician prescribed diet order .As outlined in the position description for the Cook, the ability to properly prepare texture-modified foods is a part of the required skillset for the position. The facility's contracted food service's Menus Policy Statement, dated October 2022, indicates: Menus will be planned in advance to meet nutritional needs of the residents/patients in accordance with established national guidelines 3. Menus will include standardized recipes. According to the publication All About Recipes, Part II from the College of Agriculture, Biotechnology and Natural Resources [NAME], A., and [NAME], S. 2021, It is important to follow a recipe to ensure accurate nutrition content, which is important for schools, hospitals, and nursing homes. Modifying a recipe by adding water lowers the nutritional quality of the food. The menu for the facility indicated the lunch meal on 11/12/24 included meatloaf, parmesan green beans, mashed potatoes, a cranberry muffin, and German chocolate cake. On 11/12/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dysphagia (difficulty swallowing) oropharyngeal phase. R10's prescribed diet was a consistent carbohydrate diet, dysphasia level 1 puree, with nectar consistency liquids. On 11/12/24, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] and had diagnoses including dysphagia oropharyngeal phase, pneumonitis due to inhalation of food and vomit, and unspecified severe protein calorie malnutrition. R38's prescribed diet was a regular diet, pureed texture, with nectar consistency liquids. On 11/12/24 at 11:27 AM, Surveyor observed lunch service. At 12:04 PM, Surveyor observed Dietary Manager (DM)-G take several broken pieces of meatloaf from the pan of meatloaf being served. DM-G placed the meatloaf pieces in a food processor, filled a container with water from the faucet, and poured an unmeasured amount of water in the food processor on top of the meatloaf. As DM-G pureed the meatloaf, DM-G stated to Surveyor DM-G knew DM-G should use gravy or broth and add it in one tablespoon at a time. When the meatloaf was pureed, DM-G scooped the meatloaf onto two plates. On 11/12/24 at 12:09 PM, Surveyor observed DM-G take two four-ounce scoops of green beans from the steam table and place them in a food processor. DM-G filled a container with water from the faucet and poured an unmeasured amount of water in the food processor on top of the green beans. When the beans were pureed, DM-G poured the green beans onto the plates with the pureed meatloaf. The two pureed plates of food were microwaved and a serving of mashed potatoes was added to each. The plates were then served to R10 and R38. R38's individual meal ticket for the 11/12/24 lunch meal listed 1 pureed cranberry muffin which was not provided to R38. On 11/12/24 at 2:52 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects staff to follow kitchen policies and procedures for meal preparation. On 11/13/24 at 11:02 AM, Surveyor interviewed DM-G who verified DM-G should not have used water to puree the meatloaf and green beans for the 11/12/24 lunch meal. DM-G confirmed DM-G should have used broth or gravy instead. DM-G indicated pureed food recipes were available and should be followed. DM-G also confirmed R38 should have received a pureed cranberry muffin on 11/12/24 but did not. DM-G stated the muffin was already pureed and on the dessert tray but DM-G was nervous and forgot to send the muffin with R38's meal. On 11/13/24 at 11:06 AM, Surveyor interviewed Registered Dietitian (RD)-H who indicated DM-G should have used broth or gravy to puree the meatloaf and green beans. RD-H also indicated DM-G should have used the recipes available when pureeing food to maintain the nutritional value.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 2 residents (R) (R29 and R48) of 5 sampled residents. Staff did not offer R29 or R48 the PCV20 (Prevnar 20®) vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1 dose of PPSV23, the CDC recommends you give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine. For adults 65 years or older who have received PCV13, give 1 dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of vaccine used, their vaccines are then complete. The CDC recommendation for adults 65 years or older who have no pneumococcal vaccinations is to give 1 dose of PCV15, PCV20, or PCV21. If PCV20 or PCV21 is used, their pneumococcal vaccinations are complete. If PCV15 is used, follow with one dose of PPSV23 to complete their pneumococcal vaccinations. The recommended interval between PCV15 and PPSV23 is at least 1 year. The minimum interval is 8 weeks and can be considered in adults with immunocompromising conditions, cochlear implants, or cerebrospinal fluid leaks. The facility's Infection Prevention and Control Program policy, with a review date of 7/23/24, indicates: .7. Influenza and Pneumococcal Immunization: .b. Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere . The facility's Pneumococcal Vaccine (Series) policy, with a review date of 9/18/24, indicates: .The type of pneumococcal vaccine (PCV15, PCV20, PCV21 or PPSV23) offered will depend upon the recipient's age, having certain risk conditions, and previously received pneumococcal vaccines, in accordance with current CDC guidelines and recommendations . On 11/12/24 at approximately 10:00 AM, Surveyor reviewed vaccines for 5 residents and noted R29 and R48's pneumococcal vaccines were not up to date. Surveyor noted R29 and R48's medical records did not contain declination forms for pneumococcal vaccines in 2024 or progress notes that indicated the risks and benefits of the vaccines were discussed. According to the CDC, R29 should be given one dose of PCV15, PCV20, or PCV21. If PCV20 or PCV21 were administered, R29's pneumococcal vaccination was complete. According to the CDC, R48 should be given one dose of PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23 which (according to R48's Wisconsin Immunization Record) was administered on 11/7/2000. On 11/13/24 at 10:33 AM, Surveyor interviewed Infection Preventionist (IP)-F who provided R29's pneumococcal, influenza, and COVID-19 declination forms from 8/22/23 (R29 was admitted to facility on 8/10/23). IP-F did not have a pneumococcal declination form for R48 (R48 was admitted to the facility on [DATE]). IP-F indicated the facility's Social Worker gets vaccine declination forms signed on admission. IP-F indicated IP-F did not have a system in place for pneumococcal vaccines and focused more on COVID-19 and influenza vaccines. IP-F indicated if IP-F is aware that a resident needs a pneumococcal vaccine, IP-F contacts the pharmacist to verify which pneumococcal vaccine the resident should receive and then asks the resident if they want the vaccine.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 50 of 53 residents residing in the facility. Three residents received nutrition via tube feeding. Staff did not store food in a manner to ensure food safety and did not date food appropriately. Staff did not follow safe microwave safe heating procedures. Staff did not adhere to temperature requirements for testing sanitizing solution. Findings include: On 11/11/24 at 9:20 AM, Dietary Manager (DM)-G indicated the facility followed the Food and Drug Administration (FDA) Food Code as their standard of practice. Food Labeling/Storage: The 2022 FDA Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food (TCS), Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the Food shall be consumed on the premises, sold, or discarded when held at a temperature of 5º C (Celsius) (41º F) (Fahrenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The 2022 FDA Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition: (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or package that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3-501.17(A). The facility's contracted food service's Labeling and Dating document, dated 2017, indicates: Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a first in, first out (FIFO) manner .All foods should be dated upon receipt before being stored. Food labels must include: The food item name; The date of preparation/receipt/removal from freezer; The use-by date as outlined in the attached guidelines .Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and the use by date .Leftovers must be labeled and dated with the date they are prepared and the use-by date .The manufacturer's date, when available, is the use-by for unopened items .Day of preparation or opening is considered Day 1 when establishing the use-by date .Guidelines apply, regardless of storage location (e.g., kitchen, pantries, etc.) .All Time/Temperature Control for Safety (TCS) foods that are to be help for more than 24 hours at a temperature of 40 degrees or less will be labeled and dated with a prepared date (Day 1) and a use-by date (Day 7). During an initial kitchen tour that began at 9:20 AM on 11/11/24, Surveyor and DM-G observed the following items in the walk-in cooler and dry storage area: Cooler: - Two open and partially used half gallons of tomato juice. One was dated 11/11 and the other was dated 11/7. Per DM-G, the dates on the containers were the received dates. There were no open dates or use-by dates. - Five English muffins in a package with a received date of 11/11. There was no open or use-by date. - Two open and partially used bags of cinnamon raisin bagels. One bag had a received date of 11/6. The other bag had a received date of 11/1. There were no open or use-by dates. Dry Storage: - Two open and partially used 25-pound bags of salt. Both bags were dated 9/5/24. Per DM-G, the dates were received dates There were no open or use-by dates. - One open and partially used 25-pound bag of powdered sugar dated 12/13/23. Per DM-G, the date was the received date. There was no open or use-by date. - One open and partially used 50-pound bag of flour dated 10/21/24. Per DM-G, the date was the received date. There was no open or use by date. - One open and partially used 50-pound bag of sugar dated 5/9/24. Per DM-G, the date was the received date. There was no open or use-by date. - One plastic container of [NAME] Krispies with an open date of 11/4/24 and a use-by date of 2/4/24. - One plastic container of Corn Flakes with an open date of 10/2/24 and a use-by date of 1/2/24. - One plastic container of Toasted Oats with an open date of 11/5/24 and a use-by date of 1/5/24. - One plastic container of Raisin Bran with an open date of 10/21/24 and a use-by date of 11/21/24. Surveyor interviewed DM-G who stated the single dates on the opened food items were received dates. DM-G stated all items should have a received on date that indicates the date the food was received, an opened on date that indicates when then item was opened, and a use-by date that indicates when the item should be used by or discarded. DM-G could not indicate the use by date on many of the open and undated items. DM-G eventually located a policy posted in the kitchen, however, the policy didn't mention some of the items (including sugar and salt) and there were no opened on dates on the items. Surveyor noted the cereals were incorrectly dated and/or inconsistent with the facility's dating policy. DM-G indicated the incorrect date was DM-G's fault when DM-G dated in a hurry. Microwave Procedure: The 2022 FDA Food Code documents at 3-401.12 Microwave Cooking: The rapid increase in food temperature resulting from microwave heating does not provide the same cumulative time and temperature relationship necessary for the destruction of microorganisms as do conventional cooking methods. In order to achieve comparable lethality, the food must attain a temperature of 74 degrees C (165 degrees F) in all parts of the food. Since cold spots may exist in food cooking in a microwave oven, it is critical to measure the food temperature at multiple sites when the food is removed from the oven and then allow the food to stand covered for two minutes post microwave heating to allow thermal equalization and exposure. Although some microwave ovens are designed and engineered to deliver energy more evenly to the food than others, the important factor is to measure and ensure that the final temperature reaches 74 degrees C (165 degrees F) throughout the food. The 2022 FDA Food Code documents at 3-403.11 Reheating for Hot Holding (B): Time/Temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 165 degrees F and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. The facility's undated Microwave Temp Log document indicates: How to safely reheat foods in a microwave: 1. Place food in a microwave safe bowl and cover with lid. 2. Reheat food, then let it sit for two minutes. 3. Remove the lid and stir well with a clean utensil. 4. Wipe clean the probe of the food thermometer using single use food grade wipe, then insert probe into food so stem is covered. 5. Food is ready for consumption at 165 degrees F. 6. Clean probe with new wipe and discard wipe. On 11/12/24 at 12:07 PM, Surveyor observed Registered Dietician (RD)-H open a can of baked beans and pour the contents into a bowl. RD-H microwaved the beans uncovered and immediately took the temperature. RD-H again microwaved the beans and temped the beans without waiting two minutes. RD-H then put the beans on a resident's tray. On 11/12/24 at 12:09 PM, Surveyor observed DM-G put pureed meatloaf and pureed green beans on two plates. DM-G put one plate on top of the other and put both plates in the microwave uncovered. DM-G removed the plates and immediately temped the meatloaf. DM-G stacked the plates of food and put them back in the microwave uncovered. DM-G again removed the plates and temped the meatloaf with no time delay. The meatloaf was not stirred. DM-G again stacked the two plates of food and put them back in the microwave uncovered. DM-G removed the plates a third time and temped the meatloaf right away. DM-G again stacked the plates of food and put them back in the microwave uncovered. DM-G repeated the same process a total of five times. After the fifth time, DM-G stated the meatloaf was 180 degrees and sent the meatloaf for service. DM-G did not temp the pureed green beans during the process. On 11/13/24 at 11:02 AM, Surveyor interviewed DM-G who indicated the meatloaf was hard to temp because it was a small amount so DM-G kept putting the meatloaf back in the microwave. DM-G indicated DM-G should have pureed the food ahead of time and had the food at serving temp on the steam table. On 11/13/24 at 11:06 Surveyor interviewed RD-H who agreed with DM-G that the food should have been prepped ahead of time. RD-H did not respond to Surveyor's question why the two minute wait time was not observed for temping microwaved food. Sanitizing Solution Testing: The 2022 FDA Food Code documents at 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. During an initial kitchen tour that began at 9:20 AM on 11/11/24, Surveyor observed red and green buckets with sanitizing solution in the kitchen. One set of each color bucket was near an empty three-compartment sink and an empty single sink near the microwave. Surveyor interviewed DM-G who indicated the sanitizer buckets were checked once per shift with Hydrion test strips. DM-G stated DM-G did not test the temperature of the sanitizing solution but used the strips to record the parts per million (PPM) of sanitizing solution. Surveyor noted the facility used Ecolab Oasis 146 Multi Quat Sanitizer. A poster on the wall contained Quat Sanitizer manufacturer directions that indicated the appropriate sanitization was 150-400 PPM for sanitizing buckets and sanitization of cookware, dishes, and utensils during manual dishwashing. The Hydrion Quaternary test strip package insert directions indicated the test solution should be between 65 and 75 degrees F at the time of testing. On 11/12/24 at 12:30 PM, Surveyor observed red and green buckets of sanitizing solution in the kitchen. One set of each color bucket was near an empty three-compartment sink and by a sink near the microwave. Surveyor reviewed the facility's Three Compartment Sink and Sanitizer Bucket Log that contained documentation of sanitizing solution testing that was completed three times daily (once at each meal). The columns for each daily meal included time, water temp (Water *F), PPM, and initials. The PPMs documented on the daily logs were within the PPMs indicated on the Quat sanitizer directions and Hydrion Quaternary test strip indications for appropriate sanitization. There were no missing PPMs. Surveyor noted the Water *F column was crossed out for every day and every meal. There were no water temperatures recorded on any of the sanitizer testing logs in October 2024 and through 11/12/24. On 11/12/24 at 12:37 PM, Surveyor asked DM-G to test the sanitizing solution in the buckets. DM-G dipped a Hydrion test strip in a green bucket. Approximately 5 seconds later, DM-G removed the test trip and compared it to the back of the package. The color registered 400 PPM. DM-G again indicated DM-G does not test the water temperature, just the PPMs. On 11/12/24 at 1:56 PM, RD-H indicated the sanitizing solutions buckets should be tested according to what it says on the Hydrion test strip package. On 11/12/24 at 2:52 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects staff to follow the facility's kitchen policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 11/12/24 at 4:07 PM, Surveyor interviewed IP-F who provided an incomplete staff line list titled Employee Infection Line List/Log. The log did not have a date in the space provided at the top left side of the form but listed 8 dates next to the 8 staff listed on the form. The dates listed were 5/7, 6/5, 6/4, 6/5, 6/11, 7/7, 7/15, and 7/27. The form listed the unit where each staff worked and their symptoms. The form contained columns that were not filled out for any of the staff including Seen by Physician Y/N, Confirmed Infection (MD or Lab), Number of Hours with No Symptoms, and Return to Work Date. The Date/Time of Onset of Symptoms column contained two dates listed for two of the staff. When Surveyor asked IP-F about return to work dates for staff with complaints of nausea, emesis (vomiting), and diarrhea to ensure staff did not infect residents or other staff upon their return to work, IP-F indicated return to work dates depended on symptoms and were usually 24 hours after symptoms subsided. IP-F stated the facility calls and asks staff if they are able to return for their next shift. For COVID-19, IP-F indicated IP-F would have staff test and return to work 24 hours after their symptoms resolved and 1 negative test unless the policy stated otherwise. For nausea and diarrhea, IP-F indicated staff can return to work 24 hours after their symptoms subside. IP-F indicated IP-F had no further information regarding the dates and times of staffs' last illness symptoms and when staff returned to work. Per the Wisconsin Department of Health Services, staff should not return to work until at least 48 hours after their last episode of diarrhea or vomiting. On 11/13/24 at 10:33 AM, Surveyor interviewed IP-F and requested a completed Surveillance Map since the only Surveillance Map located in the facility's Infection Control binder to track resident infections was blank. IP-F verified IP-F had not been completing Surveillance Maps. On 11/13/24 at 2:42 PM, Surveyor reviewed the March 2024 Monthly Resident Infection Control Log which indicated 6 residents were Respiratory Syncytial Virus (RSV) positive between 3/19/24 and 3/21/24 which constituted an outbreak per the Wisconsin Department of Health Services and should have been reported within 24 hours. On 11/14/24 at 10:38 AM, Surveyor interviewed PHN-J who indicated the RSV outbreak was reported via phone and e-mail on 3/26/24. 5. On 11/13/24 at 3:33 PM, Surveyor interviewed IP-F who indicated IP-F did not have enough time to maintain the facility's infection prevention and control program and indicated it should be a designated 40-hour per week position. When Surveyor asked IP-F how many hours IP-F currently devoted to the position, IP-F stated maybe 2 hours a week and indicated IP-F also worked as a floor nurse. 6. On 11/11/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including type two diabetes mellitus with diabetic neuropathy, congestive heart failure (CHF), and dementia. R6's Minimum Data Set (MDS) assessment, dated 10/09/24, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R6 had moderately impaired cognition. R6's medical record indicated R6 had a diabetic ulcer on the ball of the right foot. R6's plan of care did not indicate R6 was on EBP. On 11/11/24 at 12:37 PM, Surveyor observed R6's room entrance and noted there was no EBP sign on or near the door. On 11/11/24 at 12:51 PM, Surveyor interviewed DON-B who stated there should be an EBP sign outside R6's room since R6 was on EBP due to an active foot wound. DON-B posted an EBP sign near R6's room entrance. On 11/12/24, Surveyor reviewed R6's physician orders. R6 had a wound care order, dated 10/4/24, for the diabetic ulcer on R6's right foot. R6 did not have an order for EBP. Surveyor reviewed R6's diagnoses list which did not contain R6's right diabetic foot ulcer. On 11/13/24 at 8:49 AM, Surveyor interviewed R6 who indicated R6 had an open foot wound that nursing staff cleaned and dressed regularly. Surveyor observed a bandage on R6's right foot that was dated 11/11/24. On 11/13/24 at 8:50 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who indicated CNA-L used EBP for R6 due to R6's foot wound. On 11/13/24 at 8:56 AM, Surveyor interviewed CNA-M who indicated CNA-M used EBP for R6 due to R6's foot wound. On 11/13/24 at 1:50 PM, Surveyor interviewed IP-F who stated R6 was on EBP for a foot wound and should have an order in R6's medical record. IP-F indicated R6 used to have an EBP order, however, the EBP order wasn't reinitiated after R6 went to the hospital in September 2024. IP-F indicated IP-F and others involved with admissions should have ensured an order for EBP was in R6's medical record upon readmission. On 11/13/24 at 2:54 PM, Surveyor interviewed DON-B who confirmed R6's EBP order should have already been in place since staff were implementing EBP. DON-B indicated R6 should also have a care plan for EBP and indicated R6's foot wound should be listed on R6's diagnoses list. 7. On 11/11/24, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF), bipolar disorder, excoriation (skin picking) disorder, and anxiety. R8's MDS assessment, dated 9/17/24, had a BIMS score of 13 out of 15 which indicated R8 was not cognitively impaired. R8's medical record indicated R8 had an order for EBP due to an MDRO. A care plan, dated 10/28/24, indicated R8 was on EBP due to an MDRO and for wounds due to skin picking. R8 had a physician order for EBP, dated 10/30/24, due to MDROs. R8's diagnoses list did not contain an MDROs. On 11/11/24 at 12:37 PM, Surveyor observed R8's room entrance and noted there was no EBP sign on or near R8's door. (R6 and R8 were roommates) On 11/11/24 at 12:51 PM, Surveyor interviewed DON-B who stated R8 was not on EBP. On 11/13/24 at 8:50 AM, Surveyor interviewed CNA-L who indicated R8 was not on EBP and CNA-L did not know of any reason why R8 would be on EBP. CNA-L indicated EBP was for R8's roommate (R6). On 11/13/24 at 8:56 AM, Surveyor interviewed CNA-M who indicated CNA-M did not use EBP for R8. CNA-M indicated EBP was for R8's roommate (R6) only. On 11/13/24 at 9:53 AM, Surveyor interviewed DON-B. When Surveyor asked why R8 had an order and a care plan for EBP but staff did not use EBP for R8, DON-B stated DON-B was wrong and staff should use EBP for R8 if R8 had an EBP order. When Surveyor asked why R8 had a care plan for MDROs and an EBP order for MDROs but did not have an MDRO diagnosis in R8's diagnoses list, DON-B stated DON-B would look into it. On 11/13/24 at 10:14 AM, Surveyor interviewed DON-B who indicated DON-B spoke with AIT-C and confirmed R8 had a history of an MDRO. DON-B indicated R8's diagnoses list would be updated and DON-B would ensure staff used EBP for R8. On 11/13/24 at 1:50 PM, Surveyor interviewed IP-F who stated IP-F was not aware R8 had an EBP order or why EBP would be used for R8 just for an MDRO. When Surveyor asked if an MDRO should be listed in a resident's diagnoses list, IP-F indicated IP-F was unsure. On 11/13/24 at 2:54 PM, Surveyor interviewed DON-B who confirmed R8 had a history of an MDRO and indicated extended-spectrum beta lactamase (ESBL) resistance was added to R8's active diagnoses list. DON-B confirmed the orders should have already been in place and EBP should have been ongoing. DON-B indicated R8 was now on the EBP list and staff would use EBP with R8 going forward. Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 53 residents residing in the facility. The facility did not maintain thorough surveillance/tracking documentation for a COVID-19 outbreak in September 2024 and did not report the outbreak to the local health department in a timely manner. In addition, the facility did not maintain thorough surveillance/tracking for a Respiratory Syncytial Virus (RSV) outbreak between 3/19/24 and 3/21/24 and did not report the outbreak to the local health department in a timely manner. The facility did not ensure consistent symptom tracking and documentation was completed for 5 residents (R) (R2, R18, R28, R31, and R163) of 6 residents who tested positive for COVID-19 in September 2024. Infection Preventionist (IP)-F also worked as a floor nurse. IP-F was unable to maintain the facility's infection prevention and control program which resulted in incomplete and/or inaccurate infection control surveillance. R6 had a wound but did not have an order or a care plan for enhanced barrier precautions (EBP). R8 had a multidrug-resistant organism (MDRO) and was not on EBP. Findings include: The facility's COVID-19 Prevention, Response and Reporting policy, dated 5/18/23, indicates: It is the policy of the facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. COVID-19 information will be reported through the proper channels as per federal, state and/or local health authority guidance .26. Responding to a newly identified SARS-CoV-2 infected HCP or resident: a. The facility should defer to the recommendations of the jurisdiction's public health authority when performing an outbreak response. b. A single new case of SARS-CoV-2 infection in a healthcare provider (HCP) or resident should be evaluated to determine if others in the facility could have been exposed. c. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contact cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission .27. The Infection Preventionist, or designee, will monitor and track COVID-19 related information including, but no limited to: a. The number of residents and staff who exhibit signs and symptoms of COVID-19. b. The number of residents and staff who have suspected or confirmed COVID-19 and date of confirmation. c. Staff and resident vaccination status .e. Employee compliance with standard and transmission-based precautions . According to the Wisconsin State Legislature, Chapter DHS 145, Appendix A, Communicable Diseases and Other Notifiable Conditions: The following diseases are of urgent public health importance and shall be reported by telephone to the patient's local health officer or to the local health officer's designee upon identification of a case or suspected case .In addition to the immediate report, complete and fax, mail, or electronically report an Acute and Communicable Disease Case Report (DHS F-44151) to the address on the form, or enter the data into the Wisconsin Electronic Disease Surveillance System, within 24 hours .Severe Acute Respiratory Syndrome-associated Coronavirus (SARS-CoV) . The facility's Infection Outbreak Response and Investigation Policy, with a review date of 2/26/23, indicates: .d. An outbreak will be reported to the local and/or state health department in accordance with the state's reportable diseases website. The facility's Infection Surveillance policy, revised on 3/8/23, indicates: .10. Employee, volunteer, and contract employee infections will be tracked, as appropriate, such as influenza or gastrointestinal infection outbreaks. The Wisconsin Department of Health Services' Nursing Homes Provider Resources webpage indicates under Outbreak Reporting Requirements: In Wisconsin, confirmed or suspected outbreaks of any disease in health care facilities, including long-term care facilities, are a Category I Disease, meaning they shall be reported immediately by telephone to the patient's local health officer, or to the local health officer's designee, upon identification. The Wisconsin Department of Health Services publication Prevention and Control Recommendation for Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities, dated December 2017, indicates: Staff should exclude themselves from resident care and food service duties at the onset of the symptoms, including nausea, vomiting, abdominal pain, and/or diarrhea .Such exclusions shall remain in effect until the employee is asymptomatic and free of diarrhea and vomiting for 48 hours .A log should be maintained to record ill staff symptoms, date when they became ill, date they became well, and date they returned to work. The facility's Infection Preventionist policy, dated 9/22/22, indicates: .7. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the infection prevention and control program for the facility .The policy also indicates the IP must: .b. Establish facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff and visitors. The facility's Enhanced Barrier Precautions (EBP) policy, with a revised date of 8/8/24, indicates: It is the policy of this facility to implement EBP for the prevention of transmission of multidrug-resistant organisms (MDROs) .1c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .2b. An order for EBP will be initiated for residents with any of the following: .i. Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) .ii. Infection or colonization with a CDC-targeted or novel MDRO when contact precautions do not otherwise apply .4. High-contact resident care activities include: Dressing; Bathing; Transferring; Providing hygiene; Changing linens; Changing briefs or assisting with toileting . 1. From 11/11/24 through 11/13/24, Surveyor reviewed the facility's infection prevention and control program surveillance documents and noted the facility experienced a COVID-19 outbreak in September 2024. Documentation pertaining to the COVID-19 outbreak consisted of a Monthly Infection Control Log, dated September 2024. The log included 6 residents who were COVID-19 positive. The log documented where the residents resided, the date of onset, and the date resolved. No additional surveillance or tracking was noted. Surveyor reviewed the rest of the facility's infection prevention documents for the month of September 2024 and noted the following: ~ A staff and resident line list, dated September 2024, included sections for tracking symptoms, date and time of last symptom, well date, return to work date (staff), and date removed from precautions (resident). The line list included 18 entries. Surveyor noted the line list was incomplete and did not contain the date and time of the last symptom, well dates, return to works dates, and removed from precautions dates. Surveyor also noted the line list did not include the 6 residents identified as COVID-19 positive on the Monthly Infection Control Log. ~ A blank Surveillance Floor Map. ~ An Infection Summary, dated September 2024, was incomplete and only contained information the for infection type and unit. The Infection Summary did not include a section for tracking COVID-19 and did not include the 6 positive residents. The facility's September 2024 COVID-19 outbreak surveillance also did not include documentation for symptomology, testing, the facility's response to the outbreak, preventative actions, or dates of outbreak reporting. On 11/13/24 at 3:15 PM, Surveyor interviewed IP-F who confirmed IP-F was responsible for the facility's infection prevention and control program. IP-F confirmed the facility had a COVID-19 outbreak in September 2024. Surveyor reviewed with IP-F documentation from the outbreak. IP-F confirmed surveillance documents, including an infection summary, surveillance map, and infection control line list were incomplete and did not contain the necessary information to ensure adequate surveillance and tracking. 2. On 11/13/24, Surveyor reviewed the medical records of the 6 residents who were diagnosed as COVID-19 positive in September 2024 and noted 5 (R2, R18, R28, R31 and R163) of the 6 residents had contradicting documentation regarding their COVID-19 symptoms. R2 was admitted to the facility on [DATE]. R2 tested positive for COVID-19 on 9/9/24 and was placed on droplet/contact precautions. R2's nursing notes contained the following entries: ~On 9/9/24 at 10:51 AM, Licensed Practical Nurse (LPN)-K documented R2 had shortness of breath (SOB) with exertion or while lying flat and an occasional cough. ~On 9/9/24 at 6:24 PM, nursing staff documented R2 was asymptomatic. ~On 9/10/24 at 9:10 AM, Director of Nursing (DON)-B documented R2 stated R2's SOB with exertion was improving. ~On 9/11/24 at 9:50 PM, nursing staff documented R2 was asymptomatic. ~On 9/12/24 at 12:30 PM, nursing staff documented R2 was asymptomatic. ~On 9/16/24 at 1:44 PM, Administrator in Training (AIT)-C documented R2 had SOB when lying flat. ~On 9/16/24 at 2:30 PM, nursing staff documented R2 had SOB. R2's medical record did not indicate whether R2's SOB resolved or when R2 was removed from droplet/contact precautions. R18 was admitted to the facility on [DATE]. R18 tested positive for COVID-19 on 9/7/24 and was placed on droplet/contact precautions. R18's nursing notes contained the following entries: ~On 9/7/24 at 3:22 PM, LPN-K documented R18 had SOB with exertion and while laying flat and a dry cough. ~On 9/7/24 at 9:33 PM, nursing staff documented R18 had no SOB and was asymptomatic. ~On 9/9/24 at 8:20 AM, nursing staff documented R18 was asymptomatic. ~On 9/12/24 at 12:31 PM, nursing staff documented R18 was asymptomatic. R18's medical record did not indicate when R18's symptoms resolved or when R18 was removed from droplet/contact precautions. R28 was admitted to the facility on [DATE]. R28 tested positive for COVID-19 on 9/13/24 and was placed on droplet/contact precautions. R28's nursing notes contained the following entries: ~On 9/13/24 at 11:08 AM, LPN-K documented R28's lungs were diminished and R28 had an occasional cough and SOB while lying flat and with exertion. ~On 9/13/24 at 11:47 AM, IP-F documented R28 had no symptoms and noted R28's respirations were regular and unlabored. ~On 9/13/24 at 12:43 PM, IP-F documented R28 was asymptomatic. R28's medical record did not indicate when R28's symptoms resolved or when R28 was removed from droplet/contact precautions. R31 was admitted to the facility on [DATE]. R31 tested positive for COVID-19 on 9/9/24 and was placed on droplet/contact precautions. R31's nursing notes contained the following entries: ~On 9/9/24 at 10:54 AM, LPN-K documented R31 had SOB with exertion or while lying flat and an occasional dry cough. ~On 9/9/24 at 6:17 PM, nursing staff documented R31 was asymptomatic. ~On 9/10/24 at 8:40 AM, DON-B documented R31's SOB with exertion was improving. ~On 9/11/24 at 9:48 PM, nursing staff documented R31 was asymptomatic. ~On 9/12/24 at 12:29 PM, nursing staff documented R31 was asymptomatic. ~On 9/16/24 at 1:50 PM, AIT-C documented R31 had SOB when laying flat and with exertion. R31's medical record did not indicate when R31's symptoms resolved or when R31 was removed from droplet/contact precautions. R163 was admitted to the facility on [DATE]. R163 tested positive for COVID-19 on 9/5/24 and was placed on droplet/contact precautions. R163's nursing notes contained the following entries: ~On 9/5/24 at 7:33 PM, LPN-K documented R163 had a cough, chills, and congestion. R163 also had SOB at rest, while lying flat, and with exertion. ~On 9/6/24 at 9:14 AM, DON-B documented R163 had a cough and congestion. ~On 9/7/24 at 9:30 PM, nursing staff documented R163 was asymptomatic. R163's medical record did not indicate when R163's symptoms resolved or when R163 was removed from droplet/contact precautions. On 11/13/24 at 3:15 PM, Surveyor interviewed IP-F who indicated IP-F was not sure why the charting was inconsistent for 5 of the 6 residents who tested positive for COVID-19. IP-F stated none of the residents who tested positive were symptomatic. IP-F confirmed resident's symptoms were not documented as part of the IP surveillance. IP-F indicated symptoms were only monitored through charting and nurse-to-nurse communication. IP-F stated LPN-K assisted IP-F with the infection prevention and control program until October 2024 and was responsible for the line list and resident testing. On 11/13/24 at 3:50 PM, Surveyor interviewed LPN-K who stated resident symptoms were tracked on one line list. LPN-K indicated if residents were diagnosed and prescribed an antibiotic, they were placed on the Monthly Infection Control Log. LPN-K stated some of the residents who tested positive for COVID-19 were symptomatic. LPN-K stated LPN-K did not know why there were discrepancies in the charting on whether a resident had symptoms or not. LPN-K stated LPN-K charted based on LPN-K's assessment of the resident. 3. From 11/11/24 through 11/13/24, Surveyor reviewed the facility's September 2024 COVID-19 outbreak surveillance documents which indicated the first staff member tested positive on 9/4/24 and the first resident tested positive on 9/5/24. The documents did not indicate the facility reported the outbreak to the local health department. On 11/13/24 at 3:40 PM, Surveyor interviewed AIT-C who indicated AIT-C reported the outbreak to the local health department. AIT-C provided an e-mail, dated 9/12/24, that contained communication with the health department, but not the date the outbreak was reported. AIT-C stated AIT-C initially reported the outbreak via phone to the health department. AIT-C was not certain of the date and did not have documentation of the date the outbreak was reported. On 11/14/24 at 10:38 AM, Surveyor interviewed Public Health Nurse (PHN)-J who stated the facility reported the COVID-19 outbreak via phone on 9/11/24 which was 7 days after the first individual tested positive.

Based on staff interview and record review, the facility did not implement their antibiotic stewardship program by ensuring the accurate use of an antibiotic for 1 resident (R) (R261) of 5 sampled residents. R261 was transferred to the hospital on 1/5/24 and prescribed an antibiotic for a urinary tract infection (UTI) that did not meet the facility's criteria for infection. Fourteen doses of the unnecessary antibiotic were administered. Findings include: The facility's Antibiotic Stewardship Program Policy, reviewed 11/18/22, indicates: The purpose of the program is to optimize the treatment of infections while reducing adverse events associated with antibiotic use .i. Monitor response to antibiotics and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out). ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. On 11/12/24, Surveyor reviewed the facility's January 2024 resident line list. R261 was on the line list for a UTI that was identified on 1/5/24 at the hospital while R261 was being evaluated for another condition. The provider completed a urinalysis and ordered Bactrim DS (an antibiotic) (trimethoprim/sulfamethoxazole 160 milligrams (mg)/800 mg) every 12 hours for seven days. Per the line list, R261 did not meet the McGeer's criteria (a set of guidelines for identifying infections in long-term care facilities) for infection. R261's culture result from the 1/5/24 urinalysis, dated 1/7/24, indicated there was >100,000 colony-forming units per milliliter (cfu/ml) of Pseudomonas aeruginosa bacteria R261's urine. According to a graph at the bottom of the culture result, Pseudomonas aeruginosa bacteria was resistant to Bactrim DS. R261's medical record did not indicate R261's physician was updated with the culture result. As a result, R261 completed the seven-day course (fourteen doses) of Bactrim DS without identification that the antibiotic was resistant to the bacteria. On 11/12/24 at 4:07 PM, Surveyor interviewed Infection Preventionist (IP)-F who indicated when a resident starts an antibiotic, IP-F ensures the charting is complete. If a resident meets McGeer's criteria, IP-F puts a progress note on a McGeer's criteria form and monitors the effectiveness of the antibiotic. IP-F indicated an antibiotic time-out is needed if a resident is on an antibiotic for a long time. IP-F indicated the the antibiotic is stopped, a culture is obtained, and if indicated, another antibiotic order is obtained. On 11/13/24 at 10:33 AM, Surveyor interviewed IP-F about R261's antibiotic use after the 1/5/24 UTI diagnosis and Bactrim order. IP-F reviewed R261's urine culture and verified the physician should have been notified. IP-F indicated the facility's policy indicates nurses should pass along lab updates in report. IP-F verified the process for coordinating antibiotic stewardship activities was to check IP-F's folder in the Director of Nursing's (DON's) office one to two times per week or check the facility's medical record system for antibiotics ordered.

Based on staff interview and record review, the facility did not ensure the Infection Preventionist (IP) dedicated a minimum number of part-time hours to adequately manage the facility's infection prevention and control program. This had the ability to affect all 53 residents residing in the facility. Licensed Practical Nurse (LPN)-F was designated as the facility's IP. LPN-F also worked as a full-time floor nurse which resulted in LPN-F's inability to adequately maintain the facility's infection prevention and control program. Findings include: The facility's Infection Preventionist policy, dated 9/22/22, indicates: The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program .1. The facility will designate a qualified individual as Infection Preventionist (IP) whose role is to coordinate and be actively accountable for the facility's infection prevention and control program including the antibiotic stewardship program .6. The IP must be employed at least part-time. Designated IP hours per week may vary based on the facility and its resident population .7. The IP must have the time necessary to properly assess, develop, implement, monitor, and manage the infection prevention and control program for the facility, address training requirements, and participate in required committees .11. The responsibilities of the IP include but are not limited to: a. Develop and implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections b. Establish facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff, and visitors. c. Develop and implement written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevention and control. d. Oversight of and ensuring the requirements are met for the facility's antibiotic stewardship program. e. Oversight of resident care activities (i.e., use and care of urinary catheters, wound care, incontinence care, skin care, medication administration, etc.). g. Review/revise and approve infection prevention and control training topics and content and ensure staff are trained on the facility's infection prevention and control program. On 11/13/24, Surveyor reviewed the Facility Assessment, dated 8/7/24, which listed a position for Infection Preventionist and indicated the IP work at least part-time at the facility. There were no designated hours or number of hours noted. On 11/13/24 at 3:15 PM, Surveyor interviewed LPN-F who confirmed LPN-F was the facility's IP and had been for four years. LPN-F stated another nurse assisted with the line lists until September 2024, however, LPN-F was responsible for the infection prevention and control program. LPN-F stated LPN-F designated maybe 2 hours a week to infection prevention and control because LPN-F also worked as a floor nurse. LPN-F stated LPN-F did not feel that was enough time for the infection prevention and control program and indicated it should be a designated 40 hour per week position. Director of Nursing (DON)-B and Administrator in Training (AIT)-C were present during the interview with LPN-F. Neither DON-B or AIT-C disputed LPN-F's statement that LPN-F was only able to designate 2 hours per week as the IP or LPN-F's statement that it was not sufficient time to complete IP responsibilities. From 11/11/24 to 11/13/24, the survey team noted the facility did not have a thorough infection prevention and control program as evidenced by incomplete line lists, lack of symptom tracking, lack of follow through on vaccinations, and an incomplete antibiotic stewardship program. (See F880, F881, F883, and F887 for additional information.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pot for all FACILITY Infection Control 11/12/24 11:14 AM [NAME] hskp and laundry Ecolab Company check machines and product 1x month send a thing on laptop lint after each load up to 3-3 loads back up plan if maintenance not here wtg for company 4 hrs away follow directions on laundry detergent 5 yrs ago sink hands washing or delicate underwear 11/12/24 12:08 PM [NAME] CNA anybody with feeding education hiring computer training, verbal educ if out of PPE tell nurses get out of closets or downstairs R46 orders for Enhanced barrier precautions d/t pressure wound every shift -Start Date08/21/2024 1400 -No EBP sign on door and no cart of PPE next to door Interview with [NAME] LPN/IP who signed out on MAR on 11/12/24 for AM shift that EBP sign was in place. 11/12/24 01:54 PM Interveiw with LPN [NAME] re: should EBP sign be up no up, and LPN verified it was signed up, said he's got some squishiness to his heels so we put foams on them EBP because he has pressure wounds that is why he is on EBP. Why sign off, it was a habit. 11/12/24 01:56 PM wcc (wound care certified) not anymore left hip open when he arrived , which is healed heels were never open i have dressing on heels because non compliant of not wearing shoes and he has terminal cancer I dont [NAME] or [NAME] decide when to put up EBP. 11/12/24 03:46 PM Record review of Resident Line list for January 2024 3 & 4 line down on form: [NAME] (listed twice) - indicates the UTI was community classification, date resolved 1/11, no HAI dataemergency room for ostomy concern, return with dx UTI on 1/5/24 and order for Bactrim DS x7 days, according to McGeers Criteria form no parameters were indicated, result from emergency room room culture on 1/7/24 >100000 CFU/ml Pseudomonas aeruginosa and 10000-10000 proteus mirabilis identified, which according to the culture form on bottom are resistant to bactim DS. Per MAR the order Bactrim DS Oral Tablet 800-160 MG (SulfamethoxazoleTrimethoprim) Give 1 tablet by mouth every 12 hours for UTI for 7 Days -Start Date01/05/2024 2000 was charted as taken the entire course of 7 days. Surveyor could not find an ABX stewardship form that would have been sent to the physician. Progress notes indicate 1 1/5/2024 14:43 General Note Note Text: Received order from ED to start Bactrim DS q 12 hr x 7 days for UTI. Will be starting this order tonight. 1/5/2024 04:21 SBAR - Change of Condition Situation: resident bleeding from stoma site BP 83/58 P 120R 16 temp 97.8 Background: recent bowel resection with colostomy Assessment (RN)/Appearance (LPN): Assessment: resident ostomy bag full of red discharge with clots Recommendations: transferred to hospital to be eval and treated Response: Previous note indicates [NAME] was started on ABX tx for abd incision and notes indicate: 1/3/2024 21:00 Orders - Administration Note Note Text: Augmentin Tablet 875-125 MG Give 1 tablet by mouth three times a day for abd incision infection for 10 Days 11/12/24 04:07 PM Inteview with [NAME] IP When person goes on an antibiotic, I go to PCC or I get a note and see what antibiotics were ordered, I look to see what charting was done, what symptoms are and if they match McGeers criteria, if match McGeers criteria then I put the progress note on the McGeers and I montior until the end date of the antibiotic and the effectiveness, or is the infection gone usually I do have antibiotics run the course of antibiotic course as ordered Asked about staff line list and return to work [NAME] said she does have a binder and she is going to look for it. I will talk to [NAME] about it, we have a binder for staff call ins that I would keep or sue would keep in the office and the call in sick forms are in the binder which consists of what their symptoms were and usually they are off for 24 hours unless its a progressive multiple calls in usually depending on the symptom and its 24 hours since symptoms subsided and we call and ask if they will be able to return for their next shift depends on what they are calling in for like COVID I would have them test outside and they could return to work 24 hours after symptoms resolved and 1 negative test unless the policy states otherwise if its nausea/diarrhea then they can return 24 hours after symptoms subsided [NAME] will provide me the binder. [NAME] provided Suveyor a form from the call in binder which was titled Employee infection line list/log. The form has date of call in, then list employee name, then unit worked then Symptoms or complaints then y/n question seen by physician then confirmed infection (MD OR LAB) then Date/Time of onset of symptoms then number of hours with no symptoms then return to work date. On the form the first date is 5/7 (no year), [NAME], South, stomach flu nausea diarrhea, Seen by Physician is blank, Confirmed infection blank, date/time of onset indicates 5/6/24, number of hours with no symptoms blank, return to work date blank; next line 6/5 (no year), [NAME], South, Nausea emesis loose stools and rest of columns are blank; last line filled out on form is 7/27 (no year), [NAME], South, allergies and rest of columns are blank. One Surveillance map in the line list binder provided, which was blank, no other surveillance maps were found any infection prevention binder. 11/13/24 10:28 AM [NAME] can [NAME] cna flyers by time clock and yes flu yes we have to sign declineation form 11/13/24 10:33 AM Did not receive the declination form in mail yet, will check progress notes documentation of consult with APOAHC, did provide a declination form for all vaccines from 8/22/23 signed by APOAHC, there is no note in progress note about declining COVID. regarding [NAME] I have been doing infection control for about 4 years, but they just got on me to finish the (cdc training) pointing to CDC certficate on the wall mostly me doing, [NAME] was helping me with the antibiotic stuff and then I got it back after she went to MDS I started taking over the antibiotic stuff not even a month ago antibiotic time out Im trying to remember from the relias things, just basically if they are on the antibiotic for a long time then stop in then get a culture if indicated and get an order to start an antibiotic Provided WIR copy for [NAME], she admitted [DATE] and now I would contact the pharmacist about pnuemo and see what she is due for yes, I would tell her per our pharmacist this is what she could get and I would ask her if she wanted it provide risks and benefits she has bad reactions to the flu process for new admits, usually [NAME] deals with signing the declination form when admitted , new admit folder I would look and see what pile do I need to put this in future pneumonia and influenza, every monday I look at my CDC (clarified NHSN) and then I look at the folder. Why was she overlooked until today I honestly could not tell you why, I seen she refused influenza and I was stuck in my influenza stuff and put stuff in my binder and put it away [NAME] with the pneumonia Im still getting in the works with that one No system in place for pneumonia I have not been doing the surveillance map I do not have any additional information in regards to time/date of last symptoms prior to return to work date process for antibiotic stewardship I did not realize, I am not happy with my self about that ([NAME]), typically when the resident comes back from the hospital the nursing taking the return admission would notify the MD on date they come back from the hospital and discuss the antibiotic, why they are on it and if the doctor should continue the said antibiotic, the nurses should pass along in running report to call for a culture procedure or policy? I dont know if we do, seems like nursing common sense but I cant speak for everyone according to stewardship policy the Infection Preventionist coordinates all antibiotic stewardship activities how do you do that? [NAME] and management keep an eye on it, [NAME] when helping with infection control was very good and keeping up on this charted and getting cultures and sensitivities back, [NAME] and management leave me notes in my Folder in the DON office, and I check the folder at minimum 1-2x/week, and keeping eye on worsening in symptoms or changes in condition looking at cultures all nurses should be, and nurses communicate with oncoming staff of lab results we would follow care plan and physician orders 11/13/24 02:10 PM [NAME] retired nurse, worked in iron mountain covid yes symptoms of covid i coughed and coughed2 weeks on north side by myselfemember they had no visitor sign on door, i dont remember but im sure they did a month ago i tested positive but i had no symptoms this time, i was in this room and she was on the other side in the room and had no symptomstell you the truth i cant sleep so i am foggy 11/13/24 2:22 PM [NAME] no nothing why I get a shot 11/13/24 2:23PM [NAME] cna gown gloves and n95 more med supply room 11/13/24 02:42 PM March 2024 Monthly Infection control log [NAME] RSV+ 3/21/24 S unit; [NAME] RSV+ 3/22/24 S unit; [NAME] RSV+ 3/19/24 N unit; [NAME] RSV+ 3/16/24 S unit; [NAME] RSV+ 3/20/24 N unit notes indicate abx in hospital; [NAME] RSV +3/20/24 N unit; [NAME] RSV+ 3/19/24 S unit; [NAME] RSV+ 3/21/24 S unit 11/13/24 03:09 PM Record review [NAME] Progress notes: 3/17/2024 21:32 Summary Note Note Text: Resident summary: Resident is alert and oriented with some forgetfulness; able to make needs known. Hard of hearing may need to repeat self to be understood. Independant with ADLs. Staff assist as needed and with weekly shower. IND with transfers and usesw/c IND for mobility. No falls or injuries. oxygen on continuously removes for supervised smoking throughout the day. Appetite good. no n/v skin warm/dry. Elocon cream to psoriasis patches on knees. Recent vitals: Temperature: T 97.7 - 3/17/2024 09:40 Route: Forehead (non-contact) Pulse: P 95 - 3/17/2024 15:21 Pulse Type: UTD - Unable to Determine Blood Pressure:BP 130/70 - 3/17/2024 15:21 Position: Sitting r/arm Respirations: R 20.0 - 3/17/2024 09:40 O2 Sat: O2 95.0 % - 3/17/2024 20:27 Method: Oxygen via Nasal Cannula 3/20/2024 16:12 General Note Note Text: Resident sent out to marshfield hospital at 1600 for eval and treat. Hes had increased confusion and low O2 sats in the 70's and low 80's. Left via strecher with the ambulance. Resident was able to stand up and transfer to the stretcher assist x1 and aware of situation. 3/20/2024 16:25 General Note Note Text: Resident has been having increased confusion all day, taking his clothes off, and oxygen level is below 90% , as he has been taking this oxygen off all day also. Resident has wheezing and chest congestion. He has an order for oxygen via nasal cannula at all times. He is very weak and his pulse is rapid. DR. [NAME] was in house and ordered him to be sent to ED to eval and treat. 3/21/2024 12:25 General Note Note Text: Resident admitted MMC [NAME] 03/20/24. 3/25/2024 20:51 admission Summary Note Text: resident was readmitted to our facility after a 5 day stay at MMC-[NAME] for pneumonia and RSV. He was in the ICU and placed on BiPAP. He is alert and oriented x3. Heart sound are normal, lungs still have some wheezing. will continue to monitor. 3/26/2024 13:00 Clinical Follow Up Note Text: Resident is on follow up for: Readmission-rsv positive/pneumonia. The current status is Resident tolerating being back to facility. Resident moved to room [ROOM NUMBER]. No abnormalities noted. No respiratory distress noted. VSS Monigor for any changes. 3/26/2024 13:10 Daily Skilled Note Skilled Note: [NAME]'s skilled services include Physical Therapy Occupational Therapy, , Medication teaching/observations/demonstrations Safety awareness. Cognitive status: Decisions consistent/reasonable. Skin turgor: Normal - no tenting Dry - resolved with lotion 1-3 sec. Skin conditions: . Skin integrity/positioning devices: Chair/Seat Cushion. Urinary continence: Continent. Bowel incontinence: Continent. Bowel patterns: Regular elimination - 1 BM every 1-2 days. Incontinence products used: . Most recent pain level: Pnl 0 - 3/26/2024 07:42 Pain scale: Numerical . Regular Heart Rhythm: Yes. . Peripheral pulses present: Left Right. Capillary refill less than 3 seconds: Left hand Right hand. Edema present: No. Respiratory: Abnormal lungsounds (rales, rhonchi, wheezing) Labored or rapid breathing Dyspnea on exertion. Respiratory treatments: Inhaled: metered disc Aerosol/nebulizer Oxygen continuous. Neuromuscular: None of the above. Musculoskeletal: Unsteady gait. Mobility devices or equipment: Wheelchair (manual or electric), . Dietary approaches: Therapeutic diet. Safety: . Resident displayed the following: None of the above. Additional isolation precautions: Contact & droplet precautions. Active infection: Yes, describe below. RSV Positive. Summary: Resident readmitted to facility from DCH with pneumonia/rsv positive. Remains on isolation for a few more days. Oxygen via nc @ 3L continuous. Appetite good. No complaints offered this shift. Can be demanding at times. Will be starting nicotine patch tomorrow per his request. No respiratory distress or complication noted. VSS. 3/27/2024 09:18 General Note Note Text: IDT review-Resident is RSV+. He is in a private room, receives all services in room and on droplet precautions. He is currently on oxygen. Staff continue to assess resident for increased SOB, declines in functional status, and respiratory status. 3/27/2024 09:41 Clinical Follow Up Note Text: Resident is on follow up for: recent hospitalization RSV, SOB. The current status is Smoking cessation Nicotine patch applied Contact isolation for RSV 11/13/24 03:30 PM 2 per DON 3 per IP positive and reported to health department. [NAME] reported it per DON 11/13/24 03:33 PM RSV we were in outbreak on that, treated the same way as COVID , gown glove n95 masks made North a quarantine wing, [NAME] may be able to shed more light on that, to my knowledge I am not sure Maybe 2 hours a week, because I am mostly on the floor, so its comes to when I am able to as of October first [NAME] is responsible for all infection prevention throughout the building, since October 1, 2024 , 2 hours /week towards infection prevention rest of time working the floor as nurse. No the way things are going it should be designated to 40 hour position. I have me and management scheduling to try to get me at least 8 hours to stay on top of it, given scheduling permits it prior to July not tracking symptoms [NAME] yes I reported to [NAME] health department, it started as a phone call and I would have faxed it or emailed it Will look to see if reported via email or fax did not have any staff with RSV+ no list [NAME] stopped working with IP in September but I was off for a good portion of Septmeber because I was off with COVID [NAME] was doing the immunization half of it, now she is doing the entire portion of it. I was given 8 hours a week for it, but while I was working I would collect data then during the 8 hours add supporting documentation I wasn't tracking every day, they dont have the hours for that 11/13/24 04:03 PM call to public health nurse [NAME] and she is not currently here administrative assistant one minute I can access WEDS Im not sure if I can see I will give you the direct line for [NAME] and [NAME] they deal with outbraks [NAME] 7152574552 [NAME] 7155283427 both of them, I have access but I cant look at previous outbreaks 11/13/24 04:47 PM [NAME] Yeah i think so, i got a flu shot, im not doing the covid vacvcine, yeah it has been 11/13/24 04:49 PM [NAME] yes, offered it i cant remember exactly Sample residents/staff as follows: Sample one staff to verify compliance with requirements for educating and offering COVID-19 immunization (select one staff from the actual working schedules for all staff provided during entrance conference). IF there are Residents triggered on the task (above the writing area--- its okay if blank), just do your residents (drop down) select whats appropriate if on TBP (droplet or contact- NOT EBP). If on EBP leave blank. The other staff will do their residents. Sample three residents on transmission-based precautions (TBP) for purposes of determining compliance with infection prevention and control national standards such as transmission-based precautions, as well as resident care, screening, testing, and reporting. IF THERE ARE RESIDENTS TRIGGERED ON THE TASK (above the writing area) then try to use them for the 3 RES below. If not just get from line lists. 1.Positive Resident: Date screened: Date of symptoms: Testing: Date and type of isolation/precautions: Well date: 2. Resident: Date screened: Date of symptoms: Testing: Date and type of isolation/precautions: Well date: 3. Resident: Date screened: Date of symptoms: Testing: Date and type of isolation/precautions: Well date: Sample five residents for influenza, pneumococcal, and COVID-19 immunizations (select COVID-19 unvaccinated residents (a few)). FROM SAMPLE (as able) 1. Name: [NAME] DOB: [DATE] admit: 11/12/19 COVID&Booster: refused (declination form dated 4/23/21) P13: P23: P20: 8/21/24 INFL:10/14/24 2. Name: [NAME] DOB: [DATE] admit: 5/25/23 COVID&Booster: refused (declination form from 4/7/20) P13: P23: P20: 8/22/24 INFL:10/14/24 3. Name: [NAME] DOB: [DATE] admit: 8/15/24 COVID&Booster: refused (declination 8/15/24) P13: P23: P20:10/11/23 INFL: 10/14/24 4. Name: [NAME] DOB: [DATE] admit: 8/10/23 COVID&Booster:refused P13: P23: P20: refused all INFL: refused (declination for flu on 10/21/24)(declination form with COVID, pneumonia from August 2023 on admission) 5. Name: [NAME] DOB: [DATE] admit: 10/2/24 COVID&Booster: refused (10/2/24 declination form provided) P13: P23: 11/20/2008 P20: no declination form - pneumorec recommends dose of PCV15, 20 or 21 at least 1 year after last does of PPSV23 INFL: refused (provided declination form dated 10/24/24) ------------------------------------------------------------------------------------------------------------ 1. General Standard Precautions/Hand Hygiene/PPE/Source Control C19/TBP 2. IPCP Standards, PP, Education: 3. Infection Surveillance Line lists for res and staff. 4. Water Management/Legionella, etc Prevention Measures: Did the facility establish and maintain a water management program?yes Assessment and map of where the high stop points zones completed Logs on how they control to prevent the growth logs with water checks How they monitor weekly staff complete weekly checks for water temps, dead end water plumbing, showers, faucets and eye wash station flushes, 5. Laundry Services: Tour facility, get info on machines, cleaning, chemicals, dryer lint cleaning, process for laundry clean to dirty and handling. Dirty laundry handling. Clean laundry handling (covered). All areas inspected and no concerns noted 6. Antibiotic Stewardship: (see additional info in Residents Sampled above) - look at policy, f/u on residents on ABX 1 incident of no f/u with ABX found in January 2024, but no incidences found in August, Sept, October or November 2024 of ABX without culture f/up on 7. Infection Preventionist: 2 LPN's both with CDC training, both work 40 hours CDC training done on 7/30/24, mostly just me, [NAME] was doing more of the antibiotic stuff for me then she went to MDS 8. Influenza/Pneumococcal/C19 Immunizations: (see above)Completed above 9. Did the facility provide C19 immunization as required or appropriate for residents? 10. Did the facility maintain staff documentation of screening, education, offering, and current COVID-19 vaccination status? Yes Based on staff interview and record review, the facility did not ensure 3 residents (R) (R8, R11, and R29) of 5 sampled residents were offered or received a COVID-19 vaccine. R8, R11, and R29's medical records did not indicate R8, R11, and R29 received, were offered, or declined the most recent COVID-19 vaccine. Findings include: The facility's COVID-19 Vaccination policy, dated 9/13/24, indicates: It is the policy of the facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering residents and staff the COVID-19 vaccine .Up-to-date is defined as receiving a 2024-2025 updated COVID-19 vaccine (as per CDC) .11. The facility will educate and offer the COVID-19 vaccine to residents and staff and maintain documentation of such .14. Consent will be signed prior to administration of the COVID-19 vaccine. This information will be retained in the resident's medical record .16. Residents or resident representatives retain the right to accept, decline, or change their decision about COVID-19 immunization .17. The resident's medical record will include documentation of the following: a. Education to the resident or their representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or; c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. On 11/13/24, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE]. R8's medical record contained a declination form dated 4/7/20. R8's medical record did not indicate R8 received or declined the 2024-2025 COVID-19 vaccination. On 11/13/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE]. R11's medical record contained a declination form dated 4/23/21. R11's medical record did not indicate R11 received or declined the 2024-2025 COVID-19 vaccination. On 11/13/24, Surveyor reviewed R29's medical record. R29 was admitted to the facility on [DATE]. R29's medical record conained a declination form from August 2023. R29's medical record did not indicate R29 received or declined the 2024-2025 COVID-19 vaccination. On 11/13/24 at 10:33 AM, Surveyor interviewed Infection Preventionist (IP)-F who verified R8, R11 and R29's medical records did not contain documentation that indicated if R8, R11 or R29 were offered or refused the 2024-2025 COVID-19 vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition. This occurred for 1 of 3 residents (R) R1, reviewed for change in condition. R1 presented with symptoms of low blood pressure and weakness on 5/30/24 at 9:43 a.m. R1 had symptoms of vomiting and diarrhea from approximately 3:30-4:00 p.m. to 7:00 p.m. when R1 was transferred to the emergency room. R1's physician was not consulted between when episodes of vomiting and diarrhea occurred. Findings include: The facility policy, entitled Change of Condition of the Resident revision date 9/20/2022, states: Policy: Facility should . consult with the physician .when there is a .significant change in the resident's physical .status in either life-threatening condition or clinical complications. Policy Explanation and compliance Guidelines: When a resident presents with a possible change in condition .Notify the residents physician. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: ~Acute of sudden onset and: ~A marked change (i.e., more severe) in relation usual symptoms and signs or ~Unrelieved by measures already prescribed . R1 was admitted to the facility on [DATE] with diagnoses that included in part, malignant neoplasm of esophagus, dysphagia and encounter for attention gastrostomy. R1 was his own decision maker and had elected DNR (Do not resuscitate). R1's POLST (physician orders for life sustaining treatment) indicated: DNR Limited Additional Interventions: do not intubate Antibiotics: use aggressive antibiotic treatment Artificially Administered Nutrition/Hydration: long term nutrition/hydration Summary of goals: discussed with patient/resident The basis for these orders is patients/residents: request, known preference R1's nurse progress notes in part read: ~5/30/24 4:15 AM: CNA (Certified Nursing Assistant) reports resident doesn't seem like himself, when assisting to sit at bedside resident very rigid and difficult to move, felt warm to touch, phlegm noted on right side of his shirt, thick yellow phlegm, temp 98.2, BP: 78/48 58, assisted to standing at bedside with 2 assist and walker when ambulated to the bathroom, rechecked BP when resident back in bed 98/50, 114, will cont to monitor and update POA (Power of Attorney) in AM . ~5/30/24 8:08 AM: Zofran oral tablet 4 mg: give 4 mg via g-tube every 8 hours as needed for nausea, vomiting: given for nausea ~5/30/24 9:43 AM: Resident B/P 82/54, Pm 110, R 18, 02 96% RA. Resident is weak and was incontinent of bm. Residents daughter called at 8:30 am for update on low B/P's and resident not feeling well. Resident refuses to go to the hospital and stated What for resident is now lying in bed with his head elevated. Resident is coughing up yellow mucous, LSCTA (lung sounds clear to auscultation). Will monitor. On 8/15/24 at 7:30 a.m., Surveyor interviewed Nursing Home Administrator in training (NHA/DON) B who was the Director of Nursing on 5/30/24 about R1 and his change of condition. NHA/DON B was joined by [NAME] President of Success (VPS) C. NHA/DON B indicated on 5/30/24 the day shift nurse had informed her R1 was having low blood pressure. NHA/DON B expressed after the morning meeting around 9:30 a.m. she reviewed R1's nurses notes and called R1's physician who directed the facility to hold R1's blood pressure medications and to send R1 out to be evaluated. NHA/DON B expressed she spoke with R1 about the concern of low blood pressure and his physician consultation regarding going into the hospital to be evaluated but failed to document the consultation in R1's medical record. NHA/DON B further indicated R1 did not want to go into the hospital for evaluation. Nurses Progress notes continued: ~5/30/24 11:37 AM Zofran oral tablet 4 mg: PRN (as needed) administration was effective ~5/30/24 7:00 PM: resident has been vomiting and has had diarrhea at least 5-6 times so far this shift. Residents' daughter is here. She is asking for resident to be transferred to the hospital. Resident was asked if he wanted to go to the hospital earlier today, and he refused. He is now in agreement to go. DON (Director of Nursing) notified. Paperwork to be started. ~5/30/24 7:33 PM: called MMC-D and report on resident given to RN (Registered Nurse) in ED (Emergency Department). ~5/30/24 7:50 PM: resident left via ambulance to emergency room. On 8/15/24 at 7:30 a.m., Surveyor interviewed NHA/DON B about the above events. NHA/DON B stated on the p.m. shift R1 had vomiting and 5-6 bouts of diarrhea from start of shift at 2:00 p.m. to 7:00 p.m. At approximately 7:00 p.m., R1's daughter came into the facility and convinced R1 to go to the hospital at which point R1's physician was contacted, and an order was obtained to send R1 out for evaluation. NHA/DON expressed she did not make note of R1's physician consultation in R1's record when she consulted the physician about R1's low blood pressure on 5/30/24 at approximately 9:30 a.m. NHA/DON B further expressed R1's physician was not consulted again until R1 decided to be transferred to the hospital. Nursing staff should have consulted R1's physician after his symptoms of vomiting and diarrhea started. R1's physician should have been consulted as this was new onset of symptoms. On 8/15/24 at 10:28 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) E who worked the p.m. shift of 5/30/24 about R1's change in condition. LPN E reported R1 did not have vomiting at start of the pm shift on 5/30/24. LPN E reported R1 kept having episodes of vomiting and diarrhea 5-6 times with staff having to take him to the bathroom. The vomiting and diarrhea started somewhere around med pass start time of 3:30-4:00 p.m. R1 stayed in bed and is usually up in his recliner. LPN E indicated she unhooked his g-tube feeding, listened to his bowel, checked his vitals and skin turgor. LPN E indicated she could not recall if she documented this but believed this was done around 4:00 p.m. LPN E expressed R1 didn't seem dehydrated but she did not conduct a formal hydration assessment. LPN E indicated R1 did not want to go into the hospital until his daughter came into visit at which time she called the physician and got an order to send R1 in. LPN E expressed she did not make any previous contact with R1's physician to consult about his symptoms until R1 decided to go into the hospital. On 8/20/24 at 12:23 p.m., Surveyor interviewed Physician/Medical Director (MD) F about the facility consultation regarding R1 on 5/30/24. MD F expressed the facility had notified him the morning of 5/30/24 on R1 having unstable blood pressures. The facility indicated R1 was his own decision maker, had elected DNR and was adamant about not going into the hospital for evaluation and treatment earlier in the day. MD F recalls the facility contacted MD F later that day; at some point informing him R1's daughter had convinced R1 to go into the hospital. MD F gave an order for transfer for evaluation and treatment at that point. MD F indicated the symptoms of repeated episodes of vomiting and diarrhea were not reported to him, until the call around 7:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility did not ensure that a comprehensive person centered care plan was developed for 1 of 5 sampled residents (R) R1. R1 was admitted to the facility on [DATE] with diagnoses that included in part, malignant neoplasm of esophagus and was undergoing chemotherapy treatment. The facility did not develop a care plan to address R1's increased risk for infection, risk for dehydration or abnormal lab values with increased need for monitoring related to his diagnosis and chemotherapy treatments. This is evidenced by: Surveyor requested and received the facility policy titled Comprehensive Care Plan dated as most recently revised on 9/23/2022. The policy in part reads: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. Policy Explanation and Compliance Guidelines: ~The care planning process will include an assessment of the residents' strengths and needs and will incorporate the residents personal and cultural preferences in developing goals of care . ~The comprehensive care plan will describe in minimum: The services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. ~Resident specific interventions that reflect the residents needs and preferences. ~The comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to: attending physician or non-practitioner designee .A registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, the resident and the residents representative, to the extent possible and other appropriate staff or professionals . Review of R1's record shows R1 was admitted to the facility on [DATE] with diagnoses that included in part, malignant neoplasm of esophagus. R1's record shows physician appointment, treatments and labs as follows: 5/15/24 Family Medicine: Currently under direction of physician with HSHS oncology. Received R-Chop a modified regime with first cycle on 4/22/24 .He is scheduled to receive his second cycle . Plan: Follow with HSHS oncology scheduled labs with them. 5/21/24 Consultation/Clinic Referral: Progress note .Proceed w/#2 cycle chemo, rchop given today (R-Chop is a chemotherapy regimen given to treat lymphoma). New orders with stop dates: RTC (return to clinic) in 3 weeks with labs and planned #3 cycle of chemo than scans. 5/21/24 After Visit Summary: CBC (complete blood count) shows: (WBC) [NAME] blood count 10.2 elevated with reference range of normal (3.90-9.90) (RBC) Red blood count low 3.02 with a reference range of normal (4.42-5.68) (HGB) Hemoglobin low 10.4 with a reference range of normal (13.7-16.7) (HCT) Hematocrit low 33.5 with a reference range of normal (40.5-49.2) (MCV) Mean Corpuscular Volume high 111.0 with a reference range of normal (80-96) (MCH) Mean Corpuscular Hemoglobin high 34.6 with a reference range of normal (27-33) (MCHC) Mean Corpuscular Hemoglobin concentration low 31.2 with a reference range of normal (32-36) (RDW) Red Cell Distribution high 14.9 with a reference range of normal (10.5-13.5) Lymphocytes low 9.4 with a reference range of normal (15-40) Monocytes high 13.3 with a reference range of normal (3.1-9.3) ABS Neutrophils high 7.51 with a reference range of normal (1.8-6.4) (BUN) blood urea nitrogen high 57 with a reference range of normal (7-18) Creatine high 1.31 with a reference range of normal (0.70-1.30) BUN Creatinine high 43.5 with a reference range of normal (10.0-20.0) Albumin low 2.7 with a reference range of normal (3.4-5.0) The lab values above have several results that are abnormal with either high or low findings. Surveyor reviewed R1's care plan. The care plan did not address his increased risk for infection, risk for dehydration or abnormal lab values with increased need for monitoring related to his chemotherapy treatments. On 8/20/24 at 9:46 am, Surveyor interviewed Nursing Home Administrator in training who was the Director of Nursing (NHA/DON) B about the facility's expectation related to the development of a care plans related to R1's cancer diagnosis and chemotherapy treatment. NHA/DON B expressed she would expect the facility to develop a care plan to direct nursing staff on the monitoring of R1's condition, including what to expect for signs and symptoms related to chemotherapy treatment, monitoring for infections and when to reach out to R1's physician or oncologist. R1 did not have a care plan developed for this and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not comprehensively assess resident medical status with a change in resident's clinical condition. This occurred for 1 of 3 residents (R1) reviewed for change in condition. R1 presented with symptoms of low blood pressure and weakness on [DATE] at 9:43 a.m. R1 had new onset of vomiting and diarrhea noted on [DATE] on the p.m. shift without a comprehensive nursing assessment of his clinical condition from 9:43 a.m. until his time of transfer to the hospital at approximately 7:00 p.m. Findings include: The facility policy, entitled Change of Condition of the Resident revision date [DATE], states: Policy Explanation and compliance Guidelines: When a resident presents with a possible change in condition .noted changes in mental physical functioning: Assess/evaluate the resident. This assessment/evaluation could include; but is not limited to: ~Vital signs, oxygen saturation, blood glucose level ~Personality, behavioral and/or cognitive changes ~Alteration in level of consciousness, ability to respond ~Bowel and bladder control ~Sensory weakness or change ~Generalized or localized weakness ~Gait, posture or balance change ~Reflexes, response to stimuli, neurological signs Monitor the resident's condition frequently until stable or transported to a higher level of care if needed. R1 was admitted to the facility on [DATE] with diagnoses that included in part, malignant neoplasm of esophagus, dysphagia and encounter for attention gastrostomy. R1 was his own decision maker and had elected DNR (Do not resuscitate). R1's record shows physician appointment, treatments and labs as follows: [DATE] Family Medicine: Currently under direction of physician with HSHS oncology. Received R-Chop a modified regime with first cycle on [DATE] .He is scheduled to receive his second cycle . Plan: Follow with HSHS oncology scheduled labs with them. [DATE] Consultation/Clinic Referral: Progress note .Proceed w/#2 cycle chemo, rchop given today (R-Chop is a chemotherapy regimen given to treat lymphoma). New orders with stop dates: RTC (return to clinic) in 3 weeks with labs and planned #3 cycle of chemo than scans. R1's nurse progress notes in part read: ~[DATE] 4:15 AM: CNA (Certified Nursing Assistant) reports resident doesn't seem like himself, when assisting to sit at bedside resident very rigid and difficult to move, felt warm to touch, phlegm noted on right side of his shirt, thick yellow phlegm, temp 98.2, BP: 78/48 58, assisted to standing at bedside with 2 assist and walker when ambulated to the bathroom, rechecked BP when resident back in bed 98/50-114, will cont to monitor and update POA (Power of Attorney) in AM. ~[DATE] 7:14 AM: Metoprolol Tratrate oral tablet 50 mg: Give 1 tablet via g-tube for HTN (hypertension) hold if SBP less than 100 or pulse less than 60. B/P below parameters. ~[DATE] 7:16 AM: Enalapril Maleate oral tablet 20 mg: give 1 tablet via g-tube two times a day of HTN: B/P low ~[DATE] 8:08 AM: Zofran oral tablet 4 mg: give 4 mg via g-tube every 8 hours as needed for nausea, vomiting: given for nausea ~[DATE] 9:43 AM: Resident B/P 82/54, Pm 110, R 18, 02 96% RA. Resident is weak and was incontinent of bm. Residents daughter called at 8:30 am for update on low B/P's and resident not feeling well. Resident refuses to go to the hospital and stated What for resident is now lying in bed with his head elevated. Resident is coughing up yellow mucous, LSCTA (lung sounds clear to auscultation). Will monitor. ~[DATE] 11:37 AM Zofran oral tablet 4 mg: PRN (as needed) administration was effective ~[DATE] 7:00 PM: resident has been vomiting and has had diarrhea at least 5-6 times so far this shift. Residents daughter is here. She is asking for resident to be transferred to the hospital. Resident was asked if he wanted to go to the hospital earlier today, and he refused. He is now in agreement to go. DON (Director of Nursing) notified. Paperwork to be started. ~[DATE] 7:33 PM: called MMC-D and report on resident given to RN (Registered Nurse) in ED (Emergency Department). ~[DATE] 7:50 PM: resident left via ambulance to emergency room. On [DATE], at 7:30 a.m. Surveyor interviewed Nursing Home Administrator in training (NHA/DON) B who was the Director of Nursing on [DATE] about R1's change of condition and expected nursing assessment of his clinical condition. NHA/DON B was joined by [NAME] President of Success (VPS) C. NHA/DON B indicated on [DATE] the day shift nurse had informed her R1 was having low blood pressure. NHA/DON B expressed after the morning meeting around 9:30 a.m. she reviewed R1's nurses notes and called R1's physician informing him of R1's low blood pressure. No other nursing assessment was conducted or provided to R1's physician. R1's physician directed the facility to hold R1's blood pressure medications and to send R1 out to be evaluated. The blood pressure medications were held, and she spoke with R1 about his need to go into the hospital but R1 did not want to go in. R1 was administered Zofran for nausea which was effective. NHA/DON B expressed on the p.m. shift R1 had vomiting and 5-6 bouts of diarrhea from start of shift at 2:00 p.m. to 7:00 p.m. At approximately 7:00 p.m. R1's daughter came into the facility and convinced R1 to go to the hospital at which point LPN E completed the SNF/NF transfer form with an assessment of R1's vitals. NHA/DON B expressed she would have expected nursing staff to have conducted a comprehensive nursing assessment every 1-2 hours to evaluate R1's bowels and hydration status; including looking at his mouth/mucous membranes and looking at his skin integrity and cognition for hydration status, vital signs, and sharing all assessment results with R1's physician after his second bout of diarrhea. Nursing did not complete a comprehensive assessment or hydration status assessment. Medical record shows vitals were taken after R1 decided to go into the hospital. Medical record had no assessment of R1's hydration status. R1 expired in the hospital the next day. NHA/DON B provided Surveyor with R1's SNF/NF to hospital transfer form and R1's vital signs. Surveyor requested the hospital records from time of R1's admission on [DATE] to the time he expired. R1's SNF/NF to Hospital Transfer Form in part read: Reason for transfer: other: vomit, diarrhea, lethargic Relevant diagnosis: cancer Vital signs: B/P: 92/54, HR: 103, R: 20, Temp: 97.9, 02: 96.0 Code Status: DNR (do not resuscitate) Usual Mental Status: Alert, oriented, follows instructions Date of transfer: [DATE] at 7:15PM R1's Vitals Summary Notes for [DATE]: Respirations: [DATE] 1910: 20 breaths/minute Blood Pressure: 7:14 am: 78/52 7:09 pm: 92/54 7:55 pm: 92/54 Pulse: 7:14 am: 110 bpm (beats per minute): regular 7:10 pm: 103 bpm (irregular-new onset) 7:55 pm: 103 bpm (irregular-new onset) The above blood pressure and pulse are not within normal limits and would require repeat assessments of R1. On [DATE] at 9:40 a.m. Surveyor interviewed Licensed Practical Nurse (LPN) D who worked the a.m. shift on [DATE] about R1's change in condition and comprehensive nursing assessment of R1's clinical condition. LPN D expressed she had received report from night shift that R1 was weak and nauseated. LPN D did not see these symptoms as new or unusual as R1 was receiving chemotherapy. That morning LPN D checked R1's vitals and R1's blood pressure was low. R1 was weaker and stayed in bed which was not normal. LPN D informed R1 he could go into the hospital and be evaluated and he stated, What for. R1 was given Zofran for his nausea and LPN D informed NHA/DON B. NHA/DON B looked at R1 but did not conduct an assessment. On [DATE] at 10:28 a.m., Surveyor interviewed LPN E who worked the p.m. shift of [DATE] about R1's change in condition and comprehensive nursing assessment of his clinical condition. LPN E reported R1 did not have vomiting at start of the p.m. shift on [DATE]. LPN E reported R1 kept having episodes of vomiting and diarrhea 5-6 times with staff having to take him to the bathroom, starting somewhere around med pass time 3:30-4:00 p.m. R1 stayed in bed and is usually up in his recliner. LPN E indicated she unhooked R1's g-tube feeding, listened to his bowel, checked his vitals and skin turgor but could not recall is she noted the information in R1's record. LPN E expressed R1 didn't seem dehydrated, but a formal hydration assessment was not conducted. LPN E indicated R1 did not want to go into the hospital until his daughter came into visit at which time she called the physician, got an order to send him and took a set of vitals which were documented on the transfer form. NHA/DON B provided Surveyor with R1's Dehydration Risk Screener which was conducted on admission. NHA/DON B informed Surveyor the assessment dated [DATE] was the only assessment of R1's hydration status conducted by the facility. The evaluation shows on [DATE] R1 was not at risk for dehydration. NHA/DON B indicated nursing staff should have conducted a Dehydration Risk Screener after R1's second bout of diarrhea on [DATE] to evaluate R1's hydration status as part of their comprehensive nursing assessment. Surveyor reviewed the assessment and noted the following Instructions and areas to be evaluated: Instructions: Complete on admission, significant change in condition . R1's record showed no assessments of R1's condition from 9:43 a.m. until R1 was sent to the hospital. On [DATE] at 12:23 p.m., Surveyor interviewed Physician/Medical Director (MD) F about R1's change of condition. MD F expressed the facility had notified him the morning of [DATE] on R1 having unstable blood pressures. The facility indicated R1 was his own decision maker, had elected DNR and was adamant about not going into the hospital for evaluation and treatment earlier in the day. MD F recalls the facility contacted MD F later that day; at some point informing him R1's daughter had convinced R1 to go into the hospital. MD F gave an order for transfer for evaluation and treatment at that point. MD F expressed that had R1 been assessed on the evening shift and notified him. MD F would not have been alarmed with vomiting and diarrhea with a resident undergoing chemotherapy for cancer. Surveyor reviewed R1's hospital record. R1 expired with primary diagnosis of neutropenic sepsis, secondary to chemotherapy and espophageal cancer. R1 had a white blood count of 1, and a Neutropil absolute level of 0.9. (These lab results mean R1 had no ability to fight any infection due to the side effects of chemotherapy treatment).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility did not develop an individualized comprehensive care plan for 2 Residents (R) (R247 and R9) of 13 sampled residents. R247's care plan did not include pain interventions for pain management. R9's care plan did not include arm sleeves to protect R9's skin. Finding include: The facility's Comprehensive Care Plan Policy indicates: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. 1. On 9/25/23 at 11:44 AM, Surveyor interviewed R247 who stated R247's chest pain from surgery was at a level 7-8 on a pain scale of 1 to 10 and Tylenol was only somewhat effective in providing pain relief. On 9/25/23, Surveyor reviewed R247's medical record. R247 was admitted to the facility on [DATE] with diagnoses including endocarditis (inflammation of the heart valve caused by an infection), mitral valve replacement surgery, anxiety, depression, and a history of polysubstance abuse. R247 had intact cognition and did not have an activated power of attorney. On 9/25/23, Surveyor reviewed R247's pain care plan which contained a focus statement of Pain (specify location) evidenced by (specify)/potential for pain r/t (related to) (Pain). The Goal statement was Pain or analgesia will not effect participation in activities of choice or daily care. The care plan did not contain pharmacological or non-pharmacological interventions for pain. On 9/23/23 at 1:57 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated all nursing staff should be updating care plans. On 9/26/23 at 2:05 PM, Surveyor interviewed DON-B and Infection Preventionist (IP)-D who reviewed R247's care plan and verified the care plan did not contain interventions for pain management. 2. R9 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus with diabetic chronic kidney disease, chronic obstructive pulmonary disease (COPD), bipolar disorder and anxiety. R9's most recent Minimum Data Set (MDS) assessment, dated 9/1/23, contained a Brief interview for Mental Status (BIMS) score of 13 of 15 which indicated R9 had intact cognition. On 9/25/23 at 1:24 PM, Surveyor interviewed R9 who had cloth sleeves with scattered dark stains on both arms. R9 stated R9 wore the sleeves to prevent R9 from picking R9's skin and R9 wanted to have the sleeves changed more often. On 9/25/23, Surveyor reviewed R9's medical record which indicated R9 picked at the skin on R9's arms when R9 was anxious and upset. R9's plan of care did not contain an intervention for staff to apply or remove the arm sleeves to prevent skin irritation from picking. On 9/27/23, Surveyor observed R9 in R9's recliner without arm sleeves. On 9/27/23 at 10:08 AM, Surveyor interviewed R9 and Registered Nurse (RN)-G who stated the staff taking care of R9 that day were new to the facility and did not know to put arm sleeves on R9. RN-G then applied two clean arm sleeves on R9 who did not have open areas on either arm. On 9/27/23 at 10:11 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who indicated R9 wears the arm sleeves on a daily basis and the arm sleeves should be listed on R9's plan of care. On 9/27/23, Surveyor interviewed Nursing Home Administer (NHA)-A who verified the arm sleeves should be documented on R9's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not revise a plan of care in accordance with current care needs for 1 Resident (R) (R32) of 13 sampled residents. R32 had a fall with a fracture. R32's plan of care was not updated with a new intervention following the fall. R32 was changed to a Hoyer transfer after R32's fall with fracture. R32 was observed in a wheelchair sitting on a sling on multiple occasions. R32's plan of care was not updated. R32 was prescribed a PRAFO boot by the wound clinic to protect R32's left heel pressure injury. The intervention was not implemented or added to R32's plan of care. R32 was admitted the facility on dialysis. R32's dialysis ended on 7/13/23. R32's plan of care was not updated to reflect R32 was no longer on dialysis. Findings include: The facility's Comprehensive Care Plan policy, with a revised date of 9/23/22, indicated: The comprehensive care plan will describe, at a minimum, the following: A. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. B. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment 5. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and as needed with changes in condition .7. The physician, or other practitioner, or nurse designee will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. R32 was admitted to the facility on [DATE] with six pressure injuries from laying on the floor after R32 fell at home. R32 had diagnoses including acute kidney failure with tubular necrosis, rhabdomyolysis, Ogilvie syndrome (marked abdominal distension without evidence of mechanical obstruction), multiple fractures of ribs-left side, pressure ulcer of right hip-stage 4, pressure ulcer of other site-stage 4, and displaced intertrochanteric fracture of right femur. R32's most recent Minimum Data Set (MDS) assessment, dated 8/29/23, contained a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R32 had mild cognitive impairment. A Significant Change in Condition MDS was completed on 8/29/23 due to a fall in which R32 sustained a hip fracture. Surveyor noted the facility uses contracted licensed and Certified Nursing Assistant staff at times. 1. A progress note, dated 8/7/23 at 10:45 AM, indicated: (R32) had unwitnessed fall in bathroom .(R32) was observed to be on the floor. Leaning against bathroom wall, sitting on right hip with leg bent. (R32) states that (R32) got tangled up with wound vac cord and that (R32) didn't have enough room in bathroom with wheelchair in there. Background: (R32) has fallen 2 other times in the past month. (R32) self transfers frequently, impaired gait, impaired memory. (R32) forgets to ask for help. (R32) was admitted to the hospital with a hip fracture. Recommendations: Therapy to work with (R32) on transferring/caring for self with wound vac in place. Bilateral hip X-ray ordered. Will have done today .call, don't fall signs placed in room. Between 9/25/23 and 9/27/23, Surveyor reviewed R32's medical record and noted the following: ~On 7/30/23, R32 fell after R32 tripped over R32's wound vac cord while attempting to self-transfer. The care plan intervention was to place call don't fall signs in R32's room and a referral to therapy was made. R32's care plan was updated with the intervention of the call don't fall signs on 7/30/23. ~R32 was admitted to the hospital related to the fall on 8/7/23 and returned to the facility on 8/22/23. R32's plan of care did not contain an intervention related to the fall. R32 has not had any further falls. On 9/27/23 at 11:07 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated a new intervention should be added after each fall. DON-B indicated staff now place the wound vac cord facing down (which Surveyor observed during a wound vac dressing change) and hang the wound vac on the bottom of the bed which is in the low position when R32 is in bed. DON-B indicated R32's care plan should have been updated to reflect the changes. DON-B indicated a couple of staff were primarily responsible for care plan updates, however, they are no longer at the facility or have cut down their hours significantly. DON-B indicated care plans are updated by an offsite MDS coordinator who works for the corporate office. DON-B indicated the MDS staff participates in the interdisciplinary team (IDT) meetings via phone and should be updating residents' care plans with new interventions as discussed at the meetings. 2. On 9/26/23, Surveyor observed R32 in R32's room in a wheelchair doing puzzle books. Surveyor noted a sling underneath R32 while R32 was in the wheelchair on multiple occasions, including 9/25/23 at 12:30 PM, and 9/26/23 at 10:40 AM, 11:11 AM, 11:37 AM, and 12:34 PM. Between 9/25/23 and 9/27/23, Surveyor reviewed R32's medical record and noted the following: ~R32 was admitted to the facility with 6 pressure injuries related to a fall prior to admission and developed one pressure injury at the facility which had since healed. R32 did not have any pressure areas on R32's buttocks. ~R32 scored a 15 on R32's admission skin assessment, dated 8/22/23, which meant R32 was at risk for skin impairment. On 9/26/23 at 1:22 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-E who indicated R32 transferred with a Hoyer lift since R32 returned to the facility after the fall with fracture. CNA-E indicated staff usually leave the sling under R32 after transfers and stated R32 does not complain about the sling. CNA-E indicated R32 is bottom heavy and staff having to move the sling out after R32 is in the wheelchair will cause R32 pain. On 9/27/23 at 9:41 AM, Surveyor interviewed Certified Occupational Therapy Assistant (COTA)-F who indicated nursing staff usually do the assessment for leaving a sling underneath a resident. COTA-F indicated R32 is bottom heavy and moving R32 to get the sling out would be difficult once R32 is in the wheelchair. On 9/27/23 at 11:07 AM, Surveyor interviewed DON-B who indicated therapy does the assessment for leaving a sling underneath a resident after a Hoyer transfer. DON-B was not aware that a risk/benefit assessment and care plan intervention should be completed in order to leave a sling underneath R32. DON-B indicated between R32's wound vac and bottom heaviness, it would cause pain for R32 to remove the sling after each transfer. 3. Between 9/25/23 and 9/27/23, Surveyor reviewed R32's medical record and noted the following: ~On 7/24/23, R32 went to the wound clinic where an unstageable pressure injury to R32's left heel was noted. The wound clinic note (under additional orders) indicated: PRAFO pressure relieving ankle foot orthosis for pressure ulcer to heel for use in bed and sitting. Do not ambulate with this appliance. Heel offloading. ~A progress note, dated 7/27/23 at 9:10 PM, indicated: (R32) returned from the wound clinic. Paperwork stated no changes except for new pressure area on left heel with instructions to offload left heel at all times. R32's medical record and plan of care did not contain documentation, a current order, or a discontinued order that the PRAFO boot was offered or that R32 was offered the boot and refused. On 9/26/23 at 11:37 AM, Surveyor observed R32 sitting in R32's room in a wheelchair. R32 indicated R32 does not put anything on R32's heels. Surveyor observed grippy socks on R32's feet. On 9/26/23, Surveyor asked DON-B if R32 had a PRAFO boot. DON-B was unsure and indicated DON-B would check. On 9/27/23, Surveyor noted an order was added to R32's medical record regarding PRAFO boot use each shift. On 9/27/23 at 9:35 AM, DON-B informed Surveyor it was DON-B's error. DON-B indicated since R32's readmission from the hospital on 8/22/23, R32 refused to wear the boot, but DON-B did not document the refusals. DON-B indicated R32's left heel pressure injury was healed. DON-B asked R32 if R32 wanted to wear the boot earlier that morning, but R32 refused. DON-B confirmed the PRAFO boot should have been added to R32's plan of care and DON-B should have documented that R32 refused to wear the boot. 4. Between 9/25/23 and 9/27/23, Surveyor reviewed R32's medical record and noted the following care plans with approaches regarding dialysis: ~A care plan related to activities indicated: Dialysis (treatment) 3 days weekly (initiated on 6/15/23). ~A care plan related to dependence on renal dialysis (initiated on 6/22/23). ~A care plan related to renal insufficiencies (initiated on 6/12/23) with approaches that included: Dialysis 3 (times) per week; and coordinate dialysis care with dialysis team. ~A progress note, dated 7/13/23 at 1:00 PM, indicated: (R32) returned from (appointment) with (Doctor). (No new orders) per consult. Labs pending, and will see if (R32) can have (permanent) (catheter) removed and dialysis (discontinued). ~A progress note, dated 7/13/23 at 3:48 PM, indicated: Received call from (Doctor's) office stating that (R32's) kidney functioning test was 48, that (R32's) kidneys have recovered and they will be scheduling with surgeons to have dialysis port in chest removed. Await return call. ~On 8/29/23, the facility completed a Significant Change Assessment MDS for R32. On 9/27/23 at 11:07 AM, Surveyor interviewed DON-B who confirmed R32 was no longer on dialysis and should no longer have a care plan or care plan approaches related to dialysis. DON-B confirmed that corporate MDS staff should have updated R32's plan of care on the Significant Change of Condition MDS on 8/29/23 which was over a month since R32 stopped dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not provide the necessary care and services to monitor for fluid retention by ensuring post hospitalization weights were completed as ordered for 1 Resident (R) (R25) of 1 resident reviewed for hospitalization. R25 was weighed daily prior to hospitalization for a change in condition related to an exacerbation of congestive heart failure. R25 had 17.8 kilograms (kgs) or 38.58 pounds (lbs) of fluid removed while hospitalized . R25 returned to the facility with a standard order for weight monitoring. Findings include: R25 was admitted to the facility on [DATE] with diagnoses that included chronic diastolic congestive heart failure (CHF), morbid obesity (severe), and obstructive sleep apnea. R25's most recent Minimum Data Set (MDS) assessment, dated 9/4/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R25 had intact cognition. Between 9/25/23 and 9/28/23, Surveyor reviewed R25's medical record and noted the following: ~R25 had an order for daily weights related to CHF initiated upon admission [DATE]) which was discontinued on 8/22/23 (the date R25 was readmitted to the facility after hospitalization related to an exacerbation of CHF). The order indicated to contact the MD (Medical Doctor) if R25's weight increased 3 lbs. in one day or 5 lbs. in a week. ~R25 had a change in condition on 8/9/23 and was admitted to the hospital. ~R25's hospital Discharge summary, dated [DATE], indicated R25's acute discharge diagnoses were acute on chronic diastolic heart failure with preserved systolic function, acute hypoxic respiratory failure secondary to above, and obstructive sleep apnea with Pickwickian (consists of the triad of obesity, sleep disordered breathing, and chronic hypercapnia) syndrome .The discharge summary indicated R25 was diuresed (remove fluid from the body) initially with IV (intravenous) furosemide (a diuretic medication) and then IV Bumex (a diuretic medication) infusion. R25 diuresed 17.5 kilograms (38.58 pounds) from R25's admission weight. R25 was discharged on bumetanide (a diuretic medication) daily with potassium supplementation. The discharge instructions indicated: (R25) at discharge with the standard congestive heart failure discharge instructions. ~R25 was readmitted to the facility on [DATE] with the following weight order: Weight every day shift for 3 days and every Friday for 3 weeks and on the 1st of each month. R25's medical record contained the following weights since R25 returned from the hospital: 8/24/23 - 357.8 lbs. 8/25/23 - 357.1 lbs. 8/31/23 - 360.0 lbs. 9/1/23 - 359.8 lbs. 9/6/23 - 358.0 lbs. 9/12/23 - 361.9 lbs. (The last weight taken was 15 days prior to Surveyor's investigation). On 9/26/23 at 2:31 PM, Surveyor interviewed R25 who indicated that prior to going to the hospital, staff weighed R25 daily. Since R25 returned from the hospital, R25 was not sure what the schedule was, but R25 thought R25 was weighed weekly. R25 could not recall the last time R25 was weighed, but thought it was over a week ago. On 9/27/23 at 10:10 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R25 should be weighed daily and stated R25 was weighed daily prior to going to the hospital. On 9/27/23 at 11:46 AM, Surveyor interviewed MD-C who indicated MD-C would like to have R25 weighed every other day for monitoring. MD-C indicated the frequency of weight monitoring probably got lost when R25 was readmitted to the facility from the hospital. MD-C indicated R25 was stable since readmission and confirmed MD-C would want R25's weights monitored more frequently than the standard weight order. On 9/27/23 at 11:07 AM, Surveyor interviewed DON-B who was not aware R25's weights were not ordered more frequently and were not completed more frequently after R25's readmission from the hospital. DON-B confirmed R25 was weighed daily prior to R25's hospitalization. DON-B also confirmed because R25 was diuresed at the hospital and had so much fluid removed, DON-B thought R25 should be weighed at least every other day. DON-B indicated frustration with the facility's process to discontinue all orders when a resident is discharged from the facility and readmitted from the hospital. DON-B indicated when orders are reentered and the hospital discharge record does not indicate the frequency for weight monitoring, the standard facility order for weights is entered. DON-B indicated weight monitoring should have been caught and indicated DON-B would contact MD-C.

Based on observation and staff interview, the facility did not maintain an infection control program designed to prevent the development and transmission of disease and infection during a care observation for 1 Resident (R) (R3) of 3 sampled residents. Staff did not remove gloves and/or cleanse hands during an observation of incontinence care for R3. Findings include: The facility's Hand Hygiene policy, with a reviewed/revised date of 11/2/22, stated all staff will perform proper hand hygiene procedures to prevent the spread of infection. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene will be performed after handling items potentially contaminated with body fluids and after removing gloves. The Morbidity and Mortality Weekly Report, dated 10/25/02 and published by the Centers for Disease Control and Prevention (CDC), titled Guideline for Hand Hygiene in Health Care Settings contains recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The above information can also be found at: https://www.cdc.gov/handhygiene/providers/index.html with the page last reviewed on January 8, 2021. 1. On 3/30/23 at 12:16 PM, Surveyor observed Certified Nursing Assistant (CNA)-C and CNA-D provide incontinence care for R3. CNA-C and CNA-D washed hands and donned gloves. CNA-C verified R3 was incontinent of urine and cleansed R3's genital area with disposable wipes. Without removing gloves and cleansing hands, CNA-C rolled R3 to the side. CNA-D then verified R3 was incontinent of stool and cleansed R3's buttocks and anal area. Without removing gloves and cleansing hands, CNA-D placed a clean brief underneath R3, picked up a container of disposable wipes and placed the container on the table near R3's bed. CNA-C rolled R3 onto R3's back, pulled R3's shirt down, placed the brief over R3's genital area, and fastened the brief. CNA-C and CNA-D then placed a top sheet and blanket over R3 and CNA-C pulled a cord to deactivate the call light over R3's bed. CNA-C then removed gloves and washed hands. CNA-D removed gloves, and without cleansing hands, moved R3's bed. CNA-D then washed hands. On 3/30/23 at 12:25 PM, Surveyor interviewed CNA-D regarding hand hygiene during incontinence care for R3. CNA-D verified the above observations and stated yes CNA-D should have removed gloves and cleansed hands when going from dirty to clean during the provision of care. On 3/30/23 at 12:28 PM, Surveyor interviewed CNA-C regarding hand hygiene during incontinence care for R3. CNA-C verified the above observations and stated technically yes CNA-C should have removed gloves and cleansed hands when going from dirty to clean during the provision of care.