Every finding on record at Amethyst Health of Algoma

Based on observation, staff and resident 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 all 38 residents residing in the facility.The facility did not monitor and document food cooling temperatures.The facility did not test the Quaternary sanitizing solution per manufacturer's instructions.The facility did not ensure each refrigerator contained an internal thermometer to monitor safe food cooling temperatures.The facility did not practice safe food handling processes while serving food.The facility did not monitor the temperature of residents' room refrigerators.Findings include:On 3/23/26, Dietary Manager (DM)-F confirmed the facility follows the Food and Drug Administration (FDA) Food Code.Food Cooling:The 2022 FDA Food Code documents at section 3 501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celcuis (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less .Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms. A longer time near ideal bacterial incubation temperatures, 21 degrees C - 52 degrees C (70 degrees F - 125 degrees F) is to be avoided. If the food is not cooled in accordance with this code requirement, pathogens may grow to sufficient numbers to cause foodborne illness.During a self-guided initial kitchen tour that began at 8:06 AM on 3/23/26, Surveyor observed the following pre-cooked and cooled items in the reach-in cooler:~ A container labeled chicken soup, dated 3/21/26~ A container labeled hamburgers, dated 3/22/26Surveyor observed the following pre-cooked and cooled items in the walk-in freezer:~ A bag labeled goulash, dated 2/23/26~ A bag labeled beef stew, dated 3/3/26~ A container labeled chicken soup, dated 3/12/26During a continuous kitchen observation that began at 7:34 AM on 3/24/26, Surveyor observed the above foods still in the reach-in cooler and walk-in freezer.Surveyor observed the facility's food cooling log and noted the following foods were pre-cooked, cooled, and documented on the log:~ Meatloaf had a final cooking temperature of 171 degrees F on 2/5/26. No further cooling temperatures were documented. ~ Baked beans had a final cooking temperature of 201 degrees F on 2/15/26. The cooling start temperature was 162 degrees F. No further cooling temperatures were documented.~ Pureed eggs had a final cooking temperature of 169 degrees F on 2/16/26. The cooling temperature after one hour was 100 degrees F and after two hours was 79 degrees F. No further cooling temperatures were documented.~ Carrots had a final cooking temperature of 188 degrees F on 2/18/26. The cooling temperature after one hour was 170 degrees F and after two hours was 148 degrees F. The last cooling temperature documented was 90 degrees F. No further cooling temperatures were documented.~ Potato soup had a final cooking temperature of 200 degrees F on 2/18/26. The cooling start temperature was 182 degrees F. The cooling temperature after one hour was 150 degrees F and after two hours was 96 degrees F. No further cooling temperatures were documented.~ Stroganoff had a final cooking temperature of 202 degrees F on 2/24/26. The cooling start temperature was 165 degrees F and was 91 degrees F after two hours. No further cooling temperatures were documented.~ Meatloaf had a final cooking temperature of 184 degrees F on 2/24/26. The cooling start temperature was 158 degrees F. The cooling temperature after one hour was 140 degrees and after two hours was 76 degrees. No further cooling temperatures were documented.~ Broccoli had a final cooking temperature of 197 degrees F on 2/27/26. The cooling start temperature was 133 degrees F. No further cooling temperatures were documented.~ Mashed potatoes had a final cooking temperature of 172 degrees F on 3/2/26, The cooling start temperature was 170 degrees F. No further cooling temperatures were documented.~ Shepherd's pie had a final cooking temperature of 183 degrees F on 3/9/26. The cooling start temperature was 150 degrees F and was 140 degrees F after one hour. No further cooling temperatures were documented.~ Chicken had a final cooking temperature of 183 degrees F on 3/10/26. The cooling start temperature was 170 degrees F and was 100 degrees F after one hour. No further cooling temperatures were documented.~ Veg had a final cooking temperature of 190 degrees F on 3/10/26. The cooling start temperature was 160 degrees F and was 91 degrees F after one hour. No further cooling temperatures were documented.~ Egg puree had a final cooking temperature of 100 degrees F on 3/12/26. No further cooling temperatures were documented.~ Meatloaf had a final cooking temperature of 188 degrees F on 3/12/26. The cooling start temperature was 114 degrees F. No further cooling temperatures were documented.~ Chicken soup had a final cooking temperature of 190 degrees F on 3/12/26. The cooling start temperature was 150 degrees F and was 74 degrees F after one hour. No further cooling temperatures were documented.~ Chicken soup had a final cooking temperature of 105 degrees F on 3/21/26. No further cooling temperatures were documented.Quaternary Sanitizing Solution:The Hydrion Quaternary test strip package insert directions indicate the test solution should be between 65- and 75-degrees Fahrenheit (F) at the time of testing.During an initial kitchen tour that began at 8:06 AM on 3/23/26, Surveyor observed sanitizing buckets and the three-compartment sink. Surveyor noted the facility's sanitizer documentation log contained the time of day the sink and sanitizing buckets were filled and the PPM. The log did not contain temperature documentation for the sanitizing solution.Surveyor interviewed DM-F who indicated the log can be amended to include the temperature of the sanitizing solution. DM-F confirmed kitchen staff do not obtain and document the temperature of the sanitizing solution for the sanitizing buckets or the three-compartment sink used to clean prep areas and wash dishes.Thermometers in Food Cooling Equipment:The 2022 FDA Food Code documents at 4-204.112 Temperature Measuring Devices: (A) In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit. (B) Except as specified in (C) of this section, cold or hot holding equipment used for time/temperature control for safety food shall be designed to include and shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the device's temperature display . During an initial kitchen tour that began at 8:06 AM on 3/23/26, Surveyor noted the reach-in cooler did not contain an internal thermometer. Surveyor interviewed Dietary Aide (DA)-G who inspected the reach-in cooler and confirmed the cooler did not contain an internal thermometer. DM-F indicated kitchen staff use the thermometer located on the outside of the cooler to monitor the temperature. Surveyor noted the reach-in cooler's outside thermometer indicated the cooler was 52 degrees F.Safe Food Handling:The 2022 FDA Food Code documents at 3-304.15 Gloves, Use Limitation: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.During an initial kitchen tour that began at 8:06 AM on 3/23/26, Surveyor observed DM-F serve breakfast at the service line. DM-F donned gloves to use throughout meal service and touched plates and serving utensils throughout meal service with the same gloved hands. Surveyor observed DM-F pick up waffles with the same gloved hands and place them on plates for resident consumption. DM-F plated meals and touched serving spoons, the steam table, and kitchen countertops with the same gloved hands. DM-F also tore a waffle with gloved hands to cut the waffle for a resident. DM-F continued meal service with the same gloved hands and plated another meal for resident consumption. DM-F touched the plate, serving spoons, steam table, and kitchen countertops with the same gloved hands. DM-F then picked up a piece of toast and put the toast on a plate for resident consumption. DM-F did not remove gloves until after the meal service was completed.Refrigerator Temperatures:During an intial tour of the facility on 3/23/26, Surveyors observed personal refrigerators in R8, R2, R3, and R12's rooms. Surveyor did not observe temperature logs in the rooms.On 3/24/26, Surveyor reviewed the facility's Maintenance of Room Refrigerators policy, dated 7/1/25, that indicates the primary purpose of the policy and procedure is to inform staff of the proper procedures to be taken when maintaining company or resident owned refrigerators in the resident's room .1. All resident room refrigerators needs to be maintained in good working condition, monitored for appropriate temperatures and food within, and monitored for safety standards via expiration dating. 2. Resident food stored in room refrigerators must be covered, labeled, and dated. Food must be discarded after three days of the label date by the resident and/or their representative. If not, food will be discarded by housekeeping staff .An internal thermometer will be made available to monitor the temperature. A request for a thermometer can be made to housekeeping staff. Refrigerators must maintain a temperature of 33 to 40 degrees. Temperature checks of room and dayroom refrigerators will be recorded by housekeeping staff daily. Residents and/or their representatives are also responsible for monitoring and maintaining proper temperature and operation .Room and dayroom refrigerators will be checked during housekeeping rounds for cleanliness and appropriate temperatures. Housekeeping will notify the resident if they have outdated food in their room refrigerator that needs to be disposed of and will notify Environmental Services if a refrigerator is not working properly.On 3/24/26 at 7:36 AM, Surveyor interviewed Houskeeper (HSK)-H who stated HSK-H does not check the temperature of residents' refrigerators and does not monitor food in the refrigerators.On 3/24/26 at 7:42 AM, Surveyor interviewed R12 who indicated R12 keeps protein drinks and yogurt in R12's refrigerator. R12 stated staff do not monitor the temperature of the refrigerator.On 3/24/26 at 9:50 AM, Surveyor interviewed R3 who indicated staff do not clean, monitor the temperature, or do any maintenance for R3's refrigerator.On 3/24/26 at 10:00 AM, Surveyor interviewed NHA-A who indicated the facility ordered thermometers for residents' refrigerators and identified housekeeping staff were not monitoring the refrigerators. NHA-A indicated the thermometers were not delivered which was not communicated to NHA-A.

Based on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 38 residents residing in the facility.Licensed Professional Nurse (LPN)-C was the facility's designated IP. LPN-C did not complete specialized infection prevention and control training.Findings include:On 3/24/26 at 1:51PM, Surveyor interviewed LPN-C who stated LPN-C had been functioning as the facility's IP since March of 2025. LPN-C verified LPN-C did not complete specialized infection prevention and control training and stated no other staff in the facility are IP certified. LPN-C stated LPN-C completes resident and staff vaccinations and the facility's antibiotic line list but does not have much time to complete other IP-tasks. LPN-C stated the previous Director of Nursing (DON) was certified but no longer works in the facility.On 3/24/26 at 1:56 PM, Surveyor interviewed DON-B who confirmed DON-B did not complete specialized infection prevention and control training and verified the facility does not have a qualified IP. DON-B stated DON-B will complete training in the future to assist with IP duties. On 3/24/26 at 4:20 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility does not have a qualified IP. NHA-A indicated the former DON and IP ended employment with the facility and LPN-C assumed the IP role.

Based on staff interview and record review, the facility did not ensure 5 residents (R) (R18, R22, R24, R30, and R33) of 10 sampled residents were offered the COVID-19 vaccine.R18 was admitted to the facility on [DATE]. The facility did not obtain R18's consent or declination to receive a COVID-19 vaccine.R22 was admitted to the facility on [DATE]. The facility did not obtain R22's consent or declination to receive a COVID-19 vaccine.R24 was admitted to the facility on [DATE]. The facility did not obtain R24's consent or declination to receive a COVID-19 vaccine.R30 was admitted to the facility on [DATE]. The facility did not obtain R30's consent or declination to receive a COVID-19 vaccine.R33 was admitted to the facility on [DATE]. The facility did not obtain R33's consent or declination to receive a COVID-19 vaccine.Findings include: The facility's Vaccine Policy, revised 10/6/25, indicates: The purpose of this policy is to outline procedures for offering, administering, and documenting vaccines for residents in accordance with Centers for Disease Control and Prevention (CDC) recommendations, Wisconsin Department of Health Services regulations, and applicable state law. Vaccination is a key preventative measure to protect residents from .COVID-19 .which can cause severe illness in older adults .Amethyst Health is committed to: Offering recommended vaccines to all eligible residents; Ensuring informed consent is obtained prior to vaccination; Maintaining accurate vaccine records, resident charts, and immunization logs .Upon admission and annually, nursing staff will assess each resident's vaccination status. Staff will provide education regarding risks, benefits, and potential side effects of recommended vaccines .1. Between 3/23/26 and 3/25/26, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, heart failure, and type 2 diabetes. R18's Minimum Data Set (MDS) assessment, dated 2/15/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R18's cognition was intact. R18's immunization record indicated R18 last received a COVID-19 vaccine on 10/8/24.R18's medical record did not contain a COVID-19 vaccine consent or declination.(See interview under example 5.)2. Between 3/23/26 and 3/25/26, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, heart failure, and placement of a cardiac pacemaker. R22's MDS assessment, dated 2/19/26, had a BIMS score of 13 out of 15 which indicated R22's cognition was intact. R22's immunization record indicated R22 last received a COVID-19 vaccine on 10/28/22.R22's medical record did not contain a COVID-19 consent or declination.(See interview under example 5.)3. Between 3/23/26 and 3/25/26, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including frostbite with tissue necrosis of the left and right foot, moderate protein-calorie malnutrition, and type 2 diabetes. R24's MDS assessment, dated 1/22/26, had a BIMS score of 14 out of 15 which indicated R24's cognition was intact.R24's immunization record indicated R24 had no history COVID-19 vaccines.R24's medical record did not contain a COVID-19 consent or declination.(See interview under example 5.)4. Between 3/23/26 and 3/25/26, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including hepatic encephalopathy, chronic viral hepatitis C, and chronic obstructive pulmonary disease. R30's MDS assessment, dated 1/7/26, had a BIMS score of 9 out of 15 which indicated R30 had moderate cognitive impairment.R30's immunization record indicated R30 last received a COVID-19 vaccine on 5/11/22.R30's medical record did not contain a COVID-19 consent or declination.(See interview under example 5.)5. Between 3/23/26 and 3/25/26, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including heart failure, chronic obstructive pulmonary disease, emphysema, and respiratory failure with hypoxia. R33's MDS assessment, dated 2/16/26, had a BIMS score of 12 out of 15 which indicated R33 had moderate cognitive impairment. R33's immunization record indicated R33 last received a COVID-19 vaccine on 12/13/21.R33's medical record did not contain a COVID-19 consent or declination.On 3/24/26 at 2:35 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C and Director of Nursing (DON)-B. LPN-C indicated residents were last offered the COVID-19 vaccine on 10/21/25. DON-B stated DON-B and LPN-C identified residents' immunizations are not current and are in the process of reviewing residents' immunization records. LPN-C indicated LPN-C is in the process of offering and obtaining consent for vaccines for all residents, including R18, R22, R24, R30, and R33.

Based on staff interview and record review, the facility did not ensure 5 residents (R) (R18, R22, R24, R30, and R33) of 10 sampled residents were offered influenza/pneumococcal vaccines as indicated.R18 was admitted to the facility on [DATE]. The facility did not obtain R18's consent or declination for the influenza and pneumococcal vaccine.R22 was admitted to the facility on [DATE]. The facility did not obtain R22's consent or declination for the pneumococcal vaccine.R24 was admitted to the facility on [DATE]. The facility did not obtain R24's consent or declination for the influenza and pneumococcal vaccine.R30 was admitted to the facility on [DATE]. The facility did not obtain R30's consent or declination for the influenza and pneumococcal vaccine.R33 was admitted to the facility on [DATE]. The facility did not obtain R33's consent or declination for the influenza and pneumococcal vaccine.Findings include: The facility's Vaccine Policy, revised 10/6/25, indicates: The purpose of this policy is to outline procedures for offering, administering, and documenting vaccines for residents in accordance with Centers for Disease Control and Prevention (CDC) recommendations, Wisconsin Department of Health Services regulations, and applicable state law. Vaccination is a key preventative measure to protect residents from influenza, pneumococcal disease, COVID-19, and Respiratory Syncytial Virus (RSV), which can cause severe illness in older adults .Amethyst Health is committed to: Offering recommended vaccines to all eligible residents; Ensuring informed consent is obtained prior to vaccination; Maintaining accurate vaccine records, resident charts, and facility immunization logs .Upon admission and annually, nursing staff will assess each resident's vaccination status. Staff will provide education regarding benefits, risks, and potential side effects of recommended vaccines .Amethyst Health will use the CDC application PneumoRecs VaxAdvisor to determine the need for further pneumo vaccines.1. Between 3/23/26 and 3/25/26, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, heart failure, and type 2 diabetes. R18's Minimum Data Set (MDS) assessment, dated 2/15/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R18 had intact cognition. R18's immunization record indicated R18's last influenza vaccine was on 10/8/24.(See interview under example 5.)2. Between 3/23/26 and 3/25/26, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, heart failure, and placement of a cardiac pacemaker. R22's MDS assessment, dated 2/19/26, had a BIMS score of 13 out of 15 which indicated R22 had intact cognition. R22's immunization record indicated R22 received a pneumococcal 13 vaccine on 11/9/15 and a pneumococcal 23 vaccine on 10/16/06. The recommended pneumococcal vaccine for R22 based on R22's pneumococcal immunization history: Pneumococcal conjugate 20 or pneumococcal conjugate 21 five years post pneumococcal 13 administration.(See interview under example 5.)3. Between 3/23/26 and 3/25/26, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including frostbite with tissue necrosis of the left and right foot, moderate protein-calorie malnutrition, and type 2 diabetes. R24's MDS assessment, dated 1/22/26, had a BIMS score of 14 out of 15 which indicated R24's cognition was intact. R24's immunization record indicated R24's last influenza vaccine was on 3/5/25.(See interview under example 5.)4. Between 3/23/26 and 3/25/26, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including hepatic encephalopathy, chronic viral hepatitis C, and chronic obstructive pulmonary disease. R30's MDS assessment, dated 1/7/26, had a BIMS score of 9 out of 15 which indicated R30 had moderate cognitive impairment. R30's immunization indicated R30's last influenza vaccination was on 11/9/18. R30 had no history of pneumococcal vaccines.(See interview under example 5.)5. Between 3/23/26 and 3/25/26, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE] and had diagnoses including heart failure, chronic obstructive pulmonary disease, emphysema, and respiratory failure with hypoxia. R33's MDS assessment, dated 2/16/26, had a BIMS score of 12 out of 15 which indicated R33 had moderate cognitive impairment. R33's immunization record indicated R33's last influenza vaccine was on 10/18/22. R33 received the pneumococcal 23 vaccine on 10/26/20 and a pneumococcal conjugate 13 vaccine on 1/23/16. The recommended pneumococcal vaccine for R33 based on R33's pneumococcal immunization history: Pneumococcal conjugate 20 or pneumococcal conjugate 21 five years post pneumococcal 23 administration.On 3/24/26 at 2:35 PM, Surveyor interviewed LPN-C and DON-B. LPN-C indicated the last time residents were offered the influenza vaccine was 10/21/25. LPN-C was not aware of the CDC guidelines and recommendations for pneumococcal vaccination. DON-B indicated DON-B and LPN-C identified residents' immunizations are not current and are in the process of reviewing immunization records. DON-B indicated the facility will offer all vaccines to residents as necessary. LPN-C indicated LPN-C is currently in the process of offering and obtaining consent for vaccines for all residents, including R18, R22, R24, R30, and R33.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 4 residents (R) (R44, R3, R35, R5) of 4 sampled residents.R44, R3, R35, and R5 were on enhanced barrier precautions (EBP). Staff did not wear the appropriate personal protective equipment (PPE) during high-contact resident cares. Findings Include: The facility's Enhanced Barrier Precautions policy, dated 3/25/24, indicates: It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of multi drug-resistant organisms. EBP refers to an infection control intervention designed to reduce transmission of multi drug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .c. 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 .b. An order for enhancement for barrier precautions will be initiated for residents with any of the following .indwelling medical devices .3. Implementation of EBP: make gown and gloves available immediately near or outside the resident's room. b. PPE for EBP is only necessary when performing high-contact care activities .4. High-contact resident care activities include: c. transferring d. providing hygiene. 5. EBP should we followed outside the resident's room .when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. 1. Between 3/23/26 and 3/25/26, Sureyor reviewed R44's medical record. R44 was admitted to the facility on [DATE] and had diagnoses including peritoneal abscess, enterotoxigenic escherichia coli infection, and type 2 diabetes. R44's Minimum Data Set (MDS) assessment, dated 3/24/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R44 had intact cognition. A care plan, dated 3/19/26, indicated R44 was at risk for complications due to an intravenous/peripherally inserted central catheter (IV/PICC) line. The care plan contained an intervention for EBP, dated 3/24/26. R44's medical record contained the following order: ~ Change IV/PICC line dressing every 7 days and as needed using sterile technique. Measure PICC. Every day shift every 7 days (dated 3/18/26) ~ Enhanced barrier precautions every shift (dated 3/24/26) Surveyor reviewed R44's progress notes related to cares that require PPE and noted the following: ~ On 3/18/26, R44 was admitted for IV antibiotics following an abdominal abscess that was drained using a Jackson Pratt (JP) drain (a closed-suction device used to remove excess fluids from surgical sites to prevent infection and reduce swelling) which was removed before discharge. ~ On 3/23/26, R44 had a large emesis. ~On 3/23/26 at 10:30 AM, Surveyor observed an EBP sign on the wall above R44's bed. ~On 3/23/26 at 11:40 AM, Surveyor observed a Certified Nursing Assistant (CNA) enter R44's room, provide a basin, and assist as R44 was vomiting. The CNA entered R44's room without completing hand hygiene or donning PPE and exited the room without completing hand hygiene. ~ From 3/23/36 to 3/25/26, Surveyor did not observe PPE carts outside residents' rooms. On 3/24/25 at 3:39 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C and Director of Nursing (DON)-B. LPN-C indicated R44 was not on EBP. LPN-C stated R44's surgical site was healed and R44 did not have any wounds. When Surveyor asked about the facility's EBP policy and precautions used for intravenous catheters, DON-B indicated R44 had a midline IV in the right arm and should be on EBP. DON-B also indicated staff should use PPE during cares. On 3/25/26 at 10:31 AM, Surveyor observed Physical Therapy Assistant (PTA)-D working with R44. PTA-D was not wearing PPE. PTA-D applied gloves as Surveyor was speaking with R44's Power of Attorney (POA). On 3/25/26 at 10:59 AM, Surveyor interviewed Registered Nurse (RN)-E who stated PPE is kept outside residents' rooms in a cart. RN-E indicated RN-E would have to ask DON-B or another nurse which residents are on EBP since signs aren't always visible outside residents' rooms. RN-E indicated if a resident is on EBP, staff should wear a gown and gloves when providing therapy and assisting with cares. On 3/25/26 at 12:46 PM, Surveyor interviewed PTA-D who was not aware R44 was on EBP. PTA-D stated PTA-D noticed the EBP sign on R44's wall while working with R44 so PTA-D donned gloves. 2. On 3/23/26, Surveyor reviewed R3's comprehensive care plan, revised 2/8/26. The care plan indicated R3 had end stage renal disease and was dependent on hemodialysis. R3 had a permacath (a flexible tube placed into a blood vessel in the upper chest and threaded to the right side of the heart) for hemodialysis. (Of note: R3's medical record did not contain an order for EBP.) On 3/23/26 at 9:44 AM, Surveyor interviewed R3 regarding staff wearing PPE. R3 indicated staff do not wear gowns when providing high-contact cares, only gloves on occasion. Surveyor did not observe an EBP sign inside or outside R3's room and could not locate any gowns in R3's room. On 3/25/26 at 11:14 AM, Surveyor interviewed DON-B regarding EBP for R3. DON-B verified R3 should be on EBP due to the permcath and indicated an order for EBP was added on 3/24/26. 3. On 3/25/26, Surveyor reviewed R35's medical record and noted an order, dated 10/14/25, for EBP. On 3/25/26 at 12:46 PM, Surveyor observed CNA-I and CNA-J transfer R35 into bed with a Hoyer lift. CNA-I and CNA-J adjusted R35's linens without wearing gowns or gloves. (See interview under example 4.) 4. On 3/25/26, Surveyor reviewed R5's medical record and noted an order, dated 11/7/25, for EBP. R5's comprehensive care plan, revised 2/14/26, indicated R5 was at increased risk for infection related to a urinary catheter. On 3/25/26 at 11:00 AM, Surveyor observed R5 in R5's room. An EBP sign was posted above R5's bed. On 3/25/26 at 11:07 AM, Surveyor observed CNA-K and CNA-L transfer R5 from a recliner to a wheelchair without wearing gowns or gloves. CNA-L also folded R5's blanket and moved R5's catheter bag to the wheelchair without wearing PPE. On 3/25/26 at 11:14 AM, Surveyor interviewed DON-B who verified staff should wear a gown and gloves during high-contact resident cares.

Based on staff interview and record review, the facility did not ensure appropriate weight monitoring was provided for 5 residents (R) (R20, R29, R26, R24, and R15) of 6 sampled residents.R20, R29, R26, R24 and R15 were not re-weighed for weight loss or gain greater than 5 pounds (lbs). R20, R29, R26, R24, and R15's providers and/or representatives were not notified regarding weight loss or gain greater than 5 lbs. In addition, R20, R29, R26, R24 and/or R15's weights were not obtained using a consistent device.Findings include:The facility's Weight Assessment and Intervention policy, revised March 2022, indicates: Resident weights are monitored for undesirable or unintended weight loss or gain. 1. Residents are weighed upon admission and at intervals established by the Interdisciplinary Team. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. A. If the weight is verified, nursing will immediately notify the dietitian in writing. 4. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss=(usual weight-actual weight)/(usual weight) x 100): a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. c. 6 months - 10% weight loss is significant; greater than 10% is severe. If the weight change is desirable, this is documented. 1. Between 3/23/26 and 3/25/26, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had diagnoses including morbid obesity and type 2 diabetes. R20's Minimum Data Set (MDS) assessment, dated 2/14/26, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R29's cognition was severely impaired. R20 had an activated POA.Surveyor reviewed R20's weights and noted the following:~ 3/17/26 at 9:34 PM, 303.0 lbs (mechanical lift) (R20's weight was up 42.6 lbs)~ 3/16/26 at 8:42 PM, 260.4 lbs (mechanical lift) (R20's weight was down 42.2 lbs)~ 3/9/26 at 8:54 PM, 302.6 lbs (mechanical lift)~ 3/2/26 at 9:33 PM, 299.4 lbs (mechanical lift)~ 2/23/26 at 1:38 PM, 295.6 lbs (mechanical lift) (R20's weight down 8.2 lbs)~ 2/16/26 at 10:05 PM, 303.8 lbs (mechanical lift)~ 1/26/26 at 8:42 PM, 303.0 lbs (mechanical lift)~ 1/19/26 at 9:50 PM, 302.4 lbs (mechanical lift) (R20's weight was down 7.8 lbs)~ 1/12/26 at 8:59 PM, 310.2 lbs (mechanical lift)A care plan, dated 11/18/24, indicated R20 had the potential for altered nutrition related to type 2 diabetes, morbid obesity, cognitive communication deficit, and dysphagia. The care plan indicated R20 would have gradual weight loss by 5/9/26 and would accept nutritional supplements as ordered through 5/9/26.R20 had the following orders:~ Weight every Monday (dated 8/18/25)A Nutritional Assessment note, dated 2/14/26, indicated R20's intake average was 75-100%. R20 was started on Remeron for depression which may have appetite stimulant properties. A mini-nutrition assessment of 12 indicated normal nutrition.On 3/24/26 at 2:18 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated staff re-weighed R20 on 3/17/26 and should have documented the weight on 3/17/26 as a re-weigh. LPN-C indicated if a resident's weight is over 100 lbs, a re-weight is required if there is a 5 lb weight variation from the previous weight. LPN-C indicated residents' weights are obtained weekly on their bath day. LPN-C indicated residents with a cardiac diagnosis are weighed based on the provider's order. LPN-C indicated staff noted the stand-up scale was not working in February of 2026 and a new scale was obtained on 3/3/26. LPN-C weighed all residents who use the stand up scale on 3/3/26. LPN-C stated R20's weights should have been accurate as staff used the mechanical lift to weigh R20. LPN-C verified staff should have re-weighed R20 on 1/19/26 and 2/23/26. LPN-C indicated the provider and R20's POA should have notified regarding R20's weight variation of 5 lbs.2. Between 3/23/26 and 3/25/26, Surveyor reveiewed R29's medical record. R29 was admitted to the facility on [DATE] and had diagnoses including dementia, heart failure, and multiple sclerosis. R29's MDS assessment, dated 12/27/25, had a BIMS score of 13 out of 15 which indicated R29's cognition was intact. R29 had an activated POA.Surveyor reviewed R29's weights and noted the following:~ 3/11/26 at 10:58 AM, 185.2 lbs (wheelchair) ~ 3/7/26 at 8:46 PM, 182.2 lbs (wheelchair) (R29's weight was up 7 lbs)~ 3/3/26 at 8:42 PM, 175.2 lbs (wheelchair) (R29's weight was up 6.5 lbs) ~ 2/9/26 at 9:03 PM, 168.7 lbs (wheelchair) (R29's weight was down 5.3 lbs) ~ 2/2/26 at 9:10 PM, 174.0 lbs (wheelchair) A care plan, dated 12/22/23, indicated R29 had the potential for altered nutrition related to multiple sclerosis, heart failure, depression, and dementia. The care plan contained interventions to weigh R29 per facility policy or as ordered and notify the provider per order or with significant changes.R29 had the following order:~ Weekly weight every evening shift every Saturday (dated 3/7/26)A progress note, dated 3/2/26, indicated staff were unable to obtain R29's weight because R29 could not safely balance on the standing scale and refused to be weighed in the Hoyer lift. No other functioning scale was available to weigh R29.On 3/24/26 at 2:18 PM, Surveyor interviewed LPN-C who indicated staff should have reweighed R29 on 2/9/26, 3/3/26, and 3/7/26. LPN-C verified R29's weight should be obtained weekly on R29's bath day. LPN-C indicated the provider and R29's POA should have been notified regarding R29's weight variation of 5 lbs.3. Between 3/23/26 and 3/25/26, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] and had diagnoses including obesity and type 2 diabetes. R26's MDS assessment, dated 3/12/26, had a BIMS score of 14 out of 15 which indicated R26's cognition was intact. R26 had a Guardian.Surveyor reviewed R26's weights and noted the following:~ 3/19/26 at 10:29 PM, 231.8 lbs (wheelchair) (R26's weight was down 5.8 lbs) ~ 3/12/26 at 12:15 PM, 237.6 lbs (wheelchair) ~ 3/5/26 at 8:21 PM, 237.6 lbs (wheelchair) (R26's weight was up 29.2 lbs)~ 2/5/26 at 9:01 PM, 208.4 lbs (wheelchair) (R26's weight was down 7.4 lbs)~ 2/5/25 - Weight disputed on 3/17/26 at 5:31 PM/Registered Dietitian disputed value/reassessed~ 1/29/26 at 8:09 PM, 215.8 lbs (standing) ~ 1/22/26 at 9:21 PM, 217.3 lbs (wheelchair) ~ 1/15/26 at 8:48 PM, 220.9 lbs (standing) (R26's weight was down 13.3 lbs) ~ 1/1/26 at 9:57 PM, 234.2 lbs (standing)A care plan, dated 9/15/25, indicated R26 had the potential for altered nutrition related to C-difficile, type 2 diabetes, and obesity. The care plan indicated R26 will have gradual weight loss by 6/4/26, will accept dietary restrictions through 6/4/26, will be weighed per facility policy or as ordered, and staff will notify the provider per order or with significant changes.R26 had the following order:~ Complete weight every Thursday on evening shift (dated 11/13/25)A Nutritional Assessment progress note, dated 3/12/26, indicated R26's current weight was 229 lbs and Body Mass Index (BMI) was 33.7 (class I obesity). The note indicated R26 would benefit from weight loss related to BMI. R26's medical record did not contain progress notes regarding weights or a Registered Dietician note between 12/25/25 and 3/11/26.On 3/24/26 at 2:18 PM, Surveyor interviewed LPN-C who indicated staff should have re-weighed R26 on 1/15/26, 2/5/26, 3/5/26, and 3/19/26. LPN-C indicated R26's weights are obtained weekly on R26's bath day. LPN-C indicated R26's provider and Guardian should have been notified regarding R26's weight variations of 5 lbs. 4. Between 3/23/26 and 3/25/26, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including moderate protein-calorie malnutrition and type 2 diabetes. R24's MDS assessment, dated 1/22/26, had a BIMS score of 14 out of 15 which indicated R24's cognition was intact.Surveyor reviewed R24's weights and noted the following:~ 3/16/26 at 4:52 PM, 175.0 lbs (wheelchair)~ 3/4/26 at 9:52 AM, 170.6 lbs (wheelchair) (R24's weight was up 24.2 lbs)~ 2/9/26 at 9:05 PM, 146.4 lbs (standing) ~ 1/31/26 at 3:17 PM, 148.0 lbs (wheelchair) (R24's weight was down 7 lbs)~ 1/24/26 at 1:26 PM, 155.0 lbs (wheelchair) ~ 1/17/26 at 1:12 PM, 155.8 lbs (mechanical lift) (R24's weight was down 7.6 lbs)~ 1/16/26 at 4:36 PM, 163.4 lbs (mechanical lift) (R24's weight was up 9.2 lbs)~ 1/15/26 at 5:57 PM, 154.2 lbs (wheelchair) A care plan, dated 1/30/26, indicated R24 had the potential for altered nutrition related to surgical amputation, type 2 diabetes, and moderate protein-calorie malnutrition. The care plan contained interventions to include extra protein, weigh R24 per facility policy or as ordered, and notify the provider per order or with significant changes.R24 had the following order:Weekly weight every evening shift every Monday (dated 2/7/26)A progress note, dated 3/2/26, indicated R24's weight was not obtained because the facility did not have a functioning wheelchair scale. R24 was a bilateral amputee. A nursing order was obtained to weigh R24 on 3/3/26 with the mechanical lift scale.A progress note, dated 2/8/26, contained a weight warning: 148 lbs on 1/31/26 which was a -7.5% change. The writer suspected a weight error. A Nutritional Assessment note, dated 1/22/26, indicated R24 was at risk for malnutrition. R24's nutrition needs were met via oral intakes. The Registered Dietitian recommended extra dietary protein to promote wound healing.On 3/24/26 at 2:18 PM, Surveyor interviewed LPN-C who verified R24's weights are obtained weekly on R24's bath day. LPN-C indicated staff noted the stand up/wheelchair scale was not working in February of 2026 and a new scale was obtained on 3/3/26. LPN-C indicated a mechanical lift was used to weigh R24 on 1/16/26 and 1/17/26 and staff should have re-weighed R24 and updated the provider if the re-weight was greater than a 5 lb variation. LPN-C indicated staff should have weighed R24 on a mechanical lift scale while the stand up/wheelchair scale was being ordered. LPN-C indicated staff should have documented the variations were due to scale maintenance in R24's progress notes prior to obtaining a new scale. 5. Between 3/23/26 and 3/25/26, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including protein-calorie malnutrition, dementia, Alzheimer's disease, and anorexia. R15's MDS assessment, dated 12/25/25, had a BIMS score of 10 out of 15 which indicated R15 had moderate cognitive impairment.Surveyor reviewed R15's weights and noted the following:~ 3/11/26 at 9:58 AM, 161.4 lbs (wheelchair)~ 3/10/26 at 1:38 PM, 158.0 lbs (wheelchair) (R15's weight was down 5 lbs)~ 3/6/26 at 2:25 PM, 163.0 lbs (wheelchair) (R15's weight was up 5 lbs)~ 3/3/26 at 10:21 AM, 158.0 lbs (standing) (R15's weight was down 6 lbs)~ 2/28/26 at 1:48 PM, 164.0 lbs (standing)~ 2/24/26 at 1:13 PM, 164.0 lbs (standing) (R15's weight was up 9 lbs)~ 2/24/26 at 11:44 AM, 155.0 lbs (standing) (R15's weight was down 10 lbs)~ 2/17/26 at 11:14 AM, 165.0 lbs (mechanical lift) (R15's weight was up 20 lbs)~ 2/10/26 at 11:21 AM, 145.0 lbs (wheelchair)~ 2/3/26 at 2:25 PM, 141.0 lbs (wheelchair) (R15's weigh was down 7 lbs)~ 1/27/26 at 10:31 AM, 148.0 lbs (wheelchair) A care plan, dated 10/18/25, indicated R15 had the potential for altered nutrition related to dementia, weakness, and cognitive communication deficit. The care plan contained interventions for R44 to maintain stable nutrition/weight through 6/17/26, weights per protocol or as ordered, and report changes to Registered Dietitian and provider.R15 had the following order:~ Weekly vitals and weights every day shift every Tuesday (dated 4/8/25)A progress note, dated 2/20/26, indicated R15 had a weight increase of 5% in the past 30 days. R15's weight was stable from November through January and between 150 to 145 lbs. R15 weighed 165 lbs on 2/17/26. R15 was re-weighed with an alternate scale with the same result. A Nutrition Assessment note, dated 12/25/25, indicated R15 weighed 143 lbs. A mini-nutrition assessment score of 11 indicated R15 was at risk for malnutrition.On 3/24/26 at 2:18 PM, Surveyor interviewed LPN-C who indicated R15's weight is obtained weekly on R24's bath day. LPN-C indicated staff should have used a consistent scale and contacted the provider for weight variations greater than 5 lbs as the new scale was obtained on 3/3/26. On 3/24/26 at 2:25 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated a plan of correction regarding residents' weights was started on 2/27/26. DON-B stated DON-B noticed residents' weights were missing and staff were not documenting weights. DON-B provided documentation of staff education on weighing residents and documenting weights. DON-B provided verification of the education with signatures of 5 staff. DON-B indicated Certified Nursing Assistants (CNAs) weigh residents and give the weights to the nurse. The nurse determines if a re-weight is required or if the provider should be notified. On 3/25/26 at 9:56 AM, Surveyor interviewed LPN-C and DON-B. LPN-C indicated R15 should have been re-weighed per the facility's policy. DON-B indicated although a plan of correction was initiated on 2/27/26, following the facility's weight policy is a work in progress. DON-B indicated DON-B and LPN-C are currently monitoring and auditing residents' weights to ensure they are documented accurately and the process is being followed as required. DON-B indicated DON-B is not seeing re-weights completed and providers and resident representatives updated as necessary

Based on staff interview and record review, the facility did not ensure adequate monitoring of psychotropic medication was provided for 1 resident (R) (R5) of 5 sampled residents. R5 was prescribed Rexulti (an atypical antipsychotic medication) 0.5 milligrams (mg) once daily for dementia with agitation beginning on 12/18/25. R5's medical record did not include monitoring for adverse reactions or side effects of the antipsychotic medication.The facility's Psychotropic Medication Use policy, dated 8/1/25, indicates antipsychotic medications require monitoring for adverse effects which can include cardiovascular, neurological, and psychosocial effects. On 3/25/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including dementia, diabetes, kidney disease, and hypertension. R5's most recent Minimum Data Set (MDS) assessment, dated 2/14/26, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R5 has severe cognitive impairment. Surveyor reviewed R5's physician orders, Medication Administration Record (MAR), and care plan. R5 had the following physician order: ~ Rexulti 0.5 mg by mouth once daily for one week for dementia with behavior changes then increase to 1 mg daily (start date 12/18/25). The medication was administered as ordered through the date of the survey. R5's medical record did not contain monitoring for adverse reactions or side effects of the medication. Surveyor reviewed the package insert for Rexulti and noted the following potential side effects listed: weight gain, restlessness, sleepiness, dizziness, headache, and increased risk for respiratory infections as well as dementia-related psychosis. On 3/25/26 at 1:03 PM, Surveyor interviewed Director of Nursing (DON)-B regarding monitoring for psychotropic medication. DON-B verified DON-B typically documents adverse reaction/side effect monitoring on a resident's MAR or Treatment Administration Record (TAR) and in the resident's care plan. DON-B verified R5's medical record did not contain monitoring for adverse reactions or side effects of Rexulti.

Based on staff and resident representative interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) agreed to a discharge or was notified when 1 resident (R) (R49) of 3 sampled residents was transferred to another skillled nursing facility. R49 was transferred to another skilled nursing facility on 1/7/26. R49's POAHC (POAHC-M) was not notified or contacted prior to the transfer. In addition, R49's medical record did not contain a recapitulation of stay. Findings include: The facility's undated admission Agreement indicates: All transfers or discharges will comply with Wisconsin and federal regulations (42 C.F.R. S483.15 and applicable state codes). The resident may only be transferred or discharged (whether initiated by the facility or resident) for the reasons and under the procedures outlined below .d. In all cases of facility-initiated discharge, the facility will prepare a discharge plan to help ensure a safe and orderly transfer. 4. Discharge Planning and Orientation: The facility will provide sufficient preparation and orientation to the resident to ensure a safe and smooth transfer or discharge. This includes involvement of the resident and representative in discussing discharge options, arranging a post-discharge care plan, and assisting in locating and transferring to an appropriate facility or setting that can meet the resident's needs. The facility's Social Worker or Discharge Planner will work closely on this process . Between 3/23/26 and 3/25/26, Surveyor reviewed R49's medical record. R49 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, diabetes, and right-side paralysis resulting from a cerebral infarction. R49's Minimum Data Set (MDS) assessment, dated 11/4/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R49 had severely impaired cognition. R49 had an activated POAHC (POAHC-M) to assist with medical decisions. R49's medical record contained a note that indicated on 1/7/26 at 10:00 AM, R49 was transferred to another facility via a transportation service. POAHC-M and R49's family were not present. R49's medical record did not contain any other notes related to R49's discharge, including a recapitulation of stay. On 3/24/26 at 12:09 PM, Surveyor interviewed POAHC-M who indicated the facility did not include POAHC-M in any discharge planning meetings for R49. POAHC-M stated POAHC-M did not initiate the transfer of R49 to another facility. POAHC-M stated POAHC-M was interested in the facility but had not started a transfer for R49. POAHC-M did not know R49 was transferred to the facility until POAHC-M received a call on 1/7/26 and was told the transfer had already taken place. POAHC-M stated POAHC-M did not receive a call from anyone at the facility from October 2025 through 1/7/26 regarding a potential transfer to a new facility and did not receive or sign paperwork for the transfer. POAHC-M was not aware of a recapitulation of stay for R49. R49's medical record contained a discharge order signed and dated 1/6/26 by R49's physician. The resident/resident representative signature area of the discharge paperwork was blank. On 3/24/26 at 12:31 PM, Surveyor interviewed Social Services and Admission/Discharge Coordinator (SSADC)-N who stated SSADC-N is supposed to work with the resident or their representative during discharge planning. SSADC-N indicated discharge planning should be a part of the resident's care plan, should be updated as discharge plans change, and should be addressed quarterly during care plan meetings with residents and/or resident representatives. SSADC-N indicated a signed discharge order is obtained from the physician and paperwork is signed by the resident and/or their representative. SSADC-N indicated there should be documentation in R49's medical record regarding discharge communication. SSADC-N verified R49's medical record did not contain discharge communication. SSADC-N confirmed SSADC-N did not contact POAHC-M regarding R49's discharge and did not have POAHC-M sign discharge paperwork. SSADC-N confirmed the facility should have had an accurate discharge plan for R49 with appropriate documentation. SSADC-N indicated SSADC-N dropped the ball on R49's discharge. On 3/25/26 at 2:17 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who acknowledged the discharge process for R49 did not go as it should have and was not done in accordance with the facility's policy.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R11) of 5 sampled residents was free from a significant medication error.R11 did not receive warfarin (a blood-thinning medication) 2.5 milligrams (mg) as ordered from 1/15/26 through 1/18/26 for a total of four missed doses. The facility's Administering Medications policy, revised April 2019, indicates: Medications are to be administered in accordance with prescriber orders .Medication errors are documented, reported, and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee to inform process changes and/or the need for additional staff training. On 3/24/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including dementia, atrial fibrillation, history of stroke, history of deep vein thrombosis, and hypertension. R11's Minimum Data Set (MDS) assessment, dated 2/14/26, indicated R11 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated R11 had severe cognitive impairment. R11's comprehensive care plan, dated 9/1/23, indicated R11 received anticoagulant therapy related to atrial fibrillation. The care plan contained interventions to: administer anticoagulant medication as ordered by the physician; obtain labs; inform the physician of the results and follow-up as ordered. R11's January 2026 Medication Administration Record (MAR) indicated warfarin 2.5 mg was administered as ordered from 1/12/26 to 1/14/26. R11's 1/15/26 Internationalized Normalized Ratio (INR) (how long it takes for blood to clot) results were 1.1 seconds. (Of note: The therapeutic range is 2-3 seconds.) A physician fax, dated 1/15/26, contained orders to continue warfarin 2.5 mg daily and recheck R11's INR on 1/19/26. (Of note: From 1/15/26 to 1/18/26, warfarin 2.5 mg was not added to R11's MAR and not administered for 4 days.) R11's 1/19/26 INR results were 1.0 seconds. A nursing progress note, dated 1/19/26, indicated R11's INR was completed and R11 had not received warfarin since 1/14/26. The writer verified with the Assistant Director of Nursing that warfarin was missed from 1/15/26 to 1/19/26. The physician and R11's Power of Attorney (POA) were updated. A Notification to Physician, dated 1/19/26, indicated a medication error occurred and warfarin 2.5 mg was last administered on 1/14/26. The physician indicated to continue warfarin 2.5 mg and check R11's INR on 1/22/26. R11's 1/22/26 INR results were 1.1 seconds.On 3/25/26 at 10:21 AM, Surveyor interviewed Nursing Home Administrator (NHA)- A regarding R11's missed warfarin doses. NHA-A was not aware R11 had missed four doses of warfarin. NHA-A could not provide evidence of staff education related to the medication error or review by the QAPI committee.

Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 Resident (R) (R2) of 2 sampled residents. On 8/5/25, R2 developed a facility-acquired stage 2 pressure injury on the gluteal cleft. R2 also had treatment orders for coccyx and sacral wounds. On 9/16/25, R2 was seen at the wound clinic. A provider note indicated R2 did not have an adequate wheelchair cushion when R2 arrived. The pressure injury was classified as a stage 4 and was infected. The facility did not ensure weekly wound assessments were completed timely or accurately for each of R2's wounds. The gluteal cleft pressure injury was not added to R2's care plan until 9/26/25. R2 was prescribed 2 courses of oral antibiotics, required a wound vac and a catheter, and was to start intravenous (IV) antibiotics for osteomyelitis (a bone infection that causes inflammation and destruction of bone tissue). In addition, R2's specialty bed was not on the correct weight setting and R2's wound vac was not changed as ordered. The facility's failure to ensure a resident received the appropriate care and treatment for a stage 2 facility-acquired pressure injury that progressed to a stage 4 infected pressure injury led to a finding of immediate jeopardy that began on 9/16/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 10/29/25 at 4:30 PM. The immediate jeopardy was removed on 10/29/25, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include:The facility's Pressure Injuries and Non-Pressure Injuries policy, revised 7/2025, indicates: For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. The staging of pressure injuries is consistent with the recommendations of the National Pressure Injury Advisory Panel (NPIAP) and the Resident Assessment Instrument (RAI) manual.If pressure injury: Initiate the Pressure Injury Weekly Tracker User-Defined Assessment (UDA) - one per wound. If non-pressure injury: initiate the Non-Pressure Injury Tracker UDA - one per wound. Complete the Braden Scale to assess risk of developing a pressure injury. A Braden assessment tool will be completed.iii. Upon a significant change of condition.v. As needed.4. As needed or upon a significant change of condition: a. Complete a Braden Scale and update the plan of care as needed if changing/new risk factors. B. Review and update plan of care (if indicated) related to skin risk (actual/potential) for alteration in skin integrity. Mobility: As mobility scores decrease, concern about the adequacy of the support surface should increase - evaluate the need for specialty wheelchair cushion and specialty mattress.On 10/28/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including cerebral palsy, pressure ulcer of the sacral region stage 4, and osteomyelitis of vertebra sacral and sacrococcygeal region. A Significant Change of Condition Minimum Data Set (MDS) assessment, dated 9/23/25, indicated R2's cognition was not assessed. An MDS assessment, dated 7/24/25, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R2 had severe cognitive impairment. R2 had a Corporate Guardian ((CG)-C) for healthcare decisions.R2's most recent Braden Scale assessment was completed 7/20/25 and indicated R2 was at high risk for the development of pressure injuries. Of note: The facility's policy indicates a new Braden Scale assessment should be completed with a Significant Change of Condition MDS which was not done on 9/23/25.A care plan (initiated 11/21/22 and last revised 10/2/25) indicated R2 had the potential for impaired skin integrity and/or pressure ulcer development related to impaired mobility, impaired cognition, bowel incontinence, and history of moisture-associated skin damage (MASD) to the gluteal cleft. The care plan contained interventions (dated 5/14/25) to encourage and assist R2 with turning/repositioning every 2 hours or more often as needed or requested; and Encourage and assist R2 to lie on R2's side after lunch.A care plan (initiated 9/26/25 and last revised 9/28/25) indicated R2 had a stage 4 pressure injury on the sacral region that was debrided at the wound clinic on 9/16/25 and 9/26/25. A wound vac was initiated on 9/26/25. The care plan contained interventions (dated 9/28/25) to complete treatments as ordered and monitor for effectiveness and adverse side effects; Implement pressure reducing devices (i.e., ROHO cushion in chair, air mattress, offloading heels); Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration to MD; and Weekly wound documentation to include measurement of area of skin breakdown width, length, depth, type of tissue and exudate, and other notable changes or observations.On 8/5/25, staff identified a new area of concern on R2's gluteal cleft during a shower. A Weekly Skin and Wound Evaluation, dated 8/5/25, indicated R2 had a new in-house acquired stage 2 pressure injury that began on 8/5/25. The wound was 0.8 centimeters (cm) squared and measured 1.3 cm (length) x 0.9 cm (width). The evaluation did not list the location of the wound but indicated education was provided to R2 and staff on the importance of turning and repositioning every 2 hours, to sit upright for short periods in a chair, and to off-load pressure while in a seated position. R2's physician and CG-C were notified. Treatment orders were initiated.A Weekly Skin and Wound Evaluation, dated 8/14/25, indicated R2 had a stage 2 pressure injury that was 19.6 cm squared and measured 9.4 cm x 4.5 cm. The evaluation did not list the location of the wound. Progress was stalled.A Weekly Skin Check completed during a shower on 8/19/25 indicated R2 had a pressure injury on the coccyx. On 8/25/25, a physician provided the following orders: ~ Sacral wound - Cleanse with normal saline. Apply Santyl to wound bed. Do not apply to intact skin. Cover with bordered foam and change daily and as needed (PRN).~ Coccyx wounds - Cleanse with normal saline. Cover wound beds with collagen sheet and bordered foam. Change every 3 days and PRN. On 8/26/25, the following orders were entered in R2's medical record: ~ Measure open area to sacrum and document in wound skin tracker UDA. ~ Measure open area to coccyx and document in wound skin tracker UDA. (R2's medical record did not contain measurements for the above orders.) A Weekly Skin and Wound Evaluation, dated 9/7/25, indicated R2 had a stage 2 pressure injury that was 3.6 cm squared and measured 2.8 cm x 1.8 cm. The evaluation did not list the location of the wound. Progress was stable. Of note: The last Weekly Skin and Wound Evaluation was completed 8/14/25.A Weekly Skin Check, dated 9/9/25, indicated R2 had 2 sacral wounds and an order for Santyl to the wound bed and to cover with a foam dressing.On 9/9/25, R2's physician provided a wound clinic referral. A progress note, dated 9/12/25 at 3:31 PM, indicated the referral was faxed to the wound clinic.A progress note, dated 9/12/25 at 3:11 PM, indicated R2 had nasal congestion, did not feel well, and wanted to stay in bed.A Weekly Skin and Wound Evaluation, dated 9/14/25, indicated R2 had a new (no start date indicated) unstageable pressure injury with slough and/or eschar that was 4.7 cm squared and measured 3.2 cm x 2.0 cm x 0.4 cm (depth). The evaluation did not list the location of the wound or indicate notifications were completed. Progress was deteriorating. On 9/14/25, the following orders were entered in R2's medical record:~ Coccyx wound - Cleanse with Vashe. Apply Santyl to wound bed. Cover with moist gauze for mild exudate. If heavy exudate, cover with calcium alginate instead every day and evening shift.~ Cleanse open area on gluteal fold with soap and water. Rinse well and pat dry. Cover with Exuderm Thin 2 x 2 for increased exudate every other day.A progress note, dated 9/15/25 at 2:53 PM, indicated R2 did not feel well, was tired, had a decreased appetite, and loose stool. R2's dressing was changed. Previous gauze packed in the wound was saturated with green/dark brown/black drainage and the wound was malodorous. A wound clinic appointment was scheduled for 9/16/25.A wound clinic note, dated 9/16/25, indicated R2 arrived alone in a wheelchair with a thin polyurethane foam cushion. There was an urgent recommendation for a ROHO cushion for offloading. Pre-debridement, R2 had a stage 4 decubitus sacral ulcer that measured 3.5 cm x 1.2 cm x 0.7 cm. The wound bed contained chronic subcutaneous tissue that extended to the fascia. The periwound contained maceration. The wound was malodorous and had moderate seropurulent drainage. A culture was obtained. The facility was encouraged to evaluate R2 for a group 2 off-loading mattress as soon as possible. Wound vac therapy would be considered when R2's periwound was improved.The wound clinic provided the following orders:~ Stage 4 sacral ulcer - Remove dressing. May perform a gentle dry gauze rub to remove any loose tissue. Place Dakin's dampened gauze to fill wound cavity. Cover with ABD pad and Medipore tape or equivalent. Change dressing at least once daily and PRN for fecal soiling. Of note: An addendum to the order indicated the facility could use Vashe instead of Dakin's to cleanse the wound. On 10/30/25 at 8:45 AM, Surveyor interviewed Wound Care Physician (WCP)-D who clarified a statement in the wound clinic note that indicated R2 had an adequate wheelchair offloading cushion. WCP-D indicated there was a transcription error and the note should have stated R2 had an inadequate wheelchair offloading cushion.R2's medical record contained an order (dated 9/16/25) for a fully inflated ROHO cushion when up in chair every shift. A progress note, dated 9/17/25 at 1:59 PM, indicated the facility's physician saw R2 for worsening sacrum wound concerns post-surgical debridement. The wounds had increased and had purulent, malodorous drainage. Treatment options were discussed, including the need for more in-depth wound treatment and a wound vac. The wound clinic was contacted to collaborate on a treatment plan to manage R2's exudate. The wound clinic indicated a wound vac may be needed and should be implemented prior to R2's next appointment. On 9/17/25, the facility's physician noted R2 had a post-debridement stage 4 ulcer that was malodorous and contained necrotic tissue at the borders. The wound contained saturated gauze packing. Pictures and wound care notes were reviewed. On 9/17/25, an order was initiated to cleanse R2's coccyx wound with Vashe, moist gauze for exudate, and cover with bordered foam dressing. Every day shift. Discontinue when wound vac applied. Of note: The order did not match the wound clinic order on 9/16/25.On 9/19/25, R2 started Bactrim (an antibiotic) when the culture from 9/16/25 grew Proteus mirabilis.A Weekly Skin and Wound Evaluation, dated 9/19/25, indicated R2 had an unstageable pressure injury (despite the wound clinic indicating the wound was a stage 4) that was 6 cm squared and measured 2.3 cm x 3.5 cm. The evaluation did not list the location of the wound which was stable and contained light exudate with a moderate odor. An order from R2's wound clinic appointment on 9/16/25 that was transcribed on 9/20/25 indicated: ~ Wound care: Coccyx - Cleanse periwound and wound bed with Vashe using gauze. Do not scrub. Fill wound with Vashe dampened roll gauze and cover with ABD. Secure with paper tape. Once daily every day shift. Discontinue when wound vac applied. A Weekly Skin and Wound Evaluation, dated 9/25/25, indicated R2 had an unstageable pressure injury that was 8.3 cm squared and measured 3.1 cm x 3.6 cm. The evaluation did not list the location of the wound.A wound clinic note, dated 9/26/25, indicated R2 had a new specialty bed and a ROHO cushion. A wound vac was applied. Post debridement, R2's wound measured 4.2 cm x 1.9 cm x 1.6 cm. The wound bed contained early granulations with subcutaneous necrosis that was debrided to viable tissue. The wound contained a large amount serosanguineous drainage but no odor. R2 had an order to change the wound vac every Monday/Wednesday/Friday.On 9/29/25, a urinary catheter was inserted to keep the wound from getting soiled.A progress note, dated 9/29/25 at 9:39 PM, indicated the wound vac was not changed because supplies were unavailable. The physician stated to contact the wound clinic in the morning. Of note: R2's medical record did not indicate the wound clinic was contacted. R2's Treatment Administration Record (TAR) indicated the wound vac was changed on the next scheduled date (10/1/25). Of note: R2's wound vac was applied at the wound clinic on 9/26/25 and not changed for 5 days.A Weekly Skin and Wound Evaluation, dated 10/2/25, indicated R2 had an unstageable pressure injury that was 8.3 cm squared and measured 3.3 cm x 3.2 cm. The evaluation did not list the location of the wound.A wound clinic note, dated 10/3/25, indicated R2 had exposed sacral bone indicative of osteomyelitis. Post debridement, R2's wound measured 3.9 cm x 2.0 cm x 0.4 cm. The wound bed contained granulations (new connective tissue that forms in the healing stage of a wound). The wound contained a large amount of serosanguineous drainage with no odor and was improved. A culture was obtained. R2 was scheduled for a magnetic resonance imaging (MRI) scan (a medical imaging technique that uses a strong magnetic field and radio waves to produce detailed images of the body's internal structures) on 10/9/25. On 10/6/25, R2 was prescribed levofloxacin (an antibiotic) when the culture grew Escherichia (E) coli.On 10/8/25, staff were unable to obtain a photo of R2's coccyx due to iPad log in issues.A wound clinic note, dated 10/10/25, indicated R2 had exposed bone indicative of osteomyelitis. R2 was prescribed a 14-day course of levofloxacin and referred to the Infectious Disease clinic. Post debridement, R2's wound measured 4.2 cm x 2.2 cm x 1.1 cm with undermining on the left side that reached 1.9 cm at 7 o'clock. The wound bed had granulations. The wound contained a large amount of serosanguineous drainage with no odor and was improved. An MRI confirmed sacral osteomyelitis with exposed bone. R2 was referred to Infectious Disease and would likely benefit from IV antibiotics.On 10/17/25 and 10/24/25, R2 saw the wound clinic and had continued orders for a wound vac. On 10/22/25, R2's TAR indicated the wound vac should have been changed. The treatment was not documented as completed and there was no corresponding progress note. On 10/27/25, R2 saw the Infectious Disease clinic who recommended a peripherally inserted central catheter (PICC) line and 2 grams of IV ceftriaxone (an antibiotic) every 24 hours for 6 weeks.On 10/28/25 at 12:58 PM, Surveyor interviewed CG-C who indicated R2 had previous areas of concern but not to this extent. CG-C wondered if the severity of the pressure injury was avoidable. On 10/28/25 at 3:38 PM, Surveyor interviewed Registered Nurse (RN)-E via phone who was the interim DON from April through August 2025. RN-E indicated R2 had areas that opened and closed but nothing to this extent. When asked about R2's coccyx, sacrum, and gluteal cleft wound orders, RN-E thought the MASD and gluteal fold were healed and the coccyx/sacral region was not. RN-E contacted R2's facility physician for a wound clinic referral after RN-E observed R2's wound on 9/9/25 and noted it was worse than the last time RN-E saw it. RN-E could not recall when RN-E last saw the wound prior to 9/9/25.On 10/28/25 at 3:53 PM, Surveyor interviewed RN-F via phone who indicated weekly wound assessments are completed when the facility's system indicates they should be. RN-F confirmed pictures are obtained with an iPad. RN-F was surprised the evaluations did not contain a wound location. RN-F indicated R2's wound started at the gluteal crease and extended toward the coccyx. RN-F stated staff did a good job repositioning R2 who did not always like to be on R2's side. On 10/28/25 at 2:20 PM, Surveyor interviewed DON-B who had recently started at the facility and was not involved with R2's wound progression. DON-B acknowledged there were missing weekly wound evaluations and verified the evaluations did not contain the location of the wound. When asked about treatment orders for R2's coccyx, sacrum, etc., DON-B indicated the facility did not have assessments for each of the treatment areas. DON-B verified R2's care plan was not updated until 9/26/25 but should have been updated upon discovery of the gluteal cleft wound on 8/5/25. When asked to check R2's wound clinic order from 9/16/25, DON-B verified the order entered on 9/17/25 did not match the wound clinic order. When informed about WCP-D's concern for R2's wheelchair cushion, DON-B verified interventions should have been addressed and updated as soon as the wound was noted. DON-B also confirmed a Braden Scale assessment was not completed with R2's Significant Change of Condition MDS assessment. DON-B indicated photos were not obtained due to iPad issues when the facility changed ownership.On 10/28/25 at 3:53 PM, Surveyor observed R2 in bed and noted R2's air mattress was set at 400 pounds. Of note: R2's weight on 10/28/25 was 228.8 pounds.On 10/29/25 at 12:50 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G via phone. Surveyor noted R2 had a stage 2 pressure injury on the gluteal cleft on 8/5/25; however, a weekly skin check on 8/19/25 indicated R2 had a wound on the coccyx. When asked if the physician was notified, LPN-G indicated it was probably the same area and stated R2 had three areas that were discovered at approximately the same time. Each wound progressed differently and more than likely merged into one wound with healed tissue in between. At one point, staff completed three different treatments. When asked if a wound assessment should have been completed for each area since each area had different orders, LPN-G indicated staff looked at the wound as one area. LPN-G verified accurate and thorough assessments should have been completed and should have contained the location of the wound. LPN-G verified there were issues with an iPad used for wound assessments and indicated assessments were likely missed. LPN-G entered an order for staff to document wound measurements in a progress note (which was not completed). When asked if staff could enter an assessment in R2's medical record without a photo, LPN-G indicated that was possible. LPN-G also indicated Braden Scale assessments and care plan updates may have been missed. LPN-G indicated R2 could have used a ROHO cushion for longer than R2's medical record indicated. R2 had a Broda chair which was too big to use for transport. LPN-G indicated R2 used a smaller wheelchair for transport to the wound clinic and stated the ROHO cushion may not have been put in the wheelchair. LPN-G confirmed R2's medical record did not indicate R2 had a ROHO cushion prior to 9/16/25. When informed that R2's bed was set to 400 pounds, LPN-G indicated the bed should be set to R2's weight. LPN-G indicated staff enter an order to ensure the mattress is checked for functioning, however, the order does not usually contain a weight setting. LPN-G verified R2 did not have orders for either. When asked if R2's wound vac was changed on 10/22/25, LPN-G indicated if the wound vac was not changed, staff should have entered a note to indicate why.The failure to ensure a resident received the appropriate care and treatment for a stage 2 facility-acquired pressure injury that progressed to a stage 4 infected pressure injury created a reasonable likelihood for serious harm which led to a finding of immediate jeopardy. The immediate jeopardy was removed on 10/29/25. The deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement the following action plan: Educated staff on the facility's skin and wound assessment process, timely transcription and implementation of physician orders, what to do if supplies are unavailable, care plan updates, and Braden Scale assessments Wound physician to round weekly with facility staff devoted to wound care. Implemented new skin and wound assessment forms.Implemented skin impairment/new pressure area audits twice weekly for 6 weeks.

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 all 34 residents residing in the facility. The facility did not store food in a manner to ensure food safety and did not use proper food dating practices. The facility did not follow safe food cooling protocols. Findings include: On 1/6/25 at 8:44 AM, Surveyor interviewed Dietary Manager (DM)-D who was unsure which food code the facility followed. DM-D conferred with the facility's Registered Dietician (RD) and then indicated to Surveyor that the facility followed the Federal Food and Drug Administration (FDA) Food Code. Food Labeling/Storage: The facility's Food Receiving and Storage policy, revised November 2024, indicates: Food shall be received and stored in a manner that complies with safe food handling practices .Dry Storage: .4. Dry foods that are stored in bins and removed from the original packaging, labeled and dated (use by date) .Refrigerated/Frozen Storage: 1. All foods in the refrigerator or freezer are covered, labeled, and dated (use by date). 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 S 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 5 C (Celsius) (41 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). During an initial kitchen tour that began at 8:44 AM on 1/6/25, Surveyor and DM-D observed the following items in the cooler, freezer, and dry storage areas: Cooler: ~ Various half sandwiches dated 1/4/25 with no use by dates ~ A tray of individual servings of pears dated 1/5/25 with no use by dates ~ Four sour cream cups dated 12/23/24 with no use by dates ~ A one half-full 5-pound bag of shredded cheddar cheese dated 1/3/25 with no use by date ~ A one third-full 5-pound bag of shredded parmesan cheese with no open or use by dates Freezer: ~ Cooked cheese pizza slices individually wrapped and dated 1/1/24 with no use by dates ~ A pan of brownies dated 12/31/24 with no use by date ~ A container of stroganoff dated 12/20/24 with no use by date ~ A container of pizza sauce dated 1/1/25 with no use by date ~ A container of cooked ground beef dated 12/15 with no use by date ~ A container of cooked ground beef dated 12/19/24 with no use by date ~ A container of cooked Italian sausage dated 12/26/24 with no use by date ~ Cooked pork cutlets dated 12/19/24 with no use by date Dry Storage: ~ A container of bulk sugar dated 11/8/24 with no use by date ~ A container of bulk flour dated 10/24/24 with no use by date ~ A one third-full bag of penne pasta with a received date (per DM-D) of 10/24/24 and no open or use by dates ~ A one third-full bag of elbow pasta with a received date (per DM-D) of 12/10/24 and no open or use by dates ~ A three quarters-full bag of rotini pasta with a received date (per DM-D) of 12/27/24 and no open or use by dates ~ A container of Corn Flakes with a received date (per DM-D) of 10/18/24 and no open or use by dates ~ A container of Raisin Bran with an open date (per DM-D) of 1/5/25 and no use by date ~ A container of crisp rice cereal with a received date (per DM-D) of 11/5/24 and no open or use by dates ~ A package of dry powder identified as brown gravy mix (per DM-D) with an open date (per DM-D) of 12/30/24 and no use by date ~ A package of bread crumbs with a received date (per DM-D) of 11/27/24 and no open or use by dates Surveyor interviewed DM-D who indicated DM-D was unaware of a food dating policy and indicated DM-D did not know specific dates of how long food could be stored in the refrigerator, freezer, or dry storage. DM-D was unaware that open and/or cooked food should contain use by dates. DM-D stated DM-D was not aware of the facility's policy for how long to store cooked and open food. DM-D asked Surveyor how long to store food, how to date food, how to write a policy for storing food, and where someone finds food storage information. On 1/7/25 at 3:32 PM, Surveyor interviewed [NAME] (CK)-E who was unclear on how long items should be stored. CK-E stated many items in the refrigerator were kept for three days, however, CK-E could not specify how long open dry goods and freezer items should be stored. CK-E was not aware of a policy that contained specifics on food storage, but thought CK-E may have received training after CK-E was hired. On 1/7/25 at 3:40 PM, Surveyor interviewed Dietary Aide (DA)-F who was unclear on the facility's dating policy for food storage. DA-F indicated DA-F dated foods when they were received but did not know the use by dates. DA-F was unaware of a food dating policy. Cooling Temperatures: The facility's Food Receiving and Storage policy, revised November 2024, indicates: Food shall be received and stored in a manner that complies with safe food handling practices .Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or six hours (if cooked and cooled) may cause foodborne illness outbreak if consumed . The 2022 FDA Food Code documents at 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The 2022 FDA Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. During an initial kitchen tour that began at 8:44 AM on 1/6/25, Surveyor observed the facility's food cooling logs with DM-D. The cooling logs contained food items and dates. There was a column for the final cooking temperature and a header column that stated 135 degrees to 70 degrees in 2 hours. Under the header column were three additional columns to record cooling temperatures and times which stated cool start, 1 hour, and 2 hour. A second header column stated 70 degrees to 41 degrees F in 4 hours under which there were 4 columns marked 3 hour, 4 hour, 5 hour, and 6 hour for staff to record times and cooling temperatures at those markers. Surveyor reviewed 6 pages of cooling log entries with DM-D. There were 50 food entries on the logs. Of the 50 entries, 6 items were cooled to 41 degrees or less within the 6-hour time frame. The other 44 entries were either not completed, contained blank spots, or contained temperatures on each entry that were well above 70 degrees in two hours and/or above 41 degrees in 6 hours. Surveyor interviewed DM-D who indicated food should be between 135 and 70 degrees F in the first two hours. DM-D was not aware food items should be 60 degrees F or less in the first two hours and 41 degrees F or less in a 6-hour time frame. DM-D indicated DM-D must have misunderstood the cooling log directions. DM-D indicated DM-D and others should have filled out the cooling logs via the proper cool down to 41 degrees within 6 hours. On 1/7/25 at 3:32 PM, Surveyor interviewed CK-E who was unable to correctly identify food cooling steps or appropriate food cooling temperatures. CK-E indicated food should cool on the counter for a couple of hours with the lid ajar and be refrigerated when it is under 100 degrees. CK-E indicated CK-E was aware of and had used food cooling logs. On 1/7/25 at 4:07 PM, Nursing Home Administrator (NHA)-A indicated NHA-A expects kitchen staff to know appropriate food storage and food cooling procedures.

Based on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable temperature for 4 residents (R) (R24, R32, R87, and R239) of 14 sampled residents. R24, R32, R87, and R239 indicated hot food was not always served hot. During the breakfast meal on 1/7/25, food items were not served at a palatable temperature. Findings include: The facility served residents in the dining room as well as on individual room trays. Surveyor twice requested the facility's policy on meal serving/food temperatures. A policy was not provided. The U.S. Food and Drug Administration (FDA) provides guidelines for cooking and serving temperatures to ensure food safety. According to the 2022 FDA Food Code, the following minimum internal temperatures should be achieved when cooking various foods: ~ Poultry (whole, pieces, or ground): 165 Fahrenheit (F) (74 Celsius (C)) for at least 15 seconds ~ Ground meats (beef, pork, other than poultry): 155 F (68 C) for at least 15 seconds ~ Seafood (fish, shellfish, and crustaceans): 145 F (63 C) for at least 15 seconds ~ Eggs: For immediate service: 145 F (63 C) for at least 15 seconds; Hot-held for service: 155 F (68 C) for at least 15 seconds. ~ Roasts (beef, pork, veal, lamb): 145 F (63 C) for at least 4 minutes ~ Fruits and vegetables cooked for hot holding: 135 F (57 C) The temperatures are designed to reduce the risk of foodborne illnesses by ensuring harmful pathogens are destroyed during cooking. 1. From 1/6/25 to 1/7/25, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE]. R24's Minimum Data Set (MDS) assessment, dated 1/3/25, had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 which indicated R24 was severely cognitively impaired. On 1/7/25 at 8:23 AM, Surveyor interviewed R24 who indicated R24's breakfast and coffee were cold. R24 also stated breakfast was served late. R24 indicated breakfast isn't always hot and reported the cold meal and coffee to staff. R24 told staff that morning time was R24's best time of day and R24's best time was ruined because of the cold food. 2. From 1/6/25 to 1/7/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE]. R24's MDS assessment, dated 11/14/24, had a BIMS score of 2 out of 15 which indicated R32 was severely cognitively impaired. On 1/7/25 at 8:36 AM, Surveyor observed staff serve meal trays and noted the trays were not in a heated serving cart. Surveyor asked staff to temp a tray designated for R32 and noted the following temperatures: ~ Eggs: 98.2 degrees F ~ Sausage: 93.5 degrees F ~ Waffle: 89.9 degrees F 3. From 1/6/25 to 1/7/25, Surveyor reviewed R87's medical record. R87 was admitted to the facility on [DATE]. R87's MDS assessment, dated 1/3/25, had a BIMS score of 13 out of 15 which indicated R87 was not cognitively impaired. On 1/7/25 at 8:48 AM, Surveyor interviewed R87 who indicated R87's breakfast was served cool and indicated hot food was not served hot. 4. From 1/6/25 to 1/7/25, Surveyor reviewed R239's medical record. R239 was admitted to the facility on [DATE]. R239's MDS assessment, dated 1/3/25, had a BIMS score of 13 out of 15 which indicated R239 was not cognitively impaired. On 1/7/25 at 8:36 AM, Surveyor observed staff serve meal trays and noted the trays were not in a heated serving cart. At 8:38 AM, Surveyor asked staff to temp a tray designated for R239 and noted the following temperatures: ~ Eggs: 94.1 degrees F ~ Sausage: 91.5 degrees F ~ Waffle: 93.9 degrees F ~ Milk: 56.8 degrees F ~ Coffee: 134 degrees F On 1/7/25 at 8:41 AM, Surveyor interviewed R239 who indicated R239's breakfast was cold. R239 indicated breakfast was usually served cold, but it was exceptionally cold that day. R239 indicated R239's waffle was tough and inedible because it was so cold. R239 indicated it was harder for elderly people to chew cold food. On 1/7/25 at 8:29 AM, Surveyor interviewed Dietary Manager (DM)-D who indicated breakfast was usually served at 7:30 AM, however, kitchen staff were running late because the dining room was reopened that morning without appropriate communication with the kitchen. DM-D stated room trays were delivered at 7:55 AM. When asked why the trays had not yet been delivered to all residents, DM-D indicated kitchen staff brought the food out on a cart and Certified Nursing Assistants (CNAs) and nurses were responsible for delivering residents' trays. DM-D indicated DM-D did not know why it took the CNAs and nurses so long to deliver food trays but it happened often. DM-D indicated food was temped in the kitchen before it was delivered to ensure the food was hot and within an acceptable temperature range. DM-D stated there was a resident concern that meal trays got cool while waiting too long to be served/delivered the day prior. DM-D confirmed residents' food should be served at a palatable temperature. On 1/7/25 at 8:33 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B did not know why breakfast trays were still being delivered and indicated the process usually went quicker. DON-B stated meal delivery took longer because staff had to don and doff gowns, gloves, and masks to deliver food trays due to illness. When asked if the food was still hot, DON-B was not sure. On 1/7/25 at 4:07 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A expects kitchen staff to follow the kitchen's policies regarding preparing, temping, and serving food.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R87) of 2 sampled residents received appropriate care and services to prevent urinary tract infections (UTIs). The facility did not ensure R87 received catheter care in a manner that decreased the risk of infection. On 1/7/25, R87's uncovered catheter drainage bag was observed on the floor of R87's room. Findings include: The facility's Catheter Care, Urinary policy, dated 11/2023, indicates: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Infection Control: .2. Be sure the catheter tubing and drainage bag are kept off the floor . On 1/6/25, Surveyor reviewed R87's medical record. R87 had diagnoses including pneumonia, diabetes mellitus type 2, and urinary catheter with benign prostatic hyperplasia. R87's Minimum Data Set (MDS) assessment, dated 1/3/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R87 was not cognitively impaired. On 1/7/25 at 9:15 AM, Surveyor observed R87 in a recliner. Surveyor noted R87's catheter bag was not covered with a dignity bag and was in contact with the floor under the recliner. On 1/7/25 at 9:24 AM, Surveyor observed Certified Nursing Assistant (CNA)-C provide catheter care for R87. Following the observation, Surveyor interviewed R87 who indicated staff assisted with transferring R87's catheter bag from the other side of the bed so R87 could transfer from the bed to the recliner. R87 indicated an unknown staff placed R87's catheter bag on the floor. Surveyor interviewed CNA-C who indicated R87's catheter bag should not be on the floor and should be placed in a dignity bag and hung below the level of R87's bladder. CNA-C indicated CNA-C did not know who assisted R87 with the transfer. On 1/8/25 at 11:05 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed catheter bags should be hung below the level of the bladder and should not touch the floor.

Based on staff interview and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 3 residents reviewed for elopement. R1 was assessed to be at risk for elopement after exiting the building without supervision on 3/5/24. A Wanderguard (a security device that triggers an alarm if the wearer exits the facility) was placed on R1's right ankle. On 4/27/24 at 1:35 PM, Housekeeper (HK)-C observed R1 outside the facility near the staff parking lot. Staff were unaware R1 had left the facility and redirected R1 back into the facility. An assessment indicated R1 had no injuries. An investigation determined R1 had exited the facility through a door that did not have a Wanderguard sensor installed. The door through which R1 exited had a door alarm that was not functioning and did not alarm and alert staff when R1 exited the building. The failure to provide adequate supervision for a resident created a finding of immediate jeopardy (IJ) which began on 4/27/24. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 5/31/24 at 3:00 PM. The immediate jeopardy was removed and corrected on 4/27/24. This deficiency is being cited as past non-compliance. Findings include: The facility's Elopement/Unsafe Wandering policy, with a review date of 3/5/24, indicates: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. On 5/31/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including history of stroke, vascular dementia, weakness, and dysphasia (difficulty swallowing). R1's Minimum Data Set (MDS) assessment, dated 2/19/24, contained a Brief Interview for Mental Status (BIMS) score of 1 out of 15 which indicated R1 had severely impaired cognition. R1's medical record indicated R1 had an activated Power of Attorney for Healthcare (POAHC). A fall risk assessment, dated 2/12/24, indicated R1 was at high risk for falls due to intermittent confusion, decreased muscular coordination, and predisposing medication and diagnoses. R1 required the use of assistive devices. A community survival skills assessment, dated 2/6/24, indicated R1 did not know the facility's address, location, or how to contact the facility in an emergency. R1's care plan, revised on 3/5/24, indicated R1 was at risk for elopement due to attempts to leave the facility unattended. A Wanderguard was placed on R1's right ankle. The care plan also stated R1 had poor impulse control and impaired safety awareness. A skilled nursing note, dated 2/22/24, indicated R1 required extensive assistance from one staff for activities of daily living (ADLs). R1 was impulsive while ambulating and needed frequent reminders to slow down and take time between steps. R1 required cues and reminders to use R1's walker correctly and was able to self-propel throughout the facility in a wheelchair. A skilled nursing note, dated 2/14/24, indicated R1 walked in the hall with the assistance of one staff, a walker, and a gait belt. R1 had a tendency to drag R1's right foot. On 5/31/24, Surveyor reviewed the facility's investigation which indicated on 4/27/24 at 1:35 PM, HK-C visualized R1 outside the facility unsupervised and without R1's wheelchair. R1 was standing three feet from the west exit door. HK-C redirected R1 back into the facility without difficulty. HK-C called Housekeeping and Laundry Supervisor (HLS)-F who brought R1's wheelchair to the door. An assessment was completed. R1 sustained no injuries. R1's physician and POAHC were notified. Prior to the elopement, R1 was last seen in R1's room by Licensed Practical Nurse (LPN)-E at approximately 1:10 PM. According to weatherunderground.com, the temperature at the time was approximately 53 degrees with wind gusts near twenty miles per hour. On 5/31/24, Surveyor reviewed a map of Algoma and noted Lake Michigan was approximately one mile from the facility. A major highway with a speed limit of 45 miles per hour was approximately a quarter of a mile from the facility. The investigation summary indicated staff completed a head count of residents and notified Director of Maintenance (DM)-D and NHA-A of R1's elopement and the failure of the door system to alarm. Staff were assigned to each of the facility's exits to ensure no other residents exited the building. DM-D determined the door system was disarmed and immediately installed motion sensor alarms on each of the exit doors. The company who serviced the door alarm system provided same-day onsite troubleshooting and education to all staff. As of 6:15 PM, both alarm systems (Wanderguard and motion sensor) were armed and working appropriately. The investigation included statements from staff as well as daily audits to ensure functioning of the alarm systems. Although R1 was not injured, a reasonable likelihood for serious harm from falling and from environmental hazards exists when a severely confused resident who is at high risk for falls is outside unsupervised. This created a finding of immediate jeopardy. The facility removed and corrected the jeopardy on 4/27/24 when it completed the following: 1. Initiated 1:1 supervision for R1 2. Posted staff at each doorway to ensure no other residents left unsupervised 2. Interviewed and assessed other residents for elopement risk 3. Educated all staff on the alarm system and elopement 4. Completed an elopement drill and tested both alarm systems daily On 5/31/24, Surveyor observed R1 at 9:25 AM, 11:47 AM, and 1:14 PM. R1's Wanderguard was in place and functioning. Surveyor also noted the Wanderguard system was armed and functioning. On 5/31/24 at 9:55 AM, Surveyor opened the north door and activated the motion sensor alarm. Surveyor observed staff respond immediately to the alarm and conduct a head count of residents to ensure safety.

Based on staff interview and record review, the facility's governing body did not ensure safe and efficient management of the facility by ensuring adequate funds were provided to pay vendors who supplied services to the facility. In addition, the facility did not ensure staff received their health insurance benefits and paychecks on a timely basis. This practice had the potential to affect all 34 residents residing in the facility. The governing body did not maintain current payment status with multiple vendors which resulted in past due balances, account holds, disconnection notices, or lapses in service for supplies, food, staff, medical record management, waste removal, lawn maintenance, and the emergency generator. The corporation's failure to keep service vendor contracts in good standing had the potential to negatively impact residents' quality of care and quality of life. In addition, the corporation did not pay employees or their insurance premiums in a timely manner which resulted in overdraft fees and a lapse in coverage. Findings include: The facility's Governing Body Duties and Responsibilities policy, dated December 2019, indicates: The company must have a Governing Body that assumes full legal responsibility for establishing and implementing policies regarding the management and operation of the facility .The Governing Body, in conjunction with regular reporting by the Administrator, should assess on a regular basis that services are being provided in accordance with facility policies .and that there is an efficient use of resources .C. Appointment of Administrator: The Governing Body is responsible for appointing an Administrator who shall: .c. Report to and be accountable to the Governing Body .ii. The Administrator and Governing Body will determine which types of problems and information, including compliance concerns, overpayments and underpayments, and other risk areas should be reported to the Governing Body and the method of communication .g. Have a thorough working knowledge of the overall operation of the facility, including the scope of services provided, policies governing these services, and budgetary and fiscal matters. On 5/31/24, Surveyor toured the facility after receiving financial concerns with the potential to affect day-to-day operations and resident care. On 5/31/24 at 9:55 AM and 1:05 PM, Surveyor interviewed Housekeeping and Laundry Supervisor (HLS)-F who verified HLS-F ordered supplies for the facility, including janitorial supplies, medical supplies, and Wanderguards. HLS-F confirmed the facility's account with Janitorial Supply (JS)-G was on hold due to nonpayment. HLS-F stated HLS-F ordered janitorial supplies from other companies, including Medical Supply (MS)-H. HLS-F confirmed the facility had an account with MS-H, but owed $29,871.65. HLS-F stated the facility bought biohazard bags and rented underpads (used as a barrier for incontinence) from Supply Company (SC)-I and confirmed their account was on hold due to nonpayment and a balance of $4,518.55. HLS-F stated for the last month, SC-I did not deliver, pick up, or launder underpads. HLS-F stated the facility had a supply of underpads that SC-I did not pick up which the facility laundered and reused. HLS-F stated HLS-F ordered dietary, housekeeping and laundry chemicals from SC-K. HLS-F confirmed the account was on hold in the past; however, HLS-F ordered supplies on 5/28/24 and received them on 5/29/24. HLS-F stated HLS-F ordered Wanderguards through SC-L and confirmed the account was on hold. HLS-F confirmed a resident's Wanderguard stopped working in January of 2024 and the facility didn't have a replacement. HLS-F stated staff completed 15 minute checks for twenty four hours until an overnight shipment of Wanderguards arrived. HLS-F confirmed there were approximately three Wanderguards left as of 5/31/24 and two residents' Wanderguards were due to be changed next week. In order to receive a shipment of Wanderguards, HLS-F used a credit card on 5/31/24 to pay past due invoices from February that totaled $339.20. When asked if HLS-F received paychecks timely, HLS-F confirmed staff were supposed to be paid on 5/30/24, but paychecks were not deposited until 5/31/24 which caused staff to incur overdraft fees for automatic withdrawals. HLS-F stated the last time paychecks were late (the first pay period in May), Corporate Manager (CM)-M posted a notice by the time clock that stated staff would be reimbursed for overdraft fees. HLS-F confirmed the facility didn't have a working lawn [NAME] and the grass was overgrown until a Certified Nursing Assistant (CNA) cut the grass with their own lawn [NAME] on 5/23/24. HLS-F confirmed staff were begging people to plow the parking lot in the winter because the man who previously plowed wasn't paid. On 5/31/24 at 10:15 AM, Surveyor interviewed Director of Maintenance (DM)-D who verified the facility did not have a working lawnmower. When asked if DM-D was able to order parts and supplies, DM-D stated if DM-D had a concern, DM-D notified the corporate office and they took care of it. DM-D verified DM-D had to use a company credit card for payment or pay upfront at times. On 5/31/24 at 10:20 AM, Surveyor interviewed Dietary Manager (DM)-N who verified the facility had accounts with Food Supply (FS)-O and FS-P. DM-N confirmed the account with FS-O was on hold and estimated the facility owed over $12,000. DM-N confirmed the account with FS-P was in pending status last week and an order placed on 5/28/24 was on hold until FS-P received a credit card payment of $14,000. DM-N confirmed part of the order (what the facility needed for the weekend) was delivered on 5/30/24 and the rest was scheduled to arrive on 6/3/24. DM-N verified residents were served three meals and snacks. When asked if kitchen equipment was in working order, DM-N confirmed the facility couldn't get contractors to service items in the kitchen, including ovens and air conditioners. DM-N confirmed the oven vendor wouldn't return because he wasn't paid for previous service calls. DM-N stated DM-D recently fixed the cooler and convection oven, but it was likely the facility would switch to pre-made cookies and baked goods in case the oven went out again. DM-N confirmed the convention ovens were old and didn't work efficiently and the air conditioners over the dish room, dry goods area, and kitchen needed service. On 5/31/24 at 10:40 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON-B). NHA-A and DON-B stated they were focused on resident care and staff retention. In addition to concerns from staff, NHA-A confirmed NHA-A received approximately five to six calls per day from angry vendors and contractors. When asked about the facility's account with Pharmaceutical Supply (PS)-Q, NHA-A confirmed the account wasn't on hold but had an outstanding balance of approximately $48,000. When asked about the facility's account with Medical Record Company (MRC)-R, NHA-A confirmed NHA-A was notified by the corporate office that the facility had an outstanding balance and a partial payment was made on 5/30/24. NHA-A was unsure how much was owed and indicated if the account was put on hold or terminated, the facility wouldn't have electronic access to residents' medical records. When asked about the facility's account with Staffing Agency (SA)-S, NHA-A confirmed the facility needed to make a payment on 5/31/24 or the account would switch to pending status (which would be the fourth time since October of 2023) which meant SA-S would honor already scheduled shifts but wouldn't allow the facility to schedule more shifts. NHA-A and DON-B verified the facility used agency staff regularly. DON-B confirmed the facility used to use SA-T but could not longer use them due to nonpayment. When asked if the facility could get by without agency staff, NHA-A and DON-B stated they could but they feared staff burnout. When asked about the building rent, NHA-A stated NHA-A hadn't received calls regarding past due rent and was told the rent was paid. A court filing, dated 4/9/24, documented the amount owed the [NAME] for 2023 was $120,000. No rent payments were made in 2023. The amount owed the [NAME] for 2024 was also projected at $120,000. The amount currently owed the [NAME] for January to May of 2024 was $50,000. When asked about the facility's bed tax status, NHA-A stated NHA-A wasn't sure if the bed tax was paid and was unsure how much was owed. According to information obtained from the State of Wisconsin, the facility owed approximately $75,015 in bed taxes as of 6/1/24. NHA-A confirmed the facility rented a generator for emergency power, received a disconnection notice for nonpayment, and was told the generator would be repossessed the following week if payment wasn't made. NHA-A confirmed the facility was charged $2600 per month for the generator and owed approximately $16,000 on the account. When asked about gas, water, and electric, NHA-A confirmed the facility received disconnection notices in the past from Public Service Company (PSC)-U; however, payments were made at the last minute and service wasn't shut off. When asked about garbage pickup, NHA-A confirmed the facility didn't receive garbage pickup for two to three weeks due to nonpayment. NHA-A stated a payment was made and service was resumed; however, the facility received a notice that the account would be suspended again if another payment wasn't made. NHA-A verified there were account concerns with FS-O and FS-P who were the facility's main food suppliers. NHA-A and DON-B stated they tried to prioritize food, payroll and medical record access and indicated the facility frequently changed vendors and contractors which made it difficult. NHA-A and DON-B stated they were concerned if the facility kept taking admissions they wouldn't be able to care for them. When asked if CM-M was active in the building's operation, NHA-A and DON-B indicated CM-M's support and presence in the building had decreased. When asked about payroll, DON-B confirmed paychecks were late multiple times in the last twelve weeks. On 5/31/24 at 2:55 PM, Surveyor interviewed Supply Company I Staff (SCIS)-V who verified the facility had outstanding invoices and indicated their account was on hold. SCIS-V confirmed the facility needed to pay invoices that were at 90 days or more to regain service. On 5/31/24 at 3:31 PM, Surveyor interviewed Garbage and Recycling Staff (GRS)-X who confirmed the facility's garbage and recycling pickup was suspended on 3/28/24 due to nonpayment. GRS-X confirmed a partial payment was received on 4/19/24 and service was restored. GRS-X confirmed a payment of $1,562.70 was needed as of 5/28/24 or the account would be suspended again in fourteen days. On 5/31/24 at 3:35 PM, Surveyor interviewed Food Service O Staff (FSOS)-Y who confirmed the facility's account was on hold with a balance of approximately $12,500 from January of 2024 to the present. FSOS-Y confirmed the facility's last delivery was on 4/4/24 and the facility's last payment was on 3/26/24. On 6/3/24 at 10:17 AM, Surveyor interviewed Food Service P Staff (FSPS)-W who stated the facility's account was not on hold but may be in the future due to nonpayment. FSPS-W was unsure of the amount owed. On 6/5/24 at 10:19 AM, Surveyor interviewed NHA-A and DON-B via telephone. NHA-A confirmed NHA-A was informed that morning that employees' health insurance was canceled at the end of April due to nonpayment of the premium. NHA-A notified CM-M who stated CM-M was working on a payment on 6/4/24 and hoped to have the issue resolved by the end of the day. NHA-A confirmed NHA-A became aware of the cancellation after an employee picked up a prescription at the pharmacy and had to pay full price. NHA-A was notified four other employees had insurance issues in May but did not report them to NHA-A until 6/5/24. NHA-A confirmed staff were not given notice that their insurance was canceled and confirmed insurance premiums were still being deducted from their paychecks. NHA-A and DON-B confirmed Medical Director (MD)-J had not been paid since MD-J started in January of 2023. NHA-A and DON-B indicated MD-J was issued a check in November of 2023, but the check bounced. NHA-A confirmed NHA-A sent the corporate office an email on 6/3/24 which was the third or fourth email sent regarding the nonpayment. NHA-A confirmed the facility's weekly food order with FS-P was in pending status due to nonpayment. NHA-A was told by corporate staff that a payment was made on 6/4/24; however, NHA-A was waiting to hear from FSPS-W if the facility's order would arrive on 6/6/24. NHA-A confirmed the facility's account with FS-O was still on hold due to nonpayment. NHA-A stated the invoice for the generator was paid and the generator would not be repossessed. On 6/5/24 at 3:45 PM, Surveyor interviewed NHA-A via phone. NHA-A confirmed a payment of $3,000 was made to FS-P and the facility's food order should arrive on 6/6/24. NHA-A also confirmed NHA-A was told by corporate staff that a spreadsheet of outstanding accounts payable and a plan for payment would be provided to NHA-A by the end of the day. On 6/6/24 at 4:55 PM, Surveyor interviewed NHA-A via phone. NHA-A confirmed the facility's food order did not arrive on 6/6/24 because the facility missed their loading and shipping windows when payment was not received in time. NHA-A stated NHA-A and DM-N purchased enough food with a credit card at FS-P's local store to last until 6/13/24. NHA-A confirmed employees' health insurance was reinstated on 6/6/24 and backdated to 4/30/24. NHA-A also verified NHA-A received a payment plan spreadsheet that included MD-J. NHA-A confirmed MD-J was in the facility on 6/6/24 and NHA-A informed MD-J of the payment plan. On 6/11/24 at 9:55 AM, Surveyor interviewed NHA-A who stated employees' health insurance was not reinstated on 6/6/24 as previously indicated by corporate staff. NHA-A stated employees are still paying out of pocket for medical expenses and were told to save their receipts for reimbursement.

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 all 38 residents residing in the facility. The facility did not monitor and document food cooling or cooked temperatures. Findings include: The facility's Food Preparation and Service policy, revised November 2022, indicated: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices .General guidelines: Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness .the danger zone for food temperatures is above 41 degrees Fahrenheit (F) and below 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous food includes meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained at or below 41 degrees F or at or above 135 degrees F. Potentially hazardous foods held in the danger zone for more than four hours (if being prepared at room temperature of six hours if cooked and then cooled) may cause foodborne illness .Previously cooked food is reheated to an internal temperature of 165 degrees F for at least 15 seconds before holding for hot service. Reheated foods that are not consumed within two hours are discarded .Mechanically altered foods prepared for a modified consistency diet remain above 135 degrees F during preparation or they are reheated to 165 degrees F for at least 15 seconds if holding for hot service .Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 degrees F to 70 degrees F within two hours and then to a temperature of 41 degrees F or below within four hours. The total cooling time between 135 degrees F and 41 degrees F is not to exceed six hours .The temperatures of foods held in steam tables are monitored throughout the meal service by food and nutrition staff .Food that has been served to residents without temperature controls will be discarded if not eaten within two hours. Cooling Temperatures: The Food and Drug Administration (FDA) Food Code 2022 documents at 3-501.14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celcius (C) (135 Fahrenheit (F)) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less. The FDA Food Code 2022 section 3-501.15 documents Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. On 11/6/23 at 8:18 AM, Surveyor conducted an initial kitchen tour with Dietary Manager (DM)-D. Surveyor observed the freezer and noted the following items: ~One large Ziplock bag labeled Precooked Hamburger Patties dated 10/31/23 ~One container labeled Roast beef dated 10/22/23 ~One container labeled Beef Stew dated 10/17/23 ~One container labeled Biscuits dated 10/10/23 ~One container labeled Spaghetti Sauce dated 9/30/23 ~One container labeled Chicken dated 10/23/23 ~One container labeled Turkey Burgers dated 10/28/23 ~Two containers labeled Ham; one container dated 10/21/23, and the other container dated 11/5/23 ~One container labeled Chicken Filet dated 10/20/23 ~Two containers labeled Sloppy Joes dated 10/26/23 ~One container labeled Meatloaf dated 11/2/23 During an initial kitchen tour that began at 8:18 AM on 11/6/23, Surveyor and DM-D observed the following items in the reach-in cooler: ~One container labeled Mashed Potatoes dated 11/4/23 ~One container labeled Broccoli Slaw dated 11/4/23 ~One container labeled Sausage Tuesday AM dated 11/5/23 Surveyor interviewed DM-D following the observations in the freezer and cooler. DM-D indicated staff save leftovers from the steam table and put them in the cooler or freezer. DM-D verified the food observed in the freezer and cooler and was pre-made food to be used for residents who ordered alternative menu items, or leftover food to be used for future resident meals. When Surveyor inquired about a cooling log for pre-made foods and leftovers that are cooled and stored in the cooler or freezer for future use, DM-D indicated the facility did not have a cooling log or cooling system to monitor the temperatures of pre-made and leftover food. DM-D indicated DM-D received education from the facility's consultant the previous week regarding cooling logs and obtaining cooling temperatures to ensure food is cooled properly to prevent the spread of bacteria. DM-D stated the consultant provided education last week Friday and DM-D did not get to starting the cooling log yet. On 11/7/23 at 9:41 AM, Surveyor observed Cook (CK)-E finish cooking spaghetti casserole (which contained ground beef), place the casserole in the steam table, obtain the temperature of the casserole, and document the temperature on the facility's cooling temperature log. DM-D indicated the facility started using a cooling log yesterday afternoon. DM-D confirmed the labeled and dated pre-made and leftover food Surveyor observed in the freezer and cooler were still in the freezer and cooler. DM-D indicated staff probably should throw away the food since the food was not monitored with an appropriate cooling method and temperature. DM-D also indicated DM-D was unsure what temperature to document on the cooling log as the starting temperature, and stated the facility documented the temperature when the food was ready to be placed in the freezer or cooler. Cooked Temperatures: The FDA Food Code 2022 indicates at section 3-401.11 Raw Animal Foods. (A) Except as specified under (B) and in (C) and (D) of this section, raw animal foods such as eggs, fish, meat, poultry, and food containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked .Internal Cooking Temperature Specifications for Raw Animal Foods .Raw eggs cooked for immediate service, Fish, Intact Meat, except whole meat roasts and whole muscle intact beef steak at 145 F for 15 seconds .Commercially raised game animals, rabbits at 155 F for 17 seconds .Non-Intact Meats and raw eggs not for immediate service, wild game animals, poultry, stuffed fish, meat, pork, pasta, ratites, or stuffing containing fish, meat, poultry or ratites at 165 F for greater than 1 second . The FDA Food Code 2022 indicates at section 3-403.11 .(C) and (D) Food that is taken from a commercially processed, hermetically sealed container or intact package cooked to a temperature of 135 F. During an observation that began at 11:25 AM on 11/6/23, Surveyor observed CK-E obtain temperatures of food placed in the steam table prior to the start of the lunch meal. Surveyor interviewed CK-E regarding the temperatures that were obtained and documented on the cooking temperature log. CK-E indicated temperatures are obtained 10 minutes before line service begins. CK-E stated the procedure is to take items out of the oven after they are cooked or reheated, obtain the temperature, and place the items in the steam table. CK-E confirmed staff do not take temperatures prior to meal service and stated, I guess we should be doing a temperature to ensure there is a cooked temperature and a holding temperature. Surveyor observed the following temperatures obtained at the steam table for the lunch meal: ~Beef pepper steak -180 degrees F ~Rice - 175 degrees F ~Carrots - 138 degrees F ~Mechanical soft pepper steak - 180 degrees F ~Pureed pepper steak - 145 degrees F ~Pureed rice - 145 degrees F ~Pureed carrots - 137 degrees F Surveyor noted the temperature of the pureed pepper steak was under the appropriate temperature for food reheated in a microwave. Surveyor noted CK-E did not reheat the food prior to service. During an observation that began at 11:30 AM on 11/7/23, Surveyor noted food temperatures on the steam table were already obtained by CK-E. Surveyor noted the temperature log did not contain cooked temperatures for foods on the steam table. CK-E confirmed the temperatures documented on the temperature log were temperatures obtained before staff placed the food in the steam table for service and were holding temperatures. CK-E confirmed no other temperatures were taken for food contained in the steam table besides a cooling temperature.

Based on observation, staff and resident interview, and record review, the facility did not ensure nutritional needs were met for 6 Residents (R) (R4,R5, R7, R21, R24 and R79) of 6 residents reviewed who had an order for a carbohydrate-controlled diet. The facility did not follow physician ordered therapeutic carbohydrate-controlled diets when residents were served full carbohydrate meals, including full servings of dessert. Findings include: The facility's Therapeutic Diets document, revised October 2017, indicated: A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: a. diabetic/calorie controlled diet . On 11/6/23 at 9:48 AM, Surveyor interviewed R4 who indicated R4 watched carbohydrates served to R4 because R4 was diagnosed with type 2 diabetes and had an order for a low carbohydrate diet. R4 indicated the facility did not provide R4 with a low carbohydrate diet as indicated by the types of food and portions served. On 11/6/23 at 10:20 AM, Surveyor interviewed R5 who was unsure if R5 was ordered a special diet. R5 indicated R5 was diabetic, did not know how to count carbohydrates, and relied on the facility to make R5's meals. R5 indicated a desire to lose weight, but did not recall meeting with kitchen staff or a dietician. During an observation that began at 11:25 AM on 11/6/23, Surveyor observed Cook (CK)-E begin lunch meal service at the steam table. Surveyor noted the lunch meal consisted of beef pepper steak, steamed rice, buttered carrots, and apple fruit crisp with whipped cream for dessert. Surveyor interviewed CK-E regarding carbohydrate-controlled or low concentrated sweets diets and what the facility provided to residents to ensure the diet was adhered to. CK-E indicated residents are given either a smaller portion of carbohydrates or a smaller dessert. Surveyor noted meal tickets located on meal trays for R4, R5, R7, R21, R24 and R79 indicated: Diet: Low Concentrated Sweets (LCS)/Carbohydrate Controlled. Surveyor observed CK-E serve lunch trays to R4, R5, R7, R21, R24 and R79 that contained a full #8 scoop of beef pepper steak, a full #8 scoop of steamed rice, a full #8 scoop of buttered carrots, and a full dessert cup of apple fruit crisp with whipped topping. During an observation that began at 9:41 AM on 11/7/23, Surveyor requested from Dietary Manager (DM)-D the 11/6/23 and 11/7/23 recipe spreadsheets with the serving sizes for all diets. Surveyor reviewed the recipe spreadsheet for 11/6/23 and noted the LCS diet indicated the following: Beef pepper steak (#8 scoop=2 ounces of protein) Steamed rice (#8 scoop=1/2 cup) Buttered carrots (#8 scoop=1/2 cup) Diet fruit gel (#6 scoop) Surveyor did not observe diet fruit gel served to residents on an LCS diet during the 11/6/23 lunch meal and noted the residents were served a dessert cup full of apple crisp with whipped topping. Surveyor did not note a serving size for apple crisp on the recipe spreadsheet. Surveyor reviewed the recipe spreadsheet and serving sizes for LCS diets for the 11/7/23 lunch meal and noted the following: Skillet lasagna (facility menu stated Skillet Spaghetti, ground beef, spaghetti sauce and noodles) (#8 scoop=2 ounces protein) Seasoned zucchini ((#8 scoop=1/2 cup) Garlic Texas toast (1/2 slice) Chilled peaches (#8 scoop=1/2 cup) Surveyor noted the recipe spreadsheets and serving sizes for 11/6/23 and 11/7/23 did not contain serving sizes for alternative menu items. Finger foods was listed on the recipe spreadsheet and indicated the following for both 11/6/23 and 11/7/23: Hot sandwich (1 sandwich=2 ounces protein) Drain vegetable (1/2 cup) Drain fruit (1/2 cup) Surveyor also noted the 11/6/23 dinner recipe spreadsheet contained rice krispy treat as the dessert item and noted the serving size for LCS diets was a half bar. During an observation that began at 11:20 AM on 11/7/23, Surveyor observed CK-E begin lunch service at the steam table. Surveyor observed the following meal trays served: R4: Full serving of spaghetti skillet (#8 scoop=2 ounces protein), seasoned zucchini (#8 scoop=1/2 cup) garlic Texas toast (1/2 slice), and a full serving size rice krispy treat. R5: Full serving of spaghetti skillet (#8 scoop=2 ounces protein), seasoned zucchini (#8 scoop=1/2 cup) garlic Texas toast (1 full slice), and one oatmeal creme pie cookie (two oatmeal cookies with marshmallow cream sandwiched between the cookies). R7: Alternative menu meal: One hamburger patty on a bun, seasoned zucchini (#8 scoop=1/2 cup), one kitchen tong of french fries, and a full serving size rice krispy treat. R21: Full serving of spaghetti skillet (#8 scoop=2 ounces protein), seasoned zucchini (#8 scoop=1/2 cup), garlic Texas toast (1 full slice), and one full serving size rice krispy treat. R24: Alternative menu meal: One hamburger patty on a bun, seasoned zucchini (#8 scoop=1/2 cup), and one kitchen tong of french fries R79: Full serving of spaghetti skillet (#8 scoop=2 ounces protein), seasoned zucchini (#8 scoop=1/2 cup), garlic Texas toast (1 full slice), one dessert cup of mandarin orange slices, and one oatmeal creme pie cookie. On 11/7/23 at 1:00 PM, Surveyor requested diet orders for R4, R5, R7, R21, R24, and R79 from Nursing Home Administrator (NHA)-A and noted the following physician ordered diets: R4: Carbohydrate-controlled diet, dated 1/3/23 R5: Carbohydrate-controlled diet, dated 4/4/23 R7: Carbohydrate-controlled diet, dated 1/3/23 R21: Carbohydrate-controlled diet, dated 7/21/23 R24: Carbohydrate-controlled diet, dated 10/4/23 R79: Carbohydrate-controlled diet, dated 10/31/23 On 11/7/23 at 2:00 PM, Surveyor interviewed DM-D regarding carbohydrate-controlled diets. DM-D confirmed the desserts served to the residents on carbohydrate-controlled diets (LCS) were the same desserts and same portion sizes served to residents on a general diet. DM-D also confirmed desserts and serving sizes served to residents on carbohydrate-controlled diets (LCS) did not match the recipe spreadsheet for the type of dessert and serving size of carbohydrates.

Based on staff interview and record review, the facility did not ensure neurological checks were completed per policy for 2 Residents (R) (R24 and R9) of 5 residents reviewed for falls. Staff did not complete neurological checks after R24 fell on [DATE] and 9/22/23. Staff did not consistently complete neurological checks after R9 fell on [DATE]. Findings include: The National Library of Medicine (https://www.ncbi.nlm.nih.gov/) contains the following information: The neurological examination in the setting of trauma is a systematic evaluation of important clinical signs that provide evidence to help determine further management and investigation of the patient's condition .In the setting of trauma, a neurologic examination is focused on identifying and assessing the functions of vital portions of the central nervous system. The facility's Neurological Assessment document contained the following information: General Guidelines 1. Neurological assessments are indicated: b. Following an unwitnessed fall. The facility's Fall Management Program, dated 10/21/22, contained the following information: Neurochecks - every 15 minutes x 4, then every hour x 4, then each shift until 72 hours after the fall. 1. From 11/6/23 through 11/8/23, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] with diagnoses including hip fractures, atrial fibrillation, diabetes mellitus, and anxiety disorder. R24's medical record indicated R24 had intact cognition. R24 had unwitnessed falls on 9/14/23 and 9/22/23. R24's medical record did not indicate neurological checks were completed post fall. On 11/8/23 at 10:58 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R24's neurochecks. DON-B verified neurochecks were not completed following R24's unwitnessed falls on 9/14/23 and 9/22/23 because R24 was alert and oriented and able to state that R24 did not hit R24's head. 2. From 11/6/23 through 11/8/23, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including muscle weakness, polyosteoarthritis, repeated falls, and difficulty walking. R9's medical record indicated R9 had intact cognition. R9 had an unwitnessed fall on 9/12/23. R9's medical record did not indicate neurological checks were consistently completed post fall. R9's medical record contained an initial neurological check at the time of the fall on 9/12/23 at 8:45 PM, and neurological checks on 9/13/23 at 7:00 AM and 4:17 PM. On 11/8/23 at 11:33 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F regarding the expectation for neurochecks for a resident who had an unwitnessed fall. LPN-F stated LPN-F would complete neurochecks if a fall was unwitnessed, even if the resident was cognitively intact. On 11/8/23 at 11:38 AM, Surveyor interviewed Registered Nurse (RN)-G regarding the expectation for neurochecks for a resident who had an unwitnessed fall. RN-G stated even if the resident was cognitively intact, RN-G would still complete neurochecks. On 11/8/23 at 12:07 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated NHA-A, based on policy, would only do neurochecks if the resident hit their head or if the resident was not alert and oriented and could not tell staff whether or not they hit their head. When Surveyor indicated the facility's policy stated neurochecks should be completed following an unwitnessed fall, NHA-A stated the facility's policy can be interpreted differently.

Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 Residents (R) (R21 and R15) of 2 residents reviewed. The facility did not report a resident-to-resident physical altercation involving R21 and R15 to the State Agency (SA). Findings include: The facility's Facility Responsibility for Reporting Allegations policy, revised September 2022, indicated: The following addresses facility responsibilities for reporting allegations/occurrences involving staff-to-resident abuse, resident-to-resident altercations, injuries of unknown source, and misappropriation of resident property/exploitation .Reporting Resident-to-Resident Altercations: Resident-to-resident altercations that must be reported in accordance with the regulations include any willful action that results in physical injury, mental anguish, or pain .The list below includes examples of resident-to-resident altercations and whether they are required to be reported .Resident-to- resident physical altercations .Resident-to-resident physical altercations that must be reported include any willful action that results in physical injury, mental anguish, or pain (the action itself was deliberate or non-accidental, not that the individual intended to inflict injury or harm. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions.) .Willful actions include, but are not limited to, the following: hitting, slapping, punching, choking, pinching, biting, kicking, throwing objects, grabbing, shoving .pain resulting from the willful action including, but not limited to, the following: complaints of pain related to the altercation The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, indicated: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: .9. Investigate and report any allegations within timeframes required by federal requirements. The facility's Resident to Resident Altercations policy, revised September 2022, indicated: All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing and to the administrator .4. If residents are involved in an altercation staff: .I. complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record and j. Report incidents, findings and corrective measures to appropriate agencies . On 11/6/23, Surveyor reviewed R21's medical record. R21 was admitted to the facility with diagnoses including Alzheimer's disease, vascular dementia, and depression. R21's medical record indicated R21 had moderate cognitive impairment and had an activated decision maker for all health care decisions. R21's care plan, initiated 10/13/23, included behavior monitoring and indicated R21 had the potential to be verbally aggressive related to poor impulse control. A progress note, dated 9/6/23, indicated the following: R21 indicated R21's roommate (R15) slammed the bedroom door on R21. R21 yelled obscenities at R15, threatened violence, grabbed R15 by the shirt collar, and threatened to punch R15 in the face. Staff separated R15 and R21. R15 was assessed and had pain from scratches and a reddened area near R15's shirt collar. R15 also reported pain to the thumb where R21 pulled on R15's thumb and bent it backward during the altercation. Documentation indicated R15 was in the middle of the room when the altercation occurred, was not near the bedroom door, and did not slam the door on R21. R15 was removed from the room and chose to move to another room. On 11/6/23, Surveyor reviewed the facility's grievance and self-report files and noted a self-report was not submitted to the SA regarding the incident. On 11/7/23 at 8:56 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing(DON)-B regarding the altercation between R21 and R15. DON-B indicated DON-B was present during the altercation and verified R21 was aggressive toward R15. DON-B stated the facility did an internal investigation, but did not report the incident to the SA because there was no intent or injury to R15. DON-B stated the marks on R15's neck went away quickly and there was no further pain to R15 because R15 changed rooms and no longer lived with R21. DON-B confirmed DON-B was responsible for submitting reports of resident-to-resident altercations, suspected abuse, and neglect a few times to the SA and believed the altercation between R21 and R15 was not a reportable incident. DON-B stated the facility's investigation included all the required components and there was no need to report the incident. NHA-A indicated the previous NHA completed an investigation and there was no intent or injury to either resident. NHA-A stated the facility immediately resolved the problem and believed the incident was not reportable. Surveyor requested the internal investigation for the 9/6/23 altercation. On 11/7/23 at 2:35 PM, NHA-A gave Surveyor the facility's investigation of the 9/6/23 altercation between R21 and R15. Surveyor reviewed the investigation and noted R15's physician was notified that R21 was physically and verbally aggressive toward R15. R15 incurred scratches and redness to the upper chest which was resolved, and complained of right thumb discomfort with no redness or swelling. R15 was seen by the physician the following day with no new orders.

Based on staff interview and record review, the facility did not ensure a resident-to-resident altercation was thoroughly investigated for 2 Residents (R) (R21 and R15) of 2 residents reviewed. The facility did not thoroughly investigate a resident-to-resident altercation involving R21 and R15. Findings include: The facility's Resident to Resident Altercations policy, revised September 2022, indicated: All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing and to the administrator .4. If residents are involved in an altercation staff .F. make any necessary changes in the care plan approaches to any or all of the involved individuals; G. document in the resident's clinical record all interventions and their effectiveness; I. complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; and J. report incidents, findings and corrective measures to appropriate agencies . The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, indicated: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .Policy Interpretation and Implementation: the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives .8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. The facility's Protection of Residents During Abuse Investigations policy, revised April 2021, indicated: Residents are protected from harm, retaliation, reprisal, discrimination, or coercion during investigations of abuse, neglect, exploitation and misappropriation of resident property .3. If the alleged abuse involves another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended. On 11/6/23, Surveyor reviewed R21's medical record. R21 was admitted to the facility with diagnoses including Alzheimer's disease, vascular dementia, and depression. R21's medical record indicated R21 had moderate cognitive impairment and had an activated decision maker for all health care decision. R21's care plan, initiated 10/13/23, indicated R21 had the potential to be verbally aggressive related to poor impulse control and included behavior monitoring. A progress note, dated 9/6/23, indicated: R21 indicated R21's roommate (R15) slammed the bedroom door on R21. R21 yelled obscenities at R15, grabbed R15 by the shirt collar, and threatened to punch R15 in the face. Nursing staff separated R21 and R15 who reported pain from scratches and a reddened area near R15's shirt collar. R15 also reported pain to R15's thumb where R21 pulled on R15's thumb and bent it backward during the altercation. Documentation indicated R15 was in the middle of the room when the altercation occurred, was not near the bedroom door, and did not slam the door on R21. R15 was removed from the room and chose to move to another room. On 11/7/23 at 8:56 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing(DON)-B regarding the resident-to-resident altercation between R21 and R15. DON-B indicated DON-B was present during the altercation. DON-B indicated R21 was aggressive toward R15, and stated the facility did an internal investigation. DON-B confirmed DON-B was responsible for submitting reports of resident-to-resident altercations, suspected abuse, and neglect a few times to the State Agency. DON-B stated DON-B believed the altercation was not a reportable incident and the internal investigation was completed thoroughly and included all investigation components. NHA-A indicated the previous NHA completed an investigation, there was no intent or injury to either resident, and the facility immediately resolved the problem. Surveyor requested the internal investigation for the resident-to-resident altercation. On 11/7/23 at 2:35 PM, NHA-A provided the facility's investigation of the altercation and indicated NHA-A was confident the facility completed a thorough investigation and made appropriate revisions to R21's care plan. When Surveyor asked NHA-A what care plan updates were initiated after the altercation, NHA-A confirmed R21's care plan was not revised until after 10/20/23 when behavioral care plans for all residents were reviewed and revised. On 11/6/23 Surveyor reviewed the facility's grievance and self-report files and noted an investigation was not submitted to the State Agency for the resident-to-resident altercation. Surveyor reviewed the facility's investigation and noted the investigation did not contain resident or staff interviews, witness statements, or staff education. R15 was no longer a resident of the facility and was unable to be interviewed during Surveyor's investigation. Surveyor reviewed R21's care plan and noted there was no behavioral monitoring or changes to R21's care plan after the altercation on 9/6/23. Surveyor reviewed R21's progress notes and noted R21 had verbal altercations with R15 on the following dates: 10/8/23, 10/7/23, and 10/11/23. Surveyor noted there were no changes to R21's care plan following the incidents. Surveyor noted behavioral interventions for R21 were not added or changed until 10/20/23 following a physical altercation with R15 on 10/18/23.

Based on observation, policy review and staff interview, the facility did not maintain and implement an Infection Control Program designed to prevent the development and transmission of infection during an ARI (Acute Respiratory Infection) outbreak and ensure staff followed professional standards related to hand hygiene practices for 4 (R1, R8, R2 and R3) of 10 sampled residents observed receiving cares. The facility's Infection Control program failed to prevent the spread of an ARI starting [DATE] when 4 residents (R12, R9, R1 and R14) of 11 sampled and supplemental sampled residents were identified with ARI. The facility failed to ensure staff with signs and symptoms of ARI did not return to work until being symptom free for 24 hours. The facility failed to demonstrate staff usage of PPEs (Personal Protective Equipment) when CNA (Certified Nursing Assistant)-H entered R20's room, who was on contact and droplet precautions. Findings include: 1. The Facility's Respiratory Outbreak Policy and Procedure dated [DATE]: Purpose: To prevent and control respiratory outbreaks Procedure: Reporting Outbreak - A respiratory outbreak is considered 3 or more cases within 72 hours of pneumonia, an ARI, or an acute respiratory infection confirmed by lab (this includes influenza). Outbreaks are to be reported via telephone to the local health department. The DON (Director of Nursing) and administrator should be notified. Definition of ARI - must have 2 of the following: fever, cough, runny nose, nasal congestion, sore throat, and more muscle aches then typical. A fever is defined as a temperature 2 degrees above the resident's baseline temperature. Precautions - Staff and visitors should follow the listed precautions when interacting with infected residents. If the cause of an ARI is unknown, both droplet and contact precautions should be followed. Both droplet .the room. A mask should be worn for droplet precautions and should be put on before entering the room. Residents on .rhino/[MEDICATION NAME]. Contact precautions should be followed when providing cares that may involve contact with contaminated areas. Contact precautions include a gown and gloves. These should be applied before entering the room. Respiratory viruses .purulent sputum. Staff with an ARI - Staff with an ARI should not work until at least 24 hours after they don't have a fever without the use of antipyretics (med that reduce fevers). Staff who have a cough or a sneeze should wear a surgical mask during resident care. A 2008 study in the Southern Medical Journal found that Nursing home residents had a mortality of 17.6%. Increasing age, residing in a nursing home, and comorbidity were shown to be significant predictors of death. More recent studies in 2009 and 2010 have shown that Nursing home-acquired pneumonia (NHAP) .is one of the most common infectious diseases in long-term care facilities and is a significant cause of mortality and morbidity among residents of such facilities. On [DATE] the Surveyor reviewed the facility's infection control program. The documentation included an ARI outbreak, which indicated implementation of facility ARI outbreak procedures began on [DATE], instead of on [DATE], when the following documentation indicated the outbreak should have been identified on [DATE]. The facility's infection logs, line list and resident medical records included the following information: ~ Nursing note dated [DATE] documented R12 had audible congestion, Chest X-ray and CBC (complete blood count) ordered. Nursing progress note dated [DATE] documented R12 was placed on isolation (contact and droplet precautions) due to [DIAGNOSES REDACTED].m .admitted R12 on [DATE] with [DIAGNOSES REDACTED]. Hospital's Death Summary note dated [DATE] at 7:52 p.m., documented R12's cause of death as Severe Sepsis, Aspiration Pneumonia and Advanced Dementia. ~ Nursing note dated [DATE] documented R9 with an onset of audible wheezing and placed on contact and droplet isolation. R9 was sent toER on [DATE] and was diagnosed with [REDACTED]. ~ Nursing note dated [DATE] documented R1 with onset of dry cough and was placed on contact and droplet isolation. Chest X-ray dated [DATE] documented left lower lobe pneumonia. Respiratory PCR (Polymerase Chain Reaction) Panel dated [DATE] detected Human Metapneumovirus. ~ Nursing note dated [DATE] documented R14 with onset of congested cough and temperature of 99 degrees Fahrenheit (F) and was placed on contact and droplet precautions. Documentation indicated R14 was receiving Hospice services and the resident's POA (Power Of Attorney) refused a Chest X-ray and antibiotics. ~ Nursing note dated [DATE] documented R13 lung sounds as wheezing with crackles bilateral lower lobes and was placed on contact and droplet precautions. Chest X-ray results completed on [DATE] documented bilateral minimal infiltrates. ~ Nursing note dated [DATE] at 9:45 p.m., documented R15 with audible congestion. Chest X-ray results completed on [DATE] documented bilateral airspace disease commonly related to pneumonia. Respiratory PCR Panel dated [DATE] detected Human Metapneumovirus. Physician's note dated [DATE] documented R15 was diagnosed with [REDACTED]. R15's HCPOA (Health Care Power Of Attorney) agreed to oral antibiotic treatment at the facility and R15 expired on [DATE] at 10:35 p.m. ~ Nursing note dated [DATE] documented R16 to have increased congestion, diminished lung sounds, rhonchi throughout and was placed on contact and droplet isolation. Chest X-ray results completed on [DATE] documented worsening right pleural effusion with adjacent atelectatic (the collapse of one or more areas of the lung) or consolidation (characterized by swelling and hardening of the lung tissue due to the presence of fluid in the air sacs (alveoli) and smaller airways) lung. ~ Nursing note dated [DATE] documented R17 to have non-productive cough and placed on contact and droplet precautions. Respiratory PCR Panel dated [DATE] detected Human Metapneumovirus. ~ Nursing note dated [DATE] documented R19 to have audible wheeze. On [DATE] documentation indicated Physician's assessment indicated R19's lungs were clear and did not order a Chest X-ray. Documentation on [DATE] indicated R19 was transported to ER and Chest X-ray results indicated focal density in the right lung, a nonspecific finding and could represent consolidation from pneumonia and R19 was admitted the hospital. On [DATE], documentation indicated a hospital nurse's communication with facility staff informed Chest X-ray and CT (computed tomography) scan were performed with leaning toward the [DIAGNOSES REDACTED]. ~ Nursing note dated [DATE] documented R18 developed a harsh congested sounding cough and placed on contact and droplet precautions. Respiratory PCR Panel dated [DATE] detected Human Metapneumovirus. ~ Nursing note dated [DATE] documented R2 was seen by physician who ordered Chest X-ray on [DATE], with results as mild right lower lobe pneumonia and placed on contact and droplet precautions. On [DATE] at 12:50 p.m., the Surveyor interviewed ADON (Assistant Director of Nursing)-E regarding the [DATE] ARI outbreak. ADON-E verified the facility had identified the ARI outbreak date as [DATE]. ADON-E initially commented the definition of an ARI outbreak would be when 2 residents become ill. Upon review of the facility's policy, ADON-E indicated an ARI outbreak is 3 or more residents with qualifying signs and symptom in a 72 hour period of time on the same unit. ADON-E then reviewed the facility's infection control surveillance information and indicated the ARI outbreak should have been identified on [DATE], not on [DATE] when the facility implemented their outbreak procedures. On [DATE] at 9:40 a.m., the Surveyor interviewed RN-P regarding implementation of precautions and identification of an outbreak when ADON-E is not in house. RN-P indicated RNs document the resident's signs and symptoms of the illness on the 24 hour report, fill out an Infection control report form and contact all departments. 2. On [DATE], the Surveyor reviewed the facility's employee line list. Documentation indicated on [DATE], CNA-R informed the facility was unable to work related to being ill. Documentation on [DATE], indicated CNA-R continued off work with sinus congestion, new cough, nasal drainage and loose stool. The line list documented CNA-R returned to work on [DATE]. On [DATE] at 2:44 p.m., the Surveyor interviewed NHA-D and ADON-E regarding employee CNA-R's return to work date after being sick and unable to work. ADON-E indicated according to the facility's policy and procedure, employees should not return to work until 48 hours after signs and symptoms of illness have subsided. NHA-D verified CNA-R returned to work less than 24 hours after signs and symptoms of illness had subsided. NHA-D further indicated the facility was fully staffed and it was not necessary for CNA-R to return to work on [DATE]. 3. On [DATE] at 9:15 a.m., the Surveyor observed CNA-H in R20's room, who was on contact and droplet precautions without wearing PPEs. When CNA-H came out of R20's room and began to apply PPEs, the Surveyor interviewed CNA-H regarding the observation without the PPEs. CNA-H verified had not applied PPEs prior to initially entering R20's room and touched R20's bedding and assisted RN (Registered Nurse)-P. CNA-H further indicated according to facility policy and procedure gloves, gown and mask should have been applied prior to entering R-20's room as the resident was on contact and droplet precautions. On [DATE] at 2:44 p.m., the Surveyor interviewed NHA (Nursing Home Administrator)-D regarding PPEs that should be worn prior to entering resident's rooms that are on contact and droplet precautions. NHA-D indicated according to the facility's policy and procedure, PPEs included gloves, gown and mask. NHA-D verified CNA-R should have applied gloves, gown and mask prior to entering R20's room. NHA-D stated CNA-R received education on proper PPEs to be worn with each type of precaution and CNA-R would be given addition education. On [DATE] at 11:58 a.m., the Surveyor interviewed RN-Q regarding PPEs that should be worn prior to entering resident's rooms that are on contact and droplet precautions. RN-Q indicated gloves, gown and mask should be applied prior to entering the resident's room. RN-Q further indicated the last in-service relating to PPE usage and precautions was [DATE]. On [DATE] at 12:00 p.m., Surveyor interviewed RN-G regarding PPEs that should be worn prior to entering residents' rooms that are on contact and droplet precautions. RN-G indicated contact precautions would include gloves for medications and cares and a gown and mask should applied prior to entering the resident's room. RN-Q further indicated when a resident is placed on precautions, the nurses are responsible for posting appropriate signs outside the resident's door, arranging for placement of isolation table with supplies outside the resident's door, documenting and communicating the reason and/or type of precautions. On [DATE] at 12:32 p.m., the Surveyor interviewed CNA-L regarding PPEs that should be worn prior to entering resident's rooms that are on contact and droplet precautions. CNA-L indicated would apply gloves, gown and mask before entering the resident's room on contact precautions. CNA-L further indicated would apply the same PPE for a resident on droplet precautions even if only entering the room to talk with the resident. CNA-L stated the last in-service relating to PPEs and precautions was [DATE]. On [DATE] at 12:37 p.m., the Surveyor interviewed CNA-C regarding PPEs that should be worn prior to entering resident's rooms that are on contact and droplet precautions. CNA-C stated wear gloves, gown and mask for both contact and droplet precautions for both cares and just entering the room. CNA-C indicated last in-service related to PPEs and precautions was sometime in the beginning of summer. 4. The Morbidity and Mortality Weekly Report dated [DATE] and published by the Centers for Disease Control and Prevention entitled Guideline for Hand Hygiene in Health Care Settings indicated 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. Following observations include: ~ On [DATE] at 1:00 p.m., the Surveyor observed CNA-I with cleansed and gloved hands provide personal cares and transferred R1 to toilet without concern. After R1 urinated and wiped self with toilet paper, CNA-I provided R1 a washcloth to cleanse the resident's perineal area. CNA-I took the soiled washcloth from the resident with one hand and gave R1 a towel to dry perineal area. CNA-I then assisted R1 to pull up underwear and pants prior to removing soiled gloves and sanitizing hands. Immediately following the above observation, the Surveyor interviewed CNA-I regarding the observation. CNA-I indicated the facility's policy is to remove gloves and cleanse hands whenever coming into contact with solid items and when going from dirty to clean tasks. CNA-I verified not changing gloves or sanitizing hands after touching R1's soiled washcloth and prior to touching R1's brief and pants. ~ On [DATE] at 10:55 a.m., the Surveyor observed CNA-L and CNA-N with cleansed and gloved hands wash R8's face, underarms, upper torso, and anterior perineal area without concern. With cleansed and gloved hands, CNA-N assisted R8 to reposition of their right side and CNA-L cleansed stool from gluteal crease using a front to back motion, using a clean surface of the disposable wipe with each swipe. CNA-N used up the supply of disposable wipes and without removing gloves and cleansing hands, CNA-N retrieved additional wipes. CNA-L and CNA-N completed the remaining provision of care without concern. Immediately following the observation, the Surveyor interviewed CNA-L regarding the above observation. CNA-L indicated it was the facility's policy to change gloves and cleanse and sanitize hands before and after resident contact and when going from a dirty to a clean task. CNA-L verified the above observation. On [DATE] at 1:05 p.m., the Surveyor interviewed NHA-D regarding the facility's hand hygiene policy and observations that had been made. NHA-D indicated the facility's policy is to change gloves with each task when going from a dirty to a clean task and/or area. NHA-D stated staff should have removed gloves and cleansed hands after assisting R1 with perineal cares, prior to touching the resident and resident personal items. In addition, NHA-D indicated staff should have changed gloves and sanitized hands after providing posterior perineal care with R8 and prior to retrieving addition wipes. ~ R2's most recent MDS (Minimum Data Set) assessment dated [DATE], documented R2 requires extensive assist with transfers, bed mobility, dressing, hygiene and bathing. R2 currently has a small open area on buttocks that is being treated with saline rinse and Duoderm dressing daily. On [DATE] at 9:28 a.m., the Surveyor observed incontinence cares and wound cares provided to R2. CNA-L and CNA-N washed hands and applied gloves. CNA-N cleansed the peri area front to back using a folded wipe prior to front to back motion and then CNA-N removed gloves and sanitized hands. CNA-L and CNA-N repositioned R2 onto their right side and CNA-L cleansed the buttocks area front to back twice, using a clean wipe. CNA-L then sprayed a washcloth with cleansing soap, wiped the buttocks front to back, not folding the washcloth. Visible feces was noted on the washcloth as CNA-L wiped the open wound area on the resident's buttocks. CNA-L removed gloves and sanitized hands. ADON-E then entered R2's room, washed and sanitized hands then applied gloves. ADON-E removed the soiled dressing and placed it onto paper toweling that had been placed on bed for discarded items. ADON-E removed gloves, sanitized hands and applied clean gloves after measuring the buttock wound at 0.2 cm (centimeters) by 0.3 cm on right buttock and the excoriated area on the left buttock measured 7.7 cm by 0.2 cm., and after cleansing the wound twice with gauze and saline solution and placed the contaminated gauze onto the paper towel on bed. ADON-E removed gloves, sanitized hands and applied clean gloves and then applied skin prep to the resident's buttocks and applied a new dressing. At this time, ADON-E removed the soiled dressing and contaminated gauze from the bed and placed the items into the garbage. While wearing the same gloves, ADON-E applied peri guard cream to the resident's excoriated area on the buttocks, then removed gloves and sanitized hands. On [DATE] at 10:20 a.m., the Surveyor interviewed CNA-L and ADON-E regarding the above observation. CNA-L verified wiping the resident's excoriated open area on buttocks with the soiled washcloth and ADON-E verified after touching contaminated items, applied peri guard cream to R2's excoriated area on buttocks while wearing the same soiled gloves. ~ R3 was admitted to facility on [DATE], with [DIAGNOSES REDACTED]. R3's most recent MDS assessment dated [DATE], documented the resident requires extensive assist with transfer, bed mobility, dressing, eating, hygiene and bathing. On [DATE] at 1:50 p.m., the Surveyor observed incontinence and wound cares with R3. CNA-L washed hands and applied gloves and washed around the meatus with clean cloth. Using a clean cloth, washed the Foley tubing from meatus downward. CNA-L removed gloves, applied clean gloves without washing or sanitizing hands. CNA-L then assisted completing R3's cares, removed gloves and sanitized hands. On [DATE] at 2:35 p.m., the Surveyor interviewed CNA-L, who verified did not wash or sanitize hands after removing soiled gloves and applying clean gloves during the observation of care with R3.