Every finding on record at Eden Rehab Suites and Green House Homes

Based on observation, 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 more than 4 of the 33 residents residing in the facility.Refrigerators and freezers in unit kitchenettes contained unlabeled, undated, and/or expired food. Staff did not complete appropriate hand hygiene during food service.Findings include:Food Storage:The facility's Food from Outside Sources policy, dated January 2026, indicates: .Nutritional needs of residents will be met by consuming nourishing meals and snacks. Meals meeting the nutritional needs of residents will be provided .However, food from outside sources may be brought by visitors for consumption by residents .1. Food requiring storage will be received by staff for proper and immediate storage. 2. Food will be labeled and dated according to facility standards. 3. Food will be stored in unit kitchenettes under the appropriate sanitary conditions according to current regulations .The Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food:(A) .Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1.On 7/13/26 beginning at 9:39 AM, Surveyor completed a self-guided tour of the unit kitchenette refrigerators and freezers and observed the following items in the Rehab Wing A kitchenette refrigerator:~ A container of Sweet Baby Ray's honey mustard dipping sauce with an expiration date of 6/30/26~ An open and undated container of Starbucks coffee creamer~ Open and undated butter~ An open, unlabeled, and undated jar of olives~ Open and undated hamburger buns (freezer)Surveyor observed the following items in the Rehab Wing B kitchenette refrigerator: ~ An undated resident meal ~ Two containers of Snack Pack Jell-O with an expiration date of 5/31/26~ A ketchup bottle with a resident's name and room number with an expiration date of 8/1/25~ Two unlabeled and undated half-gallon containers of ice cream (freezer)~ An unlabeled and undated box of Hot Pockets (freezer) Surveyor observed the following items in the East Wing kitchenette refrigerator:~ Open and undated containers of apple and cranberry juiceOn 7/14/26 at 9:36 AM, Surveyor observed the Rehab Wing A refrigerator and freezer with Dietary Manager (DM)-L. In addition to the above listed items, Surveyor and DM-L observed:~ An unlabeled bottle of Mountain DewSurveyor and DM-L also observed the above listed items in the Rehab Wing B refrigerator/freezer and the East Wing refrigerator.DM-L confirmed the items were opened, unlabeled, and/or expired. DM-L stated kitchen staff are responsible for ensuring all items are labeled and dated when opened and expired items are disposed of. DM-L stated if nursing staff leave resident items in the refrigerator or freezer or open juice and milk containers, they should label the items with the resident's name and date. DM-L verified Rehab Wings A and B and the East Wing were not following the facility's policy for food storage. DM-L stated the bottle of Mountain Dew in the Rehab Wing A refrigerator was most likely an employee's drink and should not be stored with resident food.Hand Hygiene:The Wisconsin 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 .On 7/13/26 beginning at 12:16 PM, Surveyor observed Certified Nursing Assistant (CNA)-K begin lunch service in the East Wing kitchenette. CNA-K picked up a head of lettuce with gloved hands and began chopping the lettuce for salads. CNA-K touched faucet handles on the sink while washing the lettuce and continued to chop the lettuce with a knife. CNA-K washed the lettuce again, touched faucet handles, countertops, and kitchen surfaces, and continued to chop the lettuce without changing gloves or washing hands. CNA-K finished preparing salads, washed hands, donned clean gloves, and began plating food. CNA-K used gloved hands to put chicken on residents' plates. With the same gloved hands, CNA-K opened the refrigerator and retrieved containers of juice and salad dressing. CNA-K then heated food in the microwave, opened cupboards, threw away food and empty juice containers, and retrieved divided plates. Without changing gloves or washing hands, CNA-K touched kitchen surfaces, appliances, and food with same gloved hands.On 7/14/26 at 9:36 AM, Surveyor interviewed DM-L who stated staff should not touch surfaces and food items with soiled gloves. DM-L stated staff should cut residents' food with utensils since gloves touch food and kitchen surfaces and do not protect residents from cross-contamination.

Based on interview and record review, the facility did not ensure their abuse policy was implemented for 1 (Licensed Practical Nurse (LPN)-I) of 8 staff reviewed for caregiver background checks.LPN-I was hired on 7/27/23 and had lived in two other states within the last three years. The facility did not complete out-of-state background checks for LPN-I. The Facility's Abuse Policy, dated January 2025. indicates: .Screening: 1. Screening of potential employees determines appropriateness for the position they are seeking .2. Federal and state background checks after employment is accepted and prior to first day of work. Surveyor reviewed LPN-I's background check information. LPN-I was hired on 7/27/23. A caregiver background check completed by the facility on 7/10/23 indicated LPN-I had lived in 2 states other than Wisconsin within the last three years. Surveyor reviewed all background check information provided by Nursing Home Administrator (NHA)-A and noted out-of-state criminal and caregiver background checks were not included.On 7/14/26 at 9:11 AM, Surveyor requested LPN-I's out-of-state background checks from NHA-A who stated they would ask Human Resources (HR). On 7/15/26 at 3:13 PM, Surveyor interviewed Human Resources (HR)-J who stated the facility used a company for out-of-state background checks. HR-J indicated they must not have checked the correct boxes for the out-of-state background checks which was a mistake on their part.

Based on observation, interview and record review, the facility did not ensure 1 resident (R) (R23) of 13 sampled residents was assessed able to self-administer medication. R23 had a tube of 0.1% triamcinolone acetonide cream in their bathroom. R23's most recent self-administration of medication assessment indicated they did not wish to self-administer medication. In addition, a physician order indicated R23 was unable to self-administer medication.Findings include:The facility's Self-Administration of Medications policy, dated January 2026, indicates: It is the policy of [NAME] Rehabilitation Suites & [NAME] House Homes to support resident rights to self-administer medication when it is safe and clinically appropriate. Self-administration of medication must be authorized by the provider, assessed by nursing staff, and consented to by the resident or their legal representative. Nursing staff remain responsible for ensuring resident safety, compliance with treatment, and regulatory requirements .The admitting nurse shall provide the resident with a Self-Administration of Medication Consent Form and review the available medication administration options. The resident shall determine whether they wish to self-administer their medication. If the resident elects to self-administer medication, the resident must meet all established eligibility requirements, and the facility shall follow the applicable assessment and approval process in accordance with facility policy. Eligibility Requirements: 1. A written order from the attending physician, Nurse Practitioner (NP), or Physician Assistant (PA) is required. 2. A licensed nurse will complete and document an assessment of the resident's ability to self-administer medication safely. 3. The resident (or their legal representative) must sign a consent form .Nursing Staff Responsibilities: 1. Verify which residents are authorized for self-administration . On 7/13/26, Surveyor reviewed R23's medical record. R23 had a diagnosis of a chronic rash. A Quarterly Minimum Data Set (MDS) assessment, dated 7/4/26, stated R23's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating intact cognition. On 7/13/26 at 10:25 AM and on 7/14/26 at 9:04 AM, Surveyor interviewed R23 and observed a tube of 0.1% triamcinolone acetonide cream in their bathroom. R23 stated they used the cream daily for a rash that covered their body. R23 stated they have applied the cream independently but a nurse usually applies it. R23's medical record did not contain a self-administration of medication assessment. Surveyor requested an assessment from Nursing Home Administrator (NHA)-A. On 7/14/26 at 1:43 PM, Surveyor reviewed a Self-Administration of Medication form for R23 provided by Director of Nursing (DON)-B. The document was signed by R23 on 9/25/23 and indicated, I do not want to self-administer my own medication. DON-B confirmed R23 did not have an order to self-administer medication and did not want to self-administer medication. DON-B confirmed R23 should not have medication in their bathroom.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R38 and R24) of 2 sampled residents.R38 was on enhanced barrier precautions (EBP) due to an indwelling Foley catheter. Staff completed high-contact resident care without donning the appropriate personal protective equipment (PPE).Staff did not appropriately change gloves during the provision of catheter care for R24. Findings include: The facility's Enhanced Barrier Precautions policy, dated January 2026, indicates: Residents in nursing homes are at increased risk of becoming colonized and developing infection with multidrug-resistant organisms (MDROs). Studies published by the Centers for Disease Control and Prevention (CDC) estimate that 50% of nursing home residents may be colonized with an MDRO. EBP is an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Examples of high-contact resident care activities requiring gowns and gloves include: dressing, bathing/showering, and transferring. The facility's Infection Control Hand Hygiene policy, dated January 2026, indicates: The facility must establish hand hygiene procedures to be followed by staff involved in direct resident contact. Hand hygiene (e.g., hand washing and/or alcohol- based hand rub (ABHR)) .Decontaminate hands before donning sterile gloves. Decontaminate hands if moving from a contaminated body site to a clean body site during resident care. Decontaminate hands after removing gloves. 1. R38 was admitted to the facility on [DATE] and had diagnoses including neurogenic bladder and urinary retention. R38 had an indwelling Foley catheter. A Minimum Data Set (MDS) assessment, dated 7/14/26, indicated R38 had an indwelling catheter and a history of sepsis and urinary tract infection. On 7/14/26 at 8:53 AM, Surveyor observed an EBP sign posted outside the doorway of R38's room. Surveyor observed Certified Nursing Assistant (CNA)-E transfer R38 from bed to wheelchair without a gown and noted R38's Foley drainage bag was on the floor. CNA-E stated AM cares had just been completed. CNA-E picked the drainage bag off the floor and attached the bag to R38's wheelchair. On 7/14/26 at 8:56 AM, Surveyor interviewed CNA-E who confirmed they should have worn a gown when completing cares for R38. CNA-E confirmed R38 was on EBP which required a gown and gloves. On 7/15/26 at 10:58 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R38 was on EBP and CNA-E should have worn a gown during cares for R38. 2. R24 was admitted to facility on 4/1/25 and had diagnoses including Parkinson's disease, neuromuscular dysfunction of bladder, multiple sclerosis, urinary incontinence, and history of urinary tract infections. An MDS assessment, dated 7/8/26, indicated R24 was dependent on staff for transfers, toileting, and hygiene and required substantial/maximal assistance with dressing. On 7/14/26 at 8:24 AM, Surveyor observed CNA-F complete catheter care for R24. CNA-F sanitized hands and donned a gown and gloves. CNA-F cleansed and rinsed the catheter tubing from the meatus downward. CNA-F removed gloves and donned clean gloves without cleansing hands and touched R24's bedding. CNA-F then entered the bathroom to get R24's leg pumps and applied the pumps to R24's right and left legs. CNA-F then removed gloves and touched objects in the room before sanitizing hands. On 7/14/26 at 8:41 AM, Surveyor interviewed CNA-F who verified they did not wash or sanitize hands in between glove changes after providing catheter care for R24.

Based on staff interview and record review, the facility did not notify Hospice in a timely manner of uncontrolled pain for 1 resident (R) (R2) of 5 sampled residents.R2 received Hospice services and complained of uncontrolled pain. The facility did not notify R2's Hospice agency so adequate pain relief could be provided.Findings include:From 2/4/26 to 2/5/26, Surveyor reviewed R2's medical record. R2 received Hospice services and was admitted to the facility on [DATE]. R2 had diagnoses including prostate cancer metastasized to the bone, right heel stage 4 pressure ulcer, osteomyelitis, cervical radiculopathy, chronic pain, peripheral neuropathy, and opioid dependence. R2's Minimum Data Set (MDS) assessment, dated 1/23/26, indicated a Brief Interview for Mental Status (BIMS) assessment was not completed. A Staff Assessment for Mental Status indicated R1's cognition was modified independent. R2's Power of Attorney for Healthcare (POAHC) was activated on 1/21/26. R2 was sent to the emergency room (ER) on 1/23/26 and passed away at the hospital on 1/31/26. On 2/4/26 at 3:06 PM, Surveyor interviewed Admissions Coordinator (AC)-E who stated AC-E was informed on 1/23/26 that R2 maxed out on pain medication but still complained of pain at level 10 out of 10. AC-E spoke to the hospital discharge planner and stated R2's refusal of care was a concern. R2 had also activated the call light overnight and yelled at the nurses at the nurses' station. AC-E stated AC-E called Hospice and notified R2's family on 1/23/26 that R2's pain was at a level 10 out of 10 and R2 was asking for more pain medication than the facility could provide. On 2/4/26 at 2:13 PM, Surveyor interviewed Hospice Director of Clinical Services (DCS)-G who stated DCS-G was informed on the morning of 1/23/26 by Nursing Home Administrator (NHA)-A and AC-E that the facility had maxed out on scheduled and as needed (PRN) pain medication for R2; however, R2's pain rating was still a 9-10 out of 10 and R2 was being sent to the ER. DCS-G stated R2 did not max out on pain medication and indicated R2's medications could have been increased or changed. DCS-G stated Hospice had not received any reports of uncontrolled pain prior to that day and was not notified of R2's verbally aggressive behavior or pain escalation before R2's pain became uncontrolled. On 2/5/26 at 11:11 AM, Surveyor interviewed Director of Nursing (DON)-B who stated Registered Nurse (RN)-I had provided all of the pain medication that R2 could have; however, R2's pain was still at a level 10 out of 10 and the medication was ineffective. DON-B stated RN-I notified the on-call provider and sent R2 to the ER for evaluation. When asked if Hospice was contacted prior to sending R2 to the ER, DON-B could not recall. DON-B stated if Hospice was notified and wanted to assess R2, they would have been allowed to do so. DON-B stated AC-E contacted R2's POAHC to ask if R2 should go to the hospital and R2's POAHC agreed. DON-B did not know if RN-I had spoken to R2's POAHC.On 2/5/26 at 1:49 PM, Surveyor interviewed RN-I who worked the 1/22/26 AM and PM shifts and the 1/23/26 AM shift. RN-I stated R2 was not physically or verbally aggressive on 1/22/26. RN-I stated R2 was impatient on 1/23/26 regarding call light response time although it had only been 1-2 minutes. RN-I stated R2 repeatedly complained of pain everywhere at a level 10 out of 10 and requested IV pain medication which the facility could not provide. When RN-I asked if R2 wanted to go to the hospital, R2 stated yes. RN-I stated RN-I told Director of Nursing (DON)-B that R2 wanted to go to the hospital but did not notify Hospice because R2's mind was made up. RN-I stated R2's POAHC was at the facility and was talking to Hospice when Emergency Medical Services (EMS) arrived. RN-I verified RN-I did not initially notify R2's POAHC.

Based on staff and resident representative interview and record review, the facility did not ensure written bed-hold and transfer/discharge notices were provided to 2 residents (R) (R2 and R13) of 3 sampled residents. In addition, the facility did not ensure notices that were provided contained required information on appeal rights. R2 was transferred to the hospital on 1/23/26. Neither R2 or R2's activated Power of Attorney (POA) were provided with a written bed-hold or transfer/discharge notice. R13 was transferred to hospital on 2/1/26. R13's written bed-hold and transfer/discharge notice did not include information pertaining to appeal rights. Findings include: On 2/5/26 at 2:43 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility's Bed-Hold for Hospitalization and Therapeutic Leave/Discharge form is also the facility's policy. DON-B confirmed the facility does not have a separate bed-hold or transfer/discharge policy. 1. From 2/4/26 to 2/5/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE]. R2 received Hospice services and had diagnoses including metastasized prostate cancer, stage 4 pressure ulcer to the right heel, opioid dependence, spinal stenosis, cervical region, and chronic pain. R2's Minimum Data Set (MDS) assessment, dated 1/23/26, indicated R2's Brief Interview for Mental Status (BIMS) score was not completed. A Staff Assessment for Mental Status indicated R2 had moderate cognitive impairment. R2 had an activated POA who assisted with healthcare decisions. R2's medical record indicated R2 was transferred to the hospital on 1/23/26, due to chronic pain and refusal of care. R2's medical record did not indicate R2 or R2's POA were provided with a written bed-hold or transfer/discharge notice. On 2/4/26 at 1:42 PM, Surveyor interviewed POA-C who stated prior to R2's transfer to the hospital on the morning of 1/23/26, POA-C and POA-D met with Admissions Coordinator (AC)-E who informed POA-C and POA-D that R2 was being kicked out of the facility due to R2's complaints of pain, behaviors, and refusal of cares. POA-C stated AC-E said R2 would not be allowed back to the facility because R2 was not fit to be there. POA-C verified POA-C did not receive a bed-hold or transfer/discharge notice for R2's hospital transfer. On 2/4/26 at 2:02 PM, Surveyor interviewed POA-D who confirmed a bed-hold and transfer/discharge notice was not provided or discussed with the facility. POA-D stated POA-D was informed by AC-E that R2 would not be allowed back to the facility because R2 had uncontrolled pain and was combative with staff. On 2/4/26 at 3:06 PM, Surveyor interviewed AC-E who confirmed AC-E met with POA-C and POA-D prior to R2's transfer to the hospital. AC-E confirmed that AC-E told POA-C and POA-D the transfer was due to R2's uncontrolled pain and refusal of care. AC-E verified that AC-E did not discuss a bed-hold or transfer/discharge notice with POA-C or POA-D and informed POA-C and POA-D that the facility would not accept R2 back. On 2/5/26 at 11:11 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed a bed-hold and transfer/discharge notice was not reviewed or provided to R2, POA-C, or POA-D because the facility would not be accepting R2 back. DON-B was not aware of the facility's responsibility to provide bed-hold and transfer/discharge notices to all residents who transfer to the hospital and that the notices must include the facility's requirement to permit residents to return and their appeal rights. 2. From 2/4/26 to 2/5/26, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including acute on chronic combined systolic and diastolic congestive heart failure and aspiration pneumonia. R13's MDS assessment, dated 1/29/26, had a BIMS score of 13 out of 15 which indicated R13 had intact cognition. R13 was responsible for R13's healthcare decisions. R13's medical record indicated R13 was transferred to the hospital on 2/1/26. R13's signed Bed-Hold for Hospitalization and Therapeutic Leave/Discharge form did not contain appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests, or information on how to obtain an appeal form and receive assistance with completing the form and submitting the appeal hearing request. On 2/5/26 at 11:11 AM, Surveyor interviewed DON-B who indicated DON-B was not aware bed-hold and transfer/discharge notices must include information on appeals rights. DON-B verified the facility's form did not include the required information.

Based on staff interview and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R3) of 5 sampled residents. Staff did not assess R3's lungs prior to set-up or after R3's self-administered nebulizer treatments. Findings include: The facility's Respiratory policy, dated 1/2025, indicates: .3. Nebulizer Administration: Nebulizer treatments are ordered by a Medical Doctor (MD). Equipment is set up in the room as ordered. Nebulizer medications are provided by (Pharmacy) and stored in the medication cart. Qualified nursing staff prepare equipment and medications as ordered. Prior to administration of nebulizer medications, nursing staff assesses the resident's pulse, oxygen saturation, and auscultate lung sounds. After administering nebulizer medication, nursing staff assess the resident's pulse, oxygen saturation, minutes of nebulizer use, and auscultate lung sounds. Staff monitor for any adverse side effects after administration. 4. Documentation and Reporting: Nursing staff use nursing judgement and nursing assessment skills when documenting. Respiratory nursing documentation includes: 1. Pre/post nebulizer treatment assessment. On 2/4/26, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), acute pulmonary edema, and heart failure. R3's Minimum Data Set (MDS) assessment, dated 6/9/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R3 had intact cognition. R3 had an activated Power of Attorney for Healthcare (POAHC). On 2/4/26, Surveyor reviewed R3's physician orders and Medication Administration Record (MAR) which contained the following orders: ~ Self-administer nebulizers and inhaler after nurse set-up three times daily for self-administration (dated 2/20/25) ~ Nebulizer: Assess prior to administering nebulizer treatment. Document lung sounds, pulse, and respirations every 6 hours for COPD. R3's MAR indicated all nebulizer treatments were provided; however, nebulizer assessments were not completed as ordered. On 2/4/26 at 4:49 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated nebulizer assessments should be documented in the MAR. DON-B verified R3's nebulizer assessments were not consistently documented in R3's MAR.

Based on staff and resident interview and record review, the facility did not provide adequate pain relief for 1 resident (R) (R2) of 5 sampled residents. R2 received Hospice services and was admitted to the facility on [DATE]. R2 complained of pain at a level 10 out of 10 on 1/23/26 and had aggressive behavior. Without consulting Hospice, the facility notified an on-call provider, indicated they had administered all of R2's ordered pain medication, and wanted to send R2 to the emergency room (ER). Hospice indicated they could have assessed R2 prior to the transfer to see if R2's pain medications could have been increased or changed which might have prevented the transfer. In addition, R2 had an order for morphine sulfate which could have been administered on the morning of 1/23/26 prior to the transfer.Findings include:The facility's Pain Management policy, revised January 2026, indicates: The facility must ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences .The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. Recognition: 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances whe the pain can be anticipated. B. Evaluate the resident for pain and the cause(s) .when a significant change in condition or status occurs (e.g., change in behavior or mental status .or an exacerbation of pain). c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 2. Facility staff will observe for non-verbal indicators which may indicate the presence of pain. These indicators include but are not limited to: .e. Behaviors such as: resisting care, distressed pacing, irritability, depressed mood .i. Negative vocalizations (e.g., groaning, crying, whimpering, or screaming). Pain Assessment: 1. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. 2. Based on professional standards of practice, an assessment or evaluation of pain .may necessitate gathering the following information .b. History of addiction, past and/or ongoing and related treatment for opioid use disorder (OUD) .h. Impact of pain on quality of life (e.g., sleeping, functioning, appetite, and mood) .j. The resident's goals for pain management and his/her satisfaction with the current level of pain control .Pain Management and Treatment: 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals, and the resident .will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain .4. Factors influencing the choice of treatments include: b. The resident's current medical condition. c. The resident's current medications. d. The resident's desired level of relief .Available treatment options g.Resident's elected Hospice benefit .5. For residents with an addiction history or opioid use disorder, the facility should use strategies to relieve pain while also considering the OUD or addiction history .6. Non-pharmacological interventions .f. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication .i. Opioid treatment should be individualized for each resident with consideration by the prescriber of utilizing immediate-release opioids instead of extended-release and long-acting forms of opioids. j. Facility staff will notify the provider, if the resident's pain is not controlled by the current treatment regimen. From 2/4/26 to 2/5/26, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE]. R2 receied Hospice services and had diagnoses including prostate cancer metastasized to the bone, right heel stage 4 pressure ulcer, osteomyelitis, cervical radiculopathy, chronic pain, peripheral neuropathy, and opioid dependence. R2's Minimum Data Set (MDS) assessment, dated 1/23/26, indicated a Brief Interview for Mental Status (BIMS) score was not completed. A Staff Assessment for Mental Status indicated R2 had moderate cognitive impairment. R2's Power of Attorney for Healthcare (POAHC) was activated on 1/21/26 and was responsible for assisting R2 with healthcare decisions. R2 was transferred to the emergency room (ER) on 1/23/26 and passed away at the hospital on 1/31/26. On 2/5/26 at 10:43 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who provided care for R2 on the 1/23/26 AM shift. CNA-K stated R2 requested medication for gas or pain and was rude and demanding. When CNA-K returned to R2's room later, R2 was balled up and was non-verbal.On 2/5/26 at 12:08 PM, Surveyor interviewed CNA-L who provided care for R2 on the 1/23/26 AM shift. CNA-L stated CNA-L turned R2's call light off at approximately 6:45 AM and R2 said R2 was waiting for pain medication. CNA-L returned to get R2's breakfast order approximately 40 minutes later and was told R2 was still in pain and did not want breakfast. CNA-L stated R2 raised R2's voice due to the the pain and refused breakfast, an ice pack, and repositioning.On 2/4/26 at 2:13 PM, Surveyor interviewed Hospice Director of Clinical Services (DCS)-G who stated DCS-G was informed on the morning of 1/23/26 by Nursing Home Administrator (NHA)-A and Admissions Coordinator (AC)-E that the facility had maxed out on scheduled and as needed (PRN) pain medication for R2; however, R2's pain rating was still at a level 9-10 out of 10 and R2 was being sent to the ER. DCS-G stated R2 did not max out on pain medication and indicated R2's medications could have been increased or changed. DCS-G stated Hospice was not given the opportunity to complete an assessment and adjust R2's pain medication. DCS-G offered to notify the Hospice Medical Director to increase R2's pain medication and to send a nurse to the facility to address pain management; however, the facility declined and stated they were sending R2 to the ER. DCS-G stated R2's hospitalization would not have been necessary had the facility involved Hospice in managing R2's pain. DCS-G stated the Hospice Hospital Liason met with R2 and R2's family in the ER and contacted the Hospice Medical Director who ordered Dilaudid 1 milligram (mg) intravenous (IV) x 2; however, R2 still had no relief. R2 was then given dexamethasone IV and lorazepam 1 mg IV and was still squirmish in pain. DCS-G stated R2 reported pain everywhere but it was worse in the abdomen and chest. R2 was admitted to the hospital on [DATE] and remained in the hospital until R2 passed away on 1/31/26.On 2/4/26 at 3:06 PM, Surveyor interviewed AC-E who stated AC-E was informed on 1/23/26 that R2 had maxed out on pain medication but still complained of pain at level 10 out of 10. AC-E spoke to the hospital discharge planner and stated R2's refusal of care was a concern. R2 had also activated the call light overnight and yelled at the nurses at the nurses' station. AC-E stated AC-E called R2's Hospice agency and notified R2's family on 1/23/26 that R2's pain was at a level 10 out of 10 and R2 was asking for more pain medication than the facility could provide. AC-E stated AC-E also informed R2's family about R2's refusals of cares and assessments. On 2/5/26 at 11:11 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B attempted assess R2 on the day of admission [DATE]) and the morning of 1/23/26; however, R2 refused and stated R2's pain was at a level 10 out of 10. DON-B stated Registered Nurse (RN)-I had provided all of the pain medication that R2 could have; however, R2's pain was still at a level 10 out of 10 and the medication was ineffective. DON-B stated RN-I discussed the matter with the Interdisciplinary Team (IDT) and notified the on-call provider. R2 was sent to the ER for evaluation of intractable and uncontrolled pain. When asked if Hospice was contacted prior to sending R2 to the ER, DON-B could not recall. DON-B stated if Hospice was notified and wanted to assess R2, they would have been allowed to do so. DON-B stated the expectation is that Hospice evaluate before a resident is sent out. DON-B stated the increase in R2's behavior was due to a progression of pain over time. DON-B stated AC-E contacted R2's POAHC to ask if R2 should go to the hospital to which R2's POAHC agreed. DON-B did not know if RN-I had spoken to R2's POAHC but indicated RN-I should have done so. Surveyor reviewed R2's Medication Administration Record (MAR) with DON-B who confirmed R2 could have received more PRN morphine since R2 was not transferred to ER on [DATE] until 12:45 PM. DON-B stated DON-B trusted RN-I that all medications that could be given were given.R2's MAR contained the following orders:~ Morphine sulfate oral tablet 30 milligrams (mg) 1 tablet every 12 hours for pain/shortness of breath (SOB). (The medication was administered on 1/22/26 at 8:00 PM and 1/23/26 at 8:00 AM.) ~ Morphine sulfate oral solution 10 mg/5 milliliters (ml) Give 2.5 ml every 2 hours PRN for chronic pain x 3 days. (The medication was not administered on 1/22/26. The medication was administered on 1/23/26 at 7:01 AM in addition to non-pharmacological interventions of distraction and repositioning.) ~ Lyrica (pregabalin) oral capsule 75 mg Give 2 capsules three times daily. (The medication was administered on 1/22/26 at bedtime (HS) and 1/23/26 in the AM.) (Of note: R2 did not receive PRN Tylenol or lorazepam on 1/22/26 or 1/23/26.) ~ Pain Monitoring - Assess for pain monitoring for 3 days (dated 1/22/26). (R2's pain level on the 1/22/26-1/23/26 night shift was documeted as 0; R2's pain level on the 1/23/26 AM shift was documented as 10.)On 2/5/26 at 1:49 PM, Surveyor interviewed RN-I who worked the 1/22/26 AM and PM shifts and the 1/23/26 AM shift. RN-I stated R2 was not physically or verbally aggressive on the 1/22/26 AM shift. RN-I stated R2 was impatient on 1/23/26 regarding call light response time although it had only been 1-2 minutes. RN-I stated R2 repeatedly complained of pain everywhere at a level 10 out of 10 and requested IV pain medication which the facility could not provide. RN-I stated R2 received scheduled morphine and PRN morphine close to the same time. RN-I stated R2 said R2 used to take 6 Oxy per day and the pain was not going to be controlled by RN-I. RN-I opted to administer morphine because R2 was aggressive in conversation and jerked toward RN-I like R2 was going to jump on RN-I. R2 insisted the morphine would not work and requested 6 Oxy tablets or IV pain medication. When Surveyor asked why RN-I documented the morphine solution as effective, RN-I stated the morphine was effective even though R2 was aggressive. When RN-I asked if R2 wanted to go to the hospital, R2 stated yes. RN-I stated RN-I offtered R2 PRN morphine again at approximately 9:00 AM but R2 refused. (Of note: R2's medical record did not indicate PRN morphine was offered and refused). RN-I stated RN-I told DON-B that R2 wanted to go to the hospital and R2's mind was made up. RN-I denied that RN-I said R2 was given the maximum amount of pain medication. RN-I stated R2's POAHC was at the facility and was talking to Hospice when Emergency Medical Services (EMS) arrived.On 2/5/26 at 2:33 PM, Surveyor interviewed Hospital Case Manager (HCM)-H who stated the facility called HCM-H on 1/22/26 before R2 went to the ER and stated they were sending R2 back due to pain control and behavior concerns. HCM-H stated HCM-H received a message from the Hospice Hospital Liason who indicated the facility was offered solutions but declined to give R2 more pain medication and sent R2 to the ER. On 2/5/26 at 3:40 PM, Surveyor interviewed DON-B who confirmed that R2's medical record did not indicate R2 was offered PRN morphine after 7:01 AM on 1/23/26. DON-B stated if PRN morphine was offered and refused, it should have been documented in R2's medical record.

Based on staff interview and resident representative interview and record review, the facility did not provide timely access to a medical record for 1 resident (R) (R1) of 3 sampled residents. R1 requested a copy of R1's medical record in writing on 1/20/26. As of 2/5/26, R1 had not received the requested records. Findings include: On 2/5/26 at 4:36 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility does not have a policy for medical record requests but follows state and federal regulations. From 2/4/26 to 2/5/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease with (acute) exacerbation. R1's Minimum Data Set (MDS) assessment, dated 12/10/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was responsible for R1's healthcare decisions. R1 was discharged from the facility on 12/10/25. On 2/4/26 at 1:24 PM, Surveyor interviewed Family Member (FM)-J who stated R1 and FM-J submitted a request for R1's medical record to Nursing Home Administrator (NHA)-A via email on 1/20/26. FM-J stated email communication continued through 1/22/26 when R1 signed a formal request for medical records that was also sent via email to NHA-A. FM-J stated R1 and FM-J had not yet received the requested records. FM-J stated NHA-A's email response indicated the facility had up to 30 days to provide the medical records. On 2/4/26 at 3:32 PM, Surveyor interviewed Social Worker (SW)-F who was aware of R1's request for medical records. SW-F stated SW-F was uncertain of the timeframe to release records but thought the facility had 48 hours. On 2/4/26 at 3:42 PM, Surveyor interviewed NHA-A who showed Surveyor a paper copy of R1's medical record. NHA-A stated the facility was going to have a meeting to review the records on 2/4/26; however, the meeting was postponed until 2/6/26. NHA-A stated NHA-A was going to call R1 and let R1 know the medical records were ready to pick up after the meeting.

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 35 residents residing in the facility. The kitchen microwave was not kept in a clean and sanitary condition to prevent cross-contamination. The refrigerator in the main kitchen contained food that was past the discard date and/or open to air. The facility's dishwasher did not reach minimum temperature requirements to prevent the spread of foodborne illness. Findings include: On 5/12/25 at 9:25 AM, Surveyor began an initial tour of the kitchen with Dietary Manager (DM)-N who stated the facility followed the State Food Code. Microwave Cleanliness: The Wisconsin Food Code documents at section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The Wisconsin Food Code documents at section 4-602.12 Cooking and Baking Equipment: (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. The facility's Cleaning and Sanitizing Surfaces policy, dated March 2025, indicates: .A. Clean and sanitize to remove food and debris using hot soapy water, and sanitize using a food-safe sanitizer on all food contact surfaces .Frequency: Before and after food prep .After spills or contamination. During the initial tour of the kitchen with DM-N on 5/12/25 at 9:25 AM, Surveyor and DM-N observed the microwave in the main kitchen and noted the interior had dried food debris on the top and sides. DM-N stated the microwave should be cleaned after each use. On 5/14/25 at 7:51 AM, Surveyor interviewed DM-N who stated DM-N cleaned the microwave right after Surveyor completed the kitchen tour. Food Storage: The Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food:(A) .Refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1. The Wisconsin Food Code documents at 3-202.15 Package Integrity: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. The Wisconsin Food Code documents at 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation: (A) Food shall be protected from cross-contamination by .(4) except as specified in subparagraph 3-501.15 (b)(2) and in (b) of this section, storing the food in packages, covered containers, or wrappings. Food Safety.gov indicates celery if kept refrigerated should be consumed within 1-2 weeks. During the initial tour of the kitchen with DM-N on 5/12/25 at 9:25 AM, Surveyor and DM-O observed a partially open container of marinara sauce in the cooler with a prepared date of 5/6/25 and a use-by date of 5/9/25. DM-N confirmed the marinara sauce should have been discarded. Surveyor and DM-N also observed a package of celery in the original bag and open to air with an open date of 4/25/25 and no use-by date. Dishwasher: The Wisconsin Food Code documents at 4-204.113 Warewashing Machine, Data Plate Operating Specifications: A warewashing machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operating specifications including the: (A) Temperatures required for washing, rinsing, and sanitizing; (B) Pressure required for the fresh water sanitizing rinse unless the machine is designed to use only a pumped sanitizing rinse; and (C) Conveyor speed for conveyor machines or cycle time for stationary rack machines. The Wisconsin Food Code documents at 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (1) For a stationary rack single temperature machine, 74 degrees C (165 degrees F); (2) For a stationary rack dual temperature machine, 66 degrees C (150 degrees F); (3) For a single tank, conveyor, dual temperature machine, 71 degrees C (160 degrees F); or (4) For a multi-tank, conveyor multi-temperature machine, 66 degrees C (150 degrees F). (B) The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 49 degrees C (120 degrees F). The Wisconsin Food Code documents at 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures: (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 90 degrees C (194 degrees F), or less than: (1) For a stationary rack single temperature machine, 74 degrees C (165 degrees F); or (2) For all other machines, 82 degrees C (180 degrees F). On 5/13/25 at 1:02 PM, Surveyor observed DM-N wash dishes. Surveyor noted the facility had a [NAME] AM15 dish machine. A data plate on the front of the machine indicated a minimum wash temperature of 150 degrees F and a minimum rinse temperature of 180 degrees F. Surveyor observed DM-N run the machine and noted the machine reached a wash temperature of 148 degrees F and a rinse temperature of 178 degrees F. DM-N ran the machine again which resulted in a wash temperature of 151 degrees F and a rinse temperature of 175 degrees F. DM-N indicated at times the machine needs to be run a few times to reach the appropriate temperatures. DM-N ran the machine again with a wash temperature of 154 degrees F and a rinse temperature of 168 degrees F. DM-N stated because the machine was run 3 times and still did not reach the appropriate rinse temperature, DM-N would have maintenance staff check the machine. Maintenance Director (MD)-O drained and refilled the dish machine and ran the machine an additional 7 times. The rinse temperature remained below the 180 degrees F minimum temperature. DM-N confirmed the machine did not reach the minimum rinse temperature.

Based on staff interview and record review, the facility did not ensure the right to make healthcare decisions was extended only to those delegated by the resident and in accordance with applicable law for 2 residents (R) (R3 and R28) of 16 sampled residents. R3 was declared incapacitated and had an activated Power of Attorney for Healthcare (POAHC). The facility did not ensure the individual making healthcare decisions on behalf of R3 was the representative delegated by R3. R28 was admitted to the facility on [DATE] and had an activated POAHC. The facility had R28 sign medical consents and did not ensure healthcare decisions were delegated to R28's representative as R28 was deemed incapacitated. Findings include: Wisconsin Stat. Chapter 155.01, defines Health Care Agent as an individual designated by the principal to make healthcare decisions on behalf of the principal or, if that individual is unable or unwilling to make those decisions, an alternate individual designated by the principle to do so .it also defines incapacity as the inability to receive and evaluate information effectively or to communicate decisions to such an extent that the individual lacks the capacity to manage his or her healthcare decisions. The facility's undated Residents' Rights Regarding Treatment and Advanced Directives Policy indicates it is the policy of the facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment .The policy defines advanced directive as a written instruction, such as a living will or durable power of attorney for healthcare, recognized under state law, relating to the provision of healthcare when the individual is incapacitated .1) On admission, the facility will determine if the resident has executed an advanced directive .3) Should the resident have an advanced directive, copies will be made and placed in the chart as well as communicated to the staff. 4) The facility will periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. 5) The facility will identify .an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant healthcare decisions. 1. From [DATE] to [DATE], Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including heart failure, type 2 diabetes, repeated falls, and moderate dementia with agitation. R3's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R3 had moderate cognitive impairment. Significant Other (SO)-E was R3's activated POAHC and was responsible for R3's healthcare decisions. A POAHC document, signed by R3 on [DATE], indicated if R3 was no longer able to make healthcare decisions due to incapacity, R3 designated SO-E to be R3's healthcare agent for purposes of making healthcare decisions. If SO-E was unable or unwilling to do so, R3 designated Alternate Agent (AA)-F to be the alternate healthcare agent. The document stated incapacity exists if two physicians or a physician and psychologist, who have personally examined R3, sign a statement indicating R3 is no longer able to make healthcare decisions. A provider visit note, dated [DATE], indicated R3 was hospitalized from [DATE] through [DATE] due to altered mental status and urinary tract infection. The note indicated R3 was deemed incapacitated on [DATE] and R3's POAHC was activated. SO-E was listed as R3's healthcare decision maker. R3's medical record included a handwritten note, dated [DATE] and signed by SO-E, that stated SO-E was resigning as R3's primary POAHC agent and would like Family Member (FM)-G to act as primary healthcare decision maker. FM-G was not listed on R3's POAHC document as a designated agent. R3's medical record contained documented healthcare decisions by FM-G, including: ~ A pneumococcal vaccine declination, signed and dated by FM-G on [DATE] ~ An informed consent for medication form for Xanax, signed and dated by FM-G on [DATE] ~ A progress note, dated [DATE] at 8:19 PM, indicated FM-G gave permission for nursing staff to administer morphine for signs of pain. ~ A progress note, dated [DATE] at 5:37 PM, stated FM-G gave verbal consent to begin Xanax as ordered and wanted all as needed (PRN) medications put on hold until the effectiveness of Xanax was known. ~ A progress note, dated [DATE], indicated FM-G was updated on R3's fall and behavior. On [DATE] at 11:54 AM, Surveyor interviewed Social Worker (SW)-H who confirmed SO-E was R3's primary POAHC agent but chose to resign and asked FM-G to take over. Surveyor and SW-H reviewed R3's POAHC document. SW-H did not know who AA-F was and indicated SW-H needed to follow-up with R3's family. SW-H was not aware that FM-G was not listed as a healthcare agent on R3's POAHC document. SW-H confirmed if FM-G was not listed on the document, FM-G should not be making healthcare decisions for R3. On [DATE] at 2:20 PM, Surveyor interviewed SW-H who stated SO-E would resume responsibility for R3's healthcare decisions. SW-H stated AA-F was not involved with the family any longer and was not involved in R3's healthcare. 2. From [DATE] to [DATE], Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] and had diagnoses including dementia, cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R28's MDS assessment, dated [DATE], had a BIMS score of 9 out of 15 which indicated R28 had moderate cognitive impairment. R28 had an activated POAHC who was responsible for R28's healthcare decisions. R28's medical record included a POAHC document, signed by R28 on [DATE], and two Statement of Incapacity documents, one activated on [DATE] and the other on [DATE], that indicated R28's primary POAHC agent (POAHC-I) was R28's healthcare decision maker when R28 admitted to the facility on [DATE]. R28's medical record included healthcare documents signed by R28 after R28 was deemed incapacitated. The documents included: ~ An informed consent for medication form for trazodone, dated [DATE] ~ An informed consent for medication form for Ativan, dated [DATE] ~ An informed consent for medication form for clomipramine, dated [DATE] ~ A cardiopulmonary resuscitation (CPR) directive form, dated [DATE] ~ A podiatry consent form, dated [DATE] ~ A COVID-19 vaccine consent form, dated [DATE] On [DATE] at 11:54 AM, Surveyor interviewed SW-H who confirmed R28 was deemed incapacitated and had an activated POAHC. SW-H confirmed R28 should not have signed healthcare documents and verified R28's POAHC should have signed medical consents.

Based on staff interview and record review, the facility did not ensure Pre-admission Screen and Resident Review (PASRR) requirements were met for 3 residents (R) (R3, R6 and R28) of 15 sampled residents. R3's medical record indicated R3 had a mental illness (MI) diagnosis and was prescribed psychotropic medication. The facility did not update R3's PASRR Level I Screen with medication changes and did not submit for a PASRR Level II Screen timely when R3 remained in the facility past 30-days. In addition, the facility did not obtain a county exemption (Department of Health Services (DHS) form F-20822) when R3 was admitted to the facility. R6's medical record indicated R6 had MI diagnoses and was prescribed psychotropic medication. The facility did not submit for a PASRR Level II Screen timely when R6 remained in the facility past 30-days. In addition, the facility did not obtain a county exemption (DHS form F-20822) when R6 was admitted from the hospital. R28's medical record indicated R28 had an MI diagnosis and was prescribed psychotropic medication. The facility did not update R28's PASRR Level I with medication changes and did not submit for a PASRR Level II Screen timely when R28 remained in the facility past 30-days. In addition, the facility did not obtain a county exemption (DHS form F-20822) when R28 was admitted from the hospital. Findings include: According to the State of Wisconsin Department of Health Services (DHS), PASRR is a federal requirement that all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual disability (ID)/developmental disability (DD) and/or an MI. This is called a Level I Screen. The purpose of a Level I Screen is to identify individuals whose total needs require that they receive additional services for their ID/DD and/or MI. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an ID/DD and/or MI for PASRR purposes. This is a Level II Screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care. Nursing facilities may seek county exemption (DHS form F-20822) for applicants with ID/DD and/or MI whose stay in the facility is expected to be recuperative care or short-term. 1. From 5/12/25 to 5/14/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and has diagnoses including major depressive disorder and moderate dementia with agitation. R3's Minimum Data Set (MDS) assessment, dated 3/20/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R3 had moderate cognitive impairment. R3's PASRR Level I Screen, with admission date 4/4/24, was marked Yes for MI and psychotropic medications and indicated R3 was prescribed Seroquel (an antipsychotic medication) and Ativan (an antianxiety medication). The Screen stated R3 was on medication for restlessness and agitation associated with end of life. R3's PASRR Level I Screen was marked No for county exemption. R3 had physician orders for risperidone (an antipsychotic medication) 1 milligram (mg) twice daily for agitation and Xanax (an antianxiety medication) 0.5 mg twice daily and as needed for agitation. R3's physician orders did not include Seroquel or Ativan. On 5/14/25 at 12:05 PM, Surveyor interviewed Social Worker (SW)-H who confirmed SW-H was responsible for completion of the PASRR process. SW-H confirmed R3's Level I Screen should have been updated with the medication changes. SW-H stated SW-H completed an audit of all PASRRs within the last couple of months and did submit for a PASRR Level II Screen which SW-H would provide. SW-H indicated SW-H submits for county exemption from the county where the resident lives. SW-H was unable to confirm if a county exemption was requested for R3 but stated SW-H would get back to Surveyor. On 5/14/25 at 1:00 PM, Surveyor reviewed R3's PASRR Level II Screen with a referral date of 3/31/25 and determination date of 4/1/25. The PASRR Level II Screen did not include R3's medication changes. R3's PASRR Level II Screen was not submitted timely when R3 remained in the facility. 2. From 5/12/25 to 5/14/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had a diagnosis of acute respiratory failure. R6's diagnoses list does not indicate R6 had diagnoses of depression and anxiety, however, R6 was prescribed psychotropic medication for depression and anxiety. R6's MDS assessment, dated 3/4/25, had a BIMS score of 13 out of 15 which indicated R6 had intact cognition. R6's undated PASRR Level I Screen was marked Yes for MI, psychotropic medications (Ativan), and 30-day hospital exemption. R6 had physician orders for Lexapro (an antidepressant medication) 10 mg daily for depression (dated 2/26/25) and Ativan 0.5 mg every 8 hours as needed for anxiety (dated 2/26/25). On 5/12/25 at 2:45 PM, Surveyor requested R6's PASRR Level II Screen and county exemption F-20822 form. On 5/14/25 at 10:30 AM, Surveyor reviewed R6's medical record and noted a PASRR Level II Screen was uploaded to R6's medical record on 5/14/25. The PASRR Level II Screen had a submit date of 5/12/25 and a determination date of 5/13/25. Surveyor also noted an updated PASRR Level I Screen that included Lexapro and Ativan and was marked No for MI and 30-day exemption and Yes for medications. R6's PASRR Level II Screen was not submitted timely after R6 remained in the facility past 30-days. On 5/14/25 at 12:05 PM, Surveyor interviewed SW-H who stated R6's PASRR Level II Screen was submitted because R6 continued to stay at the facility for long term care. SW-H stated SW-H did not know when the PASRR Level II Screen was submitted or when the determination was received. SW-H denied submitting for R6's PASRR Level II Screen after Surveyor requested the documents. SW-H stated SW-H submitted to the county for a 30-day exemption for R6 and SW-H would provide a copy of the exemption form. 3. From 5/12/25 to 5/14/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] and had diagnoses including non-ST-elevation myocardial infarction (NSTEMI) and dementia. R28's diagnoses list did not include diagnoses of anxiety or obsessive-compulsive disorder (OCD) with skin picking, however, R28 was prescribed medication for anxiety and OCD skin picking. R28's diagnosis list also did not include a diagnosis of depression, however, physician visit notes listed a history of depression as an active diagnosis. R28's MDS assessment, dated 2/18/25, had a BIMS score of 9 out of 15 which indicated R28 had moderate cognitive impairment. R28 had physician orders for clomipramine (an antidepressant medication) 50 mg once daily for OCD skin picking (dated 10/24/24), sertraline 50 mg once daily for anxiety, and trazodone 150 mg once daily for sleep. On 5/12/25 at 2:45 PM, Surveyor requested R28's PASRR Level I Screen, PASRR Level II Screen, and county exemption form F-20822. On 5/13/25, Surveyor reviewed R28's PASRR Level I Screen, admission date 5/22/24, which was marked No for MI and psychotropic medications but listed trazadone and lorazepam as medications taken for non-MI related diagnoses. R28's Level I Screen did not include sertraline or clomipramine A provider visit note, dated 10/24/24 and completed by R28's Nurse Practitioner, indicated under active diagnoses that R28 had a history of depression. The note also listed OCD with picking of the skin. On 5/14/25 at 12:05 PM, Surveyor interviewed SW-H who was not aware of R28's history of depression and did not know if OCD was a symptom of a medical condition or MI. SW-H confirmed R28's Level I Screen should have been updated with the changes in medication but could not confirm if a PASRR Level II Screen was submitted. SW-H indicated SW-H would have submitted to the county for a 30-day exemption. Surveyor requested R28's county exemption form F-20288 and PASRR Level II Screen. From 5/12/25 to 5/14/25, Surveyor made several requests for PASRR paperwork from the facility. The facility did not provide R28's PASRR Level II Screen or county exemption forms for R3, R6, or R28.

Based on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R31 and R10) of 2 sampled residents received assistance with activities of daily living (ADLs) in order to maintain their highest practicable physical well being. R31 had a perirectal abscess that extended to the left gluteal region following surgery. Staff did not provide timely care which caused R31 to be incontinent and posed a risk for wound infection. R10's Physical Therapy Discharge Summary contained an ambulation program that indicated to ambulate R10 in the hallway once per shift with caregiver stand-by assist (SBA)/contact guard assist (CGA) and wheelchair follow for 30-35 foot intervals. The ambulation program was not consistently implemented. In addition, R10's care plan did not include ambulation or a restorative program. Findings include: The facility's Dignity Policy for All Staff Category: Resident Rights, dated May 2025, indicates: Staff are employees in the resident's home. Residents have the right to be treated with respect and dignity in their home. It is the responsibility of the staff to protect residents' rights. Violations of residents' rights can be subtle and elusive. Staff members will be held accountable for the effects of careless, thoughtless, tactless, or insensitive actions because these undermine self-esteem, dignity and the respect the resident deserves. The facility's Call Lights: Accessibility and Timely Response Policy, revised May 2025, indicates: .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The facility's Activities of Daily Living (ADLs) policy, dated January 2025, indicates: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: .2. Transfer and ambulation .2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment .5. The facility will maintain individual objectives of the care plan and periodic review and evaluation. The facility's Restorative Nursing Program, with a copyright date of 2024, indicates: It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living independently and as safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning .7. Residents may receive restorative nursing services .upon discharge from therapy .10. A resident's restorative nursing plan will include: a. The problem, need, or strength the restorative tasks are to address; b. The type of activities performed; c. Frequency of activities; d. Duration of activities; e. Measurable goal and target time .12. Restorative aides will implement the plan for a designated length of time, performing the activities and documenting on the Restorative Aide Documentation Form or other facility designated form. 1. From 5/12/25 to 5/14/25, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] and had diagnoses including diabetes, perirectal abscess status post incision and drainage on 9/24 with a large residual wound that extended onto the left gluteal region, obesity, anxiety, and urinary incontinence. R31's Minimum Data Set (MDS) assessment, dated 2/19/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31 made R31's own healthcare decisions. R31's medical record indicated R31 received daily (and as needed after incontinence) wound care. R31 had an order to clean the wound, apply collagen directly to the wound, and apply an ABD dressing. Wound care nurses at the facility saw R31 during weekly wound rounds. The wound clinic saw R31 approximately every three weeks. R31 had an indwelling Foley catheter to enhance wound healing. A provider note, dated 11/14/24, indicated R31 had a rectal abscess that measured 18.5 centimeters (cm) x 7 cm x 9.5 cm. A skin note, dated 12/12/24, indicated R31 had an open perirectal lesion that measured 19 cm x 4.5 cm x 4.5 cm and was in direct line with the anus. The note indicated R31 was incontinent of bowel during the assessment which presented an infection risk and hindered successful wound vac placement. R31 was referred to the wound clinic. A wound clinic note, dated 12/18/24, indicated R31 was seen for the first time. A colostomy was discussed given the proximity of the wound to the rectum. There was a concern regarding the potential ramifications of fecal soiling. A wound clinic note, dated 4/9/25, indicated R31 was upset because R31 asked staff to toilet R31 prior to the appointment. Staff did not toilet R31 who had been sitting in stool. R31 was fearful it would affect wound healing. R31's wound measured 14.4 cm x 4.7 cm x 0.2 cm and was improving. R31 was reminded to be diligent about asking staff to provide assistance when needed. A wound clinic note, dated 4/30/25, indicated R31 presented with stool impacted in the wound. It appeared as though dressings and stool were becoming balled up and stuck in the gluteal cleft which created increased pressure and delays in wound healing. A wound clinic note, dated 5/5/25, indicated R31 complained of incontinence since R31's Foley catheter was removed and stated R31 had to sit in urine/stool for hours at times. The wound was smaller and measured 13.0 cm x 4.0 cm x 1.0 cm. A nursing note, dated 5/9/25 at 11:08 AM, indicated R31 was functionally incontinent of bowel and bladder and had a bedside commode. R31 complained of general discomfort related to the left buttock wound and stated, I want the Foley back in. This just isn't working. I've been sitting here wet for an hour and now it's burning. R31 stated, I'm just having too many accidents. By the time I turn on my call light I've already went. On 5/12/25 at 9:23 AM, Surveyor interviewed R31 who indicated call light response time was approximately two hours. On 5/13/25 at 12:44 PM, Surveyor interviewed R31 in the presence of R31's sisters. R31 indicated R31 had a wound clinic appointment on 4/30/25 and told Certified Nursing assistant (CNA)-J that R31 had a bowel movement. CNA-J stood at the edge of the bed, spread R31's legs, and twice stated there was no stool. R31 stated CNA-J did not turn R31 to look. After getting in the wheelchair, R31 noticed stool on R31's Chux pad and sheet. CNA-J told R31 that CNA-J did not have time to clean R31 and stated staff at the wound clinic could do it. R31 stated R31 was embarrassed to ask wound clinic staff to clean R31. R31 noted two other instances when the call light response time was approximately two hours. R31 stated on the 5/6/25 AM shift at approximately 1:00 PM, R31 was incontinent of urine and stool. On the 5/6/25 PM shift at approximately 7:00 or 8:00 PM, R31 was incontinent of urine. R31 had a voiding trial on 5/5/25 and indicated staff could not get R31 to the commode in time. R31 eventually requested a Foley catheter. R31 indicated R31 activated the call light on the morning of 5/8/25. CNA-J turned off the call light from the nurses' station and said CNA-J would be right there. R31 indicated CNA-J left R31 sitting in stool and R31 was told by a nurse that CNA-J left the facility to go to CNA-J's pharmacy. R31 was upset and called R31's insurance company to check on home care so R31 could leave the facility. On 5/13/25 at 2:30 PM, Surveyor observed Licensed Practical Nurse (LPN)-S complete wound care for R31. LPN-S changed R31's dressing and indicated R31's left buttock was healing. On 5/13/25 at 3:40 PM, Surveyor interviewed Director of Nursing (DON)-B who was not aware of the 4/30/25 wound clinic note and indicated the nurses had not relayed concerns. On 5/13/25 at 4:00 PM, Surveyor interviewed Social Worker (SW)-H and NHA-A who met with R31 to follow-up on the concerns. SW-H indicated R31 liked CNA-J as a person but did not feel R31 was being washed up appropriately. R31 asked if the facility could retrain CNA-J. SW-H planned to talk to CNA-J prior to CNA-J's next shift. R31 wanted CNA-J to continue to care for R31 and wanted to reestablish a good relationship. SW-H planned to follow-up with R31 regarding cares. SW-H also planned to interview other residents. On 5/14/25 at 1:24 PM and 1:37 PM, Surveyor interviewed RN-P who indicated the facility had wound care meetings on Fridays during which RN-P compared wound measurements from week to week. RN-P indicated nurses review wound care notes when a resident returns from the wound clinic. RN-P was not aware if R31 was properly cleaned after incontinence episodes. 2. From 5/12/25 to 5/14/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including diabetes type 2 with polyneuropathy (a condition that affects the nerves of the hands and feet), infection and inflammatory reaction due to internal right hip prostheses, and repeated falls. R10's MDS assessment, dated 2/26/25, had a BIMS score of 8 out of 15 which indicated R10 had moderate cognitive impairment. The MDS assessment also indicated R10 could walk 50 feet and make 2 turns with partial/moderate assistance. R10 had an activated Power of Attorney for Healthcare (POAHC). On 5/12/25 at 10:09 AM, Surveyor interviewed R10 who stated R10 had a couple spots of irritation on R10's buttocks and was not walking much. R10 stated R10 would walk to the bathroom independently with a 2-wheeled walker, however, R10 no longer had PT and the CNAs did not walk R10 in the hallway. R10 was unsure if R10 had a restorative program and expressed a desire to walk in the hallway with staff. R10's medical record indicated R10 participated in physical therapy from 3/5/25 to 4/2/25. R10's PT Discharge Summary indicated R10 met the maximum benefit from skilled PT interventions with R10 staying long term in the facility. The note indicated R10 had a restorative ambulation program that included ambulating in the hallway once per shift with caregiver SBA/CGA and wheelchair to follow for 30-50-foot intervals. Surveyor noted R10's care plan did not include ambulation or a restorative program. On 5/12/25 at 10:19 AM, Surveyor interviewed CNA-J who indicated R10 did not have a restorative program and staff did not walk R10 in the hallway. CNA-J stated R10 needed assistance with pericare at times and completed R10's own exercises. On 5/14/25 at 3:45 PM, Surveyor interviewed CNA-J and Registered Nurse (RN)-K. CNA-J was not aware R10 had a walking schedule for restorative care until CNA-J was shown a CNA sheet by RN-K. On 5/14/25, Surveyor reviewed a follow-up question report for ADL-Walk in corridor in R10's medical record. Surveyor noted between 4/2/25 and 5/14/25, R10 had approximately 84 opportunities to ambulate on the AM and PM shift. Surveyor noted R10 ambulated once per day on 4/2/25, 4/4/25, 4/13/25, 4/14/25, 4/18/25, 4/26/25, 4/27/25, 5/2/25, 5/8/25, and 5/12/25. The documentation did not indicate R10 was walked twice on any day. The documentation also indicated R10 had 2 refusals, 2 not availables, and 55 not applicables. On 5/14/25 at 4:59 and 5:21 PM, Surveyor interviewed DON-B who reviewed R10's follow-up question report for ADL-Walk in Corridor for 4/2/25 to 5/14/25 and agreed with Surveyor's findings. DON-B indicated not applicable meant the task did not occur. DON-B stated restorative program notes are hung in resident rooms, including the resident's transfer status and ADLs. DON-B also verified R10 did not have a care plan that included ambulation or a restorative program.

3. From 5/12/25 to 5/14/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including dementia, encephalopathy, osteoarthritis, and weakness. R7's MDS assessment, dated 3/20/25, had a BIMS score of 9 out of 15 which indicated R7 was moderately cognitively impaired. The MDS assessment also indicated R7 required substantial/maximal assistance for transfers. R7's medical record indicated R7 had unwitnessed falls on 2/1/25 and 3/24/25. R7 was found on the floor following both falls. Surveyor reviewed the investigations for both falls and noted the facility did not identify a root cause for the falls or update R7's care plan with new interventions. R7's falls care plan (revised 3/11/25) did not contain any new interventions following the falls on 2/1/25 and 3/24/25. Surveyor reviewed R7's neuro checks for the unwitnessed falls. Several neuro checks were missing following the fall on 2/1/25, including the second, third, and fourth fifteen minute check, the first and third hourly check, and all three shift checks. R7's fall on 3/24/25 had missing neurochecks for every shift x 3 shifts. In addition, staff did 30 minute neuro checks four times versus hourly 4 times. On 5/14/25 at 3:21 PM, Surveyor interviewed DON-B who verified the fall investigations did not identify a root cause for R7's falls and R7's care plan was not updated with any new interventions. DON-B also verified there were missing neuro checks for R7's falls on 2/1/25 and 3/24/25. Based on staff interview and record review, the facility did not ensure fall procedures were followed and preventative measures were implemented to ensure safety for 3 residents (R) (R3, R28, and R7) of 6 sampled residents. R3 had five falls from 3/31/25 to 4/13/25. The facility did not identify a root cause for the falls or update R3's care plan with new fall interventions. In addition, R3's neurological checks were incomplete. R28 had six falls from 5/23/24 to 2/8/25. The facility did not identify a root cause for the falls or update R28's care plan with new fall interventions. R28's neurological checks were also incomplete. In addition, the facility did not complete a fall investigation for R28's fall on 6/4/24. R7 had unwitnessed falls on 2/1/25 and 3/24/25. The facility did not identify a root cause for the falls or update R7's care plan with new fall interventions. In addition, R7's neurological checks were incomplete. Findings include: On 5/14/25 at 2:04 PM, Surveyor interviewed Director of Nursing (DON)-B who stated the facility did not have a falls policy. DON-B indicated staff are expected to follow the facility's Fall Checklist. The facility's undated Fall Checklist indicates there is no need to do neurochecks for a witnessed fall unless the resident hit their head. Ask resident if they recall hitting their head. If the fall is unwitnessed, neuro checks should be completed no matter what. Initiate Neuro Check Forms .neuro checks every 15 minutes times 4, then every hour times 4, and then every shift times 3 .Complete Fall Incident Report in electronic medical record. 1. From 5/12/25 to 5/14/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, major depressive disorder, repeated falls, and moderate dementia with agitation. R3's Minimum Data Set (MDS) assessment, dated 3/20/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R3 had moderate cognitive impairment. Significant Other (SO)-E was R3's activated Power of Attorney for Healthcare (POAHC) and was responsible for R3's healthcare decisions. R3's fall care plan (initiated 10/9/24) stated R3 was at high risk for falls related to deconditioning, frequent falls, and confusion. R3's care plan contained the following interventions (dated 10/9/24): ~ Anticipate and meet R3's needs ~ Be sure R3's call light is within reach and encourage R3 to use it for assistance as needed. R3 needs prompt response to all requests for assistance. ~ Educate R3/family/caregivers about safety reminders and what to do if a fall occurs. ~ Follow fall protocol. (revised on 12/9/24 to include Call Don't Fall poster.) ~ Physical therapy evaluation and treat as ordered or as needed. ~ Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate R3/family/caregivers/interdisciplinary team as to the cause. R3's medical record indicated R3 had unwitnessed falls in R3's room on 3/31/25, 4/3/25, 4/9/25, 4/11/25, and 4/13/25. Surveyor reviewed fall investigations for R3's falls. The fall investigations did not indicate the root cause of the falls. For 4 of the 5 falls (3/31/25, 4/3/25, 4/9/25, and 4/11/25), neither the fall investigation or R3's care plan were updated with new interventions to prevent additional falls. (Between 12/9/24 and 4/13/25, no additional safety measures were added to R3's care plan.) In addition, R3's post-fall neuro checks were inconsistently filled out or incomplete for all of R3's unwitnessed falls. On 5/14/25 at 2:04 PM, Surveyor interviewed DON-B who confirmed the fall investigations did not identify a root cause for R3's falls. DON-B confirmed safety measures/interventions were not implemented and R3's care plan was not updated following the unwitnessed falls. DON-B also verified neuro checks were not thoroughly completed following R3's unwitnessed falls. 2. From 5/12/25 to 5/14/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE] and had diagnoses including dementia, cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R28's MDS assessment, dated 2/18/25, had a BIMS score of 9 out of 15 which indicated R28 had moderate cognitive impairment. R28 had an activated POAHC for healthcare decisions. R28's falls care plan (initiated 11/26/24) stated R28 was at high risk for falls related to deconditioning. R28's care plan contained the following interventions (dated 11/26/24): ~ Anticipate and meet R28's needs. ~ Be sure R28's call light is within reach and encourage R28 to use it for assistance as needed. R28 needs prompt response to all requests for assistance. ~ Educate R28/family/caregivers about safety reminders and what to do if a fall occurs. ~ Follow fall protocol. ~ Physical Therapy eval and treat as ordered or as needed. ~ Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate R28/family/caregivers/interdisciplinary team as to the cause. R28's medical record indicated R28 had unwitnessed falls on 5/23/24, 5/24/24, 6/2/24, 6/4/24, 1/23/25, and 2/8/25. A fall investigation, dated 5/23/24, indicated R28 had an unwitnessed fall in R28's room. The investigation did not specify the root cause of the fall and did not indicate if safety interventions were implemented. In addition, R28's care plan was not updated following the fall. The fall investigation and R28's medical record did not include post-fall neuro checks following the initial assessment. A fall investigation, dated 5/24/24, indicated R28 had an unwitnessed fall in the bathroom. R28 complained of hip pain and was sent to the emergency room (ER) A progress note, dated 5/24/24 at 1:22 PM, indicated R28 returned to facility after a computed tomography (CT) scan with X-ray revealed no fracture. R28 was placed on 1:1 supervision. R28's care plan was not updated. The fall investigation and R28's medical record did not include post-fall neuro checks following the initial assessment. A fall investigation, dated 6/2/24, indicated R28 had an unwitnessed fall in R28's room. The investigation did not specify a root cause. The fall investigation and R28's medical record did not include post-fall neuro checks following the initial assessment. A progress note, dated 6/4/24 at 11:29 AM, indicated R28 had an unwitnessed fall in the bathroom while attempting to self-transfer. Staff noted bruising and a bulging mass on R28's right hip and a bruise behind R28's right ear. R28's provider was updated and ordered an X-ray that indicated R28 had a contusion on the right hip. A fall investigation, dated 1/23/25, indicated R28 had an unwitnessed fall in the bathroom that resulted in a laceration on the right side of head. R28 was transferred to the hospital. A CT scan and X-ray revealed no acute findings. R28 received 3 staples to the right occipital scalp and returned to the facility. Neither the investigation or R28's care plan indicated new safety interventions were implemented. Neuro checks were incomplete following the fall. A fall investigation, dated 2/8/25, indicated R28 had an unwitnessed fall. The investigation did not specify the root cause of the fall and did not indicate safety interventions were implemented. R28's care plan was not updated. Neuro checks were incomplete following the fall. No additional interventions were added to R28's care plan after 11/26/24. (R28 had a previous care plan (dated 9/2/24), however, the interventions were not transitioned to R28's current care plan.) On 5/14/25 at 2:04 PM, Surveyor interviewed DON-B who confirmed the fall investigations did not identify a root cause and safety measures were not implemented. DON-B confirmed R28's care plan was not updated following the unwitnessed falls. DON-B also verified neuro checks were not thoroughly completed following the unwitnessed falls. In addition, DON-B verified the facility did not complete an investigation following R28's fall on 6/4/24.

2. From 5/12/25 to 5/14/25, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, mononeuropathy of bilateral lower limbs, adult failure to thrive, and urinary retention due to neurologic bladder. R27's MDS assessment, dated 4/7/25, had a BIMS score of 13 out of 15 which indicated R27 had intact cognition. R27 had a Foley catheter and was on EBP. On 5/13/25 at 1:27 PM, Surveyor observed CNA-J and CNA-M complete pericare for R27 and transfer R27 to a recliner via Hoyer lift. CNA-J and CNA-M completed hand hygiene and donned gloves and a gown prior to care. CNA-M provided peri-rectal care after R27 was incontinent of a large amount of stool. Without completing hand hygiene, CNA-M changed gloves and assisted R27 onto the left side. CNA-J then washed R27's rectal area, removed soiled gloves, and donned clean gloves without completing hand hygiene. CNA-J applied cream to R27's rectal area and again changed gloves without completing hand hygiene. Surveyor noted CNA-J and CNA-M changed gloves numerous times during the observation without completing hand hygiene between glove changes. CNA-J and CNA-M touched R27's clean incontinence brief, clothing, bedding, trash bin, Foley bag and tubing, recliner, and the Hoyer lift without changing gloves or without completing hand hygiene between glove changes. CNA-J removed CNA-J's gown and gloves after care and left R27's room to cleanse hands with an ABHR. CNA-M removed CNA-M's gown and gloves and washed hands before leaving R27's room. On 5/13/25 at 2:08 PM, Surveyor interviewed CNA-J and CNA-M who verified hand hygiene should have been completed between glove changes. On 5/13/25 at 2:47 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed hand hygiene should have been completed between glove changes. Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R23 and R27) of 3 sampled residents. R23 had a percutaneous endoscopic gastrostomy (PEG) tube. There was not an enhanced barrier precautions (EBP) sign on or near the entrance to R23's room or a personal protective equipment (PPE) cart outside R23's room. During an observation of pericare for R23, Licensed Practical Nurse (LPN)-C did not wash hands prior to applying gloves and did not wear a gown. During an observation of perineal care for R27, Certified Nursing Assistant (CNA)-J and CNA-M removed soiled gloves and did not wash or sanitize hands before donning clean gloves. Findings include: The facility's Enhanced Barrier Precautions (EBP) Policy (last updated January 2025) indicates: Enhanced Barrier Precautions are infection control interventions designed to reduce the transmission of multidrug-resistant organisms (MDROs) in nursing homes. EBP involve gowns and gloves during high-contact resident care activities for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .Examples of high-contact resident care activities requiring a gown and gloves for EBP include: transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care or use: .urinary catheter. The facility's Infection Control-Hand Hygiene Policy, dated 1/2025, indicates: .1. Indications for hand washing and hand antisepsis .staff is to understand that glove use does not replace the need for hand hygiene. A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. B If hands are not visibly soiled, use an alcohol-based hand rub (ABHR) for routinely decontaminating hands .C. Decontaminate hands before having direct contact with patients . F. Decontaminate hands after contact with patient's intact skin. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. H. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care. I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves. The facility's Transmission-Based Precautions policy, dated 4/2055, indicates: EBP expands the use of personal protective equipment (PPE) beyond situations in which exposure to blood and bodily fluids is anticipated .refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO) to staffs' hands and clothing. EPB is recommended for residents known to be colonized or infected with an MDRO as well as those at increased risk of MDRO acquisition .Examples of high-contact resident care activities requiring gown and glove use .Device care or use: central line care, urinary catheter, feeding tube, tracheostomy/ventilator .When implementing contact precautions or EBP, it is critical to ensure staff have an awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside the resident's room indicating the type of precautions and required PPE. For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Make PPE including gloves and gowns available immediately outside the resident's room. 1. From 5/12/25 to 5/14/25, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] and had a diagnosis of Parkinson's disease and a PEG tube. R23's Minimum Data Set (MDS) assessment, dated 5/17/25, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R23 had intact cognition. On 5/15/25 at 11:06 AM, Surveyor observed LPN-C complete pericare for R23. LPN-C did not wash hands prior to applying gloves and did not wear a gown. Surveyor interviewed LPN-C who indicated LPN-C did not think LPN-C needed to wear a gown during pericare for a resident with a PEG tube. LPN-C indicated a gown was only needed if a resident was sick. LPN-C verified there was not an EBP sign or PPE cart outside R23's room. On 5/15/25 at 11:18 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated there should be an EBP sign outside R23's room. DON-B indicated LPN-C should have washed hands before donning gloves for cares and should have worn a gown per the facility's EBP policy and procedure.

Based on observation, staff and resident interview, and record review, the facility did not ensure a call light was accessible for 1 resident (R) (R13) of 16 sampled residents. On 5/12/25, R13's call light was not within reach or accessible for R13 to use. Findings include: The facility's Call Lights: Accessibility and Timely Response policy, revised 5/25, indicates the call system must be accessible to the resident while in bed or other sleeping accommodations within the resident's room. From 5/12/25 to 5/14/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease and a history of urinary tract infections. R13's Minimum Data Set (MDS) assessment, dated 2/14/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R13 had moderate cognitive impairment. The MDS assessment also indicated R13 required assistance with transfers, ambulation, and toileting. R13 used a wheelchair and a walker. R13 had an activated Power of Attorney for Healthcare (POAHC). On 5/12/25 at 9:17 AM, Surveyor observed R13 in bed. Surveyor interviewed R13 and observed R13's call light lying on the floor approximately 5 feet from the bed. On 5/12/25 at 9:52 AM, Surveyor observed R13's call light in the same position on the the floor approximately 5 feet from the bed. On 5/12/25 at 11:03 AM, Surveyor interviewed R13 who indicated R13 needed to use the bathroom and could not find the call light. Surveyor noted R13's call light was still on the floor approximately 5 feet from R13's bed. Surveyor informed R13 that Surveyor would ask staff to assist R13 to the bathroom. On 5/12/25 at 11:05 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-D who verified R13's call light was on the floor and R13 was unable to reach it. CNA-D placed the call light on R13's bed and assisted R13 to the bathroom. On 5/12/25 at 11:15 AM, Surveyor interviewed CNA-D who verified call lights should always be in reach for all residents. On 5/14/25 at 12:19 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R13's call light should always be in reach per the facility's call light policy and procedure.

Based on staff interview and record review, the facility did not ensure wound care was completed as ordered and in accordance with the resident's care plan for 2 residents (R) (R1 and R4) of 4 sampled residents. R1 was admitted to the facility on [DATE] for rehab following surgery for Charcot's foot (a foot/ankle structural and nerve damage due to diabetes) and had an order for a daily dressing change. R1's daily dressing change was not completed from 5/22/24 until 5/27/24. During a dressing change on 5/27/24 at approximately 1:00 AM, Registered Nurse (RN)-C observed maggots in R1's pin site surgical wound. RN-C also noted areas of redness, warmth, tenderness, and swelling. R1 was transferred to the hospital on 5/27/24 where the wound was debrided (mechanical removal of dead tissue) and flushed twice with sterile saline. R1 received intravenous (IV) antibiotics and was discharged to another skilled nursing facility on 5/30/24. The facility's failure to complete surgical wound treatment for a resident created a finding of immediate jeopardy that began on 5/27/24. Surveyor notified Nursing Home Administrator (NHA)-A of the immediate jeopardy on 6/18/24 at 9:46 AM. The immediate jeopardy was removed on 6/18/24, however, the deficient practice continues at a severity/scope level D (no actual harm with potential for more than minimal harm) as evidenced by the following example. R4's dressing change was not completed as ordered on 6/14/24. Findings include: The facility's Healthy Skin policy, revised May 2024, states the facility strives to ensure residents receive care consistent with professional standards of practice .If a resident is admitted with .skin concerns, the following may be implemented: .2. Assess skin concerns for signs of wound infection .9. Consider prevention measures and interventions for skin concerns as appropriate .13. Update the resident care plan as necessary. 1. On 6/17/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] following surgery for Charcot's foot and had diagnoses including type 2 diabetes, kidney disease, lymphedema, and hypothyroidism. R1's most recent Minimum Data Set (MDS) assessment, dated 5/12/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 had intact cognition. R1 was R1's own decision maker. R1's care plan, dated 5/6/24, contained an intervention to complete dressing changes as ordered and monitor the surgical wound for signs or symptoms of infection. A physician order, dated 5/16/24, stated to cleanse the around the pin sites with chlorhexidine, apply Xeroform (a fine mesh gauze occlusive dressing) at the top of the pin site, and wrap with Kerlix daily on the PM shift. A wound assessment for R1's left lower extremity, dated 5/21/24, indicated R1's superior pin site measured 0.9 cm (centimeters) (length) x 1 cm (width) x .3 cm (depth) with minimal serous (clear) drainage. R1's May 2024 Treatment Administration Record (TAR) indicated the following: ~ On 5/22/24, the wound treatment was held by Registered Nurse (RN)-D with no documented rationale. ~ On 5/23/24, the wound treatment was not completed and had no documented rationale. ~ On 5/24/24, the wound treatment was signed out as completed by RN-D. ~ On 5/25/24, the wound treatment was not completed and had no documented rationale. A progress note, dated 5/27/24 at 3:05 AM and written by RN-C, indicated when RN-C completed R1's left lower extremity dressing change, RN-C observed maggots in R1's wound. RN-C immediately notified Director of Nursing (DON)-B who instructed RN-C to notify the on-call provider. The on-call provider told RN-C to cleanse the wound as best as possible and have the AM shift follow up. RN-C administered R1's as needed (PRN) Vicodin after R1 complained of pain. RN-C continued with the dressing change and observed more maggots as well as areas of redness, tenderness, warmth, and swelling around the superior pin site. After RN-C completed the dressing change, RN-C notified the on-call provider of infection concerns and R1 was sent to the hospital. On 6/18/24, Surveyor interviewed RN-C who verified the information in the 5/27/24 progress note. RN-C stated RN-C began R1's dressing change at approximately 1:00 AM because RN-C had to deal with an emergent situation with another resident at the beginning of the shift (10:00 PM). On 6/18/24, Surveyor reviewed R1's hospital notes, dated 5/27/24 to 5/30/24. The notes indicated R1 was administered two IV antibiotics and narcotic pain medication while in the emergency room (ER) and was admitted to the hospital for additional wound management. On 5/27/24, R1's wound measured 2 cm x 1 cm x 4 cm with notable maggots, white necrotic tissue, and serosanguinous (blood tinged) drainage. R1's wound was mechanically debrided and flushed with sterile saline twice. R1 discharged to another skilled nursing facility on 5/30/24. On 5/27/24, the facility initiated an investigation for R1's wound. A facility-wide sweep was done for all residents with wounds. Resident interviews were completed with no concerns. RN-F, RN-D, and Licensed Practical Nurse (LPN)-E were suspended pending the investigation due to suspicion of not completing dressing changes. The facility's interview with RN-F on 5/27/24 verified RN-F did not complete R1's dressing change on 5/25/24 because RN-F was too busy. The facility attempted to interview RN-D several times with no success. Surveyor attempted to interview RN-D on 6/17/24 with no success. Surveyor left a voicemail for RN-D and has not received a return call as of this writing. Based on the date of the last dressing change (5/21/24), NHA-A concluded RN-D did not complete R1's dressing changes on 5/22/24 and 5/24/24. The facility's interview with LPN-E on 5/27/24 verified LPN-E did not complete R1's dressing change on 5/23/24 because LPN-E did not see the order in R1's TAR. On 5/30/24, NHA-A substantiated neglect for three staff members, RN-D, LPN-E, and RN-F. The failure to complete ordered treatment for a surgical wound led to serious harm for R1 which created a finding of immediate jeopardy. The facility removed the jeopardy on 6/17/24 when it completed the following: 1. Initiated staff-wide education regarding wound care, neglect, TAR/Medication Administration Record (MAR) sign-outs, and resources. 2. Initiated ongoing review with staff during weekly huddles. 3. Reviewed all current residents with wounds to ensure dressings were changed as ordered. 4. Initiated a plan to complete daily dressing change audits to ensure all dressings are changed as ordered. The deficient practice continues at a severity/scope level D based on the following example: 2. On 6/17/24, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including non-pressure chronic ulcer of the right heel and midfoot with fat layer exposed, peripheral vascular disease (PVD), type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene and with other circulatory complications, infection of amputation stump-left lower extremity, and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. R4's MDS assessment, dated 5/30/24, had a BIMS score of 13 out of 15 which indicated R4 had intact cognition. R4 had a treatment order, dated 5/22/24, for the right lower extremity that indicated: Clean with soap and water, apply silver gel to wound bed, cover with foam border dressing, and apply blue top lotion to right lower extremity three times per week on Monday, Wednesday, and Friday PM. Update the wound clinic Nurse Practitioner and wound care clinic if the area worsens or show signs or symptoms of infection. R4's June 2024 TAR contained a right lower extremity treatment on 6/14/24 that was not signed out by LPN-H. R4's medical record did not contain documentation to indicate the treatment was performed as ordered. On 6/17/24 at 12:44 PM, NHA-A provided a copy of R4's June 2024 TAR and plan of care. NHA-A confirmed there were treatments that were not signed out but stated there should be documentation in the nurses' charting to coincide with the missed treatments on the TAR. Surveyor was unable to locate any documentation related to the missed dressing change in R4's medical record. On 6/17/24 at 2:37 PM, DON-B confirmed R4's treatment was not completed on 6/14/24. DON-B provided Surveyor with a Medication Error Form that stated Dressing change was not changed as ordered on 6/14/24 and not signed out. DON-B stated DON-B had been printing daily dressing change audits Monday through Friday while at the facility and reviewed the audits for Saturday and Sunday on the following Monday. DON-B stated DON-B had not yet reviewed the audits for R4's treatments from 6/14/24 through 6/16/24 as of 2:37 PM on 6/17/24 because DON-B was busy with other tasks. DON-B verified there were no staff assigned to review the audits over the weekend. On 6/17/24 at 3:01 PM, RN-G completed wound care on R4's lower extremity as ordered. RN-G verified the soiled dressing that RN-G removed was dated 6/12/24 which indicated R4's 6/14/24 dressing change was not completed.

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 24 residents residing in the facility. Staff did not ensure proper methods were used to rapidly cool time/temperature control for safety food. In addition, staff did not document cooling temperatures for time/temperature control for safety food not held hot or not for consumption within 4 hours. Staff did not clean the kitchenettes daily which resulted in unclean and unsanitary conditions. Findings include: Food Cooling: During an initial kitchen tour on 3/8/24 that began at 8:18 AM, Dietary Manager (DM)-C indicated the facility followed the Wisconsin Food Code. The Wisconsin Food Code 2022 documents at section 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 Wisconsin Food Code 2022 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 the initial kitchen tour Surveyor noted the kitchen cooler contained the following items: ~One container labeled Beef tips dated 3/6 ~One container labeled Cream of [NAME] soup dated 3/16 ~One container labeled Turkey soup dated 2/1 Surveyor reviewed the facility's Cooling and Heating Chart Time/Temperature Log for potentially hazardous foods which indicated: Critical control points: food is cooled quickly and safely from 140 degrees Fahrenheit (F) to 70 degrees F or below within an additional 4 hours (total cooling time 6 hours) . The form contained the following information: 2/1 nothing left 2/2 Salmon with starting time 12:15 .starting temp 108 F .temp after two hours .52 F .2/3 BBQ Ribs .starting time 12:25 .starting temp 110 . Surveyor noted the items in the cooler were not listed on the cooling log. Surveyor interviewed DM-C who confirmed the facility's process is to document food cooling temperatures on the cooling log to ensure food is cooled safely with an approved cooling method. DM-C confirmed the leftover items in the cooler were stored for future without following the facility's cooling policy. Cleanliness: On 3/18/24 at 11:45 AM, Surveyor toured the [NAME] Garden Home kitchenette and noted the following: ~The toaster contained crumbs on top and around the bottom that accumulated on the countertop around the toaster. ~The outside of the refrigerator contained multiple brown and white smudged food particles on the outside doors and door handles. ~The inside door of the vegetable crisper contained brown food particles, dried brown and green lettuce leaves, and onion skins. The drawer contained onions skins. ~The bottom of the refrigerator contained multiple brown and red stains and drops of an unknown substance. ~The bottom drawer of the freezer contained multiple discarded twist ties and brown food particles. On 3/19/24 at 11:58 AM, Surveyor again toured the [NAME] Garden Home kitchenette and noted the same conditions listed above. On 3/19/24 at 2:00 PM, Surveyor interviewed DM-C who indicated the kitchenettes should be cleaned daily and as needed by staff.

Based on observation, staff and resident interview, and record review, the facility did not ensure the resident environment for 1 Resident (R) (R8) of 2 residents was as free of accident hazards as possible. The facility did not implement fall interventions contained in R8's person-centered comprehensive care plan and medical record. Findings include: The facility's Fall Risk Assessment and Management policy, last updated in March 2018, indicates: It is the policy of this facility to provide as safe an environment for our residents as possible .Following the falls risk assessment, a team approach to initiate fall prevention interventions is recommended. If the resident is at risk for falls, this guide suggests interdisciplinary interventions that include medical, nursing and rehabilitation management .If any of the following medical factors are present, implement standard fall prevention interventions impaired mobility .frequent toileting history of falls .loss of balance, weakness musculoskeletal/give way .Standard Falls Prevention Interventions include: .use safety and positioning devices as listed on plan of care .High Risk Fall Prevention Interventions are interventions designed to be implemented for residents with multiple fall risk factors and those who have fallen. These interventions are designed to reduce severity of injuries due to falls as well as prevents falls from reoccurring, supplementing stand fall prevention interventions .All Staff: Look in room when walking by to monitor for unsafe situations .Equipment: Consider use of technology for fall prevention and to decrease the chance of injury with falls: non-skid floor mat .low beds for residents at risk for falls . On 3/18/24 at 11:29 AM, Surveyor observed R8 in a wheelchair with R8's arm in a sling. Surveyor interviewed R8 who indicated R8 fell in the bathroom when R8 reached for an item. R8 indicated R8's arm and leg were hurt in the fall. R8 spent time in the hospital and returned to the facility. On 3/18/24, Surveyor reviewed R8's medical record. R8 had diagnoses including chronic diastolic heart failure, type 2 diabetes, stress incontinence, and non-displaced fracture of left shoulder and femur. R8 was enrolled in Hospice services. R8's Minimum Data Set (MDS) assessment, dated 3/3/24, indicated R8 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated R8 had severe cognitive impairment. The MDS indicated R8 self-propelled R8's wheelchair, was non-weight bearing, required a Hoyer lift for transfers, and required assistance of one staff for bed mobility. R8's care plan indicated R8 had falls with injury. R8's falls care plan, last revised on 2/28/24, contained the following interventions: Nursing staff to observe behaviors; Keep bed low to the ground and keep wheels locked; Place mat on the floor beneath bed in case R8 rolls out; Frequent checks; Observe during toileting; Non-skid footwear; Encourage to ask for assistance; Report pain; Dycem to wheelchair and recliner; Call light within reach; Report behaviors that would cause harm; Assist with all transfers; Encourage to eat meals in dining room with supervision. R8's medical record indicated: ~On 12/30/23, R8 slid out of R8's wheelchair. ~On 2/4/24, R8 slid out of R8's recliner and sustained a hematoma to the left eye. ~On 2/12/24, R8 fell when R8 reached for an item in the bathroom and fractured R8's left arm and femur. ~On 2/27/24, R8 fell from R8's bed without injury. ~On 3/16/24, R8 crawled on the floor to find R8's recliner after R8 fell off the edge of the bed without injury. On 3/19/24 at 8:00 AM, Surveyor observed R8 in bed. R8's bed was not in the lowest position and the floor mat was resting against a chair across the room. On 3/19/24, Surveyor reviewed R8's care plan and fall investigations. R8's current interventions for falls included: Bed in lowest position with fall mat placed next to bed in case R8 rolls out of bed (initiated 2/26/24). R8 fell from bed on 2/27/24 and 3/16/24. On 3/19/24 at 11:09 AM, Surveyor observed R8 in bed with the bed in a high position and the floor mat resting against a chair across the room. On 3/19/24 at 12:16 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the intervention for bed in lowest position with fall mat placed next to bed in case R8 rolls out of bed was initiated on 2/26/24 after R8 returned from the hospital following a fall on 2/12/24 that resulted in a fractured femur and left shoulder. DON-B stated due to R8's change in condition from the fall on 2/12/24, the intervention was put in place to prevent further injuries from falls. DON-B verified R8 was assessed as a high fall risk and verified R8 fell from bed on 2/27/24. DON-B confirmed the low bed and fall mat were required when R8 was in bed. When Surveyor indicated Surveyor observed R8 in bed without a low bed and fall mat, DON-B indicated DON-B expected staff to implement the interventions to prevent further injuries. DON-B stated DON-B would ensure the interventions were followed and provide education to staff.

Based on observation and resident and staff interview, the facility did not ensure a continuous positive airway pressure (CPAP) machine (a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep apnea and other respiratory disorders) was cleaned for 2 Residents (R) (R89 and R95) of 2 residents reviewed with CPAP machines. R89 and R95 used a CPAP machine for obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Staff did not clean R89 and R95's CPAP machines per the facility's policy. In addition, R89 and R95 did not have physician orders or care plans for CPAP use. Findings include: The facility uses Lippincott Nursing Procedures book (Ninth Edition, copyright 2023) as their policy which contained the following information: .When the CPAP therapy has been completed, follow these steps, perform hand hygiene, gloves, turn off the pressure generator, and remove the headgear and appliance from the patient. Disinfect the equipment using a facility-approved disinfectant according to the manufacturer's instructions, and store it properly. 1. On 3/7/23 during an initial interview with R89, Surveyor observed a CPAP machine on a table located on the side of R89's bed. Surveyor noted the CPAP machine had the headgear and hose still attached to the device and contained water in the water chamber. On 3/7/23, Surveyor reviewed R89's medical record. R89 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and obstructive sleep apnea. R89's BIMS (Brief Interview for Mental Status) score was 14 out of 15 which indicated R89 had intact cognition. There were no physician orders in R89's medical record for use or cleaning of the CPAP machine. In addition, R89's medical record contained no documentation or care plan related to use of the CPAP machine. On 3/7/23 at 9:53 AM, Surveyor interviewed R89 regarding how often staff cleaned R89's CPAP machine. R89 stated staff did not clean the CPAP machine. On 3/7/23 at 1:54 PM, Surveyor interviewed CNA (Certified Nursing Assistant)-D regarding R89's CPAP machine. CNA-D stated CNA-D did not clean R89's CPAP machine and was not aware CNA-D was supposed to clean the CPAP machine. On 3/8/23 at 8:34 AM, Surveyor interviewed LPN (Licensed Practical Nurse)-C regarding R89's CPAP machine. LPN-C told Surveyor LPN-C emptied the water out of the chamber, but did not clean or disinfect any of part of the machine. On 3/8/23 at 10:21 AM, Surveyor interviewed DON (Director of Nursing)-B who verified R89's CPAP machine was not cleaned by staff. DON-B stated DON-B expected CNAs to wash/rinse the mask with dish soap and rinse the water reservoir daily in the morning, and wash, rinse and hang the tubing to dry weekly on R89's bath day). 2. On 3/7/23 during an initial interview with R95, Surveyor observed a CPAP machine on a table on the side of R95's bed. Surveyor noted the CPAP machine had the headgear and hose still attached to the device and contained water in the water chamber. On 3/7/23, Surveyor reviewed R95's medical record. R95 was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure with hypoxia (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide), chronic obstructive pulmonary disease, and sleep apnea. R95's BIMS score was 13 out of 15 which indicated R95 had intact cognition. There were no physician orders in R95's medical record for use or cleaning of the CPAP machine. In addition, R95's medical record contained no documentation or care plan related to use of the CPAP machine. On 3/7/23 at 9:10 AM, Surveyor interviewed R95 regarding how often staff cleaned R95's CPAP machine. R95 stated R95 had not seen anyone clean the machine since R95 was admitted . On 3/7/23 at 1:54 PM, Surveyor interviewed CNA-D regarding R95's CPAP machine. CNA-D stated CNA-D did not clean R95's CPAP machine and was not aware CNA-D was supposed to clean the CPAP machine. On 3/8/23 at 8:34 AM, Surveyor interviewed LPN-C regarding R95's CPAP machine. LPN-C told Surveyor LPN-C emptied the water out of the chamber, but did not clean or disinfect any of part of the machine. On 3/8/23 at 10:21 AM, Surveyor interviewed DON-B who verified R95's CPAP machine was not cleaned by staff. DON-B stated DON-B expected CNAs to wash/rinse the mask with dish soap and rinse the water reservoir daily in the morning, and wash, rinse and hang the tubing to dry weekly on R95's bath day.