Every finding on record at Evergreen Health Center

Based on observation, staff and resident 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 3 residents (R) (R1, R5, and R10) of 4 sampled residents.R1 had a presure injury on the sacral region but was not on enhanced barrier precautions (EBP). In addition, staff completed wound care for R1 without wearing gowns.R5 had an indwelling catheter and was on EBP. Staff provided care for R5 without wearing gowns or gloves. In addition, R5's catheter bag was on the floor.R10 had a pressure injury on the sacral region and was on EBP. Staff transferred R10 without wearing gowns or gloves. Findings include: The facility's Infection Control Program, dated 11/25/25, indicates: .Enhanced barrier precautions (EBP): 1. EBP is used in addition to standard precautions when contact precautions do not apply. 2. Personal protective equipment (PPE) to include gloves and gowns (mask and goggles or face shield if splash potential is present) during high-contact resident care activities .5. Facility will implement EBP for residents with current or history of multidrug-resistant organisms (MDROs) targeted by the Centers for Disease Control and Prevention (CDC) as listed below. The facility will also implement EBP for residents with wound or indwelling medical devices, regardless of MDRO colonization . The facility's Indwelling Urinary Catheters policy, dated 7/25/24, indicates: .Indwelling Urinary Catheter Care: .Maintain proper position of the catheter, the drainage bag, and the collection tube. The drainage bag should be below the level of the bladder. This will promote drainage and prevent urine from sitting in the collection tubing or moving back into the bladder. The bag should never touch the floor . 1. On 5/27/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of prostate and pressure ulcer of sacral region. R1's Minimum Data Set (MDS) assessment, dated 4/30/26, stated R1 had Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. On 5/27/26 at 12:15 PM, Surveyor also observed Registered Nurse (RN)-D and Certified Nursing Assistant (CNA)-F complete a dressing change for R1's unstageable pressure injury. RN-D and CNA-F did not wear gowns during wound care. Surveyor noted there was not an EBP sign on or near R1's door to alert staff of the need to wear personal protective equipment (PPE) during high-contact cares. On 5/27/26 at 2:22 PM, Surveyor interviewed Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-C who verified R1 should have been on EBP related to the unstageable pressure injury. ADON-C indicated R1 changed rooms on 5/11/26 and R1's wound was noted to be unstageable on 5/15/26. ADON-C indicated staff should have followed EBP from that date forward. 2. On 5/27/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including dementia, retention of urine, and chronic kidney disease. R5's MDS assessment, dated 4/21/26, stated R5 had a BIMS score of 10 out of 15, indicating moderately impaired cognition. On 5/26/26 at 11:20 AM, Surveyor observed CNA-E toilet R5 and transfer R5 from the wheelchair to a recliner. CNA-E did not wear PPE while providing care. Surveyor noted a sign outside R5's room that indicated R5 was on EBP and PPE was required when providing personal care and transfers. At 11:21 AM, Surveyor interviewed R5 who complained about the urine odor in R5's room and indicated it was related to R5's night time catheter bag which was placed on the floor and leaked. On 5/26/26 at 11:36 AM, Surveyor interviewed CNA-E who indicated CNA-E should have worn PPE to toilet and transfer R5 but forgot. On 5/27/26 at 8:29 AM, Surveyor interviewed CNA-E who indicated when CNA-E entered R5's room, R5 was sitting in the recliner and R5's catheter bag was on the floor. CNA-E indicated a catheter bag should not be on the floor. CNA-E was not aware of a urine leak but acknowledged R5 had a different night bag from the previous day. CNA-E was not sure if the bag was changed due to leakage. On 5/27/26 at 12:55 PM, Surveyor interviewed DON-B who indicated staff should wear PPE during direct contact for a resident on EBP. DON-B verified a catheter bag should not be on the floor. DON-B was not aware of a urine smell in R5's room and entered a work order for the carpet to be cleaned. 3. Between 5/26/26 and 5/27/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility in 2020 with diagnoses including Alzheimer's disease and osteoporosis. R10 had a current stage 3 pressure injury (a wound characterized by full-thickness skin loss where subcutaneous fat is visible) on the sacral region. R10's MDS assessment, dated 5/6/26. stated R10 had a BIMS score of 5 out of 15, indicating severely impaired cognition. R10's medical record contained a care sheet that indicated R10 was on EBP. On 5/26/26 at 2:52 PM, Surveyor observed CNA-G and CNA-H transfer R10 from wheelchair to toilet via sit-to-stand lift. CNA-G did not wear a gown or gloves. CNA-H did not wear a gown while transferring R10 to the toilet or completing personal hygiene care for R10 after toilet use. On 5/26/26 at 3:01 PM, Licensed Practical Nurse (LPN)-I entered R10's room wearing a gown and gloves to complete wound care. On 5/26/26 at 3:04 PM, CNA-G and CNA-H exited R10's room. CNA-G and CNA-H re-entered the room at 3:06 PM wearing gowns and gloves and transferred R10 back into the wheelchair after LPN-I completed wound care. On 5/26/26 at 3:27 PM, Surveyor interviewed CNA-G regarding the facility's EBP policy. CNA-G stated CNA-G and CNA-H should have been worn gowns and gloves while transferring and toileting R10. CNA-G stated CNA-G did not realize R10 was on EBP. CNA-G acknowledged the EBP sign posted at the entrance of R10's room and the PPE cart next to R10's door. CNA-G indicated staff are expected to wear PPE during transfers and toileting for residents on EBP. On 5/27/26 at 10:00 AM, Surveyor interviewed DON-B who stated staff are expected to wear gowns and gloves during transfers and cares for residents on EBP.

Based on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R10) of 2 sampled residents received the necessary care and services to prevent pressure injuries from developing and/or promote healing. R10 had an air mattress that was implemented on 7/16/24. The mattress was not set to R10's current weight. R10's medical record did not contain an order to check the mattress settings or ensure the mattress was set appropriately. Findings include: The facility's Skin Care and Pressure Injury Management policy, revised 12/18/25 and based on the National Pressure Injury Advisory Panel (NPIAP) Quick Reference Guide, indicates: .Stage 1 Pressure Injury: Intact skin with an area of non-blanchable erythema .Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroondiscoloration; these may indicate deep tissue pressure injury .2. Interventions: .K. Low air loss mattress if available; Stage 2 Pressure Injury: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is notvisible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present .commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel .2. Interventions (in addition to those listed under stage 1 ): A. Initiate low air loss mattress if available. Medline Max-Air Air Mattress manufacturer's instructions for the Advanced Low Air Loss mattress indicate: .3. Check resident weight for appropriate firmness setting . Between 5/26/26 and 5/27/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility in 2020 with diagnoses including Alzheimer's diseaase, weight loss, and osteoporosis, R10 had a current stage 3 pressure injury (deep wound characterized by full-thickness skin loss where subcutaneous fat is visible) on the sacral region. R10's Minimum Data Set (MDS) assessment, dated 5/6/26, stated R10 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognition. The MDS assessment indicated R10 had an unhealed stage 3 pressure injury and had a pressure-reducing device for bed. A care plan, dated 4/5/26, indicated R10 had impaired skin integrity and wounds related to decreased mobility, bladder incontinence, history of steroids, history of stage 2 pressure injury on the coccyx, and the inability to consistently reposition in bed and chair. On 4/5/26, R10 was noted to have moisture-associated skin damage (MASD) on the coccyx. On 4/16/26, R10 was noted to have a stage 3 pressure injury. R10 was more restless and confused and slid down in the recliner which resulted in shearing of the skin. The care plan contained a goal that R10 would remain free of further skin breakdown and R10's stage 3 coccyx pressure injury would resolve without complication over the next 90 days. The care plan contained an intervention to administer/monitor effectiveness of skin-related treatments and for signs and symptoms of wound infection. An air mattress was provided on 7/16/24 .Medline air mattress setting: See care sheet for current setting. On 5/26/26 at 2:40 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J and asked CNA-J to observe R10's air mattress. Surveyor and CNA-J noted R10's air mattress was set at 10 (which was the most firm setting). This was evidenced by 9 green lights and a 10th light that was red. CNA-J felt the mattress and stated the air mattress was working. CNA-J stated CNAs do not adjust air mattress settings and indicated nurses are responsible for adjusting mattress settings. CNA-J stated CNAs observe and check air mattresses for inflation, listen for alarms that activate due to malfunction, and inform nurses of any concerns. CNA-J stated air mattresses contain stickers with weight ranges and the corresponding settings. Setting 10 was indicated for a weight of 400 pounds or greater. On 5/26/26 at 3:26 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who verified R10's care sheet, Treatment Administration Record (TAR), and physician orders did not contain an air mattress setting. LPN-I stated air mattress settings are documented under treatments in the medical record and staff have to document when they check the setting and that the mattress is working. Between 4/27/26 and 5/25/26, R10's weights were documented between 130.6 pounds and 138 pounds. R10's medical record contained the following orders: ~ 4/6/26 to 4/16/26: Wound care to open area on coccyx: Apply remedy protect barrier cream every shift and as needed to coccyx for moisture-associated skin damage (MASD)~ 4/16/26 to 4/30/26: Wound care once daily to coccyx: Apply skin prep to peri wound, cover with bordered foam, change daily and as needed~ 4/19/26: Update MD every two weeks with progress of coccyx wound~ 4/30/26: Wound care to coccyx: Cleanse with normal saline or wound cleanser, apply skin prep to peri wound, follow with silver alginate (absorbent antimicrobial wound dressing) to wound base, cover with bordered foam, and change daily and as needed On 5/27/26 at 8:28 AM, Surveyor observed R10 in the dining room in a wheelchair. Surveyor observed R10's air mattress and noted it was still set at 10. On 5/27/26 at 9:42 AM, Surveyor and Director of Nursing (DON)-B observed R10's air mattress and noted the mattress was set at 10. DON-B stated R10's care card should contain an air mattress setting. DON-B stated R10's air mattress should be set lower than 10 and DON-B would have it set appropriately per R10's weight. DON-B stated Bath Aide (BA)-K weighs residents on their bath days and sets air mattresses accordingly. On the way to interview BA-K at 9:47 AM, DON-B asked Certified Occupational Therapy Assistant (COTA)-L about weights and air mattress settings. COTA-L stated BA-K sets air mattresses. On 5/27/26 at 9:49 AM, DON-B and Surveyor interviewed BA-K who stated BA-K weighs residents but does not check air mattress settings. On 5/27/26 at 2:21 PM, Surveyor observed R10's air mattress which was set at 5 (150 pounds). On 5/27/26 at 2:23 PM, Surveyor interviewed CNA-G who stated CNA-G had not changed R10's air mattress setting. CNA-G stated bath aides set air mattresses by residents' weights. On 5/27/26 at 2:26 PM, Surveyor again interviewed DON-B who reviewed R10's coccyx wound timeline with Surveyor which indicated an air mattress was implemented for wound prevention on 7/16/24. R10 had a previous stage 2 pressure injury on the coccyx which had healed and closed. R10's coccyx wound re-opened on 4/24/25. R10's coccyx wound healed on 5/8/25. R10's coccyx wound re-opened on 4/5/26 and was currently a stage 3 pressure injury. DON-B stated an air mattress should be set in accordance with a resident's weight and verified R10's medical record and plan of care did not contain an air mattress setting. DON-B stated all air mattresses were checked on 5/11/26 during a facility-wide audit.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 57 residents residing in the facility. Staff did not document food cooling temperatures. Staff did not follow safe reheating protocols for food meant for resident consumption. Food in freezers, coolers, and the dry storage area was not appropriately labeled and/or dated. Staff did not follow safe holding temperatures protocols for food meant for resident consumption. Staff did not consistently monitor and document dishwasher surface temperatures. Findings include: On [DATE] at 7:33 PM, Surveyor received a follow-up email from Culinary Services Manager (CSM)-J who confirmed the facility follows the Food and Drug Administration (FDA) Food Code. The 2022 FDA Food Code documents at ,d+[DATE].12 Records, Creation and Retention: Records must be maintained to verify that the critical limits required for food safety are being met. Records provide a check for both the operator and the regulator in determining that monitoring and corrective actions have taken place. Cooling Temperatures: The 2022 FDA Food Code documents at ,d+[DATE].14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 Fahrenheit (F) to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperatures, such as reconstituted foods and canned tuna. The 2022 FDA Food Code documents at ,d+[DATE].15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S ,d+[DATE].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. From [DATE] to [DATE], Surveyor requested the facility's policy on food cooling practices. The facility did not provide a policy. On [DATE] at 9:10 AM, Surveyor completed an initial tour of the kitchen with Dietary and Nutritional Coordinator (DNC)-D. During an observation of the coolers and freezers, Surveyor observed several pre-cooked foods meant for resident consumption. DNC-D confirmed staff regularly pre-cook and cool food for future meals. DNC-D stated DNC-D thought staff completed a cooling log. On [DATE] at 9:10 AM, Surveyor interviewed Lead [NAME] (LC)-G who confirmed staff often pre-cook and cool food for future consumption. LC-G was uncertain where food cooling logs were kept. On [DATE] at 1:37 PM and [DATE] at 10:01 AM, Surveyor interviewed DNC-D who was unable to locate the cooling logs. Microwave Reheating Food Safety Temperatures: The 2022 FDA Food Code documents at ,d+[DATE].11 Reheating for Hot Holding: (A) Except as specified under (B) and (C) and (E) of this section, time/temperature control for safety food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees Celsius (C) (165 degrees Fahrenheit (F)) for 15 seconds. (B) Except as specified under (C) of this section, time/temperature control for safety food reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. The facility's Food Temperatures policy, dated [DATE], states all food must be served at optimum serving temperatures .4. If the food is not high enough, heat it to the proper temperature (165 degrees F), and record the measurement. On the units, put food in the microwave and heat it to the proper temperature (165 degrees F). The facility's Daily Temperature Log-Health Center form states if the food temperature is below 140 degrees F, reheat the item to 165 degrees F. On [DATE] at 12:05 PM, Surveyor observed tray line service in Household 1. Plating was completed by Certified Nursing Assistant (CNA)-I who temperature checked the ground BBQ rib patty at 104 degrees F, mashed potatoes at 118 degrees F, and beef gravy at 134 degrees F. CNA-I stated hot holding temperatures should be at 140 degrees F. Surveyor also observed CNA-I heat the food on a resident's uncovered plate in the microwave for one minute. CNA-I then removed the plate and immediately served the resident. CNA-I stated reheated food should be between 140 and 160 degrees F. CNA-I did not temp the reheated food to ensure it reached 165 degrees F. On [DATE] at 1:37 PM, Surveyor interviewed DNC-D who stated hot foods should be held at 140 degrees F or above and reheated to 165 degrees F. DNC-D confirmed the temperature of a reheated food should be checked to ensure the safety temperature is met. Open and Undated/Expired Food Items: The 2022 FDA Food Code documents at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .(B) Except as specified in (E)-(G) of this section, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. On [DATE] at 8:37 AM, Surveyor interviewed DNC-D who stated the facility does not have a specific policy for labeling and dating food. DNC-D provided Surveyor with an FDA Refrigerator and Freezer Storage Chart, a New Horizon Foods Food Storage chart, and a Product Dating chart and indicated the facility uses those items for labeling and dating. The FDA Refrigerator and Freezer Storage Chart, dated [DATE], lists the following recommended storage dates: ~ Steaks: ,d+[DATE] months (freezer); ,d+[DATE] days (refrigerator) ~ Chicken: 9 months (freezer) ~ Pork Chops: ,d+[DATE] days (refrigerator) The New Horizon Food Storage chart states to cover, date, and label food removed from its original container. The facility's Product Dating chart states all products listed must be labeled with an open and use-by date. The chart lists the following recommended use-by dates: ~ Dairy (whipped topping): 7 days ~ Opened dry goods: 7 days On [DATE] at 7:33 PM, Surveyor received a follow up email from Culinary Services Manager (CSM)-J who stated all food should be labeled with the date it was opened/prepared and should be discarded after 7 days (including the day it was prepped). On [DATE] at 9:10 AM, Surveyor completed an initial tour of the kitchen with DNC-D who confirmed the following unlabeled and/or undated items: Dry Storage: ~ An open bag of multi-colored tortilla chips with no open or use-by date Cooler: ~ An unlabeled powdered food substance in a plastic bag open to air (dated [DATE]) with no use-by date ~ A container of Cool Whip with no open date ~ Bone-in pork chops (dated [DATE]) with no use-by date ~ An unlabeled and undated plastic bag of steaks Freezer: ~ Porterhouse steaks (dated ,d+[DATE]) with no year or use-by date ~ Chicken wings (dated ,d+[DATE]) with no year or use-by date Holding Temperatures: The 2022 FDA Food Code documents at ,d+[DATE].16 Time/Temperature Control for Safety Food, for Hot and Cold Holding: Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone of 41 degrees Fahrenheit (F) to 135 degrees F too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control .(1) At 135 degrees F or above or (2) At 41 degrees F or less. The facility's Kitchen Sanitization and Cleaning policy, dated [DATE], states the facility will maintain clean, sanitary, and safe food preparation, serving, and storage areas .Perishable foods are maintained at 41 degrees F or below, or 135 degrees F or above, except when being prepared. On [DATE] at 12:01 PM, Surveyor observed the lunch meal on Household 2. Plating was completed by Hospitality Aide (HA)-H. Prior to plating food, HA-H completed holding temperatures including roast turkey at 135 degrees F, buttered noodles at 124 degrees F, and cooked carrots at 128 degrees F. Surveyor reviewed the temperature log from breakfast on [DATE] (completed by HA-H) which included ground eggs at 129 degrees F, pureed eggs at 123 degrees F, and pureed sausage at 124 degrees F. Surveyor interviewed HA-H who stated HA-H worked at the facility for one month. HA-H was unsure what food temperatures should be or what should be done if food temperatures are too low. HA-H stated HA-H documents temperatures on the log. HA-H confirmed HA-H completed and documented breakfast temperatures on [DATE]. On [DATE] at 12:05 PM, Surveyor observed tray line service in Household 1. Plating was completed by CNA-I. CNA-I completed holding temperatures including sausage at 135 degrees F, beef gravy at 134 degrees F, mashed potatoes at 118 degrees F, and ground BBQ rib patty at 104 degrees F. CNA-I confirmed hot holding temperatures should be above 140 degrees F. Surveyor also observed CNA-I heat food on a resident's uncovered plate in the microwave for one minute. CNA-I then removed the plate and immediately served the resident. CNA-I stated the reheated food should be between 140 and 160 degrees F. On [DATE] at 1:37 PM, Surveyor interviewed DNC-D who stated hot foods should be held at 140 degrees F or above and reheated to 165 degrees F. DNC-D confirmed reheated food should be temperature checked to ensure the safety temperature is met. Dishwasher Surface Temperatures: The 2022 FDA Food Code documents at ,d+[DATE].13 Temperature Measuring Devices, Manual Warewashing: Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. The effectiveness of cleaners and chemical sanitizers is also determined by the temperature of the water used. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 71 C (160 F). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine the surface temperatures of utensils are reaching 71 C (160 F). The regular use of irreversible registering temperature indicators provides a simple method to verify the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 71 C (160 F). The facility's Kitchen Sanitization and Cleaning policy, dated [DATE], indicates the facility will maintain clean, sanitary, and safe food preparation, serving, and storage areas .Dishwashing: .Run thermometer through the dishwasher verifying the middle of the dishwasher is 160 degrees F or above. Place a temperature strip on a piece of silverware or rack and run it through ensuring the strip turns the appropriate color to verify a temperature of 180 degrees or above. On [DATE] at 9:10 AM, Surveyor observed the facility's dishwashing temperature logs. Surveyor noted internal temperatures were not documented from [DATE] to the present. Staff indicated surface temperatures are done daily. DNC-D indicated the facility ran out of surface temperature strips on [DATE] and stated strips should be ordered today. On [DATE] at 1:37 PM, Surveyor completed a follow-up interview with DNC-D who stated surface temperature strips are on the board to be ordered but were not yet ordered.

Based on staff interview and record review, the facility did not ensure a written transfer notice was provided for 4 residents (R) (R7, R45, R49, and R4) of 4 sampled residents reviewed for hospitalizations. R7 was transferred to the hospital on [DATE] and 12/18/24. Neither R7 or R7's Power of Attorney for Healthcare (POAHC) were provided with written transfer notices. In addition, the facility did not notify the Ombudsman of R7's hospital transfers. R45 was transferred to the hospital on 9/26/24. Neither R45 or R45's representative were provided with a written transfer notice. In addition, the facility did not notify the Ombudsman of R45's hospital transfer. R49 was transferred to the hospital on 1/23/25. Neither R49 or R49's representative were provided with a written transfer notice. R4 was transferred to the hospital on [DATE] and the emergency room (ER) on 12/13/24. The Ombudsman was not notified of either transfer. Findings include: The facility's Resident Transfers and Discharges policy, dated 10/25/19, indicates staff will assist a resident and/or the resident's representative in preparation for .transfer to the hospital. A resident has the right to appeal any transfer .Transfer from the Health Center to the Hospital: .3. The following information will be sent with a resident in the transfer envelope: .G. Notice of Transfer or Discharge for Resident/Resident Representative. Send with resident to hospital. Keep a copy on file. 1. From 3/10/25 to 3/12/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including neurocognitive disorder with Lewy bodies, dementia, visual hallucinations, delusional disorder, and diabetes mellitus. R7's Minimum Data Set (MDS) assessment, dated 12/4/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R7 had moderate cognitive impairment. R7 had an activated POAHC. On 12/1/24, R7 had an unwitnessed fall. R7 sustained an abrasion on the scalp and complained of left upper leg and knee pain. On 12/2/24, R7 complained of left hip pain and was sent to ER for evaluation. R7 was diagnosed with a urinary tract infection (UTI) and returned to the facility on [DATE]. R7 continued to have intermittent leg pain. On 12/18/24, R7 was evaluated by a physician for worsening pain and was sent to the ER for evaluation. R7's medical record did not indicate written transfer notices were provided to R7 or R7's POAHC on 12/2/24 or 12/18/24. On 3/11/25 at 1:53 PM and on 3/12/25 at 9:52 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated a transfer notice forms is sent with a resident to the ER. If the resident has an activated POAHC and is unable to sign, staff call the POAHC. DON-B indicated the Social Worker (SW) then emails the form to the POAHC. DON-B indicated transfer notices for 12/2/24 and 12/18/24 should have been mailed but were not.2. From 3/10/25 to 3/12/25, Surveyor reviewed R45's medical record. R45 was admitted to the facility on [DATE]. On 9/26/24, R45 had a change in condition. R45 was transferred to the hospital and admitted for abnormal labs. R45's medical record did not indicate a written transfer notice was provided to R45 or R45's representative. Surveyor reviewed the facility's discharge/transfer list provided to the State Long Term Care Ombudsman for September 2024 and noted the list did not include R45's hospital transfer. 3. From 3/10/25 to 3/12/25, Surveyor reviewed R49's medical record. R49 was admitted to the facility on [DATE]. On 1/23/25, R49 had a change in condition and was transferred to the hospital and admitted for hypothermia. R49 did not return to the facility. R49's medical record did not indicate a written transfer notice was provided to R49 or R49's representative. On 3/12/25 at 10:32 AM, Surveyor interviewed Unit Manager (UM)-C who confirmed UM-C was responsible for sending transfer and discharge notifications to the Ombudsman. UM-C stated UM-C was not aware hospital discharges needed to be sent to the Ombudsman and confirmed R45 was not on the list provided to the Ombudsman. 4. From 3/10/25 to 3/12/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including chronic heart failure, pulmonary edema, and iron deficiency anemia. R4 was R4's own decision maker. R4's medical record indicated R4 was transferred to the hospital on [DATE] due to a critical hemoglobin level. R4 was also sent to the ER on [DATE] due to signs and symptoms of a gastrointestinal bleed. R4's medical record did not indicate the Ombudsman was notified of either transfer. On 3/11/25, Surveyor requested Ombudsman notification of transfers and discharges from Nursing Home Administrator (NHA)-A. Surveyor reviewed the facility's monthly transfer and discharge reports that were sent to the Ombudsman. Surveyor noted R4 was not listed on the reports. On 3/12/25 at 10:32 AM, Surveyor interviewed UM-C who oversaw Ombudsman transfer and discharge notifications. UM-C indicated UM-C was not aware the Ombudsman should be notified of hospital and ER transfers. UM-C verified the Ombudsman was not informed of R4's hospital transfer on 10/17/24 and ER transfer on 12/13/24.

Based on staff interview and record review, the facility did not ensure the appropriate care and treatment was provided for 3 residents (R) (R36, R41, and R254) of 4 residents reviewed for weight monitoring. The facility did not consistently monitor R36's weight per the physician's order. In addition, the facility did not ensure the physician was notified when R36 had a significant weight loss. The facility did not ensure the physician was notified when R41 had a significant weight loss. The facility did not follow-up on a supplement order for R254 in a timely manner. In addition, the facility did not ensure physician notification was documented when R254 had significant weight loss or gain. Findings include: The facility's Resident Weight policy, dated 5/2/20, indicates: Resident weights will be monitored to determine any unplanned weight loss or gain. If need is evident, appropriate follow-up will be initiated by the dietary and/or nursing departments .Performed by Registered Nurses (RNs), Licensed Practical Nurse (LPNs), and Certified Nursing Assistants (CNAs): .1. All residents will be weighed at time of admission .4. All residents on Health Center units will be weighed monthly unless ordered otherwise, or their condition warrants more frequent weights. 5. Residents will be weighed on the same scale every time. 6. Weights will be entered in the electronic medical record. 7. When a weight is obtained, compare the weight to the previous weight. If a five pound loss or gain is noted, the following should occur: a) Reweigh the resident; b) Report the difference to the unit nurse; c) Nurse to send a diet memo to the diet office for follow-up and documentation; d) Any weight loss or gain must be reported to the physician or Nurse Practitioner; 8) Weight scales will be checked monthly by the building services department for accuracy. The facility's Nutrition policy, dated 5/2/20, indicates: The food and nutritional needs of the residents shall be met in accordance with physician orders .Nutritional Assessments: .A nutritional interview and assessment is done by the Diet/Nutrition Coordinator (DNC) or dietitian upon admission and annually thereafter. In addition, a nutritional assessment will be completed any time a significant change in condition occurs. Documentation is done in the progress notes, quarterly or nutritional assessment (annually or change in condition) .Quarterly reviews are done by the DNC or diet clerk using clinical notes in the electronic medical record .The DNC and the dietitian document additional resident concerns as they arise all in the process notes. (Ex: weight changes, abnormal labs, poor food/fluid intake, altered skin integrity, chewing/swallowing concerns, etc.) 1. From 3/10/25 to 3/12/25, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had diagnoses including neurocognitive disorder with Lewy bodies, dementia, frostbite with tissue necrosis of the left toe(s), left knee and lower leg, right finger(s), right hand, left finger(s), and left hand, urinary tract infection (UTI), chronic kidney disease stage 3, moderate protein-calorie malnutrition, and anemia. R36's Minimum Data Set (MDS) assessment, dated 2/24/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R36 was not cognitively impaired. R36 had an activated Power of Attorney for Healthcare (POAHC). Surveyor reviewed R36's weights and noted the following: ~ On 2/18/25, R36 weighed 138 pounds (lbs). ~ On 3/3/25, R36 weighed 124 lbs (which was a 10.14% weight loss). There were no other weights noted in R36's medical record. R36's nutritional care plan, as noted on a Nutritional assessment dated [DATE], indicated R36 had protein calorie malnutrition, increased nutritional needs for wound healing, and needed assistance with meals. The care plan also indicated R36 had frostbite on both hands which may affect R36's meal intake and weight status. R36 had a physician order, dated 2/18/25, to weigh R36 one time a week prior to eating or drinking. A Nutritional Assessment completed by Dietary and Nutritional Coordinator (DNC)-D and reviewed by Registered Dietitian (RD)-E, dated 2/27/25, indicated R36's usual body weight (UBW) prior to admission was between 145 and 150 lbs. RD-E noted R36 had an 8% weight loss from R36's UBW. RD-E started R36 on ProSource and a sugar-free shake once daily. RD-E indicated there was a plan to monitor R36's daily meal intake and weights per the physician's order. R36's meal intakes indicated R36 had an 89% intake per meal from 2/25/25 through 3/3/25. Surveyor noted from 3/4/25 through 3/10/25, R36's average intake decreased to 63.3%. A weekly nursing assessment, dated 3/11/25, indicated R36 had a weight loss of 14 lbs in 2 weeks. The assessment indicated to notify the Dietary Manager and physician of a weight loss or gain of 5 lbs in one week which the assessment indicated was not applicable. On 3/11/25 at 3:39 PM, Surveyor interviewed Unit Manager (UM)-C who stated the facility's policy is for all residents to be weighed for 3 days after admission. UM-C acknowledged R36 was not weighed for 3 days after admission and weekly weights were not completed per the physician's order. UM-C stated the physician was not updated regarding R36's significant weight loss and education was provided to the nurse who completed R36's weekly nursing assessment. UM-C stated if nursing staff notice a significant weight variance, they should notify DNC-D who will update the physician and RD-E. 2. From 3/10/25 through 3/12/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including aphasia and dysphasia following cerebral infarction. R41's MDS assessment, dated 12/27/24, had a BIMS score of 3 out of 15 which indicated R41 had severely impaired cognition. R41 had an activated POAHC. Surveyor reviewed R41's weights and noted the following: ~ On 12/27/24, R41 weighed 170.4 lbs. ~ On 3/5/25, R41 weighed 155.2 lbs (which was an 8.92% weight loss) R41's medical record did not include an order for weight monitoring. A Nutritional Assessment, completed by DNC-D and RD-E and dated 1/9/25, indicated R41 had a poor appetite. RD-E recommended a diet change to No Added Salt (NAS) and Dysphagia Level 3 (for individuals with mild dysphagia who can chew and swallow most foods but should avoid hard, sticky, or crunchy foods) and for R41 to have Ensure three times daily. A weekly nursing assessment, dated 2/27/25, indicated R41 had a weight loss. The assessment indicated to notify the Dietary Manager and physician of a weight loss or gain of 5 lbs. in one week which the assessment indicated was not applicable. On 3/12/25 at 10:27 AM, Surveyor interviewed UM-C who stated the facility does not have documentation that the physician was notified of R41's weight loss. On 3/12/25 at 10:40 AM, Surveyor interviewed Direction of Nursing (DON)-B who stated nursing staff should complete a weekly nursing assessment which includes a review of nutrition and weights. DON-B stated if nursing staff notice a significant weight variance, they should ask for a re-weight notify the physician if the weight is still a concern. On 3/12/25 at 11:51 AM and 1:31 PM, Surveyor interviewed DNC-D who stated DNC-D reviews a weight tracker at the end of each month and notifies RD-E of any weight variances. DNC-D stated occasionally nursing staff notify DNC-D of weight changes and DNC-D notifies RD-E. DNC-D indicated RD-E responds with recommendations and DNC-D notifies the physician. DNC-D stated nursing staff update the physician if there are no recommendations from RD-E. DNC-D stated DNC-D does not follow-up with the physician after the initial notification to ensure acknowledgement and does not document RD-E or physician notification. DNC-D could not confirm if DNC-D notified the physician of R36 or R41's weight loss. 51044 3. From 3/10/25 to 3/12/25, Surveyor reviewed R254's medical record. R254 was admitted to the facility on [DATE] and had diagnoses including malignant neoplasm of the left kidney, vitamin D deficiency, type 2 diabetes mellitus with hyperglycemia, and chronic systolic heart failure. R254's MDS assessment, dated 2/24/25, had a BIMS score of 13 out of 15 which indicated R254 was not cognitively impaired. R254 had an activated POAHC. On 3/10/25, Surveyor reviewed the facility's matrix and noted R254 was listed as having excessive weight loss without a prescribed weight loss program. On 3/10/25, Surveyor reviewed R254's weights and noted the following: ~ On 2/24/25, R254 weighed 191.8 lbs (on admission). ~ On 2/26/25, R254 weighed 177.2 lbs (down 14.6 lbs). ~ On 2/27/25, R254 weighed 170.0 lbs (down 7.2 lbs). ~ On 2/28/25 at 8:20 AM, R254 weighed 173.60 lbs. ~ On 2/28/25 at 9:54 AM, R254 weighed 173.60 lbs. ~ On 3/1/25 at 9:59 AM, R254 weighed 173.60 lbs. ~ On 3/1/25 at 10:37 AM, R254 weighed 173.60 lbs. ~ On 3/2/25 at 9:03 AM, R254 weighed 172.80 lbs. ~ On 3/2/25 at 10:46 AM, R254 weighed 178.20 lbs (up 5.40 lbs). ~ On 3/3/25 at 8:57 AM, R254 weighed 193.80 lbs (up 15.60 lbs). ~ On 3/3/25 at 9:21 AM, R254 weighed 193.80 lbs. ~ On 3/3/25 at 9:45 AM, R254 weighed 173.00 lbs (down 20.8 lbs). ~ On 3/4/25 at 8:57 AM, R254 weighed 193 lbs (up 20 lbs). ~ On 3/4/25 at 11:28 AM, R254 weighed 193 lbs. R254's medical record did not indicate the physician was notified of R254's 5 lb weight losses and gains from admission to 3/4/25. A nutritional care plan, dated 2/28/25, indicated R254 had altered nutritional needs related to diabetes mellitus as evidenced by the need for a therapeutic diet. The care plan indicated R254 had unplanned significant weight loss in the setting of chronic illness. The care plan contained a goal that indicated R254's nutrition status will be maintained over the next 90 days and R254's weight will remain stable. A Nutritional Assessment, completed by RD-E and dated 2/28/25, indicated R254 was prescribed a therapeutic diet and had unplanned significant weight loss in the setting of chronic illness. R254 was prescribed a No Concentrated Sweets (NCS) diet and ate independently with an intake of 100% and 1294 milliliters (ml) of fluids. The assessment indicated R254 had no chewing or swallowing issues and R254's hospital weight prior to admission was 206-209 lbs. RD-E recommended a sugar-free house supplements twice daily for nutritional support due to significant weight loss. A dietary note from DNC-D, dated 3/3/25, indicated a fax was sent to the physician requesting an order for a ProSource supplement. An order was received on 3/8/25 to start ProSource once daily. On 3/12/25 at 11:29 AM, Surveyor interviewed DON-B who indicated staff are responsible for notifying the physician of a 5 lb weight increase or decrease and should document the notification in a progress note. DON-B verified R254's weight documentation and stated staff should have questioned the large increases and decreases. DON-B contacted Registered Nurse (RN)-F to discuss R254's weight variation. RN-F verified RN-F noticed the weight difference and contacted the physician. RN-F stated the physician questioned the accuracy of the weights because R254 did not show signs or symptoms of significant weight loss or gain. RN-F verified RN-F did not document the physician notification. DON-B indicated DON-B was aware of RD-E's recommendations on 2/28/25, DNC-D's fax to the physician on 3/3/25, and the physician's order order on 3/8/25. DON-B indicated RD-E provides recommendations and DNC-D gets the order. DON-B indicated notifying a physician, obtaining an order, and initiating the order should be done within 24 hours. DON-B indicated RD-E should have questioned R254's significant weight loss and gain. On 3/12/25 at 1:31 PM, Surveyor interviewed DNC-D who stated DNC-D reviews a weight tracker at the end of each month. DNC-D indicated DNC-D notifies RD-E of any weight variances. DNC-D stated occasionally nursing staff notify DNC-D of weight changes and DNC-D notifies RD-E. DNC-D indicated RD-E responds with recommendations and DNC-D notifies the physician. DNC-D stated nursing staff update the physician if there are no recommendations from RD-E. DNC-D stated DNC-D does not follow-up with the physician after the initial notification to ensure acknowledgement and does not document RD-E or physician notification.

Based on staff interview and record review, the facility did not implement their written policies and procedures to prevent abuse for 1 (Registered Nurse (RN)-C) of 8 staff reviewed for background checks. The facility did not complete a thorough background check prior to hiring RN-C as a contracted employee. Findings include: The Wisconsin Background Check and Misconduct Investigation Program Manual by the Department of Health Services (DHS), with a revision date of January 2024, indicates: At a minimum, a complete caregiver background check completed for a caregiver consists of the following three documents: 1. A completed DHS form F-82064, Background Information Disclosure (BID) 2. A response from the Department of Justice (DOJ), either: A 'no record found' response or criminal record transcript; and 3. A Governmental Findings Report (previously know as the Integrated Background Information System (IBIS) letter) that indicates the person's status, including administrative findings or licensing restrictions. An entity is required to complete caregiver background checks on caregivers .who are .contractors with the entity . The facility's Abuse, Neglect, Exploitation or Misappropriation of Resident Property Policy indicates: The facility will require all employees to complete a Background Information Disclosure form to allow the facility to complete a caregiver background check prior to hire. The results of background checks, checking registry and appropriate licensing boards and job references, will be used when making employment decisions with the objective of preventing resident abuse, neglect, exploitation of a resident, or theft . On 1/11/24, Surveyor selected a sample of 8 staff to review for background checks. Surveyor noted RN-C started work at the facility on 9/1/22 and worked approximately 3-4 times per week from 9/1/22 through 1/10/24. The facility did not obtain a BID form or GFR from RN-C until the information was requested in an email on 1/9/24. On 1/11/24 at 1:07 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated RN-C was a contracted employee. On 1/11/24 at 1:57 PM, Surveyor interviewed [NAME] President of Human Resources (VPHR)-D who provided Surveyor with an email that VPHR-D sent to RN-C during the survey that requested a copy of RN-C's BID form, DOJ letter, GFR, and license number. The facility received RN-C's BID form, GFR, and license number; however, they did not receive RN-C's DOJ letter. VPHR-D indicated RN-C's DOJ letter would be received the following week. VPHR-D stated the facility did not obtain RN-C's BID form, DOJ letter, GFR, and license number prior to hiring RN-C as a contracted employee due to an omission.

Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R100, R101, and R102) of 3 residents signed and received copies of the Notice of Medicare Non-Coverage (NOMNC) form and/or Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form which are used to inform residents of their final day of Medicare Part A insurance coverage, potential liability for payment (daily cost of care and services at the facility) and standard claim appeal rights and instructions. The facility did not provide an ABN form (a document which explains financial liability, including the facility's daily rate for services) to R100 when R100's Medicare Part A benefits ended on [DATE] and R100 remained in the facility. The facility did not provide an ABN form to R101 when R1's Medicare Part A benefits ended on [DATE] and R101 remained in the facility. The facility did not obtain a signed NOMNC form for R102 who was discharged home. Findings include: Instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (ABN) form indicate: The ABN provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. Instructions for the Notice of Medicare Non-Coverage (NOMNC) form indicate: The NOMNC must be delivered at least two calendar days before Medicare-covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48 hour requirement .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. 1. On [DATE], Surveyor reviewed R100's medical record as part of a sample of residents whose Medicare Part A coverage ended. R100's Medicare Part A Skilled Services last covered day was [DATE]. R100 remained in the facility. Surveyor reviewed the Beneficiary Protection Notification Review in which the facility noted R100's last covered day was [DATE]. The ABN form was waived and R100 elected to receive hospice services. R100 expired on [DATE]. The facility did not ensure the form was signed. 2. On [DATE], Surveyor reviewed R101's medical record as part of a sample of residents whose Medicare Part A coverage ended. R101's Medicare Part A Skilled Services last covered day was [DATE]. R100 remained in the facility. Surveyor reviewed the Beneficiary Protection Notification Review. The facility noted the form was missed because the Social Worker was covering short and long-term care. 3. On [DATE], Surveyor reviewed R102's medical record as part of a sample of residents whose Medicare Part A coverage ended. R102 was discharged home. Surveyor reviewed the Beneficiary Protection Notification Review in which the facility noted the NOMNC form was issued timely, but R102's Power of Attorney for Healthcare (POAHC) did not sign the form. On [DATE] at 11:15 AM, Surveyor interviewed Social Worker (SW)-E who indicated it is usually the Social Worker's responsibility to complete the beneficiary notices. SW-E stated prior to [DATE], the ABN form was signed on either the last covered day or the day after. The expectation was to have the ABN form signed 48 hours in advance of the last covered day. SW-E stated going forward, the new process is to have the ABN form signed the same day as the NOMNC form. SW-E stated the NOMNC date is provided by the resident's insurance company and it is SW-E's responsibility to provide the form to the resident. SW-E verified R100 passed away on the day R100's ABN form was going to be provided. SW-E verified R101's ABN form was missed and was unsure why. On [DATE] at 12:10 PM, Surveyor interviewed SW-E who verified R102's POAHC was given the information in the ABN form (which may have been the NOMNC form) over the phone on [DATE]. SW-E stated R102's POAHC understood the right to appeal, but chose not to, and was going to return to the facility to sign the NOMNC form. R102 discharged home on [DATE]. SW-E gave Surveyor a note written on [DATE] at 4:04 PM that indicated: (SW-E) spoke to (R102's POAHC) regarding last coverage day and NOMNC. R102's POAHC stated they will come in and sign the NOMNC form. SW-E called R102's POAHC on [DATE] who indicated they signed the NOMNC form and left the form at the front desk. SW-E stated the facility could not find the signed copy.

Based on observation, interview, and record review the facility did not ensure food was stored and prepared in a safe and sanitary manner, which had the potential to affect all 48 Residents (R) at the facility. Staff attempted to serve R3's breakfast tray to R3 after it was left sitting uncovered on the counter for over 1 hour and 45 minutes. 1 Staff did not wash hands prior to putting clean dishes away. 4 of 6 household refrigerator units did not have freezer temperatures being monitored and did not contain thermometers. 3 of 6 Household refrigerator units reviewed had undated and/or expired food items. 3 of 6 household refrigerator units reviewed were not in a sanitary condition. Findings include: On [DATE] at 8:39 AM, Surveyor began the initial kitchen tour with Sous Chef (SC-K) who indicated the facility utilizes the Wisconsin State Food Code. Uncovered breakfast meal Wisconsin Food Code at ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding indicates: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control . time / temperature control for safety food shall be maintained: (1) At 135 degrees Fahrenheit (F) or above and (2) At 41 degrees F or less. Wisconsin Food Code at ,d+[DATE].11 Packaged and Unpackaged Food (A) Food shall be protected from cross contamination by: 4 .storing the food in packages, covered containers, or wrappings. On [DATE] at 8:42 AM, Surveyor entered the household and observed R3's breakfast tray sitting on the counter in the household dining area. The plate was uncovered and contained bacon and eggs, which are time / temperature controlled foods. Staff were no longer serving residents and only 1 resident was left eating in the household dining room. On [DATE] at 9:13 AM, Surveyor observed a Housekeeping Staff (HK-N), spraying a disinfectant spray on the counter where R3's tray was sitting and wiping the counter off around the tray. On [DATE] at 10:29 AM, Surveyor observed Certified Nursing Assistant (CNA-D) remove R3's plate off the tray and place tray in the microwave for reheating. Surveyor interviewed CNA-D who indicated that CNA-D was planning on bringing R3's breakfast to R3's room. Surveyor intervened and requested CNA-D not serve the item to the resident due to it being uncovered on the counter for at least 1 hour and 45 minutes (8:42 AM to 10:29 AM) and staff did spray a disinfectant around the tray when cleaning the counter. CNA-D indicated that it would probably be a good idea to not serve it and would find something else. Another CNA assisted CNA-D in getting R3 another plate. On [DATE] at 2:02 PM, Surveyor interviewed Unit Manager (UM-G) who indicated that UM-G would not expect that tray to be served to a resident and UM-G confirmed it should have been covered and placed in the refrigerator. Hand Hygiene The Wisconsin Food Code at ,d+[DATE].14 titled When to Wash states Food employees shall clean their hands and exposed portions of their arms as specified under ,d+[DATE].12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single -use articles. On [DATE] at 1:06 PM, Surveyor observed housekeeper (HK-F) while cleaning up the household kitchen area. Surveyor observed HK-F cleaning off the dirty tables from lunch with a rag and disinfectant spray. HK-F then went over to the dishwasher, opened the dishwasher, and began putting the clean dishes away. Surveyor did not observe HK-F wash hands prior to touching the clean dishes. HK-F confirmed this in interview at the time it happened. Freezer Temperatures The Wisconsin Food Code at ,d+[DATE].112 Temperature Measuring Devices indicates: (B) cold or hot holding equipment used for time/temperature control for safety food shall be designed to include and shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the device's temperature display. Wisconsin Food Code at ,d+[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding indicates: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control . time / temperature control for safety food shall be maintained: (1) At 135 degrees Fahrenheit (F) or above and (2) At 41 degrees F or less. Also, Facility policy titled, Food Storage for Residents foods with revision date of [DATE] indicated: Thermometers are placed inside of each refrigerator / freezer. Refrigerators are kept at 41 degrees F and Freezers at 0 degrees F. On [DATE], Surveyor observed 4 of 6 household freezers to not have a thermometer in them and did not contain a freezer temperature log. On [DATE], Surveyor interviewed CNA-L who indicated that the night shift does the temperatures for the refrigerators but didn't think freezer temperatures were completed. CNA-L and Surveyor could not locate a Freezer temperature log. On [DATE] at 2:02 PM, Surveyor interviewed UM-G who indicated the facility was not doing freezer temperature logs. Undated/expired items The Wisconsin State Food Code at ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .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. Commercially processed food open and hold cold .refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations. On [DATE], Surveyor observed the following items undated or expired in 3 of 4 household unit refrigerators. ~2 pieces of homemade cherry pie covered in a pie tin that had no label. ~1 - 46 oz opened container of Thick n Easy Clear Thickened Cranberry Juice with no open date ~1 - 46 oz opened container of Thick n Easy Clear Thickened Orange Juice with no open date ~1 - 64 oz opened container Ocean Spray Cranberry Juice with no open date. ~1 - 8 oz lactose free milk opened and ,d+[DATE] full with no open date and manufacturer expiration date of [DATE]. ~7 - 8 oz lactose free milk with manufacturer expiration date of [DATE] ~1 - ,d+[DATE] gallon of [NAME] 2% milk with no open date ~1 - 32 oz med pass fortified nutritional vanilla shake, ,d+[DATE] full, with no open date. On [DATE], Surveyor interviewed CNA-L who indicated that items in the refrigerators should be labeled and dated with open dates. CNA-L confirmed the pie should be tossed. [DATE] at 9:43 AM, Surveyor interviewed Dietary Staff (DS-M) who indicated DS-M's role is to restock the refrigerators on the household and check for expired items. DS-M confirmed the expired milks should be removed from the refrigerator and all items should have an open date once they are opened. Cleanliness of Household Refrigerators The Wisconsin Food Code at ,d+[DATE].11 Equipment, .(C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On [DATE], Facility provided a cleaning list titled Evergreen Household 3&4 (no date) indicating 12:25 - 1:25 Clean Household 3 and 4 Kitchens using 5 step cleaning method. Facility also provided another cleaning list titled Evergreen, Kitchens - Refrigerator cleaned inside and out and top dusted. On [DATE] Surveyor reviewed 4 of 6 household refrigerators and noted the following regarding cleanliness of the inside of the refrigerators: ~Household 1 refrigerator contained a crusty substance on the lip of the freezer drawer and a yellow spill and crusty substance on the floor of the freezer. ~Household 2 freezer contained what looked like a pink spill frozen to the bottom of the freezer and crumbs throughout the bottom of the freezer as well. ~Household 7 refrigerator contained a brown food splatter on the door and refrigerator shelves had a white crusty substance with splatter and crumbs. ~Household 8 refrigerator contained crumbs on the bottom of the refrigerator. The inside back of the refrigerator contained brown crusty substance in the crevice. There was also brown splatter on the inside door. On [DATE] at 1:03 PM, Surveyor interviewed the Account Manager for the housekeeping company at the facility. The housekeeping company is responsible for the cleanliness of the household kitchen areas. Account Manager (AM-J) indicated that AM-J would expect if there is a spill in the refrigerator that it would be cleaned. AM-J indicated staff have a cleaning list to follow but there is no specific check off for the refrigerator and AM-J did not know when the last time the refrigerator was cleaned. AM-J indicated the expectation is for staff to keep up on the cleanliness of the units.

Based on record review and interview, the facility did not ensure 1 of 5 Certified Nursing Assistants (CNAs) reviewed for verification of a current CNA certification had a valid CNA certification. CNA-C's Certified Nursing Assistant Certification lapsed on [DATE]. CNA-C continued to work at the facility beyond this date. Findings include: On [DATE], Surveyor requested CNA-C's records, along with 4 other reviewed staff. The records were provided to Surveyor on [DATE] at 11:06 AM. On [DATE] at 3:09 PM, Surveyor reviewed CNA-C's Certified Nursing Assistant Certification from https://wi.tmuniverse.com which indicated CNA-C's certification expired on [DATE]. It also indicated, This nurse aide's employment eligibility to work in federally certified nursing homes, intermediate care facilities for individuals with intellectual disabilities, home health agencies, and hospices has lapsed. On [DATE] at 3:09 PM, the facility also provided CNA-C's schedule for the past 30 days which showed CNA-C worked on the following days with a lapsed certification: ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. On [DATE] at 11:06 AM, Surveyor interviewed Recruitment and Retention Coordinator (RRC-I) who indicated that CNA-C's certification was expired. RRC-I confirmed CNA-C did work a lot of shifts at the facility since CNA-C's certification expiration date of [DATE]. On [DATE] at 3:09 PM, RRC-I indicated CNA-C's certification expiration was missed. RRC-I indicated there is one staff in Human Resources who tracks the certifications but ultimately it is RRC-I's responsibility to ensure certifications are current. RRC-I indicated CNA-C's certification expiration was missed and it should have been followed up on.

Based on interview and record review, the facility did not ensure provision of bathing assistance for depended residents was completed for 3 residents (R) (R34, R3, and R27) of 14 residents reviewed for bathing. R34 did not receive a bath at least weekly. R3 did not receive a bath at least weekly. R27 did not receive a bath at least weekly. Finding Include: Facility provided policy titled Bathing Last revision date of 10/12/16 stated: 1. All residents will be scheduled for a weekly bath, more often if indicated or per resident preference . The Surveyor reviewed 6 months of resident council meeting minutes which included resident concerns of baths not happening regularly in June 2022. Again, in November 2022 resident concerns were voiced about bathing. 1. R34 was admitted to the facility on [DATE] with diagnoses to include congestive heart failure, diabetes, end stage renal disease, fractures to left and right wrist and fracture to left patella (knee). R34's Brief Interview for Mental status (BIMs) was 13/15 on 10/13/22 indicating no impaired cognition. The Minimum Data Set (MDS) dated [DATE] indicated R34 was dependent upon staff for total assist with bathing. On 11/21/22 at 2:22 PM, Surveyor interviewed R34 who explained staff will occasionally provide a bed bath, but not each week. R34 was not sure if some of the medical conditions R34 experienced was preventing a regular bathing schedule. Between 11/21/22 through 11/23/22 the Surveyor reviewed bath records which identified 10 missing baths for R34 in 14 weeks. between 8/14/22 and 11/23/22. Dates of missed baths included: 8/16/22, 8/30/22, 9/6/22, 9/20/22, 10/4/22, 10/18/22, 10/25/22, 11/8/22, 11/15/22 and 11/22/22. On 11/22/22 at 8:49 AM, the Surveyor interviewed Certified Nursing Assistant (CNA)-D who explained R34 had dressings to wrist and left knee which allowed for bed baths only, no tub bath. CNA-D indicated it was difficult to get the baths done each week, if baths not signed out on the weekly bath sheet, they were not completed. CNA-D described when the bath was completed for a resident, staff should sign their initials and date that is was completed on the bath sheet. CNA-D stated if staff did not have time to complete the resident's bath for the day, they were expected to report that to the charge nurse. Additonally, CNA-D revealed a bath aide assisted with baths Monday through Friday between 6am to 11am. On 11/22/22 at 1:09 PM, the Surveyor interviewed CNA-E who was a bath aide for the facility. CNA-E explained it had been a struggle for the past months to complete the baths. The need for other tasks has been taking priority over the bath schedule along with days the bath aide has off work. It is stressful for me when I can't get the baths done (the aide began to cry during this part of the interview). When asking for help for missed bath the pressure gets placed back to CNA-E reminding them the baths are their responsibility. The CNA-E explained that more then 50-75% of the week they are taken off of bath duty and asked to provide other cares. CNA-E stated if baths were missed on Monday and Tuesdays they will attempt to make up those baths one Wednesday and Thursdays which would then push the schedule for the resident on Wednesdays and Thursdays. The CNA-E pointed out on the schedule the reasons for the date of the baths not matching the date of the resident schedule day. On 11/22/22 at 2:06 PM, the Surveyor interviewed the Director of Nursing (DON)-B who stated early last summer the facility began a Quality Assurance Improvement Plan (QAPI) which focused on having a bath aide completing baths Monday through Thursday, four days a week 6am to 11am then move to other CNA tasks on Fridays full day of the bath aide role. They trained all staff to give baths so when the time came the bath aide was off or couldn't complete, the bath other aide could help. Along with other non-nursing roles, staff were crossed trained for answering call lights and lobby monitoring so CNA's could give baths. Audits were going to take place by the Social Worker (SW)-F and DON-B had not heard any concerns about bathing not being completed. On 11/23/22 at 9:41 AM, the Surveyor interviewed SW-F who explained that there was a struggle when the bath aide is on vacation. The surveyor asked for audit information of the QAPI program and no documentation of auditing was completed. SW-F stated they are working to make reviews and updates to the QAPI program. 2. R3 was admitted to the facility on [DATE] with diagnoses to include hemiplgia following cerebral infarction affecting the left side (stroke with left side weakness), chronic renal disease on dialysis, congestive heart failure, and atrial fibrillation. R3's Brief Interview for Mental status (BIMs) was 8/15 on 10/25/22 which showed moderately impaired cognition. The Minimum Data Set (MDS) dated [DATE] showed R3 was total depended assist for baths. On 11/22/22 at 1:50 PM, Surveyor interviewed R3 regarding weekly baths. R3 explained they had only been receiving a bath once or twice a month. R3 indicated it was unpredictable and felt like a surprise if the staff would be able to give R3 a bath on their scheduled bath day which was Friday. R3 explained that they go out for dialysis appointments on Tuesdays, Thursdays and Saturdays and are too fatigued for a weekly bath on those days which is why Fridays work best. R3 will refuse a bath on dialysis days so they are not late for the appointment. R3 express they would like to take a bath each week but felt unsure that could happen. Between 11/21/22 through 11/23/22 the Surveyor reviewed bath record which identified 10 missed baths in 14 weeks between 8/7/22 through 11/20/22. One documented refusal occurred on 11/12/22 R3's scheduled bath day was 11/11/22. R3 was offer a bath on 11/12/22 but refused that Saturday was a dialysis appointment. Dates of missed baths included: 8/12/22, 8/19/22, 9/2/22, 9/23/22, 9/30/22, 10/7/22, 10/14/22, 10/28/22, 11/11/22 and 11/18/22. See interviews from example #1. 3. R27 was admitted to the facility on [DATE] with diagnoses to include diabetes, congestive heart failure, chronic kidney disease and right knee surgery with wound therapy. R27's Brief Interview for Mental status (BIMs) was 15/15 on 9/12/22 which showed no impaired cognition. The Minimum Data Set (MDS) dated [DATE] showed R27 was total depended assist for baths. On 11/21/22 at 10:14 AM, the Surveyor interviewed R27 who expressed wanting a tub bath since the wound on R27 knee was healed. R27 was told they could take a bath in the tub but has been waiting weeks to have one. On 11/21/22 at 11:00 AM, the Surveyor interviewed R27's spouse who also had concerns regarding how long they had been waiting to hear back when R27 will get a tub bath. On 11/22/22 at 1:09 PM, the Surveyor interviewed CNA-E who explained that R27 was able to have a tub bath but since the bath schedule is so far behind they are waiting to schedule the bath. The Surveyor reviewed R27's medical record which indicated the wound was healed on 10/23/22. Between 11/21/22 through 11/23/22 the Surveyor reviewed bath records which identified 1 missed baths in 4 weeks between 10/16/22 through 11/18/22. Dates of missed bath included: 11/18/22. On 11/23/22 at 10:55 AM, the Surveyor interviewed SW-F who verified that R27 was on the schedule for a tub bath 11/24/22. See interviews from example #1.

Based on observation, staff interview and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect 42 residents. Food cooling logs were not completed in their entirety. Appropriate haircovering was not worn by dietary staff (DS)-F. Sanitizing solution utilized to clean kitchen surfaces was not tested for parts per million (ppm)/effectiveness. Household unit kitchen refrigerator temperature logs were incomplete. Household kitchens contained undated and expired food items. Findings: Wisconsin Food Code reads as follows: ,d+[DATE].14 Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 degrees F (Fahrenheit) to 70 degrees F; and (2) Within a total of 6 hours from 135 degrees F to 41 degrees F or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F. ,d+[DATE].11 Hair Restraints Effectiveness. (A) Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment and utensils. ,d+[DATE].116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Facility policy titled Kitchen Sanitation and Cleanliness read as follows: Protocol - Coolers are at 41 degrees F or below. Facility policy titled Organizational Dress Code and Personal Hygiene read as follows: Culinary Services Staff: 1. Hair restraints (completely covering hair) must be worn at all times when in kitchen. Facility policy titled Food Storage for Resident Foods reads as follows: All perishable foods are maintained at 41 degrees F or 0 degrees F. Refrigerators are kept at 41 degrees F and freezers 0 degrees F. Food storage areas are kept clean and all items for residents have their name and date. Procedure: Food or beverage in the original container that is past the manufacturer's expiration date will be discarded by facility staff. Facility-provided guidelines for staff related to sanitizer usage, ppm and test strips included the following requirements for Apex Solid Quat Broad Range Sanitizer: Testing Quat: . TEST to make sure that the solution is strong enough to sanitize. Make sure that the solution is strong enough to sanitize. Make sure that your Quat solution is within appropriate range using the color reference chart. If the solution is out of range, inform manager or person in-charge to contact (vendor). 1. On [DATE] at 8:35 AM, the Surveyor conducted an initial tour of the kitchen along with Dietary Manger (DM)-D. The Surveyor reviewed the temperature log for cooling foods. There were five entries on the log ranging from [DATE] to [DATE]. Each entry was labeled as chicken stock. Each date entry included: ~ a data entry location for start time, ~ a data entry location to record the temperature at 2 hours with a prompt to be less than 70 degrees F, ~ a data entry location to record the temperature at 4 hours with a prompt to be under 41 degrees F, and ~ a data entry location for staff initials. The data entered for [DATE], without a start time, noted a temperature of 192 degrees F; at 2 hours the temperature was 69 degrees F and there was no data indicating the food temperature was tested any further. The data entered for [DATE] indicated no start time, but did note a temperature of 190 degrees F; at 2 hours the food cooled to 75 degrees F (Food Code states 70 degrees F at 2 hours) and then at 4 hours was noted 40 degrees F. On [DATE], the only entry is that the temperature started at 182 degrees F, no start time or subsequent entries of temperatures were entered. The surveyor interviewed DM-D, who indicated the missing date entries were likely due to shift change and staff coming in for the next shift not carrying out the process of checking temperatures for cooling foods. DM-D confirmed the expectation is to check the cooling food and document the temperatures until the food gets to below 41 degrees F within the required timeframe. 2. During the initial tour, the Surveyor noted employee DS-F to be wearing a hair covering which appeared to be crocheted with yarn and had openings in it that allowed DS-F hair to protrude through. In addition, DS-F bangs were noted to be fully out of the hair covering. DM-D was interviewed and relayed the expectation was to have hair covered fully. DM-D requested DS-F to adjust the haircover to include the bangs. On [DATE] at 10:24 AM, Nursing Home Administrator (NHA)-A was interviewed regarding the hair covering and confirmed the expectation is that all hair should be covered while in the kitchen. NHA-A indicated, DS-F needs to put one of our (facility) hairnets on. 3. On [DATE] at 1:00 PM, the surveyor conducted a second tour of the kitchen and observed the area where the 3 compartment sink was located. In this area was a dispensing system for sanitizing solution. An instructional poster for Apex Solid Quat Broad Range Sanitizer was located on the wall above the sink area. The poster indicated: Testing solution should be tested at room temperature, ,d+[DATE] degrees F, and testing solution should be between ,d+[DATE] ppm. The Surveyor reviewed the clipboard located near the sanitizer dispenser which contained a piece of copy paper, the top of paper had Sept/[DATE] handwritten on it and a list of dates and numbers handwritten on it along with the initials EM after each entry. DS-G was interviewed and stated that the paper was the log for testing parts per million of the sanitizing solution. DS-G confirmed the sanitizing solution is used daily and should be tested daily as well. The Surveyor noted the dates of ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and ,d+[DATE] missing. DS-G confirmed these were likely weekend dates; DS-G added that there is one employee, DS-F, who tests the sanitizing solution and DS-F does not work weekends. On [DATE] at 1:25 PM, the Surveyor interviewed DM-D who confirmed the sink is utilized in addition to a dishwashing machine and that Quat sanitizer is utilized for the sinks as well as for kitchen surfaces such as countertops as the sanitizing solution. DM-D confirmed that the ppm was to be tested daily and is used daily. DM-D stated, I had addressed this (need to test and document ppm) with the lead workers a couple months ago. DM-D reviewed the missing date entries and confirmed they were weekends and one holiday. DM-D indicated that DS-F is the staff who typically tests and documents the sanitizer ppm, but DS-F does not work weekends and the staff who work the weekend shifts failed to follow through with ppm testing/documentation. DM-D indicated that staff are trained on an annual basis to test the ppm for the sanitizing solution and there is also instructions on the wall near the dispenser. DM-D indicated the expectation is to test the solution one time a day in the morning and document the findings on the log. 4. On [DATE] at 1:40 PM, the Surveyor reviewed the household kitchen areas. Household 1 contained the following items: In the refrigerator, an open half gallon of milk with no open date; manufacturer sell-by date of [DATE]. On the countertop, a large pump-bottle of coffee sweetener with an open date noted as [DATE], which was past the 30 days of manufacturer recommendation for use. The September refrigerator temperature log was noted to be on the refrigerator and was missing five date entries for the month. Household 2 contained the following items: An open bottle of honey on the countertop, with no open date; manufacturer best-by date of [DATE]. A large opened pump-bottle of coffee sweetener manufacturer instructions state, Record the date the bottle is opened on the white date code area of the label with a permanent maker, remove cap and safety seal. In the white date code area it read, For best quality use within 30 days of opening. No open date was written on the date line. In the refrigerator, an open half gallon of milk with no open date with a manufacturer sell-by date of [DATE]. The September refrigerator temperature log was noted to be on the refrigerator and was missing seven date entries for the month. Household 4 contained the following items: In the refrigerator, an open half gallon of milk which had no open date. In the refrigerator, a 32 fluid ounce opened bottle of french vanilla coffee creamer, with a first name written on it, but no open date. On the countertop, an open bottle of honey, without an open date on it; manufacturer best-by date of [DATE]. On the countertop, a large opened pump-bottle of coffee sweetener; manufacturer instructions state, Record the date the bottle is opened on the white date code area of the label with a permanent maker, remove cap and safety seal. In the white date code area it read, For best quality use within 30 days of opening. No open date was written on the date line. Household 6 contained the following items: In the refrigerator, an open half gallon of milk with no open date noted; manufacturer sell-by date of ,d+[DATE]. On the countertop, a large opened pump-bottle of coffee sweetener manufacturer instructions state, Record the date the bottle is opened on the white date code area of the label with a permanent maker, remove cap and safety seal. In the white date code area it read, For best quality use within 30 days of opening. No open date was written on the date line. On [DATE] at 10:06 AM, the Surveyor interviewed DM-D who indicated that nursing staff are in charge of the household kitchens, that milk and coffee creamer/sweetener are delivered to the household unopened and once the nursing staff open them, the expectation is for them to write an open date on the food item. DM-D also explained that refrigerator temperature monitoring is to be done by nursing staff for the household kitchen units. On [DATE] at 11:31 AM, the Surveyor interviewed DON-B who confirmed nursing staff are responsible for dating food items when opened and logging temperatures for the refrigerators on the household kitchens. DON-B confirmed the expectation is for the refrigerator temperatures to be completed daily. DON-B indicated that it is the night shift staff's responsibility to get rid of expired foods or undated items. DON-B explained this is on a duty calendar for nursing to do these kitchen tasks.

Based on observation, staff and resident interview and record review, the facility did not maintain an infection prevention and control program to prevent the transmission of infections for 3 of 13 sampled R (Residents) (R27, R46 and R13) reviewed for infection. Additionally, the facility did not ensure hand hygiene was performed at mealtime for 6 (R19, R49, R12, R13, R251, and R47) of 42 residents reviewed for hand hygiene. R27 was not placed on TBP (Transmission Based Precautions) or placed on the infection control line list with the onset of new symptoms of infection. R46 was not placed on transmission based precautions or placed on the infection control line list with the onset of new symptoms of infection. R13 was not placed on transmission based precautions or placed on the infection control line list in a timely manner with the onset of new symptoms of infection. Hand hygiene was not offered to R19, R49, R12, R13, R251, and R47 at mealtime. Findings include: 1. On 9/27/21 Surveyor conducted a record review. R27 was admitted to facility on 8/05/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R27's BIMS (Brief Interview for Mental Status) exam score was coded as 11 (moderate cognitive impairment). R27 was coded as extensive assist for ADLs (activities of daily living). On 9/27/21 at 10:00 AM, Surveyor observed R27 sitting in the unit common/dining area at a table. R27 was sitting alone at the table. R27 told Surveyor that R27 had a head cold. R27 was noted to have a cough and was using tissue to wipe R27's nose. R27 told surveyor that R27's nose was running. R27 was not wearing a mask. Surveyor observed no mask on the table or near R27. On 9/27/21 at 12:30 PM, R27 was observed in the common/dining area of the unit eating the noon meal. Two other residents were in the common/dining area at a separate table. R27 did not have signage on R27's room door indicating R27 was on TBP. R27's medical record contained a progress note dated 9/25/21 at 2:54 AM, that stated, Lung sounds clear, productive cough noted, no SOB (shortness of breath). Progress note dated 9/26/21 at 6:13 AM, stated, Lung sounds clear. Intermittent productive cough noted. Denies any shortness of breath or difficulty breathing. Afebrile. Oxygen saturation at 94% room air. Denies any pain or discomfort. Progress note dated 9/26/21 at 6:48 PM, stated, Resident has an intermittent non productive cough and nasal drainage that started a few days ago. No c/o (complaint of) SOB, difficulty breathing, pain, or discomfort. Breathing is even and non labored. Denied any other cold or respiratory symptoms. VSS (vital signs stable). Schedule meds given and no PRNs (as needed) needed. Appetite is good and fluids encouraged. COVID swab was negative and fax sent to update (named nurse practitioner), APNP (advanced practice nurse practitioner). Family is aware of (R27's) symptoms. On 9/29/21 at 10:13 AM Surveyor interviewed RN (Registered Nurse)-E. RN-E was aware that R27 had a cough and runny nose. RN-E said a COVID swab completed on R27 was negative. RN-E was unsure if R27 was placed on TBP at the start of R27's symptoms. On 9/29/21 at 11:30 AM, Surveyor interviewed IP (Infection Preventionist)-C. IP-C reported that R27 was not placed on TBP and was not placed on the infection control line list because IP-C understood that R27's nasal congestion was not new for R27, that R27 was always nasally, and R27's COVID swab was negative. R27's medical record contained no information that R27's normal presentation included cough and nasal drainage. 2. On 9/27/21, Surveyor conducted a medical record review. R46 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's progress notes dated 9/21/21 at 11:46 PM, stated, Around 20:30 (8:30 PM) resident complained of a sore throat that started yesterday. Same progress note indicated R46 had no cough. Progress notes dated from 9/21/21 through 9/24/21 referred to R46's sore throat. Progress note dated 9/25/21 at 12:05 AM, stated R46 continued with a sore throat and now had intermittent coughing. Progress note dated 9/26/21 at 2:57 AM, stated Lung sounds clear. Nasal congestion and cough noted. Denies any difficulty breathing. Resident on 2L (liters) oxygen saturation at 98% Offers no other complaints at this time. On 9/29/21 at 10:13 AM, Surveyor interviewed RN-E. RN-E said R46 had a sore throat and cough. RN-E said R46 was COVID tested and the test was negative. RN-E was not sure if R46 was placed on TBP with the onset of symptoms. RN-E indicated R46's sore throat could have been from dry air. On 9/29/21 at 10:25 AM, R46 was in R46's room in bed. R46 was coughing and reported a congested cough. R46 stated, I want to get that mucous up. R46 indicated R46 asked nursing staff for cough medicine. On 9/29/21 at 11:30 AM, Surveyor interviewed IP-C. IP-C reported that R46 was not placed on TBP and was not placed on the infection control line list because R46 had respiratory failure with a chronic cough and was on Hospice. IP-C indicated R46's sore throat was probably caused by R46's use of inhalers and oxygen. R46's progress notes contained no information that R46's normal presentation included cough. Facility policy titled, Infection Control Program states the following: -Healthcare personnel must contain respiratory secretions to prevent droplet transmission of respiratory pathogens. Offer masks to coughing residents and to any other symptomatic persons upon their entry into the facility. -Anytime a resident presents with signs or symptoms of an influenza-like illness, the resident will be isolated within their room. Appendix C of facility infection control policy includes New or increased cough, as an influenza-like illness/COVID-19. -As early detection is essential to prevent the spread of pandemic influenza, daily surveillance of the resident infections is accomplished using the Unit Infection Surveillance Logs. -Residents who have signs or symptoms of COVID-19 must be tested . While test results are pending, residents with signs or symptoms should be placed on transmission-based precautions in accordance with CDC guidance. Once tests results are obtained, the facility must take the appropriate actions based on the results. -COVID-19 Outbreak - Reported illnesses have ranged from mild symptoms to severe illness and death for confirmed COVID-19 cases. The following symptoms may appear 2-14 days after exposure: Initially symptoms can be vague complaints followed by fever, cough, and shortness of breath. On 9/29/21 at 12:15 PM, the Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. DON-B stated it was in the policy to not wait to put people on precautions, but it depended on the individual resident and their norm. NHA-A indicated, We do not want to wait, I would rather put somebody on precautions right away rather than wait. The Center for Disease Control (CDC) Precautions to Prevent Transmission of Infectious Agentsnotes the following: III.C. Syndromic and Empiric Applications of Transmission-Based Precautions diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Use of appropriate Transmission-Based Precautions at the time a patient develops symptoms or signs of transmissible infection, or arrives at a healthcare facility for care, reduces transmission opportunities. While it is not possible to identify prospectively all patients needing Transmission-Based Precautions, certain clinical syndromes and conditions carry a sufficiently high risk to warrant their use empirically while confirmatory tests are pending (Table 2). Infection control professionals are encouraged to modify or adapt this table according to local conditions. Department of Health Services (DHS) Health Alert Network, COVID-19 Health Alert # 17: Important Considerations for Use of COVID-19 [MEDICATION(S)] Tests Bureau of Communicable Diseases, September 24, 2020 Summary: A number of assays for rapid [CONDITION(S)]-CoV-2 [MEDICATION(S)] detection have received emergency use authorization (EUA) from the U.S. Food and Drug Administration. While [MEDICATION(S)] tests are less expensive and have a shorter turnaround time than most molecular tests (e.g., RT-PCR), they are less accurate and results should be interpreted carefully. Rapid [CONDITION(S)]-CoV-2 [MEDICATION(S)] tests perform best when used for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Positive tests in symptomatic patients, or when there is a high pre-test probability (e.g., in outbreak settings or among close contacts of exposed cases), should be considered presumptive evidence of infection and do not require confirmatory testing. Because of the risk of false negative results, symptomatic patients who have a negative [MEDICATION(S)] test result should be re-tested with an alternative method to confirm the result. The use of [CONDITION(S)]-CoV-2 [MEDICATION(S)] tests for screening asymptomatic persons was not included in the FDA Emergency Use Authorization. [MEDICATION(S)] testing of patients without symptoms is therefore considered off-label use and is not recommended for routine screening. FDA has provided guidance, however, that such off-label use may be appropriate in some settings where access to highly sensitive tests is inadequate. If used for asymptomatic screening, [CONDITION(S)]-CoV-2 [MEDICATION(S)] tests are expected to result in a high proportion of false positive results. A two-test strategy is therefore required in order to yield reliable results in this setting. All positive [MEDICATION(S)] results obtained from asymptomatic, non-close contacts should be followed by a different test as soon as possible and within 48 hours. Presumptive negative results do not need confirmation testing in this setting. 3. On 9/27/21 at 11:23 AM, Surveyor interviewed R13. R13 stated, I have this cough, in the past I have had something like this and they called it [CONDITION(S)]. Surveyor noted cough drops on the stand in front of R13. R13 confirmed that the nurses know about the cough and they gave R13 the cough drops. The surveyor noted there was no signage at the resident's door indicating droplet precautions. (precautions used to prevent the spread of pathogens that are passed through respiratory secretions such as with coughing) nor was there PPE (personal protective equipment) such as gowns outside R13's door for staff to utilize prior to entering R13's room. On 9/27/21 at 11:28, while in the unit lounge area outside R13's room, the Surveyor could hear R13 coughing from R13's room. On 9/27/21 at 11:54 AM, while walking past R13's room, the Surveyor could hear R13 coughing from R13's room. On 9/27/21, the Surveyor conducted a record review. R13 was admitted to the facility 8/15/17. R13's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/13/21, R13's BIMS (Brief Interview of Mental Status) score was coded as 13 (intact cognitive response) and R13 was coded as needing extensive assist of staff for ADLS (Activities of Daily Living.) Nursing progress notes indicated the following: 9/22/21 at 4:19 PM, After breakfast, c/o (complaint of) sore throat. Slight irritation and redness noted to back of throat. 9/22/21 at 11:27 PM, (R13) c/o phlegm in chest that cannot cough up . Fax sent to update APNP and requested [MEDICATION(S)] (a medication used to relieve cough.) 9/23/21 at 3:24 PM, (R13) tested for COVID-19 using BinaxNOW (a rapid results test method) nasal swab this morning for outbreak testing, results negative. 9/23/21 at 4:27 PM, LS (lung sounds) clear. Afebrile (without fever). (R13) continues with wet, non-productive cough. Order received from APNP for rapid COVID swab, CXR (chest x-ray) 2 view, and [MEDICATION(S)] 600 mg ER (extended release) (1-2 tabs) PO (by mouth) q 12 hours (every 12 hours) PRN for cough and congestion. COVID swab negative . 9/23/21 at 6:57 PM, (R13) had a chest x-ray today d/t (due to) chest congestion. Impressions show no evidence of pneumonia or CHF (congestive heart failure). (R13)and APNP (Advanced Practice Nurse Practioner) updated on results. Received order to continue and update if temperature or HR (heart rate) greater than 100 or oxygen saturations (amount of oxygen carried in blood) less than 90%. 9/24/21 at 2:10 PM, (R13) continues normal routine on unit; out to breakfast and remains in recliner at noon meal. Appetite fair per resident's usual. Congestion continues; PRN [MEDICATION(S)] administered with some effect. (R13)encouraged to deep breath, forcefully cough, and drink fluids. VSS and entered into Vision (electronic medical record system); afebrile. (R13) reports, Around October every year I always had gotten something called [CONDITION(S)]. Intermittent, non-productive, wet cough noted . 9/25/21 at 12:17 AM, Lungs are clear, but diminished in the bases. VSS. No new cold or respiratory symptoms assessed. (R13) said chest congestion is better today. No coughing, SOB (shortness of breath), difficulty breath assessed. 9/26/21 at 4:11 PM, LS (lung sounds) clear. Afebrile with no change in taste, smell, or respiratory status. PRN [MEDICATION(S)] given x 1 (once) this shift with effective results. 9/26/21 at 4:24 PM (R13) says chest congestion is better, but continues to have an intermittent dry cough. 9/27/21 at 4:08 PM, (R13) updated orally and in writing of new roommate coming in on this date. 9/27/21 at 8:30 PM, LS clear. Afebrile with no change in respiratory status. (R13) continues with cough. On 9/28/21 at 11:06 AM, the Surveyor interviewed DON-B. DON-B indicated that if a (R13) had only the symptom of a cough they would be looked at case by case to determine if they were to be put on precautions. DON-B explained that if there was presence of a fever, chills or weakness precautions would be initiated immediately; if just a cough or tickle - would evaluate case by case. On 9/28/21 at 11:08 AM, the Surveyor interviewed IP-C who indicated R13 has an intermittent dry cough which started on 9/23 and R13 gets [MEDICATION(S)] for that. IP-C indicated that a (R13) would not be put on TBP for a dry or nonproductive cough. IC-P stated, R13 doesn't come out of the room and staff are already wearing facemasks and shields. A copy of R13 respiratory care plan was requested; IC-P indicated that R13 does not have a respiratory care plan. With regards to COVID testing, IP-C indicated, residents are tested weekly because of an outbreak status at the facility. On 9/29/21 at 1:07 PM, in a follow-up interview, IP-C confirmed that following R13's rapid COVID test, a follow up PCR (polymerase chain reaction) (a more definitive COVID test) was not conducted. IP-C explained that R13 symptoms were not felt to be acute so we did not do a PCR. IP-C indicated that R13's symptoms were intermittent, R13 had a sore throat which resolved and then the cough. The Surveyor reviewed the Daily Symptom Log for Residents (the infection line list) for September in which R13's name and symptoms of cough was entered as 9/23/21 but was placed after R28's entry of 9/26/21. IP-C explained that R13's symptom information came to IP-C late. IP-C confirmed the log is used to monitor for outbreaks of illness in the facility. 4. On 9/27/21 during the lunch meal the Surveyor made the following observations: 11:41 AM, R29 was noted to be seated at the dining room table, R29 was observed touching the wheels and brake levers on R29's wheel chair and at one point wheeled self around the dining area and then came back to the table. Hand hygiene was not offered prior to meal service. 11:48 AM, R49 was observed by Surveyor to be in R49's room working with therapy staff, R49 was then pushed to the dining room table by therapy staff; hand hygiene was not offered prior to meal service. 11:50 AM, the Surveyor observed R12 seated in a wheelchair and propelling the wheelchair wheels with R12's hands from R12's room to the dining room area. Prior to eating, hand hygiene was not offered to R12. 12:03 PM, The Surveyor interviewed facility household staff who stated, we washed R29's hands when we took R29 to the bathroom earlier; R49 came from therapy so I do not know if hands were washed and that R12 comes and goes. When asked what is usually done to provide resident hand hygiene, staff stated, We would offer those who eat in their rooms a washcloth and for those eating in the dining room, we would take them up to their room sinks to wash hands. 12:15 PM, The Surveyor interviewed R13 who was eating lunch in R13's room. R13 confirmed staff had not offered hand hygiene. On 9/28/21 during the lunch meal the Surveyor made the following observations: 12:14 PM, Resident Assistant (RA)-H entered R251's room with a lunch tray; R251 was laying in bed. Surveyor did not observe hand hygiene being offered. 12:16 PM, the Surveyor interviewed R251; who confirmed staff did not and do not routinely offer hand hygiene at mealtime. 12:17 PM, the Surveyor observed RA-H enter R47's room and delivery a lunch tray. Surveyor did not observe hand hygiene being offered. 12:25 PM, the Surveyor interviewed R47, who confirmed staff did not offer hand hygiene. On 9/28/21 at 12:41 PM, the Surveyor interviewed RA-H regarding hand hygiene for residents prior to meals. RA-H stated, we do have wipes in the rooms from the green tubs. When asked if these wipes were the ones used for pericare, RA-H confirmed they were the same ones. Surveyor asked if they were alcohol-based, at which time RN-I joined in the interview and RH-I indicated, those wipes are not alcohol based but that hand hygiene in offered to residents in their rooms prior to mealtimes typically but it (hand hygiene for meals) is something we could improve on. RA-H confirmed not offering R47 hand hygiene and that R251 was washed up when provided cares prior to lunch, RA-H stated a towel with soap on it was used to wash R251's hands. On 9/29/21 at 11:32 AM, the Surveyor interviewed DON-B. DON-B indicated the expectation is that hand hygiene should be offered to residents before meals at each meal.

Based on observation, record review, and staff interview, the facility did not provide appropriate treatment and services to prevent Urinary Tract Infections (UTIs) and to restore continence to the extent possible for 2 of 2 sampled Residents (R) (R12 and R16). R12 and R16 were not offered or provided incontinence cares in accordance with R12's and R16's plans of care. When toileted by staff R12 was incontinent of bowel and bladder, and R16 was incontinent of bladder. Findings include: 1. The Surveyor reviewed R12's medical record from 12/16/19-12/18/19. R12 was admitted to the facility on [DATE]. R12's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/24/19 documented R12 to be dependent on staff for bed mobility, transfer, and ADLs (Activities of Daily Living.) R12's MDS documented R12 to be frequently incontinent of bladder and occasionally incontinent of bowel. R12's undated CNA (Certified Nursing Assistant) Care Sheet documented toileting: 1A (one person assist) 2-3 times at night. Upon rising, before/after meals and HS (bedtime.) R12 had an undated care plan in place titled, Urinary Continence: R12 is frequently incontinent of bladder and occasionally incontinent of bowel related to dementia and impaired mobility. Functional and urge incontinence noted with interventions in place including: ~ Remind R12 to empty bladder before meals, at bedtime, and before activities. ~ Assist with toilet transfers, peri-care and use of pads/briefs. ~ Assist with toileting when requested to have bowel movement. ~ R12 will wake up during the night when incontinent. On 12/18/19 from 8:15 AM until 12:00 PM, the Surveyor conducted continuous observations of R12 on the unit. On 12/18/19 at 9:25 AM, the hospice RA (Restorative Aide) pushed R12 in w/c (wheelchair) into the unit lobby in front of the television. The Surveyor reviewed the hospice RA visit note which documented the hospice RA was with R12 from 8:00 AM until 9:30 AM. On 12/18/19 at 11:00 AM., CNA-I pushed R12 in w/c from the unit lobby into R12's room. CNA-I informed the Surveyor she would be toileting R12. CNA-I transferred R12 with a sit-to-stand lift, and took R12 to the toilet. The Surveyor observed R12's brief and noted R12 was incontinent of bowel and bladder. CNA-I confirmed to the Surveyor R12 was incontinent of bowel and bladder. CNA-I stated she got R12 up this morning at approximately 7:00 AM. CNA-I stated R12 was with the hospice RA who comes and visits with the residents. CNA-I stated the hospice RA's are not allowed to toilet R12 alone, so facility staff would have to be in the room to assist with the transfer to the toilet. CNA-I stated she would be the only staff member to toilet R12, and the last time R12 was toileted was at 7:00 AM., when R12 got out of bed. On 12/18/19 at 11:33 AM., the Surveyor interviewed DON (Director of Nursing)-B who stated residents who are assessed to be incontinent should be toileted before and after meals. DON-B stated R12 should have been taken to the toilet after breakfast as stated in R12's CNA care plan. 2. The Surveyor reviewed R16 medical record from 12/16/19-12/18/19. R16 was admitted to the facility on [DATE]. R16's most recent quarterly MDS with an ARD of 10/8/19 documented R16 to be dependent on staff for bed mobility, transfer, and ADLs (Activities of Daily Living.) R16's MDS documented R16 to be frequently incontinent of bowel and bladder. R16's undated CNA Care Sheet documented toileting: 2A (2 person assist.) R16 had an undated care plan in place titled Urinary Continence: R16 is frequently incontinent. Decrease in mobility, DX (diagnosis) of dementia, on hospice. R16's care plan had interventions in place including: ~ Check skin for areas of redness. ~ Report any changes to the nurse. ~ Use pads/briefs to manage incontinence. ~ Staff assists with toileting upon rising, before and after meals, HS and PRN (as needed.) On 12/18/19 from 8:15 AM until 12:00 PM, the Surveyor conducted continuous observations of R16 on the unit. On 12/18/19 at 8:15 AM, the Surveyor observed R16 in w/c in the dining area on the unit. On 12/18/19 at 9:00 AM, R16 remained in w/c in the dining area near the television. On 12/18/19 at 11:17 AM, CNA-I and CNA-J took R16 to R16's room to take to the toilet. R16 was transferred with a Hoyer lift to the toilet. The Surveyor observed R16 to be incontinent of bladder. CNA-I and CNA-J confirmed R16 was incontinent of bladder. CNA-I and CNA-J stated they would be the only staff that would have taken R16 to the bathroom. CNA-I and CNA-J stated R16 morning cares were completed about 6:45 AM, and that was the last time R16 was taken to the bathroom. On 12/18/19 at 11:33 AM, the Surveyor interviewed DON-B who stated residents who are assessed to be incontinent should be toileted before and after meals. DON-B stated R16 should have been taken to the toilet after breakfast as stated in R16's care plan.

Based on observation, interview and record review, the facility did not ensure implementation of infection control policy designed to prevent the development and transmission of disease and infection during 1 resident (R) (R49) of 2 sampled residents' care observations. RN (Registered Nurse)-F did not utilize appropriate infection prevention techniques during the provision of IV (intravenous) therapy care for R49. Findings include: Facility provided policy titled IV Therapy stated, (facility name) nurses will utilize the policies and procedures detailed in The Nurses' Infusion Manual for Long Term Care Facilities as provided by (name of pharmacy), for all aspects of IV Therapy. Facility provided policy document titled Flushing stated, . 7. g. Disconnect medication from cap h. Disinfect cap with appropriate antiseptic solution i. Connect second preservative free 0.9% sodium chloride (NaCl) syringe to cap j. Flush with NaCl and remove syringe and discard k. Disinfect cap with appropriate antiseptic solution l. Connect [MEDICATION NAME] (a medication used to prevent blood clots) filled syringe to cap and slowly aspirate (pull back on syringe) to reconfirm positive blood return m. Slowly inject flush solution n. Disconnect syringe from cap and discard . 10. Remove gloves and wash hands. 11. Document procedure in MAR (medication administration record) or IV care sheet. Facility provided policy titled Hand Hygiene stated, . 6. Decontaminate hands after contact with inanimate object (including medical equipment) in the immediate vicinity of the patient . 10. Decontaminate hands after removing gloves . On 12/16/19 at 2:06 PM, Surveyor reviewed R49's medical record. R49 was admitted to that facility on 11/8/19 with [DIAGNOSES REDACTED]. (a type of brain disorder that causes problems with memory, thinking and behavior). R49's medical record included a physician's orders [REDACTED]. On 12/17/19 at 8:51 AM, Surveyor observed RN-F disconnect R49's completed IV medication administration and flush the IV as directed by procedure. R49 was in bed. RN-F performed hand hygiene upon entering R49's room. RN-F raised R49's bed to a working level and pulled up R49's right sleeve to get to the IV site. RN-F assessed the IV site. RN-F put on gloves. RN-F removed the IV tubing which was connected to the empty medication bag from the IV catheter in R49's right arm. Without disinfecting the cap of R49's IV catheter, RN-F attached a syringe of NaCl and flushed the catheter. RN-F then removed the syringe of NaCl and, without disinfecting the cap of R49's IV catheter, attached a syringe of [MEDICATION NAME] and flushed R49's IV catheter. RN-F removed the [MEDICATION NAME] syringe, adjusted R49's clothing then removed RN-F's gloves. RN-F then lowered R49's bed into the original position, gathered used supplies and disposed of into garbage can at bedside, moved R49's over-bed table and IV pole then exited R49's room with the used IV tubing and medication bag. RN-F documented into the computer located in the common area outside R49's room, walked to a hallway nearby, dropped keys onto the floor, picked up the keys, opened a locked door and disposed of the used IV tubing and medication bag. RN-F then returned to the common area outside of R49's room and performed hand hygiene. On 12/18/19 at 10:34 AM, Surveyor interviewed DON (Director of Nursing)-B who indicated the expectation was for the nurses to follow the facility's policies as written.

Based on observation, staff interview, and record review, the facility did not provide necessary treatment and services to prevent pressure injury (PI) development for 2 Residents (R) (R12 and R16) of 3 residents reviewed for PI risk. R12 and R16 were assessed to be at risk of PI development. R12 and R16 were observed to not be repositioned as required in R12's and R16's plans of care. Additionally, R16 was not laid down after meals as required in R16's plan of care. Findings include: 1. The Surveyor reviewed R12's medical record from 12/16/19-12/18/19. R12 was admitted to the facility on [DATE]. R12's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/24/19 documented R12 to be dependent on staff for bed mobility, transfer, and ADLs (Activities of Daily Living.) R12's MDS documented R12 to be at risk for development of pressure injury, frequently incontinent of bladder and occasionally incontinent of bowel. R12's most recent Braden (a tool used to predict PI risk) dated 11/27/19, documented a score of 15, which indicated R12 was at risk for developing a PI. R12 had an undated care plan in place indicating, (R12) is at risk for skin breakdown related to: spastic movements, bowel and bladder incontinence and decreased awareness, poor intake on hospice care. With interventions in place to include: ~ Assess and document skin for color, moisture, texture, and turgor. Report abnormal findings. ~ Check skin for redness, skin tears, swelling, bruising or pressure areas with daily cares and with weekly bath and with scheduled skin and risk assessment. ~ Reposition/redistribute weight every 2 hours when in bed. ~ Use pillows to off load heels when in bed ~ Use pressure redistribution mattress on bed and cushion for the w/c (wheelchair) or sitting surface. On 12/18/19 from 8:15 AM., until 12:00 PM., the Surveyor conducted continuous observations of R12 on the unit. On 12/18/19 at 9:25 AM., the hospice RA (Restorative Aide) pushed R12 in w/c into the unit lobby near the television. The Surveyor reviewed the hospice RA visit note which documented the hospice RA was with R12 from 8:00 AM until 9:30 AM. On 12/18/19 at 11:00 AM, Certified Nursing Assistant (CNA)-I pushed R12 in w/c from the unit lobby into R12's room. CNA-I informed the Surveyor she will be taking R12 to the bathroom. CNA-I stated she got R12 up this morning at approximately 7:00 AM. CNA-I stated R12 was with the hospice RA from 8:00 AM until approximately 9:30 AM. CNA-I stated the hospice RA's is not allowed to reposition R12. CNA-I stated she would be the only staff member to reposition R12, and R12 had not been repositioned since approximately 7:00 AM. On 12/18/19 at 11:33 AM., the Surveyor interviewed DON (Director of Nursing)-B who stated residents who are assessed to be dependent on staff for repositioning are expected to be repositioned at a minimum of every two hours. DON-B stated R12 should have been repositioned every two hours to prevent pressure injuries from occurring. 2. The Surveyor reviewed the medical record of R16 from 12/16/19-12/18/19. R16 was admitted to the facility on [DATE]. R16's most recent quarterly MDS with an ARD of 10/8/19 documented R16 to be dependent on staff for bed mobility, transfer, and ADLs. R16's MDS documented R16 to be at risk for development of PIs, and frequently incontinent of bowel and bladder. R16's most recent Braden assessment dated [DATE], documented a score of 13, which indicated R16 was at risk for developing a PI. R16's undated CNA Care Sheet documented, Special Notes: Lay down after each meal. Reposition every 2 hours when in bed and every 1 hour when in chair. R16 had an undated care plan in place indicating R16 was at risk of PI development related to decreased mobility, bowel and bladder incontinence, DX (diagnosis) of breast CA (cancer), bruises easily, history of DTI (Deep Tissue Injury) to sacrum, on hospice care. R16's care plan had interventions in place to include: ~ Avoid friction and shearing with transfers. ~ Check skin for redness, skin tears, swelling, bruising or pressure areas. Report any signs of skin breakdown. ~ Skin checked daily with cares, weekly with bath and with scheduled skin/risk assessment. ~ Use chair cushion to reduce pressure. ~ Reposition/redistribute weight every 2 hours. ~ Has a pressure redistribution mattress on bed. ~ 8/7/19- Hospice contacted and to be providing an air mattress. ~ Lay down after meals. ~ Reposition every 2 hours in bed and every 1 hour when in chair. Turning clock. ~ Skin sealant to coccyx as ordered. ~ Use pillows, wedges to reduce pressure on heels and pressure points. On 12/18/19 from 8:15 AM until 12:00 PM., the Surveyor conducted continuous observations of R16 on the unit. On 12/18/19 at 8:15 AM., the Surveyor observed R16 in w/c in the unit dining room. On 12/18/19 at 9:00 AM., R16 remained in w/c in the unit dining area watching television. On 12/18/19 at 11:17 AM., CNA-I and CNA-J removed R16 from the dining area and took R16 to room. CNA-I and CNA-J stated they had plans to take R16 to the bathroom. CNA-I and CNA-J stated they got R16 up at approximately 6:45 AM and that was the last time R16 was repositioned by staff. CNA-I and CNA-J stated no other staff would reposition R16 other than CNA-I and CNA-[NAME] On 12/18/19 at 11:33 AM., the Surveyor interviewed DON-B who stated R16 should have been laid down after meals as stated in R16's plan of care. DON-B stated R16 also should have been repositioned at a minimum of every two hours because R16 is at risk for development of a PI and has had a PI in the past.

Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 Resident (R) (R46) of 6 residents reviewed for falls. R46's plan of care included specific interventions related to fall prevention which the facility failed to implement. Findings include: On 12/16/2019 and 12/17/2019, Surveyor reviewed the medical record of R46 which indicated that R46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R46 had an activated power of attorney for healthcare. On 11/12/2019, the facility completed a Fall Risk Assessment for R46. The assessment indicated a fall risk score of 11. The assessment criteria read, If the total score is 10 or greater, the resident should be considered at high risk for potential falls. The facility's assessment noted that a fall prevention care plan was initiated or updated at the conclusion of the Fall Risk Assessment. Records further indicated that on Sunday 12/15/2019, R46 fell at approximately 11:00 AM. Facility's fall assessment of 12/15/2019 noted R46 was found to be sitting on buttocks on the wheelchair pedals, back wheels of the wheelchair off the ground, knees bent, feet on the floor and back resting against seat of wheelchair; resident facing the TV/sitting area on the unit. The facility's clinical note related to the fall of 12/15/2019 also indicated, Resident representative updated and suggested just leaving foot pedals off of the wheelchair. Possible interventions; apply anti-tippers to front of wheelchair, assist resident into recliner after all meals, and/or remove foot pedals of wheelchair. R46's care plan included the following interventions initiated post fall: 12/15/2019: Assist to recliner after meals; if not in recliner, take foot pedals off. 12/15/2019: Dycem (a material which prevents slipping or sliding) applied. 12/15/2019: Anti-tippers (w.o. (work order) placed 12/15/2019) (Anti-tippers are a device put on wheelchairs to prevent the wheelchair from tipping.) On 12/17/2019 at 8:52 AM, R46 was observed at breakfast table, with eyes closed, staff arousing to assist in feeding R46 breakfast. Following breakfast, R46 was assisted to the TV/sitting area on the unit, where the resident sat in the wheelchair with foot pedals on the wheelchair. The Surveyor observed that anti-tip devices had not been installed on R46's wheelchair. On 12/17/2019 at 10:58 AM, Surveyor interviewed Unit CNA (Certified Nursing Assistant)-G regarding fall risk interventions for residents on the unit, CNA-G noted the COTAs (Certified Occupational Therapy Assistants) might complete these, CNA-G reported using the care plan to review fall interventions for the residents on the unit. On 12/17/2019 at 12:43 PM, Surveyor observed COTA-H instructing CNA-G, to lay resident down in recliner and remove foot pedals after meals. On 12/17/2019 at 12:58 PM, Surveyor interviewed CNA-G who confirmed the anti-tip device intiated on 12/15/19 had not yet been applied. On 12/17/2019 at 2:05 PM, Surveyor reviewed the medical record of R46 which indicated the resident had an unwitnessed fall in the dining room/living room at approximately 8:30 AM on 12/17/2019. On 12/17/2019 at 2:55 PM, Surveyor interviewed DON (Director of Nursing)-B, regarding the wheelchair anti-tip device intervention. DON-B confirmed the intervention had not been put in place but that the facility's maintenance employee was putting anti-tip device on right now. On 12/17/2019 at 3:15 PM, Surveyor interviewed COTA H, who confirmed review of R46's fall from the weekend (12/15/2019) and confirmed a maintenance work order was put in place for anti-tip devices for the front of the resident's wheelchair following the fall. When asked if the intervention of the anti-tip device was in place at the time of the 12/17/2019 fall; COTA-H confirmed they were not. When asked if the anti-tip device would have prevented 12/17/2019 fall, COTA-H confirmed the anti-tip device would have prevented the fall. When asked if the foot pedals were on the wheelchair at the time of the 12/17/2019 fall, COTA-H confirmed they were on the wheelchair at the time of the fall. COTA-H further explained that the resident was in the area of the kitchen and dining room where there is a rubber floor transition; the fall investigation concluded R46 was trying to maneuver over that transition and the chair tipped forward. 12/18/2019 at 8:30 AM, DON-B provided Surveyor with a plan the facility had now put in place to identify rapid maintenance needs such as fall interventions to include anti-tipping devices. When asked about weekend maintenance coverage, DON-B stated that they do have a maintenance worker on call. 12/18/2019 at 8:47 AM, Surveyor interviewed CNA-G related to R46's fall of 12/17/2019, who stated R46 was in the area between the unit's dining room and living room prior to breakfast and that CNA-G needed to go get a lift for another resident. CNA-G then proceeded to assist the other resident and when returned, saw R46 on the floor, wheelchair tipped over. CNA-G stated there was a work order put in on Sunday (12/15/2019) for R46's wheelchair to get anti-tippers. CNA-G stated, had that have been done, maybe R46 would not have had another fall. 12/18/2019 at 9:30 AM, Surveyor reviewed the medical record of R46 which included a clinical note dated 12/17/2019 7:15 PM related to the 12/17/2019 8:25 AM fall that stated, Root cause of fall was resident was trying to move wheelchair over floor divider between the kitchen and the living room, causing the wheelchair to tip forward.

Based on observation, interview and record review the facility did not provide pharmaceutical services to assure accurate administration of medications for 2 Residents (R) (R61 and R32) of 2 resident reviewed for self-administration of medication. R61 self-administered Nasogel nasal spray (used to relieve dry nose) without a physician's orders [REDACTED]. R32 self-administered [MEDICATION NAME] nasal spray (used to relieve symptoms such as sneezing and a runny, stuffy, or itchy nose and itchy, watery eyes caused by allergies [REDACTED]. R32 was observed self-administering [MEDICATION NAME] inhaler with incorrect technique. Findings include: Facility provided policy titled Medications Brought to Facility by Resident or Family Member stated, Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Facility provided policy titled Bedside Storage of Medications stated, The resident is instructed in the proper use of the bedside medications, including what the medication is for, how it is used, how often it may be used, proper cleaning of inhalers where applicable, proper storage of the medication, and the necessity of reporting each dose when used to the nursing staff. Further stated in this policy, All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Facility provided policy titled Self-Administration of Medications by Residents stated, If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 1) On 12/16/19 at 9:40 AM, Surveyor observed a bottle of nasal spray on R61's over-bed table. The bottle had a manufacturer's label which stated, [MEDICATION NAME] Nasogel for Dry Noses and had an expiration date of 7/2020. There was not a pharmacy label observed on the bottle. On 12/17/19 at 8:22 AM, Surveyor observed the same bottle of nasal spray on R61's over-bed table. On 12/17/19 at 12:44 PM, Surveyor interviewed R61 who indicated the bottle of nasal spray was brought from R61's home. R61 stated, My nose is so dry, my son brought it in for me. You put two squirts up your nose. It helps. On 12/17/19 at 12:54 PM, Surveyor reviewed R61's medical record. R61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R61's medical record did not contain a physician's orders [REDACTED]. On 12/17/19, Surveyor reviewed the manufacturer's information for [MEDICATION NAME] Nasogel found at the following website: http://shop.[MEDICATION NAME].com/Products/NasoGel-For-Dry-Noses/[MEDICATION NAME]-NasoGel-Drip-Free-Gel-Spray which stated, NasoGel Spray is a drug-free saline based water soluble nasal gel spray formulated with sodium hyaluronate to provide nasal moisture. Further reviewed in the Directions and Warnings section was Keep out of reach of children. Do not use for mouth dryness. Please do not discard the printed box. The inside final product may not have all the details you require for the ongoing use of the product. Do not use this product if you are allergic to any of the ingredients listed on the box. On 12/18/19 at 10:59 AM, Surveyor observed the same bottle of nasal spray on R61's over-bed table. There was not a box for the nasal spray observed in R61's room. On 12/18/19 at 1:13 PM, Surveyor interviewed DON (Director of Nursing)-B who indicated the expectation was that if staff see medications brought in from home they should report to nurse to get an order, get it labeled, and to assess for self-administration safety. DON-B verified facility had not completed a self-medication assessment for R61. 2) On 12/17/19 at 1:07 PM, Surveyor observed a bottle of [MEDICATION NAME] nasal spray on R32's over-bed table. In R32's hand was a [MEDICATION NAME] inhaler. Surveyor observed R32 take one puff of the [MEDICATION NAME] inhaler. R32 did not rinse and spit after the use of the inhaler. Surveyor interviewed R32 who stated, They (staff) keep in that locked drawer. I just call to have them (staff) to get it for me. They (staff) leave it here for me to use. On 12/17/19, Surveyor reviewed manufacturer recommendations for [MEDICATION NAME] inhaler from the manufacturer's website https://www.[MEDICATION NAME].com/ which stated, After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis (yeast infection of mouth and throat). On 12/17/19, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R61's medical record contained the following physician orders: - [MEDICATION NAME] HFA 220 mcg/actuation aerosol inhaler 2 Times Daily - [MEDICATION NAME] propionate 50 mcg/actuation nasal spray,suspension 1 Time Daily R32's medical record did not contain physician order [REDACTED]. On 12/18/19 at 10:44 AM, Surveyor interviewed RNMC (Registered Nurse Medicare Coordinator)-D who indicated a self-medication administration assessment was completed for R32 on admission but facility was unable to locate the documentation. RNMC-D further indicated a self-medication administration assessment was completed on 12/17/19 after Surveyor had requested assessment documentation and that R32 was assessed as safe to self-administer inhaler and nasal spray at bedside. 12/18/19 at 11:06 AM, Surveyor reviewed facility provided document for R32 titled Self Administration of Medication Decision and dated 12/17/19 which stated, If able to self-administer medication, state medication below: Medication Inhalers Other: [MEDICATION NAME] nasal spray, to keep at bedside. Wishes for all other medications to be given by nurse . Able to use inhaler as directed. Yes. On 12/18/19 at 12:24 PM, Surveyor observed R32 self-administer [MEDICATION NAME] inhaler in the presence of LPN (Licensed Practical Nurse)-E. LPN-E provided a spit-basin to R32. R32 stated, What's that for? LPN-E instructed R32 to rinse mouth with water after use of inhaler and spit into basin. On 12/18/19 at 12:34 PM, Surveyor interviewed R32 who indicated R32 normally does not rinse and spit after use of inhaler. R32 indicated R32 did the rinse and spit as observed above because the nurse reminded R32 and was watching. R32 further stated, Normally they (staff) leave and I do it (use inhaler) on my own. On 12/18/19 at 1:16 PM, Surveyor interviewed DON-B who indicated medications should not have been at R32's bedside without a may keep at bedside order. When questioned about self-medication administration assessment DON-B stated, (RNMC-D) said (RNMC-D) did assess on admission but didn't complete the form so the process was broken. (RNMC-D) said (RNMC-D) did re-assess yesterday and I assume (RNMC-D) educated (on rinse and spit recommendation) but I wasn't there.

Based on observation, record review, and staff interview, the facility did not assess for risk of entrapment for 1 Residents (R) (R24) of 16 sampled residents. R24 was observed with an assistive device on the right side of bed without the facility assessing R24's risk of entrapment. Findings include: R24 was admitted to the facility on [DATE]. R24's [DIAGNOSES REDACTED]. On 12/16/19-12/18/19, the Surveyor observed an assistive device connected to the right side of R24's bed. R24's record did not include an assessment by the facility to ensure R24 would not be at risk of entrapment related to the use of the assistive device. On 12/18/19 at 12:17 PM., the Surveyor interviewed DON (Director of Nursing)-B regarding R24's assistive device on right side of R24's bed. DON-B informed the Surveyor the facility does not complete an assessment for assistive device on the side of residents bed. DON-B stated they are added based on residents individual needs and if there was an injury they would then be removed.

Based on observation, staff interviews, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. STORAGE · Ice machine had black residue on the interior water curtain and along the door seal · Expired dairy was stored mixed with unexpired dairy and not marked to prevent service · Open, undated dairy was stored in the walk-in-cooler PREPARATION · Facial hair was not restrained · Used cleansing cloths were left on countertops between uses · Household mechanical warewashing machine (dishwashers) were not monitored for required wash and sanitation temperatures · Main kitchen dishwasher did not reach required utensil surface temperature to effectively sanitize · Hand Hygiene - dishwasher moved from dirty to clean dishes without washing hands · Hand Hygiene - cook taste tested food with bare hand and did not wash hands prior to continuing food preparation · Temperature monitoring after microwave reheating for hot holding was not accurate These practices had the potential to effect 75 of the 76 residents in the facility. (One resident tube fed.) Findings include: On 8/2/16 at 9:18 a.m., Dietary Manager (DM)-F indicated the facility kitchen utilizes the Wisconsin (WI) Food Code 2013 as its standard of practice. STORAGE - ICE MACHINE WI Food Code 2013 4-602.11(E) documents, Surfaces of utensils and equipment contacting food that is not potentially hazardous (time/temperature control for safety food) shall be cleaned: (4) in equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers .(a) At a frequency specified by the manufacturer, or (b) absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. Hoshizaki Owner's Manual documents, Hoshizaki recommends cleaning and sanitizing this unit at least twice a year. More frequent cleaning and sanitizing, however, may be required in some existing water conditions. On 8/2/16 during initial tour of the facility main kitchen beginning at 9:18 a.m., Surveyor observed, and Dietary Manager (DM)-F verified, black residue on the interior of the ice machine. The black residue ran the entire length of the top edge of the interior water curtain and extended down approximately 1/2 inch in width. Black residue was also present along the full length of the door seal under the area where the door seal meets the ice machine frame. At that time DM-F ran a finger along the surface where black residue was present. Black residue easily released from the surface and was present on DM-F's finger. STORAGE - EXPIRED DAIRY On 8/2/16 during initial tour of the facility main kitchen beginning at 9:18 a.m., Surveyor observed the following in the facility walk-in cooler: · 1 - fat free milk, 1 quart, manufacturer expiration dated 7/27/16 · 2 - fat free milks, 1 quart, manufacturer expiration dated 8/1/16 · 2 - 2% milk, 1 quart, manufacturer expiration dated 8/1/16 · 5 - Half & Half, 1 quart, manufacturer expiration dated 8/1/16 · 1 - fat free milk, 1/2 gallon, manufacturer expiration dated 7/30/16 and open dated 7/28/16 At the time of observation, Surveyor interviewed DM-F. DM-F indicated the dairy vendor rotates dairy for the facility each Tuesday and Thursday and removes expired stock. DM-F verified one fat free milk, expiration dated 7/27/16 was not removed by the vendor on the previous vendor visit date (7/28/16). DM-F also verified the expired products were mixed in with non-expired products in the same crate. DM-F indicated the staff have a process to tape a sign on a crate of expired products or place an X on the actual container of an expired product. DM-F verified neither process was present to assist staff in identifying expired products to be excluded from service while awaiting vendor pickup. DM-F indicated the 1/2 gallon of fat free milk, manufacturer expiration dated 7/30/16 and open dated 7/28/16 should have been removed from the walk-in cooler and discarded because an open item could not be returned to the vendor. STORAGE - OPEN, UNDATED DAIRY WI Food Code 2013 3-501.17(B) documents, Refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. On 8/2/16 during initial tour of the facility main kitchen beginning at 9:18 a.m., Surveyor observed in the following in the facility walk-in cooler: · 1 - chocolate milk, 1/2 gallon, open and undated · 1 - heavy whipping cream, 1/2 gallon, open and undated At the time of observation, Surveyor interviewed DM-F. DM-F verified the chocolate milk and heavy whipping cream were open and should be marked with an open date. DM-F was unable to locate an open date on either product container. PREPARATION - FACIAL HAIR RESTRAINTS WI Food Code 2013 2-402.11 documents, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens On 8/3/16 at 9:18 a.m., Surveyor entered the facility main kitchen and observed Dietary Cook (DC)-G preparing stuffed peppers. DC-G had facial hair on the chin that was not restrained/covered. At the same time, DC-K was preparing marinated skirt steaks. DC-K also had facial hair on the chin that was not restrained/covered. At 9:21 a.m., DC-K looked at Surveyor and immediately left the preparation area to get a beard restraint. At 9:28 a.m., Surveyor interviewed DC-K regarding beard restraints. DC-K said, I forgot to put on the restraint immediately upon starting and I just started. DC-K verified the kitchen expectation is to wear a beard restraint if you can pull the hair. On 8/8/16 at 1:16 p.m., Surveyor entered the facility main kitchen and observed DC-K preparing a chicken and cheese pasta bake. DC-K had facial hair on the chin that was not restrained/covered. At that time, Surveyor interviewed DC-K. DC-K said, I just got back from break. I forgot. At that time, DC-K put on a beard restraint. PREPARATION - CLEANSING CLOTHS WI Food Code 2013 3-304.14(B) documents, Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114 On 8/2/16 upon entering the facility main kitchen to begin initial tour at 9:18 a.m., Surveyor observed three damp cleansing cloths on food preparation surfaces. At 9:55 a.m., Surveyor interviewed DM-F regarding the three cleansing cloths which were still on preparation table surfaces. DM-F verified cleansing cloths are not to be left out. DM-F said, They (cloths) should be in (sanitizing) solution. On 8/3/16 at 1:21 p.m., Surveyor observed cleansing cloths placed on top of a wheeled insulated cart utilized to transport steam trays instead of in a bucket of solution. A bucket of solution was located in the kitchen approximately 15 feet from the cart. PREPARATION - MECHANICAL WAREWASHING MACHINE (DISHWASHER) TEMPERATURE MONITORING WI Food Code 2013 4-501.112(A) documents, In a mechanical operation, the temperature of the fresh hot water sanitizing rise as it enters the manifold may not be more than 90 degrees C /194 degrees F, or less than: (2) 82 degrees C/180 degrees F WI Food Code 2013 4-703.11 documents, After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in (B) Hot water mechanical operations . achieving a utensil surface temperature of 71 degrees C/160 degrees F as measured by an irreversible registering temperature indicator On 8/2/16 during initial tour of the facility main kitchen beginning at 9:18 a.m., Surveyor observed the facility monitoring log of internal surface temperatures for the main kitchen hot water sanitization dishwasher. The posted (August) log had three entries per day (one per meal). Surveyor noted the third entry for 8/1/16 documented a temperature of 154.2 degrees. At that time, Surveyor interviewed DM-F. DM-F verified the internal monitoring of surface temperature must reach 160 degrees F and the facility did not have information posted regarding the 160 degree F minimum temperature or what to do if 160 degree F temperature was not reached. DM-F indicated a managerial practice to check the dishwasher monitoring logs weekly and again at the end of the month when the logs were collected. DM-F indicated DM-F was not aware of the sub-160 degree F temperature prior to Surveyor pointing it out as it was not yet the end of the week. At that time, additional internal surface temperature monitoring logs were requested for June and July 2016. Monitoring logs for household dishwashers were requested. DM-F indicated the household dishwashers were hot water sanitizing machines but the facility did not have a practice to monitor the internal utensil surface temperatures. Facility monitoring logs revealed the following entries that recorded dishwasher utensil surface temperatures below 160 degree F (all temperatures in Fahrenheit): 6/6/16 - 158.7 6/7/16 - 153.3 6/9/16 - 159.0 6/10/16 - 159.0; 159.0; 159.6 6/11/16 - 159.1; 159.5; entry absent 6/12/16 - 158.3; 159.5 6/13/16 - 159.6 6/15/16 - 159.2 6/21/16 - 155.3 6/22/16 - 158.0; 158.0; 155.3 6/23/16 - 155.3; 155.3; 155.2 6/24/16 - 155.3; 155.3; 156.5 6/25/16 - 155.1; 154.9; 156.5 6/26/16 - 155.3; 155.4 6/28/16 - 158.2 7/1/16 - 159.6 7/2/16 - 159.6; 159.6; 156.2 7/3/16 - 159.6 7/4/16 - 159.5 7/5/16 - 158.9 7/6/16 - 158.9; 158.3 7/7/16 - 158.9; 159.2 7/9/16 - 156.2 7/12/16 - 156.3 7/15/16 - 157.2 7/18/16 - 153.5; 155.3 7/19/16 - 153.4; 154.1; 154.4 7/20/16 - 153.5; 156.7 7/21/16 - 156.7 7/25/16 - 151.8 7/26/16 - 155.1; 155.1; 154.9 7/27/16 - 155.2; 155.0 7/28/16 - 155.3; 149.1 7/31/16 - 159.9 8/1/16 - 154.2 On 8/3/16 at 9:37 a.m., DM-F verified the above dates were documented as utensil surface temperatures below 160 degrees F. At that time, DM-F was unable to provide information what actions were taken when the utensil surface temperature was below 160 degrees F. DM-F provided a Reinhart Foodservice Preventative Service report, dated 7/21/16, documenting the facility main dishwasher's maintenance check. The document includes wash tank, rinse tank, and final rinse temperatures. The internal utensil surface temperature is not documented on the report as part of the quality check. On 8/4/16 at 10:38 a.m., Surveyor observed the household 7 dishwasher display which read 174 degrees F rinse. At that time, Surveyor interviewed Housekeeper (H)-AA, who was in the kitchen. H-AA indicated the housekeeper runs dishes after each meal and explained being responsible to check the dishwasher is on, there are no blinking lights, the chemicals aren't empty, check for leaks, check the chemical cabinet is locked. H-AA denied checking or documenting temperatures of dishwashers. On 8/8/16 at 3:17 p.m., Surveyor interviewed Facility Manager (FM)-I who verified 2 of 8 household dishwashers were not reaching 180 degrees at the manifold. PREPARATION - HAND HYGIENE WI Food Code 2013 2-301.14 documents, When to Wash. Food employees shall clean their hands and exposed portions of their arms . (D) After . eating; (E) After handling soiled equipment or utensils On 8/8/16 at 1:16 p.m., Surveyor entered the facility main kitchen and observed DC-K putting food from a bare hand into DC-K's own mouth. DC-K did not wash hands and proceeded to empty a bag of unknown product into a mixer and then picked up a utensil to begin stirring chicken cheese pasta bake. At that time, Surveyor interviewed DC-K who indicated the food DC-K sampled with a bare hand was chicken cheese pasta bake. At that time, DC-K verified hands should be washed after taste testing without a utensil. On 8/8/16 at 1:18 p.m., Surveyor entered the main kitchen dishwasher area and observed Dishwasher (D)-H loading items into a tray entering the conveyor style dishwasher's dirty side. D-H did not wash hands and proceeded to the clean side to unload clean dishes. As D-H touched a clean steam tray, Surveyor stopped D-H for an interview. D-H indicated D-H had just loaded dirty glasses onto a tray entering the dishwasher. D-H verified hands should be washed when moving from dirty to clean. D-H then went and washed hands. PREPARATION - MICROWAVE REHEATING FOR HOT HOLDING WI Food Code 2013 3-403.11(B) documents, Potentially hazardous food (time/temperature control for safety food) reheated in a microwave oven for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees Celsius (C)/165 degrees Fahrenheit (F) and the food is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating On 8/8/16 at 5:45 p.m., Surveyor observed Certified Nursing Assistant (CNA)-J taking hot holding temperatures of food for supper meal service on household 8. The mixed vegetable's temperature was 132 degrees F. At that time, Licensed Practical Nurse (LPN)-O removed the vegetables from the steam tray and separated the contents into twp bowls. Each bowl was placed in the microwave in turn. After removal from the microwave, the vegetables were not covered and allowed to stand for two minutes prior to the temperature being taken.

Based on observation, record review and staff interviews, the facility did not ensure residents received the necessary treatment and services to prevent pressure injury development for 5 (Residents 6, 7, 11, 4, and 9) of 13 sampled residents reviewed for prevention of pressure injury. Resident 6 was assessed at risk for pressure injury development. Resident 6 was to wear heel boots and staff were to follow standard interventions for skin. Resident 6 was observed in bed with both heels placed directly on the mattress. Resident 7 was assessed at risk for pressure injury development. Resident 7 was to have a pressure redistribution cushion on all seated surfaces per facility standard of practice. Resident 7 was observed sitting on a foam cushion in the wheelchair and was observed sitting in a recliner without a pressure redistribution cushion on the seated surface of the recliner. The resident's heels were observed to be not free floating while in bed. Resident 11 was assessed at risk for pressure injury development. Resident 11 was to have a pressure redistribution cushion on all seated surfaces per facility standard of practice. Resident 11 was observed sitting in a recliner without a pressure redistribution cushion on the seated surface of the recliner. Resident 4 had a stage 3 pressure injury to the resident's right ischial tuberosity and was assessed to be at high risk for the development of pressure injuries. Resident 4 had a care plan intervention to include a Roho cushion (a cushion to relieve pressure) in the resident's wheelchair. Additionally, Resident 4 had a care plan intervention for a house barrier cream (a cream to protect skin against irritation) after each incontinence episode. Both care plan interventions were not consistently implemented. Resident 9 had a stage 2 pressure injury to the left ear, wore oxygen tubing around both ears and consistently laid on left side. The facility did not provide interventions to offload pressure to the ear when lying on the left side, provide pressure redistribution protection from the oxygen tubing, or initiate a therapy referral for additional interventions. Findings include: The Quick Reference Guide entitled, Pressure Ulcer Prevention, published by the NPUAP in 2009 indicated high pressures over bony prominences, for a short period of time, and low pressures over bony prominences, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure he/she is exposed to. Ensure that the heels are free of the surface of the bed. Heel protection devices should elevate the heel, completely off loading them. The second edition of Prevention and treatment of [REDACTED]. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called 'floating heels.' Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows. The Clinical Guideline, published by the NPUAP in 2009, entitled Pressure Ulcer Prevention encourages healthcare personnel to consider individuals who are bedfast and/or chair fast to be at risk of pressure ulcer development and to develop and implement a prevention plan when individuals have been identified at risk of developing pressure ulcers .Pressure redistribution seat cushions should be used for individuals sitting in a chair when mobility is reduced and who are thus at risk of pressure ulcer development. Different studies indicate the use of a pressure redistributing seat cushion prevents the development of pressure ulcers. The second edition published in 2014, entitled Prevention and treatment of [REDACTED]. Pressure redistributing support surfaces are designed to either increase the body surface area that comes in contact with the support surface (to reduce interface pressure) or to sequentially alter the parts of the body that bear load, thus reducing the duration of loading at any given anatomical site. Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced. Ensure that selection of a pressure redistributing seat cushion is appropriate to the individual. Provide complete and accurate training on use and maintenance of a seating support surface and cushion devices delivered to the individual. NPUAP (National Pressure Ulcer Advisory Panel) www.npuap.org Pressure Ulcer Prevention documents Risk Assessment: 10. Conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by the individual's condition. Reassessment should also be undertaken if there is any change in patient condition. Skin Assessment: 3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. 6. Observe the skin for pressure damage caused by medical devices. 2010 research indicates patients with a medical device were 2.4 times more likely to develop a pressure ulcer. NPUAP: MDRPU (Medical Device Related Pressure Ulcers): The Hidden Epidemic Across the Lifespan documents MDRPU occur because of: · rigidity & inelasticity of devices · difficulties in adjusting/securing to the body · may be difficult to safely remove/lift · prolonged pressure in the same place · altered microclimate with increased moisture and heat · tight securement · poor positioning or fixation of device · inappropriate size, selection · obscured skin from visualization · lack of awareness of [MEDICAL CONDITION] impact Practice: thorough skin assessment under devices Q (every) shift if not medically contraindicated; avoid replacing devices on injured skin as feasible; Ensure proper sizing (resize with [MEDICAL CONDITION]). Common MDRPU (Medical Device Related Pressure Ulcers): oxygen via Nasal Cannula Prevention Measures: · inspect skin under and around tubing at least q (every) 8-12 hrs · educate patients/family to inform staff of discomfort · clearly assign responsibility for assessment · document findings · use ear protectors on tubing (intervene early) · check strap tension · stock ear protectors close to nasal cannulas According to education provided by the Primary Care Dermatology Society, last updated November 23, 2014, [MEDICAL CONDITION] nodule helicus (Sleeper's Nodule) .is caused by a combination of pressure and a compromised local blood supply .in some patients this arises as a result of habitually sleeping on one side at night .Conservative measures should be the first line of treatment: Patients should be encouraged to avoid sleeping on the affected side and use foam pillows .Alternatively .can cut a hole out of foam, rubber or a bath sponge to fit around the ear at night and hold in place with an elastic headband. Examples: 1. Resident 6's electronic face sheet dated 8/8/16, indicated the resident was admitted to the facility with [DIAGNOSES REDACTED]. Resident 6's MDS (Minimum Data Set) quarterly assessment dated [DATE], documented the resident was assessed to score 3 of 15 on the cognitive screen (the higher the score, the more cognizant) and required extensive assistance from staff for bed mobility/transfers. Resident 6 did not ambulate and was at risk for the development of pressure injury. Resident 6 developed an unstageable pressure injury to the left great toe bone and a stage 1 pressure injury to the right great toe bone. The resident had a pressure reducing device for the bed and chair. Resident 6's Braden Scale for Predicting Pressure Sore Risk, dated 8/3/16, indicated the resident scored a 13. A score of 13 indicated Resident 6's risk level for the development of pressure injury was moderate. According to the Braden Scale assessment, Resident 6 is chair fast and the ability to change and control body position is very limited. Resident 6's current CAA (Care Area Assessment) dated 4/5/16, indicated the resident triggered due to extensive assist of one to two staff needed for bed mobility related to a [DIAGNOSES REDACTED]. Once in bed, Resident 6 is able to reposition self somewhat with staff assistance. The resident has a pressure redistribution mattress on bed and cushion in seat of chair. Resident 6's current plan of care with a goal date of 9/28/16, indicated the resident was at risk of developing pressure injury. The care plan indicated the resident had a history of [REDACTED]. The care plan interventions included heel boots folded over to prevent pressure to toes and to follow standard interventions for skin. Additionally, the care plan indicated the resident had impaired mobility and interventions included a pressure redistribution cushion on all seated surfaces. On 8/2/16 at 3:15 p.m., Surveyor observed Resident 6 laying in bed with blue boots on. There was a pillow placed under the resident's legs and both heels were placed directly on the mattress, not free floating. On 8/3/16 at 1:45 p.m., Surveyor observed CNA (Certified Nursing Assistant)-S and CNA-U transfer Resident 6 from the wheelchair to the bed using a sit to stand lift. After the heel boots were placed on the resident's feet and a pillow was placed under the resident's legs, CNA-S verified the resident's right heel was placed directly on the mattress. CNA-U adjusted the pillow and free floated the resident's right heel after Surveyor questioned the placement of the right heel. 2. Resident 7's electronic face sheet, dated 8/8/16, indicated the resident was admitted to the facility with [DIAGNOSES REDACTED]. Resident 7's MDS significant change assessment dated [DATE], documented the resident was assessed to score 8 of 15 on the cognitive screen (the higher the score, the more cognizant) and required extensive assist with transfers/bed mobility. Resident 7 did not ambulate and was at risk for the development of pressure injury. The resident had a pressure reducing device for bed and chair. Resident 7's Braden Scale for Predicting Pressure Sore Risk, dated 8/1/16, indicated the resident scored a 13. A score of 13 indicated Resident 7's risk level for the development of pressure injury was moderate. According to the Braden Scale assessment, Resident 7 is chair fast and the ability to change and control body position is very limited. Resident 7's current CAA dated 5/31/16, indicated the resident triggered due to being at risk for skin breakdown related to decreased mobility. Extrinsic risk factors included needing staff assistance to move sufficiently to relieve pressure over any one site, confined to bed or chair all or most of the time, and needing a special mattress or seat cushion to reduce/relieve pressure. Resident 7's current plan of care with a goal date of 8/31/16, indicated the resident was at risk of pressure injury development related to decreased mobility and history of [MEDICAL CONDITION] with right sided weakness. Care plan interventions included the use of bilateral heel boots when in bed, if refuses boots, heel riser on bed. Additional intervention included an air mattress on bed and cushion in wheelchair. On 8/2/16 at 3:16 p.m., Surveyor observed Resident 7 laying in bed on back with the heels up device under legs and both heels placed directly on the mattress. On 8/3/16 from 10:43 a.m. to 1:00 p.m., Surveyor observed Resident 7 sitting in the wheelchair on a foam cushion covered with a white/black pillowcase. On 8/3/16 at 1:01 p.m., Surveyor observed CNA-S and CNA-T take a full mechanical lift to Resident 7's room. CNA-S and CNA-T verified the resident had been sitting in the wheelchair on the foam cushion covered by a pillowcase since getting up this morning. At 1:17 p.m., after placing heel boots on resident's feet, CNA-T placed the heel riser under the resident's legs. The right heel boot was then placed up against the resident's left inner ankle area and the left heel inside the boot was placed directly on the heel riser. After Surveyor interviewed staff regarding the placement of the heels, CNA-T adjusted the resident's heels. On 8/8/16 from 3:38 p.m. to 4:36 p.m., Surveyor observed Resident 7 sitting in a recliner without a pressure redistribution cushion on the seated surface of the recliner. At 4:40 p.m., CNA-V and CNA-W attached the resident to a full mechanical lift to transfer. CNA-V verified the resident was not sitting on a pressure redistribution cushion in the recliner and was not aware the resident needed a cushion while seated in the recliner. After cares were completed at 4:54 p.m., CNA-V and CNA-W transferred the resident to the wheelchair that had a foam cushion on the seated surface. Surveyor observed the resident sitting in the wheelchair on the foam cushion from 4:54 p.m. to 6:12 p.m. when transferred to bed. On 8/8/16 at 6:56 p.m., Surveyor interviewed RN/WCC (Registered Nurse/Wound Care Certified)-A regarding Resident 7. RN/WCC-A verified the resident was sitting on a foam cushion covered with a pillowcase rather than a pressure redistribution cushion. RN/WCC-A then stated the foam cushion is not a good cushion for the resident to be sitting on and the resident shouldn't have a pillowcase over the cushion either. RN/WCC-A verified Resident 7 should have a pressure redistribution cushion when seated in the recliner. Surveyor also interviewed RN/WCC-A regarding the standard of practice followed by the facility related to pressure injury prevention. RN/WCC-A verified the facility follows the current NPUAP guidelines for the prevention and treatment of [REDACTED]. On 8/9/16 at 9:55 a.m., Surveyor observed Resident 7 laying in bed with boots on and the heels placed directly on the mattress. The heel riser was against the wall in the room. On 8/9/16 at 10:38 a.m., Surveyor interviewed RN/UM (Registered Nurse/Unit Manager)-B regarding the placement of Resident 7's heels while in bed. RN/UM-B verified placement of heels as above and indicated staff had been educated on how to free float heels with the use of the heel riser. 3. Resident 11's electronic face sheet, dated 8/9/16, indicated the resident was admitted to the facility with [DIAGNOSES REDACTED]. Resident 11's MDS quarterly assessment dated [DATE], documented the resident was assessed to score 7 of 15 on the cognitive screen (the higher the score, the more cognizant) and required extensive assist with transfers/bed mobility. Resident 11 did not ambulate,was at risk for the development of pressure injury and had one stage 3 pressure injury present on admission. The resident had a pressure reducing device for bed and chair. Resident 11's Braden Scale for Predicting Pressure Sore Risk, dated 8/5/16, indicated the resident scored a 16. A score of 16 indicated Resident 11 was at risk for the development of pressure injury. According to the Braden Scale assessment, Resident 11 is chairfast and the ability to change and control body position is slightly limited. Resident 11's current CAA dated 10/20/15, indicated the resident triggered due to admission with a stage 3 pressure injury to coccyx area. Extrinsic risk factors included needing staff assistance to move sufficiently to relieve pressure over any one site, confined to bed or chair all or most of the time and needing a special mattress or seat cushion to reduce or relieve pressure. Resident 11's current plan of care with a goal date of 9/28/16, indicated the resident had impaired skin integrity related to stage 3 pressure injury on coccyx. Care plan interventions included an air mattress on bed and Roho cushion in chair. On 8/8/16 at 6:36 p.m., Surveyor observed CNA-V transfer Resident 11 from the toilet to the recliner that did not have a pressure redistribution cushion on the seated surface with a sit to stand lift. At 6:46 p.m., Surveyor interviewed CNA-V who verified the resident does not sit on a pressure redistribution cushion while in the recliner, only in the wheelchair. On 8/8/16 at 6:56 p.m., Surveyor interviewed RN/WCC-A regarding Resident 11. RN/WCC-A verified Resident 11 should have a pressure redistribution cushion when seated in the recliner. On 8/9/16 at 9:59 a.m., Surveyor observed Resident 11 sitting in the recliner that did not have a pressure redistribution cushion on the seated surface of the recliner. At 10:31 a.m., Surveyor interviewed CNA-X regarding the use of a pressure redistribution cushion while the resident is sitting in the recliner. CNA-X verified the resident is suppose to have a pressure redistribution cushion on the seated surface of the recliner. CNA-X indicated education was provided this morning regarding the use of cushions in recliner, but CNA-X spaced out and did not put the cushion on the seated surface of the recliner for Resident 11. CNA-X also verified the resident had been sitting in the recliner since finishing breakfast about an hour ago. 4. On 8/2/16, Surveyor reviewed the medical record of Resident 4. The medical record indicated Resident 4 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 4's quarterly MDS assessment dated [DATE], documented the resident was non-ambulatory, required extensive assistance from staff to transfer and perform bed mobility, and was frequently incontinent of bladder. Additionally, the MDS indicated Resident 4 was at risk for the development of pressure related injuries and had one stage 3 pressure injury. A Braden pressure ulcer risk assessment dated [DATE], indicated Resident 4 was at high risk for the development of pressure injuries. The 10/14/15 Care Area Assessment (CAA) for pressure injuries documented the following summary: (Resident 4) is at risk for skin breakdown related to decreased mobility, bowel and bladder incontinence, requiring extensive assist with ADL's (Activities of Daily Living). Has a pressure redistribution mattress on bed and cushion in seat of chair. Skin checked daily with cares, weekly with bath, and skin assessments done based on the Braden score. Will proceed with care plan. The current skin integrity plan of care for Resident 4 dated 6/29/16, indicated Resident 4 had alteration in skin integrity due to decreased mobility, [MEDICAL CONDITION], incontinence, chronic MAD (Moisture Associated [MEDICAL CONDITION]). The care plan included the following interventions: Roho cushion in wheelchair must follow Resident 4 from seated surface to seated surface, peri-care after incontinence, house barrier cream applied, keep clean and dry . A Wound Measurement form dated 8/1/16, indicated Resident 4 had a stage 3 pressure injury on the resident's right ischial tuberosity that measured 2.20 cm (centimeters) by 3.30 cm by 0.10 cm in depth. On 8/3/16 at 8:15 a.m., Surveyor observed CNA-E provide cares for Resident 4. CNA-E transferred Resident 4 from the bed to the bathroom with a mechanical lift. CNA-E verified Resident 4 had been incontinent of urine in the disposable brief. CNA-E provided incontinence cares, placed a new disposable brief on the resident, and transferred the resident into the wheelchair without a Roho cushion. Additionally, CNA-E did not apply house barrier cream to Resident 4. On 8/3/16 from 8:25 a.m. until 9:50 a.m., Surveyor observed Resident 4 sitting up in the wheelchair, without a Roho cushion in the wheelchair seat. On 8/3/16 at 9:45 a.m., Surveyor spoke with RN/WCC (Registered Nurse/Wound Care Certified)-A regarding Resident 4. RN/WCC indicated, Resident 4's current plan of care included the use of a Roho cushion in the resident's wheelchair seat. RN/WCC-A verified Resident 4 did not have a Roho cushion placed in the wheelchair seat. RN/WCC-A stated, I will get a Roho cushion now and make sure the Roho cushion is placed in the wheelchair seat. On 8/3/16 at 9:50 a.m., Surveyor observed CNA-E transfer Resident 4 from the wheelchair to the bathroom with a mechanical lift. CNA-E verified Resident 4 had been incontinent of urine in the disposable brief. CNA-E provided incontinence cares, placed a new disposable brief on the resident, and transferred the resident into bed. CNA-E did not apply house barrier cream to Resident 4. On 8/3/16 at 1:50 p.m., Surveyor interviewed CNA-E regarding the above observations. CNA-E verified she did not place a Roho cushion in Resident 4's wheelchair seat and did not apply barrier cream to the resident. CNA-E stated, I forgot. On 8/3/16 at 3:55 p.m., Surveyor interviewed RN/WCC-A. RN/WCC-A verified the house barrier cream was a part of Resident 4's current plan of care and should have been applied after every incontinence episode. 5. On 8/4/16 Surveyor reviewed Resident 9's medical record. The 5/2/16 MDS (Minimum Data Set) assessment showed the resident's 5/2/16 BIMS (Brief Interview for Mental Status) score was 3 (severely impaired) and indicated the resident was dependant upon staff for extensive assistance with bed mobility, activities of daily living and utilized oxygen therapy. The 7/3/16 Braden assessment score was 14, which indicated the resident was at risk for the development of pressure injury. Resident 9's plan of care, last updated 8/4/16, indicated the resident had multiple [DIAGNOSES REDACTED]. The plan of care indicated the pressure ulcer appeared as a nodule to left ear that had rubbed off and scabbed over, area reopened. Prefers to lay on left side despite education. An 8/4/16 entry reported: skin fragile and closed to left ear. The 8/2/16 physician progress notes [REDACTED].sleeper's nodule on the left outer helix of left pinna (ear) .is being positioned on right by staff. The CNA (Certified Nursing Assistant) Sheet dated 8/5/16, included the following instructions to staff: · Encourage to lay on back and right side due to pressure injury to left ear. · Oxygen Nasal Cannula; Oxygen 1 Liter On 8/3/16 at 9:20 a.m., 10:00 a.m., and 11:00 a.m., Surveyor observed Resident 9 lying on resident's left side in bed with ear directly on pillow. On 8/3/16 at 11:00 a.m., CNA-FF confirmed to Surveyor that Resident 9 had a dressing on the left ear and liked to lay on the left side. CNA-FF assisted the resident to position off of the left side and verified the resident's left ear dressing was in place, with oxygen tubing behind the left ear and without an ear protector. On 8/3/16 at 11:30 a.m., Surveyor observed Resident 9 lying on the left side in bed with left ear directly on pillow, and oxygen tubing in place behind left ear with no ear protection on tubing. On 8/3/16 at 11:32 a.m., Surveyor interviewed RN (Registered Nurse)-C, who confirmed Resident 9 was at risk for pressure injury and had an open, stage 2 pressure injury to the left ear. RN-C indicated an intervention of a foam dressing had been placed on the injury for protection from pressure, and confirmed the resident had nasal cannula tubing around the ears most of the time and laid primarily on left side, despite staff attempts to position the resident on back, or right side. On 8/3/16 at 12:35 p.m., Surveyor observed a dressing to the upper edge of the resident's left ear. No ear protection was on the nasal cannula oxygen tubing. On 8/8/16 at 9:15 a.m., Surveyor observed Resident 9 without a foam ear dressing or ear protection around oxygen tubing during care provided by LPN-GG. On 8/8/16 at 9:30 a.m., after leaving the resident's room, LPN-GG confirmed to Surveyor that Resident 9's left ear injury was no longer open so the pressure injury was open to air and no longer had a foam dressing for protection. Surveyor asked LPN-GG what preventative interventions were in place to protect the ear from re-opening. LPN-GG verified We put foam (ear protectors) on the tubing to protect the ear from pressure injury (from pressure caused by the oxygen tubing/medical device). On 8/8/16 at 9:35 a.m., CNA (Certified Nursing Assistant)-HH confirmed to Surveyor , while observing Resident 9 that the resident did not have a foam dressing, or foam on oxygen (nasal cannula) tubing. CNA-HH verified foam tubing protectors were not listed as an intervention on the resident's care sheet, none were located in the resident's room and would need to be provided by the nurses. On 8/8/16 at 4:55 p.m., Surveyor observed Resident 9 with ear protection in place behind ears on the oxygen tubing. CNA-II verified the protectors were placed earlier that day after asking the nurse for them. On 8/8/16 at 6:00 p.m., Surveyor interviewed RN/WCC (Registered Nurse/Wound Care Certified)-A who confirmed Resident 9's left ear wound was due to a nodule that opened and verified a foam dressing had been placed on the wound, which would remain on for protection even though the wound was now closed. RN/WCC-A reported being unaware the foam dressing had been removed from the resident's ear. On 8/9/16 at 8:40 a.m., Surveyor observed Resident 9 in wheelchair with left ear dressing and ear protectors on oxygen tubing. On 8/9/16 at 8:50 a.m., RN/WCC-A indicated to Surveyor that Resident 9's pressure injury was from a sleeper's nodule, not from oxygen tubing on the ear. RN/WCC-A indicated the sleeper's nodule opened up and developed into a stage 2 pressure injury. RN/WCC-A reported to Surveyor that sleeper's nodules come with age and indicated the resident frequently lies on left side (putting pressure on the ear) despite education to stay off of the left side. RN/WCC-A then verified Resident 9 was elderly, frail, and has severely impaired cognition and added that ear protection would be protective and helpful. At 11:45 a.m. on 8/9/16, RN/WCC-A confirmed that lying on the left ear was a component of pressure which caused Resident 9's ear wound to advance to a stage 2. RN/WCC-A verified repositioning, education, the ear dressing and more recently, ear protectors on the oxygen tubing were the only interventions used to prevent or manage this pressure injury, adding (Resident 9) needs a therapy referral to see what they can do to help offload the ear and confirmed a referral had not yet been made.

Based on observation, staff and resident interviews, and record reviews the facility did not store, prepare, serve, and distribute food under sanitary conditions. The facility did not cook unpasteurized eggs to appropriate temperatures to prevent the potential for food borne illness for 1 out of 8 households with the potential for harm to 1 (resident #9) of 11 residents on that unit (unit 8). The serving of undercooked, unpasteurized eggs created a potential for salmonella poisoning and resulted in a finding of Immediate Jeopardy. The facility was officially notified of this finding on 6/3/15. The Immediate Jeopardy was removed on 6/3/15; however the deficient practice continues at a scope and severity level of F (potential for harm/widespread). The facility still needs to address the additional food sanitation issues, as evidenced below. The facility did not ensure proper holding temperatures of hot food at 135 degrees F (Fahrenheit) or higher on 8 of 8 units, which had the potential to affect all 73 residents in the facility. The facility did not use chemicals at a safe distance from food being prepared in the main kitchen, which had the potential to affect all residents that ate the chicken that was being prepared. The facility did not ensure Quat (Quaternary) sanitizing spray solution that is used to sanitize food prep areas reached the appropriate 200 ppm (parts per million) to adequately sanitize the surface. In addition, staff did not allow the chemical to air dry, which had the potential to affect all 73 residents in the facility. The facility did not maintain food and storage prep areas in a clean condition and did not ensure food pans were appropriately cleaned, which had the potential to affect all 73 residents in the facility. The facility did not ensure proper labeling and dating of food in 2 of 8 unit refrigerators. The facility did not ensure dietary staff wore proper beard and mustache restraints in food prep areas of the main kitchen, which had the potential to affect all 73 residents in the facility. Findings include: POTENTIAL FOR FOOD BORNE ILLNESS: IMPROPER COOKING OF UNPASTEURIZED EGGS - IMMEDIATE JEOPARDY. 1. The facility did not prepare unpasteurized eggs in a manner to prevent the potential for food borne illness in 1 of 8 households for 1 of 11 residents. The facility served two unpasteurized poached eggs with a runny center to resident #9 on Unit 8 on 6/1, 6/2, and 6/3/15 and did not have a method to test the temperature of the eggs before serving them. A State of Wisconsin memo dated 8/31/10, sent to all facilities, indicated: Epidemiological outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in retail and food service establishments as contributing to foodborne illness: improper holding temperatures, inadequate cooking, such as undercooking raw shell eggs, contaminated equipment, food from unsafe sources. According to the Centers for Disease Control, Salmonellosis is an infection with bacteria called Salmonella. Most persons infected with Salmonella develop diarrhea, fever, and abdominal cramps 12 to 72 hours after infection. The illness usually lasts 4 to 7 days, and most persons recover without treatment. However, in some persons, the diarrhea may be so severe that the patient needs to be hospitalized . In these patients, the Salmonella infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics. The elderly, infants, and those with impaired immune systems are more likely to have a severe illness. The 2013 FDA (Food and Drug Administration) Food Code states there are special requirements when serving a highly susceptible population: * Highly susceptible population means persons who are more likely than other people in the general population to experience forborne disease because they are: (1) Immunocompromised: preschool age children, or older adults and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center. * Unless pasteurized, soft-cook eggs are not to be served to a highly susceptible population. * .highly susceptible populations have increased vulnerability to foodborne illness. For example, foodborne illness in a healthy individual may be manifested by mild flu-like symptoms. The same foodborne illness may have serious medical consequences. * Salmonella (a harmful pathogen found in eggs) often survives traditional preparation techniques. It survives in a lightly cooked omelet, French toast, stuffed pasta, and meringue pies. In 1986 there was a large multistate outbreak of Salmonella Enteritidis traced to stuffed pasta made with raw eggs and labeled fully cooked. Eggs remain a major source of these infections, causing large outbreaks when they are combined and undercooked as was the case in the 1986 outbreak linked to stuffed past. Therefore, special added precautions need to be in place with those most susceptible to foodborne illness. * Employees are to be particularly careful in cooking those foods known to cause severe foodborne illness and death, such as eggs. ServeSafe 6th edition based on the 2013 FDA Food Code indicates shell eggs that will be served immediately must have a minimum internal cooking temperature of 145 degrees F for 15 seconds and 165 degrees F if cooked in a microwave oven. Check the food in two places to make sure that the food is cooked through. Example: From 6/1/15 through 6/4/15, surveyor # reviewed the facility dining practices and food preparation for this facility. This facility has a main kitchen with a kitchenette on each of its eight units/pods. Breakfast meals are made to order on units 1, 2, 3, 4, 7, and 8. The Rehab units 5 and 6 receive breakfast from the main kitchen. The breakfast morning cook on unit 8, Cook-P also functions as the unit's housekeeper. On 6/1/15 at 8:50 a.m., during the initial tour of the kitchen, surveyor # interviewed CSM (Culinary Services Manager)-J. CSM-J stated the facility followed the Federal Food Code as their Standard of Practice and the ServeSafe 6th edition. CSM-J showed surveyor # that white eggs with a P indicated the eggs were pasteurized and were used on the resident units. CSM-J stated the brown non-pasteurized eggs were used in baking. In addition, CSM-J indicated all food was procured from Reinhardt Food Services. On 6/3/15 at 8:45 a.m., surveyor # observed breakfast preparation on Unit 8, where a pallet of brown eggs was noted on the counter next to the frying pan. Cook-P informed surveyor # that she had prepared eggs for residents #9 and #16 from this pallet of brown eggs. Resident #9 had finished eating the eggs that were served to the resident and resident #16 was noted eating scrambled eggs, which appeared to be firmly cooked. Cook-P stated she cooked resident #16's eggs until they were solid and had cooked two poached eggs for resident #9, which were runny. Cook-P stated resident #9 always eats one to two poached eggs per day. Cook-P indicated that the eggs are usually white with a P on them, but wasn't sure what the P stood for. Cook-P stated there were white eggs on the unit last week through Friday, but when she came back to work on Monday, June 1st, the brown eggs were on the unit. Cook-P confirmed she had cooked poached eggs, using the brown eggs and served them to resident #9 on 6/1/15, 6/2/15 and 6/3/15. Cook-P stated she cooked them for 25 seconds in the microwave and then cooked them an additional 25 seconds in the microwave. Cook-P confirmed she did not take a temperature of the scrambled or poached eggs that were cooked using the brown eggs, stating never have. On 6/3/15 at 9:03 a.m., surveyor # interviewed CSM-J regarding the use of brown eggs on unit 8. CSM-J confirmed the brown eggs were unpasteurized and should never have been taken to unit 8, as they were only to be used in baking and should never be used to cook eggs for residents because of the danger of illness. CSM-J removed the remaining brown, unpasteurized eggs from unit 8. Surveyor # and CSM-J then checked units 1, 2, 3, 4, 5, 6, and 7, and only white pasteurized eggs in use on these units. On 6/3/15, surveyor # reviewed resident #9's medical record. The resident's MDS (minimum data set) assessment dated [DATE], documented the resident had moderate cognitive impairment and was admitted on [DATE]. On 6/3/15 at 10:00 a.m. and 10:48 a.m., surveyor # interviewed resident #9. Resident #9 stated (resident) ate 2 poached eggs every day since admission and indicated the yolks are runny when (resident) eats them. On 6/3/15 at 10:20 a.m., surveyor # interviewed Cook-P regarding the poached eggs that she prepared. Cook-P confirmed that only resident #9 ate poached eggs. Cook-P stated she is also the housekeeper and did not receive training in the kitchen and was not aware that there was a difference in white eggs with a P and brown eggs. Cook-P indicated there were no thermometers on the units to take temperatures and that she had not taken any temperatures of any food cooked or served when she worked as the cook. On 6/3/15 at 10:50 a.m., Cook-P demonstrated the cooking of poached eggs in the microwave for surveyor # . Using a dessert bowl that was approximately 4 inches round, Cook-P cracked two eggs and placed them in the bowl and then filled the bowl with water from the tap. Cook-P poked each egg once, without breaking the yolk. Cook-P then placed the bowl of raw eggs in water into the microwave and cooked it for 25 seconds in an 1100 watt microwave. Then immediately after the 25 seconds were complete, cooked the eggs for an additional 25 seconds. After the eggs cooked for a total of 50 seconds, Cook-P indicated this is how she cooked and served the poached eggs to resident #9. Surveyor # immediately checked the temperature of the poached eggs to be 134 degrees F at the center. Cook-P verified the temperature of the eggs to be 134 degrees F. The appearance of the poached eggs had a white to clear congealed mucous on the bottom of the eggs, with the top being white and a runny pourable yolk. Cook-P then informed surveyors # and # that she did not have any training in how to cook poach eggs or take temperatures of the eggs. On 6/3/15 at 11:50 a.m., surveyor # interviewed NHA (Nursing Home Administrator)-H regarding taking food temperatures on the units. NHA-H indicated trained kitchen staff were taking food temps on all units until all staff could be trained. During an additional interview with NHA-H at 1:30 p.m., NHA-H indicated training was in progress and only trained staff would be allowed to cook and take temperatures on the units at this time. NHA-H indicated managers were recording attendance at the staff trainings and were completing monitoring. On 6/4/15 at 8:00 a.m., during an interview with surveyor # , CSM-J indicated thermometers were now on each unit as of 6/3/15, to record serving temperatures and temperatures of food being cooked. CSM-J indicated all non-pasteurized eggs were removed from the building as of 6/3/15, so no error could occur again. CSM-J indicated staff were trained in the difference between pasteurized and non-pasteurized eggs, how to take food holding and cooking temperatures, what those temperatures needed to be, and how to keep a temperature log. On 6/4/15, surveyors # , # , # , and # observed staff on units 1 through 8, taking and recording temperatures of food and using only pasteurized eggs. Interviews with staff confirmed they had received the training on 6/3/15. The source of the immediate jeopardy, non-pasteurized eggs, were removed from the facility on 6/3/15. In addition, NHA-H provided surveyor # a copy the facility's removal plan that included: 1. All nonpasteurized eggs pulled from the facility and only pasteurized eggs to be used starting 6/3/15. 2. Dining Services staff will be temping all food on the Household units until Household staff are trained. 3. All Health Center Household staff will be trained on temping foods and acceptable temperature by 6/4/15. 4. All food will be temped before serving. 5. All Health Center staff will be trained on needed food temperatures for reheating. 6. All Health Center staff will be provided handouts of above information and it will be posted on all units. 7. Logs provided to record all temps. Leadership staff will be responsible for monitoring logs. HOLDING FOOD TEMPS Example: ServeSafe 6th edition based on the 2013 FDA Food Code, indicates to hold hot food at an internal temperature of 135 degrees F or higher. Hold cold food at an internal temperature of 41 degrees F or lower. Hot food that is held below 135 degrees F can be reheated and placed back in the hot-holding unit. Use a thermometer to check temperatures. Never use the temperature gauge on a holding unit to do it. It does not check the internal temperature of the food. 1. On 6/2/15 at 12:15 p.m., surveyor # observed the food service for unit 2. UC (Unit clerk/cook)-N began food service to residents on this unit from the steam table without taking food temperatures. Surveyor # interviewed UC-N at that time regarding taking food temperatures. UC-N indicated she wasn't taking the temperature of the food because they do that in the main kitchen. UC-N indicated she use to work in the kitchen and knew how to take the temperatures. UC-N indicated she thought chicken had to be at least at 130 degrees F to serve and if other food was over 120 degrees F, it should be okay to serve. At that time, UC-N took the following temperatures: ~ chicken cacciatore was 138 degrees F ~ mashed potatoes were 140 degrees F ~ mixed vegetables were 120 degrees F ~ rice was 140 degrees F ~ hamburger patties were 140 degrees F. UC-N began serving the mixed vegetables onto plates when surveyor # informed her all food temperatures need to be held at 135 degrees F or above to serve. UC-N stated she was not aware of that. The mixed vegetables were then heated to the proper temperature before served. The unit did not have food temperature logs available for surveyor # to review. 2. On 6/3/15 at 8:08 a.m., surveyor # observed food service observed the food service for unit 5. RA (Resident Assistant)-O began food service to residents on this unit from the steam table that had been delivered from the main kitchen without taking food temperatures. Surveyor # asked if she could take the temperatures of the food. RA-O indicated she didn't think they needed to take temperatures of the food because it came from the kitchen. RA-O indicated she did not have a thermometer on unit 5 to take the temperatures. RA-O served all the residents their meals while calling to the kitchen to get a thermometer. At 8:25 a.m., CSM-J brought a thermometer to unit 5 and RA-O took the following food temperatures: ~ omelettes were 144.6 degrees F ~ poached eggs were 108 degrees F ~ oatmeal was 165 degrees F. CSM-J confirmed the food temperatures should be 145 degrees F to serve. CSM-J indicated only pasteurized eggs were used in preparing the foods that are cooked in the main kitchen. The unit did not have food temperature logs available for surveyor # to review. 3. On 6/3/15 at 8:30 a.m., surveyor # observed food service for unit 6. CNA (Certified Nursing Assistant)-Q began food service to residents on this unit from the steam table that had been delivered from the main kitchen without taking food temperatures. Surveyor # asked if she could take the temperatures of the food. CNA-Q indicated that the kitchen takes the food temperatures and she has never taken the temperatures from the steam table before serving the food. CNA-Q obtained the food temperatures and they were all 144.5 degrees F or higher and appropriate for serving. The unit did not have food temperature logs available for surveyor # to review. 4. On 6/3/15 at 8:45 a.m., surveyor # observed food service for unit 8. Unit 8 had a pallet of brown eggs on the counter next to the frying pan. Cook-P told surveyor # she had prepared eggs for residents #9 and #16 using the eggs from this pallet of brown eggs. Resident #9 had finished eating the poached eggs served and resident #16 was noted eating scrambled eggs which appeared to be firmly cooked. Cook-P said she cooked resident #16's eggs until they were solid and had cooked two poached eggs for resident #9 which were runny. Cook-P stated resident #9 always eats one to two poached eggs every day. Cook-P verified she did not take the temperature of the scrambled or poached eggs that she served, stating never have. On 6/3/15 at 10:20 a.m., surveyor # interviewed Cook-P regarding taking the temperature of foods served. Cook-P stated there were no thermometers on the units to take food temperatures and she has never taken food temperatures of food she cooked and/or served when she worked as the cook. The unit did not have food temperature logs available for surveyor # to review. On 6/4/15 at 8:00 a.m., surveyor # interviewed CSM-J regarding staff taking food temperatures on the units. CSM-J stated staff had not been taking food temperatures or kept food temperature logs until 6/3/15. CSM-J stated all units now have thermometers, alcohol swabs for cleansing the thermometer in between foods and food logs. SANITATION AND SAFE USE OF CHEMICALS IN FOOD PREP AREAS ServeSafe 6th edition based on the 2013 FDA Food Code indicates to sanitize to reduce pathogens on a surface to safe levels. Food-contact surfaces must be sanitized after they have been cleaned and rinsed and allowed to air dry. This can be done by using heat or chemicals. ~ Several factors influence the effectiveness of chemical sanitizers. The most critical include concentration, water temperature, contact time, water hardness, and pH. Concentration is measured in ppm (parts per million). Sanitizer concentration for Quats, as per manufacturer's recommendation of 200 ppm or above. The facility did not use chemicals at a safe distance from food being prepared in the main kitchen which had the potential to affect all residents who ate the chicken being prepared. The facility did not ensure Quat sanitizing spray solution used to sanitize food prep areas reached the appropriate 200 ppm to adequately sanitize the surface and did not allow the chemical to air dry which had the potential to affect all 73 residents in the facility. 1. On 6/2/15 at 8:30 a.m., surveyor # observed DA (Dietary Aide)-K preparing/cutting melon on a food prep surface. DA-K indicated that when she is done she would sanitize the food prep table by spraying with Quat sanitizer solution from the spray bottle and then wipe with a cloth to dry. On 6/2/15 at 9:30 a.m., Cook-M was observed preparing raw chicken for baking. After placing the raw chicken onto a pan on the counter, Cook-M began to sanitize the food prep sink with the Quat sanitizer solution. While Cook-M was spraying the sink with the Quat sanitizer solution, surveyor # noted a fine mist of the spray rising from the sink. The pan of raw chicken was approximately 4 inches from the edge of the sink that Cook-M was sanitizing with the Quat solution. After allowing the Quat solution remain of the surface of the sink, Cook-M wiped out the sink with a towel. At that time, surveyor # interviewed Cook-M regarding the practice of spraying the Quat solution near the raw chicken that was placed in a pan, Cook-M indicated he was careful to spray the Quat solution into the sink and didn't think any of the Quat solution that was sprayed got onto the raw chicken. Cook-M confirmed that he always wipes down the prep areas with a towel after sanitizing them. On 6/2/15 at 9:45 a.m., surveyor # reviewed the instructions on the ProPower Quaternary Sanitizer solution bottle with Cook-M. Cook-M read aloud Allow surface to remain wet for 60 seconds and let air dry. Do not rinse. In addition, the Quat solution indicated a Health Hazard of 1 = slight. On 6/2/15 at 9:40 a.m., surveyor # observed Baker-L cleaning the baking food prep area. Baker-L used a neutral citrus cleaner, then sprayed the area with the Quat sanitizer solution, then dried the area with a towel. Three out of three staff observed, DA-K, Cook-M and Baker-L were not aware they were to allow the area to air dry after sanitizing. 2. On 6/2/15 at 7:45 a.m., surveyor # and CSM-J observed the food service in the main kitchen that served all 73 residents. Surveyor # interviewed CSM-J regarding the chemical concentration of the Quat solution in the spray bottles. CSM-J indicated the spray bottles were filled about once a week from the main sanitizing solution at the sink. CSM-J indicated the concentration was not routinely tested . At that time, CSM-J tested the concentration of the Quat solution in a spray bottle. The results of the concentration was zero ppm, indicating the Quat solution was ineffective for sanitization. CSM-J indicated he did not know when the Quat solution in the spray bottle had been prepared and/or did not know how long the solution was ineffective. CSM-J stated DA (Dietary Aide)-I fills and tests the Quat solution in the spray bottles. DA-I confirmed that Quat solution tested at zero ppm was not effective and that the test results had to reach the green zone of 200 to 400 ppm to be effective. DA-I reviewed the results of the Quat solution testing on the ongoing log, which indicated that daily testing of the Quat chemicals at the sink and all were above 200 ppm and verified that he never tested the Quat solution in the spray bottles which were only filled as needed, every week or so. Two additional spray bottles with Quat solution were noted in the kitchen and both met the 200 ppm when tested . THE FACILITY DID NOT MAINTAIN FOOD PREP AREAS IN A CLEAN AND SANITARY CONDITION INCLUDING AN UNCLEAN BAKING PAN. ServeSafe 6th edition based on the 2013 Federal Food Code indicates: ~ All surfaces must be cleaned and rinsed. This includes walls, storage shelves, and garbage containers, However, any surface that touches food, such as knives, stockpots, cutting boards, or prep tables, must be cleaned and sanitized. Storing tableware and equipment: Once utensils, tableware, and equipment have been cleaned and sanitized, they must be stored in a way that will protect them from contamination. ~ Nonfood-contact surfaces must be cleaned regularly. Examples include floors, ceilings, equipment exteriors, restrooms, and walls. Regular cleaning prevents dust, dirt, and food residue from building up. Examples: 1. On 6/2/14 at approximately 8:20 a.m., surveyor # and CSM-J observed the main kitchen area to include pots and pans. Surveyor # lifted a baking pan from a stack of clean pans in the clean dish area and noted the pan had a residue of dry scrambled eggs. Surveyor # interviewed CSM-J regarding this pan that had the dried eggs. CSM-J verified the baking pan had dried eggs residue. CSM-J then removed the baking pan and the pan that it was resting on. CSM-J indicated he did not know how that soiled baking pan got into the clean dish area. 2. On 6/2/14 at approximately 8:25 a.m., surveyor # and CSM-J observed the main kitchen's South Bend oven doors to be soiled and in need of deep cleaning. CSM-J indicated the oven doors were difficult to clean and some of the soil was inside the glass panels. 3. On 6/2/14 at approximately 8:30 a.m., surveyor # and CSM-J observed the main kitchen's vents and noted two ceiling vents above the dish washing area had a build up of black colored dust and debris, to include 6 ceiling panels surrounding the vents. Two additional vents along the back of the kitchen, next to the baking and sandwich prep area were noted to be dusty and in need of cleaning. CSM-J completed a work order to have the vents and tiles cleaned by the maintenance department. CSM-J then presented a work order indicating the maintenance department had cleaned the vents in the kitchen during the beginning of May 2015. CSM-J indicated the vents that needed to be cleaned must have been missed in May, as the other vents in the kitchen were clean. PROPER LABELING AND DATING OF FOOD IN RESIDENT REFRIGERATORS. Example: ServeSafe 6th edition based on the 2013 Federal Food Code indicates: Any item not stored in its original container must be labeled. Refrigerated food held for longer than 24 hours must be date marked. On 6/3/15 at 8:08 a.m., surveyor # observed the refrigerator on unit 5 and noted a small container of watermelon that was undated and unmarked. At that time, during an interview with RA-O, RA-O indicated she did not know who the watermelon belonged to or when it expired. On 6/3/15 at 8:30 a.m., surveyor # observed the refrigerator on unit 6 and noted a plate with fillet mignon and rice pilaf with a resident's name on it. At that time, during an interview with CNA-Q, CNA-Q indicated she did not know how long the steak and rice had been in the refrigerator or when it expired. On 6/4/15 at 8:00 a.m., surveyor # interviewed CSM-J regarding labeling of food items in the refrigerators. CSM-J confirmed all food in resident and unit refrigerators should be labeled and dated. STAFF ARE TO WEAR APPROPRIATE MUSTACHE AND BEARD RESTRAINTS Example: ServeSafe 6th edition based on the 2013 Federal Food Code indicates: Pathogens can be found on hair and skin. Wear a clean hat or other hair restraint when in a prep area. Food handlers with facial hair should also wear a beard restraint. On 6/1/15 at 8:50 a.m., surveyor # observed CSM-J, wearing a beard restraint over his beard, but not over his mustache. CSM-J was observed entering coolers, freezers, and food prep areas without restraining his mustache. On 6/2/15 from 7:15 a.m. until 9:00 a.m., surveyor # observed CSM-J wearing a beard restraint over his beard, but not over his mustache. CSM-J was observed in the food prep areas without restraining his mustache. At 9:15 a.m., CSM-J was observed entering the food prep areas without restraining his beard and mustache. During an interview at that time, CSM-J confirmed that staff with facial hair were required to wear a restrain over their beard and mustache, as well as hair nets in the food prep area. On 6/2/15 at 9:15 a.m., surveyor # observed DA-I in the kitchen food prep area without wearing a restraint over his mustache, putting clean dishes away and entering food prep areas. At that time, surveyor # interviewed DA-I regarding hair restraints. DA-I confirmed he should always have a hair restraint over his mustache, but just forgot it today.